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

Comparison of clinical outcomes and prognosis between surgery and endoscopic submucosal dissection in patients with synchronous multifocal early gastric cancer

BACKGROUND

Synchronous multiple early gastric cancer (SMEGC) refers to the simultaneous occurrence of two or more malignant cancer lesions in the stomach. For patients with multiple early gastric carcinomas, the choice of appropriate treatment remains controversial. This study is dedicated to comparing the clinical outcomes and prognosis of patients with SMEGC who underwent endoscopic submucosal dissection (ESD) or gastrectomy.

METHODS

A total of 180 patients with more than one malignant cancer lesion in the stomach who had received gastrectomy or ESD between 2012 and 2021 were retrospectively evaluated to determine their clinical outcomes and prognosis. Univariate and multivariate logistic regression were utilized to identify risk factors for tumor recurrence.

RESULTS

Over the 57.5 months median follow-up period for the 140 enrolled cases, tumor recurrence occurred in 8 (12%) in the ESD group but only 1 (1%) in the surgery group. Relapse-free survival (RFS) was higher in the surgery group (p = 0.023) in all cases; however, there was no significant difference in Overall survival (OS, p = 0.772). Complications were significantly higher in the surgery group than in the ESD group, but fewer in the radical distal gastrectomy group. Multivariate regression analysis revealed that ESD(p = 0.034), the main lesion size > 2 cm(p = 0.019), and undifferentiated tumor(p = 0.022) were independent risk factors for tumor recurrence.

CONCLUSIONS

For the treatment of simultaneous multifocal early gastric cancer, ESD has a good short-term effect and higher quality of life. However, ESD has a higher risk of recurrence than surgery. And we found that the partial gastrectomy appears to be considered as adequate treatment for some SMEGC patients.

Endoscopic Screening for Missed Lesions of Synchronous Multiple Early Gastric Cancer during Endoscopic Submucosal Dissection

Aims

To evaluate the value of endoscopic screening during endoscopic submucosal dissection (ESD) in the detection of synchronous multiple early gastric cancer (SMEGC) and the risk factors for missed diagnosis of SMEGC.

Methods

We conducted gastric endoscopic screening during ESD operation in 271 patients with early gastric cancer (EGC) referred for ESD, and endoscopic follow-up within 1 year after the operation. The detection and characteristics of SMEGC were analyzed in three stages: before ESD, during ESD operation, and within 1 year after ESD.

Results

SMEGC was detected in 37 of 271 patients (13.6%). Among them, 21 patients with SMEGC (56.8%) were diagnosed before ESD, 9 (24.3%) were diagnosed with SMEGC by endoscopic screening during ESD operation, and 7 (18.9%) were found to have EGC lesions in the stomach during postoperative endoscopic follow-up within 1 year. The preoperative missed detection rate of SMEGC was 43.2%, and the rate of missed detection could be reduced by 24.3% (9/37) with endoscopic screening during ESD operation. Missed SMEGC lesions were more common in flat or depressed type and smaller in size than the lesions found before ESD. The presence of severe atrophic gastritis and age ≥60 years were significantly correlated with SMEGC (P < 0.05), while multivariate analysis showed that age ≥60 years was an independent risk factor (OR = 2.63, P < 0.05) for SMEGC.

Conclusions

SMEGC lesions are apt to be missed endoscopically. Special attention should be paid to small, depressed, or flat lesions in detecting SMEGC, especially in elderly patients or (and) patients with severe atrophic gastritis. Endoscopic screening during ESD operation can effectively reduce the missed diagnosis rate of SMEGC.

Long-term outcomes and clinical safety of expanded indication early gastric cancer treated with endoscopic submucosal dissection versus surgical resection: a meta-analysis

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) remains an investigational issue for early gastric cancer (EGC) with expanded indications owing to the risk of lymph node metastasis. In this study, we aimed to evaluate the clinical outcomes and safety of ESD versus surgical resection (SR) for EGC with expanded indications.

METHODS

The systematic review selected studies from PubMed, Embase, Cochrane and Web of Science databases from 2010 to 2020, and compared survival and clinical safety data of ESD with those of surgical resection for EGC with expanded indications. The fixed-effects or random-effects model was used to calculate the differences between the two groups. To assess the validity of the eligible studies, risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Nine retrospective studies were used to calculate the differences in survival and clinical safety data between the two groups for EGC with expanded indications. Differences were not significant between the groups in terms of age, sex, tumour size, tumour histology or lesion morphology. Regarding tumour site, tumours located in the L area (the lower third of the stomach) were more likely to be found in the ESD group. With regard to metachronous and synchronous carcinomas, there was a significant difference favouring SR treatment (metachronous: OR=0.12, 95% CI=0.05 to 0.25, p<0.00001; synchronous: OR=0.11, 95% CI=0.02 to 0.46, p=0.003). Adverse event data were identified in six studies showing a significant difference favouring ESD treatment (ESD vs SR, OR=0.49, 95% CI=0.34 to 0.72. p=0.002). Additionally, six studies evaluating 5-year overall survival showed no significant differences between the two groups (HR=1.22, 95% CI=0.66 to 2.25, p=0.53). With regard to 5-year disease-free survival, patients with expanded indication EGC undergoing SR showed better survival (ESD vs SR, HR=3.29, 95% CI=1.60 to 6.76, p=0.001).

