Background Of Intestinal Metaplasia Research Articles

“Find Your Y”: histological differences in early stage (pT) and post-treatment (ypT) oesophageal adenocarcinoma with implications for salvage endoscopic resection

AimsCurrent guidelines offer limited strategies for managing recurrent/persistent oesophageal adenocarcinoma (EAC). Salvage endoscopic mucosal/submucosal resection (ER) shows promise in oesophageal squamous cell carcinoma, however its success in EAC is limited....

OLFM4 promotes the progression of intestinal metaplasia through activation of the MYH9/GSK3β/β-catenin pathway

BackgroundIntestinal metaplasia (IM) is classified into complete intestinal metaplasia (CIM) and incomplete intestinal metaplasia (IIM). Patients diagnosed with IIM face an elevated susceptibility to the development of gastric cancer, underscoring the critical need for early screening measures. In addition to the complexities associated with diagnosis, the exact mechanisms driving the progression of gastric cancer in IIM patients remain poorly understood. OLFM4 is overexpressed in several types of tumors, including colorectal, gastric, pancreatic, and ovarian cancers, and its expression has been associated with tumor progression.MethodsIn this study, we used pathological sections from two clinical centers, biopsies of IM tissues, precancerous lesions of gastric cancer (PLGC) cell models, animal models, and organoids to explore the role of OLFM4 in IIM.ResultsOur results show that OLFM4 expression is highly increased in IIM, with superior diagnostic accuracy of IIM when compared to CDX2 and MUC2. OLFM4, along with MYH9, was overexpressed in IM organoids and PLGC animal models. Furthermore, OLFM4, in combination with Myosin heavy chain 9 (MYH9), accelerated the ubiquitination of GSK3β and resulted in increased β-catenin levels through the Wnt signaling pathway, promoting the proliferation and invasion abilities of PLGC cells.ConclusionsOLFM4 represents a novel biomarker for IIM and could be utilized as an important auxiliary means to delimit the key population for early gastric cancer screening. Finally, our study identifies cell signaling pathways involved in the progression of IM.

Mucin-Phenotype and Expression of the Protein V-Set and Immunoglobulin Domain Containing 1 (VSIG1): New Insights into Gastric Carcinogenesis.

In gastric cancer (GC), intestinal metaplasia (IM) is a common precursor lesion, but its relationship to the MUC2/MUC5AC/CDX2 axis is not completely understood. Although V-set and immunoglobulin domain containing 1 (VSIG1) is supposed to be a specific marker for gastric mucosa and GC, respectively, no data about its relationship with IM or mucin phenotype have been published. The aim of our study was to explore the possible linkage between IM and these four molecules. The clinicopathological features of 60 randomly selected GCs were examined in association with VSIG1, MUC2, MUC5AC and CDX2. Two online database platforms were also used to establish the transcription factors (TFs) network involved in MUC2/MUC5AC/CDX2 cascade. IM was more frequently encountered in females (11/16 cases) and in patients below 60 years old (10/16 cases). Poorly differentiated (G3) carcinomas tended to show a loss of CDX2 (27/33 cases) but not of MUC2 and MUC5AC. MUC5AC and CDX2 were lost in parallel with the depth of invasion of the pT4 stage (28/35 and 29/35 cases), while an advanced Dukes-MAC-like stage was only correlated with CDX2 and VSIG1 loss (20/37 and 30/37 cases). VSIG1 was directly correlated with MUC5AC (p = 0.04) as an indicator of gastric phenotype. MUC2-negative cases showed a propensity towards lymphatic invasion (37/40 cases) and distant metastases, while CDX2-negative cases tended to associate with hematogenous dissemination (30/40 cases). Regarding the molecular network, only 3 of the 19 TFs involved in this carcinogenic cascade (SP1, RELA, NFKB1) interacted with all targeted genes. In GC, VSIG1 can be considered an indicator of gastric phenotype carcinomas, where carcinogenesis is mainly driven by MUC5AC. Although infrequently encountered in GC, CDX2 positivity might indicate a locally advanced stage and risk for vascular invasion, especially in tumors developed against the background of IM. The loss of VSIG1 indicates a risk for lymph node metastases.

Undifferentiated Carcinoma of Esophagus with SMARCA4 Deletion Expressing Synaptophysin: A Potential Diagnostic Pitfall.

