Alpha-fetoprotein-producing adenocarcinoma of the sigmoid colon with possible hepatoid differentiation

A case report of two instances of colorectal hepatoid adenocarcinoma, accompanied by a comprehensive literature review

OBJECTIVE

The study aimed to explore the clinical and pathological characteristics, survival outcomes, and prognostic factors of colorectal hepatoid adenocarcinoma.

METHODS

We performed two cases of colorectal hepatoid adenocarcinoma treated at the Oncology Department of the First Affiliated Hospital of Nanchang University. We also reviewed literature up to the present and performed a retrospective study of colorectal hepatoid adenocarcinoma.

RESULTS

Among the 39 patients included in this study, 28 had primary tumors in the colon, 9 in the rectum, and 2 in the rectosigmoid junction. The median age was 52 years (range 31-75 years); 28 patients (71.8%) were male. Out of the 32 patients for whom survival data were available, 24 patients succumbed to disease-related causes. The median overall survival of 32 patients was 8 months, with 1-year and 2-year overall survival rates of 31.0% and 16.0%, respectively. Univariate analysis revealed that depth of infiltration, presence of liver metastases, TNM stage, and the completeness of surgical resection were significantly associated with the overall survival period of colorectal hepatoid adenocarcinoma.

CONCLUSION

Colorectal hepatoid adenocarcinoma exhibits a high degree of aggressiveness and poor prognosis. The major strategy for early-stage HAC was radical surgery and chemoradiotherapy demonstrates limited efficacy for extending survival.

Hepatoid tumors of the gastrointestinal/pancreatobiliary district: morphology, immunohistochemistry, and molecular profiles

Hepatoid tumors (HTs) histologically resemble hepatocellular carcinoma (HCC) but manifest outside the liver. Regarding immunohistochemistry (IHC), the classical markers of hepatoid differentiation are Hep Par-1, CD10, and arginase-1. This study provides a critical overview of HT in the gastrointestinal/biliopancreatic system, which is the most common site of origin. Gastric HTs are malignant neoplasms recognized by the current WHO classification as a variant of adenocarcinoma. In addition to the classic IHC markers, SALL4 and claudin-6 can help exclude a metastatic HCC at this site. Next-generation sequencing revealed the most common alterations, including TP53 mutation, microsatellite instability (MSI), and Her2 amplification. Esophageal HTs are exceptionally rare and usually arise in the context of Barrett's esophagus. In the intestine, HTs are classified within the adenocarcinoma spectrum and manifest more often in the background of inflammatory bowel disease. Regarding their molecular profile, recurrent alterations included MSI and NCOA4-RET fusions. In the pancreas, the current WHO classification acknowledges HT only as a possible variant of ductal adenocarcinoma, characterized by a poor prognosis. However, at this site, neuroendocrine tumors (NETs) and solid pseudopapillary neoplasms (SPNs) may also show hepatoid differentiation. Hepatoid NETs show aggressive behavior, whereas hepatoid SPNs harbor CTNNB1 mutations and are characterized by an indolent clinical course. Lastly, biliary HTs belong to the adenocarcinoma category and usually show a poor prognosis. In conclusion, gastrointestinal/pancreatobiliary HTs show specific histomolecular features, which should be considered for improving routine diagnostic activity and clinical management.

Alpha-fetoprotein-producing advanced colorectal cancer: a rare case report and literature review

Alpha-fetoprotein(AFP)-producing colorectal cancer is a rare form of colorectal cancer with a high degree of malignancy, advanced stage, strong invasiveness, poor response to treatment, rapid progression, and poor prognosis. Herein, we present the case of a middle-aged (in his 50s) male patient who underwent left neck lymph node biopsy due to "left neck lymph node enlargement for 5 months." Biopsy results revealed metastatic adenocarcinoma, and computed tomography examination of the chest and abdomen suggested a malignant tumor of the sigmoid colon with multiple metastases. Subsequently, the patient underwent colonoscopy, and the pathological result was colonic adenocarcinoma. Regarding tumor markers, serum alpha-fetoprotein (AFP) was 214 ng/mL. The patient received first- and second-line treatments for colon cancer, but progression-free survival was short. AFP was consistently elevated; after 8 months, the patient had AFP levels of 11,371.8 ng/mL, and imaging confirmed disease progression. The patient subsequently died, with an overall survival of more than 9 months. Compared with other tumor markers, AFP better reflects tumor progression in AFP-producing colorectal cancer.

