A Rare Case of Krukenberg Tumor in a Young Female Initially Misdiagnosed as Ovarian Tuberculosis

Abstract  
Krukenberg tumour is a metastatic ovarian tumour made up of mucin-rich signet-ring cells. The stomach is the most typical initial location for this tumour. The lymphatic system is most likely how these tumours spread. We describe a remarkably unusual case of a 28-year-old woman who presented with a krukenberg tumour with an unknown primary focus. This case is an exceptional incidence of a young person developing metastatic carcinoma with an unknown primary focus presenting as a krukenberg tumour. The patient's initial complaints were abdominal pain and nausea. The initial workup of the patient revealed bilateral ovarian tumours, which were incorrectly treated as ovarian tuberculosis. A ct scan and further studies revealed deposits in the peritoneum and omentum, which were suggestive of metastatic illness. Laparotomy was performed and biopsies from the ovarian tumors were taken to investigate other diagnoses. Signet-ring cells were discovered through immunohistochemical and histopathological analyses, supporting the diagnosis of a metastatic krukenberg tumour with an unknown primary focus.

Keywords: krukenberg tumour; peritoneum; omentum  

Introduction  
Adult tumours that spread to the ovaries commonly do so; in fact, 5-30% of ovarian cancer cases are metastatic diseases.¹ adenocarcinoma with pleomorphic mucin-filled signet-ring cells, initially described by krukenberg in 1896, accounts for approximately 5% of all carcinomas that have spread to the ovaries.² this tumour is also known as the krukenberg tumour. The stomach (which accounts for 70% of cases) is the most typical location of the primary tumour in this patient group, followed by the large bowel, appendix, and occasionally several other sites.^1,3 however, the primary tumour can go undetected in 25% of the cases because it is very small. The involvement of the ovary, which is typically bilateral and can take on enormous proportions, is assumed to be the result of the selective retrograde lymphatic spread of the initial tumour along the stomach-ovarian axis.⁴ with a median life span of 14 months, individuals with krukenberg tumours typically die, as there is currently no viable treatment available.⁵ due to their vague clinical manifestations and similarities to benign illnesses, such as ovarian tb, krukenberg tumours are renowned for being diagnostic dilemmas. To highlight the need for accurate differential diagnosis in treating unusual neoplastic disorders, we provide an example of a 28-year-old female patient with a krukenberg tumour who was initially misdiagnosed as having ovarian tuberculosis.

Case presentation
A 28-year-old female patient presented with abdominal pain, bloating, decreased appetite and irregular menstrual cycles to a physician who suspected her to be a case of ovarian tuberculosis (tb) based on her symptoms and computed tomography (ct) findings which initially showed suspicion of tuberculosis and put her on anti-tuberculous therapy (att). Three months later, she presented to our emergency department with worsening symptoms and ascites. Based on her ct findings, we suspected ovarian tb but her unresponsiveness to att forced us to consider an alternate diagnosis. To be safe, we started a workup to rule out any malignancy. The patient presented with complaints including nausea, abdominal pain, and decreased appetite. The patient experienced severe discomfort due to abdominal pain. On examination, she was cachexic, her abdomen was mildly tender, and there were ascites with dullness to percussion. The rest of the examinations were unremarkable. Except for lower blood pressure, the other vital signs were stable. Large heterogeneous cystic mass lesions with irregular margins and ascites were observed on abdominal ultrasonography (us). Computed tomography (ct) showed a large well-defined heterogeneous cystic mass lesion with irregular lobulated margins, measuring approximately 10 x 11 cm, which is noted in the left adnexa. The lesion appears to arise from the left ovary. It had a small solid peripheral enhancing component and a large internal non-enhancing necrotic area. It had thin enhancing walls with few septations. The lesions have a distinct interface with the surrounding structures and do not invade the gut loops or pelvic walls. Posteriorly, the lesion did not extend to the pelvic sidewall or rectum. Superiorly, the lesion extended into the lower abdomen with the displacement of the bowel in the region. There was no evidence of calcification or haemorrhage within or adjacent to the lesion. Another large heterogeneous enhancing lesion was seen in the right adnexa measuring 5.3 x 3 cm. The right ovary was visualized separately from the lesion shown in (figure 1).


Figure 1. Black arrow shows right ovarian lesion. White arrow shows peritoneal involvement.

The uterus was normal in both size and shape. Focal lesions were not observed. Multiple enlarged, rounded, and enhancing lymph nodes are seen in the pelvis. Gross abdominopelvic ascites were observed. No scalloping of the abdominal viscera was observed, and multiple large soft tissue density-enhancing deposits of variable sizes were seen in the omentum, predominantly on the left side of the abdomen measuring 2.8 x 1.5 cm as shown in (figure 2).


figure 2. White arrow showing ascities. Blue arrow showing omental deposits.

All of these findings were suggestive of ovarian malignancy with metastasis. Except for slightly high serum levels of ca 19-9 equals 41.9 u/ml (normal values 0 - 37), ca 125 equals 73.26 u/ml (normal values 0 - 37), and chromogranin a 37.0 u/l (normal values 2 - 18), the findings of the laboratory work-up were within normal ranges. The impression given by the imaging of a large tumour potentially harming the ovarian tissue was confirmed by laparotomy. Due to the lack of adhesions between the masses and the nearby organs and tissues, the excision of both masses together with bilateral salpingectomy was completed after obtaining informed consent on the basis that ovarian function had been lost. Exploration of the abdominal cavity revealed tumour deposits and ascites in multiple areas. Masses and metastatic lesions were removed and sent for histopathological analysis. Histopathology gave the following reports on gross examination of a skin-covered tissue piece separately present in containers along with bilateral fallopian tubes. The uterus measured 40 mm × 33 mm × 24 mm. On serial slicing, the endometrial cavity measured 20 mm × 2 mm. The maximum thickness of the endometrium was 1 mm, and that of the myometrium was 14 mm. A fibroid (separately present in the container) measured 20 mm × 19 mm × 15 mm. Serial slicing revealed a tan-white whorled cut surface. The skin-covered tissue piece measured 21 mm × 19 mm. The skin was grossly unremarkable. The soft tissue fragments measured 135 × 65 × 30 mm. The first fallopian tube measured 45 mm × 9 mm. The second fallopian tube measured 51 mm × 9 mm. The cut surfaces of both fallopian tubes were unremarkable. Microscopic examination revealed a malignant tumour made up of sheets of signet-ringed cells diffusely invading multiple tissue fragments. Immunohistochemical findings are shown in (table 1).

table 1. Immuno/histochemical stain(s)