Tumor size as a simple prognostic indicator for gastric carcinoma

Genetic variant in PSCA predicts survival of diffuse-type gastric cancer in a Chinese population

Recent genome-wide association study (GWAS) has identified that the prostate stem cell antigen (PSCA) rs2294008 is involving in regulating gastric epithelial-cell proliferation, influencing the risk of diffuse-type gastric cancer. We hypothesized that PSCA rs2294008 is also associated with gastric cancer survival. We genotyped PSCA rs2294008 using TaqMan method in 943 patients with surgically resected gastric cancer. Analyses of genotype association with survival outcomes were assessed by the Kaplan-Meier method, Cox proportional hazards models and the log-rank test. There was no significant association between rs2294008 and survival of gastric cancer (log-rank p=0.085 for CT/TT versus CC). However, in the stratification analysis of histology, we found that rs2294008 CT/TT genotypes were associated with significantly improved survival among diffuse-type gastric cancer (log-rank p=0.025, hazard ratio [HR]=0.75, 95% confidence interval [CI]=0.59-0.96), compared to the CC genotype. Moreover, this protective effect was more predominant for diffuse-type gastric cancer patients with tumor size >5 cm and distant metastasis. If validated in further studies, PSCA rs2294008 could be useful marker of survival assessment and individualized clinical therapy for gastric cancer, particularly among the diffuse-type gastric cancer.

The gene-reduction effect of chromosomal losses detected in gastric cancers

Background

The level of loss of heterozygosity (LOH) that reduces a gene dose and exerts a cell-adverse effect is known to be a parameter for the genetic staging of gastric cancers. This study investigated if the cell-adverse effect induced with the gene reduction was a rate-limiting factor for the LOH events in two distinct histologic types of gastric cancers, the diffuse- and intestinal-types.

Methods

The pathologic specimens obtained from 145 gastric cancer patients were examined for the level of LOH using 40 microsatellite markers on eight cancer-associated chromosomes (3p, 4p, 5q, 8p, 9p, 13q, 17p and 18q).

Results

Most of the cancer-associated chromosomes were found to belong to the gene-poor chromosomes and to contain a few stomach-specific genes that were highly expressed. A baseline-level LOH involving one or no chromosome was frequent in diffuse-type gastric cancers. The chromosome 17 containing a relatively high density of genes was commonly lost in intestinal-type cancers but not in diffuse-type cancers. A high-level LOH involving four or more chromosomes tended to be frequent in the gastric cancers with intestinal and mixed differentiation. Disease relapse was common for gastric cancers with high-level LOH through both the hematogenous (38%) and non-hematogenous (36%) routes, and for the baseline-level LOH cases through the non-hematogenous route (67%).

Conclusions

The cell-adverse effect of gene reduction is more tolerated in intestinal-type gastric cancers than in diffuse-type cancers, and the loss of high-dose genes is associated with hematogenous metastasis.

Role of tumor size in the pre-operative management of rectal cancer patients

Background

Clinical management of rectal cancer patients relies on pre-operative staging. Studies however continue to report moderate degrees of over/understaging as well as inter-observer variability. The aim of this study was to determine the sensitivity, specificity and accuracy of tumor size for predicting T and N stages in pre-operatively untreated rectal cancers.

Methods

We examined a test cohort of 418 well-documented patients with pre-operatively untreated rectal cancer admitted to the University Hospital of Basel between 1987 and 1996. Classification and regression tree (CART) and logistic regression analysis were carried out to determine the ability of tumor size to discriminate between early (pT1-2) and late (pT3-4) T stages and between node-negative (pN0) and node-positive (pN1-2) patients. Results were validated by an external patient cohort (n = 28).

Results

A tumor diameter threshold of 34 mm was identified from the test cohort resulting in a sensitivity and specificity for late T stage of 76.3%, and 67.4%, respectively and an odds ratio (OR) of 6.67 (95%CI:3.4-12.9). At a threshold value of 29 mm, sensitivity and specificity for node-positive disease were 94% and 15.5%, respectively with an OR of 3.02 (95%CI:1.5-6.1). Applying these threshold values to the validation cohort, sensitivity and specificity for T stage were 73.7% and 77.8% and for N stage 50% and 75%, respectively.

Conclusions

Tumor size at a threshold value of 34 mm is a reproducible predictive factor for late T stage in rectal cancers. Tumor size may help to complement clinical staging and further optimize the pre-operative management of patients with rectal cancer.

Prognostic significance of host- and tumor-related factors in patients with gastric cancer

BACKGROUND

Various factors regarding the biological state of tumors or the nutritional status of patients have been reported individually to correlate with prognosis. Identification of defined patient groups based on a prognostic score may improve the prediction of survival and individualization of therapy. The aim of the present study was to identify clinically useful parameters obtainable before treatment that could be used for predicting clinical outcomes in patients with gastric cancer.

METHODS

In 357 consecutive patients who had been treated for potentially curable gastric cancer, we retrospectively analyzed the following clinicopathological factors: sex, age, body mass index, body weight changes, hemoglobin, white blood cell count, neutrophil to lymphocyte (N/L) ratio, serum C-reactive protein (CRP), serum albumin, serum cholinesterase, tumor location, tumor size, histology, and clinical tumor node metastasis (TNM) stage. Factors related to prognosis were evaluated by univariate and multivariate analysis.

RESULTS

From univariate analysis, significant differences in survival were found for age, hemoglobin, N/L ratio, serum CRP, serum albumin, serum cholinesterase, tumor size, and clinical T and N grouping. N/L ratio, tumor size, and clinical T grouping were identified as independent prognostic indicators in multivariate analysis. A prognostic score was constructed using these variables to estimate the probability of death. The model gave an area under the receiver operating characteristic curve of 0.85 for prediction of death at 5 years.

CONCLUSIONS

This model based on N/L ratio, tumor size, and clinical T grouping before treatment offers a very informative scoring system for predicting prognosis of gastric cancer.

