signet ring cell carcinoma of the colon radiologically...

$: Signet ring cell carcinoma of the colon radiologically ...downloads.hindawi.com/journals/cjgh/1992/656898.pdf · diseases such as ischemic coliLi~ nr Crohn\ disease. In the present$
CASE RECORD

Signet ring cell carcinoma of the colon radiologically simulating

ileocecal tuberculosis

WC PETER KW1\N, MD, FRCPC, HJ FREEMAN, MD, FRCPC, FACP

WCP KWAN, HJ FREEMAN. Signet ring cell carcinoma of the colon radiologically simulating ileocecal tuberculosis. Can J Gastroenterol 1992;6(6):341 -344. A 65-ycar-o ld East Indian woman with episod ic vomiting and anemia had radiological evaluations showing calcified lymph nodes in the abdomen anJ chest, with na rrowing of the ileocecal va lve and ascending colon suggesting chc possibility of ileoccal tuberculosis. Evaluations subsequently proved this to be a signet ring cell carc inoma of the colon with infiltration of th e terminal ileum.

Key Words: Crohn's disease , Ileal stenosis, Inflammatory bowel disease, Intestinal ruberculosis, Signet ring cell colon cancer

Cancer des cellules en bague du colon simulant la tuberculose ileo-caecale a la radiologie

RESUME: Une Ancillaise de 65 ans prcsentant des episodes de vomissemcn cs et de !'anemic a subi des ana lyses radiologiques qui one revelc J es ganglions lymphatiques calcifies au niveau Jc !'abdomen e t du thorax, a insi qu'un retreci ~emenc de la va lvul e ileo-caecale et du c0lon ascendant, ce qui laisse ~urposer un diagnostic possible de tube rculosc ileo-caecale . Les examens subsequents confirment qu'il s'agit en fait d'un cancer des cellules en bague du colon avec infiltrat ion de l'ilcon terminal.

Deparrmenr of Medicine (( ;,lqrn,'mero/ogy), Unrwrsiry I /rJ.1/)iw/ and L/11il'Cr.111y of Bnr1.1h Columbia . \/anrnrrwr. Brirish Co/111n/,i11

Corres/)()nclence mu/ re/>rinrs: Dr \\'IC Per<'r Ku•cm. Gmrmcntcm/og:,.•, ACU-F- 1 'l7, L'niversiry Hospiwl ( UBCJ, 221 / \\'le.,hrook Mall , Vcmc<> 11wr, British Co/wnhrci \/6 T I \X/5 . re1~11ho11e (604) ,~22-7216

Received for /mhlica ru111 ./m11wry /0, /992. Acce/)( <'ll }uly 15, 1992

CAN J GA~TROl::NTl:RL)l Vm 6 Nt) 6 N<.WEMBER/D l·t HlflER 1992

S ll ,NET RIN<, Ct\RCINOMA or Tl IE

colon is an unusual colonic muc inllUS adcnocarc inoma. Recause of its in filtrn t ive nature, it may produce rndiologica l ch,mge~ that mimic othe r diseases such as ischemic coliLi~ nr C roh n\ disease. In the present report, a case of signet ring cell carcinoma ti the cecum involving the ileocecal valve and term inal ileum that simul ated ileocecal tuherc ulosis is desc ribed.

CASE PRESENTATION A 65-year-old Ea~t Indian woman

who emigrated t,> C,inada nine year~ rrev1ously ITom India pre~enced with n five-year hi , tnry of recurrent na usea, vomiting and diftu,e ahdnmina l discomfort. Diagnnstic lap,m ltomy done in a community hllSpiral at the onset o (

symptlllns 1de nt ifieJ no c n1,e. No ha rium enema examination lir endnscopi c , tudies were performed prior to

surgery. The re wa, no history of rec tal bleeding, a ltered hnwcl habit , fever or weight loss. In 198 1 , he wa~ exposeJ tO

a ~ister wi th active pulmonary cuber-

H I

KWAN AN!) FRl:EMAN

Figure l) Barium enema $howing fixed and srenoric renninal ilet1m, cect1m ancl ascemling colon. Calcified ahclominal /:;mph nodes are Jlresenr

Figure 2) Detailed radiographic view of ileocecal region showing feawreless renninal ile11m wich rigid stenosis

culosis. The deta ils of her surveillance were not avai lab le but she d id not receive amituberculous tre(l tmen t and she was not deemed to have active pulmonary tuberculo~is. In March 199[, a harium swallow suggested multiple gastric erosiom hut gastroscupy fa iled to demonstrate ;iny lesion.

