Metastases to the female genital tract. Analysis of 325 cases

Uterine Metastasis Presenting as Abnormal Uterine Bleeding in a Case of Primary Breast Cancer Identified on 18F-FDG PET/CT

Metastases to the female genital tract are rare, especially from extragenital primaries. The most common extragenital sites associated with genital metastasis are the gastrointestinal tract (37.6%) followed by the breast (34.9%). It is crucial to differentiate primary from metastatic involvement of the uterus for appropriate patient management. We present one such case of endometrial metastasis in a patient who presented clinically with abnormal uterine bleeding and was diagnosed with primary breast cancer via 18F-FDG PET/CT.

Extraovarian Dysgerminoma Involving the Uterine Cervix: A Rare Case Report With Literature Review

Primary extraovarian dysgerminoma (EOD) is a very rare disease. There is no literature about primary EOD involving the uterine cervix. We herein present details of a unique case of primary EOD involving the uterine cervix. A 46-year-old woman with uterine cervical tumor was referred to our institution with atypical genital bleeding. A polypoid tumor localized to the uterine cervix was found. Cervical biopsy detected malignant components of likely nonepithelial cell origin. Preoperative imaging examinations showed a uterine cervical tumor measuring ~5 cm, suggestive of malignancy without distant or lymph node metastases. The patient underwent abdominal radical hysterectomy with pelvic lymph node dissection according to the standard treatment for stage IB3 cervical cancers. The pathological diagnosis was dysgerminoma involving the uterine cervix and the right fallopian tube. Immunohistochemical results were as follows: SALL4 (+), octamer-binding transcription factor 4 (+), D2-40 (+), and c-Kit (+). She received 3 cycles of adjuvant chemotherapy with bleomycin, etoposide, and cisplatin. The disease did not recur up to 14 months after surgery. This is the first-ever published case of primary EOD involving the uterine cervix among previously reported EOD cases. Reported cases of EOD in female genital tract are also reviewed. Our case provides more extensive insights for pathologists to consider the differential diagnosis of cervical lesions. In our case, combination therapy involving a surgical approach-according to cervical cancers and adjuvant chemotherapy as used for ovarian dysgerminomas-was effective. Future verification is needed regarding the best approach for treating uterine cervical dysgerminomas.

Vaginal metastasis of lung cancer: A case report

Lung adenosquamous carcinoma (ASC) is a rare biphasic malignant tumor with squamous cell carcinoma (SCC) and adenocarcinoma (AC) components. ASC is reported to be aggressive; the most common metastatic sites are the regional lymph nodes and surrounding areas. A 46-year-old woman was referred to the emergency department with a persistent dry cough. She underwent fibro-bronchoscopy and was diagnosed with an adenosquamous lung carcinoma. Other than pulmonary and lymphatic findings, a total-body computed tomography (CT) examination highlighted a hypodense formation, of about 9 mm, with a cystic appearance, at the level of the vaginal region. A biopsy performed in the posterior vaginal wall highlighted a vaginal wall flap with subepithelial localization of neoplasia, compatible with the pulmonary ASC. Oncologists took charge of the case and the patient commenced medical therapy with entrectinib. Four months later, she developed dyspnea, and high-resolution CT highlighted an increase in the pathological tissue causing bronchial occlusion. The patient underwent endobronchial stent placement and thereafter restarted therapy with entrectinib, previously stopped because of the new symptoms, and was closely monitored. Apparently only one case of vaginal metastasis from pulmonary tumor has been previously reported, and this is the first report of vaginal metastasis from ASC. Although extremely rare, the presence of such metastasis should be considered in women with suspected vaginal neoformations.

Clinicopathologic Review of Metastatic Breast Cancer to the Gynecologic Tract

Metastatic spread is the single most significant predictor of poor survival in breast cancer. Some of the most common metastatic sites are the bones, lungs, liver, brain, and peritoneal cavity. Clinically metastatic breast cancer to the gynecologic tract is usually asymptomatic and diagnosed as an incidental finding during a histologic examination of gynecologic specimens resected for other reasons. Cases of metastatic breast cancer to gynecologic organs diagnosed from August 1995 to January 2021 were retrieved from our institution's pathology databases, and their clinicopathologic features were reviewed. The most common site of metastasis was the ovary which was involved in about 79% (22 of 28 cases) of metastases to the gynecologic tract. Clinically, only 8 cases (36%) presented with ovarian mass detected in imaging studies and the rest of the cases were all incidental findings. Among ovarian metastasis, 59% of cases were invasive lobular carcinoma and 41% were invasive ductal carcinoma. In 5 cases, metastatic breast cancer was found in the endometrium, including 2 cases with endometrial metastasis only and 3 cases with multiple gynecologic organs involved. Metastatic breast cancer rarely involved the lower gynecologic tract, with only 7% vaginal metastasis and 4% found in the vulva. The absolute majority of metastatic breast cancer outside of the ovaries were lobular carcinoma (88%). Most of the metastatic breast carcinomas were positive for estrogen receptor on immunohistochemistry (27 of 28 cases, 96%). Her-2/neu immunostaining was positive in 4 cases only (14%). Metastatic breast cancer needs to be distinguished from gynecologic primary neoplasms and metastatic tumors from adjacent urinary and GI tracts. A careful review of the patient's history and adequate immunohistochemistry panel are helpful to render the diagnosis.

Metastatic signet-ring carcinoma to the uterus presenting as an endometrial polyp

Primary signet-ring cell carcinoma of the uterus is rare and requires exclusion of possible metastatic tumour to the uterus. We report a case of a woman in her 70s who underwent hysteroscopy and a polypectomy for a polyp arising from the uterine wall. On histological examination, malignant cells with signet-ring cell morphology were found within the fragments of endometrial tissue. Immunohistochemical studies indicated a metastatic adenocarcinoma possibly from the gastrointestinal tract. Additional radiological investigations revealed a possible primary gastric tumour, which was further confirmed on subsequent biopsies. This case illustrates that gastric carcinomas can rarely metastasise to the endometrium and highlights the importance of clinical correlation in arriving at the final diagnosis.

