Clinicopathological properties of the superficial spreading type early gastric cancer

Successful treatment of gastric cancer with gastroduodenal intussusception by laparoscopic distal gastrectomy

We report a case of a 93-year-old woman with gastric cancer who presented with gastroduodenal intussusception and was treated with laparoscopic distal gastrectomy. Esophagogastroduodenoscopy showed a giant protruding lesion in the gastric antrum extending into the duodenal bulb, and biopsy confirmed a well-differentiated adenocarcinoma. Abdominal contrast-enhanced computed tomography (CT) revealed a well-defined mass with homogeneous enhancement and a stalk arising from the distal stomach extending into the duodenal bulb. With a clinical diagnosis of gastric cancer with gastroduodenal intussusception, the patient underwent laparoscopic distal gastrectomy with regional lymph node dissection and reconstruction using the Billroth I method. Reduction of the intussusception was performed through a 4 cm incision under the xiphoid process in the epigastric region because it could not be laparoscopically reduced. Gross examination of the resected specimen showed a well-circumscribed, elevated lesion measuring 11.2 × 4.7 × 3.6 cm in the antrum. Microscopic examination of the elevated tumor confirmed the diagnosis of well-differentiated adenocarcinoma invading the gastric submucosal layer without lymph node metastasis. There was no lymphatic or venous invasion or lymph node metastasis. The postoperative course was uneventful, and her hemoglobin level improved to 11.9 g/dL. The patient has been postoperatively well without evidence of recurrence for 3 months. Part of the superficial spreading-type tumor may be drawn into the duodenum under strong peristaltic movement because it does not infiltrate the muscle layer.

A case of superficial spreading type of poorly differentiated adenocarcinoma of the stomach with invasion to the esophagus

Background

Invasion is more likely to occur in gastric cancer affecting larger areas. Poorly differentiated adenocarcinoma tends to invade deep. The cardiac region prefers submucosal invasion because the submucosa is coarser than the other regions.

Case presentation

A 75-year-old man presented with a chief complaint of abdominal discomfort and weight loss. Esophagogastroduodenoscopy revealed an irregular ulcerative lesion with partial redness of the upper body and lesser curve of the stomach. A continuous shallow depressed lesion invaded the abdominal esophagus by approximately 40 mm. Poorly differentiated adenocarcinomas (por, sig) were observed on biopsy. Grossly, the cancer appeared to extend into the muscle layer; however, we could not confirm invasion into the muscle layer in our biopsy tissue. We diagnosed the lesion as a superficial spreading type of advanced gastric cancer and performed a total gastrectomy, D2-lymph node dissection (spleen preservation), Roux-en-Y reconstruction, and cholecystectomy. Postoperative histopathological examination revealed extensive infiltration of poorly differentiated adenocarcinoma (90 mm × 55 mm), and all were intramucosal lesions. The final pathological diagnosis was T1a, N0, M0, and Stage IA. The postoperative course was uneventful and the patient was discharged on postoperative day (POD) 11. Five years have passed since the operation, and the patient is alive without recurrence.

Conclusion

We encountered a case of gastric carcinoma in which poorly differentiated adenocarcinomas expanded extensively. All lesions were intramucosal.

Superficial Spreading-type Gastric Cancer with Situs Inversus Totalis

Situs inversus totalis (SIT) is a congenital anomaly characterized by a complete mirror-image transposition of the thoracic and abdominal viscera. We report on a rare case of superficial spreading gastric cancer associated with SIT in a 66-year-old woman referred to our hospital for examination of gastric cancer initially diagnosed by medical check-up. Esophagogastroduodenoscopy showed a slightly depressed lesion in the lesser curvature side of the stomach. Abdominal contrast-enhanced computed tomography showed complete transposition of the abdominal viscera, confirming SIT. The patient underwent total gastrectomy with regional lymph node dissection and Roux-en-Y reconstruction. Gross examination of the surgically resected specimen showed a slightly depressed lesion measuring 12×8 cm in diameter, and histopathology confirmed the diagnosis of signet-ring cell carcinoma, confined to the gastric mucosal layer without lymph node metastasis. The postoperative course was favorable, and the patient has been well without evidence of recurrence for 11 years following the operation. To the best of our knowledge, this is only the second case of a superficial spreading-type gastric cancer in a patient with SIT reported in the English literature.