342

The patient was admitted ro University Hospital in August 199 I for furthe r investigatio n hecause of persistent abdo minal pai n and nausea. Physical examination revealed an obese woman with a normal chest and abdominal examination; fecal occult blood testing was positive. S he was anemic with hemoglobin 109 mg/L and a mean cell volume of 68 fl. lron profile confirmed iron defic iency with fc rritin 8 µ g/L. An a ir contrast barium e nema showed a gross ly abno rmal cecum with contract ion and loss of normal mucosa! outline while the ilcocccal va lve was stenoric and fixed (Figure l ). Cecal ahnormality extended up the ascending colon to the region of the hepatic fl exure. Several calcific densities were present consistent with calcified lymph nodes. Distal terminal ile um was fcaurre lcss and appeared dilated (Figure 2) . C hes t radiographs revealed a calc ified density in the right upper lobe con-i tent with previous granulomarous

disease. Computed tomography scan of the abdomen and pelvis revea led a thickened cecum, ascending colon and distal tenninal ileum.

T he·c radiological changes suggested possible tuberc ulous involvement of the distal terminal ileum and ascending colon. Differential diagnoses included Crohn's disease, amcbias is and a colon ic neoplasm. The patient had a negative tuberculosis skin rest ( 5 TU) and she was not ancrgic.

The carc inoembryonic antigen wa 1.2 ~Lg/L ( normal less than 4 µ g/L). Stoo l cultures and examinations for parasit ic pathogens were negative.

Colo noscopy revealed an ahruptly narrowed lumen in the ascending colon ; the cecum could nm be intubated. The colonic muco a was extremely fr iable and abnorma lly thickened; b iopsies of these chicken ed mucosa! folds demonstrated signet ring cell carc inoma.

Laparotomy revealed a firm 6 cm mas· in the region of the cecum and terminal ileum. There was a 1.5 cm calc ified lymph node in the portal region. The omentum was c losely allied to the tumour but oth erwise there were no o bvious signs of local extension. A righ t hemicolectomy was performed wirh a resection of a port ion of the

involved term ina l ileum. I listolngically, resection margins were free from tumour, and signet r ing celb extended through the wall of the cecum and into distal te rm inal ileum (Figures 3,4). In some sectio ns of term inal ileum, scatte red signer rings ce lls were seen infi ltrating the mucosa! lamina propria (Figure 5 ). T here were tumour deposi t, in two meserneric lymph nodes. Other lymph nodes showed only calcitkar ion (no tumour deposi t or ev idence of prior tubercu losis).

The patient did well fo llowing surgery. Since there was lymph node involvement, adjuvant chemotherapy with s-nuorourac il and levamisole was offered ( I) , but the patient refused treatment.

DISCUSSION Signet ring cell carc inoma of the

colon is an unusual adcnncnrcinoma cha1 wa~ fi rst de c ribcd in l 95 1 as a ' lini tis plastica' type of colon cancer ( 2). The tumour docs not rip pear t()

follow the hypothetical polyp-cancer sequence suggested for more typical colonic adenacarcinomas. Althm1gh n is known to be uncommon, rh1.: exact incidence of colonic signet ring cell carcinoma has not been determined. O ne series suggested it could he found in approximately l. 5% of all cases of colonic cancer (3), bur figures as low as 0 . l % have been reported ( 4). The clinical and radiographic features ha\'e been rev iewed (5) - most reports ind icate that patients with signet ring cell colo n cancer a rc younger than those wi th the usual colonic adenocarc inoma and that t he ini tial clin ical features commonly may mimic innarnmatory or ischemic diseases of the C()lon because of their radiographic aprearance~ on barium enema (6).

