Outcome after ovarian/adnexal metastectomy in metastatic colorectal carcinoma

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).

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.

Clinics and pathology of Krukenberg tumor: a systematic review and meta-analysis

INTRODUCTION

Krukenberg tumor (KT) is defined as a secondary neoplasm of the ovary. While ovarian metastases account for about 30% of ovarian tumors, KTs are rare, accounting for about 1-2% of the total. The rarity of KT is at least in part responsible for the lack of a precise clinic-pathological characterization of these tumors. Clinically, KT may have a subtle clinical presentation, with few symptomatic manifestations and nonspecific clinical signs, even though in literature there is disagreement about the clinical presentation of these patients; such difficulties in the diagnostic framework often leads to a delayed diagnosis with serious consequences on the patient outcome. We aimed to provide a clinico-pathological characterization of Krukenberg Tumor (KT) through a systematic review and meta-analysis to improve the diagnosis and management of KT.

EVIDENCE ACQUISITION

Electronic databases were searched for all studies assessing clinico-pathological features of KT series. Pooled prevalence of each clinical or pathological factor was calculated according to the random-effect model.

EVIDENCE SYNTHESIS

Forty-eight studies with 3025 KT patients were included; 39.7% of patients were ≥50 and 39.8% were postmenopausal. The most common primary tumor sites were stomach (42.5%), colon-rectum (26.1%), breast (9.3%), and appendix (5%); 48.7% of KTs were synchronous with the primary tumor, 64.3% were bilateral, 40.5% had a diameter ≥10 cm; 55.3% showed extraovarian extent and 49% showed peritoneal involvement. The most common presenting symptoms were ascites (51.7%), palpable mass (31.3%), pain (29.3%), abdominal distention (28.7%), irregular bleeding (9.1%), asymptomatic (11.2%).

CONCLUSIONS

KT shows a highly variable presentation. Understanding the prevalence of clinico-pathological factors may be helpful to improve the diagnosis and management of KT.

Colorectal cancer ovarian metastases

OBJECTIVE

Ovarian metastases occur in 3%-5% of patients with colorectal cancer. The role of oophorectomy in that setting continues to be debated. We aimed to assess the survival of women treated with metastasectomy for ovarian metastasis.

METHODS

Retrospective cohort study of patients in the California Cancer Registry (2000-2012) with stage IV colorectal cancer and ovarian metastases. Pathology other than adenocarcinoma was excluded. Adjusted Cox-proportional hazard analysis was applied to assess the risk of death.

RESULTS

A total of 756 patients with synchronous ovarian metastases and 516 patients with metachronous ovarian metastases form the basis of this analysis. Median follow-up for the synchronous cohort was 21 months (IQR: 8-36). Median overall survival was 23 months (IQR: 10-42). Estimated 5-year survival reached 17% and 10-year survival was 8%. There was a significant difference in unadjusted survival between patients with solitary ovarian metastasis (median overall survival: 51 months) compared with those who had both ovarian and extraovarian metastases (20 months) (log-rank test, P<0.0001). For patients with solitary ovarian metastases, the 5- and 10-year survival was 46% and 31%, respectively. Among patients with synchronous ovarian metastases, longer unadjusted survival was observed after oophorectomy (median overall survival: 24 months) compared with no oophorectomy (18 months, log-rank P=0.01). For patients with metachronous diagnoses of colorectal cancer ovarian metastasis, the median disease-free survival was 19 months. The median survival after resection of metachronous ovarian metastases was 25 months, with the survival directly related to the disease-free interval until metastasis. For patients with resected metachronous ovarian metastases, the 5- and 10-year post-metastasectomy survival was 14% and 5%, respectively.

CONCLUSIONS

Patients with colorectal cancer ovarian metastasis have favorable long-term survival. Survival rates are higher if the tumor is isolated to the ovary or if metachronous to the primary cancer.

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.

Development and clinical application of bispecific antibody in the treatment of colorectal cancer

INTRODUCTION

Treatment of colorectal cancer as one of the most commonly diagnosed and a frequent cause of cancer-related deaths is of great challenges in health-related issues.

AREAS COVERED

Immunotherapy is the fourth pillar of cancer treatment which provides more novel therapeutic options with expanding investigational potentials. One of the modalities in immunotherapy is the use of bispecific antibodies. Despite demonstrating many promising roles, it still needs more advanced studies to identify the actual pros and cons. In this review, the application of bispecific antibody in the treatment of colorectal cancer has been explained, based on preclinical and clinical studies. The literature search was conducted mainly through PubMed in June and September 2019.

