Hoof beats could mean zebras: A rare late metastasis of breast carcinoma in the rectum

Breast cancer metastasis is most commonly observed in bone, lung, liver, and brain and is rarely observed in the gastrointestinal tract (GI). In rarer cases, GI metastasis reaches the rectum and generally presents as late metastasis. The type of breast cancer usually associated with GI metastasis is invasive lobular carcinoma; however, few case reports also show their association with invasive ductal carcinoma (IDC). Here, we report a case that unfortunately is a coalescence of all these atypical events, with metastatic rectal linitis plastica (RLP) of the breast, 15 years after the treatment of the primary tumor, originating from IDC. This is the first case report from India, reporting the late metastatic presentation of breast cancer as RLP. The report emphasizes the need to correlate persistent GI symptoms to breast cancer history; however, late the presentation may be.

Yeyunostomía laparoscópica / Laparoscopic jejunostomy / Jejunostomia laparoscópica

La yeyunostomía implica el abocamiento del yeyuno a la piel y se utiliza como vía de nutrición enteral en pacientes con imposibilidad de alimentarse por vía oral; en quienes la gastrostomía no es una opción adecuada. La misma puede realizarse por vía mínimamente invasiva, como percutánea y laparoscópica

Gastropatía isquémica crónica como simuladora de linitis plástica / Chronic ischemic gastropathy as a simulator of plastic linitis

Resumen La gastropatía isquémica es una entidad rara, cuya etiología más frecuente es la obstrucción al flujo sanguíneo secundaria a aterosclerosis. Sus manifestaciones clínicas y endoscópicas son inespe cíficas, pudiendo simular afecciones más prevalentes. La sospecha clínica en pacientes con factores de riesgo cardiovascular permite un diagnóstico precoz y tratamiento adecuado. Presentamos el caso de una paciente con gastropatía isquémica crónica que se manifestó con dolor abdominal, pérdida de peso y hallazgos endoscópicos compatibles con linitis plástica. Se arribó al diagnóstico con una biopsia endoscópica en bloque luego de haber obtenido dos biopsias previas no concluyentes.

Abstract Chronic ischemic gastropathy is a rare entity, being the atheroesclerotic vascular the most prevalent cause. Clinical and endoscopic manifestations are unspecific and may simulate more frequent pathologies. Cardio vascular risk factors allow us to diagnose and treat these patients earlier. We present the case of a patient with chronic ischemic gastropathy that manifested abdominal pain, weight loss and endoscopic findings as a simula tor of linitis plastica. The diagnosis was made with an endoscopic block biopsy after two inconclusive biopsies.

Escudo de Blumer: signo diagnóstico de la diseminación a distancia del cáncer gástrico difuso / Blumer ́s shelf: diagnostic sign of distant spread of diffuse gastric cancer

Introducción. Se conoce como escudo de Blumer al engrosamiento neoplásico del fondo de saco de Douglas, palpable al tacto rectal como una protrusión en forma de resalte, presente en pacientes afectados por carcinomas con infiltración difusa. A pesar de haber sido descrito hace más de un siglo, se trata de un proceso diagnosticado infrecuentemente y con escasa mención en la literatura científica. Es preciso tener un alto nivel de sospecha clínica para correlacionar los síntomas pélvicos con la presencia de un tumor, habitualmente gástrico. Casos clínicos. Presentamos dos pacientes con hallazgo de escudo de Blumer, asociado a cáncer gástrico difuso, uno como diagnóstico primario de enfermedad metastásica y otro como recidiva de la enfermedad, meses después de ser operado. Ambos casos presentan un complejo proceso diagnóstico, en el que prima la sospecha clínica, apoyado sobre pruebas de imagen como tomografía computarizada y resonancia nuclear magnética, ya que tanto las biopsias obtenidas por endoscopia, como las biopsias intraoperatorias fueron negativas. Discusión. En el escudo de Blumer, las células tumorales infiltran el fondo de saco de Douglas de forma difusa por debajo de la serosa, sin necesidad de que existan implantes macroscópicamente visibles en el peritoneo visceral. La infiltración tumoral puede afectar extrínsecamente al recto, causando una estenosis del mismo, lo que produce sintomatología pélvica inespecífica, como tenesmo rectal y proctalgia. Por lo tanto, este ominoso proceso debe ser sospechado en pacientes con sintomatología pélvica, que presenten o hayan presentado cáncer gástrico

