SummaryObjectiveSynchronous primary malignant neoplasms of the uterus are uncommon. Patients with synchronous cervical and endometrial cancers are even rarer. We describe a case of cervical squamous cell carcinoma and endometrial endometrioid adenocarcinoma occurring simultaneously in a 47-year-old woman presenting with massive menstrual bleeding. The concept of synchronous primary malignancies of the genital tract is also reviewed in this report.Case ReportA 47-year-old overtly obese female presented with menometrorrhagia of over 6 months' duration. Pelvic examination detected a large cervix but apparently normal externals. Magnetic resonance imaging revealed a mass over the cervical region and endometrial lesions in the uterine cavity. Surgical exploration disclosed a cervical tumor and erosion of the endometrium. The pathologic findings were compatible with synchronous occurrence of primary neoplasms in the uterus with squamous cell carcinoma of the cervix and adenocarcinoma of the endometrium.ConclusionSynchronous genital tract neoplasms are rare but cause more clinical problems than a single neoplasm. It is practical to pay more attention to the differential diagnosis of primary and metastatic tumors. The second primary cancer that occurs in an individual with endometrial cancer may offer an opportunity for early detection. The prognosis for a patient with synchronous gynecologic malignancies does not seem to be worse

Chu, Ta-Wei

Lai, Hung-Cheng

Lin, Cheng-Kuo

Yu, Mu-Hsien

Taiwanese Journal of Obstetrics and Gynecology

Objective: Synchronous primary malignant neoplasms of the uterus are uncommon. Patients with synchronous cervical and endometrial cancers are even rarer. We describe a case of cervical squamous cell carcinoma and endometrial endometrioid adenocarcinoma occurring simultaneously in a 47-year-old woman presenting with massive menstrual bleeding. The concept of synchronous primary malignancies of the genital tract is also reviewed in this report.
Case Report: A 47-year-old overtly obese female presented with menometrorrhagia of over 6 months' duration. Pelvic examination detected a large cervix but apparently normal externals. Magnetic resonance imaging revealed a mass over the cervical region and endometrial lesions in the uterine cavity. Surgical exploration disclosed a cervical tumor and erosion of the endometrium. The pathologic findings were compatible with synchronous occurrence of primary neoplasms in the uterus with squamous cell carcinoma of the cervix and adenocarcinoma of the endometrium.
Conclusion: Synchronous genital tract neoplasms are rare but cause more clinical problems than a single neoplasm. It is practical to pay more attention to the differential diagnosis of primary and metastatic tumors. The second primary cancer that occurs in an individual with endometrial cancer may offer an opportunity for early detection. The prognosis for a patient with synchronous gynecologic malignancies does not seem to be worse

Cheng-Kuo Lin

Mu-Hsien Yu

Ta-Wei Chu

Hung-Cheng Lai

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Synchronous Occurrence of Primary Neoplasms in the Uterus with Squamous Cell Carcinoma of the Cervix and Adenocarcinoma of the Endometrium

