Endoscopy of Scirrhous Gastric Carcinoma involving the entire Fundus, Body and the Antrum.

Video Endoscopic Sequence 1 of 47.

Endoscopy of Scirrhous Gastric Carcinoma involving the entire Fundus, Body and the Antrum.

This 52 year-old female presented with abdominal discomfort, nausea, vomiting, early satiety, satiety and weight loss of 20 Pounds, She had no history of tobacco or alcohol consumption.

Extensive malignant infiltration from the pre-pyloric antrum to the gastric cardias. The biopsies displayed signet ring cells.

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.

 

PubMedLinitis plastica denotes a diffuse type of carcinoma which accounts for 3–19% of gastric adenocarcinomas.
Sah BK, Zhu Jg, Chen MM, Yan M, Yin HR, Zhen LY.
Hepatogastroenterology. 2008;55:2259–63.

[PubMed] [Ref list]


For more endoscopic details download the video clips by
clicking on the endoscopic images, wait to be downloaded
complete then press Alt and Enter that you can appreciate
the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.



Endoscopic Image of Linitis Plastica.

Video Endoscopic Sequence 2 of 47.

Endoscopic Image of Linitis Plastica.

General thickening of the tissues and an irregular ulcer in
the posterior wall of the gastric body is noted.

 Linitis Plastica of the stomach is a rare malignancy which involves diffuse proliferation of the connective tissue in the submucosal plane. This leads to subsequent luminal narrowing, gastric wall rigidity, nondistensibility, and hypo peristalsis resulting in a rigid and constricted stomach. Due to the submucosal proliferation of the malignant cells, these tumors are easily missed on esophagogastroduodenoscopy and pose a diagnostic challenge.

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. In 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.


Endoscopic View of Linitis Plastica

Video Endoscopic Sequence 3 of 47.

Endoscopic View of Linitis Plastica

Diffuse nodular thickening of the gastric folds

Linitis plastica may shows very little mucosal lesions on gross appearance. As a rule, since macroscopic features do not often permit the distinction between benign and malignant lesions, multiple endoscopic biopsies are required. However, standard endoscopic biopsy specimens which usually contain only mucosa offer frequently negative results for malignancy. In order to increase the diagnostic yield, the use of a diathermic snare which permits theb obtaining of larger and deeper histologic samples is advised.

This technique has a substantial risk of complications, particularly hemorrhage and perforation. Another possibility is to take multiple forceps biopsies from the same site (endoscopic “forage”).

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 4 of 47.

Endoscopy of Plastic Linitis

The gastric cardias is infiltrated


The most common cause of secondary achalasia is gastric adenocarcinoma with or without esophageal invasion. The diagnosis must be suspected in patients over 50 years, with recent dysphagia and severe weight loss Plastic linitis, a rare form of primary or secondary undifferentiated adenocarcinoma may rarely manifest as pseudoachalasia secondary to massive invasion of the gastric walls and of the cardial area.

In fact, the tumor cells are not easily
detected in frozen sections of the surgical specimens.
Negative findings at endoscopic biopsy or brushing cause
a substantial delay in the diagnosis and treatment of these
tumors; therefore, it is clinically important to diagnosis
scirrhous gastric carcinoma before planning the treatment.


carcinoma with diffuse signet-ring cell.

Video Endoscopic Sequence 5 of 47.

(Hematoxylin-Eosin).

In this sequence of images showing histopathological cell
carcinoma with diffuse signet-ring cell.

Adenocarcinomas are malignant tumors with glandular growth and/or supposed intracellular mucin as identified by periodic acid-Schiff (PAS) positivity. Gastric signet ring cell carcinomas are classified as diffuse type. A proportion of diffuse-type adenocarcinomas have previously been suggested to be of neuroendocrine origin. In the present study we examined gastric signet ring cell carcinomas for neuroendocrine differentiation.


The staging system of metastatic lymph node ratio in gastric carcinoma.
Yu J, Yang D, Wei F, Sui Y, Li H, Shao F, et al.
Hepatogastroenterology. 2008;55:2287–90.

[PubMed] [Ref list]

 

Showing the Signet Ring Cells

Video Endoscopic Sequence 6 of 47.

Alcian blue staining

Showing the Signet Ring Cells

This condition is marked by thickening and Deeper biopsy from the same nodule confirming the presence of independent cells in the submucosa. fibrosis of the gastric wall, the malignant cells being scarcely.

Signet-ring cell carcinoma (SRCC), a unique subtype of mucin-producing adenocarcinoma, can arise from virtually all organs. However, more than 90% of cases of human SRCCs arise from the stomach, breast, and colon. In the breast, most cases of SRCC are infiltrating lobular carcinoma, and a minority of cases are infiltrating ductal carcinoma. Breast SRCC shows a distinctive systemic metastatic pattern. A statistically significant greater frequency of metastatic breast SRCC can be found in the peritoneum, gastrointestinal tract, lung, and gynecologic organs than other cases of breast carcinoma.


Signet Ring

Video Endoscopic Sequence 7 of 47.

Pancytokeratin (AE3/AE1)

It shows undifferentiated malignant epithelial neoplasm infiltrating the lamina propria with Signet Ring Cells confirmed with Alcian blue and cytokeratin.

Intra-abdominal metastases tend to involve the serosal surface, retroperitoneum, gastric mucosa, and ovaries. Gastric SRCC preferentially involves lymph nodes and peritoneal surfaces. Colon SRCC is notorious for its diffuse intramural infiltration, with lymph node involvement and peritoneal surface metastasis. Because SRCCs from other peritoneal organs (such as bladder, ovary, uterus, and prostate) are uncommon, most cases of intraabdominal and intralymphatic SRCC are metastases from the stomach, breast, or colon.


Signet Ring

Video Endoscopic Sequence 8 of 47.

Pancytokeratin (AE3/AE1).

Non-SRCC adenocarcinomas from the breast, stomach, and colon express characteristic patterns of keratins, which commonly are used in the differential diagnosis of metastatic adenocarcinomas from these sites.

 

Linitis Plastica

Video Endoscopic Sequence 9 of 47.

