AN ENDOCRINE CELL CARCINOMA WITH GASTRIC‐AND‐INTESTINAL MIXED PHENOTYPE ADENOCARCINOMA COMPONENT IN THE STOMACH

A 77‐year‐old man complained of bodyweight loss, and a Borrmann 3 type lesion was observed endoscopically in the anterior wall of angular region of the stomach. The endocrine cell carcinoma (ECC) having the cytoplasmic staining of chromogranin A (CgA) was detected pathologically in the biopsy samples. The patient underwent distal gastrectomy plus systemic lymph node (LN) dissection (D2 LN dissection), and pathological examination revealed ECC invading the subserosa, and no LN metastasis (pT2N0M0). None of the gastric and intestinal endocrine cell marker expression was apparent in the ECC cells. The lesion also contained a moderately differentiated type tubular adenocarcinoma component, which was judged to be gastric‐and‐intestinal mixed (GI type) phenotype, using gastric and intestinal exocrine cell markers. After the surgery, he left the hospital and started oral doxifluridine (600 mg/day). The patient now (March 2008, about 19 months since the surgery) continues this chemotherapy with no recurrence. In conclusion, we experienced ECC with a GI type adenocarcinoma component. The ECC cases with the GI type adenocarcinoma component may have a relatively good prognosis, being similar to the results of advanced gastric cancers from the viewpoint of gastric and intestinal phenotypic expression.     

Endoscopic mucosal resection for early adenocarcinoma arising in Barrett's esophagus

A 58‐year‐old man was diagnosed to have an esophageal adenocarcinoma arising in Barrett's esophagus by screening examination at the previous hospital. Endoscopically, a slightly reddish elevated lesion with a central depressed component was detected in the Barrett's epithelium. Endoscopic ultrasonography showed the thickness of the second layer of the esophagus and no enlarged lymph node. Histological examination of a biopsy specimen revealed well or moderately differentiated adenocarcinoma. From these findings, the lesion was diagnosed as a mucosal esophageal cancer, type IIa + IIc, arising in Barrett's esophagus. As he refused operation, the lesion was resected endoscopically with his informed consent. Histologically, the resected specimens showed moderately differentiated adenocarcinoma arising in Barrett's esophagus. The adenocarcinoma had invaded the superficial muscularis mucosa, but was limited to the deep one with no vessel invasion. Barrett's esophagus often has a double muscularis mucosa. Connective tissues containing vascular and lymphatic vessels exist between them. However, one consideration is whether the existence of vessels between the double muscularis mucosa and the presence of vessel invasion are risk factors for metastasis. In order for a definitive indication for endoscopic mucosal resection, the frequency of lymph node and distant metastasis in cases of early Barrett's cancer needs to be investigated.     

Mucin phenotype of gastric cancer and clinicopathology of gastric-type differentiated adenocarcinoma

Differentiated adenocarcinoma of the stomach is classified into gastric or intestinal phenotypes based on mucus expression. Recent advances in mucin histochemistry and immunohistochemistry have highlighted the importance of such a distinction, and it is important clinically to distinguish between gastricand intestinal-type differentiated adenocarcinoma. However, a clinical and pathological diagnosis of this type is often difficult in early gastric cancer because of histological similarities between a hyperp...     

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.     

Synchronous occurrence of early neuroendocrine carcinoma and tubular adenocarcinoma in the stomach

This report describes a patient with early neuroendocrine carcinoma (NEC) and tubular adenocarcinoma in the stomach. A 74-year-old Japanese male experienced epigastralgia. Endoscopic examination revealed two small lesions; one was an elevated lesion with ulceration at the posterior wall of the pre-pylorus and the other was a depressed lesion at the greater curvature of the antrum. Pathological diagnosis of the biopsies indicated poorly differentiated adenocarcinoma from the lesion on the pre-pylorus and well differentiated adenocarcinoma from the lesion on the antrum. He was referred to the surgical outpatient clinic with early double cancer of the stomach. A distal partial gastrectomy with lymph node dissection was performed. A histopathological examination revealed NEC at the lesion on the pre-pylorus and well differentiated tubular adenocarcinoma at the lesion on the antrum. These two lesions were completely separate from each other. Therefore, this case is thought to demonstrate the synchronous occurrence of early NEC and tubular adenocarcinoma in the stomach.     

