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	Krukenberg tumor

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Latest revision as of 13:47, 8 April 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soujanya Thummathati, MBBS [2]

Synonyms and keywords: Carcinoma mucocellulare; Ovarian tumor

Overview

Krukenberg tumor is a rare metastatic signet ring cell adenocarcinoma of the ovary. Krukenberg tumor was first described as a new type of primary ovarian malignancy by Friedrich Ernst Krukenberg (1871–1946), a German gynecologist and pathologist, in 1896 which was later confirmed to be of metastatic gastrointestinal tract origin. The pathogenesis of Krukenberg tumors involves metastasis of tumor cells from the stomach, appendix or colon to the ovaries. Metastasis is more likely via the lymphatic spread. However, direct seeding across the abdominal cavity may also occur. On gross pathology, asymmetrically enlarged ovaries with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or peritoneal deposits are characteristic findings of Krukenberg tumors. Krukenberg tumor must be differentiated from primary mucinous carcinoma, mucinous carcinoid tumor, signet ring stromal tumor, sclerosing stromal cell tumor, clear cell adenocarcinoma of the ovary, and Sertoli-Leydig cell tumor. The incidence of Krukenberg tumors is estimated to be approximately 0.16 per 100,000 individuals. Krukenberg tumor is more commonly observed among women in their fifth decade of lives, with an average around 45 years of age. The majority of patients with Krukenberg tumor remain asymptomatic or have non-specific gastrointestinal symptoms. Early clinical features include abdominal pain and distension (from the large, bilateral ovarian masses). If left untreated, patients with Krukenberg tumors may progress to develop virilization from the excessive hormone production from the ovarian stroma. Prognosis is generally poor, and the 5 year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum CA-125 levels greater than 75 U/mL when compared with patients with CA-125 levels less than 75 U/mL. The median survival of patients is between 7 to 14 months. X rays, ultrasound, CT, MRI and immunohistochemistry help in the diagnosis of Krukenberg tumors. Management of Krukenberg tumors is driven by the identification and treatment of the primary cancer. Bilateral oophorectomy may only be performed for patients where the metastasis is localized to the ovaries. The significance of early detection of ovarian metastasis and the importance of monitoring serum CA-125 level may improve the prognosis. Surgical resection may not be an option if the tumor has already metastasized to other sites.

Historical Perspective

Krukenberg tumor was first described as a new type of primary ovarian malignancy by Friedrich Ernst Krukenberg (1871–1946), a German gynecologist and pathologist, in 1896 which was later confirmed to be of metastatic gastrointestinal tract origin.^[1]

Pathophysiology

The majority of Krukenberg tumors are bilateral.^[1]
Stomach and colon are the primary sites in the majority of Krukenberg tumor cases (70%).^[1]
The pathogenesis of Krukenberg tumors involves metastasis of tumor cells from the stomach, appendix, or colon to the ovaries.^[2]
- Metastasis is more likely via the lymphatic spread. However, direct seeding across the abdominal cavity may also occur.
On gross pathology, asymmetrically enlarged ovaries with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or peritoneal deposits are characteristic findings of Krukenberg tumors.^[1]
On microscopic histopathological analysis, Krukenberg tumors are characterized by the following features:
- Tumor composed of two components:
  - Epithelial
    - Mucin-secreting signet ring cells with eccentric hyperchromatic nuclei
    - Cytoplasm may be eosinophilic and granular, pale and vacuolated, or a bull's eye (targetoid) appearance with a large vacuole with a central to paracentral eosinophilic body composed of a droplet of mucin
    - Signet ring cells may be single, clustered, nested, or arranged in tubules, acini, trabeculae, or cords
  - Stromal
    - Plump and spindle-shaped cells with minimal cytologic atypia or mitotic activity
    - Focal or diffuse stromal edema which may form pseudo cysts
    - Desmoplastic reaction may be present
Stomach is the primary site in the majority of Krukenberg tumor cases (70%).^[1]

Bilateral ovarian neoplasm retaining the shape of ovary. Cut section of the tumor shows solid with mucinous areas^[3]

Causes

Krukenberg tumor may be caused by metastasis of the tumor cells from a primary cancer in the stomach, appendix, or the colon via:^[2]
- Lymphatic spread or
- Direct seeding across the abdominal cavity

Differentiating Krukenberg tumor from other Diseases

Krukenberg tumor must be differentiated from:^[1]

Epidemiology and Demographics

Incidence

The incidence of Krukenberg tumor is estimated to be approximately 0.16 per 100,000 individuals.^[4]^[5]

Age

Patients of all age groups may develop Krukenberg tumor.
Krukenberg tumor is more commonly observed among women in the fifth decade, with an average age of presentation at 45 years of age.

