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.     

A case of gastric hamartomatous inverted polyp (submucosal tumor type) accompanied by gastric cancer]

Endoscopic examination of a 39-year-old woman revealed a flat-elevated submucosal tumor (SMT) in the upper third area of the stomach and a IIc lesion in the anterior wall of the lower third of the stomach. Endoscopic ultrasonography findings suggested an aberrant pancreas. Both lesions were resected by distal gastrectomy. Histological examination of the SMT revealed the dilated glands with cyst formation and proliferation of smooth muscle bundles in the submucosal layer, and it was diagnosed as a gastric hamartomatous inverted polyp. The IIc lesion was a signet ring cell carcinoma. Cases of gastric hamartomatous inverted polyps coexistent with gastric cancer have been rarely reported in Japan.     

Two cases of histopathologically advanced (stage IV) early gastric cancer]

Various minimally invasive surgical techniques in some cases of early gastric cancer are becoming common practice. However, there are rare cases of advanced cancer with distant metastasis although the invasion of the gastric wall is limited to the mucosa and/or submucosa (defined as early gastric cancer according to UICC-TNM classification). We report two cases of early gastric cancer with distant metastasis (stage IV). Both tumors were defined as early cancer because they were confined to the submucosa. One was a type IIa early cancer, histologically classifiable as a signet ring cell carcinoma (according to the Japanese Classification of Gastric Carcinoma and UICC-TNM classification); the other was a surface spreading type IIb + IIc, classifiable as a signet ring cell carcinoma, too. Stage IV factors were ovarian metastasis (Krukenberg tumor) in the former and N3 in the latter case.     

Endoscopic features of early-stage signet-ring-cell carcinoma of the stomach

AIM: To identify the features of early signet ring cell gastric carcinoma using magnification endoscopy with narrow band imaging (NBI).METHODS: A retrospective review was conducted of 12 cases of early signet ring cell gastric carcinoma who underwent treatment in a single institution between January 2009 and April 2013. All patients had magnification endoscopy with NBI and indigo carmine contrast to closely examine the mucosal architecture, including the microvasculature and arrangement of gastric pits. Histologic examination of the final endoscopic submucosal dissection or gastrectomy specimen was performed and compared with the endoscopic findings to identify patterns specific to signet ring cell carcinoma.RESULTS: Twelve patients with early signet ring cell gastric carcinoma were identified; 75% were male, and average age was 61 years. Most of the lesions were stage T1a (83%), while the remainder were T1b (17%). The mean lesion size was 1.4 cm². On standard endoscopy, all 12 patients had a pale, flat lesion without any evidence of mucosal abnormality such as ulceration, elevation, or depression. On magnification endoscopy with NBI, all of the patients had irregularities in the glands and microvasculature consistent with early gastric cancer. In addition, all 12 patients exhibited the “stretch sign”, an elongation or expansion of the architectural structure. Histologic examination of the resected specimens demonstrated an expanded and edematous mucosal layer infiltrated with tumor cells.CONCLUSION: The “stretch sign” appears to be specific for signet ring cell carcinoma and may aid in the early diagnosis and treatment of this aggressive pathology.     

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.     

Minute signet ring cell carcinoma occurring in gastric hyperplastic polyp

We describe a 45-year-old woman with minute signet ring cell carcinoma occurring in a gastric hyperplastic polyp. A biopsy specimen obtained from the gastric hyperplastic polyp revealed signet ring cell carcinoma. Endoscopic mucosal resection （EMR） was performed to confirm the diagnosis. Histological examination of the EMR specimen revealed focal signet ring cell carcinoma in the hyperplastic polyp. There are few cases of gastric hyperplastic polyp associated with signet ring cell carcinoma.     

SYNCHRONOUS MULTICENTRIC SIGNET‐RING CELL CARCINOMA OF THE STOMACH

A case of simultaneous multicentric signet‐ring cell carcinoma (SRC) of stomach is presented. Initially, an early gastric cancer (IIc) was diagnosed and this was cured with distal gastrectomy. Thirty‐eight months after the operation, follow‐up endoscopy revealed a tiny mucosal discoloration lesion, which was diagnosed as a minute SRC focus with biopsy. This was successfully treated with endoscopic mucosal resection (EMR). Nine months later, gastroscopy discovered another small mucosal lesion and it was again diagnosed as a tiny SRC lesion, which was also successfully treated with EMR. After a further 2 months, endoscopy showed three small mucosal lesions (discoloration) similar to previous lesions, two of which proved to be SRC with biopsy. As these lesions distributed widely over the remnant stomach, total gastrectomy of the residual stomach was performed. Pathological examination demonstrated a total of 22 simultaneous multifocal SRC lesions, which were all very small mucosal cancer. These cancers, including previously EMR‐treated ones, seemed to develop in a multicentric manner, as they were diagnosed within 11 months. This case also indicated that even subtle endoscopic findings should vigorously be sought and, if in doubt, be biopsied in order to locate gastric cancer early enough for minimal invasive curative treatment to be feasible.     

