When a 25-year-old woman arrived at a Mumbai hospital with abdominal pain, irregular periods, loss of appetite and unexplained weight loss, scans revealed what appeared to be a large tumour in her right ovary. The diagnosis initially pointed to ovarian cancer. Further investigations, however, revealed that the ovarian tumour was secondary. The cancer had actually originated in her stomach and spread silently to the ovary.In another case, a 37-year-old mother of two presented with abdominal pain, menstrual irregularities, weight loss and changes in bowel habits. Imaging showed large tumours in both ovaries, but subsequent testing established that they had spread from an underlying stomach cancer.The two cases, documented by doctors at Mumbai’s Government Medical College and Cama and Albless Hospital, highlight an uncommon but important clinical challenge: not every ovarian tumour originates in the ovary. In rare cases, it may represent metastatic cancer from another organ, most commonly the stomach. Distinguishing between the two is critical because treatment is determined by the site where the cancer began, not where it has spread.The findings have been published in the International Journal of Reproduction, Contraception, Obstetrics and Gynaecology in a paper titled ‘A gastrointestinal malignancy presenting as an ovarian mass: a case report of Krukenberg tumours’ by Dr Pratiksha Dattu Khamkar, Dr Tushar Palve and Dr Anusha Shetty from the Department of Obstetrics and Gynaecology of the two institutions.A rare form of metastatic cancerThe condition described in the report is called a Krukenberg tumour — a rare and aggressive form of metastatic ovarian cancer in which malignant cells spread to one or both ovaries from another organ, most often the stomach. Less commonly, the primary cancer arises in the colon, appendix, pancreas or breast.Krukenberg tumours account for only 1-2 per cent of all ovarian tumours and are seen more often in women of reproductive age, although they can occur at any age. Cancer cells typically spread through the bloodstream or lymphatic system before implanting in the ovaries. Because the disease has already metastasised by the time it is detected in the ovaries, the prognosis is generally poorer than that of primary ovarian cancer.Symptoms often mask the underlying diseaseThe condition is particularly difficult to diagnose because its symptoms overlap with those of primary ovarian cancer as well as several common gastrointestinal and gynaecological disorders. Patients may experience abdominal pain, bloating, irregular menstrual cycles, loss of appetite, unexplained weight loss, early satiety or changes in bowel habits.Story continues below this adDr Pratiksha Dattu Khamkar, lead author of the study, said both women initially presented with severe abdominal pain. “We decided to document these cases because both women presented with severe abdominal pain but the diagnosis turned out to be something we don’t encounter very often,” she said.While ovarian cancer is often the first suspicion, clinicians should also consider whether an ovarian mass could represent metastatic disease from the gastrointestinal tract, she added.“Women who present with ovarian masses, along with persistent symptoms such as abdominal pain, unexplained weight loss, loss of appetite or changes in bowel habits, should undergo further evaluation to rule out an underlying stomach or intestinal cancer.”Dr Khamkar said Krukenberg tumours are most commonly diagnosed in women between 25 and 40 years of age. Delayed diagnosis is common because the symptoms are non-specific and the primary stomach cancer often progresses silently before spreading.Story continues below this adDiagnosis and treatmentAlthough ultrasound and CT scans can detect ovarian masses, they cannot reliably establish where the cancer originated. Doctors often need endoscopy, tissue biopsy and specialised pathological testing to identify the primary tumour.This distinction directly influences treatment. Surgery may be required to remove ovarian tumours or relieve symptoms, but management is centred on the primary stomach cancer. Patients are typically treated with chemotherapy used for advanced gastric cancer, while targeted therapies or immunotherapy may be considered in selected cases based on the tumour’s molecular profile.The Mumbai casesBoth women sought medical care after nearly 25 days of persistent abdominal pain and underwent surgery.In the first case, imaging detected a large ovarian mass along with thickening of the stomach wall. Endoscopy confirmed stomach cancer, while pathological examination established that the ovarian tumour had originated in the stomach. She subsequently underwent surgery and was referred for further oncological treatment.Story continues below this adThe second patient had tumours in both ovaries along with abnormalities in the stomach. Following surgery and specialised testing, doctors confirmed the same diagnosis. She received six cycles of chemotherapy and remained clinically stable during follow-up. Earlier identification of the primary tumour could help ensure timely, appropriate treatment.