Virchows Arch (2005) 446:181184
DOI 10.1007/s00428-004-1156-4
CASE REPORT
Carla Oliveira Herculano Moreira Raquel Seruca
Manuel Cardoso de Oliveira F
tima Carneiro
Role of pathology in the identification
of hereditary diffuse gastric cancer: report of a Portuguese family
Received: 27 August 2004 / Accepted: 30 September 2004 / Published online: 11 December 2004

Springer-Verlag 2004
Abstract Mutations in E-cadherin gene are the underly-
ing genetic defect in approximately one-third of the he-
reditary diffuse gastric cancer (HDGC) families described
to date. Positive family history of diffuse gastric cancer
and early age of onset of gastric tumours are the clinical
criteria currently used to qualify for HDGC. In the present
study, we describe a Portuguese family with HDGC that
was selected for CDH1 mutation screening after histo-
logical observation of the gastrectomy specimen of one
member, who died at the age of 23 years from widely
invasive diffuse gastric carcinoma. The detection in the
surgical specimen of tiny foci of intramucosal diffuse
carcinoma as well as in situ carcinoma lesions and pag-
etoid spread of signet ring cells raised the hypothesis of
HDGC, which was confirmed by pedigree analysis of the
family and detection of CDH1 germline mutation. We
conclude that there are morphological hints that may help
in the identification of HDGC.
The authors wish it to be known that Carla Oliveira and Herculano
Moreira should be regarded as joint first authors
C. Oliveira R. Seruca M. Cardoso de Oliveira F. Carneiro ())
Institute of Molecular Pathology and Immunology,
University of Porto (IPATIMUP),
Rua Dr Roberto Frias s/n, 4200-465 Porto, Portugal
e-mail: fcarneiro@ipatimup.pt
Tel.: +351-2-25570700
Fax: +351-2-25570799
H. Moreira M. Cardoso de Oliveira
Department of Surgery,
Hospital S. Joo,
Porto, Portugal
F. Carneiro
Department of Pathology,
Hospital S. Joo,
Porto, Portugal
R. Seruca M. Cardoso de Oliveira F. Carneiro
Medical Faculty,
University of Porto,
Porto, Portugal
Keywords E-cadherin Hereditary diffuse gastric
cancer In situ carcinoma Pagetoid spread
Introduction
Knowledge regarding pathology and genetic basis of fa-
milial gastric cancer has greatly increased in the last
years, due to the definition of hereditary diffuse gastric
cancer (HDGC) syndrome and the discovery of segre-
gating germline mutations in the E-cadherin (CDH1) gene
[2, 6]. Mutations in CDH1 are the underlying genetic
defect in one-third of the HDGC families [9]. Clinical
criteria to qualify for HDGC were established by the In-
ternational Gastric Cancer Linkage Consortium (IGCLC)
[2]. The thorough study of prophylactic gastrectomies
performed in asymptomatic carriers of germline CDH1
mutations led to the identification of precursor lesions of
HDGC, such as in situ signet ring cell carcinoma and
pagetoid spread [3].
In the present study, we describe a Portuguese fami-
ly with HDGC that was selected for CDH1 mutation
screening after morphological observation of the gastrec-
tomy specimen of one member with early-onset diffuse
gastric carcinoma. The detection of multiple foci of dif-
fuse carcinoma and in situ carcinoma with pagetoid spread
raised the hypothesis of HDGC, which was confirmed by
pedigree analysis and detection of CDH1 germline muta-
tion.
Case report
A 23-year-old female reported in early 2001 for investigation of
frequent epigastric pain, hematemesis and anaemia. Endoscopy
revealed a large gastric ulcer. Multiple endoscopic biopsies showed
the presence of chronic gastritis and signet ring cell carcinoma. The
patient was submitted to total gastrectomy with oesophago-jejun-
ostomy. A tumour (855 cm) was observed in the body of the
stomach, with serosal invasion and metastases in 6 of 18 regional
lymph nodes (pT3N1Mx). The patient died 9 months after surgery.
Autopsy was not performed.
182
Fig. 1 Different lesions ob-
served in the proband. A
Widely invasive diffuse carci-
noma [haematoxylin and eosin
(H&E), 10]. B Tiny focus of
intramucosal diffuse carcinoma
displaying signet ring cell phe-
notype (H&E, 20). C In situ
carcinoma (H&E, 40). D Pag-
etoid spread of signet ring cells
along an adjacent foveolae
(H&E, 40)

Fig. 2 Pedigree of the family.

