• Users Online: 89
  • Print this page
  • Email this page

 
Table of Contents
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 88-90

Laparoscopically diagnosed and treated ruptured metastatic ovarian tumor


Department of Obstetrics and Gynecology, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan

Date of Submission18-Mar-2019
Date of Decision22-Jul-2019
Date of Acceptance24-Oct-2019
Date of Web Publication28-Apr-2020

Correspondence Address:
Dr. Mai Nishimura
4-8-12-206, Teine Honcho 2 Jo, Teineku, Sapporo, Hokkaido 006-0022
Japan
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GMIT.GMIT_10_19

Get Permissions

  Abstract 


A 51-year-old woman visited our institution with a chief complaint of abdominal pain. Blood laboratory testing revealed a carcinoembryonic antigen level of 13.4 ng/mL. Magnetic resonance imaging revealed a massive pelvic mass with marked wall thickening, partly accompanied by a high-signal-intensity cystic component in T2-weighted images. The entire tumor had low-signal intensity in T1-weighted images. We diagnosed a ruptured ovarian tumor, and the patient underwent emergent laparoscopic left salpingo-oophorectomy. Pathological examination revealed metastatic colon cancer to the ovary, and lower gastrointestinal endoscopy confirmed sigmoid colon carcinoma. Laparoscopic sigmoidectomy was performed followed by adjuvant chemotherapy with capecitabine + oxaliplatin. Ruptured metastatic ovarian tumor is extremely rare. With early diagnosis and laparoscopic resection, the primary lesion can be identified and treated quickly.

Keywords: Colon cancer, laparoscopy, metastatic ovarian tumor


How to cite this article:
Nishimura M, Matsumoto S, Ohara Y, Imai K, Wada S, Fujino T. Laparoscopically diagnosed and treated ruptured metastatic ovarian tumor. Gynecol Minim Invasive Ther 2020;9:88-90

How to cite this URL:
Nishimura M, Matsumoto S, Ohara Y, Imai K, Wada S, Fujino T. Laparoscopically diagnosed and treated ruptured metastatic ovarian tumor. Gynecol Minim Invasive Ther [serial online] 2020 [cited 2020 Sep 29];9:88-90. Available from: http://www.e-gmit.com/text.asp?2020/9/2/88/283330




  Introduction Top


Ruptured ovarian tumor is one of the several emergency diseases that cause abdominal pain. Ruptured ovarian cyst is common in women of reproductive age,[1] and most are benign ovarian tumors, including endometrial cysts and mature teratomas. Ruptured metastatic ovarian tumor is extremely rare. To our knowledge, there have been only two case reports of ruptured metastatic ovarian tumor. We describe a case of ruptured metastatic ovarian tumor, and we review the relevant literature.


  Case Report Top


A 51-year-old woman visited a previous physician with a chief complaint of abdominal pain. Abdominal computed tomography (CT) revealed a large amount of ascites and a massive pelvic tumor with a diameter of 132 mm. The patient then consulted our hospital. She had a medical history of hypertension, diabetes mellitus, and appendicitis and an unremarkable family medical history. Strong tenderness was found in her lower abdomen; however, no abdominal guarding was seen. Pelvic examination revealed a palpable tumor in the left side of her uterus, and strong tenderness was confirmed. Transvaginal ultrasonography revealed ascites in Douglas' pouch. The left ovary had a solid part and was enlarged at 88 mm × 72 mm.