Introduction. The neoplastic thickening of the cul-de-sac of Douglas is known as "Blumer's shelf". It is palpable on rectal examination as a protrusion in the form of a projection, and it presents in patients affected by carcinomas with diffuse infiltration. Despite being described more than a century ago, it is a rare process with little mention in the scientific literature. A high level of clinical suspicion is required to correlate pelvic symptoms with the presence of a typically gastric tumor.Clinical cases. We present two patients with a Blumer's shelf finding associated with diffuse gastric cancer, one as a primary diagnosis of metastatic disease and the other as a recurrence of the disease, months after being operated on. Both cases present a complex diagnostic process, in which clinical suspicion prevails, supported by imaging tests such as computed tomography and magnetic resonance imaging, since both endoscopic biopsies and intraoperative biopsies were negative.Discussion. In Blumer's shelf, tumor cells infiltrate the cul-de-sac of Douglas in a diffuse and subserous manner, without the need for macroscopically visible implants in the visceral peritoneum. Tumor infiltration can extrinsically affect the rectum, causing its stenosis, which produces nonspecific pelvic symptoms such as rectal tenesmus and proctalgia. Therefore, this ominous process should be suspected in patients with pelvic symptoms, who present or have presented gastric cancer

Valor del ultrasonido endoscópico en el diagnóstico de la linitis plástica gástrica / Value of endoscopic ultrasound in the diagnosis of gastric plastic linitis

RESUMEN Fundamento: la linitis plástica gástrica es una forma avanzada de cáncer gástrico de pronóstico desfavorable y diagnóstico complejo. Objetivo: presentar el caso de un paciente con linitis plástica gástrica cuya evaluación inicial no fue concluyente para diagnóstico. Presentación del caso: paciente masculino de 51 años de edad que presenta dolor abdominal en epigastrio, vómitos, pérdida de peso y decaimiento. Se realiza estudios analíticos que concluyen linitis plástica gástrica difusa con posible carcinosis peritoneal. Conclusiones: la linitis plástica gástrica es una enfermedad infrecuente con alta morbi-mortalidad y que requiere en algunos casos de estudios especiales como el ultrasonido endoscópico en los pacientes con alta sospecha diagnóstica.

ABSTRACT Background: gastric plastic linitis is an advanced form of gastric cancer with an unfavorable prognosis and a complex diagnosis. Objective: to present the case of a patient with gastric plastic linitis whose initial evaluation was inconclusive for diagnosis. Case report: a 51-year-old male patient presented with abdominal pain in the epigastrium, vomiting, weight loss and decay. Analytical studies are performed and they conclude diffuse gastric plastic linitis with possible peritoneal carcinosis. Conclusions: gastric plastic linitis is an infrequent disease with high morbidity and mortality and in some cases requires special studies such as endoscopic ultrasound in patients with high diagnostic suspicion.

Primary Gastric Small Cell Carcinoma (Presenting as Linitis Plastica) Diagnosed Using Endoscopic Ultrasound-Guided Biopsy: A Case Report

Small cell carcinomas are the most aggressive, highly malignant neuroendocrine tumors; among these, gastric small cell carcinoma (GSCC) is extremely rare. Here we report a case of a patient with primary GSCC, presenting as linitis plastic, who was diagnosed using endoscopic ultrasound (EUS)-guided biopsy. With undiagnosed linitis plastica, an 80-year-old woman was referred to our institution. Abdominal computed tomography revealed irregular wall thickening extending from the gastric body to the antrum. Endoscopy suspected to have Borrmann type IV advanced gastric cancer. EUS of the stomach showed diffuse submucosal thickening of the gastric wall, mainly the antrum. EUS-guided bite-on-bite biopsy confirmed the diagnosis of GSCC. In general, GSCC is difficult to diagnose and careful examination is necessary to determine the therapeutic strategy; however, EUS is particularly helpful in the differential diagnosis of a lesion presenting as linitis plastica.

