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Krukenberg tumor with osteoplastic metastases
KRUKENBERG
TUMOR
WITH
OSTEOPLASTIC
JOSEPH H. ZEIGERMAN, M.D., M.Sc. (From
the
Department
of
Obstetrics
and versity
(MED.),
Gynecology, of Pennsylvania)
MIZTASTASES
PHILADELPHIA,
Graduate
School
PA. of
Medicine
of
Uni-
A MONG found
the numerous articles written on Krukenberg tumors no cases were where osteoplastic met,astases were noted. Following is the report of a case’ where massive osteoplastic metastases were .seen.
H. L., a married, white multipara, 27 years old, was admitted to the Graduate Hbspital in August, 1944, complaining of vaginal bleeding and a mass in the abdomen. Her medical history included a salpingo-oophorectomy for tumor of the right ovary at another hospital in August, 1943. Her postoperative convalescence was uneventful and she left the hospital on the fourteenth day. She had remained in good health for one year and had not returned for follow-up care. The pathologic report was as follows: Specimen is a solid mass which has been previously bisected. It is 11 by 7 by 5 cm. The cut surfaces are pale yellow brown. Attached is a Fallopian tube which is hemorrhagic; it measures 3.5 by 2.5 by 2.5 cm. The microscopic picture is that of a solid tumor presenting an interesting and very unusual picture. In some regions there are solid islands of what superficially appear to be epithelial cells. The supportive structure of the ovary appears to In other regions, the follicular be composed of dense, elongated cells, resembling fibroblasts. arrangements of cells are more definite in the form of cysts, with large empty spaces lined by several rows of follicular cells. Comment : The exact nature of this tumor cannot be determined at this time. It was the impression that the tissue resembled in part, a thecal cell tumor of the ovary and in other regions, that of folliculoma. The slides were shown to other pathologists, all of whom differed to some extent in the diagnosis{ and none of whom was very definite in his opinion. One pathologist actually thought that the epithelium-like cells were truly epithelial nests and the others felt that it represented some tumor represented a Krukenberg tumor of the ovary; endocrine or developmental tumor of the ovary. On the present admission to Graduate Hospital, University of Pennsylvania, August, 1944, the patient complained of vaginal bleeding and a mass in the abdomen. The general examination was essentially negative. The pelvic examination revealed a freely movable, firm, globular mass, the size of a large grapefruit, attached to the uterus by a pedicle. The mass was thought to be a tumor of the left ovary or a pedunculated fibroid. At operation an ovarian cyst the size of a large grapefruit, half twisted on its pedicle, was removed together with the uterus. The ovarian tumor was 18 by 11 by 8 cm., in its greatest thick, with a number of scarlike depressions, whitish in color, largest 3 cm., in diameter. The cut surface was pink with edematous tissue with rounded opaque structures. Microscopy cinoma of the Krukenberg type (Fig. 1). Following the operation there were reactions. During her stay in the hospital
no complications an attempt was 187
diameter. The capsule was containing several cysts, the a background of translucent (Dr. Case). Mucoid car-
except for made to locate
several transfusion the primary growth
Fig.
@ia.
hlec. 1948
ZEIGEltMAN
188
l.-MUCC
Z.-Chalky
Iid
signc
white
appearance
of
dorsal
spine
is
characteristic
of
osteoplastic
!t-r,ing
metad
type
9ses
OSTEOPLASTIC
Volume 56 Number 1
of the Krukenberg tumor She was were negative. duties a few weeks later. portal, alternating anteriorly in air to each portal using aluminum filtration) was upper 10 by 15 cm. Three the death of the patient.
Fig.
3.-Spotty
mottling
189
METASTASES
in the intestines. However, all studies of the gastrointestinal tract discharged in fairly good condition and resumed her household She was treated daily by x-ray through two portals, 200 R to each and posteriorly. A total of 2,000 Roentgen units (as measured 190 K.V., 10 M.A., 50 cm., distance, 0.5 cm., copper, and 1 mm., given. The lower abdominal portals measured 15 by 20 cm., the courses were proposed but only one course was completed before
involving
due
the entire dorsal to osteoplastic
spine, upper metastases.
ends
of the
humerus
and
ribs.
