Ovarian metastases resection from extragenital primary sites: outcome and prognostic factor analysis of 147 patients

Krukenberg Tumor Related to Gallbladder Cancer in a Young Woman: A Case Report and Review of the Literature

A gallbladder tumor is a rare condition, which usually spreads to the liver, lymph nodes, and other organs. A Krukenberg tumor, derived from the biliary tract and gallbladder cancers (GBCs), is an uncommon finding in routine clinical practice. Here, a case of a young woman with a Krukenberg tumor related to a previous diagnosis of GBC is reported. Differential diagnosis of an ovarian malignant lesion is challenging for both clinicians and pathologists. In order to provide a proper diagnosis, integrated multidisciplinary management is essential. The occurrence of Krukenberg tumors should be evaluated in the management of GBC, even if this is rare in clinical practice.

Role of Surgery in Metastatic Breast Cancer: Insights from a Narrative Review

Metastatic breast cancer is difficult to cure and has a worse prognosis with higher rates of mortality. Recently, breast surgery is believed to improve the survival rates among these women, but due to limited evidence, definite conclusions cannot be made. Therefore, we undertook this narrative review to synthesize the evidence from existing studies to assess the effectiveness of locoregional surgery and surgery of metastatic sites in improving the outcomes among women diagnosed with metastatic cancer disease along with the summary of current treatment guidelines. We reviewed PubMed and Embase and included both observational studies and randomized controlled trials (RCTs) that were published in English between 2000 and 2021. Outcomes were either survival, quality of life, toxicity related to local treatment assessed by mortality at the end of one month, progression-free survival, and breast cancer-specific survival. The main effect size assessed was hazard ratio with their 95% CIs. After literature search, we found 8 observational studies and 3 RCTs. The findings of the observational studies revealed that breast cancer surgery improves survival from 30% to 50% among women. However, findings from RCTs were mixed for local and distant progression survival. Surgery improved the local progression-free survival but worsened the distant progression-free survival. Besides, there was no effect of breast surgery on quality of life. Regarding the surgery of metastatic site, studies are complex with mixed findings and variation in survival depending upon the type of metastatic site and response to initial systematic therapy and other factors. Based on the existing mixed evidence, it is not possible to make firm and definite conclusions about the effectiveness of breast surgery in improving the survival or quality of life among women with metastatic breast cancer. In future, more RCTs are required with a larger sample size to confirm the findings of observational studies.

Two Concurrent Cancers in a 19-Year-Old Patient: Yolk Sac Ovarian Tumor and Metastatic Gastrointestinal Tract Malignancy-Case Report

BACKGROUND

Two concurrent malignancies present in a young person is an extremely rare condition. Diagnoses of gastric cancer primarily concern older patients. There are very few reports of concomitant Krukenberg tumor and germ-cell ovarian malignancy.

CASE

A 19-year-old girl was admitted to the gynecologic oncology department with symptoms of advanced malignancy. Radiological imaging revealed disseminated neoplastic disease with bulky adnexal tumors. Cytoreductive surgery was performed, achieving no visible disease (T = 0 cm). The final pathology report confirmed metastatic mixed adenoneuroendocrine carcinoma (MANEC) in both ovaries, originating from the gastrointestinal tract. Moreover, the primary germ cell yolk sac tumor was found in the left ovary.

CONCLUSION

In cases of concomitant gastric and ovarian tumors, metastatic disease (Krukenberg tumor) should be considered in the differential diagnosis. This concerns even adolescent patients. In particular cases, including tumors with germ cell components, primary debulking surgery is crucial for prognosis.

Metastasis to breast from ovarian cancer and primary ovarian cancer concurrently diagnosis