Epstein-Barr virus-associated early gastric carcinoma with lymphoid stroma, accompanied with lymph node metastasis

The present case report presents a rare case of Epstein-Barr virus (EBV)-associated early gastric carcinoma with lymphoid stroma, accompanied by lymph node metastasis. A 61-year-old woman was referred to our hospital following observation of a gastric mass lesion that was initially diagnosed at a medical check-up. Esophagogastroduodenoscopy revealed a slightly elevated lesion with a central irregular depression in the middle third of the stomach. Endoscopic ultrasonography revealed a well-circumscribed hypoechoic mass located predominantly within the submucosa and the mucosa. Biopsy specimens of the lesion indicated the possibility of carcinoma with lymphoid stroma with a lymphoepithelial lesion. Abdominal contrast-enhanced computed tomography (CT) revealed a well-defined mass with homogeneous enhancement approximately 1.2 cm in diameter in the middle part of the stomach, demonstrating lymphadenopathy in the perigastric area at a maximum size of 1.4 cm in diameter. The patient underwent laparoscopic distal gastrectomy with regional lymphadenectomy due to suspicion of a gastric carcinoma with lymphoid stroma. Histopathological and immunohistochemical findings verified the diagnosis of carcinoma with lymphoid stroma, which were positive for EBV-encoded RNA (EBER-ISH) by in situ hybridization. There was one lymph node metastasis, which was in line with the CT imaging. Marked infiltration of lymphoid cells was observed in the tumor stroma, which were negative for EBER-ISH. The present case is informative of the pathological characteristics of this condition, and clinicians should recognize the features of this disease to make an accurate diagnosis and select the appropriate treatment.

Metachronous solitary splenic metastasis arising from early gastric cancer: a case report and literature review

BACKGROUND

The metastasis of malignant tumors to the spleen is rare, and only a small percentage of cases can be treated surgically, as splenic metastases generally occur in the context of multivisceral metastatic cancer at a terminal stage. We report a rare case of metachronous solitary splenic metastasis arising from early gastric cancer.

CASE PRESENTATION

A 75-year-old man was initially referred to our hospital for examination of gastric cancer, diagnosed at a medical check-up. Esophagogastroduodenoscopy showed a slightly elevated lesion with a central irregular depression in the upper-third of the stomach. Biopsy specimens of the lesion showed a moderately-differentiated adenocarcinoma, and abdominal computed tomography showed no evidence of distant metastases. Endoscopic submucosal dissection was performed, with histological confirmation of a moderately-differentiated adenocarcinoma invading the submucosal layer. The patient subsequently underwent laparoscopic total gastrectomy with regional lymph node dissection, resulting in no residual carcinoma and no lymph node metastasis. Computed tomography, 28 months later, showed a well-defined mass measuring 4.2 cm in diameter in the spleen, and the patient underwent a splenectomy, since there was no evidence of further metastatic lesions in any other organs. Histological examination confirmed the diagnosis of a poorly-differentiated adenocarcinoma originating from the previous gastric cancer. The patient was alive 2 months after surgical resection of the splenic metastasis without any recurrence.

CONCLUSION

To the best of our knowledge, this is only the second case of a solitary splenic metastasis from early gastric cancer to be reported in the English literature. The present case suggests surgical resection may be the preferred treatment of choice for patients with a solitary splenic metastasis from gastric cancer.

Gastric adenocarcinoma at the anastomotic site 50 years after gastrojejunostomy: A case report

We herein report a rare case of superficially spreading early gastric cancer occurring 50 years after gastrojejunostomy. An 83-year-old woman was diagnosed with gastric cancer after complaining of epigastric discomfort. The patient had undergone gastrojejunostomy with Braun jejunojejunostomy for benign chronic peptic ulcer 50 years prior. Esophagogastroduodenoscopy revealed an irregular nodular lesion on the gastric side of the anastomosis of the gastrojejunostomy. No abnormal lesions were identified by abdominal contrast-enhanced computed tomography. The patient underwent distal gastrectomy with regional lymphadenectomy. The final diagnosis was signet ring cell carcinoma invading the gastric submucosal layer, without lymph node metastasis, located in the area surrounding the original gastrojejunostomy and measuring 9.5×4.5 cm. In addition, dilated cystic glands were found in the submucosal layer, indicating gastritis cystica profunda. Following surgery, the patient remained symptom-free without evidence of recurrence for 46 months. Although it is not clear whether the adenocarcinoma at the stomal site was associated with the superficial spreading-type tumor in the present case, the observations may provide clues as to the pathogenic process of this entity.

