Metastases to the female genital tract. Analysis of 325 cases

Recurrent breast carcinoma presenting as postmenopausal vaginal bleeding: A case report

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We discuss the recurrence of breast carcinoma presenting as postmenopausal vaginal bleeding in a patient on Tamoxifen therapy.

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Case report illustrates widespread genital tract manifestation of recurrent disease at time of presentation and rapid disease progression.

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Discusses the importance of maintaining broad differential in diagnosis of postmenopausal vaginal bleeding

Lung cancer diagnosis on ovary mass: a case report

Metastatic neoplasms to the ovary often cause diagnostic problems, in particular those large ovarian masses mimicking primary tumors. Most of these tumors arise from digestive system or breast, while 37-year-old woman diagnosed as right adnexal complex mass, with a subpleural nodule in the apical part of the left lower lobe, at preoperative chest computed tomography scan. The patient underwent total abdominal hysterectomy with right salpingo-oophorectomy (ovarian mass 220 × 200 mm), total omentectomy, left ovarian biopsy, peritoneal random biopsies, and peritoneal washings for cytology. Pathologic and immunohistochemical examination of ovarian specimen suggested morphology and expression of metastatic lung adenocarcinoma with an intense positivity for Thyroid Transcriptional Factor-1 (TTF-1) and Cytokeratin 7 (CK7) staining. Fine needle biopsy of the lung nodule found epithelioid like malignant cells, confirming the diagnosis of an ovarian metastasis from a primary lung cancer.

This report focused on the clinical and pathologic diagnostic challenge of distinguishing secondary from primary ovarian neoplasms. Issues on useful immunohistochemical stains are also discussed.

Ovarian metastasis from lung cancer: a rare entity

This paper describes a case of ovarian metastasis from lung carcinoma along with its diagnostic challenges, clinical management, and review of the literature. A 49-year-old woman was admitted to our emergency department with complaints of abdominal pain and vomiting. A laparoscopic appendectomy was performed due to acute appendicitis, and a unilateral oophorectomy (left side) via laparoscopy was performed due to the detection of an ovarian mass. Immunohistochemical staining of the ovarian mass revealed that it was reactive to cytokeratin-7 (CK-7) but negative for CK-20. The immunohistochemical and pathological features of the tumor indicated an ovarian metastasis of non-small-cell lung cancer. The patient underwent chemotherapy and was followed up by the oncology department. Her postoperative regular followup of 6 months showed that her condition was stable with no recurrence. The management of female patients with acute abdominal pain and pelvic masses should consist of a multidisciplinary approach to include the diagnosis of any distant organ metastasis.

Challenging diagnosis of a jejunal adenocarcinoma with ovarian metastasis: report of an unusual case

We report the first documented case of ovarian metastasis from a jejunal primary adenocarcinoma in an Australian patient. The presentation was unusual, initially a suspicious abdominal nodule in the epigastric area, which turned out to be an adenocarcinoma of possible intestinal origin. Gastroscopy and colonoscopy were performed with no suspicious lesion identified. 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. The ovarian mass showed similar features from the epigastric nodule, again suggestive of intestinal primary. Definitive diagnosis was obtained when the patient represented 2 months later with malignant bowel obstruction requiring palliative resection of the proximal jejunum. This case demonstrates the difficulty in diagnosing ovarian metastasis from a small bowel primary, which has the potential to mimic an ovarian primary tumour clinically, and a large bowel or ovarian primary pathologically.

Isolated uterine metastasis of invasive ductal carcinoma

Introduction. Most common metastasis sites of breast cancer are the lungs, bones, liver, and brain, whereas uterine involvement by metastatic breast disease is rare. Metastatic carcinoma of the uterus usually originates from other genital sites, most commonly being from the ovaries. Invasive lobular carcinoma spreads to gynecologic organs more frequently than invasive ductal carcinoma. Case Report. A 57-year-old postmenopausal woman was diagnosed with breast carcinoma 2 years ago and modified radical mastectomy was performed. Pathological examination of tumor revealed invasive ductal carcinoma, stage IIIc. She presented with abdominal pain and distension. Diagnostic workup and gynecologic examination revealed lesions that caused diffuse thickening of the uterus wall. Endometrial sampling was performed for confirmation of the diagnosis. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Breast carcinoma metastases in endometrium and myometrium were confirmed histopathologically and immunohistochemically. Conclusion. We herein report the first case of isolated uterine patient who had invasive ductal carcinoma of breast.

