Ovarian metastases from cancer of the lung: problems in interpretation--a report of seven cases

Unique Ovarian Metastasis of Small-Cell Lung Cancer and Complete Response After Chemo-Immunotherapy: An Unusual Spread as a Predictor Factor

A 41-year-old woman, never-smoker, accessed the emergency room for an episode of hemoptysis in September 2019. CT scan showed a defect of opacification in the left pulmonary artery and a solid mass of 12 cm in the left annex. PET confirmed high metabolic activity in the ovarian mass and, surprisingly, in the left hilar lung. The patient underwent a left annessiectomy and the histological examination showed a metastasis of small-cell lung cancer (SCLC) that mimicked a primary ovarian cancer. Fibrobronchoscopy and echo-guided biopsy confirmed the diagnosis of pulmonary SCLC. From January 2020, we started systemic therapy with carboplatin, etoposide, and atezolizumab. After six cycles of induction therapy with a complete response, thoracic and prophylactic cranial radiotherapy was done and maintenance therapy with atezolizumab was administered. After 53 months, the patient is still under treatment with a complete radiological response. This case report describes a rare instance of ovarian metastasis from SCLC that responded exceptionally well to immunotherapy. By reviewing literature from 1950 to the present, we identified other cases of ovarian metastases from SCLC, highlighting shared clinical and pathological traits and distinguishing them from primary ovarian tumors. We also examined the potential mechanisms behind the prolonged immunotherapy response observed in this case. As research on SCLC and immunotherapy evolves, this case may offer valuable insights into prognostic and predictive factors for this typically fatal cancer.

A case of ruptured ovarian metastasis of small cell lung cancer

A 53-year-old woman with small-cell lung cancer (SCLC) presented at our hospital complaining of abdominal distention. Blood tests revealed rapidly progressive normocytic anemia and elevated lactate dehydrogenase levels. Pelvic magnetic resonance imaging revealed a left ovarian tumor and ascites. As her symptoms rapidly worsened, she underwent emergency surgery, which revealed a ruptured metastatic ovarian tumor of SCLC. Emergency surgery averted a life-threatening situation in this patient, and subsequent chemotherapy facilitated long-term survival. As seen from literature review, in female SCLC patients, ovarian metastasis and rupture is a rare but possible complication that should be considered because of its life-threatening nature.

Targeted siRNA nanotherapeutics against breast and ovarian metastatic cancer: a comprehensive review of the literature

Metastasis is considered the major cause of unsuccessful cancer therapy. The metastatic development requires tumor cells to leave their initial site, circulate in the blood stream, acclimate to new cellular environments at a remote secondary site and endure there. There are several steps in metastasis, including invasion, intravasation, circulation, extravasation, premetastatic niche formation, micrometastasis and metastatic colonization. siRNA therapeutics are appreciated for their usefulness in treatment of cancer metastasis. However, siRNA therapy as a single therapy may not be a sufficient option for control of metastasis. By combining siRNA with targeting, functional agents or small-molecule drugs have shown potential effects that enhance therapeutic effectiveness. This review addresses multidrug resistance and metastasis in breast and ovarian cancers and highlights drug-delivery strategies using siRNA therapeutics.

Ovarian metastasis from non-small cell lung cancer with ALK and EGFR mutations: A report of two cases

Ovarian metastasis from non-small cell lung cancer (NSCLC) is a rare condition. The current study presents the cases of 2 female patients aged 38 and 47 years old, respectively, who were initially diagnosed with NSCLC adenocarcinoma on histology. Both patients initially presented with chest pain and a cough, and subsequently developed ovarian metastases following multiple treatments. The 38-year old patient exhibited an epidermal growth factor receptor mutation, confirmed by scorpion/amplified refractory mutation system analysis from a lung biopsy. The 47-year old exhibited an anaplastic lymphoma receptor tyrosine kinase (ALK) rearrangement, revealed by fluorescence in situ hybridization analysis of the breast tissue biopsy, confirming a diagnosis of ALK rearrangement-positive NSCLC. These patients developed ovarian metastasis in the course of the disease. The current study reports the diagnostic challenges and clinical management of the disease, and provides a review of the literature.

