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Clinicopathological Characteristics of Ovarian Metastasis from Colorectal and Pancreatobiliary Carcinomas Mimicking Primary Ovar

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Clinicopathological Characteristics of Ovarian Metastasis from Colorectal and Pancreatobiliary Carcinomas Mimicking Primary Ovar ANTICANCER RESEARCH 38 : 5465-5473 (2018) doi:10.21873/anticanres.12879 Clinicopathological Characteristics of Ovarian Metastasis from Colorectal and Pancreatobiliary Carcinomas Mimicking Primary Ovarian Mucinous Tumor CHEOL KEUN PARK 1 and HYUN-SOO KIM 2 1Department of Pathology, Armed Forces Capital Hospital, Seongnam, Republic of Korea; 2Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea Abstract. Background/Aim: A subset of carcinomas metastatic The ovary is a common site of metastasis from a variety of to the ovary can exhibit growth patterns closely resembling primary tumors (1, 2). Although in most cases the primary ovarian mucinous cystadenoma and borderline tumor. They can tumors are diagnosed before the detection of the metastatic be misinterpreted as underlying primary ovarian mucinous ovarian tumors, an ovarian mass can sometimes be the initial tumors and can be erroneously used to suggest that the clinical manifestation of the primary disease. It is well carcinomatous component arises from mucinous precursor established that primary epithelial tumors of the ovary can lesions. Materials and Methods: We investigated the be mimicked by metastatic carcinoma from the clinicopathological characteristics of 11 cases of metastatic abdominopelvic organs, leading to misdiagnosis (3). It is of carcinoma that had metastasized from colorectal and utmost importance to correctly classify ovarian tumors as pancreatobiliary carcinoma and mimicked primary ovarian either primary or metastatic because the prognoses of these mucinous tumors. Results: The patient age ranged from 37 to 81 conditions differ significantly and determining the correct years old. Seven patients presented to gynecologists with non- diagnosis has implications on the effective clinical specific pelvic symptoms similar to those of primary ovarian management of patients (2, 4, 5). tumors. The primary tumor was identified before the detection Among primary ovarian epithelial tumors, mucinous of the ovarian lesion in 6 cases, synchronously in 5, and tumors pose the greatest difficulty with regard to distinction postoperatively in 1 case. The ovarian tumors were bilateral in of primary from metastatic tumors (6). Metastatic 6 cases. The greatest dimension of the metastatic tumors ranged carcinomas to the ovary are usually easily distinguished from from 4.8 to 23.0 cm. Multinodularity was present in 7 cases, and primary ovarian mucinous tumors, including mucinous surface involvement was identified in 5 cases. An infiltrative borderline tumors and carcinomas, when they exhibit growth pattern was present, at least focally, in 8 cases. Six and characteristic gross and histological features. Primary 2 cases exhibited cystadenomatous and borderline-like growth ovarian mucinous tumors are typically large, unilateral, and patterns, respectively. Conclusion: Although the diagnosis of multilocular cystic lesions, with smooth capsules. Moreover, metastatic tumors to the ovary is possible in most cases on the primary ovarian mucinous carcinoma most often arises in basis of clinical presentation and standard diagnostic criteria, association with mucinous cystadenoma and borderline their differential diagnosis may be problematic because of tumors. Although primary mucinous ovarian carcinomas can morphological patterns that strikingly overlap with those of exhibit destructive stromal invasion, they frequently show a primary ovarian benign, borderline, and malignant mucinous dominantly expansile (confluent glandular) invasive pattern tumors. The possibility of metastases should be considered when (7). In contrast, the typical features of metastatic carcinomas evaluating ovarian mucinous tumors. that distinguish them from primary ovarian mucinous tumors include a smaller size, bilaterality, involvement of the ovarian surface and superficial cortex, a multinodular growth pattern, and a dominantly infiltrative pattern of stromal Correspondence to: Hyun-Soo Kim, Department of Pathology, invasion (4, 6, 8, 9). Severance Hospital, Yonsei University College of Medicine, 50-1, A subset of metastatic carcinomas can manifest with one Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea. Tel: +82 222281794, +82 23620860, e-mail: [email protected] or more features suggesting a primary ovarian tumor both clinically and pathologically. These include i) presentation Key Words: Ovary, mucinous tumor, metastasis, pancreaticobiliary, as a large, unilateral, multilocular cystic tumor lacking colorectal, adenocarcinoma. surface involvement, sometimes as the first manifestation of 5465 ANTICANCER RESEARCH 