An early gastric carcinoma treatment strategy based on analysis of lymph node metastasis

A multi-institutional study of immunohistochemical investigation for the roles of cyclin D1 and E-cadherin in superficial squamous cell carcinoma of the esophagus

BACKGROUND AND OBJECTIVES

Aiming to clarify and possibly extend indications for minimally invasive treatment, we characterized superficial esophageal cancers (SEC) with respect to biologic properties regulating malignant potential.

METHODS

Surgical specimens obtained at eight cancer institutes from 222 Japanese patients with SEC (all squamous cell carcinomas) were investigated immunohistochemically for expression of cyclin D1 and E-cadherin.

RESULTS

Perturbations of cyclin D1 (overexpression) and E-cadherin (reduced expression) were observed in 37.6% (68 of 181) and 39.9% (71 of 178) of SEC patients. E-cadherin expression was more frequently reduced in cancers that invaded the submucosal layer, while cyclin D1 overexpression was constant, irrespective of depth of invasion. Overexpression of cyclin D1 was more frequent in poorly differentiated squamous cell carcinomas, while E-cadherin did not vary according to histologic differentiation. Lymph node metastasis, the only independent postoperative prognostic factor in these patients, occurred in only 4.8% of mucosal cancers (2 of 42), but in 51.1% of submucosal cancers (92 of 180). However, neither cyclin D1 nor E-cadherin status affected lymph node metastasis.

CONCLUSION

Both E-cadherin and cyclin D1 play important roles in esophageal carcinogenesis, but neither can be used to identify patients who do not require lymph node dissection and might be treated by endoscopic mucosal resection.

Results of local resection with regional lymphadenectomy for early gastric cancer

BACKGROUND

In 1999, the authors reported preliminary results of local resection with regional lymphadenectomy(LR) for early gastric cancer.

METHODS

Twenty-four patients underwent LR until May 2000. Laparoscopic techniques were recently applied. The dissected area for lymphadenectomy depended on the lymphatic flow from the tumor. Local gastric resection was performed with a 2 cm cancer-free margin. Among the 24 patients, 14 who had been followed up for more than 1 year were eligible for the nutritional study, and the nutritional parameters were compared with those for patients undergoing pylorus-preserving gastrectomy (PPG).

RESULTS

Twenty-two patients not receiving additional gastrectomy needed no restriction of food intake and had neither postgastrectomy symptoms nor recurrence. All nutritional parameters remained stable between the preoperative and the subsequent period. Nutritional superiority of LR over PPG was observed.

CONCLUSIONS

For selected patients with early gastric cancer, LR can be a treatment of choice to provide a good quality of life.

Analysis of early (pT1) gastric cancer with submucosal invasion: surgical management and possibility to schedule less invasive surgery

BACKGROUND

Early gastric cancer (EGC) is one of the popular targets of less invasive surgery. The aim of the present study is to clarify the possibility of scheduling a less invasive surgery for EGC cases with submucosal (SM) invasion.

METHODS

Eighty cases of EGC with SM invasion were analyzed clinicopathologically and immunohistochemically. Correlations between factors that reflect cancer progression and data from endoscopic examination were investigated.

RESULTS

Thirteen cases (16.3%) showed lymph node metastasis and the numbers of metastasis-positive lymph nodes ranged from 1 to 18. Two cases showed lymph node metastasis not only in the perigastric area, but also along the left gastric artery and the common hepatic artery. Only the tumor size showed a significant correlation with lymph node metastasis (P = .014) using the data from preoperative endoscopic examination. With respect to p53 overexpression, there was no significant correlation with pathologic factors in EGC with SM invasion. The simple protuberance types that were <2 cm in diameter had no lymph node metastasis.

CONCLUSIONS

It seems difficult to predict the progression of EGC with SM invasion from the data currently obtained by preoperative endoscopic examination. It was suggested that less invasive surgery could be scheduled only for simple protuberance type cases that were <2 cm in diameter. Radical gastrectomy and D2 lymph node dissection is required, in open surgery or laparoscopic surgery, for any other type of EGC with SM invasion.

