Comparison of secondary and primary ovarian malignancies reveals differences in their pre- and perioperative characteristics

Efficacy of chemotherapy combined with surgical resection for gastric cancer with synchronous ovarian metastasis: A propensity score matching analysis

BACKGROUND

Ovarian metastasis from gastric cancer (GC) is characterized by aggressive biological behavior and poor outcome. Currently, there is no standard treatment mode for such patients. Thus, we evaluated the efficacy of conversion therapy in patients with synchronous ovarian metastasis from GC in this study.

METHODS

About 219 GC patients with ovarian metastasis in 2011-2020 were enrolled. Two groups were established based on the different treatment: the conversion therapy group (chemotherapy combined with surgical resection, CS group) and the non-conversion therapy group (NCS group). Propensity score matching (PSM) was used to analyze the efficacy of different treatment modes on the prognosis of these patients.

RESULTS

Ninety-two patients were included according to PSM results, with 46 patients each in CS and NCS groups. The median overall survival (OS) in the CS group was notably better than that in the NCS group (p < 0.001). Twenty-six patients (56.52%) in the CS group achieved R0 resection, and they had a better prognosis (p = 0.003). Compared with patients who underwent simultaneous gastrectomy and ovarian metastasectomy (CSb group), those who underwent ovarian metastasectomy before systemic chemotherapy (CSa group) had a higher R0 resection rate (p = 0.016) and longer survival time (p = 0.002). A total of 38 patients (41.30%) across both groups received hyperthermic intraperitoneal chemotherapy (HIPEC), and these patients had a better survival (p = 0.043).

CONCLUSION

The conversion therapy is safe and effective for patients with synchronous ovarian metastasis from GC and can improve their prognosis. However, our results need to be confirmed by more randomized controlled clinical studies.

Real-time contrast-enhanced ultrasound-guided percutaneous biopsy in the diagnosis of ovarian metastasis of gallbladder carcinoma: a case report

BACKGROUND

Multiple-organ primary tumors can invade the ovary through lymphatic and hematogenous routes, presenting as ovarian Krukenberg tumors, but these rarely originate from the gallbladder. Krukenberg tumors can present similar to primary ovarian tumors; however, their treatments are completely different.

PATIENT CONCERNS

A 62-year-old Chinese woman presented with abdominal distension for six months and weight loss of five kilograms for two months.

DIAGNOSES

Based on multiple imaging examinations, the patient was preliminarily diagnosed with a malignant tumor of unknown origin with multiple metastases (omentum). To identify the origin of the malignancy, the patient underwent real-time contrast-enhanced ultrasound-guided percutaneous biopsy. The results revealed a perihepatic hypoechoic lesion and right adnexal mass that were both metastatic adenocarcinomas from the gallbladder.

INTERVENTIONS

The patient initially received chemotherapy with gemcitabine and cisplatin instead of surgery. However, the tumor increased in size on re-examination after two cycles, so the treatment was shifted to a combination regimen with durvalumab for six cycles.

OUTCOMES

The treatment proceeded smoothly, with no recurrence or obvious progression of the cancer during follow-up.

CONCLUSIONS

Differentiating between primary and metastatic ovarian tumors is important. Early diagnosis and effective treatment options are essential for patient survival. CEUS-guided percutaneous biopsy is a valuable procedure for patients with multiple metastases who cannot tolerate surgery.

Misdiagnosed appendiceal mucinous neoplasms and primary ovarian mucinous tumors present with different pre- and intraoperative characteristics

Objective

To identify the differences between the pre- and intraoperative characteristics in misdiagnosed appendiceal mucinous neoplasms (AMNs) and those in primary ovarian mucinous tumors (POMTs) and to establish an effective model for differentiating AMNs from pelvic mucinous tumors.

Methods

This study enrolled 70 AMN patients who were misdiagnosed with ovarian tumors and 140 POMT patients who were treated from November 1998 to April 2021 at Peking Union Medical College Hospital. The clinical features and operative findings of the two groups of patients were collected and compared.

Results

There were significant differences in age and menopausal status, but no difference in the patients’ clinical manifestations between the two groups. The preoperative serum CA125 and CA199 levels were not different between the two groups. The CEA level (31.04 ± 42.7 vs. 7.11 ± 24.2 ng/ml) was higher in the misdiagnosed AMN group (P < 0.001). The AMNs were smaller than the POMTs that were measured preoperatively by ultrasonography (US) (P<0.05) and measured at surgery (P<0.05). Furthermore, the patients with AMNs more commonly had multinodularity and ascites noted on the preoperative US (P<0.001), on CT (P<0.001), and at surgery (P< 0.001). The two groups also differed in the presence of bilateral disease, in the appendiceal appearance and peritoneal dissemination. Subsequently, a prediction model was developed using multivariable logistic regression, which was evaluated through internal validation.

Conclusions

The suspicion of a nongenital organs originated tumor especially origing from appendiceal should be considered in a patient who is older, tumor size less than 12cm, multinodular, presence of mucinous ascites, and elevated serum CEA levels. Bilateral ovarian involvement, peritoneal dissemination, and an abnormal appendiceal appearance found during surgery were the typical features associated with AMNs.

Ovary metastasis from lung cancer mimicking primary ovarian cancer: A rare case report

Introduction

Ovarian metastasis from lung cancer is very rare, which might lead to a misdiagnosis as primary ovarian cancer.

