Ovarian neoplasms in patients with colorectal cancer: understanding the role of prophylactic oophorectomy

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

Aim

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

Methods

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

Results

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

Conclusion

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION NUMBER

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Role Of Ovarian Metastases In Colorectal Cancer (ROMIC): a Dutch study protocol to evaluate the effect of prophylactic salpingo-oophorectomy in postmenopausal women

Background

The mean incidence of ovarian metastases (OM) in patients with colorectal cancer (CRC) is 3.4%. The 5-year survival of these patients, even when operated with curative intent, is remarkably low. The lifetime risk of ovarian cancer is approximately 1.3%. Prophylactic salpingo-oophorectomy (PSO, or surgical removal of the ovaries and fallopian tubes) could reduce the number of CRC patients that develop OM after removal of the primary tumor, as well as preventing the occurrence of primary ovarian cancer. Recently, the care pathway for CRC has been changed in several hospitals in line with the updated Dutch guideline. The possibility of PSO is now discussed with postmenopausal CRC patients in these hospitals. The aims of the current study are firstly to estimate the incidence of OM and primary ovarian cancer in postmenopausal patients with CRC, and secondly to evaluate the effect of PSO in these patients.

Methods

An information bulletin and decision guide on this topic was implemented in several Dutch hospitals in 2020. Post-decision outcomes will be collected prospectively. The study population consists of postmenopausal (≥ 60 years of age) patients that are operated with curative intent for CRC. Based on their own preference, patients will be divided into two groups: those who choose to undergo PSO and those who do not. The main study parameters are the reduction in incidence of ovarian malignancies (metastatic or primary) following PSO, and the number needed to treat (NNT) by PSO to prevent one case of ovarian malignancy.

Discussion

This will be the first study to evaluate the effect of PSO in postmenopausal CRC patients that is facilitated by an altered CRC care pathway. The results of this study are expected to provide relevant information on whether PSO adds significant value to postmenopausal patients with CRC.

Trial registration

International Clinical Trials Registry Platform, NL7870. Registered on 2019 July 12. URL of trial registry record: https://trialsearch.who.int/Trial2.aspx?TrialID=NL7870.

Protocol version: 1.0, date 2021 June 8. 

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary ovarian cancer after colorectal cancer: a Dutch nationwide population-based study

BACKGROUND AND PURPOSE

Women with colorectal cancer (CRC) are at risk not only of developing ovarian metastases, but also of developing a primary ovarian malignancy. Several earlier studies have in fact shown a link between the development of primary ovarian cancer and CRC. The purpose of this study was therefore to determine the risk of developing a primary ovarian cancer in women with prior CRC compared to the general population.

METHODS

Data from the Netherlands Cancer Registry were used. All women diagnosed with invasive CRC between 1989 and 2017 were included. Standardized incidence ratios (SIRs) and absolute excess risks (AERs) per 10,000 person-years were calculated.

RESULTS

During the study period, 410 (0.3%) CRC patients were diagnosed with primary ovarian cancer. Women with CRC had a 20% increased risk of developing ovarian cancer compared to the general population (SIR = 1.2, 95% CI: 1.1-1.3). The AER of ovarian cancer was 0.9 per 10,000 person-years. The risk was especially increased within the first year of a CRC diagnosis (SIR = 3.3, 95% CI: 2.8-3.8) and in women aged ≤ 55 years (SIR = 2.0, 95% CI: 1.6-2.6).

CONCLUSION

This study found a slightly increased risk of primary ovarian cancer in women diagnosed with CRC compared to the general population. However, this may be partly attributable to surveillance or detection bias. Nevertheless, our findings could be helpful for patient counseling, as CRC patients do not currently receive information concerning the increased risk of ovarian cancer.

Ovarian metastases from colorectal cancer in young women: a systematic review of the literature

BACKGROUND AND PURPOSE

In female colorectal cancer patients, a mean proportion of synchronous and/or metachronous ovarian metastases of 3.4% was described. Previous literature showed that young or premenopausal women (≤ 55 years of age) may be more frequently affected. Once ovarian metastases are diagnosed, the prognosis of the patient is generally dismal, with 5-year survival varying from 12 to 27%. The present study is aimed at determining the proportion of young or premenopausal women diagnosed with colorectal cancer who presented with or developed ovarian metastases by reviewing the current literature on this topic.

