The interstitial cells of Cajal (ICC) are a group of cells distributed throughout the gut from the lower esophagus to the anus. 24 ICCs are considered to be the pacemaker cells of the gut, 26 intermediaries in the neural control of gut muscular activity, 7 spatial coordinators of gut motility, 9 and as stretch receptors. 10 The development of ICCs is dependent on c-kit, a transmembrane tyrosine kinase receptor. 15 Immunohistochemical staining using an anti-c-kit antibody provides a sensitive technique for the identification of ICCs in animal 25 and human tissues 27 and facilitates the study of ICCs in the gut.
Several disorders are found to be associated with anomaly of ICCs. Abnormal distribution of ICCs has been reported in bowel affected by Hirschsprung's disease, 29 allied Hirschsprung's disease, 31 infantile pyloric stenosis, 28 and chronic idiopathic intestinal pseudo-obstruction. 30 c-Kit is expressed in most gastrointestinal stromal tumors (GISTs) and gain-of-function mutations of juxtamembrane domain of c-kit gene have been found in GISTs. 11 Hence, GISTs are considered to originate from ICCs, and a new term [ldquo]gastrointestinal pacemaker cell tumor (GIPACT)[rdquo] has been proposed to replace the noncommittal acronym GIST. 13
We describe the first case of congenital ICC hyperplasia of the large intestine and demonstrate that this disease is not associated with mutation of the c-kit gene.
This girl was born in a teaching hospital in Taipei on July 16, 1994, by cesarean section. The birth weight was 4500 g. There was no family history of GIST or intestinal motility disorder. She had scanty stool passage since birth. Clinical findings and rectal suction biopsy were suggestive of neuronal intestinal dysplasia. She received T-loop colostomy at 21 days of age. Abdominal distension, constipation, and intermittent diarrhea were noted postoperatively, and stenosis of the stoma was suspected. She was admitted to our hospital for the first time at age 1 year 9 months. The barium enema revealed the distal colon was rigid and the proximal colon was dilated and atonic. During laparotomy, the ascending and transverse colon were found to be dilated, whereas the descending and sigmoid colon were narrow and rigid. Full thickness biopsies were taken from the ascending, transverse, descending, and sigmoid colon and the stoma was revised. The initial diagnosis based on the biopsies was neuronal intestinal dysplasia with hyperplasia of myenteric plexus. Right hemicolectomy was done at 32 months of age. Ileostomy and biopsies of ileum were done. Except for several episodes of diarrhea, she was well with no evidence of disease 3 years after the operation.
MATERIALS AND METHODS
The tissue specimen from right hemicolectomy and biopsy specimens obtained during laparotomy were examined. Histologic and immunohistochemical evaluation was performed on paraffin-embedded, formalin-fixed tissues. Acetylcholinesterase staining was performed on frozen tissue, as described previously. 5 Hematoxylin-eosin stain was used for assessing morphology. The antibodies used for immunohistochemical staining are listed in Table 1. The labeled streptavidin-biotin (LSAB) method after antigen retrieval was used. 21
DNA was extracted from paraffin blocks using DNA/RNA extraction kit (Viogene, Sunnyvale, CA, USA). For the analysis of mutation, primers for PCR were designed to amplify a 192-bp fragment of exon 11 (juxtamembrane domain) of the c-kit gene, based on the published genomic sequence of human c-kit. 1 The primer sequences are[colon]
- 5[acute]-CCAGAGTGCTCTAATGACTG-3[acute] (forward)
- 5[acute]-ACTCAGCCTGTTTCTGGGAAACTC-3[acute] (reverse)
DNA samples were amplified for 35 cycles on a DNA Thermal cycler (Perkin Elmer, Branchburg, NJ, USA) at 94[deg], denaturation for 30 seconds, 56[deg] annealing for 40 seconds, and 72[deg] extension for 30 seconds. PCR reaction was performed in a volume of 10 [mgr]L with 100 ng of genomic DNA in a PCR buffer containing 1.5 mM MgCl2, 200 [mgr]M dNTP, 5 pmol of each primer, and 0.25 U Taq polymerase (Life Technologies, Grand Island, NY, USA). DNA sequencing was done using an ABI 373 Automated Sequencer, with the ABI Prism Dye Terminator Cycle Sequencing Ready Reaction Kit (Perkin Elmer).
The colon portion of the right hemicolectomy specimen measured 14 cm in length and 7.5 cm in diameter. On cut, there was a thick, white fibrous band between the inner circular and outer longitudinal muscle layers throughout the full length of the colon (Fig. 1A). Microscopically, the band-like layer was composed of spindle to oval cells in a haphazard arrangement (Fig. 1B[ndash]D). The nuclei were long and oval in shape with slightly tapered ends and possessed hyperchromatic or clumped chromatin and occasional small nucleoli. The cells had a moderate amount of eosinophilic cytoplasm. Mitotic figures were rare. The muscle layers were partially replaced by the hyperplastic spindle cells, and focally, the full thickness of the inner muscular layer was involved. Residual myenteric plexuses could be identified in the midst of the hyperplastic cells. On immunohistochemical staining, these spindle cells were diffusely immunoreactive for c-kit (Fig. 1E), CD34, and vimentin, but nonreactive for S-100 (Fig. 1F), smooth muscle actin, muscle-specific actin, desmin, neurofilament, and neuron-specific enolase. Because ICCs are the only cells that are double-positive for c-kit and CD34 in the normal gastrointestinal wall, and because the myenteric plexus region is the major location of ICCs, the result suggest that the hyperplastic cells were derived from ICCs. Isolated ganglion cells were seen in the lamina propria and occasional giant ganglia were seen in the submucosa (Fig. 1G). The acetylcholinesterase activity in the parasympathetic nerve fibers of the lamina propria and muscularis mucosae was moderately increased (Fig. 1H). These findings fulfilled the diagnosis criteria of neuronal intestinal dysplasia type B. 8 In the rectal suction biopsy, ganglion cells were present in the submucosal plexuses. No giant ganglion was seen. The acetylcholinesterase activity was mildly increased. In the ileum biopsy, normal submucosal and myenteric plexuses were demonstrated, but no ICC hyperplasia.