Pancytokeratin (AE3/AE1).

 



Linitis Plastica

Video Endoscopic Sequence 10 of 47.

A folollow up endoscopy (one month later)

Gastric Linitis Plastica: Initial Misdiagnosis is Still Common

Endoscopy display of the same diffuse nodular thickening of the gastric folds.

Due to the controversy of the case in one of the Social Security hospitals in El Salvador, we repeated the endoscopy with multiple biopsies(taken a total of 30 biopsies and send them to three different pathologists with intent to silence mouths). Endoscopy was performed approximately a month after the first and it was obvious that the endoscopic image belonged to a scirrhous carcinoma. We took only two seconds to determine the correct diagnosis at the first endoscopy.



Linitis Plastica

Video Endoscopic Sequence 11 of 47.

Second endoscopy one month after

Note the irregularity with diffuse nodular image through the gastric camera.

Other advice for novice endoscopists suspect

If linitis plastica is suspected, take multiple jumbo biopsies and should take in mind that often biopsies are not sufficient to determine the microscopic level the presence of malignant cells in cases of linitis plastica and in cases in which biopsies are negative should be repeated the endoscopy.


Linitis Plastica

Video Endoscopic Sequence 12 of 47.

A close up in water immersion, which notes the irregular nodular polypoid pattern.

The diagnosis of diffuse type gastric carcinoma is very difficult. The delay of diagnosis is often due to false-negative endoscopic and histologic evaluation.

The differential diagnosis of large gastric folds represents a challenge for the endoscopist and it includes malignancies. (adenocarcinoma, lymphoma) as well as benign conditions (Menetrier’s gastritis, lymphoid hyperplasia and amyloidosis).


Linitis Plastica

Video Endoscopic Sequence 13 of 47.

Another image and video of scirrhous carcinoma

Treatment of gastric linitis without carcinomatosis is based on surgical resection, mainly a total gastrectomy. However, prognosis is poor, leading some surgeons to question the interest of such resection. A chemotherapy is usually offered to the patient, but no guideline has been really established, and results are also variable.

Linitis plastica is a diffuse infiltrative gastric adenocarcinoma. This condition is marked by thickening and Deeper biopsy from the same nodule confirming the presence of independent cells in the submucosa fibrosis of the gastric wall, the malignant cells being scarcely distributed in the fibrous stroma. Frequently the gastric mucosa is spared of malignant invasion, making an endoscopic diagnosis very difficult.

 

 

Linitis Plastica

Video Endoscopic Sequence 14 of 47.

Diffuse nodular thickening of the gastric folds

Linitis plastica is a diffuse infiltrative gastric adenocarcinoma. This condition is marked by thickening and Deeper biopsy from the same nodule confirming the presence of independent cells in the submucosa. fibrosis of the gastric wall, the malignant cells being scarcely distributed in the fibrous stroma. Frequently the gastric mucosa is spared of malignant invasion, making an endoscopic diagnosis very difficult. The most common site of gastric linitis is the antral and pyloric regions (with variable spread proximally towards the gastric body). The fundus is least often involved. Our patient’s main complaint was progressive dysphagia. The pericardial gastric folds viewed in endoscopy were probably associated with local extension of the adenocarcinoma and responsible for the clinical manifestations.

 

Linitis Plastica

Video Endoscopic Sequence 15 of 47.

Endoscopic image of plastic linitis

In this video image shows the ulcer of the gastric cardias observed in the previous endoscopy, see image 4 of 43, however as I said before, the endoscopist in the Social Security hospital had not seen this infiltrative ulceration and also the ulcer seen in the image 2 of 43..

We advise to the novice endoscopist to wash vigorously areas where the mucosa is covered by secretions before omitting an opinion concerning of an endoscopic diagnoses to avoid mistakes.


Linitis Plastica

Video Endoscopic Sequence 16 of 47.

Endoscopy of Plastic Linitis (Scirrhous Carcinoma)

Image and video clip, obtained during endoscopy shows enlarged gastric rugae, with hyperemic change. The stomach was not fully distended, despite air insufflation.

Diffuse nodular thickening of the gastric folds and loss of architecture and space as well.


Linitis Plastica

Video Endoscopic Sequence 17 of 47.

An Endoscopic View in Gastric Linitis

Gastric adenocarcinomas are further subclassified according to their gross appearance (polypoid, fungating, ulcerated, or infiltrative); their histologic features (intestinal or diffuse); and their location within the stomach (cardia, corpus, or antrum). A rare subtype of stomach cancer is scirrhous carcinoma, or linitus plastica, a poorly differentiated mixture of mucin-producing carcinoma cells that infiltrates the muscle wall and turns the stomach tissue rigid and leatherlike, limiting its distensibility.



Linitis Plastica

Video Endoscopic Sequence 18 of 47.

An abdominal CT scan confirmed the thickening of the gastric walls.

Computed tomography scan of the abdomen, both so that we had ordered as social security hospital, had revealed thickening of the gastric layers suggestive of linitis plastica.

The CT scan and the endoscopic ultrasound may be useful for the diagnosis of gastric linitis and also for the evaluation of the local extension. The endoscopic ultrasound aspect of thickened deep layers is considered to be an independent predictive factor of malignancy.

In patients with negative biopsy results on endoscopy, a fine needle biopsy can be performed under echographic, echoendoscopic or CT guidance with a good sensitivity and specificity for the diagnosis of malignancy.

Click on the image to enlarge on a new windows.


Linitis Plastica

Video Endoscopic Sequence 19 of 47.

CT is used preoperatively primarily to determine the stage and extragastric spread of a gastric carcinoma. This information is vital in deciding between palliative surgery and curative radical surgery (ie, identifying patients who would not benefit from radical surgery). Additionally, CT is used to monitor a patient's response to treatment.

Linitis Plastica

Video Endoscopic Sequence 20 of 47.

Detection of gastric carcinoma is improved by using thin-section sequences and helical or multidetector-row CT. When thin collimation is used, near-isotropic imaging of the stomach is possible, allowing high-quality multiplanar reformation and 3-dimensional reconstruction of gastric images. An intravenous contrast medium is used, along with water or gas as a negative intraluminal agent. Prone views improve visualization of tumors of the cardia and distal stomach.

