Characterization of early gastric cancer and proposal of the optimal therapeutic strategy

Long-term prognosis of patients with cancer-related genes detected in postoperative peritoneal washings obtained during curative gastrectomy

BACKGROUND

Cancer cells in intraoperative peritoneal washings (PW) indicate increased peritoneal recurrence. Detection of CEA or CK20 genes indicates poor prognosis. We assessed long-term prognosis of patients with amplification of cancer-related genes in PW obtained intraoperatively during curative gastric cancer surgery.

METHODS

PW was collected before and immediately after curative gastrectomy. CEA, CK20, TFF1, MUC2, and FABP1-mRNA were selected as marker genes for reverse transcription polymerase chain reaction. Peritoneal recurrence-free survival (PRFS) and overall survival (OS) after >7-year follow-up were examined using the Kaplan-Meier method.

RESULTS

Of 138 patients who underwent gastrectomy with negative cytological findings at laparotomy, 80 patients showed negative cancer-related gene amplification in preoperative PW. Fifty-eight patients were excluded due to positive gene amplification, which suggested presence of preoperative peritoneal cancer cells. The 80 patients had mRNA amplification in PW after surgery. Amplification of multiple and single cancer-related marker genes was observed in 38 and 21 patients; 21 cases had marker-negative results. Five-year PRFS was 69.1%, 95.2%, and 100% in multi-marker-positive, single marker-positive, and marker-negative cases, respectively. Multi-marker-positive patients had significantly worse PRFS than the other groups (p < 0.05). Multivariate analysis in the Cox proportional hazards model identified multi-marker-positivity as an independent prognostic factor for PRFS (hazard ratio, 7.6; 95% confidence interval, 1.07-62.63; p = 0.046), and multi-marker-positive patients had significantly worse OS than other groups (p < 0.01).

CONCLUSION

Multi-marker cancer-related gene amplification in PW is associated with worse prognosis in PRFS and OS even after a long follow-up; PRFS can be stratified by the number of genes amplified.

Optimal extent of lymph node dissection in patients with gastric cancer who underwent non-curative endoscopic submucosal dissection with a positive vertical margin

BACKGROUND

The optimal extent of lymph node dissection in patients receiving non-curative endoscopic submucosal dissection (ESD) and diagnosed with a positive vertical margin is unclear. This study attempted to identify optimal candidates for D2 lymph node dissection among these patients.

METHODS

This study included patients who underwent gastrectomy for primary gastric cancer following non-curative ESD with a positive vertical margin between January 2002 and December 2018. We classified the patients according to the positive vertical margin pattern into an obvious exposure group and a non-obvious exposure group. We developed a score model for predicting lymph node metastasis (LNM) using factors selected by multivariate analyses and beta regression coefficients, and the incidence of LNM was evaluated.

RESULTS

This study included 110 patients. LNM was detected in 17 patients (15%). We developed a predictive scoring system as follows: tumor size >30 mm (0, No; 1, Yes) + undifferentiated type tumor in the invasive front (0, No; 2, Yes) + depth of submucosal invasion > 1500 μm (0, No; 1, Yes) + obvious tumor exposure at the vertical margin (0, No; 1, Yes). In patients with 5 points, the incidence rates of all and group 2 LNM were as high as 60% and 40%, respectively. Conversely, in patients with fewer than 5 points, the incidence rates of all and group 2 LNM were just 11% and 5%, respectively.

CONCLUSION

In patients with 5 points according to our score model for predicting LNM, gastrectomy with D2 lymph node dissection is recommended.

A single-institution retrospective analysis of gastric carcinoma with positive peritoneal lavage cytology and without serosal invasion: A case series

BACKGROUND AND OBJECTIVES

Peritoneal dissemination of gastric cancer is often associated with serosal infiltration. The aim of this study was to evaluate the clinical importance of peritoneal lavage cytology in patients with gastric carcinoma without serosal invasion. The incidence and impact on prognosis of positive cytology were analyzed.

METHODS

Of 2768 patients with gastric cancer, outcomes and pathological characteristics of 973 patients were reviewed retrospectively. All patients underwent peritoneal lavage at laparotomy for curative or palliative resection of gastric cancer between 1999 and 2017. Among these, 479 who underwent surgery from January 1999 to March 2012 were also reviewed to analyze 5-year survival.

RESULTS

Of 973 patients enrolled, 338 (35%) did not have serosal invasion, and peritoneal cytology was positive in 4/338 (1.2%). Of these four patients, one had submucosal invasion and three had muscularis propria invasion. Of 635 patients with serosal invasion, peritoneal cytology was positive in 74/635 (12%). Of 479 patients reviewed for survival, cytology was positive in 32/479, with 3/32 (9%) surviving for five years, and cytology was negative in 447 patients with 266/447 (60%) surviving for five years.

CONCLUSIONS

Cytologic evaluation should be routinely performed in patients with early-stage gastric cancer.

Potential for peritoneal cancer cell seeding in endoscopic full-thickness resection for early gastric cancer

BACKGROUND AND AIMS

During endoscopic full-thickness resection (EFTR) for cancers, whether exposure of the lumen to the abdominal cavity during the procedure is acceptable is controversial because of the potential risk of tumor cell seeding. To assess the possibility of transplantation as a result of contact with tumor cells during the procedure, we prospectively investigated the ability of cancer cells to be detached by touching the tumor surface.

METHODS

In 48 patients with a single early gastric cancer resected by endoscopic submucosal dissection, stamp cytology was performed by touching the surface of the specimens to glass slides. Samples were obtained from cancerous and noncancerous areas, constituting the study and control groups, respectively. The detection rate of malignant class IV or V (C-IV/C-V) samples was investigated with Papanicolaou staining. The rate of CD44v9-positive cases, a cancer stem cell marker, was assessed in C-IV/C-V samples with immunohistochemical staining.

RESULTS

Detection rates of C-IV/C-V samples in the cancerous group (53/192 slides, 27.6%) differed significantly from those of the C-IV/C-V samples in the noncancerous group (0/96 slides, 0%). Among the 53 slides of C-IV/C-V samples in the cancerous group, CD44v9 cells were expressed in 18 slides (34.0%).

CONCLUSIONS

These data suggest that cancer cells, including cancer stem cells, in early gastric cancers are easily detached via contact with the tumor surface. In EFTR, a nonexposure approach is recommended to avoid the risk of iatrogenic cancer cell seeding via contact with and transplantation of cancer cells.

CT volumetry for gastric adenocarcinoma: association with lymphovascular invasion and T-stages

Purpose

To determine whether gross tumor volume of resectable gastric adenocarcinoma on multidetector computed tomography could predict presence of lymphovascular invasion and T-stages.

Results

Gross tumor volume increased with the lymphovascular invasion (r = 0.426, P < 0.0001) and T stage (r = 0.656, P < 0.0001). Univariate analysis showed gross tumor volume could predict lymphovascular invasion (P < 0.0001). Multivariate analyses indicated gross tumor volume as an independent risk factor of lymphovascular invasion (P = 0.026, odds ratio = 2.284). The Mann-Whitney U test showed gross tumor volume could distinguish T2 from T3, T1 from T2–T4a, T1–T2 from T3–T4a and T1–T3 from T4a (P = 0.000). In the development cohort, gross tumor volume could predict lymphovascular invasion (cutoff, 15.92 cm³; AUC, 0.760), and distinguish T2 from T3 (cutoff, 10.09 cm³; AUC, 0.828), T1 from T2-T4a (cutoff, 8.20 cm³; AUC, 0.860), T1-T2 from T3-T4a (cutoff, 15.88 cm³; AUC, 0.883), and T1-T3 from T4a (cutoff, 21.53 cm³; AUC, 0.834). In validation cohort, gross tumor volume could predict presence of lymphovascular invasion (AUC, 0.742), and distinguish T2 from T3 (AUC, 0.861), T1 from T2-T4a (AUC, 0.859), T1–T2 from T3–T4a (AUC, 0.875), and T1–T3 from T4a (AUC, 0.773).