Carcinosarcoma of the stomach with alpha-fetoprotein-producing hepatoid adenocarcinoma: an unexpected combination of two rare subtypes of gastric cancer in one tumor

Carcinosarcoma is a rare malignant neoplasm comprising both epithelial and mesenchymal components. Hepatoid adenocarcinoma (HAC) is another rare type of cancer. To date, there are only four reported cases of concurrent carcinosarcomas with HAC across all tumor types, all of which were observed in uterine tumors. Here, we report an unusual case of gastric carcinosarcoma associated with alpha-fetoprotein (AFP)-producing HAC in a 76-year-old woman. Upon admission, the patient had an elevated serum AFP concentration (448 µg/L), a necrotic polypoid tumor of the central gastric cardia revealed by endoscopy, and no evidence of distant metastasis indicated by computed tomography (CT). Owing to malignancy indicated by biopsy, the patient underwent proximal subtotal gastrectomy. The resected tumor was composed of both an HAC component and a sarcoma component, microscopically. The sample was positive for AFP, hepatocyte paraffin (Hep-Par) 1, glypican-3, SALL4, CDX2, cytokeratin (CK) (pan), CK18, desmin, and vimentin staining immunohistochemically. In summary, the tumor was diagnosed as carcinosarcoma of the stomach with AFP-producing HAC. To our knowledge, this is the first report of gastric carcinosarcoma with AFP-producing HAC in the English literature describing gastric tumors.

Clinicopathological features and prognosis of AFP-producing colorectal cancer: a single-center analysis of 20 cases

Background: High serum levels of alpha-fetoprotein (AFP) are observed in some gastrointestinal cancers. However, primary AFP-producing colorectal cancer (CRC) is extremely rare and causes confusion among clinicians. In this study, we analyzed the clinicopathological features and clinical outcomes of AFP-producing CRC and provide a brief view of this rare carcinoma.

Patients and methods: Twenty patients with AFP-producing CRC were enrolled at the Fudan University Shanghai Cancer Center from 2012 to 2015. Clinical information, including serum AFP and CEA levels, and outcomes were collected. Tumors were divided into three histologic types: the common adenocarcinoma (COM) type, mucinous adenocarcinoma type and hepatoid type (HPT). Immunohistochemical (IHC) staining of GPC3, Hepa-1, SALL4 and Arg-1 was performed. Additionally, mutations of the KRAS, NRAS and BRAF genes were examined. Finally, another 40 stage-matched patients with traditional CRC were enrolled as controls for survival analysis.

Results: AFP-producing CRC was more likely to occur in males (60%) and arose mainly from the ascending (40%) and sigmoid (35%) colon. In addition, the majority of patients with AFP-producing CRC had poor differentiation (50%), advanced local invasion (80%) and lymph node (LN) metastasis (60%). Synchronous distant metastasis was commonly observed (35%). Interestingly, serum AFP levels were closely associated with LN metastasis. Histopathologically, the COM type was the most common pattern. In IHC staining, the HPT pattern was the most distinct due to high positivity rates of GPC3, Hepa-1 and Arg-1. One patient had mismatch repair deficiency, and another had a KRAS mutation. Patients with AFP-producing CRC had worse progression-free and overall survival than patients with traditional CRC.

Conclusion: AFP-producing CRC has unique clinical and histopathological characteristics, showing an aggressive biological behavior and worse prognosis than traditional CRC.

Liver Metastasis of Hepatoid Colonic Adenocarcinoma: A Rare and Unusual Entity With Poor Prognosis and Review of the Literature

Hepatoid adenocarcinoma (HAC) is rare and was first reported as α-fetoprotein (AFP)-producing tumor. It is an important variant of extrahepatic adenocarcinoma with clinicopathological presentation mimicking hepatocellular carcinoma and carries exceedingly poor prognosis. HAC most commonly originates in the stomach, and less commonly in the ovary, esophagus, lung, among other organs. HAC originating in the colon is exceedingly rare. Here we report such a case of a 63-year-old man presented as decompensated liver failure with jaundice and weakness. Computed tomography (CT) imaging findings showed multiple lesions in the liver with ascites and descending colonic mass suspicious for malignancy. The flexible sigmoidoscopy showed a 1.5 cm mass in the descending colon, and biopsy showed superficial fragments of tubular adenoma, but could not exclude deep invasive carcinoma. A liver biopsy was performed and showed a carcinoma with morphologic features resembling hepatocellular carcinoma. The tumor cells were positive for glypican-3, MOC31, CDX2, SATB2 and CK20, negative for arginase-1, p63, synaptophysin and chromogranin. Ki-67 highlighted 80% of the tumor cells. The pathology diagnosis was liver with metastatic hepatoid adenocarcinoma consistent with colonic primary. The patient experienced a rapid worsening of his liver function and died 3 weeks later of hepatic failure without any surgery and chemotherapy. A subsequent literature review of the 17 reported cases of HAC showed that this type of cancer frequently metastasizes to the liver with an astonishingly poor prognosis with eight patients died of the disease in less than 5 months after the diagnosis was made. Radical surgery followed by adjuvant chemotherapy with chemotherapy regimen used for colorectal cancer or primary hepatocellular carcinoma may be the treatment option for colorectal HAC.

