Huge Tumor Research Articles

Intracranial Ameloblastoma Arising from the Maxilla: An Interdisciplinary Surgical Approach.

Background Ameloblastomas are a rare tumor entity accounting for only 10% of all odontogenic tumors. They mostly originate from the mandible. Only a few cases are known to grow aggressively and to invade the orbit, nasal cavity, or even the brain. Patient and Methods/Case Report We present the case of a 57-year-old patient who was admitted with a huge tumor involving the nasal cavity, the left maxilla, and the anterior fossa. Histologic diagnosis was made by biopsy. A combined two-stage neurosurgical maxillofacial approach was planned. First the intracranial tumor mass was removed using bifrontal trepanation. A duraplasty was sewn in to cover the brain. In the second procedure, a combined bifrontal and midfacial approach was used by craniofacial plastic surgeons and neurosurgeons. A perisinusoidal tumor mass and retropharyngeal tumor mass was removed up to the skull base. The left orbit was completely exenterated, and a fibular bone-muscle graft was used for palatal, orbital, and facial reconstruction. The facial vein and artery were carefully prepared to feed the bone-muscle graft by end-to-end anastomoses. Conclusion Ameloblastomas are very rare slow-growing tumors that show a tendency to recur. They are responsible for only 1% of all oral tumors. Their growth can be enormous, and they can extend into sinusoidal cavities, the orbit, and the brain. Complex and extensive palliative surgery can ease the concerns of these patients and prolong their survival.

Embolo-sclerotherapy with coils and absolute ethanol in complex venous malformations

Objective To evaluate the safety and effectiveness of embolo-sclerotherapy with coils and absolute ethanol in complex venous malformations. Methods The clinical data of 13 children with complex venous malformations treated by embolo-sclerotherapy with coils and absolute ethanol were retrospectively analyzed, including 4 males and 9 females with an average age of (5.0±0.5) years. Direct puncture angiography under DSA was performed in complex venous malformations, then the nidus diameter parameters were measured for choosing suitable coils. Nidus were punctured by needle and coils were implanted under road map, absolute ethanol was finally infused untill the nidus structrue was disappeared or more than 95%. The follow-up time ranged from 5 months to 5 years, with an average of (2.3±0.6) years. The clinical symptoms, imaging data, therapeutic effects, and postoperative complications were evaluated. Results The total treatment was 36 times with 1 to 8 times/case. Eight cases were located in neck (including 3 cases comebined with maxillofacia low reflux lesions), 4 cases in back, and 1 case in chest wall. The lesions were cured in 9 cases, partially relieved in 3 cases, and no remission in 1 case. One coil was displaced to pulmonary artery, but was captured though interventional techniques. Transient pain and skin erythema were revealed in 4 cases with superficial lesions. The treatment effect was not satisfied in 1 patient because the huge tumor was not significantly decreased in size . No ulcer, nerve damage, pulmonary hypertension, and other complications occurred in all patients. Conclusion Embolo-sclerotherapy with coils and absolute ethanol is a safe and effective treatment option in complex venous malformations. Key words: Vascular Malformations; Radiology, interventional; Embolization, therapeutic; Stents; Absolute ethanol

Safe Anaesthesia Management in a patient with ventricular fibrillation in huge mediastinum tumor resection

Mediastinum tumor is a common disease in thoracic disease; surgical resection is the mainstay of treatment. Many cases have been reported of hemodynamic and airway collapse induced by general anesthesia in patients with an anterior mediastinal mass, and it is a challenge for the anesthesiologists. Preoperative evaluation should be comprehensive, and a good response could be taken in the event of threatening situation. Ventricular fibrillation occurred in the process of particle implantation in this case. After defibrillation, injecting adrenaline, changing position and so on, cardiopulmonary resuscitation (CPR) was successful.

Imaging of neuroendocrine tumors of the pancreas.

