Signet-ring cell carcinoma of the stomach: Impact on prognosis and specific therapeutic challenge

Patient-Derived Organoids and Xenografts Uncover Therapeutic Vulnerabilities in Colorectal Signet Ring Cell Carcinomas

PURPOSE

Identifying therapeutic targets for signet ring cell carcinoma (SRCC) of the colon and rectum is a clinical challenge because of the lack of patient-derived organoids (PDO) or patient-derived xenografts (PDX). To address this unmet need, we present a robust method for establishing PDO and PDX models. We demonstrate that these models identify novel therapeutic strategies targeting therapy resistance and peritoneal metastasis.

EXPERIMENTAL DESIGN

We derived nine PDO and PDX models from patients with colorectal SRCC. Detailed histopathologic characterization confirmed the fidelity of these models to the original tumors. Drug sensitivity assays were conducted in vitro and in vivo to assess the therapeutic efficacy and impact on peritoneal metastasis. An RNA sequencing analysis was performed to identify critical pathways contributing to therapy resistance and metastatic progression.

RESULTS

We successfully developed and characterized PDO and PDX models from nine patients with SRCC. The SRCC PDO and PDX models exhibited histopathologic features consistent with those of the original tumors, including high mucin content and eccentric nuclei. They demonstrated increased sensitivity to FOLFIRI combined with paclitaxel or vincristine, reducing peritoneal metastasis. RNA sequencing analysis revealed the upregulation of autophagy genes in SRCC. Treatment with chloroquine alone resulted in decreased tumor growth and peritoneal metastasis.

CONCLUSIONS

Our study establishes PDO and PDX models as robust platforms for studying SRCC and identifying potential therapeutic strategies. Combining FOLFIRI with paclitaxel/vincristine or chloroquine alone inhibits tumor growth and prevents peritoneal metastasis, showing promise for clinical translation. These findings suggest that combining FOLFIRI with intraperitoneal paclitaxel warrants further investigation in phase I clinical trials for patients with SRCC.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for gastric cancer with peritoneal metastases at an Australian centre

INTRODUCTION

Gastric cancer is a major cause of cancer mortality, with poorer prognosis in the presence of peritoneal metastases as low as 2.8-9 months. Systemic therapy has a limited role. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival. This study evaluates survival of patients with gastric cancer and peritoneal metastases (GCPM) undergoing CRS and HIPEC at an Australian centre.

METHODS

A retrospective analysis was conducted on a prospectively collected database of patients who underwent CRS and HIPEC for GCPM from January 2009 to December 2023. Data included demographics, perioperative factors, histopathology and survival.

RESULTS

Twenty-four patients were identified, with median postoperative overall survival of 11.7 months (95% CI 8.6-34.2 months). Most patients had poorly differentiated adenocarcinoma (n = 23, 96%), with 14 (58%) exhibiting signet cell pathology. 62% (n = 15) received preoperative chemotherapy. Median PCI was 5, with a CC score of 0 in 96% of patients (n = 23). Clavien-Dindo III/IV morbidity was noted in 8 patients (33%) with no perioperative mortality. No survival differences were found between those with signet cell pathology and those without (10.6 vs. 11.7 months, p = 0.83), nor between those receiving preoperative chemotherapy and those who did not (11.7 vs. 10.6 months, p = 0.60). Age, sex, PCI, CC and tumour markers demonstrated correlations with survival in linear regression, but no individual factor significantly influenced outcomes.

CONCLUSION

CRS and HIPEC for low volume GCPM should be considered in select patients.

Scaling up spatial transcriptomics for large-sized tissues: uncovering cellular-level tissue architecture beyond conventional platforms with iSCALE

Recent advances in spatial transcriptomics (ST) technologies have transformed our ability to profile gene expression while retaining the crucial spatial context within tissues. However, existing ST platforms suffer from high costs, long turnaround times, low resolution, limited gene coverage, and small tissue capture areas, which hinder their broad applications. Here we present iSCALE, a method that predicts super-resolution gene expression and automatically annotates cellular-level tissue architecture for large-sized tissues that exceed the capture areas of standard ST platforms. The accuracy of iSCALE were validated by comprehensive evaluations, involving benchmarking experiments, immunohistochemistry staining, and manual annotation by pathologists. When applied to multiple sclerosis human brain samples, iSCALE uncovered lesion associated cellular characteristics that were undetectable by conventional ST experiments. Our results demonstrate iSCALE's utility in analyzing large-sized tissues with automatic and unbiased tissue annotation, inferring cell type composition, and pinpointing regions of interest for features not discernible through human visual assessment.

Mapping the landscape of gastric signet ring cell carcinoma: Overcoming hurdles and charting new paths for advancement

BACKGROUND

In recent years, the global prevalence of gastric cancer (GC) has witnessed a progressive decrease, accompanied by a step-growth in the incidence of gastric signet ring cell carcinoma (GSRCC). As precision medicine concepts progress, GSRCC, a distinct sub-type of GC, has drawn considerable attention from researchers. However, there still persist some controversies regarding the associated research findings.

AIM

To summarize the current obstacles and potential future directions for research on GSRCC.

METHODS

To begin with, all literature related to GSRCC published from January 1, 2004 to December 31, 2023 was subjected to bibliometric analysis in this article. Additionally, this paper analyzed the research data using CiteSpace, GraphPad Prism v8.0.2, and VOSviewer, which was obtained from the Web of Science Core Collection database. The analysis results were visually represented.

RESULTS

This study provided a comprehensive overview of the statistical characteristics of the 995 English articles related to GSRCC, including cited references, authors, journals, countries, institutions, and keywords. The popular keywords and clusters contain "prognosis", "survival", "expression", "histology", and "chemotherapy".

CONCLUSION

The prognosis, precise definition and classification, as well as chemoresistance of GSRCC, continue to be crucial areas of ongoing research, whose directions are closely tied to advancements in molecular biology research on GSRCC.

Deep visual proteomics reveals DNA replication stress as a hallmark of signet ring cell carcinoma

Signet Ring Cell Carcinoma (SRCC) is a rare and highly malignant form of adenocarcinoma with increasing incidence and poor prognosis due to late diagnosis and limited treatment options. We employed Deep Visual Proteomics (DVP), which combines AI-directed cell segmentation and classification with laser microdissection and ultra-high sensitivity mass spectrometry, for cell-type-specific proteomic analysis of SRCC across the bladder, prostate, seminal vesicle, and a lymph node of a single patient. DVP identified significant alterations in DNA damage response (DDR) proteins, particularly within the ATR and mismatch repair (MMR) pathways, indicating replication stress as a crucial factor in SRCC mutagenicity. Additionally, we observed substantial enrichment of immune-related proteins, reflecting high levels of cytotoxic T lymphocyte infiltration and elevated PD-1 expression. These findings suggest that pembrolizumab immunotherapy may be more effective than conventional chemotherapy for this patient. Our results provide novel insights into the proteomic landscape of SRCC, identify potential targets, and open up for personalized therapeutic strategies in managing SRCC.

Association of Gastric Sarcina With Malignant Pyloric Stenosis

Sarcina ventriculi (SV) is a Gram-positive cocci that thrives in the acidic stomach environment and may cause gastrointestinal symptoms. A 65-year-old woman with a history of Helicobacter pylori gastritis and diabetes presented with abdominal pain, vomiting, diarrhea, and weight loss. Initial esophagogastroduodenoscopy revealed pyloric stenosis with thickened prepyloric gastric folds, and endoscopic biopsy revealed SV without malignancy. Owing to persistent symptoms, endoscopic ultrasound was done with repeat biopsies and was nondiagnostic. Subsequently, a robotic gastrojejunostomy was done due to persistent gastric outlet obstruction symptoms. Surgical specimens revealed signet ring cell carcinoma. This case highlights the importance of suspecting underlying malignancy in patients with SV and the necessity of comprehensive diagnostic evaluation when endoscopic findings are inconclusive.

