Positive alpha-fetoglobulin in a case of gastric carcinoma

A unique case of an alpha-fetoprotein-producing lung cancer with testicular metastasis

Alpha-fetoprotein (AFP)-producing primary lung tumours are rare; we present the first case of an AFP-producing lung tumour with metastasis to testes. The patient, a 72-year-old man, presented with a history of flu-like symptoms and abdominal pain. On examination he had a hard, tender left scrotal mass. Imaging showed a 4.4-cm right lower lobe lung mass and the serum-AFP was raised (1189 ng/mL). Left orchidectomy excised a necrotic tumour. Microscopy showed complete hemorrhagic infarction and immunohistochemistry showed a lack of staining for AFP. Serum-AFP rose 3 days post-orchidectomy to 1466 ng/mL. The patient subsequently developed melaena and died. Autopsy revealed a 9 × 5-cm necrotic right lower lobe lung tumour. Immunohistochemistry showed the tumour cells reacted with a pan-cytokeratin antibody and less than 5% expressed AFP. Bilateral adrenal tumour deposits were also identified in addition to those in the bowel and spleen. The expression of AFP solely in the lung lesion and lack of expression in both testes, together with a rise in serum-AFP post-orchidectomy and the bilateral adrenal metastases, is overwhelming evidence for the reversal of the usual situation: a poorly differentiated AFP-secreting metastatic lung adenocarcinoma.

Primary adenocarcinoma of the stomach in von Recklinghausen's disease with high serum levels of multiple tumor markers: a case report

INTRODUCTION

Gastric tumors in patients affected by neurofibromatosis type 1 are usually carcinoids or stromal tumors, and rarely adenocarcinomas.

CASE PRESENTATION

We report a case of an adenocarcinoma of the stomach in a 53-year-old Japanese man with neurofibromatosis type 1. An abdominal computed tomography scan and ultrasonography showed tumors in his liver. Gastric fibroscopy revealed a Borrmann type III tumor on his cardia that had spread to his esophagus and was highly suspicious for malignancy. Multiple biopsies showed an adenocarcinoma of the stomach, which was evaluated as gastric cancer, stage IV. Chemotherapy with TS-1 was performed. Our patient died four weeks after initial admission. Histological examination of a liver needle biopsy showed metastatic adenocarcinoma in his liver.

CONCLUSION

To the best of our knowledge, high serum levels of α-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 72-4, resulting from gastric adenocarcinoma, have not been reported previously in a patient with neurofibromatosis type 1. We report this rare case along with a review of the literature.

The role of serum alpha-fetoprotein estimation in the diagnosis and management of hepatocellular carcinoma

Forty years after its discovery, estimation of serum AFP remains a useful test for clinicians involved in management of patients with HCC or chronic liver disease. The test, when used with the conventional cut-off point of 500 ng/mL, has a sensitivity of about 50% and a specificity of more than 90% in detecting the presence of HCC in a patient with coexisting liver disease. New tests that can significantly increase the specificity at lower levels (i.e., between 10 and 500 ng/mL) are available but have, to date, been too complex to be widely applied in clinical practice. Serum AFP estimation may also be useful in monitoring response to therapy, particularly as more effective systemic regimens are becoming available. Indeed, there is preliminary evidence that changes in serum AFP may be a more accurate and sensitive way of determining the degree of response to treatment than conventional imaging procedures that rely on physical determination of tumor size. It may, perhaps, be time to add changes in serum AFP to the conventional imaging criteria for assessing response in clinical trials.

