Spatial Epidemiology of Signet-ring Cell Colorectal Cancer in India

Background

Signet-ring cell colorectal carcinoma (SRCC) is an extremely aggressive yet uncommon histologic subtype of colorectal cancer (CRC) with an unknown etiology. There is a stark difference in the prevalence of signet cancers between Western countries and the Indian subcontinent; however, India itself is a vast and diverse country with variable cancer incidence.

Objective

To study the spatial epidemiology of SRCC in India for identifying regions with high prevalence.

Methods

This retrospective study included all patients diagnosed with colorectal adenocarcinoma at Tata Memorial Hospital, the largest colorectal cancer referral unit in India, between January 2020 and December 2022. Geocoding based on the location of the residence was done to map the incidences. Comparisons were performed between the proportion of signet cell and non-signet colorectal cancers.

Results

A total of 4100 patients with colon or rectal adenocarcinomas were included, of which signet cell histology was found in 624 (15%) patients. SRCC accounted for the highest proportions of CRCs in the Central (19%) and Northern (19%) regions, and the lowest in the North-Eastern (10%) and Western (12%) regions of India (P < 0.001), with non-overlapping confidence intervals. Compared with patients with non-signet CRCs, those with SRCC more commonly had colon cancers (22% vs. 17%; P = 0.003) and belonged to a lower socioeconomic background (67% vs. 59%; P < 0.001).

Conclusions

This study found that SRCCs accounted for a significant proportion of CRC cases in India, but there was no substantial disparity in distribution across regions.

The Travels of Signet-Ring Cell Carcinoma: From Colon to Stomach and Duodenum

Colorectal cancer (CRC) metastasizing to the stomach and duodenum is rare. Even rarer is when the CRC subtype is signet-ring cell carcinoma (SRCC). Endoscopic findings of CRC metastasis to the stomach have been described as solitary and submucosal while duodenal metastasis has been observed to be exophytic. In this report, we describe a case of a middle-aged man with colon SRCC presenting with oral intolerance. He was found to have concurrent metastases to the stomach and duodenum and died 8 months after his SRCC diagnosis.

Gastric Flat Elevated Undifferentiated Signet-ring Cell Mucosal Cancer Lesion Detected in a Case without Helicobacter pylori Infection

Protruded signet-ring cell carcinoma (SRCC) is extremely rare. We herein report a rare case of flat elevated gastric SRCC in a patient without Helicobacter pylori infection. Esophagogastroduodenoscopy of a woman in her 50s revealed a flat, whitish lesion in the gastric body with elevation. Histological results of an endoscopically biopsied specimen led to a diagnosis of SRCC. Resection using endoscopic submucosal dissection was performed, and histology results revealed that the tumor was localized in the lamina propria. The size was 10×6 mm, and a protrusion had been formed by SRCC enlargement without destruction of the surface epithelium structure.

Microsatellite Instability-high Signet Ring Cell Carcinoma of the Colon Treated With Immunotherapy: Report of a Case

BACKGROUND

Immune checkpoint inhibitors (ICIs) are attracting increasing attention as a novel and potentially curative therapy for microsatellite instability-high (MSI-H) colorectal cancer (CRC).

CASE REPORT

An 80-year-old female visited our hospital with complaints of lower abdominal pain due to bowel obstruction caused by descending colon cancer. After 1 month of metallic stent detention, she underwent radical surgery, although laparotomy showed broad peritoneal dissemination. Based on the genetic finding of MSI-H status, pembrolizumab therapy was administered in two cycles. Unfortunately, the therapy was ineffective, and the patient died after being discharged 5 months after surgery.

CONCLUSION

The findings in this case of MSI-H CRC with a poor response to an ICI suggest the importance of confirming HLA status, including beta-2-microglobulin and HLA expression, before starting ICI therapy in cases of MSI-H CRC.

Primary Lung Adenocarcinoma With ALK Gene Rearrangement Mostly Occupied by the Signet-Ring Cell Carcinoma Component: A Case Report

Primary lung carcinoma tumors possessing a signet-ring cell carcinoma (SRCC) component at varying proportions are rare, while those primarily composed of an SRCC component are much rarer. Reported here is a case of primary lung adenocarcinoma primarily composed of an SRCC component with a scant acinar component that developed in an 81-year-old male. Approximately 95% of the adenocarcinoma was occupied by an SRCC component that was shown to be diastase-resistant based on positive periodic acid-Schiff staining. Immunostaining for ALK and fluorescence in situ hybridization analysis (break-apart assay) showed the presence of an ALK gene rearrangement. Findings in this case indicated a primary lung adenocarcinoma with ALK gene rearrangement, in which an SRCC component accounted for approximately 95% of the tumor.

Signet-Ring Cutaneous Metastasis Presenting with Huge Bunches of Grapes

Signet-ring cell (SRC) is a histologic type in which cells show unique features under the microscope. We mainly found signet-ring cells (SRCs) in gastrointestinal and breast tumors. Cutaneous metastasis from internal carcinomas was an uncommon presentation. The cases of signet-ring cell carcinoma (SRCC) metastasis to the skin were rarely reported. Cutaneous metastasis indicated a poor prognosis for a patient. Here, we report a female who had huge grape-like nodules arising from gastrointestinal SRCC in her trunk and thigh.

An unusual testicular mass in a young male: Metastasis from occult gastric carcinoma

Metastases to the testis are uncommon. Signet-ring cell carcinomas from the gastrointestinal tract (GIT) can rarely disseminate to the testicles, mimicking primary testicular malignancies with signet-ring cells. We hereby describe a case of a 26-year-old male who presented with left testicular swelling, multiple lymphadenopathies, and normal serum tumor markers. Lymph node biopsy revealed clusters and singly lying signet-ring cells. Judicious use of immunohistochemistry confirmed the tumor to be GIT primary. Further investigations confirmed a gastric tumor extending to the duodenum. Although rare, metastatic tumors to the testis should be considered in differential diagnoses of testicular masses in a young patient, particularly when serum germ cell tumor markers are normal or mildly deranged.

Deep learning-based AI model for signet-ring cell carcinoma diagnosis and chemotherapy response prediction in gastric cancer

PURPOSE

We aimed to develop a noninvasive artificial intelligence (AI) model to diagnose signet-ring cell carcinoma (SRCC) of gastric cancer (GC) and identify patients with SRCC who could benefit from postoperative chemotherapy based on preoperative contrast-enhanced computed tomography (CT).

METHODS

A total of 855 GC patients with 855 single GCs were included, of which 249 patients were diagnosed as SRCC by histopathologic examinations. The AI model was generated with clinical, hand-crafted radiomic, and deep learning features. Model diagnostic performance was measured by area under the receiver operating characteristic curve (AUC), sensitivity, and specificity, while predictive performance was measured by Kaplan-Meier curves.