Linitis Plastica

Video Endoscopic Sequence 21 of 47.

Helical scanning allows for a biphasic technique. The early arterial phase is used to assess enhancement of the gastric wall; the later portal venous phase is used to assess the liver parenchyma for metastases.

 

Linitis Plastica

Video Endoscopic Sequence 22 of 47.

Linitis plastica, a scirrhous carcinoma most commonly of gastric origin, is characterized by diffuse infiltration resulting in thickening and stiffening of the gastric wall. Despite improved treatment outcome for other types of gastric carcinoma in Japan, the prognosis in linitis plastica remains extremely poor . In this disease, death often results from peritoneal carcinomatosis, a consequence of dissemination of free cancer cells from the primary lesion. Gross findings indicating peritoneal seeding sometimes are evident at laparotomy. Even when this is not apparent, patients with this disease remain at high risk for peritoneal carcinomatosis.

 

Video Endoscopic Sequence 23 of 47.

Computed tomography of her abdomen revealed diffuse thickening of a portion of the gastric wall.


 


Video Endoscopic Sequence 24 of 47.

An abdominal CT scan confirmed the thickening of the
gastric walls affecting the gastro-esophageal junction, the
gastric body (especially the lesser curvature) and the
gastric antrum. There was no evidence of bowel obstruction
or extrinsic compression.

Click on the image to enlarge on a new windows.

 

Video Endoscopic Sequence 25 of 47.

This study was conducted in one of the social security
hospitals in El Salvador, where there is little distensibility
of the gastric antrum.

Double-contrast barium image obtained in the supine
position shows loss of distensibility with effacement of
folds at the entire body and the antrum. 

Press on the images to enlarge.

 



Video Endoscopic Sequence 26 of 47.

Another image of Rx. Upper Digestive Tract

Scirrhous carcinomas typically cause irregular narrowing
and rigidity of the stomach, giving rise to the typical linitis
plastica, or "leather bottle" appearance. Although some
are lobulated lesions in the fundus or body, others consist
of thickened, irregular mucosal folds and nodularity without
significant narrowing.

Click on the image to enlarge on a new windows.

 



Video Endoscopic Sequence 27 of 47.

 

 

Click on the image to enlarge on a new windows.

Video Endoscopic Sequence 28 of 47.

Image of Plastic Linitis (Scirrhous Carcinoma)

The surgical specimen of total esophago-gastrectomy

Observing the cardia up and down the antrum and pylorus,
the fundus and the the gastric body with nodular infiltrative
pattern.

 

 

Click on the image to enlarge on a new windows.


Video Endoscopic Sequence 29 of 47.

Thickening of the antrum is marked with scissors

In contrast with usual cases of gastric cancers, scirrhous
gastric carcinoma tends to spread over the peritoneum
with rapid growth and early metastasis. Thus, the
prognosis is poor in patients with this disease, and the
5-year survival rate is low. In general, the tumor cells in
patients with scirrhous gastric cancer are located
predominantly in the submucosa and are separated by
large areas of abundant connective tissue. Sometimes
these unique tumor growth patterns make it difficult for
radiologists or endoscopists to detect the tumor with
upper gastrointestinal (UGI) series or endoscopic
examinations.

 

 

 

Video Endoscopic Sequence 30 of 47.

Linitis plastica (scirrhous gastric carcinoma) has a poor
prognosis due to delay in diagnosis. Pathological feature
of this tumor is diffuse fibrosis of the gastric wall.

Detection of small fibrotic lesion in the gastric wall would
contribute to early diagnosis of linitis plastica, since the
primary lesion usually lacks remarkable protrusion or
ulceration.

 

 


Video Endoscopic Sequence 31 of 47.

 Linitis Plastica of the stomach is a rare malignancy which involves diffuse proliferation of the connective tissue in the submucosal plane. This leads to subsequent luminal narrowing, gastric wall rigidity, nondistensibility, and hypo peristalsis resulting in a rigid and constricted stomach. Due to the submucosal proliferation of the malignant cells, these tumors are easily missed on esophagogastroduodenoscopy and pose a diagnostic challenge

Video Endoscopic Sequence 32 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

Marked thickening of the antrum.

 

 

 

Click on the image to enlarge on a new windows.

 

Video Endoscopic Sequence 33 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

Since linitis plastica often involves the entire stomach,
total gastrectomy is usually performed. Indications for
radical resection therefore should be carefully weighed
against potential complications of major surgery. Ideally,
such resection should be performed only for patients with
a chance of cure.

 

 

 

Click on the image to enlarge on a new windows.

Video Endoscopic Sequence 34 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

The macroscopic appearance of advanced gastric
carcinoma varies and was classified by Borrmann as
fungating (type I), excavated (type II), ulcerated and
infiltrating (type III), and diffusely thickened or scirrhous
(type IV). Type IV carcinoma, or scirrhous gastric
carcinoma, represents diffuse infiltrating
adenocarcinoma—which is predominantly poorly
differentiated and shows no circumscribed lesion.
When the entire stomach wall is involved with type IV
gastric carcinoma, the condition is called linitis plastica .

 

Video Endoscopic Sequence 35 of 47.

Total gastrectomy was successfully performed.

A diagnosis of linitis plastic type of schirrhus carcinoma of the stomach was made.

 

 

 

Click on the image to enlarge on a new windows.

Video Endoscopic Sequence 36 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

The hands are taken the pre-pyloric area.



Video Endoscopic Sequence 37 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

Thickened & rigid of gastric walls, with or without mucosal ulceration.

 

Video Endoscopic Sequence 38 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

Nodular pattern and fibrinoid infiltration are displayed



Video Endoscopic Sequence 39 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

 

Video Endoscopic Sequence 40 of 47.

 

Video Endoscopic Sequence 41 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

 

Video Endoscopic Sequence 42 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

 

 

 

 

 

Click on the image to enlarge on a new windows.

Video Endoscopic Sequence 43 of 47.

