Krukenberg tumor: Difference between revisions

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   Image          = krukenberg.jpg|
   Image          = krukenberg.jpg|
   Caption        = Krukenberg tumor|
   Caption        = Krukenberg tumor|
   DiseasesDB    = 30081 |
    
  ICD10          = {{ICD10|C|56||c|51}} |
  ICD9          = {{ICD9|183}} |
  ICDO          = 8490/6 |
  OMIM          = |
  MedlinePlus    = |
  MeshName      = Krukenberg+Tumor |
  MeshNumber    = C04.557.470.200.025.415.410 |
}}
}}
__NOTOC__
__NOTOC__
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{{CMG}} {{AE}} {{STM}}
{{CMG}} {{AE}} {{STM}}
   
   
{{SK}} carcinoma mucocellulare; Synonym 2; Synonym 3
{{SK}} Carcinoma mucocellulare; Ovarian tumor
   
   
==Overview==
==Overview==
Krukenberg's tumor  is a rare metastatic signet ring cell adenocarcinoma of the ovary.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
Krukenberg tumor  is a rare metastatic [[signet ring cell]] [[adenocarcinoma]] of the [[ovary]]. Krukenberg tumor was first described as a new type of primary [[Ovarian cancer|ovarian malignancy]] by Friedrich Ernst Krukenberg (1871–1946), a German [[gynecologist]] and [[pathologist]], in 1896 which was later confirmed to be of [[metastatic]] [[gastrointestinal tract]] origin. The [[pathogenesis]] of Krukenberg tumors involves [[metastasis]] of [[tumor]] cells from the [[stomach]], [[appendix]] or [[colon]] to the [[ovaries]]. [[Metastasis]] is more likely via the [[lymphatic]] spread. However, direct seeding across the [[abdominal cavity]] may also occur. On [[gross pathology]], asymmetrically enlarged [[ovaries]] with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or [[peritoneal]] deposits are characteristic findings of Krukenberg tumors. Krukenberg tumor must be differentiated from [[Mucinous carcinoma|primary mucinous carcinoma]], [[Carcinoid tumor|mucinous carcinoid tumor]], [[Gastrointestinal stromal tumor|signet ring stromal tumor]], sclerosing stromal cell tumor, clear cell [[adenocarcinoma]] of the [[ovary]], and [[Sertoli-Leydig cell tumour|Sertoli-Leydig cell tumor]]. The [[incidence]] of Krukenberg tumors is estimated to be approximately 0.16 per 100,000 individuals. Krukenberg tumor is more commonly observed among women in their fifth decade of lives, with an average around 45 years of age. The majority of patients with Krukenberg tumor remain [[asymptomatic]] or have non-specific [[gastrointestinal]] symptoms. Early clinical features include [[abdominal pain]] and [[distension]] (from the large, bilateral [[ovarian mass]]es). If left untreated, patients with Krukenberg tumors may progress to develop [[virilization]] from the excessive hormone production from the ovarian stroma. [[Prognosis]] is generally poor, and the 5 ­year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum [[CA-125]] levels greater than 75 U/mL when compared with patients with [[CA-125]] levels less than 75 U/mL. The median survival of patients is between 7 to 14 months. [[X rays]], [[ultrasound]], [[CT]], [[Magnetic resonance imaging|MRI]] and [[immunohistochemistry]] help in the diagnosis of Krukenberg tumors. Management of Krukenberg tumors is driven by the identification and treatment of the primary cancer. Bilateral [[oophorectomy]] may only be performed for patients where the [[metastasis]] is localized to the [[ovaries]]. The significance of early detection of ovarian [[metastasis]] and the importance of monitoring serum [[CA-125]] level may improve the prognosis. [[Surgical resection]] may not be an option if the [[tumor]] has already metastasized to other sites.