RESULTS

In the test cohort (n = 257), the AUC, sensitivity, and specificity of our AI model for diagnosing SRCC were 0.786 (95% CI: 0.721-0.845), 77.3%, and 69.2%, respectively. For the entire cohort, patients with AI-predicted high risk had a significantly shorter median OS compared with those with low risk (median overall survival (OS), 38.8 vs. 64.2 months, p = 0.009). Importantly, in pathologically-confirmed advanced SRCC patients, AI-predicted high-risk status was indicative of a shorter overall survival (median overall survival (OS), 31.0 vs. 54.4 months, p = 0.036) and marked chemotherapy resistance, whereas AI-predicted low-risk status had substantial chemotherapy benefit (median OS [without vs. with chemotherapy], 26.0 vs. not reached, p = 0.013).

CONCLUSIONS

The CT-based AI model demonstrated good performance for diagnosing SRCC, stratifying patient prognosis, and predicting chemotherapy responses. Advanced SRCC patients with AI-predicted low-risk status may benefit substantially from adjuvant chemotherapy. This article is protected by copyright. All rights reserved.

Breast Metastasis From Rectal Signet-Ring Cell Carcinoma: A Case Report and Review of Literature

BACKGROUND

Metastatic rectal cancer (mRC) of the breast is an extremely rare clinical situation. There are few reported cases in domestic or foreign literature. The clinicopathologic characteristics along with the diagnostic and therapeutic strategies of such cases remain relatively unclear. Here, we would like to provide our comprehensive insights into this rare entity.

METHODS

We present a case that till now is the first reported breast metastasis from rectal cancer pathologically diagnosed as a signet-ring cell carcinoma, and we review the current literature on this rare event. The detailed clinical data, histopathology, management, and follow-up aspects were gathered for analysis.

RESULTS

A total of 15 cases were collected including the current case. Breast metastases from rectal cancer present at an average age of 47.7 years (range, 28 to 69 years) and appear with an average interval of 28.4 months (range, 5 months to 18 years) following primary tumor diagnoses. Of the 15 cases, 8 and 5 are pathologically diagnosed as adenocarcinomas and mucinous adenocarcinomas, respectively. Most cases (11/15) are accompanied by extramammary metastases. About half of the breast metastases (7/15) were to the left. In all cases, the main complaints were palpable mass. The average maximum diameter of the metastatic mass is 2.7 cm (range, 1-11 cm). The majority (8/12) of cases with accessible therapy information exclude the option of local surgery.

CONCLUSION

Previous cancer history and accurate immunohistochemistry data play critical roles to distinguish mammary metastasis from a primary neoplasm of the breast. Mastectomy and molecular-targeted drugs should be considered with priority if systemic condition supports them.

Histological and mutational profile of diffuse gastric cancer: current knowledge and future challenges

Gastric cancer (GC) pathogenesis is complex and heterogeneous, reflecting morphological, molecular and genetic diversity. Diffuse gastric cancer (DGC) and intestinal gastric cancer (IGC) are the major histological types. GC may be sporadic or hereditary; sporadic GC is related to environmental and genetic low-risk factors and hereditary GC is caused by inherited high-risk mutations, so far identified only for the diffuse histotype. DGC phenotypic heterogeneity challenges the current understanding of molecular mechanisms underlying carcinogenesis. The definition of a DGC-specific mutational profile remains controversial, possibly reflecting the heterogeneity of DGC-related histological subtypes [signet-ring cell carcinoma (SRCC) and poorly cohesive carcinoma not otherwise specified (PCC-NOS)]. Indeed, DGC and DGC-related subtypes may present specific mutational profiles underlying the particularly aggressive behaviour and dismal prognosis of DGC vs IGC and PCC-NOS vs SRCC. In this systematic review, we revised the histological presentations, molecular classifications and approved therapies for gastric cancer, with a focus on DGC. We then analysed results from the most relevant studies, reporting mutational analysis data specifying mutational frequencies, and their relationship with DGC and IGC histological types, and with specific DGC subtypes (SRCC and PCC-NOS). We aimed at identifying histology-associated mutational profiles with an emphasis in DGC and its subtypes (DGC vs IGC; sporadic vs hereditary DGC; and SRCC vs PCC-NOS). We further used these mutational profiles to identify the most commonly affected molecular pathways and biological functions, and explored the clinical trials directed specifically to patients with DGC. This systematic analysis is expected to expose a DGC-specific molecular profile and shed light into potential targets for therapeutic intervention, which are currently missing.

Trends in the Incidence and Survival Rates of Colorectal Signet-Ring Cell Carcinoma in the South Korean Population: Analysis of the Korea Central Cancer Registry Database

Objective: Signet-ring cell carcinoma (SRCC) is a rare histopathological subtype of colorectal cancer (CRC) constituting approximately 1% of CRC cases. This study analyzed the incidence and survival rates of colorectal SRCC. Methods: We analyzed the incidence and survival rates of colorectal SRCCs based on patients’ data of the Korea Central Cancer Registry. Results: The age-standardized incidence rates of colon and rectum SRCC in 2017 were 0.17 and 0.07 individuals per 100,000, respectively. Between 1993 and 2017, the 1-, 2-, 3-, 4-, and 5-year relative survival rates of patients with colon SRCC were 65.6%, 49.0%, 38.9%, 34.9%, and 33.0%, respectively, while those of patients with rectum SRCC were 69.6%, 47.8%, 38.5%, 32.8%, and 29.4%, respectively. According to the Surveillance, Epidemiology, and End Results summary stages, the 5-year relative survival rates of colon SRCC between 1993 and 2017 were 70.4% for the localized stage, 41.0% for the regional stage, and 7.0% for the distant stage, while those for rectum SRCC were 60.7%, 34.4, and 3.3%, respectively. Conclusions: Although the incidence of colorectal SRCC is extremely low in South Korea, it has been increasing in recent decades. As the prognosis of colorectal SRCC is extremely poor; clinicians should be aware of the differential diagnosis of SRCC in colorectal cancer cases.

Clinicopathological Features and Survival of Signet-Ring Cell Carcinoma and Mucinous Adenocarcinoma of Right Colon, Left Colon, and Rectum

Histological subtype plays an important role in the different clinical characteristics and survival outcomes of patients with colorectal carcinoma (CRC). However, in previous studies, the influences of tumor locations and tumor stages have not been strictly controlled. This study focused on the assessment of the prognostic value of each histological subtype in different tumor locations and tumor stages of CRC. We used the Surveillance, Epidemiology, and End Results (SEER) database (1973-2011) to analyze 818,229 CRC patients with different clinical and pathological features, and analyzed the prognostic value of each histological subtype. Under the condition of stratification by tumor stage, signet-ring cell carcinoma (SRCC) presented the worst survival in each stage of right colon cancer (stage I, log-rank, p = 0.002, stages II, III, and IV, log-rank, p < 0.001), rectal cancer (RC) (log-rank, p < 0.001), and in stages II, III, and IV of left colon cancer (log-rank, p < 0.001). Multivariate survival analysis suggested SRCC subtype, male gender, age ≥ 70 years, tumor size ≥ 5 cm, stage progression, and poor differentiation were all significant factors worsening survival in CRC (p < 0.001, respectively). Mucinous adenocarcinoma (MC) histological subtype proved to be an independent protective factor for the prognosis of right colon cancer (p = 0.003). Overall, in our study, the results suggested SRCC had the worst survival among the three histological subtypes of CRC. MC was associated with favorable prognosis in right colon cancer but not with other tumor locations.

