Elsevier

Clinical Imaging

Volume 37, Issue 4, July–August 2013, Pages 794-797
Clinical Imaging

Case Report
Computed tomography enterography and 18F-FDG PET/CT features of primary signet ring cell carcinoma of the small bowel in a patient with Crohn's disease

https://doi.org/10.1016/j.clinimag.2013.02.010Get rights and content

Abstract

We report a case of a primary signet ring cell carcinoma (PSRCC) of the small bowel in a patient with long-standing Crohn's disease, describing computed tomography (CT)-enterography (CTE) and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT features of this rare tumor. CTE demonstrated submucosal thickening of a long ileal segment with preserved mural stratification. PET/CT examination showed increased 18F-FDG uptake in the affected ileal loop, hypermetabolic abdominal and mediastinal lymphadenopathies, and multiple hypermetabolic bone lesions. Iliac crest osteo-medullary biopsy revealed bone marrow infiltration by “signet ring” cells with intestinal differentiation. Double-balloon enteroscopy was used to obtain biopsies that confirmed the ileal origin of the PSRCC.

Introduction

Primary signet ring cell carcinoma (PSRCC), or scirrhous adenocarcinoma, is an epithelial malignancy that most often arises from the glandular cells of the stomach but may affect other areas of the body, including the breasts, pancreas, ampulla of Vater, gallbladder, urinary bladder, ovaries, and lungs [1]. In the digestive tract, it may develop in the esophagus, small bowel, caecal appendix, and large bowel, most often involving the recto-sigmoid colon [2], [3], [4].

A few cases of small-bowel carcinoma containing signet ring cells have been reported in patients with Crohn's disease (CD) [5], [6]. In a recent work [6], Placé et al. described the magnetic resonance enterography features of an ileal mucinous adenocarcinoma containing signet ring cells in a patient with a 15-year history of CD. Histologically, inflammatory bowel disease (IBD)-related colorectal cancers contain signet ring cells in a higher proportion of cases than that observed in sporadic colorectal cancers. This association has been recently confirmed by Hristova et al. [7], who found six adenocarcinomas containing signet ring cells in a series of 17 patients with an IBD-related large bowel cancer (35.3%). We report herein a case of small-bowel PSRCC in a patient with long-standing CD, which was documented by computed tomography (CT)-enterography (CTE) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT imaging, and ultimately confirmed using double-balloon enteroscopy and histopathological analysis. The 18F-FDG PET/CT features of this entity have never been reported yet. The patient presented to our observation due to the clinical suspicion of CD recurrence and was found to have a metastatic PSRCC arising from the ileum at the end of an articulate diagnostic pathway, including CTE, 18F-FDG PET/CT, bone marrow biopsy, and double-balloon enteroscopy with endoscopic biopsies. This case underlines the ambiguous CT features of small bowel PSRCC and the value of 18F-FDG PET/CT imaging and double-balloon enteroscopy to reach a definite diagnosis.

Section snippets

Case report

A 59-year-old man with a 28-year history of CD was referred to our radiology department to undergo a CTE examination due to clinical suspicion of CD recurrence. He presented at the outpatient clinic with cramping abdominal pain localized in the right lower quadrant, fatigue, diarrhea, and weight loss since 7 months.

At physical examination, the abdomen was tender to palpation, without signs of peritonism.

No palpable mass was appreciable. Laboratory examinations revealed a slightly increased

Discussion

CD patients have an increased risk of cancer, and the early detection of neoplastic degeneration on severely inflamed bowel segments is a clinical challenge [8], [11]. Clinically, similarities between the presentation of small bowel adenocarcinoma and that of CD recurrence exist, thus creating major difficulties in diagnosis. The most common clinical presentation of small bowel adenocarcinoma is intestinal obstruction or subobstruction. In addition, the other presenting symptoms include

Conclusion

PSRCC of the small bowel may really mimic CD recurrence at both endoscopy and CT. Its diagnosis is a true clinical challenge, in which multimodality imaging (including 18FDG PET/CT) and immunohistochemistry play a pivotal role.

References (16)

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