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  Table of Contents    
CASE REPORT  
Year : 2014  |  Volume : 57  |  Issue : 1  |  Page : 124-126
Krukenberg tumor in a young woman: A rare presentation


1 Department of Pathology, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar, Pauri-Garhwal, Uttarakhand, India
2 Department of Obstetrics and Gynaecology, Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar, Pauri-Garhwal, Uttarakhand, India

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Date of Web Publication17-Apr-2014
 

   Abstract 

Krukenberg tumors mostly occur after 40 years. Metastatic ovarian tumors in young age are very rare and reported to be 2% of all the cases. Thirty percent of all ovarian neoplasms occurring during childhood and adolescence are malignant. A 25-year-old woman, parity- 2, presented with abdominal distension, pain in abdomen and amenorrhea. On examination, 18 weeks lump was palpable, firm to hard in consistency, non-tender and mobile. On ultrasonography bilateral ovarian tumors were reported, without any peritoneal free fluid. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Microscopic examination revealed signet ring cells with glandular differentiation, diffusely invading the ovarian parenchyma. Tumor cells exhibited strong, diffuse immunopositivity for CEA with focal strong immunopositivity for CK7 and CK20 and immunonegativity for SATB2. Diagnosis of Krukenberg tumor was made. Endoscopic biopsy confirmed the diagnosis of adenocarcinoma stomach.
This case is reported because of its rarity in younger age group.

Keywords: CEA, CK7, CK20, immunohistochemistry, krukenberg, SATB2

How to cite this article:
Hatwal D, Joshi C, Chaudhari S, Bhatt P. Krukenberg tumor in a young woman: A rare presentation. Indian J Pathol Microbiol 2014;57:124-6

How to cite this URL:
Hatwal D, Joshi C, Chaudhari S, Bhatt P. Krukenberg tumor in a young woman: A rare presentation. Indian J Pathol Microbiol [serial online] 2014 [cited 2020 Aug 4];57:124-6. Available from: http://www.ijpmonline.org/text.asp?2014/57/1/124/130919



   Introduction Top


Krukenberg tumors are named after Friedrich Ernst Krukenberg (1871-1946). They refer to a malignancy in the ovary that metastasizes from a primary site, classically the gastrointestinal tract and breast. [1] Krukenberg tumors are often (over 80%) found in both ovaries, consistent with their metastatic nature. Metastatic cancer to ovary accounts for 1-2% of all ovarian cancers. [2] Review of literature indicates that 35-45% of the patients reported were less than 40 years, with an average range of 40-46 years. It is rarely seen in younger age group and only a few such cases have been reported. Gupta et al., and Khurana et al., reported Krukenberg tumor in women aged 20 years and 13 years, respectively. [3],[4] We are reporting a case of Krukenberg tumor in a 25-year-old woman.


   Case Report Top


A 25-year-old woman, with parity-2 presented with abdominal distension, pain abdomen and amenorrhea. On examination, 18 weeks lump was palpable, firm to hard in consistency, non-tender and mobile. Her urine pregnancy test was negative. Ultrasonography revealed bilateral enlargement of ovary. CA 125 was normal. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. The resected tumor measured 16 × 11 × 8 cm 3 on right side and 9 × 7 × 10 cm 3 on left side. The external surface of the tumor was tense, cystic, bosselated and firm to hard in consistency [Figure 1]a. The cut section of the tumor was solid, homogenous and yellowish white, with mucinous areas [Figure 1]b. The microscopic examination revealed predominance of signet ring cells with foci of glandular differentiation and solid sheets diffusely invading the ovarian parenchyma [Figure 1]c. The tumor cells were enlarged and hyperchromatic. At some places, areas of extracellular mucin with mucin lakes were seen [Figure 1]d. On immunohistochemistry tumor cells showed strong diffuse immunopositivity for carcinoembryonic antigen (CEA) [Figure 2]a and b] with focal strong immunopositivity for cytokeratin (CK7) and CK20 [Figure 2]c and d] while immunonegativity for Special AT rich sequence-binding protein 2 (SATB2) [Figure 3]. The diagnosis of metastatic adenocarcinoma of ovary (Krukenberg tumor) with possible primary from gastropancreatobiliary system was made. During follow up, endoscopic biopsy confirmed the diagnosis of adenocarcinoma stomach. The patient died after few months of surgery.
Figure 1: Photomicrographs of krukenberg tumor showing (a) Bilateral solid multinodular enlargement of ovaries (b) Cut surface of ovary showing multinodularity (c) Signet ring cells (H and E 40) (d) Mucin lake (H and E 40)

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Figure 2 : Photo micrograph s o f Krukenberg tumor on immunohistochemistry showing (a) CEA diffuse positivity (10) (b) CEA diffuse positivity (40) (c) CK7 focal positivity (40) (d) CK20 focal positivity (40)

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Figure 3: Photomicrographs of Krukenberg tumor showing immunonegativity for SATB2 (40)

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   Discussion Top


Krukenberg tumor most commonly metastasizes from gastric carcinoma, particularly adenocarcinoma of stomach. The other sites implicated for Krukenberg tumor are breast (invasive lobular breast carcinoma), appendix, colon, small intestine, rectum, urinary bladder, gallbladder, biliary tract, pancreas, ampulla of vater and uterine cervix. [5] The mode of spread of the tumor cells to the ovaries are direct, hematogenous or through lymphatics.