Undifferentiated carcinoma of the esophagus is an entity that is included in WHO classification of digestive systems fifth edition (2018). The definition of this entity is a malignant esophageal epithelial tumor that lacks definite microscopic features of squamous, glandular, or neuroendocrine differentiation. It is a challenging diagnosis to make due to lack of diagnostic criteria. We report a case from a 45 years old man with a mass in the lower third of esophagus. Biopsy showed an epitheloid neoplasm with sheet like growth pattern and no glandular formation. The tumor cells had prominent nucleoli and indistinct cell borders. There were occasional rhabdoid cells. By immunostains, tumor cells were focally positive for pankeratin, keratin 7, synaptophysin, negative for CDX2 and p40, INSM1, chromogranin, and CD56. Background intestinal metaplasia (Barrett esophagus) was present. Next generation sequencing of the tumor revealed SMARCA4 deep deletion. The tumor showed loss of SMARCA4 by immunostain. This case demonstrates that undifferentiated carcinoma of the esophagus with SMARCA4 deletion can express synaptophysin. Awareness of this entity is important for the correct classification of this tumor.

Abstract P059: A case of stage I esophageal adenocarcinoma diagnosed using a multi-cancer early detection test

Abstract Introduction: There is no guideline-recommended screening test for esophageal cancer, a cancer that occurs in approximately 1 in 125 men and 1 in 417 women in the US. Risk factors for esophageal adenocarcinoma include gastroesophageal reflux disease, Barrett’s esophagus, obesity, and smoking. A multi-cancer early detection (MCED) test that analyzes methylation patterns of cell-free DNA in the blood using sequencing assays and machine-learning classifiers is available as a complement to existing single-cancer screening tests. The MCED test reports either (1) ‘cancer signal detected’ with 1 or 2 cancer signal origin (CSO) prediction(s) or (2) ‘cancer signal not detected’. A case of esophageal adenocarcinoma is presented here to demonstrate early detection using the MCED test and to review the diagnostic journey following a cancer signal detected (positive) test result. Case Description/Methods: An asymptomatic 63-year-old White male (BMI: 27 kg/m2) with history of peptic ulcer disease was screened using the MCED test. He reported moderate alcohol use (6/week) and no tobacco use. His last colonoscopy was 5 years prior to using the test. Nine days after a blood sample was collected for analysis by the MCED test, a positive test result (CSO prediction=Stomach/Esophagus) was reported and communicated to the patient (Day 1). Computed tomography (CT) of the chest, abdomen, and pelvis with contrast showed no significant findings (Day 13). A submucosal bulge just below the gastroesophageal junction (GEJ) was noted on upper endoscopy. The lesion, and area above the GEJ were extensively biopsied (Day 15). Pathologic evaluation confirmed diagnosis of Clinical Stage I esophageal adenocarcinoma with superficial focally invasive adenocarcinoma arising in a background of intestinal metaplasia with high grade dysplasia (Day 29). The patient underwent total gastrectomy without complications (Day 104). He will undergo appropriate follow-up 6 months post-op. Discussion: The MCED test detected a cancer signal and predicted a gastrointestinal CSO for an asymptomatic individual with Clinical Stage I esophageal cancer. Diagnostic resolution was achieved within 1 month and treatment was provided with curative intent. Given that there is no guideline-recommended screening test available for esophageal cancer, the use of this MCED test detected cancer early, directed diagnostic workup, and potentially improved outcomes for this asymptomatic patient. Citation Format: David DeAtkine Jr. A case of stage I esophageal adenocarcinoma diagnosed using a multi-cancer early detection test. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P059.

S3581 Common Variable Immunodeficiency and Gastric Carcinogenesis: Two Illustrative Cases

Introduction: Common variable immunodeficiency (CVID) is linked to an increased risk for gastric cancer which seems to be associated with achlorhydria, H. pylori infection, decreased production of gastric IgA, and autoimmune phenomena. We present two patients illustrating progression of gastric pathology in CVID through dysplasia to cancer. Case Description/Methods: A 42-year-old woman with CVID presented with dyspepsia, diarrhea and a 75 lb weight loss. Small intestinal bacterial overgrowth was diagnosed and treated. EGD revealed a superficial ulcer at the incisura. Pathological examination demonstrated chronic active gastritis with H. pylori and intestinal metaplasia (IM) without dysplasia. Triple therapy was unsuccessful; repeat EGD 1 year later demonstrated 3 superficial ulcers at the incisura and antrum; biopsies revealed chronic active gastritis with H. pylori and IM without dysplasia. Second-line therapy failed. 3 years later, EGD showed a non-bleeding cratered ulcer with a nodular edge on the greater curvature in the antrum. Biopsies demonstrated an invasive tubular adenocarcinoma arising in a background of IM with low and high grade dysplasia and no evidence of H. pylori. Partial gastrectomy with Roux-en-Y gastrojejunostomy and modified D2 lymphadenectomy was performed. Pathologic examination confirmed a T1aN0M0 moderately differentiated adenocarcinoma. A 64-year-old woman with CVID, celiac disease, pernicious anemia and a CTLA4 gene mutation presented in 2019 for surveillance following removal of a gastric adenoma by EMR 2 months earlier. From 2018-2022, EGDs with gastric mapping were performed every 6 months and revealed progression from low to focal high grade dysplasia. In 2019, surveillance biopsies showed foci of low and high grade dysplasia in the antrum. EMR of a sessile polyp and ESD of 2 sessile polyps were performed followed by EMR of a sessile antral polyp and EMR of diffusely nodular mucosa at the incisura 5 months later. Biopsies have been consistently negative for H. pylori. Discussion: These cases illustrate progression to cancer in CVID and exemplify two risk factors: Helicobacter pylori and achlorhydria. Both progressed from low to high grade dysplasia and, in one, to invasive cancer within 4 years. Guidance on surveillance for IM in the non-CVID population varies in terms of frequency and intervals; with the risk of progression to cancer in CVID increased 10-47-fold, there is an urgent need for guidelines on surveillance.

