Gastric Miscellaneous ,El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Ovarian Carcinoma Metastatic to Stomach and Duodenum. This is the case of a 50 year-old woman, presented with weight loss, nausea and vomiting, the endoscopy found a unusual image with multiple tiny yellowish nodules in the gastric fundus and duodenum, the wall of the duodenum were thickened, at the beginning one thought that it was a lymphoma, the biopsies shown a metastatic carcinoma, Immunohistochemical studies rule out a malignant melanoma and breast carcinoma, the mammography were negative as well as the physical examination to find any mass in both breast. Multiple lymph-node were palpable at the neck as well as supraclavicular lymphadenopathy. At the computer tomography cat scan showed mediastinal and para-aortic lymph-node enlarged, a large mass in the left ovary was detected, which were histologically identical and consistent with an ovarian primary.

Video Endoscopic Sequence 1 of 20.

 Ovarian Carcinoma Metastatic to Stomach and Duodenum

 This is the case of a 50 year-old woman, presented with
 weight loss, nausea and vomiting, the endoscopy found a
 unusual image with multiple tiny yellowish nodules in the
 gastric fundus and duodenum, the wall of the duodenum
 were thickened, at the beginning one thought that it was a
 lymphoma, the biopsies shown a metastatic carcinoma,
 Immunohistochemical studies rule out a malignant
 melanoma and breast carcinoma, the mammography were
 negative as well as the physical examination to find any
 mass in both breast. Multiple lymph-node were palpable at
 the neck as well as supraclavicular lymphadenopathy. At
 the computer tomography cat scan showed mediastinal and
 para-aortic lymph-node enlarged, a large mass in the left
 ovary was detected, which were histologically identical and
 consistent with an ovarian primary neoplasia.

Gastric metastasis of ovarian cancer is extremely rare.

 For more endoscopic details download the video clips by
 clicking on the endoscopic images, wait to be downloaded
 complete then press Alt and Enter that you can appreciate
 the video in full screen.

 All endoscopic images shown in this Atlas contain
 video clips.
 
Involvement of the stomach by blood-borne metastatic malignancy in relatively uncommon. The primary neoplasms which most frequently metastasize to the stomach via the blood are malign melanoma and carcinoma of the breast.

Video Endoscopic Sequence 2 of 20.

 Involvement of the stomach by blood-borne metastatic
 malignancy in relatively uncommon. The primary
 neoplasms which most frequently metastasize to the
 stomach via the blood are malign melanoma and carcinoma
 of the breast.

 Secondary neoplastic involvement of the stomach is most
 commonly the result of commonly the direct spread from a
 contiguous neoplasm such as carcinoma of the pancreas or
 non-contiguous tumor such as carcinoma of the transverse
 colon which may spread to the stomach via the gastrocolic
 ligament.

 Gastric metastasis from breast cancer is uncommon and
 typically occurs in patients with disseminated disease. The
 vast majority of patients with gastric lesions have a known
 preexisting diagnosis of breast cancer.

 Carcinoma of unknown primary (CUP) is defined as the
 histological diagnosis of metastasis without the detection of
 a primary tumor.
The duodenal bulb with more accentuated image than the fundus displaying infiltration with multiple tiny nodules. The abdominal ultrasound also showed para-aortic.

Video Endoscopic Sequence 3 of 20.

 The duodenal bulb with more accentuated image than the
 fundus displaying infiltration with multiple tiny nodules
 tumor seeding

 The abdominal ultrasound also showed para-aortic
 lymph-node metastasis.

Ovarian cancer continues to pose a major challenge to physicians and radiologists. It is the leading cause of mortality from female genital tract malignancy. There are no established population-based screening programmes for the disease and few specific symptoms and signs of ovarian cancer. Consequently the majority of women present with advanced disease with poor prognosis. Survival in all cases at 1 year is 55% and at 5 years is 29%. Median survival is 14 months.

