Carcinoma of the stomach. Why are we falling to improve survival?

Nutritional effects of oesophageal, gastric and pancreatic carcinoma

Cancer of the oesophagus, stomach or pancreas has profound effects on the nutritional status of the individual as normal functioning of these digestive organs is essential to physiological well-being. Thus the cancer patient is subjected not only to the localized and systemic effects of carcinoma but to the body's inability to properly nourish itself. It is therefore surprising that there is such a dearth of knowledge with respect to the effects of cancer of these organs on the totality of nutritional status as the technology is now available to address this important issue. Furthermore, as the value of nutritional support for such patients is gaining widespread acknowledgement the use of such technology should be employed, not only to accurately and precisely define the changes in nutritional status, body composition, physiological function and psychological state, but to monitor the effect of established treatment and assess the efficacy of novel new treatments. The purpose of this review is to describe the technology which is available to achieve this, outline some of the published work on nutrition and cancer of the oesophagus, stomach and pancreas and, finally, to discuss possible future trends in this area of clinical practice.

Gastrointestinal tract cancer in the elderly

Gastrointestinal cancers are common in the elderly. In the 1990s, modest advances in the early diagnosis, staging, and treatment of gastrointestinal cancers were made. Emphasis has been placed on screening for colorectal cancer; development of new diagnostic and staging modalities, particularly endoscopic ultrasound; and introduction of new treatment regimens, such as chemoradiation programs for esophageal, pancreatic, and colorectal cancers as well as endoscopic mucosal resection of early gastrointestinal cancers. New palliative techniques, such as laser and photodynamic therapy and placement of enteral stents, are being used increasingly in patients who have advanced cancer and are not surgical candidates. In the past, attitudes toward the elderly affected the management of cancer. Age should not be the only parameter considered when addressing the treatment of a gastrointestinal malignancy. Management decisions in the elderly should follow the same principles as those in younger patients. A thorough medical evaluation in the elderly is necessary to evaluate the patient's risk and to optimize surgical, chemotherapeutic, and palliative outcomes.

Surgical resection of gastric cancer in the octogenarian population

The medical records of 80 patients whose mean age was 81.1 years (range 80 to 94 years) were retrospectively evaluated for morbidity, mortality, and survival following gastric resection for gastric carcinoma. The overall 5-year survival of 68 patients who had undergone a total or subtotal gastrectomy for adenocarcinoma was 11%, with a mean and median survival of 25 and 175 months, respectively. In contrast, eight patients who did not undergo gastric resection for adenocarcinoma were found to have a mean and median survival of only 3.6 and 2.0 months, respectively. The 30-day perioperative morbidity and mortality rates for patients who had undergone gastric resection were 45.8% and 5.0%, respectively. The total gastric resection group had no perioperative deaths or anastomotic leaks. We conclude that with careful selection of patients and precise surgical technique, gastric resections can safely be performed in octogenarian patients with minimal morbidity and mortality.

A selective therapeutic approach to gastric cancer in a large public hospital

BACKGROUND

Gastric cancer is a common malignancy with a poor prognosis. The improved survival reported from Japan may be due to earlier detection or to more radical surgery, or both. The relevance of their methods to gastric cancer seen in Western countries is uncertain.

PATIENTS AND METHODS

The study involved 204 patients with gastric carcinoma. Preoperative staging by computed tomography scan and endoscopic ultrasound showed that 120 patients (59%) had stage IV disease.

RESULTS

Curative resection was performed in 66 patients, palliative resection in 32, bypass/intubation in 39, chemotherapy alone in 41, and supportive treatment in 26. Neoadjuvant chemotherapy was given to 40 of 66 patients treated with curative resection. The mortality of gastrectomy was 3%. Survival was significantly improved after curative resection compared with palliative resection, which in turn was improved over non-resectional or nonsurgical therapy. Postoperative morbidity included four intra-abdominal abscesses, all associated with splenectomy.

