Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Tumour-to-tumour metastasis of lung adenocarcinoma to ovarian serous cystadenoma K.-W. Min, S. S. Paik, H. Han, W. S. Kim & K. Jang To cite this article: K.-W. Min, S. S. Paik, H. Han, W. S. Kim & K. Jang (2014) Tumour-to-tumour metastasis of lung adenocarcinoma to ovarian serous cystadenoma, Journal of Obstetrics and Gynaecology, 34:7, 650-658 To link to this article: http://dx.doi.org/10.3109/01443615.2014.902431
Published online: 11 Apr 2014.
Submit your article to this journal
Article views: 47
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [NUS National University of Singapore]
Date: 06 November 2015, At: 20:13
Journal of Obstetrics and Gynaecology, October 2014; 34: 650–658 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online
GYNAECOLOGY CASE REPORTS
Tumour-to-tumour metastasis of lung adenocarcinoma to ovarian serous cystadenoma
Downloaded by [NUS National University of Singapore] at 20:13 06 November 2015
K.-W. Min1, S. S. Paik2, H. Han2, W. S. Kim3 & K. Jang2 Departments of Pathology, 1Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 2College of Medicine, Hanyang University, and 3Konkuk University School of Medicine, Seoul, Republic of Korea DOI: 10.3109/01443615.2014.902431 Correspondence: K. Jang, Department of Pathology, College of Medicine, Hanyang University, 17 Haengdang-Dong, Seongdong-Gu, Seoul, 133–792, Korea. E-mail: [email protected]
Introduction Tumour-to-tumour metastasis is a rare phenomenon, although double primary neoplasms are fairly common. Since it was first described by Berent in 1902, fewer than 200 cases have been reported in the English-language literature (Berent 1902). The most frequent donor tumour is lung cancer, followed by breast, prostate and thyroid carcinoma (Ro et al. 1990). Renal cell carcinomas are the most common recipients of metastases in the case of malignant tumours, while meningioma appears to be the most common recipient of benign tumours (Honma et al. 1989; Sella and Ro 1987).
Metastasis to the ovary is more common in younger women, which suggests that the abundant vascularity and local hormonal effects may be important. Tumours that are known to secondarily involve the ovary typically include carcinomas of the breast and the gastrointestinal tract. We describe the first case of lung adenocarcinoma that metastasised into a large ovarian serous cystadenoma.
Case report A 68-year-old woman was admitted to the outpatient department with enlarged ovarian masses detected during a routine medical check-up. Pelvic sonography and computed tomography (CT) revealed a multiseptated cystic mass in each ovary (Figure 1a). During routine preoperative check-up, chest X-ray incidentally detected a relatively well-defined nodular lesion in the right lower lobe. Subsequent chest CT confirmed an approximately 2.5 cm illdefined mass, with multiple enlarged lymph nodes, in the superior segment of the right lower lobe (Figure 1b). Fine-needle aspiration biopsy identified acinar structures made up of atypical cells and thus consistent with adenocarcinoma. Whole-body positron emission tomography (PET) showed diffuse low-level fluorodeoxyglucose (18F-FDG) uptake by the lung adenocarcinoma. The bilateral ovarian cysts were non-18F-FDG-avid, and the assessment of other organs was unrevealing. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. The right ovarian mass (ovary: 21 ⫻ 19 ⫻ 15 cm, 2,400 g) was a multilocular cyst filled with serous fluid (Figure 1c) and with focal solid and papillary nodules. The left ovarian mass was also a multilocular cyst filled with serous fluid. On microscopy, both ovarian masses showed multilocular cystic spaces lined with a single layer of ciliated
Figure 1. (a) Axial pelvic CT with contrast enhancement shows an 18.4 cm lobulating and multiseptated cystic tumour without significant enhancement in the right ovary. (b) Axial chest CT shows a 2.5 cm ill-defined cavitary mass in the superior segment of the right lower lobe (white arrow), and enlargement of conglomerulated metastatic lymph nodes in the right hilum and mediastinum (black arrows). (c) Viewed grossly, the right ovarian mass is mostly multilobular, cystic and filled with serous fluid. (d) Micrographic findings show glandular and/or acinar structures in the cystic stroma, and a single layer of ciliated and/or non-ciliated columnar cells (H&E, ⫻ 100). Immunohistochemical staining is positive for thyroid transcription factor-1 in the metastatic tumor within the ovary (inset, ⫻ 400).
