Tubular Krukenberg tumor. A problem in histopathologic diagnosis

Clinics and pathology of Krukenberg tumor: a systematic review and meta-analysis

INTRODUCTION

Krukenberg tumor (KT) is defined as a secondary neoplasm of the ovary. While ovarian metastases account for about 30% of ovarian tumors, KTs are rare, accounting for about 1-2% of the total. The rarity of KT is at least in part responsible for the lack of a precise clinic-pathological characterization of these tumors. Clinically, KT may have a subtle clinical presentation, with few symptomatic manifestations and nonspecific clinical signs, even though in literature there is disagreement about the clinical presentation of these patients; such difficulties in the diagnostic framework often leads to a delayed diagnosis with serious consequences on the patient outcome. We aimed to provide a clinico-pathological characterization of Krukenberg Tumor (KT) through a systematic review and meta-analysis to improve the diagnosis and management of KT.

EVIDENCE ACQUISITION

Electronic databases were searched for all studies assessing clinico-pathological features of KT series. Pooled prevalence of each clinical or pathological factor was calculated according to the random-effect model.

EVIDENCE SYNTHESIS

Forty-eight studies with 3025 KT patients were included; 39.7% of patients were ≥50 and 39.8% were postmenopausal. The most common primary tumor sites were stomach (42.5%), colon-rectum (26.1%), breast (9.3%), and appendix (5%); 48.7% of KTs were synchronous with the primary tumor, 64.3% were bilateral, 40.5% had a diameter ≥10 cm; 55.3% showed extraovarian extent and 49% showed peritoneal involvement. The most common presenting symptoms were ascites (51.7%), palpable mass (31.3%), pain (29.3%), abdominal distention (28.7%), irregular bleeding (9.1%), asymptomatic (11.2%).

CONCLUSIONS

KT shows a highly variable presentation. Understanding the prevalence of clinico-pathological factors may be helpful to improve the diagnosis and management of KT.

An Epithelioid Smooth Muscle Neoplasm Mimicking a Signet Ring Cell Carcinoma in the Ovary

A 53-yr-old woman who presented with elevated renal indices was discovered to have a 4.5 cm right renal mass and an incidental 9.7 cm left ovarian mass on imaging studies. She underwent a partial nephrectomy and bilateral salpingo-oophorectomy, revealing a chromophobe renal cell carcinoma and an unusual ovarian neoplasm with epithelioid cells displaying prominent signet ring cell-like morphology. Immunohistochemical analysis of the ovarian neoplasm demonstrated that the tumor cells were diffusely immunoreactive for smooth muscle markers and negative for all tested cytokeratins and epithelial membrane antigen. On the basis of these results, the tumor was interpreted as an unusual epithelioid smooth muscle neoplasm with extensive signet ring cell-like features. Along with primary ovarian signet ring stromal tumors and sclerosing stromal tumors, this example adds epithelioid smooth muscle neoplasms with unusual cytologic alterations to the list of uncommon nonepithelial tumors that can simulate metastatic signet ring cell carcinoma (Krukenberg tumor) in the ovary.

Frozen Section Diagnosis of Ovarian Epithelial Tumors: Diagnostic Pearls and Pitfalls

CONTEXT.—

Epithelial tumors of the ovary are one of the most frequently encountered gynecologic specimens in the frozen section laboratory. The preoperative diagnostic workup of an ovarian mass is typically limited to imaging studies and serum markers, both of which suffer from low sensitivity and specificity. Therefore, intraoperative frozen section evaluation is crucial for determining the required extent of surgery, that is, cystectomy for benign tumors, oophorectomy or limited surgical staging for borderline tumors in younger patients to preserve fertility, or extensive staging procedure for ovarian carcinomas. Ovarian epithelial tumors may exhibit a wide range of morphologic patterns, which often overlap with each other and can mimic a variety of other ovarian nonepithelial neoplasms as well. A combination of careful gross examination, appropriate sampling and interpretation of morphologic findings, and familiarity with the clinical context is the key to the accurate frozen section diagnosis and successful intraoperative consultation.

OBJECTIVE.—

To review the salient frozen section diagnostic features of ovarian epithelial tumors, with special emphasis on useful clinicopathologic and morphologic clues and potential diagnostic pitfalls.

DATA SOURCES.—

Review of the literature and personal experience of the author.

CONCLUSIONS.—

Frozen section evaluation of ovarian tumors continues to pose a significant diagnostic challenge for practicing pathologists. This review article presents detailed discussions of the most common clinical scenarios and diagnostic problems encountered during intraoperative frozen section evaluation of mucinous, serous, endometrioid, and clear cell ovarian tumors.

Ovarian tumors: a survey of selected advances of note during the life of this journal

