Loss of phenotypic expression is related to tumour progression in early gastric differentiated adenocarcinoma.

AIMS: To evaluate the relationship between phenotypic expression and tumour progression as represented by macroscopic features, submucosal invasion and lymph node metastasis in early differentiated gastric adenocarcinoma. METHODS: One hundred and fifty-five cases of early gastric differentiated adenocarcinoma without any poorly differentiated components were studied. The mucosal and submucosal components of carcinomas and lymph node metastatic lesions were classified into four categories, gastric type (G-type), incomplete intestinal type (I-type), complete intestinal type (C-type) and unclassified type (U-type), based on the combination of the phenotypic expression of HGM (gastric foveolar epithelium), MUC 6 (gastric pyloric glands), MUC 2 (intestinal goblet cells) and CD 10 (small intestinal brush border). In addition, a new classification representing a phenotypic shift from mucosa to submucosa or from primary lesion to lymph node metastasis was established with the categories of preserved group (P-group), loss group (L-group) and acquired group (A-group). RESULTS: (1) In submucosal carcinoma, U-type was more common in the submucosa (39%) than in the mucosa (9%). (2) U-type was more common in the metastatic lesions (42%) than in the primary lesions (5%). (3) The submucosal component and lymph node metastatic lesions were classified as P-group in 48% and 43% of cases, respectively, and as L-group in 50% and 52% of cases, respectively. (4) Lymph node metastatic lesions comprising undifferentiated carcinoma were classified as L-group in 100% of cases. CONCLUSION: During the course of tumour progression, early differentiated adenocarcinoma at first tends to lose its phenotypic expression despite preserving its morphology, but subsequently morphological dedifferentiation occurs.

Significance of immunohistochemical over-expression of CD44v6 as an indicator of malignant potential in esophageal squamous cell carcinoma.

PURPOSE: The aim of the current study was to find out a clinicopathologic significance of CD44v6 over-expression in esophageal squamous cell carcinoma (ESCC), which has not been elucidated fully. METHODS: Immunohistochemical expression of CD44v6 was examined for 81 ESCCs. Correlation of CD44 over-expression with the clinicopathologic features were investigated. RESULTS: Thirty-eight ESCCs (46.9%) had over-expression of CD44v6. The proportions of the incidence of lymph node metastasis (P=0.039), lymphatic permeation (P=0.003), and blood vessel invasion (P=0.037) in ESCCs with over-expression of CD44v6 were significantly higher than those in ESCCs without over-expression of CD44v6. The stage of the tumor in ESCCs with over-expression of CD44v6 was significantly more advanced (P=0.045). Survival rates of patients with ESCC with over-expression of CD44v6 were significantly worse (P=0.0005). Moreover, CD44v6 over-expression (P=0.048) as well as blood vessel invasion (P=0.014) and stage of the tumor ( P=0.010) were factors independently associated with the unfavorable prognosis of the patients with ESCC. CONCLUSIONS: Over-expression of CD44v6 can be an indicator of the malignant potential of ESCC.

Development of colonic neoplasms and expressions of p53 and p21 proteins in experimental colitis of mice induced by dextran sulfate sodium.

The mechanisms underlying the frequent development of colorectal carcinomas in patients with ulcerative colitis (UC) are still not understood. This study was conducted to investigate whether p53 and p21 protein expressions contribute to carcinogenesis in an experimental model with dextran sulfate sodium (DSS) treatment, and to establish if this colitis model is suitable for study of cancer development in UC. A total of 40 mice were subjected to four administration cycles of 4% DSS for 7 days followed by plain water for the subsequent 14 days. The 33-surviving mice were sacrificed to examine the malignant transformation of colonic mucosa morphologically and to determine p53 and p21 expressions immunohistochemically. After DSS treatment periods, there were marked irregularities in the mucosal layer, the thickness of the entire bowel wall and the shortness of the colon. Histologically, tumors were found in 13 out of 33 (39.4%) mice. These 13 cases included 9 with a solitary lesion and 4 with double tumors. There were occurrences of invasive carcinomas in 8 lesions, high-grade dysplasia in 3 lesions and low-grade-dysplasia in 6 lesions. One presented with a polypoid tumor, 5 mm in diameter, while 16 had small flat lesions. There were 13 tumors on the left-sided colon, as opposed to 4 on the right-sided colon. Histological differentiation of invading carcinomas revealed that 6 out of 8 lesions were comprised of well differentiated adenocarcinomas, while 2 were moderately differentiated adenocarcinomas. Overexpression of p53 protein was found in 4 out of 8 invasive carcinomas, 2 out of 3 high-grade dysplasia cases and 2 out of 6 low-grade dysplasia cases, whereas only 1 out of 8 with invasive carcinoma was positive for p21. This experimental colitis model suggests that p53 and p21 protein expressions may contribute to carcinogenesis in DSS-induced colitis in mice and appears suitable to study cancer development in UC.

