Krukenberg Tumor (Ovarian Tumor)
Lesson: Krukenberg Tumor – Clinical and Sonographic Assessment
Introduction
Krukenberg tumor is a metastatic ovarian malignancy characterized by mucin-producing signet-ring cells infiltrating the ovarian stroma, typically with stromal proliferation. It most frequently originates from gastric carcinoma, although colorectal, appendiceal, and other primary cancers may be responsible.
These tumors are frequently bilateral and appear on ultrasonography as solid or predominantly solid ovarian masses with variable cystic areas and internal vascularity. Imaging can suggest metastatic ovarian disease, but a definitive diagnosis requires histopathological confirmation and correlation with the primary malignancy.
Historical Background
Friedrich Ernst Krukenberg (1871–1946), a German pathologist, described this tumor in 1896. Initially thought to represent a primary ovarian tumor, it was subsequently recognized as a metastatic malignancy, usually arising from the gastrointestinal tract.
Clinical Significance
- Metastatic nature: Secondary ovarian involvement from an extraovarian primary malignancy, most often gastrointestinal.
- Bilateral involvement: Both ovaries are commonly affected, although unilateral disease is possible.
- Clinical presentation: Pelvic pain, abdominal distension, palpable adnexal masses, menstrual disturbances, or ascites; some patients are asymptomatic.
- Sonographic features: Solid or predominantly solid adnexal masses, often with internal vascularity and sometimes cystic degeneration.
- Pathological hallmark: Mucin-producing signet-ring cells infiltrating ovarian stroma with associated stromal reaction.
- Clinical correlation: A suspicious ovarian mass warrants evaluation for a gastrointestinal or other primary tumor.
How to Perform the Sonographic Assessment
- Perform transabdominal and, where appropriate, transvaginal ultrasonography.
- Identify both ovaries and measure the ovarian masses in three orthogonal dimensions.
- Document laterality, contours, solid and cystic components, and internal echotexture.
- Use color or power Doppler to evaluate intralesional vascularity.
- Assess the pelvis and accessible abdomen for ascites, peritoneal nodules, and other abnormalities.
- Recommend appropriate clinical, cross-sectional imaging, and histopathological correlation.
A 48-year-old woman presents with progressive abdominal distension, lower abdominal discomfort, early satiety, and unintentional weight loss. She has a history of gastric adenocarcinoma. Clinical examination reveals bilateral adnexal fullness, raising concern for ovarian metastatic involvement.
Pelvic ultrasonography demonstrates bilateral enlarged ovaries replaced by predominantly solid, mildly heterogeneous masses. The right adnexal mass measures approximately 9.2 × 7.1 × 6.5 cm and the left measures 7.8 × 6.4 × 5.9 cm. Small internal cystic areas are present. Color Doppler demonstrates vascular flow within the solid components. A small volume of free pelvic fluid is identified.
Given the history of gastric carcinoma, the bilateral predominantly solid ovarian masses are suspicious for metastatic ovarian involvement, including Krukenberg tumor. Sonography alone cannot establish the specific histological diagnosis.
- Bilateral ovarian masses: Enlargement of both ovaries with predominantly solid adnexal lesions.
- Internal echotexture: Mildly heterogeneous solid tissue with scattered small cystic areas.
- Doppler vascularity: Detectable internal vascular flow within solid tumor components.
- Associated fluid: Small-volume free fluid within the pelvis, nonspecific but relevant in the oncological context.
- Additional assessment: Evaluate for peritoneal disease and correlate with contrast-enhanced CT or MRI for staging and assessment of the primary malignancy.
Bilateral predominantly solid, vascular ovarian masses with small-volume pelvic free fluid in a patient with known gastric adenocarcinoma. Findings are highly suspicious for bilateral ovarian metastases (possible Krukenberg tumors). Recommend oncological evaluation, appropriate staging imaging, and tissue diagnosis when clinically indicated.
Krukenberg tumor is a histopathological diagnosis associated with metastatic malignancy. Although bilateral solid ovarian masses in a patient with gastrointestinal cancer are suggestive, the differential diagnosis includes primary ovarian malignancy and other metastatic tumors. Histopathology, often supported by immunohistochemistry and comparison with the primary tumor, is essential for definitive classification.
