Krukenberg tumor from an occult appendiceal adenocarcinoid: a case report and review of the literature
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Ovarian tumor
Krukenberg tumor
Occult
Signet ring cell
Mucinous Tumor
Metastatic tumours are only rarely seen within the testis. We report a signet‐ring cell carcinoma of stomach metastasizing to a maldescended testis in a young male. The routes of spread are discussed and support is given to the theory of transperitoneal (transcoelemic) spread. The similarities with Krukenberg tumour of ovary are discussed.
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Krukenberg tumor is a metastatic signet ring cell adenocarcinoma of the ovary. It is uncommon, accounting for 1% to 2% of all ovarian tumors, most commonly observed in the stomach-ovarian axis. Here a case of Krukenberg berg tumor is presenting whose primary site was from breast.
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Krunkenberg tumor is defined as the ovarian metastases of a primary digestive tumor composed of a signet ring cells.Describe the different characteristics of Krukenberg's tumor to improve diagnostic criteria and the therapeutic approche.Five cases of Krukenberg tumor are diagnosed in 5 year period between 2002 and 2005. The clinico-pathological feature are reported.The patient age was ranged from 31 to 58 years. Most ovarian tumors were diagnosed synchronously (3 cases). It was a gastric carcinoma in 3 cases and a colonic carcinoma in 2 patients. Histological diagnosis wass easy. We found in 2 cases a metastasis of colonic mucinous adenocarcinoma with signet ring-cell, in 2 other cases it was a gastric adenocarcinoma with exclusively signet ring cell and in the later case it was a gastric moderately differentiated adenocarcinoma with signet ring cell component. Surgical treatment was given in only 3 patients.Prognosis is always unfavourable. The only hope for improved prognosis is to search for ovarian metastasis in all cases of digestive tumor.
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Purpose: A Krukenberg tumor is an ovarian tumor of a signet-ring cell type. This tumor arises more commonly in young women, and the prognosis is poor. The primary focus of this tumor is often found at gastrointestinal malignancy, especially gastric cancer. We tried to identify the clinical characteristics of this tumor, and in that regard, this report might be helpful. Materials and Methods: We reviewed the 61 patients with Krukenberg tumors, who had been diagnosed at our hospital from 1994 to 2002, and retrospectively analyzed the clinical features. Results: The age distribution ranged from 15 to 59 years, and the mean age was 41 years. The most common symptom was a lower abdominal mass (). Fourty-two cases () showed bilateral ovarian involvement, and the size of this tumor was variable, but in 24 cases () the size was cm for the largest diameter. Among 54 cases, 40 cases had ascites, and the volume of ascites was variable. The median survival of the 61 patients was 10 months, and Krukenberg tumor developed 19.7 months after the primary operation. The median survival durations of recurrence patterns were 20 months for the Krukenberg tumor alone, and 7 months for the Krukenberg tumor with peritoneal seeding. Conclusion: In young women treated with a gastrectomy, especially one for an advanced tumor, closed observation with abdominal ultrasonography or computed tomography to detect a Krukenberg tumor is recommended. The patient with a Krukenberg tumor alone has a better prognosis than one with a Krukenberg tumor combined peritoneal seeding. We will have to consider more progressive treatment for the patient with a Krukenberg tumor alone.
