AJR 2003; 181:428-430
© American Roentgen Ray Society
MR Imaging of Linitis Plastica of the Rectum
V. Rudralingam1,
M. J. Dobson1,
M. Pitt2,
D. J. Stewart3,
A. Hearn3 and
S. Susnerwala4
1 Department of Radiology, Royal Preston Hospital, Sharoe Green Ln., Preston,
PR2 9HT, United Kingdom.
2 Department of Pathology, Royal Preston Hospital, Preston, PR2 9HT, United
Kingdom.
3 Department of Surgery, Royal Preston Hospital, Preston, PR2 9HT, United
Kingdom.
4 Department of Oncology, Royal Preston Hospital, Preston, PR2 9HT, United
Kingdom.
Received July 23, 2002;
accepted after revision January 8, 2003.
Address correspondence to M. J. Dobson.
Introduction
Linitis plastica refers to a circumferentially infiltrating intramural
anaplastic carcinoma in a hollow viscus, usually the stomach, though rarely
the colon or rectum [1]. The
tumor cells or their products cause a marked desmoplastic response resulting
in a rigid shrunken viscus with thickened walls
[2]. We report two patients
with rectal linitis plastica with particular reference to the appearance on MR
imaging which, to our knowledge, has not been previously described.
Case Report
A 54-year-old man presented with a 4-day history of passing frequent small
stools mixed with fresh blood. He had no significant medical history. Clinical
examination and laboratory tests were unremarkable. Images of the rectal wall
were poor at sigmoidoscopy. There was midrectal stricturing, though no gross
mucosal abnormality was seen. The clinical impression, however, was that of a
fixed rectal tumor. Biopsies showed fibromyxoid changes in the submucosa
containing scattered foci of malignant signet-ring cells in keeping with
linitis plastica (Fig. 1A).
Abdominal CT performed with a Secura scanner (Philips, Einthoven, Holland) was
used to exclude primary or secondary disease elsewhere in the abdomen or
pelvis. CT also showed marked thickening of the rectal wall and perirectal
fascia. In line with our current practice for local staging of rectal tumors,
pelvic MR imaging was performed on a Magnetom scanner (Siemens, Erlangen,
Germany). T2-weighted MR images obtained parallel to the rectum showed
stratification in the rectal wall that was markedly thickened
(Fig. 1B). T2-weighted images
obtained perpendicular to the tumor showed a concentric ring pattern (Figs.
1C and
1D). There was also extensive,
abnormal low-signal material infiltrating the seminal vesicles, attributable
to peritumoral fibrosis. Diffuse perirectal fascial thickening and enlarged
mesorectal lymph nodes were also noted. IV gadolinium was not administered in
either of our patients. Serum prostate-specific antigen levels were normal.
Using the TNM system [3] and
the combination of CT and MR images, we staged this tumor as T3 N1 M0. The
patient was treated with 5 weeks of neoadjuvant radiotherapy followed by a
total abdominoperineal mesorectal excision and is still symptomfree 8 months
after treatment.
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Fig. 1A. —54-year-old man with linitis plastica of rectum. Histopathologic
section from rectal biopsy shows fibromyxoid change in submucosa (white
arrows), which contains scattered malignant signet-ring cells
(straight arrow). Mucosa (black curved arrows) is
normal.
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Fig. 1B. —54-year-old man with linitis plastica of rectum. Fast T2-weighted MR
image (TR/TE, 5670/104; slice thickness, 3 mm; matrix, 256 x 512; field
of view, 180 cm) parallel to lower rectum shows mural thickening with
stratified appearance (r).
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Fig. 1C. —54-year-old man with linitis plastica of rectum. Fast T2-weighted
high-resolution image (slice thickness, 3 mm; matrix, 512; field of view, 165
cm) at level of prostate (P) perpendicular to lower rectum shows concentric
mural ring pattern (arrowheads).
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Fig. 1D. —54-year-old man with linitis plastica of rectum. Fast T2-weighted
image (5670/104; slice thickness, 3 mm; matrix, 256 x 512; field of
view, 180 cm) perpendicular to lower rectum at level of seminal vesicles shows
that they are replaced by low-signal desmoplastic tissue (asterisk).
Note again thickened, stratified rectal wall (r), enlarged perirectal lymph
node (arrow), and thickened right perirectal fascia
(arrowheads).
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Our second patient was a 63-year-old man who presented with a 2-year
history of weight loss and recent fecal incontinence. He also had a history of
dysphagia that had recently been investigated extensively, and the upper
gastrointestinal tract had been found normal. There was no other significant
medical history. Clinical examination was unhelpful and laboratory tests
revealed only mild iron deficiency anemia. Barium enema showed a stricture at
the splenic flexure but no overt rectal abnormality. Colonoscopy showed the
splenic flexure to be inflamed and constricted, though biopsies had negative
findings. A mild rectal stricture was seen, but no overt mucosal lesion. CT of
the abdomen and pelvis showed mural thickening at the splenic flexure, severe
thickening of the perirectal fascia, and rectal mural thickening. Because of
the disparity between the rectal appearances on barium enema and CT, MR
imaging was performed. T1-weighted imaging
(Fig. 2A) showed severe
concentric thickening of the rectal wall and perirectal fascia. T2-weighted
appearances closely resembled the findings in our first patient. On images
obtained perpendicular to the rectum, there was a concentric ring pattern to
the rectal wall and extensive involvement of the seminal vesicles by
low-signal tissue (Fig. 2B).
