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Unusual Abdominal and Pelvic Tumors

CASE 2. SPONTANEOUS REGRESSION OF PERITONEAL IMPLANTS IN BORDERLINE OVARIAN TUMOR AFTER SALPINGO-OOPHORECTOMY

Institut Gustave Roussy, Villejuif, France; and Centre Hospitalier Universitaire Bichat, Paris, France

A 49-year-old woman, with a history of right salpingo-oophorectomy for ovarian borderline tumor 20 years previously, underwent a laparoscopic procedure for pelvic pains. A suspicious tumor on the left ovary, with numerous peritoneal implants on the pelvic cavity and a myoma, were found during the laparoscopy. A conversion to laparotomy was performed to carry out a left salpingo-oophorectomy, myomectomy, and peritoneal biopsies. Histologic examinations revealed the presence of serous borderline tumor of the ovary with micropapillary component, positive peritoneal cytology, and noninvasive peritoneal implants (Fig 1). At the end of surgical procedure, residual disease was persistent on the peritoneum of the pelvic cavity (numerous peritoneal implants from 1 to 5 mm). A radical surgery (hysterectomy and resection of the peritoneal implants) was proposed, but was refused by the patient. A second-look resection of residual peritoneal implants was planned using a laparoscopic approach 6 months following the salpingo-ooporectomy. At that time, the clinical examination, CA125 antigen level, and abdominopelvic computed tomography scan were normal. During the laparoscopic procedure, we noted an adhesion of the omentum to the uterine scar of myomectomy with 2 peritoneal implants of 2 mm. On the peritoneum of the pelvic cavity an important regression of the peritoneal implants was observed. Several implants of 1 mm were found on the Douglas pouch, on the peritoneum of the broad ligament and on the surface of the peritoneum of the bladder. Large peritonectomies were performed with a partial omentectomy by laparoscopy. There was no residual tumor at the end of this surgical procedure. Histologic examination revealed the presence of only two small, noninvasive implants on the omentum. Calcospherites with fibrosis were found on the surface of the peritoneum, but residual peritoneal implants were absent (Fig 2).

View larger version (116K): [in this window] [in a new window]   Fig 1. Noninvasive implants on the peritoneum removed during initial surgery (hematoxylin and eosin, magnification x50).

View larger version (122K): [in this window] [in a new window]   Fig 2. Aspect of peritoneal lesion removed during second-look surgery. Calcospherites with fibrosis were found on the surface of the peritoneum, but without residual tumoral implants (hematoxylin and eosin, magnification x100).

The pathogenesis of peritoneal implants is debated: some authors think that peritoneal implants are "metastases" from the ovarian tumor³ whereas others think that peritoneal and ovarian tumors arise independently in response to the same tumorigenic agents.⁴ A recent important study using clonality testing (based on inactivation of X chromosome) in patients with ovarian borderline tumor and peritoneal implants suggests that peritoneal implants and the ovarian borderline tumor arise independently.⁵ Our case suggests that the clinical behavior of peritoneal implants is related to the primary ovarian tumor possibly due to the secretion of prosurvival factors.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The authors indicated no potential conflicts of interest.

REFERENCES

1. Morice P, Camatte S, Rey A, et al: Prognostic factors of patients with advanced stage serous borderline tumor of the ovary. Ann Oncol 14:592–598, 2003[Abstract/Free Full Text]

2. Gershenson DM: Contemporary treatment of borderline ovarian tumors. Cancer Invest 17:206–210, 1999[Medline]

3. Segal GH, Hart WR: Ovarian serous tumors of low malignant potential (serous borderline tumors): The relationship of exophytic surface tumor to peritoneal "implants." Am J Surg Pathol 16:577–583, 1992[Medline]

4. Russel P: The pathological assessment of ovarian neoplasms, I: Introduction to the common "epithelial" tumours and analysis of benign "epithelial" tumours. Pathology 11:5–26, 1979[Medline]

5. Gu J, Roth LM, Younger C, et al: Molecular evidence for the independent origin of extra-ovarian papillary serous tumors of low malignant potential. J Natl Cancer Inst 93:1147–1152, 2001[Abstract/Free Full Text]

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