Downloaded by [NUS National University of Singapore] at 20:13 06 November 2015
Gynaecology Case Reports and non-ciliated epithelia, subsequently diagnosed as serous cystadenoma. In addition, atypical glandular structures were observed in the right ovary. The immunostaining was positive for TTF-1, napsin A, surfactant and cytokeratin-7. Their distinct histological features were consistent with metastatic adenocarcinoma from the lung (Figure 1d). Subsequently, she was transferred to a regional hospital for adjuvant chemotherapy and was lost to further follow-up.
A. Macciò1, C. Madeddu2, P. Kotsonis3, M. Pietrangeli1 & A. M. Paoletti4
Discussion
1Department of Gynaecologic Oncology, A. Businco Hospital,
Although renal cell carcinoma is by far the most common recipient among malignant tumours, ovarian tumours are also potential recipients of metastases. A previous study demonstrated similar general metastatic tendencies among all lung cancers in tumour-to-tumour metastasis, regardless of their histological subgroup. Metastatic lesions involving primary ovarian tumours have been reported infrequently. In a review of the English literature, six of these cases originated in the breast, four in the stomach and one in the uterine cervix. Eight of the 11 tumours were benign and included three dermoid cysts, two Brenner tumours, one combined cystadenoma/Brenner tumour, one fibroma and one thecoma. The remaining neoplasms were potentially malignant and included one pseudomucinous cystadenocarcinoma, one borderline cystadenoma and one cystic ovarium carcinoma. In our patient’s case, we observed the coexistence of two neoplasms within one site: a serous cystadenoma of local origin and a metastasis of lung adenocarcinoma. A similar case had not been reported previously. The mechanism of tumour-to-tumour metastasis results from a complex cascade of interactions between the tumour cells and their environment (Hart and Saini 1992). The process begins with shedding of cells from a primary tumour into the circulation, where they must survive until they can arrest in another organ, followed by extravasation into the surrounding tissue, growth, and vascularisation (Chambers et al. 2002). These complex interactions between the primary tumour and the organ-specific patterns of metastasis are consisted with the ‘seed and soil’ analogy, first proposed over a century ago by Paget (1989). It is not known why tumours so rarely become sites of metastasis of malignant neoplasms. Metastasis is a ‘hidden’ process that occurs inside the body and so is inherently difficult to observe (Chambers et al. 2002). Since the normal ovarian environment provides rich ‘soil’ for the growth of metastases, ovarian tumours could play host to metastases from specific organs. In each specific case, it is possible that molecular factors in the environment associated with a benign ovarian cyst influence the metastatic implantation of lung adenocarcinomas. However, the pre-existing tumour could even produce factors that inhibit colonisation by other neoplasms. In conclusion, we report for the first time, a case of tumour-totumour metastasis of lung adenocarcinoma into an ovarian serous cystadenoma. Although the incidence of tumour-to-tumour metastasis is very rare, raising awareness of this pathology is important to avoid unnecessary diagnostic procedures in the evaluation of mass lesions with dimorphic patterns. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Berent W. 1902. Seltene Metastasenbildung. Zentralblatt fur Allgemeine Pathologie und Pathologische Anatomie 13:406–410. Chambers AF, Groom AC, MacDonald IC. 2002. Dissemination and growth of cancer cells in metastatic sites. Nature Reviews. Cancer 2:563–572. Hart IR, Saini A. 1992. Biology of tumour metastasis. Lancet 339:1453–1457. Honma K, Hara K, Sawai T. 1989. Tumour-to-tumour metastasis. A report of two unusual autopsy cases. Virchows Archives A, Pathological Anatomy and Histopathology 416:153–157. Paget S. 1989. The distribution of secondary growths in cancer of the breast. 1889. Cancer and Metastasis Reviews 8:98–101. Ro JY, Sahin AA, Ayala AG et al. 1990. Lung carcinoma with metastasis to testicular seminoma. Cancer 66:347–353. Sella A, Ro JY. 1987. Renal cell cancer: best recipient of tumor-to-tumor metastasis. Urology 30:35–38.