Unique metastases of ALK mutated lung cancer activated to the adnexa of the uterus

Anaplastic lymphoma kinase (ALK) fusion positive non-small cell lung cancer (NSCLC) is a relatively novel molecular subtype in lung cancer. ALK targeted therapies such as crizotinib increase survival benefit in this patient population. However, further understanding of the disease subtype including patterns of metastasis and pathways of treatment resistance are needed. We describe a 50 year-old-woman diagnosed with stage IV NSCLC, T2N3M1b, ALK fusion positive disease. Although her initial sites of metastasis included the liver and bone, her story is notable for crizotinib resistant growth of a metastatic lesion to her adnexa. This report brings to attention unique mechanisms of metastasis in ALK positive patients.

Metastasis to a uterine leiomyoma originating from lung cancer: A case report

The uterus is an uncommon site of metastasis especially from a primary lung adenocarcinoma. More frequently, extragenital primary tumours, including lung cancer, metastasize to the ovaries. In the literature, lung cancer metastasizing to the uterus is rare and has been reported to involve the endometrium and uterine serosa. Here, we report an unusual case of a 58-year-old woman who had a history of lung adenocarcinoma with subsequent metastasis to a single uterine fibroid only. The patient was known to have a long history of asymptomatic fibroids. In 2008, she was diagnosed with lung adenocarcinoma which was treated with primary surgery and adjuvant chemotherapy. Four years later, a routine abdominal computerised tomography scan showed an enlargement of the fibroid and she underwent a hysterectomy and bilateral salpingo-oophorectomy. Pathology reported a lung adenocarcinoma metastatic to the uterine leiomyoma with a similar morphology to the original pulmonary malignancy and this was confirmed with immunohistochemical staining. She had no evidence of metastatic disease elsewhere. The final diagnosis was metastasis of a primary lung adenocarcinoma confined to a uterine leiomyoma. Our patient also fulfilled the criteria for a phenomenon called tumour-to-tumour metastasis in this case a primary malignancy having metastasized to a benign tumour. In conclusion, metastasis of a primary lung cancer to the female reproductive tract has been documented, but clinicians should also be aware that metastasis to benign gynaecological tumours such as fibroids can also occur, especially in the setting of tumour-to-tumour metastasis. In addition, the clinical history and use of immunohistochemistry are invaluable in reaching a diagnosis.

Autotransplantation of cryopreserved ovarian tissue in cancer survivors and the risk of reintroducing malignancy: a systematic review

BACKGROUND The risk of recurrent oncological disease due to the reintroduction of cancer cells via autotransplantation of cryopreserved ovarian tissue is unknown. METHODS A systematic review of literature derived from MEDLINE, EMBASE and the Cochrane Library was conducted. Studies on follow-up after autotransplantation; detection of cancer cells in ovarian tissue from oncological patients by histology, polymerase chain reaction or xenotransplantation; and epidemiological data on ovarian metastases were included. RESULTS A total of 289 studies were included. Metastases were repeatedly detected in ovarian tissue obtained for cryopreservation purposes from patients with leukaemia, as well as in one patient with Ewing sarcoma. No metastases were detected in ovarian tissue from lymphoma and breast cancer patients who had their ovarian tissue cryopreserved. Clinical studies indicated that one should be concerned about autotransplantation safety in patients with colorectal, gastric and endometrial cancer. For patients with low-stage cervical carcinoma, clinical data were relatively reassuring, but studies focused on the detection of metastases were scarce. Oncological recurrence has been described in one survivor of cervical cancer and one survivor of breast cancer who had their ovarian tissue autotransplanted, although these recurrences may not be related to the transplantation. CONCLUSIONS It is advisable to refrain from ovarian tissue autotransplantation in survivors of leukaemia. With survivors of all other malignancies, current knowledge regarding the safety of autotransplantation should be discussed. The most reassuring data regarding autotransplantation safety were found for lymphoma patients.

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.

[Influence of the primary malignant tumor site on the incidence and features of metastatic ovarian tumors]

BACKGROUND/AIM

Ovary is the organ of the female reproductive system most commonly affected by metastases. The aim of the study was to determine the frequency and features of metastatic ovarian tumors (MOT) depending on the site of the primary malignant tumor.

METHODS

The study group consisted of 488 patients with histopathologically confirmed ovarian cancers treated at the Clinic of Oncology, Clinical Center Nis, in the period from 1 January 1998 to 31 December 2005. MOT were found in 41 patients. Regarding the site of the primary malignant tumor, those with secondary ovarian tumor were divided into two groups: group A--primary malignant tumor involving the genital organs (n = 30) and group B--primary malignant tumor of extragenital origin (n = 11).

