Prognosis of gastric carcinoma after curative surgery. A population-based study using multivariate crude and relative survival analysis

Parametric Model to Analyse the Survival of Gastric Cancer in the Presence of Interval Censoring

Aims and background

The objective of the study was to assess the impact of prognostic factors on survival of patients with gastric cancer in the presence of interval censoring using parametric models.

Methods and study design

In a retrospective cohort study, 178 patients with gastric cancer were studied from February 2003 to January 2008. Gender, age at diagnosis, distant metastasis, tumor size, histology type, tumor grade, lymph node metastasis and pathologic stage were selected as prognostic and entered in the models. Weibull, exponential, log-logistic and log-normal analyses with interval censoring were performed as parametric models, and Akaike Information Criterion (AIC) was used to compare the efficiency of models.

Results

The risk of death for patients at an older age, with tumor size greater than 35 mm, distant metastasis and advanced stage of disease was statistically higher. Other clinical and demographic factors were not significant. According to AIC, the log logistic model is the most efficient of all the models in multivariable analysis.

Conclusions

The results indicated that the early detection of a cancer at a young patient age and in primary stages is important to increase survival from gastric cancer. According to statistical criteria, a parametric model can also be a useful statistical model to find prognostic factors in the presence of interval censoring. Although it seems that all models in this analysis fit well, AIC supported the log logistic regression as the best option.

Clinical Outcomes after Surgery for Linitis Plastica of the Stomach: Analysis of a Population Cancer Registry

Linitis plastica (LP), a subset of gastric adenocarcinoma (GA), has been considered as a fatal disease with few management options. Little evidence has been reported regarding the role for surgical therapy in treating LP. A retrospective review of GA patients with LP from the surveillance, epidemiology, and end results database (2004–2009) was performed. 29,440 patients with GA were identified, of whom 948 (3.2%) had LP. After matching for American Joint Commission on Cancer (AJCC) stage, LP patients had significantly worse 5-year disease specific survival (DSS) compared with GA (6 vs 34%, P < 0.001). For potentially resectable LP patients (i.e., stage I–III), 5-year DSS was 0 per cent for no treatment and for radiation therapy alone, 18 per cent for both and surgery and radiation, and 20 per cent for surgery alone(P < 0.001). LP is a marker of poor survival in patients with GA. However, surgical resection provides the best oncologic outcomes in these patients with a 20 per cent 5-year DSS in patients with loco-regional disease.

Application of smoothing methods for determining of the effecting factors on the survival rate of gastric cancer patients

Background

Smoothing methods are widely used to analyze epidemiologic data, particularly in the area of environmental health where non-linear relationships are not uncommon. This study focused on three different smoothing methods in Cox models: penalized splines, restricted cubic splines and fractional polynomials.

Objectives

The aim of this study was to assess the effects of prognostic factors on survival of patients with gastric cancer using the smoothing methods in Cox model and Cox proportional hazards. Also, all models were compared to each other in order to find the best one.

Materials and Methods

We retrospectively studied 216 patients with gastric cancer who were registered in one referral cancer registry center in Tehran, Iran. Age at diagnosis, sex, presence of metastasis, tumor size, histology type, lymph node metastasis, and pathologic stages were entered in to analysis using the Cox proportional hazards model and smoothing methods in Cox model. The SPSS version 18.0 and R version 2.14.1 were used for data analysis. These models compared with Akaike information criterion.

Results

In this study, The 5 year survival rate was 30%. The Cox proportional hazards, penalized spline and fractional polynomial models let to similar results and Akaike information criterion showed a better performance for these three models comparing to the restricted cubic spline. Also, P-value and likelihood ratio test in restricted cubic spline was greater than other models. Note that the best model is indicated by the lowest Akaike information criterion.

Conclusions

The use of smoothing methods helps us to eliminate non-linear effects but it is more appropriate to use Cox proportional hazards model in medical data because of its’ ease of interpretation and capability of modeling both continuous and discrete covariates. Also, Cox proportional hazards model and smoothing methods analysis identified that age at diagnosis and tumor size were independent prognostic factors for the survival of patients with gastric cancer (P < 0.05). According to these results the early detection of patients at younger age and in primary stages may be important to increase survival.

Estimation of hazard function and its associated factors in gastric cancer patients using wavelet and kernel smoothing methods

BACKGROUND AND OBJECTIVES

Increase of mortality rates of gastric cancer in Iran and the world in recent years reveal necessity of studies on this disease. Here, hazard function for gastric cancer patients was estimated using Wavelet and Kernel methods and some related factors were assessed.

MATERIALS AND METHODS

Ninety- five gastric cancer patients in Fayazbakhsh Hospital between 1996 and 2003 were studied. The effects of age of patients, gender, stage of disease and treatment method on patient's lifetime were assessed. For data analyses, survival analyses using Wavelet method and Log-rank test in R software were used.

