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DeRidder AM, Check CM, Kunk PR, Martin C. Early Detection of Krukenberg Tumors Utilizing ctDNA Testing and CEA Monitoring. Case Rep Oncol Med 2025; 2025:5335858. [PMID: 40026534 PMCID: PMC11870764 DOI: 10.1155/crom/5335858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2024] [Accepted: 02/01/2025] [Indexed: 03/05/2025] Open
Abstract
Krukenberg tumors are rare cancers involving metastatic disease in the ovaries but classically originate from gastrointestinal malignancies, and often present diagnostic challenges due to their nonspecific symptoms and advanced stage at detection. Traditional imaging techniques like ultrasound, CT, and MRI are common methods of cancer monitoring but are limited in detecting micrometastatic disease and early-stage metastases. Circulating tumor DNA (ctDNA) testing, a noninvasive liquid biopsy method, offers a promising alternative to traditional screening methods, enabling earlier detection and precise molecular profiling of metastatic tumors. We present a case study involving a female patient who initially presented with stage IV colon cancer with oligometastatic disease to a single mesenteric lymph node. Despite neoadjuvant chemotherapy and resection of known disease, postresection ctDNA returned positive. Imaging after metastectomy failed to reveal any sites of ongoing disease, although did show a small, 2.4-cm hypodensity in the right ovary interpreted by radiology as likely an ovarian follicle. Given her ctDNA positivity, she was started on capecitabine. ctDNA levels improved, but her serum carcinoembryonic antigen (CEA) tumor marker continued to rise, and imaging subsequently revealed increased bilateral ovarian masses. She underwent bilateral salpingo-oophorectomy and total abdominal hysterectomy, with pathology confirming metastatic colon adenocarcinoma, and subsequent normalization of her CEA and ctDNA levels. Our findings underscore ctDNA's potential to complement imaging, particularly for high-risk patients, for disease monitoring and to refine therapeutic management when treating Krukenberg tumors.
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Affiliation(s)
- Angela M. DeRidder
- Department of Hematology and Oncology, Riverside Health System, Williamsburg, Virginia, USA
| | - Corrine M. Check
- Department of Hematology and Oncology, Riverside Health System, Williamsburg, Virginia, USA
| | - Paul R. Kunk
- Department of Hematology and Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Christina Martin
- Department of Hematology and Oncology, Riverside Health System, Williamsburg, Virginia, USA
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Miyagawa Y, Kitazawa M, Tokumaru S, Nakamura S, Koyama M, Yamamoto Y, Miyazaki S, Hondo N, Soejima Y. Impact of Oophorectomy on Survival and Improving Nutritional Status in Ovarian Metastasis from Colorectal Adenocarcinoma. Oncology 2023; 102:114-121. [PMID: 37699374 DOI: 10.1159/000533599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Ovarian metastasis of colorectal cancer is known to have a poor prognosis. This study aimed to elucidate the characteristics of patients who underwent oophorectomy for ovarian metastasis from colorectal cancer. METHODS This retrospective study included 16 patients who underwent oophorectomy for colorectal cancer metastasis to the ovary from January 2004 to December 2017. Improvement in patient's symptoms and pre- and postoperative changes in various nutritional and inflammatory indicators were assessed. Survival analysis and identification of prognostic factors were conducted with a median follow-up of 40.7 (5-109) months. RESULTS Of 16 patients, 12 had (75%) synchronous and 4 (25%) had metachronous metastasis. Fourteen patients were symptomatic but symptoms resolved postoperatively. Thirteen patients (81.3%) had ascites and 5 (31.3%) had pleural effusion on preoperative computed tomography that disappeared after surgery in all cases. The median value of prognostic nutritional factor was significantly increased postoperatively (36.0 [preoperatively] vs. 47.5, p < 0.0001). The median (interquartile range) values for lymphocyte-C-reactive protein ratio were 715.2 (110-2,607) preoperatively and 6,095.2 (1,612.3-14,431.8) postoperatively (p = 0.0214). The median survival of the entire cohort was 60.4 months. The 3-year survival rates for R0 + R1 and R2 cases were 83% and 24% (p = 0.018), respectively. Univariate analysis showed that R2 resection and low postoperative lymphocyte-C-reactive protein ratio were associated with poor prognosis. CONCLUSIONS Oophorectomy for ovarian metastasis from colorectal cancers was safely performed. It improved the patients' symptoms and nutritional status and may result in improved prognosis.
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Affiliation(s)
- Yusuke Miyagawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masato Kitazawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shigeo Tokumaru
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoshi Nakamura
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Makoto Koyama
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuta Yamamoto
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Miyazaki
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nao Hondo
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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Nomura M, Tei M, Nishida K, Mori S, Yasuyama A, Yoshikawa Y, Tamai K, Hamakawa T, Takiuchi D, Tsujie M, Akamaru Y. Aggressive surgical intervention may improve prognosis in patients with ovarian metastasis from colorectal cancer. Langenbecks Arch Surg 2023; 408:313. [PMID: 37582897 DOI: 10.1007/s00423-023-03060-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/09/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE The current study aimed to investigate the prognostic clinicopathological factors of synchronous and metachronous ovarian metastasis (OM) from colorectal cancer (CRC) in patients with and without oophorectomy. METHODS Female patients with OM from CRC who underwent primary tumor resection at our institution from January 2013 to December 2020 were evaluated. RESULTS Of 661 female patients, 22 (3.3%) were diagnosed with OM. Among 22 patients with OM, 12 underwent OM resection. Twenty (91%) patients had extra OM upon diagnosis. Thirteen (59%) patients in the non-surgery group had peritoneal dissemination at surgery or on computed tomography scan or positron emission tomography-computed tomography. Two patients in the OM surgery group had emergency surgery because of abdominal pain. Four patients had postoperative complications, and the median duration of hospital admission was 16.5 days. The median survival time from OM diagnosis to mortality was 20.9 months. Then, the association between the clinicopathological factors and overall survival (OS) was investigated. Tumor location and surgery were found to be related to OS (p = 0.03, 0.006, respectively) in the univariate analysis. However, only surgery was associated with OS (p = 0.02) in the multivariate analysis. CONCLUSION Surgery is an important prognostic clinicopathological factor of OM from CRC. OM tumors should be resected because OM surgery is less likely to cause complications and symptoms.
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Affiliation(s)
- Masatoshi Nomura
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan.
| | - Mitsuyoshi Tei
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Kentaro Nishida
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Soichiro Mori
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Akinobu Yasuyama
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Yukihiro Yoshikawa
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Koki Tamai
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Takuya Hamakawa
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Daisuke Takiuchi
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Masanori Tsujie
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
| | - Yusuke Akamaru
- Department of Gastroenterological Surgery, Osaka Rosai Hospital, Nagasone 1179-3, Kita Ward, Sakai, Osaka, 591-8025, Japan
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Van der Meer R, de Hingh IHJT, Bloemen JG, Janssen L, Roumen RMH. Role Of Ovarian Metastases In Colorectal Cancer (ROMIC): a Dutch study protocol to evaluate the effect of prophylactic salpingo-oophorectomy in postmenopausal women. BMC Womens Health 2022; 22:441. [PMID: 36369055 PMCID: PMC9652988 DOI: 10.1186/s12905-022-02040-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 10/28/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The mean incidence of ovarian metastases (OM) in patients with colorectal cancer (CRC) is 3.4%. The 5-year survival of these patients, even when operated with curative intent, is remarkably low. The lifetime risk of ovarian cancer is approximately 1.3%. Prophylactic salpingo-oophorectomy (PSO, or surgical removal of the ovaries and fallopian tubes) could reduce the number of CRC patients that develop OM after removal of the primary tumor, as well as preventing the occurrence of primary ovarian cancer. Recently, the care pathway for CRC has been changed in several hospitals in line with the updated Dutch guideline. The possibility of PSO is now discussed with postmenopausal CRC patients in these hospitals. The aims of the current study are firstly to estimate the incidence of OM and primary ovarian cancer in postmenopausal patients with CRC, and secondly to evaluate the effect of PSO in these patients. METHODS An information bulletin and decision guide on this topic was implemented in several Dutch hospitals in 2020. Post-decision outcomes will be collected prospectively. The study population consists of postmenopausal (≥ 60 years of age) patients that are operated with curative intent for CRC. Based on their own preference, patients will be divided into two groups: those who choose to undergo PSO and those who do not. The main study parameters are the reduction in incidence of ovarian malignancies (metastatic or primary) following PSO, and the number needed to treat (NNT) by PSO to prevent one case of ovarian malignancy. DISCUSSION This will be the first study to evaluate the effect of PSO in postmenopausal CRC patients that is facilitated by an altered CRC care pathway. The results of this study are expected to provide relevant information on whether PSO adds significant value to postmenopausal patients with CRC. TRIAL REGISTRATION International Clinical Trials Registry Platform, NL7870. Registered on 2019 July 12. URL of trial registry record: https://trialsearch.who.int/Trial2.aspx?TrialID=NL7870 . PROTOCOL VERSION 1.0, date 2021 June 8.