EXPERT OPINION

Bispecific antibody is in its early stages in colorectal cancer treatment, requiring modern technologies in manufacturing, better biomarkers and more specific target antigens, more studies on individual genetic variations, and conducting later phase clinical trials and systematic reviews to achieve better survival benefits.

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.

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).

Surgical Resection of Colorectal Cancer With Distant Metastases to Other than Liver or Lung

BACKGROUND/AIM

If both distant metastases and the primary tumour of colorectal cancer (CRC) are resectable, resection of the distant metastases is considered. The aim of this retrospective study was to determine the efficacy of curative resection of both primary and metastatic lesions in organs other than liver or lung in CRC patients.

PATIENTS AND METHODS

The medical records of 23 CRC patients who received R0 resection for primary and metastatic regions between 2009 and 2018 were retrospectively analyzed.

RESULTS

The 3-year overall survival (OS) in all 23 cases was 80.0%. There was no clinicopathological factor associated with OS on univariate analysis.

CONCLUSION

Curative surgical resection appears to be useful for distant CRC metastases to organs other than liver or lung.

Prognostic factors in Krukenberg tumor

BACKGROUND

Krukenberg tumor (KT) is a rare secondary ovarian tumor. Little is known about clinicopathologic factors affecting prognosis in KT.

OBJECTIVE

To assess the prognostic value of clinicopathologic factors in KT through a systematic review and meta-analysis.

METHODS

Electronic databases were searched from their inception to February 2019 for studies assessing the association of clinicopathologic factors with overall survival in KT. Pooled hazard ratio (HR) was calculated for each factor; a p value < 0.05 was considered significant.

RESULTS

Twenty-three studies with 1743 patients were included. A decreased overall survival was significantly associated with peritoneal involvement (HR 1.944; p = 0.003), ascites (HR 2.055; p = 0.034), synchronous presentation (HR 1.679; p = 0.034) and increased serum CEA levels (HR 1.380; p = 0.010), but not with age > 50 (HR 0.946; p = 0.743), menopausal status (HR 1.565; p = 0.204), gastric origin (HR 1.600; p = 0.201), size > 5 cm (HR 1.292; p = 0.119), size > 10 cm (HR 0.925; p = 0.714), bilateral ovarian involvement (HR 1.113; p = 0.347), non-peritoneal extaovarian metastases (HR 1.648; p = 0.237), liver metastases (HR 1.118, p = 0.555), predominant signet ring cell morphology (HR 1.322; p = 0.208) and levels of CA125 (HR 0.933; p = 0.828) and CA19.9 (HR 0.996; p = 0.992).

CONCLUSION

Peritoneal involvement, synchronous presentation, ascites and increased serum CEA levels appear as unfavorable prognostic factors in KT and might affect the patient management.

Treatments and overall survival in patients with Krukenberg tumor

BACKGROUND

Krukenberg tumor (KT) is a rare secondary ovarian tumor, primarily localized at the gastrointestinal tract in most cases. KT is related to severe prognosis due to its aggressiveness, diagnostic difficulties and poor treatment efficacy. Several treatments have been used, such as cytoreductive surgery (CRS), adjuvant chemotherapy (CT) and/or hyperthermic intraperitoneal chemotherapy (HIPEC). To date, it is still unclear which treatment or combination of treatments is related to better survival.

OBJECTIVE

To assess the most effective therapeutic protocol in terms of overall survival (OS).

METHODS

A systematic review of the literature was performed by searching MEDLINE, Scopus, EMBASE, ClinicalTrial.gov, OVID, Web of Sciences, Cochrane Library, and Google Scholar for all studies assessing the association of treatments with OS in KTs. The effectiveness of each treatment protocol was evaluated by comparing the OS between patients treated with different treatment protocols.

RESULTS

Twenty retrospective studies, with a total sample size of 1533 KTs, were included in the systematic review. Therapeutic protocols used were CRS in 18 studies, CT in 13 studies, HIPEC in 7 studies, neoadjuvant CT in 2 studies, and some combinations of these in 6 studies. Seven studies showed that CRS significantly improved OS compared to other treatments or association of treatments without it. 11 studies showed that CRS without residual (R0 CRS) had a significantly better OS than CRS with residual (R + CRS). Five studies showed that CT significantly improved OS, but other five showed it did not. Two studies showed that HIPEC in association with CRS improved OS, while another study showed that efficacy of HIPEC was comparable to CT. Two studies evaluated neoadjuvant CT, but results were conflicting.

