Clinicopathological features and medical management of early gastric cancer

A prediction model for lymph node metastasis in early-stage gastric cancer: Toward tailored lymphadenectomy

BACKGROUND

The aim of this study was to develop a prediction model for the presence and location of lymph node metastasis (LNM) in early gastric cancer.

METHOD

We reviewed medical records of 4 929 patients who underwent radical gastrectomy for early gastric cancer. Variables of age, sex, lymphatic invasion, depth of invasion, location, gross type, differentiation, and tumor size were analyzed. Logistic regression analysis was used to determine independent predictors of LNM at each LN station.

RESULT

Overall incidence of LNM was 9.1% (448/4 929 patients). For the presence of LNM, risk factors of age, sex, lymphatic invasion, depth of invasion, anatomical part, gross ulceration, size, and tumor differentiation were significantly associated with LNM. The area under the curve (AUC) for predicting LNM after validation was 0.834 for the test set. For the location of LNM, age, sex, lymphatic invasion, depth of invasion, anatomical part, circumferential portion, gross type, differentiation, and tumor size were significantly associated with LNM. The AUC of each LN station was favorable with the test set.

CONCLUSION

Predicting the location of metastatic LNs appeared to be possible in patients with early gastric cancer.

Fluorescence Imaging for Cancer Screening and Surveillance

The advent of fluorescence imaging (FI) for cancer cell detection in the field of oncology is promising for both cancer screening and surgical resection. Particularly, FI in cancer screening and surveillance is actively being evaluated in many new clinical trials with over 30 listed on Clinical Trials.gov . While surgical resection forms the foundation of many oncologic treatments, early detection is the cornerstone for improving outcomes and reducing cancer-related morbidity and mortality. The applications of FI are twofold as it can be applied to high-risk patients in addition to those undergoing active surveillance. This technology has the promise of highlighting lesions not readily detected by conventional imaging or physical examination, allowing disease detection at an earlier stage of development. Additionally, there is a persistent need for innovative, cost-effective imaging modalities to ameliorate healthcare disparities and the global burden of cancer worldwide. In this review, we outline the current utility of FI for screening and detection in a range of cancer types.

Preoperative Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio Cannot Predict Lymph Node Metastasis and Prognosis in Patients with Early Gastric Cancer: a Single Institution Investigation in China

In the present study, we aimed at exploring the applied value of preoperative neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) in the prediction of lymph node metastasis (LNM) and prognosis in patients with early gastric cancer (EGC). We retrospectively analyzed a total of248 consecutive patients who underwent curative gastrectomy to be identified T1 stage gastric adenocarcinoma between January 1, 2010 and May 1, 2016 in a single institution. According to median preoperative NLR and PLR value, we divided the patients into four groups: high NLR >1.73 and low NLR <1.73, high PLR >117.78 and low PLR <117.78. Furthermore, to evaluate the relationship between preoperative NLR and PLR values, we categorized patients according to cutoff preoperative NLR-PLR score of 2 [high NLR (>1.73) and high PLR (>117.78)], 1 [either high NLR or high PLR], and 0 [neither high NLR nor high PLR], Statistical analyses were conducted using SPSS 20.0 software. The results showed that the preoperative NLR or PLR values, lower or higher, could not predict the LNM in patients with EGC (both P=0.544>0.05). The invasive depth of tumor was significantly correlated with LNM of EGC (P0.001). Kaplan-Meier plots illustrated that preoperative NLR and PLR values were not associated with overall survival (OS) in patients with EGC. It was concluded that the preoperative NLR and PLR may be the predictors for LNM and prognosis in patients with advanced gastric cancer; nevertheless, they cannot predict LNM and prognosis in patients with EGC.

Immunohistochemical features and staging of early gastric cancer

INTRODUCTION

The aim of this study was to analyze the particularities of early gastric cancer (EGC) and their importance for staging, prognosis, and therapy.

MATERIAL AND METHODS

A total of 338 GCs diagnosed and surgically removed in three medical institutes from Eastern Europe were retrospectively examined, and the EGCs were further examined. Besides the demographic factors and tumor characteristics, immunostains were performed with E-cadherin, HER-2, p53, Ki67, MLH-1, MSH-2, COX-2, VEGF-A, CD31, and CD105.

