Incidence, diagnosis and significance of multiple gastric cancer

Using the geriatric nutritional risk index to predict outcomes in older patients with remnant gastric cancer after gastrectomy: a retrospective multicenter study in Japan

PURPOSE

This study investigated the prognostic value of the geriatric nutritional risk index (GNRI) in patients undergoing curative gastrectomy for remnant gastric cancer (RGC).

METHODS

This multicenter retrospective study included 105 patients with RGC of ≥ 65 years of age who underwent curative gastrectomy at 10 institutions in Japan between January 2000 and December 2016. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) were analyzed.

RESULTS

Receiver operating curve analyses indicated that the optimal cutoff value of the GNRI for OS was 95.4. Patients were categorized into high and low GNRI groups based on the optimal GNRI cutoff value. The GNRI was significantly correlated with body mass index (p < 0.001), amount of bleeding (p = 0.021), Clavien-Dindo grade 5 postoperative complications (p = 0.040), death caused by primary disease (p = 0.010), and death caused by other diseases (p = 0.002). The OS and DSS were significantly worse in the low GNRI group. A low GNRI and T3 or deeper tumor invasion were independent prognostic factors for OS and DSS.

CONCLUSIONS

The GNRI is a promising predictor of both short- and long-term outcomes in older patients with RGC.

Utility and Feasibility of Removing Surgical Staples from the Remnant Stomach or Gastric Conduit during Endoscopic Submucosal Dissection

Objective Endoscopic submucosal dissection (ESD) for gastric cancer in the remnant stomach poses some specific technical difficulties due to severe fibrosis and the presence of surgical staples. Therefore, we clarified the feasibility and safety of removing staples. Methods We retrospectively analyzed ESD outcomes of cases of gastric cancer in the remnant stomach. Materials This study reviewed 227 patients who underwent ESD for gastric cancer in the remnant stomach or gastric conduit. Patients were divided into those in whom resection extended to the anastomotic site or suture line (AS group; n=90) and those without such extension (non-AS group; n=137). The AS group was further divided into cases in which staples were removed (staple group; n=22) and those in which they were not (control group; n=68). Results The rates of specimen damage and curative resection and the duration and speed of the procedure were significantly worse in the AS group than the non-AS group. There were no significant differences between the staple group and the control group in the curative or complete resection rates, and no complications occurred in the staple group. In a propensity score-matched analysis, the rate of specimen damage was significantly lower in the staple group than in the control group (p=0.002), and the procedure speed tended to be faster (p=0.077). Conclusion Staple removal may improve the outcomes of ESD in patients with gastric cancer in the remnant stomach or gastric conduit by reducing the risk of specimen damage and increasing the procedure speed without complications.

Robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy

The utility of robotic surgery for remnant gastric cancer remains unclear. We report a case of a robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy and Child reconstruction with Braun enteroenterostomy. Adhesiolysis, lymphadenectomy, and gastrectomy were robotically performed. Indocyanine green fluorescence imaging confirmed the tissue perfusion of the reconstructive tract. The patient's postoperative course was uneventful. Robotic surgery facilitates safety for gastrectomy after pancreaticoduodenectomy because of its precise manipulation; its advantages can be further exploited by maximizing usage of the assistant's forceps. Indocyanine green fluorescence imaging capability of the da Vinci Xi Surgical System allows timely evaluation of tissue perfusion at the site of interest, leading to a more reliable procedure.

Involvement in the tumor-infiltrating CD8+ T cell expression by the initial disease of remnant gastric cancer

BACKGROUND

Remnant gastric cancer (RGC) has been increasing for various reasons such as a longer life span, medical progress, and others. It generally has a poor prognosis, and its mechanism of occurrence is unknown. The purpose of this study was to evaluate the clinicopathological features of and clarify the oncological features of RGC.

METHODS

Between January 2002 and January 2017, 39 patients with RGC following distal gastrectomy underwent curative surgical resection at the Okayama University Hospital; their medical records and immunohistochemically stained extracted specimens were used for retrospective analysis.

RESULTS

On univariate analysis, initial gastric disease, pathological lymph node metastasis, and pathological stage were the significant factors associated with poor overall survival (p=0.014, 0.0061, and 0.016, respectively). Multivariate analysis of these 3 factors showed that only initial gastric disease caused by malignant disease was an independent factor associated with a poor prognosis (p=0.014, hazard ratio: 4.2, 95% confidence interval: 1.3-13.0). In addition, tumor-infiltrating CD8⁺ T cells expression was higher in the benign disease group than in the malignant group (p=0.046).

CONCLUSIONS

Initial gastrectomy caused by malignant disease was an independent poor prognostic factor of RGC, and as one of the causes, lower level of tumor-infiltrating CD8⁺ T cells in RGC may involve in.

Clinicopathological Features of Remnant Gastric Cancer After Gastrectomy

BACKGROUND

Remnant gastric cancer (RGC) encompasses all cancers arising from the remnant stomach. Various studies have reported on RGC and its prognosis, but no consensus on its surgical treatment and postoperative management has been reached. Moreover, the correlation between the clinicopathological characteristics and long-term outcomes of RGC remains unclear. This study investigated the clinicopathological factors associated with the long-term survival of RGC patients.

METHODS

The medical records (March 1993-September 2020) of 104 RGC patients from Tokyo Medical University Hospital database were analyzed. Of these 104 patients, the medical records of 63 patients who underwent surgical curative resection were analyzed using R. Kaplan-Meier plots of cumulative incidence of RGC were made. Differences in survival rates were compared using the log-rank test. Prognostic factors were analyzed using multivariate Cox regression analysis (P < .05).

RESULTS

Of the 104 RGC patients, 63 underwent total remnant stomach excision. The median time from the first surgery to the total excision was 10 years. The 5-year survival rate of the 63 RGC patients was .55 ((95% CI); .417-.671). The clinicopathological factors that were significantly associated with the long-term outcome of the RGC patients were tumor diameter (≥3.5 cm), presence or absence of combined resection of multiple organs, tumor invasion (deeper than T2), TNM stage, and postoperative morbidity. The multivariate Cox regression analysis showed that tumor invasion depth was the only independent prognostic factor for RGC patients [HR (95% CI): 5.49 (2.629-11.5), P ≤ .005].

CONCLUSIONS

Among prognostic factors, tumor invasion depth was the only independent factor affecting RGC's long-term outcome.

