Synchronous multiple early gastric carcinoma: a study of 178 cases

Analysis of Characteristics and Risk Factors of Patients with Single Gastric Cancer and Synchronous Multiple Gastric Cancer among 14,603 Patients

Background/Aims

Synchronous multiple gastric cancer (SMGC) accounts for approximately 6% to 14% of gastric cancer (GC) cases. This study aimed to identify risk factors for SMGC.

Methods

A total of 14,603 patients diagnosed with GC were prospectively enrolled. Data including age, sex, body mass index, smoking, alcohol consumption, family history, p53 expression, microsatellite instability, cancer classification, lymph node metastasis, and treatment were collected. Risk factors were analyzed using logistic regression analysis between a single GC and SMGC.

Results

The incidence of SMGC was 4.04%, and that of early GC (EGC) and advanced GC (AGC) was 5.43% and 3.11%, respectively. Patients with SMGC were older (65.33 years vs 61.75 years, p<0.001) and more likely to be male. Lymph node metastasis was found in 27% of patients with SMGC and 32% of patients with single GC. Multivariate analysis showed that SMGC was associated with sex (male odds ratio [OR], 1.669; 95% confidence interval [CI], 1.223 to 2.278; p=0.001), age (≥65 years OR, 1.532; 95% CI, 1.169 to 2.008; p=0.002), and EGC (OR, 1.929; 95% CI, 1.432 to 2.600; p<0.001). Survival rates were affected by Lauren classification, sex, tumor size, cancer type, distant metastasis, and venous invasion but were not related to the number of GCs. However, the survival rate of AGC with SMGC was very high.

Conclusions

SMGC had unique characteristics such as male sex, older age, and EGC, and the survival rate of AGC, in which the intestinal type was much more frequent, was very good (Trial registration number: NCT04973631).

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

Background

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

Methods

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

Results

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

Conclusions

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

Trimodal imaging endoscopy reduces the risk of synchronous gastric neoplasia

BACKGROUND AND AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Can we resect EGC with Signet ring cells in Europe?

PURPOSE

The proposed guideline for performing endoscopic resection of early gastric carcinoma (EGC) in Paris classification is a well-differentiated carcinoma with maximum involvement Sm1. Signet ring cell carcinomas (SRC) are excluded from this recommendation. Authors from Eastern countries have proposed extending this resection to include selected undifferentiated EGC. Via an analysis of a series of cases of signet ring carcinoma, we will discuss whether it is possible to resect EGC with signet ring cells in Europe.

METHODS

We retrospectively included patients with histological classification pT1 of EGC showing SRC. Data was extracted from the hospital gastrectomy register. Lymphadenomectomy D1.5 was performed on all patients. Histology results were retrospectively obtained from the electronic patient file.

RESULTS

Twelve patients (mean age = 55.4, four women, eight men) underwent surgery, without previous chemotherapy, between 2000 and 2012, for EGC with SRC. Mean size of the lesions was 20.2 mm (5-35 mm). Seven lesions were located in the antrum, five in the fundus. In the case of nine patients, histology showed no lymphovascular involvement. None of these nine patients presented lymph node metastases (LNM). Five patients had intramucosal carcinoma, four were classified as Sm1, one patient was Sm2, and one patient was Sm3. On surgery, the three patients with lymphovascular invasion showed LNM.

CONCLUSION

Endoscopic resection of EGC with SRC does not systematically imply complementary treatment by surgery, although criteria for endoscopic resection are difficult to determine because of the lack of data in Europe.

Multifocal gastric cancer with a variety of histological findings coexisting with hyperplastic polyps: report of a case

We report a case of multifocal gastric cancer with a variety of macroscopic and histological findings. A 65-year-old woman was admitted with upper abdominal pain. Her familial history was remarkable in that her mother had died of gastric cancer. The hematological and blood biochemical values were normal, but the serum was positive for Helicobacter pylori immunoglobulin G, and the serum pepsinogen test was also positive. Gastrointestinal fiberscopy showed many granulomatous lesions coexisting with pedunculated polypoid lesions and marked atrophic gastritis throughout the stomach. We performed total gastrectomy with regional lymph node dissection. There were four separate cancers and three hyperplastic polyps with entire intestinal metaplasia. The pathological findings of these multifocal gastric cancers varied, with coexisting differentiated and undifferentiated types, and early and advanced types. One of the pedunculated polypoid lesions was accompanied by papillary adenocarcinoma. Although multifocal gastric cancer is not uncommon, the present case is considered an extremely unusual example of gastric cancer.

