A de novo frameshift in HNRNPK causing a Kabuki-like syndrome with nodular heterotopia

Kabuki syndrome is a heterogeneous condition characterized by distinctive facial features, intellectual disability, growth retardation, skeletal abnormalities and a range of organ malformations. Although at least two major causative genes have been identified, these do not explain all cases. Here we describe a patient with a complex Kabuki-like syndrome that included nodular heterotopia, in whom testing for several single-gene disorders had proved negative. Exome sequencing uncovered a de novo c.931_932insTT variant in HNRNPK (heterogeneous nuclear ribonucleoprotein K). Although this variant was identified in March 2012, its clinical relevance could only be confirmed following the August 2015 publication of two cases with HNRNPK mutations and an overlapping phenotype that included intellectual disability, distinctive facial dysmorphism and skeletal/connective tissue abnormalities. Whilst we had attempted (unsuccessfully) to identify additional cases through existing collaborators, the two published cases were 'matched' using GeneMatcher, a web-based tool for connecting researchers and clinicians working on identical genes. Our report therefore exemplifies the importance of such online tools in clinical genetics research and the benefits of periodically reviewing cases with variants of unproven significance. Our study also suggests that loss of function variants in HNRNPK should be considered as a molecular basis for patients with Kabuki-like syndrome.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Update on Kleefstra Syndrome

Kleefstra syndrome is characterized by the core phenotype of developmental delay/intellectual disability, (childhood) hypotonia and distinct facial features. The syndrome can be either caused by a microdeletion in chromosomal region 9q34.3 or by a mutation in the euchromatin histone methyltransferase 1 (EHMT1) gene. Since the early 1990s, 85 patients have been described, of which the majority had a 9q34.3 microdeletion (>85%). So far, no clear genotype-phenotype correlation could be observed by studying the clinical and molecular features of both 9q34.3 microdeletion patients and patients with an intragenic EHMT1 mutation. Thus, to further expand the genotypic and phenotypic knowledge about the syndrome, we here report 29 newly diagnosed patients, including 16 patients with a 9q34.3 microdeletion and 13 patients with an EHMT1 mutation, and review previous literature. The present findings are comparable to previous reports. In addition to our former findings and recommendations, we suggest cardiac screening during follow-up, because of the possible occurrence of cardiac arrhythmias. In addition, clinicians and caretakers should be aware of the regressive behavioral phenotype that might develop at adolescent/adult age and seems to have no clear neurological substrate, but is rather a so far unexplained neuropsychiatric feature.

Sixteen New Cases Contributing to the Characterization of Patients with Distal 22q11.2 Microduplications

The chromosome region 22q11.2 has long been recognized to be susceptible to genomic rearrangement. More recently, this genomic instability has been shown to extend distally (involving LCR22E-H) to the commonly deleted/duplicated region. To date, 21 index cases with 'distal' 22q11.2 duplications have been reported. We report on the clinical and molecular characterization of 16 individuals with distal 22q11.2 duplications identified by DNA microarray analysis. Two of the individuals have been partly described previously. The clinical phenotype varied among the patients in this study, although the majority displayed various degrees of developmental delay and speech disturbances. Other clinical features included behavioral problems, hypotonia, and dysmorphic facial features. Notably, none of the patients was diagnosed with a congenital heart defect. We found a high degree of inherited duplications. Additional copy number changes of unclear clinical significance were identified in 5 of our patients, and it is possible that these may contribute to the phenotypic expression in these patients as has been suggested recently in a 2-hit 'digenic' model for 16p12.1 deletions. The varied phenotypic expression and incomplete penetrance observed for distal 22q11.2 duplications makes it exceedingly difficult to ascribe pathogenicity for these duplications. Given the observed enrichment of the duplication in patient samples versus healthy controls, it is likely that distal 22q11.2 duplications represent a susceptibility/risk locus for speech and mild developmental delay.

Pregnancy with epilepsy: obstetric and neonatal outcome of a controlled study

PURPOSE

To determine the influence of epilepsy and its treatment on pregnancy and its outcome.

DESIGN

Controlled, observational study.

