Krukenberg tumor with concomitant ipsilateral hydronephrosis and spermatic cord metastasis in a man: A case report

BACKGROUND Tumors of the spermatic cord are rare,and approximately 25%are malignant neoplasms.Metastatic spermatic cord tumors are even rarer.Several studies have revealed that the most frequent primary tumors metastasizing to the spermatic cord and peritesticular tissues are neoplasms of the stomach and prostate.Furthermore,metastasis to the spermatic cord or epididymis may occur via retrograde lymphatic and hematic routes.We present the case of a man with gastric cancer that metastasized to the spermatic cord and epididymis,with concomitant ipsilateral hydronephrosis after surgical resection and chemotherapy for his primary tumor.CASE SUMMARY A 71-year-old man underwent total gastrectomy for pT4aN2 poorly differentiated gastric adenocarcinoma in December 2016.Two months after surgery,he received adjuvant chemotherapy with TS-1 from February 2017 to February 2018.Surveillance computed tomography(CT)was performed in June 2018,which did not reveal any sign of tumor recurrence.In November 2019,he presented with left lower quadrant abdominal pain and a palpable left inguinal-scrotal mass.CT revealed left mild hydronephrosis and a left scrotal mass measuring 4.0 cm×1.7 cm.Tumor biomarkers,including alpha-fetoprotein(AFP),lactate dehydrogenase(LDH),beta-human chorionic gonadotropin(βHCG),carcinoembryonic antigen(CEA),and carbohydrate antigen 19-9(CA19-9)were all normal.Renal and testicular echography showed left hydronephrosis and a left peritesticular soft tissue lesion with blood flow.Diagnostic ureteroscopy showed left lower ureter narrowing without an intraluminal lesion.A biopsy was obtained for the indurated spermatic cord and epididymis,which showed poorly differentiated adenocarcinoma.Immunohistochemical staining demonstrated that the tumor was diffusely and strongly positive for homeobox protein CDX2.The features were consistent with metastatic adenocarcinoma of a primary gastric tumor.CONCLUSION In patients with a history of primary cancer,an inguinal mass of unknown cause with accompanying ipsilateral hydronephrosis may be a sign of distant metastasis from a primary tumor,especially of gastrointestinal origin.

An Up-to-Date Understanding of the “Krukenberg Tumor” Mechanism

Krukenbergtumor is a metastatic ovarian tumor with its primary site being the gastrointestinal tract. The pathogenesis of Krukenberg tumor formation is still in its hypothetical stage though the current understanding suggests lymphatic, hematogenous and transcoelomic route as the 3 major route of metastasis. There is a lack of description in the literature related to the pathway of metastasis. Here, we intend to search the available literature and provide a thorough review, which may be helpful to the readers to understand the issue of mechanism of Krukenberg tumor metastasis more clearly.

Expression and correlation of CD44v6, vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 in Krukenberg tumor

AIM: To explore the expression and correlation of CD44v6,vascular endothelial growth factor (VEGF), matrix metalloproteinase (MMP)-2 and matrix metalloproteinase (MMP)-9 in Krukenberg and primary epithelial ovarian carcinoma.METHODS: The expressions of CD44v6, VEGF, MMP-2and MMP-9 were detected by immunohistochemical method in 20 cases of normal ovarian tissues, 38 cases of Krukenberg tumor and 45 cases of primary epithelial ovarian carcinoma.RESULTS: The expression of CD44v6 (primary epithelial ovarian carcinoma tissue vs normal ovarian tissue:x2= 4.516, P= 0.034; Krukenberg tumor tissue vsnormal ovarian tissue: x2 = 19.537, P= 0.001) and VEGF (primary epithelial ovarian carcinoma tissue vs normal ovarian tissue: P = 0.026; Krukenberg tumor tissue vs normal ovarian tissue: x2= 22.895, P = 0.001) was significantly higher in primary epithelial ovarian carcinoma tissue and Krukenberg tumor tissue than in normal ovarian tissue.The positive expression rate of MMP-2 and MMP-9 was 0%in the normal ovarian tissue. The positive expression rate of CD44v6 (x2 = 10.398, P = 0.001), VEGF (x2 = 13.149,P= 0.001), MMP-2 (x2= 33.668, P= 0.001) and MMP-9(x2= 38.839, P = 0.001) was remarkably higher in Krukenberg tumor than in primary epithelial ovarian carcinoma. The correlation of CD44v6, VEGF, MMP-2, and MMP-9 was observed in primary epithelial ovarian carcinoma and Krukenberg tumor.CONCLUSION: CD44v6, VEGF, MMP-2, and MMP-9 are involved in ovarian carcinoma, gastric cancer and Krukenberg tumor. Detection of CD44v6, VEGF, MMP-2and MMP-9 may contribute to the diagnosis of ovarian carcinoma, gastric cancer, and Krukenberg tumor.

