| Abstract|| |
Metastasization and distinction from mammary carcinoma is of great clinical importance because of different treatment modalities. Here, we discuss a case of stage IIIC ovarian serous carcinoma, presenting with bilateral axillary nodes metastasis after 25 months interval of its initial presentation. Increased serum CA-125 level caused clinical suspicion. Computed tomography scan of abdomen and pelvis showed no residual disease or any abdominal lymphadenopathy. Mammography of both breast were normal. Bilateral axillary nodes were noted. Guided fine needle aspiration cytology (FNAC) and biopsy of ovarian carcinoma to axillary node is a rare event. Its recogn done. Cytomorphology revealed poorly differentiated carcinoma, compatible to that of primary ovarian tumor. Thus, metastatic carcinoma to axillary node from ovary was confirmed. This case illustrates a rare metastatic presentation of ovarian carcinoma and unequivocal role of FNAC to provide rapid diagnosis and preferred to be first line diagnostic procedure.
Keywords: Axillary node, fine needle aspiration cytology, metastasis, serous carcinoma
|How to cite this article:|
Patel TS, Shah C, Shah MC, Shah MJ. Axillary node metastasis from primary ovarian carcinoma. J Cytol 2014;31:202-4
| Introduction|| |
Ovarian carcinoma is the most common cause of death from gynecological malignancy in Europe and in the United States.  Most patients have local or systemic metastasis at the time of diagnosis. , Although the intraperitoneal route of dissemination is considered the most common, it may also metastasize through lymphatic channels and hematogenous spread.  Metastasis of ovarian serous carcinoma to the axillary lymph node is uncommon with only isolated case reports so far. ,,, These metastases may represent a pitfall for the pathologist. A correct diagnosis is important for proper management and also had prognostic importance. The present case shows rare occurrence of metastatic serous carcinoma of the ovary to axillary lymph node and role of fine needle aspiration cytology (FNAC) as reliable, safe and rapid first line diagnostic procedure.
| Case Report|| |
A 50-year-old lady presented with a lump in axilla. She had taken treatment for stage IIIC serous papillary carcinoma of the ovary that was diagnosed before 25 months. Now she had rise in serum cancer antigen-125 (CA-125) level after 7 months of disease free period. Computed tomography abdomen-pelvis showed no residual/recurrent lesion in pelvis and no paraaortic, and external iliac lymphadenopathy was seen. Mammography of both breasts was normal. Multiple bilateral axillary nodes were seen suggestive of metastasis. Her previous treatment for ovarian carcinoma included three cycles of chemotherapy of paclitaxol and carboplatin, followed by debulking of ovarian tumor and again two cycles chemotherapy for residual disease. Serum CA-125 levels were 1,328 u/ml at the time of admission that reduced to 196 u/ml after first cycle of chemotherapy. It was 71 u/ml after surgery and again rose to 204 u/ml after 7 months of disease free period. Ultrasound guided fine needle aspiration and biopsy from axillary node was done. Slides were stained with Papanicolaou stain by standard procedure. Simultaneous biopsy was received at histopathology department and stained with hematoxylin and eosin.
Cellular smears revealed tumor cells arranged in clusters, in sheets and papillaroid pattern. Tumor cells were large, high N:C ratio, vesicular hyperchromatic nuclei, prominent nucleoli and scanty to moderate pale cytoplasm [Figure 1]. In the background, tumor necrosis and lymphoid cells are seen along with hemorrhage. Histology section was consistent with metastatic poorly differentiated carcinoma in axillary node. On immunohistochemistry (IHC), the tumor cells were positive for cytokeratin 7, Wilms tumor-1 (WT-1) and CA-125 and were negative for estrogen receptor (ER), progesterone receptor (PR) and GCDF-15 consistent with metastasis of ovarian carcinoma to axillary node. Previous biopsy from ovarian carcinoma correlates well morphologically with the current cytological finding [Figure 2].
|Figure 1: Tumor cells arranged in papillaroid pattern having large vesicular hyperchromatic nuclei and prominent nucleoli (Pap, ×100)|
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|Figure 2: Section revealed poorly diff erentiated carcinoma, ovarian biopsy (H and E, ×400)|
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| Discussion|| |
Ovarian cancer is a major cause of cancer death in women, usually presenting with diffuse abdominal dissemination. Data from the literature concerning distant metastases in ovarian carcinoma are scarce. Distant hematogenous metastasis is unusual during the course of the disease or rarely at presentation. Vascular dissemination occurs to internal organs commonly to the liver, lung, pleura and rarely other organs like central nervous system, bone, skin, spleen, breast. 