JGOG2046: a feasibility study of neoadjuvant chemotherapy followed by debulking surgery for clinically diagnosed FIGO stage IVb endometrial cancer

BACKGROUND

We evaluated the feasibility of neoadjuvant chemotherapy, followed by debulking surgery, for clinically diagnosed FIGO stage IVb endometrial cancer (protocol number: JGOG2046).

METHODS

The experimental treatment consisted of 3 cycles of paclitaxel (180 mg/m2) plus carboplatin (AUC5) followed by debulking surgery, including total abdominal hysterectomy, bilateral salpingo-oophorectomy, and 3 cycles of adjuvant chemotherapy. Patients were considered as eligible if they were pathologically diagnosed as primary endometrial cancer, and had both endometrial tumor and distant metastasis confirmed by imaging examinations. The primary endpoint was the incidence of patients who completed debulking surgery after the neoadjuvant chemotherapy.

RESULTS

While 51 patients were enrolled from 23 hospitals, the final study cohort consisted of 49 patients with a mean age of 59.0 years. Although the response ratio of the neoadjuvant chemotherapy was 65.3% (95% CI 50.4-78.3%), 67.3% (95% confidence interval (CI) 52.5-80.1%) underwent debulking surgery after the neoadjuvant chemotherapy and 59.2% (95% CI 45.2-71.8%) completed the protocol treatment including 3 courses of adjuvant chemotherapy. The median disease-free survival time was 9.1 months (95% CI 6.5-11.9), while the median overall survival time was 23.2 months (95% CI 11.9-27.8). A patient with sigmoid colon cancer and another with cervical cancer were included in this study.

CONCLUSIONS

Neoadjuvant chemotherapy followed by debulking surgery was a feasible and acceptable treatment for metastatic endometrial cancer. (225 words).

Tumor to Tumor Metastasis: A Case Report of Metastatic Angiosarcoma to an Ovarian Brenner Tumor and Review of the Literature

While angiosarcoma metastatic to the ovary is rare, metastatic angiosarcoma to an ovarian tumor has never been reported in the literature, so far. We report a case of a 61-yr-old postmenopausal woman with history of breast cancer, presenting with metastatic angiosarcoma to an ovarian Brenner tumor. Initially at the frozen section examination, on limited sampling, and without knowledge of the patient's history, a diagnosis of at least proliferating Brenner tumor was rendered. Upon review of permanent sections, an intermixed angiosarcoma component was identified within Brenner tumor. Tumor to ovarian tumor metastasis is a rare phenomenon, with only 18 cases reported in the last 50 yr. It poses diagnostic challenges during sampling and histopathologic interpretation. Detailed clinical history, careful gross examination and sampling are important to recognize the separate tumor components.

HPV-Negative Adenocarcinomas of the Uterine Cervix: From Molecular Characterization to Clinical Implications

Cervical cancer is the fourth most common cancer in women. It is the leading cause of female deaths in developing countries. Most of these cervical neoplasms are represented by squamous lesions. Cervical adenocarcinoma causes about a quarter of cervical cancers. In contrast to squamous lesions, cervical glandular disease is HPV-negative in about 15-20% of cases. HPV-negative cervical adenocarcinomas typically present in advanced stages at clinical evaluation, resulting in a poorer prognosis. The overall and disease-free survival of glandular lesions is lower than that of squamous lesions. Treatment options require definitive treatments, as fertility-sparing is not recommended. Moreover, the impact of HPV vaccination and primary HPV screening is likely to affect these lesions less; hence, the interest in this challenging topic for clinical practice. An updated review focusing on clinical and molecular characterization, prognostic factors, and therapeutic options may be helpful for properly managing such cervical lesions.

Asymptomatic uterine metastasis of breast cancer: Case report and literature review

RATIONALE

Uterine metastasis from breast cancer is extremely rare. Asymptomatic patients with cervical metastases from breast cancer are rarer and more likely to be missed. We present an asymptomatic patient with breast cancer metastasized to the uterus and share opinions on diagnosing and treating for this kind of cases.

PATIENT CONCERNS

We present the case of a 64-year-old woman who was diagnosed with both breast cancer and uterine fibroids after examination. She had no symptoms of gynecological disease during breast cancer treatment. A positron emission tomography/computed tomography (PET/CT) scan was performed during reexamination, revealing multiple metastases of the bone throughout the body and an abnormal hypermetabolic mass in the uterus. It was later confirmed as uterine metastasis by pathology.

DIAGNOSIS

A diagnosis of metastatic breast invasive lobular carcinoma was established after a uterine curettage.

INTERVENTIONS AND OUTCOMES

Treatment of the uterine metastasis included systemic chemotherapy, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO), postoperative radiotherapy, and postoperative chemotherapy. The patient eventually refused further treatment for personal reasons and died at home.

LESSONS

Breast cancer metastases to the uterus are very rare and further research is needed for their diagnosis and treatment. During reexamination of breast cancer patients, clinicians must be alert to metastasis to gynecologic organs. This is particularly important in hormone receptor-positive patients with asymptomatic distant metastasis.

[Metastasis of medullary thyroid carcinoma to the endometrium: A case report and review of the literature]

Uterine metastases from extra pelvic tumors are rare; involvement of the uterus is usually by direct neoplastic extension from adjacent organs. We report the case of a 68-year-old woman with a history of total thyroidectomy. She presented with urinary incontinence associated with episodes of metrorrhagia. Ultrasound showed a thickened endometrium. A legrado was performed and the biopsy revealed a proliferation of neoplastic cells with oval nuclei, «salt and pepper» chromatin, evident nucleoli and a moderate amount of eosinophilic cytoplasm. These cells were positive for CKAE1 / AE3, TTF-1, CEA and calcitonin. The histological and immunohistochemical findings corresponded to a metástasis from a medullary thyroid carcinoma. Although metastatic tumors in the uterus are extremely rare, they may give rise to abnormal uterine bleeding and should be considered when the patient's history and the histological findings are not characteristic of a primary lesion.