Significance of lymphatic invasion and cancer invasion-related proteins on lymph node metastasis in gastric cancer

BACKGROUND AND AIMS

Cancer invasion and metastasis are critical events for patient prognosis; however, the most important step in the whole process of lymph node (LN) metastasis in gastric cancer remains obscure. In this study, the significance of cancer cell behaviors, such as cell detachment, stromal invasion and lymphatic invasion on regional LN metastasis in gastric cancer was investigated by comprehensive immunohistochemistry.

METHODS

A total of 210 cases with gastric cancer were selected. These consisted of 105 cases with regional LN metastasis (LN[+] group) and 105 cases without LN metastasis (LN[-] group). Both groups exhibited the same depth of invasion. Cancer tissues were subjected to immunohistochemistry with antibodies against claudin-3, claudin-4, beta-catenin, matrix metalloproteinase (MMP)-1, and MMP-2, as well as endothelial markers of lymphatic vessel endothelial hyaluronan receptor-1 and von Willebrand factor for the objective discrimination between lymphatics and blood vessels. The expression of each protein as well as the histopathological parameters were compared between LN(+) and LN(-) groups.

RESULTS

Along with lymphatic invasion by cancer cells and gross tumor size, MMP-1 expression in cancer cells at the invasive front of the primary tumor was a significant, independent predictor of LN metastasis. The expression of claudins and beta-catenin was associated with the histopathological type of cancer, but not with LN status.

CONCLUSION

Among the cancer invasion-related proteins examined, MMP-1 plays a vital role in LN metastasis of gastric cancer. Tumor size, lymphatic invasion and MMP-1 expression level at the invasive front were the predictive factors of LN metastasis of gastric cancer.

Risk factors of survival and surgical treatment for advanced gastric cancer with large tumor size

BACKGROUND

The purpose of this study was to clarify the clinical significance of tumor size in advanced gastric cancer and to evaluate the risk factors of survival in advanced gastric cancer with large tumor size.

METHODS

The cut-off point for tumor size, 90th percentile value of tumor size in advanced gastric cancer, was determined to be 10 cm. We retrospectively studied the clinicopathological features and prognosis of 406 patients with advanced gastric tumors measuring 10 cm or more.

RESULTS

Large tumors had a propensity for the following: Borrmann type IV, adjacent organ invasion, lymph node and distant metastasis, and stage IV classification. Tumor size was an independent risk factor for lymph node metastasis and survival in advanced gastric cancer. In patients with large advanced gastric cancer, Borrmann type IV, adjacent organ invasion, and N2-3 nodal involvement were independent factors associated with a poorer prognosis. The 5-year survival rate in large gastric cancer patients without any risk factors (65.5%) was similar with those in small gastric cancer patients (59.3%, P = 0.123).

CONCLUSION

Tumor size was a simple predictor for lymph node metastasis and survival in advanced gastric cancer. Radical surgery should be recommended for large advanced gastric cancer patients without risk factors, while large gastric cancer with risk factors may not be a surgically treatable disease.

Prognosis of gastric cancer patients with node-negative metastasis following curative resection: outcomes of the survival and recurrence

BACKGROUND

The purpose of the present study was to provide valuable prognostic information on lymph node-negative gastric cancer patients following curative resection.

METHODS

Data from 112 lymph node-negative gastric cancer patients who underwent curative resection were reviewed to identify the independent factors of overall survival and recurrence.

RESULTS

The five-year survival rate of lymph node-negative gastric cancer patients was 85.7%, and recurrence was identified in 25 patients after curative surgery. The five-year survival rate of lymph node-negative gastric cancer patients was higher than that of lymph node-positive gastric cancer patients (P<0.001). Recurrence in lymph node-negative gastric cancer patients was less than that of lymph node-positive gastric cancer patients (P=0.001). The median survival after recurrence of lymph node-negative gastric cancer patients was longer than that of lymph node-positive gastric cancer patients (P=0.021). Using multivariate analyses, the following results were determined for lymph node-negative gastric cancer patients: sex, operative type and the presence of serosal involvement were independent factors of overall survival; and lymphadenectomy, number of dissected nodes and the presence of serosal involvement were independent factors of recurrence.

CONCLUSIONS

The prognosis of lymph node-negative gastric cancer patients was better than that of lymph node-positive gastric cancer patients. Male sex, subtotal gastrectomy and nonserosal involvement should be considered to be the favourable predictors of postoperative long-term survival of lymph node-negative gastric cancer patients. Conversely, limited lymphadenectomy, few dissected nodes and serosal involvement should be considered to be risk factors of postoperative recurrence of lymph node-negative gastric cancer patients.

Does tumor size have an impact on gastric cancer? A single institute experience

PURPOSE

The present study investigated the prognostic significance of tumor size in gastric carcinoma patients.

METHODS

Nine hundred seventy-three gastric carcinoma patients who underwent curative gastrectomy were included and hospital records were reviewed to determine the relationship between tumor size and survival.

RESULTS

First, the patients were divided based on the mean value of the tumor size in respective stages to control selection bias. Only in stages I and III was tumor size a significant independent prognostic factor. Second, we analyzed the appropriate cutoff value for the large tumor. The minimum criterion for a large tumor, which was determined by the receiver-operating characteristic curve for cancer-related death, was 3.5 cm. There were significant differences between patients with large and small tumors with respect to depth of invasion, number of lymph node metastasis, and stage of disease.

CONCLUSIONS

Tumor size serves as an indicator of prognosis in gastric cancer patients and a tumor size of 3.5 cm can be used as a significant lower limit of standard size criterion.

Tumor size: a non-neglectable independent prognostic factor for gastric cancer

BACKGROUND AND OBJECTIVES

The role of tumor size should not be neglected in the management of gastric cancer and its prognostic value needs precise reevaluation.

