Pathology and prognosis of carcinoma of the stomach

Grading as a Prognostic Factor: Review of 209 Primary Gastric Cancer Patients

Two hundred and nine cases of primary gastric cancer were treated surgically from January 1968 to December 1983 and analyzed retrospectively. All patients were followed up for a minimum of 5 years. There were 25 SI cases (12 %), 22 SII (10.5%), 55 SIII (26.3%) and 107 SIV (51.2%). Tumor grade according to Broders classification showed 50 cases of G1 lesions (23.9%), 44 G2 (21.1 %) and 115 G3 (55%). Patients with well differentiated G1 lesion, compared to G2-G3 patients, presented a greater incidence of T1-T2 tumors and decreased incidence of T4 tumors (p < 0.05). The lymph node involvement rate significantly increased with variation of T (p < 0.001) but not with tumor grade. Survival results correlated with tumor stage (p < 0.01) but not with tumor grade or histological type.

Mucin histochemistry of stomach in metaplasia and adenocarcinoma: An observation

Background:

There is a variable pattern of occurrence of gastric carcinomas world-wide, partially reflecting the frequency of various changes of gastric mucosa from, which such neoplasm occur. Many cases of gastric carcinoma originate in the background of chronic gastritis caused by Helicobacter pylori. Subsequent intestinal metaplasia (IM) can be morphologically classified by routine and special histopathological stains.

Materials and Methods:

The present study was conducted over the 2 years at NRSMC & H, Kolkata. Aims of the present study were to search for evidences of H. pylori infection, classification of different metaplastic and/or malignant changes, identification of types of mucin by mucin histochemistry and their interrelationship in gastrectomy and gastric biopsy specimens (total 70). After obtaining clinical history, radiological and endoscopic findings were noted. After macroscopic study of the specimen, hematoxylene and eosin, southgate mucicarmine, periodic acid schiff-alcian blue (PAS-AB) and gomori aldehyde fuchsin (GAF)/AB staining were performed to classify gastric carcinoma and metaplastic changes and to correlate with staining patterns of mucin.

Results:

The overall male to female ratio was 2.89:1. Age ranged from 22 years to 78 years and the commonest age group of gastric carcinomas being 41-50 years (26 cases, 37.1%). Gastric adenocarcinoma was found in 61 (87.1%) cases (22.9% were of intestinal type and 77.1% of diffuse type) and only IM was found in 9 (12.9%) cases. Overall the rapid urease test was positive in 18 (25.7%) cases majority of which showing either pure IM or IM associated with intestinal type of gastric carcinoma. All diffuse types of gastric carcinoma (47 cases, 77.1%) were showed PAS positive staining (indicating neutral mucin) whereas in 15 (65.2%) cases of IM columnar cells stained with AB (representing acidic mucin). GAF/AB stain revealed Type II IM in 10 (43.5%) cases and Type III IM in 4 (17.4%) cases.

Conclusion:

Routine and special histological staining is particularly useful for histological subtyping of gastric carcinomas and IMs.

High PRL-3 expression in human gastric cancer is a marker of metastasis and grades of malignancies: an in situ hybridization study

Phosphatase of regenerating liver (PRL)-3, encoding a 22-kD low molecular weight tyrosine phosphatase, has been reported to be associated with metastasis of colorectal carcinoma. We assessed the levels of PRL-3 mRNA expression to know whether its up-regulation was involved in progression and metastasis of gastric carcinoma. Levels of PRL-3 expression in 94 human gastric adenocarcinomas and 54 matched lymph node metastases were detected by in situ hybridization and compared with clinicopathological characteristics including prognosis. High PRL-3 expression was detected in 36.2% of primary gastric carcinoma (with nodal metastasis, 55.6%; without nodal metastasis, 10%; P < 0.001) and in 74.1% of lymph node metastases. The incidence of high PRL-3 expression in lymph node metastasis was significantly higher than in primary tumors (P < 0.044). Moreover, high expression of PRL-3 was closely associated with tumor size, lymphatic invasion, venous invasion, extent of lymph node metastasis, and tumor stage. These results suggest that high PRL-3 expression may participate in the progression and metastasis of gastric carcinoma. PRL-3 might be a novel molecular marker for aggressive gastric cancer.

Molecular markers (PECAM-1, ICAM-3, HLA-DR) determine prognosis in primary non-Hodgkin's gastric lymphoma patients

AIM

To investigate the prognostic significance of PECAM-1, ICAM-3 and HLA-DR antigens in patients with primary non-Hodgkin's gastric lymphoma.

METHODS

We immunohistochemically studied PECAM-1, ICAM-3 and HLA-DR antigen expression in 36 B-cell MALT-type primary gastric lymphoma patients. Ten non-malignant and ten healthy gastric tissue specimens were used as controls. Clinicopathological and survival data were correlated with the staining results.

