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

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 Due to Peritoneal Carcinomatosis from Pulmonary : 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 , “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] 5 Department of , “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] (B.M.); [email protected] (S.L.) 6 Department of , “Ponderas” Academic Hospital, 021188 Bucharest, Romania; [email protected] 7 Department of , “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 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 in association with a few suspect pulmonary and peritoneal nodules, one of them invading the right . A 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 and represent ovarian metastases that usually originate from mucosecretory signet ring cell of the . The most commonly encountered sites are the and the colon [1–3]. In less common situations, Krukenberg tumors originate from other primaries such as the , , and [3]. For 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 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 all the raised other suspicion tests (including of an extrinsic tumoral compression markers, ofurinary the medial and 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 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 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.

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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 uterine cervix invading the right ureter and with no apparent connection to tosuspicion the uterine of peritoneal cervix (Figures nodules4 and at the5). Inpelvic the meantime,level and confirmed other few-millimeter the presence nodules of the tumoral of peritoneal nodule the uterine cervix (Figures 4 and 5). In the meantime, other few-millimeter nodules of peritoneal carcinomatosisin close proximity were to the found uterine in the cervix pelvic invading areawith the right no other ureter suspect and with aspects. no apparent The gynecologicalconnection to carcinomatosis were found in the pelvic area with no other suspect aspects. The gynecological examinationthe uterine cervix confirmed (Figures the presence 4 and 5). of In a tumoralthe meantime, mass of 3other/1.5 cm few invading-millimeter the rightnodules ureter, of developedperitoneal examination confirmed the presence of a tumoral mass of 3/1.5 cm invading the right ureter, incarcinomatosis close proximity were to thefound uterine in the cervix pelvic but witharea nowith apparent no other appurtenance suspect aspects. to the gynecologicalThe gynecological tract. developed in close proximity to the uterine cervix but with no apparent appurtenance to the Noexamination other pathological confirmed images the presence were encountered, of a tumoral and mass the Papanicolaouof 3/1.5 cm invading test failed the to demonstrateright ureter, gynecological tract. No other pathological images were encountered, and the Papanicolaou test anydeveloped modification. in close proximity to the uterine cervix but with no apparent appurtenance to the failedgynecological to demonstrate tract. N anyo other modification. pathological images were encountered, and the Papanicolaou test failed to demonstrate any modification.

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Figure 4. Pelvic magnetic resonance imaging (MRI) revealing the presence of a large tumoral nodule Figure 4. Pelvic magnetic resonance i imagingmaging ( (MRI)MRI) revealing the presence of a large tumoral nodule compressing the right ureter. compressing the right ureter.ureter.

FigureFigure 5. 5. PelvicPelvic MRI MRI revealing revealing the the presence presence of of a a large large tumoral tumoral nodule nodule compressing compressing the right ureter ureter.. Figure 5. Pelvic MRI revealing the presence of a large tumoral nodule compressing the right ureter. Due to an important ureteral stenosis being found, the patient also underwent Cook Due to an important ureteral stenosis being found, the patient also underwent Cook catheter placement onon the the right right side. side At. theAt timethe oftime the of catheter the catheter placement, placement, a cisto- a cisto-ureteroscopy was performed, was placement on the right side. At the time of the catheter placement, a cisto-ureteroscopy was performed,which demonstrated which demonstrated an extrinsic compression an extrinsic ofcompression the right ureter, of the with right the ureter, ureteral with and the urinary ureteral bladder and performed, which demonstrated an extrinsic compression of the right ureter, with the ureteral and urinarymucosa bladder being normal mucosa (Figures being 6normal–8). (Figures 6–8). mucosa being normal (Figures 6–8).

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Figure 6. RightFigureFigure ureteroscopy 6.6. RightRight ureteroscopyureteroscopy presenting presentingpresenting right ureteral rightright ureteralureteral stenosis stenosisstenosis probably probablyprobably due to duedue external toto externalexternal compression, a normal aspectcompression,compression, of the ureteral aa normalnormal aspect lining.aspect ofof thethe ureteralureteral lining.lining.