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Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4336
■ SHORT COMMUNICATION ■
Introduction
Synchronous multiple malignant neoplasms of the
female genital tract are somewhat rare. For the most
part, concomitant malignancies in the genital system are
frequently diagnosed as metastatic disease. For patients
with more than one gynecologic neoplasm, most cases
are reported as synchronous endometrial and ovarian
cancers. However, synchronous primary malignancies of
the uterus are relatively rare. The prognoses of patients
with synchronous primary cancers are related to the
stage of disease at the time of diagnosis. We herein
present an unusual case of cervical squamous cell car-
cinoma and endometrial endometrioid adenocarcinoma
occurring simultaneously and presenting with massive
vaginal bleeding.
Case Report
A 47-year-old overtly obese (body mass index, 36)
female, gravida 3, para 3, had a history of poorly con-
trolled non-insulin-dependent diabetes mellitus. Also,
SYNCHRONOUS OCCURRENCE OF PRIMARY
NEOPLASMS IN THE UTERUS WITH SQUAMOUS
CELL CARCINOMA OF THE CERVIX AND
ADENOCARCINOMA OF THE ENDOMETRIUM
Cheng-Kuo Lin, Mu-Hsien Yu, Ta-Wei Chu1, Hung-Cheng Lai*
Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, and
1Department of Obstetrics and Gynecology, Armed Forces Tao-Yuan General Hospital, Tao-Yuan, Taiwan.
SUMMARY
Objective: Synchronous primary malignant neoplasms of the uterus are uncommon. Patients with synchronous
cervical and endometrial cancers are even rarer. We describe a case of cervical squamous cell carcinoma and
endometrial endometrioid adenocarcinoma occurring simultaneously in a 47-year-old woman presenting with
massive menstrual bleeding. The concept of synchronous primary malignancies of the genital tract is also
reviewed in this report.
Case Report: A 47-year-old overtly obese female presented with menometrorrhagia of over 6 months’ duration.
Pelvic examination detected a large cervix but apparently normal externals. Magnetic resonance imaging revealed
a mass over the cervical region and endometrial lesions in the uterine cavity. Surgical exploration disclosed a
cervical tumor and erosion of the endometrium. The pathologic findings were compatible with synchronous
occurrence of primary neoplasms in the uterus with squamous cell carcinoma of the cervix and adenocarcinoma
of the endometrium.
Conclusion: Synchronous genital tract neoplasms are rare but cause more clinical problems than a single neo-
plasm. It is practical to pay more attention to the differential diagnosis of primary and metastatic tumors. The
second primary cancer that occurs in an individual with endometrial cancer may offer an opportunity for early
detection. The prognosis for a patient with synchronous gynecologic malignancies does not seem to be worse.
[Taiwanese J Obstet Gynecol 2006;45(4):336–339]
Key Words: cervical cancer, endometrial cancer, synchronous primary malignancies
*Correspondence to: Dr Hung-Cheng Lai, Department of Obstetrics
and Gynecology, Tri-Service General Hospital, National Defense
Medical Center, 325, Section 2, Cheng-Kung Road, Neihu, Taipei
114, Taiwan.
E-mail: jolint1129@yahoo.com.tw
Accepted: June 29, 2006
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4 337
Synchronous Cancers of Cervix and Endometrium
she had never been part of a cervical screening program
in the past 10 years. She had endured menometrorrha-
gia with her menstrual cycles for more than 6 months.
She was referred to our emergency service due to mas-
sive vaginal bleeding during the procedure of diagnos-
tic dilatation and curettage for potential endometrial
lesions at a regional hospital. The endometrial biopsy
tissues were carried with her and sent for histopatho-
logic examination.
On examination, she was initially found to have a
blood pressure of 78/61 mmHg with impending hypo-
volemic shock. Emergency blood transfusion and resus-
citation were carried out. Physical examination revealed
a soft abdomen and palpable enlarged uterus as at 12
gestational weeks in size. Rectovaginal bimanual exam-
ination revealed a large movable cervix with grossly
smooth appearance, well supported smooth vagina,
free parametrium and movable uterosacral ligaments.
Magnetic resonance imaging (MRI) demonstrated a
lobulated mass over the cervical region and multifocal
cystic lesions in the uterine cavity with asymmetrical
thickening of the upper-third portion of the corpus
(Figure 1). Subsequent cystoscopic and proctoscopic
examinations were both normal. The Pap smear was
deferred due to uterine bleeding. According to the imag-
ing interpretation, we applied Lugol’s iodine solution
to stain the cervix and took a biopsy from the promi-
nent region even though the cervix looked normal. The
cervical specimen showed poorly differentiated cervical
carcinoma. The pathology of the endometrial tissues was
well differentiated endometrioid adenocarcinoma.
