Ovarian Carcinoma Metastatic to Stomach
Ovarian Carcinoma Metastatic to Stomach

Video Endoscopic Sequence 1 of 20.

Ovarian Carcinoma Metastatic to Stomach and Duodenum

Melanomas are malignant neoplasms caused by the transformation of melanocytes.

Gastric metastasis of ovarian cancer is extremely rare.

 

 

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Ovarian Carcinoma Metastatic to Stomach

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.

 

 

 


Ovarian Carcinoma Metastatic to Stomach

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 Carcinoma Metastatic to Stomach

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 Carcinoma Metastatic to Stomach

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.


Ovarian Carcinoma Metastatic to Stomach

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.

 

Ovarian Carcinoma Metastatic to Stomach

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.

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Ovarian Carcinoma Metastatic to Stomach and Duodenum

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.




















Ovarian Carcinoma Metastatic to Stomach and Duodenum

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.

 

Ovarian Carcinoma Metastatic to Stomach and Duodenum

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 preterminalevent with a 30-day mortality rate of 29 to 50%, treatment isdirected toward symptomatic relief with minimal discomfort,inconvenience and cost.


Ovarian Carcinoma Metastatic to Stomach and Duodenum

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 bycarcinomas of the breast, lung, gastrointestinal tract or ovary andby lymphomas. In male patients about half of malignant effusionsare 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 femalepatients, about 40% of malignant effusions are caused by breastcancer, 20% from tumors arising in the female genital tract, 15%from lung primaries, 8% from lymphomas or leukemia, 4% fromgastrointestinal tract primaries, 3% from melanoma, and 9% fromtumors of unknown primary site. Effusions may be secondary toimpaired pleural lymphatic drainage from mediastinal tumor(especially in lymphomas) and not due to direct pleural invasion.

Ovarian Carcinoma Metastatic to Stomach and Duodenum

Video Endoscopic Sequence 12 of 20.

Left Pleural Effusion

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

 

Ovarian Carcinoma Metastatic to Stomach and Duodenum

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

 

Ovarian Carcinoma Metastatic to Stomach and Duodenum

Video Endoscopic Sequence 14 of 20.

Endoscopic Biopsies

A high power view of metastasis to duodenum


Ovarian Carcinoma Metastatic to Stomach and Duodenum

Video Endoscopic Sequence 15 of 20.

Endoscopic Biopsies

Duodenal Metastatic Carcinoma




Ovarian Carcinoma Metastatic to Stomach and Duodenum

Video Endoscopic Sequence 16 of 20.

Endoscopic Biopsies

Metastatic epithelial nodule in duodenal mucosa

 

Ovarian Carcinoma Metastatic to Stomach

Video Endoscopic Sequence 17 of 20.

Endoscopic Biopsies

Another view of metastasis at duodenal mucosa

Ovarian Carcinoma Metastatic to Stomach and Duodenum

Video Endoscopic Sequence 18 of 20.

Endoscopic Biopsies

Another high power view of metastatic tumor to duodenal mucosa.


Ovarian Carcinoma Metastatic to Stomach and Duodenum

Video Endoscopic Sequence 19 of 20.

Ovarian Carcinoma Metastatic to Stomach and Duodenum

Video Endoscopic Sequence 20 of 20.

Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 1 of 23.

Metastatic malignant melanoma of the gastrointestinal tract.

This is a 66 year-old female, with with a history of Malignant melanoma that iniciated in her groin, Had episodes of upper gastrointestinal bleeding manifested with of melena.

 

 






Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 2 of 23.

Endoscopic picture of gastric metastatic melanoma.

Malignant melanoma is one of the most common malignancies to metastasize to the gastrointestinal (GI) tract. Metastases to the GI tract can present at the time of primary diagnosis or decades later as the first sign of recurrence.

Symptoms may include abdominal pain, dysphagia, small bowel obstruction, hematemesis, and melena.


In patients with a history of melanoma, a high index of suspicion for metastasis must be maintained if they present with seemingly unrelated symptoms. Diagnosis requires careful inspection of the mucosa for metastatic lesions and biopsy with special immunohistochemical stains. Management may include surgical resection, chemotherapy, immunotherapy, observation, or enrollment in clinical trials. Prognosis is poor, with a median survival of 4 to 6 months.




Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 3 of 23.

Endoscopic picture of gastric metastatic melanoma.