..

Medicina 2020, 56, x FORFigure PEERFigureFigure 7.REVIEWIntravesical 7.7. Intravesical Intravesical positioning positioningpositioning ofof of thethe the rightright right CookCook Cook catheter.catheter. catheter. 6 of 12

Figure 8.FigureAbdominal 8. Abdominal X-ray X-ray revealing revealing the correct correct position position of the of Cook the catheter Cook catheter..

A diagnosticA diagnostic laparoscopy was was performed performed onon the patient, patient, which which demonstrated demonstrated the presence the presenceof a of a few peritoneal nodules at the level of the pelvic area, retrieved in association with the nodule few peritoneal nodules at the level of the pelvic area, retrieved in association with the nodule invading invading the right ureter. However, the right was also found to have a pathological aspect, so it was retrieved by performing a right adnexectomy (Figures 9–11).

Figure 9. Laparoscopic biopsy of a peritoneal nodule on the anterior surface of the left broad uterine ligament.

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Medicina 2020, 56, 187 Figure 8. Abdominal X-ray revealing the correct position of the Cook catheter. 6 of 11

A diagnostic laparoscopy was performed on the patient, which demonstrated the presence of a the rightfew peritoneal ureter. However, nodules at the the right level ovary of the was pelvic also area found, retrieved to have in aassociation pathological with aspect, the nodule so it was retrievedinvading by performing the right ureter. a right However, adnexectomy the right (Figuresovary was9– also11). found to have a pathological aspect, so it was retrieved by performing a right adnexectomy (Figures 9–11).

FigureFigure 9. Laparoscopic9. Laparoscopic biopsybiopsy of of a aperitoneal peritoneal nodule nodule on the on anterior the anterior surface of surface the left ofbroad the uterine left broad ligament. uterineMedicina 2020 ligament.2020,, 5566,, xx FORFOR PEERPEER REVIEWREVIEW 77 ofof 1212

Figure 10. Laparoscopic exploration revealed tumoral transformation of the right adnexa, so a right FigureFigure 10. Laparoscopic 10. Laparoscopic exploration exploration revealed revealed tumoraltumoral transformation of ofthe the right right adnexa adnexa,, so a soright aright adnexectomy was performed. adnexectomyadnexectomy was was performed. performed.

FigureFigure 11. Laparoscopic 11. Laparoscopic exploration exploration revealing revealing thethe nodulenodule of of peritoneal peritoneal carcinomato carcinomatosississis invadinginvading invading thethe the rightrightright ureter. ureterureter..

The final histopathological studies of the specimens demonstrated the presence of a well--differentiated adenocarcinoma, with thethe ovarianovarian parenchymaparenchyma presentingpresenting tumoraltumoral invasioninvasion onon up to 90% of the volume (Figure 12a–d)).. TheThe iimmunohistochemical studies established the final diagnostic of pulmonary adenocarcinoma (diffuse and intense positivity for cytokeratin 7 ((CK7)) and thyroidthyroid transcriptiontranscription factorfactor--1 ((TTF--1);); positivity for carcinoembryonic antigen ((CEA);); poor positivity forfor estrogenestrogen receptorsreceptors ((ERs);s); negativity for GATA3 transcription factor, paired--box gene 8 ((PAX8)),, Wilms’’ ttumor 1 ((WT1)) factor,factor, homeobox protein (CDX2)(CDX2),, p16p16--cyclin--dependent kinase inhibitor 2A, and S--100 proteins;; Figure 13a–ff).). InIn thisthis context,, thethe genital,genital, breast,breast, gastric,gastric, colonic,colonic, esophagealesophageal,, and pancreatic malignancies were excluded, with thethe finalfinal aspectaspect pulmonarypulmonary adenocarcinoma.adenocarcinoma. Epidermal growth factor receptor ((EGFR)),, anaplasticanaplastic lymlymphoma kinase ((ALK)),, and programmed cell death ligand 1 ((PD--L1)) teststests werewere performedperformed demonstratingdemonstrating thethe presencepresence ofof mutationsmutations,, soso thethe patient was laterlater confined to the medical oncology clinic forfor biological treatment.

