Total gastrectomy for advanced cancer. A worthwhile palliative procedure

Palliation of anastomotic obstructions in recurrent gastric carcinoma with the use of covered metallic stents: clinical results in 25 patients

BACKGROUND

The purpose of this study was to investigate the technical feasibility and the clinical effectiveness of the placement of covered self-expandable metallic stents for the treatment of anastomotic obstructions in recurrent gastric carcinoma.

METHODS

With fluoroscopic guidance, covered stents were placed in 25 patients with recurrent gastric carcinoma for the palliation of obstructions at anastomotic sites (14 gastrojejunostomy, 11 esophagojejunostomy). All patients had severe nausea and recurrent vomiting before the stent placement.

RESULTS

Stent placement was technically successful in 24 patients (96%). After stent placement, symptoms improved in all 24 patients. During the follow-up of 2 to 65 weeks (mean, 13.7 weeks), stent migration occurred in 1 patient 16 days after the procedure. He needed percutaneous catheter drainage because of an abscess, which was followed by esophagojejunostomy site rupture during a second stent trial. Stricture recurred in 4 patients because of tumor overgrowth 10 to 55 weeks after the procedure; all patients underwent coaxial placement of a second stent and had good oral intake.

CONCLUSIONS

The placement of covered expandable metallic stents seems to be both technically feasible and an effective means for the palliation of anastomotic obstructions in recurrent gastric carcinoma. This procedure can be considered to be the primary choice for the palliation in those patients.

Effective therapy for peritoneal dissemination in gastric cancer

Peritoneal dissemination is the most frequent cause of death from gastric cancer, accounting for death in 20% to 40% of patients. Preoperative intraperitoneal chemotherapy, peritonectomy, intraoperative chemohyperthermic perfusion, and early postoperative intraperitoneal chemotherapy are treatment modalities specifically designed to eliminate peritoneal dissemination and progression. Preoperative intraperitoneal chemotherapy is for containment of peritoneal free cancer cells, and also may facilitate complete eradication of visible peritoneal dissemination by peritonectomy. Further, complete cytoreduction can be achieved more often when peritonectomy is included in the surgical treatment of gastric cancer with peritoneal dissemination. Phase III data shows prolonged survival attributed to complete cytoreduction. Aggressive cytoreduction of peritoneal dissemination by peritonectomy can reduce residual tumor burden to micrometastases on the peritoneal surface that can be treated by intraoperative intraperitoneal chemotherapy and early postoperative intraperitoneal chemotherapy. Among all these modalities, surgical cytoreduction is probably the most important for survival benefit. If the surgical cytoreduction is visibly incomplete, prolonged survival cannot be expected, despite subsequent treatment. The surgeon's goal is to reduce the cancer cell burden to a microscopic level. Continued refinement of phase II studies is needed for maximal benefit and to standardize the technical and chemotherapeutic options of each modality.

Enteral stenting in 21 patients with malignant gastroduodenal obstruction

Placement of an enteral stent is emerging as an effective alternative to surgery for symptomatic relief in patients with malignant gastric outflow and duodenal obstruction. We report experience in a series of patients who had the Wallstent enteral prosthesis inserted. 21 consecutive patients with inoperable obstruction, median age 75 years, had twenty-three procedures for insertion of the Wallstent under fluoroscopic guidance. Stent implantation was successful in 18 patients (86%), all of whom gained relief from nausea and vomiting. There were no short-term complications. Median survival after the procedure was four months (longest ten months), and no deaths were related to insertion. The efficacy and lack of complications in this series support use of the endoscopically placed stent for palliative management of malignant upper gastrointestinal obstruction.

Asian ethnicity-related differences in gastric cancer presentation and outcome among patients treated at a canadian cancer center

PURPOSE

Differences in stage-stratified survival have been reported between Asian and Western populations with gastric cancer. This study examines differences in presentation and outcomes among Asian and non-Asian patients evaluated and treated at a Canadian institution.

PATIENTS AND METHODS

We reviewed 2,043 patients (159 Asians and 1,884 non-Asians) with gastric adenocarcinoma treated between 1978 and 1997. Overall survival was examined by the Kaplan-Meier method, and multivariable analysis by Cox proportional hazards was used to identify whether Asian ethnicity had independent prognostic significance for survival.