Synchronous Presentation of Hepatoid Alpha-Fetoprotein-Producing Lung Cancer and Colorectal Adenocarcinoma

We describe the synchronous presentation of hepatoid adenocarcinoma of the lung and colorectal adenocarcinoma in a patient with elevated alpha-fetoprotein (AFP) serum levels. Our patient was treated after surgery with a conventional chemotherapy regimen including bevacizumab, an anti-vascular endothelial growth factor monoclonal antibody, which was demonstrated to improve the clinical results in the treatment of colorectal and lung cancer compared with chemotherapy alone, and is today approved both for colon and lung cancer.

Besides the unconventional association of the two cancer types in our patient and the unsatisfactory clinical benefit obtained with the medical treatment administered, we report on the significance of AFP serum levels as a tumor marker in this peculiar situation. In our patient these levels, monitored from the first clinical symptoms through the last chemotherapy course, did not show any correlation with the response to treatment or with the patient's overall outcome. In particular, the serum marker remained essentially unchanged after the surgical removal of the lung mass and the subsequent chemotherapy.

Clinicopathological features and prognosis of intestinal hepatoid adenocarcinoma: evaluation of a pooled case series

BACKGROUD

Intestinal hepatoid adenocarcinoma (IHA) is a very rare and unique intestinal malignancy. Due to the lack of case series specifically pertaining to IHA, the clinicopathological features and prognosis of it remain unclear.

RESULTS

Of the 42 patients enrolled in this study, 30 (71.4%) were male. Twenty-one cases (50.0%) were located in the colon. Eight cases (19.0%) had accompanying inflammatory bowel disease (IBD). Elevated serum alpha-fetoprotein (AFP) was detected for most patients (25/33, 84.8%). Twenty-five (59.5%) patients received complete resections. Vascular invasion (22/36, 61.1%), lymph node metastasis (28/36, 77.8%) and distant metastasis (21/42, 50.0%) were common. The 1-year progression-free survival (PFS) and disease-specific survival (DSS) of IHA were 26.9% and 30.6%, respectively. Multivariate analysis showed that only pTNM stage was an independent risk factor for PFS and DSS. PFS and DSS in patients with IHA were significantly lower than those with colorectal adenocarcinoma (CA) and hepatoid adenocarcinoma of the stomach (HAS).

CONCLUSIONS

IHA most commonly occurred in the colon and accompanied by IBD in several cases. pTNM stage was an independent factor for prognosis. The prognosis of IHA was significantly worse than that of CA and HAS.

PATIENTS AND METHODS

Clinical data of IHA from four patients managed at our institution between January 2010 and December 2016, and 38 cases from research databases prior to 2017 were retrospectively studied.

CT features of hepatic metastases from hepatoid adenocarcinoma

PURPOSE

The purpose of this study was to report the imaging presentation of hepatic metastases from hepatoid adenocarcinoma (HAC).

METHODS

We retrospectively identified 11 patients (10 men and 1 woman; median age 66) with HAC liver metastasis who underwent contrast-enhanced computed tomography (CT) which included arterial phase and portal venous phase. Two radiologists analyzed the imaging parameters, which included the enhancement pattern on arterial and portal phase images, necrosis, venous thrombi, and overall imaging diagnosis, and arrived at a consensus.

RESULTS

On arterial phase, the liver lesions had global hyper-enhancement (n = 0), heterogeneous hyper-enhancement (63.6%; n = 7/11), peripheral hyper-enhancement (n = 0), iso-enhancement (n = 0/11), or hypo-enhancement (36.4%; n = 4/11). On portal venous phase, homogenous hypo-enhancement (18.2%; n = 2/11) and heterogenous hypo-enhancement (81.8%; n = 9/11) were observed. Venous thromboses occurred in four patients (36.4%; n = 4/11). The overall imaging diagnoses were "HCC-like" in seven patients (63.6%; n = 7/11), "indeterminable" in 1 patient (9.1%; n = 1/11), and "HCC-unlike" in three patients (27.3%; n = 3/11).