Palliative surgery for Krukenberg tumors—12-year experience and review of the literature

AIM To determine the clinical characteristics of patients undergoing palliative surgery for Krukenberg tumors,including disease presentation,outcomes,and prognostic factors.METHODS This was a retrospective clinical study of all patients who underwent palliative surgery for Krukenberg tumors between January 2004 and December 2015.Patient information was obtained from inpatient and outpatient case notes as well as the hospital electronic records.Patients who underwent potential y curative resection,and patients with Krukenberg tumors who did not undergo surgery were also excluded from the study.Palliative surgery was defined as those performed for either alleviation of symptoms or for asymptomatic patients for whom surgical removal of the tumors were deemed necessary following a multidisciplinary consensus.Tumors were diagnosed pre-operatively by computed tomography scans and all had histologic confirmation of the surgical specimens.RESULTS Over the study duration,38 female patients underwent palliative surgery for Krukenberg tumors at our institution.Mean age was 54.2±11.7 years.The colon was the most frequent primary source of metastases(n=21)followed by the stomach(n=4).Prophylactic palliative surgery was performed for eight(21.1%)asymptomatic patients.Median post-operative length of stay was 8 d(IQR 6-12 d).Five patients(13.2%)experienced postoperative complications,although high grade morbidity was only seen in one patient(2.6%).Median overall survival from surgery was 17 mo(95%CI:12.1-21.9)at a median follow-up duration of 12 mo(IQR 8-17mo).The median survival was shorter for patients who underwent emergency surgery,younger patients,those with a colorectal primary,larger tumors,or synchronous peritoneal or hepatic metastases.CONCLUSION Pal iative surgery for Krukenberg tumors can be performed safely with acceptable complication rates.Bilateral oophorectomy should be performed to prevent the risk of symptomatic contralateral tumors.

Tumor-Specific Histo-Blood Group Antigens: Apropos of Two Cases

Cancer cells with immunogenic properties having altered protein glycosylation, modified blood group substances have been widely studied. Due to the genetic instability occurring during carcinogenesis the glycosyltransferases may suffer from posttranslation sequence modification. The author describes 2 autopsy cases, where in the background of the unusual metastatic tumor presentation, incompatible blood group antigenic determinants have been demonstrated using blood group specific lectins and monoclonal antibodies (mAb). In the first case, reported here, a 10-year-old girl developed an acute myeloid leukemia and died in a septic endotoxin shock after successful cytostatic treatment of a juvenile signet ring cell cancer of her colon. At autopsy there were no signs of tumor except bilateral apple-sized mucinous ovarian (Krukenberg) metastases. While she had erythrocyte phenotype of blood group A, the signet ring adenocarcinoma cells expressed blood group B incompatible antigenic determinants with lectin/mAb. In the second case, the autopsy of a 78-year-old female resulted in no macroscopic tumor sign except a moderately enlarged, ham hard spleen. Light microscopy revealed adenocarcinomatous infiltration in the splenic sinusoids. The patient had blood group O, while the metastatic cells in the spleen reacted with Breast Carcinoma Antigen (BioGenex) and incompatible anti-B Banderiaeasimplicifolia agglutinin I and anti-B mAb. It proved to be a case of an occult, completely regressed breast cancer. Based on these observations the expression of tumor specific incompatible blood group antigens might occur from time to time, mostly in adenocarcinomas. Accordingly, blood group-based specific immuno-oncotherapy could be considered in some cancer cases.