CONCLUSION

CRS and in particular R0 CRS are the treatments showing the clearest results in improving OS in KT patients. Results about CT are conflicting. HIPEC appears effective both alone and in combination with CRS, and also related to fewer adverse effect than CT. The usefulness of neoadjuvant CT is still unclear. The association of R0 CRS with HIPEC seems to be the most effective and safe therapeutic protocol for KT patients.

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.

Ovarian Metastases of Colorectal Origin: Treatment Patterns and Factors Affecting Outcomes

The purpose of this study is to evaluate the patterns of treatment and factors affecting outcomes in ovarian metastases of colorectal origins treated at our institution and to assess the response of ovarian metastases to chemotherapy. Survival in R0 and R+ resections and patients receiving only chemotherapy is also analyzed. This is a retrospective study of 25 patients registered between January 2012 and December 2015. Patient's age, disease status, mode of presentation, disease spread, mode of treatment, response to chemotherapy, completeness of resection, histology, and outcomes were considered as variables for analysis. There were 21 synchronous presentations and 4 metachronous presentations. In synchronous presentations, only 2 had extra-abdominal disease. Of these patients, 15 underwent surgeries of various extents. The remaining 6 patients were treated with chemotherarpy initially. Only one of them could come up to surgery later. In R0 resections, disease recurred between 1 and 9 months (median 3.5 months). The recurrence was in peritoneum and ovaries. In operated cases, 12 of 15 patients received chemotherapy and 9 patients progressed on first line chemotherapy. In all 4 metachronous patients, the disease was in the peritoneum. No one underwent surgery for the recurrence due to the extensive nature of the disease. All received chemotherapy. Sixty-six percent ovarian metastases showed progression on chemotherapy. There was no significant difference in the median survival between patients treated with surgery plus chemotherapy (23 months) vs. those treated with chemotherapy alone (28 months). Age and presence of disease at other sites did not affect the outcomes. Non-signet ring cell histologies showed better outcomes compared to signet ring cell histology (p = 0.02). Synchronous presentation, R0 resections, and responsive disease showed better survival, however it was clinically not significant. Treatment of ovarian metastases of colorectal origins is varied but has consistently poor outcome. Non-signet histology was the only prognostic factor which showed better outcome. Survival was not different between patients treated with surgery+chemotherapy and chemotherapy alone but majority of ovarian metastases progressed on chemotherapy. Considering the poor response to chemotherapy and peritoneum being the most common site of disease, both in primary and recurrent setting, R0 resection should always be attempted after selecting the correct patients using PET scan, laparoscopy and standard exploratory protocols. Treatment should be tailored upon patient's status and disease burden with an aim to do complete cytoreduction whenever possible. CRS+HIPEC (cytoreductive surgery + hyperthermic intraperitoneal chemotherapy) can be considered on case to case basis as even R0 resections tend to recur.

Krukenberg tumors: Seed, route and soil

The aim of this narrative review was to summarize the current evidence on Krukenberg tumors (KTs), addressing what is known on their natural history and their impact on the clinical prognosis and which are the most appropriate management strategies to treat this condition. A literature search was conducted on Pubmed up to December 2016, selecting the most relevant studies on the basis of the scope of the review. KTs are ovarian metastases from primary signet-ring cell carcinomas., characterized by the presence of a sarcoma-like stroma. They have three possible routes of diffusion (lymphatic, peritoneal and hematogenous), but the preferential one is still unclear. Prognosis is dismal. When KTs are encountered in the clinical practice, it is reasonable to offer surgical resection to young, fit patients with limited disease. Palliative surgery should be considered for all patients with symptomatic disease. Further studies should clarify the clinicopathologic characteristics of KTs, their main routes of diffusion, and the possible role of prophylactic oophorectomy, lymphadenectomy and intraperitoneal chemotherapy. Molecular and transitional research should parallel the clinical one to help understanding the natural history of signet-ring cell carcinomas.

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

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

Clinical analysis of Krukenberg tumours in patients with colorectal cancer-a review of 57 cases

BACKGROUND

A Krukenberg tumour (KT) is defined as an ovarian metastasis from a gastrointestinal adenocarcinoma and suggests a terminal condition. This study aimed to identify the prognostic factors affecting the survival of patients with KTs of colorectal origin who receive cytoreductive surgery.

METHODS

Medical records of patients who had received cytoreductive surgery and had been pathologically diagnosed with KT of colorectal origin in two centres were reviewed. Information about the patients' clinicopathological features and follow-up visit were collected. Factors influencing patient survival were analysed.

