Metastasizing intramucosal gastric carcinomas. Well differentiated type and proliferative activity using proliferative cell nuclear antigen and Ki-67

Case report: A rare case of very well-differentiated gastric adenocarcinoma of gastric type with a lymphovascular invasion

Background

Very well-differentiated gastric adenocarcinoma (VWDA) is a rare variant of gastric cancer, for which the diagnostic criteria and clinical behavior are not fully established. We reported a case of an intramucosal VWDA of gastric type with a lymphovascular invasion (LVI).

Case presentation

A 67-year-old female was diagnosed as intramucosal gastric adenocarcinoma after a biopsy at the local hospital 3 weeks ago and then visited our hospital for further treatment. The endoscopic examination in our hospital showed a rough, slightly faded, 30-mm, flat, and elevated lesion on the lesser curvature of the middle gastric body. Histopathologically, the lesion consisted of superficial foveolar-type papillary adenocarcinoma and deep pyloric gland-type tubular adenocarcinoma. The immunostaining results showed that the foveolar-type papillary adenocarcinoma was positive for MUC5AC and had a high index of Ki-67, but the pyloric gland-type tubular adenocarcinoma was positive for MUC6 and had a low index of Ki-67. Both components were negative for MSH2 and MSH6, which suggested the high microsatellite instability phenotype. Moreover, a LVI was detected in the lesion. The pathological diagnosis was VWDA of gastric type.

Conclusion

The case has unique histological and immunophenotypic characteristics, which not only indicates the importance of architectural features in the diagnosis of VWDA but also further proves that the aggressive behavior of VWDA is correlated with tumor histological type and immunophenotype.

Rapidly Growing Papillary Well-Differentiated Adenocarcinoma in a Patient With a Helicobacter pylori-Naive Gastric Mucosa

Although undifferentiated adenocarcinomas and fundic gland-type carcinomas are known as Helicobacter pylori-naive gastric carcinomas, well-differentiated gastric phenotype adenocarcinomas with papillary growth are rare. We encountered a case of a rapidly growing pedunculated well-differentiated adenocarcinoma in a patient with a H. pylori-naive gastric mucosa. The tumor had characteristics of a gastric phenotype (pepsinogen I and H and K-adenosine triphosphatase staining negative; diffusely positive for both mucin-5AC [MUC-5AC] and MUC-6; and MUC-2, common acute lymphocytic leukemia antigen 10 [CD-10], and p53 negative) and treated with endoscopic mucosal resection. We report our case along with a relevant literature review.

Endoscopic Submucosal Dissection for Adenocarcinomas of the Esophagogastric Junction

BACKGROUND

Adenocarcinoma of the esophagogastric junction (EGJ) is uncommon in Eastern countries, including Japan, but it is believed that the incidence of EGJ adenocarcinoma will increase in Asia in the future due to the decreasing incidence of Helicobacter pylori infection. Endoscopic submucosal dissection (ESD) is a minimally invasive and curative treatment that allows precise pathological assessment.

SUMMARY

Magnifying endoscopy with narrow-band imaging may be useful for differential diagnoses and for delineating the cancer margin of EGJ adenocarcinoma, but subsquamous carcinoma extension, which is the invasion of EGJ adenocarcinoma beneath the normal esophageal squamous epithelium, makes it difficult to detect cancer margins of the oral side in ESD for EGJ adenocarcinoma. Since subsquamous carcinoma extension was reported to be less than 1 cm in most cases, the oral safety margin that is placed 1 cm from the squamocolumnar junction is useful for negative cancerous horizontal margin. A multicenter retrospective study of esophageal adenocarcinoma including EGJ adenocarcinoma showed that mucosal and submucosal cancer within 500 μm from the muscularis mucosa without lymphovascular involvement, a poorly differentiated component, and lesion size over 3 cm were not associated with metastasis. Several retrospective studies about ESD for EGJ adenocarcinoma have suggested feasible short-term and long-term outcomes using curative criteria based on gastric cancer guidelines. Key Messages: ESD would be a good first-line treatment for superficial EGJ adenocarcinoma, including Barrett's adenocarcinoma. Additional information about the incidence of metastasis would help confirm the indication of ESD for EGJ adenocarcinoma.