Borrmann Type 4 Advanced Gastric Cancer: Focus on the Development of Scirrhous Gastric Cancer

Early diagnosis of Borrmann type 4 advanced gastric cancer (AGC) is very important for improving the prognosis of AGC patients. Because there is no definite mass in most cases of Borrmann type 4 AGC, its accurate diagnosis via endoscopy requires an understanding of its pathogenesis and developmental process. Moreover, many people confuse linitis plastica (LP) type gastric cancer (GC), scirrhous GC, and Borrmann type 4 AGC. To distinguish each of these cancers, knowledge of their endoscopic and pathological differences is necessary, especially for LP type GCs in the developmental stage. In conclusion, diagnosis of pre-stage or latent LP type GC before progression to typical LP type GC requires the detection of IIc-like lesions in the fundic gland area. It is also crucial to identify any abnormalities such as sclerosis of the gastric wall and hypertrophy of the mucosal folds during endoscopy.

Ductal Breast Carcinoma Metastatic to the Stomach Resembling Primary Linitis Plastica in a Male Patient / 한국유방암학회지

Breast cancer metastases to the gastrointestinal tract are very rare occurrences. Among the histological subtypes of breast cancer, invasive lobular carcinomas have a high capacity of metastasis to uncommon sites including the stomach. Conversely, there has not been sufficient evidence supporting the gastric metastasis of invasive ductal carcinoma. Herein, we report a unique case of metastatic ductal breast carcinoma mimicking primary linitis plastica in a male patient, particularly focusing on the clinical and pathological features of presentation. Moreover, we propose a immunohistochemical panel of selected antibodies including those for cytokeratin 20, cytokeratin 7, estrogen receptor, progesterone receptor, E-cadherin, gross cystic disease fluid protein 15, and GATA binding protein 3 for an accurate differential diagnosis.

Acute Renal Failure with Metabolic Alkalosis Due to Gastric Scirrhous Carcinoma / General Medicine

A 51-year-old man was emergently admitted for acute renal failure. Blood tests showed a high serum creatinine level and metabolic alkalosis. He had a history of recurrent vomiting starting one month prior to admission to our hospital, and had circumferential thickening of the cardia on upper gastrointestinal endoscopy and CT. He underwent total gastrectomy and was given a diagnosis of scirrhous gastric carcinoma at the pylorus. After total gastrectomy, acute renal failure and metabolic alkalosis showed amelioration. We report this very rare case with metabolic alkalosis and acute renal failure resulting from pyloric stenosis caused by scirrhous gastric carcinoma.

Gastric Cancer Presenting as a Krukenberg Tumor at 22 Weeks' Gestation

Gastric cancer is rare during pregnancy, and often advanced upon presentation. A Krukenberg tumor presents a diagnostic and therapeutic challenge in the pregnant patient. We present a case of a 38-year-old woman at 22 weeks' gestation who presented with worsening epigastric pain, and was found to have a left pelvic mass on ultrasound, which was confirmed by magnetic resonance imaging. She went into active labor and delivered a viable infant via vaginal delivery. An exploratory laparotomy revealed a large mass originating from her left ovary and diffuse thickening of the lesser curvature of the stomach. Frozen section investigation revealed the presence of signet cell adenocarcinoma. Subsequent upper endoscopy showed linitis plastica, while biopsy confirmed the presence of adenocarcinoma. In conclusion, the occurrence of gastric cancer in pregnancy is rare despite extremely common symptoms. The management poses a challenge because of the need for early treatment, and the continuation of the pregnancy.

Linitis plástica gástrica. A propósito de un caso / Gastric-plastic letinitis. A case report

Fundamento: el cáncer gástrico es una de las principales causas de muerte. En Cuba la mayoría son diagnosticados en fases avanzadas ensombreciendo el pronóstico. La linitis plástica es una forma de crecimiento submucoso del adenocarcinoma. Objetivo: ofrecer lección a médicos sobre los signos endoscópicos de sospecha y complementarios a utilizar para diagnosticarlo rápidamente. Presentación de caso: paciente que refería epigastralgia, vómitos y pérdida de peso. La radiografía contrastada de estómago evidenció rigidez y defecto de lleno en curvatura mayor y menor. La esofagogastroduodenoscopía mostró ausencia de peristalsis y estenosis de la luz del estómago. En el examen laparoscópico se observó exteriorización del tumor. El diagnóstico definitivo se realizó por macrobiopsia después de la cirugía. Conclusiones: se ha de sospechar la entidad ante un paciente con la clínica sugestiva de tumor y hallazgos endoscópicos como la disminución de la peristalsis y la reducción de la luz del órgano.

