Endometrioid carcinoma arising from diaphragmatic endometriosis treated with laparoscopy: A case report

Diaphragmatic clear cell carcinoma with Lynch syndrome after surgery for atypical endometrial hyperplasia and ovarian endometriosis: A case report

Clear cell carcinoma (CCC) of the diaphragm is rare, with an origin that is reported to be associated with malignant transformation of extraperitoneal endometriosis. Lynch syndrome (LS) is an autosomal dominant hereditary cancer syndrome caused by germline pathogenic variants in one of the DNA mismatch repair (MMR) genes, MLH1, MSH2, MSH6 and PMS2. Women with LS have a significantly increased lifetime risk of endometrial and ovarian cancer. CCC is a common histology of endometriosis- and LS-associated malignancy. The present study describes the case of a 51-year-old woman with an intra-abdominal mass found during a routine physical examination. The patient had undergone total hysterectomy and bilateral adnexectomy for atypical endometrial hyperplasia (AEH) and ovarian endometriosis, respectively, 3 years previously. Enhanced computed tomography showed a mass on the surface of the liver. Laparoscopic examination of the abdominal cavity revealed a tumor on the underside of the right diaphragm, which was then surgically excised. Pathological examination of the excised tumor, along with immunohistochemistry, led to a diagnosis of CCC. Since LS was suspected due to the genetic family history of the patient, microsatellite instability analysis was performed on the diaphragmatic tumor, and the results were positive. Immunohistochemistry was performed for MMR proteins in AEH and CCC cells, both of which revealed loss of MSH2 and MSH6 expression. Following detailed genetic counseling, genetic testing of MMR genes was performed, revealing a germline pathogenic variant in MSH2 (c.1000C>T, p.Gln344*), thus confirming the diagnosis of LS. To the best of our knowledge, this is the first case report of concurrent diaphragmatic CCC and LS. Patients with LS and endometriosis are at risk of developing ovarian cancer or intra-abdominal malignant tumors. In addition, immunohistochemistry screening for MMR proteins should be considered in patients with AEH and a family history of LS-related cancer, to enable early clinical intervention in cases of endometrial cancer.

Adenomyosis and Its Possible Malignancy: A Review of the Literature

Cancer arising from adenomyosis is very rare, with transformation occurring in only 1% of cases and in older individuals. Adenomyosis, endometriosis and cancers may share a common pathogenic mechanism that includes hormonal factors, genetic predisposition, growth factors, inflammation, immune system dysregulation, environmental factors and oxidative stress. Endometriosis and adenomyosis both exhibit malignant behaviour. The most common risk factor for malignant transformation is prolonged exposure to oestrogens. The golden standard for diagnosis is histopathology. Colman and Rosenthal emphasised the most important characteristics in adenomyosis-associated cancer. Kumar and Anderson emphasised the importance of demonstrating a transition between benign and malignant endometrial glands in cancer arising from adenomyosis. As it is very rare, it is difficult to standardize treatment. In this manuscript, we try to emphasize some aspects regarding the management strategy, as well as how heterogenous the studies from the literature are in terms of prognosis in both cancers that develop from adenomyosis or those that are only associated with adenomyosis. The pathogenic mechanisms of transformation remain unclear. As these types of cancer are so rare, there is no standardised treatment. A novel target in the diagnosis and treatment of gynaecological malignancies associated with adenomyosis is also being studied for the development of new therapeutic concepts.

Case report: dual primary malignancies treated by laparoscopic multiorgan resection with natural orifice specimen extraction surgery

With microtrauma becoming a consensus, in order to improve surgical treatment capability, the clinical application of laparoscopic multiorgan resection is becoming more and more complicated and diversified. Recently, we successfully presented a case of transvaginal specimen extraction surgery that included laparoscopic anatomical left hemihepatectomy combined with laparoscopic total hysterectomy and bilateral adnexectomy and the pelvic and para-aortic lymphadenectomy. The patient, a 75-year-old woman, was hospitalized with abnormal vaginal discharge and bleeding. The pathologic diagnosis of uterine curettage was endometrioid adenocarcinoma. After completing examinations such as color Doppler ultrasound, CEUS, MRCP and thoracoabdominal enhanced spiral CT, preoperative diagnosis was considered as endometrial cancer and a space-occupying lesion in the liver (primary or secondary site)?. No lymphatic or distant metastasis had been found. We also excluded Lynch syndrome by digestive endoscopy and gene sequencing. After a multidisciplinary consultation, the patient underwent surgery under general anesthesia on 24 September 2021. The operation was completed uneventfully in 6 hours, then the patient was transferred to the ICU for follow-up monitoring. The patient began to eat and was able to leave bed on the 4th postoperative day. According to immunohistochemistry, the patient's postoperative diagnosis was intrahepatic cholangiocarcinoma (ICC) and endometrial cancer. Compared with open surgery, laparoscopic multiorgan resection with natural orifice specimen extraction surgery (NOSES) has many advantages such as fewer traumas, shorter recovery time, and better postoperative quality of life. However, combined large-scale laparoscopic surgeries of different organs can be challenging for surgeons and anesthesiologists. No similar cases have been searched.

