INTRODUCTION
Krukenberg tumor is a mysterious ovarian metastasis of a gastric tumor accounting for 1 to 2% of all ovarian tumors. They are characterized by their ability to occasionally reproduce mimicking the clinical and morphological appearance of primary tumors. Thus, they are a diagnostic challenge to the physician. We present a case report of a young woman who presented with acute abdomen.
CASE REPORT
A 36-year-old parous lady presented to the emergency department with complaints of left lower quadrant abdominal pain for few hours with increasing intensity, continuous, nonradiating, and not associated with any history of vomiting or fever.
Menstrual history was normal. She had two full-term lower segment cesarean sections. Past medical and surgical history was insignificant.
On physical examination, her general condition was fair, vitals were normal; there was no pallor, icterus, and lymphadenopathy.
Breast and thyroid examination was normal. Respiratory and cardiovascular system detected no abnormality. There was a vertical midline scar with no herniation, no engorged veins or sinuses, and hernial orifices were free. On abdominal examination, a tender mass of size 12 × 10 × 8 cm cystic to firm in consistency occupying the left lumbar iliac extending into the pelvis and left hypochondriac region was found. There were no local signs of inflammation. Lower border of the mass was not felt with restricted mobility. The mass was dull on percussion. On auscultation, bowel sounds were present.
Pelvic examination revealed a mass lying in anterior, left lateral fornix, and uterus could not be made out separately. Abdominal ultrasonography showed cystic to solid mass with multiple septations in left lumbar region, giving the impression as ovarian mass (14 × 10 × 8 cm) with minimal free fluid in abdomen and left pleural effusion. Hemoglobin was 10 gm%, liver and renal function tests and other routine investigations done were normal. On explorative laparotomy, there was minimal hemoperitoneum, and hemorrhagic fluid was sent for cytology. Cystic to solid mass with bosselated appearance of size 14 × 10 × 8 cm with torsion of two turns of right ovary and hemorrhagic areas was found. Left ovary too was asymmetrically enlarged to size of 9 × 5 × 3 cm, variegated in appearance and consistency. Hence, frozen section was decided, which was inconclusive, giving torsion-related changes and tubular structures of columnar to cuboidal origin (Fig. 1). Intraoperatively, surgeon opinion was taken in view of suspicious frozen report for search of the primary malignancy. Both lobes of liver and its surface were normal. No peritoneal, omental deposits, or serosal invasion were detected. Infiltrative growth was felt in greater curvature of stomach. Thus, total abdominal hysterectomy with bilateral salpingo oophorectomy was planned. Upper gastrointestinal (GI) endoscopy was planned awaiting the final histopathology report. Fluid cytology came negative for malignant cells. Tumor markers, cancer antigen 125 (18.9 U/mL) and carcinoembryonic antigen (2.12 ng/mL), were normal. Histopathologic details revealed right ovarian mass of size 13 × 10 × 7 cm, weight of 150 gm, and having bosselated external surface. Cut section showed solid and cystic spaces filled with hemorrhagic fluid. Left ovary of size 9 × 5 × 3 cm and cut surface showed circumscribed yellow firm mass with focal cystic degeneration. Microscopy of right ovary revealed extensive areas of hemorrhagic infarction and interspersed tumor cells with features of metastatic adenocarcinoma. Left ovary too showed features of metastatic adenocarcinoma with intracellular mucin. Final report given was bilateral metastatic adenocarcinoma (Fig. 2). Upper GI endoscopy done after the final report showed ulceroproliferative growth in greater curvature of stomach for which biopsy was taken. Poorly differentiated adenocarcinoma with focal signet ring cell formation was the biopsy report, and, therefore, radical surgery was planned. Subtotal gastrectomy with feeding jejunostomy was done for our patient. Intraoperatively, growth in greater curvature was seen measuring 3 × 2 cm with two palpable lymph nodes. The final pathological report came as intestinal type of adenocarcinoma with focal diffuse type, poorly differentiated, and regional lymph node involvement. The specimen revealed chronic gastritis with Helicobacter pylori involvement (pT3 N2 C M1-G2-G3) and tumor-free margins (Fig. 3).
DISCUSSION
In 1896, Krukenberg described what he presumed was a new type of primary ovarian neoplasm.1 The true metastatic nature of the tumor was established 6 years later. About 10% of all ovarian malignant lesions are regarded as metastatic. Of these, approximately 50% are Krukenberg tumors. The tumor is well-defined histologically and is usually secondary to a tumor in the GI tract. But, these tumors during reproductive age group are fewer as the incidence of gastric carcinoma is only 0.4 to 0.5%. Krukenberg tumors tend to be in younger age group with median age of 45 years.2 Most common presenting symptoms are abdominal pain and distension in relation to the ovarian involvement. Bilateral in more than 80% of the reported cases, the ovaries are asymmetrically enlarged, with a bosselated contour. Sectioned surfaces are yellow or white; they are usually solid, although they are occasionally cystic as in our case. Route of metastasis is through three possible paths. Lymphatic is the most common route with vascular as well as peritoneal invasion. This is evident as ovarian metastasis is seen in early gastric cancers due to rich lymphatic plexus of gastric mucosa and submucosa. Surface implants too are given as another route in few studies. Premenopausal ovary is more receptive, as it is richly supplied with vessels and lymphatic plexus. Hence, we see Krukenberg tumors in younger age group compared with the other malignant ovarian lesions. Frozen section diagnosis is a reliable method with good sensitivity and higher specificity for the surgical management of patients with an ovarian mass.3 Immunohistochemistry is helpful in distinguishing the primary and metastatic ovarian carcinoma. Thus, pathological diagnosis forms an essential part in secondary ovarian tumors. Prognosis of the tumor is poor. Median survival rate is 14 months. Prognosis is poor when the primary tumor is identified after the ovarian metastasis is discovered. It is much lower in gastric than with breast and colorectal carcinoma. Absence of residual disease and limited disease extent are favorable factors for metachronous tumors of gastric origin, not the age, size, and stage of gastric adenocarcinoma after the ovarian metastasis.4 The role of tumor-free surgery and platinum-based chemotherapy is reasonable to improve the survival of these patients.5,6 Our patient has received totally six cycles of chemotherapy until now. The first two cycles were cisplatin. Other four cycles were paclitaxel with cisplatin given every 3 weeks. She is with oncology follow-up and faring better.