Gastric Signet Ring Cell Adenocarcinoma Research Articles

Gastric signet-ring cell adenocarcinoma masquerading as sarcoidosis

Gastric signet-ring cell adenocarcinoma masquerading as sarcoidosis

Early Gastric Signet Ring Cell Adenocarcinoma as a Flat Pale Patch on an Esophagogastroduodenoscopy.

Early Gastric Signet Ring Cell Adenocarcinoma as a Flat Pale Patch on an Esophagogastroduodenoscopy.

A160 A CASE OF BREAST CANCER METASTASIS MASQUERADING AS SIGNET RING CELL ADENOCARCINOMA OF THE STOMACH

Abstract Background Gastric cancer has a poor prognosis, particularly at advanced stages. Endoscopic submucosal dissection (ESD) can be used to treat selected early-stage gastric cancers. This case study explores the challenge of diagnosing and managing patients when metastatic lesions mimic primary gastric cancer, as seen in this case of breast cancer metastasis resembling signet ring cell adenocarcinoma of the stomach. Aims The aim of this case report is to describe an unusual case of breast cancer metastasis to the stomach identified unexpectedly on random gastric biopsies, initially diagnosed as a primary gastric signet ring cell adenocarcinoma. Methods Clinical and pathological records of the described patient were reviewed retrospectively. Furthermore, a review of the relevant literature was also performed. Results A 68 year-old-woman underwent gastroscopy for nausea and vomiting. Her past medical history was remarkable for bilateral mastectomies ten years ago for invasive lobular carcinoma, with metastatic bone disease diagnosed by imaging five years prior. She had been well controlled on letrozole taken intermittently due to side effects. At endoscopy, while the stomach appeared grossly normal, random biopsies done for Helicobacter pylori identified a single focus of signet ring cell adenocarcinoma. Subsequent chromoendoscopy identified an area of subtle mucosal abnormality for which the patient declined surgery and was instead managed by ESD which surprisingly yielded no dysplasia. A follow up gastroscopy with random biopsies also failed to identify any areas of dysplasia, but random biopsies on a subsequent gastroscopy again identified a minute focus of adenocarcinoma with signet ring cell morphology. Given the unusual presentation of apparent signet ring cell adenocarcinoma in two distinct areas in the stomach without any visible endoscopic abnormality an in-depth pathological analysis was conducted. By immunohistochemistry the tumor cells stained positive for Estrogen Receptor, GATA3, and CK7 and negative for antibodies targeting CK20 and CDX2, which supported an interpretation of minute multifocal breast cancer metastases to the stomach from hematogenous spread. Conclusions In this case, repeated endoscopic investigations and immunohistochemical staining revealed minute multifocal breast cancer metastases to the stomach. Conventional tumor staging methods often cannot identify microscopic metastases, potentially impacting disease progression and patient care. A high level of suspicion for metastatic breast cancer and a detailed pathological analysis allowed for the correct diagnosis in this patient. Funding Agencies None

Curschmanns Spirals in Pleural Effusion in a 66-Year-Old Male with a History of Gastric Signet Ring Cell Adenocarcinoma with No Evidence of Metastasis

Curschmanns Spirals in Pleural Effusion in a 66-Year-Old Male with a History of Gastric Signet Ring Cell Adenocarcinoma with No Evidence of Metastasis

Gastric Signet-Ring Cell Adenocarcinoma in a Dog

Gastric Signet-Ring Cell Adenocarcinoma in a Dog

Incidental Krukenberg Tumor During Cesarean Section

We present the case of a 29-year-old woman in her 30th week of pregnancy admitted for preterm contractions. She had an emergent cesarean delivery and was noted to have a large ovarian mass diagnosed on pathology as a Krukenberg tumor. Subsequent upper gastrointestinal endoscopy revealed gastric signet ring cell adenocarcinoma as the primary cancer. The patient received palliative chemotherapy and immunotherapy and is pending clinical trial participation. Pregnancy-associated gastric cancer is a rare condition with a poor prognosis as most symptoms may be attributed to a normal pregnancy. This misinterpretation often leads to a late diagnosis and poor outcomes.

