Early gastric carcinoma with special reference to macroscopic classification

The Japanese experience with endoscopic ultrasonography in the staging of gastric cancer

The Japanese experience with endoscopic ultrasonography in the staging of gastric cancer is reviewed and compared with Western results. Various graphic classifications for prediction of the depth of transmural penetration characterize the Japanese approach. Differentiation of early gastric cancers from advanced cancers has been emphasized, with the concordance rate of the ultrasonographic interpretation and the pathology exceeding 90%. When pre-operative staging by the TNM system was attempted, results were similar to the reports from the West, with overall concordance rate for tumor depth of greater than 80%. The Japanese system of classification may be useful in differentiating advanced cancers from early gastric cancers with co-existing ulceration and fibrosis. The reliability of endoscopic ultrasonography in the pre-operative staging of gastric cancer in Japan is similar to that in the West.

Endoscopic evaluation of the depth of invasion of the depressed type early gastric cancer and apparently early advanced cancer in cases of a peptic ulcer within the cancer lesion

Depressed-type early and apparently early advanced cancers were divided into two groups according to whether or not an associated peptic ulcer was present within the cancer lesion, and the accuracy of preoperative endoscopic diagnosis was reviewed. As a result it was found that evaluation of depth of invasion was more difficult in the ulcer [UL(+)] group than in the group without an ulcer [UL(-)]. In the UL(+) group it was difficult to identify endoscopic findings which indicate depth of invasion at the tip of the folds, the volume of cancer invasion of the deeper layers was small, and there many cases of invasion of deeper layers in a portion of the margins of the peptic ulcers.

Early gastric cancer: an analysis of 44 cases with emphasis on the prognostic significance of the macroscopic and microscopic growth patterns

Forty-four consecutive cases of "early gastric cancer" were studied according to the macroscopic classification proposed by the Japanese Gastroenterological and Endoscopy Society and further analyzed in terms of growth patterns. The tumours were then classified into the small mucosal type, the superficially spreading (Super) type and the penetrating growth (Pen) type. The Lauren type (intestinal vs. diffuse), presence of lymphatic and venous invasion, and lymph node metastasis were also assessed. Most elevated tumours showed a superficial growth pattern and were classified as Lauren's intestinal type, whereas depressed lesions were associated with submucosal invasion and were classified as diffuse. Microscopic patterns did not show any correlation with Lauren's classification. Mean duration of follow-up was 67.8 months and the overall actuarial survival was 93%, 80%, and 72%, at 2, 5, and 10 years, respectively. Aside from venous invasion no correlation was found between survival and any of the morphological parameters analysed.

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.

Early gastric cancer

Early gastric cancer comprises more than 30 per cent of gastric carcinomas treated in Japan but remains an uncommon entity in the western hemisphere. A retrospective review of 48 patients with early gastric cancer undergoing operative treatment between 1965 and 1984 was carried out. The mean patient age was 70 years, in 31 men and 17 women. Preoperative diagnosis was made in 88 per cent of patients undergoing oesophagogastroduodenoscopy with biopsy but upper gastrointestinal radiography was diagnostic in only 20 per cent. Surgical management consisted of subtotal gastrectomy (86 per cent), total gastrectomy (10 per cent) and wide local excision (4 per cent). The operative mortality and morbidity rates were 0 and 38 per cent, respectively. Mean follow-up was 7.7 years, with 44 per cent of patients still alive. Multivariate analysis disclosed only a healthy Eastern Cooperative Oncology Group score (P = 0.002) and a diploid DNA tumour pattern (P = 0.05) as significant prognostic variables of survival. The overall survival rate of patients with early gastric cancer (70 per cent at 5 years) was equivalent to that of an age- and sex-matched control population.

Early gastric cancer

Early gastric cancer is a unique form of gastric carcinoma with an excellent prognosis. Now recognized worldwide, this tumor is most commonly diagnosed in Japan secondary to aggressive screening practices. Early detection is dependent on a low threshold for esophagogastroduodenoscopy with biopsies, because specific symptoms and physical findings or diagnostic laboratory tests are rarely present with early gastric cancer. Once the disease is diagnosed, subtotal gastrectomy achieves survival rates equivalent to those of age-matched controls. Consideration of total gastrectomy is warranted with proximal tumor location or multicentric carcinoma. Radical lymphadenectomy should be undertaken in patients with regional nodal metastasis. After operative resection, patient outcome is usually excellent. Large submucosal tumors with an aneuploid DNA pattern and nodal involvement denote a more ominous outlook. Close patient follow-up is necessary to detect both the uncommon recurrence and the more common nongastric malignancy.

