P1570Cardiac strain detects subclinical decline of cardiac function after hematopoietic stem cell transplantation in patients with hematologic malignancies

Background

Hematopoietic stem cell transplantation (HSCT) has been established as a treatment of various hematologic malignancies and improved their prognoses. HSCT includes intensive chemotherapy and systemic radiation, which occasionally induces cardiac dysfunction. However, early predictor of cardiac dysfunction associated with HSCT is still elusive. Recently, left ventricular (LV) global longitudinal strain (GLS) has been recognized as an early detector of cardiotoxicity. In this study, we retrospectively analyzed GLS and cardiac parameters in patients with hematologic malignancies before and after HSCT to explore HSCT-induced cardiac dysfunction.

Methods

Thirty-one consecutive patients undergone HSCT were enrolled and reviewed their cardiac comorbidities, medications, chemotherapy, and radiotherapy before HSCT. Transthoracic echocardiographic variables including GLS, cardiac troponin-I, and B-type natriuretic peptide were analyzed prior to and 1 month after HSCT.

Results

The patients were 49.7±13.5 years of age, 61% were male, and 52% had cardiovascular risk factors. Cardiac troponin-I was significantly increased following HSCT from 0.010±0.002 ng/ml to 0.016±0.014 ng/ml (P=0.02), indicating that HSCT should have certain impact on cardiac myocytes. Echocardiographic analyses revealed that LV GLS was significantly decreased after HSCT from −19.4±0.8% to −18.8±0.8% (P<0.001), whereas there was no significant difference in LV ejection fraction between these time points of HSCT (63.6±5.5% vs. 64.7±4.6%; P=0.13). Although there was no correlation between the decline of GLS and the increase of troponin-I in this cohort, these results clearly indicated that GLS, but not LVEF, predicted HSCT-induced early and subclinical cardiac dysfunction at 1 month after the HSCT.

Conclusion

GLS detected early decline of cardiac function after HSCT in the patients with hematologic malignancies. Further follow-up investigations will reveal relationship between GLS, troponin-I and prognosis of cardiac function after HSCT in patients with hematologic malignancies.

Evaluation of the Effects of Chronic Kidney Disease and Hemodialysis on the Inner Ear Using Multifrequency Tympanometry

OBJECTIVES

To evaluate the effects of chronic kidney disease (CKD) and hemodialysis (HD) on the inner ear using the G width (the width between the bimodal peaks of the conductance (G) tympanogram at 2,000 Hz), which reflects the inner ear pressure and/or the existence of endolymphatic hydrops.

MATERIALS AND METHODS

We selected five patients (10 ears) from the patients with CKD who were hospitalized for creation of arteriovenous fistula prior to initiation of HD (non-HD group), and we selected seven patients (14 ears) from the patients with CKD who were undergoing HD (the HD group). As a control group, we selected 80 healthy individuals (160 ears); these were mainly the medical staff of the hospital. We measured the G width of the control group and that of patients with CKD using multifrequency tympanometry.

RESULTS

The mean G widths of the HD (measured just before an HD session), non-HD, and control groups were 210.7, 128.4, and 97.0 daPa, respectively. The G width of the HD group was significantly greater than that of the control and non-HD groups (p<0.01 and p<0.01, respectively; Tukey-Kramer test after one-way analysis of variance). The non-HD group also had a greater G width than the control, but it was not significant (p=0.20; Tukey-Kramer). No significant changes were observed in the G widths of the HD group, just before and after a single HD session (p=0.423; paired t-test).

CONCLUSION

The greater G width observed in hemodialyzed CKD patients suggests either an increased inner ear pressure or the existence of endolymphatic hydrops in these patients, which is probably related to their otologic symptoms.

