Gastric adenosquamous carcinoma producing granulocyte-colony stimulating factor: a case of a rare malignancy

Imaging findings of granulocyte colony-stimulating factor-producing tumors: a case series and review of the literature

Granulocyte colony-stimulating factor (G-CSF)-producing tumors have an aggressive clinical course. Here, we report five cases of G-CSF-producing tumors and review the literature, focusing on imaging findings related to tumor-produced G-CSF. In addition to our cases, we identified 30 previous reports of G-CSF-producing tumors on which ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT, bone scintigraphy, or evaluation of bone marrow MR findings was performed. White blood cell count, serum C-reactive protein, and serum interleukin-6 were elevated in all cases for which these parameters were measured. G-CSF-producing tumors presented large necrotic masses (mean diameter 83.2 mm, range 17–195 mm) with marked FDG uptake (mean maximum standardized uptake value: 20.09). Diffuse FDG uptake into the bone marrow was shown in 28 of the 31 cases in which FDG-PET/CT was performed. The signal intensity of bone marrow suggested marrow reconversion in all seven MRI-assessable cases. Bone scintigraphy demonstrated no significant uptake, except in two cases with bone metastases. Splenic FDG uptake was increased in 8 of 10 cases in which it was evaluated. These imaging findings may reflect the effects of tumor-produced G-CSF. The presence of G-CSF-producing tumors should be considered in patients with cancer who show these imaging findings and marked inflammatory features of unknown origin.

G-CSF in tumors: Aggressiveness, tumor microenvironment and immune cell regulation

Granulocyte colony-stimulating factor (G-CSF) is a cytokine most well-known for maturation and mobilization of bone marrow neutrophils. Although it is used therapeutically to treat chemotherapy induced neutropenia, it is also highly expressed in some tumors. Case reports suggest that tumors expressing high levels of G-CSF are aggressive, more difficult to treat, and present with poor prognosis and high mortality rates. Research on this topic suggests that G-CSF has tumor-promoting effects on both tumor cells and the tumor microenvironment. G-CSF has a direct effect on tumor cells to promote tumor stem cell longevity and overall tumor cell proliferation and migration. Additionally, it may promote pro-tumorigenic immune cell phenotypes such as M2 macrophages, myeloid-derived suppressor cells, and regulatory T cells. Overall, the literature suggests a plethora of pro-tumorigenic activity that should be balanced with the therapeutic use. In this review, we present an overview of the multiple complex roles of G-CSF and G-CSFR in tumors and their microenvironment and discuss how clinical advances and strategies may open new therapeutic avenues.

Adenosquamous carcinoma may have an inferior prognosis to signet ring cell carcinoma in patients with stages I and II gastric cancer

BACKGROUND

Primary gastric adenosquamous carcinoma (ASC) is an exceedingly rare histological subtype. Gastric signet ring cell carcinoma (SRC) is a unique subtype with distinct tumor biology and clinical features. The prognosis of gastric ASC vs SRC has not been well established to date. We hypothesized that further knowledge about these distinct cancers would improve the clinical management of such patients.

AIM

To investigate the clinicopathological characteristics and prognosis of gastric ASC vs SRC.

METHODS

A cohort of gastric cancer patients was retrospectively collected from the Surveillance, epidemiology, and end results program database. The 1:4 propensity score matching was performed among this cohort. The clinicopathological features and prognosis of gastric ASC were compared with gastric SRC by descriptive statistics. Kaplan-Meier method was utilized to calculate the median survival of the two groups of patients. Cox proportional hazard regression models were used to identify prognostic factors.

RESULTS

Totally 6063 patients with gastric ASC or SRC were identified. A cohort of 465 patients was recruited to the matched population, including 370 patients with SRC and 95 patients with ASC. Gastric ASC showed an inferior prognosis to SRC after propensity score matching. In the post-matching cohort, the median cancer specific survival was 13.0 (9.7-16.3) mo in the ASC group vs 20.0 (15.7-24.3) mo in the SRC group, and the median overall survival had a similar trend (P < 0.05). ASC and higher tumor-node-metastasis stage were independently associated with a poor survival, while radiotherapy and surgery were independent protective factors for improved prognosis. Subgroup survival analysis revealed that the prognosis of ASC was inferior to SRC only in stages I and II patients.

