Macroscopic Serosal Invasion in Advanced Gastric Cancer

PURPOSE: The macroscopic findings of tumors are not always identical with the microscopic findings. This study investigated the oncologic implications of macroscopic serosal invasion in advanced gastric cancer to find out how to improve the accuracy for the depth of invasion assessed by the surgeon during an operation. MATERIALS AND METHODS: The medical records of 789 patients with advanced gastric cancer who underwent a gastrectomy at Kyungpook National University Hospital between 1995 and 1999 were reviewed. The prognoses and the recurrence patterns were analyzed according to macroscopic serosal invasion and microscopic serosal invasion, and the clinico-pathological factors of cT3/ss cancers were compared with those of cT3/se cancers. RESULTS: Difference of survival rates according to macroscopic serosal invasion and microscopic serosal invasion revealed statistically significant. Recurrence rates were similar in patients with macroscopic and microscopic serosal invasion (42.2% and 41.4%, respectively). Peritoneal recurrence rates were also similar (19.8% and 21.9%, respectively). The sensitivity and the specificity of macroscopic assessment of serosal invasion were 70.3% and 77.8%, respectively. On univariate and multivariate analyses, Borrmann type I/II cancers and the absence of distant metastases revealed the risk factors for overestimating of serosal invasion. CONCLUSION: Macroscopic serosal invasion assessed by a surgeon intraoperatively can be used to give a prognosis and to predict the recurrence pattern precisely, although there is a risk for overestimation when the tumor is a Borrmann type I/II cancer or the tumor has no distant metastases.

Indications for Surgical Resection of Stage IV Gastric Cancer

PURPOSE: In general, surgical resection has been accepted as the primary treatment for resectable stage IV gastric cancer as the survival can be improved over that of non-resectional therapy, although the main prognostic factors are invasion to adjacent organs, involvement of distant lymph nodes, hepatic metastasis and peritoneal dissemination. However, there is a lack of proper criteria or surgical resection in these patients, so it is unclear which patients will benefit from a resection. METHODS: Overall, 498 patients underwent surgery, 314 had a gastrectomy, extended lymph node dissection, with or without co-resection or early postoperative intraperitoneal chemotherapy (resection group), and 184 had non-resectional surgery (non-resection group). The mean survival durations were compared with the Student's t-test. In 310 patients with a single factor, the cumulative survival rates were calculated by the Kaplan-Meier method and compared using the log-rank test. The efficacy of early postoperative intraperitoneal chemotherapy (EPIC) was also evaluated. RESULTS: In patients with one and two factors, the mean survival durations of the resection group were significantly longer than those of the non-resection group (21.4+/-23.3 months vs. 5.9+/-4.8 months; P<0.001, 13.8+/-17.5 months vs. 6.5+/-6.6 months; P=0.003, respectively). The mean survival durations with T factor were 17.4+/-18.2 and 6.3+/-4.7 months in the resection and non-resection groups, respectively (P=0.007). The mean survival durations with N factor, P factor and N&P factors were also significantly longer in resection than the non-resection group (19.2+/-21.1 months vs. 4.6+/-3.1 months; P<0.001, 26.4+/-27.4 months vs. 6.1+/-5.3 months; P<0.001, and 20.0+/-27.1 months vs. 5.7+/-5.1 months; P=0.024, respectively). The five-year survival rates of the patients with single factor were 10.9 and 0% in the resection and non-resection groups, respectively (P<0.001). The five-year survival rates of the patients with P factor were 28.9% and 9.7% in the resection and EPIC and resection only groups, respectively (P=0.0254). CONCLUSION: A survival benefit can be obtained by a surgical resection in patients with a single factor involvement, with the exception of hepatic metastasis, and with two factors involvement composed of distant lymph nodes involvement and peritoneal dissemination.

