Endometrial cancer presenting as a snowball in the pelvis

Explanation image

Endometrial cancer is the commonest gynaecologic malignancy in the west and the third commonest after cervical and ovarian cancer in India [1]. The standard treatment for endometrial cancer has been primary surgery. Locally advanced disease, comprising lymph node metastases, adjacent organ invasion, positive peritoneal cytology or serosal invasion is uncommon and accounts for only 7% of cases [2]. To categorise a patient as having serosal invasion, it is mandatory to have full-thickness myometrial invasion with macroscopic tumour on the uterine surface. We present a patient with serosal disease with spontaneous perforation of the uterine wall by tumour, which presented in a unique manner at laparoscopy.

A 66-year-old lady presented with post-menopausal vaginal bleeding on and off for 9 months. Imaging with transvaginal ultrasound and MRI revealed a uterine mass with endometrial thickness of 12 mm. Under anaesthesia, a D&C with frozen-section analysis revealed a grade II endometroid adenocarcinoma. At laparoscopy, a bulky uterus with tumour plaque on the uterine surface which had formed a dense white sheet was seen (Figs. 1 and 2). The right ovary was also enlarged. Standard surgical staging and pan hysterectomy was done. The permanent sections revealed a FIGO grade II endometroid adenocarcinoma with uterine serosal invasion and an ovarian deposit as well. There were no metastases in the pelvic nodes or outside the pelvis. The disease was staged as IIIA grade II. She made an uneventful recovery and is currently receiving chemo-radiation. Review of literature did not reveal report of any similar case presenting like a snowball.

Fig. 1

Snowball in the pelvis

Fig. 2

Uterus covered by dense uniform whitish plaque