Case presentation

We report a 49-year-old woman presenting to our hospital because of a painful mass in the lower abdomen, with no respiratory symptoms. Her initial diagnosis was stage IVB ovarian cancer with pulmonary metastasis. Therefore, the patient underwent neo-adjuvant Paclitaxel - Carbolatin chemotherapy followed by interval debulking surgery. However, postoperative histopathology and immunohistochemistry findings confirmed the diagnosis of primary lung cancer with ovarian metastases. EGFR exon 19 deletion mutation was found by tumor analysis. Therefore, she was then treated with erlotinib and the disease achieved the partial response and remained stable for 7 months.

Conclusion

Diagnosis of lung cancer in the context of ovarian and peritoneal metastases can be difficult. In this circumstance, thorough systemic assessment and immunohistochemistry are essential to confirm the primary.

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Ovarian metastasis from lung cancer is very rare, which might lead to a misdiagnosis as primary ovarian cancer.

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In this circumstance, thorough systemic assessment and immunohistochemistry are essential to confirm the primary.

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Our clinical case provides a lesson learned in diagnosing and treating lung cancer, which has a unique and rare clinical presentation.

Diagnostic Accuracy of Whole-Body Computed Tomography for Incidental Ovarian Tumors in Patients with Prior Breast Cancer

Whole-body computed tomography (WBCT) serves as the first-line imaging modality for breast cancer follow-up. To investigate the imaging characteristics and diagnostic accuracy of WBCT for incidental ovarian tumors in patients with prior breast cancer, we retrospectively reviewed a consecutive cohort of 13,845 patients with breast cancer, of whom 149 had pathologically-proven ovarian lesions. We excluded patients with ovarian diagnosis before breast cancer, CT scan not including ovary, CT-pathology interval >30 days, and severe CT artifact. Among our 60 breast cancer patients (median age, 46 years) with pathologically proven ovarian lesions, 49 patients had benign diseases, seven had primary ovarian cancer and four had ovarian metastasis from breast cancer. The histologic types of breast cancer with ovarian metastases included invasive ductal carcinoma, lobular carcinoma and angiosarcoma. Cystic ovarian lesions identified on WBCT during the breast cancer follow-up are more likely to be benign, while solid-cystic lesions are likely to be primary ovarian cancers, and solid lesions may indicate ovarian metastasis. The diagnostic accuracy, sensitivity, specificity, and areas under the receiver operating characteristic curve of WBCT were 98.3%, 100.0%, 98.0%, and 0.99 (malignant vs. benign); 90.0%, 100.0%, 85.7%, and 0.93 (metastasis vs. primary ovarian cancer), respectively. The only false positive solid lesion was a Sertoli–Leydig tumor. In conclusion, WBCT may help diagnose incidental ovarian tumors in patients with prior breast cancers and guide disease management.

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.

Tumores anexiales incidentales en cirugía abdominal

La posibilidad de encontrar una neoplasia benigna o maligna del ovario, de forma inesperada durante una intervención quirúrgica abdominal, es una realidad para todos los especialistas en cirugía. Si bien en muchos casos se tratará de una lesión benigna, el riesgo de cáncer no debe subestimarse, ya que, por ejemplo, la ruptura intraoperatoria de una lesión quística maligna puede reestadificar a una paciente con cáncer de ovario del estadio IA al IC, con todas las consecuencias que esto implica, como la necesidad de requerir quimioterapia adyuvante y tener un peor pronóstico. Por otro lado, en mujeres premenopáusicas debe discutirse con la familia o la paciente (idealmente) el riesgo e implicaciones de la ooforectomía uni o bilateral, incluso si esto amerita dejar el quirófano para obtener el consentimiento, o posponer el procedimiento definitivo para un segundo tiempo. La consulta intraoperatoria a un ginecólogo, siempre que sea posible, se debe llevar a cabo con el fin de respaldar la conducta adoptada. Conocer el manejo adecuado de las masas anexiales encontradas de forma incidental durante una cirugía abdominal, es una prioridad para todos los cirujanos generales

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.

Diagnostic performance of dynamic contrast-enhanced magnetic resonance imaging for malignant ovarian tumors: a systematic review and meta-analysis

BACKGROUND

Accurate preoperative diagnosis of malignant ovarian tumors (MOTs) is particularly important for selecting the optimal treatment strategy and avoiding overtreatment.

PURPOSE

To evaluate the diagnostic efficacy of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for MOTs.

MATERIAL AND METHODS

A systematic search was performed in PubMed, Embase, the Cochrane Library, and Web of Science databases to find relevant original articles up to October 2019. The included studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Studies on the diagnosis of MOTs with quantitative or semi-quantitative DCE-MRI were analyzed separately. The bivariate random-effects model was used to assess the diagnostic authenticity. Meta-regression analyses were performed to analyze the potential heterogeneity.

RESULTS

For semi-quantitative DCE-MRI, the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and the area under the summary receiver operating characteristic curves (AUC) were 85% (95% confidence interval [CI] 0.75-0.92), 85% (95% CI 0.77-0.91), 5.8 (95% CI 3.8-8.8), 0.17 (95% CI 0.10-0.30), 33 (95% CI 18-61), and 0.92 (95% CI 0.89-0.94), respectively. For quantitative DCE-MRI, the pooled sensitivity, specificity, positive LR, negative LR, DOR, and AUC were 88% (95% CI 0.65-0.96), 93% (95% CI 0.78-0.98), 12.3 (95% CI 3.4-43.9), 0.13 (95% CI 0.04-0.45), 91 (95% CI 10-857), and 0.96 (95% CI 0.94-0.98), respectively.