RESULTS

HLA-DR antigen expression was detected in 33 gastric lymphoma patients (91.7%) and 6 non-malignant patients (54.5%). PECAM-1 stained tumor cells of 10 patients (27.8%), endothelial cells of 9 patients (25%) and inflammatory infiltrate of 4 patients (40%) with benign gastric disease. ICAM-3 expression was observed on the tumor cells of 17 patients (47.2%), while 5 non-malignant patients (50%) were stained positive as well. None of the healthy controls was stained for any of the genes studied. In the multivariate analysis, HLA-DR antigen and PECAM-1 were proved to be statistically significant independent prognostic factors associated with a favourable and an unfavourable prognosis respectively (P=0.009 and P=0.003). In the univariate analysis, PECAM-1(+)/ICAM-3(-) and HLA-DR(-)/ICAM-3(-) patients exhibited a significantly decreased overall survival compared to those with the exactly opposite gene expression patterns (P=0.0041 and P=0.0091, respectively). Those patients who were HLA-DR(+)/ICAM-3(+)/PECAM-1(-) (n=8) had a significantly higher survival rate compared to the rest of the group (n=24) (P=0.0289).

CONCLUSION

PECAM-1, ICAM-3 and HLA-DR are representative markers of tumor expansion potential and host immune surveillance respectively. Their combined use may help us to identify high-risk patients who could benefit from more aggressive therapeutic protocols.

Prognostic indicators in locally advanced gastric cancer (LAGC) treated with preoperative chemotherapy and D2-gastrectomy

BACKGROUND AND OBJECTIVES

Neoadjuvant chemotherapy is increasingly considered an effective treatment option for patients with gastric carcinoma. Aim of the study is to evaluate the prognostic significance of the pathological response and of known prognostic factors in a group of accurately staged locally advanced gastric cancer (LAGC) patients.

METHODS

Thirty-three patients with LAGC, staged by laparoscopy, underwent D2-gastrectomy after preoperative chemotherapy. Survival was calculated by Kaplan-Meier method and differences were assessed by the Log-rank and Breslow test. Multivariate analysis was performed using the Cox proportional hazard model in backward stepwise regression.

RESULTS

Curative resection (R0) was achieved in 81.8% of patients. A complete or subtotal pathological response was documented in 3 and 6%, respectively. Nineteen out of thirty-three (57.6%) patients were alive and 16 of them were free of relapse at last follow-up. Survival rates were 81, 67, and 59% at 12, 24, and 36 months, respectively. At univariate and multivariate analysis, only R0 resection was found to be an independent prognostic factor.

CONCLUSIONS

In the current study, R0 resection is the most important prognostic factor for resectable LAGC; according to our results we feel encouraged to consider neoadjuvant chemotherapy a promising modality for increasing the R0-percentage of gastric carcinoma patients who could benefit from a curative surgery.

HLA-DR Antigen and Bax Protein Expression in Patients with Primary Non-Hodgkin's Gastric Lymphoma

Primary gastric lymphoma represents a rare gastrointestinal malignancy with an unclear prognosis. The aim of this study was to determine the prognostic significance of HLA-DR antigen and bax expression in patients with primary non-Hodgkin's gastric lymphoma. We immunohistochemically studied bax protein and HLA-DR antigen expression in 36 B-cell, MALT-type primary gastric lymphoma patients diagnosed and treated in our department from 1990 to 1995. Ten non-malignant gastric tissue specimens were used as benign controls. Clinicopathological and survival data were correlated with the staining results. HLA-DR antigen expression was observed in 33 gastric lymphoma patients (91.7%). Positive bax staining was found in 24 gastric lymphomas (66.7%) and in none of the benign cases studied. In the univariate analysis, those gastric lymphoma patients who expressed HLA-DR antigen in more than 15% of their tumor cells, presented a significantly improved 5-year survival rate (75% vs. 37.5%, p = 0.04). Furthermore, gastric lymphoma patients who were bax(+)/HLA-DR(+) had a statistically better overall survival compared to those who were bax(-)/HLA-DR(-) (82.4% vs. 25%, p = 0.01). HLA-DR antigen expression was associated with a favorable clinical outcome. Its expression improved the predictive value of bax protein expression in non-Hodgkin's gastric lymphoma patients. The combined use of these markers permits the identification of a high-risk group of patients that may benefit from a more aggressive therapeutic approach.

The skewing to Th1 induced by lentinan is directed through the distinctive cytokine production by macrophages with elevated intracellular glutathione content

In vivo lentinan (LNT)-elicited peritoneal macrophages (Mps) showed the reduced release of prostaglandins (PGs), IL-10 and IL-6, while it endowed Mps with the elevated capability to produce IL-12 and nitric oxide (NO) upon in vitro triggering, due to the elevated intracellular glutathione (GSH) content in Mps. Deprivation of intracellular GSH completely ablated the production of IL-12. Conversely, lipopolysaccharide (LPS) induced peritoneal Mps with the reduced intracellular GSH content and the reciprocal profile of mediator production. Mps with the elevated intracelluar GSH is arbitrarily termed as reductive Mp (RMp) and that with reduced amount as oxidative Mp (OMp). OMp was converted to RMp when GSH was replenished with glutathione monoethylester (GSH-OEt). The IL-2 administration in combination with LNT exerted the synergistic induction of RMp, resulting in synergistic augmentation of IL-12, NO and reduction of IL-6 production. It was also confirmed that CD4+T cells derived of LNT-administered mice showed augmented IFN-gamma and reduced IL-4 production upon in vitro anti-CD3 stimulation. Taken together it is concluded that skewing of Th1/Th2 balance to Th1 by a beta-(1-3)-glucan, LNT, is directed through the distinctive production of IL-12 versus IL-6, IL-10 and prostaglandin E2 (PGE2) by Mps, depending on intracellular GSH redox status. To the efficient tumor immunotherapy, it may be one of the critical elements to induce a reductive form of Mps in tumor stromal tissues to maintain Th1 response.