Materials and Methods

360 consecutive patients with gastric adenocarcinoma were retrospectively identified. Gross tumor volume was evaluated on multidetector computed tomography images. Statistical analysis was performed to determine whether gross tumor volume could predict presence of lymphovascular invasion and T-stages. Cutoffs of gross tumor volume were first investigated in 212 patients and then validated in an independent 148 patients using area under the receiver operating characteristic curve (AUC) for predicting lymphovascular invasion and T-stages.

Conclusions

Gross tumor volume of resectable gastric adenocarcinoma at multidetector computed tomography demonstrated capability in predicting lymphovascular invasion and distinguishing T-stages.

Clinicopathological characteristics of patients who underwent additional gastrectomy after incomplete endoscopic resection for early gastric cancer

To evaluate the clinicopathological characteristics and factors that lead to residual tumors in patients who underwent additional gastrectomy for incomplete endoscopic resection (ER) for early gastric cancer (EGC).Between 2003 and 2013, the medical records of patients underwent additional gastrectomy after incomplete ER were retrospectively reviewed. Those diagnosed with the presence of histologic residual tumor in specimens obtained by gastrectomy were assigned to the residual tumor (RT) group (n = 47); those diagnosed with the absence of histologic residual tumor were assigned to the nonresidual tumor (NRT) group (n = 33).In the multivariate analysis, endoscopic piecemeal resection, Helicobacter pylori infection, large tumor size (>2 cm), and both (lateral and vertical) marginal involvement were independent factors of the presence of residual tumor in additional gastrectomy after incomplete resection ER for EGC and the rates of independent factors were significantly higher in the RT group than in the NRT group (P < 0.05).Before ER, preexamination to accurately determine the GC invasion depth and the presence of LN metastasis is very important. During ER, surgeons should attempt to perform en bloc resection and to resect the mucous membrane with adequate safety margins to prevent tumor invasion into the lateral and vertical margins.

Race Is a Risk for Lymph Node Metastasis in Patients With Gastric Cancer

BACKGROUND

The frequency of lymph node metastasis in each T stage of gastric cancer has not been as well described for Western populations as it has for Asian populations. This study aimed to determine these frequencies and to investigate risk factors associated with lymph node metastases in a racially diverse U.S.

POPULATION

METHODS

A prospectively maintained database of 8260 patients with gastric or gastroesophageal junction adenocarcinoma treated at our institution from 1995 to 2013 was reviewed to identify those who underwent surgical resection without preoperative therapy. Associations between clinicopathologic variables and lymph node metastasis were tested with uni- and multivariate analyses.

RESULTS

The study identified 218 patients with a pathologic diagnosis of gastric adenocarcinoma who underwent upfront gastrectomy. These study subjects included 115 white (53 %), 19 black (9 %), and 41 Asian (19 %) patients. At least 15 lymph nodes were examined in 148 (68 %) of the patients. The lymph node metastasis rates were 10 % for stage T1a, 34 % for stage T1b, 44 % for stage T2, 73 % for stage T3, and 95 % for stage T4 tumors. Univariate analysis showed that submucosal invasion, race, 15 or more lymph nodes examined, and lymphovascular invasion were associated with lymph node metastasis in T1 and T2 tumors. The multivariate analysis showed all but lymphovascular invasion to be independent risk factors for nodal metastasis.

CONCLUSIONS

The rates of lymph node metastasis observed in this study were higher than those reported in Asian reports. Race was an independent risk factor for lymph node metastasis. Caution is therefore needed when evidence from Asian countries is extrapolated to more racially diverse Western countries.

Positive Peritoneal Lavage Cytology -Implications for Staging and Management of Gastric Cancer

The survival rates of gastric cancer patients with cytology-positive peritoneal lavage fluid without macroscopic dissemination (CY+/P-) is the same as that of patients with overt peritoneal metastasis.The 5-year survival rate of such patients is only 2%. The current study aims to highlight its significance in the staging of gastrointestinal malignancies and its implications for patient care. Prospective nonrandom analysis of peritoneal wash cytology in patients with gastrointestinal malignancies was conducted in the department of Surgical Gastroenterology, Nizams Institute of Medical Sciences, Hyderabad from January 2012 to June 2013. Descriptive statistics and ANOVA variance analysis was performed to estimate incidence, risk factors and the effect of surgery in causing peritoneal dissemination of malignancy. A total of 60 patients with operable gastric cancer underwent peritoneal lavage for evaluation of malignant cells. The incidence of Positive peritoneal lavage cytology was 8.3% (5/60).Four patients with positive lavage fluid belong to T3 stage (11.7%, p-0.309).Poorly differentiating and mucinous tumors had a higher incidence of positive cytology (18.1% and 25%).None of the patients with positive cytology had positive resection margin. Tumors with advanced T stage, lymph nodal involvement, lympho-vascular and perineural invasion have higher incidence of positive peritoneal cytology. Surgical handling has a negligible effect in peritoneal dissemination of tumor. Large scale studies are warranted to validate the findings and define it's role in management of gastric cancer.

State-of-the-art preoperative staging of gastric cancer by MDCT and magnetic resonance imaging

Gastric cancer is one of the most common and fatal cancers. The importance of accurate staging for gastric cancer has become more critical due to the recent introduction of less invasive treatment options, such as endoscopic mucosal resection or laparoscopic surgery. The tumor-node-metastasis staging system is the generally accepted staging system for predicting the prognosis of patients with gastric cancer. Multidetector row computed tomography (MDCT) is a widely accepted imaging modality for the preoperative staging of gastric cancer that can simultaneously assess locoregional staging, including the gastric mass, regional lymph nodes, and distant metastasis. The diagnostic performance of MDCT for T- and N-staging has been improved by the technical development of isotropic imaging and 3D reformation. Although magnetic resonance imaging (MRI) was not previously used to evaluate gastric cancer due to the modality’s limitations, the development of high-speed sequences has made MRI a feasible tool for the staging of gastric cancer.

Surgery-induced peritoneal cancer cells in patients who have undergone curative gastrectomy for gastric cancer

BACKGROUND

Some patients who undergo curative gastrectomy with lymph node dissection (LND) for gastric cancer (GC) show subsequent peritoneal metastasis. The source of these metastatic cells remains unclear.

METHODS

Curative gastrectomy with LND was performed in 102 patients with GC. Peritoneal washing was collected before and after gastrectomy. Cytology, reverse transcription-polymerase chain reaction, and cell culture were used to determine the presence of cancer cells. The proliferative potential of tumor cells was evaluated using Ki-67 staining. Tumorigenic capacity was assessed by cell injection into the peritoneal cavity of NOD/ShiJic-scid mice. Peritoneal recurrence-free survival (RFS) and peritoneal recurrence rate (RR) were examined to determine the clinical relevance of detected cancer cells.

