The patient initially underwent laparoscopic right hemicolectomy in July 2024. Pathology classified the 2.5 by 2.5 by 0.7-centimeter tumor as moderately to well-differentiated adenocarcinoma that had invaded the visceral peritoneum, designated pT4a. All 23 examined lymph nodes were negative, and there was no omental metastasis, giving the original tumor a stage IIB, or pT4aN0M0, classification. Perineural invasion was also identified. She completed eight cycles of XELOX, comprising oxaliplatin and oral capecitabine, between August 2024 and March 2025, after which surveillance was scheduled every three months with clinical examinations, tumor markers, ultrasound, and contrast-enhanced CT every six months. She attended two follow-up visits without symptoms or detected abnormalities but did not return for later appointments for personal reasons.

Progressive lower-abdominal distension and mild discomfort finally prompted evaluation in February 2026. The remaining serum marker results were markedly abnormal: CEA reached 188.25 nanograms per milliliter, compared with a reference value below 5; CA19-9 reached 462.77 units per milliliter, versus below 35; and CA125 reached 303.91 units per milliliter, also versus below 35. Ultrasonography showed bilateral adnexal masses. CT then identified multiple cystic-solid pelvic masses, the largest measuring 94 by 73 millimeters, together with diffuse peritoneal thickening and apparent involvement of the bladder and rectal walls. Colonoscopy found no recurrence at the colonic anastomosis. Whole-body fluorine-18 fluorodeoxyglucose PET-CT showed heterogeneous uptake in the pelvic masses and diffuse peritoneal abnormality with ascites, leading clinicians to consider metastatic colorectal cancer involving the ovaries, although a primary ovarian malignancy could not be excluded radiologically.

A multidisciplinary team including radiologists, gastrointestinal and gynecologic surgeons, anesthesiologists, and medical oncologists judged the pelvic disease potentially resectable even though complete cytoreduction was not expected because of the visible peritoneal involvement. They selected surgery rather than a purely palliative approach, reasoning that delay could allow further growth, hemorrhage, or bowel obstruction and could narrow the opportunity for macroscopic tumor removal. When the abdominal cavity was opened in March 2026, however, the team encountered massive hemorrhagic ascites and a tense cystic-solid mass about 14 centimeters across with active bleeding from ruptured surfaces. The authors could not determine the precise time of rupture and proposed that it may have occurred at some point before surgery. The procedure included bilateral salpingo-oophorectomy, omentectomy, placement of a hyperthermic intraperitoneal chemotherapy catheter, and exploration of the abdominal cavity.

Surgery also revealed numerous miliary peritoneal implants, and complete cytoreduction was not achieved; the residual disease was classified as CC-2/3. The previous colonic anastomosis was intact, without obstruction or local recurrence. Microscopic examination confirmed bilateral ovarian metastatic adenocarcinoma of colorectal origin. Immunohistochemistry was CK7-negative, CK20-positive, and CDX2-positive, while SATB2 was partially positive and PAX-8 negative. No signet-ring cells were found, excluding a true Krukenberg tumor, and the metastatic lesions retained a mismatch-repair-proficient, microsatellite-stable profile. The Ki-67 index rose from 50% in the primary tumor to 70% in the ovarian metastases, and p53 showed mutant-type expression. Genetic testing of the metastases identified eight somatic variants, including NRAS p.G12D and TP53 p.C176R, with no germline variants detected. The tumor mutation burden was 8.33 mutations per megabase, classified as high.

After surgery, the patient received three sessions of hyperthermic intraperitoneal chemotherapy on postoperative days one, three, and five. Each 4,000-milliliter perfusion contained sterile water, 4 milligrams of raltitrexed, and 200 milligrams of oxaliplatin and was delivered at a target intraperitoneal temperature of 42 to 43 degrees Celsius for 60 minutes. The regimen was individualized according to the institution’s experience and the patient’s tolerance, rather than tested in a controlled comparison. Catheters were removed on postoperative day seven after drainage became clear and the daily volume fell below 100 milliliters. During 90 days of postoperative surveillance, the patient experienced no major complication: there was no anastomotic leak, intra-abdominal infection, recurrent hemorrhage, bowel obstruction, or catheter-related event requiring intervention. Her Clavien-Dindo complication grade was 0 to 1.

Following multidisciplinary review of the molecular findings, the patient began XELOX chemotherapy every three weeks together with bevacizumab and serplulimab, an antibody targeting PD-1. The researchers cited the phase 2 portion of the randomized ASTRUM-015 trial as supporting this combination. In that first-line trial of metastatic colorectal cancer, adding serplulimab and a bevacizumab biosimilar to XELOX was associated with longer median progression-free survival than placebo plus bevacizumab and XELOX: 17.2 versus 10.7 months, with a hazard ratio of 0.60. The report also noted benefits in microsatellite-stable and KRAS-mutant subgroups, but the NRAS subgroup was very small. After six cycles of triplet treatment, imaging and tumor-marker assessments showed stable disease. The anti-PD-1 drug was subsequently withheld because of an immune-related adverse event, and the patient remained under regular follow-up at the time of publication.