CONCLUSIONS

Curative surgery for gastric cancer is worthwhile, but the advanced stage of the disease in a public hospital should encourage the establishment of a screening program in high risk populations.

Potentially resectable gastric carcinoma: current approaches to staging and preoperative therapy

The incidence of gastric carcinoma has declined worldwide during the past several decades, and yet this cancer remains the most common malignancy in several countries around the world, particularly Japan, Chile, and Costa Rica. Gastric carcinoma, although not as common in the United States as it was in the past, is still the eighth most frequent cause of cancer death. For patients with localized gastric carcinoma, surgery remains the most effective therapy, resulting in a consistent but low rate of cure. Unresectable gastric carcinoma is an incurable disease with the exception of a small fraction of patients who are salvaged with chemoradiotherapy. In Western countries curative resection rates have been dismal because of the lack of early diagnosis. Additionally, postoperative adjuvant strategies in the United States and Europe have been ineffective. Even patients with curative resection frequently develop intraperitoneal and systemic carcinoma in addition to locoregional relapses. Many investigators have therefore embarked on the therapeutic strategies of preoperative chemotherapy and postoperative intraperitoneal chemotherapy. The preoperative chemotherapy strategy has particular appeal because of its potential to reduce the size of the primary tumor, thereby allowing a higher rate of curative resection; early systemic therapy of micrometastases might prove biologically more effective. To date, several studies using preoperative chemotherapy have demonstrated its feasibility. The effectiveness of repeated courses of postoperative intraperitoneal chemotherapy remains unsettled mainly owing to the inadequacy of peritoneal drug distribution and the associated toxic effects. Additional investigations are necessary to improve preoperative staging with the use of endoscopic ultrasonography and laparoscopy (peritoneal staging).(ABSTRACT TRUNCATED AT 250 WORDS)

Concentration and distribution of tumor associated antigens TAG-72 and CEA in stomach cancer

We measured the concentration and distribution of tumor associated antigens, TAG-72 and CEA, in stomach cancer by in vitro quantitative autoradiography (IV-QAR). Frozen sections of 33 specimens were incubated with varying concentrations of 125I-labeled CEA-79.1 and B72.3 antibodies specific for carcinoembryonic antigen (CEA) and tumor-associated glycoprotein-72 (TAG-72), respectively. Computer analysis of specific antibody binding gave maximal binding values which were equal to the concentrations of the antigen or epitope. TAG-72 was detected in 25 specimens, at a concentration ranging from 8.4 to 562.9 pmol/g. CEA was detected in 32 of the 33 specimens and its concentration ranged from 8.8 to 525.3 pmol/g. The distribution of TAG-72 by IV-QAR coincided with that of the tumor cells in 41.4% of the pathologic lesions. The distribution of CEA coincided with the tumor cells in 80.5% of pathologic lesions, nearly twice the TAG-72. The concentration of TAG-72 was significantly higher in mucinous adenocarcinoma and mucin containing adenocarcinomas than other types of adenocarcinomas. There was no significant difference in the concentration of CEA among the pathologic types of stomach cancer. In summary, stomach cancer exhibited wide variations in TAG-72 and CEA expression. CEA expression was more frequent and homogeneous than TAG-72.

Combination chemotherapy of 5-fluorouracil, epidoxorubicin and mitomycin C in the palliative treatment of locally advanced and/or metastatic adenocarcinoma of the stomach

Thirty-seven consecutive patients with advanced and/or metastatic gastric adenocarcinoma received a combination of 5-fluorouracil 600 mg/m2 on days 1, 8, 29, 36; epidoxorubicin 75 mg/m2 i.v. on days 1, 29; mitomycin C 10 mg/m2 i.v. on day 1. This cycle was repeated every 8 weeks. Out of a total of 34 evaluable patients, 2 (5.8%) had a complete response and 7 (20.6%) had a partial response with an overall median duration of 40 weeks (range 20-128). The median survival of responding patients was not reached after a mean follow-up of 76 weeks, while that of patients with no change and progressive disease was reached at 36 and 13 weeks respectively. Treatment was generally well tolerated with hematological and gastrointestinal toxicities being the major side-effects. Despite the use of epidoxorubicin 75 mg/m2, the 26.4% (95% confidence limits 16-36%) objective response rate is not satisfactory. Evaluation of more aggressive protocols is strongly recommended within the limits of controlled trials.

