Primary linitis plastica of the colon: Report of a case and review of the literature

Primary Signet Ring Cell Carcinoma of Rectum Diagnosed by Boring Biopsy in Combination with Endoscopic Mucosal Resection

A 46-year-old man with severe back pain visited our hospital. Magnetic resonance imaging revealed extensive bone metastasis and rectal wall thickness. Colonoscopy revealed circumferential stenosis with edematous mucosa, suggesting colon cancer. However, histological findings of biopsy specimens revealed inflammatory cells but no malignant cells. The patient underwent endoscopic ultrasound, which demonstrated edematous wall thickness without destruction of the normal layer structure. After unsuccessful detection of neoplastic cells by boring biopsies, we performed endoscopic mucosal resection followed by boring biopsies that finally revealed signet ring cell carcinoma. Herein, we present a case and provide a review of the literature.

Primary rectal signet ring cell carcinoma with peritoneal dissemination and gastric secondaries

Disseminated signet ring cell carcinomas frequently arise from the stomach. However, primaries in the colon and rectum have also been reported. We present a 68 year old lady who presented with a change in her bowel habit. Colonoscopy showed a stenosing rectal tumour at 7 cm to 8 cm from the anal verge. Multiple scattered ulcers were also noted along the entire length of the colon. Biopsy of the lesions revealed signet ring cell adenocarcinoma. Gastroscopy showed multiple nodules with ulceration over several areas of the stomach which were similar in appearance to the colonic lesions. However, no primary tumour of the stomach was seen. Biopsy of the gastric lesions also showed signet ring cell adenocarcinoma. Computed tomography scan of the abdomen and pelvis revealed circumferential tumour at the rectosigmoid junction with possible invasion into the left ischiorectal fossa. The overall picture was that of a primary rectal signet ring cell carcinoma with peritoneal dissemination. The patient was referred for palliative chemotherapy in view of the disseminated disease. In the present report, we discuss this interesting pathological entity and review the role of various histolological techniques in helping to identify the primary tumor.

CT features of primary colorectal signet-ring cell carcinoma

PURPOSE

The purpose of this work was to evaluate the CT features of 15 patients with primary colorectal signet-ring cell carcinomas.

METHOD

We retrospectively reviewed the CT scans of 15 patients (mean age 44 years) with pathologically proved colorectal signet-ring cell carcinoma. On CT, we evaluated the site and length of the tumor, bowel wall thickening patterns, perirectal or pericolic infiltration, the presence or absence of colonic obstruction, and metastasis to other organs.

RESULTS

The tumors were located in the rectum in nine patients, the sigmoid colon in one, the hepatic flexure in one, the transverse colon in one, the ascending colon in two, and the cecum in one. The tumor length ranged from 4.0 to 10.0 cm (mean 6.1 cm) with mean thickness of 2.1 cm. CT showed concentric bowel wall thickening in all patients ("even" in 8 and "uneven" in 7), target appearance was noted in 4, perirectal or pericolic infiltrations were moderate to severe in 12, and colorectal obstruction was seen in 6. In the tumor spread patterns, lymphadenopathy was noted in 13, invasion to adjacent pelvic organs in 5, peritoneal carcinomatosis in 4, liver metastasis in 2, and periureteric metastasis in 1.

CONCLUSION

Primary signet-ring cell colorectal carcinoma should be included for differential consideration when CT shows a long length of concentric bowel wall thickening and target sign, especially when such findings occur in the rectum and in young patients.

Ordinary colorectal adenocarcinoma vs. primary colorectal signet-ring cell carcinoma: study matched for age, gender, grade, and stage

PURPOSE

This study contributes to the characterization of primary colorectal signet-ring cell cancer in contrast to ordinary colorectal carcinoma. Primary colorectal signet-ring cell cancer is a rare but distinctive primary neoplasm of the large bowel with still-controversial clinicopathologic features.

METHODS

Clinicopathologic features and survival data are evaluated in comparison with those of the ordinary colorectal adenocarcinoma (non-signet colorectal carcinoma) in a retrospective study matched for age, gender, grade, and stage.

RESULTS

In a series of 1,600 consecutive colorectal cancer patients since 1979, 14 patients (0.88 percent) with a signet-ring cell cancer were identified. Gender ratio was balanced, and mean age was 67.5 years. The majority of patients had an advanced tumor stage at the time of diagnosis (57.1 percent Stage IV and 35.7 percent Stage III). Median survival time was only 16 months. In a study matched for age, gender, grade, and stage, a lower survival rate was found for patients with signet-ring cell cancer, but the difference did not reach statistical significance. In contrast to non-signet colorectal carcinoma, signet-ring cell cancer was characterized by a significantly higher incidence of peritoneal tumor spread (64.3 percent) and a lower incidence of hepatic metastases (14.3 percent).

CONCLUSIONS

Signet-ring cell cancer represents a rare but distinctive primary neoplasm of the large bowel. It is frequently diagnosed in an advanced tumor stage, thus showing an overall poorer prognosis than nonsignet colorectal carcinoma. Usually only palliative surgery is possible. A high incidence of peritoneal seeding and a low incidence of hepatic metastasis is characteristic of signet-ring cell cancer.

