Alpha-fetoprotein (AFP)-producing adrenocortical carcinoma--long survival with various therapeutic strategies including a lung resection: report of a case

Alpha-Fetoprotein-Producing Gastric Cancer with Nonbiliary Pancreatitis

Alpha-fetoprotein (AFP)-producing gastric cancer (AFPGC) is a rare, aggressive tumor. In the absence of metastasis in diagnosis, close observation and long-term follow-up is needed to monitor and slow its progress. We report a young patient who presented with nonbiliary pancreatitis. Upon finding Virchow's nodule, we conducted tests and observed multiple lymph nodes and liver and pancreatic metastasis. We subsequently made a diagnosis of AFPGC. This study describes the different presentations of this rare but aggressive subtype of gastric cancer with a review of the literature.

Mimics of hepatocellular carcinoma: a review and an approach to avoiding histopathological diagnostic missteps

Hepatocellular carcinoma (HCC) is one of the commonest carcinomas and leading causes of cancer-related death. Although, in patients with cirrhosis, radiologic diagnosis has improved significantly over the years, needle biopsy and histopathological assessment remains an important diagnostic modality. Most importantly, histopathological diagnosis is essential in patients with contending extrahepatic primaries, those with no known HCC risk factors, patients with ambiguous radiological features, and many other clinical contexts. Helpful features such as high serum alpha-fetoprotein (AFP) serologies are known to be present in many other tumor (including but not only HCC) and nontumor contexts and therefore not only lack sufficient diagnostic specificity for HCC but also create the potential to overlook non-HCC AFP-producing tumors, of which there are many. Therefore, using clinical examples and other examples from the medical literature, this review discusses several clinical and histological mimics of HCC and proffers an approach for practicing pathologists geared toward avoiding missteps.

Pedunculated Hepatocellular Carcinoma Mimicking Right Adrenal Tumor on FDG PET/CT

Pedunculated hepatocellular carcinoma is an unusual form of hepatocellular carcinoma protruding from the liver with or without a pedicle. We present a case of pedunculated hepatocellular carcinoma misdiagnosed as right adrenal tumor on MRI and FDG PET/CT. Intraoperative exploration revealed the mass was attached to the liver, but the right adrenal gland was intact. Laparoscopic biopsy revealed poorly differentiated hepatocellular carcinoma. This case indicates it may be difficult to diagnose pedunculated hepatocellular carcinoma because it is hard to define its origin on imaging. Elevated alpha-fetoprotein level and a history of viral hepatitis may be helpful for the diagnosis.

Clinicopathological and prognostic characteristics in patients with AFP-secreting gastric carcinoma

The aim of the present study was to determine whether there are any clinicopathological or prognostic differences between patients with α-fetoprotein-secreting gastric carcinoma (AFP-SGC) and non-AFP-SGC. Pathological parameters, clinical parameters, and treatment efficacy were compared in patients with AFP-SGC and non-AFP-SGC. In total, 362 patients (53 with AFP-SGC and 309 with non-AFP-SGC) were included in the present study. Patients with AFP-SGC had significantly higher levels of lymphovascular invasion, perineural invasion (PNI), rate of liver metastasis, and stage IV cancer compared with patients with non-AFP-SGC (P<0.05). The median overall survival (OS) rate was 12.6 months in the AFP-SGC group, and 22.1 months in the non-AFP-SGC group (P<0.001). The median OS and disease free survival (DFS) of patients with stage I-III AFP-SGC were 28.1 and 13.4 months, respectively, whereas for patients with non-AFP-SGC, the OS and DFS were 45.3 and 38.0 months, respectively (P=0.01; P=0.02). The median OS for the stage IV AFP-SGC and non-AFP-SGC groups was 9.3 and 11.5 months, respectively (P=0.14). Multivariate analysis of the entire patient group revealed that the Eastern Cooperative Oncology Group (ECOG) performance score of ≥2, lymph node involvement, presence of PNI, high levels of carcinoembryonic antigen, and distant metastasis were significantly correlated with OS. The lymph node involvement, ECOG performance score of ≥2, AFP-SGC type, and weight loss at diagnosis were also significant factors influencing the DFS in the stage I-III group. In conclusion, patients with AFP-SGC had more aggressive clinicopathological features and biological behavior with an increased tendency of liver metastasis compared with patients with non-AFP-SGC. In the near future, AFP may become an important surrogate marker to manage therapies of patients with gastric cancer.