Blood laboratory testing revealed a white blood cell count of 13,720/μL, neutrophil count of 10,220/μL, lactate dehydrogenase level of 382 U/L, and blood glucose level of 261 mg/dL. Serum tumor markers revealed a carcinoembryonic antigen level of 13.4 ng/mL; carbohydrate antigen-19-9 and-125 levels and squamous cell carcinoma antigen levels were within normal limits. Magnetic resonance imaging (MRI) of the pelvic mass revealed marked wall thickening, partly accompanied by a high-signal-intensity cystic component in T2-weighted images; the entire tumor had low-signal intensity in T1-weighted images [Figure 1]. MRI findings seemed atypical for primary ovarian tumor; therefore, we suspected the possibility of metastatic ovarian tumor. We diagnosed ruptured ovarian tumor, and the patient underwent emergent exploratory laparoscopy. Pale yellow opaque ascites and a ruptured left ovary with scattered soft, white lesions were found in the abdominal cavity [Figure 2]. We collected a sample of the ascitic fluid for cytology. The uterus and right adnexa were normal in appearance except for fibrinoid lesions. We diagnosed ruptured ovarian tumor, and the patient underwent laparoscopic left salpingo-oophorectomy. To avoid shredding the specimen, we made a 4-cm-long incision in the lower abdominal midline and removed the left adnexa.
Figure 1: Magnetic resonance image of the left ovary. The left ovarian tumor had marked wall thickening and was partly accompanied by a high-signal-intensity cystic component in T2-weighted images; the entire tumor had low-signal intensity in T1-weighted images

Click here to view
Figure 2: Intra-abdominal findings during emergent exploratory laparoscopy. Pale yellow opaque ascitic fluid and left ovarian rupture with scattered soft, white lesions were found in the abdominal cavity

Click here to view


Cytology of the ascitic fluid was negative. Macroscopically, the left ovarian tumor showed extensive necrosis and was growing and papillary infiltration was also seen. Pathological examination of the left adnexa revealed a well-to-moderately-differentiated tubular adenocarcinoma. Cytokeratin-7 (CK-7) testing was negative and CK-20 testing was diffusely positive on immunohistochemical staining. Test results for homodomain factor CDX2 and p53 tumor-suppressor gene were both positive, and estrogen receptor test results were negative. The final diagnoses were metastatic colon cancer to the ovary.

The patient's postoperative course was favorable, and she was discharged on the 2nd postoperative day. Lower gastrointestinal (GI) endoscopy revealed a type-2 tumor accompanied by stenosis circumferentially at a site 20 cm from the anal margin. Biopsy of the tumor confirmed adenocarcinoma. Upper GI endoscopy was normal except for reflux esophagitis, gastric erosion, and a fundic gland polyp. Therefore, upper GI malignant tumors including stomach cancer and cholangiocarcinoma were denied. Neither lymph node enlargement nor hepatic metastasis was seen with postoperative contrast CT. Laparoscopic sigmoidectomy with D3 lymphadenectomy was performed by a general surgeon for the sigmoid colon carcinoma, and no significant postoperative adhesions were observed during sigmoidectomy. The patient received postoperative adjuvant chemotherapy with capecitabine + oxaliplatin therapy, and no signs of recurrence have been seen 12 months after surgery.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. This study has been approved by the research ethics committee of Teine Keijinkai Hospital (IRB Reference Number: 20190141; approval date: February 3, 2019).


  Discussion Top


Among ovarian cancers, 10%–15% are metastatic ovarian cancers. The primary lesion of metastatic ovarian cancer is reported to originate in the stomach in approximately 76% of patients, large intestine in approximately 11%, mammary glands in approximately 4%, and biliary tract system in approximately 4%.[2] Even when ovarian malignancy is suspected preoperatively, it is difficult to distinguish whether the lesion is a primary or metastatic tumor based on imaging. Ulbright et al. reported that 45% of colorectal cancer metastases to the ovary were misdiagnosed as primary ovarian tumors.[3] Choi et al. argued that metastasis should be strongly suspected if the ovarian tumor is bilateral and the surface is smooth. Ovarian metastatic lesions from colon cancer appear more cystic, less frequently have dense enhancement of the solid portion, and are larger compared with ovarian metastatic lesions from stomach cancer on contrast-enhanced CT.[4] Rupture of ovarian tumors occurs most often with benign ovarian tumors such as endometrial cysts and mature teratomas, and only two cases of ruptured metastatic ovarian tumors have been reported in Japan.[5],[6]

Preventive resection of the adnexa on the contralateral side of the metastasis is controversial. In our patient, the right adnexa appeared normal, and we saw no peritoneal dissemination, even during sigmoidectomy; therefore, we preserved the right adnexa.