Risk Factors

There are no known direct causes for Krukenberg tumors. Common risk factors for ovarian cancer may include:^[6]
- Nulliparity
- Early menarche
- Late menopause
- Hormone therapy
- Fertility medications

Natural History, Complications and Prognosis

The majority of patients with Krukenberg tumor remain asymptomatic or have non-specific gastrointestinal symptoms.^[1]
Early clinical features include abdominal pain and distension (from the large, bilateral ovarian masses).^[1]
If left untreated, patients with Krukenberg tumor may progress to develop virilization from the excessive hormone production from the ovarian stroma.^[7]
Common complications of Krukenberg tumors include ascites, virilization, and pseudo-Meig syndrome.^[7]^[1]
- Pseudo-Meig syndrome is defined as a hydrothorax with ascites, but with the absence of tumor cells.
Prognosis is generally poor, and the 5 year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum CA-125 levels greater than 75 U/mL when compared with patients with CA-125 levels less than 75 U/mL.^[8] The median survival of patients is between 7 to 14 months.^[7]

Diagnosis

Symptoms

Krukenberg tumor is usually asymptomatic.^[1]
Symptoms of Krukenberg tumor may include the following:^[1]^[2]

Physical Examination

Patients with Krukenberg tumor usually appear well in the early stages.
Physical examination may be remarkable for:^[1]^[2]

Abdominal or pelvic mass
Ascites
Hirsutism

Laboratory Findings

There are no specific laboratory findings associated with Krukenberg tumors.

Imaging Findings

X Ray

On x ray, Krukenberg tumor may present with the following findings:^[5]
- Prominent small bowel loops filled with gas
- No air-fluid level
- No radiographic signs of intestinal obstruction

X ray showing prominent small bowel loops filled with gas, no air-fluid level, no radiographic signs of intestinal obstruction^[9]

Ultrasound

On pelvic ultrasound, Krukenberg tumor is characterized by the following:^[4]^[5]
- Bilateral, solid ovarian masses with clear, well defined margins
- An irregular hyper-echoic solid pattern and moth eaten like cyst formation is also considered a characteristic feature

Large, solid, well defined bilateral ovarian masses^[9]
Large, solid, well defined bilateral ovarian masses^[9]
Large, solid, well defined bilateral ovarian masses^[9]
Large, solid, well defined bilateral ovarian masses^[9]

CT

On CT, Krukenberg tumor is characterized by the following:^[5]^[10]
- Large, lobulated, and multicystic masses with soft-tissue components which are indistinguishable from primary ovarian cancers
- Presence of a concurrent gastric or colic mural lesion

Krukenberg tumour of the right ovary from colon cancer^[9]

MRI

On pelvic MRI, Krukenberg tumor is characterized by the following:^[5]^[11]^[12]^[13]
- Bilateral complex masses with hypo-intense solid components (dense stromal reaction)
- Internal hyperintensity (mucin) on T1 and T2 weighted MR images
- Strong contrast enhancement is usually seen in the solid component or the wall of the intratumoral cyst

Coronal T2 image^[9]
Axial T1 image^[9]
Sagittal T2 image^[9]
Axial T2 image^[9]
Axial T1 C+ fat sat dynamic contrast study image^[9]

Other Diagnostic Studies

Immunohistochemistry

Krukenberg tumor may also be diagnosed using immunohistochemistry.^[1]
Findings on immunohistochemistry include:
- Cytokeratins (AE1/AE3) positive
- Epithelial membrane antigen positive
- Vimentin negative
- Inhibin negative

Serum CA-125

Serum concentrations of CA-125 may be helpful for:^[1]
- Post-operative follow-up of patients for evaluation of complete resection of the tumor
- Follow-up of patients with a history of primary adenocarcinomas (particularly gastrointestinal) for early detection of ovarian metastasis

Treatment

Medical Therapy

Management of Krukenberg tumor is driven by the identification and treatment of the primary cancer.
Chemotherapy/radiation has no significant effect on the prognosis of patients with Krukenberg tumors.^[1]

Surgery

Bilateral oophorectomy may only be performed for patients where the metastasis is localized to the ovaries.^[14]
The significance of early detection of ovarian metastasis and the importance of monitoring serum CA-125 level may improve the prognosis.
Surgical resection may not be an option if the tumor has already metastasized to other sites.

Prevention

There are no preventive measures available for Krukenberg tumors.