RESULTS

Nearly 25.3% of patients were female. Fourteen percent had surgery treatment and the rest had treatment without surgery. Three fourths died and the rest were censored. Almost 9.5% of patients were in early stages of the disease, 53.7% in locally advance stage and 36.8% in metastatic stage. Hazard function estimation with the wavelet method showed significant difference for stages of disease (P<0.001) and did not reveal any significant difference for age, gender and treatment method.

CONCLUSION

Only stage of disease had effects on hazard and most patients were diagnosed in late stages of disease, which is possibly one of the most reasons for high hazard rate and low survival. Therefore, it seems to be necessary a public education about symptoms of disease by media and regular tests and screening for early diagnosis.

Intraperitoneal delivery of a small interfering RNA targeting NEDD1 prolongs the survival of scirrhous gastric cancer model mice

The prognosis of patients with advanced diffuse-type gastric cancer (GC), especially scirrhous gastric cancer (SGC) remains extremely poor. Peritoneal carcinomatosis is a frequent form of metastasis of SGC. With survival rates of patients with peritoneal metastasis at 3 and 5 years being only 9.8% and 0%, respectively, development of a new treatment is urgently crucial. For such development, the establishment of a therapeutic mouse model is required. Among the 11 GC cell lines we examined, HSC-60 showed the most well-preserved expression profiles of the Hedgehog and epithelial-mesenchymal transition pathways found in primary SGCs. After six cycles of harvest of ascitic tumor cells and their orthotopic inoculation in scid mice, a highly metastatic subclone of HSC-60, 60As6 was obtained, by means of which we successfully developed peritoneal metastasis model mice. The mice treated with small interfering (si) RNA targeting NEDD1, which encodes a gamma-tubulin ring complex-binding protein, by the atelocollagen-mediated delivery system showed a significantly prolonged survival. Our mouse model could thus be useful for the development of a new therapeutic modality. Intraperitoneal administration of siRNAs of targeted genes such as NEDD1 could provide a new opportunity in the treatment of the peritoneal metastasis of SGC.

Comparison of colorectal and gastric cancer: survival and prognostic factors

BACKGROUND/AIMS

Gastric and colorectal cancers are the most common gastrointestinal malignancies in Iran. We aim to compare the survival rates and prognostic factors between these two cancers.

METHODS

We studied 1873 patients with either gastric or colorectal cancer who were registered in one referral cancer registry center in Tehran, Iran. All patients were followed from their time of diagnosis until December 2006 (as failure time). Survival curves were calculated according to the Kaplan-Meier Method and compared by the Log-rank test. Multivariate analysis of prognostic factors was carried out using the Cox proportional hazard model.

RESULTS

Of 1873 patients, there were 746 with gastric cancer and 1138 with colorectal cancer. According to the Kaplan-Meier method 1, 3, 5, and 7-year survival rates were 71.2, 37.8, 25.3, and 19.5%, respectively, in gastric cancer patients and 91.1, 73.1, 61, and 54.9%, respectively, in patients with colorectal cancer. Also, univariate analysis showed that age at diagnosis, sex, grade of tumor, and distant metastasis were of prognostic significance in both cancers (P < 0.0001). However, in multivariate analysis, only distant metastasis in colorectal cancer and age at diagnosis, grade of tumor, and distant metastasis in colorectal cancer were identified as independent prognostic factors influencing survival.

CONCLUSIONS

According to our findings, survival is significantly related to histological differentiation of tumor and distant metastasis in colorectal cancer patients and only to distant metastasis in gastric cancer patients.

Ecoendoscopia na avaliação pré-operatória do estádio em doentes com câncer gástrico: correlação com os achados cirúrgicos e/ou histopatológicos

RACIONAL: O câncer gástrico é a maior causa de morte por câncer no Brasil. Na avaliação do prognóstico e no planejamento da terapêutica, é importante determinar o estádio e classificá-lo em TNM. OBJETIVO: Estudar os resultados da ecoendoscopia na determinação pré-operatória das categorias T e N. MÉTODOS: Foram examinados prospectivamente e de forma consecutiva 30 pacientes com adenocarcinoma gástrico no período de 1 ano. Utilizou-se o aparelho Olympus GIF-UM-20. Após seu posicionamento na terceira porção duodenal, estudaram-se as estações linfonodais 16, 13, 12, 6, 5, 4, 3, 8, 7, 9, 10, 11, 1 e 2, usando a freqüência de 7,5 MHz. Os resultados T e N foram comparados com os achados cirúrgicos e/ou histopatológicos. Nos casos irressecáveis, a correlação foi feita com os achados macroscópicos. Para a análise estatística utilizou-se o teste de correlação coeficiente kappa. RESULTADOS: Foram realizadas 16 gastrectomias totais, 7 subtotais, 5 laparotomias exploradoras e 2 videolaparoscopias. Para a categoria T a ecoendoscopia acertou em 25/30 casos (83,3%). Todos os restantes 16,7% foram superestimados. A precisão variou de 90% a 96,7%, de acordo com as subdivisões T1 a T4. Para a categoria N, a ecoendoscopia foi correta em 23/30 casos (76,7%), sendo 16,6% subestimados e 6,7% superestimados. A precisão variou de 76,7% a 90%, de acordo com as subdivisões N0 a N2. CONCLUSÃO: Houve nítida correlação entre a ecoendoscopia pré-operatória e os achados cirúrgicos e/ou histopatológicos em pacientes com adenocarcinoma gástrico.

