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Montecino RMB, Sukhorosl M, Francis MA, Kancherla N, Akuma O, Nwangene NL, Nandyal S, Raj R, Akuma CM, Zahdeh T, Kaushik S, Khan AM. A Rare Case of Primary Gastric Signet Ring Cell Carcinoma: a Review of Guidelines for the Management of Gastric Cancer. Indian J Surg Oncol 2024; 15:153-159. [PMID: 38511028 PMCID: PMC10948689 DOI: 10.1007/s13193-023-01852-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/18/2023] [Indexed: 03/22/2024] Open
Abstract
Gastric carcinoma is the fifth most common and the third leading cause of cancer deaths worldwide. The incidence of diffuse-type gastric cancer, of which signet ring cell carcinoma is a subtype, is rising in the world. Due to non-specific gastritis-like symptoms, difficulty in assessing true tumor characteristics owing to its horizontal spread, and non-distinguishable endoscopic appearance from other gastric pathologies, the diagnosis of this subtype is challenging. We present a case of a 67-year-old woman with progressively worsening abdominal pain who came for an endoscopic ultrasound evaluation of an incidentally noted pancreatic cyst on a previous MRI. During endoscopy, a 1-cm gastric ulcer was noted along the lesser curvature of the gastric body. Biopsy confirmed a diagnosis of gastric signet ring cell carcinoma (SRCC) with CDX-2 and keratin positivity. The patient underwent total gastrectomy with Roux-en-Y reconstruction. Gross specimen revealed a diffuse SRCC invading the muscularis propria, along with lymphovascular and perineural invasion. In the context of our case, we discuss the morphological features of SRCC and the effectiveness of treatment options based on existing literature. Early accurate diagnosis and staging play an important role in determining treatment options as well as the clinical course of gastric SRCC.
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Affiliation(s)
| | - Mikhail Sukhorosl
- S M Kirov Military Medical Academy: Voenno-Medicinskaa Akademia Imeni S M Kirova Ministerstva Oborony Rossijskoj Federacii, Saint Petersburg, Russia
| | - Mayi Ann Francis
- Windsor University School of Medicine, Cayon, Saint Kitts and Nevis
| | | | | | | | - Shreyas Nandyal
- Gandhi Medical College, 8-2-601/B/3 G2, Ashoka Silent Valley, Road Number 10, Banjara Hills, Hyderabad, TS 500034 India
| | - Rohan Raj
- Nalanda Medical College and Hospital, Patna, India
| | | | | | - Sharanya Kaushik
- Bangalore Medical College and Research Institute: Bangalore Medical College, Bengaluru, India
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Wang X, Li X, Yang P, Qin X, Yu J, Cheng Y, Zhang G, Tang L. The differences in biological behavior and gene expression characteristics between pure and mixed early gastric signet ring cell carcinomas. Dig Liver Dis 2023; 55:815-822. [PMID: 36529637 DOI: 10.1016/j.dld.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/01/2022] [Accepted: 11/16/2022] [Indexed: 05/29/2023]
Abstract
BACKGROUND The biological behavior of signet ring cell carcinoma (SRCC) in early gastric cancer (EGC) is not well understood. AIMS We aimed to investigate the clinicopathologic and prognostic differences, and explore differences in the gene expression characteristics between pure early SRCC and mixed early SRCC. METHODS We retrospectively analyzed 1707 EGC patients. We also conducted a meta-analysis to compare biological behavior in pure SRCC and mixed SRCC. We explored gene expression levels of N6-methyadenosine (m6A) regulators in pure SRCC and mixed SRCC. RESULTS Compared with pure SRCC, mixed SRCC was associated with an increased risk of submucosal invasion, perineural invasion, LVI and LNM. LNM was more common in mixed SRCC than with pure SRCC who met the indications for endoscopic submucosal dissection (ESD) (16.67% vs 2.78%). There was no difference in the overall survival between pure SRCC and mixed SRCC in EGCs (P=0.10). Expression of m6A regulators WTAP, FTO and VIRMA was significantly higher in mixed SRCC than that in pure SRCC (P<0.05). CONCLUSION Mixed SRCC displayed more aggressive biological behavior than pure SRCC in EGC. WTAP, FTO and VIRMA were expressed at significantly different levels in the two types of EGC, and may have important roles in the observed differences in biological behavior.