Metastatic Neoplasms to the Vulva-A Review

INTRODUCTION

Metastatic neoplasms to the vulva are rare and can pose a diagnostic dilemma. As identification of the primary site can influence patient treatment and prognosis, correct diagnosis is important.

METHODS

PubMed was searched for applicable publications using the terms vulva, vulvar neoplasms, metastasis, and vulvar metastasis.

RESULTS

Most neoplasms metastatic to the vulva originate from other genital sources; however, extragenital primary neoplasms can also metastasize to the vulva. Vulvar metastases often occur in the setting of widespread disease.

CONCLUSIONS

It is important to consider biopsy for appropriate histologic and immunohistochemical studies, as well as consider patient history to establish the primary site of metastatic lesions to the vulva, allowing optimal therapy.

Ovarian Carcinoma Presenting With a Large Cervical Mass

Cervical metastasis in ovarian cancer is a rare entity. Therefore, care should be taken in the differential diagnosis of cervical masses as it may mimic a primary tumor. This report aimed to emphasize the importance of a multidisciplinary approach in these tumors. We present a case of a 73-year-old female who presented with post-menopausal vaginal bleeding and cervical mass. The patient was diagnosed with ovarian carcinoma with a multidisciplinary approach. Although cervical metastasis of ovarian cancer is rare, the possibility of secondary cancer should be kept in mind, especially in cervical tumors with atypical clinical course.

Targeted siRNA nanotherapeutics against breast and ovarian metastatic cancer: a comprehensive review of the literature

Metastasis is considered the major cause of unsuccessful cancer therapy. The metastatic development requires tumor cells to leave their initial site, circulate in the blood stream, acclimate to new cellular environments at a remote secondary site and endure there. There are several steps in metastasis, including invasion, intravasation, circulation, extravasation, premetastatic niche formation, micrometastasis and metastatic colonization. siRNA therapeutics are appreciated for their usefulness in treatment of cancer metastasis. However, siRNA therapy as a single therapy may not be a sufficient option for control of metastasis. By combining siRNA with targeting, functional agents or small-molecule drugs have shown potential effects that enhance therapeutic effectiveness. This review addresses multidrug resistance and metastasis in breast and ovarian cancers and highlights drug-delivery strategies using siRNA therapeutics.

Molecular Pathology of Human Papilloma Virus-Negative Cervical Cancers

Cervical cancer is the fourth most common cancer in women worldwide and is predominantly caused by infection with human papillomavirus (HPV). However, a small subset of cervical cancers tests negative for HPV, including true HPV-independent cancers and false-negative cases. True HPV-negative cancers appear to be more prevalent in certain pathological adenocarcinoma subtypes, such as gastric- and clear-cell-type adenocarcinomas. Moreover, HPV-negative cervical cancers have proven to be a biologically distinct tumor subset that follows a different pathogenetic pathway to HPV-associated cervical cancers. HPV-negative cervical cancers are often diagnosed at an advanced stage with a poor prognosis and are expected to persist in the post-HPV vaccination era; therefore, it is important to understand HPV-negative cancers. In this review, we provide a concise overview of the molecular pathology of HPV-negative cervical cancers, with a focus on their definitions, the potential causes of false-negative HPV tests, and the histology, genetic profiles, and pathogenesis of HPV-negative cancers.

An Unusual Occurrence of Uterine Metastases in a Case of Invasive Ductal Breast Carcinoma

Breast cancer is the most frequent cancer in women and has a high proclivity for metastasizing, yet it seldom affects gynaecological organs. We present a case of invasive ductal carcinoma of the breast that metastasized to the uterus following initial curative treatment. Our patient was taking tamoxifen, which can induce endometrial hyperplasia and make diagnosis more complicated.

Uterine metastasis of lobular breast carcinoma under tamoxifen therapy: A case report

Uterine metastases from breast cancer are uncommon and have rarely been reported in the previous literature. The present report describes the case of a 66-year-old female who developed uterine metastasis 23 years following the primary treatment of invasive breast cancer. Specifically, the patient experienced multiple bone metastases 14 years following primary treatment and had previously been treated with aromatase inhibitors followed by tamoxifen citrate. The patient presented with abnormal genital bleeding and was referred to the Gynecology Department of the Osaka City University Hospital (Osaka, Japan) 23 years following the primary treatment. The results of an endometrial biopsy revealed adenocarcinoma. Initially, it was difficult to differentiate between primary endometrial adenocarcinoma and metastatic adenocarcinoma from breast cancer. The results of pelvic magnetic resonance imaging demonstrated uterine myometrium enlargement and no endometrial thickness. Furthermore, an abdominal total hysterectomy, bilateral salpingo-oophorectomy and a biopsy of the peritoneum were performed. The pathological examination of the resected uterus revealed adenocarcinoma, which proliferated diffusively in the cervical stroma, myometrium, cardinal ligament, bilateral adnexa, omentum and peritoneum. Immunohistochemical results revealed the positive staining of gross cystic disease fluid protein-15, as well as negative staining for CD10 and E-cadherin. Thus, the tumor was diagnosed as metastatic adenocarcinoma from the breast lobular carcinoma. The patient has since been treated with fulvestrant, toremifene citrate and tegafur, and the current patient survival duration is 2 years and 8 months. In conclusion, when patients with breast cancer undergoing hormonal therapy, such as tamoxifen, present with abnormal genital bleeding, future diagnoses should consider both endometrial cancer and uterine metastasis from breast cancer.