Phenotypic expression of colorectal adenocarcinomas with reference to tumor development and biological behavior.

The purpose of this study is to clarify the correlation between cell differentiation and tumor development, including tumor aggressiveness and biological behavior. Eighty-three cases of advanced colorectal adenocarcinoma were randomly selected. Using immunohistochemical staining with antibodies to CD10, MUC2 and human gastric mucin (HGM), the colorectal adenocarcinomas could be classified into five types (18 small intestinal, 27 large intestinal, 2 gastric, 9 mixed and 27 unclassified). Each type had characteristic features. The small-intestinal type showed a relatively lower incidence of lymphatic permeation and higher venous invasion. The large-intestinal type showed a low incidence of venous invasion and lymph node metastasis. The mixed type revealed female and right-side-dominant distribution, large tumor size, high incidence of mucinous carcinoma, and low incidence of venous invasion. Gastric type was seen in only two cases (2%), which exhibited high histologic grade, lymphatic permeation and lymph node metastasis with no venous invasion. Such phenotypic classifications are considered to be useful not only for evaluation of the biological behavior of the carcinoma, but also for analysis of tumorigenesis.

Clinical significance of vascular endothelial growth factor-C (VEGF-C) in breast cancer.

Vascular endothelial growth factor-C (VEGF-C) is a specific ligand which induces lymphangiogenesis. We examined the expression of VEGF-C protein to determine its role in the progression of breast cancer. Immunohistochemical analysis revealed that VEGF-C was overexpressed in 39 of 98 breast cancer specimens (39.8%) but not in adjacent normal mammary glands. The expression of VEGF-C showed a significant correlation with lymphatic vessel invasion (p = 0.0004). It is noteworthy that the 5-year disease free survival rate of the VEGF-C positive group was significantly poorer than that of negative group (p = 0.0356). We suggest that as expression of VEGF-C is not implicated in lymphatic spread, it may prove to be a promising marker to predict the recurrence of breast cancer.

Overexpression of vascular endothelial growth factor C is related to lymphogenous metastasis in early gastric carcinoma.

Vascular endothelial growth factor C (VEGF-C) is considered to be potentially lymphangiogenic and can selectively induce hyperplasia of the lymphatic vasculature. In this study, we clarified the clinicopathological features of early gastric carcinoma (EGC) that has metastasized to the lymph nodes, as well as the correlation between lymphogenous metastases in EGC and the expression of VEGF-C and VEGF. We selected 35 cases of lymph node metastasis-positive [n(+)] EGC and 70 cases of lymph node metastasis-negative [n(-)] EGC for the present study. The expression of VEGF and VEGF-C was investigated with immunohistochemical staining using monoclonal antibodies against VEGF and VEGF-C. Clinicopathologically, there were significant differences in median size (4.1 +/- 2.4 vs. 2.4 +/- 1.7 cm), lymphatic invasion (54 vs. 4%) and venous invasion (23 vs. 3%) between n(+) EGC and n(-) EGC. Immunohistochemically, the incidence of positive expression of VEGF-C in lymphatic invasion-positive EGC (36%) was significantly higher than that in lymphatic invasion-negative EGC (14%). The incidence of positive expression of VEGF-C in n(+) or venous invasion-positive EGC tended to be higher than that in n(-) or venous invasion-negative EGC. In conclusion, lymphatic invasion was significantly increased in VEGF-C-positive EGC.