==Historical Perspective==
==Historical Perspective==
*Krukenberg's tumor was first described as a new type of primary ovarian malignancy by Friedrich Ernst Krukenberg (1871–1946), a German gynecologist and pathologist, in 1896 which was later confirmed to be of metastatic gastrointestinal tract origin.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
Krukenberg tumor was first described as a new type of primary [[Ovarian cancer|ovarian malignancy]] by Friedrich Ernst Krukenberg (1871–1946), a German [[gynecologist]] and [[pathologist]], in 1896 which was later confirmed to be of metastatic [[gastrointestinal tract]] origin.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
 
==Classification==
*Krukenberg's tumor may be classified according to [classification method] into [number] subtypes/groups:
:*[group1]
:*[group2]
:*[group3]
*Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].
==Pathophysiology==
==Pathophysiology==
*The majority of Krukenberg’s tumors are bilateral.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*The majority of Krukenberg tumors are bilateral.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*Stomach is the primary site in the majority of Krukenberg tumor cases (70%).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*[[Stomach]] and [[colon]] are the primary sites in the majority of Krukenberg tumor cases (70%).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
*The [[pathogenesis]] of Krukenberg tumors involves [[metastasis]] of [[tumor]] cells from the [[stomach]], [[appendix]], or [[colon]] to the [[ovaries]].<ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
*The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
**[[Metastasis]] is more likely via the [[lymphatic]] spread. However, direct seeding across the [[abdominal cavity]] may also occur.
*On gross pathology, asymmetrically enlarged ovaries with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and absence of adhesions or peritoneal deposits are characteristic findings of krukenberg tumors.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*On [[gross pathology]], asymmetrically enlarged [[ovaries]] with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or [[peritoneal]] deposits are characteristic findings of Krukenberg tumors.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*On microscopic histopathological analysis, krukenberg tumors are characterized by the following features:
*On microscopic [[Histopathological|histopathological analysis]], Krukenberg tumors are characterized by the following features:
**Tumor composed of two components:
**[[Tumor]] composed of two components:
***Epithelial  
***[[Epithelial]]
****Mucin-secreting signet ring cells with eccentric hyperchromatic nuclei
****[[Mucin]]-secreting [[signet ring cell]]s with eccentric [[Hyperchromicity|hyperchromatic nuclei]]
****Cytoplasm may be eosinophilic and granular, pale and vacuolated, or a bull's eye (targetoid) appearance with a large vacuole with a central to paracentral eosinophilic body composed of a droplet of mucin
****[[Cytoplasm]] may be [[eosinophilic]] and granular, pale and vacuolated, or a bull's eye (targetoid) appearance with a large vacuole with a central to paracentral [[eosinophilic]] body composed of a droplet of [[mucin]]
****Signet ring cells may be single, clustered, nested, or arranged in tubules, acini, trabeculae, or cords
****[[Signet ring cell]]s may be single, clustered, nested, or arranged in tubules, acini, trabeculae, or cords
***Stromal
***Stromal
**** Plump and spindle-shaped cells with minimal cytologic atypia or mitotic activity
**** Plump and spindle-shaped cells with minimal cytologic [[atypia]] or mitotic activity
****Focal or diffuse stromal edema which may form pseudo cysts  
****Focal or diffuse stromal [[edema]] which may form pseudo cysts  
****Desmoplastic reaction may be present
****[[Desmoplastic]] reaction may be present
*Stomach is the primary site in the majority of Krukenberg tumor cases (70%).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*[[Stomach]] is the primary site in the majority of Krukenberg tumor cases (70%).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
 
<gallery>
Image:Krukenberg_tumor_-3.jpg|Bilateral ovarian neoplasm retaining the shape of ovary. Cut section of the tumor shows solid with mucinous areas<ref>Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#/media/File:Krukenberg_tumor_-3.jpg. Accessed on March 23, 2016</ref>
</gallery>
 
==Causes==
==Causes==
* Krukenberg's tumor may be caused by either [cause1], [cause2], or [cause3].
*Krukenberg tumor may be caused by [[metastasis]] of the [[tumor]] cells from a primary cancer in the stomach, [[appendix]], or the [[colon]] via:<ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
* Krukenberg's tumor is caused by a mutation in the [gene1], [gene2], or [gene3] gene[s].
**[[Lymphatic]] spread or
* There are no established causes for [disease name].
**Direct seeding across the [[abdominal cavity]]
 
