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Case Report
Isolated Abdominal Wall Metastasis of Endometrial Carcinoma
Rita Luz, Rui Leal, Jorge Simões, Matilde Gonçalves, and Isabel Matos
Centro Hospitalar de Set´
ubal, Rua Camilo Castelo Branco, 2910-446 Set´
ubal, Portugal
Correspondence should be addressed to Rita Luz; rita.luz@gmail.com
Received August ; Revised September ; Accepted September ; Published September
Academic Editor: Maria Grazia Porpora
Copyright © Rita Luz et al. is is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
A woman in her mid-s presented with a bulky mass on the anterior abdominal wall. She had a previous incidental diagnosis
of endometrial adenocarcinoma FIGO stage IB following a vaginal hysterectomy. Physical exam and imaging revealed a well
circumscribed bulging tumour at the umbilical region, measuring ×× cm, with overlying intact skin and subcutaneous
tissue. Surgical resection was undertaken, and histological examination showed features of endometrial carcinoma. She began
chemotherapy and is alive with no signs of recurrent disease one year aer surgery. is case brings up to light an atypical location
of a solitary metastasis of endometrial carcinoma.
1. Introduction
Uterine cancer is the most frequently diagnosed gynaeco-
logical malignancy in developed countries. In , more
than , new cases were registered in the world, with a
mortality rate of . per , women [].
e majority of women with endometrial carcinoma
are diagnosed with localized early stage disease, yielding a
high survival rate. e rst step of treatment is complete
surgical staging that can be followed by adjuvant radiotherapy
and chemotherapy or both. In early stage disease, adjuvant
radiotherapy has shown to signicantly reduce locoregional
recurrence, although it does not appear to increase overall
survival or distant recurrence rates. Adjuvant chemotherapy
can be considered in high-risk patients, but compared to
radiotherapy alone, no dierences were found in overall
survival and progression-free survival, although further stud-
ies are needed. Combined modality treatment in high-risk
patients was associated with a reduction in risk of recurrence
or death in two randomized clinical trials and is the subject of
the ongoing PORTEC study []. For medically inoperable
patients, radiation therapy is useful and can provide some
measure of pelvic control and long-term progression-free
survival [].
Following primary treatment, the overall recurrence risk
ranges from to % []. Treatment should be individualized
depending on location and performance status. Surgical
resection of isolated metastasis might be considered, but
chemotherapy is usually the mainstay of treatment. e diag-
nosis of distant metastases carries an overall poor prognosis,
and median survival is reduced to only about one year [,].
e authors describe a case of an atypical location of
endometrial carcinoma metastasis on the anterior abdominal
wall without other signs of advanced disease.
2. Case Presentation
A Caucasian woman in her mid-s, gravida para , with
toxic multinodular goiter with an intrathoracic extension,
hypertension, chronic anaemia, and obesity (BMI Kg/m2)
presented years before with stage IV uterine prolapse
and occasional vaginal spotting related to ulceration of the
protruding cervix. Preoperative evaluation included a pelvic
ultrasound that showed an enlarged uterus (L ×AP ×
W mm) with various small broids (around mm) that
distorted endometrial cavity hindering an accurate measure-
ment of endometrial thickness. Both ovaries were normal
in shape and size, and no malignancy was suspected. e
optimization of the underlying diseases delayed surgery for
several months. In July , a vaginal hysterectomy was
performed. Intraoperatively, inspection of both ovaries was
unsuspicious. e histopathology examination revealed an
enlarged uterus distorted by the presence of multiple broids
andanintracavitarytumourinvadingmorethanhalfof
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Case Reports in Obstetrics and Gynecology
Volume 2014, Article ID 505403, 4 pages
http://dx.doi.org/10.1155/2014/505403
CaseReportsinObstetricsandGynecology
(a) (b)
F : MRI demonstrates the tumour on the le side of the anterior abdominal wall protruding into the abdominal cavity. (a) Axial
T-weighted image and (b) sagittal T-weighted image.
the myometrium. e tumour was grade , poorly dieren-
tiated endometrial adenocarcinoma, without vascular space
invasion, FIGO stage IB. Given her general condition and
absence of signs or symptoms of the disease, despite incom-
plete surgical staging and high intermediate-risk disease,
it was decided by a multidisciplinary team of gynecologic
surgeons, pathologists, medical, and radiation oncologists to
proceed with adjuvant radiotherapy. Chemotherapy was not
considered due to her medical and social background. e
patient received Gy ( fractions of Gy) of external pelvic
irradiation and Gy ( fractions of Gy) of brachytherapy
to the vaginal cu.
