Tumor necrosis observed after uterine artery embolization for bleeding control in a woman with suspected endometrial cancer: a case report

A 46-year-old nulliparous woman with no notable medical or family history visited a physician for abnormal uterine bleeding and underwent endometrial biopsy. Two days later, genital bleeding increased, and she was transferred to hospital. On admission, speculum examination revealed continuous bleeding from the external cervical os. Transvaginal ultrasonography showed a mass measuring 78 × 51 mm within the uterine cavity, and laboratory testing demonstrated anemia with hemoglobin 8.4 g/dL. Contrast-enhanced abdominal computed tomography (CT) performed to identify the source of bleeding revealed contrast extravasation into the uterine cavity ( Fig. 1 A, B). Because malignancy could not be ruled out and definitive diagnosis was required before determining surgical management, UAE was selected as a temporizing measure rather than immediate hysterectomy. Fig. 1 Contrast-enhanced computed tomography performed prior to embolization. (A) Active contrast extravasation into the uterine cavity (arrow) and the presence of an intrauterine tumor (arrow heads). (B) Dilation of the right uterine artery (arrow). Fig. 1 Contrast-enhanced computed tomography performed prior to embolization. (A) Active contrast extravasation into the uterine cavity (arrow) and the presence of an intrauterine tumor (arrow heads). (B) Dilation of the right uterine artery (arrow). Uterine arteriography showed no active extravasation but revealed bilateral uterine artery enlargement ( Fig. 2 A,B). Selective UAE was therefore performed on both uterine arteries using gelatin sponge particles. Hemostasis was achieved, and the patient's anemia improved following transfusion of four units of red blood cells. Fig. 2 Selective uterine arteriography demonstrating bilateral enlargement of the uterine arteries, before uterine artery embolization (A, right side; B, left side). Fig. 2 Selective uterine arteriography demonstrating bilateral enlargement of the uterine arteries, before uterine artery embolization (A, right side; B, left side). On postoperative day 4, the patient developed fever and elevated inflammatory markers, raising concern for tumor necrosis or bacterial infection. As no laboratory findings suggested tumor lysis syndrome, she was treated with antibiotics, resulting in defervescence and improvement of inflammation. Contrast-enhanced magnetic resonance imaging (MRI) performed two days after UAE showed no enhancement in the intrauterine tumor or fibroid-like mass ( Fig. 3 ), indicating successful embolization. Although tumor assessment was challenging due to lack of enhancement, myometrial invasion appeared to be less than one-half based on myometrial contrast patterns. Chest and abdominal CT revealed no distant metastases or lymph node enlargement. Fig. 3 Post-embolization contrast-enhanced pelvic magnetic resonance image (T1-weighted) showing absence of enhancement in the intrauterine lesion, consistent with treatment effect following uterine artery embolization. Fig. 3 Post-embolization contrast-enhanced pelvic magnetic resonance image (T1-weighted) showing absence of enhancement in the intrauterine lesion, consistent with treatment effect following uterine artery embolization. Based on clinical presentation and imaging findings, the differential diagnosis included endometrial carcinoma, submucosal leiomyoma