Synovial Metallosis After Ceramic Total Ankle Arthroplasty Treated With a Total Talar Prosthesis: A Case Report

Total ankle arthroplasty is a useful surgical procedure for osteoarthritis of the ankle, but aseptic loosening of components is an issue. We report here a case of aseptic implant loosening with metallosis after total ankle arthroplasty using the TNK ankle (Kyocera, Kyoto, Japan), which occurred despite the components being ceramic. We also report favorable results from our method of treatment using a total talar prosthesis in the revision surgery. During the revision surgery, synovial metallosis was found, probably related to superficial damage to the screw affixing the tibial component to the bone. Because both the tibial and talar components were loose, all the components and the remaining talar bone were removed. A new tibial component and a custom-made alumina-ceramic total talar prosthesis was inserted. Pain relief was achieved and maintained through the latest follow-up visit at 42 months after revision surgery. Dorsiflexion of the ankle improved from 0° to 5° and plantarflexion remained unchanged from its preoperative range of 20°. The American Orthopaedic Foot & Ankle Society ankle-hindfoot score improved from 38 to 80 points. To the best of our knowledge, this is the first reported case of an alumina-ceramic total ankle prosthesis loosening caused by metallosis resulting from screw abrasion. Favorable treatment results were obtained by using a total talar prosthesis in the revision surgery.

[Hypoxia epigenetically bestows astrocytic differentiation potential on human pluripotent cell-derived neural stem/precursor cells]

The central nervous system (CNS) is composed of three major cell types, neurons, astrocytes, and oligodendrocytes, which differentiate from common multipotent neural stem/precursor cells (NS/PCs). However, NS/PCs do not have this multipotentiality from the beginning: neurons are generated first and astrocytes are later during CNS development. This developmental progression is observed in vitro by using human (h) NS/PCs derived from pluripotent cells, such as embryonic- and induced pluripotent-stem cells (ES/iPSCs), however, in contrast to rodent's pluripotent cells, they require quite long time to obtain astrocytic differentiation potential. Here, we show that hypoxia confers astrocytic differentiation potential on hNS/PCs through epigenetic alteration for gene regulation. Furthermore, we found that these molecular mechanisms can be applied to functional analysis of patient' iPSC-derived astrocytes. In this review, we summarize recent findings that address molecular mechanisms of epigenetic and transcription factor-mediated regulation that specify NS/PC fate and the development of potential therapeutic strategies for treating astrocyte-mediated neurological disorders.

Cooperation of PU.1 With IRF8 and NFATc1 Defines Chromatin Landscapes During RANKL-Induced Osteoclastogenesis

Receptor activator of nuclear factor κB ligand (RANKL) induces osteoclast (OC) differentiation from bone marrow-derived macrophages (BMMs). The transcription factors nuclear factor of activated T cells 1 (NFATc1) and interferon regulatory factor (IRF) 8 play positive and negative roles, respectively, in this process. However, genomewide mapping of the active cis-regulatory elements regulating OC differentiation has not been performed, and little is known about the global landscape of OC-specific gene regulation. We used chromatin immunoprecipitation and formaldehyde-assisted isolation of regulatory elements followed by sequencing to show that PU.1 transcription factor binding motifs were overrepresented at active cis-regulatory regions in both murine BMMs and OCs, while IRF and NFAT binding motifs were selectively enriched at these regions in BMMs and OCs, respectively. We also found that RANKL induced the downregulation of Irf8 and upregulation of Nfatc1 expression, which was associated with dramatic alterations in histone modification. BMM-specific PU.1 binding sites were observed to overlap with IRF8 binding sites in BMMs, and this also occurred for OC-specific PU.1 binding sites and NFATc1 binding sites in OCs. The expression of genes with IRF8 peaks within BMM-specific PU.1 binding sites was significantly higher in BMMs than in OCs, while that of genes with NFATc1 peaks within OC-specific PU.1 binding sites was significantly higher in OCs than in BMMs. Our results suggest that PU.1 switches its transcription partner from IRF8 to NFATc1 and alters the binding regions during RANKL-induced osteoclastogenesis, which is associated with changes in epigenetic profiles and the control of cell type-specific gene expression. © 2019 American Society for Bone and Mineral Research.

Appropriate management of high-flow priapism based on color Doppler ultrasonography findings in pediatric patients: four case reports and a review of the literature

INTRODUCTION

High-flow priapism in children is a very rare condition, and there is no clear consensus on its management. High-flow priapism is associated with increased cavernosal blood flow and broadly divided into two groups based on the presence or absence of arteriocavernous fistula in the corpora cavernosa.

OBJECTIVE

This study aimed to determine the appropriate management of high-flow priapism based on the existence of arteriocavernous fistula using penile color Doppler ultrasonography (CDU) findings in the pediatric population.

