Patterns of spread of clear cell ovarian cancer: Case report and case series
A 56 year old woman presented with pelvic discomfort. Ultrasound revealed a 10 cm complex right adnexal mass. The CA-125 was 134. Laparotomy revealed high grade clear cell carcinoma of the right ovary (OCCC) only, without surface involvement but with positive ascitic fluid and no extra-ovarian spread, FIGO stage IC (A).\nSubsequent left lumbosacral pain developed, radiating to the left buttock, thigh and leg. A bone scan revealed a solitary focus of increased uptake in the intertrochanteric region of the proximal left femur (A), with metastasis suspected. Correlative poorly marginated osteosclerosis was subsequently identified on radiography. There was no osteolysis or fracture. These findings were confirmed on CT, with no evidence of cortical disruption. The lesion demonstrated medullary T1 hypointensity and STIR hyperintensity on MR, with no associated soft tissue mass. Maximal dimensions were 4.2 × 2.6 × 7.0 cm craniocaudal, with additional lobules of involvement extending into the metadiaphysis. These findings of infiltrative disease were consistent with metastasis, and less likely primary neoplasia. A core biopsy of the left proximal femur subsequently confirmed the presence of metastatic ovarian carcinoma of OCCC histology (B). This metastasis was also visualized on 18F-FDG PET/CT (B), which also revealed regions of increased activity in the left sacrum and right ilium.\nThe patient had received 3 cycles of carboplatin and paclitaxel by the time of the bone biopsy. The chemotherapy did not treat the bone involvement. Subsequent irradiation to the left hip and sacroiliac region resulted in significant symptomatic benefit. The patient continued with 4 more cycles of carboplatinum and paclitaxel chemotherapy. A follow-up 18F-FDG-PET scan revealed progression with new areas of disease in the thoracic spine and right sacroiliac region. The previously irradiated area of the left femur however had “interval metabolic response to treatment with only minimal residual FDG accumulation persisting” (C).