What is the management of a Krukenberg tumor?

Management of Krukenberg Tumor

For Krukenberg tumors, systemic chemotherapy combined with complete cytoreductive surgery (R0 resection) offers the best survival outcomes, with R0 resection being the single most important prognostic factor for overall survival. 1, 2, 3

Primary Treatment Approach

Initial Assessment and Diagnosis

• Identify the primary tumor site through comprehensive workup including upper endoscopy, colonoscopy, and cross-sectional imaging, as the stomach (42.5%), colon-rectum (26.1%), and breast (9.3%) are the most common primary sites 4
• Evaluate resectability of both the primary tumor and ovarian metastases, as well as extent of peritoneal disease 1
• Assess performance status (ECOG 0-1 is associated with better outcomes) and ability to tolerate aggressive multimodal therapy 1

Treatment Strategy Based on Clinical Scenario

For resectable disease (primary and ovarian metastases):

• Systemic chemotherapy is the main treatment for all Krukenberg tumors 1
• Complete cytoreductive surgery (R0 resection) of both the primary tumor and ovarian metastases significantly improves overall survival (hazard ratio 0.09 for R0 resection) 2, 3
• R0 resection is superior to R+ resection (surgery with residual disease), with seven studies demonstrating significantly better overall survival with complete resection 3
• Postoperative systemic chemotherapy should be administered following R0 resection 1
• The median overall survival with R0 resection is 20 months, with disease-free survival of 32 months 2

For unresectable or extensive peritoneal disease:

• Systemic chemotherapy alone is the primary treatment modality 1
• Consider hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with cytoreductive surgery when feasible, as it shows efficacy comparable to systemic chemotherapy with fewer adverse effects 3
• The combination of R0 cytoreductive surgery with HIPEC appears to be the most effective and safe therapeutic protocol 3

Chemotherapy Regimens

• Treat according to the primary tumor type using regimens appropriate for metastatic gastric, colorectal, or breast cancer 1
• For gastric primary: platinum-based chemotherapy combinations; consider anti-HER2 therapy if HER2-positive (higher amplification rate in liver/ovarian metastases) 1
• For colorectal primary: fluoropyrimidine-based combinations with oxaliplatin or irinotecan, with or without biologics (bevacizumab for all; anti-EGFR only for KRAS wild-type) 1

Prognostic Factors

Favorable prognostic indicators:

• Breast cancer as primary site (hazard ratio 0.31) 2
• R0 resection of both primary and Krukenberg tumor (hazard ratio 2.5 for resection of both sites) 2
• ECOG performance status 0-1 1
• Absence of peritoneal/omental metastases (only significant predictor of disease-free survival after R0 resection) 2

Unfavorable features:

• Bilateral ovarian involvement (present in 64.3-80% of cases) 4, 5
• Peritoneal carcinomatosis 2
• R+ resection (residual disease) 3

Critical Management Pitfalls

• Do not perform ovarian resection alone without addressing the primary tumor - resection of both sites is essential for survival benefit 2
• Avoid surgery if R0 resection is not achievable - R+ resection does not provide the same survival advantage as R0 resection 3
• Do not delay systemic chemotherapy - it remains the cornerstone of treatment even when surgery is planned 1
• Recognize that Krukenberg tumors in pregnancy carry dismal prognosis despite aggressive treatment 5

Follow-up After R0 Resection

• Monitor for recurrence with clinical assessment and imaging, as disease-free survival averages 32 months 2
• Patients without peritoneal/omental spread at initial surgery have longer disease-free survival and should be followed accordingly 2