Metastatic tumors to the ovaries: a study of 170 cases in northern Thailand

Abstract.   Khunamornpong S, Suprasert P, Na Chiangmai W, Siriaunkgul S. Metastatic tumors to the ovaries: a study of 170 cases in northern Thailand. Int J Gynecol Cancer 2006; 16(Suppl. 1): 132–138.
The cases of malignant ovarian tumors treated at Chiang Mai University hospital between 1992 and 2003 were histologically reviewed. The medical records, the radiologic findings, and the follow-up outcome in the cases suspicious or diagnostic of metastases were reviewed to confirm the diagnosis and to determine the primary sites. Metastatic tumors accounted for 30% of malignant ovarian tumors. A total of 170 cases of metastatic tumors included 117 cases with nongynecologic origin and 53 cases with gynecologic origin. Nongynecologic metastatic tumors were from large intestine (31%), stomach (14%), intrahepatic bile duct (10%), breast (9%), extrahepatic bile duct/gallbladder (7%), appendix (5%), hematologic tumors (3%), others (4%), and unknown primary site (16%). Metastatic gynecologic tumors were from cervix (53%), corpus (34%), fallopian tube (11%), and gestational trophoblastic disease (2%). The proportion of metastatic tumors to malignant ovarian tumors in northern Thailand was comparable to those of the Western or Japanese studies. However, the distribution of the primary sites was different and was correlated with the cancer incidence in Thai women. The majority of mucin-producing adenocarcinomas involving the ovaries were metastatic tumors.     

Pulmonary Resection in Metastatic Uterine and Cervical Malignancies

OBJECTIVE: Although thoracotomy for removal of pulmonary metastasis is well documented in a wide variety of solid tumors, data are sparse regarding management of patients with gynecologic malignancies metastatic to the lung. METHODS: We retrospectively reviewed the Roswell Park Cancer Institute experience between 1982 and 1999. Of 82 eligible patients with gynecologic tumors metastatic and confined to the lung, 25 underwent pulmonary resection. RESULTS: There were 60 uterine and 22 cervix cancer patients with pulmonary metastases. Among patients with uterine cancer primaries undergoing pulmonary resection (n = 19) median survival was 26 months. Uterine cancer patients who underwent surgical resection for leiomyosarcomas (n = 11) had a median survival of 25 months compared to 46 months in patients with adenocarcinoma (n = 6, P = 0.02). Median survival in cervix cancer patients undergoing resection for pulmonary metastases (n = 6) was 36 months. CONCLUSIONS: Pulmonary resection may provide a survival advantage for selected patients with uterine and cervical malignancies with metastases isolated to the lung.     

Microscopic ovarian metastasis of the uterine cervical cancer

Six hundred forty-seven cases of carcinoma of the uterine cervix with FIGO stages Ib or more were initially treated with hysterectomy at Kyushu University Hospital from 1973 to 1987. In these, 597 cases could be pathologically reviewed for ovarian metastasis. In these 597 cases, 335 were stage Ib, 71 IIa, 185 IIb, and 6 IIIb. Only 3 (0.5%) of 597 showed ovarian metastasis. All 3 cases were stage IIb. None of stage Ib cancer cases had ovarian metastasis. One (0.19%) of 524 squamous cell carcinomas metastasized to the ovary, whereas 2 (5.5%) of 36 pure adenocarcinomas revealed ovarian metastasis. Interestingly, all ovarian metastatic lesions were microscopic in size and found in the ovarian hilus. As for the primary lesion, all cases with ovarian metastasis showed deep myometrial invasion, corpus invasion, and lymphatic permeation. Two cases showed pelvic lymph node metastases and positive peritoneal washing cytology. From the results of our study, it can be said that it is fairly safe to preserve the ovary at the time of radical operation in squamous cell carcinoma of the uterine cervix, but it may not be safe to preserve the ovary in pure adenocarcinoma of the uterine cervix.     

