Characteristics of intramural metastasis in gastric cancer

Tumor budding is associated with poor prognosis and clinicopathologic factors in esophageal carcinoma: A meta-analysis

BACKGROUND AND OBJECTIVE

Tumor budding is associated with the prognosis of several solid cancers, but further evidence is needed to identify its relation with esophageal cancer. Our study aims to assess the relationship between tumor budding and overall survival, disease-free survival, and clinicopathologic variables in EC.

METHODS

Multiple electronic databases were searched and 20 relevant studies containing 3370 patients were identified. The fixed effects and a random-effects model were used to perform a meta-analysis.

RESULT

Tumor budding was associated with poor overall survival in EC in both univariate analyses (HR:2.63; 95 % CI 2.06-3.38; p < 0.001) and multivariate analysis (HR: 2.00; 95 % CI 1.68 to 2.39; P < 0.001). Tumor budding was also associated with poor overall survival in subtypes of EC in subgroup analyses i.e. ESCC (HR:3.26; 95 % CI 2.48 to 4.29; P < 0.001), and EAC (HR:2.00; 95 % CI 1.36 to 2.95; P < 0.001) in univariate analysis and ESCC (HR: 2.95; 95 % CI 2.18 to 3.99; P < 0.001) and EAC (HR: 1.65; 95 % CI 1.33 to 2.04; P < 0.001) in multivariate analyses. In addition, tumor budding was also associated with poor DFS (HR: 3.39; 95 % CI 2.1 to 5.48; P < 0.001). Furthermore, tumor budding was associated with poor clinicopathologic factors like advanced T-stage, lymph node metastasis, lymphatic invasion, and venous invasion.

CONCLUSION

The findings of our study suggest that tumor budding is a promising independent prognostic factor and is correlated with poor clinicopathologic variables of esophageal carcinoma. The inclusion of tumor budding in future grading systems may help in improving currently available staging systems of esophageal carcinoma.

Clinical Significance and Prognostic Implications of Discontinuous Growth Pattern in Esophageal Adenocarcinoma: A Multi-Institutional Study

The significance of discontinuous growth (DG) of the tumor to include tumor deposits and intramural metastasis in esophageal adenocarcinoma (EAC) is unclear. Esophagectomy specimens from 151 treatment-naïve and 121 treated patients with EAC were reviewed. DG was defined as discrete (≥2 mm away) tumor foci identified at the periphery of the main tumor in the submucosa, muscularis propria, and/or periadventitial tissue. Patients' demographics, clinicopathologic parameters, and oncologic outcomes were compared between tumors with DG versus without DG. DGs were identified in 16% of treatment-naïve and 29% of treated cases ( P =0.01). Age, gender, and tumor location were comparable in DG+ and DG- groups. For the treatment-naïve group, DG+ tumors were larger with higher tumor grade and stage and more frequent extranodal extension, lymphovascular/perineural invasion, and positive margin. Patients with treated tumors presented at higher disease stages with higher rates of recurrence and metastasis compared with treatment-naïve patients. In this group, DG was also associated with TNM stage and more frequent lymphovascular/perineural spread and positive margin, but not with tumor size, grade, or extranodal extension. In multivariate analysis, in all patients adjusted for tumor size, lymphovascular involvement, margin, T and N stage, metastasis, neoadjuvant therapy status, treatment year, and DG, DG was found to be an independent adverse predictor of survival outcomes in EAC. DG in EAC is associated with adverse clinicopathologic features and worse patient outcomes. DG should be considered throughout the entire clinicopathologic evaluation of treatment-naïve and treated tumors as well as in future staging systems.