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

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

When do we miss synchronous gastric neoplasms with endoscopy?

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

MAIN OUTCOME MEASUREMENTS

We compared preoperative gastroscopic findings with surgically resected stomach specimens.

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Subtotal gastrectomy as treatment for distal multifocal early gastric cancer

INTRODUCTION

Multifocal early gastric cancer (MEGC) is frequently observed and represents a serious risk when minimally invasive treatments are performed.

PATIENTS AND METHODS

We present the experience of two Italian centers situated in a relatively high incidence area for gastric cancer. Out of a total of 791 surgical resections for EGC carried out in two Italian centers from 1976 to 2006, we identified 98 patients with multifocal EGC (12.3%). Two hundred and sixteen lesions were observed. Generally sited near the principal tumors, secondary lesions were, however, sometimes detected distally from the upper primary lesion. No secondary lesions were detected in the upper third when the principal lesion was sited at the lower third.

RESULTS

Survival of MEGC patients was not significantly lower than that of patients with monofocal EGC. No cases of gastric remnant relapse were observed at a mean follow-up of 9 years (range 1-28) after subtotal gastrectomy.

DISCUSSION

When EGCs are detected, the possibility of MEGC must always be investigated by endoscopy and chromoendoscopy. When a MEGC is found in the lower third of the stomach and chromoendoscopy of the upper third has been performed, subtotal gastrectomy can be considered as sufficient treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinicopathologic characteristics and prognosis of synchronous multifocal gastric carcinomas

BACKGROUND

We sought to define differences between multifocal and solitary gastric carcinoma to decrease the risk of missing a cancer while resecting another more evident carcinoma.

METHODS

We retrospectively examined clinicopathologic characteristics of multifocal gastric carcinoma including anatomic distribution and postoperative survival.

RESULTS

Multifocal gastric carcinoma was seen more frequently when patients were older and when the largest tumor was small and at an early stage. More than half of accessory lesions were located near the main tumor. No significant difference in postoperative survival was seen between patients with multifocal and solitary carcinoma, whether early or advanced.

CONCLUSIONS

The entire stomach should be examined carefully before and during resection, especially when local or endoscopic surgery is performed.

Treatment and prognosis of early multiple gastric cancer

AIM

Early gastric cancer (EGC) may have a 5-year survival rate of over 90% following surgery. Early multifocal gastric cancer (EMGC) accounts for between 8.3 and 17% of all EGCs. A multicenter retrospective study is reported of prevalence, characteristics, prognosis and type of resection for EMGC patients.

METHOD

333 patients with EGC were operated on, between January 1979 and December 1988, and followed to June 1996.

RESULTS

33 EGC patients had EMGC. There was no significant difference in clinico-pathological features between EGC and EMGC. 21 cases of EMGC underwent a subtotal gastrectomy and 12 underwent a total gastrectomy. Recurrences after subtotal gastrectomy were, respectively, 10 and 18% for EGC and EMGC patients (p=0.2). The cumulative 5 years specific survival rate for 298 EGC and 34 EMGC were 94 and 90%, respectively (p=0.9). Five-year survival rates after subtotal gastrectomy were 92 and 90% for EGC and EMGC patients, respectively (p=0.8).

CONCLUSION

EGC and EMGC had the same clinico-pathological features and prognosis. A careful follow up of the stomach remnant is essential.

The recognition and endoscopic treatment of early gastric and colonic cancer

As the prognosis of both gastric and colonic cancer remains poor, the challenge is to detect lesions at an early and treatable stage. The benefit of early detection is not only improved survival, but also that patients may be treated with endoscopic mucosal resection, a low-cost, low-morbidity and low-mortality alternative to surgery. In spite of the increasing use of endoscopy in the West, we are not detecting as many early cancers as in Japan. This chapter will discuss the possible reasons for this discrepancy and give a practical guide to 'Japanese endoscopy techniques'. Finally, we have compiled a comprehensive review of the indications, techniques and complications of endoscopic mucosal resection. Throughout the chapter, controversies have been highlighted to give an insight into the limits of our knowledge and stimulate future research.

Early Gastric Cancer: Diagnosis, Surgical Treatment and Follow-Up of 45 Cases

Aims and background

The 5-year survival rate of early gastric cancer (EGC) is 85%-100% after “curative” resection, as compared to 20%-30% in advanced gastric cancer (AGC). Because of this relatively high cure rate, the interest in the diagnosis and therapy of EGC has been steadily increasing. The present study, based on 45 EGCs, is aimed at a critical evaluation of the diagnostic procedures and surgical options.