METHODS

The survival data of 513 patients who underwent radical resection between 2000 and 2005 were collected retrospectively. Tumor size, measured as the maximum diameter of tumor, was categorized into four subgroups (< or =2, < or =3, < or =5, >5 cm) using the method of minimizing the estimated average expected distance (AED) objective function. The prognostic value of tumor size and the correlation between tumor size and other clinicopathologic factors were investigated.

RESULTS

In multivariate analysis, status of lymph nodes (P < 0.001), depth of invasion (P < 0.001), type of resection (P = 0.004), age (P = 0.008), tumor size (P = 0.014), and perioperative blood transfusion (P = 0.034) were confirmed as independent prognostic predictors for patients with gastric cancer. Log linear model suggested that the status of lymph nodes and the depth of invasion associated with the tumor size significantly.

CONCLUSIONS

The tumor size is a non-neglectable independent prognostic factor for patients with gastric cancer and more attention should be paid to its role in the management of gastric cancer.

Tumor diameter as a prognostic factor in patients with gastric cancer

BACKGROUND

The aim of this study was to evaluate the prognostic value of tumor diameter in gastric cancer.

METHODS

The study group comprised a series of 1215 patients who underwent curative gastrectomy. The appropriate tumor diameter cutoff value was determined. Prognostic factors were evaluated by univariate and multivariate analyses.

RESULTS

The tumor diameter cutoff value was 100 mm. Multivariate analysis showed that tumor site, macroscopic appearance, tumor diameter, depth of invasion, and presence of lymph node metastasis independently affected prognosis in all patients. Multivariate analysis of patients with larger tumors identified depth of invasion as an independent prognostic factor. A comparison between patients with smaller and larger tumors showed marked differences in the survival of those with stage II, IIIA, and IIIB tumors. A comparison of clinicopathological factors between stage II and III patients revealed that tumors occupying the entire stomach, ill-defined, undifferentiated, and serosa-penetrating tumors, and peritoneal metastases were far more frequent in patients with larger tumors.

CONCLUSIONS

Tumor diameter in gastric cancer is a reliable prognostic factor that might be a candidate for use in the staging system. To improve outcomes for patients with tumors >/=100 mm in diameter, it is necessary to establish therapeutic strategies for peritoneal metastasis, particularly in stage II and III tumors.

Advanced gastric carcinoma with signet ring cell histology

BACKGROUND

Gastric signet ring cell carcinoma (SRC) is a histological type based on microscopic characteristics and not on biological behavior. This study compared the clinicopathological features and prognosis of advanced SRC with non-signet ring cell adenocarcinoma (NSRC) of the stomach.

METHODS

We reviewed the records of 4,759 consecutive patients diagnosed with advanced gastric adenocarcinoma who were resected surgically from 1987 to 2003. Of these, 662 patients (13.9%) had SRC and were compared with 4,097 patients with NSRC.

RESULTS

Significant differences were noted in tumor size, Borrmann type, depth of invasion, lymph node metastasis, peritoneal dissemination and TNM stage. The cumulative 5-year survival rate for advanced SRC was 42.4%, compared with 50.1% in NSRC (p = 0.009). Multivariate analysis showed that tumor size > or =5 cm, Borrmann III and IV, T3-4 invasion and SRC histology were independent risk factors for lymph node metastasis. Depth of invasion, lymph node metastasis, hepatic and peritoneal metastasis and surgical curability were significant factors affecting survival. SRC histology alone was not an independent prognostic factor.

CONCLUSIONS

Advanced gastric SRC tends toward deeper tumor invasion and more lymph node and peritoneal metastasis than NSRC. Advanced gastric SRC had a worse prognosis than NSRC. Therefore, curative surgical operation with extended lymph node dissection is recommended.

Multivariate prognostic study on large gastric cancer

BACKGROUND

Although many authors investigate the prognostic factors of gastric cancer, there are few comprehensive studies on the prognosis of patients with large gastric cancer. The aim of this study was to clarify the prognostic factors of large gastric cancer using multivariate analysis.

METHODS

The study included 95 patients who underwent gastrectomy for gastric cancer measuring 10 cm or more in diameter. We examined 24 clinicopathologic factors based on patient, operation, and tumor findings. Survival rates were analyzed by the Kaplan-Meier and Mantel-Cox method, and multivariate analysis was done using the Cox proportional hazards model.

RESULTS

Overall 5-year survival rate was 22%, and median survival period was 15 months. The 5-year survival rate was influenced by the tumor size, gross type, serosal invasion, extragastric lymph node metastasis, liver metastasis, peritoneal dissemination, stage of disease (I, II vs. III, IV), resection margin, and operative curability (R0 vs. R1, R2). Of these, independent prognostic factors were three tumor findings: serosal invasion (absent vs. present, odds ratio 3.06, P < 0.01), extragastric lymph node metastasis (absent vs. present, odds ratio 2.13, P < 0.05), and liver metastasis (absent vs. present, odds ratio 3.77, P < 0.05). The survival was not significantly associated with any of the patient factors or operation factors including the extent of lymph node dissection.

CONCLUSION

In patients with large gastric cancer, independent prognostic factors were serosal invasion, extragastric lymph node metastasis, and liver metastasis. Prognosis after gastectomy was determined by these tumor factors and was not associated with the patient or operation factors.

Is palliative resection necessary for gastric carcinoma patients?

BACKGROUND AND AIMS

The benefit of palliative resection for gastric carcinoma patients remains controversial. We thus evaluated the survival benefit of palliative resection in advanced gastric carcinoma patients.

MATERIALS AND METHODS

We reviewed the hospital records of 466 gastric carcinoma patients who had palliative resection and compared the clinicopathologic findings to those of patients who underwent a bypass or exploration from 1986 to 2000.