A case of primary gastric small cell carcinoma with a rare pattern of lymph node metastasis

We report a very rare case of primary gastric small cell carcinoma (GSCC) that was accompanied with gastric tubular adenocarcinoma. A male in his 60s had an elevated tumor with a central ulceration in the middle stomach. The patient underwent a distal gastrectomy with lymph node dissection. The pathological examination showed two separated lesions of the stomach, which contained the components of primary GSCC and primary gastric tubular adenocarcinoma. Immunohistochemical (IHC) examination demonstrated that the tumor cells in the small cell carcinoma stained positive for synaptophysin, chromogranin A, and neural cell adhesion molecule (NCAM). GSCC cells and adenocarcinoma cells independently metastasized to each regional lymph node. Further studies on the biological behavior of individual tumors may allow the development of new treatment strategies for GSCC.     

Simultaneous adenocarcinoma and leiomyoma of the stomach presenting as a collision tumor

A 68-year old Japanese man was referred to the Cancer Institute Hospital for the treatment of a rectal cancer. Preoperative esophagogastroduodenoscopy revealed a submucosal tumor with ulcer formation near the esophagogastric junction of the stomach. The initial treatment strategy was to perform a proximal gastrectomy with limited lymph node dissection as well as a simultaneous anterior resection. However, histopathological examination of a biopsy specimen of the submucosal tumor revealed a moderately differentiated adenocarcinoma, and therefore a total gastrectomy with D2 lymph node dissection was performed. Histopathological examination of the resected specimen revealed both adenocarcinoma and leiomyoma presenting as a collision tumor. Preoperative accurate histopathological diagnosis of a gastric submucosal tumor is generally difficult. Consequently, surgical resection of large gastric submucosal tumors may be indicated in the absence of histopathological confirmation of the diagnosis. However, in this case preoperative histopathological diagnosis enabled surgeons to perform the appropriate surgery. We conclude that to determine the appropriate treatment strategy, preoperative histopathological examination of tumors should be performed even in a case of suspected submucosal tumor, particularly if mucosal ulceration is present.     

Gastric cancer following total proctocolectomy for colon cancer associated with ulcerative colitis

Here we report a case of advanced gastric cancer seen after total proctocolectomy for an early colon cancer associated with ulcerative colitis (UC). A 42-year-old man, diagnosed with UC at the age of 21, had undergone total proctocolectomy at the age of 38 for an early ascending colon cancer. Three years later the patient developed tarry stools and epigastric discomfort. Laboratory data showed anemia together with elevated serum p53 antibody. Gastric endoscopy showed thickening folds around a lesion in the stomach body. The pathological diagnosis was poorly differentiated adenocarcinoma with signet-ring cell carcinoma. Total gastrectomy was performed and the resected specimens showed a diffuse infiltrating tumor (scirrhous gastric carcinoma), 11 × 15 cm in size, with multiple lymph node metastases. Histopathological examination revealed diffuse infiltration of cancer cells throughout the gastric wall and invasion of the serosa. Results of cytology on abdominal lavage were positive for cancer cells. Likewise, immunohistochemical staining showed gastric mucin phenotype cancer cells positive for p53. In conclusion, it is important to bear in mind that patients with UC, especially chronically active pancolitis, potentially bear the risk of upper gastrointestinal complications.     

Histogenesis and characteristics of gastric-type adenocarcinomas in the stomach

The characteristics and histogenesis of gastric-type adenocarcinomas were studied for endoscopically removed hyperplastic polyps and intramucosal cancers found in surgically resected stomachs (m-cancers). Among 421 hyperplastic polyps, 14 differentiated-type carcinomas were found (HP-cancer). Eleven (78.6%) of these lesions were gastric-type adenocarcinomas. Out of 65 m-cancers, 22 were undifferentiated-type carcinomas and 43 were differentiated-type carcinomas, the latter being classified into 10 gastric-type adenocarcinomas (23.2%) and 13 intestinal-type adenocarcinomas: the remaining 20 were of mixed gastric and intestinal type. The mean age of the gastric-type adenocarcinoma patients did not differ from that of patients with other differentiated-type carcinomas. No appreciable signs of intestinal metaplasia were noted in HP-cancer polyps. In m-cancers, the degree of intestinal metaplasia of the surrounding mucosa of gastric-type adenocarcinomas tended to be lower than in the other differentiated-type carcinomas, indicating a weak relationship between the histogenesis of gastric-type adenocarcinomas and intestinal metaplasia. Studies by PCNA (proliferating cell nuclear antigen) immunohistochemistry, showed that in over half of the gastric-type adenocarcinoma cases PCNA-positive cells tended to be localized within tumor tissues. In addition, point mutations of the c-Ki-ras gene were detected in 1 gastric-type adenocarcinoma and 2 intestinal-type adenocarcinomas, suggesting the occurence of a common genetic abnormality.Abbreviations PCNA proliferating cell nuclear antigen - GOS galactose-oxidase/Schiff staining - CPSIII paradoxical staining for stable class III mucosubstances using concanavalin A - HP cancer adenocarcinoma arising in a gastric hyperplastic polyp - m-cancer intramucosal carcinomas found in a surgically resected stomach     

