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Video Endoscopic Sequence 1 of 47.
Endoscopy of Scirrhous Gastric Carcinoma involving the entire Fundus, Body and the Antrum.
This 52 year-old female presented with abdominal
discomfort, nausea, vomiting, early satiety,
satiety and weight loss of 20 Pounds, She had no history of
tobacco or alcohol consumption.
Extensive malignant infiltration from the pre-pyloric
antrum to the gastric cardias. The biopsies displayed
signet ring cells..
Nevertheless, the patient went to one of the Social
Security Hospitals in El Salvador where this case, was
complicated by controversial diagnostics delaying the
appropriate treatment by a month and doubting my
diagnosis that took only two seconds in perform it is
obvious by endoscopic image which is unmistakably of
infiltrating Scirrhous Carcinoma from the gastric cardias to
the pre-pyloric antrum.
To avoid errors of this kind, here are some details on a
scientific level despite the fact that in an atlas of this kind,
some controversies that happen with discrepancies in
diagnostics can be unwelcomed.
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Video Endoscopic Sequence 2 of 47.
Endoscopic Image of Linitis Plastica
General thickening of the tissues and an irregular ulcer in
the posterior wall of the gastric body is noted.
Continuation of this clinical case during admission at the
hospital of the Seguro Social.
A colleague (apparently without any endoscopic experience)
repeated the endoscopy, taking ten biopsies that were
negative for malignancy: as he had not observed any cancer
but noted intense inflammation, and lack of full distention
despite air insufflation. . However the Computed
tomography (CT) performed at that hospital and our
CT Scan both display diffuse thickening of layers of the
gastric camera. Rx. images of the upper digestive tract
shows images compatible with linitis plastica
see images below.
As the biopsies were negative, the case was discussed in
two medical conferences in the social security hospital
(Hospital del Seguro Social and it had reached my ears that
colleagues had expressed criticism against my person and
spoke negatively behind my back.
The patient improved clinically and was discharged with an
appointment to follow-up in three months. While out of
the hospital, her son contacted me again and I repeated the
endoscopy. There was no doubt from the first endoscopy,
since reaching the gastroesophagic junction. The image
was of a linitis plastica of almost the entire stomach.
However, I decided to send the biopsies to an additional
three pathologists to shut his mouth because of the
comments and speculation that occured within the Social
Security hospital conference.
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Video Endoscopic Sequence 3 of 47.
Endoscopic View of Linitis Plastica
Diffuse nodular thickening of the gastric folds
After re-making the diagnosis of both endoscopies, as
confirmed by the biopsies seen by three pathologists, the
patient was referred to another social security hospital
where a total esophago-gastrectomy was performed.
Linitis plastica may shows very little mucosal lesions on
gross appearance. As a rule, since macroscopic features
do not often permit the distinction between benign and
malignant lesions, multiple endoscopic biopsies are
required. However, standard endoscopic biopsy specimens
which usually contain only mucosa offer frequently
negative results for malignancy. In order to increase the
diagnostic yield, the use of a diathermic snare which
permits theb obtaining of larger and deeper histologic
samples is advised.
This technique has a substantial risk of complications,
particularly hemorrhage and perforation. Another
possibility is to take multiple forceps biopsies from the
same site (endoscopic “forage”).
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Video Endoscopic Sequence 4 of 47.
Endoscopy of Plastic Linitis
The gastric cardias is infiltrated
The most common cause of secondary achalasia is gastric
adenocarcinoma with or without esophageal invasion. The
diagnosis must be suspected in patients over 50 years, with
recent dysphagia and severe weight loss Plastic linitis, a
rare form of primary or secondary undifferentiated
adenocarcinoma may rarely manifest as pseudoachalasia
secondary to massive invasion of the gastric walls and of
the cardial area.
In fact, the tumor cells are not easily
detected in frozen sections of the surgical specimens.
Negative findings at endoscopic biopsy or brushing cause
a substantial delay in the diagnosis and treatment of these
tumors; therefore, it is clinically important to diagnosis
scirrhous gastric carcinoma before planning the treatment.
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Video Endoscopic Sequence 5 of 47.
(Hematoxylin-Eosin).
In this sequence of images showing histopathological cell
carcinoma with diffuse signet-ring cell.
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Video Endoscopic Sequence 6 of 47.
Alcian blue staining
Showing the Signet Ring Cells
This condition is marked by thickening
and Deeper biopsy from the same nodule confirming the
presence of independent cells in the submucosa. fibrosis of
the gastric wall, the malignant cells being scarcely.
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Video Endoscopic Sequence 7 of 47.
Pancytokeratin (AE3/AE1)
It appreciates undifferentiated malignant epithelial
neoplasm infiltrating the lamina propria with Signet Ring
Cells confirmed with Alcian blue and cytokeratin.
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Video Endoscopic Sequence 8 of 47.
Pancytokeratin (AE3/AE1)
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Video Endoscopic Sequence 9 of 47.
Pancytokeratin (AE3/AE1)
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Video Endoscopic Sequence 10 of 47.
A folollow up endoscopy (one month later)
Gastric Linitis Plastica: Initial Misdiagnosis is Still Common
Endoscopy display of the same diffuse nodular thickening of the gastric folds.
