Modified posterior exenteration for ovarian cancer

The operative description of a modified posterior exenteration along with operative findings, other operative procedures, postoperative course, and follow-up information are presented for 47 patients (37 primary cytoreduction, ten secondary cytoreduction). All had stage IIIC or IV epithelial ovarian cancer with pelvic disease encasing the reproductive organs, pelvic peritoneum, cul-de-sac, and sigmoid colon. In addition to modified posterior exenteration, all patients had multiple other procedures performed as part of the cytoreductive efforts. Forty-five (95.7%) had optimal (less than 2 cm) cytoreduction and 18 (38.3%) had complete cytoreductive surgery. Thirty-four patients were ultimately rendered continent of feces (25 primarily and nine after colostomy reversal). Nine patients (19.1%) had serious morbidity and one (2.1%) died postoperatively. The median follow-up for those undergoing primary cytoreduction was 13.3 months (6-84). Nineteen (51.4%) were alive at the time of writing, 16 (43.2%) were dead, and two (5.4%) were lost to follow-up. Modified posterior exenteration effectively removes all visible pelvic disease with acceptable mortality. Hence, even patients with the most advanced cases of ovarian cancer may attain optimal cytoreduction and become ideal candidates for adjunctive therapy, with improved survival or a chance for cure.

[Imaging diagnosis of splenic metastasis]

The splenic metastasis of malignant diseases is uncommon. The relative paucity of this condition is thought to be due to the property of the spleen as an organ of immunity and the sharp angle of the splenic artery at its origin from the coeliac axis making it difficult for the tumor emboli to enter the spleen. The primary sites of 15 splenic metastases were: 7 (43%) ovarian tumors, and 8 (57%) others. All 15 patients had been repeatedly examined by ultrasonography. 6 patients were shown to give hyperechoic, 6 hypoechoic and 3 nonechoic findings. 10 patients had been examined by CT scan. Except one splenic metastasis of malignant teratoma with calcification, reduced density lesions were seen on ordinary and enhanced CT scans in all. We are of the opinion ther the most common route of splenic metastasis is hematogenous or direct seeding. The high incidence of splenic metastasis in gynecologic tumors may be related to their particular biologic behavior of being prone to direct seeding.

Fine needle aspiration biopsy diagnosis of a splenic metastasis from a papillary serous ovarian adenocarcinoma

Abdominal computed tomography (CT) revealed an asymptomatic, solitary splenic mass in a woman who had undergone hysterectomy and bilateral salpingo-oophorectomy for papillary serous ovarian adenocarcinoma four years previously. CT-guided fine needle aspiration (FNA) biopsy of the mass demonstrated the presence of nests of malignant epithelial cells in papillary structures. The FNA diagnosis of metastatic ovarian adenocarcinoma was confirmed by histologic study of the splenectomy specimen. Five years later, following several courses of chemotherapy, the patient was in apparent good health. This case again illustrates the value of FNA biopsy in diagnosing lesions in deeply situated organs, such as the spleen.

Ovarian carcinoma metastatic to the breast and axillary node

Breast cancer is a common primary malignancy in women. On rare occasion the breast is also the site of metastatic disease. This report describes the evaluation of breast and axillary masses in a patient with known ovarian cancer, including the radiographic evaluation and special immunohistochemical stains with CA-125. Flow cytometric determinations and hormonal receptor analysis on both the primary and metastatic tumors demonstrate similar biologic characteristics. Both tumor sites demonstrated positive CA-125 staining, aneuploid DNA populations, moderately positive estrogen receptor content, and negative progesterone receptors. The mammogram demonstrated a well-circumscribed lesion with several areas of microcalcifications. Blood-borne metastasis from the ovary to the breast can show a varied clinical picture that can be differentiated from that of a primary breast carcinoma.

Mucin-producing tumor of the pancreas

A new pancreatic tumor, called mucin-producing tumor, has received great attention in Japan. These tumors are found inside the pancreatic duct and produce large quantities of copious mucus. The authors examined 22 cases of these tumors histologically and histochemically. In 12 malignant cases, the tumors inside the ducts consisted of cancerous lesions over small areas along with papillary or atypical hyperplasia. Tumors in ten benign cases mainly consisted of papillary hyperplasia. Except for three patients with carcinoma in situ, cancerous tumors infiltrated the pancreatic parenchyma and, in some cases, were observed invading the bile duct or duodenum. A mucous histochemical study showed evidence of sialomucin in malignant cases; neutral mucin was dominant in benign cases. Characteristics of this disease were also compared with 13 cases of mucinous cystic neoplasm. From the results, it was concluded that these two diseases can be classified into the same conceptual category.