SETTING

National Health Service maternity hospitals in Liverpool and Manchester regions.

POPULATION

277 women with epilepsy (WWE) and 315 control women.

METHODS

WWE were recruited from antenatal clinics. Controls were matched for age and parity but not gestational age. Information was obtained by interview and from clinical records.

MAIN OUTCOME MEASURES

Obstetric complications, mode of delivery, condition of newborn.

RESULTS

Distribution of epilepsy syndromes was similar to previous surveys. Most WWE (67%) received monotherapy with carbamazepine, sodium valproate or lamotrigine. Half WWE had no seizures during pregnancy but 34% had tonic clonic seizures. Seizure-related injuries were infrequent. Pregnancies with obstetric complications were increased in women with treated epilepsy (WWTE 45%, controls 33%; p=0.01). Most had normal vaginal delivery (WWTE 63%, controls 61%; p=0.65). Low birth weight was not increased (WWTE 6.2%, controls 5.2%; p=0.69). There were more major congenital malformations (MCM) (WWTE 6.6%, controls 2.1%; p=0.02) and fetal/infant deaths (WWTE 2.2%, controls 0.3%; p=0.09). Amongst monotherapies MCM prevalence was highest with valproate (11.3%; p=0.005). Lamotrigine (5.4%; p=0.23) and carbamazepine (3.0%; p=0.65) were closer to controls (2.1%). There was no association between MCM and dose of folic acid pre-conception.

CONCLUSION

MCM were more prevalent in the babies of WWTE particularly amongst those receiving sodium valproate.

The behavioral consequences of exposure to antiepileptic drugs in utero

The aim of the study was to examine the behavior of 242 children, aged between 6 and 16 years, born to mothers with epilepsy. Exposure to sodium valproate (VPA) in utero was associated with high levels of parental stress induced by the child's maladaptive behavior. These children were also poorer for daily living skills and skills relating to socialization. The outcomes on both measures were strongly affected by the Full Scale IQ (FSIQ) of the child; however, no significant differences were found between the groups and therefore this pattern of results cannot simply be attributed to a lower FSIQ. The results of this study suggest that exposure to VPA in utero and the presence of a lowered FSIQ are risk factors for the development of poorer adaptive behavior and a higher rate of maladaptive behaviors.

Dysmorphic features: an important clue to the diagnosis and severity of fetal anticonvulsant syndromes

BACKGROUND

In utero exposure to antiepileptic drugs (AEDs) can result in several different teratogenic effects including major malformations, dysmorphic facial features, and learning and behavioural problems. It is estimated that there is a 2-3-fold increase in the risk of malformations compared with the general population. The risk of cognitive impairment and behavioural problems is less clear.

OBJECTIVE

To report the frequency and specificity of individual dysmorphic features and to relate the dysmorphic facial phenotype to developmental outcome.

METHODS

A retrospective study of 375 children born to 219 mothers with epilepsy. The age of the study group ranged from 6 months to 16 years. Each child underwent a physical examination and a battery of neuropsychological tests. Dysmorphic features were scored from photographs on a blind basis by a panel of dysmorphologists.

RESULTS

A total of 274 children were exposed to AEDs (63 to valproate, 94 to carbamazepine, 26 to phenytoin, 15 to other monotherapies, and 76 to polytherapy). Major malformations were identified in 14% of children exposed to valproate in utero, 5% exposed to carbamazepine, and 4% in the non-exposed group. Overall, 47% of exposed children were correctly identified as having been exposed to AEDs in utero. There was a significant correlation between verbal intelligence quotient and dysmorphic facial features in the valproate exposed children only.

CONCLUSION

Children exposed to valproate have more distinctive facial features, but a subtle and distinctive facial phenotype is also seen in children exposed to carbamazepine. Nearly half (45%) of unexposed children had some of the facial features associated with AED exposure, showing that many of these features may be seen as part of normal variation and that the diagnosis of the fetal anticonvulsant syndrome is difficult to make on the basis of facial gestalt alone. Developmental surveillance should be offered to children with prenatal exposure to AEDs, particularly those with exposure to high doses of valproate.