RESULTS

Cox's proportional hazard regression model revealed only one independent statistically significant prognostic parameter, the presence of peritoneal dissemination (risk ratio, 0.739; 95% confidence interval, 0.564-0.967; P < 0.05). The 5-year survival rate of patients who had palliative resection was higher than that of patients who did not (7.03 vs 0%, P < 0.001). When the 5-year survival rates of patients with peritoneal dissemination were examined, the rate was higher for those who underwent resection (4.43 vs 0%, P < 0.001).

CONCLUSION

The results highlight the improved survivorship of gastric carcinoma patients with palliative resection compared to those who did not undergo the procedure. Although curative resection is not possible in this group of patients, we recommend performing resection aimed at palliation.

Predictors of long-term survival in node-positive gastric carcinoma patients with curative resection

BACKGROUND AND AIMS

We analyzed the clinicopathologic features of node-positive gastric carcinoma patients who were long-term survivors (5 years or longer) and evaluated the predictive factors associated with long-term survival.

PATIENTS AND METHODS

Of 554 node-positive gastric carcinoma patients with curative resection, 161 (29.1%) were long-term survivors, and 393 died of the disease before 5 years.

RESULTS

The long-term survivor group had a recurrence rate of 16.1%, while the recurrence rate was 95.4% in the short-term survivor group (P < 0.05). The mean tumor size in the long-term survivors (4.5 cm) was significantly smaller than that in the short-term survivors (5.3 cm; P < 0.001). A depth of invasion greater than T3 was found more frequently in the short-term survivor group (88.1%) than in the long-term survivor group (70.1%; P < 0.001). Using Cox's proportional hazard regression model, the only factor found to be an independent, statistically significant prognostic parameter was tumor size (risk ratio, 0.301; 95% confidence interval, 0.10-0.88; P < 0.05).

CONCLUSION

The tumor size emerged as the only independent, significant factor for the prediction of long-term survival in node-positive gastric carcinoma patients with curative resection.

Macroscopic tumor size as a simple prognostic indicator in patients with gastric cancer

BACKGROUND

In some cancers, such as breast and lung, tumor size is included in the classification of disease stage. However, it's clinical significance remains elusive in gastric cancer.

METHODS

To investigate the prognostic significance of macroscopic tumor size, we reviewed 1473 gastric cancer patients who underwent curative gastrectomy.

RESULTS

An appropriate threshold of tumor size affecting patient survival was 8 cm. Patients were divided into 2 groups as follows: small size group (SSG=tumor size<8 cm) and large size group (LSG=tumor size>or=8 cm). LSG tumors were frequently observed in patients with undifferentiated types and with lymphatic and venous invasion. Moreover, tumor size was significantly related to depth of invasion and lymph node metastasis. The prognosis of LSG patients was significantly worse than that of SSG patients. Multivariate analysis showed that tumor size was an independent prognostic factor along with depth of invasion, lymph node metastasis, and lymphatic invasion. Recurrence patterns differed between the 2 groups. Peritoneal recurrence was observed in LSG more frequently than SSG patients (P<.001), whereas hematogenous recurrence was observed in SSG more frequently than in LSG patients (P<.05). The survival rates of patient with stages II-, IIIa-, and IIIb-LSG disease were almost the same as those with stages IIIa-, IIIb-, and IV-SSG disease, respectively.

COMMENTS

Tumor size serves as a simple predictor of survival in patients with gastric cancer.

The efficacy of gastrectomy for large gastric cancer

BACKGROUND

Large gastric cancer (LGC) is frequently associated with extended disease, and the role of surgical resection has been debated. We investigated the efficacy of surgical treatment for LGC.

METHODS

The size of LGC was defined as 8 cm or greater. Four hundred and fifteen patients with LGC who underwent gastrectomy were included. The clinicopathological features, the status of the residual tumor, the incidence and patterns of relapse, and the survival were analyzed.

RESULTS

Macroscopically, diffuse-type tumors were dominant (60%). The numbers of patients with tumors of T3 or greater, lymph node involvement, and peritoneal metastases were 356 (86%), 359 (87%), and 126 (30%), respectively. One hundred and eighty-eight patients (45%) underwent incomplete tumor resection (R2). The R2/R0 (no residual tumor) ratio was greater than 1 in patients with type 4 tumors and N1 or greater metastasis and in those with type 3 tumors and N2 or greater metastasis. In contrast, T2, type 2, and type 5 tumors were more likely to be completely resected. The 5-year survival for all 415 patients was 26%. The survival rates were inversely related to the tumor type, size, and lymph node metastasis. In the 216 patients with R0, the 5-year survivals of those with pN (International Union Against Cancer [UICC] classification) 0, 1, 2, and 3 were 66%, 56%, 36%, and 5%, respectively (P = 0.001). In 96 of these 216 patients (44%) the tumor recurred, and peritoneal metastasis was the most frequent mode of recurrence (48%). By Cox's proportional hazard model, the tumor size was an independent prognostic factor.

CONCLUSION

The chance of achieving R0 resection for LGC is low, except for T2, type 2, or type 5 tumors. Primary resection should be avoided for other types of LGC.

Prognostic factors in patients with node-negative gastric carcinoma: A comparison with node-positive gastric carcinoma

AIM: To identify the clinicopathological characteristics of lymph node-negative gastric carcinoma, and also to evaluate outcome indicators in the lymph node-negative patients.

METHODS: Of 2848 gastric carcinoma patients, 1524 (53.5%) were lymph node-negative. A statistical analysis was performed using the Cox model to estimate outcome indicators.

RESULTS: There was a significant difference in the recurrence rate between lymph node-negative and lymph node-positive patients (14.4% vs 41.0%, P < 0.001). The 5-year survival rate was significantly lower in lymph node-positive than in lymph node-negative patients (31.1% vs 77.4%, P < 0.001). Univariate analysis revealed that the following factors influenced the 5-year survival rate: patient age, tumor size, depth of invasion, tumor location, operative type, and tumor stage at initial diagnosis. The Cox proportional hazard regression model revealed that tumor size, serosal invasion, and curability were independent, statistically significant, prognostic indicators of lymph node-negative gastric carcinoma.

