Answer for BIR CoW 19 Mar 2023
KRUKENBERG TUMOR
Findings
E/o well defined enlarged bilateral adnexal mass sowing heterogenous contrast enhancement with multiple arterial feeders and shows few internal non enhancing areas reflecting intratumoral cystic components. E/o asymmetric wall thickening involving the fundus and body of stomach along the lesser curvature of stomach extending upto antropyloric region and loss of fat plane with the pancreas Few enlarged lymph nodes noted along the lesser curvature of stomach Multiple deposits noted in omentum and pelvis along with omental nodularities. Loculated ascitis with peitoneal thickening associated with scalooping of liver Bilateral multiple simple renal cysts noted. Lung base clear, No suspicious lesions in bones.
Impression : Features suggestive of Metastatic Carcinoma stomach with peritoneal carcinomatosis, pseudomyxoma peritonei and Krukenberg tumor.
Discussion
Approximately 10% of ovarian tumors are metastatic masses, among which almost 50% of which are Krukenberg tumors. Nearly 80% of Krukenberg tumors are bilateral. Incidence of Krukenberg tumors is approximately 0.16 tumors per 100,000 population per year. What is Krukenberg tumor ? A mucin-secreting signet ring cell carcinoma in the dense fibroblastic stroma of the ovary is referred to as Krukenberg tumor. When bilateral mixed solid and cystic ovarian masses are identified and a possible Krukenberg tumor is suspected by the radiologist on imaging, it is important to look for the primary site, especially on CT and MRI. The stomach is the most common primary tumor site, chiefly the pylorus and followed by the colon, appendix, and breast. Compared with primary ovarian cancers, Krukenberg tumors more often occur in younger women( Median age – 48, Range – 27 to 65), possibly because the functioning ovary is prone to metastatic disease as a result of the normal rich ovarian blood supply. USG Krukenberg metastases will have clear well-defined and smooth margins 1.solid (stomach or breast primary tumor), 2.mixed solid and cystic (colon, rectum, appendix, or biliary tract primary tumor), 3. predominantly cystic masses (colon or appendix primary tumor) The solid component is heterogeneous. Moth-eaten–like cyst formation is considered a characteristic feature Doppler - randomly dispersed tumor vessels with low-impedance flow. Presence of prominent vascular signal along the wall of the well-demarcated intratumoral cysts CT The ovaries are replaced by bilateral pelvic masses that may be solid, mixed solid and cystic, or, less commonly, predominantly cystic. A well-demarcated intratumoral cystic component is often identified. The cyst walls show contrast enhancement. CT is very useful for establishing the extent of extraovarian involvement, and it also helps evaluate for the presence of any extraovarian primary tumor. MRI The solid components appear to be T1 and T2 hypointense because of dense stromal reaction, and they show corresponding diffusion restriction and enhancement on contrast-enhanced sequences. T2 hyperintensity is seen in the cystic areas, representing mucin that does not enhance.
Findings
E/o well defined enlarged bilateral adnexal mass sowing heterogenous contrast enhancement with multiple arterial feeders and shows few internal non enhancing areas reflecting intratumoral cystic components. E/o asymmetric wall thickening involving the fundus and body of stomach along the lesser curvature of stomach extending upto antropyloric region and loss of fat plane with the pancreas Few enlarged lymph nodes noted along the lesser curvature of stomach Multiple deposits noted in omentum and pelvis along with omental nodularities. Loculated ascitis with peitoneal thickening associated with scalooping of liver Bilateral multiple simple renal cysts noted. Lung base clear, No suspicious lesions in bones.
Impression : Features suggestive of Metastatic Carcinoma stomach with peritoneal carcinomatosis, pseudomyxoma peritonei and Krukenberg tumor.
Discussion
Approximately 10% of ovarian tumors are metastatic masses, among which almost 50% of which are Krukenberg tumors. Nearly 80% of Krukenberg tumors are bilateral. Incidence of Krukenberg tumors is approximately 0.16 tumors per 100,000 population per year. What is Krukenberg tumor ? A mucin-secreting signet ring cell carcinoma in the dense fibroblastic stroma of the ovary is referred to as Krukenberg tumor. When bilateral mixed solid and cystic ovarian masses are identified and a possible Krukenberg tumor is suspected by the radiologist on imaging, it is important to look for the primary site, especially on CT and MRI. The stomach is the most common primary tumor site, chiefly the pylorus and followed by the colon, appendix, and breast. Compared with primary ovarian cancers, Krukenberg tumors more often occur in younger women( Median age – 48, Range – 27 to 65), possibly because the functioning ovary is prone to metastatic disease as a result of the normal rich ovarian blood supply. USG Krukenberg metastases will have clear well-defined and smooth margins 1.solid (stomach or breast primary tumor), 2.mixed solid and cystic (colon, rectum, appendix, or biliary tract primary tumor), 3. predominantly cystic masses (colon or appendix primary tumor) The solid component is heterogeneous. Moth-eaten–like cyst formation is considered a characteristic feature Doppler - randomly dispersed tumor vessels with low-impedance flow. Presence of prominent vascular signal along the wall of the well-demarcated intratumoral cysts CT The ovaries are replaced by bilateral pelvic masses that may be solid, mixed solid and cystic, or, less commonly, predominantly cystic. A well-demarcated intratumoral cystic component is often identified. The cyst walls show contrast enhancement. CT is very useful for establishing the extent of extraovarian involvement, and it also helps evaluate for the presence of any extraovarian primary tumor. MRI The solid components appear to be T1 and T2 hypointense because of dense stromal reaction, and they show corresponding diffusion restriction and enhancement on contrast-enhanced sequences. T2 hyperintensity is seen in the cystic areas, representing mucin that does not enhance.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!