The author reviews highlights of advances in knowledge concerning ovarian tumor pathology since the time of an essay in the first issue of this Journal written by Dr Robert E. Scully, who, both before and for several decades after the Journal was instituted, made many original contributions to the field and was the major architect of the 1973 World Health Organization classification of ovarian tumors which was much more clear and logical than prior ones. The current review considers the neoplasms in essentially the same order as was done in the first issue of this journal and presents a personal look at the highlights of new information concerning various well-known categories, surface epithelial, germ cell, sex cord-stromal, metastatic neoplasms and briefly, benign so-called tumor-like lesions. Some of the most notable developments are as follows: (1) an orderly approach to the classification of implants of serous borderline tumors into noninvasive and invasive categories; (2) recognition of distinctive micropapillary patterns seen in some borderline tumors and low-grade carcinomas; (3) a remarkable propensity for some endometrioid carcinomas to mimic sex cord- stromal tumors; (4) appreciation of the differences between primary mucinous tumors of intestinal and müllerian types; (5) the importance of distinguishing within primary mucinous carcinomas between expansile and destructive stromal invasion; (6) emphasis on the diagnosis of immature teratoma being based on the presence of primitive-embryonic-appearing tissues; (7) appreciation of variant morphology of cases of struma ovarii which may lead to significant diagnostic problems; (8) subdivision of granulosa cell tumors into adult and juvenile types because of the differing features of the two groups including in the second category the propensity for more malignant neoplasms to be mimicked; (9) recognition of a distinctive form of Sertoli-Leydig cell tumor, the retiform variant, with a propensity to occur in the young; (10) appreciation of a unique highly malignant neoplasm that typically afflicts the young and may be associated with hypercalcemia, so-called small cell carcinoma of hypercalcemic type; (11) greater awareness than was hitherto the case of the propensity for metastatic intestinal adenocarcinoma to mimic primary endometrioid carcinoma and similarly for metastatic mucinous carcinomas to simulate primary mucinous cystic tumors; (12) recognition of the distinctive features of low-grade appendiceal mucinous neoplasms that spread to the ovary and are typically associated with pseudomyxoma peritonei; and (13) appreciation that the histologic spectrum seen in cases of Krukenberg tumor is broader than often previously thought.

Ovarian Sex Cord-Stromal Tumors: Reflections on a 40-Year Experience With a Fascinating Group of Tumors, Including Comments on the Seminal Observations of Robert E. Scully, MD

CONTEXT.—

This year being the 60th anniversary of the publication of the excellent book Endocrine Pathology of the Ovary by John McLean Morris, MD, and Robert E. Scully, MD, the writer reflects on that work and in particular the remarkable contributions of its second author to our knowledge in this area.

OBJECTIVE.—

To review ovarian sex cord-stromal tumors.

DATA SOURCES.—

Literature and personal experience.

CONCLUSIONS.—

The essay begins with remarks on the oftentimes straightforward stromal tumors of the ovary because the commonest of them, the fibroma, dominates from the viewpoint of case numbers. Then, the sclerosing stromal tumor and the peculiar so-called luteinized thecomas of the type associated with sclerosing peritonitis are discussed in greater detail and their wide spectrum is illustrated. Brief mention is made of 2 rare neoplasms: the ovarian myxoma and signet-ring stromal tumor. Discussion then turns to the more recently recognized intriguing tumor tentatively designated microcystic stromal tumor and the commonest malignant tumor in this entire family, the so-called adult granulosa cell tumor, which despite its name may occasionally be seen in young individuals. The second variant of granulosa cell tumor-that which usually, but not always, occurs in the young-the so-called juvenile granulosa cell tumor, is then discussed. In the section of Sertoli-Leydig cell tumors, particular attention is focused on unusual tumors with heterologous elements and the remarkable so-called retiform tumors, which have a predilection for the young, often have distinctive gross features, and exhibit slitlike spaces and papillae. The essay concludes with consideration of the sex cord tumor with annular tubules.

Adenocarcinoma of the Lung Metastatic to the Ovary With a Signet Ring Cell Component

A nonsmoker 45-year-old woman, presented with a solid right ovarian mass. Microscopic examination revealed heterogeneous histology with tubular formations and extensive signet ring cell component that resembled the usual appearance of metastatic gastric carcinoma to the ovary. Moreover, the histology also showed solid nests of cells with a microvacuolated basophilic cytoplasm similar to those found in adenosquamous cervical carcinoma of glassy cell type. However, analysis of the patient's past history revealed a lung adenocarcinoma, diagnosed 4 years before, which prompted an immunohistochemical differential diagnosis, showing a strong expression for TTF-1 and Napsin A. A cervical primary was excluded taking into account both macroscopic findings and the negative expression of PAX8 and absence of human papillomavirus-related marker p16. This confirmed the pulmonary origin of ovarian tumor despite its heterogeneous morphology. This is the first reported case of ovarian metastatic lung adenocarcinoma, with a signet ring cell component and solid nests, mimicking both metastatic gastric carcinoma and adenosquamous carcinoma of glassy cell type.

Feto-maternal outcomes of pregnancy complicated by Krukenberg tumor: a systematic review of literature

PURPOSE

Krukenberg tumor is a rare type of ovarian cancer with a poor prognosis, and little is known about its behavior during pregnancy.

METHODS

A systematic review was conducted to identify pregnancies complicated by Krukenberg tumor, correlated to oncologic and neonatal outcomes (n = 35).

RESULTS

Mean age of cases was 30.4 years, and the most common origin of primary cancer was the stomach (68.6 %) followed by the colon (14.3 %). The two most common presenting symptoms were abdominal/pelvic pain (51.4 %) and nausea/vomiting (48.6 %). Two-thirds of tumors were bilateral (65.7 %) and the average size was 16.7 cm. Ascites (45.7 %), carcinomatosis (25.7 %) and non-ovarian distant metastases (14.3 %) were found at the time of surgery. Chemotherapy was administered in 20 cases, with fetal exposure in two of these. The ovarian tumor was identified prior to the primary cancer diagnosis in all 28 cases. The overall number of live births was 27 (81.8 %). The median survival was 6 months after Krukenberg tumor diagnosis. In univariate analysis, decreased overall survival was associated with dyspnea, ascites, carcinomatosis, non-radical surgery for the primary cancer, and residual disease at surgery (all, p < 0.05). On multivariate analysis, dyspnea and carcinomatosis remained independent prognostic factors for decreased overall survival after Krukenberg tumor diagnosis (2-year overall survival rates, dyspnea 0 vs. 56.6 %, adjusted-hazard ratio [HR] 9.74, 95 % confidence interval [CI] 2.04-46.2, p < 0.01; and carcinomatosis, 0 vs. 58.1 %, adjusted-HR 7.95, 95 % CI 1.76-36.0, p < 0.01).

