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.     

Phenotypic classification of gastric signet ring cell carcinoma and its relationship with clinicopathologic parameters and prognosis

AIM: To distinguish subtypes of gastric signet ring cell (SRC) carcinoma by investigating the expression of gastric and intestinal phenotypic markers, and to study the significance of phenotypic classification in predicting tumor progression and outcome. METHODS: Immunohistochemistry was performed in 66 cases of SRC carcinoma with MUC2, VILLIN, CDX2, Li-cadherin antibodies as intestinal phenotype markers and MUC5AC, HGM, MUC6 antibodies as gastric phenotype markers, and the relationship was analyzed between the phenotypic expression pattern and clinicopathologic parameters, as well as the 3-year survival rate. RESULTS: Expression of intestinal phenotypic markers was positively associated with tumor size, wall invasion, vascular invasion, lymph node metastasis and tumor-node-metastasis (TNM) stage. Cases expressing one or more intestinal markers had a significant lower survival rate than cases expressing none of the intestinal markers. CONCLUSION: The SRC carcinomas expressing intestinal phenotype markers exhibited a high pro-liferative potential, bad biological behaviors and poor prognosis. Examination of phenotype expression may be useful in distinguishing histological type and in predicting the prognosis of gastric SRC carcinoma.     

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.     

Tumour size is related to the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection: A retrospective single centre study

Background

Endoscopic submucosal dissection is applied in selected cases of signet ring cell early gastric cancer. However, factors related to curability of signet ring cell early gastric cancer with this method have not been fully evaluated. Our aim was to evaluate factors related to incomplete resection in signet ring cell early gastric cancer with endoscopic submucosal dissection.

Methods

A retrospective analysis was performed on a total of 126 consecutive patients with signet ring cell early gastric cancer who had undergone endoscopic submucosal dissection at the Severance Hospital in Korea, between March 2007 and March 2012. The clinical outcomes were reviewed and factors related to incomplete resection were analysed.

Results

Multivariate analysis showed that large tumour size was the only significant factor related to incomplete resection (P = 0.006; hazard ratio, 1.040; 95% confidence interval, 1.101–1.084). In addition, large tumour size was the only significant factor related to endoscopic size underestimation (P < 0.001; hazard ratio, 1.391; 95% confidence interval, 1.221–1.586). The rate of endoscopic size underestimation was significantly higher in tumours with a size ≥20 mm (P < 0.001).

Conclusions

To improve the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection, larger tumours (especially tumour with a size ≥20 mm) should be resected with a larger margin.     

Primary rectal signet ring cell carcinoma with peritoneal dissemination and gastric secondaries

Disseminated signet ring cell carcinomas frequently arise from the stomach. However, primaries in the colon and rectum have also been reported. We present a 68 year old lady who presented with a change in her bowel habit. Colonoscopy showed a stenosing rectal tumour at 7 cm to 8 cm from the anal verge. Multiple scattered ulcers were also noted along the entire length of the colon. Biopsy of the lesions revealed signet ring cell adenocarcinoma. Gastroscopy showed multiple nodules with ulceration over several areas of the stomach which were similar in appearance to the colonic lesions. However, no primary tumour of the stomach was seen. Biopsy of the gastric lesions also showed signet ring cell adenocarcinoma. Computed tomography scan of the abdomen and pelvis revealed circumferential tumour at the rectosigmoid junction with possible invasion into the left ischiorectal fossa. The overall picture was that of a primary rectal signet ring cell carcinoma with peritoneal dissemination. The patient was referred for palliative chemotherapy in view of the disseminated disease. In the present report, we discuss this interesting pathological entity and review the role of various histolological techniques in helping to identify the primary tumor.     

