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Ovarian Metastasis

Ovarian metastasis is not a rare condition and occurs secondary to malignancies originating from the stomach, colon, breast, endometrium, fallopian tubes, or cervix. Clinical manifestations are due to the primary tumor as well as due to the metastases. Diagnosis depends on imaging studies and can only be confirmed with a histopathological examination of the ovarian tissue specimen.


Presentation

Ovarian metastasis accounts for up to 30% of all ovarian malignancies. The term "Krukenberg tumor" is used in practice to include all metastatic ovarian tumors although only 40% of ovarian metastases are due to Krukenberg tumor which is a signet cell gastrointestinal malignancy [1]. Cancerous tumors from several organ systems, such as gastrointestinal and female genital tract, could spread to the ovaries [2]. Of these, the commonest are from the breast, colon, and stomach [2]. Lymphatic spread of tumor is faster and more common from the stomach to the ovaries than from the colon while the vascular spread is higher from the colon than from the stomach [2].

A majority of patients with ovarian metastases may be asymptomatic. When they present with symptoms, either the primary malignancy may be diagnosed concomitantly or may have been identified earlier [1] [3]. In addition to clinical manifestations of the primary malignancy, patients may complain of abdominal pain, swelling [4], bloating, and increase in abdominal girth (due to ascites) [5]. Hypertrophy of the ovarian tissue may result in endocrine manifestations such as virilization [6]. Common symptoms and signs of a malignancy such as weight loss, anorexia, easy fatiguability, asthenia, nausea, vomiting, and diarrhea may also be present. In addition, patients may complain of dysuria, increased frequency of micturition, and constipation due to compression of neighboring organs by the enlarged ovaries. Lower limb deep vein thrombosis and paraneoplastic syndromes are some of the other manifestations in individuals with ovarian metastases.

Krukenberg tumors are associated with bilateral, asymmetrical enlargement of the ovaries without peritoneal adhesions and deposits while metastases from other tumors are embedded within the ovarian capsule or in the peritoneum [1].

Fishing
  • Fluorescence in situ hybridization (FISH) analysis of the resected tumor tissue revealed the presence of an ALK rearrangement. Twenty months later, a large intrapelvic mass was detected in the patient at follow-up.[ncbi.nlm.nih.gov]
Pelvic Mass
  • A 5-year-old girl with stage M neuroblastoma presented with an upper abdominal and a pelvic mass. Evaluation after induction showed very good tumour response with three remaining localisations: two abdominal and one pelvic.[ncbi.nlm.nih.gov]
  • The value of the recently described ovarian pedicle sign in confirming the organ of origin of the pelvic mass is emphasized.[ncbi.nlm.nih.gov]
  • Abdominal and pelvic ultrasound imaging showed a complex pelvic mass suspicious of ovarian cancer. Laparoscopy was performed to exclude possibility of ovarian cancer and small bowel cancer.[ncbi.nlm.nih.gov]
  • Four years later, she complained of vaginal bleeding, and a pelvic mass was discovered by an abdominal computerized tomography scan. Tumor debulking and total hysterectomy with bilateral salpingo-oopherectomy were performed.[ncbi.nlm.nih.gov]
  • A computed tomography (CT) scan revealed a pelvic mass approximately 10 cm in diameter, but no mass was evident on a CT image taken 6 months before. The patient was diagnosed with left ovarian metastasis from colon cancer.[ncbi.nlm.nih.gov]
Abdominal Pain
  • After receiving a 6 course first line chemotherapy and 8 course maintenance therapy, the patient suffered acute abdominal pain, so surgery was performed.[ncbi.nlm.nih.gov]
  • The most common symptoms were abdominal pain or increased abdominal girth (63%). None of them had rectal bleeding. The ratio of cancer antigen-125 to carcinoembryonic antigen was available in 13 out 19 patients (less than 25 in 76.9%).[ncbi.nlm.nih.gov]
  • In addition to clinical manifestations of the primary malignancy, patients may complain of abdominal pain, swelling, bloating, and increase in abdominal girth (due to ascites).[symptoma.com]
  • Clinical description Malignant SCST of ovary may occur at any age but usually occurs in child bearing or post menopausal age groups, presenting with manifestations of mass effect (abdominal pain or distention, gastrointestinal symptoms, or abdominal mass[orpha.net]
  • Case report We report the case of a 36-year-old woman with previous complains of abdominal pain and moderate abdominal distension who was admitted in our hospital.[medichub.ro]
Forgetful
  • In conclusion, to investigate the primary site of a metastatic ovarian cancer, clinicians should not forget the lungs since the incidence of lung cancer in females is increasing.[ncbi.nlm.nih.gov]
Pelvic Pain
  • Abdominal or pelvic pain, abdominal bloating, or pain during intercourse, may be the presenting symptom. Irregular bleeding may also be seen. Median patient age at presentation is 48 years.[radiopaedia.org]
  • pain, bloating, ascites , or pain during sexual intercourse.[en.wikipedia.org]
  • We repot the case of a 36-year-old woman who was admitted in our hospital with pelvic pain and ascites and also with suspicion of peritoneal carcinomatosis.[medichub.ro]
  • The first case of EOPPC was reported by Swerdlow in 1959.[7] He described a 27-year-old woman experiencing pelvic pain, who, upon examination, was found to have an adnexal mass.[cancernetwork.com]
Incontinence
  • In May 2001, the patient was hospitalized with a three-month history of progressive vaginal bleeding and lower-abdominal discomfort with urinary incontinence.[academic.oup.com]

