Scalp metastasis of a serous ovarian cancer

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Aggressive cytoreductive surgery and cisplatin-containing combination chemotherapy for ovarian cancer have certainly led to longer disease-free survival, while the incidence of distant metastasis is increasing (1,2). We report a case of serous ovarian cancer with FIGO Stage 2C, which suddenly recurred in the scalp without lung metastases and widespread intraperitoneal involvement at 29 months after primary surgery. The patient is a 64-year-old Japanese woman, gravida 0, para 0, who was referred to our university hospital with suspected ovarian cancer in February 1994. The patient's preoperative CA-125 level was 2900 U/mL. On March 24, 1994, she underwent laparotomy. A 10 × 15 cm right ovarian tumor was firmly adherent to the posterior uterine wall and the serosa of the rectosigmoid colon. The ascites were positive for cytology and the clinical stage was determined to be FIGO stage 2C. Right salpingo-oophorectomy, partial omentectomy, and selective pelvic and paraaortic lymph node biopsies were performed. Histologic examination revealed serous adenocarcinoma without lymph nodes metastases. Postoperatively, she received three cycles of chemotherapy consisting of carboplatin, adriamycin and ifosfamide. She had a second cytoreduction surgery on September 29, 1994. At second laparotomy, there were no ascites and peritoneal washings were negative for cytology. Abdominal total hysterectomy, left salpingo-oophorectomy and a full exploration of peritoneal surfaces, and biopsies were carried out. They were without evidence of ovarian cancer. Four cycles of maintenance chemotherapy with carboplatin and ifosfamide were repeated from March 1995 to April 1996 and she was clinically without evidence of disease. On August 19, 1996, she noted a gradually enlarging mass in the right occipital region of her scalp that felt like a small balloon. The soft mass 5 cm in size had been noted to grow over a course of 1 month (Fig. 1). Her CA-125 level at this time was elevated again to 98.8 U/mL. General physical examination of the abdomen and pelvis, and chest X-ray was normal, while the lymph-nodes metastases in the paraaorta and pelvis were suspected with enhanced computed tomography and whole-body Gallium scintigram. Irradiation and combination chemotherapy were given, but the response to therapy was poor. She died of the disease on August 27, 1997, about 1 year from the onset of scalp metastases and 3 years 5 months after the primary operation. The scalp metastasis on August 1996. The mass was soft and the patient had no pain and tenderness. Brownstein et al. (3) reported that ovarian cancer was the fourth most frequent primary tumor in women metastasizing to the skin. The majority of these skin metastases were located on the trunk (abdomen, umbilicus) and usually accompanied by widespread intraperitoneal disease. The pathogenesis of these metastases was explained by the direct invasion from the underlying growth, contiguous extension of the tumor cells through lymphatics, and accidental implantation of the tumor cells during surgical procedures. In our case, a solitary scalp metastasis presented as the initial symptom from recurrent ovarian carcinoma, about 2 years after the negative second laparotomy. The pathogenesis of this solitary scalp metastasis appears to utilize the hematogenous route, and there are no ascites, pleural effusion or dissemination to other organs except retroperitoneal lymph nodes. Although the incidence of distant metastasis from ovarian carcinoma appears to be increasing (1), scalp metastasis from ovarian cancer has been rarely reported (4) and few guidelines are available for selecting therapy for scalp metastasis. The prognosis of ovarian carcinoma with skin metastases is also poor (median survival was 12 months) (1), and no effective treatments have been demonstrated. Though some patients with abdominal skin metastasis were treated with chemotherapy and surgical resection and survived for many years (5,6) in our case, irradiation and combination chemotherapy were selected, while the response to therapy was poor. The findings of this case report suggest that ovarian cancer should not be considered a disease that always remains confined to the pelvis and abdomen. A scalp swelling in any patient with a past history of ovarian cancer should be biopsied or explored even if there is no evidence of intra-abdominal lesions.