Primary and secondary malignant involvement of gynaecological organs at radical cystectomy for bladder cancer: review of literature and retrospective analysis of 360 cases

The pathological analysis of cystectomy specimens from 360 female patients who underwent radical cystectomy for bladder cancer was retrospectively reported. The uterus was not available in 29 specimens, while one ovary was absent in 18 specimens and the two ovaries were absent in 20 specimens. Uterine involvement was observed in one case of transitional cell carcinoma, and benign uterine pathology was detected in 37 cases. All patients had normal ovaries, while the vagina was involved in 13 cases. A total of 12% of the patients had urethral involvement. None of the 29 patients, in whom the internal genitalia were totally or partially preserved, had late ovarian, vaginal or uterine recurrence at the last follow-up. Thus, the preservation of female internal genitalia in young patients undergoing radical cystectomy should be considered under strict criteria (low-grade, low-stage tumours away from the bladder neck). This will improve the quality-of-life (QoL) and the functional outcome without compromising cancer control.

LAPTM4B overexpression is a novel independent prognostic marker for metastatic ovarian tumors

OBJECTIVE

Metastatic ovarian tumors are a series of lethal carcinomas that almost always have bad prognosis. Their prognoses, however, vary depending on the primary tumor malignancies of each. It has been reported that LAPTM4B, a novel tumor-associated gene, might indicate a worse prognosis when it was overexpressed in other carcinomas. Therefore, the authors expected to investigate whether LAPTM4B overexpression is an independent prognostic marker in metastatic ovarian tumors.

METHODS

Immunohistochemistry was used to assess LAPTM4B expression in metastatic ovarian tumors from 102 patients. Subsequently, univariate and multivariate survival analyses with Cox regression were performed to determine the association between LAPTM4B expression and prognosis. To identify any differences in prognosis between the 2 groups of patients with differing primary malignancies, the log-rank test was used.

RESULTS

The median overall and progression-free survival rates of patients with tumors of gastrointestinal tract origin were 0.97 and 0.51 years, respectively, and both were statistically significantly lower than those of patients with tumors of breast origin (P < 0.0001), which were 2.68 and 1.96 years, accordingly. Of 102 patients, 77 were classified as having a high expression of LAPTM4B, and LAPTM4B expression had a significant association with the prognosis of metastatic ovarian tumors (P < 0.01); no statistically significant interaction between LAPTM4B expression and primary malignancies was detected (P > 0.1). On the other hand, medians of overall survival and progression-free survival of patients with tumors of gastrointestinal tract origin were significantly lower than those of patients with tumors of breast origin (P < 0.0001).

CONCLUSIONS

Patients with metastatic ovarian tumors of breast origin had significantly better prognosis than those with the disease from gastrointestinal tract primary malignancies. LAPTM4B overexpression might be an independent prognostic marker of metastatic ovarian tumors.

A gene expression profile test for the differential diagnosis of ovarian versus endometrial cancers

We have developed a gene expression profile test (Pathwork Tissue of Origin Endometrial Test) that distinguishes primary epithelial ovarian and endometrial cancers in formalin-fixed, paraffin-embedded (FFPE) specimens using a 316–gene classification model. The test was validated in a blinded study using a pre-specified algorithm and microarray files for 75 metastatic, poorly differentiated or undifferentiated specimens with a known ovarian or endometrial cancer diagnosis. Measures of test performance include a 94.7% overall agreement with the known diagnosis, an area under the ROC curve (AUC) of 0.997 and a diagnostic odds ratio (DOR) of 406. Ovarian cancers (n=30) gave an agreement of 96.7% with the known diagnosis while endometrial cancers (n=45) gave an agreement of 93.3%. In a precision study, concordance in test results was 100%. Reproducibility in test results between three laboratories was 94.3%. The Tissue of Origin Endometrial Test can aid in resolving important differential diagnostic questions in gynecologic oncology.

