A rare case report of endometrial adenosarcoma in the cesarean scar diverticulum

Introduction

Endometrial adenosarcoma is an unusual type of uterine tumor that features a seemingly benign epithelial component, paired with a low-grade sarcomatous component, usually similar in appearance to endometrial stromal sarcoma (1). To our knowledge, no image of endometrial adenocarcinoma in the cesarean scar diverticulum has been reported previously. We present a case of this kind to offer clinicians insight into the diagnosis and treatment of such cases. We present this case in accordance with the CARE reporting checklist (available at https://tcr.amegroups.com/article/view/10.21037/tcr-23-2155/rc).

Case presentation

A 44-year-old female patient was admitted to our hospital complaining of irregular vaginal bleeding that had lasted for over two months. A B-ultrasound performed at another hospital revealed a 1+ cm mass behind the cesarean incision. One week prior to admission, magnetic resonance imaging (MRI) confirmed a mass (1.2 cm × 0.9 cm × 1.3 cm) at the junction of the corpus uteri and cervix (Figure 1). The patient had undergone a cesarean 12 years prior and had a non-unique past and family history. The examination of her cervix revealed polyp-like growths, and following a curettage, pathological analyses indicated the presence of atypical cells. We subsequently performed a hysteroscopy, which revealed an irregular mass at the cesarean section incision with an indistinct boundary; pathological analysis led to a confirmed diagnosis of endometrial adenosarcoma. As a result, the patient underwent hysterectomy and salpingo-oophorectomy. The postoperative examination of the specimen demonstrated a large cesarean scar diverticulum with a small amount of residual tumor remaining in the area (Figure 2). The patient was discharged home four days after the surgery and remained recurrence-free for one year after follow-up. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The study was approved by the ethics committee of the West China Second University Hospital [2022(161)]. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Magnetic resonance imaging shows a mass (1.2 cm × 0.9 cm × 1.3 cm) (the arrow indicated the location) at the junction between the corpus uteri and cervix, suspected to correspond with the cesarean scar diverticulum incision.

Figure 2 The intraoperative surgical gross resected specimen shows a diverticulum at the cesarean section incision site and a small residual tumor in the diverticulum (the arrow indicated the location).

Discussion

Although ultrasound has only moderate diagnostic accuracy when it comes to differentiating uterine diseases, due to its moderate sensitivity and specificity, it remains the first-line imaging technique as a result of its affordability, non-invasiveness, and reproducibility (2,3). MRI has shown very high accuracy in the differentiation of uterine sarcomas, demonstrating good sensitivity and even better specificity, which supports its use as second-line diagnostic tool after ultrasound (4). Hysteroscopy can be used as a diagnostic tool to identify a lesion in this unique condition, particularly when curettage fails to diagnose this uncommon condition. The standard treatment for endometrial adenosarcoma is hysterectomy and bilateral salpingo-oophorectomy, although there remain controversial aspects regarding lymphadenectomies and postoperative treatments. Due to the rarity of the case, the etiology of our patient’s condition remains unclear; however, we suspect that the adenosarcoma may be associated with poor wound healing at the site of the previous cesarean section. We hope that this case would bring awareness of this potential scenario, enabling clinicians in the future to identify similar cases more readily. In the future, tumors located in the cesarean section incision should be reported more frequently, as this may reveal the underlying cause.

Conclusions

Hysteroscopy can serve as a valuable diagnostic tool to identify the lesion in this unique scenario, particularly when curettage fails to diagnose this uncommon condition. We hope that this case would bring awareness to this potential occurrence through this case.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tcr.amegroups.com/article/view/10.21037/tcr-23-2155/rc

Peer Review File: Available at https://tcr.amegroups.com/article/view/10.21037/tcr-23-2155/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tcr.amegroups.com/article/view/10.21037/tcr-23-2155/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The study was approved by the ethics committee of the West China Second University Hospital [2022(161)]. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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