CONCLUSION

ESD provided favourable results for patients with EGC with expanded indications regarding clinical outcomes and safety in retrospective studies. Further, to detect synchronous or metachronous lesions, endoscopic surveillance should be performed following ESD. However, the included studies were observational, some did not have adequate adjustment for confounding factors and their results lacked generalisability due to their origin. Thus, further related randomised controlled trials are urgently encouraged.

PROSPERO REGISTRATION NUMBER

CRD42021251068.

Diagnosis and clinical implication of collision gastric adenocarcinomas: a case report

BACKGROUND

Collision tumors are a subtype of simultaneous tumors wherein two unrelated tumors collide or infiltrate each other. Collision gastric adenocarcinomas (CGA) are rare and difficult to diagnose, and their clinical implications remain unclear. Herein, we aimed to reveal diagnostic methods for CGA and provide insight into its implications.

CASE PRESENTATION

Among 1041 cases of gastric cancers (GCs) resected between 2008 and 2018, we included cases of confirmed CGA. Patients' backgrounds, preoperative endoscopy findings, macroscopic imaging findings, and histopathology findings [including immunostaining for CK 7, MUC2, and mismatch repair (MMR) proteins] were investigated. The incidence of CGA was 0.5%: 5 of 81 cases having simultaneous multiple GCs. Tumors were mainly in the distal stomach. The CGA in two cases was between early cancers, in two cases was between early and advanced cancers, and in one case was between advanced cancers. There were three cases of collision between differentiated and undifferentiated types and two cases between differentiated types. Immunostaining with CK7 and MUC2 was useful for diagnosing collision tumor when the histology was similar to each other. Among ten GCs comprising CGA, nine tumors (90%) exhibited deficient MMR proteins, suggesting high microsatellite instability (MSI).

CONCLUSIONS

CGA is rare and usually found in the distal stomach. Close observation of shape, optimal dissection, and detailed pathological examination, including immunostaining, facilitated diagnosis. CGAs may have high MSI potential.

High Expression of Claudin-4 Is Associated with Synchronous Tumors in Patients with Early Gastric Cancer

Claudin (CLDN) is a tight junction protein found in human epithelial cells and its altered expression is known to be associated with the progression of gastric cancer. We aimed to investigate the differential expression of CLDN-4 in early gastric cancer (EGC) according to its clinicopathological characteristics. We enrolled 53 patients with EGC who underwent surgical gastric resection from January 2007 to December 2018. The staining intensity of the tumor cells was scored as 0–3, and the percentage of staining was scored as 0–5; high expression was defined if the intensity plus percentage score was 7 or 8, and low expression was defined if the score was 0–6. Among the 53 patients, 16 (30.2%) showed low CLDN-4 expression, while 37 (69.8%) had high CLDN-4 expression. High CLDN-4 expression was significantly associated with intestinal-type EGC (low: 12.5% vs. high: 56.8%, p = 0.003), open-type atrophic change (low: 60.0% vs. high: 90.9%, p = 0.011), and the presence of synchronous tumors (0 vs. 32.4%, p = 0.010), and all 12 EGCs with synchronous tumors showed high CLDN-4 expression. However, expression of CLDN-3, a typical intestinal phenotype CLDN, was neither correlated with CLDN-4 expression nor associated with synchronous tumors. Taken together, high CLDN-4 expression may be considered as an auxiliary tool for screening synchronous tumors in patients with EGC.

A predictive risk-scoring model for multiple synchronous early gastric cancers or gastric dysplasia before initial endoscopic resection

OBJECTIVE

To establish a new and easy-to-use risk-scoring predictive model to help identify high-risk patients with multiple synchronous gastric neoplasms (MSGN), including early gastric cancer (EGC) and gastric dysplasia (GD), before initial endoscopic resection (ER).

METHODS

We retrospectively enrolled 1361 patients with EGC or GD who had undergone ER from November 2006 to September 2019. The patients were randomly divided into the training (n = 681) and validation cohorts (n = 680). In the training phase a prediction score was constructed to assess the independent predictors of MSGN based on multivariate logistic regression analysis. The performance of the prediction model was evaluated using the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow test.

