Clinical correlates of resectability and survival in gastric carcinoma

Gastrectomy in advanced gastric cancer effectively palliates symptoms and may improve survival in select patients

BACKGROUND

The role of gastrectomy in the face of incurable gastric cancer is evolving. We sought to evaluate our experience with incomplete (i.e., R2) gastrectomy in advanced gastric cancer.

METHODS

We reviewed 210 locally advanced or metastatic gastric cancers (1992-2008). Patient characteristics and outcomes were compared between three groups: gastrectomy (N = 99), exploration without resection (N = 66), and no surgery (N = 45).

RESULTS

Clinicopathologic characteristics were similar between groups. Symptoms successfully resolved after gastrectomy in 48 % with a complication rate of 32 % and mortality of 6 %. Overall median survival for all patients was 6.2 months: 10.0 months after gastrectomy, 4.1 months after exploration without resection, and 5.3 months for no surgery (p < 0.001). Perioperative complications were the only predictor of symptom resolution following resection (OR = 0.175). Resolution of symptoms (p < 0.001, Hazards Ratio (HR) = 0.09) and preoperative nausea/vomiting (p = 0.017, HR = 0.55) improved survival, while linitis plastica (p = 0.035, HR = 4.05) and spindle cell morphology (p = 0.011, HR = 1.98) were predictors of poor survival in patients undergoing resection.

CONCLUSIONS

Gastrectomy in the setting of advanced gastric cancer may be useful in up to half of patients with an acceptable perioperative mortality rate. Symptom resolution offers a potential survival advantage but is dependent upon a complication-free course, so should only be considered selectively.

The efficacy of preoperative PET/CT for prediction of curability in surgery for locally advanced gastric carcinoma

Background

The benefits of preoperative ¹⁸FDG-PET/CT for gastric cancer remain uncertain. The aim of this study was to investigate the effects of preoperative ¹⁸FDG-PET/CT on the surgical strategy for locally advanced gastric cancer retrospectively.

Methods

From January 2007 to November 2008, ¹⁸FDG-PET/CT was performed in 142 patients who had been diagnosed with advanced gastric cancer by computed tomography or gastrofiberscope findings.

Results

Detection rates were 88.7% (126/142) for primary tumors and 24.6% (35/142) for local lymph nodes (LN). Nine patients with metastatic lesions underwent induction chemotherapy without operation. Of 133 patients subjected to operation, positive FDG uptake in primary tumors (p = 0.047) and local lymph nodes (p < 0.001) was related to non-curable operations. The mean standard uptake value (SUV) of primary tumors of patients who underwent non-curable operations was significantly higher than that of patients with curable operations (p = 0.001). When the SUV was greater than 5 and FDG uptake of LN was positive, non-curable operations were predicted with a sensitivity of 35.2%, a specificity of 91.0% and an accuracy of 76.7%.

Conclusions

High SUV of the primary tumor and positive FDG uptake in local lymph nodes at PET/CT could predict non-curative resection in locally advanced gastric cancer. Therefore, information from preoperative PET/CT can help physician decisions regarding other modalities without laparotomy.

Pancreaticoduodenectomy for locally advanced stomach cancer: preliminary results

BACKGROUND

Pancreaticoduodenectomy (PD) for locally advanced stomach cancer involving duodenum or/and pancreatic head was controversial and rarely carried out. It was mainly reported from the Japanese institutions.

METHODS

A review of prospective database from January 2003 to December 2006 of patients who had locally advanced stomach cancer involving duodenum or/and head of pancreas that precluded curative subtotal gastrectomy who underwent diagnostic laparoscopy or exploratory laparotomy to exclude peritoneal metastatic disease. Patients were advised to undergo neoadjuvant chemotherapy before PD.

RESULTS

Seven patients underwent PD during the above-mentioned period. Only four patients had neoadjuvant chemotherapy before PD. The median operative time was 8 h (range 6-9 h). Five patients had combined tranverse colectomy done. There was no 30-day operative mortality or re-operation. Three patients developed controlled pancreatic leaks and fistulas that were successfully treated with conservative measures. The length of hospital stay was 10-53 days (median 15 days). Median survival was 13 months and 2-year survival rate was 60%. Patients who received neoadjuvant chemotherapy seemed to have better survival rate (P = 0.039).

CONCLUSION

Our initial experience has shown that with careful and stringent patients selection, PD for locally advanced stomach cancer can be carried out with acceptable morbidity and mortality. Early results for patients who received neoadjuvant chemotherapy showed trend towards prolonged survival. However, longer follow up and further patient recruitment are needed to confirm our initial optimistic findings.

Expression and prognostic impact of PRL-3 in lymph node metastasis of gastric cancer: its molecular mechanism was investigated using artificial microRNA interference

High PRL-3 expression had been reported to have close association with lymph node metastasis (LNM) of gastric cancer. However, the prognostic significance of highly expressing PRL-3 in LNM of human gastric cancer and the role in the metastasis remain unclear. Our study examined PRL-3 expression both in the LNM (n = 107) and in the primary lesion (n = 137) of gastric cancer, and compared the overall survival rates. RNA interference, induced by recombinant plasmid pcDNA.rPRL3-miR expressing artificial PRL-3 miRNA, was employed to knockdown PRL-3 expression in human SGC7901 gastric cancer cells. Invasion assay and migration assay in vitro were conducted to determine the role of PRL-3 in the metastasis. The role of PRL-3 in the proliferation of SGC7901 cells and tumor growth were also determined. We observed that high PRL-3 expression was more frequently detected in the LNM than in the matched primary lesion (72.9 vs. 47.7%, p < 0.001). Furthermore, the overall survival rate of the patients with high expression of PRL-3 in the LNM was significantly less than those with moderate/low expression (p = 0.003). Importantly, knockdown of PRL-3 can significantly reduce both invasion and migration potencies of SGC7901 cells (p < 0.001), and significantly suppressed the proliferation of SGC7901 cells and slowed down the tumor growth (p < 0.001). It was concluded that high expression of PRL-3 in the LNM had a negative impact on the prognosis of the patients, and plays important roles in LNM of gastric cancer and the tumor growth, which can be a potential therapeutic target and a prognostic factor.