CONCLUSION: Lymph node-negative patients have a favorable outcome attributable to high curability, but the patients with relatively large tumors and serosal invasion have a poor prognosis. Curability is one of the most reliable predictors of long-term survival for lymph node-negative gastric carcinoma patients.

Clinicopathological characteristics of signet ring cell carcinoma of the stomach

BACKGROUND

Signet ring cell (SRC) carcinoma of the stomach is characterized by its poor prognosis and potential to infiltrate the wall of stomach, although survival studies comparing carcinomas with and without SRC features have yielded inconsistent results. This study compared the clinicopathological features and prognosis of patients with SRC carcinoma with those with non-signet ring cell carcinoma of the stomach (NSRC).

METHODS

We reviewed the records of 2358 patients diagnosed with gastric carcinoma who were treated surgically between January 1980 and December 1999 at the Department of Surgery, Chonnam National University Hospital. There were 204 patients (8.7%) with SRC carcinoma as compared to 2154 with NSRC.

RESULTS

Significant differences were noted in the mean patient age, mean tumour size, depth of invasion, prevalence of hepatic and regional lymph node metastases, tumour stage, and curability between the patients with SRC histology and NSRC. There were no statistically significant differences in patient gender, location, or peritoneal dissemination between patients with SRC carcinoma and NSRC. SRC carcinoma of the stomach had a higher prevalence of early gastric carcinoma (46.1%) than NSRC (21.7%). The overall 5-year survival of all the patients with SRC carcinoma was 60.2% as compared with 48.9% for the patients with NSRC (P < 0.01). Using Cox proportional hazards model, lymph node metastasis and curability were significant factors affecting the outcome. Signet ring cell histology itself was not an independent prognostic factor.

CONCLUSIONS

Patients with SRC histology do not have a worse prognosis than patients with other types of gastric carcinoma.

Characteristics of intramucosal gastric carcinoma with lymph node metastatic disease

AIM

Recent trends in treatment strategy for early gastric cancer (EGC) are towards minimal surgical procedures, such as endoscopic mucosal resection and laparoscopic partial resection. There is a possibility of incomplete removal of regional lymph nodes in minimal procedures, which may subsequently decrease the chance of a cure. Therefore, it is essential to be able to predict lymph node status and to make careful selection of candidates for mucosal resection.

METHODS AND RESULTS

We studied the relationship between lymph node status and various pathological parameters including macroscopic appearance, location, size, differentiation, presence of ulceration, vascularity, presence of gastritis cystica profunda-like glandular proliferation, disruption of the muscularis mucosae and invasion into the muscularis mucosae, using age- and sex-matched samples of 40 node-positive and 80 node-negative tumours to define the characteristics of intramucosal EGCs. Histological differentiation (P < 0.001), increased submucosal vascularity (P < 0.05), breakdown of the muscularis mucosae (P < 0.05), and invasion of tumour cells into the muscularis mucosae (P < 0.05) were correlated with the lymph node status of intramucosal gastric carcinoma. Furthermore, diffuse type histology (P < 0.001) and deep invasion into the muscularis mucosae (P < 0.05) were indicators of node-positive intramucosal EGCs.

CONCLUSIONS

These histological indicators are easily accessible and seem to predict lymph node metastatic disease in limited surgical specimens. Patients should be carefully selected despite the recent trend toward less invasive resection of EGCs, especially for those apparently confined to the mucosa.

Preoperative genetic diagnosis of gastric carcinoma based on chromosomal loss and microsatellite instability

The degree of chromosomal losses and the presence of microsatellite instability (MSI) in gastric carcinomas have been categorized into low-risk (low-level loss and MSI) and high-risk (baseline- and high-level losses) genotypes. With the aim of making a preoperative diagnosis, this study confirmed the stem line genotype that is common over an entire tumor as well as in a single biopsy specimen. Biopsy specimens were obtained from 91 gastric carcinoma patients and examined for their microsatellite genotypes using a panel of 41 microsatellite markers on 8 cancer-associated chromosomes. The genotype of the biopsy specimens was compared with that of a surgical specimen, which had been multifocally examined for its intratumoral heterogeneity. Of the 91 pairs of biopsy and surgical specimens, 87 (96%) containing either the same (60 cases) or a similar (17 cases) number of chromosomal losses were categorized into the same microsatellite genotype, and the remaining 4 pairs (4%) were classified into a different genotype. The surgical specimens showed that an extraserosal invasion and lymph node metastasis are frequently associated with either a high-level (4 or more) of chromosomal losses irrespective of the tumor size (73% and 85%) or the large carcinomas > 5 cm in diameter irrespective of the tumor genotype (76% and 83%). The status of the extraserosal invasion and lymph node metastasis (0.691 and 0.802 receiver operating characteristic areas, respectively) predicted by the biopsy genotype and the tumor size corresponded closely to the surgical pathology results. Therefore, the extent of chromosomal losses and the presence of an MSI determined on a biopsy specimen will provide valuable information for making a preoperative genetic diagnosis of a gastric carcinoma.

Superficially spreading cancer of the stomach

BACKGROUND

Superficially spreading cancer (SSC) of the stomach is rare and extends widely along the mucosa or submucosa of the stomach. This study was conducted to clarify the clinicopathologic characteristics and prognosis of patients with SSC.

METHODS

SSC was defined as a tumor invading the mucosa or submucosa and measuring > or =5 cm in size. The clinicopathologic findings and outcomes of 36 patients with SSC were compared with those of 300 patients with early gastric cancer (EGC) measuring < or =5 cm and 271 with advanced gastric cancer measuring > or =5 cm.