Focus of signet ring cell carcinoma in an adenoma of the sigmoid colon

A case of a pedunculated adenomatous polyp of the sigmoid colon was found to have a primary focus of signet ring cell carcinoma. Histologic examination of the medium-sized polyp was consistent with an adenoma to carcinoma sequence for signet ring cell carcinoma of the colon, similar to that for the common adenocarcinomas.

Primary linitis plastica of the rectum: report of four cases and review of the literature

Primary linitis plastica of the rectum is a rare form of large bowel carcinoma, with only 30 cases having been reported in the English literature to date. Of significance is the fact that it carries a prognosis that is poor compared to other types of colorectal cancers. We report herein the cases of four patients with primary linitis plastica of the rectum who underwent surgery, followed by intensive postoperative chemotherapy using 5-fluorouracil (5-FU) derivatives in our institution. A review of the literature is presented with special reference to the diverse treatment and prognosis of this unusual disease. Although three of the patients died of recurrent cancer, one has survived for 5 years and 10 months despite advanced disease. This is only the third reported case of a patient with linitis plastica of the rectum achieving 5-year survival. We believe that this unexpected long survival could be related to the patient's extensive lymphadenectomy and intensive postoperative chemotherapy using cisplatin and 5-FU derivatives.

Primary signet-ring cell carcinoma of the colon and rectum

BACKGROUND

Primary signet-ring cell carcinoma of the colon and rectum is a rare form of adenocarcinoma of the large intestine. The purpose of this study was to help better define the natural history of this entity.

METHODS

The medical records of 3,690 patients with colorectal cancer seen at The Roswell Park Cancer Institute between September 1971 and December 1993 were reviewed. We report on 29 patients with pathologic confirmation of primary signet-ring cell carcinoma. Patient demographics, clinical, and histologic parameters were evaluated. Survival was calculated by the Kaplan-Meier method.

RESULTS

There was a nearly equal distribution of primary signet-ring cell carcinoma between the right colon and left colon/rectum. In most cases the tumors were > 6 cm, ulcerated, and involved the full thickness of the bowel wall. Nodal or metastatic disease was present in 21 of 29 patients (72%) at the time of diagnosis. Four patients (14%) had synchronous colorectal adenocarcinomas. Twenty-two patients died of disease progression. At the time of death, two patients (9%) had failed in the liver, whereas all 22 patients had peritoneal carcinomatosis.

CONCLUSIONS

Patients with primary signet-ring cell colorectal carcinoma frequently present with late-stage disease. In 23 of 29 patients, the disease rapidly recurred or progressed. Peritoneal carcinomatosis is the most common pattern of failure.

Primary linitis plastica carcinoma of the colon and rectum

BACKGROUND

Linitis plastica carcinoma (LPC) usually shows a scirrhous growth pattern with a severe stromal desmoplastic reaction. Another growth pattern showing lymphangiosis carcinomatosa rather than scirrhous growth pattern, however, was noted. This study was designed to clarify the clinical and pathologic characteristics of colorectal LPC.

METHODS

Linitis plastica carcinoma was reviewed clinicopathologically and classified into two types according to the histologic growth pattern: The first was a scirrhous type (nine patients) and the second, a lymphangiosis type (three patients).

RESULTS

Grossly, the mucosal surface of the scirrhous type had a granular, cobblestone, gyriform-like appearance. The cancer cells were composed mainly of poorly differentiated or signet-ring cells and were accompanied by a severe stromal desmoplastic reaction; lymphatic permeation was not so marked. Most patients with this type of cancer died of peritonitis carcinomatosa. The mucosal surface of the lymphangiosis carcinomatosa had a smooth and glossy appearance. The cancer cells were composed mainly of moderately differentiated cells, frequently with a glandular formation. Stromal desmoplastic reaction was not so marked. The growth pattern was characterized by lymphangiosis carcinomatosa and marked venous invasion. All patients who had this type died of distant metastases.

CONCLUSION

Perhaps with earlier diagnosis and aggressive treatment, the peritoneal dissemination of scirrhous LPC and distant metastasis of lymphangiosis LPC may be minimized.

Histopathological prediction of liver metastasis after curative resection of colorectal cancer

To estimate the risk of liver metastasis after curative resection of colorectal cancer, resected specimens from 290 patients (45 with metachronous liver metastasis) were examined and the relationships between 10 histopathological variables and liver metastasis were analysed using our application of the Akaike information criterion (AIC). Of the 10 variables examined, the depth of venous invasion (Vd) had the greatest prognostic value for metastasis, followed by the number of venous invasions, the number of lymphovascular invasions, lymph node metastasis and type of infiltration. The prediction of liver metastasis was further improved by combining Vd with lymphocyte infiltration, mucinous production, interstitial fibrosis or depth of penetration, although these four variables per se were minimally informative for metastasis. We conclude that the prediction of liver metastasis is best achieved by combining Vd with other variables. Our risk group classification, and the estimated probability of liver metastasis for each group, are shown.