Neuropsychological effects of exposure to anticonvulsant medication in utero

OBJECTIVE

To investigate the long-term differential drug effects on cognitive functioning in school-aged children exposed to antiepileptic drugs (AEDs) in utero.

METHODS

Mothers with epilepsy were recruited from specialist epilepsy clinics and obstetric clinics from the Liverpool and Manchester region. The mothers and their children were recruited without prior knowledge of their AED treatment during pregnancy or the health of the offspring. A battery of neuropsychological tests was applied to each mother-child pair in order to obtain a neuropsychological profile for each child.

RESULTS

Neuropsychological investigation was performed on 249 children between the ages of 6 and 16. Children exposed to sodium valproate had a significantly lower verbal IQ when compared to children exposed to other antiepileptic drugs or not exposed at all. The same children were more likely to have an IQ below 69 and more likely to have memory impairment when compared to the other groups. The mothers' IQ, exposure to sodium valproate, and the number of tonic-clonic seizures during pregnancy were significant predictors of verbal IQ in this population.

CONCLUSIONS

This retrospective study highlights the potential harmful effects of sodium valproate exposure in utero on neuropsychological development.

The longer term outcome of children born to mothers with epilepsy

OBJECTIVES

To determine the prevalence of cognitive delay and possible associated dysmorphic features in children exposed to antiepileptic drugs (AEDs) in utero.

DESIGN

Retrospective study of children born to mothers with epilepsy.

SETTING

Regional epilepsy clinics in Liverpool and Manchester, UK.

PARTICIPANTS

Children aged between 6 months and 16 years born to mothers with epilepsy.

MAIN OUTCOME MEASURES

Structured interviews, hospital records, clinical examination, and psychometric tests (Wechsler) were used to assess exposure and intelligence quotient (IQ). Blinded assessment of photographs was used to score children with characteristic dysmorphic features.

RESULTS

A total of 249 children aged 6 and over were studied: 41 were exposed to sodium valproate, 52 to carbamazepine, 21 to phenytoin, 49 to polytherapy, and 80 were unexposed. Mean verbal IQ was significantly lower in the valproate group compared to unexposed and other monotherapy groups. Multiple regression analysis showed that both valproate exposure and frequent tonic-clonic seizures in pregnancy were significantly associated with a lower verbal IQ despite adjusting for other confounding factors. There was a significant negative correlation between dysmorphic features and verbal IQ in children exposed to valproate.

CONCLUSIONS

This study identifies valproate as a drug carrying potential risks for developmental delay and cognitive impairment and is the first to suggest that frequent tonic-clonic seizures have a similar effect. Our results need to be interpreted with caution given their retrospective nature. Women with epilepsy need careful counselling about individual risk benefit of AED treatment before pregnancy.

Angioleiomyoma in the tonsil: an uncommon tumour in a rare site

An angioleiomyoma was excised from the palatine tonsil in a 30-year-old woman who complained of a painless swelling in the region of the tonsil. The mucosa covering the lesion showed prominent dilated blood vessels, necessitating vascular laboratory investigations to exclude any possibility of an aneurysm arising from the carotid system. The mass was excised with little blood loss. This was an uncommon tumour in an unusual site and required radio-imaging and angiographic studies of the great vessels of the head and neck before any operation was attempted. To the best of our knowledge, this is the first case reported in English.

Rhinosporidiosis of the parotid duct cyst: cytomorphological diagnosis of an unusual extranasal presentation

This cytology report highlights a case of rhinosporidiosis of the parotid duct cyst not associated with nasal manifestations. In an endemic area, one should be familiar with its morphologic features in fine-needle aspiration cytology even on scanty material, for it could be one of the investigations in the initial workup of a case.

Hirschsprung's disease, associated rare congenital anomalies

OBJECTIVE

Hirschsprung's disease may be associated with a number of congenital anomalies of which Down's syndrome and intestinal atresias are commonly encountered. The study aimed to assess the impact of rare associated anomalies on the diagnosis and management of Hirschsprung's disease.

METHODS

A retrospective review of the clinical presentation, diagnosis and outcome of thirty five consecutive newly diagnosed cases of Hirschsprung's disease encountered over two years was performed.