Ovarian metastases of pancreatic adenocarcinoma: clinical presentation, role of surgery, and potential value of the mutational profile for the differential diagnosis with primary mucinous ovarian carcinoma

Background:

Ovarian metastases (OM) of pancreatic adenocarcinoma (PA) (OM-PA) can mimic primary ovarian mucinous carcinoma (POMC) on imaging and histology. These metastases are often symptomatic and not highly chemosensitive, so that oophorectomy may be considered.

Aims:

The aims of this study were to compare the characteristics of OM-PA and POMC, and discuss the role of surgery.

Patients and Methods:

Clinical, imaging, and histological data of patients with OM-PA and POMC (2000–2017) in three tertiary centers were reviewed. Twenty-six genes were analyzed by next generation sequencing (NGS) on both primary PA and OM-PA.

Results:

Twenty-two women with OM-PA (n = 13, 11 with surgical resection) or POMC (n = 9) were selected. OM-PA were smaller than POMC (p = 0.02); imaging, histological, and immunohistochemistry data did not clearly differentiate OM-PA from POMC in 12 of 22 cases (54%). Seven PA/OM-PA pairs were analyzed, and a concordant KRAS mutation was identified in all cases. In four OM-PA, concordant mutations were also found in TP53 (n = 3), SMAD4 (n = 1), MET (n = 1), and PDGFRA (n = 1) genes. The aim of oophorectomy in 11 OM-PA was for antalgic (n = 6) or curative (n = 5) intent. Pain improved in 4/6 of the former patients, but 2/6 had significant morbidity, and 2/6 died of rapid tumor progression. After oophorectomy, median progression-free and overall survivals were 6 (0–11) and 8 months (1–131), respectively.

Conclusion:

Analysis of mutation profiles in both primary PA and ovarian tumors, especially KRAS, can help to determine the pancreatic origin of OM-PA. Surgical resection of OM-AP in highly selected patients may improve pelvic symptoms but may also cause significant morbidity. The benefit to survival requires further studies.

Uterine cervix metastasis from primary colon adenocarcinoma: a case report and review of the literature

Introduction

Metastases to the female genital tract from extragenital primary tumors are unusual. We report a rare case of uterine cervix metastasis from colon adenocarcinoma and discuss diagnostic and therapeutic issues.

Case report

We report a case of a 38-year-old North African Caucasian woman treated for a non-metastatic colon adenocarcinoma. She had a sigmoidectomy and incomplete adjuvant chemotherapy. Six months later, she consulted with vaginal bleeding caused by a cervical tumor, which was confirmed to be metastatic disease, and the patient underwent decompressive and hemostatic radiotherapy.

Conclusion

Uterine cervix metastasis from primary colon adenocarcinoma is rare. The resection remains the standard protocol for the local treatment of resectable metastatic disease. Otherwise, systemic therapy is the preferable option.

Vaginal oligometastatic disease of colorectal primary: Report of a novel therapeutic approach

Vaginal oligometastatic disease of colorectal primary is a rare malignancy with few reported cases in the literature and no standardized treatment paradigm. We report on the definitive management of an unusual case of an elderly woman with the aforementioned disease. A 78-year-old African-American woman presented with vaginal spotting and was found to have a vaginal lesion. Final pathology was consistent with moderately differentiated adenocarcinoma of colorectal primary. Extensive work up, which included endoscopies, pathologic analyzes, and imaging workup, did not reveal a primary gastrointestinal malignancy. The patient underwent partial vaginectomy and final pathology once again confirmed moderately differentiated adenocarcinoma of colorectal primary (CDX 2 and CEA positive, ER/PR, and CK 7 negative) with negative margins. She went on to receive adjuvant concurrent chemoradiation with 5-FU based chemotherapy. She received 45 Gy in 25 fractions to the whole pelvis followed by an HDR brachytherapy boost to 12 Gy in two fractions. Unfortunately, 10 months after completing radiation, she was found to have adenocarcinoma arising from a hepatic flexure colon polyp on colonoscopy. She required definitive surgical resection and was staged as mpT3N0M1. She received 12 cycles of 5-FU and at 2-year follow-up was found to be disease free with no evidence of locoregional recurrence or distant metastatic disease. Continued long-term follow up is warranted.

Next-generation sequencing assisted diagnosis of cervical metastasis in EGFR-mutated lung adenocarcinoma: A case report

EGFR mutation has been detected in more than half of non-small cell lung cancer (NSCLC) patients in Asia. Lung cancer is the main cause of malignant tumor-related death worldwide. Although distant metastases often occurs in patients with advanced NSCLC, uterine cervical metastasis is rare. Here, we report a case of EGFR-mutated lung adenocarcinoma with cervical metastasis. A 63-year-old female with known lung adenocarcinoma was found to have abnormal vaginal bleeding during osimertinib follow-up visits. Immunohistochemical (IHC) staining and next-generation sequencing (NGS) of the biopsy sample from the uterine cervical tumor confirmed metastatic dissemination from the primary lung malignancy. NGS assisted the diagnosis of uterine cervical metastasis from the primary lung. This is another major clinical application of NGS in addition to medication guidance and identification of drug resistance mechanisms.

Metastatic Breast Lobular Carcinoma to Unusual Sites: A Report of Three Cases and Review of Literature

Invasive lobular carcinoma of the breast is the second most common type of invasive breast carcinoma. Invasive lobular carcinoma has an unusual pattern of metastases, which poses a diagnostic challenge for both clinicians and pathologists. We herein present three cases of breast invasive lobular carcinoma presented with metastasis to unusual sites, namely, uterus, colon and stomach. We recommend a higher index of suspicion in any case with breast cancer developing gastrointestinal tract or genital tract symptoms.

Metastatic gallbladder cancer to the ovary presenting as primary ovarian cancer: a case report

Background

Krukenberg tumors are uncommon and are indicative of an ovarian metastatic carcinoma that originates from another site of primary malignancy. The majority of metastases to ovaries are derived from the stomach and colon. We present a rare case of a metastatic ovarian malignant tumor that originated from gallbladder adenocarcinoma.