METHODS

This review was performed by querying MEDLINE and EMBASE databases using a combination of terms: "colorectal neoplasms, colorectal cancer, ovarian neoplasms, Krukenberg tumor, young adult, young age, premenopause." Studies that indicated ovarian metastases, either synchronous or metachronous (or a combination of the two), in young women were retrieved and analyzed.

RESULTS

The review identified 14 studies encompassing 3379 young or premenopausal female colorectal cancer patients. In this selected group of patients, a mean proportion of ovarian metastases of 4.6% [95% CI: 4.0;5.4] was found.

CONCLUSIONS

This review showed that approximately one in twenty young female colorectal cancer patients will present with or develop ovarian metastases. Since outcome of this specific oncological pathology is often dismal, this finding is clinically relevant. It demonstrates the need to develop strategies to lower the incidence of ovarian metastases with adequate treatment and counseling of these patients.

The incidence and prognostic importance of ovarian involvement in patients with peritoneal metastasis undergoing CRS-HIPEC

BACKGROUND

Oophorectomy is a common procedure in women with peritoneal metastasis (PM) undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), which has unique consequences on hormonal balance and fertility before menopause. The objective of this study was to analyze histopathological results and the prognostic influence of ovarian involvement.

MATERIAL AND METHODS

A prospective HIPEC database was used to identify 442 patients with PM from colorectal cancer, pseudomyxoma peritonei and appendix cancer scheduled for CRS-HIPEC between 2012 and 2019 at the University Hospital, Uppsala, Sweden. Statistical analyses were performed using the Chi-square test and Cox regression analysis.

RESULTS

In all, 103 of 180 females underwent oophorectomy. Unilateral oophorectomy was performed in 19% (n = 20) and bilateral oophorectomy in 81% (n = 83). The median age was 61 (range 20-80). Benign ovarian histopathology was seen in 23% (n = 24). Of these, two patients were ≤35 years and 8 patients ≤50 years. The median peritoneal cancer index (PCI) was 16 in women undergoing oophorectomy, and 7 in those with no oophorectomy. Bilateral oophorectomy was associated with negative impact on overall survival (HR 4.84; 95% CI; 1.14-20.61). Malignant ovarian histopathology was also associated with a negative impact on overall survival (p = 0.043).

CONCLUSION

Almost a quarter of the patients had benign histopathology after oophorectomy. This is crucial information for females with childbearing potential when planning for extensive surgery. Extensive pelvic peritoneal cancer growth resulted more often in bilateral oophorectomy which influenced survival negatively.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Prognosis and factors affecting colorectal cancer with ovarian metastasis

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

Adnexal masses in patients with colorectal cancer

OBJECTIVE

To evaluate the clinicopathological features and outcomes of patients undergone surgery for benign and metastatic adnexal masses during the surveillance of colorectal cancer (CRC).

METHODS

A single institute retrospective study involving 90 patients diagnosed with CRC that undergone surgery at Hacettepe University Hospital between 2000-2018. Clinicopathological and survival data was obtained from hospital records.

RESULTS

Elevated blood levels of CEA (HR, 1.23; 95 % CI: 1.03-1.24; p = 0.01), adnexal masses larger than 5 cm (HR, 3.296; 95 % CI: 1.527-7.076; p = 0.002), bilaterality of adnexal mass (HR, 2.200; 95 % CI: 2.464-11.969; p = 0.001) and high PCI score (HR, 0.150; 95 % CI: 0.044-0.479; p = 0.01) were found to be significantly associated with ovarian metastasis. There was a significant difference in overall survival (OS), with respect to complete and incomplete resection in adnexal surgery of ovarian metastasis (46.6 vs. 29.6 months; p = 0.004). The median survival time was 32.8 months for patients with ≤ 24 months interval time to adnexal metastasis surgery, and 48.5 months for patients with >24 months interval time to adnexal metastasis surgery (p = 0.001).

CONCLUSION

This study showed that numerous clinicopathological variables such as bilaterality and size of adnexal mass, serum blood levels of CEA and PCI score may have a significant impact on the prediction and management of ovarian masses diagnosed during CRC surveillance. Complete resection and interval time to adnexal surgery is significantly associated with OS.