CONCLUSIONS

The imaging features of HAC liver metastasis were varied. Arterial phase enhancement coupled with venous phase washout (resembling HCC imaging features) was a major finding, but arterial phase hypo-enhancement (distinct from HCC imaging features) was also frequently encountered.

Clinicopathologic and immunohistochemical characteristics of gastric adenocarcinoma with enteroblastic differentiation: a study of 29 cases

BACKGROUND

Gastric adenocarcinoma with enteroblastic differentiation (GAED) has been recognized as a variant of alpha-fetoprotein (AFP)-producing gastric carcinoma, although its clinicopathologic and immunohistochemical features have not been fully elucidated.

METHODS

To elucidate the clinicopathologic and immunohistochemical features of GAED, we analyzed 29 cases of GAED, including ten early and 19 advanced lesions, and compared these cases with 100 cases of conventional gastric adenocarcinoma (CGA). Immunohistochemistry for AFP, glypican 3, SALL4, and p53 was performed, and the phenotypic expression of the tumors was evaluated by immunostaining with antibodies against MUC5AC, MUC6, MUC2, CD10, and caudal-type homeobox 2 (CDX2).

RESULTS

Lymphatic and venous invasion was more frequent in GAED (76 and 72 %) than in CGA (41 and 31 %; P ≤ 0.001). Lymph node metastasis was more frequently observed in GAED (69 %) than in CGA (38 %; P = 0.005), as were synchronous or metachronous liver metastases (GAED, 31 %; CGA, 6 %; P ≤ 0.001). Immunohistochemically, all GAED were positive for at least one of three enteroblastic linage markers (AFP, glypican 3, and SALL4). Glypican 3 was the most sensitive marker (83 %) for GAED, followed by SALL4 (72 %) and AFP (45 %), whereas no CGA was positive. Furthermore, the rate of positive p53 staining was 59 % in GAED. Regarding the mucin phenotype, CD10 and CDX2 were diffusely or focally expressed in all GAED cases. Invasive areas with hepatoid or enteroblastic differentiation were negative for CD10 and CDX2.

CONCLUSIONS

Clinicopathologic features of GAED differ from those of CGA. GAED shows aggressive biological behavior, and is characteristically immunoreactive to AFP, glypican 3, or SALL4.

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.

Alpha-fetoprotein-producing early rectal carcinoma: a rare case report and review

BACKGROUND

Alpha-fetoprotein (AFP)-producing rectal cancer is very rare, and this type of cancer frequently metastasizes to the liver with a poor prognosis. To date, only 11 cases of AFP-producing colorectal cancer have been reported.

CASE PRESENTATION

A 41-year-old woman was first presented to the hospital for anal bleeding. An elevated tumor with a central shallow depression in the lower rectum was detected by colonoscopy. Transanal excision was performed, and the histology revealed adenocarcinoma. Further immunohistopathological examination revealed that the tumor was an AFP-producing adenocarcinoma of the rectum. Although local resection was performed 2 months before the diagnosis of AFP tumor, the serum AFP level was normal. The depth of the submucosal invasion was 5,000 μm, and there was venous invasion. Also, no lymphatic invasion was detected. Therefore, additional surgical resection with lymph node dissection was conducted, and the patient underwent laparoscopic intersphincteric resection. No residual cancer was identified in the surgical specimens, and there was no evidence of lymph node metastasis. The patient was discharged 18 days postoperatively, and 12 months after the operation, there are no signs of recurrence.

CONCLUSION

To the best of our knowledge, this is the first case of an AFP-producing rectal cancer that was diagnosed at an early stage.

Characteristic analysis of α-fetoprotein-producing gastric carcinoma in China

α-Fetoprotein-producing gastric cancer (AFPGC) is a rare type of gastric cancer. The largest population of patients with AFPGC is found in China. In the present study, a total of 4,779 GC patients, including 317 AFPGC patients, from 11 clinical studies in China with a general AFPGC/GC ratio of 6.63% were summarized and analyzed. On the basis of analysis of the clinical data, the patients with AFPGC had larger tumor size, weaker cell differentiation, worse histopathological types, deeper serosal infiltration, more lymph node and liver metastases, poorer stages, shorter survival time and more positive expression of vascular endothelial growth factors than the patients without AFPGC. Our observation is consistent with previous results reported in studies of AFPGC. Overall, AFPGC is a subtype of GC with a poor prognosis.