Investigation of Endoscopic and Pathologic Features for Safe Endoscopic Treatment of Superficial Spreading Early Gastric Cancer

Superficial spreading early gastric cancer (EGC) is a rare disease that is treated mainly by surgery. There are few studies on the safety of endoscopic treatment for patients with superficial spreading EGC. The aims of this study were to (1) investigate the risk of lymph node metastasis of superficial spreading EGC and (2) investigate the potential criteria for endoscopic treatment of superficial spreading EGC using surgical specimens.Between 2000 and 2010, patients who received curative surgery of R0 resection at Severance Hospital (Seoul, Korea) for early gastric cancer were enrolled. The superficial spreading EGC was defined as cancer in which the longest tumor length was ≥6 cm. The medical records of the patients were reviewed retrospectively.Of the 3813 patients with EGC, 140 (3.7%) had lesions ≥ 6 cm, whereas 3673 (96.3%) had lesions < 6 cm. Patients with superficial spreading EGC had higher rates of submucosal cancer (59.3% vs 45.7%, P = 0.002), lymphovascular invasion (18.6% vs 9.8%, P < 0.001), and lymph node metastasis (15.7% vs 10.1%, P = 0.033) compared with patients with common EGC (< 6 cm). Multivariate analysis revealed that a tumor ≥ 6 cm was not strongly associated with lymph node metastasis in EGC, as compared with a tumor < 6 cm, but submucosal invasion and lymphovascular invasion were strongly associated with lymph node metastasis in EGC. In mucosal cancer without ulcers, tumors ≥ 6 cm had a higher rate of lymph node metastasis than tumors ≤ 2 cm; however, this trend was not significant (7.7% vs 5.3%, P = 0.455).Superficial spreading EGC was not associated with an increased risk of lymph node metastasis compared with common EGC. We suggest that differentiated intramucosal superficial spreading EGC without ulceration can be treated by endoscopic submucosal dissection.

Endoscopic ultrasonography for staging depth of invasion in early gastric cancer: A meta-analysis

BACKGROUND AND AIM

Endoscopic ultrasonography (EUS) is a widely used imaging modality for detecting the depth of early gastric cancer (EGC) invasion. However, the studies pertaining to EUS for staging early gastric cancer have reported widely varied sensitivities and specificities. This study was conducted to estimate the overall diagnostic accuracy of EUS for staging the depth in EGCs.

METHODS

The literatures were identified by searching in PubMed, Embase, and Web of Knowledge databases. Two reviewers independently extracted the information from the literatures for constructing 2 × 2 table. A random-effect model or a fixed-effect model was used to estimate the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. A summary receiver operating characteristic curve also was constructed. Meta-regression and subgroup analysis were used to explore the sources of heterogeneity.

RESULTS

The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of EUS for M staging were 76% (95% confidence interval [CI], 74-78%), 72% (95% CI, 69-75%), 3.67 (95% CI, 2.48-5.44), and 0.31 (95% CI, 0.24-0.40), respectively. For SM staging, these results were 62% (95% CI, 59-66%), 78% (95% CI, 76-80%), 2.99 (95% CI, 2.26-3.96), and 0.43 (95% CI, 0.32-0.57), respectively. For M/SM1 staging, they were 90% (95% CI, 88-92%), 67% (95% CI, 61-72%), 3.14 (95% CI, 2.08-4.73), and 0.12 (95% CI, 0.07-0.22), respectively. The area under the curve for mucosal, submucosal, and mucosal/minimal submucosal invasion staging were 0.85, 0.82, and 0.81, respectively.

CONCLUSIONS

Endoscopic ultrasonography only has a relatively low accuracy for staging the depth of invasion in EGCs. Accordingly, EUS may be not indispensable in the staging of EGCs.

Impact on survival of the number of lymph nodes resected in patients with lymph node-negative gastric cancer

Background

Patients with lymph node-negative gastric cancer show a better overall survival rate than those who have a pathological lymph node-positive gastric cancer. But a large number of patients still develop recurrence. We aimed to explore the significant prognostic factors of lymph node-negative gastric cancer and determine how many lymph nodes should be removed.

Methods

A total of 3103 patients who underwent radical operation are identified from the Surveillance, Epidemiology, and End Results database. Standard survival methods and restricted multivariable Cox regression models were applied.

