Synchronous and metachronous primary malignancies in organs other than the stomach in patients with early gastric cancer

BACKGROUND/AIMS: We investigated the outcomes of patients with early gastric cancer, with special reference to the prognosis of patients with synchronous or metachronous primary malignancies in organs other than the stomach. PATIENTS AND METHODS: Among 890 patients with early gastric cancer, 97 (10.9%) had synchronous or metachronous primary malignancies in organs other than the stomach. Ten-year survival rates were compared between patients who had additional malignancies and patients who had early gastric cancer but no other malignant disease (control group). RESULTS: Synchronous primary malignancies were detected in 32 patients and metachronous primary malignancies were detected in 65 patients (17 had developed before gastrectomy and 48 developed after gastrectomy). Hepatic cell carcinoma, lung cancer and colorectal cancer were frequently detected between 2 and 24 years after gastrectomy. The 10-year survival rate was 80.8% for 769 patients in the control group but it was only 49.7% for the 92 patients with additional malignancies. Moreover, metachronous malignant disease was found more over 10 years after gastrectomy in 30 of the 48 cases (62.5%). CONCLUSIONS: These results suggest the importance of long-term follow-up for detection of metachronous carcinomas at sites other than the stomach for patients with early gastric cancer.     

Early gastric cancer in the remnant stomach

BACKGROUND/AIMS: Early gastric cancer in the remnant stomach is rare. Periodical endoscopic examinations are mandatory for patients with partial gastrectomy for a good prognosis. Our goal is to improve the surgical management of gastric cancer in the remnant stomach. We have retrospectively investigated a total of 15 rare cases of early gastric cancer after partial gastrectomy. METHODOLOGY: From 1976 to 1994, a total of 2,102 cases of gastric cancer were resected in our Department. Among these resected cases, 845 cases were histologically diagnosed as having early gastric cancer of the stomach. Of these, 15 patients had previously undergone a partial gastric resection. The time interval between the initial partial gastrectomy and the second resection of the remnant stomach, was more than 10 years for 8 patients (Group 1) and less than 10 years for 7 patients (Group 2). Here we investigate these rare cases of remnant early gastric cancer. RESULTS: The incidence of early gastric cancer in the remnant stomach was 1.8% (15/845). The cancer location in the remnant stomach was around the stoma and suture line in 75% of Group 1 and in 28.6% of Group 2. The incidence rate of mucosal cancer (m-cancer) was 87.5% for Group 1, and 14.3% for Group 2. Total gastrectomy was selected for 37.5% of Group 1, and for 100% of Group 2. No lymph node metastasis was discovered in both groups. The postoperative mortality was zero in both groups. One patient from Group 2, later died of liver metastasis 2 years after the second total gastrectomy, while the other 9 patients continued to live for more than 5 years with no gastric cancer recurrence to date. CONCLUSIONS: The outcome for patients with gastric cancer in the remnant stomach is generally considered poor. However, the outcome of early gastric cancer in the remnant stomach was good without major postoperative complications. Therefore, to improve surgical management of remnant-stump gastric cancer, early diagnosis is most important, using periodic endoscopic follow-up examinations, especially around the stoma. When mucosal cancer around the stoma is diagnosed, subtotal gastrectomy can be selected even in gastrectomized patient for a good prognosis.     

Surgery for gastric remnant carcinoma following Billroth II gastrectomy

Between January 1983 and December 1995, 31 patients with gastric remnant carcinoma were operated on 6-45 years after a Billroth II resection for peptic ulcer disease. Total gastrectomy with Roux-en-Y reconstruction was performed in all cases. In 16 patients (52%) extended resection with removal of one or more adjacent organs was necessary for oncological reasons. In this elderly population with a high incidence of pre-operative risk factors (55%), most tumours were classified as stage III or IV (45%). Although total gastrectomy should be the surgical option of first choice for gastric remnant carcinoma, it resulted in high levels of post-operative mortality and morbidity (13% and 35%, respectively), especially in patients with stage III and IV tumours who underwent resection of an adjacent organ. Despite extended surgery, if necessary, the recurrence rate after 'curative' surgery is high (8/20 patients) and the cumulative disease-free 5-year survival rate was 48%. Detection of the tumour at an earlier stage not only limits the extent of resection and lowers the complication rate, but also improves survival.     