CONCLUSIONS

Our results showed that prognosis of Krukenberg tumor complicated pregnancies is extremely poor, however it may be improved if radical surgery is achievable.

Autotransplantation of cryopreserved ovarian tissue in cancer survivors and the risk of reintroducing malignancy: a systematic review

BACKGROUND The risk of recurrent oncological disease due to the reintroduction of cancer cells via autotransplantation of cryopreserved ovarian tissue is unknown. METHODS A systematic review of literature derived from MEDLINE, EMBASE and the Cochrane Library was conducted. Studies on follow-up after autotransplantation; detection of cancer cells in ovarian tissue from oncological patients by histology, polymerase chain reaction or xenotransplantation; and epidemiological data on ovarian metastases were included. RESULTS A total of 289 studies were included. Metastases were repeatedly detected in ovarian tissue obtained for cryopreservation purposes from patients with leukaemia, as well as in one patient with Ewing sarcoma. No metastases were detected in ovarian tissue from lymphoma and breast cancer patients who had their ovarian tissue cryopreserved. Clinical studies indicated that one should be concerned about autotransplantation safety in patients with colorectal, gastric and endometrial cancer. For patients with low-stage cervical carcinoma, clinical data were relatively reassuring, but studies focused on the detection of metastases were scarce. Oncological recurrence has been described in one survivor of cervical cancer and one survivor of breast cancer who had their ovarian tissue autotransplanted, although these recurrences may not be related to the transplantation. CONCLUSIONS It is advisable to refrain from ovarian tissue autotransplantation in survivors of leukaemia. With survivors of all other malignancies, current knowledge regarding the safety of autotransplantation should be discussed. The most reassuring data regarding autotransplantation safety were found for lymphoma patients.

Metastatic Neoplasms Involving the Ovary

In this review, ovarian metastatic carcinomas from various sites, as well as other neoplasms secondarily involving the ovary, are discussed. As well as describing the morphology, the value of immunohistochemistry in distinguishing between primary and metastatic neoplasms in the ovary is discussed. While immunohistochemistry has a valuable role to play and is paramount in some cases, the results should be interpreted with caution and with regard to the clinical picture and gross and microscopic pathologic findings.

Ovarian Metastases of Appendiceal Tumors With Goblet Cell Carcinoidlike and Signet Ring Cell Patterns

Synchronous and metachronous ovarian and appendiceal mucinous tumors are often the subject of diagnostic consultations in gynecologic pathology practices to address whether the tumors are independent neoplasms or related as primary and metastasis. Those with goblet cell carcinoidlike patterns have not been extensively evaluated in a large series. Clinicopathologic features of 30 cases were examined. All patients presented with signs or symptoms related to a pelvic/adnexal or abdominal mass. The ovarian tumors were bilateral in 25 of 28 cases with data on both ovaries and were typically large (mean/median: 14 cm, range: 4.5 to 24.0 cm). The appendices were often firm or thickened but usually did not have a discrete measurable tumor and were not notably enlarged; microscopically, transmural invasion was present in all of them. The ovarian and appendiceal tumors exhibited a variety of patterns of differentiation, including signet ring cell and glandular, with all displaying some goblet cell carcinoidlike patterns (nests, islands, cords, or cryptlike tubules with goblet cells); teratomatous elements were not identified in any ovarian tumors. Chromogranin was expressed in 7 of 19 ovarian tumors (mean/median: 6.3%/0%; range: 0% to 20%) and synaptophysin was expressed in 4 of 18 of these (mean/median: 7.8%/0%; range: 0% to 90%). Chromogranin was expressed in 6 of 16 appendiceal tumors (mean/median: 11.9%/0%; range: 0% to 70%) and synaptophysin was expressed in 6 of 15 of these (mean/median: 16.7%/0%; range: 0% to 90%). Follow-up was available for 25 patients: 17 died of disease at intervals ranging from 4 to 47 months (mean/median: 18/16) and 8 were alive with disease at 1 to 25 months (mean/median: 11/10); median survival was 19 months and the 1-year and 2-year survival rates were 63% and 34%, respectively. The clinicopathologic features of these ovarian tumors indicate they should be labeled as metastatic appendiceal adenocarcinomas rather than as goblet cell carcinoid tumors both to reflect their behavior and help distinguish them from the rare true primary ovarian goblet cell carcinoid tumors. As the ovarian tumors have appreciable components of signet ring cells they qualify as Krukenberg tumors. In cases in which the primary tumor is not already evident, their "goblet cell carcinoidlike" patterns should direct attention to the appendix as a possible source.

[Differential diagnosis of ovarian metastases]

Ovarian metastases comprise 7-10% of all malignant ovarian tumors. The detection of ovarian metastases is difficult because primary ovarian tumors are a morphologically very heterogeneous group, and metastases can simulate an primary ovarian tumor perfectly. A correct diagnosis, however, is most important in order to avoid an unnecessary and ineffective chemotherapy. Therefore, every morphologically unusual ovarian tumor should raise doubts. In addition, mucinous and endometrioid tumors may also be metastatic in nature. Immunohistochemistry, as well as knowledge on the patient's history, will clarify most of the suspicious cases.