Estrogen receptors in fine-needle aspirates from metastatic lesions of gynecologic tumors

The estrogen receptor content in metastases of gynecological tumors was analyzed with an immunocytochemical technique in material obtained by fine-needle aspiration. Eighteen patients with metastasis from ovarian (10 cases), endometrial (4 cases), and uterine cervical (4 cases) carcinomas were studied. Three metastases showed specific nuclear staining for estrogen receptors and they originated from primary tumors in the ovary, the cervix, and the endometrium. Thus needle aspirates can be used for cytomorphologic diagnosis as well as determination of estrogen receptors and their use has potential value when a decision must be made between hormonal therapy or chemotherapy in patients with generalized gynecological carcinomas.     

Surgical management of pulmonary metastasis from carcinoma of the uterine cervix

The present study was designed to evaluate the efficacy of surgical management of pulmonary metastasis from carcinoma of the uterine cervix. We saw 609 cases of carcinoma of the uterine cervix from 1979 to 1987, and during the same period also saw 110 cases of recurrent carcinoma of the uterine cervix. Fourteen of these 110 cases were identified as having pulmonary metastasis, and in 11 of 14 cases the recurrent tumors were limited to the lung. Seven of these 11 cases underwent pulmonary resection. Six of the 7 survived more than 2 years after pulmonary resection. Among them, 1 patient has survived more than 4 years, and 1 patient more than 8 years. The tumor cells were thought to metastasize to the lung through the vertebral venous plexus (Batson's plexus) which was suggested as a metastatic route by Thomford et al. in their report on recurrent colon cancer. As a result of this study, if the recurrent tumor is clinically limited to the lung in patients with recurrent carcinoma of the uterine cervix, they should be treated by surgical resection of the pulmonary tumor.     

Mucinous ovarian tumors associated with mucinous adenocarcinomas of the cervix. A clinicopathological analysis of 16 cases

Sixteen cases of mucinous adenocarcinoma of the cervix that were associated with a mucinous tumor of one or both ovaries are reported. The patients ranged from 25 to 70 (average, 44) years of age; two of them had the Peutz-Jeghers syndrome. Eight patients complained of abdominal swelling; most of the remainder had symptoms of uterine origin. Twelve patients had bilateral and four had unilateral ovarian tumors, which were typically large and cystic. Microscopic examination of most of the ovarian tumors revealed various combinations of benign-appearing, borderline, and carcinomatous mucinous epithelium within the same specimen. Most of the cervical tumors were deeply invasive; 10 of them were of the adenoma malignum type. Although there were varying degrees of uncertainty in individual cases, consideration of several features including the extent and distribution of disease in the abdomen, the comparative histology of the tumors, and the pattern of ovarian involvement suggested that 10 of the ovarian tumors were independent primary tumors, three were metastatic from the cervix, and in three cases the ovaries contained both primary and metastatic tumors.     

Synchronous carcinomas of endometrium and ovary

Five cases of synchronous carcinomas of uterine endometrium and ovary are reported. All uterine cancers were typical endometrial adenocarcinomas. Among the ovarian cancers, four were serous papillary cystadenocarcinomas and one was an endometrioid carcinoma. There is much controversy with respect to staging and management of such cases since these tumors may represent either two synchronously occurring primaries or a single primary with metastases. It is suggested that when each tumor is confined within the limits of its tissue of origin the tumors may be considered as two separate primaries and surgery may be less aggressive. When there is evidence that at least one tumor is spreading to adjacent tissues and organs the question of two separate primaries or one metastatic tumor becomes academic only and aggressive surgical treatment with adjuvant chemotherapy is indicated.     

Synchronous carcinomas of endometrium and ovary

Five cases of synchronous carcinomas of uterine endometrium and ovary are reported. All uterine cancers were typical endometrial adenocarcinomas. Among the ovarian cancers, four were serous papillary cystadenocarcinomas and one was an endometrioid carcinoma. There is much controversy with respect to staging and management of such cases since these tumors may represent either two synchronously occurring primaries or a single primary with metastases. It is suggested that when each tumor is confined within the limits of its tissue of origin the tumors may be considered as two separate primaries and surgery may be less aggressive. When there is evidence that at least one tumor is spreading to adjacent tissues and organs the question of two separate primaries or one metastatic tumor becomes academic only and aggressive surgical treatment with adjuvant chemotherapy is indicated.     