Characterization of early gastric cancer and proposal of the optimal therapeutic strategy

BACKGROUND AND AIMS

The optimal protocol of the treatment for early gastric cancer has not been fully established. The current study was designed to elucidate the relationship between the depth of tumors with or without an ulcer and the presence of lymph node metastasis and to establish the optimal and practical therapeutic strategy for patients with early gastric cancer.

PATIENTS AND METHODS

A retrospective analysis of 1051 patients with early gastric cancer treated by gastrectomy with D1 or D2 lymph node dissection was performed. The patients were divided into those with mucosal (M) tumors and those with submucosal (SM) tumors. These 2 groups were subclassified, depending on the coexistence of ulcer or the degree of submucosal invasion, and were characterized in relation to clinicopathologic factors and 5-year prognosis.

RESULTS

The incidence of lymph node metastases from SM tumors (19.8%, 85 of 430) was more frequent than that from M tumors (2.3%, 14 of 621) (P <.001). All M tumors with lymph node involvement, including tumors smaller than 1.5 cm in diameter, had ulceration or ulceration scar in the lesions. SM tumors that had invaded less than 200 microm in depth (SM1a) had significantly less lymph node involvement than those with deeper invasion. The node metastases were confined to epigastric lymph nodes (N1) in both M tumors with ulceration or ulceration scar and SM1a tumors.

CONCLUSIONS

All macroscopic M tumors without ulceration or ulceration scar should be considered for endoscopic mucosal resection. The need for reoperation for a formal gastrectomy with lymphadenectomy or a limited surgical operation will vary depending on the pathologic analysis of endoscopic mucosal resection specimens (depth of invasion, presence of ulceration).

Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer

BACKGROUND

A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported.

METHODS

Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision.

RESULTS

The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated.

CONCLUSION

A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.

Interventional procedures

During the past year, numerous articles were published on interventional procedures of the stomach, focusing on upper gastrointestinal tract bleeding, gastric cancer, gastric outlet obstruction, and benign disease. In the area of upper gastrointestinal tract bleeding, early endoscopy is warranted for early therapeutic intervention and for triage. In patients with bleeding related to peptic ulcer disease, combination therapy (epinephrine injection in conjunction with electrocoagulation therapy) remains the standard of care. Hemoclipping is a new technique that may be helpful in cases in which conventional therapy fails. Repeat endoscopy should always be considered in patients in whom the first attempt at endoscopic therapy fails. In patients with bleeding related to portal hypertension, prophylactic antibiotics may decrease the risk of infections. Banding remains the therapy of choice for this group of patients. There is no documented benefit for combination therapy (banding and sclerotherapy). Transjugular intrahepatic portosystemic shunts may be helpful in the treatment of hypertensive portal gastropathy but not gastric vascular ectasias. In the area of gastric cancer, management revolves around staging. This can be accomplished best through the use of CT scan and endoscopic ultrasound. In patients with early limited disease, attempt at endoscopic mucosal resection should be considered. This technique can be performed in a variety of ways: the most common method seems to be through the use of a saline injection, to separate the mucosa-submucosal layer, followed by a cap-assisted snare resection with suction. The safety, efficacy, and outcome of this technique are reviewed. Gastric outlet obstruction remains a difficult problem to treat endoscopically. However, there is some evidence that endoscopic therapy may be successful in benign disease and should be considered prior to surgical intervention.

Endoscopic mucosal resection. Current concepts

Recent advances in endoscopic mucosal resection of superficial early digestive tract cancers are truly remarkable. The extraordinary long-term outcomes of patients who have been treated with endoscopic mucosal resection have encouraged the widespread practice of endoscopic mucosal resection in Japan. These minimally invasive techniques allow safe and effective treatment of diseases that would otherwise require major surgery. This article provides an overview of endoscopic mucosal resection techniques, their associated outcomes, and other potential applications of endoscopic mucosal resection.