Case Studies

Case #1

References

↑ ^1.00 ^1.01 ^1.02 ^1.03 ^1.04 ^1.05 ^1.06 ^1.07 ^1.08 ^1.09 ^1.10 ^1.11 ^1.12 ^1.13 ^1.14 Al-Agha OM, Nicastri AD (2006). "An in-depth look at Krukenberg tumor: an overview". Arch Pathol Lab Med. 130 (11): 1725–30. doi:10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2. PMID 17076540.
↑ ^2.0 ^2.1 ^2.2 ^2.3 Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.
↑ Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#/media/File:Krukenberg_tumor_-3.jpg. Accessed on March 23, 2016
↑ ^4.0 ^4.1 Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R; et al. (2012). "Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin". Biomed Opt Express. 3 (9): 2306–16. doi:10.1364/BOE.3.002306. PMC 3447570. PMID 23024922.
↑ ^5.0 ^5.1 ^5.2 ^5.3 ^5.4 Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.
↑ Ovarian cancer. Wikipedia. https://en.wikipedia.org/wiki/Ovarian_cancer#Genetics Accessed on March 23, 2016.
↑ ^7.0 ^7.1 ^7.2 Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U (2008). "A case of virilization induced by a Krukenberg tumor from gastric cancer". World J Surg Oncol. 6: 19. doi:10.1186/1477-7819-6-19. PMC 2275731. PMID 18279511.
↑ Khan M, Bhatti RP, Mukherjee S, Ali AM, Gilman AD, Mirrakhimov AE; et al. (2015). "A 26-year-old female with metastatic primary gastrointestinal malignancy presenting as menorrhagia". J Gastrointest Oncol. 6 (2): E21–5. doi:10.3978/j.issn.2078-6891.2014.080. PMC 4311099. PMID 25830046.
↑ ^9.00 ^9.01 ^9.02 ^9.03 ^9.04 ^9.05 ^9.06 ^9.07 ^9.08 ^9.09 ^9.10 Image courtesy of Dr Hani Al Salam. Radiopaedia (original file ‘’here’’). Creative Commons BY-SA-NC
↑ Cho KC, Gold BM (1985). "Computed tomography of Krukenberg tumors". AJR Am J Roentgenol. 145 (2): 285–8. doi:10.2214/ajr.145.2.285. PMID 2992252.
↑ Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST (2002). "CT and MR imaging of ovarian tumors with emphasis on differential diagnosis". Radiographics. 22 (6): 1305–25. doi:10.1148/rg.226025033. PMID 12432104.
↑ Ha HK, Baek SY, Kim SH, Kim HH, Chung EC, Yeon KM (1995). "Krukenberg's tumor of the ovary: MR imaging features". AJR Am J Roentgenol. 164 (6): 1435–9. doi:10.2214/ajr.164.6.7754887. PMID 7754887.
↑ Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M; et al. (2006). "Developing an MR imaging strategy for diagnosis of ovarian masses". Radiographics. 26 (5): 1431–48. doi:10.1148/rg.265045206. PMID 16973774.
↑ Kim WY, Kim TJ, Kim SE, Lee JW, Lee JH, Kim BG; et al. (2010). "The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries". Eur J Obstet Gynecol Reprod Biol. 149 (1): 97–101. doi:10.1016/j.ejogrb.2009.11.011. PMID 20018420.

[pmid17076540-1] 1.00 ^1.01 ^1.02 ^1.03 ^1.04 ^1.05 ^1.06 ^1.07 ^1.08 ^1.09 ^1.10 ^1.11 ^1.12 ^1.13 ^1.14 Al-Agha OM, Nicastri AD (2006). "An in-depth look at Krukenberg tumor: an overview". Arch Pathol Lab Med. 130 (11): 1725–30. doi:10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2. PMID 17076540.

[jh-2] 2.0 ^2.1 ^2.2 ^2.3 Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.

[3] Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#/media/File:Krukenberg_tumor_-3.jpg. Accessed on March 23, 2016

[pmid23024922-4] 4.0 ^4.1 Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R; et al. (2012). "Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin". Biomed Opt Express. 3 (9): 2306–16. doi:10.1364/BOE.3.002306. PMC 3447570. PMID 23024922.

[ok-5] 5.0 ^5.1 ^5.2 ^5.3 ^5.4 Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.

[6] Ovarian cancer. Wikipedia. https://en.wikipedia.org/wiki/Ovarian_cancer#Genetics Accessed on March 23, 2016.

[pmid18279511-7] 7.0 ^7.1 ^7.2 Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U (2008). "A case of virilization induced by a Krukenberg tumor from gastric cancer". World J Surg Oncol. 6: 19. doi:10.1186/1477-7819-6-19. PMC 2275731. PMID 18279511.

[pmid25830046-8] Khan M, Bhatti RP, Mukherjee S, Ali AM, Gilman AD, Mirrakhimov AE; et al. (2015). "A 26-year-old female with metastatic primary gastrointestinal malignancy presenting as menorrhagia". J Gastrointest Oncol. 6 (2): E21–5. doi:10.3978/j.issn.2078-6891.2014.080. PMC 4311099. PMID 25830046.

[op-9] 9.00 ^9.01 ^9.02 ^9.03 ^9.04 ^9.05 ^9.06 ^9.07 ^9.08 ^9.09 ^9.10 Image courtesy of Dr Hani Al Salam. Radiopaedia (original file ‘’here’’). Creative Commons BY-SA-NC

[pmid2992252-10] Cho KC, Gold BM (1985). "Computed tomography of Krukenberg tumors". AJR Am J Roentgenol. 145 (2): 285–8. doi:10.2214/ajr.145.2.285. PMID 2992252.

[pmid12432104-11] Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST (2002). "CT and MR imaging of ovarian tumors with emphasis on differential diagnosis". Radiographics. 22 (6): 1305–25. doi:10.1148/rg.226025033. PMID 12432104.

[pmid7754887-12] Ha HK, Baek SY, Kim SH, Kim HH, Chung EC, Yeon KM (1995). "Krukenberg's tumor of the ovary: MR imaging features". AJR Am J Roentgenol. 164 (6): 1435–9. doi:10.2214/ajr.164.6.7754887. PMID 7754887.

