What is gastric pseudolymphoma?

GASTROENTEROLOGY

SELECTED

1985:88:845-g

SUMMARIES

ROBERT M. GLICKMAN Selected Summaries Editor Columbia University College of Physicians & Surgeons New York. New York 10032 STAFF Thomas A. Brasitus, Chicago, Ill. Richard J. Deckelbaum, Jerusalem, Israel Serge Erlinger, Paris, France Robert S. Fisher, Philadelphia, Pa. W. G. M. Hardison. San Diego, Calif. Lucien R. Jacobs, Davis, Calif. Khursheed Jeejeebhoy, Toronto, Canada Rayford S. Jones, Charlottesville, Va.

OF CONTRIBUTORS

Martin F. Kagnoff, San Diego, Calif. Sumner C. Kraft, Chicago, Ill. Robert C. Kurtz, New York, N.Y. Richard P. MacDermott, Boston, Mass. James McManus, Temple, Tex. Esteban Mezey, Baltimore, Md.

Ann Ouyang. Philadelphia, Pa. David F. Ransohoff. Cleveland. Ohio

CELLULAR DNA AND PROGNOSIS ESOPHAGEAL CANCER

OF

Sugimachi K, Hiroko I, Okamura I, et al. (Department of Surgery II, Kyushu University, Fukuoka and Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical College, Japan) Cytophotometric DNA analysis of mucosal and submucosal carcinoma of the esophagus. Cancer 1984;53:2683-7 (June).

Thirty-five cases of mucosal and submucosal esophageal cancer were studied in order to determine the relationship of tumor cell DNA content distribution patterns to clinical prognosis. All patients had been treated by surgical resection, without additional radiation or chemotherapy. Thirteen patients had confirmed lymph node involvement and 30 patients showed invasion of the submucosa. Tumors were also analyzed according to histologic type, 8 cases being well differentiated, 18 moderately, and 7 cases poorly differentiated. Fourteen specimens showed no evidence of lymphatic invasion, with 11 cases showing slight invasion and the remainder a marked degree of invasion. Cell DNA content was measured with a microspectrophotometer using Feulgen-stained histologic sections. In each case, DNA content was determined in 100 cancer cells. The distribution patterns of DNA content were grouped into four types. These ranged from type I to IV according to the degree of dispersion on the DNA histogram, in the order of wider distribution. Marked lymphatic invasion was observed in 20% of the type II and III cases, whereas in type IV invasion was present in 55.6% of cases. The percentage of lymph node metastases increased from 20% in type II to 66.9% in type IV. Deoxyribonucleic acid analysis of patients with types I and II patterns, in which there was a relatively regular distribution and a high peak, showed an uneventful postoperative course with no recurrence, whereas 20% and 55.6% of patients with types III and IV, showing a widely scattered DNA distribution without a high peak, died following recurrence. Comment. Conventional histopathologic opsy specimens yield little information malignant tumors of the gastrointestinal

studies on mucosal pertinent to prognosis tract. Quantification

biof of

Seymour M. Sabesin, Memphis. Tenn. Melvin Schapiro. Los Angeles, Calif. Konrad Schulztl-Delrieu. Iolva City. Iowa Joseph Sweet@. New York. N.Y. Phillip P. Toskes, Gainesville, Fla. Martin H. Ulshen, Chapel Hill, N.C. Ernest Urban. San Antonio, Tex. Milton M. LVeiser. Buffalo, N.Y.