RESULTS

From the 338 GCs, 29 were EGCs, the average being similar in Poland and Hungary (12.37% and 13.33% respectively) but lower in Romania (5.61%). The rate of lymph node metastases was 20.69% (n = 6). Two of the cases presented liver metastases, both of them having a multifocal aspect. In 1 of these cases, limited to the mucosa, intramural carcinomatosis of the lymph vessels was seen in submucosa, muscularis propria, and subserosa. COX-2 positivity was observed in 14 (48.72%) cases. COX-2 was directly correlated with microvessel density determined with CD31 (p < 0.001) and CD105 (p = 0.03). Same correlation with CD31 and CD105 was seen for HER-2 (p = 0.03 and p = 0.0007). The only negative independent prognostic factors for overall survival were tumor localization at the proximal stomach and male gender, regardless of age.

CONCLUSIONS

In EGCs, intramural carcinomatosis of the lymph vessels and multifocality should be separately described in every surgical pathology report, as indicators of aggressiveness. Microsatellite status, E-cadherin, HER-2, p53, and Ki67 do not have prognostic value in EGC, but the highly angiogenic pattern is a possible therapeutic target.

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.

Tumour infiltrating lymphocytes are predictors of lymph node metastasis in early gastric cancers

Lymph node metastasis (LNM) is an important factor for predicting prognosis and selecting appropriate treatment in early gastric cancers (EGCs). We investigated the histopathological and microenvironmental predictors of LNM in EGCs. We retrieved 43 cases of EGC without LNM and 59 cases with LNM. Clinicopathological variables and tumour-infiltrating lymphocytes (TILs), Crohn's-like lymphoid reaction (CLR), tumour stromal percentage (TSP), and FOXA1 expression were evaluated and correlated with LNM. Among the 102 cases, 68 cases (66.7%) had low TILs and 34 cases (33.3%) had high TILs. High TILs were significantly correlated with the absence of LNM (p<0.001), less extent of invasion (p=0.004), absence of LVI (p=0.035), conspicuous CLR (p<0.001), and the absence of TSP (p=0.009). Conspicuous CLR was observed in 47 cases (46.1%) and TSP was present in 17 cases (16.7%) and neither was correlated with LNM. High FOXA1 expression was significantly associated with presence of LNM, low TILs, and submucosal invasion. In multivariate analysis, low TILs (p=0.023), LVI (p=0.008), and submucosal invasion (p=0.001) were independent predictive factors for LNM in EGCs. Evaluation of TILs in biopsied or endoscopically resected EGC specimens may help to predict LNM and select subsequent proper treatment modalities and follow-up.

Evaluation the Survival of Patients with Gastric Cancer Treated with Adjuvant or Palliative Chemotherapy

AIM

Our aim was to evaluate impact of chemotherapy (5-fluorouracil plus docetaxel and cisplatin) on the survival of gastric cancer cases.

METHOD

Seventy-nine patients were eligible to take part in this study between November 2006 and April 2013, who received 5-fluorouracil (700 mg/m², 21-h infusion within 5 days), cisplatin (60 mg/m² on day 3), and Docetaxel (60 mg/m² on day 2). Radiotherapy was added to the treatment only in the cases with entire stomach body cancer (positive margin) and with giant ulcer (above 50 mm) in proximal gastric cancer.

RESULTS

Twenty-four patients were female and 55 were male. The median age was 54. In this study, 54 % of the tumors were located in the proximal and 46 % in the distal of stomach. Seventy five percent of patients were at stage I-III (adjuvant chemotherapy), and 25 % at stage IV (palliative chemotherapy). Ninety-one percent of the patients at stages I-II, 68.3 % of the patients at stage III, and one out of 20 patients at stage IV were alive at the end of follow-up. Median disease-free survival for the patients at stages I-III was 63 months, and the overall survival for all patients was 50 months.

CONCLUSION

The results of our study indicate that the survival of the patients with stomach cancer increases with chemotherapy. Radiotherapy was used for our patients with gastric cancer in specific cases.

Predictive Factors for Lymph Node Metastasis in Undifferentiated Early Gastric Cancer: a Systematic Review and Meta-analysis

OBJECTIVES

Less invasive surgery is gaining popularity for the treatment of early gastric cancer (EGC), but there are no definitive guidelines for the use of less invasive surgery for the treatment of undifferentiated EGC. The aims of this meta-analysis were to identify potential predictive factors for lymph node metastasis (LNM) in undifferentiated EGC and to guide the personalized therapeutic modality for patients with undifferentiated EGC.

