Carcino-fetal proteins and gastric cancer: The site of alpha-fetoprotein synthesis in gastric cancer

Multimodality Therapy Including Proton Beam Therapy for AFP Producing Esophageal Cancer with Multiple Liver Metastases

A 50-year-old man who presented with a fever and epigastralgia was diagnosed to have esophageal carcinoma which was identified as poorly differentiated adenocarcinoma producing alpha-fetoprotein (AFP) with Barrett's esophagus. Computed tomography revealed multiple liver metastases and lymph node metastases surrounding the stomach. We first performed chemotherapy for the systemic lesions and proton beam therapy for the local control of lesions without complete remission and we were able to successfully control the frequently recurring lesions by proton beam therapy, cryotherapy and chemotherapy. A complete response has been maintained for 16 months and the overall survival time is 4 years and 2 months. Proton beam therapy for primary esophageal cancer and metastatic lesions was thus found to be an effective therapeutic option for such cases.

Gastric hepatoid adenocarcinoma resulting in a spontaneous gastric perforation: a case report and review of the literature

Background

Gastric hepatoid adenocarcinoma (GHAC) is an atypical form of gastric cancer (GC) that has similar tissue morphology to hepatocellular carcinoma and frequently produces alpha-fetoprotein. We present an exceedingly rare case of GHAC resulting in a spontaneous gastric perforation.

Case presentation

A 61-year-old man presented at our institution complaining of abdominal and back pain. A computed tomography scan revealed a spontaneous gastric perforation with a solitary liver tumor and lymph node swelling. Following a diagnosis of advanced-stage GC with a gastric perforation, perforative peritonitis, multiple lymph node metastases, and a solitary metastasis of the lateral segment of the liver, the patient underwent distal gastrectomy. Histopathology of the resected specimen revealed that the tumor cells were arranged in a hepatoid pattern. On immunohistochemical staining, the tumor cells were positive for alpha-fetoprotein and Sal-like protein 4. Thus, the patient was diagnosed with GHAC. Hepatic resection of the solitary liver metastasis was performed. However, recurrence occurred and the patient achieved complete response following tegafur/gimeracil/oteracil-based chemotherapy.

Conclusions

GHAC is a highly malignant histological subtype of GC. We reported on an extremely rare case of GHAC resulting in a spontaneous gastric perforation and reviewed the literature, including epidemiological data, treatment regimens, and the association between GHAC and alpha-fetoprotein-producing GC.

Alpha-fetoprotein-producing Collecting Duct Carcinoma of the Kidney

A case of collecting duct carcinoma of the kidney, with bone marrow metastases, in which there was production of alpha-fetoprotein is described. The tumor showed the typical light microscopic and immunohistochemical characteristics of collecting duct carcinoma. Alpha-fetoprotein was demonstrated immunohistochemically within tumor cells in both the primary and metastatic lesions. The clinical course was aggres sive ; the patient died within a few months of diagnosis. Int J Surg Pathol 1(4):239-244, 1994

Resection of liver metastasis derived from alpha-fetoprotein-producing gastric cancer-report of 4 cases

As is the case for metastatic liver tumors derived from standard gastric cancers, there is no consensus about the optimal treatment for metastatic liver tumors derived from alpha-fetoprotein (AFP)-producing gastric cancer, including regarding the surgical indications for such lesions. We report the cases of 4 patients in whom metastatic liver tumors derived from AFP-producing gastric cancer that were curatively resected. One of the patients had a thrombus in his inferior vena cava at the time of the liver resection, and both the liver tumor and thrombus were completely removed. The patient has survived 93 months after receiving multidisciplinary therapy including partial pneumonectomy, chemotherapy, and radiotherapy and currently has no evaluable disease. Another patient has survived for 3 years without suffering any recurrence. Since long-term survival is possible, liver resection should be considered as a treatment for liver metastases from AFP-producing gastric cancers.

Clinicopathologic features and prognostic factors in alpha-fetoprotein-producing gastric cancers: analysis of 104 cases

BACKGROUND AND OBJECTIVES

There were no comprehensive studies on the clinicopathologic features and prognosis of alpha-protein-producing gastric cancer. The aim of this study was to elucidate the clinicopathologic characteristics and prognostic factors of alpha-fetoprotein (AFP)-producing gastric cancer.

