Coexistence of multifocal gastric adenocarcinoma with signet-ring cell morphology and a gastrointestinal stromal tumour in a stomach with hp-associated gastritis

A 79-year-old man was admitted because of anemia during marcumar therapy with suspected bleeding in the gastrointestinal tract. Endoscopy revealed a large mutifocal poorly differentiated gastric signet ring cell adenocarcinoma. After staging by the usual oesophagogastroduodenoscopic method, a total D 2 gastrectomy was performed. In the pathological resection specimen of the stomach, a multifocal poorly differentiated signet ring cell adenocarcinoma, infiltrating the submucosa (so called early cancer of sm-type) and an incidental gastroinstinal stromal tumour, 0.8 cm in diameter, was diagnosed. This is the first case report of the synchronous occurrence of a multifocal poorly differentiated gastric adenocarcinoma with signet-ring cell morphology (diffuse type according to the Lauren classification) and a GIST incidentally within a stomach with Hp-associated gastritis.     

A rare case of a signet ring cell carcinoma of the colon mimicking a juvenile polyp

Primary signet ring cell carcinoma (SRC) of colon at early stage is quite rare. Only 26 cases were reported until now. We report an early stage of primary SRC which was misdiagnosed as a juvenile polyp and treated with polypectomy followed by surgical resection. A 21-year-old male was administered for hematochezia. Abdominopelvic enhanced computed tomography revealed a polyp with active bleeding at the proximal rectum just below the rectosigmoid junction. Colonoscopy examination revealed a colon polyp with 0.5 cm sized head. Polypectomy was performed with snare and the polyp was completely removed. Biopsy revealed SRC. Surgical resection was also performed and there were no residual tumor or lymph node metastasis in the surgical specimen.     

Pedunculated gastric carcinoma demonstrating a gastric foveolar phenotype

We report a case of gastric cancer complicated with very well differentiated adenocarcinoma containing signet ring cells. An endoscopic examination revealed a pedunculated polyp in the fornix of the stomach. A surgical operation was performed and the pathological findings showed very well differentiated adenocarcinoma mimicking gastric foveolae with a poorly differentiated component containing signet ring cells. This is the first case of pedunculated gastric cancer complicated with very well differentiated adenocarcinoma containing signet ring cells and also demonstrating a gastric foveolar phenotype.     

Early-stage primary signet ring cell carcinoma of the colon

Primary signet ring cell carcinoma of the colorectum detected at an early stage is very rare; most cases are detected at an advanced stage. Therefore, its progno-sis is poorer than that of ordinary colorectal cancer. A 56-year-old Korean man was seen at this hospital for management of signet ring cell carcinoma of the co-lon. Colonoscopic examination revealed a Ⅱa-like, ill-defined and flatly elevated 9-mm residual tumor in the cecum. Endoscopic mucosal resection was preformed. Pathological examination of the resected specimen re-vealed signet ring cell carcinoma that had invaded the lamina propria without venous or perineural invasion. Abdominal computed tomography (CT) and positron CT showed no evidence of primary lesions or distant me-tastasis. An additional laparoscopic right-hemicolectomy was performed; no residual tumor or lymph node me-tastasis was found. We report a case of primary signet ring cell carcinoma of the colon detected at an early stage and provide a review of the literature.     

A case of Sister Mary Joseph's nodule as a presenting sign of gastric cancer]

The cutaneous metastasis of a visceral malignancy to the umbilicus is known as "Sister Mary Joseph's nodule (SMJN)". It is considered to be a predictor of poor prognosis because it mostly occurs in advanced, metastasizing cancer. However, it is a very rare condition as an initial presenting sign of primary cancer. We recently encountered a 48-year-old man presented with an umbilical lump. The lesion was a firm, ill-delineated, painful nodule with regular surface in the umbilicus. Abdominal computed tomography showed a 2.2 cm sized, ill-defined, delayed enhancing mass at the periumbilical area accounting for umbilical nodule. Diffuse irregular thickening of peritoneum and diffuse wall thickening of stomach implied the diagnosis of gastric cancer. Esophagogastroduodenoscopy revealed diffuse nodular infiltrative lesion from cardia through body of the stomach, compatible with Bormann type 4 advanced gastric cancer. Later, histopathologic confirmation showed a presence of signet ring cell adenocarcinoma from biopsy specimens. We experienced a case presenting with an umbilical metastasis as the first sign of gastric adenocarcinoma. It is thought that direct extension of tumor through the peritoneum might be the route for umbilical metastasis. Careful examination of all umbilical lesions must be needed for the early diagnosis of internal malignancy.     

