Survival benefit of metastasectomy for Krukenberg tumors from gastric cancer

Clinical Outcomes in Patients With Krukenberg Tumors From Colorectal Cancer

INTRODUCTION

Ovarian metastases from gastrointestinal cancers such as colorectal cancer, also known as Krukenberg tumors (KTs), present unique challenges in management due to diagnostic uncertainty, decreased responsiveness to systemic therapies compared to other sites of metastasis, and associated debilitating symptomatology. Thus, we sought to characterize our institutional outcomes in metastatic colorectal cancer (mCRC) patients with KTs.

METHODS

A retrospective single-institution study was performed identifying adult, female patients from 2012 to 2021 with a diagnosis of mCRC. Patient demographics and clinicopathologic characteristics were collected and analyzed. Descriptive statistics, univariate and multivariable analyses, and Kaplan-Meier survival analyses were performed.

RESULTS

Of 235 mCRC patients, 45 (19.1%) had KTs, 41 (91.1%) of whom had KTs in conjunction with other metastatic sites. Other initial sites of metastasis included the liver (n = 93, 39.6%), lung (n = 28, 11.9%), and peritoneum (n = 18, 7.7%). In the KT cohort, the median age was 48 y, 53.3% were non-Hispanic White, 100% had microsatellite stable tumors, 33.3% had Kristen Rat Sarcoma Virus (KRAS) mutations, and 6.7% had V-raf Murine Sarcoma Viral Oncogene Homolog B (BRAF) mutations. Fifty five point six percent of KT patients underwent cytoreductive surgery (CRS), 24.4% underwent palliative debulking, and 20% underwent no surgical intervention. Reasons for not undergoing CRS were disease-related (n = 14, 70%), due to poor performance status (n = 1, 5%), or both (n = 5, 25%). Five-year overall survival was 48.2% in KT patients who underwent CRS. Poor tumor grade was an independent predictor of mortality (hazard ratio 10.69, 95% confidence interval 1.20-95.47, P = 0.03).

CONCLUSIONS

Almost 90% of our patient cohort with KTs from mCRC experience additional sites of metastasis. Around half of KT patients who underwent CRS were alive at 5 y.

[68Ga]Ga-FAPI-04 PET/MR imaging strategy in management of Krukenberg tumors (KTs) from gastric signet-ring-cell carcinoma: to overcome limitation of [68Ga]Ga-FAPI-04 PET imaging in KTs

PURPOSE

To compare performance of whole-body [68Ga]Ga-FAPI-04 and [18F]FDG PET imaging in the detection of Krukenberg tumors (KTs), primary site and extra-ovarian metastases of gastric signet-ring-cell carcinoma (GSRCC), and evaluate the value of [68Ga]Ga-FAPI-04 PET/MR imaging strategy and its potential impact on the management of KTs from GSRCC.

METHODS

Twelve patients with twenty-three KTs from GSRCC, who underwent both [68Ga]Ga-FAPI-04 pelvic PET/MR and whole-body [68Ga]Ga-FAPI-04 and [18F]FDG PET imaging were retrospectively analyzed. [68Ga]Ga-FAPI-04 and [18F]FDG uptakes were compared by using Wilcoxon signed-rank test or paired t test. McNemar's test was used to compare lesion detectability between two modalities. Two-tailed P<0.05 was considered statistically significant. Immunohistochemistry staining was utilized to analyze the fibroblast activation protein (FAP) expression in KTs.

RESULTS

A total of 12 patients with 23 KTs from GSRCC (8 synchronous and 4 metachronous) were evaluated. [68Ga]Ga-FAPI-04 was superior to [18F]FDG PET in detecting primary sites of GSRCC (100% [11/11] vs. 18.2% [2/11], p = 0.002), involved lymph nodes (90.9% [10/11] vs. 54.5% [6/11], p = 0.046) and peritoneal metastases (100% [12/12] vs. 41.7% [5/12], p = 0.008), with higher SUVmax and TBR (all p < 0.005). Both tracers had limited value in identifying KTs, with 100% false negative rate on [68Ga]Ga-FAPI-04 PET and a low detection rate of 8.7% on [18F]FDG PET. Fap immunohistochemistry showed negative or slight FAP expression in neoplastic signet ring cells and ovarian stroma. [68Ga]Ga-FAPI-04 PET/MR imaging strategy greatly improved the detection rate of Krukenberg tumors (87%, 20/23). After adding diffusion-weighted imaging (DWI), the detection rate was further improved (87.5% vs. 100%, p = 0.083). [68Ga]Ga-FAPI-04 PET/MR imaging strategy either upgraded TNM staging or changed treatment management in twelve patients.

CONCLUSIONS

[68Ga]Ga-FAPI-04 PET outperformed [18F]FDG PET in detecting primary site and most extra-ovarian metastases of GSRCC, but both tracers had limited value in identifying Krukenberg tumors. Pelvis MRI should be applied to compensate the limitation of [68Ga]Ga-FAPI-04 PET imaging to identify Krukenberg tumours. The [68Ga]Ga-FAPI-04 PET/MR imaging strategy has the potential to impact treatment decisions for GSRCC patients with KTs.

R0 resection of linitis plastica of the stomach with synchronous bilateral Krukenberg tumours in a young woman

We report a case of linitis plastica (LP) with synchronous bilateral Krukenberg Tumours in a young woman, which could be resected fully. Such a case is rarely reported because of rarity (LP), dismal prognosis (LP and Krukenberg Tumours), nonresectability due to peritoneal spread at presentation, and lack of clear treatment protocols (LP and Krukenberg Tumours). This case report suggests that LP, with Krukenberg Tumours, can achieve complete resection in a select subset of cases; this may improve survival.