[pmid16973774-13] Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M; et al. (2006). "Developing an MR imaging strategy for diagnosis of ovarian masses". Radiographics. 26 (5): 1431–48. doi:10.1148/rg.265045206. PMID 16973774.

[pmid20018420-14] Kim WY, Kim TJ, Kim SE, Lee JW, Lee JH, Kim BG; et al. (2010). "The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries". Eur J Obstet Gynecol Reprod Biol. 149 (1): 97–101. doi:10.1016/j.ejogrb.2009.11.011. PMID 20018420.

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@@ Line 10: / Line 10: @@
 {{CMG}} {{AE}} {{STM}}
-{{SK}} carcinoma mucocellulare; Ovarian tumor
+{{SK}} Carcinoma mucocellulare; Ovarian tumor
 ==Overview==
-Krukenberg tumor  is a rare metastatic [[signet ring cell]] [[adenocarcinoma]] of the [[ovary]].<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref> Krukenberg tumor was first described as a new type of primary ovarian [[malignancy]] by Friedrich Ernst Krukenberg (1871–1946), a German [[gynecologist]] and [[pathologist]], in 1896 which was later confirmed to be of metastatic [[gastrointestinal tract]] origin.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref> The pathogenesis of Krukenberg tumors involves [[metastasis]] of [[tumor]] cells from the [[stomach]], [[appendix]] or [[colon]] to the [[ovaries]].<ref name=jh>Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref> [[Metastasis]] is more likely via the [[lymphatic]] spread. However, direct seeding across the [[abdominal cavity]] may also occur. On [[gross pathology]], asymmetrically enlarged ovaries with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or [[peritoneal]] deposits are characteristic findings of Krukenberg tumors.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref> Krukenberg tumor must be differentiated from primary mucinous carcinoma, mucinous carcinoid tumor, signet ring stromal tumor, sclerosing stromal cell tumor, clear cell [[adenocarcinoma]] of the [[ovary]], and [[sertoli-leydig cell tumor]].<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref> The [[incidence]] of Krukenberg tumors is estimated to be approximately 0.16 per 100,000 individuals.<ref name="pmid23024922">{{cite journal| author=Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R et al.| title=Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin. | journal=Biomed Opt Express | year= 2012 | volume= 3 | issue= 9 | pages= 2306-16 | pmid=23024922 | doi=10.1364/BOE.3.002306 | pmc=PMC3447570 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024922  }} </ref><ref name=ok>Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.</ref> Krukenberg tumor is more commonly observed among women in their fifth decade of lives, with an average around 45 years of age. The majority of patients with Krukenberg tumor remain asymptomatic or have non-specific [[gastrointestinal]] symptoms.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref> Early clinical features include abdominal pain and distension(from the large, bilateral [[ovarian mass]]es). If left untreated, patients with Krukenberg tumors may progress to develop [[virilization]] from the excessive hormone production from the ovarian stroma.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511  }} </ref> [[Prognosis]] is generally poor, and the 5 year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum [[CA-125]] levels greater than 75 U/mL when compared with patients with [[CA-125]] levels less than 75 U/mL.<ref name="pmid25830046">{{cite journal| author=Khan M, Bhatti RP, Mukherjee S, Ali AM, Gilman AD, Mirrakhimov AE et al.| title=A 26-year-old female with metastatic primary gastrointestinal malignancy presenting as menorrhagia. | journal=J Gastrointest Oncol | year= 2015 | volume= 6 | issue= 2 | pages= E21-5 | pmid=25830046 | doi=10.3978/j.issn.2078-6891.2014.080 | pmc=PMC4311099 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25830046  }} </ref> The median survival of patients is between 7 to 14 months.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511  }} </ref> X rays, ultrasound, CT, MRI and immunohistochemistry help in the diagnosis of Krukenberg tumors. Management of Krukenberg tumors is driven by the identification and treatment of the primary cancer. Bilateral [[oophorectomy]] may only be performed for patients where the [[metastasis]] is localized to the ovaries.<ref name="pmid20018420">{{cite journal| author=Kim WY, Kim TJ, Kim SE, Lee JW, Lee JH, Kim BG et al.| title=The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2010 | volume= 149 | issue= 1 | pages= 97-101 | pmid=20018420 | doi=10.1016/j.ejogrb.2009.11.011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20018420  }} </ref> The significance of early detection of ovarian [[metastasis]] and the importance of monitoring serum [[CA-125]] level may improve the prognosis. Surgical resection may not be an option if the [[tumor]] has already metastasized to other sites.