From krukenberg to today: the ever present problems posed by metastatic tumors in the ovary: part I. Historical perspective, general principles, mucinous tumors including the krukenberg tumor

This review considers historical aspects of metastatic tumors to the ovary, general principles that aid in their evaluation, and metastatic mucinous tumors, including the Krukenberg tumor. The historical timeline on the Krukenberg tumor dates back to the legendary Sir James Paget and the story is followed through the well-known, albeit flawed, contribution of Friedrich Krukenberg and others who have contributed important papers over the years, including the overlooked contribution of the French investigator Gauthier-Villars. Knowledge of metastatic colorectal carcinoma is traced back to the famed British surgeon Sir John Bland-Sutton and followed through to more recent contributions, including the important one of Lash and Hart. Contributions on mucinous tumors conclude the historical perspective, note being made of the recent evidence suggesting that the long held contention of Dr Robert E. Scully that ovarian mucinous tumors in patients with pseudomyxoma peritonei usually originate from the appendix is correct. The section on general principles highlights the many clinical, gross, microscopic, and special techniques such as immunohistochemistry that may aid in determining that an ovarian tumor is metastatic with emphasis on the first 3 mentioned aspects. Problematic features such as a tendency for metastatic tumors to be cystic, even when the primary tumors are not, and for many metastatic tumors to mature in the ovary (so-called maturation phenomenon), are emphasized. Of the many helpful findings that resolve the problem, the characteristic features of surface implants are highlighted. The contribution on the Krukenberg tumor reviews the varied microscopy of this tumor pointing out that the well-known pattern of signet-ring cells in a cellular stroma, albeit characteristic, is often not striking and frequently overshadowed by other microscopic features. The latter include, in many cases, a rather unique microcystic pattern. The final portion of the essay reviews mucinous tumors of non-Krukenberg type, beginning with those that originate from the appendix. The appendiceal neoplasms have distinctive features in most cases being particularly well differentiated, and this is also seen in their ovarian metastases. Other mucinous tumors that commonly simulate closely metastatic neoplasms, include those from the pancreas in particular, but also diverse other sites, are then reviewed.

Metastatic neoplasms involving the ovary: a review with an emphasis on morphological and immunohistochemical features

The ovary is a common site of metastatic tumour. In many cases of ovarian metastasis there is a known history of malignancy but in other cases the ovarian tumour is the first manifestation of disease. In this review metastatic colorectal, appendiceal, gastric, breast, pancreatic and biliary tract, hepatocellular, renal, transitional and cervical carcinomas and metastatic malignant melanoma involving the ovary are discussed, as is the issue of synchronous ovarian and endometrial carcinomas. Peritoneal tumours, including primary peritoneal carcinoma, mesothelioma and intra-abdominal desmoplastic small round cell tumour, involving the ovary are also discussed, together with a variety of other rare, metastatic ovarian neoplasms. Many metastatic adenocarcinomas involving the ovary, especially those exhibiting mucinous differentiation, closely mimic primary ovarian adenocarcinomas with morphologically bland areas simulating benign and borderline cystadenoma. This is referred to as a maturation phenomenon. In recent years immunohistochemistry, especially but not exclusively differential cytokeratin (CK7 and CK20) staining, has been widely used as an aid to distinguish between a primary and secondary ovarian adenocarcinoma. While immunohistochemistry undoubtedly has a valuable role to play and is paramount in diagnosis in some cases, the results must be interepreted with caution, especially in mucinous tumours, and within the relevant clinical context. We feel the significance of differential cytokeratin staining is not always understood by histopathologists and this can result in erroneous interpretation. We critically discuss the value of immunohistochemistry and associated pitfalls with each tumour type described.

Diagnostic challenge of secondary (metastatic) ovarian tumors simulating primary endometrioid and mucinous neoplasms

Secondary (metastatic) neoplasms to the ovary often cause diagnostic problems, especially those tumors that produce large, symptomatic ovarian tumors that masquerade clinically and pathologically as primary ovarian tumors of surface epithelial type. Most of these tumors arise from organs of the digestive system. Except for typical Krukenberg tumors, which usually originate in the stomach and generally are easily recognized, the most diagnostically problematic secondary ovarian tumors are those that originate in the large intestine, appendix, and pancreas. Metastases from these sites typically produce histologic patterns resembling primary ovarian endometrioid carcinoma or mucinous epithelial neoplasms of borderline and malignant types. This review focuses on the diagnostic challenge of distinguishing these secondary ovarian tumors from primary ovarian neoplasms. Studies on useful or potentially applicable immunohistochemical stains are also detailed.

Ovarian carcinomas, including secondary tumors: diagnostically challenging areas

The differential diagnosis of ovarian carcinomas, including secondary tumors, remains a challenging task. Mucinous carcinomas of the ovary are rare and can be easily confused with metastatic mucinous carcinomas that may present clinically as a primary ovarian tumor. Most of these originate in the gastrointestinal tract and pancreas. International Federation of Gynecology and Obstetrics (FIGO) stage is the single most important prognostic factor, and stage I carcinomas have an excellent prognosis; FIGO stage is largely related to the histologic features of the ovarian tumors. Infiltrative stromal invasion proved to be biologically more aggressive than expansile invasion. Metastatic colon cancer is frequent and often simulates ovarian endometrioid adenocarcinoma. Although immunostains for cytokeratins 7 and 20 can be helpful in the differential diagnosis, they should always be interpreted in the light of all clinical information. Occasionally, endometrioid carcinomas may exhibit a microglandular pattern simulating sex cord-stromal tumors. However, typical endometrioid glands, squamous differentiation, or an adenofibroma component are each present in 75% of these tumors whereas immunostains for calretinin and alpha-inhibin are negative. Endometrioid carcinoma of the ovary is associated in 15-20% of the cases with carcinoma of the endometrium. Most of these tumors have a favorable outcome and they most likely represent independent primary carcinomas arising as a result of a Mullerian field effect. Although the criteria for distinguishing metastatic from independent primary carcinomas rely mainly upon conventional clinicopathologic findings, loss of heterozygosity and gene mutation analyses can be helpful. Transitional cell carcinomas are distinguished from undifferentiated carcinomas by the presence of thick, undulating papillae with smooth luminal borders, microspaces, and tumor cells with distinctive 'urothelial' appearance. Krukenberg tumors are metastatic adenocarcinomas traditionally perceived as composed of mucin-filled signet-ring cells associated with a striking proliferation of the ovarian stroma but many variations on this pattern occur.