Retrospective analysis of prognosis for scirrhous-type gastric cancer: one institution's experience

BACKGROUND

Scirrhous gastric cancer is biologically aggressive, and the prognosis is poor even with curative surgery. We compared outcomes with different therapies in order to identify prognostic factors.

METHODS

Records for 83 patients, who were treated between 1991 and 2004, were evaluated for survival and stage, treatment, and clinicopathological factors.

RESULTS

Cumulative 5-year overall survival was 10.2% for all 83 patients, including 27 (32.5%) patients with stage II/III disease and 56 (67.4%) with stage IV disease. The 5-year overall survival rate and median survival time for patients with stage II/III disease after curative surgery were 24.3% and 1150 days. For patients with stage IV disease, 2-year and 5-year survival rates after initial surgery were 13.7% and 0% and median survival was 250 days. In contrast, preoperative chemotherapy for advanced, unresectable disease produced 2-year and 3-year overall survival rates of 53.6% and 26.8% and medican survival was 910 days.

CONCLUSION

Aggressive surgery alone does not seem to improve outcome, but preoperative chemotherapy might be beneficial and should be investigated further.

Clinicopathological analysis of Borrmann type IV gastric cancer

PURPOSE

Borrmann type IV gastric cancer is often diagnosed only at an advanced stage, resulting in a prognosis poor. We performed a retrospective study of the clinical characteristics of Borrmann type IV gastric cancer and the prognostic factors affecting the survival rate in such patients.

MATERIALS AND METHODS

Of 4,063 patients with all gastric cancers, 370 (9%) with Borrmann type IV gastric cancer were analyzed.

RESULTS

The clinical characteristics of these patients included a higher incidence rate in young females, and higher rates of serosa exposure, metastasis to lymph nodes and early peritoneal dissemination. Of patients presenting with peritoneal seeding, those resected had a higher survival rate than those that were not. A univariate analysis showed that the prognostic factors affecting the survival rate following a curative resection were the location, occupied area and depth of the primary tumor, as well as the presence of lymph node metastasis and the tumor stage. A multivariate analysis indicated that the tumor location and stage were significant independent prognostic factors after a curative resection for Borrmann type IV gastric cancer.

CONCLUSION

In conclusion, the early diagnosis and treatment of patients with Borrmann type IV gastric cancer are essential for the better survival of these patients. Even in patients with advanced tumors, a noncurative palliative resection may improve the prognosis.

Comparison of Cox's and relative survival models when estimating the effects of prognostic factors on disease-specific mortality: a simulation study under proportional excess hazards

In many prognostic studies focusing on mortality of persons affected by a particular disease, the cause of death of individual patients is not recorded. In such situations, the conventional survival analytical methods, such as the Cox's proportional hazards regression model, do not allow to discriminate the effects of prognostic factors on disease-specific mortality from their effects on all-causes mortality. In the last decade, the relative survival approach has been proposed to deal with the analyses involving population-based cancer registries, where the problem of missing information on the cause of death is very common. However, some questions regarding the ability of the relative survival methods to accurately discriminate between the two sources of mortality remain open. In order to systematically assess the performance of the relative survival model proposed by Esteve et al., and to quantify its potential advantages over the Cox's model analyses, we carried out a series of simulation experiments, based on the population-based colon cancer registry in the French region of Burgundy. Simulations showed a systematic bias induced by the 'crude' conventional Cox's model analyses when individual causes of death are unknown. In simulations where only about 10 per cent of patients died of causes other than colon cancer, the Cox's model over-estimated the effects of male gender and oldest age category by about 17 and 13 per cent, respectively, with the coverage rate of the 95 per cent CI for the latter estimate as low as 65 per cent. In contrast, the effect of higher cancer stages was under-estimated by 8-28 per cent. In contrast to crude survival, relative survival model largely reduced such problems and handled well even such challenging tasks as separating the opposite effects of the same variable on cancer-related versus other-causes mortality. Specifically, in all the cases discussed above, the relative bias in the estimates from the Esteve et al.'s model was always below 10 per cent, with the coverage rates above 81 per cent.

Outcome of surgical treatment for patients with scirrhous carcinoma of the stomach

BACKGROUND

Postoperative survival in patients with scirrhous gastric carcinoma is poorer than that in patients with other gastric carcinomas.

METHODS

We retrospectively examined outcome in patients with scirrhous gastric carcinoma who underwent gastrectomy to determine how to increase postoperative survival. Postoperative survival in patients with scirrhous gastric carcinoma was compared with that in patients having other gastric cancers overall and by disease stage. Prognostic factors were examined for all patients including those with stage III disease.

