Ovarian transposition and metachronous ovarian metastasis in a premenopausal colorectal carcinoma patient: a case report

Abstract

Colon cancer has a high incidence of metastasis, with an estimated 0.8-7.4% of colorectal adenocarcinoma (CRC) cases metastasizing to the ovary. The role of prophylactic bilateral oophorectomy in CRC is contested in the literature, particularly in premenopausal patients. Further, it is unclear if prophylactic removal of the contralateral ovary is indicated in cases of direct involvement of one ovary to reduce recurrence. Facing a lack of evidence for survival benefit, hormonal complications, and sterilization, some choose to pursue fertility sparing options. For female patients interested in additional pregnancies, the ovaries can be surgically relocated in a prophylactic procedure known as ovarian transposition; as even small doses of radiation to the ovary can effectively sterilize women in their 30 s. We present a case of a 29-year-old female who underwent ovarian transposition of the right ovary before initiating chemoradiation for primary left sided colon adenocarcinoma with direct invasion of the left ovary. Months later, she presented to the emergency department (ED) with abdominal pain suspicious for ovarian torsion. On restaging computerized tomography (CT), she was diagnosed with symptomatic right ovarian metastasis in the transposed ovary, requiring reoperation and oophorectomy. For this patient, and for others facing critical decisions about ovarian preservation in advanced colorectal cancer, the question remains how to balance fertility concerns with optimal minimization of metastasis and recurrence.

Keywords: Ovarian transposition; case report; ovarian metastasis; prophylactic oophorectomy.

Figure 1

Metastatic progression in the transposed ovary of a 29-year-old female with colorectal adenocarcinoma primary. CT scans of the abdomen and pelvis, 2 months progression. (A) Status post left oophorectomy, post interval transposition of the right ovary into the right lower quadrant with adjacent surgical clips. The ovary is situated between the anterior abdominal wall and the ascending colon. The right ovary appears enlarged, measuring 5.2×2.5 cm², previously normal in size. (B) The right ovary is enlarged, measuring 7.9×3.9 cm², and contains multiple cysts. Differential included ovarian torsion and metastasis. Subsequent oophorectomy and pathological analysis confirmed metastasis. CT, computerized tomography.

Figure 2

Tumor Histology in a 29-year-old female with metachronous ovarian metastasis. Pictomicrographs of an ovarian tumor in a 29-year-old female with metachronous metastasis after undergoing low anterior resection, left oophorectomy, and right ovarian transposition for colon adenocarcinoma. The tumor is composed of large glands with extensive necrosis and occasional calcifications (A). By immunohistochemistry, it is positive for CK20 (B), CDX2 (C), while negative for PAX8 (D) and CK7 (not shown). All images are shown under 40× magnifications.

Figure 3

Modes of metastasis from colorectal carcinoma to the ovary. Illustration of the modes of metastasis from colorectal carcinoma to the ovary. Proposed modes of metastasis include hematogenous spread via the blood, lymphatic spread via the pelvic lymph nodes, direct extension from the primary tumor into the adjacent ovary, and transcoelomic spread across the peritoneal cavity.