The general rules for the gastric cancer study in surgery and pathology. Part I. Clinical classification

Desmoplastic reaction of gastric carcinoma: a light- and electron-microscopic immunohistochemical analysis using collagen type-specific antibodies

The desmoplastic reaction in ten cases of gastric carcinoma was investigated light and electron immunohistochemically by using monospecific antibodies to collagen types. In addition to type I and III collagens, type V collagen was constantly recognized in the fibrous stroma, increasingly of the scirrhous carcinoma. Type IV collagen delineated the basement membranes of carcinoma nests linearly with occasional discontinuity, whereas in the scirrhous carcinoma, it was present along the thick bundles of collagenous fibers. Immunoelectron microscopic studies revealed that type I and III collagens were distributed on the collagen fibers, and type V collagen was stained in the margin of these fibers. These antibodies also reacted in the rough endoplasmic reticulum of fibroblasts or myofibroblasts in a few cases. Type IV collagen was localized in the periphery of smooth muscle cells, endothelial cells of collapsed capillaries, and myofibroblasts scattered in the stroma of scirrhous carcinoma. Carcinoma cells were not reactive with any antibodies examined. These findings suggest that type V collagen, as well as type I and III collagens, is involved in the formation of desmoplastic stroma, and that these collagens are reactively synthesized by fibroblasts and myofibroblasts in some interaction with invading carcinoma cells.

Endoscopic intratumoral injection of OK-432 and Langerhans' cells in patients with gastric carcinoma

OK-432, a compound composed of penicillin-G-treated, attenuated Streptococcus pyogenes of human origin, was administered by intratumoral injection (IT) to 15 of 49 patients with Stage III gastric carcinoma, at the time of preoperative endoscopic examination. The 5-year survival rate of patients given IT was 73.3%, whereas the rate was only 36.5% in those not given IT (P less than 0.05). A study of recurrent cases revealed a significantly low incidence of peritoneal recurrence in the group on OK-432 IT (P less than 0.01). In previous work, the authors noted a favorable prognosis of patients with Stage III gastric carcinoma and with a marked infiltration of Langerhans' cells (LC) in the tumor tissues. All of the 49 in the current study were thus examined immunohistochemically, using anti-S-100 protein antibody, the objective being to clarify the relationship between OK-432 IT and the density of LC. The density of LC among those given IT was significantly increased as compared with those not given IT (P less than 0.05). The results of this study suggest that OK-432 IT may lead to augmentation of the density of LC in tumor tissues and hence prevent peritoneal recurrences in patients with Stage III gastric carcinoma.

Correlation between serum immunosuppressive substance and clinico-pathological findings in patients with gastric carcinoma

Serum levels of immunosuppressive substance (IS) were determined in 99 patients with gastric cancer and in 32 healthy individuals. The serum IS levels in the patients (769.6 +/- 314.8 micrograms/ml) were significantly higher than those in the healthy individuals (549.7 +/- 104.7 micrograms/ml). A multivariate analysis on the correlation between serum IS levels and clinicopathological findings in the patients disclosed that there was a close correlation between the serum IS levels and the depth of invasion, in particular, the prognostic serosal invasion, metastasis to the distal lymph nodes and peritoneal dissemination. There was, however, no correlation between the serum IS level and hepatic metastasis. Serum IS levels were higher in patients with well-differentiated adenocarcinoma than in those with poorly differentiated adenocarcinoma or signet ring cell carcinoma. A serum IS level higher than 1000 micrograms/ml indicates the possibility that the tumor is only palliatively resectable because of involvement of the distal lymph nodes or peritoneal dissemination.

Modified Schoemacher Resection for Distal Gastric Cancer

Between October 1979 and February 1987, 30 consecutive patients with cancer of the lower stomach underwent B1-Schoemacher resection with a tubular gastric pouch. Operative mortality was 0% and operative morbidity 10% (leak 3%, anastomotic stricture 3% and abscess 3%). After a mean follow-up of 30 months, the expected 5-year survival was 32%. The causes of death were: 7 distant relapses, 2 noncancer diseases and 1 new primary cancer. The overall incidence of postgastrectomy symptoms was 23% for the whole series and 35% for the patients harboring small tumors. Mild dyspepsia occurred in 71%. The declining concept of total gastrectomy as an essential requirement for curative resection and the recent evidence that B2 for gastric lesions is a carcinogenic operation necessitate alternative procedures. The data show that modified Schoemacher resection can be consider a valid challenge to B2.