Signet ring cell early gastric cancer presenting as an elevated lesion

Early gastric cancer composed of signet ring cell carcinoma is usually present as a depressed lesion and rarely manifests as a protruding lesion. To our knowledge, only eight cases have been reported in the literature. We herein report such a rare lesion which developed in an asymptomatic 55-year-old man.     

PEDUNCULATED GASTRIC SIGNET RING CELL CARCINOMA

Signet ring cell carcinoma (SRCC) is characterized by poor ductal formation and a diffuse progression pattern and generally presents as a depressed lesion in the majority of cases. We describe here an extremely rare case of gastric SRCC that presented as a pedunculated lesion. We hypothesize that the major factor responsible for the elevation of this lesion was proliferation of signet ring cells that did not lose their mutual connections. Among the two cases of early elevated‐type gastric SRCC that have been reported in the literature, this is the first case of pedunculated intramucosal SRCC. Pathological examination revealed no cancer cells in the basal part of the elevated lesion. The cellular morphology was consistent with SRCC, although the ductal structure was well preserved and more similar to well‐differentiated adenocarcinoma. Endoscopic examination showed a smooth‐surfaced lesion with no depressed region around the basal part of the elevated lesion. Because these findings differ significantly from previous reports of elevated SRCC, this report provides further insight into the nature of SRCC.     

Early gastric cancer with Krukenberg tumor and review of cases of intramucosal gastric cancers with Krukenberg tumor

A 47-year-old woman was admitted because of hypermenorrhea. Transvaginal ultrasonography revealed an ovarian tumor and myoma uteri, and total hysterectomy with bilateral salpingo-oophorectomy was performed. Histology revealed signet-ring cell carcinoma in the right ovary. In order to find out the primary site of this tumor, gastroendoscopy was performed after the operation, and showed a IIc lesion in the lower body of the stomach; biopsy specimens showed signet-ring cell carcinoma similar to that in the right ovary. Total gastrectomy revealed that the lesion was an early gastric cancer confined to the mucosa, but there was lymphatic invasion slightly beneath the muscularis mucosa, with regional lymph node metastasis. In the light of a review of the seven cases of early gastric cancer with Krukenberg tumor previously reported, lymphatic metastasis seemed to be the most likely pathway of ovarian metastasis in early gastric cancers.     

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.     

A Type IIc Like Advanced Carcinoma of the Sigmoid Colon —A Case Report—

Abstract: We studied a patient with a sigmoid colon carcinoma, which looked like a type IIc carcinoma when it was, in fact, an advanced carcinoma. This lesion was considered to have developed from an early carcinoma with a depressed appearance. A 79-year-old woman was admitted complaining of a small amount of rectal bleeding. A barium enema examination revealed a flat elevated lesion with converging folds. A colonoscopy revealed a slightly reddish lesion with a central depression 40～50 cm from the anal verge. A biopsy specimen revealed the features of a well differentiated adenocarcinoma. A sigmoidectomy with lymph node dissection was performed. The resected specimen showed a tumor which looked like a so-called type IIc advanced carcinoma, measuring 10×6 mm in size. This lesion was histologically diagnosed as being a well differentiated adenocarcinoma without any adenomatous component. The tumor showed a massive invasion into the submucosal layer and a slight invasion into the proper muscle layer.     

Ultrastructural cytochemical study of enzymes expressed by signet ring cells in gastric cancer

AIM: To study the ultrastructural localization of five marker enzymes (ALPase, ACPase, G6Pase, TPPase and CCOase) in gastric cancer signet ring cells to demonstrate their biologic behaviors.METHODS: Five marker enzymes were examined in signet ring cells of seven gastric cancer patients by ultrastructural enzyme cytochemical techniques.RESULTS: The number of corresponding organelles and the activities of marker enzymes, especially ACPase and TPPase, increased, leading to stronger mucus synthesis, secretion and digestion in gastric cancer signet ring cells. There was a lack of collagenous fibers in the stroma around the cancer nests.CONCLUSION: Signet ring cell carcinoma is very invasive with metastasis rates due to the secretion of proteolytic enzymes.     

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.     

