Risk of lymph node metastasis in early gastric cancer and indications for endoscopic resection: is it worth applying the east rules to the west?

BACKGROUND: Early gastric cancers are associated with lymph node metastasis (LNM) in 15% of cases. Risk factors for LNM are well established in Eastern countries. Less invasive treatments, such as endoscopic or surgical laparoscopic resection, are well accepted in Eastern countries and a matter of intense debate in the West, were indications for such treatments are still contested The objective of the study is to determine risk factors related to LNM and to validate endoscopic resection indications. METHODS: The study was a retrospective cohort of 178 patients with early gastric cancer who underwent gastrectomy. Clinical and pathological factors were analyzed. The new rules of ER from JGCA were applied to the studied cohort. RESULTS: LNM was present in 13.48% of the cases, 3.96% (3/76) in T1a tumors and 20.58% (21/102) in T1b tumors. In univariate analysis ulceration (p = 0.04), differentiation grade (p = 0.04), submucosal invasion (p = 0.001), lymphatic invasion (p < 0.001), and vascular invasion (p < 0.001) were associated with LNM. In multivariate analysis, differentiation grade (p = 0.005) and submucosal invasion (p = 0.005) were independent risk factors. One patient classified in the expanded criteria group and seven from the relative criteria group had LNM. There were no LNM for undifferentiated mucosal lesions without ulceration. CONCLUSIONS: Undifferentiated tumors and submucosal invasion are risks factors associated with LNM in early gastric cancer in our study. Endoscopic Resection or less invasive and radical surgical treatments are an option to be carefully considered.

Prognostic role of positive peritoneal cytology in patients with resectable gastric cancer.

OBJECTIVE: To evaluate the prognostic value of positive peritoneal lavage in patients with gastric cancer without signs of peritoneal or hematogenous spread. METHODS: We evaluated patients with gastric adenocarcinoma treated with curative intent operation. The peritoneal lavage was classified as positive or negative for neoplastic cells. We obtained demographics, performance status, histology and type of surgery. The results were statistically compared and were considered significant for values of p <0.05. RESULTS: We included 72 patients with gastric adenocarcinoma. During a mean follow up of 26 months (one to 39 months) we observed 20 local or distant recurrences and 21 deaths. Only the presence of lymph node metastases and the need for resection of adjacent organs were associated with a significant reduction in relapse-free survival. There was a significant reduction in overall survival in patients with angio-lymphatic invasion, lymph node metastasis, requiring resection of multiple organs, need for total gastrectomy and greater invasion of the gastric wall. The presence of tumor cells in the peritoneal cavity was associated with worse overall survival, but without statistical significance. CONCLUSION: There was no statistically significant associations between positive peritoneal citology and recurrence-free survival or overall survival among patients with resectable gastric cancer.

Valor prognóstico da citologia positiva no lavado peritoneal de pacientes com câncer gástrico ressecável / Prognostic role of positive peritoneal cytology in patients with resectable gastric cancer

OBJETIVO: Avaliar o valor prognóstico do lavado peritoneal positivo em pacientes com câncer gástrico sem sinais de disseminação peritoneal ou hematogênica. MÉTODOS: Foram avaliados os pacientes com adenocarcinoma gástrico tratados com operação de intenção curativa. O lavado peritoneal foi classificado como positivo ou negativo para células neoplásicas. Foram obtidos dados demográficos, performance status, histológicos e tipo de operação realizada. Os resultados foram estatisticamente comparados e considerados significantes para valores de p<0,05. RESULTADOS: Foram incluídos 72 portadores de adenocarcinoma gástrico. Durante seguimento médio de 26 meses (um a 39 meses) foram observadas 20 recidivas locais ou à distância e 21 mortes. Apenas a presença de metástases linfonodais e a necessidade de ressecção de órgãos adjacentes foram associados à redução significativa da sobrevida livre de recidiva. Houve redução significativa da sobrevida global entre os pacientes com invasão angiolinfática, metástase linfonodal, com necessidade de ressecção de múltiplos órgãos, necessidade de gastrectomia total e maior invasão da parede gástrica. A presença de células tumorais na cavidade peritoneal foi associada a pior sobrevida global, porém sem significância estatística. CONCLUSÃO: Não foi demonstrada associação significativa entre o lavado peritoneal positivo e a sobrevida livre de recidiva ou de sobrevida global entre pacientes com câncer gástrico ressecável.

