doi 10.15296/ijwhr.2015.46 doi 10.15296/ijwhr.2015.27
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Case Report Review International Journal of Women’s and Reproduction Sciences International Journal of Women’s HealthHealth and Reproduction Sciences Vol.Vol. 3, No. 3, July 2015, 126–131 3, No. 4, October 2015, 220–222 ISSN 2330- 4456 ISSN 2330- 4456
Women on theEndometrial Other Side of and War Ovarian and Poverty: Its Effect Synchronous Cancer With on the Health of Reproduction Sigmoid Colon Metastasis One Year After Primary Ayse Cevirme , Yasemin Hamlaci , Kevser Ozdemir Surgery: A Case Report 1
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Abstract
1 1 2 Kadir Guzin , Burcin Karamustafaoglu Balci1*by , Kemal , Ahmet Gocmen1public , Ozgur Ekinci , ’ War and War and poverty are ‘extraordinary conditions created human Sandal intervention’ and ‘preventable health problems. 3 3 Abdullah Aydin , Meryem Yuvruk poverty have many negative effects on human health, especially women’s health. Health problems arising due to war and poverty are
being observed as sexual abuse and rape, all kinds of violence and subsequent gynecologic and obstetrics problems with physiological and psychological courses, and pregnancies as the result of undesired but forced or obliged marriages and even rapes. Certainly, Abstract unjust treatment such as being unable to gain footing on the land it is lived (asylum seeker, refugee, etc.) and being deprived of Introduction: We describe a patient who had ovarian and endometrial cancer which metastasized to sigmoid colon one year after social security, citizenship rights and human rights brings about the deprivation of access to health services and of provision of surgery. service intended for gynecology and obstetrics. The purpose of this article is to address effects of war and poverty on the health of Case Presentation: A and 53-year-old womancontribution was admitted with the complaints of abdominal pain, abdominal distension and reproduction of women to offer scientific and solutions. postmenopausal bleeding. Her transvaginal ultrasound scan revealed a cystic mass containing papillary projections with the Keywords: Poverty, Reproductive health, War
dimensions of 6.5 × 5 × 4 cm on the right ovary. Level of (carbohydrate antigen) (CA) 125 was 223 IU. Dilation and curettage revealed endometrioid adenocarcinoma. Debulking surgerywas carried out. Histopathological diagnosis was grade 2 adenocarcinoma with squamous differentiation for endometrial cancer and grade 2 endometrioid adenocarcinoma with squamous and mucinous thought that severe military conflicts in Africa shorten Introduction differentiation ovarian The stage was 1A forhad endometrial andlifetime 1A for ovarian cancer. the operation the cancer expected for more than12 2 months years. Inafter general, Throughout thefor history ofcancer. the world, the ones who CA 125 level was 112 IU. Positron emission tomography (PET) scan showed a small lesion (1.5×1.5 cm) in the pelvic cavity with WHO had calculated that 269 thousand people had died confronted the bitterest face of poverty and war had alincreased fluorodeoxyglucose (FDG) uptake. Five months after the chemotherapy, CA 125 level elevated from 10 to 60 IU and in 1999 due to the effect of wars and that loss of 8.44 milways been the women. As known poverty and war affects subsequent magnetic resonance imaging (MRI) revealed a tumoral mass with the dimensions of 3×2.2 cm. A second laparotomy lion healthy years of life had occurred (2,3). human health either directly or indirectly, the effects of wascondition performedonand the metastasis excited. in The endometrioid with infiltration the serosa and negativelyadenocarcinoma affect the provision of health in services. this health and statuswas of women thetumor so- wasWars Health institutions such as hospitals, laboratories and ciety shouldpropria not be of ignored. study intends to cast muscularis sigmoidThis colon. healthincenters are direct of war. Moreover, themalignancies. wars light on the effects of war and povertythe on possibility the reproductive Conclusion: It is needed to consider of double cancer the diagnosis andtargets treatment of gynecological cause the migration of antigen qualified health employees, and health of women. For thisneoplasms, purpose, the face of war affect- Ovarian Keywords: Endometrial Neoplasm metastasis, neoplasms, CA-125 thus the health services hitches. Assessments made indiing the women, the problem of immigration, inequalities cate that the effect of destruction in the infrastructure of in distribution of income based on gender and the effects health continues for 5-10 years even after the finalization of all these on the reproductive health of women will be Introduction missed abortus, admitted to our clinic with the complaints (3). Duepain, to resource requirements in the addressed. The presence of synchronous primary malignancies in the of conflicts of abdominal abdominal distension andrepostmenoafterfamily war, the share allocated to histofemale genital tract is relatively rare. Primary tumors in structuring pausal investments bleeding. Her and previous disease haswere decreased (1). Warorgans and Women’s two withinHealth