CDX2, SATB2, GATA3, TTF1, and PAX8 Immunohistochemistry in Krukenberg Tumors.

Twenty-six Krukenberg tumors (16 lower gastrointestinal, 4 upper gastrointestinal, and 6 of unknown origin) and their primaries when known were stained with CDX2, SATB2, GATA3, TTF1, and PAX8 using a tissue microarray containing predominantly or exclusively signet ring cells. The most common primary was appendiceal mixed adenoneuroendocrine carcinoma. CDX2 and SATB2 were positive in all known lower gastrointestinal primary tumors and negative in nearly all known upper gastrointestinal primary tumors. Primaries showed identical immunophenotypes to their metastases. Among cases of unknown primary origin, 3 were positive and 3 were negative for CDX2 and SATB2. Chest images, upper endoscopies, colonoscopies, appendectomies, and mammogram were performed with negative results in all, 4, 2, 2, and 1 cases, respectively. No cystoscopies were attempted. PAX8, GATA3, and TTF1 were negative in all cases. The literature was reviewed with emphasis on immunohistochemistry of signet ring cell-containing carcinomas from the appendix, colon, stomach, breast, lung, and bladder. Three quarters of gastric primaries stain for CDX2 and only rare examples stain for SATB2. Colorectal primaries (most of them) and appendiceal primaries (all of them) are positive for CDX2 and SATB2. GATA3 stains almost all breast primaries and approximately half of bladder primaries. All pulmonary primaries are positive for TTF1. PAX8 is negative in the gastric, colorectal, and appendiceal primaries reported. This study shows that the panel of immunostains is useful in confirming the site of origin of a metastatic Krukenberg tumor when one is known and has limited diagnostic value for diagnosing metastases of unknown origin.

Comparison of a Panel of Biomarkers Between Gastric Primary Cancer and the Paired Krukenberg Tumor.

To compare a panel of selected biomarkers between gastric primary cancer and the paired Krukenberg tumor, a total of 21 cases of metastatic tumors originating from stomach and the paired gastric primary cancers were collected. The expressions of a panel of selected biomarkers were tested by IHC. FISH was used to determine the status of HER2/neu in cases scored IHC 2+. The differences of the expressions of the biomarkers were evaluated between metastatic tumors and the paired gastric primary cancers. Bcl-2 was negative in all the cases. The HER2/neu expression was consistent between the gastric primary cancers and the paired metastatic tumors in 17 patients. In the other 4 cases, the HER2/neu expression was negative in gastric primary cancers but positive in the matched metastatic tumors. The concordance rate of c-MET, p53, and Ki-67 expression was 71.4%, 81.0%, and 76.2%, respectively. In conclusion, the expression of Bcl-2 is negative in all gastric primary tumors and the paired metastatic cancers. There is major concordance of the expression of HER2/neu, c-MET, p53, and Ki-67 between gastric primary cancers and the paired metastatic tumors, which suggests that the status of these biomarkers remain stable during the metastatic process.

The Application Value of HNF-1ß Transcription Factor in the Diagnosis of Ovarian Clear Cell Carcinoma.

The purpose of this study was to investigate the expression of HNF-1ß in various types of epithelial ovarian cancers and to discuss its utilization in the diagnosis of ovarian clear cell carcinoma (OCCC). This study was designed to detect HNF-1ß proteins in 27 OCCCs, 35 high-grade serous carcinomas, 21 endometrioid adenocarcinomas, 10 mucinous carcinomas, 2 transitional cell carcinomas, and 13 metastatic Krukenberg tumors by EnVision immunohistochemical system. Twenty-three of 27 (85.2%) OCCCs showed diffuse moderate to strong nuclear staining for HNF-1ß. In the 35 high-grade serous ovarian cancers, HNF-1ß was detected in 1 (2.9%) case. Five of 21 (23.8%) ovarian endometrioid adenocarcinomas were positive for HNF-1ß. Six cases of ovarian mucinous carcinomas displayed diffused moderate to strong nuclear HNF-1ß expression, yielding a positive rate of 60%. In the 13 Krukenberg tumors, HNF-1ß was detected in 7 cases with a positive rate of 53.8% and both ovary transitional cell carcinomas were negative for HNF-1ß transcription factor. Compared with HNF1ß expression in OCCCs, serous carcinomas and endometrial adenocarcinomas were significantly lower (P<0.01). However, HNF1ß expression in mucinous carcinomas and Krukenberg tumors were not significantly different from the expression in OCCCs (P>0.05). Using HNF-1ß as a diagnostic tool for OCCC showed a sensitivity and specificity of 85.2% and 76.5%, respectively. HNF-1ß can serve as an OCCC marker with a relatively high sensitivity. The diffuse and strong HNF-1ß expression pattern can be used to diagnose OCCCs with high specificity.

