Krukenberg tumor: Difference between revisions
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*[[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 [[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 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> | ||
**[[Lymphatic]] spread; or | **[[Lymphatic]] spread; or | ||
**Direct seeding across the [[abdominal cavity]] | **Direct seeding across the [[abdominal cavity]] | ||
Revision as of 19:37, 22 March 2016
| Krukenberg tumor | ||
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| Krukenberg tumor | ||
| ICD-10 | C56 | |
| ICD-9 | 183 | |
| ICD-O: | 8490/6 | |
| DiseasesDB | 30081 | |
| MeSH | C04.557.470.200.025.415.410 | |
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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's tumor is a rare metastatic signet ring cell adenocarcinoma of the ovary.[1]
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.[1]
Pathophysiology
- The majority of Krukenberg’s tumors are bilateral.[1]
- Stomach and colon are the primary sites in the majority of Krukenberg tumor cases (70%).[1]
- The pathogenesis of krukenberg tumors involves metastasis of tumor cells from the stomach, appendix or colon to the ovaries.[2]
- 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.[1]
- On microscopic histopathological analysis, krukenberg tumors are characterized by the following features:
- Tumor composed of two components:
- Epithelial
- Mucin-secreting signet ring cells with eccentric 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
- Signet ring cells may be single, clustered, nested, or arranged in tubules, acini, trabeculae, or cords
- Stromal
- Epithelial
- Tumor composed of two components:
- Stomach is the primary site in the majority of Krukenberg tumor cases (70%).[1]
-
![Bilateral ovarian neoplasm retaining the shape of ovary. Cut section of the tumor shows solid with mucinous areas[3]](/images/0/0c/Krukenberg_tumor_-3.jpg)
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]](/index.php/File:Krukenberg_tumor_-3.jpg)
Causes
- Krukenberg's tumor may be caused by metastasis of the tumor cells from a primary cancer in the stomach, appendix, or the colon via:[2]
- Lymphatic spread; or
- Direct seeding across the abdominal cavity
Differentiating [disease name] from other Diseases
- Krukenberg's tumor must be differentiated from the following:[1]
- Primary mucinous carcinoma
- Mucinous carcinoid tumor
- Signet ring stromal tumor
- Sclerosing stromal cell tumor
- Clear cell adenocarcinoma of the ovary
- Sertoli-Leydig cell tumor
Epidemiology and Demographics
Incidence
- The incidence of krukenberg tumors is estimated to be approximately 0.16 per 100,000 individuals.[4][5]
Age
- Patients of all age groups may develop krukenberg tumors.
- Krukenberg's tumor is more commonly observed among women in their fifth decade of lives, with an average around 45 years of age.
Risk Factors
- There are no known direct causes for krukenberg tumors. Common risk factors for ovarian cancer may include:[6]
- Nulliparity
- Early menarche
- Late menopause
- Hormone therapy
- Fertility medications
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 tumors 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]
- Pseudo-Meig syndrome is defined as a hydrothorax with ascites, but with the absence of tumor cells.
- 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's tumor is usually asymptomatic.[1]
- Symptoms of krukenberg tumors may include the following:[1][2]
- Non-specific gastrointestinal symptoms
- Abdominal or pelvic pain
- Abdominal distension
- Bloating
- Dyspareunia
- Vaginal bleeding
- Menstrual irregularities
- Hirsutism
Physical Examination
- Patients with krukenberg tumor usually appear well in the early stages.
- Physical examination may be remarkable for:[2][1]
Laboratory Findings
- There are no specific laboratory findings associated with krukenberg tumors.
