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

Odd localisation for a gastric cancer histology

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More than 96% of signet-ring cell carcinomas occur in the stomach.

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Primary SRC carcinoma of the colon and rectum is very rare.

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It spreads mainly to the lymph nodes and to the peritoneum and rarely to the liver.

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It presents at advanced stages and has a dismal prognosis.

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Upper endoscopy is the investigation of choice to exclude a primary gastric cancer.

Introduction

More than 96% of signet-ring cell carcinomas occur in the stomach and the rest in other organs, including the gallbladder, pancreas, urinary bladder and breast. Primary signet-ring cell carcinoma of the colon and rectum is very rare, accounting for 0.1%–2.4% of all colorectal cancers.

Presentation of case

We report a case of a 55-year old man who is operated for a caecal mass evocative of an appendicitis abscess. Intraoperatively, we discover a large, ulcerated ilio-caecal mass with several lymphadenopathies. The further workup reveals a primary signet-ring cell carcinoma of the colon with multiple lymph nodes and osteolytic bony metastases.

Discussion

Primary signet-ring cell carcinoma of the colon and rectum presents usually as an advanced stage disease with a dismal prognosis. It spreads mainly to the lymph nodes and to the peritoneum and very rarely to the liver. The mean age of patients diagnosed with primary signet-ring cell carcinoma is significantly younger than for ordinary adenocarcinoma. The upper endoscopy is the investigation of choice to exclude a primary gastric pathology. There are very few reports about this type of cancer and no reports about this type of cancer associated with osteolytic bony metastases.

Conclusion

The characteristics and pathophysiology of a primary signet-ring cell carcinoma of the colon and rectum are not well understood. Usually only palliative treatment is possible. The importance of an early diagnosis of this tumor is mandatory to have a curative approach.

Early-stage primary signet ring cell carcinoma of the colon

Primary signet ring cell carcinoma of the colorectum detected at an early stage is very rare; most cases are detected at an advanced stage. Therefore, its prognosis is poorer than that of ordinary colorectal cancer. A 56-year-old Korean man was seen at this hospital for management of signet ring cell carcinoma of the colon. Colonoscopic examination revealed a IIa-like, ill-defined and flatly elevated 9-mm residual tumor in the cecum. Endoscopic mucosal resection was preformed. Pathological examination of the resected specimen revealed signet ring cell carcinoma that had invaded the lamina propria without venous or perineural invasion. Abdominal computed tomography (CT) and positron CT showed no evidence of primary lesions or distant metastasis. An additional laparoscopic right-hemicolectomy was performed; no residual tumor or lymph node metastasis was found. We report a case of primary signet ring cell carcinoma of the colon detected at an early stage and provide a review of the literature.

HNPCC-associated synchronous early-stage signet-ring cell carcinomas of colonic origin. A comparative morphological and immunohistochemical study of an intramucosal and a submucosal example

Signet-ring cell carcinoma (SRCC) developing in the colorectum (CR) is infrequently identified at an early stage (no deeper than submucosa). Most such examples involve the submucosa. Merely 13 cases of intramucosal CR SRCC are at hand. We recently had the opportunity to study a specimen with two synchronous early-stage SRCC, developed in a 65-year-old hereditary nonpolyposis colorectal cancer male patient with a known disease-causing mutation in MLH1. A right hemicolectomy specimen comprised a 15-mm intramucosal cecal lesion, featuring zones of conventional tubular adenoma and intraepithelial SRCC as well as tumor cells multifocally permeating the lamina propria and a 12-mm submucosally expanding SRCC of the ascending colon. The intramucosal and intraepithelial as well as stromal lesional cells displayed a normal membranous expression of beta-catenin and E-cadherin; submucosally infiltrating cells featured alterations in this complex with loss of membranous expression of both proteins and a shift with nuclear accumulation of beta-catenin, suggesting a disruption of the Wingless signaling pathway taking place at the transition from the intramucosal to the submucosal level.

Critical role of type IV collagens in the growth of bile duct carcinoma. In vivo and in vitro studies

Most extrahepatic bile duct carcinomas (EBDC) are characterized by a striking stromal response (desmoplasia). Our previous studies showed deposition of type IV collagen in the desmoplastic stroma beyond the basement membrane. Although type IV collagen is expressed in EBDC, little is known about the pattern of deposition in tumor stroma and how this matrix component influences the behavior of tumor cells. With the progression of desmoplasia in EBDC, different changes occurred in the quantity and localization of type IV collagen from that of type I collagen. Type I collagen was diffusely distributed in the stroma and appeared to be concentrated in the center of the tumors. In contrast, type IV collagen was deposited in the interstitium alongside carcinoma cells at the tumors' periphery. Weak or no type IV collagen deposition was detected in the more central portion of the tumors containing sclerotic collagens. To investigate the role of stromal type IV collagen in tumor cell proliferation, EBDC cell lines were cultured in a three-dimensional matrix containing varying compositions of type I collagen and type IV collagen. They were also assayed for cell adhesion and migration using in vitro models. Type IV collagen more extensively stimulated tumor cell proliferation, adhesion and migration in a dose-dependent manner than did type I collagen. All of these results suggest that modified tumor stroma with the presence of type IV collagen in EBDC provides a better environment for tumor growth and invasion.