Macroscopic Specimen of Plastic Linitis (Scirrhous Carcinoma)

Diffuse thickening and rigidity of the gastric wall.

 

 

 

Click on the image to enlarge on a new windows.


Video Endoscopic Sequence 44 of 47.

This photograph clearly shows the invasion of the muscular layer with signet ring cells.


Video Endoscopic Sequence 45 of 47.

This photograph shows invasion of signet ring cells in the muscularis and a blood vessel.

 

Video Endoscopic Sequence 46 of 47.

Endoscopy of Status after the Total Gastrectomy

Five months after the surgery the status posterior of
Esophagus-Total-Gastrectomy is observed, in the
video clip are seen some rest of surgical staples and the
jejuno Multiple biopsies were taken and no evidence
macroscopic tumor recurrence at the time.


Video Endoscopic Sequence 47 of 47.

Endoscopic Image of Linitis Plastica

More images and video clip after the surgery.

 

Video Endoscopic Sequence 1 of 15.

Scirrhous Gastric Carcinoma (Linitis Plastica).

An 80 year-old female with satiety and weight loss.

The image and the video clip shows diffuse infiltrating adenocarcinoma with signet-ring cells.

Gastric linitis plastica is a very particular malignant gastric tumor different from the usual gastric adenocarcinoma. Linitis plastica refers to the diffuse proliferation of the connective tissue, resulting in tissue thickening so that the stomach is constricted and rigid. Pathological exams reported a strong connective stroma-reaction associated with a malignant glandular proliferation of independent cells (signet-ring cells), invading all the layers of the digestive tract, the mucosa being usually save not affected.

In spite of well-defined diagnostic criteria in endoscopy and radiology, gastric linitis plastica often presents a diagnostic problem. Due to a unique pattern of infiltration, histological proof of cancer is difficult to achieve and depends upon immunohistological staining. 


Video Endoscopic Sequence 2 of 15.

Linitis Plastica.

The posterior wall of the stomach is infiltrating from the
antrum to the fundus.

The term ”Linitis Plastica” refers to a scirrhous form of
carcinoma that spreads predominantly in the submucosa,
eliciting a marked desmoplastic response in the gastric
wall.
They classically arise in the antrum and infiltrate towards
the fundus. 

Diagnosis is based on the association of pathological
results findings revealed by endoscopic, endoscopic
ultrasonography, radiological and surgical examinations.



Video Endoscopic Sequence 3 of 15.

Endoscopic Image of Linitis Plastica

Indigo Carmine Stain.

The diffuse type of gastric cancer often manifests itself as
a linitis plastica. It is harder to diagnose than the intestinal
type, particularly in the earlier stages. Thus, although
diagnostic techniques have improved, some gastric cancers
are still missed on the initial investigation.

Scirrhous carcinoma (linitis plastica) is a poorly
differentiated mixture of mucin-producing carcinoma cells
that infiltrates the muscle wall and turns it into rigid,
leatherlike scar tissue that cannot stretch or move during
the normal digestive process (peristalsis).


Video Endoscopic Sequence 4 of 15.

This image shows the contrast between normal folds and infiltrating adenocarcinoma.

Findings suggest that the difficulty of detection and the rapid growth of this tumor may explain why it is seldom detected at an early stage and has a very poor prognosis.

Opposed to the adenocarcinoma, Helicobacter Pylori
seems not to be associated with the occurrence of gastric
linitis.

Familial forms of gastric linitis and
breast cancer-associated forms have been reported.

 




Video Endoscopic Sequence 5 of 15.

Endoscopic Image of Linitis Plastica

High Magnification Endoscopy.

You can observe a close up of the malign nodules.

Tumor mass of the stomach from patients with scirrhous.
carcinoma was analyzed biochemically and
immunohistochemically to elucidate whether or not
infiltrating carcinoma cells are directly responsible for
overproductions of collagen in the lesion. Collagen content
per unit transverse section of the tumor was two to four
times higher than the normal. Of particular interest was
that the contents of hyaluronic acid and chondroitin sulfate
were five to ten times higher than the normal, suggesting
that cells in the lesion of the tumor are in an actively
proliferating stage.


Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 6 of 15.

Endoscopic Image of Linitis Plastica

Chromoendoscopy using methylene blue.

Chromoendoscopy involves the topical application of stains
or dyes to improve mucosal visualization during endoscopy.
stain.

Although collagen synthesis is increased in gastric
carcinoma tissues irrespective of the amount of the stroma,
it is suggested that decreased collagenase activities and
increased expression of TIMP-1 would result in collagen
deposition in scirrhous gastric carcinoma tissue and the
response might actually benefit the invasion of tumor cells.

 

Endoscopic Image of Linitis Plastica

ideo Endoscopic Sequence 7 of 15.

Endoscopic Image of Linitis Plastica

Lugol´s Stain.

Chromoendoscopy involves the application of vital dyes
that enhance the visibility of abnormal tissues.

Intestinal-type carcinoma is common in old men, whereas diffuse-type carcinoma is comparatively frequent in young women.

Diffuse-type carcinoma with worse prognosis is more malignant than its intestinal-type counterpart, with early invasion into the muscularis propria and the lymphatic vessel, and frequent metastasis to the lymph node.

Compared with diffuse-type carcinoma, intestinal-type carcinoma exhibits high levels of proliferation and apoptosis, which are closely linked to high expression of fragile histine triad, phosphatase and tensin homology deleted from human chromosome 10, and mutant p53.

Extracellular matrix metalloproteinase inducer (EMMPRIN) is more frequently expressed in the intestinal-type carcinoma than diffuse-type lesion, and is used as a good marker to differentiate between both kinds of carcinomas. Higher EMMPRIN expression in intestinal-type gastric carcinomas underlies the molecular basis of their higher proliferation.


Endosonography

Video Endoscopic Sequence 8 of 15.

Endosonography of Image of Linitis Plastica

The endosonography can clearly visualize the architecture
of the stomach. This make it possible to find destruction
of the gastric layers.
In infiltrating gastric cancer there are typical
endosonographic pictures. The layers are visualized, but
there are larger and with irregular contour.
Especially the submucosa and muscularis are concentrically
enlarged.

