St. Vincent's Medical Center, Quinnipiac University Bridgeport, CT, United States
Rishi Chadha, MD1, Sasraku Amanor-Boadu, MD, MPH2, Mahmoud Abdelrahman, MD1, Pankaj Nepal, MD1, Eddy Castillo, MD1 1St. Vincent's Medical Center, Quinnipiac University, Bridgeport, CT; 2St. Vincent's Medical Center, Quinnipiac University, Fairfield, CT
Introduction: Pancreatic cancer is a devastating disease with the majority of cases being discovered metastatic with spread to the lung, liver, spleen, bone, and other organs through the lymphoid system. Ovarian metastasis is rare. Here we present a case of a patient that presented with metastatic pancreatic cancer, and later being found to have bilateral ovarian involvement with ulceration into the recto-sigmoid junction.
Case Description/Methods: A 66-year-old female with a medical history of hypertension and rheumatoid arthritis presented with 60-pound weight loss and abdominal pain for a year. She underwent CT scan which showed distention of the duodenum to the distal transverse portion concerning for duodenal mass versus adjacent pancreatic neoplasm. PET scan was conducted and showed hypermetabolic activity in the region of the pancreatic uncinate process, hypermetabolic activity with multiple nodules throughout the peritoneal cavity, increased activity in the right adnexa, and focal activity in the liver. CT-guided biopsy of the peritoneal deposit revealed adenocarcinoma with immunohistochemical staining suggesting pancreaticobiliary origin. Patient was started on gemcitabine/abraxane every two weeks with marked clinical improvement. Months later, she began developing worsening pelvic pain. On surveillance CT, she was found to have bilateral adnexal densities measuring up to 4.5 cm on the left and 3.3 cm on the right, CA125 level was 104. Patient was sent for lower EUS and a single 1.2 cm ulcer was found in the recto-sigmoid junction with biopsy results showing metastatic adenocarcinoma. Patient was subsequently referred for palliative radiotherapy with clinical improvement.
Discussion: Metastatic ovarian cancer due to gastrointestinal cancers are known as Kruckenberg tumors, but ovarian metastasis due to pancreatic cancer is a rare occurrence with one analysis reporting 35 cases. Much of the time, the patient will present with abdominal pain, and ovarian metastasis are found incidentally with no specific clinical symptoms. Our patient developed pelvic pain and had involvement of the colon, which has not been reported previously. CA125 elevation has been noted in previous cases, with one report mentioning 9/10 cases. Features suggesting ovarian metastasis is bilateral involvement, moderate tumor size (< 10 cm), and intra-abdominal spread. Palliative ovariectomy is recommended to relieve clinical symptoms, but our patient had developed recto-sigmoid invasion making surgical intervention difficult.
Figure: Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast, images acquired on portal venous phase. A) Axial and B) Coronal section images demonstrate a heterogeneous enhancing infiltrative mass arising from lower head and uncinated process of the pancreas (yellow thin arrows) causing extrinsic narrowing of the third part of the duodenum with dilation of proximal segments (red thin arrows). A nodular enhancing peritoneal deposit is seen in right para-colic gutter (green thin arrow). C, D) Axial section images of the pelvis showing masses or deposits in left adnexa (yellow bold arrow), right adnexa (blue bold arrow), and recto- sigmoid junction at cul-de-sac (red curved arrow).
Rishi Chadha indicated no relevant financial relationships.
Sasraku Amanor-Boadu indicated no relevant financial relationships.
Mahmoud Abdelrahman indicated no relevant financial relationships.
Pankaj Nepal indicated no relevant financial relationships.
Eddy Castillo indicated no relevant financial relationships.
Rishi Chadha, MD1, Sasraku Amanor-Boadu, MD, MPH2, Mahmoud Abdelrahman, MD1, Pankaj Nepal, MD1, Eddy Castillo, MD1. P0071 - Pancreatic Adenocarcinoma With Ovarian Metastasis and Recto-Sigmoid Junction Involvement, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.