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

Background

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

Methods

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

Results

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

Conclusion

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

Incidence, risk factors, treatment, and survival of ovarian metastases of colorectal origin: a Dutch population-based study

OBJECTIVE

The aim of this nationwide study was to provide insight in the incidence, risk factors, treatment, and survival of patients with ovarian metastases from colorectal cancer (CRC).

METHODS

Data from the Netherlands Cancer Registry were used. All newly diagnosed female CRC patients between 2008 and 2016 were included. Treatment was categorized as follows: cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (CRS-HIPEC); resection of the primary tumor; palliative treatment; and no treatment. Overall survival (OS) was investigated using Kaplan-Meier and multivariable Cox regression analyses.

RESULTS

Of 53,883 female CRC patients, 11,343 (21.1%) had metastases at time of diagnosis. Among them, 471 (4.2%) had ovarian metastases. Within latter group, 27.2% received CRS-HIPEC; 38.4% underwent resection of the primary tumor; 25.3% received palliative treatment; and 9.1% received no treatment. Median OS of all patients with ovarian metastases was 17.5 months. In patients receiving CRS-HIPEC, OS was significantly longer than in patients undergoing resection only (median OS 34.1 vs. 17.5 months, adjusted HR 0.44 [0.33-0.66]). Five-year OS was 28.5% for patients having underwent CRS-HIPEC, 11.0% for patients having underwent resection of the primary tumor, 1.2% for patients having underwent palliative treatment, and 0.0% for patients without treatment.

CONCLUSIONS

Synchronous ovarian metastases are diagnosed in 4.2% of female colorectal patients presenting with metastatic disease. Risk factors are young age, T4/N+ tumor and histology of signet ring cell carcinoma. Median OS of the entire cohort was 17.5 months, ranging from 3.1 months in patients without treatment to 34.1 months in patients undergoing CRS-HIPEC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR PRACTICE

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

Metachronous Ovarian Metastases in a Patient with Primary Colorectal Cancer. A Case Report and Review of the Literature

BACKGROUND Metachronous ovarian metastasis from primary colorectal cancer (CRC) is a rare condition that is diagnosed after the treatment of CRC. In most cases, ovarian metastases present without specific symptoms or signs and are usually diagnosed during follow-up imaging. A rare case is presented of metachronous ovarian metastasis from primary CRC, diagnosed on follow-up by computed tomography (CT) and magnetic resonance imaging (MRI), and includes a review of the literature. CASE REPORT A 66-year-old woman recently underwent a left hemicolectomy for a stage T3, N0, M0 primary adenocarcinoma of the sigmoid colon, which was completely excised. Three years later, follow-up CT and MRI imaging showed a right ovarian cyst. She underwent exploratory laparotomy and bilateral salpingo-oophorectomy, which identified tumor in the right ovary. Histopathology and immunohistochemistry confirmed metachronous ovarian metastasis from CRC. The patient was referred for further treatment. CONCLUSIONS Newly-diagnosed ovarian metastasis from primary colorectal cancer (CRC) is challenging to diagnose and manage, and may initially be incorrectly diagnosed as malignancy of primary ovarian origin. This case demonstrated that it is important to confirm the diagnosis with imaging, histology, and the appropriate use of tumor markers. Because ovarian metastases do not respond favorably to chemotherapy, the treatment of choice is surgery. However, for women who are treated for CRC, the use of prophylactic oophorectomy remains controversial.

Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: A Systematic Review

BACKGROUND

The incidence of colorectal cancer among reproductive-aged women is increasing. Concerns regarding future fertility are secondary only to concerns regarding survival and may significantly impact quality of life among reproductive-aged female cancer survivors. Fertility preservation counseling reduces long-term regret and dissatisfaction among cancer survivors. Health care providers counseling patients with colorectal cancer must understand the impact of cancer treatment on future reproductive potential.

OBJECTIVE

This review aims to examine the effects that colorectal cancer treatments have on female fertility and summarize existing and emerging options for fertility preservation.

DATA SOURCES

EMBASE, National Library of Medicine (MEDLINE)/PubMed, Cochrane Review Library were the data sources for this review.

STUDY SELECTION

A systematic literature review was performed using exploded MeSH terms to identify articles examining the effect of surgery, chemotherapy, and radiation, as well as fertility preservation options for colorectal cancer on female fertility. Relevant studies were included.

