GYNAECOLOGY Flashcards
Ovary blood supply
Right ovarian vein drains into the IVC. Left drains into the left renal vein. Ovarian artery from the aorta.
Ovary physiology
Recruitment of follicules, Day 1-5: folllicular selection, those sized between 5-10mm are recruited, the rest become atretic. Day 5-7 there will be a dominant follicale, 10mm in size. grows around 2mm perday. The follicle will reach roughly 20mm in size prior to ovulation.
Average volume. Ovaries
7cc in females 20-39years. in post menopausal medial volume is 1cc. Ovaries found between the iliac vessels form the lateral border of the ovarian fossa where the ovaries lies. MRI provides the most detailed assess of the ovaries.
How to find the ovaries
look for the ovarian vein. follow the Ovarian vienw along the anterior surface of the psoas . Ureter Ov are typically located anterior or anteromediaal to the pelvic portion of the uretery.
Lexicon
Cyst: fluid containing structure with avascular internal contents that may have differing degrees of internal echoes. a cust can contain solid comp that is tissue r non-tissue, avascular or vascular. A cyst can be physiologic or nonphysiological. Solid or solid appearing: mass or component of a mass that has some echos suggestive of tissue, usually iso or hyperechoic when compared with the echogenicity of the normal ovarian parenchyma. Anechoic fluid: smile fluid. Fluid containing internal echoes: not simple fluid. The follicle is a simple cyst < 3cm in a premenopausal group. Ascites: fluid extending above the uterine fundus beyond the POD. Cul-de-sac fluid. Fontined to the pouch of dough below the uterine fundus or between the uterus and bladder. Papillary projections or nodules. >3mm in height.
Reporting an ovarian lesion
- Cystic or solid or both. Internal contests echogenicity. Border smooth or irregular, papillary projections 2. Uni lat or bilat 3 size, Max diameter 4. Vascularity: peripheral circumferential, doppler flow vs internal colour doppler. can score this via ORADS. 5. General and extra ovarian findings.
Benign ovarian lesions
CORPUS LUTEUM: unilocular cyst with thickened irregular crenelated wall. Prominent vascular flow within the cust wall “ring of fire appearance”. Can contain haemorrhage. usuaing less than 3cm. No papillary projections or mural nodule.
Haemorragic cyst
reticular pattern fine intersecting lines representing fibrin strands. Reteaching clot: an avascular echogenic component with angular, straigt or concave margins. Assess with real time movement. Might look jelly-like/mobile. Mx: premenopausal: less than 5cm no follow up required. >5cm but <10cm follow up in 8-12weeks. If persists or enlarges referral to specialist or MRI. Post menopausal: Straight to US specialized, Gynecologist or MRI
OVARIAN ENDOMETRIOUS
ground glass, low level internal echoes, cyst usually unilocuular, thick walled homogenous echogenic material consisting with old haemorrgaer. No internal doppler flower can contain a fluid-fluid level. Bilateral ovarian involvement in 30-50%. MRI: t2 shading, T2 dark spot. Black dot. Endometrioma associated neoplasm 1% of women. An ovarian endometrioid ca and clear cell can arise in endometriomas. Polypoid endome;triosis - polypoid masses projecting into the lumen of the endometriome. Decidualisation durial pregnancy can respond to hormonal stimulation in pregnancy. Pute mostly during pregnancy with rapid growth.
OVARIAN DERMOID
Mature teratoma: hyperechoic component with acoustic shadowing. Hyperechoic lines and dotes. Tip of the iceberg sign. Fat/fluid level. Floating echogenic spherical structures. White ball. presence of fat on CT or MRI is diagnostic. Bilateral in 20% of cases. Complications rupture, torsion, malignant transformation.
IOTA score
B-Features: M-Features: M1 - irregular solid tumor (80% is solid in 2 dimensions) M2 - Presence of ascities. M3 - at least 4 papillary projections. (needs to >3mm); M4 - Irrgular multilocularsolid tumour, maximal diamter >100mm M5 - is very strong blood flow (colour score 4).
ADNEX MODEL OF CLASSIFICATION
age, onology center. maximal dimeter of the lesion. max diameter of the larges solid part. more then 10 locules number of paillations. Acoustic shadows present. ascities. Serum Ca-125
- rupture follicle bleeds internally and re-expands
- homogenous mass with enhanced thru transmission(tumour wont do that)
- similar to endometrioma
- lacy fishnet appearance
- no dopple flow.