Primary ovarian mucinous carcinoma and a metastatic mucinous carcinoma can be differentiated on the basis of clinical features, morphological and pathological findings. The presence of signet ring cells is one of the most important morphological feature of metastatic mucinous carcinoma of ovary, which are rare in primary ovarian mucinous tumors. [6] The features favoring secondary mucinous carcinomas are, surface tumor deposits, a nodular growth pattern, and lymphovascular permeation. The features more in favor of primary carcinoma of ovary are unilateral tumor, lower tumor staging, and background of adenofibroma or cyst adenoma. The immunohistochemistry may help in diagnosing Krukenberg tumor from primary ovarian neoplasm, but needs to be applied with discretion. [7],[8] The tumors that are immunoreactive for CEA or CK20 and negative for CK7 are more likely to be of colorectal in origin. However, the tumors that are immunoreactive to CK7 and CK20 are more likely to be of gastropancreatobiliary in origin. CK7 and CK20 are usually not reactive in primary carcinoma. [9] SATB2 is a nuclear matrix associated transcription factor, expression of which is restricted to glandular lining of the lower gastrointestinal tract. [10] In present case the tumor cells were immunoreactive to CEA, CK7, CK20 and immunonegative to SATB2. These findings of immunochemistry favor and further strengthen the diagnosis of metastatic adenocarcinoma of ovary from gastropancreatobilliary system.

There are very few reports in literature with pregnancy related bilateral Krukenberg tumors. [11] In our cases tumor was bilateral and was not associated with pregnancy.

The rarity of this case is due to the rarity of gastric cancer in young women. Indeed, only 0.4 to 0.5% of gastric cancers occur in women aged less than 30 years. [12] The prognosis is worse if the primary tumor is identified after ovarian metastasis. Our patient died after 2 month of surgery. The significance of early detection of ovarian metastasis and serum CA 125 level monitoring are vital. Chemotherapy and radiotherapy have no significant role in the management and clinical course of Krukenberg tumors.

As no curative treatment is available, some authorities advocate bilateral oophorectomy during surgery of the primary tumor. This treatment option requires further study and evaluation for better outcome.


   Conclusion Top


Krukenberg tumors are very rare in younger age group. There poor prognosis emphasizes the importance of early diagnosis and treatment. Better awareness in younger patients is important for timely detection, fertility sparing treatment and survival.

 
   References Top

1.Rosai J and Ackerman. Surgical pathology. 9th Ed. Elsevier. 2005. pp.1706.   Back to cited text no. 1
    
2.Al-Agha OM, Nicastri AD. An in-depth look at Krukenberg tumor: An overview. Arch Pathol Lab Med 2006;130:1725-30.   Back to cited text no. 2
    
3.Gupta P, Snebold MA, O'Donnelly S. Krukenberg's tumor in the young population. J Am Osteopath Assoc 1989;89:500-2.   Back to cited text no. 3
[PUBMED]    
4.Khurana P, Sachdev R, Uppal S, Bisaria D. Krukenberg tumor in a 13-year-old girl: A rare occurrence. Indian J Pathol Microbiol 2010;53:874-5.   Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Kiyokawa T, Young RH, Scully RE. Krukenberg tumors of the ovary: A clinicopathologic analysis of 120 cases with emphasis on their variable pathologic manifestations. Am J Surg Pathol 2006;30:277-99.   Back to cited text no. 5
    
6.Mc Cluggage WG, Young RH. Primary ovarian mucinous tumors with signet ring cells: Report of 3 cases with discussion of so-called primary Krukenberg tumor. Am J Surg Pathol 2008;32:1373-9.   Back to cited text no. 6
    
7.Young RH. From krukenberg to today: The ever present problems posed by metastatic tumors in the ovary. Part II. Adv Anat Pathol 2007; 14:149-177.  Back to cited text no. 7
[PUBMED]    
8.Chu PG, Weiss LM. Keratin expression in human tissues and neoplasm. Histopathology 2002;40:403-39.  Back to cited text no. 8
    
9.Wauters CC, Smedts F, Gerrits LG, Bosman FT, Ramaekers FC. Keratin 7 and 20 as diagnostic markers of carcinomas metastatic to the ovary. Hum Pathol 1995;26:852-5.  Back to cited text no. 9
    
10.Magnusson K, de Wit M, Brennan DJ, Johnson LB, McGee SF, Lundberg E, et al. SATB2 in combination with cytokeratin 20 identifies over 95% of all colorectal carcinomas. Am J Surg Pathol 2011;35:937-48.  Back to cited text no. 10
    
11.Dueñas-García OF, Diaz-Sotomayor M, Chanana C. Bilateral Ovarian Krukenberg Tumor in a Full-Term Pregnancy. ISRN Obstet Gynecol 2011;2011:620380.  Back to cited text no. 11
    
12.Sandemeier D, Lobrunus JA, Vial Y, Delaloy JF, Genton CY. Bilateral Krukenberg tumor of the ovary during pregnancy. Eur J Gynaecol Oncol 1999;21:58-60.  Back to cited text no. 12
    

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Correspondence Address:
Deepa Hatwal
Associate Professer, Pathology, Health Care Center, Upper Bazar, Srinagar, Garhwal Pauri Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.130919

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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