MAIN OUTCOME MEASURES

The primary outcome was the effect of colorectal cancer treatment on fertility.

RESULTS

There are limited data regarding the impact of colorectal surgery on fertility. The gonadotoxic effects of chemotherapy on reproductive capacity depend on age at the time of chemotherapy administration, cumulative chemotherapy, radiation dose, type of agent, and baseline fertility status. Chemotherapy-induced risks for colorectal cancers are considered low to moderate, whereas pelvic radiation with a dose of 45 to 50 Gray induces premature menopause in greater than 90% of patients. Ovarian transposition may reduce but not eliminate the damaging effect of radiation on the ovaries. Embryo and oocyte cryopreservation are considered standard of care for women desiring fertility preservation, with oocyte cryopreservation no longer being considered experimental. Ovarian tissue cryopreservation remains experimental but may be an option for select patients. The use of gonadotropin-releasing hormone agonists remains controversial and has not been definitively shown to preserve fertility.

LIMITATIONS

The limitations of this review are the lack of randomized controlled trials and high-quality studies, as well as the small sample sizes and the use of surrogate fertility markers.

CONCLUSION

Reproductive-aged women with colorectal cancer benefit from fertility preservation counseling before the initiation of cancer treatment.

A case of metachronous left ovarian metastasis 8 years after surgery for cecal cancer and right ovarian metastasis: Report of a case

Metachronous ovarian metastasis of colorectal adenocarcinoma is mostly identified within 3 years. Here we present a case of a 64-year-old woman with cecal cancer who underwent right oophorectomy for ovarian metastasis. Imaging was performed because of abdominal bloating; it detected a swollen right ovary with ascites. On laparotomy, a right ovarian tumor and cecal cancer were identified. After right oophorectomy, a diagnosis of unilateral ovarian metastasis from colon cancer was made. One month later, right hemicolectomy was performed. Eight years after initial surgery, the patient presented with vaginal bleeding. A computed tomography (CT) scan revealed a pelvic mass approximately 10 cm in diameter, but no mass was evident on a CT image taken 6 months before. The patient was diagnosed with left ovarian metastasis from colon cancer. A third laparotomy revealed a left ovarian tumor, but there was no evidence of other metastases or peritoneal dissemination. Left oophorectomy was performed. Oophorectomy is considered to be associated with a survival benefit in ovarian metastasis without other extensive metastasis. However, ovarian metastasis is often bilateral. Although complete resection was achieved in the present case, the findings support performing prophylactic bilateral oophorectomy if metastasis is identified in a unilateral ovary.

Heterogeneity in Colorectal Cancer: A Challenge for Personalized Medicine?

High inter-patient variability and high spatial heterogeneity are features of colorectal cancer (CRC). This may influence the molecular characterization of tumor tissue, now mandatory for patients with metastatic CRC who are candidates for treatment with an anti-EGFR mAb, as false-negative results can occur, leading to non optimal therapy. Moreover, temporal molecular heterogeneity during treatment is known to influence the response to therapy and prognosis. We present a literature overview of advances made in characterizing molecular heterogeneity in CRC, underlining that the analysis of liquid biopsy could represent an efficient non-invasive tool to overcome the problem. We believe that understanding CRC heterogeneity is fundamental for a more accurate diagnosis, for selecting the best targets to ensure prolonged antitumor response, and for monitoring minimal residual disease and the onset of resistance to therapy, all essential components of successful personalized treatment.

A comprehensive gene mutation analysis of liquid biopsy samples from patients with metastatic colorectal cancer to the ovary: A case report

