The differential response to chemotherapy of ovarian metastases from colorectal carcinoma

Clinical Outcomes in Patients With Krukenberg Tumors From Colorectal Cancer

INTRODUCTION

Ovarian metastases from gastrointestinal cancers such as colorectal cancer, also known as Krukenberg tumors (KTs), present unique challenges in management due to diagnostic uncertainty, decreased responsiveness to systemic therapies compared to other sites of metastasis, and associated debilitating symptomatology. Thus, we sought to characterize our institutional outcomes in metastatic colorectal cancer (mCRC) patients with KTs.

METHODS

A retrospective single-institution study was performed identifying adult, female patients from 2012 to 2021 with a diagnosis of mCRC. Patient demographics and clinicopathologic characteristics were collected and analyzed. Descriptive statistics, univariate and multivariable analyses, and Kaplan-Meier survival analyses were performed.

RESULTS

Of 235 mCRC patients, 45 (19.1%) had KTs, 41 (91.1%) of whom had KTs in conjunction with other metastatic sites. Other initial sites of metastasis included the liver (n = 93, 39.6%), lung (n = 28, 11.9%), and peritoneum (n = 18, 7.7%). In the KT cohort, the median age was 48 y, 53.3% were non-Hispanic White, 100% had microsatellite stable tumors, 33.3% had Kristen Rat Sarcoma Virus (KRAS) mutations, and 6.7% had V-raf Murine Sarcoma Viral Oncogene Homolog B (BRAF) mutations. Fifty five point six percent of KT patients underwent cytoreductive surgery (CRS), 24.4% underwent palliative debulking, and 20% underwent no surgical intervention. Reasons for not undergoing CRS were disease-related (n = 14, 70%), due to poor performance status (n = 1, 5%), or both (n = 5, 25%). Five-year overall survival was 48.2% in KT patients who underwent CRS. Poor tumor grade was an independent predictor of mortality (hazard ratio 10.69, 95% confidence interval 1.20-95.47, P = 0.03).

CONCLUSIONS

Almost 90% of our patient cohort with KTs from mCRC experience additional sites of metastasis. Around half of KT patients who underwent CRS were alive at 5 y.

Mutation characteristics and molecular evolution of ovarian metastasis from gastric cancer and potential biomarkers for paclitaxel treatment

Ovarian metastasis is one of the major causes of treatment failure in patients with gastric cancer (GC). However, the genomic characteristics of ovarian metastasis in GC remain poorly understood. In this study, we enroll 74 GC patients with ovarian metastasis, with 64 having matched primary and metastatic samples. Here, we show a characterization of the mutation landscape of this disease, alongside an investigation into the molecular heterogeneity and pathway mutation enrichments between synchronous and metachronous metastasis. We classify patients into distinct clonal evolution patterns based on the distribution of mutations in paired samples. Notably, the parallel evolution group exhibits the most favorable prognosis. Additionally, by analyzing the differential response to chemotherapy, we identify potential biomarkers, including SALL4, CCDC105, and CLDN18, for predicting the efficacy of paclitaxel treatment. Furthermore, we validate that CLDN18 fusion mutations improve tumor response to paclitaxel treatment in GC with ovarian metastasis in vitro and vivo.

Colorectal Origin: A Marker of Favorable Outcome in Krukenberg Tumor? Results from Clinical and Prognostic Analysis

Purnima Thakur This study aimed to identify the prognostic factors affecting the survival of patients suffering from Krukenberg tumor (KT) and also to determine the survival in these patients. A retrospective review of patients diagnosed with KT between January 2015 and December 2021 was conducted at a tertiary cancer center. Clinicopathological variables were scrutinized, and survival analysis was performed. Thirty-six patients were enrolled in this study. The median age at diagnosis was 48 years (ranging from 22 to 71 years). The median overall survival (OS) was 9.9 months (95% confidence interval [CI]: 6.6 to 13 months). The mean OS for tumors originating in the colorectal region was longer compared to that for tumors of other sites (15.4 vs. 9 months, respectively; p  = 0.048). In univariate analysis, patients who received chemotherapy had better survival, while those presenting with ascites had a poor prognosis. No correlation was observed between age, menstrual status, bilaterality, size of ovarian metastases, extent of metastatic disease, metastasectomy, and survival. Multivariate Cox regression analysis showed that chemotherapy predicted a favorable survival outcome (hazard ratio [HR] = 0.200, 95% CI: 0.046-0.877, p -value = 0.033). KT is an aggressive tumor with a median OS of less than a year. Chemotherapy may improve survival. Patients with a primary tumor in the colorectal region have a better outcome, while those presenting with ascites indicate a poor prognosis.

Impact of resection for ovarian metastases from colorectal cancer and clinicopathologic analysis: A multicenter retrospective study in Japan

Aim

The aim of this study was to clarify the significance of resection of ovarian metastases from colorectal cancer and to identify the clinicopathologic characteristics.

Methods

In this multicenter retrospective study, we evaluated data on ovarian metastases from colorectal cancer obtained from patients at 20 centers in Japan between 2000 and 2014. We examined the impact of resection on the prognosis of patients with ovarian metastases and examined prognostic factors.

Results

The study included 296 patients with ovarian metastasis. The 3-y overall survival rate was 68.6% for solitary ovarian metastases. In all cases of this cohort, the 3-y overall survival rates after curative resection, noncurative resection, and nonresection were 65.9%, 31.8%, and 6.1%, respectively (curative resection vs noncurative resection [P < 0.01] and noncurative resection vs nonresection [P < 0.01]). In the multivariate analysis of prognostic factors, tumor size of ovarian metastasis (P < 0.01), bilateral ovarian metastasis (P = 0.01), peritoneal metastasis (P < 0.01), pulmonary metastasis (P = 0.04), liver metastasis (P < 0.01), and remnant of ovarian metastasis (P < 0.01) were statistically significantly different.

Conclusion

The prognosis after curative resection for solitary ovarian metastases was shown to be relatively favorable as Stage IV colorectal cancer. Resection of ovarian metastases, not only curative resection but also noncurative resection, confers a survival benefit. Prognostic factors were large ovarian metastases, bilateral ovarian metastases, the presence of extraovarian metastases, and remnant ovarian metastases.

Prediction of Chemotherapy Efficacy in Patients with Colorectal Cancer Ovarian Metastases: A Preliminary Study Using Contrast-Enhanced Computed-Tomography-Based Radiomics

Ovarian metastasis (OM) from colorectal cancer (CRC) is infrequent and has a poor prognosis. The purpose of this study is to investigate the value of a contrast-enhanced CT-based radiomics model in predicting ovarian metastasis from colorectal cancer outcomes after systemic chemotherapy. A total of 52 ovarian metastatic CRC patients who received first-line systemic chemotherapy were retrospectively included in this study and were categorized into chemo-benefit (C+) and no-chemo-benefit (C-) groups, using Response Criteria in Solid Tumors (RECIST v1.1) as the standard. A total of 1743 radiomics features were extracted from baseline CT, three methods were adopted during the feature selection, and five prediction models were constructed. Receiver operating characteristic (ROC) analysis, calibration analysis, and decision curve analysis (DCA) were used to evaluate the diagnostic performance and clinical utility of each model. Among those machine-learning-based radiomics models, the SVM model showed the best performance on the validation dataset, with AUC, accuracy, sensitivity, and specificity of 0.903 (95% CI, 0.788-0.967), 88.5%, 95.7%, and 82.8%, respectively. All radiomics models exhibited good calibration, and the DCA demonstrated that the SVM model had a higher net benefit than other models across the majority of the range of threshold probabilities. Our findings showed that contrast-enhanced CT-based radiomics models have high discriminating power in predicting the outcome of colorectal cancer ovarian metastases patients receiving chemotherapy.

Impact of Oophorectomy on Survival and Improving Nutritional Status in Ovarian Metastasis from Colorectal Adenocarcinoma

INTRODUCTION

Ovarian metastasis of colorectal cancer is known to have a poor prognosis. This study aimed to elucidate the characteristics of patients who underwent oophorectomy for ovarian metastasis from colorectal cancer.

METHODS

This retrospective study included 16 patients who underwent oophorectomy for colorectal cancer metastasis to the ovary from January 2004 to December 2017. Improvement in patient's symptoms and pre- and postoperative changes in various nutritional and inflammatory indicators were assessed. Survival analysis and identification of prognostic factors were conducted with a median follow-up of 40.7 (5-109) months.