651
Successful laparoscopic management of a giant ovarian cyst
Regional Referral Center for Cancer Disease, 2Department of Medical Science ‘Mario Aresu’, 4Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, and 3Department of Obstetrics and Gynaecology, Sirai Hospital, Carbonia, Italy DOI: 10.3109/01443615.2014.902432 Correspondence: A. Macciò, Department of Gynaecologic Oncology, Businco Hospital, Regional Referral Center for Cancer Disease, via Edward Jenner, 09121 Cagliari, Italy. E-mail: [email protected]
Introduction Laparoscopy is considered the treatment of choice for the management of benign ovarian cysts. Its benefits include reduced invasiveness, reduced postoperative analgesic requirement, shorter hospitalisation, quicker recovery and an earlier resumption of patients’ social and professional life. A major factor for surgeons when deciding whether to perform a laparoscopy or laparotomy is the size of the ovarian mass. We report the case of a very large ovarian cyst safely and successfully treated with laparoscopy.
Case report A 72-year-old woman was referred to our department with a giant abdominal mass, worsening dyspnoea and swallowing problems. The patient weighed 122 kg and was unable to walk due to the huge mass. She had a 6-month history of vague abdominal pain and abdominal swelling, which gradually increased over the previous 4 months. Her bowel and bladder habits were normal. The abdominal wall was maximally tense, with a tumour filling the whole abdominal cavity with engorged veins (Figure 1a). Abdominal ultrasound showed a cystic unilocular structure with increased echogenicity. She was anaemic (haemoglobin 8.5 g/dl) with normal liver and renal functions and the CA125 was 89.7 ng/ml. Given the patient’s clinical picture and symptoms, urgent surgery was required. We opted for a laparoscopic approach on the assumption that this would afford the patient the best and most effective overall management and care. Following a minilaparotomy of about 5 cm above the umbilicus, to achieve the cyst decompression and minimise spillage we used a specially designed double balloon catheter (SAND balloon catheter, Hakko Medical, Tokyo, Japan). The punctured cyst wall was sandwiched between the two inflated balloons. About 35 litres of apparently haematic fluid were collected. Patient respiratory function improved soon after. We then used an abdominal hand-assisted laparoscopic device (Endopath® Dextrus™ Ethicon) placed in the supraumbilical port. Laparotomic access: a successful pneumoperitoneum was obtained by insertion of the first 10 mm trocar and was maintained throughout the surgery. The intra-abdominal cavity was visualised using a 10 mm, 0 degree telescope (Karl Storz, Tuttlingen, Germany) and four ancillary trocars (5 mm) were positioned under laparoscopic visualisation: two in the bilateral lower quadrants, one between the umbilicus and the pubic symphysis and one in the left side above and parallel to the lower homolateral trocar site (Figure 1b). The liver, gallbladder, stomach and diaphragm appeared normal. We proceeded to carefully separate the mass from its adherences to the abdominal wall. We found the mass arising from the right adnexa. Following coagulation with BiClamp LAP forceps (ERBE GmbH, Tubingen, Germany) of the uteroovarian and infundibulopelvic ligaments and the tube, the annex with the giant ovarian cyst was dissected using monopolar forceps. The cyst was excised intact. Thereafter, total laparoscopic
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Tumour-to-tumour metastasis of lung adenocarcinoma to ovarian serous cystadenoma K.-W. Min, S. S. Paik, H. Han, W. S. Kim & K. Jang To cite this article: K.-W. Min, S. S. Paik, H. Han, W. S. Kim & K. Jang (2014) Tumour-to-tumour metastasis of lung adenocarcinoma to ovarian serous cystadenoma, Journal of Obstetrics and Gynaecology, 34:7, 650-658 To link to this article: http://dx.doi.org/10.3109/01443615.2014.902431
Published online: 11 Apr 2014.