STUDY DESIGN

The cases of four boys aged between 6 and 11 years with high-flow priapism treated between 2009 and 2017 are reported. Two boys had prior perineal trauma, one boy had blunt penile glans trauma, and one had no obvious cause for the condition. All boys initially underwent penile CDU and were treated conservatively or via selective arterial embolization depending upon the presence or absence of an arteriocavernous fistula.

RESULTS

Penile CDU revealed an arteriocavernous fistula inside the corpus cavernosum penis in two of four boys and increased blood flow inside the corpus spongiosum in the remaining boys. The former two boys underwent selective arterial embolization and one boy underwent repeated embolization because of remaining arteriocavernous fistula feeding from the contralateral cavernosal artery, whereas the boys with no arteriocavernous fistula on CDU were managed conservatively. All boys were successfully treated within 1 month, and they had normal morning erection and no evidence of recurrent priapism at the follow-up.

DISCUSSION

Unlike low-flow priapism, high-flow priapism is not a medical emergency. Therefore, conservative therapy is an appropriate initial treatment, although selective arterial embolization can be effective for high-flow priapism with arteriocavernous fistula, with a success rate of 97% and no reported complications to date. Penile CDU is an imaging technique that can detect focal areas of turbulent flow with sensitivity close to 100%. This study has several limitations including a small number of cases, limited follow-up duration, and possibility of spontaneous arteriocavernous fistula closure in cases treated by arterial embolization.

CONCLUSION

Penile CDU could be a reliable tool to diagnose high-flow priapism and detect the presence or absence of arteriocavernous fistula. Although conservative therapy remains the first choice, selective arterial embolization may be an early treatment option when CDU reveals an arteriocavernous fistula.

Prior Treatment with Anti-High Mobility Group Box-1 Antibody Boosts Human Neural Stem Cell Transplantation-Mediated Functional Recovery After Spinal Cord Injury

Together with residual host neurons, transplanted neural stem cell (NSC)-derived neurons play a critical role in reconstructing disrupted neural circuits after spinal cord injury (SCI). Since a large number of tracts are disrupted and the majority of host neurons die around the lesion site as the damage spreads, minimizing this spreading and preserving the lesion site are important for attaining further improvements in reconstruction. High mobility group box-1 (HMGB1) is a damage-associated molecular pattern protein that triggers sterile inflammation after tissue injury. In the ischemic and injured brain, neutralization of HMGB1 with a specific antibody reportedly stabilizes the blood-brain barrier, suppresses inflammatory cytokine expression, and improves functional recovery. Using a SCI model mouse, we here developed a combinatorial treatment for SCI: administering anti-HMGB1 antibody prior to transplantation of NSCs derived from human induced pluripotent stem cells (hiPSC-NSCs) yielded a dramatic improvement in locomotion recovery after SCI. Even anti-HMGB1 antibody treatment alone alleviated blood-spinal cord barrier disruption and edema formation, and increased the number of neurites from spared axons and the survival of host neurons, resulting in functional recovery. However, this recovery was greatly enhanced by the subsequent hiPSC-NSC transplantation, reaching an extent that has never before been reported. We also found that this improved recovery was directly associated with connections established between surviving host neurons and transplant-derived neurons. Taken together, our results highlight combinatorial treatment with anti-HMGB1 antibody and hiPSC-NSC transplantation as a promising novel therapy for SCI. Stem Cells 2018;36:737-750.

Hypoxia Epigenetically Confers Astrocytic Differentiation Potential on Human Pluripotent Cell-Derived Neural Precursor Cells

Human neural precursor cells (hNPCs) derived from pluripotent stem cells display a high propensity for neuronal differentiation, but they require long-term culturing to differentiate efficiently into astrocytes. The mechanisms underlying this biased fate specification of hNPCs remain elusive. Here, we show that hypoxia confers astrocytic differentiation potential on hNPCs through epigenetic gene regulation, and that this was achieved by cooperation between hypoxia-inducible factor 1α and Notch signaling, accompanied by a reduction of DNA methylation level in the promoter region of a typical astrocyte-specific gene, Glial fibrillary acidic protein. Furthermore, we found that this hypoxic culture condition could be applied to rapid generation of astrocytes from Rett syndrome patient-derived hNPCs, and that these astrocytes impaired neuronal development. Thus, our findings shed further light on the molecular mechanisms regulating hNPC differentiation and provide attractive tools for the development of therapeutic strategies for treating astrocyte-mediated neurological disorders.