Alpha-fetoprotein-producing carcinoma of the colon: report of a case

We report herein the rare case of a 67-year-old man in whom alpha-feto-protein (AFP)-producing carcinoma originated in the transverse colon, describing the clinical course of the patient and the histological features of the tumor. At the age of 63, the patient had been diagnosed as having sigmoid colon carcinoma, and surgery was carried out. However, 4 years later, his fecal occult blood test was positive, and further investigation revealed a transverse colon carcinoma with liver metastasis. The serum AFP measured preoperatively was 10978 ng/ml. Resection of the transverse colon and a liver biopsy were performed, following which his serum AFP level decreased to 4804 ng/ml. Histology of the ulcerated lesion in the transverse colon showed a poorly differentiated adenocarcinoma with a medullary growth pattern. Using an immunohistochemical staining method, AFP-producing cells were detected in the transverse colon carcinoma and the liver metastasis. Based on our experience of this patient and a review of the literature on the few cases previously reported, we conclude that AFP-producing coloretal carcinoma has a tendency to produce blood-borne metastasis and to be associated with a poor prognosis.

Alpha-fetoprotein-producing gastric carcinoma with enteroblastic differentiation

BACKGROUND

Alpha-fetoprotein (AFP) is a useful tumor marker for hepatoma and yolk sac tumor. Recently, elevations of serum AFP were reported in patients with other malignancies, especially gastric cancers. Two distinct tumor morphologies, hepatoid and clear cell, have been correlated with AFP production.

METHODS

Two patients with AFP-producing gastric carcinoma were evaluated with immunohistochemical, ultrastructural, and biochemical studies.

RESULTS

In Patient 1, the primary and metastatic carcinomas consisted homogeneously of tubulopapillary carcinoma with clear cytoplasm. In Patient 2, the cancer was composed of three different areas: tubulopapillary carcinoma with clear cytoplasm, tumor cartilage, and so-called hepatoid carcinoma. The morphologic characteristics of tubulopapillary carcinoma with clear cytoplasm were similar to those of the developing gut epithelium at the stage of 2-4 months' gestation. The elution patterns of the serum AFP on lectin-affinity sepharose column study also suggested a correlation with fetal gut differentiation.

CONCLUSIONS

AFP-producing clear cell gastric carcinomas are differentiated into fetal intestine. One patient also had hepatocytic and cartilaginous differentiation, indicative of a blastomatous characteristic of the tumor. These tumors arose in association with intestinal metaplasia.

Hepatoid adenocarcinoma of the stomach. A clinicopathologic and immunohistochemical analysis

BACKGROUND

The clinicopathologic and immunohistochemical features of the primary gastric hepatoid adenocarcinomas still remain unclear.

METHODS

The authors evaluated 28 hepatoid adenocarcinomas (HC) of the stomach on the basis of characteristic histologic features resembling hepatocellular carcinoma, which were selected from the 7200 cases of primary gastric carcinoma in their files. Additionally, 22 alpha-fetoprotein (AFP)-positive adenocarcinomas without hepatoid features (APC) were also selected.

RESULTS

The HC cases fell into the following two groups: HC with AFP-positive tumor cells (Group 1; 15 cases) and HC without AFP-positive cells (Group 2; 13 cases). Histologically, the glycogen granules and hyaline globules were common features in HC. The incidence of a venous invasion of HC (Groups 1 and 2) was higher than that of APC (Group 3). There were no significant differences among the three groups regarding clinical features, macroscopic features, and the incidence of lymphatic permeation. An immunohistochemical study showed that HC had differentiation into various directions. As for the advanced carcinomas, the 5-year survival rates of patients with HC (Groups 1 and 2) and those with APC (Group 3) were 11.9% (21.4%, 8.3%) and 38.2%, respectively. The prognosis of Group 1 was similar to that of Group 2, but was poorer than that of Group 3.

CONCLUSIONS

The findings suggested that HC, as shown by its characteristic histologic features, had a poor prognosis whether producing AFP or not, and that HC should therefore be distinguished from AFP-positive carcinoma without hepatoid features.