RESULTS

Fifty-seven patients were included in this study. The median survival time was 35 months. Five-year overall survival was 25%. Patients who had recurrence 2 years after resection of the primary tumour, achieved complete cytoreduction, had metastases confined to the pelvis, had no lymph node involvement, and received systemic chemotherapy had a significantly longer median survival than those who had recurrence at the same time as resection of the primary tumour (P = 0.027), received incomplete cytoreduction (P < 0.001), had metastases beyond the pelvis (P < 0.001), had lymph node involvement (P = 0.011), and did not receive systemic chemotherapy (P = 0.006) on log-rank test. Less extensive metastatic disease, achievement of complete cytoreduction, and use of systemic chemotherapy were significantly associated with improved prognosis on multivariate analysis.

CONCLUSIONS

Cytoreductive surgery may confer survival benefits in patients with KTs of colorectal origin who attain complete cytoreduction and whose metastases are confined to the pelvis and when combined with active systemic chemotherapy.

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.

Synchronous ovarian metastasis from colorectal cancer: A report of two cases

Ovarian metastasis of colorectal cancer is relatively rare. The present study reports two cases of synchronous ovarian metastasis from colorectal cancer, which were managed by cytoreductive surgery. In case one, a 60-year-old female patient presented with a multilocular pelvic tumor and ascites. Virtual colonoscopy revealed a mass in the sigmoid colon; however, no tumor cells were identified on histological examination. Ovarian metastasis from sigmoid colon cancer was suspected and adnexectomy was subsequently performed. Histological examination of the excised tumor revealed adenocarcinoma. Immunohistochemical analysis of the resected tumor revealed positive staining for cytokeratin (CK)20 and caudal-type homeobox 2 (CDX2), and negative staining for CK7, estrogen receptor, progesterone receptor and inhibin. The immunohistological results supported the diagnosis of ovarian metastasis from sigmoid colon cancer. In case two, a 56-year-old female patient presented with a multilocular pelvic tumor and ascites. Colonoscopy identified a rectal tumor, and histological examination revealed moderately-differentiated adenocarcinoma, which was confirmed by cytological analysis of ascites. Subsequently, ovarian metastasis from rectal cancer with peritoneal dissemination was diagnosed, and left ovariectomy and transverse colostomy were performed. Histological examination of the excised tumor revealed moderately-differentiated adenocarcinoma, and immunohistochemical investigation revealed positive staining for CK20 and CDX2, but negative staining for CK7. These immunohistological results indicated ovarian metastasis from rectal cancer. Both patients recovered well and are currently undergoing regular follow-up examinations. The observations from the two cases indicate that ovarian metastases of primary colorectal cancer may present as pelvic tumors and, thus, preoperative examination of the gastrointestinal tract is required. Furthermore, even in cases of widespread colorectal cancer metastases, excision of the ovarian tumor is required to establish a histological diagnosis for the selection of appropriate treatments.

[Morphology of secondary ovarian tumors and metastases]

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

Treatment of ovarian metastases of colorectal and appendiceal carcinoma in the era of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

AIM

To compare outcome of women with ovarian metastasis who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) to outcome of women without ovarian metastasis who underwent CRS-HIPEC.

METHODS

A prospective CRS-HIPEC database was searched to identify women with surgically treated colorectal carcinoma between 2000 and 2012. Patients with ovarian metastasis were identified and patients with peritoneal carcinomatosis but without ovarian metastasis were included as control cases.

RESULTS

75 patients with macroscopic ovarian metastasis underwent CRS-HIPEC with curative intent, while 50 female patients without ovarian metastasis were identified who underwent CRS-HIPEC. Patients with ovarian metastasis more often had a primary appendiceal tumour and had a more extensive intra-abdominal tumour load compared to patients without ovarian metastases. Median follow-up time was 45 months (95% confidence interval (CI): 37-53 months). Overall survival (OS) did not differ significantly between the two groups with a median OS in the ovarian metastasis group of 40 months (95% CI 26-54) compared to 64 months (95% CI 17-111, P = 0.478) in the non-ovarian metastasis group. Recurrence patterns did not differ significantly between groups (p = 0.183).

CONCLUSIONS

Patients with ovarian metastasis of colorectal and appendiceal origin who underwent CRS-HIPEC had similar outcome compared to patients without ovarian metastasis. Given the findings of high coincidence of peritoneal metastases with ovarian metastases and ovarian metastases not being an independent factor for survival after CRS-HIPEC, this procedure should be recommended for patients with peritoneal metastases and ovarian metastases of colorectal and appendiceal carcinoma.