Due to the controversy of the case in one of the Social
Security hospitals in El Salvador, we repeated the
endoscopy with multiple biopsies(taken a total of 30
biopsies and send them to three different pathologists with
intent to silence mouths). Endoscopy was performed
approximately a month after the first and it was obvious
that the endoscopic image belonged to a scirrhous
carcinoma. We took only two seconds to determine the
correct diagnosis at the first endoscopy.
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Video Endoscopic Sequence 11 of 47.
Second endoscopy one month after
Note the irregularity with diffuse nodular image through
the gastric camera.
Other advice for novice endoscopists suspect
If linitis plastica is suspected, take multiple jumbo biopsies
and should take in mind that often biopsies are not
sufficient to determine the microscopic level the presence
of malignant cells in cases of linitis plastica and in cases in
which biopsies are negative should be repeated the
endoscopy.
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Video Endoscopic Sequence 12 of 47.
A close up in water immersion, which notes the irregular nodular polypoid pattern.
The diagnosis of diffuse type gastric carcinoma is very
difficult. The delay of diagnosis is often due to
false-negative endoscopic and histologic evaluation.
The differential diagnosis of large gastric folds represents
a challenge for the endoscopist and it includes malignancies
(adenocarcinoma, lymphoma) as well as benign conditions
(Menetrier’s gastritis, lymphoid hyperplasia and
amyloidosis).
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Video Endoscopic Sequence 13 of 47.
Another image and video of scirrhous carcinoma
Treatment of gastric linitis without carcinomatosis is
based on surgical resection, mainly a total gastrectomy.
However, prognosis is poor, leading some surgeons to
question the interest of such resection. A chemotherapy is
usually offered to the patient, but no guideline has been
really established, and results are also variable.
Linitis plastica is a diffuse infiltrative gastric
adenocarcinoma. This condition is marked by thickening
and Deeper biopsy from the same nodule confirming the
presence of independent cells in the submucosa fibrosis of
the gastric wall, the malignant cells being scarcely
distributed in the fibrous stroma. Frequently the gastric
mucosa is spared of malignant invasion, making an
endoscopic diagnosis very difficult.
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Video Endoscopic Sequence 14 of 47.
Diffuse nodular thickening of the gastric folds
Linitis plastica is a diffuse infiltrative gastric
adenocarcinoma. This condition is marked by thickening
and Deeper biopsy from the same nodule confirming the
presence of independent cells in the submucosa. fibrosis of
the gastric wall, the malignant cells being scarcely
distributed in the fibrous stroma. Frequently the gastric
mucosa is spared of malignant invasion, making an
endoscopic diagnosis very difficult. The most common site
of gastric linitis is the antral and pyloric regions (with
variable spread proximally towards the gastric body). The
fundus is least often involved. Our patient’s main
complaint was progressive dysphagia. The pericardial
gastric folds viewed in endoscopy were probably
associated with local extension of the adenocarcinoma and
responsible for the clinical manifestations.
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Video Endoscopic Sequence 15 of 47.
In this video image shows the ulcer of the gastric cardias
observed in the previous endoscopy, see image
4 of 43, however as I said before, the endoscopist in the
Social Security hospital had not seen this infiltrative
ulceration and also the ulcer seen in the image 2 of 43.
We advise to the novice endoscopist to wash vigorously
areas where the mucosa is covered by secretions before
omitting an opinion concerning of an endoscopic diagnoses
to avoid mistakes.
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Video Endoscopic Sequence 16 of 47.
Endoscopy of Plastic Linitis (Scirrhous Carcinoma)
Image and video clip, obtained during endoscopy shows
enlarged gastric rugae, with hyperemic change. The
stomach was not fully distended, despite air insufflation.
Diffuse nodular thickening of the gastric folds and loss of architecture and space as well.
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Video Endoscopic Sequence 17 of 47.
An Endoscopic View in Gastric Linitis
Gastric adenocarcinomas are further subclassified
according to their gross appearance (polypoid, fungating,
ulcerated, or infiltrative); their histologic features
(intestinal or diffuse); and their location within the stomach
(cardia, corpus, or antrum). A rare subtype of stomach
cancer is scirrhous carcinoma, or linitus plastica, a poorly
differentiated mixture of mucin-producing carcinoma cells
that infiltrates the muscle wall and turns the stomach
tissue rigid and leatherlike, limiting its distensibility.
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Video Endoscopic Sequence 18 of 47.
An abdominal CT scan confirmed the thickening of the gastric walls
Computed tomography scan of the abdomen, both so that
we had ordered as social security hospital, had revealed
thickening of the gastric layers suggestive of linitis plastica.
The CT scan and the endoscopic ultrasound may be useful
for the diagnosis of gastric linitis and also for the
evaluation of the local extension. The endoscopic
ultrasound aspect of thickened deep layers is considered
to be an independent predictive factor of malignancy.
In patients with negative biopsy results on endoscopy, a
fine needle biopsy can be performed under echographic,
echoendoscopic or CT guidance with a good sensitivity and
specificity for the diagnosis of malignancy.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 19 of 47.
CT is used preoperatively primarily to determine the stage
and extragastric spread of a gastric carcinoma. This
information is vital in deciding between palliative surgery
and curative radical surgery (ie, identifying patients who
would not benefit from radical surgery). Additionally, CT is
used to monitor a patient's response to treatment.