Ovarian tumors with functioning stroma: a clinicopathologic study with special reference to serum estrogen level, stromal morphology, and aromatase expression.

Ovarian tumors with functioning stroma often show estrogenic manifestations. The range of serum estrogen level, however, has not been analyzed, nor the correlation with the stromal morphology. We reviewed the preoperative serum level of estradiol (E2) in 20 postmenopausal ovarian tumors that contained lutein- or theca-like cells in the stroma. Tumor histology included mucinous (n=7), endometrioid (n=4), clear (n=4), or Brenner tumor (n=2), carcinosarcoma (n=2), and Krukenberg tumor (n=1). Overall, the preoperative serum level of E2 ranged widely from 12.1 to 162.4 pg/mL (reference range, 10-30 pg/mL). The range of serum E2 was 24.9 to 162.4 pg/mL (mean, 58.0 pg/mL) in 7 tumors containing lutein-like cells, and 12.1 to 157.8 pg/mL (mean, 57.0 pg/mL) in 13 tumors containing theca-like cells alone. There was no significant difference in the serum E2 level between the 2 groups. To determine whether the functioning stroma is capable of final conversion of androgens to estrogens, the expression of P450 aromatase was examined immunohistochemically. P450 aromatase was exclusively expressed in the stromal cells, both lutein- and theca-like cells, in 16 tumors. In all tumors, however, it was focally or sparsely distributed, and there was no correlation between the immunoreactivity for P450 aromatase and the serum E2 level. These findings indicate that the functioning stroma, regardless of cell morphology, has a capacity for converting androgens to estrogens, but a significant amount of serum estrogens is finally qualified in the aromatase-rich peripheral tissues.

Clinical significance of VEGFR-2 and VEGFR-3 expression in ovarian cancer patients.

The vascular endothelial growth factor (VEGF) family and VEGF receptors (VEGFR) play an essential role in angiogenesis and lymphangiogenesis. The aim of this study was to clarify the prognostic significance of VEGFR expression in ovarian carcinoma. Levels of VEGFR-2 and VEGFR-3 tissue expression in human ovarian tumours were assayed by immunoblotting and the correlations between analysed factors and clinicopathological features were examined. Tissue samples consisted of 42 benign and 10 borderline (low malignant potential - LMP) tumours, 76 ovarian carcinomas, 8 Krukenberg tumours and 32 normal ovarian tissues. The highest relative level of VEGFR-2 was detected in cases with at the early stages of cancer development. The highest level of VEGFR-3 was detected advanced cancer stages and those with Krukenberg tumours. Overexpression of VEGFR-3 was found to correlate with the debulking status (p = 0.02) and positive response to chemotherapy (p = 0.04). A statistically significant longer progression free survival (PFS) was observed in women with a low than with a high expression of VEGFR-3 (p = 0.01). Increased levels of VEGFR-2 expression at the early stages of ovarian cancer may indicate the significance of neoangiogenesis at these stages. Overexpression of VEGFR-3 reflects the aggressiveness of ovarian carcinoma spread and has a predictive value for identifying high-risk patients with poor prognosis.

Maspin overexpression correlates with positive response to primary chemotherapy in ovarian cancer patients.

OBJECTIVE: Maspin is a member of the serine protease inhibitor superfamily. Experimental studies revealed that maspin suppresses tumor growth, angiogenesis, invasion and metastasis. We examined maspin expression in human ovarian tumors and relation between maspin expression and clinicopathological features as well as the role of maspin in predicting clinical outcome in patients with ovarian cancer. METHODS: Tissue samples consisted of 42 benign tumors, 10 borderline (LMP) tumors, 76 ovarian carcinomas, 8 Krukenberg tumors and 32 normal tissues. Immunoblot analysis was performed to evaluate the relative expression of maspin/beta-actin. RESULTS: Relative maspin level was significantly higher in patients with LMP tumors (median 0.74) and early stages ovarian cancers (median 0.46) when compared with healthy tissues (median 0.03), those with benign (median 0.23) and metastatic tumors (median 0.22). Overexpression of maspin was found to correlate with the early stage of the disease (p=0.001), non-serous subtype of ovarian cancer (p=0.03) and positive response to chemotherapy (p=0.02). A statistically significant longer PFS was seen in women with high as compared with low expression of maspin (p=0.03). CONCLUSIONS: Maspin is upregulated in borderline tumors and the early stages of ovarian carcinoma and then significantly downregulated with malignant transformation. High expression may paradoxically promote the invasion and metastasis of ovarian carcinomas. Our study revealed that maspin expression could play an important role in predicting the results of treatment of ovarian cancer patients.