METHODS

An extensive search of the PubMed, Embase, and Cochrane Library databases was performed to identify relevant articles involving undifferentiated EGC and LNM. Eligible data were systematically reviewed through a meta-analysis using Review Manager 5.3.

RESULTS

In total, 23 studies were included in this analysis. The meta-analysis found that the variables sex (female), age (greater than 60 years), tumor size (greater than 20 mm), depth of invasion (submucosal invasion), presence of lymphovascular involvement, presence of ulcer findings, histology type (non-signet ring carcinoma), and tumor location (not in the middle part of the stomach) were significantly associated with LNM.

CONCLUSIONS

Eight variables were identified as predictive factors for LNM in undifferentiated EGC. The significance of these variables should be further confirmed during the process of LNM in undifferentiated EGC patients for future clinical application.

Gene amplification of CCNE1, CCND1, and CDK6 in gastric cancers detected by multiplex ligation-dependent probe amplification and fluorescence in situ hybridization

New and effective treatments for advanced gastric cancer are urgently needed. Cyclins E and D1 form a complex with cyclin-dependent kinase 2, 4, or 6 to regulate G1-S transition. The G1-S regulatory genes encoding cyclin E (CCNE1), cyclin D1 (CCND1), and CDK6 (CDK6) are frequently amplified in gastric cancer and may therefore influence molecularly targeted therapies against ERBB2 or EGFR when coamplified. A total of 179 formalin-fixed and paraffin-embedded gastric cancer specimens were examined for these gene amplifications by multiplex ligation-dependent probe amplification and fluorescence in situ hybridization. Amplification of at least 1 G1-S regulatory gene was found in 35 tumors (CCNE1 amplification, 15% of samples; CCND1, 6%; CDK6, 1%). In 13 of the 35 tumors, dual-color fluorescence in situ hybridization identified coamplification of the G1-S regulatory genes with ERBB2, EGFR, and/or KRAS in single cancer nuclei. The observation that cells with G1-S regulatory gene amplification contained clonal subpopulations with coamplification of ERBB2, EGFR, or KRAS in 5 early and 3 advanced cancers suggests that amplification of the G1-S regulatory genes represents an early event, which precedes ERBB2, EGFR, or KRAS amplification. Amplified CCNE1, CCND1, and CDK6 in advanced gastric cancer may be potentially useful as direct targets for molecular therapy or for combination therapy with ERBB2 or EGFR inhibitors. Multiplex ligation-dependent probe amplification could be a useful tool for identification of patients who would benefit from such therapies.

Risk factors of lymph node metastasis in early gastric carcinomas diagnosed by WHO criteria in 379 Chinese patients

OBJECTIVE

To investigate risk factors of lymph node metastasis (LNM) in Chinese early gastric carcinoma (EGC) patients diagnosed using the World Health Organization (WHO) criteria and compare the differences in those factors between proximal (PGC) and distal gastric carcinoma (DGC).

METHODS

Among 3 176 gastric cancer resections we identified 379 (11.9%) consecutive EGC (104 PGC and 275 DGC) with lymphadenectomy performed at the Affiliated Nanjing Drum Tower Hospital of Nanjing University (Nanjing, Jiangsu Province, China) between January 2005 and December 2012. Endoscopic and clinicopathological features related to LNM were analyzed.

RESULTS

LNM occurred in 49 (12.9%) EGC, including three PGC and 46 DGC. In early DGC, middle age (41-60 years), tumor size ≥3.1 cm, submucosal invasion, poorly cohesive carcinoma, micropapillary adenocarcinoma and lymphovascular invasion were risk factors by univariate analysis. In contrast, no risk factors of LNM were identified in early PGC. By multivariate analysis, female sex (odds ratio [OR] 2.4), DGC (OR 8.1), poorly cohesive carcinoma (OR 8.8) and lymphovascular invasion (OR 38.8) were found to be significant independent risk factors for LNM. The risk of LNM was effectively stratified using a scoring model of mild (score ≤3.5), moderate (score 4.0-8.5) and high (score ≥16) risk groups.

CONCLUSIONS

LNM occurred in 12.9% of EGC diagnosed with the WHO criteria in Chinese patients. Independent risk factors of LNM were identified in early DGC only and included female sex, DGC, poorly cohesive carcinoma and lymphovascular invasion. Early PGC has a much lower risk for LNM than early DGC.