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Affiliation(s)
- R. Van der Meer
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands
| | - I. H. J. T. de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
- GROW - School for Oncology and Development Biology, Maastricht University, Maastricht, The Netherlands
| | - J. G. Bloemen
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - L. Janssen
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands
| | - R. M. H. Roumen
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, 5500 MB Veldhoven, The Netherlands
- GROW - School for Oncology and Development Biology, Maastricht University, Maastricht, The Netherlands
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Ovarian metastases in young women with colorectal cancer: a retrospective multicenter cohort study. Int J Colorectal Dis 2022; 37:1865-1873. [PMID: 35857105 DOI: 10.1007/s00384-022-04217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE Previous studies indicated that approximately 3.4% of female colorectal cancer (CRC) patients are at increased risk of developing ovarian metastases (OM). It has been suggested that young women more frequently develop this form of metastatic disease. METHODS This study evaluated, in 6 Dutch hospitals, the proportion of young women with CRC who developed OM. RESULTS In a cohort of 200 young (age ≤ 55) women with CRC, the proportion of patients diagnosed with synchronous or metachronous OM was calculated. This study revealed that 5% (n = 10) of young female CRC patients developed ovarian metastases resulting in a 5-year overall survival rate of approximately 40%. Furthermore, six patients had concurrent peritoneal metastases, five patients had bilateral ovarian metastases, and five patients had synchronous metastases, while the median time of the occurrence of metachronous metastases (n = 5) was 19 months. CONCLUSION This retrospective multicenter cohort study indicates that 5% of young women with CRC either present with or develop OM. This result appears to be clinically relevant and demonstrates the need for improved surveillance for young women diagnosed with CRC.
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Kubeček O, Laco J, Špaček J, Kubečková A, Petera J, Krulichová IS, Bezrouk A, Filip S, Kopecký J. Clinicopathological Characteristics and Prognostic Factors in Ovarian Metastases from Right- and Left-Sided Colorectal Cancer. ACTA ACUST UNITED AC 2021; 28:2914-2927. [PMID: 34436021 PMCID: PMC8395391 DOI: 10.3390/curroncol28040255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/18/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary tumors of the ovary (STOs) account for 10-25% of all ovarian malignancies, including metastases from primary gynecological tumors. Colorectal cancer (CRC) has been recognized as one of the most common causes of STOs in Western countries. Despite it being well-known that CRC originating from the right versus left side of the colon/rectum differ substantially, there is a paucity of information regarding the effect of the primary tumor sidedness on the clinicopathological characteristics of STOs. METHODS This retrospective, observational chart review study included patients with histologically confirmed STOs of CRC origin diagnosed between January 2000 and December 2019. The clinicopathological characteristics of STOs originating from left-sided and right-sided CRC were compared. Univariable and multivariable analyses employing elastic net Cox proportional hazard models were used to evaluate potential prognostic factors. Further, the role of imaging methods in STOs diagnostics was evaluated. RESULTS Fifty-one patients with STOs of colorectal origin were identified. The primary tumor originated in the right and left colon/rectum in 39% and 61% of the cases, respectively. STOs originating from right-sided primary tumors were more frequently bilateral, associated with peritoneal carcinomatosis, had the ovarian surface affected by the tumor, and contained a mucinous component. The independent prognostic factors for overall survival in the whole cohort included: the presence of macroscopic residual disease after cytoreductive surgery, menopausal status, the application of systemic therapy, and the application of targeted therapy. In 54% of cases, the imaging methods failed to determine the laterality of the STOs correctly as compared to pathological reports and/or intraoperative findings. CONCLUSION STOs originating from left-sided and right-sided CRC show distinct clinicopathological characteristics. Moreover, different metastatic pathways might be employed according to the primary tumor sidedness. Considering the discrepancies between radiological assessment and histopathological findings regarding the laterality of STOs, bilateral adnexectomy should be advised whenever feasible.
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Affiliation(s)
- Ondřej Kubeček
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Hradec Králové, Charles University, Sokolská 581, 50005 Hradec Králové, Czech Republic; (O.K.); (J.P.); (S.F.)
| | - Jan Laco
- The Fingerland Department of Pathology, Faculty of Medicine and University Hospital in Hradec Králové, Charles University, Sokolská 581, 50005 Hradec Králové, Czech Republic;
| | - Jiří Špaček
- Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital in Hradec Králové, Charles University, Sokolská 581, 50005 Hradec Králové, Czech Republic;
| | - Alena Kubečková
- Department of Gynecology, First Private Surgical Center, Ltd., Sanus Hradec Králové, Labská kotlina I/1220, 50002 Hradec Králové, Czech Republic;
| | - Jiří Petera
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Hradec Králové, Charles University, Sokolská 581, 50005 Hradec Králové, Czech Republic; (O.K.); (J.P.); (S.F.)
| | - Iva Selke Krulichová
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 50003 Hradec Králové, Czech Republic; (I.S.K.); (A.B.)
| | - Aleš Bezrouk
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 50003 Hradec Králové, Czech Republic; (I.S.K.); (A.B.)
| | - Stanislav Filip
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Hradec Králové, Charles University, Sokolská 581, 50005 Hradec Králové, Czech Republic; (O.K.); (J.P.); (S.F.)
| | - Jindřich Kopecký
- Department of Oncology and Radiotherapy, Faculty of Medicine and University Hospital in Hradec Králové, Charles University, Sokolská 581, 50005 Hradec Králové, Czech Republic; (O.K.); (J.P.); (S.F.)
- Correspondence: ; Tel.: +420-495-832-176
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Thornblade LW, Han E, Fong Y. Colorectal cancer ovarian metastases. Int J Gynecol Cancer 2021; 31:1137-1144. [PMID: 34083378 DOI: 10.1136/ijgc-2020-002328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/24/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Ovarian metastases occur in 3%-5% of patients with colorectal cancer. The role of oophorectomy in that setting continues to be debated. We aimed to assess the survival of women treated with metastasectomy for ovarian metastasis. METHODS Retrospective cohort study of patients in the California Cancer Registry (2000-2012) with stage IV colorectal cancer and ovarian metastases. Pathology other than adenocarcinoma was excluded. Adjusted Cox-proportional hazard analysis was applied to assess the risk of death. RESULTS A total of 756 patients with synchronous ovarian metastases and 516 patients with metachronous ovarian metastases form the basis of this analysis. Median follow-up for the synchronous cohort was 21 months (IQR: 8-36). Median overall survival was 23 months (IQR: 10-42). Estimated 5-year survival reached 17% and 10-year survival was 8%. There was a significant difference in unadjusted survival between patients with solitary ovarian metastasis (median overall survival: 51 months) compared with those who had both ovarian and extraovarian metastases (20 months) (log-rank test, P<0.0001). For patients with solitary ovarian metastases, the 5- and 10-year survival was 46% and 31%, respectively. Among patients with synchronous ovarian metastases, longer unadjusted survival was observed after oophorectomy (median overall survival: 24 months) compared with no oophorectomy (18 months, log-rank P=0.01). For patients with metachronous diagnoses of colorectal cancer ovarian metastasis, the median disease-free survival was 19 months. The median survival after resection of metachronous ovarian metastases was 25 months, with the survival directly related to the disease-free interval until metastasis. For patients with resected metachronous ovarian metastases, the 5- and 10-year post-metastasectomy survival was 14% and 5%, respectively. CONCLUSIONS Patients with colorectal cancer ovarian metastasis have favorable long-term survival. Survival rates are higher if the tumor is isolated to the ovary or if metachronous to the primary cancer.
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Affiliation(s)
- Lucas W Thornblade
- Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Ernest Han
- Gynecologic Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Yuman Fong
- Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
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Yoshihara T, Noura S, Tanida T, Ogino T, Noguchi K, Nagase H, Hirota M, Tomimaru Y, Imamura H, Dono K. The Validity of a New Edition of Classification for Ovarian Metastasis from Colorectal Cancer. J Anus Rectum Colon 2021; 5:40-45. [PMID: 33537499 PMCID: PMC7843136 DOI: 10.23922/jarc.2020-047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/08/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES In the 9th edition of the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma (JCCRC), ovarian metastasis is classified as distant metastasis. We assessed the significance of resection of ovarian metastases and the validity of this 9th edition of JCCRC for ovarian metastases from colorectal cancer (CRC). METHODS We retrospectively analyzed the clinicopathological factors and overall survival of 17 patients with ovarian metastases from CRC who underwent resection and 110 female CRC patients with Stage IV (M1a) disease. RESULTS The patients with only ovarian metastases who underwent resection had a longer median survival time than patients with both ovarian and peritoneal metastases who underwent resection (45.4 months vs. 9.3 months, P = 0.029). The 5-year overall survival of the patients with only ovarian metastases who underwent R0 resection was as long as that of the female Stage IV (M1a) CRC patients after R0 resection (50% vs. 48%, P = 0.334). CONCLUSIONS We found that, after resection, patients with only ovarian metastases had significantly better prognoses than patients with ovarian and peritoneal metastases. R0 resection of ovarian metastasis indicated as good prognosis as R0 resection of metastasis to one distant organ without ovaries. So the 9th edition of JCCRC, which classifies ovarian metastasis from CRC as distant metastasis, is appropriate.
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Affiliation(s)
| | - Shingo Noura
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Tsukasa Tanida
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Takayuki Ogino
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Kozo Noguchi
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Hirotsugu Nagase
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masashi Hirota
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Yoshito Tomimaru
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Hiroshi Imamura
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Keizo Dono
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka, Japan
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Primary Ovarian Carcinoma with Rectal Metastasis-a Rare Presentation (a Case Report). Indian J Surg Oncol 2019; 10:520-522. [PMID: 31496603 DOI: 10.1007/s13193-019-00946-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022] Open
Abstract
Rectal metastasis from primary ovarian cancer is a rare condition. In this case report, we present a case of 45-year-old female presented with chief complaint of pain abdomen and vomiting and with on and off history of per rectal bleeding. On examination, patient was pallor, hemoglobin level of 5.5 for which she was admitted. On per rectal examination, there was circumferential rectal growth around 7 cm from anal verge. Imaging was suggestive of ovarian lesion with rectal growth. Biopsy and immunohistochemistry of rectal growth was suggestive of metastatic well-differentiated papillary adenocarcinoma probably of ovarian origin. In view of its rare presentation, we want to report this case.