Methods and results

Forty-five patients with early gastric cancer (27 men and 18 women; median age, 62 years; range, 28-84) were diagnosed and operated on. They represented 22.5% of all patients with gastric cancer (200) treated in the period July 1987 to January 1998. Forty-one patients were from the northeastern part of Italy. The most frequent symptom was epigastric pain (84%). Barium upper gastrointestinal radiography findings were strongly suggestive of malignancy in 41 cases (91%). Preoperative histopathological diagnosis of adenocarcinoma was performed in 43 cases (95.5%). In two cases (4.5%) severe epithelial dysplasia (associated with ulcer) was the first diagnosis, but the final diagnosis on the basis of the resected specimens was a well differentiated adenocarcinoma. The primary surgical procedure included i) subtotal distal resection (37 cases) with Billroth II (33) and Billroth I (4) reconstructions; ii) total gastrectomy (3) for proximal neoplastic extension; iii) proximal gastric resection (2) for cardial cancer; iv) degastro-total gastrectomy (3) for cancer of the stump. Two patients, previously treated with conservative surgery, underwent degastro-total gastrectomy for neoplastic microfocal extension to the margin of resection and for early anastomotic recurrence, respectively. Mural infiltration was limited to the mucosa and submucosa in 27 and 18 cases, respectively. Lymph node metastases were found in three mucosal and five submucosal tumor cases, involving either the first or the second echelon. No operative deaths or postsurgical complications occurred in this series. In the follow-up period (median, 36 months; range, 3-120) four patients died due to other causes; one developed liver metastases, another developed oropharyngeal cancer and two died of biopsy-proven lung cancer without evidence of gastric cancer recurrence.

Conclusions

The clinical presentation of EGC is aspecific. Preoperative endoscopy with biopsy remains the most sensitive diagnostic procedure. For treatment, subtotal distal gastric resection with lymphadenectomy is the “gold standard” but in some instances total gastrectomy may be indicated. Accurate pathological examination establishes the depth of infiltration, as well as the superficial extension of tumors and the lymph node status. Although the prognosis of EGC is favorable, a medium-term follow-up should be planned.

Five primary synchronous neoplasms of the gastrointestinal tract

Multiple primary malignant neoplasms in a single patient have been well documented in the literature over the past hundred years. The lesions can be limited to a single organ or involve multiple organ systems. It is relatively common for patients with colorectal carcinoma or carcinoid tumors to have more than one primary neoplasm. Colonic lesions can be synchronous or metachronous in presentation and colonic or extracolonic in location. We present a patient with five primary synchronous neoplasms of the gastrointestinal tract, involving the stomach, small bowel, and colon. The patient had no evidence of metastatic disease and underwent resection of all the lesions. This case illustrates the need for a thorough search for additional neoplasms in the treatment of patients with cancer.

Early gastric lymphoma: a clinicopathologic study of ten patients, literature review, and comparison with early gastric adenocarcinoma

BACKGROUND

Improved diagnostic techniques have increased early detection of gastric lymphoma as well as the early detection of adenocarcinoma. However, clinicopathologic features of early gastric lymphoma are presently undefined.

METHODS

Clinicopathologic features of 10 patients with early gastric lymphoma were compared with the same features of 180 patients with early gastric adenocarcinoma. In addition, 46 articles were reviewed to evaluate clinicopathologic differences.

RESULTS

Early gastric lymphoma was found in 29.2% of the patients who underwent surgery for gastric lymphoma. Early gastric lymphoma was associated with lymph node involvement in 29.9% of the patients, superficial spreading tumors in 48.6%, and multifocal lesions in 40%. These rates are greater than those in patients with adenocarcinomas (P < 0.05%). The survival rate was identical in both groups. Early gastric lymphoma may develop into large, multifocal tumors, accompanied by lymph node involvement.

CONCLUSIONS

Surgical treatment with a wide resection of the stomach and extensive lymph node dissection is necessary for early gastric lymphomas.