METHODS

Among 4,426 gastric cancer patients receiving surgery in the Cancer Hospital of Fudan University from 1996 to 2007, there were 111 patients with elevated serum level of AFP preoperatively after excluding chronic hepatitis, hepatocirrhosis, and hepatocellular carcinoma. Primary lesions of 104 patients were stained positively for AFP. The clinicopathologic characteristics and prognostic factors of AFP-producing gastric cancer were analyzed. Additionally, 208 stage-matched AFP-negative gastric cancer patients were selected as control.

RESULTS

There was a significantly higher incidence of vascular invasion, lymph node metastasis, and liver metastasis in AFP-positive group than in the negative group. The overall 5-year survival rates of AFP-positive and negative groups were 28% and 38%, respectively. The AFP-positive group had a significantly poorer survival in comparison to the stage-matched negative group. The independent prognostic factors of AFP-positive group included liver metastasis and pathological stage.

CONCLUSIONS

AFP-positive gastric cancer had more aggressive behavior than that of AFP-negative gastric cancer. In addition to surgery, multimodal therapy should be considered.

Long-term results of gastrectomy for alpha-fetoprotein-producing gastric cancer

BACKGROUND

alpha-Fetoprotein (AFP)-producing gastric cancer is a rare tumour. It is said to have a high incidence of liver metastasis and poor prognosis. This study sought to evaluate long-term outcomes in such patients.

METHODS

Records of consecutive patients with gastric carcinoma who underwent preoperative measurement of serum AFP levels and gastrectomy were reviewed to identify those who satisfied the following criteria: preoperative AFP level exceeding 40 ng/ml with a decrease after gastrectomy, or raised preoperative AFP level (10-39 ng/ml) and resected tumour showing histologically characteristic features or immunohistochemically positive AFP production.

RESULTS

Of 3374 patients with gastric cancer, 53 (1.6 per cent) met the selection criteria. Tumours were characterized by a high incidence of nodal (79 per cent) or liver (53 per cent) metastasis. Preoperative serum AFP levels showed no correlation with tumour size, depth of invasion, disease stage or survival. The 5-year survival rate was 34 per cent. Five patients survived after recurrence following multimodal treatment. A rising AFP level during follow-up always led to tumour recurrence, but the level remained normal in 11 of 31 patients with recurrence.

CONCLUSION

AFP-producing tumours represent a small subgroup of gastric cancer with high metastatic potential. Postoperative serum AFP level can help predict recurrence but a normal level does not mean absence of recurrence. Prognosis is not as poor as previously thought, and multimodal treatment may be worthwhile even in patients with recurrent tumour.

Evidence for hepatocellular differentiation in alpha-fetoprotein-negative gastric adenocarcinoma with hepatoid morphology: a study with in situ hybridisation for albumin mRNA

AIM

Hepatoid adenocarcinoma, a putative chemosensitive tumour, is defined as a tumour with aberrant hepatocellular differentiation occurring in extrahepatic organs such as the stomach, usually in the gastrointestinal tract. Differentiation in the hepatocellular direction is usually supported by the production of alpha-fetoprotein (AFP) and, more recently, albumin (ALB) mRNA. We investigated ALB mRNA to address whether adenocarcinoma with hepatoid morphology, regardless of AFP production, can be diagnosed solely by morphological criteria as a hepatoid adenocarcinoma.

METHODS

We performed in situ hybridisation (ISH) and immunohistochemistry (IH) for ALB mRNA on AFP-negative gastric adenocarcinomas with hepatoid morphology. AFP-positive hepatoid adenocarcinomas and AFP-negative conventional gastric adenocarcinomas were also investigated as positive and negative controls, respectively.

RESULTS

All three gastric adenocarcinomas with hepatoid morphology with no evidence of AFP production stained positive for ALB mRNA, thus providing evidence of differentiation in the hepatocellular direction. Three of five cases of AFP-positive hepatoid adenocarcinoma of the stomach were positive for ALB mRNA, while 11 cases of AFP-negative conventional gastric adenocarcinoma were negative.

CONCLUSION

The present study demonstrates that, irrespective of AFP production, gastric adenocarcinoma with morphological patterns suggestive of hepatoid differentiation should be diagnosed as hepatoid adenocarcinoma with important prognostic implications.