Submit your article to this journal
Article views: 47
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [NUS National University of Singapore]
Date: 06 November 2015, At: 20:13
Journal of Obstetrics and Gynaecology, October 2014; 34: 650–658 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online
GYNAECOLOGY CASE REPORTS
Tumour-to-tumour metastasis of lung adenocarcinoma to ovarian serous cystadenoma
Downloaded by [NUS National University of Singapore] at 20:13 06 November 2015
K.-W. Min1, S. S. Paik2, H. Han2, W. S. Kim3 & K. Jang2 Departments of Pathology, 1Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 2College of Medicine, Hanyang University, and 3Konkuk University School of Medicine, Seoul, Republic of Korea DOI: 10.3109/01443615.2014.902431 Correspondence: K. Jang, Department of Pathology, College of Medicine, Hanyang University, 17 Haengdang-Dong, Seongdong-Gu, Seoul, 133–792, Korea. E-mail: [email protected]
Introduction Tumour-to-tumour metastasis is a rare phenomenon, although double primary neoplasms are fairly common. Since it was first described by Berent in 1902, fewer than 200 cases have been reported in the English-language literature (Berent 1902). The most frequent donor tumour is lung cancer, followed by breast, prostate and thyroid carcinoma (Ro et al. 1990). Renal cell carcinomas are the most common recipients of metastases in the case of malignant tumours, while meningioma appears to be the most common recipient of benign tumours (Honma et al. 1989; Sella and Ro 1987).
Metastasis to the ovary is more common in younger women, which suggests that the abundant vascularity and local hormonal effects may be important. Tumours that are known to secondarily involve the ovary typically include carcinomas of the breast and the gastrointestinal tract. We describe the first case of lung adenocarcinoma that metastasised into a large ovarian serous cystadenoma.
Case report A 68-year-old woman was admitted to the outpatient department with enlarged ovarian masses detected during a routine medical check-up. Pelvic sonography and computed tomography (CT) revealed a multiseptated cystic mass in each ovary (Figure 1a). During routine preoperative check-up, chest X-ray incidentally detected a relatively well-defined nodular lesion in the right lower lobe. Subsequent chest CT confirmed an approximately 2.5 cm illdefined mass, with multiple enlarged lymph nodes, in the superior segment of the right lower lobe (Figure 1b). Fine-needle aspiration biopsy identified acinar structures made up of atypical cells and thus consistent with adenocarcinoma. Whole-body positron emission tomography (PET) showed diffuse low-level fluorodeoxyglucose (18F-FDG) uptake by the lung adenocarcinoma. The bilateral ovarian cysts were non-18F-FDG-avid, and the assessment of other organs was unrevealing. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. The right ovarian mass (ovary: 21 ⫻ 19 ⫻ 15 cm, 2,400 g) was a multilocular cyst filled with serous fluid (Figure 1c) and with focal solid and papillary nodules. The left ovarian mass was also a multilocular cyst filled with serous fluid. On microscopy, both ovarian masses showed multilocular cystic spaces lined with a single layer of ciliated
Figure 1. (a) Axial pelvic CT with contrast enhancement shows an 18.4 cm lobulating and multiseptated cystic tumour without significant enhancement in the right ovary. (b) Axial chest CT shows a 2.5 cm ill-defined cavitary mass in the superior segment of the right lower lobe (white arrow), and enlargement of conglomerulated metastatic lymph nodes in the right hilum and mediastinum (black arrows). (c) Viewed grossly, the right ovarian mass is mostly multilobular, cystic and filled with serous fluid. (d) Micrographic findings show glandular and/or acinar structures in the cystic stroma, and a single layer of ciliated and/or non-ciliated columnar cells (H&E, ⫻ 100). Immunohistochemical staining is positive for thyroid transcription factor-1 in the metastatic tumor within the ovary (inset, ⫻ 400).