Ovarian metastasis is uncommon among women with colorectal cancer, with reported frequencies of approximately 0.8% to 7.4%, and is generally associated with unfavorable outcomes. A strict Krukenberg tumor contains signet-ring cells in more than 10% of the lesion, whereas non-signet-ring metastases may retain glandular features resembling the primary adenocarcinoma. Because Krukenberg tumors are often regarded as particularly aggressive and chemoresistant, other histologic forms can sometimes appear less threatening. This case challenges that simple distinction. The patient had no signet-ring cells, yet her tumors involved both ovaries, reached at least 14 centimeters, accompanied extensive peritoneal dissemination, ruptured with active hemorrhage, and recurred after a standardized adjuvant regimen. The report therefore emphasizes that the absence of signet-ring cells does not guarantee indolent behavior. It does not, however, establish that all non-signet-ring ovarian metastases are equally aggressive, a conclusion that would require data from larger series.

The timing was also consistent with patterns described in the report’s small literature review. Among cases of metachronous ovarian metastasis following curative resection of colorectal cancer without initial distant metastasis, the interval ranged from about 12 months to three years, with most occurring within two years. Many previous reports involved unilateral, relatively localized disease without peritoneal implants, whereas this patient had bilateral tumors and widespread seeding. Her spontaneous rupture was not identified in the other summarized cases. The pT4a classification may be important because invasion of the visceral peritoneum can expose tumor cells directly to the peritoneal cavity, potentially enabling transcoelomic spread to the ovaries and peritoneal surfaces without requiring lymph-node involvement. This provides a plausible route in a patient whose sampled nodes were negative. It remains a proposed mechanism, however, rather than a route directly demonstrated in this individual patient.

The case is also limited by several important constraints. It describes one patient, so the observed course and disease stabilization cannot be extrapolated to other people with colorectal ovarian metastases or establish a treatment benefit. The contribution of hyperthermic intraperitoneal chemotherapy is especially uncertain: the report notes that the phase 3 PRODIGE 7 trial did not demonstrate a significant overall-survival benefit from adding HIPEC to complete cytoreductive surgery in the setting studied, and complete cytoreduction was not achieved here. Follow-up was also relatively short, long-term survival was unknown, and systemic treatment was modified after an immune-related adverse event. The selection of surgery, HIPEC, bevacizumab, and serplulimab was therefore individualized and partly based on emerging evidence. What the case reliably documents is a rare rupture of bilateral non-signet-ring ovarian metastases after treated pT4a colon cancer, followed by cytoreductive surgery and systemic therapy that produced stable disease at the reported follow-up. It highlights the need for further prospective evidence while showing how molecular testing and multidisciplinary review shaped care in one complex recurrence.

Subject of Research: Ruptured bilateral ovarian metastases following resection of stage pT4a colorectal cancer

Article Title: Metachronous bilateral ovarian metastasis with spontaneous rupture following curative resection of stage T4a colon cancer: a case report and literature review

Article References: Zheng, Y., & Zhang, Z. (2026). Metachronous bilateral ovarian metastasis with spontaneous rupture following curative resection of stage T4a colon cancer: a case report and literature review. Frontiers in Oncology, 16, Article 1950347. https://doi.org/10.3389/fonc.2026.1950347

Image Credits: AI Generated

DOI: 10.3389/fonc.2026.1950347

Keywords: colorectal cancer, ovarian metastasis, tumor rupture, peritoneal carcinomatosis, NRAS mutation, high tumor mutational burden, cytoreductive surgery, HIPEC, immune checkpoint therapy, case report, Metachronous, bilateral

Malignant ascites, the pathological accumulation of fluid within the peritoneal cavity driven by cancer involving the peritoneal membrane, increased vascular permeability, or lymphatic blockage, accounts for roughly 10 to 15 percent of all ascites cases and carries a poor prognosis. The condition produces a cascade of debilitating symptoms: abdominal fullness and bloating, pain, nausea, difficulty breathing, reduced mobility, and loss of appetite, all of which erode quality of life at a stage when patients and their families have limited time together. Unlike ascites caused by cirrhosis or heart failure, dietary modification and diuretics tend to be ineffective in the malignant form, leaving fluid evacuation as the mainstay of palliative treatment.

Repeated large-volume paracentesis addresses the symptom but never the underlying cause, so the procedure must be performed regularly, at considerable cost to both patients and health systems and with a cumulative risk of procedural complications. Tunneled indwelling peritoneal catheters, or IPCs, have emerged as an alternative that allows drainage at home. The United Kingdom’s National Institute for Health and Care Excellence approved first-generation devices as cost-effective in 2012 and reaffirmed that judgment in 2022, but many supporting studies involved small patient numbers, and clear criteria identifying which patients are most likely to benefit have been lacking.

The new analysis, led by Krasen Zdravkov Ivanov of University Hospital Saint Ekaterina in Sofia, Bulgaria, together with Hans-Ulrich Laasch of the University of Manchester, examined a large single-center cohort treated with a second-generation device. Patients were eligible if their ascites required at least two drainage procedures per month. Exclusion criteria included active peritoneal infection, deranged clotting with an INR above 1.8 or platelet counts below 50,000 per microliter, loculated ascites, an ECOG performance status of 4 with estimated survival under three weeks, and known allergy to catheter components. Every patient underwent history and physical examination, laboratory testing, and abdominal ultrasound at least 48 hours before implantation.

