Open Journal of Obstetrics and Gynecology, 2011, 1, 225-227 OJOG
doi:10.4236/ojog.2011.14044 Published Online December 2011 (
Published Online December 2011 in SciRes.
Type I endometrial cancer after chemoradiation therapy for
carcinoma of the cervix: a case report
Vibha Kundi Gupta1, Anna Hoekstra2
1Michigan State University College of Human Medicine, Kalamazoo Center for Medical Studies, Kalamazoo, USA;
2West Michigan Cancer Center, Division of Gynecologic Oncology, Kalamazoo, USA.
Received 7 September 2011; revised 10 October 2011; accepted 25 October 2011.
Standard treatment for cervical cancer has been ra-
diation and chemotherapy. Ionizing radiation has been
associated with damage to normal tissues included in
the radiation field. Post-radiation uterine cancers are
characterized by high stage, high grade, and a pre-
ponderance of type II histologic subtypes. We report
a case of type I endometrioid adenocarcinoma diag-
nosed 19 years after definitive chemoradiation for cer-
vical cancer.
Keywords: Postradiation Endometrial Adenocarcinoma;
Type I Endometriod Adenocarinoma; Pelvic Radiation
The standard treatment for locoregionally advanced cer-
vical cancer includes radiation and chemotherapy. A nu-
mber of studies have suggested that ionizing radiation
causes damage to normal tissues included in the radia-
tion field [1-13]. Long-term investigations of cervical
cancer patients have revealed an increased rate of a
variety of second cancers [1]. Although the risk of can-
cer of the uterus has not been shown to increase after
pelvic radiation, po st-radiation endometrial cancers h ave
poorer prognosis than those that are spontaneous[1,2].
Post-radiation uterine cancers are characterized by high
stage, high grade, and a preponderance of type II histo-
logic subtypes [1,2]. We report a case of type I endo-
metrioid adenocarcinoma diagnosed 19 years after defi-
nitive chemoradiation for cervical cancer.
K. H. is an obese, diabetic 59 years old G4P4 with a re-
mote history of cervical cancer. She was diagnosed with
stage IIIB squamous cell carcinoma of the cervix in
1992, treated with chemoradiation on the BuDR sensiti-
zer protocol, receiving a total of 8020 cGy. In 2004, she
was diagnosed with Stage I moderately differentiated in-
filtrating ductal carcinoma of the left breast, treated with
lumpectomy followed with radiation therapy and aroma-
tase inhibitors. In the same year, she was diagnosed with
basal cell carcinoma of the face, treated with wide local
excision alone. In late 2010, the patient presented with
symptoms of diarrhea. Surveillance CT scans revealed of
a small amount of fluid in her endometrial canal, PET
scan showed increased activity in the intrauterine canal
(see Figure 1), and MRI was suspicious for intrauterine
thickening. Complete obliteration of her upper vagina
with a vaginal depth of 3 cm precluded endometrial bio-
psy or adequate examination. The patient underwent out-
patient laparoscopic supracervical hysterectomy for his-
tologic diagnosis of the endometrium. Pathology reveal-
ed grade 2 endometrioid adenocarcinoma, invading 6 of
15 mm of the myometrium, with pos itive washings. The
patient then underwent staging to remove her ovaries,
tubes, pelvic and para-aortic lymph nodes, and omentum.
The decision was made to leave the cervix in-situ due to
the high risk of permanent damage to the urogenital tract.
There was no gross evidence of disease intraoperatively;
Figure 1. Pet scan showing increased attenuation in
the endometrial canal.
V. K. Gupta et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 225-227
pathology was negative, with the exception of micros-
copic metastases to the omentum. She is currently under-
going a planned 6 cycles of platinum and taxane based
The risk of uterine cancer after radiation for cervical
cancer is not increased, compared to that of unradiated
populations [1,3]. The estimated incidence of post-radia-
tion uterine cancer is 0.5% - 0.8% [4]. International stu-
dies [6,11-13] have reported a high number of combin-
ed (type I and II) endometrial cancers. In the largest
study of post radiation endometrial cancer, 308 cases of
endometroid and endometroid cancer were reported over
40 years [1]. Of the 147 cases described in the US lite-
rature, however, the vast majority were of non-endome-
trioid histologic subtypes. Only 6 0 cases of endometrioid
adenocarcinoma of the uterus are reported, many of whi-
ch are grade 3 [2,4]. Although a large number of studies
have demonstrated that radiotherapy can lead to secon-
dary cancers [2-13], it appears that well or moderately
differentiated endometrioid adenocarcinoma is exceedingly
rare after pelvic radiation for cervical cancer. Diagnosis
of radiation-associated endometrial cancer varies from
sporadic cancers, which are most often diagnosed by ab-
normal vaginal bleeding. Cervical stenosis and oblitera-
tion of the upper vagina due to radiation damage may
prevent vaginal bleeding. Evaluation after abnormal ima-
ging can be accomplished with endometrial curettage,
ultrasound guided aspiration, or hysterectomy. Differen-
ces in diagnosis are associated with significant delays of
diagnosis, contributing to the poorer prognosis associa-
ted with post-radiation endometrial cancer. Advanced s-
tage and aggressive histology of most uterine tumors af-
ter radiation for cervical cancer may require more aggre-
ssive surgical staging and adjuvant treatment than spo-
radic endometrial cancers. Many patients reported in ca-
se series have been surgically treated without extensive
lymph node sampling or omentectomy, which may signi-
ficantly affect adjuvant treatment recommendations. Rou-
tine omentectomy, pelvic and para-aortic lymphadenec-
tomy may be both diagnostic, to guide adjuvant treat-
ment, and therapeutic to remove microscopic disease. In
the case reported here, the microscopically po sitive ome-
ntum changed her treatment recommendation to include
cytotoxic chemotherapy. More aggressive treatment both
surgically, and adjuvantly, may be considered for this
particular patient population to improve prognosis. The
etiology of endo metrial cancer after radiation therap y for
cervical cancer has been the subject of multiple reviews
[1-4]. Evaluation of this patien ts history and curren t eva-
luation suggests a multifactorial etio logy for her disease,
including traditional risk factors, genetic predisposition,
and radiation effect. The patient is obese with a modera-
tely differentiated endometrioid tumor. Microscopic spread
outside the uterus may be explained by trans-tubal s-
pread after a significant delay in diagnosis due to obli-
teration of the upper vagina. The contribution of genetic
predisposition is suggested by her personal history of 3
prior cancers. Lastly, the direct effect of ionizing ra-
diation cannot be ignored. Pelvic radiation for cervical
cancer has been implicated in the development of a va-
riety of second cancers 1, often temporally distant from
the radiation (5 years - 20 years). This is consistent with
the 19 years gap between treatment of cervical cancer an d
diagnosis of uterine cancer. This case suggests endome-
trioid post-radiation tumors may have a complex origin.
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