Diagnostic and Interventional Imaging (2014) 95, 87—89
LETTER / Genitourinary imaging Atypical presentation of ovarian metastases of a gastric cancer Keywords: Ovarian metastases; Ovarian mucinous tumors; Krukenberg tumors Observation A 55-year-old female patient, with no noteworthy history, consulted because of recently worsening abdominal heaviness, which had been developing for about a month.
Clinical examination found a voluminous abdominopelvic mass. An ultrasound examination showed a complex multilocular abdominopelvic mass, so that an abdominopelvic MRI was requested in order to characterize it. The MRI found two very large, multilocular, ovarian masses (of 17 cm on the left and 12 cm on the right), containing loculi with different signal intensities, including some, which were hyperintense with T1-weighting. In the left ovarian mass, a solid tissue portion was detected within one loculus: it was of intermediate intensity with T2-weighting, hyperintense with diffusion-weighting (Fig. 1) and had a type 3 enhancement curve after dynamic injection of gadolinium (Fig. 2). The
Figure 1. Pelvic MRI. Bilateral multilocular ovarian masses with solid ovarian portion on the left (arrow). T2-weighted axial sequence (a), diffusion-weighted axial sequence b1000 (b), T1-weighted axial sequence (c), T1-weighted FAT SAT axial sequence after gadolinium injection (d). 2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.08.011
88
Letter
Figure 2. Perfusion MRI. The violet curve shows enhancement of the myometrium and the green curve enhancement of the solid tumor portion. Type 3 enhancement curve of the solid tumor portion.
abdominopelvic MRI did not show any evidence of peritoneal carcinomatosis. The diagnosis suggested by the MRI was either mucinous cystadenocarcinoma or ovarian metastasis of a digestive cancer. A CT scan was performed for staging and found circumferential thickening of the gastric fundus (Fig. 3). Gastric fibroscopy with biopsy showed gastric linitis plastica (Fig. 4). Bilateral adnexectomy was performed, with omentectomy and exploration of the peritoneal cavity with cytology, given the volume and the functional hindrance resulting from these ovarian masses. Macroscopic examination of the two ovaries was virtually identical. An externally smooth tumor was seen with no vegetation or rupture. When sectioned, it was found to be a solid, cystic tumor with mucoid contents. The left adnexal tumor, the more voluminous, included a solid mass measuring 4.5 by 4 cm (Fig. 5). Histological examination found adenocarcinomatous proliferation within the ovarian masses consisting of glandular and trabecular structures with a few rare signet ring cells, with no significant stromal hypertrophy. The final diagnosis was therefore gastric adenocarcinoma with bilateral, intestinal type (IT) ovarian metastasis. Discussion Ovarian metastases represent between 5 and 15% of malignant ovarian tumors [1]. The main cancers producing ovarian
Figure 4. Histological section of gastric biopsy. Histological appearance ×10 magnification. Moderately differentiated adenocarcinomatous infiltration.
metastasis are those of the stomach, breast and colon [2]. Two subtypes of ovarian metastasis of gastric cancer need to be distinguished, Krukenberg tumors (KT) and intestinal type (IT) metastasis. Their appearance in imaging and their histology is quite different [3]. The term KT, often used excessively, has a strict histological definition: signet ring cells making up at least 10% of the tumor cells [4,5]. Seventy-five percent of KTs have a primary site in the stomach; more rarely they may originate in the colon, breast, bile ducts or the appendix [5]. KTs are the most common histological type encountered in ovarian metastases of a gastric cancer, and several histopathological and clinical criteria distinguish them from the intestinal type. The macroscopic appearance of KTs is predominantly solid, without tumor necrosis [3,5], reflected by MRI hypointensity with T2-weighting [4,6]. The appearance of the IT, on the other hand, is mixed, both solid and cystic, and can, as in this patient, mimic a primary mucinous lesion [5]. A large, multilocular, ovarian lesion with a honeycomb appearance and loculi of varying intensity with T1 and T2-weighting, depending on the richness in mucin, does indeed suggest a mucinous
Figure 3. Abdominal CT scan. Gastric linitis plastica. Circumferential thickening of the gastric mucosa (arrows). Contrast-enhanced CT scan, axial (a) and coronary (b) slices.