==Differentiating [disease name] from other Diseases==
==Differentiating Krukenberg tumor from other Diseases==
*Krukenberg's tumor must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
*Krukenberg tumor must be differentiated from:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
:*[Differential dx1]
:*[[Mucinous carcinoma|Primary mucinous carcinoma]]
:*[Differential dx2]
:*[[Carcinoid tumor|Mucinous carcinoid tumor]]
:*[Differential dx3]
:*[[Gastrointestinal stromal tumor|Signet ring stromal tumor]]
:*Sclerosing stromal cell tumor
:*Clear cell [[adenocarcinoma]] of the [[ovary]]
:*[[Sertoli-Leydig cell tumour|Sertoli-Leydig cell tumor]]
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
===Incidence===
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
*The [[incidence]] of Krukenberg tumor is estimated to be approximately 0.16 per 100,000 individuals.<ref name="pmid23024922">{{cite journal| author=Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R et al.| title=Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin. | journal=Biomed Opt Express | year= 2012 | volume= 3 | issue= 9 | pages= 2306-16 | pmid=23024922 | doi=10.1364/BOE.3.002306 | pmc=PMC3447570 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024922  }} </ref><ref name="ok">Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.</ref>
   
   
===Age===
===Age===
*Patients of all age groups may develop [disease name].
*Patients of all age groups may develop Krukenberg tumor.
*Krukenberg tumor is more commonly observed among women in the fifth decade, with an average age of presentation at 45 years of age.
*Krukenberg's tumor is more commonly observed among patients aged [age range] years old.
 
*Krukenberg's tumor is more commonly observed among [elderly patients/young patients/children].
===Gender===
*Krukenberg's tumor affects men and women equally.
*[Gender 1] are more commonly affected with [disease name] than [gender 2].
* The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.
===Race===
*There is no racial predilection for [disease name].
*Krukenberg's tumor usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].
==Risk Factors==
==Risk Factors==
*Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
*There are no known direct causes for Krukenberg tumors. Common risk factors for ovarian cancer may include:<ref>Ovarian cancer. Wikipedia. https://en.wikipedia.org/wiki/Ovarian_cancer#Genetics Accessed on March 23, 2016.</ref>
**Nulliparity
== Natural History, Complications and Prognosis==
**Early [[menarche]]
*The majority of patients with [disease name] remain asymptomatic for [duration/years].  
**Late [[menopause]]
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
**[[Hormone therapy]]
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
**[[Fertility medication]]s
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
 
*Prognosis is generally poor, and the 5 ­year survival rate of patients with krukenberg tumor is lower in patients in with a preoperative serum CA 125 levels greater than 75 U/mL when compared with patients with CA 125 levels less than 75 U/mL.<ref name="pmid25830046">{{cite journal| author=Khan M, Bhatti RP, Mukherjee S, Ali AM, Gilman AD, Mirrakhimov AE et al.| title=A 26-year-old female with metastatic primary gastrointestinal malignancy presenting as menorrhagia. | journal=J Gastrointest Oncol | year= 2015 | volume= 6 | issue= 2 | pages= E21-5 | pmid=25830046 | doi=10.3978/j.issn.2078-6891.2014.080 | pmc=PMC4311099 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25830046  }} </ref>
==Natural History, Complications and Prognosis==
*The majority of patients with Krukenberg tumor remain [[asymptomatic]] or have non-specific [[gastrointestinal]] symptoms.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
== Diagnosis ==
*Early clinical features include [[abdominal pain]] and [[distension]] (from the large, bilateral [[ovarian mass]]es).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
===Diagnostic Criteria===
*If left untreated, patients with Krukenberg tumor may progress to develop [[virilization]] from the excessive hormone production from the [[ovarian]] stroma.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511  }} </ref>
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
*Common complications of Krukenberg tumors include [[ascites]], [[virilization]], and pseudo-Meig syndrome.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511  }} </ref><ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
:*[criterion 1]
**Pseudo-Meig syndrome is defined as a [[hydrothorax]] with [[ascites]], but with the absence of [[tumor]] cells.  
:*[criterion 2]
*[[Prognosis]] is generally poor, and the 5 ­year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum [[CA-125]] levels greater than 75 U/mL when compared with patients with [[CA-125]] levels less than 75 U/mL.<ref name="pmid25830046">{{cite journal| author=Khan M, Bhatti RP, Mukherjee S, Ali AM, Gilman AD, Mirrakhimov AE et al.| title=A 26-year-old female with metastatic primary gastrointestinal malignancy presenting as menorrhagia. | journal=J Gastrointest Oncol | year= 2015 | volume= 6 | issue= 2 | pages= E21-5 | pmid=25830046 | doi=10.3978/j.issn.2078-6891.2014.080 | pmc=PMC4311099 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25830046 }} </ref> The median survival of patients is between 7 to 14 months.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511 }} </ref>
:*[criterion 3]
 