The technical details of the procedure are central to its success. The Aspira catheter is a 15.5-French, 72-centimeter fenestrated silicone tube with 50 drainage holes on its intraperitoneal end. A single experienced interventionalist performed all insertions using an antegrade tunneling technique under sterile conditions, with local anesthesia and perioperative intravenous ceftriaxone. After ultrasonography identified an implantation site away from scars, tumor masses, bowel, and other organs, typically in the iliac fossa, a subcutaneous tunnel of roughly five to eight centimeters was fashioned, the abdominal cavity was punctured under ultrasound guidance, and a peel-away sheath fitted with a leakage-preventing valve was placed over a guidewire. Correct positioning of the catheter tip in the pelvis was confirmed with ultrasound or X-ray. Technical success was achieved in all 124 patients without exception.

The cohort, with a mean age of 60.6 years and a strong female majority at 67.7 percent, reflected the typical epidemiology of malignant ascites: ovarian cancer was the most common primary malignancy at 19.4 percent, followed by breast cancer at 18.5 percent and colon cancer at 14.5 percent. Adenocarcinoma accounted for more than three-quarters of tumor types, peritoneal carcinomatosis was the leading mechanism at 42.7 percent, and the fluid was predominantly an exudate. Nearly three-quarters of patients were actively receiving chemotherapy, radiotherapy, or immunotherapy, while the remainder were on supportive or palliative care.

Symptom outcomes were striking. Using the Edmonton Symptom Assessment System modified for ascites, researchers found statistically significant improvement in every symptom measured at 30 days, including pain, general weakness, nausea, depression, anxiety, drowsiness, appetite, sense of well-being, shortness of breath, abdominal bloating, and impaired mobility, all with p-values below 0.001. The largest average changes were in abdominal bloating, which improved by 8.1 points on the 10-point scale, impaired mobility by 6.3 points, and pain by 6.0 points. Significant improvements in fluid-volume symptoms such as shortness of breath and bloating persisted at 90 days, although anxiety, appetite, well-being, and mobility gains were no longer statistically significant at that point, a pattern the authors attribute partly to cancer progression and the side effects of ongoing anticancer therapy. The mean number of hospital visits fell by 45.4 percent between the 30-day and 90-day periods, from 1.1 to 0.6 per interval. The mean duration of catheter use was 103.3 days.

Safety results were also reassuring. Twenty-six patients, or 21.0 percent, experienced catheter-related complications, but most were minor and easily managed. These included cellulitis in seven patients treated successfully with antibiotics, ascites leakage at the implantation site within 48 hours in five patients corrected with sutures, valve defects in two patients whose valves were replaced without removing the catheter, and subcutaneous hematomas in two patients. Ten complications, or 8.1 percent, were classified as moderate because they required catheter removal: one device obstruction from adjacent tumor overgrowth, one dislocation, and eight cases of secondary bacterial peritonitis. All patients recovered after systemic antibiotics or device replacement, and no infection-related deaths occurred. Notably, patients with serous and fibrinous ascites fluid experienced complications more frequently, an observation that may help guide aftercare intensity.

Beyond the numbers, the study’s practical contribution is a treatment algorithm to help clinicians select candidates most likely to benefit, an area where formal guidelines have been notably absent. The authors emphasize that adequate control of ascites symptoms can determine whether a patient is well enough to continue treatment for the underlying malignancy, and that reliable home drainage helps patients return home sooner and spend quality time with loved ones. They also highlight device-specific advantages, including a valve system that nearly eliminates fluid spillage during implantation, an infection control benefit as well as a slip hazard reduction, the option of retrograde tunneling to improve cuff fixation, and repairability that avoids removal and reinsertion in cases of accidental damage.

The authors acknowledge the limitations of a single-center, retrospective, non-comparative design, and note that the number of patients with quality-of-life data declined at 90 days. Nevertheless, they conclude that tunneled indwelling peritoneal catheters combine a high rate of technical success, durable clinical benefit, and manageable complications, offering physicians an effective, cost-conscious approach to caring for one of the most vulnerable populations in oncology.

Subject of Research: Clinical outcomes of tunneled indwelling peritoneal catheters for malignant ascites palliation

Article Title: Clinical outcomes following insertion of second-generation (Aspira®) tunneled indwelling peritoneal catheters to treat malignant ascites

Article References: Ivanov, K. Z., & Laasch, H.-U. (2026). Clinical outcomes following insertion of second-generation (Aspira®) tunneled indwelling peritoneal catheters to treat malignant ascites. CVIR Oncology, 2(1), Article 16. https://doi.org/10.1007/s44343-026-00047-1

Image Credits: AI Generated

DOI: 10.1007/s44343-026-00047-1

Keywords: malignant ascites, peritoneal catheter, palliative care, paracentesis, oncology, interventional radiology, quality of life, catheter complications, Aspira drainage system, cancer symptoms, peritoneal carcinomatosis, Clinical