Cancer of the stomach: a review of two hospitals in Korea and Japan

The records of 525 patients with primary adenocarcinoma of the stomach treated at Korea University Hospital (K.U.H.), Seoul, Korea, and 1,932 patients treated at National Cancer Center Hospital (N.C.C.), Tokyo, Japan, over a 7-year period were reviewed to study biologic characteristics and treatment results in the two hospitals. More than 70% of the patients were 41 to 70 years old in both hospitals, though K.U.H. had more younger patients and N.C.C. had more older patients. Comparison in regard to clinicopathologic features showed significant differences in type of cancer, tumor size, depth of invasion, lymph node metastasis, stage, and histologic type. Such a difference mostly was due to a greater frequency of early gastric cancer in N.C.C. patients (51.2%) than in K.U.H. patients (19.0%). Patients of K.U.H. were more likely to have advanced cancer, large invasive tumors, a higher percentage of lymph node metastasis, a higher stage, and more undifferentiated tumors. The 5-year survival rate of all resected cases was 69.5% in N.C.C. and 54.2% in K.U.H. (p > 0.05). Those factors which showed a significant difference in clinicopathologic features did not affect the survival difference between the two hospitals except in stage IIIb and signet-ring-cell cancer. The 5-year survival rate for stage IIIb was 18.0% in K.U.H. and 36.8% in N.C.C. It would seem that survival difference in stage IIIb related to extensive lymph node dissection in N.C.C. Survival difference in signet-ring-cell gastric cancer (31.2% in K.U.H. and 91.0% in N.C.C.) was related to the fact that 79.1% of signet-ring-cell gastric cancer patients in N.C.C. had early gastric cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Radioimmunoscintigraphy of advanced gastrointestinal carcinomas employing I-131 labeled CEA-79 monoclonal antibody

CEA-79 is a murine IgG2a type monoclonal antibody (MoAb) generated using purified CEA from culture supernatants of a human colon cancer cell line, LS174T. The association constant and immunoreactivity of the I-131 labeled CEA-79 ranged from 2.0 to 3.2 x 10(9) l/mole, and from 54 to 74%, respectively. The purpose of this study was to evaluate the feasibility of radioimmunoscintigraphy employing MoAb CEA-79 in patients with advanced gastrointestinal carcinomas. Two mgs of MoAb CEA-79 was labeled with 111 MBq (3 mCi) of I-131, and infused intravenously in 6 stomach cancer and 16 colon cancer patients. Out of 6 patients with stomach cancer, immunoscintigraphy was able to detect the tumors in 4 cases. However, immunoscintigraphy found out tumors in all patients with colon cancer. Moreover, 1 patient with stomach cancer and 2 patients with colon cancer showed increased uptake of MoAb in the tumor lesions despite normal serum levels of CEA. We could conclude that this antibody has a potential as a new imaging agent for the diagnosis of gastrointestinal carcinoma.

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.

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.

Resectable gastric carcinoma. An evaluation of preoperative and postoperative chemotherapy

Patients with locoregional gastric carcinoma often die because of the low rates of curative resection and frequent appearance of distant metastases (mainly peritoneal and hepatic). To evaluate the feasibility of preoperative and postoperative chemotherapy, 25 consecutive previously untreated patients with potentially resectable locoregional gastric carcinoma received two preoperative and three postoperative courses of etoposide, 5-fluorouracil, and cisplatin (EFP). Ninety-eight courses (median, five courses; range, two to five courses) were administered. Six patients had major responses to EFP. Eighteen patients (72%) had curative resections, and three specimens (12%) contained only microscopic carcinoma. At a median follow-up of 25 months, the median survival of 25 patients was 15 months (range, 4 to 32+ months). Peritoneal carcinomatosis was the most common indication of failure. One patient died of postoperative complications, but there were no deaths due to chemotherapy. EFP-induced toxic reactions were moderate. Preoperative and postoperative chemotherapy for locoregional gastric carcinoma is feasible, and additional studies to develop regimens that could result in 5% to 10% complete pathologic responses may be warranted.