+Krukenberg tumor  is a rare metastatic [[signet ring cell]] [[adenocarcinoma]] of the [[ovary]]. Krukenberg tumor was first described as a new type of primary [[Ovarian cancer|ovarian malignancy]] by Friedrich Ernst Krukenberg (1871–1946), a German [[gynecologist]] and [[pathologist]], in 1896 which was later confirmed to be of [[metastatic]] [[gastrointestinal tract]] origin. The [[pathogenesis]] of Krukenberg tumors involves [[metastasis]] of [[tumor]] cells from the [[stomach]], [[appendix]] or [[colon]] to the [[ovaries]]. [[Metastasis]] is more likely via the [[lymphatic]] spread. However, direct seeding across the [[abdominal cavity]] may also occur. On [[gross pathology]], asymmetrically enlarged [[ovaries]] with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or [[peritoneal]] deposits are characteristic findings of Krukenberg tumors. Krukenberg tumor must be differentiated from [[Mucinous carcinoma|primary mucinous carcinoma]], [[Carcinoid tumor|mucinous carcinoid tumor]], [[Gastrointestinal stromal tumor|signet ring stromal tumor]], sclerosing stromal cell tumor, clear cell [[adenocarcinoma]] of the [[ovary]], and [[Sertoli-Leydig cell tumour|Sertoli-Leydig cell tumor]]. The [[incidence]] of Krukenberg tumors is estimated to be approximately 0.16 per 100,000 individuals. Krukenberg tumor is more commonly observed among women in their fifth decade of lives, with an average around 45 years of age. The majority of patients with Krukenberg tumor remain [[asymptomatic]] or have non-specific [[gastrointestinal]] symptoms. Early clinical features include [[abdominal pain]] and [[distension]] (from the large, bilateral [[ovarian mass]]es). If left untreated, patients with Krukenberg tumors may progress to develop [[virilization]] from the excessive hormone production from the ovarian stroma. [[Prognosis]] is generally poor, and the 5 year survival rate of patients with Krukenberg tumor is lower in patients in with a preoperative serum [[CA-125]] levels greater than 75 U/mL when compared with patients with [[CA-125]] levels less than 75 U/mL. The median survival of patients is between 7 to 14 months. [[X rays]], [[ultrasound]], [[CT]], [[Magnetic resonance imaging|MRI]] and [[immunohistochemistry]] help in the diagnosis of Krukenberg tumors. Management of Krukenberg tumors is driven by the identification and treatment of the primary cancer. Bilateral [[oophorectomy]] may only be performed for patients where the [[metastasis]] is localized to the [[ovaries]]. The significance of early detection of ovarian [[metastasis]] and the importance of monitoring serum [[CA-125]] level may improve the prognosis. [[Surgical resection]] may not be an option if the [[tumor]] has already metastasized to other sites.
 ==Historical Perspective==
-Krukenberg tumor was first described as a new type of primary ovarian [[malignancy]] by Friedrich Ernst Krukenberg (1871–1946), a German [[gynecologist]] and [[pathologist]], in 1896 which was later confirmed to be of metastatic [[gastrointestinal tract]] origin.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
+Krukenberg tumor was first described as a new type of primary [[Ovarian cancer|ovarian malignancy]] by Friedrich Ernst Krukenberg (1871–1946), a German [[gynecologist]] and [[pathologist]], in 1896 which was later confirmed to be of metastatic [[gastrointestinal tract]] origin.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
 ==Pathophysiology==
 *The majority of Krukenberg tumors are bilateral.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
-*[[Stomach]] and colon are the primary sites in the majority of Krukenberg tumor cases (70%).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
+*[[Stomach]] and [[colon]] are the primary sites in the majority of Krukenberg tumor cases (70%).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
-*The pathogenesis of Krukenberg tumors involves [[metastasis]] of [[tumor]] cells from the [[stomach]], [[appendix]], or [[colon]] to the [[ovaries]].<ref name=jh>Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
+*The [[pathogenesis]] of Krukenberg tumors involves [[metastasis]] of [[tumor]] cells from the [[stomach]], [[appendix]], or [[colon]] to the [[ovaries]].<ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
 **[[Metastasis]] is more likely via the [[lymphatic]] spread. However, direct seeding across the [[abdominal cavity]] may also occur.
-*On [[gross pathology]], asymmetrically enlarged ovaries with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or [[peritoneal]] deposits are characteristic findings of Krukenberg tumors.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
+*On [[gross pathology]], asymmetrically enlarged [[ovaries]] with a bosselated contour, usually solid, yellow or white cross sectioned surfaces, and the absence of adhesions or [[peritoneal]] deposits are characteristic findings of Krukenberg tumors.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
-*On microscopic histopathological analysis, Krukenberg tumors are characterized by the following features:
+*On microscopic [[Histopathological|histopathological analysis]], Krukenberg tumors are characterized by the following features:
 **[[Tumor]] composed of two components:
 ***[[Epithelial]]
-****[[Mucin]]-secreting [[signet ring cell]]s with eccentric [[hyperchromatic nuclei]]
+****[[Mucin]]-secreting [[signet ring cell]]s with eccentric [[Hyperchromicity|hyperchromatic nuclei]]
-****[[Cytoplasm]] may be [[eosinophilic]] and granular, pale and vacuolated, or a bull's eye (targetoid) appearance with a large vacuole with a central to paracentral eosinophilic body composed of a droplet of [[mucin]]