The efficacy of modified docetaxel-cisplatin-5-fluorouracil regimen as first-line treatment in patients with alpha-fetoprotein producing gastric carcinoma

Alpha-fetoprotein producing gastric carcinoma (AFP-PGC) is a rare cancer for which limited data on the clinicopathological features and treatment modalities exist. The aim of this study was to compare the efficacy of modified docetaxel-cisplatin-5-fluorouracil (mDCF) as the first-line chemotherapy regimen in metastatic AFP-PGC and non-AFP-PGC. The patients diagnosed with metastatic gastric cancer who were given mDCF as first-line therapy were retrospectively reviewed. The patients with a basal serum AFP level over 9 ng/ml were defined as AFP-PGC patients. In total, 169 patients (34 with AFP-PGC and 135 with non-AFP-PGC) were included in this study. AFP-PGC patients had more liver metastases than non-AFP-PGC patients (p < 0.001). A decrease in basal AFP levels after three cycles of chemotherapy was significantly different in AFP-PGC group (p = 0.001).Overall disease control rate was 79.4% (partial response [PR] - 44.1%, stable disease [SD] - 35.3%), and 82.2% (complete response - 3%, PR - 36.2%, SD - 43%) in AFP-PGC and non-AFP-PGC patients, respectively. There was no difference between AFP-PGC and non-AFP-PGC groups in overall and progression-free survival rates (11.3 versus 11.4 months and 7.7 versus 7.1 months, respectively). Rates of grade 3-4 hematologic toxicity were 8.8% and 6.7% for neutropenia in AFP-PGC and non-AFP-PGC group, respectively and 5.9% and 7.4% for anemia. In conclusion, mDCF regimen is well-tolerated with acceptable toxicity outcomes in both AFP-PGC and non-AFP-PGC patients. A statistically significant decrease in AFP levels after mDCF regimen indicate that AFP might be considered as a supplemental marker of response to mDCF chemotherapy in AFP-PGC patients. However, further prospective clinical trials are required in this area.

Clinicopathological features of alpha-fetoprotein producing early gastric cancer with enteroblastic differentiation

AIM

To investigate clinicopathological features of early stage gastric cancer with enteroblastic differentiation (GCED).

METHODS

We retrospectively investigated data on 6 cases of early stage GCED and 186 cases of early stage conventional gastric cancer (CGC: well or moderately differentiated adenocarcinoma) who underwent endoscopic submucosal dissection or endoscopic mucosal resection from September 2011 to February 2015 in our hospital. GCED was defined as a tumor having a primitive intestine-like structure composed of cuboidal or columnar cells with clear cytoplasm and immunohistochemical positivity for either alpha-fetoprotein, Glypican 3 or SALL4. The following were compared between GCED and CGC: age, gender, location and size of tumor, macroscopic type, ulceration, depth of invasion, lymphatic and venous invasion, positive horizontal and vertical margin, curative resection rate.

RESULTS

Six cases (5 males, 1 female; mean age 75.7 years; 6 lesions) of early gastric cancer with a GCED component and 186 cases (139 males, 47 females; mean age 72.7 years; 209 lesions) of early stage CGC were investigated. Mean tumor diameters were similar but rates of submucosal invasion, lymphatic invasion, venous invasion, and non-curative resection were higher in GCED than CGC (66.6% vs 11.4%, 33.3% vs 2.3%, 66.6% vs 0.4%, 83.3% vs 11% respectively, P < 0.01). Deep submucosal invasion was not revealed endoscopically or by preoperative biopsy. Histologically, in GCED the superficial mucosal layer was covered with a CGC component. The GCED component tended to exist in the deeper part of the mucosa to the submucosa by lymphatic and/or venous invasion, without severe stromal reaction. In addition, Glypican 3 was the most sensitive marker for GCED (positivity, 83.3%), immunohistochemically.

CONCLUSION

Even in the early stage GCED has high malignant potential, and preoperative diagnosis is considered difficult. Endoscopists and pathologists should know the clinicopathological features of this highly malignant type of cancer.

Misdiagnosis of an α-fetoprotein-producing esophageal carcinoma: A case report and literature review