Cell-mediated cytotoxic activity of spleen cells from patients with gastric carcinoma

The cell-mediated cytotoxic activities of cells from the spleens (SP cells) of patients with gastric carcinoma were assayed in comparison with the activities of peripheral blood mononuclear cells (PBM cells) from the same patients, and from patients with benign lesions. The natural killer cell (NK) activity of the SP cells and their capacity to generate allogeneic cytotoxicity in mixed lymphocyte culture (MLC) were very similar to those of the PBM cells. The cytotoxic activity of SP cells induced by alloactivation in MLC, however, was significantly higher than that of the PBM cells from the same patient as well as from patients with benign lesions. The production of interleukin 2 (IL 2) and the ability to induce cytotoxic cells after activation with IL 2 (LAK) were therefore examined. Both the ability to produce IL 2 and to generate LAK cells were shown to be significantly increased in SP cells when compared to PBM cells. These results indicate that the spleen may be a potential reservoir for the precursors of these activated killer cells in patients with gastric carcinoma. Furthermore, it may play an important role in the defence against tumors in these patients.

Serum zinc and copper changes after gastrectomy in aged patients with gastric cancer

Serum zinc and copper levels were evaluated in patients with gastric cancer who had undergone gastrectomy. These patients were divided into two age categories; namely, the aged group, comprising 39 patients over the age of 70 years, and the younger group, comprising 23 patients younger than 50 years. The data before and after surgery were compared between the two groups. Serum zinc levels in the aged group were significantly lower than those in the younger group, both before and after surgery. Serum copper levels, however, did not differ significantly between the two groups. The serum Cu/Zn ratio was also analyzed according to the histological stages of cancer (stages I to IV), and compared between the two age-classified groups. The aged group showed a higher Cu/Zn ratio at all stages, whereas in the younger group, the ratio was significantly higher at stage IV than in the earlier stages. Preoperative serum zinc, copper, and the Cu/Zn ratio were studied in relation to the complication of anastomotic leak after surgery. The Cu/Zn ratio in the aged patients with this complication was significantly higher than that in the aged patients without it. These results suggest that the Cu/Zn ratio may be an important factor in determining nutritional parameters in the aged.

Lymphadenectomy for cure in patients with early gastric cancer and lymph node metastasis

The anatomic distribution, size, and histologic mode of involvement of 98 metastatic lymph nodes in 49 of 370 patients were examined to determine to what extent lymphadenectomy should be performed in addition to gastrectomy in patients with early gastric cancer. Nodal involvement in the marginal sinus (30 nodes) and partial medullary sinus (37 nodes) were commonly seen, and the lymph nodes of those types were enlarged compared with 1,086 patients with no metastatic lymph nodes (control group). Lymph nodes of the wide medullary sinus (11 nodes), small nodule (3 nodes), and massive involvement types (17 nodes) did not enlarge compared with those of the other types and those of the control group. Most of the metastatic sites (76.6 percent) were in the perigastric lymph nodes along the lesser and greater curvatures, about a fifth were in the extraperigastric nodes along the left gastric, common hepatic, celiac, and splenic arteries, and the least were in the extraperigastric nodes (3.1 percent) along the hepatoduodenal ligament. Since the rate of macroscopic diagnosis during operation was so poor, regardless of the histologic modes of nodal involvement, and also in cases of metastatic lymph nodes less than 15 mm in widest diameter, for curative operation of patients with early gastric cancer, perigastric and extraperigastric lymph nodes along the main arteries near the stomach should be completely dissected, in addition to resection of the stomach.

Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma

The contention that the R2 radical gastrectomy for localized and potentially curable gastric carcinoma may be superior to gastrectomy without lymphadenectomy (R1) was assessed by randomized trial. Five years after commencement 403 patients have been evaluated at surgery and only 43 (11 per cent) found eligible (S0-2, P0, H0, N0-1), 22 of whom underwent R1 and 21 R2 gastrectomy. Seven patients had final histological stages in excess of the protocol. The R2 group had a longer operating time (P less than 0.005), a greater blood transfusion requirement (P less than 0.005), a longer hospital stay (0.05 greater than P greater than 0.025) and required reoperation in four cases. There were no postoperative deaths. Four patients have died from the disease in the R1 group and five in the R2 group, there being no difference in the probability of survival at a median follow-up of 3.1 years. The small proportion of patients suitable for radical R2 surgery, the high associated morbidity and the fact that survival advantage has yet to be proven in trial suggest that this procedure should not yet be performed outside of controlled clinical trials.

Gastric cancer: an audit of 122 consecutive cases and the results of R1 gastrectomy

In a consecutive series of 122 patients with gastric carcinoma, 9 per cent had no operation, 27 per cent had incurable disease at laparotomy, and 64 per cent underwent gastric resection. R1 gastrectomy was performed in 73 of the 78 resections. The operative mortality after gastric resection was 4 per cent, but there were no deaths after potentially curative resections. The actuarial 5-year survival was 20 per cent overall, 60 per cent in patients undergoing a 'curative' resection with N0 disease, and 18 per cent in patients with N1 disease. Local or regional recurrence without evidence of distant metastases was identified in 11 per cent of cases after 'curative' resections. The probability of survival was adversely affected by N1 nodal involvement (P less than 0.005) and by the presence of poorly differentiated or anaplastic tumours (P less than 0.001). Only 6 per cent of patients had early gastric cancer, and absolute curative resections by Japanese criteria were possible in only 5 per cent of cases. The results suggest that the unfavourable presenting pathology is the principal determinant of the poor prognosis of gastric cancer. A more radical or extended lymphadenectomy (R2/3 gastrectomy) might have cured more patients with N1 metastases, but only 12 per cent of potentially curable patients had N1 disease in this study, and it appears that more radical surgery may have little effect on the overall survival rates for gastric cancer.

