Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer.

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer (GC), published in late 2022 and the updated ESMO Gastric Cancer Living Guideline published in July 2023, were adapted in August 2023, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with GC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with GC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), coordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with GC across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.

Incidence, clinicopathological features, and clinical outcomes of low HER2 expressed, inoperable, advanced, or recurrent gastric/gastroesophageal junction adenocarcinoma.

BACKGROUND: According to the DESTINY-Breast04 trial, treating patients with breast cancer and low human epidermal growth factor receptor 2 expressions (HER2-low) varies from that of those with no HER2 expression. However, it is interesting to know if HER2-low indicates for anti-HER2 therapy in the gastric or gastroesophageal junction (G/GEJ) adenocarcinoma. Hence we conducted this study to assess the incidence, clinicopathological features, and treatment outcomes of patients with HER2-low G/GEJ adenocarcinoma. PATIENTS AND METHODS: This was a single-center, retrospective observational study. Patients with previously untreated G/GEJ adenocarcinoma were classified based on their HER2 status using immunohistochemistry (IHC) with or without in situ hybridization (ISH) as follows: HER2 negative (IHC 0), HER2-low (IHC 1+ or 2+/ISH-), and HER2-positive (IHC2+/ISH+ or 3+). RESULTS: In total, 734 patients with G/GEJ adenocarcinoma were divided into three groups (HER2-negative, n = 410; HER2-low, n = 154, and HER2-positive, n = 170). The intestinal-type histology, peritoneal metastasis, and higher serum carcinoembryonic antigen (CEA) levels differed significantly among patients with negative, low, and positive HER2 statuses: intestinal-type histology (21.0%, 44.2%, and 59.8%, respectively), peritoneal metastasis (56.3%, 44.8%, and 21.8%, respectively), and higher serum CEA level (32.2%, 41.6%, and 56.5%, respectively). Improved survival was observed in the HER2-positive group than in the HER2-negative G/GEJ adenocarcinoma group [hazard ratio (HR) = 0.73, 95% confidence interval (CI) 0.59-0.89; P = 0.002]. However, the prognoses of the HER2-low and HER2-negative groups were similar (HR = 1.01, 95% CI 0.82-1.23; P = 0.843). CONCLUSIONS: Patients with HER2-low G/GEJ adenocarcinoma exhibited intermediate and distinct characteristics than those in the HER2-negative group. Similarly, the HER2-low group's prognosis was worse than that of the HER2-positive group. Therefore developing novel therapeutic strategies targeting HER2-low G/GEJ adenocarcinoma is required.

A novel clinical prognostic index for patients with advanced gastric cancer: possible contribution to the continuum of care.

BACKGROUND: The Japan Clinical Oncology Group (JCOG) prognostic index, consisting of performance status, primary tumor resected, number of metastases, and serum alkaline phosphatase, has been one of the robust prognostic indices for patients with advanced gastric cancer on the basis of which clinical trials have stratified prognosis. Only a few studies, however, have utilized the JCOG prognostic index in daily practice. METHODS: We conducted a retrospective study on patients with advanced gastric cancer who received first-line platinum-containing chemotherapy at a single institute between 2011 and 2017. Prognostic factors were evaluated using a Cox proportional regression model. RESULTS: A total of 608 patients were enrolled. Multivariate analysis showed that performance status ≥1, presence or absence of primary tumor, serum alkaline phosphatase, neutrophil-to-lymphocyte ratio ≥4, and diffuse-type histology were significantly associated with worse prognosis, whereas the number of metastases was not. Although the original prognostic index could not adequately stratify patients into three risk groups, the modified index (good: 0 and 1, moderate: 2 and 3, poor: 4-6), which was established by incorporating diffuse-type histology and high neutrophil-to-lymphocyte ratio, demonstrated excellent stratification. The median overall survival of the good (n = 315), moderate (n = 243), and poor (n = 54) risk groups was 20.5, 13.5, and 10.2 months, respectively. Hazard ratios (HRs) were 1.69 [95% confidence interval (CI), 1.40-2.04; good versus moderate] and 1.52 (95% CI, 1.11-2.08; moderate versus poor). This novel index also demonstrated a statistically significant stratification of survival after progression following first-line chemotherapy (good versus moderate: HR, 1.41; 95% CI, 1.16-1.70; moderate versus poor: HR, 2.00; 95% CI, 1.45-2.74). CONCLUSIONS: The modified JCOG prognostic index showed excellent stratification of overall survival in real-world patients, which could also help determine the need for treatment changes throughout the continuum of chemotherapy.