An Umbilical Mass in a Young Female

Question: A 38-year-old woman with a past medical history of invasive signet ring cell gastric adenocarcinoma, status post total gastrectomy, presented with a newly swollen and painful umbilical mass. She completed 6 cycles of adjuvant chemotherapy (FOLFOX) followed by radiotherapy, that has been stable on imaging for two years. On physical examination, it is an erythematous, firm, and tender umbilical mass that is not reducible on examination (Figure A).

An Immaculate Deception: Persistently Elevated Serum β-Hcg in Metastatic Signet Ring Cell Gastric Adenocarcinoma

BackgroundPersistent elevations in beta-human chorionic gonadotropin (β-hCG) can be an ominous sign of both trophoblastic and non-trophoblastic malignancies. The absence of a clearly identified etiology of β-hCG elevation warrants pursuit of further diagnostic testing to determine the source of ectopic β-hCG. Case ReportA virginal 26-year-old woman with past medical history significant for persistently elevated β-hCG presented to our Emergency Department with shortness of breath, pleuritic chest pain, nausea, and vomiting, and was found to have widely metastatic gastric signet ring cell adenocarcinoma. Why Should an Emergency Physician Be Aware of This?Although elevated serum β-hCG is a generally a marker of pregnancy, β-hCG elevation without clear etiology necessitates ruling out other insidious processes. Failure to maintain and pursue a broad differential in the context of unexplained elevations of β-hCG can result in catastrophic missed or delayed diagnosis.

Association Between Hereditary Lobular Breast Cancer Due to CDH1 Variants and Gastric Cancer Risk

Hereditary cancer risk is informed by the presence of a germline gene variant more so than by family history of cancer. To assess gastric cancer risk among patients who received a diagnosis of hereditary lobular breast cancer (HLBC) owing to a germline loss-of-function variant in CDH1 by establishing prevalence of signet ring cell carcinomas among asymptomatic patients. A prospective cohort study of patients with germline CDH1 pathogenic or likely pathogenic (P/LP) variants at a quaternary medical center were enrolled between October 2017 and January 2021. Data analysis was performed in May 2021. Analyses for associations were performed for these 3 patient groups: (1) family history of breast cancer and no gastric cancer in the HLBC group; (2) family history of gastric cancer and no breast cancer in the hereditary diffuse gastric cancer (HDGC) group; and (3) family history of both breast and gastric cancers in the mixed group. Categorical variables were compared using the Pearson χ2 test. The primary end point of this study was the prevalence of occult signet ring cell carcinoma of the stomach in patients with HLBC. Personal and family medical history, genotype, and pathologic data from risk-reducing total gastrectomy and surveillance endoscopy were examined. A total of 283 patients with CDH1 P/LP variants (199 [70.3%] were female, and 259 [91.5%] were White; median age, 48 years [range, 18-81 years]) were enrolled in a prospective study of HDGC. The cohort consisted of 151 families. Patients were categorized according to family history of breast and/or gastric cancer: HLBC 15.5% [44 of 283 patients]), HDGC (16.2% [46 of 283 patients]), and mixed (68.2% [193 of 283 patients]). The HLBC group included 31 distinct families with 19 CDH1 variants; 10 of those variants were also present in the HDGC and mixed groups (52.6% [10 of 19 variants]). Nearly all of the patients with HLBC (93.8% [15 of 16 variants]) who elected for risk-reducing total gastrectomy owing to their underlying CDH1 P/LP variant harbored occult signet ring cell gastric adenocarcinoma on final pathology (median age, 50 years [range, 21-67 years]). The prevalence of occult gastric cancer among asymptomatic patients in the HDGC group was similar (94.7% [18 of 19 of variants]; P = .98). Carriers of CDH1 P/LP variants with no family history of gastric cancer exhibited high rates of occult signet ring cell gastric cancer. Germline CDH1 P/LP variants appear to have a highly penetrant gastric phenotype irrespective of family history. These data may prove useful for counseling families with CDH1 variants presumed to have HLBC.