Primary ovarian mucinous tumors with signet ring cells: report of 3 cases with discussion of so-called primary Krukenberg tumor.

The distinction between a primary ovarian mucinous carcinoma or even a borderline mucinous tumor and a metastatic mucinous carcinoma may be difficult. A constellation of clinical, gross pathologic and morphologic features is used in this distinction. One of the most important morphologic features suggesting a metastatic mucinous carcinoma in the ovary is the presence of signet ring cells; these are considered rare in primary ovarian mucinous tumors. In this study, we report 3 primary ovarian mucinous tumors with a component of signet ring cells. The tumors arose in patients aged 27, 55, and 60, were unilateral, confined to the ovary and stage IA. They ranged from 9 to 27 cm; 1 was grossly a multiloculated cystic lesion and 2 were cystic and solid. In one case, the neoplasm had the architecture of a mucinous adenofibroma but had frankly malignant cells lining glands and forming solid aggregates of cells. A second tumor also had the background of an adenofibroma. The third was mostly a mucinous cystadenoma. In one case, endometriosis was present in the same ovary; teratomatous elements were not identified in any case. Immunohistochemistry, performed in 2 cases, showed both to be diffusely positive with CK7 and CA19.9, including the signet ring cells. CK20 was positive in both cases (1 focal; 1 diffuse). Estrogen receptor and CA125 were diffusely positive and carcinoembryonic antigen and CDX2 focally positive in 1 case. Chromogranin and synaptophysin were negative. Investigations to exclude a gastrointestinal neoplasm in 2 cases were negative. Features favoring a primary rather than a metastatic neoplasm are unilateral tumor, low stage, background of adenofibroma or cystadenoma, associated endometriosis in 1 case and an absence of features which are characteristic of secondary mucinous carcinomas in the ovary, such as surface tumor deposits, a nodular growth pattern, and lymphovascular permeation. Immunohistochemistry is of limited value because of overlapping immunophenotype between a primary ovarian mucinous tumor and a metastasis from the stomach, pancreas, biliary tree, appendix, or colorectum, the most likely primary sites for a secondary exhibiting similar features. Our study illustrates that signet ring cells occur rarely in a primary ovarian mucinous tumor; even when conspicuous the features differ from those of the usual Krukenberg tumor. At least some cases of so-called primary Krukenberg tumor may be similar to our cases. However, the designation primary Krukenberg tumor should not be used as, apart from the signet ring cells, a resemblance to a "true" Krukenberg tumor of the secondary type is limited. The tumors should be classified according to the underlying background neoplasm with a notation concerning the signet ring cell component.

Krukenberg tumor with yolk sac tumor differentiation.

An unusual case of bilateral Krukenberg tumor with foci of yolk sac tumor (YST) differentiation occurring in a 50-year-old patient is reported. The primary tumor was in the gastric antrum, and it showed morphology of poorly differentiated adenocarcinoma with diffuse and solid growth pattern. A component of typical YST was not found in the gastric primary and lymph node metastases, although some cells in these locations were positive for alpha-fetoprotein. In the ovarian metastases, YST element showed microcystic/reticular and solid patterns, whereas the adenocarcinoma component was of diffuse type with signet ring cells and with some undifferentiated areas. The case represents further example of the somatic cell-derived tumor with focal germ cell-type differentiation and the first report of YST differentiation in Krukenberg tumor.

Ovarian metastases of intestinal-type gastric carcinoma: A clinicopathologic study of 4 cases with contrasting features to those of the Krukenberg tumor.