Expression of beta-catenin, E-cadherin and cyclin D1 in adenoid cystic carcinoma of the salivary gland.

We evaluated the expression of beta-catenin, E-cadherin, and cyclin-D1 in 23 cases of adenoid cystic carcinoma (ACC) of the salivary gland. We detected beta-catenin on the cell membranes in all ACCs, but its distribution was irregular, as compared to that on normal structures. In three out of the 23 cases, beta-catenin was detected in the nuclei, as well as on cell membranes. Polymerase chain reaction (PCR) and direct sequencing revealed a missense mutation in one case in which beta-catenin had been detected in the nuclei of tumor cells. We also detected E-cadherin on cell membranes with a similar irregular distribution to that of beta-catenin. In 11 cases (almost 48%) of ACC, cyclin D1 was localized in cell nuclei but there was no correlation with the nuclear staining of the beta-catenin. Our results suggest that disturbances in the distribution of beta-catenin and E-cadherin might affect the morphology ofACC and that a small fraction of cases of ACC are characterized by a mutation in the beta-catenin gene, which is associated with the nuclear accumulation of the product of this gene but does not affect the transcription of the gene for cyclin-D1.

Reduced-intensity stem-cell transplantation for adult acute lymphoblastic leukemia: a retrospective study of 33 patients.

Efficacy of reduced-intensity stem-cell transplantation (RIST) for acute lymphoblastic leukemia (ALL) was investigated in 33 patients (median age, 55 years). RIST sources comprised 20 HLA-identical related donors, five HLA-mismatched related, and eight unrelated donors. Six patients had undergone previous transplantation. Disease status at RIST was first remission (n=13), second remission (n=6), and induction failure or relapse (n=14). All patients tolerated preparatory regimens and achieved neutrophil engraftment (median, day 12.5). Acute and chronic graft-versus-host disease (GVHD) developed in 45 and 64%, respectively. Six patients received donor lymphocyte infusion (DLI), for prophylaxis (n=1) or treatment of recurrent ALL (n=5). Nine patients died of transplant-related mortality, with six deaths due to GVHD. The median follow-up of surviving patients was 11.6 months (range, 3.5-37.3 months). The 1-year relapse-free and overall survival rates were 29.8 and 39.6%, respectively. Of the 14 patients transplanted in relapse, five remained relapse free for longer than 6 months. Cumulative rates of progression and progression-free mortality at 3 years were 50.9 and 30.4%, respectively. These findings suggest the presence of a graft-versus-leukemia effect for ALL. RIST for ALL is worth considering for further evaluation.

Preferential transcription of a gene for alpha amylase in the carcinoid tumor of African rodent Mastomys natalensis.

The carcinoid tumor in Mastomys natalensis provides a useful animal model of tumorigenesis. We investigated preferentially transcribed genes in this carcinoid tumor by differential hybridization. Fourteen clones corresponding to high levels of transcription were isolated from a cDNA library. Sequencing analysis and a homology search revealed that the clones corresponded to genes for chromogranin and alpha-amylase. High-level transcription of a gene for alpha-amylase gene in Mastomys carcinoid tumor was confirmed by Northern blotting analysis. Furthermore, Western blotting analysis confirmed the expression of alpha-amylase in tumors at the protein level. Immunohistochemical staining revealed alpha-amylase in the cytoplasm of Mastomys carcinoid tumors. Our results demonstrated that an exocrine enzyme 'amylase' could be produced ectopically by a neuroen docrine tumor.