High dose of ascorbic acid induces selective cell growth inhibition and cell death in human gastric signet-ring cell carcinoma-derived NUGC-4 cells

Anticancer effects of high-dose vitamin C (VC) have been evaluated on many cancer cell lines, and its efficacy in clinical trials and in combination with anticancer drugs or radiation have been reported; however, its effect on gastric cancer and its mechanisms remain unclear. In the present study, the cell growth inhibitory/lethal effects of high-dose ascorbic acid (AsA), a reduced form of VC was examined on three gastric cancer cell lines. Of these, signet ring cell carcinoma NUGC-4 cells were the most sensitive, but the effects were small and limited in normal cells. Second, high-dose AsA was effective in NUGC-4 cells, whereas dehydroascorbic acid, an oxidized form of VC, was less effective. Third, high-dose AsA showed stronger cell growth inhibitory/lethal effects on floating cells than on adherent cells, and was effective even under hypoxic microenvironment conditions. A single 1-h treatment of high-dose AsA strongly inhibited cell growth, causing apoptosis-like cell death over 72 h after treatment, triggered by hydrogen peroxide generation, actin abnormality, DNA synthesis suppression, DNA damage induction, and ATP level decrease. The effects of high-dose AsA were inhibited either by adding or chelating iron ions, but was not affected via inhibiting AsA transport. Inhibition of glutathione synthesis enhanced the anticancer effects of high-dose AsA. These results indicate that a single high-dose of AsA induces cancer cell-selective, sustained cell growth inhibition and cell death, and these effects may be regulated by iron ion and/or intracellular oxidative stress levels in human gastric signet-ring cell carcinoma-derived NUGC-4 cells.

Primary signet-ring cell carcinoma of the prostate involving the pelvis: a case report

Background

Signet-ring cell carcinoma (SRCC) originates from undifferentiated stem cells in the neck of glands within the lamina propria of the mucosa. Primarily affecting the stomach, SRCC can also involve the breast, pancreas, gallbladder, colon, and bladder, although these cases are rare. SRCC of the prostate is extremely rare, and diagnosing it via pelvic puncture is particularly challenging. Prostate SRCC is a distinct type of malignant tumor characterized by unique biological behavior, high malignancy, rapid disease progression, and poor prognosis. Due to its rarity, early diagnosis and treatment are critical. Currently, the diagnosis and treatment of this disease present significant challenges.

Case demonstration

A 74-year-old male patient was admitted to our hospital with "left lower abdominal pain, changes in bowel habits, and bloody stools for 2 months." A contrast-enhanced pelvic CT scan revealed a soft tissue density mass on the left side of the pelvis. Contrast-enhanced Pelvic MRI suggested a tumor with a rich blood supply on the left side of the pelvis, indistinguishable from the left seminal vesicle and prostate gland, indicating the presence of a suspected malignant tumor. Pathologic biopsy of the pelvic mass confirmed the diagnosis of prostate SRCC. The patient subsequently underwent chemoradiotherapy and has been followed up for three months. He is currently in good condition.

Conclusion

SRCC predominantly occurs in the digestive tract and rarely originates in the prostate. Diagnosing prostate SRCC through abdominal paracentesis is challenging. To the best of our knowledge, this is the first reported case of SRCC of the prostate initially presenting with gastrointestinal symptoms. Additionally, it presents a case of prostate SRCC involving the pelvis, confirmed through pelvic puncture. highlighting its significance for clinical diagnosis.

Development and validation of a nomogram for predicting survival in gastric signet ring cell carcinoma patients treated with radiotherapy

There is no effective clinical prediction model to predict the prognosis of gastric signet ring cell carcinoma (GSRC) patients treated with radiotherapy. This study retrospectively analyzed the clinical data of 20-80-year-old patients diagnosed with GSRC between 2004 and 2019 from the Surveillance, Epidemiology, and End Results (SEER) database. Using Cox regression analyses revealed independent prognostic factors, and a nomogram was constructed. The C-index, net reclassification index (NRI) and integrated discrimination improvement (IDI) of the nomogram were greater than those of the TNM staging system for predicting OS, indicating that the nomogram predicted prognosis with greater accuracy. The area under the curve (AUC) values were 0.725, 0.753 and 0.745 for the training group; 0.725, 0.763 and 0.752 for the internal validation group; and 0.795, 0.764 and 0.765 for the external validation group, respectively. Calibration plots demonstrated high agreement between the nomogram's prediction and the actual observations. The risk stratification system was able to accurately stratify patients who underwent radiotherapy for GSRC into high- and low-risk subgroups, with significant differences in prognosis. The Kaplan‒Meier survival analysis according to different treatments indicated that surgery combined with chemoradiotherapy is a more effective treatment strategy for improving OS in for GSRC patients. The nomogram is sufficiently accurate to predict the prognostic factors of GSRC receiving radiotherapy, allowing for clinicians to predict the 1-, 3-, and 5-year OS.

Disappearing Signet Ring Cell Adenocarcinoma in Gastric Cancer Patients

BACKGROUND

The incidence of diffuse-type gastric cancer is increasing steadily in the United States, Europe, and Asia. This subtype is known for aggressive clinical characteristics and transmural invasion. However, T1a diffuse-type cancers have been observed to have a better 5-year, disease-specific mortality than stage-matched intestinal tumors, supporting a clinical difference in these early-stage cancers.

METHODS

Data on all living patients with T1a gastric adenocarcinoma with a finding of signet ring cell morphology on pathology and ≥1 year of follow-up from 2013 to 2023 at Memorial Sloan Kettering Cancer Center (MSK) was collected from a prospectively maintained database. Patients with known CDH1 or CTNNA1 mutations were excluded.

RESULTS

In 7 of 30 patients, sporadic pathologically confirmed T1a signet ring cell (diffuse) cancer identified on initial biopsy was no longer detectable upon subsequent biopsy or resection with mean follow-up of 50 months.

CONCLUSIONS

These cases allude to the distinct pathways of carcinogenesis in T1a signet ring cell cancers. Potential factors that may underlie the spontaneous regression of these T1a cancers include complete removal at initial biopsy, immune clearance, and lack of survival advantage conferred by signet ring cell genetic alterations in these cases. Given their more indolent behavior at an earlier stage, we suggest that these lesions can be closely followed by endoscopy in select circumstances with thorough disease assessment and an experienced care team.

A predictive and prognostic model for metastasis risk and prognostic factors in gastrointestinal signet ring cell carcinoma

BACKGROUND

This study aimed to predict metastasis risk and identify prognostic factors of gastrointestinal signet ring cell carcinoma (SRCC) using data from the SEER database, the largest cancer dataset in North America.

METHODS

Data were obtained from the SEER database, covering 17 cancer registries from 2004 to 2020. Demographic and clinical data included sex, age, race, tumor location, size, pathological grade, stage, overall survival time, and treatment modalities. Statistical analyses were conducted using SPSS and R software. Propensity Score Matching (PSM) ensured comparable baseline characteristics between gastric cancer (GC) and colorectal cancer (CRC) groups. LASSO regression analysis identified predictors of metastasis, leading to the construction of predictive models using the lrm function in R. Nomograms were visualized with the "rms" package and assessed via ROC curves, calibration curves, and decision curve analysis (DCA). Cox regression analyses identified prognostic indicators for overall survival (OS), and Kaplan-Meier curves compared OS between high-risk and low-risk groups.

RESULTS

From 2004 to 2020, 7680 SRCC patients were identified, including 4980 GC and 2700 CRC patients. CRC patients were older and had larger tumors, higher staging, and worse differentiation. Nomograms demonstrated good discriminative ability, with AUCs of 0.704 and 0.694 for GC, and 0.694 and 0.701 for CRC in training and validation cohorts, respectively. The DCA curve indicates that this predictive model has a high gain in predicting metastasis and OS.

CONCLUSIONS

The nomograms effectively predicted metastasis risk and OS in metastatic SRCC patients, offering clinical utility in stratifying patients and guiding treatment decisions, thereby enhancing personalized treatment approaches.

IDO1-mediated catabolism of tryptophan in gastric tumors: Its potential role in the axis of histopathology, differentiation and metastasis

BACKGROUND

Indoleamine 2,3-Dioxygenase 1 (IDO1)-mediated tryptophan degradation, which is the rate-limiting enzyme of tryptophan/kynurenine pathway, may cause immune suppression in the tumor microenvironment, while potentiating proliferative and metastatic activity in the tumor focus, Phase studies of IDO1 inhibitors are ongoing, and our study aims to evaluate the potential contribution of IDO1 gene expression to the tryptophan/kynurenine pathway in tumor and tumor microenvironment foci in gastric cancer (GC) on a clinicopathological axis, METHOD: In the case-control study design, the determination of tryptophan and its metabolites in the serum of 51 GC and 49 healthy controls was made using High Pressure Liquid Chromatography-Fluorescence Detector (HPLC-FD). IDO1 expression in a total of 102 tissues with tumor and tumor microenvironment was detected by quantitative PCR (q-PCR).