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Video Endoscopic Sequence 20 of 47.
Detection of gastric carcinoma is improved by using
thin-section sequences and helical or multidetector-row
CT. When thin collimation is used, near-isotropic imaging
of the stomach is possible, allowing high-quality
multiplanar reformation and 3-dimensional reconstruction
of gastric images. An intravenous contrast medium is used,
along with water or gas as a negative intraluminal agent.
Prone views improve visualization of tumors of the cardia
and distal stomach.
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Video Endoscopic Sequence 21 of 47.
Helical scanning allows for a biphasic technique. The early
arterial phase is used to assess enhancement of the gastric
wall; the later portal venous phase is used to assess the
liver parenchyma for metastases.
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Video Endoscopic Sequence 22 of 47.
Linitis plastica, a scirrhous carcinoma most commonly of
gastric origin, is characterized by diffuse infiltration
resulting in thickening and stiffening of the gastric wall.
Despite improved treatment outcome for other types of
gastric carcinoma in Japan, the prognosis in linitis plastica
remains extremely poor . In this disease, death often
results from peritoneal carcinomatosis, a consequence of
dissemination of free cancer cells from the primary lesion.
Gross findings indicating peritoneal seeding sometimes are
evident at laparotomy. Even when this is not apparent,
patients with this disease remain at high risk for peritoneal
carcinomatosis.
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Video Endoscopic Sequence 23 of 47.
Computed tomography of her abdomen revealed diffuse thickening of a portion of the gastric wall
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Video Endoscopic Sequence 24 of 47.
An abdominal CT scan confirmed the thickening of the
gastric walls affecting the gastro-esophageal junction, the
gastric body (especially the lesser curvature) and the
gastric antrum. There was no evidence of bowel obstruction
or extrinsic compression.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 25 of 47.
This study was conducted in one of the social security hospitals in El Salvador, where there is little distensibility of the gastric antrum.
Double-contrast barium image obtained in the supine position shows loss of distensibility with effacement of folds at the entire body and the antrum.
Press on the images to enlarge
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Video Endoscopic Sequence 26 of 47.
Another image of Rx. Upper Digestive Tract
Scirrhous carcinomas typically cause irregular narrowing
and rigidity of the stomach, giving rise to the typical linitis
plastica, or "leather bottle" appearance. Although some
are lobulated lesions in the fundus or body, others consist
of thickened, irregular mucosal folds and nodularity without
significant narrowing.
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Video Endoscopic Sequence 27 of 47.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 28 of 47.
Image of Plastic Linitis (Scirrhous Carcinoma)
The surgical specimen of total esophago-gastrectomy
Observing the cardia up and down the antrum and pylorus,
the fundus and the the gastric body with nodular infiltrative
pattern.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 29 of 47.
Thickening of the antrum is marked with scissors
In contrast with usual cases of gastric cancers, scirrhous
gastric carcinoma tends to spread over the peritoneum
with rapid growth and early metastasis. Thus, the
prognosis is poor in patients with this disease, and the
5-year survival rate is low. In general, the tumor cells in
patients with scirrhous gastric cancer are located
predominantly in the submucosa and are separated by
large areas of abundant connective tissue. Sometimes
these unique tumor growth patterns make it difficult for
radiologists or endoscopists to detect the tumor with
upper gastrointestinal (UGI) series or endoscopic
examinations.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 30 of 47.
Linitis plastica (scirrhous gastric carcinoma) has a poor
prognosis due to delay in diagnosis. Pathological feature
of this tumor is diffuse fibrosis of the gastric wall.
Detection of small fibrotic lesion in the gastric wall would
contribute to early diagnosis of linitis plastica, since the
primary lesion usually lacks remarkable protrusion or
ulceration.
Click on the image to enlarge on a new windows.
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Video Endoscopic Sequence 31 of 47.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 32 of 47.
Marked thickening of the antrum
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Video Endoscopic Sequence 33 of 47.
Since linitis plastica often involves the entire stomach,
total gastrectomy is usually performed. Indications for
radical resection therefore should be carefully weighed
against potential complications of major surgery. Ideally,
such resection should be performed only for patients with
a chance of cure.
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Video Endoscopic Sequence 34 of 47.
Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)
The macroscopic appearance of advanced gastric
carcinoma varies and was classified by Borrmann as
fungating (type I), excavated (type II), ulcerated and
infiltrating (type III), and diffusely thickened or scirrhous
(type IV). Type IV carcinoma, or scirrhous gastric
carcinoma, represents diffuse infiltrating
adenocarcinoma—which is predominantly poorly
differentiated and shows no circumscribed lesion.
When the entire stomach wall is involved with type IV
gastric carcinoma, the condition is called linitis plastica .
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 35 of 47.
Total gastrectomy was successfully performed.
A diagnosis of linitis plastic type of schirrhus carcinoma of the stomach was made.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 36 of 47.
The hands are taken the pre-pyloric area
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 37 of 47.
Thickened & rigid of gastric walls, with or without mucosal ulceration.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 38 of 47.
Nodular pattern and fibrinoid infiltration are displayed
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Video Endoscopic Sequence 39 of 47.
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Video Endoscopic Sequence 40 of 47.
Click on the image to enlarge on a new windows.
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Video Endoscopic Sequence 41 of 47.