Case presentation

A 45-year-old premenopausal Korean woman presented with abdominal distension. Bilateral multiseptated ovarian tumors and a wall-thickened gallbladder were found on abdominal computed tomography. The patient was diagnosed with metastatic ovarian carcinoma arising from gallbladder adenocarcinoma and was treated with adjuvant chemotherapy.

Conclusions

Metastases to the ovaries from other sites, including the gallbladder, are rare and usually resemble primary ovarian tumors. Therefore, potential metastatic ovarian tumors of newly diagnosed pelvic masses should be considered in differential diagnoses.

Different etiologies of an unusual disease: Colouterine fistula - Report of two cases

Colouterine fistula is an extremely rare condition, as the uterus is a thick, muscular organ. Here, we present two different etiologies for this rare condition—diverticulitis and malignancy. A 77-year-old female with colouterine fistula due to diverticulitis presented with complaints of lower abdominal pain localized particularly in the left iliac fossa and fever. Another case was of 73-year-old female with colouterine fistula due to malignancy who presented with abdominal pain, blood in stools, and whitish discharge from vagina. Both cases were evaluated with contrast-enhanced computed tomography (CECT). The presence of air and fluid within the uterus on ultrasound or CT scan, prompts the possibility of colouterine fistula with CECT providing accurate preoperative assessment.

Solitary vulvar metastasis from early-stage endometrial cancer: Case report and literature review

RATIONALE

Endometrial cancer (EC) is the most common gynecological malignancy in developed countries. It is usually diagnosed at early-stage and presents a favorable prognosis. Conversely, advanced or recurrent disease shows poor outcome. Most recurrences occur within 2 years postoperatively, typically in pelvic and para-aortic lymph nodes, vagina, peritoneum, and lungs. Vulvar metastasis (VM) is indeed anecdotal probably because of the different regional lymphatic drainage from corpus uteri.

PATIENT CONCERNS

A 3 cm, reddish, bleeding lesion of the posterior commissura/right labia was found in a 74-year-old woman treated with radical hysterectomy, surgical staging, and adjuvant radiotherapy 1 year before for a grade 2 endometrioid type, International Federation of Gynecology and Obstetrics Stage IB. Vulvar biopsy confirmed the EC recurrence. Pelvic magnetic resonance imaging and positron emission tomography excluded other metastases so VM was radically resected.

DIAGNOSIS

Postoperative histopathology confirmed the diagnosis of grade 2 EC VM.

INTERVENTIONS

A radical excision of VM was performed.

OUTCOMES

Patient died from a severe sepsis 27 months after first surgery.

LESSONS

Vulvar metastases can show different appearance, occurring as single or diffuse lesions on healthy or injured skin. The surgical approach seems not to influence the metastatic risk, but tumor seeding and vaginal injuries should be avoided. Whether isolated or associated with recurrence in other locations, vulvar metastases imply poor prognosis despite radical treatment. Therefore, any suspected vulvar lesion arisen during EC follow-up should be biopsied and monitored closely, despite that the vulva represents an unusual metastatic site.

Lung cancer diagnosed on pap smear: A case report and review of the literature

•Pap smear test can detect metastases of extragenital malignancies.•Metastases of extragenital cancers to the cervix are predominantly adenocarcinomas.•Immunostaining is critical in determining the primary cancer site.

Massive metastasis of breast cancer to female genital organs

OBJECTIVE

Breast cancer metastasis to the female genital tract is rare, and the ovaries are the most frequent site of extragenital cancer metastasis. The uterus and cervix have been rarely reported as the site of metastasis.

CASE REPORT

A 57-year-old woman diagnosed with invasive lobular carcinoma of the left breast 2 years prior was undergoing tamoxifen treatment. She presented with a right breast mass and postmenopausal bleeding. Synchronous right breast invasive lobular carcinoma with endometrium metastasis was diagnosed. The metastasis tumor involved the endometrium, myometrium, cervix, ovaries, and fallopian tubes.

CONCLUSION

We noted the rarity of massive metastasis of the female genital tract from breast cancer. Gynecological surveillance and prompt evaluation of the endometrium led to timely diagnosis and treatment.

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

Background

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

Main body

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

Conclusion

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

Human Papillomavirus-Negative Cervical Cancer: A Comprehensive Review

Human papillomavirus (HPV) has been the leading cause of cervical cancer for over 25 years. Approximately 5.5–11% of all cervical cancers are reported to be HPV-negative, which can be attributed to truly negative and false-negative results. The truly HPV-negative cervical cancers are almost all cervical adenocarcinomas with unclear etiology. False HPV negativity can arise from histological misclassification, latent HPV infection, disruption of the targeting fragment, non-high risk HPV infection, and HPV testing methods. HPV-negative cervical cancers are often diagnosed at an advanced FIGO stage and have a poor prognosis; thus, the management of these cases requires greater attention.

Secondary Involvement of the Uterine Cervix by Nongynecologic Neoplasms: A Detailed Clinicopathologic Analysis

