It is important to distinguish between primary ovarian cancer and metastatic tumors in the ovary because their management is different, in terms of treatment and follow-up. We report the perioperative management of a year-old female patient with bilateral Krukenberg tumors.
Este important să se facă distincţia între cancerul ovarian primar şi tumorile metastatice ale ovarului, deoarece managementul lor este diferit în ceea ce priveşte tratamentul şi urmărirea. Raportăm managementul perioperator al unei paciente de 40 de ani, cu tumori bilaterale Krukenberg.
Managementul perioperator al unui pacient cu tumoră Krukenberg - studiu de caz
Cuvinte cheie tumora Krukenberg cancer gastric imunohistochimie Introduction Ovarian tumors comprise a heterogeneous group of lesions, displaying distinct tumor pathology and oncogenic potential and being subclassified into several categories based on two criteria: the degree of epithelial proliferation and invasion and the histotype of the epithelium composing the tumors 1.
In particular, Krukenberg tumors are represented by metastases of mucin-secreting signet ring cell cancer, arising primarily from the gastric carcinoma, to ovarian tissues 2.
Several previous studies have identified an association between endometriosis and the development of ovarian carcinomas.
The clinical presentation of Krukenberg tumors includes abdominal or pelvic pain, bloating, ascites, unexplained lethargy, irregular period and pain during sexual intercourse. Krukenberg tumors can occasionally provoke a reaction of the ovarian stroma which leads to hormone production, that results in vaginal bleeding, a change in menstrual habits, hirsutism, or occasionally virilization as a main symptom 5,6.
Regarding the paraclinical diagnostic, most imaging features are non-specific, consisting of predominantly solid components or a mixture of cystic and papillomavirus nhs areas; typically, those tumors are ovarian cancer under 50 sonographically as bilateral ovarian masses, with an irregular hyperechoic solid pattern, with clear well defined margins and moth-eaten cyst formation 7. Deep invasion, lymph node involvement, and peritoneal metastasis are more frequent in gastric SRCC compared with other subtypes of gastric cancer, so the prognosis of Krukenberg tumor is reticent 9.
Case report We report the case of a year-old ovarian cancer under 50 patient, without a significant pathological personal history, who has been admitted two months ago in the Department of Gynecology of a regional hospital, accusing pelvic pain and dysfunctional menstrual cycles.
She was diagnosed with bilateral ovarian cysts for which reevaluation was recommended. About 3 weeks ago, the patient was referred to the Department of Obstetrics and Gynecology of University Emergency Hospital in Bucharest for an interdisciplinary consultation.
Ovarian cancer under 50 transvaginal ultrasound showed two non-homogeneous tumors, predominantly with a tissue aspect, alternating with hypo-echogenic areas and zones of intratumoral necrosis, without capsular breakage; uterus of normal size and echogenity, evidence of fluid within the pouch of Douglas 10 mm.
CA tumor markers were recommended. The local clinical examination revealed normal non-specific vaginosis for which the patient received antibiotic and antiinflammatory treatment for 7 days. When reevaluating, the patient showed discrete relief of symptoms, with persistence of pelvic pain, and accusing meteorism. The patient was admitted in the hospital for reevaluation and for establishing the therapeutic conduct. We performed a new transvaginal ultrasound which indicated the same aspects, except for increased peritoneal fluid 30 mm in the recto-uterine pounch - Figure 1 and Figure 2.
Figure 1. Tumoral transformation of the right ovary; non-homogenous structure, predominantly tisular Figure 2. Figure 3. CT of thorax - note the lack of pulmonary ovarian cancer under 50 Figure 4. CT of pelvis - note the presence of bilateral ovarian tumors with predominant tisular and The general condition ovarian cancer under 50 the patient deteriorated, with the occurrence of vomiting and pain in the right hypochondria and the epigastrium.
General surgery consultation was requested to exclude a sub-occlusive syndrome, followed by upper endoscopy which showed a normal aspect, with the exception ovarian cancer under 50 enlarged folds in ovarian cancer under 50 vertical portion of the stomach, but which ovarian cancer under 50 fully under insufflation. The hematology consult confirmed the diagnosis of coagulopathy of possibly paraneoplastic etiology.
We decided to improve the coagulopathy by the administration of fresh frozen plasma. Under general anesthesia, an exploratory laparotomy was performed see Figure 5. We detected peritoneal carcinomatosis with infra-centimetric disseminations on the epiploon and mesentery.
We also observed free peritoneal fluid in a small amount and multiple liver metastases with various sizes cm. Figure 5.
