Unusual Metastasis of Signet-Ring Cell Gastric Cancer That Could Not Be Detected With 18 F-FDG PET But With 68 Ga-FAPI PET/CT

ABSTRACT

A 70-year-old man who was scheduled for surgery because of the recurrence of gastric cancer was referred to our clinic preoperatively. The patient underwent a comprehensive evaluation through 18 F-FDG and 68 Ga-FAPI ( 68 Ga-labeled FAP inhibitors) PET/CT scans. The 68 Ga-FAPI PET/CT scan was particularly valuable in this case because of its ability to detect recurrent mass lesions and identify unusual metastatic sites compared with the 18 F-FDG PET/CT scan.

Comparison of 18 F-FDG and 18 F-FAPI PET/CT Findings of Signet-Ring Cell Carcinoma of the Stomach

ABSTRACT

A 66-year-old man with gastric signet-ring cell carcinoma underwent both 18 F-FDG and 18 FAl-NOTA-FAPI PET/CT imaging. There was no abnormal FDG activity in the stomach, but there was diffuse intense 18 FAl-NOTA-FAPI uptake in the known lesion and an adjacent metastasis.

Identification of gastric signet ring cell carcinoma based on endoscopic images using few-shot learning

BACKGROUND

Deep learning (DL) models perform poorly when there are limited gastric signet ring cell carcinoma (SRCC) samples. Few-shot learning (FSL) can address the small sample problem.

METHODS

EfficientNetV2-S was first pretrained on ImageNet and then pretrained on esophageal endoscopic images (i.e., base classes: normal vs. early cancer vs. advanced cancer) using transfer learning. Second, images of gastric benign ulcers, adenocarcinoma and SRCC, i.e., novel classes (n = 50 per class), were included. Image features were extracted as vectors using the dual pretrained EfficientNetV2-S. Finally, a k-nearest neighbor classifier was used to identify SRCC. The above proposed 3-way 3-shot FSL framework was conducted in three rounds.

RESULTS

Dual pretrained FSL performed better than single pretrained FSL, endoscopists and traditional EfficientNetV2-S models. Dual pretrained FSL obtained the highest accuracy (79.4%), sensitivity (68.8%), recall (68.8%), precision (69.3%) and F1-score (0.691), and the senior endoscopist achieved the highest specificity of 93.6% when identifying SRCC. The macro-AUC and F1-score for dual pretraining (0.763 and 0.703, respectively) were higher than those for single pretraining (0.656 and 0.537, respectively), along with endoscopists and traditional EfficientNetV2-S models. The 2-way 3-shot FSL also performed better.

CONCLUSION

The proposed FSL framework showed practical performance in the differentiation of SRCC on endoscopic images, suggesting the potential of FSL in the computer-aided diagnosis for rare diseases.

Factors associated with detection of hereditary diffuse gastric cancer on endoscopy in individuals with germline CDH1 mutations

BACKGROUND AND AIMS

Individuals with germline pathogenic CDH1 variants have a high risk of hereditary diffuse gastric cancer. The sensitivity of EGD in detecting signet ring cell carcinoma (SRCC) in this population is low. We aimed to identify endoscopic findings and biopsy practices associated with detection of SRCC.

METHODS

This retrospective cohort included individuals with a germline pathogenic/likely pathogenic CDH1 variant undergoing at least 1 EGD at Memorial Sloan Kettering Cancer Center between January 1, 2006, and March 25, 2022. The primary outcome was detection of SRCC on EGD. Findings on gastrectomy were also assessed. The study included periods before and after implementation of the Cambridge protocol for endoscopic surveillance, allowing for assessment of a spectrum of biopsy practices.

RESULTS

Ninety-eight CDH1 patients underwent at least 1 EGD at our institution. SRCC was detected in 20 (20%) individuals on EGD overall and in 50 (86%) of the 58 patients undergoing gastrectomy. Most SRCC foci were detected in the gastric cardia/fundus (EGD, 50%; gastrectomy, 62%) and body/transition zone (EGD, 60%; gastrectomy, 62%). Biopsy results of gastric pale mucosal areas were associated with detection of SRCC (P < .01). The total number of biopsy samples taken on EGD was associated with increased detection of SRCC (P = .01), with 43% detected when ≥40 samples were taken.

CONCLUSIONS

Targeted biopsy sampling of gastric pale mucosal areas and increasing number of biopsy samples taken on EGD were associated with detection of SRCC. SRCC foci were mostly detected in the proximal stomach, supporting updated endoscopic surveillance guidelines. Further studies are needed to refine endoscopic protocols to improve SRCC detection in this high-risk population.

The Correlation Between 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography Semiquantitative Parameters and the Clinical Features and Pathological Biological Indexes of Gastric Cancer

Objective: This study explored the application value of the maximum standard uptake value (SUVmax) of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) in gastric cancer. Materials and Methods: Data of 164 patients with gastric cancer who had undergone18F-FDG PET/CT before a biopsy were collected, and the correlation of SUVmax with clinical stage, pathological differentiation degree, human epidermal growth factor receptor-2 (HER-2) status, and Ki-67 index of gastric cancer was analyzed. Results: The SUVmax of poorly differentiated adenocarcinoma was significantly higher than that of moderately differentiated adenocarcinoma and signet-ring cell carcinoma (p < 0.01), and SUVmax in the well-differentiated adenocarcinoma group was higher than that in the signet-ring cell carcinoma group (p < 0.01). The SUVmax in the HER-2 negative group was higher than that in the HER-2 positive group (p < 0.01). The SUVmax was higher in the Ki-67 high expression group than in the low expression group (p < 0.01), and there was a significant positive correlation between the two (p < 0.01). Conclusion: 18F-FDG PET/CT SUVmax can, to some extent, predict the degree of differentiation, HER-2 status, and Ki-67 index of gastric cancer patients.

A rare cause of intestinal obstruction in children: signet-ring cell adenocarcinoma of the colon

BACKGROUND

Signet-ring cell adenocarcinoma of the colon is well-recognized in adult patients who are extremely rare and not well-documented in children. Our study aims to raise awareness about this rare disease and its long-term outcomes.

METHODS

We retrospectively evaluated patients with signet-ring cell colon adenocarcinoma.