Metastatic carcinoid tumor to the ovary: a clinicopathologic analysis of seventeen cases

OBJECTIVES: To evaluate the clinical behavior and histologic characteristics of metastatic carcinoid tumors to the ovary. METHODS: Retrospective chart review and histologic specimen analysis of all patients with pathologically confirmed metastatic carcinoid tumor to the ovaries seen at the H. Lee Moffitt Cancer Center. RESULTS: Seventeen patients with metastatic carcinoid tumors to the ovary were identified. The distal ileum was the site of origin among all patients with identifiable primary tumor. Fifteen patients (88%) had bilateral ovarian metastases. Other metastatic sites (in order of frequency) included liver, peritoneum breast and bone. Fifteen patients (88%) had elevated urinary 5-hydroxyindoleacetic acid (5-HIAA), indicating active serotonin secretion, and sixteen patients (94%) had radiotracer uptake on indium-111-pentetreotide scans. Five-year survival rate was 94%. CONCLUSIONS: Metastatic carcinoid tumors to the ovary typically originate from distal ileal tumors and are nearly always bilateral. Synchronous metastases involve liver and peritoneal surfaces. Favorable survival rates may be associated with octretide treatment and cytoreductive surgery.     

Coexistent choriocarcinoma and malignant mixed mesodermal tumor of the uterus

OBJECTIVE: The purpose of this article is to report a case of coexisting uterine choriocarcinoma and uterine malignant mixed mesodermal tumor (MMMT). The relevant literature is reviewed and possible pathogenesis discussed. METHODS: The clinical course and histopathology of the case were reviewed and a Medline literature search for other cases was performed. RESULTS: The patient's uterine tumor contained syncytiotrophoblastic and cytotrophoblastic cells that stained positively for the beta subunit of human chorionic gonadotrophin consistent with uterine choriocarcinoma. Pathology also revealed a second distinct neoplasm composed of adenocarcinoma admixed with sarcoma, compatible with a uterine MMMT. The patient experienced metastatic choriocarcinoma to her lungs, lymph nodes, and brain. She suffered a complicated clinical course and died 7 months after her initial diagnosis. The literature search revealed that various gynecologic and nongynecologic carcinomas with trophoblastic differentiation have been described, but an association with uterine MMMT has not been previously reported. CONCLUSIONS: Trophoblastic differentiation and choriocarcinoma associated with gynecologic and nongynecologic tumors is rare. We document the presence of uterine MMMT coexisting with uterine choriocarcinoma that followed an aggressive clinical course and review the possible pathogenesis of this lesion.     

Metastatic tumor extending through the inferior vena cava into the right atrium: a case report of carcinoma of the uterine cervix with para-aortic lymph node metastases

Carcinoma of the uterine cervix with cardiac metastasis is not uncommon in autopsy cases. However, an intraatrial tumor extending through the inferior vena cava (IVC) from the site of para-aortic lymph node metastasis has never been reported. A 57-year-old Japanese woman was admitted to an emergency care unit complaining of mild chest pain and shortness of breath. She had progressive multiple lymphatic metastases of stage IIIB squamous cell carcinoma of the uterine cervix that had initially been treated with concurrent chemoradiation. Echocardiogram showed pedunculated tumor in the right atrium (RA), and computed tomography demonstrated multiple pulmonary tumor embolism. Surgical specimen from the RA showed squamous cell carcinoma resembling the primary cervical tumor, and the peduncle appeared to originate from within the IVC. Postoperative ultrasonography showed severe stenosis of the abdominal IVC due to the invasive growth of para-aortic lymph node metastases. The stalk of the tumor originated from this lesion. We present an extremely unusual case of intraatrial metastatic tumor originating from the para-aortic lymph nodes of cervical cancer.     

Retrograde Lymphatic Spread: A Likely Route for Metastatic Ovarian Cancers of Gastrointestinal Origin

