Large Primary Jejunal Adenocarcinoma Presenting as Bilateral Ovarian Carcinomatosis: Not Always a Krukenberg Tumor

Abstract

Introduction: Adenocarcinoma of the small intestine (ASI) accounts for less than 2% of all gastrointestinal (GI) cancers. Metastatic ovarian neoplasm accounts for 3-8% of all ovarian tumors; however, metastasis from jejunal origin is extremely rare. Involvement of both ovaries, mainly originating from gastric cancer, is widely characterized as Krukenberg tumor, with classic signet-ring cell morphology and ovarian stromal sarcomatoid proliferation. We present a rare case of a woman with bilateral ovarian carcinomatosis of intestinal-type adenocarcinoma, without histologic features of Krukenberg tumor. A 37-year-old woman with recent bilateral oophorectomy and hysterectomy due to intestinal type carcinomatosis of the ovaries presented with dull epigastric pain associated with nausea and relieved by self-induced bilious, nonbloody vomiting. She denied changes in bowel habits or blood in the stool and was not anemic. Abdominal computed tomography showed a mildly dilated loop of small intestine in the left upper quadrant measuring 3.6 cm in diameter, with a distal mass-like transition. Push enteroscopy revealed a near-obstructing jejunal mass located 60 cm distal to the duodenal bulb. Colonoscopy was unremarkable. Biopsy of this mass showed invasive, moderately differentiated ASI. The patient underwent laparoscopic small bowel resection with primary anastomosis and omental biopsy. Final pathology report revealed a moderately differentiated, infiltrating ASI, invading the pericolonic adipose tissue with lymph node involvement. There were no histologic features of Krukenberg tumor in either the ovarian or intestinal adenocarcinoma. Primary jejunal adenocarcinoma (PJA) with involvement of both ovaries without histologic features of Krukenberg tumor is extremely rare. Lymphatic or direct spread is considered to be the main route of metastasis. Unless the tumor is causing intestinal obstruction, the diagnosis is frequently evasive until late in the course of the disease. Physicians should have a high index of suspicion for PJA in patients who present with vague symptoms of abdominal pain, vomiting, GI bleeding, unexplained weight loss, or other signs of small intestinal obstruction and bilateral ovarian carcinomatosis.Figure 1: Jejunal tumor.