Efficacy of chemotherapy combined with surgical resection for gastric cancer with synchronous ovarian metastasis: A propensity score matching analysis

BACKGROUND

Ovarian metastasis from gastric cancer (GC) is characterized by aggressive biological behavior and poor outcome. Currently, there is no standard treatment mode for such patients. Thus, we evaluated the efficacy of conversion therapy in patients with synchronous ovarian metastasis from GC in this study.

METHODS

About 219 GC patients with ovarian metastasis in 2011-2020 were enrolled. Two groups were established based on the different treatment: the conversion therapy group (chemotherapy combined with surgical resection, CS group) and the non-conversion therapy group (NCS group). Propensity score matching (PSM) was used to analyze the efficacy of different treatment modes on the prognosis of these patients.

RESULTS

Ninety-two patients were included according to PSM results, with 46 patients each in CS and NCS groups. The median overall survival (OS) in the CS group was notably better than that in the NCS group (p < 0.001). Twenty-six patients (56.52%) in the CS group achieved R0 resection, and they had a better prognosis (p = 0.003). Compared with patients who underwent simultaneous gastrectomy and ovarian metastasectomy (CSb group), those who underwent ovarian metastasectomy before systemic chemotherapy (CSa group) had a higher R0 resection rate (p = 0.016) and longer survival time (p = 0.002). A total of 38 patients (41.30%) across both groups received hyperthermic intraperitoneal chemotherapy (HIPEC), and these patients had a better survival (p = 0.043).

CONCLUSION

The conversion therapy is safe and effective for patients with synchronous ovarian metastasis from GC and can improve their prognosis. However, our results need to be confirmed by more randomized controlled clinical studies.

Apatinib combined with SOX regimen for conversion therapy in advanced gastric cancer patients: a retrospective cohort study

BACKGROUND

Recently, many studies have shown that the progress of conversion therapy can provide surgical opportunities for patients with advanced gastric cancer (GC) and bring survival benefits. However, the results of the current study show that the regimen used in conversion therapy is still controversial. Apatinib, as the standard third-line treatment for GC, has an inconclusive status in conversion therapy.

METHODS

This study retrospectively analyzed GC patients admitted to Zhejiang Provincial People's Hospital from June 2016 to November 2019. All patients were pathologically diagnosed, had unresectable factors, and received SOX regimen with or without apatinib as conversion therapy.

RESULTS

A total of 50 patients were enrolled in the study. Altogether 33 patients (66%) received conversion surgery and 17 patients (34%) received conversion therapy without surgery. The median progression-free survival (PFS) between surgery group and non-surgery group were 21.0 versus 4.0 months (p < 0.0001), and the median overall survival (OS) were 29.0 versus 14.0 months (p < 0.0001). In conversion surgery group, 16 patients (16/33) were treated with SOX plus apatinib, and the R0 resection rate was 81.3%; 17 patients (17/33) were treated with SOX regimen along, and the R0 resection rate was 41.2% (p = 0.032). The PFS in the SOX combined with apatinib group was significantly longer than that of SOX group (25.5 versus 16 months, p = 0.045), and the median OS were 34.0 versus 23.0 months (p = 0.048). The addition of apatinib did not increase the incidence of serious adverse reactions throughout the preoperative therapy period.

CONCLUSIONS

Patients with advanced inoperable gastric cancer could benefit probably from conversion chemotherapy and subsequence conversion surgery. Apatinib-targeted therapy combined with SOX chemotherapy may be a safe and feasible option for conversion therapy.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

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.

Metastasectomy Improves the Survival of Gastric Cancer Patients with Krukenberg Tumors: A Retrospective Analysis of 182 patients

Purpose

There is no consensus regarding whether metastasectomy in gastric cancer patients with Krukenberg tumors (KTs) is associated with survival benefits. The aim of this study was to evaluate the treatment of KTs of gastric origin in a large series of patients and to identify prognostic factors affecting survival.

Patients and Methods

All patients who were diagnosed with gastric cancer and ovarian metastases in a single medical center between January 2006 and December 2016 were identified and included. The patients were divided into two groups according to treatment modality: a metastasectomy group and a nonmetastasectomy group. Clinicopathological features and overall survival (OS) were compared between the groups.

Results

In total, 182 patients were identified; 94 patients presented with synchronous KTs, and 88 developed metachronous KTs during follow-up. OS was significantly longer in the metastasectomy group than in the nonmetastasectomy group among those with synchronous (14.0 months vs 8.0 months; p = 0.001) and metachronous (14 months vs 8 months; p = 0.018) KTs. Multivariate analysis indicated that metastasectomy (hazard ratio [HR] 0.537; 95% confidence interval [CI] 0.344-0.839; p = 0.006), ascites (HR 1.523; 95% CI 1.058-2.193; p = 0.024), linitis plastica (HR 1.995; 95% CI 1.115-3.571; p = 0.020), and systemic chemotherapy (HR 0.456; 95% CI 0.280-0.742; p = 0.002) were independent predictors of OS.

Conclusion

Metastasectomy combined with systemic chemotherapy should be performed in gastric cancer patients with synchronous or metachronous KTs. Metastasectomy, systemic therapy, linitis plastica, and ascites are prognostic factors for OS. Further prospective randomized studies are needed.