A rational technique for surgical operation on Borrmann type 4 gastric carcinoma: left upper abdominal evisceration plus Appleby's method

Borrmann type 4 gastric carcinoma, including linitis plastica, is difficult to detect at an early stage and the results of surgical treatment remain poor. We have used 'left upper abdominal evisceration plus Appleby's method (LUAE + Apl.)' as a radical surgical procedure for this disease. During the period 1983-86, 30 cases of Borrmann type 4 gastric carcinoma underwent this procedure (Group A). These cases were compared with 30 patients who underwent total gastrectomy with pancreaticosplenectomy (Group B) during the period 1980-82. Although this is not a randomized study and the extent of resection was greater in Group A, the operation time, amount of blood loss, and number of complications were similar for both methods. When the survival rates were compared, the 3-year survival rate in stage II-III cases was higher for Group A (83.3 per cent) than for Group B (42.2 per cent) (P less than 0.05). One patient in Group A and 12 patients in Group B died with peritoneal metastasis within 3 years of operation in stage II-III. The LUAE + Apl. method is a rational and useful technique for the surgical treatment of Borrmann type 4 gastric carcinoma.

Prophylactic therapy for peritoneal recurrence of gastric cancer by continuous hyperthermic peritoneal perfusion with mitomycin C

Continuous hyperthermic peritoneal perfusion (CHPP) with a solution that contains mitomycin C (CHPP-M) has been clinically introduced as a prophylactic treatment for peritoneal recurrence of gastric cancer with serosal invasion. Two studies, each with a treated and a control group, were performed. In the historical control study the postoperative 3-year survival rate of patients (73.7%) in the treated group (n = 38) was significantly higher than the survival rate (52.7%) of those in the control group (n = 55) (P less than 0.04). In the random control study the survival rate (83%) of patients in the treated group (n = 26) was also higher than that (67.3%) of those in the control group (n = 21) in the 30 months that followed gastric surgery. However, there was no significant difference. In the historical control study with respect to the postoperative complications, anastomotic leak was observed in 8.5% of patients who were given CHPP-M and 12.8% patients who did not have CHPP-M. In the random control study anastomotic leak was observed in 3.1% of patients who had CHPP-M and 7.1% of patients who did not have CHPP-M. The incidence of adhesive ileus in patients having CHPP-M did not increase in historical or random control groups. Postoperative prolonged intestinal paresis or chemical peritonitis were not induced by CHPP-M. These results indicate that CHPP-M is a simple, safe, and readily available prophylactic therapy for peritoneal recurrence that may follow gastric cancer surgery.

Cell kinetic study of human carcinomas using bromodeoxyuridine

Cell kinetics in human malignant tumours were studied in vivo using bromodeoxyuridine (BrdU) and immunohistochemistry. BrdU was administered to twenty-four patients with gastric cancer at a dose of 1 g pre-operatively. Specimens were obtained during the operation, fixed in 70% ethanol and embedded in paraffin. BrdU-incorporating cells were detected by immunohistochemical staining using anti-BrdU monoclonal antibody. The labelling index (LI), determined by counting tumour cells microscopically, ranged from 4.0 to 41.4%. The LI was higher at the site of invasion than in the central area of the tumour, but no correlation was found between histological differentiation and LI. The LI of stage I gastric cancer was statistically lower than that of stage II, III and IV gastric cancers (P less than 0.005). This technique, which is less cumbersome and time-consuming than using radioactive isotopes of thymidine, appears to be useful for studying cell kinetics of human malignant tumours.

The prognostic significance of resection of primary tumor in gastric and colorectal cancer patients with synchronous liver metastasis

The significance of primary tumor resection in gastric and colorectal cancer patients with liver metastasis (H(+)) was evaluated in terms of operative mortality and survival rate by dividing the materials [293 gastric cancer and 80 colorectal cancer patients (53 colon and 27 rectum) with synchronous liver metastasis] into the following groups: Firstly, with or without peritoneal dissemination (P), secondly, with or without resection of the primary tumor and thirdly, with or without postoperative adjuvant chemotherapy. The following results were obtained: (1) The direct operative death rate of primary tumor resection, excluding death from other causes, showed an absence of statistically significant differences between the P0H(+) and P(+)H(+) gastric and colorectal cancer patients. (2) There was no significance in the prognosis between the primary tumor resection + postoperative chemotherapy group and the non-resectable group in the P(+)H(+) gastric and colorectal cancer patients, revealing no prognostic value of the primary tumor. (3) In the P0H(+) gastric and colorectal cancer patients, the primary tumor resection + postoperative chemotherapy group was significantly more favorable in prognosis than was the primary tumor resection alone group or the non-resectable group, showing the value of primary tumor resection.