S3166 Signet Ring Cell Gastric Adenocarcinoma Presenting as Diffuse Mucosal Hypertrophy and Gastric Outlet Obstruction: A Diagnostic Dilemma

Introduction: Gastric cancer is the third most common cause of cancer-associated mortality worldwide. Signet-ring cell carcinoma (SRCC) is a rare aggressive histological subtype of gastric cancer, the proportion of which has been steadily rising despite the decline in the incidence of gastric carcinomas due to more effective treatment for H. pylori. When advanced, this subtype may rarely have diffuse involvement of the gastric wall leading to gastric outlet obstruction (GOO). Case Description/Methods: A 75-year-old female with no past history presented with abdominal pain, nausea, and emesis for 3 weeks with 30 lbs weight loss. Physical exam showed a HR of 122/min, abdominal distension, and labs significant for metabolic alkalosis. CT scan showed gastric distension with mucosal thickening greatest on the posterior aspect, extending to the lesser curvature and pylorus. An EGD with EUS revealed grade-B esophagitis with hypertrophic folds of gastric mucosa causing significant edema surrounding the pylorus causing a GOO. Multiple mucosal biopsies were obtained and an NJ tube was placed to address feeding. Biopsies showed hypertrophic fundic glands without malignancy. Gastrin levels were normal at 104pg/ml. Due to inconclusive diagnosis, repeat EGD and EUS with pyloric dilatation and PEG-J placement was performed, with full-thickness gastric biopsies obtained showing poorly differentiated signet-ring cell adenocarcinoma and immunocytochemistry positive for cytokeratin AE1/AE3. Diagnostic laparoscopy with peritoneal biopsies showed peritoneal spread. The patient denied surgical treatment and opted for hospice care. Discussion: Signet-ring cell adenocarcinoma of the stomach has lately become more common with a decline in H. pylori. It has been described to have an association with germline mutations in CDH1 gene. The aggressive forms of SRCC can rarely present with diffuse gastric wall thickening without a well-defined mass or ulceration. Extensive mucosal hypertrophy occurs due to diffuse infiltration of tumor cells and resultant fibrous proliferation. The extent of involvement can vary between mucosal and submucosal layers, making the diagnosis particularly challenging by isolated superficial biopsies. These subtypes usually are diagnosed at an advanced stage and have a poor prognostic outcome. SRCC is shown to have poor chemosensitivity that non-SRCC subtypes to traditional chemotherapy regimens. Thus, early and accurate diagnosis via endoscopy remains the cornerstone in improving the prognosis of gastric SRCC.Figure 1.: Endoscopic images showing diffuse black esophagus.

A Retrospective Experience of Helicobacter pylori Histology in a Large Sample of Subjects in Northern Italy.

Updated data about the prevalence of Helicobacter pylori (H. pylori) and its correlation with histological results are scarce. The aim of our study was to provide current data on the impact of H. pylori in a third-level endoscopy service. We performed a large, retrospective study analyzing the results of all histological samples of gastroscopy from the year 2019. In total, 1512 subjects were included. The prevalence of H. pylori was 16.8%. A significant difference between the prevalence in subjects born in Italy and those from eastern Europe, south America, or Africa was found (p < 0.0001, p = 0.006, and p = 0.0006, respectively). An association was found between H. pylori and active superficial gastritis (p < 0.0001). Current H. pylori and/or a previous finding of H. pylori was related to antral atrophy (p < 0.0001). Fifteen patients had low-grade dysplasia. There were no statistically significant associations with current or past H. pylori infection. One patient presented gastric cardia adenocarcinoma with regular gastric mucosa. One patient, H. pylori positive, was diagnosed with gastric signet ring cell adenocarcinoma in a setting of diffuse atrophy, without metaplasia.. Our study provides updated, solid (biopsy diagnosis and large population) data on the prevalence of H. pylori infection in a representative region of southern Europe.

An unusual case of gastric signet-ring cell adenocarcinoma metastasizing to the urinary bladder

An unusual case of gastric signet-ring cell adenocarcinoma metastasizing to the urinary bladder

CDH1 Gene Mutation Hereditary Diffuse Gastric Cancer Outcomes: Analysis of a Large Cohort, Systematic Review of Endoscopic Surveillance, and Secondary Cancer Risk Postulation.

