Intestinal metastasis and operation in ovarian cancer: a report on 62 cases

Unusual Synchronous Colonic Metastasis of Ovarian Cancer

Colorectal metastasis is rare and can be confused with primary colorectal cancer. We report the case of a 63-year-old patient who presented with synchronous metastasis of the rectosigmoid junction and ovarian cancer. Initially thought to be a Krukenberg tumor, the diagnosis of metastasis from ovarian origin was confirmed through an immunohistochemical study of the colonic biopsy.

Colorectal Metastasis from Ovarian Neoplasm Mimicking Primary Colon Cancer

Metastasis to the colon from another primary internal malignancy is an untypical and a seldom reported entity. Direct visualization during colonoscopy is considered the gold standard of diagnosis. Pathologic diagnosis with immunohistochemical staining is essential to differentiate primary colorectal malignancy from secondary metastasis to the colon. We, hereby, present a case of a 53-year-old female status-post resection of left-sided papillary serous ovarian neoplasm who presented 2 years later with a single rectosigmoid intraluminal ulcerative mass imitating a primary colon cancer. Biopsies of the mass were consistent with metastasis from her primary ovarian carcinoma. We believe this case is unique because of the rarity of ovarian cancer metastasizing to the colon intraluminally rather than through direct locoregional invasion. Furthermore, it highlights the importance of considering secondary metastasis in patients with previous history of another primary internal malignancy.

Metachronous Synchronous Sternal and Colonic Metastasis with Asymptomatic Colo-colic Fistula from Carcinoma Ovary Rare Presentation of Ovarian Cancer

Ovarian cancer is one of the most common gynecological cancers worldwide. It is the third leading cause of cancer among women in India. Metastatic disease to the visceral organs from ovarian cancer occurs as a terminal event in the natural history of the disease. In particular, spread to the bone and large bowel is infrequently described. The risk of distant metastasis increases in a recurrent setting. We describe a case of a 77-year-old lady, who was diagnosed for ovarian carcinoma in 2007 and underwent primary cytoreductive surgery, stage IIIc. She presented to us with asymptomatic rising cancer antigen (CA) 125 levels during follow-up. On evaluation she was found to have sternal and colonic deposits. She underwent left hemicolectomy and biopsy of sternal deposit. Histopathology revealed metastasis from the carcinoma ovary to the colon and sternum. This case report highlights the rare synchronous metastatic disease in a metachronous setting from ovarian carcinoma.

Can we identify the patients who are likely to undergo bowel resectionat the time of surgery for ovarian cancer?

Surgery for ovarian cancer carries a risk of bowel resection to either achieve optimal debulking or relieve obstruction. This prospective study assessed the likelihood of bowel resection in 842 women undergoing surgery for ovarian cancer and identified factors associated with increased risk. Bowel resection was performed in 8.6% of women. The likelihood of bowel resection increased significantly (p < 0.0001, chi2 test) with: Secondary surgery (22% vs 5.8% at primary surgery). Symptoms of bowel disturbance (21.9% vs 6.3% if no symptoms). FIGO stage III/IV disease (12.8% vs 2% in stage I/II). CA125 levels >or=2500 (12.9% vs 4.8% if CA125<2500). These women should be selectively offered pre-operative computerised tomography, stoma marking and counselling by stoma nurses. The 5-year survival was 14% in patients following bowel resection compared with 44% in patients not having bowel resection. Bowel resection should be performed only if it will result in optimal debulking or it relieves imminent bowel obstruction.

Can bowel endoscopy predict colorectal surgery in patients with an adnexal mass?

The objective of this retrospective study was to identify the ability of preoperative endoscopy of the lower gastrointestinal tract and other tests to predict large bowel resection in patients with an adnexal mass. We reviewed 573 patients with a suspected adnexal mass admitted for surgery between 1987 and 1997. Two hundred fifty four patients (44%) had preoperative sigmoidoscopy (n = 97) or colonoscopy (n = 157). We identified patients who underwent a colorectal operation as part of their surgery and correlated surgical findings with the results of preoperative endoscopy, preexisting clinical symptoms, preoperative pelvic exam and ultrasonography, and the CA125 level. The sensitivity and positive predictive value of bowel endoscopy for predicting large bowel surgery were 18% and 59%, respectively. Multivariate analysis showed preexisting bowel-related symptoms, a pelvic exam suggestive of malignancy, a CA125 value >1000 U/ml, and infiltration of the colorectal wall at bowel endoscopy to be independently associated with subsequent colorectal surgery. We conclude that preoperative bowel endoscopy cannot accurately predict colon resection in patients with a suspected adnexal mass. Preexisting bowel-related symptoms, a pelvic exam suggestive of malignancy and a CA125 value >1000 U/ml are associated with subsequent colorectal surgery.

The place of bowel resection in initial debulking surgery for advanced ovarian cancer

OBJECTIVE

To evaluate the efficacy and morbidity associated with bowel resection at the initial debulking procedure for patients with advanced ovarian cancer.

DESIGN

Retrospective medical record and computerised database review.

SETTING

John Hunter Hospital, Newcastle, New South Wales.

