Effects of metastasectomy and other factors on survival of patients with ovarian metastases from gastric cancer: a systematic review and meta-analysis

Ovarian metastasis from gastric cancer (Krukenberg tumor [KT]) has no consensus treatment and the role of surgical treatment is still controversial. Identifying prognostic factors for KT could help guide the management of this tumor. We used a meta-analysis to evaluate the prognostic value of metastasectomy and other factors in patients with KT to develop a treatment plan. We searched literature in PubMed, Cochrane library and EMBASE. We analyzed hazard ratios (HR) and 95% confidence intervals (CI) with respect to overall survival (OS). The meta-analysis included 12 cohort studies with 1,031 patients associated with longer OS following metastasectomy (HR = 0.41; 95% CI = 0.32-0.53; P < 0.001), R0 resection (HR = 0.37; 95% CI = 0.26-0.53; P < 0.001), metachronous ovarian metastasis (HR = 0.74; 95% CI = 0.58-0.93; P = 0.012), size of KT (<5 cm) (HR = 0.74; 95% CI = 0.58-0.95; P = 0.019), ECOG PS (Eastern Cooperative Oncology Group performance status) 0 to 1 (HR = 0.48; 95% CI = 0.29-0.80; P  = 0.004), tumor confined to ovary (HR = 0.40; 95% CI = 0.16-0.99; P  = 0.047), and tumor confined to pelvic cavity (HR = 0.36; 95% CI = 0.14-0.92; P  = 0.033). Shorter OS was associated with peritoneal carcinomatosis (HR = 2.00; 95% CI = 1.25-3.21; P  = 0.004), ascites (HR = 1.66; 95% CI = 1.19-2.31; P  = 0.003) and positive CEA (HR = 1.41; 95% CI = 1.10-1.82; P  = 0.007). Gastrectomy led to a slight improvement in OS, but without statistical significance (HR = 0.69; 95% CI = 0.47-1.02; P  = 0.061). No significant difference in OS was observed in patients with signet-ring cells (HR = 1.17; 95% CI = 0.91-1.51; P  = 0.226), bilateral ovarian metastasis (HR = 0.87; 95% CI = 0.70-1.08; P  = 0.212), age ≥ 50 years (HR = 0.93; 95% CI = 0.71-1.22; P  = 0.619), positive CA19-9 (HR = 1.01; 95% CI = 0.75-1.35; P  = 0.960), and positive CA-125 (HR = 0.98; 95% CI = 0.73-1.33; P  = 0.915). Various factors affect OS in patients with KT.

Is a Surgical Approach Justified in Metachronous Krukenberg Tumor from Gastric Cancer? A Systematic Review

BACKGROUND

The treatment of metachronous Krukenberg tumor (mKT) from gastric cancer remains unexplored. We performed a literature review to evaluate whether or not surgical treatment improves survival.

METHODS

A systematic review according to PRISMA guidelines was performed. Studies reporting on patients who underwent surgical treatment for mKT from gastric cancer were selected. Metachronous disease was divided as follows: confined to the ovaries, confined to the pelvis, or beyond the pelvis. Outcomes evaluated included overall survival (OS), progression-free survival (PFS), resection rate (R0), and factors predicting survival.

RESULTS

13 retrospective reports fulfilled the selection criteria (512 patients). Most of the patients presented at a premenopausal age. The median presentation interval from gastrectomy ranged from 16 to 21.4 months. Median OS ranged between 9 and 36 months. 1-year OS ranged between 52.5 and 59%, and 3-years OS between 9.8 and 36.5%. Resection margin, peritoneal seeding, and chemotherapy regimen and cycles influenced survival.

CONCLUSION

Surgical treatment and adjuvant chemotherapy in patients with mKT from gastric cancer seems to be associated with improved survival and is justified especially in young patients. Disease location and R0 resection should be considered when selecting patients.

Pressurized intraperitoneal aerosol chemotheprapy after misdiagnosed gastric cancer: Case report and review of the literature

We report the first application of pressurized intraperitoneal aerosol chemotherapy (PIPAC) as a rescue therapy before palliative D2 gastrectomy combined with liver metastasectomy performed in a 49-year-old woman with peritoneal carcinomatosis who was primarily diagnosed with and underwent surgery for a Krukenberg tumor. The PIPAC procedure was performed with the use of cisplatin at 7.5 mg/m² and doxorubicin at 1.5 mg/m² for 30 min at 37 °C. Eight weeks after the PIPAC procedure, the patient underwent open classic D2 gastrectomy with the creation of a Roux-en-Y anastomosis (RNY) combined with liver metastasectomy. The patient underwent the classic protocol for chemotherapy combined with Xeloda. The patient felt better and returned to her daily activities. Multicenter data should be gathered to confirm the usefulness of PIPAC as a rescue or neoadjuvant supportive therapy in a very select group of patients who have been recently qualified to undergo classic chemotherapy or standard oncologic surgical procedures.

Pregnancy With Bilateral Metastatic Ovarian Tumour

Metastatic ovarian tumours are extremely rare. The commonest primary site is usually stomach and the metastasis from this site is termed as krukenberg tumour. It accounts for 1-2% of malignant ovarian tumours. We present a case of 14 weeks' pregnancy with metastatic bilateral malignant ovarian tumour is presented. Diagnosis was made on ultrasound. Tumour markers were insignificant. Patient underwent staging laparotomy with total abdominal hysterectomy and bilateral salpingo oophorectomy and partial omentectomy. She also had haematemesis. Endoscopy revealed suspicious growth in stomach, but biopsy report excluded it. Case was handed over to the oncologist for further management.

Misdiagnosed ovarian Krukenberg tumor during pregnancy with virilization

Krukenberg tumor with pregnancy is rare but it is a challenge for treatment and diagnosis. The authors report a case of a 29-week pregnant patient with a massive bilateral Krukenberg tumor which was misdiagnosed as myoma preoperatively and as ovarian stromal tumor intraoperatively. Prenatally the woman was asymptomatic except for preeclamptic symptoms, but red acne on the skin and elevated testosterone were observed. Pelvic ultrasound detected a heterogeneous solid mass mimicking a subserous myoma. The deterioration of preeclampsia prompted a cesarean section, but the neonate died nine days after he was born. A bilateral adnexal mass was found and considered as stromal tumor by frozen section because of luteinization of the stroma. The final pathology showed low differentiation adenocarcinoma of ovary, which was confirmed by gastric biopsies. The patient had undergone chemotherapy 16 times without surgical debulking and she was in generally well 1.5-year follow-up.

Comparison of Surgery Plus Chemotherapy and Palliative Chemotherapy Alone for Advanced Gastric Cancer with Krukenberg Tumor

PURPOSE

This study was conducted to validate the survival benefit of metastasectomy plus chemotherapy over chemotherapy alone for treatment of Krukenberg tumors from gastric cancer and to identify prognostic factors for survival.

MATERIALS AND METHODS

Clinical data from 216 patients with Krukenberg tumors from gastric cancer were collected. Patients were divided into two arms according to treatment modality: arm A, metastasectomy plus chemotherapy and arm B, chemotherapy alone.