Prognostic comparison of the pathological classifications of gastric cancer: a population-based study

AIMS

There is controversy over the value of the pathological classifications of gastric carcinomas in the prediction of patient survival. This study was designed to assess the prognostic value of four widely used pathological classifications, in addition to classical prognostic factors.

METHODS AND RESULTS

Records from the population-based registry of digestive tract tumours in the department of Côte d'Or (France) have been analysed. All available histopathological slides of gastric cancer resected between 1976 and 1985 were reviewed and classified according to World Health Organization (WHO), Laurén, Ming and Goseki pathological coding systems. A relative survival analysis was performed using a relative survival model with proportional hazard applied to net mortality by interval. WHO, Laurén or Goseki classifications were not found to be independent prognostic factors. In addition to advanced age group, depth of parietal involvement, nodal involvement, presence of metastases, tumour site and gross appearance of the tumour, the Ming's infiltrative type was associated with a lower survival.

CONCLUSION

This study suggests an independent prognostic value of the Ming subtypes with respect to survival in patients resected for gastric carcinoma.

Can endoscopic biopsy specimens be used for reliable Laurén classification of gastric cancer?

BACKGROUND

The aim of this study was to ascertain whether routine endoscopic biopsy specimens are of sufficient quality and representative enough to enable reliable classification of histologic type, grade of differentiation, and frequency of signet ring cells.

METHODS

As part of a population-based etiologic study of gastric cancer in Sweden, the histologic slides of 687 incident cases were independently reviewed by one pathologist. In 305 cases both biopsy and surgical specimens were available for assessment of sensitivity and specificity of diagnoses on the basis of biopsy specimens, with the classification based on surgical specimens as the gold standard.

RESULTS

The sensitivity and specificity of the diagnoses on the basis of biopsy specimens was 86% and 82%, respectively, for detecting the intestinal type, and 87% and 90%, respectively, for the diffuse type of gastric cancer. The percentage agreement between biopsy and surgical specimens with regard to grade of differentiation was 71%.

CONCLUSIONS

This study shows that misclassification of Laurén type due to random intraobserver variation needs to be taken into account in epidemiologic studies. The degree of misclassification appears to be of similar magnitude regardless of the source material.

Prognostic factors for gastric cancer influencing clinical practice

Despite a slow decline in the incidence of gastric cancer over the last 90 years, we can still expect to see over 100,000 patients die of this disease each decade in England and Wales. The 5-year survival rate has not improved during this century, which is largely due to the stage at diagnosis being unchanged. There are a number of prognostic determinants in gastric cancer which have clinical relevance. Age is an important determinant; patients under 40 years commonly have more advanced diffuse lesions than older patients so that a higher index of suspicion needs to be maintained in younger patients with persistent symptoms. Conflicting reports make it unclear whether the duration of symptoms bears any relationship to tumor stage, but there is some evidence that actively shortening the symptom duration by early investigation can have a beneficial effect in the proportion of patients diagnosed with early cancers. The site of the tumor is important; unfortunately, the proportion of patients with cardia lesions is increasing and this has had the effect of reducing the overall survival. Tumor size should not play a part in the decision to resect a lesion as most studies show no clear relationship between tumor size and stage. Tumor stage is the most important prognostic determinant and efforts to increase the proportion of stage I cancers presenting for surgery can be shown to alter the natural history of the disease, by diagnosing it when it is still surgically curable.

Goseki histological grading of gastric cancer is an important predictor of outcome

TNM (tumour, node, metastases) staging has thus far been the most important guide to prognosis in patients with gastric cancer. Histological grading, in contrast, has not provided any additional information. Recently a novel grading system based on tubular differentiation and mucus production has been proposed, which was correlated with patterns of tumour spread found at necropsy. This study set out to assess its value as a determinant of survival after gastric resection. In a consecutive series of 211 patients who had potentially curative resection for gastric cancer, five histological grading systems were assessed: the Lauren type, the WHO type, degree of differentiation, the type of tumour border, and the lymphocytic response to the tumour and compared with the Goseki grading (I-IV). When T and N stage were taken into account, using Cox's proportional hazards model, only the Goseki grading added further to the ability to predict survival. The proportional hazards ratios were: node negative v node positive 6.5 T1 v T3 2.45; Goseki I v Goseki IV 3.1. Five year survival of patients with mucus rich (Goseki II and IV) T3 tumours was significantly worse than that of patients with mucus poor (Goseki I and III) T3 tumours (18% v 53%, p < 0.003). Goseki grading identifies subgroups of patients with a poorer prognosis than is predicted by TNM staging alone. It could prove useful in the selection of patients for adjuvant therapy after potentially curative resection for gastric cancer.

Gastric cancer: a curable disease in Britain

OBJECTIVE

To determine whether more vigorous efforts aimed at earlier diagnosis allied to radical surgical resection lead to improved survival of patients with gastric cancer.

DESIGN

Prospective audit of all cases of gastric cancer treated during 1970-89.

SETTING

Department of surgery, general hospital.

SUBJECTS

493 consecutive patients with gastric adenocarcinoma.

MAIN OUTCOME MEASURES

Operative mortality, postoperative morbidity, and five year survival after radical potentially curative resection.