OBJECTIVE: To evaluate the prognostic value of positive peritoneal lavage in patients with gastric cancer without signs of peritoneal or hematogenous spread. METHODS: We evaluated patients with gastric adenocarcinoma treated with curative intent operation. The peritoneal lavage was classified as positive or negative for neoplastic cells. We obtained demographics, performance status, histology and type of surgery. The results were statistically compared and were considered significant for values of p <0.05. RESULTS: We included 72 patients with gastric adenocarcinoma. During a mean follow up of 26 months (one to 39 months) we observed 20 local or distant recurrences and 21 deaths. Only the presence of lymph node metastases and the need for resection of adjacent organs were associated with a significant reduction in relapse-free survival. There was a significant reduction in overall survival in patients with angio-lymphatic invasion, lymph node metastasis, requiring resection of multiple organs, need for total gastrectomy and greater invasion of the gastric wall. The presence of tumor cells in the peritoneal cavity was associated with worse overall survival, but without statistical significance. CONCLUSION: There was no statistically significant associations between positive peritoneal citology and recurrence-free survival or overall survival among patients with resectable gastric cancer.

Frequência e fatores preditivos relacionados a metástase linfática em câncer gástrico precoce / Frequency and predictive factors related to lymphatic metastasis in early gastric cancer

RACIONAL: O tratamento padrão do câncer gástrico ainda apresenta alta morbidade e mortalidade em populações ocidentais. Grupos de pacientes com risco negligenciável de metástase linfonodal podem se beneficiar de tratamentos menos invasivos. Dados referentes à frequência e fatores preditivos relacionados a metástase linfática em câncer gástrico precoce são raros. OBJETIVOS: Realizar a análise de frequência e fatores preditivos relacionados à metástase linfática em pacientes com câncer gástrico precoce tratados em centro terciário do Brasil. MÉTODOS: Novecentos e vinte e três pacientes foram submetidos à gastrectomias por adenocarcinoma gástrico. Destes, 126 tinham tumores precoces e foram avaliadas características clínicas e patológicas relacionadas e metástases linfáticas. RESULTADOS: Metástases linfonodais foram observadas em 7,8% dos pacientes com tumores mucosos e 22,6% dos tumores submucosos. A presença de ulceração, tipo histológico de Lauren, tumores maiores que 50 mm, invasão de submucosa e presença de invasão linfática ou vascular foram fatores significativos em análise univariada. A presença de ulceração, lesões maiores que 50 mm, infiltração da camada submucosa e invasão linfática foram fatores independentemente relacionados à metástase linfática em análise multivariada. CONCLUSÃO: Ulceração, lesões maiores que 50 mm, infiltração da camada submucosa e invasão linfática são fatores de risco independentes relacionados à metástase linfática em câncer gástrico precoce.

BACKGROUND: The standard treatment of gastric cancer still has high morbidity and mortality in western populations. Groups of patients with negligible risk of lymph node metastasis may benefit from less invasive treatments. Data regarding the frequency and predictive factors related to lymphatic metastasis in early gastric cancer are rare. AIM: To perform the analysis of frequency and predictive factors related to lymphatic metastasis in patients with early gastric cancer treated in a tertiary center in Brazil. METHODS: Nine hundred and twenty three patients underwent gastrectomy for gastric adenocarcinoma at the hospital. Of these, 126 had early tumors and were included in the analysis. Clinical and pathological related findings and lymphatic metastasis were evaluated. RESULTS: Lymph node metastases were observed in 7.8% of patients with mucosal tumors and 22.6% of submucosal tumors. The presence of ulceration, Lauren histologic type, tumors larger than 50 mm, submucosal invasion, and presence of lymphatic or vascular invasion were significant factors in univariate analysis. The presence of ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion were factors independently related to lymphatic metastasis in multivariate analysis. CONCLUSION: Ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion are independent risk factors related to lymphatic metastasis in early gastric cancer.