Around six months aer surgery, she noted a painless
nodule on the anterior abdominal wall. On physical exami-
nation,therewasalargemassonthelesideoftheumbilical
region, measuring ×cm.emasswashardonpalpation,
with irregular edges and surface, and was well circumscribed
butxedtosurroundingsotissue.Overlyingskinand
umbilicus had a typical appearance. General examination
including the pelvic exam was otherwise unremarkable.
Laboratory investigations were normal except for
hypochromic microcytic anaemia (Hb . g/dL), lactate
dehydrogenase mildly raised (UI/L), and elevated CA
( UI/mL). Magnetic resonance imaging (MRI)
(Figures (a) and (b))revealedatumourontheumbilical
region, slightly shied to the le side, protruding into the
abdominalcavity,measuring×× cm. e tumour
was well demarcated from the surrounding fat tissue and
muscular layer with an anterior relationship with the
umbilicus. It was highly heterogeneous with central areas
of necrosis. ere was no local or regional recurrence,
pelvic lymph node involvement, or hepatic metastases.
oracic computed tomography (CT) showed no pulmonary
metastases.
Surgical resection of the tumour was performed followed
by peritoneal washing and bilateral salpingo-oophorectomy.
Reconstruction of the abdominal wall was accomplished with
theuseofasyntheticmesh.ecrosssectionofthetumour
is shown in Figure . Histological examination revealed a
solidtumourlinedbyadiposetissueandperitoneumwith
the same histology as the primary endometrial carcinoma.
Immunohistochemistry showed positivity for cytokeratin
F : Cross section of the solid tumour with central necrosis
and intact umbilicus.
(CK) and oestrogen receptor and was negative for CK
(Figures (a) and (b)). e peritoneal washing was positive
forneoplasticcells,andbothfallopiantubesandovarieswere
not invaded.
She began chemotherapy one month aer surgery with
paclitaxel ( mg/m2) and carboplatin ( mg/m2)and
completed six cycles. At the end of treatment, radiologic
imaging with thoracic and abdominal CT and pelvic MRI did
not show any signs of recurrence. More than one year aer
surgery,thepatientisaliveandasymptomatic.
3. Discussion
Endometrial carcinoma can spread through several routes,
depending on the histological type and local invasion. e
patterns of spread include direct extension, lymphatic and
haematogenous dissemination, and retrograde passage of
neoplastic cells through the fallopian tubes []. e ante-
rior abdominal wall, especially the umbilical region, has a
rich arterial supply, an anastomotic venous network, and
a lymphatic system that drains cranially and caudally to
several lymphatic chains including pelvic and para-aortic
lymph nodes. All these systems could be involved in the
dissemination of neoplastic cells to the so tissue of the
abdominal wall. Another explanation may be related to
Case Reports in Obstetrics and Gynecology
(a) (b)
F : Microphotograph showing a section of the abdominal wall mass with cytokeratin (a) and oestrogen receptor (b) positive
immunohistochemistry.
peritoneal direct extension and spread through embryonic
remnants [,].
Endometrial cancer relapses are most frequently localized
in the vaginal cu, pelvic and para-aortic lymph nodes, peri-
toneum, lungs, and liver. Unusual sites include abdominal
wall and muscle (–%), spleen (%), central nervous system
(<%), extra-abdominal lymph nodes (,–%), and, more
rarely, adrenals, pancreas, and appendix [–].
In this case and taking into account its location near
the umbilicus, the hypothesis of an umbilical metastasis,
also termed Sister Mary Joseph’s nodule, was raised. Sister
Mary Joseph’s nodule most typically presents as an irregular
lump on the umbilicus, ranging in size from . to cm,
although there are reports with nodules reaching up to
cm. It may be ulcerated and necrotic and have a bloody,
mucinous, serous, or purulent discharge. It can be detected
beforeorduringdiagnosisoftheprimarytumouroraer
treatment. is umbilical metastasis is found in –% of
patients with gastrointestinal or genitourinary malignancy,
including endometrial cancer [,].erearelittlemore
than cases reported in the literature originating from
endometrial cancer. e presence of this nodule generally
indicates advanced cancer with widespread metastases and,
therefore, poor prognosis [–]. In patients with good
clinical state, a combination of surgery and adjuvant therapy
can improve survival, but in some cases only palliative
care is feasible []. In this case, although anatomically
close, the abdominal wall mass seems separated from the
umbilicus, does not display the typical signs of Sister Mary
Joseph’s nodule, and was not associated with widespread
disease.
Abdominal wall metastases have also been linked to sur-
gical incision, regardless of the surgical approach (laparotomy
or laparoscopy). Although rare, it has been described in cases
of endometrial carcinoma [–]. e exact mechanism of
this event is usually explained by haematogenous dissem-
ination to the site of recent trauma, seeding of neoplastic
cells aer direct contact between the tumour and the wound,
eects of pneumoperitoneum, surgical technique, and local
immune response. Management of port-site metastases and
laparotomy wound recurrences includes an extensive workup
to rule out other metastases. In the absence of distant disease,
enlarged excision and exploratory laparotomy or laparoscopy
should be attained []. In this case, the rst surgery was
vaginal, and the patient had no history of abdominal surgery,
which discards this hypothesis.