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.

Malignant mixed mullerian tumor: an immunohistochemical study

Malignant mixed Mullerian tumor (MMMT) is an uncommon aggressive neoplasm composed of both malignant epithelial and mesenchymal components. In this study, immunohistochemical stains of germ cell markers, including SALL4, OCT3/4, glypican-3, and alpha-fetal protein (AFP), and CDX2 were performed in a series of MMMTs. SALL4 nuclear immunoreactivity was detected in 6 out of 19 cases (33%). The staining extent ranged from focal to extensive. The staining intensity was usually intermediate to strong (the score ranged from 1.5 to 3, and average score was 2.3 ± 0.5 in the positive cases). In addition, glypican-3 cytoplasmic reactivity was detected in 14 out of 16 cases (88%) with a mean score of 1.8 ± 0.7 (score ranging from 1 to 3). In contrast, OCT3/4 was only positive in 1 out of 19 cases and AFP in 2 out of 18 cases (11%). In summary, SALL4 and glypican-3 were frequently expressed in a subset of MMMTs. Their roles in the pathogenesis and biology of MMMT are yet to be determined. MMMT should be included in the differential diagnosis when a tumor is positive for SALL4 and/or glypican-3.

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.

Noninvasive diagnostic criteria for hepatocellular carcinoma in hepatic masses >2 cm in a hepatitis B virus-endemic area

BACKGROUND

Noninvasive criteria for diagnosing hepatocellular carcinoma (HCC) suggested by the American Association for the Study of Liver Diseases (AASLD) in 2005 consisted of serum α-fetoprotein (AFP) level >200 ng/ml or a typical enhancement pattern (arterial enhancement and portal/delayed washed out) on dynamic imaging of hepatic mass(es) >2 cm in a cirrhotic liver.

AIMS

To validate these criteria in a Korean population and to evaluate whether these criteria are applicable to patients without cirrhosis at a high risk of developing HCC.

METHODS

We prospectively investigated 206 consecutive patients with hepatic mass(es) >2 cm who underwent biopsy or surgical resection. Patients were evaluated by four-phase dynamic computed tomography (CT) and by assays of serum AFP concentrations at baseline. Patients were classified according to the presence of risk factors or cirrhosis, and the diagnostic accuracy of each test was determined.

RESULTS

The positive predictive values (PPV) of typical CT findings or serum AFP >200 ng/ml were 97.8% in cirrhotic patients, 89.6% in high-risk patients without cirrhosis and 82.4% in low-risk patients. The PPVs of typical CT findings alone in these groups were 98.8, 97.6 and 87.5% respectively. In high-risk patients without cirrhosis, the addition of serum AFP levels to typical CT findings minimally increased the diagnostic sensitivity from 81.6 to 87.8% but reduced the PPV from 97.6 to 89.6%.

CONCLUSIONS

Serum AFP concentration is not a suitable diagnostic criterion for HCC. Typical CT findings can be used to diagnose HCC >2 cm both in cirrhotic patients and in high-risk patients without cirrhosis.

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.

CDX2 Expression in Yolk Sac Component of Testicular Germ Cell Tumors

CDX2 has been detected in the majority of colorectal adenocarcinoma cases and may be useful in determining the sites of origin of tumors. In this study, the authors evaluated CDX2 expression in germ cell tumors (GCTs) by immunohistochemistry. Forty cases of testicular GCTs and 8 cases of metastatic GCTs were retrieved for study. In the 40 cases of testicular GCTs, 13 were pure seminomas and 27 mixed GCTs. Yolk sac tumor (YST) was identified by morphology and glypican 3 staining in 20 testicular mixed GCTs. Of these 20 cases, 8 cases showed 1+ positivity for CDX2. Other primitive components of GCTs were negative. For the 6 cases of metastatic mixed GCT with YST, 4 cases were positive, 2+ in 2 cases and 1+ in 2 cases. The positivity of CDX2 in GCTs warrants including YST in the differential diagnosis of adenocarcinoma of unknown origin.