Due to the cervical cancer being at clinical stage Ib2,
a radical hysterectomy, bilateral salpingo-oophorectomy,
bilateral pelvic and common iliac and paraaortic
lymph node dissection, and partial omentectomy were
carried out. In addition, we measured the preoperative
serum levels of tumor markers CA125, SCC and CEA,
which were 128.10 U/mL, 6.0 ng/mL and <1.0 ng/mL,
respectively. Macroscopically, the uterus was enlarged,
measuring 17 × 10 × 8 cm, with a large cervix. Both
adnexa and parametrium were unremarkable. On cut-
ting, an ulcerative tumor could be seen to have replaced
the whole layer of the cervix (Figure 2). In the uterine
cavity, there was a fungating tumor, 4 × 4 × 1 cm, over
the endometrium with superficial myometrial invasion
(Figure 3). Microscopic examination showed squa-
mous cell carcinoma of the cervix and endometrioid
adenocarcinoma of the endometrium, grade II, with
A B
Figure 1. (A) Sagittal T2-weighted magnetic resonance imaging shows a large heterogeneous tumor arising from the cervix
and thickening of the endometrial stripe with focal invasion of the junctional zone at the uterine fundal level. (B) Axial post-
contrast enhanced imaging shows loss of integrity of the endometrial mucosa with thickening at the right lateral aspect of the
endometrium.
Figure 2. Solid tumor originating in the endocervix and
extending outward and forward to the external os, leaving
the surface uninvolved.
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4338
C.K. Lin, et al
myometrial invasion (invasive depth, 0.5 cm; full thick-
ness of myometrium, 4 cm) (Figure 4). Histopathology
of the cervix showed that non-keratinized squamous
cell carcinoma had invaded almost the whole layer of
the cervix, and there was stromal invasion and positive
lymph–vascular space invasion (LVSI). The bilateral
ovaries, tubes, omentum, parametrium and vaginal sur-
gical margins were all free. Surgical vaginal cuff and
cutting end were free of tumor invasion (4.2 cm total
length of vagina). Also, there was no LVSI of the endo-
metrial cancer. The lymphadenopathy was as follows:
metastatic carcinoma with the same patterns as the
cervical carcinoma, including right common iliac (1/8),
right pelvic (4/8) and left pelvic (5/12) lymph nodes.
The left common iliac (0/8) and paraaortic (0/10)
lymph nodes were announced free of tumor metasta-
sis. This patient was thoroughly evaluated and the FIGO
stages were cervical cancer stage Ib2 with lymph node
metastases and endometrial cancer stage Ib, grade II.
Standard therapies include surgery and/or radiation
therapy and/or adjuvant chemotherapy. Management
with radical hysterectomy and adjuvant concurrent
chemoradiation therapy (CCRT) appears to be the treat-
ment of choice. Thus, we performed CCRT with a reg-
imen of cisplatin and 5-fluorouracil. The radiation
programs were started with initial teletherapy fol-
lowed by brachytherapy. The first course of adjuvant
chemotherapy with cisplatin (75 mg /m2, day 1) and
5-fluorouracil (1,000 mg/m2, day 2 to day 5) were
given on the 16th day after surgery. The whole process
was smooth and the patient tolerated it well. She was
discharged and will be admitted next time for a further
course of CCRT.
Discussion
Multiple primary cancers associated with gynecologic
malignancies are observed infrequently. The incidence
of synchronous primary tumors of the female genital
tract is only 1–6% of all genital neoplasms. Further,
endometrial cancer with simultaneous ovarian cancer
is the most commonly occurring [1,2]. In a retrospec-
tive study of 3,863 patients with female genital malig-
nancies, 26 (0.7%) patients with synchronous primaries
were identified [3]. Eisner et al found that the most
frequently documented synchronous malignancies were
coexistence of endometrial and ovarian cancers, which
were seen in 11 patients, although four patients had a
primary malignancy of the cervix and endometrium.
These patients all had squamous cell carcinomas of
the cervix, three associated with adenocarcinoma of
the endometrium and one with a mixed müllerian
tumor of the endometrium. Ayhan et al showed that
29 patients diagnosed as having synchronous tumors
constituted 1.7% of all patients with genital malignan-
cies (29/1,690) [2]. The most common cancer was
BA
Figure 4. (A) Invasive squamous tumor nests adjacent to the endocervical gland (hematoxylin and eosin, 100×). (B) Infiltrating
endometrioid adenocarcinoma with glandular tumor cell invasion to almost half of the myometrium (hematoxylin and eosin, 40×).
Figure 3. Fungating masses about 4 cm in size over the
endometrium with superficial myometrial invasion.
Taiwanese J Obstet Gynecol • December 2006 • Vol 45 • No 4 339
Synchronous Cancers of Cervix and Endometrium
that of the ovary concomitant with other gynecologic
malignancies, and the endometrial and ovarian cancer
group consisted of 15 patients. Further, three patients
had concurrent neoplasms of the cervix and endo-
metrium. The histologic subtypes of the cervical can-
