OVARIAN CARCINOMA WITH AXILLARY NODAL RECURRENCE-AN UNUSUAL METASTATIC PATHWAY

Abstract

Carcinoma ovary is the fourth most common malignancy among women in
India. Most patients present with locally advanced disease, where cytoreductive surgery followed by
adjuvant chemotherapy is standard of care. Ovarian cancer recurrences are predominantly intraabdominal
and managed by chemotherapy and salvage surgery. Distant metastasis is found in lung
and paraaortic nodes. Metastasis to the axillary nodes is unusual and requires evaluation to rule out
coexisting breast primary. We present a case of recurrent ovarian cancer with isolated axillary nodal
metastasis. Case report-A 47 year old lady presented in 2011 after suboptimal surgery for a pelvic
mass. She was evaluated and diagnosed as stage IIIc Grade 2, papillary serous cystadenocarcinoma
Ovary for which she received six cycles of chemotherapy with Carboplatin and Paclitaxel. On follow
up she was found to have pelvic and para-aortic nodal recurrence in 2012. She underwent secondary
debulking and received three cycles of Liposomal Doxorubicin .On follow up in April 2014 she had
increased CA-125,PET-CT showed increased uptake in the right axilla and vault. Biopsy of the right
axillary node revealed metastatic papillary adenocarcinoma, morphologically consistent with ovarian
primary. Bilateral mammography and ultrasound of the breasts and axillae ruled out breast primary.
Immunohistochemistry showed WT-1 positivity indicating possibility of an ovarian primary. She was
rechallenged with Paclitaxel and Carboplatin. Discussion-Ovarian carcinoma metastasizes by either
hematogenous, lymphatic, direct or transcoelomic dissemination. Our present knowledge of
metastasis is insufficient to fully explain the pathway of axillary nodal metastasis from an ovarian
primary. Lymphatic drainage to axillary nodes commonly occurs through lymphatics along Pectoralis
major. An unusual pathway describes lymphatic drainage from rectus abdominis, subhepatic and
subperitoneal plexuses. This pathway could most likely explain the route of axillary node metastasis
in this patient. Literature review revealed occurrence of axillary nodal metastasis from a breast
primary more frequently than from ovarian primary. Thorough clinical examination and
comprehensive imaging of breasts is warranted to rule out coexisting breast primary. An excision
biopsy of the node is mandatory. Immunohistochemical markers aid in establishing the origin. The
treatment options vary widely as does the prognosis.