Effects of metastasectomy and other factors on survival of patients with ovarian metastases from gastric cancer: a systematic review and meta-analysis

Ovarian metastasis from gastric cancer (Krukenberg tumor [KT]) has no consensus treatment and the role of surgical treatment is still controversial. Identifying prognostic factors for KT could help guide the management of this tumor. We used a meta-analysis to evaluate the prognostic value of metastasectomy and other factors in patients with KT to develop a treatment plan. We searched literature in PubMed, Cochrane library and EMBASE. We analyzed hazard ratios (HR) and 95% confidence intervals (CI) with respect to overall survival (OS). The meta-analysis included 12 cohort studies with 1,031 patients associated with longer OS following metastasectomy (HR = 0.41; 95% CI = 0.32-0.53; P < 0.001), R0 resection (HR = 0.37; 95% CI = 0.26-0.53; P < 0.001), metachronous ovarian metastasis (HR = 0.74; 95% CI = 0.58-0.93; P = 0.012), size of KT (<5 cm) (HR = 0.74; 95% CI = 0.58-0.95; P = 0.019), ECOG PS (Eastern Cooperative Oncology Group performance status) 0 to 1 (HR = 0.48; 95% CI = 0.29-0.80; P  = 0.004), tumor confined to ovary (HR = 0.40; 95% CI = 0.16-0.99; P  = 0.047), and tumor confined to pelvic cavity (HR = 0.36; 95% CI = 0.14-0.92; P  = 0.033). Shorter OS was associated with peritoneal carcinomatosis (HR = 2.00; 95% CI = 1.25-3.21; P  = 0.004), ascites (HR = 1.66; 95% CI = 1.19-2.31; P  = 0.003) and positive CEA (HR = 1.41; 95% CI = 1.10-1.82; P  = 0.007). Gastrectomy led to a slight improvement in OS, but without statistical significance (HR = 0.69; 95% CI = 0.47-1.02; P  = 0.061). No significant difference in OS was observed in patients with signet-ring cells (HR = 1.17; 95% CI = 0.91-1.51; P  = 0.226), bilateral ovarian metastasis (HR = 0.87; 95% CI = 0.70-1.08; P  = 0.212), age ≥ 50 years (HR = 0.93; 95% CI = 0.71-1.22; P  = 0.619), positive CA19-9 (HR = 1.01; 95% CI = 0.75-1.35; P  = 0.960), and positive CA-125 (HR = 0.98; 95% CI = 0.73-1.33; P  = 0.915). Various factors affect OS in patients with KT.

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.

Is a Surgical Approach Justified in Metachronous Krukenberg Tumor from Gastric Cancer? A Systematic Review

BACKGROUND

The treatment of metachronous Krukenberg tumor (mKT) from gastric cancer remains unexplored. We performed a literature review to evaluate whether or not surgical treatment improves survival.

METHODS

A systematic review according to PRISMA guidelines was performed. Studies reporting on patients who underwent surgical treatment for mKT from gastric cancer were selected. Metachronous disease was divided as follows: confined to the ovaries, confined to the pelvis, or beyond the pelvis. Outcomes evaluated included overall survival (OS), progression-free survival (PFS), resection rate (R0), and factors predicting survival.

RESULTS

13 retrospective reports fulfilled the selection criteria (512 patients). Most of the patients presented at a premenopausal age. The median presentation interval from gastrectomy ranged from 16 to 21.4 months. Median OS ranged between 9 and 36 months. 1-year OS ranged between 52.5 and 59%, and 3-years OS between 9.8 and 36.5%. Resection margin, peritoneal seeding, and chemotherapy regimen and cycles influenced survival.

CONCLUSION

Surgical treatment and adjuvant chemotherapy in patients with mKT from gastric cancer seems to be associated with improved survival and is justified especially in young patients. Disease location and R0 resection should be considered when selecting patients.

PD-L1 Expression Predicts a Distinct Prognosis in Krukenberg Tumor with Corresponding Origins

Krukenberg tumor (KT) is an uncommon ovarian metastatic signet-ring cell adenocarcinoma that mostly metastasizes from gastrointestinal carcinoma. Optimal treatment options for KTs are limited. Programmed death-1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors have shown remarkable activity in clinical trials for metastatic tumors. Here, we evaluated PD-L1 expression and T cell infiltration in KTs and their corresponding primary tumors. Positive tumor PD-L1 expression was detected in 9 (25.7%) KTs from gastric carcinomas (GCs) and in 20 (66.7%) KTs from colorectal carcinomas (CRCs). Patient survival was assessed according to the PD-L1 status and CD8⁺ T cell density. Positive tumor PD-L1 expression in KTs from GCs was associated with poor prognosis. In contrast, positive tumor PD-L1 expression in KTs from CRCs was associated with an improved prognosis. We analyzed copy number variations of the PD-L1 gene in KTs. PD-L1 expression was higher in cases with copy number gains. The T cell densities within KTs and their corresponding primary tumors were compared. The densities of CD8⁺ T cells correlated significantly between the primary tumors and KTs from the same case. Taken together, the research further highlighted targets for immune-based therapy in KTs from GCs and CRCs.

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.