Prognosis and Biological Behavior of Gastric Signet-Ring Cell Carcinoma Better or Worse: A Meta-Analysis

BACKGROUND

The clinical pathology of gastric signet-ring cell carcinoma (SRC) is still unclear. This meta-analysis was performed to evaluate the difference in biological behavior and prognosis between SRC and non-signet ring cell carcinoma (NSRC).

METHODS

A total of 58 eligible studies were analyzed using RevMan and other auxiliary software. Biological behaviors were compared based on odds ratio (OR) and mean difference (MD). Hazards ratio (HR) was calculated for prognosis based on Kaplan-Meier curves.

RESULTS

Totally, 28,946 SRC patients were compared with 81,917 NSRC patients. Compared with NSRC patients, lower male: female ratio (OR = 0.53, P < 0.01), younger age (MD = -4.89, P < 0.01), more middle location (OR = 1.64, P < 0.01), more depressed type at early stage (OR = 1.31, P < 0.05), higher incidence of Borrmann type IV (OR = 1.96, P < 0.01), less lymph node metastasis at early stage (OR = 0.78, P < 0.05), better prognosis at early stage (HR = 0.59, P < 0.01), and worse prognosis at advanced stage (HR = 1.19, P < 0.01) were associated with SRC patients.

CONCLUSION

The prognosis of SRC at early stage is better than other types of gastric cancer, while that of SRC at advanced stage is relatively poorer.

Signet-ring Cell Carcinoma Component as an Indicator of Anaplastic Lymphoma Kinase Mutations in Colorectal Cancer

Objectives

Molecular profiling of marker mutations has become an essential aspect in the treatment planning for colorectal cancer (CRC). Anaplastic lymphoma kinase (ALK) mutations could be used as markers in CRC molecular profiling. However, the extremely low frequency of these mutations makes their confirmation in all patients inefficient. Thus, to determine whether ALK positivity could be indicated by morphological features, we have analyzed ALK positivity in CRC tissues with a signet-ring cell carcinoma (SRCC) component.

Methods

We screened cases of patients who underwent CRC surgical resection at the Department of Gastrointestinal Surgery of the Kanagawa Cancer Center between January 2015 and December 2019. The selected samples were then assessed immunohistochemically using an antibody against p80 ALK.

Results

In total, we were able to retrieve 29 cases of CRC with the SRCC component from the database; however, 5 cases were excluded owing to the absence of formalin-fixed paraffin-embedded tissue sections or the absence of the SRCC component when the tissues were observed. In the immunohistochemical analysis, two cases showed diffused positive immunoreactivity for ALK and were defined as ALK-positive CRC. Thus, the ALK positivity rate in CRC with SRCC was determined to be 8.3%.

Conclusions

This present study sheds light on the morphological features of ALK-positive CRC. Our findings could contribute to the effective screening and improvement of front-line therapy for CRC.

Risk of Second Primary Malignancies Based on the Histological Subtypes of Colorectal Cancer

Background: Previous studies have revealed an increased risk of second primary malignancies (SPMs) after colorectal cancer (CRC); however, no previous investigation has quantified differences in the risk of SPMs based on the histological subtypes of first primary CRC.

Methods: Patients diagnosed with first primary CRC between 2000 and 2011 were identified from the Surveillance, Epidemiology, and End Results cancer registries. The patients were divided into three cohorts: classical adenocarcinoma (CA), mucinous adenocarcinoma (MA), and signet-ring cell carcinoma (SRCC). Standardized incidence ratios were calculated to assess the risk of SPMs among the patients.

Results: Overall risk of SPMs was significantly higher among patients with three histological subtypes of CRC than in the general population. The risk of esophagus cancer was significantly increased in SRCC. The risk of small intestine, colon and rectum, and corpus uteri cancers was high in three histological subtypes, with the highest risk observed in SRCC, followed by MA. Increased risks of second stomach, uterus, urinary bladder, kidney, and thyroid cancers were only observed in CA patients, while increased risk of second renal pelvis cancer was limited to MA patients. Furthermore, the high overall risk of SPMs in CA patients persisted regardless of clinicopathological factors. After surgery combined with chemotherapy treatment, CA patients were more prone to developing second small intestine, colon and rectum cancers than those treated with surgery only. A lower second prostate cancer risk was observed in rectal CA patients treated with surgery combined with radiotherapy than in patients treated with surgery only.

Conclusion: The present study revealed that the risk of developing SPMs after CRC varied based on the histological subtypes of the first primary CRC. Although the mechanisms underlying the observed patterns of SPM risk remain unknown, the study provided insights into future cancer surveillance based on the histological subtypes of CRC.

Primary signet-ring cell carcinoma of the lung in an HIV-positive patient

Primary lung signet-ring cell carcinomas are a rare entity and only a few cases of pure signet-ring cell carcinomas of the lung are reported in the English literature. They usually have an aggressive behavior and a poor prognosis because in most cases they are identified at an advanced stage. We present a unique case of primary signet-ring cell carcinoma of the lung because the patient was HIV positive, a heavy smoker, and also the tumor, discovered incidentally during chest x-ray, was a pure type of signet-ring cell carcinoma. Surgical therapy associated with chemoradiotherapy represents the gold standard in the care of these patients.

Clinical characteristics and survival profile of young versus old colorectal cancer patients at a tertiary cancer center in North India over a period of 5 years

Background

Colorectal cancer (CRC) is mostly considered a disease of the elderly. But the rate is increasing among young adults and is associated with different clinical patterns. The objective was to study the frequency of CRC in young patients and compare the clinicopathological profile and survival with the older cohort.

Methods

Five-year (2012-2016) data of the 912 consecutive CRC cases treated at the center were analyzed. Clinical and histopathological characteristics were compared in young (≤40) and older (>40) patients. Descriptive statistics were used for data presentation. Categorical data were compared by the Chi-square test; survival analyses were performed by Kaplan-Meier method.

Results

In total, 231 (25.3%) and 681 (74.7%) cases were in the young and older age groups, respectively. Male predominance was noted. Young patients presented predominantly in stage III (46%). Majority of the young patients harbored left-sided tumors (75.8% vs 63.7% in old patients, P = 0.001) and rectum was the favored site in young patients (53.7% vs 37%; P < 0.001). Poorly differentiated adenocarcinoma was more common in the young age group (46.88% vs 24.16% in old patients, P < 0.001), also signet-ring cell morphology occurred more often in young patients (11.7% vs 4%, P < 0.001). Survival was inferior in the patients presenting at an advanced stage or with adverse histology or poor tumor grade. However, stage-specific survival showed no significant difference between both groups.

Conclusion

This study shows that though young CRC patients present with higher stage, aggressive morphology, and predominantly rectal localization, the overall survival and stage-specific survival did not differ significantly from the older patients.