Lymph node metastasis from early gastric cancer: endoscopic resection of tumour

The clinicopathological features of 748 solitary early gastric cancers were examined with regard to lymph node metastasis. Among several factors, only depth of invasion and tumour size correlated significantly with node involvement. Tumours which satisfy the following criteria may not metastasize to lymph nodes: (1) confined to the mucosa; (2) less than 1.5 cm in diameter; (3) macroscopically elevated; (4) macroscopically depressed, without intramural ulcers or ulcer scars (endoscopically, no fold convergence); and (5) histologically differentiated. With a recently developed endoscopic technique small gastric tumours can safely be resected. The cut margin and depth of tumour invasion can be verified histologically in the specimen. If an endoscopically removed tumour satisfies the above criteria, further surgical intervention may be optional as the outcome of endoscopic resection is comparable to that of radical surgery in the absence of node involvement.

Independent clinical and flow cytometric prognostic factors for the survival of patients with stage I gastric cancer

Paraffin-embedded tumor samples from 151 patients with stage I gastric cancer were analyzed by DNA flow cytometry, and 80 patients received an infusion of bromodeoxyuridine (BrdU) to determine S-phase fraction. S-phase fractions of tumors were measured by the immunohistochemical method using anti-BrdU monoclonal antibody. Of the 151 patients, 81 (54%), and 70 (46%) showed diploid and aneuploid patterns. There was no significant association between DNA ploidy and wall invasion, histologic type, or lymphatic invasion. Aneuploid tumors were associated with positive-vessel invasion. When the DNA ploidy and clinicopathological parameters were simultaneously entered into the Cox regression model, DNA ploidy and wall invasion emerged as independent prognostic parameters. Aneuploid tumors had significantly higher values of BrdU labeling indices than diploid ones. These results indicate that the determination of DNA ploidy patterns may be an important prognostic factor in patients with stage I gastric cancer, and may be useful in deciding the therapeutic schedule of patients with gastric cancer.

Evaluation of tumor growth rate in patients with early gastric carcinoma of the elevated type

The growth rates of elevated-type early gastric carcinoma in 12 patients were determined chronologically using serial radiographs. Eight progressed from an early to an advanced stage during periods of observation ranging from 4-82 months (mean 31.7 months), while four patients were still in an early stage at final examination, despite an increase in tumor size. The tumor volume doubling months) but varied considerably among patients. Aggressive endoscopy should be performed for all elevated lesions of the stomach because they can harbor malignancy; some can grow rapidly as reported here.

Total gastrectomy for advanced cancer. A worthwhile palliative procedure

Subtotal gastric resection usually provides the best palliation in advanced gastric cancer; however, if total gastrectomy (TG) is required there is doubt about its benefit. The authors reviewed 53 consecutive patients undergoing TG for advanced gastric adenocarcinoma between 1980 and 1989. Indications for TG were tumor location in 30% and extent of tumor in 70%, including nine patients (17%) with linitis plastica. Four patients (8%) died postoperatively, and six patients required reoperation for postoperative complications. The median postoperative hospital stay was 13 days. The median survival was 19 months, and 13 patients (24%) lived for more than 2 years. The quality of life was graded in survivors as good in 59%, satisfactory in 28%, and poor in 13% of patients. It was concluded that TG is a worthwhile procedure for selected patients, even in the presence of advanced disease, providing prolongation of good quality of life with low morbidity and mortality.

Meningeal carcinomatosis from a clinically undiagnosed early gastric cancer

Meningeal carcinomatosis is a rare complication of systemic cancer, of which advanced gastric carcinomas have predominated. The present case happens to be the first reported of meningeal carcinomatosis caused by an early gastric cancer, which was first diagnosed at autopsy. Various pathological aspects of early gastric cancer, which may have influenced the outcome of the present case, are considered.

[Early stomach cancer in comparison with advanced stomach cancer. Results of a prospective study of diagnosis and 5-year survival of 131 patients with early stomach cancer and 795 patients with advanced stomach cancer]