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Video Endoscopic Sequence 42 of 47.
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 43 of 47.
Diffuse thickening and rigidity of the gastric wall
Click on the image to enlarge on a new windows
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Video Endoscopic Sequence 44 of 47.
This photograph clearly shows the invasion of the muscular layer with signet ring cells.
Click on the image to enlarge on a new windows.
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Video Endoscopic Sequence 45 of 47.
This photograph shows invasion of signet ring cells in the muscularis and a blood vessel.
Click on the image to enlarge on a new windows.
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Video Endoscopic Sequence 46 of 47.
Endoscopy of Status after the Total Gastrectomy
Five months after the surgery the status posterior of
Esophagus-Total-Gastrectomy is observed, in the
video clip are seen some rest of surgical staples and the
jejuno Multiple biopsies were taken and no evidence
macroscopic tumor recurrence at the time.
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Video Endoscopic Sequence 47 of 47.
More images and video clip after the surgery
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Video Endoscopic Sequence 1 of 15.
Scirrhous Gastric Carcinoma (Linitis Plastica).
An 80 year-old female with satiety and weight loss.
The image and the video clip shows diffuse infiltrating
adenocarcinoma with signet-ring cells.
Gastric linitis plastica is a very particular malignant gastric
tumor different from the usual gastric adenocarcinoma.
Linitis plastica refers to the diffuse proliferation of the
connective tissue, resulting in tissue thickening so that the
stomach is constricted and rigid. Pathological exams
reported a strong connective stroma-reaction associated
with a malignant glandular proliferation of independent
cells (signet-ring cells), invading all the layers of the
digestive tract, the mucosa being usually save not affected.
In spite of well-defined diagnostic criteria in endoscopy and
radiology, gastric linitis plastica often presents a diagnostic
problem. Due to a unique pattern of infiltration, histological
proof of cancer is difficult to achieve and depends upon
immunohistological staining.
For more endoscopic details download the video clips by
clicking on the endoscopic images, wait to be downloaded
complete then press Alt and Enter that you can appreciate
the video in full screen.
All endoscopic images shown in this Atlas contain
video clips.
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Video Endoscopic Sequence 2 of 15.
Linitis Plastica.
The posterior wall of the stomach is infiltrating from the
antrum to the fundus.
The term ”Linitis Plastica” refers to a scirrhous form of
carcinoma that spreads predominantly in the submucosa,
eliciting a marked desmoplastic response in the gastric
wall.
They classically arise in the antrum and infiltrate towards
the fundus.
Diagnosis is based on the association of pathological
results findings revealed by endoscopic, endoscopic
ultrasonography, radiological and surgical examinations.
Medline.
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Video Endoscopic Sequence 3 of 15.
Indigo Carmine Stain.
The diffuse type of gastric cancer often manifests itself as
a linitis plastica. It is harder to diagnose than the intestinal
type, particularly in the earlier stages. Thus, although
diagnostic techniques have improved, some gastric cancers
are still missed on the initial investigation.
Scirrhous carcinoma (linitis plastica) is a poorly
differentiated mixture of mucin-producing carcinoma cells
that infiltrates the muscle wall and turns it into rigid,
leatherlike scar tissue that cannot stretch or move during
the normal digestive process (peristalsis).
Medline.
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Video Endoscopic Sequence 4 of 15.
This image shows the contrast between normal folds and
infiltrating adenocarcinoma.
Findings suggest that the difficulty of detection and the
rapid growth of this tumor may explain why it is seldom
detected at an early stage and has a very poor prognosis.
Opposed to the adenocarcinoma, Helicobacter Pylori
seems not to be associated with the occurrence of gastric
linitis.
Familial forms of gastric linitis and
breast cancer-associated forms have been reported.
Medline.
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Video Endoscopic Sequence 5 of 15.
High Magnification Endoscopy.
You can observe a close up of the malign nodules.
Tumor mass of the stomach from patients with scirrhous.
carcinoma was analyzed biochemically and
immunohistochemically to elucidate whether or not
infiltrating carcinoma cells are directly responsible for
overproductions of collagen in the lesion. Collagen content
per unit transverse section of the tumor was two to four
times higher than the normal. Of particular interest was
that the contents of hyaluronic acid and chondroitin sulfate
were five to ten times higher than the normal, suggesting
that cells in the lesion of the tumor are in an actively
proliferating stage.
Medline.
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Video Endoscopic Sequence 6 of 15.
Chromoendoscopy using methylene blue.
Chromoendoscopy involves the topical application of stains
or dyes to improve mucosal visualization during endoscopy.
stain.
Although collagen synthesis is increased in gastric
carcinoma tissues irrespective of the amount of the stroma,
it is suggested that decreased collagenase activities and
increased expression of TIMP-1 would result in collagen
deposition in scirrhous gastric carcinoma tissue and the
response might actually benefit the invasion of tumor cells.
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Video Endoscopic Sequence 7 of 15.
Lugol´s Stain.
Chromoendoscopy involves the application of vital dyes
that enhance the visibility of abnormal tissues.
- · Intestinal-type carcinoma is common in old men, whereas diffuse-type carcinoma is comparatively frequent in young women.
- · Diffuse-type carcinoma with worse prognosis is more malignant than its intestinal-type counterpart, with early invasion into the muscularis propria and the lymphatic vessel, and frequent metastasis to the lymph node.