Signet ring cell carcinoma of the lower bile duct with rapid growth: report of a case

Signet ring cell carcinoma occurring in the biliary tract is extremely rare. We herein report the case of a 78-year-old Japanese woman demonstrating signet ring cell carcinoma of the lower bile duct with a rapid growth. Computed tomography of the pancreas head pointed out a circular thickness in the lower bile ductal wall and stenosis of the common bile duct. Cholangiography revealed tapering stenosis at the lower bile duct. Biopsy specimens taken from these lesions and scratched specimens taken from stenotic portion of the lower bile duct were analyzed and demonstrated signet ring cell carcinoma. To the best of our knowledge, this is the first reported case of primary signet ring cell carcinoma of the lower bile duct reported in the English literature. Based on our experience, signet ring cell carcinoma of the lower bile duct is considered to demonstrate both transmural dispersion and an aggressive nature.     

Pseudomesotheliomatous presentation of primary signet ring cell carcinoma of lung

Signet ring cell carcinoma is a unique mucin secreting adenocarcinoma. It generally arises from stomach, colon, rectum or breast and rarely from lung. Pleural membrane involvement is common in lung cancer manifesting as pleural effusion. Rarely, it may encase the whole lung without effusion mimicking mesothelioma and is termed as "pseudomesothelioma". A 35-year-old male presented with a pleural mass encasing the whole of the right lung without any pleural effusion and investigations revealed it to be primary signet ring cell adenocarcinoma of the lung.     

Synchronic signet ring carcinoma and adenocarcinoma complicating extensive and long-standing ulcerative colitis

We report the case of a 38 year-old woman with extensive ulcerative colitis (UC) for 9 years that had consistently been under close endoscopic surveillance. She had had two previous severe attacks requiring hospital admission, with good response to intravenous steroids. In the last relapse, a total colonoscopy demonstrated extensive lesions of UC throughout the entire colon. Multiple biopsies taken every 3 cm revealed only low-grade dysplasia and lesions characteristic of UC. Due to medical therapy failure, the patient was submitted for proctocolectomy. Pathological examination of the resected specimen showed a signet ring carcinoma and a synchronic adenocarcinoma in the sigmoid colon, both undetected by colonoscopy and biopsies. The issue of surveillance in patients with extensive and long-standing UC is discussed.     

A Case of Rectal Carcinoma in a Part of a Giant Periproctal Abscess

Abstract: A 58-year-old male was admitted to our hospital complaining of perineal pain and weight loss. On digital examination, a hard mass with a central depression was palpable in the circumference of the rectum. A barium enema study revealed a giant periproctal abscess formation, and a colonoscopy showed a giant irregular-shaped ulceration in the circumference of the rectum. Biopsy specimens obtained from the rectal ulcer revealed a well differentiated adenocarcinoma, and this case was diagnosed as being carcinoma of the rectum with periproctal abscess formation. A pelvic exenteration and colostomy were performed. The macroscopic findings of the resected rectal specimen showed a giant abscess formation measuring 13 cm over the anal verge in the circumference of the lower rectum. The abscess, with a thickened wall measuring 50 mm, was accompanied by an ulcerated lesion on its oral and anal side. The tumor was adherent to the bladder and prostate with direct invasion. The post operative diagnosis made was an unclassified type of rectal carcinoma (type 5). Its clinical staging was stage 5 (HIPON1A3) in gross appearance. The histopathological findings of the resected specimen indicated a poorly differentiated adenocarcinoma partly containing signet ring cell carcinoma. The frequency with which a rectal carcinoma with a regional abscess has been reported is less than 1%. It has been assumed that a regional abscess is caused by the perforation of the rectum contributing with the invasion of carcinoma over the proper muscle layer. In this case, it was inferred that the rapid development of this tumor caused secondary, ischemia at its center and then an abscess was formed with tumor necrosis.     