Signet-ring Stromal Tumor of the Ovary: Clinicopathologic Analysis and Comparison With Krukenberg Tumor

Signet-ring stromal tumor is a rare ovarian neoplasm that can mimic Krukenberg tumor because of the presence of signet-ring cells in both tumors. The clinicopathologic features of three signet-ring stromal tumors, one of which has been previously reported, were analyzed and compared with 10 Krukenberg tumors. Patients with signet-ring stromal tumor ranged in age from 34 to 41 years (mean: 36.7 years). All signet-ring stromal tumors were unilateral and stage IA, whereas 60% and 40% of Krukenberg tumors were bilateral or associated with extraovarian tumor, respectively. The signet-ring stromal tumors were devoid of epithelial differentiation (glands, nests, cords), whereas all of the Krukenberg tumors contained these epithelial structures at least focally. In contrast to signet-ring stromal tumors, the signet-ring cells of Krukenberg tumors were positive for periodic acid-Schiff with diastase and cytokeratins but negative for vimentin. The patients with signet-ring stromal tumors were alive without disease at follow-up interval of 1 month to 17.4 years (mean: 7.4 years). In summary, signet-ring stromal tumor is a rare, benign, ovarian tumor that may be mistaken for Krukenberg tumor. Although the combination of operative and histopathologic findings allow their distinction, histochemical and immunohistochemical stains may also be useful.

Ovarian mucinous carcinoids including some with a carcinomatous component: a report of 17 cases

Only rare primary mucinous (goblet cell) carcinoids of the ovary have been reported, and their clinicopathologic features have not been well delineated. The authors studied 17 examples from patients 14 to 74 years of age. The clinical presentations were similar to those of ovarian neoplasms in general. The tumors ranged from 0.8 to 30 cm in diameter. In six cases the tumor was in the wall of a mature cystic teratoma, appearing grossly as solid nodules or areas of thickening in four of them, six tumors were entirely solid, and five were solid associated with other types of cystic tumor. The tumors were divided into three groups on the basis of their microscopic features. Six neoplasms, designated "well differentiated," were composed of small glands, many of which floated in pools of mucin. The glands were lined by goblet cells and columnar cells, some of which were of neuroendocrine type. Three tumors, designated "atypical," were characterized by crowded glands, some of which were confluent, small islands with a cribriform pattern, and scattered microcystic glands. The glands were lined by cuboidal to columnar cells, some of them neuroendocrine, admixed with goblet cells. Eight tumors, designated "carcinoma arising in mucinous carcinoid," contained islands and larger nodules of tumor cells, or closely packed glands, as well as single cells, mainly of the signet ring cell type. Most of the cells were devoid of mucin and were severely atypical with marked mitotic activity. Necrosis was present in all eight tumors. Seven of the eight tumors with a carcinomatous component contained at least minor foci of well-differentiated mucinous carcinoid; the eighth contained only foci of atypical mucinous carcinoid. The neuroendocrine nature of a variable proportion of the cells in all three groups was demonstrated by staining for neuroendocrine markers. The mucinous nature of other cells was confirmed by mucicarmine or Alcian blue stains. The ovary contained an intrinsic component of trabecular and insular carcinoid, and of strumal carcinoid in one case each, an adjacent mature cystic teratoma in six cases, mucinous cystadenocarcinoma in three cases, and borderline mucinous cystic tumor, borderline Brenner tumor, and epidermoid cyst in one case each. Fifteen tumors were stage I, one was stage II, and one was stage III. The last two tumors had a carcinomatous component. Follow-up data were available for 15 patients; 12 were alive and free of tumor 2.3 to 14 years (average, 4.7 years) after the ovarian tumor was excised. One patient, whose tumor had a carcinomatous component, died 3 years postoperatively of unrelated causes. Two patients, both of whom had a carcinomatous component in their tumor, died 9 and 12 months postoperatively. Primary mucinous carcinoids must be distinguished from metastatic mucinous carcinoid tumors from the appendix or elsewhere. Features supporting an ovarian origin are the additional presence in the specimen of teratoma or an ovarian surface epithelial tumor, an absence of blood vessel or lymphatic space invasion, and confinement to a single ovary. Similar features help to distinguish mucinous carcinoids from Krukenberg tumors. Mucinous carcinoids should also be distinguished from strumal carcinoids, which can contain mucinous glands, and insular carcinoid tumors that arise rarely in the wall of a mucinous cystic neoplasm. Although the number of cases in this series is small, the follow-up data suggest that the degree of differentiation, particularly the presence of frank carcinoma, is an important prognostic factor.