Cormio et al.  reported 8% of their patients had distant metastasis at initial presentation, and 22% developed them during the course of their diseases, only five of their 162 patients had extra-abdominal spread. They also concluded that distant metastasis occurs in about one-third (30%) of epithelial ovarian carcinoma, and the interval time between diagnosis of ovarian cancer and documentation of distant metastases is the most important prognostic factor.
The present case of high-grade serous ovarian carcinoma was of advanced stage and had metastasis to axillary node that occurred after 25 months of its initial presentation. Our findings correlate well with Recine et al.  Walsh et al.  reviewed 76 cases with abnormal axillary adenopathy, only three patients had extramammary cancer.
Ovarian tumors, such as serous carcinoma, dysgerminoma, endometrioid carcinoma, carcinoid tumor, granulosa cell tumor, and choriocarcinoma have been metastatic in the breast. 77.7% of these cases were of serous carcinoma with synchronous axillary node involvement in <60-67% of these patients.  Isolated axillary node metastasis such as in our case has been reported in few patients. ,,,,
Tumor markers may also be helpful in establishing the primary site of tumor origin. CA-125 level is rarely elevated in breast cancer patients. The use of IHC markers such as gross cystic disease fluid protein-15, CA-125, ER-PR receptor study, and WT-1 may aid in determining the origin of the tumor. In our case rise in CA-125 level rouse the suspicion for recurrence and/or metastasis. Since cytology of breast and ovarian cancer may look similar, the diagnosis may be difficult at the time of diagnosis of axillary node metastasis. Comparison of cytomorphology with that of the primary tumor is of great help along with a serum marker as in our case and also suggested by Bansal et al.  in their study of cutaneous and subcutaneous metastases from internal malignancy.
Metastatic ovarian carcinoma involving axillary nodes are a rare event; its recognition and distinction from primary breast carcinoma are of great clinical importance because the treatment and prognosis differ significantly. Physician should be aware of the existence of axillary lymph node metastasis in primary ovarian carcinoma cancer. FNAC proves to be safe, rapid and reliable diagnostic first line investigative procedure, and its validity is ensured through the correlation with the histology of the previous excised ovarian carcinoma.
| References|| |
Wingo PA, Tong T, Bolden S. Cancer statistics, 1995. CA Cancer J Clin 1995;45:8-30.
Jemal A, Thomas A, Murray T, Thun M. Cancer statistics, 2002. CA Cancer J Clin 2002;52:23-47.
Trimble EL, Karlan BY, Lagasse LD, Hoskins WJ. Diagnosing the correct ovarian cancer syndrome. Obstet Gynecol 1991;78:1023-6.
Rose PG, Piver MS, Tsukada Y, Lau TS. Metastatic patterns in histologic variants of ovarian cancer. An autopsy study. Cancer 1989;64:1508-13.
Orris BG, Geisler JP, Geisler HE. Ovarian carcinoma metastatic to bilateral axillary lymph nodes. A case report. Eur J Gynaecol Oncol 1999;20:189-90.
Walsh R, Kornguth PJ, Soo MS, Bentley R, DeLong DM. Axillary lymph nodes: Mammographic, pathologic, and clinical correlation. AJR Am J Roentgenol 1997;168:33-8.
Aydin C, Unalp HR, Baloglu A, Inci AG, Yigit S, Yavuzcan A. Axillary lymph node metastasis from serous ovarian cancer: A case report and review of the literature. Arch Gynecol Obstet 2009;279:203-7.
Skagias L, Ntinis A, Vasou O, Kondi-Pafiti A, Politi E. Ovarian carcinoma presenting with axillary lymph node metastasis: A case diagnosed by fine-needle aspiration and brief review of the literature. Diagn Cytopathol 2008;36:891-3.
Cormio G, Rossi C, Cazzolla A, Resta L, Loverro G, Greco P, et al.
Distant metastases in ovarian carcinoma. Int J Gynecol Cancer 2003;13:125-9.
Recine MA, Deavers MT, Middleton LP, Silva EG, Malpica A. Serous carcinoma of the ovary and peritoneum with metastases to the breast and axillary lymph nodes: A potential pitfall. Am J Surg Pathol 2004;28:1646-51.
Monica A, Micheal T, Lavinia P, Elvio G, Anais M. Serous carcinoma of the ovary and peritoneum with metastasis to the breast and axillary lymph nodes. Am J Surg Pathol 2004;28:1646-51.
Bansal R, Patel T, Sarin J, Parikh B, Ohri A, Trivedi P. Cutaneous and subcutaneous metastases from internal malignancies: An analysis of cases diagnosed by fine needle aspiration. Diagn Cytopathol 2011;39:882-7.
Trupti S Patel
Department of Cytology, Gujarat Cancer and Research Institute, M. P. Shah Cancer Hospital, Room No. 401, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]