Estrogen receptor beta is expressed in human stomach adenocarcinoma

PURPOSE: In stomach adenocarcinoma, the role of the hormonal receptor, estrogen receptor (ER), has been controversial. Recently, a new estrogen receptor, called estrogen receptor beta (ER beta), was found to be expressed in various tissues including normal gastrointestinal tract. In this paper, the expression of ER beta in stomach adenocarcinomas has been investigated for the first time, specifically in signet ring cell adenocarcinomas, together with surrounding non-cancerous tissues. METHODS: By immunohistochemistry the expression of ER alpha and beta was studied in 29 stomach adenocarcinomas, ten signet ring cell adenocarcinomas, and 19 other adenocarcinomas. Western blotting was performed to examine the immunohistochemical result. Statistical studies (Student's t test and chi(2)-test) explored the relation between the immunohistochemical result and clinicopathological characteristics. RESULTS: All 29 adenocarcinomas, including the signet ring cell ones, demonstrated clear ER beta nucleus staining. Lymphocytes, venous endothelial cells, smooth muscle, and non-cancerous stomach glands also showed strong ER beta staining, while no staining was observed in the immunohistochemistry of ER alpha. Western blotting showed equivalent ER beta protein levels in cancerous and non-cancerous tissues, which was consistent with the results of immunohistochemical staining. Among signet ring cell adenocarcinomas of the stomach, cytoplasm were stained in addition to nuclei, specifically in patients under the age of 40 years. CONCLUSIONS: Our results imply that the effects of estrogen in stomach cancer, as well as those in normal stomach, may be mediated by ER beta, and that the role of ER beta may differ by the subtype of stomach adenocarcinoma - specifically signet ring cell adenocarcinomas and other ones - although large scale samples are needed to confirm these findings.     

Concurrent occurrence of gastric adenocarcinoma and duodenal neuroendocrine cell carcinoma: a composite tumour or collision tumours ?

BACKGROUND: Neuroendocrine cell (NEC) carcinoma is occasionally accompanied by adenocarcinoma but the relationship between these two morphologically distinct tumours is unclear. Two hypotheses have arisen regarding the mechanism for the association of adenocarcinoma and NEC carcinoma. One is that both are derived from a common multipotential epithelial stem cell. The second hypothesis is that adenocarcinoma and NEC carcinoma arise from a multipotential epithelial stem cell and a primitive NEC, respectively. AIMS: To elucidate the relationship between the two histologically distinct tumours, adenocarcinoma of the stomach and NEC carcinoma of the duodenum. PATIENT/METHODS: We present a case in which the tumour extended across the pyloric ring, the gastric portion of which revealed adenocarcinoma while the duodenal portion showed argyrophil NEC carcinoma. The two histologically distinct lesions of the tumour were examined by immunohistochemistry and genetic analysis of p53. RESULTS: The gastric region was negative for chromogranin A staining but positive for carcinoembryonic antigen (CEA) staining. In contrast, the duodenal region was positive for chromogranin A but negative for CEA. All tumour regions showed a point mutation in p53 gene at exon 7 (GGC (glycine)-->GTC (valine) at codon 245). The distal portion of the duodenal tumour showed an additional point mutation in p53 gene at exon 5 (GCC (alanine)-->GTC (valine) at codon 129). CONCLUSIONS: The two histologically distinct tumours, adenocarcinoma of the stomach and NEC carcinoma of the duodenum, appear to be derived from a common epithelial cell.     

Multiple depressed‐type colonic cancer (IIC)‐like configurations: metastases from gastric cancer

We present a rare case of multiple colonic metastases from advanced gastric cancer presenting colon depressed‐type multiple early cancer (IIc)‐like configuration. The case was a 74‐year‐old man who presented with a symptom of abdominal fullness. Colonoscopy and barium enema study revealed multiple IIc‐like lesions, which were shown histologically to be metastatic deposits of signet ring cell carcinoma. He had synchronous gastric cancer, which histologically demonstrated moderate to poorly differentiated adenocarcinoma with signet ring cell differentiation. In addition, he had concomitant multiple small bowel metastatic lesions. This appears to be the first published report of multiple IIc‐like colonic metastatic lesions from a gastric cancer.     