- haemorrhaigic cyst will go away in 1-2 cycles
- so rpt USS in 6-12 weeks.
- Endometrioma is homogenous with low level echos
Haemorrhagic ovarian cyst
Dr Rania Adel Anan and Radswiki◉ et al.
Haemorrhagic ovarian cysts (HOCs) usually result from haemorrhage into a corpus luteum or other functional cyst. Radiographic features are variable depending on the age of the haemorrhage. They typically resolve within eight weeks.
Clinical presentation
Patients may present with sudden-onset pelvic pain, pelvic mass, or they may be asymptomatic and the haemorrhagic ovarian cyst is an incidental finding 4. A haemorrhagic or a ruptured ovarian cyst is the most common cause of acute pelvic pain in an afebrile, premenopausal woman presenting to the emergency room 5. They can occur during pregnancy.
Pathology
Haemorrhagic ovarian cysts typically develop as a result of ovulation. Secondary to a hormone response the stromal cells surrounding a maturing Graafian follicle become more vascular, and after the oocyte has been expelled, the Graafian follicle develops into a corpus luteum with a highly vascular and fragile granulosa layer, which ruptures easily, forming a haemorrhagic ovarian cyst 4.
Radiographic features
Ultrasound
Haemorrhagic ovarian cysts can have a variety of appearances depending on the stage of evolution of the blood products and clot.
lace-like reticular echoes or an intracystic solid clot
a fluid-fluid level is possible.
thin wall
clot may adhere to the cyst wall mimicking a nodule, but has no blood flow on Doppler imaging
retracting clot may have sharp or concave borders, mural nodularity does not
posterior acoustic enhancement
may be less noticeable if harmonics or compounding is used
there should not be any internal blood flow
circumferential blood flow in the cyst wall is typical
If there is rupture of a haemorrhagic cyst, other findings may be present.
MRI
Relatively well defined cystic lesion in association with the ovary. Signal characteristics can vary depending on the age of the haemorrhage.
T1: high signal
T2: high signal
“T2 shading” is suggestive of chronic blood products and is more typical of endometrioma
haemorrhage evolves from the centre of the cyst and then extends peripherally (i.e. the centre may show chronic stage of haemorrhage while the periphery is more subacute)
T1 C+ (Gd): no enhancement
Treatment and prognosis
Most haemorrhagic cysts resolve completely within two menstrual cycles (8 weeks).
Cysts with a typical appearance of a haemorrhagic cyst should lead to follow-up ultrasound or MRI imaging in 6-12 weeks if:
the cyst is > 5 cm in diameter if the patient is pre-menopausal
or
any size of a haemorrhagic cyst if the patient is perimenopausal 2
In the postmenopausal patient, surgical evaluation is warranted.
A cystic structure that does not convincingly satisfy the criteria for a benign cyst cannot be considered a cyst and should be evaluated with a short interval follow-up ultrasound or MRI
Differential diagnosis
Differential considerations on ultrasound include:
cystic ovarian neoplasm: the most helpful feature in distinguishing ovarian neoplasms from haemorrhagic cysts are
papillary projections
nodular septae
colour Doppler flow in the cystic structure
endometrioma
typically contains uniform low-level internal echoes with a hypervascular wall on Doppler ultrasound.
more often multiple
on MRI, endometrioma shows high signal in T1 and low signal in T2 (shading sign), although there is overlap in appearance with haemorrhagic cysts
See also
haemorrhagic corpus luteal cyst
Quiz questions
Mature cystic ovarian teratoma
- Typical in young women 20-30.
- most common ovarian neoplasm in patients younger than 20.
- Tip of the ice berg sign.
- cystic mass
- hyperechoic solid mural nodule - rokitansky nodule/dermoid plug
- septations in 10%
- MRI: will be bright on T1 (fat), and will fat suppress (unlike hemorragic cystcs and endometriomas)
- 1% of dermoids can undergo malignant transformation - to SCC usually.
- Risk factors are size >10cm and age >50 yo.
- Gross fat containing ovarian mass on CT.
- Dot dash pattern = hair in cyst.
Annotated ultrasound images showing the Rrokitansky nodule, echogenic mesh (hair), dense shadowing foci (tip of the iceberg) and focus of possible tooth/ossification which are the characteristic features of an ovarian dermoid cyst.