Secondary involvement of the uterine cervix by nongynecologic neoplasms is rare accounting for <2% of metastases to the gynecologic tract. This study aimed to analyze the clinicopathologic features of cervical involvement by nongynecologic malignancies. A total of 47 cases were identified including 39 (83%) carcinomas, 6 lymphomas (12.8%), and 2 (4.2%) cutaneous malignant melanomas. The most common primary site of origin among carcinomas was the gastrointestinal tract (27, 69.2%), followed by breast and urothelium (5 each, 12.8%), gallbladder, and lung (1 each, 2.6%). The gynecologic tract was involved at the presentation in 16 patients (34%), including 5 (10.6%) with the cervix being the first site, 7 (14.9%) with synchronous involvement of the cervix and other gynecologic sites, and 4 (8.5%) with the involvement of other gynecologic sites before the cervical presentation. Patients with lymphoma were younger compared with those with carcinoma (43.7 vs. >50.5) (P=0.01). Mean time to identification of cervical metastases was <1 year for gallbladder carcinoma, melanomas, and gastrointestinal signet ring cell carcinomas (P=0.03). Features that varied with different types of metastatic tumor included lymphovascular space invasion, depth of stromal invasion, growth pattern (glands lacking architectural complexity, cribriforming, solid), presence of goblet cells, and signet ring cells, degree of cytologic atypia, and overall findings mimicking a benign/noninvasive process (P≤0.027). Six tumors (12.8%) were initially misdiagnosed as cervical primary. Metastatic nongynecologic tumors can mimic primary in situ or invasive neoplasms in both ectocervix and endocervix. In patients with a known prior malignancy, the clinical history with ancillary studies and a high level of suspicion are crucial to ensure accurate diagnosis.

Tumor-to-Tumor Metastasis of Colorectal Adenocarcinoma to Ovarian Cystadenofibroma: A Case Report and Review of the Literature

Tumor-to-tumor metastasis is being described in different types of tumors and in increasing amount of cases. Being aware of this phenomenon is important, as it affects disease stage and treatment approach. In this report, we descried an incidental histopathologic finding of metastatic adenocarcinoma to an ovarian cystadenofibroma and review cases published previously in the literature.

Uterine metastasis from invasive ductal breast carcinoma: A case report with literature review

Breast cancer is the leading cause of cancer death in women, and most breast cancer related deaths are due to metastases. Uterine metastases from breast cancer are uncommon and rarely reported in the literature. We described the case of a 50 years-old-woman who developed a uterine metastasis, 6 years after the diagnosis of an invasive ductal breast carcinoma. Indeed, although the patient was asymptomatic, the monitoring imaging examinations, particularly the computed tomography (CT) and the positron emission tomography/computed tomography (PET/CT), showed a myometrial lesion. Non-conservative total hysterectomy was performed. The anatomo-pathological examination revealed a myometrial metastasis from an invasive ductal breast carcinoma. Seventeen months after surgery, the patient had no pelvic recurrence, but lungs and bones metastases progressed despite chemotherapy. In the lack of guidelines of uterine metastases from breast cancer's management, we reviewed the existing literature with the aim to provide a rational framework for clinical presentation, diagnostic approach, histological findings and treatment of this rare and heterogeneous pathology. Uterine metastases of breast cancer are frequently revealed with metrorrhagia. They occur preferentially in tumours with initial lobular carcinoma, initial lymph node involvement and positive hormonal receptors.

Ovarian metastasis from nongynecologic primary sites: a retrospective analysis of 177 cases and 13-year experience

BACKGROUND

Metastasis to the ovary from nongynecologic organs accounts for 9% of all ovarian malignancies. Although the most common nongynecologic primary site of ovarian metastasis is the gastrointestinal tract, metastasis from other sites to the ovary is not uncommon. Differential diagnosis of primary and metastatic ovarian tumors is important; otherwise, appropriate treatment cannot be determined. Furthermore, an optimal treatment strategy for ovarian metastasis from nongynecologic primary sites still needs to be explored.

METHODS

One hundred seventy-seven patients with ovarian metastasis from nongynecologic primary sites admitted to Peking Union Medical College Hospital between May 2005 and May 2018 were retrospectively evaluated.

RESULTS

The mean age was 48 years (range, 18-83). Approximately 60% of patients were premenopausal women. The two most common nongynecologic primary sites of ovarian metastasis were the colorectum (68 cases) and stomach (61 cases). In addition to the most common symptoms of abdominal distension (39.0%), abdominal pain (37.9%), and ascites (27.7%), 18.1% of patients presented with abnormal uterine bleeding. Half of the patients who tested serum CA-125 preoperatively had elevated CA-125 levels within the range of 35 U/ml to 200 U/ml. More than 70% of synchronous ovarian metastases were preoperatively misdiagnosed as primary ovarian cancer. Of all included cases, 56.5% achieved optimal cytoreductive surgery (the diameter of the largest residual lesion < 2 cm). The overall 5-year survival rate and median survival time were 10% and 20 months, respectively. The primary site, optimal cytoreductive surgery, tumor differentiation, and postoperative adjuvant treatment were identified as prognostic indicators.

CONCLUSIONS

The colorectum and stomach are the most common nongynecologic primary sites of ovarian metastasis. Synchronous ovarian metastasis is easily misdiagnosed as primary ovarian cancer. Optimal cytoreductive surgery and postoperative adjuvant treatment can be performed to confer survival benefit in selected patients.

Would extirpative pelvic surgery improve survival in gynecological metastases of lung cancer? Case report and review of the literature

Lung cancer is the 3rd most common cancer in the UK and the numbers of new cases increase every year. In contrast to gastrointestinal tumours and breast cancer, lung cancer, metastases to the female genital tract are incredibly rare with only five cases reported with uterine metastases on review of the published English literature. We report an interesting case of successful ongoing management of metastatic lung cancer to the pelvis along with an extensive literature review. A 47-year-old lady with recurrent respiratory tract symptoms and chest pain was diagnosed with advanced stage non-small-cell lung cancer (Stage T4N2M1A). Five years following diagnosis and several cycles of chemotherapy and radiotherapy, aged 52, she complained of post-menopausal bleeding and pelvic discomfort. An endometrial biopsy confirmed a malignancy morphologically and immunohistochemically similar to her lung adenocarcinoma, in keeping with metastatic disease. She underwent robotic surgery to excise the pelvic organs and successfully gain local disease control. The patient remains clinically stable 3 years following hysterectomy. Although metastases of lung cancer to uterus are very rare, any patient with abnormal uterine bleeding with known cancer should be investigated thoroughly to rule out metastatic disease. Combined multimodal treatment as in this case may increase overall survival.