+****[[Cytoplasm]] may be [[eosinophilic]] and granular, pale and vacuolated, or a bull's eye (targetoid) appearance with a large vacuole with a central to paracentral [[eosinophilic]] body composed of a droplet of [[mucin]]
 ****[[Signet ring cell]]s may be single, clustered, nested, or arranged in tubules, acini, trabeculae, or cords
 ***Stromal
 **** Plump and spindle-shaped cells with minimal cytologic [[atypia]] or mitotic activity
 ****Focal or diffuse stromal [[edema]] which may form pseudo cysts
-****Desmoplastic reaction may be present
+****[[Desmoplastic]] reaction may be present
 *[[Stomach]] is the primary site in the majority of Krukenberg tumor cases (70%).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
@@ Line 41: / Line 41: @@
 ==Causes==
-*Krukenberg tumor may be caused by [[metastasis]] of the [[tumor]] cells from a primary cancer in the stomach, [[appendix]], or the [[colon]] via:<ref name=jh>Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
+*Krukenberg tumor may be caused by [[metastasis]] of the [[tumor]] cells from a primary cancer in the stomach, [[appendix]], or the [[colon]] via:<ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
 **[[Lymphatic]] spread or
 **Direct seeding across the [[abdominal cavity]]
@@ Line 47: / Line 47: @@
 ==Differentiating Krukenberg tumor from other Diseases==
 *Krukenberg tumor must be differentiated from:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
-:*Primary mucinous carcinoma
+:*[[Mucinous carcinoma|Primary mucinous carcinoma]]
-:*Mucinous carcinoid tumor
+:*[[Carcinoid tumor|Mucinous carcinoid tumor]]
-:*Signet ring stromal tumor
+:*[[Gastrointestinal stromal tumor|Signet ring stromal tumor]]
 :*Sclerosing stromal cell tumor
 :*Clear cell [[adenocarcinoma]] of the [[ovary]]
-:*[[Sertoli-Leydig cell tumor]]
+:*[[Sertoli-Leydig cell tumour|Sertoli-Leydig cell tumor]]
 ==Epidemiology and Demographics==
 ===Incidence===
-*The [[incidence]] of Krukenberg tumor is estimated to be approximately 0.16 per 100,000 individuals.<ref name="pmid23024922">{{cite journal| author=Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R et al.| title=Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin. | journal=Biomed Opt Express | year= 2012 | volume= 3 | issue= 9 | pages= 2306-16 | pmid=23024922 | doi=10.1364/BOE.3.002306 | pmc=PMC3447570 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024922  }} </ref><ref name=ok>Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.</ref>
+*The [[incidence]] of Krukenberg tumor is estimated to be approximately 0.16 per 100,000 individuals.<ref name="pmid23024922">{{cite journal| author=Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R et al.| title=Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin. | journal=Biomed Opt Express | year= 2012 | volume= 3 | issue= 9 | pages= 2306-16 | pmid=23024922 | doi=10.1364/BOE.3.002306 | pmc=PMC3447570 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024922  }} </ref><ref name="ok">Krukenberg tumour. Radiopedia. Accessed on March 23, 2016.</ref>
 ===Age===
@@ Line 71: / Line 71: @@
 ==Natural History, Complications and Prognosis==
-*The majority of patients with Krukenberg tumor remain asymptomatic or have non-specific [[gastrointestinal]] symptoms.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
+*The majority of patients with Krukenberg tumor remain [[asymptomatic]] or have non-specific [[gastrointestinal]] symptoms.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
-*Early clinical features include abdominal pain and distension (from the large, bilateral [[ovarian mass]]es).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
+*Early clinical features include [[abdominal pain]] and [[distension]] (from the large, bilateral [[ovarian mass]]es).<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
-*If left untreated, patients with Krukenberg tumor may progress to develop [[virilization]] from the excessive hormone production from the ovarian stroma.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511  }} </ref>
+*If left untreated, patients with Krukenberg tumor may progress to develop [[virilization]] from the excessive hormone production from the [[ovarian]] stroma.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511  }} </ref>
 *Common complications of Krukenberg tumors include [[ascites]], [[virilization]], and pseudo-Meig syndrome.<ref name="pmid18279511">{{cite journal| author=Hornung M, Vogel P, Schubert T, Schlitt HJ, Bolder U| title=A case of virilization induced by a Krukenberg tumor from gastric cancer. | journal=World J Surg Oncol | year= 2008 | volume= 6 | issue=  | pages= 19 | pmid=18279511 | doi=10.1186/1477-7819-6-19 | pmc=PMC2275731 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18279511  }} </ref><ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
 **Pseudo-Meig syndrome is defined as a [[hydrothorax]] with [[ascites]], but with the absence of [[tumor]] cells.
@@ Line 80: / Line 80: @@
 ==Diagnosis==
 ===Symptoms===
-*Krukenberg tumor is usually asymptomatic.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
+*Krukenberg tumor is usually [[asymptomatic]].<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
-*Symptoms of Krukenberg tumors may include the following:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref><ref name=jh>Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