Pancreatic neuroendocrine tumors (PNETs) are rare and represent a heterogeneous disease. PNET can be functioning or non-functioning with different clinical presentations and different prognosis based on WHO and pTNM classifications. The role of imaging includes the localization of small functioning tumor, differentiation of these tumors from adenocarcinoma, identification of signs of malignancy and evaluation of extent. PNETs have a broad spectrum of appearance. On CT and MRI, most of functioning PNETs are well defined small tumors with intense and homogeneous enhancement on arterial and portal phases. However, some PNETs with a more fibrous content may have a more delayed enhancement that is best depicted on the delayed phase. Other PNETs can present as purely cystic, complex cystic and solid tumors and calcified tumors. Non-functioning PNETs are larger with less intense and more heterogeneous enhancement. Functional imaging is useful for disease staging, to detect disease recurrence or the primary but also to select patient candidate for peptide receptor radiometabolic treatment. Somatostatin receptor scintigraphy (SRS) (Octreoscan®) is still the most available technique. Gallium 68-SST analogue PET have been demonstrated to be more sensitive than SRS-SPEC and it will be the future of functional imaging for NET. Finally, 18FDG PET/CT is indicated for more aggressive PNET as defined either by negative SRS and huge tumor burden or ki67 above 10% or poorly differentiated PNEC tumors.

Tremendous non-progressed chromophobe renal cell carcinoma for eight years performed by laparoscope.

The prognostic role of chromophobe renal cell carcinoma (ChRCC) is still controversial. Here, we report on a patient who lived with tremendous non-progressed renal malignant tumour for eight years. The 32-year-old patient presented to our hospital with a huge renal tumour. Computed tomography (CT) scan showed a tumour 12 cm in diameter at the upper pole of the right kidney. Trans-abdominal laparoscopic right radical nephrectomy was performed. Histopathological examination confirmed this tumour to be a ChRCC. The phenomenon of long-term non-progressed renal malignant tumour will help us further understand the characteristics of ChRCC.

Childhood retroperitoneal teratomas

Background Retroperitoneal teratomas are rare paediatric neoplasms. One should be well versed with the presenting features, relationship with surrounding vital organs and the extent of tumour before operating. Aim The present study was planned to highlight the presenting symptoms, preoperative investigatory findings, intraoperative findings, follow-up protocol and the surgeons’ experience in handling these huge tumours. Setting and design This was a retrospective, tertiary-care hospital-based study. Patients and methods Patients with retroperitoneal teratomas operated between 2010 and 2015 were studied in detail. All the data were collected from case files. Results During the mentioned period, there were seven patients including four males and three females. There was no side predilection (three right, two midline, one left and one lesser omentum). All the tumours were completely excised, and histopathology confirmed the benign nature in all cases. All patients were followed-up with postoperative ultrasound and were found to be normal. Conclusion Retroperitoneal teratomas are benign tumours, and complete excision is curative.

Application of laparoscopic transection of median hepatic fissure in difficult laparoscopic liver resections

Objective: The aim was to explore the strategy and clinical value of laparoscopic transection of median hepatic fissure (MHF) in difficult laparoscopic liver resections. Methods: First the MHF was located and marked, then the transection plane of the MHF was set. Next, the laparoscopic Multifuctional Operative Dissector (LPMOD) and the technique of curettage and aspiration were utilized to transect the liver beginning from the middle portion of the gallbladder fossa, in a caudal-to-cranial and anterior-to-posterior direction, until the clear exposure of the anterior surface of the intrahepatic inferior vena cava. Transection of the MHF was accurately achieved. Finally, dissection of the second and third porta hepatis were carefully performed and mobilization of the transected liver was achieved. This technique of laparoscopic transection of MHF was successfully performed in 13 patients in difficult laparoscopic liver resections. Results: Between April 2014 and August 2015, 13 patients received the technique of laparoscopic transection of MHF in difficult laparoscopic liver resections, including 10 cases of laparoscopic right hepatectomy, two cases of laparoscopic left hepatectomy and one case of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). The maximum size of the transected tumor was 15 centimeter. Duration of surgery was 240-430 min[Mean, 324.4±50.0]; the time for transection of the MHF was 40-118 min[mean, 66.4±22.7]. Blood loss was 200-2 000 ml[583.3±452.9]. The length of postoperative hospital stay was 6-25 days[mean, 13.2±5.2]. Seven patients received intraoperative transfusions. No postoperative intraabdominal bleeding, liver failure or other severe postoperative complications occurred. No perioperative death occurred. Conclusions: Application of laparoscopic transection of the MHF in difficult laparoscopic liver resections can help to clearly expose the second and third porta hepatis, especially in patients who have huge tumors and poor exposure for hepatic dissection. Moreover, precise location and transection of the MHF remains very important strategies of applying this technique.