Reconstruction with Jejunal Pouch after Gastrectomy for Gastric Cancer

The construction of a gastric substitute pouch after gastrectomy for gastric cancer has been proposed to help ameliorate postprandial symptoms and nutritional performance. Adequate reconstruction after gastrectomy is an important issue, because postoperative patient quality of life (QOL) primarily depends on the reconstruction method. To this end, jejunal pouch (JP) reconstructions were developed to improve the patient's eating capacity and QOL by creating large reservoirs with improved reflux barriers to prevent esophagitis and residual gastritis. It is important that such reconstructions also preserve blood and extrinsic neural integrity for maintaining pouch function, because JP motility is associated directly with QOL. Some problems remain to be resolved with the JP reconstructions method including gastrointestinal motility, which plays a major role in food transfer, digestion, and absorption of nutrients. Further studies including basic research and larger prospective randomized control trials are also needed to obtain definitive results. With persistent innovations in surgical techniques, JP after gastrectomy could become a safe and preferable reconstructive modality to improve patient QOL after gastrectomy.

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.

Aberrant metastatic behavior and particular features of early gastric cancer

In this paper, we have focused on the metastatic behavior of EGC and its particularities. The main factors that are currently considered as predictors of the metastatic behavior and that are used in the therapeutic decision (endoscopic resection vs surgical removal) are the tumor size (upper or bellow 2 cm), depth of infiltration, angiolymphatic invasion, the presence or absence of ulceration, and histologic type (undifferentiated vs differentiated carcinomas). However, most of the metastatic cases were published as case reports or case series. This is the reason why a proper estimation of metastatic risk in EGC is not well known. To date, 79 cases presenting bone metastases, three reports of brain metastases, and one EGC that was associated with skin metastasis were published. However, occult metastasis, lymph node micrometastasis, and skip metastasis can also occur and should be identified. Making a synthesis of the literature data that is correlated with our experience, we finally proposed the inclusion of the six Japanese subgrouping system, tumor size, angiolymphatic invasion, and micrometastasis as components of the pTNM staging system, which should be particularly adapted for EGC.

Prognostic role of lymph node metastasis in early gastric cancer

OBJECTIVE

To clarify the relationship between clinicopathological features and lymph node metastasis and to propose the potential indications of lymph node metastasis for prognosis in early gastric cancer (EGC) patients.

METHODS

We retrospectively observed 226 EGC patients with lymph node resection, and analyzed the associations between lymph node metastasis and clinicopathological parameters using the chi-square test in univariate analysis and logistic regression analysis in multivariate analysis. Overall survival analysis was determined using the Kaplan-Meier and log-rank test. We conducted multivariate prognosis analysis using the Cox proportional hazards model.

RESULTS

Of all the EGC patients, 7.5% (17/226) were histologically shown to have lymph node metastasis. The differentiation, lymphovascular invasion and depth of invasion were independent risk factors for lymph node metastasis in EGC. The 5- and 10-year survival rates were significantly lower in patients with lymph node metastasis than in those without and the patients also had shorter progress-free survival time. Lymph node metastasis and tumor size were independent prognostic factors for EGC. The status of the lymph nodes was a significant factor in predicting recurrence or metastasis after surgery.

CONCLUSIONS

The undifferentiated carcinoma and lymphovascular and/or submucosal invasion were associated with a higher incidence of lymph node metastasis in EGC patients, whom need to perform subsequent D2 lymphadenectomy or laparoscopic lymph node dissection and more rigorous follow-up or additional chemotherapy/radiation after D2 gastrectomy for poor prognosis and high recurrence/metastasis rate.

Intratumoral heterogeneous amplification of ERBB2 and subclonal genetic diversity in gastric cancers revealed by multiple ligation-dependent probe amplification and fluorescence in situ hybridization