RESULTS

In gastric tumors, 3,25-fold decreased expression of IDO1 was detected according to the tumor microenvironment (p=0,05), IDO1 expression was found to be more than 2 times higher in signet ring cell carcinoma (SRCC) and poorly differentiated tumors without distant organ metastasis (p<0,05), In GC, tryptophan level was found to be 1,6 times lower than in control (AUC:0889; cut off≤21,57; p<0001), Low tryptophan level was found in advanced tumor stage compared to early stage and in the presence of perineural invasion compared to its absence (p<0,05) The level of kynurenine was found to be approximately 1,8 times lower in SRCC (p=0,04), CONCLUSION: Increased tryptophan accumulation in the gastric tumor and its microenvironment, when catabolized via IDO1, exhibits histological type, tumor differentiation, and metastasis-promoting effects more prominently in aggressive subtypes such as SRCC.

Primary Signet-Ring-Cell Carcinoma in the Colorectum: A Case-Based Literature Review

Primary colorectal signet-ring-cell carcinoma of the colon and rectum (PSRCCR) is an extremely rare subtype of mucinous adenocarcinoma with a reported rate of less than 1%. This low rate is mainly because it is generally diagnosed at advanced stages. The most common stage at which it is diagnosed for the first time is III or IV, with a lower median survival than other histological subtypes. To diagnose PSRCCR of the colon, at least half of the tumor must be consistent with a signet-ring-cell pattern. This review aims to provide a comprehensive overview of PSRCCR by synthesizing the existing literature and clinical data. Our objective was to elucidate the clinical features, diagnostic challenges, histopathological characteristics, molecular alterations, treatment modalities, and prognostic factors associated with this carcinoma. Additionally, we highlighted the significance of early detection, accurate diagnosis, and personalized therapeutic approaches in improving outcomes for patients with this challenging malignancy. By presenting a case report on the topic, we aimed to enhance understanding among clinicians, pathologists, and researchers, ultimately contributing to optimized management strategies and improved patient care for PSRCCR.

Gastroesophageal signet ring cell carcinoma morbidity and mortality: A retrospective review

BACKGROUND

Upper gastrointestinal (GI) signet ring cell carcinomas (SRCC) confer a poor prognosis. The benefit of operative intervention for this patient group is controversial in terms of overall survival.

AIM

To investigate factors relating to survival in patients with upper GI SRCC.

METHODS

A retrospective, tertiary, single-centre review of patients who were diagnosed with oesophageal, gastroesophageal junction and gastric SRCC was performed. The primary outcome was to compare mortality of patients who underwent operative management with those who had nonoperative management. Secondary outcomes included assessing the relationship between demographic and histopathological factors, and survival.

RESULTS

One hundred and thirty-one patients were included. The one-year survival for the operative group was 81% and for the nonoperative group was 19.1%. The five-year survival in the operative group was 28.6% vs 1.5% in the nonoperative group. The difference in overall survival between groups was statistically significant (HR 0.19, 95%CI (0.13-0.30), P < 0.001). There was no difference in survival when adjusting for age, smoking status or gender. On multivariate analysis, patients who underwent surgical management, those with a lower stage of disease, and those with a lower Charlson Comorbidity Index (CCI) had significantly improved survival.

CONCLUSION

Well-selected patients with upper GI SRCC appear to have reasonable medium-term survival following surgery. Offering surgery to a carefully selected patient group may improve the outcome for this disease.

Effect of chemotherapy on prognosis in patients with primary pancreatic signet ring cell carcinoma: A large real-world study based on machine learning

BACKGROUND

Primary pancreatic signet ring cell carcinoma (PSRCC), an extremely rare histologic variant of pancreatic cancer, has a poor prognosis. This study aimed to investigate the prognostic value of chemotherapy in PSRCC.

METHODS

Patients with PSRCC between 2000 and 2019 were identified using the Surveillance Epidemiology and End Results (SEER) database. The main outcomes in this study were cancer-specific survival (CSS) and overall survival (OS). The baseline characteristics of patients were compared using Pearson's Chi-square test. Kaplan-Meier analysis was used to generate the survival curves. Least absolute shrinkage and selection operator (LASSO), univariate and multivariate Cox regression models, and Random Survival Forest model were used to analyze the prognostic variables for OS and CSS. The variance inflation factors (VIFs) were used to analyze whether there was an overfitting problem.

RESULTS

A total of 588 patients were identified. Chemotherapy was an independent prognostic factor for OS and CSS, and significantly associated with OS (HR = 0.33, 95% CI = 0.27-0.40, P <0.001) and CSS (HR = 0.32, 95% CI = 0.26-0.39, P <0.001).

CONCLUSIONS

Chemotherapy showed beneficial effects on OS and CSS in patients with PSRCC and should be recommended in clinical practice.

Is neoadjuvant chemotherapy followed by surgery the appropriate treatment for esophagogastric signet ring cell carcinomas? A systematic review and meta-analysis

Background

The impact of neoadjuvant chemotherapy (nCTX) on survival and tumor response in patients with esophagogastric signet ring cell carcinoma (SRCC) is still controversial.

Methods

Two independent reviewers performed a systematic literature search in Medline, CENTRAL, and Web of Science including prospective and retrospective two-arm non-randomized and randomized controlled studies (RCTs). Data was extracted on overall survival (OS) and tumor regression in resected esophagogastric SRCC patients with or without nCTX. Survival data was analyzed using published hazard ratios (HR) if available or determined it from other survival data or survival curves. OS and histopathological response rates by type of tumor (SRCC vs. non-SRCC) were also investigated.

Results

Out of 559 studies, ten (1 RCT, 9 non-RCTs) were included in this meta-analysis (PROSPERO CRD42022298743) investigating 3,653 patients in total. The four studies investigating survival in SRCC patients treated with nCTX + surgery vs. surgery alone showed no survival benefit for neither intervention, but heterogeneity was considerable (HR, 1.01; 95% CI, 0.61-1.67; p = 0.98; I2 = 89%). In patients treated by nCTX + surgery SRCC patients showed worse survival (HR, 1.45; 95% CI, 1.21-1.74; p < 0.01) and lower rate of major histopathological response than non-SRCC patients (OR, 2.47; 95% CI, 1.78-3.44; p < 0.01).

Conclusion

The current meta-analysis could not demonstrate beneficial effects of nCTX for SRCC patients. Histopathological response to and survival benefits of non-taxane-based nCTX seem to be lower in comparison to non-SRC esophagogastric cancer. However, certainty of evidence is low due to the scarcity of high-quality trials. Further research is necessary to determine optimal treatment for SRCC patients.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42022298743).

Success rate of current human-derived gastric cancer organoids establishment and influencing factors: A systematic review and meta-analysis

BACKGROUND

Human-derived gastric cancer organoids (GCOs) are widely used in gastric cancer research; however, the culture success rate is generally low.

AIM

To explore the potential influencing factors, and the literature on successful culture rates of GCOs was reviewed using meta-analysis.

METHODS

PubMed, Web of Science, and EMBASE were searched for studies. Two trained researchers selected the studies and extracted data. STATA 17.0 software was used for meta-analysis of the incidence of each outcome event. The adjusted Methodological Index for Non-Randomized Studies scale was used to assess the quality of the included studies. Funnel plots and Egger's test were used to detect publication bias. Subgroup analyses were conducted for sex, tissue source, histological classification, and the pathological tumor-node-metastasis (pTNM) cancer staging system.

RESULTS

Eight studies with a pooled success rate of 66.6% were included. GCOs derived from women and men had success rates of 67% and 46.7%, respectively. GCOs from surgery or biopsy/endoscopic submucosal dissection showed success rates of 70.9% and 53.7%, respectively. GCOs of poorly-differentiated, moderately-differentiated and signet-ring cell cancer showed success rates of 64.6%, 31%, and 32.7%, respectively. GCOs with pTNM stages I-II and III-IV showed success rates of 38.3% and 65.2%, respectively. Y-27632 and non-Y-27632 use showed success rates of 58.2% and 70%, respectively. GCOs generated with collagenase were more successful than those constructed with Liberase TH and TrypLE (72.1% vs 71%, respectively). EDTA digestion showed a 50% lower success rate than other methods (P = 0.04).

CONCLUSION

GCO establishment rate is low and varies by sex, tissue source, histological type, and pTNM stage. Omitting Y-27632, and using Liberase TH, TrypLE, or collagenase yields greater success than EDTA.

Bariatric surgery discovering unexpected silent gastric cancer: a case report

This research paper discusses a case in which stomach cancer was incidentally discovered during a bariatric surgery procedure. Bariatric surgery is well-known for its significant effects on weight loss and overall health enhancement, and its prevalence has been rising globally. While its primary aim is weight reduction, it also offers the chance for surgeons to detect and manage other medical conditions. In this specific case, a patient scheduled for bariatric surgery was incidentally discovered with stomach cancer, underscoring the significance of comprehensive operative assessments and vigilant monitoring during surgery.