Long-term follow-up in early gastric cancer: evaluation of prognostic factors

Four hundred and fourteen cases of early gastric cancer (EGC), diagnosed between 1977 and 1993, were studied. The percentage of EGC increased from 1977 to 1984, but thereafter remained more or less stable, despite a continuous increase in the number of endoscopic examinations. Three hundred and ninety-six patients were followed up. Twenty-nine patients died from the tumour, giving a 5-year survival rate of 82.8 per cent. The 'large' size type of EGC, the presence of submucosal penetration, and lymph-node metastasis showed a highly significant association with a lower survival rate. A small number of patients died despite the presence of 'favourable' prognostic factors. Other still unknown factors may therefore be important in determining the aggressive behaviour of certain EGCs.

Incidence, diagnosis and significance of multiple gastric cancer

Of 2790 patients with gastric cancer undergoing surgery between January 1978 and December 1993, 160 (with 356 neoplastic lesions) had synchronous multiple cancer. Of these lesions 271 (76 percent) were early cancers. Only 85 (53 percent) of the 160 patients were diagnosed before operation as having multiple cancer; 69 further patients (43 percent) were diagnosed during the course of the operation. Small flat (IIb) and depressed (IIc) type lesions had a propensity to be missed before operation. The incidence of multiple cancer was relatively low, indicating that several microscopic lesions might have been overlooked in this series. There has, however, only been one patient (1 percent) with subsequent cancer of the gastric remnant of 126 with multiple cancer and postoperative gastric remnants over the past 16 years. This might be because of co-resection of unrecognized lesions by distal gastrectomy in 68 percent of the patients. Alternatively some microscopic cancers might not invariably be destined to grow into clinically significant lesions over 10 or more years.

Early gastric cancer. A 25-year surgical experience

OBJECTIVE

Special emphasis has been placed on pathologic features, survival after surgical treatment, and prognostic factors.

SUMMARY BACKGROUND DATA

Incidence is much lower in Western countries than in Japan. All degrees of tumor differentiation met in invasive cancer may be found. Prognosis is remarkably good, compared with advanced gastric cancer.

METHODS

After reexamination of the pathologic specimens of 115 patients, 101 patients were included in this study; 58 were male. Mean age was 60.7 years. Preoperative biopsies were positive in 88%. The lesion was located in the antrum in 78 patients. Subtotal gastrectomy was performed in 85 patients and total gastrectomy in 13 patients with a RI lymph node resection.

RESULTS

Cancer was extended to submucosa in 68.3%, poorly differentiated in 48.5%, and multifocal in 12.9% of patients. Lymph node involvement was present in 18.8%. Secondary deaths (n = 25) were in relation with the cancer in 6 patients only. The 5-, 10-, 15-, and 20-year actuarial crude survival rates were 88, 65, 58, and 51%, respectively. The survival rate was significantly higher for mucosal lesions than for submucosal lesions (p < 0.01). Survival showed no significant correlation with lymph node involvement, tumor size, and differentiation.

CONCLUSIONS

Subtotal gastrectomy is recommended, except for proximal lesions, with survey of the gastric stump. Prognosis is significantly better for cancers limited to mucosa. Early gastric cancer is not a specific entity. Transitions between early and advanced carcinomas, especially observed in the poorly differentiated carcinomas with signet ring cells, suggest that this type of cancer should be a precursor of the invasive gastric carcinomas.

Surgical strategy for early gastric cancer

The diagnostic and therapeutic options in early gastric cancer are reviewed. In Japan, the rate of detection of early gastric cancers has increased so that minute gastric cancers can now be identified as a result of advances in diagnostic methods. The results of histopathological staging of a large number of resected specimens have led to three surgical options based on size and depth of the primary lesion, namely classical R2 resection, radical resection with limited lymphadenectomy and endoscopic surgery.

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.

Relation between severity and extent of precancerous lesions in the postoperative stomach

The relation between the severity and extent of precancerous lesions in a precancerous condition of the stomach was assessed, to find a means of reducing the endoscopic workload required for the detection of such lesions. 87 subjects who had had gastric surgery for peptic ulcer more than 20 years ago underwent gastric endoscopy and biopsy. Severity of dysplasia correlated with its extent. Severity of intestinal metaplasia correlated with its extent and with severity of dysplasia. Type of operation, but not sex or type of ulcer, was the factor most strongly associated with dysplasia. Previous Billroth II operations were more strongly associated with occurrence of dysplasia (85%) than were other operations. In patients with previous Billroth II operations, moderate and severe dysplasia were commoner around the stoma (37%) than in the body (10%). These findings indicate that there is a relation between the severity and extent of precancerous lesions, which suggests that patients with dysplasia have widespread gastric mucosal instability. They also indicate that, if endoscopic screening is limited to Bilroth II subjects and if biopsies are limited to the stoma, endoscopic workload can be reduced by 85%, with only a small reduction (15%) in detection of moderate and severe dysplasia.

