Improving results in the treatment of gastric cancer: an 11-year audit

Loss of Ep-CAM (CO17-1A) expression predicts survival in patients with gastric cancer

Preoperative staging of gastric cancer is difficult and not optimal. The TNM stage is an important prognostic factor, but it can only be assessed reliably after surgery. Therefore, there is need for additional, reliable prognostic factors that can be determined preoperatively in order to select patients who might benefit from (neo) adjuvant treatment. Expression of immunohistochemical markers was demonstrated to be associated with tumour progression and metastasis. The expression of p53, CD44 (splice variants v5, v6 and v9), E-cadherin, Ep-CAM (CO17-1A antigen) and c-erB2/neu were investigated in tumour tissues of 300 patients from the Dutch Gastric Cancer Trial, investigating the value of extended lymphadenectomy compared to that of limited lymphadenectomy). The expression of tumour markers was analysed with respect to patient survival. Patients without loss of Ep-CAM-expression of tumour cells (19%) had a significantly better 10-year survival (P<0.0001) compared to patients with any loss: 42% (s.e.=7%) vs 22% (s.e.=3%). Patients with CD44v6 (VFF18) expression in more than 25% of the tumour cells (69% of the patients) also had a significantly better survival (P=0.01) compared to patients with expression in less than 25% of the tumour cells: 10 year survival rate of 29% (s.e.=3%) vs 19% (s.e.=4%). The prognostic value of both markers was stronger in stages I and II, and independent of the TNM stage. Ep-CAM and CD44v6-expression provides prognostic information additional to the TNM stage. Loss of Ep-CAM-expression identifies aggressive tumours especially in patients with stage I and II disease. This information may be helpful in selecting patients suitable for surgery or for additional treatment pre- or postoperatively.

CDH1 associated gastric cancer: a report of a family and review of the literature

AIMS

Hereditary diffuse gastric cancer (HDGC) is an autosomal-dominant inherited form of gastric cancer associated with inactivating germline mutations in the CDH1 gene. We set out to outline the role of CDH1 in HDGC. Investigation of a family suspected as having HDGC is discussed. The role of surgery in the management of affected individuals is then examined.

METHODS

A search was conducted of Medline and the National Library of Medicine to identify key articles concerning CDH1 gene mutations, familial gastric cancer and gastrectomy. Further, relevant articles were obtained by manual scanning of the reference lists of identified papers. Mutation-specific CDH1 genetic testing was performed on six living family members and on gastric tissue obtained from two deceased members.

RESULTS

CDH1 mutations cause inactivation of the cell adhesion protein E-cadherin. Carriers of the CDH1 germline gene mutation develop an aggressive, diffuse, submucosal gastric cancer at an early age. Current endoscopic screening is ineffective at detecting HDGC. The presence of a CDH1 germline gene mutation was confirmed in both deceased family members and also in four of the six living members tested.

CONCLUSION

Genetic counselling and CDH1 gene mutation testing is indicated in families with suspected HDGC. In the absence of a satisfactory surveillance mechanism, prophylactic total gastrectomy would appear to be an appropriate therapeutic option in mutation carriers.

Trends in oesophago-gastric surgery in Scotland

BACKGROUND

The last twenty years have seen significant changes in both the incidence and treatment of gastro-oesophageal disorders as well as a process of subspecialisation in general surgery. The aim of this study is to identify the changes in gastro-oesophageal surgery in Scotland during this period.

METHODS

A retrospective analysis of three years of data, taken over a 20-year period (1977, 1987 and 1997) obtained from the Information and Statistics Division of the Scottish National Health Service, examining the number of patients with oesophageal cancer, gastric cancer and gastro-oesophageal reflux disease (GORD) treated by general and thoracic surgeons.