Malignant melanoma that involves the gastrointestinal (GI) tract may be either primary or metastatic. Gastric metastases are rare and represent advanced disease. The incidence of metastases to the stomach is difficult to assess; however, the number of cases of gastric metastases from melanomas is significant. A series of necropsies in individuals with melanoma revealed gastric metastases rates of more than 22%.

High index of suspicion for GI malignant melanoma metastases in patients with GI symptomps and history of malignant melanoma (metastases may present also decades after the diagnosis of primary tumor)

Malignant melanoma is reported to metastasize to all organs of the human body. Although it is common for it to metastasize to the gastrointestinal tract, a melanoma located primarily in the gastric mucosa is an uncommon tumor. Gastrointestinal metastases are rarely diagnosed before death with radiological and endoscopic techniques.


Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 4 of 23.

Metastatic melanoma in various areas, from an unknown primary lesion, is well documented in the literature. The stomach, after the small bowel, is the second most common site involved. The primary origin of a melanoma in the stomach is extremely unlikely and can be accepted only if the absence of any other primary lesion is confirmed. Endoscopy has been shown to be the most reliable form of examination for the diagnosis of gastric metastases. In addition, gastric invasion is most often associated with the invasion of other organs and the mean survival time of patients presenting with a gastric metastasis is consistently less than one year. Therefore, every metastatic malignant melanoma case should undergo endoscopic examination for gastrointestinal metastases.





Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 5 of 23.

Endoscopic picture of gastric metastatic melanoma Multiple nodular polypoid lesions of the gastric body, with central ulceration.

Usually polypoid ulcerated lesions, are often multiple, either pigmented or non pigmented

MM is notorious for fast multi-organ metastasis and has poor prognosis. The incidence of a second melanoma recurrence has the cumulative risk ranging from 2 to 5 percent within 5 to 20 years after initial diagnosis. The common sites of MM in decreasing order are small bowel, colon, rectum and stomach. The most common Sx of gastric melanoma is anemia /w bleeding, pain and obstruction,

A diagnosis of recurrent metastatic melanoma should always be considered in patients re-presenting in whom there is a prior history of melanoma.

 


Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 6 of 23.

Melanocytes are normal residents of the mucous membranes of the upper aerodigestive tract, gastrointestinal, and urogenital tracts. These cells give rise to malignant melanomas of the mucous membranes lining the GI tract. Malignant melanomas involving the GI tract may be primary (i.e., anorectum, esophagus, and gallbladder) or metastatic lesions (i.e., stomach and liver) . Mucosal melanomas of the gastrointestinal tract are rare tumors that represent about 1.5%–2.0% of all melanomas. The overwhelming majority of malignant melanomas involving the GI tract are secondary to metastatic disease. The interval time between diagnosis of the primary and metastatic disease is variable (average, 7.0 years). Patients with GI metastasis may present with bleeding, anemia, obstruction, abdominal discomfort, pain, and intestinal perforation. GI metastases usually appear as multiple polypoid lesions and can be either pigmented or amelanotic and often ulcerated. Less commonly the presentation is of a solitary melanotic tumor. Metastases to the GI tract can present both at the time of primary diagnosis or years later as the first sign of recurrence. Diagnosis of metastatic melanoma is generally made by radiographic contrast studies, including CT, ultrasonography, PET scan and barium studies, and endoscopic evaluation. The sensitivity of CT for detecting metastases is only 60% to 70%.

Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 7 of 23.

In Gastric Fundus (gastric cardia) another metastasis of malignant melanoma is observed.

Metastatic melanoma has been observed in almost all regions of the human body. The most common sites of metastases were the lymph nodes (74%) and lungs (71%), followed by the liver (58%), brain (55%), bone (49%), adrenal glands (47%), and GI tract (44%), but only 1% to 4% of them are diagnosed antemortem.

Computed tomography (CT) is the most commonly used imaging technique for staging and follow up in the malignant melanoma patients.

Two studies have compared staging with Positron emission tomography (PET) and CT scan in all stages. Both studies found PET to be superior in terms of sensitivity and specificity to CT in all stages of Melanoma.

Magnetic resonance imaging (MRI) is a good investigation for detection of brain and bone metastases. For anorectal region, MRI and endorectal ultrasonography are the good investigational methods for preoperative evaluation both of primary tumor and local nodal status.

whole-body MRI has been reported to have an overall accuracy for the detection of lesion slightly lower than PET-CT (78.8% vs. 86.7%), but the sensitivity for the detection of bone and liver metastases was better than PET-CT.


