Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Nov 15, 2017; 9(11): 452-456
Published online Nov 15, 2017. doi: 10.4251/wjgo.v9.i11.452
Gastric metastasis from ovarian adenocarcinoma presenting as a subepithelial tumor and diagnosed by endoscopic ultrasound-guided tissue acquisition
Filippo Antonini, Liboria Laterza, Lorenzo Fuccio, Massimo Marcellini, Lucia Angelelli, Sonia Calcina, Corrado Rubini, Giampiero Macarri
Filippo Antonini, Giampiero Macarri, Department of Gastroenterology, A. Murri Hospital, Polytechnic University of Marche, Fermo 63900, Italy
Liboria Laterza, Endoscopy Unit, AUSL, Reggio Emilia 42121, Italy
Lorenzo Fuccio, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna 40138, Italy
Massimo Marcellini, Medical Oncology, Principe di Piemonte Hospital, Senigallia 60019, Italy
Lucia Angelelli, Medical Oncology, Mazzoni Hospital, Ascoli Piceno 63100, Italy
Sonia Calcina, Department of Gastroenterology, San Salvatore Hospital, University of L’Aquila, L’Aquila 67100, Italy
Corrado Rubini, Department of Biomedical Sciences and Public Health, Pathological Anatomy and Histopathology, Polytechnic University of Marche, Ancona 60126, Italy
ORCID number: Filippo Antonini (0000-0001-5453-3310); Liboria Laterza (0000-0003-3555-281X); Lorenzo Fuccio (0000-0001-8618-2447); Massimo Marcellini (0000-0002-5281-7819); Lucia Angelelli (0000-0002-3311-1650); Sonia Calcina (0000-0002-0615-3409); Corrado Rubini (0000-0002-1724-6221); Giampiero Macarri (0000-0001-8467-6072).
Author contributions: All authors made equal contributions to this manuscript.
Institutional review board statement: Since this is not a clinical study, this case report was not reviewed by the institutional review board.
Informed consent statement: Written informed consent for endoscopic examinations was obtained from the patient.
Conflict-of-interest statement: The authors state that they have no conflicts of interest regarding this case report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Filippo Antonini, MD, Department of Gastroenterology, A. Murri Hospital, Polytechnic University of Marche, Ospedale “A. Murri”, Fermo 63900, Italy. filippo.antonini@sanita.marche.it
Telephone: +39-734-6252249 Fax: +39-734-6252252
Received: May 27, 2017
Peer-review started: June 1, 2017
First decision: July 10, 2017
Revised: July 19, 2017
Accepted: August 17, 2017
Article in press: August 17, 2017
Published online: November 15, 2017

Abstract

We describe an uncommon case of a patient with a metastatic adenocarcinoma of ovarian origin presented as a gastric subepithelial tumor (SET) and that was diagnosed by endoscopic ultrasound fine-needle biopsy (EUS-FNB). Malignant gastric lesions are rarely metastatic and the primary tumor is mainly breast, lung, esophageal cancer or cutaneous melanoma. Gastric metastasis from ovarian cancer is unusual, presenting synchronously with the primary tumor but also several years later than the initial diagnosis. From an endoscopic point of view, gastric metastasis does not present specific features. They may mimic both a primary gastric tumor or, less frequently, an SET. This case demonstrates the importance of EUS-FNB in distinguishing SETs and how this may alter treatment and prognosis.

Key Words: Metastasis, Subepithelial lesion, Gastric cancer, Ovarian, Endoscopic ultrasonography

Core tip: Gastric metastasis from ovarian cancer is unusual, either as synchronous with the primary tumor or appearing several years after its initial diagnosis. The diagnosis is challenging because of the low incidence, especially when gastric metastases present as a subepithelial tumor. This case emphasizes the crucial role of endoscopic ultrasound fine-needle biopsy in the differential diagnosis of this rare condition.