RESULTS

Median survival was 13.1 months for Asians and 11.1 months for non-Asians (P =.0016). Asian patients were younger and had a greater proportion of signet ring cell histology but were less likely to have proximal disease. Signet ring cell histology did not adversely affect survival. By multivariable analysis, proximal location, poor differentiation, and extent of disease were independently associated with worse survival. Survival was improved with curative resection, palliative resection, and palliative chemotherapy. Asian ethnicity was not independently associated with survival (hazard ratio, 0.89; 95% confidence interval, 0.74 to 1.08). Although a similar proportion of patients underwent curative resection, an interaction was observed between Asian ethnicity and efficacy of resection, with Asians achieving a greater benefit as compared with non-Asians even when adjusted for age and location.

CONCLUSION

The disparity between Eastern and Western gastric cancer survival is not explained by the hypothesis of ethnicity-related differences in tumor biology. Although it is not an independent predictor of survival, Asian ethnicity is associated with distinct characteristics at presentation and more favorable outcomes after curative surgery.

Value of palliative resection in gastric cancer

BACKGROUND

Western patients with gastric cancer often present with incurable disease. The role of palliative surgical resection is still debatable. Non-curatively treated patients from the Dutch Gastric Cancer Trial were studied to define more accurately which patients might benefit from palliative resection.

METHODS

In the Dutch Gastric Cancer Trial 285 (26 per cent) of the randomized patients were found to have incurable tumours at laparotomy. Four signs of incurability were noted: irresectable tumour (T+), hepatic metastasis (H+), peritoneal metastasis (P+) and distant lymph node metastasis (N4+). Patients had either an explorative laparotomy, a gastroenterostomy, or a resection (partial or total). In the analysis, particular attention was paid to the prognostic factors of age, number of metastatic features, and a combination of these.

RESULTS

Overall survival time was greater if a resection was performed (8.1 versus 5.4 months; P < 0.001). For patients aged over 70 years there was still a survival advantage of about 3 months if resection was carried out. Morbidity and perioperative mortality rates in this older age group were, however, high (50 and 20 per cent respectively). For patients with one metastatic site a resection was of significant benefit (survival 10.5 versus 6.7 months; P = 0.034). For patients with two or more metastatic sites resection had no significant survival advantage (5.7 versus 4.6 months; P = 0.084). Combination of these factors indicates that patients aged less than 70 years with one metastatic site will benefit significantly from a palliative resection, in contrast to other combinations of factors.

CONCLUSION

Age as well as the number of metastatic sites should be taken into account when a palliative resection is considered. Palliative resection may be beneficial for patients under 70 years of age if the tumour load is restricted to one metastatic site.

Methods of palliation of esophageal and gastric cancer

Esophageal and gastric malignancies are common worldwide. Less than half are amenable to curative treatment at the time of diagnosis because of advanced or metastatic disease. Palliation is often required for symptoms, such as dysphagia, gastrointestinal bleeding, aspiration caused by tracheoesophageal fistula, nausea and emesis secondary to gastric outlet obstruction, and malnutrition. This article reviews the gastric outlet obstruction, and malnutrition. This article reviews the medical, endoscopic, and surgical options for palliative treatment.

Fluoroscopically guided placement of a covered self-expandable metallic stent for malignant antroduodenal obstructions: preliminary results in 18 patients

OBJECTIVE

The purpose of this study was to investigate the technical feasibility and the clinical effectiveness of fluoroscopically guided placement of covered self-expandable metallic stents in the treatment of malignant antroduodenal obstructions.

SUBJECTS AND METHODS

With fluoroscopic guidance, covered self-expandable metallic stents were placed in 18 consecutive patients with inoperable malignant antroduodenal obstructions. All patients were treated for severe nausea and recurrent vomiting.

RESULTS

Stent placement was technically successful in all patients with or without gastrostomy (n = 2) and balloon dilatation (n = 3). After stent placement, symptoms improved in all but one patient, who had another stenosis in the proximal jejunum. During the follow-up of 2-73 weeks (mean, 12 weeks), stent migration occurred in three patients (16.7%) from 1 to 41 days after the procedure. These patients were treated successfully by means of placing a second covered metallic stent. Two patients, who were followed up for longer than 30 weeks, showed a recurrence of strictures because of mechanical failure of the stents; one of the patients was treated with coaxial placement of a second covered metallic stent, which had a positive clinical outcome.