 When faced with a woman with an ovarian mass the
 physician is required to make a judgement about the
 likelihood of malignancy. Following clinical assessment,
 ultrasound (US) and serum CA-125 estimation are the next
 investigations. Based on these three evaluations women
 can be divided into those with an ovarian mass and
 evidence of peritoneal spread.

 
Ovarian cancer is the 7th most common cancer in women and the leading cause of death among those with gynecologic malignancies.

Video Endoscopic Sequence 4 of 20.

The second part of the duodenum.

 Ovarian cancer is the 7th most common cancer in women
 and the leading cause of death among those with
 gynecologic malignancies.

 Malignant melanoma is the most common cause of
 metastases to the GI tract.
Ovarian tumors are derived from epithelial cells and occur in women between 40 and 65 years of age. Epithelial ovarian cancers commonly spread along the peritoneal surfaces by exfoliation of cells, and lymphatic dissemination to the pelvic and para- ortic nodes is noted in advanced disease. Hematogenous spread at diagnosis is rare, with only 2% to 3% of patients having lung or liver metastases.

Video Endoscopic Sequence 5 of 20.

The duodenal walls are thick

 Ovarian tumors are derived from epithelial cells and occur
 in women between 40 and 65 years of age. Epithelial
 ovarian cancers commonly spread along the peritoneal
 surfaces by exfoliation of cells, and lymphatic
 dissemination to the pelvic and para-aortic nodes is noted
 in advanced disease. Hematogenous spread at diagnosis is
 rare, with only 2% to 3% of patients having lung or liver
 metastases.
A close up to the mucosa of the gastric fundus. GI involvement usually is caused by superficial infiltration of the bowel wall and its mesentery. Gastric metastasis of ovarian cancer is extremely rare, there being only a handful of cases reported.

Video Endoscopic Sequence 6 of 20.

A close up to the mucosa of the gastric fundus

 GI involvement usually is caused by superficial infiltration
 of the bowel wall and its mesentery. Gastric metastasis of
 ovarian cancer is extremely rare, there being only a
 handful of cases reported.
Abdominal ultrasound shows para-aortic lymph-node. Ovarian cancer is the most common cause of cancer death from gynecologic tumors in the United States. Early disease causes minimal, nonspecific, or no symptoms. Therefore, most patients are diagnosed in an advanced stage. Overall, prognosis for these patients remains poor. Standard treatment involves aggressive debulking surgery followed by chemotherapy. Many histological types of ovarian tumors are described. However, more than 90% of malignant tumors are epithelial tumors.

 Video Endoscopic Sequence 7 of 20.

 Abdominal ultrasound shows para-aortic lymph-node
 adenopathy.

 Ovarian cancer is the most common cause of cancer death
 from gynecologic tumors in the United States. Early
 disease causes minimal, nonspecific, or no symptoms.
 Therefore, most patients are diagnosed in an advanced
 stage. Overall, prognosis for these patients remains poor.
 Standard treatment involves aggressive debulking surgery
 followed by chemotherapy. Many histological types of
 ovarian tumors are described. However, more than 90%
 of malignant tumors are epithelial tumors.

 
Ultrasound shows an enlarged para-aortic lymph node. Ovarian carcinoma can spread by local extension, lymphatic invasion, intraperitoneal implantation, hematogenous dissemination, and transdiaphragmatic passage. Intraperitoneal dissemination is the most common and recognized characteristic of ovarian cancer. Malignant cells can implant anywhere in the peritoneal cavity but are more likely to implant in sites of stasis along the peritoneal fluid circulation. As discussed later, these mechanisms of dissemination represent the rationale to conduct surgical staging, debulking surgery, and intraperitoneal administration of chemotherapy. On the other hand, early hematogenous spread is clinically unusual, although it is not infrequent in patients with advanced disease.

 Video Endoscopic Sequence 8 of 20.

