Observations on gastric cancer in San Marino. I. Familial factors

The Republic of San Marino (RSM) is a 23-square mile independent country within Italy with a population of 20,000. A large percentage of deaths have been found to be due to gastic cancer (9.2% of all death certificate diagnoses for 1969 through 1973). The frequency of gastric cancer in the families of all 36 patients (78% male) who were born and died in RSM with this diagnosis for this period was compared with the frequency in relatives of age and sex-matched controls. Although 42--44% of both groups had relatives with death certificate diagnoses of stomach cancer, 25% of the patients had first degree relatives affected versus 5.6% of the controls. A high prevalence has also been reported in the area of Italy near RSM. San Marino's size and stability of population provide unique opportunities for elucidating genetic and environmental etiological factors in stomach cancer.

Establishment of a cell culture line from a transplantable rat stomach cancer induced by N-methyl-N'-nitro-N-nitrosoguanidine

A cell line designated as BV9 was established in culture from a transplantable rat stomach cancer, which was originally induced in the glandular stomach of a Wistar rat by p.o. administration of N-methyl-N'-nitro-N-nitrosoguanidine. The monolayer cells, which have been subcultured for more than 35 passages, revealed pleomorphic features. Chromosomal analysis showed hypertetraploidy (mode, 95), and marker chromosomes were present. Cultured cells were injected s.c. into cyclophosphamide-conditioned syngeneic rats and produced tubular adenocarcinomas resembling the original tumor.

Familial juvenile polyposis of the stomach

Innumerable polyps of the stomach were recognized in a 13-yr old girl. She had no extragastric polyps on roentgenographic and endoscopic studies. Her elder brother received a subtotal gastrectomy because of gastric polyposis at 14 yr of age. Their mother died of gastric cancer at 37 yr of age. Only these three subjects in this family had unusual brown hair and were low in normal intelligence. Polyps produced chronic and severe loss of both blood and protein, which resolved after a subtotal gastrectomy at 18 yr of age. Macroscopic and histologic observations of polyps in the resected stomach confirmed the diagnosis of juvenile polyposis. Both siblings are now in good health. Classification of this hereditary syndrome as a newly recognized entity, familial juvenile polyposis of the stomach, is proposed.

[Gardner's syndrome (author's transl)]

An exact history was taken and clinical, endoscopic and histologic studies were performed in 14 family members of a case of Gardner's syndrome with triple symptomatology documented with biopsy and autopsy findings. Among the symptom-free probands five cases of colonic polyposis and three cases with gastric polyps were found. All polyps were histologically adenomatous. Dysplasias grade I and II were found repeatedly, in one 16-year-old adolescent there was already severe dysplasia within the gastric mucosal polyps. A warning is given against sub-classification of familial colonic polyposis and other syndromes within the definition of Gardner's syndrome. In future during diagnostic investigations for cases of Gardner's syndrome isolated gastric polyposis should be sought for as well as monosymptomatic colonic polyposis. Diagnostic procedures and treatment should depend on endoscopic and histological findings. Regular follow-up with endoscopic biopsies are to be encouraged not only in the diseased cases but also in all family members available.

Cancer in families with xeroderma pigmentosum

In 31 families of xeroderma pigmentosum (XP) patients, significantly more blood relatives than spouse controls had had nonmelanoma skin cancer. These family data support the hypothesis that heterozygosity for XP genes may predispose persons to skin cancer, particularly in association with substantial exposure to sunlight.

Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.

Morphological, functional and immunological state of the gastric mucosa in gastric carcinoma families. Comparison with a computer-matched family sample