- · Compared with diffuse-type carcinoma, intestinal-type carcinoma exhibits high levels of proliferation and apoptosis, which are closely linked to high expression of fragile histine triad, phosphatase and tensin homology deleted from human chromosome 10, and mutant p53.
- · Extracellular matrix metalloproteinase inducer (EMMPRIN) is more frequently expressed in the intestinal-type carcinoma than diffuse-type lesion, and is used as a good marker to differentiate between both kinds of carcinomas. Higher EMMPRIN expression in intestinal-type gastric carcinomas underlies the molecular basis of their higher proliferation.
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Video Endoscopic Sequence 8 of 15.
Endosonography.
The endosonography can clearly visualize the architecture
of the stomach. This make it possible to find destruction
of the gastric layers.
In infiltrating gastric cancer there are typical
endosonographic pictures. The layers are visualized, but
there are larger and with irregular contour.
Especially the submucosa and muscularis are concentrically
enlarged.
Download the video clips.
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Video Endoscopic Sequence 9 of 15.
Endoscopic Ultrasonography.
Characteristic features of scirrhous carcinoma included an
irregular hypoechoic enlargement of the third (submucosa)
and fourth (muscularis propria) layers.
As many linitis plastica-type adenocarcinomas are
submucosal lesions, mucosal sampling by biopsy may yield
nondiagnostic material in up to one third of cases. With its
ability to sample deep submucosal lesions, EUS-FNA is an
appropriate technique for establishing this diagnosis and
guiding patient treatment.
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Video Endoscopic Sequence 10 of 15.
The diagnosis of diffuse type gastric carcinoma is very
difficult. The delay of diagnosis is often due to
false-negative endoscopic and histologic evaluation. The
architecture of the stomach can be clearly visualized by
endosonography. Therefore, already minor destructions of
the gastric layers can be found. The endosonographic
picture includes the presence of the layers, which are larger
and of irregular contour. In infiltrating gastric cancer
typically the submucosal layer and the muscularis are
concentrically enlarged and appear folded.
Advanced gastric cancer. EUS staging helps assess the
resectability and prognosis of advanced gastric cancer.
EUS is more accuracy than CT in the T staging
(92% vs 48 %). This has recently become more
importan as neo-adjuvant therapy is now the standard of
care for patients with locally advanced gastric cancer
CT, is the best method to detect distant metastases,
as part of standard evalution of gastric cancer.
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Video Endoscopic Sequence 11 of 15.
Note the difuse mural thickening of the gastric camera due to a infiltrating tumor.
Scirrhous carcinomas showed both a thick outer layer and
a thick inner layer, whereas non-scirrhous carcinomas did
not have appearance. This classification can serve as a
guideline for predicting scirrhous carcinoma on the basis of
CT findings.
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Video Endoscopic Sequence 12 of 15.
Note the liver metastasis.
CT is an important complimentary imaging technique to
detect scirrhous carcinoma. The sensitivity of detection
depends on the size of the lesion and the quality of the
examination. CT has limitations in staging early lesions but
shows a high sensitivity (89%) in detecting avanced
carcinomas.
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Video Endoscopic Sequence 13 of 15.
More images of the cat scan.
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Video Endoscopic Sequence 14 of 15.
"leather-bottle stomach".
The radiological study of the patient.
While the radiological features are not diagnostic, they
are, in many cases, suggestive of this entity.
Medline.
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Video Endoscopic Sequence 15 of 15.
Cells of the "Signet Ring" type.
After multiple histologic sections it was found between the
muscularis mucosa a small group of epithelial cells of the
"Signet Ring" type.
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This picture outlines the Signet Ring Cells
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Video Endoscopic Sequence 1 of 15.
Scirrhous Gastric Carcinoma (Linitis Plastica).
This 16 year-old female, two months previously initiates
with abdominal pain, abdominal discomfort, nauseas,
vomiting, early diminished appetite, satiety and weight loss.
One year and a half we found that her grandmother had a gastric carcinoma.
Perhaps this patient is one of youngest one that has
suffered from gastric cancer in medical Literature.
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Video Endoscopic Sequence 2 of 15.
In this video endoscopic sequence shows extensive
infiltration of this neoplasia from the gastric antrum to the
fundus and gastric cardias.
Gastric cancer is uncommon in the young. Occasional
reports are found in the literature.
Anaplastic infiltrative adenocarcinoma of the linitis plastica
morphologic type is rare in adolescents.
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Video Endoscopic Sequence 3 of 15.
Scirrhous tumors metastasize early, grow quickly, and
spread over the peritoneum. Prognosis is poor. Tumor cells
are in the submucosa and are separated by abundant
connective tissue. It can be difficult to diagnosis with UGI
or endoscopy.
The prognosis of patients with scirrhous gastric cancer
(SGC) is extremely poor. However, recent advances in
therapeutic strategies against SGC, using effective
anticancer drugs, have prolonged the survival of patients
with SGC.
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Video Endoscopic Sequence 4 of 15.
Endoscopy is 95% to 98% sensitive in diagnosing gastric
cancer when performed along with biopsy. It has much
lower sensitivity in diagnosing linitis plastica because the
tumor is in the submucosa and the overlying mucosa is
normal. Scirrhous tumors are also difficult to diagnose
because tumor cells are spread within a dense fibrous
matrix and are far apart. Preoperative diagnosis is
important.