Metastasis to breast from ovarian cancer is very rare, and it is very difficult to distinguish the primary breast cancer from the secondary one. In our case, a 61-year-old woman presented to the hospital with complaints of lower abdominal pain and distention. Abdominal-pelvic computed tomography (CT) imaging revealed a solid ovarian cystic tumor with numerable ascites in the abdominal cavity and disseminated peritoneal carcinomatosis. To confirm the presence of metastasis in other organs, a preoperative imaging studies including chest CT was performed. Chest CT imaging revealed an enlargement of both the axillary lymph nodes (r/o metastatic lymphadenopathy) and breast imaging studies (breast sonography and mammography) revealed masses penetrated the pectoralis major muscle in the left breast and metastatic lymphadenopathy in Lt axilla. The core needle biopsy result of breast lesion showed unknown origin carcinoma with micropapillary features and no psammoma bodies. So, we could not distinguish primary breast cancer and breast metastasis from ovarian cancer because breast metastasis from ovary could be contained psammoma bodies, generally. Although the possibility of primary breast cancer could not be ruled out absolutely, the neoadjuvant chemotherapy included Paclitaxel and Carboplatin is known to be effective for both breast and ovarian cancer. So after neoadjuvant chemotherapy, mastectomy concurrently with ovarian cancer surgery was performed. The histopathologic features of the ovaries and breast were similar and psammoma bodies also could be observed, which were not detected in previous core needle biopsied specimen. And lymph nodes from the breast and the ovaries also showed consistent findings. Combined with histopathologic report and medical records, the final diagnosis confirmed as a metastasis of ovarian cancer to breast. After surgery, the patient has continued with metastatic ovarian cancer specific treatment. Breast metastatic tumors must be distinguished from primary breast tumors to avoid any unnecessary surgery. It might be difficult to diagnosis precisely by using only core needle biopsy because of inadequate specimen volume. Although surgical resection may be effective for both diagnosis and palliative treatment, further studies focused on less invasive biopsy are needed for exact histopathological diagnosis.

Primary mucinous ovarian tumors vs. ovarian metastases from gastrointestinal tract, pancreas and biliary tree: a review of current problematics

Background

Making the distinction between primary mucinous and metastatic ovarian tumors is often difficult, especially in tumors with a primary source from the gastrointestinal tract, pancreas and biliary tree. The aim of the following paper is to provide an overview of the problematics, with a focus on the possibilities of the differential diagnosis at the macroscopic, microscopic and immunohistochemical level.

Main body

The three main aspects of mucinous ovarian tumors are described in detail, including the comparison of the available diagnostic algorithms based on the evaluation of mostly macroscopic features, characterization of the spectrum of microscopic features, and a detailed analysis of the immunophenotype comparing 20 antibodies with the assessment of their statistical significance for differential diagnosis purposes. Specific features, including Krukenberg tumor and pseudomyxoma peritonei, are also discussed.

Conclusion

Despite the growing knowledge of the macroscopic and microscopic features of ovarian mucinous tumors and the availability of a wide range of immunohistochemical antibodies useful in this setting, there still remains a group of tumors which cannot be precisely classified without close clinical-pathological cooperation.

Text Message Preferences for Surveillance Colonoscopy Reminders Among Colorectal Cancer Survivors

Background. Surveillance colonoscopy 1-year after colorectal cancer (CRC) surgery effectively reduces CRC mortality, yet less than half of survivors undergo this procedure. Text message reminders can improve CRC screening and other health behaviors, but use of this strategy to address barriers to CRC surveillance has not been reported. Objectives. The goal of this qualitative study was to assess CRC survivor perspectives on barriers to colonoscopy to inform the design of a theory-based, short message service (SMS) intervention to increase surveillance colonoscopy utilization. Method. CRC survivors in Western Washington participated in one of two focus groups to explore perceived barriers to completing surveillance colonoscopy and preferences for SMS communication. Content analysis using codes representative of the health belief model and prospect theory constructs were applied to qualitative data. Results. Thirteen CRC survivors reported individual-, interpersonal-, and system-level barriers to surveillance colonoscopy completion. Participants were receptive to receiving SMS reminders to mitigate these barriers. They suggested that reminders offer supportive, loss-framed messaging; include educational content; and be personalized to communication preferences. Finally, they recommended that reminders begin no earlier than 9 months following CRC surgery and not include response prompts. Conclusions. Our study demonstrates that CRC survivors perceive SMS reminders as an acceptable, valuable tool for CRC surveillance. Furthermore, there may be value in integrating theoretical frameworks to design, implement, and evaluate SMS interventions to address barriers to CRC surveillance. As physicians play a key role in CRC surveillance, provider- and system-level interventions that could additively improve the impact of SMS interventions are also worth exploring.