Expression of vascular endothelial growth factor and its receptors in the developing rat lung.

We examined the regulation of the expression of vascular endothelial growth factor (VEGF) and its specific receptors, fetal liver kinase receptor (Flk-1), and fms-like tyrosine kinase receptor (Flt-1) during formation of the capillary network in the developing rat lung. An immunohistochemical study of lung tissue from 19- and 21-d-old fetuses and 1-, 3-, 5-, 7-, and 14-d-old animals revealed that the level of expression of both VEGF and Flk-1 is significantly higher before birth (p < 0.0001) than after. Increased expression of Flt-1 on the first day after birth (p < 0.0001) suggests that this receptor might play an important role in capillary growth in the perinatal period. Immunostaining also revealed the colocalization of VEGF, Flt-1, and Flk-1 in endothelial cells of the lung capillaries at the ultrastructural level. The present studies revealed that VEGF and its two receptors are upregulated during the development of capillaries in the fetal and newborn rat lung.

Epithelial-myoepithelial carcinoma harboring p53 mutation.

A case of epithelial-myoepithelial carcinoma of the parotid gland harboring p53 mutation is reported. The tumor removed from a 67-year-old Japanese female was composed of an organoid biphasic population of cells: inner dark epithelial cells were surrounded by clear myoepithelial cells. The cells were immunopositive for EMA and smooth muscle actin, respectively. Some of the epithelial cells formed solid nests. Immunostaining for proliferating cell nuclear antigen (PCNA) resulted in a higher percentage of labeled cells in the solid epithelial region than in the region with the more general biphasic pattern. Genetic analysis, including polymerase chain reaction-single strand conformational polymorphism (PCR-SSCP) and nucleotide sequencing, revealed a mutation in codon 207 (aspartic acid to glycine) of the p53 tumor-suppressor gene. To our knowledge, this is the first report of a mutation in the p53 gene in an epithelial-myoepithelial carcinoma of the salivary gland.

Quantitative immunohistochemical analysis of the expression of CD31 during lung development in the rat.

The CD31 antigen, known also as the platelet/endothelial cell adhesion molecule 1, has been shown to be a good marker for monitoring the formation of the vasculature in mammals. Available evidence suggests that the expression of CD31 is regulated during embryonal and fetal development. The aim of the present study was to evaluate the changes in the expression of CD31 during the development of the rat lung. We studied samples of lung tissue from rat fetuses (17, 19 and 21 days after conception), newborns (1, 3, 5, 7, 14 and 21 days after birth) and adult animals. The tissue samples from rats in the various age groups were divided into sets, with all age groups being represented in every set. After immunohistochemical localization of the antigen, the amount of chromogen deposited after the immunoreaction (defined in terms of optical density; OD) was evaluated by image analysis in the various sets. Measurements were obtained twice from each set, and the results were reproducible (paired t test, alpha = 0.05). We subjected the results of measurements from all sets to an analysis of variance (ANOVA). The amount of chromogen (OD) decreased from fetal day 19 to 5 days after delivery and then increased again. The decrease in the level of expression of CD31 on days 3 and 5 after delivery was significant (p < 0.0001).

Myxoid adrenal cortical adenoma.

