Linitis plastica of the rectum: an unusual type of rectal
cancer.
Poster No.:
C-1723
Congress:
ECR 2016
Type:
Educational Exhibit
Authors:
D. M. Angulo, C. De Juan, B. Rodriguez Fisac, M. Vilchez Mira;
Palma de Mallorca/ES
Keywords:
Neoplasia, Cancer, Biopsy, MR, CT, Oncology, Colon, Abdomen
DOI:
10.1594/ecr2016/C-1723
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Page 1 of 11
Learning objectives
Review and to describe the radiological features of linitis plastica of the rectum on CT
and MRI.
Background
Rectal linitis plastica (RLP) is an unusual neoplastic condition characterized by the
infiltration of the deep layers of the rectal wall (submucosal and muscular layers) with no
infiltration of the mucosa. RLP represents less than 0.1% of all malignancies affecting
the rectum [1] and can be a primary rectal carcinoma or, more frequently, a secondary
metastasic infiltration. The most common primary tumors of metastasic RLP are bladder
and prostate neoplasm, however it has been described in breast, gastric, lung, and
pancreaticobiliary carcinomas[2].
Histologically RLP is a poorly differentiated neoplasm infiltrating the deep rectal layers
associated with fibrosis and proliferation of connective tissue giving a strong desmoplastic
reaction (scirrhous carcinoma). Are three main spreading routes for RLP: hematogenous,
lymphatic and direct extension from the peritoneal cavity [4].
Diagnosis is often difficult and delayed because symptoms are insidious, nonspecific
(rectal pain, tenesmus, changed bowel habit) and different from the usual clinical
symptoms of rectal adenocarcinoma (rectal bleeding is a late symptom in RLP). The
stiffness and loss of distensibility of the rectum translates into a stony consistency in the
clinical rectal examination.
Endoscopy findings can be misleading and rectal mucosa endoscopic biopsies are
frequently false negative due to the absence of mucosal infiltration. The performance of
a deep biopsy sampling the submucosa and the muscularis propia is essential to reach
the diagnosis. The knowledge of the radiological features of RLP is of utmost importance
since it is the clue to suggest the diagnosis, which should prompt the performance of a
deep endoscopic biopsy that will permit the correct diagnosis.
Prognosis is poor due to its strong aggressiveness with frequent involvement of peritoneal
structures and lymph node metastases observed in 50-80 % at the time of diagnosis.
Long-term survival is low even in patients treated with surgery.
Page 2 of 11
Images for this section:
Fig. 2: Histology and endoscopy show congestive mucosa without neoplasic infiltration.
In the deeper layers (c), histology show infiltration of the submucosa by signet ring cell
consistent with rectal mucinous adenocarcinoma in patient 5. Thickening of the rectal
wall on CT can mimic benign conditions.
© IBSALUT, SON ESPASES HOSPITAL - Palma de Mallorca/ES
Page 3 of 11
Findings and procedure details
We have reviewed the radiological findings on CT and MRI in five cases of histologically
confirmed RLP, four men and one woman, age ranging from 31 to 76. We have also
reviewed the clinical history, laboratory data and endoscopic findings. Patient data are
summarized in Table 1 (fig 3).
All patients showed a strong circumferential wall thickening of the rectum (range
10-20 mm), with mucosal integrity. The affected segment was longer than 50mm in
all patients (range 60-100 mm). On the T2W MR sequences all patients presented a
concentric double-ring pattern of the rectum wall [3], where mucosa was preserved while
submucosal and muscular layers were thickened. (fig 1,fig 4,fig 5,fig 6,fig 7). Double ring
pattern was also nicely depicted in contrast-enhanced T1W images and in Diffusion MR
images. The different thickened layers were more difficult to detect on CT images due to
its lower contrast resolution. In three cases, extension to the perirectal fat was observed
( Fig 5).
On the basis of TC and MRI results, endoscopy-guided deep biopsy was indicated and
the diagnosis was confirmed (fig 2).