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Shigeyoshi I, Komori K, Kinoshita T, Oshiro T, Ito S, Abe T, Senda Y, Misawa K, Ito Y, Uemura N, Natsume S, Kawakami J, Ouchi A, Tsutsuyama M, Hosoi T, Akazawa T, Hayashi D, Tanaka H, Yatabe Y, Shimizu Y. A case of metachronous left ovarian metastasis 8 years after surgery for cecal cancer and right ovarian metastasis: Report of a case. NAGOYA JOURNAL OF MEDICAL SCIENCE 2018. [PMID: 28626261 PMCID: PMC5472551 DOI: 10.18999/nagjms.79.2.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Metachronous ovarian metastasis of colorectal adenocarcinoma is mostly identified within 3 years. Here we present a case of a 64-year-old woman with cecal cancer who underwent right oophorectomy for ovarian metastasis. Imaging was performed because of abdominal bloating; it detected a swollen right ovary with ascites. On laparotomy, a right ovarian tumor and cecal cancer were identified. After right oophorectomy, a diagnosis of unilateral ovarian metastasis from colon cancer was made. One month later, right hemicolectomy was performed. Eight years after initial surgery, the patient presented with vaginal bleeding. A computed tomography (CT) scan revealed a pelvic mass approximately 10 cm in diameter, but no mass was evident on a CT image taken 6 months before. The patient was diagnosed with left ovarian metastasis from colon cancer. A third laparotomy revealed a left ovarian tumor, but there was no evidence of other metastases or peritoneal dissemination. Left oophorectomy was performed. Oophorectomy is considered to be associated with a survival benefit in ovarian metastasis without other extensive metastasis. However, ovarian metastasis is often bilateral. Although complete resection was achieved in the present case, the findings support performing prophylactic bilateral oophorectomy if metastasis is identified in a unilateral ovary.
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Affiliation(s)
- Itaru Shigeyoshi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Koji Komori
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Takashi Kinoshita
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Taihei Oshiro
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Seiji Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Yoshiki Senda
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Kazunari Misawa
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Yuichi Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Norihisa Uemura
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Seiji Natsume
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Jiro Kawakami
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Akira Ouchi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Masayuki Tsutsuyama
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Takahiro Hosoi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Tomoyuki Akazawa
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Daisuke Hayashi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Hideharu Tanaka
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Yasushi Yatabe
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Aichi, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
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11
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Al-Busaidi IS, Bailey T, Dobbs B, Eglinton TW, Wakeman CJ, Frizelle FA. Complete resection of colorectal cancer with ovarian metastases combined with chemotherapy is associated with improved survival. ANZ J Surg 2018; 89:1091-1096. [PMID: 30485627 DOI: 10.1111/ans.14930] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/12/2018] [Accepted: 10/02/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ovarian metastases (OM) from colorectal cancer (CRC) are uncommon, and data about optimal management are lacking. The aim of this study was to examine the management and outcomes of patients with OM from CRC. METHODS A retrospective review of records of patients with a histopathological diagnosis of OM from CRC who were treated at Christchurch Hospital between 1 January 2000 and 31 December 2016. Data related to presentation, clinicopathological characteristics, treatment and outcomes were recorded. The primary outcomes were overall survival and disease-free survival. RESULTS Thirty-one patients were identified (median age 55 years, range 28-77), with a median follow-up of 23 months (range 3-84 months). Abdominal pain was the most common presenting symptom (22 patients). Synchronous OM occurred in 22 patients, 14 patients had bilateral ovarian involvement. Twenty-one patients received adjuvant chemotherapy. R0 resection was achieved in 14 patients. For all patients the 5-year disease-free and overall survival were 11% and 12%, respectively, while 5-year overall survival for R0 resections was 30%. Improved median survival was associated with negative colon resection margins (26.7 months versus 7.8 months, P = 0.03), R0 resection (30.5 months versus 23.5 months, P = 0.04), and use of adjuvant chemotherapy (28.8 months versus 8.2 months, P < 0.0001); however, on multivariate analysis adjuvant chemotherapy was the only independent factor associated with improved prognosis (P = 0.01). CONCLUSIONS OM from CRC are uncommon and carry a poor prognosis. Improved survival was associated with complete surgical resection of the primary tumour and metastatic disease in combination with systemic chemotherapy.
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Affiliation(s)
| | - Teresa Bailey
- Department of Anatomical Pathology, Christchurch Hospital, Christchurch, New Zealand
| | - Bruce Dobbs
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Tim W Eglinton
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Christopher J Wakeman
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Frank A Frizelle
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
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12
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Abstract
Mucinous tumours involving the ovary may be benign, borderline, or malignant. Malignant tumours may be primary or metastatic. Differentiation between primary and metastatic involvement of the ovary is critical for optimal patient management. Even among skilled pathologists, this distinction can be problematic, as can the distinction between borderline ovarian tumour of intestinal type and well-differentiated invasive primary mucinous ovarian carcinoma. Primary invasive mucinous ovarian carcinoma and mucinous carcinoma metastatic to the ovary do have distinct patterns of macroscopic and microscopic involvement which will reveal the correct diagnosis in many cases. There are also well-recognized patterns of immunohistochemical staining that can further assist in this differentiation. As a result of the application of these histopathological techniques, the incidence of primary invasive mucinous epithelial carcinoma has fallen over recent years from ∼12% to ∼3%. However, even in recent multicentre clinical trials such as GOG 182, expert pathological review suggests that ∼60% of tumours originally classified as primary invasive mucinous carcinomas were in fact metastatic tumours to the ovary. Review of outcome data for patients with mucinous carcinoma entered into multicentre trials suggests that this subtype of disease has a particularly poor prognosis in comparison with other subtypes of ovarian carcinoma. Historically, patients with mucinous epithelial ovarian carcinoma (mEOC) have been treated in the same way as other subtypes of ovarian carcinoma. While there is undoubtedly a response rate to platinum-based chemotherapy, retrospective reviews of individual centre experience suggest that this is substantially lower than for high-grade papillary serous carcinoma and in the order of only 30%-40%. The mEOC trial was established to investigate the possibility that the combination of capecitabine and oxaliplatin (chemotherapy drugs more commonly used in colorectal carcinoma) may be superior to conventional carboplatin and paclitaxel chemotherapy. In a 2 × 2 factorial design, there was also a randomization to bevacizumab. Unfortunately, this trial closed early, 5 years after initiation having recruited just 50 of a proposed 322 patients. mEOC is now characterized as a type I tumour with an identifiable stepwise progression from a premalignant lesion, through non-invasive, to invasive malignancy. Molecular characterization of mEOC reveals it to be distinct from other subtypes of the disease with a KRAS mutation occurring in 40%-50% of patients. Other gene abnormalities including HER2 amplification in ∼19% also occur. This raises the possibility of the use of targeted molecular therapies which with molecular analysis of individual patient tumours could form the basis of a future clinical trial. It is, however, clear that if trials are to be conducted in this rare subtype of disease, they will need to be truly international in nature and carefully designed, possibly using an adaptive stepwise approach and will require an appropriate level of funding with a realistic assessment of likely recruitment. Associated translational research will clearly be essential.
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Affiliation(s)
- T J Perren
- Professor of Women's Cancers and Oncology, Leeds Institute of Cancer Medicine and Pathology, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
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13
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Yamamoto Y, Miyagawa Y, Ehara T, Koyama M, Nakamura S, Takeuchi D, Muranaka F, Kitazawa M, Miyagawa S. Three Cases of Pseudo-Meigs' Syndrome Secondary to Ovarian Metastases from Colorectal Cancer. Case Rep Surg 2017; 2017:5235368. [PMID: 28373923 PMCID: PMC5360969 DOI: 10.1155/2017/5235368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/22/2017] [Indexed: 11/17/2022] Open
Abstract
Pseudo-Meigs' syndrome is used to describe cases of ascites and/or pleural effusion associated with ovarian neoplasms other than benign tumors, which improve after removal of the ovarian lesion. We present three cases of pseudo-Meigs' syndrome secondary to ovarian metastasis from colorectal cancer. In case 1, the patient has severe dyspnea and hypoxia due to massive right pleural effusion; therefore preoperative thoracic drainage was needed. In case 2, the patient needed paracentesis every two or three days to improve abdominal distension. After two courses of 5-fluorouracil, levofolinate, and oxaliplatin (mFOLFOX6), her ascites could be controlled by diuretics without aspiration and her general condition improved. Then she underwent operation. In case 3, the patient developed a massive pleural effusion and ascites coincident with a rapid enlargement of ovarian tumor after resection and adjuvant chemotherapy for rectal cancer. In all cases, pleural effusions and/or ascites resolved and general conditions and daily activities of the patients improved after oophorectomy. They are all currently in good health without recurrence of pleural effusion or ascites. In patients with suspected pseudo-Meigs' syndrome secondary to ovarian metastasis of colorectal cancer, operation including oophorectomy may reduce pleural effusions and/or ascites and improve the general condition.