Workup

A working diagnosis of ovarian metastasis is made on clinical suspicion and physical examination findings while confirmation requires histological examination of either ovarian tissue or ascitic fluid. So the workup consists of a detailed history, thorough physical examination, laboratory tests, imaging studies, and pathohistological examination. History may or may not elicit clinical manifestations of a concurrent primary tumor.

Urinalysis is performed to rule out renal causes of symptoms. Tumor markers like beta-human chorionic gonadotropin, alpha-fetoprotein, lactate dehydrogenase, and cancer antigen-125 (CA 125) are not diagnostic [1]. Imaging studies include abdominal and pelvic ultrasonography or computed tomography (CT) along with chest X-ray to exclude pulmonary metastases and mammography to rule out breast malignancy [7] [8]. Positron emission tomography (PET) is indicated either to look for primary tumors or confirm the presence of metastatic lesions [9]. Magnetic resonance imaging (MRI) may be considered, although it is not confirmatory [10].

Histopathology of ovarian tissue or ascitic fluid and immunohistochemistry is required to confirm the diagnosis [1]. Microscopically, signet ring cells filled with mucin are characteristic of Krukenberg tumors and the cells are immunoreactive to epithelial markers such as epithelial membrane antigen and cytokeratins but nonreactive to vimentin and inhibin [11] [12].

Gastrointestinal (GI) endoscopy or GI imaging with barium enema may be necessary to look for primary tumors in patients with suspected gastric or colorectal malignancies.

Mediastinal Mass
  • A 49-year-old woman was admitted to hospital for dyspnea due to an anterior mediastinal mass. PET (Pozitron emission tomography) and CT (Computed tomography) combined to assess the mediastinal mass and lymph nodes.[scopemed.org]
Anterior Mediastinal Mass
  • A 49-year-old woman was admitted to hospital for dyspnea due to an anterior mediastinal mass. PET (Pozitron emission tomography) and CT (Computed tomography) combined to assess the mediastinal mass and lymph nodes.[scopemed.org]
Ovarian Mass
  • After three treatments, a check-up with computed tomography demonstrated the presence of a right ovarian mass. An ovariectomy was performed, and the pathological examination confirmed the diagnosis of an ovarian metastasis from an ocular melanoma.[ncbi.nlm.nih.gov]
  • We report the case of a 51 years old woman, treated 9 years before for papillary thyroid carcinoma, presenting to our Institute with a pelvic ovarian mass revealed by ultrasound imaging.[ncbi.nlm.nih.gov]
  • The ovarian mass showed similar features from the epigastric nodule, again suggestive of intestinal primary.[ncbi.nlm.nih.gov]
  • It is important to screen for ovarian metastasis from breast cancer when evaluating suspicious ovarian masses detected via transvaginal ultrasound in patients with a breast cancer history.[ncbi.nlm.nih.gov]
  • However, there are no highly specific radiological features that differentiate primary from metastatic ovarian masses.[jcp.bmj.com]
Lymphocytic Infiltrate
  • Yamazawa K, Seki K, Matsui H, Sekiya S (2001) Significance of perivascular lymphocytic infiltrates in endometrial carcinoma. Cancer 91: 1777-1784.[omicsonline.org]