RESULTS

MOT were confirmed in 8.40% (41/488) of the patients. Secondary ovarian malignancies were the consequence of endometrial carcinoma spreading in 73.17%, breast carcinoma in 19.51%, stomach carcinoma in 4.88% and colon carcinoma in 2.44% of the cases. No significant differences were found between the group A and group B by the factors of age, body mass index, parity and menopausal status. Contrary to the group A, metastatic tumors in the group B patients were more commonly asymptomatic (p < 0.001), bilateral (p < 0.05), with larger ovarian diameter (p < 0.05), associated with ascites (p < 0.001) and abdominal metastases (p < 0.01), all of statistical significance.

CONCLUSIONS

Metastatic tumors made up 8.40% of ovarian neoplasmas. With non-genital primary tumors, secondary ovarian deposits were frequently asymptomatic, bilateral, associated with larger ovarian diameter, ascites and abdominal metastatic deposits, compared to malignant tumors of genital origin.

Occult metastatic lung carcinoma presenting as locally advanced uterine carcinosarcoma on positron emission tomography/computed tomography imaging

Increasingly, positron emission tomography/computed tomography (PET/CT) is being used as a tumor surveillance modality for multiple tumor types. A 73-year-old postmenopausal female with stage IV nonsmall cell lung cancer presented after a PET/CT demonstrated focal uptake in the superior and lateral aspects of the uterus. The patient reported a history of intermittent postmenopausal bleeding and an endometrial biopsy documented uterine carcinosarcoma. Postoperative pathologic review and immunohistochemical staining with thyroid transcription factor-1 revealed metastatic adenocarcinoma consistent with her lung primary in her uterus and adnexa. Our case represents a rare occurrence in which lung cancer has metastasized to multiple female pelvic organs. Increasing use of PET/CT may lead to the discovery of occult metastases masquerading as a second primary malignancy.

Carcinomas of ovary and lung with clear cell features: can immunohistochemistry help in differential diagnosis?

Metastatic lung carcinomas with clear cell morphology can be confused with primary ovarian clear cell carcinomas. We performed immunohistochemical stains in 14 cases of non-small cell lung carcinomas with clear cell features and 14 cases of ovarian clear cell carcinomas using a panel of markers, including thyroid transcription factor 1 (TTF-1), carcinoembryonic antigen (CEA), Wilms tumor gene 1, octamer-binding transcription factor 4 (OCT-4), cancer antigen 125 (CA-125), estrogen receptor, and progesterone receptor. Among non-small cell lung carcinomas with clear cell features, 87.5% of adenocarcinomas (or 50% overall frequency in lung carcinomas) were positive for TTF-1, whereas none of the ovarian clear cell carcinomas were positive (P = 0.002). All 14 ovarian clear cell carcinomas stained for CA-125 as compared with 1 non-small cell lung carcinoma (P < 0.001). On the other hand, 85% of non-small cell lung carcinomas stained for CEA, whereas none of the ovarian clear cell carcinomas did (P < 0.001). Interestingly, 4 ovarian clear cell carcinomas (28%) showed positive staining for the germ cell marker OCT-4. Either lung or ovarian carcinomas stained for Wilms tumor gene 1, estrogen receptor, or progesterone receptor very infrequently; and the difference between the 2 groups was not statistically significant. Our results suggest that an immunohistochemical panel consisting of TTF-1, CEA, CA-125, and OCT-4 is helpful in distinguishing most pulmonary and ovarian carcinomas with clear cell features.

A case of ovarian metastasis of gall bladder carcinoma simulating primary ovarian neoplasm: diagnostic pitfalls and review of literature

The ovary is a relatively frequent site of metastases from malignant neoplasia arising elsewhere in the body, the majority of these originating from the gastrointestinal tract. The best-known tumor of this type is signet ring cell adenocarcinoma (Krukenberg tumor) of gastric origin and large bowel. The gall bladder and bile ducts are extremely rare sources of these metastases. The casuistic describes a female patient, presented with pelvic mass and jaundice. While clinical and imaging results suggested a primary ovarian carcinoma with incidental cholelithiasis and choledocholithiasis, the final diagnosis was obtained on the basis of histopathologic findings of resected specimen.

