Case  of  the  Month  November  2015:    Krukenberg  Tumour    

Kate  Hames  PGY2  November,  2015  

Case  Report  

70  year-­‐old  female  presents  with  a  6  month  history  of    severe  worsening  heartburn,  consApaAon,  and  vague  lower  abdominal  and  pelvic  pain.      Vitals:    Non  febrile  HR  80  BP  145/95      CBC:  Normal    Liver  enzymes:  Normal  Lipase:  Normal      

Physical  Exam:  Mild  epigastric  tenderness  NegaAve  Murphy’s    Mild  tenderness  in  RLQ  and  LLQ    DRE  negaAve    

Past  Medical  Hx:  Remote  history  of  bladder  tumour  resecAon.    Previous  smoker,  quit  10  years  ago  

Ø  DiagnosMc  Imaging:  CT  and  Ultrasound    

InvesMgaMons  

Ø   Gastroscopy  and  Colonoscopy    

Ø   Biopsy  and  Pathology    

Axial  image  demonstraMng  thickened  gastric  wall  

InvesMgaMons:  CT  

CT  axial  image  of  bilateral  adnexal  masses    

Coronal  reformats  of  adnexal  masses    

SagiTal  Reformats  of  adnexal  masses  

       

   Ø   Abnormal  thickening  of  the  gastric  body  wall  with  mucosal  enhancement.        

     Ø   Abnormal  stranding  of  the  fat  planes  within  the  gastrohepaAc  ligament  as  well  as  inferior  to  the  gastric  body.        

   Ø Extensive  omental  nodularity  beneath  anterior  abdominal    wall  in  keeping  with  omental  metastases.        

   Ø   Moderate  volume  of  pelvic  free  fluid.    Ø Large  heterogenous  enhancing  mass  in  the  right  adnexa  suspicious  for  a  solid  right  ovarian  mass.  Similar  appearing  mass  in  the  leW  adnexa.      

         

CT  imaging  findings    

Ultrasound  LeW  Adnexa  with  Doppler    

Ultrasound  Right  Adnexa  with  Doppler    

   

Ø   The  uterus  is  anteverted  and  atrophic.  Normal  endometrium.      Ø Right  adnexal  lobulated  mass  measuring  5.4  x  3.2  cm  with  associated  hypervascularity.        

     Ø LeW  adnexal  lobulated  mass  measuring  4.4  x  3.2  cm  with  associated  hypervascularity.    

   Ø   Free  fluid  within  the  pelvis.            

                         

Ultrasound  Findings    

InvesMgaMons  ConMnued  

Gastroscopy  demonstrated  severe  gastriAs  along  the  lesser  curve  from  the  mid  body  to  the  GE  juncAon.    A  visible  tumour  extended  from  the  distal  esophagus  to  the  lesser  curvature  just  proximal  to  the  antrum.  There  was  marked  liniAs  plasAca.      Colonoscopy  was  unremarkable  aside  from  diverAculi.          

Biopsies  from  the  first  endoscopy  showed  poorly  differenMated  adenocarcinoma  of  the  stomach.  The  second  biopsy  demonstrated  small  foci  of  signet  ring  cell  carcinoma.      

Pathology  confirmed    metastaMc  HER2-­‐neu  negaMve  gastric  cancer.        

 Diagnosis:  

   In  the  context  of  signet  ring  cell  gastric  carcinoma,  the  bilateral  adnexal  masses  are  favoured  to  be  bilateral  ovarian  metastases  in  keeping  with  Krukenberg  tumour.      

Krukenberg  Tumor  

Ø “Signet  ring”  subtype  of  metastaMc  ovarian  tumor,  also  known  as  carcinoma  mucocellulare.    

Ø The  most  common  primary  tumours  are  stomach  and  colon,  followed  by  breast,  lung,  and  contralateral  ovarian  tumour  

 

Epidemiology    

Ø Krukenberg  tumors  are  5-­‐10%  of  all  ovarian  tumors,  and  up  to  50%  of  all  metastaAc  ovarian  tumours    

 Pathology  

 

Ø Histology  demonstrates  mucin-­‐secreAng  “signet  ring”  cells;  the  cells  typically  originate  from  the  stomach,  followed  by  colorectal,  breast,  lung,  contralateral  ovarian  carcinoma,  pancreas,  and  cholangiocarcinoma        

Jung  et  al  2002  

Webpathology.com  

Nests  and  clusters  of  signet  ring  cells  filled  with  basophilic  mucin  seen  infiltraAng  spindled  stroma    

