Presentation
Dyspepsia not responding to treatment and significant weight loss.
Patient Data
The hallmark of the patient's initial US work up was bilaterally enlarged ovaries oval in shape with abundant stroma and sparing the ovarian follicles. On color Doppler, they showed high vascularity of malignant character (Grade IV vascularity), their surface is smooth with no apparent peritoneal deposits.
Moderate ascites.
- The stomach wall is seen diffusely thickened (12-18 mm) mainly anteriorly with loss of differentiation of its layers and increased vascularity on Doppler study.
- Multiple innumerable variable sized pathological lymph nodes are seen in the left para-aortic group ranging from 7 to 15 mm.
- The liver is enlarged measuring 20 cm craniocaudally in MCL showing homogeneous echo-pattern.
- Spleen is mildly enlarged in size (14 cm in long axis) with homogeneous texture and no focal lesion.
- Diffuse gastric mural thickening with faint homogeneous post-contrast enhancement.
- The liver is enlarged (24 cm in MCL), showing smooth outline and homogeneous parenchymal texture with no focal lesion.
- Bulky spleen with no sizable focal lesions.
- Multiple para-aortic pathological lymph nodes, the largest measuring about 1.2 x 1.3 cm at the inferior mesenteric artery takeoff. Lymph nodes also noted in the perigastric, common and internal iliac groups.
- Moderate pelvic and peri-hepatic and rim of peri-splenic free fluid.
- Bilateral heterogeneous ovarian masses showing variable degree of enhancement, they are seen displacing the intimately related bowel loops.
Case Discussion
With the above radiological features, Krukenberg tumor of the ovaries of gastric origin was on top of the differential diagnosis. However, with the hepatosplenomgaly, the deep cervical and abdominal lymphadenopathy and the stromal nature of the ovarian masses, lymphoma had to be considered.
Fine needle aspiration cytology was taken from the cervical lymph nodes. Aspiration cytology of the ascitic fluid was also done.
The lymph node smear was positive for malignant epithelial cells with signet ring forms (metastatic carcinomatous deposits). Ascitic fluid showed florid reactive mesothelial irritation with highly atypical cells, suspiscious for malignant epithelial cells.
This, along with the significantly elevated CEA and CA 19-9 tumor markers, favored the diagnosis of Krukenberg over lymphoma. The lady was referred to oncology; however endoscopic assessment of the stomach was deferred since she was unfit for invasive interventions.