CONCLUSION

DCE-MRI has great diagnostic value for MOTs. Semi-quantitative DCE-MRI may be a relatively mature approach; however, quantitative DCE-MRI appears to be more promising than semi-quantitative DCE-MRI.

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.

A novel algorithm for better distinction of primary mucinous ovarian carcinomas and mucinous carcinomas metastatic to the ovary

Primary mucinous ovarian carcinomas (MOC) are notoriously difficult to distinguish from mucinous carcinomas metastatic to the ovary (mMC). Studies performed on small cohorts reported algorithms based on tumor size and laterality to aid in distinguishing MOC from mMC. We evaluated and improved these by performing a large-scale, nationwide search in the Dutch Pathology Registry. All registered pathology reports fulfilling our search criteria concerning MOC in the Netherlands from 2000 to 2011 were collected. Age, histology, laterality, and size were extracted. An existing database covering the same timeline containing tumors metastatic to the ovary was used, extracting all mMC, age, size, laterality, and primary tumor location. Existing algorithms were applied to our cohort. Subsequently, an algorithm based on tumor histology, laterality, and a nomogram based on age and size was created for differentiating MOC and mMC. We identified 735 MOC and 1018 mMC. Patients with MOC were significantly younger and MOC were significantly larger and more often unilateral than mMC. Signet ring cell carcinomas were rarely primary. Our algorithm used signet ring cell histology, bilaterality, and a nomogram integrating patient age and tumor size to diagnose mMC. Sensitivity and specificity for mMC was 90.1% and 59.0%, respectively. Applying existing algorithms on our cohort yielded a far lower sensitivity. The algorithm described here using tumor histology, laterality, size, and patient age has higher sensitivity but lower specificity compared to earlier algorithms and aids in indicating tumor origin, but for conclusive diagnosis, careful integration of morphology, immunohistochemistry, and clinical and imaging data is recommended.

The pathologic distinction of primary and metastatic mucinous tumors involving the ovary: A re-evaluation of algorithms based on gross features

The problems associated with the pathologic distinction of primary ovarian mucinous tumors from their metastatic counterparts are well-recognized. Herein, we systematically evaluate a variety of gross parameters to determine the combination of features that most optimally separate primary from secondary mucinous ovarian tumors, and to address the tumor types that are most frequently associated with exceptions. 129 consecutive mucinous tumors involving the ovary formed the study set, including 61 primary mucinous tumors (16 carcinomas, 45 borderline tumors), and 68 metastatic carcinomas (21 colon; 28 appendix; 5 breast; 3 lung; 3 pancreas; 3 cervix; 1 bladder; 4 stomach). Consistent with prior studies, we found that as compared with metastases, primary ovarian mucinous tumors tend to be larger, more frequently unilateral and were more likely to be predominantly cystic and devoid of surface nodules. 41 of the 68 cases in the metastatic group showed intraperitoneal disease, as compared with only 3 of the 61 cases in the primary group (p < 0.0001). In 21% (14/68) of the metastatic group, the ovarian tumor was the first clinical indication of the primary tumor, and 82% of those cases were of gastrointestinal tract primary; this group of cases showed significantly larger tumors than ovarian tumors for patients with an established diagnosis of cancer. Receiver operating curve analyses showed that a tumor size cut off of <13 cm for metastatic disease yielded the maximal area under the curve of 0.877 (sensitivity 80%; specificity 80%); the most frequent exception to the size cut off of <13 cm for metastases was colorectal carcinoma, 30% of which were ≥13 cm. An algorithm whereby a tumor ≥13 cm is considered primary unless it displays surface nodules or bilaterality, and a tumor <13 cm is considered metastatic unless it is unilateral, correctly classified 94% (64/68) of the metastatic tumors and 98% (60/61) of the primary tumors. 3 of the 4 incorrectly classified cases in the metastatic group had intraperitoneal disease. We conclude that gross features are very useful in the distinction of primary from metastatic mucinous tumors in the ovary, and the presence of intraperitoneal disease provides additional diagnostic information. Although algorithms such as the one described herein are imperfect classifiers, they do provide baseline information on which additional findings, including microscopic features, can be added to ultimately provide the most accurate diagnostic classification.

The Challenge of Evaluating Adnexal Masses in Patients With Breast Cancer

This narrative literature review addresses the problem of an adnexal mass discovered during the course of breast cancer (BC) care, which may represent a benign condition, a metastatic process, or a primary ovarian cancer (OC), clinical scenarios associated with distinct physiopathology and prognosis. Furthermore, the coexistence of BC and OC in the same patient may be owing to a hereditary disorder, deserving specific management strategies and counseling. The initial detection and evaluation of an adnexal mass in a patient with BC requires a high index of suspicion, and the initial workup should include a thorough medical history and physical examination, measurement of tumor markers, complete blood count, and imaging tests. Transvaginal ultrasonography remains the standard tool, and findings suggestive of malignancy include bilateral tumors, thick septations, predominance of a solid component, Doppler flow to the solid component, and ascites. From the pathology point of view, features that are suggestive of metastatic disease include bilaterality, mild ovarian enlargement, vascular emboli, no omental deposits, and the absence of transition from benign to malignant epithelium. Although there is a considerable overlap in OC and BC immunohistochemical profiles, BC usually stain positive for GCDFP-15 and negative for vimentine, PAX8, and WT1, and OC often stain positive for CK7, PAX8, WT1, and to mesothelin. Genetic counselling should always be indicated in this clinical scenario. In conclusion, diagnostic spectrum of an ovarian mass in a patient with BC is broad, and a systematic multi-professional strategy is necessary to conduct these challenging cases.