Case Discussion
A mature cystic teratoma of the ovary is also called a dermoid cyst. This patient presented with a palpable lump per abdomen. The initial ultrasound scan showed the characteristic sonographic features of an ovarian dermoid cyst. CT abdomen was done later which confirmed the findings. This case highlights some of the classic features of an ovarian dermoid cyst viz. Rokitansky nodule, tip of iceberg sign, linear mesh of hair, fat-fluid levels and tooth/ossification within. Usually, ovarian dermoid cysts tend to be not more than 10 cm in size, but in this patient, the cyst was very large, reaching superiorly up to the level of the umbilicus.
Hence, based on the characteristic sonographic features, one can reliably make a diagnosis of ovarian dermoid cyst on ultrasound. When findings are not typical, a CT scan can confirm the diagnosis.
Dr Pir Abdul Ahad Aziz◉ and Assoc Prof Frank Gaillard◉◈ et al.
Ovarian dermoid cyst and mature cystic ovarian teratoma are terms often used interchangeably to refer to the most common ovarian neoplasm. These slow-growing tumours contain elements from multiple germ cell layers and are best assessed with ultrasound.
Terminology
Although they have very similar imaging appearances, the two have a fundamental histological difference: a dermoid is composed only of dermal and epidermal elements (which are both ectodermal in origin), whereas teratomas also comprise mesodermal and endodermal elements.
For the sake of simplicity, both are discussed in this article, as much of the literature combines the two entities.
Epidemiology
Mature cystic teratomas account for ~15% (range 10-20%) of all ovarian neoplasms. They tend to be identified in young women, typically around the age of 30 years 1, and are also the most common ovarian neoplasm in patients younger than 20 years 7.
Clinical presentation
Uncomplicated ovarian dermoid tend to be asymptomatic and are often discovered incidentally. They do, however, predispose to ovarian torsion, and may then present with acute pelvic pain.
Pathology
Mature cystic teratomas are encapsulated tumours with mature tissue or organ components. They are composed of well-differentiated derivations from at least two of the three germ cell layers (i.e. ectoderm, mesoderm, and endoderm). They, therefore, contain developmentally mature skin complete with hair follicles and sweat glands, sometimes luxuriant clumps of long hair, and often pockets of sebum, blood, fat (93%) 10, bone, nails, teeth, eyes, cartilage, and thyroid tissue. Typically their diameter is smaller than 10 cm, and rarely more than 15 cm. Real organoid structures (teeth, fragments of bone) may be present in ~30% of cases.
Location
They are bilateral in 10-15% of cases 1,2.
Variants
struma ovarii tumour: contains thyroid elements, however, sometimes these are separately classified as specialised teratomas of the ovaries
Radiographic features
Plain radiograph
May show calcific and tooth components with the pelvis.
Pelvic ultrasound
Ultrasound is the preferred imaging modality. Typically an ovarian dermoid is seen as a cystic adnexal mass with some mural components. Most lesions are unilocular.
The spectrum of sonographic features includes:
diffusely or partially echogenic mass with posterior sound attenuation owing to sebaceous material and hair within the cyst cavity
an echogenic interface at the edge of mass that obscures deep structures: the tip of the iceberg sign
mural hyperechoic Rokitansky nodule (dermoid plug)
echogenic, shadowing calcific or dental (tooth) components
the presence of fluid-fluid levels 5
multiple thin, echogenic bands caused by the hair in the cyst cavity: the dot-dash pattern (dermoid mesh)
colour Doppler: no internal vascularity
internal vascularity requires further workup to exclude a malignant lesion
intracystic floating balls sign is uncommon but characteristic 9
CT
CT has high sensitivity in the diagnosis of cystic teratomas 6 though it is not routinely recommended for this purpose owing to its ionising radiation.
Typically CT images demonstrate fat (areas with very low Hounsfield values), fat-fluid level, calcification (sometimes dentiform), Rokitansky protuberance, and tufts of hair. The presence of most of the above tissues is diagnostic of ovarian cystic teratomas in 98% of cases 5. Whenever the size exceeds 10 cm or soft tissue plugs and cauliflower appearance with irregular borders are seen, malignant transformation should be suspected 5.