Hepatoid carcinoma of the uterus that collided with carcinosarcoma

The case of a 68-year-old woman who was seen at Tokyo Kousei Nenkin Hospital because of abnormal genital bleeding is described. A malignant uterine tumor was suspected based on biopsy results. Hysterectomy and bilateral salpingo-oophorectomy were performed. Grossly, a solid whitish tumor occupied the area from the endocervix to the uterine body. On the consecutive fundal side, a whitish tumor protruded into the uterine cavity. Histologically, the tumor occupying the endocervical side showed a trabecular growth pattern. Many periodic acid-Schiff (PAS)-positive hyaline globules were observed. The cytoplasm of the tumor cells and the hyaline globules were immunohistochemically positive for alpha-fetoprotein (AFP). The tumor occupying the fundal side was identified as having endometrioid adenocarcinoma and spindle cell sarcoma components. The two tumors collided at a clear boundary. The present case was pathologically diagnosed as a collision cancer involving a hepatoid carcinoma and a carcinosarcoma. To our knowledge, this is the fourth reported case of a hepatoid carcinoma of the uterus. When no lesion is detected in the liver and stomach of a patient whose serum AFP level is abnormally high, the female reproductive system, such as the ovaries and uterus, should be examined as a possible site of AFP-producing cancer.

Des-gamma carboxy prothrombin (PIVKA-II) and alpha-fetoprotein producing gastric cancer with multiple liver metastases

We describe the case of an 87-year-old woman who presented to Tokyo Kousei Nenkin Hospital because of appetite loss and general fatigue. Multiple liver masses and Borrmann type 2 gastric tumor were detected. A clinical diagnosis of hepatocellular carcinoma and gastric cancer was made based on the patient's high levels of serum alpha-fetoprotein (AFP; 490 200 ng/mL) and protein induced by vitamin K absence or antagonist-II (PIVKA-II, 2284 mAU/mL). The patient's general condition worsened gradually and she died 42 days after admission. Autopsy revealed that the predominant histological structure of the gastric tumor was trabecular or sheet-like, although a tubular structure was also found. Venous invasion was prominent. Immunohistochemically, the tumor tissue was positive for AFP and a few tumor cells were positive for PIVKA-II. The histological appearance and immunohistochemical features of the hepatic tumors resembled that of the gastric tumor. This case was pathologically diagnosed as AFP- and PIVKA-II-producing gastric carcinoma with multiple liver metastases. When tumors are found in the stomach and liver and serum PIVKA-II level is abnormally high, the possibility of PIVKA-II-producing gastric cancer with liver metastasis should be considered, especially when hepatitis virus markers are negative and liver cirrhosis is not present.

Alphafetoprotein-producing gastric adenocarcinoma

We report a rare gastric tumour characterized morphologically by its hepatoid features and alpha-fetoprotein production and which presented clinically with gastric haemorrhage. Gastric fibroscopy showed a bleeding tumour of the antrum. The microscopic appearance of the tumor showed two different patterns. The most extensive presented hepatoid features. The second pattern showed undifferentiated features. The tumour cells showed immunohistochemical positivity for alphafetoprotein, EMA and p53 protein; 37% were aneuploid with a DNA index of 1.46. The serum level of alphafetoprotein was not measured before the gastrectomy but after ten days it was elevated at 1070 ng/ml. The patient died 6 months after the admission. This case provides, for the first time, information on the DNA content and the p53 expression of this unusual and aggressive variant of gastric adenocarcinoma.

Alpha-fetoprotein-producing early gastric cancer accompanying liver cirrhosis: a case report

A rare case of alpha-fetoprotein (AFP)-producing early gastric cancer with liver cirrhosis is presented. A 61-year-old man was admitted to Shimane Medical University Hospital in 1988 because of abnormal liver function test results suggestive of liver cirrhosis with mild elevation of AFP. Liver cirrhosis was confirmed laparoscopically and histologically. Gastric cancer was found in fluoroscopic and endoscopic studies. After partial gastrectomy, the serum AFP level fluctuated transiently within normal limits, and then gradually increased soon after the operation. Therefore, complication of hepatocellular carcinoma was suspected, but no tumor in the liver was detected by any imaging examination, including angiography. Two years after the operation, swelling of abdominal periaortic lymph nodes was noted at a periodic checkup, but still no hepatic tumor was found. At this point, AFP-producing gastric cancer was suspected, and an AFP staining test was carried out on the tissue of the resected specimen. AFP-positive cells were recognized immunohistochemically. Thus, we diagnosed the condition as post-operative recurrence of an AFP-producing gastric cancer accompanying liver cirrhosis.

