Radiology

Case of the Month

Radiological Findings

Discussion

A 25-year-old female patient presented with history of vomiting, pain in the abdomen, backache and painful micturation since one month. The patient was a known hypertensive since one year and has been on antihypertensive medication.

The physical examination of the patient was unremarkable.

Routine laboratory tests were within the normal limits.

 

RADIOLOGICAL FINDINGS:

Ultrasound:

Gray scale ultrasound examination of the abdomen revealed bulky ovaries bilaterally with multiple cystic lesions. Colour Doppler examination revealed increased vascularity in both ovaries. In addition, bilateral hydronephrosis and hydroureter with with D-J stents in situ was also seen.

There was no evidence of renal or ureteric calculi. Moderate ascites was noted.

Small bowel study with barium:

Fig. 1a	Fig: 1b

 

The barium study revealed delayed gastric emptying and non distensibility of the antrum and pylorus.

Fig.2a	Fig. 2b
Fig. 2c	Fig: 2d
Fig: 2e

Plain axial CT of the abdomen and with oral contrast reveals a long segment concentric thickening of stomach in the region of the antrum and the pylorus.

Mildly bulky ovaries were noted.

Contrast enhanced CT abdomen, 5 mm cuts

Fig. 3a	Fig. 3b
Fig. 3c	Fig. 3d

A long segment concentric thickening noted in region of antrum and pylorus.

Enlarged lymph nodes in the prevascular space, left internal mammary groups, in the celiac and mesenteric region, retroperitoneal region ranging from 1-2 cm. in diameter showing homogenous enhancement were seen on contrast enhanced studies. The lymph nodes engulfed the ureter bilaterally with resultant hydronephrosis and hydroureter.

Mesenteric vessels and right renal vessels were encased by lymph node with faint delayed nephrogram on the right side. T here was moderate ascites with thickening and cocooning of omentum

A radiological diagnosis of Carcinoma of the gastric antrum with metastasis to lymph nodes, omentum, peritoneum and pleura was made.

After review of both barium meal follow-through and CT scan upper GI scopy was advised which revealed thickening in region of antrum from which biopsy had been taken.

Histopthology:

Fig. 4

H & E Stain of antral mucosa reveals multiple grey white soft tissue bit aggregating to 0.7x0.4x0.2 cm, submitted entirely s/o signet ring adenocarcinoma.

DIAGNOSIS:

Signet ring cell adenocarcinoma of antrum and pylorus with peritoneal, lymphnodes and ovarian (krukenberg tumour) metastasis.

 

DISCUSSION:

Signet ring cell carcinoma is an epithelial malignancy characterized by the histologic appearance of signet ring cell.It is a form of an adenocarcinoma.

Signet ring cell cancer is thought to arise in mucosa that is not metaplastic and is typically confined to the glandular region in a proliferating zone. Signet ring cells are most frequently associated with stomach cancer but can arise from any number of tissues including the prostate,bladder,gall bladder

Though gastric carcinomas are more common in male than female and in elderly, signet ring cell carcinomas are more common in female than male and in younger age group.

Depending upon the stage of the disease, treatment includes surgery, chemo and radiotherapy. – singly or in combination. Combination of surgery,chemotherapy and radiotherapy can also be used.

A significant number of signet ring cells, generally, are associated with a worse prognosis.