Primary signet-ring carcinoma of the large bowel. Report of nine cases

Nine cases of signet-ring carcinoma have been observed from among 800 consecutive histologic cases diagnosed as adenocarcinoma of the colon during a period of 10 years (0.9%). This group of nine patients (Group A) has been matched for sex, age, and stage with a group of 45 patients affected by ordinary carcinoma of the colon (Group B). Clinical and histologic parameters, including symptoms, primary tumor site, free interval from primary surgery, histochemical investigation of intracytoplasmic mucins, and survival, were evaluated. The results of this investigation showed no clinical differences between signet-ring carcinoma and ordinary carcinoma, and no statistically significant results were observed regarding the frequency of local recurrence and actuarial survival.

Obstructive uropathy. An unusual presentation of primary linitis plastica of the colon

A patient with primary linitis plastica of the colon has been presented. The unusually aggressive nature of this tumor is demonstrated in a young man who presented with obstructive uropathy. Extensive renal involvement is a rare complication of this disease, and obstructive uropathy is a previously undescribed presentation. If early recognition is to favorably alter prognosis, then awareness of this form of colonic malignancy is essential.

Primary colorectal signet-ring cell carcinoma in young patients: report of 3 cases

Three cases of primary signet-ring cell carcinoma of the rectum are described. They accounted for 0.2% of the 1531 cases of colorectal adenocarcinoma in the 12 yr period from 1972-1983 in the University Department of Pathology at Queen Mary Hospital. The patients were young, aged 18, 24 and 27 yr respectively, in striking contrast to the mean age of 62 in patients with the usual types of colorectal cancer. They were also younger than most patients with this tumour in the literature. They presented with alteration of bowel habit, blood and mucus in stool, and weight loss. Pathological features included constrictive narrowing of the gut lumen by intestinal wall thickened by a desmoplastic reaction to diffusely infiltrating signet-ring carcinoma cells, widespread lymph node and peritoneal metastases, and absent hepatic metastasis. Microscopically, the mucosa was largely intact, but had multifocal tumour involvement. This peculiar feature was responsible for three consecutive negative biopsies in one case. Care in distinguishing it from mucinous adenocarcinoma is emphasized. All three patients presented with Dukes' C lesions. The prognosis is poor.

Primary linitis plastica of the colon and rectum. Report of two cases

Primary linitis plastica of the colon and rectum is an uncommon entity. Sixty-six cases have been reported in the English literature. Two new cases are reported, one of the transverse colon with widespread metastases and the other of the right colon extending from the appendix to the distal resection margin of the transverse colon. Some clinical and pathologic characteristics of the tumor are discussed, based on a review of the literature.

Primary signet-ring carcinoma of the colon

Three cases of primary signet-ring carcinoma, or linitis plastica, of the colon are described. This rare form of colonic carcinoma possesses certain clinical, pathologic, and biologic characteristics that differ from those of the ordinary colorectal adenocarcinoma. Most importantly, the prognosis is poor, with only very few patients surviving more than one year following diagnosis. Some authors believe that the poor prognosis seen with this tumor may be due largely to a delay in diagnosis. Therefore, awareness of this form of colonic malignancy should be stressed so that early recognition may be made at a stage when curative treatment can still be instituted.

Primary colo-rectal linitis plastica type of carcinoma: report of two cases and review of the literature

Linitis Plastica type of carcinoma can arise primarily in the colon or rectum. Fifty-two cases have been reported in the English medical literature over a 50-yr period. Two new cases are described. One patient had primary linitis plastica of the ascending colon, the other being in the rectum. Both patients died of widespread malignancy within 10 mth of diagnosis, the fate of most of the reported cases. This rare manifestation of colo-rectal carcinoma carries an ominous prognosis.

Colorectal linitis plastica

Primary linitis plastica of the colon is an uncommon tumor, with only 22 cases having been previously reported. Experience with two men and one woman between 17 and 55 years of age, portraying a spectrum of clinical presentations ranging from rectal bleeding to large-bowel obstruction, is reviewed. Clinical and radiologic characteristics and histologic features helpful in making the diagnosis are detailed. Though the prognosis is grim, resective surgery, including oophorectomy in women, should be undertaken. Adjuvant therapy has been disappointing.

Primary linitis plastica of the rectum

Five cases of primary linitis plastica of the rectum are presented. The clinical, radiologic, and pathologic features of the disease are described with emphasis on the difficulty in establishing a correct preoperative diagnosis. Because the histologic features of primary and secondary linitis plastica are indistinguishable and because secondary involvement is twice as common as primary, it is mandatory that other sites of origin are excluded and that both the proximal and distal margins of the resected area be free of tumor.

Primary linitis plastica of the colon: report of two cases and review of the literature

Two cases of primary linitis plastica of the large intestine will be presented and discussed. Characteristic clinical features of this type of adenocarcinoma of the large intestine include younger age of presentation, low incidence of hepatic metastasis and a high incidence of ovarian, lymph node and peritoneal metastasis. Pathological features reveal thickening of the intestinal wall by diffuse infiltrating tumor cells of the characteristic signet ring cells, abortive glands and undifferentiated or anaplastic cells. The prognosis is poor.