Differences in the pathological diagnosis of colorectal neoplasia between the East and the West: Present status and future perspectives from Japan

It is well known that there are discrepancies in the diagnosis of gastrointestinal neoplasia between Western and Japanese pathologists. In the West, colorectal cancer (CRC) is defined by invasion through the muscularis mucosa into the submucosa, especially depending on the presence of desmoplasia. In Japan, however, CRC is defined based on a combination of nuclear and architectural abnormalities, regardless of invasion status. As a result, intramucosal carcinoma is diagnosed as high-grade dysplasia and even intramucosal carcinoma with poorly differentiated component is classified as 'Tis' in the West. It is logical and reasonable that the term 'T1' is used to currently describe intramucosal carcinoma. Use of the term 'high-grade dysplasia' for intramucosal CRC is outdated. In order to determine appropriate clinical treatment of CRC, the various risk factors of metastasis should be fully evaluated. With improved contributions and communication between pathologists and clinicians, overtreatment and inadequate follow up can be avoided. The discrepancies in the diagnosis of CRC between Western and Japanese pathologists may be addressed by an increase in East-West exchange. In addition, in the future, molecular analysis may also be useful for establishment of standardized diagnostic criteria of CRC.

Histopathological characteristics of hypervascular cholangiocellular carcinoma as an early stage of cholangiocellular carcinoma

AIM

Prognosis of hypervascular cholangiocellular carcinoma (h-CCC) is reportedly better than that of ordinary hypovascular CCC (o-CCC). The aim of this study is to clarify the histopathological characteristics of h-CCC.

METHODS

On the basis of the findings in the arterial phase of contrast-enhanced computed tomography, 16 cases of mass-forming-type CCC were divided into two groups (h-CCC, n = 8; o-CCC, n = 8). Areas of high (Area H-a) and low (Area H-b) attenuation in h-CCC cases and areas of low attenuation in o-CCC cases (Area O) were delineated. These areas were then evaluated histopathologically to determine the proportion of tumor cells, fibrous stroma, arterial vessel density, and immunohistochemical expression of Vascular endothelial growth factor; angiopoietin-2; cytokeratin 7, CK19, SOX9 and SOX17 genes; epithelial cell adhesion molecule; and the Bmi-1, Ki-67, epithelial membrane antigen and polyclonal carcinoembryonic antigen.

RESULTS

The areal ratio of tumor cells decreased and that of fibrous stroma increased in the following order: Area H-a, Area H-b and Area O. Values for AVD and neural cell adhesion molecule positivity rate were significantly higher in Area H-a than in Areas H-b or O. Expressions of vascular endothelial growth factor and angiopoietin-2 were significantly higher in Areas H-a and H-b than in Area O. The Ki-67 labeling index increased in the following order: Area H-a, Area H-b and Area O.

CONCLUSION

A high areal ratio of tumor cells and AVD as well as a high expression of stem cells and angiogenic markers were observed in cases of h-CCC, whereas the areal ratio of fibrous stroma and malignant potential were low. These results suggest that h-CCC may represent the early stage of CCC.

MET-Amplified Intramucosal Gastric Cancer Widely Metastatic after Complete Endoscopic Submucosal Dissection

Intramucosal gastric cancer (IGC) is associated with a very low risk of lymph node metastasis; thus it is the main candidate for minimally invasive surgical procedures, such as endoscopic submucosal dissection (ESD). Herein, we document an extraordinary case of IGC, which showed a very aggressive clinical course. A 66-year-old female underwent ESD for early gastric cancer. Histologically, the tumor consisted mainly of moderately differentiated adenocarcinoma measuring 1.6 cm in diameter, and the tumor was confined to the mucosa. Despite annual esophagogastroduodenoscopic follow-up, the tumor recurred, with wide metastasis to multiple lymph nodes and bones throughout the body after three years. Fluorescence in situ hybridization study demonstrated MET gene amplification as well as low grade polysomy 7 in both original and recurrent tumors. The clinical characteristics of metastatic IGCs and the implication of MET amplification are discussed.

Depressed type of intramucosal differentiated-type gastric cancer has high cell proliferation and reduced apoptosis compared with the elevated type

BACKGROUND

The depressed type of early gastric cancer, in comparison to the elevated type, tends to invade the submucosal layer and metastasize to the lymph nodes. This study compared the differences in tumor cell proliferation and apoptosis between the elevated and depressed types of intramucosal differentiated gastric cancer.

METHODS

A total of 57 intramucosal differentiated gastric cancers were studied. Twenty samples were the elevated type and 37 were the depressed type. The tumor cells were analyzed by immunohistochemistry for Ki-67, Bcl-2, and Bax, and terminal deoxynucleotidyl transferase 2´-deoxyuridine, 5´-triphosphate (dUTP)-biotin nick end labeling was carried out to detect apoptotic cells.