 

Endosonography

Video Endoscopic Sequence 9 of 15.

Endosonography of Linitis Plastica

Characteristic features of scirrhous carcinoma included an
irregular hypoechoic enlargement of the third (submucosa)
and fourth (muscularis propria) layers.

As many linitis plastica-type adenocarcinomas are
submucosal lesions, mucosal sampling by biopsy may yield
nondiagnostic material in up to one third of cases. With its
ability to sample deep submucosal lesions, EUS-FNA is an
appropriate technique for establishing this diagnosis and
guiding patient treatment.

 

Endosonography

Video Endoscopic Sequence 10 of 15.

Endosonography of Image of Linitis Plastica

The diagnosis of diffuse type gastric carcinoma is very
difficult. The delay of diagnosis is often due to
false-negative endoscopic and histologic evaluation. The
architecture of the stomach can be clearly visualized by
endosonography. Therefore, already minor destructions of
the gastric layers can be found. The endosonographic
picture includes the presence of the layers, which are larger
and of irregular contour. In infiltrating gastric cancer
typically the submucosal layer and the muscularis are
concentrically enlarged and appear folded.

Advanced gastric cancer. EUS staging helps assess the
resectability and prognosis of advanced gastric cancer.
EUS is more accuracy than CT in the T staging
(92% vs 48 %). This has recently become more
importan as neo-adjuvant therapy is now the standard of
care for patients with locally advanced gastric cancer
CT, is the best method to detect distant metastases,
as part of standard evalution of gastric cancer.


Computed Tomography (CT) Scan of Linitis Plastica

Video Endoscopic Sequence 11 of 15.

Computed Tomography (CT) Scan of Linitis Plastica

Note the difuse mural thickening of the gastric camera due to a infiltrating tumor.

Scirrhous carcinomas showed both a thick outer layer and
a thick inner layer, whereas non-scirrhous carcinomas did
not have appearance. This classification can serve as a
guideline for predicting scirrhous carcinoma on the basis of
CT findings.

 

Computed Tomography (CT) Scan of Linitis Plastica

Video Endoscopic Sequence 12 of 15.

Computed Tomography (CT) Scan of Linitis Plastica

Note the liver metastasis.

CT is an important complimentary imaging technique to
detect scirrhous carcinoma. The sensitivity of detection
depends on the size of the lesion and the quality of the
examination. CT has limitations in staging early lesions but
shows a high sensitivity (89%) in detecting avanced
carcinomas.



Computed Tomography (CT) Scan of Linitis Plastica

Video Endoscopic Sequence 13 of 15.

Computed Tomography (CT) Scan of Linitis Plastica

 

leather-bottle stomach

Video Endoscopic Sequence 14 of 15.

"leather-bottle stomach".

The radiological study of the patient.

While the radiological features are not diagnostic, they
are, in many cases, suggestive of this entity.

 

Endoscopic Image of Linitis Plastica Cells of the

Video Endoscopic Sequence 15 of 15.

Cells of the "Signet Ring" type.

After multiple histologic sections it was found between the
muscularis mucosa a small group of epithelial cells of the
"Signet Ring" type.



Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 1 of 15.

Scirrhous Gastric Carcinoma (Linitis Plastica).

This 16 year-old female, two months previously initiates
with abdominal pain, abdominal discomfort, nauseas,
vomiting, early diminished appetite, satiety and weight loss.

One year and a half we found that her grandmother had a gastric carcinoma.

Perhaps this patient is one of youngest one that has
suffered from gastric cancer in medical Literature.

 

Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 2 of 15.

Endoscopic Image of Linitis Plastica

In this video endoscopic sequence shows extensive
infiltration of this neoplasia from the gastric antrum to the
fundus and gastric cardias.

Gastric cancer is uncommon in the young. Occasional
reports are found in the literature.
Anaplastic infiltrative adenocarcinoma of the linitis plastica
morphologic type is rare in adolescents.

 

Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 3 of 15.

Endoscopic Image of Linitis Plastica

Scirrhous tumors metastasize early, grow quickly, and
spread over the peritoneum. Prognosis is poor. Tumor cells
are in the submucosa and are separated by abundant
connective tissue. It can be difficult to diagnosis with UGI
or endoscopy.

The prognosis of patients with scirrhous gastric cancer
(SGC) is extremely poor. However, recent advances in
therapeutic strategies against SGC, using effective
anticancer drugs, have prolonged the survival of patients
with SGC.



Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 4 of 15.

Endoscopic Image of Linitis Plastica

Endoscopy is 95% to 98% sensitive in diagnosing gastric
cancer when performed along with biopsy. It has much
lower sensitivity in diagnosing linitis plastica because the
tumor is in the submucosa and the overlying mucosa is
normal. Scirrhous tumors are also difficult to diagnose
because tumor cells are spread within a dense fibrous
matrix and are far apart. Preoperative diagnosis is
important.

Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 5 of 15.

Endoscopic Image of Linitis Plastica.

Endoscopically found to show insufficient stretching of the
gastric wall, thickening and tortuosity of folds, uneven
gastric mucosa, redness and white coating, there may be
negative in gastric biopsy.


Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 6 of 15.

Endoscopic Image of Linitis Plastica

Linitis plastica(scirrhous gastric carcinoma)is characterized
by an abundant deposition of extracellular matrix
components and has a very poor prognosis.Altered
synthesis of extracellular matrix components as well as
degradation by proteolytic enzymes contribute equally to
the formation of the tumor stroma, which would affect
various cell functions and in finally, determine the biologic
behavior of the tumor.Although little is known about the
underlying mechanisms and the significance of
desmoplasia, overexpression of extracellular matrix
components mainly by host cells, in the development of
linitis plastica, the phenomenon has a similarity with
pathological conditions such as fibrosis of the lungs and
liver.

Currently known stromal changes in linitis plastica,
focusing on extracellular macromolecules, proteolytic
enzymes, and growth factors modulating the process of
physiological tissue remodeling.

 

Endoscopic Image of Linitis Plastica

Video Endoscopic Sequence 7 of 15.

