Year : 2009 | Volume
: 52 | Issue : 1 | Page : 20--24
Evaluation of endoscopic biopsy in gastric lesions with a special reference to the significance of mast cell density
Sumana Mukherjee, Gautam Bandyopadhyay, Chanda Dutta, Aparna Bhattacharya, Rupam Karmakar, Gopinath Barui
Department of Pathology, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India
BH-62, Sector II, Saltlake City, Kolkata 700 091, West Bengal
Various studies have shown the role of mast cells in chronic inflammatory states and in tumor growth. The study is designed to have an idea of the relationship of mast cell density (MCD) to gastric ulcer and cancer, to verify whether mast cell accumulation occurred in the two conditions especially in Indian patients and thus postulate that therapeutic strategies against mast cell mediators could be useful in treatment. Also, we want to review literature and attempt to explain our findings. A total of 240 patients, who underwent their first endoscopy and biopsy for a span of 21/2 years were studied retrospectively. Out of these, 210 cases that were either gastric ulcers or cancer were chosen for this MCD study. Biopsies were sectioned and stained routinely. Toluidine blue stain and copper grid was used to calculate MCD. Student«SQ»s t-Test was used to calculate the statistical significance of MCD. MCD in benign ulcers was much higher than in control subjects. MCD in well-differentiated cancers showed MCD higher than control. Poorly-differentiated adenocarcinoma showed lower MCD than well-differentiated adenocarcinoma. It was concluded that the accumulation of mast cells in gastric ulcers is an inflammatory response. MCD is increased in well-differentiated gastric cancers, which may be a mast cell mediated immune response or mast cells may have a role in tumor angiogenesis and produce factors for tumor progression. Poorly-differentiated adenocarcinoma apparently lacks mast cell mediated anti-tumor response in some unexplained way.
|How to cite this article:|
Mukherjee S, Bandyopadhyay G, Dutta C, Bhattacharya A, Karmakar R, Barui G. Evaluation of endoscopic biopsy in gastric lesions with a special reference to the significance of mast cell density.Indian J Pathol Microbiol 2009;52:20-24
|How to cite this URL:|
Mukherjee S, Bandyopadhyay G, Dutta C, Bhattacharya A, Karmakar R, Barui G. Evaluation of endoscopic biopsy in gastric lesions with a special reference to the significance of mast cell density. Indian J Pathol Microbiol [serial online] 2009 [cited 2021 Oct 25 ];52:20-24
Available from: https://www.ijpmonline.org/text.asp?2009/52/1/20/44956
Histamine molecules normally act on H2 receptors of parietal cells to promote gastric acid secretion. In chronic inflammation of gastric mucosa, acid secretion decreases and there is an increased release of histamine in an attempt to stimulate the few remaining parietal cells.  Hypothetically increased concentrations of released histamine in gastric mucosa might activate the vascular H1 receptors with extravasation and aggravated inflammation. Study revealed that increased numbers of mast cells at the edge of a scarring ulcer may be involved in reparative activity in the ulcerative gastric lesions.
The anti-tumor effect of mast cells had been postulated by several authors, , which might be related to Tumour Necrosis Factor (TNF) and non TNF cytotoxicity.  Therefore, accumulated mast cell density (MCD) may have an effect on limiting the progression, invasion and dissemination of gastric malignancy.  A second possibility is that mast cell products could promote tumor growth and metastasis. 
The study is designed to have an assessment of the relationship of MCD to gastric ulcers and cancer, to verify whether mast cell accumulation occurred in the two conditions especially in Indian patients and thus postulate that therapeutic strategies against mast cell mediators could be useful in treatment. Also, we want to review literature and attempt to explain our findings.
Materials and Methods
In a span of about two and half years (1 January 2005 to 30 June 2007), 240 patients who had attended the Gastroenterology Endoscopy Unit of our hospital and had undergone their first endoscopy followed by a biopsy procedure for ulcerative, polypoidal and ulceropolypoidal lesions in the stomach, as described in their endoscopic findings, were considered for this study initially.