RESULTS

(1) The Ki-67 labeling index (KI) was higher in the depressed type (median: 38.6) than in the elevated type (median: 21.2). (2) Immunopositivity for Bax and the apoptosis index (AI) were lower in the depressed type (median AI: 0.20) than the elevated type (median AI: 1.05). (3) The AI/KI was lower in the depressed type (median: 0.17) than in the elevated type (median: 5.57). (4) The AI in the tumors with a Bcl-2-negative and Bax-positive pattern (median: 2.0) was higher than that in the tumors with a Bcl-2-positive and Bax-negative pattern (median: 0.2).

CONCLUSION

These results show that, regarding cell proliferation and apoptosis, the depressed type of intramucosal differentiated-type gastric cancer has high malignant potential in comparison to the elevated type.

Significance of dysadherin and E-cadherin expression in differentiated-type gastric carcinoma with submucosal invasion

Dysadherin is a cancer-associated cell membrane glycoprotein that down-regulates E-cadherin and plays important roles in tumor progression and metastasis. Differentiated-type gastric carcinoma can be classified into 2 histologic subtypes according to the presence of poorly differentiated components: a mixed type (differentiated carcinoma with poorly differentiated components) and a pure type (purely differentiated-type adenocarcinoma). We studied the clinicopathologic features of 318 cases of differentiated-type gastric carcinoma with submucosal invasion and evaluated the immunohistochemical expression of dysadherin and E-cadherin. We also evaluated 46 cases of metastatic lymph nodes. Tumors with combined dysadherin-positive (≥50%) expression and E-cadherin-negative (<50%) expression had significantly higher proportions of the moderately differentiated type, deeper submucosal invasion, positivity of lymphatic permeation, and positivity of lymph node metastasis than tumors with other combinations of dysadherin and E-cadherin expression (P = .0009, P = .0015, P = .0273, and P = .0187, respectively). Moreover, the frequency of dysadherin-positive (≥50%) expression was higher in the mixed type (60.3%) than in the pure type (12.4%) (P < .0001), whereas the frequency of E-cadherin-negative (<50%) expression was higher in the mixed type (84.5%) than in the pure type (50.5%) (P < .0001). The frequency of dysadherin expression in the metastatic lymph nodes (80.4%) was significantly higher than that in the primary tumors (45.7%) (P = .001). Dysadherin-positive (≥50%) expression and E-cadherin-negative (<50%) expression may be correlated with the mixed type. Combined dysadherin-positive (≥50%) expression and E-cadherin-negative (<50%) expression may be valuable information for predicting aggressive tumor behavior.

Predicting lymph node status in early gastric cancer

Accurate prediction of lymph node (LN) status is of crucial importance for appropriate treatment planning in patients with early gastric cancer (EGC). However, there is no definitive consensus yet on which patient and/or tumor characteristics are associated with LN metastasis. A systematic search for studies investigating the relationship between patient and/or tumor characteristics and LN metastasis in EGC was performed in PubMed/MEDLINE. Patient and/or tumor characteristics associated with LN metastasis were identified by meta-analyzing results of individual studies. Forty-five studies were included. Variables significantly associated with LN metastasis in gastric cancer limited to the mucosa were: age younger than 57 years, tumor location in the middle part of the stomach, larger tumor size, macroscopically depressed tumor type, tumor ulcerations, undifferentiated tumors, diffuse tumor type according to the Lauren classification, lymphatic tumor invasion, tumors with a proliferating cell nuclear antigen (PCNA) labeling index of more than 25%, and matrix metalloproteinase-9-positive tumors. Variables significantly associated with LN metastasis in gastric cancer limited to the submucosa were: female sex, tumor location in the lower part of the stomach, larger tumor size, undifferentiated tumors, increasing depth of submucosal invasion, lymphatic tumor invasion, vascular tumor invasion, increased submucosal vascularity, tumors with a PCNA labeling index of more than 25%, tumors with a gastric mucin phenotype, and vascular endothelial growth factor-C-positive tumors. We identified several variables associated with LN metastasis in EGC. These variables should be included in future research, in order to assess which of these variables remain as significant predictors of LN metastasis.