T stage and venous invasion are crucial prognostic factors for long-term survival of patients with remnant gastric cancer: a cohort study

Background

The incidence of remnant gastric cancer (RGC) after distal gastrectomy is 1–5%. However, as the survival rate of patients with gastric cancer improves due to early detection and treatment, more patients may develop RGC. There is no consensus on the surgical and postoperative management of RGC, and the clinicopathological characteristics correlated with the long-term outcomes remain unclear. Therefore, we investigated the clinicopathological factors associated with the long-term outcomes of RGC.

Methods

We included 65 consecutive patients who underwent gastrectomy for RGC from January 2000 to December 2015 at the Osaka Medical and Pharmaceutical University Hospital, Japan. The Kaplan–Meier method was used to create survival curves, and differences in survival were compared between the groups (clinical factors, pathological factors, and surgical factors) using the log-rank test. Multivariate analyses using the Cox proportional hazard model were used to identify factors associated with long-term survival.

Results

No significant differences were noted in the survival rate based on clinical factors (age, body mass index, diabetes mellitus, hypertension, cardiovascular disease, pulmonary complications, liver disease, diet, history of alcohol drinking, and history of smoking) or the type of remnant gastrectomy. Significant differences were noted in the survival rate based on pathological factors and surgical characteristics (intraoperative blood loss, operation time, and the number of positive lymph nodes). Multivariate analysis revealed that the T stage (hazard ratio, 5.593; 95% confidence interval [CI], 1.183–26.452; p = 0.030) and venous invasion (hazard ratio, 3.351; 95% CI, 1.030–10.903; p = 0.045) were significant independent risk factors for long-term survival in patients who underwent radical resection for RGC.

Conclusions

T stage and venous invasion are important prognostic factors of long-term survival after remnant gastrectomy for RGC and may be keys to managing and identifying therapeutic strategies for improving prognosis in RGC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02400-5.

Comparative molecular subtypes of index and metachronous gastric adenocarcinomas: a study of 42 Korean patients

To date, there have been no studies comparing the molecular subtypes of Index gastric cancers (IGCs) and metachronous gastric cancers (MGCs). We evaluated a cohort of 42 patients with 43 IGCs and 45 MGCs. Molecular subtyping was performed by immunohistochemistry of mismatch repair (MMR) proteins, E-cadherin, p53, and Epstein-Barr virus- (EBV-) in situ hybridization (ISH). Gastric adenocarcinomas were classified into 5 subtypes: EBV-associated, MMR deficient (MMRD), E-cadherin aberrant, p53-aberrant [p53(+)], and p53 non-aberrant [p53(neg)]. All IGCs had been successfully treated by either surgery (19%) or endoscopic resection (81%). The mean interval between IGCs and MGCs was 85 months. Among the IGCs, EBV-associated, MMRD, E-cadherin-aberrant, p53(+), and p53(neg) molecular subtypes represented 2 (5%), 4 (9%), 2 (5%), 21 (49%), and 14 (32%) of the cases, respectively. Two cases had concomitant p53(+) and aberrant E-cadherin molecular subtypes. Among metachronous cancers, EBV-associated, MMRD, E-cadherin-aberrant, p53(+), and p53(neg) molecular subtypes represented 3 (7%), 11 (24%), 0 (0%), 22 (49%), and 9 (20%) cases. Concomitant p53(+) was observed in 1 EBV-associated and 2 MMRD MGCs. Although, there was no significant difference in the frequency of most molecular subtypes in IGCs and MGCs, the number of MMRD gastric cancers more than doubled in the MGC group. Half of the MGCs had a divergent molecular subtype compared to that of the IGCs. Notably, the interval between the development of IGCs and MGCs was significantly longer in patients with divergent molecular subtypes (P = 0.010). All 4 patients with MMRD IGC developed MMRD MGCs. Although the concept of mucosal field cancerization may explain the matching molecular subtypes in early-developing MGCs, the presence of divergent subtypes in late-occurring MGCs suggests a shift in the carcinogenic mechanism affecting the residual mucosa possibly related to Helicobacter pylori eradication.

Incidence of Multiple Metachronous Gastric Cancers After Pyloric-Preserving Gastrectomy

AIM

Pylorus-preserving gastrectomy (PPG) is widely used for early gastric cancer located in the middle third of the stomach. The minimization of the extent of gastrectomy may increase the risk of metachronous multiple gastric cancer (MGC). We report the findings of a study that was conducted to evaluate the prevalence of MGC after PPG.

METHODS

The clinical data of 533 patients who underwent PPG for gastric cancer between 1993 and 2018 were reviewed. The clinicopathological characteristics at the time of the primary treatment that were predictive of the development of MGC were explored. The median (range) observation period was 112.4 (8.1-290.7) months.

RESULTS

Metachronous MGC was diagnosed in 33 of the 533 patients. The cumulative 5-year and 10-year event rates were 3.3% and 6.2%, respectively. The patient gender, presence/absence of synchronous MGC and the macroscopic type of the primary gastric cancer were significantly associated with the risk of development of metachronous MGC. Multivariate analysis identified the presence of synchronous MGC (hazard ratio [HR]: 4.828, 95% confidence interval [CI]; 1.611-12.30, p = 0.004) and Type 0-IIa primary gastric cancer (HR 2.810, 95% CI; 1.113-7.090, p = 0.029) as independent factors associated with the risk of development of MGC. All the patients could be treated by surgical or endoscopic resection for the metachronous MGC. Recurrence was observed in one patient.

CONCLUSIONS

There was quite a few incidence of development of metachronous MGC after PPG. Nevertheless, PPG remains reasonable treatment option, if adequate postoperative surveillance can be ensured.

Laparoscopic Total Gastrectomy for Remnant Gastric Cancer: A Single-institution Experience and Systematic Literature Review

BACKGROUND/AIM

The safety and efficacy of laparoscopic total gastrectomy (LTG) for remnant gastric cancer (RGC) remains unclear. The purpose of this study was to compare the clinical outcomes of LTG with open total gastrectomy (OTG) for RGC.

PATIENTS AND METHODS

Twenty-two patients who underwent total gastrectomy for RGC were enrolled in this study.

RESULTS

LTG was carried out in seven patients, and OTG was performed in the remaining 15 patients. The mean operation time in the LTG group was longer than that in the OTG group. The estimated blood loss in the LTG group was less than that in the OTG group. No cases in the LTG group required open conversion. Postoperatively, the first meal and defecation were earlier in the LTG group than in the OTG group. The overall survival rates of the two groups were comparable.