Effects of assisted reproductive technologies in neonates with indications for surgery (2007-2016)

PURPOSE

Recently, the number of births using assisted reproductive technologies (ART) has increased. An associated increase in the incidence of congenital malformations in babies conceived using this technology has also been reported. Therefore, we aimed to investigate the rate of malformations in babies with neonatal surgical diseases, who were conceived using ART.

MATERIALS AND METHODS

Between January 2007 and December 2016, 1737 patients were admitted to our hospital. We analyzed the incidence of congenital cardiac diseases, genetic anomalies, and congenital anomalies of the kidney and urinary tract (CAKUT) in neonates conceived by ART. The χ2 test and logistic regression analysis were used to assess the odds ratios (ORs) for congenital malformations. A P-value < 0.05 indicated statistical significance.

RESULTS

The OR for CAKUT was 16.94 for the first-birth neonates conceived using ART, [P < 0.05, AUC (area under the curve) = 0.86]. However, for non-surgery neonates, the OR for CAKUT was 5.99 (P = 0.15, AUC = 0.87), compared to 32.27 (P < 0.05, AUC = 0.93) for parallel conditions in surgery-neonates.

CONCLUSION

Neonates conceived using ART are prone to develop CAKUT, which will need surgical treatment. Therefore, more management is necessary for associated malformations in these babies, particularly in cases with CAKUT.

The vinylogous Catellani reaction: a combined computational and experimental study

In the presence of 5 mol% Pd(OAc)₂, 1 equiv. of norbornene, and K₂CO₃, the reaction of 4-iodo-2-quinolones with tertiary o-bromobenzylic alcohols produced the desired benzopyran-fused 2-quinolones in moderate to high yields.

In the presence of 5 mol% Pd(OAc)₂, 1 equiv. of norbornene, and K₂CO₃, the reaction of 4-iodo-2-quinolones with tertiary o-bromobenzylic alcohols produced the desired benzopyran-fused 2-quinolones in moderate to high yields. A Catellani-type mechanism involving vinylic C–H cleavage is proposed based on the results of control experiments and density functional theory calculations.

Neural stem cell therapy aiming at better functional recovery after spinal cord injury

Injury to the spinal cord causes transection of axon fibers and neural cell death, resulting in disruption of the neural network and severe functional loss. Reconstruction of the damaged neural circuits was once considered to be hopeless as the adult mammalian central nervous system has very poor ability to regenerate. For this reason, there is currently no effective therapeutic treatment for spinal cord injury (SCI). However, with recent developments in stem cell research and cell culture technology, regenerative therapy using neural stem cell (NSC) transplantation has rapidly been developed, and this therapeutic strategy makes it possible to rebuild the destroyed neural circuits. In this review, we discuss the recent breakthroughs in NSC transplantation therapy for SCI. Developmental Dynamics 247:75-84, 2018. © 2017 Wiley Periodicals, Inc.

Assessing joint destruction in the knees of patients with rheumatoid arthritis by using a semi-automated software for magnetic resonance imaging: therapeutic effect of methotrexate plus etanercept compared with methotrexate monotherapy

OBJECTIVES

To evaluate the prevention of knee joint destruction and clinical efficacy of methotrexate (MTX) plus etanercept (ETN) compared with MTX monotherapy in patients with rheumatoid arthritis (RA) by using semi-automated software for magnetic resonance imaging (MRI) scan analysis.

MATERIALS AND METHODS

This study enrolled patients with active moderate-to-severe RA who displayed an inadequate response to oral MTX at screening. Patients were assigned to receive either MTX plus ETN or MTX monotherapy (≥10 mg/week). The primary endpoint was the quantitative knee cartilage volume using our software developed for MRI scan analysis.

RESULTS

A total of 18 female patients were enrolled in this study and allocated to the MTX + ETN group (n = 9) or the MTX monotherapy group (n = 9). At 52 weeks, the quantitative knee cartilage volume was significantly reduced compared with baseline in both groups (MTX plus ETN group: 2.3 ± 2.3 cm³; MTX monotherapy group: 2.4 ± 1.6 cm³); however, the difference was not significant.

CONCLUSION

The semi-automated software for MRI scan analysis can reveal useful and potentially clinically important information about the characteristics of knee joint destruction in patients with RA.