Overexpression of Phosphorylated Histone H3 is an Indicator of Poor Prognosis in Gastric Adenocarcinoma Patients

Ki-67 immunostaining is commonly used for assessing cell proliferation, but studies of its use as a prognostic indicator have revealed discordant results in gastric cancer patients. Recently, antibodies for phosphorylated histone H3 have been used to identify dividing cells because of its precise overexpression in mitosis. The authors tested the hypothesis that phosphorylated histone H3 overexpression might be a good prognostic indicator for gastric cancer patients by conducting an immunohistochemical comparison with Ki-67 in gastric cancer samples. One hundred twenty-two surgically resected primary cases were selected and histologically categorized in accordance with Lauren's classification. No correlation was found between phosphorylated histone H3 and Ki-67 regarding overexpression. However, correlations between phosphorylated histone H3 overexpression and clinicopathologic variables were noted for histologic type (intestinal type predominant in high labeling indices [LIs], defined as over the value of the 75th percentile; P<0.01), vessel invasion (positive in high LIs; P=0.05), and lymph node metastasis (positive in high LIs; P=0.04). With regard to Ki-67 overexpression, no correlation was evident with the clinicopathologic variables except histologic type (intestinal type predominant; P=0.05). By the Kaplan-Meier method with the log-rank test, cases overexpressing phosphorylated histone H3 showed a poorer prognosis than cases with low expression (P<0.01). In contrast, Ki-67 expression did not influence prognosis. Multivariate analyses indicated phosphorylated histone H3 overexpression to be an independent prognostic factor, together with lymphatic invasion and venous invasion (P<0.01). In conclusion, it seems likely that phosphorylated histone H3 plays an important role in the prognosis of gastric cancer, and its immunohistochemical investigation is useful for the prediction of prognosis in gastric cancer.

Characteristics of submucosal gastric carcinoma with lymph node metastatic disease

AIM

To study the correlation between lymph node metastatic disease and various pathological parameters. Lymph node metastasis is the most important factor in determining the prognosis of patients with early gastric cancer and is significantly associated with the submucosal invasion of neoplastic cells. However, the depth of submucosal layer as well as the depth of submucosal tumour invasion varies among different cases.

METHODS AND RESULTS

We studied various pathological parameters including the macroscopic appearance, location, size, area, differentiation, invasion depth, vascularity and fibrosis of submucosal gastric carcinomas (SMGC), using 248 age- and sex-matched tissue samples. The presence of lymphatic emboli, a larger area, greater size, a non-flat gross type and an increased vascularity of the tumour were significantly associated with node-positive SMGC. Among the three depth-related parameters, the ocular scale measurement, the sm3 method and the sm2 method, only the ocular scale measurement showed a significant correlation with node-positive SMGC. Using multivariate analysis, the incidence of lymph node metastasis increased in the lymphatic tumour emboli and in the tumours that invaded more than half of the submucosal layer.

CONCLUSIONS

These histological indicators seem to be a feasible and easy way to predict lymph node metastatic disease from limited surgery specimens. Pathologists should carefully investigate the lymphatic invasion of tumour cells and measure the invasion depth of the tumour.

Characteristics of intramucosal gastric carcinoma with lymph node metastatic disease

AIM

Recent trends in treatment strategy for early gastric cancer (EGC) are towards minimal surgical procedures, such as endoscopic mucosal resection and laparoscopic partial resection. There is a possibility of incomplete removal of regional lymph nodes in minimal procedures, which may subsequently decrease the chance of a cure. Therefore, it is essential to be able to predict lymph node status and to make careful selection of candidates for mucosal resection.

METHODS AND RESULTS

We studied the relationship between lymph node status and various pathological parameters including macroscopic appearance, location, size, differentiation, presence of ulceration, vascularity, presence of gastritis cystica profunda-like glandular proliferation, disruption of the muscularis mucosae and invasion into the muscularis mucosae, using age- and sex-matched samples of 40 node-positive and 80 node-negative tumours to define the characteristics of intramucosal EGCs. Histological differentiation (P < 0.001), increased submucosal vascularity (P < 0.05), breakdown of the muscularis mucosae (P < 0.05), and invasion of tumour cells into the muscularis mucosae (P < 0.05) were correlated with the lymph node status of intramucosal gastric carcinoma. Furthermore, diffuse type histology (P < 0.001) and deep invasion into the muscularis mucosae (P < 0.05) were indicators of node-positive intramucosal EGCs.

CONCLUSIONS

These histological indicators are easily accessible and seem to predict lymph node metastatic disease in limited surgical specimens. Patients should be carefully selected despite the recent trend toward less invasive resection of EGCs, especially for those apparently confined to the mucosa.