Addition of peritonectomy to gastrectomy can predict good prognosis of gastric adenocarcinoma patients with intraoperatively proven single P1/P2 carcinomatosis

This study was to evaluate the prognosis of peritonectomy following gastrectomy for gastric adenocarcinoma patients with intraoperatively proven single P1/P2 carcinomatosis and to define the best therapeutic strategy of the patient cohort. The patients with intraoperatively proven single P1/P2 carcinomatosis from a prospectively maintained database were divided into resection group and non-resection group based on complete gross resection of peritoneal carcinomatosis. From 2005 to 2012, there were 103 patients in the resection group and 122 patients in the non-resection group. There was no difference in morbidity and mortality between groups. The patients did not have improved median survival in P1 carcinomatosis compared to P2 carcinomatosis (15.53 vs 14.80 months, p = 0.450). The median survival was significantly improved in the resection group compared to the patients in the non-resection group (21.07 vs 13.37 months, p < 0.001). The patients undergoing complete gross peritonectomy plus postoperative chemotherapy had a significantly longer median survival than patients who had complete gross peritonectomy alone, patients receiving postoperative chemotherapy alone, and patients receiving neither peritonectomy nor postoperative chemotherapy (27.33 vs 12.00 vs 16.00 vs 10.33 months, p < 0.001). In the multivariate analysis, poor performance status ( p = 0.036), absence of complete gross peritonectomy ( p < 0.001), and lack of postoperative chemotherapy ( p < 0.001) were identified as independently associated with poor survival. The data indicate complete gross peritonectomy following gastrectomy confers a survival benefit to gastric cancer patients with intraoperatively proven single P1/P2 carcinomatosis. In addition, postoperative chemotherapy improves survival regardless of resection of peritoneal carcinomatosis and should be recommended.

Current practice for gastric cancer treatment in Ukraine

Ukraine registers more than 8,000 new cases of gastric cancer (GC) annually. The disease is usually diagnosed at stage III-IV (65% of cases) and 62.2% of patients die within 1 year. About 70% of patients with GC need chemotherapy, and for most of them, this is the only way to increase their life expectancy. An unsolved problem of nationwide importance is achieving the early diagnosis of GC, which predetermines the treatment outcome. The 5-year survival rate for GC patients in Ukraine is only 13%, while early diagnosed GC is almost totally curable using surgery. Another important task is the development of national diagnosis and treatment standards, which will be based on national breakthroughs and will meet modern international requirements.

Stereotactic ablative body radiotherapy (SAbR) for oligometastatic cancer

The metastatic state of most solid cancers traditionally has been regarded as an incurable dissemination of disease, with treatment focused on delaying progression rather than eliminating all tumour burden. In this setting, local therapies including surgery and radiotherapy are directed at quality of life end points and not at improvement in survival. However, improvements in imaging and systemic therapy have highlighted populations of patients with lower burden of metastatic disease, termed "oligometastatic," who may present an exception. This condition is hypothesized to bridge the gap between incurable metastatic disease and locoregional disease, where miliary spread either has not occurred or remains eradicable. Consequently, elimination of such low-burden residual disease may "cure" some patients or delay further progression. Accordingly, use of local therapies with the intent of improving survival in oligometastatic disease has increased. Technological advances in radiation delivery with stereotactic ablative body radiotherapy (SAbR) in particular have provided a non-invasive and low-morbidity option. While observational studies have provided interesting preliminary data, significant work remains necessary to prove the merits of this treatment paradigm. This review discusses the data for the oligometastatic state and its treatment with SAbR, as well as challenges to its investigation.

Krukenberg Tumors of Gastric Origin: The Rationale of Surgical Resection and Perioperative Treatments in a Multicenter Western Experience

BACKGROUND

In case of Krukenberg tumor (KT) of gastric origin it is controversial and debated whether radical surgery in case of synchronous KT or metastasectomy in case of metachronous ones is associated with additional benefits. Role of perioperative treatments is unclear.

METHODS

Among 2515 female patients who were diagnosed with gastric cancer between January 1990 and December 2012 from 9 Italian centers, 63 presented simultaneously or developed KT as recurrence.

RESULTS

Thirty patients presented with synchronous KT, while 33 developed metachronous ovarian metastases during follow-up. The differences between the two groups were analyzed and compared. The median age of 63 patients was 48.0 years (range 31-71). Resection was possible in 53 patients (20 synchronous and 33 metachronous). Twelve patients in the synchronous group and 15 patients of the metachronous group underwent hyperthermic intraperitoneal chemotherapy after resection of KT. All of them underwent adjuvant chemotherapy after KT resection. The median survival for all population was 23 months (95 % confidence interval, 7-39 months). The median survival time in the metachronous group was 36 months, which was significantly longer than that in the synchronous group, 17 months, p < 0.0001.

CONCLUSIONS

KT remains a clinical challenge for gastric cancer therapy. The extent of disease and feasibility of removal of the metastatic lesion must be carefully evaluated prior to surgery to define the patients group who could benefit most from a resection associated with perioperative treatments.

Efficacy of modern chemotherapy and prognostic factors in patients with ovarian metastases from gastric cancer: A retrospective AGEO multicentre study

BACKGROUND

Ovarian metastases from gastrointestinal tumours frequently lead to locoregional complications and undermine quality of life. The chemosensitivity of ovarian metastases from gastric cancer is unknown.

AIM

To evaluate the efficacy of modern chemotherapy regimens in first-line treatment for patients with ovarian metastases from gastric cancer.

METHODS

All consecutive patients with ovarian metastases from gastric cancer who received at least one cycle of chemotherapy were included in this retrospective study.

RESULTS

Thirty-five patients were included (median age, 50.5 years; synchronous ovarian metastases, 60%). Seventeen patients (48.6%) underwent oophorectomy. Patients were treated with first-line chemotherapy based on platinum (n=14), irinotecan (n=8), taxane plus platinum (n=4) or epirubicin plus platinum (n=9). The median PFS and OS were 6.8 and 18.8 months, respectively. The objective response rate (ORR) for extra-ovarian (13.6%) and ovarian (20.9%) metastatic sites was not significantly different (p=0.55). There was no significant difference in terms of ORR on ovarian metastatic site according to the first-line chemotherapy (p=0.21). In multivariate analysis, oophorectomy was an independent prognostic factor for OS (p<0.01).