RESULTS

By multivariate analysis, disease stage, patient age, and scirrhous carcinoma were significant prognostic factors. Five-year survival in patients with stage III scirrhous carcinoma was significantly worse than those with other stage III gastric carcinomas. Extent of lymphadenectomy was one of the variables influencing survival in patients with stage III scirrhous carcinoma.

CONCLUSIONS

Gastrectomy with extended lymphadenectomy should be performed to maximize survival in patients with stage III scirrhous gastric carcinoma.

Clinicopathological features of patients with Borrmann type IV gastric carcinoma

BACKGROUND

To determine whether there is a specific pattern of clinicopathological features that could be used to distinguish -Borrmann type IV gastric carcinoma from other types of gastric carcinoma.

METHODS

We retrospectively analysed the clinicopathological features of patients with Borrmann type IV carcinoma of the stomach. The results were compared with the features of patients who had other types of gastric carcinoma.

RESULTS

The incidence of Borrmann type IV gastric carcinoma was 11.0% (199 patients). A poorly differentiated tumour was found in 120 out of 199 patients (60.3%) with Borrmann type IV gastric carcinoma. The positive lymph node metastasis was found in 150 out of 199 patients (75.4%) with Borrmann type IV gastric carcinoma (P < 0.0001). The incidence of serosal invasion (91.5%) and peritoneal dissemination (37.7%) was significantly higher in these patients. Of the patients with Borrmann type IV gastric carcinoma,161 patients (80.9%) were classified as either stage III or IV at initial diagnosis. The curative resection rate of patients with Borrmann type IV gastric carcinoma was lower than that of patients with other types of gastric carcinoma (P < 0.001). The survival rate was higher in patients with a curative resection(P < 0.001). The 5-year survival rate of patients with Borrmann type IV tumour was lower than that of patients with other types of gastric carcinoma (P < 0.001). The 5-year survival rates were 90.9% for stage I patients with Borrmann type IV gastric carcinoma and 39.5%, 18.6% and 8.7% for stages II, III and IV, respectively (P < 0.001).

CONCLUSION

Improving the prognosis for patients with Borrmann type IV gastric carcinoma requires early detection and a curative resection.

Impact of the latest TNM classification for gastric cancer: retrospective analysis on 94 D2 gastrectomies

The aim of this study was to determine whether the latest edition of tumor-node-metastasis (TNM) classification provides reliable prognostic information. The fifth edition of TNM Classification of Malignant Tumors has introduced for gastric cancer the numeric count of involved lymph nodes whereas their topographic location was considered in earlier editions. For our study, data from 94 patients who underwent D2-gastrectomy were reviewed. The N-factor was scored according to both the Japanese Research Society for Gastric Cancer (JRSGC) classification (n) and, retrospectively, the latest TNM classification (N). Actuarial survival was calculated for both groups. The two staging systems showed similar stratification of actuarial survival with relation to N-stage; in the JRSGC classification no statistical differences were observed between n1 and n2 patients (62.7% vs. 52.5%; p = NS), whereas the 5th TNM classification showed a significant difference between N1 and N2 patients (68.5% vs. 45.0%; p = 0.04), and between N1 and the new category of N3 patients (68.5% vs. 45.0%, p = 0.03). It appears, therefore, that the numeric count of involved nodes may represent a more reliable indicator for single-case prognosis. Reclassification of all node-positive patients in our series caused an overall stage modification in 32.9% (31/94); 22 of those patients were reclassified to a less favorable stage (23.4%). In addition, 11.7% of patients (6/51) who were previously designated n1 were reclassified as N2, shifting from an expected actuarial survival after 72 months of 62.7% to 33.3%.

A prognostic score for gastric cancer

BACKGROUND

Scoring systems are generally used for predicting prognosis in the intensive care unit, but there is no score being used frequently for predicting prognosis in gastric cancer. The aim of this study was to develop a prognostic score for gastric cancer patients.

METHODS

Demographic, clinical, laboratory, radiologic, histopathologic data, and operative findings for 128 patients who had curative or palliative resection for gastric cancer were analyzed for their effect on overall and disease-free survival. Ten variables-invasion depth of tumor, node status (American Joint Committed on Cancer, 1992), metastasis, node status (Union Internationale Contre le Cancer, 1997), metastatic lymph node ratio, resectability, tumor location, extent of lymphadenectomy, Borrmann type, Lauren type-that have independent significant effect or borderline significance on both overall and disease-free survival according to multivariate analysis were chosen. Coefficients were calculated for these variables by using Cox regression analysis, and thus the Prognostic Score for Gastric Cancer (PSGC) was designed. All patients were scored using the PSGC and also staged clinically (AJCC 1992) and histopathologically (AJCC 1992 and UICC 1997).

RESULTS

Patients were grouped according to their scores: group 1, patients with scores 20 to 50 (probability of 5-year overall survival 50% to 95%); group 2, patients with scores 51 to 80 (probability of 5-year overall survival 10% to 50%); and group 3, patients with scores 81 and higher (probability of 5-year overall survival <10%). Overall survival and disease-free survival decreased significantly with increasing scores. The association of PSGC and staging systems with survival was analyzed by stepwise logistic regression and Cox regression analyses. PSGC was proved to have the most significant association with overall and disease-free survival.