A clinicopathologic study on multiple gastric cancers with special reference to distal gastrectomy

Simultaneous multiple gastric cancer was seen in 49 (5.8%) of 852 resected stomachs. Patients with multiple cancers were older than those with single gastric cancers (P less than 0.01) and the incidence of multiple gastric cancer was significantly higher in male patients than in female patients (P less than 0.05). The incidence rates of multiple carcinomas were 9.6% of early gastric carcinomas and 4.0% of advanced gastric carcinomas. With regard to histologic type, the incidence rate of the differentiated type was 71% and the incidence rate of the undifferentiated type was 29%. In 68 serially resected stomachs, 5 (7.4%) new multiple cancers were detected microscopically, whereas 4 (5.9%) had already been diagnosed grossly. The incidence rate of multiple carcinoma increased to 13.2% by this procedure. The cases that were cut serially showed that most of the multiple cancers were located distally from the F-line presenting the line along which intestinal metaplasia appeared. This study suggests that the surgeon is required to resect the area including the F-line at the time of distal gastrectomy so as not to leave another cancer in the gastric remnant.

A clinicopathologic study on multiple gastric cancers with special reference to distal gastrectomy

Simultaneous multiple gastric cancer was seen in 49 (5.8%) of 852 resected stomachs. Patients with multiple cancers were older than those with single gastric cancers (P less than 0.01) and the incidence of multiple gastric cancer was significantly higher in male patients than in female patients (P less than 0.05). The incidence rates of multiple carcinomas were 9.6% of early gastric carcinomas and 4.0% of advanced gastric carcinomas. With regard to histologic type, the incidence rate of the differentiated type was 71% and the incidence rate of the undifferentiated type was 29%. In 68 serially resected stomachs, 5 (7.4%) new multiple cancers were detected microscopically, whereas 4 (5.9%) had already been diagnosed grossly. The incidence rate of multiple carcinoma increased to 13.2% by this procedure. The cases that were cut serially showed that most of the multiple cancers were located distally from the F-line presenting the line along which intestinal metaplasia appeared. This study suggests that the surgeon is required to resect the area including the F-line at the time of distal gastrectomy so as not to leave another cancer in the gastric remnant.

Radical surgery for gastric cancer. A review of the Japanese experience

Overall results after operations for gastric cancer in Japan are far superior to results obtained in the US and Europe. We have reviewed the Japanese literature in an effort to determine what factors explain this difference. It appears that the survival differences are due mainly to a greater frequency of early gastric cancer in Japan; meticulous histopathologic evaluation of the surgical specimens, resulting in more accurate pathologic staging; and the presumed benefit of extended nodal dissection when it extends outside of the level of node-positive disease. Although patients with both apparent and confirmed direct adjacent organ invasion can be helped by resection of those organs, extended resections of uninvolved pancreas and spleen do not improve rate of survival beyond the benefit of improved nodal dissection. Overall, there would appear to be justification for reexamining extended nodal dissection for gastric cancer in the US. Opportunities for a meaningful national study are significant.

Early gastric carcinoma with special reference to macroscopic classification

During a period beginning in 1946 and ending in October of 1978, 1000 cases of solitary early gastric carcinoma were operated on at the Cancer Institute Hospital, Tokyo, Japan. The clinical characteristics and the macroscopic and chronological changes were studied in these cases. Early gastric carcinoma comprised one third of all resected gastric carcinoma. If early gastric carcinoma was divided into two groups, the depressed and the elevated, the former was more common. By location, the depressed type lesions were more frequently seen in the middle third of the stomach and the elevated type lesions in the lower third. By age, distribution of the elevated type lesions showed a peak with a mode at the age of 60 to 69 years and of the depressed type, a plateau with a mode at the age of 50 to 59 years. The relative incidence of the elevated type of gastric carcinoma to the depressed type was one to four. In depth of invasion, the mucosa and the submucosa were equally involved. Lymph node metastases were encountered in 12.7% of early gastric carcinoma cases. The incidence of positive nodes in mucosal carcinoma was 3.4% and that of submucosal lesions was 21.7%. Of the elevated type carcinoma, 20.9% of the cases had positive nodes. The 5-year survival rate of the patients with surgery for cure was 93.8% in contrast to 56.5% of those with palliative resection.