When ruptured, the characteristic hypoattenuating fatty fluid can be found as anti dependant pockets, typically below the right hemidiaphragm, a pathognomonic finding 2. The escaped cyst content also leads to chemical peritonitis and the mesentery may be stranded and the peritoneum thickened, which may mimic peritoneal carcinomatosis 2.
Pelvic MRI
MR evaluation usually tends to be reserved for difficult cases but is exquisitely sensitive to fat components. Both fat suppression techniques and chemical shift artifact can be used to confirm the presence of fat.
Enhancement is also able to identify solid invasive components, and as such can be used to accurately locally stage malignant variants.
Treatment and prognosis
Mature ovarian teratomas are slow-growing (1-2 mm a year) and, therefore, some advocate nonsurgical management. Larger lesions are often surgically removed. Many recommend annual follow-up for lesions <7 cm to monitor growth, beyond which resection is advised.
Complications
Recognised complications include:
ovarian torsion: ~3-16% of ovarian teratomas, in general: considered the most common complication
rupture: ~1-4%
malignant transformation: ~1-2%, usually into squamous cell carcinoma (adults) or rarely into endodermal sinus tumours (paediatrics)
superimposed infection: 1%
autoimmune haemolytic anaemia: <1%
hyperthyroidism (in struma ovarii only)
carcinoid syndrome (rare)
paraneoplastic anti-N-methyl-D-aspartate receptor (anti-NMDA receptor) associated limbic encephalitis (uncommon) 8
Differential diagnosis
General differential imaging considerations include:
haemorrhagic ovarian cyst
endometrioma
a high T1 signal that does not suppress with fat saturation
T2 shading
pedunculated lipoleiomyoma of the uterus
can be traced back to the uterus
immature teratoma
ovarian serous or mucinous cystadenoma/cystadenocarcinoma
this is usually only a serious consideration if typical features of mature cystic teratoma are absent (i.e. fat is absent)
tend to occur in an older age group than dermoid cysts
Most common ovarian malignancy
- Serous ovarian cancer/cystadenocarcinoma/cystadenoma
- 60% benign
- 15% borderline
- 25% malignant - tending to occur in older women
- women of childbearing age
- unilocular with few septations
- Frequently bilateral (esp when malig)
- Papillary projections are a common finding and are suggestive of malignant
- ascities = mets
- 70% have pertioneal involvement at time of diagnosis.
Which type of ovarian ca can cause pseudomyoma pertionei?
- Mucinous ovarian cystadeoncarcinoma
- often a large mass
- typically multiloculated (although setpal are often thin
- Papillary projections are less common than with serous tumours
- Mucin causes low level echos.
- Pseudomyxoma peritoneai with scalloping along solid organs
- smoking is a risk factor
- Crack the code pg 295
Radiographic features (radiopedia)
In general, the cell type (e.g. serous, mucinous) often cannot be determined by the appearance on imaging 5. While some of the specific features can vary between the subtypes, there are certain features which are more common among mucinous tumours: 3
often larger than their serous counterparts (on occasion they may be enormous)
tend to be more multilocular with small cystic components +/- honeycomb-like locules
calcification is comparatively rare and if present tends to be linear
usually unilateral
peritoneal carcinomatosis is less common compared with serous tumours
may have accompanying pseudomyxoma peritonei
Second most common ovarian cancer
- Endometriod Ovarian cancer (Crack the core pg 295).
- serous
- endometrioid
- Mucinous
- Bilateral 15% of the time
- 25% of women will have concomitant endometrial cancer with the endometrial cancer as the primary and ovary as a met
- Endometrioid carcinoma of the ovary
Dr Bahman Rasuli◉ and Dr Alexandra Stanislavsky◉ et al.
Endometrioid carcinomas of the ovary are a sub-type of epithelial ovarian tumours. The vast majority are malignant and invasive. On imaging, they are usually characterised as complex nonspecific solid-cystic masses and found associated with endometriosis.
Epidemiology
Endometrioid carcinomas account for 8-15% of all ovarian carcinomas. It is considered the second commonest malignant ovarian neoplasm 8.
Both endometrioid and clear cell tumours are frequently associated with endometriosis 9.
Pathology
The typical gross appearance of these tumours is similar to that of other epithelial lesions, with variable cystic and solid components. Occasionally, it may be completely solid.