In order to outline the pathways of gastrointestinal malignancies metastasizing to the ovaries, we reviewed 103 cases of metastatic ovarian tumors, and also performed para-aortic lymph node sampling on 11 patients at operation for metastatic ovarian tumors. Of the 103 patients, 74% (26/35) with gastric cancer and 67% (45/67) with colorectal cancer had lymph node metastasis at or before the diagnosis of ovarian tumor. Intraperitoneal metastases presented in 49 and 42% of patients with gastric and with colorectal cancers, respectively. Twenty-three percent of gastric cancer patients and 25% of colorectal cancer patients presented with both lymph node and intraperitoneal metastases. The ovary was the first or among the early metastatic organs diagnosed in 51 of the 53 patients with metachronous ovarian metastases. Only 4 patients with colorectal cancer and none with gastric cancer showed parenchymal organ metastases. These 4 patients also showed intraperitoneal lesions, and 3 of these 4 patients had node metastasis. Among the 11 patients who underwent prospective para-aortic lymph node sampling during operation for the ovarian tumors, only 1 had enlarged para-aortic nodes depicted by computed tomography, 2 had grossly enlarged (≥1.5 cm) para-aortic lymph nodes noted at surgery, and 6 of the 7 patients with gastric cancer and all 3 with colorectal cancer had metastatic nodes histologically. Among the 58 nodes taken from these patients, 67% showed metastatic foci. We concluded that lymph node metastasis is frequently seen in patients with metastatic ovarian tumors of gastrointestinal origin, and hypothesized that retrograde lymphatic spread is a likely route for the metastases.     

Ovarian metastases are rare in stage I adenocarcinoma of the cervix

Over a 32-year period at the University of California, Los Angeles Medical Center, all cases of adenocarcinoma and adenosquamous carcinoma of the uterine cervix were reviewed to determine the incidence of ovarian metastases in stage I disease. One of 25 patients (4.0%) who underwent an exploratory laparotomy and radical hysterectomy had a microscopic ovarian metastasis. A literature review identified nine additional patients who had ovarian metastases and stage I adenocarcinoma of the cervix. Including our series, the overall reported rate of ovarian metastases is 1.8%. All ten patients had at least one of the following additional characteristics: They were postmenopausal, they had adnexal pathology, or they had positive pelvic lymph nodes. Thus, ovarian preservation is warranted in premenopausal patients who do not have ovarian pathology or evidence of other metastatic disease at surgery. Bilateral oophorectomy may be performed if frozen-section examination of enlarged or suspicious nodes documents metastases. If the ovaries are left in the pelvis at the completion of the surgical procedure and microscopic spread to other pelvic tissues is documented, pelvic irradiation can be administered.     

Ovarian metastases from carcinoma of the gallbladder and extrahepatic bile ducts simulating primary tumors of the ovary. A report of six cases

Six cases in which ovarian metastases from carcinoma of the gallbladder or bile ducts were discovered during the life of the patient are described. The patients ranged from 33 to 72 (average, 57) years of age. In one case, the ovarian tumor was discovered 5 weeks before a gallbladder carcinoma was detected: in three cases, gallbladder tumors and ovarian metastases were discovered simultaneously; and in two cases, ovarian metastases were recognized 1 and 2 years after the biliary tumors. The ovarian tumors were bilateral in five cases. One of them was a 13-cm multiloculated, cystic neoplasm that simulated a primary mucinous tumor of the ovary. The remaining neoplasms were uniformly or predominantly solid and ranged up to 6.5 cm in diameter. They typically had lobulated external surfaces and were often multinodular on sectioning. Three ovarian tumors posed significant problems in differential diagnosis on microscopic examination. One of them closely simulated an endometrioid carcinoma, another simulated a mucinous cystadeno-carcinoma, and a third suggested the possible diagnosis of a Sertoli-Leydig cell tumor. Features helpful in establishing the metastatic nature of the ovarian tumors in these and the other cases included bilaterality, surface implants, multinodularity, and extraovarian spread. The gallbladder and bile ducts are rare sources of metastatic tumors, which may simulate primary ovarian neoplasms.     

卵巢恶性肿瘤与血小板增多关系的临床研究

目的 :探讨卵巢恶性肿瘤伴发血小板增多的临床规律及病理特点。方法 :回顾分析 2 2 7例卵巢恶性肿瘤患者的临床及病理资料 ,4 8例合并血小板增多。结果 :血小板增多的患者中 >4 0岁者超过 80 % ;血小板增多的卵巢恶性肿瘤患者占卵巢恶性肿瘤患者的 2 1.15 % ,其中晚期 (Ⅲ期 +Ⅳ期 )患者占 80 %以上。病理类型 :4 8例中 ,卵巢上皮癌38例 ,生殖细胞恶性肿瘤 5例 ,性索间质肿瘤 3例 ,转移性恶性肿瘤 2例 ;卵巢上皮性癌中血小板增多的发生率为 2 5 .33% ,所有患者均经有效治疗 ,治疗后血小板计数下降。结论 :卵巢恶性肿瘤伴发血小板增多 ,以上皮性癌占多数 ,晚期患者多见 ,预后差。血小板增多常提示有隐匿的恶性肿瘤存在。     