Pulmonary papillary serous adenocarcinoma with intraperitoneal and ovarian tumors: identification of primary site. A case report

Papillary serous adenocarcinoma has been recognized as a highly malignant ovarian cancer and is also not uncommonly seen in primary lung cancer. Difficulty may exist in determining the origin of the primary tumor in women with synchronous pulmonary and ovarian tumors. We present a patient who was initially diagnosed and treated as stage IV papillary serous ovarian cancer with diffuse pulmonary metastases. Only transient symptomatic improvement was achieved after standard chemotherapy for ovarian cancer, and then she died of respiratory distress during treatment. Poor tumor response to chemotherapy prompted us to reevaluate the previous bronchoscopic biopsy, and immunohistochemical studies, which were cytokeratin (CK) 7 positive, CK20 negative, and thyroid transcription factor-1 (TTF-1)-positive, provided irrefutable evidences for the diagnosis of primary lung cancer. We suggest that in dealing with coexistence of ovarian and pulmonary tumors, immunohistochemical study by using CK7, CK20, and TTF-1 may be helpful in the differentiation of the primary origin.

Metastatic neoplasms involving the ovary: a review with an emphasis on morphological and immunohistochemical features

The ovary is a common site of metastatic tumour. In many cases of ovarian metastasis there is a known history of malignancy but in other cases the ovarian tumour is the first manifestation of disease. In this review metastatic colorectal, appendiceal, gastric, breast, pancreatic and biliary tract, hepatocellular, renal, transitional and cervical carcinomas and metastatic malignant melanoma involving the ovary are discussed, as is the issue of synchronous ovarian and endometrial carcinomas. Peritoneal tumours, including primary peritoneal carcinoma, mesothelioma and intra-abdominal desmoplastic small round cell tumour, involving the ovary are also discussed, together with a variety of other rare, metastatic ovarian neoplasms. Many metastatic adenocarcinomas involving the ovary, especially those exhibiting mucinous differentiation, closely mimic primary ovarian adenocarcinomas with morphologically bland areas simulating benign and borderline cystadenoma. This is referred to as a maturation phenomenon. In recent years immunohistochemistry, especially but not exclusively differential cytokeratin (CK7 and CK20) staining, has been widely used as an aid to distinguish between a primary and secondary ovarian adenocarcinoma. While immunohistochemistry undoubtedly has a valuable role to play and is paramount in diagnosis in some cases, the results must be interepreted with caution, especially in mucinous tumours, and within the relevant clinical context. We feel the significance of differential cytokeratin staining is not always understood by histopathologists and this can result in erroneous interpretation. We critically discuss the value of immunohistochemistry and associated pitfalls with each tumour type described.

[Ovarian metastasis and lung adenocarcinoma: a case report]

Ovarian metastasis as first dissemination site of a lung adenocarcinoma has not been described in the literature. We report the case of a 61-year-old woman who had a pneumectomy for a centrally located lung adenocarcinoma, which was discovered on a routine chest X-Ray. During the follow-up, a Positron Emission Tomography (PET)-Scan showed a hypercaptation in the pelvic region. Abdominal CT-scan confirmed the presence of a mass which was compatible with a primary ovarian tumor. The patient underwent a hysterectomy and bilateral salpingo-oophorectomy. Pathology reported an adenocarcinoma. Immunohistochemical staining revealed cells expression for Thyroid Transcription Factor 1 (TTF-1), cytokeratin 7 (CK-7) and focally cytokeratin 20 (CK-20). Clinical course, pathological and immunohistochemical data concluded to the diagnosis of ovarian metastasis of the lung adenocarcinoma. In conclusion, in the differential diagnosis of an ovarian metastasis, clinicians should not forget the lung as primary site since epidemiologic data of lung cancer in women show progressive incidence.