+*Symptoms of Krukenberg tumor may include the following:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref><ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
 :*Non-specific gastrointestinal symptoms
-:*Abdominal or [[pelvic]] pain
+:*[[Abdominal pain|Abdominal]] or [[pelvic pain]]
 :*[[Abdominal distension]]
 :*[[Bloating]]
 :*[[Dyspareunia]]
 :*[[Vaginal bleeding]]
-:*Menstrual irregularities
+:*[[Menstrual irregularities]]
 :*[[Hirsutism]]
 ===Physical Examination===
-*Patients with krukenberg tumor usually appear well in the early stages.
+*Patients with Krukenberg tumor usually appear well in the early stages.
-*Physical examination may be remarkable for:<ref name=jh>Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref><ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
+*Physical examination may be remarkable for:<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref><ref name="jh">Krukenberg tumor. Wikipedia. https://en.wikipedia.org/wiki/Krukenberg_tumor#cite_note-Young2006-4 Accessed on March 21, 2016.</ref>
 :*Abdominal or pelvic mass
 :*[[Ascites]]
@@ Line 99: / Line 99: @@
 ===Laboratory Findings===
-*There are no specific laboratory findings associated with krukenberg tumors.
+*There are no specific laboratory findings associated with Krukenberg tumors.
 ===Imaging Findings===
 ====X Ray====
-*On x rays, krukenberg tumor may present with the following findings:<ref name=ok>Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref>
+*On x ray, Krukenberg tumor may present with the following findings:<ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref>
 **Prominent [[small bowel]] loops filled with gas
 **No air-fluid level
@@ Line 109: / Line 109: @@
 <gallery>
-Image:krukenberg-tumour-2 (6).jpg|X ray showing prominent small bowel loops filled with gas, no air-fluid level, no radiographic signs of intestinal obstruction<ref name=op>Image courtesy of Dr Hani Al Salam. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
+Image:Krukenberg-tumour-2 (6).jpg|X ray showing prominent small bowel loops filled with gas, no air-fluid level, no radiographic signs of intestinal obstruction<ref name=op>Image courtesy of Dr Hani Al Salam. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
 </gallery>
 ====Ultrasound====
-*On pelvic ultrasound, krukenberg tumor is characterized by the following:<ref name="pmid23024922">{{cite journal| author=Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R et al.| title=Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin. | journal=Biomed Opt Express | year= 2012 | volume= 3 | issue= 9 | pages= 2306-16 | pmid=23024922 | doi=10.1364/BOE.3.002306 | pmc=PMC3447570 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024922  }} </ref></ref><ref name=ok>Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref>
+*On pelvic ultrasound, Krukenberg tumor is characterized by the following:<ref name="pmid23024922">{{cite journal| author=Tellier F, Steibel J, Chabrier R, Blé FX, Tubaldo H, Rasata R et al.| title=Sentinel lymph nodes fluorescence detection and imaging using Patent Blue V bound to human serum albumin. | journal=Biomed Opt Express | year= 2012 | volume= 3 | issue= 9 | pages= 2306-16 | pmid=23024922 | doi=10.1364/BOE.3.002306 | pmc=PMC3447570 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23024922  }} </ref><ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref>
 **Bilateral, solid ovarian masses with clear, well defined margins
 **An irregular hyper-echoic solid pattern and moth eaten like [[cyst]] formation is also considered a characteristic feature
-<Gallery>
+<gallery>
 Image:Krukenberg-tumour-3.JPG|Large, solid, well defined bilateral ovarian masses<ref name=op>Image courtesy of  Dr Prashant Mudgal. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-3 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
@@ Line 128: / Line 128: @@
 ====CT====
-*On [[CT]], krukenberg tumor is characterized by the following:<ref name=ok>Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref><ref name="pmid2992252">{{cite journal| author=Cho KC, Gold BM| title=Computed tomography of Krukenberg tumors. | journal=AJR Am J Roentgenol | year= 1985 | volume= 145 | issue= 2 | pages= 285-8 | pmid=2992252 | doi=10.2214/ajr.145.2.285 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2992252  }} </ref>
+*On [[CT]], Krukenberg tumor is characterized by the following:<ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref><ref name="pmid2992252">{{cite journal| author=Cho KC, Gold BM| title=Computed tomography of Krukenberg tumors. | journal=AJR Am J Roentgenol | year= 1985 | volume= 145 | issue= 2 | pages= 285-8 | pmid=2992252 | doi=10.2214/ajr.145.2.285 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2992252  }} </ref>
 **Large, lobulated, and multicystic masses with [[soft-tissue]] components which are indistinguishable from primary ovarian cancers
 **Presence of a concurrent [[gastric]] or [[colic]] mural lesion
-<Gallery>
+<gallery>
 Image:Kruckenberg-tumour.jpg|Krukenberg tumour of the right ovary from colon cancer<ref name=op>Image courtesy of Dr Natalie Yang. [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
 </gallery>
 ====MRI====