Malignancy-induced hemophagocytic lymphohistiocytosis in a case of signet ring cell carcinoma of the stomach

Hemophagocytic lymphohistiocytosis (HLH) is a rare and potentially life-threatening condition associated with high mortality and can be classified into primary (familial) and secondary HLH. Primary HLH is an inherited, autosomal recessive disorder associated with defects in perforin function, whereas secondary HLH is associated with infections, especially Epstein-Barr virus infection, malignancies, and autoimmune disorders. Patients with malignancy-associated secondary HLH experience symptoms that overlap with those described for other HLH types, which is associated with an increased incidence of misdiagnosis and mortality. Here, we report the case of a patient with secondary HLH associated with a solid malignancy (signet-ring cell carcinoma of the stomach).

Recent advances in the pathology of heritable gastric cancer syndromes

Despite the relative rarity of hereditary gastric cancer syndromes, the prompt recognition of their specific clinical features and histopathological characteristics is pivotal in offering patients the most appropriate treatment. In this article, we address the three major inherited syndromes that primarily affect the stomach: hereditary diffuse gastric cancer (HDGC), caused by germline variants in CDH1 and CTNNA1; gastric adenocarcinoma and proximal polyposis of the stomach, caused by germline mutations in promoter 1B of APC; and familial intestinal gastric cancer, which has a poorly defined genetic cause. The main focus will be on HDGC, in light of the recent publication of updated clinical practice guidelines and emerging concepts regarding HDGC histopathology. In particular, we describe the broad morphological spectrum of HDGC lesions, stressing the importance of recognising indolent and aggressive phenotypes. Moreover, we discuss the increased risk of gastric (pre)malignancies developing in patients with other well-defined hereditary cancer syndromes, such as familial adenomatous polyposis, Lynch syndrome, Peutz-Jeghers syndrome, juvenile polyposis, Li-Fraumeni syndrome, and hereditary breast and ovarian cancer syndrome.

Gastric Adenocarcinomas and Signet-Ring Cell Carcinoma: Unraveling Gastric Cancer Complexity through Microbiome Analysis-Deepening Heterogeneity for a Personalized Therapy

Gastric cancer (GC) is the fifth most prevalent cancer worldwide and the third leading cause of global cancer mortality. With the advances of the omic studies, a heterogeneous GC landscape has been revealed, with significant molecular diversity. Given the multifaceted nature of GC, identification of different patient subsets with prognostic and/or predictive outcomes is a key aspect to allow tailoring of specific treatments. Recently, the involvement of the microbiota in gastric carcinogenesis has been described. To deepen this aspect, we compared microbiota composition in signet-ring cell carcinoma (SRCC) and adenocarcinoma (ADC), two distinct GC subtypes. To this purpose, 10 ADC and 10 SRCC and their paired non-tumor (PNT) counterparts were evaluated for microbiota composition through 16S rRNA analysis. Weighted and unweighted UniFrac and Bray-Curtis dissimilarity showed significant community-level separation between ADC and SRCC. Through the LEfSe (linear discriminant analysis coupled with effect size) tool, we identified potential microbial biomarkers associated with GC subtypes. In particular, SRCCs were significantly enriched in the phyla Fusobacteria, Bacteroidetes, Patescibacteria, whereas in the ADC type, Proteobacteria and Acidobacteria phyla were found. Overall, our data add new insights into GC heterogeneity and may contribute to deepening the GC classification.

Stage III and Metastatic Lymph Node Ratio Are the only Independent Prognostic Factors in Colorectal Signet-ring Cell Carcinoma Patients

BACKGROUND/AIM

Signet-ring cell carcinoma (SRCC) is an uncommon histological variant of colorectal cancer (CRC). Knowledge is scarce due to its rarity. Our aim was to better evaluate the clinicopathologic and prognostic features of this little-known malignancy.

PATIENTS AND METHODS

Thirty-nine consecutive patients with non-metastatic colorectal SRCC undergoing curative resection at University Hospital of Parma between 2000 and 2018 were examined in this retrospective analysis.

RESULTS

Mean overall (OS) and disease-free survival (DFS) were 33.6 and 31.5 months, respectively. At univariate analysis, the lymph-related parameters (nodal status, Stage III, metastatic lymph node ratio and lymphovascular invasion) were significantly associated with shorter OS and poorer DFS. At multivariate analysis, Stage III and a metastatic lymph node ratio ≥25% were found to be the only independent prognostic factors significantly correlated with worse OS and DFS.

CONCLUSION

Nodal and lymphatic status should be carefully pondered when planning the most appropriate management of patients with colorectal SRCC.

CRS + HIPEC combined with IP + IV chemotherapy for gastric signet-ring cell carcinoma: Case report of long-term survival

RATIONALE

Signet ring cell carcinoma of the stomach is prone to relapse and metastasis after traditional surgical treatment, and the prognosis is also poor. We improved the concept of treatment and conducted cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) combined with intraperitoneal (IP) and intravenous (IV) chemotherapy for a gastric signet-cell carcinoma patient.

PATIENT CONCERNS

A 65-year-old male patient with complaint of intermittent hematemesis for over 10 days was referred to our hospital for treatment. The patient developed hematemesis of 800 mL without obvious causes on May 27, 2015, accompanied by dizziness and amaurosis fugax. After the bleeding was stopped with medicinal treatment, diagnostic gastroscopy revealed an ulcer at the less curvature of the stomach, with biopsy pathology diagnosis as severe atypical hyperplasia, which was confirmed to be poorly differentiated adenocarcinoma by a second biopsy. In past medical history, the patient had 5 coronary stents implanted because of coronary atherosclerotic heart disease 3 years ago.

DIAGNOSIS

Gastric cancer (cT4NxMx) according to the patient's history and biopsy pathology.

INTERVENTIONS

the patient was treated surgery-based multidisciplinary treatments integrating CRS + HIPEC and IP + IV adjuvant chemotherapy. The CRS was curative distal gastrectomy with D2 lymphadenectomy, and HIPEC was cisplatin 120 mg plus mitomycin C 30 mg at 43 °C, for 60 minutes. Final pathological diagnosis of after surgery was: poorly differentiate adenocarcinoma with signet-ring cells, with invasion beyond the serosal layer and into the duodenum, 10/23 lymph nodes positive, nerve invasion, vascular tumor thrombi, Borrmann type IV, Lauren type diffuse. TNM stage was pT4aN3M0, IIIC. After operation, the patient received 6 courses of IV chemotherapy with oxaliplatin and 5-fluorouracil/Tegafur Gimeracil Oteracil Potassium capsules, and IP chemotherapy with docetaxel and carboplatin.

OUTCOMES

Regular follow-up till July 20, 2020, revealed that the patient has a disease-free survival of over 61+ months.

LESSONS

CRS + HIPEC combined with IP + IV chemotherapy achieved long-term disease-free survival for this patient with gastric signet-ring cell carcinoma and deserve further study. This new treatment modality deserves appropriate consideration in routine clinical practice for patients with advanced gastric cancer.