Signet-ring cell carcinoma of the breast with uterine metastasis treated with extensive cytoreductive surgery: a case report and brief review of the literature

Primary signet-ring cell carcinoma (SRCC) of the breast is an uncommon variant, accounting for 2-4.5% of all primary breast cancers. Secondary SRCC of the endometrium is very rare and usually originates from the breast or gastrointestinal tract. A 54-year-old, postmenopausal woman with a past history of breast cancer four years previously was admitted with abnormal uterine bleeding. An endometrial biopsy revealed undifferentiated adenocarcinoma with signet-ring cells. The patient underwent laparotomy and cytoreductive surgery was performed. Pathological analysis and immunohistochemical tests demonstrated a uterine (endomyometrial) metastasis of breast SRCC. Omentum, peritoneal surfaces and retroperitoneal lymph nodes also included tumoral tissue with signet-ring cell morphology. The patient received adjuvant systemic chemotherapy with adriamycin, cyclophosphamide and paclitaxel. This case report discusses the patient's clinical characteristics and the role of cytoreductive surgery on patient survival in SRCC of the breast metastasizing to the uterus.

Adenocarcinoma metastatic to the uterine cervix: a case series

AIMS

The objectives of this report are, first, to describe the clinical behavior of cases of carcinoma metastatic to the uterine cervix treated at our institution in order to carry out a systematic review to establish the behavioral patterns of the most frequent metastases to the cervix and, second, to generate guidelines for their diagnosis and treatment.

METHODS

At the National Institute of Cancer of Mexico (INCan), we performed a review of the clinical files with a diagnosis of malignant neoplasm metastatic to the uterine cervix between 1990 and 2009. For a systematic review, we conducted a PubMed search between the years 1970 and 2009 of case reports and series of cases of patients with metastatic gastric, breast, ovarian and colorectal cancer. We analyzed each report individually and extracted the patients' clinical data from our cases and reports, including the primary tumor, cervical metastases and survival rates.

RESULTS

There were 10 cases of tumors metastatic to the uterine cervix. Metastasis was documented in one-half of the patients during follow up, with two of these cases having the cervix as the only site. We included the following reports in the systematic review: 13 reports of gastric-associated cancer, 30 related to breast cancer, nine with ovarian-associated cancer and 10 related to colorectal cancer.

CONCLUSIONS

Metastatic cervical activity is an infrequent event. The prognosis of survival is poor in the presence of gastric or ovarian cancer and cervical metastases.

Pathology of primary and metastatic mucinous ovarian neoplasms

Recent years have seen a dramatic change in the pathological approach to ovarian mucinous neoplasms. A substantial proportion of tumours previously considered to be ovarian primaries actually represent secondary ovarian involvement by tumours elsewhere in the body. Two major categories of tumour have completely disappeared from the diagnostic spectrum: ovarian ‘borderline’ mucinous tumour associated with pseudomyxoma peritonei, and widely disseminated mucinous carcinomas. The emergent picture of true ovarian primary carcinoma of pure mucinous morphology is that this is a rare malignancy that is low grade and low stage at presentation in the vast majority of cases, with a very low likelihood of aggressive clinical behaviour. A large volume of literature has appeared concerning the pathological distinction of primary from metastatic ovarian mucinous neoplasms in view of the dramatically different prognosis and treacherously similar morphology. Clinicopathological parameters useful in the distinction of primary from metastatic mucinous ovarian carcinomas are reviewed. Major features favouring metastases are bilaterality, size <10 cm, surface involvement, extensive intra-abdominal spread and an extensive infiltrative pattern with desmoplasia. Two morphological patterns essentially exclude ovarian origin: colloid and signet ring carcinomas. Features favouring primary ovarian origin are unilaterality, large size >12 cm, smooth external surface and association with other ovarian pathology. An admixture of benign, borderline and malignant patterns in the same tumour favour primary origin, but can be misleading as a ‘maturation’ pattern in metastases can result in the same appearance.