RESULTS

207 (42%) patients underwent potentially curative resection. The proportion of all patients in whom this was possible increased significantly (p < 0.01) from 31% in the first five year period to 53% in the last five year period. The proportion of patients who had early gastric cancer rose from 1% to 15% (p < 0.01) and stage I disease rose from 4% to 26% (p < 0.001). After potentially curative resection, mortality 30 days after operation was 6%. Operative mortality decreased from 9% in the 1970s to 5% in the 1980s. Likewise, the incidence of serious postoperative complications decreased from 33% in the 1970s to 17% in the 1980s (p < 0.01). Five year survival was 60% in patients who underwent curative resection, 98% in patients with early gastric cancer, and 93%, 69%, and 28% in stage I, II, and III disease respectively. By the late 1980s five year survival after operation was about 70%.

CONCLUSIONS

These findings suggest that an increasing proportion of patients with gastric cancer could be diagnosed at a relatively early pathological stage when about two thirds are curable by means of radical surgery.

Improving survival in gastric cancer: review of 5-year survival rates in English language publications from 1970

In this review of English language publications from 1970, 5-year survival rates after surgery for gastric cancer have been analysed. While the proportion of patients coming to operation has fallen from 92 per cent before 1970 to 71 per cent by 1990, the proportion of operated patients undergoing resection has increased from 37 per cent before 1970 to 48 per cent before 1990. This change suggests improved preoperative staging leading to better patient selection for operation. The 5-year survival rate following all resections has increased significantly from 20.7 per cent before 1970 to 28.4 per cent before 1990, an increase of 7.7 per cent (95 per cent confidence interval 7.1-8.3 per cent). The 5-year survival rate following curative or radical resection has risen from 37.6 to 55.4 per cent over the same period, an increase of 17.8 per cent (95 per cent confidence interval 17.1-18.5 per cent). It is likely that this improvement has contributed to the decrease in the mortality rate from gastric cancer. Comparison of Japanese series with others suggests that diagnosis and treatment of the disease at an earlier stage will result in an even greater increase in 5-year survival rates outside Japan. Of the papers studied, 56 per cent were excluded from analysis, the majority because the data provided about 5-year survival rates were insufficient or the survival calculations inappropriate. Results of survival after operations for gastric cancer should be calculated and presented in a standardized manner.

Improving survival in gastric cancer: review of operative mortality in English language publications from 1970

In this review of English language publications from 1970, operative mortality following surgery for gastric cancer has been analysed. Operative mortality has declined in series reporting operations in successive decades to 1970, 1980 and 1990. Series reporting patients having surgery for gastric cancer in the decade to 1990 show a mean operative mortality rate of 7.8 per cent (median 4.6 per cent). This improvement may have contributed to the declining mortality rates for gastric cancer in the face of unchanging surgical workload. Results of operations for gastric cancer should be reported in a standard manner.

Early gastric cancer

Eighteen cases of 'early gastric cancer' have been managed over a 14-year period. This represents only 3.5% of all patients diagnosed as having adenocarcinoma of the stomach. The symptoms of early gastric cancer are similar to those of benign peptic ulcer disease and differ from those of invasive disease. The pathology of the lesions is described and the morphology shown to be similar to that seen in Japan. The overall 5-year survival rate is 82% but no patient has developed recurrence within 5 years of surgery, confirming the biological behaviour of the lesion to be identical to that noted by Japanese researchers.

An evaluation of the prognostic significance of HLA-DR expression in gastric carcinoma

The prognostic value of histochemical staining for HLA-DR was assessed retrospectively in 52 "curative" gastrectomy specimens from patients with gastric carcinoma. In addition other tumor variables, including histologic type, degree of differentiation, extent of local spread, prominence of mononuclear infiltrate, tumor edge, and lymph-node metastases, were examined. Sixty-five percent of the tumors showed positive staining for HLA-DR, and these tumors had a higher mean and median survival at 5 years compared with negative tumors. However, on multivariate analysis the difference was not statistically significant. The authors conclude that, although HLA-DR staining is associated with tumors of better prognosis, it cannot be used as an independent prognostic factor. Of the other tumor variables, only lymph-node status was of prognostic significance.

Has there been any improvement in the staging of gastric cancer? Findings from the German Gastric Cancer TNM Study Group

This multicenter observational study examined the survival of 1420 patients with histologically proven carcinoma of the stomach. From April 1982 through October 1984, 1360 (95%) patients underwent surgery, 988 (72%) had resections, and 372 (28%) minor surgical procedures. The percentage of patients who have been followed until death or 3 to 5 years was 99.4%. Patients were staged preoperatively and intraoperatively and by pathologists using the old (1978) and new (1987) TNM stage groupings and 5-year survival was analyzed. Subgroups of patients who changed their stage group according to the new stage definitions were analyzed separately. Only age was an important prognostic factor for survival in Stage IA (P less than 0.05) and Stage IB (P less than 0.01). Residual tumor after surgery was most important for survival in Stage II (P less than 0.01) and Stage IIIA (P less than 0.001). This indicates that improvements of stage definitions for individual prognosis can only be achieved by adding data concerning the presence or absence of residual tumor (R classification).