Liquid biopsies of circulating tumor DNA (ctDNA) can detect molecular alterations, including tumor-specific mutations, and have recently been used as a non-invasive diagnostic, prognostic, and predictive tool. However, this technique is not commonly used in the gynecological field. Gene mutation profiling of liquid biopsy samples was performed using CAncer Personalized Profiling by deep Sequencing (CAPP-Seq), a novel next-generation sequencing-based approach to ultrasensitive ctDNA detection, in order to make it possible to molecularly diagnose metastatic colorectal cancer to the ovary. Liquid biopsy (plasma) samples and formalin-fixed paraffin-embedded tumor samples were obtained from two patients with ovarian tumors, who had a history of surgery for colorectal cancer, and comprehensive gene mutation profiling was conducted using CAPP-Seq. In patient 1, mutations were identified in the same three regions in both the ovarian tumor and preoperative plasma sample (in the KRAS G13D, APC E1306*, and TP53 H193Y genes). In patient 2, mutation was identified in the same one region in all the primary colorectal tumor, the ovarian tumor, and preoperative plasma sample (in APC R216* gene). These mutations are well-known genetic signatures of colorectal cancer, suggesting that the ovarian tumor was metastatic. Tthe gene mutation patterns of colorectal cancer were examined by subjecting liquid biopsy samples from patients with suspected metastatic ovarian tumors to CAPP-Seq. Gene mutation profiling of liquid biopsy samples can contribute to the preoperative differential diagnosis of metastatic ovarian cancer and its subsequent personalized treatment.

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.

Clinical and genetic determinants of ovarian metastases from colorectal cancer

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

Robotic surgery for rectosigmoid junction tumor with ovarian metastases

Isolated ovarian metastases from colorectal cancer (CRC) are rare disease presenting in approximately 3% of all patients undergoing colorectal resection. Most reports describe an open approach to the disease, but we report a case isolated ovarian metastases from CRC managed completely by robotic technique. A 54-year-old female, with a family history of CRC, was admitted for rectosigmoid junction cancer. Computed tomography scan demonstrated in rectosigmoid tumor and pelvic mass, presumed as teratoma. Robotic surgery discovered a 10-cm encapsulated tumor, attached to the left ovary, with no macroscopic peritoneal involvement. The pathologic diagnosis of the resected pelvic mass, ovarian metastases from CRC. Robotic anterior resection was performed. Operative time was lasted 165 min, considering 25 min for robotic system set up. This is the first report to describe robot-assisted anterior resection and oophorectomy in patient with isolated ovarian metastases from rectosigmoid junction cancer.

Ovarian metastases of colorectal and duodenal cancer in familial adenomatous polyposis

Metastases to the ovary occur in 0.8-9.7 % of colorectal cancer (CRC) cases (Hanna and Cohen in Clin Colorectal Cancer 3(4):215-222, 2004). The need to combine surgical resection of the primary tumor and bilateral oophorectomy is a matter of debate (Erroi et al. in J Surg Oncol 96(2):113-117, 2007). In a consecutive multi-hospital cohort of 30 CRC metastases to the ovary we came across four female patients (13 %; 95 % CI 3.6-34.1) with familial adenomatous polyposis (FAP). This number is high since the estimated incidence of FAP CRC is far below 1 % of all CRC and the expected incidence of FAP CRC that metastasized to the ovaries would thus be almost zero. In a second screen in nationwide databases we found that ovarian metastases occurred in at least 15 % of female FAP CRC cases. We provide now first evidence that especially in female FAP CRC patients bilateral oophorectomy during surgery should be discussed.

Interaction between synchronous bilateral prophylactic oophorectomy and adjuvant chemotherapy in female patients with locally advanced colorectal cancer

AIM

In this study we explored the prognostic impact of synchronous bilateral prophylactic oophorectomy in female patients with primary colorectal cancer undergoing radical surgery.

METHOD

From 1991 to 2000, 267 female patients with stage II or stage III colorectal cancer, who had undergone curative resection, were retrospectively reviewed. In 224 patients, the ovaries were preserved. The other 43 patients underwent synchronous bilateral prophylactic oophorectomy. Univariate and multivariate analyses (Kaplan-Meier and Cox regression, respectively) were used to evaluate the effect of prophylactic oophorectomy and other clinical factors on the prognosis of patients.

RESULTS

Both univariate and multivariate analyses showed that tumor stage and adjuvant chemotherapy were the only two significant clinical factors that affected the 5-year overall survival of patients (P < 0.01). There was no significant difference in the 5-year overall survival between patients who had, or had not, undergone prophylactic oophorectomy (75%vs 73%, P > 0.05). In the subgroup analysis by adjuvant chemotherapy, the 5-year overall survival in patients receiving adjuvant chemotherapy was similar between nonoophorectomy and oophorectomy groups. However, in patients without adjuvant chemotherapy, the oophorectomy group was shown to have a significantly better 5-year overall survival than the nonoophorectomy group (76%vs 51%, P = 0.047).