Clinical significance of signet ring cell rectal carcinoma

Background and aims Signet ring cell carcinoma of the rectum (SCCR) is a rare type of rectal carcinoma. This study examined the clinical significance of SCCR.Patients and methods From our medical records we retrospectively identified 61 SCCR patients and compared their clinical data and outcomes to those of 144 consecutive patients with non-SCCR mucinous rectal adenocarcinomas (NSMR) and 2,414 consecutive patients with nonmucinous rectal adenocarcinomas (NMR).Results The incidence of SCCR was 1.39% of rectal cancers. Mean patient age at onset of SCCR (48.1years, range 15–80) was significantly lower than that for NSMR (57.4 years, 9–88) and NMR (62.6 years, 12–94). The proportion of late stage (TNM III+IV) tumors was significantly higher in SCCR (90%) than in NSMR (69%) and NMR (48%). There were more tumors located in the lower rectum in SCCR (46%) than in NSMR (34%) and NMR (29%). SCCR tumors were significantly larger (5.68±3.84 cm) than NSMR (4.27±1.78 cm) and NMR tumors (3.76±1.71 cm). A higher percentage of patients with SCCR (42.6%) received abdominoperineal resection for treatment. In tumors with TNM stage IV the rate of tumor spread via the hematogenous route was significantly lower in SCCR (18.5%) than in NSMR (43.5%) and in NMR (69%). The rate of tumor spread via seeding to the peritoneum was lower in SCCR (22.2%) than in NSMR (43.5%) but higher than in NMR (2.7%). The rate of tumor spread via the lymphatic route was higher in SCCR (44.4%) than in NSMR (26.1%) and significantly higher than in NMR (12.3%). The 1-, 2-, and 5-year overall SCCR survival rates were 73.9%, 36.3%, and 23.3% respectively, which were significantly poorer than those of NSMR and NMR. For the 28 stage III and R0 SCCR tumors the 1-, 2-, and 5-year disease-free survival rates of SCCR were 84.0%, 44.2%, and 30.3%, respectively, which are comparable with general data of stage III rectal cancer in the world.Conclusion Diffuse infiltration of signet ring cells enhances the tendency of mucinous carcinomas of the rectum in more local extension and easier lymphatic spreading but not at peritoneal seeding. Although SCCR had the poorest prognosis, this outcome may be due to the advanced tumor stage rather than histology itself.     

Diagnosis of small intramucosal signet ring cell carcinoma of the stomach by non-magnifying narrow-band imaging: A pilot study

AIM: To examine the efficacy of non-magnifying narrow-band imaging(NM-NBI) imaging for small signet ring cell carcinoma(SRC).METHODS: We retrospectively analyzed 14 consecutive small intramucosal SRCs that had been treated with endoscopic submucosal dissection(ESD) and 14 randomly selected whitish gastric ulcer scars(control). The strength and shape of the SRCs and whitish scars by NM-NBI and white-light imaging(WLI) were assessed with Image J(NIH, Bethesda).RESULTS: NM-NBI findings of SRC showed a clearly isolated whitish area amid the brown color of the surrounding normal mucosa. The NBI index, which indicates the potency of NBI for visualizing SRC, was significantly higher than the WLI index(P = 0.001), indicating SRC was more clearly identified by NM-NBI. Although the NBI index was not significantly different between SRCs and controls, the circle(C)-index, as an index of circularity of tumor shape, was significantly higher in SRCs(P = 0.001). According to the receiveroperating characteristic analysis, the resulting cut-off value of the circularity index(C-index) for SRC was 0.60(85.7% sensitivity, 85.7% specificity). Thus a lesion with a C-index ≥ 0.6 was significantly more likely to be an SRC than a gastric ulcer scar(OR = 36.0; 95%CI: 4.33-299.09; P = 0.0009).CONCLUSION: Small isolated whitish round area by NM-NBI endoscopy is a useful finding of SRCs which is the indication for ESD.     