Gastric carcinoma in patients younger than age 36 years

The clinical and pathologic features of 18 patients with gastric carcinoma younger than age 36 years were studied. Of these patients, 36.8% were Hispanics of Mexican origin. Eighteen percent of the Mexican population with gastric carcinoma were younger than 36 years as compared to 2.8% of the overall population (P less than 0.05). Fifty percent of the gastric ulcers in the Mexican population were malignant as compared to 6% in the non-Mexican population (P less than 0.05). In addition, a subset of aggressive carcinomas were found. Patients presenting with symptoms of less than 6 months' duration had a survival of less than 6 months, compared to the less aggressive subset, in which patients had symptoms for greater than 6 months and survived longer than 6 months. Racial, environmental influences, or selection bias may account for the differences in gastric carcinoma in the Mexican and non-Mexican population. Factors contributing to a more aggressive form of carcinoma are unclear and require further study.

Factors influencing prognosis in gastric cancer

In a group of 322 patients with adenocarcinoma of the stomach, 158 underwent resection. The only 5 year survivors came from the resection group. Increasing age, lymph node metastases and increasing depth of invasion of the gastric wall were all adverse prognostic features. There was a high incidence (19%) of resected patients who had suture line involvement. In spite of this there were 5 year survivors among those patients with suture line involvement and also those with lymph node involvement. The judicious implementation of an aggressive resection policy will give patients with favourable tumours the chance of a 5 year cure without involving patients with widespread neoplasm in radical surgery. Patients who had undergone previous gastric surgery for any cause had an extremely bad prognosis. Improvement in 5 year survival rates in patients undergoing resection for gastric cancer could be attributed to the increase in the number of patients with early gastric cancer.

Gastric cancer survival in Sweden. Lack of improvement in 19 years

A total of 34,549 patients constituting 87.0% of all patients with gastric cancer diagnosed in Sweden in 1960-1978 and reported to the National Cancer Registry were included in a complete follow-up over a period of 1-20 years. The poor outcome in this disease was again established in this unselected material. Thus, the 5-year relative survival rate (with 95% confidence limits) was 12.7% (12.1-13.2%) among the men and 14.1% (13.4-14.9%) among the women, without any long-term difference between the sexes. The annual hazard rates in male and female patients were still 11.0% (8.3-13.7%) and 9.0% (7.1-10.9%), respectively, after 5 years and did not approach zero until 10 years after the diagnosis. Men older than 75 showed a slightly higher mortality during the first year, but there were seemingly no relationships of tumor-biological or clinical significance between age at diagnosis and long-term relative survival. The overall prognosis remained unchanged during the 19 years of the study, whereas the incidence was reduced by about 40% in the whole Swedish population.

Advanced gastric cancer and prognosis

The morphological features of 158 gastric carcinomas were analyzed in an attempt to identify patterns best correlated with prognosis. To this end, the depth of infiltration, vascular invasion, intra- and perineoplastic lymphocytic infiltrate, lymph node metastases and number of metastatic lymph nodes were evaluated according to the several classifications for advanced gastric cancer. A good correlation between prognosis and histological features of malignancy were observed, as well as different five-year survival rates for Mulligan, Lauren and Ming histotypes. However, when the influence of each single morphological criteria of malignancy was examined, these differences disappeared for Mulligan and Lauren histotypes. On the other hand, the better prognosis for Ming expanding type carcinomas appeared unrelated to any individual feature of malignancy.

Incidence and prognosis of N4 node involvement in gastric cancer

We have undertaken a prospective study of the frequency and prognosis associated with N4 node metastases in gastric cancer in 136 patients referred for surgical treatment between 1976 and 1983. N4 node metastases (pre-aortic or hepatic hilar nodes) were present in 20 of 31 patients who had a laparotomy without resection (64 per cent), in 2 of 8 patients who had a 'palliative' resection in the presence of distant metastases (25 per cent) and, in 19 of 85 patients who had a 'curative' resection (22 per cent). The median survival in patients having a 'curative' resection with N4 nodes was 4.5 months which was only marginally longer than in patients having a 'palliative' resection (median survival 3 months). In view of these findings and since immediate imprint cytology can be used to detect nodal metastases at operation, involvement of N4 nodes might be a contra-indication to extensive gastric resection in non-obstructing gastric cancer.

[Immunologic significance of the inflammatory stromal reaction in malignant tumors]

In an investigation of correlation and factor analysis the relations between cell-mediated stromalreactions and immunological parameters are checked in 63 patients with malignant tumours. The stromalreaction is determined semi-quantitatively as a cell-mediated infiltration of the tumour by neutrophiles, lymphocytes, plasma cells and macrophages. In regard to immunological parameters circulating immuncomplexes, K-cell-activity, auto-antibodies, B- and T-cells and immunglobulins are determined among others. It is shown that the stromalreaction is to be regarded as a part of an immunological answer of the organism against the tumour.

Changes in the location and type of gastric adenocarcinoma

To document our impression of major changes in aspects of gastric adenocarcinoma, we reviewed and compared 62 consecutive cases from 1975 through 1978 and 31 cases from 1938 through 1942. The average age at diagnosis increased from 58 to 68 years, the male to female ratio decreased to approximately 1:1, and carcinomas composed predominantly (50% or more) of signet-ring cells (SRC) increased from 9 to 39% of the total cases. In the recent series, carcinomas with SRC (compared with those without SRC) occurred nine years earlier, were more frequent in women, were located distally, and had an infiltrative growth pattern. Carcinomas originating in the proximal stomach (cardia) were not noted in the old series but formed 27% of the recent cases. These tumors showed a male predominance, contained SRC less often, and were less commonly associated with chronic gastritis. The implications of these observations are discussed.