Molecular characteristics of multifocal esophageal squamous cell carcinomas to discriminate multicentric origin from intramural metastasis

Multifocal esophageal squamous cell carcinomas (ESCCs) can be diagnosed as of multicentric origin (MO) or intramural metastasis (IMM). We aimed here to accurately discriminate MO from IMM and explore the tumor immune microenvironment of multifocal ESCCs. Multifocal ESCCs were identified in 333 ESCC patients, and in 145 patients discrimination between MO and IMM was not possible by histopathological examination. Of the 145 patients, tissues of 14 were analyzed by whole-exome sequencing (WES) of 71 different tumor regions, and MO, IMM, and MO/IMM mixed groups were identified in three, ten, and one cases, respectively, based on the similarity of genomic architecture between or among different tumors from one patient. Further phylogenetic analyses revealed complex clonal evolution patterns in IMM cases, and tumor cells disseminated from the primary tumors to IMM tumors were independent of lymph node metastasis. The NanoString-based assay showed that immune cell infiltrates were significantly enriched, and that the immune and proliferation pathways were more activated, in large tumors than in small ones in MO but not IMM cases. Similarly, PD-L1 expression and the density of paratumoral CD8⁺ T cells were higher in large tumors than in small tumors in MO. Taken together, through analysis of the genomic and immune landscapes, our study has comprehensively characterized the heterogeneity and clonal relationship of multifocal ESCCs, which may be helpful in distinguishing MO from IMM, and for interpreting the immunotherapy responses for multifocal ESCC patients. © 2022 The Pathological Society of Great Britain and Ireland.

Surgical Treatment for Gastric Cancer

Surgery is an essential component of curative-intent treatment strategies for gastric cancer. However, the care of each patient with gastric cancer must be individualized based on patient and tumor characteristics. It is important that all physicians who will be caring for patient with gastric cancer understand the current best practices of surgical management to provide patients with the highest quality of care. This article aims to provide this information while acknowledging areas of surgical management that are still controversial.

Advanced esophagogastric junction cancer with brain, bone and gastric intramural metastases responding to combined modality therapy

A 63-year-old man was admitted to our hospital in March 2017 with dysphagia and right homonymous hemianopsia. We diagnosed him with esophagogastric junction cancer (adenocarcinoma) with metastases to the cerebral occipital lobe, bone, and lymph nodes. After one cycle of 5FU + cisplatin (FP), the brain metastasis was resected because of the hemiplegic symptoms he developed. Histology of the resected tissue showed no viable tumor cells. After three cycles of FP, the primary lesion and metastases were resolved. Upper gastrointestinal endoscopy revealed a scar at the primary site. This was considered a complete response (CR). In April 2018, CT revealed a mass at the cardia, which was considered as lymph node metastases with gastric wall invasion. Although two additional cycles of FP were administered for recurrent tumors, the efficacy was progressive. In August 2018, proximal gastrectomy and D1 + lymph node dissection were performed. The pathological diagnosis was gastric intramural metastases and lymph node metastases (ypN1 [2/22]). Weekly paclitaxel therapy was administered for three months after surgery. Two years have passed since the last surgery without recurrence. We report a rare case of esophagogastric junction cancer with brain, bone, and gastric intramural metastases that responded to combined modality therapy.

Cancer of unknown primary inside the gastric wall identified by endoscopic submucosal dissection

We report the rare and interesting case of cancer of unknown primary (CUP) detected by endoscopic submucosal dissection (ESD). A 67-year-old man with a gastric adenoma was referred to our hospital for endoscopic treatment. Esophagogastroduodenoscopy revealed a 15-mm submucosal tumor (SMT) at the lesser curvature of the lower gastric body, near the gastric adenoma. Both lesions were resected by ESD. Pathological examination showed that the SMT was a poorly differentiated adenocarcinoma with lymphatic tissue. Additional surgical resection was performed, and the lymph nodes were found to have the same pathological findings as the SMT. These lesions were diagnosed as CUP because the obvious primary site was not detected with additional examination. The patient has been followed up for 24 months without recurrence.

Intramural metastasis to the appendix from ascending colon cancer: a case report

Background

Intramural metastasis is rare in colorectal cancer, especially metastasis of ascending colon cancer to the appendix.

Case presentation

A 64-year-old man was admitted to our hospital for surgery for ascending colon cancer detected by medical examination. Colonoscopy identified a type-2 tumor in the ascending colon, which was diagnosed as adenocarcinoma. Abdominal computed tomography revealed focal thickening of the ascending colon and middle of the appendix and swelling of the lymph nodes around the ileocolic artery. The patient underwent laparoscopic right hemi-colectomy with D3 lymph node dissection. Histopathological findings revealed that the ascending colon cancer was moderately differentiated adenocarcinoma with lymphatic and vascular invasion (stage IIIB; pT3N2M0). Additionally, moderately differentiated adenocarcinoma was observed mainly in the submucosa and muscularis propria of the appendix, which was approximately 10 cm proximal to the ascending colon cancer. These findings indicated intramural metastasis to the appendix from the ascending colon cancer. The patient experienced recurrence with lung metastasis 2.5 years after the first surgery.