Metastasis of Small Cell Carcinoma of Lung Into an Ovarian Mucinous Neoplasm: Immunohistochemistry as a Useful Ancillary Technique for Diagnosis and Classification of Rare Tumors

The authors report the first case of ovarian mucinous adenocarcinoma with metastasis from a synchronous small cell neuroendocrine carcinoma of the lung. A 62-year-old white woman presented with weight loss and increased abdominal girth. She was found to have a large, complex cystic mass in the pelvis, and during the staging evaluation, a large, right pulmonary hilar mass was detected. Bronchial brushing as well as transbronchial fine-needle aspiration was diagnostic of small cell carcinoma. The patient received 3 cycles of chemotherapy with carboplatin and subsequently underwent a supracervical hysterectomy and bilateral salpingo-oophorectomy. A large, multiloculated cystic mass was found arising from the right ovary. Microscopic examination disclosed a mucinous neoplasm with both mucinous cystadenoma and mucinous papillary adenocarcinoma components. A microscopic focus of cells with "atypical" cytomorphologic features was detected within the mucinous neoplasm. Immunohistochemistry showed that group of cells to be positive for thyroid transcription factor 1 and chromogranin, confirming them to be metastasis from the pulmonary small cell neuroendocrine carcinoma. This case, in addition to being the first reported case of such metastasis, also highlights the diagnostic utility of immunohistochemistry as a reliable and very useful ancillary technique for the diagnosis of neoplasms with unusual clinical and/or histomorphologic presentations. The clinical and prognostic implications are also discussed.

Transcriptional and posttranscriptional regulation of fibulin-1 by estrogens leads to differential induction of messenger ribonucleic acid variants in ovarian and breast cancer cells

Fibulin-1 is an extracellular matrix protein overexpressed in epithelial ovarian and breast cancers. In estrogen receptor (ER)-positive ovarian and breast cancer cell lines, fibulin-1 mRNA levels are markedly increased by estrogens. Transfection experiments using fibulin-1 promoter constructs indicate that 17beta-estradiol (E2) increases fibulin-1 gene transcription and that ERalpha is more potent than ERbeta to mediate E2 regulation of the transfected fibulin-1 promoter. Using SL2 cells devoid of specificity protein 1 (Sp1) and site-directed mutagenesis of GC boxes, we evidenced that the E2 regulation occurs through a proximal specificity protein 1 binding site. In addition, we show that fibulin-1C and -1D mRNAs, the two major fibulin-1 splicing variants, are differentially induced by E2. The induction of both mRNAs variants is direct and independent of a newly synthesized protein intermediate. Interestingly, actinomycin D chase experiments demonstrate that E2 treatment selectively shortens the fibulin-1D mRNA half-life. This indicates that estrogens affect differentially the stability of fibulin-1 variants and may explain the lower accumulation of fibulin-1D mRNA on E2 treatment. In conclusion, our data show that estrogens, via ERalpha, are key regulators of fibulin-1 expression at both the transcriptional and posttranscriptional levels. The preferential induction of the fibulin-1C variant, which is overexpressed in ovarian and breast cancer, might play an important role in estrogen-promoted carcinogenesis.

Malignant Melanoma Involving the Ovary: A Clinicopathologic and Immunohistochemical Study of 23 Cases

Ovarian malignant melanoma (MM), primary or metastatic, is an extremely rare tumor and in the absence of a previous diagnosis can represent a diagnostic challenge. We present the clinicopathologic and immunohistochemical features of 23 cases seen in our institution over a period of 40 years (1962-2001). The patients' age ranged from 14 to 53 years (mean 35.7 years). Ethnicity was known in 19 patients: 14 white, 4 Hispanic, and 1 black. A previous history of MM was definitively obtained in 14 patients; in these cases, the interval between the primary MM and the ovarian metastasis ranged from 15 to 228 months (mean 77.7 months). The tumor was unilateral in 19 and bilateral in 4 cases. The tumor size ranged from 4.5 to 23 cm (average 10 cm); the melanoma arising in a cystic teratoma was 0.2 mm in thickness. The tumor was grossly pigmented in 8 cases (35%). The architectural pattern was nodular (8 cases), diffuse (6 cases), nodular and diffuse (5 cases), nested (3 cases), and lentiginous arising in a teratoma (1 case). Follicle-like spaces were seen in 8 cases, pseudo-glandular areas in 1 case, pseudo-myxoid areas in 1 case, and cords in 1 case. The tumor cell type was epithelioid in 19 cases, spindled in 2 cases, mixed epithelioid and spindled in 1 case, and small cell in 1 case. Nucleoli were prominent in 18 cases, and nuclear inclusions were present but rare in the majority of cases. Nuclear grooves were seen in 3 cases. Necrosis was extensive in 8 cases, focal in 10 cases, and was absent in 5 cases. In 8 cases, initial diagnoses included sex cord stromal tumor, germ cell tumor, sarcoma, or undifferentiated carcinoma. S-100 was positive in 18 of 19 cases, HMB-45 in 17 of 20 cases, MART-1 in 13 of 15 cases, tyrosinase in 10 of 15 cases, and Mitf in 8 of 14 cases. Inhibin was positive in 3 of 14 cases. Calretinin was focally positive in 1 of 12 cases. Treatment performed in 18 of the cases are as follows: oophorectomy with/without chemotherapy (10); total abdominal hysterectomy with bilateral salpingo-oophorectomy with/without chemotherapy (6); vaginal hysterectomy, bilateral salpingo-oophorectomy, and chemotherapy (1); and total abdominal hysterectomy with salpingo-oophorectomy (1). Follow-up ranging from 2 to 96 months was available in 18 patients. All but one had metastases in other organs, most often in the lungs. Thirteen patients died of disease (range 2-76 months), 3 are alive with disease (6-18 months), and 2 have no evidence of disease at 24 and 96 months; one was the patient with melanoma arising within a teratoma. In conclusion, MM involving the ovary is a rare disease, predominantly seen in women of reproductive age, and is associated with a poor prognosis. The tumor is most often metastatic from another site and is unilateral in most cases. Nodular or diffuse pattern and epithelioid cell type are most frequently seen, and the tumor can be mistaken for germ cell and sex cord stromal tumors. S-100 is the most sensitive marker. MART-1 was positive in the few cases that were negative with HMB-45. Inhibin can be focally positive in some cases.