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Figure 5. Macroscopic view and histological section of the left ovarian mass. Macroscopic view (a): the area indicated by the forceps is the solid portion. Histological appearance ×20 magnification (b): presence of a moderately differentiated adenocarcinomatous proliferation composed of glands and tumor trabeculae.
lesion [2,7]. The presence of a solid component of intermediate intensity with T2-weighting within the left ovarian mass, enhancing according to a type 3 curve [8], pointed however towards malignant mucinous cystadenocarcinoma or ovarian metastasis [9,10]. Several radiological criteria have been proposed to differentiate between primary and secondary mucinous tumors, including the bilateral character and the size of the lesions. Primary malignant mucinous tumors are generally larger (> 10 cm) and very frequently unilateral (> 80%) [11] but these criteria are open to discussion [5]. Threshold values for tumor size have been suggested, but have not been confirmed by later studies, although it is agreed that very large unilateral lesions are generally primary mucinous lesions [5]. Conclusion We report here a rare case of IT bilateral ovarian metastasis of a gastric cancer presenting in MRI as multilocular bilateral lesions. This form of presentation is common for colon cancers but atypical for a gastric cancer. When faced with a multilocular lesion, the diagnosis must be considered of mucinous tumors, which may be either primary or secondary. There are few radiological criteria to differentiate between them (size and whether involvement is bilateral). A subjacent primary cancer, particularly colon cancer, must therefore be systematically sought when analyzing images. Disclosure of interests The authors declare that they have no conflicts of interest concerning this article. References [1] Brown DL, Zou KH, Tempany CM, Frates MC, Silverman SG, McNeil BJ, et al. Primary versus secondary ovarian malignancy: imaging findings of adnexal masses in the Radiology Diagnostic Oncology Group Study. Radiology 2001;219(1):213—8. [2] Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M, et al. Developing an MR imaging strategy for diagnosis of ovarian masses. Radiographics 2006;26(5):1431—48.
[3] Young RH. From Krukenberg to today: the ever present problems posed by metastatic tumors in the ovary. Part II. Adv Anat Pathol 2007;14(3):149—77. [4] Koyama T, Mikami Y, Saga T, Tamai K, Togashi K. Secondary ovarian tumors: spectrum of CT and MR features with pathologic correlation. Abdom Imaging 2007;32(6):784—95. [5] Young RH. 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. Adv Anat Pathol 2006;13(5):205—27. [6] Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. Radiographics 2002;22(6):1305—25. [7] Hussain SM, Outwater EK, Siegelman ES. MR imaging features of pelvic mucinous carcinomas. Eur Radiol 2000;10(6): 885—91. [8] Thomassin-Naggara I, Daraï E, Cuenod CA, Rouzier R, Callard P, Bazot M. Dynamic contrast-enhanced magnetic resonance imaging: a useful tool for characterizing ovarian epithelial tumors. J Magnc Reson Imaging 2008;28(1):111—20. [9] Bazot M, Nassar-Slaba J, Thomassin-Naggara I, Cortez A, Uzan S, Daraï E. MR imaging compared with intraoperative frozen-section examination for the diagnosis of adnexal tumors; correlation with final histology. Eur Radiol 2006;16(12):2687—99. [10] Bouic-Pagès E, Perrochia H, Mérigeaud S, Giacalone PY, Taourel P. MR Imaging of primary ovarian tumors with pathologic correlation. J Radiol 2011;90:787—802. [11] Harrison ML, Jameson C, Gore ME. Mucinous ovarian cancer. Int J Gynecol Cancer 2008;18(2):209—14.
P.-E. Laurent a , A. Jalaguier-Coudray a,∗ , J. Thomassin-Piana b , R. Villard-Mahjoub a , F.-M. Medina-Riera a , A. Sarran a a Department of Radiology, Paoli-Calmettes Institute, 232, boulevard Sainte-Marguerite, 13009 Marseille, France b Biopathology Department, Paoli-Calmettes Institute, 232, boulevard Sainte-Marguerite, 13009 Marseille, France ∗ Corresponding author. E-mail address: [email protected] (A. Jalaguier-Coudray)
LETTER / Genitourinary imaging Atypical presentation of ovarian metastases of a gastric cancer Keywords: Ovarian metastases; Ovarian mucinous tumors; Krukenberg tumors Observation A 55-year-old female patient, with no noteworthy history, consulted because of recently worsening abdominal heaviness, which had been developing for about a month.