She enjoyed good health the following five months, gained weight, and was not offering any complaints. At the end of the fifth month she began to complain of pain in the dorsolumbar spine and both thighs (Fig. 2). An x-ray survey of the entire skeleton at this time showed varying degrees of osteoplasia, involving all the ribs, the clavicles, the scapulae, the upper three-fourths of both humeri, and most of the cervical vertebrae (especially the second and seventh). There was also a very slight increase in density of the pelvic bones, especially the right and left ischium. The skull and the bones distal to the elbows and knees were not involved (Fig. 3). From here on her health began to fail rapidly. There was a progressive anorexia with loss of weight, emaciation, secondary anemia and excruciating pains in the involved bones. Patient died three months after the onset of the metastatic bone symptoms, and eight months after the second operation. Autopsy was not obtained.
Comment In the few reported cases of ovarian carcinoma when bone metastases were seen, the bone pathology was predominantly a process of osteoclasia. In our’ ease, however, we found an opposite picture of bone pathology, namely, osteoplasia. The cause of this unusual deviation is not known. One may consider the relationship of hormones, since it is known that estrogen may cause a deposition of calcium in the secondary trabeculae of the bone.
3.90
ZEIGERMAN
Am. J.
Obsr.%
GYM.
.July.
2.1. Levin, Geshickter, I.:
Ann. C. F.: Surg.Am. 65:J. 326, Cgncer,1917. 1936,
a-p
511,
b-p.
489,
3. Moore, A. B.: Am. J. Roentgenol. N. S. 6: 589-593,1919. 4. Recklinghausen, V. F.: I!. Diefibrose oder deformierende und die osteoplastische Carcinose in Ihren gegenseitigen zu Rudolph Virchow’s 71 Geburtstage 1891, p. 71. 1836
DELANCEY
PLACE
c-p 525,
d-p
539,
Ostitis, die Beziehungen,
e-p
544.
Osteomalaoic Fest,schrift
1948
TUMOR
WITH
OSTEOPLASTIC
JOSEPH H. ZEIGERMAN, M.D., M.Sc. (From
the
Department
of
Obstetrics
and versity
(MED.),
Gynecology, of Pennsylvania)
MIZTASTASES
PHILADELPHIA,
Graduate
School
PA. of
Medicine
of
Uni-
A MONG found
the numerous articles written on Krukenberg tumors no cases were where osteoplastic met,astases were noted. Following is the report of a case’ where massive osteoplastic metastases were .seen.
H. L., a married, white multipara, 27 years old, was admitted to the Graduate Hbspital in August, 1944, complaining of vaginal bleeding and a mass in the abdomen. Her medical history included a salpingo-oophorectomy for tumor of the right ovary at another hospital in August, 1943. Her postoperative convalescence was uneventful and she left the hospital on the fourteenth day. She had remained in good health for one year and had not returned for follow-up care. The pathologic report was as follows: Specimen is a solid mass which has been previously bisected. It is 11 by 7 by 5 cm. The cut surfaces are pale yellow brown. Attached is a Fallopian tube which is hemorrhagic; it measures 3.5 by 2.5 by 2.5 cm. The microscopic picture is that of a solid tumor presenting an interesting and very unusual picture. In some regions there are solid islands of what superficially appear to be epithelial cells. The supportive structure of the ovary appears to In other regions, the follicular be composed of dense, elongated cells, resembling fibroblasts. arrangements of cells are more definite in the form of cysts, with large empty spaces lined by several rows of follicular cells. Comment : The exact nature of this tumor cannot be determined at this time. It was the impression that the tissue resembled in part, a thecal cell tumor of the ovary and in other regions, that of folliculoma. The slides were shown to other pathologists, all of whom differed to some extent in the diagnosis{ and none of whom was very definite in his opinion. One pathologist actually thought that the epithelium-like cells were truly epithelial nests and the others felt that it represented some tumor represented a Krukenberg tumor of the ovary; endocrine or developmental tumor of the ovary. On the present admission to Graduate Hospital, University of Pennsylvania, August, 1944, the patient complained of vaginal bleeding and a mass in the abdomen. The general examination was essentially negative. The pelvic examination revealed a freely movable, firm, globular mass, the size of a large grapefruit, attached to the uterus by a pedicle. The mass was thought to be a tumor of the left ovary or a pedunculated fibroid. At operation an ovarian cyst the size of a large grapefruit, half twisted on its pedicle, was removed together with the uterus. The ovarian tumor was 18 by 11 by 8 cm., in its greatest thick, with a number of scarlike depressions, whitish in color, largest 3 cm., in diameter. The cut surface was pink with edematous tissue with rounded opaque structures. Microscopy cinoma of the Krukenberg type (Fig. 1). Following the operation there were reactions. During her stay in the hospital
no complications an attempt was 187
diameter. The capsule was containing several cysts, the a background of translucent (Dr. Case). Mucoid car-
except for made to locate
several transfusion the primary growth
Fig.
