S3914 Unlikely Clues to Colorectal Cancer: Recurrent Headaches and Amenorrhea Unveil Bilateral Krukenberg Tumors From a Sigmoid Primary

Introduction: Krukenberg tumors are an uncommon tumor of gastrointestinal origin that metastasize to the ovaries, often bilaterally. It is suspected through retrograde lymphatic spread and have a median age of 48-years-old.1 Ascites has been documented as an independent risk factor with worse prognosis.2 Case Description/Methods: We present a 31-year-old woman recently diagnosed migraines who presented for worsening headaches. Further evaluation revealed progressive dyspnea and a one-year history of amenorrhea with presumptive diagnosis of polycystic ovarian syndrome. Computed tomography of chest and abdomen showed bilateral multicystic adnexal masses, diffuse lymphadenopathy with periaortic conglomerates, and concern for metastatic lesions on the adrenal gland and liver as well as a large pleural effusion and ascites. Brain imaging with cerebellar metastases and occlusion of the straight sinus due to dural venous thrombi. Thoracentesis revealed exudative effusion with malignant cells. Biopsy of ovarian masses was focally positive for CK7, diffuse CK20 staining, and CDX2, concerning for signet cell carcinoma of gastrointestinal origin. Colonoscopy was significant for a large, partially obstructing fungating mass in the sigmoid colon, and pathology confirmed signet cell carcinoma. She completed 2 of 5 cycles of FOLFOX inpatient. Whole brain radiation was pursued due to leptomeningeal spread seen on subsequent magnetic resonance imaging. She required therapeutic paracentesis for worsening ascites and pleural catheter for recurrent pleural effusions. She is continuing adjuvant chemotherapy in preparation for debulking surgery. Discussion: Immunohistochemistry from colorectal adenocarcinomas typically are negative for CK7 but positive for CK20, whereas gastric carcinomas have shown positivity in 55% and 70% of cases, respectively.1 Colorectal primary patients tend to have better survival; the median survival rate of patients with Krukenberg tumors is low at 16 months.2 This case highlights a unique presentation of headaches and amenorrhea leading to the diagnosis of sigmoid adenocarcinoma.