SAJOG 837

Multiple metastases from ovarian cancer


D Singh, MD; A Kapoor, MD; S L Jakhar, MD; P K Bagri, MD; H S Kumar, MD


Department of Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India

Corresponding author: D Singh (drsihag123@gmail.com)


Epithelial ovarian cancer is one of the most common ovarian tumours. Ovarian cancer affects women in the age group >60 years much more frequently than younger women. At the time of diagnosis, cancer will already have spread beyond the ovaries in approximately 75% of cases. We report a case of epithelial ovarian cancer presenting with liver and thoracic vertebral metastases 4 months after completion of treatment, as part of distant spread. The patient was then treated with gemcitabine-based chemotherapy. Palliative radiotherapy was given for the involved spine.

S Afr J OG 2014;20(3):94-95. DOI:10.7196/SAJOG.837


The incidence of ovarian can­cer is 6.1/100 000 popula­tion (3.6% of all cancer) world­wide. In India, the World Health Organi­zation reports that the crude incidence rate of this cancer is 4.9/100 000 women, 5% of all malig­nancies in women.1 Ovarian cancer is primarily a disease of postmenopausal women, the highest number of cases being concentrated in the age group 50 - 70 years.

To metastasise, a tumour cell must over­come a number of factors including entrance into the vascular system, travel to a distant site while avoiding immune surveillance, localisation in the micro­vasculature of the future metastatic site, growth, and evolution of a blood supply.2 , 3 The main route of dissemination in ovarian cancer is by transcoelomic spread and through the lymphatic system. Haemato­genous spread is uncommon. Ovarian cancer usually presents with widespread intra-abdominal metastases. However, the disease remains confined to the peritoneal cavity at presentation and throughout its course in approximately 85% of cases. Occasionally patients present with aggressive disease, manifested by parenchymal liver or lung metastases, or develop metastases to distant sites such as the brain and bone during disease progression. Metastasis to bone from these tumours is rare (0.1 - 0.12%).4-7 We report a rare case of thoracic vertebral metastasis with secondary lesions in the liver 4 months after chemotherapy in a young woman.


Case report

A 38-year-old premenopausal woman presen­ted to the Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India, with complaints of weakness, distension of the abdomen, loss of appetite and vague abdominal discom­fort of 2 months’ duration. The menstrual cycle was regular and without associated complaints. Ultrasonography of the abdomen and pelvis revealed a left-sided solid-cum-cystic adnexal mass with mild ascites. A tentative diagnosis of ovarian malignancy was entertained. No hereditary or other risk factor for ovarian cancer was found in the family history. Total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy were performed. Histopathological examin­ation of the specimen revealed mucinous papillary cystic adenocarcinoma in the left ovary. The uterus, cervix and fallopian tube were free and omental deposits were negative for malignancy. The patient was categorised as stage Ic as per International Federation of Obstetricians and Gyne­cologists staging.

Taxol and platinum-based adjuvant chemo­therapy were prescribed. Four months after completion of six cycles of chemo­therapy, she developed a mass in the right hypochondrium with backache. There was no evidence of pallor, icterus or lymph­adenopathy. Examination of the abdomen showed presence of free fluid with hepato­megaly. Vaginal examination revealed no abnormalities. A contrast-enhanced computed tomography scan of the abdo­men and pelvis showed multiple space-occupying lesions in the liver suggestive of metastases and mild ascites with no residual disease, along with postoperative changes (Fig. 1). The CA-125 level was raised (1 012 U/mL). A radiograph of the lumbar spine was not conclusive, so magnetic resonance imaging (MRI) of the spine was done. This revealed collapse of the D12 vertebra (Fig. 2). Biopsy of the lesion confirmed bone metastasis. The patient was hospitalised for further management, and palliative radiotherapy (800 cGy, single fraction) was given to the involved vertebra along with monthly intravenous injections of zoledronate 4 mg. Gemcitabine-based chemotherapy was given with appropriate premedications. The CA-125 level came down to 29 U/mL at the end of six cycles of chemotherapy, and the patient was symptom-free at 6 months of follow-up.


Fig. 1. Contrast-enhanced computed tomo­graphy scan showing multiple space-occupying lesions in the liver.


Fig. 2. Magnetic resonance image showing solitary metastasis at D12 vertebra.


Discussion

The course of ovarian cancer is highly variable, and the standard clinical predictors for metastasis and poor prog­nosis have met with limited success.8 Development of distant metastases in the liver, brain, and other sites is uncommon in carcinoma of the ovary.9 , 11 A number of authors have evaluated traditional clinical parameters such as histological features, grade, stage and ascites as predictors for prognosis in patients with ovarian cancer.10-12] Exposure to multiple chemotherapeutic agents and disruption of the blood-brain barrier by these agents may be the cause of distant spread. Carcinoma of the ovary has significant potential for distant metastasis, but bony metastases are rare. The mode of bony spread appears to be haematogenous, although no definite route of spread has been documented in the literature. Dauplat et al.4 analysed 336 patients with distant metastases from ovarian cancer in his autopsy series. Of these, four had bone metastases, two thoracic vertebra involvement, and one each clavicular and bone marrow involvement. According to the authors, bony metastasis is rare and the median time to development ranged from 13 to 49 months. In the present case report, bone involvement also appeared to be a part of haematogenous spread, since both liver and bone were involved. In an autopsy series, Rose et al.6 studied the metastatic pattern in 428 ovarian cancers and correlated different histologies with sites of metastasis. The incidence of bony metastasis was 0.06 - 0.19% with epithelial histology. This reflects the rarity of bony metastasis in this malignancy. There was no difference in the pattern of spread with different histo­logical subtypes.5 Abdul Karim et al.8 did a clinicopathological audit of bone metastasis from different gynaecological malignancies. They analysed a total of 305 patients, of whom 113 had ovarian cancers. Bony metastasis was seen in seven patients only. Skeletal metastasis was seen in high-grade tumours. Rose et al.6 had observed that presence of lymph nodes in the abdominal cavity was associated with an increased incidence of bone metastasis. Advancing age is the most significant risk factor for the development of ovarian cancer. Marchetti et al.13 showed that out of 545 patients with epithelial ovarian cancer, 49 were under 35 years of age, with most of them having histopathological features of borderline tumour. Advancing age could therefore be an important prognostic factor. However, mucinous cyst adenocarcinoma in an 11-year-old girl has been reported by authors from the same institution, suggesting that no age is immune to the disease.14


In the present case, a young woman without lymphadenopathy developed bony metastasis 4 months after treatment. The authors conclude that bony metastasis should be considered in the differential diagnosis of backache in patients with ovarian cancer, even in an early stage and in middle-aged women.

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