Survival benefits of pancreatoduodenectomy for gastric cancer: relationship to the number of lymph node metastases

BACKGROUND AND AIMS

Pancreatoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high frequency of associated morbidity and mortality. The aim of this study was to determine the limited indication of PD for advanced gastric cancer.

MATERIALS AND METHODS

From January 1984 and December 2005 patient's charts were reviewed and outcomes after PD for gastric cancer were compared between two subgroups; those with a 'high' number (7<or= group) of lymph node metastases and those with 'low' numbers (6>or= group).

RESULTS

PD was intraoperatively selected because of direct tumor invasion into the pancreas (52.2% of the 7<or= group vs 12.5% of the 6>or= group) or pancreatic lymph node infiltration (47.8% of the 7<or= group vs 87.5% of the 6>or= group; P = 0.058). The postoperative histological analysis showed 22 cases from 23 (95.7%) in 7<or= group with T3 or T4 tumor, compared with only 4 cases (50%) in 6>or= group (P = 0.014). The 5-year survival rates were significantly better in the 6>or= group compared with the 7<or= group (P = 0.014).

CONCLUSIONS

The indication for PD in advanced gastric cancer should consider the degree of extensive lymph node metastases and incurable factors.

High PRL-3 expression in human gastric cancer is a marker of metastasis and grades of malignancies: an in situ hybridization study

Phosphatase of regenerating liver (PRL)-3, encoding a 22-kD low molecular weight tyrosine phosphatase, has been reported to be associated with metastasis of colorectal carcinoma. We assessed the levels of PRL-3 mRNA expression to know whether its up-regulation was involved in progression and metastasis of gastric carcinoma. Levels of PRL-3 expression in 94 human gastric adenocarcinomas and 54 matched lymph node metastases were detected by in situ hybridization and compared with clinicopathological characteristics including prognosis. High PRL-3 expression was detected in 36.2% of primary gastric carcinoma (with nodal metastasis, 55.6%; without nodal metastasis, 10%; P < 0.001) and in 74.1% of lymph node metastases. The incidence of high PRL-3 expression in lymph node metastasis was significantly higher than in primary tumors (P < 0.044). Moreover, high expression of PRL-3 was closely associated with tumor size, lymphatic invasion, venous invasion, extent of lymph node metastasis, and tumor stage. These results suggest that high PRL-3 expression may participate in the progression and metastasis of gastric carcinoma. PRL-3 might be a novel molecular marker for aggressive gastric cancer.

ICAM-1 mediated peritoneal carcinomatosis, a target for therapeutic intervention

Development of peritoneal metastasis is a significant issue in the treatment of abdominal cancers. Primary interaction between tumour cells and the mesothelium is a vital step in initiating this process. Our aim was to determine the role of the intercellular adhesion molecule-1 (ICAM-1) in mesothelial-tumour adhesion and the effectiveness of therapeutic intervention. Mesothelial cells were derived from omental tissue. ICAM-1 expression in resting state, in the presence of TNF-alpha or after the application of heparin or hyaluronan was determined by flow cytometry. Functional effects on tumour adhesion to a mesothelial monolayer were determined via a Calcein-AM in vitro adhesion assay. In vivo studies were performed utilising 30 WAG/rij rats, which underwent mini-laparotomy with the injection of 1 x 10(5 )CC 513 tumour cells intraperitoneally. Tumour growth was assessed macroscopically and microscopically by two independent examiners. Mesothelial cells expressed high level of ICAM-1, which was up-regulated by the presence of TNF-alpha. The introduction of heparin caused a decrease in ICAM-1 expression, however hyaluronan did not affect the expression. A significant decrease in tumour-mesothelial cell adhesion in vitro and complete aberration of tumour growth in vivo was observed with heparin application. In vitro studies showed utilisation of high molecular weight hyaluronan, which was more limited in vivo. These data imply that heparin may be used as a potential therapeutic through a defined molecular mechanism both in vitro and in vivo. Hyaluronan appears to function as a barrier and hence may be unreliable in blocking peritoneal recurrence.

Tumour-expressed CD43 (sialophorin) mediates tumourmesothelial cell adhesion

Mesothelial cell intercellular adhesion molecule-1 (ICAM-1) has recently been shown to play a role in tumour cell adherence to the peritoneum. However, solid tumours poorly express its most ubiquitous ligand, beta2 integrin. The aim of this study was to investigate the role of the beta2 integrin subunit and CD43, a known ligand for ICAM-1, in the development of peritoneal metastases. beta2 Integrin subunit and CD43 expression was assessed on a number of tumour cell lines. Adhesion of SW1222 and PSN-1 cells to human peritoneal mesothelial cells was investigated using a fluorometric assay incorporating an inhibitory antibody to beta2 integrin and CD43. beta2 Integrin expression was not inducible on these tumour cell lines, but Western blotting demonstrated CD43 expression in all the cancer cell lines examined and cell surface expression was confirmed by flow cytometry. The anti-CD43 antibody significantly reduced adhesion of PSN-1 and SW1222 cells to HPMC, however beta2 integrin inhibition did not reduce tumour cell adhesion. CD43 is expressed by a variety of carcinoma cell lines, and plays a role in tumour cell-peritoneal adhesion probably via interactions with its putative ligand ICAM-1.

Palliation of anastomotic obstructions in recurrent gastric carcinoma with the use of covered metallic stents: clinical results in 25 patients

BACKGROUND

The purpose of this study was to investigate the technical feasibility and the clinical effectiveness of the placement of covered self-expandable metallic stents for the treatment of anastomotic obstructions in recurrent gastric carcinoma.

METHODS

With fluoroscopic guidance, covered stents were placed in 25 patients with recurrent gastric carcinoma for the palliation of obstructions at anastomotic sites (14 gastrojejunostomy, 11 esophagojejunostomy). All patients had severe nausea and recurrent vomiting before the stent placement.

RESULTS

Stent placement was technically successful in 24 patients (96%). After stent placement, symptoms improved in all 24 patients. During the follow-up of 2 to 65 weeks (mean, 13.7 weeks), stent migration occurred in 1 patient 16 days after the procedure. He needed percutaneous catheter drainage because of an abscess, which was followed by esophagojejunostomy site rupture during a second stent trial. Stricture recurred in 4 patients because of tumor overgrowth 10 to 55 weeks after the procedure; all patients underwent coaxial placement of a second stent and had good oral intake.