Multiple early gastric stump carcinomas after gastrectomy for peptic ulcer

The remnant stomach after partial gastrectomy is considered to have a predilection for the development of primary gastric carcinoma. However, early gastric stump carcinomas are uncommon because the diagnosis of gastric stump carcinoma is more difficult than that of carcinoma in the intact stomach. Triple early gastric stump carcinomas, as in the present case, are exceedingly rare and may provide some clues for further investigation of carcinogenesis in the gastric stump. We studied about the histological appearance, genetic alterations (P-53 gene, c-erbB-2 gene and K-ras gene), and expression of tumor-associated antigens (carcinoembryonic antigen, carbohydrate antigen 19-9, and sialyl-Tn) in this rare case. The three carcinomas differed from each other histologically. With respect to genetic alterations, c-erbB-2 was amplified in one lesion, but no mutations of K-ras and P-53 gene were detected. The three carcinomas also differed from each other on the expression of tumor-associated antigens. In noncancerous mucosal epithelium at the anastomosis showing hyperplasia and cystic formation of glandular epithelial cells, no genetic alterations were detected, but sialyl-Tn and carbohydrate antigen 19-9 were expressed. These results suggest that there may be different processes of carcinogenesis of the three carcinomas even though they occurred under identical environmental conditions to those that have increased cancer risk.     

Surgical treatment for advanced carcinoma of the gastric remnant

BACKGROUND/AIMS: Carcinoma of the gastric remnant has increased in recent years, but a therapeutic strategy for this disease has not been established. This retrospective study was performed to determine the most appropriate surgical procedure for carcinoma of the gastric remnant. METHODOLOGY: A total of 25 patients who underwent operation for advanced carcinoma of the gastric remnant that had developed after distal gastrectomy (13 for benign gastric diseases, B group; 12 for gastric carcinoma, M group) were studied. Clinicopathological features, as well as the status of lymph node metastasis, were investigated in the B and M groups. RESULTS: There were more patients with carcinoma invading other organs, stage IV disease, and with N2 or more lymph node metastasis (especially, with a high metastatic rate to lymph nodes along the splenic artery) in the M group than in the B group. Forty percent of patients in the M group were treated by left upper abdominal evisceration (LUAE), but only 8% in the B group. The survival rate (5-year, 46.0%) of the B group was significantly higher than that (5-year, 11.9%) of the M group. When we compared the survival rate of carcinoma of the gastric remnant with that of primary carcinoma of the upper third of the stomach, there was no difference between the two groups in the curative resection cases. CONCLUSIONS: Almost the same surgical strategy can be adopted for the B group as for primary gastric carcinoma. On the other hand, for the M group, a radical surgical procedure, LUAE, should be recommended.     

Food intake after gastrectomy for gastric carcinoma: the role of a gastric reservoir

Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.     

D2 receptor binding in dopa-responsive dystonia

OBJECTIVES: Synchronous gastric tumors (including benign and secondary tumors) associated with esophageal cancer present diagnostic and therapeutic issues. We investigated this synchronous association, and retrospectively determined the frequency of the gastric tumors and the clinical characteristics. METHODS: In a series of 208 patients with esophageal cancer, we investigated the synchronous gastric tumors, as well as the frequency of association, clinicopathological characteristics, diagnosis, treatment, and the clinical outcome after surgery. RESULTS: Twenty-eight gastric tumors were found in 24 patients. Adenocarcinoma was most frequent. Most of these tumors were located at the upper or middle third of the stomach. Eight gastric tumors in six patients could not be detected preoperatively. Six of these tumors including a gastric remnant cancer were detected in the resected stomach, and two leiomyomas were detected during the operation. In one patient in which an endoscope could not pass through the esophagus, a leiomyoma was detected in the resected stomach. For the gastric cancers, total gastrectomy or proximal gastrectomy with lymph node dissections was performed. For the benign tumors, partial resection of the stomach was performed, and endoscopic resection was performed preoperatively for an adenoma. In both the postoperative hospital mortality rate and the survival rate after surgery, there were no significant differences between the patients with and without gastric tumors. CONCLUSIONS: Synchronous gastric tumors associated with esophageal cancer are not rare. When an endoscope cannot pass through the esophagus before surgery, other techniques must be performed to explore the stomach. For these patients, surgical treatment should be adapted positively.     