Three hundred and one first-degree relatives (series) of 73 gastric carcinoma patients and 358 control relatives (controls) of 73 computer-matched probands from a general population were studied by direct-vision gastric biopsy and functional and immunological examinations. The controls were representative of the series with respect to age, sex, birth and dwelling place, and relationship of the relatives. Series and controls behaved similarly as to total prevalence of gastritis, age and sex distribution of gastritis, serum gastrin level, and circulating gastric antibodies. On the other hand, the total prevalence of hyperplastic polyps, atrophic gastritis of the body and antrum, severe atrophic gastritis of the body, intestinal metaplasia, epithelial atypia, and achlorhydria was significantly higher in the series than in the controls. In subjects below 50 years of age the prevalence of severe atrophic gastritis of the body, intestinal metaplasia, and epithelial atypia was also significantly higher in the series. In addition, the mean age of the subjects with atrophic gastritis, intestinal metaplasia, epithelial atypia, and achlorhydria was lower in the series than in controls; however, significant differences were found only in female subjects with epithelial atypia and atrophic gastritis of the body. The results suggest that the prevalence of signs often considered premalignant is significantly higher in carcinoma relatives than in controls and that these signs show a trend to occur at an earlier age in carcinoma relatives. This could explain the significantly higher than expected death rate from gastric carcinoma in close relatives with this disease, found in the present and in other series.

Gastric polyps in familial polyposis coli

Familial polyposis coli has been considered a disease in which polyps are confined to the colon and rectum. The authors recently saw 3 cases in which either adenomatous or hyperplastic polyps were also present in the stomach and duodenum. The polyps were detected only by endoscopy or air-contrast radiographic examination. These cases and other recent studies indicate that gastric and duodenal polyps are more common in familial polyposis coli than previously recognized and should be considered an integral part of the syndrome.

Juvenile and adenomatous gastrointestinal polyposis

This is the fourth report of a case showing an association between juvenile and adenomatous polyposis. Starting at age 14, this patient underwent multiple polypectomies and gastrointestinal resections over a 15-year period. Although initial biopsies were diagnosed as juvenile polyps, later biopsies showed both adenomatous polyps and large polypoid masses with a mixture of juvenile and adenomatous features. Several typical small hyperplastic polyps were also found in the stomach. This case contrasts with the previous three cases in that the gastrointestinal tract is more widely involved and in that there is an unusual marked hyperplasia of argentaffin- and argyrophil-positive cells. The case reported here strengthens the relation between adenomatous polyposis and juvenile polyposis.

Cancer incidence in a religious isolate of Alberta, Canada, 1953-74

Members of a religious isolate who live in approximately 240 farming colonies in the Canadian prairie provinces and the United States border states were studied. The sect's 6,700 members living in the province of Alberta, Canada, comprise more than 30% of this sect's population of North America. The numbers of their cancer cases ascertained from 1953 to 1974 in Alberta were compared to those expected from Alberta Cancer Registry rates. The overall incidence of registered cases of cancer among the religious isolate's females was significantly less than expected (48 observed, 74.2 expected), and in the males the overall incidence of cancer did not differ from that expected (52 observed, 56.5 expected). Significantly fewer cases of lung cancer than expected were found in males, and significantly fewer cases of carcinoma in situ of the cervix uteri were found in females. Finally, significantly higher incidence of stomach cancer was found in the sect's males. Data on a family with two cases of stomach cancer contributed to this observed excess of stomach cancer.

[Comparative study of the karyotype and histostructure of neoplasms of the uterine body, stomach and malignant melanoma]

Direct analysis of karyotype revealed a heterogeneity of chromosome composition, variations in modal lines and chromosome aberrations, diversity of marker chromosome morphology. The variability of cytogenetic alterations was found in tumors both of the same and of different origin. These results established the nature of genome and chromosome alterations in the investigated tumors. The problem is discussed of a possible use of cytogenetic analysis for a more concrete characterization of human tumors in terms of their biological features.

Gastrointestinal polyposis with orocutaneous hamartomas (Cowden's disease)

A patient with Cowden's disease and multiple gastrointestinal polyps is presented. An association of gastrointestinal polyposis with this syndrome is made and the histopathological features are described. The cliniical features of Cowden's disease along with its familial tendency are discussed. Emphasis is placed on the importance of considering this diagnosis when evaluating patients with multiple gastrointestinal polyposis. Screening of these patients and their families for the associated malignancies should be performed.

Familial cancer and cancer families

From this brief review is should be evident that the hereditary varieties of common cancers are characterized by a high degree of genetic heterogeneity. The specific types of hereditary cancers can be identified by focusing on the histologic types and sites of involvement, not only of the primary neoplasm, but also of associated neoplasms and associated conditions or stigmata, as well as by focusing on the age of the patient at the time of diagnosis, tumor localization and frequency, and the mode of inheritance. Identification of specific types of hereditary cancers has important utility as a means of isolating homogeneous groups of patients and unaffected relatives for studies aimed at elucidating the mechanisms of carcinogenesis.