A case of an alpha-fetoprotein-producing intrahepatic cholangiocarcinoma suggests probable cancer stem cell origin

Recent evidence suggests that some cancers may originate from cancer stem cells, which may derive from carcinogenesis of normal stem cells. A hepatic progenitor cell population, which gives rise to hepatocytes and cholangiocytes, has been suggested in humans, though whether these cells can give rise to malignant tumors has not been confirmed. We report here a case of an alpha-fetoprotein (AFP)-producing intrahepatic cholangiocarcinoma (ICC) in an 81-year-old woman with chronic hepatitis C viral infection, suggesting malignant transformation of hepatic stem cells as a mechanism for hepatic neoplasia. Abdominal computed tomography revealed a low-density mass with surrounding enhancement measuring 5 cm x 5 cm in segments IV and VIII of the liver. The preoperative serum levels of tumor markers were 1.7 ng/ml of carcinoembryonic antigen, 22 mAU/ml of protein induced by vitamin K absence or antagonist II, 43.4 U/ml of carbohydrate antigen 19-9, and 1,560 ng/ml of AFP. Following central bisegmentectomy of the liver, serum AFP levels decreased dramatically. Histologically, the tumor cells showed indistinct glandular structures with abundant fibrous stroma. Immunohistochemical analysis demonstrated that the neoplastic cells reacted strongly to antibodies against AFP and cytokeratin (CK) 7. In addition, cancer cells showed partially positive reaction to anti-CK14, a liver stem cell marker, and to anticluster designation (CD) 133, a hematopoietic stem cell marker, and negative reaction to antihepatocyte paraffin (HepPar) 1. These data may indicate that the tumor was derived from a normal liver stem cell that underwent oncogenic transformation.

Expression of liver-enriched nuclear factors and their isoforms in alpha-fetoprotein-producing gastric carcinoma cells

Alpha-fetoprotein (AFP)-producing gastric cancer (AFP-GC) is a highly malignant variant of adenocarcinoma with aberrant hepatocellular phenotype. A detailed understanding of the regulation of its liver phenotype is lacking. Liver-enriched nuclear factors (LENFs) are implicated in the transcriptional regulation of AFP in the fetal liver. To investigate the regulatory role of LENFs in AFP-GCs, the expression of LENFs including CCAAT/enhancer binding protein (C/EBP)-beta, C/EBP-alpha, hepatocyte nuclear factor (HNF)-1alpha, HNF-1beta and HNF-4alpha was investigated in 3 cell lines of AFP-GC and 7 cell lines of control GC. The liver activating protein (LAP), an activating isoform of C/EBP-beta, was predominantly expressed in AFP-GCs, whereas the liver inhibitory protein (LIP), an inhibitory isoform of C/EBP-beta, predominated in the control GCs. HNF-1alpha was relatively suppressed in AFP-GCs. HNF-4alpha was expressed in one of three AFP-GC cell lines. C/EBP-alpha and HNF-1beta were expressed at the same levels in both cell types of GC. AFP-GCs expressed a set of hepatocyte-related proteins (e.g., transferrin and albumin) while they still retained the several glandular cell-related proteins (e.g., MUC2). The induction of LIP reduced transferrin expression and induced CEA expression in an AFP-GC line. Collecting these results, it was suggested that the contribution of LENFs, especially isoforms of C/EBP-beta, is possibly important in phenotypic regulation of AFP-GCs.

α-fetoprotein expression in a dedifferentiated liposarcoma

Extremely rare cases of paraneoplastic syndromes or ectopic production of proteins associated with liposarcoma are reported in literature. We describe a unique case of relapsing retroperitoneal dedifferentiated liposarcoma with biochemical, immunohistochemical, and molecular evidence of alpha-fetoprotein (AFP) ectopic production. The lesion was associated to elevated AFP plasma levels that subsided after tumor removal. Immunohistochemical studies showed AFP production by a minority of tumor cells and reverse transcriptase polymerase chain reaction confirmed AFP mRNA expression. Finding of MDM2 and CDK4 iperexpression by immunohistochemistry confirmed the diagnosis of dedifferentiated liposarcoma.

Genetic evolution of alpha fetoprotein producing gastric cancer

BACKGROUND

Alpha fetoprotein (AFP) producing gastric cancer is an unusual form of aggressive adenocarcinoma with a complex histological picture, including enteroblastic and hepatoid differentiation.

AIMS

To investigate the genetic events underlying the phenotypic diversity in AFP producing gastric cancer and the ability of these tumours to produce AFP ectopically.

METHODS

Multiple foci from 19 AFP producing gastric adenocarcinomas were microdissected and loss of heterozygosity (LOH) analysis was performed with a panel of microsatellite markers on nine chromosomal arms.

