A 64-Year-Old Woman With Advanced Endometrial Carcinoma - Episode 1

Case Overview: 64-Year-Old Woman With Advanced Endometrial Carcinoma

Dr Robert L. Coleman, US Oncology Research, reacts to how the case of a woman with advanced endometrial cancer was managed from diagnosis through treatment.

Robert L. Coleman, MD, FACOG, FACS: This is a 64-year-old postmenopausal woman who presented with abnormal uterine bleeding for about 2 months. She has 2 grown children, underwent menopause at age 57, and has no known family history of cancer. Her past medical history is significant for a body mass index [BMI] of 32. She has hypertension that’s well controlled with medication. Her physical examination is mostly notable for a large uterus, and she has some right lower quadrant abdominal tenderness on palpation.

The patient underwent a clinical work-up that consisted of an endometrial biopsy that showed endometrioid adenocarcinoma, FIGO [International Federation of Gynecology and Obstetrics] grade 1. She underwent an interventional or surgical procedure, which included an exploratory laparotomy, a total abdominal hysterectomy, and bilateral salpingo-oophorectomy with bilateral pelvic lymph node dissection. The final pathology report showed a grade 2 endometrioid adenocarcinoma. She had 18 positive pelvic nodes. The tumor was invasive at 2.1 out of 2.3 cm of the myometruim. Molecular testing showed that she had a microsatellite stable tumor, which was identified by the presence of protein and dMMR [deficient mismatch repair] testing. She was also found to be HER2 negative.

Her initial treatment consisted of postoperative radiotherapy in the form of vaginal brachytherapy that was given at a dose of 21 Gy over 3 fractions. Fourteen months after completing radiotherapy, she presented with a new right lower extremity edema and right hydroureter. She was then treated with paclitaxel and carboplatin chemotherapy, which was well tolerated. Nine months after the completion of this treatment, she was found to have a relapse with metastasis to the paraaortic nodes and her lungs. She was then treated with lenvatinib and pembrolizumab.

This case represents a pretty typical presentation of endometrial cancer. There are a number of notables in her history that I want to briefly point out. One is that she’s 64 years of age, which is very typical for endometrial cancer in the United States. She presented with the most common symptom: abnormal uterine bleeding. Most women identify this particular symptom as an abnormality because in this patient, she had been menopausal for 7 years, so the appearance of that sign is quite indicative of something going wrong. She had a number of evaluations that aren’t completely listed here, but one of which—endometrial aspiration—was critical and can be done in the office quickly. That demonstrated a grade 1 tumor.

She also has a history of hypertension, which isn’t uncommon in a 64-year-old woman. She would be considered slightly obese with a BMI of 32, which is also very commonly associated with endometrial cancer. The presence of a uterine mass would go along with an enlarged uterus, but it’s not necessary to be seen in patients with endometrial cancer, because the tumor is on the inside lining of the uterus. But all of these would be a typical presentation. As I mentioned, her work-up was done in a way that we’d expect. There’s a lot of discussion about whether extensive imaging should be done in a patient with a grade 1 tumor. I personally don’t do extensive work-up unless I’m suspicious of metastatic or extrauterine disease, because most patients—approximately two-thirds to 70% of patients—will present with uterine-confined disease. That would represent an extensive amount of evaluation.

Transcript edited for clarity.

Initial Presentation

  • A 64-year-old postmenopausal woman presented with abnormal uterine bleeding for about 2 months. She has two grown children, underwent menopause at 57 years of age, has no known family history of cancer.
  • PMH: BMI is 32, and she has hypertension that is controlled with medication
  • PE: Notable for large uterus and right lower quadrant abdominal tenderness on palpation

Clinical work-up

  • Endometrial biopsy: endometrioid adenocarcinoma, FIGO grade 1
  • Surgery: ELAP TAH BSO with bilateral pelvic node dissection
  • Pathology: grade 2 endometrioid adenocarcinoma, 18 negative pelvic nodes, invasive 2.1 cm of 2.3 cm myometrium
  • Molecular testing shows MSS, MMR proficient, and HER2-

Treatment

  • Postoperative radiotherapy: vaginal cuff brachytherapy to a dose of 21 Gy in 3 fractions
  • 14 months after completing radiotherapy, she presented with new RLE edema and right hydroureter
  • She then was treated with carboplatin/paclitaxel chemotherapy which was well tolerated
  • Nine months later the patient has disease relapse with metastases to the paraaortic lymph nodes and lung
  • She is now treated with lenvatinib/pembrolizumab