with secondary bleeding, and uterine sarcoma. Given the persistent bleeding and imaging findings suggestive of malignancy, endometrial cancer was considered the most likely diagnosis. Histopathological review of the endometrial biopsy specimen obtained at the referring institution demonstrated fused tubular and solid nest-like proliferation of atypical glandular cells with marked nuclear atypia, raising suspicion for high-grade adenocarcinoma ( Fig. 4 ). Based on these morphological findings, the differential diagnosis included grade 2 endometrioid carcinoma and serous carcinoma. Additional immunohistochemical analysis could not be performed because the available biopsy specimen was limited. Fig. 4 Endometrial biopsy obtained at the referring institution demonstrating features suggestive of high-grade adenocarcinoma (endometrioid carcinoma G2 or serous carcinoma). Fig. 4 Endometrial biopsy obtained at the referring institution demonstrating features suggestive of high-grade adenocarcinoma (endometrioid carcinoma G2 or serous carcinoma). Based on these findings, the tumor was clinically considered endometrial carcinoma stage IA. Repeat biopsy after UAE was not performed because definitive surgery had already been planned based on the preoperative pathological and imaging findings suggestive of malignancy. Definitive surgery was scheduled approximately one month after UAE to allow improvement of the patient's general condition, including recovery from anemia and resolution of post-embolization inflammation. One month after UAE, the patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and partial omentectomy because serous carcinoma could not be excluded. Peritoneal cytology was negative. On permanent pathology, all tumor tissue was completely necrotic, leaving no viable tumor cells for histologic evaluation. Even when considering all necrotic tissue as tumor, myometrial invasion depth was estimated to be less than one-half ( Fig. 5 ). The final diagnosis was endometrial carcinoma (endometrioid carcinoma G2 or serous carcinoma, pT1aN0M0), stage IA. Because the preoperative biopsy findings raised suspicion for high-grade adenocarcinoma, comprehensive surgical staging, including total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and partial omentectomy, was performed. Although the final pathological evaluation was limited by complete tumor necrosis, the patient was managed as having a high-risk histological subtype, and adjuvant chemotherapy was administered. She remained free of recurrence at 18-month follow-up. Fig. 5 (A) Gross pathological specimen from hysterectomy showing complete tumor necrosis within the uterine cavity. (B) Low-power view (loupe) of the resected specimen showing widespread coagulative necrosis throughout the tumor. (C) Intermediate-power microscopic view (×20) demonstrating necrotic tissue without viable tumor cells. (D) High-power microscopic view (×200) confirming complete tumor necrosis and absence of recognizable carcinoma cells. Fig. 5 (A) Gross pathological specimen from hysterectomy showing complete tumor necrosis within the uterine cavity. (B) Low-power view (loupe) of the resected specimen showing widespread coagulative necrosis throughout the tumor. (C) Intermediate-power microscopic view (×20) demonstrating necrotic tissue without viable tumor cells. (D) High-power microscopic view (×200) confirming complete tumor necrosis and absence of recognizable carcinoma cells.