Establishment of cultured cell lines derived from a human gastric carcinoma

A human gastric carcinoma cell line, KATO-II, and its subline, KATO-III, have been established in vitro from a pleural effusion of a 55-year-old male patient. Kato-II cells have been maintained using a culture medium containing human cord serum and KATO-III cells have been cultured with a medium containing fetal bovine serum. Both cell lines are morphologically quite similar; they grow in vitro floating free and have cytological features of signet ring cells. Population doubling times for KATO-II and KATO-III were 74 hours and 36 hours, repsectively. The modal chromosomal numbers of these cell lines fell in a tetraploid range. Heterotransplantation of KATO-II and KATO-III cells was successfully done in the cheek pouches of antithymocyte serum-treated hamsters. Microscopical appearance of the resultant tumors was consistent with poorly-differentiated adenocarcinoma comparable to the original tumor.

Genetics and cancer of the gastrointestinal system. Annual oration in honor of Herbert M. Stauffer, M.D., 1914-1970

Familial aggregations of tumors may occur in virtually all organ systems. The gastrointestinal tract is a frequent site for the development of cancers having an hereditary basis. Their recognition has important relevance to cancer control and prevention. In addition, detailed clinical and laboratory studies of inherited tumors may throw light upon the cause of the more common forms of gastrointestinal neoplasms. Radiologists must have a working knowledge of the genetic and diagnostic elements of each in order to fulfill their responsibilities to the patient, the patient's family and the referring physician.

[Contribution of cases to the new classification of polyposis syndrome in the gastrointestinal tract]

In Schweizerische Medizinische Wochenschrift 106, 894-897 (1976) an article was published on a kinship with hereditary "minor adenomatous polyposis" of the colon with a higher than expected incidence of carcinoma of the stomach. Evidence for a genetic relationship between this family (Sch.) and another branch with an isolated case (Sch. E.) of familial polyposis of the gastrointestinal tract was found. The patient Sch. E. is presented here. The polyposis of this patient is phenotypically identical with that found in the classical familial polyposis of the colon, but also exhibits features of "minor adenomatous polyposis". A systematic clinical-endoscopic examination of ten members of the patient's family produced no further cases of gastrointestinal polyposis of carcinomata. In the case of Sch. E., therefore, a spontaneous mutation is postulated. A new classification of the various types of colonic polyposis is suggested.

A behavior of Y chromatin in cancer cells of males

Y-chromatin or Y-body which is present in interphase nuclei in over 78 per cent of somatic male cells varied in frequency and multiplication in malignant tumors. The variation is characteristic of each tumor and kept fairly constant in cultured cell lines unless modulation occurs during continuous subcultures. The variation was due to chromosomal abnormality, aneuploidization or polyploidization, but in part appears to be related to abnormality of intercalary quinacrine binding to chromosomes.

Family patterns of antro- fundal gastritis

311 first-degree relatives of 78 consecutive patients with gastric carcinoma and 386 first-degree relative of control probands computer matched from a large Finnish population were studied by means of biopsies from antrum and the fundus and by functional and immunological methods. Both the A and B type of Strickland the McKay as well as the AB types of Pitchumoni and Glass were discernable in the present series and often accumulated in the same families. Particularly the A type associated with high serum gastrin values and parietal cell antibodies revealed a family accumulation. In general members of the same family tended to behave similarly with regard to morhology, function and immunology of the antro-fundal mucosa. The 386 computer matched controls from the general population were treated by means of mathematical methods derived from stochastic theory. It appeared that on a family level there was clearly discernable a line representin families with predominance of fundal gastritis (A type?) which significantly deviated from the main population. However, no such behavior was found as to the families with predominantly antral gastritis (B type?) which behaved like the population at large.

[Multiple adenomatous papillary colonic polyps in a family with frequent cases of stomach carcinoma--a new phenotype of familial colonic polyposis]

A kindred of "minor adenomatous polyposis" associated with a high incidence of gastric cancer is described. Five out of 14 mainly asymptomatic individuals in 2 generations of kindred examined clinically, by panendoscopy and coloscopy exhibited multiple polyps of colon or/and stomach and jejunum. Single or multiple papillary adenomas were detected mainly in the right or middle colon (3 times or in the jejunum (once). Hyperplastic polyps were found in the stomach (3 times) and in the colon (twice of these 5 individuals. Our findings suggest that "minor adenomatous polyposis" associated with gastric cancer may represent another, hitherto unrecognized, phenotype of familial multiple polyposis.