:*[criterion 4]
==Diagnosis==
===Symptoms===
=== Symptoms ===
*Krukenberg tumor is usually [[asymptomatic]].<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*Krukenberg's tumor is usually asymptomatic.
*Symptoms of Krukenberg tumor may include the following:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref><ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
*Symptoms of [disease name] may include the following:
:*Non-specific gastrointestinal symptoms
:*[symptom 1]
:*[[Abdominal pain|Abdominal]] or [[pelvic pain]]
:*[symptom 2]
:*[[Abdominal distension]]
:*[symptom 3]
:*[[Bloating]]
:*[symptom 4]
:*[[Dyspareunia]]
:*[symptom 5]
:*[[Vaginal bleeding]]
:*[symptom 6]
:*[[Menstrual irregularities]]
:*[[Hirsutism]]
=== Physical Examination ===
 
*Patients with [disease name] usually appear [general appearance].
===Physical Examination===
*Physical examination may be remarkable for:
*Patients with Krukenberg tumor usually appear well in the early stages.
:*[finding 1]
*Physical examination may be remarkable for:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref><ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
:*[finding 2]
:*Abdominal or pelvic mass
:*[finding 3]
:*[[Ascites]]
:*[finding 4]
:*[[Hirsutism]]
:*[finding 5]
 
:*[finding 6]
===Laboratory Findings===
*There are no specific laboratory findings associated with Krukenberg tumors.
=== Laboratory Findings ===
*There are no specific laboratory findings associated with [disease name].


*A  [positive/negative] [test name] is diagnostic of [disease name].
*An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
*Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
===Imaging Findings===
===Imaging Findings===
*There are no [imaging study] findings associated with [disease name].
====X Ray====
   
*On x ray, Krukenberg tumor may present with the following findings:<ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref>
*[Imaging study 1] is the imaging modality of choice for [disease name].
**Prominent [[small bowel]] loops filled with gas
*On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
**No air-fluid level
*[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].
**No radiographic signs of [[intestinal obstruction]]
 
<gallery>
Image:Krukenberg-tumour-2 (6).jpg|X ray showing prominent small bowel loops filled with gas, no air-fluid level, no radiographic signs of intestinal obstruction<ref name=op>Image courtesy of Dr Hani Al Salam. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
</gallery>
 
====Ultrasound====
*On pelvic ultrasound, Krukenberg tumor is characterized by the following:<ref name="pmid23024922">{{cite journal| author=Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R et al.| title=Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin. | journal=Biomed Opt Express | year= 2012 | volume= 3 | issue= 9 | pages= 2306-16 | pmid=23024922 | doi=10.1364/BOE.3.002306 | pmc=PMC3447570 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024922 }} </ref><ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref>
**Bilateral, solid ovarian masses with clear, well defined margins
**An irregular hyper-echoic solid pattern and moth eaten like [[cyst]] formation is also considered a characteristic feature
 
<gallery>
Image:Krukenberg-tumour-3.JPG|Large, solid, well defined bilateral ovarian masses<ref name=op>Image courtesy of  Dr Prashant Mudgal. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-3 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
 
Image:Krukenberg-tumour-3_(2).JPG|Large, solid, well defined bilateral ovarian masses<ref name=op>Image courtesy of Dr Prashant Mudgal. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-3 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
 