a single person is called synchronous healthries unremarkable. Her physical examination and Famine, synonymous with war and poverty, is clearer for primary malignancies. The two types of synchronous cantransvaginal ultrasound scan revealed free fluid in the women; war means deep disadvantages such as full deMortalities and Morbidities cers commonly reported have been ovarian cancer and The ones abdominal cavity and a cystic mass containing papillary struction, loss of future and uncertainty for women. Wars who are most affected from wars are women and endometrial cancer (1,2). Synchronous primary tumor projections with the dimensions of 6.5 × 5 × 4af-cm on the are conflicts that destroy families, societies and cultures children. While deaths depending on direct violence of the endometrium and ovary occur in up to 10% of all right ovary. Tumor marker (carbohydrate antigen) (CA) fect the male population, the indirect deaths kill children, that negatively affect the health of community and cause ovarian cancer cases and 5% of all endometrial cancer 125 was elevated, 223 IU. The dilatation and was women and elders more. In Iraq between 1990-1994,curettage inviolation of human rights. According to the data of World cases Patients with simultaneous uterine ovarian fant deaths performed and the had shown thishistopathological reality in its more diagnosis bare form of endoHealth(3). Organization (WHO) and World Bank, and in 2002 an increase of 600% was (4). The war taking five years wars haddobeen among show the first ten reasons whichthan killed cancers generally a better prognosis those with metrial curettage endometrioid adenocarcinoma. the childtomography deaths under age of 5 by 13%. Also 47% Under the most and caused disabilities. CivilWe losses are at the rate a increases with metastatic disease. (2,4-6). describe herein, Computed revealed no metastasis. the diagnosis refugees inof theendometrial world and 50% of asylum seekers ovarian of 90% within losses (1). patient whosealldisease was not consistent with this data, of allthe cancer and probably and displaced people areascites womensampling, and girls and 44%hysterectomy, refWarhad hasovarian many negative on human health. One cancer of she cancer effects (stage 1A) and endometrial cancer; malignant radical ugees and asylum seekers are children under the age these is its effect of shortening the average human life. (stage 1A) which metastasized to sigmoid colon one year bilateral salpingo-oophorectomy, pelvic and ofparaaortic 18 (5). According to the data of WHO, the average human life is after surgery. lymphadenectomy, omentectomy, appendectomy and As the result of wars and armed conflicts, women are 68.1 years for males and 72.7 years for females. It is being
cytologic sampling of the undersurface of the diaphragm Case Presentation were carried out (tumor free). Histopathological diagno12 December 2014, Accepted 25 April 2015, Available 1 Julyof 2015 AReceived 53-year-old postmenopausal women, with aonline history 5 sis of endometrial cancer was grade 2 adenocarcinoma 1 2 pregnancies, 2 deliveries, 1 dilatation curettage 2 with University, squamous differentiation (stage 1A) with less than Department of Nursing, Sakarya University, Sakarya, and Turkey. Departmentand of Midwifery, Sakarya Sakarya, Turkey. *Corresponding author: Yasemin Hamlaci, Department of Midwifery, Sakarya University, Sakarya, Turkey. Tel: +905556080628,
Email:
[email protected] Received 9 March 2015, Accepted 19 August 2015, Available online 1 October 2015
Department of Obstetrics and Gynecology, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey. Department of General Surgery, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey. 3Department of Pathology, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey. *Corresponding author: Burcin Karamustafaoglu Balci, Department of Obstetrics and Gynecology, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey. Email:
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half myometrial invasion (myometrial thickness 17 mm, depth of invasion 6 mm) (Figure 1A). Histopathological diagnosis of ovarian tumor was grade 2 endometrioid adenocarcinoma with squamous and mucinous differentiation (Figure 1B). The capsule of the ovarian tumor was intact, pelvic and paraaortic lymph nodes were negative. The stage was 1A for endometrial cancer and 1A for ovarian cancer. Therefore, no adjuvant chemotherapy was planned. After the operation CA 125 was within normal limits (10 IU). The patient was on follow-up and 12 months after the operation CA 125 level was 112 IU. PET scan showed a small lesion (1.5 × 1.5 cm) in the pelvic cavity with increased fluorodeoxyglucose (FDG) uptake. She was treated with 9 weekly courses of paclitaxel and carboplatin. The CA 125 level after the chemotherapy was 10 IU. Five months after the chemotherapy CA 125 level elevated to 60 IU and subsequent magnetic resonance imaging (MRI) revealed a tumoral mass with the dimensions of 3 × 2.2 cm in abdominal cavity, above psoas muscles, between intestinal loops. A second laparotomy was performed and a 2.5 × 3 cm in size tumor on sigmoid colon was seen. The tumor was placed on the serosal side of the colon and was not causing bowel obstruction. No tumoral lesion was seen on psoas muscles. Multiple biopsies were taken. They were all negative. The metastasis was excited from 5 cm below the lower border and from 10 cm up the upper border of the tumor and end-to-end anastomosis was done. The examination of the tumoral mass that was extracted showed that there was endometrioid adenocarcinoma with infiltration in the serosa and muscularis propria of sigmoid colon (Figure 1C). Immunohisto-