RESULTS

Overall survival (OS) was significantly increased in arm A relative to arm B for patients initially diagnosed with stage IV gastric cancer (18.0 months vs. 8.0 months; p < 0.001) and those with recurrent Krukenberg tumors (19.0 months vs. 9.0 months; p=0.002), respectively. Metastasectomy (hazard ratio [HR], 0.458; 95% confidence interval [CI], 0.287 to 0.732; p=0.001), signet-ring cell pathology (HR, 1.583; 95% CI, 1.057 to 2.371; p=0.026), and peritoneal carcinomatosis (HR, 3.081; 95% CI, 1.610 to 5.895; p=0.001) were significant prognostic factors for survival.

CONCLUSION

Metastasectomy plus chemotherapy offers superior OS when compared to palliative chemotherapy alone in gastric cancer with Krukenberg tumor. Prolonged survival applies to all patients, regardless of gastric cancer stage. Metastasectomy, signet-ring cell pathology, and peritoneal carcinomatosis were prognostic factors for survival. Future prospective randomized trials are needed to confirm the optimal treatment strategy for Krukenberg tumors from gastric cancer.

Diagnostic value of dual detection of hepatocyte nuclear factor 1 beta (HNF-1β) and napsin A for diagnosing ovarian clear cell carcinoma

We evaluated the diagnostic value of hepatocyte nuclear factor 1 beta (HNF-1β) and napsin A for diagnosing ovarian clear cell carcinoma. Immunohistochemical EnVision was used to measure HNF-1β and napsin A expression in 38 cases of ovarian clear cell carcinoma, 30 cases of high-grade serous carcinoma, 22 cases of endometrioid adenocarcinoma, and 16 metastatic Krukenberg tumor cases. Then we found that HNF-1β appeared in all ovarian clear cell carcinoma and was less common in high-grade serous and endometrioid adenocarcinoma (P < 0.05). However, no significant difference in HNF-1β between clear cell carcinoma and metastatic Krukenberg tumor was found (P > 0.05). Napsin A was expressed in 97.4% of ovarian clear cell carcinoma, 6.7% high-grade serous carcinoma, 22.7% endometrioid adenocarcinoma, and 0% metastatic Krukenberg tumors. Napsin A in clear cell carcinoma was greater than that found in high-grade serous carcinoma, endometrioid adenocarcinoma, and metastatic Krukenberg tumor (P < 0.05). Sensitivity and specificity of HNF-1β and napsin A for diagnosing ovarian clear cell carcinoma was 100% and 54.4%, and 97.4% and 89.7%, respectively. Sensitivity and specificity of HNF-1β and napsin A for diagnosing ovarian clear cell carcinoma was 97.4% and 91.2%, respectively. So it is concluded that HNF-1β and napsin A are more sensitive than currently used markers for diagnosing ovarian clear cell carcinoma. Moreover, napsin A is more specific than HNF-1β. Combining HNF-1β and napsin A may distinguish clear cell carcinoma from high-grade serous carcinoma, endometrioid adenocarcinoma and metastatic Krukenberg tumors.

Krukenberg carcinoma metastasized from stomach resembling mucinous cystadenocarcinoma of the ovary

The ovaries are common site of metastasis in a variety of primary neoplasms. Multiple tumors such as breast, lung, and pancreas have been reported to metastasize to the ovary, however; the colon and stomach are the most common primary cancer sites that of ovarian metastasis. An ovarian mass mostly originates from its self-tissue, but sometimes it can be a metastasis of a gastrointestinal system tumor. Such cases are often misdiagnosed as primary ovarian cancers. A 42-year-old woman was admitted to our hospital with pelvic pain. She had a history of her complaints for two months. Bilateral large ovarian mass was detected in transvaginal ultrasound. Laparotomy was performed, the pathologist suggested inspection of the stomach after the frozen section analysis; therefore, an irregular mass on the stomach was detected. The general surgeon was attended to the operation, and an inoperative stomach tumor was reported by the general surgeon. After that due to the partial obstruction of jejunum, a gastrojejunostomy was performed. It is in fact difficult to distinguish between metastatic mucinous carcinomas and primary mucinous carcinomas of the ovary, due to the similar appearance of as cystic tumors on gross examination. The clinicians should be aware of the likely concomitant gastrointestinal system tumor when a large and bilaterally mass was detected on physical examination. This case also reminds that a systemic examination is necessary even if the large ovarian tumors suspicious of primary malignancy were noticed.

Comparison of nine morphological scoring systems to detect ovarian malignancy

PURPOSE OF INVESTIGATION

The aim of this study was to prospectively compare the diagnostic performances of nine gray-scale sonographic prediction models to detect ovarian malignancy.

MATERIALS AND METHODS

Clinical data of 322 women presenting with an adnexal mass were obtained and used in nine scoring systems. For each model a ROC curve demonstrating the capacity of the model to diagnose malignancy was constructed for all cases and for the subgroups of premenopause and postmenopause. The performance of each model was expressed as area under the ROC curve, sensitivity, and specificity.

RESULTS

The area under the ROC curve, sensitivity, and specificity of these models in the present study varied between 0.737 and 0.929, 70.7% and 87.9%, 60.2% and 80.3%, respectively.

CONCLUSIONS

This study has revealed the usefulness of morphological scoring systems to correctly discriminate between benign and malignant pelvic masses.

[Successful resection of recurrent lesions in a patient with ovarian torsion diagnosed with rectal cancer]

We report the successful resection of recurrent tumors, including brain metastasis, in a patient with StageIV rectal cancer. A 29-year-old female patient was admitted with lower abdominal pain to the gynecological department in April 2005. The patient underwent emergency surgery following the diagnosis of left ovarian torsion. She was transferred to the Department of Surgery with suspected rectal cancer based on a pathological diagnosis of a Krukenberg's tumor. She underwent surgery for local advanced cancer using high anterior resection, hysterectomy, right oophorectomy, partial ileal resection, and appendectomy. In September 2007, she underwent very low anterior resection for an anastomotic recurrence. The patient then received 6 courses of modified 5-fluorouracil Leucovorin oxaliplatin (mFOLFOX6) as adjuvant chemotherapy. In March 2009, left paresis was observed. She underwent tumor resection and g-knife radiosurgery for brain metastasis in the right temporal lobe. In December 2009, metastasis in the right rectal muscle was resected following diagnosis by computed tomography (CT). In September 2013, she underwent further surgical resection of a tumor recurrence in the right rectal muscle. The pathological diagnosis of each resected tumor was metastatic rectal cancer. The patient has been disease-free since the last operation.

