Histopathology case presentation of mixed mucinous signet ring ca of colon

1. P R E S E N T E D B Y : - D R P U S H K A R C H A U D H A R Y
2 N D Y E A R P G M D P A T H O L O G Y
G U I D E D B Y : - D R N A S E E M N O O R U N N I S A
P R O F A N D H O D D E P A R T M E N T O F
P A T H O L O G Y
S S S M C & R I
MIXED MUCINOUS SIGNET
RING CARCINOMA OF SIGMOID
COLON- A CASE REPORT

2. CASE HISTORY
 A 44-year-old male chronic alcoholic patient
presented to the ER with the chief complaints of
- Abdominal pain since 1 week associated with
vomiting and loss of appetite.
- H/O Constipation +
 Patient subsequently developed abdominal
distension.
 X-Ray Abdomen- erect was taken which shows
multiple air fluid levels.

3.  Patient was posted for Exploratory Laparotomy with
a provisional diagnosis of Acute intestinal
obstruction.
 Intraoperatively - Stricture was found at the level of
sigmoid colon
-Free fluid in the peritoneum ,
-dilated bowel loops upto the level of peritoneum
 Resection of diseased bowel with end colostomy was
done
 Specimen sent to the pathology department for
histopathology report

5. GROSS
 Received already cut opened segment of colon
measuring 11x4x1cm.
 Stricture is seen at the distal end measuring 4cm in
length.
 Wall shows circumferential thickening for 4cm of the
length enclosing stricture measuring 3.5x3 cm.

6. GROSS CONTD…
 Mucosa shows an abnormal area near the proximal
margin where the folds are lost.
 The thickened wall grossly appears grey white,
mucoid and glistening.

9. MICROSCOPY

11. SECTION FROM STRICTURE

13. NESTS OF TUMOR CELLS

15. H&E
LYMPHATIC
NODULE

16. H&E MUSCULARIS EXTERNA

17. H&E POOLS OF MUCIN

18. H&E

19. H&E

20. H&E

21. H&E

22. H&E SIGNET CELL

24. H&E SEROSAL END

25. H&E

26. DISTAL RESECTED MARGIN (DRM)

27. DRM MUCOSAL END

28. DRM SEROSAL END

29. SECTION FROM ABNORMAL AREA

30. SECTION FROM ABNORMAL AREA

31. SPECIAL STAIN
 PAS (PERIODIC ACID SCHIFF) STAINING WAS
DONE.

32. PAS

33. PAS

34. PAS

35. PAS

36. PAS

37. PAS SIGNET RING CELL

38. HPE REPORT
 Multiple sections from the thickened colonic wall and the
stricture site were taken.
 They show malignant tumor formed of cells with
hyperchromatic nuclei arranged in cords,sheets,clusters
and nests infitrating the entire wall of the colon (from the
mucosa upto the serosa and pericolic fat).
 Glandular differentiation is seen in focal areas.
 Most of the tumor cells are of Signet ring type with
vacuolated cytoplasm and eccentric
nuclei(Intracellular mucin).
 Tumor also shows large lakes of extracellular
mucin entrapping groups of tumor cells

39.  Part of the bowel adjacent to the tumor shows serosal
extension.
 Sections show extensive mucosal ulceration with focal
gangrenous necrosis
 Proximal resected margin is free of tumor infiltration.
 Distal resected margin shows extensive tumor
infiltration.

40. Impression
 Sigmoid colon, Colectomy biopsy – MIXED
MUCINOUS- SIGNET RING CARCINOMA
(LINITIS PLASTICA TYPE)

41. PATHOGENESIS

42. RISK FACTORS
 The dietary factors most closely associated with
increased rates of colorectal cancer are low intake of
unabsorbable vegetable fiber and high intake of
refined carbohydrates and fat.
 It is theorized that reduced fiber content leads
to decreased stool bulk and altered composition of
the intestinal microbiota.

43.  This change may increase synthesis
of potentially toxic oxidative by-products of bacterial
metabolism, which would be expected to remain in
contact with the colonic mucosa for longer periods of
time as a result of reduced stool bulk.
 High fat intake also enhances hepatic synthesis of
cholesterol and bile acids, which can be converted
into carcinogens by intestinal bacteria.

45. Mucinous adenocarcinoma
> 50% of the lesion is composed of mucin.
 This variant is characterized by pools of extracellular
mucin that contain malignant epithelium as acinar
structures, strips of cells or single cells.

46. Signet-ring cell carcinoma
 > 50% of tumour cells with prominent
intracytoplasmic mucin .
 Large mucin vacuole fills the cytoplasm and
displaces the nucleus.

47.  In some cases of mucin-producing colorectal
adenocarcinomas, there is an admixture of
extracellular and intracellular mucin formation,
resulting in a mixed mucinous–signet cell
carcinoma.
 The greater the signet ring component, the
worse the outcome.

49. STAGING

55. REFERENCES