CONCLUSION

Fluoroscopically guided placement of covered self-expandable metallic stents is technically feasible and effective for the palliative treatment of inoperable malignant antroduodenal obstructions. The rate of stent migration in our study was lower than those in previous reports.

Adenocarcinoma of the stomach: univariate and multivariate analysis of factors associated with survival

Gastric cancer is the most frequent tumor of the digestive tract in Mexico. Most patients are diagnosed at advanced stages, and fatal outcome is expected. One hundred fifty patient charts were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the impact of clinicopathologic and treatment variables on survival. Most patients (75%) were at advanced stages, harboring poorly differentiated tumors. Surgery, mostly palliative, was performed on 114 patients. Chemotherapy was administered to 47 patients. On univariate analysis, significant prognostic factors were TNM stage, chemotherapy, surgical attempt, performance status, histology, and tumor site (p < 0.001). On multivariate analysis, independent prognostic factors were TNM stage, histology, tumor site, surgical attempt, and chemotherapy (p < 0.01). Median survival for patients with palliative or adjuvant chemotherapy was 11.4 and 10.4 months, respectively, compared with +/- 3 months for patients with no chemotherapy (p < 0.03). Nonsurgical patients receiving chemotherapy survived 5.4 months versus 1.1 months for those without chemotherapy. The favorable influence of chemotherapy persisted after a stratified analysis of subgroups eliminating potential biases. We identified prognostic factors for survival. Chemotherapy should be considered even for advanced-stage patients with either adjuvant or palliative attempts, because we consistently found a favorable impact on the median survival time. However, phase III prospective randomized trials are awaited.

Malignant obstruction of gastric outlet and duodenum: palliation with flexible covered metallic stents

PURPOSE

To assess the usefulness of flexible covered metallic stents in the palliation of malignant obstruction of the gastric outlet and duodenum.

MATERIALS AND METHODS

Twenty-four consecutive patients with malignant obstruction of the gastric outlet (n = 22) or duodenum (n = 2) underwent palliative treatment with self-expandable flexible covered metallic stents. Fourteen patients had advanced gastric carcinoma at the antrum and/or pylorus, and eight had obstruction at the anastomosis site of previous gastrojejunostomy. Complications and clinical status were investigated during the study period.

RESULTS

The technical success rate was 75% (18 of 24 patients). Twenty-one stents were placed in 18 patients by using an introducer 6 (n = 7) or 8 mm (n = 14) in diameter. The mean follow-up period was 3.4 months (range, 1 week to 9 months). Symptoms improved in 12 (67%) patients after the procedure. There was no change in symptoms in five and a decrease in one. Twelve patients died during the follow-up period (mean survival, 4.3 months). The complication rate was 25% (six of 24 patients), including stent migration (n = 5) and fracture (n = 3).

CONCLUSION

Flexible covered metallic stent placement can be useful for palliation in patients with malignant obstruction of the gastric outlet or duodenum.

Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience

PURPOSE

To investigate the technical feasibility and clinical effectiveness of a polyurethane-covered expandable nitinol stent in the treatment of malignant gastroduodenal obstructions.

MATERIALS AND METHODS

The stent was constructed in-house by weaving a single thread of 0.2-mm nitinol wire in a tubular configuration and was covered with polyurethane solution by means of a dipping method. With fluoroscopic guidance, the stent was placed in 19 consecutive patients with malignant gastric outlet obstruction (n = 15) or duodenal obstruction (n = 4). All patients had severe nausea and recurrent vomiting, and their obstructions were inoperable.

RESULTS

Stent placement was technically successful in all but one patient. After stent placement, symptoms improved in all but one patient, who had another stenosis at the proximal jejunum. One patient with stent placement in the second portion of the duodenum became jaundiced. During the mean follow-up of 11 weeks, stent migration occurred in five patients 1-4 days after the procedure. All patients with stent migration were treated by means of placing a second, uncovered nitinol stent. Two of these five patients showed recurrence of stricture because of tumor ingrowth; they underwent coaxial placement of a third, covered nitinol stent with good results.