Ovarian metastases from colorectal carcinoma. Clinicopathologic profile, immunophenotype, and karyotype analysis

Ovarian metastases from colorectal carcinoma frequently mimic primary ovarian carcinomas. The present study was performed to identify possible criteria helpful in differential diagnosis. Twenty-three ovarian metastases from colorectal carcinomas and 23 primary ovarian carcinomas were evaluated clinicopathologically and immunostained with antigastric M1 antigen, cathepsin E, CA125, vimentin, estrogen and progesterone receptors, cytokeratins 7 and 20, and alpha-inhibin antibodies. We performed a conventional and molecular cytogenetic study on 5 ovarian metastases from colorectal carcinoma using direct preparation, Q banding techniques, and fluorescence in situ hybridization. Integration of clinicopathologic, immunohistochemical, and cytogenetic features is helpful for the differential diagnosis of metastases of colorectal carcinomas from primary ovarian carcinomas. Bilaterality, extrapelvic spreading, high mitotic index, and cytokeratin 20 immunoreactivity, and lack of M1, CA125, and cytokeratin 7 immunoreactivity favor the diagnosis of ovarian metastases from colon carcinomas. The identification of 13q gain as a peculiar, sensitive, and specific marker of colorectal carcinomas seems relevant.

Metastatic intestinal carcinomas simulating primary ovarian clear cell carcinoma and secretory endometrioid carcinoma: a clinicopathologic and immunohistochemical study of five cases

Five cases of ovarian metastases of intestinal adenocarcinomas that suggested the diagnosis of clear cell adenocarcinoma or the secretory variant of endometrioid carcinoma of the ovary are reported. Patient age ranged from 27 to 71 years at the time of diagnosis of the ovarian neoplasms. In four, the ovarian and intestinal tumors were discovered synchronously, and, in the fifth, the ovarian metastasis occurred 1 year after the intestinal primary was diagnosed. The ovarian tumors were unilateral in three patients and bilateral in two. They were up to 18 cm (mean, 12 cm) in maximum dimension and were characterized on microscopic evaluation by glands and cysts lined by cells whose most striking feature was abundant clear cytoplasm. In two cases, striking subnuclear or supranuclear vacuoles were present. An important clue to the diagnosis of metastatic intestinal adenocarcinoma was the presence in all cases of "dirty necrosis." The metastatic nature of the ovarian tumors was supported by the immunohistochemical findings. All tumors stained were strongly positive for carcinoembryonic antigen and cytokeratin 20 and failed to stain for CA125, whereas staining for HAM56 and cytokeratin 7 was absent or only focally positive in one case each. Three intestinal primary tumors involved the small bowel. Microscopic evaluation of the intestinal tumors in three cases and metastases in a fourth, in which the intestinal primary was not resected, showed the features of the uncommon clear cell variant of intestinal adenocarcinoma; the fifth was predominantly a conventional intestinal adenocarcinoma with only a focal clear cell component. Although intestinal adenocarcinomas metastatic in the ovary typically simulate endometrioid adenocarcinoma of the usual type or mucinous adenocarcinoma, they may mimic either primary clear cell adenocarcinoma or the secretory variant of endometrioid adenocarcinoma, particularly when the primary tumor is, even focally, the clear cell variant of intestinal adenocarcinoma.

The morphologic spectrum of ovarian metastases of appendiceal adenocarcinomas: a clinicopathologic and immunohistochemical analysis of tumors often misinterpreted as primary ovarian tumors or metastatic tumors from other gastrointestinal sites

Twenty cases of ovarian metastases derived from appendiceal adenocarcinomas were analyzed. The most common presentation was a pelvic mass. The appendiceal and ovarian tumors were diagnosed concurrently in 15 cases; in the remaining five, the ovarian tumors were diagnosed before the appendiceal tumor. The appendiceal adenocarcinomas demonstrated four morphologic patterns: 1) signet ring cell type, with or without glandular or goblet cell differentiation (14 cases); 2) mixed signet ring cell and intestinal type (two cases); 3) intestinal type (two cases); and 4) typical colorectal type (two cases). The ovarian tumors were bilateral in 16 cases and were histologically similar to the associated appendiceal tumor in each case. Ovarian metastases that demonstrate signet ring cell, glandular, and goblet cell differentiation mimic metastases from gastric adenocarcinoma. Those that are derived from well-differentiated mucinous appendiceal adenocarcinomas mimic primary ovarian mucinous tumors and metastases from the pancreas and biliary tract. Metastases of appendiceal adenocarcinomas of colorectal type simulate both metastatic colorectal carcinoma and primary ovarian endometrioid carcinomas. The appendiceal and ovarian tumors were immunophenotypically identical in each case. Approximately 50% of the appendiceal and ovarian tumors were positive for cytokeratin 7 (CK 7), and all were positive for cytokeratin 20 (CK 20). CK 20 positivity of the ovarian tumors is consistent with gastrointestinal origin; CK 7 positivity does not confirm ovarian origin, because appendiceal carcinomas are positive in 50% of cases. Metastatic appendiceal adenocarcinoma should be considered in the differential diagnosis of mucinous ovarian tumors with signet ring cell, goblet cell, or intestinal type differentiation, especially when these tumors are associated with extraovarian disease and are bilateral.

Incidence and prognosis of Krukenberg tumour in Northern Ireland

The case notes of 15 patients with Krukenberg tumours were studied to determine the incidence, presentation, clinical findings and prognosis of the disease in Northern Ireland. Patients tended to be young and premenopausal. A short history of abdominal pain was the most frequent presenting complaint, abdominal swelling being second. Menstrual irregularities occurred infrequently and no patient was virilized. Tumours tended to be large, bilateral and associated with ascites. The stomach was the commonest primary site. The overall prognosis was poor, especially if the primary tumour remained covert at the time of diagnosis. The prognosis was unaffected by subsequent discovery of the primary source; extensive investigation is inconvenient for the patient and wasteful of resources. The incidence of the tumour in Northern Ireland was 0.16 per 100,000 per annum: it will be rarely encountered by general surgeons.