[Malignancies in relatives of retinoblastoma patients (author's transl)]

In 14 out of 25 patients with retinoblastoma there was a family history of malignancies. Most of the malignant tumours had been carcinomas. In 2 families relatives died because of leukaemia; in these cases the tumour was a so-called diffuse retinoblastoma occurring in elder children. A third family with a retinoblastoma in one child and leukaemia in another is mentioned. This unusual coincidence of two tumourous conditions of which one might be of viral origin led to detailed electron microscopic examination of the retinoblastoma in one case; but there were no signs of reduplicating viruses.

Familial cancer of the gastro-intestinal tract

A family with a high incidence of early onset gastrointestinal carcinoma is described. Individuals from four generations have been proved to have had the disease. The management of individuals as yet unaffected is discussed and a regime for follow-up suggested.

Familial 'minor' adenomatous polyposis coli associated with gastric carcinoma - a hiterto undescribed phenotype of polyposis coli?

A clinical study of a family (Sch.) with a high incidence of death from gastric cancer in the second generation is presented. Endoscopic and/or surgical evaluation of the stomach, upper small intestine, and colon in 14 mainly asymptomatic members of the third and fourth generations revealed single or multiple (solitary) papillary adenomas in the colon or jejunum in 2 members each of the two generations. In addition, single or multiple hyperplastic polyps in the stomach or colon were found in 5 members, in 4 of them in association with papillary adenomas. The findings in family Sch. are consistent with 'minor' adenomatous polyposis coli associated with gastric carcinoma. Gastric carcinoma probably represents another phenotype among the vast variety of extra-colonic and extra-alimentary neoplastic changes known to occur in association with familial polyposis coli (FPC). The relationship of hyperplastic polyps to papillary adenoma in the colon and to gastric carcinoma respectively is discussed. Finally, evidence for a genetic relationship between family Sch. and a case with probable FPC is presented.

[Multiple cartilaginous exostoses with polyposis of stomach and colon: a new, hereditary combination different from Gardner's syndrome (author's transl)]

Multiple cartilaginous exostoses were found in a 41-year-old man and his two sons, aged 11 and 15 years. The older boy had extensive polyposis of the sigmoid colon and gastric antrum, his brother had radiological changes suspicious of sigmoid polyposis, while there was no radiological evidence of polyposis in the father. None of them had any symptoms of polyposis. The described combination of findings suggests a separate entity from Gardner's syndrome, perhaps on the basis of a combined dominant gene inheritance. In case of multiple exostoses radiological and endoscopic examination of the gastro-intestinal tract for polyposis are indicated.

Future inquiries into the epidemiology of gastric cancer

The fact that gastric cancer has been shown in many studies to be strongly related to a large number of social factors, ethnic background, occupation, socioeconomic status, and the like, suggests the importance of exogenous factors in its etiology. Past studies show a variety of relationships that furnish leads requiring elucidation to further understanding of this disease, e.g., higher risks related to exposures to asbestos, metals dusts, purgatives, and poor dental hygiene. Diet inquiries have steadily improved and negative relationships have been discovered with ingestion of vegetables in studies in Wales, Liverpool, Buffalo, Honolulu, Japan, and Norway. Positive relationships with starch have been found in many of these same places as well as in Israel. These leads need further investigation, as do better methods of diet research, studies of diet and histological type of gastric cancer, diet in its relationship to familial aggregation of gastric cancer, and studies of consistencies in relationships among the various sites in the digestive tract. Because diet is so heterogeneous in modern societies, multivariate analysis is needed in addition to simpler traditional modes.

Juvenile polyposis and gastrointestinal carcinoma. A study of a kindred

A kindred contained at least 10 members with single or multiple juvenile polyps of the stomach and large intestine. Several additional polyps had both adenomatous and juvenile features. Eleven members of the kindred have had gastrointestinal carcinoma of the stomach, duodenum, pancreas, or proximal colon. The pattern of inheritance in this kindred suggests either a single or two closely linked autosomal dominant determinants for gastrointestinal carcinoma and polyposis. Management of this kindred is complicated due to the occurrence of gastrointestinal carcinoma without polyposis.