Primary signet-ring cell carcinoma of the lung: A report of seven cases

Signet‐ring cell carcinoma (SRCC) is an extremely rare subtype of adenocarcinoma with aggressive behavior that usually occurs in the gastrointestinal tract, prostate or breast. In this study, we described the clinicopathological and prognostic characteristics of, and the therapeutic strategies for seven patients with primary SRCC of the lung from Sichuan University West China Hospital to enhance our understanding of this kind of tumor. According to the information presented herein, it is believed that patients with primary pulmonary SRCC can live for a long time if the cancer is diagnosed early and treated actively. However, more investigations are still needed due to the limited reports about primary SRCC of the lung.

Key points

Significant findings of the study

Primary signet‐ring cell carcinoma of the lung is an extremely rare subtype of lung adenocarcinoma and is relatively highly invasive.

What this study adds

Early diagnosis and positive treatment lead to a good prognosis for patients with signet‐ring cell carcinoma.

Long-term outcomes and prognostic factors of young patients with mucinous and signet-ring cell colorectal cancer

INTRODUCTION

The aim of the study was to assess the clinico-pathological features and prognosis of mucinous adenocarcinoma (MAC) and signet-ring cell carcinoma (SRC) in young colorectal cancer (CRC) patients.

MATERIAL AND METHODS

We retrospectively evaluated the patient records of young patients with MAC and SRC (aged ≤ 40 years) treated at the Cancer Hospital of China Medical University from January 2006 to December 2013. Kaplan-Meier analysis and log-rank testing were performed to estimate overall survival (OS). Subsequently a Cox proportional hazard model was used to calculate hazard ratios for the risk of death.

RESULTS

A total of 90 young CRC patients (MAC = 69 and SRC = 21) were included in the analysis during the study period. The overall cumulative 5-year OS rate was 56.6 ±6%. Estimated 5-year OS was 58.1 ±7.7% for MAC and 31.3 ±12.9% for SRC (p = 0.018). On univariate analysis, metastatic disease, AJCC stage, adjuvant chemotherapy (CT), cycles of adjuvant CT, surgery type, lymphovascular invasion, perineural invasion, preoperative carcinoembryonic antigen (CEA) levels, and histologic type were significant prognostic factors for OS. In multivariate analysis, preoperative CEA levels and cycles of adjuvant CT were found to be independent prognostic factors for overall survival (hazard ratio = 2.47; 95% CI: 1.06-5.78, p = 0.037; hazard ratio = 0.18; 95% CI: 0.05-0.62, p = 0.007, respectively).

CONCLUSIONS

A greater proportion of young patients with MAC and SRC present with advanced disease. Young patients with SRC have poorer prognosis than MAC. Preoperative CEA levels and cycles of adjuvant CT are two independent predictors of overall survival for young CRC patients with MAC and SRC.

Signet-ring Cell Carcinoma in Hyperplastic Polyp of the Stomach

Signet-ring cell carcinoma rarely occurs in gastric hyperplastic polyps, with only a few such cases reported. We treated a 76-year-old woman with a signet-ring cell carcinoma arising from a hyperplastic polyp. She had been diagnosed with a gastric hyperplastic polyp four years previously. A follow-up endoscopic examination revealed the lesion in the polyp. A biopsy showed signet-ring cell carcinoma. Hybrid endoscopic submucosal dissection with snaring and a histological examination revealed signet-ring cell carcinoma in a hyperplastic polyp. The polyp was completely excised, with no evidence of recurrence one year later. A hyperplastic polyp of the stomach may transform into adenocarcinoma of an undifferentiated type.

Intramucosal poorly differentiated and signet-ring cell components in patients with ulcerative colitis-associated high-grade dysplasia

Despite the rarity of colorectal poorly differentiated adenocarcinoma (Por) and signet-ring cell carcinoma (Sig), they are more frequent in patients with ulcerative colitis (UC). However, little is known about these components of early colitis-associated cancer due to the difficulty of detection at an early stage. Here, we reviewed colitis-associated high-grade dysplasia/cancer with Por/Sig components within the submucosa among 103 lesions of 79 UC patients who presented between 1997 and 2017. In total, one Sig in situ, three intramucosal and two submucosal carcinomas (8.7%) were identified among 69 lesions within the submucosa. Depressed appearance, loss of crypt architecture and amorphous surface pattern suggested the presence of Por/Sig, rather than submucosal infiltration. All lesions were located in the rectosigmoid colon and included high-grade dysplasia. While the surrounding noncancerous mucosa expressed E-cadherin and MUC5AC, the expression of E-cadherin was reduced and the expression of MUC5AC was negative in all of the carcinomas except for the Sig in situ. The gastric type metaplasia associated with altered MUC5AC profiles may be a sign of the stepwise accumulation of molecular alterations, including TP53 defects and a reduced expression level of E-cadherin.

Using nomograms to predict prognostic factors in young colorectal mucinous and signet-ring cell adenocarcinoma patients

Due to insufficient quantitative evaluation of the clinic-pathological features and prognosis of young colorectal cancer (CRC) with mucinous adenocarcinoma (MAC) and signet-ring cell carcinoma (SRC), the aim of our study was to develop a nomogram to identify the prognostic predictors for overall survival (OS) in this patient population. We retrospectively evaluated the patient records of MAC and SRC patients aged ≤ 40 years. Kaplan–Meier analysis and log-rank testing were performed to estimate OS. A nomogram predicting OS was created for risk quantitation and decision tree analysis was performed for patient grouping. With a median follow-up of 36.5 months, we included a total of 90 young CRC patients for analysis. The overall cumulate 5-year OS rate was 57.7% (95% confidence interval (CI): 45.1–68.5%). The estimated 5-year OS was 62.9% (95% CI: 48.5–74.3%) for MAC and 37.3% (95% CI: 14.4–61.2%) for SRC (P=0.021). The recurrence rate was significantly greater in the SRC group compared with the mucinous group (52.4 compared with 26.1%, P=0.047). In the multivariate Cox regression model, preoperative carcinoembryonic antigen (CEA) levels and cycles of adjuvant chemotherapy (CT) were found to be an independent prognostic factor for OS (hazard ratio (HR): 2.43; 95% CI: 1.13–5.62, P=0.024; HR: 0.21; 95% CI: 0.083–0.57, P=0.002, respectively). Nomograms predicting 3- and 5-year OS were established that performed well (concordance index (c-indexes) of 0.636, 95% CI: 0.549–723) for OS. For MAC and SRC disease, a greater proportion of young patients present with advanced disease, and the prognosis for young SRC patients is poorer than MAC. Furthermore, preoperative CEA levels and cycles of adjuvant CT seem to independently affect the OS in this patient population.