CONCLUSION

Laparoscopic total gastrectomy is a feasible surgical option for RGC.

DNA methylation genome-wide analysis in remnant and primary gastric cancers

BACKGROUND

Although primary (PGC) and remnant gastric cancers (RGC) both originate from the same gastrointestinal organ, they have very distinct clinicopathological behaviors. We hypothesized that there would be distinct differences in DNA methylation patterns that would occur during carcinogenesis of RGC and PGC, and that the differences in methylation patterns may help identify the primary factor contributing to chronic inflammation in patients with RGC.

METHODS

We investigated the genome-wide DNA methylation patterns of PGC and RGC tissues from 48 patients using the Infinium HumanMethylation450 Beadchip assay. The results were validated by quantitative methylation-specific PCR (qMSP) in separate, independent cohorts.

RESULTS

We found that in our training cohort of 48 patients, the most variable genes from the gastric cancer tissues identified by the Infinium HumanMethylation450 Beadchip clustered the resultant heatmap into high and low methylation groups. On multivariate analysis, PGCs contributed significantly to the high methylation group (p = 0.004, OR 12.33), which suggested that the promoter methylation status in PGC is higher than that in RGC. Supporting this conclusion was the finding that in a separate qMSP analysis in a test cohort, the EPB41L3 gene, chosen because of its high β value on microarray analysis in the gastric cancer tissues, had significantly higher DNA promoter methylation in cancer tissues in the validation PGC tissues than in RGC.

CONCLUSIONS

This study demonstrated that promoter methylation status in PGC is higher than in RGC. This result may reflect the effects of the absence of Helicobacter pylori on the reduced DNA methylation in the remnant stomach.

Short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the remnant stomach is a minimally invasive treatment. Few studies compared the technical difficulty of ESD involving the suture line and anastomosis, and information on long-term outcomes is insufficient. This study aimed to elucidate the short- and long-term outcomes of ESD for EGC in the remnant stomach.

METHODS

We investigated patients who underwent ESD for EGC in the remnant stomach between September 2002 and March 2016. Clinicopathological data were retrieved to assess en bloc resection rates, complications, and long-term outcomes including overall survival and cause-specific survival.

RESULTS

A total of 136 consecutive patients with 165 lesions resected by 157 ESD procedures were retrospectively evaluated. The en bloc resection rate was 95.5%. Complications included 16 intraoperative perforations (10.2%), 2 delayed perforations (1.3%), and 15 delayed bleeding (9.6%), which were successfully treated with endoscopy. The en bloc resection rate was significantly higher in the suture line group (100%) and the non-anastomosis or suture line group (98.8%) than in the anastomosis group (82.9%). However, the intraoperative perforation rate was significantly higher in the anastomosis group (31.4%) than in other groups. The 5-year overall and cause-specific survival rates were 88.4% and 97.6%, respectively, during a median follow-up period of 50.7 months (interquartile range 30.8-91.3).

CONCLUSIONS

The long-term outcomes of ESD for EGC in the remnant stomach were favorable. However, ESD involving the anastomosis was a technically demanding procedure due to the low en bloc resection rate and high perforation rate.

A Rare Case of Local Recurrence Following Curative Endoscopic Submucosal Dissection of Intramucosal Differentiated-Type Gastric Cancer

A 78-year-old man underwent endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) (type 0-IIa) in the anterior wall of the antrum. En bloc resection was achieved. The histopathological examination revealed very well-differentiated tubular adenocarcinoma (tub1) of 30 × 22 mm in size, confined to the mucosa. No lymphovascular invasion or ulceration was observed, and there was no undifferentiated-type component and the margins were tumor-free. Therefore, this lesion fulfilled the eCuraA criteria. Two years after ESD, esophagogastroduodenoscopy revealed an irregular, slightly-depressed lesion within the post-ESD scar. Tubular adenocarcinoma was suspected based on histopathological examination of a biopsy specimen. The tumor was resected by ESD. A histopathological examination revealed well-differentiated tubular adenocarcinoma (tub1) of 6 × 4 mm in size, confined to the mucosa. No lymphovascular invasion was detected and the margins were tumor-free. These findings indicated a curative resection. Recurrence following a curative ESD of an intramucosal differentiated-type EGC which fulfilled the eCuraA criteria is rare. Careful endoscopic observation using magnifying narrow band imaging (NBI) is needed after ESD, even when curative resection is achieved.

Clinicopathological features and impact of adjuvant chemotherapy on the long-term survival of patients with multiple gastric cancers: a propensity score matching analysis

Background

Little is known about the correlation between the clinicopathological features, postoperative treatment, and prognosis of multiple gastric cancers (MGCs). In this study, we aimed to investigate the correlation between these features and the impact of postoperative adjuvant chemotherapy on the long-term survival of patients with MGC.

Methods

The clinical and pathological data of patients diagnosed with gastric adenocarcinoma who had radical gastrectomy from January 2007 to December 2016 were analyzed. Using propensity score matching, the prognostic differences, and the impact of postoperative adjuvant chemotherapy between those with MGC and solitary gastric cancers (SGC) were compared.

Results

Among the 4107 patients investigated, the incidence of MGC was 3.2% (133/4107). Before matching, patients with MGC and SGC had disparities in the type of gastrectomy, pathological tumor stage (pT), pathological node stage (pN), and pathological tumor-node-metastasis stage (pTNM). After a 1:4 ratio matching, the clinical data of 133 cases of MGC and 532 cases of SGC were found to be comparable. The 5-year overall survival (OS) rate was 56.6% in the entire matched cohort, 48.1% in the MGC group, and 58.7% in the SGC group (P = 0.013). Multivariate analysis revealed that MGC, age, pT stage, pN stage, and adjuvant chemotherapy were independent predictors of OS (all P < 0.05). Stratified analyses demonstrated that for the cohort of advanced gastric cancer (AGC) patients who did not had adjuvant chemotherapy, the 5-year OS rate of advanced cases of MGC was inferior than that of SGC patients (34.0% vs. 46.1%, respectively; P = 0.025) but there were no significant difference in the 5-year OS rate between advanced MGC and SGC patients who had adjuvant chemotherapy (48.0% vs. 53.3%, respectively; P = 0.292). Further, we found that the 5-year OS rate of advanced MGC who had adjuvant chemotherapy was significantly higher than those who did not had adjuvant chemotherapy (48.0% vs. 34.0%, P = 0.026).