Chemosensitivity in ovarian metastases from gastric cancer: a case series

The development of ovarian metastases from gastric cancer indicates a turning point of the disease progression and is usually associated with poor prognosis. Efficacy of modern chemotherapy protocols in ovarian metastases from gastric cancer is unknown. In this case series, we have evaluated the chemosensitivity of ovarian metastases from gastric cancer in eight consecutive patients treated in our institution between January 2000 and April 2012. Median age at gastric cancer diagnosis was 48.3 years and ovarian metastases were mainly metachronous (88%). Patients were treated with FOLFOX or FOLFIRI protocols in first-line and with EOX protocol in second-line chemotherapy. These protocols of chemotherapy used in first- and second-line treatment were able to control the disease in 33.3% for ovarian metastases compared to 66.7% for extraovarian metastases. Mean overall survival (OS) from ovarian metastases diagnosis was 14.2 months. The four patients treated by bilateral oophorectomy had a longer mean OS (16 months) than the four patients who did not experienced surgery (12.3 months). In conclusion, this case series suggests that ovarian metastases from gastric cancer are less sensitive than extraovarian metastases to modern protocol of chemotherapy. To confirm these observations, a large retrospective study is ongoing.

The beneficial effect of palliative resection in metastatic colorectal cancer

Background:

We aimed to determine the role of palliative resection in metastatic colorectal cancer (mCRC) and ascertain which patient populations would benefit most from this treatment.

Methods:

A total of 1015 patients diagnosed with mCRC at Seoul National University Hospital between 2000 and 2009 were retrospectively studied.

Results:

Of the 1015 patients, 168 patients with only liver and/or lung metastasis received curative resection. The remaining 847 patients were treated with palliative chemotherapy and/or palliative resection combined with best supportive care. Palliative resection was performed in 527 (62.2%) cases (complete resection with negative margin (R0) in 93, R1/2 in 434). Resected patients had a more prolonged median overall survival (OS) than unresected patients (21.3 vs 14.1 months; P<0.001). In multivariate analysis, R0 resection was found to be associated with a superior OS compared with R1/2 resection (51.3 vs 19.1 months; P<0.001) and no resection (51.3 vs 14.1 months; P<0.001). When we performed propensity score matching, palliative resection was found to be related to prolonged OS (hazard ratio=0.72, 95% confidence interval=0.59–0.89; P=0.003).

Conclusion:

Palliative resection without residual disease and chemotherapy confers a longer-term survival outcome than palliative chemotherapy alone in mCRC patient subset.

Molecular imaging for personalized cancer care

Molecular imaging is rapidly gaining recognition as a tool with the capacity to improve every facet of cancer care. Molecular imaging in oncology can be defined as in vivo characterization and measurement of the key biomolecules and molecularly based events that are fundamental to the malignant state. This article outlines the basic principles of molecular imaging as applied in oncology with both established and emerging techniques. It provides examples of the advantages that current molecular imaging techniques offer for improving clinical cancer care as well as drug development. It also discusses the importance of molecular imaging for the emerging field of theranostics and offers a vision of how molecular imaging may one day be integrated with other diagnostic techniques to dramatically increase the efficiency and effectiveness of cancer care.

Krukenberg Tumors from Colorectal Cancer: Presentation, Treatment and Outcomes

Ovarian metastases from colorectal cancer (CRC), also known as Krukenberg Tumors (KT), occur in about 3 per cent of all colorectal cancer patients and make up between 5 to 10 per cent of all colorectal metastases. We sought to determine the effects of presentation of KT on treatment patterns and outcomes of patients diagnosed with KT. Under institutional approval, 26 patients diagnosed with KT were identified from an institutional CRC database from 1994 to 2010. Twenty-two patients presented at the same time of their CRC diagnosis and four patients presented after diagnosis and treatment of their primary CRC. Demographic presentation and treatment patterns were similar between the two groups. There was no overall survival difference between the two groups. The median overall survival in the entire cohort was 27 months. Factors affecting survival may include the extent of metastases and age at time of presentation. Patients who present with metastasis to the ovary alone may trend towards a better overall survival than patients who present with metastases to additional other sites.

Metastasectomy for stage IV colorectal cancer

Metastatic colorectal cancer traditionally has been considered incurable. Over the past 3 decades, however, resection of low-volume hepatic disease has been recognized as beneficial in some cases. More recently, resection of isolated pulmonary metastases has been shown to offer long-term survival in carefully selected patients. Resection of metastases to more unusual sites (ovary, brain, peritoneal cavity) is more controversial; nevertheless, retrospective data suggest that a few patients may be cured with resection of these tumors. In this article, we review the history and current status of metastasectomy in stage IV colorectal cancer.