RESULTS

For informative cases, LOH was most frequently detected on 17p (100%), followed by 13q (88%), 3p (87%), 5q and 9p (80%), 11q (70%), 18q (58%), 16q (53%), and 8p (50%). The average fractional allelic loss was 0.72. LOH was detected either homogeneously throughout the microdissected foci, or only in some parts of the neoplastic foci for each case. Heterogeneous patterns of LOH indicated genetic progression and/or divergence in clonal evolution. Furthermore, in six cases with heterogeneous LOH of 13q, 13q LOH was restricted to immunohistochemically AFP positive neoplastic foci.

CONCLUSION

AFP-GC arises as an aggressive clone with extensive LOH and high fractional allelic loss. The presence of heterogeneous patterns of LOH suggested that the AFP producing carcinoma foci might evolve through genetic progression and/or genetic divergence. Silencing of the crucial gene on 13q may be involved in the acquisition of the AFP producing phenotype.

Rectal adenocarcinoma with germ-cell differentiation: report of a case

A 26-year-old male presented with a colorectal adenocarcinoma with germ-cell differentiation and an isolated elevation of serum alpha-fetoprotein. He was treated with platinum/etoposide/bleomycin chemotherapy with a decrease in serum alpha-fetoprotein and in the size of the primary tumor. An ongoing tumor-marker response occurred when the patient was switched to concurrent 5-fluorouracil chemotherapy and radiation therapy. The patient underwent a palliative diversion of his rectal cancer 10 months after diagnosis, developed liver metastasis at 12 months, and died 20 months after diagnosis.

Immunoreactivity for hepatocyte paraffin 1 antibody in hepatoid adenocarcinomas of the gastrointestinal tract

Hepatocyte paraffin 1 (Hep Par 1) is a monoclonal antibody considered almost specific for normal and neoplastic hepatocytes, that can be used on formalin-fixed paraffin-embedded tissues. Hep Par 1 reactivity has been demonstrated consistently in hepatocellular carcinomas and hepatoblastomas but only rarely in cholangiocarcinomas and metastatic tumors to the liver. Although its role as a marker of hepatocytic differentiation in primary liver tumors has been studied extensively, Hep Par 1 expression has not been explored in extrahepatic lesions, especially rare adenocarcinomas with hepatoid morphologic features. We studied 7 hepatoid adenocarcinomas of the gastrointestinal tract (6 gastric and 1 from the gallbladder) for Hep Par 1 immunoreactivity. Focal Hep Par 1 expression was seen in 6 of 7 tumors. These hepatoid adenocarcinomas also showed reactivity for alpha-fetoprotein and carcinoembryonic antigen. The presence of Hep Par 1 reactivity in extrahepatic hepatoid adenocarcinomas underscores the fact that Hep Par 1 expression is not unique to primary hepatocellular neoplasms. Adenocarcinomas with hepatoid features must be considered in the differential diagnosis of Hep Par 1-positive lesions.

Colonic adenocarcinoma metastasizing as a germ cell neoplasm: a case report and review of the literature

Mixed tumors of the gastrointestinal tract, including both adenocarcinoma and germ cell neoplasm, have been reported infrequently. In the colon, only 9 cases, to our knowledge, have been described in the English-language literature. This is the case of a 29-year-old man with an unsuspected mixed colonic neoplasm that metastasized as the germ cell component.

Metastatic intestinal carcinomas simulating primary ovarian clear cell carcinoma and secretory endometrioid carcinoma: a clinicopathologic and immunohistochemical study of five cases

Five cases of ovarian metastases of intestinal adenocarcinomas that suggested the diagnosis of clear cell adenocarcinoma or the secretory variant of endometrioid carcinoma of the ovary are reported. Patient age ranged from 27 to 71 years at the time of diagnosis of the ovarian neoplasms. In four, the ovarian and intestinal tumors were discovered synchronously, and, in the fifth, the ovarian metastasis occurred 1 year after the intestinal primary was diagnosed. The ovarian tumors were unilateral in three patients and bilateral in two. They were up to 18 cm (mean, 12 cm) in maximum dimension and were characterized on microscopic evaluation by glands and cysts lined by cells whose most striking feature was abundant clear cytoplasm. In two cases, striking subnuclear or supranuclear vacuoles were present. An important clue to the diagnosis of metastatic intestinal adenocarcinoma was the presence in all cases of "dirty necrosis." The metastatic nature of the ovarian tumors was supported by the immunohistochemical findings. All tumors stained were strongly positive for carcinoembryonic antigen and cytokeratin 20 and failed to stain for CA125, whereas staining for HAM56 and cytokeratin 7 was absent or only focally positive in one case each. Three intestinal primary tumors involved the small bowel. Microscopic evaluation of the intestinal tumors in three cases and metastases in a fourth, in which the intestinal primary was not resected, showed the features of the uncommon clear cell variant of intestinal adenocarcinoma; the fifth was predominantly a conventional intestinal adenocarcinoma with only a focal clear cell component. Although intestinal adenocarcinomas metastatic in the ovary typically simulate endometrioid adenocarcinoma of the usual type or mucinous adenocarcinoma, they may mimic either primary clear cell adenocarcinoma or the secretory variant of endometrioid adenocarcinoma, particularly when the primary tumor is, even focally, the clear cell variant of intestinal adenocarcinoma.