RESULTS

Of 16 patients, 12 had (75%) synchronous and 4 (25%) had metachronous metastasis. Fourteen patients were symptomatic but symptoms resolved postoperatively. Thirteen patients (81.3%) had ascites and 5 (31.3%) had pleural effusion on preoperative computed tomography that disappeared after surgery in all cases. The median value of prognostic nutritional factor was significantly increased postoperatively (36.0 [preoperatively] vs. 47.5, p < 0.0001). The median (interquartile range) values for lymphocyte-C-reactive protein ratio were 715.2 (110-2,607) preoperatively and 6,095.2 (1,612.3-14,431.8) postoperatively (p = 0.0214). The median survival of the entire cohort was 60.4 months. The 3-year survival rates for R0 + R1 and R2 cases were 83% and 24% (p = 0.018), respectively. Univariate analysis showed that R2 resection and low postoperative lymphocyte-C-reactive protein ratio were associated with poor prognosis.

CONCLUSIONS

Oophorectomy for ovarian metastasis from colorectal cancers was safely performed. It improved the patients' symptoms and nutritional status and may result in improved prognosis.

Effect of metastasectomy on the outcome of patients with ovarian metastasis of colorectal cancer: A systematic review and meta-analysis

PURPOSE

Patients with ovarian metastasis of colorectal cancer (CROM) usually have poor prognosis. Metastasectomy is controversial in patients with CROM. This study aims to evaluate the prognostic value of ovarian metastasectomy and other factors in CROM patients.

METHODS

We searched literature up to November 1, 2021 in MEDLINE (PubMed), Embase, Cochrane Library, and Clinicaltrials.gov. Retrospective studies were assessed if survival outcome of CROM patients was reported. Results were pooled in a random-effects model and reported as hazard ratios (HRs) with 95% confidence intervals (CI). Sensitivity was analyzed.

RESULTS

Among 2497 studies screened, 15 studies with 997 patients, published between 2000 and 2021, were included. Longer overall survival (OS) was correlated with ovarian metastasectomy (pooled HR = 0.44, 95% CI: 0.34-0.58, P < 0.05) and R0 resection (pooled HR = 0.26, 95% CI: 0.16-0.41, P < 0.05). Longer disease-specific survival (DSS) was associated with systematic chemotherapy (pooled HR = 0.26, 95% CI: 0.15-0.45, P < 0.0001). Shorter OS was associated with extraovarian metastases (pooled HR = 3.00, 95% CI 1.68-5.36, P < 0.05) and bilateral OM (pooled HR = 1.66, 95% CI: 1.09-2.51, P < 0.05). No significant difference in OS was observed among patients with systematic chemotherapy (pooled HR = 0.68, 95% CI: 0.35-1.31, P > 0.05).

CONCLUSION

Metastasectomy achieving R0 resection can significantly prolong OS and DSS of CROM patients as a reasonable treatment modality. Primary tumor resection and systematic chemotherapy can improve patients' outcomes.

REGISTRATION NUMBER

CRD42022299185 (http://www.crd.york.ac.uk/PROSPERO).

A propensity score-matched analysis of oncological outcome after systemic therapy for stage IV colorectal cancer: Impact of synchronous ovarian metastases

The reported incidence of synchronous and metachronous ovarian metastases (OM) from colorectal cancer (CRC) is ~3.4%. OM from CRC are often considered sanctuary sites due to their lower sensitivity to systemic treatment. It has thus been hypothesized that the presence of OM decreases overall survival. Therefore, the purpose of our study was to evaluate the impact of synchronous OM on overall survival in female patients with stage IV CRC treated with systemic therapy alone with palliative intent. The present study used data from the Netherlands Cancer Registry and included female CRC patients with synchronous systemic metastases who were treated with systemic therapy between 2008 and 2018. A subsample was created using propensity score matching to create comparable groups. Propensity scores were determined using a logistic regression model in which the dependent variable was the presence of OM and the independent variables were the variables that differed significantly between both groups. Our study included 5253 patients with stage IV CRC that received systemic therapy. Among these patients, 161 (3%) had OM while 5092 (97%) had extra-ovarian metastases only. Three-year overall survival rates did not show a significant difference between patients with OM compared to patients without ovarian metastases. Moreover, the propensity score-matched analysis showed that the presence of OM in patients treated with systemic therapy for stage IV CRC disease was not associated with decreased 3-year overall survival. However, the results of the present study should be interpreted with caution, due to its observational character and used selection criteria.

The impact of prophylactic oophorectomy on the survival for postmenopausal patients with pT4a colorectal cancer

PURPOSE

This study aimed to evaluate the prognostic effect of prophylactic oophorectomy (PO) in postmenopausal patients with pT4 colorectal cancers (CRC) in terms of overall survival (OS), disease-free survival (DFS), and peritoneal metastasis.

METHODS

The data of postmenopausal female patients with pT4 CRC undergoing surgical resection between 2000 and 2019 were analyzed. Kaplan-Meier analysis was used to evaluate survival outcomes between patients treated with and without PO. Risk factors for DFS and peritoneal metastasis were evaluated using Cox regression analysis. p-values <0.05 were considered statistically significant.

RESULTS

Totally, 176 (34.3%) patients received PO. There was no significant difference in estimated blood loss, rates of postoperative complications, and hospitalization between the PO and non-PO groups. The 5-year OS and DFS rates were similar in the two groups (47.9% vs. 54.1%, p = 0.278; 53.5% vs. 50.5%, p = 0.161, respectively). In the subgroup analysis of patients with peritoneal metastasis, the median survival was significantly longer for the PO group compared with the non-PO group (14 vs. 11 months, p < 0.001).

CONCLUSION

Undertaking PO in pT4 CRC female patients did not confer a survival benefit. Indication of PO even for advanced CRC patients should require caution. It has potential survival benefit only when the patients developed metachronous peritoneal metastases.

Biomarker concordance between primary colorectal cancer and ovarian metastases: a Dutch cohort study

PURPOSE

The genetic characteristics and mismatch repair (MMR) status of the primary tumor and corresponding metastases in colorectal cancer (CRC) are generally considered to be highly concordant. This implies that either the primary or metastatic tumor can be used for testing gene mutation and MMR status. However, whether this is also true for CRC and their ovarian metastases is currently unknown. Ovarian metastases generally show a poorer response to systemic therapy compared to other metastatic sites. Differences in biomarker status between primary CRC and ovarian metastases could possibly explain this difference in therapy response.

METHODS

The study cohort was selected from CRC patients treated in two Dutch hospitals. Eligible patients with CRC and ovarian metastasis who were surgically treated between 2011 and 2018 were included. CRC and corresponding ovarian metastatic tissues were paired. Gene mutation status was established using next-generation sequencing, while the MMR status was established using either immunohistochemistry or microsatellite instability analysis.

RESULTS

Matched samples of CRC and ovarian metastasis from 26 patients were available for analysis. A biomarker concordance of 100% was detected.

CONCLUSION

Complete biomarker concordance was found between MMR proficient CRC and their matching ovarian metastasis. Biomarker testing of MMR proficient CRC tissue appears to be sufficient, and additional testing of metastatic ovarian tissue is not necessary. Differences in therapy response between ovarian metastases and other metastases from CRC are thus unlikely to be caused by differences in the genetic status.

Ovarian metastases in young women with colorectal cancer: a retrospective multicenter cohort study

BACKGROUND AND PURPOSE

Previous studies indicated that approximately 3.4% of female colorectal cancer (CRC) patients are at increased risk of developing ovarian metastases (OM). It has been suggested that young women more frequently develop this form of metastatic disease.

METHODS

This study evaluated, in 6 Dutch hospitals, the proportion of young women with CRC who developed OM.

RESULTS

In a cohort of 200 young (age ≤ 55) women with CRC, the proportion of patients diagnosed with synchronous or metachronous OM was calculated. This study revealed that 5% (n = 10) of young female CRC patients developed ovarian metastases resulting in a 5-year overall survival rate of approximately 40%. Furthermore, six patients had concurrent peritoneal metastases, five patients had bilateral ovarian metastases, and five patients had synchronous metastases, while the median time of the occurrence of metachronous metastases (n = 5) was 19 months.

CONCLUSION

This retrospective multicenter cohort study indicates that 5% of young women with CRC either present with or develop OM. This result appears to be clinically relevant and demonstrates the need for improved surveillance for young women diagnosed with CRC.

Surgical resection for small bowel obstruction due to right ovarian metastasis after ileocecal resection for cecal cancer: A case report

Although oophorectomy for ovarian metastasis from colorectal cancer is encouraged to improve the prognosis, that is also performed to relieve the symptom such as abdominal distention. We report a surgical case of intestinal obstruction due to ovarian metastasis after ileocecal resection for cecal cancer diagnosed at 77 years old.