An acute ileocolitis of unexpected origin

The colon is a common site of primary malignancy. However, it is a very rare metastatic localisation. Here, we report a case of a signet-ring cell carcinoma of the stomach metastasizing to the ileum and colon, mimicking a presentation of an acute inflammatory ileocolitis.

Development and validation of a deep learning model for predicting postoperative survival of patients with gastric cancer

BACKGROUND

Deep learning (DL), a specialized form of machine learning (ML), is valuable for forecasting survival in various diseases. Its clinical applicability in real-world patients with gastric cancer (GC) has yet to be extensively validated.

METHODS

A combined cohort of 11,414 GC patients from the Surveillance, Epidemiology and End Results (SEER) database and 2,846 patients from a Chinese dataset were utilized. The internal validation of different algorithms, including DL model, traditional ML models, and American Joint Committee on Cancer (AJCC) stage model, was conducted by training and testing sets on the SEER database, followed by external validation on the Chinese dataset. The performance of the algorithms was assessed using the area under the receiver operating characteristic curve, decision curve, and calibration curve.

RESULTS

DL model demonstrated superior performance in terms of the area under the curve (AUC) at 1, 3, and, 5 years post-surgery across both datasets, surpassing other ML models and AJCC stage model, with AUCs of 0.77, 0.80, and 0.82 in the SEER dataset and 0.77, 0.76, and 0.75 in the Chinese dataset, respectively. Furthermore, decision curve analysis revealed that the DL model yielded greater net gains at 3 years than other ML models and AJCC stage model, and calibration plots at 3 years indicated a favorable level of consistency between the ML and actual observations during external validation.

CONCLUSIONS

DL-based model was established to accurately predict the survival rate of postoperative patients with GC.

A Rare Case of Primary Gastric Signet Ring Cell Carcinoma: a Review of Guidelines for the Management of Gastric Cancer

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.

Geographical and temporal differences in gastric and oesophageal cancer registration by subsite and morphology in Europe

Background

Gastric and oesophageal cancers pose a serious public health concern. In 2020 a total of 189,031 incident cases (136,038 stomach, 52,993 oesophagus) and 142,508 deaths (96,997 stomach, 45,511 oesophagus) were estimated in Europe. Oesophago-gastric cancers are a heterogeneous disease, with different aetiology and epidemiology for the various topographic subsites and main histopathological types. Topography subsite and morphology is key information to allow differentiating oesophago-gastric cancers. Correct registration and coding of such variables are fundamental in allowing proper description of the epidemiology of different subsites and histopathological types of oesophago-gastric cancers. The aim of this article is to highlight geographical and temporal variability in topography and morphology of oesophago-gastric cancers observed in Europe in the considered period.

Methods

Data collected in the framework of the ENCR-JRC (European Commission's Joint Research Centre) data call and feeding the European Cancer Information System (ECIS) were used to assess the variability of topography and morphology registration of gastric and oesophageal cancer in Europe in the period 1995-2014. Malignant cancers of the stomach and the oesophagus were selected following, respectively, topography codes C16 and C15 of the International Classification of Diseases for Oncology, third edition (ICD-O-3). Analyses were performed by subsite, morphology group, year, sex, and European region.

Results

A total of 840,464 incident cases occurring in the period 1995-2014 - 579,264 gastric (67.2%) and 276,260 (32.8%) oesophageal carcinomas - was selected for the analysis. Data was recorded by 53 PBCRs (9 based in Northern Europe, 14 in Western Europe, 3 in Eastern Europe and 27 in Southern Europe) from 19 countries.

Conclusion

A wide variability in oesophago-gastric cancers topographic subsites and histopathological types patterns was observed, with a corresponding improvement in accuracy of registration in the analysis period. PBCRs are ideally placed to guide the epidemiological evaluations of such a complex group of diseases, in collaboration with clinicians, patients and other public health stakeholders.

Impact of Removal of Lymph Nodes on Survival in Stage I-III Gastric Signet-Ring Cell Cancer: The More, the Better?

BACKGROUND

There is an ongoing debate over the prognostic value of the number of examined lymph nodes (ELNs) in cases of gastric signet-ring cell cancer (GSRCC). In this study, we sought to evaluate the correlation between the number of ELNs and the prognosis of GSRCC and identify the optimal number of ELNs.

METHODS

A total of 1020 patients diagnosed with GSRCC between 2011 and 2018 in the National Cancer Center database were identified. Clinicopathological characteristics were retrospectively collected, and optimal cutoff values of ELNs were calculated by using X-tile. The impact of different ELNs on overall survival (OS) was compared by using Kaplan-Meier curves. We used univariate and multivariate Cox and subgroup analyses to explore the relationship between ELNs and OS. Furthermore, nonlinear correlations were investigated by using restricted cubic splines (RCSs).

RESULTS

X-tile showed that the optimal cutoff value of ELNs was 22. The 5-year OS was higher for patients with ELNs > 22 (vs. ELNs ≤ 22, 66.9% vs. 74.9%, P = 0.026). Multivariate Cox analyses showed that high ELNs were associated with superior OS (hazard ratio = 0.56, 95% confidence interval 0.43-0.74, P < 0.001). In subgroup analyses, the significant association between tumor size > 4 cm, and TNM III stage was still observed. The RCS regression model showed a U-shaped dose-response nonlinear relationship between ELNs and OS; the inflection point, as well as the lowest risk points, corresponded to 44-52 ELNs.

CONCLUSIONS

A U-shaped, nonlinear correlation with inflection points of 44-52 ELNs between ELNs and prognosis in GSRCC was identified.

The Travels of Signet-Ring Cell Carcinoma: From Colon to Stomach and Duodenum

Colorectal cancer (CRC) metastasizing to the stomach and duodenum is rare. Even rarer is when the CRC subtype is signet-ring cell carcinoma (SRCC). Endoscopic findings of CRC metastasis to the stomach have been described as solitary and submucosal while duodenal metastasis has been observed to be exophytic. In this report, we describe a case of a middle-aged man with colon SRCC presenting with oral intolerance. He was found to have concurrent metastases to the stomach and duodenum and died 8 months after his SRCC diagnosis.

A descriptive analysis of gastric cancer with an immunohistochemical Study of Ki67 and p53 as prognostic factors.: Bahrain experience

OBJECTIVES

To describe the increasing number of gastric cancer cases at Bahrain Defense Force Hospital with implementation of immunohistochemistry markers as prognostic factors.

METHODS

This study included histologically confirmed malignant gastric tumors diagnosed at Bahrain Defense Force Hospital from January 2009 to June 2019. Various epidemiological and pathological data were abstracted and recorded with immunohistochemical analysis of the proliferation marker Ki67 and cell-cycle regulator p53 as prognostic factors.

RESULTS

A total of 53 patients with gastric cancer were included in the study, with mean age of 59.75 ± 12.9 years. The typical histological types were signet ring cell adenocarcinoma (68%) and intestinal type adenocarcinoma (17%). Helicobacter pylori and intestinal metaplasia were significantly associated with gastric cancer (p<0.01). The studied population's mortality was 39 (74%). The Ki67 proliferation index showed a mean and standard deviation of 67.09 ± 16.338, with a higher mortality rate in patients with low Ki67 but no difference in survival time. No statistically significant association was found between clinicopathological findings with p53 immunostaining positivity.

CONCLUSION

The common gastric cancers are signet ring cell adenocarcinoma and intestinal type adenocarcinoma, affecting a wide range of age groups (33-91 years), with those over 60 years at greater risk. Interestingly, low Ki67 is associated with a higher mortality rate, whereas p53 has no prognostic significance. Expression of both Ki67 and p53 showed no association with survival time.

Unusual manifestation of gastric adenocarcinoma presenting with lymphedema, chylothorax, and chylous ascites

A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies; however, treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient's skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis.

Gastrointestinal signet ring cell malignancy: current advancement and future prospects

Globally, gastrointestinal cancer is the most widespread neoplastic disease and the primary contributor to cancer-associated fatalities. Gastrointestinal signet ring cell carcinoma (SRCC) exhibits unique distinguishing features in several aspects when compared to adenocarcinomas (ACs). The scarcity of signet ring cell carcinoma has resulted in a heightened significance of related clinical and molecular investigations. However, a comprehensive and systematic review of the clinical, molecular, therapeutic, and research aspects of this disease is currently absent. This review provides an overview of the latest developments in our understanding of the clinical and molecular features of gastrointestinal signet ring cell carcinoma (SRCC). Additionally, we have compiled a list of potential therapeutic targets or biomarkers, as well as an examination of the current treatment options and the possible mechanisms of formation.

