Case discussion

Coma, seizures, hypercalcemia and an unknown abdominal tumour

• Histologic description
• Neurologic complications in uterus carcinoma
• Brain metastasis
• Hypercalcemia
• Multiple skeletal metastases
• PRLS
• Posterior reversible leukoencephalopathy
• Posterior reversible leukoencephalopathy syndrome (RPLS)
• Neuropathology

Histologic description

Histology:

• Invasive, necrotizing and low differentiated  solid carcinoma of the uterus  infiltrating the uterus wall and transgressing the serosa. Immunhistochemically the tumour reacts with pancytokeratin (AE1/AE3), with the epithelial marker CK7, and with vimentine. Staining for CK20 and estrogen as well as progestreon receptors were negative.
• Tumour classification UICC: apT3a, G3  apL1 apV1 apN1 apM1 , stadium IVB

Neurological symptoms: Obtuned consciousness, seizures were due to:

Neurologic complications in uterus carcinoma

References:

• Nathan Rojansky, David Shveiky, Assaf Ben-Meir et al Case Report: Endometrial carcinoma first presenting as paraneoplastic cerebellar degeneration Gynecologic Oncology, Volume 105, Issue 3, June 2007, Pages 826-827
• Saphner T, Gallion HH, Van NJ et al, Neurologic complications of cervical cancer: a review of 2261 cases.Cancer 1989; 42: 413-418 

Brain metastasis  and endometrial carcinoma

Brain metastases are a  rare occurrence in endometrial cancer.  If they occur, they appear in the advanced course of the disease, several months a after the cancer presentation (Cormio).

References:

• Cormio G, Lissoni A, Losa G, Zanetta G, Pellegrino A, Mangioni C Brain metastases from endometrial carcinoma. Gynecol Oncol. 1996 Apr; 61(1):40-3.

Hypercalcemia

Hypercalcemia can cause disturbances of consciousness. Initially the highly elevated calcium was considered "paraneoplastic". The discovery of multiple metastases was a reasonable explanation for hypercalcemia, however normalisation of calcium levels did resolve the comatose state..

Multiple skeletal metastases

Skeletal metastasis: Hypercalcemia was most likely caused by diffuse skeletal metastasis, which is a rare event at the initial presentation of endometrial carcinoma (Dursun). Hypercalcemia has been described as a possible paraneoplastic phenomenon in gynecological cancer (Hiller, Stewart). The small cell type of endometrial cancer, which has been excluded histologically in our case, can also be associated with neuroendokrine hormone secretion (Crowder).

References:

• Dursun P, Gültekin M, Yüce K, Ayhan A Skeletal carcinomatosis in endometrial clear cell carcinoma at initial presentation: a case reportInt J Gynecol Cancer. 2006 Mar-Apr; 16(2):891-5.
• Stewart AF, Romero R, Schwartz PE, Kohorn EI, Broadus AE. Hypercalcemia associated with gynecologic malignancies: biochemical characterization Cancer. 1982 Jun 1;49(11):2389-94
• Hiller N, Sonnenblick M, Hershko C. Paraneoplastic hypercalcemia in endometrial carcinoma Oncology. 1989;46(1):45-8. Links.
• Crowder S, Tuller E. Small cell carcinoma of the female genital tract. Semin Oncol. 2007 Feb; 34(1):57-63.

Plasmon Resonance Light Scattering  (PRLS)

Posterior reversible leukoencephalopathy

PRLS is a potentially reversible condition, characterised by visual disturbance, alteration of consciousness and seizures.

Posterior reversible leukoencephalopathy  syndrome (RPLS)

RPLS is clinically characterised by visual disturbances, disturbance of consciousness and seizures. MRI images often show characteristic white matter changes, but not exclusively in the posterior part of the brain ( the posterior lobes in particular). The condition is usually reversible (Atunes).

Although primarily described in hypertension and eklampsia and in immune suppressed patients it has also been observed patients with cancer (Vaughn), and also been attributed to treatment with CHOP, taxanes, platinum compounds as well as therapies with bevazucimab , sorafenib and sunitinib.

Histologically a vasogenic edema appears, with vacoulisation, swelling of astrocytes and little or absent inflammatory changes (Schiff).

References:

• Antunes NL, Small TN, George D, Boulad F, Lis E  Posterior leukoencephalopathy syndrome may not be reversible Pediatr Neurol. 1999 Mar;20(3):241-3.

• Christopher Vaughn, Louann Zhang and David Schiff Reversible posterior leukoencephalopathy syndrome in cancer Current Oncology Reports 2008; 10 (1); 86-91

• David Schiff , Maria-Beatriz Lopes Neuropathological Correlates of Reversible Posterior Leukoencephalopathy Neurocrit. Care 2005;2:303–305

Neuropathology

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