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Affiliation(s)
- Xiaoyong Wang
- Department of Gastroenterology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, 29 Xinglong Lane, Tianning District, Changzhou 213000, China
| | - Xuan Li
- Department of Gastroenterology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing 210000, China
| | - Peng Yang
- Department of Gastroenterology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, 29 Xinglong Lane, Tianning District, Changzhou 213000, China
| | - Xiangrong Qin
- Department of Gastroenterology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, 29 Xinglong Lane, Tianning District, Changzhou 213000, China
| | - Jing Yu
- Department of Gastroenterology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, 29 Xinglong Lane, Tianning District, Changzhou 213000, China
| | - Yuqing Cheng
- Department of Pathology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213000, China
| | - Guoxin Zhang
- Department of Gastroenterology, Jiangsu Province Hospital and Nanjing Medical University First Affiliated Hospital, Nanjing 210000, China
| | - Liming Tang
- Department of General surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213000, China.
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Tsuneki M, Kanavati F. Weakly Supervised Learning for Poorly Differentiated Adenocarcinoma Classification in GastricEndoscopic Submucosal Dissection Whole Slide Images. Technol Cancer Res Treat 2022; 21:15330338221142674. [PMID: 36476107 PMCID: PMC9742706 DOI: 10.1177/15330338221142674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: Endoscopic submucosal dissection (ESD) is the preferred technique for treating early gastric cancers including poorly differentiated adenocarcinoma without ulcerative findings. The histopathological classification of poorly differentiated adenocarcinoma including signet ring cell carcinoma is of pivotal importance for determining further optimum cancer treatment(s) and clinical outcomes. Because conventional diagnosis by pathologists using microscopes is time-consuming and limited in terms of human resources, it is very important to develop computer-aided techniques that can rapidly and accurately inspect large number of histopathological specimen whole-slide images (WSIs). Computational pathology applications which can assist pathologists in detecting and classifying gastric poorly differentiated adenocarcinoma from ESD WSIs would be of great benefit for routine histopathological diagnostic workflow. Methods: In this study, we trained the deep learning model to classify poorly differentiated adenocarcinoma in ESD WSIs by transfer and weakly supervised learning approaches. Results: We evaluated the model on ESD, endoscopic biopsy, and surgical specimen WSI test sets, achieving and ROC-AUC up to 0.975 in gastric ESD test sets for poorly differentiated adenocarcinoma. Conclusion: The deep learning model developed in this study demonstrates the high promising potential of deployment in a routine practical gastric ESD histopathological diagnostic workflow as a computer-aided diagnosis system.
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Affiliation(s)
- Masayuki Tsuneki
- Medmain Research, Medmain Inc., Fukuoka, Japan,Masayuki Tsuneki, Medmain Research, Medmain Inc., Fukuoka, 810-0042, Japan.
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Weng CY, Sun SP, Cai C, Xu JL, Lv B. Endoscopic submucosal dissection for early signet ring cell gastric cancer: A systematic review and meta-analysis. World J Clin Cases 2022; 10:6915-6926. [PMID: 36051146 PMCID: PMC9297431 DOI: 10.12998/wjcc.v10.i20.6915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/11/2021] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The use of endoscopic submucosal dissection (ESD) for treating early signet ring cell carcinoma (SRC) is controversial due to the risk of lymph node metastasis.
AIM To carry out a meta-analysis to evaluate ESD for therapeutic efficacy and safety in early signet ring cell gastric cancer.
METHODS The PubMed, Web of Science, Cochrane Library, and EMBASE databases were used to search for relevant studies evaluating the therapeutic efficacy and safety of ESD in SRC. The rates of recurrence, complete resection, incomplete resection, curative resection, en bloc resection, and adverse events were extracted and analyzed. The methodological quality of the enrolled studies was assessed using the Newcastle-Ottawa Scale. Publication bias was evaluated by the Egger’s test. Institutional review board approval and written consent were not needed for this report.
RESULTS This meta-analysis enrolled seven studies with 653 participants undergoing ESD treatment for early SRC. The overall recurrence rate was 0.010 [95% confidence interval (CI): 0.000-0.040, Z = 1.422, P = 0.155]. The total lymphovascular invasion rate was 0.038 (95%CI: 0.007-0.088, Z = 3.026, P = 0.002). The total en bloc resection rate was estimated at 0.984 (95%CI: 0.925-1.000, Z = 19.463, P = 0.000). The total complete and incomplete resection rates were estimated at 0.785 (95%CI: 0.596-0.928, Z = 9.789, P = 0.000) and 0.188 (95%CI: 0.016-0.468, Z = 2.531, P = 0.011), respectively. The total procedure-associated gastric hemorrhage and perforation rates were estimated at 0.026 (95%CI: 0.005-0.061, Z = 3.006 P = 0.003) and 0.004 (95%CI: 0.000-0.028, Z = 0.938, P = 0.348), respectively. The curative resection, vertical margin invasion, and lateral margin invasion rates were 72.1% (145/341), 2.3% (8/348), and 34.45% (41/119), respectively.