The age of onset of the tumours
or the present age of unaffected
individuals is shown underneath
the symbols: + carriers of
germline mutation,
subjects
that did not carry the mutated
alleles in the germline DNA,
arrow proband, asterisk patients
with histologically confirmed
diffuse gastric cancer

Using histology, the tumour showed the features of diffuse/
signet ring cell carcinoma (Fig. 1A). Several tiny foci of intramu-
cosal signet ring cell carcinoma were identified away from the main
tumour (Fig. 1B). Furthermore, foci of in situ carcinoma were
observed, characterised by the presence of signet ring cells partially
substituting the epithelial lining of glands (Fig. 1C). Pagetoid
spread of signet ring cells was observed along adjacent foveolae
(Fig. 1D). The similitude of these lesions with those described in
prophylactic gastrectomies from germline CDH1 mutation carriers
[3, 7] raised the hypothesis of HDGC, which was further investi-
gated.
Family history of gastric cancer was collected. The patient had
an older brother who had died 14 years previously with diffuse
gastric carcinoma, at the age of 26 years (Fig. 2). The diagnosis was

Fig. 3 Sequencing analysis showing the 1901 C>T transition in
exon 12 leading to an amino acid substitution from alanine to valine
in codon 634
confirmed by the histological evaluation of available haematoxylin
and eosin-stained slides. Living members of this family were asked
to provide informed consent to proceed for genetic testing for
CDH1 germline mutations. DNA was extracted from normal gastric
tissue from the proband of this family, and CDH1 mutation
screening revealed the presence of a heterozygous missense mu-
tation at position 1901 (C>T) in codon 634 (Fig. 3), leading to an
amino acid substitution from Ala to Val [8]. Mutation screening
was not performed in the 26-year-old brother who died from gastric
cancer, due to unavailability of paraffin-embedded tissue. The re-
maining six asymptomatic siblings were also tested, after informed
consent, and one (33-year old) was found to be a mutation carrier of
the same CDH1 mutation identified in the proband. The parents
refused genetic testing.
Discussion
The collection of family history and the identification of
several affected individuals in the same kindred are
commonly the first steps towards the identification of
familial/hereditary syndromes. Familial gastric cancer is
an uncommon disease; HDGC is even less common and
difficult to address on clinical and therapeutic grounds.
Criteria for the identification of HDGC was first estab-
lished by the IGCLC [2] and recently updated by Brooks-
Wilson and colleagues [1].
In this report, we describe a family with HDGC in
which a germline CDH1 mutation was detected after
morphological identification of multifocal diffuse/signet
ring cell gastric carcinoma and in situ carcinoma lesions
with pagetoid spread. The patient herein reported carried
a missense mutation, which was first reported in a colon
carcinoma cell line, as giving rise either to truncated
proteins due to the activation of a cryptic splice-site
created by the mutation, together with full length proteins
carrying the amino acid substitution expected to occur
after the missense mutation [12]. Soon after, this missense
mutation was found in a Portuguese early-onset diffuse
cancer patient who died at the age of 30 years [11]. By in
vitro functional analysis, the A634V mutation proved to
induce dramatic changes in cell adhesion, motility and
invasion [11].
In addition to the patient who died from multifocal
diffuse gastric cancer (the case herein reported), we have
identified another mutation carrier, a brother who remains
asymptomatic. Most probably, the brother who died from
diffuse gastric cancer was also a mutation carrier, but we
183
could not prove it due to lack of tissue for genetic anal-
ysis. One of the parents must be an obligate carrier, since
two of their children carry the same germline CDH1
mutation. Efforts to obtain informed consent for genetic
testing in the parents were fruitless.
Huntsman and colleagues described foci of early dif-
fuse gastric cancer in 100% of the prophylactic gastrec-
tomy specimens from asymptomatic CDH1 mutation
carriers [7] and showed that gastric cancer developed in
all of them, meaning that carriers of a germline CDH1
mutation have a lifetime risk of developing early gastric
cancer close to 100%. However, it is conceivable that not
all pathological changes will develop into clinically sig-
nificant cancer, leading to a decrease in the observed
penetrance, as it seemed to occur in this family, regarding
one of the parents and the asymptomatic son. Pharoah and
colleagues [10] estimated the cumulative risk of clinically
detected gastric cancer for men to be 67% and for women
to be 83% at the age of 80 years.
The mutation identified in this family typed as a