A Locally Advanced Endometrioid Adenocarcinoma Arising from Vaginal Endometriosis: Management and Review of the Literature

Endometrioid adenocarcinoma associated with endometriosis at extrauterine or extraovarian localization is a rare entity. Often presenting with local spread without nodal and distant metastasis, this entity has no specific staging system nor treatment guidelines. In the case of nodal and distant spread, the treatment decision requires personalization. In this article, we present the diagnosis and surgical and systemic treatment of a 56-year-old woman diagnosed with an endometriosis-associated advanced endometrioid adenocarcinoma of the vagina with nodal involvement. Following an extensive review of the scarce data reported to guide the treatment choices in this rare setting, we proposed a multidisciplinary treatment with laparoscopic surgical cytoreduction, four cycles of adjuvant chemotherapy with carboplatin and paclitaxel, and radiotherapy with brachytherapy. Due to an anaphylactic reaction on the first administration, paclitaxel was replaced with nab-paclitaxel. Despite many negative prognostic factors, the patient is free from relapse after 48 months. We report the case of a locally advanced endometrioid adenocarcinoma associated with endometriosis of the vagina, with pelvic nodal spread, and the relevant literature review of similar cases.

Malignancies Associated with Extraovarian Endometriosis: A Literature Review

Endometriosis-associated ovarian malignancies have been well documented. Although these malignancies also occur as extraovarian lesions, little is known about them. Thus, this literature review aimed to further explore these rarely experienced tumors. A total of 257 published cases between April 1990 and April 2020 were found using PubMed, and 212 cases were included in the analysis considering Sampson’s criteria and the history of endometriosis. We classified these cases as follows: intestine, abdominal scar, vagina and vulva, peritoneum and deep endometriosis, urinary tract, uterine cervix, and others. Age of patients, history of endometriosis, types of past hormonal therapy, symptoms, histological types, and treatment were identified. The most common tumor site was the intestine. Endometrioid carcinoma was the dominant histological type. Contrary to the ovary, clear cell carcinoma was rare in extraovarian sites. On the other hand, clear cell carcinoma represented the largest number of abdominal scars. This difference may help us to understand the development of endometriosis-related malignancies. Hormonal treatment was mentioned in 67 cases and estrogen replacement therapy in 33 cases. Although risks of estrogen therapy are still controversial, the highly differentiated histological types and hormone-dependent characteristics of endometriosis-associated malignancy should be considered. Physicians should be careful about estrogen monotherapy after hysterectomy and long-term hormone replacement therapy in patients with a history of endometriosis.

Whole-Exome Sequencing of Rare Site Endometriosis-Associated Cancer

Malignant transformation of extraovarian endometriosis is rare, with the carcinogenesis mechanism unclear. To clarify the actionable variants of rare-site endometriosis-associated cancer (RSEAC), we performed whole-exome sequencing for the tumor, in two patients. The intestine was affected in both cases, although the histology was that of clear cell carcinoma and undifferentiated carcinoma, respectively. Therefore, the cases were referred to as endometriosis-associated intestinal tumors (EIATs). Actionable variants (all frameshift mutations) were identified in tumor suppressor genes ARID1A, PTEN, and p53; however, no oncogenic variants were identified. Both cases were microsatellite stable. The patient with undifferentiated carcinoma exhibited hypermutator and homologous recombination deficiency phenotypes. The dominant mutation signatures were signature 30 (small subset of breast cancers) and 19 (pilocytic astrocytoma) in patient 1, and signature 5 (small subset of breast cancers) and 3 (breast, ovarian, and pancreatic cancers) in patient 2. Immunohistochemistry revealed positive CD8 and PD-1 expression in both patients; patient 1 also showed positive PDL-1 expression. Our results suggest that RSEAC is associated with variants of tumor suppressor genes as epigenetic alterations. Mutation signature-based whole-exome sequencing could be useful to select an adjuvant chemotherapy regimen. High CD8 and PD-1 expression in RSEAC suggests that immune checkpoint inhibitors are useful for treatment.

