Unilateral Pleural Nodules as Manifestation of Ovarian Adenocarcinoma 29 Years Post-Treatment

Abstract

The incidence of recurrence in advanced stage ovarian cancer is 70% with a median interval to first recurrence of 18-24 months after treatment with surgery, chemotherapy, and radiation. Of these, 77.6% of cases reoccur in the abdominal or pelvic cavity. Only 1.8% of recurrent cases present intrathoracic metastases and recurrence 20þ years after treatment has rarely been reported. We present a case of recurrent ERþ ovarian adenocarcinoma presenting with diffuse pleural nodules 29 years post treatment. This is the only reported case in literature where pleural nodules are the primary site of ovarian adenocarcinoma recurrence more than 20 years post-treatment. CASE PRESENTATION:A 72 year old female presented to the emergency department complaining of weakness and increasing shortness of breath over several weeks. On physical exam, she was hypoxic and pale in appearance with diminished breath sounds in the right lower lobe. Labs were remarkable for Hgb of 4. CXR at that time revealed a loculated R pleural effusion and an intact chemotherapy port from prior treatment 30 years ago. Chest CT imaging was obtained, revealing nodular densities throughout the right hemithorax suggestive of pleural neoplasm. CT-guided pleural biopsy was obtained, revealing neoplastic cells demonstrating immunoreactivity with CK7, ER, Pax-8, and CA-125, suggestive of Mullerian Primary Adenocarcinoma. PET-CT demonstrated increased activity in numerous right pleural nodules. The patient was diagnosed with Stage FIGO IVB Ovarian Adenocarcinoma. The 5-year survival rate for distantly metastasized epithelial ovarian cancer is 31%. Treatment options for patients with distant metastases diagnosed with FIGO Stage IVB Ovarian Adenocarcinoma include neoadjuvant chemotherapy followed by surgery, adjuvant therapy, and maintenance therapy. Due to the indolent nature of the disease, and after discussion with the patient regarding goals of care, conservative therapy with frequent imaging and oncologic observation was the selected clinical approach.DISCUSSION: On initial presentation with unilateral pleural nodules and respiratory symptoms, primary tumors of pleural such as malignant mesothelioma was considered highly on the differential, but on further studies including staining with TTF-1, histologic findings were found to be consistent with Mullerian primary, despite the patient having completed treatment 29 years prior and having had no recurrence or symptoms since then. CONCLUSIONS:Although malignant unilateral pleural nodules may raise suspicion for primary lung or pleural neoplasms, recurrence of extra-thoracic malignancy must always be considered when evaluating pleural nodules, regardless of how remote the primary occurrence emerged. This is the only reported case in literature where pleural nodules are the primary site of ovarian adenocarcinoma recurrence more than 20 years post-treatment.