Image:Krukenberg-tumour-3_(3).JPG|Large, solid, well defined bilateral ovarian masses<ref name=op>Image courtesy of  Dr Prashant Mudgal. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-3 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
 
Image:Krukenberg-tumour-3_(4).JPG|Large, solid, well defined bilateral ovarian masses<ref name=op>Image courtesy of  Dr Prashant Mudgal. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-3 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
</gallery>
 
====CT====
*On [[CT]], Krukenberg tumor is characterized by the following:<ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref><ref name="pmid2992252">{{cite journal| author=Cho KC, Gold BM| title=Computed tomography of Krukenberg tumors. | journal=AJR Am J Roentgenol | year= 1985 | volume= 145 | issue= 2 | pages= 285-8 | pmid=2992252 | doi=10.2214/ajr.145.2.285 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2992252  }} </ref>
**Large, lobulated, and multicystic masses with [[soft-tissue]] components which are indistinguishable from primary ovarian cancers
**Presence of a concurrent [[gastric]] or [[colic]] mural lesion
 
<gallery>
Image:Kruckenberg-tumour.jpg|Krukenberg tumour of the right ovary from colon cancer<ref name=op>Image courtesy of Dr Natalie Yang. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
</gallery>
   
   
====MRI====
*On pelvic [[MRI]], Krukenberg tumor is characterized by the following:<ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref><ref name="pmid12432104">{{cite journal| author=Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST| title=CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. | journal=Radiographics | year= 2002 | volume= 22 | issue= 6 | pages= 1305-25 | pmid=12432104 | doi=10.1148/rg.226025033 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432104  }} </ref><ref name="pmid7754887">{{cite journal| author=Ha HK, Baek SY, Kim SH, Kim HH, Chung EC, Yeon KM| title=Krukenberg's tumor of the ovary: MR imaging features. | journal=AJR Am J Roentgenol | year= 1995 | volume= 164 | issue= 6 | pages= 1435-9 | pmid=7754887 | doi=10.2214/ajr.164.6.7754887 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7754887  }} </ref><ref name="pmid16973774">{{cite journal| author=Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M et al.| title=Developing an MR imaging strategy for diagnosis of ovarian masses. | journal=Radiographics | year= 2006 | volume= 26 | issue= 5 | pages= 1431-48 | pmid=16973774 | doi=10.1148/rg.265045206 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16973774  }} </ref>
**Bilateral complex masses with hypo-intense solid components (dense stromal reaction)
**Internal hyperintensity (mucin) on T1 and T2 weighted MR images
**Strong contrast enhancement is usually seen in the solid component or the wall of the intratumoral [[cyst]]
<gallery>
Image:Krukenberg-tumour-2_(1).jpg|Coronal T2 image<ref name=op>Image courtesy of Dr Hani Al Salam . [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
Image:Krukenberg-tumour-2_(2).jpg|Axial T1 image<ref name=op>Image courtesy of Dr Hani Al Salam . [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
Image:Krukenberg-tumour-2_(3).jpg|Sagittal T2 image<ref name=op>Image courtesy of Dr Hani Al Salam . [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
Image:Krukenberg-tumour-2_(4).jpg|Axial T2 image<ref name=op>Image courtesy of Dr Hani Al Salam . [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
Image:Krukenberg-tumour-2_(5).jpg|Axial T1 C+ fat sat dynamic contrast study image<ref name=op>Image courtesy of Dr Hani Al Salam . [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
</gallery>
=== Other Diagnostic Studies ===
=== Other Diagnostic Studies ===
====Immunohistochemistry====
====Immunohistochemistry====
*Krukenberg's tumor may also be diagnosed using immunohistochemistry.
*Krukenberg tumor may also be diagnosed using [[immunohistochemistry]].<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*Findings on immunohistochemistry include:
*Findings on [[immunohistochemistry]] include:
**Cytokeratins (AE1/AE3) positive
**Cytokeratins (AE1/AE3) positive
**Epithelial membrane antigen positive
**Epithelial membrane antigen positive
**Vimentin negative
**[[Vimentin]] negative
**Inhibin negative
**[[Inhibin]] negative
 