SAMPLE

All women with FIGO stage III or IV epithelial ovarian cancer and with adequate case note documentation who underwent bowel resection as part of their primary debulking surgery at the John Hunter Hospital from 1991 to July 2000.

MAIN OUTCOME MEASURES

Cumulative overall and disease free survival, optimal (residual disease < 1 cm) versus suboptimal cytoreduction and short (< 6 weeks) and long-term postoperative morbidity.

RESULTS

For the optimally debulked patients the two and five-year overall and disease free survival rates were 49%, 30%, 19% and 8.9% respectively. The two-year overall survival rate for the suboptimally debulked patients was 20%. The major short-term morbidity rate was 17.6%. Long-term morbidity occurred in 10 of 51 patients; however, not all morbidity was surgery related.

CONCLUSIONS

Cytoreductive surgery, including bowel resection, appears indicated in the treatment of patients with advanced ovarian cancer. The surgical morbidity rate from these procedures appears acceptable.

Cytoreductive surgery for advanced stages of ovarian cancer

During the past two decades, maximum cytoreductive surgery (also called debulking surgery) has been the recommended surgical approach for advanced stages of ovarian carcinoma. The residual tumor volume after surgery is one of the strongest prognostic factors, and only patients who undergo complete or optimal surgery are likely to be long-term survivors (i.e., 50% after five years). A well-trained surgeon in the field of gynecologic oncology can achieve an optimal tumor reduction in up to 75% of patients with advanced stage ovarian cancer. During the procedure, bowel resection, especially rectosigmoid, must be undertaken in 30% to 40% of cases, and para-aortic and pelvic lymphadenectomy should be performed after adequate tumor reduction in the abdominal cavity. The experienced surgeon can perform these surgeries with an acceptable morbidity, allowing chemotherapy to be undertaken within the month following surgery. However, very advanced cancer with massive peritoneal carcinomatosis and/or Stage IV disease requires a very aggressive surgical procedure but yields a poor prognosis and a higher risk of unacceptable complications. For these worst cases, the concept of cytoreductive surgery is moving toward the alternative strategy of chemosurgical cytoreduction, in which interval cytoreductive surgery is undertaken after three cycles of front-line chemotherapy. The goal of this experimental strategy is to achieve a complete tumor response after front-line chemosurgical therapy, and a better quality of life.

Significance of cytoreductive surgery including bowel resection for patients with advanced ovarian cancer

The aim of this study was to determine the significance of bowel resection in advanced ovarian cancer. A total of 64 women with stage IIIc or IV epithelial ovarian cancer, who consecutively received primary treatment between 1991 and 1995, were entered in this prospective study. The outcome of the patients undergoing bowel resection was evaluated. Thirty-nine patients underwent cytoreductive surgery at initial surgery. Of them, 16 patients could undergo optimal operation without bowel resection. Twenty-three patients received bowel resection at initial surgery. Of these 23 patients, 16 underwent optimal operation and 7 did not. Among 25 patients judged as inoperable cases at initial surgery, 21 responded to chemotherapy and underwent second surgery. Of 21 patients receiving second surgery, 15 underwent optimal operation (7 without bowel resection and 8 with bowel resection). The 3-year survival rate for 24 patients undergoing optimal operation with bowel resection (46.8%) was not significantly different from that for 23 patients without bowel resection (59.1%). Postoperative complications were seen in 8 patients (21.6%) of the patients receiving bowel resection and 3 (13.0%) of those without bowel resection. Cytoreductive surgery including bowel resection is effective for an improvement of the survival in patients with advanced ovarian cancer, if an optimal operation can be performed.

Assessment of metastases to aortic and pelvic lymph nodes in epithelial ovarian carcinoma. A proposal for essential sites for lymph node biopsy

BACKGROUND

In staging epithelial ovarian carcinoma, it is necessary to assess the presence of lymph node metastases. However, the essential sites of selective lymph node biopsy have yet to be determined.

METHODS

The distribution of metastatic aortic and pelvic lymph nodes was studied in 48 patients with positive lymph nodes of 110 patients with ovarian carcinoma who underwent systematic lymphadenectomy of the aortic and pelvic regions extending to the level of the renal vessels. For purpose of analysis, the lymph nodes were classified into five subgroups: the aortic lymph nodes above the inferior mesenteric artery (A1), the aortic lymph nodes below the inferior mesenteric artery (A2), the common iliac and sacral lymph nodes (P1), the internal and external iliac and obturator lymph nodes (P2), and the suprainguinal (the lowest external iliac) lymph nodes (P3).

RESULTS

The incidence of metastases to A1, A2, P1, P2, and P3 was 79%, 71%, 46%, 77%, and 40%, respectively. Provided that 2 of the 5 lymph node subgroups were selected for biopsy, the combination of A1 and P2 gave the best results in sensitivity (94% [45 of 48 patients]) and negative (95% [62 of 65 patients]) predictive value for detection of lymph node metastases.

CONCLUSIONS

These data indicate that aortic lymph nodes above the inferior mesenteric artery and the internal and external iliac and obturator lymph nodes are essential sites for selective lymph node biopsy in staging epithelial ovarian carcinoma.