Necrotizing Fasciitis in a Patient With Signet-Ring Cell Gastric Adenocarcinoma

Necrotizing fasciitis is an aggressive infection of the skin and soft tissues that requires prompt recognition and management. Immediate source control and adjunctive antibiotic therapy are the cornerstones of management. There are limited reported cases of necrotizing fasciitis related to gastrointestinal malignancy, including gastric cancer. This report describes the case of a 36-year-old male who developed left abdominal wall necrotizing fasciitis related to perforated gastric adenocarcinoma with signet-ring features. Signet-ring adenocarcinoma is associated with a more aggressive malignancy. The rapid progression of the infection leading to refractory shock and acute respiratory distress rendered the patient a poor candidate for surgical source control because of high surgical risk. Patient eventually expired. Immediate recognition of necrotizing fasciitis and perforated gastric cancer can prompt early surgical referral for definitive source control and gastric resection or repair.

Development and validation of a predictive model associated with lymph node metastasis of gastric signet ring carcinoma patients

The risk factors for lymph node metastasis (LNM) in patients with gastric signet ring cell carcinoma (GSRC) have not been well-defined. This study was designed to prognosticate LNM in patients with GSRC by constructing and verifying a nomogram. A total of 2789 patients with GSRC from the Surveillance, Epidemiology, and End Results (SEER) database and Yijishan Hospital of Wannan Medical College (YJS) were retrospectively reviewed. A predictive model was established using logistic regression based on the SEER cohort. The performance of the model was evaluated using the concordance index (C-index) and decision curve analysis (DCA). In addition, its robustness was validated using the YJS cohort. Four independent predictors of LNM were identified in the SEER cohort. Next, a nomogram was constructed by incorporating these predictors. The C-index were 0.800 (95% confidence interval [CI] = 0.781-0.819) and 0.837 (95% CI = 0.784-0.890) in the training and external validation cohorts, respectively. The outcomes of DCA supported good clinical benefits. The proposed model for evaluating the LNM in patients with GSRC can help to avoid the misdiagnosis risk of N-stage, assist to screen the population suitable for neoadjuvant therapy and help clinicians to optimize clinical decisions.

Clinical characteristics and survival analysis of cutaneous metastases in a single tertiary centre in Korea

BACKGROUND

Cutaneous metastasis (CM) refers to the spread of malignancy to the skin. CM is perceived as an advanced stage. It might be the first sign of a primary cancer or an indicator of recurrence.

OBJECTIVES

To identify primary cancers associated with CMs and perform a survival analysis according to advanced stage of cutaneous metastasis at a single tertiary centre in Korea.

METHODS

A total of 219 patients from Samsung Medical Center from January 2009 to April 2020 were retrospectively analysed to identify cases with biopsy-proven CMs. According to advanced stage of metastasis, patients were divided into three stages, CM only (CMO), CM with lymph node metastasis (CM/LM) and CM with distant metastasis (CM/DM), to analyse clinical characteristics and survival rate.

RESULTS

The most common CM from primary cancer was breast cancer, followed by lung cancer, stomach cancer, colorectal cancer and others. When all primary cancers were included, the median survival period was 4.82 years for the CMO stage, 2.15 years for the CM/LM stage and 0.80 years for the CM/DM stage, with a tendency to deteriorate with advancing stage. At 1- and 3-year after occurrence of CM, the CM/DM stage showed a significantly poorer survival rate than the other two stages.

CONCLUSIONS

This study showed a median survival period of 22 months for CM patients overall. Breast cancer has greater accessibility to the skin than other cancers. Therefore, breast cancer can metastasize to the skin without involving lymph nodes or other sites.

Collagen-related gene expression level predicts the prognosis and immune therapy response

BACKGROUND

Gastric cancer patients responded differently to the same treatment strategy and had various prognoses for the lack of biomarkers to guide the therapy choice.

METHODS

RNA data of a local gastric cancer cohort with 103 patients were processed and used to explore potential treatment guiding factors. Cluster analysis was performed by non-negative matrix factorization. The expression level of collagen-related genes was evaluated by ssGSEA named collagen score (CS). Data from TCGA, ACRG, and an immune therapy cohort were utilized to explore prognosis and efficacy. Prognostic predictive power of CS was assessed using the nomogram.

RESULTS

In our study, local RNA data were processed by cluster analysis, and it was found that cluster 2 contained a worse tumor infiltration status. The GSEA result showed that collagen-related pathways were differentially activated in two clusters. In TCGA and ACRG cohorts, the CS can be used as an independent prognostic factor (TCGA OS: p = 0.018, HR = 3.5; ACRG OS: p = 0.014, HR = 4.88). An immunotherapy cohort showed that the patients with higher CS had a significantly worse ORR (p = 0.0025). The high CS group contained several cell death pathways down-regulated and contained the worse tumor microenvironment. The nomogram demonstrated the survival prediction capability of collagen score.

CONCLUSION

CS was verified as an independent prognostic factor and potentially reflected the therapeutic effect of immunotherapy. The CS could provide a new way to evaluate the clinical prognosis and response information helping develop the collagen-targeted treatment.

Impact of positive microscopic resection margins (R1) after gastrectomy in diffuse-type gastric cancer

INTRODUCTION

Diffuse-type gastric cancer (DTGC) is associated with poor outcome. Surgical resection margin status (R) is an important prognostic factor, but its exact impact on DTGC patients remains unknown. The aim of this study was to assess the prognostic value of microscopically positive margins (R1) after gastrectomy on survival and tumour recurrence in DTGC patients.

METHODS

All consecutive DTGC patients from two tertiary centers who underwent curative oncologic gastrectomy from 2005 to 2018 were analyzed. The primary endpoint was overall survival (OS) for R0 versus R1 patients. Secondary endpoints included disease-free survival (DFS), recurrence patterns as well as the overall survival benefit of chemotherapy in this DTGC patient cohort.

RESULTS

Overall, 108 patients were analysed, 88 with R0 and 20 with R1 resection. Patients with negative lymph nodes and negative margins (pN0R0) had the best OS (median 102 months, 95% CI 1-207), whereas pN + R0 patients had better median OS than pN + R1 patients (36 months 95% CI 13-59, versus 7 months, 95% CI 1-13, p < 0.001). Similar findings were observed for DFS. Perioperative chemotherapy offered a median OS of 46 months (95% CI 24-68) versus 9 months (95% CI 1-25) after upfront surgery (p = 0.022). R1 patients presented more often early recurrence (< 12 postoperative months, 30% vs 8%, p = 0.002), however, no differences were observed in recurrence location.

CONCLUSION

DTGC patients with microscopically positive margins (R1) presented poorer OS and DFS, and early tumour recurrence in the present series. R0 resection should be obtained whenever possible, even if other adverse biological features are present.

Clinical implications and chemo-sensitivity of adjuvant chemotherapy in patients with poorly cohesive cells-gastric cancer

PURPOSE

Poorly cohesive cells-gastric cancer (PCC-GC) represents distinct features within the GC spectrum. The present study investigated the clinicopathologic characteristics and chemo-sensitivity for a relatively large cohort of PCC-GC patients.

MATERIALS AND METHODS

A total of 268 patients diagnosed with stage II or III PCC-GC were included. GC cell lines were also analyzed for drug sensitivity to 5-fluorouracil (5-FU) and oxaliplatin in vitro.

RESULTS

One hundred fifteen (42.9%) patients were stage II and 153 (57.1%) were stage III. Two hundred twenty-three (83.2%) patients received adjuvant therapy. Among these patients, 139 (62.3%) received CAPOX and 84 (37.7%) received S-1. With a median follow-up of 38.9 (1.6-137.8) months, the estimated 5-year disease-free survival (DFS) and overall survival (OS) rates were 52.3% and 61.0%, respectively. In the univariate analysis, survival was significantly better in the adjuvant chemotherapy group than in the surgery only group. In the subgroup analysis, there was no significant difference in DFS or OS between the types of adjuvant chemotherapy for either disease stage. In vitro cell line analysis, different responses to 5-FU and oxaliplatin were observed in SRC and non-SRC, where the treatment in KATOIII cell lines with oxaliplatin had less effect at a higher concentration compared to non-SRC cell lines.