CONCLUSIONS

This study suggests that ovarian metastases from gastric cancer are not more resistant than extra-ovarian metastases, and that oophorectomy is an independent prognostic factor significantly linked to OS. Prospective studies are needed to confirm these results.

Comparison of Surgery Plus Chemotherapy and Palliative Chemotherapy Alone for Advanced Gastric Cancer with Krukenberg Tumor

PURPOSE

This study was conducted to validate the survival benefit of metastasectomy plus chemotherapy over chemotherapy alone for treatment of Krukenberg tumors from gastric cancer and to identify prognostic factors for survival.

MATERIALS AND METHODS

Clinical data from 216 patients with Krukenberg tumors from gastric cancer were collected. Patients were divided into two arms according to treatment modality: arm A, metastasectomy plus chemotherapy and arm B, chemotherapy alone.

RESULTS

Overall survival (OS) was significantly increased in arm A relative to arm B for patients initially diagnosed with stage IV gastric cancer (18.0 months vs. 8.0 months; p < 0.001) and those with recurrent Krukenberg tumors (19.0 months vs. 9.0 months; p=0.002), respectively. Metastasectomy (hazard ratio [HR], 0.458; 95% confidence interval [CI], 0.287 to 0.732; p=0.001), signet-ring cell pathology (HR, 1.583; 95% CI, 1.057 to 2.371; p=0.026), and peritoneal carcinomatosis (HR, 3.081; 95% CI, 1.610 to 5.895; p=0.001) were significant prognostic factors for survival.

CONCLUSION

Metastasectomy plus chemotherapy offers superior OS when compared to palliative chemotherapy alone in gastric cancer with Krukenberg tumor. Prolonged survival applies to all patients, regardless of gastric cancer stage. Metastasectomy, signet-ring cell pathology, and peritoneal carcinomatosis were prognostic factors for survival. Future prospective randomized trials are needed to confirm the optimal treatment strategy for Krukenberg tumors from gastric cancer.

Clinical characteristics and prognostic analysis of Krukenberg tumor

Krukenberg tumor is a rare metastastic tumor of the ovary, characterized by poor prognosis. In order to analyze the clinical characteristics and prognostic factors, we retrospectively investigated 128 patients who were diagnosed with Krukenberg tumor between January, 1990 and December, 2010. The median patient age was 48 years. The median overall survival (OS) of Krukenberg tumor for all patients was 16 months (95% CI: 15-19 months). The median OS among patients with Krukenberg tumors of gastric, colorectal, breast and other origins (including appendix, gallbladder, small intestine and unknown primary) was 11, 21.5, 31 and 19.5 months, respectively (P<0.0001). In the univariate analysis, synchronous metastasis, no chemotherapy, ovarian metastasis beyond the pelvis, ascites and no metastasectomy were identified as significant poor prognostic factors. The multivariate analysis suggested that synchronous metastasis (P=0.0080), pelvic invasion (P=0.0138), ascites (P<0.0001) and no metastasectomy (P=0.0060) were independent factors for predicting unfavorable OS. It was suggested that the prognosis of Krukenberg tumor is dismal and ovarian metastasectomy may prove beneficial. Adequate treatment planning is required for this group of patients.

SABR for aggressive local therapy of metastatic cancer: A new paradigm for metastatic non-small cell lung cancer

Metastectomy has been performed for many years in situations where the functional consequences allow it, for example in the liver, lung, adrenal glands, and ovaries. This history suggests that selected patients may benefit from aggressive treatment of metastases. Technological developments now allow for ablative treatment of other tumor sites and perhaps for larger volume and/or increasing multiplicity of disease using Stereotactic Ablative Radiation Therapy (SABR) with relatively lower risk of morbidity to patients. Here we further explore the concept of aggressive local treatment of metastatic disease in adult patients and review the rationale for use of SABR to treat metastases and highlight new data supporting this approach in metastatic Non-Small Cell Lung Cancer.

A 26-year-old female with metastatic primary gastrointestinal malignancy presenting as menorrhagia

Krukenberg tumor is a metastatic malignant tumor of the ovary arising from a wide variety of primary sources, with the stomach being the most common. The presenting symptoms are non-specific and the primary source is often un-identified. Here, we describe a case of a 26-year-old Hispanic gravida 4, para 3 female who presented to our hospital with dysuria, pelvic pain and irregular, heavy menstrual cycles for three months duration. An endometrial biopsy was suggestive of carcinosarcoma. The patient underwent debulking surgery with partial cystectomy and bladder repair. A week later, she presented with hematemesis and an endoscopic biopsy revealed a diagnosis of poorly differentiated gastric adenocarcinoma. The tissue specimen obtained during the initial surgery was identified as Krukenberg tumor. The patient underwent adjuvant chemotherapy with FOLFOX along with gastrectomy with intraperitoneal chemotherapy.

Krukenberg tumors of gastric origin versus colorectal origin

OBJECTIVE

The aim of this study is to compare the each clinical manifestation related with its mean survival time of Krukenberg tumors (KTs) of gastric origin versus with that of colorectal origin.

METHODS

A total of 156 consecutive patients diagnosed with KTs of the ovary who underwent surgical treatment at a single institution between 2001 and 2010 were retrospectively evaluated. Each clinical manifestation related with its mean survival time compared two different groups. Survival analyses and comparisons were performed using the Kaplan-Meier method.