Conclusions

Intramural metastasis of ascending colon cancer to the appendix is extremely rare. Because the risk of recurrence and the prognosis for intramural metastasis has not been clarified, careful follow-up is recommended.

Significance of Intramural Metastasis in Patients with Esophageal Squamous Cell Carcinoma: An Indicator of Aggressive Cancer Behavior

BACKGROUND

Intramural metastasis (IM) is occasionally noted in patients with esophageal squamous cell carcinoma (ESCC). However, few recent studies have investigated the clinicopathological characteristics of IM and its survival impact. The present study aimed to clarify the clinicopathological and prognostic significance of IM in patients with ESCC.

METHODS

We retrospectively examined 918 consecutive patients who underwent curative intent esophagectomy for ESCC. IM was defined as a pathologically confirmed metastatic lesion, which was clearly separate from the primary tumor and located within the esophageal or gastric wall. The clinicopathological characteristics and survival impact of IM were evaluated. A propensity score-matched analysis was performed to further elucidate the prognostic impact of IM.

RESULTS

Among 918 patients, 46 (5.0%) had IM. Advanced tumors were significantly more frequent in patients with IM than in those without IM. The curative resection rate was lower in patients with IM (P = 0.001). Overall survival (OS) and disease-specific survival (DSS) were worse in patients with IM (both P < 0.001). In multivariate Cox proportional hazard analysis, IM presence was an independent poor prognostic indicator for OS and DSS (both P < 0.001). After propensity score matching, advanced tumors according to pathological N stage and lymphatic invasion were more frequent in patients with IM (P = 0.015 and 0.004, respectively). Additionally, OS and DSS were different between patients with and those without IM (both P = 0.002).

CONCLUSIONS

IM from ESCC is a local indicator of lymphatic invasion and advanced cancer, as well as an independent factor for poor prognosis.

Reduced Levels of miR-28 and miR-200a Act as Predictor Biomarkers of Aggressive Clinicopathological Characteristics in Gastric Cancer Patients

Background:

MicroRNAs (miRNAs) play critical roles in different pathological processes including cancer development and progression. To find novel molecular diagnostic and prognostic markers and promising therapeutic tools for gastric cancer (GC), we aimed to investigate the relationship of the expression levels of miR–28–5p or miR–200a–3p with the clinicopathological criteria and to explore their impacts on the progression of human GC.

Materials and Methods:

Quantitative RT–PCR was performed to analyze miR–28 and miR–200a expression in 60 GC and 60 non–GC tissue samples.

Result:

Our results revealed that the expressions of miR–200a and miR–28 were significantly downregulated in GC in comparison with non– GC tissues. Tumors with low miR–28 expression had larger tumor size, more advanced histological grade, and a higher incidence of lymph node and distal metastasis than the tumors with high miR–28 expressions. Furthermore, receiver operating characteristic (ROC) analyses demonstrate that the expression of miR–28 is a predictive biomarker allows predicting the histological grade, tumor size, and occurrence of nodal and distal metastases. We also found a significant inverse association between miR–200a expression and the rate of lymph node metastasis (p = 0.010, r = –0.334).

Conclusion:

Our findings suggest that the miR–28 and miR–200a have tumor–suppressor functions and may be considered as potential biomarkers for gastric cancer diagnosis and prognosis.

Prognostic Implications of miR-302a/b/c/d in Human Gastric Cancer

BACKGROUND

The microRNA (miR)-302 family consisting four members, miR-302a, miR-302b, miR-302c and miR-302d, plays an important role in diverse biological processes, and regulates many pathological changes, including cancer. However, the involvement of the miR-302 family into human gastric cancer (GC) remains unclear. The aim of this study was to investigate the expression patterns of miR-302a/b/c/d and determine their clinical significance in GC.

