A very rare case of synchronous carcinomas of the endometrium and ovary with peritoneal keratin granulomatous involvement
A 57 year-old, nulligravid, woman was originally referred to our clinic in June 2012 with abdominal pain and distension in conjunction with a large pelvic mass that was identified on a CT of the abdomen and pelvis; further evaluation revealed bilateral lower extremity edema and extensive deep venous thrombosis, for which she received anticoagulation therapy. The patient's presenting CA-125 serum level was 925 U/mL. Her medical history was significant for anemia and ankle surgery in 1992.\nThe patient initially underwent a diagnostic laparoscopy that revealed placement of the right adnexa within a 17 cm mass; there were miliary implants identified on the serosa of the bladder and ascites pervading the right upper quadrant. Consequently, the procedure was converted to an open procedure, which comprised a laparotomy, abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy and tumor debulking procedure.\nAt the time of laparotomy, the ovarian mass was loosely adherent to the cul-de-sac and the peritoneal side wall. There was also a separate tumor implant involving the cecal mesentery and a portion of the cecum, measuring 4 × 2 cm; there was miliary disease involving the cul-de-sac and select areas of the distal ileum. An infracolic omentectomy was first performed; the right ovarian mass was then bluntly dissected away from the cul-de-sac and right pelvic sidewall peritoneum and elevated; the utero-ovarian and infundibulopelvic ligaments were then divided. The mass was sent for frozen section evaluation.\nFinal pathology revealed a stage Ic, grade 1 endometrioid adenocarcinoma of the ovary with extensive squamous differentiation; there were also surface ovarian adhesions with keratin granulomas. A serosal leiomyoma, endometriosis and both left tubo-ovarian and periovarian adhesions with keratin granulomas were identified (a–b). In addition, a deeply invasive, grade I endometrioid adenocarcinoma of the uterus was detected; interestingly, the uterine tumor did not show appreciable squamous differentiation (). The cecal and small bowel implants also contained fibrovascular and granulation tissue (a–d). The omentum and cul-de-sac nodules were negative for malignancy.\nThe remaining specimen, encompassing the uterus, cervix and the left adnexa, was resected. Henceforth, only the cecal disease and scant miliary disease on the distal ileum were present; the areas thereof were excised and submitted separately. Once the procedure was concluded, the patient was considered to be optimally debulked. She tolerated the procedure well and was admitted to the Recovery Room in stable condition. Following the patient's recovery, she commenced six cycles of adjuvant weekly paclitaxel (80 mg/m2) and monthly carboplatin (AUC = 6) chemotherapy; the patient has done well with 3 months of follow-up.