Evaluation of the histological and mechanical features of tendon healing in a rabbit model with the use of second-harmonic-generation imaging and tensile testing

OBJECTIVES

This study aimed to evaluate the histological and mechanical features of tendon healing in a rabbit model with second-harmonic-generation (SHG) imaging and tensile testing.

MATERIALS AND METHODS

A total of eight male Japanese white rabbits were used for this study. The flexor digitorum tendons in their right leg were sharply transected, and then were repaired by intratendinous stitching. At four weeks post-operatively, the rabbits were killed and the flexor digitorum tendons in both right and left legs were excised and used as specimens for tendon healing (n = 8) and control (n = 8), respectively. Each specimen was examined by SHG imaging, followed by tensile testing, and the results of the two testing modalities were assessed for correlation.

RESULTS

While the SHG light intensity of the healing tendon samples was significantly lower than that of the uninjured tendon samples, 2D Fourier transform SHG images showed a clear difference in collagen fibre structure between the uninjured and the healing samples, and among the healing samples. The mean intensity of the SHG image showed a moderate correlation (R² = 0.37) with Young's modulus obtained from the tensile testing.

CONCLUSION

Our results indicate that SHG microscopy may be a potential indicator of tendon healing.Cite this article: E. Hase, K. Sato, D. Yonekura, T. Minamikawa, M. Takahashi, T. Yasui. Evaluation of the histological and mechanical features of tendon healing in a rabbit model with the use of second-harmonic-generation imaging and tensile testing. Bone Joint Res 2016;5:577-585. DOI: 10.1302/2046-3758.511.BJR-2016-0162.R1.

Relationship between roentgenographic joint destruction in the hands and functional disorders among patients with rheumatoid arthritis

OBJECTIVES

Although a relationship between joint destruction and functional disorders seems apparent in patients with rheumatoid arthritis (RA), it has not been well proven in the literature. The aims of this study were to clarify the relationship between roentgenographic joint destruction in the hands and functional disorders in patients with RA, and to explore the appropriate assessment measures for functional disorders.

METHODS

Cross-sectional data of the Genant-modified Total Sharp Score (Genant-mTSS), Health Assessment Questionnaire-Disability Index (HAQ-DI), Disabilities of the Arm, Shoulder, and Hand (DASH), and Michigan Hand Outcomes Questionnaire (MHQ) were collected from 50 consecutive RA patients and analyzed.

RESULTS

HAQ-DI, DASH, and MHQ had close correlations with Genant-mTSS, with correlation coefficients of 0.69, 0.71, and -0.70, respectively, among patients with low disease activity (DAS28 < 3.2). A floor effect was observed in HAQ-DI, but neither floor nor ceiling effects were observed in DASH and MHQ. Both DASH and MHQ were strongly correlated with HAQ-DI, with correlation coefficients of 0.87 and 0.73, respectively.

CONCLUSIONS

Functional disorders had significant relationships with roentgenographic joint destruction in the hands among RA patients with low disease activity. As assessment measures of functional disorders, DASH and MHQ had no floor or ceiling effects, being different from HAQ-DI.

Serum carcinoembryonic antigen as a tumour marker in patients with endometrial cancer

BACKGROUND

No potential tumour markers have been validated for prognosis in endometrial cancer. However, carcinoembryonic antigen (cea) is one of the most widely used tumour markers in various types of cancer. Although cea expression in endometrial cancer has been investigated, its prognostic value remains controversial, and no studies have investigated serum cea levels in large case series. In the present study, we investigated diagnostic and prognostic applications of serum cea for endometrial cancer.

METHODS

This prospective study was approved by our Institutional Review Board. Between January 2006 and December 2012, serum cea was measured prospectively in 215 patients with endometrial cancer and was subsequently measured during treatment and at scheduled follow-up examinations in patients with elevated baseline serum cea.

RESULTS

During the study period, 215 patients (142 stage i, 19 stage ii, 32 stage iii, 22 stage iv) were treated for endometrial cancer. By the time of last follow-up, 52 had relapsed (24.2%), and the median follow-up duration was 45 months (range: 1-95 months). Elevated serum cea was identified in 25 patients (11.6%) and was associated with histologic type (p = 0.04), histologic grade (p = 0.03), and myometrial invasion depth (p = 0.01). Elevated serum cea was not related to clinical stage, lymph node metastasis, distant metastasis, age, menopausal status, or body mass index. Relapse of disease was related to elevated serum cea (p = 0.006).