Tubular Krukenberg tumor in pregnancy with virilization

A case of tubular Krukenberg tumor in pregnancy with virilization is presented. The pathology is reviewed. This rare tumor must be distinguished from a Sertoli-Leydig tumor. The index case adds to the previously recorded eight cases. All nine cases reviewed presented with progressive virilization between the third and eighth month of gestation, which regressed after surgery. The fetal outcomes of seven cases have been recorded. The fetuses were all female and of these five were virilized. A gastric primary was found in five cases. A primary breast carcinoma was postulated in another. In the remaining cases either no autopsy was performed or no primary tumor was found.

Hormone-producing tumors of the ovary

The ovary is an endocrine organ that gives rise to a wide variety of neoplastic and tumorlike nonneoplastic conditions, some of which are associated with endocrine activity. The hormones produced may be steroidal or nonsteroidal. The ovary is unique among endocrine organs in reacting to the presence of nonendocrine tumors within it by abnormal or inappropriate production of sex steroidal hormones. A classification of hormone-producing ovarian lesions is proposed based on the World Health Organization's histologicai typing of ovarian tumors.

Ovarian tumors with functioning stroma. An immunohistochemical study of 100 cases with human chorionic gonadotropin monoclonal and polyclonal antibodies

The frequency of stromal activation and its possible relation to human chorionic gonadotropin (HCG) or HCG-like secretion by tumor cells has been studied in 100 nonselected, consecutive, primary and secondary ovarian neoplasms. Stromal luteinization was present in 13 cases and stromal condensation in 16. The types of tumors most commonly associated with activation of the ovarian stroma were as follows: mucinous tumors (11 cases), endometrioid and clear cell tumors (six cases), and metastasis of gastrointestinal adenocarcinomas (six cases). We used to commercial polyclonal antibodies as well as four more specific monoclonal antibodies (FBT-10, FBT-11, FB-12, and FB-13). Immunohistochemical studies (peroxidase-antiperoxidase [PAP]) yielded the following staining results: polyclonal HCG and/or polyclonal beta-HCG positivity was present in 22 tumors (12 had an activated stroma and ten an inactive one). In addition, 44 tumors were positive for FBT-10, FBT-11, FB-12, and FB-13 monoclonal antibodies (18 showed activation of the stroma, which was inactive in 26). Only 11 of the 56 HCG-negative tumors exhibited activation of the stroma. Thus, positivity for HCG was more frequently found in tumors with morphologically active stroma than in those with an inactive one. However, five HCG polyclonal positive tumors--three of them exhibiting activation of the stroma--were negative for the monoclonal antibodies. It appears that HCG plays a role in the activation of the stroma of some ovarian tumors, yet, HCG-like substances as well as other factors may also be involved.

Adenocarcinoid tumor of appendix presenting as unilateral Krukenberg tumor

We report a case of adenocarcinoid tumor of the appendix that presented initially as a unilateral Krukenberg tumor (a signet ring cell mucinous adenocarcinoma with prominent cellular stroma). The primary tumor in the appendix was discovered 10 months later at the time of a "second look" laparotomy. The ovarian metastasis showed both goblet cell elements and tubular formations with numerous argyrophilic cells, indicating that both components of these tumors may metastasize, a finding at variance with the conclusions of some authors who suggest that only the mucinous component may metastasize. Theories of histogenesis of these tumors are discussed, and 12 previously reported cases presenting as Krukenberg tumors (all bilateral) are reviewed. Because the primary tumor in the appendix may be small and easily missed, appendectomy is recommended in all patients with Krukenberg tumors when another primary site cannot be identified at the time of surgery.

Krukenberg tumors of the ovary. Ultrastructural, histochemical and immunohistochemical studies of 15 cases

The ultrastructural, histochemical, and immunohistochemical characteristics of 12 classical signet ring cell Krukenberg tumors (CKT) and three tubular Krukenberg tumors (TKT) were evaluated and related to their possible influence on the ovarian stroma. In CKT, single signet ring cells predominated over lumen-forming cells and contained ultrastructural and histochemical characteristics similar to goblet cells in colonic and ovarian mucinous adenocarcinomas. In TKT, lumen-forming nonsecretory and secretory signet ring cells were prominent. Rare argentaffin cells were found in TKT but not in CKT. Cells in both CKT and TKT produced neutral and sialomucins. The stroma contained extracellular mucin, hypertrophied stromal fibroblasts and myofibroblasts, and in two cases stromal lutein cells with steroidogenic type ultrastructure. It appears that Krukenberg tumors are made up exclusively of intestinal type cells. Based on cell differentiation, TKT is better differentiated than CKT. Hypertrophy and hyperplasia of ovarian stromal cells may occur in response to malignant growth and/or the extracellular mucinous products of malignant cells and may play a role in the control of tumor invasiveness. None of the 15 cases were immunohistochemically positive for chorionic gonadotropin, placental lactogen, or luteinizing hormone. These hormones are suspected to be related to stromal luteinization in KT.