Biopsy materials were routinely processed and paraffin embedded 4µ thick sections were stained with Hematoxylin and Eosin (H & E) and Periodic-acid-Schiff with and without diastase after proper deparaffinization.
A total of 210 cases turned out to be non neoplastic inflammatory ulcers and malignant neoplasms were subjected to the MCD study.
Deparaffinized sections were rapidly stained by 1% Toluidine blue, as is done for counter stain by methylene blue in acid fast stain and then water-mounted for rapid screening of mast cell population. The mast cells stained red-purple (metachromatic staining) and the background stained blue (orthochromatic staining). Metachromasia (color shift) is generally attributed to the cationic or basic dye and somewhat dependent on pH, dye concentration and temperature. 
Control sections were taken from normal mucosa of the fundic area of the stomach specimen, which was received in our department from cases of stomach cancer far away from the lesional area. This control may be biased but no other option was available for control.
MCD was calculated with the help of uncoated 400-mesh copper grids and expressed in number/sq. mm. as a mean value after counting 20 h.p.f.
This study has shown that males are predominantly affected with benign gastric ulcers as well as gastric malignancies in the ratio 3:1. The mean age of patients with chronic non specific gastric ulcer is 43.3 years old and for malignant lesion it is 54.5 years old [Table 1].
Most of the benign ulcers were located in the antrum occupying lesser curvature. Most of the malignant lesions were also located in the pyloric antrum at lesser curvature.
Out of 240 cases, 188 lesions were benign gastric ulcers and 22 lesions were described as gastric adenocarcinomas.
Mast cells were well visualized in water-mounted sections with 1% Toluidine blue stain. MCD as observed in this study is much higher in chronic non specific gastric ulcer in comparison to the control [Figure 1],[Figure 2],[Figure 3],[Figure 4].
Poorly-differentiated adenocarcinoma has shown significantly lower MCD in comparison with well-differentiated adenocarcinoma as well as against the control value [Table 2] and [Table 3], [Figure 5],[Figure 6],[Figure 7].
The mast cell is an enigmatic cell type whose physiological function has preoccupied large numbers of investigators for decades. Some have concluded that the absence of mast cells is incompatible with life, at least in humans. Mast cells have long been considered to play specific roles in pathophysiology, particularly in disease states. In the setting of the gastrointestinal tract, the release of mast cell mediators has been thought to contribute to tissue injury and inflammation, as well as alterations in epithelial and smooth muscle function. The spectrum of mast cell involvement has also been expanded by recognition so that they can participate in biological events not classically related to allergic responses, such as innate immunity.  Many workers , have recorded an increase in mast cells in chronic gastritis and benign ulcers like in our study.
At a molecular level, the pathogenesis of ulcer disease is believed to reflect an imbalance between increased aggressive factors and decreased protective factors. As a result of vagal stimulation, acetylcholine is released and acts on the parietal cells to produce acid. In addition, vagal afferents stimulate the antral G cells to release gastrin. The gastrin and acetylcholine act directly on the parietal cells or the mast cells. The mast cells in turn release histamine, which stimulates gastric acid secretion. 
Regarding pathogenesis, it is known that the IgE/mast cell system is dispersed throughout the body. IgE molecules in gastric mucosa attach themselves to mast cells for recognition of antigen and response for histamine release. Hypothetically, increased concentrations of released histamine in gastric mucosa might activate the vascular H1 receptors with extravasation and aggravated inflammation.  A previous study  has shown the accumulation of mast cells in scarring gastric ulcers may happen as a part of reparative response.
TNF may be involved in the pathogenesis of inflammation by mast cells. By using immunohistochemical studies, Bischoff, et al .  showed that mast cells were an important source of TNF.
Bamba, et al .  found that the density of mast cells and stem cell factor (SCF - mast cell growth factor) positive cells were significantly greater in H. pylori positive subjects when compared with H. pylori negative subjects and decreased after the infection was cured. So SCF may be one of the factors for mast cell increase.
