Recurrent bladder cancer presenting as rectal linitis plastica

 

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A 55-year-old man presented with a 4-day history of rectal pain, urgency, and a feeling of heaviness. He had also noticed thinning of the caliber of his stool. His past history included stage II, T2 – 3, muscle invasive urothelial bladder carcinoma, diagnosed 10 months previously, for which he had received neoadjuvant chemotherapy before undergoing radical cystoprostatectomy, pelvic lymphadenectomy, and the creation of an ileal conduit. A few days prior to this presentation, evaluation by his urologist and oncologist had deemed him to be cancer-free.

Rectal examination revealed marked rectal narrowing, rigidity, and tenderness to palpation. The results of a comprehensive panel of blood tests were normal. A computed tomography (CT) scan showed diffuse rectal wall thickening, with postoperative changes in the pelvis ([Fig. 1]). Colonoscopy revealed a markedly narrowed, indurated, firm distal rectal wall, with changes extending from the anal verge to 8 cm proximally ([Fig. 2]). Rectal endoscopic ultrasound (EUS) showed a diffusely thickened rectal wall to 15 mm circumferentially, with an irregular outer border ([Fig. 3]). The architecture of the wall layers was discernible and the mucosa propria was the thickest layer, measuring 10 mm. There was one round 5-mm hypoechoic lymph node adjacent to this area.

Rectal tunnel biopsies were obtained. Hematoxylin and eosin (H&E) staining of the biopsy specimens revealed benign colonic mucosa with scattered fragments of submucosal tissue containing rare atypical cells and collections of crushed cells. Immunohistochemical staining demonstrated that the crushed cell population consisted of heterogeneous lymphoid tissue with scattered single cells in the submucosal tissue whose nuclei were positive with Ki-67, p53, and Gata3 ([Fig. 4]), consistent with rectal linitis plastica (RLP) due to infiltration of the rectal wall by the previously diagnosed urothelial carcinoma.

The patient underwent a laparoscopic diverting loop colostomy and was noted to have a 3-cm abdominal wall mass (pathology of this showed it to be metastatic urothelial carcinoma) and numerous pelvic adhesions from tumor infiltration. Postoperatively, the patient was started on chemotherapy and palliative radiotherapy.

RLP is characterized by wall thickening and rigidity due to diffuse infiltration of the submucosa and muscularis propria layers with cancer cells. It is difficult to diagnose because of the sparing of the mucosa. Even when diagnosed early, RLP can still carry a dreadful prognosis as it has been associated with peritoneal carcinomatosis [1]. There have been very few cases of secondary RLP in patients with metastatic bladder, prostate, breast, and gallbladder cancer [2]. This is the first reported patient in whom RLP was the presenting feature of his recurrent urothelial carcinoma of the bladder.

Endoscopy_UCTN_Code_CCL_1AF_2AH

• References

• 1 Ha HK, Jee KR, Yu E et al. CT features of metastatic linitis plastica to the rectum in patients with peritoneal carcinomatosis. Am J Roentgenol 2000; 174: 463-466
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• 2 Dresen RC, Beets GH, Vliegen RF et al. Linitis plastica of the rectum secondary to bladder carcinoma: a report of two cases and its MR features. Br J Radiol 2008; 81: e249-e251
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