CONCLUSION

Placement of a polyurethane-covered expandable nitinol stent seems to be technically feasible and effective for palliative treatment of inoperable malignant gastroduodenal obstructions. Stent migration, however, is problematic and requires further investigation.

Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents

Metallic stents are currently an established component of the endoluminal treatment of stenoses within the blood vessels, bile ducts, esophagus, trachea, and bronchi. With the development of newer stent designs and delivery systems and the general momentum toward minimally invasive therapies, metallic stent placement has expanded into the nonsurgical therapy for gastroduodenal and colorectal obstructions. The use of metallic stents within the stomach, duodenum, or colon is intended not to be curative but to provide nonsurgical palliation for the symptoms of gastric or colonic obstruction. This palliation may be intended for the life of the patient in the case of unresectable disease or as a temporizing procedure prior to a definitive surgical procedure. In the latter clinical scenario, the benefits of a minimally invasive intestinal decompression procedure include (a) quick and noninvasive relief of the intestinal obstruction in an acutely ill patient that obviates a more extensive procedure; (b) allowance of time to improve a patient's overall medical condition and thus to allow a patient to better tolerate the definitive surgical procedure; and (c) reduction of the complexity of the definitive procedure by eliminating the need for staged procedures and allowing the definitive procedure to be performed at one setting.

Cancer surgery: the last 25 years

Surgery is, and always has been, the main treatment modality of solid tumours. For a long period, it consisted of a number of surgical procedures dictated by basic oncologic principles, most of which are still adhered to. Over the last few decades, increased understanding of the disease, new or improved diagnostic facilities, novel and perfected adjuvant treatments, improved surgical techniques and daring challenges to established dogmas have all contributed to the development of surgical oncology. The heritage from the past came under close scrutiny, and the fruits of basic and clinical science were added to an ever expanding body of knowledge. It is impossible to review all developments in surgical oncology of the last 25 years in one comprehensive paper. Therefore we have restricted ourselves to those items that appear most representative for the changes that have taken place, and those diseases that have the greatest numerical impact.

A new approach to the palliation of advanced proximal gastric cancer

BACKGROUND

The operative mortality and morbidity rates of palliative total gastrectomy can be high, and survival is not extended. The quality of a foreshortened life is often marred by distressing postprandial symptoms and relentless weight loss. These problems can be attributed to the conventional manner of reconstruction after total gastrectomy, with small-bowel gastric reservoirs restricting the amount of caloric intake. Large-bowel gastric reservoirs have greater capacity and empty well if positioned upright within the chest for proper emptying. The scope of a combined palliative total gastrectomy, esophagectomy, and colon pull-through must be kept within the limits of patient tolerance.

STUDY DESIGN

A palliative total gastrectomy was performed in 70 patients with incurably advanced cancers of the proximal and middle third of the stomach (TNM stages: II, 4%; III, 26%; and IV, 70%) using the large-bowel as a gastric substitute. The trauma of reconstruction by colon pull-through was lowered by avoiding thoracotomy and by positioning the colon within the lumen of the deepithelialized esophagus. Proximal cervical esophagocolostomy, distal duodenocolostomy, and colocolostomy reestablished gastrointestinal continuity. Follow-up focused on subjective gastrointestinal symptoms and nutritional maintenance.

RESULTS

The operative mortality rate was 10%, postoperative complications were not inordinately high, and autopsy findings showed no defects in the technique of reconstruction. The normal esophageal mucosa was readily cored out through the neck and the abdomen, and the remaining esophageal muscular tunnel accommodated the pulled-through segment of colon. Quantitative assessment of postoperative quality of life proved impractical, but none of 58 longterm survivors (mean of 17.1 months for combined TNM stages II, III, and IV) suffered from disabling symptoms or pronounced weight loss. The quality of life, but not its length, appeared distinctly improved.

CONCLUSIONS

The frequently encountered problems of abdominal distress and weight loss after palliative total gastrectomy can be averted by safely positioning a colonic gastric substitute within the lumen of the normal esophagus from which the mucosal lining has been extracted.