No funding from an external source supported the publication of this case report.

Written informed consent was obtained from the patient for publication of the case report and accompanying images.

Uterine artery embolization may be useful for temporary bleeding control in suspected uterine malignancy. However, tissue diagnosis should be obtained prior to embolization whenever possible.

Uterine artery embolization (UAE) is widely used for the treatment of benign uterine diseases such as fibroids and adenomyosis and is also recognized as an effective minimally invasive procedure for controlling refractory bleeding in advanced gynecologic malignancies [1] . However, its role in patients with suspected early-stage endometrial cancer remains unclear. Patients with uterine tumors may occasionally present with severe bleeding requiring urgent intervention. Although emergency hysterectomy may be considered in such situations, performing definitive surgery without adequate diagnostic evaluation may result in inappropriate oncologic management [2] . In this case, UAE allowed safe control of bleeding and stabilization of the patient before definitive surgical treatment, highlighting its potential role as a bridging intervention. The vascular anatomy of the uterus is complex. While the uterine arteries represent the primary blood supply, collateral circulation from the ovarian arteries is well known [3] . Razavi et al. demonstrated that utero-ovarian collateral circulation can influence the success of embolization procedures [3] . In the case reported here, preprocedural imaging suggested that the uterine arteries were the dominant blood supply to the lesion, which may explain the marked ischemic changes observed after embolization. In contrast, the uterine cervix is reported to be supplied predominantly by branches of the uterine arteries [4] , which may explain why embolization has been reported to achieve effective hemostasis in patients with cervical cancer–related bleeding [5] . In endometrial cancer, embolization has mainly been reported as a palliative procedure for bleeding control, and its oncologic impact remains unclear [6] . UAE is primarily described as a palliative or temporizing intervention for bleeding control in advanced or inoperable gynecologic malignancies rather than as part of standard initial oncologic management [6] . Published reports have primarily focused on its role in advanced or inoperable disease, and its impact on tumor pathology and staging in early-stage settings remains poorly characterized. In the present patient, postoperative pathological examination revealed complete tumor necrosis. Previous pathological studies of uterine specimens following UAE have demonstrated extensive ischemic changes, including coagulative necrosis, hyalinization, and loss of viable cellular components [7] . Uterine necrosis is a recognized, although rare, complication of UAE, with only a limited number of cases reported in the literature [8] . Clinical manifestations of uterine necrosis include abdominal pain, fever, and abnormal vaginal discharge, reflecting underlying ischemic tissue damage [9] . Although this finding raises the possibility that ischemic changes induced by embolization may have contributed to tumor necrosis, a causal relationship between UAE and the observed pathological findings cannot be definitively established. Tumor necrosis can occur in malignant tumors through various mechanisms, including rapid tumor growth or hemorrhagic changes. These observations support the biological plausibility that UAE-induced ischemia may significantly alter tumor viability and histological interpretability. Another important clinical lesson from this case is that embolization may complicate subsequent pathological evaluation. In this patient, extensive necrosis was observed in the surgical specimen, and viable tumor cells were not identifiable. As a result, key histopathological parameters such as depth of myometrial invasion, lymphovascular space invasion, and histological subtype could not be reliably assessed. Treatment decisions, including comprehensive staging surgery and adjuvant chemotherapy, were based primarily on the preoperative suspicion of high-grade adenocarcinoma because pathological assessment of the hysterectomy specimen was substantially limited by complete necrosis. Accurate pathological assessment is essential for staging and risk stratification in endometrial cancer and directly influences clinical decision-making, including the need for adjuvant therapy [10] . Furthermore, therapeutic strategies and postoperative surveillance may differ substantially between epithelial malignancies and mesenchymal tumors, underscoring the importance of accurate histological diagnosis. When malignancy is suspected, it is therefore critical to obtain adequate tissue samples before embolization whenever possible. Despite these limitations, UAE remains clinically valuable in selected situations. In patients presenting with severe uterine bleeding, embolization can provide rapid hemostasis with relatively low invasiveness [1] , [5] . Previous studies have also suggested that the incidence of newly diagnosed gynecologic malignancy after UAE is low, but UAE itself should not be considered a definitive oncologic treatment [10] . Because this report describes a single case, the clinical significance of tumor necrosis observed after UAE remains uncertain. Nevertheless, this case highlights two important practical considerations: UAE can be an effective option for temporary bleeding control, and careful consideration should be given to obtaining tissue diagnosis before embolization. Further reports of similar cases are needed.

This article was not commissioned and was peer reviewed.

Yukari Yamano contributed to patient care, acquiring the data, drafting the manuscript, undertaking the literature review and revising the article critically for important intellectual content. Yukiko Ando contributed to patient care, interpreting the data and revising the article critically for important intellectual content. Yuri Takemura contributed to patient care and revising the article critically for important intellectual content. Yumi Onishi contributed to patient care and revising the article critically for important intellectual content. Makiko Ikeda contributed to patient care and revising the article critically for important intellectual content. Hiroshi Sato contributed to patient care, conception of the case report, interpreting the data, drafting the manuscript and revising the article critically for important intellectual content. Nao Taguchi contributed to patient care, interpreting the data and revising the article critically for important intellectual content. Kazuyo Kakui contributed to patient care and revising the article critically for important intellectual content. All authors approved the final submitted manuscript.

Uterine artery embolization (UAE) is widely used for the treatment of benign uterine conditions such as fibroids and adenomyosis. It is also recognized as a minimally invasive option for controlling refractory bleeding in gynecologic malignancies. However, its clinical role in suspected early-stage endometrial cancer has not been established and it is not included in standard treatment strategies. This report describes a case of suspected endometrial cancer in which UAE was performed for bleeding control, and complete tumor necrosis was observed in the surgical specimen.

The authors declare that they have no competing interest regarding the publication of this case report.