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□ CASE REPORT □

Pseudo-Meigs’ Syndrome Caused by a Krukenberg Tumourof Gastric Cancer

Takahiro Horimatsu 1, Shin’ichi Miyamoto 2, Yoko Mashimo 2, Hiroshi Okabe 3,

Yoshiki Mikami 4, Tsutomu Chiba 2 and Manabu Muto 1

Abstract

A 50-year-old woman who presented with a one-month history of abdominal fullness and dyspnoea was

admitted to our hospital. Esophagogastroduodenoscopy showed the scirrhous-type gastric cancer on the

greater curvature of the gastric body. Computed tomography revealed bilateral large ovarian tumours with

massive right pleural effusion and ascites. A repeated cytological examination of pleural effusion and ascites

revealed no malignant cells. The definitive diagnosis of pseudo-Meigs’ syndrome was made by confirming

the fact that pleural effusion and ascites disappeared after bilateral oophorectomy. Resection of ovarian tu-

mours may also lead to long-term survival, even in the patients with pseudo-Meigs’ syndrome caused by gas-

tric cancer.

Key words: pseudo-Meigs’ syndrome, gastric cancer, Krukenberg tumour, oophorectomy

(Intern Med 54: 2595-2597, 2015)(DOI: 10.2169/internalmedicine.54.4088)

Case Report

A 50-year-old woman who presented with a one-month

history of abdominal fullness and dyspnoea was admitted to

our hospital. Esophagogastroduodenoscopy showed

scirrhous-type gastric cancer on the greater curvature of the

middle gastric body (Fig. 1A). A biopsy specimen revealed

a poorly differentiated adenocarcinoma (Fig. 1B). Computed

tomography (CT) revealed bilateral large ovarian tumours

with massive ascites (Fig. 1C, D) and para-aortic lymph

node swelling. A chest X-ray showed right pleural effusion

(Fig. 2A) and the coronal section of the CT image showed

right pleural effusion and ascites (Fig. 2B). The laboratory

studies indicated that the serum carbohydrate antigen (CA)

19-9 and CA125 levels were 559.7 U/mL (normal range,

<37) and 489.8 U/mL (normal range, <35), respectively. No

peritoneal metastasis was detected by CT, and a repeated cy-

tological examination of the pleural effusion and ascites re-

vealed no malignant cells. Because the ovarian tumours

caused pain and debilitation, palliative oophorectomy with

the removal of ascites was performed without neoadjuvant

chemotherapy (Fig. 3A). The histopathological findings re-

vealed the presence of poorly differentiated adenocarcinoma,

which was similar to the gastric cancer of the primary re-

gion (Fig. 3B). After oophorectomy, the pleural effusion

vanished immediately (Fig. 4), suggesting pseudo-Meigs’

syndrome (P-MS). Subsequently, systemic chemotherapy

was initiated. Because marked tumour shrinkage was

achieved after seven courses of TS-1/CDDP therapy, distal

gastrectomy was performed (1). However, peritoneal metas-

tases were confirmed during surgery. Despite the continued

systemic chemotherapy (TS-1→paclitaxel→irinotecan), the

patient ultimately succumbed to the disease 27 months after

oophorectomy. No re-accumulation of the pleural effusion or

ascites was observed until peritonitis carcinomatosa devel-

oped.

Discussion

In 1937, Meigs and Cass described Meigs’ syndrome

(MS) as a benign ovarian fibroma associated with ascites

１Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Japan, ２Department of Gastroenterology and Hepatology,

Kyoto University Graduate School of Medicine, Japan, ３Department of Gastrointestinal Surgery, Kyoto University Graduate School of Medicine,

Japan and ４Department of Diagnostic Pathology, Kyoto University Hospital, Japan

Received for publication September 10, 2014; Accepted for publication February 9, 2015

Correspondence to Dr. Shin’ichi Miyamoto, shmiyamo@kuhp.kyoto-u.ac.jp

Intern Med 54: 2595-2597, 2015 DOI: 10.2169/internalmedicine.54.4088

2596

Figure　1.　Scirrhous-type gastric cancer was located on the greater curvature of the middle body (A). A biopsy specimen revealed poorly differentiated adenocarcinoma (B). Computed tomography revealed bilateral large ovarian tumours (C, D).