chemically, tumor cells were positive for pax8 (Figure 1D) and negative with WT1 and ER. The margins were clear (negative margins). The patient is still on follow up and no recurrence has occured. Discussion When there is contemporarily endometrial and ovarian malignancies, the differential diagnosis between metastasis and synchronous primary tumors is difficult. Histopathologic workup differentiating synchronous carcinoma from metastatic carcinoma was done. We found that each tumor was situated away from each other and that each tumor was not a metastasis of the other. Uterine cancer had less than half myometrial invasion and the grade of both uterine and ovarian tumors were almost the same. In such cases, the diagnosis is synchronous primary tumors, not metastasis. Consequently, the patient was diagnosed as having double simultaneous tumors. Histopathological diagnosis of the mass that was extracted from the sigmoid colon was endometrioid carcinoma and the specimen showed positive reaction to pax8 which is one of markers in distinguishing genital tract carcinomas. This positivity showed that the tumor in sigmoid colon was an endometrioid carcinoma metastasis. However, it could not be exactly decided whether the malignant cells in this mass were derived from endometrial and/or ovarian cancers. The WT1 is a marker for serous carcinoma; the tumor in sigmoid colon was negative for WT1; which shows that it is not serous carcinoma of the endometrium and/or ovary. The coexistence of synchronous multiple primary malig-
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1.6 mm 10 μ
1.6 mm 10 μ
▲ 1.6 mm 10 μ
1.6 mm 10 μ
Figure 1. (A) Endometrium: Endometrioid adenocarcinoma grade 2. Atypical glandular formation of endometrioid adenocarcinoma with squamous metaplasia (H&E 10X). ▲: Squamous differentiation area. *: Endometrioid carcinoma. (B) Ovarian tumor: Endometrioid adenocarcinoma in the right ovary. Endometrioid adenocarcinoma with atypical glands is seen (H&E 10X). ▲: Squamous differentiation area. *: Endometrioid carcinoma. (C) Endometrioid adenocarcinoma in serosa of the sigmoid colon. Atypical glands are invading the outer part of the muscularis propria of the colon (H&E 2X). Arrow: Endometrioid carcinoma on the serosal surface and muscularis propria of the sigmoid colon. (D) Nuclear Pax-8 positivity in the tumor cells of the metastasis in the colon. This marker shows that the tumor is originating from genital tract (pax-8 20X). ■: Pax8 positivity in the nuclei of tumor cells. International Journal of Women’s Health and Reproduction Sciences, Vol. 3, No. 4, October 2015
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nancies is very interesting. A case of synchronous primary carcinomas in five different organs of a female genital tract has been reported (7). Even though the treatment is similar as if they were single primary tumors, the prognosis of patients with synchronous primary cancers are generally better than the patients with metastatic disease of a single tumor (2,3). In a prospective GOG study, patients with simultaneous uterine and ovarian carcinomas showed a 5-year survival of 86% and a 10-year survival of 80% and their prognosis was better than those with metastatic disease (3). A possible explanation may be that generally ovarian tumors are diagnosed at advanced stages (75%–85% stage III/IV), while the majority of ovarian cancers in patients with synchronous multiple primary neoplasms are diagnosed at an earlier stage (8). The rationale underlying this fact is probably the symptoms that the other primary tumor cause. Another explanation may be the fact that although ovarian and endometrial cancer are generally diagnosed in the sixth or seventh decade (8), it has been demonstrated that the median age of the patients with synchronous primary tumors ranged from 41 to 54 years, suggesting that multiple primaries tend to occur at least 10-20 years earlier in life (2,9,10), which indicates a positive prognostic criterion. Meanwhile, our patient’s prognosis was not as good as expected; she experienced a metastasis only one year after surgery. Increasing CA 125 level indicates and supports the new onset of tumor on sigmoid colon. We aimed to share our experience with a patient who had two synchronous cancers in genital tract which were concurrent endometrial and ovarian cancers. It is necessary to consider the presence of double cancer in the diagnosis and treatment of gynecological cancers. Ethical Issues Not applicable. Conflict of Interests The authors declare no conflict of interests. Acknowledgements The authors declare that there is no acknowledgement. References 1. Ayhan A, Yalcin OT, Tuncer ZS, Gurgan T, Kucukali
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