Conclusions

Patients with advanced MGC was identified as having a poorer survival as to SGC patients, but the implementation of postoperative adjuvant chemotherapy showed that it had the potential to significantly improve the long-term prognoses of MGC patients.

Carcinoma in the Remnant Stomach During Long-Term Follow-up After Distal Gastrectomy for Gastric Cancer: Analysis of Cumulative Incidence and Associated Risk Factors

BACKGROUND

The number of patients with remnant gastric cancer following resection of gastric cancer may increase. The aims of this study were to investigate the development of remnant gastric cancer after distal gastrectomy for gastric cancer and to examine its cumulative incidence, clinicopathological characteristics, and risk factors.

METHODS

We examined 437 patients with relapse-free survival for 5 years or more after distal gastrectomy with Billroth I reconstruction for gastric cancer performed between 1985 and 2005.

RESULTS

A total of 17 patients suffered from remnant gastric cancer. The cumulative incidence was 3.7% at 10 years and 5.4% at 20 years. The median time until development of remnant gastric cancer was 79 months (range 30-209 months). The presence of synchronous multiple gastric cancers was a significant independent risk factor for remnant gastric cancer (hazard ratio 4.036; 95% confidence interval 1.478-11.02; P = 0.006). Of the 17 patients, the 13 whose remnant gastric cancer was detected via regular endoscopy showed better prognoses than the patients detected by other means (P < 0.001).

CONCLUSION

The cumulative incidence of remnant gastric cancer was 5.4% at 20 years. In particular, patients who had multiple gastric cancers at initial gastrectomy were at higher risk for remnant gastric cancer. Therefore, long-term endoscopic surveillance is important.

A Concurrence of Adenocarcinoma with Micropapillary Features and Composite Glandular-Endocrine Cell Carcinoma in the Stomach

We report a unique case of synchronous double primary gastric cancer consisting of adenocarcinoma components with micropapillary features and composite glandular-endocrine cell carcinoma components. The patient was a 53-year-old man presenting with a 6-month history of epigastric pain and diarrhea. A subtotal gastrectomy was performed. Histologically, one tumor was composed of micropapillary carcinoma components (50%) with tight clusters of micropapillary aggregates lying in the empty spaces, admixed with moderately differentiated adenocarcinoma components. MUC-1 was expressed at the stromal edge of the micropapillary component. The other tumor was composed of atypical carcinoid-like neuroendocrine carcinoma (50%), adenocarcinoid (30%), and adenocarcinoma components (20%). The neuroendocrine components were positive for CD56, synaptophysin, chromogranin, and creatine kinase. The adenocarcinoid components were positive for both carcinoembryonic antigen and neuroendocrine markers (amphicrine differentiation). This case is unique, due to the peculiar histologic micropapillary pattern and the histologic spectrum of adenocarcinoma adenocarcinoid-neuroendocrine carcinoma of the synchronous composite tumor.

Does remnant gastric cancer really differ from primary gastric cancer? A systematic review of the literature by the Task Force of Japanese Gastric Cancer Association

Remnant gastric cancer, most frequently defined as cancer detected in the remnant stomach after distal gastrectomy for benign disease and those cases after surgery of gastric cancer at least 5 years after the primary surgery, is often reported as a tumor with poor prognosis. The Task Force of Japanese Gastric Cancer Association for Research Promotion evaluated the clinical impact of remnant gastric cancer by systematically reviewing publications focusing on molecular carcinogenesis, lymph node status, patient survival, and surgical complications. A systematic literature search was performed using PubMed/MEDLINE with the keywords "remnant," "stomach," and "cancer," revealing 1154 relevant reports published up to the end of December 2014. The mean interval between the initial surgery and the diagnosis of remnant gastric cancer ranged from 10 to 30 years. The incidence of lymph node metastases at the splenic hilum for remnant gastric cancer is not significantly higher than that for primary proximal gastric cancer. Lymph node involvement in the jejunal mesentery is a phenomenon peculiar to remnant gastric cancer after Billroth II reconstruction. Prognosis and postoperative morbidity and mortality rates seem to be comparable to those for primary proximal gastric cancer. The crude 5-year mortality for remnant gastric cancer was 1.08 times higher than that for primary proximal gastric cancer, but this difference was not statistically significant. In conclusion, although no prospective cohort study has yet evaluated the clinical significance of remnant gastric cancer, our literature review suggests that remnant gastric cancer does not adversely affect patient prognosis and postoperative course.

Risk factors for synchronous or metachronous tumor development after endoscopic resection of gastric neoplasms

BACKGROUND

Despite many advantages, the development of synchronous or metachronous neoplasm is one of the main concerns with endoscopic resection. We aimed to clarify the independent risk factors for synchronous or metachronous gastric neoplasm.

METHODS

We retrospectively reviewed the medical records of all patients who had undergone endoscopic resection for gastric high-grade dysplasia or early gastric cancer between April 2001 and February 2011.

RESULTS

Among 971 subjects, 56 synchronous neoplasms and 42 metachronous neoplasms developed during 12-131 months of follow-up. In univariate analysis, age over 65 years, male gender, absence of Helicobacter pylori infection, lower third location, mucosal atrophy, and intestinal metaplasia were related to multiple gastric neoplasms. In multivariate analysis, absence of H. pylori infection [odds ratio (OR) 1.610, 95 % confidence interval (CI) 1.038-2.497)], lower third location (OR 1.704, 95 % CI 1.070-2.713), and intestinal metaplasia (OR 4.461, 95 % CI 1.382-14.401) were independent risk factors for multiple gastric neoplasms. For synchronous neoplasm, primary tumor size less than 1 cm was the only independent risk factor. For metachronous neoplasm, absence of H. pylori infection (OR 2.416, 95 % CI 1.214-4.810) was found to be the only independent risk factor. H. pylori eradication was found to be unrelated to the development of metachronous gastric neoplasms.

CONCLUSIONS

For tumors located in the antrum and accompanied by intestinal metaplasia, meticulous endoscopic evaluation with close follow-up after endoscopic resection is recommended.