RESULTS

Besides Down's syndrome (two), intestinal atresia (one) and pigmentary ocular defects (two), three rare anomalies (Occipital meningocele, Calcific meconium cyst with anal stenosis, Malrotation) were encountered in four of thirty five cases. The clinical features, radiologic anatomy and gross morphology of the bowel were unconventional and the diagnosis was supported by intraoperative acetylcholinesterase staining of biopsies. Though the diagnosis was relatively delayed in these cases, the outcome has been comparable to the rest. The dilemma in their diagnosis and management and their possible pathoembryology is discussed.

CONCLUSION

Awareness of such associations and a specific investigative protocol is imperative for timely diagnosis and minimal morbidity in complex presentations of Hirschsprung's disease.

Non familial juvenile polyposis presenting as chronic intestinal obstruction

Juvenile polyps are the commonest colonic polyps seen in children and present most often with rectal bleed. Intussusception is an extremely rare presentation in juvenile polyposis (JP) syndrome. This case highlights the rare association of ileo-colic intussusception with non-familial Juvenile Polyposis.

Neural hypertrophy in carcinoma stomach

Neural hypertrophy with hyperplastic Schwann cells in the wall of the stomach along with enterochromaffin cell hyperplasia was incidentally observed at histology in the gastrectomy specimen of a 43-year-old man with carcinoma stomach who had presented with upper abdominal pain of one year duration. The patient had no previous abdominal surgery or evidence of gastrointestinal obstructive pathology. The significance of this neural hypertrophy is not known.

Can we diagnose early Barrett's oesophagus?

OBJECTIVES

The definition of Barrett's oesophagus, has been of late, is stressed on the presence of specialised columnar epithelium with goblet cells and not on other metaplastic epithelia, which however could be the early, immature, undifferentiated cell types such as junctional and gastric types. Hence this study was carried out to find out the ways of detecting the early metaplastic cell forms before the goblet cells appear.

METHODS

Among 134 cases of reflux oesophagitis selected in the prospective study of 7 years from January 1992 to December 1998, 31 biopsies were diagnosed as Barrett's oesophagus (BO). These were compared with 20 age matched control biopsies from gastro-oesophageal junction. They were studied morphologically, morphometrically and histochemically for acid, neutral and sulphomucins using alcian blue (AB), alcian blue-periodic acid Schiff (AB-PAS) and high iron diamine-alcin blue (HID-AB) stains.

RESULTS

Twelve of the cases were of junctional type, 16 of specialised columnar intestinal metaplastic (IM) type (Type I = 0, Type II = 5, Type III = 11) and three showed a combination of both junctional and Type I IM. Mucins were a mixture of neutral mucin, sialomucin and sulphomucin while the control biopsies showed chiefly neutral mucin. Morphometrically, the epithelial cells in BO were taller (mean 28u in junctional types and 32u in IM) in comparison to the control (mean 24.5 u).

CONCLUSION

When the classical specialised columnar epithelium (with goblet cells) in oesophagus is absent, presence of metaplastic junctional type of mucosa, may, for all probabilities be considered as the initial step towards transformation to the classical Barrett's mucosa. In such situations, it is essential to differentiate it from the normal gastro-oesophageal junctional epithelium and is possible with histochemical analysis of the biopsy material aided by morphometry, especially so when the level of biopsy is not indicated.

Colonic carcinomas masquerading as Crohn's colitis

When colonic carcinomas present with acute abdomen, the operating surgeon and the pathologist face a plethora of diagnostic and therapeutic problems. In this retrospective study of 92 cases of carcinoma colon, 4 presented with acute intestinal obstruction of which three had a turbulent post operative period and died. The resected colonic segment showed on gross examination cobblestone appearance characteristic of Crohn's disease but microscopically was ischemic with the stricture site showing features of an infiltrating poorly differentiated adenocarcinoma. We have made an attempt to study the various pathologic features and analyse their significance with reference to prognosis.

