METASTATIC CARCINOMA TO THE OVARY Steven G. Silverberg, M.D. University of Maryland Baltimore, Maryland, U.S.A.
METASTATIC CARCINOMATO THE OVARY
Steven G. Silverberg, M.D.University of Maryland
Baltimore, Maryland, U.S.A.
CLINICAL IMPORTANCE OF METASTASES TO THE OVARY
• 10-20% of all cancers in the ovary are metastatic
• higher proportion of mucinous, ? endometrioid-appearing tumors
• surgical Rx: find metastases/“implants” vs. find the primary (first or second operation)
• chemotherapy: different for ovarian vs. other 1o sites
TIME OF DIAGNOSISOF OVARIAN METASTASES
• after primary• concurrent with primary (?FS of ovarian
tumor)• before primary (most difficult for the
pathologist; 17-38% of cases in the literature
TYPES OF CANCERS METASTASIZING TO THE OVARY
• most commonly adenocarcinomas, but anything is possible (squamous, small cell neuroendocrine, transitional cell, melanoma, sarcomas, etc.
• lymphomas/leukemic infiltrates can be 1o in the ovary or (more often) part of a disseminated process)
• if no residual ovarian tissue is found, R/O a primary parovarian process
MAIN SOURCE OF CARCINOMA METASTATIC TO THE OVARY
• genital (contralateral ovary, corpus, cervix [adeno], fallopian tube)
• extragenital (esp. colorectum, breast, stomach, pancreas, appendix)
• synchronous primaries are an important consideration mostly for genital sites
METASTATIC COLORECTAL ADENOCARCINOMA:CLINICAL FEATURES
• ~ 1/3 or more of all metastatic ovarian cancers
• 2-10% of women with colorectal carcinoma develop ovarian metastases
• up to 45% of metastases are thought clinically to be ovarian 1o
• 3% of women in one series presented with ovarian mass and unsuspected intestinal disease
METASTATIC COLORECTAL ADENOCARCINOMA:
PATHOLOGIC PROBLEMS
• 30-50% may be unilateral• usually smaller than 10 cm, but may be 20-30
cm• ~ 1/3 contain benign-appearing or borderline-
appearing foci (occasionally most or all of the sampled tumor)
• may appear mucinous or endometrioid, rarely clear cell, papillary, signet cell, or adenosquamous
SMALL CELL TUMORS IN THE OVARY:DIFFERENTIAL DIAGNOSIS
Lymphoid markers
Inhibin, calretinin
CK(7)CK, EMANE, TTF-1IHC
SheetsLut., cystsPleo.,? diff.
Small/large cellsAzzopardi effect
H&E features
LN/spleenEstrogenPerit. spread
CA++Lung 1oOther clinical features
B/UUBUBLaterality
AllYoungOlderYoungOlderAge
LymphomaJuv. GCTUndiff CAHypercalcemic SCC
Metastatic SCC
METASTASES TO THE OVARY FROM GENITAL TRACT CARCINOMAS
• endometrium• endocervix• contralateral ovary• fallopian tube
METASTASES FROM CONTRALATERAL OVARY
• LOH studies have suggested mets. more common than synchronous primaries
• usual criteria for differential diagnosis (multinodularity, surface and vascular involvement, etc.)
• serous/TCC/undiff. most frequently bilateral• clinically, staging and treatment same for
mets. and synchronous primaries
METASTASES FROM ENDOMETRIAL CARCINOMA VERSUS SEPARATE PRIMARIES
Not monoclonalMonoclonalNo vascular involvementVascular involvement
Primarily deepPrimarily surface involvedUninodularMultinodular
No other metastasesOther metastasesEndometriosisNo endometriosis
Low grade endometrioidType 2/high grade CANo myoinvasionDeep myoinvasion
YoungerOlder
Favor Synchronous PrimariesFavor Metastasis
MUCINOUS TUMORSOF OVARY AND CERVIX
(IJGP 7:99, 1988)
310316(3)Young
(Ob. Gyn. 64:553, 1984)
—145(2)Kaminski
(IJGP 1:391, 1983)
—404(1)LiVolsi
# BOTH# PRIMARY# METASTATIC# OF CASESAUTHORS
(1) 4 of 22 invasive cervical AC(2) 5 of 39 cervical mucinous AC, 6 of 51 endometrioid(3) 10 of 16 were “adenoma malignum”
MUCINOUS TUMORS OF OVARY AND CERVIX: HELPFUL CRITERIA
(Young and Scully, Int J Gynecol Pathol 7: 99, 1988)
CommonLess commonCervical tumor spread
Less commonOccasionalMucinous metaplasia of tube or endometrium
CommonUncommonLVSI in either tumor
DeepSuperficialCervical tumor invasionSimilarDissimilarTumor histology
CommonLess commonOvarian surface implantsBilateralUnilateralLaterality of ovarian tumor
ShortLongDisease-free follow-upShortLongInterval between tumors
MetastaticPrimary
Note: Endometriosis, IHC, and molecular studies not mentioned
ADENOCARCINOMAS OF OVARY AND CERVIX(Elishaev et al, AJSP 29:281-294, 2005)
• 10 Cases, all originally thought to be 1o ovarian tumors• Age 28-51• Ovary first in 2, after cervix in 3, simultaneous in 5• Ovarian tumors bilateral in 2 cases, unilateral in 8, 10 cm or
more in 7• 7 Ovarian tumors looked endometrioid, 3 mucinous; only 1 frankly
invasive• Suspicious features were combined endometrioid/mucinous
phenotype, BOT with IEC• Endocervical tumors mostly small (2 considered microinvasive)• 8 of 10 had no other metastases detected• p16 expression and identical HPV types (mostly 16) present in
cervical and ovarian tumors, ER/PR usually negative or weak