Extensive bone marrow necrosis associated with carcinomatosis 7 years after operation for gastric cancer

A case of extensive bone marrow necrosis due to cancer metastasis is reported. A 55-year-old female, who had a history of subtotal gastrectomy for signet ring cell carcinoma of the stomach 7 years ago, was admitted to our hospital with a complaint of lumbago on October 25, 1987. Red blood cell count was 92 X 10(4)/microliters, hemoglobin 2.7 g/dl, hematocrit 8.0%, platelet 6.4 X 10(4)/microliters, and white blood cell count 13,400/microliters with leukoerythroblastosis. Bone marrow aspiration of the sternum, left iliac crest, and bilateral posterior superior iliac supine showed extensive bone marrow necrosis. Serum ALP was increased to 7410IU/l, dominated isozyme of bone type. Hemostatic findings suggested a complication of consumption coagulopathy. Skull, vertebrae, iliac and pelvic bone X-ray showed multiple osteolytic lesions, and irregular isotope uptake was recognized on the bone scintigraphy using 99mTc. Sixth bone marrow examination at the right iliac crest revealed signet ring cell carcinoma metastasis. In spite of detailed examinations, there was no evidence of primary carcinoma, including the remnant of stomach. We speculated that the signet ring cells were originated from the respected gastric cancer. The patient has received anti-cancer chemotherapy with UFT and OK432, and is still alive 9 months after diagnosis.     

E-cadherin molecular expresion in the diffuse and intestinal types of gastric adenocarcinoma. A report from Lima, Peru]

OBJECTIVE: Signet ring carcinoma of the stomach is well known to be more aggressive and infiltrating than adenocarcinoma. Different studies have proposed that signet ring cell carcinoma would be more infiltrating because of the loss of E-cadherin expression, this cadherin is a class of protein cell membrane protein which plays an important role in cell-adhesion. METHODS: We carried out a transversal comparative study, in order to measure the E-cadherin expression in 10 cases of signet ring cell and in 10 cases of adenocarcinoma, with help of immunohistochemistry. RESULTS: We found a bigger expression of E-cadherin in adenocarcinomas (100%) than signet ring cell carcinoma (40%), this difference was significative using Fisher test (p = 0,011). The loss of E-cadherin would explain the bigger infiltrating capacity in comparison to adenocarcinoma.     

Gastric cancer with metastasis to the gingiva

The present case report describes a gastric cancer which showed unusual metastasis in the oral region. A 56-year-old male patient underwent total gastrectomy and splenectomy due to advanced gastric cancer in the upper third of the stomach. Fifteen months later, he presented with anorexia and gingival swelling of durations of approximately 3 and 1 month, respectively. The gastric tumor was histologically a signet ring cell and a poorly differentiated cancer with a moderate degree of vascular invasion. Biopsy specimens from the gingival tumor revealed a signet ring cell cancer. Other metastatic sites were the brain, limb bones and abdominal lymph nodes. A bone scintigram revealed an abnormal uptake in the limb bones, while it did not exhibit any abnormality in the oral region. Correlation between the histology of the gingival tumor with that of the gastric cancer, as well as the absence of a gingival tumor at the time of prior gastrectomy, led to a diagnosis that the gingival tumor was a metastasis from gastric cancer. Gastric cancer metastasizing to the oral region, either the osseus or the oral soft tissue, is very rare. Although it cannot be proved without an autopsy, negative findings in the mandible by bone scanning in the present case suggest that direct gingival metastasis can be considered, rather than mandibular metastasis involving the gingiva. Hematogenous spread could be a mechanism of metastasis for this unusual tumor.     

Multiple early gastric cancer with gastritis cystica profunda showing various histological types

We report a case of multiple early gastric cancer showing varied histological types associated with gastritis cystica profunda (GCP). A 61-year-old man who had early gastric cancer associated with GCP underwent a distal gastrectomy with lymphadenectomy. Histological examination showed various histological types of cancer -well differentiated, moderately differentiated, poorly differentiated adenocarcinoma, mucinous adenocarcinoma and signet ring cell carcinoma- that had developed independently in the mucosal and submucosal layers of the resected specimen. Furthermore, multiple cysts with a single layer of columnar epithelium were present in the submucosa around the cancerous lesions. However, no neoplastic changes were found in those epithelial cells. Helicobacter pylori was detected in the residual stomach 3 months after surgery. Although the mechanism of the relationship between gastric carcinoma and GCPs is obscure, we speculate that repeated erosion and regeneration induced by chronic inflammation causes multicentric carcinogenesis as well as an aberration of the gastric glands. GCPs may be a risk factor for multiple gastric cancer.     