Vascular endothelial growth factor-C expression predicts lymph node metastasis of human gastric carcinomas invading the submucosa

We examined the relationship between vascular endothelial growth factor (VEGF)-C expression and lymph node metastases in gastric carcinomas invading the submucosa. Of the six human gastric carcinoma cell lines, two constitutively expressed VEGF-C mRNA. In three of 12 gastric biopsy specimens (25%), VEGF-C mRNA was detected in tumour tissues, but not in corresponding normal mucosa by reverse transcriptase-polymerase chain reaction (RT-PCR). Of the 139 resected gastric carcinomas, 44 (32%) showed intense cytoplasmic VEGF-C immunoreactivity in many cancer cells at the invading edge. VEGF-C immunoreactivity was associated with greater depth of tumour invasion, lymphatic invasion and lymph node metastases. In addition, vessel count was also significantly higher in the VEGF-C immunoreactive tumours than in other tumours. These results suggest that VEGF-C may be involved in the progression of human gastric carcinoma, particularly via lymphangiogenesis. VEGF-C expression at the invading edge of a gastric carcinoma may be a sensitive marker for metastasis to the lymph nodes.

Increased proliferative activity caused by loss of p21(WAF1/CIP1) expression and its clinical significance in patients with early-stage gastric carcinoma

BACKGROUND

Recurrences of gastric carcinoma are likely to take on a variety forms, even after patients undergo curative resection for early-stage gastric carcinoma. It is important to identify the biologic markers that predict tumor progression and survival in these patients. Proliferating cell nuclear antigen (PCNA) acts as a processivity factor for DNA polymerase delta, which is involved directly in DNA synthesis, and the PCNA level is correlated with the proliferative state of cells. p21(WAF1/CIP1) interacts with PCNA to inhibit DNA synthesis and plays a central role in regulating the cell cycle. The authors investigated patients with early-stage gastric carcinoma to determine the clinical significance of proliferative activity and p21 expression.

METHODS

Tissue specimens from 133 Japanese patients with early-stage gastric carcinoma that invaded the submucosal layer were immunostained with a monoclonal antibody against PCNA and p21(WAF1/CIP1), and the correlations between the PCNA labeling index and p21(WAF1/CIP1) expression as well as clinicopathologic factors were investigated.

RESULTS

The PCNA labeling index varied from 9.9% to 81.4%, (mean, 31.2%). The incidence of p21 positive expression was 87 of 133 patients (65.4%). The patients with a high labeling index had a significantly higher rate of lymph node metastasis (P < 0.01) and loss of p21(WAF1/CIP1) expression (P < 0.05) compared with the patients with a low labeling index. The 5-year survival rate for patients in the high labeling index group (87.0%) was significantly lower compared with the 5-year survival rate for the patients in the low labeling index group (98.6%; P < 0.05).

CONCLUSIONS

Loss of p21(WAF1/CIP1) expression contributes to the amplification of proliferative activity in patients with early-stage gastric carcinoma. Estimation of the proliferative activity of early-stage gastric carcinoma provides information on lymph node metastasis and prognosis. Even after patients undergo curative resection, those with early-stage gastric carcinoma should be followed closely.

The biologic features of intramucosal gastric carcinoma with lymph node metastasis

This review concentrates on the clinicopathologic studies and molecular biologic studies of intramucosal gastric carcinomas (IMGCs) with lymph node metastasis that have been published to date. There have been several reports in which IMGCs with lymph node metastasis were compared with IMGCs without lymph node metastasis from the view of clinicopathologic features. However, there have been a few reports in which IMGCs with lymph node metastasis were compared with IMGCs without lymph node metastasis from the view of molecular biologic features. In general, IMGCs with lymph node metastasis have been commonly reported to be large lesions, poorly differentiated adenocarcinoma, and associated with peptic ulcer, in comparison with IMGCs without lymph node metastasis. Regarding genetic studies or molecular biologic studies, only DNA distribution pattern, proliferative cell nuclear antigen and the monoclonal antibody Ki-67, or matrix metalloproteinases 2 and 9 have been investigated in IMGCs with lymph node metastasis. The malignant potential of the carcinoma cells cannot been evaluated by a clinicopathologic study with the use of hematoxylin and eosin staining. It may be unavoidable that minimal operation is widely accepted for the treatment of IMGCs. It may be more essential to establish the staging by both clinicopathologic and molecular biologic examinations to rule out the presence of IMGCs with lymph node metastasis.