A humanized monoclonal antibody against ERBB2 is used in neoadjuvant therapy for patients with gastric cancer. A critical factor in determining patient eligibility and predicting outcomes of this therapy is the intratumoral heterogeneity of ERBB2 amplification in gastric adenocarcinomas. The aims of this study are to assess the underlying mechanisms of intratumoral heterogeneity of ERBB2 amplification; to characterize the diversity of coamplified oncogenes such as EGFR, FGFR2, MET, MYC, CCND1, and MDM2; and to examine the usefulness of multiple ligation-dependent probe amplification (MLPA) in the semicomprehensive detection of these gene amplifications. A combined analysis of immunohistochemistry and fluorescence in situ hybridization revealed ERBB2-amplified cancer cells in 51 of 475 formalin-fixed, paraffin-embedded gastric adenocarcinomas. The fraction of amplification-positive cells in each tumor ranged from less than 10% to almost 100%. Intratumoral heterogeneity of ERBB2 amplification, defined as less than 50% of cancer cells positive for ERBB2 amplification, was found in 41% (21/51) of ERBB2-amplified tumors. The combined analysis of MLPA and fluorescence in situ hybridization revealed that ERBB2 was coamplified with EGFR in 7 tumors, FGFR2 in 1 tumor, and FGFR2 and MET in 1 tumor; however, the respective genes were amplified in mutually exclusive cells. Coamplified ERBB2 and MYC coexisted within single nuclei in 4 tumors, and one of these cases had suspected coamplification in the same amplicon of ERBB2 with MYC. In conclusion, the amplification status of ERBB2 and other genes can be obtained semicomprehensively by MLPA and could be useful to plan individualized molecularly targeted therapy against gastric cancers.

Frequency and predictive factors related to lymphatic metastasis in early gastric cancer

BACKGROUND

The standard treatment of gastric cancer still has high morbidity and mortality in western populations. Groups of patients with negligible risk of lymph node metastasis may benefit from less invasive treatments. Data regarding the frequency and predictive factors related to lymphatic metastasis in early gastric cancer are rare.

AIM

To perform the analysis of frequency and predictive factors related to lymphatic metastasis in patients with early gastric cancer treated in a tertiary center in Brazil.

METHODS

Nine hundred and twenty three patients underwent gastrectomy for gastric adenocarcinoma at the hospital. Of these, 126 had early tumors and were included in the analysis. Clinical and pathological related findings and lymphatic metastasis were evaluated.

RESULTS

Lymph node metastases were observed in 7.8% of patients with mucosal tumors and 22.6% of submucosal tumors. The presence of ulceration, Lauren histologic type, tumors larger than 50 mm, submucosal invasion, and presence of lymphatic or vascular invasion were significant factors in univariate analysis. The presence of ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion were factors independently related to lymphatic metastasis in multivariate analysis.

CONCLUSION

Ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion are independent risk factors related to lymphatic metastasis in early 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.

Prediction of risk factors for lymph node metastasis in early gastric cancer

AIM: To explore risk factors for lymph node metastases in early gastric cancer (EGC) and to confirm the appropriate range of lymph node dissection.

METHODS: A total of 202 patients with EGC who underwent curative gastrectomy with lymphadenectomy in the Department of Surgery, Xinhua Hospital and Ruijin Hospital of Shanghai Jiaotong University Medical School between November 2003 and July 2009, were retrospectively reviewed. Both the surgical procedure and the extent of lymph node dissection were based on the recommendations of the Japanese gastric cancer treatment guidelines. The macroscopic type was classified as elevated (type I or IIa), flat (IIb), or depressed (IIc or III). Histopathologically, papillary and tubular adenocarcinomas were grouped together as differentiated adenocarcinomas, and poorly differentiated and signet-ring cell adenocarcinomas were regarded as undifferentiated adenocarcinomas. Univariate and multivariate analyses of lymph node metastases and patient and tumor characteristics were undertaken.

RESULTS: The lymph node metastases rate in patients with EGC was 14.4%. Among these, the rate for mucosal cancer was 5.4%, and 8.9% for submucosal cancer. Univariate analysis showed an obvious correlation between lymph node metastases and tumor location, depth of invasion, morphological classification and venous invasion (χ² = 122.901, P = 0.001; χ² = 7.14, P = 0.008; χ² = 79.523, P = 0.001; χ² = 8.687, P = 0.003, respectively). In patients with submucosal cancers, the lymph node metastases rate in patients with venous invasion (60%, 3/5) was higher than in those without invasion (20%, 15/75) (χ² = 4.301, P = 0.038). Multivariate logistic regression analysis revealed that the depth of invasion was the only independent risk factor for lymph node metastases in EGC [P = 0.018, Exp (B) = 2.744]. Among the patients with lymph node metastases, 29 cases (14.4%) were at N1, seven cases were at N2 (3.5%), and two cases were at N3 (1.0%). Univariate analysis of variance revealed a close relationship between the depth of invasion and lymph node metastases at pN₁ (P = 0.008).

CONCLUSION: The depth of invasion was the only independent risk factor for lymph node metastases. Risk factors for metastases should be considered when choosing surgery for EGC.