RESULTS

SSC was significantly different from ordinary EGC in tumor size, frequency of lymph node metastasis, lymphatic invasion, venous invasion, and stage II, III, and IV disease. The frequency of serosal invasion, lymph node metastasis, and lymphatic and venous invasions in cases of SSC was significantly lower than with advanced gastric cancer. Although tumor size of SSC evaluated before operation was smaller than that on the resected specimen, the 10-year survival rate was not different between SSC and ordinary EGC.

CONCLUSIONS

SSC was characterized by high frequency of lymph node metastasis and preoperative underestimation of tumor size. SSC should be treated by a gastrectomy and lymphadenectomy with sufficient resection margin.

Risk factors for complications following resection of large gastric cancer

BACKGROUND

Although there is a low mortality rate after gastrectomy in Japan, most studies include many early gastric cancers. There have been few studies on the morbidity after gastrectomy for advanced gastric cancer. The aim of this study was to clarify the characteristics and risk factors for postoperative complications after resection of large gastric cancers based on three clinical factors: patient, operation and tumour.

METHODS

A retrospective study was carried out on 97 patients with a gastric tumour measuring 10 cm or more in diameter. Postoperative complications were recorded and the patients were divided into two groups: 38 with complications and 59 without. Patient, operative and tumour findings were compared between the two groups.

RESULTS

Overall morbidity and mortality rates were 39 and 7 per cent respectively. The most frequent complication was pleural effusion (17 per cent), followed by anastomotic leakage (14 per cent), abdominal abscess (12 per cent), wound infection (12 per cent), pancreatic leakage (8 per cent) and peritonitis (6 per cent). Risk factors associated with postoperative complications were operating time (400 versus 337 min, P < 0.01), blood loss (1338 versus 782 ml, P < 0.01), pancreatic invasion (26 versus 8 per cent, P < 0.05) and raised serum carcinoembryonic antigen (CEA) level (5 ng/ml or greater) (36 versus 17 per cent, P < 0.05), independent of patient age, nutritional status, type of gastrectomy, splenectomy or pancreatectomy, extent of lymph node dissection, tumour location, size and stage of disease.

CONCLUSION

Even in Japan, the morbidity of gastrectomy for large gastric cancer is high and associated with operating time, blood loss, pancreatic invasion and serum CEA level.

Soluble E-cadherin is a valid prognostic marker in gastric carcinoma

BACKGROUND

Gastric cancer remains a major cause of cancer mortality globally but no good prognostic tumour marker is available. Soluble fragment of E-cadherin protein has been reported to increase in the sera of patients with cancer and recently was found to be elevated in 67% of patients with gastric cancer.

AIMS

To investigate if serum soluble E-cadherin is a valid prognostic marker in gastric cancer.

METHODS

Concentrations of soluble E-cadherin from 116 patients with histologically confirmed gastric adenocarcinoma and 40 healthy subjects were measured using an immunoenzymometric method with a commercially available sandwich ELISA kit based on monoclonal antibodies.

RESULTS

The logarithm of the means of soluble E-cadherin concentration was significantly higher in patients with gastric cancers (mean 3.85 (SD 0.28)) than in healthy subjects (3.71 (0.18)) (p=0.001), and in palliative/conservatively treated cancers (3.91 (0.35)) than in operable cancers (3.78 (0.19)) (p=0.015). The logarithm of the concentrations correlated with tumour size (p=0.032) and carcinoembryonic antigen concentrations (p=0.001). The cut off value calculated from discriminant analysis on operability and inoperability/palliative treatment was 7025 ng/ml. Soluble E-cadherin concentrations higher than this cut off value predicted tumour (T4) depth invasion (p=0.020, confidence interval (CI) 1.008-1.668) and palliative/conservative treatment (p=0.023, CI 1.038-2.514). In contrast, the relative risks for lymph node (N2) metastasis, distant metastasis, and stage III/IV disease were 1.41, 1.33, and 1.55 respectively, despite not reaching statistical significance.

CONCLUSION

Serum soluble E-cadherin is a potential valid prognostic marker for gastric cancer. A high concentration predicts palliative/conservative treatment and T4 invasion.

Pathology and prognosis of mucinous gastric carcinoma

BACKGROUND AND OBJECTIVES

Clinicopathologic characteristics of mucinous gastric carcinoma (MGC) are unclear, and whether surgical results of MGC are unfavorable is controversial. Pathology and prognosis of patients with MGC were studied using multivariate analysis.

METHODS

The study included 17 patients with MGC and 614 with nonmucinous gastric carcinoma (NGC). The tumor was defined as MGC when more than one half of tumor area had mucin pools. Patients were evaluated with regard to age, sex, tumor location, size, gross type, depth of wall invasion, lymph node metastasis, lymphatic and vascular permeations, stage of disease, and operative curability.

RESULTS

MGC tumors, when compared with NGC tumors, were featured by the large size (9.0 vs. 5.2 cm), grossly infiltrative type (76 vs. 30%), T2 or more invasion (100 vs 53%), positive lymph node metastasis (88 vs. 32%), lymphatic permeation (94 vs. 55%), vascular permeation (47 vs. 25%), and stages III and IV (88 vs. 32%). On a multivariate analysis, mucinous histologic type was not an independent prognostic factor. Although 5-year survival rate for all MGC patients was lower than that for all NGC patients, the survival rate was not different between the MGC and NGC patients when compared in the same category of tumor size, depth of wall invasion, lymph node metastasis, and stage.

CONCLUSIONS

MGC is rare and detected mostly in an advanced stage. Mucinous histologic type itself is not a prognostic significance in patients with gastric carcinoma, and the biologic behavior of MGC is similar to that of ordinary advanced gastric carcinoma.

Early and late recurrence after gastrectomy for gastric carcinoma. Univariate and multivariate analyses

BACKGROUND

To the authors' knowledge, there are few studies regarding the predictors of early and late recurrence after gastrectomy for gastric carcinoma, and it is unknown whether prognostic factors can be applied to the timing of recurrence. The current study analyzed patients who died of recurrent gastric carcinoma and clarified histopathologic indicators associated with early and late recurrence.

