Gilmartin, Geoffrey M.D.; Ernst, Armin M.D.
Interventional Pulmonology, Pulmonary Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.
Address reprint requests to Dr. Armin Ernst, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 U.S.A.; e-mail: firstname.lastname@example.org
We report here a case of papillary serous carcinoma of the ovary with metastasis to the lung in a 74-year-old woman. Three years after initial diagnosis of ovarian cancer, the patient presented with cough and was found to have a right upper lobe mass. Examination by flexible bronchoscopy showed extensive airway nodules. Biopsy of the airway lesions revealed metastatic papillary serous carcinoma. A review of the literature on the spread of ovarian malignancies to the lung is presented in the discussion.
The patient presented initially in 1997 with right inguinal adenopathy and a left ovarian mass. The mass was diagnosed as papillary serous carcinoma of the ovary. The patient underwent pelvic irradiation. A subsequent operative attempt at debulking resulted in inadequate cytoreduction. Follow-up chemotherapy resulted in some decrease in tumor burden. At the completion of chemotherapy, the patient's CA-125 level had normalized.
By October 1998, the patient had an elevated CA-125 level, and computed tomography revealed a new cystic mass in the left adnexa. A single-agent chemotherapy regimen was attempted with the goal of palliation.
Subsequently, the patient developed a cough with clear sputum, no hemoptysis, no fevers, and no shortness of breath. A physical exam revealed the interval development of a right supraclavicular lymph node. Follow-up chest computed tomography revealed a 3 × 3-cm mass in the right upper lobe, bilateral hilar adenopathy, as well as multiple subcentimeter, rounded nodules in both lungs consistent with metastases.
The patient was referred for bronchoscopic evaluation of these abnormalities. The bronchoscopy showed right upper lobe and right middle lobe bronchi with near-total obstruction by endobronchial lesions (Fig. 1). Multiple biopsy specimens were taken of these lesions seen throughout the airways. All cultures and stains were negative and the final pathology was poorly differentiated carcinoma. Focal psammoma bodies were seen and the findings were consistent with metastatic papillary serous carcinoma of the ovary (Fig. 2).
Epithelial cell carcinomas are the most common of the ovarian malignancies and account for approximately 90% of new cases each year. 1 These malignant tumors are subdivided further into serous, mucinous, and endometrioid. Our patient had a papillary form of serous carcinoma of the ovary.
The most common form of dissemination of epithelial tumors is throughout the peritoneal cavity by exfoliation of malignant cells through the surface of the ovarian capsule, with widespread tumor throughout the peritoneal cavity. Lymphatic spread may take metastases to a number of different locations. Spread along the infundibulopelvic ligament is to lymph nodes of the aorta and vena cava, usually at the level of the renal vessels. Lymphatic drainage through the broad ligament and parametrial channels may lead to spread to the pelvic side wall lymphatics. Finally, spread via the round ligament can lead to inguinal node involvement, which may have been the case with our patient at the time of initial diagnosis. 2,3
The spread of distant malignancies to the lungs may occur via the lymphatic system. Extensive lymph node involvement may allow the spread of cancer cells to larger lymphatic channels and then to the pulmonary vascular bed via the thoracic duct and superior vena cava. 2 In addition, extensive mediastinal involvement may lead to retrograde dissemination and a pattern of lymphangitic metastases. 1,3
There is a single case report of ovarian cancer spread exclusively to the mediastinum in a patient presenting with abdominal pain and mediastinal adenopathy on computed tomography. The presumed path of spread was via the prevertebral venous plexus because the patient had no evidence of parenchymal involvement of the lung. 4
There are case reports of the spread of ovarian carcinoma to the pulmonary parenchyma, but they are limited in number. Liu et al. 5 reported a case of a granulosa cell tumor that developed extensive abdominal metastases despite chemotherapy. Seventeen years after initial diagnosis it was determined that the patient had a 0.5-cm right upper lobe nodule with granulosa cell tumor found on fine-needle aspiration of the nodule. 5 An extensive review of the literature revealed no cases of the spread of epithelial cell carcinoma of the ovary to the lungs.
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3. Brady LW, O'Neill EA, Farber SH. Unusual sites of metastases. Semin Oncol 1977; 4:59–64.
4. Montero CA, Gimferrer JM, Baldo X, et al. Mediastinal metastasis of ovarian carcinoma. Eur J Obstet Gynecol Reprod Biol 2000; 91:199–200.
5. Liu K, Layfield LJ, Coogan AC. Cytologic features of pulmonary metastasis from a granulosa cell tumor diagnosed by fine-needle aspiration: a case report. Diagn Cytopathol 1997; 16:341–4.
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