Clinical Challenges and Images in GI

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Question: A 70-year-old woman was referred to our hospital because of attacks of vertigo and intermittent melena. Few days before admission the patient felt weak and not able to perform her regular housework. The initial hemoglobin level was 72 g/L. Ten years before admission the patient was operated because of disseminated ovarian cystadenocarcinoma with peritoneal carcinomatosis. After operation, the patient was treated with adjuvant chemotherapy with carboplatin and cyclophosphamide for >6 months. In the follow-up and until the current admission, there was no evidence for recurrence of the carcinoma.

The patient underwent upper gastrointestinal (GI) endoscopy for suspected upper GI hemorrhage. We found a large ulcerated mass at the greater curvature of the stomach with stigmata of hemorrhage (Forrest IIc) and hematin in the stomach (Image A: Large ulcerated mass at the greater curvature of the stomach with stigmata of hemorrhage [Forrest IIc] and hematin in the stomach).

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Multiple biopsies were taken and the pathologist described small roundish deposits of calcium inside a predominant malignant tumor infiltration into the regular stomach wall (Image B; Histology demonstrated small roundish deposits of calcium [arrows] inside a predominantly malignant tumor infiltration into the regular stomach wall (hematoxylin and eosin; original magnification, ×200) (with kind permission of Dr Th. Wagner, Institute of Pathology, Klinikum Augsburg). What is the diagnosis?

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Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 19): Gastric metastases of an ovarian cystadenocarcinoma with psammoma bodies 

Ovarian cancers often metastasize to peritoneal surfaces throughout the abdomen and pelvis.1 GI involvement is usually limited to seromuscular involvement of the small and large bowel and its mesentery. The mesentery is shortened and the intestinal lumen is narrowed.2 A transmural invasion is less common, as is GI hemorrhage.3

We performed a colonoscopy in addition to the gastroscopy, which showed a narrowing of the colon lumen in the area of the descending colon. Histology also proved an infiltration of the above described ovarian cancer.

Helpful in the field of pathology was the finding of psammoma bodies, which are microscopically visible round collections of calcium. The term is derived from the Greek word psammos meaning “sand.” Psammoma bodies are commonly seen in certain tumors especially papillary thyroid carcinoma, meningioma or serous papillary ovarian adenocarcinoma.

Psammoma bodies have a laminar appearance. The origin of psammoma bodies is controversial, but 1 theory postulates that the nidus for their formation is a single necrotic tumor cell, upon which layers upon layers of calcium salt deposits are added.

An additional immunohistochemical evaluation demonstrated positivity for CA125 antibodies on the tumor surface; therefore, the initial finding of invasion by ovarian cancer was confirmed.