Cytodiagnosis of Kimura's disease

Kimura's Disease, a rare chronic inflammatory disorder with a benign course affecting the lymphoid tissue is reported hare in an 18 year old South Indian male who presented with bilateral solitary swelling over the mastoid region. Its fine needle aspiration cytology characterised by the Warthin-Finkeldey type giant cells against a background of a bimodal population of lymphocytes and eosinophils prompted the diagnosis of Kimura's disease at cytology itself. This was confirmed at histology. This is the third cytological report of its kind being reported in English literature. Literature with regard to the cytological appearances of Kimura's disease has been reviewed and the various differential diagnoses discussed.

Cysts of the larynx : A clinicopathologic study of nine cases

In this only report from India, nine patients with laryngeal cysts have been diagnosed in the 24 year period from Jan 1971 through Jan 1996 representing 0.01 % of 1,05,279 general biopsies and 1.16% of 774 laryngeal biopsies received. The patients were mainly male with a mean age of 48.87 years. They presented with laryngeal obstructive symptoms. Six of the patients were chronic cigarette smokers. None had history of voice abuse. Laryngoscopic examination showed solitary cysts situated in the supraglottic region in seven cases and in the true vocal cords in two. Using modified DeSanto's classification of laryngeal cysts putforth by Newman et al (1984), four were ductal, three saccular and one of tonsillar type. However, one of the cysts having features of an epidermoid cyst could not fit into the classification. The major proposed classifications of laryngeal cysts which are in practice have resulted in much confusion for both clinicians and pathologists and these have been studied in depth and their implications discussed here.

Squamous cell carcinoma of the vulva in association with mixed vulvar dystrophy. A brief report with review of literature

Of the 74 patients of vulvar lichen sclerosus diagnosed over a period of 29 years from 1966-1995, two cases of mixed dystrophies characterised by lichen sclerosus with squamous cell hyperplasia were studied and one of these on close follow-up, developed an invasive squamous cell carcinoma after three years. The other case has been doing well and has not shown further progression of the lesion. The remaining 72 patients of vulvar lichen sclerosus alone have shown no signification change on close follow-up for a minimum of five years. This paper highlights the fact that all cases of vulvar dystrophy especially, lichen sclerosus must be regularly followed up for development of squamous cell hyperplasia and their progression to overt vulvar carcinoma, emphasizing the need for early diagnosis and treatment of non-neoplastic vulvar dystrophies.

Aspiration cytology of echinococcus oligarthrus. A case report

BACKGROUND

Fine needle aspiration cytology is a useful technique in the diagnosis of several parasitic infections. The present case highlights the aspiration cytology findings in a case of Echinococcus oligarthrus infection, a rare variant of the Echinococcus species affecting humans. To the best of our knowledge, this is the first case report on the cytology of E oligarthrus in English.

CASE

A submandibular swelling developed in a 14-year-old male. A mistaken diagnosis of Cysticercus cellulosae was made on the first aspirate and of a hydatid cyst (Echinococcus granulosus) on the second aspirate. A diagnosis of E oligarthrus was made on subsequent histopathologic examination of the excised lesion.

CONCLUSION

This seems to be the first case report in English of the cytomorphology of E oligarthrus on fine needle aspiration cytology with histopathologic confirmation.

Ocular spherulocystosis

Spherulocystosis (myospherulosis), a rare entity, is characterised by histopathological changes of sac-like refractile structures in soft tissue and presents clinically as an inflammatory lesion. It is caused by trauma or is induced iatrogenically by the topical application of fat based ointments. A case of myospherulosis confined to the region of the lacrimal caruncle, which developed soon after topical antibiotic application for suspected conjunctivitis, in a 49 year old woman is reported. Though this lesion is uncommon, this report illustrates the importance of recognising this condition to avoid confusion with and treatment for fungal infection.

Choriocarcinoma of the ovary in a post-menopausal woman

A case of a Choriocarcinoma of the Ovary has been reported in a 50 year old post-menopausal woman. At laparotomy, the lesion was seen as a large necrotic ovarian mass. The problems of distinguishing Gestational from Non-gestational ovarian choriocarcinoma are discussed. Cytogenetic studies are indicated to investigate potential reasons for the difference in prognosis.

