In August 2021, a 54-year-old Chinese woman presented to the Department of Oncology with dull abdominal pain and increased serum CA125 expression for more than 11 months. She was diagnosed with recurrence after resection of ovarian MMMT followed by adjuvant chemotherapy and found to have an enteral metastasis in the ascending colon.
The patient had a 23-year history of chronic viral hepatitis B, for which she was treated with oral entecavir dispersive tablets. She had no family history of other cancers. Uterine fibroids were diagnosed in 2001, for which she underwent regular B-mode ultrasound follow-up. A B ultrasound examination in July 2007 found uterine fibroids in the mixed spaces of the left and right adnexal areas, measuring 6.4×4.2×5.8 cm and 6.4×6.1×6.3 cm, respectively. Her serum CA125 concentration was 224.7 U/mL, much higher than the normal value, whereas her serum CEA (0.60 U/mL) and CA199 (18.0 U/mL) concentrations were within their normal ranges (Figure 1). An ovarian tumor was suspected, for which she underwent radical surgery under general anesthesia on August 3, 2007. Surgery included laparoscopic hysterectomy, bilateral adnexectomy, pelvic lymph node dissection, resection of the greater omentum and abdominal main lymph nodes, appendectomy, and tumor reduction. Intraoperative examination showed that her uterus was about 40+ days pregnant, hard and immobile, with a large number of cauliflower-like brittle nodules about 0.5–2 cm in size on the surface, cauliflower-like brittle and decayed masses about 6 cm in size on both ovaries, a large number of similar nodules about 0.5–2 cm in size on both fallopian tubes, and similar nodules 0.1–5 cm in size on the anterior wall of the rectum and sigmoid colon. The anterior aortic lymph nodes were enlarged, measuring about 4×3×2 cm, and the lymph nodes between the aorta and superior vena cava were about 5×4×3 cm in size. Postoperative pathological examination of the resected sample showed MMMT of the left ovary, with the tumor area containing high-grade serous carcinoma and sarcoma of mesenchymal origin (Figure 2a). Adenocarcinoma components were found to have widely metastasized to the serosa and mesangium of the right ovary, the right fallopian tube, the serosal and inferior musculature of the uterus (3 mm) and intestinal walls, and bilateral margins of the pelvic incision. Tumor thrombi were detected in the above vessels, along with metastases to the para-aortic lymph nodes 2/2. About 55% of tumor cells in the carcinoma area and about 40% in the sarcoma area were Ki-67 positive. Both the sarcoma and carcinoma areas were positive for CA125, wild-type P53, and estrogen receptor (ER), whereas both areas were negative for Myo-dl, CD10, and desmin (Figure 2b). The carcinoma area was positive and the sarcoma area focally positive for CK and CK7, whereas only the sarcoma area was positive for vimentin (Figure 2b). The patient was treated with ten cycles of adjuvant chemotherapy, consisting of paclitaxel (200 mg) and carboplatin (450 mg), and was regularly followed-up in the outpatient department.
A follow-up examination in June 2014 showed that this patient's serum CA125 concentration had increased to 104.92 U/mL, whereas her serum CEA and CA199 concentrations were 1.11 U/mL and 8.91 U/mL, respectively (Figure 1). 18F-fluorodeoxyglycose (FDG) positron emission/computed tomography (PET/CT) showed an abnormal increase in nodular metabolism of FDG in the ascending colon, with a maximum standard uptake value (SUV) of about 6.7 and an average SUV of about 4.7, and CT showed an isodense shadow in the same plane. After delayed imaging, the metabolism increased diffusely, with a maximum SUV of about 6.3 and an average SUV of about 5.3 (Figure 3). Colonoscopy showed a bulging lesion about 8 cm in size in the anal gyrus, with a range of 2.5×2.0 cm, indicating nodular hyperplasia and an uplift at the edge of the embankment. Pathologic examination of a biopsy sample suggested adenocarcinoma. Enhanced CT of the entire abdomen in July 2014 showed irregular nodular thickening and enhancement of the local intestinal wall of the ascending colon, to about 1.5 cm. In addition, the outer edge was slightly rough, consistent with colon cancer, suggesting that some lesions may have reached the serous surface. On July 22, 2014, the patient underwent surgery, including radical right hemicolectomy and transverse ileo-colonic anastomosis, together with intraoperative intraperitoneal chemotherapy, consisting of 4.0 mg raltetrexed in 200 mL warm saline. Intraoperative examination showed that the tumor was located at the beginning of the ascending colon, in the ascending mesocolon margin, was about 3.0×2.5 cm in size, and was uplifted, involving 1/4 of the circumference of the intestinal lumen, without obstructing the intestinal lumen. Gross tumor was found to have infiltrated outward from the intestinal lumen, permeating the entire layer of the intestinal wall and mesangial fat, with the tumor center in the intestinal lumen being crater shaped.
Postoperatively, the patient was pathologically diagnosed with a metastatic adenocarcinoma of the ascending colon and right colon, with submucosal full-layer examination showing ovarian cancer involvement, but no involvement of the muscle and serosal layers (Figure 4a). These findings, along with the medical history of the patient and the immunohistochemical phenotype of the tumor, were consistent with metastasis of an ovarian cancer. Immunohistochemistry showed that the tumor was positive for Pax-8, ER, CA125, and WT-1, weakly positive for P53, and negative for CDX-2, villin, and vimentin, with about 55% of the tumor cells being positive for Ki-67 (Figure 4b). Following surgery, the patient was treated with eight cycles of chemotherapy, consisting of docetaxel (100 mg) and carboplatin (450 mg). The patient recovered after surgery and was regularly followed-up in the outpatient department.
In September 2020, the patient's serum CA125 concentration was 35.43 U/mL, higher than the normal value, whereas her serum concentrations of CEA (1.58 U/mL) and CA199 (11.42 U/mL) were within normal ranges (Figure 1). Because imaging modalities showed no significant findings, the patient continued to be followed up in the outpatient department.
In October 2021, the patient's serum CA125 concentration was 41.82 U/mL, whereas her CEA and CA199 concentrations were 2.57 U/mL and 11.92 U/mL, respectively (Figure 1). Ovarian MMMT is highly malignant, with strong invasive and metastatic activities. Because of the rarity of these tumors and their association with poor patient prognosis, the risks of recurrence and metastasis were very high. The present patient was therefore closely followed-up over the long term. Surprisingly, she has survived for more than 14 years, and her physical, psychological and social functions have completely returned to normal. She continues to be monitored closely.