Metastases from gastric carcinoma to colon in the form of multiple flat elevated lesions: a case report

Gastric carcinoma is a common malignancy worldwide. Advanced stages of the disease may result in metastases to many other organs of the body. However, colonic metastases are rare. We report a case of gastric carcinoma with symptoms of abdominal fullness and weight loss. The serum carcinoembryonic antigen level was elevated. Esophagogastroduodenoscopy revealed giant folds occupying the whole gastric body and poor expansion of the stomach. Histologic examination of biopsy specimens from the giant fold demonstrated poorly differentiated adenocarcinoma with signet ring-cell differentiation. Total colonoscopy revealed five or six discrete flat elevated lesions in the distal transverse, descending, and sigmoid colons. These lesions were characterized by a clear margin of 3-5 mm in diameter and erosions on the tips. Polypectomy specimens demonstrated signet ring-cell carcinoma, which was histologically similar to the specimens taken from the gastric lesion. We conclude that this was a rare case in which gastric signet ring-cell carcinoma had metastasized to the colon in the form of flat elevated lesions, combined with rapid and wide lymphatic spread to the thorax and abdomen in a clinical course as short as 46 days.     

A patient with rectal cancer associated with ulcerative colitis in whom endoscopic ultrasonography was useful for diagnosis

Endoscopic ultrasonography (EUS) was helpful for the diagnosis of rectal cancer associated with ulcerative colitis. The patient was a 38-year-old Japanese man with a 19-year history of relapsing-remitting type ulcerative colitis involving the entire colon. Routine colonoscopy revealed multiple polypoid prominences in the upper portion of the rectum. EUS revealed a hypoechoic mass in the submucosa beneath and around the polypoid lesion on the most oral side. Signet ring cells were found in a biopsy specimen from this lesion. Subtotal colectomy was performed. A depressed lesion was observed around the prominence on the most oral side; histologically, this lesion was poorly differentiated mucinous and signet ring cell carcinoma extending into the subserosa. The polypoid lesion on the most anal side was well differentiated adenocarcinoma, which was limited to the mucosa. Our findings suggest that EUS is helpful for detecting invasive cancer associated with ulcerative colitis. Received: April 22, 1998 / Accepted: January 22, 1999     

APUD cells in gastric cancer

Endocrine cells (APUD cells) of digestive mucosa can be source of neoplasias, usually called "carcinoids". Nevertheless, there are some reports in literature about the presence of APUD cells in carcinomas as a tumor component. However, these tumors seem to have not the biological and clinical behavior of carcinoids. These types of neoplasias have been reported mainly in stomach and colon. In the present work, the frequency of APUD cells was studied in 42 gastric carcinomas. Argyrophil cells were observed in six cases (14.3%) and argentaffin cells in one (2.3%); their histopathological pattern were well differentiated adenocarcinoma (5) and "signet ring cell carcinoma" (1). The APUD cell distribution and number in these neoplasias were quite irregular in each case examined and in different areas of the same case.     

Signet ring cell carcinoma of the esophagus treated by video-assisted surgery: report of a case

We report a case of Barrett’s adenocarcinoma consisting of a signet ring cell carcinoma (SIG) and well-differentiated adenocarcinoma treated by video-assisted surgery. The patient was a 73-year-old man with esophagitis endoscopically detected 5 years earlier. Esophagogastroscopy showed an ulcerative tumor (lesion 1) with a small protruding tumor (lesion 2) in the lower esophagus. Biopsy specimens taken from lesions 1 and 2 showed SIG and a well-differentiated adenocarcinoma, respectively. The patient underwent video-assisted surgery for the esophageal carcinoma. Macroscopically, the resected tumor consisted of a type 2 tumor (lesion 1, 25 mm in diameter) and a type 0-IIa tumor (lesion 2, 10 mm in diameter) of the lower esophagus. Histologically, lesion 1 showed SIG invading the submucosal layer of the esophagus, and lesion 2 showed a well-differentiated adenocarcinoma limited to the mucosa. The two lesions were continuously observed, and a moderately differentiated adenocarcinoma was observed between lesions 1 and 2. Near the tumor, the double muscle layer of the mucosa and the esophageal glands were observed under the columnar epithelium. In immunohistochemistry, both lesions showed positive reactions for MUC5AC and MUC2 but showed no reaction for MUC6. The tumor was diagnosed as SIG concomitant with a well-to moderately differentiated adenocarcinoma arising from Barrett’s esophagus (pT1b pN0 M0). The patient is alive without recurrence 60 months after surgery.