Intestinal metaplasia and anastomotic recurrence of gastric carcinoma

Intestinal metaplasia (IM) of the stomach has been shown to increase the relative risk of gastric cancer. Endoscopic surveillance has been proposed and advocated for populations at risk. Those patients who had undergone surgery for gastric malignancy exhibited precancerous lesions such as atrophic gastritis and IM, and the possibility of anastomotic recurrence is higher than for the patients who had undergone benign gastric surgery. At present, there are no other recognized good markers of gastric dysplasia or cancer. We reviewed the literature on IM of the stomach to ascertain whether residual premalignant (type III) IM may predispose to anastomotic recurrence of gastric cancer.

Gastric cancer arising from the remnant stomach after distal gastrectomy: A review

Gastric stump carcinoma was initially reported by Balfore in 1922, and many reports of this disease have since been published. We herein review previous reports of gastric stump carcinoma with respect to epidemiology, carcinogenesis, Helicobacter pylori (H. pylori) infection, Epstein-Barr virus infection, clinicopathologic characteristics and endoscopic treatment. In particular, it is noteworthy that no prognostic differences are observed between gastric stump carcinoma and primary upper third gastric cancer. In addition, endoscopic submucosal dissection has recently been used to treat gastric stump carcinoma in the early stage. In contrast, many issues concerning gastric stump carcinoma remain to be clarified, including molecular biological characteristics and the carcinogenesis of H. pylori infection. We herein review the previous pertinent literature and summarize the characteristics of gastric stump carcinoma reported to date.

Simple pathological examination technique for detection of cancer located at the surgical margin of the stomach

BACKGROUND

The technique for examining surgical resection margins described in the Japanese Classification of Gastric Carcinoma is based on the examination of continuous infiltration by the primary tumor, and discontinuous lesions such as multiple cancers are not examined. However, examining lesions-particularly cancers-at the resection margins is important for the prevention of cancers in the remaining stomach that result from cancer remnants (remnant gastric cancer).

METHODS

The clinical usefulness of a simple pathological examination technique for detecting cancer located at the surgical margin of the stomach was studied. A specimen 5-8 mm wide was resected from the surgical cut margin along the entire circumference of the stomach. When the pathological margin was positive for cancer, the surgical margin was also examined, and cases that were positive for cancer were regarded as marginally positive.

RESULTS

Of the 1,498 patients with early gastric cancer who were examined using this method, 17 (1.1 %) were marginally positive for multiple cancers, and 8 of these 17 patients (57 %) had microcancers <5 mm in diameter.

CONCLUSION

This method is simple and useful for detecting cancer involving the surgical margin, which occurs at a rate of 1.1 %, making it possible to prevent remnant gastric cancer by reoperation.

Causes of missed synchronous gastric epithelial neoplasms with endoscopic submucosal dissection: a multicenter study

OBJECTIVE

Unlike surgery, endoscopic submucosal dissection (ESD) removes gastric epithelial neoplasms within a tight margin, leaving most normal tissue around the neoplasm intact, thus resulting in a high risk for missed synchronous gastric epithelial neoplasms (mSGENs). The purpose of this study was to evaluate the characteristics and risk factors of mSGENs (mSGENs) compared to simultaneously identified SGENs (siSGENs) in patients who underwent ESD.

MATERIALS AND METHODS

The authors have retrospectively examined 312 SGENs from 275 patients treated with ESD at three hospitals in Korea between January 2004 and May 2011. The incidence and clinicopathological features of SGENs, mSGENs, and siSGENs were investigated. Any second epithelial neoplasm found within 1 year of the first ESD procedure was defined as an mSGEN and any neoplasm detected simultaneously with the first neoplasm was defined as a siSGEN.

RESULTS

The overall incidence of ESD patients with SGENs was 9.1% (275 of 3018 patients). Of the SGENs, 45.2% were siSGENs and 54.8% were mSGENs. Independent risk factors for mSGENs were adenoma as the first gastric lesion (Exp (B) = 2.154, 95% CI: 1.282-3.262) and duration of endoscopic examination before the first ESD (Exp (B) = 1.074, 95% CI: 1.001-1.141). The results suggest that 33% of mSGENs could have been identified during the endoscopic examination prior to ESD.

CONCLUSION

Additional effort needs to be expended in identifying siSGENs, particularly prior to ESD for less serious adenomas. This should include sufficient time for endoscopic examination, prior to ESD, to ensure a thorough examination for siSGENs.

Simultaneous endoscopic submucosal dissection for synchronous double early gastric cancer

BACKGROUND

This study aims to evaluate the safety and efficacy of simultaneous endoscopic submucosal dissection (ESD) for synchronous double early gastric cancers.

METHODS

We retrospectively evaluated 832 single gastric cancers from 789 patients treated by single ESD (single group) and 124 synchronous double cancers from 62 patients treated by simultaneous ESD (simultaneous group).

RESULTS

The overall rate of en bloc resection and curative resection was comparable between the two groups. Procedure time was significantly longer in the simultaneous group than in the single group (131.0 ± 66.5 and 94.8 ± 64.1 min, respectively, P < 0.001). White blood cell count on the day after ESD was significantly higher in the simultaneous group (9310 ± 2774/μl) than in the single group (8633 ± 2341/μl) (P = 0.032). Length of fasting period after ESD was 1.1 ± 0.5 days in the single group and 1.4 ± 1.1 days in the simultaneous group (P = 0.082). Complications were more frequent in the simultaneous group than in the single group (11.3 vs. 5.4 %, respectively), but the difference was not significant (P = 0.082). Complication rate per one lesion did not differ between the two groups (5.6 vs. 5.4 %, respectively, P = 0.914). Multivariate analysis showed procedure time longer than 150 min was independently predictive for complications of simultaneous ESD (P < 0.042, odds ratio = 6.094). Large tumors, upper portion location and tumors not in the standard guideline criteria were significantly associated with long procedure time.

CONCLUSIONS

Simultaneous ESD for synchronous early gastric cancer can be a feasible and safe option, and it can reduce hospital stay. These results need to be validated by further studies.

Missed synchronous gastric neoplasm with endoscopic submucosal dissection for gastric neoplasm: experience in our hospital

AIM

Endoscopic submucosal dissection (ESD) has been widely accepted as a less invasive treatment for early gastric cancer and adenoma, but research on missed synchronous gastric neoplasm (SGN) with ESD has been limited. In the present study, we aimed to investigate the incidence and characteristics of missed SGN during follow-up endoscopy in patients who have undergone ESD.

METHOD

We investigated the clinicopathological features of 602 patients and gastric neoplasms treated by ESD from January 2005 through July 2009 at our institution. We defined any second neoplasm found within 1 year after ESD as a missed SGN.