A multicentre prospective observational study with 22 surgical and 14 pathological units in West-Germany gathered data from 1420 patients with gastric cancer between April 1982 and October 1989, 131 patients with early gastric cancer (EGC) and 795 patients with a resectable advanced gastric cancer (AGC) were selected for comparison. Patients with EGC were younger than those with AGC (49% vs 37% younger than 60 years) and symptoms of an ulcer were found twice in comparison to AGC (40.7% vs 23.7%). EGC in comparison to AGC were frequently multifocal (9.2% vs 3.0%) and located in the middle and lower part of the stomach (83.9% vs 56.8%). Five-year-survival rates of mucosa carcinoma was 84% and of submucosal carcinoma 69% (p = 0.0741). WHO-typing of EGC and AGC were identical. But according to Laurén's classification there were more intestinal types with EGC than with AGC (60.3% vs 51.5%) and less diffuse or mixed types with EGC than with AGC (33.6% vs 44.0%). Five-year-survival rates of diffuse and intestinal types of EGC showed no significant difference (p = 0.19). Extended lymph node dissection was done in only one third of EGC and AGC. Five-year-survival rates of 36 EGC patients with and 95 EGC patients without extended lymph node dissection were 85% versus 72% (p = 0.0916). These results are a hint that systematic lymphadenectomy may have a beneficial effect on survival.

Surgical strategy for early gastric cancer

The diagnostic and therapeutic options in early gastric cancer are reviewed. In Japan, the rate of detection of early gastric cancers has increased so that minute gastric cancers can now be identified as a result of advances in diagnostic methods. The results of histopathological staging of a large number of resected specimens have led to three surgical options based on size and depth of the primary lesion, namely classical R2 resection, radical resection with limited lymphadenectomy and endoscopic surgery.

Early gastric cancer. Endoscopic diagnosis of depth of invasion

In order to decide on a treatment strategy against gastric cancers, an accurate preoperative evaluation of the depth of cancer invasion is essential. Preoperative endoscopic diagnosis of the depth of invasion was compared with pathological results of the resected specimen in 206 early gastric cancers and 32 early-like advanced gastric cancers. The endoscopic distinction between early and early-like advanced cancers was correctly made in 83.6% of the cases. Among the early gastric cancers, mucosal and submucosal invasion was correctly presumed in 71.9% of the cases. When the tumor was an elevated type, or located in the antrum, the endoscopic diagnosis tended to be deeper than the true depth. The size of tumor contributed little to the depth diagnosis. Pathomorphological changes on the tips of converging folds were the important clue for diagnosing depth.

Clinical and morphological characteristics of early gastric cancer. A case-control study

We investigated whether previously reported differences between the frequency and survival of patients with early gastric cancer in Europe and Japan represent a selection phenomenon or differences in tumor biology. Within a 10-year period, early gastric cancer was diagnosed in 51 outpatients and advanced gastric cancer in 190 patients, amounting to a 21.2% incidence of early gastric cancer. Patients with early gastric cancer had an age distribution and clinical presentation similar to those of patients with benign gastric ulcers (589) but markedly different from those in patients with advanced cancer. Histological types and tumor locations were comparable in patients with early and advanced gastric cancer, indicating a close relationship between the two neoplasms. Patients with early gastric cancer had markedly higher 5-yr survival rates (83.4%) than those with advanced gastric cancer (14.5%) and did not differ in this regard from patients with benign gastric ulcers (82.9%). None of the 51 patients with early gastric cancer died of disseminated cancer. If survival rates were estimated for matched pairs with comparable age, sex, and length of follow-up, these data remained essentially unchanged (early gastric cancer: 83.4%, 95% confidence interval 73.2%-93.4%; gastric ulcer: 87.8%, 95% confidence interval 74.7%-94.3%). We conclude that early gastric cancer in European patients is comparable to early gastric cancer in Japan with regard to its morphology, clinical presentation, and curability. Early investigation of patients with significant gastrointestinal symptoms may improve the prognoses of patients with gastric cancer.

A small early carcinoma of the stomach with extra-perigastric lymph node metastasis: a case report

An early gastric carcinoma, measuring 1.7 X 0.6 cm, had already metastasized to the extra-perigastric lymph node in a 71 year old symptom-free man. Radiographic and endoscopic studies showed a small depressed lesion on the lesser curvature of the antrum and histology of the biopsied specimen revealed a well differentiated adenocarcinoma. Under the diagnosis of IIc type intramucosal carcinoma, partial gastrectomy and wide lymph node dissection was performed. Pathologic study of the resected specimen showed that the cancer cells had invaded the submucosa at an area via a lymphatic vessel and that only one lymph node along the common hepatic artery was involved.

Radical surgery for gastric cancer. A review of the Japanese experience

Overall results after operations for gastric cancer in Japan are far superior to results obtained in the US and Europe. We have reviewed the Japanese literature in an effort to determine what factors explain this difference. It appears that the survival differences are due mainly to a greater frequency of early gastric cancer in Japan; meticulous histopathologic evaluation of the surgical specimens, resulting in more accurate pathologic staging; and the presumed benefit of extended nodal dissection when it extends outside of the level of node-positive disease. Although patients with both apparent and confirmed direct adjacent organ invasion can be helped by resection of those organs, extended resections of uninvolved pancreas and spleen do not improve rate of survival beyond the benefit of improved nodal dissection. Overall, there would appear to be justification for reexamining extended nodal dissection for gastric cancer in the US. Opportunities for a meaningful national study are significant.