Clinical examination found a voluminous abdominopelvic mass. An ultrasound examination showed a complex multilocular abdominopelvic mass, so that an abdominopelvic MRI was requested in order to characterize it. The MRI found two very large, multilocular, ovarian masses (of 17 cm on the left and 12 cm on the right), containing loculi with different signal intensities, including some, which were hyperintense with T1-weighting. In the left ovarian mass, a solid tissue portion was detected within one loculus: it was of intermediate intensity with T2-weighting, hyperintense with diffusion-weighting (Fig. 1) and had a type 3 enhancement curve after dynamic injection of gadolinium (Fig. 2). The
Figure 1. Pelvic MRI. Bilateral multilocular ovarian masses with solid ovarian portion on the left (arrow). T2-weighted axial sequence (a), diffusion-weighted axial sequence b1000 (b), T1-weighted axial sequence (c), T1-weighted FAT SAT axial sequence after gadolinium injection (d). 2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.08.011
88
Letter
Figure 2. Perfusion MRI. The violet curve shows enhancement of the myometrium and the green curve enhancement of the solid tumor portion. Type 3 enhancement curve of the solid tumor portion.
abdominopelvic MRI did not show any evidence of peritoneal carcinomatosis. The diagnosis suggested by the MRI was either mucinous cystadenocarcinoma or ovarian metastasis of a digestive cancer. A CT scan was performed for staging and found circumferential thickening of the gastric fundus (Fig. 3). Gastric fibroscopy with biopsy showed gastric linitis plastica (Fig. 4). Bilateral adnexectomy was performed, with omentectomy and exploration of the peritoneal cavity with cytology, given the volume and the functional hindrance resulting from these ovarian masses. Macroscopic examination of the two ovaries was virtually identical. An externally smooth tumor was seen with no vegetation or rupture. When sectioned, it was found to be a solid, cystic tumor with mucoid contents. The left adnexal tumor, the more voluminous, included a solid mass measuring 4.5 by 4 cm (Fig. 5). Histological examination found adenocarcinomatous proliferation within the ovarian masses consisting of glandular and trabecular structures with a few rare signet ring cells, with no significant stromal hypertrophy. The final diagnosis was therefore gastric adenocarcinoma with bilateral, intestinal type (IT) ovarian metastasis. Discussion Ovarian metastases represent between 5 and 15% of malignant ovarian tumors [1]. The main cancers producing ovarian
Figure 4. Histological section of gastric biopsy. Histological appearance ×10 magnification. Moderately differentiated adenocarcinomatous infiltration.
metastasis are those of the stomach, breast and colon [2]. Two subtypes of ovarian metastasis of gastric cancer need to be distinguished, Krukenberg tumors (KT) and intestinal type (IT) metastasis. Their appearance in imaging and their histology is quite different [3]. The term KT, often used excessively, has a strict histological definition: signet ring cells making up at least 10% of the tumor cells [4,5]. Seventy-five percent of KTs have a primary site in the stomach; more rarely they may originate in the colon, breast, bile ducts or the appendix [5]. KTs are the most common histological type encountered in ovarian metastases of a gastric cancer, and several histopathological and clinical criteria distinguish them from the intestinal type. The macroscopic appearance of KTs is predominantly solid, without tumor necrosis [3,5], reflected by MRI hypointensity with T2-weighting [4,6]. The appearance of the IT, on the other hand, is mixed, both solid and cystic, and can, as in this patient, mimic a primary mucinous lesion [5]. A large, multilocular, ovarian lesion with a honeycomb appearance and loculi of varying intensity with T1 and T2-weighting, depending on the richness in mucin, does indeed suggest a mucinous
Figure 3. Abdominal CT scan. Gastric linitis plastica. Circumferential thickening of the gastric mucosa (arrows). Contrast-enhanced CT scan, axial (a) and coronary (b) slices.
