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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor= {{YD}},  {{SSK}} (Reviewed by Serge Korjian and  {{AJL}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Oncology
|SubCategory=Oncology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
|MainCategory=Pathology
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|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Oncology
|SubCategory=Oncology
|Prompt=A 54 year old woman presents to the physician's office complaining of abdominal distention. Following appropriate work-up, the patient is found to have a metastatic bilateral ovarian tumor obstructing the lymphatic drainage with subsequent ascites. Pathological analysis of the ovarian tumor shows signet ring cell adenocarcinoma consistent with the diagnosis. What is the most appropriate next step in management?
|Prompt=A 38-year-old woman presents to the physician's office with complaints of abdominal distention for the past 5 weeks. The patient also reports lower extremity swelling that has worsened significantly in the past 2 months. On physical examination, the patient appears weak, pale, and cachectic with marked edema and bluish discoloration of the mons pubis, lower abdomen, and back. Following appropriate work-up, the patient is found to have large bilateral ovarian tumors with moderate ascites. Cytologic analysis of the ascitic fluid reveals several signet ring cells. Which of the following is the most appropriate next step in management?
|Explanation=The patient is most likely diagnosed with Krukenberg tumor. It is characterized by epithelial and stromal mass, whose epithelial component contains mucin-laden signet ring cells with hyperchromatic nuclei and eosinophilic granular cytoplasm. It usually appears as a bilateral tumor with signs of lymphatic obstruction. Krukenberg tumor are often diagnosed in patients in their fifth decade. The most common primary site of malignancy is the stomach, warranting radiographic and endoscopic evaluation of the digestive system once the diagnosis is made.
|Explanation=A [[Krukenberg tumor]] refers to a tumor in the ovary that has metastasized from a primary site, classically the gastrointestinal tract, although it can develop in any other tissue. [[Krukenberg tumor]]s are characterized by epithelial and stromal masses, whose epithelial component contains mucin-laden signet ring cells with hyperchromatic nuclei and eosinophilic granular cytoplasm. They usually appears as bilateral tumors with signs of lymphatic obstruction. Krukenberg tumors are often diagnosed in patients in their fifth decade. The most common primary site of malignancy is the stomach, warranting radiographic and endoscopic evaluation of the upper gastrointestinal tract once the diagnosis is made.
 
Educational Objective: The stomach is the most common primary site of Krukenberg tumor. Work-up to rule out GI involvement is indicated once the diagnosis is made.
 
Reference:
Al-Agha OM, Nicastri AD. An in-depth look at krukenberg tumor - an overview. Arch Pathol Lab Med. 2006;130:1725-30
|AnswerA=Gastroscopy
|AnswerA=Gastroscopy
|AnswerAExp=Most Krukenberg tumors arise from the stomach, thus necessitating radiographic and endoscopic work-up of the digestive system.
|AnswerAExp=Most [[Krukenberg tumors]] originate in the stomach, thus work-up to rule out GI involvement is indicated once the diagnosis is made.
|AnswerB=Observation with annual check-up
|AnswerB=Observation with annual check-up
|AnswerBExp=Evaluation of a primary site of malignancy is indicated in Krukenberg tumor.
|AnswerBExp=Evaluation of the primary site of malignancy is indicated in [[Krukenberg tumors]], which often originate in the stomach.
|AnswerC=Brain MRI
|AnswerC=Brain MRI
|AnswerCExp=Brain MRI is not indicated in Krukenberg tumor if no clinical suspicion of brain involvement is found.
|AnswerCExp=Without clinical suspicion of brain involvement, a brain MRI is not necessary upon diagnosis of a [[Krukenberg tumor]].
|AnswerD=Lumbar puncture
|AnswerD=Lumbar puncture
|AnswerDExp=Lumbar puncture is not helpful.
|AnswerDExp=Lumbar punctures usually are not necessary, because [[Krukenberg tumors]] often originate in the stomach.
|AnswerE=Bronchoscopy
|AnswerE=Bronchoscopy
|AnswerEExp=Bronchoscopy is not indicated once Krukenberg tumor is diagnosed with no suspicion of pulmonary involvement.
|AnswerEExp=A bronchoscopy is not necessary upon diagnosis of a [[Krukenberg tumor]], which often originates in the stomach.
|EducationalObjectives=The stomach is the most common primary site of [[Krukenberg tumor]]s. Work-up to rule out GI involvement is indicated upon diagnosis.
|References=Al-Agha OM, Nicastri AD. An in-depth look at krukenberg tumor - an overview. Arch Pathol Lab Med. 2006;130:1725-30<br>
First Aid 2014 page 351, 583
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=krukenberg, tumor, ovarian, mass, malignant, malignancy, cancer, stomach, gastroscopy, work, up, endoscopy, management, next, step, ascites, abdominal, distention
|WBRKeyword=Krukenberg, Tumor, Ovarian, Mass, Malignant, Malignancy, Cancer, Stomach, Gastroscopy, Endoscopy, Management, Ascites
|Approved=No
|Approved=Yes
}}
}}