RESULTS

Of the 1361 patients, 122 (9.0%) had MSGN. Three predictors for MSGN were scored and weighted, as follows: elderly male (≥65 y; three points), a family history of gastric cancer (two points) and surface redness (two points). Accordingly, patients were divided into the low (risk score, 0-3 points) or high-risk groups (risk score, 4-7 points). In the validation cohort, the incidence of MSGN in the low-risk and high-risk groups were 6.1% and 32.0%, respectively (P < 0.001). Our predictive risk-scoring model showed good discrimination (the area under the ROC curve [AUROC] 0.719, 95% confidence interval [CI] 0.634-0.794, P < 0.001) and calibration ability (Hosmer-Lemeshow test, χ²  = 6.539, P = 0.587) in the validation group.

CONCLUSION

This risk-scoring model has a good performance in predicting MSGN before the initial ER.

Clinicopathological features and risk factors analysis of lymph node metastasis and long-term prognosis in patients with synchronous multiple gastric cancer

Background

As a common malignancy, gastric cancer (GC) remains an important threat to human’s health. The incidence of synchronous multiple gastric cancer (SMGC) has increased obviously with technical advances of endoscopic and pathological examinations. Several studies have investigated the relationship between SMGC and solitary gastric cancer (SGC). However, little is known about the relationship between early and advanced SMGCs, and the independent risk factors of lymph node metastasis and prognosis in SMGC patients remain unclear.

Methods

We retrospectively collected 57 patients diagnosed as SMGC and underwent radical gastrectomies from December 2011 to September 2019. Epidemiological data and clinicopathological characteristics of all patients were recorded. Postoperative follow-up was performed by telephone or outpatient service. Chi-squared test or Fisher’s exact test was adopted in analysis of categorical data. Continuous data were analyzed by using unpaired t test. Univariate and multivariate analyses were performed to investigate the independent risk factors of lymph node metastasis and tumor recurrence of SMGC.

Results

There were 45 males and 12 females. The average age was 62.1 years old. There were 20 patients with early SMGC and 37 patients with advanced SMGC. Most of patients (91.2%) had two malignant lesions. Tumor recurrence occurred in 8 patients, among which 7 patients died from recurrence. The rates of total gastrectomy, tumor size ≥ 2 cm, poorly differentiated type, lymph node metastasis, ulcer and nerve invasion, and preoperative CEA level were significantly higher in advanced SMGC patients compared to those with early SMGC. Lymphovascular cancer plug and preoperative CA125 were the independent risk factors of lymph node metastasis in patients with SMGC. Lymph node metastasis, nerve invasion, and preoperative AFP might be the risk factors of tumor recurrence of SMGC, but need further validation.

Conclusions

In patients with SMGC, the presence of tumor size ≥ 2 cm, poorly differentiated type, lymph node metastasis, ulcer, nerve invasion, and relatively high preoperative CEA level might indicate the advanced SMGC. More attention should be paid to lymph node metastasis in SMGC patients with lymphovascular cancer plug and high preoperative CA125. Lymph node metastasis, nerve invasion, and preoperative AFP might be associated with recurrence of SMGC, needing further validation.

White globe appearance is an endoscopic predictive factor for synchronous multiple gastric cancer

Background

White globe appearance (WGA) is a small white lesion with a globular shape identified during magnifying endoscopy with narrow-band imaging. However, the association between WGA and synchronous multiple gastric cancer (SMGC) remains unclear.

Methods

Consecutive patients who underwent endoscopic submucosal dissection for gastric cancer (GC) between July 2013 and April 2015 at our institution were eligible for this study. We excluded patients with a history of gastric tumor or gastrectomy. Patients who had more than 2 GCs in their postoperative pathological evaluation were classified as SMGC-positive, and patients who had at least 1 WGA-positive GC were classified as WGA-positive patients. The primary outcome was a comparison of the prevalence of WGA in patients classified as SMGC-positive and SMGC-negative. Univariate and multivariate analyses were performed using the following variables: WGA, age, sex, atrophy, and Helicobacter pylori (H. pylori) status.

Results

There were 26 and 181 patients classified as SMGC-positive and SMGC-negative, respectively. Univariate analysis revealed that WGA-positive classification (50% vs. 23%, P=0.008) and male sex (88% vs. 66%, P=0.02) were significant factors associated with SMGC classification, while age ≥65 years (81% vs. 81%, P>0.99), severe atrophy (46% vs. 46%, P>0.99), and H. pylori positivity (69% vs. 65%, P=0.8) were not. In the multivariate analysis, only WGA-positive classification (odds ratio 2.78, 95% confidence interval 1.16-6.67; P=0.02) was a significant independent risk factor for SMGC.