The small blood vessels in areas of lymphocytic infiltration around malignant neoplasms

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Surgical management of gastric carcinoma. Follow-up results in 465 consecutive cases

A retrospective study was made of a consecutive series of 465 patients with histologically proven gastric carcinoma operated on from December 1950 to December 1974. There were 352 men and 113 women, for a male-female ratio of 3.1 to 1. The peak age of incidence was 51 to 55 years. Noncurative surgical procedures were performed in 49.5 percent with no 5 year survivors; 50.5 percent had curative gastric resection. The ulcerating type was the most common lesion, and the pylorus and antrum were the most common primary sites of tumor. Applying the TNM pathologic stage grouping, the study revealed that 3.4 percent of the patients with curative resections were in stage I, 25.5 percent were in stage II and 71 percent in stage III. The 5 year survival rate was 100 percent for stage I, 70 percent for stage II and 20 percent for stage III. Eighty-four patients or 35.7 percent of those with curative gastric resection survived 5 years or longer. The operative mortality was 3.5 percent for the group with noncurative surgical procedures and 2.1 percent for the group with curative gastric resections, giving an overall operative mortality of 2.8 percent for the entire series.

Plasma protein profiles and prognosis in gastric cancer

In 104 patients with gastric cancer the serum proteins carcinoembryonic antigen (CEA), C-reactive protein (CRP), alpha 1-acid glycoprotein (AGP) (orosomucoid) and alpha 1-antichymotrypsin (ACT) were measured pre-operatively. The estimated median survival of patients with both raised CEA and ACT was only 5 weeks in contrast to 64 weeks for those with both proteins normal. An intermediary group with one of these proteins raised and the other normal had an estimated median survival of 15 weeks. Similar results were obtained by considering a combination of CEA with either AGP or CRP. For these data the results were not explicable in terms of associations between survival time and patient's age, stage, operative procedure, histological classification or site of primary tumour.

Adenocarcinoma of the stomach: areas of failure in a re-operation series (second or symptomatic look) clinicopathologic correlation and implications for adjuvant therapy

Following initial "curative" operative procedures for gastric carcinoma, 107 patients had planned single or multiple re-operations at the University of Minnesota. Later evidence of cancer was found in 86 patients at re-operation and/or other follow-up. Initial operative-pathologic extent of disease was correlated with incidence and patterns of failure. Distant metastasis (DM) alone was uncommon, but was found as a new component in 25.6% of the failure group. Nearly half of the peritoneal failures (PS) were localized, and when diffuse, were usually accompanied by a moderate sized local-regional failure. Local recurrence and/or regional lymph node metastasis (LF-RF) occurred as the only failure in 53.7% of the failure group if localized peritoneal failures were included, and as any component of failure in 87.8% (67.3% of the total 107 patients). Operation alone yields inadequate results for the majority of patients with gastric carcinoma. The rationale of adjuvant radiation and systemic therapy alone or in combination is discussed.

The biological behaviour of gastric cancer

A characterisation of the biological behaviour of gastric carcinoma was attempted by relating the histological classification to the mean number of metastases for each case (metastatic index). The material was chosen from a consecutive series of 294 gastric cancer autopsies in which only conservative therapy had been given or in which the cancer was first diagnosed at autopsy. According to the extent of metastasis it was possible to divide the nine histological types into two groups of limited invasiveness and generalised invasiveness. Unfavourable biological behaviour of the cancer was determined by the presence of the latter group of histological types in the primary site even in cases where this histological type formed the minor component of the tumour. The variation in histology within the primary tumour and between the primary site and the metastatic sites was related both to histological affinities and to the metastatic index associated with the primary site histology. It is suggested that this dual classification system adds significantly to our understanding of the natural history of gastric cancer.

A prospective trial of 5-FU and BCNU in the treatment of advanced gastric cancer

This study was undertaken to investigate the efficacy of a combination of 5-FU and BCNU in the treatment of advanced gastric cancer. Patients whose cancer was recurrent following surgery or in whom surgery was deemed inappropriate were entered in the study and given the two-drug combination at six-weekly intervals until either death or clear progression of disease occurred. Five of twenty-eight patients had unequivocal regression of their disease. The early optimism for this form of therapy in advanced gastric cancer is not supported by this study.

Immunological significance of lymphoreticular infiltration in gastrointestinal cancer

The 60 patients of gastrointestinal cancer comprising this study were in the age range of 29--70 years with 39 males and 21 females. The primary sites of cancer were: gallbladder 19, colon 13, stomach 12, anorectum 8, and liver 8. The stage of tumor spread was localized in 32 and metastatic in 28 cases. Round cell infiltration scores were classified semiquantitatively from O-V. Cellular immunity as expressed by the blood lymphocyte count and DNCB reactivity was also studied. Round cell infiltration was dense in the localized group (P less than 0.0005). The mean lymphocyte counts in all the primary sites of gastrointestinal cancer were significantly higher in the localized group as compared to metastatic group. The DNCB reactivity showed anergy in six cases and poor response in the remaining 22 cases of metastatic group. There was a statistically significant correlation between lymphoreticular infiltration, peripheral blood lymphocyte count, and the DNCB reactivity. Diminished round cell infiltration, lymphopenia, and depressed DNCB response indicate an advanced stage of gastrointestinal cancer.