CONCLUSIONS

Inclusion of more variables in PSGC seems to make it superior than staging. It is easy to adapt PSGC to different patient populations, which may make it accepted as a practical and useful scoring system in clinical practice.

Survival in stomach cancer is improving: results of a nationwide population-based Swedish study

OBJECTIVE

To monitor for secular trends in survival among patients with stomach cancer.

SUMMARY BACKGROUND DATA

The overall survival among patients with stomach cancer has remained stable at a low level for several decades.

METHODS

Relative survival was estimated for all 53,862 living patients reported from 1960 to 1989 to the Swedish Cancer Registry, which is nationwide and virtually complete, with compulsory reporting of new cases of stomach cancer. Follow-up was from cancer diagnosis until death, emigration, or December 31, 1991.

RESULTS

During the 1980s, statistically significant improvements were seen in the 2-month, 5-year, and 10-year relative survival of patients with stomach cancer, and in the subgroup with noncardiac cancer. The 5-year relative survival rate increased from 13.3% (95% confidence interval [CI] 12.4 to 14.1) among patients diagnosed with noncardiac stomach cancer in 1970-1974 to 19.4% (95% CI 18.1-20.7) among those given this diagnosis in 1985-1986; the overall mean life expectancy increased from 2.2 to 3.3 years. In patients with cancer of the gastric cardia, the 5-year relative survival rate increased from 4.7% (95% CI 2.3-7.1) to 10.4% (95% CI 7.7-13.1), but the 10-year relative survival rate did not improve. The overall mean life expectancy in this group increased from 1.4 to 2.2 years. Age at diagnosis was strongly and inversely related to relative survival. Patients diagnosed at university hospitals had a moderate survival advantage.

CONCLUSION

The survival of patients with a stomach cancer diagnosis appears to be increasing. The reasons for this are probably multifactorial and are likely to include improvements in surgical and anesthesiologic management. However, the long-term prognosis of cancer of the gastric cardia remains dismal.

Unchanged survival of gastric cancer in the southeastern Netherlands since 1982: result of differential trends in incidence according to Laurén type and subsite

Despite widespread use of endoscopy and improved surgical treatment, the prognosis for gastric cancer remains poor. Although the incidence has been declining for more than 2 decades, unfavourable changes in relative frequency of histological subtypes and subsites may have occurred. We therefore assessed the nature and impact of these changes in association with socio-economic status in a population-based study during the period 1983-1995. Furthermore, tumour characteristics were analysed as predictors of survival for 1,543 cases recorded in the Eindhoven Cancer Registry during the period 1983-1992. Overall 5-year relative survival remained at 22%, being 70%, 37% and 11% for stage I, II and III, respectively. The Laurén histological type and location were also found to have prognostic value. Tumours with the worst prognosis (diffuse type and located at the cardia) developed predominantly in younger patients and were increasing. Moreover, unlike for other tumours, high educational status was associated with unfavourable prognosis. Stage at diagnosis and survival have remained unchanged, despite likely improvements in early detection through better access to endoscopy and better supportive care after surgical treatment. The unfavourable, in part relative, changes in incidence are likely to be responsible for the lack of improvement of survival rates.

Factors correlated with number of metastatic lymph nodes in gastric cancer

OBJECTIVE

We had previously reported a reasonable categorization of the number of positive lymph nodes (LN: 0, 1-4, 5-8, and > 8) as a prognostic indicator. This study was an extension, to see which factors correlated with number of positive lymph nodes.

METHODS

A total of 533 patients with gastric adenocarcinoma, who underwent curative surgery between January 1988 and December 1995, were entered into this study. Patients were divided into four groups according to metastatic LN number (0, 1-4, 5-8, and > 8). Their survival and clinicopathological factors were analyzed.

RESULTS

A total of 16,457 LNs, with an average of 30.9 per specimen, were removed, of which 1686 (10.2%) showed metastases. The 5-yr cumulative survival rate decreased as the number of metastatic LNs increased, ie., 91.3% for LN 0; 67.4% for LN 1-4; 37.2 for LN 5-8, and 14.1% for LN > 8. Multivariate analyses showed that depth of cancer invasion (odds ratio: 2.4), gross appearance (odds ratio: 1.9), size (odds ratio: 1.9), and location (odds ratio: 1.4) of tumor were four independent factors correlated with the number of metastatic LNs. Number of metastatic LNs increased with advanced Japanese nodal stage and UICC-TNM stage.

CONCLUSIONS

Depth of tumor invasion, and gross appearance, size, and location of tumor were four pathological factors independently correlated with number of metastatic LNs in gastric cancer.

Relative survival analysis of 252 patients with COPD receiving long-term oxygen therapy

OBJECTIVES

A survival analysis was conducted on patients with COPD receiving long-term oxygen therapy (LTOT) to compare two different statistical methods.