 Ultrasound shows an enlarged para-aortic lymph node

 Ovarian carcinoma can spread by local extension,
 lymphatic invasion, intraperitoneal implantation,
 hematogenous dissemination, and transdiaphragmatic
 passage. Intraperitoneal dissemination is the most common
 and recognized characteristic of ovarian cancer. Malignant
 cells can implant anywhere in the peritoneal cavity but are
 more likely to implant in sites of stasis along the peritoneal
 fluid circulation. As discussed later, these mechanisms of
 dissemination represent the rationale to conduct surgical
 staging, debulking surgery, and intraperitoneal
 administration of chemotherapy. On the other hand, early
 hematogenous spread is clinically unusual, although it is
 not infrequent in patients with advanced disease.
Derrame pleural: Pleural Effusion, Hígado: Liver. Advanced ovarian cancer is the leading non-breast gynaecologic cause of malignant pleural effusion.

 Video Endoscopic Sequence 9 of 20.

 Derrame pleural: Pleural Effusion, Hígado: Liver

 Advanced ovarian cancer is the leading non-breast
 gynaecologic cause of malignant pleural effusion.

 Cancer accounts for 40% of all pleural effusions, especially
 in patients over 50 years old. Bronchogenic and breast
 cancer account for 75% of malignant pleural effusions, with
 the remaining 25% represented by a cross-section of other
 neoplastic diseases.

 Approximately two thirds of malignant pleural effusions
 occur in women because of the strong association with
 breast and ovarian cancer. Advanced ovarian cancer is the
 leading non-breast gynaecologic cause of malignant pleural
 effusion. Pleural metastases were found in 48% of women
 who died from ovarian cancer.
The general approach to managing malignant effusions is determined by symptoms, performance status of the patient, expected survival and response of the known primary tumor to systemic treatment. Intervention options range from observation in the case of asymptomatic effusions through simple thoracentesis to more invasive methods such as thoracoscopy, pleuroperitoneal shunting and pleurectomy. In patients with reasonable survival expectancy and good performance status every attempt should be made to prevent recurrence of the effusion. Intercostal tube drainage with instillation of a sclerosing agent, resulting in the obliteration of the pleural space, is the most widely used method to control recurrent symptomatic malignant pleural effusions.

 Video Endoscopic Sequence 10 of 20.

 The general approach to managing malignant effusions is
 determined by symptoms, performance status of the
 patient, expected survival and response of the known
 primary tumor to systemic treatment. Intervention options
 range from observation in the case of asymptomatic
 effusions through simple thoracentesis to more invasive
 methods such as thoracoscopy, pleuroperitoneal shunting
 and pleurectomy. In patients with reasonable survival
 expectancy and good performance status every attempt
 should be made to prevent recurrence of the effusion.
 Intercostal tube drainage with instillation of a sclerosing
 agent, resulting in the obliteration of the pleural space, is
 the most widely used method to control recurrent
 symptomatic malignant pleural effusions.

 Since malignant pleural effusions are frequently a preterminal
 event with a 30-day mortality rate of 29 to 50%, treatment is
 directed toward symptomatic relief with minimal discomfort,
 inconvenience and cost.
This image and the video clips shows no liver metastases. The disease is uncommon in patients younger than 40 years, after which incidence increases. Most cases are diagnosed in the seventh decade of life.

 Video Endoscopic Sequence 11 of 20.

 This image and the video clips shows no liver metastases

 The disease is uncommon in patients younger than
 40 years, after which incidence increases. Most cases are
 diagnosed in the seventh decade of life.