Results

The overall survival rate was significantly higher with an increasing number of negative lymph node resected. Among the 843 patients who had the exact T stage, the overall survival rate was significantly better in T3-4 group with more than 15 lymph nodes resected (P < 0.001) but not in T1-2 stage patients (P = 0.44). A further 25 more lymph nodes resection did not show additional survival benefits. Multivariate analysis of patients demonstrated that age, depth of tumor invasion, and the number of lymph nodes resected were the significant and independent prognostic factors.

Conclusions

A lymphadenectomy with more than 15 lymph nodes removal should be performed for T3-4 lymph node-negative gastric cancer. But the survival benefit of a lymphadenectomy with more than 25 lymph nodes removal is disputed. And the further treatment should refer to the prognostic indicators.

Similarly up-regulated microRNA-106a in matched formalin-fixed paraffin-embedded and fresh frozen samples and the dynamic changes during gastric carcinogenesis and development

Evidence increasingly suggests that miR-106a is always elevated in gastric cancer; however, little is known about the expression trend and clinical significance in the whole process of gastric carcinogenesis and development. To investigate the dynamic changes of miR-106a in each stage during gastric carcinogenesis, we used formalin-fixed, paraffin-embedded (FFPE) tissues which had been reported to have valuable information for miRNA research in our previous studies. Here, we compared the expression of miR-106a in FFPE and fresh frozen tissues using real-time polymerase chain reaction. On the basis of the high correlation of miR-106a quantitative data from the two resources, FFPE samples were subsequently performed to elucidate the location and expression of miR-106a using in situ hybridization in sequential tissues, including normal gastric mucosa, chronic atrophic gastritis combined with various degrees of dysplasia, early and advanced gastric cancer. Finally, we found that miR-106a was similarly up-regulated in gastric cancer regardless of sample types although fragmentation existed inevitably in FFPE tissues. Notably, the frequency and extent of miR-106a expression gradually increased during the transition from atypical hyperplasia to advanced carcinoma and had already had positive signals in early precancerous lesions but negative signals in normal gastric mucosal epithelial cells. Our research, according to these results, indicated that FFPE samples can serve as an important research tool for miRNA field, and the early changes of miR-106a detected in such samples may have clinical application as a potential biomarker for the discovery and diagnosis of gastric cancer.

Assessment of (18)F-fluorodeoxyglucose positron emission tomography combined with computed tomography in the preoperative management of patients with gastric cancer

BACKGROUND

The significance of (18)F-2-deoxy-2-fluoro-glucose positron emission tomography combined with computed tomography imaging (FDG-PET/CT) in the diagnosis of gastric cancer remains controversial. This study aimed to evaluate the efficacy of preoperative FDG-PET/CT in staging of gastric cancer.

METHODS

FDG-PET/CT results for 90 patients with gastric cancer were retrospectively examined. For quantitative PET analysis, FDG uptake was assessed based on the maximum standardized uptake values (SUVmax).

RESULTS

FDG-PET/CT detected the primary gastric cancer in 71 of the 90 patients (sensitivity 78.9 %). The median SUVmax was significantly higher in patients with T3/T4 disease than in those with T1/T2 (9.0 vs. 3.8; P < 0.001), in patients with distant metastasis than in those with no metastasis (9.5 vs. 7.7; P = 0.018), and with stage III/IV tumors than in those with stage I/II (9.0 vs. 4.7; P = 0.017). The SUVmax of the primary tumor was significantly correlated with tumor size (r = 0.461, P < 0.001). The sensitivity, specificity, and accuracy of FDG-PET/CT in assessing metastasis to regional lymph nodes were 64.5, 85.7, and 71.1 %, respectively.

CONCLUSIONS

FDG-PET/CT results are significantly associated with tumor progression in gastric cancer, and such findings can reliably identify cancer cell populations.

Cadherin-17 induces tumorigenesis and lymphatic metastasis in gastric cancer through activation of NFκB signaling pathway

