Case Presentation: A 55-year-old female who is G2P2 with past medical history of diabetes mellitus and who experienced menopause at 50, presented to an outside outpatient care facility with a one-month history of intermittent abdominal pain. The patient was sent home with the assumption that it was a case of left sided diverticulitis and was treated with Augmentin. At this time, a KUB scan was done and demonstrated no significant findings. A few days later, the patient called EMS and was transported to the ED due to extreme abdominal pain, vomiting, and blood on her toilet paper. On admission, a CT abdomen/pelvis found the uterus had heterogenous enhancement and patchy omental fat induration. With these atypical findings, gynecology was consulted, and she was discharged the same day. When visiting her gynecologist, further tests including the CA-125 were completed. Also, a gastroenterologist was consulted to rule out possible gastrointestinal problems and she was told it could be gastroparesis. With a two-month workup, the EGD was conducted for further evaluation of gastroparesis. Upon EGD, the differential was that of H. pylori which was treated with triple therapy. Regardless of the treatment, the abdominal pain continued along with vomiting. Patient drove to urgent care for retesting of H. pylori and there was extensive negative lab workup. One week later, the patient went to the ED again for continuous, severe abdominal pain, and ascites. Upon admission, CT, CA-125, paracentesis, and peritoneal fluid cytology were completed. Positive CT findings and elevated CA-125 levels (149 U/ml) demonstrated concerns for peritoneal carcinomatosis due to an underlying primary malignancy. The patient was discharged three days later and was given a referral to the gynecology/oncology clinic. For gynecology, her past medical history was negative for HPV, abnormal uterine bleeding, and malignancies. However, the patient’s peritoneal fluid was analyzed via cytology and was positive for malignant cells and found to be IVB high grade metastatic serous adenocarcinoma with Mullerian primary. Within a week, the patient started neoadjuvant chemotherapy to mitigate the metastasis. Paracentesis, ultrasounds, and endometrial biopsies were ordered and completed over the next few weeks. The biopsies further confirmed the diagnosis to be a primary endometrial adenocarcinoma. The patient is continuing her treatment for metastatic adenocarcinoma with chemotherapy including paclitaxel and carboplatin.
Discussion: Globally, endometrial adenocarcinoma is the most common gynecologic malignancy diagnosed in developed countries, and the second most common in developing countries, following cervical cancer (1). This case emphasizes the necessity for workup of postmenopausal women with persistent diffuse abdominal pain, including imaging that may diversify a potential differential diagnosis beyond gastrointestinal etiology.
Conclusions: Advanced stage endometrial adenocarcinoma is associated with an extremely poor prognosis, particularly for patients like ours with multiple site metastases (5-year survival rate of 5.7%). Metastatic endometrial malignancy at initial presentation is extremely rare. While multiple treatment options may exist for metastatic endometrial adenocarcinomas, prognosis remains unfavorable, thus early presentations are essential.