@ia.
hlec. 1948
ZEIGEltMAN
188
l.-MUCC
Z.-Chalky
Iid
signc
white
appearance
of
dorsal
spine
is
characteristic
of
osteoplastic
!t-r,ing
metad
type
9ses
OSTEOPLASTIC
Volume 56 Number 1
of the Krukenberg tumor She was were negative. duties a few weeks later. portal, alternating anteriorly in air to each portal using aluminum filtration) was upper 10 by 15 cm. Three the death of the patient.
Fig.
3.-Spotty
mottling
189
METASTASES
in the intestines. However, all studies of the gastrointestinal tract discharged in fairly good condition and resumed her household She was treated daily by x-ray through two portals, 200 R to each and posteriorly. A total of 2,000 Roentgen units (as measured 190 K.V., 10 M.A., 50 cm., distance, 0.5 cm., copper, and 1 mm., given. The lower abdominal portals measured 15 by 20 cm., the courses were proposed but only one course was completed before
involving
due
the entire dorsal to osteoplastic
spine, upper metastases.
ends
of the
humerus
and
ribs.
She enjoyed good health the following five months, gained weight, and was not offering any complaints. At the end of the fifth month she began to complain of pain in the dorsolumbar spine and both thighs (Fig. 2). An x-ray survey of the entire skeleton at this time showed varying degrees of osteoplasia, involving all the ribs, the clavicles, the scapulae, the upper three-fourths of both humeri, and most of the cervical vertebrae (especially the second and seventh). There was also a very slight increase in density of the pelvic bones, especially the right and left ischium. The skull and the bones distal to the elbows and knees were not involved (Fig. 3). From here on her health began to fail rapidly. There was a progressive anorexia with loss of weight, emaciation, secondary anemia and excruciating pains in the involved bones. Patient died three months after the onset of the metastatic bone symptoms, and eight months after the second operation. Autopsy was not obtained.
Comment In the few reported cases of ovarian carcinoma when bone metastases were seen, the bone pathology was predominantly a process of osteoclasia. In our’ ease, however, we found an opposite picture of bone pathology, namely, osteoplasia. The cause of this unusual deviation is not known. One may consider the relationship of hormones, since it is known that estrogen may cause a deposition of calcium in the secondary trabeculae of the bone.
3.90
ZEIGERMAN
Am. J.
Obsr.%
GYM.
.July.
2.1. Levin, Geshickter, I.:
Ann. C. F.: Surg.Am. 65:J. 326, Cgncer,1917. 1936,
a-p
511,
b-p.
489,
3. Moore, A. B.: Am. J. Roentgenol. N. S. 6: 589-593,1919. 4. Recklinghausen, V. F.: I!. Diefibrose oder deformierende und die osteoplastische Carcinose in Ihren gegenseitigen zu Rudolph Virchow’s 71 Geburtstage 1891, p. 71. 1836
DELANCEY
PLACE
c-p 525,
d-p
539,
Ostitis, die Beziehungen,
e-p
544.
Osteomalaoic Fest,schrift
1948