Quantification of TFF3 expression from a non-endoscopic device predicts clinically relevant Barrett's oesophagus by machine learning.

SummaryBackgroundIntestinal metaplasia (IM) is pre-neoplastic with variable cancer risk. Cytosponge-TFF3 test can detect IM. We aimed to 1) assess whether quantitative TFF3 scores can distinguish clinically relevant Barrett's oesophagus (BO) (C≥1 or M≥3) from focal IM pathologies (C<1, M<3 or IM of gastro-oesophageal junction); 2) whether TFF3 counts can be automated to inform clinical practice.MethodsPatients from the Barett's oEsophagus Screening Trial 2 (BEST2) case-control and BEST3 randomised trials were used. For aim 1, TFF3-positive glands were scored manually and correlated with clinical diagnosis. For aim 2, machine learning approach was used to obtain TFF3 count and logistic regression with cross-validation was trained on the BEST2 dataset (n = 529) and tested in the BEST3 dataset (n = 158).FindingsPatients with clinically relevant BO had higher mean TFF3 gland count compared to focal IM pathologies (mean difference 4.14; 95% confidence interval, CI 2.76-5.52, p < 0.001). The mean class-balanced validation accuracy was 0.84 (95% CI 0.77-0.90), and precision of 0.95 (95% CI 0.87-1.00) for detecting clinically relevant BO. Applying this model on BEST3 showed precision of 0.91 (95% CI 0.85-0.97) for focal IM pathologies with a class-balanced accuracy of 0.77 (95% CI 0.69-0.84). Using this model, 55% of patients (87/158) in BEST3 would fall below the threshold for clinically relevant BO and could avoid gastroscopy, while only missing 5.1% of patients (8/158).InterpretationAutomated Cytosponge-TFF3 gland quantification may enable thresholds to be set to trigger confirmatory gastroscopy to minimize overdiagnosis of focal IM pathologies with very low cancer-associated risk.FundingCancer Research UK (12088/16893 and C14478/A21047).

CD10 and Das1: a biomarker study using immunohistochemistry to subtype gastric intestinal metaplasia

BackgroundIntestinal metaplasia (IM) is considered a key pivot point in the Correa model of gastric cancer (GC). It is histologically subtyped into the complete and incomplete subtypes, the latter being associated with a greater risk of progression. However, the clinical utility of IM subtyping remains unclear, partially due to the absence of reliable defining biomarkers.MethodsBased on gene expression data and existing literature, we selected CD10 and Das1 as candidate biomarkers to distinguish complete and incomplete IM glands in tissues from patients without GC (IM-GC) and patients with GC (IM + GC). Immunohistochemical staining of individually subtyped IM glands was scored after blinding by two researchers using tissue belonging to both IM-GC and IM + GC patients. Whole tissue Das1 staining was further assessed using digital image quantification (cellSens Dimension, Olympus).ResultsAcross both cohorts CD10 stained the IM brush border and was shown to have a high sensitivity (87.5% and 94.9% in IM-GC and IM + GC patients respectively) and specificity (100.0% and 96.7% respectively) with an overall AUROC of 0.944 for complete IM glands. By contrast Das1 stained mainly goblet cells and the apical membrane of epithelial cells, mostly of incomplete IM glands with a low sensitivity (28.6% and 29.3% in IM-GC and IM + GC patients respectively) but high specificity (98.3% and 85.1% respectively) and an overall AUROC of 0.603 for incomplete IM glands. A combined logistic regression model showed a significant increase in AUROC for detecting complete IM glands (0.955 vs 0.970). Whole tissue digital quantification of Das1 staining showed a significant association with incomplete IM compared to complete IM, both in IM-GC and in IM + GC patients (p = 0.016 and p = 0.009 respectively, Mann–Whitney test and unpaired t test used). Additionally, complete IM in IM + GC patients exhibited significantly more Das1 staining than in IM-GC patients (p = 0.019, Mann–Whitney test).ConclusionsThese findings suggest that CD10 is an outstanding biomarker for complete IM and Das1 may be useful as a secondary biomarker for IM glands at greater risk of progression irrespective of IM subtype. Overall, the clinical use of these biomarkers could lead to improved patient stratification and targeted surveillance.