METHODS

We used a multivariate crude (observed) survival model (Cox) and a multivariate relative survival model (Hakulinen). Only the latter is able to correct the survival by adjusting it to the normal life expectancy of the studied patients.

PATIENTS

Two hundred fifty-two hypoxemic COPD patients (207 male) requiring LTOT were included. Mean PaO2 was <50 mm Hg before oxygen therapy. Mean age was >69 years (SE: 9.9). They had severe bronchial obstruction: mean FEV1 was <33% (10.6) of predicted values, with some CO2 retention: mean PaCO2 was 45.6 (7.1) mm Hg. By December 31, 1995, 189 patients had died (75%) and 13 (5%) were unavailable for follow-up.

RESULTS

The overall crude survival was poor: 80.9% after 1 year, 67.1% after 2 years, 34.7% after 5 years, and 7.1% after 10 years. In the crude multivariate analysis (Cox), the negative prognostic factors were age and hypercapnia. The overall relative survival (Hakulinen), corrected for life expectancy, was 82.8% after 1 year, 70.8% after 2 years, 41.5% after 5 years, and 10.25% after 10 years. In the final multivariate relative model, age was no longer significant and the only bad prognostic factor was hypercapnia with a relative risk of 1.97 (1.16 to 3.34).

CONCLUSION

This work shows the inadequacy of the Cox observed survival model when it comes to appreciating the real prognostic impact of age, because of the confusing factor associated with a normal life expectancy.

Extended surgical resection in T4 gastric cancer

BACKGROUND

Some physicians still consider invasion of adjacent organs by the carcinoma of stomach as a sign of incurable disease.

METHODS

This retrospective study has been done with particular reference to 353 T4 gastric cancer patients who underwent combined gastrectomies with adjacent organs.

RESULTS

Subtotal gastrectomy was performed in 237 (67.1%) patients and total gastrectomy was performed in 116 (32.9%) patients. Organs most commonly resected with the stomach were the transverse colon in 159 (45%) cases, the tail of pancreas and spleen in 150 (42.5%), the left lobe of liver in 101 (28.5%), and the head of pancreas in 37 (10.5%) patients. A total of 110 postoperative complications occurred in this subset of patients corresponding to a complication rate of 31.2%. A total of 48 postoperative deaths occurred in this subset of patients corresponding to a mortality rate of 13.6%. The 5-year survival rate for all patients who underwent combined gastrectomy with adjacent organs was 25%. Of the node-negative T4 gastric cancer resections, 37% survived 5 years whereas the T4 node-positive resections have only a 15% 5-year survival.

CONCLUSIONS

Patients who present with T4 gastric cancer (about 20% of the patient population) will benefit from aggressive en bloc surgical resection and should not be considered unresectable.

Prognostic factors in a series of 297 patients with gastric adenocarcinoma undergoing surgical resection

BACKGROUND

Gastric cancer has a poor prognosis. The aim of this study was to determine the influence of several clinicopathological variables on outcome in a series of 297 Western patients undergoing surgical resection for gastric adenocarcinoma.

METHODS

The results were analysed retrospectively and prognostic factors were identified in a univariate and Cox proportional hazards regression model. Mean patient age at the time of operation was 61.9 years; 65.7 per cent were men. Mean follow-up was 7.8 (range 1-15) years. Of the 297 patients undergoing surgery, 70 per cent had subtotal gastrectomy, 26.3 per cent underwent total gastrectomy and 3.7 per cent had proximal gastrectomy.

RESULTS

The overall survival rate was 38.9 per cent at 5 years. In th univariate analysis, survival-related factors were weight loss (P < 0.05), abdominal mass (P < 0.01), dysphagia (P < 0.001), type of gastrectomy (subtotal gastrectomy versus total gastrectomy, P < 0.001), intention of resection (curative versus palliative resection, P < 0.001), tumour site (P < 0.001), histopathological grade (low versus high grade, P < 0.05), tumour diameter less than 3 cm (P < 0.001), degree of gastric wall invasion (P < 0.001), degree of lymph node invasion (P < 0.001) and stage of the neoplasia (P < 0.001). Other variables had no significant influence. In the multivariate analysis, degree of gastric wall invasion, lymph node invasion, tumour size and dysphagia at presentation were the only independent prognostic variables.

CONCLUSION

From these data it was possible to derive a prognostic index with which patients could be classified as at low, intermediate or high risk.

Surgically curable and incurable scirrhous carcinomas of the stomach

BACKGROUND AND OBJECTIVES

The purpose of this study was to identify a subgroup of patients with scirrhous carcinoma of the stomach who are more suitable for surgery by analysis of their clinicopathologic characteristics.

METHODS

Seventy-three patients with scirrhous gastric carcinoma who underwent gastrectomy between 1979 and 1994 were included in the study. Clinicopathological characteristics of 5-year survivors and nonsurvivors were compared. A multivariate analysis of various prognostic factors was performed.

