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.
In January 2014, a 58-year-old woman was admitted to our department with a gastric submucosal tumor that was recently discovered during a routine checkup and gastroduodenoscopy. She did not complain of any symptoms. Her medical history showed that she had undergone a total thyroidectomy due to thyroid cancer in 2009, as well as wide excision and radiation treatment for ductal carcinoma in situ of the breast in 2013.\nMore relevant to the present case, the patient was diagnosed with ovarian serous adenocarcinoma (International Federation of Gynecology and Obstetrics [FIGO] stage IIIB) in 2011. She underwent a total hysterectomy with salpingo-oophorectomy and pelvic and paraaortic lymph node dissection with total omentectomy, followed by 6 cycles of adjuvant chemotherapy with carboplatin and paclitaxel. In 2012, the patient was re-examined and found to have newly developed seeding metastases in the perihepatic space, omentum, perirectal area, diaphragm, and external iliac chain. Her CA-125 level had increased to 51.06 U/ml. Following a debulking operation, she received 9 additional cycles of adjuvant chemotherapy with the previously described regimen. Subsequently, the CA-125 levels were tested every 3 months. After the additional chemotherapy, it had decreased to the normal range and a radiologic examination revealed tumor regression.\nThe gastric submucosal tumor found in January 2014 was a 2 cm low-echogenic lesion located on the greater curvature of the antrum and showed irregularity in the propria muscle layer (). The pathological diagnosis from the endoscopic biopsy before the operation was chronic active gastritis.\nA computed tomography (CT) scan indicated focal thickening and the formation of a mass in the greater curvature of the gastric body, as well as multiple enlarged lymph nodes along the greater curvature of the stomach ().\nWe considered several possible diagnoses, such as metastatic lesions deriving from the ovary or breast. The patient subsequently underwent curative subtotal gastrectomy with lymphadenectomy. During the operation, multiple enlarged lymph nodes were found to be conglomerated with the stomach, but no other recurrent tumors were found. Frozen section biopsy revealed that the lymph nodes were malignant. Macroscopically, a 3.5×3.0 cm submucosal tumor with ulceration was located in the stomach (). Microscopically, infiltration of metastatic serous adenocarcinoma cells into normal gastric tissues was observed. A total of 28 out of 48 retrieved perigastric lymph nodes were found to be metastatic. A cytologic examination revealed the absence of cancer cells. Immunohistochemical staining revealed that the tumor cells were positive for WT-1, and negative for GCDPF-15 and CD 117 (). The final diagnosis was gastric metastasis from ovarian serous adenocarcinoma. The patient's postoperative course was unremarkable and she was discharged 9 days after the operation. She will undergo another round of chemotherapy with carboplatin plus gemcitabine in consultation with gynecologists.