Nativity, complications, and pathology are determinants of surgical results for gastric cancer

Ethnic survival differences after gastrectomy for gastric cancer are better explained by factors specific for disease location and individual patient comorbidity

INTRODUCTION

Different outcomes after resection of gastric cancer between various ethnic patient groups have been described. It remains unclear whether disparity of treatment forms, disease-related variables, or individual patients accounts for this effect.

METHODS

In the 10 years between 1989 and 1999, 75 patients with gastric adenocarcinoma underwent gastrectomy at a single institution, with constant surgical standards during this time period, including complete (R0) resection attempt and extended lymphadenectomy. Ethnicity, disease characteristics, and treatment variables were analysed for their impact on survival.

RESULTS

There were 40 males and 35 females, with a median age of 67 years (range 31-97). The gastrectomy extent was total (n=25), proximal (n=18), subtotal (n=17), distal (n=14), and segmental (n=1). The mean lymph-node count was 25+/-17 (SD). There was one post-operative death, and an overall complication rate of 27%; the median hospital stay was 11 days. Overall actuarial 5-year survival was 33% (95% CI: 19-47); potentially curable disease (stage 1A-IIIB) led to a median survival of 49 months. Asian (n=18) and Hispanic patients (n=20) had significantly better survival than Caucasian (n=31) or other patients (n=6) (P=0.01). Ethnicity was linked to the location of the primary tumour ( P=0.002), the gastrectomy extent (P=0.003), and the patient's prior abdominal operation (P=0.01) or tobacco history (P=0.03), but not to resection extent parameters (such as number of lymph nodes retrieved) or differences in pathologic characteristics. When controlling for differences of disease site, stage, R status, and patient comorbidity, ethnicity did not retain an independent prognostic impact on survival.

CONCLUSIONS

Obvious survival differences after gastrectomy for gastric adenocarcinoma favouring Asian and Hispanic patients in this experience can be explained by different disease patterns (distal location), the related need for fewer extensive procedures (such as total gastrectomy), and diminished patient risks (tobacco, prior operations, non-cancer deaths). Our therapeutic approach remains an aggressive gastrectomy/lymphadenectomy combination for potentially curable gastric cancer, irrespective of ethnic patient factors.

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.

Total gastrectomy with distal pancreatectomy and splenectomy for advanced gastric cancer

BACKGROUND

Pancreaticosplenectomy (PS) is often performed simultaneously with total gastrectomy (TG) to facilitate dissection of the lymph nodes around the splenic artery and splenic hilus. To evaluate the effects of PS on survival, a retrospective study was performed.

METHODS

Various clinicopathological factors influencing lymph node metastasis around the splenic hilus (No. 10) and the splenic artery (No. 11) were studied retrospectively in the upper or middle third of advanced gastric cancer patients who underwent TG with PS. The postoperative morbidity, mortality, and survival rate of patients who underwent TG with PS (the TG with PS group) were compared with those of patients who underwent TG alone (the TG-alone group).

RESULTS

Tumor size larger than 41 mm and lymph node No. 2 metastasis were independently correlated with lymph node No. 10 and No. 11 metastasis. The mortality rate was similar, but the morbidity rate was significantly higher in the TG with PS group. In the patients with stage I and III, there was no significant difference between the two groups, but in the patients with stage II, the TG-alone group was significantly better than the TG with PS group (P = 0.0400).

CONCLUSIONS

Combined PS with TG should never be performed as the standard surgical procedure for every stage of gastric cancer, especially stage II.

Risk factors for complications following resection of large gastric cancer

BACKGROUND

Although there is a low mortality rate after gastrectomy in Japan, most studies include many early gastric cancers. There have been few studies on the morbidity after gastrectomy for advanced gastric cancer. The aim of this study was to clarify the characteristics and risk factors for postoperative complications after resection of large gastric cancers based on three clinical factors: patient, operation and tumour.

METHODS

A retrospective study was carried out on 97 patients with a gastric tumour measuring 10 cm or more in diameter. Postoperative complications were recorded and the patients were divided into two groups: 38 with complications and 59 without. Patient, operative and tumour findings were compared between the two groups.

