Ovarian cancer metastatic to the stomach diagnosed by eus-guided fine needle aspiration

Abstract

Ovarian cancer is the seventh most common cancer in women and the leading cause of death among those with gynecological malignancies. Epithelial ovarian cancers commonly spread along intraperitoneal and lymphatic channels. Gastric metastasis of ovarian cancer is extremely rare. In this report we describe the endosonographic appearance of ovarian cancer metastatic to the stomach and demonstrate the utility of EUS-FNA in providing a diagnosis. A 62 year-old woman with a history of ovarian cancer presented with gastrointestinal complaints of belching, reflux and epigastric discomfort. Seven years prior to presentation, she was diagnosed with ovarian cancer. She initally underwent surgical debulking followed by 6 cycles of paclitaxel and cisplatin. After this she was monitored closely, and was thought to be disease-free until one year prior to presentation when her CA-125 started to rise. Chest, abdomen and pelvic CT revealed no recurrence. EGD revealed a submucosal mass with central ulceration in the proximal body of the stomach. Multiple biopsies were obtained showing only mild chronic gastritis. The patient was referred for endosonography of the mass. EUS demonstrated a heterogenous 4-cm mass with irregular borders arising from the muscularis propria. FNA was performed using a 22g needle. The preliminary endosonographic and cytologic diagnoses were gastrointestinal stromal tumor (GIST). However, final pathologic findings were consistent with a poorly differentiated carcinoma. Immunoperoxidase staining was positive for CA-125, and cytokeratins 7 and AE1:3. These findings were consistent with metastatic ovarian cancer and the patient subsequently began another chemotherapeutic regimen. Two previously reported cases of ovarian cancer and intramural gastric metastases presented with gastrointestinal bleeding. The majority of submucosal tumors (SMT), however, do not cause symptoms. The role of EUS in diagnosing SMTs in now well established. By EUS, metastatic deposits in the stomach appear as hypoechoic heterogenous masses which may involve any of the sonographic layers. For gastric SMTs, EUS-FNA is only 60% sensitive in providing diagnostic pathologic material. The patient in our case-report had an unrevealing CT and the only indication of recurrent disease was an increase in serum CA-125. Hence EUS-FNA was key in diagnosing metastatic disease in this patient.