3-nitroadipate, a metabolic intermediate for mineralization of 2, 4-dinitrophenol by a new strain of a Rhodococcus species

We experienced a case of small cell carcinoma of the stomach in which chemotherapy had been markedly effective. A 54-year-old man was admitted to our hospital complaining of hematemesis. Gastric endoscopy showed a type 2 tumor at the lesser curvature of the cardia of the remnant stomach. Total gastrectomy, splenectomy and D2 lymph node dissection were performed. Histopathologically, the tumor was diagnosed as a small cell carcinoma with findings of t 2 n 1 in stage II, and conclusive curability was A. A month after the operation, CT-scan revealed multiple liver and lung metastases, so the patient was treated by combined chemotherapy with cisplatin and etoposide called PVP for three courses every four weeks for small cell lung cancer, which resulted in remarkable reduction of metastases (96% in the liver and 81% in the lung). This result suggests that PVP chemotherapy is effective in the treatment of small cell carcinoma of the stomach as well as the lung.     

Curative laparoscopic surgery for early gastric cancer: five years experience

Sixty-one patients who were diagnosed with mucosal gastric cancer have been successfully treated with two laparoscopic techniques at our institute from March 1992 to March 1997. One is laparoscopic wedge resection of the stomach using a lesion-lifting method for lesions of the anterior wall, the lesser curvature, and the greater curvature of the stomach. The other is laparoscopic intragastric mucosal resection for lesions of the posterior wall of the stomach and near the cardia or the pylorus. Indications are as follows: (1) preoperatively diagnosed mucosal cancer; (2) <25 mm diameter elevated lesions; and (3) <15 mm diameter depressed lesions without ulcer formation. Patients were discharged in 4 to 8 days uneventfully. There was no major complication or mortality. The resected specimens had sufficient surgical margins horizontally (16 +/- 5 and 8 +/- 4 mm, respectively) and vertically. In one patient histologic examination revealed slight tumor infiltration into the submucosal layer with lymphatic invasion. He underwent gastrectomy with lymph node dissection 1 month after surgery. Otherwise, histologic examination revealed curative surgery. All patients in the series have survived during the 4- to 65-month follow-up period. There have been two recurrences in the series, both of which were found near the staple line 2 years after the initial surgery and were still mucosal lesions. They were successfully treated by open gastrectomy and laser irradiation. A separate early gastric cancer was found 2 years after the initial surgery in one patient, who then underwent curative open gastrectomy. In conclusion, if the patients are selected properly, these laparoscopic procedures are curative, minimally invasive treatment for early gastric cancer.     

Pathogenesis and clinics of gastric stump carcinoma (author's transl)

Statistics of postmortem examinations and retrospective long-term observations indicate a disposition of the resected stomach for the development of a primary carcinoma. The risk to develop a carcinoma after resection for peptic ulcer shows a two- to three-fold increase compared to gastric cancer mortality of the normal population. Because of the lack of typical symptoms for gastric stump cancer surgical treatment will occur late and the 5-years survival rate is only 1.38%. The cause of the increased cancer risk after gastric resection seems to be the atrophic gastritis in the gastric remnant which is found after a few years.     

Cyclic motor activity of the gallbladder maintained in a pylorus-preserving gastrectomy in dogs

The gallbladder has cyclic motor activity (CMA), which is impaired after a conventional gastrectomy. We conducted experiments to determine whether or not a pylorus-preserving gastrectomy (PPG) could maintain gallbladder CMA. Six strain gauge force transducers were implanted into the gastrointestinal tract and gallbladder of six dogs, respectively. The motor activity of the gastrointestinal tract and gallbladder was recorded as a control. PPG was then carried out. The phasic contractions of the gallbladder, which were correlated with the antral contractions in the control state, were synchronized with contractions of the pylorus after PPG. Intravenous administration of CCK-OP (40 ng/kg) induced phasic contractions of the gallbladder at 4.6 +/- 0.2 c/min in 3 of the 6 days with gastric contractions. After PPG, the gallbladder had phasic contractions (4.5 +/- 0.2 c/m), which were synchronized with the contractions of the pylorus in all dogs regardless of the contractions in the remnant stomach. These findings suggest that gallbladder CMa has a closer relationship with the CMA of the pylorus than with the remnant stomach after PPG. Thus, a preservation of the pylorus at the time of gastric surgery will help in maintaining gallbladder function and coordination with the remnant stomach.     