Immunohistochemical confirmation of pulmonary papillary adenocarcinoma metastatic to ovaries

Metastatic papillary adenocarcinomas of the ovary are rare compared to primary ovarian papillary serous carcinomas. We report a case of pulmonary papillary adenocarcinoma metastatic to the ovary and show how this tumor can be differentiated immunohistochemically from an ovarian primary. Paraffin blocks of the ovarian tumor were analyzed for carcinoembryonic antigen, CA 125, surfactant, E-cadherin, N-cadherin, and vimentin. These markers are useful in differentiating epithelial tumors of lung versus ovarian origin. The papillary tumor showed expression of carcinoembryonic antigen, surfactant, and E-cadherin, but was negative for CA 125, N-cadherin, and vimentin. These findings support a lung carcinoma metastatic to the ovary.

Ovarian small cell tumors: an electron microscopic review

Small cell tumors of the ovary are uncommon but represent an important group to recognize in the differential diagnosis of primary and metastatic ovarian neoplasms. In some cases the correct diagnosis cannot be confidently made on the basis of clinical setting, routine light microscopy, and immunohistochemistry, and electron microscopy may be supportive or definitive in establishing cell type. The cell type is often important in choosing optimal therapy and in predicting prognosis. The authors performed electron microscopy on a moderate number of ovarian small cell tumors and here describe and illustrate the diagnostic features of representative examples of various types. The ultrastructural features of the metastatic tumors, such as embryonal rhabdomyosarcoma, neuroblastoma, and melanoma, are identical to those of their respective primary tumors, are well known, and usually pose no problem in diagnosis. On the other hand, the ultrastructural features of some primary ovarian small cell tumors may present a more difficult differential diagnosis, because they have features that are subtle and/or in common. Exemplary of tumors in this category are diffuse adult granulosa cell tumor, endometrial stromal sarcoma, and small cell carcinomas of the hypercalcemic and pulmonary (oat cell) types. Distinguishing among them may be difficult but is possible, and electron microscopy may be a valuable supplement to the diagnostic information obtained from the clinical presentation, light microscopy, immunohistochemistry and, in some tumors, cytometric analysis of these neoplasms.

Squamous cell carcinoma in the ovary of a 14-year-old girl

Squamous cell carcinoma (SCC), whether primary or metastatic, rarely involves the ovary. All previously reported cases have been in adults. Herein we describe a 14-year-old girl who underwent extensive neurologic and musculoskeletal assessment because of symptoms of generalized muscle weakness and pain. She was found to have SCC that involved the ovary, with widespread metastases. This case illustrates the importance of eliciting a thorough history and evaluating the patient's symptoms. A review of the differential diagnosis of ovarian SCC is included. To our knowledge, our patient is the youngest to be described in the literature with SCC in the ovary.

