CASE PRESENTATION

March10,2023
AHGH
HISTORY
 The patient is a 45 years old female who presented with
a 5-month history of loss of appetite weight loss easy
fatiguability and irregular menses with periods of
amenorrhoea followed by periods of menorrhagia. She
also had lower abdominal pain of 1 year.
 She was referred from grace MCH with the diagnosis of
left ovarian tumor.

 Has no known medical illness.

 On physical examination vital signs are within normal range
 Slightly pale conjunctiva, NIS

 Clear chest

 Distended abdomen with + signs of fluid collection and

ballotable mass over the left adnexa
 Conscious and well oriented
INVESTIGATIONS
 CBC WBC 9k N 45% Hb 8.2 hct 30 mcv 69 Plt 378k
 OFT: within normal range

 Uric acid: within normal range

 Urinalysis: within normal range

 HbsAg: Negative

 HCV: Negative

 VDRL: Negative
 CA-125: 1026U/ml (0-34)

 Pelvic MRI: multilocular left ovarian cystic mass with

thick enhancing septations, ascites and bilateral pelvic
lymph node metastasis

 Chest X-ray: Unremarkable

 With an assessment of stage III-c left ovarian ca, TAH +

BSO + Omentectomy was done and sample was sent for
biopsy
 Initial Biopsy report:
 Endometrioid carcinoma of the left ovary ( low grade,
FIGO I) + endometrioid endometrial carcinoma ( FIGO I,
conventional muscle invasion pattern)
 Secondary omental deposits
 Uterine intramural leiomyoma
 Suggestive of synchronous endometrial and left ovarian
tumor

 And with the above report, the patient was linked to oncology
for initiation of chemotherapy
AMENDED PATHOLOGY REPORT
 Mucinous carcinoma of the left ovary ( low grade,
FIGO I) + endometrioid endometrial carcinoma
( FIGO I, conventional muscle invasion pattern)
 Secondary omental deposits
 Uterine intramural leiomyoma
 Suggestive of synchronous endometrial and left
ovarian tumor
 Immunohistochemisry suggested to sort out the issue
SYNCHRONOUS ENDOMETRIAL
AND OVARIAN CANCER (SEOC)
 Multiple primary malignancies can occur in the same
organ or in multiple organs or systems.

 Multiplesynchronousprimary malignancies are defined

as ≥2 primary tumors that are each diagnosed at an
interval of not more than 6 months;
 In contrast, multiple metachronous primary malignancies
are defined as >2 primary tumors that are each diagnosed
at an interval of >6 months.
INTRODUCTION
 Synchronous endometrial and ovarian cancer (SEOC) is
defined as the simultaneous presence of these two cancers at
the time of diagnosis
 As opposed to metachronous cancer, where, these two cancers
are diagnosed at different chronological time points.
 Due to the different management and the favorable prognosis of
SEOCs, it is important to separate SEOCs from a metastatic
disease.
 EPIDEMIOLOGY
 Synchronous malignancies in the female genital tract are very
rare entities (0.5-1.7%).
 Among them, synchronous endometrial and ovarian tumors are
the most common types of malignancy, with a frequency of 5%
among endometrial and 10% among ovarian primary tumors
 Clinical presentation is indistinct, and extensive pathological
evaluation has to be performed to distinguish synchronous
endometrial and ovarian malignancies from the metastatic
disease.
 Risk factors: Age, family history, PCOS, infertility, PID,
endometriosis, cigarette smoking, environment and location etc

 Protective factors: Prior pregnancy, history of breastfeeding, OCP

use etc

 95% of ovarian cancers originate from the surface epithelium of

the ovary or from the Fallopian tube (Serous histology ~75%)
 OVARIAN CANCER – FIGO STAGING

FIGO stage Criteria

CONFIDENTIAL – DO NOT DISTRIBUTE

I Tumor limited to one or both ovaries

II Tumor involves one or both ovaries with

disease confinedto pelvis

III Tumor spread outside the pelvis to the

peritoneal cavity or lymph nodes

IV Distant metastases
CLASSIFICATION
 Scully et al. have classified them into three groups:
 (a) primary endometrial tumors with ovarian
metastasis,
 (b) primary ovarian tumors with endometrial
dissemination, and 
 (c) synchronous endometrial and ovarian
malignancies
 DIAGNOSTIC CRITERIA
1) Histological dissimilarity of the tumors
2) No or myometrial invasion of the endometrial tumor
3) No vascular space invasion of the endometrial tumor
4) Atypical endometrial hyperplasia additionally present
5) Absence of other evidence of spread of the endometrial tumor
6) Ovarian unilateral tumor
7) Ovarian tumor located in the ovarian parenchyma
8) No vascular invasion or surface implants
9) Absence of other evidence of spread of the ovarian tumor
10) Dissimilar molecular or karyotypic abnormalities in the tumors
MANAGEMENT
 Evaluation by a Gynecologic Oncologist
 Approach 1: surgery -> chemotherapy
 Traditional approach to ovarian cancer treatment

 Approach 2: neoadjuvant chemotherapy -> surgery ->

chemotherapy
 For patients that are not surgical candidates

 For patients with disease distribution that is not

resectable
SURVEILLANCE
 CA-125
 HE4

 Repeat imaging: Not recommended

 New onset of symptoms: MRI or PET Scan

recommended
IMMUNOHISTOCHEMISRY
 Immunohistochemisry involves the process of
selectively identifying antigens in a tissue section by
exploiting antibody binding principles specifically to
antigens in biological tissues.
 IHC is often useful to differentiate between primary
ovarian adenocarcinoma and metastatic adenocarcinoma
specially those of colorectal origin.
 It is also useful in diagnosing other ovarian metastatic
tumors, especially in the absence of a known primary
elsewhere.
 GENETIC TESTING
 All patients diagnosed with SEOC should undergo genetic testing
for hereditary breast and ovarian cancer (HBOC) genes
 15-20% of patients will have a mutation
 germ-line (in all the cells)

 somatic (in the tumor)

 It is important to undergo testing for many reasons: 

 Counseling and genetic testing of other family members
 Maintenance strategies after primary chemotherapy (PARP inhibitors)
 Clinical trial eligibility
 Future treatment options
CRITICAL REVIEW
 Accuracy of Diagnosis?
 Appropriateness of Management?

 Role of ImmuniHistoChemistry?

 Impact of IHC on management /surveillance?

REFERENCES
 Medscape clinical lirary
 UpToDate Clinical Library

 Falkenberry SS. Synchronous endometrioid tumors of

the ovary and endometrium. A clinicopathologic study.
 Khalid N, Ullah F, Synchronous Primary Endometrial
and Ovarian Cancers: Trends and Outcomes of the Rare
Disease at a South Asian Tertiary Care Cancer
Center.2020
 Lim MC, Suh DH, et al. Incidence of cervical,
endometrial, and ovarian cancer in Korea during 1999-
2015. J Gynecol Oncol. 2019