RESULTS

Among the 156 patients with KT, 111 patients with KTs of gastric origin and 45 patients with KTs of colorectal origin were identified. For all patients with KTs, median survival time was 22.7 months. Each mean survival time among all patients with KTs of gastric origin and colorectal origin was 19.2 months and 27.3 months. The results showed that mean survival time of postmenopausal patients was 19.0 months compared with 32.5 months for premenopausal patients (P=0.015). Among all patients, mean survival time of those with metachronous cancer was longer than those with synchronous cancer (P=0.001). In all cases, especially when only one ovary was invaded, the mean survival time was relatively higher (P=0.001).

CONCLUSION

Patients with KTs of colorectal origin had a better prognosis than those of gastric origin. In all cases of KT, the mean survival time was significantly longer in postmenoposal patients, metachronous disease and unilateral ovarian involvement. Notably, synchronous, ascites positive, and ovary only metastasis showed more longer mean survival time in the KTs of colorectal origin than KTs of gastric origin.

Pseudo-Meigs' syndrome caused by a Krukenberg tumour of gastric cancer

A 50-year-old woman who presented with a one-month history of abdominal fullness and dyspnoea was admitted to our hospital. Esophagogastroduodenoscopy showed the scirrhous-type gastric cancer on the greater curvature of the gastric body. Computed tomography revealed bilateral large ovarian tumours with massive right pleural effusion and ascites. A repeated cytological examination of pleural effusion and ascites revealed no malignant cells. The definitive diagnosis of pseudo-Meigs' syndrome was made by confirming the fact that pleural effusion and ascites disappeared after bilateral oophorectomy. Resection of ovarian tumours may also lead to long-term survival, even in the patients with pseudo-Meigs' syndrome caused by gastric cancer.

A Krukenberg Tumor from an Occult Intramucosal Gastric Carcinoma Identified during an Autopsy

A healthy 45-year-old Japanese female developed right pleural effusion, ascites, and a pelvic mass. Bilateral salpingo-oophorectomy resolved the pleural effusion and ascites. Histopathological examination of the ovaries showed bilateral Krukenberg tumors with signet-ring cell carcinoma (SRCC). Extensive testing including upper and lower gastrointestinal endoscopy and whole-body imaging did not detect the primary lesion. Six months after bilateral salpingo-oophorectomy, the patient developed multiple osteoblastic bone lesions in the spine, pelvis, and femurs. A biopsy of the bone marrow showed SRCC. We administered four cycles of S-1 and cisplatin, resulting in the shrinkage of osteoblastic lesions; she remained stable for a year. Then, she developed disseminated intravascular coagulation with disease progression in the bones. Although she was treated with paclitaxel, the disseminated intravascular coagulation progressed, and she died in a month. During the autopsy, microscopic examination revealed four foci of intramucosal gastric SRCC and healthy macroscopic gastric mucosa.

[Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]

Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.

Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach

Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.

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.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy improves the survival of gastric cancer patients with ovarian metastasis and peritoneal dissemination

The prognosis for ovarian metastasis of gastric cancer is poor. There is no currently available treatment for this disease. The purpose of this study was to evaluate the efficacy and safety of hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery (CRS) in female gastric cancer patients with metachronous ovarian metastasis. From January 2000 to December 2010, 62 patients developed ovarian metastasis after undergoing gastrectomy with D2 lymphadenectomy. Thirty-two patients underwent CRS plus HIPEC, and 30 patients underwent CRS alone. The median age of all 62 patients was 44 years (range 19-71 years). Metastatic carcinoma involving bilateral ovaries was observed in 50 patients (80.6 %). The median survival time in the CRS + HIPEC group was 15.5 months (95 % confidence interval [CI] 12.1-18.9 months) but was only 10.4 months (95 % CI 8.5-12.2 months) in the CRS group (P = 0.018). Among the 32 patients with pelvic peritoneal metastasis, a stratified analysis revealed that the median survival period for the 15 patients treated with CRS + HIPEC was significantly higher than that for the patients treated with CRS alone (P = 0.046). Among the 30 patients who suffered from ovarian metastasis alone, the median survival times were similar in both groups (P = 0.141). A multivariate analysis revealed that CRS + HIPEC and a low Peritoneal Cancer Index (PCI) were independent predictors for improved survival. In conclusion, our study indicates that employing the HIPEC procedure after CRS could improve the survival time of patients with ovarian metastasis with few complications; however, we do not recommend HIPEC treatment for ovarian metastasis alone.

Ovarian metastases resection from extragenital primary sites: outcome and prognostic factor analysis of 147 patients

BACKGROUND

To explore the outcomes and prognostic factors of ovarian metastasectomy intervention on overall survival from extragenital primary cancer.

METHODS

Patients with ovarian metastases from extragenital primary cancer confirmed by laparotomy surgery and ovarian metastases resection were retrospectively collected in a single institution during an 8-year period. A total of 147 cases were identified and primary tumor sites were colorectal region (49.0%), gastric (40.8%), breast (8.2%), biliary duct (1.4%) and liver (0.7%). The pathological and clinical features were evaluated. Patients' outcome with different primary tumor sites and predictive factors for overall survival were also investigated by univariate and multivariate analysis.