Post-transplantation epididymitis associated with cytomegalovirus

Cytomegalovirus (CMV) infection, though usually systemic, has been known to cause localised involvement of organs like lung, liver, testis and gastrointestinal tract. We report a case of cytomegaloviral infection involving the epididymis without systemic manifestations in an young male one month after renal transplantation. The diagnosis was made on histopathologic examination of the epididymo-orchidectomy specimen. Clinical improvement occurred after the emergency epididymo-orchidectomy. To the best of our knowledge, only three cases of CMV epididymitis have been described in the world literature--two in transplant patients and one in an AIDS patient.

Invasive mycosis of a pulmonary hydatid cyst in a non-immunocompromised host

Fungal infection of a parasitic cyst is highly unusual. A case of invasive mycosis of a hydatid cyst situated in an ectatic bronchus is reported in a patient with normal immune status.

Laryngeal carcinoma ex-papilloma in a non-irradiated, non-smoking patient: a clinical record and review of the literature

Malignant transformation of respiratory papillomata is not uncommon in the presence of precipitating factors such as tobacco smoking and therapeutic irradiation. Respiratory papilloma changing to carcinoma in the absence of smoking and irradiation is seldom seen, with only about 20 documented cases presented in the literature. Here we report one such case in a 30-year-old male patient.

Ultrasonically guided fine needle aspiration of the parathyroid. A report of two cases

Two cases of parathyroid adenoma were diagnosed with ultrasound-guided fine needle aspiration. Both patients were clinically suspected of having features of primary hyperparathyroidism. On aspiration, one had an associated cystic change with golden brown fluid and the other a markedly cellular aspirate. The cells aspirated were differentiated from thyroid epithelial cells.

A study from south India on the association between the papilloma virus and carcinoma of the penis

Specimens from 39 cases of squamous cell carcinoma of the penis were treated for the papilloma virus using the bovine papilloma virus antibody and the peroxidase-antiperoxidase technique. All 39 cases showed a viral antigen situated intranuclearly, intracytoplasmically or both intranuclearly and intracytoplasmically. No correlation could be seen between the presence of viral antigen and age of patient, duration of lesion, cell morphology and histological grade. The adjacent mucosa and skin were used as controls and showed no viral antigen. The inflammatory infiltrate was dense and predominantly "T" lymphocyte in type.

Primary pleural mesotheliomas in south India: a 25-year study

In this report from South India, 15 patients with primary pleural mesothelioma have been diagnosed in the 25-year period 1, April 1966 through 31, March 1991, representing 0.02% of 76,239 biopsies received. The patients were mainly male with a mean age of 46.5 years. All except two had lived in urban Bangalore. None had been exposed to asbestos. The presentation clinically was peculiar, being continuous pricking pain, breathlessness, and cough with sputum. Physical and roentgenogram examination showed massive pleural effusion with irregular pleural thickening. Thoracotomy findings showed a distinct sessile nodularity with many slit-like spaces. Histologically, 14 were epithelial type mesotheliomas and 1 was a sarcomatous type. While the epithelial type neoplasms showed patchy squamoid differentiation, all showed mucin production. The CEA was always observed in areas of moderate differentiation. Spread occurred centrifugally to local structures on the same side as the lesion.

Mixed mesodermal tumours of the ureter

This report is of a 78 year-old male with a mixed mesodermal tumour of the left ureter. A comparison of all reported patients with such neoplasms has been made in the discussion, in an attempt at characterization of this neoplasm.

Intestinal metaplasia in benign and malignant gastric lesions

The purpose of this study has been to determine the prevalence of intestinal metaplasia (IM) and its subtypes in normal, benign and malignant states, with special reference to the significance of presence as well as location of sulphomucins in the metaplastic epithelium. Sixty-seven specimens of the normal, benign chronic gastric disease and gastric carcinoma have been studied. The overall prevalence of IM in gastric carcinoma has been found to be much higher (67 percent) than in the normal (nil) and benign lesions of stomach (11 percent). The sulphomucins producing IM also has a higher prevalence in gastric carcinoma (70 percent) but can occur in benign conditions also (40 percent). On the other hand Type III IM, characterized by sulphomucins in the columnar cells is seen only in gastric carcinoma, and not in the benign lesions.