A Huge Polypoid Type Early Gastric Neuroendocrine Cell Carcinoma

Abstract: We report a case of a huge polypoid-type early gastric neuroendocrine cell carcinoma. Upper gastrointestinal endoscopy in a 77-year-old man revealed a gastric polyp on the anterior wall of the corpus. Endoscopically biopsied material from the polyp suggested that the lesion was malignant; specifically a poorly and moderately differentiated tubular adenocarcinoma or adenocarcinoma with neuroendocrine differentiation. Endoscopically the lesion was a huge polypoid type with a broad stalk approximately 40 mm in diameter, and its surface was tabulated with a white coat and erosion. The patient underwent total gastrectomy. The resected specimen histopathologically showed a polypoid mass with medullary carcinoma and indicated endocrine cell differentiation. Immunohis-tochemical findings supported the diagnosis of endocrine cell carcinoma. This case was an early and polypoid-type gastric endocrine cell carcinoma. Since examples of such cases are rare in the literature, we report this case in brief.     

Role of Helicobacter pylori in Gastric Neoplasia

Helicobacter pylori infection is one of the most important factors in gastric carcinogenesis in humans. Epidemiological studies have revealed that H. pylori-infected patients develop significantly more gastric cancers than uninfected individuals. In rodent models, H. pylori inoculation causes strong promoting effects in carcinogen-treated animals, whereas the bacterial infection alone causes only hyperplasic, atrophic, and/or metaplastic lesions. In both human and rodent models, eradication of H. pylori helps inhibit gastric carcinogenesis, especially when there is only mild gastric inflammation and no evidence of severe atrophy or intestinal metaplasia. Chemoprevention studies in humans have been reported and have shown the effectiveness of several medications including a cyclooxygenase-2 inhibitor. Candidate chemicals used in rodent models could hopefully be used in humans in the future.     

胃黏膜上皮内瘤变组织中COX-2表达及其临床意义

目的探讨胃黏膜上皮内瘤变组织中环氧合酶(COX)-2蛋白的表达情况及其临床意义。方法采用免疫组织化学技术,检测56例内镜活检病理证实为上皮内瘤变的标本中COX-2蛋白的表达情况。结果(1)经HE染色识别的胃黏膜组织上皮内瘤变56例中轻度不典型增生18例,中度不典型增生18例,重度不典型增生17例,原位癌3例。(2)COX-2蛋白表达在轻度不典型增生、中度不典型增生、重度不典型增生和原位癌的阳性率分别为33.33%(6/18)、50%(9/18)、70.59%(12/17)和100%(3/3),各组间比较差异显著(P0.05)。高级别上皮内瘤变的阳性表达率(75%)明显高于低级别上皮内瘤变者(41.67%),两者比较差异显著(P0.01)。结论检测胃黏膜上皮内瘤变组织中COX-2蛋白表达可以帮助临床识别胃黏膜上皮内瘤变组织,预测胃癌前病变的进展,为临床选择治疗方案(ESD、外科手术等)提供依据。     

胃上皮内瘤变的演变和逆转治疗

胃上皮内瘤变是胃黏膜癌变过程中的重要环节．临床随访研究显示部分低级别上皮内瘤变是可逆的,经适当的治疗,大部分可以消退,仅少数加重或癌变。促进胃上皮内瘤变逆转对预防胃癌具有积极意义。根除幽门螺杆菌有助于减轻胃黏膜萎缩,逆转部分低级别上皮内瘤变,延缓肠化生的发展,补充各种抗氧化剂和微量元素可能有助于预防胃癌,但有限的临床试验证据尚不足以证明其逆转效果;环氧合酶（COX）-2有望成为治疗的靶点;中医中药在治疗胃上皮内瘤变方面积累了许多经验,但尚需更多高质量的循证医学证据。     

Management of Gastric Carcinoids (Neuroendocrine Neoplasms)

Gastric neuroendocrine neoplasms of the stomach can be divided into the usually well-differentiated, hypergastrinemia-dependent type I and II lesions and the more aggressively behaving gastrin-independent type III lesions. Mainly due to better diagnostics and awareness of this tumor, the observed incidence has increased more than tenfold over the last 30?years. Small (<15?C20?mm) localized type I and II lesions that are slowly proliferating (Ki67<2%) can usually be managed conservatively with endoscopic surveillance. Reducing hypergastrinemia by surgical removal of an underlying gastrinoma is important in inhibiting growth and induce reduction of type II lesions, while the specific gastrin receptor antagonist YF476 or gastrin antibodies may become useful for both type I and II lesions. Infiltrating and metastasized tumors and type III lesions require a more aggressive approach with surgical resection and consideration of modalities such as somatostatin analogs, cytotoxics, and peptide receptor targeted treatment.     