CONCLUSIONS

The placement of covered expandable metallic stents seems to be both technically feasible and an effective means for the palliation of anastomotic obstructions in recurrent gastric carcinoma. This procedure can be considered to be the primary choice for the palliation in those patients.

Laparoscopic Palliative Gastrojejunostomy for Advanced Recurrent Gastric Cancer After Billroth I Resection

Palliative surgery for advanced gastric cancer has equivocal results. Laparoscopy is likely to provide some advantage compared to open procedures. We present a case of laparoscopic gastrojejunostomy for advanced gastric cancer, which recurred after Billroth I resection. Reproducing the results of the early experiences so far reported in the literature, laparoscopy provided us with the accurate staging of the disease along with the opportunity, at the same time, to perform a palliative procedure, avoiding laparotomy. Operative results were good, vomiting was relieved, and the patient was able to cope with his disease until death eventually occurred after 6 months.

Prediction of Response to Preoperative Chemotherapy in Gastric Carcinoma by Metabolic Imaging: Results of a Prospective Trial

Purpose: We prospectively evaluated the predictive value of therapy-induced reduction of tumor glucose use for subsequent response and patient survival in patients with gastric cancer treated by preoperative chemotherapy.

Patients and Methods: Forty-four consecutive patients with locally advanced gastric carcinomas were studied by positron emission tomography with the glucose analog fluorine-18 fluorodeoxyglucose (FDG-PET) at baseline and 14 days after initiation of cisplatin-based polychemotherapy. On the basis of a previous study, a reduction of tumor FDG uptake by more than 35% was used as a criterion for a metabolic response. The metabolic response in FDG-PET was correlated with histopathologic response after completion of therapy (< 10% viable tumor cells in the resected specimen) and patient survival.

Results: Thirty-five (80%) of the 44 tumors were visualized with sufficient contrast for quantitative analysis (two of 19 intestinal and seven of 25 nonintestinal tumors showed only low FDG uptake). In the 35 assessable patients, PET imaging after 14 days of therapy correctly predicted histopathologic response after 3 months of therapy in 10 (77%) of 13 responders and 19 (86%) of 22 nonresponders. Median overall survival for patients with a metabolic response has not been reached (2-year survival rate, 90%); for patients without a metabolic response, median survival was only 18.9 months (2-year survival rate, 25%; P = .002)

Conclusion: This study prospectively demonstrates that in patients with gastric cancer, response to preoperative chemotherapy can be predicted by FDG-PET early during the course of therapy. By avoiding the morbidity and costs of ineffective therapy, FDG-PET imaging may markedly facilitate the use of preoperative chemotherapy.

Enhanced staging and all chemotherapy preoperatively in patients with potentially resectable gastric carcinoma

PURPOSE

Patients with local-regional gastric carcinoma have a low rate of curative resection (R0) because of the advanced stage at diagnosis and suboptimal clinical staging. This study was designed to improve clinical staging with the use of laparoscopy and endoscopic ultrasonography (EUS) and to improve R0 resection rates and tolerance by delivering all chemotherapy preoperatively in patients with potentially resectable gastric carcinoma.

PATIENTS AND METHODS

All patients with histologic proof of localized adenocarcinoma of the stomach underwent a staging laparoscopy before registration. EUS was performed when feasible. The intention was to administer up to five courses of preoperative chemotherapy consisting of fluorouracil (500 mg/m(2)/d as a continuous infusion on days 1 through 5 and as a bolus on days 12 and 19), interferon alfa-2b (3 million units subcutaneously three times a week for 3 weeks), and cisplatin (15 mg/m(2)/d as a bolus on days 1 through 5). After chemotherapy, surgery was attempted to remove the primary and regional lymph nodes. Clinical response and EUS staging were correlated with surgical pathology. The feasibility of this approach, resection rates, patient survival, and patterns of failure also were assessed.

RESULTS

All 30 patients enrolled were assessed for toxicity, response, and survival. Nineteen men and 11 women were enrolled. The median number of courses delivered per patient was three (range, one to five courses). Fourteen patients (47%) received all five preoperative courses of chemotherapy. The overall clinical response rate was 34%. Twenty-nine patients (97%) underwent attempted resection. Twenty-five (83%) had an R0 resection. Two patients (7%) had no evidence of carcinoma in the surgical specimen, and three had only microscopic carcinoma (>/= 90% necrosis). Posttreatment EUS findings did not correlate well with surgical pathology. The median duration of follow-up was 30 months (range, 5 months to 65+ months). The median survival time for 30 patients, calculated by the Kaplan-Meier method, was 30 months (range, 5 months to 65+ months). There were no cases of grade 4 toxicity.

CONCLUSION

It is feasible to administer prolonged preoperative therapy in patients with potentially resectable gastric carcinoma. Enhanced staging with laparoscopy and EUS helped in proper selection of patients and better characterization of the stage.

Upper gastrointestinal tract malignant obstruction: initial results of palliation with a flexible covered stent

The authors treated 21 patients with inoperable upper gastrointestinal tract malignant obstruction from the esophagus to the duodenum by means of intubation with a flexible covered stent with fluoroscopic guidance. Stent placement was successful and relief of dysphagia was immediate in 18 (86%) patients, without serious complication. The average dysphagia score decreased from 2.6 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food). Placement of a flexible covered stent provides easy, safe, and effective palliation of upper gastrointestinal malignant obstruction.

Improved mortality rate of gastric carcinoma patients with peritoneal carcinomatosis treated with intraperitoneal hyperthermic chemoperfusion combined with surgery

BACKGROUND

Peritoneal carcinomatosis from gastric carcinoma has a very poor prognosis. The purpose of this study was to evaluate the efficacy of intraperitoneal hyperthermic chemoperfusion (IHCP) in advanced gastric carcinoma patients with peritoneal carcinomatosis.

METHODS

IHCP combined with aggressive surgery was performed in 48 gastric carcinoma patients with peritoneal carcinomatosis; 18 gastric carcinoma patients with peritoneal carcinomatosis serving as controls were treated with surgery alone.