DNA methylation contributes to expression of the human neurotensin/neuromedin N gene

The gut and liver share a common embryological origin. The gene encoding the gut hormone neurotensin/neuromedin N (NT/N) is expressed in the adult small bowel, and NT/N is transiently expressed in the fetal liver, suppressed in the adult liver, and reexpressed in certain liver cancers. In our present study, we found that the NT/N gene was expressed at high levels in the human hepatoma cell line Hep 3B but was not expressed in Hep G2 cells. To further determine the mechanisms regulating NT/N expression, we performed Southern blotting and gene cloning techniques. Neither alteration nor mutation of the NT/N gene was responsible for this differential NT/N expression pattern. Human NT/N promoter constructs were transfected into either Hep 3B or Hep G2. Both cell lines supported NT/N transcription, indicating that the absence of NT/N expression in Hep G2 cells was due to mechanisms other than the absence of positive transcription factors. The role of DNA methylation was next assessed. Methylation of NT/N promoter constructs in vitro resulted in a 67-fold reduction in promoter activity, whereas treatment with the demethylating agent 5-azacytidine induced NT/N expression in Hep G2 cells, thus suggesting that DNA methylation plays a role in the expression of the gut endocrine gene NT/N. Defining the mechanisms regulating NT/N expression in these hepatic-derived cell lines will provide not only a better understanding of cell-specific and developmental regulation of a gut endocrine gene but also possible insight into liver cell lineage patterns and the derivation of certain hepatocellular cancers.

Carcinoma of the stomach with hepatocyte differentiation (hepatoid adenocarcinoma)

A case of hepatoid adenocarcinoma of the stomach is reported, and the literature is reviewed. The stomach is one of the most common sites in which hepatoid adenocarcinomas have been detected. Of the 59 cases reviewed from the literature (including the current case), a 2:1 male predominance was noted, and the serum alpha-fetoprotein level was almost always increased. All patients were adults, and most had evidence of metastases at the time of resection. Prognosis seems less favorable than that associated with the more common intestinal type of adenocarcinoma of the stomach. Hepatoid adenocarcinomas typically show periodic acid-Schiff-positive, diastase-resistant intracytoplasmic globules, which are demonstrated to be positive with antibodies to alpha-fetoprotein. The tumor cells resemble liver cells, and rare cases, including our own, have evidence of bile production. In our case, messenger RNA for albumin, unique to liver cells, was demonstrated by in situ hybridization of the tumor cells.

Hepatoid yolk sac tumors of the mediastinum: a clinicopathologic and immunohistochemical study of four cases

Four cases of primary hepatoid yolk sac tumors of the anterior mediastinum are described. The patients were all men between the ages of 26 and 40 years (median 33). Clinically, they all presented with a history of shortness of breath and chest pain of several weeks' duration. None of the patients had a history of germ cell tumor elsewhere or evidence of any hepatic abnormality. Grossly, all the tumors were described as large mediastinal masses that impinged on adjacent structures. Histologically, they were characterized by sheets of medium-sized, round to polygonal neoplastic cells with moderate amounts of eosinophilic cytoplasm and round to oval nuclei with prominent nucleoli. The cellular proliferation was homogeneous and displayed moderate cellular atypia and scattered mitotic activity. All the tumors showed focally the presence of more conventional areas of yolk sac tumor, with islands of tumor cells showing a reticular pattern of growth admixed with scattered intra- and extracellular hyaline globules and occasional Schiller-Duval bodies. Immunohistochemical studies showed strong positivity of the tumor cells for alpha-fetoprotein in both components of the lesions. Follow-up information was available in three patients, all of whom developed lung metastases within a year after initial diagnosis. Two of these patients died of tumor within the same period, whereas a third patient has been lost to follow-up. The present cases illustrate an unusual histologic pattern of yolk sac tumor in the mediastinum and highlight the importance of considering this tumor in the differential diagnosis of lesions showing a hepatoid pattern of growth in the mediastinal area.