Aggressive endometrial carcinoma in a breast cancer patient treated with tamoxifen with normal transvaginal ultrasonography. Case report

Since tamoxifen therapy can induce endometrial disorders, surveillance schemes of women taking tamoxifen have been recommended. Transvaginal ultrasonography is a very sensitive test and therefore is often performed as a first-line screening test. We described a very atypical case of a high stage, high grade endometrial cancer associated with tamoxifen in a 64-year-old woman with a past history of breast cancer. This women was assessed yearly by ultrasonography and Pap smear. The cancer developed on a very thin endometrium and transvaginal ultrasonography failed to detect it. The patient remained asymptomatic up to the diagnosis. Normal endometrial cells in the Pap smear test were the only signs associated with this cancer. Surveillance strategies and significance of endometrial cells on the Pap smear are reviewed. In conclusion, TVUS can fail to detect cancers if the endometrial lining is not enlarged. In case of normal endometrial cells in the Pap smear, a careful evaluation should be performed.

Uterine neoplasms; Tamoxifen; Surveillance strategy; Pap smear; Transvaginal ultrasonography; Sensitivity

[1] Early Breast Cancer Trialists'Collaborative Group:'Tamoxifen for early breast cancer: an overview of the randomised trials". Lancet, 1998, 351, 1451.

[2] Pomander T.,R utqvist LE., Cedermark B., Glas U., Mattsson A., Silt'Versward C. et al.: "Adjuvant tamoxifen in early breast cancer occurrence of new primary cancers". Lancet, 1989, I (8630), 117.

[3] Andersson M., Storm H. H., Mouridsen H. T: "Incidence of new primary cancers atter adjuvant tamoxifcn therapy and radiotherapy for early breast cancer". J. Natl. Cancer Inst., 1991, 83 ( 14), 10 13.

[4] Fisher B., Costantino J. P.,R edmond C. K., Fisher E.R ., Wicherham D. L., Cronin W. M.: "Endometrial cancer in tamoxifen- treated breast cancer patients: findings from the National Surgical Adjuvant Breast and Bowel P roject (NSABP) B-14". J. Natl Cancer Inst., 1994, 86 (7), 527.

[5] Cohen L. Rosen D. J., Shapira J., Cordoba M., Gilboa S., Altaras M. M. et al.: "Endometrial changes with tamoxifen: comparison between tamoxifen-treated and nontreated asymptomatic, postmenopausal breast cancer patients". Gynecol. Oncol., 1994, 52(2), 185.

[6] Lahti E., Blanco G., Kauppila A., Apaja-Sarkkinen M., Taskmen P. J., Laatikainen T.: "Endometrial changes in postmenopausal breast cancer patients receiving tamoxifen". Obstet. Gynecol., 1993, 81 (5), 660.

[7] Kedar R. P., Bourne T. H., P owles T. J., Collins W. P., Ashley S E., Cosgrove D. 0. et al.: "Effects of tamoxifen on uterus and ovaries of postmenopausal women in a randomised breast cancer prevention trial". Lancet, 1994, 343 (8909), 1318.

[8] Neven P., De Muylder X., Van Belle Y., Vanderick G., De Muyldcr E.: "Hystcroscopic follow-up during tamoxifen treatment". Eur. J. Obstet. Gynecol. Reprod. Biol., 1990, 35 (2-3), 235.

[9] Suh-Burgmann E. J., Goodman A.: "Surveillance for endomelrial cancer in women receiving tamoxifen". Ann. Intern. Med., 1999, 131 (2), 127.

[10] Seoud M., Shamseddine A., Khalil A., Salem Z., Saghir N., Bikhazi K. et al.:'Tamoxifen and endometrial pathologies: a prospective study". Gynecol. Oncol., 1999, 75 (1), 15.

[11] Barakat R.R.: "The effect of tamoxifen on the endometrium" Oncology (Huntingt), 1995, 9 (2), 129.