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.

The pathogenesis, diagnosis, and management of metastatic tumors to the ovary: a comprehensive review

Secondary tumors of the ovary account for 10-25% of all ovarian malignancies. The most common tumors that give rise to ovarian metastases include breast, colorectal, endometrial, stomach, and appendix cancer. The correct diagnosis of secondary ovarian tumors may be challenging as they are not infrequently misdiagnosed as primary ovarian cancer, particularly in the case of mucinous adenocarcinomas. The distinction from the latter is essential, as it requires different treatment. Immunohistochemistry plays an important role in distinguishing primary ovarian tumors from extra-ovarian metastases and, furthermore, may suggest the primary tumor site. Despite extensive study, some cases remain equivocal even after assessing a broad spectrum of antigens. Therefore, gene expression profiling represents an approach able to further discriminate equivocal findings, and one that has been proven effective in determining the origin of cancer of unknown primary site. The available data concerning secondary ovarian tumors is rather limited owing to the relative heterogeneity of this group and the practical absence of any prospective trials. However, several intriguing questions are encountered in daily practice, including rational diagnostic workup, the role of cytoreductive surgery, and consequent adjuvant chemotherapy. This review seeks to address these issues comprehensively and summarize current knowledge on the epidemiology, pathogenesis, and management of secondary ovarian tumors, including further discussion on the different pathways of metastatisation, metastatic organotropism, and their possible molecular mechanisms.

An ovarian mass after breast cancer: Metachronous carcinoma or metastasis? A case report

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In the presence of an ovarian mass after breast cancer, differentiating between primary and secondary lesions can be a difficult task.

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This case report presents a 45-year-old patient with an ovarian mass two years after the diagnosis of breast cancer.

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Imaging, histology and predominantly immunohistochemistry may provide valuable tools in the assessment of ambiguous cases.

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Differences in the immunohistochemical profile of primary tumor and metastases should be anticipated.

Introduction

Differentiating between primary and secondary ovarian cancer can be a difficult task. In hereditary conditions breast malignancies and primary ovarian cancer often coexist.

Presentation of case

We present a 45-year-old patient with an ovarian mass two years after the diagnosis of a lobular, triple negative breast carcinoma. There was concern whether the lesion represented a metachronous ovarian cancer or a metastasis of the lobular carcinoma. The final histological examination showed a metastatic lesion, deriving from the lobular breast carcinoma, as evidenced by the immunohistochemical profile; nevertheless, there were changes in hormonal receptor expression in the metastatic lesion compared to the primary, triple negative tumor. The patient underwent genetic testing for BRCA1 and BRCA2 mutations and was negative. In the adjuvant setting the patient received 6 cycles of chemotherapy with carboplatin and paclitaxel; eighteen months later, the patient remains without disease recurrence.

Discussion and conclusion

This case report highlights the role of imaging, histology and predominantly immunohistochemistry as valuable tools in the assessment of ambiguous ovarian lesions after breast cancer.

The challenge of diagnosing a malignancy metastatic to the ovary: clinicopathological characteristics vary and morphology can be different from that of the corresponding primary tumor

An accurate diagnosis of metastases to the ovary is essential for adequate patient management. The aim of this retrospective study was to characterize clinicopathological features of metastatic malignancies that presented as an ovarian mass and compare them with their corresponding primary tumors. We reviewed clinical files and histological material of 120 patients with metastases to the ovary, diagnosed in our center between 2000 and 2014. Metastases were diagnosed before (18 %), synchronously (33 %), or after (49 %) the primary tumor was identified; 25 % were single, 40 % were unilateral; 47 % were ≥13 cm. Most originated from the gastrointestinal tract (73 %), followed by breast (13 %), and female reproductive organs (10 %). Gross features varied with primary tumor site. Metastases from gastrointestinal malignancies were significantly larger and frequently showed necrosis. Metastases to the appendix were cystic (94 %), and almost all metastases to the stomach (96 %) and breast (87 %) were solid. The predominant histological pattern was discordant in 44 % cases, mostly due to cystic changes in ovarian metastases which were observed across several histological types. Other metastases showed a predominant histological pattern which was present only focally in the primary tumor. Metastases showed significantly more edema, necrosis, and hemorrhage, but less lymphovascular invasion and inflammatory infiltrate than the corresponding primary tumors. Metastases to the ovary present highly variable clinicopathological features which frequently differ from those of the corresponding primary tumor. A metastasis should always be considered in the differential diagnosis of an ovarian mass. All clinical, imaging, macroscopic, and histological aspects must be taken into account to establish a correct diagnosis which is essential for adequate treatment.

