Moderator: Dr. Celeste N. Powers
Metastatic Gastric Adenocarcinoma, Of Signet-Ring Type
Dr. Terrence Colgan
Peritoneal fluid. This 30 year old woman presented to the Emergency Dept. with a 4-week history of
abdominal pain and a history of fullness in the upper abdomen, culminating in an increase in abdominal
girth in the last few days. She had otherwise been well. A CT scan of the abdomen revealed a right
ovarian mass of 12 cm, a left ovarian mass of 4 cm, massive ascites and omental thickening consistent
with metastatic disease. A serum β-HCG was negative, but a serum a-fetoprotein was increased to 160
mcg/L (normal<10). A paracentesis of the abdomen was performed
Key to diagnosis of most malignancies in malignant effusions:
Can one identify a second population of foreign cells?
Challenge in some cases:
Is a pure population of "foreign" malignant cells present?
|Breast, including lobular Ca * ||Dysgerminoma|
*may present as single isolated cells
? Yolk Sac Tumor ? ↑'d serum a-fetoprotein
Cytomorphology of Yolk Sac Tumor in Ascitic Fluid
- Paucity of specific features
- "clean background"
- Scattered mesothelial cells
§ Atypical cells in irregular & papillary
groupings cell block diagnostic features
Vacuolation of Adenocarcinoma Cells
- Cell clusters with vacuolation
- Ovary and lung especially
- Mucin and/or degeneration (beware mesothelial cells)
- Isolated cells with vacuolation
- Gastric ca "signet ring"
- (Definition: Large cytoplasmic vacuolation
with nuclear compression.)
- Lobular breast ca "bulls eye" (uncommon as
- Spieler P et al Identification of Types and Primary Sites of
Acta Cytol 1985; 5: 753.
- Spriggs A et al Intracellular mucous inclusions. J Clin
Pathol 1975; 28: 929.
How to proceed in disseminated intra-abdominal malignancy in women?
- Fact: Short survival, weeks/months,
- Alternatives: Laparotomy?, Laparoscopy?
Standard therapy for ovarian carcinoma
- Standard therapy →
- Optimal cytoreductive surgery
- Can be achieved in at least 1/3 of patients
- Subsequent chemotherapy: IV platinum-taxane (6 courses)
- Results of standard therapy →
Neoadjuvant therapy for ovarian carcinoma
- Neoadjuvant chemotherapy followed by interval
debulking surgery may be an alternative for the initial management of selected (bulky) ovarian carcinoma
- EORTC-GCG 55971 & NCIC neoadjuvant chemotx vs
primary debulking surgery in Stage 3C and 4
- Pectasides D et al in Oncology 2005; 68: 64 70
- Vergote I et al in Oncology 2005; 19: 1615 22
Now..intraperitoneal (IP) chemotherapy: ovarian carcinoma
- Randomized phase 3 trial of Stage 3 patients
following optimal cytoreductive surgery →
- Superior progression-free survival and overall survival
(↑'d 30% to 66 mo.) for 6 cycles of IV chemotx plus IP vs. IV chemotx alone
- BUT <50% could complete IP therapy
- Armstrong et al in NEJM 2006;354: 34-43.
IP chemotherapy for ovarian carcinoma: new standard of practice?
- NCI (USA) supports the use of IP chemotherapy in a
subset of ovarian carcinoma patients
- "The Society of Gynecologic Oncologists of Canada
(GOC) supports the use of intraperitoneal chemotherapy in optimally debulked stage three ovarian cancer
patients." Jan. 10, 2006
6 days after presentation the patient underwent laparotomy
- Surgeon's pre-op diagnosis → Yolk sac tumor
- Radiologist's description → Advanced ovarian
- Pathologist's pre-op diagnosis →
Adenocarcinoma, ? primary
Laparotomy (1) Findings:
- Ascites 7 litres
- Multiple peritoneal nodules throughout, including
mesentery, bowel, liver, and diaphragms
- Omentum multiple nodules, as well
- Bowel and appendix, no abnormality
- Omentectomy, BSO, and peritoneal biopsies were
Final Diagnosis & Course
Diagnosis: Metastatic Gastric Adenocarcinoma, Of Signet-Ring Type
- At laparotomy: "indurated" & "plastered"
gastric small curvature
- Subsequent GI endoscopy: 10 cm. length of
nodular, non-ulcerated abnormality
And the elevated Serum a-FP?
- "elevated concentrations of serum
a-fetoprotein occur in most hepatocellular carcinomas and 10 30% of other gastrointestinal cancers"
- Lab Medicine Practice Guidelines of the National
Academy of Clinical Biochemistry, 2006
Take home message Case 2.
- Absence of a distinctive, malignant cell
population in fluids can be diagnostically challenging
- Management options of women with ovarian carcinoma
- Designation of the primary site of abdominal
carcinomatosis may be important
- Interpret radiology and biochemistry info
cautiously to avoid diagnostic pitfalls.
- Armstrong DK, Bundy B, Wenzel L et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. NEJM 2006; 354: 34 43.
- Foot NC. Identification of types and primary sites of metastatic tumors from exfoliated cells in serous fluids. Am J Pathol 1954; 661 677.
- Gynecologic Oncologists of Canada Statement on Intraperitoneal chemotherapy for ovarian cancer. Accessed March 21, 2006 at http://www.g-o-c.org
- Pectasides D, Farmakis D, Koumarianou A. The role of neoadjuvant chemotherapy in the treatment of advanced ovarian cancer. Oncology 2005; 68: 64 70. Epub.
- Ringenberg QS, Doll DC, Loy TS, Yarbro JW. Malignant ascites of unknown origin. Cancer 1989; 64: 753 755.
- Roncalli M, Gribaudi G, Simoncelli D, Servida E. Cytology of yolk-sac tumor of the ovary in ascitic fluid report of a case. Acta Cytol 1988; 32: 113 116.
- Spieler P, Gloor F. Identification of types and primary sites of malignant tumors by examination of exfoliated tumor cells in serous fluids. Acta Cytol 1985; 5: 753 767.
- Spriggs AI, Jerrome DW. Intracellular mucous inclusions a feature of malignant cells in effusions in the serous cavities, particularly due to carcinoma of the breast. J Clin Pathol 1975; 28: 929 936.
- Stenman U-H et al. National Academy of Clinical Biochemistry Guidelines for the Use of Tumor Markers in Testicular Cancer. Accessed April 17, 2006: http://www.nacb.org/lmpg
- Vergote I, van Gorp T, Amant F, Neven P, Berteloot P. Neoadjuvant chemotherapy for ovarian cancer. Oncology 2005; 19: 1615 1622.