Infection with a hypervirulent strain of Helicobacter pylori primes gastric cells toward intestinal transdifferentiation

BackgroundIntestinal metaplasia, gastric-to-intestinal transdifferentiation, occurs as a result of the misexpression of certain regulatory factors, leading to genetic reprogramming. Here, we have evaluated the H. pylori-induced expression patterns of these candidate genes. MethodsThe expression levels of 1) tissue-specific transcription factors (RUNX3, KLF5, SOX2, SALL4, CDX1 and CDX2), 2) stemness factors (TNFRSF19, LGR5, VIL1) and 3) tissue-specific mucins (MUC5AC, MUC2) were evaluated by quantitative real-time PCR in gastric primary cells (GPCs), in parallel with two gastric cancer (MKN45 and AGS) cell lines, up to 96h following H. pylori infection. ResultsFollowing H. pylori infection of GPCs, RUNX3 declined at 24h post infection (−6.2 ± 0.3) and remained downregulated for up to 96h. Subsequently, overexpression of self-renewal and pluripotency transcription factors, KLF5 (3.6 ± 0.2), SOX2 (7.6 ± 0.5) and SALL4 (4.3 ± 0.2) occurred. The expression of TNFRSF19 and LGR5, demonstrated opposing trends, with an early rise of the former (4.5 ± 0.3) at 8h, and a simultaneous fall of the latter (-1.8 ± 0.5). This trend was reversed at 96h, with the decline in TNFRSF19 (−5.5 ± 0.2), and escalation of LGR5 (2.6 ± 0.2) and VIL1 (1.8 ± 0.3). Ultimately, CDX1 and CDX2 were upregulated by 1.9 and 4.7-fold, respectively. The above scenario was, variably observed in MKN45 and AGS cells. ConclusionOur data suggests an interdependent gene regulatory network, induced by H. pylori infection. This interaction begins with the downregulation of RUNX3, upregulation of self-renewal and pluripotency transcription factors, KLF5, SOX2 and SALL4, leading to the downregulation of TNFRSF19, upregulation of LGR5 and aberrant expression of intestine-specific transcription factors, potentially facilitating the process of gastric-to-intestinal transdifferentiation.

Long-term natural history after endoscopic resection for gastric dysplasia.

Natural history after endoscopic resection (ER) for gastric dysplasia is still unclear. The aim of this study was to evaluate the long-term clinical outcomes and risk factors after ER for gastric dysplasia between control and cases with synchronous or metachronous gastric neoplasm. A total of 1090 patients who had undergone ER for gastric dysplasia and been followed up for at least one year from December 2002 to December 2013 were finally analyzed. Risk factors affecting the development of synchronous or metachronous neoplasm (SMN) and long-term clinical outcomes after ER for gastric dysplasia were evaluated. Synchronous and metachronous neoplasms had developed in 126 (11.6%) and 133 patients(12.2%) during the mean follow-up duration of 63.6months, respectively. Five-year and 10-year risk of metachronous neoplasm were 9.8% and 27.2%, respectively. Median duration to the development of metachronous neoplasm was 103.1months. While age (P < 0.001) and mucosal atrophy (P = 0.09) of index cases were associated with the development of synchronous neoplasm, age (P = 0.017), incomplete resection (P = 0.025), and intestinal metaplasia (P = 0.017) of background mucosa of index cases were significantly related to the development of metachronous neoplasm in multivariate analysis. Cumulative incidence of SMN was not significantly different among H. pylori negative, eradicated, and persistent group. Age, incomplete ER, and background intestinal metaplasia of index gastric dysplasia were significantly associated with metachronous recurrence. Endoscopic surveillance for metachronous recurrence after ER for gastric dysplasia is mandatory for longer than 10years.

