Introduction

Ovarian carcinoma remains one of the most lethal gynecological malignancies worldwide. According to recent studies, it accounts for approximately 3.4% of all cancers in women and is the fifth leading cause of cancer-related deaths among women in the United States. The majority of ovarian cancers are epithelial in origin and typically metastasize via direct extension, lymphatic spread, or peritoneal seeding.

Classic metastatic patterns of ovarian carcinoma have been well-documented in the literature, with the peritoneum, omentum, and pelvic and para-aortic lymph nodes being the most common sites of metastasis. However, unusual metastatic sites have been occasionally reported, including liver parenchyma, lungs, pleura, brain, and bones, though these are generally considered uncommon and typically occur in the late stages of disease progression.

This manuscript presents a unique case of advanced ovarian carcinoma with an atypical metastatic pattern that presented significant diagnostic challenges and required a multidisciplinary approach to management. The rarity of this presentation merited detailed documentation and analysis, potentially contributing to the understanding of ovarian cancer biology and metastatic behavior.

Case Report

A 58-year-old woman presented to her primary care physician with a 3-month history of progressive fatigue, abdominal discomfort, and unintentional weight loss of approximately 12 pounds. Her medical history was significant for hypertension and type 2 diabetes mellitus. She had a family history of breast cancer in her mother and colorectal cancer in her paternal grandmother.

Physical examination revealed mild abdominal distension and palpable fullness in the pelvic region. No supraclavicular lymphadenopathy or palpable breast masses were noted. Laboratory tests were significant for an elevated CA-125 level at 482 U/mL (normal range: 0-35 U/mL). Complete blood count showed mild anemia (hemoglobin: 11.2 g/dL), while serum electrolytes, liver function tests, and renal function tests were within normal limits.

Transvaginal ultrasound revealed a complex right adnexal mass measuring 5.4 3.7 cm with solid and cystic components. Additional findings included moderate ascites and peritoneal thickening. Contrast-enhanced CT of the abdomen and pelvis confirmed the adnexal mass, ascites, and bilateral para-aortic lymphadenopathy. Interestingly, the scan also revealed multiple ill-defined lesions in the liver parenchyma and a solitary 2.3-cm nodule in the right upper lobe of the lung, which were not typical of the usual peritoneal spread pattern.

CT-guided biopsy of the liver lesion revealed metastatic high-grade serous carcinoma, morphologically consistent with ovarian primary. Immunohistochemical staining showed positivity for PAX8, WT-1, and CK7, and negativity for CK20 and CDX2, supporting the diagnosis of metastatic ovarian carcinoma. A simultaneous core needle biopsy of the lung nodule yielded similar findings.

Discussion

The present case demonstrates an unusually aggressive and atypical metastatic pattern of ovarian carcinoma involving hematogenous spread to the liver parenchyma and lung parenchyma, which is less commonly observed compared to the typical transcoelomic route of dissemination. While hematogenous spread of ovarian cancer is described in approximately 2-4% of cases, the involvement of both liver and lung parenchyma concurrently is exceptionally rare and typically indicates advanced disease with a poorer prognosis.

The clinical significance of this atypical metastatic pattern lies in its impact on diagnostic evaluation, staging, and therapeutic planning. The presence of parenchymal hepatic and pulmonary metastases as the primary manifestation of extra-abdominal spread presents challenges in initial differential diagnosis, as these findings can mimic primary hepatocellular carcinoma or lung cancer, respectively.

The molecular mechanisms underlying unusual metastatic patterns in ovarian carcinoma remain incompletely understood. One hypothesis involves the molecular subtype of tumor biology, with certain genomic alterations potentially predisposing to hematogenous spread. Recent studies have suggested that mutations in TP53, BRCA1/2, and alterations in the PI3K/AKT/mTOR pathway may correlate with specific metastatic behaviors.

Management of ovarian cancer with atypical metastatic presentation requires a multidisciplinary approach, incorporating surgical, chemotherapeutic, and symptomatic treatments tailored to the extent and location of disease. For our patient, treatment involved standard platinum-based chemotherapy with carboplatin and paclitaxel, along with careful monitoring of the unusual parenchymal metastases.

Conclusion

This case report highlights an unusual metastatic pattern of ovarian carcinoma involving hematogenous spread to both hepatic and pulmonary parenchyma, deviating from the typical transcoelomic dissemination commonly observed. Such atypical patterns present diagnostic challenges and necessitate a high index of suspicion for ovarian cancer metastasis when encountering unexplained hepatic and pulmonary lesions in patients with known or suspected ovarian malignancy.

While hematogenous spread in ovarian carcinoma is relatively rare, healthcare providers should remain aware of this possibility, especially in advanced stages of the disease. Future research focusing on the molecular determinants of metastatic patterns may help develop better predictive models and personalized therapeutic approaches for patients with ovarian cancer presenting with atypical metastatic dissemination.

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