RESULTS

There was a significant increase (p=0.001, chi2) in the number of patients with oesophageal cancer (2.52-fold) and gastric cancer (1.4-fold) treated by general compared with thoracic surgeons. Since 1977, the overall operability for oesophageal cancer has remained unchanged, while a significant decrease in the overall operability of gastric cancer was noted (p<0.001, chi2). There was a 3-fold increase in the incidence of GORD with a significant increase (p<0.001, chi2) of those treated surgically. Since 1977, there has also been a significant shift of workload from thoracic to general surgical units.

CONCLUSIONS

Scotland has seen a consistent increase in the surgical workload generated by gastro-oesophageal malignancies over the last three decades without any improvement in the operability rate. Surgically treated GORD has also increased, probably due to the introduction of minimally invasive techniques. These trends have implications on healthcare planning, resource allocation and surgical training. Appropriate resources and trainees should follow the patients to those units carrying out this activity. Further centralisation of these services is likely to follow.

Prognostic factors after curative resection for gastric cancer. A population-based study

The aim of this study was to document patterns of survival after resection for cure for gastric cancer in a well-defined population. A population-based series of 649 gastric cancers resected for cure between 1976 and 1995 in a 494000 population, was used. Resection for cure was performed in 44.4% of the diagnosed cases. This proportion increased from 36.8% (1976-1979) to 45.0% (1992-1995) (P=0.03) whilst operative mortality decreased from 18.3 to 12.7% (P=0.003). The overall crude 5-year survival rate (excluding operative mortality) was 32.6% (95% confidence interval (CI) 28.7-36. 5) and the corresponding relative survival rate was 40.9%. Prognosis did not improve during the study period. Stage at diagnosis was the most important prognostic factor, the 5-year relative survival rate being 81.2% (+/-5.9) in TNM stage IA, 76.9% (+/-8.0) in stage IB, 50. 4% (+/-4.6) in stage II, 24.4% (+/-3.7) in stage IIIA, 5.6% (+/-3.2) in stage IIIB and 5.2% (+/- 2.2) in stage IV. Stage at diagnosis, age, subsite and macroscopic type of growth were independent prognostic factors, in a multivariate relative survival model. Earlier detection or development of an effective adjuvant therapy could contribute to improvement in prognosis.

Chemotherapy for operable gastric cancer: results of the Dutch randomised FAMTX trial. The Dutch Gastric Cancer Group (DGCG)

The aim of this trial was to investigate whether pre-operative chemotherapy leads to a 15% higher curative resectability rate in patients with operable gastric cancer. In this randomised trial, patients were allocated to receive either four courses of chemotherapy using 5-fluorouracil, doxorubicin and methotrexate (FAMTX) prior to surgery or to undergo surgery only. Patients younger than 75 years of age with a good physical and mental condition and a histologically proven adenocarcinoma of the stomach without clinical or radiographic (computed tomography scan) evidence of distant metastases were eligible for this trial. Early gastric cancer or cardia carcinoma were excluded. The response to chemotherapy was evaluated after two and four courses. In case of progressive disease (PD) after two courses, patients were operated upon as soon as possible. Otherwise complete response (CR) partial response (PR) or stable disease (SD), two more courses were scheduled. The standard surgical procedure was a limited lymphadenectomy (D1) with staging biopsy of the para-aortic lymph nodes. Between September 1993 and February 1996, 56 eligible and evaluable patients were entered: 27 were randomised to receive FAMTX before surgery and 29 to undergo surgery only. In the FAMTX + surgery treatment group, 15/27 (56%) had curative resections versus 18/29 (62%) in the surgery only arm. There was no difference in the frequency of TNM stages I + II in both treatment arms: 15/27 versus 15/29. Due to PD and/or toxicity, 12 patients (44%) could not complete the planned four courses of FAMTX. Response evaluation after chemotherapy was possible in 25 patients: 2 CR, 6 PR, 8 SD and 9 PD. The difference in curative resectability rate was 6.5% (95% confidence interval -32 to +19%) in favour of surgery only. Downstaging for stages I + II did not occur. PD was more often the reason for not completing the planned four courses than toxicity. More active regimens than FAMTX are required for future randomised trials.