Frequency and predictive factors related to lymphatic metastasis in early gastric cancer.

BACKGROUND: The standard treatment of gastric cancer still has high morbidity and mortality in western populations. Groups of patients with negligible risk of lymph node metastasis may benefit from less invasive treatments. Data regarding the frequency and predictive factors related to lymphatic metastasis in early gastric cancer are rare. AIM: To perform the analysis of frequency and predictive factors related to lymphatic metastasis in patients with early gastric cancer treated in a tertiary center in Brazil. METHODS: Nine hundred and twenty three patients underwent gastrectomy for gastric adenocarcinoma at the hospital. Of these, 126 had early tumors and were included in the analysis. Clinical and pathological related findings and lymphatic metastasis were evaluated. RESULTS: Lymph node metastases were observed in 7.8% of patients with mucosal tumors and 22.6% of submucosal tumors. The presence of ulceration, Lauren histologic type, tumors larger than 50 mm, submucosal invasion, and presence of lymphatic or vascular invasion were significant factors in univariate analysis. The presence of ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion were factors independently related to lymphatic metastasis in multivariate analysis. CONCLUSION: Ulceration, lesions larger than 50 mm, infiltration of the submucosal layer and lymphatic invasion are independent risk factors related to lymphatic metastasis in early gastric cancer.

Expression Of Ki-67 and MUC1 In mucoepidermoid carcinomas of young and adult patients: prognostic implications.

Mucoepidermoid cancer (MEC) is the most malignant neoplasm of minor salivary glands. The aim of this study was to compare the expression of Ki-67 and MUC1 and clinicopathological data of mucoepidermoid carcinoma (MEC) in minor salivary glands of young and adult patients. The MEC cases in patients under 25 years old (n=8) and over 26 year old (n=8) were matched by gender, location and TNM staging. Immunohistochemical analysis of Ki-67 and MUC1 was carried out and correlated with clinicopathological data. The expression of Ki-67 and MUC1 was similar between the groups, although a tendency towards higher Ki-67 and MUC1 expression was observed in the younger group. Despite no significant differences, survival time was shorter in adults (71.37±17.44 months) compared to the younger group (97.62±25.81). While no patient deaths or tumor recurrences were found in the younger patient group, the adult group presented recurrence in 25% of cases and one patient died. In conclusion, our findings showed that age can be an important factor in MEC prognosis.

Initial experience in Brazil with endoscopic submucosal dissection for early gastric cancer using insulation-tipped knife: a safety and feasibility study.

BACKGROUND: Endoscopic resection is an adequate treatment for subgroups of patients with early gastric cancer. Endoscopic submucosal dissection (ESD) represents a recent advance and leads to good results when adequately indicated. There is great experience with this technique in Japan and it is gaining acceptance among Western endoscopists. We present the first gastric ESD series performed in Brazil. METHODS: Patients with well-differentiated adenocarcinomas macroscopically classified as early cancer, less than 30 mm with no ulcer or scar, were included. ESD was performed with an insulated-tip knife and electrosurgical unit with endocut mode. Clinicopathological aspects and morbidity were evaluated. The study was approved by the local ethics committee and informed consent was obtained from all participant subjects. RESULTS: From October 2005 to July 2007, 160 patients received surgical treatment for gastric cancer; 44 patients (27.5%) had early gastric cancer. In this latter group, 15 procedures (ESD) were performed in 12 patients. The mean size of the lesions was 16.8 mm. Almost half of the lesions were located in the proximal third of the stomach and the mean elapsed time for the procedure was 140 min. In 80% of the cases resection was en bloc and 80% of the resections were considered curative. We had three perforations, which were managed clinically, and no bleeding. CONCLUSION: When adequately indicated, ESD is a safe and feasible technique.

Endoscopic mucosal resection of early gastric cancer: initial experience with two technical variants.

