The management of these malignancies consists of surgery followed by platinum-based chemotherapy or radiation therapy or both. In addition to the primary treatment of the disease, control of the hypercalcemia may require aggressive hydration, loop diuretics, and the use of bisphosphonates or calcitonin. The prognosis tends to be poor, with most patients dying within 2 years of diagnosis in spite of treatment.
About 5% to 6% of ovarian tumors are metastatic from other organs, most frequently from the female genital tract, the breast, or the gastrointestinal tract (457–473). The metastases may occur from direct extension of another pelvic neoplasm, by hematogenous or lymphatic spread, or by transcoelomic dissemination, with surface implantation of tumors that spread in the peritoneal cavity.
Gynecologic Nonovarian cancers of the genital tract can spread by direct extension or metastasize to the ovaries. Tubal carcinoma involves the ovaries secondarily in 13% of cases, usually by direct extension (2,3). Under some circumstances, it is difficult to know whether the tumor originated in the tube or in the ovary when both are involved. Cervical cancer spreads to the ovary only in rare cases (<1%), and most of these are of an advanced clinical stage or are adenocarcinomas. Adenocarcinoma of the endometrium can spread and implant directly onto the surface of the ovaries in about 5% of cases, but two synchronous primary tumors probably occur with greater frequency (472). In these cases, an endometrioid carcinoma of the ovary is usually associated with the adenocarcinoma of the endometrium.
Nongynecologic The frequency of metastatic breast carcinoma to the ovaries varies according to the method of determination, but the phenomenon is common (Fig. 37.25). In autopsy data of women who died of metastatic breast cancer, the ovaries were involved in 24% of cases, and 80% of the involvement was bilateral (457–462). Similarly, when ovaries are removed to palliate
Figure 37.25 Metastatic carcinoma in the ovary. Note the linear, single cell pattern found in this metastatic breast carcinoma.
advanced breast cancer, about 20% to 30% of the cases reveal ovarian involvement, 60% of those bilaterally. The involvement of ovaries in early-stage breast cancer seems to be considerably lower, but precise figures are not available. In almost all cases, either ovarian involvement is occult or a pelvic mass is discovered after other metastatic disease becomes apparent.
Krukenberg Tumor The Krukenberg tumor, which can account for 30% to 40% of metastatic cancers to the ovaries, arises in the ovarian stroma and has characteristic mucin-filled, signet-ring cells (463–465) (Fig. 37.26). The primary tumor is frequently located in the stomach and less commonly in the colon, appendix (so-called goblet cell carcinoid), breast, or biliary tract. Rarely, the cervix or the bladder may be the primary site. Krukenberg tumors can account for about 2% of ovarian cancers at some institutions, and they are usually bilateral. The lesions are usually not discovered until the primary disease is advanced, and, therefore, most patients die of their disease within 1 year. In some cases, a primary tumor is never found.