Multiple early gastric carcinomas: Clinicopathologic features and histogenesis

Clinicopathological features and impact of adjuvant chemotherapy on the long-term survival of patients with multiple gastric cancers: a propensity score matching analysis

Background

Little is known about the correlation between the clinicopathological features, postoperative treatment, and prognosis of multiple gastric cancers (MGCs). In this study, we aimed to investigate the correlation between these features and the impact of postoperative adjuvant chemotherapy on the long-term survival of patients with MGC.

Methods

The clinical and pathological data of patients diagnosed with gastric adenocarcinoma who had radical gastrectomy from January 2007 to December 2016 were analyzed. Using propensity score matching, the prognostic differences, and the impact of postoperative adjuvant chemotherapy between those with MGC and solitary gastric cancers (SGC) were compared.

Results

Among the 4107 patients investigated, the incidence of MGC was 3.2% (133/4107). Before matching, patients with MGC and SGC had disparities in the type of gastrectomy, pathological tumor stage (pT), pathological node stage (pN), and pathological tumor-node-metastasis stage (pTNM). After a 1:4 ratio matching, the clinical data of 133 cases of MGC and 532 cases of SGC were found to be comparable. The 5-year overall survival (OS) rate was 56.6% in the entire matched cohort, 48.1% in the MGC group, and 58.7% in the SGC group (P = 0.013). Multivariate analysis revealed that MGC, age, pT stage, pN stage, and adjuvant chemotherapy were independent predictors of OS (all P < 0.05). Stratified analyses demonstrated that for the cohort of advanced gastric cancer (AGC) patients who did not had adjuvant chemotherapy, the 5-year OS rate of advanced cases of MGC was inferior than that of SGC patients (34.0% vs. 46.1%, respectively; P = 0.025) but there were no significant difference in the 5-year OS rate between advanced MGC and SGC patients who had adjuvant chemotherapy (48.0% vs. 53.3%, respectively; P = 0.292). Further, we found that the 5-year OS rate of advanced MGC who had adjuvant chemotherapy was significantly higher than those who did not had adjuvant chemotherapy (48.0% vs. 34.0%, P = 0.026).

Conclusions

Patients with advanced MGC was identified as having a poorer survival as to SGC patients, but the implementation of postoperative adjuvant chemotherapy showed that it had the potential to significantly improve the long-term prognoses of MGC patients.

Trimodal imaging endoscopy reduces the risk of synchronous gastric neoplasia

BACKGROUND AND AIM

The accurate detection of synchronous neoplasia is important to reduce the risk of recurrence after endoscopic resection. Trimodal imaging endoscopy (TMIE) was developed for this purpose. Our aim was to compare the effects of TMIE and white-light imaging endoscopy (WLIE) in gastric neoplasia detection.

PATIENTS AND METHODS

Six hundred and seventy-eight patients with gastric dysplasia or cancer initially treated by endoscopic resection and who underwent follow-up endoscopy were analyzed retrospectively. Gastric neoplasia detected within 1 year of endoscopic resection was defined as synchronous disease. WLIE or TMIE was used to detect another gastric neoplasia before endoscopic resection.

RESULTS

Synchronous gastric neoplasia was observed in 41 patients (6%), and occurred more frequently after the resection of carcinoma than dysplasia (8.5 vs. 4.6%, P=0.04). TMIE significantly reduced the frequency of synchronous gastric lesions than WLIE (2.3 vs. 9.3%, P<0.01). TMIE was more effective than WLIE in reducing the risk of missing a synchronous gastric lesion after adjusting for lesion multiplicity, experience, and resected lesion pathology (hazard ratio, 0.32; 95% confidence interval, 0.108-0.762).

CONCLUSION

The risk of missing synchronous gastric neoplasia is higher after endoscopic resection for gastric cancer than dysplasia, but is reduced by TMIE. TMIE before endoscopic treatment can be useful in decreasing the risk of synchronous gastric neoplasia.