Current strategies in the management of locoregional and metastatic gastric carcinoma

Gastric carcinoma remains a significant cause of death worldwide. A patient's prognosis depends on the degree of gastric wall penetration, presence of lymph node metastases, and location of the primary site. Metastatic gastric carcinoma is currently incurable. However, chemotherapy continues to evolve at a rapid pace. Active agents include 5-fluorouracil (5-FU), doxorubicin, cisplatin, methotrexate, mitomycin, and etoposide. Combination etoposide, doxorubicin, and cisplatin (EAP) has been reported to result in encouragingly high response rates, including a 10% complete response rate in patients with metastatic gastric carcinoma. Trials are now under way to confirm these results. Similarly, another etoposide-based combination, etoposide, leucovorin, and 5-FU (ELF), has resulted in an equally good response rate but less toxicity than EAP. The 5-FU, doxorubicin, and methotrexate (FAMTX) regimen, previously reported to have an excellent response rate, is also being investigated further. For patients with locoregional carcinoma, curative resection rate is often unsatisfactorily low; however, curative resection is consistently associated with improved survival (between 23 and 26 months). In patients with potentially resectable carcinoma, two significant problems must be recognized: (1) a low rate of curative resection and (2) the development of widespread carcinoma despite curative resection. Despite many attempts, the postoperative strategies of adjuvant chemotherapy have been ineffective. New strategies must be investigated aggressively. Combination etoposide, 5-FU, and cisplatin (EFP) has been administered preoperatively and postoperatively to patients with resectable gastric carcinoma, resulting in an encouraging curative resection rate (greater than 70%) and manageable toxicity. Based on promising results reported with EAP in patients with unresectable locoregional carcinoma of the stomach, a trial of preoperative and postoperative EAP in potentially resectable carcinoma of the stomach is now under way.

Endoscopy in gastric malignancy

Gastric cancer remains, in most parts of the world, a disease of advanced presentation and associated resistantly high mortality. To date, fiberoptic endoscopy has yet to change this seemingly inexorable fact. Nevertheless, endoscopy plays a vital role in the evaluation and diagnosis of the gastric cancer patient and provides palliative options to patients suffering from advanced disease that may not respond to other modalities. With the advent of endoscopic screening protocols identifying cases at an early stage, there is early epidemiologic evidence of impact on the mortal consequences of this disease in high incidence areas such as Japan. Endoscopic ultrasound, flow cytometry of endoscopic biopsies, and photodynamic techniques offer the prospect of increasing definition of gastric malignancy prior to therapy, and new endoscopic therapies await further study to define their potential role in treating early cancer non-operatively. Twenty years ago, scientists intent on the study of gastric neoplasia played a major role in the advent of fiberoptic endoscopy. To date, their reward has been a wealth of information. As this material is digested and applied, it seems reasonable to believe their efforts may be eventually rewarded by a reduction in the epidemiologic impact of this disease, brought about not by changing global incidence patterns, but by knowledge and technology derived and administered endoscopically.