 Malignant pleural effusions are caused most commonly by
 carcinomas of the breast, lung, gastrointestinal tract or ovary and
 by lymphomas. In male patients about half of malignant effusions
 are caused by lung cancer, 20% by lymphomas or leukemia, 7%
 from gastrointestinal primaries, 6% from genitourinary primaries,
 and 11% from tumors of unknown primary site. In female
 patients, about 40% of malignant effusions are caused by breast
 cancer, 20% from tumors arising in the female genital tract, 15%
 from lung primaries, 8% from lymphomas or leukemia, 4% from
 gastrointestinal tract primaries, 3% from melanoma, and 9% from
 tumors of unknown primary site. Effusions may be secondary to
 impaired pleural lymphatic drainage from mediastinal tumor
 (especially in lymphomas) and not due to direct pleural invasion.
Left Pleural Effusion .

 Video Endoscopic Sequence 12 of 20.

 Left Pleural Effusion

 Local treatment options include repeated thoracenteses, chest
 tube drainage with sclerotherapy, pleuroperitoneal shunt or
 pleurectomy. Repeated thoracentesis is usually a temporizing
 measure and carries the risk for pneumothorax and pleural
 infection. Inpatient drainage with large-bore tubes (28–36 F) is
 effective, with variable 30-day success rates reported between
 55% and 95%. For this reason, large-bore tube thoracostomy
 with sclerotherapy has become the most common palliative
 treatment for malignant effusions. It has to be mentioned that
 recent studies have shown that small drainage catheters
 (10 to 14 F) are as effective as large bore chest tubes in the
 treatment of malignant effusions. Using imaging guidance, small
 tubes can be placed into loculated collections, are well tolerated
 and have complication rates less than the larger tubes.

 
Meigs syndrome is defined as the co-existence of bening ovarian fibroma, hydrothorax and ascites. On the contrary, Pseudo-Meigs syndrome is characterized by the co-existence of hydrothorax, ascites and other ovarian- usually malignant-or pelvic tumors.

 Video Endoscopic Sequence 13 of 20.

 Meigs syndrome is defined as the co-existence of bening
 ovarian fibroma, hydrothorax and ascites. On the contrary,
 Pseudo-Meigs syndrome is characterized by the
 co-existence of hydrothorax, ascites and other ovarian-
 usually malignant-or pelvic tumors.

 The co-existence of pelvic tumor, hydrothorax and ascites
 has been known since the late 19th century. The features
 of the disease were described by Meigs and Cass in 1937.
 In the same year Roads named it “Meigs syndrome”.
 Today, Meigs syndrome is defined as the co-existence of
 bening ovarian fibroma, hydrothorax and ascites. On the
 contrary, Pseudo-Meigs syndrome is characterized by the
 co-existence of hydrothorax, ascites and other ovarian-
 usually malignant-or pelvic tumors. Both these syndromes
 should be considered in otherwise healthy postmenopausal
 women, who present with either new or recurrent
 hydrothorax and ascites. The preoperative differential
 diagnosis between them is useless, since the surgical
 resection of the tumor is the only therapeutic choice,
 resulting to the resolution of fluid accumulations in both
 situations
A high power view of metastasis to duodenum.

 Video Endoscopic Sequence 14 of 20.

Endoscopic Biopsies

 A high power view of metastasis to duodenum

 
Duodenal metastatic carcinoma .

 Video Endoscopic Sequence 15 of 20.

 Endoscopic Biopsies

 Duodenal Metastatic Carcinoma

 
Metastatic epithelial nodule in duodenal mucosa.

 Video Endoscopic Sequence 16 of 20.

 Endoscopic Biopsies

Metastatic epithelial nodule in duodenal mucosa

 
Another view of metastasis at duodenal mucosa.

 Video Endoscopic Sequence 17 of 20.

 Endoscopic Biopsies

 Another view of metastasis at duodenal mucosa

 
Another high power view of metastatic tumor to duodenal mucosa.

 Video Endoscopic Sequence 18 of 20.

Endoscopic Biopsies

 Another high power view of metastatic tumor to duodenal mucosa.

 
Linfoma+xz19

 Video Endoscopic Sequence 19 of 20.
Linfoma+xz20

 Video Endoscopic Sequence 20 of 20.