Conclusions

Our exploratory study showed the possibility of WGA as a predictive factor for SMGC. In cases of WGA-positive gastric cancer, careful examination might be needed to diagnose SMGC.

Clinicopathological features, risk of lymph node metastasis and survival outcome of synchronous multiple early gastric cancer

OBJECTIVE

To determine clinicopathological features, risk of lymph node metastasis (LNM) and survival outcome in synchronous multiple early gastric cancer (MEGC) patients.

METHODS

A total of 338 solitary early gastric cancer (SEGC) and 26 MEGC patients who underwent surgical resection were retrospectively reviewed. The clinicopathological features and predictive factors for MEGC patients were evaluated. Also, we analyzed risk factors for LNM and compared survival difference between SEGC and MEGC patients.

RESULTS

The frequency of multiple synchronous lesions was 7.1% in early gastric cancer (EGC) patients. The main and minor lesions were mostly confined to the same third of the stomach (84.6%, 22/26), and the most common location was the lower third of the stomach. With regard to the number of coexisting lesions, most of the patients had two lesions and more than three lesions were not common. Tumor size≤2cm (OR:2.684, 95%CI:1.131-6.368, P<0.05) and the presence of atrophic gastritis (OR:2.418, 95%CI:1.052-5.555, P<0.05) were independent risk factors for synchronous MEGC. There was no significant statistical difference between SEGC and MEGC for LNM (17.5% vs 23.1%, P=0.311). The number of coexisting lesions was not associated with the risk of LNM in EGC. In addition, the survival outcome of MEGC patients was similar to that of SEGC (5-year RFS rate, 96.0% vs 93.7%, P=0.329;5-year OS rate, 96.0% vs 88.3%, P=0.479).

CONCLUSION

Meticulous endoscopic examination at the initial diagnosis of MEGC was very important, especially for those with precancerous lesions such as atrophic gastritis. In terms of treatment methods, endoscopic resection may be equally suitable for synchronous MEGC if the lesions fulfilled its indication criteria.

Risk of multiple early gastric cancers in a patient with precursor lesions and endoscopic surveillance for 7 years: A case report

RATIONALE

Severe mucosal atrophy or intestinal metaplasia is a risk factor for synchronous and metachronous intestinal gastric cancer. Magnifying endoscopy with narrow-band imaging was useful for assessing differentiated early gastric cancer (EGC).

PATIENT CONCERNS

A 62-year-old Chinese female was diagnosed with 5 multiple EGCs or high-grade dysplasia (HGD) with endoscopic surveillance for 7 years.

DIAGNOSES

Synchronous and metachronous multiple EGCs.

INTERVENTIONS

Endoscopic submucosal dissection (ESD) with en bloc resection was performed for all 5 multiple lesions. The ESD specimens were pathologically diagnosed with adenocarcinoma confined to the mucosa or HGD.

OUTCOMES

After endoscopy resection, no residual, recurrent, or synchronous lesions were detected by endoscopic surveillance after ESD.

LESSONS

Long-term, meticulous endoscopic surveillance is needed to monitor risk factors associated with multiple EGCs in patients with severe mucosal atrophy or intestinal metaplasia despite successful Helicobacter pylori eradication.

Characteristics of Synchronous and Metachronous Multiple Gastric Tumors after Endoscopic Submucosal Dissection of Early Gastric Neoplasm

Background/Aims

Endoscopic submucosal dissection (ESD) has been widely accepted as a method of treatment of early gastric tumor. This study aimed to identify the incidence and characteristics of multiple gastric tumors after ESD.

Methods

Patients with early gastric tumors who were treated by ESD from January 2004 to June 2012 and followed up with endoscopic examination periodically for at least 1 year were enrolled. All multiple gastric lesions were subsequently treated with ESD and the medical records of the patients were retrospectively reviewed.

Results

In total, 643 patients were included. The mean duration of endoscopic follow-up was 45.27±27.59 (range, 12–148) months. Overall, 144 patients (22.4%) showed multiple gastric tumors during the follow-up period (44 synchronous [6.8%] and 100 metachronous [15.5%]). The cumulative incidence rate steadily increased during the follow-up period. More than 50% of the tumors that developed at the same longitudinal location of the stomach were of the same macroscopic and histological type as the primary lesions.

Conclusions

Because synchronous and/or metachronous gastric tumors are common, considerable attention should be paid to detect multiple gastric lesions after ESD of early gastric neoplasm.

