Bilateral Krukenberg Tumor with Undetermined Origin during Pregnancy

Abstract

Krukenberg tumor is a rare neoplasia and its occurrence during pregnancy is even more uncommon. In 80% of the cases, Krukenberg tumors are bilateral and the prognosis is poor, especially during pregnancy, which can mimic symptoms and delay diagnosis. We present the case of a 25-year-old woman with a gestational age of 15 weeks diagnosed with bilateral ovarian tumors in a routine ultrasound. Investigation with colonoscopy, esophagogastroduodenoscopy and breast ultrasound was negative. The MRI showed two expansive formations in the pelvic-abdominal region. The right-sided mass measured 12.6 x 12.8 x 14.0 cm with a volume of 1174 cc and the left-sized mass measured 6.0 x 6.8 x 5.1 cm with a volume of 108 cc. Neither side showed signs of invasion of adjacent structures. It was also observed a marked thickening of the greater omentum, minimal thickening of the iliac peritoneal surface, and a large amount of free fluid in the abdominal cavity. Ca – 125 levels were higher than 251, with normal Ca 19-9 and CEA levels. A diagnostic laparoscopy was firstly performed and further bilateral adnexectomy with omentectomy. Pathology report revealed both ovaries infiltrated by epithelioid cells with irregular nuclei consistent with signet-cells. Immunohistochemistry was positive for cytokeratin 20 (CK20), CDX2 and focally positive for cytokeratin 7 (CK7). Based on these findings, the final pathology report was mucinous adenocarcinoma with “signet ring” cells (Krukenberg tumor) favoring gastrointestinal tract origin (CK20, CDX2 and CK7 positive). Due to the need for systemic treatment, pregnancy was interrupted at 31 weeks and a C-section was performed, still showing ascites and multiple tumor implants. A viable female infant was born, weighting 1,715 g with Apgar scores 9 and 10. The infant was admitted to the neonatal intensive care unit for further care and was discharged home after five weeks in good conditions. The patient died one month after giving birth due to severe impairment of her general condition due to disease progression.