Frequent overexpression, but not activation by point mutation, of ras genes in primary human gastric cancers

To define the extent of involvement of ras oncogenes in human gastric cancers, we surveyed for the presence of ras oncogenes, activated by either point mutations within their coding sequences or overexpression of ras protein p21, by the combined use of several analytic techniques. Primary gastric cancers were first analyzed by deoxyribonucleic acid transfection assay using NIH/3T3 cells as recipients and by restriction enzyme analysis, which detects point mutations at codon 12 of the H-ras gene. None of seven tumors analyzed scored as positive. Furthermore, none of them had ras p21 with altered electrophoretic mobility on immunoprecipitation and Western blotting, confirming the absence of ras oncogenes activated by point mutations in these tumors. However, in 6 of 7 tumors, the amounts of p21 exceeded that in human placenta. Amplification of the K-ras gene was found in 1 of 11 (including the 7 described above) gastric cancers. Immunohistochemical analysis of ras p21 expression in these 11 tumors was then carried out using the anti-ras p21 monoclonal antibody RAP-5. All cancers showed more reactivity with RAP-5 than did normal mucosa adjacent to the cancers, indicating increased expression of ras p21. These results indicated that transformation of the stomach mucosa from the normal to the malignant phenotype is rarely associated with activation of ras genes by point mutations, but is frequently associated with enhanced expression of ras p21.

[Lymphadenectomy: indications--technic--invasion--documentation]

From July 1st, 1982 until December 31st, 1986 359 patients were operated on carcinoma of the stomach. On an average 27.1 +/- 7.2 lymphnodes were removed and of these 9.8 +/- 6.1 lymphnodes were positive. The number of lymphnodes may be increased up to 42.2 +/- 8.8 by extended gastrectomy + splenectomy + left resection of the pancreas, that means by clearing out compartment III. It seems that radical lymphadenectomy of compartment I and II improves prognosis for stage N 1 by adjusting the median survival time to stage N 0.

Early gastric carcinoma with special reference to macroscopic classification

During a period beginning in 1946 and ending in October of 1978, 1000 cases of solitary early gastric carcinoma were operated on at the Cancer Institute Hospital, Tokyo, Japan. The clinical characteristics and the macroscopic and chronological changes were studied in these cases. Early gastric carcinoma comprised one third of all resected gastric carcinoma. If early gastric carcinoma was divided into two groups, the depressed and the elevated, the former was more common. By location, the depressed type lesions were more frequently seen in the middle third of the stomach and the elevated type lesions in the lower third. By age, distribution of the elevated type lesions showed a peak with a mode at the age of 60 to 69 years and of the depressed type, a plateau with a mode at the age of 50 to 59 years. The relative incidence of the elevated type of gastric carcinoma to the depressed type was one to four. In depth of invasion, the mucosa and the submucosa were equally involved. Lymph node metastases were encountered in 12.7% of early gastric carcinoma cases. The incidence of positive nodes in mucosal carcinoma was 3.4% and that of submucosal lesions was 21.7%. Of the elevated type carcinoma, 20.9% of the cases had positive nodes. The 5-year survival rate of the patients with surgery for cure was 93.8% in contrast to 56.5% of those with palliative resection.

Prognostic significance of lymph vessel involvement in gastric cancer

We studied the prognostic significance of lymph vessel involvement in the gastric wall in 226 patients with advanced gastric cancer. There was no close correlation between the gross morphology of the cancer and the incidence of lymph vessel invasion. However, the more severe the degree of lymph vessel involvement, the higher was the incidence of lymph node metastasis. Severe lymph vessel invasion was found most frequently in poorly differentiated adenocarcinoma of the medullary type. Among patients with scirrhous carcinoma there were some in whom lymph vessel involvement was overlooked on routine histologic examination. Because the depth of lymph vessel invasion of the gastric wall was significantly related to the clinical course, we consider this to be of supplementary predictive value.

Node dissection in gastric cancer

Three hundred patients who underwent absolute and relative curative gastrectomy and lymph node dissection for gastric cancer were reviewed with respect to postoperative mortality; proportion of patients with node involvement according to the extent of dissection; number of metastatic nodes dissected according to the extent of dissection; accuracy of macroscopic evaluation of node involvement and microscopic node involvement according to tumour location. If more nodes were dissected the proportion of patients with node involvement and the total number of metastatic nodes increased; conversely within R0 and R3 the extent of dissection did not affect postoperative survival. Finally when the presence and extent of node involvement was only macroscopically evaluated, the patients were classified incorrectly in 9.5 per cent of the N0 group and 20.2 per cent of the N1 group. The data suggest that lymph node dissection may be useful in the treatment of gastric cancer, and within the extent studied the employment of this procedure does not affect the postoperative mortality.