Abstract PR063

Background & Objectives: Inferior vena caval (IVC) tumor thrombus with cardiac extension is a very rare phenomenon, which proliferates fast and could be very challenging to the surgery. This research was designed to investigate the influence of Transesophageal Echocardiography (TEE) on the surgical resection of IVC tumor extending into right cardiac cavities. Materials & Methods: Six cases from our medical institute, preoperatively diagnosed as IVC tumor with cardiac extension and scheduled for the surgical resection, were retrospectively analyzed. In addition to real-time and dynamic monitoring, comprehensive TEE exams were performed for all the patients respectively after anesthesia induction, namely before tumor resection and after tumor resection. Cardiac extension was defined by the preoperative finding of cardiac mass originated from IVC tumor by Transthoracic Echocardiography (TTE), computerized tomography (CT) or CT angiography (CTA). Results: In all the cases, intraoperative TEE provided an accurate and excellent view of the IVC tumor. For case three, the IVC tumor was found at the IVC entrance to right atrium without further cardiac extension; for case five, the IVC tumor proliferated into right atrium but the extended cardiac mass was very slim and flexible and the tricuspid valve was untouched; for case four, the IVC tumor extended into right atrium and even cross the tricuspid valve but the extended cardiac mass was also very slim and flexible. Based on the TEE-provided information, the originally scheduled surgical decision was modified and the surgical resection was performed without cardiopulmonary bypass (CPB). For other three cases, the intraoperative TEE showed similar results to preoperative findings. The huge IVC tumor extended into the right heart, presented almost no flexibility and dramatically compromised the intracardiac blood flow. For the three cases, CPB support was indispensible for the tumor resection. The full TEE exam after tumor resection in all the six patients displayed clear surgical resection without tumor residuals, but in those three patients suffered with severely compromised cardiac extension, severe tricuspid regurgitation was noticed. All the six patients were closely monitored until discharged, and no TEE related complications were observed. Conclusion: Our research is the first report about TEE’s utilization in a series of consecutive patients undergoing surgical resection of IVC tumor with cardiac extension. In addition to its safety and effectiveness, TEE can provide valuable information for surgical decision making, results assessment of the surgical intervention and anesthesia management strategies. Disclosure of Interest: None declared

Lymphadenectomy along the infrapyloric artery may be dispensable when performing pylorus-preserving gastrectomy for early middle-third gastric cancer.

This study investigated the incidence of gastric cancer metastasis to the lymph nodes along the infrapyloric artery (IPA), namely no. 6i, by reviewing our medical records of 348 patients who underwent complete no. 6 dissection. Metastasis to these nodes was observed in 11 (3.2%) patients. In these patients, one huge tumor was located in the middle third and ten including two early tumors were located in the lower third; the metastasis rate in early lower-third tumors was 2.1% and reached 19.5% in advanced tumors. In contrast, no early middle-third gastric cancers had no. 6i metastasis. The median diameter of 6i-positive tumors was 62 (range 18-115)mm, and the distance from the distal tumor border to the pyloric ring was no more than 44mm. Lymphadenectomy along the IPA is important for treating gastric cancer invading the antrum, but may be dispensable when performing pylorus-preserving gastrectomy for early middle-third cancer.

A resected case of huge pancreatic neuroendocrine tumor

A resected case of huge pancreatic neuroendocrine tumor

Perineal Paget's disease: A rare disorder and review of literature

IntroductionExtramammary Paget's disease (EMPD) occurs commonly in perineum, vulva and perineal region and is considered as a complex disorder due to different clinical and histological features.Presentation of caseA 61 years old woman had a dermatologic evaluation for anal itch and underwent a skin biopsy with diagnostic of Paget disease in perianal region. Pelvic magnetic resonance showed a huge tumor which involved skin, derma and gluteus and she firstly refused any surgical treatment. One year later, because of increasing of the tumor and bleeding, she underwent the surgical procedure with a complete excision, resection of the skin of the anus, inguinal lymphadenectomy and left colostomy. Because of lymph nodes metastasis, a VLS Miles was sequentially performed. She started oncological follow up that showed liver, lung and pelvic metastasis. She survived for 24 months after surgery.DiscussionIn literature, less than 200 cases of perineal Paget's disease have been reported. EMPD in some cases has an associated adenocarcinoma, which has been associated with a worse prognosis and high mortality. Wrong diagnosis and a superficial consideration of a benign evolution should be considered as the first mistake in clinical practice.ConclusionOur surgical approach is considered in literature as the best one for those cases, followed by the oncological treatment. Those patients need to be better studied and more attention should be paid to the clinical presentation.

Preclinical Biosafety Evaluation of Genetically Modified Human Adipose Tissue-Derived Mesenchymal Stem Cells for Clinical Applications to Brainstem Glioma.