RESULTS

Of 102 peritoneal washing samples obtained before gastrectomy, 57 showed no CEA or CK20 mRNA amplification. After gastrectomy, CEA or CK20 mRNA was detected in 35 of these 57 samples, and viable cancer cells were identified in 24. The viable cancer cells in all 24 cases showed Ki-67 positivity, indicating proliferative activity. Cultured viable cancer cells generated peritoneal nodules after spilling over the peritoneal cavity in NOD/ShiJic-scid mice in 4 cases. The peritoneal RFS of patients with CEA or CK20 mRNA amplification after gastrectomy was significantly poorer than that of patients with negative amplification (p < .05). The 24 patients with viable cancer cells in the peritoneal cavity after gastrectomy showed higher peritoneal RR than those without them (p = .033).

CONCLUSIONS

Viable tumorigenic cancer cells spilled into the peritoneal cavity during surgery, indicating that surgery induces peritoneal metastasis.

Novel endoscopic therapeutics for early gastric cancer

Gastrointestinal cancers are among the commonest cancers worldwide. Treatment of these cancers at an early stage will result in a significantly better prognosis. Endoscopic submucosal dissection (ESD) is a new method of endoscopic resection that can achieve higher rates of en bloc resection for early gastrointestinal neoplasia. Three retrospective case-control studies showed that ESD achieved significantly higher en bloc resection with lower recurrence rates than endoscopic mucosal resection for treatment of early gastric cancers. Most of the reports on clinical outcomes of ESD were from countries with a high incidence of gastric cancers, including Japan and Korea. The development of ESD has been slow for countries outside Japan and Korea because ESD requires a high level of endoscopic skills, and the dissection was performed single-handedly without assistance. A newly developed robotic endoscopic platform will enhance the performance of ESD through the use of 2 robotic arms: one arm for retraction of the mucosa and the other arm for dissection.

Factors associated with peritoneal metastasis in non-serosa-invasive gastric cancer: a retrospective study of a prospectively-collected database

Background

Peritoneal dissemination is the most common type of recurrence in advanced gastric cancer. The main mechanism is thought to be via the exfoliation of free cancer cells (FCCs) from tumor in the gastric serosa. The frequency of recurrence thus increases once the tumor cells penetrate the serosa. However, this type of recurrence also occurs in patients without serosal invasion, though the mechanisms responsible for have not been fully established. We therefore investigated the factors associated with peritoneal dissemination in patients with non-serosa-invasive gastric cancer.

Methods

A total of 685 patients with non-serosa-invasive gastric cancer who underwent curative resection with retrieval of more than 15 nodes were selected. The associations between clinicopathological features and peritoneal dissemination were analyzed. Among them, the tumor infiltrating growth pattern (INF) were classified into α, β and γ according to the Japanese Classification of Gastric Carcinoma (JCGC).

Results

The overall incidence of peritoneal metastasis was 20% (137/685). Age, Borrmann type, differentiation, INF, nodal status and free cancer cells (FCCs) were correlated with peritoneal dissemination using univariate analysis. However, only INF, Borrmann type and TNM node stage were identified as independent correlated factors with peritoneal metastasis by multivariate analysis when FCCs were excluded, and these were also prognostic factors. Peritoneal dissemination was more common in patients with INFγ, Borrmann III/IV and N3 stage. Among patients without FCCs, nodal involvement or vessel invasion, only INF remained an independent associated factor according to multivariate analysis.

Conclusions

Tumor infiltrating growth pattern (INF), together with Borrmann type and TNM node stage, are important factors associated with peritoneal metastasis in non-serosa-invasive gastric cancer.

Endoscopic holmium:YAG laser ablation of early gastrointestinal intramucosal cancer

Various endoscopic techniques are being increasingly used in early gastrointestinal (GI) cancer. The holmium: yttrium-aluminum-garnet (Ho:YAG) laser has precise tissue cutting ability and good hemostatic properties and has been widely applicated to soft tissue, but the use of endoscopic Ho:YAG laser ablation for early gastrointestinal cancer has not been reported. Twenty patients with biopsy-proven early GI cancer who had a high surgical risk or refused surgery were treated by endoscopic Ho:YAG laser ablation. The tumors of all patients were confined to the mucosal layer without ulceration and without lymph node metastasis. The tumor diameter was not more than 2.5 cm. Endoscopy, endoscopic ultrasound, and computed tomography scan were performed 1-3 months after the treatment, and a biopsy was performed to evaluate the effects of the therapy. Long-term endoscopic follow-up was maintained. Complete eradication was achieved in all the 20 patients, including four patients with high-grade dysplasia associated with focal canceration, seven patients with well-differentiated squamous cell cancer, and nine patients with well-differentiated adenocarcinoma, resulting in a complete response rate of 100% at 1-3 months after treatment. No recurrence was found during 36-73 months of follow-up in all 20 patients. No operative or delayed complications were observed in any of the 20 patients. Preliminary study shows that endoscopic Ho:YAG laser ablation may be an effective, safe, and minimally invasive method for selected patients with early GI intramucosal cancer. Further research is required to confirm the safety and efficacy of this technique compared to its alternative techniques in a multicenter randomized controlled trial.

A proposal of a practical and optimal prophylactic strategy for peritoneal recurrence

Peritoneal metastasis, which often arises in patients with advanced gastric cancer, is well known as a miserable and ill-fated disease. Once peritoneal metastasis is formed, it is extremely difficult to defeat. We advocated EIPL (extensive intraoperative peritoneal lavage) as a useful and practical adjuvant surgical technique for those gastric cancer patients who are likely to suffer from peritoneal recurrence. In this paper, we review the effect of EIPL therapy on prevention of peritoneal recurrence on patients with peritoneal free cancer cells without overt peritoneal metastasis (CY+/P−) through the prospective randomized study, and we verified its potential as an optimal and standard prophylactic therapeutic strategy for peritoneal recurrence.

Diagnostic performance of 64-section CT using CT gastrography in preoperative T staging of gastric cancer according to 7th edition of AJCC cancer staging manual

OBJECTIVES

To evaluate the accuracy of 64-section multidetector CT with CT gastrography for determining the depth of mural invasion in patients with gastric cancer according to the 7th edition of the AJCC cancer staging manual.

METHODS

A total of 127 patients with gastric cancer and who had undergone both esophago-gastro-duodenoscopy and 64-section CT were included in this study. Two radiologists independently reviewed the preoperative CT images with respect to the detectability and T-staging of the gastric cancers. The sensitivity, specificity, accuracy and overall accuracy of each reviewer for the T staging of gastric cancer were calculated.

RESULTS

Overall, gastric cancer was detected in 123 (96.9%) of the 127 cancers on the CT images. Reviewer 1 correctly staged 98 gastric cancers, and reviewer 2 correctly classified 105 gastric cancers. The overall diagnostic accuracy of the T staging was 77.2% (98/127) for reviewer 1 and 82.7% (105/127) for reviewer 2.

CONCLUSION

64-section CT using CT gastrography showed a reasonable diagnostic performance for determining the T staging in patients with gastric cancer according to the 7th edition of the AJCC cancer staging manual.

KEY POINTS

64-section CT is useful for determining the T staging of gastric cancer Virtual gastroscopy is helpful for detecting early gastric cancer New CT criteria may be applicable to the T staging The normal gastric wall frequently shows a multilayered pattern.