Endoscopic Image of Linitis Plastica

With difficulty it is performed the retroflexión maneuver

In the image and the video clip, it is observed the infiltration of the cardia and fundus.

Linitis plastica, a diffuse infiltrative gastric
adenocarcinoma which gives the stomach a shrunken
"leather bottle" appearance with extensive mucosal
erosion and a markedly thickened gastric wall. This type
of carcinoma has a very poor prognosis.

 

16 year-old female with Scirrhous Gastric Carcinoma

Video Endoscopic Sequence 8 of 15.

16 year-old female with Scirrhous Gastric Carcinoma (Linitis Plastica) and ascites.

This picture shows the abdomen with ascites.


16 year-old female with Scirrhous Gastric Carcinoma

Video Endoscopic Sequence 9 of 15.

Lateral Image.

The word ascites is of Greek origin (askos) and means bag or sac. Ascites describes the condition of pathologic fluid accumulation within the abdominal cavity.

 

16 year-old female with Scirrhous Gastric Carcinoma

Video Endoscopic Sequence 10 of 15.

16 year-old female with Scirrhous Gastric Carcinoma (Linitis Plastica) and ascites

 

Linitis plastica

Video Endoscopic Sequence 11 of 15.

16 year-old female with Scirrhous Gastric Carcinoma (Linitis Plastica) and ascites

Linitis plastica

To enlarge the image press on it



The walls of the stomach appeared thickened, and the
stomach distended poorly. Biopsies confirmed the
suspicion of diffusely infiltrating, poorly differentiated
adenocarcinoma with signet-ring cells.

Video Endoscopic Sequence 12 of 15.


The walls of the stomach appeared thickened, and the
stomach distended poorly. Biopsies confirmed the
suspicion of diffusely infiltrating, poorly differentiated
adenocarcinoma with signet-ring cells.

Poorly differentiated
adenocarcinoma with signet-ring cells

Video Endoscopic Sequence 13 of 15.

Poorly differentiated
adenocarcinoma with signet-ring cells.

Histologically, gastric cancers can be separated into 2
main patterns: the intestinal (expanding) type and the
diffuse (infiltrative) type, according to the Lauren
classification system The intestinal type is characterized
by the presence of distinct glands comprising
well-differentiated columnar epithelial cells. In contrast,
the diffuse type contains poorly organized mucin-rich
(signet ring) cells. If a large proportion of the stomach is
occupied by the diffuse type lesion, the phenomenon of
linitus plastica or "leather bottle stomach" may result.
Chronic atrophic gastritis (Type B gastritis) secondary to
H pylori infection generally predisposes to the intestinal
type of gastric cancer, which is more common in high
prevalence regions such as Japan and Far East Asia. The
diffuse type, on the other hand, usually occurs in areas
with a low incidence of disease, such as the United States.

Poorly differentiated
adenocarcinoma with signet-ring cells

Video Endoscopic Sequence 14 of 15.

Poorly differentiated
adenocarcinoma with signet-ring cells.


Signet-ring-like cells with intracytoplasmic mucin pooling and pushing the nuclei to the periphery

Video Endoscopic Sequence 15 of 15.

Signet-ring-like cells with intracytoplasmic mucin pooling and pushing the nuclei to the periphery.



Bilateral Krukenberg´s Tumor

Video Endoscopic Sequence 1 of 2.

Bilateral Krukenberg´s Tumor

A 47 year--old, female nurse, with extensive infiltration of
gastric adenocarcinoma, she had bilateral Krukenberg´s
Tumor.

For more details of this case see ovaries specimen and
macroscopic appearance of her stomach click here.

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 2 of 2.

Endoscopy of Plastic Linitis

The adenocarcinoma is seen in retroflexed maneuver.
She had been suffering of many inspecific symptoms, for a
long period of time, such as abdominal pain and weight
loss.
At the time that she asked for help in our clinic, she had
already many different medical procedures, such as an
upper endoscopy and colonoscopy that were negatives,
4 moths before.
The upper endoscopy practiced before was reported as an
erosive gastritis and biopsies only confirmed gastritis.
That endoscopy was practiced elsewhere.

To see ovaries specimen and macroscopic appearance of
her stomach click here.



Hereditary diffuse gastric cancer

Video Endoscopic Sequence 1 of 4.

Hereditary diffuse gastric (stomach) cancer (HDGC).

Diffusely infiltrating poorly differentiated adenocarcinoma.

A 36 year old man, who presented a weight loss more than
25 pounds, anorexia, early satiety, and severe abdominal
pain. We found that his maternal grand father suffered a
gastric carcinoma in 1991.
His maternal grand mother died because of a gastric
cancer many years ago.
His maternal uncle had gastric adenocarcinoma detected in
may 2000.
See case above described. 
Gastric Cancer in young patient is more likely to be of the
diffuse type and associated with a poorer prognosis. 

 

 

Bronchoscopyxz1

Video Endoscopic Sequence 2 of 4.

Hereditary Diffuse Gastric Cancer

The Cardias is infiltrated.

On a case on diffusely infiltrating poorly differentiated
adenocarcinoma.

 



Hereditary Diffuse Gastric Cancer

Video Endoscopic Sequence 3 of 4

Hereditary Diffuse Gastric Cancer

The image and video clip display extensive infiltration of
the body and the antrum.

The differential diagnosis of large gastric folds represents
a challenge for the endoscopist and it includes malignancies
(adenocarcinoma, lymphoma) as well as benign conditions
(Menetrier’s gastritis, lymphoid hyperplasia and
amyloidosis).


 


Hereditary Diffuse Gastric Cancer

Video Endoscopic Sequence 4 of 4.

Endoscopy of Plastic Linitis


Some ulcerated nodules are appreciated at the antrum.