Has there been any improvement in the staging of gastric cancer? Findings from the German Gastric Cancer TNM Study Group

This multicenter observational study examined the survival of 1420 patients with histologically proven carcinoma of the stomach. From April 1982 through October 1984, 1360 (95%) patients underwent surgery, 988 (72%) had resections, and 372 (28%) minor surgical procedures. The percentage of patients who have been followed until death or 3 to 5 years was 99.4%. Patients were staged preoperatively and intraoperatively and by pathologists using the old (1978) and new (1987) TNM stage groupings and 5-year survival was analyzed. Subgroups of patients who changed their stage group according to the new stage definitions were analyzed separately. Only age was an important prognostic factor for survival in Stage IA (P less than 0.05) and Stage IB (P less than 0.01). Residual tumor after surgery was most important for survival in Stage II (P less than 0.01) and Stage IIIA (P less than 0.001). This indicates that improvements of stage definitions for individual prognosis can only be achieved by adding data concerning the presence or absence of residual tumor (R classification).

Gastric cancer detected by mass survey. Comparison between mass survey and outpatient detection

Although the incidence of stomach cancer in Japan has decreased only slightly, the mortality has decreased markedly. The main reason for this success is the early diagnosis of cancer, to which mass survey has contributed. From 1964 to 1985, 290,914 screening examinations were done at the Mass Survey Center of the Cancer Institute Hospital, Tokyo. In 474 people (0.16%) cancer was detected, and of those, 52% were in an early stage of disease. For the mass survey group, the 5-year survival rate was 80%, and the 10-year survival rate 78.5%. The outpatient group rates were 56.2% and 55.1% for 5 and 10 years, respectively. This difference could be explained by the higher percentage of early gastric cancer and less extensive lymph node metastasis in patients with serosal involvement, in the outpatient group. The 10-year survival results show that early treatment results in an absolute better long-term survival. This refutes the hypothesis that 5-year survival rates of early gastric cancer patients are biased because of lead time of early diagnosis. Mass survey, even for a small district, provides an excellent opportunity to detect gastric cancer in people without symptoms. The high percentage of cases detected with cancer in an early stage reduces stomach cancer mortality.

Gastric cancer: a neoplastic enigma

Effective therapy for gastric cancer remains elusive, and thus surgeons, oncologists, and radiotherapists are continually confounded. Multiple attempts to improve survival in gastric cancer patients have failed, including extended lymphadenectomy (by American surgeons), single- or multiple-agent chemotherapy, and combined-modality therapy (multiple-agent chemotherapy combined with radiation therapy). Such studies have been plagued by the high volume of inadequate antitumor responses or by lethal toxicity. At present, chemotherapy remains the best hope for effective adjuvant therapy, but new routes of drug delivery that will decrease systemic toxicity must be developed. Since gastric cancer recurs locoregionally and infrequently metastasizes to distant sites until very late in its course, theory suggests intraperitoneal (IP) chemotherapy applied to locoregional sites should decrease recurrence without significant systemic toxicity. Such treatments have been effective in other malignancies that commonly occur IP, such as ovarian cancer. Intracavitary chemotherapy protocols for gastric cancer are under development and will soon produce data on treatment efficacy. Such studies offer a theoretic basis for improved survival from gastric cancer; however, only well-controlled treatment trials will confirm if theory can be translated into clinical reality.

Primary gastric lymphoma. Problems in staging and management

A retrospective review of 28 patients with primary gastric lymphoma was performed to determine the optimal treatment modality. The presenting signs and symptoms resembled peptic ulcer disease or gastric carcinomas. The majority of the lymphomas were of the diffuse histiocytic subtype. There was a 75 percent resectability rate in those patients operated on. Palliative resection produced a 5 year duration of survival of 28 percent and curative resection, 43 percent. Eighteen patients underwent a subtotal gastrectomy, and a total of 10 patients presented with stage I disease. The longest median duration of survival at last follow-up was 32 months for patients with stage IB disease compared with a median duration of survival of 8 months for those with stage III disease. Adjuvant radiotherapy and chemotherapy may improve survival after a curative resection is performed if there is serosal penetration or nodal involvement.