Decision-making in postoperative chemotherapy for ovarian metastasis from colorectal cancer: a retrospective single-center study

BACKGROUND

Ovarian metastases from colorectal cancer are relatively uncommon, and no consensus has been reached regarding resection of metastases or chemotherapy before and after surgery. We evaluated the clinicopathological characteristics of ovarian metastases from colorectal cancer and the impact of metastatic resection. We also performed a comparative analysis to clarify the prognostic impact of metastatic resection and the choice of chemotherapy before and after surgery.

METHODS

Between 2006 and 2014, 38 patients at our institution underwent resection of ovarian metastases from colorectal cancer. Clinicopathological data were extracted from the patients' records and evaluated with respect to the long-term outcome. For 15 patients with metachronous ovarian metastases who received chemotherapy until immediately before resection, we compared the prognosis with and without changes in the regimen after resection.

RESULTS

The 5-year overall survival rate was 19.9%, and the median survival duration was 27.2 months. The survival rate in the R0 resection group (n = 8) was significantly better than that in the R1/2 resection group (n = 30) (P = 0.0004). Patients without peritoneal dissemination (n = 15) or extra-ovarian metastases (n = 31) had a significantly better prognosis than those with peritoneal dissemination (n = 23) or extra-ovarian metastases (n = 7) (P = 0.040 and P = 0.0005, respectively). The progression-free survival and median survival times of patients who resumed chemotherapy after resection without a change in their preoperative regimen were 10.2 months and 26.2 months, respectively, while those among patients with a change in their regimen before resection versus after resection were 11.0 months and 18.1 months, respectively. The difference between the two groups was not statistically significant (progression-free survival time and median survival time: P = 0.52 and P = 0.48, respectively).

CONCLUSIONS

Patients who underwent R0 resection of ovarian metastases clearly had a better prognosis than those who underwent R1/2 resection. Additionally, a poor prognosis was associated with the presence of peritoneal dissemination and extra-ovarian metastases. The data also suggested that resumption of chemotherapy without changing the regimen after resection could preserve the next line of chemotherapy for future treatment and improve the prognosis.

Ovarian metastases of pancreatic adenocarcinoma: clinical presentation, role of surgery, and potential value of the mutational profile for the differential diagnosis with primary mucinous ovarian carcinoma

Background:

Ovarian metastases (OM) of pancreatic adenocarcinoma (PA) (OM-PA) can mimic primary ovarian mucinous carcinoma (POMC) on imaging and histology. These metastases are often symptomatic and not highly chemosensitive, so that oophorectomy may be considered.

Aims:

The aims of this study were to compare the characteristics of OM-PA and POMC, and discuss the role of surgery.

Patients and Methods:

Clinical, imaging, and histological data of patients with OM-PA and POMC (2000–2017) in three tertiary centers were reviewed. Twenty-six genes were analyzed by next generation sequencing (NGS) on both primary PA and OM-PA.

Results:

Twenty-two women with OM-PA (n = 13, 11 with surgical resection) or POMC (n = 9) were selected. OM-PA were smaller than POMC (p = 0.02); imaging, histological, and immunohistochemistry data did not clearly differentiate OM-PA from POMC in 12 of 22 cases (54%). Seven PA/OM-PA pairs were analyzed, and a concordant KRAS mutation was identified in all cases. In four OM-PA, concordant mutations were also found in TP53 (n = 3), SMAD4 (n = 1), MET (n = 1), and PDGFRA (n = 1) genes. The aim of oophorectomy in 11 OM-PA was for antalgic (n = 6) or curative (n = 5) intent. Pain improved in 4/6 of the former patients, but 2/6 had significant morbidity, and 2/6 died of rapid tumor progression. After oophorectomy, median progression-free and overall survivals were 6 (0–11) and 8 months (1–131), respectively.

Conclusion:

Analysis of mutation profiles in both primary PA and ovarian tumors, especially KRAS, can help to determine the pancreatic origin of OM-PA. Surgical resection of OM-AP in highly selected patients may improve pelvic symptoms but may also cause significant morbidity. The benefit to survival requires further studies.

Clinicopathological Characteristics and Prognostic Factors in Ovarian Metastases from Right- and Left-Sided Colorectal Cancer

BACKGROUND

Secondary tumors of the ovary (STOs) account for 10-25% of all ovarian malignancies, including metastases from primary gynecological tumors. Colorectal cancer (CRC) has been recognized as one of the most common causes of STOs in Western countries. Despite it being well-known that CRC originating from the right versus left side of the colon/rectum differ substantially, there is a paucity of information regarding the effect of the primary tumor sidedness on the clinicopathological characteristics of STOs.

METHODS

This retrospective, observational chart review study included patients with histologically confirmed STOs of CRC origin diagnosed between January 2000 and December 2019. The clinicopathological characteristics of STOs originating from left-sided and right-sided CRC were compared. Univariable and multivariable analyses employing elastic net Cox proportional hazard models were used to evaluate potential prognostic factors. Further, the role of imaging methods in STOs diagnostics was evaluated.

RESULTS

Fifty-one patients with STOs of colorectal origin were identified. The primary tumor originated in the right and left colon/rectum in 39% and 61% of the cases, respectively. STOs originating from right-sided primary tumors were more frequently bilateral, associated with peritoneal carcinomatosis, had the ovarian surface affected by the tumor, and contained a mucinous component. The independent prognostic factors for overall survival in the whole cohort included: the presence of macroscopic residual disease after cytoreductive surgery, menopausal status, the application of systemic therapy, and the application of targeted therapy. In 54% of cases, the imaging methods failed to determine the laterality of the STOs correctly as compared to pathological reports and/or intraoperative findings.

CONCLUSION

STOs originating from left-sided and right-sided CRC show distinct clinicopathological characteristics. Moreover, different metastatic pathways might be employed according to the primary tumor sidedness. Considering the discrepancies between radiological assessment and histopathological findings regarding the laterality of STOs, bilateral adnexectomy should be advised whenever feasible.

Colorectal cancer ovarian metastases

OBJECTIVE

Ovarian metastases occur in 3%-5% of patients with colorectal cancer. The role of oophorectomy in that setting continues to be debated. We aimed to assess the survival of women treated with metastasectomy for ovarian metastasis.

METHODS

Retrospective cohort study of patients in the California Cancer Registry (2000-2012) with stage IV colorectal cancer and ovarian metastases. Pathology other than adenocarcinoma was excluded. Adjusted Cox-proportional hazard analysis was applied to assess the risk of death.

RESULTS

A total of 756 patients with synchronous ovarian metastases and 516 patients with metachronous ovarian metastases form the basis of this analysis. Median follow-up for the synchronous cohort was 21 months (IQR: 8-36). Median overall survival was 23 months (IQR: 10-42). Estimated 5-year survival reached 17% and 10-year survival was 8%. There was a significant difference in unadjusted survival between patients with solitary ovarian metastasis (median overall survival: 51 months) compared with those who had both ovarian and extraovarian metastases (20 months) (log-rank test, P<0.0001). For patients with solitary ovarian metastases, the 5- and 10-year survival was 46% and 31%, respectively. Among patients with synchronous ovarian metastases, longer unadjusted survival was observed after oophorectomy (median overall survival: 24 months) compared with no oophorectomy (18 months, log-rank P=0.01). For patients with metachronous diagnoses of colorectal cancer ovarian metastasis, the median disease-free survival was 19 months. The median survival after resection of metachronous ovarian metastases was 25 months, with the survival directly related to the disease-free interval until metastasis. For patients with resected metachronous ovarian metastases, the 5- and 10-year post-metastasectomy survival was 14% and 5%, respectively.

CONCLUSIONS

Patients with colorectal cancer ovarian metastasis have favorable long-term survival. Survival rates are higher if the tumor is isolated to the ovary or if metachronous to the primary cancer.

Clinical characteristics and prognostic factors of colorectal cancer patients with ovarian metastasis: a multicenter retrospective study

PURPOSE

As a kind of secondary tumor of the ovary, ovarian metastasis from colorectal cancer (OMCRC) happens rarely. Prognostic factors of OMCRC are still undetermined. This study was conducted to analyze clinical characteristics and prognostic factors of OMCRC patients.

METHODS

Data of patients with OMCRC were collected retrospectively from four large-capacity hospitals in China. Kaplan-Meier method was applied to estimate disease-specific overall survival (OS), and multivariate Cox regression analysis was used to identify prognostic factors. A novel nomogram was developed to estimate individual survival probability, whose performance was internally validated using concordance index (C-index) and calibration curve.