CONCLUSION

The current study found that adjuvant chemotherapy was not significantly associated with survival benefit for patients with resected stage II and III PCC-GC. Plus, S-1 showed numerically longer DFS and OS compared to CAPOX in PCC-GC patients, although no significant in the multivariate analysis.

Metastatic Signet Ring Cell Adenocarcinoma Manifesting as Chronic Leg Pain

Signet ring cell carcinoma, a type of gastrointestinal system-related cancer, rarely metastasizes to the skeletal muscle. We present signet ring-cell carcinoma in a 28-year-old man who presented with left lower extremity pain and swelling. Imaging showed thickening of the distal esophagus, intestines, and bladder wall. Endoscopy revealed friable gastric mucosa and stenosis in the ascending colon, but biopsies were unrevealing. Leg muscle biopsy showed metastatic adenocarcinoma with focal signet ring features. Carcinoembryonic antigen and cancer antigen 19-9 were elevated. A gastrointestinal primary tumor was suspected. Our case urges clinicians to consider this rare cancer in patients presenting with skeletal muscle mass.

METTL3 promotes drug resistance to oxaliplatin in gastric cancer cells through DNA repair pathway

Gastric cancer (GC) poses a significant threat to human health and remains a prevalent form of cancer. Despite clinical treatments, the prognosis for Gastric cancer patients is still unsatisfactory, largely due to the development of multidrug resistance. Oxaliplatin (OXA), a second-generation platinum drug, is commonly recommended for adjuvant and palliative chemotherapy in Gastric cancer; however, the underlying mechanisms of acquired resistance to Oxaliplatin in Gastric cancer patients are not yet fully understood. In this study, we aimed to explore the potential mechanisms of Oxaliplatin resistance in Gastric cancer by employing bioinformatics analysis and conducting in vitro experiments. Specifically, we focused on investigating the role of methyltransferase-like 3 (METTL3). Our findings revealed that the knockdown of METTL3 significantly impeded the proliferation and migration of Gastric cancer cells. METTL3 knockdown induced apoptosis in OXA-resistant Gastric cancer cells and enhanced their sensitivity to Oxaliplatin. Furthermore, we found that DNA repair pathways were significantly activated in OXA-resistant Gastric cancer cells, and METTL3 knockdown significantly inhibited DNA repair pathways. Another important finding is that METTL3 knockdown and OXA-induced Gastric cancer cell death are additive, and the targeted METTL3 can assist Oxaliplatin treatment. Collectively, our findings suggest that METTL3 knockdown can augment the sensitivity of Gastric cancer cells to Oxaliplatin by impeding DNA repair processes. Consequently, targeting METTL3 holds great promise as a viable adjuvant strategy in the treatment of Gastric cancer patients.

A nomogram for predicting lymph node metastasis in early gastric signet ring cell carcinoma

At present, the risk factors for lymph node metastasis in early gastric signet ring cell carcinoma (SRCC) remain unclear. However, it is worth noting that the LNM rate and prognosis of early gastric SRCC are superior to those of other undifferentiated cancers. With advancements in endoscopic technology, the 5-year survival rate following endoscopic treatment of early gastric cancer is comparable to traditional surgery while offering a better quality of life. The objective of this study was to develop a nomogram that can predict lymph node status in early gastric SRCC before surgery, aiding clinicians in selecting the optimal treatment strategy. A research cohort was established by retrospectively collecting data from 183 patients with early gastric SRCC who underwent radical gastrectomy with lymph node dissection at our hospital between January 2014 and June 2022. The predictors of early gastric signet ring cell carcinoma lymph node metastasis were identified in the study cohort using the least absolute selection and shrinkage operator (Lasso) and multivariate regression analysis, and a nomogram was developed. The discrimination, accuracy, and clinical practicability of the nomogram were assessed using receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis. The incidence of lymph node metastasis was 21.9% (40/183) overall. Multivariate logistic regression analysis revealed that tumor size and lymphovascular invasion (LVI) were independent risk factors for lymph node metastasis. Lasso regression analysis demonstrated that tumor size, invasion depth, LVI, E-cadherin expression, dMMR, CA242, NLR, and macroscopic type were associated with lymph node metastasis. The integrated discrimination improvement (IDI) (P = 0.034) and net reclassification index (NRI) (P = 0.023) were significantly improved when dMMR was added to model 1. In addition, the area under curve (AUC) (P = 0.010), IDI (P = 0.001) and NRI (P < 0.001) of the model were significantly improved when type_1 was included. Therefore, we finally included tumor size, invasion depth, dMMR, and macroscopic type to establish a nomogram, which had good discrimination (AUC = 0.757, 95% CI 0.687-0.828) and calibration. Decision curve analysis showed that the nomogram had good clinical performance. We have developed a risk prediction model for early gastric signet ring cell carcinoma that accurately predicts lymph node involvement, providing clinicians with a valuable tool to aid in patient counseling and treatment decision-making.

The prognostic value of FAR and a novel FAR-CA125 score in resectable gastric signet ring cell carcinoma patients

BACKGROUND

The fibrinogen to albumin ratio (FAR) is increasingly regarded as a potential biomarker for predicting prognosis in variety of malignant tumors, but not in gastric signet ring cell carcinoma (GSRC). This study seeks to examine the prognostic value of the FAR and explore a novel FAR-CA125 score (FCS) in resectable GSRC patients.

METHODS

A retrospective cohort was conducted including 330 GSRC patients who underwent curative resection. Kaplan-Meier (K-M) and Cox regression were used to analysis the prognostic value of FAR and FCS. And a predictive nomogram model was developed.

RESULTS

The optimal cut-off values for CA125 and FAR were 9.88 and 0.0697, respectively, according to the receiver operating characteristic curve (ROC). Th area under the ROC curve of FCS is higher than CA125 and FAR. 330 patients were grouped into three groups according to the FCS. High FCS was related to males, anemia, tumor size, TNM stage, lymph node metastasis, tumor invasion depth, SII, and pathological subtypes. K-M analysis showed that high FCS and FAR were associated with poor survival. In the multivariate analysis, FCS, TNM stage, and SII were independent prognostic factors for poor OS in resectable GSRC patients. And the predictive accuracy of clinical nomogram contained FCS was better than TNM stage.

CONCLUSION

This study indicated that the FCS is a prognostic, and effective biomarker for patients with surgically resectable GSRC. Such developed FCS-based nomogram could be effective tools to assist the clinicians to determine the treatment strategy.

Novel nomogram to predict the overall survival of postoperative patients with gastric signet

BACKGROUND

The TNM staging system cannot accurately predict the prognosis of postoperative gastric signet ring cell carcinoma (GSRC) given its unique biological behavior, epidemiological features, and various prognostic factors. Therefore, a reliable postoperative prognostic evaluation system for GSRC is required. This study aimed to establish a nomogram to predict the overall survival (OS) rate of postoperative patients with GSRC and validate it in the real world.

METHODS

Clinical data of postoperative patients with GSRC from 2002 to 2014 were collected from the Surveillance, Epidemiology, and End Results database and randomly assigned to training and internal validation sets at a 7:3 ratio. The external validation set used data from 124 postoperative patients with GSRC who were admitted to the Affiliated Tumor Hospital of Harbin Medical University between 2002 and 2014. The independent risk factors affecting OS were screened using univariate and multivariate analyses to construct a nomogram. The performance of the model was evaluated using the C-index, receiver operating characteristic curve (ROC), calibration curve, decision analysis (DCA) curve, and adjuvant chemotherapy decision analysis.

RESULTS

Univariate/multivariate analysis indicated that age, stage, T, M, regional nodes optimized (RNE), and lymph node metastasis rate (LNMR) were independent risk factors affecting prognosis. The C-indices of the training, internal validation, and external validation sets are 0.741, 0.741, and 0.786, respectively. The ROC curves for the first, third, and fifth years in three sets had higher areas under the curves, (training set, 0.782, 0.864, 0.883; internal validation set, 0.781, 0.863, 0.877; external validation set, 0.819, 0.863, 0.835). The calibration curve showed high consistency between the nomogram-predicted 1-, 3-, and 5-year OS and the actual OS in the three queues. The DCA curve indicated that applying the nomogram enhanced the net clinical benefits. The nomogram effectively distinguished patients in each subgroup into high- and low-risk groups. Adjuvant chemotherapy can significantly improve OS in high-risk group (P = 0.034), while the presence or absence of adjuvant chemotherapy in low-risk group has no significant impact on OS (P = 0.192).

CONCLUSIONS

The nomogram can effectively predict the OS of patients with GSRC and may help doctors make personalized prognostic judgments and clinical treatment decisions.