RESULTS

Six patients, three boys and three girls, with a mean age of 14.83 (range, 13-17 years), presented with signs of intesti-nal obstruction and were diagnosed with signet-ring cell colon adenocarcinoma. All patients had air-fluid levels on abdominal X-ray. Abdominal ultrasonography of all patients revealed subileus. Abdominal computed tomography was performed in five patients, and pre-operative colonoscopy was conducted in two patients before the emergency intervention. All of the patients underwent emergent exploratory laparotomy with the preliminary diagnosis of acute abdomen. In two patients, debulking surgery followed by a stoma was performed. The remaining four patients were treated with anastomosis following intestinal resection. All girls had metastases on the ovary. One of the patients died due to the burden of multiple metastases in the early period, and three died in the sixth post-operative year. We have been following the remaining two patients since then.

CONCLUSION

Although signet-ring cell carcinomas (SRCCs) are rare, they should be considered in the differential diagnosis of acute abdomen and intestinal obstruction in pediatric patients. Despite early diagnosis and treatment, SRCC has a poor prognosis in the pediatric population.

CT-based radiomics nomograms for preoperative prediction of diffuse-type and signet ring cell gastric cancer: a multicenter development and validation cohort

BACKGROUND

The prevalence of diffuse-type gastric cancer (GC), especially signet ring cell carcinoma (SRCC), has shown an upward trend in the past decades. This study aimed to develop computed tomography (CT) based radiomics nomograms to distinguish diffuse-type and SRCC GC preoperatively.

METHODS

A total of 693 GC patients from two centers were retrospectively analyzed and divided into training, internal validation and external validation cohorts. Radiomics features were extracted from CT images, and the Lauren radiomics model was established with a support vector machine (SVM) classifier to identify diffuse-type GC. The Lauren radiomics nomogram integrating radiomics features score (Rad-score) and clinicopathological characteristics were developed and evaluated regarding prediction ability. Further, the SRCC radiomics nomogram designed to identify SRCC from diffuse-type GC was developed and evaluated following the same procedures.

RESULTS

Multivariate analysis revealed that Rad-scores was significantly associated with diffuse-type GC and SRCC (p < 0.001). The Lauren radiomics nomogram showed promising prediction performance with an area under the curve (AUC) of 0.895 (95%CI, 0.957-0.932), 0.841 (95%CI, 0.781-0.901) and 0.893 (95%CI, 0.831-0.955) in each cohort. The SRCC radiomics nomogram also showed good discrimination, with AUC of 0.905 (95%CI,0.866-0.944), 0.845 (95%CI, 0.775-0.915) and 0.918 (95%CI, 0.842-0.994) in each cohort. The radiomics nomograms showed great model fitness and clinical usefulness by calibration curve and decision curve analysis.

CONCLUSION

Our CT-based radiomics nomograms had the ability to identify the diffuse-type and SRCC GC, providing a non-invasive, efficient and preoperative diagnosis method. They may help guide preoperative clinical decision-making and benefit GC patients in the future.

[Late recurrence of gastric cancer diagnosed 10 years after curative gastrectomy: a review of 30 Japanese case reports]

A woman in her 50s was referred to our hospital with intestinal obstruction. Ten years prior, she had been treated for gastric cancer, pathologically confirmed as stage IIIA poorly differentiated adenocarcinoma with signet-ring cell carcinoma. Intraoperatively, a 4-cm hard white tumor was found in the mesoileum and around the ileum. Pathological examination revealed poorly differentiated adenocarcinoma with signet-ring cell carcinoma and infiltration and fibrosis. Late peritoneal recurrence of gastric carcinoma was diagnosed. Recurrence of gastric carcinoma more than 10 years after curative gastrectomy is extremely rare. A review of 30 cases reported in Japan revealed recurrence was more frequent in females (60%) and the mean age was around 50 years at the time of primary surgery. Poorly differentiated adenocarcinoma and/or signet-ring cell carcinoma was the primary gastric cancer in 82% of cases and bone metastasis was the most frequent site of recurrence.

Signet ring cell carcinoma of bladder: a dilemma between primary and metastatic

Signet ring cell carcinoma, in general, is a peculiar tumour. There is always a query regarding its exact site of origin. Even, immunohistochemistry shows overlapping staining patterns between various sites. On one hand, signet ring cell carcinoma of the bladder is a rare occurrence, but on the other hand metastatic signet ring cell carcinoma to the bladder is not uncommon. However, without prior knowledge of the primary site of tumour clinically and radiologically, definitive diagnosis is challenging based on morphology and immunohistochemistry.

Comparison of 18F-AlF-NOTA-FAPI and 18F-FDG Imaging in a Patient With Gastric Signet-Ring Cell Carcinoma

ABSTRACT

Several case reports have shown fibroblast activation protein inhibitor (FAPI) imaging to be superior to 18F-FDG imaging in the delineation of primary gastric signet-ring cell carcinoma lesions. In this case, 18F-AlF-NOTA-FAPI PET/CT showed more metastatic lesions that had more increased activity than 18F-FDG PET/CT. However, neither 18F-AlF-NOTA-FAPI nor 18F-FDG imaging revealed any abnormal uptake in the primary gastric lesion, which was subsequently demonstrated to be the primary lesion by pathology.

Widespread Metastatic Gastric Signet-Ring Cell Carcinoma Shown by 68Ga-FAPI PET/CT

ABSTRACT

The present study compared 68Ga-FAPI and 18F-FDG PET/CT in a patient with GSRCC (gastric signet-ring cell carcinoma). In this case, 68Ga-FAPI PET/CT shows much higher tumor-to-background contrast of primary tumor and reveals more metastatic lesions than 18F-FDG PET/CT. This case demonstrates that 68Ga-FAPI PET/CT outperforms 18F-FDG in identifying both primary and metastatic lesions in GSRCC.

Primary signet ring cell carcinoma of the pancreas A case report about an extremely rare variant of pancreatic carcinoma

INTRODUCTION

Primary signet ring cell carcinoma of the pancreas (PSRCCP) is an extremely rare histologic variant of pancreatic carcinoma, which cells are characterized by large mucin vacuoles and peripheric nucleus that producing a signet ring aspect.