RESULTS

The 5-year survival rate was 31.4%; 78% (28/36) of nonsurvivors died of malignant ascites and only 8% (3/36) died of hepatic or lung metastasis. When clinicopathologic parameters of 5-year survivors and nonsurvivors were compared, age, tumor size, macroscopic appearance, pT, pN, pM, stage, peritoneal lavage cytology, residual tumor, extent of gastric resection, operation time, volume of blood loss, and transfusion were significantly different. By the multivariate analysis, residual tumor, pathological depth of tumor infiltration, blood transfusion, and histological type were the independent prognostic factors.

CONCLUSIONS

The prognosis of scirrhous carcinoma of the stomach is mainly determined by the depth of penetration and curability. In order to obtain better survival, early detection of tumor while it is limited to T2 stage appeared most important. Aggressive surgery would be indicated for T3 tumors, but in the case of T4 tumors, extent of operation should be determined by other factors such as extent of nodal metastasis or presence of distant metastasis.

Extended surgery--left upper abdominal exenteration plus Appleby's method--for type 4 gastric carcinoma

BACKGROUND

The prognosis after surgical treatment for type 4 gastric cancer, including linitis plastica, remains poor. The most frequent recurrence mode is retroperitoneal involvement. To remove the tumor and microinvasion surrounding the stomach, extended surgery, left upper abdominal exenteration plus the Appleby's method (LUAE + Apl), has been performed for type 4 cancers since 1983.

PATIENTS AND METHODS

A total of 54 patients with type 4 cancer underwent extended surgery (LUAE + Apl) over the past 11 years. In the LUAE + Apl surgical procedure, the whole stomach, pancreas body and tail, spleen, gallbladder, transverse colon, and left adrenal were removed en bloc. The results of this treatment are reported and the most beneficial application of this procedure (group A) is evaluated and compared with findings in similar patients who underwent common surgery between 1973 and 1983 (group B).

RESULTS

As postoperative complications, pancreatic fistula (30%; control 19%), liver dysfunction (15%; 14%), anastomosis failure (6%; 9%), and infection (4%; 1%) were observed (NS). In group A, one patient died of liver dysfunction and another of multiple organ failure due to major pancreatic fistula. In stage III, the 5-year survival rate of group A (40%) was better than that of group B (20%; p < 0.05). In stage IV, the 5-year survival rate of group A (5%; 3% in group B) was not improved.

CONCLUSION

LUAE + Apl improved the survival of patients with scirrhous cancer in stage III, but it was not effective for those in stage IV. To improve the survival of patients in stage IV, a new concept of treatment and supportive therapy needs to be used.

Relation of number of positive lymph nodes to the prognosis of patients with primary gastric adenocarcinoma

BACKGROUND

No nodal grouping category of gastric cancer has been universally accepted for the grading of the effectiveness of therapeutic regimens.

AIMS

To establish an appropriate nodal grouping as a forecaster of distant disease and test its validity as a determinant in survival.

PATIENTS

Five hundred and ten patients who underwent curative resections for gastric cancer were studied.

METHODS

Retrospectively analyse the prognostic significance of the number of metastatic lymph nodes.

RESULTS

A total of 17 176 lymph nodes with an average of 34 per specimen were removed, of which 2811 (16%) showed metastases. Among the 510 patients, 287 (56%) had lymph node metastases, with an average of 9.8 per metastatic case. The survival of all patients was related to their nodal status, an abrupt decrease in survival was seen between 0 and 1 and 4 compared with 5 or more modes while little difference in survival existed among 1, 2, 3, and 4, and among 5, 6, 7, and 8 positive nodes. Multivariate analysis showed that the number of positive nodes (1-4, 5-8 versus > or = 9; relative risk 2.2) and depth of cancer invasion (three levels; relative risk 1.9) were independently correlated with survival. The current nodal stage was not a prognostic factor.

CONCLUSIONS

Gastric cancer patients with 0, 1 to 4, 5 to 8, and > 9 positive nodes may represent four appropriate prognostic groups and should be adopted for classification of nodal stage in gastric cancer.

Postoperative complications requiring relaparotomies after 700 gastretomies performed for gastric cancer

BACKGROUND

Prevention of fatal postoperative complications and improved management of patients with complications are important means of increased survival in gastric cancer patients.

PATIENTS AND METHODS

A study of 700 patients undergoing gastrectomy was performed to examine factors that contributed to a high rate of postoperative complications.

RESULTS

Of 700 patients undergoing gastrectomy for adenocarcinoma, 40 (5.7%) underwent reexploration because of serious complications. The frequency of the relaparotomies varied from 2.1% and 4.4% after regular subtotal and total gastrectomies, respectively, to 20% and 30.4% after palliative and conventional total gastrectomies, respectively. The complications that required reexploration most frequently were anastomotic leakage and incompetence of sutures (11, 27.5%), intra-abdominal abscesses (8, 20%), and pancreatic necrosis (7, 17.5%). A combination of preventive measures allowed the attainment of low rates of esophagojejunal anastomotic leakage (0.8%).