Gone but Not Forgotten: Ovarian Metastasis From a Colon Carcinoma in a 19-Year-Old Female

Ovarian tumors occurring secondarily to metastatic colorectal carcinoma remain a rare occurrence. Since ovarian tumors remain predominantly asymptomatic in the initial stages, they are often diagnosed incidentally. The vague, non-specific symptoms elicited by a secondary ovarian carcinoma, coupled with a histopathology remarkably similar to that evoked by primary ovarian tumors, render its ascertainment a diagnostic challenge. We hereby delineate an interesting case of a metachronous ovarian adenocarcinoma in a 19-year-old patient with a prior medical history significant for colorectal carcinoma treated with hemicolectomy. Subsequent diagnostic workup divulged a mass in her left adnexal region, which was ultimately diagnosed as a metastatic colon adenocarcinoma to the ovary. Unfortunately, the patient succumbed to the aggressive malignancy and did not survive. We therefore aim to accentuate the diagnostic and therapeutic dilemmas fomented by ovarian adenocarcinomas that arise secondarily to primary colorectal cancers.

A rare case of Krukenberg tumor by gallbladder cancer

INTRODUCTION

Gallbladder cancer commonly spreads by direct extension to the liver and adjacent organs of the gastrointestinal tract. Ovarian metastases by biliary origin, though known, are a very uncommon finding.

PRESENTATION OF CASE

We report a rare metastatic localization by gallbladder cancer, Krukenberg tumor mimicking a primitive ovarian cancer. A comprehensive critical review was performed and suggested strategies were analyzed.

DISCUSSION

The prognosis of ovarian metastastes by biliary origin is very poor with an overall survival estimated at around 6 months. The variable clinical presentation, radiology and serum markers make the appropriate histological diagnosis mandatory.

CONCLUSION

The presence of Krukenberg tumor should be considered in the work-up of gallbladder cancer.

Metformin Abrogates Age-Associated Ovarian Fibrosis

PURPOSE

The ovarian cancer risk factors of age and ovulation are curious because ovarian cancer incidence increases in postmenopausal women, long after ovulations have ceased. To determine how age and ovulation underlie ovarian cancer risk, we assessed the effects of these risk factors on the ovarian microenvironment.

EXPERIMENTAL DESIGN

Aged C57/lcrfa mice (0-33 months old) were generated to assess the aged ovarian microenvironment. To expand our findings into human aging, we assembled a cohort of normal human ovaries (n = 18, 21-71 years old). To validate our findings, an independent cohort of normal human ovaries was assembled (n = 9, 41-82 years old).

RESULTS

We first validated the presence of age-associated murine ovarian fibrosis. Using interdisciplinary methodologies, we provide novel evidence that ovarian fibrosis also develops in human postmenopausal ovaries across two independent cohorts (n = 27). Fibrotic ovaries have an increased CD206⁺:CD68⁺ cell ratio, CD8⁺ T-cell infiltration, and profibrotic DPP4⁺αSMA⁺ fibroblasts. Metformin use was associated with attenuated CD8⁺ T-cell infiltration and reduced CD206⁺:CD68⁺ cell ratio.

CONCLUSIONS

These data support a novel hypothesis that unifies the primary nonhereditary ovarian cancer risk factors through the development of ovarian fibrosis and the formation of a premetastatic niche, and suggests a potential use for metformin in ovarian cancer prophylaxis.See related commentary by Madariaga et al., p. 523.

Clinical significance of HER2 and EGFR expression in colorectal cancer patients with ovarian metastasis

Background

EGFR and HER2 overexpression has been reported to play important roles in colorectal cancer (CRC) development and metastasis. Ovarian metastasis is rare yet is one of the most malignant metastases of CRC, but very few studies have focused on its biological features. This study aimed to investigate the expression of EGFR and HER2 in ovarian metastases of CRC and to reveal their clinical significance.

Methods

The expression of HER2 and EGFR in both primary tumours and ovarian metastases was analysed by immunohistochemistry (IHC) in 31 CRC patients with ovarian metastases as well as in the primary tumours of 26 CRC patients with non-ovarian metastases. The overall survival time was calculated with a Kaplan-Meier survival curve and compared with a log-rank test.