The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries

OBJECTIVE

The aim of this study was to investigate prognostic factors of patients with metastases to the ovaries from non-genital organs.

STUDY DESIGN

From September 1994 to December 2006, 158 patients with pathologically confirmed metastatic tumors to the ovaries at Samsung Medical Center (SMC) were included in this study. The data were obtained from the patients' medical records and pathology reports.

RESULTS

The primary tumor origin was mostly stomach (73 cases) and colon (61 cases). Krukenberg tumor (pathologically proven signet ring cell carcinoma) was found in 34 cases: stomach (25), colon (2), appendix (1), and unknown (6). Residual disease after surgery was >2 cm in 65 (41.1%) cases and <2 cm in 93 (58.9%) cases. The overall 5-year survival was 7.2% and the median survival time was 15 months. The median survival times according to the primary tumor site showed significant differences (p=0.002) and were as follows: stomach 12 months, colon 17 months. The median survival in cases with residual disease <2 cm vs. >2 cm was 26 months vs. 15 months (p=0.017) and the median survival with vs. without adjuvant chemotherapy was 16 months vs. 10 months (p=0.001). However, age, bilateral tumors, chronology of diagnosis and mass size did not affect survival.

CONCLUSION

Cytoreductive surgery and post-operative adjuvant chemotherapy had a beneficial effect on survival in selected patients.

Ovarian Metastases in Colorectal Cancer

Purpose:

The aims of this study were to determine the incidence, clinicopathologic features, and prognostic factors of ovarian involvement in primary colorectal cancer (CRC) and also to clear the role of prophylactic oophorectomy.

Methods:

Data from women with primary CRC treated between 1990 and 2004 were retrieved, and clinical and pathologic features of those who had undergone oophorectomy during CRC surgery were reviewed.

Results:

One hundred eighty cases (mean age, 48 years) were included. In 120 cases, ovaries were preserved, and 60 cases underwent bilateral oophorectomy in addition to primary CRC resection. Reasons for oophorectomy were prophylactic in 22 (36.6%), abnormal morphology in 35 (58.3%), and undetermined in 3 cases (5%). There were 5 metastatic carcinomas, 8 primary ovarian tumors, and 47 normal ovaries in the pathologic evaluation. No complication directly related to oophorectomy was noted. Patients with ovarian metastases had higher stages of tumor. Ovarian metastases were not related to menstrual status, CRC location, size, differentiation, and mucin production, as well as abnormal morphology of the ovary. The global prevalence of ovarian metastases in CRCs was 2.7%, and isolated ovarian metastases occurred in fewer than half of them. Of 120 women who underwent colectomy alone, 8 (6.6%) developed ovarian metastasis during 2 years of follow-up. Only 3 cases had isolated ovarian metastases. No patient with synchronous or metachronous ovarian metastases from CRC survived 5 years.

Conclusions:

Isolated ovarian metastases from primary CRC occur with a low frequency, and this may partially explain the debate regarding prophylactic oophorectomy at the time of curative resection for primary CRC.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The differential response to chemotherapy of ovarian metastases from colorectal carcinoma

PATIENTS AND METHODS

All patients with metastatic (ovarian and extraovarian) CRC who underwent resection of ovarian metastases in our institution from April 1988 to August 2006 were analyzed and the response to preoperative chemotherapy was evaluated according to the RECIST criteria, and analyzed with respect to the sites of metastases (ovarian and extraovarian).

RESULTS

The studied population consisted of 23 women. At presentation, 20 patients had symptoms. Preoperative chemotherapy resulted in tumor control of measurable extraovarian metastases in 65% of cases. In contrast, no objective tumor response of ovarian metastases was observed, disease stabilization was obtained in only 3 patients (13%), and progression or occurrence of new ovarian metastases were observed in 20 patients (87%) (p=0.0005). With a median follow-up of 54 months [15-229], median overall survival was 30 months, and 3-year overall survival was 18%.

CONCLUSION

Ovarian metastases are less responsive to chemotherapy compared to other sites. As these "metastatic sanctuaries" often cause symptoms, surgical resection should always be considered for ovarian metastases, even in the case of associated extraovarian metastases.

Ovarian metastasis from colorectal cancer: prognostic value of radical oophorectomy

BACKGROUND

Ovarian metastases from primary colorectal cancer occur in 3-8% of female patients. The aim of this study was to assess the prognostic value of radical oophorectomy for ovarian metastasis from colorectal cancer.