Citation: Antonini F, Laterza L, Fuccio L, Marcellini M, Angelelli L, Calcina S, Rubini C, Macarri G. Gastric metastasis from ovarian adenocarcinoma presenting as a subepithelial tumor and diagnosed by endoscopic ultrasound-guided tissue acquisition. World J Gastrointest Oncol 2017; 9(11): 452-456
INTRODUCTION

Gastrointestinal (GI) subepithelial tumors (SETs) are lesions located under a normal-appearing mucosa that include several neoplastic and non-neoplastic conditions. Most of the GI-SETs are asymptomatic, therefore their real incidence is unknown. Stomach is the GI tract where the highest incidence is documented[1]. The diagnosis of SETs can be challenging because conventional endoscopic biopsies are frequently inconclusive. Endoscopic ultrasound (EUS) is currently recommended as the preferred investigation modality to establish the exact nature of SETs because of its accuracy in differentiating them from extrinsic compression and providing information about morphology and layer of origin[2]. Lesions arising from the muscularis propria usually represent mesenchymal tumors, such as gastrointestinal stromal tumors (GIST), leiomyomas and schwannomas[1,2]. Metastasis to the GI tract generally involves the fourth and fifth layers and can be misleading as a GIST[1,2].

Herein, we describe an uncommon case of a patient with a metastatic adenocarcinoma of ovarian origin presented as a gastric SET mimicking a GIST and diagnosed by EUS-guided tissue acquisition.

CASE REPORT

The patient was a 61-year-old woman diagnosed in November 2013 with stage IV high-grade serous carcinoma of the ovary treated with cycles of carboplatin and taxol chemotherapy with partial clinical response. After 1-year of therapy, due to the persistence of abdominal and pelvic disease, cytoreductive surgery had been performed. In June 2015, her CA125 levels had increased to 138 U/mL (normal value < 35 U/mL) and a computed tomography (CT) of the abdomen showed progression of the disease.

She was referred at that time to our endoscopic center for evaluation of dyspepsia. Upper GI endoscopy revealed an SET covered by normal mucosa on the posterior wall of the gastric antrum (Figure 1). Biopsies of the overlying mucosa proved inconclusive. EUS showed a 23-mm mass within the muscularis propria, hypoechoic but more hyperechoic than the muscular tissue (Figure 2). EUS-guided fine needle biopsy (FNB) was performed for tissue diagnosis. Histology showed adenocarcinoma with immunohistochemistry positive for WT1 and CK7, and negative for CK20 and CDX2 (Figure 3). These findings supported the final diagnosis of a metastatic adenocarcinoma of ovarian origin. The patient started paclitaxel chemotherapy and was alive at the 18-mo follow-up visit.

Figure 1
Figure 1 Upper gastrointestinal endoscopy revealing a subepithelial tumor with intact overlying mucosa (black arrow) on the posterior wall of the gastric antrum.
Figure 2
Figure 2 Endoscopic ultrasonography showing a homogenous, hypoechoic mass within the muscularis propria (white arrows). Its echogenicity appears to be more hyperechoic than that of the muscle layer.
Figure 3
Figure 3 Histopathological images showing adenocarcinoma with immunohistochemistry positive for WT1 (× 20) and CK7 (× 16), and negative for CK20 (× 20) and CDX2 (× 20).
DISCUSSION

Gastric metastasis is rare and has been reported mainly from breast, lung, esophageal cancer or cutaneous melanoma[3]. Ovarian carcinoma regularly metastasizes to the peritoneal surface[4]. The acquisition of invasiveness in ovarian carcinoma is accompanied by the process of epithelial to mesenchymal transition. Cancer-associated fibroblasts originating from stromal fibroblastic cells are a component of the tumor microenvironment and promote tumor angiogenesis and lymphangiogenesis[5]. Also, the MUC4 mucin has a role in the invasiveness of ovarian cancer cells because it is overexpressed in ovarian tumors. The overexpression of MUC4 in ovarian cancer is a morphological alteration, along with a decreased expression of epithelial markers (E-cadherin and cytokeratin-18) and an increased expression of mesenchymal markers (N-cadherin and vimentin)[6].

GI involvement from ovarian cancer is limited to the seromuscular layer of the small and large bowels but it also metastasizes through the lymphatic and hematogenous route, with a frequency ranging from 0.7% to 1.8%[7]. The stomach is highly vascularized, therefore the dissemination of ovarian carcinoma is possible but rare. Gastric metastasis from ovarian cancer is unusual, either as synchronous with the primary tumor or appearing several years after its initial diagnosis[8]. The diagnosis is challenging because of its low incidence. Clinical manifestations include epigastric pain, nausea, vomiting, anemia, melena or occult GI blood loss. Obstructive symptoms may be present in case of involvement of the cardia or pylorus[9]. In asymptomatic patients, CA-125 levels beyond normal range may be the only warning sign[7,9]. The prognosis of gastric metastases of ovarian carcinoma is still unknown, a 1-year survival rate can be optimistically expected[10,11]. From an endoscopic point of view, gastric metastases do not present specific features. They may mimic both a primary gastric tumor or, less frequently, an SET[8,12] and can be solitary or more rarely multiple[13].