RESULTS

Out of 602 patients, 12 (2.0%) had missed SGN. Among the 12 missed SGN, seven (58.3%) cases were carcinomas. All cases of missed synchronous gastric cancer (SGC) were exclusively discovered in the posterior wall of the stomach (7 of 7 cases, 100%, P = 0.016). Missed SGN were more frequently observed when the primary gastric neoplasm was adenoma (4.0% vs 1.0%; OR = 4.114; 95% CI = 1.224-13.831). Furthermore, the risk of missed SGC increased 12-fold in the primary gastric adenoma group compared to the primary gastric carcinoma group (2.9% vs 0.24%; OR = 12.308; 95% CI = 1.472-102.939).

CONCLUSION

Endoscopists need to make an effort to find SGN, especially when they carry out ESD for an adenoma, which is a less serious lesion. The important blind spot in screening endoscopic examination before ESD is the posterior wall of the upper third and middle third of the stomach.

Genetic and epigenetic markers to identify high risk patients for multiple early gastric cancers after treatment with endoscopic mucosal resection

The development of multiple gastric cancer is a major problem after the endoscopic resection of the first early gastric cancer. To find out markers to identify high risk patients, we analyzed the microsatellite instability (MSI) status and hypermethylation of tumor-related genes in multiple gastric cancers. Sixty-four adenocarcinomas resected by endoscopy, including 32 early solitary gastric cancers (SGCs) from 32 patients and 32 multiple gastric cancers (MGCs) from 14 patients, were employed. We analyzed MSI and the methylation status of promoter regions of the hMLH1, MGMT, p16 and E-cadherin using methylation-specific Polymerase Chain Reaction. Expression levels of hMLH1 were examined by immunohistochemistry. MSI (+) was detected in 5 of the 14 (35.7%) patients with MGCs, and in only 3 of the 32 patients (9.3%) with SGCs. Significant differences were observed between the 2 groups (p<0.001). Hypermethylation of hMLH1 was more frequently detected in MGCs than in SGCs (p<0.01), whereas significant difference was not observed in the frequency of MGMT, p16 or E-cadherin promoter methylation between the 2 groups. In conclusion, our results indicate that inactivation of hMLH1 through promoter hypermethylation may be involved in the development of multiple gastric cancers following the MSI pathway.

A single-institution review of the absorbable clips used in laparoscopic colorectal and gallbladder surgery: feasibility, safety, and effectiveness

This retrospective study was conducted to examine the safety and effectiveness of polymeric absorbable clips in laparoscopic gallbladder and colorectal surgery. The prospectively maintained database review included all patients undergoing elective laparoscopic cholecystectomy and colorectal resection at the institution between November 2004 and December 2009. In each patient, absorbable clips were used as the only system of vascular and cystic duct ligation. Of the 911 patients who satisfied the inclusion criteria, 664 underwent laparoscopic cholecystectomy and 247 underwent laparoscopic colonic resection. No intra-operative or post-operative bleeding related to absorbable clip use occurred in either procedure. No bile duct injuries or cystic duct leakages were observed. There were no peri-operative deaths with either procedure. In this experience, absorbable clips demonstrated easy handling and high reliability. They provided safe hemostasis and permitted complete and adequate oncologic resection.

Microsatellite instability is associated with the clinicopathologic features of gastric cancer in sporadic gastric cancer patients

Purpose

Replication error is an important mechanism in carcinogenesis. The microsatellite instability (MSI-H) of colorectal cancers is associated with the development of multiple cancers. The influence of MSI-H on the development of multiple gastric cancers in sporadic gastric cancer patients has not been defined. This study was performed to reveal the association between the clinicopathologic features and MSI in sporadic gastric cancers.

Materials and Methods

Between July 2004 and March 2009, the clinicopathologic characteristics, including MSI status, were evaluated in 128 consecutive patients with sporadic gastric cancers. None of the patients had hereditary non-polyposis colorectal cancer of familial gastric cancer. The markers that were recommended by the NCI to determine the MSI status for colorectal cancers were used.

Results

MSI-H cancers were found in 10.9% of the patients (14/128). Synchronous gastric cancers were shown in 4 patients (3.1%). Synchronous cancers were found in 2 of 14 patients with MSI-H gastric cancer (14.3%) and 2 of 114 patients with MSS gastric cancer (1.8%; P=0.059, Fisher's exact test). Among the patients with synchronous cancer 50% (2/4) had MSI-H cancer, but 9.7% of the patients (12/124) without synchronous cancer had MSI-H cancer. MSI-H (RR, 24.7; 95% CI, 1.5~398.9; P=0.024) was related with to synchronous gastric cancer, but age, gender, family history, histologic type, location, gross morphology, size, and stage were not related to synchronous gastric cancer.

Conclusions

MSI is associated with the intestinal-type gastric cancer and the presence of multiple gastric cancers in patients with sporadic gastric cancer. Special attention to the presence of synchronous and the development of metachronous multiple cancer in patients with MSI-H gastric cancer is needed.

Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria

BACKGROUND

Criteria for endoscopic resection in patients with early gastric cancer (EGC) have been expanded recently by the National Cancer Centre (NCC). This study compared long-term outcomes in patients with EGC who underwent endoscopic treatment according to guideline criteria with those treated according to expanded criteria.

METHODS

Baseline and outcome data from patients undergoing curative endoscopic resection for EGC between January 1999 and December 2005 were collected from electronic medical records. Survival time hazard ratios and 95 per cent confidence intervals were calculated using the Cox proportional hazards model.

RESULTS

Of 1485 patients who had a curative resection, 635 (42.8 per cent) underwent resection according to traditional criteria and 625 (42.1 per cent) according to expanded criteria. There was no significant difference in overall survival between the groups.

CONCLUSION

Patients who have treatment following the expanded criteria have similar long-term survival and outcomes to those treated according to guideline criteria.

Subtotal gastrectomy as treatment for distal multifocal early gastric cancer

INTRODUCTION

Multifocal early gastric cancer (MEGC) is frequently observed and represents a serious risk when minimally invasive treatments are performed.

PATIENTS AND METHODS

We present the experience of two Italian centers situated in a relatively high incidence area for gastric cancer. Out of a total of 791 surgical resections for EGC carried out in two Italian centers from 1976 to 2006, we identified 98 patients with multifocal EGC (12.3%). Two hundred and sixteen lesions were observed. Generally sited near the principal tumors, secondary lesions were, however, sometimes detected distally from the upper primary lesion. No secondary lesions were detected in the upper third when the principal lesion was sited at the lower third.

