In April, 2012, a 51-year-old female presented to the Department of Gynecology of the First Affiliated Hospital of Nanjing Medical University (Nanjing, China) complaining of lower abdominal pain of two months in duration. A computed tomography (CT) scan of the abdomen and pelvis showed bilateral adnexal complex masses. The patient subsequently underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy with pelvic lymph node dissection and omentectomy for stage III ovarian adenocarcinoma (International Federation of Gynecology and Obstetrics). The surgery was followed by four cycles of adjuvant chemotherapy with paclitaxel and cisplatin. The patient was in good condition and achieved complete clinical response in June, 2012. In December, 2013, the patient was admitted to the Department of Oncology, First Affiliated Hospital of Nanjing Medical University due to significantly elevated serum CA-125 levels (up to 96.05 U/ml; normal, <35 U/ml), which is an important tumor marker. Other tumor markers were within the normal range. The patient had no abdominal discomfort, hematemesis, melena, weight loss or any other clinical manifestations. Scanning with 18F-fluorodeoxyglucose positron emission tomography(18F-FDG PET)/CT ruled out recurrent ovarian carcinoma, which was suspected due to the high CA-125 levels. The 18F-FDG PET/CT images revealed a high-uptake lesion in the antrum of the stomach () and a high-uptake lymph node behind the pancreas (). During the subsequent endoscopic examination, a 1.5×2.0-cm submucosal mass covered with normal gastric mucosa was identified in the gastric antrum (). Due to the location of the lesion, the patient was referred for endoscopic ultrasound examination, which revealed a hypoechoic mass emanating from the muscularis propria, with the typical appearance of a gastrointestinal stromal tumor (). The patient subsequently underwent surgical resection of the gastric lesion and the intumescent lymph nodes. The intraoperative findings included a 2.5×2×2-cm isolated extrinsic mass on the wall of the gastric antrum and a 1.0×0.8-cm intumescent lymph node close to the lesser curvature of the stomach. The histopathological examination confirmed ovarian cancer relapse involving the gastric wall without mucosal involvement, although a lymph node was involved. Immunostaining for progesterone receptor, estrogen receptor, cytokeratin 7 (CK7) and Wilms’ tumor-1 (WT1) was positive; while immunostaining for CK20 was negative (). These findings were consistent with the primary ovarian cancer (). The patient was discharged on the 10th day after surgery. At the time of writing, the patient had received another two cycles of adjuvant chemotherapy, and the CA-125 level had decreased to the normal range.
The patient was a 61-year-old woman diagnosed in November 2013 with stage IV high-grade serous carcinoma of the ovary treated with cycles of carboplatin and taxol chemotherapy with partial clinical response. After 1-year of therapy, due to the persistence of abdominal and pelvic disease, cytoreductive surgery had been performed. In June 2015, her CA125 levels had increased to 138 U/mL (normal value < 35 U/mL) and a computed tomography (CT) of the abdomen showed progression of the disease.\nShe was referred at that time to our endoscopic center for evaluation of dyspepsia. Upper GI endoscopy revealed an SET covered by normal mucosa on the posterior wall of the gastric antrum (Figure ). Biopsies of the overlying mucosa proved inconclusive. EUS showed a 23-mm mass within the muscularis propria, hypoechoic but more hyperechoic than the muscular tissue (Figure ). EUS-guided fine needle biopsy (FNB) was performed for tissue diagnosis. Histology showed adenocarcinoma with immunohistochemistry positive for WT1 and CK7, and negative for CK20 and CDX2 (Figure ). These findings supported the final diagnosis of a metastatic adenocarcinoma of ovarian origin. The patient started paclitaxel chemotherapy and was alive at the 18-mo follow-up visit.