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Ovarian metastasis from adenocarcinoma of the lung

A 38-year-old woman affected by an unresectable pulmonary adenocarcinoma, diagnosed 1 year earlier by bronchoscopy with biopsies and treated with platinum–pemetrexed-based chemotherapy, was referred to our center after the incidental finding of a left ovarian mass. On ultrasound examination a solid lesion, 46 × 36 × 29 mm in size, was detected in the left ovary. The solid lesion appeared as a rounded lobulated mass, with a homogeneous echotexture with no stripes. Ovarian parenchyma adjacent to the mass (the so-called ‘crescent sign’) was clearly visible at the lateral part of the adnexum (size, 19 × 20 × 14 mm) (Figure 1). On power Doppler examination, moderate vascularization was detected (color score, 3) within the ovarian lesion (Figure 2). The contralateral ovary was normal. No free fluid in the pouch of Douglas was detected. Serum tumor markers were: CA 125, 32 U/mL; CA 19.9, 52 U/mL. The ultrasound examiner was uncertain as to the diagnosis. The first suggestion was ovarian fibroma, supported by the presence of a rounded solid lesion with an adjacent ovarian crescent sign, despite the fact that the absence of stripes meant that the echostructure was inconsistent with the typical ovarian fibroma appearance. A diagnosis of metastatic tumor was considered to be improbable because the examiner had never seen the crescent sign in the presence of an ovarian metastatic tumor. An open laparoscopy revealed that the uterus, Fallopian tubes and right ovary were normal, and confirmed the presence of a solid tumor adjacent to normal parenchyma in the left adnexal region. There were no signs of peritoneal carcinomatosis. The surgeon confirmed the suspicion of an ovarian fibroma and proceeded with enucleation of the solid ovarian lesion and its removal from the abdominal cavity through an endoscopic bag. There was no rupture of the tumor in the peritoneal cavity and ovarian parenchyma that appeared normal was left in situ. Final pathology revealed an ovarian metastasis from a poorly differentiated adenocarcinoma of the lung. The morphological diagnosis was confirmed by immunohistochemical staining, which was positive for keratin 7, thyroid transcription factor-1, cyclin-dependent kinase inhibitor 2A and tumor protein 53, and negative for vimentin, estrogen receptor, progesterone receptor, gross cystic disease fluid protein-15, cytokeratin 20 and CDX2 e WT1. Pulmonary metastases to the ovaries are extremely rare. A few cases have been reported in the pathology literature, but only around 5% of women with lung cancer have ovarian metastases at autopsy1. They typically appear as uni/bilateral multinodular lesions, with widespread necrosis and extensive lymphovascular invasion; involvement of the ovarian surface is rare for adenocarcinoma of the lung, while for the small-cell carcinoma histotype, the ovarian parenchyma is usually obliterated2. Figure 1 Gray-scale ultrasound image of ovarian metastasis from lung adenocarcinoma, showing a solid tumor with lobulated margins adjacent to normal ovarian parenchyma, the latter marked by calipers.