Published online Feb 10, 2018. doi: 10.5306/wjco.v9.i1.13
Peer-review started: September 24, 2017
First decision: November 7, 2017
Revised: November 7, 2017
Accepted: November 25, 2017
Article in press: November 25, 2017
Published online: February 10, 2018
A Krukenberg tumor is a rare ovarian tumor which has metastasized from a primary site, accounting for 1%-2% of all tumors of the ovary, and conveys a poor prognosis even with disease confirmed to the ovaries. A handful of studies have been published over the past decade with regards to the prognostic factors and outcomes of surgery for Krukenberg tumors, but no previous study focuses exclusively on the group of patients for whom surgery is considered palliative.
Many aspects of Krukenberg tumors still remain controversial, and guidelines concerning treatment of choice and appropriate timing of intervention have yet to be established. We report our experience with palliative resection of Krukenberg tumors over the past 12 years and discuss the existing literature, so as to shed light and establish best practices on the approach to management of the disease.
We aimed to determine the clinical characteristics of patients undergoing palliative surgery for Krukenberg tumors, including disease presentation, outcomes, and prognostic factors.
This was a retrospective clinical study of all patients who underwent palliative surgery for Krukenberg tumors between January 2004 and December 2015. Patient information was obtained from inpatient and outpatient case notes as well as the hospital electronic records. Patients who underwent potentially curative resection, and patients with Krukenberg tumors who did not undergo surgery were also excluded from the study. Palliative surgery was defined as those performed for either alleviation of symptoms or for asymptomatic patients for whom surgical removal of the tumors were deemed necessary following a multidisciplinary consensus. Tumors were diagnosed pre-operatively by computed tomography scans and all had histologic confirmation of the surgical specimens.
Over the study duration, 38 female patients underwent palliative surgery for Krukenberg tumors at our institution. Mean age was 54.2 ± 11.7 years. The colon was the most frequent primary source of metastases (n = 21) followed by the stomach (n = 4). Prophylactic palliative surgery was performed for eight (21.1%) asymptomatic patients. Median post-operative length of stay was 8 d (IQR 6-12 d). Five patients (13.2%) experienced post-operative complications, although high grade morbidity was only seen in one patient (2.6%). Median overall survival from surgery was 17 mo (95%CI: 12.1-21.9) at a median follow-up duration of 12 mo (IQR 8-17 mo). The median survival was shorter for patients who underwent emergency surgery, younger patients, those with a colorectal primary, larger tumors, or synchronous peritoneal or hepatic metastases.
Palliative surgery for patients with Krukenberg tumors can be performed safely in an experienced unit with acceptable complication rates. The decision to proceed with metastasectomy is influenced by several factors including the presence of symptoms, synchronous disease, and tumor response to chemotherapy, and should be made as part of a multidisciplinary team consensus. Where possible, bilateral oophorectomy should be performed to obviate the significant risk of symptomatic contralateral ovarian involvement. Tumor markers need not be routinely trended peri-operatively. Proper selection is essential for asymptomatic patients who may benefit from prophylactic surgery.
Further studies can be done to determine if symptom-free survival can be prolonged or quality of life improved with palliative surgery.