T he presented patien t had a prolonged history of abdominal symptom· consistent with intermittent intestina l obstruction. Laparotomy done fi ve years earlier was 1wrmal. Although it is diffic ul t to accept that an deocccal tumour was present five years earlier, no other explana tion of the ,ymptonb was evident; early tumour in volvement in the ileocecal valve region may have resulted in t1bstructive symptl)m~. Furthermore, experience from Ita ly indi -

CAN J CiASTROENTERl) l V Oi 6 N() 6 NOVE~1BFR/Dll 'U,IBEI\ 1992

Figure 3 ) PhoromicrograJ>li of ileal section showing submucosal mfilrrawm 111iih signer rin~ cells. (1-iemawxylin and eosin X 100)

cares that surviva l in pat ien ts with signet ring cell cancer of the colnn is similar to that of patients with the more typical h bmlogical variety of colonic adenocarcin()ma (6), sugge~-ring the growth rate of ~ignet ring cell colonic carc inoma may not be exceptionall y rapid.

The patient's harium enema showed impressive contrnctinn of the cecum, narrowing of the ascending colon and a stenotic ileocccal va lve. There were calcified abdominal lymph nodes and chest radingraphs were consistent with prior granulomatous disease.

These radiographs were n(mspecific, hut taken with the country of origin of the patient and her history of exposure to tubercu lns is, i n1 esri nal ruhercu losis uwolving the ile()Cecal region w;1s considered. It was estimated that 80 w 90% of patients wi th int estinal rube rculnsis wi ll have involvement of the ikocecal region, possibly because of the ri ch lymphatic supply in this region.

However, in a review of 81 cases nf ~bJom inal tuherculosb in Canada, including patie nts wi th tuherculow, peritonitis (7) only 21 <){1 had ileoceca l involvement. Of these cases, 59% had c\'iJence of tubercu lo ·is elsewhere. Thus, the absence of pulmonary changes indicative ofactive tuhercul()Sis wi II not necessari ly alle r the initia l radio-

Figure 4) Higher power phowmicrogra/>h of subm11cosa of ilea/ section showing signet rillg cell infiltrating musrnlaris mucosa. ( Hemawx~lin and eosin x200)

logic interpretation. The classic rad iological appearance of ilcucecal tuberculosis is a con ical, shrunken, con tracted cecum with a narrow, ulcerated Lerminal ileum. Because of mesocolon contraction, the cecum may be pulled out of iliac fossa. With more advanced disease and str ict uring of the ileocecal valve, dilation of the terminal ileum occurs (8,9), and deep ulcerations, fissures and fistulous tracts may develop.

The radiological mimicry of ilcocecal tube rcu los is in chis case is produced hy the prope ns ity of th e signe t ring carcinoma cells to infiltrate the bowel wall resulting in marked narrowing of the colon over a con iderab le distance with rigidity and fixation ( 10, 11). In the presenL patient rhe lumour in fi ltrated the cecal wall , ileocecal valve and terminal ileum, with barium enema ch;:mges resulting. Alternative radio logical diagnoses included other inflammatory condi tions, such as Crohn's disease or ischemic disease. For ~ignet ri ng ce ll carc inoma occurring elsewhere in th e colon , barium enema changes may simul ate spasm, Crohn's disease, ischemic coli t is with stricture and complica ted diverticular disease (5, 12, 13 ).

Tuberculous involvement of the colon as ide from the ileocecal region can produce varied rndingrnphic a nd

CAN J GASTRl )FNTEROI Vol 6 No 6 N1.)VH,11\FR/DF<'EMHER 1992

Signet ring cell colon cancer

Figure 5) Plwwmicrop;raph of ilea/ section slwwing signet ring cell camnoma infilrrarinl! lamina J>ro/)ria {Jericryptal region. (Hemawxylin (Ind eosin x200)

endoscopic appemances, including ;,egmencal strictures, ulceration;, or hypertrophic nodular mucosa (14). The endoscopic appearance of the right colon in the patient comprised ahnormal, hemorrhagic mucosa but because of the degree of bleeding and friability encoumered, adequate v isu,1liw1 ion was not possible. However, no large ulceration was encounte red.

Signet ring cell carcinoma of the small intestine also is quite rare; however, it has been de cribed in Crohn's disease (15), ileostomy stoma (16,17) and in an ilea! segment following ilcocysroplasry ( 18) . Spreading of the signet ring cells into the terminal ileum in the pat ient was expected, given the biological nature of this tumour as reflected by t he in vitro ohservations demonstrated for the signet ring cell carcinoma cell line, DLD-2; this li ne showed inc reased invasiveness through basement membrane compared with othe r colonic e pi thelial cell lines (19).