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.

Ovarian Metastasis as Initial Presentation of Pancreatic Carcinoma on FDG PET/CT

Pancreatic carcinoma metastasizing to the ovary is rare. We report the case of a 69-year-old woman with ovarian metastasis as initial presentation. Ultrasonography revealed a multicystic mass in the right adnexa, which was considered a malignancy. FDG PET/CT performed to detect possible metastasis revealed a right adnexal mass with mild activity and an additional FDG focus in the tail of the pancreas, which later proved to be ovarian metastasis from pancreatic carcinoma.

Endometrium-Limited Metastasis of Extragenital Malignancies: A Challenge in the Diagnosis of Endometrial Curettage Specimens

Malignancies of extragenital origin very rarely metastasize to the uterine body. Endometrium-limited metastases may pose diagnostic challenges in endometrial curettage specimens as they may be misdiagnosed as primary endometrial tumors. We investigated the clinicopathological characteristics of seven cases with endometrial-limited metastases from carcinomas of the nasopharynx (n = 1), breast (n = 2), colon (n = 2), stomach (n = 1), and appendix (n = 1). The patients' ages ranged from 36 to 71 (mean: 55.4) years. None of the patients had a remarkable gynecological history, and the presenting sign in all cases was abnormal uterine bleeding. Although myometrial involvement was absent, multiple metastases were already present in extrauterine locations such as the lung, liver, bone, abdominopelvic peritoneum, and omentum. All patients underwent ultrasonographic examination prior to endometrial curettage. The histologies of the endometrial metastases identified from the curettage specimens were identical to those of the corresponding primary tumors. Ancillary tests including immunostaining and Epstein-Barr virus-encoded RNA in situ hybridization confirmed the extragenital origin. Endometrium-limited metastases from extragenital malignancies are extremely rare. They present with abnormal vaginal bleeding and mimic endometrial carcinomas of endometrioid or poorly differentiated types. Since their clinical presentations and histological features are similar to those of primary endometrial tumors, pathologists should consider the possibility of metastases while evaluating endometrial curettage specimens obtained from patients with a history of extragenital malignancies.

Lobular breast carcinoma metastatic to the endometrium in a patient under tamoxifen therapy: A case report

Metastatic carcinomas to the uterus are rare and usually originate from nearby gynecologic sites, most commonly from the ovaries. Among non-gynecologic origins, breast tumors are the most frequent primaries, predominantly the lobular carcinoma type. A 69-year-old postmenopausal woman diagnosed with lobular breast carcinoma 5 years ago, status post modified radical mastectomy, and currently on tamoxifen therapy presented with post-menopausal bleeding. Subsequent endometrial biopsy confirmed the diagnosis of metastatic lobular breast carcinoma to the endometrium. Breast carcinomas rarely metastasize to the uterus, especially lobular carcinoma type. Abnormal uterine bleeding in a patient with known history of breast carcinoma and under tamoxifen therapy should prompt a complete diagnostic workup to rule out metastatic disease.

Sequential EGFR mutation and ALK rearrangement in adenocarcinoma lung, with rare metastasis to bilateral breast, ovary and endometrium

With the advent of targeted therapies there was a paradigm shift in the treatment of metastatic adenocarcinoma of lung. Immuno-histopathology and molecular subtyping in metastatic adenocarcinoma lung have enabled personalized treatment for each patient. Oncogenic driver mutations in non-small cell lung cancer are commonly EGFR (Epidermal Growth Factor Receptor) gene mutation and ALK (Anaplastic Lymphoma Kinase) gene rearrangement, which are mutually exclusive. Almost 60-64% patients have oncogenic mutation, which are mutually exclusive. Here, we present a case with EGFR mutation and ALK gene rearrangement which was expressed sequentially and with metastasis to rarest sites bilateral breast, ovaries and endometrium. Even though presented with upfront metastatic disease, patient was treated with multiple lines of targeted agents, by which patient survived for 5 years with good quality of life.

ALK rearrangement: a high-frequency alteration in ovarian metastasis from lung adenocarcinoma

Background

Ovarian metastatic tumors from lung adenocarcinoma are rare, and a serial study of these tumors is lacking to date. Additionally, a better understanding of the clinicopathological and molecular characteristics of metastatic tumors is needed.

Methods

Seven cases of ovarian metastasis from lung adenocarcinoma from 2013 to 2017 at our institute were investigated. The results were combined with those found in literature review. A total of 16 cases were analyzed in the present study. We examined clinicopathological and immunohistochemical characteristics, further detected ALK rearrangement by FISH (fluorescence in situ hybridization), and assessed EGFR and KRAS mutations using Sanger sequencing or the amplification refractory mutation system (ARMS).

Results

The mean age of the patients was 44.6 years (range, 33–56 years). Eleven of sixteen patients developed ovarian tumors within a mean time of 18.5 months (range, 5–48 months) from the initial diagnosis of lung adenocarcinoma; 5 patients had lung tumors and ovarian masses simultaneously. Five tumors (5/16, 31%) occurred in the bilateral ovaries, and the others were unilateral ovarian tumors (11/16, 69%). All seven cases from our institute were positive for TTF-1 and Napsin A but negative for PAX8. In four cases, ALK (D5F3) was diffusely and strongly expressed, with ALK rearrangements (4/7, 57%). Overall, ALK rearrangement was found by FISH or immunohistochemistry in 11/16 (69%) cases. In two cases, EGFR mutations in exons 19 and 21, respectively, were found. One patient did not detected EGFR or ALK mutation in the metastatic tumor, but the primary lung adenocarcinoma did harbor an EGFR mutation. Two cases had no alterations in three genes above. Although the mean survival time of the patients with ALK rearrangement was longer than those without (mean survival time 25 m vs. 20 m), no statistical significance of the difference was found.