CONCLUSION

ASC may have an inferior prognosis to SRC in patients with stages I and II gastric cancer. Our study supports radiotherapy and surgery for the future management of this clinically rare entity.

Clinical application of ceramide in cancer treatment

Development of innovative strategies for cancer treatment is a pressing public health issue. Despite recent advances, the mechanisms of cancer progression and the resistance to cancer treatment have not been fully elucidated. Sphingolipids, including ceramide and sphingoshin-1-phosphate, are bioactive mediators that regulate cancer cell death and survival through the dynamic balance of what has been termed the 'sphingolipid rheostat'. Specifically, ceramide, which acts as the central hub of sphingolipid metabolism, is generated via three major pathways by many stressors, including anti-cancer treatments, environmental stresses, and cytokines. We have previously shown in breast cancer patients that elevated ceramide correlated with less aggressive cancer phenotypes, leading to a prognostic impact. Recent studies showed that ceramide have the possibility of becoming the reinforcing agent of cancer treatment as well as other roles such as nanoparticles and diagnostic biomarker. We review ceramide as one of the key molecules to investigate in overcoming resistance to current drug therapies and in becoming one of the newest cancer treatments.

High expression of class III β-tubulin in upper gastrointestinal cancer types

Class III β-tubulin (TUBB3) is a component of microtubules of neuronal cells that is upregulated in various cancer entities. To better understand the role of TUBB3 in upper gastrointestinal tract cancer types, the present study assessed TUBB3 expression in tissue microarrays including 189 gastric and 428 esophageal cancer. TUBB3 expression was detected in 62.4% of gastric cancer, 73.8% of esophageal adenocarcinoma and 88.7% of esophageal squamous cell cancer, while control samples of normal esophageal and gastric epithelium were TUBB3-negative. TUBB3 positivity was not associated with the International Union Against Cancer classification, World Health Organization grading, lymph node involvement or distant metastasis in any entity. Of note, TUBB3 expression was associated with tumor localization and prognosis in gastric cancer, with the tumor stage in esophageal adenocarcinoma, and with the resection margin in esophageal squamous cell cancer. In conclusion, the substantial rate of positivity for TUBB3 already in early stages of gastric cancer in combination with the lack of a further increase in frequency with tumor stage, may suggest, that TUBB3 upregulation is rather relevant for cancer development than for cancer progression. TUBB3 might be a suitable prognostic biomarker in gastric cancer types.

Rapid progression of a granulocyte colony-stimulating factor-producing liver tumor metastasized from esophagogastric junction cancer: A case report and literature review

The current study presents the case of a 72-year-old woman with a rapidly enlarged liver metastasis from esophagogastric junction (EGJ) cancer, accompanied by progressive leukocytosis (47,680/µl) and elevated serum granulocyte colony-stimulating factor (G-CSF; 779 pg/ml). The patient underwent right hemihepatectomy 26 months after a total gastrectomy. On the seventh post-operative day the patient's leukocyte count and serum G-CSF level decreased to 4,280/µl and ≤19.5 pg/ml, respectively. Histologically, the lesion was a well to moderately differentiated adenocarcinoma similar to the primary lesion. Therefore, this tumor was clinically diagnosed as a G-CSF-producing liver metastasis from EGJ cancer, although immunohistochemical staining for G-CSF was negative. A right pulmonary nodule detected simultaneously with the hepatic mass was resected four months following the hepatectomy and was diagnosed as a pulmonary metastasis. The patient's leukocyte count was normal at the time of her initial surgery for EGJ cancer, and her clinical course varied for different metastatic sites. The liver metastasis was accompanied by progressive leukocytosis and elevated serum G-CSF and demonstrated rapid tumor growth during a six-month period, whereas the non-G-CSF-producing pulmonary metastasis grew slowly during the same period. In addition 21 reported cases of G-CSF-producing upper gastrointestinal tract cancer were reviewed to elucidate the clinicopathological features of this disease.