Detection of early gastric cancer using hydro-stomach CT: Blinded vs unblinded analysis

AIM: To evaluate the difference in diagnostic performance of hydro-stomach computed tomography (CT) to detect early gastric cancer (EGC) between blinded and unblinded analysis and to assess independent factors affecting visibility of cancer foci.

METHODS: Two radiologists initially blinded and then unblinded to gastroscopic and surgical-histological findings independently reviewed hydro-stomach CT images of 110 patients with single EGC. They graded the visibility of cancer foci for each of three gastric segments (upper, middle and lower thirds) using a 4-point scale (1: definitely absent, 2: probably absent, 3: probably present, and 4: definitely present). The sensitivity and specificity for detecting an EGC were calculated. Intraobserver and interobserver agreements were analyzed. The visibility of an EGC was evaluated with regard to tumor size, invasion depth, gastric segments, histological type and gross morphology using univariate and multivariate analysis.

RESULTS: The respective sensitivities and specificities [reviewer 1: blinded, 20% (22/110) and 98% (215/220); unblinded, 27% (30/110) and 100% (219/220)/reviewer 2: blinded, 19% (21/110) and 98% (216/220); unblinded, 25% (27/110) and 98% (215/220)] were not significantly different. Although intraobserver agreements were good (weighted κ = 0.677 and 0.666), interobserver agreements were fair (blinded, 0.371) or moderate (unblinded, 0.558). For both univariate and multivariate analyses, the tumor size and invasion depth were statistically significant factors affecting visibility.

CONCLUSION: The diagnostic performance of hydro-stomach CT to detect an EGC was not significantly different between blinded and unblinded analysis. The tumor size and invasion depth were independent factors for visibility.

Frequency and predictive factors of lymph node metastasis in mucosal cancer

Purpose

The incidence of lymph node metastasis has been reported to range from 2.6 to 4.8% in early stage gastric cancer with mucosal invasion (T1a cancer). Lymph node metastasis in early stage gastric cancer is known as an important predictive factor. We analyzed the prediction factors of lymph node metastasis in T1a cancer.

Materials and Methods

A total of 9,912 patients underwent radical gastrectomy due to gastric cancer from October 1994 to July 2006 in the Department Of Surgery at Samsung Medical Center. We did a retrospective analysis of 2,524 patients of these patients, ones for whom the cancer was confined within the mucosa.

Results

Among the 2,524 patients, 57 (2.2%) were diagnosed with lymph node metastasis, and of these, cancer staging was as follows: 41 were N1, 8 were N2, and 8 were N3a. Univariate analysis of clinicopathological factors showed that the following factors were significant predictors of metastasis: tumor size larger than 4 cm, the presence of middle and lower stomach cancer, poorly differentiated adenocarcinoma and signet-ring cell carcinoma, diffuse type cancer (by the Lauren classification), and lymphatic invasion. Multivariate analysis showed that lymphatic invasion and tumor larger than 4 cm were significant factors with P<0.001 and P=0.024, respectively.

Conclusions

The frequency of lymph node metastasis is extremely low in early gastric cancer with mucosal invasion. However, when lymphatic invasion is present or the tumor is larger than 4 cm, there is a greater likelihood of lymph node metastasis. In such cases, surgical treatments should be done to prevent disease recurrence.

Tumors arising at previous anastomotic site may have poor prognosis in patients with gastric stump cancer following gastrectomy

INTRODUCTION

We analyzed the clinicopathological characteristics and outcomes of patients with gastric stump cancer (GSC) to identify important prognostic factors.

PATIENTS AND METHODS

We retrospectively reviewed clinical reports of 34 patients with GSC treated at Kochi Medical School from 1982 to 2008 to analyze the clinical and pathological factors that influenced patient survival.

RESULTS

The median interval between initial and second operation was 15.8 years; this interval was significantly longer in patients diagnosed originally with benign disease than in those with previous malignant disease. Histologically, the incidence of diffuse-type cancer was significantly prominent in patients with previous benign gastric disease than in those with previous malignant gastric disease. The overall 5-year survival rate was 53.3%, with presence of lymph node metastasis and pathological serosal invasion of the tumor associated with poor survival. The final analysis revealed tumor located at anastomosis, tumor size greater than 5 cm, serosal invasion, the presence of lymph node metastasis, and stage III or higher to be significantly associated with poor survival.

CONCLUSIONS

Follow-up programs after gastrectomy should account for long latency periods of disease. Early detection, attentive observation of anastomotic site, and sufficient surgical resection were important influences on outcome for patients with GSC after Billroth I or Billroth II reconstruction.

Surgical outcome after incomplete endoscopic submucosal dissection of gastric cancer

BACKGROUND

Endoscopic resection of early gastric cancer is a relatively new and attractive treatment, but occasionally fails to remove all cancer lesions completely. This study aimed to elucidate clinicopathological factors that could be helpful in predicting residual tumour in the surgical specimen after incomplete endoscopic submucosal dissection (ESD).

METHODS

Patients who underwent gastrectomy because of incomplete ESD between August 2004 and August 2008 were analysed. Clinicopathological characteristics were reviewed retrospectively from prospectively collected medical records. Patients were classified into groups with and without residual tumour. Pathology results following gastrectomy were compared with those of incomplete ESD.

RESULTS

A total of 118 patients were included. The incidence of residual tumour in the surgical specimen was 24·6 per cent after incomplete ESD. Elevated/flat-type cancers, large tumours (at least 2 cm) and those limited to the mucosa had significantly higher incomplete ESD rates. Cancer limited to the mucosa and the presence of tumour in the lateral margin were associated with residual tumour in the surgical specimen (both P = 0·001).

CONCLUSION

Radical gastrectomy should be performed if pathological examination reveals a positive lateral resection margin after ESD.

Diagnostic performance of 64-channel multidetector CT in the evaluation of gastric cancer: differentiation of mucosal cancer (T1a) from submucosal involvement (T1b and T2)

PURPOSE

To identify the computed tomographic (CT) findings in T1a and T1b cancers and to evaluate the diagnostic performance of multidetector CT with two-dimensional multiplanar reconstruction and three-dimensional CT gastrography for evaluating the preoperative staging of gastric cancer, with special emphasis on the differentiation between T1a and T1b cancers.

MATERIALS AND METHODS

The institutional review board approved this retrospective study. A total of 148 patients with gastric cancer (64 T1a, 36 T1b, and 48 T2) were included. To identify CT findings in T1a and T1b cancers, two radiologists in consensus interpreted the preoperative CT images of the 100 T1 cancers to determine the morphologic characteristics to be used as staging criteria on CT images. By using univariate and multiple logistic regression analyses, the diagnostic criteria to identify T1a and T1b cancers were developed. To evaluate the diagnostic performance of multidetector CT by using the criteria, two other blinded reviewers independently analyzed the CT images of all 148 patients to assess the T (classifying the depth of invasion as T1a, T1b, or T2) and N (classifying nodal involvement as absent or present) stage. CT staging was correlated with histopathologic results. Interobserver agreement was assessed by using weighted kappa statistics.

RESULTS

The detectability of T1b cancer was significantly higher than that of T1a cancer (P = .003). T1b cancer showed well-enhancing mucosal thickening more frequently than did T1a cancer (P = .002). By using the modified CT criteria, the overall accuracy values of T staging and N staging were 64.9% (96/148) and 79.1% (117/148) for reviewer 1 and 63.5% (94/148) and 83.8% (124/148) for reviewer 2, respectively. Weighted kappa values of T and N staging were 0.795 and 0.641, respectively.