Selection of operative procedure for adenocarcinoma of the midstomach. Twenty years' experience with implications for future treatment strategy

Pathoanatomic studies of the regional spread of adenocarcinoma of the middle one-third of the stomach suggested the need for extensive gastric and lymphatic resection. To seek evidence of improved results, a retrospective study was made of 213 patients curatively treated by three commonly used procedures: 1) radical high subtotal gastrectomy (SG, n = 39), 2) radical total gastrectomy (TG, n = 48), and 3) extended total gastrectomy (ETG, n = 126). The overall five-year survival rates were SG:10%, TG:16%, and ETG:19%. Advanced stage tumors (N2, N3, or M1) were highly lethal, irrespective of the type of resection. However, patients with early stage tumors (T1-4, N0 or N1) showed higher survival rates after more extensive resections (ETG:42% and TG: six of eight patients, versus SG:17%). The highest survival rate (93%) was observed in a subset of patients with early stage tumors electively treated by ETG; this was achieved despite the presence of metastasis to the juxtagastric (N1) lymph nodes or direct invasion of an adjacent organ in most of these patients. These observations confirm the merit of extensive resection for carcinoma of the midstomach.

Adenocarcinoma of the gastric cardia. The choice of gastrectomy

A retrospective study of 101 patients with adenocarcinoma of the gastric cardia treated with proximal subtotal, extended proximal subtotal, total, and extended total gastrectomy demonstrated the following: 1) There were no five year survivors among patients with TNM stage III and IV disease. 2) Surgical treatment was curative only in the presence of stage I and II disease, where extended total gastrectomy resulted in a significantly higher survival rate than proximal subtotal gastrectomy (p less than 0.03). 3) Proximal subtotal gastrectomy resulted in a high incidence of local recurrence, particularly when it was applied in patients with stage I and II neoplasms. 4) There were no significant differences in operative mortality between the four procedures. Since the choice of operative procedure makes a difference only in patients with TNM stage I and II disease, intraoperative classification should be considered in the management of adenocarcinoma of the cardia. Classification should be based on lymph node biopsy unless the neoplasm has spread beyond the confines of gastrectomy.

Incorporation studies of nucleic acid precursors in gastric cancer: an attempt in individualized chemotherapy

Measurements of the rate of incorporation of radioactively labeled nucleic acid precursors into the DNA and RNA of gastric carcinoma cell suspensions indicated variable rates of proliferation for the tumors. The rate of incorporation generally correlates to the cytological level of differentiation of the carcinoma. Reduced differentiation of the tumors showed a corresponding increase in the rate of proliferation. Knowing the proliferation-dependent effect of most cytostatica, this results in a resistance to cytostatica of highly differentiated gastric cancers. The nucleic acid synthesis of proliferatively active tumors could only be partially inhibited by the cytostatica tested (5-fluorouracil, adriamycin). Carcinomas with metabolic possibility for compensation of the active mechanism of the cytostatica were biochemically resistant. Due to the resulting methodical problems and unaccountable patient-dependent causes of resistance, a conclusive statement about cytostatica-sensitive tumors is difficult to make in incorporation studies.

Chemotherapy in advanced gastric cancer: a controlled, prospective, randomised multi-centre study

Seventy-six patients with advanced gastric adenocarcinoma were studied in a prospecitive, randmoised, controlled trial using vincristine, methotrexate, cyclophosphamide, and 5-fluorouracil in an initiation course and mitomycin-C with 5-fluorouracil as maintenance therapy. Thirty-seven patients were inoperable and 39 had the primary tumour resected with histological evidence of residual disease. Survival in the inoperable group was short and showed no significant difference between treated and control patients. The median survival times for treated and control groups were 9.5 and 9.0 weeks respectively. In the resected patients there was no difference in ultimate overall survival between the groups but up to 20 weeks there was a suggestion that the probability of survival in treated patients was higher (P = 0.06). The patients were well-matched and it is concluded that chemotherapy has had an early effect but that a further trial with more detailed stratification, particularly of staging and histological grade, is needed. No patient received treatment for longer than two years and unacceptable toxicity occurred in only two patients. Nausea occurred more frequently in the treated group but was short-lived and clinically manageable.

Clinical correlates of resectability and survival in gastric carcinoma

The course of 201 patients with carcinoma of the stomach treated from 1962 through 1966 was followed with 97% determinacy for 10 years. The actual five year survival rate was 11%; the ten year rate was 7%. The mean duration of survival was 5.8 +/- 2.7 (S.D.) months. These results were similar to those reported for the period 1922-1926. Survival was strongly correlated with the surgeon's assessment after exploration. All patients alive after five years had operations thought to be curative, usually partial gastrectomies; the survival rate of this group was 24%. Gastroenterostomy was ineffectual palliation. Better results will require nonsurgical adjuncts, since the correlates of survival are those of minimally invasive cancer.