A primary lung carcinoma producing alpha-fetoprotein, carcinoembryonic antigen, and human chorionic gonadotropin. Immunohistochemical and biochemical studies

This article documents a patient with lung carcinoma that produced three oncofetal antigens including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and human chorionic gonadotropin (hCG). Serum AFP, CEA, and hCG-beta-subunit were extremely high--118,000 ng/ml, 133 ng/ml and 0.9 ng/ml, respectively. Immunohistochemical staining of these tumor markers revealed that these proteins were present in different cells. The pattern of lectin affinity electrophoresis of AFP resembled that of hepatocellular carcinoma. Also investigated was the reactivity of serum CEA to monoclonal antibodies against peptide or sugar moieties. Serum CEA values measured by antipeptide monoclonal antibodies were higher than those measured by antisugar monoclonal antibodies. The demonstration of AFP, CEA, and hCG in different tumor cells suggests that three genomes were not reactivated together in a cell, and the lung carcinoma probably consisted of at least three clones of cancer cells with different phenotypes.

Histologic and immunohistochemical studies of alpha-fetoprotein (AFP)-producing gastric carcinoma

Five gastric adenocarcinomas and their metastatic nodules in the liver with high serum AFP levels were examined by histologic and immunohistochemical methods. The examination revealed that AFP-producing stomach cancers were poorly differentiated carcinoma cells, especially with medullary arrangements, or pleomorphic or multinucleated giant cells. Well-differentiated papillotubular adenocarcinoma tissues on the glandular epithelium were not stained with anti-AFP. One out of the five AFP-producing adenocarcinomas with medullary patterns resembled liver cell carcinoma on light microscopy. However, an ultrastructural study showed tumor cells of the intestinal type, since the cells possessed a ductal lumina with abundant microvilli and a secretory granules. The findings suggest that the tumor cells differentiated in an intestinal direction rather than hepatic direction. In addition, we noted three simultaneously CEA-positive cases out of five AFP-producing gastric carcinomas. CEA was strongly stained in well differentiated adenocarcinoma tissues in the glandular epithelium or in areas of medullary type carcinoma invasion. However, CEA was not detected in undifferentiated carcinoma cells.

Alpha-fetoprotein and human chorionic gonadotropin-producing lung cancer

A 73-year-old man had primary lung cancer that produced both alphafetoprotein (AFP) and human chorionic gonadotropin (HCG). The preoperative serum AFP level of 1039 ng/ml decreased to the normal range 8 weeks after surgery. The preoperative serum HCG level of 11 mIU/ml, which temporarily decreased to the normal range after operation, soon increased thereafter. The serum HCG level decreased, however, to the normal range after postoperative mediastinal radiation therapy. During relapse, only the serum HCG level increased gradually to 26,000 mIU/ml 7 weeks before his death. The lung cancer was classified histologically as poorly differentiated adenocarcinoma. Immunohistochemically, AFP was detected in the mononuclear tumor cells of the primary tumor in the lung, and HCG was found in the giant cells of the subcarinal metastatic lymph node. The concanavalin A non-reactive fraction rate for AFP was 81.3%, and appeared to differ from those of hepatocellular carcinoma and yolk sac tumor.

Increased alpha-fetoprotein concentration in association with ileal adenocarcinoma complicating Crohn's disease

A considerably raised serum alpha-fetoprotein concentration was found in a patient with an ileal adenocarcinoma. alpha-fetoprotein was shown in both the primary tumour and the hepatic metastases by an immunoperoxidase technique. A raised alpha-fetoprotein concentration in association with ileal adenocarcinoma has not been described previously, and it is notable that the first such case should occur as a complication of longstanding Crohn's disease.

