Adenocarcinoma of the gastric cardia

Although adenocarcinoma of the stomach has decreased in incidence over the past several decades, cancer of the gastric cardia has increased rapidly over this time frame. There are several differences between adenocarcinoma of the cardia and distal stomach with respect to epidemiology, risk factors, and prognosis. In addition, recent data raise questions with regard to possible associations of cardia cancer with Barrett's esophagus, intestinal metaplasia of the cardia, and Helicobacter pylori. This article will review the current literature with regard to this important tumor and explore these potential disease associations.     

Trends in incidence rates of adenocarcinoma of the oesophagus and gastric cardia in New Zealand, 1978-1992

BACKGROUND: Increasing incidence rates for adenocarcinomas of the oesophagus and gastric cardia have been reported from the United States, Denmark, United Kingdom, Switzerland, and Sweden. This paper reports on the incidence of adenocarcinomas of the oesophagus and gastric cardia in New Zealand in the Maori (Polynesian), and non-Maori (predominantly European) populations. METHODS: Incidence data from the National Cancer Registry for 1978 through 1992 were used to compute age-adjusted rates by sex, ethnic group, anatomic subsite, morphology, 14 area health districts, and for three periods: 1978-1982, 1983-1987 and 1988-1992. Statistical tests for significance of trends and differences in frequencies were employed. RESULTS: Incidence rates for adenocarcinoma of the oesophagus are increasing in non-Maori men and women, but at a lesser rate than that reported for the US. The rate of 2.3 per 100000 population (1988-1992) for non-Maori men is similar to the rate for US white men of 2.5 (1988-1990). Rates for adenocarcinoma of the gastric cardia in non-Maori men declined from 2.5 in 1983-1987 to 1.9 in 1988-1992, and were stable at 0.4 in non-Maori women. However, rates for cases with unspecified anatomic subsite fluctuated over the 15-year period and probably caused a deflation in rates in the most recent 5-year period. CONCLUSIONS: The incidence patterns of adenocarcinomas of the oesophagus and gastric cardia in New Zealand should be monitored over the next decade for confirmation of the trends observed here. There is need to review the quality of the data in the New Zealand registry.     

Mortality due to prostatic carcinoma in northern Sweden

In a retrospective study 6890 patients with prostate cancer from the North Swedish Cancer Register were analyzed according to cancer specific survival. Prostate cancer mortality was 40% in patients with well differentiated cancers, 54% in patients with moderate differentiated prostate cancer and 72% in men with low differentiated prostate cancer. Prostate cancer mortality was 80% in men younger than 60 years, 63% in men 60-69 years old, 53% in men 70-79 years old and 49% in men older than 80 years.     

Oesophagogastrectomy for carcinoma of the oesophagus and cardia

A retrospective review was undertaken of all oesophagectomies performed within a single unit over a 12-year period. In all, 298 patients with primary oesophageal cancer underwent resection between March 1979 and December 1991. Four patients had a three-stage oesophagogastrectomy, 27 a thoracoabdominal oesophagogastrectomy and 267 a Lewis procedure. Dysphagia was the predominant presenting symptom. The duration of symptoms was not related to the stage of disease. Before diagnosis, 52 per cent of patients tolerated symptoms for 2-4 months. Adenocarcinoma was found in 180 tumours and squamous cell carcinoma in 103. Half of the patients had evidence of metastatic spread at the time of laparotomy or thoracotomy. The 30-day mortality rate was 10 per cent and the overall actuarial 5-year survival rate of all patients 23 per cent. The actuarial 5-year survival rate of patients without lymph node involvement was 39 per cent compared with 17 per cent for those with positive nodes (P < 0.05). Five of eight patients who had anastomotic leakage died. The almost unselected nature of this series, coupled with the favourable results of oesophagectomy, support the contention that resection remains the preferred mode of treatment for carcinoma of the oesophagus of all histological types.     

