- (2006) Volume 7, Issue 1
Rogelio G Silva, Laila Dahmoush, Henning Gerke
Division of Gastroenterology and Hepatology, Department of Medicine and Department of Pathology, University of Iowa Hospitals and Clinics. Iowa City, Iowa, USA
Received: 10 October 2005 Accepted: 24 November 2005
Context Malignant mixed Mullerian tumors are rare ovarian neoplasms that account for less than 2% of ovarian malignancies. They have a generally poor prognosis and often develop recurrent disease. To our knowledge, this is the first report of a malignant mixed Mullerian tumor with metastasis to the pancreas. The metastatic tumor was identified by endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and Trucut needle biopsy of the pancreas. Case report We describe a 69-year-old female with concomitant Duke’s C adenocarcinoma of the colon and stage III-C malignant mixed Mullerian tumor that presented with malignant ascites, increasing abdominal girth and a pancreatic head mass. EUS revealed an 11 cm cystic mass in the head of the pancreas that was characterized as a carcinosarcoma/malignant mesodermal mixed tumor by EUS-FNA and Trucut needle biopsy. The tumor was morphologically identical to the surgical specimen of her ovarian mass. The patient was treated with palliative chemotherapy and a three-month follow up CT scan did not reveal any new metastatic lesions. Conclusion The pancreas is a rare site of metastasis and more commonly seen in renal cell carcinoma, melanoma or lung tumors; amongst others. Although ovarian adenocarcinoma has been reported as a primary site of pancreatic metastasis, it has not been previously described originating from a mixed Mullerian tumor of the ovary presenting as a cystic pancreatic head mass.
Endosonography; Mixed Tumor, Mullerian; Neoplasm Metastasis; Pancreas
MMMT: malignant mesodermal mixed tumor
Malignant mixed Mullerian tumors are the second most common type of uterine sarcoma but are a rare cause of ovarian malignancy (less than 2%). They are generally responsive to chemotherapy but have a poor prognosis and often develop recurrent disease [1, 2, 3]. We report a case of a malignant mixed Mullerian tumor of the ovary with metastasis to the pancreas confirmed by EUS fine needle aspiration. To our knowledge, no other case has been reported in the literature.
We present a 69-year-old female with a prior history of stage III-C malignant mixed Mullerian tumor and Duke Classification C adenocarcinoma of the sigmoid colon who was referred to the endosonography service for the evaluation of a pancreatic mass. The patient had both malignancies diagnosed simultaneously 4 years earlier and had been treated with surgical resection including bilateral salpingo-oophorectomy, hysterectomy, omentectomy, liver wedge resection and sigmoid colectomy with colostomy. The patient’s initial symptoms were increasing abdominal girth and she had been found to have malignant ascites at the time of her evaluation. CT scan of the abdomen revealed normal ovaries but a barium study revealed an apple-core lesion in the sigmoid colon. During surgical resection, an 8 cm right ovarian mass was identified as well as peritoneal seeding with metastasis to the greater omentum. Another tumor was identified in the sigmoid colon and near the area of the gallbladder bed consistent with Mullerian tumor metastasis. She was subsequently treated with 6 cycles of carboplatin and taxol. Multiple peritoneal biopsies at the time of colostomy take down 6 months later as well as follow up colonoscopies failed to reveal recurrent disease. Yearly CT scans of the abdomen had been unremarkable until 4 years later when CT revealed a 7.3x9.4 cm complex cystic mass in the area of the head of the pancreas (Figure 1). EUS was performed and revealed an 11 cm cystic mass in the area of the head of the pancreas with thick septations and a solid-appearing area (Figure 2). Both fine needle aspiration and Trucut core biopsies were performed. Microscopic examination of the fine-needle aspiration material showed cohesive clusters of highly atypical hyperchromatic spindle cells embedded in a myxoid matrix (Figure 3a). Identical cells and background were noted in the concurrent Trucut biopsy (Figure 3b). Review of the patient’s previously diagnosed ovarian tumor showed a carcinosarcoma/malignant mesodermal mixed tumor (MMMT) with the sarcomatous component being morphologically identical to the tumor cells noted in the aspirate and biopsy (Figure 3c). Interestingly, the metastatic tumor was exclusively composed of the sarcomatous component.
Figure 1. Contrast enhanced CT of the abdomen revealing a 7.3x9.4 cm septated mass in the area of the head of the pancreas with distortion of the normal anatomy.
Figure 2. Linear array endosonographic image of a large cystic mass in the head of the pancreas with heterogeneous solid area.
Figure 3. a. Pancreatic FNA: cluster of highly atypical hyperchromatic spindle cells noted in a myxoid background (Papanicolaou stain). b. Pancreatic biopsy: clusters of hyperchromatic spindle cells noted in a myxoid background (H&E stain). c. Ovarian tumor: carcinosarcoma/ malignant mesodermal mixed tumor (MMMT) with serous carinoma in the center, surrounded by spindle cells myxoid sarcoma (H&E stain).
She is currently receiving repeat chemotherapy with carboplatin and taxol. Repeat CT scan of the abdomen 3 months later did not demonstrate new metastatic lesions or change in the pancreatic mass. The patient is alive and tolerating her chemotherapy well.
Metastasis to the pancreas is rare. In one study of 1,050 pancreatic FNA specimens of intraparenchymal lesions, only 3.8% were due to metastatic tumor in the pancreas [4]. Pancreatic metastases are more commonly reported in patients with renal cell carcinoma or melanoma but other causes have included lung, breast, colon, hepatic or gastric carcinomas [5, 6, 7]. The pancreatic head is the most common site of metastasis [4]. Schumacher described one case of ovarian adenocarcinoma metastasis to the pancreas in 1993 [8]. Our case describes a rare malignancy causing an even rarer metastatic lesion to the pancreas. Malignant mixed Mullerian tumors are generally considered to have a poor prognosis and often have wide metastasis at the time of diagnosis [3]. As in our case, the pancreas cannot be excluded as a potential site of distant metastasis and may mimic a cystic neoplasm of the pancreas.