The hyperplastic ICCs and mucosa of ileum were microdissected from paraffin-embedded tissue blocks for DNA extraction and analysis of c-kit gene mutation. No germline or somatic mutation of the juxtamembrane domain was detected in direct sequencing of both sense and antisense strands.
To our knowledge, we reported the first case of congenital ICC hyperplasia in the English literature. Hyperplasia of ICC is a rare phenomenon and is often associated with other diseases. Myenteric plexus hyperplasia is occasionally encountered in patients with ulcerative colitis or Crohn's disease, 17 chronic intestinal pseudo-obstruction, 18 neurofibromatosis, 22 and neuronal intestinal dysplasia. 16 However, these diseases are characterized by hyperplasia of ganglion cells and Schwann cells, not ICCs. Focal hyperplasia and hypertrophy of kit receptor-positive cells can be observed in the gastrointestinal wall adjacent to GISTs. 13 Whether this is a preneoplastic or reactive lesion is not clear. O'Brien et al. reported a mother and daughter with multiple familial gastrointestinal autonomic nerve tumors. 20 The tumors arose in conjugation with diffuse hyperplasia /dysplasia of myenteric plexuses. Further study reveals the hyperplastic/dysplastic cells are ICCs and a germline mutation of the juxtamembrane domain of c-kit gene is responsible for the ICC hyperplasia /dysplasia and multiple GISTs. 12 Another pedigree of familial GISTs was also associated with a germline mutation of the c-kit gene. 19 The authors did not mention whether there was ICC hyperplasia. However, our patient differed from these cases in several respects. No familial history of GIST or intestinal motility disorder was noted. We also failed to detect germline or somatic mutation of the c-kit gene. Our patient was a young girl with a history of difficult defecation since birth, whereas the patients with germline mutations of c-kit presented the disease in adulthood. The congenital ICC hyperplasia was limited to the colon, whereas the hyperplasia in O'Brien's patients extended throughout the bowel wall. Furthermore, GIST was not present in our patient. Nevertheless, because our patient was a young girl, the possibility to develop GIST later in her life cannot dismissed, so close long-term follow up is warranted.
Histologically, ICC hyperplasia may resemble intestinal ganglioneuromatosis. Indeed, before c-kit antibody was available, our initial diagnosis for this case was intestinal ganglioneuromatosis. Intestinal ganglioneuromatosis is common in patients with multiple endocrine neoplasia (MEN) type IIb 3,4 and neurofibromatosis. 22 The principle histologic feature is band-like and nodular enlargement of both submucosal and myenteric plexuses. This process has an increase in all nerve elements, including ganglion cells, their processes, and accompanying Schwann cells. Immunostains help distinguish ICC hyperplasia from intestinal ganglioneuromatosis. ICC shows strong uniform c-kit and CD34 reactivity, whereas the Schwann cell component of intestinal ganglioneuromatosis is positive for S-100 protein. Besides, no stigma of neurofibromatosis or MEN IIb was found in the present case. Direct sequencing of exon 16 of the ret gene revealed that germline mutation for MEN IIb was absent in our patient (data not shown).
The finding of giant ganglia, isolated ganglion cell in lamina propria, and increased acetylcholinesterase activity fulfilled the diagnostic criteria of neuronal intestinal dysplasia type B, which is a congenital malformation characterized by hyperplasia of the submucosal and myenteric plexuses, showing giant and basket-like ganglia, ectopic dysplastic ganglion cells, and increased acetylcholinesterase activity of the parasympathetic nerves. 16 A variety of diffuse intestinal neuronal abnormalities have been reported in association with multiple endocrine neoplasia IIb, von Recklinghausen's disease, and intestinal ganglioneuromatosis. 6,23 Because ICCs mediate the neural control of gut muscular motility, the finding of neuronal intestinal dysplasia in our patient is not unexpected. Neuronal intestinal dysplasia was also found in the two cases reported by O'Brien et al. 20 It is well known that reflex systems exist between submucosal ganglia and myenteric ganglia. 2 Hence, it is proposed that when abnormalities exist in the myenteric or submucosal plexuses, functioning nerve cells may become hyperactive to stimulate the abnormal plexuses, resulting in hyperplasia of ganglion cells.
We failed to detect germline or somatic mutation of the c-kit gene in our patient, suggesting other molecular mechanism result in the hyperplasia of ICC. Because most benign GISTs are also devoid of the c-kit gene mutation, 14 more studies are warranted to better clarify ICC development to further delineate the pathogenesis of this congenital malformation and the tumorigenesis of GIST.
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