Presentation
Watery vaginal discharge, mild vaginal bleeding/spotting and lower abdominal pain for 1 year. Patient also complained of vomiting, anorexia, weight loss, fatigue and difficulty in micturition. Past history of treated breast carcinom.
Patient Data
Large heterogeneous solid looking pelvic mass measuring approximately 8 x 9 cm. A few tiny calcifications are seen in it. No significant internal vascularity is seen in it on color Doppler ultrasound examination.
Enlarged uterus measuring about 13 x 12 x 10 cm with distended uterine cavity containing hypodense contents showing mild peripheral enhancement. A small focal bulge is seen along the antero-superior aspect of the uterus which is inseparable from the adjacent small bowel loops. A few small gas foci are seen in the uterine cavity which are suspicious of fistulous tract formation between the uterus and adjacent bowel. No CT evidence of urinary bladder or colonic invasion is seen. Adjacent to the uterus, there is mesenteric fat stranding, peritoneal soft tissue nodules and mild ascites adjacent to the uterus suggestive of peritoneal infiltration of disease. No significant lymphadenopathy or evidence of distant metastases (visceral, osseous or pulmonary) is seen. Two small para umbilical hernias (with one of them containing bowel loop), small hepatic cyst in segment VIII, vascular calcifications in the spleen, relatively smaller right kidney with irregular cortical outlines and bilateral renal cortical cysts. Diffuse osteopenia in the scanned skeleton and compression fracture of D9.
Case Discussion
Laboratory investigations showed normal tumor markers (CA 19.9, CA-125, CA 15.3, CEA). Endometrial biopsy was done after ultrasound examination which showed serous carcinoma. After CT scan, patient underwent total abdominal hysterectomy (TAH), right salpingectomy, omentectomy, adhesiolysis of intestine with small bowel resection and anastomosis, and paraumbilical hernial repair. Histopathology revealed malignant mixed mullerian tumor of the uterus with heterologous elements (previously known as carcinosarcoma of the uterus). Omental biopsy showed massive tumoral infiltration. Peritoneal/ascitic fluid analysis was positive for malignant cells.
A fistulous communication was found between the uterus and small bowel loop on surgery; however, no malignant infiltration was seen in the small bowel on histopathology.
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