Myxoid adrenal cortical adenoma is a rare tumor and, to our knowledge, only 16 cases have been reported. We present the case of a 56-year-old Japanese man who was admitted to hospital because of a right adrenal mass that was discovered during a routine physical examination. The resected mass was well circumscribed and contained canary yellow multinodular regions that were surrounded by a brown gelatinous region. Histologically, the multinodular regions resembled a conventional adrenal cortical adenoma, being composed of solid aggregates of large clear or eosinophilic cells. In the gelatinous region, anastomosing small eosinophilic or vesicular cells were visible within a myxoid stroma that contained large amounts of acidic mucopolysaccharides. Light-microscopic findings were consistent with a diagnosis of adenoma. Immunohistochemical staining revealed that a small number of tumor cells were positive for vimentin, and the MIB-1 labeling index was less than 1%. Flow cytometry demonstrated that cells were diploid. At the ultrastructural level, many fat droplets were found in the large clear cells in the multinodular regions. Small eosinophilic cells in the myxoid region contained many mitochondria but few fat droplets. There were no findings suggestive of malignancy. Although the adrenal cortex might have the potential to produce connective tissue-type mucin as a consequence of its mesodermal origin, the mechanism of production of acidic mucopolysaccharides in a myxoid adrenal cortical tumor remains to be clarified.

p53-inducible wip1 phosphatase mediates a negative feedback regulation of p38 MAPK-p53 signaling in response to UV radiation.

The stress-responsive p38 MAPK, when activated by genotoxic stresses such as UV radiation, enhances p53 activity by phosphorylation and leads to cell cycle arrest or apoptosis. Here we report that a member of the protein phosphatase type 2C family, Wip1, has a role in down-regulating p38-p53 signaling during the recovery phase of the damaged cells. Wip1 was originally identified as a gene whose expression is induced following gamma or UV radiation in a p53-dependent manner. We found that Wip1 is also inducible by other environmental stresses, such as anisomycin, H(2)O(2) and methyl methane sulfonate. UV-induction of Wip1 requires p38 activity in addition to the wild-type p53. Wip1 selectively inactivates p38 by specific dephosphorylation of its conserved threonine residue. Furthermore, Wip1 expression attenuates UV-induced p53 phosphorylation at Ser33 and Ser46, residues previously reported to be phosphorylated by p38. Wip1 expression also suppresses both p53-mediated transcription and apoptosis in response to UV radiation. These results suggest that p53-dependent expression of Wip1 mediates a negative feedback regulation of p38-p53 signaling and contributes to suppression of the UV-induced apoptosis.

Immunohistochemical study of the distribution of endogenous biotin and biotin-binding enzymes in ductal structures of salivary gland tumours.

To clarify the pathologic value of endogenous biotin in the salivary gland, we examined in a series of neoplasms of the salivary gland by immunohistochemical staining the distribution of endogenous biotin and of biotin-binding enzymes, namely, acetyl CoA carboxylase (AC), which is a cytosolic enzyme, and pyruvate carboxylase (PC), which is a mitochondrial enzyme. In pleomorphic adenoma, we found biotin and PC in ductal epithelial elements, while AC was found mainly in myoepithelial elements. Carcinoma ex pleomorphic adenoma, adenocarcinoma and mucoepidermoid carcinoma were frequently immunopositive for biotin, PC and AC, while adenoid cystic carcinoma was rarely immunopositive for biotin, PC or AC. These results indicate that endogenous biotin might be associated with the mitochondrial enzyme, which is present at high levels in ductal cells of the salivary gland. However, the neoplastic cells in adenoid cystic carcinoma seemed to have an unusual expression of biotin and related enzymes.

A case of orbital lymphoproliferative lesion diagnosed as malignant lymphoma after recurring 11 years later