Background: gastric cancer is one of the main causes of death. In Cuba most of the cases are diagnosed in advanced stages clouding the outlook. The plastic linitis is a form of submucosal growth adenocarcinoma. Objective: to provide medical lesson on endoscopic signs of suspicion and complementary use to diagnose it quickly. Case Presentation: a patient referred epigastralgia, vomiting and weight loss. The stomach contrasted radiography showed stiffness and squarely defect in major and minor curvature. The esophagogastroduodenoscopy showed absence of peristalsis and stenosis of the light of the stomach. In the laparoscopic exam the tumor externalization was observed. The final diagnosis was carried out by macrobiopsy after surgery. Conclusions: doctors have to suspect the disease in a patient with clinical suggestive features of tumor and endoscopic findings as decreased peristalsis and reduced organ light.

Gastric Outlet Obstruction Due to Gastric Amyloidosis Mimicking Malignancy in a Patient with Ankylosing Spondylitis

Amyloidosis is a group of disorders characterized by the extracellular accumulation of insoluble, fibrillar proteins in various organs and tissues. It is classified, on the basis of the identity of the precursor protein, as primary, secondary, or familial amyloidosis. Gastrointestinal amyloidosis usually presents as bleeding, ulceration, malabsorption, protein loss, and diarrhea. However, gastric amyloidosis with gastric outlet obstruction mimicking linitis plastica is rare. We report a case of gastrointestinal amyloidosis with gastric outlet obstruction in a patient with ankylosing spondylitis. The patient was indicated for subtotal gastrectomy because of the aggravation of obstructive symptoms, but refused the operation and was transferred to another hospital. Three months later, the patient died of aspiration pneumonia during medical treatment.

Type-Specific Diagnosis and Evaluation of Longitudinal Tumor Extent of Borrmann Type IV Gastric Cancer: CT versus Gastroscopy

OBJECTIVE: To compare the accuracy of computed tomography (CT) with that of gastroscopy for the extent of evaluation of longitudinal tumor and type-specific diagnosis of Borrmann type IV gastric cancer. MATERIALS AND METHODS: Fifty-nine patients (35 men with mean age of 60 years and 24 women with mean age of 55 years) who underwent surgical resection of Borrmann type IV gastric cancer were included in this study. Histopathological analysis data was used as a reference standard to confirm the clinical interpretations of gastroscopy and CT for the diagnosis of Borrmann type IV and evaluation of longitudinal tumor extent. For the evaluation of longitudinal extent, gastroscopic and CT results were classified as underestimated, accurate, or overestimated. The McNemar test was used to identify statistically significant differences in the accuracy between gastroscopy and CT. RESULTS: For the diagnosis of Borrmann type IV gastric cancer, the accuracy of CT was significantly higher than that of gastroscopy (74.6% [44/59] vs. 44.1% [26/59], p < 0.001). CT was significantly more accurate in assessing the overall tumor extent than gastroscopy (61.4% [35/57] vs. 28.1% [16/57], p < 0.001). The proximal (75.4% [43/57] vs. 50.9% [29/57], p = 0.003) and distal tumor extent (71.9% [41/57] vs. 43.9% [25/57], p < 0.05) were more accurately predicted by CT compared with gastroscopy. The underestimation of tumor extent was a major source of error in both examinations. CONCLUSION: CT was found to be more predictive than gastroscopy in type-specific diagnosis and the evaluation of longitudinal tumor extent in patients with Borrmann type IV gastric cancer.

Diferenciación de cáncer gástrico temprano vs linitis plástica; ¿los síntomas hacen la diferencia? / Differentiation of early gastric cancer vs linitis plastica: do symptoms make a difference?