missense mutation and proved to be pathogenic in func-
tional assays [11]. The program of surveillance of
asymptomatic CDH1 mutation carriers is being per-
formed, in this family, according to the recommendations
of Fitzgerald and Caldas [5]. The asymptomatic brother of
the proband (aged 33 years) and both parents (one of
which an obligate carrier) are currently under genetic
counselling and intensive endoscopic surveillance, aiming
to identify an early curable lesion.
According to Charlton and colleagues [4], chromoen-
doscopy using a pH-sensitive dye, congo red, following
stimulation by pentagastrin, may be useful in performing
multiple targeted biopsies in highlighted areas along the
program of endoscopic surveillance.
In summary, the case we report was first considered as
an early-onset diffuse gastric cancer, and histopathologi-
cal features led to the collection of family history and
genetic testing, which turned out to be positive for a
germline CDH1 mutation, proving the diagnosis of
HDGC in this Portuguese family. For pathologists, the
take-home lesson from this case is that there are mor-
phological hints that may help in the identification of
HDCG.
Acknowledgements This study was funded by grants from Fun-
dao para a Cincia e a Tecnologia, Portugal (POCTI/35374/CBO/
2000 and POCTI/MGI/35586/1999) and by Programa Operacional
Cincia, Tecnologia e Inovao (POCTI), of QCA III.
References
1. Brooks-Wilson AR, Kaurah P, Suriano G, Leach S, Senz J,
Grehan N, Butterfield YS, Jeyes J, Schinas J, Bacani J, Kelsey
M, Ferreira P, MacGillivray B, MacLeod P, Micek M, Ford J,
Foulkes W, Australie K, Greenberg C, LaPointe M, Gilpin C,
Nikkel S, Gilchrist D, Hughes R, Jackson CE, Monaghan KG,
Oliveira MJ, Seruca R, Gallinger S, Caldas C, Huntsman D
(2004) Germline E-cadherin mutations in hereditary diffuse
gastric cancer: assessment of 42 new families and review of
genetic screening criteria. J Med Genet 41:508517
184
2. Caldas C, Carneiro F, Lynch HT, Yokota J, Wiesner GL,
Powell SM, Lewis FR, Huntsman DG, Pharoah PD, Jankowski
JA, MacLeod P, Vogelsang H, Keller G, Park KG, Richards
FM, Maher ER, Gayther SA, Oliveira C, Grehan N, Wight D,
Seruca R, Roviello F, Ponder BA, Jackson CE (1999) Familial
gastric cancer: overview and guidelines for management. J Med
Genet 36:873880
3. Carneiro F, Huntsman DG, Smyrk TC, Owen DA, Seruca R,
Pharoah P, Caldas C, Sobrinho-Simes M (2004) Model of the
early development of diffuse gastric cancer in E-cadherin mu-
tation carriers and its implications for patient screening. J Pa-
thol 203:681687
4. Charlton A, Blair V, Shaw D, Parry S, Guilford P, Martin IG
(2004) Hereditary diffuse gastric cancer: predominance of
multiple foci of signet ring cell carcinoma in distal stomach and
transitional zone. Gut 53:814820
5. Fitzgerald RC, Caldas C (2004) Clinical implications of E-
cadherin associated hereditary diffuse gastric cancer. Gut
53:775778
6. Guilford P, Hopkins J, Harraway J, McLeod M, McLeod N,
Harawira P, Taite H, Scoular R, Miller A, Reeve AE (1998) E-
cadherin germline mutations in familial gastric cancer. Nature
392:402405
7. Huntsman DG, Carneiro F, Lewis FR, MacLeod PM, Hayashi
A, Monaghan KG, Maung R, Seruca R, Jackson CE, Caldas C
(2001) Early gastric cancer in young, asymptomatic carriers of
germ-line E-cadherin mutations. N Engl J Med 344:19041909
8. Oliveira C, Ferreira P, Nabais S, Campos L, Ferreira A, Cirnes
L, Castro Alves C, Veiga I, Fragoso M, Regateiro F, Moreira
Dias L, Moreira H, Suriano G, Carlos Machado J, Lopes C,
Castedo S, Carneiro F, Seruca R (2004) E-cadherin (CDH1)
and p53 rather than SMAD4 and caspase-10 germline muta-
tions contribute to genetic predisposition in Portuguese gastric
cancer patients. Eur J Cancer 40:18971903
9. Oliveira C, Suriano G, Ferreira P, Canedo P, Kaurah P, Mateus
R, Ferreira A, Ferreira AC, Oliveira MJ, Figueiredo C, Carneiro
F, Keller G, Huntsman D, Machado JC, Seruca R (2004) Ge-
netic screening for familial gastric cancer. Hereditary Cancer
Clin Pract 2:5164
10. Pharoah PD, Guilford P, Caldas C, International Gastric Cancer
Linkage Consortium (2001) Incidence of gastric cancer and
breast cancer in CDH1 (E-cadherin) mutation carriers from
hereditary diffuse gastric cancer families. Gastroenterology
121:13481353
11. Suriano G, Oliveira C, Ferreira P, Machado JC, Bordin MC, De
Wever O, Bruyneel EA, Moguilevsky N, Grehan N, Porter TR,
Richards FM, Hruban RH, Roviello F, Huntsman D, Mareel M,
Carneiro F, Caldas C, Seruca R (2003) Identification of CDH1
germline missense mutations associated with functional inac-
tivation of the E-cadherin protein in young gastric cancer
probands. Hum Mol Genet 12:575582
12. Vecsey-Semjen B, Becker KF, Sinski A, Blennow E, Vietor I,
Zatloukal K, Beug H, Wagner E, Huber LA (2002) Novel colon
cancer cell lines leading to better understanding of the diversity
of respective primary cancers. Oncogene 21:46464662