There was no definitive surgical proof here, though the seminal vesicle
changes were considered to reflect a desmoplastic response in view of the low
signal on T1- and T2-weighted images. No overt nodal enlargement was seen, and
this tumor was staged as T3 N0 M0. In light of the MR findings, Tru-cut
(Allegiance Healthcare, McGaw Park, IL) rectal biopsy was performed that
showed fibrous tissue containing scattered malignant cells between intact
bundles of muscularis propria, again consistent with linitis plastica
(Fig. 2C). The patient was
treated with palliative chemotherapy and surgery for subsequent bowel
obstruction and died within 12 months of his first admission.
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Fig. 2B. —63-year-old man with rectal linitis plastica. Fast T2-weighted image
perpendicular to lower rectum also shows concentric ring pattern in rectal
wall (arrowheads). Infiltrated submucosa (sm) is markedly widened and
seminal vesicles are infiltrated by low-signal desmoplastic tissue
(asterisk).
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Fig. 2C. —63-year-old man with rectal linitis plastica. Rectal core biopsy
shows intact muscle bundles (white arrows) from muscularis propria,
between which is fibrous tissue (thick black arrow) containing
scattered undifferentiated malignant cells (thin black arrows).
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Discussion
Linitis plastica of the rectum is usually the result of primary disease in
the stomach, prostate gland, or breast. Primary colorectal linitis plastica is
rare, with a reported incidence of less than 0.1% of large bowel cancers
[4]. We believe that case 1 was
due to primary linitis plastica of the rectum, because no evidence of disease
was seen elsewhere on abdominal CT and, despite the seminal vesicle
abnormalities, the prostate gland was normal on T2-weighted imaging and serum
prostate-specific antigen measurement. We cannot be sure whether case 2 had
primary or secondary linitis plastica because the splenic flexure biopsy
finding was negative and there was no further surgical proof.
Rectal linitis plastica is usually advanced at the time of diagnosis,
commonly with peritoneal or ovarian metastasis. Establishing the diagnosis
early is important because the prognosis is grave, with survival of more than
12 months extremely unusual. Proving the diagnosis may be difficult. The
rectum may be contracted and nondistensible at sigmoidoscopy, though the
mucosa appears normal because the disease is primarily submucosal. Barium
enema may show a rectal stricture with an hourglass pattern though the mucosa
is intact and the common signs of primary rectal malignancy such as
"shouldering" or an apple-core appearance may be absent
[5].
The normal rectal wall should measure no more than 5 mm thick in the
distended state [6]. In most
cases, T2-weighted images will define the combined mucosa and submucosa as an
inner, intermediate-signal (to low-signal rectal gas) layer subjacent to the
outer low-signal muscularis propria. Linitis plastica causes circumferential
thickening of the rectal wall over a long segment on CT
[7], and this feature was
evident in our patients on the CT and T1-weighted imaging. Linitis plastica
may also have a concentric mural ring pattern or target sign in some cases on
CT [7]. Both our patients
showed this concentric ring pattern on T2-weighted images acquired
perpendicular to the tumor.
Unfortunately, we do not have whole-mounted histology for precise
correlation with the various zones defined in the rectal wall. The ring
pattern might be due to an exaggeration of the normal zonal anatomy caused by
interposition of infiltrative tumor and fibrosis in the submucosa and around
the circular and longitudinal layers of the muscularis propria. Despite
extensive mural infiltration seen with linitis plastica, the muscularis
propria layer of the bowel wall is often preserved
[5], which may further explain
the ring pattern. The concentric ring pattern is not specific to linitis
plastica and has been described in inflammatory, ischemic, and infective
colitis [8]. These diseases
should, however, either show a mucosal abnormality at endoscopy or be
suggested by the clinical history and laboratory test results. In both our
patients, no overt mucosal abnormality was seen. Findings in both patients
also showed dense fibrotic changes involving the seminal vesicles, best
revealed on T2-weighted imaging.
Ongoing review of further cases will be required to assess the true
incidence of the changes we have described in linitis plastica on MR imaging.
However, we suggest that the presence of a concentric ring pattern on
T2-weighted images perpendicular to the rectum and marked rectal wall
thickening on T1-weighted images should prompt exclusion of linitis plastica
by deep biopsy if no significant mucosal abnormality is seen at endoscopy.
Early recognition of linitis plastica may help avoid major surgery for a
disease that has a uniformly poor outlook.
Acknowledgments
We thank W. Heald for his surgical expertise in case 1.
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Introduction
Case Report