α-fetoprotein (AFP)-producing esophageal carcinoma is a rare type of esophageal cancer, with its characteristics not yet fully clarified. In the present study, a case of esophageal carcinoma was misdiagnosed as an AFP-producing esophageal carcinoma. The patient was a 50-year-old woman who was referred to Qianfoshan Hospital Affiliated to Shandong University in November 2014 with a 3-month history of progressive dysphagia. A chest computed tomography (CT) scan showed thickening of the wall of the esophagus, corresponding regions of luminal stenosis and massive lymph node swelling around the lesser curvature of the esophagus. A laboratory investigation showed that the serum AFP levels of the patient were elevated to 18.97 ng/ml (normal range <12 ng/ml). These laboratory investigation findings combined with the aforementioned pathological diagnosis supported a diagnosis of AFP-producing esophageal carcinoma. An abdominal ultrasound was performed and a cystic low-density measuring 5×4 mm was identified. No metastases were revealed in the liver. The boundary of the focal low density was clear, which indicated a clinical diagnosis of liver cyst. A radical esophagectomy was performed on December 5, 2014. Microscopically, the tumor was a moderately differentiated squamous cell carcinoma invading the serous layer, with no hepatoid features. Immunohistochemistry showed that the cells were diffusely negative for AFP expression. Histopathological examination revealed the absence of hepatoid features. According to these findings, the tumor was diagnosed as a moderately differentiated squamous cell carcinoma. In the present study, the case of a patient with squamous cell carcinoma that was misdiagnosed as an α-fetoprotein-producing esophageal carcinoma was reported, with a review of the literature.

α-fetoprotein-producing gastric carcinoma: A case report of a rare subtype and literature review

α-fetoprotein (AFP)-producing gastric carcinoma is a rare type of gastric cancer, and the characteristics have not yet been fully elucidated. The present study reports the case of a patient with this type of gastric cancer. A 66-year-old male was referred to the Department of Gastrointestinal Surgery, Qianfoshan Hospital, Shandong University (Jinan, China) with a 20-day history of retrosternal pain. A computed tomography (CT) scan revealed a thickening of the wall of the cardia and massive lymph node swelling in the region of the lesser curvature of the stomach. A laboratory investigation revealed that the serum AFP levels of the patient were elevated to 46.49 ng/ml (normal level, <12.00 ng/ml), and the serum carcinoembryonic antigen (CEA) levels were 382.22 ng/ml (normal range, <5.00 ng/ml). An endoscopy revealed an elevated tumor and AFP-producing gastric cancer was diagnosed. As the tumor was surgically unresectable, the patient received systemic adjuvant chemotherapy [consisting of 1 cycle of oxaliplatin (150 mg; day 1)-fluorouracil(1.0 g; days 2-6)-calcium folinate (0.3 g; days 2-6), 4 cycles of paclitaxel (80 mg; day 1 and 8, repeated day 21) and capecitabine (1,000 g/m², twice daily; days 1-14, repeated day 21), and 2 cycles of oxaliplatin (130 mg/m²; day 1, repeated day 21) and S-1 (100 mg/d; day 1- day 14; repeated day 21)]. During the chemotherapy intermission, the patient experienced partial remission; the serum AFP levels remained between 44.5 and 32.7 ng/ml, and serum CEA levels decreased to a normal level. The CT scan revealed that the enlarged lymph nodes of the patient had decreased in size. During the preoperative examinations, an abdominal CT scan revealed no metastasis to the liver. A radical gastrectomy was performed on October 20, 2014. Additionally, the tumor did not demonstrate the diffusion of AFP. The histopathological examination revealed a poorly differentiated adenocarcinoma, with local and neuroendocrine differentiation and no hepatoid features. According to these histopathological findings, the tumor was diagnosed as AFP-producing non-hepatoid adenocarcinoma of the stomach. The patient was treated with systemic immunity-enhancing therapy and has been free of recurrence for 2 months. The present study describes a rare case of AFP-producing non-hepatoid adenocarcinoma of the stomach, with a review of the literature and an investigation of the clinical features.

Alpha-fetoprotein (AFP) elevation gastric adenocarcinoma and importance of AFP change in tumor response evaluation

BACKGROUND

Elevated serum alpha-fetoprotein (AFP) levels in adults are considered abnormal. This parameter is used mostly in the diagnosis and follow-up of hepatocellular carcinomas and yolk sac tumors. Among the other rare tumors accompanied with elevated serum AFP levels, gastric cancer is the most common. In this study, we evaluated the follow-up and comparison of the treatment and marker response of patients with metastatic gastric cancer who had elevated serum AFP levels.

MATERIALS AND METHODS

We performed a retrospective study, including all consecutive patients with advanced gastric cancer, who received systemic chemotherapy with elevated AFP level.

RESULTS

Seventeen metastatic gastric cancer patients with elevated AFP levels at the time of diagnosis were evaluated. Fourteen (82.4%) were males and three (17.6%) were females. The primary tumor localization was the gastric body in 8 (76.4%), cardia in 7 (41.2%), and antrum in 2 (11.8%). Hepatic metastasis was observed in 13 (76.4%) at the time of diagnosis. When the relationship of AFP levels and carcinoembryonic antigen (CEA) response of the patients with their radiologic responses was evaluated, it was found that the radiologic response was compatible with AFP response in 16 (94.1%) patients and with CEA response in 12 (70.6%); however, in 5 (29.4%) patients no accordance was observed between radiological and CEA responses.