Endometrial carcinomas: a review emphasizing overlapping and distinctive morphological and immunohistochemical features

This review focuses on the most common diagnostic pitfalls and helpful morphologic and immunohistochemical markers in the differential diagnosis between the different subtypes of endometrial carcinomas, including: (1) endometrioid versus serous glandular carcinoma, (2) papillary endometrioid (not otherwise specified, villoglandular and nonvillous variants) versus serous carcinoma, (3) endometrioid carcinoma with spindle cells, hyalinization, and heterologous components versus malignant mixed müllerian tumor, (4) high-grade endometrioid versus serous carcinoma, (5) high-grade endometrioid carcinoma versus dedifferentiated or undifferentiated carcinoma, (6) endometrioid carcinoma with clear cells versus clear cell carcinoma, (7) clear cell versus serous carcinoma, (8) undifferentiated versus neuroendocrine carcinoma, (9) carcinoma of mixed cell types versus carcinoma with ambiguous features or variant morphology, (10) Lynch syndrome-related endometrial carcinomas, (11) high-grade or undifferentiated carcinoma versus nonepithelial uterine tumors. As carcinomas in the endometrium are not always primary, this review also discusses the differential diagnosis between endometrial carcinomas and other gynecological malignancies such as endocervical (glandular) and ovarian/peritoneal serous carcinoma, as well as with extra-gynecologic metastases (mainly breast and colon).

NY-BR-1 and PAX8 immunoreactivity in breast, gynecologic tract, and other CK7+ carcinomas: potential use for determining site of origin

The distinction between breast and müllerian carcinomas from each other and from tumors with a similar cytokeratin profile can be difficult. We tested the usefulness of 2 new markers, NY-BR-1 and PAX8, by staining a variety of breast and gynecologic carcinomas, along with tumors of pancreas, bile ducts, stomach, and gastroesophageal junction. NY-BR-1 expression (ie, H score >10) was seen in 58.4% of breast carcinomas (111/190), 5.6% of müllerian carcinomas (8/142), 7% of pancreatic tumors (1/15), 0% of cholangiocarcinomas (0/22), 0% of gastric tumors (0/36), and 0% of gastroesophageal carcinomas (0/25). All 188 breast carcinomas were negative for PAX8. PAX8 expression was seen in 72.4% of müllerian tumors (105/145). All pancreatic tumors (n = 15), cholangiocarcinomas (n = 23), and gastric (n = 35) and gastroesophageal junction (n = 25) carcinomas were negative for PAX8. Addition of NY-BR-1 and PAX8 in a panel would be useful in distinguishing breast cancer, gynecologic tumors, and tumors of the upper gastrointestinal tract.

Cervical Metastasis From Colorectal Cancer

Metastatic carcinoma from colorectal cancer to the uterine cervix is rare. We report a case of metastatic carcinoma from a right colon cancer to the cervix with vaginal extension 3 years after primary treatment. Our report highlights the importance of immunohistochemical analysis to determine the origin of uterine cervix cancer in the event of adenocarcinoma in a patient with a history of colorectal cancer to adapt therapeutic strategy accordingly.

Presentation of renal cell carcinoma as cervical polyp metastasis

Secondary cervical adenocarcinomas are most commonly seen owing to the extension of a primary endometrial adenocarcinoma. Metastatic tumors from other sites are rather uncommon and, when seen, are most frequently from the ovaries, gastrointestinal tract, or breast. We report a case of metastatic renal cell carcinoma, clear cell variant, to the cervix, which presented as a cervical polyp in a postmenopausal female. To our knowledge, this is the fourth reported case of renal cell carcinoma metastatic to the cervix. This case is only the third in which the cervical metastasis was the presenting sign of renal cell carcinoma and the first in which the clinical presentation was as a cervical polyp.