MATERIALS AND METHODS

Expression levels of miR-302a/b/c/d in 160 pairs of human GC and matched normal mucosa tissues were detected by quantitative real-time polymerase chain reaction. Then, the associations of miR-302a/b/c/d expression with various clinicopathological characteristics and patients' prognosis were statistically evaluated.

RESULTS

The expression levels of miR-302a, miR-302b and miR-302c in GC tissues were all significantly lower than those in matched normal mucosa (all P < 0.001), but miR-302d expression had no significant differences between cancer and normal groups. Additionally, GC patients with low miR-302a, miR-302b and miR-302c expression more frequently had positive lymph node metastasis (all P < 0.05), advanced TNM stage (all P < 0.05) and great depth of invasion (all P < 0.05). More importantly, low miR-302a, miR-302b and miR-302c expression in GC tissues were significantly associated with shorter disease-free and overall survivals of GC patients (all P < 0.05). Further multivariate analysis identified miR-302a, miR-302b and miR-302c as independent prognostic markers for GC patients.

CONCLUSIONS

GC patients with the decreased expression of miR-302a, miR-302b and miR-302c may had aggressive cancer progression and unfavorable prognosis. Further rigorous validation based on a large cohort of clinical cases should be performed.

Clinical presentation and treatment of gastric metastasis from other malignancies of solid organs

The aim of the present study was to analyze the clinicopathologic features and treatment outcomes of gastric metastasis from other malignancies of solid organs. A review was conducted of patients with metastatic tumors in the stomach from other malignancies of solid organs detected endoscopically at the Department of Surgery, Kochi Medical School, from January 1991 to December 2015. Seven patients (four men and three women), with a median age of 64 years (range, 42-71 years), had metastatic gastric tumors. Median tumor size was 7.3 cm (range, 2.5-12.0 cm). The primary malignancy leading to metastatic tumors in the stomach was esophageal cancer in three patients, breast cancer in two patients, renal cell carcinoma in one patient, and ovarian cancer in one patient. Gastric metastasis presented as solitary lesions in six patients and as multiple lesions in one patient. Four patients had solitary gastric metastasis, whereas three had multiple metastases in other organs. The median tumor size was significantly smaller in patients with solitary rather than multiple metastases (4.6 vs. 12.0 cm, respectively; P=0.038). Three patients received systemic therapy and four underwent surgical resection of the metastatic tumor, and of these, only one was alive 58 months after surgery. Clinicians should be aware of the possible existence of metastatic gastric cancer, especially in breast carcinoma and esophageal cancer. Surgical resection may considerably improve patients' quality of life, and could be of benefit when there is a risk of bleeding and/or a solitary metastasis.

Multiphoton microscopy for label-free identification of intramural metastasis in human esophageal squamous cell carcinoma

For complete removal of cancerous tissue in esophageal squamous cell carcinoma (ESCC), intramural metastasis (IM) should be identified preoperatively or intraoperatively. Here, multiphoton microscopy (MPM) was introduced for label-free identification of IM in the esophageal wall, by a combination of two-photon excited fluorescence (TPEF), second harmonic generation (SHG) imaging, and spectral analysis. Three-dimensional (3D) imaging of the IM region was also performed. Quantitative parameters, including 3D fiber orientation, were measured by 3D-weighted orientation vector summation. Overall, MPM showed the potential to identify IM. With the development of the advanced MPM endoscope, clinical identification of IM by MPM will be possible.