METHODS

The study included 138 patients who died of recurrent gastric carcinoma after gastrectomy that was performed in the Department of Surgery I, Oita Medical University, between 1982-1995. Clinicopathologic findings were compared between 104 patients who died within 2 years after gastrectomy (early recurrence group) and 34 patients who died > 2 years after gastrectomy (late recurrence group). Multivariate analysis was performed to determine the independent factors correlated with the timing of recurrence.

RESULTS

When compared with the late recurrence group, the early recurrence group was characterized by a tumor size >/= 5 cm (92% in the early recurrence group vs. 74% in the late recurrence group), positive lymphatic invasion (64% vs. 38%), extended lymph node metastasis (73% vs. 35%), Stage III or IV disease (87% vs. 62%), and limited lymph node dissection (32% vs. 3%). The mean survival time was influenced by the lymphatic invasion (P < 0.01), vascular invasion (P < 0.05), level of lymph node metastasis (P < 0.01), stage of disease (P < 0.01), and extent of lymph node dissection (P < 0.01). On multivariate analysis, survival time was found to be associated independently with the stage of disease (Stage I, II vs. Stage III, IV) or the level of lymph node metastasis (N0, N1 vs. N2, N3).

CONCLUSIONS

The stage of disease and level of lymph node metastasis were found to be the most significant factors independently associated with the survival time after gastrectomy for gastric carcinoma. Patients with more advanced stage of disease (Stage III, IV) or those with extended lymph node metastasis (N2, N3) frequently died of recurrence within 2 years after gastrectomy.

Early and late recurrence after gastrectomy for gastric carcinoma. Univariate and multivariate analyses

BACKGROUND

To the authors' knowledge, there are few studies regarding the predictors of early and late recurrence after gastrectomy for gastric carcinoma, and it is unknown whether prognostic factors can be applied to the timing of recurrence. The current study analyzed patients who died of recurrent gastric carcinoma and clarified histopathologic indicators associated with early and late recurrence.

METHODS

The study included 138 patients who died of recurrent gastric carcinoma after gastrectomy that was performed in the Department of Surgery I, Oita Medical University, between 1982-1995. Clinicopathologic findings were compared between 104 patients who died within 2 years after gastrectomy (early recurrence group) and 34 patients who died > 2 years after gastrectomy (late recurrence group). Multivariate analysis was performed to determine the independent factors correlated with the timing of recurrence.

RESULTS

When compared with the late recurrence group, the early recurrence group was characterized by a tumor size >/= 5 cm (92% in the early recurrence group vs. 74% in the late recurrence group), positive lymphatic invasion (64% vs. 38%), extended lymph node metastasis (73% vs. 35%), Stage III or IV disease (87% vs. 62%), and limited lymph node dissection (32% vs. 3%). The mean survival time was influenced by the lymphatic invasion (P < 0.01), vascular invasion (P < 0.05), level of lymph node metastasis (P < 0.01), stage of disease (P < 0.01), and extent of lymph node dissection (P < 0.01). On multivariate analysis, survival time was found to be associated independently with the stage of disease (Stage I, II vs. Stage III, IV) or the level of lymph node metastasis (N0, N1 vs. N2, N3).

CONCLUSIONS

The stage of disease and level of lymph node metastasis were found to be the most significant factors independently associated with the survival time after gastrectomy for gastric carcinoma. Patients with more advanced stage of disease (Stage III, IV) or those with extended lymph node metastasis (N2, N3) frequently died of recurrence within 2 years after gastrectomy.

Rate of detection of lymph node metastasis is correlated with the depth of submucosal invasion in early stage gastric carcinoma

BACKGROUND

Gastric carcinoma invading the submucosa is often accompanied by lymph node metastasis. However, the relation between the depth of submucosal invasion and the status of metastasis has not been investigated. The objective of this study was to clarify the relation between lymph node status and the histologic features of gastric carcinoma invading the submucosa.

METHODS

The histopathology of 118 patients who underwent gastrectomy and lymph node dissection for gastric carcinoma invading the submucosa was examined. These pT1 tumors with invasion of the submucosa were confirmed by histologic examination of the resected specimens. Tumor size, depth of submucosal invasion, histologic type, and macroscopic type were investigated in association with presence or absence of and anatomic level of lymph node metastasis.

RESULTS

Among the 118 patients, 16 (14%) had lymph node metastasis, and the status of metastasis significantly correlated with tumor size and depth of submucosal invasion. The frequency of metastasis to perigastric lymph nodes and extragastric lymph nodes was 0% and 0% for < or =1-cm tumors, 5% and 1% for 1- to 4-cm tumors, and 46% and 15% for >4-cm tumors, respectively. There was no lymph from a node metastasis in tumors with less than 300 microm of submucosal invasion. The frequency of lymph node metastasis for tumors with 300-1000 microm and >1000 microm of submucosal invasion were 19% and 14%, respectively.

CONCLUSIONS

Tumor size and depth of submucosal invasion serve as simple and useful indicators of lymph node metastasis in early stage gastric carcinoma. Optimal lymph node dissection levels are as follows: 1) local resection (D0) for lesions < or =1 cm, 2) limited lymph node dissection (D1) for 1- to 4-cm lesions, and 3) radical lymph node dissection (D2) for lesions >4 cm. When submucosal invasion of a locally resected tumor is more than 300 microm, additional gastrectomy and lymph node dissection are necessary.

Indication for and outcome of laparoscopy-assisted Billroth I gastrectomy

BACKGROUND

Since 1991, laparoscopy-assisted Billroth I gastrectomy has been used for patients with early gastric cancer. The aim of this study was to clarify the outcome of 40 patients who underwent this operation and to examine the indications based on a retrospective histological study of 248 resected cases of early gastric cancer.