Gastric cancer with high telomerase activity shows rapid development and invasiveness.

Telomerase activity was reported to be activated in most immortal cells and cancers. As the clinical significance of telomerase activity in human gastric cancer is controversial, we investigated this activity using a telomeric repeat amplification protocol. The telomerase activity was tentatively defined by strength of activity as follows: 3+, observed with 0.06 microg of protein; 2+, observed with 0.6 microg of protein; 1+, observed with 6 microg of protein; 0, not observed under these three conditions. Telomerase activity was detected in 35 of 39 (89.7%) gastric cancer specimens. Tumors with high telomerase activities (2+/3+) tended to have a deeper invasion, lymphatic and vascular invasion, lymph node metastasis, liver metastasis, and peritoneal dissemination, as compared to findings in case of low telomerase activities (-/1+). Thus, telomerase activity of gastric cancer tissue may reflect the malignant potential of the tumor and intensive postoperative care might be required for such patients.

Gastric or intestinal phenotypic expression in the carcinomas and background mucosa of multiple early gastric carcinomas.

AIMS: The differences in phenotypic expression between multiple early gastric carcinomas (EGCs) and solitary EGCs were evaluated in this study. METHODS AND RESULTS: Fifty-three cases (53 lesions) of solitary EGCs and 50 cases (112 lesions) of multiple EGCs were studied. According to the classification of intestinal metaplasia, the phenotypes of carcinomas and background mucosa were classified into four categories-complete intestinal type, incomplete intestinal type, gastric type and unclassified type-based on the combination of expression of CD10 (small intestinal brush border), MUC2 (intestinal goblet cell), HGM (gastric foveolar epithelium) and Con A (gastric pyloric glands). The incidence of gastric-type carcinomas (48%) and the incidence of incomplete intestinal-type background mucosa (75%) among the multiple EGCs was higher than among the solitary EGCs. There was a significant difference in distribution of phenotypic expression of carcinomas and background mucosa between the solitary EGCs and the multiple EGCs, the latter being associated with incomplete intestinal metaplasia. CONCLUSIONS: Both the carcinomas and the background mucosa of multiple EGCs have an unstable status, since they more commonly possess the hybrid phenotype of the stomach and the small intestine than does solitary EGC. Such instability is considered to contribute to a high neoplastic potential and the multiple occurrence of carcinomas.

Clinicopathological features and overexpression of matrix metalloproteinases in intramucosal gastric carcinoma with lymph node metastasis.

Endoscopic mucosal resection, which has been widely accepted for the treatment of intramucosal gastric carcinoma (IMGC) because of the minimal invasiveness of the procedure and the sustained quality of life it provides, can only be used on the premise that the carcinoma has no lymph node metastasis. We evaluated the clinicopathological and biological features of IMGC with lymph node metastases in relation to matrix metalloproteinase (MMP) expression. Fifteen cases of lymph node metastasis-positive [n(+)] IMGC and 59 cases of lymph node metastatic-negative [n(-)] IMGC were obtained. The expression of MMP-2 and MMP-9 was investigated with immunohistochemical methods. Clinicopathologically, n(+)-IMGCs were more likely to be of a larger size, to be of poorly differentiated adenocarcinoma, to have had lymphatic permeation [ly(+)], and to have ulcerations within the lesion compared to n(-)-IMGCs. The incidence of the positive expression of MMP-9 in n(+)-IMGCs (67%) or ly(+)-IMGCs (86%) was significantly higher than that in n(-)-IMGCs (32%) or ly(-)-IMGCs (34%). Even in IMGCs, carcinoma cells may produce MMPs that can degrade the basement membrane, allowing them to permeate the lymph capillary. Ulcerations within the lesion may also facilitate the interchange of lymphatic flow between the mucosa and the submucosa, promoting the development of lymph node metastases.

Vascular invasion and potential for tumor angiogenesis and metastasis in gastric carcinoma.