Prevalence and pattern of Helicobacter pylori gastritis in the gastric cardia

OBJECTIVES: Helicobacter pylori has a predilection for antral colonization. Local acid production is the major determinant of colonization. Because production is low in the antrum and cardia, H. pylori should also colonize the cardia. We therefore investigated the histologic pattern of gastritis and the prevalence of H. pylori in the cardia compared with the antrum and corpus. METHODS: From 135 H. pylori-infected patients with gastritis, ulcer disease, or reflux esophagitis, biopsies were obtained from the antrum, corpus, and cardia. The prevalence, topography, and histologic parameters of gastritis were examined. RESULTS: All 135 patients had active antral H. pylori gastritis: in the cardia, 132 of these patients (97.7%) showed active gastritis, and 124 patients (91.9%) had H. pylori visible on staining. Gastritis of the cardia in most patients resembled antral gastritis, but the density of bacteria and the inflammatory responses were less marked. The most striking finding in the cardia of patients with gastroesophageal reflux was a lower density of bacteria compared with antrum and corpus. Intestinal metaplasia was found in 32 patients in antral mucosa (23.7%) versus 28 patients in the cardia (20.7%), versus 11 patients in the corpus (8.1%), and was multifocal in 17 patients (12.6%). CONCLUSIONS: H. pylori gastritis commonly involves the cardia. The histologic density of the bacteria and inflammatory responses are lower than in the antrum. Intestinal metaplasia in the cardia is a common finding in H. pylori gastritis. The cause of the lower bacterial density in the cardia of patients with reflux esophagitis needs further investigation.     

Esophageal intramural metastasis from an adenocarcinoma of the gastric cardia: report of a case

We report herein the rare case of a 65-year-old man found to have esophageal intramural metastasis from cancer of the gastric cardia. Endoscopic examination initially revealed an infiltrating ulcerative tumor of the gastric cardia involving the esophagogastric junction, as well as a submucosal tumor of the lower esophagus. A total thoracic esophagogastrectomy with lower mediastinal lymphadenectomy was performed, and the resected specimen demonstrated that both the cardia and esophageal tumors were adenocarcinomas with the same cellular differentiation. As lymphatic invasion and metastases to the paracardial and mediastinal lymph nodes were observed, the esophageal submucosal tumor was considered to be an intramural metastasis from the carcinoma of the gastric cardia resulting from extensive lymphatic spread. The patient died of recurrent disease 9 months after the resection. This case report serves to demonstrate that intramural metastasis may be a local indicator of the systemic spread of disease in patients with gastric carcinoma, as it is in esophageal carcinoma.     

Increasing incidence of Achilles tendon rupture

During the period 1987-91, 153 cases of total Achilles tendon rupture were diagnosed in the city of Malmo (population 230,000). Almost two thirds were caused by sporting activities, notably badminton. Ruptures caused by nonsports injuries were found in older subjects. Compared to the age-specific incidence in 1950-73, a marked increase in both sports and nonsports injuries was found and patients in the latter group were older than in the former period. Patients with Achilles tendon ruptures can be classified into two subgroups with partly different etiologies: young or middle-aged athletes and older non-athletic persons. The increase in the former group is mostly explained by increased participation in recreational sports; the cause of increase in the latter group is unknown.     

Estimates of the worldwide incidence of eighteen major cancers in 1985

The annual incidence rates (crude and age-standardized) and numbers of new cases of 18 different cancers have been estimated for the year 1985 in 24 areas of the world. The total number of new cancer cases (excluding non-melanoma skin cancer) was 7.6 million, 52% of which occur in developing countries. The most common cancer in the world today is lung cancer, accounting for 17.6% of cancers of men worldwide, and 22% of cancers in men in the developed countries. Stomach cancer is now second in frequency (it was slightly more common than lung cancer in 1980) and breast cancer--by far the most important cancer of women (19.1% of the total)--is third. There are very large differences in the relative importance of the different cancers by world area. The major cancers of developed countries (other than the 3 already named) are cancers of the colon-rectum and prostate, and, in developing countries, cancers of the cervix uteri, mouth and pharynx, liver and oesophagus. The implications of these patterns for cancer control, and specifically prevention, are discussed. Tobacco smoking and chewing are almost certainly the major preventable causes of cancer today.     