Hemoglobin content in intramucosal gastric carcinoma as a marker of histologic differentiation: a clinical application of quantitative electronic endoscopy

BACKGROUND

It has been suggested that the endoscopic color of intramucosal gastric carcinoma is correlated with mucosal vascularity within the carcinomatous tissue. The development of electronic endoscopy has made it possible to quantitatively measure the mucosal hemoglobin volume, using a hemoglobin index. The aims of the present study were to investigate whether this hemoglobin index is useful for evaluating the change in color of early gastric carcinoma and to verify the diagnostic value of this index for distinguishing between histologic degrees of differentiation.

METHODS

The ratios of the hemoglobin index of cancerous and non-cancerous mucosa for 26 differentiated and 18 undifferentiated intramucosal gastric carcinomas were determined from electronic endoscopic imaging data.

RESULTS

The mean ratio of the hemoglobin index of cancerous and non-cancerous mucosa in the differentiated gastric carcinomas was higher than it was in the undifferentiated carcinomas (1.23: 95% CI [1.15, 1.31] versus 0.84: 95% CI [0.81, 0. 88]). The sensitivity and specificity for discriminating undifferentiated from differentiated carcinoma were 100% and 85%, respectively.

CONCLUSION

Measurement of mucosal hemoglobin volume (hemoglobin index) is useful for evaluating the endoscopic color of early gastric carcinoma quantitatively and may be helpful in distinguishing differentiated from undifferentiated carcinoma.

Prognostic value of p53, proliferating cell nuclear antigen, and Ki-67 expression in undifferentiated nasopharyngeal carcinomas

In this study the prognostic importance of p53, proliferating cell nuclear antigen (PCNA), and Ki-67 expression was analyzed along with the clinical parameters in 35 consecutive patients with undifferentiated nasopharyngeal carcinomas. Immunohistochemistry was used to detect p53, PCNA, and Ki-67 staining. Among the clinical findings, stage IV disease (P = 0.01), cranial nerve paralysis (P = 0.02), and lymph node metastasis (P = 0.06) were associated with shorter survival. The p53 positivity correlated with the presence of lymph nodes, but it was not a significant factor to predict the outcome. PCNA expression was not found to be a prognostic indicator. On the other hand, the proliferative value of Ki-67 staining was suggestive of prognosis. A proliferation index of Ki-67 less than 10% indicated longer survival (P = 0.03). There was no correlation between Ki-67 staining and PCNA index. As a result, the prognostic value of Ki-67 may alert the physician to more aggressive and adjuvant treatment modalities.

Microvessel count, proliferating cell nuclear antigen and Ki-67 indices in gastric adenocarcinoma

The aim of the present study was to immunohistochemically investigate the prognostic value of neovascularization (expressed as microvessel count-MVC) and tumor cell proliferation (expressed as PCNA labeling index PLI and Ki-67 labeling index KLI) in gastric adenocarcinoma. Correlations with clinicopathologic features were also evaluated. Tumor specimens from 74 patients diagnosed as gastric adenocarcinoma were included in this study. Formalin fixed, paraffin embedded tissue sections stained immunohistochemically with F-VIII, PC10 and MIB-1 monoclonal antibodies. By ocular grid subdivided into 100 areas, number of microvessels and PC10, MIB-1 positive and negative cells were counted at x400 magnification. Chi-square test, Kaplan-Meier method and cox regression analysis were used for statistical analysis. The results showed that, MVC and PLI had a significant correlation with invasion and lymph node metastasis. The prognosis was significantly worse in patients with high MVC (>14 ) and with high PLI (>49%). However any relationship was not observed between KLI (38%) and clinicopathologic parameters, so KLI failed to predict the prognosis. Cox model showed that, MVC and PLI were independent prognostic variables. Ki-67 labeling index in gastric carcinomas has no prognostic relevance. However, the evaluation of microvessel count and proliferating cell nuclear antigen index in gastric carcinomas could be reliable indicators of prognosis.

Well-differentiated adenocarcinoma, gastric foveolar type, of the extrahepatic bile ducts: A previously unrecognized and distinctive morphologic variant of bile duct carcinoma

