LINITIS PLASTICA OR DIFFUSELY INFILTRATING TYPE OF CARCINOMA OF THE COLON.

Abstract

The linitis plastica type of scirrhous carcinoma occurs most frequently in the stomach and is extraordinarily uncommon in the colon (1, 3, 7) or elsewhere in the gastrointestinal tract (1–3). In a series of 12,000 cases of carcinoma of the colon studied by Fahl, Dockerty, and Judd (2), 11 instances of this type were found, an incidence of less than 1 in 1,000. In an additional 80 cases in that series, scirrhous features were present in the lesion, but the gross appearance was not that of linitis plastica. Many cases reported as the primary linitis plastica type of carcinoma of the colon have been associated with previous long-standing chronic ulcerative colitis. In the series noted above, 3 of the 11 cases occurred in patients with that disease. Strictures due to benign fibrosis in the wall of the colon occur in a number of patients with chronic ulcerative colitis (4) and may perhaps precede the development of a scirrhous carcinoma. Other instances of linitis plastica of the colon originally thought to be primary, have proved at laparotomy or necropsy to be metastatic (5, 6, 8). These are usually secondary to a scirrhous carcinoma of the stomach or occasionally of the breast, which has remained clinically silent, with the presenting complaints related only to the colonic process. As a result, a correct preoperative diagnosis has rarely been made This has been true also of cases reported as primary linitis plastica carcinoma of the colon. It is not surprising that a carcinoma, scirrhous or not, may be overlooked when associated with chronic ulcerative colitis. It is a coincidence that the majority of instances of linitis plastica carcinoma of the colon, in the absence of pre-existing ulcerative colitis, have also been considered clinically as inflammatory disease, specifically ulcerative colitis. This is due to the occurrence of diarrhea, sometimes with blood in the stool, and the highly atypical roentgen findings that appear to be most consistent with segmental colitis. At laparotomy, the surgeon can ordinarily make the distinction but may occasionally be deceived by apparent inflammatory changes. The prognosis in the metastatic group is obviously very poor, but this has been true of the primary group as well. Among the 11 cases reported by Fahl et al. there was only 1 survival for more than five years. While this type of carcinoma apparently can occur in any portion of the colon, it has been most frequent in the sigmoid, in our limited experience. From the pathological point of view, the diagnosis of a linitis plastica type of carcinoma is ordinarily based on the gross appearance of a long segment of the colon which is markedly thickened and rigid, while maintaining the usual tubular configuration. Microscopically, the tumor is an anaplastic adenocarcinoma of a diffusely infiltrating type with a variable amount of scirrhous reaction. The involved portion of the colon is usually several inches, frequently a foot or more, in length.