Those cases presented here of that member of this family
has the Hereditary diffuse gastric (stomach) cancer
(HDGC) is a genetic cancer susceptibility syndrome
characterized by a high risk for stomach and lobular breast
cancer. HDGC is inherited in an autosomal dominant
pattern, therefore several generations of relatives with
stomach or lobular breast cancer are often seen clustering
on one side of the family. Gastric cancers that occur in this
syndrome are of the “diffuse” type (as opposed to
“intestinal”) and often have “signet ring” cells through the
stomach wall causing thickening (“linitis plastica”) without
forming a discrete mass. The average age of onset of
gastric cancer in HDGC is 38 years old, with individuals as
young as 14 having been diagnosed. The estimated lifetime
risk of developing gastric cancer by age 80 is 67% for men
and 83% for women. Women with HDGC also have an
elevated risk of breast cancer, predominantly of the lobular
type, with a 20 – 40% lifetime risk. Most of these women
are over 50 at diagnosis.

 


Early Gastric Carcinoma with gastric carcinoma of the signet ring cell type

Video Endoscopic Sequence 1 of 3.

Early Gastric Carcinoma with gastric carcinoma of the signet ring cell type (Plastic Linitis).

A 43-year old man with a lesion that can only seen in
retroflexed maneuver, because of the antrum wall showed
some rigidity due to an early gastric carcinoma Type III. underwent subtotal gastrectomy


The image and video display some typical parameters of
criteria of a malign ulcer.

1. Fold tapering
2. Ulcer
3. Fusion of folds
4. Abrupt termination of fold
5. Discoloration
6. Depressed mucosal surface
7. Bulbous enlargement.

 

 

 

 


 


Early Gastric Carcinoma with gastric carcinoma of the signet ring cell type

Video Endoscopic Sequence 2 of 3.

Relatively small size linitis plastica of the stomach

Linitis plastica (scirrhous gastric carcinoma) has a poor
prognosis due to delay in diagnosis. Pathological feature of
this tumor is diffuse fibrosis of the gastric wall. Detection
of small fibrotic lesion in the gastric wall would contribute
to early diagnosis of linitis plastica, since the primary
lesion usually lacks remarkable protrusion or ulceration.

Early Gastric Cancer, type III typical abrupt and irregular
termination of gastric folds at the ulcer margin.
Early Gastric Cancer is defined as limited to the mucosa
and or submucosa.
Metastasis to regional lymph nodes and even to distant
organs may already exist at this stage.
More than 90 per cent of gastric cancer patients complain
of one or several abdominal symptoms. The symptoms are
nonspecific disease entity and the patient should be
evaluated with an upper endoscopy mass screening should
be done in countries of a high incidence such as the
republic of El Salvador.














Early Gastric Carcinoma with gastric carcinoma of the signet ring cell type1

Video Endoscopic Sequence 3 of 3.

Endoscopy of Plastic Linitis

Patient delayed the surgery for more than 7 months. Thecarcinoma was then found in an early phase. Theendoscopic image and video display this gastriccarcinoma after more than 7 months of the first endoscopy. (This endoscopy was taken after 7 months ofthe previous one see the previous video clips 1 of 3 and 2of 3.) Patient underwent a subtotal gastrectomy, is free of symptoms 13 years after.

Signet ring cell carcinoma is a poorly differentiatedadenocarcinoma in which the tumour cells invade singly orin small groups. Early stages of the disease can be missedeasily when using regular haematoxylin and eosin staining.

14 years later the patient is in excellent condition

 

 

 

 

 

 


 

 


Endoscopy of Plastic Linitis

Endoscopy of Plastic Linitis

This 68 year-old male, initiates with
abdominal pain, abdominal discomfort, nauseas, vomiting,
early diminished appetite, satiety and weight loss.

Gastric Adenocarcinoma that has an erosive appearance.
The histopathologic study revealed signet ring cells.

In order to increase the diagnostic yield, the use of a
diathermic snare which permits the obtaining of larger and
deeper histologic samples is advised. This technique has a
substantial risk of complications, particularly hemorrhage
and perforation. Another possibility is to take multiple
forceps biopsies from the same site: endoscopic “forage”.

 

 


Endoscopy of Plastic Linitis

Linitis Plastica.

A 27 year-old man, with weight loss more than 30
pounds, early satiety, apathy, anorexia and vomiting.
The walls of the stomach appeared thickened, the stomach
distended poorly.
Infiltrating adenocarcinoma of the diffuse type with
signet-ring cells was found.

biopsy proved to be a poorly differentiated adenocarcinoma
, signet ring cell type.

Gastric Cancer in young patient is more likely to be of
the diffuse type and associated with poorer prognosis.

 

Endoscopic Image of Linitis Plastica Hereditary Diffuse Gastric Cancer

Hereditary diffuse gastric (stomach) cancer (HDGC).

Extensive Gastric Adenocarcinoma

A 39 year-old man, who was under medical control in a
national institution for more than 4 years because of
epigastric discomfort, but no upper endoscopy was
perform.
When he asked for help in our clinic he had already lost
a weight of 20 pounds.
We performed an upper endoscopy and an advanced
adenocarcinoma was found. It infiltrated the antrum,
body and the fundus along of the minor curvature.
We detected a gastric adenocarcinoma to his father
1991 at the antrum.
His father died 10 years later at age 85, but for a different
disease.
His mother died of gastric cancer many years ago.
We found two nephew had Advanced Gastric Carcinoma
recently. See the sequences below one case of them is not
published here because we have not found the video yet.
Several member of that family had die of breast cancer.

 

 

 

 

 

 

Endoscopy of Plastic Linitis

 Video Endoscopic Sequence 1 of 3.

Endoscopy of Plastic Linitis

This 78 year-old female, underwent screening endoscopy
due to liver metastases of unknown origin. She previously
underwent a upper endoscopy in a public hospital and was
apparently negative for malignant findings.

The biopsies displayed a gastric adenocarcinoma with
Signet Ring Cell type of the antrum and body. The biopsies
of the fundus were negative.

 



Endoscopy of Plastic Linitis1

Video Endoscopic Sequence 2 of 3.

Endoscopy of Plastic Linitis

The gastric folders are observed with diffuse redness resemble a severe acute gastritis but they are also infiltrated with adenocarcinoma.

Signet Ring Cell Type

Linitis plastica is a gross descriptive term, which can refer
to a signet ring cell and or diffuse carcinoma within the
wall of the stomach.