Simultaneous endoscopic submucosal dissection for multiple early gastric cancers in a low volume center

The aim of the study is to evaluate the safety and efficacy of simultaneous endoscopic submucosal dissection (ESD) for multiple early gastric cancers.A total of 70 solitary early gastric cancers from 70 patients and 20 multiple early gastric cancers from 10 patients were included in this retrospective study. The curative resection rate, en bloc resection rate, procedure-related complications, and local recurrence were compared between the 2 groups.There was no statistical difference in the rate of complete resection, en bloc resection, and curative resection between the 2 groups (P > .05). No significant difference was found with respect to the occurrence of postoperative bleeding (P > .05). Procedure time was significantly longer in the simultaneous group than that in the single group (87.6 ± 25.1 min vs 54.6 ± 22.0 min, P = .004). The overall incidence of synchronous early gastric cancer was 7.5%.Simultaneous ESD for multiple early gastric cancers is a safe and feasible choice in low-volume hospital. The entire stomach should be examined meticulously during and after ESD. Larger randomized studies are needed to validate our results.

Predictive risk factors associated with synchronous multiple early gastric cancer

The aim of this study was to elucidate the predictive risk factors of synchronous multiple early gastric cancer regardless of the treatment modality.Patients who underwent early gastric cancer treatment between July 2005 and June 2015 were retrospectively reviewed. In total, 1529 patients who were treated for early gastric cancer were included. We analyzed the patient's data to find predictive factors of synchronous multiple early gastric cancer compared to solitary early gastric cancer. Further analysis was performed to verify the difference between endoscopic and surgical treatment groups.Among the 1529 patients, synchronous multiple early gastric cancer was diagnosed in 68 (4.4%) patients. Significant differences in sex (P = .004), gross appearance (P = .038), depth of invasion (P = .007), and lymphovascular invasion (P = .039) were found between patients with solitary early gastric cancer and synchronous multiple early gastric cancer by univariate analysis. In multivariate analysis, male sex (odds ratio, 2.475; P = .011) and submucosal invasion (odds ratio, 1.850; P = .033) were independent predictive risk factors of synchronous multiple early gastric cancer. In addition, in multivariate analysis, significant differences in age, tumor size, longitudinal location, depth of invasion, and histology were found between patients groups depending on the mode of treatment.Male sex and submucosal invasion were predictive risk factors of synchronous multiple early gastric cancer. Patients with these factors should undergo more meticulous endoscopic surveillance.

Growth Patterns of Signet Ring Cell Carcinoma of the Stomach for Endoscopic Resection

Background/Aims

It is difficult to precisely detect the lateral margin during endoscopic submucosal dissection (ESD) for signet ring cell carcinoma (SRC) because SRC often expands to lateral direction through the lamina propria. Thus, the aim of this study was to classify the intramucosal spreading patterns of SRC and to analyze the patients’ clinicopathological findings according to the spreading patterns.

Methods

The intramucosal spreading patterns of SRC were classified as expansive or infiltrative types. A total of 100 surgical and 42 ESD specimens were reviewed.

Results

In the surgical specimens, the proportions of expansive and infiltrative types were 44% and 56%, respectively. The infiltrative type was more commonly associated with old age, atrophy, and intestinal metaplasia in surrounding mucosa and the absence of Helicobacter pylori compared with the expansive type. In ESD specimens, the proportions of expansive and infiltrative types were each 50%. When lateral margin-positive lesions were compared with -negative lesions, larger size, residual lesion, and the lack of a neutrophil infiltration were more significantly associated with lateral margin-positive lesions. All cases with residual tumors in lateral margin-positive lesions were classified as the infiltrative type.

Conclusions

SRC surrounded with atrophy and/or intestinal metaplasia often spreads subepithelially in the margin. This finding may suggest that a larger safety margin is necessary in this type during ESD.

Clinicopathologic Similarities of the Main and Minor Lesions of Synchronous Multiple Early Gastric Cancer

The detection rate of early gastric cancer (EGC) is increasing due to improvements in diagnostic methods, but synchronous multiple EGC (SMEGC) remains a major problem. Therefore, we investigated the characteristics of and the correlation between the main and minor lesions of SMEGC. We retrospectively reviewed the medical records of patients with EGC between April 2008 and May 2013. The main lesion was defined as the one with the greatest invasion depth. If lesions had the same invasion depth, the tumor diameter was used to define the main lesion. Of 963 patients who had treatment for EGC, 37 patients with SMEGC were analyzed. The main and minor lesions showed a significant positive correlation of size (r = 0.533, P = 0.001). The main and minor lesions of SMEGC showed the same vertical and horizontal locations at 70.3% and 64.9%, respectively (P = 0.002 and P = 0.002). Macroscopic types were identical in 67.6% (P < 0.001), and 32.4% had identical macroscopic type and location. The main and minor lesions had identical characteristics of invasion depth, presence of lymphovascular invasion (LVI), and differentiation in 78.4%, 83.8%, and 83.8%, respectively. Differentiation, LVI, and invasion depth (microscopic characteristics) were simultaneously the same in 62.2%. The location, macroscopic type, and 3 microscopic characteristics were matched in 27%. The main and minor lesions of SMEGC have similar clinicopathologic characteristics. Therefore, the possibility of SMEGC should not be neglected in cases of EGC, considering an understanding of the characteristics and association of lesions.