El cáncer gástrico tiene un patrón de presentación que va desde el estadio temprano a la linitis plástica, con pronósticos radicalmente diferentes, el primero con sobrevida a cinco años superior a 90%, el segundo inferior a 5%. Objetivo: identificar si las características clínicas permiten diferenciar un estadio temprano de linitis plástica. Metodología: se revisaron las bases de datos de la unidad de gastroenterología y endoscopia digestiva de un hospital de tercer nivel entre julio de 2005 y julio de 2010, seleccionando los casos donde se encontró linitis plástica y cáncer gástrico temprano, todos confirmados por patología. Resultados: se incluyeron 56 pacientes, 15 linitis y 41 cáncer temprano. Edad promedio de 61.3 años, (IC95%54.5-68.2) para linitis y 63 años para cáncer temprano (39-85), 66.6% fueron mujeres y 33.4% hombres en linitis plástica y 51.2% mujeres y 48.8% hombres en cáncer temprano. Compromiso del cuerpo en linitis 76.9%, en cáncer temprano el cuerpo 29.3%, antro 43.9%Pérdida de peso presentó un 73.3% en linitis y 26.8% en cáncer temprano. No hubo diferencias significativas en síntomas como: vómito, hematemesis, melenas o epigastralgia. El 26.8% de los pacientes tenían antecedente de cáncer gástrico. Conclusion: los síntomas no son útiles como herramienta para diferenciar cáncer gástrico temprano de la linitis plástica, por lo cual se requieren otras estrategias para la detección del cáncer en estado temprano como podría ser la realización de EVDA en los pacientes con antecedentes familiares de este tumor. (Acta Med Colomb 2012; 37: 62-65).

Gastric cancer has a pattern of presentation ranging from early stage to linitis plastica, with radically different prognosis; early cancer with 5-year survival exceeding 90%, and linitis plastica with survival of less than 5%. Objective: identify if the clinical features differentiate an early stage cancer from plastic linitis. Methodology: we reviewed the databases of the unit of gastroenterology and endoscopy of a tertiary hospital between July 2005 to July 2010, selecting those cases where we found plastic linitis and early gastric cancer, all confirmed by pathology. Results: we included 56 patients, 15 with linitis, and 41 with early cancer. Mean age was 61.3 years (95% CI 54.5-68.2) for linitis and 63 years for early cancer (39-85). With plastic linitis, 66.6% were female and 33.4% men, and with early cancer, 51.2% were women and 48.8% were men. Stomach body involvement in linitis was 76.9%; in early cancer, body involvement was 29.3%; antrum involvement was 43.9%. 73.3% of patients with linitis had weight loss and 26.8% had it with early cancer. There were no significant differences in symptoms such as vomiting, hematemesis, melena or epigastralgia. 26.8% of patients had a history of gastric cancer. Conclusion: the symptoms are not useful as a tool to differentiate early gastric cancer from linitis plastica, so other strategies are required for detection of early stage cancer, such as the performance of endoscopy in patients with a family history of this tumor. (Acta Med Colomb 2012; 37: 62-65).

A Case of Mantle Cell Lymphoma Exhibiting Features of Gastric Linitis Plastica Type of Advanced Gastric Cancer

Mantle cell lymphoma has a broad spectrum of endoscopic presentations, such as thick, rigid folds that are indispensible on air insufflation, superficial confluent ulceration, or a polypoidal mass protruding into the lumen. The exact diagnosis is difficult to make because the lesion is in the submucosal layer and inaccessible by biopsy. Lesions will often exfoliate necrotic cells which make interpretation difficult, or they may be too small in number and size and thus indistinguishable from anaplastic carcinoma. We report a case of mantle cell lymphoma with diffuse wall thickening of the whole stomach in a 51-year-old man. The series of endoscopic findings in this case support the role of differential diagnosis of linitis plasica type of advanced gastric cancer with mantle cell lymphoma.