Infiltrating carcinomas cause a leather bottle stomach as a
result of spreading widely beneath the stomach mucosa
and invading the muscular wall. This pattern of 'growth'
causes thickening and stiffening of the stomach wall. As a
result the stomach also has a reduced capacity. The
resultant stiff-walled, smaller capacity stomach is much
akin to a leather bottle.

Linitis Plastica of the stomach is considered a rare type of malignancy probably because of its under diagnosis. The submucosal location of malignant cells makes it a diagnostic challenge. When diagnosed, the tumor usually has reached a late stage predisposing to its poor prognosis. Physicians should have a high index of suspicion for this type of tumor in patients with unremitting upper gastrointestinal symptoms who do not respond to treatment and who have negative biopsy results for malignancy.

 



Endoscopy of Plastic Linitis

Video Endoscopic Sequence 3 of 3.

Endoscopy of Plastic Linitis

Chromatoscopy with lugol´s stain.

A leather bottle stomach - linitis plastica - describes a
stomach that has a gastric carcinoma which is
morphologically an infiltrating carcinoma.

Linitis plastica may show very little mucosal lesions on
gross appearance. As a rule, since macroscopic features do
not often permit the distinction between benign and
malignant lesions, multiple endoscopic biopsies are
required. However, standard endoscopic biopsy specimens
which usually contain only mucosa offer frequently
negative results for malignancy.

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 1 of 9.

Scirrhous Gastric Carcinoma (Linitis Plastica).

This 75 year-old male, had an endoscopy a week earlier
by a colleague on which describes according the endoscopic
report that there was a reflux esophagitis and a hiatal
hernia of large size, having aspirate 500 cc. of foul smelling
dark liquid, biopsies taken from an ulceration of the
gastroesophageal junction were negative for malignancy
but not described lesions of the corpus or antrum, the
diagnosis was not conclusive..

looking for a second opinion we performed a second
endoscopy which found this videos and images displayed
here.

In the video clip here displayed, there are esophagitis but
caused by the vomits due to the obstructive syndrome.

In fact as it is seen in this video there are esophagitis but it
comes from obstructive syndrome and as you can observe
a big hiatus hernia, described in previous endoscopic
report, it appears that endoscopist did not advance the
endoscope due to abundant obstructive liquid our biopsies
confirmed the diagnosis of neoplasia with signet ring cells.

In the computer axial tomography CT scan there are
diffuse thickening of the walls of the stomach and not
metastasis observed .

 

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 2 of 9.

Scirrhous Gastric Carcinoma (Linitis Plastica).

After aspirated a plenty of fluids due to stasis it is observed
injuries consistent with infiltration by diffuse type
malignant neoplasm with a typical nodular scirrhous
carcinoma.

The most common site of gastric linitis is the antral and
pyloric regions (with variable spread proximally towards
the gastric body). The fundus is least often involved.


Endoscopy of Plastic Linitis

Video Endoscopic Sequence 3 of 9.

Endoscopy of Scirrhous Gastric Carcinoma (Linitis Plastica).

It is observed extensive infiltration of the body and gastric
antrum which causes a pseudo obstruction.



Endoscopy of Plastic Linitis

Video Endoscopic Sequence 4 of 9.

Endoscopy of Plastic Linitis

Extensive nodular infiltration of body and antrum.

There was marked thickening of the gastric mucosal folds,
which were difficult to distend with subsequent luminal
narrowing and gastric wall rigidity. Some gastric folds were
enlargedand some parts of the mucosa had a mosaic
pattern and a “leopard skin” aspect (photos) with localized
nodular carmine-red lesions (photos). In the antral region
the rigidity of the gastric walls and the enlarged folds gave
a stenotic aspect with difficult passage of the pylorus.


Endoscopy of Plastic Linitis

Video Endoscopic Sequence 5 of 9.

Endoscopy of Plastic Linitis

Diffuse thickening is observed at the junction of the body and gastric fundus.

 

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 6 of 9.

Endoscopy of Plastic Linitis

Stricture of the antrum due to a tumoral infiltration

It is observed decrease in the size of the antrum due to malignancy.

The tumor had infiltrated from the junction of body with the fundus to the pre-pyloric antrum.


Computed Tomography (CT) Scan of Plastic Linitis

Video Endoscopic Sequence 7 of 9.

Abdominal CT scan confirmed the thickening of the gastric walls

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.

 

 

Computed Tomography (CT) Scan of Plastic Linitis

Video Endoscopic Sequence 8 of 9.

Linitis plastica denotes a diffuse type of carcinoma which accounts for 3–19% of gastric adenocarcinomas. It is characterised by a rigidity of a major portion, or all of the stomach, with the absence of a filling defect or extensive ulceration. Gastric carcinoma is notorious for its failure to cause early symptoms so that patients do not present themselves for diagnosis until late in the course of the disease. Because of the rich lymphatic supply, the cancer rapidly disseminates beyond the reach of surgical resection. Consequently, the patients with symptoms generally have far-advanced malignancy.

Computed Tomography (CT) Scan of Plastic Linitis

Video Endoscopic Sequence 9 of 9.

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. Some authors have proposed using more radical multimodality treatments such as systemic and/or intraperitoneal chemotherapy in addition to radical surgery, whereas others suggest that these patients should be treated with primary chemotherapy even in the absence of unfavourable parameters, as the overall survival rate has been reported to be low in patients undergoing curative surgery. 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.

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 1 of 4.

Endoscopy of Plastic Linitis

This 70 year-old female who presented with weight loss
over 30 lbs, the abdominal ultrasonography shows
moderate ascites and enlarged of periaortic lymph nodes,
the gastric wall were seen thickened.

 

 

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 2 of 4.

Endoscopy of metastasis of plastic linitis to de duodenum

This video clips shows metastasis to the first and second part of the duodenum, confirmed by biopsies.

 

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 3 of 4.

Endoscopy of Plastic Linitis

The gastric fundus is infiltrated showing diffuse thickening of the wall and the gastric cardias.

 

 

 

Endoscopy of Plastic Linitis

Video Endoscopic Sequence 4 of 4.

Endoscopy of Plastic Linitis

In the gastric body, the folds are observed quite thickened

 

 

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