RESULTS

The survival period was extended for the 48 patients who underwent surgery plus IHCP compared with the control patients (P = 0.00167). Of the 29 patients with peritoneal carcinomatosis in the upper abdominal cavity, the 21 patients treated with IHCP and surgery had survival periods superior to those of the 8 patients treated by surgery alone (P = 0.000817). The 5-year survival rate of the 18 IHCP patients with countable metastases in the entire cavity was 41.6%, whereas the 50% survival duration of the control group was 110 days. Nineteen patients with numerous metastases in the entire cavity died within 673 days, regardless of whether or not IHCP was used.

CONCLUSIONS

Peritoneal carcinomatosis is not a disease beyond treatment. IHCP treatment combined with extensive surgery provides an effective and practical method of treating this disease entity.

Positive proximal resection margins after resection for carcinoma of the oesophagus and stomach: effect on survival and symptom recurrence

BACKGROUND

Our aim was to determine the frequency, survival and symptomatic local recurrence rate of patients with a positive proximal resection margin in a series of patients having a resection for carcinoma of the oesophagus or stomach.

METHODS

A retrospective study of pathology reports and case notes. Survival and data on local recurrence were obtained from the patient or general practitioner.

RESULTS

Ten (11.5%) of 87 patients having a gastric or oesophageal resection for carcinoma had a positive proximal resection margin. All 10 patients underwent a palliative resection for late-stage disease. Nine were dead at an average 8.3 months (range 2-20 months) post-resection and one patient remains alive at 9 months. Only one of these 10 patients had evidence of a local recurrence with recurrent dysphagia prior to death at 11 months.

CONCLUSION

A high incidence of a positive proximal resection margin was found. This occurred in patients who underwent a palliative resection for late-stage disease, most of whom died before local recurrence became a problem. For patients recognized as having late-stage disease, surgery for symptom palliation need not be aggressive (such as to include a thoracotomy) because achieving microscopic clearance is unlikely to affect the long-term outcome.

Gastric cancer: a curable disease in Britain

OBJECTIVE

To determine whether more vigorous efforts aimed at earlier diagnosis allied to radical surgical resection lead to improved survival of patients with gastric cancer.

DESIGN

Prospective audit of all cases of gastric cancer treated during 1970-89.

SETTING

Department of surgery, general hospital.

SUBJECTS

493 consecutive patients with gastric adenocarcinoma.

MAIN OUTCOME MEASURES

Operative mortality, postoperative morbidity, and five year survival after radical potentially curative resection.

RESULTS

207 (42%) patients underwent potentially curative resection. The proportion of all patients in whom this was possible increased significantly (p < 0.01) from 31% in the first five year period to 53% in the last five year period. The proportion of patients who had early gastric cancer rose from 1% to 15% (p < 0.01) and stage I disease rose from 4% to 26% (p < 0.001). After potentially curative resection, mortality 30 days after operation was 6%. Operative mortality decreased from 9% in the 1970s to 5% in the 1980s. Likewise, the incidence of serious postoperative complications decreased from 33% in the 1970s to 17% in the 1980s (p < 0.01). Five year survival was 60% in patients who underwent curative resection, 98% in patients with early gastric cancer, and 93%, 69%, and 28% in stage I, II, and III disease respectively. By the late 1980s five year survival after operation was about 70%.

CONCLUSIONS

These findings suggest that an increasing proportion of patients with gastric cancer could be diagnosed at a relatively early pathological stage when about two thirds are curable by means of radical surgery.

Results of surgery on 6589 gastric cancer patients and immunochemosurgery as the best treatment of advanced gastric cancer

Results of 6589 gastric cancer operations at the Department of Surgery, Seoul National University Hospital, from 1970 to 1990 were reported. About two thirds (76.6%) were advanced gastric cancer (stages III and IV). The 5-year survival rate of operated stage III gastric cancer was only 30.6%, with frequent recurrence. Conversely, cell-mediated immunities of advanced gastric cancer patients were significantly decreased. Therefore, to improve the cure rate and to prevent or delay recurrence, curative surgery with confirmation of free resection margins and systematic lymph node dissection of perigastric vessels were performed and followed by early postoperative immunotherapy and chemotherapy (immunochemosurgery) in stage III patients. To evaluate the effect of immunochemosurgery, two randomized trials were studied in 1976 and 1981. In first trial, 5-fluorouracil, mitomycin C, and cytosine arabinoside for chemotherapy and OK 432 for immunotherapy were used. The 5-year survival rates for surgery alone (n = 64) and immunochemosurgery (n = 73) were 23.4% and 44.6%, respectively, a significant difference. In the second trial, there were three groups: group I, immunochemosurgery (n = 159); group II, surgery and chemotherapy (n = 77); and group III, surgery alone (n = 94). 5-Fluorouracil and mitomycin C for chemotherapy and OK-432 for immunotherapy were administered for 2 years. The 5-year survival rate of group I was 45.3%, significantly higher than the 29.8% of group II and than the 24.4% of group III. The postoperative 1-chloro-2.4-dinitrobenzene test, T-lymphocyte percentage, phytohemagglutinin- and con-A-stimulated lymphoblastogenesis and the antibody-dependent cell-mediated cytotoxicity test showed more favorable values in the immunochemosurgery group. Therefore, immunochemosurgery is the best multimodality treatment for advanced gastric cancer.

Surgical treatment of gastric cancer. Proximal, mid, and distal stomach

At present, only radical surgical resection of gastric cancer offers a chance for cure. The objective of an operation for patients with disease that is confined locally is to maximize the potential for cure. The objective for patients with advanced incurable disease, obstruction, hemorrhage, and intractable pain is to provide the best palliation. The evaluation, staging, and surgical management of gastric cancer are described.