Krukenberg瘤的CT诊断

目的 回顾性分析胃肠道来源的Krukenberg瘤的CT表现 ,并与病灶表现为Ⅱb、Ⅱc型的原发性卵巢肿瘤相比较。资料与方法 1 6例含有印戒状粘液细胞的Krukenberg瘤和 1 6例表现为Ⅱb、Ⅱc型的原发性卵巢肿瘤。肿瘤分为 3型 :Ⅰ型为囊性 ;Ⅱ型为囊实性 ,又分为 3个亚型 ,即Ⅱa型、Ⅱb型、Ⅱc型 ;Ⅲ型为实性。Ⅱb、Ⅱc型病灶内可伴或不伴囊肿 ,囊壁可强化或不强化。结果 1 6例Krukenberg瘤CT发现 2 6个肿瘤 ,1 1例为双侧病灶(68.8% ) ,4例为单侧病灶 (2 5 .0 % ) ,1例CT未发现病灶 ;2 6个肿瘤中Ⅱa型 4个 ,Ⅱb型 7个 ,Ⅱc型 1 0个 ,Ⅲ型 5个 ;1 7个Ⅱb、Ⅱc型病灶中 1 5个有明显囊肿 ,其中 8个显示囊壁有明显强化 (47.1 % )。 1 6例原发性卵巢肿瘤CT发现 2 2个肿瘤 ,6例为双侧病灶 (37.5 % ) ,1 0例为单侧病灶 (62 .5 % )。 2 2个肿瘤中Ⅰ型 1个 ,Ⅱb型 5个 ,Ⅱc型 1 6个。2 1个Ⅱb、Ⅱc型病灶中 2 0个有明显囊肿 ,其中仅 4个显示囊壁有强化 (1 9.0 % )。结论 卵巢双侧若出现混合性或实性为主的病灶应想到Krukenberg瘤的可能 。

36例卵巢Krukenberg瘤的临床病理特点分析

目的探讨卵巢Krukenberg瘤的临床病理特点,提高对本病的重视。方法回顾性分析经手术病理证实的36例卵巢Krukenberg瘤患者的临床病理资料。结果卵巢krukenberg瘤多见于绝经前女性(23/36),多见于双侧卵巢(22/36);原发灶病理类型多为低分化腺癌及黏液腺癌;胃来源的21例,结直肠来源13例,阑尾来源2例,多数患者1年内死亡。结论了解卵巢Krukenberg瘤的临床病理特点,有助于提高诊断率;诊断卵巢恶性肿瘤时应行胃肠道检查排除转移癌;诊断胃肠道恶性肿瘤时,应行盆腔检查排除转移至卵巢;卵巢Krukenberg瘤的首选治疗方法为根治性手术加化疗。

超声检查对Krukenberg肿瘤诊断的临床价值

对30例经手术病理证实的Krukenberg肿瘤（库肯勃瘤）患者的超声或双工彩色多普勒超声扫查图像进行了分析。结果表明：病变累及双侧26例，占86.7％。超声首先提示本病诊断有22例，定性诊断正确率为73.3％。本病典型声像图特征为实质性肿块内有一至数个大小不等的类圆形的无回声区，外形如肾形或椭圆形，大多有包膜，边界清楚。本组此型占85.7％（48/56个肿块），其平均大小为9.5cm。其中6例（10个）库肯勃瘤患者同时作了彩色多普勒超声扫查，发现卵巢肿瘤周边或内部有彩色血流信号，呈动脉频谱，为高速低阻型，其测值为ps50～68cm/s（x^-±s为58.0±4.8cm/s），RI：0.38～0.46（x^-±s为0.41±0.03）。病理对照发现，病灶内类圆形无回声区系印戒细胞分泌粘液所致。