RESULTS

Survival of MEGC patients was not significantly lower than that of patients with monofocal EGC. No cases of gastric remnant relapse were observed at a mean follow-up of 9 years (range 1-28) after subtotal gastrectomy.

DISCUSSION

When EGCs are detected, the possibility of MEGC must always be investigated by endoscopy and chromoendoscopy. When a MEGC is found in the lower third of the stomach and chromoendoscopy of the upper third has been performed, subtotal gastrectomy can be considered as sufficient treatment.

Clinicopathological features and surgical outcomes of patients with remnant gastric cancer after a distal gastrectomy

BACKGROUND

The incidence of gastric cancer in the remnant stomach after distal gastrectomy is increasing. The aim of this study was to evaluate the clinicopathological features and surgical outcomes of remnant gastric cancer (RGC).

METHODS

We reviewed the medical records of 58 patients who underwent laparotomy for RGC at Seoul National University Hospital between 2000 and 2005.

RESULTS

The mean interval between the first and second operations was 12.5 years, and the rate of RGC diagnosis by tests included the follow-up program was 41.4%. The 45 RGCs occurring after distal gastrectomy for initial gastric cancer had a shorter interval and were more frequently located at the non-anastomotic site than those following benign lesions (P <0.001 and P = 0.010). Of all patients, 41 (70.7%) underwent, and the overall 3-year survival rate was 62.4%. An early stage of the initial gastric cancer, no symptoms at diagnosis, curative resection, tumor size smaller than 6 cm, and an early TNM stage of the RGC were associated with longer survival; the initial gastric disease, the interval and the location of RGC were not.

CONCLUSION

The successful curative resection and an early stage of the RGC led to good outcomes. In considering the different latency periods of the two initial gastric diseases, appropriate follow-up programs should be developed.

Endoscopic Screening for Remnant Gastric Cancer: Points to be Considered

BACKGROUND/AIMS

It is difficult to detect early gastric cancer (EGC) during endoscopic surveillance because the remnant stomach is usually deformed after surgical resection and the mucosa at the gastric stump are changed due to bile reflux. In this study, we aimed to determine the characteristic endoscopic findings of cancer in the remnant stomach.

METHODS

Fifty-five remnant gastric cancer (RGC) patients were classified into three groups according to location and elapsed time after surgery. Among 32 RGCs that developed less than 10 years after surgery, 21 lesions were located close to the anastomosis site (recurrent cancers), whereas 11 lesions were not (residual cancers). Twenty-three cancers developed at least 10 years after surgery (newly developed cancers). The endoscopic features were compared among these groups.

RESULTS

Most patients (29/32, 91%) with residual or recurrent cancer developed their tumors within five years after surgery, and the proportion of EGC was 43.8% (14/32). However, 91.3% (21/23) of newly developed cancers were advanced gastric cancers. When classified according to the Japanese classification system for EGC, 71% (5/7) of the residual cancers were of the elevated type, whereas 86% (6/7) of the recurrent cancers were of the depressed type (p=0.00).

CONCLUSIONS

During the first 5 years after subtotal gastrectomy, endoscopists should mainly try to find depressed lesions on the anastomosis site as well as elevated lesions on the non-anastomosis site.

Early gastric cancer: diagnosis and less invasive treatments

The prognosis of early gastric cancer (EGC) is excellent worldwide. Incidence of EGC shows considerable geographic variation, and in high prevalence areas where diagnostic skills are adept, EGCs are not frequently overlooked. In these countries, less invasive, function-preserving treatments such as endoscopic mucosal resection and pylorus-preserving gastrectomy have become standard options. The criteria to apply conservative treatments are being expanded along with the technological improvement. Though its natural history is relatively long, EGC could be a fatal disease and should be carefully treated. Lymph node metastasis is the most important prognostic factor that should be considered in treatment selection and follow-up planning of EGC.

Clinicopathologic and immunohistochemistry characterization of synchronous multiple primary gastric adenocarcinoma

The aim of this investigation was to evaluate clinicopathologic and immunohistochemical characteristics of synchronous primary gastric adenocarcinomas. Immunohistochemistry for p53 (suppressor pathway) and for hMLH1, hMSH2, and hMSH6 (mutator pathway) was performed using ABC-technique amplification by biotinylated tyramide. Synchronous primary gastric adenocarcinomas were detected in 19/553 (3.43%) of the patients. The tumors were localized in distal stomach in 22, body in 14, and proximal in five. There was a predominance of intestinal type in the group of synchronic tumors compared to the solitary lesions, 73.2 vs 37.3%, p = 0.001. Synchronous neoplasias were diagnosed in earlier stage than solitary neoplasias, T1-T2 = 60.9% vs T1-T2 = 28.4%, p = 0.0001; and N0 = 68.4% vs N0 = 26.2%, p = 0.001. p53 was detected in 52.6% of the patients with synchronous tumors. Altered hMLH1 immunoexpression occurred in 26.3% of the patients and hMSH6 in 5.3%. hMSH2 immunoreactivity was positive in all tumors. p53 was solely detected in 17 tumors, while hMLH1 was altered in 10/24 negative p53 tumors, p = 0.01. Synchronous gastric adenocarcinomas presented higher frequency of intestinal type and early gastric cancer in comparison to solitary gastric cancer. Two routes of carcinogenesis, mutator, and suppressor appear to be involved independently in the development of synchronous tumors.

Longterm outcomes after endoscopic mucosal resection for early gastric cancer

BACKGROUND

Despite the widespread use of endoscopic mucosal resection (EMR) in patients with early gastric cancer (EGC), its longterm outcomes have not been fully evaluated. Our aim was to evaluate longterm survival after complete EMR for EGC.

METHODS

From patients who underwent EMR between 1978 and 1996 at our center, we enrolled 131 patients with differentiated mucosal EGCs less than 2 cm (without ulcerative change) that had been completely removed by EMR. The vital status of the patients at the end of December 1998 was confirmed by the hospital cancer registry, which is linked to the Osaka Cancer Registry.

RESULTS

A total of 124 patients (95%) were completely followed-up. Two patients (1.5%) died of gastric cancer and 26 died of other causes during the mean observation period of 58 months. The overall 5- and 10-year survival rates were 84% and 64%, respectively. The disease-specific 5- and 10-year survival rates were 99% and 99%.