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【Purpose: A Krukenberg tumor is an ovarian tumor of a signet-ring cell type. This tumor arises more commonly in young women, and the prognosis is poor. The primary focus of this tumor is often found at gastrointestinal malignancy, especially gastric cancer. We tried to identify the clinical characteristics of this tumor, and in that regard, this report might be helpful. Materials and Methods: We reviewed the 61 patients with Krukenberg tumors, who had been diagnosed at our hospital from 1994 to 2002, and retrospectively analyzed the clinical features. Results: The age distribution ranged from 15 to 59 years, and the mean age was 41 years. The most common symptom was a lower abdominal mass ( $46\%$ ). Fourty-two cases ( $77\%$ ) showed bilateral ovarian involvement, and the size of this tumor was variable, but in 24 cases ( $4\%$ ) the size was $5\∼10$ cm for the largest diameter. Among 54 cases, 40 cases had ascites, and the volume of ascites was variable. The median survival of the 61 patients was 10 months, and Krukenberg tumor developed 19.7 months after the primary operation. The median survival durations of recurrence patterns were 20 months for the Krukenberg tumor alone, and 7 months for the Krukenberg tumor with peritoneal seeding. Conclusion: In young women treated with a gastrectomy, especially one for an advanced tumor, closed observation with abdominal ultrasonography or computed tomography to detect a Krukenberg tumor is recommended. The patient with a Krukenberg tumor alone has a better prognosis than one with a Krukenberg tumor combined peritoneal seeding. We will have to consider more progressive treatment for the patient with a Krukenberg tumor alone.】
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Signet-ring stromal tumor is a rare ovarian neoplasm that can mimic Krukenberg tumor because of the presence of signet-ring cells in both tumors. The clinicopathologic features of three signet-ring stromal tumors, one of which has been previously reported, were analyzed and compared with 10 Krukenberg tumors. Patients with signet-ring stromal tumor ranged in age from 34 to 41 years (mean: 36.7 years). All signet-ring stromal tumors were unilateral and stage IA, whereas 60% and 40% of Krukenberg tumors were bilateral or associated with extraovarian tumor, respectively. The signet-ring stromal tumors were devoid of epithelial differentiation (glands, nests, cords), whereas all of the Krukenberg tumors contained these epithelial structures at least focally. In contrast to signet-ring stromal tumors, the signet-ring cells of Krukenberg tumors were positive for periodic acid-Schiff with diastase and cytokeratins but negative for vimentin. The patients with signet-ring stromal tumors were alive without disease at follow-up interval of 1 month to 17.4 years (mean: 7.4 years). In summary, signet-ring stromal tumor is a rare, benign, ovarian tumor that may be mistaken for Krukenberg tumor. Although the combination of operative and histopathologic findings allow their distinction, histochemical and immunohistochemical stains may also be useful.
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First described in 1896 by Friedrich Ernst Krukenberg (1871-1946), Krukenberg tumor is a metastatic signet ring cell adenocarcinoma of the ovary.1 The incidence of Krukenberg tumors varies from 1% to 21%.2,3 The most common primary tumor sites metastasizing to ovaries include stomach usually arising in the pylorus followed by colorectal, breast, and appendix.1 The stomach has been attributed as the primary site in about 70% of cases.4 Krukenberg tumor is more prevalent in Asian countries, which have a higher prevalence of gastric carcinoma.1 There are no apparent differences between the symptoms arising from primary and secondary ovarian malignancies. Krukenberg tumors remain asymptomatic until very advanced. In some cases, the features are non-specific, like abdominal pain, weight loss, and increasing abdominal girth.1 The age profile of these patients is relatively younger than patients with other metastatic carcinomas.1 This may be attributed to the higher frequency of gastric signet ring cell carcinoma in younger females.1 Mechanisms of the spread of Krukenberg tumor proposed are retrograde lymphatic dissemination involved in gastric cancer metastases, hematogenous spread most frequent in colorectal cancer, and transperitoneal direct spread.5 Radiologically, Krukenberg tumors appear as complex semisolid masses with varying proportions of solid and cystic components.6 Secondary lymphomatous involvement of ovary usually from the upper gastrointestinal tract is solid, whereas colonic primaries are predominantly cystic in nature.6 Metastases from breast primaries to the ovaries tend to be of small size.6 Among all the other imaging characteristics of Krukenberg tumors, bilateral involvement of the ovaries appears to be the most helpful finding in differentiating from primary ones with over 80% of them being bilateral in nature.4,6 Grossly, Krukenberg tumors are asymmetrically enlarged with bosselated contour.1,4 Microscopically, they are signet ring cells adenocarcinomas accounting for at least 10% of the tumor.2 IHC plays an important ancillary method in confirming the diagnosis. The most commonly used IHC markers are