Strategies to decrease the incidence of intra-abdominal recurrence in resectable gastric cancer

Two main approaches are suggested to improve treatment results in resectable gastric cancer: extended lymphadenectomy and adjuvant antitumour therapy. Progress is to some extent stalled by the perception of gastric cancer as a pathophysiologically uniform disease; it has been demonstrated, however, that there are variants of gastric cancer associated with predominantly intra-abdominal spread or with haematogenous metastases. Recent clinicopathological studies have provided information about the mechanisms of this metastatic diversity. A review of clinical trials suggests that no single method of treatment can efficiently address all variants of gastric cancer spread, but new treatment strategies may be based on defining the pathophysiological variant of gastric cancer and selecting adjuvant therapy according to the most probable mode of tumour spread. Treatment should start with surgery which includes a 'reasonably' extended lymphadenectomy aimed at achieving an increased rate of curative resection and more accurate staging. Risk factors for peritoneal spread of tumour require the perioperative use of intraperitoneal chemotherapy. Subsequent adjuvant therapy may be indicated in patients at high risk of further cancer spread or occult metastases, as determined by pathological examination of the resected specimen.     

Self-expanding stents for the palliation of esophageal and gastric cardia cancer

Twenty-one endoscopic tube implantations were carried out in 24 patients with malignant stenosis of esophagus and gastric cardia using self-expanding metallic stents. The indications to endoscopic intubation were advanced stage of the tumor in 17 cases and risk factors which made resection inadvisable in 7 cases. In 3 patients it proved impossible to implant a stent endoscopically because the Authors were not able to pass the guide wire through the stenosis, while correct stent placement was achieved in 21 patients. Functional results were good in 18 patients, while 3 patients did not have any improvement of symptoms. Complications occurred in 9 patients (42.85%): 2 bleedings, 3 neoplastic obstructions, 1 food obstruction and 3 distal dislodgements of the prostheses were observed, but could readily be corrected. No death occurred. The median survival time was 151 days (range 25-545). This study suggests that endoscopic placement of metallic self-expanding stents is safe and has to be preferred to plastic stents for easier implantation and lower morbidity.     

Increasing number and incidence of fall-induced severe head injuries in older adults: nationwide statistics in Finland in 1970-1995 and prediction for the future

RATIONALE AND OBJECTIVES: Tumor volume is an important parameter for clinical decision making. At present, semiautomatic image segmentation is not a standard for tumor volumetry. The aim of this work was to investigate the usability of semiautomatic algorithms for tumor volume determination. METHODS: Semiautomatic region- and volume-growing, isocontour, snakes, hierarchical, and histogram-based segmentation algorithms were tested for accuracy, contour variability, and time performance. The test were performed on a newly developed organic phantom for the simulation of a human liver and liver metastases. The real tumor volumes were measured by water displacement. These measured volumes were used as the gold standard for determining the accuracy of the algorithms. RESULTS: Variability of the segmented volumes ranging from 3.9 +/- 3.2% (isocontour algorithm) to 11.5 +/- 13.9% (hierarchical segmentation) was observed. The segmentation time per slice varied between 32 (volume-growing) and 72 seconds (snakes) on an IBM/RS6000 workstation. CONCLUSIONS: Only the region-growing and isocontour algorithms have the potential to be used for tumor volumetry. However, further improvements of these algorithms are necessary before they can be placed into clinical use.     