CONCLUSION

We believe that the decision to perform an urgent reexploration, based on clinical findings, should generally be made by a group of experienced surgeons (not only the primary surgeon). Timely relaparotomy prevented death in 37.5% of the patients with serious acute postoperative complications.

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.

DNA aneuploidy in gastric carcinoma. Flow cytometric data related to survival, location, and histopathologic findings

BACKGROUND

The aim of the study was to evaluate the prognostic significance of DNA ploidy of gastric carcinomas.

METHODS

The DNA content was analyzed by flow cytometry on archival paraffin-embedded material from tumors of 97 consecutive patients.

RESULTS

A multivariate analysis showed that the DNA ploidy pattern and lymph node metastasis were the only independent prognostic markers for survival (p = 0.01 and p = 0.02, respectively). The relative risk of death due to gastric cancer was three times greater for patients with DNA hypertetraploid tumors than for patients with DNA diploid tumors and twice as high for patients with lymph node metastasis as for patients without. Well and moderately differentiated carcinomas were more frequently aneuploid than tumors with poor differentiation (p = 0.047). There was no correlation between tumor ploidy pattern and location. In univariate analysis tumor growth through the serosal wall was predictive of poor survival (p = 0.003).

CONCLUSIONS

DNA ploidy is an independent prognostic indicator for cancer-specific survival in gastric cancer.

Pre-operative serum levels of tissue polypeptide antigen in patients with gastric cancer

Pre-operative serum tissue polypeptide antigen (TPA) levels were measured in cases of gastric cancer from December 1987 to December 1992. All 351 cases received gastrectomies. The clinicopathological factors were analysed. The significant factors that correlated with the elevation of pre-operative serum TPA levels included tumour size (> 7 cm), Borrmann-type cancers, late stages (III and IV), lymph node metastasis, hepatic metastasis and Ming's expanding type cancers. Multivariate analysis showed that the tumour size (> 7 cm) and the presence of hepatic metastasis are significant factors. To clarify the relationships between gastric cancer per se and the pre-operative serum TPA levels, we selected cases without evidence of metastasis (n = 139). The tumour size was the only significant factor when multivariate analysis was applied. Possibilities of hepatic recurrence were found in cases with high pre-operative serum TPA levels (> 220 U/L), even radical gastrectomies were performed. A high pre-operative serum TPA level did not display a poor survival prognosis, if the radical gastrectomy was possible. We thus concluded that: (i) elevated pre-operative serum levels of TPA are associated with either a large size tumour (> 7 cm) or the presence of hepatic metastasis and the tumour size is the most important factor relating to the serum TPA levels; (ii) high pre-operative serum TPA levels (> 220 U/L) may serve as indicators of later hepatic recurrence; and (iii) elevated serum TPA levels were not indicators of survival prognosis.

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.

Pathology and ploidy in the prognosis of gastric cancer with no extranodal metastasis

BACKGROUND

The prognostic relevance of morphology in advanced gastric cancer is well known. Data on tumor cell DNA content are still inadequate and contradictory.

METHODS

Morphologic parameters and DNA ploidy were evaluated in 76 gastric cancer patients with no extranodal metastases (Stage I, 10 cases; Stage II, 20 cases; and Stage III, 46 cases), using formalin-fixed paraffin-embedded tissue. All cases were followed for at least 6 years after surgery or until death.

RESULTS

Among the potential prognostic factors analyzed by Mantel-Cox and generalized Wilcoxon statistics, male sex (P = 0.02), cardiac location of neoplasia (P = 0.02), deeper infiltration of the gastric wall (P = 0.001), vascular neoplastic invasion (P = 0.006), metastatic lymph nodes (P = 0.001), pathologic stage (P = 0.0001), and aneuploidy (P = 0.01) were significantly associated with lower survival rate. Testing of all of the above-mentioned variables by the Cox stepwise multiple regression model disclosed that factors independently associated with survival were stage (P = 0.0001), ploidy (P = 0.0006), and vascular carcinomatous invasion (P = 0.01).

CONCLUSIONS

In gastric cancer with no extranodal metastases, DNA ploidy was found to be the most significant prognostic parameter after pathologic stage.

Age and prognosis of non-small cell lung cancer. Usefulness of a relative survival model

The aim of our study was the comparative evaluation of a relative survival model and a Cox model to determine the prognostic factors of survival for patients with surgically cured non-small cell lung cancer (NSCLC). We focused particularly on the exact role of age in this survival. 156 patients treated between 1975 and 1988 were studied. Both univariate and multivariate analyses were performed, using the actuarial method and the Cox model for crude survival and the Hakulinen model for relative survival. This study confirmed the poor prognosis of NSCLC, even if a curative surgical procedure has been possible, with a 5-year survival of 48% for stage I tumours but only 6% for stage III tumours. The most significant prognostic factor was the postsurgical TNM staging. The relative survival method of Hakulinen dismissed age as a significant prognostic factor. Our study underlines the usefulness of relative survival methods which should be more frequently employed to allow comparisons between series of different origin and to set up multicentre therapeutic trials.