CONCLUSION ESD constitutes a promising therapeutic approach for early undifferentiated SRC gastric cancer. However, further improvements are required for increasing its treatment efficacy and reducing adverse outcomes.
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Affiliation(s)
- Chun-Yan Weng
- Department of Gastroenterology, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Shao-Peng Sun
- Department of Gastroenterology, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Chang Cai
- Department of Gastroenterology, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Jing-Li Xu
- Department of Gastrointestinal Surgery, The First Clinical Medical University of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Bin Lv
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
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Characterization of Poorly Cohesive and Signet Ring Cell Carcinomas and Identification of PTPRM as a Diagnostic Marker. Cancers (Basel) 2022; 14:cancers14102502. [PMID: 35626106 PMCID: PMC9139305 DOI: 10.3390/cancers14102502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background and aims. Signet ring cell (SRC) and poorly cohesive (PC) gastric carcinomas are morphologically similar but exhibit different biological behavior. We compared the clinical and molecular characteristics of SRC and PC carcinomas. Methods. Diffuse-type gastric cancer (GC) cases were classified into SRC carcinomas (>90% of SRCs), PC carcinomas (<10% of SRCs), and combined PC/SRC carcinomas (≤90% but ≥10% of SRCs). The gene expression patterns in SRC and PC carcinomas were examined by transcriptome and protein immunohistochemistry analyses, and diagnostic and prognostic biomarkers were identified. Results. SRC and PC carcinomas showed significantly different clinical behaviors but shared common RNA expression patterns. PC carcinomas showed an increased expression of genes related to cancer progression. Among genes differentially expressed between PC and SRC carcinomas, protein tyrosine phosphatase receptor type M (PTPRM) was overexpressed in PC and related to unfavorable clinical factors. Conclusion. We found that PC and SRC carcinomas had distinct clinical characteristics and should be classified as different carcinoma types. PTPRM was identified as a potential diagnostic and prognostic biomarker for PC carcinomas and could represent a potential therapeutic target.
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Yang S, Gu X, Tao R, Huo J, Hu Z, Sun F, Ni J, Wang X. Relationship between histological mixed-type early gastric cancer and lymph node metastasis: A systematic review and meta-analysis. PLoS One 2022; 17:e0266952. [PMID: 35427370 PMCID: PMC9012370 DOI: 10.1371/journal.pone.0266952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/30/2022] [Indexed: 12/02/2022] Open
Abstract
The clinicopathological features of early gastric cancer (EGC) with mixed-type histology (differentiated and undifferentiated) are incompletely understood, and the capacity of endoscopic submucosal dissection (ESD) to treat mixed-type cancer remains controversial. This systematic review analyzed the rate of lymph node metastasis (LNM) in mixed-type EGC. We gathered articles published up to February 21, 2021, that analyzed the relationship between LNM and mixed-type EGC from Embase, PubMed, and Web of Science. The primary outcome was the LNM rate associated with different histological types of EGC, and the secondary outcomes were the odds ratios (ORs) for LNM risk factors among EGC patients. From the 24 studies included in this meta-analysis, the overall rate of LNM in predominantly differentiated mixed-type (MD) EGC was 12%, whereas the LNM rate in predominantly undifferentiated mixed-type (MU) EGC was 22%. We further divided these studies into 2 groups according to the depth of invasion. In mixed-type mucosal EGC, the pooled LNM rate was 15%; in submucosal EGC, the rate was 33% for MU, which was higher than the rates for pure types (pure differentiated type, 13%; pure undifferentiated type, 21%; p<0.05). The LNM rate of MD was 20%, it was higher than those of the pure differentiated type and nearly the same as pure undifferentiated type. Other pooled statistics showed that submucosal invasion, pure undifferentiated EGC, and mixed-type EGC were independent risk factors for LNM. This meta-analysis showed that MD submucosal EGC has a high rate of LNM and is highly correlated with LNM; thus, the management of MD EGC as purely differentiated EGC according to the indications for ESD is inappropriate, and the mixed type should be added as a parameter in these indications.