Results

HER2 positivity in primary tumours was significantly higher in patients with ovarian metastases than in those with non-ovarian metastases (54.5% vs. 36.4%, P < 0.05). The EGFR-positive rate in primary lesions was not significantly different between patients with ovarian metastases and those with non-ovarian metastases (63.6% vs. 58.3%, P > 0.05). HER2 expression was not correlated with age, primary tumour site, tumour differentiation, tumour diameter or vascular cancer embolus (P > 0.05). The positive rates of HER2 and EGFR in ovarian metastases were 44.8 and 69.0%, respectively. HER2 expression in ovarian metastases was correlated with peritoneal metastasis and bilateral ovarian metastasis (P < 0.05) but not with age, synchronous or metachronous ovarian metastases and the primary tumour site (P > 0.05). There was no significant correlation between EGFR expression and the clinicopathological features in ovarian metastases (P > 0.05). CRC patients with HER2-positive ovarian metastases showed a shortened overall survival time compared to that of CRC patients with HER2-negative metastases (17.0 ± 5.2 vs. 32.0 ± 8.3 months).

Conclusion

Our studies revealed that EGFR and HER2 are highly expressed in the primary tumours and metastases of CRC patients with ovarian metastases. HER2 positivity may be a negative prognostic predictor in patients with ovarian metastases.

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.

A case of Krukenberg tumor, eight years after treatment of gastric cancer

Krukenberg tumor is a rare metastatic tumor of the ovary. Theprimary tumors are usually gastrointestinal cancers. Most of theKrukenberg tumors reported in the literature occurred within thefirst 2 years after treatment of the primary disease. Herein, wepresent a case of Krukenberg tumor in a 37-year-old woman whopreviously underwent surgery and chemotherapy for stomachcancer. This patient is noteworthy because it is one of the fewdocumented cases of ovarian metastasis appearing after a diseasefreeperiod of 8 years following treatment of the primary tumor.Krukenberg tumors are associated with poor prognosis; therefore,regular gynecological examination in female patients with historyof gastric cancer is very important for the early diagnosis andtreatment of this disease.

Surgical Treatment of Metastatic Ovarian Tumors From Extragenital Primary Sites

OBJECTIVE

The purpose of this study was to investigate the outcomes and prognostic factors of metastasectomy in patients with metastatic ovarian tumors from extragenital primary sites.

MATERIALS AND METHODS

All patients with pathologically confirmed metastatic ovarian tumors between January 1997 and June 2015 were included in this study. A total of 131 patients were identified. The data were obtained from the patients' medical records. Clinicopathological features were evaluated by both univariate and multivariate analyses.

RESULTS

The primary sites were colorectal region (53.4%), stomach (26%), and breast (13%). Preoperative serum CA 125 and CA 19-9 levels were elevated in 29.4% and 39.8% of the patients, respectively. Cytoreductive surgery was performed in 41.2% of the patients. Seventy-three (55.7%) patients had no residual disease after surgery. Sixty-six (49.6%) patients had combined metastases at the time of the surgery to sites including the liver, pancreas, lung, bone, lymph nodes, bladder, or the intestine. With a median follow-up of 33 months, the median survival time was 22 months. The estimated 5-year survival probability is 0.26. On univariate analysis, primary cancer site, combined metastasis outside the ovaries, residual disease, preoperative serum CA 125 and CA 19-9 levels, and histologic type were significant parameters for overall survival. Furthermore, residual disease, preoperative serum CA 19-9 level, and primary cancer site were found to be independent prognostic factors on multivariate analysis.

CONCLUSIONS

The most common primary sites for ovarian metastasis are gastrointestinal tract. Metastasectomy may have beneficial effects on survival, especially if the residual disease is less than 5 mm. Prospective studies warranted to evaluate the value of metastasectomy in patients with ovarian metastasis.

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.