Two examples of a rare but distinctive morphologic variant of extremely well-differentiated adenocarcinoma of the extrahepatic bile ducts are reported. One tumor arose in the common bile duct of a 51-year-old man; the other arose in the common hepatic duct of a 27-year-old man. Both tumors were composed predominantly (>95%) of gastric foveolar-type epithelium. Because of their bland nuclear features, low mitotic index, and focal polypoid and lobular architecture, they were initially confused with adenomas. Foci of less-differentiated adenocarcinoma and perineural invasion present in the deep portions of the tumors facilitated recognition. The neoplastic cells and extracellular mucin were periodic acid-Schiff- and alcian blue-positive. By immunohistochemistry, the tumor cells expressed cytokeratins 8 and 20 as well as cathepsin D, as reported in normal foveolar cells. Likewise, p53 overexpression was documented immunohistochemically in both adenocarcinomas, which also stained with the Ki-67 antibody. Despite the well-differentiated nature of the neoplasms and their deceptively benign microscopic appearance, one patient developed recurrence and liver metastasis 5 years after surgery. The other patient is disease-free 2 years following a segmental resection of the common hepatic duct, cystic duct, and gallbladder. The cell phenotype of these tumors can be explained by the ability of the bile duct epithelium to differentiate along gastric cell lines.

Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe

BACKGROUND

The usefulness of and problems associated with an ultrasound catheter probe in the pretreatment staging of endoscopically early gastric cancer remain unexplored.

METHODS

Endoscopic ultrasonography using a 15 MHz catheter probe of 2.6 mm diameter was performed in a prospective study to determine the pretherapy staging of endoscopically early gastric cancer in 78 patients. The results of the ultrasound images were compared with the histologic findings of the specimens obtained by endoscopic mucosal resection or surgical resection.

RESULTS

The accuracy of the catheter probe for depth of invasion of endoscopically early gastric cancers was 67% (52 of 78 patients). The accuracy in determining depth of invasion in relation to endoscopic type was significantly higher for the elevated type (91%) than for the depressed type of early cancer (56%) (p < 0.01). The staging accuracy classified by histologic type was significantly higher for differentiated (86%) than for undifferentiated (18%) cancer (p < 0.01). Staging accuracy decreased as tumor size increased. The accuracy, sensitivity, and specificity for nodal staging were 80%, 17%, and 90%, respectively.

CONCLUSIONS

A 15 MHz ultrasound catheter probe is most useful for determining depth of invasion when the tumor is histologically differentiated and endoscopically of the small elevated type early gastric cancer, but it is unreliable in the diagnosis of metastatic lymph nodes.

A new prognostic strategy for gastric carcinoma: mRNA expression of tumor growth-related factors in endoscopic biopsy specimens

OBJECTIVE

The study analyzed the prognostic value of the transcription of several tumor growth-related genes in gastric carcinoma biopsy specimens.

SUMMARY BACKGROUND DATA

The nodal status is one of the most significant prognostic factors in gastric carcinoma. There are, however, no satisfactory parameters for the preoperative assessment of nodal status.

METHODS

A reverse transcriptase-polymerase chain reaction analysis was used to analyze the transcription of several tumor growth-related genes in endoscopic biopsy specimens from 78 gastric carcinomas. The factors examined were cyclin D1, cyclin E, urokinase-type plasminogen activator, 72-kd type IV collagenase, vascular endothelial growth factor, platelet-derived growth factor-A (PDGF-A), transforming growth factor-beta, and interleukin-10. The relation between the mRNA expression and the clinical pathologic parameters was analyzed statistically.

RESULTS

The incidence of PDGF-A (p = 0.010) and transforming growth factor-beta (p = 0.009) mRNA expression increased as the pathologic stage advanced. Nodal metastasis correlated with cyclin D1 (p = 0.045), cyclin E (p = 0.037), urokinase-type plasminogen activator (p = 0.047), and PDGF-A (p = 0.003) mRNA. Interestingly, the expression of PDGF-A mRNA showed a positive correlation (p = 0.004) with the early presence of lymph node metastases.

CONCLUSIONS

Tumor growth-related factor mRNA in biopsy specimens may be a new prognostic tool.

Relationship between histological type and endosonographic detection of regional lymph node metastases in gastric cancer

The aim of the study was to compare the ability of endoscopic ultrasonography (EUS) in detecting lymph node metastases in differentiated and undifferentiated gastric adenocarcinoma. EUS was performed in 149 patients with differentiated or undifferentiated gastric cancer. Histopathological findings were compared with pre-operative EUS findings in a total of 2961 resected lymph nodes. The EUS detection rates of metastasis to individual nodes in relation to node size, the ratio of the metastasized area to the cross-sectional area of the node and to the depth of primary tumour invasion, were also investigated. The accuracy and negative predictive values of EUS for detecting metastatic lymphadenopathy in each patient were significantly higher for differentiated (87%, 94%) than for undifferentiated (71%, 71%) tumours. The detection rate of individual node metastasis was higher for differentiated (31%) than for undifferentiated (21%) tumours. For differentiated lesions, EUS detected more small nodal metastases (< 5 mm in diameter) (p < 0.01) and more nodes involved with a relatively small proportion of the metastasized area to the cross-sectional area of the node (< 1/3 involvement) (p < 0.05). In relatively superficial lesions, such as pT1 and pT2, the pre-operative EUS detection rate of metastatic nodes was higher for differentiated than for undifferentiated tumours. In conclusion, the ability of EUS to detect nodal metastases is related to the histological type of gastric cancer.