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Affiliation(s)
- Shufan Yang
- Nantong University, Nantong City, Jiangsu, P.R. China
| | - Xin Gu
- The Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Wuxi City, Jiangsu, P.R. China
| | - Rui Tao
- The Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Wuxi City, Jiangsu, P.R. China
| | - Jiahui Huo
- The Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Wuxi City, Jiangsu, P.R. China
| | - Zhen Hu
- The Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Wuxi City, Jiangsu, P.R. China
| | - Fei Sun
- The Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Wuxi City, Jiangsu, P.R. China
| | - Jinbin Ni
- The Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Wuxi City, Jiangsu, P.R. China
| | - Xiaoyun Wang
- The Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University, Wuxi City, Jiangsu, P.R. China
- The Affiliated Wuxi Clinical College of Nantong University, Wuxi City, Jiangsu, P.R. China
- * E-mail:
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Nakamura K, Eto K, Iwagami S, Ogawa K, Sawayama H, Ishimoto T, Iwatsuki M, Baba Y, Miyamoto Y, Yoshida N, Baba H. Clinicopathological characteristics and prognosis of poorly cohesive cell subtype of gastric cancer. Int J Clin Oncol 2022; 27:512-519. [PMID: 35084597 DOI: 10.1007/s10147-021-02069-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The new World Health Organization (WHO) classification of gastric cancer includes a histological subtype of poorly cohesive carcinoma (PCC), which includes signet-ring cell (SRC) phenotype. We aimed to examine the concordance between preoperative clinical and postoperative histological diagnoses according to the 2010 WHO histological subtypes and to compare the prognoses of these subtypes. METHODS The study cohort comprised 665 patients who underwent gastrectomy from 2005 to 2019. Histological subtypes were classified into PCC-NOS (non-signet ring cell subtype), SRC, and non-PCC, which were defined by the predominant component in accordance with the 2010 WHO classification of gastric cancer. The concordance of clinical and pathological diagnosis was examined and clinicopathological characteristics and survival outcome of the three subtypes compared. RESULTS The cancers of 443 patients (66.7%) were classified as non-PCC, of 112 patients (16.8%) as PCC-NOS, and of 110 patients (16.5%) as SRC predominant subtypes. Significant differences in sex, age, tumor location, size, macroscopic type, and pathological TNM category (all P<0.05) were found. The concordance rate of preoperative and postoperative histological subtypes was significantly lower for poorly cohesive than other subtypes (P<0.0001). Preoperative stage tended to be underestimated for PCC-NOS subtype and these patients had poorer overall survival than those with the other two subtypes (P=0.005). Multivariate logistic regression analysis of overall survival showed that WHO histological subtype (PCC-NOS vs. non-PCC/SRC, HR: 1.64, 95% CI: 1.18-2.29, P=0.0034) was a significant independent prognostic factor. CONCLUSION Our results suggest that poorly cohesive carcinoma subtypes have different biological characteristics and prognoses.
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Affiliation(s)
- Kenichi Nakamura
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan.
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Katsuhiro Ogawa
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Hiroshi Sawayama
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Takatsugu Ishimoto
- Gastrointestinal Cancer Biology, International Research Center for Medical Sciences, Kumamoto University, Kumamoto, 860-8556, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
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Yeo MK, Kang SH, Jeong KB, Lee HS, Jeon HJ, Eun HS, Lee ES, Moon HS, Kim SH, Sung JK, Lee BS, Jeong HY. Comparison of Gene Expression Profiles of Signet Ring Cell Carcinoma and Poorly Cohesive Carcinoma in Early Gastric Cancer. CLINICAL MEDICINE INSIGHTS: ONCOLOGY 2022; 16:11795549221097941. [PMID: 35603092 PMCID: PMC9121514 DOI: 10.1177/11795549221097941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 04/14/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction: Although signet ring cell carcinoma (SRC) is a subtype of poorly cohesive carcinoma (PC), the differences in the biological behavior between the 2 morphologically similar carcinomas have not been fully studied. Therefore, we performed transcriptome analysis to evaluate the differences of genetic expressions between SRC and PC. Methods: The study group consisted of patients with SRC or PC pathology from patients with early gastric cancer (EGC) whose depth of invasion was localized in the mucosal layer. A total of 18 patients were enrolled. The patients were divided into 3 groups based on their histologic type and lymph node (LN) status. Group 1 consisted of patients with PC and positive LN metastasis, Group 2 consisted of patients with PC without LN metastasis, and Group 3 consisted of patients with SRC without LN metastasis. Transcriptome analysis was performed using the nCounter PanCancer Progression Panel Kit. Results: The expression of 77 genes in Group 1 was altered compared to that in normal tissues. The expression of 49 and 13 genes in Groups 2 and 3, respectively, was altered when compared to that in normal tissues. Groups 1 and 2 showed similar genetic expressions. However, Group 3 showed numerous differences in gene expression including Roundabout4 (Robo4) compared to the other groups, especially Group 1. Conclusion: Our data suggest that gene expression patterns were different between SRC and PC and expression of ROBO4 may play an important role in the prognosis of SRC and PC type of EGC.