No survival benefit from combined pancreaticosplenectomy and total gastrectomy for gastric cancer

BACKGROUND

It remains unknown whether extended surgery improves the survival rate of patients with gastric cancer. This study was a review of combined pancreaticosplenectomy with total gastrectomy for gastric cancer.

METHODS

The clinicopathological details of 190 patients who underwent combined pancreaticosplenectomy with total gastrectomy between 1969 and 1996 were compared retrospectively with those of 206 patients who underwent total gastrectomy with splenectomy alone.

RESULTS

There was no statistical difference in the survival rate when pancreaticosplenectomy was added to total gastrectomy. The mortality rate was similar, but the morbidity rate was higher in patients who had pancreaticosplenectomy. Six patients who had direct pancreatic invasion and two thought to have involved lymph nodes along the splenic artery survived for more than 5 years after operation. In the latter group, the metastatic lymph nodes along the splenic artery could have been resected without pancreatectomy.

CONCLUSION

Since a combined pancreaticosplenectomy adds no survival advantage to total gastrectomy for gastric cancer, this procedure should no longer be regarded as routine.

Perigastric lymph node status as a prognostic indicator in patients with gastric cancer

BACKGROUND

The extent of lymph node dissection and histological examination of dissected lymph nodes varies among countries, which leads to the erroneous nodal stage and different surgical results in gastric cancer (stage migration, 'Will Rogers effect'). The aim of this study was to clarify the prognostic significance of the number of positive perigastric lymph nodes, which could be evaluated simply after D1 gastrectomy.

METHODS

A consecutive series of 106 patients with histologically node-positive gastric cancer treated by radical gastrectomy and lymph node dissection (D2 or D3) was studied. The number of metastatic perigastric nodes (level I, nos 1-6) was examined, and its influence on the survival of patients was analysed.

RESULTS

The overall 5-year survival rate was 50.9 per cent; the 5-year survival rate was significantly decreased when positive perigastric nodes exceeded six (62 per cent for one to six nodes versus 23 per cent for seven or more nodes, P< 0.001). Tumours having one to six positive perigastric nodes compared with those having seven or more positive perigastric nodes were more likely to have a size less than 4 cm (29 per cent versus one of 30, P< 0.001), grossly localized type (45 per cent versus seven of 30, P=0.042), absence of serosal invasion (32 per cent versus none of 30, P=0.002) and metastasis limited to the perigastric lymph nodes (70 per cent versus seven of 30, P < 0.001).

CONCLUSION

The results indicate that the number of positive perigastric nodes correlates with tumour progression and patient survival. This parameter is a simple and useful prognostic indicator for node-positive gastric cancer, and is available not only for D2 and D3 gastrectomy but also for D1 gastrectomy.

Screening for gastric cancer by Helicobacter pylori serology: a retrospective study

BACKGROUND

Screening by serology for Helicobacter pylori in young dyspeptic patients has been shown to be effective in reducing demand for endoscopy. H. pylori has been implicated in the causation of gastric cancer and the reported seropositivity rate in patients with gastric cancer ranges from 69 to 94 per cent. The aim of this study was to assess the potential value of Helicobacter antibodies as a method of selecting dyspeptic patients over the age of 45 years for endoscopy.

METHODS

A retrospective comparison of the antibody status to H. pylori was made between 154 patients with gastric cancer and a sex- and date of birth-matched dyspeptic control group. Results from the former group were correlated with demographic data and tumour characteristics.

RESULTS

Significantly more patients with gastric cancer were seropositive than controls (77 versus 66 per cent). H. pylori was not related to the Laurén classification of the tumour. Tumour site was significant: body and antrum tumours were associated with Helicobacter whereas cardial tumours appeared to be unrelated.

