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, conspaon, and vague lower abdominal and pelvic pain.

Vitals: Past Medical Hx: Non febrile Remote history of bladder HR 80 tumour resecon. BP 145/95 Previous smoker, quit 10 years ago

CBC: Normal Physical Exam: Liver enzymes: Normal Mild epigastric tenderness Lipase: Normal Negave Murphy’s Mild tenderness in RLQ and LLQ DRE negave Invesgaons

Ø Diagnosc Imaging: CT and Ultrasound

Ø Gastroscopy and Colonoscopy

Ø Biopsy and Pathology Invesgaons: CT

Axial image demonstrang thickened gastric wall CT axial image of bilateral adnexal masses Coronal reformats of adnexal masses Sagial Reformats of adnexal masses

CT imaging findings

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

Ø Abnormal stranding of the fat planes within the gastrohepac 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 le adnexa.

Ultrasound Le Adnexa with Doppler Ultrasound Right Adnexa with Doppler Ultrasound Findings

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

Ø Free fluid within the pelvis.

Invesgaons Connued

Gastroscopy demonstrated severe gastris along the lesser curve from the mid body to the GE juncon. A visible tumour extended from the distal esophagus to the lesser curvature just proximal to the antrum. There was marked linis plasca.

Colonoscopy was unremarkable aside from diverculi.

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

Pathology confirmed metastac HER2-neu negave 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 metastac 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 metastac ovarian tumours

Pathology

Ø Histology demonstrates mucin-secreng “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 Pathology: Signet Ring Cells

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

Webpathology.com Diagnosc Imaging Characteriscs of Krukenberg Tumour CT:

Ovarian masses may be mixed cysc-solid or primarily solid, and may be indisnguishable from primary ovarian carcinoma. Krukenberg tumor may be suspected if there are addional gastric or colonic lesions idenfied.

Ultrasound:

Findings are typically bilateral solid ovarian masses with well- defined margins. A characterisc feature for Krukenberg tumor includes an irregular hyper-echoic solid paern and “moth- eaten like cyst formaon” (Radiopaedia).

RG f Volume 22 ● Number 6 Jung et al 1309 RadioGraphics

Figure 5. Ruptured mucinous cystadenocarci- noma in a 36-year-old woman. (a) Sagittal turbo spin-echo T1-weighted MR image (repetition time msec/echo time msec ϭ 464/14) shows a large, multilocular mass with heterogeneous high signal intensity but with variable signal intensity in the locules. (b) On an axial turbo spin-echo T2-weighted MR image (4,511/132), the mass demonstrates high signal intensity, and there are multiple locules with a honeycomb appearance. The tumor wall is disrupted by spillage of the mucinous material (arrows). (c) Gadolinium- enhanced fat-suppressed turbo spin-echo T1- weighted MR image (782/14) demonstrates Benign vs Malignant Epithelial Neoplasms marked enhancement of the tumor wall and septa. Epithelial ovarian tumours represent 60% of all ovarian neoplasms and 85% of malignant ovarian neoplasms (Jung et al).

Table 3 Features that Suggest Either Benign or Malignant Epithelial Neoplasms

Tumor Type Variable Benign Malignant Component Entirely cystic Large soft-tissue mass with necrosis Wall thickness Thin (less than 3 mm) Thick Internal structure Lacking Papillary projection Ascites None Peritoneal, anterior to uterus Other ... Peritoneal implants, pelvic wall invasion, adenopathy

(10). Exceptionally large benign neoplasms occur more proliferation of papillary projections than do are occasionally seen and are more likely to re- benign cystadenomasJung SE et al, (FigRadiographics 6) and are often 2002 seen main clinically silent as they grow (11). Epithelial in younger patients (14,15). Epithelial tumors tumors with low malignant potential demonstrate Treatment and Prognosis

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

Ø Many paents receive chemotherapy; some receive radiaon; 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 paent was diagnosed with metastac HER2-neu negave signet ring cell carcinoma with Krukenberg ovarian tumour metastases.

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

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

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

Ø Follow up imaging post-chemo is sll 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 differenal diagnosis. RadioGraphics 2002; 22:1305-1325.