CASE REPORT

We present a case about 66 years old man, with history of chronic pancreatitis and Wirsung stenosis of unknown origin, came to our attention for abdominal pain compatible with pancreatitis exacerbation. A TC scan showed a head of pancreas' neoformation, and a MRI showed numerous metastatic liver lesions confirming the presence of pancreatic lesion (52x46) mm. Fine needle aspiration biopsy of liver was suggestive of signet ring cell carcinoma. As second step, an ERCP was performed in order to get a biopsy of pancreatic lesion and drain the biliary tract. No surgical approach was possible as well as the progressive complications arised after diagnosis contraindicated chemotherapy. The patient died 3 month after diagnosis.

CONCLUSION

PSRCCP is an aggressive malignancy with low survival rate, because of high metastatization rate. Only 9 cases are described in literature at December 2019, so we consider our work a precious contribute to knowledge.

KEY WORDS

Pancreatic tumor, Pancreas, Pancreatic carcinoma, Primary signet ring cell carcinoma of the pancreas. Signet ring cell carcinoma.

Case series of three patients with hereditary diffuse gastric cancer in a single family: Three case reports and review of literature

BACKGROUND

Hereditary diffuse gastric cancer (HDGC) is a familial cancer syndrome often associated with germline mutations in the CDH1 gene. However, the frequency of CDH1 mutations is low in patients with HDGC in East Asian countries. Herein, we report three cases of HDGC harboring a missense CDH1 variant, c.1679C>G, from a single Japanese family.

CASE SUMMARY

A 26-year-old female (Case 1) and a 51-year-old male (father of Case 1), who had a strong family history of gastric cancer, were diagnosed with advanced diffuse gastric cancer. After genetic counselling, a 25-year-old younger brother of Case 1 underwent surveillance esophagogastroduodenoscopy that detected small signet ring cell carcinoma foci as multiple pale lesions in the gastric mucosa. Genetic analysis revealed a CDH1 c.1679C>G variant in all three patients.

CONCLUSION

It is important for individuals suspected of having HDGC to be actively offered genetics evaluation. This report will contribute to an increased awareness of HDGC.

Relationship between PD-L1 expression and 18F-FDG uptake in gastric cancer

PURPOSE

Immunotherapy has been successfully utilized for treatment of gastric cancer, so the identification of clinicopathologic features that are predictive of response to this therapy is crucial. ¹⁸F-FDG PET/CT can provide information on the molecular phenotype of many malignant tumors. The correlation between ¹⁸F-FDG accumulation and PD-L1/PD-L1-TILs status in gastric cancer patients has not been investigated. The aim of the current study is to assess whether ¹⁸F-FDG accumulation is associated with PD-L1/PD-L1-TILs status, and whether ¹⁸F-FDG PET/CT may be useful for predicting PD-L1/PD-L1-TILs expression of gastric cancer.

RESULTS

Tumors with positive PD-L1 expression had higher SUVmax than in tumors with negative PD-L1 expression (15.0 ± 8.0 vs. 7.2 ± 4.2, respectively; P = 0.004). Tumors with positive PD-L1-TILs expression also had higher SUVmax than in tumors with negative PD-L1-TILs expression (10.3 ± 6.5 vs. 6.6 ± 3.7, respectively; P = 0.034). Multivariate analysis suggested that SUVmax remained significantly correlated with the status of PD-L1 (P = 0.043) and PD-L1-TILs (P = 0.016). PD-L1 expression was predicted with an accuracy of 67.2% when a SUVmax value of 8.55 was used as a cutoff point for analysis. Similarly, PD-L1-TILs expression was predicted with an accuracy of 64.2%, when a SUVmax value of 7.9 was used as the threshold for analysis.

CONCLUSION

Higher ¹⁸F-FDG accumulation in gastric cancers is correlated with positive PD-L1/PD-L1-TILs expression. ¹⁸F-FDG PET/CT may be used to predict the status of PD-L1/PD-L1-TILs and thus aid in optimal treatment decision.

METHODS

A retrospective analysis was conducted on 64 patients with gastric cancer who underwent ¹⁸F-FDG PET/CT. SUVmax was calculated from the ¹⁸F-FDG accumulation of the primary tumor. The relationship between SUVmax and PD-L1/PD-L1-TILs status was analyzed.

Refractory Chylothorax and Lymphedema Caused by Advanced Gastric Cancer

Chylothorax is the accumulation of lipid pleural effusion. Few reports have described chylothorax caused by gastric cancer. A 45-year-old woman presented with progressive lymphedema and bilateral chylothorax. Although repetitive thoracentesis was performed to relieve her dyspnea, swelling of her axillary lymph nodes became significant. Positron emission tomography/computed tomography demonstrated the accumulation of ¹⁸F-fluorodeoxyglucose in these nodes, and a lymph node biopsy showed signet ring cell carcinoma. The primary site was a 0-IIc type lesion in the gastric body that was only detected by upper gastrointestinal endoscopy. The patient was diagnosed with advanced gastric cancer 3.5 months after presentation for chylothorax.

Gastric adenocarcinoma of fundic gland type with signet-ring cell carcinoma component: A case report and review of the literature

A depressed lesion was found at a gastric angle of 76-year-old Japanese woman by esophagogastroduodenoscopy. Four years prior, she was diagnosed with a Helicobacter pylori infection but no eradication was performed. The pathological diagnosis of biopsy specimens was signet-ring cell carcinoma. Endoscopic submucosal dissection (ESD) was performed. Histopathological examination of the ESD specimen revealed proliferation of well-differentiated tubular adenocarcinoma mimicking fundic gland cells at the deep layer of the lamina propria mucosae. These tumor cells expressed focally pepsinogen-I, diffusely MUC6, and scattered H⁺/K⁺ ATPase according to immunohistochemistry. Therefore, we diagnosed this tumor as gastric adenocarcinoma of fundic gland type (GA-FG). Adjacent to the GA-FG, proliferation of signet-ring cell carcinoma which diffusely expressed MUC 2 and MUC 5AC was observed. Intestinal metaplasia was focally observed in the surrounding mucosa of the signet-ring cell carcinoma. To the best of our knowledge, this is the first case report of GA-FG with a signet-ring cell carcinoma component. The origin of signet-ring cell carcinoma, i.e., whether it accidentally arose from a non-neoplastic mucosa and coexisted with the GA-FG or dedifferentiated from the GA-FG is unclear at present. We expect the accumulation of similar cases and further analysis to clarify this issue.

