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CASE REPORT
Year : 2022 | Volume
: 13
| Issue : 3 | Page : 244-246
Synchronous primary endometrial and fallopian tube carcinoma with metchronous renal pelvis carcinoma in one patient: “Triple cancer- A rare occurrence”
Anchana Gulati, Reetika Sharma, Sudershan K Sharma
Department of Pathology, IGMC, Shimla, Himachal Pradesh, India
Correspondence Address:
Reetika Sharma
Department of Pathology, IGMC, Shimla - 177 001, Himachal Pradesh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jmh.jmh_148_22
Abstract
Triple primary cancers in one patient are a very rare finding and occur in only 0.5% of patients with cancers. Here, we report the case of triple malignancy in a 62-year-old woman who developed synchronous primary endometrial endometroid type and serous type of fallopian tube carcinoma, which is again a rare finding after 4 years of diagnosis of transitional cell carcinoma of the right renal pelvis.
Keywords: Fallopian tube cancer, synchronous endometrial cancer, triple cancer
Introduction 
Multiple malignancies are rare and most often involve two sites. The occurrence of the third malignancy is exceptional and occurs in only 0.5% of malignant tumors.[1] Primary synchronous cancers of the female genital tract are a relatively uncommon, comprising 1%6% of all genital neoplasms and have prognostic as well as therapeutic significance. Among these, simultaneously detected endometrial and ovarian malignancies constitute the most common occurrence.[2] The occurrence of synchronous primary endometrial and fallopian tube (FT) cancers is very rare, and only a very few cases have been reported in the literature.[3] Here we present the case of synchronous carcinoma of endometrium and FT who was operated for transitional cell carcinoma of the right renal pelvis 4 years back.
Case Report A 62-year-old female who is known to have diabetes mellitus and hypertension presented with complaints of polymenorrhea, lower abdomen pain, and vaginal discharge. In 2018, she underwent surgery for the right kidney tumor. The histopathological examination showed nests and sheets of tumor cells showing moderate nuclear pleomorphism, prominent nucleoli and moderate cytoplasm and diagnosis was given as transitional cell carcinoma of the renal pelvis. Ultrasound findings revealed a markedly endometrium with a right adnexal mass. Her serum CA-125 was 7.8 U/ml. We received a specimen of the uterus with a cervix with bilateral FT and ovaries with pelvic lymph nodes and omentum. Uterus with cervix measured 5 cm × 7 cm × 1.5 cm. In the cut section, there was endometrial growth involving the lower uterine segment. The tumor was involving more than half of the myometrium. The ovaries and FTs on both sides were normal. Left side FT was dilated and showed papillary excrescences [Figure 1]a. The dilated right FT showed serous carcinoma [Figure 1]b. Microscopic examination of the endometrium showed well-differentiated endometroid adenocarcinoma with invasion into the outer half of the myometrium, sparing the serosa [Figure 1]c. The patient underwent postoperative chemotherapy.
Figure 1: (a) Shows proliferative growth endometrium and right side fallopian tube dilation with papillary excrescences into the lumen. (b) Shows serous carcinoma of fallopian tube (H and E, ×40) (c) Shows endometrioid carcinoma of the endometrium (H and E, ×10) Discussion Synchronous primary neoplasms are defined when two or more neoplasms take place concurrently in the same patient and should be histologically discrete and separated from each other by means of healthy tissues, such as basal lamina or stroma.[4] It has been postulated that embryo logically similar tissues, when simultaneously exposed to hormonal influences or to carcinogens, may develop synchronous cancers.[3]
Patients with cancer of the endometrium and FT are usually postmenopausal, obese, and nulliparous and present with abdominal pain, vaginal bleeding, and a palpable pelvic mass.[3] In our case, the patient was also postmenopausal, obese, and had abdominal pain and vaginal bleeding.
According to the “theory of secondary Mullerian system,” the epithelial of the cervix, uterus, FTs, ovaries, and peritoneal surfaces simultaneously respond to a carcinogenic stimulus.[5] Embryologic, hormonal, or common etiologies such as nulliparity may be associated with the development of malignancies arising simultaneously in genital tissues.[5],[6],[7]
Primary FT carcinoma is a very rare gynecologic malignant tumor and accounts for approximately 0.14%1.8% of female genital malignancies.[8] The etiology is explained on the basis that it may be associated with chronic tubal inflammation, infertility, tuberculous salpingitis, and tubal endometriosis.[9] Like the ovarian carcinomas, the FT carcinomas are also associated with BRCA germline mutation and TP53 mutation.[10],[11] Endometrioid carcinoma and endometrial hyperplasia are associated with microsatellite instability and RAS and PTEN mutations.[12] Although we could not do any of the genetic mutations in this case, we could trace out a few risk factors such as obesity, diabetes, and hypertension for the occurrence of the disease.
In synchronous malignancies, it is quite challenging whether it is primary or metastatic and further it becomes very difficult if they are of same histological type like endometroid carcinoma of the endometrium and ovary. This difficulty is not encountered if the two malignancies are of different histological types, like in our case, in which the endometrium had an endometroid type and in the tube it was of the serous type of carcinoma. The presence of precancerous histological features generates strong evidence of in situ genesis rather than metastasis. For example, the endometriosis in the ovary and atypical hyperplasia in endometrium, in case of synchronous endometroid carcinoma of the ovary and endometrium strongly favors primary than metastatic.[13]
The optimal therapeutic strategy for synchronous primary endometrial and FT cancers has not been well-defined because of its rarity. Early stage synchronous primary cancers are managed by total abdominal hysterectomy with bilateral salpingo-oophorectomy and total omentectomy.[14]
There are few case reports and case series published on synchronous malignancies of endometrium and ovary, FT and ovary but hardly any literature is available on synchronous malignancies of endometrium and FT and on triple malignancies. Our case report describes triple malignancy in one patient with synchronous cancer of the FT and ovary. Hence, it becomes prudent to add this case report to the literature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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