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Affiliation(s)
- Yuta Yamamoto
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yusuke Miyagawa
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takehito Ehara
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Makoto Koyama
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoshi Nakamura
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Daisuke Takeuchi
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Futoshi Muranaka
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masato Kitazawa
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shinichi Miyagawa
- Department of Gastroenterological Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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14
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Shimazaki J, Tabuchi T, Nishida K, Takemura A, Motohashi G, Kajiyama H, Suzuki S. Synchronous ovarian metastasis from colorectal cancer: A report of two cases. Oncol Lett 2016; 12:257-261. [PMID: 27347134 DOI: 10.3892/ol.2016.4553] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 04/18/2016] [Indexed: 11/06/2022] Open
Abstract
Ovarian metastasis of colorectal cancer is relatively rare. The present study reports two cases of synchronous ovarian metastasis from colorectal cancer, which were managed by cytoreductive surgery. In case one, a 60-year-old female patient presented with a multilocular pelvic tumor and ascites. Virtual colonoscopy revealed a mass in the sigmoid colon; however, no tumor cells were identified on histological examination. Ovarian metastasis from sigmoid colon cancer was suspected and adnexectomy was subsequently performed. Histological examination of the excised tumor revealed adenocarcinoma. Immunohistochemical analysis of the resected tumor revealed positive staining for cytokeratin (CK)20 and caudal-type homeobox 2 (CDX2), and negative staining for CK7, estrogen receptor, progesterone receptor and inhibin. The immunohistological results supported the diagnosis of ovarian metastasis from sigmoid colon cancer. In case two, a 56-year-old female patient presented with a multilocular pelvic tumor and ascites. Colonoscopy identified a rectal tumor, and histological examination revealed moderately-differentiated adenocarcinoma, which was confirmed by cytological analysis of ascites. Subsequently, ovarian metastasis from rectal cancer with peritoneal dissemination was diagnosed, and left ovariectomy and transverse colostomy were performed. Histological examination of the excised tumor revealed moderately-differentiated adenocarcinoma, and immunohistochemical investigation revealed positive staining for CK20 and CDX2, but negative staining for CK7. These immunohistological results indicated ovarian metastasis from rectal cancer. Both patients recovered well and are currently undergoing regular follow-up examinations. The observations from the two cases indicate that ovarian metastases of primary colorectal cancer may present as pelvic tumors and, thus, preoperative examination of the gastrointestinal tract is required. Furthermore, even in cases of widespread colorectal cancer metastases, excision of the ovarian tumor is required to establish a histological diagnosis for the selection of appropriate treatments.
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Affiliation(s)
- Jiro Shimazaki
- Department of Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Inashiki, Ibaraki 300-0395, Japan
| | - Takanobu Tabuchi
- Department of Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Inashiki, Ibaraki 300-0395, Japan
| | - Kiyotaka Nishida
- Department of Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Inashiki, Ibaraki 300-0395, Japan
| | - Akira Takemura
- Department of Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Inashiki, Ibaraki 300-0395, Japan
| | - Gyo Motohashi
- Department of Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Inashiki, Ibaraki 300-0395, Japan
| | - Hideki Kajiyama
- Department of Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Inashiki, Ibaraki 300-0395, Japan
| | - Shuji Suzuki
- Department of Gastroenterological Surgery, Ibaraki Medical Center, Tokyo Medical University, Inashiki, Ibaraki 300-0395, Japan
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15
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Thompson CV, Naumann DN, Kelly M, Karandikar S, McArthur DR. Prophylactic oophorectomy during primary colorectal cancer resection: A systematic review and meta-analysis. World J Surg Proced 2015; 5:167-172. [DOI: 10.5412/wjsp.v5.i1.167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/13/2014] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To appraise the current evidence for prophylactic oophorectomy in patients undergoing primary curative colorectal cancer resection.
METHODS: Occult ovarian metastases may lead to increased mortality, therefore prophylactic oophorectomy may be considered for women undergoing colorectal resection. A systematic review and meta-analysis was performed for English language studies from 1994 to 2014 (PROSPERO Registry number: CRD42014009340), comparing outcomes following prophylactic oophorectomy (no known ovarian or other metastatic disease at time of surgery) vs no ovarian surgery, synchronous with colorectal resection for malignancy. Outcomes assessed: local recurrence, 5-year mortality, immediate post-operative morbidity and mortality, and rate of distant metastases.
RESULTS: Final analysis included 4 studies from the United States, Europe and China, which included 627 patients (210 prophylactic oophorectomy and 417 non-oophorectomy). There was one randomized controlled trials, the remainder being non-randomised cohort studies. The studies were all at high risk of bias according to the Cochrane Collaboration’s assessment tool for randomised studies and the Newcastle-Ottawa Score for the cohort studies. The mean age of patients amongst the studies ranged from 56.5 to 67 years. There were no significant differences between the patients having prophylactic oophorectomy at time of primary colorectal resection compared with patients who did not with respect to local recurrence, 5-year survival and distant metastases. There was no difference in post-operative complications or immediate post-operative mortality between the groups.
CONCLUSION: Current evidence does not favour prophylactic oophorectomy for patients without known genetic predisposition. Prophylactic surgery is not associated with additional risk of post-operative complications or death.
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16
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Challa VR, Goud YGB, Rangappa P, Deshmane V, Kumar KVV, Madhusudhana BA. "Ovarian Metastases from Colorectal Cancer: Our Experience". Indian J Surg Oncol 2014; 6:95-8. [PMID: 26405412 DOI: 10.1007/s13193-014-0369-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 12/17/2014] [Indexed: 11/26/2022] Open
Abstract
Ovarian metastases from colorectal cancer are uncommon and can present synchronously and metachronoulsy. Role of prophylactic oophorectomy for colorectal cancer is controversial and there is no definitive evidence to support it. A retrospective analysis of all the patients with colorectal cancer who had attended a single unit at our center have been analysed. Clinical presentation, Pathological features and image findings were analyzed. We had 7 patients with ovarian metastases who had presented synchronously or metachronously at our institute. Five patients presented synchronously at the time of primary surgery and 2 patients had presented metachronously after the treatment of primary. Three patients had malignancy in ascending colon and 2 had in sigmoid colon , one in rectosigmoid junction and one case in rectum. The mean overall survival rate was 12.4 months (range 6-20 months). All the patients received adjuvant chemotherapy. Ovarian metastases is rare in colorectal and occurs in younger patients.
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Affiliation(s)
- Vasu Reddy Challa
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Y G Basavana Goud
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Poornima Rangappa
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - Vijayalakshmi Deshmane
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - K V Veerendra Kumar
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
| | - B A Madhusudhana
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka India
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17
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Treatment of ovarian metastases of colorectal and appendiceal carcinoma in the era of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol 2014; 40:937-42. [PMID: 24630923 DOI: 10.1016/j.ejso.2014.02.238] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/13/2014] [Accepted: 02/14/2014] [Indexed: 11/22/2022] Open
Abstract
AIM To compare outcome of women with ovarian metastasis who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) to outcome of women without ovarian metastasis who underwent CRS-HIPEC. METHODS A prospective CRS-HIPEC database was searched to identify women with surgically treated colorectal carcinoma between 2000 and 2012. Patients with ovarian metastasis were identified and patients with peritoneal carcinomatosis but without ovarian metastasis were included as control cases. RESULTS 75 patients with macroscopic ovarian metastasis underwent CRS-HIPEC with curative intent, while 50 female patients without ovarian metastasis were identified who underwent CRS-HIPEC. Patients with ovarian metastasis more often had a primary appendiceal tumour and had a more extensive intra-abdominal tumour load compared to patients without ovarian metastases. Median follow-up time was 45 months (95% confidence interval (CI): 37-53 months). Overall survival (OS) did not differ significantly between the two groups with a median OS in the ovarian metastasis group of 40 months (95% CI 26-54) compared to 64 months (95% CI 17-111, P = 0.478) in the non-ovarian metastasis group. Recurrence patterns did not differ significantly between groups (p = 0.183). CONCLUSIONS Patients with ovarian metastasis of colorectal and appendiceal origin who underwent CRS-HIPEC had similar outcome compared to patients without ovarian metastasis. Given the findings of high coincidence of peritoneal metastases with ovarian metastases and ovarian metastases not being an independent factor for survival after CRS-HIPEC, this procedure should be recommended for patients with peritoneal metastases and ovarian metastases of colorectal and appendiceal carcinoma.
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18
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Huang YY, Pratt JJ, Dabner M, Tjhin W. Challenging diagnosis of a jejunal adenocarcinoma with ovarian metastasis: report of an unusual case. BMJ Case Rep 2013; 2013:bcr-2013-008842. [PMID: 23580681 DOI: 10.1136/bcr-2013-008842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We report the first documented case of ovarian metastasis from a jejunal primary adenocarcinoma in an Australian patient. The presentation was unusual, initially a suspicious abdominal nodule in the epigastric area, which turned out to be an adenocarcinoma of possible intestinal origin. Gastroscopy and colonoscopy were performed with no suspicious lesion identified. Abdominal and pelvic ultrasound imaging showed a complex pelvic mass suspicious of ovarian cancer. Laparoscopy was performed to exclude possibility of ovarian cancer and small bowel cancer. The ovarian mass showed similar features from the epigastric nodule, again suggestive of intestinal primary. Definitive diagnosis was obtained when the patient represented 2 months later with malignant bowel obstruction requiring palliative resection of the proximal jejunum. This case demonstrates the difficulty in diagnosing ovarian metastasis from a small bowel primary, which has the potential to mimic an ovarian primary tumour clinically, and a large bowel or ovarian primary pathologically.
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19
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Cai GX, Xu Y, Tang DF, Lian P, Peng JJ, Wang MH, Guan ZQ, Cai SJ. Interaction between synchronous bilateral prophylactic oophorectomy and adjuvant chemotherapy in female patients with locally advanced colorectal cancer. Colorectal Dis 2011; 13:414-9. [PMID: 20041916 DOI: 10.1111/j.1463-1318.2009.02179.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM In this study we explored the prognostic impact of synchronous bilateral prophylactic oophorectomy in female patients with primary colorectal cancer undergoing radical surgery. METHOD From 1991 to 2000, 267 female patients with stage II or stage III colorectal cancer, who had undergone curative resection, were retrospectively reviewed. In 224 patients, the ovaries were preserved. The other 43 patients underwent synchronous bilateral prophylactic oophorectomy. Univariate and multivariate analyses (Kaplan-Meier and Cox regression, respectively) were used to evaluate the effect of prophylactic oophorectomy and other clinical factors on the prognosis of patients. RESULTS Both univariate and multivariate analyses showed that tumor stage and adjuvant chemotherapy were the only two significant clinical factors that affected the 5-year overall survival of patients (P < 0.01). There was no significant difference in the 5-year overall survival between patients who had, or had not, undergone prophylactic oophorectomy (75%vs 73%, P > 0.05). In the subgroup analysis by adjuvant chemotherapy, the 5-year overall survival in patients receiving adjuvant chemotherapy was similar between nonoophorectomy and oophorectomy groups. However, in patients without adjuvant chemotherapy, the oophorectomy group was shown to have a significantly better 5-year overall survival than the nonoophorectomy group (76%vs 51%, P = 0.047). CONCLUSION Prophylactic oophorectomy may improve the overall survival of female patients with locally advanced colorectal cancer without adjuvant chemotherapy, but its survival benefit vanished in patients receiving adjuvant chemotherapy. The role of prophylactic oophorectomy may be substituted by adjuvant chemotherapy, which makes prophylactic oophorectomy unnecessary during surgery for locally advanced colorectal cancer.