Bilateral Krukenberg Tumours Diagnosed Primarily by Transabdominal Sonography- A Case Report

Krukenberg tumour, also known as carcinoma mucocellulare, is a metastatic adenocarcinoma of ovaries from different primary tumour sites. Gastric carcinoma is most common primary tumour responsible for approximately 50% of Krukenberg tumours. Discrimination between primary ovarian cancer and metastatic tumours in the ovary is important, because their management is different. Here we present a case of female suffering from gastric carcinoma with bilateral Krukenberg tumours, diagnosed primarily by transabdominal sonography. The patient was referred to higher centre for further treatment and followed up.

CEA in evaluation of adnexal mass: retrospective cohort analysis and review of the literature

BACKGROUND

The aim of this study was to estimate the diagnostic accuracy of serum carcinoembryonic antigen (CEA) levels in conjunction with Ca125 in the triage of adnexal masses.

METHODS

This retrospective cohort study was carried out in 495 patients referred to the Gynecology Department at Carmel Medical Center due to adnexal mass, between 2005 and 2012. All patients underwent surgery with histopathologically confirmed diagnosis and preoperative measurements of serum Ca125 and CEA. For each marker, sensitivity, specificity, positive predictive value, negative predictive value and risk ratio were calculated.

RESULTS

Combination of CEA with Ca125, compared with Ca125 levels alone, yielded a nonsignificant effect on sensitivity (87.4% vs. 88.9%, respectively, p = 0.64) and specificity (79.3% vs. 74.3%, p = 0.18) in differentiating malignant from benign adnexal masses. CEA levels were higher in mucinous histological types, but were not helpful in detection of borderline tumors. Significantly higher CEA (21.4 ± 53.6 vs. 3.2 ± 11.9 ng/mL, p = 0.0002) and lower Ca125 values (103.9 ± 84.9 vs. 796 ± 1,331.5 U/mL, p = 0.0338) were demonstrated in the 17 metastatic cases compared with 181 primary ovarian malignancies.

CONCLUSIONS

The combination of the tumor markers CEA and Ca125 did not contribute significantly to the detection of malignant adnexal masses compared with Ca125 alone. As our results suggest that higher CEA levels could be useful in differentiating metastatic tumors from primary ovarian malignancy and in diagnosis of mucinous histology, this issue should be investigated in large, well-designed, prospective cohort trials.

A national population-based study provides insight in the origin of malignancies metastatic to the ovary

A significant proportion of ovarian malignancies consists of metastatic tumors, with a wide variety in site of origin. Differentiating between a primary and metastatic malignancy of the ovaries can be difficult and misdiagnosis might have considerable impact on both treatment and prognosis. To further examine the origin of malignancies metastatic to the ovary, we performed a large-scale, nationwide search for ovarian metastases in the Dutch Pathology Registry (PALGA). All pathology reports concerning malignancies metastatic to the ovary and associated primary tumors in the Netherlands between 2000 and 2010 were collected. Age, year of diagnosis, tumor type, location of the primary tumor, and side of the ovarian tumor were extracted from the database. We identified 2312 patients fulfilling our selection criteria. The most common primary malignancy sites were colon (33.2 %), endometrium (17.1 %), breast (14.3 %), appendix (7.3 %), and stomach (4.5 %). The metastases were most frequently bilateral (46.3 %) followed by unilateral metastases in the right (26.7 %) and left ovary (19.8 %), while side was unknown in 7.2 % of cases. Of colorectal carcinomas, only 40.2 % metastasized bilaterally, compared to 63.9 % of breast, 62.9 % of gastric, and 58.9 % of appendix carcinomas. Left-sided colorectal carcinomas most often metastasized to the left ovary (p < 0.0001). We found colon carcinomas to be most frequently responsible for metastases to the ovaries, followed by endometrial and breast carcinomas. Metastases from breast, stomach, and appendix carcinomas were mostly bilateral, whereas metastases from colorectal carcinomas were mostly unilateral. The mechanisms underlying preferred sites for metastasis or side remain unclear.

[Morphology of secondary ovarian tumors and metastases]

The distinction between primary and secondary (metastatic) ovarian tumors is essential for the selection of appropriate surgical interventions, chemotherapeutic treatment and prognostic evaluation for the patient. Metastatic tumors of the ovary range between 5 % and 30 %. The majority of ovarian metastases in Europe and North America derive from colorectal (25-50 %) and breast cancers (8-25 %). A major issue is the differential diagnosis of mucinous tumors. Major features favoring metastasis include bilaterality, size < 10 cm, ovarian surface involvement, extensive intra-abdominal spread, and infiltrative growth within the ovary involving the corpus albicans and corpora lutea. An algorithm using bilaterality and tumor size (cut-off 10 cm) allows correct categorization in approximately  85 % of the cases. Although immunohistochemistry (especially CK7 and CK20 in mucinous tumors) using a panel of antibodies plays a valuable role and is paramount in the diagnosis, the results must be interpreted with caution and within the relevant clinical and histopathological context. It is necessary to note that the correct diagnosis of ovarian metastases always needs interdisciplinary and multidisciplinary approaches.

Ovarian metastasis from pulmonary adenocarcinoma

Metastatic ovarian cancer is not an uncommon finding. Such tumors almost always originate from female genital tract, colon, stomach, or breast. Lung cancer is not a common origin of ovarian metastases. Of all metastatic ovarian tumors, approximately 0.3% arise from lung cancer. Ovarian torsion is not an uncommon finding, but ovarian torsion with cancer is rare. Here, we report a 44-year-old woman who was previously diagnosed with advanced stage lung cancer and who emergently visited our hospital for abdominal pain. An imaging work-up revealed, ovarian torsion and exploratory laparotomy was performed. Pathological examination led to the diagnosis ovarian metastasis from lung cancer. This is the first case of ovarian metastasis from lung cancer, ovarian torsion.