====Serum CA-125====
*Serum concentrations of [[CA-125]] may be helpful  for:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
**Post-operative follow-up of patients for evaluation of complete resection of the [[tumor]]
**Follow-up of patients with a history of primary [[adenocarcinoma]]s (particularly gastrointestinal) for early detection of ovarian [[metastasis]]


====Serum CA-125===
*Serum concentrations of CA 125 may be helpful  for:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
**Post-operative follow-up of patients for evaluation of complete resection of the tumor
**Follow-up of patients with a history of primary adenocarcinomas (particularly gastrointestinal) for early detection of ovarian metastasis
== Treatment ==
== Treatment ==
=== Medical Therapy ===
=== Medical Therapy ===
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*Management of Krukenberg tumor is driven by the identification and treatment of the primary cancer.
*[[Chemotherapy]]/[[radiation]] has no significant effect on the prognosis of patients with Krukenberg tumors.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
 
*[Medical therapy 1] acts by [mechanism of action1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
=== Surgery ===
=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*Bilateral [[oophorectomy]] may only be performed for patients where the [[metastasis]] is localized to the ovaries.<ref name="pmid20018420">{{cite journal| author=Kim WY, Kim TJ, Kim SE, Lee JW, Lee JH, Kim BG et al.| title=The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2010 | volume= 149 | issue= 1 | pages= 97-101 | pmid=20018420 | doi=10.1016/j.ejogrb.2009.11.011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20018420  }} </ref>
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*The significance of early detection of ovarian [[metastasis]] and the importance of monitoring serum [[CA-125]] level may improve the [[prognosis]].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
*[[Surgical resection]] may not be an option if the [[tumor]] has already [[metastasized]] to other sites.
   
   
=== Prevention ===
=== Prevention ===
*There are no primary preventive measures available for [disease name].
*There are no preventive measures available for Krukenberg tumors.
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].  


==Case Studies==
==Case Studies==
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[[Category:Disease]]
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[[Category:Medicine]]
[[Category:Gynecology]]

Latest revision as of 13:47, 8 April 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soujanya Thummathati, MBBS [2]

Synonyms and keywords: Carcinoma mucocellulare; Ovarian tumor

Overview

Krukenberg tumor is a rare metastatic signet ring cell adenocarcinoma of the ovary. Krukenberg tumor was first described as a new type of primary ovarian malignancy by Friedrich Ernst Krukenberg (1871–1946), a German gynecologist and pathologist, in 1896 which was later confirmed to be of metastatic gastrointestinal tract origin. The pathogenesis of Krukenberg tumors involves metastasis of tumor cells from the stomach, appendix or colon to the ovaries. Metastasis is more likely via the lymphatic spread. However, direct seeding across the abdominal cavity may also occur. On gross pathology, asymmetrically enlarged ovaries with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or peritoneal deposits are characteristic findings of Krukenberg tumors. Krukenberg tumor must be differentiated from primary mucinous carcinoma, mucinous carcinoid tumor, signet ring stromal tumor, sclerosing stromal cell tumor, clear cell adenocarcinoma of the ovary, and Sertoli-Leydig cell tumor. The incidence of Krukenberg tumors is estimated to be approximately 0.16 per 100,000 individuals. Krukenberg tumor is more commonly observed among women in their fifth decade of lives, with an average around 45 years of age. The majority of patients with Krukenberg tumor remain asymptomatic or have non-specific gastrointestinal symptoms. Early clinical features include abdominal pain and distension (from the large, bilateral ovarian masses). If left untreated, patients with Krukenberg tumors may progress to develop virilization from the excessive hormone production from the ovarian stroma. Prognosis is generally poor, and the 5 ­year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum CA-125 levels greater than 75 U/mL when compared with patients with CA-125 levels less than 75 U/mL. The median survival of patients is between 7 to 14 months. X rays, ultrasound, CT, MRI and immunohistochemistry help in the diagnosis of Krukenberg tumors. Management of Krukenberg tumors is driven by the identification and treatment of the primary cancer. Bilateral oophorectomy may only be performed for patients where the metastasis is localized to the ovaries. The significance of early detection of ovarian metastasis and the importance of monitoring serum CA-125 level may improve the prognosis. Surgical resection may not be an option if the tumor has already metastasized to other sites.

