Metastatic ovarian cancer often origins from various organs, represents about 5-15% of all ovarian tumors[3-5], krukenberg tumors is only 1-2% of them[6],which often confused with primary ovarian tumours and teratoma.Most patients with gallbladder-derived ovarian malignant tumors have no obvious and specific clinical manifestations, often manifested as abdominal pain or abdominal distension, and only a few patients can appear with gallbladder cancer-related symptoms,such as jaundice[7-8].In our case, only abdominal distension was presented as the first symptom with the pelvic mass touched during physical examination.The patient also had insidious abdominal pain,but it is considered as gastritis.In addition,the ascites usually represents an advanced stage of cancer.
No clear differences between primary and metastatic ovarian tumors have been drawn from the current imaging reports[9]. However, imaging examination has certain diagnostic significance for ovarian metastatic tumors.First, imaging examination can detect lesions outside the accessory area, thus increasing the diagnosis of metastatic ovarian cancer.Preoperative US, CT, and PET-CT can evaluate the disease progression and provide guidance for treatment.Secondly,it has been reported that the metastatic ovarian cancer is usually bilateral and is more common on the right side[2].Therefore, when bilateral tumors are found, other organs are often examined to determine the presence of a primary malignancy.In addition, metastatic ovarian cancer often presents as solid mass or mixed cystic mass, while primary ovarian tumor often presents as cystic mass or with liquefied necrosis area[10].The imaging of our case showed a solid main mass, which is different from the primary ovarian cancer.While it appears as a unilateral ovarian mass, which increases the difficulty of diagnosis.The patient's imaging findings are useful for showing systemic metastasis,but specifc characteristics are lacking.So we chose a real-time CEUS-guided needle biopsy to identify the primary lesion.Needle biopsy may be conclusive in such a clinical situation as the case in diagnosing.
Enhanced ultrasound can show tumor blood vessels and necrotic lesions clearly,we selected the contrast enhanced site for percutaneous needle biopsy to improve the positive rate[11-12].At the same time,CEUS-guided percutaneous biopsy can monitor the position of the biopsy needle to avoid damaging tissue and blood vessels around the mass[13].In our case,after injection of contrast media,the lesion began to strengthen earlier than the uterine muscle wall which showed uneven high enhancement.Large blood vessels were seen in the lesion entering the interior from the side of the mass.And weak enhanced area internally was seen and considered as necrotic or liquefaction.Therefore, during the puncture process, we avoided the central necrotic part and selected the enhancement area and obtained positive results.
Metastatic ovarian tumors are very difficult to distinguish from primary tumors, However, it is significant to distinguish between them because the corresponding treatments are quite different.Differential diagnosis often rely on patient's medical history and immunohistochemical examination.CK7 and CK20 are important markers for distinction in ovarian tumors[14]. CDX-2 is highly expressed in gallbladder cancer,while is negative in primary ovarian cancer.SATB2 is highly expressed in the lower epithelial tissues of the digestive tract.In addition, negative expression in Pax8 can clearly exclude the primary tumor and support the metastatic origin[15].
At present, there is no standard and consensus of the treatment method for metastatic ovarian cancer.For primary tumors, appropriate surgery may prolong survival,but it works little in metastatic ones which need combination with radiotherapy or chemotherapy regimen.In addition, primary ovarian tumors are commonly sensitive to platinum,while gallbladder cancer often requires a combination of gemcitabine[16].However, the prognosis of our patient was extremely poor. After two courses of gemcitabine and platinum drugs, the mass was found to increase, and the tumor marker value increased.So we switched to combination with dovaliuzumab for 6 courses, the review results were shown to be effective.