RESULTS

Overall morbidity and mortality rates were 39 and 7 per cent respectively. The most frequent complication was pleural effusion (17 per cent), followed by anastomotic leakage (14 per cent), abdominal abscess (12 per cent), wound infection (12 per cent), pancreatic leakage (8 per cent) and peritonitis (6 per cent). Risk factors associated with postoperative complications were operating time (400 versus 337 min, P < 0.01), blood loss (1338 versus 782 ml, P < 0.01), pancreatic invasion (26 versus 8 per cent, P < 0.05) and raised serum carcinoembryonic antigen (CEA) level (5 ng/ml or greater) (36 versus 17 per cent, P < 0.05), independent of patient age, nutritional status, type of gastrectomy, splenectomy or pancreatectomy, extent of lymph node dissection, tumour location, size and stage of disease.

CONCLUSION

Even in Japan, the morbidity of gastrectomy for large gastric cancer is high and associated with operating time, blood loss, pancreatic invasion and serum CEA level.

Adenocarcinomas of the esophagus and gastric cardia: the role of diet

The incidence of adenocarcinomas of the esophagus and gastric cardia (ACEGC) has been increasing for the past 10-15 years in the United States. The reason for this increase is unknown. This hospital-based case-control study was conducted to assess the effects of dietary and nutritional factors on the risk of ACECG. A total of 95 incident cases with pathological diagnosis and 132 cancer-free controls were included in the study. Patients were recruited at Memorial Sloan-Kettering Cancer Center from 1 November 1992 to 1 November 1994. Epidemiologic data were collected by a modified National Cancer Institute Health Habits History Questionnaire. Nutritional and dietary factors were analyzed using a logistic regression model. Increased risk of ACEGC was significantly related to higher intake of dietary calories and fat after controlling for several potential confounding factors. Decreased risk of ACEGC was significantly associated with high ingestion of dietary fiber, lutein, niacin, vitamin B6, iron, and zinc. Higher intakes of vitamin A, beta-carotene, vitamin E, folate, phosphorus, and potassium were associated with a decreased risk of the disease, but these were not statistically significant. The study suggests that ACEGC can be preventable through dietary interventions.

Effect of photodynamic therapy in a multimodal approach for advanced carcinoma of the gastro-esophageal junction

Background and Objective We wanted to determine the role of additional photodynamic therapy in a multimodal approach for the treatment of patients with advanced cancer of the gastro-esophageal junction. Study Design/Materials and Methods We reviewed 53 patients, after endoluminal palliation, with advanced cancer of the gastro-esophageal junction. Combined dilatation and retrograde tumor disobliteration with Nd-YAG laser before photodynamic therapy (PDT), brachyradiotherapy, or both, became necessary in 12 patients. Brachyradiotherapy was carried out in all patients. PDT before brachyradiotherapy was performed in 25 patients. The endoluminal treatment was completed by external beam irradiation in 30 patients (15 cases with PDT and 15 without PDT) with an at least fair performance status.

RESULTS

Photodynamic therapy showed a significant difference regarding the mean opening of the tumor stenosis (mean, 6.4 mm; P = 0.0002), the mean decrease in tumor length (3.1 cm; P = 0.00001) and the increase in median survival (13. 8 months; P = 0.001). The combined multimodal approach by using PDT, brachyradiotherapy and external beam irradiation showed a median survival of 16.8 months. However, additional external beam irradiation showed no significant difference (P = 0.11). The rate of severe complications was 5.7%. The mortality rate was 1.9%.

CONCLUSION

Photodynamic therapy has been shown to be an effective treatment for palliation of advanced cancer at the gastro-esophageal junction. The use of PDT combined with irradiation was associated with an acceptable survival rate, low rates of complications and reasonable quality of life.

Is there a benefit of pancreaticosplenectomy with gastrectomy for advanced gastric cancer?

BACKGROUND

In Japan, wide resection with extended lymph node dissection has been performed for advanced cancer with good prognosis. Pancreaticosplenectomy with gastrectomy is performed to facilitate dissection of the lymph nodes around the splenic artery. We attempted to evaluate the effects of pancreaticosplenectomy and splenectomy with gastrectomy for advanced gastric cancer.

METHODS

Gastric cancer patients underwent splenectomy with gastrectomy (78 cases), pancreaticosplenectomy with gastrectomy (105 cases), or gastrectomy alone (1,755 cases). Survival rates were compared among the three groups for each factor of the depth of invasion, stage, and curability.

RESULTS

There were no significant differences among the three groups. Pancreaticosplenectomy or splenectomy with gastrectomy to dissect lymph nodes does not improve survival but is associated with severe complications.

CONCLUSIONS

The spleen should be resected when a patient has clearly positive node metastasis around the splenic hilus and artery, and pancreaticosplenectomy be performed when the cancer lesion invades the pancreas.