METHODS

Operating time, blood loss, length of skin incision, and postoperative hospital stay and complications were examined using the operation records and medical charts. The presence or absence of lymph node metastasis, tumour size, site, gross type, histological type, depth of invasion, presence or absence of ulceration, and status of lymph node metastasis were investigated in 248 early gastric cancers.

RESULTS

The mean operating time was 3 h and 48 min and the mean length of skin incision was 5.8 cm. Although one patient who had suffered from chronic bronchitis developed pneumonia and wound dehiscence, no other patients had a postoperative complication. The mean hospital stay after operation was 16 days and all patients were alive without recurrence at a median follow-up of 21 months. The incidence of lymph node metastasis in early gastric cancer was 2 per cent (three of 130) in mucosal cancers and 14 per cent (17 of 118) in submucosal cancers. These lesions could have been completely resected by laparoscopy-assisted gastrectomy.

CONCLUSION

All 40 patients were treated successfully by laparoscopy-assisted Billroth I gastrectomy without significant complications and with no recurrences to date. Pathological study of conventionally resected stomach and lymph nodes confirmed that laparoscopy-assisted Billroth I gastrectomy would be a safe and useful operation for most early gastric cancers.

Clinical results and prognostic factors of radiologically node-positive gastric carcinoma

Lymph node metastasis determined by histologic examination is an important prognostic indicator in gastric carcinoma. However, prognostic value of lymph node metastasis detected by computed tomography (CT) is unknown. The aim of this study was to evaluate clinical results and prognostic factors of patients with radiologically node-positive gastric carcinoma. The study included 78 patients with primary gastric carcinoma and lymph node metastasis confirmed by CT. The level of lymph node metastasis was simply graded as follows: level I included perigastric nodes; level II included intermediate nodes along the left gastric, common hepatic, and celiac arteries; and level III included distant nodes along the hepatoduodenal ligament, pancreas, spleen, and abdominal aorta. Sixty patients (79%) had stage IV tumors showing one or more of the following: level III lymph node metastasis in 37, pancreatic invasion in 27, peritoneal dissemination in 23, and liver metastasis in 19. Overall 1- and 5-year survival rates were 29% and 6%, respectively, and the 1-year survival rate was significantly influenced by the level of lymph node metastasis on CT (55% for level I, 27% for level II, 7% for level III, P < 0.01). In patients with gastrectomy, prognostic factors were tumor size (<10 cm versus >10 cm, P < 0.01), gross type (localized versus infiltrative, P < 0.01), histologic type (well differentiated versus poorly differentiated, P < 0.01), and curability of the disease (curative versus noncurative, P < 0.01). Our study indicates that prognosis of patients with radiologically node-positive gastric carcinoma is poor because of high frequency of extensive tumor spreads. Patients having only positive level I nodes on CT are candidates for curative gastrectomy, which may offer long-term survival.

Quality of life after laparoscopy-assisted Billroth I gastrectomy

OBJECTIVE

To evaluate the quality of life of patients who had undergone laparoscopy-assisted Billroth I gastrectomy (LAG) for cure of cancer.

SUMMARY BACKGROUND DATA

In 1994, the authors reported the first case of LAG for early gastric cancer, and this approach quickly has been adopted by Japanese surgeons. However, little is known about the subjective clinical results of this less invasive surgery.

METHODS

Quality of life was estimated using the 24-item questionnaire with a scoring system of 1, 2, and 3 and was compared between 41 consecutive patients with LAG and 35 with conventional open gastrectomy. All patients underwent Billroth I gastrectomy for early gastric cancer from January 1993 to July 1997 and were alive without recurrence.

RESULTS

Patients who had undergone LAG were taking a normal diet (100%) with >66% of volume at each meal (90%), showed no decreased performance status (90%), and were satisfied with their surgical results (88%). Patients with LAG, when compared with open gastrectomy, showed significantly better results with regard to weight loss, difficulty in swallowing, heartburn and belch, early dumping syndrome, and total score. LAG was better accepted by the patients.

CONCLUSIONS

Quality of life after Billroth I gastrectomy was significantly better in patients in whom a laparoscopic technique was used than in those who underwent a conventional method. LAG is less invasive and better accepted by patients and is the procedure of choice for the treatment of early gastric cancer.

Perigastric lymph node status as a prognostic indicator in patients with gastric cancer

BACKGROUND

The extent of lymph node dissection and histological examination of dissected lymph nodes varies among countries, which leads to the erroneous nodal stage and different surgical results in gastric cancer (stage migration, 'Will Rogers effect'). The aim of this study was to clarify the prognostic significance of the number of positive perigastric lymph nodes, which could be evaluated simply after D1 gastrectomy.

METHODS

A consecutive series of 106 patients with histologically node-positive gastric cancer treated by radical gastrectomy and lymph node dissection (D2 or D3) was studied. The number of metastatic perigastric nodes (level I, nos 1-6) was examined, and its influence on the survival of patients was analysed.

RESULTS

The overall 5-year survival rate was 50.9 per cent; the 5-year survival rate was significantly decreased when positive perigastric nodes exceeded six (62 per cent for one to six nodes versus 23 per cent for seven or more nodes, P< 0.001). Tumours having one to six positive perigastric nodes compared with those having seven or more positive perigastric nodes were more likely to have a size less than 4 cm (29 per cent versus one of 30, P< 0.001), grossly localized type (45 per cent versus seven of 30, P=0.042), absence of serosal invasion (32 per cent versus none of 30, P=0.002) and metastasis limited to the perigastric lymph nodes (70 per cent versus seven of 30, P < 0.001).

CONCLUSION

The results indicate that the number of positive perigastric nodes correlates with tumour progression and patient survival. This parameter is a simple and useful prognostic indicator for node-positive gastric cancer, and is available not only for D2 and D3 gastrectomy but also for D1 gastrectomy.