Deep inside of gastric signet-ring cell carcinoma

The histology of signet-ring cell carcinoma (SRC) of the stomach has been revisited with the support of current immuno- histochemical techniques in order to explain particular features of this tumor; its great capacity of local diffusion and lymph node metastasis, also through a neo-lymphoangiogenesis. An observational retrospective study on 50 cases of SRC in stage II and III has been performed with the addition of histochemical (Alcian Blue, DDD-Fast Blue B, Mercury Orange) and immunohistochemical (cytocheratin, CD3, CD4, CD8, CD10, CD56, CD68, perforin, granzyme B, podoplanin, collagen type IV) investigations for each case. The signet ring cells, typical for this tumor, show abundant content of electro-negative sialomucins and demonstrate a great capacity of diffusion through the gastric wall. They evoke production and deposition of collagen type IV in the sub-mucosa layer through the local action of fibroblasts. The immunological response to this tumor in the gastric wall and in the metastatic lymph nodes is represented by an increase of B and T-helper lymphocytes, but not of T-killers or natural killers. The neoplastic cells are curiously able to avoid these newly formed 'lymph nodules'. An extended neo-lymphangiogenesis has been observed around the primary tumor and in metastatic lymph nodes. A careful immunohistochemical characterization has allowed a better knowledge of SRC, regarding especially the peculiar behavior of local diffusion of its cells, the associated neo-lymph angiogenesis, and poor immunological reaction.

[Intermittent abdominal pain and abdominal distension with fatigue and massive ascites in a 13-year-old boy]

A 13-year-old boy was admitted due to intermittent abdominal pain for one year with massive ascites. The purified protein derivative (PPD) test after admission yielded positive results (3+), and ascites examination revealed a yellow color. There were 634×10⁹ nucleated cells/L in the ascites, among which 82.2% were mononuclear cells and 17.8% were multinuclear cells. The Rivalta test yielded a positive result and revealed that the ascites was exudate, suggesting the possibility of tuberculosis infection. The symptoms were not relieved after isoniazid-rifampicin anti-tuberculosis therapy and symptomatic/supportive treatment. Plain CT scan of the abdomen and contrast-enhanced CT showed that the lesion was located at the left wall of the transverse colon, with uneven thickening of the peritoneum and heterogeneous enhancement. Colonoscopic biopsy found signet ring cells in the mucosa and immunohistochemical examination revealed Syn (-), CgA (-), CD56 (-), CK(pan) (+), CDX-2 (+), CK20 (+), Muc-1 (+) and Ki-67 (+, about 80%). PET-CT scan showed an abnormal increase in fluorodeoxyglucose metabolism, which was shown as a mass near the splenic flexure of the transverse colon, with a maximum standard uptake value of 9.9, indicating a highly active lesion; this was consistent with the metabolic changes of malignant tumors. Surgical operation was performed and intraoperative exploration revealed massive ascites, a hard mass located at the hepatic flexure of the colon, involvement of the serous coat and surrounding tissues, stenosis of the bowel, lymph node enlargement around the superior mesenteric vessels and the gastrocolic ligament, and multiple metastatic nodules in the greater omentum, the abdominal wall and the pelvic cavity. The results of postoperative pathology were consistent with those of colonoscopic biopsy, i.e., poorly differentiated mucinous adenocarcinoma of the transverse colon and partly signet-ring cell carcinoma. Therefore, the boy was diagnosed with colon signet-ring cell carcinoma with peritoneal metastasis and tuberculosis infection. When a child is suffering from intractable abdominal pain, unexplained intestinal obstruction and massive intractable ascites, the possibility of malignancy should be considered. Abdominal plain CT scan as well as contrast-enhanced CT scan should be performed as early as possible, and enteroscopy should be performed when necessary.

Signet ring cell component, not the Lauren subtype, predicts poor survival: an analysis of 198 cases of gastric cancer

AIM

Prognostic differences between major histologic gastric cancer groups, intestinal and diffuse are uncertain, since cellular components in each of them possibly have different behaviors.

MATERIALS & METHODS

We reviewed 198 gastric cancer patients charts diagnosed from January 2003 to December 2015 in a tertiary hospital. Multivariate Cox proportional survival models were used to evaluate the impact of histologic groups on overall survival.

RESULTS

About a third had the signet-ring cell carcinoma (SRCC). In a comparison of the different histologic subtypes, SRCC had the worst prognosis of all. The median durations of survival for patients with stage III and stage IV were 19.7 and 7.7 months, respectively.

CONCLUSION

Signet-ring cell component seem to have a relevant role in defining prognosis for gastric cancer.

An Autopsy Case of Pulmonary Tumor Thrombotic Microangiopathy Due to Rapidly Progressing Colon Cancer in a Patient with Type 2 Diabetes

We herein describe a case of pulmonary tumor thrombotic microangiopathy (PTTM) with rapidly progressing colon cancer. A 61-year-old man who had been receiving treatment for type 2 diabetes mellitus for 3 years was hospitalized due to critical hypoxemia. Computed tomography, which had not shown any abnormalities 3 months previously, revealed a tumor in the ascending colon, multiple nodules in the liver, and the absence of any lung abnormalities. On day 3 of hospitalization, a sudden onset of severe dyspnea and tachycardia occurred, followed by death. Autopsy revealed microscopic metastatic tumor emboli in multiple pulmonary vessels with fibrin thrombus and intimal proliferation, which led to a diagnosis of PTTM.

Signet-ring Cell Carcinoma Derived from a Main Duct-type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Case Report with Long-term Follow-up

We herein report the case of a 74-year-old man who underwent surgery 9 years after his initial visit and who was pathologically diagnosed with signet-ring cell carcinoma (SRCC) derived from a main-duct-type intraductal papillary mucinous neoplasm (MD-IPMN). At the first imaging examination, only a small pancreatic cyst with mild dilation of the main pancreatic duct (MPD) was detected in the pancreatic head. Eventually, MD-IPMN with mural nodules and MPD dilation (30 mm) developed in the pancreatic body, while the pancreatic head cyst remained unchanged. Total pancreatectomy was performed and the MD-IPMN was pathologically diagnosed as SRCC derived from an intestinal-type MD-IPMN.

Occurrence of signet-ring cell carcinoma with cholangiocarcinoma 25 years after choledochal cyst excision: A case report

RATIONALE

Choledochal cysts are a risk factor for the development of cholangiocarcinoma. Hence, complete surgical excision is the preferred treatment in most cases. However, cholangiocarcinoma still can develop from the remnant biliary system after surgical excision. Signet-ring cell carcinoma is a rare type of cancer of the biliary system, and the occurrence of signet-ring cell carcinoma after surgical excision of choledochal cysts has not been reported in the English literature to date.

PATIENT CONCERNS

We report a case of a 32-year-old woman who presented with a 1-month history of abdominal pain,obstructive jaundice, itching, and fever. The patient had undergone choledochal cyst excision and Roux-en-Y hepatico-jejunostomy 25 years previously and had now developed signet-ring cell carcinoma along with cholangiocarcinoma at the anastomotic site. DIAGNOSES:: signet-ring cell carcinoma along with cholangiocarcinoma.

INTERVENTIONS

Interventions included laparotomy with evacuation,blood transfusion,and other adjuvant therapy.

OUTCOMES

The patient died five months later.