Radiofrequency ablation for the treatment of gastric dysplasia: a pilot experience in three patients

Different endoscopic techniques such as endoscopic mucosal resection, endoscopic submucosal dissection, argon-plasma coagulation, and photodynamic therapy have been used in the treatment of gastric dysplasia. Radiofrequency ablation (RFA) has become a recognized tool in the treatment of dysplastic Barrett's esophagus, but its use in gastric dysplasia has not yet been studied. We aim to describe three cases of RFA treatment in patients with persistent dysplastic gastric mucosa confirmed by consensus of two expert gastrointestinal pathologists. In each patient, two catheter-based RFA procedures were performed 8 weeks apart in an outpatient setting. Although each patient reported minor epigastric pain after RFA, there were no major complications such as bleeding, perforation, stricture, or the need for hospitalization. Endoscopic follow-up with extensive biopsy sampling 2, 4, 6, 12, and 18 months after the last RFA revealed negative results for dysplasia in all patients. These results suggest that RFA may be considered in the treatment of gastric dysplasia. The confirmation of these data with a large series can lead to a change in the paradigm of gastric dysplasia management.

Eleven metachronous early gastric cancers in an elderly woman

We report on a patient with 11 metachronous multiple early gastric cancers treated by gastrectomy after endoscopic resection. An 87-year-old Japanese woman was admitted to our hospital for treatment of four synchronous multiple early gastric cancers detected by endoscopic examination. The patient had a history of two endoscopic treatments for four metachronous early gastric cancers. The pathological findings of four lesions resected by endoscopic resection and four biopsy specimens showed well-differentiated carcinoma. In March 2012, we performed a distal gastrectomy for four lesions. The surgical specimen revealed 3 minute lesions after surgery in addition to these four lesions. Histologically, all seven lesions were intramucosal well-differentiated adenocarcinomas without vascular invasion. Although the incidence of synchronous and metachronous early gastric cancer is reportedly 11-14.5 % and 8.5-14 %, respectively, only two or three lesions are generally present. Moreover, multiple early gastric cancers usually originate as differentiated adenocarcinoma in male elderly patients with intestinal metaplasia. In the present case, there were multiple early gastric cancers, whose origin may be correlated with the background of intestinal metaplasia, in excess of the number generally expected.

Endoscopic hemostasis with endoscopic mucosal resection and multiple synchronous early gastric cancers: a case report

INTRODUCTION

Endoscopic hemostasis for severe upper gastrointestinal bleeding due to tumors, such as gastrointestinal stromal tumors and malignant lymphoma, is temporarily effective. However, permanent hemostasis is difficult in many cases because of diffuse bleeding.

CASE PRESENTATION

A 60-year-old Japanese woman was admitted to our hospital with hematemesis. Endoscopy revealed multiple gastric polyps and fresh blood in her stomach. One of the gastric polyps, which was associated with oozing bleeding, was found near the anterior wall of the lower gastric body. We initially applied hemostatic forceps and argon plasma coagulation over the tumor surface, but the bleeding persisted. After endoscopic mucosal resection, exposed vessels were seen at the base of the mucosal resection site with oozing bleeding. Coagulation of the bleeding vessels using hemostatic forceps allowed successful completion of the hemostatic procedure. Our patient also had eight synchronous gastric cancer lesions. Histological examination of the resected specimens showed various types of cancer.

CONCLUSION

This is a case report of gastric cancer associated with eight gastric cancer lesions, confirmed by histology, in which hemostasis was achieved through endoscopy.

Autofluorescence imaging for predicting development of metachronous gastric cancer after Helicobacter pylori eradication

BACKGROUND AND AIMS

Although Helicobacter pylori eradication decreases the incidence of metachronous gastric cancer after endoscopic treatment for early gastric cancer (EGC), metachronous cancer still develops after successful eradication, particularly in patients with severe corpus gastritis. We investigated whether the extent of atrophic fundic gastritis diagnosed by autofluorescence imaging (AFI) videoendoscopy is predictive of development of metachronous gastric cancer after H. pylori eradication in patients treated with endoscopic submucosal dissection (ESD) for EGC.

