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Krukenberg Tumor in Association with Ureteral Stenosis Due to Peritoneal Carcinomatosis from Pulmonary Adenocarcinoma: a Case Report

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Krukenberg Tumor in Association with Ureteral Stenosis Due to Peritoneal Carcinomatosis from Pulmonary Adenocarcinoma: a Case Report medicina Case Report Krukenberg Tumor in Association with Ureteral Stenosis Due to Peritoneal Carcinomatosis from Pulmonary Adenocarcinoma: A Case Report Irina Balescu 1,2,*, Nona Bejinariu 3, Simona Slaniceanu 3, Mircea Gongu 4, Brandusa Masoud 5, Smarandita Lacau 5, George Tie 6, Maria Ciocirlan 7, Nicolae Bacalbasa 2,8 and Catalin Copaescu 1,9 1 Department of Surgery, “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] 2 “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; [email protected] 3 Department of Pathology, “Santomar Oncodiagnostic”, 400664 Cluj Napoca, Romania; [email protected] (N.B.); [email protected] (S.S.) 4 Department of Oncology, “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] 5 Department of Radiology, “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] (B.M.); [email protected] (S.L.) 6 Department of Urology, “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] 7 Department of Gastroenterology, “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] 8 Center of Excellence in Translational Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania 9 ”Grigore T Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania * Correspondence: [email protected]; Tel.: +40-724-077-709 Received: 10 March 2020; Accepted: 12 April 2020; Published: 17 April 2020 Abstract: Krukenberg tumors from pulmonary adenocarcinoma represent an extremely rare situation; only a few cases have been reported. The aim of this paper is to report an unusual such case in which almost complete dysphagia and ureteral stenosis occurred. The 62-year-old patient was initially investigated for dysphagia and weight loss. Computed tomography showed the presence of a thoracic mass compressing the esophagus in association with a few suspect pulmonary and peritoneal nodules, one of them invading the right ureter. A biopsy was performed laparoscopically on the peritoneal nodules. The right adnexa presented an atypical aspect; right adnexectomy was also found. The histopathological and immunohistochemical studies confirmed that the primitive origin was pulmonary adenocarcinoma. Although both peritoneal carcinomatosis and ovarian metastases from pulmonary adenocarcinoma represent a very uncommon situation, this pathology should not be excluded, especially in cases presenting suspect pulmonary lesions. Keywords: pulmonary adenocarcinoma; Krukenberg tumors; ureteral stenosis 1. Introduction Krukenberg tumors account for less than 2% of all ovarian carcinomas and represent ovarian metastases that usually originate from mucosecretory signet ring cell adenocarcinomas of the gastrointestinal tract. The most commonly encountered sites are the stomach and the colon [1–3]. In less common situations, Krukenberg tumors originate from other primaries such as the breast, small intestine, and appendix [3]. For lung cancer ovarian metastases, data are even scarcer, with only a few Medicina 2020, 56, 187; doi:10.3390/medicina56040187 www.mdpi.com/journal/medicina Medicina 2020, 56, x FOR PEER REVIEW 2 of 12 Medicina 2020, 56, 187 2 of 11 intestine, and appendix [3]. For lung cancer ovarian metastases, data are even scarcer, with only a few cases being reported so far [4–6]. Most often, these cases are represented by pulmonary cases being reported so far [4–6]. Most often, these cases are represented by pulmonary adenocarcinomas adenocarcinomas (in up to 45% of cases), and the exact mechanism of development is not well (in up to 45% of cases), and the exact mechanism of development is not well understood [6]. The understood [6]. The aim of this paper is to report the case of a patient diagnosed with Krukenberg aim of this paper is to report the case of a patient diagnosed with Krukenberg tumor and peritoneal tumor and peritoneal carcinomatosis invading the right ureter originating from pulmonary carcinomatosis invading the right ureter originating from pulmonary adenocarcinoma, in which the adenocarcinoma, in which the final diagnostic was established after performing a laparoscopic final diagnostic was established after performing a laparoscopic adnexectomy. adnexectomy. 