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 is a 55-year-old female with known stage III b serous ovarian cancer. She had undergone an abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy, followed by 6 cycles of carbo/taxol chemotherapy with complete clinical response. She was free of disease for 2 years until her disease recurred and was treated with Carboplatin and Taxol. The carboplatin was eventually switched to Doxil. However, the repeat positron emission tomography (PET) scan at that time showed progression of her disease. Thus she underwent exploratory laparotomy with removal of a splenic mass. She was noted to have peritoneal carcinomatosis at that time and was then treated with Gemzar. The patient had stable disease after this treatment. Five years after the initial diagnosis, the patient was admitted to the hospital with anemia, hemoglobin of 7.0 gm/dl, fatigue, and melena. Computerized Tomography (CT) of the abdomen without IV contrast was obtained on admission, which revealed calcified, heterogeneous, mixed intermediate and high-density deposits worrisome for peritoneal carcinomatosis (, arrows). No IV contrast was administered due to her poor kidney function. She was referred for an EGD, which showed a 7 mm erythematous lesion at the gastroesophageal junction and a 1.5 to 2 cm subepithelial mass () with a superficial overlying erosion in the antrum, but no obvious source for any active bleeding. Initial endoscopic biopsies of the gastroesophageal junction lesion showed granulation tissue polyp with foveolar hyperplasia, and the antral biopsies were normal. Due to the presence of a subepithelial lesion in the antrum, the patient was referred for EUS. Two subepithelial lesions were discovered by EUS, one in the antrum measuring 3.4 × 3.7 cm () and one in the body of the stomach 1.2 × 0.8 cm (). The lesion in the body of the stomach was not appreciated during the EGD. The lesions were hypoechoic masses emanating from the muscularis propria and had the typical appearance of gastrointestinal stromal tumors. FNA was performed of both masses. Both sites revealed papillary adenocarcinoma from an ovarian papillary serous adenocarcinoma primary (). Immunostains for progesterone receptor, estrogen receptor and p 53 were focally positive and confirmatory. The patient was treated with Taxol and is undergoing surveillance imaging.