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The final histopathological studies of the specimens demonstrated the presence of a well-differentiated adenocarcinoma, with the ovarian parenchyma presenting tumoral invasion on up to 90% of the volume (Figure 12a–d). The immunohistochemical studies established the final diagnostic of pulmonary adenocarcinoma (diffuse and intense positivity for cytokeratin 7 (CK7) and transcription factor-1 (TTF-1); positivity for carcinoembryonic antigen (CEA); poor positivity for estrogen receptors (ERs); negativity for GATA3 transcription factor, paired-box gene 8 (PAX8), Wilms’ tumor 1 (WT1) factor, homeobox protein (CDX2), p16-cyclin-dependent kinase inhibitor 2A, and S-100 proteins; Figure 13a–f). In this context, the genital, breast, gastric, colonic, esophageal, and pancreatic malignancies were excluded, with the final aspect pulmonary adenocarcinoma. Epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed cell death ligand 1 (PD-L1) tests were performed demonstrating the presence of mutations, so the patient was later confinedMedicina 2020 to, the56, xmedical FOR PEER oncology REVIEW clinic for biological treatment. 8 of 12

(a) (b)

(c) (d)

Figure 12.12. HistopathologicalHistopathological study. study. (a (a) )H Hematoxylinematoxylin and and eosin eosin (H&E) (H&E) staining staining of the ovarianovarian parenchyma revealing tumoral infiltration in more than 90% of the parenchyma (5 ); (b) H&E staining parenchyma revealing tumoral infiltration in more than 90% of the parenchyma× (5×); (b) H&E of the ovarian parenchyma revealing tumoral infiltration in more than 90% of the parenchyma (40 ); staining of the ovarian parenchyma revealing tumoral infiltration in more than 90% of the× (c) H&E staining of the revealing the presence of tumoral deposits (5 ); (d) H&E staining parenchyma (40×); (c) H&E staining of the peritoneum revealing the presence ×of tumoral deposits of the peritoneum revealing perineural invasion (10 ). (5×); (d) H&E staining of the peritoneum revealing perineural× invasion (10×).

(a) (b)

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(a) (b)

(c) (d)

Figure 12. Histopathological study. (a) Hematoxylin and eosin (H&E) staining of the ovarian parenchyma revealing tumoral infiltration in more than 90% of the parenchyma (5×); (b) H&E staining of the ovarian parenchyma revealing tumoral infiltration in more than 90% of the Medicinaparenchyma2020, 56, 187 (40×); (c) H&E staining of the peritoneum revealing the presence of tumoral deposits8 of 11 (5×); (d) H&E staining of the peritoneum revealing perineural invasion (10×).

Medicina 2020, 56, x FOR PEER REVIEW 9 of 12 (a) (b)

(c) (d)

(e) (f)

Figure 13.13. ImmunohistochemicalImmunohistochemical study study revealing revealing diff usediffuse positivity. positivity (a) TTF-1. (a) TTF staining;-1 staining (b) CK7; ( staining;b) CK7 staining(c) CEA;staining; (c) CEA staining (d) PAX8; ( staining;d) PAX8 (staininge) ER staining;; (e) ER (stainingf) WT1 staining.; (f) WT1 staining.