Per magna-ovarian metastases from primary locally advanced colorectal cancer--a review of the literature with a description of three clinical cases

Krukenberg tumor is defined as metastatic lesions of gastrointestinal cancers. Several specific immunohistochemical methods can identify the main focus of malignant neoplasm. Ovarian metastases from colorectal cancer are rarely seen phenomenon. The authors examine in detail the literature on this issue and describe three own clinical cases of metachronous ovarian meta lesions in women undergoing surgery for locally advanced colorectal cancer--two of these metastases are unilateral, while one--bilateral established in a short time interval despite the casuistic nature of the pathology. One of the patients died in the early postoperative period of co-morbid complications unrelated to the underlying disease, and the other two monitoring continues during the adjuvant. Krukenberg-metastases from colorectal cancer occur in the blood-vascular pattern in time without damage to the left or right ovary. Metachronous development and operative treatment of ovarian metastases is far better prognosis of the cases with and operated simultaneously established metastases in the ovaries.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy improves the survival of gastric cancer patients with ovarian metastasis and peritoneal dissemination

The prognosis for ovarian metastasis of gastric cancer is poor. There is no currently available treatment for this disease. The purpose of this study was to evaluate the efficacy and safety of hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery (CRS) in female gastric cancer patients with metachronous ovarian metastasis. From January 2000 to December 2010, 62 patients developed ovarian metastasis after undergoing gastrectomy with D2 lymphadenectomy. Thirty-two patients underwent CRS plus HIPEC, and 30 patients underwent CRS alone. The median age of all 62 patients was 44 years (range 19-71 years). Metastatic carcinoma involving bilateral ovaries was observed in 50 patients (80.6 %). The median survival time in the CRS + HIPEC group was 15.5 months (95 % confidence interval [CI] 12.1-18.9 months) but was only 10.4 months (95 % CI 8.5-12.2 months) in the CRS group (P = 0.018). Among the 32 patients with pelvic peritoneal metastasis, a stratified analysis revealed that the median survival period for the 15 patients treated with CRS + HIPEC was significantly higher than that for the patients treated with CRS alone (P = 0.046). Among the 30 patients who suffered from ovarian metastasis alone, the median survival times were similar in both groups (P = 0.141). A multivariate analysis revealed that CRS + HIPEC and a low Peritoneal Cancer Index (PCI) were independent predictors for improved survival. In conclusion, our study indicates that employing the HIPEC procedure after CRS could improve the survival time of patients with ovarian metastasis with few complications; however, we do not recommend HIPEC treatment for ovarian metastasis alone.

Metastasectomy of Krukenberg tumors may be associated with survival benefits in patients with metastatic gastric cancer

BACKGROUND

The current standard treatment for patients with metastatic gastric cancer (MGC) is systemic chemotherapy. For gastric cancer patients with ovarian metastases, i.e. Krukenberg tumors, it is not known whether metastasectomy is associated with additional benefits.

PATIENTS AND METHODS

All patients who were diagnosed with gastric cancer and ovarian metastases between March 2000 and July 2010 in a medical center were included in the current study. The clinicopathological features and the treatment records were reviewed in detail and their association with overall survival (OS) was analyzed.

RESULTS

A total of 85 patients were identified. Thirty five (41.2%) and 50 (58.8%) patients did and did not undergo metastasectomy of Krukenberg tumors, respectively. The performance status and the proportion of patients receiving subsequent systemic therapy were well-matched between the two groups. Regarding disease status, patients who underwent metastasectomy had significantly larger Krukenberg tumors, pronounced bilateral disease and less extensive metastases outside the ovaries than patients who did not undergo metastasectomy. Patients who underwent metastasectomy had a better OS [median=14.1 months; 95% confidence interval (CI)=8.6-19.6 months] than patients who did not undergo metastasectomy (median OS=8 months; 95% CI=5.6-10.4 months, p=0.001). There was no aberrant postoperative morbiditie rate observed, and the median length of hospital stay after metastasectomy alone was 6 days. Based on multivariate analysis, metastasectomy remained an independent predictor of better OS (hazard ratio=0.36, p=0.002). The administration of subsequent systemic therapy, the use of platinum-based chemotherapy, and a better performance status also predict a better OS.

CONCLUSION

Metastasectomy of Krukenberg tumors may be associated with survival benefits in patients with MGC. Further prospective studies are warranted.

Krukenberg tumor: report of two cases

Krukenberg tumor (KT) is a metastatic signet-ring adenocarcinoma of the ovary with variants of gastro-intestinal primary either detected synchronously or metachronously. Here two cases of Krukenberg tumor are reported with detected primary sites, one arising from the stomach and the second from the pancreas. The first case, a 35 year old multiparous woman with a past history of endoscopically proven gastric ulcer was diagnosed as a case of advanced gastric carcinoma with concomitant right adnexal mass. Endoscopic biopsy from the gastric growth revealed adenocarcimona (signet ring variety). As the primary gastric growth was not feasilble for surgical resection, palliative total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathology of the ovary revealed metastatic adenocarcinoma with negative peritoneal cytology. After 4 cycles of chemotherapy, the patient died due to progression of primary cancer. The second patient, a 55 year old menopausal lady was diagnosed as a case of metastatic ovarian tumour with recurring ascitis upon chemotherapy. Comprehensive scanning revealed a thick walled lesion in the left side of the body and tail of the pancreas along with a left adnexal mass. Upon surgical exploration a vascular solid mass was identified in the pancreas which was not feasible for any sort of resection. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Poorly differentiated adenocarcinoma was found in the apparently shriveled up right ovary with positive peritoneal cytology. She succumbed to death due to reappearance of epigastric pain and haemorrhagic ascitis.

Acute abdomen secondary to torsion of Krukenberg tumour

Krukenberg tumour is a rare clinical entity. We report an unusual case of acute abdomen due to right sided adnexal torsion in a 23 year old nulliparous girl with bilateral Krukenberg tumour and primary gastric carcinoma. Possibility of Krukenberg tumour should always be kept in mind while managing ovarian tumours.

Krukenberg tumor of gastric origin in pregnancy with dismal outcome

Krukenberg tumors are mostly found as metastatic signet-ring cell adenomucinous carcinomas in young, premenopausal women. They are bilateral in 80% of the cases, and thus can be expected in pregnancy. A 31-year-old female was diagnosed by explorative laparotomy at 27 weeks of gestation with a Krukenberg tumor due to bilateral adnexal masses and a large amount of ascites. At surgery cesarean section with total abdominal hysterectomy, bilateral salpingo-oophorectomy, total omentectomy and pelvic lymphadenectomy was performed. The neonate died 24 hours later due to prematurity and respiratory distress syndrome. The primary site of the cancer was detected metachronously two months after surgery and postoperative chemotherapy, as stomach adenomucinous carcinoma. In spite of surgery and postoperative multiagent chemotherapy, the patient died six months from the diagnosis of Krukenberg.