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Affiliation(s)
- Min Kyung Yeo
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Sun Hyung Kang
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Ku Bean Jeong
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyun Seok Lee
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hong Jae Jeon
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyuk Soo Eun
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Eaum Seok Lee
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hee Seok Moon
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Seok Hyun Kim
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Jae Kyu Sung
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Byung Seok Lee
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyun Yong Jeong
- Division of gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
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Wei Q, Gao Y, Qi C, Yuan X, Li J, Xu Q, Luo C, Chen L, Zhuo W, Xu Z, Ying J. Clinicopathological Characteristics and Prognosis of Signet Ring Gastric Cancer: A Population-Based Study. Front Oncol 2021; 11:580545. [PMID: 34490073 PMCID: PMC8418067 DOI: 10.3389/fonc.2021.580545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 06/16/2021] [Indexed: 12/14/2022] Open
Abstract
Background To better define the clinicopathologic characteristics of signet ring cell (SRC) gastric cancer and build a prognostic model for it. Methods SRC patient information from 2010 to 2015 were identified using Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier method and log-rank test were used to estimate Overall survival (OS) and to determine associations with histologic subtypes. In COX proportional hazards regression model–based univariate and multivariate analyses, significant variables for construction of a nomogram were screened out. The nomogram was validated by means of the concordance index (CI), calibration plots, and receiver operating characteristics (ROCs) curves. Results A total of 11,363 gastric cancer patients were enrolled. On dividing the patients into SRC, well-to-moderately differentiated (WMD) adenocarcinoma, and poorly differentiated (PD) adenocarcinoma, differences among these subgroups emerged. SRC patients were more likely to occur in female and young patients than other histologic subtypes. Larger tumors, stage T4, and node stage N3 were more likely to be found in the SRC group. The survival for SRC patients was better than non-SRC patients in stage I. Univariate and multivariate analyses identified age, tumor site, larger tumor size, advanced T classification, advanced N classification, advanced TNM stage, and surgery of primary site as independent prognostic indicators. Then an OS nomogram was formulated. Conclusions SRC had distinct clinicopathological characteristics. The nomogram provided an accurate tool to evaluate the prognosis of SRC.
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Affiliation(s)
- Qing Wei
- Department of Abdominal Medical Oncology, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yiding Gao
- The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Changsong Qi
- Department of Gastrointestinal Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China
| | - Xing Yuan
- Department of Abdominal Medical Oncology, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
| | - Jingjing Li
- Department of Abdominal Medical Oncology, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
| | - Qi Xu
- Department of Abdominal Medical Oncology, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
| | - Cong Luo
- Department of Abdominal Medical Oncology, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
| | - Lei Chen
- Department of Abdominal Medical Oncology, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
| | - Wei Zhuo
- Department of Cell Biology, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhiyuan Xu
- Department of Gastric Surgery, Institute of Cancer and Basic Medicine (ICBM), Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Chinese Academy of Sciences, Hangzhou, China
| | - Jieer Ying
- Department of Abdominal Medical Oncology, Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
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Díaz Del Arco C, Ortega Medina L, Estrada Muñoz L, García Gómez de Las Heras S, Fernández Aceñero MJ. Is there still a place for conventional histopathology in the age of molecular medicine? Laurén classification, inflammatory infiltration and other current topics in gastric cancer diagnosis and prognosis. Histol Histopathol 2021; 36:587-613. [PMID: 33565601 DOI: 10.14670/hh-18-309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastric cancer (GC) is the fifth most common cancer and the third cause of cancer-related deaths worldwide. In western countries, more than half of GC patients are diagnosed at advanced stages and 5-year survival rates range between 20-30%. The only curative treatment is surgery, and despite recent advances in oncological therapies, GC prognosis is still poor. The main prognostic tool for patient categorization and treatment selection is the TNM classification, but its limitations are being increasingly recognized. Early recurrences may occur in early-stage disease, and patients at the same stage show heterogeneous outcomes. Thus, there is a need to improve GC stratification and to identify new prognostic factors, which may allow us to select drug-susceptible populations, refine patient grouping for clinical trials and discover new therapeutic targets. Molecular classifications have been developed, but they have not been translated to the clinical practice. On the other hand, histological assessment is cheap and widely available, and it is still a mainstay in the era of molecular medicine. Furthermore, histological features are acquiring new roles as reflectors of the genotype-phenotype correlation, and their potential impact on patient management is currently being analyzed. The aim of this literature review is to provide a modern overview of the histological assessment of GC. In this study, we discuss recent topics on the histological diagnosis of GC, focusing on the current role of Laurén classification and the potential value of new histological features in GC, such as inflammatory infiltration and tumor budding.
