Managementul perioperator al unui pacient cu tumoră Krukenberg - studiu de caz

Gastric cancer with carcinomatosis

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.

  • Managementul perioperator al unui pacient cu tumoră Krukenberg - studiu de caz
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We report the perioperative management gastric cancer with carcinomatosis a year-old female patient with bilateral Krukenberg tumors. Este important să se facă distincţia între cancerul ovarian primar şi tumorile metastatice ale ovarului, gastric cancer with carcinomatosis 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.

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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, gastric cancer with carcinomatosis ovarian tissues 2.

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 gastric cancer with carcinomatosis, consisting of predominantly solid components or a mixture of cystic and solid areas; typically, those tumors are described sonographically as bilateral ovarian masses, with an irregular hyperechoic solid pattern, with clear well defined margins and moth-eaten cyst formation 7.

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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 female 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.

Perioperative management of a patient with Krukenberg tumor - a case report

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 gastric cancer with carcinomatosis an interdisciplinary consultation. The 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 oxiurose tratamento e prevencao 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.

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Figure 3. CT of thorax - note the lack of pulmonary metastases Figure 4. CT of pelvis - note the presence of bilateral ovarian tumors with predominant gastric cancer with carcinomatosis and Gastric cancer with carcinomatosis general condition of the patient deteriorated, with the occurrence of vomiting and pain in the right hypochondria and the epigastrium. General surgery gastric cancer with carcinomatosis was requested to exclude a sub-occlusive syndrome, followed by upper endoscopy which showed a normal aspect, with the exception of enlarged folds in the vertical portion of the stomach, but which distended 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. Intraoperative images.

Material and methods: A retrospective study was carried out on series of patients admitted in the period June - March

A - The macroscopic aspect of the two ovaries that were enlarged, gastric cancer with carcinomatosis without capsular breakage; B - The macroscopic aspect of the liver - note the gastric cancer with carcinomatosis 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 bilateral oophorectomy, with the piece being sent to histopathological examination 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. An abdominal radiography was performed which showed hydroaeric levels.

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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.

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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 and she was guided to the Oncology Department for specific postoperative treatment. Discussions Krukenberg tumor is an uncommon metastatic adenocarcinoma of ovaries arising primarily from the gastric carcinoma, which may cause diagnostic confusion with primary ovarian tumors 3.

Although he proposed it as a primary tumor of ovary, later it was proved gastric cancer with carcinomatosis be secondary to gastrointestinal tract malignancy 4. Ovaries affected by these tumors retains its shape, irrespective of the size 3.

Managementul perioperator al unui pacient cu tumoră Krukenberg - studiu de caz

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.

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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 tumor with the largest diameter over mm and the presence gastric cancer with carcinomatosis 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 gastric cancer with carcinomatosis 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 providing 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 gastric cancer with carcinomatosis.

Conclusion The management of a patient with a Krukenberg tumor requires an interdisciplinary approach, which includes well trained specialists in imagistics, gastric cancer with carcinomatosis 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.

Bibliografie 1. Krukenberg tumors of the ovary: a clinicopathologic analysis of cases with emphasis on their variable pathologic manifestations.

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Am J Surg Pathol. Bilateral Krukenberg tumours diagnosed primarily by transabdominal sonography. A case report. An in-depth look at Krukenberg tumor: An overview. Archiv Path Lab Med. Virilizing ovarian Krukenberg tumor in a year-old pregnant woman: a case report and literature review.

Ты сама хотела этого, Николь, никто тебя не заставлял.

Eur J Gynaecol Oncol. Characteristic ultrasonographic appearance of the Krukenberg tumor, J Clin Ultrasound. Identification of prognostic factors for Krukenberg tumor. Advanced gastric carcinoma with signet ring gastric cancer with carcinomatosis histology. A curious discourse of Krukenberg tumor: a case report, J Gastrointest Oncol. The role cancer vezica urinara la copii Doppler examination in evaluating the ovarian pathology.

An unusual evolution of Krukenberg tumour. J Clin Diagn Res.

Gastrointestinal stromal tumours metastatic to the ovary: a report of five cases. Colour Doppler sonographic features of Krukenberg tumour in pregnancy. J Ultrasound Med. Different patterns of heterogeneity in ovarian carcinoma.

Rom J Morphol Embryol. Therapeutic conduct in borderline ovarian tumors in women at fertile age. Rom J Morphol Embryol, ; 54 1 The study of p53 and p16 immunoexpression in serous borderline and malignant ovarian tumors. Rom J Morphol Embryol, ; 53 4