[12] Barakat R. R.: "Benign and hyperplastic endometrial changes associated with tamoxifen use". Oncology (Huntingt), 1997, 11 (2 Suppl. 1), 35.

[13] ACGO committee opinion: "Tamoxifen and endometrial cancer". No. 169, February 1996, Committee on Gynecologic P ractice American College of Obstetricians and Gynecologists". 1nt. J. Gynaecol. Obstet., 1996, 53 (2), 197.

[14] Neven P., De Muylder X.: "Gynaecology. Hormonal interventions and cancer risk". Lancet, 1995, 346 Suppl., 8.

[15] Look K.:'The Barakat article reviewed". Oncology , 1995, 9 (2), 139.

[16] Berck J., Hacker N.: "P ractical Gynecologic Oncology". Balt1-more: Williams and Wilkin, 1988.

[17] Cardosi R. J., Fiorica J. V: "Surveillance of the endometnum in tamoxifen treated women". Curr. Opin. Obstet. Gynecol., 2000, 12(1), 27.

[18] Berliere M., Charles A., Galanl C., Donnez J.: "Uterine side effects of tamoxifen: a need for systematic pretreatment screening". Ohstet. Gynecol., 1998, 91 (1), 40.

[19] Franchi M., Ghezzi F., Donadello N., Zanaboni F, Bcretta P., Bolis P.: "Endometrial thickness in tamoxifen-treated patients: an independent predictor of endometrial disease". Ohstet. Gynecol., 1999,93(6), 1004.

[20] NCI Advisors: "Resume trials, add endometrial sampling". Cancer Lett., 1994, 20, 3.

[21] Neven P., Vergote I.: "Should tamoxifen users be screened for endometrial lesion? Lancet, 1998, 351 (9097), 155.

[22] Neven P.: "Tamoxifen: the need for a monitoring protocol". The Breast, 1996, 5, 330.

[23] Assikis V. J., Jordan V. C.: "Gynecologic effects of tamoxifen and the association with endometrial carcinoma". Int..I. Gynaecol. Ohstet., 1995, 49 (3), 241.

[24] Vosse M., Renard F., Co心on M., Neven P., Nogaret J.M.. Hertens D.: "Endometrial disorders in 406 breast cancer patients on tamoxifen: advocating for a low aggre、sive monitoring". Eur..I Ohstet. Gynecol. Reprod. Biol. (in press), 2001.

[25] Yancey M., Magelssen D., Demaurez A., Lee R. B.: "Classification of endometrial cells on cervical cytology". Obstet. Gynecol., 1990, 76 (6), 1000.

[26] Ng A. B., Regan J. W., Hawliczek S., Wentz B. W.: "Significance of endometrial cells in the detection of endometrial carcinoma and its precursors". Acta Cytol., 1974, 18 (5), 356.

[27] Gondos B., King E. B.: "Significance of endometrial cells m cervicovaginal smears". Ann. Clin. Lab. Sci., 1977, 7 (6), 486.

[28] Zucker P. K., Kasdon E. J., Feldstein M. L.: "The validity of Pap smear parameters as predictors of endometrial pathology in menopausal women". Cancer, 1985, 56 (9), 2256.

[29] Abadi M.A., Barakat R.R., Saigo P. E.: "Effects of tamoxifen on cervicovaginal smears from patients with breast cancer". Acta Cytol., 2000, 44 (2), 141.

[30] Barakat R. R., Wong G., Curtin J.P., Vlamis V., Hoskins W. J.: "Tamoxifen use in breast cancer patients who subsequently develop corpus cancer is not associated with a higher incidence of adverse histologic features". Gynecol. Oneal., 1994, 55 (2), 164.

[31] Magriples U., Naftolin F., Schwartz P. E., Carcangiu M. L.: "Highgrade endometrial carcinoma in tamoxifen-treated breast cancer patients". J. Clin. Oneal., 1993, 11 (3), 485.