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.

Signet-ring cell carcinoma of the colon and rectum: a matched control study

PURPOSE

There is little information comparing signet-ring cell carcinoma to common non-signet-ring cell colon and rectal cancers. The aim of this study was to better define the clinicopathologic differences between these two distinct entities.

METHODS

Using a prospective database of 5,350 surgical patients with rectal cancers operated on at Memorial Sloan-Kettering Cancer Center between 1986 and 1997, 46 patients with signet-ring cell carcinoma were identified. Signet-ring cell carcinoma lesions were those in which signet-ring cells constituted more then 50 percent of the tumor. Six patients who presented with recurrent disease were excluded from the study. Control patients were matched for age, gender, TNM stage, primary site, procedure, and adjuvant therapy. Age, primary site of the tumor, stage at presentation, and survival times of patients with signet-ring cell carcinoma were also compared with 3,371 patients with primary non-signet-ring cell rectal cancers. Survival was calculated using Kaplan-Meier survival estimates.

RESULTS

Mean age of the signet-ring cell carcinoma group was 59 +/- 12 years and median age was 61 (range, 20-91) years. Male-to-female ratio was 1.1:1. Lymphatic and peritoneal spread was more common among the signet-ring cell carcinoma group. Approximately one-third of signet-ring cell carcinoma patients presented with metastatic disease. Mean survival time of the signet-ring cell carcinoma group was 45.4 months (95 percent confidence interval, 26.9-63.8) compared with 78.5 months (95 percent confidence interval, 62.0-94.9) for the control patients group; P = 0.02 by the log-rank test. The cumulative survival curve of patients with signet-ring cell carcinoma resembles that of patients with poorly differentiated rectal cancers.

CONCLUSIONS

Patients with signet-ring cell carcinoma of the colon and rectum have a worse prognosis compared with matched controls with the same stage of disease.

The significance of stromal desmoplasia in intrahepatic cholangiocarcinoma: a special reference of 'scirrhous-type' and 'nonscirrhous-type' growth

Fifty-eight surgically resected cases of intrahepatic cholangiocarcinoma (ICC) were examined grossly and microscopically. We microscopically categorized the ICC into two groups, "scirrhous-type" ICC (SICC) and "nonscirrhous-type" ICC (NSICC), according to the degree of the stromal desmoplasia in the tumor. We next assessed the histologic characteristics including proliferative activities and prognoses. Additionally, the prognostic factors of ICC were examined by univariate and multivariate analyses. Histologically, the incidences of lymphatic permeation and perineural invasion in SICC (85.7% and 100.0%, respectively) were significantly higher than those in NSICC (47.7% and 45.6%, respectively). The mean MIB-1 labeling index of SICC (mean+/-standard deviation, 29.9%+/-14.3%) was significantly higher than that of NSICC (mean+/-standard deviation, 19.1%+/-14.3%). Additionally, the 1- and 3-year survival rates of the SICC were 64.3% and 22.0%, respectively, and those of NSICC were 72.8% and 55.8%, respectively. The survival rate of SICC was significantly lower than that of NSICC. Overall, lymphatic permeation, intrahepatic metastasis, and lymph node metastasis were all considered to be independent prognostic factors for a worse prognosis based on the multivariate analyses, whereas our new category based on stromal desmoplasia or other variables were not. Our study thus indicates that lymphatic permeation, perineural invasion, and a higher proliferative activity of tumor cells carry a poorer prognosis in SICCs than in NSICCs. Although the overall independent prognostic factors were lymphatic permeation, intrahepatic permeation, and lymph node metastasis based on a multivariate analysis, a detailed histologic examination related to the stromal desmoplasia in the tumor is also considered to be useful for evaluating the biologic behavior of the ICC.

Endoscopic ultrasonography in rectal linitis plastica

BACKGROUND

Rectal linitis plastica (RLP) is a rare tumor with a poor prognosis. RLP can be a primary tumor, secondary to gastric linitis, or a metastatic form of breast or prostate carcinoma. Diagnosis is difficult because of nonspecific clinical and endoscopic findings and frequent negative biopsies (50%). The aim of this study was to evaluate the endosonographic appearance of RLP and to study the usefulness of endoscopic ultrasonography (EUS) in the follow-up of patients with RLP.