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Affiliation(s)
- Cristina Díaz Del Arco
- Department of Surgical Pathology, Hospital Clínico San Carlos, Madrid, Spain. .,Complutense University of Madrid, Madrid, Spain
| | - Luis Ortega Medina
- Complutense University of Madrid, Madrid, Spain.,Department of Surgical Pathology, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - Mª Jesús Fernández Aceñero
- Complutense University of Madrid, Madrid, Spain.,Department of Surgical Pathology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Lee YM, Kang SH, Kim JS, Eun HS, Joo JS, Rou WS, Park JH, Moon HS, Lee ES, Kim SH, Sung JK, Lee BS, Jeong HY, Yeo MK, Song KS, Yoo HM. Subepithelial Spread of Early Gastric Signet Ring Cell Carcinoma: How Far They Can Reach? Dig Dis 2020; 38:442-448. [PMID: 32187603 DOI: 10.1159/000507322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/17/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Although signet ring cell carcinoma (SRC) is a poorly differentiated cancer subtype, recent studies suggest that endoscopic resection can be applied in small, mucosal early gastric SRC. However, other studies report frequent positive lines at the lateral resection margin after endoscopic treatment. Subepithelial spread beneath normal mucosa can exist in SRC, and such lesions may be the cause of positive margins after endoscopic resection. Thus, we conducted a retrospective study in order to evaluate the significance of subepithelial spread in early gastric SRC. METHOD Medical records of early gastric SRC patients who underwent surgery or endoscopic resection from January 2011 to December 2016 at a single tertiary hospital (Daejeon, South Korea) were reviewed to examine subepithelial spread and clinical datum. Two expert pathologists reviewed all pathologic specimens, and only patients showing a pure SRC component were included. RESULTS Eighty-six patients were initially enrolled, and subepithelial spread existed in 62 patients (72.1%). The mean distance of subepithelial spread was 1,132.1 µm, and the maximal distance was 6,000 μm. Only discoloration was significantly associated with the presence of a subepithelial spread (p < 0.05, χ2 test, and logistic regression test). Distance of subepithelial spread did not correlate with total lesion size. CONCLUSION Subepithelial spread of early gastric SRC occurs frequently and can reach up to 6 mm. Lesion discoloration may be associated with the presence of subepithelial spread. Our results suggest that careful decision of the margin is needed when performing endoscopic resection of early gastric SRC.
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Affiliation(s)
- Yong Moon Lee
- Department of Pathology, Dankook University School of Medicine, Cheonan, Republic of Korea
| | - Sun Hyung Kang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea,
| | - Ju Seok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyuk Soo Eun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Jong Seok Joo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Woo Sun Rou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Jae Ho Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hee Seok Moon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Eaum Seok Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Seok Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Jae Kyu Sung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Byung Seok Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hyun Yong Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Min Kyung Yeo
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Kyu Sang Song
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hee Min Yoo
- Center for Bioanalysis, Korea Research Institute of Standards and Science, Daejeon, Republic of Korea
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Zou Y, Wu L, Yang Y, Shen X, Zhu C. Risk factors of tumor invasion and node metastasis in early gastric cancer with undifferentiated component: a multicenter retrospective study on biopsy specimens and clinical data. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:360. [PMID: 32355804 PMCID: PMC7186605 DOI: 10.21037/atm.2020.02.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Early gastric cancer (EGC) with undifferentiated component (UDC) is a more aggressive entity, where the significance of preoperative data to tumor invasion and lymph node metastasis (LNM) remains unclarified. Methods A total of 5,020 GC patients undergoing radical gastrectomy in three centers were reviewed, of which, EGC with UDC in preoperative biopsy specimens were enrolled. The histology of biopsy and surgical specimens was graded according to the proportion of UDC and signet ring cells (SRCs). Risk factors of tumor invasion and LNM were evaluated with histological, clinical and demographic data. Results Lower body mass index (BMI), melena and larger tumor size were the independent preoperative risk factors of both LNM and LVI, while ulcerative lesion (UL) and the lower third stomach were only correlated with LNM. No relevance was found between the histological features of biopsy specimens and LNM, but SRC or >50% UDC lowered the risk of lymphovascular invasion (LVI) and/or submucosal (SM) invasion. When surgical data (depth of invasion and LVI included) were added, lower BMI, melena and the lower third stomach were still the independent preoperative risk factors of LNM, and LVI, SRC and SM invasion also showed relevance to LNM. The performance of predictive models using pre- or postoperative histological data was comparable. Conclusions The preoperative data were significantly relevant to tumor invasion and LNM, showing comparable risk strength with surgical specimens in histology.