cellular DNA content provides a specific and sensitive method to discriminate tumor from normal cell populations as well as assessment of proliferative properties (Am J Med 1980;69:195203). However, DNA patterns cannot be determined from conventional histopathologic data. Two approaches to the quantification of cancer cell DNA content are currently becoming more widely applied. The application of flow cytometry (FCM) to the early diagnosis of neoplasia in chronic ulcerative colitis was recently summarized on these pages (Gastroenterology 1984;87:1199-1200). Using the technique of DNA FCM, monodispersed cells from tissue biopsy specimens can be analyzed for abnormal DNA content (aneuploidy). Using this technique, analyses of colonic cancers have shown a better prognosis for diploid tumors, whereas the nondiploid neoplasms tend to disseminate more rapidly (J Nat1 Cancer Inst 1982;69:15-22, Acta Pathol Microbial Immunol Stand [A] 1983;91:89-95). However, there are several drawbacks to using this technique. First, the sample for FCM must be processed separately from the usual pathology specimen; second the anatomic relationship is lost between the sample used for FCM and that used for histopathologic diagnosis; and finally, patients must be studied prospectively to determine clinical outcome. These drawbacks can be avoided by making measurements of nuclear DNA stain content on thin sections of paraffinembedded material. The present study shows that a preoperative cytophotometric DNA analysis of mucosal biopsy specimens can provide information that will aid in the planning and implementation of appropriate treatment in addition to assessing prognosis. A further application of this technique may be in the screening of individuals known to be predisposed to esophageal cancer. For example, those patients with Barrett’s epithelium, achalasia, caustic injury to the esophagus with stricture, and Plummer-Vinson syndrome might all be candidates for regular esophagoscopy with biopsy and cellular DNA analysis in order to detect early cancer or premalignant transformation. L R. Ji\COBS, M.D.

WHAT IS GASTRIC

PSEUDOLYMPHOMA?

Orr RK, Lininger JR, Lawrence W (Divisions of Surgical Oncology, Surgical Pathology, and the Massey Cancer Center, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia) Gastric pseudolymphoma. Ann Surg 1984;200:185-94.

846 SELECTED SUMMARIES

During a 15-yr period (1968-1983) 12 cases of gastric pseudolymphoma were histologically documented by the Laboratory of Surgical Pathology of the Medical College of Virginia. This article reviews that experience. The 12 patients ranged in age from 13 to 78 yr at the time of diagnosis with a mean age of 47 yr. All but 2 patients had symptoms for longer than 6 mo and 4 patients had symptoms for at least z yr. Pain was the predominant symptom, being present in 11 patients. Weight loss, ranging from 10 to 33 lb, was also noted in 9 patients and gastrointestinal bleeding in 6 patients. Nausea and vomiting were noted in 4 patients, diarrhea in 2, and 1 patient presented with an acute abdomen from gastric perforation. None of the patients had lymphadenopathy, splenomegaly, or an abdominal mass. Laboratory data were, in general, not helpful, although 4 patients presented with anemia. Upper gastrointestinal series were performed on 10 of 12 patients and were abnormal in all. Five patients had benign-appearing gastric ulcers, 3 had thickened rugal folds, and 2 had large greater curvature masses that were believed to be malignant by the reporting radiologist. Gastroduodenal endoscopy was performed on 11 patients and demonstrated either ulcers, gastritis, or “neoplastic” masses. All 12 of the patients underwent some form of gastric resection. In 10 patients, gastric resection was the definitive treatment, whereas 2 others required subsequent laparotomies: 1 patient for recurrent pseudolymphoma in the proximal gastric remnant 39 mo after a distal subtotal gastrectomy for pseudolymphoma, and the other for Hodgkin’s disease of the gastric remnant 35 mo after subtotal gastrectomy for pseudolymphoma.

GASTROENTEROLOGY Vol. 88, No. 3

ly, however, germinal centers may be present in malignant lymphomas (Hum Path01 1973;4:305), so that establishment of the diagnosis of pseudolymphoma also requires the cellular elements to be truly benign. The histologic findings may often not be so “typical” of pseudolymphoma. In these difficult cases, the use of immunologic techniques (Hum Path01 1981;12:713, Histopathology 1982;6:61] may be very useful. The appropriate management of gastric pseudolymphomas has not been well defined. Orr et al. believe that gastric resection is the definitive way to diagnose gastric pseudolymphoma. Resection should also provide curative therapy in most cases. Others, however, suggest that at least in certain patients, gastric pseudolymphoma may not require gastric resection (Dig Dis 1977;22:465, Am J Gastroenterol 1976;65:226). This issue, therefore, remains unresolved. It appears that after resection this entity may rarely recur. Additionally, a few scattered cases, including one by Orr et al., suggest that gastric pseudolymphoma may progress to malignant lymphoma. I would, therefore, agree with the recommendation of these authors that all patients with this entity, even those having gastric resection, should have long-term follow-up. T.A. BRASITUS,M.D.