卵巢印戒细胞间质瘤与Krukenberg瘤鉴别诊断的探讨

目的:探讨卵巢印戒细胞间质瘤(signet-ring stromal tumor,SRST)与Krukenberg瘤的鉴别诊断。方法:对4例卵巢SRST和10例Krukenberg瘤进行病理学对比观察。结果:SRST为单侧发生,无复发和转移,组织学无上皮分化,PAS-D和CK阴性,Vim阳性。Krukenberg瘤双侧发生或伴有卵巢外肿瘤,平均生存期18.1个月。组织学有上皮分化,PAS-D和CK阳性,Vim阴性。结论:SRST易误诊为Krukenberg瘤,结合临床病理特征、组织化学和免疫组织化学有助于二者的鉴别。

卵巢Krukenberg瘤的临床诊治(附20例分析)

目的:探讨卵巢Krukenberg(库肯勃)瘤的临床特点、诊断及治疗方法。方法:回顾分析我院2002年6月至2007年12月收治的20例卵巢Krukenberg瘤患者的临床资料。结果:20例患者年龄28～83岁,平均(50±14)岁,多为中青年女性。本组转移灶位于双侧卵巢者13例(65%),单侧者7例(其中右侧5,左侧2例);原发灶病理类型为胃低分化腺癌,部分印戒细胞16例,结肠腺癌3例,乳腺浸润性导管癌1例;同时性转移13例(65%),异时性转移7例(35%,转移时间为6个月至3年)。结论:Krukenberg瘤有其特珠临床特点,易漏诊、误诊;确诊为卵巢恶性肿瘤时应首先排除转移癌的可能;发现卵巢转移肿瘤者,应常规行胃肠道检查以寻找原发灶;手术是卵巢Krukenberg瘤首选治疗方式。

卵巢krukenberg瘤的高场磁共振诊断

目的分析krukenberg瘤的MR表现,以期提高临床诊断的准确性。方法回顾性分析13例经临床及手术病理证实的Krukenberg’s瘤的MR表现。结果 13例krukenberg瘤共发现22例病灶,发生于双侧卵巢9例,单侧卵巢4例。22个病灶中有实性12个,囊实性7个,多房囊性3个,增强扫描病灶实性部分明显强化。结论 Krukenberg瘤有其特珠临床特点,易漏诊、误诊,若双侧卵巢出现实性、囊实性及多房囊性的病灶应想到Krukenberg瘤的可能,尤其肿块出现明显强化且胃肠道有原发病灶。

阑尾原发性腺癌晚期形成Krukenberg瘤的临床分析

目的:探讨阑尾原发性腺癌晚期形成Krukenberg瘤的临床特点、诊断及治疗。方法:分析1例表现为Krukenberg瘤的阑尾原发性腺癌患者的临床资料,并复习相关文献。结果:阑尾原发性腺癌晚期转移形成Krukenberg瘤的病例较为罕见,并且缺乏特异性临床表现,极易漏诊、误诊,术前或术中即明确诊断者极少见,绝大多数是通过术后组织病理学诊断而最终确诊。右半结肠切除术是阑尾原发性腺癌的首选治疗方式,术后辅以化疗等综合治疗。结论:以Krukenberg瘤为首发表现的病例在寻找原发癌灶时应考虑到原发性阑尾恶性肿瘤的可能。术中对阑尾的仔细探查是必要的,若发现阑尾形态异常改变除了及时行阑尾切除,术中还应对其进行冰冻病理检查以提高术中确诊率,指导手术治疗。

34例Krukenberg瘤的临床病理分析

目的分析Krukenberg瘤患者的临床病理特点及治疗,寻找预后相关因素。方法回顾性分析34例确诊为Krukenberg瘤且有完整生存资料者的临床病理特征,对生存相关参数进行单因素及多因素分析。结果年龄14～73岁,中位年龄41岁;原发瘤包括胃癌20例(58.8%),结肠癌6例(17.7%),直肠癌7例(20.6%),不明者1例(2.9%);单侧卵巢转移12例(35.3%);双侧卵巢转移22例(64.7%);全组患者生存时间为0～55个月,中位生存11.0个月。单因素分析显示,年龄≤50岁者预后较差(P=0.011),化疗≥4周期者生存期较长(P=0.006);多因素分析显示仅年龄与预后相关(P=0.005)。结论 Krukenberg瘤患者预后差,目前尚未发现有效化疗方案,绝经后女性、经积极手术治疗并完成≥4周期化疗者预后相对较好。