Granulosa cell, Sertoli-Leydig cell, and unclassified sex cord-stromal tumors associated with pregnancy: a clinicopathological analysis of thirty-six cases

Seventeen granulosa cell, thirteen Sertoli-Leydig cell and six unclassified sex cord-stromal tumors diagnosed during pregnancy or the puerperium were reviewed. Eleven patients presented with abdominal pain or swelling, five in shock, two with virilization, and one with vaginal bleeding. Three asymptomatic patients were explored because of a palpable mass and one because of an adnexal mass found on ultrasound examination. In thirteen patients the tumor was discovered during a cesarean section; five of them had had dystocia and in eight of them the tumor was an incidental finding. All the tumors were Stage I but 13 of them had ruptured; all but one were unilateral. Hemoperitoneum was present in seven cases. On microscopical examination many of the tumors differed from tumors in the same diagnostic categories occurring in the absence of pregnancy by having a disorderly arrangement of their cells, lacking recognizable differentiation in many areas, showing prominent edema, and containing unusually large numbers of lutein or Leydig cells. The last two features were most obtrusive in tumors removed at term. With one exception the patients were initially treated by conservative surgical procedures. Two of them received chemotherapy and two radiation therapy postoperatively. A hysterectomy and salpingo-oophorectomy was performed at a second operation in eight cases; no residual tumor was found in any of the specimens. Only one patient had a recurrence, which was treated surgically. Follow-up for an average of 4.7 years is available for 30 of the 36 patients; all of them were alive and free of disease at the time of the last examination.

Metastases to the female genital tract. Analysis of 325 cases

In order to better define the frequency and patterns of metastasis to the female genital tract, all cases of nonhematopoietic metastases to the adnexa, uterus, vagina, and vulva encountered in patients treated at Barnes Hospital between 1950 and 1981 were reviewed. Three hundred twenty-five metastatic cancers from 269 patients were recovered. One hundred forty-nine cases were from extragenital primaries; the remaining tumors were intragenital metastases. Ovary and vagina were the most frequent metastatic sites for both extragenital and genital primaries. The majority of the extragenital metastases were adenocarcinomas from the gastrointestinal tract, but a variety of other primaries did spread, on occasion, to the genital tract. Twenty-seven percent of the metastases presented as possible primary gynecologic lesions, and 75% of these tumors had an extragenital origin. It is shown that despite certain trends in the distribution of metastases, all sites in the female genital tract are at risk for the occurrence of metastases.

Secondary ovarian neoplasia. A clinicopathologic study of 35 cases

The authors reviewed the clinical and pathologic features of 35 cases of secondary ovarian neoplasms in which the clinical presentation was that of a primary ovarian tumor. The most common secondary neoplasms to mimic an ovarian tumor were colonic adenocarcinoma, breast carcinoma, lymphoma, carcinoid, and gastric adenocarcinoma. It was found that a classification based on gross appearance was useful in evaluating these neoplasms. Solid neoplasms with either a diffuse or nodular gross appearance had distinct histologies so that accurate diagnosis was possible. Cystic neoplasms, especially colon adenocarcinomas, were deceptive and frequently misclassified as primary ovarian adenocarcinoma. Since all of the metastatic colonic carcinomas had mucus-containing cells, the main differential diagnosis was between metastatic colonic carcinoma and primary mucinous carcinoma of the ovary. The absence of a mucus-cell predominant pattern and the lack of transition from benign-appearing epithelium to malignant epithelium are two useful criteria in making this important distinction. Other features may also prove helpful.

Krukenberg tumors of the ovary: a clinicopathologic analysis of 27 cases

A series of 27 typical Krukenberg tumors of the ovary were analyzed. By definition, all examples were characterized by the presence of mucinous signet-ring carcinoma cells within a cellular, nonneoplastic ovarian stroma. The patients' ages ranged from 20-70 years; almost one-half were 40 years of age or younger. A primary carcinoma of the stomach (16 cases) or colon (four cases) was found in 20 (90.9%) of 22 patients with available follow-up data. The primary gastrointestinal carcinomas had been diagnosed before emergence of the ovarian tumors in only five cases. The ovarian and gastrointestinal tumors were synchronously diagnosed in ten cases, while in five instances the primary carcinomas were not discovered until after the ovarian tumors had been treated. An acceptable primary extraovarian cancer was not detected in two women. Both had bilateral Krukenberg tumors and died with widespread carcinomatosis less than two years postoperatively. Typically, the ovarian tumors were bilateral, asymmetrically large and solid. Important histologic features included a greater abundance of intracellular neutral glycoproteins than acidic mucins, a storiform pattern of hyperplastic cortical stromal cells (44.4%) and carcinomatous emboli (51.6%). While the entity of "primary" Krukenberg tumor cannot be unequivocally denied, all women with typical Krukenberg tumors should be considered as having metastatic carcinoma, usually from the stomach, until proven otherwise.

Ovarian endometrioid tumors mimicking Sertoli and Sertoli-Leydig cell tumors: Sertoliform variant of endometrioid carcinoma

We have encountered four cases of an unusual variant of well-differentiated endometrioid carcinoma that was predominantly composed of tubules, solid or hollow, as well as cord-like areas histologically mimicking Sertoli and Sertoli-Leydig cell tumors. The two features most helpful in differential diagnosis were the presence of areas of tumor with the typical confluent pattern of endometrioid carcinoma, and the presence of mucin at the apical borders of the tumor cells and/or within glandular lumina. Other features that were helpful if present, but were observed only in one case each, were foci of squamous metaplasia or the presence of ciliated epithelium. In two cases, ultrastructural studies showed well developed microvilli and perinuclear microfilaments confirming the endometrioid nature of the neoplasm. The patients varied from 22-74 years in age. All tumors were confined to a single ovary, and no tumor is known to have recurred or metastasized. One of the patients died at age 80, six years following operation, presumably without evidence of recurrent neoplasm or metastases. Two other patients are living and well, one and 14 years after diagnosis. In one patient follow-up is short. The clinicopathologic features of this variant of endometrioid carcinoma are reviewed with emphasis on differential morphologic features.