Perioperative management of a patient with Krukenberg tumor - a case report
Intraoperative images. A - The macroscopic aspect of the two ovaries that were enlarged, but without capsular breakage; B - The macroscopic aspect of the liver - note the presence of multiple metastases; C - The macroscopic aspect of the intestinal loops and mesentery - note peritoneal carcinomatosis; D - Sectioned left ovary - note the presence of large tumors that distorted the normal anatomy We decided and practiced tumor cytoreduction through total hysterectomy with ovarian cancer under 50 oophorectomy, with the piece being sent to histopathological ovarian cancer under 50 histopathological extemporaneous examination showed undifferentiated ovarian carcinoma with Mullerian cells ; tactical omentectomy and biopsy of all secondary lesions were also performed.
The postoperative evolution was favorable with the improvement of genital symptomatology; the patient was discharged after 5 days and she was guided to the Oncology Department to follow the specialized treatment after receiving the final histopathological result.
After 4 days she returned to the Emergency Room for epigastric pain, vomiting, intense meteorism and absent intestinal transit.
Ovarian cancer under 50 abdominal radiography was performed which ovarian cancer under 50 hydroaeric levels. The patient was admitted in the Department of General Surgery with the diagnosis of occlusive syndrome. A surgical reintervention in a multidisciplinary team was performed. Intraoperatively, we found an early adherence syndrome. After an extensive histopathological analysis which included multiple immunohistochemistry tests, the diagnosis of Krukenberg tumors was established Figure 6.
Figure 6. Histopathological analysis The postoperative evolution was favorable, with improvement of digestive symptomatology; the patient will perform other specialized investigation echo-endoscopy ovarian cancer under 50 she was guided to the Oncology Department for specific postoperative treatment. Discussions Krukenberg papiloma humano k es is an uncommon metastatic adenocarcinoma of ovaries arising primarily from the gastric carcinoma, which may cause diagnostic confusion with primary ovarian ovarian cancer under 50 3.
Although he proposed it as a primary tumor of ovary, later it was proved to be secondary to gastrointestinal tract malignancy ovarian cancer under 50. Ovaries affected by these tumors retains its shape, irrespective of the size 3.
Our case sustains the bilateral feature of the tumors, with tumoral sizes described in literature. Transabdominal sonography of abdomen and pelvis is the primary imaging and screening modality for females with gynecological complaints.
The ultrasound examination of patients with Krukenberg tumors shows varied echogenicity ranging from purely solid to purely cystic.
In contrast with the primary ovarian tumors in which criteria used to describe the ovarian malignancy irregular solid tumor, ascites, at least 4 papillary structures, multi-loculated solid ovarian cancer under 50 with the largest diameter over mm and the presence of increased Doppler flowmost frequently, Krukenberg tumors will be homogenously hyperechoic solid masses with few cysts within.
There will be large lead vessel penetrating the mass from the periphery and nourishing the tumour by branching in tree pattern, known as lead vessel sign, with high speed and low resistance on spectral Doppler 3,11, During the histopathological analysis, these tumors are characterized by the presence of signet ring cells and pseudo-sarcoma proliferation of ovarian stroma Immunohistochemical tests have a large impact on the diagnostic of ovarian carcinomas, by ovarian cancer under 50 useful assessment criteria for a better reproducibility of cell type diagnosis For a good differentiation of the histological subtype and for assessing tumor aggressiveness, it is necessary to conduct immunohistochemical tests, which commonly target the expression of proliferation markers and aggression CK7, WT1, p53 and ki67 We conducted an extensive histopathological examination and also performed multiple immunohistochemistry tests in order to establish the final diagnosis of Krukenberg tumor.
Cancerul ovarian si mutatiile BRCA Importanta mutatiilor genetice in evolutia cancerului ovarian Aflati cum va puteti imbunatatiti perspectivele cu un simplu test Cancerul ovarian este relativ rar locul 5 ca incidenta intre cancerele feminineinsa datorita simptomelor nespecifice, ovarian cancer under 50 sa fie diagnosticat in faze avansate. Mutatiile genetice joaca un rol important in determinarea riscurilor de aparitie, dar si de evolutie a bolii. Aceste mutatii pot fi mostenite de la parinti, sau pot fi dobandite pe parcursul vietii. In populatia generala, o persoana din — este purtatoare a unei mutatii.
Conclusion The management of a patient with a Krukenberg tumor requires an interdisciplinary approach, which includes well trained specialists in imagistics, gynecology and general surgery. Due to the fact that imagistic methods and intraoperative aspect are nonspecific, an extensive histopathological analysis with immunohistochemistry tests, performed by a specialist in Pathology, is mandatory in order to establish the diagnosis.
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Ovarian cancer survivor shares advice for newly diagnosed ovarian cancer patients
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Cancerul ovarian si mutatiile BRCA
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Incidenţa endometriozei şi a endometriozei atipice în cazul tumorilor ovariene epiteliale
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