Stem-cell based gene therapy is a promising novel therapeutic approach for inoperable invasive tumors, including brainstem glioma. Previously, we demonstrated the therapeutic potential of human adipose tissue-derived mesenchymal stem cells (hAT-MSC) genetically engineered to express a secreted form of tumor necrosis factor-related apoptosis-inducing ligand (sTRAIL) against brainstem glioma. However, safety concerns should be comprehensively investigated before clinical applications of hAT-MSC.sTRAIL. At first, we injected stereotactically low (1.2 × 10(5) cells/18 μL), medium (2.4 × 10(5)/18 μL), or high dose (3.6 × 10(5)/18 μL) of hAT-MSC.sTRAIL into the brainstems of immunodeficient mice reflecting the plan of the future clinical trial. Local toxicity, systemic toxicity, secondary tumor formation, and biodistribution of hAT-MSC.sTRAIL were investigated. Next, presence of hAT-MSC.sTRAIL was confirmed in the brain and major organs at 4, 9, and 14 weeks in brainstem glioma-bearing mice. In the 15-week subchronic toxicity test, no serious adverse events in terms of body weight, food consumption, clinical symptom, urinalysis, hematology, clinical chemistry, organ weight, and histopathology were observed. In the 26-week tumorigenicity test, hAT-MSC.sTRAIL made no detectable tumors, whereas positive control U-87 MG cells made huge tumors in the brainstem. No remaining hAT-MSC.sTRAIL was observed in any organs examined, including the brainstem at 15 or 26 weeks. In brainstem glioma-bearing mice, injected hAT-MSC.sTRAIL was observed, but gradually decreased over time in the brain. The mRNA of human specific GAPDH and TRAIL was not detected in all major organs. These results indicate that the hAT-MSC.sTRAIL could be applicable to the future clinical trials in terms of biosafety.

Portal Vein Embolization via Percutaneous Transsplenic Access prior to Major Hepatectomy for Patients with Insufficient Future Liver Remnant

PurposeTo evaluate the feasibility and safety of percutaneous transsplenic portal vein embolization (PVE) before major hepatectomy for patients with insufficient future liver remnant. Materials and MethodsFrom May 2014 to June 2015, 27 transsplenic PVEs were attempted in 26 patients. In 16 patients, transsplenic PVE was indicated because of huge or multiple tumors in the trajectory of the puncture (n = 15) or a high-positioned liver (n = 1), which prevented safe ipsilateral transhepatic access. In the remaining 10 patients, transsplenic access was planned. A perihilar splenic vein was punctured using a 21-gauge Chiba needle under ultrasound and fluoroscopic guidance. Embolization of portal venous branches was performed using gelatin sponge particles followed by application of coils, an AMPLATZER Vascular Plug (AGA Medical Corporation, Golden Valley, Minnesota), or glue to prevent recanalization. Embolization of transsplenic routes was performed using coils followed by glue. ResultsTranssplenic PVE was successful in 24 (88.9%) of 27 sessions; 3 procedures failed because of splenic vein dissection (n = 1) and failed splenic vein puncture (n = 2). Major complications occurred in 1 patient (3.8%) with splenic vein dissection. Minor complications occurred in 2 patients: a small amount of fluid collection in the splenic hilar area in 1 patient and glue migration along the splenic vein in 1 patient. Planned liver resection was performed in 24 of 26 patients at 4.9 weeks ± 3.5 after PVE. ConclusionsTranssplenic PVE is safe and feasible and can be an effective alternative treatment for patients with a challenging ipsilateral, transhepatic route.

Giant Pleomorphic Adenoma of the Parotid Gland

Pleomorphic adenomas account for the majority of parotid masses arising mostly in the superficial part of the gland and enlarging slowly over time. The vast majority are 2 to 6 cm in size when resected. We report resection of a huge mixed parotid tumor. A 40 year-old man had a 15-year history of an enlarging right periauricular mass that had developed areas of discoloration of the overlying skin due to underlying necrosis The patient ultimately underwent resection of the mass, which measured 24 cm in diameter, weighed 4.65 kg, and proved on pathologic examination to be a benign mixed tumor without malignant degeneration. The implications of this unusual case for the management of mixed tumors are discussed, and a review of the world literature on giant pleomorphic adenomas is presented.

Surgical Treatment of Sacral Neurogenic Tumor: A 10-year Experience with 64 Cases.

