Ann R CollSurg Engl 2001;83: 81-84
Oophorectomy in primary colorectal cancer
A Schofield, J Pitt, G Biring, PM Dawson
Colorectal Surgical Unit, West Middlesex University Hospital NHS Trust, Isleworth, Middlesex, UK
Colorectal cancer is a common cancer affecting women which may metastasize to the
ovaries. We present five cases of ovarian metastases requiring surgery and review the
debate regarding oophorectomy at the primary resection for colorectal cancer. Although
prophylactic oophorectomy has not been proven to affect survival, further surgery for
symptomatic ovarian metastases may be avoided and the increased risk of developing
primary ovarian cancer is abolished.
Key words: Colorectal cancer-Metastasis-Ovary
Colorectal cancer is the third most common cancer
in women and causes over 7500 deaths per annum
in the UK.' Although metastases to the ovaries are not
common, they may be symptomatic and require sur-
gical excision. Due to the large number of patients with
colorectal cancer, this clinical problem recurs regularly
in a colorectal surgical practice, but may be avoided if
resection. However, there is controversy regarding the
role of oophorectomy if the ovaries are not obviously
abnormal. We review the clinical features of patients
with symptomatic ovarian metastases from colorectal
cancer and present the arguments for and against
A 67-year-old woman presented with large bowel
obstruction and underwent a Hartmann's procedure
for a Dukes C adenocarcinoma of the sigmoid colon.
She elected not to have adjuvant therapy. Eleven
months later she developed abdominal pain and
vomiting and a CT scan demonstrated a fluid filled
pelvic mass measuring 10 x 5 x 5 cm. At laparotomy,
the mass was found to be the right ovary, and a
bilateral salpingo-oophorectomy and subtotal hyster-
ectomy was performed. Histology confirmed meta-
static carcinoma of the colon in the right ovary with
microscopic deposits in the left ovary. Subsequently,
she has had pelvic radiotherapy and, at 20 months
from her initial presentation, she remains well.
A 49-year-old premenopausal woman was investigated
for a left iliac fossa mass and found to have a poorly
differentiated adenocarcinoma of the sigmoid colon. At
laparotomy, a large tumour was found adjacent to the
left ovary and there were multiple liver metastases. A
Ann R Coll Surg Engl 2001; 83
Correspondence to: Mr PM Dawson, Consultant Surgeon, West Middlesex University Hospital NHS Trust, Twickenham Road,
Isleworth, Middlesex TW7 6AF, UK
Tel: +44 20 8565 5972, Fax: +44 20 8565 5042
TheRoyal College of Surgeons ofEngland
OOPHORECTOMY IN PRIMARY COLORECTAL CANCER
Table 1 The clinicalfeatures ofpatients with primary colonic cancer and ovarian metastases
Age (years) 67 49 3863
Menopausal statusPost Pre Pre Post
Site of colon primary
Liver metastasesNo YesNo No
Ovarian metastases synchronous
or metachronousMetachronous Both
21x13x9.5 16x10x8 13x8x88x6x5
19 x 12 x 7
Survival from initial presentation
Alive at 20
Died at 14
Died at 21
Alive- at 15
Died at 7
left hemicolectomy and left salpingo-oophorectomy was
performed. Postoperatively, she completed a 6 month
course of adjuvant 5-fluorouracil and
chemotherapy. Six months later, she re-presented with
pelvic pain and, despite partial regression of the liver
lesions, a CT scan showed a 21 x 13 x 9.5 cm right
ovarian mass. The mass was excised for palliation and
histology confirmed metastatic carcinoma of the colon.
The patient died 2 months later from extensive disease.
A 38-year-old premenopausal woman presented with
an iron deficiency anaemia and underwent a right
hemicolectomy for a moderately differentiated Dukes
C carcinoma of the caecum. At operation, the ovaries
were specifically examined and considered normal.
She had postoperative chemotherapy but 8 months
later presented with suprapubic discomfort. The CT
scan showed a 16 x 10 x 8 cm cystic ovarian mass. She
underwent a hysterectomy and bilateral salpingo-
radiotherapy. Histology confirmed a colonic metastasis
in the ovary. She died at 21 months from presentation.
A 63-year-old postmenopausal woman was admitted for
an elective hysterectomy for presumed fibroids. At
laparotomy, she was found to have a Dukes C carcinoma
of the caecum with deposits on the right ovary, uterus and
the sigmoid colon. A total abdominal hysterectomy and
hemicolectomy and sigmoid colectomy were performed.
as well as a right
The histology demonstrated a colonic primary with
metastases in the right ovary measuring 13 x 8 x 8 cm,
chemotherapy and is presently well at 15 months.