Downloaded by [NUS National University of Singapore] at 20:13 06 November 2015
Gynaecology Case Reports and non-ciliated epithelia, subsequently diagnosed as serous cystadenoma. In addition, atypical glandular structures were observed in the right ovary. The immunostaining was positive for TTF-1, napsin A, surfactant and cytokeratin-7. Their distinct histological features were consistent with metastatic adenocarcinoma from the lung (Figure 1d). Subsequently, she was transferred to a regional hospital for adjuvant chemotherapy and was lost to further follow-up.
A. Macciò1, C. Madeddu2, P. Kotsonis3, M. Pietrangeli1 & A. M. Paoletti4
Discussion
1Department of Gynaecologic Oncology, A. Businco Hospital,
Although renal cell carcinoma is by far the most common recipient among malignant tumours, ovarian tumours are also potential recipients of metastases. A previous study demonstrated similar general metastatic tendencies among all lung cancers in tumour-to-tumour metastasis, regardless of their histological subgroup. Metastatic lesions involving primary ovarian tumours have been reported infrequently. In a review of the English literature, six of these cases originated in the breast, four in the stomach and one in the uterine cervix. Eight of the 11 tumours were benign and included three dermoid cysts, two Brenner tumours, one combined cystadenoma/Brenner tumour, one fibroma and one thecoma. The remaining neoplasms were potentially malignant and included one pseudomucinous cystadenocarcinoma, one borderline cystadenoma and one cystic ovarium carcinoma. In our patient’s case, we observed the coexistence of two neoplasms within one site: a serous cystadenoma of local origin and a metastasis of lung adenocarcinoma. A similar case had not been reported previously. The mechanism of tumour-to-tumour metastasis results from a complex cascade of interactions between the tumour cells and their environment (Hart and Saini 1992). The process begins with shedding of cells from a primary tumour into the circulation, where they must survive until they can arrest in another organ, followed by extravasation into the surrounding tissue, growth, and vascularisation (Chambers et al. 2002). These complex interactions between the primary tumour and the organ-specific patterns of metastasis are consisted with the ‘seed and soil’ analogy, first proposed over a century ago by Paget (1989). It is not known why tumours so rarely become sites of metastasis of malignant neoplasms. Metastasis is a ‘hidden’ process that occurs inside the body and so is inherently difficult to observe (Chambers et al. 2002). Since the normal ovarian environment provides rich ‘soil’ for the growth of metastases, ovarian tumours could play host to metastases from specific organs. In each specific case, it is possible that molecular factors in the environment associated with a benign ovarian cyst influence the metastatic implantation of lung adenocarcinomas. However, the pre-existing tumour could even produce factors that inhibit colonisation by other neoplasms. In conclusion, we report for the first time, a case of tumour-totumour metastasis of lung adenocarcinoma into an ovarian serous cystadenoma. Although the incidence of tumour-to-tumour metastasis is very rare, raising awareness of this pathology is important to avoid unnecessary diagnostic procedures in the evaluation of mass lesions with dimorphic patterns. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Berent W. 1902. Seltene Metastasenbildung. Zentralblatt fur Allgemeine Pathologie und Pathologische Anatomie 13:406–410. Chambers AF, Groom AC, MacDonald IC. 2002. Dissemination and growth of cancer cells in metastatic sites. Nature Reviews. Cancer 2:563–572. Hart IR, Saini A. 1992. Biology of tumour metastasis. Lancet 339:1453–1457. Honma K, Hara K, Sawai T. 1989. Tumour-to-tumour metastasis. A report of two unusual autopsy cases. Virchows Archives A, Pathological Anatomy and Histopathology 416:153–157. Paget S. 1989. The distribution of secondary growths in cancer of the breast. 1889. Cancer and Metastasis Reviews 8:98–101. Ro JY, Sahin AA, Ayala AG et al. 1990. Lung carcinoma with metastasis to testicular seminoma. Cancer 66:347–353. Sella A, Ro JY. 1987. Renal cell cancer: best recipient of tumor-to-tumor metastasis. Urology 30:35–38.