Evaluation of treatment strategies for gastric cancer in the elderly according to the number of abnormal parameters on preoperative examination

The treatment strategies in patients with gastric cancer aged 80 years or older have not yet been well defined. We examined the incidence of postoperative complications and hospital mortality regarding the preoperative condition of such patients. A preoperative examination included evaluations of the cardiac, pulmonary, renal, and hepatic functions, the presence or absence of anemia, nutritional status, and blood sugar content. The incidence of postoperative complications and hospital mortality were then studied in relation to the number of preoperative abnormal parameters. The incidence of postoperative complications was 37.0%. The rate of hospital mortality was 11.1%. Among the patients with abnormalities in five or more items, the incidence of complications was 76.9% and the rate of hospital mortality was 23.1%. In the patients with an operative time of 4 h or longer, the same incidence was 71.4%. Among the patients who underwent a curative resection, the 5-year survival rate was 92.3%. For elderly gastric cancer patients with abnormalities in five or more items during a preoperative examination and for those showing a poor level of daily life activity, a less invasive treatment modality should be planned. Patients with abnormalities of four or fewer items at a preoperative examination appear to be good candidates for curative resection.

Total gastrectomy with simultaneous pancreaticosplenectomy or splenectomy in patients with advanced gastric carcinoma

A splenectomy or distal pancreaticosplenectomy is often performed simultaneously with total gastrectomy in the treatment of gastric carcinoma to facilitate dissection of the lymph nodes around the splenic artery and splenic hilus. However, the negative impact of splenectomy and pancreaticosplenectomy has also been reported. A retrospective analysis was performed to evaluate the outcomes of distal pancreaticosplenectomy and total gastrectomy, splenectomy and total gastrectomy, and gastrectomy alone in the patients with advanced gastric carcinoma without distant metastasis. Prognostic factors were examined. No significant differences existed in 5-year survival in the patients who underwent gastrectomy with splenectomy, gastrectomy with distal pancreaticosplenectomy, or gastrectomy alone. Neither splenectomy, nor distal pancreaticosplenectomy were prognostic factors. However, distal pancreaticosplenectomy was an independent predictor of pancreatic fistula. In conclusion, the addition of distal pancreaticosplenectomy or splenectomy to total gastrectomy for gastric cancer increases the risk of severe complications, but does not improve survival.

End results of simultaneous pancreatectomy, splenectomy and total gastrectomy for patients with gastric carcinoma

A distal pancreatectomy is often performed simultaneously with splenectomy and total gastrectomy in the treatment of gastric carcinoma to facilitate dissection of the lymph nodes around the splenic artery. However, the morbidity of partial pancreatectomy is high. Patients undergoing pancreaticosplenectomy in conjunction with total gastrectomy are subject to leaks from the pancreatic stump, which may cause further complications. We performed a retrospective analysis to evaluate the end results of simultaneous distal pancreatectomy with total gastrectomy. The effect of distal pancreatectomy on survival was studied by examination of the records of 174 patients who underwent splenectomy and total gastrectomy for gastric carcinoma. Of these, 93 underwent distal pancreatectomy. Prognostic factors were determined and were examined in relation to the post-operative complications. There was no significant difference in the 5-year survival of the patients who did or did not undergo distal pancreatectomy. There was no correlation between any prognostic factor and distal pancreatectomy. In contrast, distal pancreatectomy was independently associated with post-operative complications. In this retrospective study, the addition of distal pancreatectomy to splenectomy at total gastrectomy for patients with gastric cancer did not affect survival but was associated with severe complications.

Laparoscopic lymph node assessment in pretherapeutic staging of gastric and esophageal cancer

In gastric cancer lymph node metastases at the hepatoduodenal ligament and in esophageal cancer, metastases at the celiac axis are classified as distant metastases (M1 LYMPH) and implying a poor prognosis. In pretherapeutic staging, imaging procedures such as computed tomography of the abdomen or transcutaneous ultrasonic examination are of limited value in the assessment of enlarged or metastatic lymph nodes. Conversely, laparoscopic staging with subsequent biopsy of suspicious lymph nodes provides essential diagnostic information. After exclusion of distant metastases (liver, lung, bone) in 73 patients with esophageal-(n = 21) and gastric cancer (n = 52), staging laparoscopy, including laparoscopic ultrasound, were performed during an 18-month-period (July/ 93-December/94). After laparoscopic exclusion of peritoneal seedings, the hepatoduodenal ligament was examined and enlarged lymph nodes were biopsied. In a total of 73 patients, laparoscopy revealed previously undiagnosed liver metastases in 14 and peritoneal carcinosis in 19 patients. Additionally, in eight (esophageal cancer; n = 3, gastric cancer; n = 5) of the remaining 40 patients, lymph nodes in the M1-position were regarded suspicious and biopsied. In six of these, malignant spread was observed. Thus, in a further six of 40 patients, surgically incurable situations could be detected. In esophageal and gastric cancer, staging laparoscopy, including laparoscopic ultrasound and biopsy, is a sensitive technique to assess local tumor spread and distant metastases. The detection of M1- lymph node metastases is facilitated by the use of laparoscopic ultrasound. Tumor spread, which limits surgical curability, can be properly assessed and exploratory laparotomy avoided.