CONCLUSION

Screening by antibody assays to H. pylori would miss more than 30 per cent of current gastric cancers. The increasing incidence of cardial cancer would cause this percentage to rise in the future.

Expression of oncoproteins and the amount of eosinophilic and lymphocytic infiltrates can be used as prognostic factors in gastric cancer. Dutch Gastric Cancer Group (DGCG)

Preoperative staging of gastric cancer is difficult. Several molecular markers associated with initiation and progression of cancer seem promising for obtaining preoperative prognostic information. To investigate whether these markers are indicative especially for the presence of lymph node metastases in patients with gastric cancer, we have examined primary tumour specimens from 105 patients with primary adenocarcinoma of the stomach entered in a surgical trial. In this trial, lymph node status was determined by strictly quality-controlled lymph node dissection and examination. The selected markers were growth regulators (p53, Rb and myc), metastasis-suppressor gene product (nm23), adhesion molecules (Ep-CAM, E-cadherin, CD44v5 and CD44v6) and urokinase-type plasminogen activator (u-PA). Also, the amount of eosinophilic and lymphocytic infiltrates available post-operatively was analysed with respect to its prognostic value for lymph node status. Moreover, the association of these parameters with survival and disease-free period (DFP) was evaluated. Of all molecular markers investigated, only Rb expression had a significant association with the presence of lymph node metastasis in both univariate and multivariate analysis. For curative resectability, a significant association was found with Rb and E-cadherin expression, while in multivariate analysis Rb and myc were selected as the combination with additional independent prognostic value, and E-cadherin had no additional independent value. For overall survival in univariate analysis, the amount of both eosinophilic and lymphocytic infiltrates and Rb and myc expression were of significant prognostic value. Only the amount of lymphocytic infiltrate had a prognostic significance for DFP. In stepwise multivariate analysis, TNM stage (I + II) and marked lymphocytic infiltrate were associated with better overall survival and longer DFP. We conclude that, if these results are confirmed in a larger series of patients, molecular markers can provide useful prognostic information.

Prognostic value of the plasminogen activation system in patients with gastric carcinoma

BACKGROUND

Patients with gastric cancer have a poor prognosis and can be cured by surgery only if the cancer is detected in an early stage. Extended surgery, down staging with chemotherapy before operation, and new postoperative treatments are recent approaches to increase survival rates. Categorizing patients' prognoses as good or poor by pathophysiologic markers, however, may be of great help in selecting therapies for these patients. For example, plasminogen activation (PA) parameters, that play an important role in tumor invasion and metastasis, have prognostic value for several human malignancies.

METHODS

We evaluated the relation between several PA parameters in tissue with standard clinicopathologic parameters and with the overall survival of 50 consecutive patients with gastric carcinoma.

RESULTS

Univariate analysis showed that a low tissue-type plasminogen activator (t-PA) activity in normal mucosa and in carcinomas and a high antigen level of inhibitor type-1 (PAI-1), and, to a lesser extent, of urokinase-type plasminogen activator (u-PA) receptor, in carcinomas are associated with a poor overall survival of the patients. In contrast, of the 14 clinicopathological parameters only the number of eosinophils in the tumors was associated with survival. Multivariate analysis revealed that the t-PA and PAI-1 levels are independently associated with survival.

CONCLUSIONS

Plasminogen activation parameters in both normal and carcinomatous tissue of the stomach of patients with gastric carcinoma are of particular clinical interest because of their prognostic impact on overall survival.