Massive edema of the ovary: a report of two cases due to lymphatic permeation by metastatic carcinoma from the uterine cervix

BACKGROUND: Massive ovarian edema (MOE) due to permeation of the ovarian lymphatics by metastatic carcinoma is rare, with a few cases reported to date. CASES: We present two cases of MOE in patients with advanced carcinoma of the uterine cervix. Bilateral and unilateral MOEs in the first and second case, respectively, due to lymphatic permeation of the ovaries by metastatic squamous cell carcinoma and adenocarcinoma were found. Details of clinical history, operative procedure, pathological findings, therapy, and outcome are summarized. CONCLUSION: MOE is the unusual manifestation of the metastatic disease of the ovaries from the carcinomas of the uterine cervix in these cases.     

Expression of carbohydrate antigens in advanced-stage ovarian carcinomas and their metastases-A clinicopathologic study

OBJECTIVE: Up-regulated expression or loss of expression of various carbohydrate antigens on the surface of cancer cells has been associated with a metastatic phenotype and poor survival in epithelial malignancies of different origins. The object of this study was to investigate the expression of carbohydrate antigens in two groups of patients diagnosed with advanced-stage ovarian carcinoma-one with an extremely favorable outcome and the other with a uniformly poor survival. METHODS: Sections from 76 paraffin-embedded blocks (primary ovarian carcinomas and metastatic lesions) from 45 patients diagnosed with advanced-stage ovarian carcinomas (FIGO stages III-IV) were immunohistochemically stained using five monoclonal antibodies for Lewis(y) (Le(y))(two antibodies), Sialyl Lewis(x) (Slex), Tn, and Sialyl Tn (STn) antigens. Patients were divided in two groups based on outcome. Long-term survivors (21 patients) and short-term survivors (24 patients) were defined using a double cut-off of 36 months for disease-free survival (DFS) and 60 months for overall survival (OS). Staining results for primary tumors and metastases were analyzed separately. RESULTS: Mean follow-up period was 70 months. The mean values for DFS and OS were 109 and 125 months for long-term survivors and 3 and 25 months for short-term survivors. Staining for all four antigens was seen in the majority of cases (range = 72-96%) and tended to be comparable in primary tumors and their metastases. However, absence of immunoreactivity for STn was seen in 9/38 (24%) metastatic lesions and only 1/38 (3%) primary tumors. This finding did not reach statistical significance (P > 0.05). A combined pattern of membranous and cytoplasmic staining was predominant in the majority of cases. Enhanced staining for Le(y) and STn was detected in the invasive front of some tumors, while Slex and Tn immunoreactivity did not relate to cell location. Primary tumors and metastatic lesions of long-term survivors displayed immunoreactivity patterns that were comparable to those of short-term survivors. In the evaluation of survival curves, more diffuse staining for Slex showed marginal correlation with poor survival (P = 0.05), while a trend toward poorer survival was seen in tumors that were more extensively stained for Le(y) and Tn (P > 0.05). CONCLUSIONS: Le(y), Slex, STn, and Tn antigens are widely expressed in primary ovarian carcinomas and their metastases. Altered expression of Sialyl Tn is observed with tumor progression in a fraction of ovarian carcinomas. Expression of membrane carbohydrate residues is prevalent in tumors of both long-term and short-term survivors and does not appear to be a strong predictor of disease outcome. However, larger studies are needed to further elucidate the role of these molecules in ovarian carcinogenesis.     