Gastric cancer--delay in diagnosis and its causes

Over a period of 1 year 83 patients, admitted to Nottingham hospitals with gastric neoplasms, were interviewed in order to identify the extent of delay in diagnosis and the possible causes. The mean age was 71 (S.D. +/- 10) and there was a male preponderance of 1.8:1. The median delay from onset of symptoms to diagnosis was 22 weeks (IQR 14-35). Delay by the patient after the onset of symptoms before seeking medical help was 4 weeks (IQR 2-12). Family doctor delay was 7 weeks (IQR 3-14) and this was caused by trial of medication and radiological investigations. The hospital delay of 3 weeks (IQR 2-7) was due to patients waiting for multiple out-patient investigations, inadequate investigation of iron-deficiency anaemia, failure to follow-up gastric ulcers and difficulty in getting histological confirmation of clinically suspicious lesions. Seventeen (20%) patients were treated with a H2-receptor antagonist (Cimetidine). There was no significant difference in the delay caused by Cimetidine when compared with that due to antacids (Mann-Whitney U = 232, P greater than 0.5), and there was no difference in survival between these patients and those not treated with Cimetidine (chi 2 = 1.9, P less than 0.1). In this study only one of 80 patients had an early gastric cancer, which supports the view that gastric carcinoma is asymptomatic in its early stages and mass screening of the population would be the only way to detect carcinoma at this stage in its development. Family doctor delay can be reduced by immediate referral of patients to hospital for investigation prior to commencing medication. Hospital delay can be improved by avoiding duplication of investigations, fully investigating iron-deficiency anaemia and following up gastric ulcers with endoscopy and biopsy till fully healed.

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.

Node dissection in gastric cancer

Three hundred patients who underwent absolute and relative curative gastrectomy and lymph node dissection for gastric cancer were reviewed with respect to postoperative mortality; proportion of patients with node involvement according to the extent of dissection; number of metastatic nodes dissected according to the extent of dissection; accuracy of macroscopic evaluation of node involvement and microscopic node involvement according to tumour location. If more nodes were dissected the proportion of patients with node involvement and the total number of metastatic nodes increased; conversely within R0 and R3 the extent of dissection did not affect postoperative survival. Finally when the presence and extent of node involvement was only macroscopically evaluated, the patients were classified incorrectly in 9.5 per cent of the N0 group and 20.2 per cent of the N1 group. The data suggest that lymph node dissection may be useful in the treatment of gastric cancer, and within the extent studied the employment of this procedure does not affect the postoperative mortality.

Adenocarcinoma of the stomach. Changing patterns over the last 4 decades

A retrospective study was performed on 255 consecutive patients admitted to a single hospital from 1953-1983 with a follow-up of 100%. The number of proximal esophagogastric junction and fundus tumors increased significantly over the last 4 decades from 21% to 44% (p less than 0.001), accompanied by a significant decrease in antral carcinomas from 60% to 33% (p less than 0.01). Patients with proximal neoplasms were significantly more likely to be white (71% vs. 29%, p less than 0.001), whereas patients with antral cancer were significantly more likely to be black (64% vs. 36%, p less than 0.001). There were no significant differences in nodal status, presence of distant metastases, or the overall 5-year survival rate between these two sites. The 5-year survival rate for the entire group was 6%. Sixty-five patients (30%) underwent curative resection, and the 5-year survival rate in this group was 24%, which was significantly better than palliative procedures. The 5-year survival rate was strongly influenced by TNM stage, local invasiveness, nodal status, and presence or absence of distal metastases (p less than 0.001). Although the overall survival rate has not changed over the past 30 years, there were definite epidemiologic differences between proximal and antral lesions, which suggest that new treatment protocols should be designed to include the location of the neoplasm.