Background: Most primary lymphoproliferative lesions in the ocular adnexa, including the eyelid, conjunctiva, and orbit, are diagnosed as low-grade malignant lymphomas. Recurrence and dissemination of these tumors are rare in Japan. The long-term prognosis for this disorder still remains to be clarified.Case and Method: A 53-year-old woman was first referred to us for right orbital tumor in 1986. After subtotal resection of the tumor, the patient received no additional treatment. She visited us in 1997 with the complaint of bilateral orbital tumor. Biopsied specimens were examined histologically using hematoxylin-eosin and immunohistological staining. Southern blot hybridization was used to detect immunoglobulin gene rearrangement. The paraffin-embedded specimen obtained in 1986 was also examined for immunoglobulin gene rearrangement using nested polymerase chain reaction technique. Findings: The specimens from 1997 and 1986 were both diagnosed as lymphoid type of inflammatory pseudotumor, based on polyclonal B cell immunohistological staining. Immunoglobulin gene rearrangement was present in both specimens.Conclusions: The orbital tumor resected in 1986 was a low-grade malignant lymphoma which disseminated systematically 11 years later. This case shows a long-term course of orbital lymphoproliferative lesion with positive immunoglobulin gene rearrangement. It also shows the importance of follow-up over 10 years in the case of low-grade malignant lymphoma of the ocular adnexa.

Activation of the TCL1 protein in B cell lymphomas.

The TCL1 gene, localized near the break point of chromosome 14q32.1 often involved in T cell leukemias, is also expressed in normal precursor T and B cells, and B cell lymphoma cell lines. We investigated the expression of the TCL1 protein in various types of B cell lymphomas according to the Revised European-American Classification of Lymphoid neoplasms. Paraffin-embedded tissue sections of lymphoma specimens were subjected to TCL1 immunohistochemistry, and positivity was scored on a three-tiered scale: - (< 25% cells), + (25-50% cells), and ++ (> 50% cells). The TCL1 protein was expressed in low-grade B cell lymphomas including mucosa-associated lymphoid tissue type in ocular adnexa (18/20, 90%). It was also expressed in follicular, lymphoplasmacytic, and mantle cell lymphoma, but not in high-grade diffuse large B cell lymphoma (2/11, 18%). These data suggest that the expression of the TCL1 gene characterizes low-grade B cell lymphomas, and may be involved in certain processes of lymphomatogenesis.

Clonal analysis of the epithelial component of Warthin's tumor.

The proliferation of the epithelial component of Warthin's tumor is generally considered to represent a neoplastic condition. There has been much controversy about the histogenesis of this tumor, and the clonality of the epithelial component has not been clarified. We examined the clonal status of epithelial cells of Warthin's tumor by using a polymerase chain reaction (PCR) method based on trinucleotide repeat polymorphism of the X chromosome-linked human androgen receptor gene (HUMARA) and on random inactivation of the gene by methylation. Total DNA was isolated from formalin-fixed, paraffin-embedded tissue from 16 women with Warthin's tumor. Of the 16 cases analyzed, 7 were heterozygous for the HUMARA polymorphism and informative. The epithelial components of the tumors from the 7 cases were microdissected under the light microscope, and were subjected to extraction of DNA and HUMARA analysis. Using a permanent aqueous mounting medium during microdissection, we succeeded in reducing the rate of contamination by lymphocytes in the samples to less than 10%. All 7 cases showed patterns of polyclonal proliferation in the HUMARA analysis. Our results showed the nonclonal nature of Warthin's tumor, suggesting that Warthin's tumor is a non-neoplastic tumor-like condition. HUM PATHOL 31:1377-1380.

[Clinical studies of azithromycin, a new macrolide antibiotic, for infections in the field of surgery].

