A retrospective study of clinicopathological characteristics and prognostic factors of Krukenberg tumor with gastric origin

Abstract

Background: Krukenberg tumor (KT) of gastric origin has a poor prognosis. The present study of KTs are mainly case reports and clinical analysis with few samples. Therefore, it is urgent to explore the clinicopathologic characteristics of KTs through large sample studies. To improve the understanding of the clinical diagnosis and treatment of KT, this paper retrospectively analyzed 10 years of gastric cancer (GC) database data, including clinicopathological and prognostic features, aiming to provide a clinical reference for the diagnosis and treatment of the tumor.

Methods: The clinicopathological characteristics, treatments, and survival data were collected and analyzed from 130 patients with KTs of GC. Clinicopathological data included clinical manifestations, laboratory findings, imaging reports, pathology and immunohistochemistry (IHC) reports. We collected treatment regimens information on whether they had undergone surgery and chemotherapy and performed survival follow-up. Univariate and multivariate analysis were used to investigate the risk factors of KTs with gastric origin.

Results: The median age of the patients was 41 years. A total of 63.1% of patients had synchronous ovarian metastasis, 70.8% had bilateral ovarian metastasis, 68.5% had peritoneum metastasis, and 98.5% had pathologically poorly differentiated adenocarcinoma. The positive rate of human epidermal growth factor receptor 2 (HER-2) was 1.8%. The follow-up rate was 90.8%, and the median overall survival (mOS) of ovarian metastasis was 13.0 months. Univariate analysis showed statistically significant prognostic factors including menstrual status, size of the gastric lesions and ovarian metastases, number of lymph node metastasis, interval to ovarian metastasis, resection of gastric lesions, peritoneal metastasis, oophorectomy, chemotherapy after ovarian metastases, two-drug regimen chemotherapy, albumin, serum cancer antigen 125 (CA-125) levels, platelet count, D-dimer, fibrinogen, and high pretreatment platelet-to-lymphocyte ratio (PLR) and systemic immune-inflammation index (SII). Fibrinogen [hazard ration (HR) =0.483; 95% confidence interval (CI): 0.300-0.777; P=0.003], size of ovarian metastasis (HR =1.808; 95% CI: 1.178-2.776; P=0.007), chemotherapy after ovarian metastasis (HR =0.195; 95% CI: 0.101-0.379; P=0.000), peritoneal metastasis (HR =2.742; 95% CI: 1.606-4.682; P=0.000) and oophorectomy (HR =1.720; 95% CI: 1.066-2.778; P=0.026) were independent prognostic factors.

Conclusions: GC patients with KTs have some unique clinical features. Hypercoagulable states, peritoneal metastasis, and untimely chemotherapy and oophorectomy might be a worse predictor for KTs derived from gastric origin.

Keywords: Gastric cancer (GC); Krukenberg tumor (KT); clinicopathological characteristics; prognosis.

Figure 1

A 43-year-old woman with a KT underwent oophorectomy. (A) PET/CT images showed localized gastric wall thickening at the greater curvature of the gastric body (SUVmax =2.7) and [(B) right 11.7×11.2 cm and (C) left 8.5×9.0 cm] irregular mixed cystic and solid masses in bilateral ovaries (SUVmax =9.1). (D) Gastric endoscopy showed ulcerative erosion foci at the greater curvature of the gastric body. (E) Gross specimens of KTs. Photomicrograph (H&E staining, ×20) showed gastric low differentiated adenocarcinoma with signet ring cell carcinoma (F) and ovarian metastasis adenocarcinoma (G). KT, Krukenberg tumor; PET, positron emission tomography; CT, computed tomography; SUVmax, maximum standardized uptake value; H&E, hematoxylin and eosin.

Figure 2

ROC curve analysis to find the optimal cut-off points for NLR (A), PLR (B), and SII (C), and Kaplan-Meier survival curves for patients with KTs based on NLR (D), PLR (E), and SII (F). NLR, neutrophil-to-lymphocyte ratio; AUC, area under the curve; PLR, platelet-to-lymphocyte ratio; SII, systemic immune-inflammation index; OS, overall survival; ROC, receiver operating characteristic; KTs, Krukenberg tumors.

Figure 3

Kaplan-Meier survival curves for patients with KTs based on fibrinogen (A), resection of ovarian metastasis (B), chemotherapy (C), size of ovarian metastasis (D), and peritoneal metastasis (E), all P<0.05. OS, overall survival; KTs, Krukenberg tumors.