Clinical significance of VEGFR-2 and VEGFR-3 expression in ovarian cancer patients

The vascular endothelial growth factor (VEGF) family and VEGF receptors (VEGFR) play an essential role in angiogenesis and lymphangiogenesis. The aim of this study was to clarify the prognostic significance of VEGFR expression in ovarian carcinoma. Levels of VEGFR-2 and VEGFR-3 tissue expression in human ovarian tumours were assayed by immunoblotting and the correlations between analysed factors and clinicopathological features were examined. Tissue samples consisted of 42 benign and 10 borderline (low malignant potential - LMP) tumours, 76 ovarian carcinomas, 8 Krukenberg tumours and 32 normal ovarian tissues. The highest relative level of VEGFR-2 was detected in cases with at the early stages of cancer development. The highest level of VEGFR-3 was detected advanced cancer stages and those with Krukenberg tumours. Overexpression of VEGFR-3 was found to correlate with the debulking status (p = 0.02) and positive response to chemotherapy (p = 0.04). A statistically significant longer progression free survival (PFS) was observed in women with a low than with a high expression of VEGFR-3 (p = 0.01). Increased levels of VEGFR-2 expression at the early stages of ovarian cancer may indicate the significance of neoangiogenesis at these stages. Overexpression of VEGFR-3 reflects the aggressiveness of ovarian carcinoma spread and has a predictive value for identifying high-risk patients with poor prognosis.

Virilizing ovarian Krukenberg tumor in a 27-year-old pregnant woman. A case report and literature review

A case is reported of a 27-year-old pregnant woman with ovarian tumors, measuring 12 cm and 11.5 cm in the greatest diameter, discovered during investigation for virilization symptoms. Termination of the pregnancy at the 22nd week of gestation and tumorectomy with both adnexa were performed, with the provisional diagnosis of arrhenoblastoma. Pathological examination of the tumors showed typical Krukenberg neoplasms and subsequent upper GI tract endoscopy revealed a gastric cancer that was excised. The pathological examination revealed a diffuse type gastric adenocarcinoma with signet ring morphology, similar to ovarian tumors. In any case of ovarian tumor with unusual hormonal manifestations, in addition to hormonally active sex cord-stromal neoplasms, metastatic ovarian tumors must be considered as well, especially in cases of bilateral tumors.

Krukenberg tumour simulating uterine fibroids and pelvic inflammatory disease

OBJECTIVE

To report a case of cancer of the colon which presented as secondaries to the ovaries.

METHOD

Case report.

SUMMARY

The case presented is that of a 39-year-old female who presented with lower abdominal pain and a multinodular pelvic mass which led to an initial diagnosis of multiple uterine fibroids and pelvic inflammatory disease. The presence of a colonic mass was first suggested by ultrasound. Laparotomy revealed carcinoma of the colon with bilateral krukenberg's tumour and an insignificant fibroleiomyoma.

CONCLUSION

This case is reported to alert practitioners that all multinodular pelvic masses should not be assumed to be multiple fibroids.

[Krukenberg tumor--8 years after surgical treatment of gastric carcinoma]

The aim of the study was to discuss the case of Krukenberg tumor in a patient, eight years after the diagnosis and surgical treatment of gastric carcinoma. We have concluded that there was no safe period after which distant metastases may be excluded. In case of gastric carcinoma diagnosed in women, a regular gynecological examination is necessary due to a high propability of metastases into ovaries, even if the clinical stage of gastric carcinoma is low.

[Comparison of clinicopathological features and operative prognosis of gastric carcinoma complicated with Krukenberg tumor and with pelvic peritoneal dissemination]

OBJECTIVE

To compare the clinicopathological characters and operative prognosis of gastric cancer complicated with Krukenberg tumor and with pelvic peritoneal dissemination.

METHODS

Thirty-nine female cases of gastric carcinoma with pelvic metastasis were treated operated on between August 1994 and March 2006. Among them, 18 cases were complicated with Krukenberg tumor and 21 cases with pelvic peritoneal dissemination. The clinicopathological characters in the two groups were recorded and compared and the operative prognosis were analyzed.

RESULTS

There was no significant difference in age, tumor location and size, hepatic metastasis, organic encroachment, infiltration degree, positive lymph nodes, differentiated degree, tissue typing, Borrmann typing, value of carcinoembryonic antigen between the two groups (P > 0.05). The rate of P3 (peritoneal dissemination) in the cases of Krukenberg tumor (44.4%) was significantly lower than that in pelvic peritoneal dissemination group (85.7%) (P < 0.01), whereas the focal resection rate (77.8%) and multi-organ dissection rate (55.6%) were significantly higher than in pelvic peritoneal dissemination (38.0%, 23.8%) (P < 0.05). The mean survival of all cases was 12.6 months. The mean survival in the patients with Krukenberg tumor and pelvic peritoneal dissemination was 20.5, 15.0 months, respectively (P < 0.05). The mean survival of total focal resection, palliative focal resection, non-focal resection was 19.9, 12.5 and 5.7 months, respectively (P < 0.01). Non-focal resection, pelvic peritoneal dissemination, P3 of peritoneal implantation, hepatic metastasis, organic encroachment, total gastric cancer were unfavorable prognosis factors for all cases.

CONCLUSIONS

Compared with pelvic peritoneal dissemination, the gastric cancer with Krukenberg tumor is associated with more limited peritoneal dissemination, higher resection rate and better prognosis. Focal resection can improve the prognosis.

Metastatic ovarian tumour in patient of carcinoma stomach

Krukenberg tumour (KT) is a metastatic ovarian tumour with primary usually seen in the gastrointestinal tract. Here we report the case of a 50-year old menopausal patient with gastric tumour presenting with solitary metastasis to the ovary within 5 months of primary gastric surgery, for which total abdominal hysterectomy with bilateral salpingo-oophorectomy was done. This case stresses the urgent need for early detection and surveillance of treatable tumours metastasising to the ovary.

[Features of Krukenberg-type tumors--clinical study and review]

Krukenberg-type tumors (KT) are rare among ovarian metastases, but responsible for the most frequent diagnostic confusions with ovarian cancer. They are peculiar: uncertain pathogenesis, challenging etiological diagnosis, poorer prognosis for the primary. We studied 9 cases, with a mean age of 52 years, operated since 2001; no case was discovered as a result of prophylactic oophorectomy. Timing of TK diagnosis: 3--metachronous, 4--synchronous, as incidental discovery and 2--retrospective pathological diagnosis. Site of primary: 3--gastric, 5--colonic or appendiceal, 1--breast. Imaging appearance was useful only if interpreted in clinical conditions. Morphology: 7/9 bilateral, solid or mixed gross appearance, oval, mean diameters 9.4/7.8 cm. Microscopy: in 8 KT of digestive origin, 3--signet-ring cell carcinoma, 3--mucinous adenocarcinoma, 2--mixed pattern; 1 KT or breast origin was diagnosed by immunohistochemistry; 6/9 presented microscopic peritoneal despite a lack of strong correlation with the appearance of carcinomatosis or cytology of ascites. Survival: 3--no evidence, 5--disease-free after 4-13 months, 1--survived 2 years after debulking (4 years after colectomy). Clinical, evolutive and prognostic features of KT are determined by the biologically behavior of the primary (rapid lymphatic and hematogenous spread to the ovary), so the benefit of surgery is limited. Bilateral ovarian tumors, particularly in premenopausal women, must raise a high index of suspicion for KT, before or during surgery; diagnosis is a team challenge.