Treatment

  • There have been several reports about successful fertility-preserving treatment of endometrial carcinoma with subsequent pregnancy. However, conservative hormonal treatment for early-stage endometrial cancer still entails some risk.[ncbi.nlm.nih.gov]
  • Little meaningful information is available regarding the treatment and outcome of synchronous ovarian metastasis of colon carcinoma.[ncbi.nlm.nih.gov]
  • In addition, this is the first account of an ovarian metastasis 10 years after primary treatment for cervical cancer.[ncbi.nlm.nih.gov]
  • BACKGROUND: The aim of this study was to determine the treatment strategy for ovarian metastases from gastric cancer, by a retrospective study of the treatment results.[ncbi.nlm.nih.gov]
  • Clinical presentations, pathologic findings, and treatment outcomes were analyzed. RESULTS: In total, 19 cases were collected in the study through a hospital tumor registry.[ncbi.nlm.nih.gov]

Prognosis

  • The lymph node status was of importance to determine the prognosis of patients with ovarian metastasis.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To study the prognosis and metastatic route of cervical carcinoma with ovarian metastasis. METHOD: From 1980 to 1993, 10 of the 1507 patients with cervical carcinoma operated and who had ovarian metastasis were analyzed.[ncbi.nlm.nih.gov]
  • This and five other reported cases demonstrate that ovarian metastasis from colorectal cancer may occasionally cause pseudo-Meigs' syndrome, and that resection of the ovarian lesions could improve the prognosis.[ncbi.nlm.nih.gov]
  • The prognosis of ovarian metastasis is dismal, because this is frequently associated with the peritoneal disseminations.[ncbi.nlm.nih.gov]
  • Consideration should also be given to the efficacy of oophorectomy for ovarian metastases and of intensive chemotherapy combined with jejunal resection for carcinoma because of the poor prognosis of these treatment modalities.[ncbi.nlm.nih.gov]

Etiology

  • Etiology Metastases to the ovary commonly arise from the gastrointestinal tract, breast, lungs and contralateral ovaries.[radiopaedia.org]
  • Etiology Mutations in the DICER1 (14q32.13) gene have been found to be a susceptibility factor for SCST, particularly in malignant Sertoli-Leydig cell tumor of ovary.[orpha.net]
  • Ki 67 positive 50% - IHC x40 Discussions Ovarian high-grade carcinoma in young women is rare and of unknown etiological factors, since current incriminated risk agents such as nulliparity, increased number of menstrual cycles, oral contraceptive use are[medichub.ro]

Epidemiology

  • Ovarian preservation in young patients with stage I cervical adenocarcinoma: a surveillance, epidemiology, and end results study. International Journal of Gynecological Cancer. 24(8):1513-20, 2014 Oct. Abstract .[rcog.org.uk]
  • Eltabbakh GH, Piver MS, Natarajan N, et al: Epidemiological differences between women with extra-ovarian primary peritoneal carcinoma and women with epithelial ovarian cancer. Obstet Gynecol 91:254-259, 1998. 20.[cancernetwork.com]
  • Summary Epidemiology Age related incidence rate was found to be 1 per 500,000 women. Sex cord stromal tumors constitute about 5% of ovarian malignancies.[orpha.net]
  • Below is the relative five-year survival rate for epithelial ovarian cancer: Below is the relative five-year survival rate for ovarian stromal tumors: Below is the relative five-year survival rate for ovarian germ cell tumors: The Surveillance, Epidemiology[healthline.com]
Sex distribution
Age distribution