Uterine metastases in ovarian carcinoma: frequency and survival in women who underwent hysterectomy

OBJECTIVE

Possible reasons for hysterectomy in the initial surgical management of advanced invasive epithelial ovarian carcinoma (EOC) might be a high frequency of uterine involvement and its impact on survival. The aim of the present study was to describe the frequency of uterine involvement and its association with survival in an unselected population of EOC patients who underwent hysterectomy.

METHODS

All incident cases of EOC diagnosed in Israeli Jewish women between March 1994 to June 1999, were identified within the framework of a nationwide case-control epidemiological study. The target population of the present report includes all stage II-IV EOC patients who had a uterus at the time of diagnosis. Of the 822 such patients, 695 fulfilled the inclusion criterion. Excluded were 141 patients for various reasons. The present analysis is based on the remaining 554 patients.

RESULTS

Uterine involvement was present in 291 (52.5%) of the patients and it was macroscopic in only 78 (14.1%). The serosa was the most common site of isolated metastases. Multivariate analysis showed that advanced stage significantly increased the risk for uterine involvement. The overall median survival with any uterine involvement was significantly lower compared to those with no involvement (38.9 months vs. 58.0 months; p<0.001).

CONCLUSION

There is an association between uterine involvement, whether macro- or microscopic, and lower survival even after hysterectomy although residual tumor could not be included in the analysis. Further studies are required to establish whether uterine involvement itself is an unfavorable risk factor or merely a marker of other unfavorable prognostic factors.

A genomic and transcriptomic approach for a differential diagnosis between primary and secondary ovarian carcinomas in patients with a previous history of breast cancer

Background

The distinction between primary and secondary ovarian tumors may be challenging for pathologists. The purpose of the present work was to develop genomic and transcriptomic tools to further refine the pathological diagnosis of ovarian tumors after a previous history of breast cancer.

Methods

Sixteen paired breast-ovary tumors from patients with a former diagnosis of breast cancer were collected. The genomic profiles of paired tumors were analyzed using the Affymetrix GeneChip^® Mapping 50 K Xba Array or Genome-Wide Human SNP Array 6.0 (for one pair), and the data were normalized with ITALICS (ITerative and Alternative normaLIzation and Copy number calling for affymetrix Snp arrays) algorithm or Partek Genomic Suite, respectively. The transcriptome of paired samples was analyzed using Affymetrix GeneChip^® Human Genome U133 Plus 2.0 Arrays, and the data were normalized with gc-Robust Multi-array Average (gcRMA) algorithm. A hierarchical clustering of these samples was performed, combined with a dataset of well-identified primary and secondary ovarian tumors.

Results

In 12 of the 16 paired tumors analyzed, the comparison of genomic profiles confirmed the pathological diagnosis of primary ovarian tumor (n = 5) or metastasis of breast cancer (n = 7). Among four cases with uncertain pathological diagnosis, genomic profiles were clearly distinct between the ovarian and breast tumors in two pairs, thus indicating primary ovarian carcinomas, and showed common patterns in the two others, indicating metastases from breast cancer. In all pairs, the result of the transcriptomic analysis was concordant with that of the genomic analysis.

Conclusions

In patients with ovarian carcinoma and a previous history of breast cancer, SNP array analysis can be used to distinguish primary and secondary ovarian tumors. Transcriptomic analysis may be used when primary breast tissue specimen is not available.

Secondary ovarian malignancies: frequency, origin, and characteristics

OBJECTIVE

To evaluate the frequency of metastatic tumors among malignant ovarian neoplasms, the site distribution of the primary malignancies that give rise to ovarian metastasis and the clinicopathologic features of metastatic tumors.

