0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Diagnosis FREE

[+] Author Affiliations

SECTION EDITOR: CARL E. BREDENBERG, MD

More Author Information
Arch Surg. 2012;147(9):886. doi:10.1001/archsurg.147.9.886.
Text Size: A A A
Published online

ANSWER: PRIMARY COLORECTAL CARCINOMA WITH OVARIAN METASTASIS

Pathologic examination of the operative specimens confirmed a primary moderately to poorly differentiated, circumferential, transverse colon adenocarcinoma with histologic and staining profiles consistent with metastases to the ovary, peritoneum, and omentum (stage IVB [T4N2M1] colorectal adenocarcinoma).

A review of ovarian malignant neoplasms estimates that in 10% of all cases the ovarian metastasis is the presenting symptom leading to diagnosis of the primary nongynecologic tumor.1 The actual incidence of ovarian metastases from colorectal cancer is not well established, ranging from less than 1% to 9% in clinical and autopsy studies; however, gastrointestinal malignant neoplasms are the most common to metastasize to the ovary, with most being a primary colorectal cancer.24 In patients with an ovarian mass determined to be of nongynecologic origin, 27% to 45% are due to colon cancer metastases.2,5,6 Abdominal pain or an identified adnexal mass are the most common presenting symptoms, with the minority of patients having a more classic presentation of colorectal cancer.2 Definitive diagnosis is pathologic with histologic findings of mixed solid and cystic components, the well-described “dirty necrosis,” and immunohistochemical staining that differentiates ovarian primary disease from metastatic disease. Positive prognostic factors for patients with colon cancer and ovarian metastases include unilateral disease, disease limited to the pelvis (ie, no intra-abdominal metastases), and residual tumor volume less than 2 cm.7 Histologic grade and menopausal status have not been demonstrated as significant for prognosis.6,7 While size of the ovarian metastasis does not affect prognosis, it is common for the ovarian mass to be larger than the primary colon cancer.3

Colorectal cancer is the third most common cause of both new cancers and cancer deaths, composing approximately 10% of all cases in men and women.8 Ovarian cancer composes 3% of new cancers and 6% of cancer deaths in women. Relative survival for patients with colorectal cancer is currently 83% at 1 year and 65% at 5 years. The estimated 5-year survival for this patient is 23% to 30%.2,7 Although the ovaries are a known site of metastasis in colorectal cancer, it is not common practice to perform colonoscopy beyond standard screening recommendations when evaluating an ovarian mass. Resection of ovarian metastases is a well-accepted practice owing to its reduction of tumor burden. The role of prophylactic oophorectomy in colorectal cancer remains controversial. The proposed benefit of prophylactic oophorectomy is primarily removal of undiscovered metastases, thereby preventing development of resistant disease in a chemotherapy sanctuary site and limiting future reoperation.9,10 It may also be a preventive measure against primary ovarian cancer, as patients with colorectal cancer are at increased risk especially in association with hereditary cancer syndromes.4,10 Two retrospective studies have shown a survival benefit in women undergoing prophylactic oophorectomy, particularly those with limited primary disease where complete resection can be accomplished.4,11 The only prospective randomized trial to date examining the benefit of prophylactic oophorectomy was unable to demonstrate a statistically significant improvement in survival or recurrence rates; however, this study was underpowered and is currently still enrolling patients.12 While no clear consensus exists, several authors suggest that prophylactic oophorectomy be offered to postmenopausal women with a family history of cancer.4,9,10 Outside these parameters, the associated hormonal and psychological morbidity coupled with the low occurrence of ovarian metastases in colorectal cancer have limited its application in current therapy.13,14

Return to Quiz Case.

Correspondence: Clay Cothren Burlew, MD, Department of Surgery, Denver Health Medical Center, 777 Bannock St, MC 0206, Denver, CO 80204 (clay.cothren@dhha.org).

Accepted for Publication: September 21, 2011.

Author Contributions:Study concept and design: Burlew and Barnett. Acquisition of data: Yi and Barnett. Analysis and interpretation of data: Yi, Burlew, Barnett, and Moore. Drafting of the manuscript: Yi and Burlew. Critical revision of the manuscript for important intellectual content: Yi, Burlew, Barnett, and Moore. Administrative, technical, and material support: Burlew, Barnett, and Moore. Study supervision: Burlew and Barnett.

Financial Disclosure: None reported.