CONCLUSIONS

Follow-up of AFP levels in metastatic gastric cancer patients with elevated AFP levels may allow prediction of early treatment response and could be more useful than the CEA marker for follow-up in response evaluation.

Expression of AFP and STAT3 is involved in arsenic trioxide-induced apoptosis and inhibition of proliferation in AFP-producing gastric cancer cells

Alpha-fetoprotein (AFP)-producing gastric cancer (AFPGC), represented by the production of AFP, has a more aggressive behavior than common gastric cancer. The underlying mechanisms are not well understood. Arsenic trioxide (As₂O₃) is used clinically to treat acute promyelocytic leukemia(APL) and has activity in vitro against several solid tumor cell lines, with induction of apoptosis and inhibition of proliferation the prime effects. Signal transducer and activator of transcription 3 (STAT3) has an important role in tumorigenesis of various primary cancers and cancer cell by upregulating cell-survival and downregulating tumor suppressor proteins. Here, we found decreased expression of AFP and STAT3 after induction of apoptosis by As₂O₃ in the AFPGC FU97 cells. Also, the level of the STAT3 target oncogene Bcl-2 was decreased with As₂O₃, and that of the tumor suppressor Bax was increased. Furthermore, STAT3 expression and depth of invasion and lymph node metastasis were associated. Survival of patients with gastric cancer was lower with AFP and STAT3 double overexpression than with overexpression of either alone. Downregulation of AFP and STAT3 expression plays an important role in As₂O₃-induced apoptosis of AFPGC cells, which suggests a new mechanism of As₂O₃-induced cell apoptosis. As₂O₃ may be a possible agent for AFPGC treatment.

An analysis of clinicopathological features and prognosis by comparing hepatoid adenocarcinoma of the stomach with AFP-producing gastric cancer

OBJECTIVE

To investigate the differences between alpha-fetoprotein-producing gastric cancer (AFPPGC) and hepatoid adenocarcinoma of the stomach (HAS), and the clinicopathologic features and prognosis of HAS.

METHODS

From 1996 to 2007, there were 111 patients with elevated serum level of alpha-fetoprotein (AFP) preoperatively in Fudan University Shanghai Cancer Center. Primary lesions of 104 patients were stained positively for AFP. Among these patients, 45 patients were diagnosed as HAS. The clinicopathologic characteristics and prognostic factors of AFPPGC and HAS were analyzed. Additionally, 208 stage-matched AFP-negative gastric cancer patients were selected as control.

RESULTS

Immunohistochemically, the tumor cells were positive for AFP in AFPPGC. Histologically, the polygonal tumor cells were arranged in trabecular fashion or solid nests separated by narrow fibrous stroma composed of sinusoid-like capillaries in HAS. The survival rates of the three groups were statistically different (P < 0.01).

CONCLUSION

AFP-producing gastric cancer and HAS had more aggressive behavior than that of common gastric cancer. The prognosis of HAS was poorer than that of AFPPGC, therefore it should be distinguished from the latter.

Giant hemorrhagic adrenal pseudocyst in a primiparous pregnancy: report of a case

Adrenal cysts are rare and are usually discovered incidentally during diagnostic imaging, surgery, or autopsy. Most cystic lesions of the adrenal gland are nonfunctioning and become symptomatic when complicated by rupture, hemorrhage, or infection. A 40-year-old woman presented with a history of gradual-onset pain in her left flank region at 20 weeks' gestation. Ultrasound showed a 20-cm cystic mass in her left abdominal cavity. Pertinent laboratory tests were within normal limits. The patient underwent exploratory laparotomy, which revealed a 20 × 15-cm left adrenal cyst; thus, we performed left adrenalectomy with complete excision of the cyst. Histological examination confirmed a hemorrhagic adrenal pseudocyst. The patient had an uneventful postoperative course, and subsequent routine obstetric ultrasound examinations showed normal fetal activity and development until the pregnancy terminated with a stillbirth caused by pre-eclampsia at 34 weeks' gestation. To the best of our knowledge, this is only the 12th reported case of adrenal pseudocyst discovered during pregnancy. We analyze the clinicopathologic findings and discuss the possible association of pregnancy, with special reference to etiopathogenesis, presentation, diagnosis, and treatment.

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.