Detection of early adenocarcinoma of the esophagogastric junction by spraying an enzyme-activatable fluorescent probe targeting Dipeptidyl peptidase-IV

BackgroundIt is still difficult to detect and diagnose early adenocarcinoma of the esophagogastric junction (EGJ) using conventional endoscopy or image-enhanced endoscopy. A glutamylprolyl hydroxymethyl rhodamine green (EP-HMRG) fluorescent probe that can be enzymatically activated to become fluorescent after the cleavage of a dipeptidyl peptidase (DPP)-IV-specific sequence has been developed and is reported to be useful for the detection of squamous cell carcinoma of the head and neck, and esophagus; however, there is a lack of studies that focuses on detecting EGJ adenocarcinoma by fluorescence molecular imaging. Therefore, we investigated the visualization of early EGJ adenocarcinoma by applying EP-HMRG and using clinical samples resected by endoscopic submucosal dissection (ESD).MethodsFluorescence imaging with EP-HMRG was performed in 21 clinical samples resected by ESD, and the fluorescence intensity of the tumor and non-tumor regions of interest was prospectively measured. Immunohistochemistry was also performed to determine the expression of DPP-IV.ResultsFluorescence imaging of the clinical samples showed that the tumor lesions were visualized within a few minutes after the application of EP-HMRG, with a sensitivity, specificity, and accuracy of 85.7, 85.7, and 85.7%, respectively. However, tumors with a background of intestinal metaplasia did not have a sufficient contrast-to-background ratio since complete intestinal metaplasia also expresses DPP-IV. Immunohistochemistry measurements revealed that all fluorescent tumor lesions expressed DPP-IV.ConclusionsFluorescence imaging with EP-HMRG could be useful for the detection of early EGJ adenocarcinoma lesions that do not have a background of intestinal metaplasia.

1686 Laparoscopic-Assisted Endoscopic Submucosal Dissection of Early Gastric Adenocarcinoma

INTRODUCTION: A 69-year-old man underwent esophagogastroduodenoscopy (EGD) a year ago which showed intestinal metaplasia without dysplasia in the gastric antrum and incisura. A repeat EGD showed a single plague in the distal esophagus and erosive gastritis. Biopsies revealed high grade dysplasia (HGD) in the gastric cardia and extensive intestinal metaplasia in the rest of the stomach. A subsequent endoscopic ultrasound and CT imaging of chest, abdomen and pelvis revealed no evidence of extraluminal extension or distant metastasis. Given the tumor location surgical resection would require a total gastrectomy. After consultation with surgical oncology, a decision was made to attempt endoscopic submucosal dissection (ESD) with laparoscopic assistance. CASE DESCRIPTION/METHODS: In this video report, an initial EGD was performed which confirmed a superficial gastric ulcer in the cardia. A laparoscopic gastrotomy with placement of the 15mm laparoscopic port was performed. The endoscope with a cap was introduced through the port directly into the stomach. The lesion in the gastric cardia was visualized in a retrograde direction. ESD was performed using a Dual-J Knife. A 15mm area was resected. The ESD site was examined for any perforation, bleeding or defects and none were noted. Following the endoscopic portion of the procedure, the abdomen was re-insufflated and inspected for signs of perforation and none were found. The gastrotomy was then closed. On gross pathologic examination the gastric cardia specimen measured 1.9 × 1.7 × 0.3 cm. Microscopic examination revealed well differentiated (G1) focal intramucosal adenocarcinoma arising in a background of intestinal metaplasia with HGD. Tumor invaded lamina propria but no invasion of muscularis mucosa was identified. All margins were uninvolved by carcinoma and dysplasia. The final pathologic stage of the resected specimen was pT1a. Given the findings, lymph node disease was determined to be extremely low and less invasive ESD was expected to be curative 1, 2. A follow up EGD 2-months post-procedure showed no evidence of recurrence. DISCUSSION: In conclusion, tumors of the gastric cardia are among the most technically difficult lesions to be removed by ESD with curative rates around 66% 3. This decreases further with tumors located in the anterior hemisphere or have deep submucosal invasion. Laparoscopic assistance provides a head on view for a full thickness ESD. Our case demonstrates this technique is safe and effective. Watch the video: http://bit.ly/2LuEe7N.

2705 Incidental Finding of Gastric Adenocarcinoma on Random Gastric Biopsy: A Call for Methodical Examination of the Gastric Mucosa