Park and Hwang reported a case of a postmenopausal
woman with an abdominal wall metastasis in stage IA
serous endometrial adenocarcinoma, eight months aer sur-
gical staging. Treatment consisted of surgical excision and
chemotherapy, and three years aer surgery she is alive with
no signs of disease []. Comparing to the current case site
andtimetorecurrenceweresimilaraswellasthetreatment
chosen. Most guidelines only support surgical resection
in selected patients with good performance status. Pelvic
exenteration or even partial vaginectomy may be considered
in pelvic central recurrences, especially aer radiotherapy
failure. Other pelvic, abdominal, retroperitoneal, and extra-
abdominalrecurrencescanbeamenabletosalvagecytore-
ductive surgery [,]. In small retrospective studies, optimal
debulking signicantly improved survival and patients who
had solitary metastasis were more likely to achieve complete
cytoreduction [–]. Campagnutta et al. reported a %
rate of major surgical complications, which supports the
importance of proper selection criteria []. Resection of
abdominal wall tumours with negative margins is feasible
but oen requires reconstruction of the abdominal wall
defect with prosthetic mesh []. Chemotherapy can also be
considered, especially in unresectable or disseminated metas-
tases. Combination regimens with paclitaxel and carboplatin
or cisplatin are frequently used for recurrent endometrial
cancer, based on a good response rate on ovarian cancer
studies [].
is case highlights an unusual location of a solitary
metastasis of endometrial cancer on the so tissue of the
abdominal wall. Almost all cases reported in the literature
are diagnosed aer primary treatment and are related to
the surgical incision. In this case, it is dicult to know
exactly how neoplastic cells implanted in the so tissue and
developed into a mass. Surgical resection was feasible and the
patient completed chemotherapy with no signs of recurrence
aer one year.
CaseReportsinObstetricsandGynecology
Consent
Written informed consent was obtained from the patient for
publication of this case report and accompanying images.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
References
[] J. Ferlay, H. Shin, and F. Bray, GLOBOCAN 2008 v2.0: Cancer
Incidence and Mortality Worldwide: IARC CancerBase no. 10,
International Agency for Research on Cancer, Lyon, France,
, http://globocan.iarc.fr.
[]N.Colombo,E.Preti,F.Landonietal.,“Endometrialcancer:
ESMO clinical practice guidelines for diagnosis, treatment and
follow-up,” Annals of Oncology, vol. , supplement , pp. vi–
vi, .
[] B.E.Greer,W.-J.Koh,N.Abu-Rustumetal.,“Uterineneo-
plasms,” Journal of the National Comprehensive Cancer Network,
vol. , no. , pp. –, .
[] M. Fung-Kee-Fung, J. Dodge, L. Elit, H. Lukka, A. Chambers,
and T. Oliver, “Follow-up aer primary therapy for endometrial
cancer: a systematic review,” Gynecologic Oncology,vol.,no.
, pp. –, .
[] M. Ray and G. Fleming, “Management of advanced-stage and
recurrent endometrial cancer,” Seminars in Oncology,vol.,
no. , pp. –, .
[] N. Hacker and M. Friedlander, “Uterine cancer,” in Berek
and Hacker’s Gynecology Oncology,pp.–,Lippincott
Williams & Wilkins, Philadelphia, Pa, USA, .
[] R. Gabriele, M. Conte, F. Egidi, and M. Borghese, “Umbilical
metastases: current viewpoint,” World Journal of Surgical Oncol-
ogy,vol.,article,.
[] D.M.Coll,J.M.Meyer,M.Mader,andR.C.Smith,“Imaging
appearances of Sister Mary Joseph nodule,” e British Journal
of Radiology,vol.,no.,pp.–,.
[]V.Kurra,K.M.Krajewski,J.Jagannathan,A.Giardino,S.
Berlin, and N. Ramaiya, “Typical and atypical metastatic sites
of recurrent endometrial carcinoma,” Cancer Imaging,vol.,
no.,pp.–,.
[] S.S.Zaidi,V.T.Lakhani,O.Fadare,andD.Khabele,“Adrenal
gland metastasis is an unusual manifestation of endometrial
cancer,” Case Reports in Surgery,vol.,ArticleID,
pages,.
[] D. G. Blazer III, P. T. Ramirez, H. Wang, and J. B. Fleming,
“Distal pancreatectomy for isolated metastasis of endometrial
carcinoma to the pancreas,” Journal of the Pancreas,vol.,no.,
pp.–,.