Ovarian metastases from cervical carcinomas other than pure adenocarcinomas. A report of 12 cases

Twelve cases of ovarian metastases from cervical carcinomas, most with clinical manifestations of ovarian involvement, are reported. The patients were 23-73 years of age (average, 43 years). The ovarian and cervical tumors were synchronous in eight patients; in three, ovarian tumors were discovered 10 months, 2.5, and 3 years after the detection of a cervical neoplasm. In one patient, the cervical tumor was not discovered until autopsy 7 months after presentation. Four patients had abdominal swelling or distention, three had vaginal bleeding, three had an abnormal Papanicolaou smear, and two had masses discovered during pelvic examination. The ovarian tumors, six of which were bilateral, ranged from 5-17 cm (average, 9.5 cm) in maximal dimension in 11 patients; in the 12th patient, the involved ovary was not enlarged. The cervical tumors were grossly evident in 10 patients. They were usually deeply invasive, often with extracervical extension. Four were squamous cell carcinomas; two, small cell carcinomas; one, a mixed small cell carcinoma and adenocarcinoma; one, a mixed poorly differentiated carcinoid and adenocarcinoma; two, adenosquamous carcinomas; one, a transitional cell carcinoma; and one, an undifferentiated carcinoma. Various features, including bilaterality of the ovarian tumors, the finding that the histologic features of the ovarian tumors typically were unusual for a primary ovarian neoplasm, and the presence of extensive extracervical disease, led to the conclusion that the ovarian tumors were metastatic from the cervix. Although ovarian metastases of cervical carcinoma are uncommon, this series illustrates that, occasionally striking examples with clinical manifestations of ovarian involvement occur.

Nonpulmonary small cell carcinomas of extragenital origin metastatic to the ovary

Seven small cell carcinomas of extragenital and extrapulmonary origin that metastasized to the ovary are described. The tumors occurred in women who were 21-77 years of age (mean, 49 years) and were discovered at, or close to, the time of presentation. The primary sites were the intestine (three cases), thymus (two cases), and inguinal skin (one case), and in one case it was undetermined. The ovarian tumors, four of which were bilateral, ranged from 1.2 to 25 cm in diameter (mean, 11 cm). Microscopic examination showed typical features of small (oat) cell carcinoma in six cases; one neoplasm resembled a small cell carcinoma of intermediate cell type and contained rare glands. On immunohistochemical examination, six of six tumors stained for cytokeratin, five of five for neuron-specific enolase, two of six for chromogranin, and none of four for vimentin. The primary cutaneous tumor was a Merkel cell carcinoma. The patient with that case died at 8 months. Two patients with intestinal tumors died at 1 and 2 months, and one is free of disease at 4 years after receiving chemotherapy. Both patients with mediastinal tumors received chemotherapy; one died at 11 months and one had brain metastases at 5 months and was lost to follow-up. The final case is recent. The differential diagnoses in these cases include primary ovarian small cell carcinomas of hypercalcemic and pulmonary types and various other small cell malignant tumors metastatic to the ovary. Consideration of a variety of clinical and pathologic features should enable these important distinctions to be made.

Intraabdominal hemorrhage with pulmonary large cell carcinoma metastatic to the ovary

Secondary tumors comprise nearly 10% of ovarian malignancies; however, metastatic cancers arising from the lung are uncommon, with fewer than 15 cases reported. A patient with pulmonary large cell carcinoma and ovarian metastases resulting in recurrent refractory intraabdominal hemorrhage is presented. Metastatic involvement of the ovary from pulmonary malignancy is reviewed.

Hepatocellular carcinoma metastatic to the ovary: a report of three cases discovered during life with discussion of the differential diagnosis of hepatoid tumors of the ovary

Three cases of hepatocellular carcinoma with ovarian metastases discovered during the patient's life are reported. A 31-year-old woman presented with back pain, and radiographic studies disclosed massive liver enlargement and bilateral ovarian tumors. The second patient, a 38-year-old woman, had an enlarged liver at the time of laparoscopic tubal ligation, and subsequently underwent right hepatic lobectomy for hepatocellular carcinoma. Three months later a left ovarian tumor was detected and a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed. The third patient, a 68-year-old woman, presented with gastrointestinal symptoms and weight loss, and had bilateral ovarian tumors and widespread tumor at laparotomy. Two patients died of their disease at 18 months and 4 years 7 months; the third patient is alive with residual tumor at 7 months. The ovarian tumors, which were bilateral and multinodular in two cases and focally cystic in one case, ranged from 4 to 11 cm in maximum dimension, and had yellow-green or yellow sectioned surfaces. On microscopic examination, they were composed of cells with moderate to abundant eosinophilic cytoplasm growing diffusely and in nodules, nests, and trabeculae; cysts or glands were conspicuous in two cases. Bile was present in one tumor. The main differential diagnostic considerations were hepatoid yolk sac tumor and hepatoid carcinoma, primary or metastatic in the ovary. A variety of features, including the age of the patient, unilaterality or bilaterality of the ovarian tumors, distribution of disease, and microscopic features of the neoplasm, including the identification of bile, established the diagnosis. Metastatic hepatocellular carcinoma must be included in the differential diagnosis of oxyphil cell tumors of the ovary.

