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.
Sixty-three-year-old nulliparous patient, presenting with second relapse of epithelial ovarian cancer diagnosed by the increasing level of serum tumor markers with negative radiological studies.\nThe patient was diagnosed with epithelial ovarian cancer 7 years ago, when she underwent surgical resection (Wertheim-Meigs surgery), associated with adjuvant chemotherapy using cisplatin/paclitaxel (CP), presenting complete clinical remission, with the absence of signs and symptoms, normal levels of CA-125 and negative PET-CT.\nFive years ago, she developed the peritoneal relapse, and was treated with neoadjuvant chemotherapy with CP, peritonectomy with hyperthermic intraperitoneal chemotherapy, followed by adjuvant chemotherapy with the same drugs, once again, presenting complete clinical remission.\nOne year ago, she presented with an increase in CA-125 serum level for 3 months. On this occasion, she had a PET-CT, which showed the densification of peritoneal fat in the lower abdomen with fibro-cicatricial characteristics, unchanged in comparison to the previous examinations, besides showing heterogeneous parietal gastric thickening associated with the densification of the surrounding fat planes. There was no evidence of abnormal contrast enhancement []. The upper digestive echo-endoscopy showed unspecific parietal gastric thickening, a small slide with perihepatic ascites and three oval-shaped hypo-echogenic and heterogeneous formations with septations and anechoic content, measuring around 10 mm [], located between the hepatic hilum and the peripancreatic cephalic region that were punctured with 22-gauge needle.\nHistologic study confirmed the diagnosis of metastatic serous cystadenocarcinoma, the immunohistochemical study indicated the gynecological tract as the primary site []. It was not possible to determine accurately whether the injury observed in endoscopic ultrasound (EUS) were tumor implants or lymph node recurrence.\nAfter the diagnosis of a second relapse, the patient underwent chemotherapy with CP, but did not show significant improvement. Due to resistance to platinum-based chemotherapy, she switched to bevacizumab and liposomal doxorubicin therapy, with good response, presenting, once again, complete clinical remission. Nowadays, the patient's clinical exams are normal. CA-125 serum levels been normal and the upper digestive echo-endoscopy confirmed regression of the previously identified lesions.