Latest revision as of 23:34, 27 October 2020
Author [[PageAuthor::Yazan Daaboul, M.D., Serge Korjian M.D. (Reviewed by Serge Korjian and Alison Leibowitz [1])]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Oncology
Prompt [[Prompt::A 38-year-old woman presents to the physician's office with complaints of abdominal distention for the past 5 weeks. The patient also reports lower extremity swelling that has worsened significantly in the past 2 months. On physical examination, the patient appears weak, pale, and cachectic with marked edema and bluish discoloration of the mons pubis, lower abdomen, and back. Following appropriate work-up, the patient is found to have large bilateral ovarian tumors with moderate ascites. Cytologic analysis of the ascitic fluid reveals several signet ring cells. Which of the following is the most appropriate next step in management?]]
Answer A AnswerA::Gastroscopy
Answer A Explanation [[AnswerAExp::Most Krukenberg tumors originate in the stomach, thus work-up to rule out GI involvement is indicated once the diagnosis is made.]]
Answer B AnswerB::Observation with annual check-up
Answer B Explanation [[AnswerBExp::Evaluation of the primary site of malignancy is indicated in Krukenberg tumors, which often originate in the stomach.]]
Answer C AnswerC::Brain MRI
Answer C Explanation [[AnswerCExp::Without clinical suspicion of brain involvement, a brain MRI is not necessary upon diagnosis of a Krukenberg tumor.]]
Answer D AnswerD::Lumbar puncture
Answer D Explanation [[AnswerDExp::Lumbar punctures usually are not necessary, because Krukenberg tumors often originate in the stomach.]]
Answer E AnswerE::Bronchoscopy
Answer E Explanation [[AnswerEExp::A bronchoscopy is not necessary upon diagnosis of a Krukenberg tumor, which often originates in the stomach.]]
Right Answer RightAnswer::A
Explanation [[Explanation::A Krukenberg tumor refers to a tumor in the ovary that has metastasized from a primary site, classically the gastrointestinal tract, although it can develop in any other tissue. Krukenberg tumors are characterized by epithelial and stromal masses, whose epithelial component contains mucin-laden signet ring cells with hyperchromatic nuclei and eosinophilic granular cytoplasm. They usually appears as bilateral tumors with signs of lymphatic obstruction. Krukenberg tumors are often diagnosed in patients in their fifth decade. The most common primary site of malignancy is the stomach, warranting radiographic and endoscopic evaluation of the upper gastrointestinal tract once the diagnosis is made.

Educational Objective: The stomach is the most common primary site of Krukenberg tumors. Work-up to rule out GI involvement is indicated upon diagnosis.
References: Al-Agha OM, Nicastri AD. An in-depth look at krukenberg tumor - an overview. Arch Pathol Lab Med. 2006;130:1725-30
First Aid 2014 page 351, 583]]

Approved Approved::Yes
Keyword WBRKeyword::Krukenberg, WBRKeyword::Tumor, WBRKeyword::Ovarian, WBRKeyword::Mass, WBRKeyword::Malignant, WBRKeyword::Malignancy, WBRKeyword::Cancer, WBRKeyword::Stomach, WBRKeyword::Gastroscopy, WBRKeyword::Endoscopy, WBRKeyword::Management, WBRKeyword::Ascites
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