GASTRIC CANCER RETROSPECTIVELY INVESTIGATED FOR 9 YEARS AND 6 MONTHS: A CASE OF LINITIS PLASTICA

This report presents a rare case of a patient with gastric cancer whose clinical course with the development of tumor from early cancer type IIc to advanced cancer of linitis plastica was observed for 9.5 years. The cancer remained in early stage for 3 years and 8 months after the patient’s first endoscopy. At 5 years and 10 months after initial endoscopy, the lesion progressed to advanced cancer, and after 6 years and 7 months sclerotic changes in the gastric wall were detected at the lesion site. After 9 years, advanced gastric cancer of linitis plastica was present throughout the stomach. The initial stage of linitis plastica is considered to be early gastric cancer type IIc with histologically undifferentiated cancer cells. It is widely accepted that a period of 6–8 years is required for this type of cancer to develop from carcinogenesis to completion of lesions. The present case is valuable in that development from early gastric cancer type IIc to linitis plastica during approximately 10 years of follow up was clinically observed, and will contribute to knowledge of the natural history of gastric cancer.     

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     

Hereditary diffuse gastric cancer: predominance of multiple foci of signet ring cell carcinoma in distal stomach and transitional zone

BACKGROUND AND AIMS: Germline mutations in the CDH-1/E-cadherin gene are, to date, the only known cause of hereditary diffuse gastric cancer (HDGC). While two recent series of prophylactic gastrectomy described microscopic foci of signet ring cell carcinoma in sample sections from 10 macroscopically normal stomachs, whole stomach phenotype has not been mapped. We aimed to describe the size and distribution of foci in relation to mucosal zones and anatomical location. METHODS: Six patients (from three HDGC kindred) were referred for total gastrectomy via three different referral pathways. Following fixation, five stomachs were completely blocked and one extensively sampled. Histopathology was mapped to a mucosal photograph of each stomach, enabling precise localisation of carcinoma foci, benign pathology, and mucosal zones. RESULTS: There were 4-318 microscopic foci of intramucosal signet ring cell adenocarcinoma in the six macroscopically normal stomachs (foci size 0.1-10 mm in diameter). The distal third of the stomach contained 48% of total foci (range 29-75%). The body-antral transitional zone occupied 7.7% of mucosal area (range 3.6-11.8) but had 37% of foci (range 10%-75%). The largest foci were found in the transitional zone and foci density was five times greater in the transitional zone than in body or antral type mucosa. CONCLUSIONS: In germline CDH-1 mutation carriers, multiple microscopic foci of intramucosal signet ring cell carcinoma show a predilection for the distal stomach and the body-antral transitional zone. Targeting the transitional zone would maximise the likelihood of finding foci in macroscopically normal gastrectomies, and particular attention should be paid to this area during endoscopy.     

Natural history of gastric cancer—a case followed up for eight years: early to advanced gastric cancer

We experienced a case of gastric cancer that was prospectively followed up for 8?years. With severe heart disease, the patient did not wish surgery or anticancer drug treatment. After informed consent was obtained, he was followed up for 8?years. He received upper gastrointestinal endoscopy every year, which revealed IIc early gastric cancer, and biopsy showed well differentiated adenocarcinoma. A flat and mildly depressed lesion with redness was observed on endoscopy, exhibiting typical morphology of IIc-type early gastric cancer. The appearance of IIc M cancer was observed macroscopically from 2000 to 2003. Four years later, surface irregularity with ulceration appeared. Then, the whole lesion was elevated, which suggested submucosal invasion, and the tumor exhibited the morphology of IIa?+?IIc or type 3. The ulcer became deeper and elevated boundaries were formed. Horizontal expansion of the flat lesion was mild, while invasion to deeper layers was predominant. Eventually, he died of heart failure. Estimated M cancer was observed for about 3?years, followed by invasion to deeper layers. Taken together, this is a valuable case that followed up the manner of invasion to deeper layers over time from early to advanced gastric cancer.     

Small gastrointestinal stromal tumor concomitant with early gastric cancer： A case report

The term gastrointestinal stromal tumors (GISTs)is defined diagnostically as the main group of mesenchymal tumors with spindle or epithelioid cells arising from the wall of the gastrointestinal tract with immunohistochemical reactivity for CD117 antibody.Previous studies revealed that cells in GISTs express a growth factor receptor with tyrosine kinase activity (termed c-kit), which is the product of the c-kit protooncogene. The most specific and practical diagnostic criteria for GISTs are: immunohistochemically determined c-kit (CD117) expression; mitotic score; and tumor size.A small GIST concomitant with early gastric cancer is rarely encountered clinically. Herein we have reported a case of a 1.1-cm GIST detected by esophagogastroduo denoscopy concomitant with a Ⅱc type of early gastric cancer (signet ring cell type). It was detected during a routine physical health examination. To our knowledge,this is the first report of a small GIST concomitant with a signet ring cell type of early gastric cancer.     

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.