A patient with 43 synchronous early gastric carcinomas with a Krukenberg tumor and pericardial metastasis

A 53-year-old Japanese woman with bilateral ovarian tumors consulted our department. Gastroendoscopy disclosed 16 superficial depressed gastric lesions, and the histopathological diagnosis of the biopsy specimens was poorly differentiated adenocarcinoma and signet-ring cell carcinoma. Computed tomography (CT), ultrasonography (US), and positron emission tomography (PET) examinations revealed no other metastasis except for that observed in the ovaries. We performed a total gastrectomy with radical lymph node dissection and bilateral ovarian resection. A postoperative histological examination revealed 43 isolated gastric lesions which were scattered over the entire resected stomach; they were all confined to the mucosa. Cancer cell invasion in the lymphatics was detected only in the submucosal region beneath the main tumor. Both ovarian tumors were diagnosed as metastasis of signet-ring cell carcinoma (Krukenberg tumor). Adjuvant chemotherapy with irinotecan (CPT-11) and low-dose cisplatin (CDDP) was given on an outpatient basis, but 1 year after the surgery, carcinomatous pericarditis occurred. Administration of mitomycin C (MMC) into the pericardial space was performed twice; however, unfortunately, the patient died 13 months after surgery.

[Krukenberg tumors of gastric origin versus Krukenberg tumors of colorectal origin]

The aim of this study was to analyze the incidence and origin of Krukenberg tumors in our region to determine their clinical behavior and to compare some anatomo-clinical features of Krukenberg tumors of gastric origin versus those of colorectal origin. This is a retrospective, descriptive and comparative study of Krukenberg tumors diagnosed and treated in the IV-th Surgical Clinic of Cluj-Napoca. The epidemiologic features concerning global incidence, age, and menopausal status overlap the data from literature. Characteristic for our series of cases were the higher incidence of Krukenberg tumor of colorectal origin compared with those of gastric origin , significantly more frequent bilaterality of lesions of gastric origin and the prevalence of the unilateral left ovarian localization for Krukenberg tumors of colorectal origin. The differences in anatomo-clinical behavior between the Krukenberg tumors of gastric and colorectal origin may indicate different pathways of metastasizing and seeding.

[The Krukenberg tumor caused by an adenocarcinoma of the gallbladder]

This work presents the case of a 62 year-old woman's Krukenberg tumor caused by an adenocarcinoma of the gallbladder. This was the presumptive diagnosis that was confirmed during the operation. The characteristic feature of this case consists of the rarity of the Krukenberg tumors caused by a cancer of the gallbladder, the paraneoplastic pleurisy and the presence of the cells with "a ring with a seal" in the pleural liquid and in the ascites liquid. The paraclinical investigations (echography, computerised tomography) were not able to specify the diagnosis before the operation. The surgical intervention (cholecystectomy and total hysterectomy with bilateral adnexectomy) has had favourable consequences. Nevertheless, the woman died 5 months after the operation.

[Krukenberg tumour: diagnostic findings and surgical therapy. Recent acquisitions]

The authors report on their experience with two cases of Krukenberg's tumour treated at Chioggia Hospital in patients admitted for pelvic tumours. The clinical manifestation of Krukenberg's tumour is mainly related to the presence of the pelvic mass even in advanced forms of gastrointestinal cancers. The authors stress the importance of an adequate follow-up of premenopausal patients with a previous gastrectomy for adenocarcinoma because the incidence of ovarian metastases is quite frequent and influences the prognosis. The Authors do not consider a bilateral preventive ovariectomy associated with gastrectomy as advisable in premenopausal patients, because the studies to date are inadequate for the purposes of drawing conclusions regarding the benefit of these procedures. They consider a more valid policy to be a thorough follow-up in women with a previous gastrectomy for adenocarcinoma because the priority must be accorded to diagnosing secondary lesions so as to be able to perform an ovariectomy which may improve the prognosis. With this in mind it is important to assess Ca 19.9 and perform radiological procedures, such as CT and MRI. The prognosis may be distinctly unfavourable as in one of the cases reported by the Authors involving a very rare form of secondary lesion of the bone marrow and consequent medullary aplasia, with the onset of severe haemorrhages in several areas leading to the patient's death. They consider that surgical treatment should be preceded by a diagnostic laparoscopy. When there are other concomitant negative prognostic factors such as neoplastic ascites and perineal carcinosis, ovariectomy will prove ineffective from the prognostic point of view.

Krukenberg tumor mimicking pregnancy luteoma

BACKGROUND

Pregnancy-associated Krukenberg tumor is very rare, and the diagnosis in pregnancy is even more difficult. Usually symptoms are attributed to pregnancy luteomas, which are hormone-active benign neoplasms.

CASE

A 22-year-old female presented at the 28th week of gestation with rapid onset of hirsutism and acne since the 20th week of gestation. Physical and ultrasonographic examinations revealed bilateral ovarian solid masses which were considered as pregnancy luteomas. The patient underwent exploratory laparotomy due to the onset of ascites and elevated tumor markers four months after delivery. Histopathologic examination revealed adenocarcinoma with signet-ring-type cells.

CONCLUSION

Krukenberg tumors should be considered in the differential diagnosis of pregnancy luteomas. Otherwise, early diagnosis of the tumor can be delayed.

[A case of long-term survival of 3-years 4 months after combination chemotherapy of MTX, 5-FU and low-dose CDDP (MFP) for type 4 gastric cancer with pleuritis, peritoneal dissemination and Krukenberg tumor]

A 41-year-old woman presented to the Department of Obstetrics and Gynecology of our hospital because of abdominal distension and irregular genital bleeding. Computed tomography and ultrasonography of the abdomen revealed bilateral ovarian tumors, massive ascites, and bilateral pleural effusion. Type IV advanced gastric cancer was diagnosed on upper gastrointestinal endoscopy. The patient was admitted to our department. She received 3 courses of combination chemotherapy with methotrexate, 5-fluorouracil, and low-dose cisplatin. Pleural effusion and ascites disappeared. Surgery (total gastrectomy, resection of the tail of the pancreas, lymph-node dissection, total hysterectomy, and adnexectomy) was performed, and the patient was discharged. Chemotherapy was repeated after surgery. Lymph-node metastasis recurred 1 year 8 months after the start of chemotherapy. Treatment was switched to irinotecan plus cisplatin, and the lymph nodes shrank. After 9 months, 3 courses of TS-1 were administered. Two years 10 months after starting chemotherapy, abdominal and low back pain developed. Bone scintigraphy revealed bone metastasis. Lymph node swelling was present. The patient responded to radiotherapy with chemotherapy (cisplatin plus 5-fluorouracil). Subsequently, abdominal computed tomography showed lymph-node swelling, multiple metastases to the liver, ascites, and a right pleural effusion. She was readmitted to the hospital and received intraperitoneal chemotherapy with cisplatin. Her condition deteriorated, and she died. The patient survived for about 3 years 4 months after the start of treatment. Chemotherapy with methotrexate, 5-fluorouracil, and low-dose cisplatin may thus be an effective therapeutic option in patients who have advanced gastric cancer with peritoneal dissemination.