Differing Clinical Courses and Prognoses in Patients With Gastric Neuroendocrine Tumors Based on the 2010-WHO Classification Scheme

The aim of this study is to test the prognostic accuracy of the 2010-WHO classification for postsurgery survival in nonmetastatic gastric neuroendocrine tumor (NET) cases. Whether the 2010-WHO classification of NETs can predict relapse after surgical resection has not yet been established.We selected 175 nonmetastatic gastric NET patients at Asan Medical Center, Seoul, Korea between 1996 and 2013. All tumors were classified using the WHO-2010 scheme.Among 175 patients with gastric NETs, we diagnosed 39 cases as WHO grade 1, 13 cases as grade 2, 66 cases as grade 3 (neuroendocrine carcinomas; NECs), and 57 cases as mixed with adenocarcinoma. Patients with grade 3 had a lower relapse-free survival (RFS) and overall survival (OS) than those with WHO grade 1/2 and had a lower OS than patients with mixed type tumors. Patients with grade 1/2 had a better OS than patients with mixed type. There was no significant difference in RFS and OS between small and large cell type lesions. Among WHO grade 1/2 patients with ≤1 cm sized lesions, none exhibited lympho-vascular, perineural, mucosal, or submucosal invasion, and we detected no lymph node metastases or recurrences.Our findings strongly suggest that WHO grade 3 behaves more aggressively than adenocarcinoma. Additionally, the survival of cases with large and small cell NEC was similar. Among WHO grade 1/2 patients who had ≤1 cm lesions, none exhibited lympho-vascular, perineural, mucosal, or submucosal invasion and all could be treated by endoscopic resection or minimally invasive surgery without node dissection.     

Sustained Suppression of Gastric Secretion and the Risk of Neoplasia in the Gastric Mucosa

Long-term risks of medications that cause profound and sustained suppression of acid secretion are an increasing source of concern. Because of concerns over a potentially increased incidence of gastric malignancies in patients with pernicious anemia, clinicians have become increasingly aware of changes in gastric flora, and levels of carcinogen, as well as changes in hormonal milieu, which can accompany profound suppression of acid secretion. The risks of gastric epithelial and endocrine cell neoplasia in patients receiving powerful antisecretory agents are not yet known, but cannot be dismissed until long-term follow-up studies are available. The relationship between proliferation of epithelial and endocrine elements and sustained suppression of acid secretion may provide new insight into processes that regulate replication and growth of cells in the gastric mucosa.     

消化道上皮内瘤变和黏膜瘤变的概念和临床应用

对重度异型增生和早期癌的鉴别，日本和欧关有不同观点，活检诊断的一致率很低。近十年来国际上病理学家达成了一些共识，对异型增生提出了新的分类方案：Padova分类、Vienna分类和世界卫生组织（WHO）专家工作纽意见，共同点是均采用了两级分类法，分为低级别和高级别，但分类术语的命名法和内涵不同。WHO建议对异型增生采用上皮内瘤变的术语，高级别上皮内瘤变包括重度异型增生和原位癌，而Vienna分类的黏膜高级别瘤变包括重度异型增生／腺瘤、非浸润癌（原位癌）、疑浸润癌和黏膜内癌。本文评述新分类的异同点和临床应用注意点。     

Pathologic Validation of Endoscopic Ablative Therapy for Gastric Epithelial Neoplasia: A Randomized Controlled Trial

BackgroundThe effectiveness of endoscopic ablative therapy such as monopolar coagulation (MC) or argon plasma coagulation (APC) have not been validated histologically. The aim of this study was the histologic validation of endoscopic ablative therapy for gastric epithelial neoplasia.Methods: We designed a prospective randomized controlled trial involving patients with gastric low-grade dysplasia. Patients were randomly assigned to either the APC or the MC group. Endoscopic ablative therapy was followed by endoscopic submucosal dissection (ESD) for histologic evaluation. The main outcome was histologic completeness of endoscopic ablative therapy. Results: Sixty-eight patients were recruited, of whom 34 patients underwent APC and 34 patients underwent MC followed by ESD. The APC group showed significantly higher complete eradication rate compared to the MC group (55.9% vs. 11.8%, P < .001). APC was the only significant predictor of histologic complete eradication in multivariate analysis (OR: 7.66; 95% CI: 2.139-27.448). No adverse events related to the procedure occurred in either group.Conclusions: Although APC is a more effective treatment option than MC in the management of gastric epithelial neoplasia, the effectiveness of both methods was limited in eradicating gastric epithelial neoplasia completely. Therefore, endoscopic resection should be a first option for treatment of gastric epithelial neoplasia until the optimal method is established with further studies.     