Differential Diagnosis of Primary and Metastatic Ovarian Tumors by Determination of Serum Testosteronelevels:Preliminary Investigation

Serum testosterone concentration levels were measured in 27 female patients with ovarian masses and n 8 female patients with malignant gastrointestinal tumors. The serum testasterone levels were found to be a more specific marker,compared with other methods, in the differential diagnosis of primary and metastatic tumors(P<0.01).Serum testosterone was at abnormally high levels inpatients with Krukenberg tumors assoiated with signet cells and luteinized stroma cells, but fell to very low levels after oophoiectomy. Testosterone levels were normal showever in patients with poorly-differentiated metastatic ovarisn tumors, or with gastro-intestinal cancers not involving the ovaries.We also found that testosaterone levels in patients with mucinous adenocarcinoma of either ovary or of the gastro-intestinal tract were higher than in patients with other types of tumor(P<0.05).

在 Krukenberg 肿瘤的一种情况中的 ultrasonography 和提高对比的 ultrasonography 的角色

We report a case of Krukenberg tumor of gastric origin with adnexal metastasis,in which ultrasonography(US) and contrast-enhanced US(CEUS) played a key diagnostic role.An 64-year-old female patient was referred to our department for abdominal pain,nausea and ascites.US examination was performed as first line diagnostic imaging approach,confirming the presence of ascites and detecting marked thickness of the gastric wall and a right adnexal mass.CEUS was immediately performed and showed arterial enhancement followed by wash-out in the venous phase of both the gastric wall and the adnexal mass,suggesting the diagnosis of gastric cancer with right adnexal metastasis(Krukenberg syndrome).The patient underwent USguided paracentesis and esophagogastroduodenoscopy that showed linitis plastica.Cytologic examination of the peritoneal fluid revealed the presence of signetring cells,and histologic examination of the specimen obtained by endoscopic biopsy showed primary gastric mucus-producing adenocarcinoma with signetring cells.Although transvaginal US is undoubtedly the method of choice to evaluate ovarian tumors,abdominal US and CEUS can provide key diagnostic elements,supporting clinicians in the first steps of the diagnostic work-up of abdominal and pelvic masses.

Krukenberg瘤的磁共振诊断

目的:比较Krukenberg瘤与原发性卵巢肿瘤的MRI特点,探讨Krukenberg瘤的影像学特征。方法:回顾性分析经手术病理证实的24例Krukenberg瘤和60例原发性卵巢肿瘤的MRI表现。依据MRI信号将肿瘤分为3型:实性为主型、囊实性及囊性为主型。结果:24个Krukenberg瘤患者共发现39个病灶,发生于双侧卵巢15例、单侧9例。39个病灶中,实性为主型20个、囊实性11个、囊性为主型8个;增强后病灶实性成分和(或)囊壁明显强化。60例卵巢原发肿瘤患者共发现87个病灶,发生于双侧卵巢27例、单侧33例。87个病灶中,16个实性为主,19个囊实性,52个囊性为主。19个囊实性肿块增强后有4个(4/19,21.0%)囊肿壁明显强化。结论:当双侧卵巢出现实性或囊实性肿块,尤其肿块中囊肿壁出现明显强化时,应考虑Krukenberg瘤的可能。

24例库肯勃瘤的诊治分析

目的探讨Krukenberg瘤的临床特点、诊断及治疗方法.方法回顾性分析我院1980～2004年收治的24例Krukenberg瘤的临床资料.结果 Krukenberg瘤好发于中年女性,多为双侧(18/24),原发灶病理类型多为低分化腺癌或粘液腺癌.临床分期多为中晚期(Ⅲ期、Ⅳ期胃癌15例,Dukes C、D期大肠癌7例,Dukes B期大肠癌1例,阑尾粘液类癌1例).恶性度高,易漏诊,预后极差,平均生存期不超过2年.结论确诊为卵巢恶性肿瘤时应首先排除转移癌的可能,发现卵巢转移肿瘤者,应常规行胃肠道检查以寻找原发灶.女性胃肠癌患者应考虑有无卵巢转移.有卵巢转移者,手术为首选治疗方式,需同时切除胃肠原发病灶、子宫及双侧附件.无卵巢转移者是否行预防性卵巢切除术应遵循个体化原则.