Simple SummarySome patients carry a mutated copy of the CDH1 gene that can lead to a very rare form of hereditary gastric cancer called signet-ring cell adenocarcinoma (SRCC). SRCCs rarely form visible tumors prior to spreading. Hence, patients are recommended to have prophylactic gastrectomies at a young age. Many patients wish to avoid surgery and thus have regular checks with upper endoscopy with biopsies to rule out cancer. Further, these patients may also be at risk of other cancers beyond the already known breast cancer risks, but this is not known. In this study, we show that despite systematic biopsy protocols, many early cancers might be missed on endoscopy. Therefore, patients should not rely on endoscopy to delay surgery. These patients may also be at increased risk of colorectal SRCC, which has very poor survival outcomes. To confirm this, we need a central database that captures outcomes for this patient population.Hereditary diffuse gastric cancer (HDGC) is a rare signet-ring cell adenocarcinoma (SRCC) linked to CDH1 (E-cadherin) inactivating germline mutations, and increasingly other gene mutations. Female CDH1 mutation carriers have additional risk of lobular breast cancer. Risk management includes prophylactic total gastrectomy (PTG). The utility of endoscopic surveillance is unclear, as early disease lacks macroscopic lesions. The current systematic biopsy protocols have unknown efficacy, and other secondary cancer risks are postulated. We conducted a retrospective study of consecutive asymptomatic HDGC patients undergoing PTG, detailing endoscopic, pathologic, and outcome results. A systematic review compared endoscopic biopsy foci detection via random sampling versus Cambridge Protocol against PTG findings. A population-level secondary-cancer-risk postulation among sporadic gastric SRCC patients was completed using the Surveillance, Epidemiology, and End Results database. Of 97 patients, 67 underwent PTG, with 25% having foci detection on random endoscopic biopsy despite 75% having foci on final pathology. There was no improvement in the endoscopic detection rate by Cambridge Protocol. The postulated hazard ratio among sporadic gastric SRCC patients for a secondary colorectal SRCC was three-fold higher, relative to conventional adenocarcinoma patients. Overall, HDGC patients should not rely on endoscopic surveillance to delay PTG, and may have secondary SRCC risks. A definitive determination of actual risk requires collaborative patient outcome data banking.

Clinicopathological Evaluation of Gastric Signet Ring Cell Carcinoma: Our Experience.

AimGastric cancer is one of the most common cancers worldwide. In Turkey, stomach cancer is ranked 5th among men and 8th among women in all cancers and is located in the forefront in cancer-related deaths. Signet ring cell adenocarcinoma, which is the histopathological subtype of gastric cancer, has a poor prognosis. The incidence of signet ring cell adenocarcinoma is rising. In the present study, we aimed to describe the clinicopathologic features of signet ring cell adenocarcinoma.Materials and MethodsA total of 79 patients with 30 being female (38%) and 49 male (62%) who were diagnosed with gastric signet ring cell adenocarcinoma in the Medical Oncology Department of Ankara Numune Training and Research Hospital between January 2004 and October 2015 were retrospectively evaluated.ResultsThe baseline demographic characteristics of the patients, such as tumor localization, tumor stage, preoperative serum tumor markers, and treatment type (surgery and chemotherapy regimen), and the effects of these variables on survival and mortality were evaluated. Total surgery, stage III disease, moderate to poor grade, preoperative serum CA 19-9 and CEA levels were found as independent predictors of progression risk (p < 0.05). Each 1 ng/mL increase in preoperative serum CEA level was found to increase the risk of progression by 1.20 folds. Again, each 1 U/mL in preoperative serum CA 19-9 level was found to increase the risk of progression and mortality by 1.06 folds.ConclusionThe clinicopathologic features of signet ring cell stomach cancer were described. Tumor localization and disease, CA 19-9 and CEA levels, and treatment type (surgery and chemotherapy regimen) were effective on survival and mortality. However, further studies with larger patient groups are needed on this issue.How to cite this articleAltay SB, Akkurt G, Yılmaz N, et al. Clinicopathological Evaluation of Gastric Signet Ring Cell Carcinoma: Our Experience. Euroasian J Hepato-Gastroenterol 2020;10(2):76–84.