Improving survival in gastric cancer: review of 5-year survival rates in English language publications from 1970

In this review of English language publications from 1970, 5-year survival rates after surgery for gastric cancer have been analysed. While the proportion of patients coming to operation has fallen from 92 per cent before 1970 to 71 per cent by 1990, the proportion of operated patients undergoing resection has increased from 37 per cent before 1970 to 48 per cent before 1990. This change suggests improved preoperative staging leading to better patient selection for operation. The 5-year survival rate following all resections has increased significantly from 20.7 per cent before 1970 to 28.4 per cent before 1990, an increase of 7.7 per cent (95 per cent confidence interval 7.1-8.3 per cent). The 5-year survival rate following curative or radical resection has risen from 37.6 to 55.4 per cent over the same period, an increase of 17.8 per cent (95 per cent confidence interval 17.1-18.5 per cent). It is likely that this improvement has contributed to the decrease in the mortality rate from gastric cancer. Comparison of Japanese series with others suggests that diagnosis and treatment of the disease at an earlier stage will result in an even greater increase in 5-year survival rates outside Japan. Of the papers studied, 56 per cent were excluded from analysis, the majority because the data provided about 5-year survival rates were insufficient or the survival calculations inappropriate. Results of survival after operations for gastric cancer should be calculated and presented in a standardized manner.

Prevalence of subtypes of intestinal metaplasia in gastric antral mucosa

A prospective gastroscopic-bioptic study of 533 patients was performed to assess the prevalence and distribution of intestinal metaplasia (IM) and its subtypes in the antral mucosa of patients with various upper intestinal disorders and to assess whether the presence of certain IM subtypes might be of help in selecting patients for careful endoscopic-bioptic surveillance in the screening for gastric carcinoma. IM was found in 135 patients (25.3%). Its prevalence increased with age (P < 0.001) and was strongly associated with intestinal-type carcinoma as compared to diffuse-type carcinoma (P < 0.001), gastritis (P < 0.001), and gastric ulcer (P < 0.05). Type I IM was predominant (98.5%), whereas types II and III IM, respectively, were found in 77.8% and 15.6% of the patients with IM. No difference in the prevalence of type I and II IM was found among the various gastric disease states. Type III IM was strongly associated with intestinal-type carcinoma as compared to either benign lesions (P < 0.01) or diffuse-type carcinoma. These results suggest that type III IM may play a special role in the histogenesis of intestinal-type carcinoma and suggest that the finding of this IM subtype in gastric biopsies may possibly be of help in identifying patients at greater risk of developing carcinoma.

Improving survival in gastric cancer: review of operative mortality in English language publications from 1970

In this review of English language publications from 1970, operative mortality following surgery for gastric cancer has been analysed. Operative mortality has declined in series reporting operations in successive decades to 1970, 1980 and 1990. Series reporting patients having surgery for gastric cancer in the decade to 1990 show a mean operative mortality rate of 7.8 per cent (median 4.6 per cent). This improvement may have contributed to the declining mortality rates for gastric cancer in the face of unchanging surgical workload. Results of operations for gastric cancer should be reported in a standard manner.

Endoscopic screening and surveillance for gastrointestinal malignancy

In the US, the cumulative lifetime risk of developing carcinoma of the upper gastrointestinal tract is less than 1 per cent, premalignant conditions are uncommon, and esophageal and gastric malignancies are rarely curable even when identified early. Endoscopic screening of the upper gastrointestinal tract in asymptomatic persons thus cannot be justified. Surveillance of persons with certain uncommon conditions associated with a higher risk of upper gastrointestinal cancer may be of benefit. These conditions include achalasia, Barrett's esophagus, chronic atrophic gastritis with intestinal metaplasia, familial polyposis coli, gastric polyps, lye stricture, Plummer-Vinson syndrome, and tylosis. In the lower gastrointestinal tract, however, the lifetime risk of developing carcinoma is 5 per cent, premalignant conditions and lesions are common, and carcinoma is curable when detected at an early stage. Sigmoidoscopic screening of asymptomatic adults has been advocated by the American Cancer Society but has not become widely practiced because of its cost, required physician effort, low overall yield, and poor patient compliance. Surveillance by flexible sigmoidoscopy is recommended for persons at slightly increased risk of colorectal carcinoma who have prior breast or gynecologic malignancy or a family history of colorectal malignancy. Colonoscopic surveillance is recommended for patients with high risk of colorectal cancer who have had prior colorectal carcinoma or adenoma or who have inflammatory bowel disease or a ureterosigmoidostomy.

Surgical treatment of gastric carcinoma

To investigate changes in the results of treatment of gastric carcinoma, two 10-year periods between 1963 and 1982 with 641 and 630 patients, respectively, were compared. In the two groups, 94 percent and 92 percent of patients were operated on. The operation was considered curative in 200 and 265 patients in Groups 1 and 2, respectively. There was a shift towards more radical operations, with 215 total or subtotal gastrectomies in Group 2 compared with 76 in Group 1, when distal gastric resection was considered radical enough. Despite the increasing number of curative operations and more radical surgery in Group 2, no progress in the 5-year survival rate was noted. Distal and subtotal gastrectomies gave slightly better results than total gastrectomies, but the most important single factor contributing to the long-term survival was cancerous invasion of the serosa. It is concluded that in the past 20 years, the results of surgical treatment of gastric carcinoma have not improved, despite the more advanced diagnostic methods and more radical surgery.

The survival benefit of resection in patients with advanced stomach cancer: the Norwegian multicenter experience. Norwegian Stomach Cancer Trial

Five hundred three of 1,165 patients with stomach cancer included in a national multicenter study received noncurative treatment. This study elucidates whether a palliative resection offered any survival advantage compared to nonresectional treatment. One hundred eighty-two (36%) of 503 patients had gastric resection (including total gastrectomy in 64 patients), 70 (14%) had a bypass procedure, and an exploratory laparotomy was carried out in 156 (31%). Seventy-eight patients (16%) were not subjected to surgery. Resection carried the same postoperative mortality rate as a nonresectional procedure (13% versus 12%). Univariate survival analysis demonstrated that median survival and 1- and 2-year survival rates were significantly higher in resected patients; however, as basic patient characteristics (age, stage, etc.) differed between the 2 main treatment groups, survival and factors affecting survival were analyzed using the Cox proportional hazards model. Given similar age and preoperative weight loss, resection doubled median survival both for stage III disease (9 versus 4.5 mo) and for stage IV disease (6 versus 3 mo) compared to nonresection or no operation. In conclusion, resection seems justified in patients with advanced stomach cancer since a survival benefit is documented.