Clinicopathologic study of early stage esophageal carcinoma

As part of a consecutive series of 370 patients who underwent subtotal esophagectomy because of carcinoma of the thoracic area of the esophagus, between January 1965 and July 1988, in the Second Department of Surgery, Kyushu University Hospital, 42 patients (11.4%) with early stage esophageal carcinomas confined to the intraepithelium, mucosa, or submucosa were studied clinicopathologically. Of these 42, 26 (61.9%) had symptoms; slight dysphagia or chest discomfort was the most common symptom. The remaining 16 (38.1%) had no subjective symptoms. Endoscopic examination proved to be more useful than barium studies. Lugol-combined endoscopy was most effective in detecting the presence and spread of small malignant lesions of the esophagus. At the time of surgery, six patients with submucosal carcinoma of the esophagus had lymph node metastasis, and five died of recurrence. Described herein are the diagnostic features, clinicopathologic characteristics, and long-term results of these 42 patients with early stage, and 328 patients with advanced, carcinomas of the esophagus, detected and surgically treated in our clinics.

Complete ten-year postgastrectomy follow-up of early gastric cancer

The postoperative courses of 109 patients with early gastric carcinoma treated from 1970 through 1976 were followed for 10 years. The cumulative 5-year survival rate was 96 percent and the 10-year survival rate was 92 percent. In this series, there was no significant difference in the survival rates between the mucosal cancer and submucosal invasion groups or between patients with and without lymph node metastasis. Five patients died from the recurrent cancer. The other causes of death were metachronous primary cancer in eight patients, synchronous primary cancer of sigmoid colon or rectum in two, cerebrovascular accident in six, heart disease in six, other causes in four, and unknown causes in four. Although the prognosis of early gastric cancer is remarkably good, patients should be carefully followed over a long period for late recurrence of the primary cancer and possible metachronous cancer of the other organs.

[Surgical treatment of early stomach cancer]

At the department of surgery at the university hospital in Cologne 94 patients suffering from early gastric cancer of the stomach were operated in the years between 1968 and 1983. From 1972 till 1987 the department of surgery at the university hospital Mainz has had 74 patients. Survival rates and times without recurrence were calculated dependent on the surgical treatment carried out. In both collectives the prognosis for the patients with mucosal carcinoma was good no matter which operation was carried out. In the case of submucosal infiltration the frequency of recurrence was smaller and the survival rates significantly higher in those patients who subjected to a cancer operation than in those on whom only a resection of two third of the stomach was performed. The results indicate a radical approach in the treatment of early gastric cancer. At least in the case of submucosal carcinoma a dissection of the N2 lymph nodes is advisable.

Treatment of stomach cancer, a national experience

A total of 1165 patients with stomach cancer were entered into a prospective, observational national study. They represented 54 per cent of all stomach cancer patients reported to the Cancer Registry in Norway during the study period, and data are analysed for three hospital levels (local, county and university hospitals). The median age was 71 years (range 18-96 years). The median pretreatment delay was 113 days, and 46 per cent of patients had a performance status (Karnofsky index) of less than or equal to 80. The diagnosis was confirmed by pre-operative histology in 88 per cent of cases. In all, 88 per cent of patients underwent surgery, the resectability rate was 67 per cent and 50 per cent had a potential curative operation. Total gastrectomy was most commonly performed. Lymph node dissection was performed in 14 per cent of those undergoing a curative resection. The postoperative complication rate was 27 per cent but varied with the type of operation, being highest in proximal resection (55 per cent) and lowest after distal resection (19 per cent). A total of 7 per cent of the patients died postoperatively. Most patients had advanced disease at the time of treatment and only 6 per cent had stage I tumours. There were significant differences in patient and treatment characteristics between the three hospital levels. In conclusion, patient selection bias which will influence results does occur. A fairly aggressive attitude towards local disease was found, but the low proportion of patients undergoing lymph node dissection not only leads to questions regarding the efficacy of this treatment policy, but also casts doubt on the validity of staging of stomach cancer. Morbidity and mortality rates are still high. The consequences of the differences revealed between hospital groups are difficult to interpret. Proponents of both regionalization of treatment and small hospital care may find arguments for their case in the data.