METHODS

We analyzed a total number of 116 patients diagnosed with metastasis to the ovary between 1985 and 2007 at the Radboud University Nijmegen Medical Centre. The medical records of the patients were reviewed for age at diagnosis, medical history, menopausal state, clinical manifestation, primary tumor, intraoperative findings, and prognosis. The pathology reports were reviewed for macroscopic appearances and histopathologic features.

RESULTS

Metastasis to the ovary accounted for 15% of all ovarian malignancies identified in the 22-year period at the Radboud University Nijmegen Medical Centre. The gastrointestinal tract was the most common primary site (39%), followed by breast (28%) and endometrium (20%). There were 22 metastases to the ovary that mimicked a primary ovarian tumor at first clinical presentation, of which the single greatest number of cases (36%) originated from a primary tumor of the large intestine. Ovarian cysts were present in 71% of patients, and most ovaries with metastatic disease were 10 cm in diameter or less. Bilateral ovarian involvement was present in 69% of the patients, including all patients with tumors of the stomach.

CONCLUSION

In case of an ovarian tumor, metastatic disease should always be considered to avoid pitfalls in diagnosis and therapy. The gastrointestinal tract is the most likely location of the primary tumor, followed by breast and endometrium.

Ovarian Metastases in Colorectal Cancer

Purpose:

The aims of this study were to determine the incidence, clinicopathologic features, and prognostic factors of ovarian involvement in primary colorectal cancer (CRC) and also to clear the role of prophylactic oophorectomy.

Methods:

Data from women with primary CRC treated between 1990 and 2004 were retrieved, and clinical and pathologic features of those who had undergone oophorectomy during CRC surgery were reviewed.

Results:

One hundred eighty cases (mean age, 48 years) were included. In 120 cases, ovaries were preserved, and 60 cases underwent bilateral oophorectomy in addition to primary CRC resection. Reasons for oophorectomy were prophylactic in 22 (36.6%), abnormal morphology in 35 (58.3%), and undetermined in 3 cases (5%). There were 5 metastatic carcinomas, 8 primary ovarian tumors, and 47 normal ovaries in the pathologic evaluation. No complication directly related to oophorectomy was noted. Patients with ovarian metastases had higher stages of tumor. Ovarian metastases were not related to menstrual status, CRC location, size, differentiation, and mucin production, as well as abnormal morphology of the ovary. The global prevalence of ovarian metastases in CRCs was 2.7%, and isolated ovarian metastases occurred in fewer than half of them. Of 120 women who underwent colectomy alone, 8 (6.6%) developed ovarian metastasis during 2 years of follow-up. Only 3 cases had isolated ovarian metastases. No patient with synchronous or metachronous ovarian metastases from CRC survived 5 years.

Conclusions:

Isolated ovarian metastases from primary CRC occur with a low frequency, and this may partially explain the debate regarding prophylactic oophorectomy at the time of curative resection for primary CRC.

Metastatic versus primary oncocytic papillary adenocarcinoma of the endometrium: a report of a case and review of the literature

We report a case of an oncocytic papillary adenocarcinoma of the endometrium in an 89-year-old female with vaginal bleeding. Imaging studies revealed lesions in the uterus, kidneys, pancreas, gluteus, and an enlarged portacaval lymph node. Diagnostic workup included an endometrial biopsy which showed malignant, oncocytic cells in a predominantly papillary pattern. These cells stained positive for epithelial markers (pan-cytokeratin, CK7, epithelial membrane antigen) and weakly for estrogen receptor. The cells were negative for cytokeratin 903, CAM 5.2, progesterone receptor, CD10, RCC Marker, CA-125, c-kit, and vimentin. Consultation with experts in Gynecologic and Genitourinary pathology returned a diagnosis of "adenocarcinoma compatible with metastatic renal cell carcinoma"--an intriguing possibility worthy of further exploration. To our knowledge, there are no reports in the literature of metastatic oncocytic papillary renal cell carcinoma to the endometrium. The clinical and pathologic features of oncocytic papillary endometrial lesions, including primary and metastatic processes, are reviewed.