BACKGROUND: When performed in carefully selected cases, the endoscopic treatment of early gastric cancer yields results which are comparable to the conventional surgical treatment, but with lower morbidity and mortality and better quality of life. Several technical options to perform endoscopic mucosal resection have been described and there is a large amount of accumulated experience with this procedure in eastern countries. In western countries, particularly in Brazil, technical limitations associated with the small number of cases of early gastric cancer reflect the little experience with this therapeutic mode. AIM: This study was carried out in order to assess the indications, pathological results and morbidity of a series of endoscopic mucosal resections using two technical variants in addition to investigating the safety and feasibility of the method. METHODS: Individuals with well-differentiated early gastric adenocarcinomas with up to 30 mm in diameter without scar or ulcer underwent endoscopic treatment. Two variants of the strip biopsy technique were used. The pathological study assessed the depth of the vertical invasion, lateral and basal margins as well as angio-lymphatic invasion. RESULTS: Thirteen tumors in 12 patients were resected between June 2002 and August 2005. The most common macroscopic types were IIa and IIa + IIc. Tumor size ranged from 10 to 30 mm (mean = 16.5 mm). En bloc resection was carried out in nine patients. Angio-lymphatic invasion was not observed; however, submucosal invasion was found in two cases. In four cases, the lateral margin was involved. Perforation occurred in two patients who then received conservative treatment. CONCLUSION: The relatively small series presented here suggests that the method is safe and feasible. Appropriate patient selection is the most important criteria. Long follow-up is required after treatment due to the risk of relapse.

Endoscopic mucosal resection of early gastric cancer: initial experience with two technical variants

BACKGROUND: When performed in carefully selected cases, the endoscopic treatment of early gastric cancer yields results which are comparable to the conventional surgical treatment, but with lower morbidity and mortality and better quality of life. Several technical options to perform endoscopic mucosal resection have been described and there is a large amount of accumulated experience with this procedure in eastern countries. In western countries, particularly in Brazil, technical limitations associated with the small number of cases of early gastric cancer reflect the little experience with this therapeutic mode. AIM: This study was carried out in order to assess the indications, pathological results and morbidity of a series of endoscopic mucosal resections using two technical variants in addition to investigating the safety and feasibility of the method. METHODS: Individuals with well-differentiated early gastric adenocarcinomas with up to 30 mm in diameter without scar or ulcer underwent endoscopic treatment. Two variants of the strip biopsy technique were used. The pathological study assessed the depth of the vertical invasion, lateral and basal margins as well as angio-lymphatic invasion. RESULTS: Thirteen tumors in 12 patients were resected between June 2002 and August 2005. The most common macroscopic types were IIa and IIa + IIc. Tumor size ranged from 10 to 30 mm (mean = 16.5 mm). En bloc resection was carried out in nine patients. Angio-lymphatic invasion was not observed; however, submucosal invasion was found in two cases. In four cases, the lateral margin was involved. Perforation occurred in two patients who then received conservative treatment. CONCLUSION: The relatively small series presented here suggests that the method is safe and feasible. Appropriate patient selection is the most important criteria. Long follow-up is required after treatment due to the risk of relapse.

RACIONAL: O tratamento endoscópico do câncer gástrico precoce quando realizado em casos bem selecionados proporciona resultados comparáveis ao tratamento cirúrgico convencional, porém com menor morbidade, menor mortalidade e melhor qualidade de vida. Diversas opções técnicas para a realização de ressecção endoscópica mucosa já foram descritas e há grande experiência acumulada nos países orientais com este procedimento. Nos países ocidentais, em particular no Brasil, as limitações técnicas associadas ao pequeno número de casos de câncer gástrico precoce se refletem na pequena experiência com esta modalidade terapêutica. OBJETIVO: Avaliar as indicações, resultados histopatológicos e morbidade de uma série de ressecções mucosas endoscópicas utilizando duas variantes técnicas, além de verificar a segurança e exeqüibilidade do método. MÉTODO: Pacientes com adenocarcinomas gástricos precoces e bem diferenciados, com até 30 mm de diâmetro, sem cicatriz ou úlcera foram submetidos a tratamento endoscópico. Foram utilizadas duas variantes técnicas de "strip biopsy". O estudo histopatológico avaliou a profundidade de invasão, margens laterais e profundas além da invasão angiolinfática. RESULTADOS: Foram ressecadas 13 lesões em 12 pacientes no período de junho de 2002 a agosto de 2005. Os tipos macroscópicos mais comuns foram IIa e IIa + IIc. O tamanho das lesões variou de 10 a 30 mm (média de 16,5 mm). A ressecção foi efetuada em monobloco em nove casos. Não foi observada invasão angiolinfática, porém em duas oportunidades havia acometimento da camada submucosa. Quatro lesões tinham comprometimento da margem lateral. Dois pacientes apresentaram perfuração gástrica e foram tratados de forma conservadora. CONCLUSÃO: A série relativamente pequena aqui apresentada demonstra que o método é seguro e exeqüível, quando realizado em pacientes adequadamente selecionados. É necessário que estes sejam mantidos sob estreita vigilância para verificação dos resultados...