METHODS

Twenty-two video-recorded EUS examinations performed in 11 patients with histologically proven RLP were retrospectively studied. Response to conservative treatment was evaluated in three patients with secondary RLP.

RESULTS

In every case of RLP, EUS showed a circumferential thickening of the rectal wall (mean 13 mm); the thickening was mainly seen in the submucosa and the muscularis propria. In nine cases EUS showed signs of locoregional involvement (perirectal fat infiltration [n = 6], ascites [n = 5], lymph nodes [n = 3]) which was not seen by CT. In follow-up evaluations, EUS showed a lack of response to treatment in two patients with RLP secondary to gastric linitis. In the remaining patient with RLP secondary to breast carcinoma, EUS at first showed no response. The chemotherapy protocol was modified, and then improvement became evident at EUS.

CONCLUSIONS

RLP shows typical features of rectal EUS that may assist in the diagnosis of this rare disease. Moreover, EUS can be useful in evaluating the response of this disease to treatment.

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.

Trends in colorectal cancer incidence and histologic findings in Maori and Polynesian residents of New Zealand

BACKGROUND

The aim of this study was to combine an epidemiologic survey of colorectal cancer among Maori, Polynesian, and white inhabitants of New Zealand with a detailed analysis of tumor subsite and histopathology.

METHODS

Data were obtained from the New Zealand National Cancer Registry and included all registrants from 1970 to 1984. Sections of histologic specimens of colorectal cancer of Maori and non-Maori were retrieved from three Auckland hospitals.

RESULTS

The annual age-adjusted incidence rates of large intestinal cancer among male and female Maoris and male and female Polynesians were 40%, 40%, 39%, and 29%, respectively, of the total population incidence. Time-trend analysis showed the incidence of large intestinal cancer to be increasing among all racial groups. The relative proportion of rectal cancers was higher in male and female Maoris and female Polynesians than in the general population, whereas male Polynesians had a relatively high proportion of right colonic cancers. High-grade carcinoma and mucinous carcinoma occurred more frequently in young individuals regardless of race. Carcinomas were diagnosed at a more advanced stage in Maoris.

CONCLUSION

Given the similar environmental characteristics of the three racial groups, the findings indicate the presence of powerful protective factors in Maoris and Polynesians. These could be constitutional or mediated by unrecognized dietary constituents.

Linitis plastica carcinoma of the colon mimicking Crohn's colitis

Primary linitis plastica carcinoma of the colon is an uncommon morphological type of colorectal carcinoma. Linitis plastica of the stomach may spread to the colon producing a similar lesion to primary colonic linitis plastica. This case report describes a case of linitis plastica of the colon that had many of the clinical, endoscopic, radiological and operative features of Crohn's colitis. The precise origin of the linitis plastica carcinoma was not clear: it may have been clonic or gastric, although the former is favoured. This case illustrates a number of facets of this unusual colonic carcinoma.

CT demonstration of pelvic wall spread in primary colonic linitis plastica

Primary linitis plastica of the colon is a rare entity, and its radiographic and CT findings have been described in previously published literature. We present the CT demonstration of the pelvic wall spread in this unusual disease, and briefly review its radiologic and pathologic features.

A case of linitis plastica of the rectum treated by pelvic exenteration after aggressive immunochemotherapy

Multidisciplinary treatment was administered to a 32 year-old man with primary linitis plastica of the rectum, which was considered inoperable due to an extensive local spread at the first operation. Thirty KE of OK-432 was injected into the tumor per week (total 90-KE) and 5 KE of OK-432 was inoculated into the intracutaneous space per week (total 125 KE). Also methotrexete (MTX 50 mg) and 5-FU (500 mg) combined were given each week by intra-arterial infusion (total 20 courses). After this immuno-chemotherapy the CEA decreased from the pretreatment value of 12.7 ng/ml to 3.6 ng/ml and the tumor size was reduced. A total pelvic exenteration could then be performed almost curatively. As a result, this patient was able to return to the society with a better quality of life and has survived for 20 months since presentation.

Linitis plastica of the colon: computed tomography findings

Primary linitis plastica of the colon is a rare entity and its radiographic findings have been described previously in the literature. We present the computed tomography findings of this unusual lesion and briefly review its pathogenesis.

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 linitis plastica carcinoma of urinary bladder

Primary linitis plastica type carcinoma of the urinary bladder in a sixty-one-year-old man is described. Only 2 other cases have been reported in the English medical literature.