CONCLUSION

On multidetector CT images, T1a cancer shows different imaging features than does T1b cancer regarding enhancing characteristics and detectability. Multidetector CT provides relatively valuable results of T and N staging, including differentiation between T1a, T1b, and T2 gastric cancers.

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.

Recurrence after curative resection of early gastric cancer

BACKGROUND

Few studies have evaluated the recurrence of EGC after curative gastrectomy, due to its relatively low incidence. This study evaluated recurrence patterns and independent predictive factors for recurrence in order to determine appropriate follow-up and early detection of recurrence.

METHODS

We reviewed the medical records of 3,883 consecutive patients who underwent curative gastrectomy for EGC at Samsung Medical Center between February 1995 and January 2006 and were followed up until January 2008. The clinical and pathological characteristics and the predictive factors for recurrence were evaluated retrospectively.

RESULTS

Eighty-five (2.2%) patients had recurrence, and liver was the most common site of recurrence (45.9%). The recurrence rates within 2, 3, and 5 years were 43.5%, 67.1%, and 85.6%, respectively. There were 106 overall recurrences, with 86 (81.1%) being detected by computed tomography (CT). Second primary cancer was the primary cause of death after gastrectomy, followed by recurrence. Old age (>60 years), tumor size (>3 cm), multiple tumor, N category, and N2 station metastasis were significant factors for recurrence by multivariate analysis, but depth of invasion was not a significant factor.

CONCLUSIONS

Age, tumor size, number of tumors, N category, and N2 station metastasis were predictive factors for recurrence, with lymph node metastasis being the most significant factor. After curative gastrectomy, follow-up programs should be applied for more than 5 years for EGC patients, and computed tomography could be an essential diagnostic tool.

Pattern of lymph node involvement in proximal gastric cancer

BACKGROUND

The operative methods for proximal gastric cancer differ depending on the institution, thus there is no optimal therapeutic strategy. A splenic hilum lymph node (No. 10) dissection is necessary for D2 operation for proximal gastric cancer, which means it requires splenectomy. However, unnecessary splenectomy should be avoided.

METHODS

A total of 127 proximal gastric cancer cases from our institution were studied retrospectively. In addition, 1,569 cases were collected from the literature and were used as pooled data for further analysis. All cases were examined for the depth of tumor invasion and lymph node metastasis.

RESULTS

A retrospective analysis revealed that proximal gastric cancer within submucosa (40 cases) had no N2 lymph node metastasis in our study. The 5-year overall survival of all cases was 25.2% and the disease-free survival was 23.6%. From the pooled data analysis, No. 10 lymph node metastasis was observed in 0.9% of the patients with submucosa proximal gastric cancer. Furthermore, there was no No. 4d lymph node metastasis when the depth of cancer was limited to within the subserosa.

CONCLUSIONS

Although a randomized, controlled trial concerning survival is necessary, according to this study, there is a possibility that limited resection might be accepted for proximal gastric cancer according to the depth of wall invasion.

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.

Predicting lymph node status in early gastric cancer

Accurate prediction of lymph node (LN) status is of crucial importance for appropriate treatment planning in patients with early gastric cancer (EGC). However, there is no definitive consensus yet on which patient and/or tumor characteristics are associated with LN metastasis. A systematic search for studies investigating the relationship between patient and/or tumor characteristics and LN metastasis in EGC was performed in PubMed/MEDLINE. Patient and/or tumor characteristics associated with LN metastasis were identified by meta-analyzing results of individual studies. Forty-five studies were included. Variables significantly associated with LN metastasis in gastric cancer limited to the mucosa were: age younger than 57 years, tumor location in the middle part of the stomach, larger tumor size, macroscopically depressed tumor type, tumor ulcerations, undifferentiated tumors, diffuse tumor type according to the Lauren classification, lymphatic tumor invasion, tumors with a proliferating cell nuclear antigen (PCNA) labeling index of more than 25%, and matrix metalloproteinase-9-positive tumors. Variables significantly associated with LN metastasis in gastric cancer limited to the submucosa were: female sex, tumor location in the lower part of the stomach, larger tumor size, undifferentiated tumors, increasing depth of submucosal invasion, lymphatic tumor invasion, vascular tumor invasion, increased submucosal vascularity, tumors with a PCNA labeling index of more than 25%, tumors with a gastric mucin phenotype, and vascular endothelial growth factor-C-positive tumors. We identified several variables associated with LN metastasis in EGC. These variables should be included in future research, in order to assess which of these variables remain as significant predictors of LN metastasis.

Risk factors associated with local recurrence of early gastric cancers after endoscopic submucosal dissection

BACKGROUND

Although endoscopic submucosal dissection (ESD) is expected to reduce the local recurrence of gastric cancers, we still experience cases of recurrence after an ESD.

OBJECTIVE

To characterize clinical and pathologic features of cases with local recurrence of early gastric cancer after an ESD.

DESIGN

A prospective cohort study.

SETTING AND PATIENTS

A total of 306 patients with gastric cancers removed by ESD at Okayama University Hospital and Tsuyama Central Hospital between March 2001 and December 2005 were enrolled.

INTERVENTION

ESD.

MAIN OUTCOME MEASUREMENT

Local recurrence.

RESULTS

The incidence of a complete en bloc resection was 80.4% when pathologically evaluated. Within a median follow-up period of 26 months (12-64 months), a local recurrence was found in 7 cases, all of which had been declared incomplete resections. One patient underwent a second ESD, and the remaining 6 underwent a surgical resection. All removed lesions were mucosal cancers. No lymph-node metastases were found in patients with a surgical resection. There was a significant correlation between the incidence of an incomplete resection and that of a local recurrence (P < .0001). Among the clinical characteristics, tumor size (>30 mm vs <20 mm; odds ratio [OR] 16 mm [95% CI, 2.0-130 mm]) and tumor location (upper vs middle or lower; OR 7.6 [95% CI, 1.3-45]) were identified as factors that were significantly associated with the incidence of a local recurrence.

LIMITATION

Short follow-up duration.

CONCLUSIONS

The incidence of a local recurrence was strongly associated with that of an incomplete resection. The frequency of a local recurrence also showed significant correlations with the tumor size and location within the stomach.

Is gastrectomy mandatory for all residual or recurrent gastric cancer following endoscopic resection? A large-scale Korean multi-center study

BACKGROUND AND OBJECTIVES

To clarify optimal treatment guidelines for residual or local recurrence after endoscopic resection (ER).

METHODS

Eighty-six patients underwent gastrectomy due to incomplete ER and local recurrence after ER. The pathological findings of ER and gastrectomy specimens were analyzed.

RESULTS

The cause of gastrectomy was categorized into five groups; submucosal (sm) invasion without margin involvement, positive margin, margin not evaluable, high risk of lymph node metastasis and local recurrence after ER. According to the pathological findings of gastrectomy specimens, remnant cancer and lymph node metastases were found in 56 (65.1%) and in 5 patients (5.8%), respectively. At 10 gastrectomy specimens which were sm invasion without margin involvement, the scattered residual cancer cells were found around the ulcer scar in 2 (20%) patients. In 11 of 44 margin involvement specimens, no residual cancer or lymph node metastasis was found. In patients with local recurrence, mean duration from ER to surgery was 14.8 months, and 19% of patients were found to have sm or deeper depth of invasion.

CONCLUSION

Gastrectomy with lymph node dissection should be performed in patients with sm invasion with or without margin involvement. However, minimal approach other than gastrectomy could further be applied to selected patients.

Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?: prospective, multicenter study

BACKGROUND

Laparoscopic surgery has been adopted for the treatment of gastric cancer, and many reports have confirmed its favorable outcomes. Most surgeons prefer to laparoscopy-assisted gastrectomy using minilaparotomy rather than totally laparoscopic procedures because of technical difficulties of intracorporeal anastomosis. We conducted this study to compare laparoscopy-assisted distal gastrectomy with totally laparoscopic distal gastrectomy. In addition, laparoscopic procedures were compared with open distal gastrectomy.

MATERIAL AND METHODS

This prospective, nonrandomized, multicenter study enrolled 60 patients with early gastric cancer at three branch hospitals of our institutes. Twenty-five- to 30-cm-long mid-line incision, 5-cm midline or transverse incision, and 3-cm U-shaped incision were used in open distal gastrectomy, laparoscopy-assisted distal gastrectomy, and totally laparoscopic distal gastrectomy, respectively. Postoperative outcomes, immunologic changes, and operation-related costs were compared between the three groups.

RESULTS

There was no difference in gender, mean age, body mass index, and tumor characteristics between the three groups. No operation-related death occurred. Estimated blood loss, number of additional analgesics use, first flatus, and soft meal diet time were significantly different between the three groups (P < 0.05). In totally laparoscopic distal gastrectomy, the time to first flatus was significantly shorter than laparoscopy-assisted distal gastrectomy (3.7 vs. 2.8 days, in laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy, respectively, P < 0.05). White blood cell count and C-reactive protein level at postoperative day 1 were significantly higher in open distal gastrectomy than the other groups; however, there was no difference between laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy. The operation-related costs were significantly greater in totally laparoscopic distal gastrectomy (P < 0.05).

CONCLUSION

Although totally laparoscopic distal gastrectomy needs more cost, totally laparoscopic distal gastrectomy provides shorter bowel recovery time than laparoscopy-assisted distal gastrectomy.

Lymph node metastasis in submucosal gastric cancer and reduction surgery

Although the concept of early gastric cancer (EGC) has been accepted, lymph node metastasis is the most important prognostic factor for EGC. Submucosal gastric cancer is greatly concerned because of its high lymph node metastasis incidence accounting for about 20% of all lymph node metastases. Many researchers suggest that reduction surgery should be performed for submucosal gastric cancer patients at a lower risk of developing lymph node metastasis. Submucosal gastric cancer can be divided into 3 levels (Sm1, Sm2, Sm3) based on its depth of invasion, which has been proven useful for predicting lymph node metastasis, directing treatment and evaluating prognosis. Recently, with the advances in clinical pathology and molecular biology, the risk factor for lymph node metastasis of submucosal gastric cancer can be accurately evaluated and its treatment has become rather rational. This paper reviews the relative factors for lymph node metastasis of submucosal gastric cancer and advances in its rational surgical treatment.

Clinicopathological features and medical management of early gastric cancer

BACKGROUND

The detection of early gastric carcinoma (EGC) has increased worldwide due to advances in endoscopic techniques and equipment. The aim of the current study was to compare the clinicopathological findings of patients with and without lymph node metastasis.

METHODS

A total of 440 cases of early gastric carcinoma in patients who underwent surgical procedures between 1981 and 2002 at Kochi Medical School were studied.

RESULTS

Lymph node metastasis was observed in 38 patients (8.6%) with EGC. Multivariate analysis identified 4 independent risk factors of lymph node metastasis: (1) submucosal invasion; (2) tumor diameter greater than 3.5 cm; (3) the presence of vascular invasion; and (4) the presence of lymphatic permeation.

CONCLUSION

For patients with tumor size between 1 cm and 3.5 cm we would recommend endoscopic resection initially, with a consideration for additional surgical resection if microscopic vascular invasion or lymphatic permeation is demonstrated.

Multiple early gastric cancer with duodenal invasion

Background

Early gastric cancers with duodenal invasion are rare, and no previous case of multiple early gastric cancer, one invading the duodenal bulb, has been reported.

Case presentation

A 79-year-old woman was investigated for upper abdominal discomfort. Endoscopic examination revealed an irregular nodulated lesion in the antrum area, and a reddish aggregated-type semi-circumferential nodulated lesion extending from the prepyloric area to the duodenal bulb through the normal mucosa with the antrum lesion. Biopsy revealed a tubular adenoma for the antrum lesion and a well-differentiated tubular adenocarcinoma for the prepyloric lesion. Distal gastrectomy with sufficient duodenal resection was performed. Microscopically, the antrum lesion appeared as a papillary adenocarcinoma, and the prepyloric lesion as a mainly papillary adenocarcinoma which partially invaded the submucosa without any sequential elongation for endoscopic findings. The lesion extended into the duodenal bulb, and was 12 mm in length from the oral end of Brunner's gland's area and limited within the duodenal mucosa.

Conclusion

Here, we present an unusual case of multiple early gastric cancer, one of which invaded the duodenum with relative wide mucosal spreading. This case illustrates that even early stage cancers located in the gastric antrum, particularly in the prepyloric area can invade the duodenum directly.

Risk factors for lymph node metastasis and evaluation of reasonable surgery for early gastric cancer

AIM

To give the evidence for rationalizing surgical therapy for early gastric cancer with different lymph node status.

METHODS

A series of 322 early gastric cancer patients who underwent gastrectomy with more than 15 lymph nodes retrieved were reviewed in this study. The rate of lymph node metastasis was calculated. Univariate and multivariate analyses were performed to evaluate the independent factors for predicting lymph node metastasis.

RESULTS

No metastasis was detected in No.5, 6 lymph nodes (LN) during proximal gastric cancer total gastrectomy, and in No.10, 11p, 11d during for combined resection of spleen and splenic artery and in No.15 LN during combined resection of transverse colon mesentery. No.11p, 12a, 14v LN were proved negative for metastasis. The global metastastic rate was 14.6% for LN, 5.9% for mucosa, and 22.4% for submucosa carcinoma, respectively. The metastasis in group II was almost limited in No.7, 8a LN. Multivariate analysis identified that the depth of invasion, histological type and lymphatic invasion were independent risk factors for LN metastasis. No metastasis from distal cancer (3.0 cm in diameter.

CONCLUSION

Segmental/subtotal gastrectomy plus D1/D1+No.7 should be performed for carcinoma (3.0 cm in diameter). Total gastrectomy should not be performed in proximal, so does combined resection or D2+/D3 lymphadenectomy.

Outcome of segmental gastrectomy versus distal gastrectomy for early gastric cancer

BACKGROUND

Because of the frequent occurrence of postgastrectomy disturbances after distal gastrectomy (DG), segmental gastrectomy (SG) has recently been applied to early gastric cancer (EGC). Outcomes of SG and DG in patients with EGC were compared to clarify the usefulness of SG as a treatment for EGC.

METHODS

This retrospective study involved 61 patients with EGC: 28 patients who underwent DG before March 1996 and 33 patients who underwent SG after April 1996 during the period April 1991 through March 2002. Patient and tumor characteristics, operative results, and postoperative outcomes were compared between the two groups.

RESULTS

The postoperative/preoperative body weight ratio was higher in the SG group than in the DG group. Early dumping syndrome and reflux gastritis occurred less frequently after SG than after DG. The incidence of postoperative complications was similar in the two groups. All patients remained alive without recurrence during a mean follow-up period of 54.7 months in the SG group and 99.9 months in the DG group.