Figure　2.　A chest X-ray showed right pleural effusion on admission (A). The coronal section CT image showed right pleural effusion and ascites (B).

Figure　3.　Macroscopic findings of the resected ovarian specimens are shown (A). The histopatho-logical findings revealed a poorly differentiated adenocarcinoma, which was similar to the gastric cancer (B).

Intern Med 54: 2595-2597, 2015 DOI: 10.2169/internalmedicine.54.4088

2597

Figure　4.　The pleural effusion vanished immediately after oophorectomy.

and hydrothorax that resolved on removal of the fibroma.

Meigs distinguished the definition of MS from P-MS ac-

cording to the histology of the primary tumour (2). He at-

tributed the name P-MS to pelvic pathology other than be-

nign ovarian tumours that caused the same clinical pic-

ture (3). In 1950, Dick et al. reported the first case of P-MS

caused by a Krukenberg tumour of gastric cancer (4). Since

then, only eight cases have been reported: two cases in the

English literature (4, 5), two in the Japanese literature (6, 7),

and four in Japanese proceedings. Characteristically, the on-

set age is relatively young and all of the pathologies were

the diffuse-type gastric cancer. Pleural effusion is more

prevalent on the right side, and the ovarian tumour is pre-

dominantly bilateral. The final survival times previously de-

scribed in the literature were 32.5 (5), 27 (present case), and

17 months (7), which is longer than typical for stage IV

gastric cancer (median survival time of approximately12

months). These reports suggest that resection of ovarian tu-

mours may provide not only a palliative benefit, but also

lead to long-term survival in patients with and without P-

MS (8, 9). However, the reason why resection of ovarian tu-

mours may lead to long-term survival remains unclear. One

possible reason is that metastasectomy for ovarian tumour

often leads to the improvement of the performance status,

which makes it possible to continue adequate systemic che-

motherapy.

In conclusion, gastric cancer with metastatic disease to

the ovary may result in P-MS. The recognition of this syn-

drome may allow for a prompt diagnosis and appropriate

treatment, including resection of the ovarian tumours.

The authors state that they have no Conflict of Interest (COI).

References

1. Satoh S, Hasegawa S, Ozaki N, et al. Retrospective analysis of 45

consecutive patients with advanced gastric cancer treated with

neoadjuvant chemotherapy using an S-1/CDDP combination. Gas-

tric Cancer 9: 129-135, 2006.

2. Meigs JV, Cass JW. Fibroma of the ovary with ascites and hy-

drothorax: with a report of seven cases. Am J Obstet Gynecol 33:

249-266, 1937.

3. Meigs JV. Pelvic tumor other than fibromas of the ovary with as-

cites and hydrothorax. Obstet Gynecol 3: 471-486, 1954.

4. Dick HJ, Spire LJ, Worboys CS. The association of Meigs’ syn-

drome with Krukenberg tumors. NY J Med 50: 1842-1843, 1950.

5. Cetin B, Aslan S, Akinci M, Atalay C, Cetin A. A long surviving

case of Pseudomeigs’ syndrome caused by Krukenberg tumor of

the stomach. Jpn J Clin Oncol 35: 221-223, 2005.

6. Okazaki Y, Yonezawa K, Shimomatuya T, Komai Y, Yukioka N. A

case of pseudo-Meigs’ syndrome caused by metastatic ovarian tu-

mors from gastric cancer. Nihon Shokakibyo Gakkai Zasshi (Japa-

nese Journal of Gastroenterology) 106: 529-535, 2009 (in Japa-

nese, Abstract in English).

7. Miyata R, Hosoda Y, Hashimoto M, Ko J. A case of gastric ade-

nocarcinoma presenting pseudo-Meigs syndrome. Nihon Rinsho

Geka Gakkai Zasshi (Japanese Journal of Gastroenterology) 65:

508-513, 2004 (in Japanese, Abstract in English).

8. Cheong JH, Hyung WJ, Chen J, Kim J, Choi SH, Noh SH. Sur-

vival benefit of metastasectomy for Krukenberg tumors from gas-

tric cancer. Gynecol Oncol 94: 477-482, 2004.

9. Lu LC, Shao YY, Hsu CH, et al. Metastasectomy of Krukenberg

tumors may be associated with survival benefits in patients with

metastatic gastric cancer. Anticancer Res 32: 3397-3401, 2012.

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