Early gastric cancer

Thirty-six patients with early gastric cancer were studied. In 15 patients, malignancy was restricted to the mucosa; in 21 patients, submucosal invasion was noted. Lymph node involvement was found in four patients. Kaplan-Meier estimates for 5-year survival were 92 percent for mucosal lesions and 65 percent for submucosal lesions (overall 5-year survival rate 73 percent). Mucosal lesions were significantly larger than were submucosal lesions (3.7 +/- 0.6 cm versus 2.5 +/- 0.4 cm, mean +/- SE; p less than 0.005). Associated malignancy was recorded in 13 of 36 patients. When compared with data from a large Japanese study, early gastric cancer in the United States tends to develop more distally in the stomach and in patients approximately one decade older. Survival was not as favorable as in Japan. This may be related to patient age and the high incidence of associated nongastric malignancy.

Total versus subtotal gastrectomy for adenocarcinoma of the gastric antrum. A French prospective controlled study

In a multicentric trial the postoperative mortality and the 5-year survival of elective total gastrectomy (TG) was compared with subtotal gastrectomy (SG) for adenocarcinoma of the antrum operated on with intent of cure. Two hundred and one patients were included in the study; 32 were excluded after pathologic examination (linitis plastica, superficial cancer, lymphoma). One hundred sixty-nine patients remained for analysis, with 93 undergoing TG and 76 undergoing SG. Elective TG did not increase postoperative mortality (1.3%) compared with SG (3.2%). There was no difference in the 5-year survival rate (48%). Analysis of survival showed no difference in the two techniques when related to nodal involvement and serosal extension. It is concluded that both TG and SG can be performed safely in patients with adenocarcinoma of the antrum; however TG did not increase the survival rate.

Gastric cancer in primary care: how hard should you look?

This article addresses the question of how vigorously a physician should search for gastric cancer among dyspeptic patients. To address this subject, two major questions are posed: Which patients presenting with dyspepsia are at highest risk of having gastric cancer? Does early diagnosis of symptomatic gastric cancer affect outcome? Although early detection of gastric cancer has been increasingly reported since the advent of fiberoptic endoscopy, factors such as lead time bias and an unchanged case-fatality rate preclude a definitive conclusion of improved treatment outcomes resulting from early detection. At present, a policy of routine immediate investigation of dyspeptic patients has not been shown to reduce gastric cancer mortality.

Lymph node involvement as the only prognostic factor in curative resected gastric carcinoma: a multivariate analysis

The aim of this study was to evaluate the independent influence of clinical and pathological variables on survival of patients with gastric carcinoma using the Cox regression proportional hazard model. Of 156 patients operated on for gastric carcinoma, 46 (29.5%) underwent palliative operation, 24 (15.5%) had a palliative resection, and 86 (55%) had a curative resection. The overall 5-year survival rate was 25 +/- 4%. After curative resection, the 5-year survival rate was 44 +/- 6%. Univariate analysis applied to these patients showed that poor survival was related (p less than 0.01) to: age (over 80 years), absence of epigastric pain, vomiting and dysphagia, total gastrectomy, tumor size (more than 4 cm), lymph node involvement (LNI), invasion through the muscularis propria, absence of intestinal metaplasia near the tumor, and linitis plastica. In multivariate analysis, lymph node involvement was found to be the only independent prognostic factor. The 5-year survival rate was 75.5 +/- 8% without LNI, 28 +/- 10% with proximal LNI, and 7 +/- 6% with distal LNI. Our results suggest that classification into 3 LNI groups is the best staging system for curative resection in gastric carcinoma.

Results of resection of gastric cancer extending to adjacent organs

We report the late results of resection in 281 patients with gastric carcinoma extending to adjacent organs. In 92 without incurable factors (peritoneal dissemination, liver metastasis and widespread nodal involvement) the 5-year survival rate was 36.7 per cent in those treated by gastrectomy and complete removal of the invaded organ. This value is significantly higher than the 17.4 per cent recorded in those undergoing gastrectomy alone or with incomplete removal of the invaded organs (P less than 0.05). In 189 patients with incurable factors, the 5-year survival rates were 5.4 and 2.8 per cent respectively in cases of complete and incomplete excisions. This tendency was similar in patients with a single invaded organ and also in those with plural organ involvement. In potentially curable patients treated by complete excision, the probability of long-term survival was statistically better than that following incomplete excision only when the pancreas was involved (P less than 0.05). We recommend complete excision of invaded organs, irrespective of the number or site of organs involved, provided that there is no evidence of incurable factors.

Impact of endoscopy on mortality from occult cancer in radiographically benign gastric ulcers. A probability analysis model

Endoscopy is commonly used in the management of patients with radiographically benign gastric ulcers to detect occult malignancy. Clinical studies examining the cost-effectiveness of using endoscopy in such patients, however, have not been done. To address this issue using probability analysis, a probability tree was designed incorporating the possible clinical courses of patients with radiographically benign gastric ulcers managed with and without endoscopy, and probability estimates for each course were derived by compiling data from the literature. Probability and sensitivity analysis was used to compare the impact on overall mortality rate and cost-effectiveness of six commonly practiced methods of using endoscopy to manage patients with radiographically benign gastric ulcers: (1) all follow-up by upper gastrointestinal x-ray only; (2) endoscopy for nonhealing ulcers only; (3) endoscopy for all ulcers before medical therapy with all follow-up by upper gastrointestinal x-ray; (4) endoscopy for all ulcers after an initial trial of medical therapy; (5) endoscopy for all ulcers before therapy and for nonhealers; (6) endoscopy before therapy, and all follow-up by endoscopy. This analysis predicts that the greatest decrease in mortality rate occurs when endoscopy is used before medical therapy and for all follow-up, reducing the estimated number of deaths per 1000 patients with radiographically benign gastric ulcers from 36.7 with follow-up by upper gastrointestinal x-ray only to 27.2. However, initial endoscopy with all subsequent follow-up by upper gastrointestinal x-ray increased the overall death rate by only a small amount, to 28.0, and was consistently the most cost-effective method, requiring 116 endoscopies and approximately 60,000 diagnostic dollars per additional 5-yr survivor.

