DISCUSSION
SPEOC is found in approximately 10% of all females with ovarian cancer
and in 5% of all females with endometrial cancer. As the entity is
uncommon, it is often misdiagnosed as FIGO stage III of endometrial
cancer or FIGO stage II of ovarian
cancer.5The majority of women with SEOC are 41–54 years old, 40% of them are
nulliparous, 2/3 of them are premenopausal, and 1/3 are
obese.7 In
the reported case, the patient is multiparous, premenopausal, and had a
BMI of 25.4kg/m2. Moreover, SPEOC is observed among
the younger age group as compared to endometrial or ovarian cancer
alone.8
As with this case, abnormal uterine bleeding is the most common
presentation of synchronous endometrial and ovarian cancer, though some
patients may present with pelvic pain or a palpable pelvic
mass.7 In
ultrasonography, most of the ovarian masses in SPEOC appear as
unilateral multilocular-solid or solid mass but such ovarian masses in
cases of endometrial cancers with ovarian metastasis are often solid
masses
bilaterally.9Our patient also had a solid-cystic lesion in her left ovary only
supporting this statement.
The Endometroid subtype of the primary tumors is the commonest
histological finding which is found in 50–70% of cases and the primary
independent tumors often grade 1 or
2.7 In the
reported case, it was endometroid subtype with histological grade
2.Development of surface epithelium of the ovary from the embryological
Mullerian duct and sharing of estrogen receptors in predisposed tissues
are the likely reasons for their synchronous
growth.10Because of this common histological finding in both the localization,
differentiation of the primary origins from primary endometrial cancer
with metastases to ovaries, or primary ovarian cancer with metastases to
the endometrium is
pivotal.11
In our case, histology revealed no evidence of metastasis as the tumor
from the section of endometrium was limited to the inner half of the
myometrium and 5mm within the capsule of the ovary without
lymphovascular invasion.
Although primary surgery has been recognized as the main treatment for
SPEOC, whether adjuvant therapy should be administered remains
controversial. Using FIGO guidelines, a patient with dual primaries
limited to the ovary and the uterus represents two Stage I cancers.
Systematic surgical staging is the mainstay of the management for such
patients and often includes total abdominal hysterectomy with bilateral
salpingo-oophorectomy, total omentectomy, appendectomy, pelvic and
para-aortic lymphadenectomy, and complete resection of all
diseases.10Considering the positive frozen section examination, our patient too
underwent the aforementioned staging surgery.
These patients have a good prognosis and depending on the substage may
not require radio or chemotherapy. However, no guidelines for adjuvant
therapy in patients with synchronous cancers have been established yet
and the treatment of respective cancer guides the adjuvant treatment. In
ovarian cancer, all but stage IA/B are to receive chemotherapy and in
endometrial cancer, it is indicated when the risk of distant metastasis
is high.11Considering stage Ia of the ovarian tumor, adjuvant chemotherapy was
not given to our patient.
The prognosis of patients with synchronous endometrial and ovarian
carcinoma is better than the patients with single-organ cancer with
ovarian or endometrial spread with the median 5-year disease-free
survival (DFS) rate reported to be 65% for synchronous endometrial and
ovarian cancer but is less than 50% for stage IIIA endometrial cancer
with ovarian spread.12,13A review of
43 cases of SPEOC showed that nine patients had recurrence (20.93%).
The median time to recurrence was 10 months (range, 5–30). The
five-year survival rate of the patients was
86.05%.8In addition, A study of double cancer in 1500 patients showed that the
prognosis improved with younger age (less than 55 years), earlier stage,
lower stage, the premenopausal state, and lymph node
dissection.13Also, synchronous primary endometrial and ovarian cancer endometroid
types have better overall survival than patients with non-endometrioid
or mixed histologic
types.14Considering all, the prognosis of our patient is good and our patient is
now disease-free at nine months of surgery and is under regular
follow-up.