RESULTS

Metachronous ovarian metastasis occurred in 92 (62.6%) and synchronous in 55 (37.4%) patients. Combined metastases occurred in 40 (27.2%). Bilateral metastasis was found in 97 (66%) patients. The median ovarian metastasis tumor size was 9 cm. There were 39 (26.5%) patients with massive ascites ≥ 1000 mL on intraoperative evaluation. With a median follow-up of 48 months, the median OS after ovarian metastasectomy for all patients was 8.2 months (95% CI 7.2-9.3 months). In univariate analyses, there is significant (8.0 months vs. 41.0 months, P = 0.000) difference in OS between patients with gastrointestinal cancer origin from breast origin, and between patients with gastric origin from colorectal origin (7.4 months vs. 8.8 months, P = 0.036). In univariate analyses, synchronous metastases, locally invasion, massive intraoperative ascites (≥ 1000 mL), and combined metastasis, were identified as significant poor prognostic factors. In multivariate analyses combined metastasis (RR, 1.72; 95% CI, 1.09-2.69, P = 0.018), locally invasion (RR, 1.62; 95% CI, 1.03-2.54, P = 0.038) and massive intraoperative ascites (RR, 1.58; 95% CI, 1.02-2.49, P = 0.04) were independent factors for predicting unfavorable overall survival.

CONCLUSION

Ovarian metastases are more commonly originated from primary gastrointestinal tract. The prognosis of ovarian metastasis is dismal and the benefit of ovarian metastatectomy is limited. Combined metastasis outside ovaries, locally invasion and massive intraoperative ascites were independent factors for predicting unfavorable overall survival. The identification of the primary tumor is required to plan for adequate treatment for this group of patients.

Left-sided renal colic as a symptom of advanced stomach cancer - a case report

The typical symptoms of advanced cancer of the stomach are well known in clinical practice. The presented case concerns a patient with symptoms of left-sided renal colic, caused by a malignant tumour involving the ureter, which was diagnosed with a CT scan. The multifocal process, involving the stomach, two parts of the colon, the left ovary and the side of the pelvis, was confirmed only during surgery.

The resection or partial resection of the above-mentioned organs involved by the malignant process and reconstruction of the alimentary tract as well as the ureter were performed at time of this operation. The patient's recovery was without any complications. The histopathological findings support the diagnosis of this malignant process as disseminated stomach cancer.

In the available literature only two cases of stomach cancer metastasis to the ureter have been described. In both cited examples resection of the ureter with nephrectomy was performed. The review of the literature supports the value of stomach palliative resection in prolonging life and improving quality of life.

Pathways of metastases from primary organs to the ovaries

To investigate the metastatic pathways from the primary organs to the ovaries, we examined the microscopic findings from 18 original and 18 metastatic ovarian tumors carefully. In addition, we examined the immunohistochemical findings (Victoria blue stain for vascular invasion and D2-40 expression for lymphangio invasion) of metastatic ovarian tumors carefully. There were 4 (57%) ovarian lymphangio invasion cases in the 7 gastric cancers, but there were no cases in the 6 colorectal cancers (P < 0.05). There were 4 (67%) ovarian vascular invasion cases and one (17%) liver metastasis case in the 6 colorectal cancers, while there were no ovarian vascular invasions (P < 0.05) or no liver metastases in the 7 gastric cancers. The patients with metastatic ovarian tumors originating from distant organs who were treated at the same time as the original cancers had a significantly poorer prognosis than the patients with ovarian tumors treated later (P < 0.05). The rate of lymphatic metastasis from the stomach to the ovary was significantly higher than from the colon to the ovary. In addition we hypothesized that the rate of intravascular metastasis from the colorectum to the ovary was relatively higher than from the stomach to the ovary.

Survival benefit of gastrectomy ± metastasectomy in patients with metastatic gastric cancer receiving chemotherapy

BACKGROUND

This study was performed to investigate the role of surgery in patients with gastric cancer and distant metastases who had received systemic chemotherapy.

METHODS

Patients with newly diagnosed gastric cancer and synchronous distant metastases who had received chemotherapy (n = 274) were categorized into 3 groups according to the surgical treatment rendered: complete gross resection of both primary and metastatic sites (group A; n = 42); debulking gastrectomy (group B; n = 47); and chemotherapy without debulking (group C; n = 185).

RESULTS

The median overall survival of all patients was 11.8 months. The median overall survival and 3-year survival rates were 28.0, 15.5, and 9.0 months and 42.8, 8.1, and 3.5% in groups A, B, and C, respectively. In group A, patients with peritoneal seeding, intra-abdominal distant lymph nodes, or ovarian or hepatic metastases underwent complete gross resection, and 12 (29%) were disease-free at the time of the last analysis (median follow-up duration, 29.1 months). On multivariate analysis, the adjusted hazard ratios for death were 0.27 (P < 0.001) and 0.64 (P = 0.024) for groups A and B, respectively, as compared to group C.

CONCLUSIONS

Our study suggests survival benefits of debulking gastrectomy or gastrectomy plus metastasectomy in gastric cancer patients with distant metastases receiving systemic chemotherapy. Prolonged disease-free survival was observed after complete resection (gastrectomy plus metastasectomy) that may lead to cure in some patients. Well-designed prospective trials of the role of multidisciplinary approaches combining chemotherapy and surgery are needed to confirm the observations of our study.

Metachronous ovarian metastases following resection of the primary gastric cancer

PURPOSE

We performed this study to evaluate the clinical presentation as well as the proper surgical intervention for ovarian metastasis from gastric cancers and these tumors were identified during postoperative follow-up. This will help establish the optimal strategy for improving the survival of patients with this entity.

MATERIALS AND METHODS

22 patients (3.2%) with ovarian metastasis were noted when performing a retrospective chart review of (693) females patients who had undergone a resection for gastric cancer between 1981 and 2008. The covariates used for the survival analysis were the patient age at the time of ovarian relapse, the size of the tumor, the initial TNM stage of the gastric cancer, the interval to metastasis and the presence of gross residual disease after treatment for Krukenberg tumor. The cumulative survival curves for the patient groups were calculated with the Kaplan-Meier method and they were compared by means of the Log-Rank test.