Total and near-total gastrectomy for gastric cancer in patients over 70 years of age

A total or near-total gastrectomy was performed in 52 patients over 70 years of age in our hospital from 1975 through 1982. The hospital mortality rate was 9.6 percent. The operation was palliative in nine patients. In these patients, the operation was performed because of an obstructing cancer. At last follow-up, 11 patients had survived more than 5 years and 6 patients were alive and free of disease more than 3 years after the operation. Total and near-total gastrectomies seem to be justified in elderly patients in good overall physical condition.

Hepatic metastases in Hong Kong Chinese: evidence for an East-West difference in gastric cancer

The incidence of hepatic metastases found at laparotomy for colorectal and gastric cancer amongst Hong Kong Chinese was found to be 16% and 5% respectively. These figures were compared to similar Western series, and the incidence of metastases from gastric cancer was significantly lower in the Chinese population. This geographical variation may have important implications for the interpretation of treatment results for gastric cancer in different parts of the world.

Subtotal versus total gastrectomy for cancer of the lower two-thirds of the stomach: a new approach to an old problem

Many surgeons favour total gastrectomy (TG) 'de principe' in the treatment of gastric cancer, but final demonstration of its advantage over subtotal gastrectomy (SG) is still lacking. We analysed survival after curative TG or SG within groups of patients stratified according to the main prognostic variables as found in multivariate analysis, i.e., nodal status, degree of invasion of the gastric wall, patient age and sex. Our series consisted of 361 patients treated by curative SG and 41 by curative TG, admitted to the Istituto Nazionale Tumori of Milan between 1965 and 1979. In patients with lymph node involvement survival appeared to be significantly better (P = 0.0005) after SG. However, stratifying for age it was found that the benefit was limited to patients over 60 years old. No significant difference in survival was found in the group without nodal involvement (N -) and invasion of the wall to the serosa or beyond. No statistical comparison was possible in N - groups with invasion confined to mucosa, submucosa or muscularis propria because of the small number of such patients who underwent TG. We conclude that SG still represents the standard reference operation for gastric carcinoma provided that a safe proximal margin of resection is guaranteed.

Adenocarcinoma of the esophagus and gastroesophageal junction. Prognostic factors and results of therapy

Adenocarcinomas of the esophagus and gastroesophageal junction (AE and GE) are uncommon neoplasms with a poor prognosis. AE or GE are usually analyzed as part of the larger group of carcinomas in patients with either epidermoid carcinoma of the esophagus or with gastric cancer. The prognostic variables and outcome of therapy for patients with AE and GE alone have not been well described. The records of 131 patients treated at Memorial Hospital during the period 1978 to 1982 were reviewed. The majority underwent surgery as their primary therapy. Clinical staging was found to be highly inaccurate, with almost all patients having Stage III disease at surgery. Operative mortality was 7.1%. Adjuvant chemotherapy did not appear to influence survival. Treatment of advanced disease with either conventional or investigational agents yielded modest objective response rates. Prognostic variables for those presenting with locoregional disease who were candidates for potentially curative surgery were analyzed. Only the presence or absence of weight loss and location of the primary tumor (AE versus GE) were significant variables. A model for predicting survival was employed.

Immunochemosurgery for gastric cancer

The effects of immunochemosurgery on 73 patients with stage III gastric cancer who were treated with radical subtotal gastrectomy followed by immunochemotherapy for 18 months during the 5-year period between 1975 and 1980 were compared to the effects of therapy on 64 patients with stage III gastric cancer treated with radical subtotal gastrectomy alone during the period between 1970 and 1980. For immunotherapy, picibanil (streptococcus pyogenes preparation) was intramuscularly given weekly, and for chemotherapy, either MFC (mitomycin-C, 5-FU, and cytosine arabinoside) regimen I.V. ten times followed by oral 5-FU or FME (5-FU and methyl-CCNU) regimen was given. The percentage of survivors who received postoperative immunochemotherapy compared to that of survivors who received surgery alone differed by approximately 15%. This difference was rather constant with more than 5 years of follow-up. The 5-year survival rate in the immunochemosurgery group was 38.1%, whereas that in the surgery alone group was 24.8%, which was statistically significant (p less than 0.01). Various immune parameter studies such as 1-chloro-2, 4-dinitrobenzene (DNCB) test, T lymphocyte count and percent, PHA- and concanavalin-A-stimulated lymphoblastogenesis, and antibody dependent cellular cytotoxicity (ADCC) activity showed more favorable data in the immunochemosurgery group than in the surgery alone group. The effects of early postoperative immunochemotherapy (immunotherapy from the fourth to fifth postoperative day, and chemotherapy from the eighth to tenth postoperative day) after radical gastrectomy seems to be superior to that of surgery alone for stage III gastric cancer. For stage I and II gastric cancer, radical gastrectomy and postoperative immunotherapy for 3 months would be the best treatment.

[Gastrectomy in the aged]

Between 1969 and 1983 a total of 152 patients underwent total gastrectomy. 58 patients were older than 70 years. Surgical lethality was 14.47% with only minor differences between those patients younger than 70 and the older ones: 13.8 and 15.5%, respectively. Moreover, it did not make any major difference whether surgery was curative or merely palliative. Of 27 patients with the tumor stage TNM IV, only one patient died. Of the 66, who were operated upon during the recent 5 years period between 1979 and 1983, only one patient died. These results suggest that this remarkable decline of lethality is due to a precise standardisation of surgical technique, improvements in preoperative management of the patient and aftercare. 5 years survival rate was 17.3%; again there was no major difference between the group of patients older than 70 and those being younger than 70 years (16.5% and 19.4% respectively). It is of interest that the patients having additional splenectomy presented with an essentially worse prognosis as opposed to those without splenectomy although there were no differences between the TNM-stages. Even if the small numbers of patients can not yet be definitely conclusive, these preliminary results indicate that the indication for splenectomy in the course of total gastrectomy should be critically evaluated.

Malignancy in the aged: two 'cures' of stomach cancer

Two elderly patients with longstanding gastrointestinal symptoms were eventually diagnosed as having cancer of the stomach. Both were treated-one surgically, the other with chemotherapy. While they were `cured' of the disease, they succumbed to the treatment. These cases raise questions of the approach to be taken to malignancy in the aged.