INTRODUCTION: Gastric cancer is the 5th most common neoplasm and the 3rd most deadly cancer worldwide. Adenocarcinomas account for 95% of cases. It is more prevalent and has a higher mortality in males. We present a case of gastric adenocarcinoma detected incidentally on random gastric biopsy. CASE DESCRIPTION/METHODS: A 73-year old white male underwent upper endoscopy for reflux. He had a 55-pack year smoking history, no significant alcohol use, and normal BMI. Esophagogastroduodenoscopy (EGD) revealed a 4 mm hypopigmented area in the incisura and was otherwise normal. Random gastric biopsies included the area. One of 6 specimens revealed intramucosal adenocarcinoma in a background of intestinal metaplasia, and H. pylori organisms. It involved the lamina propria and was suspicious for invasion. On repeat EGD 11 days later, previous biopsy sites were seen showing some fibrosis, likely given the short interval between endoscopies. Frozen section biopsy of the incisura confirmed cancer. Due absence of a visible lesion, the site was biopsied extensively and tattooed prior to surgical referral. The patient underwent distal gastrectomy with Roux en Y reconstruction and lymphadenectomy. The surgical specimens showed no residual malignancy, negative and viable margins, and benign lymph nodes. Quadruple therapy successfully eradicated H. pylori. DISCUSSION: The incidence of gastric cancer in North America is 5.6 per 100,000, higher than that for esophageal cancer. The 5-year survival rate in the US is 31%, reflecting that most diagnoses are made when the cancer has metastasized. This rate increases dramatically to 94% and 88% when stage IA and IB tumors are surgically treated, respectively. Early gastric cancer can be subtle in appearance and may be missed during routine endoscopy. Retrospective studies comparing examination time for EGD reveal that endoscopists with longer mean exam (longer than 7 min in the US, 3 min in Korea) detect more neoplastic lesions than shorter exams. The European Society of Gastrointestinal Endoscopy to recommends an examination time of 7 minutes from intubation of the esophagus to extubation. This case highlights (1) that a comprehensive systematic exam must be consistently performed to investigate the entire stomach, (2) the importance of NBI with near focus mode to closely examine mucosal vascularization and pit pattern in order to diagnosis of a small malignant lesions, and (3) the need for targeted biopsies to be placed in separate jars.

Expression of GCRG213p, LINE-1 endonuclease variant, significantly different in gastric complete and incomplete intestinal metaplasia

BackgroundIntestinal metaplasia (IM) of the gastric mucosa is classified as complete (Type I) and incomplete IM (Type II and III) subtypes, which showed significantly different risk for developing to gastric adenocarcinoma (GAC). GCRG213, a variant of L1-endonuclease (L1-EN), first identified in our lab, was upregulated in GAC tissue. However, the relationship between GCRG213 and IM subtypes is not clear. Our study explored the association of GCRG213 protein (GCRG213p) with IM subtypes.MethodsGastric cancer and/or para-tumor tissue samples were collected from 123 patients who underwent gastrectomy for intestinal type gastric adenocarcinoma. The subtypes of IM were characterized with Alcian blue-periodic acid-Schiff and High Iron Diamine-Alcian blue staining methods. Immunohistochemistry of GCRG213p was performed, and its expression in gastric adenocarcinoma and para-tumor tissue including dysplasia, IM, and normal mucosa were analyzed.ResultsGCRG213p was expressed in 48.94% IM, 57.14% dysplasia and 55.32% GAC, respectively. GCRG213p expression was higher in well and moderately differentiated adenocarcinoma (P = 0.037). In IM glands, GCRG213p expressed mainly in the cytoplasm of absorptive enterocytes with defined brush borders, but not in goblet cells. The expression of GCRG213p in type I IM (90.00%) was significantly higher than that in type II (36.36%) and type III (25.00%) (P < 0.001). In normal gastric mucosa, GCRG213p was exclusively positive in the cytoplasm of gastric chief cells.ConclusionsThe expression of GCRG213p in complete IM was significantly higher than in incomplete IM, which implies that GCRG213p may play a role on the developing of IM to adenocarcinoma. GCRG213p was exclusively expressed in chief cells, suggesting that it might be involved in cell differentiation from the chief cells to IM.

SOX2 interferes with the function of CDX2 in bile acid-induced gastric intestinal metaplasia