Comparative study of endoscopic surveillance in hereditary diffuse gastric cancer according to CDH1 mutation status

BACKGROUND AND AIMS

Hereditary diffuse gastric cancer (HDGC) accounts for 1% of gastric cancer cases. For patients with a germline CDH1 mutation, risk-reducing gastrectomy is recommended. However, for those delaying surgery or for families with no causative mutation identified, regular endoscopy is advised. This study aimed to determine the yield of signet ring cell carcinoma (SRCC) foci in individuals with a CDH1 pathogenic variant compared with those without and how this varies with successive endoscopies.

METHODS

Patients fulfilling HDGC criteria were recruited to a prospective longitudinal cohort study. Endoscopy was performed according to a strict protocol with visual inspection followed by focal lesion and random biopsy sampling to detect foci of SRCC. Survival analysis determined progression to finding of SRCC according to CDH1 mutation status. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and 36-item Short Form Health Survey questionnaires assessed quality of life before surveillance and each endoscopy.

RESULTS

Eighty-five individuals fulfilling HDGC criteria underwent 201 endoscopies; 54 (63.5%) tested positive for CDH1 mutation. SRCC yield was 61.1% in CDH1 mutation carriers compared with 9.7% in noncarriers, and mutation-positive patients had a 10-fold risk of SRCC on endoscopy compared with those with no mutation detected (P < .0005). Yield of SRCC decreased substantially with subsequent endoscopies. Surveillance was associated with improved psychological health.

CONCLUSIONS

SRCC foci are prevalent in CDH1 mutation carriers and can be detected at endoscopy using a standardized, multiple biopsy sampling protocol. Decreasing yield over time suggests that the frequency of endoscopy might be reduced. For patients with no CDH1 pathogenic variant detected, the cost-to-benefit ratio needs to be assessed in view of the low yield.

In vivo histological diagnosis for gastric cancer using endocytoscopy

AIM

To examine usefulness of virtual biopsy using endocytoscopy by comparing the in vivo endocytoscopic and histopathological images of gastric cancers.

METHODS

Endocytoscopy was performed in 30 patients with early gastric cancer. Of these, 26 patients showed well differentiated adenocarcinomas, while 4 patients showed poorly differentiated adenocarcinomas (including one signet ring cell carcinoma). Cancerous and non-cancerous areas were observed after double staining with 0.05% crystal violet and 0.1% methylene blue. The endocytoscopic images obtained were evaluated by an expert endoscopist and an expert pathologist without knowledge of patient clinical data, and endocytoscopic and histopathological diagnoses were compared.

RESULTS

The endocytoscopic images of the cancerous area were assessed as evaluable in 25 (83.3%) and 27 (90%) patients by endoscopist A and pathologist B, respectively, and those of the non-cancerous area as evaluable in 28 (93.3%) and 23 (76.7%) patients by the endoscopist and pathologist, respectively. The sensitivity, specificity, and diagnostic accuracy of gastric cancer diagnosis using evaluable endocytoscopic images were 88.0% and 92.9%, and 90.6% by endoscopist A, and 88.9% and 91.3%, and 90.0% by pathologist B, respectively. Evaluation of the diagnostic concordance rate between the endoscopist and the pathologist by inter-observer agreement calculation revealed no significant difference between the two observers. The inter-observer agreement (κ-value) for endocytoscopic diagnosis was 0.745.

CONCLUSION

Endocytoscopy is useful for the differentiation of cancerous from non-cancerous gastric mucosa, making it a promising tool for virtual biopsy.

Serial renography for evaluation of the impact of capecitabine therapy on renal function: A case report

RATIONALE

Cancer can cause renal dysfunction and disease either directly or indirectly, through adverse effects of therapies, including chemotherapy and radiation. The assessment of renal function in cancer patients is necessary in clinical practice.

PATIENT CONCERNS

A 31-year-old woman had proctoscopy performed in our hospital for a principal complaint of bloody stool for 6 months and worsening 1 month prior to presentation.

DIAGNOSES

Following proctoscopy, she was diagnosed with a signet-ring cell carcinoma of the rectum. Hartman surgery was performed. Metastasis of the carcinoma to regional lymph nodes around the rectum was verified by postoperative pathology.

INTERVENTIONS

The patient was treated with capecitabine, and renal function was monitored over the course of treatment by renography before, during, and after chemotherapy.

OUTCOMES

We found that capecitabine caused a reversible decline of renal function. However, the value of blood urea nitrogen (BUN) and serum creatinine (Cr) remained within the normal range during chemotherapy. The patient's chemotherapy regimen was altered after her oncologists concluded that she was developing nephrotoxicity from capecitabine. She was treated with tegafur, gimeracil and oteracil potassium capsules. This patient was followed over the next 6 months, and no abnormal renal function re-occurred.

LESSONS

Our experience with capecitabine shows that dosing adjustments can be warranted for chemotherapy in cancer patients, requiring monitoring of renal function. Renography may provide an early warning to protect the renal function of tumor patients when they receive chemotherapy.

[Comparison of CT manifestations of primary colorectal mucinous adenocarcinoma and signet ring cell carcinoma]

OBJECTIVE

To compare the difference in CT manifestations between primary colorectal mucinous adenocarcinoma and signet ring cell carcinoma in order to improve radiologic diagnosis.

METHODS

Clinicopathological data and CT findings of 109 patients with colorectal mucinous adenocarcinoma and 46 patients with primary colorectal signet-ring cell carcinoma confirmed by surgery and pathology from March 2008 to February 2015 in the Tumor Hospital of Yunnan Province were retrospectively collected. Differences in age, gender, tumor location, length and thickness of the involved intestinal wall, thickening pattern of the intestinal wall, lesion density, calcification, contrast-enhanced form, peri-intestinal invasion, occurrence of intestinal obstruction and metastasis of other organs were compared between the two groups.

