Polypoid endometriosis mimicking invasive cancer in an obese, postmenopausal tamoxifen user

Abstract

BackgroundTamoxifen is a medication often used for the treatment and prevention of breast cancer. It is classically associated with several gynecological side effects to include a thickened endometrial stripe, increased uterine polyp formation, and an increased risk of uterine cancer. Rarely tamoxifen use has been associated with proliferation of endometriosis often severe enough to mimic a late-stage gynecologic malignancy.CaseA 62-year-old Gravida 0 postmenopausal female with a medical history of severe obesity, infertility, and preventative tamoxifen use presented for evaluation of gross hematuria. A CT urogram was performed and demonstrated findings concerning for carcinomatosis, likely gynecologic in origin. Cervical cancer screening was up-to-date and she had a negative colonoscopy within the prior 2 years. Serum tumor markers were remarkable only for a mildly elevated CA125 of 37.6. Diagnostic laparoscopy demonstrated apparent operable carcinomatosis limited to the pelvis. The procedure was converted to an exploratory laparotomy, where radical tumor cytoreduction was performed to no gross residual disease. Frozen sections performed intraoperatively were unclear of origin but suggestive of low malignant potential. Final pathology resulted for endometriosis.ConclusionThis case illustrates a presentation of endometriosis in a postmenopausal woman mimicking advanced mullerian malignancy. The patient's estrogenic state from obesity in combination with the agonist action of the tamoxifen likely contributed to her rare presentation. While findings such as a thickened endometrial stripe are typical of tamoxifen use, such widespread proliferation of endometriosis resulting in a pelvic mass, genito-urinary obstruction, and plaque-like pelvic spread are not.PrécisEndometriosis is a benign estrogen dependent condition rarely problematic in a postmenopausal patient. Tamoxifen use in the setting of an obese patient may contribute to a proliferation of pre-existing endometriosis which resembles an aggressive late-stage gynecological malignancy.

Polypoid Endometriosis of the Rectum and Vagina in an Adolescent

“…The reports about tamoxifen causing the proliferation of existing EMs are rare and most of the patients are menopausal and older than 50 years old. 5 The rebound of GnRH agonist withdrawal more likely occurred in young women, 2 but few were reported without exposure to any of these drugs.…”

Symptomatic endometriosis developing several years after menopause in the absence of increased circulating estrogen concentrations: a systematic review and seven case reports

“…Plasma concentrations of 17b-estradiol were low (20-40 pg/ml); cyst fluid concentrations were 80 pg/ml returning to normal after GnRha treatment [50]. A series of reports describe progressive endometriosis in women taking tamoxifen [51][52][53][54].…”

Clinical study on 7 cases of polypoid endometriosis. PEM: a mimic of malignancy, the symptoms of adenomyosis, endometrial polyps and infertility can assist in diagnosis

“…(Table 4). [11] 43 post vaginal fornix / prolonged menstruation 3 MRI CEA 2017 Zhuang, L [12] 62 ureteric tamoxifen gross hematuria 1.5⋅1.0 CA 125 37.6 2017 Han, K [13] 58 Colonic / uterine bleeding 13x7x4 / 2017 Iida, Y [14] 44 ovary / müllerianosis of the pelvic lymph node 3.0 MRI 2017 Jaegle, WT [15] 62 endocervical, uterine serosal surface tamoxifen pelvic mass 1. individual in ureter, fallopian tubes, greater omentum and retroperitoneal region [3][4][5][6]7,9] . As shown in Table 1, ovarian PEM accounted for 4 of the 7 cases in this group, followed by uterine serosal and cervical PEM.…”

“…Parker [2] believed that PEM was common in elderly women, and 60% of the 24 PEM patients they observed were older than 50 years old (23-78 years old), with multifocal lesions, and most of the cases had a history of EMs. In addition, 13 international cases reported in the past 5 years, aged 20-62 (51.14±3.78) years old (as Table 4) [10][11][12][13][14][15][16][17][18][19][20][21] , were summarized. Gunawardane DN reported a 50-year-old female had a hysterectomy and bilateral salpingo-oophorectomy for adenomyosis, uterine leiomyomas, ovarian and cervical endometriosis.…”