The efficacy of a newly developed macrolide antibiotic, azithromycin, for infections in the field of surgery, was investigated clinically by means of collaborative studies conducted in 17 major institutes and their affiliated hospitals throughout Japan. The following results were obtained. Clinical assessment: Azithromycin was administered at a dose of 250 mg or 500 mg once a day for 3 days. Clinical efficacy was evaluated in 170 patients. These subjects consisted of 81 with superficial purulent diseases, 12 with mastitis, 25 with periproctal abscess, 42 with superficial secondary infection due to trauma, burn and operative wound, 5 with cholecystitis or cholangitis, and 5 with other infections. The clinical efficacy rate was 96.3% (78/81) for superficial purulent diseases, 83.3% (10/12) for mastitis, 84.0%(21/25) for periproctal abscess, and 76.2%(32/42) for superficial secondary infection due to trauma, burn and operative wound. The overall clinical efficacy rate was 88.8%(151/170) respectively. The bacteriological eradication rate was 87.9%(116/132) for gram-positive bacteria, 85.0%(34/40) for gram-negative bacteria, and 100%(63/63) for anaerobic strains of casual bacteria, which were isolated from 140 patients. The overall bacteriological eradication rate was 90.6%(213/235) respectively. Adverse effects were observed in 6 of 170 patients in whom they were evaluated. They consisted of gastrointestinal symptoms in 5 patients and exanthema in 1. Abnormal changes in clinical laboratory test values were observed in 5 patients, and consisted of eosinophilia in 1, elevations of S-GOT and S-GPT in 1, elevations of S-GOT, S-GPT and gamma-GTP in 1, elevation of S-GPT in 1, and elevations of AL-P and gamma-GTP in 1. These results suggest that azithromycin is very useful for surgical infections in the field of surgery.

[A case of orbital lymphoproliferative lesion diagnosed as malignant lymphoma after recurring 11 years later].

BACKGROUND: Most primary lymphoproliferative lesions in the ocular adnexa, including the eyelid, conjunctiva, and orbit, are diagnosed as low-grade malignant lymphomas. Recurrence and dissemination of these tumors are rare in Japan. The long-term prognosis for this disorder still remains to be clarified. CASE AND METHOD: A 53-year-old woman was first referred to us for right orbital tumor in 1986. After subtotal resection of the tumor, the patient received no additional treatment. She visited us in 1997 with the complaint of bilateral orbital tumor. Biopsied specimens were examined histologically using hematoxylin-eosine and immunohistological staining. Southern blot hybridization was used to detect immunoglobulin gene rearrangement. The paraffin-embedded specimen obtained in 1986 was also examined for immunoglobulin gene rearrangement using nested polymerase chain reaction technique. FINDINGS: The specimens from 1997 and 1986 were both diagnosed as lymphoid type of inflammatory pseudotumor, based on polyclonal B cell immunohistological staining. Immunoglobulin gene rearrangement was present in both specimens. CONCLUSION: The orbital tumor resected in 1986 was a low-grade malignant lymphoma which disseminated systemically 11 years later. This case shows a long-term course of orbital lymphoproliferative lesion with positive immunoglobulin gene rearrangement. It also shows the importance of follow-up over 10 years in the case of low-grade malignant lymphoma of the ocular adnexa.

Mutations of p53 in thyroid carcinoma with an insular component.

Thyroid carcinoma with an insular component (TCIC) is considered noteworthy in view of its peculiar histopathological features and clinicopathological behavior. The purpose of the present study was to clarify the rate of mutation in the p53 gene in TCIC as compared with rates in papillary and follicular carcinomas of the thyroid. Formalin-fixed and paraffin-embedded blocks of tissue from 46 cases of TCIC were analyzed. DNA was extracted from tissues and exons 5 through 8 of the p53 gene were amplified by the polymerase chain reaction. Mutations were detected by analysis of single-strand conformation polymorphism. Of the 46 cases of TCIC, 6 had a mutation in exon 5, 2 in exon 7, and 5 in exon 8, while 1 case had mutations in all exons examined. The mutation rate of the p53 gene in TCIC was 38%. Immunostaining revealed overexpression of p53 in nuclei that were mainly in areas of the insular component rather than in surrounding areas of well-differentiated carcinoma. The frequency of positive immunostaining in TCIC was 53%. Considering that TCIC is intermediate between papillary plus follicular carcinoma and anaplastic carcinoma in terms of survival and the rate of mutation of the p53 gene, we can speculate that mutation in the p53 gene might be associated with the insular component and might play an important role in the clinicopathological behavior of thyroid carcinoma.