PATIENTS AND METHODS

A total of 82 patients who underwent ESD for EGC from 2003 to 2006, who received eradication therapy participated in this study. The extent of chronic atrophic fundic gastritis was evaluated by AFI and categorized into closed and open type. The main outcome was the incidence of metachronous gastric cancer detected by annual surveillance endoscopy.

RESULTS

During a median observation period of 55 months, metachronous gastric cancer developed in 12 of 82 patients (14.6%). Multivariate Cox's proportional hazard analysis revealed that open-type, atrophic fundic gastritis diagnosed by AFI was significantly associated with development of metachronous gastric cancer (hazard ratio: 4.88, 95% confidence interval [CI]: 1.32-18.2, P = 0.018) after adjustment for age, sex, histological intestinal metaplasia, serum pepsinogen level, and H. pylori status.

CONCLUSIONS

Metachronous EGC developed after successful H. pylori eradication, and extensive atrophic fundic gastritis diagnosed by AFI was a significant predictor, thus it could identify patients undergoing ESD for EGC who still required intensive surveillance after eradication.

Epidemiology, pathology and clinical management of multiple gastric cancers: a mini-review

The incidence of multiple gastric cancers (MGCs) has been increasing over the recent decades due to the advance in diagnostic techniques combining with the detailed pathological examinations of surgical resection specimens. Reduction of the surgical extent and trauma under the premise of radical resection improves the quality of life of patients with gastric cancer. However, MGC lesions may have been missed, which can result in adverse consequences. We carried out this systematic review of previous literatures, in order to provide deep insights into epidemiological, pathological and clinical features of MGCs and to establish an efficient way to screen the individuals with high risks. MGCs represent a special type of malignant gastric tumor and possess distinctive features compared with the solitary one. More attention should be paid to both diagnosis and treatment of MGCs. Possibility of overlooking accessory lesions must be kept in mind constantly. For the population at high risk, such as the elderly with differentiated type, strict perioperative tissue examinations and follow-up are essential.

When do we miss synchronous gastric neoplasms with endoscopy?

BACKGROUND

Accurate detection of synchronous multifocal gastric cancer is mandatory for the successful management of stomach cancer.

OBJECTIVE

We compared the sensitivities of gastroscopy and the current criterion standard of surgical resection and investigated the risk factors involved when clinicians fail to recognize additional gastric lesions.

DESIGN

We performed a retrospective examination of the clinicopathological features of synchronous multifocal gastric carcinoma in a recent sample of gastrectomy patients.

PATIENTS

In this study, we enrolled a total of 51 patients (5.17%) with synchronous multifocal gastric carcinoma who had undergone gastrectomy between 2005 and 2008. During that time, 80.43% of patients who had multifocal lesions underwent gastric resection.

MAIN OUTCOME MEASUREMENTS

We compared preoperative gastroscopic findings with surgically resected stomach specimens.

RESULTS

Synchronous multifocal gastric carcinoma was more frequent in older patients, males, and those with early gastric cancer. Using upper endoscopy, we missed accessory lesions in 14 (27.5%) of 51 patients. A total of 109 lesions were present in the resected stomachs, and upper endoscopy detected 93 of these (85.3% sensitivity). Thus, 16 lesions (14.67%) were missed out of a total of 109 gastric lesions. We found that small lesion size was the major risk factor for endoscopic failure to recognize additional lesions.

LIMITATIONS

Our study sample was small, and a large-scale study exploring these risk factors is warranted. Most of the study sample (80.39%) underwent subtotal gastrectomy; therefore, whole-stomach pathology could not be evaluated. Because early gastric cancer has a higher likelihood of being treated by EMR without surgery, there can be problems associated with reliance on surgical specimens. The findings of this study might have been affected by the higher rate of gastric cancers seen in East Asians.

CONCLUSIONS

The entire stomach should be examined with particular care during endoscopy procedures, especially when endoscopic resections of tumors are to be performed. Further, to improve detection, the approaches used to evaluate patients for multifocal tumors need to be improved. A large-scale prospective study is necessary to follow up on our findings.