Mechanism of anticancer effect of gambogic acid on gastric signet ring cell carcinoma

Gambogic acid has demonstrated inhibitory effects on the growth of various cancer cell types, such as breast cancer, pancreatic cancer, prostate cancer, lung cancer, and osteosarcoma. This study aims to investigate the antiproliferative activity of Gambogic acid on SNU-16 cells derived from gastric signet ring cell carcinoma and elucidate the underlying mechanisms. The cytotoxic effect of gambogic acid was evaluated in SNU-16 cells by treating them with different concentrations of the compound, and the XTT cell viability assay was employed to assess cell viability. ELISA was used to measure bax, BCL-2, caspase 3, PARP, and 8-oxo-dG levels. Additionally, immunofluorescence staining was applied to assess 8-oxo-dG and LC3β levels in SNU-16 cells. It was observed that gambogic acid exerted a dose-dependent and statistically significant antiproliferative effect on SNU-16 cells. The IC50 value of gambogic acid in SNU-16 cells was found to be 655.1 nM for 24 h. Subsequent investigations conducted using the IC50 dose revealed a significant upregulation of apoptotic proteins including cleaved caspase 3, Bax, and cleaved PARP (p < 0.001), along with a downregulation of BCL-2 (p < 0.001), an anti-apoptotic protein. Moreover, the administration of this drug led to an upregulation of 8-oxo-dG (p < 0.001), a widely acknowledged biomarker indicating oxidative damage in DNA, as well as an increase in LC3β levels (p < 0.05), a marker associated with autophagy. The antiproliferative effect of gambogic acid against gastric signet ring cell carcinoma is attributed to its ability to induce apoptosis and autophagy. This discovery highlights the promising potential of gambogic acid as a treatment option for gastric signet ring cell carcinoma.

Lower Limb Edema Caused by Metastatic Signet Ring Cell Stomach Cancer

Overall gastric cancer incidence is decreasing, but incidence of gastric signet ring cell carcinoma has been rising. The diagnosis can be challenging. It has a poorer prognosis because it tends to be diagnosed at advanced stages. Lymphedema is a rare presentation. We report a rare presentation of signet ring cell carcinoma in a 49-year old male, with no underlying medical condition. The patient presented with lymphedema of lower limbs, scrotum and abdominal wall.

LEARNING POINTS

Signet ring cell carcinoma tends to have an infiltrative behavior. Endoscopic analysis may not lead to any macroscopic finding.In highly suspicious cases, endoscopic exploration should be complemented with an endoscopic ultrasound or blind random biopsies.

Efficacy of chemotherapy combined with surgical resection for gastric cancer with synchronous ovarian metastasis: A propensity score matching analysis

BACKGROUND

Ovarian metastasis from gastric cancer (GC) is characterized by aggressive biological behavior and poor outcome. Currently, there is no standard treatment mode for such patients. Thus, we evaluated the efficacy of conversion therapy in patients with synchronous ovarian metastasis from GC in this study.

METHODS

About 219 GC patients with ovarian metastasis in 2011-2020 were enrolled. Two groups were established based on the different treatment: the conversion therapy group (chemotherapy combined with surgical resection, CS group) and the non-conversion therapy group (NCS group). Propensity score matching (PSM) was used to analyze the efficacy of different treatment modes on the prognosis of these patients.

RESULTS

Ninety-two patients were included according to PSM results, with 46 patients each in CS and NCS groups. The median overall survival (OS) in the CS group was notably better than that in the NCS group (p < 0.001). Twenty-six patients (56.52%) in the CS group achieved R0 resection, and they had a better prognosis (p = 0.003). Compared with patients who underwent simultaneous gastrectomy and ovarian metastasectomy (CSb group), those who underwent ovarian metastasectomy before systemic chemotherapy (CSa group) had a higher R0 resection rate (p = 0.016) and longer survival time (p = 0.002). A total of 38 patients (41.30%) across both groups received hyperthermic intraperitoneal chemotherapy (HIPEC), and these patients had a better survival (p = 0.043).

CONCLUSION

The conversion therapy is safe and effective for patients with synchronous ovarian metastasis from GC and can improve their prognosis. However, our results need to be confirmed by more randomized controlled clinical studies.

Comparative analysis of tumor biology and prognosis in mucinous and signet-ring cell colon cancers versus classical adenocarcinoma

Background: Limited information is currently available on the natural history and prognosis of two distinct histological subtypes of adenocarcinoma (AC) in the colon: mucinous adenocarcinoma (MAC) and signet-ring cell carcinoma (SRCC). Therefore, the aim of this study is to examine the clinicopathological characteristics of colon MAC and SRCC, comparing them to classical AC, using a large cohort of cases from the United States. Methods: Patients diagnosed with colon AC, MAC, or SRCC from the SEER database between 2000 and 2018 were included in our study. Incidence trends, patient demographics, tumor characteristics, treatment, and survival were analyzed. Results: In our study, we analyzed a total of 310,813 patients with colon cancers, including 271,382 cases of classical AC, 34,750 cases of MAC, and 4,681 cases of SRCC. Over the study period, we observed a decline in the age-adjusted incidence rates of colon AC, MAC, and SRCC. Notably, the MAC and SRCC cohorts differed significantly from AC in terms of patient characteristics, tumor locations, and treatment patterns. Patients with MAC and SRCC had poorer survival outcomes compared to those with AC. Factors associated with worse survival included older age, male sex, poorly differentiated tumors, advanced stage, and the presence of MAC or SRCC histology. On the other hand, surgical intervention was associated with improved survival. Conclusion: Our study underscores the significance of recognizing the distinct features and outcomes associated with different histological subtypes of colon cancer. Further research is warranted to delve into the underlying biological traits that contribute to these differences and to develop more tailored treatment strategies.

Prognostic Survival Significance of Signet Ring Cell (SRC) Gastric Cancer: Retrospective Analysis from a Single Western Center

INTRODUCTION

Signet ring cell carcinoma accounts for 35% to 45% of all gastric cancer. Despite the acknowledgment of its more aggressive pathological features, various controversies surrounding this topic still exist. Thus, we investigate the clinical pathological characteristics and survival prognostic significance of signet ring cell components in patients affected by gastric cancer.

METHODS

From January 2004 to December 2020, in a retrospective study, we enrolled 404 patients with gastric cancer who were curatively treated in our department. The male-to-female ratio was 249/142, and the median age was 75 (range 37-94). We dichotomized patients into two groups (75 patients vs. 316 patients) based on the signet ring cell presence; according to preoperative, operative, and postoperative characteristics, we performed a univariate and multivariate analysis for overall survival.

RESULTS

Signet ring cell carcinoma indicated an increasing incidence trend over the time analyzed. Overall median survival of signet ring cell and non-signet ring cell carcinoma were, respectively, 16 vs. 35 months, p < 0.05. In early gastric cancer, the prognosis of the signet ring cell is better than that of the non-signet ring cell, as opposed to advanced cancer. Among the entire population in the multivariate analysis, the only independent factors were preoperative serum albumin level, complete surgical resection, level of lymphadenectomy, and pathological stage. Recurrence occurred more frequently in patients affected by signet ring cell, but in our data, we could not identify a peculiar site of recurrence.

CONCLUSIONS

Signet ring cell carcinoma has a specific oncogenetic phenotype and treatment resistance heterogeneity; however, it is not always associated with poor prognosis. According to our results, a radical surgical procedure associated with an adequate lymphadenectomy should be advocated to improve patients survival. Gastric cancer patients with signet ring cell components should draw clinicians' attention.

Early onset, development and histological features of gastric signet-ring cell carcinoma

Objective

To explore the early onset, development and histological features of gastric signet-ring cell carcinoma (SRCC).

Methods

Three hundred and sixty-two patients with differentiated adenocarcinoma with signet-ring cells were enrolled. Histomorphological and immunohistochemical features and patterns of the specimens were observed in detail.

Results

Infection of the gastric mucosa, especially by Helicobacter pylori, can cause massive cell proliferation and transformation in the deep gastric foveola, the isthmus of the gastric gland, and the proliferative zone of the upper neck of the gland. Signet-ring-like heterocysts monoclonally proliferated after the redifferentiation and reproliferation, extending horizontally along the gastric foveola. Gastric foveolar-type SRCC grew infiltratively into the lamina propria of the mucosa and the submucosa, signet-ring cells could differentiate into undifferentiated adenocarcinoma with signet-ring cell differentiation, mucinous adenocarcinoma with signet-ring cell differentiation, gastric adenocarcinoma with signet-ring cell differentiation, and fundus gland adenocarcinoma with signet-ring cell differentiation.