Role of Ca-125 in the differential diagnosis of adnexal mass in breast cancer patients

OBJECTIVES: Serum CA-125 is of value in differential diagnosis of benign and malignant adnexal masses, especially in postmenopausal women. In ovarian cancer preoperative CA-125 levels are related to tumor stage, histologic grade, but are not an independent prognostic factor. Design: The aim of our study was to determine CA-125 serum level in women with ovarian tumor treated previously because of breast cancer. MATERIALS AND METHODS: Due to our research, we examined 51 women operated on for adnexal masses in the Department of Oncological Gynaecology in Bydgoszcz, 1996 - 2002. All those patients were treated because of breast cancer previously. RESULTS: In 19 women (37,3%) benign ovarian tumors were found, in 4 cases (7,8) - primary ovarian cancer whereas in 28 patients (54,9%) breast cancer metastases were detected. Based on CA-125 levels before surgery, correlation between CA-125 concentration and malignant histologic type was observed. CONCLUSIONS: 1. Higher CA-125 serum levels were found in a group of patients with metastatic adnexal masses compared to primary ovarian cancer. 2. In a group of women with breast cancer and ovarian tumor, metastatic adnexal masses were observed in more than 50% of cases.     

Resection of pulmonary metastases from uterine sarcomas.

Long-term survival following resection of pulmonary metastases has been well documented. Variables that are believed to have an effect on survival are site of primary tumor, number and size of metastases, resectability, laterality of the metastases, doubling time, and disease-free interval. Published information regarding resection of pulmonary metastases in patients with gynecologic primary tumors is limited. We reviewed 45 patients whose pulmonary metastases from uterine sarcomas were resected at Memorial Sloan Kettering Cancer Center between 1960 and 1989. All cases met carefully defined criteria at time of thoracotomy: prior hysterectomy for uterine sarcoma, no extrathoracic tumor, known disease thought to be resectable, histology consistent with uterine sarcoma, and no medical contraindication to thoracotomy. Seventy-one percent had unilateral lesions, fifty-one percent had one lesion, and seventy percent had nodules greater than 2 cm. Thirty-six percent had incomplete resection at thoracotomy. Actuarial 5- and 10-year survival from hysterectomy for uterine sarcoma was 65 and 50%, respectively, with a mean follow-up of 89 months. Five- and ten-year survival from resection of pulmonary metastases was 43 and 35%, respectively, with a mean follow-up of 25 months. Unilateral vs bilateral disease was a significant predictor of survival after pulmonary resection (P = 0.02). Metastases size, number of metastases, disease-free interval, and patient age were not significant. Among this carefully selected group of patients undergoing resection of pulmonary metastases from uterine sarcomas, long-term survival was achieved by a substantial proportion of patients. No single risk factor is sufficiently accurate to exclude an individual patient from consideration for pulmonary resection.     

Sarcomas metastatic to the ovary: a report of 21 cases

Twenty-one cases in which sarcomas metastasized to the ovaries are reported. The patients ranged from 18 to 79 (average 42) years of age; only five of them were over 50 years old. Eleven tumors were primary in the uterus and 10 outside the genital tract. Three uterine tumors were leiomyosarcomas, and eight, endometrial stromal sarcomas. The extragenital primary tumors were leiomyosarcoma of the stomach (1) and small intestine (2), retrovesical leiomyosarcoma (1), fibrosarcoma of the anterior abdominal wall (1), sarcoma of the mesentery of smooth muscle or neural type (1), hemangiosarcoma probably primary in the heart (1), osteosarcoma of the maxilla (1), chondrosarcoma of the rib (1), and Ewing's sarcoma of the pubic bone (1). The ovarian tumors, most of which were large, were discovered at the same time as the primary tumors in 11 cases; in seven cases, the ovarian tumor was discovered 7 months to 9 years after diagnosis of the primary tumor. In three cases, the ovarian tumors were discovered 4, 7, and 10 months before detection of the primary neoplasm. Two of these tumors were endometrial stromal sarcomas, and one, an epithelioid leiomyosarcoma of the stomach. Eleven ovarian metastases were bilateral. On microscopic examination, the greatest difficulty in pathologic interpretation was posed by the metastatic endometrial stromal sarcomas because of their simulation of sex cord-stromal tumors. Features helpful in their distinction from these tumors included the frequent presence of extra-ovarian disease, bilaterality, and a characteristic content of small arteries resembling the spiral arteries of the late secretory endometrium. The other tumor that caused major diagnostic difficulty was the metastatic epithelioid leiomyosarcoma from the stomach, which had a pattern that initially suggested the solid-tubular pattern of a Sertoli cell tumor.