Study of clinicopathological factors associated with the occurrence of synchronous multiple gastric carcinomas

BACKGROUND

Multiple gastric carcinomas often arise in gastric mucosa with chronic gastritis, particularly severe intestinal metaplasia. In regard to such characteristics, several clinicopathological risk factors for multiple carcinomas have been reported, but no clinically useful criteria are available at present for assessing the onset of multiple gastric carcinomas. If the risk for multiple gastric carcinomas could be accurately assessed, efficient and accurate surveillance could be performed following minimally invasive therapies.

METHODS

In the present study, we investigated clinicopathological differences between 94 cases of multiple early gastric carcinomas and 285 cases of solitary early gastric carcinoma. We tested 379 specimens of gastric carcinomas that had been surgically resected at the Department of General and Gastroenterological Surgery of Osaka Medical College, Japan, from April 1999 to December 2006.

RESULTS

Univariate analysis of clinicopathological factors in the present study showed that multiple gastric carcinomas were significantly correlated to old age (> or =65 years), well- and moderately differentiated histological type, mucin phenotype (intestinal type), distribution of atrophic mucosa in the stomach (severe), degree of intestinal metaplasia in the surrounding mucosa (severe), and heterotopic glandular cysts. Multivariate analysis using the stepwise method identified age (> or =65 years) and degree of intestinal metaplasia in the surrounding mucosa (severe) as significant independent risk factors for multiple gastric carcinomas.

CONCLUSION

While other studies have shown risk factors for multiple gastric carcinomas, the present study is unique in showing risk assessment criteria based on a combination of risk factors for multiple gastric carcinomas.

Twenty-two metachronous multiple signet-ring cell carcinomas treated with repeated gastrectomies and repeated endoscopic mucosal resections: report of a case

A 45-year-old Japanese woman underwent an endoscopic mucosal resection (EMR) for early gastric cancer at the Cancer Institute Hospital in July 1996. The patient then underwent a distal gastrectomy in 2002 because of a new early gastric cancer and repeated EMR for a total of six early gastric cancers in 2007. Finally, a total gastrectomy was performed in February 2008. The pathological examination of the resected specimen indicated 14 synchronous multiple early gastric cancers. Although the incidence of multiple gastric cancers has been reported to range from 5% to 15%, there is usually only a double or triple lesion. Moreover, multiple gastric cancer is typically observed in male elderly patients as differentiated adenocarcinomas. The present case was a young female patient and all of the lesions were intramucosal signet-ring cell adenocarcinomas. The carcinogenetic mechanism in this case may therefore be different from that in typical multiple gastric cancers. A thorough preoperative examination and regular postoperative follow-up are therefore essential for detecting multiple gastric cancers in their early stages.

Pre-pyloric site gastric cancer after pylorus-preserving gastrectomy (PPG): a case report

Pylorus-preserving gastrectomy (PPG) is a function-preserving surgical procedure which is now applied to treat early gastric cancer in the mid-portion of the stomach. We report a patient who developed a pre-pyloric site gastric cancer after PPG. To our knowledge, this is the first report on the development of pre-pyloric site gastric cancer after PPG in the English literature using PubMed.

Synchronous early gastric cancer resembling submucosal tumor at the fundus

Concern about detecting gastric carcinoma in its early stages has increased the incidence of detecting multiple synchronous gastric carcinomas. Although gastric carcinomas may present with various gross features, those showing the features of submucosal tumor (SMT) are rare. We report on a case of synchronous gastric carcinomas comprising one lesion with typical features of superficial early gastric carcinoma and the other with atypical features that mimicked SMT. Even though synchronous gastric carcinoma is rare, it may be worthwhile to make a pathological diagnosis of coexisting SMT using endoscopic-ultrasound-guided fine-needle aspiration or endoscopic mucosal resection.