BackgroundIntestinal metaplasia (IM) is a premalignant lesion associated with gastric cancer. Both animal and clinical studies have revealed that bile acid reflux and subsequent chronic inflammation are key causal factors of IM. Previous studies indicated that SOX2, the key transcription factor in gastric differentiation, was downregulated during IM development while CDX2, the pivotal intestine-specific transcription factor was upregulated significantly. However, it remains unclear whether the downregulation of SOX2 promotes gastric IM emergence or is merely a concomitant phenomenon. In addition, the underlying mechanisms of SOX2 downregulation during IM development are unclear.MethodsGastric cell lines were treated with deoxycholic acid (DCA) in a dose-dependent manner. The expression of CDX2 and miR-21 in gastric tissue microarray were detected by immunohistochemistry and in situ hybridization. Coimmunoprecipitation and immunofluorescence were performed to ascertain the interaction of SOX2 and CDX2. Luciferase reporter assays were used to detect the transcriptional activity of CDX2, and confirm miR-21 binding to SOX2 3′-UTR. The protein level of SOX2, CDX2 and downstream IM-specific genes were investigated using western blotting. mRNA level of miR-21, SOX2, CDX2 and downstream IM-specific genes were detected by qRT-PCR.ResultsBile acid treatment could suppress SOX2 expression and simultaneously induce expression of CDX2 in gastric cell lines. Furthermore, we demonstrated that SOX2 overexpression could significantly inhibit bile acid- and exogenous CDX2-induced IM-specific gene expression, including KLF4, cadherin 17 and HNF4α expression. In contrast, SOX2 knockdown had the opposite effect. A dual-luciferase reporter assay demonstrated that SOX2 overexpression could significantly suppress CDX2 transcriptional activity in HEK293T cells. CDX2 and SOX2 could form protein complexes in the nucleus. In addition, bile acid induced the expression of miR-21. The inhibition of SOX2 in bile acid-treated gastric cell lines was rescued by miR-21 knockdown.ConclusionsThese findings suggested that SOX2 can interfere with the transcriptional activity of CDX2 in bile acid-induced IM and that miR-21 might play a key role in this process, which shed new lights in the prevention of gastric cancer.

Findings in exudates can help distinguish benign gastric ulcers from ulcerated adenocarcinomas.

Most gastric carcinomas develop in association with mucosal atrophy and hypochlorhydria, whereas benign peptic ulcers are acid-related. Given that acid sterilises the gastric contents, we hypothesised that ulcerated gastric cancers may be associated with increased numbers of luminal microorganisms as compared with peptic ulcers, and that this feature may represent a helpful diagnostic clue to the presence of malignancy. We performed this study to determine whether the features of luminal debris, including microorganisms, from ulcerated gastric cancers were significantly different from those of debris associated with benign ulcers. We retrospectively identified 50 ulcerated adenocarcinomas and 50 site-matched peptic ulcers. Luminal debris was evaluated for the nature of inflammation, necrosis, and the presence of mixed bacterial colonies or yeasts. Non-lesional mucosa was assessed for chronic gastritis, Helicobacter pylori, chemical gastropathy, and intestinal metaplasia. Patients in both groups were adults (mean age: 69 years and 62 years, respectively) with similar amounts of inflammation and cellular necrosis in biopsy material. However, 76% of ulcerated cancers harboured non-H. pylori bacterial colonies, as compared with only 22% of peptic ulcers (P < 0.01). Filamentous bacteria and fungi were highly specific for carcinoma (98% and P = 0.02 for both comparisons). Background intestinal metaplasia was more common among gastric cancers than among peptic ulcers (50% versus 26%, P = 0.02), whereas chemical gastropathy was more commonly associated with the latter (50% versus 10%, P < 0.01). Gastric cancers may be colonised by non-H. pylori microorganisms. Detection of numerous bacterial colonies, filamentous bacteria or fungi in biopsy material obtained from ulcerated gastric lesions should raise suspicion for underlying malignancy.

LINE-1 hypomethylation is inversely correlated with UHRF1 overexpression in gastric cancer.

DNA methylation is an important epigenetic modification that alters gene expression; DNA hypomethylation contributes to tumorigenesis through multiple processes. In the present study, the methylation of long interspersed element-1 (LINE-1) in 95 gastric cancer (GC) tissues and matched adjacent normal tissues was investigated by pyrosequencing. LINE-1 methylation was compared with the expression of ubiquitin-like with PHD and ring-finger protein 1 (UHRF1), an essential regulator of DNA methylation, using reverse transcription-quantitative polymerase chain reaction. Significant hypomethylation of LINE-1 and overexpression of UHRF1 were observed in GC tissues compared with the matched controls (P<0.001 and P=0.001, respectively). LINE-1 hypomethylation was inversely correlated with UHRF1 overexpression in GC tissues (r=-0.026, P=0.028). In addition, LINE-1 hypomethylation in GC was significantly associated with Lauren's histological classification, tumor differentiation and background intestinal metaplasia (P=0.014, P=0.042 and P=0.034, respectively). These results suggest that LINE-1 hypomethylation may be a potential biomarker for GC and it is indirectly regulated by UHRF1 overexpression.

Intestinal metaplasia of the bladder in 89 patients: a study with emphasis on long-term outcome.