胃印戒细胞癌的形态发生

目的观察胃印戒细胞癌癌前病变及癌变形态发生．方法全切除胃印戒细胞癌标本６８例，常规固定，包埋制片，光镜检查．结果腺管增殖带延长３５例，颈粘液细胞依次变为小立方形细胞（Ⅰ型细胞）、中等大小组织细胞样细胞（Ⅱ型细胞）及典型印戒细胞（Ⅲ型细胞）；见到球样异型增生灶１６例；癌细胞始发为Ⅱ型细胞６例；管状腺癌演变为印戒细胞２例．结论胃印戒细胞癌的形态发生可能有数种途径．印戒细胞癌与肠化关系应进一步探明     

内镜黏膜下剥离术治疗早期胃印戒细胞癌的疗效及非治愈性切除的危险因素分析

目的 探讨内镜黏膜下剥离术(ESD)治疗早期胃印戒细胞癌(SRCC)的疗效及预后,并探讨非治愈性切除的危险因素.方法 回顾性分析2012年10月至2020年10月在南京大学医学院附属鼓楼医院、南京医科大学附属无锡人民医院、泰州市人民医院、南京市高淳人民医院行ESD治疗的62例早期胃SRCC患者的临床病理资料,根据术后病...     

Neoadjuvant chemotherapy vs upfront surgery for gastric signet ring cell carcinoma:A retrospective,propensity score-matched study

BACKGROUND The benefit of neoadjuvant chemotherapy for patients with signet-ring cell carcinoma of the stomach is controversial.AIM To evaluate the perioperative and long-term outcomes of neoadjuvant chemotherapy for locally advanced gastric signet-ring cell carcinoma.METHODS This retrospective study identified patients with locally advanced signet-ring cell carcinomas of the stomach(cT3/4 and cN any)diagnosed from January 2012 to December 2017 by using the clinical Tumor-Node-Metastasis(cTNM)staging system.We performed 1:1 propensity score matching(PSM)to reduce bias in patient selection.The histologic and prognostic effects of neoadjuvant chemotherapy were assessed.The overall survival rates were used as the outcome measure to compare the efficacy of neoadjuvant chemotherapy vs surgery-first treatment in the selected patients.RESULTS Of the 144 patients eligible for this study,36 received neoadjuvant chemotherapy,and 108 received initial surgery after diagnosis.After adjustment by PSM,36 pairs of patients were generated,and baseline characteristics,including age,sex,American Society of Anesthesiologists score,tumor location,and cTNM stage,were similar between the two groups.The R0 resection rates were 88.9%and 86.1%in the surgery-first and neoadjuvant chemotherapy groups after PSM,respectively(P=1.000).The median follow-up period was 46.4 mo.The 5-year overall survival rates of the neoadjuvant chemotherapy group and surgery-first group were 50.0%and 65.0%(P=0.235),respectively,before PSM and 50%and 64.7%(P=0.192),respectively,after PSM.Multivariate analyses conducted before and after PSM showed that NAC was not a prognostic factor.CONCLUSION Neoadjuvant chemotherapy provides no survival benefit in patients with locally advanced gastric signet-ring cell carcinoma.For resectable gastric signet-ring cell carcinoma,upfront surgery should be the primary therapy.     

Cardiac tamponade originating from primary gastric signet ring cell carcinoma

A 45-year-old man with dry cough and dyspnea was referred by a medical practitioner for evaluation of heart failure on February 10, 1996. Chest X-ray revealed increased cardiothoracic ratio, and ultrasonographic echocardiography disclosed massive pericardial effusion with right ventricular collapse. Cardiac tamponade was diagnosed and pericardiocentesis was performed. Ten days after admission, the pleural effusion had become more pronounced, and thoracocentesis was performed. Carcinoembryonic antigen level was elevated in both the pericardial and pleural effusion, and cytology implicated adenocarcinoma, which suggested malignant effusion. Endoscopic study disclosed gastric cancer in the posterior wall of the upper body, and the histopathological diagnosis was signet-ring cell carcinoma. The patient died of respiratory failure on May 2, 1996, and autopsy was performed. The final diagnosis was gastric cancer with pulmonary lymphangitis, pericarditis, and pleuritis carcinomatosa, accompanied by enlargement of mediastinal and paraaortic lymph nodes. Interestingly, the primary signet-ring cell carcinoma of the stomach was situated mostly in the mucosa. Deep in the submucosal region, there was prominent invasion of the intra-lymphatic vessels, without direct destruction of the mucosa muscularis. (Received Mar. 10, 1998; accepted Nov. 27, 1998)     