The 7th AJCC/UICC TNM staging system may be not suitable in predicting prognosis of synchronous multiple gastric carcinoma patients with D2 gastrectomy

To assess the suitability of the 7th AJCC/UICC TNM staging system in predicting the prognosis of synchronous multiple gastric carcinomas (SMGCs). A total of 129 SMGC patients who underwent gastrectomy with D2 lymphadenectomy from January 1999 to January 2009 were enrolled in this study. The location, diameter, and depth of invasion of the main tumor were all related to prognosis (P < 0.05). Multivariate analysis revealed depth of invasion as an independent predictive factor for survival (P < 0.05). Interestingly, logistic regression analysis showed that the 7th AJCC/UICC N staging system was unable to significantly predict survival in SMGCS patients (P > 0.05). Cut-point survival analysis identified the most appropriate cut-offs for metastatic lymph nodes (MLNs) as 0, 1, 6, 10, and 19: patients with 0, 1-6, 7-10, and 11-19, and ≥ 20 MLNs had median survival times of 70, 56, 35, 52, and 32 months, respectively. Multivariate analysis suggested this new categorization of MLNs to be a significant predictor of survival (P < 0.05). Preoperative assessment of depth of invasion can help in the prognosis of SMGCs patients. The 7th UICC TNM staging system may be not suitable for SMGC patients and needs improvement for rational grading of SMGCs.

Increased incidence of secondary gastric neoplasia in patients with early gastric cancer and coexisting gastric neoplasia at the initial endoscopic evaluation

BACKGROUND AND AIMS

Multiple synchronous gastric cancers are found in up to 14% of affected patients. The aim of this study was to determine the incidence of secondary gastric neoplasia including missed synchronous gastric neoplasia in this patient group compared with that after a single cancer resection.

PATIENTS AND METHODS

Four hundred and forty patients who underwent endoscopic resection for early gastric cancer (EGC) were divided into two groups: those with or without synchronous gastric neoplasia at the initial assessment. Secondary gastric neoplasia was defined as missed synchronous gastric neoplasia or metachronous gastric neoplasia. We compared the clinicopathological characteristics and the incidence of secondary gastric neoplasia between the two groups.

RESULTS

Synchronous gastric neoplasias were found in 34 patients (7.7%) at the initial endoscopic examination of EGC. Secondary gastric neoplasias were found in 67 of 440 patients (15.2%) during the follow-up period (median 24.0 months). The incidence of secondary gastric neoplasia and missed synchronous gastric neoplasia was higher in those patients with synchronous gastric neoplasia than in those with a solitary EGC at the initial treatment (P<0.01). Between the two groups, the risk of the secondary neoplasia was significantly higher within 1 year after endoscopic resection (P<0.01), but not after 1 year (P=0.20).

CONCLUSION

EGC with synchronous gastric neoplasia at the initial endoscopic examination was associated with an increased risk of secondary gastric neoplasia. These patients should be evaluated carefully with a shorter interval after the initial treatment.

Endoscopic surveillance strategy after endoscopic resection for early gastric cancer

Early detection of early gastric cancer (EGC) is important to improve the prognosis of patients with gastric cancer. Recent advances in endoscopic modalities and treatment devices, such as image-enhanced endoscopy and high-frequency generators, may make endoscopic treatment, such as endoscopic submucosal dissection, a therapeutic option for gastric intraepithelial neoplasia. Consequently, short-term outcomes of endoscopic resection (ER) for EGC have improved. Therefore, surveillance with endoscopy after ER for EGC is becoming more important, but how to perform endoscopic surveillance after ER has not been established, even though the follow-up strategy for more advanced gastric cancer has been outlined. Therefore, a surveillance strategy for patients with EGC after ER is needed.

Incidence of metachronous gastric cancer in the remnant stomach after synchronous multiple cancer surgery

BACKGROUND

In the preoperative evaluation for gastric cancer, high-resolution endoscopic technologies allow us to detect small accessory lesions. However, it is not known if the gastric remnant after partial gastrectomy for synchronous multiple gastric cancers has a greater risk for metachronous cancer. The purpose of this study was to determine the incidence of metachronous cancer in this patient subset compared with that after solitary cancer surgery.