CK7, and CK20.1 Metastatic gastric carcinomas are CK7 and CK20 positive in 55%, and 70% of cases, respectively.7 Colorectal carcinomas are usually negative for CK7 but positive for CK20 in most cases.7 In contrast, primary ovarian carcinomas are almost always positive for CK7 and usually negative for CK20.1,7 Thus, a combination of CK7+/CK20− favors a primary ovarian carcinoma, whereas an immunophenotype of CK7−/CK20+ or CK7+/CK20+ favors a Krukenberg tumor metastasis from the gastrointestinal tract.1,7 Positive IHC for MUC5AC suggests gastric primary.8 Krukenberg tumor must be differentiated from ovarian tumors showing signet-ring cells morphology and filled with either mucinous or non-mucinous material.8 Primary mucinous ovarian carcinomas and mucinous carcinoid tumors are the important differential diagnoses for tumors with signet-ring cells filled with mucin.8 Primary mucinous ovarian tumors have a complex papillary pattern and are usually unilateral.9 IHC for chromogranin and synaptophysin help in ruling out mucinous carcinoid.9 Ovarian signet-ring stromal tumor, sclerosing stromal cell tumor and clear cell adenocarcinoma are the differential diagnoses for tumors that can contain signet-ring cells filled with non-mucinous material.9 Usually, these tumors are non-reactive for AB-PAS stain.9 The various unfavorable prognostic factors in Krukenberg tumors include peritoneal involvement, synchronous presentation, ascites, and increased serum carcinoembryonic antigen (CEA) levels.10 Krukenberg tumors are stage IV disease and have a poor prognosis with a median survival of 14 months.4 Figure 1 represents the surgical specimen of a total abdominal hysterectomy with bilateral salpingo-oophorectomy from a 35-year-old female that was hospitalized with the working diagnosis of bilateral malignant adnexal masses. On gross examination, the uterus, along with the cervix, measured 9.5 cm at its longest axis with asymmetrically enlarged ovaries. The right ovarian mass measured 5 cm in the largest dimension, and the left ovary measured 23 cm in the largest dimension. The external surface of both ovaries was bosselated (Figure 1A and 1B). The capsules were intact and smooth without any adhesions or deposits. The attached fallopian tubes were uninvolved. On cut surface, both ovaries were solid, whitish, and with foci of congestion (Figure 1C). Figure 1The external surface of both A – the right ovary and B – the left ovary was bosselated; C – The cut surface of the left ovary was solid, whitish with foci of congestion; D – Photomicrograph of the ovary showing signet ring cell adenocarcinoma (H&E, 400X).: Microscopic examination revealed infiltrating signet ring cell adenocarcinoma (Figure 1D). Alcian blue in the combination with Periodic acid-Schiff (AB-PAS) at pH 2.5 highlighted the cytoplasmic mucin in the signet ring cells. Immunohistochemistry (IHC) performed showed tumor cells positive for cytokeratin 20 (CK20) and MUC5AC. The tumor cells were negative for cytokeratin 7 (CK7), chromogranin, and synaptophysin. Upper gastrointestinal endoscopy revealed an ulcer measuring 2 cm in diameter in the greater curvature, a biopsy from which confirmed a diagnosis of signet ring cell carcinoma. Thus, a final diagnosis of the Krukenberg tumor was made.
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Preoperative diagnosis mainly including presumptive pathological diagnosis on adnexal tumors has various issues such as differentiation from tumors of other adjacent organs. We experienced a case of appendix tumor after diagnosis as right ovarian cyst at this time. Further, this case had a very rare condition with a simultaneous appendix tumor of low-grade appendiceal mucinous tumor and appendiceal carcinoid tumor, and is reported by adding bibliographic consideration.
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Leptomeningeal carcinomatosis (LCM) is a rare complication of gastric cancer.It usually occurs late in advanced stage of disease and is sometimes misdiagnosed as toxicity of chemotherapeutic agents.Here we report a rare case of gastric cancer that developed LCM in follow-up.A 28-year-old woman with signet ring cell gastric cancer associated with Krukenberg tumor was admitted with persistent headache, nausea, vomiting, vertigo, and diplopia.Linear appearance of contrast enhancement in cerebellar fissures and around cranial nerves was seen in magnetic resonance imaging and cerebrospinal fluid was hypercellular with numerous carcinoma cells.LMC was confirmed and treated with intrathecal methotrexate and additional whole-brain irradiation.LCM is a rare complication, but occurs more often than expected and is often misdiagnosed.If patient who is being treated for gastric cancer presents with neurological symptoms, LCM should be kept in mind.Clinical improvement can be achieved with current treatment modalities, including radiotherapy, chemotherapy, or targeted molecules.
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Krukenberg tumor is the malignant metastatic ovarian. tumor with the characteristic histo logic picture of mucin-laden, signet-ring cells infiltrating a hyperplastic ovarian stroma of spindle-shaped cells. A case of metastatic krukenberg tumor from stomach carcinoma is presented with a brief review of literatures.
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