Colonic carcinoma metastatic to the endometrium: the importance of clinical history in averting misdiagnosis as a primary endometrial carcinoma

Metastases to endometrium are a rare event. A case of a 53-year-old woman with a previous colon cancer presenting with a dysfunctional uterine bleeding is reported. The curettage specimens consisted of multiple fragments of proliferative endometrial tissue mixed with irregular glands, focally amputated, lined by very cells with elongated, hyperchromatic nuclei and solid sheets of neoplastic cells often filled with necrotic debris and inflammatory cells, resembling endometrioid adenocarcinoma. Neoplastic cells resulted positive at immunohistochemical reaction for CK20, CDX2, p53 and negative for CK7, vimentin, ER, and PR suggesting a metastatic colon adenocarcinoma. Absence of premalignant changes, such as hyperplasia, besides frankly malignant glands in an endometrial curette should be regarded as an alarming feature for a secondary nature mostly from large bowel. In these cases clinical history is crucial and an immunohistochemical panel made up of CK7, CK20, CDX2, p53, vimentin, ER, and PR is useful for the correct diagnosis.

Ovarian metastases from colorectal cancer: a clinicopathological analysis of 103 patients

OBJECTIVE

To improve management of ovarian metastasis through assessment of clinicopathological features and treatment outcomes associated with ovarian metastasis from colorectal cancer.

METHOD

We recruited 103 subjects who were diagnosed with ovarian metastasis and subjected to surgery between June 1989 and December 2005. Clinical and pathological variables were evaluated. Survival and its associated factors were analysed with a median follow-up of 31 months after ovarian surgery (range 1-129 months).

RESULTS

The mean age at diagnosis was 46 years (range 14-72 years), synchronous ovarian metastasis occurred in 74 patients and metachronous in 29 patients. The primary tumour was more commonly associated with the colon rather than the rectum (84/1608, 5.2%vs 19/1534, 1.2%, P < 0.001). Combined metastases occurred in 69 patients (67%). Complete resection was achieved in 34 (33%) patients without other metastases. The estimated 5-year disease free survival and overall survival rate were 40.1% and 26.6%, respectively. From univariate analysis, lymphovascular invasion (35.6%vs 12.8%, P = 0.034), combined metastasis (50.9%vs 15.6%, P = 0.0035) and bilaterale ovarian metastasis (36.4%vs 10.6%, P = 0.015) were identified as significant poor prognosis factors, and from multivariate analysis combined metastasis and bilaterale ovarian metastasis were significant (P = 0.034 and P = 0.015, respectively).

CONCLUSION

This study suggests a role for regular follow-up computed tomography scans within 6 months postoperatively and tumour marker assays for the early detection of ovarian metastasis in premenopausal women after primary surgery, especially in colonic patients with poor prognostic factors.

Establishment of an ovarian metastasis model and possible involvement of E-cadherin down-regulation in the metastasis

Clinical observations of cases of ovarian metastasis suggest that there may be a unique mechanism underlying ovarian-specific metastasis. This study was undertaken to establish an in vivo model of metastasis to the ovary, and to investigate the mechanism of ovarian-specific metastasis. We examined the capacity for ovarian metastasis in eight different human carcinoma cell lines by implantation in female NOD/SCID mice transvenously and intraperitoneally. By transvenous inoculation, only RERF-LC-AI, a poorly differentiated carcinoma cell line, frequently demonstrated ovarian metastasis. By intraperitoneal inoculation, four of the eight cell lines (HGC27, MKN-45, KATO-III, and RERF-LC-AI) metastasized to the ovary. We compared E-cadherin expression among ovarian metastatic cell lines and others. All of these four ovarian metastatic cell lines and HSKTC, a Krukenberg tumor cell line, showed E-cadherin down-regulation and others did not. E-cadherin was then forcibly expressed in RERF-LC-AI, and inhibited ovarian metastasis completely. The capacity for metastasizing to the other organs was not affected by E-cadherin expression. We also performed histological investigation of clinical ovarian-metastatic tumor cases. About half of all ovarian-metastatic tumor cases showed loss or reduction of E-cadherin expression. These data suggest that E-cadherin down-regulation may be involved in ovarian-specific metastasis.

