Peritoneal biopsy frozen section: cachexia manifesting as signet ring-like cells
-
Lakhdar Khellaf
and
Philippe Rouanet
Abstract
Peritoneal metastases from signet ring cell adenocarcinoma may be overlooked at laparoscopy, resulting in problematic false-negative diagnoses. Conversely, false-positive diagnoses are rarely reported. For the surgeon, cachexia may rise suspicion for peritoneal metastases by exhibiting a worrisome micronodular appearance of the peritoneum, and atrophic adipocytes looks like signet ring cells at the microscopical level. Being aware of this underdiagnosed condition may help avoiding unfortunate false-positive diagnoses of peritoneal metastases during intraoperative consultation.
A 73-year-old woman underwent surgery for a gastric signet ring cell adenocarcinoma. Laparoscopic examination reported suspect micronodules of the lesser omentum (Figure 1A, formalin-fixed gross specimen). On frozen section, fat lobulation was accentuated by thickened fibrous septa (Figure 1B, circled area in 1A, toluidine blue, ×100) with signet ring-appearing cell clusters (Figure 1C, circled area in 1B, ×400). Despite a quite challenging diagnosis solely based on morphology, their lobular configuration unfavored the diagnosis of peritoneal metastasis. Their adipocytic nature was subsequently confirmed by positive S100 immunostaining and pancytokeratin negative staining (Figure 1D, hematoxylin-eosin-saffron, ×400 and insets). Cytoplasmic lipofuscin pigments are an interesting sign, well preserved by freezing. Body mass index was 14.7 kg/m2.
Intraoperative consultation of suspect peritoneal micronodules.
(A) Gross specimen of the gastrectomy after formalin fixation: peritoneum of the lesser omentum is involved by micronodules (circled), biopsied for intraoperative consultation. (B) Frozen section showing clusters of small cells circled by fibrous tissue (toluidine blue, ×100). (C) Higher magnification evidencing signet ring-like cells (area circled in B, ×400). (D) Formalin-fixed and paraffin-embedded tissue for definitive diagnosis: signet ring-like cells were proved to be depleted adipocytes in a context of cachexia (hematoxylin-eosin-saffron, ×400), highlighted by pS100 immunostaining, an adipocyte marker (inset).
Cachexia is underestimated in cancer patients [1]. Peritoneal metastases of diffuse-type adenocarcinoma may be overlooked [2], [, 3]. We emphasize here fat atrophy as a potential false-positive mimic, especially during critical time of surgery, both at the macroscopic and microscopic level.
Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Ethical approval: Not applicable.
References
1. Sun, L, Quan, XQ, Yu, S. An epidemiological survey of cachexia in advanced cancer patients and analysis on its diagnostic and treatment status. Nutr Canc 2015;67:1056–62. https://doi.org/10.1080/01635581.2015.1073753.Search in Google Scholar
2. Schnelldorfer, T, Ware, MP, Liu, LP, Sarr, MG, Birkett, DH, Ruthazer, R. Can we accurately identify peritoneal metastases based on their appearance? An assessment of the current practice of intraoperative gastrointestinal cancer staging. Ann Surg Oncol 2019;26:1795–804. https://doi.org/10.1245/s10434-019-07292-0.Search in Google Scholar
3. McAuliffe, JC, Tang, LH, Kamrani, K, Olino, K, Klimstra, DS, Brennan, MF, et al.. Prevalence of false-negative results of intraoperative consultation on surgical margins during resection of gastric and gastroesophageal adenocarcinoma. JAMA Surg 2018;154:126–32. doi:https://doi.org/10.1001/jamasurg.2018.3863.Search in Google Scholar
© 2020 Lakhdar Khellaf and Philippe Rouanet, published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.
Articles in the same Issue
- Opinion Paper
- Anaesthesia considerations and techniques for Pressurised IntraPeritoneal Aerosol Chemotherapy (PIPAC)
- Research Articles
- A review of the outcomes of rigid medical thoracoscopy in a large UK district general hospital
- Technique of pressurized intrathoracic aerosol chemotherapy (PITAC) for malignant pleural effusion
- Pharmacokinetics and toxicity of carboplatin used for hyperthermic intraperitoneal chemotherapy (HIPEC) in treatment of epithelial ovarian cancer
- Growth factors in the regulation of reparative response in the presence of peritoneal damage
- Clinical Images
- Peritoneal biopsy frozen section: cachexia manifesting as signet ring-like cells
Articles in the same Issue
- Opinion Paper
- Anaesthesia considerations and techniques for Pressurised IntraPeritoneal Aerosol Chemotherapy (PIPAC)
- Research Articles
- A review of the outcomes of rigid medical thoracoscopy in a large UK district general hospital
- Technique of pressurized intrathoracic aerosol chemotherapy (PITAC) for malignant pleural effusion
- Pharmacokinetics and toxicity of carboplatin used for hyperthermic intraperitoneal chemotherapy (HIPEC) in treatment of epithelial ovarian cancer
- Growth factors in the regulation of reparative response in the presence of peritoneal damage
- Clinical Images
- Peritoneal biopsy frozen section: cachexia manifesting as signet ring-like cells