S2983 Gastric Signet Ring Cell Adenocarcinoma Presenting as Intermittent Volvulus of Small Bowel: A Case Presentation

INTRODUCTION: Signet ring cell carcinoma (SRCC) is an uncommon and poorly-differentiated tumor. It arises mostly in the gastrointestinal tract. Its incidence has increased in past few years. Volvulus is the twisting of bowel around its mesentery. It is relatively common in cecum and sigmoid colon and rare in other parts of gastrointestinal tract. It is usually primary in nature but can be secondary to tumors, diverticulosis, pregnancy, or others. Herein, we present a case of advanced gastric SRCC with peritoneal carcinomatosis presenting initially as a secondary small bowel volvulus (SBV) without appreciated gastric mass on imaging. We believe our case is unique due to rarity of such presentation. CASE DESCRIPTION/METHODS: An 80-year-old male presented for abdominal fullness, early satiety, weight loss, and excessive flatulence and postprandial vomiting with gastric outlet obstruction-like symptoms for three weeks. Computed tomography scan of abdomen (CT) showed a jejunal volvulus. The patient was treated conservatively. Repeat CT of abdomen showed resolution of the SBV. Magnetic resonance enterography of the abdomen and pelvis showed duodenum distension of 3.4 cm, however proximal jejunum never appeared fluid distended and a jejunal obstructing process could not be excluded. No gastric lesions or thickening was appreciated on all imaging. Deep Enteroscopy revealed antral circumferential mucosal thickening with mucosal changes under white light and Narrow Band Imaging suggestive of carcinoma. Dilated duodenum with transition area and obstructed proximal jejunum were noted with no intrinsic lesion or mucosal abnormalities. Biopsy from gastric mucosa revealed gastric adenocarcinoma, signet ring cell type. Diagnostic laparoscopy revealed peritoneal implants throughout abdominal cavity. A large, hard, and fixed mass was found in the distal stomach causing tethering of proximal jejunum. Side to side loop duodenojejunostomy and partial omentectomy were done, gastrojejunostomy was not possible. Pathology from right upper quadrant peritoneal implant, peritoneal biopsy, and omentum was consistent with metastatic adenocarcinoma from primary gastric site. Palliative chemotherapy and palliative trans-pyloric duodenal stent were performed. DISCUSSION: To the best of our knowledge, this is the first case of gastric SRCC presenting as intermittent SBV without noted tumor on imaging. In such a presentation of SBV with no notable tumor on imaging, high suspicion of a primary gastrointestinal tumor should be always considered.Figure 1.: Computed tomography scan of the abdomen (CT) showing a jejunal volvulus (A). Repeat CT of the abdomen without contrast showed dilation of proximal small bowel up to 4.2 cm with a transition point at the superior mesenteric artery take-off, no small bowel volvulus was seen (B).Figure 2.: Enteroscopy showing hard consistency in the prepyloric region and antrum (A), and diffuse circumferential nodularity of the gastric mucosa with ulcerations and irregular margins (B).

Vulvar Lymphangitic Carcinomatosis: A Rare Metastasis from Gastric Adenocarcinoma

Vulvar lymphangitic carcinomatosis (VLC) secondary to gastric carcinoma is a very rare entity. In this paper, we describe the clinical and pathological characteristics, evolution, of a patient with VLC of signet ring cell gastric adenocarcinoma. To our knowledge this is among the very rare reported cases in the literature.

ASO Author Reflections: A Surgery-First Approach for Patients With Clinical Stage 1 Signet Ring Cell Gastric Adenocarcinoma.

ASO Author Reflections: A Surgery-First Approach for Patients With Clinical Stage 1 Signet Ring Cell Gastric Adenocarcinoma.

Should Signet Ring Cell Histology Alter the Treatment Approach for Clinical Stage I Gastric Cancer?