Genetic problems in tumours of the gastrointestinal tract

The role of heredity in the production of gastrointestinal tumours is reviewed. The rare forms showing Mendelian inheritance are described, with special reference to oesophageal cancer and to familial polyposis of the colon. The high risks in these disorders are contrasted with the generally low risks to family members for the common cancers of the digestive tract. The part played by genetic factors in production of the premalignant state is critically discussed, with emphasis on gastric and hepatic cancer. The various experimental genetic approaches to the causation and early detection of cancer are outlined, and it is concluded that both genetic and environmental factors should be considered together when the etiology is being investigated.

[Cytogenetic mechanisms in the pathogenesis of malignant neoplasms]

Malignant tumors and pre-cancer processes are characterized by a high proliferative activity of cells, high chromosome variability and extremely high genome variability which is 10 times, as high as that in non-tumor actively proliferating tissues. A clear positive correlation is found between the cell division rate and the level of chromosome variability.

Peutz-Jeghers syndrome: its natural course and management

Two hundred and twenty-two patients with Peutz-Jeghers syndrome were ascertained in Japan between 1961 and 1974 through two nationwide surveys, medical literature, and personal examinations. Genetic analysis was made of this group as well as 102 follow-up cases. The average age at diagnosis was 23 in males and 26 in females, with male to female ratio of 1:1.13. Presenting complaints of 170 patients included obstruction (42.8 per cent of patients), abdominal pain (23.4 per cent), rectal bleeding (13.5 per cent), extrusion of polyp (7.2 percent). Diagnosis of 52 patients was based on melanin pigmentation. Intussusception occurred in 46.9 per cent of the patients, most often in the small intestine. Polyps occurred in the stomach in 108 patients (48.6 per cent), small intestine, 142 patients (64 per cent), colon, 118 patients (53.2 per cent) and rectum, 71 patients (32 per cent). Among the 222 patients, cancer was histologically verified in 28. Fifteen early cancers occurred (3 gastric, 8 small intestine, 4 colon), and 11 advanced cancers (3 gastric, 1 small intestine, 6 colon, and 1 both colon and small intestine). Mortality was lower than in patients with familial polyposis coli but higher than in the general population. Conservative surgical management, planned medical follow-up, and the need for a national registration system are stressed.

A family with atypical colonic polyposis and gastric cancer: a three-decade followup

A three-decade followup of a family in whom multiple colonic polyps were found in 5 out of 11 members of one generation is presented. In 3 of these members, cancer was present in the colorectum. The clinical picture as well as the pathologic findings differ from those seen in familial polyposis. In the previous generation two cases of gastric cancer were found, as well as one case of colonic cancer. The high incidence of colonic polyps and cancer suggests a hereditary disease, but the mode of transmission cannot be definitely determined without following this family for a longer period.

Heterogeneity in susceptibility to chronic gastritis in relatives of gastric cancer patients with different histology of carcinoma

The morphological state of gastric body mucosa was examined in 269 first-degree relatives of 64 index patients with gastric carcinoma and in 142 subjects selected at random. Gastric carcinoma was divided into three groups according to histological properties: carcinoma mucocellulare, carcinoma adenomatosum, and carcinoma anaplasticum. The state of gastric body mucosa was divided into five stages: normal, superficial gastritis, slight moderate, and severe atrophic gastritis. The results were subjected to the numerical analysis based on the stochastic theory. The term 'age-adjusted score' (AAS) employed therein defines the individual susceptiability to chronic gastritis. In terms of AAS, the material could be divided into 'high' and 'low' gastritis risk families. It appeared that the subjects belonging to carcinoma mucocellulare index patient families had a significantly higher susceptibility to chronic gastritis than the other relatives examined. These families were also significantly concentrated in the group of 'high risk' families. The heterogeneity of the relatives of gastric cancer patients as regards their gastritis risk should obviously be taken into account in future epidemiological studies. These findings constitute further justification of the genetic approach in studies concerning gastritis-gastric cancer relationship.