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A Rare Initial Presentation of Linitis Plastica with Back Pain
Mahdis Solhjoo1, Ruchi Bhatt2, Pouyan Gohari2. 1Medicine, Nassau University Medical Center, Westbury, New York, United States, 2Hematology/Oncology, Nassau Univ Med Ctr, East Meadow, New York, United States

Purpose of Study Linitis plastica (LP) is one of the most aggressive subtypes of the gastric adenocarcinoma. Bone metastases is more commonly seen in the LP type of the gastric cancer and is rarely reported as the initial symptom without previous gastrointestinal manifestations. We describe an unusual presentation of LP which initially presented with lower back pain. We aim to expand understanding of this rare case.
Methods Used Not applicable
Summary of Results A 70 year old female admitted for a lower back pain and weight loss. Laboratory examinations showed hemoglobin of 10.2 g/dl and Alkaline phosphatase (ALP) of 3000 U/L with normal Gamma-, Glutamyl Transpeptidase. The remaining serum biochemistry values, including calcium, were normal. Lumbosacral x-ray revealed degenerative changes. Complete bone survey was negative for discrete lytic or sclerotic lesions. In the computed tomography (CT) of thorax, abdomen and pelvis multiple areas of sclerosis and lucency was noted. Positron Emission Tomography/Computed Tomography revealed diffusely heterogeneous fluorodeoxyglucose activity throughout the skeleton corresponding to diffuse skeletal changes on CT scan representing osseous involvement of the underlying malignancy. A bone marrow biopsy and aspiration was performed to determine the underlying malignancy which revealed an extensive infiltration of signet ring cells. Patient underwent an upper endoscopy to rule out the gastric malignancy which demonestrated erythematous mucosa of the stomach body. The biopsy of the stomach was positive for signet ring cell adenocarcinoma and patient initiated on palliative chemotherapy with mFOLFOX 6 regimen. ALP trended down to 983 U/L after systemic chemotherapy
Our case highlights the importance of a broad differential diagnosis when approaching a patient with bone pain. It is prudent to consider gastric cancer as the possible primary site of disease even in the absence of overt gastrointestinal symptoms. Also an elevated serum ALP level is an important diagnostic factor in patients with bone metastases and is suggestive as a predictive marker of the treatment response.

Fig 1. Bone marrow, non-hematopoietic cells fill the bone marrow interstitial space. (10x power field)

Fig 2. Bone marrow, neoplastic cells are signet ring shaped, abundant cytoplasm push nuclear to the side. (40x power field)

Fig 3. Stomach. Beneath superficial gastric epithelium are neoplastic cells. (10x power field).

Fig 4. Stomach, signet ring shaped gastric adenocarcinoma cells. (40x power filed).

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