BACKGROUND: Hematogenous metastasis occurs when cancer cells released from the primary site enter blood vessels and are transported to distant organs, where they attach and proliferate. Angiogenesis is essential for tumor growth and metastasis and depends on the production of angiogenic factors by tumor cells. METHODS: We analyzed data on 1184 Japanese adult men and women with gastric cancer with respect to the relation between vascular invasion and the potential for tumor angiogenesis and metastasis. All these patients were treated from 1976 to 1995 in the Department of Surgery II, Kyushu University. In 300 patients, the expression of vascular endothelial growth factor (VEGF) and p53 protein in tumor tissues was examined by using an immunohistochemical staining method or Northern blotting or both. Intratumoral microvessels were stained with anti-CD31 monoclonal antibody. RESULTS: Vascular invasion was evident in 254 patients (21.5%), and in these patients lymphatic invasion was more frequent and the rate of lymph node metastasis was higher in relation to the extent of vascular invasion. The positive findings were directly related to the depth of invasion and the presence of lymph node and liver metastasis. Tumor invasive and metastatic rates increased in relation to the extent of vascular invasion. Expressions of VEGF and p53 protein were higher and microvessel density was more prominent in tumor tissues in relation to the extent of vascular invasion. A close relation between VEGF and p53 protein expressions was also noted in tumors that showed vascular invasion. The expression of VEGF is one of the independent risk factors for vascular invasion. The postoperative outcome was poorer in patients with vascular invasion in relation to the extent of vascular invasion. CONCLUSIONS: Our findings show that gastric cancers with characteristics of vascular invasion have greater intratumoral angiogenesis and that VEGF and p53 overexpression is associated with intratumoral angiogenesis and metastases to distant organs.

Thymidine phosphorylase activity and angiogenesis in gastric cancer.

Angiogenesis has an important role in the growth and metastasis of solid tumors. Several angiogenic factors have been identified, one being platelet-derived endothelial cell growth factor (PD-ECGF), which is identical to thymidine phosphorylase (dThdPase). We investigated the activity of dThdPase in 84 samples of 42 human gastric cancers, by liquid chromatography. The dThdPase activity significantly correlated to the microvessel density assessed by immunostaining to CD-31 antigen (P<0.05). Expression of dThdPase has an important role in the promotion of angiogenesis in human gastric cancer.

Recurrences and relation to tumor growth potential and local immune response in node-negative advanced gastric cancer.

Biological characteristics and the prognosis for subjects with node-negative advanced gastric cancer have been given little attention in related literature. We analyzed data on 112 patients with serosally invasive gastric cancer who were lymph node metastasis-negative; all had been surgically treated in the Department of Surgery II, Kyushu University Hospital, between 1970 and 1992. Recurrences and relation to the growth potential of the tumor and local immune response were examined. Thirty patients died with a recurrence of the gastric cancer, and in these patients, the tumor was larger, the whole stomach was more frequently involved and infiltrative growth was more common, compared to findings in patients who were recurrence-free. Peritoneal recurrence was evident in half the number of patients and the 5-year survival rate was 74. 5%. Tumor growth potential was evaluated, based on the level of proliferating cell nuclear antigen (PCNA) of the primary tumor and on dendritic cell infiltration into the tumor, determined as a level of local immune function of the host. Higher growth potential and lower immune levels were more frequent in patients with recurrences. Multivariate analysis revealed that tumor size and PCNA labeling index were significant prognostic factors for node-negative gastric cancers. In a subset of advanced gastric cancers, there was no apparent distinct lymph node metastasis and the prognosis was better. However, cancer cells with a higher growth potential and a lower immune response in the host can biologically amplify and mainly infiltrate the gastric wall, extend to the serosa and disseminate transserosally into the peritoneum.

Prognostic value of p53 protein expression for patients with gastric cancer--a multivariate analysis.