Images for this section:
Page 4 of 11
Fig. 3: Graphic. Details of five patients.
© IBSALUT, SON ESPASES HOSPITAL - Palma de Mallorca/ES
Page 5 of 11
Fig. 1: Patient 2. Axial and coronal T2W MRI (a and b) and DWI (e): circumferential
wall thickening of the rectum with an isointense inner (submucosal) layer (star) and
a hypointense outer (muscular) layer (white arrow). Axial and coronal T1W contrast
enhanced MRI: thickening of rectal wall with integrity of the unaffected mucosa (c and
d). Axial contrast enhanced CT (f).
© IBSALUT, SON ESPASES HOSPITAL - Palma de Mallorca/ES
Page 6 of 11
Fig. 4: Patient 1. Axial contrast enhanced CT: malignant target sign in the rectal wall and
urinary bladder neoplasm (a). Axial and coronal T2W MR: double-layered wall thickening
with normal mucosa (b and e). Coronal and axial DWI: lamination layers (c and d).
© IBSALUT, SON ESPASES HOSPITAL - Palma de Mallorca/ES
Page 7 of 11
Fig. 5: RLP with perirectal fat infiltration seen on contrast enhanced CT of patient 3 (a,
b and c) and T2W MR of patient 5 (d) and patient 2 (e).
© IBSALUT, SON ESPASES HOSPITAL - Palma de Mallorca/ES
Page 8 of 11
Fig. 6: Patient 4. Wall thickening of RLP. Malignant target sign on axial contrast enhanced
CT (a and c). Double-layered wall thickening on T2W Mr and DWI (b and d). Coronal
contrast enhanced CT and T2W MR with regional lymphadenopathies (e and f).
© IBSALUT, SON ESPASES HOSPITAL - Palma de Mallorca/ES
Page 9 of 11
Fig. 7: Patient 5. Primary rectal mucinous adenocarcinoma. Axial, sagital and coronal
contrast enhanced CT (a, c and e) and T2W MR (b, d and f). Circumferentially thickened
rectal wall, double-layered sign and preserved mucosa with extensive infiltration of the
perirectal fat (a, b and f). The thickened wall is heterogeneous with multiple hyperintense
foci due to the presence of mucine.
© IBSALUT, SON ESPASES HOSPITAL - Palma de Mallorca/ES
Page 10 of 11
Conclusion
RLP is an unusual malignancy with poor prognosis.
Double-layered circumferential thickening of the rectal wall with unaffected mucosa over
a long segment is the characteristic radiological finding of RLP on MRI.
Radiological recognition of the disease in an appropriate clinical context is the key to
indicate a deep biopsy which will allow us to find the proper diagnosis.
Personal information
References
1.
2.
3.
4.
Secondary rectal linitis plastica as first manifestation of urinary bladder
carcinoma. Katsinelos P, Papaziogas B, Chatzimavroudis G, Katsinelos T,
Dimou E, Atmatzidis S, Beltsis A, Terzoudis S, Kamperis E, Lazaraki G Ann
Gastroenterol. 2012;25(2):173-175
Scirrhous metastases to the gastrointestinal tract at CT: the malignant
target sign. Gollub MJ1, Schwartz MB, Shia J. AJR Am J Roentgenol. 2009
Apr;192(4):936-40. doi:10.2214/AJR.08.1152.
Linitis plastica of the rectum secondary to bladder carcinoma: a report of two
cases and its MR features. Dresen RC1, Beets GH, Vliegen RF, Creytens
DH, Beets-Tan RG. Br J Radiol. 2008 Oct;81(970):e249-51. doi: 10.1259/
bjr/59924178.
Linitis plastica of the rectum: utility of transrectal ultrasonography. Keogh
CF, Brown JA, Phang PT. J Ultrasound Med. 2002 Jan;21(1):103-6.
Page 11 of 11