Gastric cancer survival in Sweden. Lack of improvement in 19 years

A total of 34,549 patients constituting 87.0% of all patients with gastric cancer diagnosed in Sweden in 1960-1978 and reported to the National Cancer Registry were included in a complete follow-up over a period of 1-20 years. The poor outcome in this disease was again established in this unselected material. Thus, the 5-year relative survival rate (with 95% confidence limits) was 12.7% (12.1-13.2%) among the men and 14.1% (13.4-14.9%) among the women, without any long-term difference between the sexes. The annual hazard rates in male and female patients were still 11.0% (8.3-13.7%) and 9.0% (7.1-10.9%), respectively, after 5 years and did not approach zero until 10 years after the diagnosis. Men older than 75 showed a slightly higher mortality during the first year, but there were seemingly no relationships of tumor-biological or clinical significance between age at diagnosis and long-term relative survival. The overall prognosis remained unchanged during the 19 years of the study, whereas the incidence was reduced by about 40% in the whole Swedish population.

Gastric carcinoma in Côte d'Or (France). A population-based study

The registry of digestive cancer in the Department of Cote d'Or, France, recorded newly diagnosed cases of gastric cancer between 1976 and 1980. The annual incidence rate, adjusted to the world population, was 15.2/100,000 for men and 6.1/100,000 for women. Stomach cancer incidence showed a substantial decline during the 5 yr of the study and this decline was more pronounced in men than in women. The operability rate was 62.4% and the resectability rate was 40.2%. Operative mortality after curative surgery was 17.6%. For all subjects, 17.6%, 29.1%, and 26.0% had localized, regional, and distant disease, respectively. The remaining 27.3%, not operated upon, with no evidence of metastases, had unclassifiable disease. The overall 5-yr corrected survival rate was 16.5%. In the absence of curative surgery all patients died in the 4 yr after diagnosis. After curative surgery the 5-yr corrected survival rate (excluding operative mortality) was 42.8%. The most important determinant of the survival was the pathological stage of the tumor. The age-corrected 5-yr survival was 98.7% for cases limited to the digestive wall, 45.5% for cases involving the serosa, and 26.6% for cases with locoregional extension. These results support the fact that, although declining, gastric cancer remains relatively frequent. Its overall prognosis in a well-defined population, where cases limited to the digestive wall are rare, remains poor.

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.

Contribution of endoscopy to diagnosis and treatment of gastric cancer

The contribution of fiberoptic endoscopy to the diagnosis and treatment of gastric cancer was evaluated in 174 patients. For the purpose of staging, they were compared with 99 patients admitted to the same institution in the pre-endoscopy era. The frequency of minimal gastric cancer (stages I and II) was 16.5 percent in the patients who had esophagogastroduodenoscopy in contrast with only 4 percent in the patients without endoscopy. Fiberoptic endoscopy was superior to barium gastrography in the diagnosis of minimal gastric cancer. The effect of early diagnosis on survival was such that at 3 year follow-up, the cumulative proportion of stage I and II patients still alive was 85 percent compared with only 17.5 percent of stage III patients and none of the stage IV patients.

Gastric carcinoma. A ten-year review

Data on 164 patients treated at the Cleveland Clinic with gastric adenocarcinoma during the ten year period 1970 to 1980 was analyzed. Fiberoptic esophagogastroduodenoscopy was introduced as a routine diagnostic modality during this time and yielded a positive tissue diagnosis in 86% of patients in this series. Laparotomy was performed on 150 patients; 49 patients (30%) were biopsied only, 19 (12%) were bypassed for palliation, and 82 (58%) underwent gastrectomy. Of the latter group, only 45 patients (27%) were resected for cure. The overall operative mortality rate was 6%. All patients were staged according to the International TNM classification (stage I--10%, II--24%, III--12%, and IV--53%). Survival at 5 years was influenced by tumor location and extent of gastric resection but was most significantly related to stage of disease at operation (stage I--65%, II--22%, III--5%, and IV--0%; p less than 0.0001) and to the status of regional nodes (positive--17%, negative--56%; p less than 0.005). Despite the routine use of fiberoptic endoscopy, the majority of gastric cancers were advanced at diagnosis and their prognosis remains discouraging. Improvement of results will require a more aggressive approach to the endoscopic investigation of upper gastrointestinal symptoms and earlier surgical intervention.

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.