Describe krukenberg tumour — its aetiology, clinical features and management.

Definition

A Krukenberg tumour is a metastatic (secondary) tumour of the ovary, characteristically bilateral, arising from a gastrointestinal primary — most often the stomach (also colon, breast), and composed of mucin-secreting "signet-ring" cells in a cellular stroma.

Pathology

The ovaries are usually bilateral, solid and enlarged, retaining the ovarian shape with a smooth surface. Microscopy shows the diagnostic signet-ring cells (mucin pushing the nucleus to one side) scattered in the stroma. Spread to the ovary is transcoelomic, lymphatic and haematogenous.

Clinical Features

Features of the primary gastrointestinal cancer, an abdominal/pelvic mass and ascites; the tumour may be hormonally active (oestrogen/androgen), producing menstrual disturbance or post-menopausal bleeding or virilisation.

Spread to the Ovary

Tumour reaches the ovaries by transcoelomic seeding, lymphatic and haematogenous routes; the bilateral, solid enlargement with preservation of the ovarian outline is characteristic. Peritoneal deposits and ascites are usually present, indicating advanced disease.

Gross and Microscopic Appearance

The ovaries are bilaterally enlarged, solid and smooth, retaining the ovarian shape. Microscopy shows the diagnostic "signet-ring" cells (mucin displacing the nucleus) scattered in a cellular (sarcoma-like) stroma.

Investigations and Management

Ultrasound shows bilateral solid masses; tumour markers and gastrointestinal endoscopy are done to find the primary. Treatment is directed at the primary tumour with cytoreduction where feasible; the response to chemotherapy is poor.

A Note on WHY a Krukenberg Tumour Changes the Whole Diagnosis

A useful point is understanding why finding a Krukenberg tumour transforms the clinical problem — from a gynaecological one into a gastrointestinal one. A woman presents with what appears to be an ovarian mass (often bilateral, with ascites), and it is natural to assume primary ovarian cancer. But the Krukenberg tumour is a metastasis, not a primary — characteristically from a gastric carcinoma (the commonest source), and also from colon, breast, appendix or gallbladder. Its recognition therefore redirects the entire search: the true task is to find the primary tumour, which means endoscopy and imaging of the gastrointestinal tract — and until that is done, an operation on the ovary treats a shadow while the substance is missed. Two features should raise the suspicion: it is characteristically bilateral (whereas most primary epithelial ovarian cancers are unilateral at presentation), and it is often seen in relatively young women. The histology is diagnostic: mucin-secreting 'signet-ring' cells (the nucleus pushed to one side by a vacuole of mucin) within a cellular ovarian stroma. The prognosis is poor, because by definition the disease is already metastatic. Understanding that a bilateral ovarian mass may be the first sign of a stomach cancer explains why this eponym matters.

Bilateral ovarian masses should prompt a search for a GI primary.

• Krukenberg tumour = a metastatic ovarian tumour, characteristically bilateral — the commonest primary is gastric carcinoma (also colon, breast, appendix, gallbladder).
• Histology: mucin-secreting signet-ring cells in a cellular ovarian stroma — diagnostic.
• Spread is thought to be transcoelomic and lymphatic/haematogenous.
• Suspect it in a young woman with bilateral solid ovarian masses — and search for the gastrointestinal primary (endoscopy, imaging).
• The prognosis is poor, since the disease is by definition already metastatic; treatment is directed at the primary tumour.