Metastatic malignant melanoma of the gastrointestinal tract.

Video Endoscopic Sequence 8 of 23.

Endoscopy of malignant melanoma metastatic to the duodenum.

Metastases into small bowel are more common than esophageal, stomach and large bowel metastases

Melanoma is a malignancy originating from melanocytes. The primary melanoma usually occurs on the skin, retina, anal canal or occasionally at other organs such as the esophagus, penis or vagina. Although melanoma represents about one-third of all metastatic lesions in the gastrointestinal tract, metastasis of melanoma to the GI tract, detected radiologically or endoscopically, is relatively rare. In most cases of malignant melanoma, recurrence and death occur within 10 years after treatment of the primary lesion.





Endoscopic Picture of Duodenal Metastatic Melanoma.

Video Endoscopic Sequence 9 of 23.

Endoscopic Picture of Duodenal Metastatic Melanoma.

POSITRON EMISSION TOMOGRAPHY (PET)
Positron emission tomography (PET) is an advanced diagnostic imaging technique. This technique exploits the increased metabolism of glucose in malignant viable cells. 18F-fluorodeoxyglucose (FDG) is one of the most commonly used radioisotopes. FDG is transported into tumor cells like glucose molecule. There is a many-fold increase in glucose metabolism in malignant tumors as compared with normal cells, therefore, the different in metabolism of tumor call and normal tissue can be detected by this technique. The potential benefits of FDG-PET for melanoma included the detection of locoregional and distant metastasis for staging.

The presence or absence of regional lymph node metastases is an important prognostic factor for patients with melanoma. FDG-PET has shown a limitation of sensitivity and wide variation of the data from previous studies. The sensitivity of FDG-PET is varied from 8% to 100%. Moreover, in the subgroup of subclinical nodal disease in stage I and II melanoma, the sensitivity of FDG-PET is only 14-17% whereas, sentinel node biopsy reached 86-94%.

Endoscopic Picture of Duodenal Metastatic Melanoma.

Video Endoscopic Sequence 10 of 23.

Endoscopy of malignant melanoma metastatic to the duodenum.


Endoscopy of malignant melanoma metastatic to the duodenum

Video Endoscopic Sequence 11 of 23.

Endoscopy of malignant melanoma metastatic to the duodenum.



Endoscopy of malignant melanoma metastatic to the duodenum

Video Endoscopic Sequence 12 of 23.

Endoscopy of malignant melanoma metastatic to the duodenum.

 

 

Video Endoscopic Sequence 13 of 23.

Shown, at the microscope both in the duodenum and gastric, there are tumor samples contain cells and ovoid polygonal, round and elongated, with eosinophilic cytoplasm and hyperchromatic nuclei. pigment was not detected with routine stains so, supplementing with quote immunohistochemistry for keratin markers for melanoma

 


 

Video Endoscopic Sequence14 of 23.

Endoscopy Biopsies of malignant melanoma metastatic to stomach and duodenum.


Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 15 of 23.

Endoscopy Biopsies of malignant melanoma metastatic to stomach.





Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 16 of 23.

Endoscopy Biopsies of malignant melanoma metastatic to stomach and duodenum.

 

Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 17 of 23.

Endoscopy Biopsies of malignant melanoma metastatic to duodenum.

 

Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 18 of 23.

Endoscopy Biopsies of malignant melanoma metastatic to stomach and duodenum.

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Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 19 of 23.

Endoscopy Biopsies of malignant melanoma metastatic to stomach and duodenum.

Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 20 of 23.

Immunohistochemistry Mart-1 melanoma.

Transmembrane protein with cytoplasmic staining localization;

The photographs illustrate red positivity for melanoma tumor cells in the gastric mucosa.

 


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Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 21 of 23.

Histopathologic image of gastric metastasis of the malignant melanoma. Immunohistochemical staining was performed for Melan-A (MART-1): A new monoclonal antibody for malignant melanoma diagnosis.

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Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 22 of 23.

Histopathologic image of gastric metastasis of the malignant melanoma. Immunohistochemical staining was performed for Melan-A (MART-1): A new monoclonal antibody for malignant melanoma.

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Endoscopy Biopsies of malignant melanoma metastatic to stomach.

Video Endoscopic Sequence 23 of 23.

Histopathologic image of gastric metastasis of the malignant melanoma. Immunohistochemical staining was performed for Melan-A (MART-1): A new monoclonal antibody for malignant melanoma.

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