萎缩性胃炎、肠化、黏膜上皮内瘤变和胃癌

萎缩性胃炎、肠化和上皮内瘤变广义上都被称为胃癌的癌前病变㈡,是胃癌的危险因子,临床提高对其认识,进行随访监视可以检出早期癌变,从而改善患者预后。埘这些病变因观点和体会不同,临床实际操作上有很大不同。     

普通型胃癌伴神经内分泌分化的免疫组织化学观察

目的研究普通型胃腺癌组织学类型、分化程度与神经内分泌（NE）分化的关系.方法随机收集88例手术切除石蜡包埋的胃癌标本,采用Syn、CgA及NSE等3种神经内分泌抗体,用免疫组织化学方法研究其神经内分泌的表达情况.结果在88例普通型胃癌中,38例（43.2%）表达Syn,13例（14%）表达CgA,10例（11%）表达NSE.58例（65.9%）至少有一种NE标记表达,其中18例表达2种标记,仅4例3种标记均表达,3种标记表达彼此相关（P＜0.05）.胃癌中以低分化腺癌、黏液腺癌、印戒细胞癌阳性多见（P＜0.05）.NE阳性与肿瘤大小和浸润深度有关（P＜0.05）,但是NE标志阳性与淋巴转移及临床分期差异无统计学意义（P＞0.05）.结论选择3种NE标记可以检测出胃癌的NE分化,三者联合应用可提高NE分化的诊断率.胃癌的组织类型、分化程度及肿瘤大小和浸润深度与NE分化有关,而NE分化与淋巴结转移及临床分期无关.     

Gastric Neoplasia Developed After Proximal Gastrectomy: Report of Three Cases

The incidence of proximal gastric cancer is increasing and proximal gastrectomy is widely accepted as a standard operation for early staged proximal gastric cancer. Recently, we encountered three aged patients with distal gastric cancer or adenoma after proximal gastrectomy: one with mucosal adenocarcinoma and two with adenoma. These patients showed that carcinoma or adenoma could develop in the distal gastric remnant after proximal gastrectomy. Although gastric remnant cancer has been defined as a cancer that arises in the proximal gastric remnant after distal gastrectomy, it hereafter includes a cancer that arises in the distal gastric remnant after proximal gastrectomy. Endoscopic examination of the distal gastric remnant is important in asymptomatic patients who underwent proximal gastrectomy.     

早期胃癌的临床病理学研究

本文总结了我院经内镜及手术病理证实的早期胃癌53例,认为提高对早期胃癌内镜下分型的认识与鉴别水平,重视内镜普查和对癌前病变的随访,可早期发现胃癌,提高早期胃癌术后5年生存率.同时作者还对影响早期胃癌预后的因素进行了分析,认为癌浸润深度和是否有淋巴结转移是影响早期胃癌预后的主要因素.     

Parietal Cell Dysfunction: A Rare Cause of Gastric Neuroendocrine Neoplasm with Achlorhydria and Extreme Hypergastrinemia

A 69-year-old woman with multiple neuroendocrine neoplasms (NENs) was referred to our hospital. Although she had extreme hypergastrinemia (11,675 pg/mL), no findings that indicated types I to III gastric NENs were found. Although gastric corpus atrophy was suspected on conventional white-light imaging, findings on magnifying endoscopy with narrow-band imaging indicated no severe atrophy. A biopsy from the background fundic gland mucosa revealed no atrophic changes, parietal cells with vacuolated cytoplasm and negative findings for H⁺K⁺-ATPase. Thus, this case was diagnosed as multiple NENs with parietal cell dysfunction. Neither progression nor metastasis has been confirmed during two-year follow-up.     

Stent Thrombosis: A Clinical Perspective

The invention of intracoronary stents greatly increased the safety and applicability of percutaneous coronary interventions. At this time, >1 million coronary stent implantations are performed each year in the United States. But together with the growing use of stents, stent thrombosis, the most feared complication after stent implantation, has emerged as an important entity to understand and prevent. Adjunct pharmacological therapy, stent design, and deployment technique have been adjusted ever since to reduce its occurrence. The current clinical overview of stent thrombosis ranges from its pathophysiology to current state-of-the-art technical and pharmacological recommendations to avoid this complication.