Young RH. From Krukenberg to today: the ever present problems posed by metastatic tumors in the ovary, part II.  Adv Anat Pathol. 2007;14(3):149-177
PubMed   |  Link to Article
Benoit MF, Hannigan EV, Smith RP, Smith ER, Byers LJ. Primary gastrointestinal cancers presenting as gynecologic malignancies.  Gynecol Oncol. 2004;95(2):388-392
PubMed   |  Link to Article
Miller BE, Pittman B, Wan JY, Fleming M. Colon cancer with metastasis to the ovary at time of initial diagnosis.  Gynecol Oncol. 1997;66(3):368-371
PubMed   |  Link to Article
Hanna NN, Cohen AM. Ovarian neoplasms in patients with colorectal cancer: understanding the role of prophylactic oophorectomy.  Clin Colorectal Cancer. 2004;3(4):215-222
PubMed   |  Link to Article
Dionigi A, Facco C, Tibiletti MG, Bernasconi B, Riva C, Capella C. Ovarian metastases from colorectal carcinoma: clinicopathologic profile, immunophenotype, and karyotype analysis.  Am J Clin Pathol. 2000;114(1):111-122
PubMed   |  Link to Article
Moore RG, Chung M, Granai CO, Gajewski W, Steinhoff MM. Incidence of metastasis to the ovaries from nongenital tract primary tumors.  Gynecol Oncol. 2004;93(1):87-91
PubMed   |  Link to Article
Petru E, Pickel H, Heydarfadai M,  et al.  Nongenital cancers metastatic to the ovary.  Gynecol Oncol. 1992;44(1):83-86
PubMed   |  Link to Article
American Cancer Society.  Cancer Facts and Figures 2011. Atlanta, GA: American Cancer Society; 2011
Banerjee S, Kapur S, Moran BJ. The role of prophylactic oophorectomy in women undergoing surgery for colorectal cancer.  Colorectal Dis. 2005;7(3):214-217
PubMed   |  Link to Article
Schofield A, Pitt J, Biring G, Dawson PM. Oophorectomy in primary colorectal cancer.  Ann R Coll Surg Engl. 2001;83(2):81-84
PubMed
Rayson D, Bouttell E, Whiston F, Stitt L. Outcome after ovarian/adnexal metastectomy in metastatic colorectal carcinoma.  J Surg Oncol. 2000;75(3):186-192
PubMed   |  Link to Article
Young-Fadok TM, Wolff BG, Nivatvongs S, Metzger PP, Ilstrup DM. Prophylactic oophorectomy in colorectal carcinoma: preliminary results of a randomized, prospective trial.  Dis Colon Rectum. 1998;41(3):277-285
PubMed   |  Link to Article
Segelman J, Flöter-Rådestad A, Hellborg H, Sjövall A, Martling A. Epidemiology and prognosis of ovarian metastases in colorectal cancer.  Br J Surg. 2010;97(11):1704-1709
PubMed   |  Link to Article
Omranipour R, Abasahl A. Ovarian metastases in colorectal cancer.  Int J Gynecol Cancer. 2009;19(9):1524-1528
PubMed   |  Link to Article

Figures

Tables

References

Young RH. From Krukenberg to today: the ever present problems posed by metastatic tumors in the ovary, part II.  Adv Anat Pathol. 2007;14(3):149-177
PubMed   |  Link to Article
Benoit MF, Hannigan EV, Smith RP, Smith ER, Byers LJ. Primary gastrointestinal cancers presenting as gynecologic malignancies.  Gynecol Oncol. 2004;95(2):388-392
PubMed   |  Link to Article
Miller BE, Pittman B, Wan JY, Fleming M. Colon cancer with metastasis to the ovary at time of initial diagnosis.  Gynecol Oncol. 1997;66(3):368-371
PubMed   |  Link to Article
Hanna NN, Cohen AM. Ovarian neoplasms in patients with colorectal cancer: understanding the role of prophylactic oophorectomy.  Clin Colorectal Cancer. 2004;3(4):215-222
PubMed   |  Link to Article
Dionigi A, Facco C, Tibiletti MG, Bernasconi B, Riva C, Capella C. Ovarian metastases from colorectal carcinoma: clinicopathologic profile, immunophenotype, and karyotype analysis.  Am J Clin Pathol. 2000;114(1):111-122
PubMed   |  Link to Article
Moore RG, Chung M, Granai CO, Gajewski W, Steinhoff MM. Incidence of metastasis to the ovaries from nongenital tract primary tumors.  Gynecol Oncol. 2004;93(1):87-91
PubMed   |  Link to Article
Petru E, Pickel H, Heydarfadai M,  et al.  Nongenital cancers metastatic to the ovary.  Gynecol Oncol. 1992;44(1):83-86
PubMed   |  Link to Article
American Cancer Society.  Cancer Facts and Figures 2011. Atlanta, GA: American Cancer Society; 2011
Banerjee S, Kapur S, Moran BJ. The role of prophylactic oophorectomy in women undergoing surgery for colorectal cancer.  Colorectal Dis. 2005;7(3):214-217
PubMed   |  Link to Article
Schofield A, Pitt J, Biring G, Dawson PM. Oophorectomy in primary colorectal cancer.  Ann R Coll Surg Engl. 2001;83(2):81-84
PubMed
Rayson D, Bouttell E, Whiston F, Stitt L. Outcome after ovarian/adnexal metastectomy in metastatic colorectal carcinoma.  J Surg Oncol. 2000;75(3):186-192
PubMed   |  Link to Article
Young-Fadok TM, Wolff BG, Nivatvongs S, Metzger PP, Ilstrup DM. Prophylactic oophorectomy in colorectal carcinoma: preliminary results of a randomized, prospective trial.  Dis Colon Rectum. 1998;41(3):277-285
PubMed   |  Link to Article
Segelman J, Flöter-Rådestad A, Hellborg H, Sjövall A, Martling A. Epidemiology and prognosis of ovarian metastases in colorectal cancer.  Br J Surg. 2010;97(11):1704-1709
PubMed   |  Link to Article
Omranipour R, Abasahl A. Ovarian metastases in colorectal cancer.  Int J Gynecol Cancer. 2009;19(9):1524-1528
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

The Rational Clinical Examination
Make the Diagnosis: Cancer, Family History

The Rational Clinical Examination
Original Article: Does This Patient Have a Family History of Cancer?