CONCLUSION

En bloc EMR ensured an excellent prognosis, and should be the first choice of treatment in patients with small differentiated mucosal EGC. Careful histological examination and longterm endoscopic surveillance are important.

Metachronous gastric cancers after endoscopic resection: how effective is annual endoscopic surveillance?

BACKGROUND

Endoscopic resection (ER) has been widely accepted in Japan as a less invasive treatment for early gastric cancer, but the incidence of subsequent metachronous gastric cancer (MGC) and the appropriate endoscopic follow-up interval after ER have not been determined as yet. In this study, we investigated the incidence of MGC after ER and assessed our annual endoscopic surveillance program after ER.

METHODS

We studied the clinicopathological features of 633 consecutive ER patients (575 with a single lesion and 58 with synchronous multiple lesions) treated at our institution from 1987 through 2002, after excluding 158 patients who underwent additional surgery due to noncurative ERs, 180 patients whose surveillance periods were less than 1 year, 1 patient with hereditary non-polyposis colorectal cancer, and 1 patient with gastric tube cancer. We defined a second cancer found within 1 year after ER as "synchronous" and a second cancer found after 1 year as "metachronous."

RESULTS

First MGCs had an overall incidence of 8.2% (52 out of 633 patients); the annual incidence was constant, and the cumulative 3-year incidence was 5.9%. The average time to the discovery of a first MGC after the initial ER was 3.1 +/- 1.7 years (range, 1-8.6 years). Almost all first MGCs (96.2%, 50 out of 52 lesions) were treated curatively with repeat ER.

CONCLUSION

In order to detect MGC at a stage early enough for a curative repeat ER, an annual endoscopic surveillance program is both practical and effective for post-ER patients.

Mucin phenotype and microsatellite instability in early multiple gastric cancers

Clinicopathologically, multiple gastric cancers (MGCs) are reported to involve predominantly intestinal-type adenocarcinoma and frequently to be associated with severe intestinal metaplasia. However, there are few reports concerning the characteristic biomarkers of early MGCs. The aim of our study was to identify the cellular lineage defined by mucin phenotypes and the relationships among mucin phenotypes, background mucosa and microsatellite instability (MSI) of early MGCs. We examined mucin phenotypes of 63 surgically resected carcinomas from 25 patients with early MGCs and 39 early solitary gastric cancers (SGCs) by immunohistochemical analysis using a panel of monoclonal antibodies. MSI and the degree of intestinal metaplasia (IM) on the background mucosa were also examined. In early MGCs, the incidence of cancer exhibiting the gastric phenotype (G-type) was 59% (37 of 63 cancers), which was higher than that in early SGCs (23%, 9 of 39 cancers). There was a significant difference between the distributions of mucin phenotypes in early MGCs and early SGCs (p = 0.001). Whereas half of the G-type cancers in early MGCs were related to severe IM, none of the G-type cancers in early SGCs were related to severe IM. In the early MGCs, MSI was observed in 21 of 63 cancers (33.3%). In contrast, MSI was observed in only 3 of the 39 (7.7%) early SGCs, indicating a significant difference between these 2 groups (p < 0.01). Our results suggest that the characteristic features of early MGCs are the gastric mucin dominant phenotype and high frequency of MSI.

Multiple simultaneous gastric carcinomas

A total of 1664 patients with gastric cancer were examined to evaluate the rate of multiple synchronous primary tumours. In cases of multiple synchronous cancer (MSC), the tumours were analysed immunohistochemically for their expression pattern of p53, c-erbB2, ras, E-cadherin and proliferative activity. Multiple synchronous gastric carcinomas (MSCs) were observed in 61 out of 1664 patients (3.7%), with a total of 134 carcinomas. In our series, early carcinoma was observed more frequently in MSC than in solitary cancers. The comparison of tumour stage in MSC and solitary tumours revealed that multiple early gastric cancers were significantly more often of type I (protruded type) and IIa (superficial elevated type) than solitary early cancer. Multiple advanced carcinomas were more often of a lower pT category than solitary advanced gastric cancer. Performing immunohistochemistry for p53, c-erbB2 and ras in 134 tumours with MSCs, we observed positivity rates of 33%, 59% and 87% respectively. In 43 patients, the multiple tumours in each individual patient demonstrated an identical status of p53 and c-erbB2, and in 42 patients a similar pattern of E-cadherin expression was observed. The proliferative index, determined by proliferating cell nuclear antigen (PCNA) immunolabelling, did not differ significantly between the MSC in each patient. Ras immunostaining was detected in 53 out of 61 patients, but also in metaplasia and regenerative hyperplasia in the specimens. In survival analysis, no difference was observed between patients with solitary or multiple early or advanced carcinomas. Our results suggest that in at least a high proportion of patients with gastric cancer multiple primary tumours arise from precancerous conditions leading to similar genetic alterations.

Five primary synchronous neoplasms of the gastrointestinal tract

Multiple primary malignant neoplasms in a single patient have been well documented in the literature over the past hundred years. The lesions can be limited to a single organ or involve multiple organ systems. It is relatively common for patients with colorectal carcinoma or carcinoid tumors to have more than one primary neoplasm. Colonic lesions can be synchronous or metachronous in presentation and colonic or extracolonic in location. We present a patient with five primary synchronous neoplasms of the gastrointestinal tract, involving the stomach, small bowel, and colon. The patient had no evidence of metastatic disease and underwent resection of all the lesions. This case illustrates the need for a thorough search for additional neoplasms in the treatment of patients with cancer.

Gastric stump carcinoma after partial gastrectomy for benign gastric lesion: what is feasible as standard surgical treatment?

METHOD

Clinicopathological features and prognostic factors were evaluated in 26 cases of stump carcinoma, operated on in the recent 20 years, in search of the standard surgical treatment.

BACKGROUND

Stump carcinoma usually emerges more than 20 years after the initial gastrectomy and is often not diagnosed in the early clinical stage, resulting in a significantly low incidence of curative resection compared with primary gastric carcinoma.

RESULTS

No improvement in the survival curves for stump carcinoma was observed between the past two decades. Nodal metastases were frequently found within the first tier nodes, and no 5-year survivor was found among the patients with nodal metastasis beyond pN1.

CONCLUSIONS

Subtotal gastrectomy might suffice for the treatment of stomal cancer, and most patients might not benefit from extensive lymphadenectomy.