Large multilocular cystic-solid adnexal mass with multiple septations and variable internal echogenicity.
Complex ovarian neoplasm; mucinous epithelial tumor is a differential consideration.
Gynecologic oncology consultation, appropriate imaging and histopathological confirmation.
Complex solid-cystic adnexal mass with irregular solid tissue, papillary projections and internal Doppler vascularity.
Suspicious malignant ovarian neoplasm; high-grade serous carcinoma is a differential consideration.
Urgent gynecologic oncology assessment, staging evaluation and tissue diagnosis.
Well-defined solid hypoechoic ovarian mass with posterior acoustic shadowing and limited Doppler flow.
Solid ovarian lesion with imaging features suggestive of ovarian fibroma.
Gynecologic correlation and pelvic MRI when clinically indicated.
Relatively homogeneous hypoechoic solid ovarian mass with increased vascularity and relatively preserved ovarian contours.
Solid ovarian neoplasm; lymphomatous involvement is a differential consideration.
Hematologic correlation, cross-sectional imaging and tissue diagnosis as appropriate.
| Patient Name | Age / Sex | ||
|---|---|---|---|
| Referring Doctor | Date |
Indication: Routine abdominal sonography. Relevant clinical history and laboratory findings: Not supplied.
Technique: Real-time grayscale ultrasonography of the abdomen and pelvis performed using a curvilinear transducer. Targeted color Doppler assessment performed where clinically indicated. Examination performed with appropriate bladder filling, as feasible.
Liver: Liver is normal in size, shape and contour, with smooth capsular outline and homogeneous parenchymal echotexture. Hepatic echogenicity is within normal limits. No focal solid or cystic hepatic lesion is identified. No intrahepatic collection is seen. Right lobe span in midclavicular line: 140 mm; left lobe: 75 mm; caudate lobe: 25 mm.
Intrahepatic Biliary Radicles / Hepatic Ducts: Intrahepatic biliary radicles are not dilated. Visualized right and left hepatic ducts show no abnormal dilatation.
Portal Vein: Main portal vein is normal in caliber and course, with patent lumen. Hepatopetal flow is demonstrated on color Doppler when assessed. No visible portal venous thrombus. Portal vein diameter: 11 mm.
Gallbladder: Gallbladder is adequately distended with normal contour. Wall thickness is within normal limits. No echogenic calculus, sludge, intraluminal mass or polyp is seen. No pericholecystic collection is identified. Gallbladder wall thickness: 2 mm. Sonographic Murphy sign: negative (example).
Common Bile Duct (CBD): Visualized CBD is normal in caliber without evident intraluminal calculus or biliary obstruction. CBD diameter: 4 mm.
Pancreas: Visualized head, body and tail of the pancreas are normal in size, outline and echotexture. No definite focal lesion, pancreatic duct dilatation or peripancreatic fluid collection is seen. Main pancreatic duct: 2 mm (illustrative).
Spleen: Spleen is normal in size and shape with homogeneous echotexture and smooth outline. No focal splenic lesion or perisplenic collection is detected. Splenic bipolar length: 105 mm.
Inferior Vena Cava (IVC): Visualized IVC is patent and normal in caliber. No definite intraluminal thrombus is seen. Respiratory caliber variation is present when assessed.
Abdominal Aorta: Visualized abdominal aorta is normal in course and caliber, without aneurysmal dilatation. Maximum visualized aortic diameter: 18 mm.
Right Kidney: Right kidney is normally located and shows normal size, contour and renal parenchymal echogenicity. Cortical thickness and corticomedullary differentiation are maintained. No renal calculus, focal mass, cyst or hydronephrosis is identified. Size: 105 × 48 mm; cortical thickness: 8 mm.
Left Kidney: Left kidney is normally located and shows normal size, contour and renal parenchymal echogenicity. Cortical thickness and corticomedullary differentiation are maintained. No renal calculus, focal mass, cyst or hydronephrosis is identified. Size: 108 × 50 mm; cortical thickness: 8 mm.