Minor gastric resections with modified lymphadenectomy in early gastric cancer with negative sentinel node

OBJECTIVE

To study the sentinel lymph node in early gastric cancer as a diagnostic method of unsuspected lymph node metastasis, which may allow the performance, in those with negative lymph nodes, of smaller gastric resections with limited lymphadenectomy.

METHODS

We studied seven patients with early gastric cancer treated at the Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, from September 2008 to May 2011, who underwent sentinel lymph node exams, performed by intraoperative peritumoral endoscopic injection of patent blue dye.

RESULTS

We found an average of three sentinel nodes per patient. The frozen biopsy of lymph nodes was negative for metastases, which allowed the realization of atypical gastric resection in three cases and antrectomy with BI reconstruction in four. The performed lymphadenectomy was modified D1. There was no operative mortality. The duration of postoperative follow-up ranged from five to 37 months, without evidence of recurrence. One patient developed a second early tumor 13 months after the initial surgery and underwent total gastrectomy.

CONCLUSION

The sentinel lymph node in early gastric cancer proved to be an effective method for the evaluation of nodal metastases in seven patients and allowed for smaller gastric resections and limited lymphadenectomies. These minor procedures reduce the risk of postoperative complications, maintaining, on the other hand, the oncological radicality that is required in the treatment of gastric cancer.

Gastroscopic and clinical diagnosis of early gastric cancer in elderly patients: an analysis of 124 cases

AIM: To investigate the clinicopathologic characteristics of early gastric cancer (EGC) in elderly patients.

METHODS: The clinical data for 124 elderly patients who were endoscopically diagnosed with EGC from May 1985 to December 2009 were retrospectively analyzed.

RESULTS: The mean age of these patients was 72.1 years. Elderly EGC patients usually had non-specific symptoms and physical signs. The tumors, most of which belonged to type IIb and IIc, were mainly located in the gastric sinus. Tumor diameter was usually less than 2 cm. Adenocarcinoma was the most common pathological type. Lymph node metastasis was noted in 3.2% (4/124) of patients.

CONCLUSION: There are usually no typical symptoms in elderly EGC patients. Mass screening by gastroscopy in combination with pathological examination is the most effective method to find EGC in elderly patients.

Clinicopathological properties of the superficial spreading type early gastric cancer

INTRODUCTION

We investigated differences in characteristics between the superficial spreading type early gastric cancer (EGC) characterized by a wide and superficial extension and the common type EGC.

PATIENTS AND METHODS

Between 1982 and 2008, we retrospectively reviewed clinical reports of patients with the EGC treated at Kochi Medical School.

RESULTS

Sixty-one patients (9.6%) out of 646 patients had the superficial spreading type EGC. The occurrences of diffuse type histology and lymph node metastasis were significantly greater in the superficial spreading type than in the common type. The incidence of EGC confined to the mucosa was significantly greater in the lymph node-positive superficial spreading type than in the lymph node-positive common type.

CONCLUSIONS

In patients with the superficial spreading type EGC, lymph node metastasis was more prominent regardless of the degree of tumor invasion. Therefore, appropriate extensive lymph node dissection and wide surgical resection are required for the curative resection of the superficial spreading type EGC.

Clinicopathological features associated with lymph node metastasis in early gastric cancer: analysis of a single-institution experience in China

BACKGROUND

An accurate assessment of potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the number of invasive procedures used in cancer therapy is critical for improving the patient's quality of life.

OBJECTIVE

To evaluate the clinicopathological features associated with lymph node metastasis of early gastric cancer in patients from a single institution in China.

METHODS

A retrospective review of data from 410 patients surgically treated for early gastric cancer at the First Affiliated Hospital (Nanjing, China) between 1998 and 2007, was conducted. The clinicopathological variables associated with lymph node metastasis were evaluated.

RESULTS

Lymph node metastasis was observed in 12.20% of patients. The macroscopic type, tumour size, location in the stomach, depth of gastric carcinoma infiltration, and presence of vascular or lymphatic invasion showed a positive correlation with the incidence of lymph node metastasis by univariate analysis. Multivariate analyses revealed histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion to be significantly and independently related to lymph node metastasis. The depth of gastric carcinoma infiltration was the strongest predictive factor for lymph node metastasis. For intramucosal cancer, tumour size was the unique risk factor for lymph node metastasis. For submucosal cancer, histological classification and tumour size were independent risk factors for lymph node metastasis.