PATIENTS AND METHODS

From our series of 859 patients operated for colorectal cancer from 1982 to 2005 ten patients with isolated ovarian metastasis were retrieved. Ovarian colorectal metastasis diagnosis was confirmed by pathology revision. Overall and disease-free survival after radical oophorectomy for metastases were assessed and compared with literature data.

RESULTS

The median follow-up from ovarian metastases resection was 36 months (range 194-14). Survival analysis showed that survival rate after ovarian metastasectomy was 100% at 1 year and 80% at 5 years of follow up.

CONCLUSION

Our study, although limited by a relatively short follow-up and small sample size, shows that bilateral oophorectomy for ovarian metastasis from colorectal cancer has a good impact on disease-free and overall survival.

The role of cytoreductive surgery for colon cancer metastatic to the ovary

OBJECTIVE

We sought to further elucidate the survival impact of cytoreductive surgery among patients with colon cancer metastatic to the ovary.

METHODS

All women diagnosed with primary colon cancer metastatic to the ovary at a single institution from 1980 to 2005 were retrospectively identified. Survival analyses and comparisons were performed using Kaplan-Meier plots and the log rank test.

RESULTS

A total of 39 patients with 40 cases of colon cancer metastatic to the ovary were identified. Patients with metastatic disease confined to the ovaries (n=11) had a median overall survival (OS) time of 61 months (range 15-120) compared to 17 months (range 0.5-73) for those with more extensive metastases (n=24) (p=0.0428). Patients undergoing optimal cytoreduction (residual < or =1 cm) had a median progression-free survival (PFS) of 11 months (range 0.5-120, n=26) compared to 2.5 months (range 0.5-12, n=9) for those receiving suboptimal cytoreduction (p=0.0001). Optimal cytoreduction was also associated with a significantly longer median OS (35 months, range 0.5-120) compared to suboptimal cytoreduction (median OS=7 months, range=0.5-17) (p<0.0001). The peri-operative mortality rate was 5%. Significant morbidity occurred in 10% of the cases. All major complications occurred in women with diffuse disease who underwent extensive cytoreductive surgery.

CONCLUSIONS

The observation that optimal cytoreduction was associated with prolonged PFS and OS in both patients with localized ovarian and widespread metastases of colon cancer suggests a role for surgical management of metastatic colon cancer in women.

The role of cytoreductive surgery in nongenital cancers metastatic to the ovaries

OBJECTIVE

To investigate the role of cytoreductive surgery in patients with nongenital cancers metastatic to the ovaries.

PATIENTS AND METHODS

One hundred and fifty-four patients with nongenital cancers metastatic to the ovaries treated in Hacettepe University Hospital, Gynecologic Oncology Unit between 1982 and 2004 years were retrospectively evaluated. Data were obtained from patients' records and pathology reports. Demographic characteristics, prognostic factors, 5-year and median survivals were analyzed in all patients.

RESULTS

During study period, nongenital cancers metastatic to the ovaries constituted 9% of all malignant ovarian neoplasms. Primary cancers were breast (35), stomach (35) and colorectal (33) cancers, lymphoma (17), undetermined origin (16), appendix (7), ileum (4), pancreas (3), gallbladder cancer (2) and mesothelioma (2). Of patients, 67% were premenopausal and 33% were postmenopausal. Although most common presenting symptoms were abdominal distension with dyspeptic complaints in 46%, abdominal mass in 22%, and pressure symptoms in 8.4%, 15 patients (10%) were asymptomatic and were diagnosed in routine control examinations. Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO), omentectomy, and bilateral pelvic and para-aortic lymphadenectomy (BP-PALND) with cytoreduction were performed in 102 patients (66%), TAH + BSO + omentectomy in 21 patients (14%), TAH + BSO in 23 patients (15%), minimal surgical effort including BSO or biopsy in 8 patients (5%). Eighty-four percent of patients received adjuvant treatment according to the primary origins. Mean follow-up was 47.3 +/- 5.9 months. Overall, 5-year survival was 36% and median survival was 42 months. Comparison of median survival times for the primary sites showed a significant overall differences (P = 0.0001) and were as follows: breast 54 months, stomach 18 months, colorectal 48 months, lymphoma 181 months, unknown primary 16 months, appendix 18 months, ileum 40 months, pancreas 3 months, gallbladder 8 months and mesothelioma 20 months. Median survival time of patients who underwent cytoreductive surgery was 48 months, compared with 26 months for patients with suboptimal cytoreductive surgery (P = 0.0039). The 5-year survival rate was 47% and 23%, respectively. Multivariate analysis identified age, menopausal status, primary site, diffuse peritoneal involvement and type of operation as prognostic factors.