Prognostic Value of Early Postoperative Intraperitoneal Chemotherapy for Gastric Cancer with Serosal Invasion

PURPOSE: There is no established treatment-related prognostic factor for gastric cancer except a curative tumor resection. This study was done to clarify the prognostic value of early postoperative intraperitoneal chemotherapy (EPIC) in patients with serosa-positive gastric cancer. MATERIALS AND METHODS: We analyzed retrospectively the postoperative survival data of 209 patients with serosa- positive gastric cancer treated by surgery and chemotherapy. The survival period for patients was calculated from the date of resection until cancer-related death or the last date of follow-up; Kaplan-Meier survival curves were plotted and compared by using the log-rank test. A multivariate analysis was done by using the Cox proportional hazards model. RESULTS: Statistically significant differences in survival rates were noted based on gender, depth of invasion, lymph node metastasis, distant metastasis, stage, location of tumor, macroscopic type, extent of gastric resection, curability of surgery, and adjuvant chemotherapy. Five-year survival rates of patients who received EPIC and systemic chemotherapy were 49 per cent and 25 per cent, respectively (P=0.009). A multivariate analysis revealed that invasion of an adjacent organ, lymph node metastasis, total gastrectomy, and palliative surgery were poor independent prognostic factors. Also, EPIC had a marginal prognostic value (P=0.056). CONCLUSION: Perioperative intraperitoneal chemotherapy can possibly be one of the independent prognostic indicators in case of serosa-positive gastric cancer.

p53 Gene Mutation, Tumor p53 Protein Overexpression, and Serum Anti-p53 Antibody in Patients with Gastric Cancer

PURPOSE: The clinical implication of p53 mutation in gastric cancer is still unclear, as shown by the discordant results that continue to be reported in the literature. MATENRIALS AND METHODS: To assess p53 gene mutation, tumor p53 overexpression, and serum anti-p53 antibody, we employed a polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) analysis, an immunohistochemistry using monoclonal antibody DO-7, and an enzyme-linked immunosorbent assay (ELISA), respectively. RESULTS: Of 169 surgical specimens of gastric cancer, mutation at exon 5~8 of the p53 was identified in 33 (19.5%) and was significantly correlated with lymph node metastasis. Overexpression of p53 was found in 62 specimens (36.7%) and had a significant correlation with tumor differentiation. Serum anti-p53 antibody was positive in 18 patients (10.7%). Twenty-three of the mutated tumors (69.7%) and 39 of the non-mutated tumors (28.7%) displayed immunoreactivity. Twelve of the immunopositive tumors (19.4%) and 6 of the immunonegative tumors produced anti-p53 antibody. These differences were statistically significant (P<0.001 and P=0.005, respectively). There was no significant difference in survival according to the mutation of p53. CONCLUSION: Mutation and overexpression of p53 can be easily detected by immunohistochemistry. However, standardization of the immunohistochemical staining method, as well as guidelines for interpreting the stained result, will produce concordant results and thereby improve clinical application.

Prognostic Value of Preoperative Serum Alpha- Fetoprotein Level in Resectable Gastric Cancer

PURPOSE: Alpha-fetoprotein (AFP) is widely accepted as a useful tumor marker for diagnosis of hepatocellular carcinomas. On rare occasions, however, an abnormal elevation of serum AFP also has been reported in an adenocarcinoma of the gastrointestinal tract. We evaluated the influence of preoperative abnormal elevation of serum AFP (AFP positivity) on the prognosis of resectable gastric cancers. MATENRIALS AND METHODS: 812 gastric cancer patients, who were investigated for serum AFP before their operations and who underwent gastric resections with D2 or more extended lymph node dissection, were enrolled in the study. The survival rates were calculated by using the Kaplan-Meier method and were compared by using the log-rank test. A multivariate analysis was performed using the Cox proportional hazards model. RESULTS: Fifty patients (6.2%) were AFP positive (10.1~4322.6 ng/ml). The survival rate of the AFP positive group was significantly lower than that of the AFP negative group ( 46.6% vs. 67.0%; P=0.0002). The depth of tumor invasion, the degree of regional lymph node metastasis, distant metastases, the TNM stage, the gross type, differentiation, the extent of gastric resection, and the curability of the surgery also significantly influenced survival. Multivariate analysis revealed that the depth of tumor invasion, the degree of regional lymph node metastasis, the curability of the surgery, and AFP positivity were independent prognostic indicators. CONCLUSION: Preoperative serum AFP can be used as an independent prognostic factor of resectable gastric cancer.