[Lymphangiosis carcinomatosa of the skin in ovarian cancer simulating scleroderma]

Skin metastases, as the first site of manifestation of ovarian carcinoma, are very uncommon. A report on a case of dermal lymphatic carcinomatosis of the lower part of the body and the breast with the clinical appearance of scleroderma is made. Skin biopsies were performed several times and an invasion of cutaneous lymphatic vessels by carcinoma cells and psammoma bodies due to ovarian cancer was observed, which led to the correct diagnosis of ovarian carcinoma.

[A case of ovarian cancer with liver metastasis successfully treated by PAC therapy]

Surgery was attempted in a case of stage IV ovarian cancer with a hepatic metastatic lesion measuring 119 x 96 mm. However, radical surgery was impossible and the operation ended up as no more than exploratory laparotomy. Before closing, Cisplatin 100 mg and Etoposide 200 mg were instilled into the intraperitoneal cavity. Two courses of systemic chemotherapy with PAC (Cisplatin 50 mg, Pirarubicin 40 mg, Cyclophosphamide 400 mg) were instituted. To examine shrinkage of the hepatic metastasis and the peritoneal tumors, A "Second look" operation was conducted. Abdominal simple total hysterectomy, bilateral salpingo-oophorectomy, omentectomy and partial sigmoidectomy resulted in no residual lesions in the peritoneal cavity with the exception of the hepatic metastatic lesion (69 x 57 mm). Two additional courses of PAC therapy were administered after the "Second look" operation. The hepatic metastatic lesion shrank to 45 x 41 mm; a decrease of 83.8% compared to the pre-therapy in size. Liver function tests and tumor chemical markers (TPA, CA 125, SLX) revealed decreased values that were consistent with a tumor size reduction. Good PR was achieved with only a systemic chemotherapy; i.e., without resorting to local injections of chemotherapeutic agents into the liver.

Biliary cystadenoma and cystadenocarcinoma: some unusual features

Biliary cystadenoma and cystadenocarcinoma are rare tumours which have a good prognosis after complete surgical removal. Correct pre-operative diagnosis depends on the imaging characteristics of the tumours. We have observed some unusual features including multifocal tumours with attachment to other abdominal organs, tumour presenting as cholangitic abscess, and distant metastasis after apparently complete resection by hemihepatectomy.

[Clinico-pathologic evaluation of retroperitoneal lymph node metastasis in ovarian carcinoma]

Retroperitoneal lymph node dissection was performed in 18 cases of ovarian carcinoma. Of 18 patients, 8 (44.4%) patients had lymph node metastasis. It was found that 50.0% of patients with stage III and 100% of patients with stage IV had lymph node metastasis. Serous cystadenocarcinoma and poorly differentiated carcinoma were demonstrated to be the risk factors in lymph node metastasis. Lymph node metastasis was found to be significantly correlated with the volume of ascites, peritoneal cytology, or peritoneal dissemination. Patients without peritoneal dissemination or positive peritoneal cytology had no lymph node metastasis. Patients with bilateral ovarian tumors tended to have a higher incidence of lymph node metastasis than those with a unilateral ovarian tumor. The incidence of para-aortic lymph node metastasis was found to be higher than that of pelvic or inguinal lymph node metastasis. We concluded that in the clinical stage, serous cystadenocarcinoma, poorly differentiated epithelial carcinoma, ascites, peritoneal cytology, peritoneal dissemination and bilateral ovarian tumors were assumed to affect the incidence of retroperitoneal lymph node metastasis of ovarian carcinoma. It was suspected that the lymphatic spread of ovarian carcinoma had two routes: via ascites and peritoneal dissemination.

[A case of recurrent ovarian cancer markedly responding to daily oral administration of low dose etoposide]

A 67-year-old woman with recurrent ovarian cancer, who had carcinomatous peritonitis and large abdominal cystic lesions, was treated by daily oral etoposide at a dose of 50 mg/day for 21 consecutive days at 2-week intervals in the outpatient department. After 15 days of administration, the serum level of CA125 decreased from 2,220U/ml to 445U/ml, and that of LDH from 2,725 WU to 906 WU. After the third course of treatment, the abdominal cystic lesions were remarkably reduced, and the performance status improved grade 1 from 3 prior to the administration. No severe side effects except for alopecia and mild myelosuppression were noted during the 3-month treatment.