Conclusion

Early SRCC developed from the proliferative zones of the fundus of the gastric foveola and the neck of the gastric gland, growing horizontally along the gastric foveola. It developed into gastric adenocarcinoma with signet-ring cell differentiation after reproliferation and retransformation in the mucosa.

Clinicopathological and prognostic features of Borrmann type IV gastric cancer versus other Borrmann types: A unique role of signet ring cell carcinoma

Background

Evidence specifically comparing the clinicopathology of Borrmann type IV (B-IV) gastric cancer with that of other Borrmann types is insufficient.

Methods

A total of 3130 patients with advanced gastric cancer who underwent gastrectomy from January 2001 to September 2017 were enrolled in the analysis. Logistic regression and survival analysis methodology were used to investigate factors associated with peritoneal metastasis and overall survival (OS).

Results

Of the total cohort, 264 (8.43%) patients were B-IV type, 1752 (55.97%) were small-size other Borrmann types, and 1114 (35.59%) were large-size other Borrmann types. Signet ring cell carcinoma (SRC) was more common in B-IV types than in other Borrmann types (33.71% vs 11.42% vs 12.66%, P < 0.001). In B-IV gastric cancers, SRC was significantly associated with peritoneal metastasis (HR = 1.898, 95% CI = 1.112 ~ 3.241, P = 0.019) and poorer OS (HR = 1.492, 95% CI = 1.088 ~ 2.045, P = 0.013) in multivariable analysis. Furthermore, stratified analysis revealed that SRC had worse survival than adenocarcinoma in the B-IV subgroups, with locally advanced stages (stages II ~ III) or negative surgical margins (all P < 0.05). In contrast, SRC failed to be significantly associated with peritoneal metastasis and poor OS in other Borrmann types (all P > 0.05).

Conclusion

SRC was more common in B-IV gastric cancer than in other Borrmann types. It was significantly associated with peritoneal metastasis and poorer OS in the B-IV type but not in other Borrmann types. As a unique prognostic factor for B-IV gastric cancer, SRC might help evaluate risk stratification and optimize treatment for this entity, especially for patients with locally advanced stages or R0 resection.

Impact of Signet-Ring Cell Histology in the Management of Patients with Non-Metastatic Gastric Cancer: Results from a Retrospective Multicenter Analysis Comparing FLOT Perioperative Chemotherapy vs. Surgery Followed by Adjuvant Chemotherapy

BACKGROUND

FLOT perioperative chemotherapy represents the standard of care in non-metastatic gastric cancer patients. Signet-ring cell positivity is associated with a worse prognosis in patients with gastric cancer treated with chemotherapy. Comparison between FLOT perioperative chemotherapy vs. surgery followed by adjuvant chemotherapy based on signet-ring cell positivity is lacking. The aim of the analysis was to compare perioperative FLOT with adjuvant chemotherapy in gastric cancer patients stratified by signet-ring cell positivity.

METHODS

We conducted a retrospective multicenter analysis based on disease-free survival (DFS) and overall survival (OS) in patients with gastric cancer who received perioperative chemotherapy with a FLOT regimen and compared their survival with a historical cohort of patients treated with adjuvant chemotherapy, matched by cT and cN stage and by tumor histological features.

RESULTS

Seventy-six patients were enrolled and 24 (32%) were signet-ring cell positive. At a median follow-up time of 39 months, the median DFS was 26.3 months and the median OS was 37.3 months. Signet-ring cell positivity was associated with a shorter OS (median OS: 20.4 vs. 46.9 months, HR: 3.30, 95%CI: 1.56-6.99, p = 0.0018) and DFS (mDFS: 15.2 vs. 38.6 months, HR: 3.18, 95%CI: 1.55-6.54, p = 0.0016). This was confirmed by multivariate analysis for DFS (Exp(B): 2.55) and OS (Exp(B): 2.68). After propensity score matching, statistically significant shorter DFS (HR: 3.30, 95%CI: 1.50-7.35, p = 0.003) and OS (HR: 5.25, 95%CI: 2.18-12-68, p = 0.0002) were observed for patients with signet-ring cell positivity who received perioperative treatment vs. those who received surgery followed by adjuvant chemotherapy.

CONCLUSIONS

Signet-ring positivity was associated with shorter DFS and OS in patients who received perioperative treatment with FLOT compared with surgery followed by adjuvant therapy. These data suggest that for patients with signet-ring cell histology, FLOT perioperative treatment might not always be the best choice of treatment, and further research should be focused on this group of patients.

Prognostic Performance of Three Lymph-Node Staging Systems on Gastric Signet-Ring-Cell Carcinoma

BACKGROUND

The lymph-node staging system can predict the prognosis of gastric signet-ring-cell carcinoma (SRCC). However, there are significant differences in lymph-node status between early SRCC and advanced SRCC. Additionally, the optimal system for early and advanced SRCC remains unknown.

METHODS

This study retrospectively analyzed 693 SRCC patients who underwent radical resection in the Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital. The predicted performance of three lymph-node staging systems, including pN staging, lymph-node metastasis rate (LNR), and log odds of positive lymph nodes (LODDS), was compared using the receiver characteristic operating curve (ROC) and c-index. The Kaplan-Meier method and the log-rank test analyzed the overall survival of patients. The Cox risk regression model identified independent risk factors associated with patient outcomes. The nomogram was made by R studio.

RESULTS

The 693 SRCC included 165 early SRCC and 528 advanced SRCC. ROC showed that LODDS had better predictive performance than pN and LNR in predicting prognosis regardless of early or advanced SRCC. LODDS can be used to predict the prognosis of early and advanced SRCC and was an independent risk factor associated with patient outcomes (p = 0.002, p < 0.001). Furthermore, the nomogram constructed by LODDS and clinicopathological features had good predictive performance.

CONCLUSIONS

LODDS showed clear prognostic superiority over both pN and LNR in early and advanced SRCC.

Single-cell analysis of gastric signet ring cell carcinoma reveals cytological and immune microenvironment features

Gastric signet ring cell carcinoma (GSRC) is a special subtype of gastric cancer (GC) associated with poor prognosis, but an in-depth and systematic study of GSRC is lacking. Here, we perform single-cell RNA sequencing to assess GC samples. We identify signet ring cell carcinoma (SRCC) cells. Microseminoprotein-beta (MSMB) can be used as a marker gene to guide the identification of moderately/poorly differentiated adenocarcinoma and signet ring cell carcinoma (SRCC). The upregulated differentially expressed genes in SRCC cells are mainly enriched in abnormally activated cancer-related signalling pathways and immune response signalling pathways. SRCC cells are also significantly enriched in mitogen-activated protein kinase and oestrogen signalling pathways, which can interact and promote each other in a positive feedback loop. SRCC cells are shown to have lower cell adhesion and higher immune evasion capabilities as well as an immunosuppressive microenvironment, which may be closely associated with the relatively poor prognosis of GSRC. In summary, GSRC exhibits unique cytological characteristics and a unique immune microenvironment, which may be advantageous for accurate diagnosis and treatment.

Prognosis prediction in esophageal signet-ring-cell carcinoma: a competing risk analysis

OBJECTIVE

This study aims to construct and validate a competing risk nomogram model to predict 1-year, 3-year, and 5-year cancer-specific survival (CSS) for patients with esophageal signet-ring-cell carcinoma.

METHODS

Patients diagnosed with esophageal signet-ring-cell carcinoma (ESRCC) between 2010 and 2015 were abstracted from the Surveillance, Epidemiology, and End Results (SEER) database. We performed the competing risk model to select significant variables to build a competing risk nomogram, which was used to estimate 1-year, 3-year, and 5-year CSS probability. The C-index, receiver operating characteristic (ROC) curve, calibration plot, Brier score, and decision curve analysis were performed in the internal validation.

RESULTS

A total of 564 patients with esophageal signet-ring-cell carcinoma fulfilled the eligibility criteria. The competing risk nomogram identified 4 prognostic variables, involving the gender, lung metastases, liver metastases, and receiving surgery. The C indexes of nomogram were 0.61, 0.75, and 0.70, respectively for 5-year, 3-year, and 1-year CSS prediction. The calibration plots displayed high consistency. The Brier scores and decision curve analysis respectively favored good prediction ability and clinical utility of the nomogram.

CONCLUSIONS

A competing risk nomogram for esophageal signet-ring-cell carcinoma was successfully constructed and internally validated. This model is expected to predict 1-year, 3-year, and 5-year CSS, and help oncologists and pathologists in clinical decision making and health care management for esophageal signet-ring-cell carcinoma patients.