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Affiliation(s)
- G X Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Centre, Shanghai, China
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20
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Fujiwara A, Noura S, Ohue M, Shingai T, Yamada T, Miyashiro I, Ohigashi H, Yano M, Ishikawa O, Kamiura S, Tomita Y. Significance of the resection of ovarian metastasis from colorectal cancers. J Surg Oncol 2010; 102:582-7. [DOI: 10.1002/jso.21675] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kim DD, Park IJ, Kim HC, Yu CS, Kim JC. Ovarian metastases from colorectal cancer: a clinicopathological analysis of 103 patients. Colorectal Dis 2009; 11:32-8. [PMID: 18462217 DOI: 10.1111/j.1463-1318.2008.01543.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To improve management of ovarian metastasis through assessment of clinicopathological features and treatment outcomes associated with ovarian metastasis from colorectal cancer. METHOD We recruited 103 subjects who were diagnosed with ovarian metastasis and subjected to surgery between June 1989 and December 2005. Clinical and pathological variables were evaluated. Survival and its associated factors were analysed with a median follow-up of 31 months after ovarian surgery (range 1-129 months). RESULTS The mean age at diagnosis was 46 years (range 14-72 years), synchronous ovarian metastasis occurred in 74 patients and metachronous in 29 patients. The primary tumour was more commonly associated with the colon rather than the rectum (84/1608, 5.2%vs 19/1534, 1.2%, P < 0.001). Combined metastases occurred in 69 patients (67%). Complete resection was achieved in 34 (33%) patients without other metastases. The estimated 5-year disease free survival and overall survival rate were 40.1% and 26.6%, respectively. From univariate analysis, lymphovascular invasion (35.6%vs 12.8%, P = 0.034), combined metastasis (50.9%vs 15.6%, P = 0.0035) and bilaterale ovarian metastasis (36.4%vs 10.6%, P = 0.015) were identified as significant poor prognosis factors, and from multivariate analysis combined metastasis and bilaterale ovarian metastasis were significant (P = 0.034 and P = 0.015, respectively). CONCLUSION This study suggests a role for regular follow-up computed tomography scans within 6 months postoperatively and tumour marker assays for the early detection of ovarian metastasis in premenopausal women after primary surgery, especially in colonic patients with poor prognostic factors.
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Affiliation(s)
- Dae D Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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22
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Erroi F, Scarpa M, Angriman I, Cecchetto A, Pasetto L, Mollica E, Bettiol M, Ruffolo C, Polese L, Cillo U, D'Amico DF. Ovarian metastasis from colorectal cancer: prognostic value of radical oophorectomy. J Surg Oncol 2007; 96:113-7. [PMID: 17443728 DOI: 10.1002/jso.20803] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Ovarian metastases from primary colorectal cancer occur in 3-8% of female patients. The aim of this study was to assess the prognostic value of radical oophorectomy for ovarian metastasis from colorectal cancer. PATIENTS AND METHODS From our series of 859 patients operated for colorectal cancer from 1982 to 2005 ten patients with isolated ovarian metastasis were retrieved. Ovarian colorectal metastasis diagnosis was confirmed by pathology revision. Overall and disease-free survival after radical oophorectomy for metastases were assessed and compared with literature data. RESULTS The median follow-up from ovarian metastases resection was 36 months (range 194-14). Survival analysis showed that survival rate after ovarian metastasectomy was 100% at 1 year and 80% at 5 years of follow up. CONCLUSION Our study, although limited by a relatively short follow-up and small sample size, shows that bilateral oophorectomy for ovarian metastasis from colorectal cancer has a good impact on disease-free and overall survival.
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Affiliation(s)
- Francesca Erroi
- Dipartmento di Scienze Chirurgiche e Gastroenterologiche, sez. di Clinica Chirurgica I, University of Padova, Italy
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23
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Liang JT, Lai HS, Wu CT, Huang KC, Lee PH, Shun CT. Laparoscopic Prophylactic Oophorectomy Plus N3 Lymphadenectomy for Advanced Rectosigmoid Cancer. Ann Surg Oncol 2007; 14:1991-9. [PMID: 17447107 DOI: 10.1245/s10434-007-9346-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Accepted: 12/19/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND The primary aim of the present retrospective study was to evaluate the feasibility and efficacy of laparoscopic prophylactic oophorectomy plus N3 lymph node dissection for patients with rectosigmoid cancer. The secondary aim was to explore the clinicopathologic features of ovarian micrometastasis from rectosigmoid cancer. METHODS We performed 244 laparoscopic resections of rectosigmoid cancer in women during a 6-year period. In them, 34 patients (13.9%) were subjected to prophylactic oophorectomy plus N3 lymphadenectomy in addition to the standard anterior or low anterior resection of rectosigmoid cancer, because the patients presented with ovarian cystic lesions, tethering of the ovary to the primary rectosigmoid tumor, and/or pelvic ascites accumulation, which were postulated as the indicative findings for the synchronous ovarian micrometastasis. The surgical procedures are detailed in the attached video. The surgical outcomes were compared between patients with (n = 34) and without (n = 210) these two additional procedures. In analyzing the clinicopathologic features of ovarian micrometastasis, we included both cases of laparoscopic (n = 34) and traditional open surgery (n = 30), whose prophylactic oophorectomy was performed by the same surgical indications. RESULTS Although the operation time was significantly longer (264.2 +/- 24.5 vs. 192.5 +/- 24.2 minutes, P < .0001) in patients with prophylactic oophorectomy and N3 lymphadenectomy, there was no significant difference between patients with and without the two additional procedures in blood loss, wound length, postoperative complications, diverting ileostomy, and mortality. Although flatus passage, hospitalization, postoperative pain, and return to partial activity were statistically different between the study groups, they were deemed clinically unimportant because the difference of mean was very small. Foley removal was delayed in patients with N3 lymphadenectomy by 2 days. With respect to surgical efficacy, we found that patients undergoing the two additional procedures could collect significantly more lymph nodes (22.0 +/- 4.0 vs. 14.4 +/- 2.4, P < .0001) for pathologic staging and facilitated upstaging of nodal status in three patients (8.8%). Patients undergoing prophylactic oophorectomy plus N3 lymphadenectomy could achieve good oncologic outcome, with the estimated 5-year survival rate of 62.5% and 69.2% in patients with and without ovarian micrometastasis, respectively. Clinicopathologically, patients with ovarian micrometastasis (n = 15) tended to have vascular invasion of tumor cells, as compared with those without (n = 49). However, ovarian micrometastasis was not related to menstrual status of patients, tumor location, tumor size, morphology, differentiation, mucin production, T stage, nodal invasion, and level of carcinoembryonic antigen. CONCLUSIONS Laparoscopic surgical techniques could be safely applied to perform prophylactic oophorectomy plus N3 lymphadenectomy with acceptable efficacy in a highly selected subset of patients with rectosigmoid cancer.
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Affiliation(s)
- Jin-Tung Liang
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, ROC.
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Gurbuz A, Kir G, Karateke A, Haliloglu B, Kabaca C. Metastatic ovarian carcinoma one year after surgical removal of colon carcinoma during pregnancy: a case report. Int J Gynecol Cancer 2006; 16 Suppl 1:330-3. [PMID: 16515616 DOI: 10.1111/j.1525-1438.2006.00334.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Colorectal carcinoma during pregnancy is a very rare event. We presented a woman with metachronous metastatic ovarian tumor existing 1 year after surgical removal of perforated sigmoid colon carcinoma encountered during cesarean section of woman of 36-week gestation for fetal distress. Pregnant women with suspicious abdominal mass should be evaluated for a possible colorectal carcinoma even in the absence of any other gastrointestinal symptoms associated with it and undergo rectal examination and sigmoidoscopy. In addition, as synchronous and metachronous ovarian metastases are common in these patients, ovaries must be evaluated carefully by bisection during operation for possible metastasis, and in women who do not have a desire for fertility, prophylactic oophorectomy seems an appropriate treatment modality for resecting synchronous metastasis and preventing future metastasis.
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Affiliation(s)
- A Gurbuz
- Department of Obstetrics & Gynecology, Zeynep Kamil Maternity Hospital, Istanbul, Turkey
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25
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Abstract
BACKGROUND Current gynaecological practice is to remove surgically accessible ovaries with prior consent in post menopausal women to eradicate the risk of subsequent development of ovarian cancer. However in colorectal surgery opinion is divided, although evidence suggests that ovarian metastases from colorectal adenocarcinoma occur in 3-4% of cases. METHODS The review is based on published literature of the role of prophylactic oophrectomy in women undergoing surgery for colorectal cancer, obtained from Medline/PubMed and other online databases using the terms 'prophylactic oophorectomy' and 'colon cancer'. Additional references were sourced by manually searching bibliographies of articles located. RESULTS AND CONCLUSION There is a paucity of published information and published reports have conflicting conclusions. A preliminary report of a randomised prospective trial suggests the probability of increased recurrence free survival in the oophorectomy group. It would seem appropriate to consider the necessity and possible benefits of oophorectomy in women prior to surgery for colorectal cancer. This would seem particularly relevant in distal sigmoid or upper rectal cancers when the ovaries or uterus may be directly invaded and curative surgery would involve en bloc resection. Post menopausal women with a family history of ovarian cancer should be advised to have oophorectomy.