Ovarian metastases of intestinal-type gastric adenocarcinomas are rare, and information on them is very limited compared with that on signet-ring cell carcinomas that result in the Krukenberg tumor. Four cases are reported herein. The patients averaged 55 years of age. In 3 patients, the ovarian metastases were identified several to 21 months after the diagnosis of the gastric primary, and the tumors were synchronous in the fourth. Two tumors were bilateral, 1 unilateral, and for 1, the laterality was unknown. The ovarian tumors were characteristically solid and cystic, with multinodular growth in 2. In 2 cases, the ovarian tumors had a pseudoendometrioid morphology with tubulo-glandular, cribriform, and papillary patterns; they also had focal trabecular and insular patterns. Prominent necrosis was present, including segmental and intraluminal "dirty" necrosis. In the other 2 cases, the ovarian tumors had a mucinous appearance, 1 being dominantly cystic with occasional goblet cells and the other with prominent foveolar-type cells. Nuclei ranged from deceptively bland to highly atypical. Surface implants were identified in 2 cases. Two ovarian tumors examined expressed cytokeratin 7 and 20 but not estrogen receptor. Three patients with follow-up information all died within 1 year of the ovarian metastases. Although information is limited, our results suggest that metastatic spread to the ovary by intestinal-type gastric adenocarcinoma is usually seen in patients older than those with Krukenberg tumors, with a known history of gastric carcinoma, and with concomitant widespread disease. Involvement of the ovary by intestinal-type gastric carcinoma produces a microscopic picture distinctly different from that of a Krukenberg tumor. These metastatic intestinal-type tumors may be confused with metastases from other gastrointestinal sites that are more frequently the cause of pseudoendometrioid or mucinous metastases, and like such tumors may be confused with primary ovarian endometrioid and mucinous neoplasms.

Expression and correlation of CD44v6, vascular endothelial growth factor, matrix metalloproteinase-2, and matrix metalloproteinase-9 in Krukenberg tumor.

AIM: To explore the expression and correlation of CD44v6, vascular endothelial growth factor (VEGF), matrix metalloproteinase (MMP)-2 and matrix metalloproteinase (MMP)-9 in Krukenberg and primary epithelial ovarian carcinoma. METHODS: The expressions of CD44v6, VEGF, MMP-2 and MMP-9 were detected by immunohistochemical method in 20 cases of normal ovarian tissues, 38 cases of Krukenberg tumor and 45 cases of primary epithelial ovarian carcinoma. RESULTS: The expression of CD44v6 (primary epithelial ovarian carcinoma tissue vs normal ovarian tissue: chi(2) = 4.516, P = 0.034; Krukenberg tumor tissue vs normal ovarian tissue: chi(2) = 19.537, P = 0.001) and VEGF (primary epithelial ovarian carcinoma tissue vs normal ovarian tissue: P = 0.026; Krukenberg tumor tissue vs normal ovarian tissue: chi(2) = 22.895, P = 0.001) was significantly higher in primary epithelial ovarian carcinoma tissue and Krukenberg tumor tissue than in normal ovarian tissue. The positive expression rate of MMP-2 and MMP-9 was 0% in the normal ovarian tissue. The positive expression rate of CD44v6 (chi(2) = 10.398, P = 0.001), VEGF (chi(2) = 13.149, P = 0.001), MMP-2 (chi(2) = 33.668, P = 0.001) and MMP-9 (chi(2) = 38.839, P = 0.001) was remarkably higher in Krukenberg tumor than in primary epithelial ovarian carcinoma. The correlation of CD44v6, VEGF, MMP-2, and MMP-9 was observed in primary epithelial ovarian carcinoma and Krukenberg tumor. CONCLUSION: CD44v6, VEGF, MMP-2, and MMP-9 are involved in ovarian carcinoma, gastric cancer and Krukenberg tumor. Detection of CD44v6, VEGF, MMP-2 and MMP-9 may contribute to the diagnosis of ovarian carcinoma, gastric cancer, and Krukenberg tumor.

Bilateral ovarian carcinoma metastatic from the ampulla of Vater: a rare Krukenberg tumor.

Carcinoma of the ampulla of Vater is a relatively rare neoplasm and its longterm survival rate is considerably high. However, because of differences in tumor pathologic features and local invasiveness, a 5-year survival rate differ widely. We present a case of metastatic carcinoma of the ampulla of Vater presenting as a Krukenberg tumor in a 59-year-old woman. Eight months earlier, she had been diagnosed as well-differentiated adenocarcinoma of the ampulla of Vater. Abdominal examination revealed a hard mass with mild tenderness in the RLQ area. The laboratory findings were unremarkable except for mild anemia. CT scan of the abdomen revealed enlargement of both ovaries. An exploratory laparotomy disclosed bilateral ovarian masses, 18 x 12 x 8 cm and 8 x 5.5 x 4 cm in size, respectively. Histologic findings of the both ovarian masses were consistent with metastatic adenocarcinoma from the ampulla of Vater.

