1. POSTER TEMPLATE BY: www.PosterPresentations.com Spontaneous rupture of a pyometra in a woman with a mixed mullerian tumour of the uterine corpus - A review of the literature T Aojanepong, S Sheikh, C Aung, J Norton, N Hill Princess Royal University Hospital, uk Introduction Pyometra is a rare condition predominantly affecting elderly women involving the accumulation of purulent material in the uterine cavity. Although often resulting from benign causes, it can also be associated with genital malignancy, most commonly cervical. We present an interesting case of a 61 year old patient with a rare utero carcinosarcoma or mixed mullerian tumour who presented acutely with a ruptured pyometra. Furthermore we present a review of the literature on both pyometra and mixed mullerian tumours of the uterus to highlight the importance of suspecting this diagnosis in elderly female patients presenting with an acute abdomen. Case Presentation Discussion Conclusions We present a rare case of a spontaneously ruptured pyometra in combination with an unusual endometrial carcinoma. We believe that this is the first case of its kind and also adds to the existing case series of spontaneously ruptured pyometra to emphasise the importance of this as a differential diagnosis when assessing elderly women presenting acutely with abdominal pain. Methods A literature search was performed using the keywords ‘spontaneous rupture, pyometra’ and ‘mixed mullerian tumour, uterine corpus’. To our knowledge only 30 cases of spontaneously ruptured pyometra have been reported within the English literature. Of those associated with malignancy, cervical tumours are the most commonly implicated. Only two cases have been associated with endometrial cancer. A 61 year old postmenopausal woman presented to the clinic with a three week history of offensive red/brown vaginal discharge and abdominal pain localised to the left iliac fossa. Examination revealed a soft and non-tender abdomen and a black fungating lesion over the cervix with offensive vaginal discharge. Initial ultrasound scan showed an anteverted bulky uterus with an endometrial thickness of 6.5mm and no obvious adnexal masses. She was urgently listed for hysteroscopy, endometrial biopsy and cervical biopsy. Whilst awaiting the procedure she presented to the emergency department with a three day history of increased abdominal pain, severe bloating, nausea, vomiting and constipation. On arrival, her vital signs were stable. Examination revealed a distended abdomen, which was globally tender with guarding and absent bowel sounds. Blood tests revealed Hb 11.1, WCC16.3, Na 131, K 4.5, Ur 22.4, creatinine 172, amylase 17 and normal liver function tests. Erect chest x-ray and abdominal x-ray showed no abnormalities. The patient was admitted, commenced on antibiotics and kept nil by mouth. A CT abdomen showed a perforated uterus and pyometra. A laparotomy was performed in conjunction with the general surgeons. One litre of free pus was found in the abdominal cavity. The uterus was 18 weeks in size with a fundal perforation. A total abdominal hysterectomy and bilateral salpingo- oophrectomy was performed. Histological findings confirmed a uterine carcinosarcoma with a predominant leiomyosarcoma component. Pyometra is defined as the accumulation of purulent material in the uterine cavity. Its incidence is around 13.6% in elderly women (1). Clinically patients may complain of purulent vaginal discharge, post-menopausal bleeding and lower abdominal pain. There are several reports of the condition presenting as an acute abdomen with nausea and vomiting (2,3) all of which were seen in our patient. In the majority of patients a ruptured pyometra is diagnosed intra-operatively. Although in a few cases including ours, computed tomography and magnetic resonance imaging is useful in diagnosis. In the cases of spontaneously ruptured pyometra associated with malignancy, cervical carcinoma has been implicated the most. In our patient, histology revealed changes consistent with uterine carcinosarcoma otherwise known as a mixed mullerian tumour of the uterine corpus. A review of literature has found only two cases of endometrial cancer associated with a ruptured pyometra, one in 1985 (4) and one in 1993 from a case series of fifteen patients (5). The exact histological findings from these two cases were not specified. The patient made a good recovery post-operatively and was discharged home after a total of 23 days in hospital, of which one was spent in the intensive care unit. Follow up at a tertiary cancer centre has been arranged. Figure 1: H & E staining on High microscopic power showing junction between malignant glandular epithelium and malignant stroma cells. References 1.Yildizhan B, Uyar E, Sismanoglu A, Gulluoglu G and Kavak Z. Spontaneous Perforation of Pyometra: A Case Report. Infectious Diseases in Obstetrics and Gynaecology 2006; 2006: 1-3 2.Vyas S, Kumar A, Prakash M, Kapoor R, Kumar P and Khandelwal. Spontaneous perforation of pyometra in a cervical cancer patient: a case report and literature review. Cancer Imaging 2009; 9(1): 12-14 3.Geranpayeh L, Fadaei-Araghi M, Shakiba B. Spontaneous uterine perforation due to pyometra presenting as an acute abdomen. Infectious Disease Obstet Gynaecology 2006;2006:60276 4.Hosking SW. Spontaneous perforation of a pyometra presenting as generalised peritonitis. Postgraduate Medical Journal. 1985;61(717):645-646 5.Imachi M, Tanaka S, Ishikawa S, Matsuo K. Spontaneous perforation of pyometra presenting as generalised peritonitis in a patient with cervical cancer. Gynaecol Oncol. 1993; 50(3): 384-8