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Affiliation(s)
- S Banerjee
- Colorectal Research Unit, North Hampshire Hospital, Basingstoke, UK
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26
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Udezue NO. Colorectal cancer associated with pregnancy in Kaduna. J OBSTET GYNAECOL 2004; 19:477-81. [PMID: 15512369 DOI: 10.1080/01443619964247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The incidence of colorectal cancer associated with pregnancy is low. Only 2-6% of all females suffering from colorectal cancer are within the child bearing age (i.e. under 40 years). This paper describes the experience at the Ahmadu Belle University Teaching Hospital, Kaduna, Nigeria, from 1 January 1975 to 31 December 1997. Twenty-five cases of colorectal cancer associated with pregnancy were seen and treated; 15 cases in which colorectal cancer occurred de novo in pregnant patients; and 10 cases in which pregnancy(ies) occurred in patients with a previous diagnosis of colorectal cancer. Treatment of the cancer, future pregnancies and their management, and the question of possible prophylactic oophorectomy in selected patients are discussed.
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Affiliation(s)
- N O Udezue
- Department of Surgery, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
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27
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Raspollini MR, Amunni G, Villanucci A, Baroni G, Taddei A, Taddei GL. Utility of CDX-2 in distinguishing between primary and secondary (intestinal) mucinous ovarian carcinoma: an immunohistochemical comparison of 43 cases. Appl Immunohistochem Mol Morphol 2004; 12:127-31. [PMID: 15354737 DOI: 10.1097/00129039-200406000-00005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Primary and secondary mucinous tumors can involve the ovaries and have similar histologic appearances. The differential diagnosis is important for surgical and chemotherapeutic treatment and for the prognosis, but often it is extremely difficult. This article discusses an immunohistochemical panel that includes carcinoembryonic antigen (CEA), cytokeratin (CK) 7, CK20, CA125, CA19.9, and a new marker, CDX-2, for the distinction between primary ovarian mucinous carcinomas and metastatic (intestinal) ovarian tumors. Forty-three cases representing primary and secondary ovarian tumors were considered and consisted of 14 primary mucinous ovarian carcinomas (PMOCs) and 29 secondary (intestinal) ovarian tumors (SIOTs). Fisher exact test was performed to evaluate the reliability of the respective antibodies to discriminate between PMOCs and SIOTs. CDX-2 was diffusely positive in all SIOTs and was expressed focally in 3 cases (21.42%) of PMOCs. CK7 was diffusely positive in 13 cases (44.82%) of SIOTs and in 13 cases (92.85%) of PMOCs. CK20 was diffusely positive in 17 cases (58.62%) of SIOTs and in 6 cases (42.85%) of PMOCs. CEA was diffusely positive in 28 cases (96.55%) of SlOTs and in 12 cases (85.71%) of PMOCs. CA 19.9 was positive in all SIOTs and in 12 cases (85.71%) of PMOCs. CA125 was positive in 3 cases (10.34%) of SIOTs and in 4 cases (28.57%) of PMOCs. CK7 and especially CDX-2, a specific and sensitive marker, can aid pathologists in making a differential diagnosis (P = 0.003 and P < 0.0005, respectively), whereas CEA, CK20, CA125, and CA 19.9 markers are not high enough to distinguish between primary and secondary mucinous ovarian tumors.
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28
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Hanna NN, Cohen AM. Ovarian neoplasms in patients with colorectal cancer: understanding the role of prophylactic oophorectomy. Clin Colorectal Cancer 2004; 3:215-22. [PMID: 15025793 DOI: 10.3816/ccc.2004.n.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Although the role of prophylactic oophorectomy is currently under debate and not well defined, it is of increasing and considerable relevance, especially in premenopausal women, particularly those with identifiable hereditary cancer syndromes. Patients with colorectal cancer with ovarian metastases are often symptomatic, require surgery, and have poor survival. Prophylactic oophorectomy abolishes the increased risk of primary ovarian cancer in these patients, resects synchronous metastases, and prevents development of metachronous ovarian metastases. Prophylactic oophorectomy trials, mostly conducted in postmenopausal women, have not shown survival advantage. In patients with ovarian metastases of colorectal cancer, maximal cytoreductive surgery followed by adjuvant therapy employing newer chemotherapeutic agents, whole abdominal irradiation with chemosensitization, or hyperthermic intraperitoneal chemotherapy may improve outcomes in selected patients.
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Affiliation(s)
- Nader N Hanna
- Department of Surgery, Surgical Oncology Service, Markey Cancer Center, University of Kentucky, Lexington, USA.
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29
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Moore RG, Chung M, Granai CO, Gajewski W, Steinhoff MM. Incidence of metastasis to the ovaries from nongenital tract primary tumors. Gynecol Oncol 2004; 93:87-91. [PMID: 15047218 DOI: 10.1016/j.ygyno.2003.12.039] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2003] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the characteristics of metastatic tumors to the ovaries in nongenital tract primaries and to determine the route of dissemination. METHODS An IRB-approved study retrospectively reviewed patient records from January 1992 to January 2003. A tumor registry and pathology database search identified women with metastatic disease to the ovaries that had undergone surgery for the presence of an adnexal mass. The charts were reviewed for age at diagnosis, presenting symptoms, size of ovarian metastasis, laterality of metastasis, and primary tumor site. Pathology reports and specimen slides were reviewed to confirm the diagnosis and evaluate the tumors for various pathological features. RESULTS A total of 59 cases of metastasis to the ovary were identified. The median age of the study group was 55 years old (range: 27-78). Primary colon cancer was identified in 19 (32.2%) cases; appendix 12 (20.3%); breast 5 (8.4%); small bowel and gastric each contributed 4 (6.8%) cases. Pancreatic cancer added 3 (5.1%), while gallbladder and urinary bladder each contributed 1 (1.7%) case. Tumors of unknown primary contributed 10 (18.5%) of the cases. Stromal invasion was seen in 56 (95%) of the cases and surface involvement in 9 (15%) cases. Bilateral metastasis was found in 39 (66.1%) patients and unilateral metastasis in 20 (33.9%) patients. CONCLUSIONS Metastatic lesions to the ovary are more commonly seen from primary colon cancer, appendiceal, and breast carcinomas. The mechanism of metastasis is through hematogenous pathways as opposed to a transserosal route.
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Affiliation(s)
- Richard G Moore
- Program in Women's Oncology, Department of Obstetrics and Gynecology, Woman and Infants' Hospital/Brown University, Providence, RI 02905, USA
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30
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Henley T, Reddy MP, Ramaswamy MR, Lilien DL. Bilateral Ovarian Metastases From Colon Carcinoma Visualized on F-18 FDG PET Scan. Clin Nucl Med 2004; 29:322-3. [PMID: 15069335 DOI: 10.1097/01.rlu.0000124010.98447.47] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Travis Henley
- Department of Radiology (Nuclear Medicine Section), Louisiana State University School of Medicine, Shreveport, Louisiana 71130, USA
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31
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Wright JD, Powell MA, Mutch DG, Rader JS, Gibb RK, Huettner PC, Herzog TJ. Synchronous ovarian metastases at the time of laparotomy for colon cancer. Gynecol Oncol 2004; 92:851-5. [PMID: 14984952 DOI: 10.1016/j.ygyno.2003.12.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2003] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of the study was to identify clinical features, define prognostic factors and optimize treatment in patients with colorectal cancer with synchronous ovarian metastases at the time of initial diagnosis. METHODS A retrospective analysis of patients treated by the gynecologic oncology service at Barnes Jewish Hospital between 1990 and 2001 was performed. Twenty-eight patients with colorectal carcinomas with synchronous ovarian metastases at the time of diagnosis were identified. Clinical and pathological characteristics were evaluated, and survival was analyzed by the method of Kaplan and Meier. RESULTS Abdominal pain was the most common symptom at presentation. Only 14% of the patients presented with gastrointestinal bleeding. Fifty-four percent of patients who underwent barium enema had intrinsic colonic lesions, while 40% of patients who had endoscopies performed had their colonic tumors identified. Preoperatively colon cancer was considered in the differential diagnosis of 71% of the patients. At exploration, the ovarian metastases were significantly larger than the primary colon tumors. Overall, 68% of patients had intraperitoneal nodal metastasis and 86% had transmural extension of their tumors. The only pathological variable associated with survival was tumor grade. The median disease-free survival was 10.3 months while the median overall survival was 18.4 months. CONCLUSION Most patients with colon cancer with synchronous ovarian metastases present with vague symptoms. At exploration, locally advanced tumors and other distant metastases such as in the liver are common. Surgical management should include extirpation of the primary tumor and any bulky ovarian metastases. Cytoreduction may be considered in highly selected patients.