3. Discussion Discussion Krukenberg tumors were initially described by by Friedrich Ernst Krukenberg in in 1896, when he revealedrevealed the the first first five five such such cases cases [7] [7].. Since Since then, then, this this histopathological histopathological finding finding has has been been treated treated as as a separatea separate entity, entity, and and further further studies studies demonstrated demonstrated that that the the most most common common origins origins of of the primaries thatthat might lead to the development of of such tumors are are represented by gastric cancer (up (up to to 76 76%% of cases), followed by by colorectal cancer (up (up to to 11% of cases) cases).. O Otherther possible possible origins origins include include the the breast, breast, biliary system, , urinary tract tract,, and gynecological tract [2,3]. [2,3]. Most Most often often,, Krukenberg Krukenberg tumors are found bilaterally, and in up to half of cases, they are associated with the presence of ascites [8]. As for Krukenberg tumors with lung cancer origins, it is estimated that less than 4% of all lung lead to the development of ovarian metastases, with up to half of them being represented by small cell carcinomas [4]. To establish that an ovarian tumor has a metastatic origin from a primary lung , detection of TTF-1 at the level of the ovarian lesion plays a central role [4]. In our case, the identification of this marker at the level of the specimen of adnexectomy enabled us to suspect the pulmonary origin of the metastatic islets that had been found at the level of the ovarian tissue. The final diagnostic in our case was established based on immunohistochemical studies, which were strongly suggestive for pulmonary adenocarcinoma. The lesions proved to have positive staining for TTF1, CK7, and CEA. In a recent study conducted on a group of 665 specimens of resected pulmonary cancer and 425 resected metastases, Vidarsdottir et al. routinely studied the presence of CK7, CK20, CDX2, CK5, p40, p63, TTF-1, napsin A, GATA3, and PAX8, and demonstrated that primary adenocarcinoma of the lung presented strong positive expression for TTF1 in 90% of cases and for napsin A in 84%, whereas only less than 10% of cases were positive for p63, CDX2, CK20, and GATA3. Additionally, 68% of cases with pulmonary adenocarcinoma

