A 68-year-old woman presented to our department with abnormal vaginal bleeding. Her family history was not contributory, and she had no previous medical history. Transvaginal ultrasonography revealed a tumor in the uterine cavity. On endometrial biopsy, the papillary growth of tumor cells was observed. On magnetic resonance imaging (MRI), T2-weighted images showed thickening of the endometrium and contrast enhancement (Fig.
1). On computed tomography (CT) images, no distant metastasis was observed. Transabdominal simple hysterectomy, bilateral adnexectomy, and pelvic lymphadenectomy were performed. The resected tumor filled the uterine cavity with papillary excrescence and its size was 60 mm (Fig.
2a). Histopathological examination demonstrated a papillary architecture with the papillae comprising broad fibrovascular cores and cancer had spread into the inner half of the myometrium (Fig.
2b, c). However, there were adnexal and perimetrium metastases. Based on these findings, a diagnosis of stage IIIA (pT3aN0M0) ESC was made. As postoperative adjuvant therapy, combination chemotherapy of paclitaxel and carboplatin (TC) was administered. Before the second cycle, the regimen was changed to docetaxel and cisplatin (DP) because of skin eruptions induced by paclitaxel or carboplatin. Four cycles of DP were administered. After 5 months, CT revealed tumors in the vaginal wall and left internal iliac lymph node. As fluorodeoxyglucose positron emission tomography (FDG-PET) showed accumulation with maximum standardized uptake values (SUV
max) of 15.4 in the vaginal wall and 5.1 in the left internal iliac lymph node, the first recurrence of ESC was diagnosed (Fig.
3a, b). Concurrent chemoradiotherapy (CCRT) was performed. Chemotherapy comprised nedaplatin and docetaxel (nedaplatin 20 mg/body plus docetaxel 20 mg/body, on day two, every week for three cycles). Concurrent radiotherapy of 66 Gy (22 fractions of 3 Gy, 5 days/week) was delivered over 5 weeks using intensity modulated radiation therapy (IMRT) (Fig.
4a, b). The planning target volume (PTV) was the clinical target volume (CTV) + a 5-mm margin. Tumor regression was observed and the uptake in the recurrent site decreased considerably on the FDG-PET scan. After 4 months, the second recurrence was detected in the right internal iliac lymph node using FDG-PET with an SUV
max of 13.8. CCRT was performed again (Fig.
5a). The PTV was also the same. Tumor regression was observed and the uptake in the recurrent site decreased considerably on the FDG-PET scan. After 4 months, the third recurrence was detected in the right common iliac node using FDG-PET with an SUV
max of 9.0. CCRT was performed once more (Fig.
5b). The PTV again was the same. Tumor regression was observed and the uptake in the recurrent site decreased considerably on the FDG-PET. After 8 months, the fourth recurrence was detected in the horizontal portion of the duodenum using FDG-PET with an SUV
max of 8.6. IMRT (50 Gy in 25 fractions) was performed (Fig.
5c). The PTV was the same. The tumor regression was observed and the uptake in the recurrent site decreased considerably on the FDG-PET scan. After 9 months, small tumor induration was palpable on vaginal and rectal examinations. The fifth recurrence was detected in the vaginal wall, via vaginal tumor biopsy. Histological examination revealed papillary tumor cells, which were identical to those of the primary uterine lesion, with necrosis, and FDG-PET showed accumulation with an SUV
max of 4.2 in this site. Interstitial brachytherapy (48 Gy in 8 fractions) was performed. Tumor regression was observed and the uptake in the recurrent site decreased considerably on the FDG-PET. Grade 2 gastrointestinal fistula, nausea and radiodermatitis (CTCAE; Common Toxicity Criteria for Adverse Events, version 4.03) were observed during the treatment. During the subsequent 13-month follow-up, there has been no recurrence.