CONCLUSIONS

In comparison to DG, SG is associated with improved postoperative quality of life with no decrease in operative curability of EGC. Thus, SG is a feasible treatment for EGC.

The role of surgery after incomplete endoscopic mucosal resection for early gastric cancer

PURPOSE

Endoscopic mucosal resection (EMR) is a relatively new treatment option for early gastric cancer (EGC). However, cases of incomplete EMR resulting in a positive lateral margin or submucosal invasion (positive vertical margin) have been reported. We conducted this study to evaluate the role of surgery after incomplete EMR for EGC.

METHODS

We analyzed 19 patients who underwent gastrectomy as a result of an incomplete EMR. The patients were divided into three groups according to the type of incomplete EMR: a positive lateral margin (LM) group (n = 9), a positive vertical margin (VM) group (n = 4), and a positive lateral and vertical margin (LM + VM) group (n = 6).

RESULTS

The positive residual tumor rate and the positive lymph node rate were 44.4% (4/9) and 0% (0/9) in the LM group, 50.0% (2/4) and 25.0% (1/4) in the VM group, and 83.3% (5/6) and 16.7% (1/6), LM + VM group, respectively. Curative resection was performed in all patients and there was no recurrence in 30.8 months of follow-up.

CONCLUSION

Radical surgery is recommended for patients with a positive lateral resection margin or submucosal invasion, or both, after EMR for EGC, because of the possibility of residual tumor or lymph node metastasis.

Post-Gastric Endoscopic Mucosal Resection Surveillance Biopsies: Evaluation of Mucosal Changes and Recognition of Potential Mimics of Residual Adenocarcinoma

Endoscopic mucosal resection (EMR) offers curative treatment for patients with node-negative early gastric carcinoma of less than 2 cm without ulceration or ulceration scar. Follow-up biopsies are frequently performed to ensure the absence of residual neoplasia. We performed a retrospective analysis of post-EMR biopsies from 33 patients who underwent gastric EMR. Histologic changes included inflammation (100%), stromal edema (97.0%), foveolar hyperplasia (78.8%), ectatic vessels (66.7%), epithelial atypia (60.6%), increased glandular mitoses (57.6%), epithelial anisonucleosis (54.5%), fibrinopurulent materials (51.5%), ischemia (48.5%), stromal hemorrhage (33.3%), mucin depletion (12.1%), clear cell degeneration (15.2%), and signet-ring cell-like change (6.1%). Especially, clear cell degeneration and signet-ring cell-like change were conspicuous in the area of ischemia. Residual adenocarcinomas were noted in 4 of 33 cases, and consistently showed high nuclear-to-cytoplasmic ratio with high glandular density. Glandular clear cell degeneration and/or signet-ring cell-like change were worrisome and sometimes difficult to be distinguished from residual neoplastic glands. However, these degenerative glands were usually embedded in a nondesmoplastic stroma and showed anisonucleosis of glandular epithelia. Mimics of residual adenocarcinoma, namely clear cell degeneration and signet-ring cell-like change should be judiciously assessed to avoid unnecessary surgery.

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a promising therapeutic option for removal of superficial carcinomas or premalignant lesions throughout the gastrointestinal tract. This review discusses indications and the several techniques of EMR in early tumors of esophagus, stomach, duodenum, and colon. EMR is not yet widely utilized in the West. However, great benefits may be obtained from this non-invasive technique after an accurate evaluation of patients and a careful staging of lesions that may assess the depth of infiltration and exclude the presence of lymph node metastases. EMR permits a complete removal of the lesion with histologic assessment of the entire specimen and the change in the pathologic stage in a significant number of patients. To minimize the risk of serious complications (mostly bleeding and perforation), only experienced endoscopists should undertake EMR in an appropriate environment. Data from literature are encouraging on the use of EMR, but a long-term follow-up of a large number of patients is necessary to confirm the effectiveness of this therapy.

Extended lymphadenectomy (D2) in patients with early gastric cancer

AIMS

To investigate the survival benefit of extended lymphadenectomy (D2) in EGC patients in one European Institution.

METHODS

A review was made of our prospective gastric database from January 1980 to December 2001. Of 527 patients with primary gastric adenocarcinoma, 119 with EGC underwent potentially curative resection (R0) with D2 lymphadenectomy.

RESULTS

There were two post-operative deaths. Of the 117 evaluable cases, 96 were classified as N0 and 21 as N+, with metastases in the perigastric lymph nodes (level 1) in 13, and beyond this site (level 2) in eight. Five-year survival was 85.9 and 83.0% in N0 and N+ patients, respectively. During a median follow-up of 90 months, five of the eight patients with level 2 metastases died of recurrent disease and three were alive. The estimated survival benefit for 119 patients with EGC was 2.5% (3/119 cases).

CONCLUSIONS

In patients with EGC, metastases to level 2 are rare. Our results indicate that D2 lymphadenectomy has a limited survival benefit and that in these cases a less extensive lymphadenectomy (D1) could be performed.

Laparoscopic assisted distal gastrectomy for early gastric cancer: Five years' experience

BACKGROUND

Laparoscopic assisted gastrectomy is being reported increasingly as the treatment of choice for early gastric cancer. However, no reports concerning the prognosis of patients who have undergone laparoscopic assisted distal gastrectomy (LADG) for early gastric cancer or data comparing the results to those obtained after open gastric surgery are yet available.

METHODS

A retrospective study was performed comparing laparoscopic assisted and open distal gastrectomies for early gastric cancer. Eighty-nine patients who underwent LADG were compared to 60 who underwent conventional open distal gastrectomy (DG) in terms of pathologic findings, operative outcome, complications, and survival.

RESULTS

There were no significant differences between LADG and DG in operation time (209 vs 200 minutes), complication rate (9% vs 18%), and 5-year survival rate (98% vs 95%). There were differences between LADG and DG with regard to blood loss (237 vs 412 mL), number of lymph nodes (19 vs 25), postoperative stay (17 vs 25 days), and the duration of epidural analgesia (2 vs 4 days) ( P < .05 each).

CONCLUSIONS

For properly selected patients, LADG can be a curative and minimally invasive treatment for early gastric cancer.

Novel endoscopic therapies for gastrointestinal malignancies: endoscopic mucosal resection and endoscopic ablation

Gastrointestinal malignancies are often detected at advanced stages when the prognosis is poor. Screening guidelines that vary accord-ing to the regional disease prevalence are needed. High-resolution endoscopy, magnification endoscopy, chromoendoscopy, light autofluorescence endoscopy, and optical coherence tomography are new technologies designed to improve endoscopic detection. Once detected, lesions must be accurately staged, including depth of mucosal penetration and lymph node involvement, to determine endoscopic resectability. Widely applicable, relatively safe, and minimally invasive alternatives to surgery are needed. Endoscopic mucosal resection and endoscopic ablation are potentially curative for malignancies limited to the mucosa, obviating the need for surgery in these patients.