Recent data have expanded the concept that inflammation is a critical component of tumor progression. Many cancers arise from sites of infection, chronic irritation and inflammation. It is now becoming clear that the tumor microenvironment, which is largely orchestrated by inflammatory cells, is an indispensable participant in the neoplastic process, fostering proliferation, survival and migration. In addition, tumor cells have co-opted some of the signalling molecules of the innate immune system, such as selectins, chemokines and their receptors for invasion, migration and metastasis.  So there is an intimate connection between ulcers and cancer and possibly a decrease in MCD may help in the diagnosis of a malignant ulcer. Another worker has postulated a similar scenario. 
A review article  summarised data on the role of mast cells in tumor progression. Two hypotheses were suggested. The first refers to the possibility that the accumulation of mast cells is part of a general immunological host-defense reaction since mast cells have been shown to be cytotoxic for some tumors. A second possibility is that mast cell products could promote tumor growth and metastasis. Heparin, combined to a range of heparin-binding factors such as bFGF or TGF beta is able to promote neovascularisation and mast cell proteases cause cell structural alterations and the loss of the extracellular matrix integrity. The role of histamine secreted by mast cells is less clear. There is indeed controversial experimental data referring to histamine's content within tumor tissues and to histamine's proper effect on tumor expansion.
Angiogenesis is tightly regulated by pro- and anti-angiogenic factors. Secreting mast cells are able to induce and enhance angiogenesis via multiple in part interacting pathways. They include mast cell-derived (i) potent pro-angiogenic factors such as VEGF, bFGF, TGF-beta, TNF-alpha and IL-8, (ii) proteinases and heparin that release heparin-binding pro-angiogenic factors lodged on cell surfaces and in the extracellular matrix (ECM), (iii) histamine, VEGF and certain lipid-derived mediators that induce microvascular hyperpermeability having pro-angiogenic effects, (iv) chemotactic recruitment of monocytes/macrophages and lymphocytes that are able to contribute with angiogenesis-modulating molecules, (v) activation of platelets that release pro-angiogenic factors, (vi) activation of neighbouring stationary non mast cells, which secrete pro-angiogenic factors, ECM-degrading proteinases and stem cell factor that attracts, mitogenically stimulates and activates mast cells, (vii) auto and paracrine stimulation of mast cells by stem cell factor and (viii) recruitment of mast cells by pro-angiogenic factors such as VEGF, bFGF and TGF-beta. As a result of ECM-degradation and changes in the microenvironment following initial mast cell secretion, the mast cell populations may change significantly in number, phenotype and function. In tumor models, mast cells have been shown to play a decisive role in inducing the angiogenic switch that precedes malignant transformation. There is, moreover, strong evidence that mast cells significantly influence angiogenesis and thus growth and progression in human cancers.  Various workers have studied mast cells in angiogenesis  not only in gastric cancer ,,, but also in the lungs,  lymphoma,  colorectal cancer,  etc. Jiang, et al .  have found that higher MCD significantly correlates with low proliferating cell nuclear antigen and p185 expression. They found that well-differentiated adenocarcinoma had significantly higher MCD, similar to our study. Significant correlation between MCD and microvessel density , has been obtained.
We may postulate that the accumulation of mast cells around benign ulcers is a part of the cytokine-mediated inflammatory response. An increase in MCD in well-differentiated adenocarcinoma may be a mast cell mediated immune response or the mast cell may have a role in tumor angiogenesis producing factors for tumor progression. New therapeutic strategies associated with mast cell presence and activation may be useful in inflammation and cancer. ,,
Poorly-differentiated malignancies by virtue of their own invasive character may be associated with the loss of anti-tumor response in some unexplained way and thereby lack the accumulation of mast cells. As differentiation is not the only criterion for prognosis, other parameters like lymph node spread, proliferative markers, microvessel density and a larger study population are required to hypothesize more accurately.
Further study is required to establish the role of mast cells in tumor progression and mediators for mast cell response in gastric malignancies.
Due to the limited number of cases and controls available, our study sample size while calculating significance was rather small, which might have been reflected in the results. Further study with larger samples is required for more accurate findings. Also, the method used for identifying mast cells was a simple one and better methods like ultrastructural study could increase the accuracy of the findings.
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