The clinical usefulness of preoperative CEA determination in gastric cancer

Between 1980 and 1984, preoperative serum carcinoembryonic antigen (CEA) was determined in 468 patients with gastric cancer to evaluate its clinical usefulness. The positive rate of preoperative CEA was 20.9 per cent in these 468 patients. A significantly higher CEA positive rate was obtained in those patients with liver metastasis (69.2 per cent), n3-4 (40.0 per cent), stage IV gastric cancer (37.0 per cent) and Pap, Tub1 histological type (26.3 per cent) (p less than 0.01). It is interesting that the positive rate of the 49 unresectable patients was 51.0 per cent, which was significantly higher than 17.4 per cent of the 419 resectable cases (p less than 0.01). CEA levels in 16 of the 39 patients with liver metastasis were more than 100 ng/ml. In contrast, serosal invasion and peritoneal metastasis were less correlated to the CEA positive rate. In the 419 resected cases, the 5 year survival rate in the higher CEA group of more than 50 ng/ml (35 cases) was 4.4 per cent, which was significantly lower than 64.0 per cent in the negative group (346 cases) (p less than 0.01). These results show that CEA determination in patients with gastric cancer is useful for the prediction of prognosis, as well as for a diagnostic tool to discover the presence of liver or lymph node metastasis.

Histologic and immunohistochemical studies of alpha-fetoprotein (AFP)-producing gastric carcinoma

Five gastric adenocarcinomas and their metastatic nodules in the liver with high serum AFP levels were examined by histologic and immunohistochemical methods. The examination revealed that AFP-producing stomach cancers were poorly differentiated carcinoma cells, especially with medullary arrangements, or pleomorphic or multinucleated giant cells. Well-differentiated papillotubular adenocarcinoma tissues on the glandular epithelium were not stained with anti-AFP. One out of the five AFP-producing adenocarcinomas with medullary patterns resembled liver cell carcinoma on light microscopy. However, an ultrastructural study showed tumor cells of the intestinal type, since the cells possessed a ductal lumina with abundant microvilli and a secretory granules. The findings suggest that the tumor cells differentiated in an intestinal direction rather than hepatic direction. In addition, we noted three simultaneously CEA-positive cases out of five AFP-producing gastric carcinomas. CEA was strongly stained in well differentiated adenocarcinoma tissues in the glandular epithelium or in areas of medullary type carcinoma invasion. However, CEA was not detected in undifferentiated carcinoma cells.

Prognostic factors of early gastric cancer--results of long-term follow-up and analysis of recurrent cases

The prognosis of early gastric cancer (EGC) is generally excellent, however, EGC is not an exception to recurrence. In order to know what type of EGC is liable to recur, long-term results were studied in 304 cases of resection. The cumulative 10-year survival rate was poorer in patients with positive lymph nodes than in those with negative nodes (52.8 +/- 15.8 per cent vs 94.1 +/- 2.4 per cent; p less than 0.05). It was also less favorable when the EGC was greater than 5 cm in diameter (61.5 +/- 13.2 per cent vs 92.9 +/- 2.4 per cent; p less than 0.05). Among 50 cases which died postoperatively, six deaths were due to recurrence. A predominant mode of recurrence was hematogenous metastasis (4/6). The characteristics of EGC which recurred later included large cancer (greater than or equal to 5 cm) (6/6), macroscopically combined-type cancer (5/6), cancer of depth invasion to the submucosa (4/6) and histologically differentiated cancer (6/6). Lymph node dissection was not carried out in two of these patients at their primary operation. Adjuvant therapy should be added in the EGC bearing risk factors depicted above. Primary cancer in other organs, either metachronous or synchronous, was found in 13 cases (4.3 per cent). Colonic cancer, in particular, was seen in three, and it was 4.8 times as frequent as the expected number of the general population, calculated using the person-year method.

Gastric cancer with synchronous unresectable hepatic metastasis and a positive response to chemotherapy--report of two cases

We report herein the clinical events seen in two longterm survivors of gastric cancer with unresectable synchronous hepatic metastases. Partial gastrectomy was performed against the primary lesion and continuous intra-arterial infusion of anti-tumor drugs, followed by prolonged systemic antitumor drug treatment, were prescribed. A 43-year-old man with moderately-differentiated tubular adenocarcinoma had an uneventful course during his first 21 postoperative months. However, multiple liver metastases became manifest at 24 months and enlargement of the intrahepatic foci led to death 27 months after gastrectomy. A 51-year-old woman with moderately-differentiated tubular adenocarcinoma had an uneventful postoperative course and is now well with no signs of recurrence 6 years and 6 months after gastrectomy.