A 49-year-old perimenopausal woman presented with a
change of bowel habit and abdominal distension. At
laparotomy, she had a carcinoma of the sigmoid with
bilateral ovarian masses measuring 19 x 12 x 7cm and 8 x
6 x 5 cm. A sigmoid colectomy, total abdominal hyster-
ectomy and bilateral salpingo-oophorectomy and oment-
ectomy was performed. Histology showed a Dukes C
colonic cancer with ovarian metastases. She received
postoperative chemotherapy, but died 7 months later.
The ovary is not an uncommon site for colorectal cancer
metastases. In this series of 93 consecutive female
treated by a single surgeon (PMD), the
incidence of macroscopic metastases requiring surgery
was 5.4% (5/93). This compares with 3.4-5% described
in other series.23 The incidence of ovarian metastases is
higher in post mortem studies,4'5 or if microscopic
metastases are younger (mean age 51.5 years) than the
mean age (59.6 years) for all those with colorectal cancer6
and our series confirmed that there are relatively more
premenopausal women (see Table 1).278
Ovarian metastases arise from all parts of the large
bowel in proportion to the frequency of the colorectal
Women with ovarian
Ann R Coll Surg Engl 2001; 83
OOPHORECTOMY IN PRIMARY COLORECTAL CANCER
cancer, and increase with more advanced stages of the
primary (Dukes B and C).2'9'10 All of our cases occurred
with Dukes C colorectal cancers.
Ovarian metastases may be identified at the resection of
the primary colorectal cancer (synchronous), or meta-
chronous in those women who retain their ovaries.
Metachronous ovarian metastases occur in 1.3-2.4% of
colorectal cancers,2'5 tend to occur within 2 years of the
primary resection11 and, presumably, are due to the
growth of undetected or microscopic metastases.
The spread of colon cancer to the ovaries occurs by
direct extension to the surface of the ovary in a few cases.
More frequently, the deposits are found deep in the
substance of the ovary and are often bilateral suggesting
haematogenous spread.37 To avoid a metachronous
recurrence, as in case 2, a bilateral, rather than unilateral,
oophorectomy should be performed.
Ovarian metastases, similar to primary ovarian
cancers, tend to present late as symptoms are due to the
size of the deposits. All our cases had large (mean size,
14.5 x 9 x 7 cm) symptomatic deposits necessitating
palliative surgery. In cases 1, 2 and 3 this would have
been avoided by a prophylactic oophorectomy.
The prognosis of women with ovarian metastases from
colorectal cancer is poor,12'13 reflecting the presence of
disseminated disease. The survival of premenopausal
women is no different from postmenopausal women
with ovarian metastases.10 Several small, retrospective
reviews have recommended prophylactic oophor-
ectomy.2'3'14 However, the only prospective, random-
ized study to determine the impact of prophylactic
oophorectomy on survival of women with colorectal
cancer has, to date, failed to accrue sufficient patients
over 10 years
difference.11 Nevertheless, the preliminary results sug-
gest a trend towards improved disease-free survival
following prophylactic oophorectomy.
The arguments against prophylactic oophorectomy in
women with colorectal cancer, therefore, concern: (i) the
potential surgical risk of the oophorectomy (none has
been reported in association with a primary colorectal
resection); (ii) the psychological morbidity of steriliz-
ation; and (iii) the premature menopause induced in
premenopausal women. The adverse
premature menopause, such as ischaemic heart disease
or reduced bone density, may shorten life expectancy,
but can be reversed by hormone replacement therapy.
In favour of prophylactic oophorectomy is that this
additional procedure, at the time of the primary colonic
resection, may eradicate the disease in a few patients
with isolated ovarian deposits. In those women with
disseminated disease, oophorectomy reduces the resid-
ual tumour load prior to adjuvant treatment.
addition, it has been suggested that the ovary is a
sanctuary site from chemotherapy.15 This would appear
to have happened in case 2.
Furthermore, oophorectomy removes a fertile bed for
metachronous metastases and abolishes the risk of deve-
loping primary ovarian cancer. Patients with colorectal
cancer have a 3-fold increased risk of developing
primary ovarian cancer compared to women without
colonic cancer.16 Although it has not been proven to
affect survival, prophylactic oophorectomy would also
prevent another major operation on some women who
have advanced colorectal disease and reduced
effects of a
In summary, the decision to offer prophylactic bilateral
oophorectomy to women undergoing resection for a
primary colorectal cancer has not been resolved.
Certainly, the ovaries should be specifically examined
intra-operatively in advanced colorectal cancers. Even if
the ovaries appear normal, in postmenopausal women
oophorectomy may be readily acceptable as the physio-
logical function of the ovaries has ceased. In premeno-
pausal women who have completed their families,
however, the risks and benefits of oophorectomy should
be discussed pre-operatively and the requirement for
postoperative hormone replacement therapy must be
explained. Although as yet there is no proven survival
benefit, oophorectomy in women with primary colo-
rectal cancer would prevent the development of symp-
tomatic ovarian recurrence and abolish the increased
risk of subsequent primary ovarian cancer.
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