Krukenberg tumor C79.6

In 1895, Marchant had Friedrich Ernst Krukenberg describe for the first time the ovarian tumor named after Krukenberg, which contained mucus-like cells in the form of signet rings, so-called signet ring cells surrounded by the cell body and cell nucleus (Kermauner 1932). The tumor was initially thought to be a new type of ovarian carcinoma. The actual metastasis was not detected until 6 years later (Al-Agha 2006).

Since Krukenberg's description, it has been disputed whether primary blastomas of the ovary even exist (Kermauner 1932).

In 1930, Jolker was the first to describe a primary gastric cancer with abundant seeding in the peritoneum and ovaries (Kermauner 1932).

A Krukenberg tumor is a drip metastasis of a mucin-producing signet ring gastric carcinoma into the ovaries (Herold 2025 / Kasper 2015).

In a broader sense, metastases of a colon, breast or appendix carcinoma that metastasize lymphogenously or haematogenously to the ovaries are also referred to as drip metastases (Pschyrembel 2025).

By definition, FIGO staging is not used for metastatic tumors (Petru 2019).

Metastatic tumors of the ovaries account for approx. 6 - 28 % of all ovarian malignancies (Petru 1998). They are found in 1 in 100,000 women per year (Petru 2019).

The primary tumor is found in the gastrointestinal tract in 70% of all cases (Aziz 2024).

Risk factors are previous carcinoma in the following frequency:

• of the breast
• of the stomach
• of the colon / rectum
• the appendix
• of the gallbladder / pancreas
• the lungs (Petru 2019)

Metastasis probably occurs by hematogenous seeding (Petru 2019) per continuitatem (Buchta 2002), but also lymphogenously and transcoelomically (Aziz 2024).

Both ovaries are affected in 49 - 81 % of cases. The metastases spread intra- and retroperitoneally, essentially like primary ovarian carcinomas (Petru 1998).

The average age of onset is around 58 years of age (Petru 2019).

Krukenberg tumors are most common in Asian countries such as Japan, Korea and China, where there is a higher prevalence of gastric cancer (Aziz 2024).

The patients complain of:

• unspecific general symptoms
• lower abdominal pain
• vaginal or post-coital bleeding (Pschyrembel 2025)
• Stool irregularities alternating between diarrhea and constipation
• Pencil stools
• Melena (Petru 2019)
• Increase in the abdominal circumference (Aziz 2024)

As the Krukenberg tumor sometimes grows faster than the primary tumor, the first symptoms often relate to the metastasis and not the primary tumor (Riede 2009).

It is not uncommon for no primary tumor to be found during diagnosis and surgical treatment is performed under the suspicion of primary ovarian carcinoma. Preoperative targeted diagnostics in the form of gastroscopy, colonoscopy, CT and sonography are therefore recommended (Petru 2019).

Sonography:

Sonographically, a solid tumor is found in the area of one or both adnexa. Ascites is also frequently present (Petru 2019).

Computed tomography:

In addition to the primary tumor, CT can also show the extent of metastasis (Aziz 2024).

In primary colon or appendix carcinomas, the tumor marker CEA is usually elevated (Petru 2019).

In primary breast cancer, the hormone receptors and HER2-neu status should be determined (Petru 2019).

Patients with Krukenberg tumors sometimes show elevated serum CA-125 levels preoperatively, which decrease again postoperatively (Al-Agha 2006).

Histologically, mucin-rich signet ring cells with hyperchromatic nuclei (Azin 2024) are typically found in Krukenberg tumors.

• Peritoneal carcinomatosis (Petru 2019)
• Ovarian torsion
• Ileus (Azin 2024)

Treatment is based on the primary tumor (Pschyrembel 2025). There are no standardized treatment guidelines, as the Krukenberg tumor has a heterogeneous tumor biology (Aziz 2024).

Radiotherapy can be useful in palliative therapy, e.g. for painful pelvic recurrences, lymphoedema of the lower extremities and bleeding vaginal recurrences (Petru 2019).

A palliative approach may involve chemotherapy, depending on the location of the primary tumor (Petru 2019).

Anti-hormonal therapy is indicated for hormone receptor-positive metastases of breast cancer (Petru 2019).

In addition to resection of the primary tumour - if it can be localized - bilateral adnexal extirpation, hysterectomy and omentectomy are performed, provided there is no massive metastasis in the abdomen. Lymphadenectomy is not recommended (Petru 2019).

The median survival rate for Krukenberg tumors is only 14 months (Aziz 2024).

The overall survival rate for Krukenberg tumors is around 10% after 5 years. Long-term survival > 5 years is rarely observed (Petru 2019).

In patients with primary colon or breast cancer, on the other hand, the 5-year survival rate is only 0-27 %. The worst prognosis is found in patients with primary carcinoma of the stomach. Here the 5-year survival rate is 0 % (Petru 1998).

Favorable prognostic factors are:

• Higher Karnofsky performance status
• Intraperitoneal residual tumor < 2 cm
• Exclusive involvement of the pelvis
• Absence of ascites
• Unilateral involvement of the ovaries
• Metachromic occurrence of metastases in the ovary
• High degree of differentiation (Petru 2019)

Due to the advanced stage of the disease, patients with Krukenberg's tumor require continuous follow-up care (Petru 2019).

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