Managing Gastric Linitis Plastica Keep the scalpel sheathed *

Gastric linitis plastica is a diffuse type of cancer which is characterised by a thickening and rigidity of the stomach wall. It is notorious for its failure to cause early symptoms, and patients with symptoms generally have a more advanced form of the disease. We report our 18-month-long experience of managing gastric linitis plastica at Barnsley District General Hospital, UK. In our series of 8 patients, only one patient was offered surgery; the rest were offered palliative or supportive treatment. The findings in our series were consistent with the available evidence that curative treatment is not an option for the majority of cases with linitis plastica.


Case Series
In this series, 8 patients diagnosed with linitis plastica are discussed.Their demographic details, symptoms, endoscopic and computed tomography (CT) findings, treatment details, and survival statistics are given in Table 1.The average age upon presentation was 75 years (range 59-87 years).All patients were symptomatic at presentation.One patient (Case 7) was scoped 3 times as the first endoscopy showed diffuse mucosal inflammation, and biopsies showed only chronic inflammation with no evidence of dysplasia.Her CT scan was suspicious for linitis plastica but, in the absence of histological diagnosis, she underwent a repeat endoscopy and had negative biopsies.A diagnostic laparoscopy did not show serosal or peritoneal disease and she remained under close observation.However, 10 months after presentation, she started having dyspepsia despite being on proton-pump inhibitors.A repeat endoscopy and biopsy showed an intramucosal adenocarcinoma.Four patients with metastatic disease and two patients with extensive local disease were not offered surgery.One patient had local lymph node involvement and was not known to have any major comorbidities Out of 8 patients, 5 patients died within 5 months of follow-up.The maximum survival recorded so far in this cohort of patients has been 6 months.

Discussion
Gastric linitis plastica is a diffuse type of cancer in which the cells invade throughout the stomach, resulting in the thickening and rigidity of the stomach wall.Most of the patients presenting with symptoms have an advanced form of the disease, with the reason being the limited sensory qualities of the stomach.All the patients in these series were symptomatic.Dyspepsia was the commonest feature of presentation (55%), followed by dysphagia (33%), vomiting (33%) and weight loss (33%).The infiltration of malignant cells reduces the volume of the stomach and interferes with peristalsis so that the stomach acts as a funnel between the oesophagus and duodenum.As a result, food is easily regurgitated into the oesophagus.This was the commonest presentation in these series.
Linitis plastica generally arises from the lower third of the mucosa without destroying the architecture of the stomach wall.The mucosa is often spared malignant infiltration, making endoscopic diagnosis extremely difficult.Since macroscopic features do not permit the distinction between benign and malignant lesions, multiple endoscopic biopsies are required.The characteristic stroma reaction of the tissue is especially apparent in the submucosa, although it can also be noted in the muscle layer and subserosa. 3In most typical cases, the cells appear in a signet-ring form.The standard endoscopic biopsy specimens which contain only mucosa may result in a negative yield.One patient in these series had a negative first biopsy.In such patients with endoscopic suspicion, a diathermic snare can be used which will allow the acquisition    of larger and deeper tissue, but this procedure has a higher risk of perforation.The diagnostic yield can also be increased by taking multiple forceps biopsies from the same site.
The preoperative work-up involves an assessment of the spread of the disease.A CT scan of the abdomen may reveal thickening of the stomach wall with poor definition of the plane between the stomach and adjacent organs, or the involvement of surrounding nodes.Sometimes an endoscopic ultrasound is useful to establish the diagnosis and in guiding treatment.
The treatment for linitis plastica is a controversial issue.5][6] Aranha et al. reported a slightly improved survival rate, with an average of 11 months, in patients who received palliative chemotherapy or radiotherapy when compared to those patients who did not receive any treatment. 7uring their 21-year experience, Moreaux et al. reported a 5-year survival rate of 11% after curative resection, but this was only possible in a small number of cases. 8In the series reported by Schauer et al., only one-third of their cases had complete resection despite undergoing multivisceral resection and metatsatectomy. 9Although a survival advantage was reported in this series, the median survival only increased from 8 to 17 months with complete resection.In contrast, Kodera et al. reported an improved survival from 7.8 months in patients who did not receive any treatment to 30.2 months with complete resection, with no survival advantage in those undergoing palliative resection. 10n our series, the patients with locally advanced disease had poor physiological or functional status and were deemed unfit for major local resection.Our findings are limited by the small number of patients in the series, the majority of whom were elderly and unfit for extensive local resections.

Conclusion
In conclusion, gastric linitis plastica is one of the forms of adenocarcinoma which usually presents at a later stage, where curative treatment is not an option for the majority of cases.The prognosis may be ameliorated with complete resection.Surgery should only be offered where complete resection is anticipated.In the era of modern medicine, we are increasingly being faced with an ageing population where surgery may not be a viable option.

Figure 2 :
Figure 2: Computed tomography scan showing the grossly thickened wall (oblique arrow) and the perigastric extension of tumour (horizontal arrow).

Figure 3 :
Figure 3: Endoscopy showing a circumferential tumour with gross stomach contraction.

Table 1 :
Charateristics of each of the 8 linitis plastica cases Sadaf Jafferbhoy, Hanif Shiwani and Quatullah Rustum Case Series | 445 but, because of poor functional status, he was deemed unfit for surgery.Only one patient was offered surgery in this cohort, but she declined the treatment.