Preoperative clinical and radiological features of metastatic ovarian tumors

PURPOSE

To investigate the clinical characteristics and pre-operative imaging features of non-genital metastatic ovarian tumors.

METHODS

A retrospective case series study that compared 18 patients with histologically confirmed non-genital metastatic ovarian tumors (the study group) with 25 patients who were diagnosed with a primary ovarian cancer (control group).

RESULTS

The most common primary disease was breast cancer (n = 10; 55 %), followed by colon cancer, gastric cancer, lymphoma, and unknown primary malignancy. The diagnosis of the previous primary neoplasm preceded the ovarian tumor diagnosis by 1-20 years (mean 7 years). No differences were found in the presenting signs and symptoms between the two groups. Statistically significant differences were noted between the two groups in the composition of the adnexal mass on sonography (p < 0.0005) and the CA-125 levels (p = 0.007). The presence of a complex adnexal mass with papillary projections and CA-125 >170 U/ml predicted primary ovarian cancer in 95.7 % of patients. Pre-operative CT scan revealed a greater tendency toward omental involvement and ascites in the control group (p = 0.058). The median risk of malignancy index (RMI) 2 score was significantly higher in the control group compared to the study group (8,000 and 1,120 respectively, p = 0.001). Using a RMI 2 cut-off level of 3,800 for diagnosing primary ovarian cancer versus metastatic ovarian cancer, the sensitivity was 70 %, with a positive predictive value of 87.5 %.

CONCLUSION

Pre-operative sonography findings, CA-125 levels and RMI 2 scores can be highly accurate in differentiating between primary and metastatic ovarian tumors.

Carbohydrate biomarker recognition using synthetic lectin mimics

Carbohydrate biomarkers play very important roles in a wide range of biological and pathological processes. Compounds that can specifically recognize a carbohydrate biomarker are useful for targeted delivery of imaging agents and for development of new diagnostics. Furthermore, such compounds could also be candidates for the development of therapeutic agents. A tremendous amount of active work on synthetic lectin mimics has been reported in recent years. Amongst all the synthetic lectins, boronic-acid-based lectins (boronolectins) have shown great promise. Along this line, four classes of boronolectins including peptide-, nucleic-acid-, polymer-, and small-molecule-based ones are discussed with a focus on the design principles and recent advances. We hope that by presenting the potentials of this field, this review will stimulate more research in this area.

Fine needle aspiration cytology of ovarian tumors with histological correlation

BACKGROUND

Till today, there has been some hesitation to accept the role of fine needle aspiration cytology (FNAC) in pelvic mass. We have tried to study the role of ultrasonography (USG) and computed tomography (CT) guided FNAC as diagnostic and supportive investigation for ovarian tumors.

AIM

To evaluate the current status of image-directed percutaneous aspiration of ovarian neoplasm for the purpose of early detection of malignancy.

MATERIALS AND METHODS

Seventy-four fine needle aspirations of ovarian neoplasms were performed between January 2007 and December 2008 by transabdominal approach under USG and CT guidance and correlated with histopathological findings and tumor markers.

RESULTS

A total of 47 (63.5%) cases were assessed as malignant and 21 (28.3%) as benign and 6 (8.1%) as inconclusive. The neoplastic lesions were categorized as per World Health Organization (WHO) classification.

CONCLUSION

With the availability of modern techniques, USG and CT guided FNAC can be an optimum modality for the diagnosis of primary and metastatic ovarian neoplasms and evaluation of recurrent malignant tumors, which has great impact on patient management consequently.

Preoperative diagnosis of metastatic ovarian cancer is related to origin of primary tumor

OBJECTIVE

To describe the gray-scale and color Doppler ultrasound features as well as some clinical and biochemical features of metastatic ovarian tumors according to the origin of the primary tumor in a large study population,

METHODS

This was a retrospective analysis of 116 masses in 92 patients (mean age, 51 years) evaluated and treated at three European university centers for a metastatic tumor in the ovary. All patients had undergone transvaginal color Doppler ultrasound according to a standardized protocol prior to surgery and tumor removal. Ultrasound features analyzed were bilaterality, tumor volume, morphologic gray-scale appearance and color score. CA 125 was also recorded.

RESULTS

Primary tumor histological diagnosis was as follows: colon-sigmoid (n = 32), stomach (n = 28), breast (n = 20), uterus (n = 17), lymphoma (n = 4), liver-pancreas-biliary tract (n = 4) and miscellaneous (n = 11). There were no differences in age, menopausal status or CA 125 values according to origin of primary tumor. Bilaterality was significantly more frequent in stomach metastases (56%) in comparison with colon-sigmoid and liver-pancreas-biliary tract metastases (18.5% and 0%, respectively, P < 0.05). Median tumor volume was significantly lower in breast metastases (33.5 mL) compared with other metastases (P < 0.05) except stomach metastases and metastatic tumors from the miscellaneous group. Ovarian metastases from breast cancers were significantly more frequently solid in comparison to stomach, colorectal and uterine cancer metastases (95.0% vs. 60.8%, 46.8% and 70.6%, respectively, P < 0.05), and tended to appear moderately or highly vascularized. There were no differences in color score among all groups, although the percentage of masses with abundant color was high (50-82%).