Cystic tumors of the pancreas. New clinical, radiologic, and pathologic observations in 67 patients

Within a 12-year period we treated 67 patients (49 women, 18 men; mean age, 61 years) with cystic neoplasms of the pancreas, including 18 serous cystic adenomas, 15 benign mucinous cystic neoplasms, 27 mucinous cystadenocarcinomas, 3 papillary cystic tumors, 2 cystic islet cell tumors, and 2 cases of mucinous ductal ectasia. Mean tumor size was 6 cm (2 to 16 cm). In 39% the patients had no symptoms, and in 37% the lesions had been misdiagnosed as a pseudocyst. Computed tomography was useful for detection, for distinguishing the microcystic subgroup of serous cystadenoma, and for showing rim calcification (all 7 cases were malignant) but was not reliable for distinguishing neoplasm from pseudocyst, serous from mucinous tumors, or benign from malignant. Arteriography showed hypervascularity in 4 of 10 serous adenomas, 3 of 11 mucinous carcinomas, and 1 of 1 papillary cystic tumors. Endoscopic pancreatography showed no communication with the cyst cavity in 37 of 37 cases of cystic neoplasms but opacified the ectatic ducts in 2 of 2 cases of mucinous ductal ectasia. Stenosis or obstruction of the pancreatic duct indicated cancer. The tumor was resected by distal pancreatectomy in 25 patients, by proximal resection in 29, and by total pancreatectomy in one, with no operative deaths. Forty-four per cent of the tumors were malignant. In 10 cases the tumor was unresectable because of local extension or distant metastases, and those patients died at a mean of 4 months. Seventy-five per cent of those resected for cure are alive without evident recurrence. Because the epithelial lining of the tumor was partially (5% to 98%) absent in 40% to 72% of cases of the major tumor types, and the mucinous component comprised only about 65% of mucinous cystadenoma lining, misdiagnoses on frozen and even permanent sections were made. Mitoses and histologic solid growth correlated with malignancy. Neuroendocrine elements were seen in 87% of benign and 47% of malignant mucinous tumors. It is recommended that the terms macrocystic and microcystic be abandoned in favor of the histologic designations serous and mucinous. Incomplete examination of the cyst wall can be misleading, however. It is suggested that mucinous ductal ectasia be recognized separately from cystic tumors and that all of these lesions be resected, with the possible exception of asymptomatic confirmed serous cystadenomas.

[Clinical aspects and morphology of extra-ovarian serous cancer of the pelvis]

An extraovarian peritoneal serous carcinoma is characterised macroscopically by ovaries without pathology, histologically, however, by a serous carcinomatous structure in the pelvis, in an advanced tumour stage of usually marked peritoneal carcinomatosis. Extraovarian pelvic serous carcinomas are rarely described in literature. In our study on five patients with such carcinomas, laparotomy findings revealed peritoneal carcinomatosis as in advanced ovarian carcinomas, but without ovarian involvement. Histogenesis does not reveal any difference between the extraovarian mesothel, which is of Mullerian origin and the serous ovarian carcinoma. Therapy of extraovarian peritoneal carcinoma is similar to that of ovarian cancer with maximal tumour reduction and cisplatinum or carboplatinum containing chemotherapy. The prognosis is extremely unfavourable with little expectation of lengthy remission and survival rates are short. Extraovarian serous carcinomas deserve better recognition because they are underreported. They must be differentiated from malignant mesotheliomas, which are not of Mullerian origin.

Serous adenocarcinoma of the uterus metastatic to the urinary bladder mimicking primary bladder neoplasia. A report of a case

A 72-year-old woman with a history of transitional cell carcinoma of the urinary bladder was found to have a vesical neoplasm at cystoscopy. Microscopic examination of a biopsy specimen showed papillary adenocarcinoma. A subsequent endometrial biopsy, performed because of vaginal spotting, disclosed a serous papillary adenocarcinoma. A hysterectomy was performed. Pathologic examination showed that the tumor was deeply invasive of the myometrium. The uterine and bladder tumors were similar histologically. This case suggests that when examining a pure adenocarcinoma of the bladder, the pathologist should consider the possibility that it represents metastatic disease even in the absence of a known tumor elsewhere.

[Gastric metastases of ovarian adenocarcinoma. Apropos of a case]

A case report and review of literature. Four types of neoplastic dissemination exist in presence of ovarian adenocarcinomas. Commonly, these tumors metastasize along intraperitoneal ways or lymphatic channels. Less frequently, the tumors are invading surrounding organs by direct extension. Rarely, there is a hematogenous dissemination. The observation of a gastric metastasis is reported; we consider it as a hematogenous one. Reviewing the literature, we find few similar cases. Gastric metastases originate more frequently from malignant melanomas, adenocarcinomas of the breast and bronchogenic tumors.