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Figure 5. Macroscopic view and histological section of the left ovarian mass. Macroscopic view (a): the area indicated by the forceps is the solid portion. Histological appearance ×20 magnification (b): presence of a moderately differentiated adenocarcinomatous proliferation composed of glands and tumor trabeculae.
lesion [2,7]. The presence of a solid component of intermediate intensity with T2-weighting within the left ovarian mass, enhancing according to a type 3 curve [8], pointed however towards malignant mucinous cystadenocarcinoma or ovarian metastasis [9,10]. Several radiological criteria have been proposed to differentiate between primary and secondary mucinous tumors, including the bilateral character and the size of the lesions. Primary malignant mucinous tumors are generally larger (> 10 cm) and very frequently unilateral (> 80%) [11] but these criteria are open to discussion [5]. Threshold values for tumor size have been suggested, but have not been confirmed by later studies, although it is agreed that very large unilateral lesions are generally primary mucinous lesions [5]. Conclusion We report here a rare case of IT bilateral ovarian metastasis of a gastric cancer presenting in MRI as multilocular bilateral lesions. This form of presentation is common for colon cancers but atypical for a gastric cancer. When faced with a multilocular lesion, the diagnosis must be considered of mucinous tumors, which may be either primary or secondary. There are few radiological criteria to differentiate between them (size and whether involvement is bilateral). A subjacent primary cancer, particularly colon cancer, must therefore be systematically sought when analyzing images. Disclosure of interests The authors declare that they have no conflicts of interest concerning this article. References [1] Brown DL, Zou KH, Tempany CM, Frates MC, Silverman SG, McNeil BJ, et al. Primary versus secondary ovarian malignancy: imaging findings of adnexal masses in the Radiology Diagnostic Oncology Group Study. Radiology 2001;219(1):213—8. [2] Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M, et al. Developing an MR imaging strategy for diagnosis of ovarian masses. Radiographics 2006;26(5):1431—48.
[3] Young RH. From Krukenberg to today: the ever present problems posed by metastatic tumors in the ovary. Part II. Adv Anat Pathol 2007;14(3):149—77. [4] Koyama T, Mikami Y, Saga T, Tamai K, Togashi K. Secondary ovarian tumors: spectrum of CT and MR features with pathologic correlation. Abdom Imaging 2007;32(6):784—95. [5] Young RH. 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. Adv Anat Pathol 2006;13(5):205—27. [6] Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. Radiographics 2002;22(6):1305—25. [7] Hussain SM, Outwater EK, Siegelman ES. MR imaging features of pelvic mucinous carcinomas. Eur Radiol 2000;10(6): 885—91. [8] Thomassin-Naggara I, Daraï E, Cuenod CA, Rouzier R, Callard P, Bazot M. Dynamic contrast-enhanced magnetic resonance imaging: a useful tool for characterizing ovarian epithelial tumors. J Magnc Reson Imaging 2008;28(1):111—20. [9] Bazot M, Nassar-Slaba J, Thomassin-Naggara I, Cortez A, Uzan S, Daraï E. MR imaging compared with intraoperative frozen-section examination for the diagnosis of adnexal tumors; correlation with final histology. Eur Radiol 2006;16(12):2687—99. [10] Bouic-Pagès E, Perrochia H, Mérigeaud S, Giacalone PY, Taourel P. MR Imaging of primary ovarian tumors with pathologic correlation. J Radiol 2011;90:787—802. [11] Harrison ML, Jameson C, Gore ME. Mucinous ovarian cancer. Int J Gynecol Cancer 2008;18(2):209—14.
P.-E. Laurent a , A. Jalaguier-Coudray a,∗ , J. Thomassin-Piana b , R. Villard-Mahjoub a , F.-M. Medina-Riera a , A. Sarran a a Department of Radiology, Paoli-Calmettes Institute, 232, boulevard Sainte-Marguerite, 13009 Marseille, France b Biopathology Department, Paoli-Calmettes Institute, 232, boulevard Sainte-Marguerite, 13009 Marseille, France ∗ Corresponding author. E-mail address: [email protected] (A. Jalaguier-Coudray)