RESULTS

Totally, 162 cases were eligible, with a median age at diagnosis of 49 years old. The median size of ovarian metastases was 9.0 cm (95% CI: 8.5-10.4 cm). 93.8% of patients received surgery of ovarian metastases. Median time from CRC diagnosis to metachronous ovarian metastasis was 13.0 months (95% CI: 13.5-17.7 months). Median OS after ovarian metastasis diagnosis was 26.0 months (95% CI: 22.3-29.7 months). Integrating univariate and multivariate analyses, eight factors (including age, menopausal status, primary tumor location, N stage of primary tumor, surgery of primary tumor, differentiation grade, bilateral metastasis, and systemic chemotherapy) were used to develop a novel nomogram, with a C-index of 0.65 (95% CI: 0.595-0.705). Calibration curves indicated relatively good agreement between predicted and actual survival.

CONCLUSIONS

This nomogram could be a promising tool to help clinicians to estimate individual survival outcome of patients with OMCRC. Further study is warranted to validate the practicality of this model.

The diagnosis and outcome of Krukenberg tumors

Background

Accurate diagnostic tools are crucial to distinguish patients with Krukenberg tumors from those with ovarian cancers before decision on initial management. To address this unmet need, we aimed to evaluate the diagnostic utility of clinical, biochemical, and radiographic factors in this patient population.

Methods

Patients with Krukenberg tumors or primary ovarian cancers were retrospectively identified from institutional cancer registry. Kaplan-Meier method and Cox proportional hazards models were used for survival analysis. Logistic regression evaluated clinical, biochemical, and radiographic factors; residual deep neural network model evaluated features in computed tomography images as predictors to distinguish Krukenberg tumors from ovarian cancers. Model performance was summarized as accuracy and area under the receiver operating characteristic curve (AUC).

Results

This study included 214 patients with Krukenberg tumors with median age of 52 years. Among 104 (48.6%) patients with colorectal cancer, those who received palliative surgery had significantly higher median overall survival (48.1 versus 30.6 months, P=0.015) and progression-free survival (22.2 versus 6.7 months, P<0.001) than those with medical management only. The accuracy of radiology reports to make either diagnosis of Krukenberg tumors or primary ovarian cancers was 60.7%. In contrast, multivariable logistic regression model with age [odds ratio (OR) 2.98, P<0.001], carbohydrate antigen 125 (OR 1.57, P=0.004), and carcinoembryonic antigen (OR 0.03, P=0.031) had 87.5% [95% confidence interval (CI): 75.0-100.0%] accuracy with AUC 0.96 (95% CI: 0.87-1.00). The neural network model had 62.8% (95% CI: 51.8-74.5%) accuracy with AUC of 0.61 (95% CI: 0.53-0.72).

Conclusions

We developed a diagnostic model with clinical and biochemical features to distinguish Krukenberg tumors from primary ovarian cancers with promising accuracy.

Significance of Surgery in the Treatment of Colorectal Cancer Ovarian Metastases: A Retrospective Case Matching Study

PURPOSE

Colorectal cancer (CRC) is one of the most common malignant tumors worldwide. Ovarian metastases (OM), which are low in frequency, are reported to occur in 3-14% of women with CRC and have a poor prognosis. Studies have shown that surgical treatment may benefit patients with ovarian metastases arising from CRC. However, the precise benefit of surgery is uncertain. This study was implemented to identify treatment outcomes associated with ovarian metastases from CRC, as well as to clarify the importance of primary and metastatic lesion resection.

PATIENTS AND METHODS

Between January 2008 and December 2018, the medical records of 93 patients diagnosed with CRC ovarian metastases (CRC-OM) at Zhongshan Hospital, Fudan University, Shanghai, were retrospectively analyzed. Clinicopathological characteristics as well as prognostic conditions were evaluated. Nineteen patients with only synchronous OM and 38 patients without metastases were matched to compare surgical outcomes.

RESULTS

The median overall survival (OS) of the total 93 CRC-OM patients was 26 months. The median OS times of patients with ovary-only metastases (n=37) and those with other metastases (n=56) were 49 months and 20 months, respectively. Patients with only ovarian metastases had a longer OS time (p<0.001) than patients with other metastases. Patients with ovarian metastases resected (n=76) (p<0.001) had a longer OS time than those unresected (n=17). Synchronous (n=54) and metachronous (n=39) metastases indicated no significant survival difference. Patients with only ovarian metastases could achieve similar OS times to those of patients without metastases after primary and metastasis surgery.

CONCLUSION

Surgical treatment is very important for CRC-OM patients. Primary and metastatic lesion resection can help achieve longer survival times.

Prognosis and factors affecting colorectal cancer with ovarian metastasis

Colorectal cancer is one of the most common malignant tumors. Its incidence has been increasing in recent years, as has the number of cases of ovarian metastasis of colorectal cancer. The prognosis of colorectal cancer with ovarian metastasis is poor, and it is an important cause of death in female patients. A variety of clinicopathological factors were found to be related to the prognosis of patients with colorectal cancer with ovarian metastasis, such as menopausal status, metastasis limited to the pelvis, and tumor differentiation. Tumor genetic characteristics also provide a new perspective for the prognostic evaluation of colorectal cancer with ovarian metastasis. The prognosis of ovarian metastasis is also closely associated with treatment. The major treatment methods are prophylactic oophorectomy, surgical resection of the primary and metastatic lesions, cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy and systematic therapy. If feasible, complete surgical resection of the primary and ovarian metastatic macroscopic lesions combined with postoperative chemotherapy might currently be the most effective treatment for improving the prognosis of patients with colorectal cancer with ovarian metastasis. Genetic analysis also provides a theoretical basis for potential targeted therapy and immunotherapy.

The Validity of a New Edition of Classification for Ovarian Metastasis from Colorectal Cancer

OBJECTIVES

In the 9th edition of the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma (JCCRC), ovarian metastasis is classified as distant metastasis. We assessed the significance of resection of ovarian metastases and the validity of this 9th edition of JCCRC for ovarian metastases from colorectal cancer (CRC).

METHODS

We retrospectively analyzed the clinicopathological factors and overall survival of 17 patients with ovarian metastases from CRC who underwent resection and 110 female CRC patients with Stage IV (M1a) disease.

RESULTS

The patients with only ovarian metastases who underwent resection had a longer median survival time than patients with both ovarian and peritoneal metastases who underwent resection (45.4 months vs. 9.3 months, P = 0.029). The 5-year overall survival of the patients with only ovarian metastases who underwent R0 resection was as long as that of the female Stage IV (M1a) CRC patients after R0 resection (50% vs. 48%, P = 0.334).

CONCLUSIONS

We found that, after resection, patients with only ovarian metastases had significantly better prognoses than patients with ovarian and peritoneal metastases. R0 resection of ovarian metastasis indicated as good prognosis as R0 resection of metastasis to one distant organ without ovaries. So the 9th edition of JCCRC, which classifies ovarian metastasis from CRC as distant metastasis, is appropriate.

Ovarian metastasis from nongynecologic primary sites: a retrospective analysis of 177 cases and 13-year experience

BACKGROUND

Metastasis to the ovary from nongynecologic organs accounts for 9% of all ovarian malignancies. Although the most common nongynecologic primary site of ovarian metastasis is the gastrointestinal tract, metastasis from other sites to the ovary is not uncommon. Differential diagnosis of primary and metastatic ovarian tumors is important; otherwise, appropriate treatment cannot be determined. Furthermore, an optimal treatment strategy for ovarian metastasis from nongynecologic primary sites still needs to be explored.

METHODS

One hundred seventy-seven patients with ovarian metastasis from nongynecologic primary sites admitted to Peking Union Medical College Hospital between May 2005 and May 2018 were retrospectively evaluated.

RESULTS

The mean age was 48 years (range, 18-83). Approximately 60% of patients were premenopausal women. The two most common nongynecologic primary sites of ovarian metastasis were the colorectum (68 cases) and stomach (61 cases). In addition to the most common symptoms of abdominal distension (39.0%), abdominal pain (37.9%), and ascites (27.7%), 18.1% of patients presented with abnormal uterine bleeding. Half of the patients who tested serum CA-125 preoperatively had elevated CA-125 levels within the range of 35 U/ml to 200 U/ml. More than 70% of synchronous ovarian metastases were preoperatively misdiagnosed as primary ovarian cancer. Of all included cases, 56.5% achieved optimal cytoreductive surgery (the diameter of the largest residual lesion < 2 cm). The overall 5-year survival rate and median survival time were 10% and 20 months, respectively. The primary site, optimal cytoreductive surgery, tumor differentiation, and postoperative adjuvant treatment were identified as prognostic indicators.

CONCLUSIONS

The colorectum and stomach are the most common nongynecologic primary sites of ovarian metastasis. Synchronous ovarian metastasis is easily misdiagnosed as primary ovarian cancer. Optimal cytoreductive surgery and postoperative adjuvant treatment can be performed to confer survival benefit in selected patients.