-*On pelvic [[MRI]], krukenberg tumor is characterized by the following:<ref name="pmid12432104">{{cite journal| author=Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST| title=CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. | journal=Radiographics | year= 2002 | volume= 22 | issue= 6 | pages= 1305-25 | pmid=12432104 | doi=10.1148/rg.226025033 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432104  }} </ref><ref name="pmid7754887">{{cite journal| author=Ha HK, Baek SY, Kim SH, Kim HH, Chung EC, Yeon KM| title=Krukenberg's tumor of the ovary: MR imaging features. | journal=AJR Am J Roentgenol | year= 1995 | volume= 164 | issue= 6 | pages= 1435-9 | pmid=7754887 | doi=10.2214/ajr.164.6.7754887 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7754887  }} </ref><ref name="pmid16973774">{{cite journal| author=Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M et al.| title=Developing an MR imaging strategy for diagnosis of ovarian masses. | journal=Radiographics | year= 2006 | volume= 26 | issue= 5 | pages= 1431-48 | pmid=16973774 | doi=10.1148/rg.265045206 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16973774  }} </ref><ref name=ok>Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref>
+*On pelvic [[MRI]], Krukenberg tumor is characterized by the following:<ref name="ok">Krukenberg tumour. Radiopedia. http://radiopaedia.org/articles/krukenberg-tumour-1 Accessed on March 23, 2016.</ref><ref name="pmid12432104">{{cite journal| author=Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST| title=CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. | journal=Radiographics | year= 2002 | volume= 22 | issue= 6 | pages= 1305-25 | pmid=12432104 | doi=10.1148/rg.226025033 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12432104  }} </ref><ref name="pmid7754887">{{cite journal| author=Ha HK, Baek SY, Kim SH, Kim HH, Chung EC, Yeon KM| title=Krukenberg's tumor of the ovary: MR imaging features. | journal=AJR Am J Roentgenol | year= 1995 | volume= 164 | issue= 6 | pages= 1435-9 | pmid=7754887 | doi=10.2214/ajr.164.6.7754887 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7754887  }} </ref><ref name="pmid16973774">{{cite journal| author=Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M et al.| title=Developing an MR imaging strategy for diagnosis of ovarian masses. | journal=Radiographics | year= 2006 | volume= 26 | issue= 5 | pages= 1431-48 | pmid=16973774 | doi=10.1148/rg.265045206 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16973774  }} </ref>
 **Bilateral complex masses with hypo-intense solid components (dense stromal reaction)
 **Internal hyperintensity (mucin) on T1 and T2 weighted MR images
 **Strong contrast enhancement is usually seen in the solid component or the wall of the intratumoral [[cyst]]
-<Gallery>
+<gallery>
 Image:Krukenberg-tumour-2_(1).jpg|Coronal T2 image<ref name=op>Image courtesy of Dr Hani Al Salam . [http://www.radiopaedia.org Radiopaedia] (original file [http://radiopaedia.org/cases/krukenberg-tumour-2 ‘’here’’]). [http://radiopaedia.org/licence Creative Commons BY-SA-NC]</ref>
@@ Line 167: / Line 167: @@
 **Post-operative follow-up of patients for evaluation of complete resection of the [[tumor]]
 **Follow-up of patients with a history of primary [[adenocarcinoma]]s (particularly gastrointestinal) for early detection of ovarian [[metastasis]]
 == Treatment ==
 === Medical Therapy ===
-*Management of krukenberg tumors is driven by the identification and treatment of the primary cancer.
+*Management of Krukenberg tumor is driven by the identification and treatment of the primary cancer.
 *[[Chemotherapy]]/[[radiation]] has no significant effect on the prognosis of patients with Krukenberg tumors.<ref name="pmid17076540">{{cite journal| author=Al-Agha OM, Nicastri AD| title=An in-depth look at Krukenberg tumor: an overview. | journal=Arch Pathol Lab Med | year= 2006 | volume= 130 | issue= 11 | pages= 1725-30 | pmid=17076540 | doi=10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17076540  }} </ref>
 === Surgery ===
 *Bilateral [[oophorectomy]] may only be performed for patients where the [[metastasis]] is localized to the ovaries.<ref name="pmid20018420">{{cite journal| author=Kim WY, Kim TJ, Kim SE, Lee JW, Lee JH, Kim BG et al.| title=The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2010 | volume= 149 | issue= 1 | pages= 97-101 | pmid=20018420 | doi=10.1016/j.ejogrb.2009.11.011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20018420  }} </ref>
-*The significance of early detection of ovarian [[metastasis]] and the importance of monitoring serum [[CA-125]] level may improve the prognosis.
+*The significance of early detection of ovarian [[metastasis]] and the importance of monitoring serum [[CA-125]] level may improve the [[prognosis]].
-*Surgical resection may not be an option if the [[tumor]] has already metastasized to other sites.
+*[[Surgical resection]] may not be an option if the [[tumor]] has already [[metastasized]] to other sites.
 === Prevention ===
-*There are no preventive measures available for krukenberg tumors.
+*There are no preventive measures available for Krukenberg tumors.
 ==Case Studies==
@@ Line 191: / Line 191: @@
 [[Category:Oncology]]
 [[Category:Disease]]
+ [[Category:Up-To-Date]]
+[[Category:Oncology]]
+[[Category:Medicine]]
+[[Category:Gynecology]]


Krukenberg tumor
Krukenberg tumor