Secondary rectal linitis plastica as first manifestation of urinary bladder carcinoma
A 68-year-old man presented to the Department of Endoscopy with a six-month history of anal outlet obstruction, constipation and tenesmus. The patient had no relevant past medical history. Digital examination revealed a circumferential rectal narrowing with a firm, mass-like area, palpable all around the rectal wall and extending to a few centimeters of the anal margin. Laboratory tests, including urinalysis, were unremarkable. Subsequent endoscopy demonstrated a narrow distal rectum, with the overlying mucosa being indurated, non-ulcerated, with a cobblestone appearance (). Several biopsies and fine-needle aspiration were taken, but none was conclusive for diagnosis. T2-weighted MRI showed a double-layered thickening of the rectal wall with an inner iso-intense circumferential thickening of the submucosa and outer hypo-intense circumferential thickening of the muscular rectal wall, as well as a thickened bladder wall. Transrectal ultrasonography showed circumferential infiltration of the submucosa, whereas the other layers were normal (); an image compatible with “linitis plastica”. The patient underwent rectal extirpation and total cystectomy with lymph node dissection. Macroscopic examination of a sagittal section of resected rectum demonstrated an expanded submucosal layer due to infiltration with cancer cells, with intact mucosa and muscular layer (). Histological examination of the resected bladder showed a grade III papillary transitional cell carcinoma. In the rectum clusters of tumor cells of a poorly differentiated adenocarcinoma were observed. Immunostaining was positive for both CK7 and CK20; PSA was negative. Combining the cytokeratine profile histology and transrectal ultrasonography findings, the diagnosis of a primary urinary bladder tumor with hematogenous spread to rectal submucosal layer was established.\nThe patient received postoperative radiation followed by gemcitabine (100 g/m2 on days 1, 8, 15) and cisplatin (70 mg/ m2 on day 2) for a 28-day cycle for six months, but he died eight months later due to disseminated peritoneal carcinomatosis.