Medicina 2020, 56, 187 9 of 11 are found bilaterally, and in up to half of cases, they are associated with the presence of ascites [8]. As for Krukenberg tumors with lung cancer origins, it is estimated that less than 4% of all lung cancers lead to the development of ovarian metastases, with up to half of them being represented by small cell carcinomas [4]. To establish that an ovarian tumor has a metastatic origin from a primary lung carcinoma, detection of TTF-1 at the level of the ovarian lesion plays a central role [4]. In our case, the identification of this marker at the level of the specimen of adnexectomy enabled us to suspect the pulmonary origin of the metastatic islets that had been found at the level of the ovarian tissue. The final diagnostic in our case was established based on immunohistochemical studies, which were strongly suggestive for pulmonary adenocarcinoma. The lesions proved to have positive staining for TTF1, CK7, and CEA. In a recent study conducted on a group of 665 specimens of resected pulmonary cancer and 425 resected metastases, Vidarsdottir et al. routinely studied the presence of CK7, CK20, CDX2, CK5, p40, p63, TTF-1, napsin A, GATA3, and PAX8, and demonstrated that primary adenocarcinoma of the lung presented strong positive expression for TTF1 in 90% of cases and for napsin A in 84%, whereas only less than 10% of cases were positive for p63, CDX2, CK20, and GATA3. Additionally, 68% of cases with pulmonary adenocarcinoma presented positive staining for CK7, TTF-1, and napsin A and were negative for the other studied parameters [9]. The authors demonstrated that the presence of TTF1 and CK7 could also be used to differentiate pulmonary adenocarcinoma by . In the latter histopathological subtype, the positivity of TTF-1 and CK7 was demonstrated in only 3% and 44% of cases, respectively [9]. The therapeutic strategies in such cases are mainly decided according to the primary tumor; however, due to the metastatic character of Krukenberg lesions, the presence of ovarian metastases is usually considered as a sign of a systemic disease, which transforms the patient into a candidate for palliative systemic treatment. This pathological finding is usually associated with poor rates of long-term survival [5]. However, in our case, a right adnexectomy was performed as part of the diagnostic strategy and not with curative intent. The patient also showed a large mediastinal mass and peritoneal carcinomatosis nodules invading the ureter as a sign of systemic disease. Another particularity of our case is the presence of peritoneal carcinomatosis with a pulmonary adenocarcinoma origin. One nodule of peritoneal carcinomatosis developed in close proximity with the right ureter, where almost complete stenosis had developed. Based on autopsy studies, peritoneal carcinomatosis from pulmonary adenocarcinoma can be encountered in up to 16% of cases; however, clinical manifestation of such lesions are rarely encountered, with obstructive symptomatology being the most common [10,11]. Although this symptomatology is to be expected at the level of the gastrointestinal tract due to the presence of mesenteric nodules, in rare cases, other abdominal structures might be involved. In the case we presented here, obstruction of the right ureter caused a grade III uretero-. In our case, during laparoscopy, no other nodules of peritoneal carcinomatosis were found, except for few-millimeter lesions at the level of the pelvic area, especially on the uterine serosa and its ligaments. The rarity of peritoneal carcinomatosis from lung cancer was also demonstrated by the study conducted by Satoh et al., which included 1041 cases with pulmonary cancer over a period of 26 years. Among these cases, only eight patients developed clinically evident peritoneal carcinomatosis [12]; however, regarding histopathological subtypes of pulmonary cancer that present the highest risk of developing peritoneal metastases, adenocarcinoma seems to play the most important role. In another more recent study conducted on the issue of peritoneal carcinomatosis from non-small cell lung carcinoma, Nassereddine et al. included 12 patients diagnosed with peritoneal carcinomatosis from non-small cell lung carcinoma, with 11 cases diagnosed with pulmonary adenocarcinoma. The authors underlined that all cases presented other metastases at the time of the initial diagnosis. The most commonly encountered sites for the metastatic disease were represented by pleura, , adrenal glands, liver, and colon. These authors also reported the presence of ovarian metastases, but the incidence of this finding was not reported. In this case series, the most commonly encountered Medicina 2020, 56, 187 10 of 11 positivity of the immunostaining was the one for PD-L1 (in 37.5% of cases), a finding that was also encountered in the case we reported [13]. The prognosis for these cases seems to be extremely poor, with the overall survival time usually only a few months from the time peritoneal carcinomatosis is diagnosed. Regardless, attention should be paid to identifying the cases that present with EGFR mutation (consisting of exon 19 deletion), which seem to be associated with a more favorable outcome [14]. In such cases tyrosine kinase inhibitors might be administrated, and a significant benefit of survival (of more than 1 year) is expected [15,16]. In the aforementioned case, the presence of EGFR mutation allowed us to introduce this biological treatment with good chances of prolonging the patient’s survival. In addition, a differential diagnostic of the primary tumor with pleural mesothelioma should be ruled out; immunohistochemical studies are the cornerstone process by which to establish this differential diagnosis [17].

4. Conclusions Association between peritoneal carcinomatosis creating urinary tract obstruction and Krukenberg tumor is an extremely rare eventuality in patients with pulmonary adenocarcinoma. The case we reported presents a series of particularities: the symptomatology at the time of presentation, almost complete dysphagia due to a thoracic mass compressing the esophagus, the modality in which the final diagnostic was established, and laparoscopic adnexectomy in association with peritoneal nodules biopsy, which revealed positive immunohistochemical staining for TTF-1, CK7, and CEA. The demonstration of EGFR, PD-L1, and ALK mutations offered a chance for improved survival for our patient, who thereby became a candidate for immunotherapy.

Author Contributions: I.B. performed surgery; N.B. and S.S. performed histopathological and immunohistochemical studies; M.G. advised about oncologic testing; B.M. and S.L. performed the imaging studies; G.T. performed urological procedure; M.C. performed endoscopic evaluation; N.B. performed literature data review; C.C. finally reviewed the manuscript. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Conflicts of Interest: The authors have no conflicts of interest to declare regarding this study.

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