Metastatic gastric cancer to the female genital tract

Metastases to the female genital tract from gastric cancer are rare, but they significantly worsen the prognosis of such patients. The potential routes for metastasis to the female genital tract from gastric cancer include hematogenous spread, lymphatic spread and surface implantation. The rate of lymphatic metastasis to the ovary from gastric cancer has been reported to be higher compared with that from colorectal cancer. Uterine or Fallopian tube metastases are usually secondary to ovarian metastases, which are typically identified prior to the detection of gastric cancer in half of all synchronous cases, with complaints of abdominal distention, pain, palpable mass, or abnormal uterine bleeding. The prognosis of patients with female genital tract metastases from gastric cancer is extremely poor, and is worse compared with that of other primary sites, such as the breast and colorectum. In the past, surgical intervention in such patients consisted mainly of palliative resection to relieve the symptoms associated with a sizeable pelvic mass. However, recent retrospective studies based on a relatively small number of patients have reported that surgical tumor debulking plus chemotherapy may improve the prognosis of patients with metastatic ovarian cancer originating from gastric cancer.

Clinical characteristics of young-age onset gastric cancer in Korea

Background

Gastric cancer is the fourth most common cancer worldwide and more frequently detected in Asian countries including Korea and Japan. The incidence of young-age gastric cancer (GC) is increasing worldwide, but clinical behavior of young-age GC patients is not well established. We retrospectively analyzed the clinical features and outcomes of GC diagnosed at young-age population.

Methods

Between Jan. 2009 to Jan. 2015, 163 patients diagnosed as early, advanced, recurrent, or metastatic GC at ages between 22 ~ 39 years were analyzed. Based on medical records, authors analyzed the clinicopathologic characteristics and survival outcomes including overall survival (OS), disease free survival (DFS), and progression free survival (PFS).

Results

One-hundred and four patients (82.8 %) were diagnosed as GC at their thirties; especially 81 patients (31.2 %) patients were diagnosed over 35 years of age. The ratio of early GC and advanced GC were relatively similar (47.2 % vs. 52.8 %, respectively). Among stage II and III patients, 45 patients received 5-FU based adjuvant chemotherapy and recurrence rate was 48.9 %. Among patients diagnosed as recurrent or metastatic GC, recurrent GC patients showed relatively superior PFS and OS after cancer recurrence, compared to metastatic GC patients, but without statistical significance. Among metastatic GC patients, patients receiving palliative debulking surgery for ovary metastases showed superior PFS compared to patients who only received palliative systemic chemotherapy (P = 0.021, PFS 7.7 vs. 3.37 months, respectively).

Conclusions

Young age GC were commonly diagnosed at their thirties, without sexual predominance. The incidence of advanced GC in young age patients were higher compared to general patient population. Among recurrent GC patients, palliative debulking surgery might have role for superior survival outcomes. Considering relatively higher incidence for advanced GC, active surveillance for gastric cancer is warranted.

Clinical characteristics and prognostic analysis of Krukenberg tumor

Krukenberg tumor is a rare metastastic tumor of the ovary, characterized by poor prognosis. In order to analyze the clinical characteristics and prognostic factors, we retrospectively investigated 128 patients who were diagnosed with Krukenberg tumor between January, 1990 and December, 2010. The median patient age was 48 years. The median overall survival (OS) of Krukenberg tumor for all patients was 16 months (95% CI: 15-19 months). The median OS among patients with Krukenberg tumors of gastric, colorectal, breast and other origins (including appendix, gallbladder, small intestine and unknown primary) was 11, 21.5, 31 and 19.5 months, respectively (P<0.0001). In the univariate analysis, synchronous metastasis, no chemotherapy, ovarian metastasis beyond the pelvis, ascites and no metastasectomy were identified as significant poor prognostic factors. The multivariate analysis suggested that synchronous metastasis (P=0.0080), pelvic invasion (P=0.0138), ascites (P<0.0001) and no metastasectomy (P=0.0060) were independent factors for predicting unfavorable OS. It was suggested that the prognosis of Krukenberg tumor is dismal and ovarian metastasectomy may prove beneficial. Adequate treatment planning is required for this group of patients.

The performance of contrast-enhanced FDG PET/CT for the differential diagnosis of unexpected ovarian mass lesions in patients with nongynecologic cancer

PURPOSE

This study aimed to evaluate the diagnostic accuracy of contrast-enhanced FDG PET/CT for unexpected ovarian lesions in patients with nongynecologic cancers.