CONCLUSION

Prophylactic oophorectomy may improve the overall survival of female patients with locally advanced colorectal cancer without adjuvant chemotherapy, but its survival benefit vanished in patients receiving adjuvant chemotherapy. The role of prophylactic oophorectomy may be substituted by adjuvant chemotherapy, which makes prophylactic oophorectomy unnecessary during surgery for locally advanced colorectal cancer.

Indication for oophorectomy during cytoreduction for intraperitoneal metastatic spread of colorectal or appendiceal origin

BACKGROUND

The incidence of ovarian metastases at the time of peritoneal carcinomatosis, and the influence of such metastases on survival after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), are unknown.

METHODS

This retrospective analysis included 194 women subjected to CRS and HIPEC since 2001. The incidence of ovarian metastases, disease-free survival and disease-specific survival were analysed.

RESULTS

The histological diagnosis was colorectal cancer carcinomatosis in 108 patients, peritoneal mucinous carcinomatosis (PMCA) in 23 and disseminated peritoneal adenomucinosis (DPAM) in 63. Ninety-nine patients underwent oophorectomy during the HIPEC procedure. Ovarian metastases were confirmed in at least 52 per cent of the patients. There was a significant difference in disease-free survival between women with or without ovarian metastases in both PMCA and DPAM groups (P = 0·044 and P = 0·010 respectively). No significant differences in survival were found in the group with colorectal cancer carcinomatosis.

CONCLUSION

When peritoneal carcinomatosis of colorectal or appendiceal origin is confirmed, at least 52 per cent of ovaries will have synchronous metastases. Disease-free survival after a HIPEC procedure for PMCA or DPAM is significantly lower in women with ovarian metastases. Oophorectomy during CRS for peritoneal carcinomatosis should be strongly considered.

Epidemiology and prognosis of ovarian metastases in colorectal cancer

BACKGROUND

National guidelines for prophylactic oophorectomy in women with colorectal cancer are lacking. The aim of this population-based cohort study was to report on the prevalence, incidence and prognosis of ovarian metastases from colorectal cancer, providing information relevant to the discussion of prophylactic oophorectomy.

METHODS

All 4566 women with colorectal cancer in Stockholm County during 1995-2006 were included and followed until 2008. Prospectively collected data regarding clinical characteristics, treatment and outcome were obtained from the Regional Quality Registry.

RESULTS

The prevalence of ovarian metastases at the time of diagnosis of colorectal cancer was 1.1 per cent (34 of 3172) among women with colonic cancer and 0.6 per cent (8 of 1394) among those with rectal cancer (P = 0.105). After radical resection of stage I-III colorectal cancer, metachronous ovarian metastases were found during follow-up in 1.1 per cent (22 of 1971) with colonic cancer and 0.1 per cent (1 of 881) with rectal cancer (P = 0.006). Survival in patients with ovarian metastases was poor.

CONCLUSION

Ovarian metastases from colorectal cancer are uncommon.

Diagnosis of primary versus metastatic ovarian adenocarcinoma using p53 gene mutation analysis

Distinguishing primary ovarian cancer from metastatic colorectal cancer is often difficult by a conventional pathological examination alone. We assessed the usefulness of p53 gene mutation analysis for the differential diagnosis of ovarian adenocarcinoma. A 66-year-old woman suffered multiple organ metastases, including the liver, para-aortic lymph node, and right ovary, following an operation for advanced sigmoid colon cancer. She underwent ovarian resection after effective chemotherapy against the liver and para-aortic lymph node cancer. Histological analysis suggested primary ovarian cancer. Therefore, we applied p53 gene mutation analysis for the differential diagnosis of primary versus metastatic ovarian cancer from sigmoid colon cancer. The direct sequence of the p53 gene demonstrated the same gene mutation in codon 211 (ACT to ATT) in both the sigmoid colon and ovarian cancers. According to the International Agency for Research on Cancer TP53 mutation database, this type of p53 mutation in colorectal cancer and ovarian cancer is 0.13% (5/3,693) and 0% (0/1,494), respectively. Therefore, we determined that the ovarian tumor was metastatic. Although p53 gene mutation analysis has been applied in some cases, this modality is very useful for the differential diagnosis of primary and metastatic cancer.

Clinicopathologic and immunohistochemical profile of ovarian metastases from colorectal carcinoma

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