Several cases of metastatic ovarian cancer presenting as gastric SET have been reported in the literature[10,13-17] but only few have been diagnosed by EUS-guided tissue acquisition, as in our case (Table 1). In other cases, surgical excision or endoscopic submucosal dissection with enucleation has been performed[8,11].

Table 1 Cases of gastric metastases from ovarian adenocarcinoma presenting as subepithelial tumor and diagnosed by endoscopic ultrasound-guided tissue acquisition.
Ref.AgeClinicalpresentationDiagnosis of ovarian cancerEndoscopicaspect of gastric SETEUS morphology
Shanga et al[13], 200362Epigastric discomfort7 yr beforeBody, 4 cmIrregular border, hypoechoic lesion, fourth layer
Jung et al[10], 200949Asymptomatic52 mo from surgeryAntrum, 2.5 cm × 2.5 cmHypoechoic lesion, fourth layer
Carrara et al[14], 201170Mild anemia, dyspepsiaNRBody, 3.8 cm × 4.8 cm, ulceratedThird layer
Akce et al[15], 201255Anemia, melena5 yr beforeAntrum, 3.4 cm × 3.7 cm and body, 1.2 cm × 0.8 cmHypoechoic lesions, fourth layer
Yamao et al[16], 201551NR25 mo from surgeryAntrum, 3 cmHypoechoic lesion with marginal rim, fourth layer
Current case61Dyspepsia2 yr beforeAntrum, 2.3 cmHypoechoic lesion (more hyperechoic than the muscular tissue), fourth layer

In the present case, the lesion was mimicking a GIST, even if a metastasis from ovarian cancer had been considered. For these reasons, a tissue diagnosis was considered necessary. After a diagnosis of metastatic ovarian cancer to the stomach had been achieved, surgical intervention or more aggressive options would become unnecessary considering the progression of the disease.

In conclusion, although rare, gastric metastasis from primary ovarian cancer should be considered in any patient with a history of ovarian adenocarcinoma who presents with gastric tumor. This case emphasizes the crucial role of EUS-FNB in the differential diagnosis.

COMMENTS
Case characteristics

A 61-year-old woman diagnosed 3 years previously with stage IV high-grade serous carcinoma of the ovary and treated with debulking surgery and chemotherapy presented for evaluation of dyspepsia.

Clinical diagnosis

General physical examination was unremarkable.

Differential diagnosis

Gastrointestinal stromal tumor, gastric tumor, metastasis.

Laboratory diagnosis

CA125 levels had increased to 138 U/mL (normal value < 35 U/mL).

Imaging diagnosis

Endoscopic ultrasonography (EU) showed a 23-mm mass within the muscularis propria, hypoechoic but more hyperechoic than the muscular tissue.

Pathological diagnosis

Histology obtained via EUS-guided fine needle biopsy showed adenocarcinoma with immunohistochemistry positive for WT1 and CK7, and negative for CK20 and CDX2, supporting the final diagnosis of a metastatic adenocarcinoma of ovarian origin.

Treatment

Palliative chemotherapy.

Related reports

Several cases of metastatic ovarian cancer presenting as gastric subepithelial tumor have been reported in the literature, but only few of them have been diagnosed by EUS-guided tissue acquisition, as in our case. In other cases, surgical excision or endoscopic submucosal dissection with enucleation has been performed.

Experiences and lessons

Although rare, metastatic ovarian cancer to the stomach should be considered in any patient with a history of ovarian adenocarcinoma who presents with gastric tumor.

Peer-review

This is an interesting case report.

Footnotes

Manuscript source: Invited manuscript

Specialty type: Oncology

Country of origin: Italy

Peer-review report classification

Grade A (Excellent): 0

Grade B (Very good): B

Grade C (Good): C, C

Grade D (Fair): 0

Grade E (Poor): 0

P- Reviewer: Erturk SM, Langdon S, Sergi CM S- Editor: Ji FF L- Editor: A E- Editor: Zhao LM

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