Lymphatic invasion in small differentiated-type mucosal gastric cancer

Endoscopic resection for early gastric cancer is indicated for patients who are at negligible risk of lymph node metastasis. A 71-year-old female underwent endoscopic resection for a 15-mm differentiated-type mucosal gastric tumor, as recommended in the Japanese treatment guidelines. A histological examination revealed lymphatic invasion. Therefore, we performed laparoscopy-assisted distal gastrectomy and D1+ lymph node dissection. A histological examination detected no.3 lymph node metastasis, but no residual cancer cells were observed at the site of the endoscopic resection. This case is rare as lymphatic invasion and lymph node metastasis are highly unusual in small differentiated-type mucosal gastric cancer. Having experienced this case, we consider that en-bloc endoscopic resection of such lesions is extremely important, as it allows precise histological examinations to be performed, which can determine the necessity of additional treatment.     

Syndecan-1 and E-cadherin expression in differentiated type of early gastric cancer

AIM: To elucidate the role and alterations of syndecan-1 and E-cadherin expression in different cellular phenotypes of differentiated-type gastric cancers (DGCs). METHODS: A total of 120 DGCs at an early stage, and their adjacent mucosa, were studied both by immunohis-tochemistry. Syndecan-1 and E-cadherin were assessed by immunohistochemical staining with anti-syndecan-1 and anti-E-cadherin antibodies, respectively. Based on immunohistochemistry, DGCs and their surrounding mucosa were divided into four types: gastric type (G-type), ordinary type (O-type), complete-intestinal type (CI-type), and null type (N-type). RESULTS: Syndecan-1 expression was significantly lower in G-type cancers (29.4%) than in O-type (79.6%) and CI-type cancers (90%) (P<0.05, respectively), but E-cadherin did not show this result. In addition, syndecan-1 expression was significantly reduced in DGCs comprised partly of poorly differentiated adenocarcinoma or signet-ring cell carcinoma, compared to DGCs demonstrating papillary and/or tubular adenocarcinoma (P<0.05). G-type intestinal metaplasia (IM) surrounding the tumors was observed in 23.8% of G-type, 4.9% of O-type, and 6.7% of CI-type cancers (P<0.05; G-type vs O-type). Reduction of syndecan-1 expression was significant in G-type IM (25%) compared to non-G-type IM (75%; P<0.05). CONCLUSION: Loss of syndecan-1 plays a role in the growth of G-type cancers of DGCs at an early stage, and the reduction of syndecan-1 expression in IM surrounding the tumors may influence the growth of G-type cancer.     

Cardiac tamponade due to metastasis from early gastric cancer

We report a case of cardiac tamponade caused by metastasis from early gastric cancer. A 44-year-old woman was detected to have an abnormality of the stomach on barium meal during an annual medical checkup. Gastroendoscopy disclosed superficial depressed gastric lesions, and histopathological examination of biopsy specimens revealed the diagnosis of poorly differentiated adenocarcinoma and signet-ring cell carcinoma. Computed tomography (CT) and ultrasonography (US) revealed no evidence of metastasis. We performed distal gastrectomy with regional lymph node dissection. Histopathological examination revealed poorly differentiated adenocarcinoma and signet-ring cell carcinoma confined to the mucosal layer. Lymphatic invasion was detected only in the mucosal region beneath the tumor; however, lymph node metastasis was found in almost half of dissected lymph nodes. Adjuvant chemotherapy was administered on an outpatient basis with 36 courses of mitomycinC infused (8 mg/day) once every 4 weeks. However, 3 years after the surgery, the patient developed cardiac tamponade due to carcinomatous pericarditis. We performed drainage of the malignant effusion and initiated treatment with S-1 and docetaxel. Although the patient showed some clinical improvement, the patient died 15 months after the occurrence of cardiac tamponade.     