Comparison between resectable gastric adenocarcinomas seropositive and seronegative for Helicobacter pylori

The preoperative seropositivity of Helicobacter pylori was determined in 128 patients who had undergone gastrectomy for primary gastric adenocarcinoma during the past 5 years. The overall seroprevalence of H. pylori was 64 per cent. Gastric cancers positive for H. pylori were associated with tumours located in the lower third of the stomach which were of localized type (Borrmann I and II) (P < 0.05), but not with age, sex, blood type, tumour size, invasion depth, lymph node metastases, histological type, DNA ploidy or type of surgery. The cumulative 5-year survival curves after surgical resection were significantly better in patients who were positive for H. pylori. Multivariate analysis revealed that seropositivity for H. pylori was not an independent prognostic factor. Pathological tumour node metastasis staging was the only prognostic indicator. Better prognosis for those with H. pylori-seropositive gastric cancer may be attributed to the more advanced stage of H. pylori-seronegative gastric cancers. The potential role of H. pylori in gastric cancer carcinogenesis and its biological significance warrant further investigation.

Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy

OBJECTIVE

The authors used prolamine (Ethibloc, Ethicon GmBH, Norderstedt, Germany) for segmental obstruction of the pancreatic duct to prevent pancreatic fistula development after distal pancreatectomy combined with total gastrectomy for gastric malignancies.

SUMMARY BACKGROUND DATA

Although the initial clinical application of prolamine was pancreatic duct obstruction for patients with pancreatitis and undergoing pancreatic transplantation and pancreaticoduodenectomy for pancreatic cancer, there are no reports on prevention of pancreatic fistula formation after distal pancreatectomy.

METHODS

Prolamine (0.2 mL) was injected into the distal segment of the main duct in the remaining pancreata of 51 patients. Small pancreatic ducts on the cut surface, from which prolamine extravasates, were closed by ligation, the main duct was ligated doubly, and the transected pancreatic margin was closed 15 minutes after phenylpropanolamine hydrochloride injection.

RESULTS

No patient developed a pancreatic fistula or the complication of arterial bleeding due to prolonged infection.

CONCLUSION

Segmental obstruction of the pancreatic duct with prolamine is useful for preventing pancreatic fistula development after distal pancreatectomy.

Laparoscopy and laparoscopic ultrasound for staging of upper gastrointestinal tumours

Conventional imaging studies are often not sensitive enough to allow accurate preoperative staging of intra-abdominal tumour spread. Laparoscopy and laparoscopic ultrasound appear to be suitable to improve staging of gastrointestinal tumors. Within a 10-month period 40 patients with upper GI tract cancer underwent laparoscopy for intra-abdominal staging. Additionally laparoscopic ultrasound was performed on 20 of these patients using a flexible echo-endoscope equipped with a curved array transducer (5/7.5 MHz). By laparoscopy additional information compared to conventional staging was obtained in 16 patients (40%). Laparoscopy revealed peritoneal carcinomatosis and liver metastases in seven and four patients, respectively. M1-lymph nodes were detected in four patients. Laparoscopic ultrasound was able to image otherwise inaccessible regions of the abdominal cavity and induced a change of staging in seven of 20 patients in whom laparoscopy was uneventful. Ultrasound also proved to be valuable for localization of M1-lymph nodes. In summary, combination of laparoscopy and laparoscopic ultrasound improved staging in 23 of 40 patients (57%). Consequently surgery was abandoned in 16 patients due to incurable or non-resectable disease, while down-staging occurred in seven patients, who subsequently underwent resection. Laparoscopy is capable of improving staging of intra-abdominal malignancy by detection and subsequent biopsy of small lesions. Laparoscopic ultrasound can replace the lack of tactile sensitivity in laparoscopy, thus enabling the detection of non-superficial lesions.