Prognostic value of resection-line involvement in patients undergoing curative resections for gastric cancer

Prognostic value of microscopical resection-line involvement of the proximal and distal resection lines was examined in patients undergoing potentially curative resection in a multicentre trial with strict quality control. Tumour-positive resection lines were seen in 41 of the 699 evaluable patients (5.9%). Resection-line involvement was associated with T stage (P < 0.001), N stage (P = 0.003), tumour location (P < 0.001) and tumour differentiation (P < 0.001). Presence of resection-line involvement was also associated with significantly worse survival. Together with T3 and T4 stage (relative risk (RR) 2.04), N(+) stage (RR 4.02) and tumour differentiation (RR 1.33), resection-line involvement (RR 2.28) was also an independent prognostic factor for survival. Survival in patients with resection-line involvement was comparable with patients with positive cytology. In patients undergoing potentially curative resection for gastric cancer, peri-operative frozen-section examination should be mandatory, especially in those with poorly differentiated, signet ring cell or anaplastic tumours, with tumours covering the entire stomach and T3 or T4 tumours. In case of tumour-positive margin(s) at final histology, re-laparotomy could be considered if achieving tumour-free resection lines seems realistic.

A 10-year experience with Japanese-type radical lymph node dissection for gastric cancer outside of Japan

BACKGROUND

The prognosis for surgically treated gastric cancer remains poor in most Western countries compared with reports from Japanese investigators during the past 3 decades.

METHODS

A radical surgical procedure principally to extended lymphadenectomy as defined by the Japanese Research Society for Gastric Cancer was performed prospectively from January 1984 to June 30, 1994 for 512 patients with gastric cancer, 345 of whom were treated with potentially curative surgery. Clinical, histopathologic, and surgical factors were examined for their influence on long term survival by univariate and multivariate analyses.

RESULTS

Five- and 10-year survival rates for all patients were 40.5% and 34.3%, respectively, and for patients who underwent tumor resection were 45.7% and 38.6%, respectively. For patients who underwent curative surgery, 5- and 10-year adjusted survival rates were 57.7% and 44.3%, respectively, with a median survival of 96 months. Postoperative hospital mortality was 6.8%:4.9% for R-0 resected patients, 9% for R-1 and R-2 resected patients, and 13.4% for those with palliative procedures. Multivariate analysis using the Cox model identified age older than 65 years, prior total gastrectomy, an increasing number of positive lymph nodes, a high pathologic N classification, male sex, a high pT classification, and low preoperative hemoglobin level as detrimental factors with an independent influence on survival.

CONCLUSION

Radical lymphadenectomy in this 10-year Austrian study yielded survival rates similar to those in Japanese investigations without sacrificing low postoperative mortality. In particular, the relatively high overall survival rates seemed to reaffirm the value of radical lymph node dissection with wide resection margins.

Pathological prognostic factors in the second British Stomach Cancer Group trial of adjuvant therapy in resectable gastric cancer

The second British Stomach Cancer Group trial was a prospective randomised controlled trial of adjuvant radiotherapy or cytotoxic chemotherapy after gastrectomy for adenocarcinoma. It recruited between 1981 and 1986. No survival advantage has been demonstrated for the patients receiving either type of adjuvant therapy compared with those undergoing surgery alone. We report on 436 patients randomised into the trial together with 203 patients, who did not fulfil the trial criteria, referred to the trial. A univariate (log-rank) analysis of pathological factors obtained from the local referring centres showed that tumour size, macroscopic type, number os sites involved, depth of invasion, involvement of resection lines and lymph nodes and histological grade were significant determinants of survival. Histological review by two experienced histopathologists found that the Lauren classification and histological grade, but not the Ming classification, were significant prognostic factors. The degree of lymphocytic and eosinophilic infiltration and presence of dysplasia assessed by one of the pathologists showed a significant correlation with survival. However, inter-observer correlation for these histological parameters and grade was poor. Multivariate analysis identified only depth of invasion, resection line and nodal involvement as significant independent pathological variables influencing survival. This study confirms the need for expert preparation of the resected specimen to obtain the important information on depth of invasion and nodal status and also reveals some variation in histological assessment, particularly grading, in gastric carcinoma.