Histologically, an endometrioid carcinoma is characterised by the appearance of tubular glands and bears a strong resemblance to the endometrium. Gross morphological appearance is that of a mass with both solid and cystic areas 2. Squamous differentiation can be present in more than a third of patients 8.
A benign endometrioid carcinoma is relatively uncommon and when it is benign it tends to be an ovarian cystadenofibroma 3.
Associations
synchronous endometrial carcinoma or endometrial hyperplasia may be present in up to a third of cases
the endometrial abnormality is thought to represent an independent, primary lesion rather than metastatic disease
endometrioid carcinoma is the most common malignant neoplasm arising within an endometrioma, although overall this is an uncommon occurrence
Location - laterality
Bilateral involvement can be seen in 25-40% of cases 1-2,8.
Radiographic features
Imaging findings are often non-specific and include a large, complex cystic mass with solid components.
There may be associated endometrial thickening, evidence of endometriosis or a contralateral mass.
MRI
Reported signal characteristics include:
T2:
relatively low signal intensity of the tumour wall
shading sign may be seen 3
T1 C + (Gd): can show mild enhancement 3
Treatment and prognosis
Endometrioid histology may carry a slightly better prognosis than a serous or mucinous cystadenocarcinoma of the ovary (not a serous tumour in general) independent of stage 5,8. Pure endometrioid tumours carry a far better outcome than a mixed variety.
Differential diagnosis
Metastases to the ovary with colon cancer could be considered especially if the ovarian lesion is bilateral or if there is a known colonic mass, especially due to strong histological similarity. Differentiation from metastatic endometrial cancer can also sometimes be difficult.
See also
ovarian tumours
References
differential for BFM (big fucking mass) in an adult
- Adult
- Ovarian masses (mucinous and serous)
- Desmoids (Gardner Syndrome)
- Sarcomas
Gardner syndrome
Dr Francis Deng◉ and Assoc Prof Frank Gaillard◉◈ et al.
Gardner syndrome is one of the polyposis syndromes. It is characterised by:
familial adenopolyposis
multiple osteomas: especially of the mandible, skull, and long bones
epidermal cysts
fibromatoses
desmoid tumours of mesentery and anterior abdominal wall
Other abnormalities include:
supernumerary teeth and odontomas 4
duodenal tumours / ampullary carcinoma 2,3
papillary thyroid carcinoma
Pathology
There is an autosomal dominant inheritance in the FAP gene (chromosome 5q) in a majority of patients but with 20% of cases resulting from new mutations. Extracolonic features often precede the diagnosis of colonic polyps.
History and etymology
First described in 1953 by Gardner and Richards 3.
brenner tumour
- epithelial tumour of the ovary seen in women in their 50s-70s.
- Fibrous
- T2 dark
- Unlike fibromas calcs are COMMON (80%)
- AKA - Ovarian transitional cell carcinoma
Brenner tumour
Dr Bahman Rasuli◉ and Dr Gagandeep Choudhary et al.
Brenner tumours are an uncommon surface epithelial tumour of the ovary. It was originally known as a transitional cell tumour due to its histological similarity to the urothelium. Brenner tumours account for ~3% of ovarian epithelial neoplasms. They can very rarely occur in other locations, including the testis.
Epidemiology
Most often found incidentally in women between their 5th and 7th decades of life.
Clinical presentation
They are most frequently found incidentally on pelvic examination or at laparotomy.
Pathology
Histological specimens often show transitional cells similar to neoplasms of the urothelium 8.
Associations
Brenner tumours are associated with another epithelial ovarian neoplasm of either the ipsilateral or contralateral ovary in ~30% of cases 6.
Location
Brenner tumours can be bilateral in 6-7% of cases.
Radiographic features
Often manifesting as a multilocular cystic mass with a solid component or as a mostly solid mass.
Tumours are usually small (<2 cm). Even with the occasional large tumour (>10 cm), there is often a lack of local invasion, lymphadenopathy, ascites, or metastases (i.e. peritoneal metastases, omental caking), which help distinguish it from other malignant ovarian neoplasms.
Pelvic ultrasound
Brenner tumours are similar to other solid ovarian neoplasms, particularly fibromas-thecomas, and can also be confused with pedunculated leiomyomas.
They are mainly hypoechoic solid masses. Calcifications have been reported in 50% of Brenner tumours on ultrasound.