Clinicopathological characteristics and prognosis analysis of ovarian metastases in colorectal cancer: a single-center experience

PURPOSE

This study aimed to improve the management of ovarian metastases (OM) in colorectal cancer (CRC) by evaluating the clinicopathological characteristics, therapeutic strategies, and prognostic factors associated with OM originating from CRC.

METHODS

Medical records of patients who were histopathologically diagnosed with OM of CRC origin were reviewed from January 2011 to December 2018 in our medical center. Data related to clinicopathological characteristics, therapeutic strategies, and survival time were recorded and analyzed. Survival and prognosis analyses were carried out to identify variables significantly associated with the outcomes.

RESULTS

Forty-six patients were included in the study with a median follow-up of 14 months. Premenopausal (< 50 years) and colon cancer patients were more likely to develop OM. Synchronous OM was found in 34 patients and elevated carbohydrate antigen 125 value could be seen in 67.4% of patients. Bilateral ovarian involvement (27/46, 58.8%) and combined extra-ovarian metastases (32/46, 69.6%) were common in included patients. Complete cytoreduction surgery (R0 resection) was finally achieved in 19 of included patients and 41 patients received postoperative chemotherapy. However, the overall prognosis remains poor, with a median survival time of only 12 months. In univariate analysis, histological types (P = 0.002), peritoneal metastasis (P < 0.0001), the extent of metastatic lesions (P = 0.0001), and completeness of cytoreduction surgery (P < 0.0001) were found to be closely related to prognosis. Finally, completeness of cytoreduction surgery was considered to be the independent determinant of patients' outcome (HR 0.186, 95% CI 0.047-0.727, P = 0.016) by multivariate analysis.

CONCLUSIONS

In multitudinous factors, complete cytoreduction surgery (R0 resection) may provide survival benefits in patients with OM of CRC origin. Thus, it is reasonable to recommend aggressive surgery with curative intent even if extra-ovarian metastases are present. Furthermore, postoperative chemotherapy may exert a positive effect on the treatment, but needs to be confirmed by large-scale trials with more participants in the future.

Impact of Ovarian Metastatectomy on Survival Outcome of Colorectal Cancer Patients with Ovarian Metastasis: A Retrospective Study

Background

Ovarian metastasis from colorectal cancer (CRC) is rare and lacks standard treatment. The benefit of metastatectomy remains to be elucidated. This study was conducted to assess the impact of metastatectomy on survival outcome and explore prognostic factors in ovarian metastatic CRC patients.

Methods

Information of ovarian metastatic CRC patients between January 2008 and December 2017 were collected retrospectively from database of West China Hospital, Sichuan University. Kaplan–Meier method was used to estimate disease-specific survival (DSS) after diagnosis of ovarian metastasis, and multivariate Cox regression analysis was applied to identify prognostic factors.

Results

Totally, 68 female patients from a cohort of 2170 cases were eligible. The median age at diagnosis was 46.5 years. The median DSS was 25.0 months (95% confidence interval (CI): 21.0–29.0 months). Kaplan–Meier analysis and Log rank test showed that complete resection of ovarian metastases (median DSS: 33.0 months) could significantly prolong patients’ survival time, compared with palliative and no resection (median DSS: 20.0 months and 22.0 months, respectively), regardless of systemic chemotherapy (P<0.05). Multivariate analysis demonstrated regional lymph nodes metastasis of primary tumor (hazard ratio (HR): 3.438, 95% CI: 1.094–10.810, P=0.035), primary tumor resection (HR: 6.436, 95% CI: 1.770–23.399, P=0.005), differentiation grade (HR: 0.272, 95% CI: 0.107–0.693, P=0.006), complete resection of ovarian metastases (vs palliative resection: HR: 17.091, 95% CI: 3.040–96.099, P=0.001; vs no resection: HR: 9.519, 95% CI: 1.581–57.320, P=0.014), and systemic chemotherapy (HR: 3.059, 95% CI: 1.089–8.595 P=0.034) were independent prognostic factors.

Conclusion

Complete resection of ovarian metastases could independently predict favorable survival in ovarian metastatic CRC, while palliative resection could not improve patients’ prognosis compared with no resection.

Appendiceal tumours and pseudomyxoma peritonei: Literature review with PSOGI/EURACAN clinical practice guidelines for diagnosis and treatment

Pseudomyxoma Peritonei (PMP) is a rare peritoneal malignancy, most commonly originating from a perforated epithelial tumour of the appendix. Given its rarity, randomized controlled trials on treatment strategies are lacking, nor likely to be performed in the foreseeable future. However, many questions regarding the management of appendiceal tumours, especially when accompanied by PMP, remain unanswered. This consensus statement was initiated by members of the Peritoneal Surface Oncology Group International (PSOGI) Executive Committee as part of a global advisory role in the management of uncommon peritoneal malignancies. The manuscript concerns an overview and analysis of the literature on mucinous appendiceal tumours with, or without, PMP. Recommendations are provided based on three Delphi voting rounds with GRADE-based questions amongst a panel of 80 worldwide PMP experts.

Clinicopathologic Characteristics and Impact of Oophorectomy for Ovarian Metastases from Colorectal Cancer

BACKGROUND

As survival with metastatic colorectal cancer (CRC) and imaging modalities improve, detection of ovarian metastases may be increasing. The ovary may serve as a sanctuary site for malignant cells; however, there is a paucity of data regarding the role for oophorectomy.

METHODS

This is a single-institution retrospective study of patients with CRC with ovarian metastases from 2009 to 2017. We evaluated patient, disease, and treatment related factors associated with overall survival (OS) from initial diagnosis of metastatic CRC.

RESULTS

Of 108 patients assessed, the median age was 50, 19% had localized disease at initial presentation, 64% had ovarian metastases at initial CRC diagnosis, and 77% underwent oophorectomy. Median OS was 29.6 months across all patients, and it was 36.7 months in patients who underwent oophorectomy versus 25.0 months in patients who did not (hazard ratio [HR] 0.54). In multivariate analysis, the effect of oophorectomy on OS suggested protection but was not statistically significant (HR 0.57). Resection of primary tumor was performed in 71% of patients, which was independently associated with improved OS (HR 0.21). Twelve patients (11%) remained alive at 5 years after diagnosis of metastatic disease.

CONCLUSION

Although it has been previously reported that patients with CRC with ovarian metastases have poor prognosis, the median OS for this cohort was comparable to existing OS data for patients with metastatic CRC. In patients treated with chemotherapy, we did not find the ovarian metastasis to frequently serve as a sanctuary site of disease. However, we found that in carefully selected patients, oophorectomy may confer a survival benefit.

IMPLICATIONS FOR PRACTICE

In colorectal cancer (CRC) ovarian metastasis is not necessarily associated with worse prognosis than metastasis to other sites. In carefully selected patients with ovarian metastases from CRC, oophorectomy may confer a survival benefit. Specifically, development of ovarian metastasis early in the disease course, resection of the primary tumor, and limited extraovarian metastatic disease are clinical features that are potentially associated with benefit from oophorectomy. A subset of patients with ovarian metastasis from CRC have potential to become long-term survivors (>5 years).

Differentiation between ovarian metastasis from colorectal carcinoma and primary ovarian carcinoma: Evaluation of tumour markers and "mille-feuille sign" on computed tomography/magnetic resonance imaging

PURPOSE

The purpose of this retrospective study was to evaluate the usefulness of serum tumour markers and morphological characteristics in CT/MRI to differentiate between ovarian metastases from colorectal carcinomas (OMCRC) and primary ovarian carcinomas (POC).

METHOD

Preoperative radiological images of 41 OMCRCs from 27 patients (mean age ± SD: 52.2 ± 10.7 years) and 46 POCs from 36 patients (52.1 ± 12.7 years) were included. Three blinded gynecological radiologists classified tumour morphology into 'mille-feuille sign', 'solid and cystic', 'multicystic without nodules', and 'multicystic with nodules' groups and analysed using Fisher's exact test. Serum carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), and carbohydrate antigen 19-9 levels were compared by Wilcoxon rank-sum test.

RESULTS

'Mille-feuille sign' indicated OMCRC (OMCRC: 8/41, POC: 1/46, specificity = 0.98, p = 0.011) and had excellent interobserver agreement (Fleiss's kappa value = 0.96). 'Solid and cystic' indicated POC (18/41 vs 41/45, p < 0.001) and 'multicystic without nodules' indicated OMCRC (8/41 vs 2/46, p = 0.041). There was no significant difference in 'multicystic with nodules'. CA125 levels were higher in POCs (292.5 U/mL vs. 41.0 U/mL, p = 0.003). CEA levels were higher in OMCRCs (24.5 ng/mL vs 2 ng/mL, p < 0.001). CEA (< 6.3 ng/mL) AND (CA125 (≥87.0 U/mL) OR 'solid and cystic') indicated POC with high accuracy (3/41 vs 44/46, accuracy = 0.94, p < 0.001).