To explore the outcomes of surgical treatment of sacral neurogenic tumors Between 1 January 2003 and 31 December 2012, data on 64 patients with sacral neurogenic tumors treated with surgery were retrospectively analyzed. The mean age of the 64 cases (35 males and 29 females) was 37.2 years (range, 21-69 years); 38 had neurilemmomas and 26 neurofibromas. Thirty-four of the tumors involved S 1 and S 2 , 11 S 3 or lower, and 19 were single presacral soft tissue masses. Tumors were removed via anterior, posterior or combined anteroposterior approaches. Patients with unstable sacroiliac joints underwent iliolumbar fixation. Depending on the extent of tumor involvement, one of three surgical approaches was used: a single anterior approach (19 patients), single posterior approach (25 patients), or a combined anteroposterior approach (20 patients). The mean operation time was 3 h (range, 2-6 h) and the mean blood loss 878 mL (range, 400-3120 mL). The mean duration of follow-up was 58.2 months (range, 24-93 months). These surgeries had the following complications. Three patients had massive intraoperative hemorrhage and posterior back pain and discomfort postoperatively. One patient had intraoperative ureteral injuries requiring intraoperative ureteral catheterization. In two patients, the tumor involved the S 1 nerve roots bilaterally, necessitating their removal, which resulted in obvious lower limb motion and sphincteric dysfunction. In 13 patients with unilateral tumor involvement of the nerve roots of S 1 and lower spinal levels, only the contralateral nerve roots of the S1 and lower levels were preserved; eight of these patients had impaired bladder and bowel function. Posterior incisions failed to heal in 10 patients, secondary wound healing occurred in nine of them and one required a gluteus maximus myocutaneous flap. Three patients developed postoperative cerebrospinal fluid leaks that were and alleviated by waist belt compression bandaging and placing them in the Trendelenburg position. Eight patients developed tumor recurrences postoperatively; pathological examination of the tissue excised in the second surgeries revealed malignant changes in the three patients with neurilemmomas. There were no intraoperative deaths. Rod fractures occurred in three of the 18 patients requiring iliolumbar reconstruction. The clinical characteristics of sacral neurogenic tumors make them easy to diagnose. The approach to resection should be determined by the location and size of the tumor. Patients with huge tumors may lose considerable blood intraoperatively and a have higher risk rate of postoperative complications.

Rapid Diagnosis of an AT/RT by the Detection of a Heterozygous SMARCB1 Germ Line Deletion in an Infant

We report the successful use of multiplex ligation-dependent probe amplification (MLPA) to detect heterozygous loss of SMARCB1/INI1/SNF5 in the germ line of an infant with a huge posterior fossa tumor. MLPA and Sanger sequencing of the SMARCB1 gene in the germ line may be useful for the initial diagnosis in a defined subgroup of infants with rhabdoid tumors, in which biopsies cannot be performed.

Usefulness of a recanalized umbilical vein for vascular reconstruction in pediatric hepatic surgery.

Pediatric surgeons currently engage in various abdominal vascular surgeries, which sometimes require vascular conduits or grafts. Herein, we report our experience with patients undergoing vascular reconstruction using a recanalized umbilical vein (rUV) and their long-term outcome. Five patients with extrahepatic portal vein obstruction (EHPVO) underwent mesenterico-/porto-left portal vein (PV) bypass surgery using a short rUV conduit with an interposition vein graft. A sixth neonate with a huge hepatic tumor underwent PV reconstruction with anastomosis of rUV to the proximal PV stump following right hepatectomy with partial PV resection. A seventh patient underwent living donor liver transplantation for recurrent hepatoblastoma. The hepatic inferior vena cava (IVC) was resected because of tumor involvement and reconstructed by transposition of the infrahepatic IVC and interposition of rUV obtained from the donor liver graft. Sufficient flow through rUV was achieved and maintained in all patients without any complications during follow-up (0.7-6.9years). Esophageal varices, splenomegaly, and other laboratory test abnormalities because of portal hypertension disappeared after surgery in patients with EHPVO. Our experience confirmed the usefulness and long-term patency of rUV as an entry to the intrahepatic PV and as a free vascular graft to reconstruct PV or IVC.