Early carcinoma of the gastric cardia. A clinicopathologic study of 21 cases

A clinicopathologic study was done on 21 cases of early carcinoma of the gastric cardia. The disease was preponderant in men, with a male-female ratio of 17:4. Five patients had no symptoms, while the other 16 had epigastric pain, epigastric discomfort, or other symptoms. Melena or hematemesis occurred in five patients. The first detection was made by barium study in 16 and by endoscopy in five. Detailed examinations using double-contrast radiography in both the prone right anterior oblique and supine left lateral projections were useful to detect the early carcinoma of the gastric cardia. All depressed-type carcinomas were incidentally detected during endoscopic examinations of benign peptic ulcers, therefore, whenever endoscopic examinations are being done for other entities, all the stomach including the cardia should be examined, carefully and continuously. Compared with early carcinomas of the other areas of the stomach, grossly elevated and histologically well-differentiated early carcinomas were more common in the gastric cardia. In the mucosa adjacent to the carcinoma, chronic gastritis was apparent in almost all cases, although intestinal metaplasia was found less frequently than in other areas of the stomach.

Malignant lymphoma associated with reactive lymphoreticular hyperplasia of the stomach--a case report

We report a case of early malignant lymphoma of the stomach, associated with reactive lymphoreticular hyperplasia. This case seems to prove that there is some evidence of sarcomatous change in reactive lymphoreticular hyperplasia.

Adenosquamous carcinoma of the stomach. Histogenetic and ultrastructural studies

Adenosquamous carcinoma of the stomach in a 45-yr-old Japanese woman was studied ultrastructurally and light microscopically. The tumor consisted of combined areas of poorly and moderately differentiated adenocarcinoma and squamous cell carcinoma, with keratinization. Noteworthy was the demonstration of individual cells containing both tonofibrils and mucous vacuoles. The frequencies of this type of tumor in early and advanced gastric carcinomas are given attention and the pathogenesis is discussed with respect to our own observations and to data in the literature.

Cell-mediated cytotoxic activity of regional lymph node cells from patients with gastric carcinoma

The cell-mediated cytotoxic activities of cells from the perigastric lymph nodes (LNC) were assayed in patients with gastric carcinoma. These activities were compared with those of the peripheral blood mononuclear cells (PBM), and also with the LNC of patients with benign lesions. The capacity of LNC to be converted to cytotoxic cells in mixed cell culture was significantly impaired in the cancer patients as compared to that of either the PBM from the same patient, or the LNC from patients with benign lesions. The natural killer cell (NK) activity of LNC was significantly lower than that of the PBM in both groups of patients. The cytotoxic activity induced by phytohemagglutinin activation (PAK) in the LNC from patients with carcinoma, as well as from those with benign lesions was also significantly decreased, when compared to that of the PBM, although the ability of LNC to produce interleukin 2 (IL 2) was significantly increased. The ability of these cells to generate cytotoxicity after activation with IL 2 (LAK) was therefore examined, and a decreased capacity in LNC was observed. These results indicated that the ability of T cells in LNC to develop into cytotoxic cells in patients with gastric carcinoma was impaired, and that the nonspecific cytotoxicity, including NK or PAK, as well as LAK activity, was essentially low in the perigastric lymph nodes.

Surgical staging of gastric carcinoma: sources and consequences of error

Macroscopic 'TNM' staging was performed during 78 consecutive operations for gastric carcinoma and compared with subsequent pathological staging. Surgical assessment was correct for tumour (T) in 60 per cent when depth of invasion was assessed, for nodes (N) in 61 per cent, for liver metastases (M) in 92 per cent but for all aspects in only 21 per cent. Curability (conservatively defined as T1-3, N0-1, M0) was correct in 8 of 18 patients thus assessed at surgery and incurability was pathologically correct in 58 of 60 patients. Despite inaccurate surgical staging, no patient was denied a resection although 10 patients had unduly radical procedures for their stage and 2 had inappropriately conservative procedures for their stage (but without evidence of residual disease). Staging errors did not jeopardize conventional surgical management substantially and use of intra-operative microscopic sampling of nodes would have improved surgical treatment only minimally.

Langerhans cells and prognosis in patients with gastric carcinoma

Infiltration of Langerhans cells (LC) and macrophages into tumor tissues was investigated using immunohistochemical methods, anti-S-100 protein and anti-lysozyme antibodies in 174 cases of gastric carcinoma. Varying population densities of S-100-positive LC were noted in tumor tissues; lysozyme-positive macrophages, however, were found in almost equal quantities. LC were mainly interspersed among the tumor cells, whereas macrophages were present in the stroma and around the necrotic foci. Although the survival time of patients with Stage I, II or IV gastric carcinoma did not relate to the density of LC, survival time in Stage III patients correlated well with the density of LC. In patients with a marked infiltration of LC, survival time was longer than in cases of only a slight infiltration (P less than 0.001). Therefore, LC in immunological defense mechanisms of the host against the tumor may be clinically effective in a certain phase of tumor development.