CONCLUSION

Presence of ovarian metastasis is associated with a poor prognosis in nongenital cancers. Surgery is essential for diagnosis of primary tumor and necessary for relief of symptoms. Cytoreductive surgery seems to have a beneficial effect on survival of selected patients, especially for patients with colorectal cancer metastatic to the ovary.

Survival benefit of metastasectomy for Krukenberg tumors from gastric cancer

OBJECTIVE

An optimal treatment strategy for ovarian metastases of gastric cancer has not been clearly established. The aim of this study was to examine the role of a metastasectomy in the management of metachronous Krukenberg tumors after curative surgery for gastric cancer.

METHODS

Among 1235 female patients who had undergone a curative gastric resection for stomach cancer between 1987 and 1998, 54 (4.4%) developed Krukenberg tumors as a first recurrence without evidence of a distant metastasis. Of these 54 patients, 33 underwent a metastasectomy while 21 did not. The survival duration between the two groups was analyzed and compared.

RESULTS

The clinicopathological features of Krukenberg tumors as well as those of the primary cancers in the two groups were similar. All 33 patients in the resection group underwent subsequent adjuvant chemotherapy, including the 7 who received intraperitoneal chemotherapy. The 21 patients in the non-resection group were managed by either systemic chemotherapy (n = 16) or supportive care (n = 5) alone. The median survival duration of all the patients was 9 months (95% confidence interval, 3-15 months). The median survival time in the resection group was 17 months (95% confidence interval, 10-24 months), which was significantly longer than that in the non-resection group, 3 months (95% confidence interval, 2-4 months) (P < 0.001).

CONCLUSION

Our results suggest that a metastasectomy was associated with an improved survival in patients with metachronous Krukenberg tumors from gastric cancer. These data offer a strong argument in favor of performing metastasectomy for Krukenberg tumors in the absence of an obvious distant metastasis.

Surgical management and outcome of metachronous Krukenberg tumors from gastric cancer

BACKGROUND AND OBJECTIVES

The question of whether resection should be performed in Krukenberg tumors from gastric cancer has yet to be adequately examined. Despite some reports on the surgical treatment of Krukenberg tumors, the outcomes after resection are not well characterized.

PATIENTS AND METHODS

Using a gastric cancer database, a total of 34 patients who underwent a resection of metastatic ovarian tumors after curative surgery for gastric cancer were identified. A prospective database of these patients was reviewed for the presentation, clinical features, and outcomes after resection.

RESULTS

The median age of 34 patients was 44 years (range, 24-66). The majority of patients was in the premenopausal state and had bilateral ovarian involvement. The most common presenting symptom was an abdominal mass (35.3%). Tumor size ranged from 3.5 to 20 cm with 61.8% measuring larger than 10 cm. In 17 patients who had metastatic disease confined to the pelvis, a complete gross resection (R0) was achieved. In the other 17 with the disease beyond the pelvis gross residual tumors remained after the resection (R1). The median survival of all patients was 11 months (95% confidence interval [CI] 8-14), and that of the patients rendered R0 was 18 months (95% CI, 14-22), in comparison with 9 months (95% CI, 3-15) for those with R1 resection (P = 0.0001; log-rank test). The median progression free survival was also significantly longer for the patients with R0 resection than those with R1 resection (8 months, 95% CI, 5-11 vs. 5 months, 95% CI, 4-6, P = 0.0103). Multivariate analysis identified R0 resection as the only significant factor predictive of survival.

CONCLUSIONS

In the management of Krukenberg tumors after gastric cancer, a metastasectomy may significantly improve the overall and progression free survival if it could render a complete gross resection. To define the patient group that benefits most from resection, the extent of disease and resectability must be carefully evaluated before surgery.

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

Although the role of prophylactic oophorectomy is currently under debate and not well defined, it is of increasing and considerable relevance, especially in premenopausal women, particularly those with identifiable hereditary cancer syndromes. Patients with colorectal cancer with ovarian metastases are often symptomatic, require surgery, and have poor survival. Prophylactic oophorectomy abolishes the increased risk of primary ovarian cancer in these patients, resects synchronous metastases, and prevents development of metachronous ovarian metastases. Prophylactic oophorectomy trials, mostly conducted in postmenopausal women, have not shown survival advantage. In patients with ovarian metastases of colorectal cancer, maximal cytoreductive surgery followed by adjuvant therapy employing newer chemotherapeutic agents, whole abdominal irradiation with chemosensitization, or hyperthermic intraperitoneal chemotherapy may improve outcomes in selected patients.