Imaging Findings
X Ray
- On x rays, krukenberg tumor may present with the following findings:[5]
- Prominent small bowel loops filled with gas
- No air-fluid level
- No radiographic signs of intestinal obstruction
-
![X ray showing prominent small bowel loops filled with gas, no air-fluid level, no radiographic signs of intestinal obstruction[9]](/images/2/26/Krukenberg-tumour-2_%286%29.jpg)
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]](/index.php/File:Krukenberg-tumour-2_(6).jpg)
Ultrasound
- On pelvic ultrasound, krukenberg tumor is characterized by the following:[4]</ref>[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]](/images/0/0b/Krukenberg-tumour-3.JPG)
Large, solid, well defined bilateral ovarian masses[9] -
![Large, solid, well defined bilateral ovarian masses[9]](/images/5/57/Krukenberg-tumour-3_%282%29.JPG)
Large, solid, well defined bilateral ovarian masses[9] -
![Large, solid, well defined bilateral ovarian masses[9]](/images/e/e6/Krukenberg-tumour-3_%283%29.JPG)
Large, solid, well defined bilateral ovarian masses[9] -
![Large, solid, well defined bilateral ovarian masses[9]](/images/4/4d/Krukenberg-tumour-3_%284%29.JPG)
Large, solid, well defined bilateral ovarian masses[9]
![Large, solid, well defined bilateral ovarian masses[9]](/index.php/File:Krukenberg-tumour-3.JPG)
![Large, solid, well defined bilateral ovarian masses[9]](/index.php/File:Krukenberg-tumour-3_(2).JPG)
![Large, solid, well defined bilateral ovarian masses[9]](/index.php/File:Krukenberg-tumour-3_(3).JPG)
![Large, solid, well defined bilateral ovarian masses[9]](/index.php/File:Krukenberg-tumour-3_(4).JPG)
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]](/images/1/15/Kruckenberg-tumour.jpg)
Krukenberg tumour of the right ovary from colon cancer[9]
![Krukenberg tumour of the right ovary from colon cancer[9]](/index.php/File:Kruckenberg-tumour.jpg)
MRI
- On pelvic MRI, krukenberg tumor is characterized by the following:[11][12][13][5]
- 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]](/images/7/77/Krukenberg-tumour-2_%281%29.jpg)
Coronal T2 image[9] -
![Axial T1 image[9]](/images/6/63/Krukenberg-tumour-2_%282%29.jpg)
Axial T1 image[9] -
![Sagittal T2 image[9]](/images/a/af/Krukenberg-tumour-2_%283%29.jpg)
Sagittal T2 image[9] -
![Axial T2 image[9]](/images/a/a9/Krukenberg-tumour-2_%284%29.jpg)
Axial T2 image[9] -
![Axial T1 C+ fat sat dynamic contrast study image[9]](/images/0/08/Krukenberg-tumour-2_%285%29.jpg)
Axial T1 C+ fat sat dynamic contrast study image[9]
![Coronal T2 image[9]](/index.php/File:Krukenberg-tumour-2_(1).jpg)
![Axial T1 image[9]](/index.php/File:Krukenberg-tumour-2_(2).jpg)
![Sagittal T2 image[9]](/index.php/File:Krukenberg-tumour-2_(3).jpg)
![Axial T2 image[9]](/index.php/File:Krukenberg-tumour-2_(4).jpg)
![Axial T1 C+ fat sat dynamic contrast study image[9]](/index.php/File:Krukenberg-tumour-2_(5).jpg)
Other Diagnostic Studies
Immunohistochemistry
- Krukenberg's tumor may also be diagnosed using immunohistochemistry.[1]
- Findings on immunohistochemistry include:
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 tumors 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
- Bilateral oophorectomy may only be performed for patients where the metastasis is localized to the ovaries.[14]
- 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.
Prevention
- There are no preventive measures available for krukenberg tumors.
Case Studies
References
- ↑ 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 1.15 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.
- ↑ 2.0 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.
- ↑ Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#/media/File:Krukenberg_tumor_-3.jpg. Accessed on March 23, 2016
- ↑ 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.
- ↑ 5.0 5.1 5.2 5.3 5.4 Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.
- ↑ Ovarian cancer. Wikipedia. https://en.wikipedia.org/wiki/Ovarian_cancer#Genetics Accessed on March 23, 2016.
- ↑ 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.
- ↑ 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.
- ↑ 9.00 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