Studies on the relationship between gastric acidity and the development of MRSA. Especially for the prevention of MRSA enterocolitis

Enterocolitis caused by methicillin-resistant Staphylococcus aureus (MRSA) has recently been recognized as one of the severe postoperative complications in surgery on the digestive organs. This disease often occurs in the early days after gastrointestinal operation, especially after gastrectomy. MRSA enterocolitis seems to occur when MRSA has first infected the naso-pharyngeal mucosa preoperatively, and then moved into the stomach, and subsequently proliferated in the higher pH gastric juices. The aim of this experiment was to reveal the relationship between the acidity of gastric juices and bacterial growth in the stomach during the pre and post operative period in an effort to prevent of MRSA enterocolitis. In vitro, MRSA was cultured for various periods at various pH values, and its proliferation was observed. MRSA did not grow in the culture at pH 1 at all, neither did it grow at pH 2 when cultured for more than 8 hours. This data shows the germicidal effect of high acidity in the stomach. Clinically, twenty patients with cancer in the digestive tract had the bacteria in their gastric juices examined in terms of acidity before and after operation. In cases with an increased pH level in the gastric juices after the operation. S. aureus including MRSA, was isolated frequently from the stomach. In vitro, incubation of MRSA with gastric juices collected from those cases showed no development of MRSA when the pH was below 3.98. In order to prevent the onset of MRSA enterocolitis, the remnant stomachs of ten patients with stomach cancer were filled with hydrochloric acid lemonade just after operative reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Altered microsatellites in incomplete-type intestinal metaplasia adjacent to primary gastric cancers

AIM: To investigate the presence of genetic instability in precancerous lesions of the stomach. METHODS: Fifteen cases of sporadic gastric cancers with a background of intestinal metaplasia were studied by microsatellite assay at nine loci. Altered metaplastic mucosa was microdissected, reconstructed topographically, and examined immunohistochemically with an anti-p53 antibody, comparing its positive area with foci of microsatellite instability in each individual. RESULTS: Alterations at one or more loci were observed in seven of 15 cancers (46.7%) and four of 15 intestinal metaplasias (26.7%). Two cases of replication error positive phenotype had no microsatellite alterations in their metaplastic mucosa. All the microsatellite alterations in the metaplastic mucosa were restricted to incomplete-type intestinal metaplasia around the respective cancers. Moreover, in one case, an identical pattern of microsatellite alteration was detected in the cancer tissue and in the adjacent metaplastic mucosa, suggesting the sequential development of gastric cancer from intestinal metaplasia. Frequent alteration was found at the locus D1S191 (1q), indicating that this locus might be altered early in the development of intestinal-type gastric cancer. No significant association between microsatellite instability and p53 immunoreactivity was observed in the cases examined. CONCLUSION: These results indicate that microsatellite instability may be an early event in stomach carcinogenesis, especially in intestinal-type cancers.     

Transcranial Doppler ultrasound battery reliably identifies severe internal carotid artery stenosis

BACKGROUND: The clinical significance of plasma concentration of matrix metalloproteinase 9 (MMP-9) was investigated in patients with gastric cancer. METHODS: Plasma was obtained from 138 healthy individuals and 70 patients who underwent gastrectomy for gastric cancer at Aichi Cancer Centre between August 1994 and July 1995. Plasma concentrations of MMP-9 were measured using a one-step sandwich enzyme immunoassay employing monoclonal antibodies. RESULTS: Patients with gastric cancer had plasma higher concentrations of MMP-9 than normal subjects. Postoperative concentrations of MMP-9 were lower than preoperative levels. In addition to patients with advanced cancer, those with early gastric cancer also exhibited higher mean values of and positivity rates for MMP-9 than healthy individuals. Preoperative plasma MMP-9 concentration correlated closely with Union Internacional Contra la Cancrum tumour node metastasis (pTNM) stage, severity of T, N and M classification, and tumour size. CONCLUSION: Plasma MMP-9 concentration can be used for detection of primary or recurrent gastric cancer, and for estimation of tumour extent.     

直径小于2厘米胃癌预制因素分析

Objective:The aim of our study was to identify clinicopathological characteristics as predictive factors for gastric cancer tumours of less than 2 cm in diameter. Methods: The clinicopathological features of 129 patients with gastric cancer tumour of less than 2 cm in diameter were reviewed retrospectively from hospital records between 1980 and 2000. The results of retrospective analysis of clinicopathological data of 58 patients with advanced cancer were compared with those of 71 patients with early cancer. Univariate and multivariate analyses of patients with gastric cancer tumours were performed to evaluate the prognostic significance of clinicopathological features. Results: Lymph-node metastasis was found more frequently in the advanced cancer group than in the early cancer group. In univariate analysis, unfavorable prognostic factors included deep cancer invasion. Using Cox's proportional hazard regression model, only depth of invasion emerged as an independent statistically significant prognostic parameter associated with long-term survival. Conclusion: Depth of invasion is an independent prognostic factor for gastric cancer tumours of less than 2 cm in diameter. Laparoscopic surgery should not be performed on tumours that are diagnosis in advanced stage and lymph-node involvement. We recommend laparoscopic surgery involving local resection of the stomach without lymphadenectomy for small, early gastric cancer tumours. However, the validity of this recommendation should be tested by a prospective randomized control trial in the future.     