Alpha-fetoprotein-producing gastric carcinoma with enteroblastic differentiation

BACKGROUND

Alpha-fetoprotein (AFP) is a useful tumor marker for hepatoma and yolk sac tumor. Recently, elevations of serum AFP were reported in patients with other malignancies, especially gastric cancers. Two distinct tumor morphologies, hepatoid and clear cell, have been correlated with AFP production.

METHODS

Two patients with AFP-producing gastric carcinoma were evaluated with immunohistochemical, ultrastructural, and biochemical studies.

RESULTS

In Patient 1, the primary and metastatic carcinomas consisted homogeneously of tubulopapillary carcinoma with clear cytoplasm. In Patient 2, the cancer was composed of three different areas: tubulopapillary carcinoma with clear cytoplasm, tumor cartilage, and so-called hepatoid carcinoma. The morphologic characteristics of tubulopapillary carcinoma with clear cytoplasm were similar to those of the developing gut epithelium at the stage of 2-4 months' gestation. The elution patterns of the serum AFP on lectin-affinity sepharose column study also suggested a correlation with fetal gut differentiation.

CONCLUSIONS

AFP-producing clear cell gastric carcinomas are differentiated into fetal intestine. One patient also had hepatocytic and cartilaginous differentiation, indicative of a blastomatous characteristic of the tumor. These tumors arose in association with intestinal metaplasia.

Hepatoid gastric adenocarcinoma

A case of hepatoid gastric adenocarcinoma is reported. The tumor had the histological and immunohistochemical features of both liver cell carcinoma and conventional intestinal-type adenocarcinoma. We discuss the main clinical and pathological features of this uncommon variety of gastric cancer.

Histologic and immunohistochemical studies of alpha-fetoprotein (AFP)-producing gastric carcinoma

Five gastric adenocarcinomas and their metastatic nodules in the liver with high serum AFP levels were examined by histologic and immunohistochemical methods. The examination revealed that AFP-producing stomach cancers were poorly differentiated carcinoma cells, especially with medullary arrangements, or pleomorphic or multinucleated giant cells. Well-differentiated papillotubular adenocarcinoma tissues on the glandular epithelium were not stained with anti-AFP. One out of the five AFP-producing adenocarcinomas with medullary patterns resembled liver cell carcinoma on light microscopy. However, an ultrastructural study showed tumor cells of the intestinal type, since the cells possessed a ductal lumina with abundant microvilli and a secretory granules. The findings suggest that the tumor cells differentiated in an intestinal direction rather than hepatic direction. In addition, we noted three simultaneously CEA-positive cases out of five AFP-producing gastric carcinomas. CEA was strongly stained in well differentiated adenocarcinoma tissues in the glandular epithelium or in areas of medullary type carcinoma invasion. However, CEA was not detected in undifferentiated carcinoma cells.

An AFP-producing gastric carcinoma with features of hepatic differentiation. A case report

A patient with primary gastric adenocarcinoma with extremely high serum alpha-fetoprotein (AFP) levels (12,000 ng/ml) is described. Histologically, foci strongly resembling hepatocellular carcinoma with hyaline globules were noted. Within tumor cells, AFP was identified with both light and electron microscopy, showing the production of AFP by tumor cells themselves. Furthermore, 88% of serum AFP combined with Concanavalin A (ConA), revealing that it was hepatic-type AFP and not germ-cell-type. Localization of alpha-1-antitrypsin within tumor cells was also noted. Ultrastructural study showed that there were two types of structures corresponding to periodic acid-Schiff (PAS)-positive globules, one of which, the proteinaceous material in intracytoplasmic lumina, was found to contain AFP. Among gastric adenocarcinomas with a high serum AFP level (several thousand or more ng/ml of AFP), foci resembling hepatocellular carcinomas have been reported by several investigators. Those gastric carcinomas, together with the current case, may constitute a clinicopathologic entity, hepatoid adenocarcinoma of the stomach.