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Affiliation(s)
- Jason D Wright
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO 63110, USA
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32
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Becker SO, Tomacruz R, Kaufman HS, Bristow RE, Montz FJ. Gynecologic abnormalities in surgically treated women with stage II or III rectal cancer. J Am Coll Surg 2002; 194:315-23. [PMID: 11893135 DOI: 10.1016/s1072-7515(01)01165-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The objective of this article is to review the incidence and management of gynecologic abnormalities in women undergoing surgery for rectal cancer. STUDY DESIGN We performed a retrospective chart review utilizing the Johns Hopkins Tumor Registry and Pathology database. Eighty-six female patients who underwent abdominal surgery between 1985 and 1996 for Stage II or Stage III rectal cancer were identified. Data gathered included: patient demographics, history, intraoperative findings and complications, cancer stage and histology, adjuvant treatments, and followup. Specific attention was focused on the diagnosis, management, and followup of concurrent gynecologic problems. RESULTS At the time of surgery, nineteen women (22%) had previously undergone hysterectomy and bilateral salpingo-oophorectomy. Of the remaining 67 patients, 25 (37%) were found to have gynecologic abnormalities at the time of surgery, 15 (22%) underwent adnexectomy or hysterectomy or both. Forty-two women (63%) had normal internal genitalia. Of the 61 peri- and postmenopausal women, nine underwent bilateral oophorectomy for therapeutic reasons. No prophylactic oophorectomies were performed in any of the patients. CONCLUSION Incidental pathologic findings necessitating gynecological procedures are common in patients undergoing surgery for rectal cancer. These findings are frequently suboptimally assessed and managed in the pre-, intra-, and postoperative periods. Colorectal surgeons operating on women with Stage II and III rectal cancer should be cognizant of the high likelihood of identifying incidental gynecologic pathology and be prepared for definitive management of the pathology. The utilization of prophylactic oophorectomy in postmenopausal women undergoing surgery for rectal cancer is currently not optimal; preoperative discussion should address this option.
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Affiliation(s)
- Sven O Becker
- The Kelly Gynecologic Oncology Service, Departments of Gynecology and Obstetrics, The Johns Hopkins Hospital and Medical Institutions, Baltimore, MD 21287, USA
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33
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Kauffman WM, Jenkins JJ, Helton K, Rao BN, Winer-Muram HT, Pratt CB. Imaging features of ovarian metastases from colonic adenocarcinoma in adolescents. Pediatr Radiol 2001; 25:286-8. [PMID: 7567240 DOI: 10.1007/bf02011103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This paper describes the imaging features of ovarian metastases from adenocarcinoma of the colon in adolescent females. We reviewed retrospectively abdominal and pelvic computed tomographic and pelvic ultrasound examinations, histologic slices, and clinical charts of six adolescent females with ovarian metastases secondary to adenocarcinoma of the colon. One patient had ovarian metastasis at presentation and was presumed to have a primary ovarian tumor. The ovarian metastases were either solid (n = 3), complex with both solid and cystic components (n = 2), or multilocular cysts (n = 1). The ovarian lesions were large, ranging from 6 cm to 18 cm in diameter. Colorectal carcinoma in adolescent females is frequently associated with ovarian metastases. One imaging characteristic differs in adult and adolescent ovarian metastases, although they do have features in common: in adolescents, a smaller proportion of colorectal ovarian metastases are multicystic (17%) compared with the adult series (45%). These lesions are frequently large and may be complex, multicystic, or solid. Although it is a rare disease, the differential diagnosis of adnexal masses in adolescent females should include ovarian metastases from adenocarcinoma of the colon.
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Affiliation(s)
- W M Kauffman
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN 38101, USA
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34
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Yang TS, Hsu KC, Tang R, Chang TC. Colon carcinoma with synchronous ovarian metastasis--report and discussion of five cases. Anticancer Drugs 2000; 11:279-83. [PMID: 10898544 DOI: 10.1097/00001813-200004000-00009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Ovarian metastasis may present at the time of initial diagnosis of colon carcinoma or as a later recurrence. Little meaningful information is available regarding the treatment and outcome of synchronous ovarian metastasis of colon carcinoma. This report describes the clinical course of five patients with synchronous ovarian metastasis of colon carcinoma who were treated with aggressive surgery and chemotherapy. The treatment consisted of maximal surgical debulking followed by systemic chemotherapy with weekly 24 h infusion of high-dose 5-fluorouracil and leucovorin. All of the five patients had subsequent disease-free periods ranging from 6 to 43+ months following operation. Two of the patients who had no or minimal peritoneal involvement were still alive without disease at 33 and 43 months. The data from these cases suggest that aggressive surgery and systemic chemotherapy may be highly efficacious in the treatment of colon carcinoma with synchronous ovarian metastasis. Maximal debulking followed by chemotherapy may be particularly effective in those patients with minimal peritoneal involvement.
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Affiliation(s)
- T S Yang
- Department of Internal Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan.
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35
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Killackey MA. Avoidance of female genital tract complications in relation to pelvic surgery for cancer. SEMINARS IN SURGICAL ONCOLOGY 2000; 18:229-34. [PMID: 10757888 DOI: 10.1002/(sici)1098-2388(200004/05)18:3<229::aid-ssu6>3.0.co;2-#] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
As pelvic surgeons, it is essential that the colorectal surgeon and gynecologist have knowledge of and mutual respect for the areas of expertise that each specialty offers. The surgeon will encounter situations in which knowledge of the gynecologic anatomy is essential if injury is to be avoided during colorectal procedures. Gynecologic oncologists are trained not only to resect gynecologic cancers, but to also manage any complications that may result from cancer therapy or progressive disease. In many communities in which a gynecologic oncologist is not available, the surgical oncologist or colorectal surgeon will be consulted to assist in the management of gynecologic cancers. These surgeons must have the technical prerequisites and detailed knowledge about the mechanisms of spread, patterns of distant and local recurrences, the probability for cure, and the treatment methods to achieve management in the various cancers. We will discuss problems and complications of the female genital tract encountered by the colorectal surgeon during pelvic surgery for both bowel and gynecologic cancers, with an emphasis on prevention. Additionally, issues such as prophylactic oophorectomy and hysterectomy, management of gastrointestinal (GI) tract involvement in gynecologic cancer patients, the approach to peritoneal carcinomatosis, and situations where both the gynecologic and colorectal teams are required will be presented.
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Affiliation(s)
- M A Killackey
- Gynecologic Oncology, St. Luke's-Roosevelt Hospital Center, Columbia University, New York, New York 10019, USA
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36
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Kim NK, Kim HK, Park BJ, Kim MS, Kim YI, Heo DS, Bang YJ. Risk factors for ovarian metastasis following curative resection of gastric adenocarcinoma. Cancer 1999. [PMID: 10193938 DOI: 10.1002/(sici)1097-0142(19990401)85:7<1490::aid-cncr9>3.0.co;2-g] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Surgery for potentially curable colorectal cancer most commonly involves resection of the primary tumor and regional lymph nodes. However, the site, extent and presentation of disease have an impact on surgical strategy and the use of combined modality therapy. For colon cancer, complex presentations such as obstructing or perforated colon cancer may influence surgical therapy, and issues pertaining to en bloc resection and oophorectomy remain unresolved. For rectal cancer, surgical management may range from local excision to radical resection. Extent of resection and relatively new operative techniques such as coloanal anastomosis with or without a colonic pouch reservoir are directed towards optimizing both oncologic and functional results.
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Affiliation(s)
- L Ruo
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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38
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Abstract
Colorectal carcinoma complicating pregnancy is rare but associated with a high maternal mortality rate. Stage for stage the survival data are the same for pregnant patients and nonpregnant controls, however diagnosis is often delayed due to pregnancy-associated gastrointestinal symptoms masking cancer symptoms. A high degree of suspicion, especially in high-risk patients, is the key to early detection and improved prognosis. Digital rectal exams, occult fecal blood tests, and flexible sigmoidoscopy or colonoscopy are performed as indicated. Treatment primarily consists of en-bloc resection of the malignancy and regional lymph nodes; timing of colorectal surgery and delivery are based upon clinical presentation, fetal age, and maternal desires.
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Affiliation(s)
- J S Skilling
- Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Sacramento, USA
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39
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Abstract
Women have special physiologic considerations that may increase their risk of being diagnosed with certain cancers; however, the most important aspect to remember is that women are diagnosed with and die from many of the same malignancies as men. Health care providers need to be vigilant in evaluating women because one of the best ways to increase the chance of survival is early detection.
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Affiliation(s)
- C M Broome
- Department of Medicine, George Washington University, Washington, DC, USA
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40
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Young-Fadok TM, Wolff BG, Nivatvongs S, Metzger PP, Ilstrup DM. Prophylactic oophorectomy in colorectal carcinoma: preliminary results of a randomized, prospective trial. Dis Colon Rectum 1998; 41:277-83; discussion 283-5. [PMID: 9514421 DOI: 10.1007/bf02237479] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED Controversy exists regarding the role of prophylactic oophorectomy during resection for primary colorectal cancer. PURPOSE A prospective, randomized trial was initiated to evaluate the influence of oophorectomy on recurrence and survival in patients with Dukes Stages B and C colorectal cancer. METHOD Between November 1986 and March 1997, 155 patients were randomized to oophorectomy or no oophorectomy at laparotomy for resection of colorectal cancer. RESULTS No incidence of gross or microscopic metastatic disease to the ovary was found among 77 patients randomized to oophorectomy, in contrast to previous reports. Preliminary crude survival curves suggested a survival benefit for oophorectomy between two and three years from surgery, but Kaplan-Meier survival analysis indicated that this was not statistically significant and the benefit does not appear to persist at five years. Kaplan-Meier curves of recurrence-free survival, however, suggest a more substantial separation of the curves, with 80 percent vs. 65 percent five-year disease-free survival for oophorectomy vs. nonoophorectomy, but further patient accrual is necessary to provide sufficient statistical power. CONCLUSIONS Occult colorectal carcinoma metastatic to the ovaries has not been documented in this series of putative Dukes Stages B and C tumors. The possibility of a recurrence-free survival advantage emphasizes the need to continue this preliminary work.