RESULTS

Among 109 patients with colorectal mucinous adenocarcinoma, 68 were men and 41 were women with a mean age of (56.8±15.4) years. Among 46 patients with primary colorectal signet-ring cell carcinoma, 26 were men and 20 were women with a mean age of (42.9±15.6) years. Compared with mucinous adenocarcinoma group, signet-ring cell carcinoma group showed more concentric bowel-wall thickening[93.5%(43/46) vs. 81.6%(89/109), χ²=9.19, P=0.030], higher lesion density [(42.0±3.0) Hu vs. (28.5±1.5) Hu, t=37.30, P=0.000], more marked enhancement [54.3%(25/46) vs. 12.8%(14/109), χ²=35.21, P=0.000], less vast-low-density region in enhanced CT imaging[2.2%(1/46) vs. 45.0%(49/109), χ²=73.31, P=0.000] and more severe peri-intestinal invasion [41.3% (19/46) vs. 17.4%(19/109), χ²=10.25, P=0.006]. Calcification was found in 18.3%(20/109) of mucinous adenocarcinoma cases, but was not found in signet-ring cell carcinoma cases (χ²=9.69, P=0.002). Target ring sign in contrast-enhanced scan was observed in 15.2%(7/46) of signet-ring cell carcinoma cases, while in none of mucinous adenocarcinoma cases (χ²=17.37, P=0.000). There were no statistically significant differences in lesion location, length and thickness of the involved intestinal wall, occurrence of intestinal obstruction, lymph node metastasis, liver or peritoneum metastasis between two groups(all P>0.05).

CONCLUSIONS

Signet-ring cell carcinoma is often found in younger patients, whose CT manifestation is characterized by the target ring sign in contrast-enhanced scan, while primary colorectal mucinous adenocarcinoma is often in older patients, whose CT manifestation is characterized by calcification in unenhanced scan and low density region in enhanced CT show.

Signet ring cell carcinoma of the jejunum: an uncommon finding within the reach of capsule endoscopy

An 80 year-old female presented with ductal breast carcinoma (stage II) three years ago, complained of asthenia and iron-deficiency anemia. No diagnosis was obtained after conventional endoscopy and iron supplements were indicated. Ten months later visible digestive hemorrhage was presented. Upper and lower endoscopy was repeated but non-diagnosis was obtained. Thus, video capsule endoscopy was indicated identifying a stenotic lesion arising in the mucosa of distal jejunum. Histopathological examination revealed a poorly mucinous differentiated signet-ring cell adenocarcinoma with an intense peri-tumoral lymphoid (Crohn´s-like lymphoid reaction) and lympho-vascular infiltration with no nodal metastases (pT3N0;7ª edition TNM classification). Immunochemistry revealed negative stained for estrogen and progesterone receptors in contrast with prior breast cancer. Thus, metastatic origin was rule out. Primary small-bowel malignancies are extremely rare. They account for 2% of all gastrointestinal tract malignancies. Carcinoid tumor (40%), adenocarcinoma (33%), lymphoma (17%) and sarcoma (8%) are most common histological types. Symptomatic lesions are rare, but when present: gastrointestinal bleeding, abdominal pain and weight loss are most common digestive symptoms. Primary signet ring cell adenocarcinoma is a rarely histopathological variety of adenocarcinoma with poor prognosis, usually identified in esophageal or gastric locations (95%). They are less commonly detected in remaining gastrointestinal tract, and when present, metastatic origin must always rule out. Nowadays, diagnostic delayed is common and leads to detected small bowel neoplasms at late stages with poor treatment outcomes. Thus, capsule endoscopy may help to improve this situation as it may identify them at early stages.

Gastric cancer: texture analysis from multidetector computed tomography as a potential preoperative prognostic biomarker

OBJECTIVES

To investigate the association between preoperative texture analysis from multidetector computed tomography (MDCT) and overall survival in patients with gastric cancer.

METHODS

Institutional review board approval and informed consent were obtained. Fifty-six patients with biopsy-proved gastric cancer were examined by MDCT and treated with surgery. Image features from texture analysis were quantified, with and without filters for fine to coarse textures. The association with survival time was assessed using Kaplan-Meier and Cox analysis.

RESULTS

The following parameters were significantly associated with a negative prognosis, according to different thresholds: energy [no filter] - Logarithm of relative risk (Log RR): 3.25; p = 0.046; entropy [no filter] (Log RR: 5.96; p = 0.002); entropy [filter 1.5] (Log RR: 3.54; p = 0.027); maximum Hounsfield unit value [filter 1.5] (Log RR: 3.44; p = 0.027); skewness [filter 2] (Log RR: 5.83; p = 0.004); root mean square [filter 1] (Log RR: - 2.66; p = 0.024) and mean absolute deviation [filter 2] (Log RR: - 4.22; p = 0.007).

CONCLUSIONS

Texture analysis could increase the performance of a multivariate prognostic model for risk stratification in gastric cancer. Further evaluations are warranted to clarify the clinical role of texture analysis from MDCT.

KEY POINTS

• Textural analysis from computed tomography can be applied in gastric cancer. • Preoperative non-invasive texture features are related to prognosis in gastric cancer. • Texture analysis could help to evaluate the aggressiveness of this tumour.

Ependymoma with diffuse signet-ring features: report of a case and review of the literature

Signet-ring cell ependymoma is a rare variant of ependymoma with only seven cases described in literature. Biological behavior and prognosis of this entity are not well-known until now. We present a case of a 49-year-old female with a history of headache and gait instability. Magnetic resonance imaging showed an upper cervical tumor with cystic component and mural nodule. The patient underwent surgery. Microscopically some cells displayed an eccentric nucleus compressed to the periphery by vacuolated cytoplasm. Perivascular pseudorosettes and ependymal rosettes were seen only focally. The cells were positive for glial fibrillary acidic protein and epithelial membrane antigen. The diagnosis was ependymoma with diffuse signet-ring features, grade II according to the World Health Organization. It may be difficult to diagnose this unusual variant of ependymoma especially on small biopsies or frozen sections. A complete examination of the specimen is recommended with immunohistochemical confirmation to rule out potential morphologic mimics, such as metastatic adenocarcinomas and gliomas in the differential diagnosis.

[Hereditary diffuse gastric cancer]

Hereditary diffuse gastric cancer is an autosomal dominant syndrome associated to CDH1 gene mutation that affects at least 30% of CDH1+ families, with a penetrance of 80% at 80 years, and multifocal signed ring cell in most of the cases. The suggested treatment is a prophylactic total gastrectomy with Roux-en-Y esophagojejunostomy, malignancy sing must be imperative a gastrectomy.