A patient with 43 synchronous early gastric carcinomas with a Krukenberg tumor and pericardial metastasis

A 53-year-old Japanese woman with bilateral ovarian tumors consulted our department. Gastroendoscopy disclosed 16 superficial depressed gastric lesions, and the histopathological diagnosis of the biopsy specimens was poorly differentiated adenocarcinoma and signet-ring cell carcinoma. Computed tomography (CT), ultrasonography (US), and positron emission tomography (PET) examinations revealed no other metastasis except for that observed in the ovaries. We performed a total gastrectomy with radical lymph node dissection and bilateral ovarian resection. A postoperative histological examination revealed 43 isolated gastric lesions which were scattered over the entire resected stomach; they were all confined to the mucosa. Cancer cell invasion in the lymphatics was detected only in the submucosal region beneath the main tumor. Both ovarian tumors were diagnosed as metastasis of signet-ring cell carcinoma (Krukenberg tumor). Adjuvant chemotherapy with irinotecan (CPT-11) and low-dose cisplatin (CDDP) was given on an outpatient basis, but 1 year after the surgery, carcinomatous pericarditis occurred. Administration of mitomycin C (MMC) into the pericardial space was performed twice; however, unfortunately, the patient died 13 months after surgery.

Evaluation of in vivo endoscopic autofluorescence spectroscopy in gastric cancer

BACKGROUND

The aim of this study was to evaluate light-induced autofluorescence spectroscopy for the in vivo diagnosis of gastric cancer.

METHODS

A total of 344 endogenous fluorescence spectra were obtained from normal (164) and cancerous gastric mucosa (180) in 15 patients with pure adenocarcinoma and in 16 patients with gastric cancer containing signet-ring cells. A special light source capable of delivering either white or violet-blue light for the excitation of tissue autofluorescence via the endoscope was used. Endogenous fluorescence spectra emitted by the tissue were collected with a fiberoptic probe and analyzed with a spectrograph.

RESULTS

Gastric adenocarcinoma exhibits specific changes in the emitted fluorescence spectra as compared with normal gastric mucosa. By algorithmic classification of the spectra, a sensitivity of 84%, specificity of 87%, a likelihood ratio for a positive test of 6.5 and for a negative test of 0.18 were obtained for the diagnosis of pure adenocarcinoma of the stomach. However, gastric cancer with signet-ring cells exhibits great variation in emitted autofluorescence spectra as compared with normal mucosa. The sensitivity for the diagnosis of all carcinomas containing signet-ring cells was 55%, specificity 85%, the likelihood ratio for a positive test was 3.7 and for a negative test, 0.53. The diagnostic value decreases with increasing numbers of signet-ring cells and tumor grade.

CONCLUSIONS

Light-induced autofluorescence spectroscopy is a new and promising bio-optical technique for the endoscopic in vivo diagnosis of gastric adenocarcinoma. The poor diagnostic accuracy for signet-ring cell carcinoma may be explained by the diffuse and frequent submucosal growth of this tumor and the presence of collagen fibers.

Gastric or intestinal phenotypic expression in the carcinomas and background mucosa of multiple early gastric carcinomas

AIMS

The differences in phenotypic expression between multiple early gastric carcinomas (EGCs) and solitary EGCs were evaluated in this study.

METHODS AND RESULTS

Fifty-three cases (53 lesions) of solitary EGCs and 50 cases (112 lesions) of multiple EGCs were studied. According to the classification of intestinal metaplasia, the phenotypes of carcinomas and background mucosa were classified into four categories-complete intestinal type, incomplete intestinal type, gastric type and unclassified type-based on the combination of expression of CD10 (small intestinal brush border), MUC2 (intestinal goblet cell), HGM (gastric foveolar epithelium) and Con A (gastric pyloric glands). The incidence of gastric-type carcinomas (48%) and the incidence of incomplete intestinal-type background mucosa (75%) among the multiple EGCs was higher than among the solitary EGCs. There was a significant difference in distribution of phenotypic expression of carcinomas and background mucosa between the solitary EGCs and the multiple EGCs, the latter being associated with incomplete intestinal metaplasia.

CONCLUSIONS

Both the carcinomas and the background mucosa of multiple EGCs have an unstable status, since they more commonly possess the hybrid phenotype of the stomach and the small intestine than does solitary EGC. Such instability is considered to contribute to a high neoplastic potential and the multiple occurrence of carcinomas.