Original Article
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World J Gastroenterol. Mar 7, 2012; 18(9): 896-904
Published online Mar 7, 2012. doi: 10.3748/wjg.v18.i9.896
Histotype-based prognostic classification of gastric cancer
Anna Maria Chiaravalli, Catherine Klersy, Alessandro Vanoli, Andrea Ferretti, Carlo Capella, Enrico Solcia
Anna Maria Chiaravalli, Andrea Ferretti, Carlo Capella, Department of Human Morphology and Centro Insubre di Biotecnologie per la Salute Umana, University of Insubria and Ospedale di Circolo, Varese 21100, Italy
Catherine Klersy, Unit of Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
Alessandro Vanoli, Enrico Solcia, Department of Human Pathology, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
Author contributions: Chiaravalli AM, Capella C and Solcia E designed the research; Chiaravalli AM, Vanoli A and Ferretti A performed the research; Klersy C analyzed the data; Chiaravalli AM, Capella C and Solcia E wrote the paper.
Supported by Grants from the Italian Ministry of Health, No. RF-PSM-2006-401346 (to Solcia E and Capella C)
Correspondence to: Anna Maria Chiaravalli, BSc, Department of Human Morphology, University of Insubria and Ospedale di Circolo, Viale Borri 57, Varese 21100, Italy. annamaria.chiaravalli@tin.it
Telephone: +39-332-270601 Fax: +39-332-270600
Received: June 28, 2011
Revised: December 21, 2011
Accepted: December 31, 2011
Published online: March 7, 2012
Abstract

AIM: To test the efficiency of a recently proposed histotype-based grading system in a consecutive series of gastric cancers.

METHODS: Two hundred advanced gastric cancers operated upon in 1980-1987 and followed for a median 159 mo were investigated on hematoxylin-eosin-stained sections to identify low-grade [muconodular, well differentiated tubular, diffuse desmoplastic and high lymphoid response (HLR)], high-grade (anaplastic and mucinous invasive) and intermediate-grade (ordinary cohesive, diffuse and mucinous) cancers, in parallel with a previously investigated series of 292 cases. In addition, immunohistochemical analyses for CD8, CD11 and HLA-DR antigens, pancytokeratin and podoplanin, as well as immunohistochemical and molecular tests for microsatellite DNA instability and in situ hybridization for the Epstein-Barr virus (EBV) EBER1 gene were performed. Patient survival was assessed with death rates per 100 person-years and with Kaplan-Meier or Cox model estimates.

RESULTS: Collectively, the four low-grade histotypes accounted for 22% and the two high-grade histotypes for 7% of the consecutive cancers investigated, while the remaining 71% of cases were intermediate-grade cancers, with highly significant, stage-independent, survival differences among the three tumor grades (P = 0.004 for grade 1 vs 2 and P = 0.0019 for grade 2 vs grade 3), thus confirming the results in the original series. A combined analysis of 492 cases showed an improved prognostic value of histotype-based grading compared with the Lauren classification. In addition, it allowed better characterization of rare histotypes, particularly the three subsets of prognostically different mucinous neoplasms, of which 10 ordinary mucinous cancers showed stage-inclusive survival worse than that of 20 muconodular (P = 0.037) and better than that of 21 high-grade (P < 0.001) cases. Tumors with high-level microsatellite DNA instability (MSI-H) or EBV infection, together with a third subset negative for both conditions, formed the T8 cell-rich HLR group, the largest group among low-grade histotypes. Coexisting HLR proved to be a factor in improved prognosis in tumors with microsatellite instability (P = 0.0015 vs HLR-/MSI-H tumors) or DR type human leukocyte antigen expression (P = 0.033 vs HLR-/HLA-DR+ tumors).

CONCLUSION: Identification of low- and high-grade histotypes can improve the prognostic assessment of a substantial proportion of gastric cancers in routine diagnostic practice.

Keywords: Gastric cancer; High-grade histotype; Low-grade histotype; Lymphoid response; Epstein-Barr virus; Microsatellite instability