CONCLUSIONS

Histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion are independent risk factors for lymph node metastasis in patients with early gastric cancer in China. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible for highly selected cancers.

Clinicopathological features of early gastric cancer with duodenal invasion

The incidence of early gastric cancer (EGC) with duodenal invasion is extremely low, although advanced gastric cancer that arises in the antrum occasionally invades the duodenum. We investigated the clinicopathological features of EGC with duodenal invasion and provided strategies for clinical management. A Medline search was performed using the keyword “early gastric cancer” and “duodenal invasion”. Additional articles were obtained from references within the papers identified by the Medline search. We revealed that EGC with duodenal invasion was of the superficial spreading type of tumor. Tumors > 60 mm in size invaded the duodenum more extensively, and the distance of duodenal invasion from the pyloric ring was further in the elevated type than in the depressed type of tumor. There was no significant difference between the length of duodenal invasion and the histological type of the tumor. Gastric cancer located adjacent to the pyloric ring, even if cancer invasion was confined to the mucosa or submucosa, was more likely to invade the duodenum. The present study reveals that the elevated type of EGC is associated with more extensive duodenal invasion when the tumor size is > 60 mm, thus highlighting the importance of identification of duodenal invasion in these cases. We also reveal that sufficient duodenal resection with a cancer-free distal surgical margin should be performed in cases of duodenal invasion.

Prognostic role of lymphatic vessel invasion in early gastric cancer: a retrospective study of 188 cases

BACKGROUND

Lymphatic vessel invasion is an important prognostic factor for the gastric cancer without lymph node metastasis. However, the studies on early gastric cancers is still sparse. Therefore, we carried out this study to determine clinicopathological and surgical prognostic factors, especially lymphatic vessel invasion, for early gastric cancers.

METHODS

Clinicopathological characteristics and prognostic outcomes of 188 patients who received a gastrectomy for early gastric cancer between 1980 and 2000 were retrospectively evaluated based on the subclassification of pN category. A multivariate analysis was performed by using the Cox regression model, where lymphatic vessel invasion and other potential prognostic factors were included.

RESULTS

Of the 188 patients, 158 had T1N0M0 and 30 T1N1M0 cancers. In patients with T1N0M0 cancers, the survival rate was significantly lower in those with lymphatic vessel invasion than in those without (chi(2)=4.025, P=0.045). However, in patients with T1N1M0 cancers, the survival rates were not significantly different between those with and those without lymphatic vessel invasion (chi(2)=0.253, P=0.615). The multivariate analysis identified that age (P=0.033) and lymph node metastasis (P=0.019) were independent prognostic factors for all early gastric cancers. However, age (P=0.042), tumor location (P=0.032), and lymphatic vessel invasion (P=0.010) were the independent prognostic factors for T1N0M0 cancers.

CONCLUSIONS

Lymphatic vessel invasion was an independent prognostic factor for T1N0M0 early gastric cancers, and thus may be a potential prominent factor that should be considered to be included in the category of lymphoid metastasis (both lymph node metastasis and lymphatic vessel invasion) in patients with early gastric cancer.

A case with synchronous multiple liver metastases from gastric carcinoma: postoperative long-term disease-free survival

PURPOSE

We herein report a case with synchronous multiple liver metastases from gastric carcinoma surviving disease-free for more than 10 years after hepatic resection.

METHODS

A 64-year-old male admitted to our hospital because of constitutional wariness. Preoperative diagnosis was type 1 gastric cancer at the lower third of the stomach and multiple metastases of both hepatic lobes. After we performed distal gastrectomy with regional lymphadenectomy and wedge hepatic resection for eight metastatic liver tumors, he received 5-fluoropyrimidine and platinum-based adjuvant chemotherapy during the early postoperative period.

RESULTS

The pathologic examination revealed moderately differentiated gastric adenocarcinoma with regional lymph node metastasis and multiple liver metastases. The postoperative course was uneventful and the patient is doing well without disease recurrence after more than 10 years following surgery.

CONCLUSION

To the best of our knowledge, this patient is the longest disease-free survivor after liver resection for synchronous multiple liver metastases from advanced gastric cancer. In this modern era of developing liver surgery and adjuvant chemotherapy, combination therapy of aggressive surgery and early postoperative adjuvant chemotherapy for advanced gastric cancer with liver metastasis may allow long-term survival in selected patients.