RESULTS

The average age of the patients was 48.6 years (range: 24 to 78 years) and the average survival time of the 22 patients was 18.8 months (the estimated 3-year survival rate was 15.8%) with a range of 2 to 59 months after the diagnosis of Krukenberg tumor. The survival rate for patients without gross residual disease was longer than that of the patients with gross residual disease (P=0.0003). In contrast, patient age, the size of ovarian tumor, the initial stage of gastric adenocarcinoma, the interval to metastasis and adjuvant chemotherapy were not prognostic indicators for survival after the development of ovarian metastasis.

CONCLUSIONS

Early diagnosis and complete resection are the only possible hope to improve survival. As the 3-year survival rate after resection of Krukenberg tumor is 15.8%, it seems worthwhile to consider performing tumorectomy as the second cytoreduction.

Breast metastatic localization of signet-ring cell gastric carcinoma

Metastatic tumors in the breast are quite rare and constitute 0,5 to 6% of all breast malignancies. They often occur in a polymetastatic context. Gastrointestinal lesions rarely metastasize to the breast. The first case of a metastasis deposit to the breast and ovary from gastric signet-ring cell carcinoma was reported in the literature in 1999. Since this report, only 5 cases have been reported. We present a case report of a 37-year-old woman who complained of a lump in the left breast. Two months earlier, the woman underwent a subtotal gastrectomy and a total hysterectomy with double anexectomy, which histologically was diagnosed of gastric signet-ring carcinoma, disseminated with Krukenberg's tumor. In those days, the patient was following a chemotherapy treatment. A core needle biopsy of the lesion in left breast revealed cells with signet-ring features, with probably gastric origin.

Clinical characteristics of metastatic tumors to the ovaries

Approximately 5-30% of the ovarian cancers are metastatic malignancies. The prevalence of metastatic ovarian tumors varies with the incidence rates and spread patterns of primary malignancies. We evaluated the prevalence, pre- and postoperative characteristics of metastatic ovarian cancer in Korean women. We reviewed the records for 821 ovarian malignancies with pathological consultation from 1996-2006 and recorded patient demographical, radiological, histopathological, and survival data. The study included 112 cases of histologically confirmed metastatic ovarian cancer. Metastatic ovarian cancer accounted for 13.6% of all ovarian malignancy, primarily arising from the gastrointestinal tract. The preoperative detection rate with imaging was 75%, and none of the radiological or serological features were useful for differential diagnosis. In multivariate analysis for prognostic variables, the only significant factor was the primary tumor site (p=0.004). Furthermore, extensive resection increased survival for some patients. The differential diagnosis of metastatic ovarian cancer can be problematic, so multiple diagnostic approaches are necessary. The extent of cytoreductive surgery for this type of tumor must be decided on a case-by-case basis.

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.

Prognostic factors for ovarian metastases from primary gastric cancer

The purpose of this study was to analyze prognostic factors for ovarian metastases from primary gastric cancer, helping establish optimal strategy in ameliorating survival for this entity. Clinical data of 68 consecutive patients histologically diagnosed with ovarian metastases from primary gastric cancer were accrued from 1096 cases with female gastric cancer. Metachronous surgery was performed on 36 patients and 32 received synchronous surgery. There were 14 patients treated with surgery alone and 54 with combined modality therapy. After the median follow-up time of 9.1 months, the median survival time (MST) of 12.4 months was observed for all patients. Patients treated with synchronous surgery tended to have an inferior survival compared with those treated with metachronous surgery (MST: 10.9 vs 14.3 months; P = 0.100). Combined modality showed a significantly better MST compared with surgery alone (13.6 vs 7.9 months; P = 0.004). Chemotherapy cycles (more than four or less than or equal to four) were found to have an impact on survival (MST: 14.3 vs 9.4 months; P = 0.031). Peritoneal metastases, lymphovascular involvement, and unilateral ovarian metastasectomy were independent unfavorable prognostic factors. Combined modality therapy as primary therapy resulted in good outcome, and more aggressive chemotherapy (more than four cycles) was accompanied by an improvement in survival. Innovative systemic treatments need to be explored in treatment of peritoneal metastases and lymphovascular involvement. Bilateral oophorectomy was considered when ovarian metastases were histologically diagnosed.

Surgical treatment of recurrent gastric cancer

BACKGROUND

The value of programs to detect recurrence of a previously operated gastric cancer is a controversial subject. D2 lymphadenectomy achieves better local control and a lower local recurrence rate than D1 lymphadenectomy.

METHODS

The results achieved with surgical treatment of recurrent gastric cancer in a series of 126 consecutive patients who had been treated with gastrectomy with D2 lymphadenectomy are reported. In-hospital mortality was 1.6%.

RESULTS

Follow-up of the remaining 124 patients for a median period of 73.6 months detected recurrence in 46 patients (37%). There were 14 local, 12 peritoneal, and 15 distant recurrences. Recurrent gastric cancer was detected within 2 years in 76% of the patients. Of the 46 patients with recurrence, 5 patients (11%) were selected for surgery (4 local and 1 peritoneal recurrence). The median disease-free time after surgery for recurrence was 26 months (range, 14-58 months). There was no in-hospital mortality. The median survival time after surgery for recurrence was 26 months (range, 9-87 months). One patient died during follow-up, while none of the other patients have any evidence of new recurrence.

CONCLUSION

Surgery for recurrent gastric cancer is a valid alternative in selected patients, provided it is performed by specialized work teams.

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