An incidental diagnosis of endometrial cancer in a young and underweight female with isolated symptom of amenorrhea

Abstract

Objective: We demonstrate a young woman with the incidental diagnosis of endometrial cancer, although all common risk factors of endometrial cancer were absent and endometrial lining in ultrasound was smooth either.

Case report: A 23-year-old female was referral from local clinic for frequent lower abdominal pain, enlarged right adnexal cystic tumor and suspected adnexal torsion. A special symptom of annual menses (menses around every year) was also complained. The onset of the amenorrhea was 6 years ago just after a laparoscopic salpingostomy for right pyosalpinx. Her body mass index (BMI) was 16.8 kg/m². Laboratory examination documented the level of prolactin, thyroid function, gonadotropins, estradiol and free testosterone were all within normal range. Pelvic ultrasound revealed the smooth endometrial lining with 1.2 cm in thickness. Laparoscopic surgery was arranged for the adnexal torsion. Besides, a diagnostic hysteroscopic was simultaneously planned for a further endometrial survey and endometrial sampling. Apart from a large functional cyst noted in right adnexa, the hysteroscopy disclosed diffuse polypoid endometrial lesions with neovascularity. The pathology showed atypical hyperplasia with focal endometrioid carcinoma. Postoperative magnetic resonance image revealed no residual tumor and FIGO IA status. Fertility preservation treatment with Mirena insertion was performed.

Conclusion: Generally, the clues to detect endometrial neoplasm in a young female include family or genetic predisposition, menstrual patterns of abnormal spotting, obesity, risk of polycystic ovary syndrome and/or bizarre images of endometrial lining. However, the above conditions are all absent in the presenting case except the symptom of amenorrhea, in which the chronic anovulatory status may overstimulate the endometrium from the unopposed estrogen and potentially lead to the malignant transformation. Endometrial tissue assessment would be crucial for any young woman suspected to have prolonged exposure (≥6-12 months) of unopposed estrogenic stimulation. Endometrial tissue sampling in premenopausal group with amenorrhea for more than 6-12 months could not be ignored even for the young patient without common risk factors of endometrial cancer.

Keywords: Amenorrhea; Endometrial cancer; Hysteroscopy.