Pathology:  Signet  Ring  Cells      

DiagnosMc  Imaging  CharacterisMcs    of  Krukenberg  Tumour        

CT:    Ovarian  masses  may  be  mixed  cysAc-­‐solid  or  primarily  solid,  and  may  be  indisAnguishable  from  primary  ovarian  carcinoma.  Krukenberg  tumor  may  be  suspected  if  there  are  addiMonal  gastric  or  colonic  lesions  idenMfied.    Ultrasound:    Findings  are  typically  bilateral  solid  ovarian  masses  with  well-­‐defined  margins.  A  characterisAc  feature  for  Krukenberg  tumor  includes  an  irregular  hyper-­‐echoic  solid  paTern  and  “moth-­‐eaten  like  cyst  formaMon”  (Radiopaedia).          

Jung  SE  et  al,  Radiographics  2002  

           Benign  vs  Malignant  Epithelial  Neoplasms  

Epithelial  ovarian  tumours  represent  60%  of  all  ovarian  neoplasms  and  85%  of  malignant  ovarian  neoplasms  (Jung  et  al).      

(10). Exceptionally large benign neoplasms occurare occasionally seen and are more likely to re-main clinically silent as they grow (11). Epithelialtumors with low malignant potential demonstrate

more proliferation of papillary projections than dobenign cystadenomas (Fig 6) and are often seenin younger patients (14,15). Epithelial tumors

Figure 5. Ruptured mucinous cystadenocarci-noma in a 36-year-old woman. (a) Sagittal turbospin-echo T1-weighted MR image (repetitiontime msec/echo time msec ! 464/14) shows alarge, multilocular mass with heterogeneous highsignal intensity but with variable signal intensityin the locules. (b) On an axial turbo spin-echoT2-weighted MR image (4,511/132), the massdemonstrates high signal intensity, and there aremultiple locules with a honeycomb appearance.The tumor wall is disrupted by spillage of themucinous material (arrows). (c) Gadolinium-enhanced fat-suppressed turbo spin-echo T1-weighted MR image (782/14) demonstratesmarked enhancement of the tumor wall andsepta.

Table 3Features that Suggest Either Benign or Malignant Epithelial Neoplasms

Variable

Tumor Type

Benign Malignant

Component Entirely cystic Large soft-tissue mass with necrosisWall thickness Thin (less than 3 mm) ThickInternal structure Lacking Papillary projectionAscites None Peritoneal, anterior to uterusOther . . . Peritoneal implants, pelvic wall invasion, adenopathy

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Treatment  and  Prognosis  

Ø  Treatment  varies  widely  depending  on  primary  tumour,  extent  of  metastases,  invasion  of  nearby  organs,  and  overall  baseline  health  of  the  paAent.  

 Ø Many  paAents  receive  chemotherapy;  some  receive  

radiaAon;  some  may  receive  surgery  for  the  primary  tumour  and/or  debulking  surgery.    

 Ø  Prognosis  also  varies  widely  depending  on  the  primary  

tumour  and  extent  of  metastases.    

Case  report  conclusion    

Ø Our  paAent  was  diagnosed  with  metastaAc  HER2-­‐neu  negaAve  signet  ring  cell  carcinoma  with  Krukenberg  ovarian  tumour  metastases.    

 

Ø  She  received  six  cycles  of  ECF/X  chemotherapy  and  now  conAnues  on  Capecitabine.    

 

Ø  She  was  not  a  candidate  for  radiaAon  therapy  and  has  not  undergone  surgery.  

 

Ø  She  is  now  1  month  post-­‐chemo  and  progress  reports  indicate  she  is  declining  in  health  but  sAll  living  at  home  with  her  husband.    

 

Ø  Follow  up  imaging  post-­‐chemo  is  sAll  pending.    

References  

Al-­‐Agha  OM,  Nicastri  AD  et  al.  An  in-­‐depth  look  at  Krukenberg  tumor.  Arch  pathol  Lab  Med  2006;  130:  1725-­‐1730.    Cho  KC,  Gold  BM.  Computed  tomography  of  Krukenberg  tumors.  AJR  Am  J  Roentgenol.  1985;145:  285-­‐8.    Goel  A,  Weerakkody  Y  et  al.  Krukenberg  tumour.  Radiopaedia.org  2015.      Ha  HK,  Baek  SY  et  al.  Kruenberg’s  tumor  of  the  ovary:  MR  imaging  features.  AJR  1995;  164:1435-­‐1439.    Jung  SE,  Lee  JM  et  al.  CT  and  MR  imaging  of  ovarian  tumors  with  emphasis  on  differenAal  diagnosis.  RadioGraphics  2002;  22:1305-­‐1325.