Historical Perspective

Krukenberg tumor was first described as a new type of primary ovarian malignancy by Friedrich Ernst Krukenberg (1871–1946), a German gynecologist and pathologist, in 1896 which was later confirmed to be of metastatic gastrointestinal tract origin.[1]

Pathophysiology

  • Bilateral ovarian neoplasm retaining the shape of ovary. Cut section of the tumor shows solid with mucinous areas[3]

    Bilateral ovarian neoplasm retaining the shape of ovary. Cut section of the tumor shows solid with mucinous areas[3]

Causes

Differentiating Krukenberg tumor from other Diseases

  • Krukenberg tumor must be differentiated from:[1]

Epidemiology and Demographics

Incidence

  • The incidence of Krukenberg tumor is estimated to be approximately 0.16 per 100,000 individuals.[4][5]

Age

  • Patients of all age groups may develop Krukenberg tumor.
  • Krukenberg tumor is more commonly observed among women in the fifth decade, with an average age of presentation at 45 years of age.

Risk Factors

Natural History, Complications and Prognosis

  • The majority of patients with Krukenberg tumor remain asymptomatic or have non-specific gastrointestinal symptoms.[1]
  • Early clinical features include abdominal pain and distension (from the large, bilateral ovarian masses).[1]
  • If left untreated, patients with Krukenberg tumor may progress to develop virilization from the excessive hormone production from the ovarian stroma.[7]
  • Common complications of Krukenberg tumors include ascites, virilization, and pseudo-Meig syndrome.[7][1]
  • Prognosis is generally poor, and the 5 ­year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum CA-125 levels greater than 75 U/mL when compared with patients with CA-125 levels less than 75 U/mL.[8] The median survival of patients is between 7 to 14 months.[7]

Diagnosis

Symptoms

  • Krukenberg tumor is usually asymptomatic.[1]
  • Symptoms of Krukenberg tumor may include the following:[1][2]

Physical Examination

  • Patients with Krukenberg tumor usually appear well in the early stages.
  • Physical examination may be remarkable for:[1][2]

Laboratory Findings

  • There are no specific laboratory findings associated with Krukenberg tumors.

Imaging Findings

X Ray

  • On x ray, Krukenberg tumor may present with the following findings:[5]
  • X ray showing prominent small bowel loops filled with gas, no air-fluid level, no radiographic signs of intestinal obstruction[9]

    X ray showing prominent small bowel loops filled with gas, no air-fluid level, no radiographic signs of intestinal obstruction[9]

Ultrasound

  • On pelvic ultrasound, Krukenberg tumor is characterized by the following:[4][5]
    • Bilateral, solid ovarian masses with clear, well defined margins
    • An irregular hyper-echoic solid pattern and moth eaten like cyst formation is also considered a characteristic feature
  • Large, solid, well defined bilateral ovarian masses[9]

    Large, solid, well defined bilateral ovarian masses[9]

  • Large, solid, well defined bilateral ovarian masses[9]

    Large, solid, well defined bilateral ovarian masses[9]

  • Large, solid, well defined bilateral ovarian masses[9]

    Large, solid, well defined bilateral ovarian masses[9]

  • Large, solid, well defined bilateral ovarian masses[9]

    Large, solid, well defined bilateral ovarian masses[9]

CT

  • On CT, Krukenberg tumor is characterized by the following:[5][10]
    • Large, lobulated, and multicystic masses with soft-tissue components which are indistinguishable from primary ovarian cancers
    • Presence of a concurrent gastric or colic mural lesion
  • Krukenberg tumour of the right ovary from colon cancer[9]

    Krukenberg tumour of the right ovary from colon cancer[9]

MRI

  • On pelvic MRI, Krukenberg tumor is characterized by the following:[5][11][12][13]
    • Bilateral complex masses with hypo-intense solid components (dense stromal reaction)
    • Internal hyperintensity (mucin) on T1 and T2 weighted MR images
    • Strong contrast enhancement is usually seen in the solid component or the wall of the intratumoral cyst
  • Coronal T2 image[9]