Palliative total gastrectomy and esophagogastrectomy. A reevaluation

In the interval from 1941-1981 when 1887 patients with gastric cancer were seen at The University of Texas System Cancer Center M.D. Anderson Hospital and Tumor Institute, 151 curative and 45 palliative total gastrectomies or esophagogastrectomies were performed. Over the same interval, 21 patients with extent of primary and metastatic tumor roughly comparable to that seen in the palliative resection group were treated by exploration only or, infrequently, by attempted bypass. In individual patients subtle differences in extent of disease as well as differences in philosophy of the operating surgeon regarding the value of palliative resection undoubtedly contributed to the procedure selected. Survival after curative resection was greater than after palliative resection which in turn was greater than survival after exploration bypass (P less than or equal to .0006). Operative mortality fell significantly in CR patients in the interval 1970-1981 compared to 1941-1969 and was significantly lower than in the PR group in the interval 1970-1981 (P less than or equal to 0.01). Five-year survival increased significantly (P less than or equal to 0.03) in the CR group when results in the two time intervals were compared but not in other groups.

Adenocarcinoma of the stomach: current results of treatment

One hundred-seventy-one patients with gastric adenocarcinoma seen at this medical center from 1972 through 1976 were reviewed. Proper TNM staging was possible in 154 patients. The overall 5-year survival (NED) was 10% and was 20.5% in those patients resected for cure. The operative mortality was 13.7% with most deaths occurring in patients with advanced stage disease. Although operating mortality has decreased in the past 50 years, long-term survival has not changed appreciably in spite of the additional use of radiotherapy or chemotherapy either as adjuvant therapy or for advanced residual neoplasm. Microscopic involvement of margins of resection must be avoided at operation as it is nearly synonymous with early recurrence and death.

Changing state of gastric cancer in Japan. Histologic perspective of the past 76 years

One thousand thirty-eight patients with primary gastric cancer treated operatively during the past 20 year period were described. The results were compared with those in the period from 1904 to 1927 to illustrate the changes which have taken place in diagnosis and treatment of gastric cancer during the past 76 years in Japan. All data was from the Department of Surgery I, Kyushu University. After half a century of status quo, improvement started around the mid 1960s, which coincided with the introduction of newer, improved procedures for diagnosis of gastric cancer, such as double contrast roentgenography of the stomach, endoscopic observation, and biopsy of suspected lesions. A mass population survey for the presence of gastric cancer in persons of approximately 40 years of age has led to an ever increasing number of early gastric cancer cases. The emergence of early simulating advanced cancer with relatively good prognosis and the changing state of the Borrmann type of advanced cancer have contributed to the improvement. The present study demonstrates once again the importance of early detection of gastric cancer for an increased chance of cure, since conventional lymph node dissection seems to be unnecessary, and of even earlier detection of gastric tumors of less than 1 cm in diameter for the best chance of complete cure in the latter.

Adequacy of margins of resection in gastrectomy for cancer

This study determines the infiltration rate of proximal and distal margins of resection in patients operated on for gastric cancer at the Istituto Nazionale Tumori of Milan. Two hundred and eighty-five proximal margins and 286 distal margins were reviewed, and the incidence of infiltration was related to the length of grossly tumor-free edge, the location, site, size and gross appearance of the tumor, degree of invasion of the gastric wall, histologic type, and status of perigastric lymph nodes. Infiltration occurred in 7.3% of oral margins of transection and in 2.6% of aboral margins. Except for the degree of invasion of the gastric wall, no correlation was found among the infiltration rate and the above parameters. In fact, the incidence of infiltration of the proximal edge was significantly higher (6.4+ vs. 0.8%, p less than 0.01) when the tumor penetrated the serosa or spread beyond it than when the lesion was confined to the mucosa, submucosa, or muscular layer. With reference to the length of margin of resection, it is noteworthy that no involvement was found when cranial distance between the lesion and line of transection was equal to or greater than 6 cm. Proximal or distal infiltration for a distance greater than 3 cm did not occur in patients with lesions confined to the mucosa, submucosa, and muscularis. This data should provide the surgeon with a rational basis for assessing the extent of resection when performing gastrectomy for cancer.

Diagnosis and treatment of dyspepsia. A cost-effectiveness analysis

Dyspepsia is a common problem in ambulatory care. While many authorities recommend ordering upper gastrointestinal x-ray series (UGI) before therapy, there is evidence that clinicians frequently treat dyspepsia without diagnostic procedures. Decision analysis was performed to select optimal management based on probabilities and outcome values from the published literature. The choices evaluated were Symptomatic Therapy (low dose antacids or anticholinergics), Ulcer Therapy (high dose antacids or cimetidine), or UGI followed by further tests or therapy. Our model indicates that mortality is minimized if UGI is performed prior to selection of therapy, and if endoscopy is performed when the x ray shows gastric ulcer. Weeks of pain are minimized if Ulcer Therapy is begun immediately, but direct health care costs are minimized by beginning with Symptomatic Therapy. The marginal cost per additional life saved by performing a UGI rather than beginning with Ulcer Therapy was +1.6 million to +2.3 million, depending on whether endoscopy followed the finding of gastric ulcer. Mortality advantages of the strategies beginning with UGI were sensitive to assumptions regarding the incidence of gastric cancer and the benefits of early diagnosis. With slight reductions in these base case values, the Ulcer Therapy strategy appeared to minimize all outcomes except dollar cost.

Selection of gastrectomy for adenocarcinomas arising in the gastric fundus

A retrospective study involving 174 patients with adenocarcinoma of the gastric fundus treated with proximal subtotal (PS), extended proximal subtotal (EPS), total (T), and extended total (ET) gastrectomy showed that 1)there were no statistically significant differences in operative mortality between the four gastrectomy types; 2)ET was associated with a significantly lower incidence of local recurrence than T (P less than 0.05) and PS (P less than 0.001); 3)ET resulted in a significantly higher survival rate than PS or T (P less than 0.01) when the three procedures were applied in patients who had TNM stage I and II tumors; 4)patients with stage III and IV tumors did poorly regardless of gastrectomy type. The study implies that intraoperative tumor staging might identify stage I and II patients who benefit the most from radical surgery and those with stage III and IV tumors who should receive palliative surgery.