METHODS

Data on a consecutive series of 1,281 patients gastrectomized for early gastric cancer from 1991 to 2007 were analyzed retrospectively. The 715 gastric remnants after distal gastrectomy were periodically surveyed by endoscopic examination in Shikoku Cancer Center. Among those surveyed cases, 642 patients were pathologically diagnosed with solitary lesion (SO group) and 73 patients with synchronous multiple lesions (MU group) at the time of the initial surgery.

RESULTS

In the follow-up period, 15 patients in the SO group and 3 patients in the MU group were diagnosed as having metachronous cancer in the gastric remnant. The cumulative 4-year incidence rate was 1.9 % in the SO group and 5.5 % in the MU group. The difference did not reach the significant level by the log-rank test.

CONCLUSIONS

The incidence of metachronous cancer is higher after multiple cancer surgery; however, the difference is not statistically significant.

Characteristics and prognosis of synchronous multiple early gastric cancer

AIM: To assess the clinicopathologic characteristics, risk factors, and prognosis for synchronous multiple early gastric cancer (SMGC).

METHODS: A total of 146 patients with SMGC and 1194 patients with single gastric cancer who had undergone gastrectomy between 1989 and 2008 were retrospectively analyzed to determine their clinicopathologic characteristics and postoperative survival. Tumors were classified into groups on the basis of location and histology. Smoking habits were evaluated using the Brinkman index. Clinical and pathological factors were compared using either Fisher’s exact test or Pearson’s χ² test. Logistic regression analysis was performed to identify independent risk factors. Survival rate was calculated using the Kaplan-Meier method.

RESULTS: SMGCs accounted for 10.9% of gastric cancer cases and occurred predominantly in elderly male patients with a family history of gastric cancer who were both smokers and drinkers. These tumors were typically macroscopically elevated and histologically differentiated. There were no significant differences between SMGC and single gastric cancer patients with respect to tumor location, tumor size, lymph node metastasis, the number of metastatic lymph nodes, venous invasion, or tumor stage (P = 0.052, P = 0.347, P = 0.595, P = 0.805, P = 0.559, and P = 0.408, respectively). Further, there was no significant difference in postoperative survival between the patient groups (P = 0.200). Of the 146 SMGC patients, a single patient had remnant cancer.

CONCLUSION: A careful preoperative endoscopy is necessary for patients who are at high risk of SMGC, and minimally invasive treatment may be indicated in some cases.

How can we predict the presence of missed synchronous lesions after endoscopic submucosal dissection for early gastric cancers or gastric adenomas?

GOALS

To identify predictive factors associated with the presence of missed synchronous lesions after endoscopic submucosal dissection (ESD) for gastric adenoma or early gastric cancer (EGC).

BACKGROUND

Secondary gastric neoplasms that develop during follow-up period after ESD for gastric adenoma or EGC are divided into metachronous lesions and missed synchronous lesions.

METHODS

ESD was performed in 250 patients with EGC or gastric adenoma. The patients with endoscopic follow-ups of <1 year, patients without curative resection, and patients with additional surgery were excluded from the study. Missed synchronous lesions were defined as secondary gastric neoplasms detected within one year of ESD but initially missed. We compared clinicopathologic factors between patients with missed synchronous lesions and patients without missed synchronous lesions.

RESULTS

Missed synchronous lesions were found in 11.6% of the patients (29/250). The occurrence of missed synchronous lesions had significant correlation with tumor number at the time of ESD and age in the univariate analysis. Tumor number at the time of ESD and age were significant independent predictive factors for presence of missed synchronous lesions by multivariate logistic regression analysis (odds ratio 5.302, P = 0.006; odds ratio 2.315, P = 0.040, respectively). Missed synchronous lesions tended to be smaller, often located in the same third of the stomach as the main lesions.

CONCLUSIONS

Tumor number at the time of ESD and age could be predictive factors for the presence of missed synchronous lesions after ESD. Careful endoscopic surveillance should be performed after ESD for multiple lesions or for elderly patients.

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.

X-ray diagnosis of synchronous multiple primary carcinoma in the upper gastrointestinal tract

AIM: To analyze the radiological features of multiple primary carcinoma (MPC) in the upper gastrointestinal (GI) tract, study its biological characteristics and evaluate X-ray examination in its diagnosis.

METHODS: Hypotonic double-contrast GI radiography was performed in 59 multiple primary carcinoma cases, pathologically proved by surgery or endoscopy biopsy. Radiological findings were analyzed.

