Diagnostic Ultrasound - Abdomen and Pelvis

Ovarian Metastases Including Krukenberg Tumor
Diagnoses: Female Pelvis
Gross Pathologic & Surgical Features
• Cut surfaces of ovaries may be solid, solid-cystic, or
multicystic
• Have tendency to preserve contour of ovary
• Hemorrhage or necrosis may be present within mass
Microscopic Features
• Hyperplasia of ovarian stromal cells with significant number
of signet ring cells
• Features favoring metastatic rather than primary ovarian
neoplasm include
○ Bilaterality
○ Nodular pattern of ovarian involvement
○ Infiltrative pattern of stromal invasion
○ Microscopic surface deposits of tumor
○ Marked lymphovascular invasion (especially in hilum and
outside ovary)
○ Signet ring cells
○ Cells floating in mucin
○ Variation in growth pattern from 1 nodule to another
• Due to high risk of ovarian metastasis, palliative bilateral
oophorectomy may be performed during surgery for colon
cancer
DIAGNOSTIC CHECKLIST
Consider
• Imaging findings of primary ovarian cancer and metastases
to ovaries overlap in many cases, and confident imaging
distinction between the 2 may be challenging
• In patients with metastases to ovaries, primary tumor is
often clinically overt and associated with findings of
widespread metastatic disease
• Investigation of gastrointestinal tract is recommended in
patient without known primary cancer
Image Interpretation Pearls
• Features that are more often seen in metastases to
ovary include
○ Bilateral ovarian masses
○ Predominantly solid appearance of mass
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Abdominal pain
○ Palpable pelvic masses
• Other signs/symptoms
○ Occasionally associated hormonal activity can be seen
due to reactive ovarian stromal hyperplasia
• Clinical profile
○ In many cases, there is known history of primary
neoplasm
○ Usually symptoms of primary disease precede symptoms
secondary to ovarian metastasis
○ On occasion, presentation is with symptoms related to
ovarian mass in patient with no known history of
malignancy
Demographics
• Age
○ More common in premenopausal women due to
vascularity of ovaries
• Epidemiology
○ 5-15% of malignant ovarian tumors are metastatic
tumors to ovary
○ 5-30% of cancer patients have ovarian metastases at
autopsy
○ Only 30-40% of ovarian metastases are true Krukenberg
tumors
Natural History & Prognosis
• Poor prognosis with mortality rate of ~ 90% 1 year after
ovarian metastasis is discovered
• Krukenburg tumors: Mean survival 23 months
○ Premenopausal patients and metachronous lesions fair
better
Treatment
• Radical tumor-reductive surgery
• Often have poor response to chemotherapy
SELECTED REFERENCES
1. Jeung YJ et al: Krukenberg tumors of gastric origin versus colorectal origin.
Obstet Gynecol Sci. 58(1):32-9, 2015
2. Nakamura Y et al: A Krukenberg Tumor from an Occult Intramucosal Gastric
Carcinoma Identified during an Autopsy. Case Rep Oncol Med. 2014:797429,
2014
3. Alvarado-Cabrero I et al: Metastatic ovarian tumors: a clinicopathologic study
of 150 cases. Anal Quant Cytol Histol. 35(5):241-8, 2013
4. La Fianza A et al: Intralesional hemorrhage in Krukenberg tumor: a case
report and review of the literature. J Ultrasound. 16(2):89-91, 2013
5. Guerriero S et al: Preoperative diagnosis of metastatic ovarian cancer is
related to origin of primary tumor. Ultrasound Obstet Gynecol. 39(5):581-6,
2012
6. Ho L et al: Bilateral ovarian metastases from gastric carcinoma on FDG
PET/CT. Clin Nucl Med. 37(5):524-7, 2012
7. Willmott F et al: Radiological manifestations of metastasis to the ovary. J Clin
Pathol. 65(7):585-90, 2012
8. Kitajima K et al: FDG PET/CT features of ovarian metastasis. Clin Radiol.
66(3):264-8, 2011
9. Maeda-Taniguchi M et al: Metastatic mucinous adenocarcinoma of the ovary
is characterized by advanced patient age, small tumor size, and elevated
serum CA125. Gynecol Obstet Invest. 72(3):196-202, 2011
10. de Waal YR et al: Secondary ovarian malignancies: frequency, origin, and
characteristics. Int J Gynecol Cancer. 19(7):1160-5, 2009
11. Koyama T et al: Secondary ovarian tumors: spectrum of CT and MR features
with pathologic correlation. Abdom Imaging. 32(6):784-95, 2007
12. Testa AC et al: Imaging in gynecological disease (1): ultrasound features of
metastases in the ovaries differ depending on the origin of the primary
tumor. Ultrasound Obstet Gynecol. 29(5):505-11, 2007
13. Chang WC et al: CT and MRI of adnexal masses in patients with primary
nonovarian malignancy. AJR Am J Roentgenol. 186(4):1039-45, 2006
14. Khunamornpong S et al: Primary and metastatic mucinous adenocarcinomas
of the ovary: Evaluation of the diagnostic approach using tumor size and
laterality. Gynecol Oncol. 101(1):152-7, 2006
15. Kiyokawa T et al: Krukenberg tumors of the ovary: a clinicopathologic
analysis of 120 cases with emphasis on their variable pathologic
manifestations. Am J Surg Pathol. 30(3):277-99, 2006
16. Alcazar JL et al: Transvaginal gray scale and color Doppler sonography in
primary ovarian cancer and metastatic tumors to the ovary. J Ultrasound
Med. 22(3):243-7, 2003
17. Jung SE et al: CT and MR imaging of ovarian tumors with emphasis on
differential diagnosis. Radiographics. 22(6):1305-25, 2002
18. Brown DL et al: Primary versus secondary ovarian malignancy: imaging
findings of adnexal masses in the Radiology Diagnostic Oncology Group
Study. Radiology. 219(1):213-8, 2001
19. Hann LE et al: Adnexal masses in women with breast cancer: US findings with
clinical and histopathologic correlation. Radiology. 216(1):242-7, 2000
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