Successful distal gastrectomy after distal pancreatectomy combined with splenectomy by assuring the blood flow to the remnant stomach from the left inferior phrenic artery

BACKGROUND/AIMS

The current literature would suggest that patients with gastric cancer who have a previous history of ligation of the splenic artery undergo total gastrectomy. However, an analysis of the risk factors for postoperative complications in elderly patients showed a higher rate of morbidities for total gastrectomy compared to subtotal gastrectomy. Case

REPORT

We herein report a rare case of successful distal gastrectomy in a 78-year-old female diagnosed with gastric cancer with a previous history of distal pancreatectomy combined with splenectomy, because an adequate blood flow was provided by the fundic branches from the left inferior phrenic artery. Preoperative computed tomography demonstrated a ligated splenic artery and left gastric artery with developed fundic branches from the left inferior phrenic artery. The intraoperative findings showed a sufficient blood flow to the proximal stomach after ligation of all main gastric arteries, thus suggesting that the gastric remnant could be supplied by the fundic branches from the LIPA. The patient’s postoperative course was uneventful.

CONCLUSION

This case suggests that a distal gastrectomy is a possible treatment modality even after distal pancreatectomy combined with splenectomy.

Metastatic signet ring cell carcinoma presenting as a thyroid diffuse involvement: report of a case studied with Q-elastographic and acoustic radiation force impulse imaging features

Metastatic carcinomas to the thyroid are rare in daily clinical practice. However, when encountered they represent a diagnostic challenge, since it is difficult to distinguish them from primary thyroid lesions, especially when occurring in patients with occult malignant history. Nevertheless, it is critical to differentiate a metastatic tumor from primary thyroid lesions, as the clinical management and the prognosis are different for the two entities. More recently, elastosonography opened new possibilities to ultrasound in different fields, such as thyroid nodule differentiation. Herein, we report a case of metastatic signet ring cell carcinoma to the thyroid studied with quantitative elastography and acoustic radiation force impulse imaging.

Acute aortic thrombosis during cisplatin based chemotherapy for gastric cancer

The development of aortic thrombosis without the presence of atheroscrelosis, dissection, or aneurysms is rare. A cancer-related hypercoagulable state is a well-known risk factor for venous thrombosis, however, atrial thrombosis has rarely been reported in cancer patients. Cisplatin-based chemotherapy is known to cause various side-effects. Detecting aortic thrombosis is important because it is a fatal condition. We herein present the first reported case of endo-aortic thrombosis occurring during cisplatin-based chemotherapy for gastric cancer.

Primary signet-ring cell adenocarcinoma of the uterine cervix: case report and review of the literature

Signet-ring cell adenocarcinoma is a rare subtype of the uterine cervix; thus there are no guidelines and the prognosis is unknown. There seems to be a significant role for reporting the treatment and outcome of this rare disease in order to establish guidelines and to assist in decision-making. However, treatment should be tailored to each patient according to clinical status and disease stage. Excluding extra-genital origin is mandatory, as it will change treatment management considerably.

Good response chemotherapy for late-recurring gastric cancer in the gluteals, with peritoneal and retroperitoneal dissemination

A 64-year-old woman presented with advanced gastric cancer (signet ring cell carcinoma) and underwent total gastrectomy in 1996. Postoperative recovery was good, and she was monitored regularly on an outpatient basis. Abdominal computed tomography in 1999 revealed a soft tissue shadow ventral to the origin of the celiac artery. Careful monitoring was continued on an outpatient basis. The patient began to experience gluteal swelling and pain in April 2008. Symptoms rapidly exacerbated and the patient was hospitalized for further examination. Gluteal muscle biopsy revealed signet ring cell carcinoma and bilateral hydronephrosis. Gluteal recurrence of the original gastric cancer was suggested, and systemic chemotherapy consisting of S-1 at 100 mg/day (3 weeks on, 1 week off) and CDDP (day 8) was started. Following the 6th cycle of chemotherapy, gluteal symptoms disappeared and the patient was judged to have achieved clinical complete response (CR). No adverse events or image findings suggesting new recurrence have since been identified. The patient received a total CDDP dose of 585 mg and clinical CR has been maintained as of 14 years after total gastrectomy and 18 months after recurrence.

A case with cardiac tamponade as the first sign of primary gastric signet-ring cell carcinoma treated with combination therapy

BACKGROUND

This report presents a rare patient with cardiac tamponade as the first manifestation of primary gastric signet-ring cell carcinoma.

CASE REPORT

A 56-year-old woman with emergent dyspnea, anterior chest oppression, and hypotension was diagnosed as having cardiac tamponade due to massive pericardial effusion. The endoscopic examination of the stomach disclosed gastric cancer in the posterior wall of the antrum and the biopsy showed signet-ring cell carcinoma. The gastric cancer was complicated by malignant pericardial effusion and pleural effusion as well as metastasis to the peripheral lymph nodes and bones. The patient was treated with percutaneous pericardiocentesis followed by systemic chemotherapy (oxaliplatin and sequential 5-fluorouracil plus leucovorin). The pericardial effusion gradually disappeared and there was no cardiac tamponade occurrence. The patient has survived more than 6 months so far.

CONCLUSIONS

Cardiac tamponade may originate from a primary gastric signet-ring cell carcinoma. Pericardiocentesis followed by systemic chemotherapy may be effective in controlling such advanced gastric signet-ring cell carcinoma.

[A case of metastatic lung tumor with multiple ground glass opacities on chest CT]

A 70-year-old man was admitted to our hospital because of multiple ground-glass opacities on his chest CT scan. A transbronchial lung biopsy specimen revealed signet-ring cell carcinoma infiltrating into the alveolar septa. The histological findings of the carcinoma obtained from the lung were very similar to those of his gastric carcinoma which had been resected at age 66. Immunohistochemical staining of the cancer cells were positive for keratin 7 and keratin 20, therefore a metastatic lung tumor from gastric cancer was diagnosed. Although multiple, well-defined nodules are typically considered to be the presentation of pulmonary metastases, clinicians should also be aware that multiple, ill-defined ground-glass opacities can also be recognized as pulmonary metastasis.

Signet-ring cell carcinoma arising from the urinary bladder

INTRODUCTION

Signet-ring cell carcinoma of the urinary bladder can be primary - arising from the bladder wall or urachus remnants - or metastatic from tumors originating in the stomach, colon, or breast. Saphir first described primary signet-ring cell cancer of the urinary bladder in 1955. Less than 100 cases have been reported in the literature since then.

