PMC3307215_01
Contrast-enhanced coronal CT images of the abdomen and pelvis, demonstrate a large predominantly cystic left adnexal mass containing multiple septations almost completely occupying the abdomen (black arrow). The twisted vascular pedicle in the left lower quadrant demonstrates a whirlpool sign (white arrows) (similar to what is described in the ultrasound literature).
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F1
A contrast-enhanced CT scan of the abdomen and pelvis was ordered and revealed a large poorly enhancing, predominantly cystic mass arising from the left adnexa, measuring 21.6 cm craniocaudal x 11.7 cm AP (anteroposterior) x 22.8 cm transverse, with numerous thin non-enhancing septations and small vessels coursing throughout the lesion [Figure 1].
(a) Contrast-enhanced axial and (b) coronal CT images through the pelvis demonstrate a solid heterogeneously enhancing right-adnexal mass, with a thick enhancing rind, consistent with a Krukenberg Tumor (arrow).
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F2
A second large mass measuring 5.3 cm craniocaudal x 6.5 cm AP x 5.4 cm transverse, originating from the contralateral right ovary with enhancing solid rind and central hypoattenuation, representing the right ovarian Krukenberg tumor [Figure 2] was also noted.
Contrast-enhanced axial CT at the level of the liver reveals a focal nodular thickening of the gastric body along the greater curvature and antrum (arrow) suggestive of gastric carcinoma that was subsequently confirmed by histopathology.
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F3
There was an irregular plaque-like, mildly enhancing, mass-like area in the mid-gastric body, along the lesser curvature, relating to a primary gastric malignancy [Figure 3]. The patient underwent esophagogastroduodenoscopy / colonoscopy showing a large friable ulcer located in the posterior wall of the stomach measuring approximately 10 cm, extending to both the lesser and greater curvature, showing a concern for malignancy [Figure 3].
Four contiguous sagittal images showing a discrete 'swirl sign' at the vascular pedicle (white arrows) at the base of the large left ovarian mass, consistent with the torsion of ovarian Krukenberg tumor at its pedicle.
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F4
These findings helped clinch the diagnosis of an ovarian torsion [Figure 4(a-d)].
A gross image of bi-valved left ovary weighing 2475 g and measuring 26 x 21 x 6 cm. Note the large hemorrhagic area on one end of the ovary (white arrow), measuring 11 x 5 x 2.5 cm, and other smaller areas of hemorrhage within the solid ovarian mass. The black arrows depict areas of infarction. (The deceptive cystic appearance on CT was due to a poor flow, with large areas of infarction).
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F5