Preservation of the spleen improves survival after radical surgery for gastric cancer

One hundred and ninety five consecutive, potentially curative resections for adenocarcinoma of the stomach were performed in one surgical department between 1970 and 1989: 76 patients underwent gastrectomy with splenectomy and 119 gastrectomy without splenectomy. Operative mortality was 12% after gastrectomy with splenectomy, but only 2.5% after gastrectomy without splenectomy (p < 0.05). Postoperative complications were also significantly more common when splenectomy was combined with gastrectomy (41% v 14%, p < 0.01). Cumulative five year survival was 45% after gastrectomy with splenectomy, compared with 71% after gastrectomy alone (p < 0.01). When the results of the two groups of patients were compared, stage for pathological stage, no evidence was found that splenectomy improved survival. Application of Cox's proportional hazards model, which makes allowance for other variables such as the T and N stages, showed that splenectomy had an adverse influence on patients' survival. Splenectomy does not benefit the patient and its routine use in the course of radical resections for carcinoma of the stomach should be abandoned.

Gastric cancer in Iceland: a retrospective study of resected gastric specimens in a high-risk country during 30 years (1960-1989)

The world-wide incidence of gastric cancer is decreasing, especially in high-risk populations such as the Icelanders. We examined retrospectively 1,040 specimens of resected gastric cancers from a 30-year period, 1960-1989. The decrease in incidence in both sexes involved mainly the largest histological group, the intestinal-type tumours. In males there was also a decrease in diffuse tumours but in females these remained relatively unchanged. Tumours of the antrum and the corpus decreased in both sexes. In males there was a significant increase in tumours of the cardia and most of these were of the intestinal type. In females there was a minor increase in tumours of the cardia, all of which were of the intestinal type. An increase in incidence of tumours of the cardia concomitant with a decrease in incidence of tumours in other parts of the stomach suggests a difference in aetiological factors. The death risk for patients with tumours of the cardia was 59% higher than that for those with tumours in other parts. The death risk following gastric resection was not significantly different when patients with intestinal-type tumours and diffuse tumours were compared.

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

BACKGROUND

About half the patients involved in the current study were born outside of the United States. Epidemiologic and histologic features and survival estimates were compared with persons born in the United States. Results of gastrectomy with lymph node dissection were studied.

METHODS

Records of 187 patients with adenocarcinoma of the stomach were reviewed. Seventy-six with a curative gastrectomy were staged retrospectively. Univariate and multivariate analyses were done.

RESULTS

Seventy-six percent of histologically reviewed curative resections had the intestinal subtype with the same frequency in U.S.-born and foreign-born patients. Fewer patients with proximal third lesions were foreign born. Thirty-six percent had complications. The overall 5-year Kaplan-Meier survival estimate was 46%: 77% for patients with negative nodes and 33% for patients with positive nodes. N1 survival estimate was 44%; N2, 25%; N3(M1), 0%. All six patients with early gastric cancer are alive 50-147 months after surgery. Other stage I patients had estimated survival of 65%; Stage II, 52%; Stage III, 40%; and Stage IV, 0%. Multivariate analysis revealed four significant prognostic variables: nativity, histologic subgroup, presence of complications, and number of positive nodes.

CONCLUSIONS

Proximal gastric cancer was more common in U.S.-born persons. Gastric cancer may be more malignant in U.S.-born persons than in foreign-born persons because their survival was significantly poorer. Complications, a significant adverse factor, were more common in U.S. series. Pancreatectomy with gastrectomy is rarely indicated, because microscopic involvement is rare and complications frequent. The prognostic advantage of a regional lymphadenectomy remains unclear.

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.

