In other cases of metastasis from the gastrointestinal tract to the ovary, the tumor does not have the classic histologic appearance of a Krukenberg tumor; most of these are from the colon and, less commonly, the pancreato-biliary tract, appendix, and small intestine (Fig. 37.27). As many as 1% to 2% of women with intestinal carcinomas will develop metastases to the ovaries during the course of their disease (459). Before exploration for an adnexal tumor in a woman older than 40 years, a barium enema is indicated to exclude a primary gastrointestinal carcinoma with metastases to the ovaries, particularly if there are any gastrointestinal symptoms. Metastatic colon cancer can mimic a mucinous cystadenocarcinoma of the ovary histologically, and the histological distinction between the two can be difficult (458,459,466–470). Lesions that arise in the appendix may be associated with ovarian metastasis and confused with primary ovarian malignancies, especially when associated with pseudomyxoma peritonei (466,470). It is reasonable to consider the performance of prophylactic bilateral salpingo-oophorectomy at the time of surgery for women with colon cancer (471).
Figure 37.26 Krukenberg tumor of the ovary metastatic from a gastric carcinoma. Malignant cells have discrete vacuoles that push nuclei eccentrically, giving a signet-ring appearance. Mucicarmine stain demonstrates the cytoplasmic vacuoles to be mucin.
CHAPTER 37 Ovarian, Fallopian Tube, and Peritoneal Cancer
Figure 37.27 Metastatic colorectal carcinoma in the ovary often has areas of necrotic debris (so-called dirty necrosis) adjacent to partial gland structures showing a cribriform pattern.
Lymphoma and Leukemia Lymphomas and leukemia can involve the ovary. When they do, the involvement is usually bilateral (477–479). About 5% of patients with Hodgkin’s lymphoma will have lymphomatous involvement of the ovaries, but this involvement occurs typically with advanced-stage disease. With Burkitt’s lymphoma, ovarian involvement is very common. Other types of lymphoma involve the ovaries less frequently, and leukemic infiltration of the ovaries is uncommon (479). Sometimes the ovaries can be the only apparent sites of involvement of the abdominal or pelvic viscera with a lymphoma; if this circumstance is found, a careful surgical exploration may be necessary. Intraoperatively, a hematologist-oncologist should be consulted to determine the need for these procedures if frozen section of a solid ovarian mass reveals a lymphoma. Most lymphomas no longer require extensive surgical staging; biopsy of enlarged lymph nodes should be performed. In some cases of Hodgkin’s lymphoma, a more extensive evaluation may be necessary. Treatment involves that of the lymphoma or leukemia. Removal of a large ovarian mass may improve patient comfort and facilitate a response to subsequent radiation or chemotherapy.
Figure 37.28 Carcinoma of the fallopian tube. This is a high-grade serous carcinoma that has invaded the lamina propria of the tubal mucosa. Most primary fallopian tube carcinomas arise in the distal (fimbria) portion of the fallopian tube.