Diagnostics of small gastric carcinoma

We studied the diagnostic features of 32 early gastric carcinomas less than or equal to 1 cm in maximum diameter, which were detected in 28 patients. A correct preoperative qualitative diagnosis was made in 19% of the lesions by means of barium studies, in 72% by endoscopy, and in 90% by endoscopic biopsy. Endoscopy and endoscopic biopsies are the most useful diagnostics for detection of these small cancers. Since most carcinomas with a diameter between 6 and 10 mm have a mucosal unevenness such as a shallow depression with an irregular perimeter and are associated with or without elevated marginal mucosa on gross inspection, it was not very difficult to detect these carcinomas with careful endoscopic observations. When endoscopists procure such evidence, biopsies should be done for confirmation. Even in ulcers that appear benign, biopsies are recommended. With regard to carcinomas of less than or equal to 5 mm in diameter, it is difficult to detect the lesions, particularly the flat-type, which make up a relatively large percentage of those minute carcinomas.

Peroxidase-antiperoxidase staining for estrogen and progesterone in scirrhous type of gastric cancer: possible existence of the estrogen receptor

Tissue specimens from patients with the scirrhous type of gastric carcinoma were stained using the peroxidase-antiperoxidase (PAP) method. Nine out of thirty-seven specimens (24 per cent) showed positive estrogen staining, and here tissues from male or older patients were usually stained. Cumulative survival rate in patients whose tissue showed a positive estrogen staining was higher than that in case of a negative estrogen staining. Four out of thirty-one specimens (13 per cent) stained positively for progesterone, all four patients being male. These results suggest that estrogen and progesterone may relate to the growth of the scirrhous type of gastric cancer.

Second primary cancer following adjuvant chemotherapy, radiotherapy and endocrine therapy for breast cancer: a nationwide survey on 47,005 Japanese patients who underwent mastectomy from 1963-1982

Out of a total of 47,005 cases of primary breast cancer with curative surgery recorded in Japan in the 20 year period from 1963 to 1982, 764, or 1.6 per cent had a second primary cancer occurring during the same period. The distribution of the second site was gastric cancer in 200 (26.2 per cent), breast cancer in 200 (26.2 per cent), colorectal cancer in 59 (7.7 per cent), cancer of the cervix uteri in 54 (7.1 per cent) and thyroid cancer in 37 (4.8 per cent). The gastric cancer was the Borrmann type 4, and the poorly differentiated scirrhous type. Incidence of the second cancer was enhanced, in the first period before 1971 and by contrast, in the second period after 1971 it was diminished. In the chemotherapy (+) group, the occurrence of the second cancer seemed to be strongly influenced by mitomycin C. In the radiotherapy prescribed group, leukemia was as frequent as esophageal cancer, and in those given endocrine therapy, breast cancer strongly inhibited the current one.

Clinicopathological features of mucosal carcinoma of the stomach with lymph node metastasis in eleven patients

Of 568 patients with mucosal carcinoma of the stomach, only 11 (1.9 per cent) had a lymph node metastasis. The clinicopathological findings in these 11 patients are reviewed. Diameters of the lesions were over 2.0 cm. Seven were located in the body of the stomach and four in the antrum. Nine showed depressed lesions comprised of poorly differentiated adenocarcinoma and two were classed as elevated lesions consisting of well and moderately differentiated adenocarcinomas. There were six with accompanying peptic ulcers, all of which revealed depressed lesions with poorly differentiated adenocarcinoma. Metastases to proximal perigastric lymph nodes were found in eight while there were three with involvement of distant lymph nodes. All patients were surgically treated and all are doing well except for one who died of hepatic failure one month after operation. We recommend that the standard operation with lymph node dissection is essential, even in cases of mucosal carcinoma.

Prognostic study of intramucosal carcinoma of the stomach with DNA aneuploidy

Cell nuclear DNA content was microspectophotometrically measured in 70 patients with a gastric carcinoma lesion of less than 4.0 cm in diameter and with mucosal or minimal submucosal invasion. Two groups were prepared; low ploidy and high ploidy, according to the degree of dispersion on the DNA histogram. Twenty-four cases of high ploidy were reviewed from the aspects of clinicopathology and prognosis and the findings compared with data on 46 of low ploidy. The high ploidy group was characterized by an elevated lesion and a differentiated carcinoma while the low ploidy group had a depressed lesion and an undifferentiated carcinoma Postoperative recurrence was confirmed in none of the low ploidy cases and 2/24 of the high ploidy cases. The five and ten-year survival rates of the patients with high ploidy were 100 per cent and 91.1 per cent, respectively. Compared to the findings that patients with submucosal carcinoma of high ploidy survived at a rate of only 64.8 per cent in the 5-year follow-up, efforts should be directed toward a higher detection of gastric carcinoma with aneuploidy at the stage limited to within the intramucosal layer. Endoscopic treatment for early gastric carcinoma is not recommended, especially for a differentiated carcinoma, even if the invasion is confined to the mucosa, since it may include aneuploid carcinoma.