库肯勃瘤组织VEGF,TGF-β_1,MMP-2,MMP-9表达的意义

目的:研究VEGF,TGF-β1,MMP-2,MMP-9在卵巢原发上皮性肿瘤、库肯勃瘤中的表达及其相关性, 以探讨其在库肯勃瘤发生、发展中的作用. 方法:应用免疫组化S-P法检测VEGF,TGF-β1, MMP-2,MMP-9在45例卵巢原发上皮性肿瘤、38 例库肯勃瘤中的表达情况. 结果:VEGF、TGF-β1在卵巢原发上皮性肿瘤和库肯勃瘤组织中的表达显著高于正常卵巢组织(VEGF: x2=5.318,P=0.021;x2=22.985,P=0.001. TGFβ1:x2=9.778,P=0.002;x2=12.584,P=0.001). MMP-2,MMP-9在正常卵巢组织中表达缺如; VEGF,MMP-2,MMP-9在库肯勃中阳性表达率明显高于卵巢原发上皮性肿瘤(VEGF:x2=13.149,P=0.001; MMP-2:x2=33.668,P=0.001;MMP-9:x2=38.839, P=0.001);TGF-β1阳性表达率在卵巢原发上皮性肿瘤和库肯勃瘤之间无显著差异.VEGF,TGF-β1, MMP-2,MMP-9在卵巢原发上皮性肿瘤、库肯勃瘤中,任意两指标阳性表达均有正相关性(P<0.05或P<0.01). 结论:VEGF,TGF-β1,MMP-2,MMP-9参与卵巢癌、库肯勃瘤的发生、发展及演进过程,并可为卵巢上皮性肿瘤及库肯勃瘤的鉴别诊断提供一定依据.

卵巢转移性肿瘤70例临床分析

自１９５７年３月～１９９５年１２月，共收治卵巢转移性肿瘤７０例，占同期收治的卵巢恶性肿瘤１２．７％。原发部位肿瘤主要是胃癌（占７５．７％）。主要临床表现是消化道症状和盆腔包块伴腹水。术前诊断率为３８．６％。术后病检为卵巢库肯勃克瘤占６８．６％，其余主要为其他类型转移性腺癌。治疗仍以手术为主，但存活期一般不超过１年。如何提高术前诊断正确率，作者提出了四点建议，供同道们参考。

VEGF、MMP-2、MMP-9在卵巢原发性与转移性癌中表达的研究

目的 :探讨VEGF、MMP 2、MMP 9在卵巢原发上皮癌、库肯勃氏瘤中的表达差异及临床病理意义。方法 :采用免疫组化S P染色技术对 83例卵巢癌 (卵巢原发癌 4 5例、库肯勃氏瘤 38例 )进行分析 ,观察VEGF、MMP 2、MMP 9在卵巢癌中的表达。结果 :VEGF在卵巢原发癌和库肯勃氏瘤组织中的表达显著高于正常卵巢组织 (P <0 .0 5 ) ;MMP 2、MMP 9在正常卵巢组织中表达缺如 ;VEGF、MMP 2、MMP 9在卵巢原发癌与库肯勃氏瘤中表达均有显著差异 (P <0 .0 5 ) ;VEGF、MMP 2、MMP 9在库肯勃氏瘤中及卵巢原发癌中 ,任意两指标阳性表达均有正相关性 (P <0 .0 5 )。结论 :VEGF、MMP 2、MMP 9在库肯勃氏瘤的形成机制中起重要作用 ,与肿瘤的浸润转移密切相关 。