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Affiliation(s)
- Yi Zou
- Department of Pathology, Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China
| | - Long Wu
- Department of Pathology, Union Hospital of Fujian Medical University, Fuzhou 350001, China
| | - Yubin Yang
- Department of Pathology, Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, China
| | - Xin Shen
- College of Computer Science and Technology, Zhejiang University, Hangzhou 310027, China
| | - Chunpeng Zhu
- Department of Gastroenterology, Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China
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Kim DK, Kang SH, Kim JS, Rou WS, Joo JS, Kim MH, Eun HS, Moon HS, Lee ES, Kim SH, Sung JK, Lee BS, Jeong HY. Feasibility of using two-dimensional axial computed tomography in pretreatment decision making for patients with early gastric cancer. Medicine (Baltimore) 2020; 99:e18928. [PMID: 31977908 PMCID: PMC7004674 DOI: 10.1097/md.0000000000018928] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Computed tomography (CT) is widely used in the pretreatment period of early gastric cancer (EGC). Only few studies have reported low accuracy of CT imaging for T and N staging in patients with EGC. However, owing to the limited number of studies, the value of CT imaging for EGC staging is not well known. Thus, we conducted a retrospective cross-sectional study regarding the associations among submucosal invasion, lymph node metastasis, and CT findings.The medical records of patients with EGC who had surgery or endoscopic resection were reviewed in a single center from January 2011 to December 2016. We evaluated the histological type, invasion depth, and lymph node (LN) metastasis on the basis of two-dimensional CT findings.We enrolled 1544 patients. Submucosal (SM) invasion was related to tumor size, histological type, and wall thickening or enhancement on CT images. Deep SM invasion (>500 μm) was also related to tumor size, poorly differentiated type, and abnormal CT findings (wall thickening, enhancement, and central depression). Among the patients with LN reactive positivity (0.5-1 cm), those who were female and had a tumor invasion of >1000 μm showed a higher prevalence of LN metastasis. The false-negative LN group had a higher prevalence of large tumors (>3 cm), poor differentiation, and SM invasion than the true-negative group.Wall thickening, enhancement, and central depression on CT images might be related to SM invasion. Patients with any positive CT findings needs more attention when performing ESD.
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Bang CS, Yang YJ, Lee JJ, Baik GH. Endoscopic Submucosal Dissection of Early Gastric Cancer with Mixed-Type Histology: A Systematic Review. Dig Dis Sci 2020; 65:276-291. [PMID: 31367880 DOI: 10.1007/s10620-019-05761-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 07/23/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) criteria are histologically categorized by early gastric cancer (EGC) with differentiated- and undifferentiated-type histology. However, EGC is histologically heterogenous and there have been no separate criteria for EGC with mixed-type histology [EGC-MH; differentiated-type predominant EGC mixed with an undifferentiated component (EGC-MD) or undifferentiated-type predominant EGC mixed with a differentiated component (EGC-MU)]. Moreover, therapeutic outcomes of ESD for EGC-MH have not been clearly described. AIM This study aimed to evaluate the feasibility of ESD for EGC-MH. METHODS We searched core databases for specific inclusion factors: patients with EGC-MH, intervention of ESD, and at least one of the following outcomes: rate of en bloc, complete, curative resection, recurrence, procedure-related adverse event, lymphovascular invasion (LVI), or lymph node metastasis (LNM) that enabled evaluation of feasibility of ESD. RESULTS A total of eight (systematic review) and four studies (meta-analysis) were included. There was no robustness in age, location, or morphology of EGC-MH. Moderately differentiated adenocarcinoma was frequent in pre-ESD biopsy. EGC-MH showed larger size, deeper invasion, and higher rates of LVI/LNM than pure-type EGC. Total en bloc, complete resection, and curative resection rates were 94.6% (95% confidence interval 86.6-97.9%), 77.8% (57.9-89.9%), and 55.1% (50.4-59.6%), respectively. There was no LNM or extra-gastric recurrence after ESD if the EGC-MD met the curative resection criteria. However, the EGC-MD itself was a risk factor for non-curative resection. (Margin positivity was the most common reason.) CONCLUSIONS: Although ESD seems to be technically feasible, inaccurate prediction of lateral or vertical margin leads to lower curative resection rate. Application of more strict indication is needed for EGC-MH.