CASE REPORT

We report a case of a 45-year-old woman who was admitted with gross hematuria. Cystoscopy revealed a necrotic tumor on the left bladder wall. A transurethral biopsy showed signet-ring cell carcinoma. The bladder tumor was diagnosed as the primary one. Radical cystectomy was performed with ureterosigmoidostomy (Mainz pouch II). Histological examination showed a primary signet-ring cell carcinoma of the bladder (pT3bN0M0). Following surgery, the patient received adjuvant chemotherapy with cisplatin and fluorouracil.

CONCLUSIONS

Primary signet-ring cell carcinoma of the urinary bladder is an extremely rare tumor, accounting for approximately 0.24% of all bladder malignances. Patients with this type of cancer generally have a poor prognosis. However, our patient is free of disease 5 years after radical cystectomy.

Signet ring cell carcinoma of the lower bile duct with rapid growth: report of a case

Signet ring cell carcinoma occurring in the biliary tract is extremely rare. We herein report the case of a 78-year-old Japanese woman demonstrating signet ring cell carcinoma of the lower bile duct with a rapid growth. Computed tomography of the pancreas head pointed out a circular thickness in the lower bile ductal wall and stenosis of the common bile duct. Cholangiography revealed tapering stenosis at the lower bile duct. Biopsy specimens taken from these lesions and scratched specimens taken from stenotic portion of the lower bile duct were analyzed and demonstrated signet ring cell carcinoma. To the best of our knowledge, this is the first reported case of primary signet ring cell carcinoma of the lower bile duct reported in the English literature. Based on our experience, signet ring cell carcinoma of the lower bile duct is considered to demonstrate both transmural dispersion and an aggressive nature.

Carcinogenic hypergastrinemia: signet-ring cell carcinoma in a patient with multiple endocrine neoplasia type 1 with Zollinger-Ellison's syndrome

CONTEXT

Gastric neuroendocrine tumors are rare neoplasms that originate from gastric enterochromaffin-like (ECL) cells in the oxyntic mucosa. Gastrin and its derivates have been reported to regulate epithelial cell proliferation, migration, and differentiation. Mutations in the epithelial cadherin (E-cadherin) gene have been shown to be associated with the occurrence of diffuse gastric carcinomas in affected families.

OBJECTIVE

In this study we investigated the histopathological and molecular findings in the gastrointestinal wall of a patient with multiple endocrine neoplasia type 1 with malignant duodenal gastrinoma and multiple gastric ECL cell tumors, who additionally developed a signet-ring cell carcinoma of the stomach.

DESIGN AND PATIENT

Biopsies from the gastrointestinal tract of a patient with multiple endocrine neoplasia type 1 were immunostained for vesicular monoamine transporter-2 and E-cadherin. Nonamidated gastrin products were measured in the serum of the patient using antibodies that react with progastrin, Gly-extended, and amidated gastrins. Genetic analyses were performed to exclude germ-line mutations within the E-cadherin gene.

RESULTS

Immunohistochemical studies of gastric ECL cell tumors showed a largely diminished E-cadherin expression in comparison to gastric surface mucosa cells and a loss of E-cadherin expression in the cells of the signet-ring carcinoma. Detailed biochemical measurements revealed progastrin concentrations that were approximately 20%, and Gly-gastrin concentrations that were approximately 10% the amidated gastrin concentrations in plasma. Molecular analyses revealed no E-cadherin germ-line mutation.

CONCLUSION

Our immunohistochemical studies might suggest that the gastrinoma-associated excessive progastrin tissue concentrations led to diminished expression of E-cadherin within the gastric mucosa and promoted tumor development of a signet-ring cell carcinoma.

[Metastatic signet ring cell carcinoma to the breast from stomach]

Metastatic tumors in the breast are quite rare and constitute 0.5 to 6% of all breast malignancies. They often occur in a polymetastatic context. The most frequent primitive tumors are lymphoma, leukaemia and malignant melanoma. The gastric origin is seldom reported. We report here the observation of a 40-years woman operated in urgency for an acute abdominal syndrome. A gastric tumor was discovered intraoperatively with ovarian metastasis and peritoneal carcinosis. The pathological examination revealed a gastric signet ring cell carcinoma with an infiltration of the right ovary. Four months later, the patient presented with a lump of the right breast. The histologic examination corresponded to a mammary metastasis by a signet ring cell carcinoma from stomach. The objective of our work is to discuss through this observation the anatomoclinical and evolutionary characteristics of breast metastasis.

[Adenocarcinoma of the appendix. A case report and review of the literature]

Primary adenocarcinoma of the appendix is a rare malignancy that constitutes less than 0.5% of all gastrointestinal neoplasms. Usually the diagnosis is made only after histological examination of surgically removed inflamed appendix. Alternatively represent an unexpected finding, confirmed by frozen section, during surgery performed for acute appendicitis or other non appendiceal pathologies. Natural history is strongly influenced by anatomic peculiarities of the appendix that predispose to early spread and perforation. Frequently is associated with synchronous and metachronous colorectal or extraintestinal cancers. The correct management is the right hemicolectomy as a primary procedure in the case of preoperatively or intraoperatively diagnosis or as secondary procedure, after two-three weeks from appendectomy, when the microscopic examination of specimen reveals the presence of adenocarcinoma. Right hemicolectomy is the best treatment for all histologic types (colonic, mucinous, adenocarcinoid), in presence of perforation and even in Dukes A tumors. A careful intraoperative search for synchronous lesions and a life-long program of surveillance for the detection of early stage metachronous carcinomas are recommended. The Authors report a case of primary adenocarcinoma of the appendix occurred in a 78 year-old female patient, diagnosed incidentally during surgery performed for ileus from suspected cecal neoplasm.

Advanced gastric carcinoma with signet ring cell carcinoma versus non-signet ring cell carcinoma: differentiation with multidetector CT

OBJECTIVE

The purpose of this study is to assess the capability of multidetector computed tomography (MDCT) to assist in the differentiation of advanced gastric carcinoma with signet ring cell type from that with non-signet ring cell carcinoma (NSRC) with a focus on the thickened stomach wall itself.

METHODS

We retrospectively reviewed MDCT results in 80 patients with pathologically proven advanced gastric carcinoma with signet ring cell carcinoma (SRC) (n = 35) and NSRC (n = 45). MDCT images of 80 patients were analyzed retrospectively on gross appearance of thickened gastric wall (polypoid/fungating/ulcerative/diffuse infiltrative), predominantly thickened layer (inner/outer), contrast-enhancement pattern (nonlayered/layered) and degree of enhancement (high/moderate/low).