Primary Linitis Plastica of the Colon with Mucinous Adenocarcinoma in Young Woman

Adenocarcinoma is the most common pathologic diagnosis, representing >95% of colorectal cancers; mucinous adenocarcinoma (MA) accounts for 10-15% and SRC accounts for 0.1-2.4% of colorectal cancers. MA is defined as a tumor with > or =50% mucin. Patients with MAs have a poor prognosis, a higher proportion of peritoneal metastases, and present at a more advanced stage of disease. Linitis plastica involving the colon and rectum is usually a metastatic lesion from gastric cancer and other organs, such as the prostate, gallbladder, and breast. Primary linitis plastica of the colon is very rare. We managed a case of colon cancer occurring in a 19-year-old female with a histologic diagnosis of mucinous adenocarcinoma and morphologic features of linitis plastica. Herein we report a rare case of primary linitis plastica of the colon with a review of the literature.

Primary Linitis Plastica of the Colon with Mucinous Adenocarcinoma in Young Woman

Adenocarcinoma is the most common pathologic diagnosis, representing >95% of colorectal cancers; mucinous adenocarcinoma (MA) accounts for 10-15% and SRC accounts for 0.1-2.4% of colorectal cancers. MA is defined as a tumor with > or =50% mucin. Patients with MAs have a poor prognosis, a higher proportion of peritoneal metastases, and present at a more advanced stage of disease. Linitis plastica involving the colon and rectum is usually a metastatic lesion from gastric cancer and other organs, such as the prostate, gallbladder, and breast. Primary linitis plastica of the colon is very rare. We managed a case of colon cancer occurring in a 19-year-old female with a histologic diagnosis of mucinous adenocarcinoma and morphologic features of linitis plastica. Herein we report a rare case of primary linitis plastica of the colon with a review of the literature.

Linitis plástica: presentación como gastropatía hipertrófica / Linitis plastica: presentation as hypertrophic gastropathy

Presentamos el caso de una mujer de 78 años, que presentaba importante pérdida de peso y su endoscopia digestiva alta demostró pliegues gástricos gigantes. Se realizaron biopsias con asa de polipectomía en busca del diagnóstico y posible enfermedad neoplásica. La histopatología documentó gastropatía hipertrófica. La ecoendoscopia gástrica demostró una pared muy gruesa y aunque se sospechó neoplasia no podía ser conclusiva, solamente después de realizada la gastrectomía total se diagnosticó linitis plástica. Presentamos la revisión de pliegues gástricos gigantes así como las causas y clasificación de la gastropatía hipertrófica.

We present 78 year old Colombian lady who had lost weight and had giant gastric folds in her upper endoscopy. Intensive work up was done including extra large biopsies done with polipectomy snares. The pathology diagnosed hypertrophic gastropathy. Endoscopic ultrasound of the stomach diagnosed a very thick gastric wall. Only after total gastrectomy was done, Linitis Plastica was diagnosed. We review giant gastric folds as well as causes and classification of the hypertrophic gastropathy.

Metastatic Gastric Linitis Plastica from Bladder Cancer Mimicking a Primary Gastric Carcinoma: a Case Report

Primary gastric carcinoma is the most common cause of linitis plastica. Less frequently, metastatic gastric cancer from the breast, omental metastases and non-Hodgkin lymphoma involving the stomach have been reported to show similar radiographic findings as for linitis plastica. A metastatic gastric cancer from bladder cancer is extremely rare. We present an unusual case, the first to our knowledge, of gastric linitis plastica that resulted from a metastatic urothelial carcinoma of the bladder.

A case of solitary rectal recurrence of gastric cancer / 대한내과학회지

The present research was conducted through the research fund of Dankook University in 2006. Rectal recurrence of gastric cancer is uncommon. A few cases have been reported, with the majority of them associated with peritoneal recurrence. A 71-year-old man visited our hospital complaining of bowel habit changes and fecal incontinence. He had undergone radical subtotal gastrectomy and postoperative adjuvant chemotherapy for advanced gastric cancer 9 years earlier. Colonoscopy showed a rigidly constricted and erythematous rectum. Abdominopelvic CT showed diffuse rectal wall thickening with enhancement. PET-CT showed a hot uptake in the corresponding area on abdominopelvic CT scan, with no evidence of distant metastasis. We performed transanal full thickness biopsy and confirmed a diagnosis of adenocarcinoma pathologically similar to the former gastric cancer. The patient was diagnosed with solitary rectal recurrence simulating linitis plastica, without gastric remnant recurrence. We report this case with a review of the literature.