Effect of histamine on the growth of human gastrointestinal tumours: reversal by cimetidine

The proliferative effects of histamine were examined on the human gastric tumour cell lines; MKN45, the gastrin producing subline, MKN45G, and the colorectal lines; LoVo and C170. The proliferation of MKN45 as assessed by 75[Se] selenomethionine uptake and cell counts was increased by histamine concentrations of 10(-7) and 10(-9) M. Histamine concentrations between 10(-6) and 10(-7) M maximally stimulated MKN45G proliferation which titrated out at lower histamine concentrations. The accumulation of cyclic adenosine 3',5' monophosphate (cAMP) in response to the same histamine concentrations was also increased in the two gastric cell lines. The histamine receptor antagonist, cimetidine (10(-5) M) reversed the histamine stimulated proliferation of both gastric cell lines despite having no effect on basal growth. The proliferation of the colorectal lines was unaffected by histamine. Histamine given locally at the subcutaneous implantation site of the tumour (1 mg/kg/day) increased the growth of MKN45G xenografts in nude mice. This was reversed by coadministration of cimetidine (100 mg/kg/day, given in the drinking water). Cimetidine also inhibited the basal proliferation of MKN45 xenografts. Histamine acting locally may enhance the proliferation of tumours arising within the stomach. Such effects may be blocked by administration of histamine receptor antagonists, such as cimetidine.

Early gastric cancer: 46 cases treated in one surgical department

Forty six consecutive patients with early gastric cancer were treated between 1970 and 1990. The proportion of cases of early gastric cancer increased significantly (p < 0.01) from 1% of all cases in the first five year period to 15% in the last five year period, because of greater awareness of the condition and more widespread use of endoscopy. There were 33 men and 13 women, of median age 69 years (range 38-86). Most patients (91%) presented with symptoms indistinguishable from those of peptic ulceration. The median duration of symptoms was four months (range 0.1-36 months). All 46 patients were treated surgically. Three patients (6.5%) died after operation and a further 10 (22%) suffered postoperative complications. None of the surviving patients has been lost to follow up and 25 have been followed up for a minimum period of five years. Five year survival by life table analysis was 98%. These findings suggest that in Britain in the 1990s, as in Japan, it may be possible to diagnose an increasing proportion of patients with gastric cancer at a relatively early pathological stage, when most patients can be cured by radical surgical resection with lymphadenectomy.

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.

Extended lymph node dissection for gastric cancer. Is it of value?

The value of extended lymph node dissection for gastric cancer has not been clearly defined. The incidence, staging, and, possibly, the biology of gastric carcinoma in Japanese and Western confound the evaluations of radical lymph node dissection. Surgeons and pathologists must be familiar with the unified international gastric cancer staging system, and careful attention should be given to accurate identification and rigorous examination of regional lymph nodal groups.

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.

Gastric cancer in Scotland: changing epidemiology, unchanging workload

OBJECTIVE

To determine the changes in incidence of and mortality from gastric cancer in Scotland between 1978 and 1987 and in the operative workload in Lothian between 1979 and 1988.

DESIGN

Analysis of national incidence statistics for gastric cancer derived from the Scottish national cancer registry, deaths from gastric cancer recorded by the registrar general for Scotland, and Lothian surgical audit data.

SETTING

Scotland and Lothian Health Board area.

PATIENTS

Patients in Scotland with gastric cancer during 1978 to 1987 inclusive; patients in Scotland with gastric cancer recorded on their death certificate as cause of death during 1978 to 1987; patients who had an operation in Lothian for gastric cancer during 1979 to 1988.

MAIN OUTCOME MEASURES

Changes in incidence of and mortality from gastric cancer in Scotland from 1978 to 1987 and in the number of operations performed for gastric cancer in Lothian from 1979 to 1988.

RESULTS

Mortality from gastric cancer in Scotland fell by about 25% over the 10 years. The incidence and standardised incidence of gastric cancer showed a marginal decline of about 9%. The differences in trends between incidence and mortality were significant (p less than 0.05).

CONCLUSIONS

This study shows that the surgical workload associated with gastric cancer is not declining. This is because the incidence has remained almost static, which may be due to the relative increase in the numbers of older people in the population, who are at greater risk of developing gastric cancer. Gastric cancer should not be regarded as a disease in decline. Incidence and workload should determine resources allocated to this disease rather than mortality statistics.