Analysis of 242 cases of gastric carcinoma

New elements for an updated classification of the carcinomas of the stomach

Based upon the results of a thorough study of 213 patients submitted to potentially curative resection we propose the following histologic classification of gastric carcinoma: isolated-cell carcinoma (6.6%), glandular carcinoma (41.8%), solid carcinoma (13.1%) and mixed carcinoma (38.5%). Half of the mixed carcinomas displayed a predominant isolated-cell pattern, whereas in the other half the isolated-cells were a minor component (the predominant component being either glandular, solid, or both). The survival of patients with mixed carcinomas is significantly worse than those of patients with other histologic types of gastric carcinoma regardless of the site of tumors and the inclusion, or not, in the series, of post-operative deaths. The proposed classification keeps its independent prognostic significance in a multifactorial analysis, appearing as the second most important prognostic factor in patients with gastric carcinomas, after the TNM staging and before venous invasion.

Infiltration of dendritic cells into regional lymph nodes in gastric cancer

BACKGROUND

Dendritic cells (DC), including epidermal Langerhans cells, are potent antigen-presenting cells that can carry and present tumor antigens to helper T-cells. An immunohistochemical study was performed to clarify the relationship between the extent of infiltration by DCs in primary gastric cancer and that in the regional lymph nodes.

METHODS

Paraffin blocks were prepared for staining with antibody against S-100 protein in 121 cases of gastric cancer. Infiltration of S-100 protein-positive DCs was evaluated in the primary tumor and in the peritumoral, primary, secondary, and tertiary nodes.

RESULTS

The extent of infiltration by DCs into the regional lymph nodes decreased significantly with an increasing distance of the nodes from the primary tumor. Correlation of the extent of such infiltration was observed among the peritumoral, primary, secondary, and tertiary nodes. However, the extent of infiltration into the primary tumor did not correlate with that into the primary, secondary, and tertiary nodes. Infiltration by DCs of the peritumoral nodes correlated with that of the tumor, particularly when lymph node metastasis was absent. There was no significant difference in the extent of infiltration into the peritumoral nodes even when lymph nodes were involved. However, infiltration of DCs increased in the primary and secondary nodes when the primary nodes were involved.

CONCLUSION

Infiltration of DCs may be regulated in the primary lesion of gastric cancer. The peritumoral lymph nodes serve as transmitters of DCs from the primary tumor to the regional lymph nodes. DCs in the regional lymph nodes are important for establishing immunologic defense mechanisms in cases of gastric cancer when metastasis is absent or limited to the primary nodes.

Early gastric cancer: an analysis of 44 cases with emphasis on the prognostic significance of the macroscopic and microscopic growth patterns

Forty-four consecutive cases of "early gastric cancer" were studied according to the macroscopic classification proposed by the Japanese Gastroenterological and Endoscopy Society and further analyzed in terms of growth patterns. The tumours were then classified into the small mucosal type, the superficially spreading (Super) type and the penetrating growth (Pen) type. The Lauren type (intestinal vs. diffuse), presence of lymphatic and venous invasion, and lymph node metastasis were also assessed. Most elevated tumours showed a superficial growth pattern and were classified as Lauren's intestinal type, whereas depressed lesions were associated with submucosal invasion and were classified as diffuse. Microscopic patterns did not show any correlation with Lauren's classification. Mean duration of follow-up was 67.8 months and the overall actuarial survival was 93%, 80%, and 72%, at 2, 5, and 10 years, respectively. Aside from venous invasion no correlation was found between survival and any of the morphological parameters analysed.

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

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

Infiltration of dendritic cells in relation to tumor invasion and lymph node metastasis in human gastric cancer

The infiltration of dendritic cells determined in 210 patients with gastric carcinoma was investigated from the standpoint of tumor invasion, lymph node metastasis, and prognosis. Dendritic cell infiltration was graded as "slight" and "marked." The 39% frequency in the marked infiltration group at the mucosal stage did not change in proportion to invasion into the deeper layers. The 5-year survival rate was 60.4% in patients with marked infiltration and 38.8% in those with slight infiltration, which was statistically different (P less than 0.01). The difference in survival rates was only statistically significant in those with cancer emerging from the serosa (P less than 0.001). There was a similar incidence of lymph node metastasis between the marked and slight infiltration groups in each grade of tumor invasion. However, marked infiltration of dendritic cells prevented widespread nodal involvement beyond the primary node in cases of advanced carcinoma (P less than 0.05). These findings indicate that infiltrating dendritic cells do not prevent the spread of tumor invasion but do prevent nodal involvement; therefore, for patients with a gastric cancer emerging from the serosa, the prognosis will be good.

Gastric adenocarcinoma: prognostic significance of several pathologic parameters and histologic classifications

Considerable controversy exists about the value of histologic classifications of gastric adenocarcinoma in the prediction of patient survival. Histologic sections of 75 consecutive gastrectomies were used to compare Lauren and Ming classifications with emphasis on clinical stage, size, location of tumor, desmoplasia, inflammatory reaction, and 5-year survival. Both classifications generally correlated and, when combined, proved helpful in defining certain cases. At surgery, about one third of the total cases of intestinal (INT, Lauren) and expanding (ET, Ming) were in early stages, whereas almost all the diffuse (DT, Lauren) and infiltrative (INF, Ming) types were in late stages. When the Lauren classification was applied to preoperative endoscopic biopsies, a 72% diagnostic correlation with the surgical specimens was found. Followup revealed no survivors of the DT and INF and 12 and 11 survivors of INT and ET, respectively, regardless of stage. Inflammatory response was associated with good prognosis. Desmoplasia and size had no prognostic significance. Tumors of the cardia had worse prognoses than those in the body or antrum. Both Lauren and Ming classifications, and especially the degree of inflammation, were significant in predicting survival. Lauren INT and Ming ET should be declared only when they are the sole or predominant features.

Surgical treatment of gastric carcinoma

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

DNA ploidy is closely linked to tumor invasion, lymph node metastasis, and prognosis in clinical gastric cancer

DNA ploidy microspectrophotometrically determined in 254 patients with gastric carcinoma was investigated from the standpoint of tumor invasion, lymph node metastasis, and prognosis. DNA distribution patterns were grouped into low and high ploidies. The 24.0% frequency in the high ploidy group, at the mucosal stage, increased in proportion to invasion into the deeper layers. There was a high incidence of lymph node metastasis in the high ploidy group, compared with the low ploidy group, in case of invasion beyond the mucosa. Widespread nodal involvement was frequent in the high ploidy group. The 5-year survival rate was 73.7% in patients of high ploidy, with a statistical difference compared to the 90.6% in those of low ploidy (P less than 0.01). In the multivariate analysis of 226 patients undergoing curative surgery, the DNA ploidy proved to be a major independent prognostic factor. These findings indicate a close correlation among DNA ploidy, tumor invasion and nodal involvement, and the significant clinical value of DNA analysis for predicting the prognosis in patients with gastric carcinoma.