Intrahepatic pseudocyst following acute panceatitis: Report of a case

Introduction: Pancreatic pseudocysts are a common complication of acute pancreatitis. Most commonly, pseudocysts are located in the lesser sac and the retroperitoneum. The intrahepatic location of a pseudocyst is a rare event. Herein, we report a case of intrahepatic pseudocyst, located in left hepatic lobe, following acute pancreatitis. Case report: A 70-year-old woman was referred to out hospital with a upper abdominal pain of 3 days' duration. An abdominal CT scan revealed a 11 × 10 cm sized cystic mass in the left lateral section of liver. On EUS findings, a huge hypoechoic lesion was noted with internal echogenicity in the lesser sac. When the cystic lesion was punctured, dark green colored turbid fluid was aspirated. An EUS-guided gastrocystostomy was performed. The cystic fluid analysis showed a high level of amylase in the fluid collection. (21,200 U/L) After the endoscopic procedure, a severe abdominal pain was developed. Physical examination revealed severe tenderness and rebound tenderness. An emergency left hemihepatectomy was performed. On operation findings, a huge cystic tumor was located in the left lateral section of liver. It did not communicated with pancreas or peripancreatic tissue. However, mass-like necrotic tissue was filled with in the hepatoduodenal ligament, hepatogastric ligament, and Glisson sheath of the left hepatic lobe. Pathologic examination confirmed the pseudocyst by proving nonepithelialized granulation tissue of the cystic wall. Conclusion: The presence of intrahepatic cystic lesions in patients with acute pancreatitis should raise the possibility of intrahepatic pseudocysts, even when they are not associated with pancreas or peripancreatic tissue.

Mixed spindle and epithelioid cell type gastrointestinal stromal tumor of the esophagus: a case report

Fewer than 1 % of gastrointestinal stromal tumors (GISTs) are of the esophagus. This report describes a 63-year-old female diagnosed with mixed spindle/epithelioid cell GIST of the esophagus. She was admitted to our hospital with symptoms of nausea and hematemesis. Preoperative imaging showed a huge submucosal tumor in the lower thoracic and abdominal esophagus. Pathologic examination of an endoscopic biopsy sample suggested squamous cell carcinoma. She underwent subtotal esophagectomy and reconstruction with a gastric tube. Postoperative pathological diagnosis revealed a mixed spindle/epithelioid cell type GIST. The tumor measured 8 × 6 cm, with 30–50 mitotic counts per high power field, immunohistochemical positivity for C-kit (CD117) and CD34 and high risk by modified Fletcher classification. Adjuvant chemotherapy with imatinib mesylate was started 3 months after surgery. Preoperative pathological examination, including staining for CD117 and CD34, of biopsy samples of apparently stromal tumors may be required to rule out rare subtypes of GIST.

Primary tiny pure signet-ring cell carcinoma of vermiform appendix presenting as bilateral huge Krukenberg tumors

Primary signet-ring cell carcinoma (SRCC) of vermiform appendix is extremely rare; only three cases have been reported in the English literature. A 52-year-old woman presented with abdominal mass. Physical examination revealed bilateral huge tumors in her ovarian sites. Blood tests demonstrated anemia and elevated tumor markers (CEA, 40 ng/ml; CA125, 580 ng/ml; CA72.4, 1771 U/ml; STN-AG, 19,000 U/ml; sialyl LE, 75 U/ml). Serum AFP, CA19-9, and CA15-3 were within normal limits. Upper and lower gastrointestinal endoscopy revealed no remarkable pathology. CT and MRI showed huge bilateral ovarian solid tumors without clinically apparent other tumors. The clinical diagnosis was primary bilateral ovarian tumors and bilateral oophorectomy was performed. During operation, several quick frozen sections were performed and both ovarian tumors (left: 18 cm, right: 13 cm) were found to be Krukenberg tumors. Accordingly, gynecologists did comprehensive abdominal examination to find out the primary site. They found a small tumor (3 cm × 1 cm) in the distal part of vermiform appendix, frozen sections of which revealed an SRCC. Cytologic evaluation of associated ascites at the operation was positive for carcinoma cells. Then the diagnosis of primary SRCC of appendix with both ovarian metastases (Krukenberg tumors) with peritoneal dissemination was given. Subsequent formalin fixation pathological examination gave the diagnosis. Immunohistochemically, the signet ring cells were positive for cytokeratin (CK) AE1/3, CK CAM5.2, CK8, CK18, CK19, CK20, EMA, CEA, CA19-9, p53, Ki-67 in 50% of tumor cells, CDX2, and MUC2. They were negative for CK34E1, CK5/6, CK7, CK14, p63, vimentin, TTF-1, MUC1, MUC5AC, MUC6, NSE, synaptophysin, chromogranin, and CD56. She was now treated with chemotherapy 3 months after the operation.