Ovarian involvement by the intra-abdominal desmoplastic small round cell tumor with divergent differentiation: a report of three cases

Three girls, one 14 and two 15 years of age, with the recently described neoplasm that has been designated "intra-abdominal desmoplastic small round cell tumor with divergent differentiation," and ovarian involvement at presentation are described. In two cases the ovarian tumor was initially thought to be the primary neoplasm. In all cases there was extensive extraovarian tumor at the time of presentation. The ovarian involvement was bilateral in two cases and unilateral in the third. Microscopic examination showed prominent nodular growth within the ovaries. The tumors were characterized predominantly by nests of small cells with hyperchromatic nuclei and scant cytoplasm separated by a prominent desmoplastic stroma. A few tubules containing mucinous secretion were present in one case. On immunohistochemical staining many of the tumor cells stained positively for cytokeratin, epithelial membrane antigen, desmin, and vimentin. Staining for neuron-specific enolase was present in two cases but was conspicuous in only one of them. Leu-7 was expressed by the tumor cells in two cases, and S-100 protein by one, giving further support to the possibility of neuroectodermal differentiation within some of these neoplasms. The two cases studied by electron microscopy both showed frequent intercellular junctions, basal lamina, cytoplasmic filaments, and sparse, small dense granules of either neuroendocrine or lysosomal type. Paranuclear aggregates of filaments were found in one case and cellular processes were prominent in the other case. The differential diagnosis in these cases was extensive and included a number of small cell tumors that may involve the ovary, either primarily or secondarily, in young females. The desmoplastic small round cell tumor should be considered in such cases when the appearances on routine examination are consistent with the diagnosis, and appropriate immunohistochemical stains should be performed to confirm the diagnosis.

Alveolar rhabdomyosarcoma metastatic to the ovary. A report of two cases and a discussion of the differential diagnosis of small cell malignant tumors of the ovary

Two young women with alveolar rhabdomyosarcoma metastatic to the ovary are reported. In each case, the ovarian involvement was detected within a few weeks of the discovery of a soft tissue mass by the patient. Symptoms attributable to the ovarian tumor dominated the initial clinical picture in one case. In the other case, the soft tissue mass was not appreciated by the treating physicians until after the diagnosis of rhabdomyosarcoma had been established by examination of the ovarian tumor. The ovarian tumor was unilateral in one case and bilateral in the other. One primary site was the right foot and the other primary site was the left forearm. These cases illustrate that metastatic alveolar rhabdomyosarcoma rarely enters into the differential diagnosis of a small cell malignant tumor of the ovary. Both patients experienced progression of their disease and died, despite aggressive chemotherapy, within 1 year of presentation.

Hepatoid carcinoma of the ovary. A newly described tumor

Five cases of ovarian carcinoma with hepatoid features, three of them primary and two probably primary, are described. The tumor cells were arranged predominantly in sheets and contained moderate to abundant amounts of eosinophilic cytoplasm; varying numbers of tumor cells stained immunohistochemically for alpha fetoprotein. In contrast to the much younger age range of patients with ovarian hepatoid yolk sac tumors, the ages of the five patients with hepatoid carcinomas ranged from 42 to 78 (average, 63 years), and none of them had gonadal dysgenesis or recognizable germ cell components within their tumors. All the tumors presented as adnexal masses; in four cases they were Stage III and in one case, Stage IIB; this last tumor spread to the upper abdomen within 4 years. In three cases the clinical course and pathology findings indicated that the tumor had originated in the ovary; in the remaining two cases the tumors were interpreted as only probably primary in the ovary. Hepatoid carcinomas must be distinguished from other ovarian neoplasms, especially from hepatoid yolk sac tumors.