Bilateral symmetrical adnexal masses - think Krukenberg!!

Clinical History

A 38-year-old woman presented with chief complaints of nausea and vomiting and loss of appetite for 3 months. The patient also reported dull pelvic pain of 2 month's duration and irregular vaginal bleeding.

Imaging Findings

Transabdominal ultrasound of the pelvis showed bilateral and symmetric adnexal lesions with homogeneous echotexture and minimal vascularity, with the ovaries not being seen separately (Fig. 1a). On careful evaluation of the stomach, gastric wall thickening was noted in the pyloric region (Fig. 1b), and the patient was referred for further evaluation by contrast-enhanced CT study of the abdomen and pelvis. CECT revealed a distended stomach with circumferential thickening of the wall of the antro- pyloric region (Fig. 2a, b) along with bilateral symmetric heterogeneous ovarian masses (Fig. 3a, b) and moderate ascites. Few enlarged perigastric and para-aortic lymph nodes (the largest measuring 8 mm in short-axis diameter) were noted. The liver showed no evidence of any metastatic lesions.

Discussion

Krukenberg tumours refer to metastatic tumours to the ovary containing “signet ring” cells, which are mucin-secreting cells. They originate from a primary malignancy located in the gastrointestinal tract, most commonly the stomach or the colon. Other primary sites that can metastasize to the ovaries include breast, pancreas, gall bladder, lung, kidneys as well as melanoma, carcinoid tumours and sarcoma. On ultrasound these lesions may be of mixed echogenicity consisting of solid and cystic components and cannot be distinguished from ovarian cystadenocarcinoma. [1] However, Shiimizu H and et al found in their study of 14 cases of Krukenberg tumours that 13 of them were irregular hyperechoic solid masses, with well-defined margins and moth-eaten cystic components when compared to ovarian malignancies, which showed ill-defined margins, irregular hypoechoic solid pattern, small cyst formations, papillary projections and thick septae. Cho et al suggested the possible diagnosis of Krukenberg tumour in the presence of relatively prominent vascular signal along the wall of well-demarcated intratumoural cysts in a solid ovarian mass [2, 3]. CT is often the next imaging modality and findings include thick irregular walls, solid components, internal septations, irregular calcifications, contrast enhancement and extracapsular extension. Kim et al suggested the presence of Krukenberg tumours if solid ovarian masses with well-defined cystic parts are seen, especially if the walls of those cysts demonstrate strong contrast enhancement. CT provides useful information regarding the extent of the disease, presence of lymphadenopathy and metastatic mesenteric deposits. It is also useful for the evaluation of tumour recurrence and for assessing treatment response. [2-4] On MRI, these lesions present as bilateral adnexal masses, partly solid-cystic with the solid components being hypointense on T2-weighted images due to a dense stromal reaction. [5, 6] With regards to management of Krukenberg tumours, Peng et al found that when the primary was a gastric carcinoma, the survival rates of the patients increased when they underwent gastrectomy combined with ovarian metastasectomy as compared to ovarian metastasectomy alone. Another independent risk factor was ascites, which showed a poorer prognosis. Therefore it is crucial to screen the GI tract and especially the stomach when bilateral symmetrical adnexal masses retaining the shape of the ovaries are seen. [7] Our patient underwent distal subtotal gastrectomy with bilateral salpingo-oophorectomy. Histopathological evaluation of the excised ovarian masses revealed "signet ring" cells suggestive of Krukenberg tumour. The gastric growth was confirmed as gastric signet ring cell cancer.

Differential Diagnosis List

Final Diagnosis

Bilateral Krukenberg tumour secondary to gastric carcinoma

URL:	https://www.eurorad.org/case/13015
DOI:	10.1594/EURORAD/CASE.13015
ISSN:	1563-4086