SHOULD HEMOCCULT CARDS BE DISCARDED? Ahlquist D, McGill D, Schwartz S (Rochester and Minneapolis, Minnesota) HemoQuant: A new quantitative assay for fecal hemoglobin. Ann Intern Med 1984;101:297-309 (September).

There cannot be many clinicians for whom the “stool for occult blood” is not an important and frequently performed test. Major diagnostic procedures as well as therapeutic decisions often hinge on the presence of a positive Comment. Pseudolymphoma is a benign proliferation of lymstool test. Yet the procedure, despite its apparent simplicphoid tissue that can closely mimic malignant lymphoma on both ity and reliability, is poorly understood. The original pathological and clinical grounds (Am J Clin Path01 1963;40:379). guaiac test depended on the reaction between a colorless Pseudolymphoma was first described in the stomach in 1958 [Am dye (gum guaiac) and hemoglobin in the presence of H202 J Path01 1958;34:553 (abstract)] and has subsequently been seen in to yield a blue color. At present, most of the tests are done the orbit, salivary glands, soft tissues, lungs, breasts, mediastiwith guaiac-impregnated cards that have the advantage of num, as well as in the small and large intestine (Ann Surg permitting some storage before they are tested. In the 1984;200:185]. To date, -200 cases of gastric pseudolymphoma course of evaluating a new quantitative stool hemoglobin have been described. test (HemoQuant), the authors of the present study evaluAs in the current series of Orr et al., most cases of gastric pseudolymphoma present with epigastric pain which often mimated some of the deficiencies of the current card tests. ics peptic ulcer disease. Chronic gastrointestinal bleeding and The results are distressing. Winawer (Gastroenterology weight loss are also commonly seen in these patients. 1982;82:986-91) reviewed many of the technical problems Unfortunately, upper gastrointestinal radiography rarely even with guaiac-impregnated cards. These include both falsesuggests the diagnosis of pseudolymphoma. As pointed out by the positive and false-negative tests. Oxidizing agents such as authors, it is virtually impossible to diagnose this entity on a ascorbic acid as well as delay in performing the test radiologic basis alone and, therefore, pseudolymphoma must be beyond 5 days give false-negative results. Peroxidaseconsidered in the differential of gastric infiltrative lesions or containing foods such as fresh fruits and meats give false tumor masses. positives. Iron and cimetidine have recently been reported Similarly, endoscopy has not proven to be effective in establishing the diagnosis of gastric pseudolymphoma (Ann Surg to give false-positive reactions. It also appears that these 1984;200:185). To date, a single case of gastric pseudolymphoma, tests do not detect the portion of hemoglobin that is diagnosed by endoscopy, has been published (Dig Dis Sci converted to porphyrins in the gut. In the present study, 1982;27:1051). I must say, however, that our personal experience known concentrations of hemoglobin were added to stool. suggests that endoscopic biopsies may be useful in diagnosing Hemoccult cards (the most widely used guaiac-impregnatthis entity (unpublished observations). ed cards) were used to check for its presence. The results In the classic form of gastric pseudolymphoma (Am J Clin were widely erratic. At concentrations of 6.4-12.8 mg Hb/g Path01 1963;40:379, Ann Surg 1970;171:92), benign lymphocytes of stool, 80% of the tests were negative. These concentraare arranged in follicles which resemble germinal centers. Benigntions are three to four times above the 2 mg Hblg of stool appearing plasma cells, eosinophils, and neutrophils are also that is the usually quoted figure for maximal stool hemopresent. Muscle bundles may be splayed apart but destruction of these bundles is not seen as in malignant lymphoma. Occasionalglobin found in normals. More disturbing, still, were some