Survival after surgical treatment of early gastric cancer, surgical techniques, and long-term survival

Early gastric cancer (EGC) is well accepted as having a favorable prognosis after surgical treatment. Difference in treatment strategies for EGC between Japan and western countries indicates a need for current information to be evaluated with regard to long-term survival rates of EGC patients throughout the world. To analyze survival rates and recurrence after resection of EGC, we investigated 51 reports in English that each included more than 50 cases of EGC treated by gastrectomy and had been published during the past 12 years (1992-2003). Prevalence of EGC among all gastric cancers was 45%-51% in Japan, but only 7%-28% in western countries. Mean age at diagnosis was less than 60 years in Japan and Korea, but was more than 60 in most of the Western countries. Actuarial and disease-specific 5-year survival rates for EGC were 72%-95.8% and 88%-98.3%, respectively. Those for EGC that were invading the submucosal layer were 71.6%-94.1% and 82%-96.6%, respectively. Those for EGC with lymph node metastasis were 57%-89.1% and 72%-93.5%, respectively. Prevalence of recurrence ranged from 1.0% to 13.8%. Larger clinical series with more EGC cases showed a lower prevalence of recurrence (P=0.531, P=0.0026). Liver and blood-borne distant metastasis represented the predominant pattern of relapse, accounting for over half (54%). Local recurrence and peritoneal dissemination represented 20% and 18% of all recurrences, respectively. Clinicopathological studies have shown lymph node metastasis to be closely related to depth of invasion, size of lesion, histological type, presence of ulcer or ulcer scar, and vessel involvement. Information on these factors is the key to successful treatment of EGC. When sufficient information has been assessed preoperatively, surgeons can select patients for whom less-invasive surgery should not increase the risk of recurrence.

Gastric Adenocarcinoma

Adenocarcinoma of the stomach is advanced enough in some patients to preclude curative treatment, but many gastric cancer patients have what appears to be localized disease that is amenable to surgical resection, which is the only truly effective treatment. Long-term results of what appear to be "curative resections" are relatively poor, however, and new management tools such as sentinel lymph node biopsy, recently promising adjunctive therapies (such as radiochemotherapy), and the organization of the order of treatment combinations do require further study with an eye to improving outcomes. However, there appears to be little hope for a dramatic improvement in treatment results from these innovations for patients with established gastric cancer. Fortunately, gastric cancer in the United States has gone from being the number one cause of cancer death in our population 50 years ago to that of being the number eight cause of cancer death at this time. This intriguing major decrease in the incidence of this disease must be considered secondary to one or more changes in our own environment that we hope will be exploitable in the future. As with cancers of all types and in all sites, a prevention strategy may prove more effective than the treatment strategies that are outlined here. The management strategies outlined are hopefully only temporary ones until we are able to develop a better handle on primary prevention.

[Prolapsed malignant polyp of the stomach causing acute pancreatitis]

Polyps of the stomach are rare lesions with an incidence between 1.7% and 3.9%. Until now, most cases were asymptomatic and found during endoscopic examination. Only three cases of prolapsing gastric polyps causing acute pancreatitis have been reported. Prolapsed polyps of the stomach should be included in the differential diagnosis of secondary pancreatitis. If endoscopic polypectomy is impossible, surgical treatment is necessary. In case early gastric cancer of the mucosa is detected in a polyp, limited surgery is possible. Otherwise, gastrectomy with lymphadenectomy of the D2 compartment is required

Preoperative simulation of vascular anatomy by three-dimensional computed tomography imaging in laparoscopic gastric cancer surgery

BACKGROUND

Treatment of early gastric cancer may be an ideal application for laparoscopic surgery. But laparoscopic surgery has various limitations derived from the lack of tactile feedback and a two-dimensional display of the operative field. So, laparoscopic surgery is technically challenging and requires a more detailed understanding of local anatomy than conventional open surgery does. The purpose of this study was to evaluate the value of three-dimensional computed tomography imaging in the preoperative simulation of laparoscopic gastric cancer surgery.

STUDY DESIGN

Multidetector-row helical CT was performed preoperatively in 49 patients who underwent laparoscopic gastric cancer surgery. Scanning was initiated approximately 20 seconds after an intravenous injection of 100 mL of contrast material at 5 mL/second. Three-dimensional CT images were reconstructed using the volume-rendering technique.

RESULTS

3D-CT imaging depicted the stomach, arterial, and venous anatomy and was able to identify important vascular variants. Preoperative information concerning the right gastric artery led us to the site of its branching and facilitated dissection of suprapyloric lymph nodes. The left gastric artery furnishing the aberrant left hepatic artery was successfully revealed and this information enabled us to avoid accidental hemorrhage and ischemic liver damage. Preoperative confirmation of the drainage routes of the left gastric vein was also useful in accomplishing secure lymphadenectomy.

CONCLUSIONS

3D-CT imaging provides a vascular "road map," which is critical for surgical guidance, and prevents the risks involved in surgery. Preoperative 3D-CT imaging may be an informative device to overcome the disadvantages of laparoscopic gastric cancer surgery.

Preoperative administration of rebamipide significantly lowers body temperature and circulating interleukin-6 in gastric cancer patients after gastrectomy

BACKGROUND/AIMS

It has recently been reported that rebamipide (OPC-12759) inhibits inflammatory cytokines and activation of neutrophils. The aim of the present study was to investigate the effects of preoperative administration of rebamipide on parameters of systemic inflammatory response syndrome (SIRS) and serum levels of inflammatory cytokines in gastric cancer patients after gastrectomy.

PATIENTS AND METHODS

We measured the parameters of SIRS, circulating cytokines and acute phase reactants in patients after (i). distal gastrectomy with D2 lymph node dissection (group 1, n = 10); (ii). distal gastrectomy with D2 lymph node dissection following administration of rebamipide (group 2, n = 10), and (iii). laparoscopy-assisted distal gastrectomy (LADG) with D1 lymph node dissection (group 3, n = 10). Group 2 was administered 100 mg of rebamipide 3 times/day after meals for 7 days before surgery.

RESULTS

Among the parameters of SIRS, a difference was observed in body temperature on day 3. The mean body temperature of group 2 was significantly lower than group 1 (p = 0.006), and was similar to group 3. In proinflammatory cytokines, a significant difference was observed in the serum levels of interleukin (IL)-6. On day 1 the IL-6 levels of group 2 were significantly lower than those of group 1 (p < 0.001). The changes in the IL-6 level of group 2 were similar to group 3, except in the very early postoperative phase. However, other proinflammatory cytokines, such as IL-8 and IL-10, were not detected, and there was no difference in C-reactive protein between the 3 groups.

CONCLUSION

Preoperative administration of rebamipide significantly decreased postoperative body temperatures and circulating IL-6 in gastric cancer patients after gastrectomy to levels similar to those of patients with LADG.

Treatment strategy of limited surgery in the treatment guidelines for gastric cancer in Japan

Surgical practice for gastric cancer in Japan is based on the Gastric Cancer Treatment Guidelines issued in 2001 by the Japanese Gastric Cancer Association. These recommendations list options for treatment of each stage of cancer, with clear distinctions between interventions recommended for routine use and those that should be confined to trial settings until further evidence for their curative potential becomes available. In this review, we discuss standard surgery, local resection, segmental resection, and pylorus-preserving gastrectomy (PPG) as examples of limited resection and describe in detail the indications for limited lymph-node dissection in cases of early-stage gastric cancer. At present, evidence does not support the conclusion that limited surgery is effective for local resection or for improving quality of life. Thus, use of limited surgery should be considered an experimental approach both in Japan and the West. We conclude that surgeons who are familiar with the criteria for selecting surgical procedures should decide on a case-by-case basis which technique is most appropriate. Choices should be made with consideration of the stage of the cancer, invasiveness of the surgical procedure, and the patient's history. For all procedures, the patient must give informed consent and the surgeons must accurately assess the success of the operation after surgery.