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Video Endoscopic Sequence 5 of 15.
Endoscopic Image of Linitis Plastica
Endoscopically found to show insufficient stretching of the
gastric wall, thickening and tortuosity of folds, uneven
gastric mucosa, redness and white coating, there may be
negative in gastric biopsy.
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Video Endoscopic Sequence 6 of 15.
Linitis plastica(scirrhous gastric carcinoma)is characterized
by an abundant deposition of extracellular matrix
components and has a very poor prognosis.Altered
synthesis of extracellular matrix components as well as
degradation by proteolytic enzymes contribute equally to
the formation of the tumor stroma, which would affect
various cell functions and in finally, determine the biologic
behavior of the tumor.Although little is known about the
underlying mechanisms and the significance of
desmoplasia, overexpression of extracellular matrix
components mainly by host cells, in the development of
linitis plastica, the phenomenon has a similarity with
pathological conditions such as fibrosis of the lungs and
liver.
Currently known stromal changes in linitis plastica,
focusing on extracellular macromolecules, proteolytic
enzymes, and growth factors modulating the process of
physiological tissue remodeling.
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Video Endoscopic Sequence 7 of 15.
With difficulty it is performed the retroflexión maneuver
In the image and the video clip, it is observed the infiltration of the cardia and fundus.
Linitis plastica, a diffuse infiltrative gastric
adenocarcinoma which gives the stomach a shrunken
"leather bottle" appearance with extensive mucosal
erosion and a markedly thickened gastric wall. This type
of carcinoma has a very poor prognosis.
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Video Endoscopic Sequence 8 of 15.
16 year-old female with Scirrhous Gastric Carcinoma (Linitis Plastica) and ascites.
This picture shows the abdomen with ascites.
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Video Endoscopic Sequence 9 of 15.
Lateral Image.
The word ascites is of Greek origin (askos) and means bag or sac. Ascites describes the condition of pathologic fluid accumulation within the abdominal cavity.
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Video Endoscopic Sequence 10 of 15.
More pictures of her abdomen
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Video Endoscopic Sequence 11 of 15.
To download a high resolution and large image click here
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Video Endoscopic Sequence 12 of 15.
The walls of the stomach appeared thickened, and the
stomach distended poorly. Biopsies confirmed the
suspicion of diffusely infiltrating, poorly differentiated
adenocarcinoma with signet-ring cells.
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Video Endoscopic Sequence 13 of 15.
Histologically, gastric cancers can be separated into 2
main patterns: the intestinal (expanding) type and the
diffuse (infiltrative) type, according to the Lauren
classification system The intestinal type is characterized
by the presence of distinct glands comprising
well-differentiated columnar epithelial cells. In contrast,
the diffuse type contains poorly organized mucin-rich
(signet ring) cells. If a large proportion of the stomach is
occupied by the diffuse type lesion, the phenomenon of
linitus plastica or "leather bottle stomach" may result.
Chronic atrophic gastritis (Type B gastritis) secondary to
H pylori infection generally predisposes to the intestinal
type of gastric cancer, which is more common in high
prevalence regions such as Japan and Far East Asia. The
diffuse type, on the other hand, usually occurs in areas
with a low incidence of disease, such as the United States.
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Video Endoscopic Sequence 14 of 15.
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Video Endoscopic Sequence 15 of 15.
Signet-ring-like cells with intracytoplasmic mucin pooling and pushing the nuclei to the periphery.
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Video Endoscopic Sequence 1 of 3.
Plastic Linitis.
This 78 year-old female underwent screening endoscopy
due to liver metastases of unknown origin. She previously
underwent a upper endoscopy in a public hospital and was
apparently negative for malignant findings.
The biopsies displayed a gastric adenocarcinoma with
Signet Ring Cell type of the antrum and body. The biopsies
of the fundus were negative.
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Video Endoscopic Sequence 2 of 3.
The gastric folders are observed with diffuse redness resemble a severe acute gastritis but they are also infiltrated with adenocarcinoma.
Signet Ring Cell Type
Linitis plastica is a gross descriptive term, which can refer
to a signet ring cell and or diffuse carcinoma within the
wall of the stomach.
Infiltrating carcinomas cause a leather bottle stomach as a
result of spreading widely beneath the stomach mucosa
and invading the muscular wall. This pattern of 'growth'
causes thickening and stiffening of the stomach wall. As a
result the stomach also has a reduced capacity. The
resultant stiff-walled, smaller capacity stomach is much
akin to a leather bottle.
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Video Endoscopic Sequence 3 of 3.
Chromatoscopy with lugol´s stain.
A leather bottle stomach - linitis plastica - describes a
stomach that has a gastric carcinoma which is
morphologically an infiltrating carcinoma.
Linitis plastica may show very little mucosal lesions on
gross appearance. As a rule, since macroscopic features do
not often permit the distinction between benign and
malignant lesions, multiple endoscopic biopsies are
required. However, standard endoscopic biopsy specimens
which usually contain only mucosa offer frequently
negative results for malignancy.
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Video Endoscopic Sequence 1 of 2.