RESULTS: Of the 59 cases, esophageal MPC (EMPC) was seen in 24, esophageal and gastric MPC (EGMPC) in 27 and gastric MPC (GMPC) in 8. Of the 49 lesions found in 24 EMPC, hyperplastic type was seen in 23, medullary type in 9. The lesions were located at the upper (n = 17), middle (n = 19) or lower (n = 13) segment of the esophagus. In 27 EGMPC, the esophageal lesions were located at the middle (n = 16) or lower (n = 11) segment of the esophagus, while the gastric lesions were located at the gastric cardia (n = 16), fundus (n = 1), body (n = 3) and antrum (n = 7). The esophageal lesions were mainly of the hyperplastic type (n = 12) or medullary type (n = 7), while the gastric lesions were mainly of the hyperplastic type (n = 18). A total of 119 lesions in the 59 patients with synchronous multiple carcinoma were proved by surgery or endoscopy biopsy, and preoperative upper radiographic examination detected 100 of them (84.03% sensitivity). Eighteen (52.94%) of the T₁ lesions were found during preoperative diagnosis by radiographic examination. Moreover, only 3 (3.53%) of the T_2-4 lesions were misdiagnosed.

CONCLUSION: Hypotonic double-contrast upper gastrointestinal examination, providing accurate information about lesion morphology, location and size, can serve as a sensitive technique for the preoperative diagnosis of MPC.

P27(Kip1), regulated by glycogen synthase kinase-3β, results in HMBA-induced differentiation of human gastric cancer cells

BACKGROUND

Gastric cancer is the second most common cause of global cancer-related mortality. Although dedifferentiation predicts poor prognosis in gastric cancer, the molecular mechanism underlying dedifferentiation, which could provide fundamental insights into tumor development and progression, has yet to be elucidated. Furthermore, the molecular mechanism underlying the effects of hexamethylene bisacetamide (HMBA), a recently discovered differentiation inducer, requires investigation and there are no reported studies concerning the effect of HMBA on gastric cancer.

METHODS

Based on the results of FACS analysis, the levels of proteins involved in the cell cycle or apoptosis were determined using western blotting after single treatments and sequential combinations of HMBA and LiCl. GSK-3β and proton pump were investigated by western blotting after up-regulating Akt expression by Ad-Akt infection. To investigate the effects of HMBA on protein localization and the activities of GSK-3β, CDK2 and CDK4, kinase assays, immunoprecipitation and western blotting were performed. In addition, northern blotting and RNase protection assays were carried out to determine the functional concentration of HMBA.

RESULTS

HMBA increased p27(Kip1) expression and induced cell cycle arrest associated with gastric epithelial cell differentiation. In addition, treating gastric-derived cells with HMBA induced G0/G1 arrest and up-regulation of the proton pump, a marker of gastric cancer differentiation. Moreover, treatment with HMBA increased the expression and activity of GSK-3β in the nucleus but not the cytosol. HMBA decreased CDK2 activity and induced p27(Kip1) expression, which could be rescued by inhibition of GSK-3β. Furthermore, HMBA increased p27(Kip1) binding to CDK2, and this was abolished by GSK-3β inhibition.

CONCLUSIONS

The results presented herein suggest that GSK-3β functions by regulating p27(Kip1) assembly with CDK2, thereby playing a critical role in G0/G1 arrest associated with HMBA-induced gastric epithelial cell differentiation.

Endoscopic ultrasonography is valuable for identifying early gastric cancers meeting expanded-indication criteria for endoscopic submucosal dissection

BACKGROUND

Endoscopic ultrasonography (EUS) has become a reliable method for predicting the invasion depth of early gastric cancer (EGC). This study evaluated the accuracy of EUS in identifying lesions meeting expanded-indication criteria for endoscopic submucosal dissection (ESD) and analyzed clinicopathologic factors influencing the diagnostic accuracy of EUS in assessing tumor invasion depth.

METHODS

This study investigated 542 EGCs of 515 patients who underwent EUS pretreatment. The pretreatment EUS-determined diagnosis was compared with the final histopathologic evaluation of resected specimens, and the impact of various clinicopathologic parameters on diagnostic accuracy was analyzed.

RESULTS

The diagnostic accuracy of EUS in identifying lesions meeting expanded-indication criteria for ESD was 87.8% (259/295) for differentiated adenocarcinoma (D-type) 30 mm in diameter or smaller, 43.5% (10/23) for D-type tumor larger than 30 mm in diameter, and 75% (42/56) for undifferentiated adenocarcinoma (UD-type) 20 mm in diameter or smaller. Using multivariate analysis, the diagnostic accuracy of EUS in predicting tumor invasion depth was determined to be decreased significantly by ulcerous change and large tumor size (diameter, ≥30 mm).

CONCLUSION

For patients with EGC, D-type lesions 30 mm in diameter or smaller and UD-type lesions 20 mm in diameter or smaller can be diagnosed with high accuracy by EUS, but larger D-type lesions (diameter, >30 mm) should be considered carefully in terms of EUS-based treatment decisions. Findings of ulceration and large tumors are associated with incorrect diagnosis of tumor invasion depth by EUS.

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.