Primary signet ring cell carcinoma of the appendix： A rare case report and our 18-year experience

Primary adenocarcinoma of the appendix is a rare malignancy that constitutes 〈 0.5% of all gastrointestinal neoplasms. Moreover, primary signet ring cell carc noma of the appendix is an exceedingly rare entity. We have encountered 15 cases of primary appendiceal cancer among 3389 patients who underwent appen- dectomy over the past 18 years. In the present report, we describe a rare case of primary signet ring cell carcinoma of the appendix with ovarian metastases and unresectable peritoneal dissemination occurring in a 67-year-old female patient. She underwent ap- pendectomy and bilateral salpingo-oophorectomy with a laparoscopy procedure. She then received palliative systemic chemotherapy with 12 cycles of oxaliplatin, 5-flurorouracil, and leucovorin （FOIFOX-4）. The patient currently is well without progression of disease 12 mo after beginning chemotherapy.     

Signet-ring cell carcinoma arising from a fundic gland polyp in the stomach

Fundic gland polyps (FGPs) are currently the most common type of gastric polyps and are usually benign. However, although rare, gastric adenocarcinoma of FGP has been recently proposed as a new variant of gastric adenocarcinoma. Here we report the first case of a 49-year-old woman with focal signet ring cell carcinoma that arose from an FGP of the stomach. The tumor was completely excised by endoscopic snare polypectomy. FGPs should therefore be evaluated for malignant changes although they occur rarely, if the FGP has an erosive or irregular surface.     

Overexpression of the M2 isoform of pyruvate kinase is an adverse prognostic factor for signet ring cell gastric cancer

AIM: To investigate M2 isoform of pyruvate kinase (PKM2) expression in gastric cancers and evaluate its potential as a prognostic biomarker and an anticancer target.METHODS: All tissue samples were derived from gastric cancer patients underwent curative gastrectomy as a primary treatment. Clinical and pathological information were obtained from the medical records. Gene expression microarray data from 60 cancer and 19 non-cancer gastric tissues were analyzed to evaluate the expression level of PKM2 mRNA. Tissue microarrays were constructed from 368 gastric cancer patients. Immunohistochemistry was used to measure PKM2 expression and PKM2 positivity of cancer was determined by proportion of PKM2-positive tumor cells and staining intensity. Association between PKM2 expression and the clinicopathological factors was evaluated and the correlation between PKM2 and cancer prognosis was evaluated.RESULTS: PKM2 mRNA levels were increased more than 2-fold in primary gastric cancers compared to adjacent normal tissues from the same patients (log transformed expression level: 7.6 ± 0.65 vs 6.3 ± 0.51, P < 0.001). Moreover, differentiated type cancers had significantly higher PKM2 mRNA compared to undifferentiated type cancers (log transformed expression level: 7.8 ± 0.70 vs 6.7 ± 0.71, P < 0.001). PKM2 protein was mainly localized in the cytoplasm of primary cancer cells and detected in 144 of 368 (39.1%) human gastric cancer cases. PKM2 expression was not related with stage (P = 0.811), but strongly correlated with gastric cancer differentiation (P < 0.001). Differentiated type cancers expressed more PKM2 protein than did the undifferentiated ones. Well differentiated adenocarcinoma showed 63.6% PKM2-positive cells; in contrast, signet-ring cell cancers showed only 17.7% PKM2-positive cells. Importantly, PKM2 expression was correlated with shorter overall survival (P < 0.05) independent of stage only in signet-ring cell cancers.CONCLUSION: PKM2 expression might be an adverse prognostic factor for signet-ring cell carcinomas. Its function and potential as a prognostic marker should be further verified in gastric cancer.     

