Low Peh Hueh International Medical University, Malaysia

Background history 45 year-old Chinese female History of left breast carcinoma with bone metastasis. Pathology of breast specimen showed infiltrating lobular carcinoma. Left mastectomy and level 2 axillary clearance done in July 2003.

Current complaint: Abdominal distension and increased bone pain Physical findings: Distended abdomen No palpable mass Re-staging with CT scan bilateral lobulated heterogenous ovarian masses noted.

CT of the thorax shows evidence of left mastectomy (A) and left sided pleural effusion (B).
B

CT scan of the pelvis shows bilateral lobulated heterogenous ovarian masses. The left adnexal mass (A) measures 4.3 x 3.7cm, and the right adnexal mass (B) measures 5.8 x 4cm.

There is marked ascites (A) causing displacement of solid organs and bowel loops centrally.

The ovarian masses detected are indicative of Krukenberg tumors as it involves both ovaries following resection of an infiltrating lobular carcinoma of the breast. However, the possibilities of the presence of a primary ovarian tumor cannot be ommitted, thus, further investigation with hematoxylin-eosinstained section is needed to view its characteristic light microscopic features, as misclassification of Krukenberg tumor as a primary ovarian tumor may lead to suboptimal treatment of the patient. 1

Metastatic neoplasm to the ovary consists of mucinsecreting signet ring cells. This accounts for 30%-40% of metastatic cancers to the ovaries and possibly 1%-2% of all malignant ovarian tumors. The stomach is the primary site in most cases (70%). The colon, appendix and breast (mainly invasive lobular carcinoma) are the next most common primary sites.

Rare cases originating from carcinoma of the gallbladder, biliary tract, pancreas, small intestine, ampulla of Vater, cervix, and urinary bladder/urachus.2 In many cases, the primary tumor is not detected as it is very small. A history of a primary tumor can only be obtained in 20% to 30% of the cases. 1

There is some debate over the exact mechanism of metastases of the tumor cells. It was thought that spread was through direct seeding (transcoelomic) across the abdominal cavity. But recently, some researchers have suggested that lymphatic or haematogenous spread is more likely, as most of these tumors are found on the inside of the ovaries. metastases are never found in the omentum. tumor cells are found within the ovary and are not growing inwards.

Women in the fifth decade of their lives, with an average age of 45 years. Common presenting symptoms include: Abdominal pain Abdominal distension Nonspecific gastrointestinal symptoms Asymptomatic

Associated with virilization resulting from hormone production by ovarian stroma.3 Ascites is present in 50% of the cases

1) Imaging: Appear as bilateral solid (commoner) or cystic ovarian masses on abdominopelvic sonography and computed tomographic scans. 2) Serum CA 125 for: Postoperative follow-up of patients for evaluation of complete resection of the tumor.

Predict the prognosis 5-year survival rate was lower in patients in whom preoperative serum CA 125 levels were greater than 75 U/mL compared with patients with CA 125 levels less than 75 U/mL.4

A) Gross Features bilateral in > 80% of the reported cases. Usually asymmetrically enlarged, with a bosselated contour. Capsular surface of the ovaries involved are typically smooth and free of adhesions or peritoneal deposits. (other metastatic tumors to the ovary tend to be associated with surface implants.)

B) Microscopic Features Epithelial component: composed chiefly of mucin-laden signet ring cells with eccentric hyperchromatic nuclei. Stromal component: composed of plump and spindle-shaped cells with minimal cytologic atypia or mitotic activity.

Prognosis is poor: 5-10% 5-year survival rates. Most patients die within 2 years (median survival, 14 months).5 Prognosis is poor when the primary tumor is identified after the metastasis to the ovary is discovered Prognosis becomes worse if the primary tumor remains covert.

There is no established treatment for Krukenberg tumors. Chemotherapy or radiotherapy has no significant effect on prognosis of patients with Krukenberg tumors. Prophylatic treatment by bilateral oophorectomy at time of operation of the primary tumor has been considered by some authorities 6 but this requires further study and evaluation.

Case contributed by: Dr. Lynette Teo

1)

Al-Agha OM, Nicastri AD. An In-depth Look at Krukenberg Tumor: An Overview. Archives of Pathology and Laboratory Medicine: Vol. 130, No. 11, pp. 17251730. Hale RW. Krukenberg tumor of the ovaries: a review of 81 records. Obstet Gynecol 1968;32:221225. [PubMed Citation] De Palma P, Wronski M, Bifernino V, Bovani I. Krukenberg tumor in pregnancy with virilization: a case report. Eur J Gynaecol Oncol 1995;16:5964. [PubMed Citation] Kikkawa F, Shibata K, Ino K. et al. Preoperative findings in nongynecologic carcinomas metastasizing to the ovaries. Gynecol Obstet Invest 2002;54:221227. [PubMed Citation] Benaaboud I, Ghazli M, Kerroumi M, Mansouri A. Krukenberg tumor: 9 cases report [in French]. J Gynecol Obstet Biol Reprod (Paris) 2002;31:365370. [PubMed Citation]

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3)

4)

5)

6)

McGill FM, Ritter DB, Rickard CS, Kaleya RN. Krukenberg tumors: can management be improved?. Gynecol Obstet Invest 1999;48:6165. [PubMed Citation] Holtz F, Hart WR. Krukenberg tumors of the ovary: a clinicopathological analysis of 27 cases. Cancer 1982;50:24382447 Kim SH, Kim WH, Park KJ, Lee JK, Kim JS. CT and MR findings of Krukenberg tumors: comparison with primary ovarian tumors. J Comput Assist Tomogr 1996;20:393398. [PubMed Citation] Beckmann CRB, Ling FW, et al. Obstetrics and Gynecology, 5th ed. Lippincott Williams & Wilkins, 2006. p.474.

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10) Holland JF, Pollock RE, et al. Cancer Medicine, 5th ed. B.C.Decker Inc, 2000. p.1712.