BackgroundIntestinal metaplasia of the bladder is an uncommon glandular proliferation. We examined a large series of intestinal metaplasia for the clinicopathological features and discuss the significance of this lesion.MethodsAll cases of intestinal metaplasia diagnosed in our institution between 1990 and 2014 were retrospectively reviewed. Patients with a history of urothelial carcinoma or concurrent adenocarcinoma were excluded. Patient characteristics, pathological features, and follow-up outcomes were obtained.ResultsWe identified 89 patients with intestinal metaplasia during this period. Sixty seven were men and 22 were women. Mean age at diagnosis was 57 years (range 23–81). Common presenting complaints included haematuria (73 cases), mucosuria (13 cases), and irritative voiding symptoms (seven cases). The majority of intestinal metaplasias located on or near the trigone (67 cases). Eighty-two patients underwent transurethral resection of their lesions. Partial cystectomy was performed in the remaining seven patients. The mean follow-up of 78 patients was 105 months (range 6–255). One case of bladder adenocarcinoma was indentified 6 months later. The initial histologic findings had revealed intestinal metaplasia with severe dysplasia. Four patients presented recurrence during the follow-up, and this occurred 9, 13, 17 and 24 months after the surgery.ConclusionsAlthough intestinal metaplasia can be treated effectively by transurethral resection in most cases, its potential malignancy need to be taken into consideration after the evidence of recurrences and its association with bladder adenocarcinoma. Therefore, it is necessary to perform close surveillance following the surgery, particularly in patients with dysplastic changes.

Metastatic Gastrointestinal Adenocarcinoma with Osteoblastic Activity: A Case Report of Esophageal and Colonic Primaries

Adenocarcinoma with osteoblastic metastases is classically seen in prostate, breast, and lung primaries. Less common primary sites include thyroid, kidney, and stomach. We present two cases of primary gastrointestinal adenocarcinoma with metastatic osteoblastic activity from two previously unreported sites. The first case represents an esophageal adenocarcinoma arising in a background of intestinal metaplasia that metastasized with osteoblastic activity to the deltoid muscle. The second case demonstrates a Stage IV sigmoid colon adenocarcinoma with osteoblastic metastases to the liver and lymph nodes. The findings indicate that metastases from various gastrointestinal primary adenocarcinomas can have prominent bone formation.

Esophageal Adenocarcinoma Masquerading as Hyperplastic Polyps

Introduction: We report a case with the rare occurrence of hyperplastic polypoid lesions in the background of Barrett's esophagus in associated with invasive adenocarcinoma of the esophagogastric junction (EGJ). Case Report: A 65 year old Caucasian male with chronic acid reflux presented with progressive dysphagia and weight loss. Exam was unremarkable except for a body mass index of 37. Lab studies showed mild anemia with hemoglobin of 12.5 gm/dl. Esophagogastroduodenoscopy (EGD) revealed a diffuse, polypoid growth involving the distal 14 cm of the esophagus. Histological exam revealed glandular mucosa with elongated hyperplastic foveolar epithelium and cystic changes, consistent with hyperplastic polyp. EGD was repeated and tissue specimen collected with cold snare as well as multiple 4 quadrant biopsies every 1 cm, histology revealed hyperplastic polyps in the background of intestinal metaplasia without dysplasia. Endoscopic ultrasonography (EUS) showed that the growth was limited to the mucosal layer, positron emission test (PET) scan showed increased uptake only in the distal esophagus. Patient was referred to surgery and underwent esophagectomy with proximal gastrectomy. Esophago-gastric continuity could not be achieved, thus a left sided esophageal spit fistula was created. Surgical specimen showed moderately differentiated adenocarcinoma with tumor invasion through muscularis propria into the serosal fat at the EGJ and multiple lymph nodes involvement. Discussion: Epithelial polypoid lesions of the esophagus and EGJ are uncommon. Most of these lesions reportedly occur at the EGJ (67%) followed by distal esophagus (30%). Among these lesions, hyperplastic polyps are quite rare and usually occur in the setting of long-standing gastro esophageal reflux disease. In the largest reported case series by Abraham et al., among 27 patients with hyperplastic esophageal and EGJ polyps, only 15% had concomitant Barrett's esophagus. There have been only two cases reported of hyperplastic polyps at EGJ where subsequent endoscopic mucosal resection showed foci of high grade dysplasia and adenocarcinoma. Our case is unique due to the presence of long segment Barrett's esophagus with concomitant circumferential, villiform polypoid growth where multiple repeat mucosal biopsies showed reactive changes. Due to the diffuse extensive nature of the lesion it was not amenable to safe endoscopic resection and thus required surgical resection which revealed an invasive adenocarcinoma of the EGJ. This case highlights the extremely rare occurrence of the hyperplastic polyps in the setting of Barrett's esophagus and invasive adenocarcinoma of the EGJ. It also underscores the fact that malignancy in this setting should always be suspected even when mucosal biopsies are negative.Figure 1Figure 2Figure 3