Pathophysiology

  • Most common metastases are from endometrium, appendix (adenocarcinoid or mucinous adenocarcinoma), breast, colon, carcinoid, pancreas and stomach Metastatic mucinous carcinomas are most difficult to distinguish from primary mucinous ovarian neoplasm Pathophysiology[pathologyoutlines.com]

Prevention

  • Preventive Services Task Force Reaffirmation Recommendation Statement. USPSTF [On-line information].Available online at October 2012.[labtestsonline.it]
  • Intravenous octreotide is usually given before surgery to prevent carcinoid crisis. Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have.[cancer.net]
  • This finding indicates that miR-200 family not only inhibits CSC phenotypical formation but also acts as a gatekeeper to prevent OC cells from detaching and intravasation.[frontiersin.org]
  • Endometrial and ovarian cancer in women with Lynch syndrome: Update in screening and prevention. Fam Cancer,2013;12(2):273-7. 10.[medichub.ro]
  • Prior to the examination, patients whose images were obtained in 3.0T Signa EXCITE HD received intramuscular administration of 20 mg butyl-scopolamine (Buscopan; Nippon Boehringer Ingelheim, Tokyo, Japan) to prevent peristalsis artifacts, unless contraindicated[ncbi.nlm.nih.gov]

References

Article

  1. Fetohi M, Errarhay S, Bazine A, Namad T. Exophthalmos revealing a Krukenberg tumor: a case presentation and review of the literature. Case Rep Oncol. 2016;9(2): 409-414.
  2. Yamanishi Y, Koshiyama M, Ohnaka M, et al. Pathways of metastases from primary organs to the ovaries. Obstetrics and Gynecology International. 2011;2011:1-6.
  3. Hale RW. Krukenberg tumor of the ovaries. A review of 81 records. Obstet Gynecol. 1968;32:221.
  4. Young RH, Scully RE. Metastatic tumors of the ovary. In: Kurman RJ, editor. Blaustein's pathology of the female genital tract. New York: Springer; 2002; 1074.
  5. Goff BA, Mandel LS, Drescher CW, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007;109(2):221-227.
  6. Forest MG, Orgiazzi J, Tranchant DJ. Approach to the mechanism of androgen overproduction in a case of Krukenberg tumor responsible for virilisation during pregnancy. J Clin Endocrinol Metab. 1978;47:428.
  7. Fleischer A. Ovarian Cancer. In: Fleischer AC, Javitt MC, Jeffrey RB Jr, et al. Clinical Gynecologic Imaging. Philadelphia, Pa: Lippincott Williams & Wilkins. 1996; 107.
  8. Yazbek J, Raju SK, Ben-Nagi J, Holland TK, Hillaby K, Jurkovic D. Effect of quality of gynaecological ultrasonography on management of patients with suspected ovarian cancer: a randomized controlled trial. Lancet Oncol. 2008;9(2):124-131.
  9. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology, Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer. Available at http://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf. Version 1.2016; Accessed: March 30, 2017.
  10. Iyer VR, Lee SI. MRI, CT, and PET/CT for ovarian cancer detection and adnexal lesion characterization. AJR Am J Roentgenol. 2010;194(2):311-321.
  11. Ramzy I. Signet ring stromal tumor of ovary: histochemical, light, and electron microscopic study. Cancer. 1976;38:166–172.
  12. Wong PC, Ferenczy A, Fan L-D, McCaughey E. Krukenberg tumors of the ovary: ultrastructural, histochemical, and immunohistochemical studies of 15 cases. Cancer. 1986;57:751–760.

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Last updated: 2019-06-28 11:30