Page 20 - Delaware Medical Journal July 2015

Postmenopausal Bleeding Resulting from Acute Myeloid Leukemia Infiltration of the Endometrium
Megan Wasson, DO; Moses Hochman MD; and Mark Cadungog, MD
Postmenopausal bleeding can be the result of numerous etiologies including endometrial carcinoma, vaginal atrophy, and endometrial polyps. Manifestation of a hematologic disease, such as acute myeloid leukemia (AML),
is a rare occurrence. A 65-year-old woman with pancytopenia and postmenopausal bleeding was diagnosed with AML. Endometrial biopsy following dilation and curettage of the uterus revealed extensive mononuclear cell infiltrate consistent with AML. The patient was a poor surgical candidate and subsequently underwent treatment with chemotherapy, hormonal therapy, pelvic radiation, and uterine artery embolization to control her vaginal bleeding.
A multi-disciplinary approach is necessary for treatment of post-menopausal bleeding resulting from AML infiltration of the endometrium.
IntroductionPostmenopausal bleeding (PMB) refers to any uterine
bleeding that occurs more than 12 months after a woman’s last normal menstrual period. In 11.1 percent of women, the cause of bleeding is endometrial carcinoma.1 However, the most commonly seen etiology is vaginal mucosa or endometrial atrophy, which accounts for 83.1 percent of cases.1 In addition to diseases associated with the genital tract causing PMB, hematological diseases can rarely be the source. It is estimated that acute myeloid leukemia (AML) can cause extramedullary disease in 3-5 percent of patients.2 When this occurs, it is referred to as granulocytic sarcoma and commonly presents as lymph node, bone, and soft tissue involvement.2 However, granulocytic sarcoma has also been less commonly isolated in the orbit, gastrointestinal tract, mediastinum, uterus, and ovary.2 Treatment of such manifestations poses several challenges, however limited data is available to guide appropriate management.
CASE DESCRIPTION
A 65-year-old woman presented to the emergency department with complaints of generalized weakness, dizziness, and exertional shortness of breath. She experienced these symptoms for approximately six months duration prior to evaluation.
The patient also reported occasional vaginal spotting since
the time of menopause at age 57. The bleeding had increased
in frequency and volume over the course of several months
and acutely worsened during the week prior to evaluation that required several pad changes daily. Her past medical history was mellitus, pulmonary hypertension, and degenerative joint disease.
Laboratory analysis at the time of her emergency department
visit revealed a white blood cell count of 92.6/nL, blasts 57 percent, hemoglobin of 4.2g/dL, and platelet count of 7/nL. Given her pancytopenia and fatigue, a presumptive diagnosis of acute meyloid leukemia (AML) was made and the patient was admitted for inpatient management. She was transfused with four units of packed red blood cells and two packs of platelets. A bone marrow
A gynecologic evaluation then took place for assessment of
the patient’s post-menopausal bleeding. An examination under anesthesia revealed a grossly normal appearing cervix, normal sized uterus, and no active bleeding. The external os was opened to 0.5 cm with clotted blood protruding. An endometrial biopsy was obtained which revealed fragments of endometrial polyp and with acute myeloid leukemia involvement (Figures 1-3). The
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Del Med J | July 2015 | Vol. 87 | No. 7
Abstract