CT
calcifications have been reported in ~85% of Brenner tumours on CT
solid component may show mild to moderate enhancement post-contrast
MRI
due to its predominantly fibrous content, they appear hypointense on T2-weighted sequences
Treatment and prognosis
Most Brenner tumours are benign.
Differential diagnosis
General imaging differential considerations include:
ovarian fibroma
ovarian fibrothecoma
pedunculated leiomyoma
References
% of ovarian malig which is metastatic
- 10% of malignant ovarian tyours are mets
- the primary is most commonly from colon, gastric, breast, lung and contralateral ovary
- the most common look is bilateral solid tumours
- KRUKENBURG tumour
- met to the ovariy from the GIT - usually stomack
Krukenberg tumour (case)
Dr Mohammad Taghi Niknejad and Dr Yuranga Weerakkody◉ et al.
Krukenberg tumour, also known as carcinoma mucocellulare, refers to the “signet ring” subtype of metastatic tumour to the ovary. The colon and stomach are the most common primary tumours to result in ovarian metastases, followed by the breast, lung, and contralateral ovary.
Epidemiology
The tumours represent 5-10% of all ovarian tumours and up to 50% of all metastatic tumours to the ovary. The estimated incidence of Krukenberg tumour is at approximately 0.16/100000 per year. They tend to develop during the reproductive years 4-5.
Clinical presentation
Abdominal or pelvic pain, abdominal bloating, or pain during intercourse, may be the presenting symptom. Irregular bleeding may also be seen.
Median patient age at presentation is 48 years.
Pathology
Krukenberg tumours are metastatic tumours to the ovary that contain well defined histological characteristics - mucin-secreting “signet ring” cells and usually originate in the gastrointestinal tract 4.
The time from diagnosis of the primary neoplasm to the development of ovarian metastasis is variable and can range from several months to >10 years.
Cytologic examination often reveals mucoid degeneration and many large cells shaped like signet rings.
They can originate from 1:
stomach cancer (signet-ring cells): most common
colorectal carcinoma: second most common
breast cancer
lung cancer
contralateral ovarian carcinoma
pancreatic carcinoma
cholangiocarcionoma/gallbladder carcinoma
Radiographic features
Most imaging features are non-specific, consisting of predominantly solid components or a mixture of cystic and solid areas. It is often difficult to differentiate from other ovarian neoplasms 4-5. There are a variety of metastatic carcinomas to the ovary that can mimic primary ovarian tumours 4.
Pelvic ultrasound
These tumours are typically seen sonographically as bilateral, solid ovarian masses, with clear well-defined margins. An irregular hyper-echoic solid pattern and moth-eaten like cyst formation is also considered a characteristic feature.
CT
CT appearances can be indistinguishable from primary ovarian carcinoma 2. Features will favour towards a Krukenberg tumour if a concurrent gastric or colic mural lesion is seen. There is some evidence that tumours originating from the stomach may be denser on contrast-enhanced CT than those originating from the colon 3.
Pelvic MRI
The great majority of Krukenberg tumours are signet-ring cell carcinomas arising in the stomach. Signet-ring cells scatter in the ovarian stroma with abundant collagen formation or marked oedema. Therefore, Krukenberg tumours can occasionally show low or high signal intensity on T2-weighted images 6.
Krukenberg tumours may demonstrate some distinctive findings on MRI, including:
bilateral complex masses with hypo-intense solid components (dense stromal reaction) 4-5
internal hyperintensity (mucin) on T1 and T2 weighted MR images 4
Strong contrast enhancement is usually seen in the solid component or the wall of the intratumoural cyst 6.
Treatment and prognosis
Differentiation between primary and metastatic ovarian carcinoma is of great importance with respect to treatment and prognosis but may be very difficult based upon imaging findings solely.
Median survival
Median overall survival is of the order of approximately 16 months 8. The breakdown by primary tumour location is as follows 8:
gastric: 11 months
colorectal: 21.5 months
breast: 31 months
other (appendix, gallbladder, small intestine, unknown): 19.5 months
Associated factors for poor prognosis and predictors of unfavourable outcome include 8:
univariate analysis
synchronous metastasis
no chemotherapy
ovarian metastasis beyond the pelvis
multivariate analysis
synchronous metastasis
pelvic invasion
ascites
no metastasectomy
History and etymology
It is named after Friedrich E. Krukenberg, German pathologist (1871-1946) who first described them in 1896.