CONCLUSIONS

Our new method with morphological classification and tumour markers were useful for differentiating the two tumours. In particular, the 'mille-feuille sign' frequently indicated OMCRC with high specificity and excellent interobserver agreement.

Systematic mutation analysis in rare colorectal cancer presenting ovarian metastases

Although colorectal cancer is one of the most lethal cancer types in the world, its metastasis to the ovary is rare, compared to metastasis to other organs. Consequently, the genomic basis for colon-to-ovary metastasis remains unstudied, due to limited available patients, and thus there have been no attempts to construct individual-specific networks. Due to its rarity, the small sample size makes common mutations difficult to find. To overcome this problem, we herein attempted to apply a biological connectivity map called a sample-specific network (SSN), to reveal common biological functions in three samples. Our three samples were compared to a clinical dataset contained in The Cancer Genome Atlas (TCGA) Colorectal Adenocarcinoma (COAD), showing different mutational spectra, compared to matched samples based on age, gender, microsatellite instability (MSI) status, and tumor, node, metastasis (TNM) stage. The SSNs for the three samples revealed significant correlations of the mutation statuses of several apoptosis genes, in contrast to the TCGA-matched samples. Further analysis of a targeted-gene panel sequencing dataset for colon-to-ovary metastasis of primary tumor samples also confirmed significant correlations of the mutational statuses among apoptosis genes. In summary, using SSN, we successfully identified a common function (apoptosis) among our three patients having colon-to-ovary metastasis, despite no common mutations in the three patients. Such computational analyses could facilitate productive study of rare cancers and other diseases.

The great escape: How metastases of melanoma, and other carcinomas, avoid elimination

IMPACT STATEMENT

Cancers kill mainly because metastatic disease is resistant to systemic therapies. It was hoped that newer targeted and immunomodulatory interventions could overcome these issues. However, recent findings point to a generalized resistance to elimination imparted by both cancer-intrinsic and -extrinsic changes to provide survival advantages to the disseminated tumor cells. Here, we present a novel conceptual framework for the microenvironmental inputs and changes that contribute to this generalized therapeutic resistance. In addition we address the issues of experimental systems in terms of studying this phenomenon with their advantages and limitations. This is meant to spur studies into this critical aspect of tumor progression that directly leads to cancer mortality.

Complete resection of colorectal cancer with ovarian metastases combined with chemotherapy is associated with improved survival

BACKGROUND

Ovarian metastases (OM) from colorectal cancer (CRC) are uncommon, and data about optimal management are lacking. The aim of this study was to examine the management and outcomes of patients with OM from CRC.

METHODS

A retrospective review of records of patients with a histopathological diagnosis of OM from CRC who were treated at Christchurch Hospital between 1 January 2000 and 31 December 2016. Data related to presentation, clinicopathological characteristics, treatment and outcomes were recorded. The primary outcomes were overall survival and disease-free survival.

RESULTS

Thirty-one patients were identified (median age 55 years, range 28-77), with a median follow-up of 23 months (range 3-84 months). Abdominal pain was the most common presenting symptom (22 patients). Synchronous OM occurred in 22 patients, 14 patients had bilateral ovarian involvement. Twenty-one patients received adjuvant chemotherapy. R0 resection was achieved in 14 patients. For all patients the 5-year disease-free and overall survival were 11% and 12%, respectively, while 5-year overall survival for R0 resections was 30%. Improved median survival was associated with negative colon resection margins (26.7 months versus 7.8 months, P = 0.03), R0 resection (30.5 months versus 23.5 months, P = 0.04), and use of adjuvant chemotherapy (28.8 months versus 8.2 months, P < 0.0001); however, on multivariate analysis adjuvant chemotherapy was the only independent factor associated with improved prognosis (P = 0.01).

CONCLUSIONS

OM from CRC are uncommon and carry a poor prognosis. Improved survival was associated with complete surgical resection of the primary tumour and metastatic disease in combination with systemic chemotherapy.

Clinical outcomes of women with ovarian metastases of colorectal cancer treated with oophorectomy with respect to their somatic mutation profiles

We clarified the clinical prevalence of ovarian metastases from colorectal cancers (CRCs) in 296 female patients with CRC and evaluated clinical outcomes with relation to their mutational profiles, such as BRAF/KRAS mutation and microsatellite instability (MSI) status. The female CRCs were categorised into three subsets: CRCs with ovarian metastases [6.4% (n = 19), 5-year overall survival (OS) = 24.7%], CRCs with extra-ovarian metastases only [32.4% (n = 96), 5-year OS = 34.5%] and CRCs without any recurrence or metastasis [61.2% (n = 181), 5-year OS = 91.3%]. All patients with ovarian metastases underwent oophorectomy; of these, 9 who received preoperative chemotherapy had measurable metastases to extra-ovarian sites and the ovaries. Although 5 of 9 (56%) achieved partial response or complete response at extra-ovarian sites, no patient archived objective response at ovarian sites. Regarding the mutation profiles, in CRCs with extra-ovarian metastases only, the median survival time (MST) after initial treatments to progression to stage IV or recurrence was 13 [95% confidence interval (CI): 7–16 months] in BRAF-mutant and 34 months (95% CI: 22–58 months) in BRAF wild-type (P = 0.0033). Although ovarian metastases demonstrated poor response to systemic chemotherapy in CRCs with ovarian metastases, the MST after initial treatments to progression to stage IV or recurrence was 22 (95% CI: 21–25 months) in BRAF-mutant and 38 months (95% CI: 24–42 months) in BRAF wild-type (P = 0.0398). The outcomes of patients with ovarian metastases could be improved by oophorectomy regardless of their mutation profiles.

Palliative surgery for Krukenberg tumors – 12-year experience and review of the literature

AIM

To determine the clinical characteristics of patients undergoing palliative surgery for Krukenberg tumors, including disease presentation, outcomes, and prognostic factors.

METHODS

This was a retrospective clinical study of all patients who underwent palliative surgery for Krukenberg tumors between January 2004 and December 2015. Patient information was obtained from inpatient and outpatient case notes as well as the hospital electronic records. Patients who underwent potentially curative resection, and patients with Krukenberg tumors who did not undergo surgery were also excluded from the study. Palliative surgery was defined as those performed for either alleviation of symptoms or for asymptomatic patients for whom surgical removal of the tumors were deemed necessary following a multidisciplinary consensus. Tumors were diagnosed pre-operatively by computed tomography scans and all had histologic confirmation of the surgical specimens.

RESULTS

Over the study duration, 38 female patients underwent palliative surgery for Krukenberg tumors at our institution. Mean age was 54.2 ± 11.7 years. The colon was the most frequent primary source of metastases (n = 21) followed by the stomach (n = 4). Prophylactic palliative surgery was performed for eight (21.1%) asymptomatic patients. Median post-operative length of stay was 8 d (IQR 6-12 d). Five patients (13.2%) experienced post-operative complications, although high grade morbidity was only seen in one patient (2.6%). Median overall survival from surgery was 17 mo (95%CI: 12.1-21.9) at a median follow-up duration of 12 mo (IQR 8-17 mo). The median survival was shorter for patients who underwent emergency surgery, younger patients, those with a colorectal primary, larger tumors, or synchronous peritoneal or hepatic metastases.

CONCLUSION

Palliative surgery for Krukenberg tumors can be performed safely with acceptable complication rates. Bilateral oophorectomy should be performed to prevent the risk of symptomatic contralateral tumors.