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Affiliation(s)
- Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, Gangwon-do, 24253, Korea. .,Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea. .,Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea.
| | - Young Joo Yang
- Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, Gangwon-do, 24253, Korea.,Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea
| | - Jae Jun Lee
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea.,Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, Gangwon-do, 24253, Korea.,Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Korea
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Machlowska J, Pucułek M, Sitarz M, Terlecki P, Maciejewski R, Sitarz R. State of the art for gastric signet ring cell carcinoma: from classification, prognosis, and genomic characteristics to specified treatments. Cancer Manag Res 2019; 11:2151-2161. [PMID: 30936747 PMCID: PMC6421895 DOI: 10.2147/cmar.s188622] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Gastric cancer (GC) is responsible for 9% of cancer deaths worldwide. Over 950,000 new cases are diagnosed each year, and about 90% of them are in advanced stage, requiring chemotherapy. In Europe there has been research based on pre- and postoperative chemotherapy treatment, using 5-fluorouracil, epirubicin, cisplatin, capecitabine, and docetaxel. Chemotherapy significantly impairs the quality of life of patients; however, the final effects are not always satisfactory. There is scientific evidence that gastric mucus tumors and signet ring cell carcinomas have a pattern of specific signatures, that distinguish them from other gastric cancer subtypes, and may be associated with a poor response to systematic treatment. Signet ring cell carcinoma is less chemosensitive than others, and the increase in the percentage of signet ring cells correlates with resistance to chemotherapy. Perioperative chemotherapy in advanced signet ring cell carcinomas is an independent factor of poor prognosis and survival, which is explained by the toxicity of neoadjuvant treatment. Therefore, curative surgical resection enhanced by standardized lymphadenectomy remains the recommended gold standard in GC therapy. According to presented studies, early detection and aggressive treatments for this subtype of GC is a reasonable approach. This review paper is mostly addressed to physicians who are interested in updating to the state of the art concerning different subtypes of gastric carcinoma.
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Affiliation(s)
- Julita Machlowska
- Department of Human Anatomy, Medical University of Lublin, Lublin, Poland,
| | - Małgorzata Pucułek
- Department of Human Anatomy, Medical University of Lublin, Lublin, Poland,
| | - Monika Sitarz
- Department of Conservative Dentistry and Endodontics, Medical University of Lublin, Lublin, Poland
| | - Paweł Terlecki
- Department of Surgery, St. John's Cancer Center, Lublin, Poland,
| | | | - Robert Sitarz
- Department of Human Anatomy, Medical University of Lublin, Lublin, Poland, .,Department of Surgery, St. John's Cancer Center, Lublin, Poland,
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Tailored treatment for signet ring cell gastric cancer. Updates Surg 2018; 70:167-171. [PMID: 29948660 DOI: 10.1007/s13304-018-0550-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 05/13/2018] [Indexed: 02/08/2023]
Abstract
Gastric cancer with Laurèn diffuse types is increasing in the West. The raising trend is more evident when considering signet ring cells (SRC) histology. However, to control the biologic potential of this GC subtype, some hypotheses of tailored therapeutic strategies for SRC cancers have been made. A review of the literature was performed using the key words "signet ring cells" AND "gastric cancer". Results of literature review were descriptively reported. Endoscopic submucosal dissection (ESD), according to the Japanese extended criteria, could be a therapeutic option for early SRC tumours. However, according to the evidences from more recent studies, indications for ESD to these tumours types should be carefully considered. Concerning the optimal surgical treatment, considering the high lymphotropism and infiltrating behaviour of SRC histotype, the extension of gastric resection should be wider than for intestinal type cancer and laparoscopic surgery should be performed carefully. Moreover, D3 lymphadenectomy could provide a benefit in diffuse-type and SRC histology. The role of surgery in gastric cancer with peritoneal carcinomatosis is still debated and studies on this topic should stratify the good results according to GC histotype. Finally, despite the evidences of chemoresistance in SRC, ongoing randomized trials suggest that multimodal therapy could be the best treatment. Based on the assumption that SRC tumours have specific features, they deserve a specific multimodal treatment. However, a preliminary step to generate strong evidences in this field is the standardization of terminology used to define signet ring cells carcinoma.
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