CONCLUSIONS

Serum cea is a potential prognostic indicator for endometrial cancer.

Identification of Nedd9 as a TGF-β-Smad2/3 Target Gene Involved in RANKL-Induced Osteoclastogenesis by Comprehensive Analysis

TGF-ß is a multifunctional cytokine that is involved in cell proliferation, differentiation and function. We previously reported an essential role of the TGF-ß -Smad2/3 pathways in RANKL-induced osteoclastogenesis. Using chromatin immunoprecipitation followed by sequencing, we comprehensively identified Smad2/3 target genes in bone marrow macrophages. These genes were enriched in the gene population upregulated by TGF-ß and downregulated by RANKL. Recent studies have revealed that histone modifications, such as trimethylation of histone H3 lysine 4 (H3K4me3) and lysine 27 (H3K27me3), critically regulate key developmental steps. We identified Nedd9 as a Smad2/3 target gene whose histone modification pattern was converted from H3K4me3(+)/H3K4me27(+) to H3K4me3(+)/H3K4me27(-) by TGF-ß. Nedd9 expression was increased by TGF-ß and suppressed by RANKL. Overexpression of Nedd9 partially rescued an inhibitory effect of a TGF-ß inhibitor, while gene silencing of Nedd9 suppressed RANKL-induced osteoclastogenesis. RANKL-induced osteoclastogenesis were reduced and stimulatory effects of TGF-ß on RANKL-induced osteoclastogenesis were partially abrogated in cells from Nedd9-deficient mice although knockout mice did not show abnormal skeletal phenotypes. These results suggest that Nedd9 is a Smad2/3 target gene implicated in RANKL-induced osteoclastogenesis.

Comparison of mouse and human ankles and establishment of mouse ankle osteoarthritis models by surgically-induced instability

OBJECTIVE

Prevalence of ankle osteoarthritis (OA) is lower than that of knee OA, however, the molecular mechanisms underlying the difference remain unrevealed. In the present study, we developed mouse ankle OA models for use as tools to investigate pathophysiology of ankle OA and molecular characteristics of ankle cartilage.

DESIGN

We anatomically and histologically examined ankle and knee joints of C57BL/6 mice, and compared them with human samples. We examined joints of 8-week-old and 25-month-old mice. For experimental models, we developed three different ankle OA models: a medial model, a lateral model, and a bilateral model, by resection of respective structures. OA severity was evaluated 8 weeks after the surgery by safranin O staining, and cartilage degradation in the medial model was sequentially examined.

RESULTS

Anatomical and histological features of human and mouse ankle joints were comparable. Additionally, the mouse ankle joint was more resistant to cartilage degeneration with aging than the mouse knee joint. In the medial model, the tibiotalar joint was markedly affected while the subtalar joint was less degenerated. In the lateral model, the subtalar joint was mainly affected while the tibiotalar joint was less altered. In the bilateral model, both joints were markedly degenerated. In the time course of the medial model, TdT-mediated dUTP nick end labeling (TUNEL) staining and Adamts5 expression were enhanced at early and middle stages, while Mmp13 expression was gradually increased during the OA development.

CONCLUSION

Since human and mouse ankles are comparable, the present models will contribute to ankle OA pathophysiology and general cartilage research in future.

Krukenberg tumor in a 18-year-old-female: a rare case

BACKGROUND

Krukenberg tumors mostly occur after 40 years. Metastatic ovarian tumors in young age are very rare.

CASE

A 18-year-old female presented with colon cancer which was accompanied by Krukenberg tumor. The present case was a very rare case of metastatic ovarian tumor in very young age. The present patient presented with abdominal pain. On examination, colon tumor was detected and bilateral ovary were almost normal with only slight swelling. During the operation for colon tumor, biopsy of bilateral ovary was performed for histopathological evaluation. Although there were no specific findings in bilateral ovary, microscopic examination revealed poorly differentiated adenocarcinoma, diffusely invading the ovarian parenchyma. Diagnosis of colon cancer was made postoperatively and ovarian Krukenberg tumor was confirmed.

CONCLUSION

In case of suspecting colon cancer even in very young patient with normal ovary, biopsy of ovary should be considered for the diagnosis of Krukenberg tumor.