Bilateral Krukenberg´s Tumor
A 47 year--old, female nurse, with extensive infiltration of
gastric adenocarcinoma, she had bilateral Krukenberg´s
Tumor.
For more details of this case see ovaries specimen and
macroscopic appearance of her stomach click here.
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Video Endoscopic Sequence 2 of 2.
The adenocarcinoma is seen in retroflexed maneuver.
She had been suffering of many inspecific symptoms, for a
long period of time, such as abdominal pain and weight
loss.
At the time that she asked for help in our clinic, she had
already many different medical procedures, such as an
upper endoscopy and colonoscopy that were negatives,
4 moths before.
The upper endoscopy practiced before was reported as an
erosive gastritis and biopsies only confirmed gastritis.
That endoscopy was practiced elsewhere.
To see ovaries specimen and macroscopic appearance of
her stomach click here.
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Video Endoscopic Sequence 1 of 3.
Early Gastric Carcinoma with gastric carcinoma of the signet ring cell type (Plastic Linitis).
A 43-year old man with a lesion that can only seen in
retroflexed maneuver, because of the antrum wall showed
some rigidity due to an early gastric carcinoma Type III.
The image and video display some typical parameters of
criteria of a malign ulcer.
1. Fold tapering
2. Ulcer
3. Fusion of folds
4. Abrupt termination of fold
5. Discoloration
6. Depressed mucosal surface
7. Bulbous enlargement.
Diagnostic evaluation of patients with early gastric
cancer--a literature review.
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Video Endoscopic Sequence 2 of 3.
Relatively small size linitis plastica of the stomach
Linitis plastica (scirrhous gastric carcinoma) has a poor
prognosis due to delay in diagnosis. Pathological feature of
this tumor is diffuse fibrosis of the gastric wall. Detection
of small fibrotic lesion in the gastric wall would contribute
to early diagnosis of linitis plastica, since the primary
lesion usually lacks remarkable protrusion or ulceration.
Early Gastric Cancer, type III typical abrupt and irregular
termination of gastric folds at the ulcer margin.
Early Gastric Cancer is defined as limited to the mucosa
and or submucosa.
Metastasis to regional lymph nodes and even to distant
organs may already exist at this stage.
More than 90 per cent of gastric cancer patients complain
of one or several abdominal symptoms. The symptoms are
nonspecific disease entity and the patient should be
evaluated with an upper endoscopy mass screening should
be done in countries of a high incidence such as the
republic of El Salvador.
Medline.
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Video Endoscopic Sequence 3 of 3.
Patient delayed the surgery for more than 7 months. The
carcinoma was then found in an early phase. The
endoscopic image and video display this gastric
carcinoma after more than 7 months of the first
endoscopy. (This endoscopy was taken after 7 months of
the previous one see the previous video clips 1 of 3 and 2
of 3.) Patient underwent a subtotal gastrectomy, is free of
symptoms 7 years after.
Signet ring cell carcinoma is a poorly differentiated
adenocarcinoma in which the tumour cells invade singly or
in small groups. Early stages of the disease can be missed
easily when using regular haematoxylin and eosin staining.
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 Linitis Plastica.
A 27 year-old man with weight loss more than 30
pounds, early satiety, apathy, anorexia and vomiting.
The walls of the stomach appeared thickened, the stomach
distended poorly.
Infiltrating adenocarcinoma of the diffuse type with
signet-ring cells was found.
biopsy proved to be a poorly differentiated adenocarcinoma
, signet ring cell type.
Gastric Cancer in young patient is more likely to be of
the diffuse type and associated with poorer prognosis.
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Linitis Plastica.
This 68 year-old male presented with initiates with
abdominal pain, abdominal discomfort, nauseas, vomiting,
early diminished appetite, satiety and weight loss.
Gastric Adenocarcinoma that has an erosive appearance.
The histopathologic study revealed signet ring cells.
In order to increase the diagnostic yield, the use of a
diathermic snare which permits the obtaining of larger and
deeper histologic samples is advised. This technique has a
substantial risk of complications, particularly hemorrhage
and perforation. Another possibility is to take multiple
forceps biopsies from the same site: endoscopic “forage”.
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Hereditary diffuse gastric (stomach) cancer (HDGC).
Extensive Gastric Adenocarcinoma
A 39 year-old man, who was under medical control in a
national institution for more than 4 years because of
epigastric discomfort, but no upper endoscopy was
perform.
When he asked for help in our clinic he had already lost
a weight of 20 pounds.
We performed an upper endoscopy and an advanced
adenocarcinoma was found. It infiltrated the antrum,
body and the fundus along of the minor curvature.
We detected a gastric adenocarcinoma to his father
1991 at the antrum.
His father died 10 years later at age 85, but for a different
disease.
His mother died of gastric cancer many years ago.
We found two nephew had Advanced Gastric Carcinoma
recently. See the sequences below one case of them is not
published here because we have not found the video yet.
Several member of that family had die of breast cancer.
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Video Endoscopic Sequence 1 of 4.
Hereditary diffuse gastric (stomach) cancer (HDGC).
Diffusely infiltrating poorly differentiated adenocarcinoma.
A 36 year old man, who presented a weight loss more than
25 pounds, anorexia, early satiety, and severe abdominal
pain. We found that his maternal grand father suffered a
gastric carcinoma in 1991.
His maternal grand mother died because of a gastric
cancer many years ago.