[Clinical analysis of patients with Krukenberg tumor of the ovary]

OBJECTIVE

The aim of this study was to analyze clinical data such as diagnosis, surgical treatment and follow-up of patients with Krukenberg tumor (KT). We also reviewed literature of the subject.

MATERIAL AND METHODS

We retrospectively analyzes medical data of 34 patients who were operated in Gynecology Clinic of Medical University of Gdansk in years 1999-2003. The definition of KT was that of Krukenberg's.

RESULTS

The mean age of patients was 52, 23 of them were postmenopausal. Fourteen patients were diagnosed with malignant disease before surgery for ovarian tumor--11 were treated for breast cancer, 2 underwent resection of the stomach and one had rectosigmoidectomy. Before surgery a diagnosis for ovarian tumor such as ultrasonography, computer tomography and Ca125 were performed--in most cases sonography findings revealed mixed cystic and solid tumor of 320 cm in diameter; in 70% cases serum Ca125 was elevated with the highest result of 772 IU/ml. From among 20 patients who were suspected for primary ovarian cancer with no other malignant disease before surgery 9 had stomach cancer, 6 colon cancer, in 2 cases ovarian tumor was a metastasis from breast and in 1 from gall bladder; in 2 patients primary tumor was not found. The surgery performed in patients with KT was that of done for primary ovarian cancer. In 5 cased partial resection of colon was necessary. Surgical findings revealed ovarian tumor of 3-10 cm in diameter, solid and bilateral in most cases. The mean survival in our group was 4,7 months. The mean time between diagnosis of malignant disease and metastases to the ovary was 18 months. The best overall prognosis was for patients with breast cancer and the worst for cases with stomach cancer.

CONCLUSIONS

There is a poor prognosis for patients with Krukenberg tumor. The diagnosis is late, in most cases during surgery for ovarian tumor. The most often site of primary malignancy was breast and stomach.

[Krukenberg tumor - common problem of gynecologists, surgeons oncologists and pathologists. Report of three cases and review of the literature]

Ovarian cancer constitutes one of the most frequent malignant tumours in the female population not only in Poland. The screening of this tumour type is unsolved. The tumours are usually diagnosed in the advanced stage, thus the survival rate are usually poor. Their histopathological appearance has a wide variety, with the occurrence of numerous metastatic forms. Among the metastatic tumours, the primary tumours of the digestive tract occur the most frequently. They are known as the Krukenberg tumours. In these cases the choice of treatment is more difficult and prognosis is also worse in most cases with fatal outcome in one year. Early diagnosis and complete resection is the only possible hope. In this paper authors present three cases of Krukenberg tumour with nonspecific symptoms, difficulties during diagnostics, late beginning of treatment and poor prognosis.

[A case of advanced gastric cancer with lymphangitis carcinomatosa after operation of Krukenberg tumor treated by TS-1 plus CPT-11 as third-line chemotherapy]

Chemotherapies for recurrent gastric cancer have not yet been established. Here we report a case of type 4 gastric cancer associated with lymphangitis carcinomatosis which became refractory to the previous chemotherapies. The case was a 40-year-old woman. She had been diagnosed with gastric cancer after a Krukenberg tumor operation. Chemotherapies (TS-1 plus CDDP as first-line, and TS-1 plus taxanes as second-line) were performed, and a partial response was achieved. Disease activity has been well controlled until this time. Since recurrence of left pleural effusion and lymphangitis carcinomatosis was recognized, we changed the chemotherapy TS-1 plus CPT-11. Pleural effusion decreased and lymphangitis carcinomatosis improved. The serum CA 19-9 level rose transiently after CPT-11 administration, and tended to fall at the second week of chemotherapy. However, the patient died 2 years 4 months after the onset. TS-1 plus CPT-11 combination chemotherapy would be effective for lymphangitis carcinomatosis and also useful as third-line chemotherapy for recurrent gastric cancer.

A long surviving case of Pseudomeigs' syndrome caused by Krukenberg tumor of the stomach

Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolve after resection of the tumor. Pseudomeigs' syndrome is a serious disease characterized by malignant ovarian tumor, but ascites and hydrothorax usually reveal no malignant cells. Here, we report a 47-year-old pre-menapausal female patient with cardia cancer. Nearly 14 months after D3 dissection, she developed Krukenberg tumors on both ovaries causing a Pseudomeigs' syndrome with benign ascites and right hydrothorax, which resolved dramatically after resection of the tumors and rectouterine pouch peritonectomy. She survived nearly 3 years after metastasectomy with a total survival of 46 months. The patient died because of massive liver metastases. The present case suggests that Pseudomeigs' syndrome should be considered in patients with Krukenberg tumors, ascites and hydrothorax and that resection of the tumors may bring long-term palliation.

Survival benefit of metastasectomy for Krukenberg tumors from gastric cancer

OBJECTIVE

An optimal treatment strategy for ovarian metastases of gastric cancer has not been clearly established. The aim of this study was to examine the role of a metastasectomy in the management of metachronous Krukenberg tumors after curative surgery for gastric cancer.

METHODS

Among 1235 female patients who had undergone a curative gastric resection for stomach cancer between 1987 and 1998, 54 (4.4%) developed Krukenberg tumors as a first recurrence without evidence of a distant metastasis. Of these 54 patients, 33 underwent a metastasectomy while 21 did not. The survival duration between the two groups was analyzed and compared.

RESULTS

The clinicopathological features of Krukenberg tumors as well as those of the primary cancers in the two groups were similar. All 33 patients in the resection group underwent subsequent adjuvant chemotherapy, including the 7 who received intraperitoneal chemotherapy. The 21 patients in the non-resection group were managed by either systemic chemotherapy (n = 16) or supportive care (n = 5) alone. The median survival duration of all the patients was 9 months (95% confidence interval, 3-15 months). The median survival time in the resection group was 17 months (95% confidence interval, 10-24 months), which was significantly longer than that in the non-resection group, 3 months (95% confidence interval, 2-4 months) (P < 0.001).

CONCLUSION

Our results suggest that a metastasectomy was associated with an improved survival in patients with metachronous Krukenberg tumors from gastric cancer. These data offer a strong argument in favor of performing metastasectomy for Krukenberg tumors in the absence of an obvious distant metastasis.

Management of postoperative follow-up and surgical treatment for Krukenberg tumor from colorectal cancers

BACKGROUND/AIMS

The purpose of this retrospective study was to evaluate the clinical presentation as well as surgical intervention for ovarian metastasis from colorectal cancers identified during postoperative follow-up.

METHODOLOGY

Nine cases of ovarian metastasis were observed among 452 female patients with colon cancers between 1990 and 2000. Initial symptoms were pain (67%), pelvic mass (50%), vaginal bleeding (33%), and uterine bleeding (17%). On pathological evaluation, six cases (67%) were found to be moderately differentiated, and three (33%) well differentiated adenocarcinomas.

