A 45-year-old woman comes to the office due to unintentional loss of 6.8 kg (15 lb) over the past 6 months. She used to enjoy dining with friends but now avoids it due to excessive lower abdominal pressure and feeling full very quickly. She also has epigastric pain but no dysphagia, regurgitation, vomiting, or diarrhea. Physical examination shows bilateral adnexal fullness. A pelvic ultrasound shows bilateral complex ovarian masses with solid and cystic components. Chest x-ray is normal. CT scan shows stomach wall thickening in addition to the ovarian masses. Which of the following is most likely to be seen on histologic evaluation of the ovaries?

Question

A 45-year-old woman comes to the office due to unintentional loss of 6.8 kg (15 lb) over the past 6 months.  She used to enjoy dining with friends but now avoids it due to excessive lower abdominal pressure and feeling full very quickly.  She also has epigastric pain but no dysphagia, regurgitation, vomiting, or diarrhea.  Physical examination shows bilateral adnexal fullness.  A pelvic ultrasound shows bilateral complex ovarian masses with solid and cystic components.  Chest x-ray is normal.  CT scan shows stomach wall thickening in addition to the ovarian masses.  Which of the following is most likely to be seen on histologic evaluation of the ovaries?

Quizplus · Accepted Answer

11ec160b_3921_2f4b_9249_25c31855108a_MD0001_00 This patient's unintentional weight loss and early satiety are concerning for malignancy. The epigastric pain and gastric thickening on CT scan, as well as the lower abdominal pressure and adnexal masses, suggest gastric and ovarian involvement, respectively. The ovaries are a common site for metastases, often from a primary gastrointestinal tract cancer. This patient likely has a Krukenberg tumor, a primary gastric cancer that has metastasized to the ovary, often presenting with bilateral ovarian lesions. The cardinal histologic feature is nests of signet ring cells. The appearance is a result of large amounts of mucin displacing the nucleus. Gastric signet ring cell cancer is particularly infiltrative and spreads to the ovaries by hematogenous or lymphatic invasion and peritoneal seeding. In contrast, primary ovarian and other cancers rarely metastasize to the stomach. (Choice A) Hodgkin lymphoma is notable for Reed-Sternberg cells, which are derived from B cells and show bilobed ("owl's eye") or multiple nuclei and prominent inclusion-like nucleoli. Most patients have an enlarged lymph node in the neck or a mediastinal mass on chest x-ray, with no involvement of other organ systems. (Choice B) Intercellular bridges are connections between squamous epithelial cells, and keratin pearls are whorl-shaped accumulations of keratin seen in squamous cell carcinoma (SCC). Common sites of SCC include the skin (eg, scaly patch or plaque on face), lung (cough, hemoptysis, chest pain, dyspnea), and middle third of the esophagus (dysphagia, unintentional weight loss). (Choice D) Renal cell carcinoma causes the triad of flank pain, hematuria, and a palpable abdominal mass. Clear cell carcinoma is the most common type and appears as nests of epithelial cells with abundant clear cytoplasm separated by branching vascular tissue. This tumor spreads to the lungs and bone by invasion of the inferior vena cava without gastric or ovarian involvement. (Choice E) Sebaceous glands and keratinaceous debris are histologic features of mature cystic teratomas of the ovaries, which are benign tumors that are most commonly asymptomatic or can cause torsion (acute pelvic pain) if very large. Educational objective: A Krukenberg tumor is a gastric tumor that has metastasized to the ovary and can present with unintentional weight loss, epigastric pain, and adnexal masses. Histologically, the metastatic tumor cells have large amounts of mucin with displaced nuclei, resulting in a signet ring appearance. __________ References: Isolated ovarian metastasis of gastric cancer: Krukenberg tumor. (http://www.ncbi.nlm.nih.gov/pubmed/24592139) A curious discourse of Krukenberg tumor: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/25436134)

A 45-Year-Old Woman Comes to the Office Due to Unintentional