Ovarian Metastases of Colorectal Origin: Treatment Patterns and Factors Affecting Outcomes

The purpose of this study is to evaluate the patterns of treatment and factors affecting outcomes in ovarian metastases of colorectal origins treated at our institution and to assess the response of ovarian metastases to chemotherapy. Survival in R0 and R+ resections and patients receiving only chemotherapy is also analyzed. This is a retrospective study of 25 patients registered between January 2012 and December 2015. Patient's age, disease status, mode of presentation, disease spread, mode of treatment, response to chemotherapy, completeness of resection, histology, and outcomes were considered as variables for analysis. There were 21 synchronous presentations and 4 metachronous presentations. In synchronous presentations, only 2 had extra-abdominal disease. Of these patients, 15 underwent surgeries of various extents. The remaining 6 patients were treated with chemotherarpy initially. Only one of them could come up to surgery later. In R0 resections, disease recurred between 1 and 9 months (median 3.5 months). The recurrence was in peritoneum and ovaries. In operated cases, 12 of 15 patients received chemotherapy and 9 patients progressed on first line chemotherapy. In all 4 metachronous patients, the disease was in the peritoneum. No one underwent surgery for the recurrence due to the extensive nature of the disease. All received chemotherapy. Sixty-six percent ovarian metastases showed progression on chemotherapy. There was no significant difference in the median survival between patients treated with surgery plus chemotherapy (23 months) vs. those treated with chemotherapy alone (28 months). Age and presence of disease at other sites did not affect the outcomes. Non-signet ring cell histologies showed better outcomes compared to signet ring cell histology (p = 0.02). Synchronous presentation, R0 resections, and responsive disease showed better survival, however it was clinically not significant. Treatment of ovarian metastases of colorectal origins is varied but has consistently poor outcome. Non-signet histology was the only prognostic factor which showed better outcome. Survival was not different between patients treated with surgery+chemotherapy and chemotherapy alone but majority of ovarian metastases progressed on chemotherapy. Considering the poor response to chemotherapy and peritoneum being the most common site of disease, both in primary and recurrent setting, R0 resection should always be attempted after selecting the correct patients using PET scan, laparoscopy and standard exploratory protocols. Treatment should be tailored upon patient's status and disease burden with an aim to do complete cytoreduction whenever possible. CRS+HIPEC (cytoreductive surgery + hyperthermic intraperitoneal chemotherapy) can be considered on case to case basis as even R0 resections tend to recur.

The role of surgical excision for the Krukenberg tumour: A case report

INTRODUCTION

Krukenberg tumour (KT), which represents carcinoma in the ovary, is an uncommon manifestation of metastatic colorectal cancer. It is associated with poor prognosis and a high incidence of peritoneal metastatic disease.

PRESENTATION OF CASE

The authors present a case of a 51-year-old female who had a symptomatic, metachronous right ovarian KT diagnosed 12 months after her initial resection. Surgery was performed to excise the 23cm tumour as well as the contralateral ovary and isolated peritoneal disease, with an R0 resection achieved.

DISCUSSION

KT from colorectal origin behave differently to non-ovarian colorectal metastases, with features suggestive of transcoloemic dissemination. Surgical removal of isolated ovarian metastasis without peritoneal involvement is associated with improved outcomes. Treatment with cytoreductive surgery and heated intraperitoneal chemotherapy offers promise for patients with KT and concominant peritoneal involvement.

CONCLUSION

This case is illustrative of the clinical features of KT including its chemo-resistance and concomitant carcinomatosis peritoneii. Cytoreductive surgery for KT provides symptom control and confers survival benefit in selected patients.

Risk of Ovarian Involvement in Advanced Colorectal or Appendiceal Tumors Involving the Peritoneum

BACKGROUND

Ovarian metastases of GI tumors grow rapidly and are relatively resistant to systemic chemotherapy. They may be unilateral or bilateral and macroscopic or occult. The risk of macroscopic ovarian involvement or occult involvement of macroscopically normal ovaries is unquantified.

OBJECTIVE

This study aims to quantify the risks of ovarian involvement in patients with peritoneal malignancy undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

DESIGN

This was a retrospective analysis of a dedicated prospective malignancy database.

SETTINGS

This study was conducted at a high-volume tertiary referral center for peritoneal malignancy.

PATIENTS

Female patients with at least 1 remaining ovary, undergoing complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendiceal tumors or colorectal peritoneal metastases between January 2010 and March 2015 were included.

OUTCOME MEASURES

Data regarding ovarian involvement was extracted from surgical and histological records.

RESULTS

Two hundred fifty-eight female patients with at least 1 ovary underwent complete cytoreduction and hyperthermic intraperitoneal chemotherapy during the study period. In total, 141 of 258 (54.7%) patients had ovarian tumor involvement, and 80% with at least 1 macroscopically abnormal ovary had bilateral involvement. Of 40 patients with 1 macroscopic ovarian metastasis, microscopic involvement of the contralateral ovary was found in 18 of 40 (45.0%). Of 141 patients in whom both ovaries were macroscopically normal, 24 of 141 (17.0%) patients had microscopic ovarian involvement.

LIMITATIONS

The retrospective nature limits the interpretation of these results.

CONCLUSIONS

Occult malignancy was present in 17% when both ovaries looked macroscopically normal and in 45% of contralateral normal-looking ovaries if the other ovary was macroscopically involved. These results help to inform preoperative consent and intraoperative decision making in patients with advanced appendiceal and colorectal malignancy, and are of benefit in managing advanced lower GI tract malignancy.

BRAZILIAN CONSENSUS FOR MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 3: CONTROVERSIES AND UNRESECTABLE METASTASES

In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

Clinical and genetic determinants of ovarian metastases from colorectal cancer

BACKGROUND

Ovarian metastases from colorectal cancer (OM-CRC) often are unresponsive to chemotherapy and are associated with poor survival. To the authors' knowledge, the clinicopathologic and genomic predictors of OM-CRC are poorly characterized and optimal clinical management remains unclear.

METHODS

Women with a histopathological diagnosis of OM-CRC who were treated at Memorial Sloan Kettering Cancer Center from 1999 to 2015 were identified. Next-generation somatic mutation profiling (Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets [MSK-IMPACT]) was performed on 38 OM-CRC cases, including 21 matched tumor pairs/trios. Regression models were used to analyze variables associated with progression-free survival and overall survival (OS).

RESULTS

Kirsten Rat Sarcoma Viral Oncogene Homolog (KRAS), SMAD family member 4 (SMAD4), and neurotrophic receptor tyrosine kinase 1 (NTRK1) mutations were more frequent in cases of OM-CRC than in instances of CRC occurring without OM. SMAD4 and lysine methyltransferase 2D (KMT2D) mutations were associated with reduced OS. Matched multisite tumor sequencing did not identify OM-specific genomic alterations. Of the 195 patients who underwent oophorectomy for OM-CRC (median age, 49 years with a progression-free survival of 9.4 months and an OS of 23 months from oophorectomy), 76% had extraovarian metastasis (EOM). In multivariable analysis, residual disease after surgery (R2 resection) was associated with worse survival. Patients with EOM were less likely to achieve R0/R1 surgical resection status (complete macroscopic resection without clinical/radiological evidence of disease) (48% vs 94%). However, if R0/R1 resection status was achieved, both patients with (35.9 months vs 12 months) and without (43.2 months vs 14.5 months) EOM were found to have better OS. Among 114 patients with R0/R1 resection status, 23 (20%) had no disease recurrence, including 10 patients (9%) with > 3 years of follow-up.

CONCLUSIONS

Loss-of-function alterations in SMAD4 are frequent and predictive of worse survival in patients with OM-CRC. Similar to oligometastatic CRC to the lung or liver, surgical resection of OM-CRC is associated with a better outcome only if all macroscopic metastatic disease is resected. Cancer 2017;123:1134-1143. © 2016 American Cancer Society.

Molecular profiling of 6,892 colorectal cancer samples suggests different possible treatment options specific to metastatic sites

Metastatic colorectal cancer (mCRC) carries a poor prognosis with an overall 5-year survival of 13.1%. Therapies guided by tumor profiling have suggested benefit in advanced cancer. We used a multiplatform molecular profiling (MP) approach to identify key molecular changes that may provide therapeutic options not typically considered in mCRC. We evaluated 6892 mCRC referred to Caris Life Sciences by MP including sequencing (Sanger/NGS), immunohistochemistry (IHC) and in-situ hybridization (ISH). mCRC metastases to liver, brain, ovary or lung (n = 1507) showed differential expression of markers including high protein expression of TOPO1 (52%) and/or low RRM1 (57%), TS (71%) and MGMT (39%), suggesting possible benefit from irinotecan, gemcitabine, 5FU/capecitabine and temozolomide, respectively. Lung metastases harbored a higher Her2 protein expression than the primary colon tumors (4% vs. 1.8%, p = 0.028). Brain and lung metastases had higher KRAS mutations than other sites (65% vs 59% vs 47%, respectively, p = 0.07, <0.01), suggesting poor response to anti-EGFR therapies. BRAF-mutated CRC (n = 455) showed coincident high protein expression of RRM1 (56%), TS (53%) and low PDGFR (22%) as compared with BRAF wild-type tumors. KRAS-mutated mCRC had higher protein expression of c-MET (47% vs. 36%) and lower MGMT (56% vs. 63%), suggesting consideration of c-MET inhibitors and temozolomide. KRAS-mutated CRC had high TUBB3 (42% vs. 33%) and low Her2 by IHC (0.5%) and HER2 by FISH (3%, p <0.05). CRC primaries had a lower incidence of PIK3CA and BRAF mutations in rectal cancer versus colon cancer (10% and 3.3%, respectively). MP of 6892 CRCs identified significant differences between primary and metastatic sites and among BRAF/KRAS sub-types. Our findings are hypothesis generating and need to be examined in prospective studies. Specific therapies may be considered for different actionable targets in mCRC as revealed by MP.