LESSONS

Surgery is the best treatment for CCCs, and the surgeon should try to remove as much as of the bile duct cyst as possible.

An updated review on primary signet-ring cell carcinoma of the urinary bladder and report of a case

OBJECTIVE

The aim of the present study was to emphasize the critical importance of the clinician's awareness of signet-ring cell carcinoma (SRCC) of the urinary bladder, a rare and aggressive disease entity.

MATERIALS AND METHODS

A review of the current literature was conducted and a classic case of advanced SRCC of the urinary bladder is reported, clearly demonstrating the severity of this disease and the imperative need for standardized recommendations for the diagnostic work-up and management of urinary bladder SRCC.

RESULTS

The prognosis for patients with SRCC of the urinary bladder is poor, attributed to presentation at advanced stages following asymptomatic progression, inefficacy of multimodality therapy and possibly an aggressive underlying biological phenotype. Treatment options are limited and not well studied.

CONCLUSION

Given the rarity of SRCC, multi-institutional clinical trials and international cooperation are mandatory to improve survival for patients with primary SRCC of the bladder.

Differences between gastric signet-ring cell carcinoma and poorly differentiated adenocarcinoma: A comparison of histopathologic features determined by mucin core protein and trefoil factor family peptide immunohistochemistry

We investigated differences between the pathological features of gastric signet-ring cell carcinoma (sig) and poorly differentiated adenocarcinoma (por) by examining the expressions of the trefoil factor family peptides (TFFs) and mucin core proteins (MUCs). Ninety-seven tissues of 97 gastric cancer patients were selected for this study. After gastrectomy, the major histopathologic types were determined to be sig, solid-type poorly differentiated adenocarcinoma (por1), non-solid type poorly differentiated adenocarcinoma (por2), and well-differentiated tubular adenocarcinoma (tub1). We evaluated the prevalence of positive staining for MUCs (MUC5AC and MUC2) and TFFs (TFF1 and TFF3) and assessed the correlation between MUCs and TFFs in each histopathological type. The rate of MUC2 expression significantly differed between sig and por2 (50.0% vs 11.7%, P = 0.011). TFF3 expression in sig significantly differed from TFF3 expression in both por2 (100% vs 17.6%, P < 0.0001) and por1 (100% vs 33.3%, P = 0.0004). MUC5AC and TFF1 expressions were significantly correlated in por1 (r = 0.705, P = 0.002), por2 (r = 0.535, P = 0.0009), and tub1 (r = 0.470, P = 0.0034), while MUC2 and TFF3 expressions were significantly correlated only in sig (r = 0.593, P = 0.040). The expression and correlation patterns of the TFFs and MUCs suggest that the histopathologic features of gastric sig differ from those of por.

Distribution of Lgr5-positive cancer cells in intramucosal gastric signet-ring cell carcinoma

Leucine-rich repeat-containing G-protein-coupled receptor 5 (Lgr5) is a putative intestinal stem cell marker that is also expressed in various tumors. To analyze its pathological characteristics in mucosal gastric signet-ring cell carcinoma (SRCC), we investigated Lgr5 expression in 35 intramucosal gastric SRCC patients using RNAscope, a newly developed RNA in situ hybridization technique. Lgr5 expression in individual tumor cells was scored semi-quantitatively from 0 to 400. Ki67 was also examined by immunohistochemistry, with a linear arrangement of Ki67-expressing cells present in 20 of 35 cases. This area of Ki67-expressing cells was topographically divided into upper, middle, and lower regions. All cases with linear Ki67 expression patterns also had Lgr5-positive cells arranged in a linear fashion in the lower area-which was distinct from the area of high Ki67 expression. The rate of Ki67 positivity in Lgr5-positive cells was significantly lower than that of Lgr5-negative cells in areas of high Ki67 expression. In intramucosal SRCC, the low mitotic activity of Lgr5-positive cells suggests that they may represent cancer stem cells as seen in other types of stomach carcinomas. Intramucosal SRCC may therefore contain stem cells expressing Lgr5 in the lower area of the lamina propria, akin to normal gastric pyloric mucosa.

Altered Expression of Yes-associated Protein and β-Catenin in Non-neoplastic and Neoplastic Gastric Surface Epithelia

AIM

To investigate whether differential expression of Yes-associated protein (YAP) and β-catenin is important in gastric carcinogenesis.

MATERIALS AND METHODS

A total of 284 paraffin-embedded samples collected from 232 patients with gastric adenocarcinoma were used to evaluate YAP and β-catenin expression by immunohistochemistry, and the experimental findings were compared against those for gastric adenocarcinoma cell lines.

RESULTS

Nuclear YAP expression gradually increased from non-neoplastic epithelia to tubular or papillary adenocarcinomas (TPADs) and decreased in signet-ring cell carcinoma (SRCC). Cytoplasmic β-catenin expression increased from non-neoplastic epithelia to high-grade dysplasia and was decreased in TPAD and SRCC. YAP-overexpressing cell lines exhibited marked tumor cell invasion, whereas YAP-depleted cells showed reduced invasion.

CONCLUSION

Nuclear YAP and cytoplasmic β-catenin play important roles in carcinogenesis, and the differential patterns YAP and β-catenin expression between TPAD and SRCC imply the existence of different carcinogenic pathways in these conditions.

Signet-ring cell carcinoma of the colon: A case report of a 9-year-old boy

Colorectal carcinomas are common in adults; however, they rarely occur in children. The present study reported the case of a colorectal carcinoma diagnosed as signet-ring cell carcinoma in a 9-year-old boy. The patient presented with acute intestinal obstruction symptoms, which persisted following 3 days of conservative treatment. The diagnosis was determined by emergency laparotomy and a mass was identified in the transverse colon proximal to the splenic flexure. Histological examination of the mass revealed signet-ring cell carcinoma. In addition, the present study aimed to discuss the diagnostic establishment and treatment of this rare disease in children. Due to the high mortality rate caused by delays in accurate diagnoses, signet-ring cell carcinoma in children promotes a specific diagnostic and surgical challenge.

Breast metastases of gastric signet-ring cell carcinoma: a report of two cases and review of the literature

It is occasionally difficult to diagnose breast metastasis of gastric carcinoma because of its rarity. However, to appropriately treat patients with breast tumors without delay, it is important to distinguish metastatic cancer from primary breast cancer. We report two cases of breast metastasis of gastric carcinoma and review the literature. The first case was a 41-year-old female diagnosed with bilateral pelvic tumors who visited the outpatient clinic because of pain and enlargement of both breasts. Ultrasonography showed diffuse hypoechoic lesions, which were enhanced on gadolinium-enhanced magnetic resonance imaging in the bilateral mammary gland. Core needle biopsy of the right breast revealed signet-ring cells, which were also identified in the resected bilateral pelvic tumors. Subsequent upper gastrointestinal endoscopy revealed signet-ring cell carcinoma in the stomach, and the bilateral breast lesions were diagnosed as metastases of gastric carcinoma. The second case was a 34-year-old female diagnosed with cervical metastasis of signet-ring cell carcinoma who was referred to the breast cancer clinic because of a nodule in the left breast detected by computed tomography. Ultrasonography showed a hypoechoic nodule that was enhanced on gadolinium-enhanced magnetic resonance imaging. Because the pathologic findings for the left breast nodule were quite similar to those of gastric cancer and its cervical metastasis, the breast nodule was diagnosed as a metastasis of gastric carcinoma. When a breast tumor is suspected to have metastasized from a primary tumor in another organ, particularly if signet-ring cells are found, the possibility that gastric cancer is present should be considered.

