Ovarian metastasis from colorectal adenocarcinoma

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

Initially presented to GP with 2/12 history of abdominal pain, pelvic mass, early satiety and poor urinary stream for investigation. Elevated CEA levels concerning of bowel malignancy - no colonoscopy performed as patient did not tolerate bowel prep.

Patient Data

Age: 42
Gender: Female
Ultrasound

Pelvic ultrasound

Large right ovarian tumour, most likely malignant.

- 18.7cm left ovarian solid and cystic mass with extensive ascites

- Abdominopelvic peritoneal metastatic disease with omental caking

- Bilateral pleural effusions

- In keeping with metastatic left ovarian carcinoma.

- 17cm anterior pelvis midline mass

- Small volume ascites & pleural effusions

- Multiple simple cysts of liver and a solitary left suprahilar lymph node suspicious of metastasis

Circumferential wall thickening of the sigmoid colon which is displaced superiorly by the pelvic mass.

Underwent elective left salpingoophorectomy and high anterior resection with primary anastomosis

 Constrictive sigmoid lesion at the level of the pelvic brim  - Large left ovarian mass  - Intense inflammatory reaction of pelvic peritoneum    

Histology : T4N0M1 (0/16)  - Sigmoid colon : 30x25mm ulcerated polypoid constricting tumour. Moderately differentiated adenoCA infiltrating through muscularis propria and pericolic fat into serosa. Lymphovascular invasion noted. Clear resection margins

CT

Post operative CT.

Large right pleural effusion with right lower lobe atelectasis. Subpleural left apical nodule measures 3 mm, stable. Left hilar lymph node measures 12 x 15 mm, stable. No pericardial effusion. No mediastinal or axillary enlarged lymph nodes.

Numerous liver hypodensities appear stable in size and number. Those imaged on the chest CT demonstrate peripheral arterial phase enhancement in keeping with metastasis. Adrenal glands, kidneys, spleen, gallbladder and pancreas have a normal appearance. The large bowel, especially the right colon is distended with faeces. Appearances of a stricture within the distal colon (Se 8 Im 56) with no faecal material distal to this point. Bladder is massively distended and contains a few locules of gas. Left para-aortic lymph node (Se 8 Im 35) measures 21 x 7 mm, previously 16 x 7 mm. No other enlarged lymph nodes are identified but sensitivity is reduced by the lack of intra-abdominal fat. Abdominal drain and laparotomy staples noted.No suspicious bone lesion identified.

Conclusion: Multiple liver hypodensities are in keeping with metastasis. Left hilar lymph node and left para-aortic lymph node suspicious for metastases. No peritoneal fluid collection identified. Prominent soft tissue within the distal colon is mild swelling at the anastomosis not causing obstruction. There is minor colonic faecal loading. Massively distended bladder is noted. Locules of gas would be in keeping with recent instrumentation but this has not occurred infection should be considered. Large right pleural effusion has developed since the prior CT.

Pathology

Resected ovarian mass.

Left ovary : 250mm metastatic moderately differentiated colonic adenocarcinoma.

 

Note the T2 hyper intense spaces seen on MR represent areas of necrosis and debris primarily (only little mucin).

Case Discussion

Non specific imaging findings of a large ovarian mass, likely malignant. Pathological features of the ovarian tumour resemble those of the T4 colon carcinoma. Although there is no method to categorically exclude a separate, primary ovarian carcinoma, the probability of such presence in a 41 year old would be approaching zero. The ovarian mass is therefore considered a metastasis from the colon cancer.

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Case information

rID: 35120
Case created: 23rd Mar 2015
Last edited: 13th Sep 2016
Inclusion in quiz mode: Included

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