CONCLUSIONS

Ovarian metastases derived from breast cancers tend to be small, solid and vascularized; they seem to be the only ovarian metastases whose primary tumor origin can be suspected by ultrasonography preoperatively. Color score does not seem to help suspect the origin of the primary tumor.

Ultrasonographic appearance of metastatic non-gynecological pelvic tumors

OBJECTIVE

To describe the ultrasound (sonomorphologic and vascular) characteristics of metastatic non-gynecological pelvic tumors, and to identify ultrasound characteristics typical of the most common non-gynecological pelvic tumors.

METHODS

In 92 patients with a pelvic mass who had undergone ultrasound examination with subsequent surgery or tru-cut biopsy revealing a metastatic non-gynecological tumor origin, we analyzed retrospectively the sonomorphologic and vascular parameters. All parameters were evaluated for the whole group of non-gynecological tumors as well as separately for each specific tumor type. The findings were compared with those from 100 women with epithelial ovarian cancer.

RESULTS

We found that CA 125, size of tumor, echogenicity, homogeneity of solid portion, mobility, and presence of ovarian crescent sign, parenchymal metastases and suspicious necrosis were individual statistically significant discriminators (P < 0.01) between the metastatic non-gynecological tumor group and the epithelial ovarian cancer group.

CONCLUSIONS

Metastatic non-gynecological tumors in the pelvis have a significantly different sonomorphologic pattern compared with primary epithelial ovarian cancer. This pattern is dependent on the primary origin of the tumor. Doppler parameters, however, cannot differentiate between primary ovarian cancer and metastatic non-gynecological tumors.

Distinguishing primary from secondary mucinous ovarian tumors: an algorithm using the novel marker DPEP1

Distinguishing primary mucinous ovarian cancers from ovarian metastases of digestive organ cancers is often challenging. Dipeptidase 1 was selected as the candidate novel marker of colorectal cancer based on an analysis of a gene expression microarray. Immunohistochemical analysis indicated that 13/16 ovarian metastases of colorectal cancers, but only 1/58 primary mucinous ovarian cancers, were dipeptidase 1-positive (threshold; ≧25% expression, P<0.0001). Next, five immunohistochemical markers (dipeptidase 1, estrogen receptor-α, cytokeratin 7, cytokeratin 20, and caudal type homeobox 2) were analyzed in combination. In a hierarchical clustering analysis, the mutually exclusive expression of cytokeratin 7 and dipeptidase 1 specifically identified the ovarian metastases of colorectal cancers (P<0.0001). In a decision tree analysis, cytokeratin 7, caudal type homeobox 2, and dipeptidase 1 classified primary mucinous ovarian cancers and ovarian metastases of digestive organ cancers with 90% accuracy. Finally, the five immunohistochemical markers were combined with six preoperative factors (patient's age, tumor size, laterality, serum CEA, CA19-9, and CA125) and combinations were analyzed. Of the 11 factors, 4 (dipeptidase 1, cytokeratin 7, caudal type homeobox 2, and tumor size) were used to generate a decision tree to classify primary mucinous ovarian cancers and metastases of digestive organ cancers with 93% accuracy. In conclusion, we identified a novel immunohistochemical marker, dipeptidase 1, to distinguish primary mucinous ovarian cancers from ovarian metastasis of colorectal cancers. The algorithm using immunohistochemical and clinical factors to distinguish metastases of digestive organ cancers from primary mucinous ovarian cancers will be useful to establish a protocol for the diagnosis of ovarian metastasis.

Carbohydrate recognition by boronolectins, small molecules, and lectins

Carbohydrates are known to mediate a large number of biological and pathological events. Small and macromolecules capable of carbohydrate recognition have great potentials as research tools, diagnostics, vectors for targeted delivery of therapeutic and imaging agents, and therapeutic agents. However, this potential is far from being realized. One key issue is the difficulty in the development of "binders" capable of specific recognition of carbohydrates of biological relevance. This review discusses systematically the general approaches that are available in developing carbohydrate sensors and "binders/receptors," and their applications. The focus is on discoveries during the last 5 years.

Secondary ovarian malignancies: frequency, origin, and characteristics

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Metastatic ovarian tumor

58-year-old woman with a history of breast carcinoma presented with a bilateral ovarian tumor. On fine needle aspiration cytology, diagnosis of metastatic adenocarcinoma was made. At subsequent hysterectomy and bilateral salpingo-oophrectomy, specimen showed extensive metastatic carcinoma involving both ovaries.

[Ovarian metastasis of breast cancer: a case report. Role of cytoreductive surgery]

The ovaries are a common metastatic site for breast cancer. The diagnosis and treatment of ovarian masses from a metastatic breast cancer are difficult. The complete resection of these metastatic masses seems to give a benefit in terms of global survival. This benefit depends on the residual tumoral volume and on the free interval between initial breast cancer diagnosis and apparition of the metastatic ovarian masses. We discuss the treatment of a patient with ovarian metastasis as first sign of a metastatic breast cancer.