    Coronal T2 image[9]

  • Axial T1 image[9]

    Axial T1 image[9]

  • Sagittal T2 image[9]

    Sagittal T2 image[9]

  • Axial T2 image[9]

    Axial T2 image[9]

  • Axial T1 C+ fat sat dynamic contrast study image[9]

    Axial T1 C+ fat sat dynamic contrast study image[9]

Other Diagnostic Studies

Immunohistochemistry

Serum CA-125

  • Serum concentrations of CA-125 may be helpful for:[1]
    • Post-operative follow-up of patients for evaluation of complete resection of the tumor
    • Follow-up of patients with a history of primary adenocarcinomas (particularly gastrointestinal) for early detection of ovarian metastasis

Treatment

Medical Therapy

  • Management of Krukenberg tumor is driven by the identification and treatment of the primary cancer.
  • Chemotherapy/radiation has no significant effect on the prognosis of patients with Krukenberg tumors.[1]

Surgery

Prevention

  • There are no preventive measures available for Krukenberg tumors.

Case Studies

Case #1

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Al-Agha OM, Nicastri AD (2006). "An in-depth look at Krukenberg tumor: an overview". Arch Pathol Lab Med. 130 (11): 1725–30. doi:10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2. PMID 17076540.
  2. ↑ 2.0 2.1 2.2 2.3 Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.
  3. ↑ Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#/media/File:Krukenberg_tumor_-3.jpg. Accessed on March 23, 2016
  4. ↑ 4.0 4.1 Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R; et al. (2012). "Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin". Biomed Opt Express. 3 (9): 2306–16. doi:10.1364/BOE.3.002306. PMC 3447570. PMID 23024922.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.
  6. ↑ Ovarian cancer. Wikipedia. https://en.wikipedia.org/wiki/Ovarian_cancer#Genetics Accessed on March 23, 2016.
  7. ↑ 7.0 7.1 7.2 Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U (2008). "A case of virilization induced by a Krukenberg tumor from gastric cancer". World J Surg Oncol. 6: 19. doi:10.1186/1477-7819-6-19. PMC 2275731. PMID 18279511.
  8. ↑ Khan M, Bhatti RP, Mukherjee S, Ali AM, Gilman AD, Mirrakhimov AE; et al. (2015). "A 26-year-old female with metastatic primary gastrointestinal malignancy presenting as menorrhagia". J Gastrointest Oncol. 6 (2): E21–5. doi:10.3978/j.issn.2078-6891.2014.080. PMC 4311099. PMID 25830046.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Image courtesy of Dr Hani Al Salam. Radiopaedia (original file ‘’here’’). Creative Commons BY-SA-NC
  10. ↑ Cho KC, Gold BM (1985). "Computed tomography of Krukenberg tumors". AJR Am J Roentgenol. 145 (2): 285–8. doi:10.2214/ajr.145.2.285. PMID 2992252.
  11. ↑ Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST (2002). "CT and MR imaging of ovarian tumors with emphasis on differential diagnosis". Radiographics. 22 (6): 1305–25. doi:10.1148/rg.226025033. PMID 12432104.
  12. ↑ Ha HK, Baek SY, Kim SH, Kim HH, Chung EC, Yeon KM (1995). "Krukenberg's tumor of the ovary: MR imaging features". AJR Am J Roentgenol. 164 (6): 1435–9. doi:10.2214/ajr.164.6.7754887. PMID 7754887.
  13. ↑ Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M; et al. (2006). "Developing an MR imaging strategy for diagnosis of ovarian masses". Radiographics. 26 (5): 1431–48. doi:10.1148/rg.265045206. PMID 16973774.
  14. ↑ Kim WY, Kim TJ, Kim SE, Lee JW, Lee JH, Kim BG; et al. (2010). "The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries". Eur J Obstet Gynecol Reprod Biol. 149 (1): 97–101. doi:10.1016/j.ejogrb.2009.11.011. PMID 20018420.
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