Solitary gastric Peutz-Jeghers type stomach polyp mimicking a malignant gastric tumor

Most cases of Peutz-Jeghers type polyps of the stomach are associated with mucocutaneous pigmentation and multiple intestinal polyposis. A solitary Peutz-Jeghers type polyp of the stomach is rare. We here report a case of a 71-year-old woman with a solitary Peutz-Jeghers type polyp of the stomach who presented with intolerable epigastric pain and weight loss of 5 kg over the prior two months. During the hospital treatment course for this patient, endoscopic examination revealed a bulging lesion with a central hole, mucosal ulceration, an asymmetrical wall thickness and a narrowing of the gastric lumen. A gastric biopsy further revealed ulceration with moderate dysplasia. The patient received endoscopic ultrasonography which showed a second subepithelial lesion that measured 4 cm × 3 cm. Computed tomography of the abdomen subsequently showed a thickened gastric wall with three visibly enlarged lymph nodes, all greater than 1 cm. The suspected diagnosis was malignant gastric cancer with lymph node metastases. The other lesion, which measured 2 cm × 2 cm × 1 cm was noted in the submucosa of the jejunum during surgery. The patient was treated using a subtotal gastrectomy and partial resection of the jejunal tumor. The final pathological report indicated a gastric Peutz-Jeghers type polyp with proliferation of smooth muscle bundles in the submucosal layer, and hyperplastic glands in the mucosal layer and ectopic pancreas of the jejunum. This is the first reported clinical case of a solitary Peutz-Jeghers type polyp of the stomach accompanying a lymph node enlargement and ectopic pancreas in the jejunum that simulates stomach cancer with lymph node metastases.     

P27和Fas在胃癌组织中的表达及其临床意义

目的研究P27和Fas在不同病理类型胃癌组织中的表达,以探讨P27和Fas在胃癌发生中的作用与其预后的关系。方法应用免疫组化SP法检测P27、Fas在135例胃癌组织及45例正常胃黏膜组织中的表达情况,胃癌病理组织学分型应用HE染色法。结果胃癌组织中P27、Fas阳性表达率分别为45.93%和42.96%,明显低于正常胃黏膜组织的84.44%和77.78%,胃高中分化腺癌P27阳性表达率(65.45%)高于胃低分化腺癌(33.96%)和黏液癌(40.74%)(P均<0.05),胃高中分化腺癌Fas阳性表达率(60.00%)也明显高于胃低分化腺癌(33.96%)和黏液癌(33.33%)(P均<0.05),P27和Fas阳性表达在胃低分化腺癌与胃黏液癌之间均无显著性差异;无淋巴结转移组P27和Fas阳性表达率分别为48.00%和72.00%,均明显高于有淋巴结转移组的22.50%和40.00%;术后生存期≥5年的胃癌组织中P27表达阳性率(52.63%),Fas表达阳性率(57.89%)均高于生存期<5年组两者阳性表达率(均为16.67%),胃癌组织中P27阳性者的Fas阳性表达率显著高于P27阴性者(P<0.05),二者呈正相关。结论胃癌组织中P27、Fas表达下降,二者在胃癌中的低表达可能与胃癌的分型、恶性程度、淋巴结转移及生存期有关,对胃癌的发生可能起协同作用。检测胃癌组织中P27和Fas的表达有助于判断肿瘤的进展程度和预后。     

EARLY GASTRIC CANCER WITH WIDESPREAD DUODENAL INVASION WITHIN THE MUCOSA

We report a rare case of early gastric cancer confined to the mucosal layer with extensive duodenal invasion, curatively removed with distal gastrectomy. An 84‐year‐old Japanese woman was referred to our hospital with gastric cancer. A barium meal examination and esophagogastroduodenoscopy revealed an irregular nodulated lesion measuring 6.5 x 5.5 cm in the gastric antrum and an aggregation of small nodules in the duodenal bulb. A biopsy specimen showed well‐differentiated adenocarcinoma. The patient underwent distal gastrectomy with partial resection of the duodenal region containing the tumor and regional lymph node dissection, with no complication. Histological examination of the resected tissue confirmed well‐differentiated adenocarcinoma limited to the mucosal layer and without lymph node metastasis. The cancer extended into the duodenum as far as 38 mm distant from the pyloric ring, and the resected margins were free of cancer cells. Gastric cancer located adjacent to the pyloric ring thus has the potential for duodenal invasion, even when tumor invasion is confined to the mucosal layer. In such cases, care should be taken during examinations to detect duodenal invasion, and the distal surgical margin must be negative given sufficient duodenal resection.     