Roles of ZIC family genes in human gastric cancer

The human zinc finger of the cerebellum (ZIC)family genes, comprised of 5 members, which are vertebrate homologues of the Drosophila odd-paired gene and encode zinc-finger transcription factors, have been shown to be involved in various diseases, including cancer. However, the roles of ZICs in human gastric cancer (GC) have not yet been fully elucidated. This study aimed to investigate the expression patterns of ZICs and determine their clinical significance in GC. The mRNA and protein expression levels of ZIC1-5 were detected by RT-qPCR and western blot analysis, respectively using 60 pairs of human GC and matched normal mucosa tissues. The expression pattern and subcellular localization of ZIC1 in 160 pairs of human GC and matched normal mucosa tissues were verified by immunohistochemistry. Moreover, the associations of ZIC1 expression with various clinicopathological characteristics and patient prognosis were evaluated. The mRNA and protein expression levels of ZIC1 were both found to be significantly decreased in the GC tissues compared to matched normal mucosa tissues (GC vs. normal, 2.15±0.69 vs. 4.28±0.95; P<0.001); however, ZIC2-5 expression exhibited no significant difference between the cancer and normal tissue samples. In addition, the downregulation of ZIC1 (ZIC1-low) was more frequently observed in the GC tissues with positive lymph node metastasis (P=0.006), an advanced TNM stage (P<0.001) and a great depth of invasion (P=0.01). Notably, a low ZIC1 expression was significantly associated with a poor disease-free and overall survival. Furthermore, multivariate analysis revealed that ZIC1 expression was an independent prognostic marker for patients with GC. In conclusion, among the human ZIC family genes, the dysregulation of ZIC1, but not of ZIC2, ZIC3, ZIC4 and ZIC5, may play a crucial role in the progression of GC. ZIC1 may thus serve as a novel molecular marker to predict the progression, survival and relapse of patients with GC.

Intramural metastasis of T1 rectal cancer: report of a case report

BACKGROUND

Intramural metastasis (IM) is extremely rare in colorectal cancer, although it often occurred in esophageal cancer.

CASE PRESENTATION

We report a rare case of T1 rectal cancer with IM which was successfully resected by laparoscopic surgery. A 62-year-old man was admitted to our institution for the treatment of rectal cancer detected by medical examination. Colonoscopy revealed two tumors in the rectum: a type II rectal cancer of 2 cm in diameter located 5 cm proximal to the anal verge and a submucosal tumor of 1 cm in diameter located approximately 1.5 cm proximal to the rectal cancer. Abdominal computed tomography (CT), magnetic resonance imaging (MRI), and transrectal ultrasonography indicated the rectal cancer invaded into the submucosal layer with no metastasis to regional lymph nodes or distant organs. The patient underwent laparoscopic intersphincteric resection.Histopathological analysis revealed that the rectal cancer was moderately differentiated adenocarcinoma (stage I; pT1N0M0 according to the 7th edition of UICC) with severe lymphovascular invasion (ly1, v3) and that the submucosal tumor was composed of moderately differentiated adenocarcinoma proliferating within the muscularis propria. A number of features of the submucosal tumor indicated that this was an IM of the rectal cancer: clearly distinct location from the rectal cancer, growth predominantly within the muscularis propria, similar structural and cellular heterogeneity, and the presence of tumor emboli within vascular vessels. The patient was postoperatively followed for more than 4 years without any sign of recurrence.

CONCLUSIONS

To the best of our knowledge, this is the first report of the T1 rectal cancer with IM.

Gastric cancer with multiple intramural metastases and metastasis to the small intestine which eventually developed Trousseau's syndrome: report of a case

Here we report a rare case of Trousseau's syndrome in a patient with gastric cancer with multiple intramural metastases and metastasis to the small intestine. A 70 year-old male complaining of appetite loss and weight loss of 7 kg within 3 months was admitted to hospital. Esophagogastroduodenal endoscopy revealed an advanced gastric cancer at the pylorus almost occluding the outlet of the stomach, and multiple ulcerative lesions throughout the stomach. A biopsy showed poorly differentiated adenocarcinoma. The patient underwent total gastrectomy. During surgery, part of the distal ileum was found to be abnormally firm and approximately 1 m of the ileum with the cecum colon was resected. Pathologic examination confirmed poorly differentiated adenocarcinoma at the pylorus and multiple intramural metastases in most other areas of the stomach. Lymph node metastases were confirmed in 12 out of 40 harvested regional lymph nodes including one positive paraaortic lymph node. The resected ileum contained multiple tumors with ulceration. Massive lymphatic invasion in the stomach and the small intestine was observed, which strongly suggested lymphatic spread of the gastric cancer. The patient was discharged on post-operative day 21; however, 2 months after surgery, he developed multiple cerebral thromboembolisms and died 2 weeks later.