Efficacy of modern chemotherapy and prognostic factors in patients with ovarian metastases from gastric cancer: A retrospective AGEO multicentre study

BACKGROUND

Ovarian metastases from gastrointestinal tumours frequently lead to locoregional complications and undermine quality of life. The chemosensitivity of ovarian metastases from gastric cancer is unknown.

AIM

To evaluate the efficacy of modern chemotherapy regimens in first-line treatment for patients with ovarian metastases from gastric cancer.

METHODS

All consecutive patients with ovarian metastases from gastric cancer who received at least one cycle of chemotherapy were included in this retrospective study.

RESULTS

Thirty-five patients were included (median age, 50.5 years; synchronous ovarian metastases, 60%). Seventeen patients (48.6%) underwent oophorectomy. Patients were treated with first-line chemotherapy based on platinum (n=14), irinotecan (n=8), taxane plus platinum (n=4) or epirubicin plus platinum (n=9). The median PFS and OS were 6.8 and 18.8 months, respectively. The objective response rate (ORR) for extra-ovarian (13.6%) and ovarian (20.9%) metastatic sites was not significantly different (p=0.55). There was no significant difference in terms of ORR on ovarian metastatic site according to the first-line chemotherapy (p=0.21). In multivariate analysis, oophorectomy was an independent prognostic factor for OS (p<0.01).

CONCLUSIONS

This study suggests that ovarian metastases from gastric cancer are not more resistant than extra-ovarian metastases, and that oophorectomy is an independent prognostic factor significantly linked to OS. Prospective studies are needed to confirm these results.

Prophylactic oophorectomy during primary colorectal cancer resection: A systematic review and meta-analysis

AIM: To appraise the current evidence for prophylactic oophorectomy in patients undergoing primary curative colorectal cancer resection.

METHODS: Occult ovarian metastases may lead to increased mortality, therefore prophylactic oophorectomy may be considered for women undergoing colorectal resection. A systematic review and meta-analysis was performed for English language studies from 1994 to 2014 (PROSPERO Registry number: CRD42014009340), comparing outcomes following prophylactic oophorectomy (no known ovarian or other metastatic disease at time of surgery) vs no ovarian surgery, synchronous with colorectal resection for malignancy. Outcomes assessed: local recurrence, 5-year mortality, immediate post-operative morbidity and mortality, and rate of distant metastases.

RESULTS: Final analysis included 4 studies from the United States, Europe and China, which included 627 patients (210 prophylactic oophorectomy and 417 non-oophorectomy). There was one randomized controlled trials, the remainder being non-randomised cohort studies. The studies were all at high risk of bias according to the Cochrane Collaboration’s assessment tool for randomised studies and the Newcastle-Ottawa Score for the cohort studies. The mean age of patients amongst the studies ranged from 56.5 to 67 years. There were no significant differences between the patients having prophylactic oophorectomy at time of primary colorectal resection compared with patients who did not with respect to local recurrence, 5-year survival and distant metastases. There was no difference in post-operative complications or immediate post-operative mortality between the groups.

CONCLUSION: Current evidence does not favour prophylactic oophorectomy for patients without known genetic predisposition. Prophylactic surgery is not associated with additional risk of post-operative complications or death.

How can we determine the best neoadjuvant chemoradiotherapy regimen for rectal cancer?

SUMMARY 

The current management of patients with clinically defined ‘locally advanced rectal cancer’ often involves fluoropyrimidine-based preoperative chemoradiotherapy (CRT) followed by total mesorectal excision. The focus remains primarily on reducing local recurrence, and improving survival, with organ preservation an increasing target. The best neoadjuvant CRT is the most effective regimen, balanced against the tolerability and late functional consequences, which should be selected for the individual according to their individual risk of local and distant recurrence. Hence, what makes the best neoadjuvant treatment depends on the activity and toxicity of the particular schedule, the aims of treatment, the individual disease characteristics and the individual patient pharmacogenomics. Current research efforts focus on enhancing the efficacy of CRT by integrating additional cytotoxics and biologically targeted agents.

Treatment of ovarian metastases of colorectal and appendiceal carcinoma in the era of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

AIM

To compare outcome of women with ovarian metastasis who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) to outcome of women without ovarian metastasis who underwent CRS-HIPEC.

METHODS

A prospective CRS-HIPEC database was searched to identify women with surgically treated colorectal carcinoma between 2000 and 2012. Patients with ovarian metastasis were identified and patients with peritoneal carcinomatosis but without ovarian metastasis were included as control cases.

RESULTS

75 patients with macroscopic ovarian metastasis underwent CRS-HIPEC with curative intent, while 50 female patients without ovarian metastasis were identified who underwent CRS-HIPEC. Patients with ovarian metastasis more often had a primary appendiceal tumour and had a more extensive intra-abdominal tumour load compared to patients without ovarian metastases. Median follow-up time was 45 months (95% confidence interval (CI): 37-53 months). Overall survival (OS) did not differ significantly between the two groups with a median OS in the ovarian metastasis group of 40 months (95% CI 26-54) compared to 64 months (95% CI 17-111, P = 0.478) in the non-ovarian metastasis group. Recurrence patterns did not differ significantly between groups (p = 0.183).

CONCLUSIONS

Patients with ovarian metastasis of colorectal and appendiceal origin who underwent CRS-HIPEC had similar outcome compared to patients without ovarian metastasis. Given the findings of high coincidence of peritoneal metastases with ovarian metastases and ovarian metastases not being an independent factor for survival after CRS-HIPEC, this procedure should be recommended for patients with peritoneal metastases and ovarian metastases of colorectal and appendiceal carcinoma.

Chemosensitivity in ovarian metastases from gastric cancer: a case series

The development of ovarian metastases from gastric cancer indicates a turning point of the disease progression and is usually associated with poor prognosis. Efficacy of modern chemotherapy protocols in ovarian metastases from gastric cancer is unknown. In this case series, we have evaluated the chemosensitivity of ovarian metastases from gastric cancer in eight consecutive patients treated in our institution between January 2000 and April 2012. Median age at gastric cancer diagnosis was 48.3 years and ovarian metastases were mainly metachronous (88%). Patients were treated with FOLFOX or FOLFIRI protocols in first-line and with EOX protocol in second-line chemotherapy. These protocols of chemotherapy used in first- and second-line treatment were able to control the disease in 33.3% for ovarian metastases compared to 66.7% for extraovarian metastases. Mean overall survival (OS) from ovarian metastases diagnosis was 14.2 months. The four patients treated by bilateral oophorectomy had a longer mean OS (16 months) than the four patients who did not experienced surgery (12.3 months). In conclusion, this case series suggests that ovarian metastases from gastric cancer are less sensitive than extraovarian metastases to modern protocol of chemotherapy. To confirm these observations, a large retrospective study is ongoing.

Survival benefit associated with surgical oophorectomy in patients with colorectal cancer metastatic to the ovary

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine the outcome of patients with colorectal cancer metastatic to the ovary and the impact of surgical oophorectomy on the outcome.

METHODS

We conducted a retrospective evaluation of patients with metastatic colorectal cancer to the ovary. Of 3776 female patients with colorectal cancer seen at MD Anderson from 2001-2008, 110 (2.9%) were identified as having metastases to the ovary. The Kaplan-Meier method and log-rank test were used to examine the survival functions.

RESULTS

Seventy-one patients (64.5%) had disease metastatic to the ovary at the time of initial presentation; in 39 patients (35.5%) the ovaries were a site of relapse after previous curative colorectal surgical resection. Patients who presented with ovarian relapse after previous colorectal surgery and who underwent oophorectomy had a median survival of 50 months compared with 12 months for those who did not (P < .0001). Patients with metastatic disease at the time of presentation who underwent oophorectomy had a median survival of 39.4 months vs. 18.2 months for those who did not.

CONCLUSIONS

This retrospective analysis suggests that women with metastatic colorectal cancer metastatic to the ovary may derive a survival benefit from palliative oophorectomy.

Clinicopathologic and immunohistochemical profile of ovarian metastases from colorectal carcinoma

Metastasis of colorectal adenocarcinoma of the ovary is not an uncommon occurrence and ovarian metastases from colorectal carcinoma frequently mimic endometrioid and mucinous primary ovarian carcinoma. The clinical and pathologic features of metastatic colorectal adenocarcinoma involving the ovary is reviewed with particular focus on the diagnostic challenge of distinguishing these secondary ovarian tumors from primary ovarian neoplasm. Immunohistochemical stains that may be useful in the differential diagnosis of metastatic colorectal tumors to the ovary and primary ovarian tumors are detailed.