D2 lymphadenectomy with para-aortic sampling improves lymph node staging for gastric cancer / Linfadenectomia D2 com amostragem para-aórtica melhora o estadiamento linfonodal do câncer gástrico

BACKGROUND: An important aspect dealing with gastric cancer is the role of lymphadenectomy in gastric cancer staging. AIM: To verify if lymphadenectomy with stations separation increases the number of dissected lymph nodes and establish comparison between TNM 2002 and JGCA 1998 evaluating lymph nodal status (N). METHODS: This is a retrospective analysis of the patients that underwent curative gastrectomy and D2 dissections for adenocarcinoma between 2004 and 2006. Between January of 2004 and June of 2005 (group 1), lymphadenectomy was performed en-bloc with gastrectomy and only TNM system was used. After June of 2005 (group 2), the surgeon himself dissected lymph nodal stations, allowing use of TNM and JGCA systems. Studied aspects were age, Borrmann classification, histological grade, venous or lymphatic invasion, depth of invasion, peritoneal cytology and type of gastrectomy. End points were number of dissected lymph nodes, number of positive lymph nodes and agreement between staging systems. Chi-square test and T-test were used for statistical analysis. RESULTS: One hundred forty-five gastrectomies were performed, 76 in group 1 and 69 in group 2. In group 1, mean age was of 61 years and 59 years in group 2 (P=0,12). Eighty per cent of tumors were advanced in both groups. Venous or lymphatic invasion and positive peritoneal cytology were more frequent in group 1, 65.6% vs 35,3% (P= 0,001) e 13.9% vs 3.1% (P=0,03), respectively. Borrmann classification, histological grade, Lauren classification and type of gastrectomy were not different between the groups. In group 1, mean number of lymph nodes was 32,7 and 37,35 in group 2 (P= 0,09). Rates of positive lymph nodes in groups 1 and 2 were 72.2% and 53%, respectively (P= 0,02). Migration analysis of lymph node status (N) realized only in group 2 (69 patients) showed agreement between TNM and JGCA in 50 patients (72,5%). Using JGCA system, modification in 19 patients occurred (27,5%), with upstaging in 13 (18,8%) and downstaging in six (8,7%). CONCLUSION: In this study, a tendency of increase in number of lymph nodes was verified when the surgeon himself dissected lymph nodal stations. JGCA system modified the lymph nodal staging in comparison to TNM system in 30% of all cases.