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Affiliation(s)
- T M Young-Fadok
- Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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41
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Sielezneff I, Salle E, Antoine K, Thirion X, Brunet C, Sastre B. Simultaneous bilateral oophorectomy does not improve prognosis of postmenopausal women undergoing colorectal resection for cancer. Dis Colon Rectum 1997; 40:1299-302. [PMID: 9369103 DOI: 10.1007/bf02050813] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Synchronous or metachronous ovarian metastases are common along the natural course of colorectal carcinoma. We attempted to prospectively assess the prognostic impact of simultaneous bilateral oophorectomy in postmenopausal women undergoing curative resection for colorectal cancer. METHODS Between 1980 and 1990, simultaneous bilateral oophorectomy was proposed in each postmenopausal woman referred to our institution for treatment of colorectal cancer. A subset of 92 patients underwent a curative resection. Therefore, two groups were designed for comparison of the procedure. Group I included 41 patients who accepted surgical castration, and Group II consisted of the 51 remaining patients who refused. Prospective analysis of all patients was performed. Results were assessed with a follow-up of 60 months after surgery, with 97.9 percent completion. Local recurrence and liver metastases rates were compared by the chi-squared test. Survival in each group was calculated by the Kaplan-Meier method and compared by the log-rank test. RESULTS One patient (1/41; 2.4 percent) had ovarian metastases detected on the operative specimen. Local recurrence or liver metastases rates were not affected by oophorectomy (P = 0.73; P = 0.25). Five-year actuarial survival rates were not significantly different whether patients had oophorectomy (81.6 percent) or not (87.9 percent; P = 0.62). CONCLUSIONS Our results suggest that microscopic synchronous ovarian metastasis is rare at the time of curative resection of a colorectal carcinoma in postmenopausal women. Because simultaneous bilateral oophorectomy does not modify prognosis, this procedure seems to be unwarranted.
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Affiliation(s)
- I Sielezneff
- Department of Digestive Surgery, Hôpital Sainte-Marguerite, Marseille, France
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42
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Miller BE, Pittman B, Wan JY, Fleming M. Colon cancer with metastasis to the ovary at time of initial diagnosis. Gynecol Oncol 1997; 66:368-71. [PMID: 9299247 DOI: 10.1006/gyno.1997.4811] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Colon cancer with a synchronous ovarian metastasis is occasionally diagnosed at the time of laparotomy for a pelvic mass. The purpose of this retrospective study is to evaluate the clinical presentation as well as the impact of the type of metastatic spread and surgical intervention on overall survival. We reviewed charts of 23 patients treated between 1980 and 1995. Pain was the initial symptom in 14 patients (61%), with only four patients (17%) complaining of rectal bleeding, but with five patients (22%) complaining of uterine bleeding. At the time of laparotomy, the ovarian capsule was intact in 12 patients. Metastatic disease to the peritoneum was seen in seven patients and to the liver in six patients. On pathological evaluation, the median ovarian tumor size was 10 cm, significantly larger than the median colon tumor size of 4.5 cm. Surgical treatment consisted of colon resection in all but one patient, bilateral or unilateral salpingo-oophorectomy in 22 patients, and hysterectomy in nine patients. Only one patient survived 5 years. Sixteen patients died of colon cancer. The median survival time was 17.8 months, ranging from 1 to 86 months. Tumor size was of no prognostic importance. Median survival time of patients with peritoneal disease (10.8 months) was significantly shorter compared to patients without peritoneal disease (25.2 months). In the presence of liver metastasis, the median survival time was, likewise, significantly reduced from 20.1 months to 8.1 months. In conclusion, macroscopic metastatic disease to the ovary is a poor prognostic factor in colon cancer. In selected patients who can be rendered disease-free by surgery, prolonged survival is possible and an aggressive approach is recommended. Survival of patients with peritoneal disease or liver metastasis is short and a mainly palliative approach is recommended.
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Affiliation(s)
- B E Miller
- Department of Obstetrics and Gynecology, University of Tennessee, Memphis, Tennessee 38103, USA
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43
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Sugarbaker PH, Averbach AM. Krukenberg syndrome as a natural manifestation of tumor cell entrapment. Cancer Treat Res 1996; 82:163-191. [PMID: 8849950 DOI: 10.1007/978-1-4613-1247-5_11] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
In summary, confusion exists among clinicians regarding the possibilities of treatment for ovarian metastases in general, and of the Krukenberg tumors in particular. The ovaries themselves are easily removable irrespective of their sizes, but disappointing long-term results of oophorectomy alone leave most surgeons with only the choice of conservative therapy unless there is a debilitating tumor mass. In most patients nothing is done until surgical palliation becomes mandatory. There is a group of patients with isolated peritoneal dissemination of gastrointestinal cancers who are eligible for new treatment strategies. This group includes patients who have small-volume peritoneal spread or who can be completely cytoreduced, and those who have no evidence of liver or extraabdominal metastases. An aggressive approach with cytoreductive surgery and intraperitoneal chemotherapy with or without additional systemic chemotherapy should be considered for the treatment of selected patients.
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44
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Abstract
PURPOSE Incidental surgery is a common occurrence in abdominal operations. This article is a review of recent publications on the safety and efficacy of such secondary procedures. METHODS A recent review of the literature as well as incorporation of some original data were conducted. RESULTS Incidental surgery is safe, but the indication should be clear in the surgeon's mind, including epidemiologic risk of disease in such organs as the gallbladder and appendix. CONCLUSION Factors that must be included into a decision to perform incidental surgery should be the age and general health of the patient, prognosis, setting of the original operation (emergency vs. nonemergency), and epidemiologic risk of disease when incidental surgery is performed prophylactically.
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Affiliation(s)
- B G Wolff
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Taylor AE, Nicolson VM, Cunningham D. Ovarian metastases from primary gastrointestinal malignancies: the Royal Marsden Hospital experience and implications for adjuvant treatment. Br J Cancer 1995; 71:92-6. [PMID: 7819057 PMCID: PMC2033445 DOI: 10.1038/bjc.1995.18] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
We investigated the pattern and frequency of ovarian metastases in patients with primary gastrointestinal malignancies and evaluated the response to surgery, chemotherapy and in three cases radiotherapy. The literature reports that this group of patients have a poor prognosis, but no report has specifically addressed the response to chemotherapy. Using a database which is generated prospectively, we analysed 51 patients with primary gastrointestinal malignancies and ovarian metastases. All patients received chemotherapy but only 36 were evaluable for response; five had adjuvant treatment and ten had non-measurable disease. Seventeen patients had surgical oophorectomy and three patients received radiotherapy. The overall response rate to chemotherapy was 22%; eight partial responses and no complete responses. When stratified according to site of response, 11 (31%) patients had a partial response at sites of extraovarian metastases and only five (14%) had a partial response in the ovaries. Seven patients with primary colorectal cancer had a differential response in favour of extraovarian sites. The median survival was 9 months for the 51 patients. Three premenopausal women with resected gastric carcinoma received adjuvant chemotherapy and relapsed only in the ovaries. In primary colorectal tumours the response of ovarian metastases to chemotherapy is less than that for other sites. Therefore, the ovary may be a sanctuary site for metastases which has important implications for adjuvant chemotherapy in women. These women could be followed up regularly by transvaginal ultrasonography to detect such metastases at an early stage when they would be amenable to surgical resection. Surgery should be considered for selected patients who develop metachronous metastases, as patients may be rendered disease free for several months.
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Affiliation(s)
- A E Taylor
- CRC Section of Medicine, Royal Marsden Hospital, Sutton, Surrey, UK
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Abstract
Plasma lysozyme levels are elevated in several different pathological conditions. In our study we show that well differentiated human hepatoma cells Hep3B and HepG2 are active synthesis sites of lysozyme and that this synthesis can be modulated by acute phase mediators. The production and modulation of lysozyme synthesis was studied by means of Northern-blot analysis, sodium dodecyl sulfate-polyacrylamide gel electrophoresis and a specific bioassay after treatment of the cells with interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha. Hep3B and HepG2 cells constitutively synthesize high amounts of lysozyme. Lysozyme synthesis and secretion were found to be augmented by interleukin-1 beta and tumor necrosis factor-alpha in both cell lines. Interleukin-6 caused an increase in lysozyme production in Hep3B but a decrease in the HepG2 cells. As expected, the synthesis of albumin was decreased in both cell lines. Furthermore we demonstrated that HepG2 and Hep3B cells produce a biologically active form of the enzyme as measured by a specific bioassay. The results demonstrate that lysozyme is constitutively synthesized by Hep3B and HepG2 hepatoma cell lines and that lysozyme synthesis is modulated by acute-phase mediators. Well differentiated human hepatoma cells may respond differently to different cytokines.
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Affiliation(s)
- N Köbsel
- Abteilung Gastroenterologie und Endokrinologie, Georg-August-Universität Göttingen, Germany
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Abstract
Although surgery has been the mainstay of treatment for patients with colorectal carcinoma for more than a century, debate continues regarding the appropriate magnitude of operation for optimal survival. Invasion of contiguous organs is a legitimate indication for extended en bloc resection, including pelvic exenteration, in appropriately selected individuals. Extended lymphadenectomy, especially in resections for carcinoma of the rectum, is being reexamined with renewed enthusiasm. Improved perioperative care has permitted performance of more aggressive operative intervention, with improved cure rates for patients with colorectal neoplasms.
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Affiliation(s)
- R J Staniunas
- Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts
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Affiliation(s)
- R R Dozois
- Mayo Medical School, Rochester, Minnesota
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Crowther ME, Britton KE, Granowska M, Shepherd JH. Monoclonal antibodies and their usefulness in epithelial ovarian cancer. A review. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1989; 96:516-21. [PMID: 2667627 DOI: 10.1111/j.1471-0528.1989.tb03249.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- M E Crowther
- Department of Gynaecological Oncology, St Bartholomew's Hospital, London
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