Synchronous ovarian metastasis from colorectal cancer is more common than metachronous, and peritoneal dissemination and distant metastasis are seen frequently in synchronous ovarian metastasis. The prognosis for women with synchronous ovarian metastases is poor, with a median overall survival of 18.4 months.[7] However, one report stated a 5-year survival rate after resection of 67.5% in patients with only ovarian metastasis and no other peritoneal dissemination or distant metastasis.[8]

Histopathologically, it is often difficult to distinguish metastatic ovarian cancer from primary ovarian cancer with hematoxylin and eosin staining alone; however, CK-7 and CK-20 immunostaining is useful for distinguishing metastatic colon cancer from primary ovarian carcinomas.[9] Colorectal cancer is CK-7 negative and CK-20 positive, and ovarian cancer is CK-7 negative. We diagnosed ovarian metastasis of sigmoid colon carcinoma in our patient based on CK-7-negative and CK-20-positive results.

Although rupture of metastatic ovarian tumor is extremely rare, we considered the possibility of metastatic ovarian tumor from the beginning in our patient because of the atypical MRI findings. Because of the early diagnosis and minimally invasive laparoscopic surgery, the patient's postoperative course was good, and we were quickly able to identify and treat the primary lesion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol 2009;23:711-24.  Back to cited text no. 1
    
2.
Young RH. From Krukenberg to today: the ever present problems posed by metastatic tumors in the ovary: part I. Historical perspective, general principles, mucinous tumors including the Krukenberg tumor. Adv Anat Pathol 2006;13:205-27.  Back to cited text no. 2
    
3.
Ulbright TM, Roth LM, Stehman FB. Secondary ovarian neoplasia – A clinicopathologic study of 35 cases. Cancer 1984;53:1164-74.  Back to cited text no. 3
    
4.
Choi HJ, Lee JH, Kang S, Seo SS, Choi, JI, Lee S, et al. Contrast-enhanced CT for differentiation of ovarian metastasis from gastrointestinal tract cancer: Stomach cancer versus colon cancer. Am J Roentgenol 2006;187:741-5.  Back to cited text no. 4
    
5.
Oohira G, Miyauchi H, Shuto K, Matsubara H. A case of ovarian metastasis from sigmoid colon cancer that caused intraperitoneal bleeding and required emergency surgery. Nihon Rinsho Geka Gakkai Zasshi 2008;69:2048-52.  Back to cited text no. 5
    
6.
Takebayashi R, Izuishi K, Sano T, Hagiike M, Okano K, Suzuki Y. A case of ovarian metastasis from sigmoid colon cancer that caused intraperitoneal rupture. Nihon Rinsho Geka Gakkai Zasshi 2010;71:1822-7.  Back to cited text no. 6
    
7.
Wright JD, Powell MA, Mutch DG, Rader JS, Gibb RK, Huettner PC, et al. Synchronous ovarian metastasis at the time of laparotomy for colon cancer. Gynecol Oncol 2004;9:851–55.  Back to cited text no. 7
    
8.
Tomiki Y, Kamano T, Kunii Y, Okada T, Kasamaki S, Negami N, et al. Risk factors of ovarian metastasis from colorectal cancer by using multivariate analysis. Jpn J Gastroenterol Surg 2002;35:11-7.  Back to cited text no. 8
    
9.
Loy TS, Calaluce RD, Keeney GL. Cytokeratin immunostaining in differentiating primary ovarian carcinoma from metastatic colonic adenocarcinoma. Mod Pathol 1996;11:1040-4.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed310    
    Printed27    
    Emailed0    
    PDF Downloaded65    
    Comments [Add]    

Recommend this journal