T his case illustrates that in signet ring cell carcinoma of the colon, the biological behaviour of the malignant cells can result in an unusual constell;;icion of barium radiographic findings that may simulate other inflammatory diseases, part icu larly infection including ileocecal tuberculosis.

143

KWAN /\NI) FRl:FM1\N

REFERENCES I. Mortel CG . Fleming TE. MacDonald

JS, ct al. Levasirnolc nnd fluomurncil fo r ndjuvanl therapy of resecteJ colon carcino ma. N Engl J Med I 990;322:352-8.

2. La ufman J-1 , Saphir 0. l'rirnary linitis pla,tica type of carc inoma ,if the colon. Arch Surg 1951 ;62: 79-9 1.

3. Lui IOL, Kung ITM, LeeJMH, Boey JH . Primary colorecra l signet-ring carcinoma in young patients. Report of 3 cases. Pathology 1985; 17:3 1-5.

4 . Fahl JC, Dockerly MD. Judd ES. Scirrho us carcinoma of the cok,n and rectum. S urg Cynccol Obstct 1960; 1 l l :759-66.

5. Kwan W C P, Frecmnn HJ . S ignet-ring cell carcinoma tif the colon radiologically simulming C rohn's colit is. Can J Gastroentero l 199 I ; 5: 7 1 -4.

6. Giacchcm A, A,tc H, Bmacchini P. er al. Primary signet-ring c:ircinoma ,if th.: large bowel. Rcpnrt nf nine crn,cs. Cancer 1985;56:272 3-6.

344

7.

8.

9.

10.

II.

12.

I>.

14.

Jakubowski A, Elwood RK, Enarson DA. Cl inica l features ,l abdomina l tuberculosis. J Infect Dis l 988; 158:687-92. Anscombe AR, KcJdie NC, Schofield PF. Caec,11 lllbercu losis. Gut 1967;8:337-43. Reeder MM, Palmer PES. A limentary Traer Radiology, v,i l 2, 4 th .:dn. In: Margu lis AR, Rurhcne HJ , eds. S t Louis: C V Mmby Co, l 989: 14 78-8 l . Raskin MM. Some specific rndk,lngical find ings and considerntions of linitis plastica of the gastrointestina l tract. C RC C rit Rev C lin R,1diol Nucl Med l 976;8:87- I 06. Wolff BS, Marchak RE. Linitis pbstica ,1r diffusely infiltrating type of carc inoma ,if the colon. Radiology 1983;8 I :502-7. Jacobi MA. Primary linitis p lastica carcino ma of the colon. Wisconsin Med J l 970;69:2 I 1- 3. Nelson PG. Primary linius pla,uca carc inoma ,if the colon. Aust NZ J Surg 1965:34:288-9 1. Aoki G, Nagasakn K, Nakac Y, Suzuki

H, Endt1 M, T :1kemoto T. The fihercolonoscopic diugno.sis of intestina l tubercul\1sb. Endoscopy l 975;7: l 12-2 I.

l 5. Petra, RE, Mir-Madjbsi SH. Farmer RG. Crohn's dise,1se and mt('stina I c,1rc inoma. Gasrrocntcrology 1987;9'3: 1307 - l 4.

16. J-1hnson CD. Primary mucinow, adenncmcinoma developmg m an ileostomy stoma. G ut l 989; 30:889.

I 7. Sman PJ, Samy S. Wells S. Primary mucinous aJ enocarc moma developing in an ilc(1sromy stoma. G ut 1988;29: 1607- 12.

18. T :ib,aki E, Murahashi I, T,1ynda M, l-fond,1 M, W,, ku S. Signe! ring adenocarcinnma of ilea! segment foll,nving ilencystoplasty. J Urn! 1981; l 30:562- 3.

19. DanekcrGW Jr, r,a.:zn AJ , Steele CD Jr, Mercurio AM. ln1crnc11on~ of hum,111 culorecw I c:i rcmoma cc I b with hascmcnl mc111 hrnnes. Analy,1s (llld corrcl:HllHl with differential inn. A rch Surg l 979; l 24: 181- 7.

CAN J l~N,TRl\ENTFR( l l Vl lL 6 Nu 6 N\ Wl ~ !BI-R/Dl-l l·M lllcR 1992

Submit your manuscripts athttp://www.hindawi.com

Stem CellsInternational

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014

Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

signet ring cell carcinoma of the colon radiologically...

Documents