RACIONAL: O papel da linfadenectomia no estadiamento de câncer gástrico é de grande importância quando lidando com câncer gástrico. OBJETIVO: Verificar se a linfadenectomia com estações linfonodais separadas aumenta o número da dissecção de linfonodos e estabelecer comparação entre o TNM 2002 e o JGCA 1998, avaliando o status dos linfonodos (N). MÉTODOS: Foi realizada análise retrospectiva de pacientes que foram submetidos à gastrectomia curativa e dissecções do tipo D2 para adenocarcinomas, entre 2004 e 2006. Entre janeiro de 2004 e junho de 2005 (grupo 1), a linfadenectomia foi realizada em flape único com gastrectomia e somente o sistema TNM foi utilizado. Após junho de 2005 (grupo 2), o cirurgião realizou a dissecção de estações linfonodais, permitindo o uso dos sistemas TNM e JGCA. Os aspectos estudados e analisados foram idade, classificação de Borrmann, grau histológico, invasão venosa ou linfática, profundidade da invasão, citologia peritoneal e tipo de gastrectomia. Foram analisados o número de linfonodos dissecados, o número de linfonodos positivos e o entendimento entre os sistemas de estadiamento. O teste do Chi-quadrado e teste-t foram utilizados para realizar a análise estatística. RESULTADOS: Foram realizadas 145 gastrectomias, sendo 76 no grupo 1 e 69 no grupo 2. A idade média referente ao grupo 1 foi de 61 anos e de 59 no grupo 2 (P=0,12). Em ambos os grupos 80% dos tumores eram avançados. Invasão venosa e linfática e citologia peritonial positiva foram mais freqüentes no grupo 1, 65.6% vs 35.3% (P=0,001) e 13.9% vs 3.1% (P=0,03), respectivamente. A classificação de Borrmann, grau histológico, classificação de Lauren e tipo de gastrectomia não foram diferentes entre os grupos. No grupo 1, a média de linfonodos foi de 32.7 e no grupo 2 de 37.35 (P=0,09). O índice de linfonodos positivos nos grupos 1 e 2 foi de 72.2% e 53%, respectivamente (P=0,02). A análise de migração do status de linfonodos (N) foi realizada no grupo 2 (69 pacientes) em concordância com o TNM e JGCA em 50 pacientes (72.5%). Ao utilizar o sistema JGCA, ocorreram modificações em 19 pacientes (27.5%), com aumento de estadiamento em 13 (18.8%) e diminuição em 6 (8.7%). CONCLUSÃO: Neste estudo, foi verificada tendência ao aumento do número de linfonodos quando o cirugião realizou, ele mesmo, a dissecção das estações linfonodais. O sistema JGCA modificou o estadiamento linfonodal quando comparado ao sistema TNM em 30% de todos os casos.

Metastatic cancer to the stomach.

BACKGROUND: Metastases in the stomach are rare. The increased use of esophagogastroduodenoscopy (EGD), associated with better treatment results for malignancies, requires them to be acknowledged. The aim of this study was to describe a series of cases of metastasis to the stomach, their primary sites, clinical and endoscopic features, treatment, and results. METHODS: Twenty cases were diagnosed between December 1999 and January 2004. Their analysis included symptomatology, macroscopic presentation, time from diagnosis of the primary tumor to the detection of the gastric metastasis, treatment approach, and survival. RESULTS: The primary sites were the esophagus, skin, lung, cervix, breast, sigmoid colon, and testis. The symptom most frequently requiring EGD was upper gastrointestinal bleeding. Ten patients showed concomitant metastases to other organs. The mean time between diagnosis of the primary tumor and diagnosis of gastric metastasis was 16 months (range, 0 to 56 months). Only seven patients were given some form of treatment after diagnosis of the gastric metastasis. The median survival was 4.75 months. Overall survival during the first year was 20% and survival was nil at 2 years. CONCLUSIONS: Gastric metastasis marks advanced disease and the prognosis is poor. New advances in diagnosis and treatment are required for better results.

Indicações e resultados do tratamento do linfoma MALT do estômago através da erradicação do Helicobacter pylory / Indications and results of the treatment of stomach MALT lymphoma by eradicating Helicobacter pylori

O linfoma gástrico constitui doença de incidência crescente e em muitos casos mantém estreita relação com o Helicobacter pylori. O tratamento do linfoma gástrico através da erradicação do H. pylori proporcionou melhor conhecimento da patogenia desta neoplasia. As indicações para essa modalidade terapêutica são ainda bastante restritas e se baseiam na presença do H. pylori, na classificação histológica e no refinado estadiamento por métodos de imagem. Os resultados obtidos, ainda que muito variáveis entre os diferentes estudos, são animadores. Destaca-se o fato de ser tratamento conservador, de baixo custo, de fácil adesão e com bons índices de resposta, além da possibilidade de terapia de resgate nos casos de falha terapêutica