cers were all epidermoid. Ohel et al documented an
incidence of 2.5% and 0.4% of primary ovarian and
cervical malignancies, respectively, associated with
endometrial cancer [4]. In 1879, Billroth was the first
to report the development of different primary malig-
nant tumors in the same individual [5]. Warrens and
Gates established the following criteria for the diagno-
sis of multiple primary tumors: (1) each of the tumors
must present a definite picture of malignancy; (2) each
must be clinicopathologically distinct; (3) the proba-
bility of one being a metastasis or recurrence must be
excluded [6].
While the etiology and pathogenesis of this phe-
nomenon remain unclear, it has been postulated that
embryologically similar tissues of the female genital
tract, when simultaneously subjected to irritants, may
develop synchronous neoplasms [3,7]. Others suggest
that these multifocal lesions may represent metaplasia
occurring in similar histopathologic epithelia of the
genital tract and peritoneal surfaces [7]. This suggests
that it may be a multifocal response to carcinogenic
influences acting upon the müllerian paramesonephric
tissue and the coelomic epithelium during embryolo-
gic development.
Primary malignancies of the genital tract seem to
occur synchronously more often than one would expect
by chance. Axelrod et al studied 36 patients with dou-
ble gynecologic primary malignancies and observed 
a statistically increased incidence of a second gyneco-
logic malignancy [8]. They also found an increased
incidence of primary malignancy of the cervix, ovary,
fallopian tube, breast and colon in patients with primary
endometrial cancer. Rose et al noted that a patient
with a malignancy of the lower genital tract appears to
be at a statistically increased risk for a second such
malignancy [9]. In a study of 1,007 patients, Ohel et al
showed that a statistically significant higher risk for
developing ovarian and cervical malignancy was demon-
strated in patients with endometrial cancer, compared
to the general population [4].
Multifocal lesions may be expressed by the fact
that, at the time of diagnosis, the majority of patients
have low-stage disease. The association of low-grade
histologies indicates that they may have arisen as syn-
chronous separate, multifocal primary lesions rather
than metastasis [3]. The prognosis in these patients is
more favorable when compared to metastatic lesions
of individual tumors [1]. Ayhan et al reported similarly
favorable outcomes in the endometrial and ovarian
cancer group as well as the other synchronous tumor
groups [2]. The survival of patients with synchronous
primary cancers is related to the stage of disease of
either of the two tumors at the time of diagnosis [4].
Endometrial cancer usually produces early symptoms
with abnormal bleeding. Nevertheless, early invasive
cervical carcinoma may be asymptomatic. While the
cervical tumor grows and presents exophytically, vagi-
nal bleeding and abnormal discharge may be signs.
The clinical features of squamous cell carcinomas are
that they are substantially exophytic, obvious growth
tumors of polypoid or papillary excrescence. However,
a portion of squamous cell carcinomas may be endo-
phytic, deeply infiltrating into the surrounding struc-
tures without visible surface lesions. They contribute
to diffuse enlargement of the cervix (a barrel-shaped
cervix) and act like certain types of adenocarcinoma of
the cervix.
Our patient had never been part of a cervical screen-
ing program. Furthermore, the cervical lesion was con-
fined to the endocervix so that diagnosis of cervical
cancer might not have been considered if no manifes-
tation of abnormal vaginal bleeding had derived from
the endometrial cancer.
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2. Ayhan A, Yalcin OT, Tuncer ZS, Gurgan T, Kucukali T.
Synchronous primary malignancies of the female genital
tract. Eur J Obstet Gynecol Reprod Biol 1992;45:63–6.
3. Eisner RF, Nieberg RK, Berek JS. Synchronous primary neo-
plasms of the female reproductive tract. Gynecol Oncol
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4. Ohel G, Schwartz Z, Birkenfeld A, Anteby SO, Schenker JG.
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endometrial cancer. Arch Gynecol 1986;239:75–80.
5. Billroth T. Wien 1871–6; nebs einem gesamnt-bericht über
die chirurgischen kliniken in Zürich und Wien während der
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the upper genital canal. Obstet Gynecol 1985;65:695–8.
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Synchronous Occurrence of Primary Neoplasms in the Uterus with Squamous Cell Carcinoma of the Cervix and Adenocarcinoma of the Endometrium 

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Synchronous Occurrence of Primary Neoplasms in the Uterus with Squamous Cell Carcinoma of the Cervix and Adenocarcinoma of the Endometrium

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