Immunosuppressive factor from the spleen in gastric cancer patients

The spleens of gastric cancer patients were examined to determine whether this organ releases an immunosuppressive factor. Compared to serum from peripheral blood, serum from splenic venous blood of advanced gastric cancer patients had greater suppressive activity to normal lymphocyte responses to phytohemagglutinin (PHA); it also contained significantly more immune complexes. Furthermore, the supernatant from spleen cell cultures from advanced gastric cancer patients significantly suppressed normal lymphocyte responses to PHA. This immunosuppressive activity was enhanced when the supernatant was from cultures of separated nonadherent subpopulations. These observations were not detected in patients with early gastric cancer. The blastogenic response to PHA and the percentage of T-cells among spleen cells was not affected by the cancer stage. These results suggest that the spleen of patients with advanced gastric cancer participates in the induction of serum immunosuppressive factors, possibly due to a change in splenic lymphocyte subsets.

Evaluation of treatment for gastric cancer with liver metastasis

In 161 cases of gastric cancer with liver metastasis but without peritoneal dissemination, evaluations were executed to find effective treatment. The most favorable results with best prognosis were obtained in the group receiving gastrectomy + hepatectomy + chemotherapy, followed by gastrectomy + chemotherapy, and gastrectomy alone. The most unfavorable outcome was in nonresected cases. Chief chemotherapy to be used after gastrectomy was FML (5-fluorouracil (5-FU) + mitomycin C [MMC] + lentinan) continuous intra-arterial infusion. Hepatectomy was found to be effective as an active measure for tumor reduction in cases of liver metastasis so far as the metastatic lesions are only a few scattered ones in both lobes.

Early gastric carcinoma in Japanese patients under 30 years of age

The clinicopathological characteristics of early gastric carcinoma (EGC) in 23 Japanese under 30 years of age were reviewed and the findings compared with data on 53 patients over age 70. In the young patients, there was a female preponderance, a macroscopic solitary lesion and the cancer was of the poorly differentiated type without intestinal metaplasia in the surrounding mucosa. In the old patients, there was a male preponderance; about half the number of patients had macroscopically elevated lesions and 10 of the 53 had a multifocal gastric carcinoma. Here, most lesions were well to moderately differentiated types with intestinal metaplasia in the surrounding area. Growth patterns of EGC in the young patients were analysed. Curative operations with dissection of regional lymph nodes were done in all the young patients. Metastases to the regional lymph nodes were present in only 2 of 23. Twenty of twenty-three followed for 5 years or longer are well.

Surgical treatment of concurrent cancer of the esophagus and stomach

Out of a total of 250 resections for carcinoma of the esophagus done in our department between 1965 and 1983, there were 11 patients with a concurrent esophageal cancer, nine being gastric cancer and seven of them early gastric cancer. In these nine, four underwent resection of the esophagus and lesser curvature of the stomach with gastric tube reconstruction. Two of the four patients are alive 10 and 3 yr postoperatively. We hold the view that detailed preoperative gastric examination is most important to plan the surgical repair and that the small gastric tube may serve as a substitute by resecting the lesser curvature of the stomach in cases of early proximal gastric cancer.

Alteration of adenosine deaminase levels in peripheral blood lymphocytes of patients with gastric cancer

The present study was undertaken to determine the adenosine deaminase (ADA) activity of peripheral lymphocytes in patients with gastric cancer, with respect to the cancer progression, the effect of surgery and/or immunotherapy. The gastric cancer patients showed lower lymphocyte ADA activity than did the normal control. The lymphocyte ADA activity did not decrease with the cancer progression. There was a significant correlation between lymphocyte ADA activity and blastogenesis of lymphocyte by phytohemaglutinin or concanavalin A. Six months following gastrectomy, the lymphocyte ADA activity was increased, as compared with the preoperative value. The ADA activity of patients on post-operative OK-432 showed a greater increase, as compared to that of patients not given this treatment. In conclusion, decreased lymphocyte ADA activity in gastric cancer patients might be due to either the cancer bearing status or to the immunological suppression.

High incidence of liver metastasis in gastric cancer with medullary growth pattern

We studied the histology of resected specimens from 71 gastric cancer patients with synchronous and metachronous liver metastasis to assess the predominance of a particular histological pattern in gastric cancer with a tendency for liver metastasis. Poorly differentiated adenocarcinoma manifesting a medullary growth pattern was the most frequent histologic pattern (33%), followed by papillary adenocarcinoma (28%) in 39 patients with synchronous liver metastasis. In 32 patients who developed metachronous liver metastasis as the main pattern of recurrence, papillary adenocarcinoma was most frequent (47%), followed by poorly differentiated adenocarcinoma of the medullary type (28%). Scirrhous carcinoma was not encountered in patients manifesting metachronous liver metastasis. As most of the papillary adenocarcinomas exhibited a medullary growth pattern, we hypothesize that gastric cancer of the medullary type tends to metastasize to the liver, irrespective of the basic histologic pattern, and that poorly differentiated adenocarcinoma of the medullary type has a particularly high tendency for metastasizing to the liver.