Urinary Bladder: Urinary bladder is adequately distended with smooth, regular walls and anechoic contents.
Uterus: Uterus measures 95 x 55 x 45 mm, with preserved shape and configuration, smooth outline and homogeneous myometrial echotexture. No definite focal myometrial lesion is identified. Endometrial echo is central and regular. Endometrial thickness: _____ mm.
Right Ovary: Right ovary is markedly enlarged, measuring approximately _____ x _____ x _____ mm, and is predominantly replaced by a solid, heterogeneous, hypoechoic mass with relatively well-defined lobulated margins and scattered small cystic areas. Normal ovarian follicular architecture is largely obscured. Color Doppler examination demonstrates _____ internal vascularity. The appearance is suspicious for a malignant ovarian neoplasm, including metastatic ovarian involvement (Krukenberg tumor).
Left Ovary: Left ovary is markedly enlarged, measuring approximately _____ x _____ x _____ mm, and is predominantly replaced by a solid, heterogeneous, hypoechoic mass with relatively well-defined lobulated margins and scattered small cystic areas. Normal ovarian follicular architecture is largely obscured. Color Doppler examination demonstrates _____ internal vascularity. Bilateral ovarian involvement raises suspicion for metastatic ovarian malignancy, particularly Krukenberg tumors.
Bowel Loops: Visualized bowel loops are not abnormally dilated. No obvious segmental bowel wall thickening or localized fluid collection is identified on this routine survey. However, routine ultrasonography cannot reliably exclude an underlying gastrointestinal primary malignancy. Bowel gas limits detailed assessment.
Peritoneal Cavity / Pelvis: Free intraperitoneal fluid / ascites: _____. Peritoneal or omental deposits: _____. No additional localized collection is identified in the accessible regions, subject to actual sonographic findings.
Retroperitoneum / Lymph Nodes: Enlarged retroperitoneal or pelvic lymph nodes: _____. Assessment of the retroperitoneum is limited by overlying bowel gas. Further evaluation with contrast-enhanced cross-sectional imaging is advised.
Additional Findings: Bilateral predominantly solid ovarian masses are suspicious for secondary ovarian malignancy. Clinical correlation is required to identify a possible primary malignancy, particularly of gastrointestinal origin, including the stomach and colorectum. _____.
Bilateral enlarged ovaries with predominantly solid, heterogeneous masses, suspicious for bilateral malignant ovarian neoplasms. The bilateral appearance raises strong suspicion for metastatic ovarian involvement, including Krukenberg tumors, particularly in the setting of a known gastrointestinal malignancy. Primary ovarian malignancy remains an important differential diagnosis. Definitive characterization requires histopathological confirmation.
Urgent gynecologic oncology consultation is recommended. Contrast-enhanced CT of the chest, abdomen and pelvis is advised for evaluation of disease extent, possible primary malignancy, lymphadenopathy and peritoneal involvement. Gastrointestinal evaluation, including upper gastrointestinal endoscopy and/or colonoscopy, should be considered according to clinical findings and imaging results. Serum tumor markers, including CA-125, CEA and CA 19-9, may be obtained as clinically appropriate. Histopathological examination with immunohistochemical correlation is essential for definitive diagnosis and identification of the primary tumor.
Ultrasound is operator-dependent. Bowel gas, body habitus, patient preparation and bladder distension may limit evaluation of abdominal and pelvic structures. Large adnexal masses may obscure normal ovarian architecture and make determination of their exact origin difficult. Routine transabdominal ultrasonography cannot reliably distinguish primary ovarian malignancy from metastatic ovarian tumors or establish the diagnosis of Krukenberg tumor. Small peritoneal deposits, retroperitoneal lymphadenopathy and gastrointestinal primary lesions may remain undetected. Further transvaginal ultrasonography, contrast-enhanced CT or MRI and histopathological correlation may be required. All measurements, Doppler findings and statements must be verified against the actual examination before finalizing the report.
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MBBS MD (Consultant Radiologist)