Possibility of Targeting Claudin-2 in Therapy for Human Endometrioid Endometrial Carcinoma

Claudin-2 (CLDN-2) is a leaky-type tight junction protein, and its overexpression increases tumorigenesis of some types of cancer cells. In the present study, to examine the possibility of targeting CLDN-2 in the therapy for endometrioid endometrial adenocarcinoma, we investigated the regulation and role of CLDN-2 in endometriosis and endometrioid endometrial adenocarcinoma. In endometrioid endometrial adenocarcinoma tissues, marked upregulation of CLDN-2 was observed together with malignancy, while in endometriosis tissues, a change in the localization of CLDN-2 was observed. In cells of the endometrial adenocarcinoma cell line Sawano, which highly express CLDN-2, downregulation of CLDN-2 induced by the siRNA upregulated the epithelial barrier and inhibited cell migration. Furthermore, the downregulation of CLDN-2 affected the cell cycle and inhibited cell proliferation. In Sawano cells cultured with high-glucose medium, CLDN-2 expression was downregulated at the mRNA and protein levels. The high-glucose medium upregulated the epithelial barrier, cell proliferation, and migration, and inhibited cell invasion. The histone deacetylase (HDAC) inhibitor tricostatin A (TSA), which has antitumor effects, downregulated CLDN-2 expression, cell proliferation, invasion, and migration, and upregulated the epithelial barrier. The mitochondrial respiration level, an indicator of cancer metabolism, was downregulated by CLDN-2 knockdown and upregulated by the high-glucose condition. Taken together, these results indicated that overexpression of CLDN-2 closely contributed to the malignancy of endometrioid endometrial adenocarcinoma. Downregulation of CLDN-2 via the changes of the glucose concentration and treatment with HDAC inhibitors may be important in the therapy for endometrial cancer.

Isolated Diaphragmatic Metastasis Originating From Early Endometrial Cancer

Metastatic diaphragm tumors are rare. We herein describe an extremely rare case of isolated diaphragmatic metastasis from an endometrial cancer. A 47-year-old asymptomatic woman, who had previously undergone surgical resection for stage IA endometrial cancer with high uptake of fluorodeoxyglucose, presented with a diaphragmatic tumor. The resected diaphragmatic specimen revealed adenocarcinoma within the diaphragm, which was similar to the previous endometrial cancer. The tumor was eventually diagnosed as a diaphragmatic metastasis from endometrioid adenocarcinoma of uterus. Diaphragmatic metastasis should be considered in the differential diagnosis in patients with previous malignancies that show high fluorodeoxyglucose uptake, even in early-stage primary tumors.

Endometrioid adenocarcinoma of the rectovaginal septum with invasion of the rectum: a case report and review of literature

Background

Malignant transformation of endometriosis in the rectovaginal septum is rare and usually misdiagnosed as a colorectal or gynecological tumor. We report a rare case of primary endometrioid adenocarcinoma of the rectovaginal septum with invasion of the rectum.

Case presentation

A 57-year-old overweight woman presented with vaginal bleeding and self-reported left lower abdominal pain during the previous 2 weeks. Preoperative imaging showed a large pelvic mass with invasion of the rectum, suggestive of a gynecologic malignancy. Multiple endoscopic biopsies and immunohistochemical analyses of specimens was performed. The patient received joint gynecological-surgical laparotomy, and there were no intra- or postoperative complications. The histopathological diagnosis was rectovaginal endometrioid adenocarcinoma with rectum infiltration. The patient received adjuvant chemotherapy and achieved good treatment response, with no early complications. At 12 months after surgery, there was no evidence of recurrence.

Conclusions

A high index of clinical suspicion is required for the diagnosis of endometrioid adenocarcinoma in the rectovaginal septum. Surgery combined with additional chemotherapy or radiotherapy seems to be a standard treatment, and hormonal therapy is optional. The efficacies of other therapies, including targeted medication and immunotherapy, are unknown.