Ovarian carcinoma metastatic to breast: a case report and review of the literature

Breast metastasis from ovarian carcinoma is a rare event, with only 26 cases being previously reported in the English literature. The twenty-seventh such case is presented herein, and the literature on this topic is reviewed. Metastases to the breast from the ovary signal widespread metastases and generally herald a rapid deterioration and death. Although rare, it is important that metastatic cancer to the breast be differentiated from primary breast carcinoma as both the treatment and prognosis differ significantly.

Six new monoclonal antibodies to serous, mucinous, and poorly differentiated ovarian adenocarcinomas

Six monoclonal antibodies directed against ovarian adenocarcinoma were generated by use of 100,000 x g supernatants of Triton-X-100 solubilized extracts of ovarian serous adenocarcinoma as the antigen source. Immunoperoxidase preparation of frozen-sections and routinely processed paraffin section specimens revealed a highly restricted reactivity of these antibodies when tested with adult (n = 2) and fetal (n = 3) tissue types. Coreactivities were occasionally observed with epithelia of the kidney, mammary gland, and pancreas. One monoclonal antibody, Ki-OC I-6-2, cross-reacted only with epididymal epithelia. No coreaction occurred with normal tissue of the ovary, Fallopian tube, or uterus. All antibodies were additionally tested on 74 cases of nonovarian malignancies, 15 cases of ovarian metastases of nonovarian carcinomas, and 114 specimens of ovarian neoplasms other than carcinomas. Ki-OC I-6-2 had no cross-reactivity with these tumors except for one case of renal cell carcinoma. This monoclonal antibody recognized serous, mucinous, and poorly differentiated adenocarcinoma cell types. None of the six antibodies reacted with clear cell or endometrioid carcinoma. All were found to be of the IgG-1 subclass. The tumor antigen to which Ki-OC I-6-2 immunoreacted was estimated to have a molecular weight of 80 kilodaltons (KD).

Serous papillary adenocarcinoma of the endometrium. Analysis of proto-oncogene amplification, flow cytometry, estrogen and progesterone receptors, and immunohistochemistry

Primary and metastatic tumor tissues of serous papillary adenocarcinoma of the endometrium were examined for the following: (1) amplification of int-2, c-erbB-2 and c-myc proto-oncogenes by Southern blot hybridization; (2) DNA ploidy by flow cytometric study; (3) and expression of specific proteins, such as estrogen and progesterone receptors, keratin, vimentin, and carcinoembryonic antigen (CEA) using immunohistochemical and biochemical techniques. Amplification of c-myc was observed in the specimens from the endometrium (ten-fold) and from omental metastasis (five-fold). Both int-2 and c-erbB-2 amplification were not observed. The tumor showed aneuploidy, with the specimens from the endometrium and omental metastasis exhibiting multiple populations of aneuploid tumor cells. Estrogen and progesterone receptors could not be detected biochemically; however, immunohistochemically, estrogen receptors were observed in tumor cells forming papillary structures but not in the tumor cells of the solid, more poorly differentiated areas. A similar distribution was observed for both low and high molecular weight keratin. The findings of c-myc amplification and aneuploidy in the serous papillary adenocarcinoma of the endometrium are consistent with its aggressive behavior observed clinically and emphasize the importance of distinguishing this lesion from other types of endometrial carcinoma.

[Omental metastasis in primary ovarian cancer]

Omentectomy was performed in 74 patients with primary cancer of the ovary. Omental metastasis was found in 60.8% (45 cases). The highest rates of omental metastasis were observed in serous carcinoma (56%) and endodermal sinus tumor (67%). Omental metastasis was correlated to types of tumor, amount of ascitic fluid, survival rate and extent of resection of omentum. The authors believe that omentectomy should routinely carried out in patients with primary ovarian cancer.

Interactive morphometry of normal and hyperplastic peritoneal mesothelial cells and dysplastic and malignant ovarian cells

This study used computerized interactive morphometry to evaluate the differential characteristics of mesothelial normal cells, mesothelial hyperplastic cells, and carcinomatous cells, and also compared hyperplastic mesothelial cells with ovarian dysplastic cells from a previous study. The procedure included extraction of multiple descriptors of the nuclear profile: perimeter length, area, longest chord, circularity factors, standard deviations of these characteristics, and a 10-bin size distribution table of the nuclear area. The final classification is achieved by stepwise discriminant analysis of these variables. The analysis classified all cases correctly with high posterior probabilities.