Bilateral ovarian carcinoma metastatic from the ampulla of Vater: a rare Krukenberg tumor

Carcinoma of the ampulla of Vater is a relatively rare neoplasm and its longterm survival rate is considerably high. However, because of differences in tumor pathologic features and local invasiveness, a 5-year survival rate differ widely. We present a case of metastatic carcinoma of the ampulla of Vater presenting as a Krukenberg tumor in a 59-year-old woman. Eight months earlier, she had been diagnosed as well-differentiated adenocarcinoma of the ampulla of Vater. Abdominal examination revealed a hard mass with mild tenderness in the RLQ area. The laboratory findings were unremarkable except for mild anemia. CT scan of the abdomen revealed enlargement of both ovaries. An exploratory laparotomy disclosed bilateral ovarian masses, 18 x 12 x 8 cm and 8 x 5.5 x 4 cm in size, respectively. Histologic findings of the both ovarian masses were consistent with metastatic adenocarcinoma from the ampulla of Vater.

Characterization of Krukenberg tumor cell line, especially the biological relationship between cancer and stromal cells.

The signet-ring cell adenocarcinoma cell line (HSKT-C) and the fibroblast cell strain (HSKT-F) were established from a Krukenberg tumor. The HSKT-C cells are small, roundish or spindle-like in shape and form monolayer sheets of epithelial pavement cells and produce carcinoembryonic proteins such as carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), etc. They show a stable proliferation after successful passages of 45 times within 13 months. The chromosome number varied widely and showed aneuploidy. The HSKT-C cells were transplanted to hamster cheek pouches and produced a tumor (signet-ring cell adenocarcinoma). On the other hand, HSKT-F cells are fibroblast-like. Their chromosome number is 46, and no karyological abnormality was observed. They could not be transplanted in the nude mouse or the hamster and did not produce carcinoembryonic proteins. It should be noted that they produce estrogens (estrone and 17 beta-estradiol). Sarcomatous morphological change of the stromal cells in Krukenberg tumor is considered to be a reactive change against invasion of the signet-ring cell adenocarcinoma into stromal tissues.

[Krukenberg tumor of the ovary].

Light microscopic, ultrastructural and histochemical observation of 46 cases of ovarian Krukenberg tumors are described. The clinical material is also analysed. The histologic classification of this tumor is suggested to be four types: 1. classical Krukenberg tumor (CKT), 27 cases; 2. tubular Krukenberg tumor (TKT), 9 cases; 3. sclerosing Krukenberg tumor (SKT), 5 cases; and 4. mixed Krukenberg tumor (MKT), 5 cases. In CKT, single signet ring cells predominated over lumen-forming cells and contained ultrastructural and histochemical characteristics similar to cylindral cells of colonic and ovarian mucinous adenocarcinomas. The stroma contained extracellular mucin. In TKT, the lumen was formed by non-secretory and secretory cylindral cells. Some rare argentaffin cells were observed. Steroidgenic stromal lutein cells were identified in one case by electron microscope. Cells in both CKT and TKT produced neutral and sialomucins. Hypertrophic stromal fibroblasts were extremely rich in five SKT with signet ring cells occasionally located inside. It is easy to be misdiagnosed as fibroma or sclerosing stromal tumor. Five cases of MKT showed the mixed features of the above two or three types. Krukenberg tumors are almost always made up of intestinal type cells basing on cell differentiation. The TKT is better differentiated than CKT and SKT. Hypertrophy and hyperplasia of ovarian stromal cells may occur in response to malignant growth or the extracellular mucinous products of malignant cells. They may play a role in the control of tumor invasion.

Clinical and ultrastructural findings of an androgenizing Krukenberg tumor in pregnancy.

A clinical and ultrastructural study of an androgenizing Krukenberg tumor in pregnancy is presented. Ultrastructural observations suggested the abundant, hyperplastic, luteinized ovarian interstitial cells as the probable cause of elevated circulating levels of testosterone (5400 ng/dL). The unusual fine structure of these cells, which included large intramitochondrial lipid droplets and abundant smooth endoplasmic reticulum, was indistinguishable from that reported to occur in Leydig cells stimulated by exogenous gonadotropins.