[] A. B. Addison, K. Miller, D. Hammouch et al., “Appendiceal
metastasis years following “curative” resection for low-grade
primary endometrial carcinoma,” BMJ Case Reports,vol.,
.
[] A.Arif,Z.U.Abideen,N.Zia,M.A.Khan,T.Nawaz,andA.
Z. Malik, “Metastatic involvement of the spleen by endometrial
adenocarcioma; a rare asylum for a common malignancy: a case
report,” BMC Research Notes,vol.,no.,article,.
[] F. L. Urbano, “Sister Joseph’s nodule,” Hospital Physician,vol.,
no. , pp. –, .
[] B.Piura,M.Meirovitz,M.Bayme,andR.Shaco-Levy,“Sister
Mary Joseph's nodule originating from endometrial carcinoma
incidentally detected during surgery for an umbilical hernia: a
case report,” Archives of Gynecolog y and Obstetrics,vol.,no.
, pp. –, .
[] C. Nolan and D. Semer, “Endometrial cancer diagnosed by
Sister Mary Joseph nodule biopsy: case report,” Gynecologic
Oncology Case Reports, vol. , no. , pp. –, .
[] U. Pua and L. Quek, “Endometrial cancer presenting as a
paraumbilical hernia containing a Sister Mary Joseph nodule,”
International Journal of Gynecology and Obstetrics,vol.,no.
, p. , .
[] A. Daniilidis, A. Pantelis, K. Lathouras, O. Papathanasiou, A.
Loufopoulos, and N. Vrachnis, “A rare case of umbilical and
vaginal metastasis from endometrial cancer—review of the
literature,” EuropeanJournalofGynaecologicalOncology,vol.,
no. , pp. –, .
[] F. G¨
ucer, F. Oz-Puyan, ¨
O. Yilmaz, N. M¨
ulayim, P. Balkanli-
Kaplan, and M. A. Y ¨
uce, “Endometrial carcinoma with laparo-
tomy wound recurrence: complete remission following surgery
and chemotherapy consisting of paclitaxel and carboplatin,”
International Journal of Gynecological Cancer,vol.,no.,pp.
–, .
[]V.Macias,B.Baiotto,J.Pardo,F.Mu
˜
noz, and P. Gabriele,
“Laparotomy wound recurrence of endometrial carcinoma,”
Gynecologic Oncology,vol.,no.,pp.–,.
[] M.-L.T.Nguyen,J.Friedman,T.S.Pradhan,T.L.Pua,andS.S.
Tedjarati, “Abdominal wall port site metastasis aer robotically
staged endometrial carcinoma: a case report,” International
Journal of Surgery Case Reports,vol.,no.,pp.–,.
[] S. Rau and J. S. Ng, “Port-site recurrence in a patient undergo-
ing robot-assisted gynecologic cancer surgery for endometrial
cancer: a case report,” Gynecologic Oncology Case Reports,vol.
, no. , pp. –, .
[] S. Palomba, A. Falbo, R. Oppedisano, T. Russo, and F. Zullo,
“Isolated port-site metastasis aer laparoscopic surgery for
endometrial cancer: a case report,” Gynecologic Oncology Case
Reports,vol.,no.,pp.–,.
[] T.C.Chua,T.D.Yan,D.L.Morris,andP.H.Sugarbaker,“Port-
site metastasis following laparoscopic surgery,” in Advanced
Laparoscopy,A.Shamsa,Ed.,pp.–,InTech,.
[] J.-W. Park and S.-O. Hwang, “Abd ominal wall metastas is of uter-
ine papillary serous carcinoma in a post-menopausal woman: a
case report,” JournalofMenopausalMedicine,vol.,no.,p.
, .
[] E. Campagnutta, G. Giorda, G. de Piero et al., “Surgical treat-
ment of recurrent endometrial carcinoma,” Cancer,vol.,no.
,pp.–,.
[] Y. Ren, B. Shan, D. Shi, and H. Wang, “Salvage cytoreductive
surgery for patients with recurrent endometrial cancer: a
retrospective study,” BMC Cancer,vol.,no.,article,.
[] R.E.Bristow,A.Santillan,M.L.Zahurak,G.J.Gardner,R.
L. Giuntoli II, and D. K. Armstrong, “Salvage cytoreductive
surgery for recurrent endometrial cancer,” Gynecologic Oncol-
ogy,vol.,no.,pp.–,.
[]T.Pencavel,D.C.Strauss,J.M.omas,andA.J.Hayes,
“e surgical management of so tissue tumours arising in the
abdominal wall,” EuropeanJournalofSurgicalOncology,vol.,
no.,pp.–,.