Ki67 labelling index in gastric carcinomas. An immunohistochemical study using double staining for the evaluation of the proliferative activity of diffuse-type carcinomas

The aim of the present study was to clarify the conflicting recorded data on the proliferative features of gastric carcinoma. The Ki67 labelling index (Ki67 LI) was evaluated using MIB-1 in 43 carcinomas (24 diffuse and 19 intestinal). In 18 cases, differential counts were performed in superficial and deep layers. In ten diffuse carcinomas with a prominent desmoplastic response, Ki67 LI was evaluated in sections double-stained with MIB-1 and CAM5.2. Flow cytometry was performed in 26 cases. Ki67 LI of diffuse carcinomas (36.3 +/- 19.0) was not significantly different from that of intestinal carcinomas (28.2 +/- 18.5). Ki67 LI was significantly higher (P = 0.006) in superficial than in deep areas (41.9 +/- 22.7 and 29.7 +/- 19.7, respectively) regardless of histological tumour type. No significant relationship was observed between Ki67 LI and wall invasion, lymph node metastasis, vascular invasion or ploidy. The following conclusions were drawn: double immunostaining techniques are apparently the best way to overcome the underestimation of cell proliferation in diffuse gastric carcinomas with a prominent desmoplastic response; the diffuse and intestinal types of gastric carcinoma have proliferation rates within the same range, even when the comparison is restricted to diploid tumours; and, finally, the major pool of proliferating cells resides in the superficial areas of gastric carcinomas, regardless of the histotype, which should be taken into consideration when overall counts are performed, using either immunohistochemical markers in tissue sections or suspensions of nuclei in flow cytometry.

Differences in cell proliferation and prognostic significance of proliferating cell nuclear antigen and Ki-67 antigen immunoreactivity in in situ and invasive carcinomas of the extrahepatic biliary tract

BACKGROUND

Cell proliferative activity is an important indicator of growth and behavior of various human tumors. Immunostaining of tissue sections with proliferating cell nuclear antigen (PCNA) and Ki-67 antibodies appears to be reliable in the assessment of tumor cell proliferation. This study examined differences in cell kinetics between neoplastic and nonneoplastic lesions of the gallbladder and biliary tract using an antibody against PCNA and Ki-67.

METHODS

There were a total of 27 cancer cases comprising patients with invasive carcinoma of the gallbladder (n = 13), common bile duct (n = 5) and ampulla of Vater (n = 8). Cases of chronic cholecystitis (n = 11) from the nonneoplastic group; carcinoma in situ (CIS) of the gallbladder (n = 4) and ampulla (n = 6) from the noninvasive group. Cell cycle activity was determined in sections of routinely formalin fixed, paraffin processed, biopsy material using immunohistochemical stains for the monoclonal PCNA, PC10, KI-67, and MIB-1. The expression of PCNA and MIB-1 in these conditions was determined by calculating the percentage of cell nuclei that stained positively to obtain the PCNA and MIB-1 indices, respectively.

RESULTS

The PCNA and MIB-1 indices in chronic cholecystitis were significantly lower than those obtained in both moderately and poorly differentiated adenocarcinoma of the gallbladder (P < 0.001). Similarly, cases of ampullary and gallbladder CIS had significantly lower PCNA and MIB-1 indices than the invasive carcinoma cases (P < 0.001). There was a strong correlation between PCNA and MIB-1 expression (r = 0.828, r2 = 0.686; P = 0.001), although the PCNA index was generally higher than that of MIB-1. The poorly differentiated adenocarcinomas of the gallbladder had higher mean PCNA and MIB-1 indices but reduced patient survival when compared with the moderately differentiated carcinomas.

CONCLUSIONS

In conclusion, gallbladder, ampulla, and common bile duct carcinomas have significantly higher PCNA and MIB-1 indices than CIS and nonneoplastic lesions. Because tumors with higher PCNA or MIB-1 indices are associated with a poorer prognosis, both PCNA and MIB-1 may be useful markers of tumor cell proliferative activity and biologic behavior in gallbladder, ampullary, and common bile duct carcinomas.