Simultaneous occurrence of ovarian and uterine endometrial cancer is relatively uncommon. According to previous estimates, approximately 3-10% of women with cancer of ovary have simultaneous presence of endometrial cancer while 3-5% of women with cancer of uterine endometrium have simultaneous presence of cancer of ovary [1-4].
In one landmark study [5] (n=235,454 women with endometrial carcinoma), synchronous ovarian cancer was found in 1.7% of women with endometrial carcinoma, the incidence being highest (3.1-5%) in women between 29-47 years of age. The women with synchronous endometrial carcinoma and ovarian cancer were more often young black women with grade 1-2 tumors of endometrioid or serous histology type and stage I-II disease [5]. Most common histological combination was endometrioid cancer in both ovary and uterus (45.6%) followed by endometrioid cancer in uterus and non-endometrioid cancer in ovary (33%) and non-endometrioid cancer in both ovary and uterus (16.1%). Women with synchronous endometrioid cancer in both ovary and uterus were younger and had better 10 year survival rate (88.7%) compared to women with endometrioid carcinoma of uterus and non-endometrioid cancer of ovary (74.2%), non endometrioid cancer in both ovary and uterus (62.9%) and women with only endometrial carcinoma (80.7%) [5]. In another study [6], 3.3% of women with endometrial cancer and 2.7% of women with cancer of ovary had evidence of synchronous cancer of ovary or uterus respectively.
The exact mechanisms for this association remain to be determined. One possible explanation may be related to the fact that molecular receptors present in epithelial lining of ovaries and uterus are shared. Their concurrent response to a common carcinogenic insult in an index patient may lead to development of synchronous cancers in uterus and ovary [6].
The common clinical symptoms of synchronous ovarian and uterine cancer include abnormal vaginal bleeding (41%), pain (21%) or fullness (18%) in abdomen [6]. The symptoms which can be attributed to uterine carcinoma usually dominate the symptoms. In fact presence of abnormal vascular bleeding in setting of endometrioid ovarian cancer suggests coexistent endometrial pathology as was the case in our patient. In one study [7], 10/11 (90.9%) of women with abnormal vaginal bleeding in setting of endometrioid ovarian tumor had coexistent pathology which is much higher than that of general population (1.3% of premenopausal [8] and 17.1% of menopausal women [9] with abnormal vaginal bleeding harbor endometrial cancer or atypical hyperplasia). In fact women with abnormal vaginal bleeding may be detected and treated as they seek medical help earlier. The median survival of women with synchronous ovarian and uterine cancer was 60 months in presence of abnormal vaginal bleeding compared to 54 months in its absence in one study [6], likely related to early detection and treatment of women with abnormal vaginal bleeding.
Synchronous ovarian and uterine carcinomas are usually characterized by low histological grade and early disease stage [6]. Staging of disease in women with synchronous cancers of ovary and uterus poses difficulties more so in women with similar histology at both sites. In conveyance with cancer staging, such a situation may qualify either for stage III uterine cancer or stage IIA ovarian cancer, instead of qualifying for synchronous primarily independent cancers. However the prognosis of patients with synchronous ovarian and uterine cancers is better than either of stage III endometrial or stage IIA ovarian cancer, suggesting synchronous cancers to be an independent entity [6].
Recommended treatment for management of endometrial adenocarcinoma is total abdominal hysterectomy with bilateral salpingo-oophorectomy ± pelvic and para-aortic lymphadenectomy [10]. However, such an approach may not be feasible in women desiring future fertility. The universally accepted indications for fertility preserving treatment include strong desire for preserving fertility, nulliparous status, endometrioid carcinoma, stage I disease, reliable follow up, normal serum CA125 and grade I (grade II in some studies) histology [10]. Our patients qualified for all these criteria and were chosen for fertility preserving treatment with high dose progesterone therapy as reported in another study [11].
Similar to endometrial carcinoma, management of endometrioid ovarian tumors requires several important considerations in women with strong desire for future fertility. Though radical surgery (bilateral salpingo-oophorectomy with hysterectomy and staging surgery) remains the treatment of choice for ovarian malignancies, it may not be possible in women who desire to preserve their fertility. Accordingly, conservative approach has to be adopted sometimes especially in younger women with desire for future pregnancy [4]. In one review [12] including 507 women undergoing fertility sparing surgery for women with early stage ovarian cancer, risk of recurrence was 10.3% and risk of death from disease was 5.5%. These values were similar to those reported for historical controls. 36.7% of these women had full term deliveries. However other series have reported recurrence rate of 4-6% in preserved ovary [13, 14]. Morice et al [15] concluded that stage IA grade 1 and possibly grade 2 tumors (serous, mucinous or endometrioid subtypes) can be considered for fertility sparing surgery. They also suggested that even women with Grade 1 stage 1C disease can be considered for surgery.
The fact that only close to 1/3rd of women with cancers of ovary are able to achieve full term pregnancy following fertility sparing treatment [12] raises concerns. The reasons for poor fertility outcomes in these women are not clear but may be related to coexistent endometrial pathology and adhesions and alteration of ovarian function after surgery. Our patient also did not conceive spontaneously and even after treatment for infertility. However she did conceive following in vitro fertilization and had successful pregnancy outcome.
While fertility sparing treatment is well documented in patients with both endometrial and ovarian carcinomas, the reports of fertility sparing treatment are sparse in literature with regards to synchronous cancers of ovary and uterus [16]. Atallah et al [16] reported a lady with synchronous ovarian and uterine cancer who conceived spontaneously and had a successful pregnancy outcome following fertility sparing treatment. However unlike their report, our patient could not conceive spontaneously and needed in vitro fertilization.