Cadherin-17 (CDH17), as a structurally unique member of the cadherin superfamily, has been identified to predict a poor prognosis for gastric cancer (GC). Our previous study demonstrated the positive correlation between CDH17 and lymph node micrometastasis in GC. We sought to further identify the role of CDH17 in the tumorigenesis and lymphatic metastasis of GC. Hence, we inhibited the CDH17 expression in MKN-45 gastric cancer cells by using RNA interference. Consequently, the malignant potency of cancer cells was evaluated, and the change in NFκB signaling pathway was also probed. Tumor growth and lymphatic metastasis model were conducted in nude mice to confirm the hypothesis. Downregulation of CDH17 not only suppressed the proliferation, adherence and invasion potency of MKN-45 cells, but also induced cell cycle arrest. Meanwhile, the NFκB signaling pathway was inactivated as well, with the reductions of downstream proteins including VEGF-C and MMP-9. Moreover, silencing CDH17 inhibited tumor growth in vivo significantly, and there was no lymph node metastasis detected in the mice without CDH17 expression, as opposed to the positive nodes found in controls. CDH17 is a novel oncogene in gastric cancer cells, which is associated with lymphatic metastasis and proliferation strongly. The inactivation of NFκB signaling pathway might be involved in targeting CDH17 in GC. On the whole, CDH17 is proposed to serve as a biomarker and attractive therapeutic target in GC.

Metachronous liver and bone metastasis from small early gastric carcinoma without lymph node involvement: A case report

A 65-year-old man was referred to our Hospital for examination of gastric cancer initially diagnosed by medical check-up. Esophagogastroduodenoscopy demonstrated a superficial depressed-type gastric cancer in the antrum, and abdominal computed tomography showed no evidence of distant metastases. A tumor measuring 11 mm in diameter was removed by endoscopic submucosal dissection (ESD). Since histological examinations of ESD specimens showed a well-differentiated adenocarcinoma invading the submucosal layer with lymphatic invasion, the patient subsequently underwent laparoscopy-assisted distal gastrectomy with regional lymph node dissection, resulting in no residual carcinoma and no lymph node metastasis. The patient developed solitary liver metastasis one year later and was treated with trastuzumab plus capecitabine/cisplatin since results of the immunohistochemical analysis of the resected specimens demonstrated overexpression of the human epidermal growth factor receptor 2 (HER2). The patient was alive 12 months after surgical resection of the liver metastasis and subsequently developed bone metastasis. Controversy remains over the role of HER2 status as a prognostic factor in gastric cancer. However, it has been generally reported that HER2 overexpression correlates with aggressive biological behavior and poor prognosis. HER2 overexpression is a potentially useful predictive factor for tumor recurrence and poor prognosis even in early gastric cancer cases.

Effect of lymph node number on survival of patients with lymph node-negative gastric cancer according to the 7th edition UICC TNM system

BACKGROUND

For the patients with node-negative gastric cancer, the 7th edition classification does not define the minimum number of lymph nodes necessary. We aimed to explore the prognostic significance of examined lymph nodes and determine how many nodes must be examined.

METHODOLOGY/PRINCIPAL FINDINGS

435 patients underwent D2 gastrectomy with node-negative gastric cancer between December 1992 and December 2006 were obtained. Patients were classified into 4 groups by the number of negative LNs examined during surgery (1-6LNs, 7-10 LNs, 11-15 LNs, and > = 16 LNs). Stratified and Cox regression analyses were used to evaluate the association between survival and the number of negative LNs. Survival was significantly better in the > = 16 LNs, compared with the 1-5 LNs, 6-10 LNs and 11-15 LNs group in T2-4 patients; Multivariate analysis demonstrated tumor size, depth of invasion, 7th UICC stage and the number of examined nodes are strongly independent predictors of survival.

CONCLUSIONS

This study first demonstrates that patients with lymph node-negative gastric cancer underwent D2 dissection should have at least 16 LNs examined, especially in advanced gastric cancer. These results are a reasonable supplement to our previous tumor-ratio-metastasis staging system and a stratification criterion in clinical practice.

Treatment strategy for early gastric cancer

Gastric cancer ranks the second leading cause of cancer-specific mortality worldwide. With a poor prognosis, 5-year survival rate of gastric cancer is less than 20%-25% in the USA, Europe, and China [1]. However, early gastric cancer(EGC) offers an excellent (over 90%) chance of cure based on surgical resection [2]. As the increasing detection of EGC, more treatment options have been developed both curatively and minimally invasively to maintain a good quality of life(QOL). One of the advanced therapeutic techniques is endoscopic dissection. Improvements in surgical treatment include minimizing lymph node dissection, reconstruction methods, laparoscopy-assisted surgery, and sentinel node navigation surgery(SNNS) [3]. With technological advances, even Natural Orifice Transluminal Endoscopy Surgery (NOTES) and robotic surgery are expected to represent the next revolution [4]. However, there still remains much dispute among these treatments, which arouses further clinical trials to verify. Update of the treatments, controversial indications, prognosis and current strategies for EGC are discussed in this review.