Increasing incidence of childhood class V lupus nephritis

1. Homozygously mdr1a gene disrupted mice (mdr1a(-/-) mice) and wild type mice (mdr1a(+/+) mice) were used to develop a method for P-glycoprotein (P-gp) function imaging non-invasively and to study the effect of a P-gp reversal agent on its function in vivo. 2. [11C]verapamil (0.1 mg/kg) was administered and the changes in tissue concentrations were determined ex vivo by organ extirpation and in vivo with PET. To block P-gp function, cyclosporin A was administered. 3. Biodistribution studies revealed 9.5-fold (P < 0.001) and 3.4-fold (P < 0.001) higher [11C]verapamil in the brain and testes of mdr1a(-/-) mice than in mdr1a(+/+) mice. Cyclosporin A (25 mg/kg) increased [11C]verapamil levels in the brain and testes of mdr1a(+/+) mice in both cases 3.3-fold (P < 0.01 (brain); P < 0.001 (testes)). Fifty mg/kg cyclosporin A increased [11C]verapamil in the brain 10.6-fold (P < 0.01) and in the testes 4.1-fold (P < 0.001). No increases were found in the mdr1a(-/-) mice. This indicates complete inhibition of P-gp mediated [11C]verapamil efflux. 4. Positron camera data showed lower [11C]verapamil levels in the brain of mdr1a(+/+) mice compared to those in mdr1a(-/-) mice. [11C]verapamil accumulation in the brain of mdr1a(+/+) mice was increased by cyclosporin A to levels comparable with those in mdr1a(-/-) mice, indicating that reversal of P-gp mediated efflux can be monitored by PET. 5. We conclude that cyclosporin A can fully block the P-gp function in the blood brain barrier and the testes and that PET enables the in vivo measurement of P-gp function and reversal of its function non-invasively.     

The incidence of solitary pulmonary metastasis from carcinoma of the large intestine

Two hundred and two consecutive patients who underwent resection of an adenocarcinoma of the colon or rectum from January 1958 to December 1972 were evaluated for the development of a metastatic tumor in the lungs. In the 185 patients who survived the 30 day postoperative period, 30 malignant pulmonary lesions were subsequently recognized. Six of these were a solitary lesion and 24 were multiple lesions. Three of these malignant lesions were proved to be other than metastatic disease. Metastatic adenocarcinoma from the colon or rectum was proved to be present in 27 patients, an incidence of 14.5 per cent. Only four of these lesions were solitary, 14.8 per cent of the metastatic pulmonary lesions. The solitary metastatic tumors represented an incidence of 2.1 per cent in this patient population, but long term tumor-free survival was possible with appropriate pulmonary resection of the metastatic disease. It is suggested that periodic roentgenographic examination of the chest, every four to six months, be an integral part of the postoperative follow-up study carried out on these patients.     

nm23 in the primary and metastatic sites of gastric carcinoma. Relation to AFP-producing carcinoma

Tumor metastasis is the major cause of treatment failure and death in cancer patients. The present study was designed to extrapolate the association of nm23 expression with acquisition of metastatic potential of gastric carcinoma with special reference to the alpha-fetoprotein-producing gastric carcinoma (APGC). The primary tumor with surrounding normal mucosa and metastatic lymph nodes of 30 patients with APGC and 29 randomly selected matched controls of non-AFP gastric carcinoma (NAGC) were immunostained for nm23 and an image analyzer system was used for quantitative evaluation. Overexpression of nm23 was noted in 71% (42/59) of the primary tumors and 18% (10/55) of the metastatic tumors and there was no difference between the APGC and NAGC groups. The overexpression of nm23 in the primary tumors correlated with tumor invasion, metastasis and progression in all cases and similar results were obtained in the APGC and NAGC groups except for the tumor stage which was insignificant in the APGC group. The patient survival was adversely affected by the overexpression of nm23 in the primary sites and downregulation in the metastatic sites in all cases but lost their significance in the multivariate analysis. However, nm23 status did not affect patient survival in the APGC group.     

Improvements in staging of gastric carcinoma from using the new edition of TNM classification

AIMS: To recognize possible advantages of the 5th edition of TNM of gastric carcinoma in comparison to the former edition. METHODS: Data from Erlangen Cancer Center for 898 patients with gastric carcinoma treated surgically by total or subtotal gastrectomy with en bloc lymphadenectomy were analysed. RESULTS: The prognostic significance of TNM has been improved by the new edition as demonstrated by the likelihood ratio test. In addition, uncertainties of method in the pathological classification of regional lymph-node metastasis inherent in the 4th edition can now be avoided. CONCLUSION: The changes in the TNM classification introduced by the 5th edition are justified by data from the Erlangen Cancer Center, have methodic advantages in determining the N classification, and lead to an improvement in estimation of outcome.