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I dont think there are any signet ring cells.

----Comment by: Iago on 7/14/2008 6:57:27 AM

It seems busy between the glands, though? (see arrows)

----Comment by: PathDoc15 on 7/14/2008 12:52:09 PM Click to add this comment's arrows to the image above

Maybe a little. Some of those cells look like plasma cells. I'd like to see a little more atypia in a signet ring cell though, but I know what they say about them.

----Comment by: Iago on 7/14/2008 1:42:33 PM

I see vacuoles in the interstitial space, but some are not associated with nuclei, and some have round nuclei near them, such that it could be either a signet ring nucleus (I would like to see the nuclear membrane more “pushed” into by the cytoplasm) or a lymphocyte. I can't tell from this power.

----Comment by: Iago on 7/15/2008 5:49:00 AM

OK, Not easy. This patient has an inheritted loss of function mutation in E-cadherin (causing familial gastric adenocarcinoma). This is section from a PROPHYLACTIC gastrectomy. The cells in the lamina propria are in fact signet ring cells (that would become very apparent with a stain for mucin - which some practices perform routinely on gastric biopsies - or so I'm told). Perhaps this is signet ring 'carcinoma in situ' if such a thing could exist. Regardless, this is the far end of difficult. Thanks to Iago for keeping me honest with a more typical appearing signet ring cell carcinoma. [Ref #1].

----Comment by: PathDoc15 on 7/15/2008 5:09:10 PM

So this was an incidental (maybe not really the appropriate term to use here, but aside from the mutation, there was no indication that this patient had gastric adenoCa, right?) gastric signet ring cell carcinoma? Are prophylactic gastrectomies routinely performed on patients with E-cadherin mutations? Are these patients at frisk for any other types of cancer? Nice case.

----Comment by: Iago on 7/15/2008 7:13:39 PM

There are two ways to handle patients with E-Cadherin mutations: i. intense surveillance, 2. Prophylactic gastrectomy. Picking up these early lesions by surveillance biopsies can be difficult. Gastrectomy has significant morbidity. Prospective studies are lacking. As you can imagine, this is a controversial issue. CDH1 mutations have a variable penetrance – among carriers about 2/3rd of men and 80% of women will develop gastric cancer by the age of 80. Women are also at risk for breast cancer – lobular carcinoma (as you would have probably guessed, since we sometimes use CHD1 IHC to distinguish lobular in situ from ductal in situ). A great summary of familial gastrict cancer can be found here [Ref #1]

----Comment by: PathDoc15 on 7/16/2008 4:15:12 AM

This image depicts chronic gastritis. There is no signet ring cell adenocarcinoma on this image.

----Comment by: apath on 8/15/2008 11:12:55 PM

Apath - Welcome to the site! Concerning this image - the rare cells in the lamina propria with a clear cytoplasm and squashed nuclei (see arrow) are infact CK positive and contain mucin on a mucin stain. I suspect that the pathway to carcinoma is different in individuals with a consitutional loss of one copy of E-cadherin, so the histology is certainly different on these prophylactic gastrectomy. That said - you are certainly not the only person who has expressed skepticism here. Even outside of this context Finding the rare signet ring cell on the edge of a gastric ulcer can be so difficult that some practice do mucin stains on EVERY gastric biopsy (cheap and fast) I'll see if I can find the IHC and mucin stains to prove the point - this is from a teaching set that may not have these stains available. Again WELCOME, and thanks for all the great comments.

----Comment by: PathDoc15 on 8/18/2008 6:03:32 PM Click to add this comment's arrows to the image above

Maybe it's the quality of the image or H&E stain. It would be nice to see the cytokeratin and mucin stains. Then I would be more convinced.

----Comment by: apath on 8/18/2008 7:49:02 PM

Apath - the more I look at this image, the less convinced I become myself. I have offered this as a comprimise. [Ref #1]

----Comment by: PathDoc15 on 8/28/2008 1:20:14 PM

     

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