651
Successful laparoscopic management of a giant ovarian cyst
Regional Referral Center for Cancer Disease, 2Department of Medical Science ‘Mario Aresu’, 4Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, and 3Department of Obstetrics and Gynaecology, Sirai Hospital, Carbonia, Italy DOI: 10.3109/01443615.2014.902432 Correspondence: A. Macciò, Department of Gynaecologic Oncology, Businco Hospital, Regional Referral Center for Cancer Disease, via Edward Jenner, 09121 Cagliari, Italy. E-mail: [email protected]
Introduction Laparoscopy is considered the treatment of choice for the management of benign ovarian cysts. Its benefits include reduced invasiveness, reduced postoperative analgesic requirement, shorter hospitalisation, quicker recovery and an earlier resumption of patients’ social and professional life. A major factor for surgeons when deciding whether to perform a laparoscopy or laparotomy is the size of the ovarian mass. We report the case of a very large ovarian cyst safely and successfully treated with laparoscopy.
Case report A 72-year-old woman was referred to our department with a giant abdominal mass, worsening dyspnoea and swallowing problems. The patient weighed 122 kg and was unable to walk due to the huge mass. She had a 6-month history of vague abdominal pain and abdominal swelling, which gradually increased over the previous 4 months. Her bowel and bladder habits were normal. The abdominal wall was maximally tense, with a tumour filling the whole abdominal cavity with engorged veins (Figure 1a). Abdominal ultrasound showed a cystic unilocular structure with increased echogenicity. She was anaemic (haemoglobin 8.5 g/dl) with normal liver and renal functions and the CA125 was 89.7 ng/ml. Given the patient’s clinical picture and symptoms, urgent surgery was required. We opted for a laparoscopic approach on the assumption that this would afford the patient the best and most effective overall management and care. Following a minilaparotomy of about 5 cm above the umbilicus, to achieve the cyst decompression and minimise spillage we used a specially designed double balloon catheter (SAND balloon catheter, Hakko Medical, Tokyo, Japan). The punctured cyst wall was sandwiched between the two inflated balloons. About 35 litres of apparently haematic fluid were collected. Patient respiratory function improved soon after. We then used an abdominal hand-assisted laparoscopic device (Endopath® Dextrus™ Ethicon) placed in the supraumbilical port. Laparotomic access: a successful pneumoperitoneum was obtained by insertion of the first 10 mm trocar and was maintained throughout the surgery. The intra-abdominal cavity was visualised using a 10 mm, 0 degree telescope (Karl Storz, Tuttlingen, Germany) and four ancillary trocars (5 mm) were positioned under laparoscopic visualisation: two in the bilateral lower quadrants, one between the umbilicus and the pubic symphysis and one in the left side above and parallel to the lower homolateral trocar site (Figure 1b). The liver, gallbladder, stomach and diaphragm appeared normal. We proceeded to carefully separate the mass from its adherences to the abdominal wall. We found the mass arising from the right adnexa. Following coagulation with BiClamp LAP forceps (ERBE GmbH, Tubingen, Germany) of the uteroovarian and infundibulopelvic ligaments and the tube, the annex with the giant ovarian cyst was dissected using monopolar forceps. The cyst was excised intact. Thereafter, total laparoscopic