Mutations in the p53 gene, one of the most common genetic alterations in human cancer, are implicated in tumorigenesis and tumour progression. Although p53 protein expression appears to be correlated to prognosis in patients with malignancy, its prognostic role in gastric cancer has remained controversial. We examined the clinical significance of p53 overexpression in 427 patients with gastric cancer, using multivariate analysis. Tumour sections of gastric cancer tissues from these 427 Japanese patients were stained immunohistochemically with monoclonal antibody PAb1801. The presence of p53 expression was statistically compared with clinicopathological features and post-operative survival, using univariate and multivariate analyses. p53 expression was detected in 38.6% (165 out of 427) of these gastric cancers and immunoreactivity was not observed in normal mucosa adjacent to the tumour. A higher rate of p53 detection was observed among large tumours and in those with a prominent depth of invasion, lymphatic and vascular invasion and lymph node involvement. Prognosis was significantly worse for patients with p53-positive-staining tumours. The 5-year survival rate was 62.5% for patients with p53-negative tumours and 43.3% for those with positive malignancies. p53 expression was a significant prognostic factor for node-positive gastric cancers in subjects undergoing treatment with curative resection, as assessed by Cox regression analysis. Thus, the expression of p53 was closely related to the potential for tumour advance and a poorer post-operative prognosis for patients with gastric cancer.

Role of transforming growth factor-beta 1 in invasion and metastasis in gastric carcinoma.

PURPOSE: Transforming growth factor-beta1 (TGF-beta1) is a major modulator of cellular proliferation and extracellular matrix formation. We determined the role of TGF-beta1 in invasion and metastasis in gastric cancer. MATERIALS AND METHODS: We detected TGF-beta1 expression in primary and lymph node metastatic lesions of gastric cancer, using an antibody and in situ hybridization. The plasma TGF-beta1 levels in the peripheral vein and in the tumor drainage vein were assayed. RESULTS: In the cytoplasm of cancer cells, TGF- beta1 was immunostained in 35.9% (78 of 217) of primary gastric carcinomas, and this expression was confirmed by in situ hybridization. Of 59 gastric carcinomas with a TGF-beta1-negative primary tumor, metastatic lymph nodes were positive for TGF-beta1 staining in 32 cases (54.2%). Positive staining of TGF-beta1 in gastric cancer tissues was closely related to serosal invasion, infiltrative growth, and lymph node metastasis. Multivariate analysis showed that the expression of TGF-beta1 was an independent risk factor for serosal invasion and infiltrative growth of the tumor. The plasma level of TGF-beta1 did not differ between TGF-beta1-negative and -positive groups. There were also no differences in plasma TGF-beta1 levels among each tumor stage, between the peripheral and the tumor drainage veins, and between preoperative and postoperative testings. CONCLUSION: Transforming growth factor-beta1 is closely related to the invasion and metastasis of gastric cancer, and production of TGF-beta1 in the tumor does not contribute to the total amount of TGF-beta1 in the blood circulation. We interpret our observations to mean that in a tumor microenvironment, TGF-beta1 alters the biologic behavior of the tumor.

Long-term results of corticosteroid administration via appendicostomy in patients with ulcerative colitis involving the entire colon.

BACKGROUND: Ulcerative colitis (UC) of an unknown etiology frequently demonstrates repeated active and inactive stages. As a result, it is difficult to sustain long-term remission under conservative therapy. METHODS: Ten patients who presented suffering from UC involving the entire colon were treated. All patients had been previously treated at other hospitals usually with sulphasalazine and either corticosteroids or steroid enemas for the primary complaints of muco-bloody stool or frequent diarrhea. All patients underwent either an appendicostomy or cecostomy, and were injected with dexamethasone via an artificial fistula twice a day. RESULTS: This treatment led to remission, and, as a result, the symptoms of anal bleeding or muco-bloody stools disappeared in all patients. Radiological, endoscopic, and pathological studies revealed a dramatic response to steroid injection from the fistula. The mean follow-up period was 44.7 months (3-122 months). Eight patients remained free from any symptoms of UC. One underwent a proctocolectomy because of side effects due to steroid treatment. The other patient died suddenly of unknown causes. The mean symptom-free period after cecal injection was 39.5 months (1-119 months). The mean proportion of disease free period from UC, compared with the total follow-up period after surgery, was 88%. After remission, eight patients were able to return to a normal lifestyle at home using a peritoneal button. They could also take a bath and continue their school or social lives in almost the same way as healthy persons. CONCLUSIONS: We thus recommend this new, minimally-invasive therapy for patients with UC involving the entire colon who demonstrate resistance to conventional conservative therapy. As a result of such treatment, all patients were able to achieve a comfortable lifestyle after undergoing minimally-invasive surgery.