38 : 5465-5473 (2018) a disease with a clinically occult extraovarian source, and ii) oncology for examination. They examined all available hematoxylin certain growth patterns, including cystadenomatous, and eosin-stained slides using light microscopy (BX43 System borderline-like, and expansile, which cannot be readily Microscope, Olympus, Tokyo, Japan), made definite pathological diagnoses, and chose the most representative slide to perform recognized as primary or metastatic. The metastases immunohistochemical staining. For descriptive purposes, architectural exhibiting borderline-like growth patterns often show growth patterns of the tumors were assessed as cystadenomatous, obvious nuclear atypia and thus simulate ovarian mucinous borderline-like, expansile, or infiltrative, on the basis of their borderline tumors with intraepithelial carcinoma. Metastases resemblance to these patterns seen in primary ovarian mucinous with small infiltrative foci simulate microinvasion derived tumors (6, 8, 18). Nuclear atypia was assessed as mild, moderate, or from the adjacent mucinous borderline tumor. Furthermore, severe. Additional pathological findings that were assessed included metastases with sufficiently crowded confluent glands, but the presence of surface involvement, multinodular growth, extracellular mucin, and signet-ring cells. lacking destructive stromal invasion simulate primary ovarian mucinous carcinomas with an expansile invasive Immunohistochemistry. The paraffin-embedded slices were pattern (6, 8, 10-12). Despite recognition of the ability of deparaffinized and rehydrated with a xylene and alcohol solution. these metastases to simulate primary tumors, and recent Immunohistochemical staining was performed using an automatic studies providing refined diagnostic criteria for primary immunostaining instrument (Ventana Benchmark XT, Ventana ovarian mucinous tumors (4, 13, 14), the problem of Medical Systems) according to the manufacturer’s recommendations distinguishing these tumors remains unresolved. This issue (19-36). Antigen retrieval was performed using a Cell Conditioning Solution (CC1, Ventana Medical Systems). The slices were is compounded by the fact that in routine practice, metastatic incubated with primary antibodies against cytokeratin 7 (CK7; mucinous carcinomas are more common than primary 1:100; clone OV-TL 12/30; Dako, Glostrup, Denmark), CK20 ovarian mucinous carcinomas, with those of gastrointestinal (1:100; clone Ks20.8; Dako), and caudal-related homeobox 2 and pancreaticobiliary origin being the most commonly (CDX2; 1:400; clone EPR2764Y; Cell Marque, Rocklin, CA, USA). encountered types (15, 16). After chromogenic visualization using an ultraView Universal DAB Herein, we comprehensively describe the clinicopathological Detection Kit (Ventana Medical Systems), slices were characteristics of colorectal and pancreaticobiliary carcinomas counterstained with hematoxylin. Appropriate positive and negative controls were concurrently stained to validate the staining method. that metastasized to the ovaries and mimicked primary ovarian Negative controls were prepared by substituting non-immune serum tumors, with emphasis on the ability of these tumors to exhibit for the primary antibody and resulted in no detectable staining. For gross and histological features simulating primary ovarian CK7 and CK20 immunostaining, staining with a moderate-to-strong tumors. intensity in the cell membrane was interpreted as positive expression. For CDX2 immunostaining, staining with a moderate- Materials and Methods to-strong intensity in the nuclei was interpreted as positive expression. Positive staining was considered diffuse when at least Case selection. Following approval (4-2018-0193) by the 50% of tumor cells were immunoreactive and focal when less than Institutional Review Board at the Severance Hospital, 11 cases of 50% of the cells were stained. metastatic carcinoma to the ovary of colorectal (7 cases), pancreatic (3 cases), or extrahepatic biliary (1 case) origin were extracted from Results the surgical pathology files between July 2015 and December 2017. The diagnosis of an ovarian metastasis was based on standard Clinical features. The patients’ ages ranged from 37 to 81 diagnostic criteria (4, 9, 13, 17). The clinical features and years (median, 51 years). There was no history of malignancy intraoperative findings were obtained by review of the patients’ before the detection of colorectal, pancreatobiliary, or ovarian electronic medical records or by communication with the referring tumors in any patient. Seven patients presented to gynecologists. Available preoperative and postoperative imaging gynecologists with nonspecific pelvic symptoms, including materials were reviewed. In all cases, the primary tumor was palpable pelvic masses, and abdominal pain, discomfort, available for histological examination. Pathology reports
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