Gastric composite tumor of alpha fetoprotein-producing carcinoma/hepatoid adenocarcinoma and endocrine carcinoma with reference to cellular phenotypes

Hepatoid adenocarcinoma of the stomach with neuroendocrine differentiation: A case report and review of literature

BACKGROUND

Both hepatoid adenocarcinoma of the stomach (HAS) and neuroendocrine differentiation (NED) are rare histological subtypes of gastric cancer with unique clinicopathological features and unfavorable outcomes. HAS with NED is even rarer.

CASE SUMMARY

Here, we report a 61-year-old man with HAS with NED, as detected by gastric wall thickening by positron emission tomography/computed tomography for a pulmonary nodule. Distal gastrectomy was performed, and pathological examination led to the diagnosis of HAS with NED. However, liver metastases occurred 6 mo later despite adjuvant chemotherapy, and the patient died 27 mo postoperatively.

CONCLUSION

We treated a patient with HAS with NED who underwent adjuvant chemotherapy after radical surgery and still developed liver metastases. We first report the detailed processes of the treatment and development of HAS with NED, providing an important reference for the clinical diagnosis and treatment of this condition.

Hepatoid adenocarcinoma of the stomach with neuroendocrine differentiation: A case report and review of literature

BACKGROUND

Both hepatoid adenocarcinoma of the stomach (HAS) and neuroendocrine differentiation (NED) are rare histological subtypes of gastric cancer with unique clinicopathological features and unfavorable outcomes. HAS with NED is even rarer.

CASE SUMMARY

Here, we report a 61-year-old man with HAS with NED, as detected by gastric wall thickening by positron emission tomography/computed tomography for a pulmonary nodule. Distal gastrectomy was performed, and pathological examination led to the diagnosis of HAS with NED. However, liver metastases occurred 6 mo later despite adjuvant chemotherapy, and the patient died 27 mo postoperatively.

CONCLUSION

We treated a patient with HAS with NED who underwent adjuvant chemotherapy after radical surgery and still developed liver metastases. We first report the detailed processes of the treatment and development of HAS with NED, providing an important reference for the clinical diagnosis and treatment of this condition.

Hepatoid Adenocarcinoma of the Lung

Hepatoid adenocarcinoma of the lung (HAL) is an comparatively rare malignant tumor originating from the lung with shorter survival. HAL morphologically and pathologically exhibits hepatocellular carcinoma (HCC)-like characteristics, while its clinical features resemble pulmonary adenocarcinoma. High concentration of alpha-fetoprotein (AFP) is often detected in the serum of HAL patients with no hepatic occupying lesion. Patients with AFP-negative HAL survive a few months longer than those with positive AFP test. HAL is a rare type of carcinoma, so there is a lack of systematic and extensive statistical research. The treatment strategy for HAL is similar to common lung adenocarcinoma. Complete surgical resection and adjuvant chemotherapy are the current major treatments for HAL patients. There are also a few of case reports suggesting that HAL patients may benefit from immunotherapy and targeted therapy. This review focuses on the clinical and pathological features, immunohistochemical staining characteristics, treatment and prognosis of HAL.

Both the serum AFP test and AFP/GPC3/SALL4 immunohistochemistry are beneficial for predicting the prognosis of gastric adenocarcinoma

BACKGROUND

Both gastric adenocarcinoma with primitive enterocyte phenotype (GAPEP) (including hepatoid adenocarcinoma) and alpha-fetoprotein (AFP)-producing gastric adenocarcinoma have poor prognoses. However, the value of the serum AFP test and AFP/glypican-3 (GPC3)/spalt-like transcription factor 4 (SALL4) immunohistochemistry is still not clear, and these two methods have not yet been thoroughly compared.

METHODS

We collected 421 consecutive non-neoadjuvant surgically or endoscopically resected gastric adenocarcinoma patients with serum AFP results before surgery (group A). We divided these cases into serum AFP-high (sAFP-H) and serum AFP-normal (sAFP-N) by serum AFP levels, and into GAPEP (expressing AFP, GPC3, or SALL4) and non-GAPEP (nGAPEP) by AFP/GPC3/SALL4 immunohistochemistry results. We also collected 12 non-resected gastric adenocarcinoma patients with serum AFP ≥ 7 ng/mL before treatment (group B). We analyzed these patients' clinicopathological characteristics and prognoses.

RESULTS

Seventeen (4.04%) patients in group A were sAFP-H. These patients were younger and mainly had tubular adenocarcinoma with later pT (P = 0.014) and pN (P = 0.047) categories and more lymphovascular invasion (P < 0.001), perineural spread (P = 0.008), and metastases or recurrence (P < 0.001). For immunohistochemistry, 34 (8.08%) cases were GAPEP, and GAPEP cases also had later pT categories than nGAPEP cases (P = 0.001). Most group B patients with elevated serum AFP (especially > 1000 ng/mL) had simultaneous metastases, mainly liver metastases. Both the serological method and immunohistochemical method were useful for predicting prognosis (AUC _sAFP = 0.625, AUC _A/G/S-IHC = 0.723, z statistic = 1.726, P = 0.084). The serum AFP level (especially > 1000 ng/mL) is more specific (100%), and immunohistochemistry is more sensitive (50%).

CONCLUSION

Both the serum AFP level and immunohistochemical expression of AFP/GPC3/SALL4 can be used to indicate a poor prognosis for gastric adenocarcinoma.