Laparoscopic repair of a perforated duodenal ulcer in two patients.

The laparoscopic repair of a perforated duodenal ulcer was effectively done in two patients both of whom were poor risks for surgery. One was a 39-year-old woman with a history of bronchial asthma since she was 20 years of age, while the other was a 76-year-old man with hepatocellular carcinoma, lung cancer, and diabetes mellitus. The postoperative course of these patients was uneventful. Based on these findings, the laparoscopic repair of a perforated duodenal ulcer should thus be considered as a first choice of treatment for a perforated duodenal ulcer, even in poor-risk patients.

Long-term survival of patients with stage IV gastric carcinoma.

BACKGROUND: Survival of patients with Stage IV (based on general rules established by the Japanese Research Society for Gastric Cancer) gastric carcinoma often is unfavorable. Among patients with a poor prognosis, a few do survive > 5 years. The authors examined pathologic and biologic features of tumors of long term survivors. METHODS: The authors analyzed data from 442 patients with Stage IV gastric carcinoma, including 20 surviving for > 5 years after gastrectomy (Group A) and 422 who died of gastric carcinoma within 5 years (Group B). Mutant p53 was immunohistochemically stained using the monoclonal antibody PAb1801. Proliferative activity was estimated by argyrophilic nuclear organizer region (AgNOR) staining and proliferating cell nuclear antigen (PCNA) staining. RESULTS: Group A had smaller and more localized tumors than Group B (P < 0.05 and P < 0.01, respectively). Lymphatic or venous invasion and peritoneal dissemination were less frequent in Group A than in Group B (P < 0.01). Abnormalities of p53 expression were found in 3 of the 14 tumors in Group A (21%), a value significantly lower than the 58 of 118 tumors in Group B (49%; P < 0.05). AgNOR count and percentage of PCNA labeling were not significantly different between Groups A and B. A multivariate analysis showed that lymph node dissection, liver metastasis, gastric resection, venous invasion, and tumor size were independent prognostic factors. CONCLUSIONS: Even in patients with Stage IV gastric carcinoma, radical gastrectomy and extensive lymph node dissection can lead to long term survival. The authors believe that combination analysis of pathologic features and p53 overexpression predict length of survival for patients with Stage IV gastric carcinoma.

Significance of routine annual esophagram for early detection of carcinoma of the esophagus.

BACKGROUND/AIMS: In order to achieve increased survival rates for patients with carcinoma of the esophagus, early detection of the disease is vital. Serial esophagrams were evaluated to clarify which interval would be effective for early detection of carcinoma of the esophagus during routine examination. MATERIALS AND METHODS: One hundred eighty-nine patients with carcinoma of the esophagus were grouped into three, according to the experience and the time of the previous roentgenograms before the definite diagnosis. RESULTS: Five patients were in Group 1, in which roentgenographic examination had been done within 12 months prior to the diagnosis. Retrospective observation revealed a slight but certain abnormal shadow at the same location as the esophageal tumor seen on the second films. In Group 2, seven had received an esophagram between 12 and 24 months before the diagnosis. In contrast to Group 1, neither abnormality nor findings indicating esophageal tumors were detected on the former x-ray films, in all seven cases. Group 2 was characterized by relatively small tumors and low stage of the disease. Mean tumor length was 4.1 +/- 2.9 cm, and three of seven were classified as Stage I and two as Stage IIA. On the other hand, most of the 177 patients in Group 3, with no previous examination of the esophagus within 24 months before the diagnosis, had far advanced disease. Mean tumor length was 6.3 +/- 2.6 cm. Only nine (5.1%) were classified as Stage I, whereas 115 (65.0%) were classified as Stage III or IV. CONCLUSION: In light of these data, for populations in which esophageal cancer frequently occurs, esophageal examination every 12 months will no doubt contribute towards the early detection of lesions.