胃肝样腺癌:1例报告

Objective:We reported a case with AFP produced gastric hepatoid adenocarcinoma. Methods:A male patient,77 year-old, was admitted to our hospital due to an unreasonable elevation of serum AFP. The tumors were revealed by PETCT,but until the tumors were removed during the surgery, we did not recognize the primary lesion was the gastric cancer.Results:Radical distal gastrectomy was performed. The gastric lesion was confirmed by histology as a hepatic adenocarcinoma in its early stage. Conclusion:The rare etiology of the AFP elevation should be kept in mind in clinic, extrahepatic lesions should be excluded.     

Electromyographical study on the residual stomach following proximal gastrectomy (author's transl)

The role of the antral gastric vagi and the pyloric sphincter on the residual stomach following proximal gastrectomy were studied electromyographically, using adult mongrel dogs. At the first stage of surgery, proximal gastrectomy was performed preserving the bilateral antral gastric vagi followed by esophagogastrostomy by end-to-side anastomosis. The residual stomach was equipped with four bipolar silver needle electrodes and two waterproof strain gauges on the wall of the stomach. At the second and third stage of surgery, the same dog subsequently underwent trancal vagotomy and pyloromyotomy at 4 weeks intervals. Following proximal vagotomy, the interval of the BER in fasting was prolonged. Dysrhythmia was observed quite frequently, and the amplitude and rhythmicity of contractile activities of the residual stomach became lowered and distorted, however, after feeding the interval of the EBR was shortened and dysrhythmia was altered to a regular rhythmic pattern. Frequent episodes of vomiting were observed following over feeding. Subsequent trancal vagotomy showed increased incidence of dysrhythmia in fasting, and gave no favourable effects on the vomiting episodes or the amount of feeding. After pyloromyotomy, the amount of feeding could be increased by about 50% from the original optimal amount.     

A prospective study of gastric and oesophageal carcinoma

A prospective study of carcinoma of the stomach and oesophagus has been carried out for 2 1/2 years. Seventy-three cases of carcinoma of the stomach, and 16 cases of carcinoma of the oesophagus have been documented. For carcinoma of the stomach, operability rate was 72-6% and resectability rate was 41-9%; overall survival was poor, 20-9% at 12 months. For those who underwent resection, survival at 12 months was 45-5%. No cases of early gastric cancer are among those studied. For carcinoma of the oesophagus, four patients had a resection, and only one has survived for more than 12 months. In the clinical sphere there is a need for early endoscopic as well as radiological investigation of dyspeptic symptoms. In the research field there is a need for studies of chemotherapy in combination with surgery in the initial treatment of gastric carcinoma.     

Surgical treatment of stomach cancer: analysis of our personal experience

The "curative" treatment of gastric carcinoma includes the complete removal of the tumour and of the nodes involved without any macroscopic residual of disease (RO). Out of 326 patients with gastric cancer observed, a series of 114 consecutive patients underwent surgical resection (total gastrectomy or subtotal distal gastrectomy) with D2 or D3 lymphadenectomy. Overall operative mortality was 5.3%. Since 1988 no postoperative death occurred. Overall morbidity was 15.8%, specific morbidity 10.5%, reduced after 1988 to 6.6%. No significant differences in operative mortality and need of blood transfusions were recorded between D2 and D3 lymphadenectomy. Overall 5-year survival was 32%. Univariate and multivariate analysis showed that only T and N stages are significant prognostic factors, whereas tumour location, total or subtotal gastrectomy in antral cancers, extent of lymphadenectomy (D2 vs D3) and histology were not significantly related to survival. Since most studies have clearly shown that T and N stages are the most important prognostic factors in gastric cancer, the present aim should be to plan the extent of surgical resection according to the T and N stages characteristics of the neoplasm.     

Tissue and blood CEA levels in stomach cancer

The assays of serum CEA is a useful prognostic marker in patients with stomach cancer. In this study pre-operative serum CEA and tissue CEA in tumour or biopsy were assayed in a group of patients with gastric carcinoma in order to assess their prognostic roles. Based on an analysis of the results the authors affirm that high serum CEA levels in patients with advanced stages of stomach cancer indicate a fatal prognosis, and likewise the finding of tissue CEA in loco-regional lymph nodes at the same concentration as that in the primary tumour is also the sign of a severe prognosis.