Establishment and characterization of the GC-030-35 cell line derived from gastric hepatoid adenocarcinoma

Purpose

Gastric hepatoid adenocarcinoma is a rare subtype of primary gastric cancer and is a high-grade form of malignancy. However, the pathogenesis and molecular biology of gastric hepatoid adenocarcinoma remain poorly understood. The aim of this study was to establish and characterize a new human gastric hepatoid adenocarcinoma cell line, GC-030-35.

Materials and methods

The GC-030-35 cell line was established from tumor cells from a 58-year-old Chinese man with gastric hepatoid adenocarcinoma. The cultured cells underwent immunocytochemistry and flow cytometry to confirm the tumor cell phenotype. RNA sequencing was performed to analyze the differences in gene expression between GC-030-35 cells compared with normal gastric epithelial cells. A zebrafish assay was performed. Gene enrichment analysis and interrogation of the bioinformatics databases, the Gene Ontology (GO) database and the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, were used for pathway analysis.

Results

Flow cytometry analysis of the GC-030-35 cells showed a positive expression rate for CD44+ of 10.7%, high cell clonality, an average plating efficiency of 32%, cell-doubling time of 29.2 hours, and cell proliferation for >15 generations in serial culture. The zebrafish assay showed the ability of the GC-030-35 cells to proliferate, promote angiogenesis, and metastasize. RNA sequencing identified the functional clustering of 6,601 differentially expressed genes of GC-030-35, which were significantly different when compared with nonneoplastic gastric epithelial cells. Pathway enrichment analysis and interrogation of the GO and KEGG bioinformatics databases identified genes for microbial metabolism in diverse environments (63 genes), metabolism of xenobiotics by cytochrome P450 (CYP450; 25 genes), and the drug metabolism cytochrome P450 (28 genes).

Conclusion

A human gastric hepatoid adenocarcinoma cell line, GC-030-35, was developed and characterized by comparison with normal gastric epithelial cells. Bioinformatics and gene analysis data showed that the CYP450 gene was significantly differentially expressed by GC-030-35 cells.

Clinicopathological Characteristics and Prognosis of Hepatoid Adenocarcinoma of the Stomach: Evaluation of a Pooled Case Series

Hepatoid adenocarcinoma of the stomach (HAS) is an extremely rare and unique gastric malignancy. The present study aimed to examine the relevance of the clinicopathological characteristics of HAS with patient prognosis. We retrospectively reviewed clinical data of 34 HAS patients treated at our institution between January 2010 and December 2016, as well as 294 cases reported prior to 2017 in research databases. Among these patients, 45.6% (115/252) had lesions in the gastric antrum and 77.0% (235/305) were male. Elevated levels of serum alpha-fetoprotein (AFP) were detected in most patients (75/93, 80.6%). Vascular invasion (199/286, 69.6%), lymph node metastasis (222/283, 78.4%), and preoperative distant metastasis (121/328, 36.9%) were commonly observed. The 5-year disease-free survival (DFS) and disease-specific survival (DSS) were 20.7% and 29.2%, respectively. DFS and DSS of patients receiving neoadjuvant therapy were significantly higher than those of patients receiving postoperative adjuvant therapy [DFS: P<0.001, hazard ratio (HR)=-1.831, 95% confidence interval (CI): 0.060-0.429; DSS: P<0.001, HR=-2.185, 95% CI: 0.032-0.401]. In conclusion, HAS exhibits distinct clinicopathological characteristics and a strikingly worse prognosis when compared with common gastric cancer. Complete surgery, early pTNM stage, and adjuvant therapy may predict a more favorable prognosis. Neoadjuvant therapy is strongly recommended for patients with lymph node metastasis or/and preoperative distant metastasis.

Gastric Adenocarcinoma with Dual Differentiation toward Neuroendocrine and α-Fetoprotein-Producing Features: Report of 2 Cases

Some gastric carcinomas show composite features of neuroendocrine carcinoma (NEC) and α-fetoprotein (AFP)-producing carcinoma, which are very rare; only a few cases have been reported to date. We reviewed an additional 2 such cases of gastric carcinoma, which were both advanced aggressive tumors showing regional lymph node metastasis and distant metastasis. Both cases were accompanied by ordinary adenocarcinoma forms, implying that they had preceded the NEC and AFP-producing carcinoma components. A distinctive feature was the finding suggestive of dual differentiation of tumor cells to neuroendocrine and AFP-producing phenotypes, which was identified even in the metastatic tumor in the regional lymph node. Because both tumors predominantly showed poorly differentiated forms, the final pathologic diagnosis must rely on the immunohistochemistry. Pathologists should always keep in mind the existence of such tumors for the correct diagnosis of some gastric carcinomas with specific phenotypes, especially in pathologic diagnosis on biopsy.

Hepatoid adenocarcinoma of the stomach--proper identification and treatment remain a challenge

OBJECTIVE

The term hepatoid adenocarcinoma (HAC) of the stomach was introduced three decades ago with the observation of high serum α-fetoprotein (AFP) levels in some gastric adenocarcinoma patients. This very rare gastric cancer patient subgroup is likely frequently misdiagnosed.

MATERIAL

Two patients who were recently diagnosed with HAC of the stomach at our institution are presented. We also performed a structured literature search and reviewed pertinent articles to provide knowledge to improve the proper identification, diagnosis and management of patients with gastric HAC.

RESULTS

HAC is a rare subgroup of gastric carcinoma with poor prognosis. Clinical management of this population may be challenging. The scientific literature is largely based on very small patient series or case reports, and the evidence for proper decision making and management is considered weak.

CONCLUSION

All physicians involved in the diagnosis and treatment of patients with gastric cancer should pay attention to this rare subgroup to improve identification.