Surgery alone is standard-of-care for stage I gastric adenocarcinoma; however, clinicians can offer preoperative therapy for clinical stage I disease with signet ring cell histology, given its presumed aggressive biology. We aimed to assess the validity of this practice. The National Cancer Database (2004-2015) was reviewed for patients with clinical stage I signet ring cell gastric adenocarcinoma who underwent treatment with surgery alone, perioperative chemotherapy, neoadjuvant therapy, or adjuvant therapy. Analysis was stratified by preoperative clinical/pathologic stage. Primary outcome was overall survival (OS). Of 1018 patients, median age was 60years (±14); 53% received surgery alone (n=542), 5% received perioperative chemotherapy (n=47), 12% received neoadjuvant therapy (n=125), and 30% received adjuvant therapy (n=304). For clinical stage I disease, surgery alone was associated with an improved 5-year OS rate (71%) versus perioperative chemotherapy (58%), neoadjuvant therapy (38%), or adjuvant therapy (52%) [overall p<0.01]. For pathologic stage I, surgery alone had equivalent or improved survival compared with perioperative, neoadjuvant, and adjuvant therapy (5-year OS: 78% vs. 89% [p=0.77] vs. 64% [p=0.04] vs. 84% [p=0.99]). Adjuvant therapy was associated with improved 5-year OS compared with pretreatment for those patients upstaged (37%) to pathologic stage II/III (55% vs. 36% and 34% vs. 7%; all p<0.01). This stage-specific study demonstrates improved survival with surgery alone for clinical stage I signet ring cell gastric adenocarcinoma. Despite 37% of clinical stage I patients being upstaged to pathologic stage II/III, adjuvant therapy offers a favorable rescue strategy, with improved outcomes compared with those treated preoperatively. Surgery alone also affords similar or improved survival for pathologic stage I disease versus multimodality therapy. This study challenges the bias to overtreat stage I signet ring cell gastric adenocarcinoma.

Secondary Multiple Cutaneous Metastases from Primary Gastric Signet-Ring Cell Adenocarcinoma

A 60-year-old man was diagnosed with gastric cancer by endoscopy in our cancer center. Preoperative CT scan showed thickening of the cardia and enlarged lymph nodes in hepatogastric space. Consequently, he accepted total gastrectomy and Roux-en-Y reconstruction. Immunohistochemical detection showed intense positivity for GST-n and Pgp antibodies and negativity for EGFR, ERCC1, P53, Ki67 and HER-2. Surprisingly, within one month, the patient had multiple asymptomatic cutaneous nodules in the left neck, right subclavian, left armpit, left upper abdomen, lower abdomen, right groin and lumbodorsal region. Abdominal CT scan showed a 22 × 22 mm high-density lesion in the splenorenal space, as well as cutaneous nodules in the left upper abdomen, lower abdomen and right groin. Histopathologic examination of cutaneous biopsy showed a poorly differentiated signet-ring cell carcinoma consistent with a diagnosis of secondary metastasis of primary gastric carcinoma. The patient received “DOF” chemotherapy which do benefit to halt the disease progression. He decided not to continue with chemotherapy and died of multiorgan metastasis 2 months later.

Paracoccidiodomycosis lung reactivation in a patient with signet-ring cell gastric adenocarcinoma after chemotherapy: Case report

Although the relationship between paracoccidioidomycosis (PCM) and solid tumors has been described more than 80 years ago, reports of PCM and gastric cancer are rare. PCM can present before or concomitantly with the diagnosis of cancer, and its clinical presentation may rise the suspicion of malignancies or be part of reactivation by immunosuppression. We present the case of a 52-year-old Peruvian man with a signet-ring cell (SRC) gastric adenocarcinoma who after 6 chemotherapy sessions with FLOT (docetaxel, oxaliplatin, leucovorin, 5-fluorouracil) presented rapidly growing lung nodules. The lung biopsy showed yeasts compatible with Paracoccidioides sp., so he received initial treatment with itraconazole and after gastrectomy maintenance therapy with trimethoprim/sulfamethoxazole accompanied by tomographic resolution of lesions.