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Special Feature
April 2008

Image of the Month—Diagnosis

Arch Surg. 2008;143(4):422. doi:10.1001/archsurg.143.4.422

Answer: Secondary Ovarian Neoplasm

Histologic examination showed a moderately differentiated adenocarcinoma forming mucus-producing glands. The tumor cells stained positively for cytokeratins 20 and 7 and negative for estrogen receptors. The immunohistochemical profile was in keeping with metastatic colon cancer. The patient made an uneventful recovery and underwent palliative chemotherapy. Unfortunately, 18 months later her disease progressed to recurrent peritoneal disease.

Between 5% and 20% of ovarian tumors are metastatic from other malignancies.1 Of the gastrointestinal metastases, between 30% and 65% (second only to the stomach) originate from a colorectal primary malignancy.2

Colorectal metastases present either as Krukenberg tumors1 or as pseudo-Meigs syndrome (nonmalignant ascites or pleural effusions).3 Most are detected incidentally either during operation or preoperative imaging. The remainder present as recurrent disease. Sixty-six percent of deposits are bilateral.4 These tumors occur more commonly in the premenopausal patient, with 43% occurring in patients younger than 40 years.5 It is thought that metastatic spread occurs hematogenously rather than transserosally.4 Clinical symptoms of ovarian metastatic tumors are nonspecific abdominal pain, weight loss, abdominal bloating or swelling, uterine bleeding, and (rarely) rectal bleeding.6

Metastases to the ovary are often cystic (81%) on computed tomography and are difficult to differentiate from primary ovarian cancer.1 Macroscopically, these lesions, often smaller than 10 cm in diameter, have a smooth or nodular surface and the cystic lesions are usually filled with mucin or blood. There is a highly variable amount of stroma within these lesions and many contain nodules, foci of necrosis, and areas of hemorrhage. Microscopically, most of these tumors are formed by mucin-producing signet ring cells forming a wide range of nodules, glands, or cysts. Other epithelial cells may form the bulk of the deposits and in those cases are more likely to form tubular gland like structures.5

The presence of ovarian metastasis is a poor prognostic indicator, with a median survival time of 17 months.6 It appears that tumor size does not play a significant role in survival time.4 Treatment is aimed at alleviating symptoms and reducing tumor bulk. Most centers would advocate resection of the primary metastasis combined with bilateral salpingo-oophorectomy and hysterectomy.3,6,7 Operative debulking has been shown to rapidly improve symptoms in patients with pseudo-Meigs syndrome.3,7 Surgical resection should be followed by palliative chemotherapy, which has shown to provide a limited survival advantage.6

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Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgery has temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid-2008. Thank you.

Correspondence: Keith Towsey, MBBS, Redcliffe Hospital, Anzac Avenue, Redcliffe, Queensland, Australia 4020 (

Accepted for Publication: November 6, 2006.

Author Contributions:Study concept and design: Towsey and Lambrianides. Acquisition of data: Towsey, Lisle, and Lambrianides. Analysis and interpretation of data: Towsey. Drafting of the manuscript: Towsey and Lisle. Critical revision of the manuscript for important intellectual content: Lambrianides. Administrative, technical, and material support: Towsey. Study supervision: Lambrianides.

Financial Disclosure: None reported.

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