BANGLADESH JOURNAL OF RADIOLOGY AND IMAGING 2013; VOL. 21(2): 87-89 Ovarian Metastases Caused by Cholangiocarcinoma: A Rare Krukenberg’s Tumor: A Case Study FAHMIDA YESHMINE1, MAHBUBA HUSSAIN2, SHARMISTHA DEY3, MD TOWHIDUR RAHMAN3, MASKURA KHATUN4

Abstract : yellowish discoloration of skin & mucous membrane Ovarian metastases represent 10% of all ovarian , severe itching , high colored urine and pale colored malignancies. They are characterized by their ability stool. On clinical examinations tender right to occasionally reproduce mimicking the clinical and hypochondriac is noted. On palpation clinician found morphological appearance of primary tumors, making a mass in right hypochondriac region and tender diagnosis difficult. Most of these tumors originate in lower abdomen. After admission serological test was the digestive tract, the best known being Krukenberg’s done. Her serum bilirubin was high (8.4 mg/dl ) , tumor in the stomach. Cholangiocarcinomas are rare SGPT – 52. Alkaline phosphatase was 627 , SGOT neoplasia that very rarely affect the ovary. We 70, HbsAg –ve, WBC 8,020 , Prothrombin time was reported this case in 50 years old female who normal , CA-19.9 was raised ( 118.4 U/ml) , CA-125 underwent for radiological examinations in BIRDEM was also raised. Radiology & Imaging Dept. Here we concluded that all clinical, radiological , serological & morphological Patient was referred to Radiology & Imaging Dept. findings give better result to diagnosis the rare of BIRDEM for USG , CT Scan & MRI of abdomen. metastases of ovary from cholangiocarcinoma . USG of whole abdomen showed that soft tissue mass Introduction : in proximal CBD with dilated intrahepatic duct, Cholangiocarcinoma are rare neoplasia that very cholelithiasis , metastases in liver , mild to rarely affect the ovary.1 moderate ascites & bilateral solid ovarian mass with clear well defined margin having irregular hyper A Krukenberg tumor (also referred to as a carcinoma echoic solid pattern & moth eaten like cyst mucocellulare) refers to the “signet ring” subtype of formation. metastatic tumor to the ovary. It is named after Friedrich E. Krukenberg : German pathologist (1871-1946) who first described them in 1896.2 They can originate from: stomach cancer (signet- ring cells) : which is most common ; colorectal carcinoma (second most common) breast cancer, lung cancer, contra lateral ovarian carcinoma ; pancreatic carcinoma, cholangiocarcionoma & gallbladder carcinoma . The time from diagnosis of the primary neoplasm to the development of ovarian metastasis is variable, and can range from several months to > 10 years.2 The prognosis worsens when the primary tumor is identified after the metastases to the ovary is discovered.3

Case Report : A 50 year old female patient admitted at BIRDEM Fig.-1 : USG of abdomen shows soft tissue mass in General Hospital with obstructive jaundice having proximal CBD and cholelithiasis. 1. Assistant Professor, 2. Registrar, 3. Junior Consultant, 4. Trainee Medical Officer, Dept. of Radiology & Imaging, BIRDEM, Dhaka

. Bangladesh Journal of Radiology and Imaging Vol. 21(2): July 2013

Fig.-3 : Contrast CT abdomen shows heterogeneously enhancing bilateral ovarian soft Fig.-2 : USG of abdomen shows bilateral ovarian itssue density masses. masses.

Fig.-4 : CT abdomen shows dilated intrahepatic Fig.-5 : MRI pelvis shows mixed intensity masses biliary channels. in both ovaries.

CT findings revealed heterogeneously enhancing duct. Patient condition was not favorable for open bilateral soft tissue mass in pelvis , secondary in Laporotomy. So the final diagnosis of patient was liver , dilated billiary channels , ascities & concluded by analysis of serological , biochemical , cholelithiasis. radiological , & histological findings.The final Pelvic MRI findings revealed bilateral complex pelvic diagnosis of the patient was concluded that ovarian mass with hypo-intense solid components with metastases from Cholangio Carcinoma , which is internal hyper intensity. Strong contrast known as Krukenberg’s Tumor. enhancement was seen in solid component & wall of intratumural cyst . Discussion : ERCP revealed Cholangiocarcinoma & dilated The tumors represent 5-10% of all ovarian tumors billiary channel .Papillotomy & stenting done & and up to 50% of all metastatic tumors to the ovary. biopsy taken from mass of complex CBD. On The estimated incidence of Krukenberg tumor is at histology study it was adenocarcinoma of the bile approximately 0.16/100.000 per year.

88 Ovarian Metastases Caused by Cholangiocarcinoma: A Rare Krukenberg’s Tumor Fahmida Yeshmine et al

Cholangiocarcinomas are rare neoplasias that very prognosis was worsened because the primary tumor rarely affect the ovary1. Their retroperitoneal was identified after metastases to the liver, ovary location and low histological specificity in the ovary and peritoneum. may lead to a misdiagnosis. This makes it necessary References : to accurately assess all clinical, radiological and 1. Dr Yuranga Weerakkody, Dr. Frank morphological symptoms so as to avoid inappropriate Gaildand. Krukenberg tumor. Radiopedia org : treatments in affected patients. Member of UBM Medica Network. Cholangio Carcinoma quickly invades adjacent 2. García A, De la Torre J, Castellví J, Gil A, structures such as stomach, liver , gallbladder , López M. Ovarian metastases caused by lymph nodes , blood vessels , local nerves . Remote cholangiocarcinoma: a rare Krukenberg’s metastasis have been reported in the breast ,lung , tumour simulating a primary neoplasm of the spleen , pancreas , adrenal gland & peritoneum ovary: a two-case study. Arch Gynecol Obstet. .Ovarian metastases of hilar Cholangio Carcinoma 2004 ;270(4):281-4. is very rare. 4 Differentiation between primary & metastatic ovarian carcinoma is of great importance 3. McGill F, Ritter DB, Rickard C, Kaleya RN, with respect to treatment & prognosis but may be Wadler S, Greston WM. Management of very difficult based upon imaging findings solely. Krukenberg tumors: an 11-year experience and It’s necessary to carefully search for gastro intestinal review of the literature. Prim Care Update tract signs and symptoms in any patient with a Ob Gyns. 1998 Jul 1;5(4):157-8. pelvic tumor.5 4. Maâouni S, Benaddi L, Kabbaj N, Errabih I, Identification of hypo intense solid components Alhamany Z, Benaïssa A. Krukenberg tumor: rare metastasis of hilar cholangiocarcinoma. within an ovarian mass on T2-weighted MR images is a characteristic, although not specific, finding 2006 Jul-Aug ; 35 (7-8) : 1181-4. for Krukenberg’s tumors, especially when the 5. KC Cho , BM Gold. Computed tomography of tumors are bilateral, have sharp margins, and have Krukenberg’s tumours . American journal of 6 an oval configuration. roentgenology . 1985;145:285-8. Conclusion : 6. H K Ha, S Y Baek, S H Kim, H H Kim, E C It is concluded that all clinical, radiological , Chung and K M Yeon. Krukenberg’s tumor of serological & morphological findings give better the ovary: MR imaging features. American result to the diagnosis of rare metastases of ovary Journal of roentgenology. 1995; 164: from cholangiocarcinoma. In this case patient 1435 – 9.

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