His maternal uncle had gastric adenocarcinoma detected in
may 2000.
See case above described.
Gastric Cancer in young patient is more likely to be of the
diffuse type and associated with a poorer prognosis.
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Video Endoscopic Sequence 2 of 4.
The Cardias is infiltrated.
On a case on diffusely infiltrating poorly differentiated
adenocarcinoma.
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Video Endoscopic Sequence 3 of 4.
The image and video clip display extensive infiltration of
the body and the antrum.
The differential diagnosis of large gastric folds represents
a challenge for the endoscopist and it includes malignancies
(adenocarcinoma, lymphoma) as well as benign conditions
(Menetrier’s gastritis, lymphoid hyperplasia and
amyloidosis).
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Video Endoscopic Sequence 4 of 4.
Some ulcerated nodules are appreciated at the antrum.
Those cases presented here of that member of this family
has the Hereditary diffuse gastric (stomach) cancer
(HDGC) is a genetic cancer susceptibility syndrome
characterized by a high risk for stomach and lobular breast
cancer. HDGC is inherited in an autosomal dominant
pattern, therefore several generations of relatives with
stomach or lobular breast cancer are often seen clustering
on one side of the family. Gastric cancers that occur in this
syndrome are of the “diffuse” type (as opposed to
“intestinal”) and often have “signet ring” cells through the
stomach wall causing thickening (“linitis plastica”) without
forming a discrete mass. The average age of onset of
gastric cancer in HDGC is 38 years old, with individuals as
young as 14 having been diagnosed. The estimated lifetime
risk of developing gastric cancer by age 80 is 67% for men
and 83% for women. Women with HDGC also have an
elevated risk of breast cancer, predominantly of the lobular
type, with a 20 – 40% lifetime risk. Most of these women
are over 50 at diagnosis.
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Linitis Plastica.
A 35 year-old female, who began her disease with jaundice,
weight loss, early satiety, nausea and vomiting.
The endoscopy was performed and all the gastric mucosa
and walls were infiltrated.
The walls of the stomach appeared thickened, and the
stomach distended poorly.
Infiltrating adenocarcinoma of the diffuse type with
signet-ring cells.
Gastric Cancer in young patients is more likely to be of the
diffuse type and associated with a poorer prognosis.
A leather bottle stomach - linitis plastica - describes a
stomach that has a gastric carcinoma which is
morphologically an infiltrating carcinoma.
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Video Endoscopic Sequence 1 of 9.
Scirrhous Gastric Carcinoma (Linitis Plastica).
This 75 year-old male, had an endoscopy a week earlier
by a colleague on which describes according the endoscopic
report that there was a reflux esophagitis and a hiatal
hernia of large size, having aspirate 500 cc. of foul smelling
dark liquid, biopsies taken from an ulceration of the
gastroesophageal junction were negative for malignancy
but not described lesions of the corpus or antrum, the
diagnosis was not conclusive..
looking for a second opinion we performed a second
endoscopy which found this videos and images displayed
here.
In the video clip here displayed, there are esophagitis but
caused by the vomits due to the obstructive syndrome.
In fact as it is seen in this video there are esophagitis but it
comes from obstructive syndrome and as you can observe
a big hiatus hernia, described in previous endoscopic
report, it appears that endoscopist did not advance the
endoscope due to abundant obstructive liquid our biopsies
confirmed the diagnosis of neoplasia with signet ring cells.
In the computer axial tomography CT scan there are
diffuse thickening of the walls of the stomach and not
metastasis observed .
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Video Endoscopic Sequence 2 of 9.
Scirrhous Gastric Carcinoma (Linitis Plastica).
After aspirated a plenty of fluids due to stasis it is observed
injuries consistent with infiltration by diffuse type
malignant neoplasm with a typical nodular scirrhous
carcinoma.
The most common site of gastric linitis is the antral and
pyloric regions (with variable spread proximally towards
the gastric body). The fundus is least often involved.
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Video Endoscopic Sequence 3 of 9.
Endoscopy of Scirrhous Gastric Carcinoma (Linitis Plastica).
It is observed extensive infiltration of the body and gastric
antrum which causes a pseudo obstruction
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Video Endoscopic Sequence 4 of 9.
Extensive nodular infiltration of body and antrum.
There was marked thickening of the gastric mucosal folds,
which were difficult to distend with subsequent luminal
narrowing and gastric wall rigidity. Some gastric folds were
enlargedand some parts of the mucosa had a mosaic
pattern and a “leopard skin” aspect (photos) with localized
nodular carmine-red lesions (photos). In the antral region
the rigidity of the gastric walls and the enlarged folds gave
a stenotic aspect with difficult passage of the pylorus.
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Video Endoscopic Sequence 5 of 9.
Diffuse thickening is observed at the junction of the body and gastric fundus.
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Video Endoscopic Sequence 6 of 9.
Stricture of the antrum due to a tumoral infiltration
It is observed decrease in the size of the antrum due to malignancy.
The tumor had infiltrated from the junction of body with the fundus to the pre-pyloric antrum.
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Video Endoscopic Sequence 7 of 9.
Abdominal CT scan confirmed the thickening of the gastric walls
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Video Endoscopic Sequence 8 of 9.
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Video Endoscopic Sequence 9 of 9.
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