Recurrent ovarian cancer presenting in the right supraclavicular lymph node with isolated metastasis: a case report
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The majority of ovarian cancer recurrences are in the abdomen. However, some cases relapse as isolated lymph node metastases, mostly in pelvic or para-aortic nodes. Peripheral isolated lymph node metastasis is rare.
A 69-year-old Japanese woman had recurrent ovarian cancer presenting with isolated right supraclavicular lymph node metastasis. After surgical resection and combination chemotherapy with carboplatin and paclitaxel, her right supraclavicular lymph node completely regressed.
Peripheral isolated lymph nodes, including right supraclavicular lymph node, can recur without a macroscopic abdominal lesion. Clinicians should carefully examine peripheral lymph nodes for recurrence.
Right supraclavicular lymph node
Left supraclavicular lymph node
Cancer-related antigen 125
Carbohydrate antigen 19–9
Paclitaxel and carboplatin
Area under the curve
Fluorine-18 fluorodeoxyglucose positron emission tomography associated with computed tomography
Wilms’ tumor 1 protein
Isolated lymph node recurrence.
The majority of ovarian cancer (OC) recurrences are within the abdomen. However, some cases relapse as isolated lymph node metastases, mostly in pelvic or para-aortic nodes; peripheral isolated lymph node metastasis is rare. Left supraclavicular lymph node (LSCLN), better known as Virchow’s node, collects lymph through the thoracic duct and from most areas of the body (mainly the abdomen). A finding of an enlarged node has been regarded as strongly indicative of the presence of cancer in the abdomen. In contrast, right supraclavicular lymph node (RSCLN) takes its supply mainly from the mediastinum, lungs, and esophagus . We report a case of recurrent OC presenting with an isolated RSCLN metastasis with no evidence of any other recurrent part after 52 months from initial surgery.
In contrast, a specimen from RSCLN showed findings similar to those in the ovaries. The tumor cells, composed of cuboidal cells with oval to round nuclei, had papillary infiltration. Psammoma bodies were frequently seen (Figure 2b). Immunohistochemically, the tumor cells were positive for CK7, CA125, and WT1 and negative for CK20 and CA19-9.
The most common routes for the spread of epithelial OC are lymphatic dissemination and transcoelomic spread through the nearby internal organs . Although isolated lymph node recurrence (ILNR) of OC is relatively rare, the literature includes several reports of large numbers of ILNRs [3, 4, 5, 6, 7, 8, 9]. In these reports, ILNR occurred in about 4% to 6% [3, 4] of patients with OC, representing approximately 10%  of the overall recurrences. In contrast, the clinical presentation of extra-abdominal lymphadenopathy without abdominal mass can occur before evidence of ovarian mass . In 205 patients with ILNR of OC, although the most frequently involved sites were para-aortic or pelvic or both, other sites, such as left supraclavicular (eight cases), inguinal (24 cases), axillary (one case), and mediastinal (five cases), may also be involved. However, no patient had ILNR in RSCLN. To the best of our knowledge, only one case report about metastatic OC of RSCLN has been published . In that report, the patient had metastatic RSCLN involvement where the primary OC manifested after three years of clinical surveillance.
We hypothesize that the ILNR routes in OC include either lymphatic dissemination or lymphatic dissemination after transcoelomic spread. LSCLN collects lymph through the thoracic duct and from most areas of the body. In contrast, RSCLN takes its supply mainly from the mediastinum, lungs, and esophagus ; in a patient with OC, the route of ILNR in LSCLN is lymphatic dissemination, and that in RSCLN is lymphatic dissemination from the transcoelomic spread site. In the present case, although the diagnosis of ILNR was surgically confirmed, the suspected presence of a peritoneal lesion was based on PET/CT findings. Bristow et al.  documented the presence of occult intraperitoneal disease in 21.4% of ILNR cases even when PET/CT scanning techniques were used. Thus, we think that, in the present case, the route was possibly lymphatic dissemination from occult peritoneal disease.
Treatment for ILNR of OC is based on various factors, such as the recurrence site, the general condition of the patient, disease-free interval, growth rate, and response to chemotherapy. Although these confounding factors could be more adequately assessed through a multivariate analysis of a larger number of patients, there are several reports about therapy for ILNR of OC. Those reports indicated that surgical removal of ILNR with or without adjuvant therapy, such as chemotherapy, radiation therapy, or both, is associated with a favorable clinical outcome for a selected subgroup of patients with ILNR of OC [3, 6, 7, 8, 9]. In the present case, the patient underwent surgical resection of ILNR and adjuvant chemotherapy and was free of disease at a follow-up consultation 29 months after the first notice of relapse.
Peripheral ILNR, including RSCLN, could occur without a macroscopic abdominal lesion. Clinicians should carefully examine peripheral lymph nodes for recurrence.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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