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INTERESTING IMAGE
Year : 2019  |  Volume : 34  |  Issue : 2  |  Page : 169-170  

Rare presentation of metastatic endometrioid adenocarcinoma of uterus mimicking as second primary in urinary bladder on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography


1 Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication8-Apr-2019

Correspondence Address:
Dr. Ashwani Sood
Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_16_19

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   Abstract 


We present a case of endometrioid carcinoma metastasis in the bladder mimicking as the second primary of urinary bladder on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT). The presentations of bladder lesions on 18F-FDG PET/CT are varied, and rare presentations of common malignancies can pose a significant diagnostic challenge as in the index case and highlight the importance of histopathological examination to confirm any unusual FDG uptake confounding the diagnosis.

Keywords: 18F-fluorodeoxyglucose positron-emission tomography/computed tomography, endometrioid carcinoma, second primary, urinary bladder


How to cite this article:
Sharma A, Vadi SK, Sood A, Mete UK, Kakkar N, Vashishta RK, Mittal BR. Rare presentation of metastatic endometrioid adenocarcinoma of uterus mimicking as second primary in urinary bladder on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography. Indian J Nucl Med 2019;34:169-70

How to cite this URL:
Sharma A, Vadi SK, Sood A, Mete UK, Kakkar N, Vashishta RK, Mittal BR. Rare presentation of metastatic endometrioid adenocarcinoma of uterus mimicking as second primary in urinary bladder on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography. Indian J Nucl Med [serial online] 2019 [cited 2019 Apr 20];34:169-70. Available from: http://www.ijnm.in/text.asp?2019/34/2/169/255606




   Case Report Top


A 69-year-old female presented with a 3-month history of painless vaginal bleeding. Initial pelvic ultrasonography revealed hypoechoic lesions (likely fibroids) in the anterior and posterior walls of the body of the uterus and additional lobulated hypoechoic lesions in the left lateral wall of the urinary bladder. A whole-body 18 F-fluorodeoxyglucose positron-emission tomography/computed tomography (18 F-FDG PET/CT) done for characterization and staging revealed intense tracer uptake in the heterogeneously enhancing soft-tissue lesion in the body and fundus of the uterus [Figure 1]a, [Figure 1]b, [Figure 1]c. In addition, there were intensely FDG-avid heterogeneously enhancing soft-tissue lesions in the left posterolateral and posterior wall of the urinary bladder with one of them showing loss of fat planes with the uterine cervix giving the impression of second primary malignancy of urinary bladder with cervical infiltration [Figure 1]d and [Figure 1]e. Intense tracer uptake was also noted in few enlarged peripancreatic, mesenteric, precaval, aortocaval, retrocaval, and bilateral external iliac lymph nodes. With a provisional diagnosis of second malignancy in the urinary bladder, the patient underwent transurethral resection of bladder tumor (TURBT). However, histopathology revealed the presence of metastatic endometrioid adenocarcinoma [Figure 2]a and [Figure 2]b.
Figure 1: 18F-fluorodeoxyglucose positron-emission tomography/computed tomography showing intense fluorodeoxyglucose uptake in the heterogeneously enhancing soft-tissue lesion in the body and fundus of the uterus highlighted with arrow (Maximum intensity projection (MIP); a, axial fused positron-emission tomography computed tomography; b and axial computed tomography; c). fluorodeoxyglucose avid wall thickening in the left posterolateral wall of the urinary bladder (broken arrow in axial fused positron-emission tomography computed tomography; d and axial contrast-enhanced computed tomography; e)

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Figure 2: Low- (a) and high-power (b) photomicrographs from the transurethral resection of bladder tumor chips shows a complex glandular pattern lined by columnar cells with elongated vesicular nuclei with prominent nucleoli, consistent with a diagnosis of metastatic endometrioid carcinoma

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   Discussion Top


Endometrial carcinoma is a common malignancy of female genital tract with an increasing incidence in the postmenopausal women.[1],[2] Local recurrence and distant metastases from advanced endometrial carcinoma, even after surgical resection, are known to occur in the pelvis, pelvic and paraaortic lymph nodes, peritoneum, and lungs. Supradiaphragmatic lymph nodes, liver, adrenals, brain, and soft tissues are the uncommon sites for metastases.[3] In advanced cases, it may rarely involve the bladder and bowel mucosa also.[4] Urinary bladder involvement in endometroid carcinoma is a rare entity resulting from direct extension, metastasis, or malignant transformation of endometriosis.[3],[4] This case showcased a diagnostic conundrum of an endometrial neoplasm metastatic to the bladder giving an initial impression of a second primary urothelial malignancy on imaging.18 F-FDG PET/CT is a very sensitive oncological imaging modality with ever-increasing role in genitourinary malignancies. The unusual presentations have been recognized with improved imaging. Few of imaging limitations and pitfalls are encountered, and some of them had been addressed.[5],[6],[7] However, in the index case, subsequent TURBT and histopathological examination revealed the features of nonurological endometroid adenocarcinoma. Thus, this case emphasizes the diagnostic challenges posed by rare presentations of certain malignancies on 18 F-FDG PET/CT and the importance of histopathological examination to ascertain the accurate diagnosis and management in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Morice P, Leary A, Creutzberg C, Abu-Rustum N, Darai E. Endometrial cancer. Lancet 2016;387:1094-108.  Back to cited text no. 1
    
2.
Saso S, Chatterjee J, Georgiou E, Ditri AM, Smith JR, Ghaem-Maghami S, et al. Endometrial cancer. BMJ 2011;343:d3954.  Back to cited text no. 2
    
3.
Kurra V, Krajewski KM, Jagannathan J, Giardino A, Berlin S, Ramaiya N, et al. Typical and atypical metastatic sites of recurrent endometrial carcinoma. Cancer Imaging 2013;13:113-22.  Back to cited text no. 3
    
4.
Tarumi Y, Mori T, Kusuki I, Ito F, Kitawaki J. Endometrioid adenocarcinoma arising from deep infiltrating endometriosis involving the bladder: A case report and review of the literature. Gynecol Oncol Rep 2015;13:68-70.  Back to cited text no. 4
    
5.
Sharma A, Mete UK, Sood A, Kakkar N, Gorla AK, Mittal BR, et al. Utility of early dynamic and delayed post-diuretic 18F-FDG PET/CT SUVmax in predicting tumour grade and T-stage of urinary bladder carcinoma: Results from a prospective single centre study. Br J Radiol 2017;90:20160787.  Back to cited text no. 5
    
6.
Beyer T, Townsend DW, Blodgett TM. Dual-modality PET/CT tomography for clinical oncology. Q J Nucl Med 2002;46:24-34.  Back to cited text no. 6
    
7.
Lakhani A, Khan SR, Bharwani N, Stewart V, Rockall AG, Khan S, et al. FDG PET/CT pitfalls in gynecologic and genitourinary oncologic imaging. Radiographics 2017;37:577-94.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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