Conclusions

As the largest case series of ovarian metastasis from lung adenocarcinoma, our findings indicate that ALK rearrangement is the most common molecular alteration. Although patients with ALK rearrangement appear to have a better prognosis than do those without ALK rearrangement, more cases with longer follow-up and multivariant analysis are needed to clarify this point.

Tumor-to-tumor metastasis from appendiceal adenocarcinoma to an ovarian mature teratoma, mimicking malignant transformation of a teratoma: a case report

Background

Tumor-to-tumor metastasis (TTM) is a rare but well-documented phenomenon that is defined as metastasis in a histologically distinct tumor. Ovarian mature teratomas (OMTs) can coexist with various cancers by malignant transformation, which may make it difficult to distinguish these from TTM. Herein, we report a case of TTM from appendiceal adenocarcinoma to the OMT, mimicking the malignant transformation of OMT.

Case presentation

A 67-year-old Japanese woman underwent abdominal total hysterectomy and bilateral salpingo-oophorectomy for an ovarian tumor in another hospital. She was initially diagnosed with mucinous carcinoma/carcinoid arising in the OMT. One year after surgery, she was referred to our hospital after the presentation of increased appendiceal mass. Cecal biopsy targeting an appendiceal tumor revealed scattered mucinous cells with signet ring features, which were morphologically similar to the malignant components in the previously diagnosed right OMT. Both the appendiceal adenocarcinoma and malignant components of the OMT stained positive for CK7, CK20, CDX-2, and SATB2 but negative for estrogen receptor, progesterone receptor, and pax-8. Finally, we confirmed the diagnosis of appendiceal goblet cell carcinoid metastasizing to the right OMT. The patient had tumor-bearing survival due to systemic chemotherapy administered for 35 months after the initial surgery.

Conclusions

Awareness of the TTM phenomenon is important to avoid an incorrect diagnosis and to select the appropriate therapy when unusual malignancy is encountered in the OMTs.

Metastatic Gallbladder Adenocarcinoma to the Endometrium: A Case Report and Review of Literature

Gallbladder carcinoma (GBC) metastasis to the uterine cervix is very rare, accounting for less than 10 reported cases. GBC is an uncommon neoplasm with a poor prognosis. Many patients remain asymptomatic until it reaches an advanced stage or discovered incidentally. Most metastatic diseases occur in the lung, liver, and bones. We report a case of a patient treated for GBC with a good clinical response, who presented with metastasis in the uterine cervix. Uterine cervix metastasis from any extragenital primary is rare and poses a radiologic, pathologic, and clinical diagnostic challenge. Here, we review and discuss the published literature on uterine cervix metastasis from extragenital sources. Gynecologic clinicians should be wary of these rare presentations of metastatic disease, as the diagnosis can alter the management.

Isolated metastatic pancreatic adenocarcinoma to the uterine cervix: A case report

The uterine cervix is an uncommon site of metastatic cancer. Specifically, pancreatic adenocarcinoma metastatic to the cervix is an exceptionally rarely reported phenomenon. We encountered a case of recurrent pancreatic adenocarcinoma presenting as a solitary metastasis to the cervix. To our knowledge, this is the only report describing an isolated recurrence of pancreatic adenocarcinoma to the cervix. When diagnosing metastatic disease to the cervix, it is also imperative for the clinician and pathologist to consider histologic mimics, such as the newly described gastric-type mucinous endocervical adenocarcinoma. Metastatic disease to the cervix may benefit from surgical resection.

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Pancreatic adenocarcinoma may recur as a solitary metastasis to the cervix.

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Metastatic adenocarcinoma to the cervix may be amenable to surgical resection.

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Gastric-type mucinous endocervical adenocarcinoma is a notable histologic mimic.

Isolated Vaginal Recurrence of Early-Stage Rectal Cancer Detected by 18F-FDG PET/CT

The relapses of rectal cancer are most frequently localized in the pelvis, liver, and pelvic and para-aortic lymph nodes and lungs, whereas the vagina is an unusual site. We present here a 60-year-old woman presenting with lower abdominal discomfort 23 months after radical resection of rectal adenocarcinoma. An isolated, solitary, hypermetabolic mass in the right part of the vagina was detected by F-FDG PET/CT. Ultimately, the vaginal neoplasm was proved to be adenocarcinoma of rectal origin based on its shared histologic features and compatible immunostaining profile.

Analysis of Metastatic Ovarian Tumors from Extragenital Primary Sites

Aims and background

The aim of this study was to evaluate patients with metastatic ovarian tumors from extragenital primary sites.

Methods

The medical records of 75 patients were reviewed retrospectively for age at diagnosis, presenting symptoms, preoperative tumor marker levels, preoperative diagnostic workup, operative technique, intraoperative evaluation, frozen-section and pathology results, laterality of metastasis, and primary tumor site. The specific impact of metastasis from colorectal and gastric primary sites on laterality, gross features and dimensions of ovarian mass, volume of ascites and tumor marker levels was investigated.

Results

Primary sites were stomach (37.3%), colorectal region (28%), lymphoma (12%), breast (6.7%), biliary system (2.7%), appendix (1.3%) and small intestine (1.3%). It was not possible to identify the primary tumor site in 8 (10.7%) patients. Bilateral metastasis was found in 86.4% patients; 42.7% of the metastatic ovarian tumors were Krukenberg tumors; 50.7% of the ovarian masses were solid. Frozen section was confirmed by postoperative pathological results in 98% of the patients. The mean preoperative serum levels of tumor markers were 298.7 U/mL, 178 U/mL and 113.3 U/mL for CA 125, CA 19-9 and CA 15-3, respectively. CA 125 levels were above 35 U/mL in 81.3% of the patients. The presence of ascites was more frequent in ovarian tumors originating from colorectal and gastric primaries.

Conclusions

Surgery is essential for the diagnosis of the primary tumor and necessary for relief of symptoms. The identification of the primary site is required to plan adequate treatment.