Palliative Surgery for Far-Advanced Gastric Cancer: A Retrospective Study on 305 Consecutive Patients

Few reports of the Western countries have investigated the value of palliative surgery for stomach cancer. The aim of this study was to evaluate the results of palliative surgery in a large series of patients affected by gastric carcinoma, consecutively treated by the same surgical team. The hospital records of 305 patients affected by gastric cancer who did not undergo surgical treatment or who underwent a palliative surgical procedure at our unit between 1981 and 1995 were reviewed. Univariate and multivariate analyses were used to calculate the 5-year survival probabilities with respect to the following variables: demographic data, tumor location and gross appearance, spread of the disease, histological type according to P. Lauren, and type of treatment. Multivariate logistic regression analysis showed that resectional surgery and tumor spread limited to local sites were independently associated with better survival. The study indicates that even though there are host-related factors that govern survival in far-advanced stomach cancer, the type of surgery can have a significant effect on prognosis; resectional surgery should be undertaken whenever possible in such patients.

Gastric outlet obstruction

Acquired gastric outlet obstruction is more commonly owing to malignancy than ulcer disease. Endoscopy is the preferred method for diagnosis. Surgical palliation for malignant disease has poor results and high rates of morbidity and mortality. Initial experiences with endoscopic palliation with expandable metallic endoprostheses appear promising. Peptic ulcer-induced gastric outlet obstruction can be treated safely with endoscopic balloon dilation. About 65% of patients have sustained symptom relief, but many require more than one dilation session. Outcomes may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures.

Gastric cancer

We are gaining a clearer insight into the causes and mechanisms of gastric carcinogenesis, and may be able to reduce the incidence in the future by Helicobacter pylori eradication, perhaps in conjunction with nutritional supplements. The work required to establish this kind of prevention programme still has a long way to go. Surveillance and early detection are a key area, and current hopes rest with an increasingly low threshold for gastroscopy together with improved awareness in both patients and general practitioners. Identification of a high-risk group for surveillance would be a major advance, and may become possible due to advances in molecular biology. In terms of treatment, surgery remains the mainstay, but for useful analysis of its' efficacy, uniform and detailed pathological staging is vital. Pre-operative assessment has improved greatly in recent years, resulting in fewer nontherapeutic laparotomies, thanks to a combination of improved imaging techniques and laparoscopy. Limited endoscopic surgery is now feasible for very early disease. The extent of radical surgery remains controversial: a strong argument can be made for concentrating this kind of surgery in the hands of a limited number of specialist units who will have the numbers and the expertise to answer the outstanding questions. Chemotherapy has yet to prove its value, but there are hopes that the newest regimes may do this. Treatment results in the West remain unsatisfactory, but they have improved in the last two decades, and should be capable of considerable further improvement.

Sex as a prognostic factor in gastric cancer

The aim of this study was to assess whether survival of gastric cancer patients differed between males and females. Although it is well known that the incidence of gastric cancer is higher for men than for women, the existence of a sex-specific prognosis has seldom been addressed. Studies based on population registries have not assessed the role of stage and histology. Cases of histologically confirmed gastric carcinoma were obtained from three Spanish hospitals in Soria (n = 405), Barcelona (n = 249) and Mataró (n = 197). Differences in possible confounders were tested between men and women and survival analyses were performed separately by hospital. Cox's proportional hazards models were used to account for age, tumour stage, histology and tumour sub-location. Only in Mataró was a significant difference in the stage distribution observed between women and men, with a lower proportion of local stage tumours among women (P = 0.047). No statistically significant differences of histological type between men and women were observed in any of the centres. After adjusting for tumour stage and age, women were observed to have significantly better survival in Barcelona (female to male hazard ratio (HR) = 0.578, P < 0.001); this effect was marginal in Soria (HR = 0.788, P = 0.092) and non-significant in Matar-o (HR = 0.895, P = 0.54). Age-adjusted hazard ratios were calculated within each tumour stage. For Barcelona, the effect of better prognosis among women was most marked at local stage (HR = 0.320, P = 0.013), and in Soria at the regional stage (HR = 0.426, P = 0.002). Although in Mataró all HRs were below unity, none were statistically significant. Little effect was observed at the disseminated stage. The other covariables exerted no influence. Women appear to have a better prognosis than men, and the difference could be tumour stage dependent. Confirmation of these findings would give a valuable insight into gastric cancer growth and ultimately be of use in planning treatment.

Postoperative complications requiring relaparotomies after 700 gastretomies performed for gastric cancer

BACKGROUND

Prevention of fatal postoperative complications and improved management of patients with complications are important means of increased survival in gastric cancer patients.