早期胃癌的内镜下治疗

随着内镜技术的不断进步,越来越多的早期胃癌可经内镜下治疗.本文简要地介绍了早期胃癌内镜下治疗的发展史.重点介绍了目前早期胃癌内镜下治疗最先进的方法一黏膜剥离术的特点、适应征、并发症及处理对策.     

Endoscopic treatment for early gastric cancer

Gastric cancer remains one of the most common causes of cancer death.However the proportion of early gastric cancer(EGC)at diagnosis is increasing.Endoscopic treatment for EGC is actively performed worldwide in cases meeting specific criteria.Endoscopic mucosal resection can treat EGC with comparable results to surgery for selected cases.Endoscopic submucosal dissection(ESD)increases the en bloc and complete resection rates and reduces the local recurrence rate.ESD has been performed with expanded indication and is expected to be more widely used in the treatment of EGC through the technological advances in the near future.This review will describe the techniques,indications and outcomes of endoscopic treatment for EGC.     

Signet ring cell carcinoma of the extrahepatic bile duct

Most tumors affecting the extrahepatic bile duct are adenocarcinomas; the other histologic types occur only rarely. We herein report the extremely rare case of signet ring cell carcinoma (SRCC) originating from the extrahepatic bile duct. A 55-year-old man was hospitalized for jaundice and pruritus. Computed tomography and positron emission tomography suggested the presence of distal extrahepatic bile-duct cancer. He underwent a pylorus preserving pancreaticoduodenectomy. A histologic study confirmed a signet ring cell neoplasm of the distal common bile duct. Because the upper resection margin was invaded by the tumor, he received postoperative concurrent chemoradiotherapy and four cycles of chemotherapy. The patient has survived with no evidence of recurrence for 2 years. This is the second case of primary SRCC of the distal extrahepatic bile duct reported in the literature; further reports of cases are warranted to determine the nature of SRCC in the extrahepatic bile duct.     

Survival in signet ring cell carcinoma varies based on primary tumor location: a Surveillance,Epidemiology, and End Results database analysis

Background: The aim of this study was to investigate the survival of patients with signet ring cell carcinoma (SRCC) based on primary tumor location.

Methods: Patient data were obtained from the Surveillance, Epidemiology, and End Results database (1988–2012) with ≥200 cases per tumor location. Cox regression analysis was used to investigate prognostic factors of cause-specific survival (CSS).

Results: We identified 24,171 patients. Of the patients, 63.4% had gastric SRCC, followed by colon (18.2%), esophageal (5.0%), rectal (3.5%), lung (3.1%), pancreatic (1.8%), breast (1.5%), bladder (1.3%), small intestine (1.1%), and gallbladder SRCC (1.0%). The 5-year CSS was 22.1%, 69.0%, 33.2%, 28.1%, 24.8%, 16.1%, 13.6%, 12.6%, 11.0%, 6.4% in patients with gastric, breast, colon, rectum, bladder, small intestine, esophageal, gallbladder, lung, and pancreatic SRCC, respectively (P < 0.001). Multivariate analyses showed that the primary tumor location was an independent prognostic factor of survival. Patients with lung, small intestine, and bladder SRCC had a comparable CSS to gastric SRCC, while breast and colorectal SRCC had better survival than gastric SRCC. Esophageal, gallbladder, and pancreatic SRCC were significantly associated with poor CSS compared with gastric SRCC.

Conclusion: Our study suggests a major difference in survival of SRCC based on the primary tumor locations.     

Outcome after endoscopic submucosal dissection for early gastric cancer in Korea

Endoscopic treatment,such as endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD),has been established as one of the treatment options for selected cases with early gastric cancer(EGC).Most studies on this topic have been carried out by researchers in Japan.Recently,the experience in EMR/ESD for EGC outside Japan is increasingly reported.In Korea,gastric cancer is the most common malignant disease,and the second leading cause of cancer death.Currently,EMR for EGC is widely performed i...