Magnifying Power: New Endoscopic Tools for the Diagnosis of Krukenberg Tumor

Excerpt

A 45-year-old woman was evaluated in an urgent care center for complaints of left lower quadrant pelvic pain, bloating, and early satiety. Physical examination revealed mild tenderness in the left lower quadrant of the abdomen. CT scan showed a confluent, heterogeneous mass in the pelvic cul-de-sac, measuring 11.9 × 9.9 × 7.9 cm. A small amount of ascites was also noted (Fig. 1). Follow-up pelvic ultrasound revealed a large, mixed solid and cystic mass in the left adnexa measuring 9.6 × 10.0 × 5.5 cm. A similar appearing, but smaller mass, measuring 5.2 × 4.5 × 4.2 cm was also observed in the right adnexa (Fig. 2). CA-125 level was normal at 20.3 U/mL. The patient was referred to Gyn-Oncology and underwent robotic-assisted operative laparoscopy that showed a homogeneous tumor measuring 14 cm in the left adnexa and 6 cm in the right adnexa. Total hysterectomy and bilateral salpingo-oophorectomy were performed. Peritoneal surfaces were smooth, without tumor studding. A small nodule involving the greater curvature of the stomach was identified, and wedge resection was performed. Pathology from the ovaries revealed metastatic adenocarcinoma with signet ring morphology. Biopsy of the stomach nodule also showed metastatic adenocarcinoma. The patient did well postoperatively and subsequently underwent upper endoscopy and colonoscopy to look for a primary site of the tumor. Upper endoscopy revealed poor stomach distensibility with thickening of the mid gastric body. On magnification endoscopy, there were irregularities in glands and microvasculature, and the surface architecture was expanded, consistent with a “stretch sign” (Fig. 3). Endoscopic ultrasound showed diffuse thickening of the gastric wall in the mid-body (Fig. 4). Directed biopsies obtained from this area showed poorly differentiated adenocarcinoma with signet ring features. Immunostains were positive for cytokeratin (CK)7 and caudal homeobox (CDX)2 (Fig. 5), supporting the diagnosis of Stage IV gastric adenocarcinoma. The patient was seen in consultation by medical oncology and offered systemic chemotherapy, which she is currently receiving in the setting of a clinical research trial.

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