PATIENTS AND METHODS

A study of 700 patients undergoing gastrectomy was performed to examine factors that contributed to a high rate of postoperative complications.

RESULTS

Of 700 patients undergoing gastrectomy for adenocarcinoma, 40 (5.7%) underwent reexploration because of serious complications. The frequency of the relaparotomies varied from 2.1% and 4.4% after regular subtotal and total gastrectomies, respectively, to 20% and 30.4% after palliative and conventional total gastrectomies, respectively. The complications that required reexploration most frequently were anastomotic leakage and incompetence of sutures (11, 27.5%), intra-abdominal abscesses (8, 20%), and pancreatic necrosis (7, 17.5%). A combination of preventive measures allowed the attainment of low rates of esophagojejunal anastomotic leakage (0.8%).

CONCLUSION

We believe that the decision to perform an urgent reexploration, based on clinical findings, should generally be made by a group of experienced surgeons (not only the primary surgeon). Timely relaparotomy prevented death in 37.5% of the patients with serious acute postoperative complications.

Modified therapy with 5-fluorouracil, doxorubicin, and methotrexate in advanced gastric cancer

BACKGROUND

In an attempt to decrease the toxic effects of fluorouracil, doxorubicin, and methotrexate (FAMTX) by reducing the dose of methotrexate from 1500 mg/m2, according to the original regimen, to 1000 mg/m2, the authors designed the modified FAMTX treatment that was evaluated in a prospective Phase II-III randomized trial.

METHODS

Patients with advanced gastric cancer were randomized to receive modified FAMTX treatment or supportive measures only (control group). In the middle of the study, the randomization was interrupted because of strong evidence of benefit in terms of tumor reduction and projected survival in the treatment arm receiving chemotherapy. By the end of the study, 30 assessable patients had received chemotherapy and 10 had received supportive treatment.

RESULTS

The overall response rate was 50% (15 patients); 12 patients (40%) had partial responses and 3 (10%) had complete responses (CR). One patient with extensive peritoneal carcinomatosis attained a CR pathologically documented by laparoscopic examination and peritoneal biopsy. The median overall survival time of the treated group was 9 months, whereas that of the control group was only 3 months (P = 0.001). The median overall survival time of the responders was 16 months, and their median remission duration was 8 months. The regimen was well tolerated, with a very acceptable toxicity profile. There was one toxic death resulting from neutropenia and sepsis in a patient who did not receive adequate leucovorin rescue.

CONCLUSIONS

This regimen appears to prolong survival in patients with advanced gastric cancer, and the reduction of the methotrexate dose does not seem to compromise its efficacy.

Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy

BACKGROUND

Despite recent advances in diagnosis and treatment, gastric carcinoma remains a major cause of death in the world.

METHODS

The clinicopathologic profile of 10,000 consecutive patients who underwent primary gastrectomy during 1962-1989 were reviewed and prognostic factors influencing survival in those with gastric carcinoma were analyzed in 7031 patients.

RESULTS

Incidence of gastrectomy for carcinoma has increased steadily and the rate of early carcinoma exceeded that of advanced carcinoma in the recent period of 1985-1989. Five-year and 10-year survival rates were 46.1% and 35.2% in 3868 patients with advanced carcinoma, and 88.8% and 77.3% in 3163 patients with early carcinoma, respectively. In patients with advanced carcinoma, significantly poorer survival rates were noticed for patients older than 70 years of age, those who underwent total gastrectomy, tumors involving the entire stomach or greater than 10 cm in diameter, a macroscopic diffusely infiltrative pattern, adenosquamous histologic type, positive surgical resection margins, or lymph node metastasis. None of the above poor prognostic features were identified in patients with early gastric carcinoma group except for those older than 70 years of age. Although lymph node metastases were present in 10% of early gastric carcinomas, this feature did not impart a poor prognosis. Patients with advanced carcinoma grossly resembling an early carcinoma had an intermediate prognosis, suggesting the existence of a developmentally midstage lesion between early and advanced carcinoma.

CONCLUSIONS

The study illustrates that the most important role for clinicians treating with gastric carcinoma should be early detection and aggressive surgery for resectable tumors, followed by detailed pathologic examination.