PATIENTS AND METHODS

The present retrospective study was approved by the hospital institutional review board. We enrolled 72 nongynecologic cancer patients (33 colorectal cancer, 20 breast cancer, and 19 gastric cancer) who showed unexpected ovarian lesions on contrast-enhanced FDG PET/CT and subsequently underwent surgical resection of the ovarian lesions. The SUVmax values of the ovarian lesions were compared according to the histopathological results, and the accuracy of PET/CT was evaluated.

RESULTS

A total of 103 ovarian lesions were surgically resected from 72 patients (64 ovarian lesions were metastases, 21 were benign, and 18 were malignant primary ovarian cancer). SUVmax among the 3 groups were different (P < 0.0001). Using a cutoff SUVmax of 2.5, the sensitivity, specificity, and accuracy of PET/CT for detecting malignant ovarian lesions were 80.5%, 81.0%, and 80.6%, respectively. Detection rates of PET/CT for colorectal, breast, and gastric cancer metastases, as well as primary ovarian cancers were 91.4%, 83.3%, 47.8%, and 100.0%, respectively. Using contrast-enhanced CT findings with SUVmax, the sensitivity, specificity, and accuracy of contrast-enhanced FDG PET/CT were improved to 95.1%, 76.2%, and 91.3%, respectively (P = 0.003).

CONCLUSIONS

Conventional FDG PET/CT showed moderate diagnostic accuracy for the detection of malignant ovarian lesions mainly due to low detection rate in gastric cancer metastases. The PET/CT detection rate of malignant ovarian lesions can be improved using contrast-enhanced CT findings with FDG uptake measurement.

A Krukenberg Tumor from an Occult Intramucosal Gastric Carcinoma Identified during an Autopsy

A healthy 45-year-old Japanese female developed right pleural effusion, ascites, and a pelvic mass. Bilateral salpingo-oophorectomy resolved the pleural effusion and ascites. Histopathological examination of the ovaries showed bilateral Krukenberg tumors with signet-ring cell carcinoma (SRCC). Extensive testing including upper and lower gastrointestinal endoscopy and whole-body imaging did not detect the primary lesion. Six months after bilateral salpingo-oophorectomy, the patient developed multiple osteoblastic bone lesions in the spine, pelvis, and femurs. A biopsy of the bone marrow showed SRCC. We administered four cycles of S-1 and cisplatin, resulting in the shrinkage of osteoblastic lesions; she remained stable for a year. Then, she developed disseminated intravascular coagulation with disease progression in the bones. Although she was treated with paclitaxel, the disseminated intravascular coagulation progressed, and she died in a month. During the autopsy, microscopic examination revealed four foci of intramucosal gastric SRCC and healthy macroscopic gastric mucosa.

Surgical treatment for patients with Krukenberg tumor of stomach origin: clinical outcome and prognostic factors analysis

Krukenberg tumor originated from stomach in female patients is common in clinical practice, but it is still uncertain whether surgical resection of ovarian metastases could improve the outcome. Some studies suggested that a certain group of patients could benefit from the resection of ovarian metastases. However, conclusions were different between studies and there was no data to illustrate if certain molecular markers were associated with patients’ survival. In this study, we analyzed the effects of resection of ovarian metastases, and investigated prognostic factors in 133 patients with ovarian metastases originated from stomach. Furthermore, we examined the expression of some cancer stem cells (CSCs) markers or related molecules in 64 ovarian metastases specimens and analyzed the correlation between these molecules and patients’ survival. We found that the median overall survival (mOS) of all 133 patients was 16 months, and “gastrectomy” and “without ascites” were two independent prognostic factors associated with longer survival. The mOS of the patients with gastrectomy was longer than that of patients had not undergone gastrectomy (19 vs. 9 months, p = 0.048). Patients without ascites survived longer than those with ascites (mOS: 21 vs. 13 months, p = 0.008). We also found that Sox2, CD44 or CD133 positive expression in ovarian metastases were risk factors correlated with poor survival, and Sox2 expression was an independent prognostic indicator. These results suggested that ovarian metastasectomy might help to prolong the survivor of some patients with Krukenberg tumor originated from stomach. Patients without ascites, and with resected or resectable primary gastric cancer lesion could get benefit from and be potential candidate for surgical treatment. The expression of Sox2 might serve as a prognostic indicator for predicting patients’ survival and be helpful for selecting patients in future.

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.