RESULTS

Early diagnosis is very difficult. The growth of metastatic ovarian tumors are slow in elder patients, its growth is rapid in younger patients, and frequently diagnosed as huge ovarian tumors. In some cases, as cystic ovarian lesions they were identified in their early stage but could not be diagnosed as ovarian metastases, later curative operation could not be performed. The consulting gynecologist could not reach the correct diagnosis. Regular postoperative pelvic CT or MRI should be helpful for diagnosis. Although serum CEA levels did not increase in most cases, tumor markers CA125 and SLX were elevated in several cases, and thus may be useful for the detection of ovarian metastases. Surgical treatment consisted of bilateral and unilateral salpingo-oophorectomy or pelvic exenteration and additional hysterectomy for one patient because of association with cervical cancer. The median survival time after the primary operation was 20.8 months, ranging from 3 to 96 months. Peritoneal dissemination and bone metastases were frequently observed as recurrence after these operations. Two cases (non-synchronous solitary metastasis or direct involvement, located in the pelvis) survived more than 5 years (85 and 96 months, respectively), and both patients were treated with pelvic exenteration.

CONCLUSIONS

This suggests that in general most cases with ovarian metastasis have a poor prognosis and that radical operation such as pelvic exenteration can improve survival only in cases of recurrent solitary ovarian metastasis or local extended disease, i.e. when the lesion is located only in the pelvis.

[A 52 year-old woman with fever, cough and dyspnoea]

A 52 year-old woman with gastric cancer treated with surgery and chemotherapy, is admitted in our Internal Medicine Department because of the presence of fever (max 41.2 degrees C), dyspnoea, non-productive cough and mental confusion. The anamnesis and the physical examination address to the diagnosis of CAP (Community-Acquired Pneumonia); in particular the alteration of consciousness and the onset of symptoms after the insertion of a nose-gastric tube let us to consider the diagnosis of aspiration pneumonia. The clinical presentation and radiological imaging (Rx and CT of thorax) suggest the pattern of bronchiolitis obliterans with organizing pneumonia (BOOP). BOOP is not a disease, but a non specific pattern of answer to a lung injury. It can be either idiopathic or associated with a variety of causes, such as infections, drugs, radiations and connective tissue diseases. Besides the clinical course is complicated by the onset of an ARDS (Adult Respiratory Distress Syndrome). The gold standard for the diagnosis is represented by lung biopsy with hystopathologic confirmation but, if it cannot be done, it's necessary to start immediately steroid therapy because BOOP may be fatal. The patient received antibiotic and steroid therapy with success.

Surgical management and outcome of metachronous Krukenberg tumors from gastric cancer

BACKGROUND AND OBJECTIVES

The question of whether resection should be performed in Krukenberg tumors from gastric cancer has yet to be adequately examined. Despite some reports on the surgical treatment of Krukenberg tumors, the outcomes after resection are not well characterized.

PATIENTS AND METHODS

Using a gastric cancer database, a total of 34 patients who underwent a resection of metastatic ovarian tumors after curative surgery for gastric cancer were identified. A prospective database of these patients was reviewed for the presentation, clinical features, and outcomes after resection.

RESULTS

The median age of 34 patients was 44 years (range, 24-66). The majority of patients was in the premenopausal state and had bilateral ovarian involvement. The most common presenting symptom was an abdominal mass (35.3%). Tumor size ranged from 3.5 to 20 cm with 61.8% measuring larger than 10 cm. In 17 patients who had metastatic disease confined to the pelvis, a complete gross resection (R0) was achieved. In the other 17 with the disease beyond the pelvis gross residual tumors remained after the resection (R1). The median survival of all patients was 11 months (95% confidence interval [CI] 8-14), and that of the patients rendered R0 was 18 months (95% CI, 14-22), in comparison with 9 months (95% CI, 3-15) for those with R1 resection (P = 0.0001; log-rank test). The median progression free survival was also significantly longer for the patients with R0 resection than those with R1 resection (8 months, 95% CI, 5-11 vs. 5 months, 95% CI, 4-6, P = 0.0103). Multivariate analysis identified R0 resection as the only significant factor predictive of survival.

CONCLUSIONS

In the management of Krukenberg tumors after gastric cancer, a metastasectomy may significantly improve the overall and progression free survival if it could render a complete gross resection. To define the patient group that benefits most from resection, the extent of disease and resectability must be carefully evaluated before surgery.

[Two patients with metastatic ovarian tumor (Krukenberg's tumor) of gastric origin who underwent oophorectomy with paraaortic and intrapelvic lymph node dissection]

We report 2 patients with metastatic ovarian tumors of gastric origin who underwent oophorectomy with paraaortic and intrapelvic lymph node dissection, and showed a relatively good outcome. Case 1 A 40-year-old female with gastric cancer located in the MULE area underwent total gastrectomy with D3 lymph node dissection on June 2, 1989. Pathological Stage was IIIB and curability was B according to the JGCA classification. In month 56 after surgery, a left ovarian tumor was detected, and bilateral oophorectomy with paraaortic and intrapelvic lymph node dissection was performed. Signet ring cell carcinoma from the stomach was confirmed in both left ovary and lymph node around the left external iliac artery. In month 51 after the oophorectomy, the patient died from carcinomatous peritonitis. Case 2 A 23-year-old female with gastric cancer located in the M area underwent distal gastrectomy with D3 lymph node dissection on November 1, 2000. Pathological Stage was IV and curability was B according to the JGCA classification. In month 19 after surgery, a left ovarian tumor was detected, and left oophorectomy with paraaortic and intrapelvic lymph node dissection was performed. Poorly differentiated adenocarcinoma from the stomach was confirmed in both left ovary and paraaortic lymph nodes. Chemoradiation therapy was performed for the bone metastasis in lumbar vertebra, which was detected in month 4 after the oophorectomy, and partial response was achieved. As of June 2003, no other malignant lesion has been detected.

[A case of type 4 gastric cancer, diagnosed after operation for Krukenberg's tumor, treated by TS-1 plus low-dose cisplatinum]

Survival of patients with advanced gastric cancer with Krukenberg's tumor is poor. We report the case of a good response in a 37-year-old woman who had type 4 gastric cancer, diagnosed after the operation of Krukenberg's tumor, and then was treated with TS-1, a DPD inhibitory fluoropyrimidine, in combination with a low-dose cisplatinum (CDDP). Endoscopic gastric biopsy showed signet-ring cell adenocarcinoma and moderately differentiated tubular adenocarcinoma, and computed tomography (CT) showed the para-aortic lymph node metastasis before the chemotherapy. The patient was treated with two courses of TS-1 (100 mg/day, day 1-21) plus CDDP (10 mg/m2, day 1-5, 8-12, 15-19) with two-week interval. After the first course, gastric biopsy did not show any cancer cells and lymph node metastasis had disappeared. Serum CA19-9 decreased gradually week by week during the chemotherapy, even during the washout period after the first course, and was normalized after two courses. This case suggests that the combination of TS-1 and low-dose CDDP is effective against type 4 advanced gastric cancer.