Production of alpha-fetoprotein, normal serum proteins, and human chorionic gonadotropin in stomach cancer: histologic and immunohistochemical analyses of 35 cases

By immunoperoxidase histochemical staining of formalin-fixed paraffin-embedded sections, the production of alpha-fetoprotein(AFP), albumin(ALB), transferrin(TF), alpha-1-antitrypsin(AAT), and human chorionic gonadotropin(HCG) was examined in 35 operatively resected stomach cancers with elevated serum AFP levels (higher than 20 ng/ml as determined by radioimmunoassay). Cells positive for AFP were found in 19 cases (54%). In 29 cases (83%), some tumor cells contained normal serum proteins (ALB, TF, or AAT). All 19 tumors with AFP-positive cells also stained positively for two or three kinds of normal serum proteins. In some cases, AFP and normal serum proteins were localized in the same cells. There were two cases in which metastatic tumors produced AFP, whereas the primary sites did not. In nine cases (26%), HCG was present in tumor cells and HCG- and AFP-positive cells were coexistent in six tumors. Histologic examination of AFP-producing stomach tumors revealed medullary or papillotubular arrangements with marked nuclear atypia and eosinophilic granular or clear cytoplasms containing no glycogen or mucin. Some tumors with medullary patterns resembled liver cell carcinomas. Concordant phenotypic expression of AFP and normal serum protein production appears to be a general feature of AFP-producing tumors such as liver cell carcinoma, yolk sac tumor, and stomach cancer.

Primary lung cancer producing alpha-fetoprotein: a case report

A case of primary lung cancer that produced both alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) is presented. Alphafetoprotein in the supernatant of tissue extract from the primary lesion amounted to more than 40 microgram/ml, and its exact origin from tumor tissues was confirmed by the immunofluorescent study. We suppose that since the lung is one of the foregut derivatives it is not unlikely for lung cancer cells to produce AFP as well as CEA.

Serum alpha-fetoprotein-positive gastric carcinoid with liver metastasis

The patient was a 60-year-old Japanese male. He complained of epigastralgia and right chest pain of 4 month's duration, and general malaise, nausea and vomiting of 2 month's duration. Physical examination revealed on the right third rib a tender mass with a diameter of 2 cm and hepatomegaly with a multi-nodular surface and red palms. There were no signs of carcinoid syndrome, such as cutaneous flushing. Laboratory examinations disclosed certain biochemical alterations; alkaline phosphatase 810 IU/l, gamma-glutamyl transpeptidase (gamma-GTP) 2090 IU/l, carcinoembryonic antigen (CEA) 23.5 ng/ml and alpha-fetoprotein (AFP) 6,800 ng/ml. Both HBs-Ag and HBs-Ab were negative. The patient died in a uremic state, with rapid increases of jaundice and ascites. Autopsy revealed gastric carcinoid with extensive metastases to the liver and the bone marrow. Tumor cells showed argyrophilia but not argentaffinity. Immunofluorescence specific for AFP was positive in the hepatocytes, particularly those adjacent to the metastatic tumor cells but not in the tumor cells, either primary or secondary. 79 cases reported in Japan of serum AFP-positive malignant tumor other than hepatocellular carcinoma and certain other malignancies of germ cell origin are reviewed and discussed.

Archenteronoma (yolk sac tumors)

Ten cases of archenteronoma are reviewed with a follow-up between 2 mo and 7 yr. Their presentation was similar to that of rhabdomyosarcoma except for testicular tumors that may present as a hydrocele. A good prognosis was found with tumors amenable to primary resection and chemotherapy. Other tumors are best treated initially with chemotherapy before relatively conservative surgery, radiotherapy being used either pre- or postoperatively.

Serum Alpha Fetal Protein in a Three Year Old Child with Hepatoma

A 3 year old child with primary hepatocellular carcinoma and high AFP concentrations is described. Following hemihepatectomy, a sharp decrease and return to normal of serum AFP concentrations indicated the completeness of the surgical procedure. Repeat-normal serum AFP concentrations (less than 19 ng/ml), found during a three year follow-up, correlated well with the absence of clinical, laboratory and x-ray evidence of tumor recurrence. The differential diagnosis of abnormal AFP concentrations in childhood is discussed, and the importance of the AFP assay in the follow-up of post-hemihepatectomy patients for the assessment of the completeness of the surgical procedure, the prognosis, and the early detection of tumor recurrence is stressed.