Clinical characteristics of metastatic tumors to the ovaries

Approximately 5-30% of the ovarian cancers are metastatic malignancies. The prevalence of metastatic ovarian tumors varies with the incidence rates and spread patterns of primary malignancies. We evaluated the prevalence, pre- and postoperative characteristics of metastatic ovarian cancer in Korean women. We reviewed the records for 821 ovarian malignancies with pathological consultation from 1996-2006 and recorded patient demographical, radiological, histopathological, and survival data. The study included 112 cases of histologically confirmed metastatic ovarian cancer. Metastatic ovarian cancer accounted for 13.6% of all ovarian malignancy, primarily arising from the gastrointestinal tract. The preoperative detection rate with imaging was 75%, and none of the radiological or serological features were useful for differential diagnosis. In multivariate analysis for prognostic variables, the only significant factor was the primary tumor site (p=0.004). Furthermore, extensive resection increased survival for some patients. The differential diagnosis of metastatic ovarian cancer can be problematic, so multiple diagnostic approaches are necessary. The extent of cytoreductive surgery for this type of tumor must be decided on a case-by-case basis.

Clinicopathological features and the value of differential Cytokeratin 7 and 20 expression in resolving diagnostic dilemmas of ovarian involvement by colorectal adenocarcinoma and vice-versa

The distinction between metastasis from a colorectal adenocarcinoma into the ovary and an ovarian adenocarcinoma is vital, but challenging at times, due to overlapping morphological features. Similarly, a distinction between an ovarian metastasis into the colorectum and a colorectal adenocarcinoma, although rare; is important and can be daunting. We report an analysis of 20 cases of ovarian involvement by metastatic colorectal adenocarcinomas and colorectal involvement by metastatic ovarian adenocarcinomas, including the value of differential expression of cytokeratins 7 & 20 by immunohistochemistry (IHC), in these cases. Nine cases (45%) were identified as colorectal adenocarcinomas metastatic to the ovary. On biopsy, all these cases showed a 'garland-like' tumor necrosis, with desmoplasia and predominantly exhibited a tubuloalveolar pattern (67% cases). On IHC, all 8 of 9 such cases, where staining for cytokeratin 20 was performed, displayed strong positivity and 7 cases, where staining for carcinoembryogenic antigen (CEA) was performed, revealed positivity for this marker (100%). Other 11 cases (55%) were ovarian adenocarcinomas, metastatic to the colorectum. These showed metachronous presentations, with the ovarian tumor preceding the colorectal tumor deposits. Morphologically, psammomatous calcification was noted in 73% of these cases, whereas 'garland-like' necrosis was absent in all. The chief morphological subtype was serous papillary cystadenocarcinoma (55% cases). On IHC, CK7 and CA 125 were positive in all 6 of 11 such cases, whereas CK 20 was negative in all these cases.In cases of complex presentations like an ovarian involvement by a metastatic colorectal adenocarcinoma and vice-versa, certain clinicopathological features are useful. Differential expression of CK 7 and CK20 is vital in resolving these dilemmas. CK20 positivity and CK7 negativity is associated with a colorectal adenocarcinoma. Markers like CEA and CA-125 have an added value.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A case of isolated ovarian recurrence from vulvar carcinoma

The hematogenous spread from vulvar cancer is extremely rare. We reported an unusual case of ovarian recurrence from vulvar carcinoma. A 78-year-old woman, with a previous (41 months before) diagnosis of vulvar cancer, was admitted to our Institution. Ultrasound revealed a solid mass of the left ovary. Fluorodeoxyglucose positron emission tomography documented an abnormal uptake in the left pelvis. At definitive pathology, the presence of the same histology in vulvar and ovarian mass and the presence of areas of necrosis and endovascular emboli in the ovarian mass led to the diagnosis of ovarian recurrence from vulvar carcinoma. The patient was triaged to salvage treatment and has currently no evidence of disease. This observation expands the range of unusual clinical presentations of recurrence sites from vulvar carcinoma, and emphasizes the need not to underestimate the role of long complete follow-up program in vulvar cancer patients.

The 'lead vessel': a vascular ultrasound feature of metastasis in the ovaries

OBJECTIVE

To investigate, in a series of metastatic and primary invasive ovarian lesions examined by color Doppler, the prevalence of a main peripheral vessel penetrating into the central part of the ovarian mass with a tree-shaped morphology, defined as the 'lead vessel'.

METHODS

This was a retrospective study of 31 patients with histopathologically confirmed metastatic involvement of the ovary and 106 patients with confirmed primary invasive ovarian carcinoma, who had undergone standardized ultrasound examination, with established definitions of ultrasound characteristics. We retrieved sonographic images and videoclips, focusing on the detection of the lead vessel.

RESULTS

The presence of the lead vessel was detected in 11/31 (35.4%) metastatic ovarian tumors, and in only two (0.01%) cases of primary ovarian carcinoma (P = 0.0001). At color Doppler analysis, metastatic ovarian lesions were characterized by significantly lower pulsatility index (P = 0.0001) and resistance index (P = 0.0001) values, and significantly higher peak systolic velocity (P = 0.0002) and time-averaged maximum velocity (P = 0.04) values, when compared with primary ovarian carcinomas. The lead vessel was detected in 11/21 (52%) solid metastatic lesions and in no cases of multilocular or multilocular-solid lesions (P = 0.008).

CONCLUSION

The lead vessel is a novel sonographic feature of vascular morphology in solid ovarian metastases. The more frequent observation of this feature in metastatic ovarian tumors compared with primary invasive ovarian carcinomas warrants further investigation in order to explore its potential role in the diagnosis of metastatic ovarian masses.