Virginia Research Day 2025

Medical Student Research Case Reports

22 Uterine Embryonal Rhabdomyosarcoma in a Postmenopausal Woman: A Case Emphasizing the Necessity of Continued Gynecologic Surveillance in Elderly Patients

Satvika Nimmagadda, OMS-III; Dr. Nicole Long, DO, FACOOG Corresponding author: snimmagadda@vcom.edu

Edward Via College of Osteopathic Medicine Seasons for Women, Holston Medical Group

Embryonal rhabdomyosarcoma (ERMS) is an aggressive and rare malignancy mostly found in the pediatric population. Its occurrence in elderly, postmenopausal women, particularly involving the uterus, is exceedingly rare and carries a poor prognosis. This case report presents a 76-year-old female diagnosed with uterine ERMS following a challenging clinical course marked by obstructive urinary symptoms, pulmonary embolism (PE), and sepsis. This report contributes valuable insight into the clinical presentation, diagnostic challenges, and aggressive behavior of ERMS in older adults, a demographic with limited treatment options and a higher susceptibility to complications. Furthermore, it emphasizes the value of continuing gynecological evaluations and promptly investigating postmenopausal bleeding. The patient, a 76-year-old gravida 3 para 2 woman initially reported having postmenopausal spotting that progressed to clot formation over several

months. She delayed seeking medical care until urinary retention and worsening dyspnea prompted an emergency visit. Imaging identified a 13.5 cm uterine mass with extensive endometrial thickening, causing compression of the urethra and bladder outlet. Her clinical course was further complicated by PE, requiring thrombolytic therapy and anticoagulation. On a pelvic exam, the cervix was obscured by a large, friable mass with necrotic tissue. A biopsy confirmed ERMS, revealing high mitotic activity, spindle-shaped tumor cells, and uniquely large, bizarre “monster” nuclei—a hallmark of an aggressive malignancy. Immunohistochemistry confirmed ERMS, showing weak progesterone receptor (PR) positivity and positive staining for SMA in a perivascular cuff pattern. Given her age, comorbidities, and poor prognosis, she was referred to palliative care. ERMS is highly uncommon in postmenopausal women, and adult cases are associated with rapid progression and poor outcomes. While pediatric

ERMS generally shows a more favorable prognosis, the aggressive pathology seen in adults—such as the “monster” nuclei and extensive necrosis in this case—suggests a virulent tumor phenotype. Hypercoagulability, a known paraneoplastic effect, further complicated her case. Unlike pediatric cases in which surgery, chemotherapy, and radiation are standard, palliative care was prioritized for this elderly patient to focus on comfort and quality of life rather than curative intervention. Although her pap smears were negative until age 65, the progression to ERMS highlights the need for awareness and timely reporting of abnormal postmenopausal symptoms. The histopathology findings highlight the aggressive nature of ERMS in adults and its divergence from the typical pediatric presentation. Given the limited data on adult ERMS, this case contributes to our understanding of the disease’s clinical behavior and the role of palliative-focused care in optimizing patient quality of life.

114