Alpha-fetoprotein

Despite all the information about AFP presented, a great deal still needs to be discovered especially in pregnancy. Geographical and racial differences remain to be elucidated. Similarly, differences in obstetric population in Helsinki and Baltimore, for example, are only now being studied. Sex differences may exist; Lardinois and associates195 cited a higher level of AFP in male than female fetuses. The important questions that need to be answered are whether AFP assays can help improve the other half of prenatal care- that directed to the fetus- and whether the AFP model can help enhance our understanding of the similarities and differences of fetal and cancer cells.

[Carcinofetal antigens. I. alpha-fetoprotein (author's transl)]

Alpha-fetoprotein (AFP) is an alpha1-glycoprotein (M.W. about 65000) appearing in the fetal serum of most mammals including man during the early stages of pregnancy; 4 weeks after birth it disappears altogether or exists at very low concentrations as in the normal adult. AFP is formed in the yolk sac, the fetal liver and the gastro-intestinal tract. One of its physiological functions in fetal life is supposed to be the protection of the fetus from maternal oestrogens (oestrophilic property). The clinical significance of AFP is based on the regular and increasing production in primary liver cell carcinoma, less frequently in teratogenetic tumors where it serves as a control of therapy and course of the disease. Less frequent, minor and temporary increases in the AFP serum level occur in several primary tumors with secondary liver involvement, and in inflammatory gastro-intestinal diseases, e.g. of the liver (hepatitis, cirrhosis). AFP has an increasing importance in gynecology (gestational age, fetal distress syndrom, malformations, hydatidiform mole/chorion carcinoma). The physico-chemical properties of AFP are widely known. Both fetal and tumor AFP appear to be immunologically and biochemically identical, as are that of tissue and biological fluids. The differences observed (variants, microheterogeneity) depend mainly on the different content of sialic acid. An antigenetic relationship exists, between the AFP of most species. The immunodiffusion (Ouchterlony) is the most frequently used but relatively insensitive test (1-5 mug/ml) in finding AFP, whereas the radioimmunoassay is the most sensitive one (up to 0,25 ng/ml) and permits the determination of normal serum levels in adults (below 20 ng/ml). The serum concentration in healthy pregnant women lies up to 500 ng/ml, in patients with hepatitis, liver cirrhosis and other liver diseases mostly under 3 mug/ml, whereas in those with primary liver cell carcinoma levels up to and above 600 mg-percent have been found.

Serum alpha-fetoprotein (AFP) in benign and malignant gastrointestinal diseases: evaluation of an immunoenzymatic assay

A quantitative immunoenzymatic assay has been developed for alpha-fetoprotein which is sensitive and specific. Seventy-eight percent of United States hepatoma patients have detectable serum alpha-fetoprotein elevations over 50 ng/ml, whereas only 2 of 93 other gastrointestinal tumors were positive. Thirteen percent of patients with acute viral hepatitis, 44% of patients with massive hepatic necrosis, and 23% of patients with chronic active hepatitis had measurable serum alpha-fetoprotein concentrations. However, patients with non-viral acute or chronic liver disease were largely alpha-fetoprotein negative and alpha-fetoprotein was undetectable on multiple postoperative samples from 6 patients after hepatic lobectomy in the rapidly regenerating phase. Therefore, alpha-fetoprotein elevations in nonmalignant liver diseases are not due solely to hepatic regeneration but appear to be related to viral injury. The immunoenzymatic assay does not require purified antigen or radioisotope equipment and can detect and quantitate clinically significant alpha-fetoprotein levels greater than 50 ng/ml.

Alpha fetoprotein in metastatic gastric carcinoma

Two patients with primary gastric carcinoma and multiple liver secondaries who developed alpha fetoprotein in the serum are reported. Both had clinical features which were initially suggestive of primary liver cell carcinoma. Fetoprotein levels fell after ligation of the hepatic artery in one patient. Alpha fetoprotein may occur in the serum of adult patients with tumours of the foregut, other than primary liver cell carcinoma, when such tumours have metastasized to the liver.