Colorectal signet-ring cell carcinoma: benefit from adjuvant chemotherapy but a poor prognostic factor

Colorectal signet-ring cell carcinoma (SRCC) has been associated with poor survival compared with mucinous adenocarcinoma (MC) and the more common adenocarcinoma (AC). Efficacy of adjuvant chemotherapy in SRCC has never been assessed. This study analyzes the prognostic impact of SRCC and determines whether colonic SRCC patients benefit from adjuvant chemotherapy equally compared with MC and AC patients. Data on 196,757 colorectal cancer (CRC) patients in the period 1989-2010 was included in this Dutch nationwide population-based study. Five-year relative survival estimates were calculated and multivariate relative survival analyses using a multiple regression model of relative excess risk (RER) were performed. SRCC was found in 1,972 (1.0%) patients. SRCC patients presented more frequently with stage III or IV disease than AC patients (75.2% vs. 43.6%, p < 0.0001) and SRCC was more frequently found in the proximal colon (57.7 vs. 32.0%, p < 0.0001). SRCC patients had a poor 5-year relative survival of 30.8% (95% CI 28.1-33.6%) in the colon and 19.5% (95% CI 14.7-24.8%) in the rectum compared with 56.8% (95% CI 56.4-57.1%) and 58.5% (95% CI 57.9-59.1%) for AC. This survival difference was found in stage II, but was most prominent in stage III. Compared with AC, there was no significant interaction between SRCC and adjuvant chemotherapy (RER 1.10, 95% CI 0.81-1.51), suggesting a comparable benefit from adjuvant chemotherapy in AC and SRCC. In conclusion, the prognostic impact of SRCC is dismal in both colon and rectal cancer patients, but adjuvant chemotherapy is associated with improved survival in AC, MC, and SRCC patients.

Metastatic pattern in colorectal cancer is strongly influenced by histological subtype

BACKGROUND

Clinical studies regarding colorectal cancer (CRC) have suggested differences in metastatic patterns between mucinous adenocarcinoma (MC), signet-ring cell carcinoma (SRCC) and the more common adenocarcinoma (AC). The current study systematically evaluates metastatic patterns of different histological subtypes in CRC patients and analyzes metastatic disease upon primary tumor localization.

PATIENTS AND METHODS

A nationwide retrospective review of pathological records of 5817 patients diagnosed with CRC who underwent an autopsy between 1991 and 2010 was performed. Patients were selected from the Dutch pathology registry (PALGA). To substantiate clinical relevance, metastatic patterns were compared with the prospective randomized multicenter Total Mesorectal Excision (TME) trial, which investigated efficacy of preoperative radiotherapy in rectal cancer patients.

RESULTS

In the autopsy study, 1675 patients had metastatic disease. MC and SRCC patients more frequently had metastatic disease (33.9% and 61.2% versus 27.6%; P < 0.0001) and had metastases at multiple sites more often compared with AC patients (58.6% and 70.7% versus 49.9%; P = 0.001). AC predominantly metastasized to the liver, and MC and SRCC more frequently had peritoneal metastases. Metastatic patterns were also related to the primary tumor site, with a high rate of abdominal metastases in colon cancer patients, whereas rectal cancer patients more often had metastases at extra-abdominal sites. Results from the TME trial confirmed findings in rectal cancer patients from the autopsy study.

CONCLUSION

There are profound differences in metastatic patterns between histological subtypes and the localization of the primary tumor in CRC. Findings from this study should encourage to take these factors into account for follow-up strategies and future studies.

Early-onset diffuse gastric cancer associated with a de novo large genomic deletion of CDH1 gene

A 41-year-old man with no familial history of gastric cancer was diagnosed as with intramucosal early gastric cancer. Two months after the first endoscopic submucosal dissection for signet-ring cell carcinoma (SRCC), the appearance of previously unrecognized multiple erosions of SRCC was noticed. Pathological examination after a total gastrectomy and Roux-en-Y reconstruction with D2 lymph node dissection were performed. Postoperative pathological examination revealed 90 and more lesions, which tempted the attending pathologist to refer to genetic tests for the predisposition though the patient had no familial history of gastric cancer. There were no mutations in all the exons of CDH1 with conventional DNA sequencing, but multiplex ligation-dependent probe amplification, and reverse transcription-polymerase chain reaction analyses disclosed a large genomic deletion (c.1566-?_1711+?del), leading to the mRNA with loss of the exon 11. Among family members, his son was found to be a carrier of this change, while his parents were negative for the familial CDH1 mutation, implying that this change is a de novo event in the proband. The present report is the first description of a de novo large genomic deletion of CDH1 gene associated with early-onset diffuse gastric cancer. When the clinician finds a relatively-young patient who has multiple SRCCs, CDH1 germline mutation should be considered, even for patients with no familial history.

Clinicopathological and prognostic differences between mucinous gastric carcinoma and signet-ring cell carcinoma

OBJECTIVE

To analyze the differences in clinicopathologic characteristics and prognosis between mucinous gastric carcinoma (MGC) and signet-ring cell carcinoma (SRCC).

METHODS

Clinicopathologic and prognostic data of 1,637 patients with histologically confirmed MGC or SRCC who received surgical operations in the Department of Gastroenterological Surgery, Beijing Cancer Hospital between December 2004 and December 2009 were retrospectively collected and analyzed. The clinicopathological features were analyzed statistically using χ(2) test. Survival was analyzed using the Kaplan-Meier method and multivariate analysis of Cox proportional hazards regression model (backward, stepwise).

RESULTS

A total of 181 patients with gastric cancer (74 MGC, 107 SRCC) were included. MGC, when compared with SRCC, was featured by senile patients, stage III and IV, upper third stomach, large tumor size, positive lymph node metastasis, and positive lymphatic vascular invasion (P<0.05). The overall 5-year survival rate showed no difference between the two groups (48.8% vs. 44.8%, P>0.05). However, the survival rate for MGC patients was significant lower than that for SRCC patients when compared among the age <60 years, negative distant metastasis, and tumor localized at upper third stomach (P<0.05). Multivariate Cox proportional hazards models revealed that distant metastasis was a significant independent prognostic indicator in MGC group, and lymph node metastasis and distant metastasis was significant independent prognostic indicators in SRCC group.

CONCLUSIONS

While compared with SRCC, MGC is associated with a more aggressive tumor biologic behavior. There is no statistically significant difference in distant metastasis, an independent prognostic indicator for both MGC and SRCC, which might be the reason for no significant difference of the overall survival rate between the patients with MGC and SRCC.