RESULTS

The most common type of gross appearance in both carcinomas was fungating, and the more common contrast-enhancement pattern in both carcinomas was a nonlayered pattern. The predominantly thickened layer was a high attenuation inner layer in both carcinomas. High-degree contrast enhancement was more common in SRC (37.1% of patients) than NSRC (15.6% of patients) with statistically significant difference (P = 0.01).

CONCLUSIONS

Multidetector CT cannot distinguish SRC from NSRC based on the thickened stomach wall alone. But, high-degree contrast enhancement was more common in advanced gastric carcinoma with SRC than that with NSRC.

Metastatic signet ring adenocarcinoma: an unusual cause of cardiac constriction

Pericardial constriction secondary to metastatic adenocarcinoma is exceedingly rare. We present the first recorded case of pericardial constriction secondary to metastatic signet-ring mucinous adenocarcinoma diagnosed by echocardiography. The cornerstones of echocardiographic diagnosis of constriction are the following: interventricular septal bounce phasic with respiration, M-mode recordings of the inferior vena cava, and the characteristic Doppler velocity patterns recorded from the mitral valve, hepatic veins, and mitral annulus.

[Malignant tumor with false negative 18F-FDG PET image]

OBJECTIVE

To investigate the FDG uptake characteristics, the factors affecting 18F-FDG uptake and the extra CT diagnostic value of 18F-FDG PET/CT scan in the malignant tumor with false negative 18F-FDG PET image.

METHODS

The data of PET/CT image in 17 patients with various kinds of cancers were reviewed and analyzed by visual observation and semi-quantity analysis ( SUV). The results were compared with the CT and histopathological diagnosis, respectively.

RESULTS

Of 6 well-differentiated HCC patients confirmed by histopathological diagnosis, one had two lesions in the right lobe of the liver. One of these two lesions showed low FDG uptake on 18F-FDG PET scan and low density on CT scan. The other one was not shown on either 18F-FDG PET or plain CT scan. But on enhanced CT scan, these two lesions were found to be inhomogeneous with high density at arterial phase. The false negative 18F-FDG PET images of one gastric signet ring cell carcinoma in the gastric fundus with right adnexa metastasis, 3 renal cell carcinoma, one greater omentum and peritoneal metastatic adenocarcinoma and one well-differentiated prostate cancer were caused by normal physical uptake in the digestive tract or FDG retention in the urinary system due to normal excretion. The size of three metastases was smaller than or equal to 1 cm in diameter, however, two primary lesions of these metastases showed high FDG uptake and only one was negative on either 18F-FDG PET or CT scan. In this series, 68.8% of the primary tumors and 66.7% of metastases were found to show abnormal density on CT scan, and 31. 2% of the primary tumors and 33. 3% of metastases were not detectable on either PET or CT images.

CONCLUSION

False negative 18F-FDG PET in malignant tumor may be correlated with the pathologic type, differentiation degree and the lesion size. Combining CT information with PET or paying attention to the scan methods during 8 F-FDG PET examination may reduce the rate of false negative 18F-FDG PET diagnosis in various kinds of malignant tumors.

Recurrencia de un carcinoma gástrico de células en anillo de sello demostrada por PET-FDG

OBJECTIVE

To present the case report of a patient with undifferentiated and diffuse signet-ring cell gastric carcinoma in which FDG-PET evidenced recurrent disease.

MATERIALS AND METHODS

The patient was diagnosed of a stage III gastric carcinoma in 1994 and was treated with a subtotal gastrectomy. In February 2003, recurrent disease was detected in mediastinal and left supraclavicular lymph nodes. The patient was treated with chemotherapy and radiotherapy, reaching a complete response. After 6 months free of disease, he presented an elevation of the tumor markers with negative results in conventional imaging methods (upper digestive endoscopy, bone scintigraphy, and CT). An FDG-PET scan was performed to rule out recurrent disease.

RESULTS

FDG-PET detected pathologic findings suggestive of malignant disease in right supraclavicular and mediastinal lymph nodes. These findings were confirmed by clinical follow-up and with another CT scan performed 4 months later.

CONCLUSIONS

In this case report we stress the importance of early recurrence by FDG-PET in a non-intestinal gastric carcinoma. This is of interest given the greater difficulty to detect mucous secreting and/or producing carcinomas with the PET-FDG.

Improvement in preoperative staging of gastric adenocarcinoma with positron emission tomography

BACKGROUND

Positron emission tomography (PET) with 18- fluorodeoxyglucose (FDG) has been used to both detect and stage a variety of malignancies. The current study examined the value of PET for preoperative staging of gastric adenocarcinoma.

METHODS

Sixty-eight patients (49 males and 19 females) with gastric adenocarcinoma, who were referred for preoperative FDG-PET scans, were enrolled in this study. The patients underwent spiral-computed tomography (CT) within 1 week of referral. The final diagnosis in all patients was made by histologic and surgical findings. For quantitative PET analysis, the regional tumor FDG uptake was measured by the standardized uptake value (SUV).

RESULTS

For the primary tumor of a gastric adenocarcinoma, PET demonstrated an increased uptake in 64 of 68 patients (sensitivity, 94%), with a mean SUV of 7.0 (range, 0.9-27.7). A comparison of FDG uptake and clinicopathologic features showed significant association between FDG uptake and macroscopic type, tumor size, lymph node metastasis, histologic type, and TNM stage. The PET scan had a similar accuracy with that of CT for diagnosing local and distant lymph node metastases as well as peritoneal status. In assessing local lymph node status, however, PET had a higher specificity than CT (92% vs. 62%, P = 0.000). Moreover, PET had additional diagnostic value in 10 (15%) of 68 patients by upstaging 4 (6%) and downstaging 6 (9%) patients. PET combined with CT was more accurate for preoperative staging than either modality alone (66% vs. 51%, 66% vs. 47%, respectively; P = 0.002).

CONCLUSIONS

FDG-PET improves the preoperative TNM staging of gastric adenocarcinoma. Based on its superior specificity, FDG-PET can facilitate the selection of patients for a curative resection by confirming a nodal status identified by CT.