Hepatocellular carcinoma presenting as uterine metastasis

Metastatic extragenital cancer that spreads to the uterus is rare. When it occurs, the extragenital primary disease is often in the breast or gastrointestinal tract. We report here on a case of hepatocellular carcinoma (HCC) that metastasis to the uterus. The patient was admitted for evaluation of a pelvic mass. The serum alpha-fetoprotein level was highly elevated. Magnetic resonance imaging of the abdomen and pelvis showed hepatic and uterine masses. The patient underwent surgical treatment. The histopathologic findings and immunohistochemical staining results of the uterine mass were characteristics of metastatic HCC. The endometrium and both ovaries were free of tumor. Up to now, there have been only two cases of uterine metastasis from HCC reported in the English literature. This case is the first documented instance of a metastatic uterine tumor from HCC that spared both ovaries.

Surgical treatment for patients with different origins of Krukenberg tumors: outcomes and prognostic factors

AIMS

We sought to investigate survival impacts of metastasectomy in women with Krukenberg tumors of the ovary and survival benefits in different origins (gastric cancer, colorectal cancer, or others).

METHODS

All patients diagnosed with Krukenberg tumors of the ovary who underwent surgical treatment at a single institution between 1997 and 2003 were retrospectively evaluated. Survival analyses and comparisons were performed using Kaplan-Meier method and log-rank test.

RESULTS

A total of 54 patients with Krukenberg tumors of the ovary were identified. The estimated 5-year survival was 12.1%. The median survival in patients with microscopic residual disease after metastasectomy was 29.6 months, compared to 10 months in those with visible residual disease (P<0.01). The median survival among patients with Krukenberg tumors of gastric origin, colon and rectum origin, and other origins were 13 months, 29.6 months, and 48.2 months, respectively (P=0.03). There was a significant difference in survival between patients with metastatic disease confined to the ovaries and those with extensive metastases, with an estimated median survival of 30.7 months and 10 months, respectively (P=0.02). Multivariate analysis suggested that the origin of ovarian metastatic carcinoma (P<0.01), residual disease after metastasectomy (P<0.01), and KPS (Karnofsky performance status) (P=0.03) were independent prognostic factors of survival.

CONCLUSIONS

Patients with Krukenberg tumors from colorectal cancer experience a better prognosis than those from gastric cancer and benefit more from metastasectomy. And metastasectomy significantly lengthens overall survival in patients with primary colorectal or breast cancer, higher KPS score, and those with optimal metastasectomy.

Small cell cervical cancer: an unusual finding at cholecystectomy

BACKGROUND

Small cell carcinoma of the cervix is a rare cancer, comprising less than 3% of all cervical neoplasms. It uniformly has a poor prognosis, and has a high mortality even with early stage disease. It can metastasise rapidly and metastatic sites include lung, liver, brain, bone, pancreas and lymph nodes.

CASE

Here, we report the case of a 60-year-old woman with no symptoms of cervical pathology who developed post-renal failure following a laparoscopic cholecystectomy. The cause was bilateral ureteric obstruction from metastatic small cell cervical cancer and metastases were subsequently found on her gallbladder specimen.

CONCLUSION

This is an unusual presentation of small cell cervical cancer and demonstrates the aggressive nature of this disease.

Unusual case of subcutaneous angiosarcoma metastatic to the ovary

The ovaries are common sites for metastatic disease, however, the most frequent ones are carcinomas. Metastatic sarcomas are very rare in ovary and most of them arise from genital tract. We present the case of a 33-year-old woman with subcutaneous angiosarcoma who had metastatic disease to the ovary resulting in acute abdominal pain. Discussion of the case and a review of the literature are presented.