Krukenberg's tumor, three years after a colic carcinoma

We report a case of left ovarian Krukenberg's tumor in a 65 year-old patient, three years after resection of a colonic carcinoma (pT3, G2, pN1, Stage 3, Dukes C). The case is briefly discussed with reference to the literature. Krukenberg's tumor usually occurs in younger patients, with a peak frequency before 40 years. Both ovaries are involved in 90% of cases. Pathogenetically the ovarian involvement arises either from hematogenous, lymphatic spreading or from contiguous extension from the primary colonic tumor. There may be some anatomic predispositions such as utero-ovarian vessel anastomosis in the ligamentum latum or by peritoneal adhesions.

Management and outcome of pregnancies complicated with adnexal masses

Our purpose was to evaluate the pathologic features and outcome of pregnancies that were complicated with adnexal masses and were managed surgically. A review of patients who had persistent adnexal masses during pregnancy and needed surgical removal of tumours was performed from January 1998 to April 2001. There were 14 cases of persistent adnexal masses identified among 2000 deliveries. There were 13 patients who had surgical interventions: nine (69.2%) had surgery during ongoing pregnancy (at mean gestational age 17+/-3.7 weeks), two (15.3%) with caesarean section, one (7.6%) after evacuation of missed abortion and one (7.5%) after delivery. Out of 13, ten (76.9%) were benign [mature cystic teratoma, six (46.9%); serous cyst adenoma, two (15.3%); mucinous cyst adenoma, one (7.6%); paratubal cyst, one (7.6%)] and three (23%) were malignant (one immature teratoma, one papillary cyst adenocarcinoma and one krukenberg tumour]. Both patients operated on after 24 weeks had pre-term delivery. The worst outcome in the form of PPROM and preterm delivery at 28 weeks occurred in a patient who underwent emergency surgery. The incidence of malignancy was four- to fivefold greater in our series than reported in the literature. Ultrasound was unable to distinguish malignant cases. Pregnancy outcome was poorer if surgical intervention was done after >24 weeks and that, too, was done as emergency surgery.

[Krukenberg tumor: 9 cases report]

INTRODUCTION

The Krukenberg tumor is a mysterious ovarian metastasis of digestive tract cancer accounting from 1 to 2% of all ovarian tumors.

PATIENTS

and method. We report a series of 9 patients with Krukenberg tumors treated at the Casablanca University Hospital between 1982 and 1999.

RESULTS

Mean age of the patients was 44 years. Pelvic signs predominated over digestive signs. Bilateral forms were more frequent. Surgical or medical treatment were given. The histological diagnosis is based on the presence of signet-ring cells associated with a pseudosarcoma stroma. The primary tumor was found in 50% of the cases. Prognosis is always unfavorable. All authors underline the gloomy prognosis of this tumor with fatal outcome in one year. Early diagnosis and complete resection is the only hope.

CONCLUSION

Krukenberg tumor is an ovarian metastasis of digestive tract cancer. The only hope for improved prognosis is to search for ovarian metastasis in all cases and prophylactic ovariectomy in women over 40 with digestive tract cancer.

Krukenberg tumor from gastric mucosal carcinoma without lymphatic or venous invasion: report of a case

A 49-year-old woman was admitted because of early gastric carcinoma. Subtotal gastrectomy was performed. In the resected specimen, gastric mucosal carcinoma without lymph node metastases was located in the prepyloric region. Histologic type was moderately differentiated adenocarcinoma and signetring cell carcinoma, and there was no lymphatic or venous invasion. One year after operation, a left ovarian tumor was detected. At the second operation, bilateral oophorectomy and hysterectomy were performed. Pathological findings revealed Krukenberg tumors originating from the gastric carcinoma in the bilateral ovaries. One year after the second operation, a hard mass due to cancer recurrence developed in the pelvis with symptoms including tenesmus and abdominal pain. Chemotherapy and palliative colostomy were performed. She died of peritonitis carcinomatosa six years and two months after the first operation. We experienced a rare case of Krukenberg tumor with two interesting points; its origin was gastric mucosal carcinoma without lymphatic or venous invasion, and the patient survived for more than four years after the diagnosis.

[Krukenberg tumor secondary to gastric carcinoma in a woman in her eighth month of pregnancy]

The association of gastric cancer and pregnancy is rare. The cases reported by non-Japanese authors are unusual. Tumors tend to be in advanced stage when diagnosed since the symptoms of gastric cancer are easily presumed to be secondary to those of normal pregnancy. We report the case of a 43-year-old female with gastric carcinoma presenting as a Krukenberg's tumor in the eighth month of gestation. A healthy child was born and after delivery, partial gastrectomy was performed and adjuvant chemotherapy was administered. The patient died 12 months after diagnosis.

Krukenberg tumors: can management be improved?

OBJECTIVE

The Montefiore Medical Center experience with women with gastrointestinal (GI) cancer was reviewed to: (1) evaluate clinical parameters in patients with Krukenberg tumor (GI cancer metastatic to the ovaries) and (2) evaluate oophorectomy in GI cancer patients.

METHODS

(1) Charts of all female patients admitted between 1985 and 1996 with gastric or colon cancer were reviewed.

RESULTS

The frequency of Krukenberg tumor was 7/1,021 (0.7%). The median age at presentation was 39.5 years (range 35-80); 5 were premenopausal, 2 of whom were postpartum. Krukenberg tumor was significantly more common in the premenopausal patients with gastric cancer (p = 0.002), colon cancer (p = 0.001), and in both sites combined (p < 0.001). Our rate of pregnancy-associated Krukenberg tumors (28.6%) was significantly higher (p < 0.05) than that found in 4 of 5 large studies. The average survival of our 7 patients was 12.3 months (range 4 days to 26 months), with secondary debulking and chemotherapy offering 1 patient the longest longevity. Only 19/788 (2.4%) women had oophorectomy during their colon cancer surgery revealing 2 (10.5%) Krukenberg tumors, 6 (31.6%) benign solid or cystic ovarian tumors, and 11 (57.9%) normal or atrophic ovaries.

CONCLUSIONS

Krukenberg tumors are rare. There is no uniformity of data reported in the literature. Krukenberg tumors were more common in premenopausal women with gastric or colon cancer compared to postmenopausal women. Our rate of pregnancy-associated Krukenberg tumors appeared to be higher compared to other studies. Prophylactic oophorectomy in pre- and postmenopausal women should be considered at the time of GI cancer surgery, and requires further study. A national registry combined with prospective, multisite studies are needed to gather data and evaluate treatment.

[Abdominal metastases from signet cell carcinoma of the appendix vermiformis]

Signet cell carcinomas are often aggressive tumours. A patient with this tumour, originally located in the appendix, was diagnosed with peritoneal metastases. When she later got abdominal symptoms, computer axial tomography indicated large infiltrating tumour masses in the pelvis. However, when a laparotomy was performed, the only macroscopic tumour masses was localised to the ovaries (Krukenberg tumour). The surgical intervention gave the patient an improved quality of life, and most likely prolonged survival. We stress the importance of thinking of this possibility.