2. Case Report 2. Case Report A 62-year-old, nonsmoker woman with no significant pathological antecedents presented to our hospitalA 62 for-year almost-old, completenonsmoker dysphagia. woman with At the no time signific of presentation,ant pathological the patientantecedents was underweight,presented to reportingour hospital an approximatefor almost weightcomplete loss dysphagia. of 15 kg during At the the time last month. of presentation During this, the period, patient she alsowas observedunderweight, the apparitionreporting an of approximate dysphagia first weight for solids loss of and 15 laterkg during also for the liquids, last month which. D worseneduring this progressively.period, she also Biochemicalobserved the testsapparition demonstrated of dysphagia slow first increase for solids of and cancer later antigen also for CA liquids 125, which levels (74.2worsened U/mL—units progressively. per millilitre), Biochemical whereas tests all demonstrated the other tests slow (including increase tumoral of cancer markers, antigen urinary CA and125 liverlevels tests) (74.2 were U/m normal.L—units The per upper millilitre digestive), whereas endoscopy all the raised other suspicion tests (including of an extrinsic tumoral compression markers, ofurinary the medial and liver third tests) of the were esophagus normal. (at The 26 cmupper from digestive the dental endoscopy arcade), which raised did suspicion not allow of an performing extrinsic thecompression maneuver of with the amedial 10 mm third endoscope. of the esophagus The stenosis (at was26 cm hardly from crossed the dental by usingarcade), a pediatric which did 5 mm not endoscope,allow performing which showedthe maneuver the extension with a 10 of mm the a endoscope.ffected area The on 5 stenosis cm. A gastrostomy was hardly feedingcrossed tubeby using was placeda pediatric during 5 endoscopy.mm endoscope However,, which the showed esophageal the liningextension was normalof the onaffected the entire areasurface, on 5 cm again. A raisinggastrostomy suspicion feeding of extrinsic tube was compression placed during (Figure endoscopy.1). However, the esophageal lining was normal on the entire surface, again raising suspicion of extrinsic compression (Figure 1). FigureFigure 1.1.Upper Upper digestive digestive endoscopy endoscopy revealed revealed an extrinsican extrinsic compression compression of the of esophagus the esophagus with normal with esophagealnormal esophageal lining. lining. InIn thisthis context,context, anan endoscopicendoscopic ultrasoundultrasound was attemptedattempted to retrieve a biopsy, butbut thethe maneuvermaneuver waswas unsuccessfulunsuccessful duedue toto thethe extremeextreme compressioncompression ofof thethe esophagus.esophagus. TheThe patientpatient laterlater underwentunderwent thoracic,thoracic, abdominal,abdominal, and pelvicpelvic computedcomputed tomographytomography thatthat demonstrateddemonstrated the presencepresence ofof suspectsuspect pulmonarypulmonary nodulesnodules inin associationassociation with a mass compressingcompressing the esophagus and invading the pleura, thethe pericardium,pericardium, the the esophageal esophageal wall, wall and, and the the aortic aortic wall wall (Figures (Figure2 ands 32), and as well 3), as as awell tumoral as a noduletumoral innodule close in proximity close proximity to the uterine to the cervixuterine invading cervix invading the right the ureter right and ureter creating and ancreating ureteral an stenosis.ureteral Thestenosis. cardiologic The cardiologic evaluation evaluation demonstrated demonstrated the presence the presence of a mild of pericardial a mild pericardial effusion, witheffusion, no other with significantno other significant modifications modifications of the cardiac of the function. cardiac function. Medicina 2020, 56, x FOR PEER REVIEW 3 of 12 Medicina 2020, 56, 187 3 of 11 Medicina 2020, 56, x FOR PEER REVIEW 3 of 12 Figure 2. Computed tomography revealing extrinsic compression of the medial third of the Figure 2. Computed tomography revealing extrinsic compression of the medial third of the esophagus. esophagus.Figure 2. Computed tomography revealing extrinsic compression of the medial third of the esophagus. FigureFigure 3.3. ComputedComputed tomography tomography revealing revealing extrinsic extrinsic compression compression of the medialof the thirdmedial of thethird esophagus of the in association with suspect pulmonary nodules. esophagusFigure 3. inComputed association tomography with suspect revealing pulmonary extrinsic nodules. compression of the medial third of the Theesophagus imagistic in association studies werewith suspect further pulmonary completed nodules. by pelvic magnetic resonance, which raised the The imagistic studies were further completed by pelvic magnetic resonance, which raised the suspicion of peritoneal nodules at the pelvic level and confirmed the presence of the tumoral nodule suspicion of peritoneal nodules at the pelvic level and confirmed the presence of the tumoral nodule in closeThe proximity imagistic tostudies the uterine were further cervix invadingcompleted the by right pelvic ureter magnetic and with resonance no apparent, which connection raised the in close proximity to the
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