Localized amyloidosis of the stomach mimicking a superficial gastric cancer

A 73-year-old man was referred to our hospital for further examination of a depressed lesion in the stomach found by cancer screening gastroscopy. A barium upper gastrointestinal series showed an area of irregular mucosa measuring 15 mm on the anterior wall of the gastric body. Esophagogastroduodenoscopy revealed a 15 mm depressed lesion on the anterior wall of the lower gastric body. We suspected an undifferentiated adenocarcinoma from the appearance and took some biopsies. However, histology of the specimens revealed amyloidal deposits in the submucosal layer without malignant findings. Congo red staining was positive for amyloidal protein and green birefringence was observed under polarized light microscopy. Congo red staining with prior potassium permanganate incubation confirmed the light chain (AL) amyloid type. There were no amyloid deposits in the colon or duodenum. Computed tomography of the chest, abdomen, and pelvis showed no remarkable findings. Thus, this case was diagnosed as a localized gastric amyloidosis characterized by AL type amyloid deposition in the mucosal or submucosal layer. As the clinical outcome of gastric AL amyloidosis seems favorable, this case is scheduled for periodic examination to recognize potential disease progression and has been stable for 2 years.     

Metastatic primary gastric adenocarcinoma in amigdala

We report the case of a 79 years old female patient, with a one year history of dysphagia, presence of a tumor in the right palatine tonsil and cervical lymph node involvement. A biopsy of the palatine tonsil tumor informed as an adenocarcinoma was performed followed by a gastroscopy that reported a lesion in gastric body and antrum whose histologycal diagnosis was a moderately differentiated tubular adenocarcinoma. The patient received chemotherapy with 5FU. We present this case due to the unusual presentation of metastasis to the palatine tonsil and also for being the first manifestation of a gastric cancer.     

Gastric cancer with multiple intramural metastases and metastasis to the small intestine which eventually developed Trousseau’s syndrome: report of a case

Here we report a rare case of Trousseau’s syndrome in a patient with gastric cancer with multiple intramural metastases and metastasis to the small intestine. A 70 year-old male complaining of appetite loss and weight loss of 7 kg within 3 months was admitted to hospital. Esophagogastroduodenal endoscopy revealed an advanced gastric cancer at the pylorus almost occluding the outlet of the stomach, and multiple ulcerative lesions throughout the stomach. A biopsy showed poorly differentiated adenocarcinoma. The patient underwent total gastrectomy. During surgery, part of the distal ileum was found to be abnormally firm and approximately 1 m of the ileum with the cecum colon was resected. Pathologic examination confirmed poorly differentiated adenocarcinoma at the pylorus and multiple intramural metastases in most other areas of the stomach. Lymph node metastases were confirmed in 12 out of 40 harvested regional lymph nodes including one positive paraaortic lymph node. The resected ileum contained multiple tumors with ulceration. Massive lymphatic invasion in the stomach and the small intestine was observed, which strongly suggested lymphatic spread of the gastric cancer. The patient was discharged on post-operative day 21; however, 2 months after surgery, he developed multiple cerebral thromboembolisms and died 2 weeks later.     

Case with double primary cancers occurring synchronously in both the lung and jejunum diagnosed according to TTF-1 expression]

A 47-year-old man was diagnosed as having adenocarcinoma of the lung (T4N0M0) in August 2002. He received chemotherapy and radiotherapy. In June 2003, he complained of lower abdominal pain with palpable mass in the left lower abdomen. On abdominal CT, we recognized a mass measuring 50 mm, which we considered a mesenteric lymph node. As the mass gradually grew and pain increased, we performed lymph node resection. The lymph node was near by the Treitz' ligament, and a tumor measuring 30 mm was observed in the jejunum. Therefore, we performed jejunectomy. Pathological examination of the lesion demonstrated adenocarcinoma. The differential diagnosis between small intestine metastasis and primary small intestine cancer was difficult. As adenocarcinoma of the jejunum was negative for TTF-1 in immunohistochemical staining and adenocarcinoma of the lung was positive, we diagnosed this patient as having primary jejunal cancer. We report this rare case of double cancer involving the lung and jejunum.