Host response and tumour biological behaviour in the two histological types of gastric carcinoma

It appears that there is validity in categorizing gastric carcinoma into two histologic types, intestinal and diffuse. The local host tissue response in 92.5% of cases of the intestinal type of gastric carcinoma was of an exudative nature. Diffuse gastric carcinoma in 70% of cases incited a dense productive fibrosis. Pools of mucin and large number of 'signet-ring' cells were mostly encountered in the intestinal type of carcinoma. Applying Dukes' parameters the tumour was found to be more than three times more invasive in cases of diffuse carcinoma. The prognostic bearing of the two histologic types, different host tissue response, behaviour of the tumour in terms of mucous production and local extension are discussed and it is suggested that diffuse gastric carcinoma carries a worse prognosis than the intestinal type. Study of a larger series of cases and longer follow-up with controlled treatment is essential to confirm this assessment.

Adenocarcinoma of the oesophagus and of the oesophagogastric junction

The clinical and pathological features of 52 adenocarcinomas invading the oesophagus and the oesophagogastric junction are reviewed. The relationship of these tumours to the presence of a concomitant hiatal hernia and the histogenesis of primary oesophageal adenocarcinomas are discussed. Adenocarcinomas of the cardio-oesophageal junction appear to have distinctive prognostic and pathological features and there may be a case for their classification into a separate category of alimentary neoplasms.

[Surgery of gastric cancer in patients older than 70 years (author's transl)]

In this study it is reported about operative mortality and long-term results of surgery of gastric carcinoma in patients over the age of 70 years. The operative mortality in 50 patients with a distal partial gastrectomy was 16%, the mortality in 24 patients with total gastrectomy was 33.3% and in 14 patients with a proximal gastrectomy the mortality was 28%. The main cause of death (40%) was a pneumonia. There was no correlation between frequency of pneumonia and preoperative results of measurement of lung function. Only advanced arteriosclerotic disease in the heart and brain has a fatal influence on mortality rate. In the old patients the long-term results are determined by the staging of the tumor at the time of operation, too. In the 60 patients, who had left the hospital and who are in our control, the half year survival rate was 78.3%, the 1-year survival rate was 58.3% and the 2-years survival rate is exceeding 41.6%. 14 patients of the 17, who are still alive and who are after 2 1/2 years again explored, are in a very good condition. In comparison with the literature it is to conclude that for the indication to surgery of gastric carcinoma there is important not only the real age of the patient but rather the biological and mental condition of the patient.

Total gastrectomy

Total gastrectomy is indicated principally for Zollinger-Ellison syndrome and for potentially curable gastric cancer. The diagnosis of cancer should be verified by biopsy before the resection is performed, and the margins of resection should usually be examined by frozen section. Of the various reconstructions, Roux-en-Y esophagojejunostomy gave the best long-term results.

Gastric carcinoma. A pathobiological classification

Gastric carcinomas had various pathological features. Based on patterns of growth and invasiveness, however, they fell into two types; expanding type and infiltrative type. These types were readily recognizable histologically: expanding carcinomas grew en masse and by expansion, resulting in the formation of discrete tumor nodules, whereas in infiltrative carcinoma tumor cells invaded individuality. Both types showed varying degrees of cell maturation, but glands were much more common in expanding carcinoma. The difference in growth pattern was reflected partly by gross appearance of the tumors. These two types of carcinoma appeared to be different in their histogenetic origins. Intestinal metaplasia probably played a role in the development of expanding, but not infiltrative, carcinoma. There were differences also in the sex and age of the patients, survival rate, and epidemiological distribution. Thus, this classification provided a simple basis for evaluation of various aspects of gastric cancer.

Cancer of the stomach: a review of 854 patients

A review is presented of 854 patients suffering from cancer of the stomach who attended St Bartholomew's Hospital between 1948 and 1962. The presentations and methods of investigations showed little change over the 15-year period, which is similar to other large series. The symptoms of anaemia and indigestion appear to be paramount in making an early diagnosis, and negative barium meal studies should not be accepted when these two symptoms are present. There are indications that early laporotomy and a more aggressive surgical approach may increase the 5-year survival rate.

Cancer prognosis predicted by preoperative lymphocyte responsiveness in vitro

The prognosis in cancer patients was studied in relation to their preoperative cell-mediated immune status. Thirty patients with various types of operable cancer were studied. Transformation of the lymphocytes in response to phytohaemagglutinin (PHA) in vitro was measured preoperatively. All the patients were followed up for 3 years. Those with normal preoperative lymphocyte responsiveness had a far better prognosis than those in whom this test was subnormal.

Morphological observations of immunobiology of laryngeal cancer. Evaluation of the defensive activity of immunocompetent cells present in tumour stroma

A series of 104 patients with squamous cell carcinoma of the larynx was studied with regard to tumour-host interaction. Prognostic evaluation was based upon histologic grading and morphological evidence of host immune response, judged by the presence and degree of lymphocyte and plasma cell infiltration in tumour stroma. Histologic grade and lymphoplasma-cellular infiltration do correlate with the 5-year survival. The immune response, however, seems to be a favourable prognostic sign only for well differentiated tumours; in our series, all poorly differentiated neoplasms showed minimal or no cellular response. The survival rate increases with the increasing intensity of cellular response within each class of tumour cell differentiation. Small lymphocytes are the basic elements of cell-mediated immune response. After tumour antigenic stimulation they change into immunoblasts which in turn would produce "committed" lymphocytes which would recognize and destroy tumour cells.