Lymph node staging in 872 patients with carcinoma of the stomach and the presumed benefit of lymphadenectomy. German Stomach Cancer TNM Study Group.

The incidence of surgically suspected and microscopically proved lymph nodes from adenocarcinoma of the stomach and the results of systematic lymphadenectomy have been studied and correlated to survival rate of 99.4 percent at a follow-up period of five years in 872 patients who underwent resection as a part of a prospective observational study in carcinoma of the proximal and distal parts of the stomach. Surgeons believe that, in the median, only one-fifth of the patients with and without systematic lymphadenectomy had positive nodes, whereas pathologists found almost three-fourths of positive lymph nodes (72.7 percent) in patients with proximal carcinoma of the stomach as compared with those without systematic lymphadenectomy (30.8 percent). The figures for middle and lower third carcinomas were even higher (63.5 versus 13.9 percent and 75.9 versus 27.1 percent). Positive nodes were most common in the perigastric area and their distribution was clearly related to the site of the tumor. Frequently, however, lymph node groups were involved, far from the primary, that is, along the hepatoduodenal ligament in 9 to 19 percent of patients with carcinoma of the proximal part of the stomach and in 7 to 16 percent of patients with carcinoma of the distal part of the stomach. There were some hints of a better survival rate for patients with systematic lymphadenectomy as compared with those without, only for low stage carcinoma of the stomach (TNM stage IA-IB, p = 0.1157, Breslow). We suggest a more extensive operation with gastric resection, always combined with systematic lymphadenectomy if no distant metastases are found.

Proximal compared with distal adenocarcinoma of the stomach: differences and consequences. German Gastric Cancer TNM Study Group.

Interest in leading prognostic determinants of proximal gastric adenocarcinoma (PGA) in comparison with distally located adenocarcinoma (DLA) of the stomach led to an analysis of data from 506 patients with PGA and 484 patients with DLA operated on between 1 April 1982 and 31 October 1984 and participating in a multicentre observational study to validate tumour node metastasis (TNM) stage groupings. The proportion of men with PGA was slightly higher than that of men with DLA (69 versus 63 per cent). Men more often had cardia carcinomas than women (14 versus 9 per cent); 74 per cent of these men but only 43 per cent of the women were less than 65 years old. Evaluation of data by a log-linear model indicated a strong partial association (P less than 0.001) between age and site; patients younger than 65 years more often had PGA than older patients. Advanced tumour stage and the intestinal type of carcinoma were more frequently seen in the elderly. More than twice as many patients with PGA in comparison with those with DLA (35 versus 15 per cent) had palliative surgery (moderate association, P less than 0.05). This may have resulted from different stages at different sites; advanced carcinomas (TNM stages IIIb and IV) were more often diagnosed in patients with PGA than in those with DLA (60 versus 38 per cent). Residual tumour left after surgery was associated with deeper infiltration (P less than 0.001). No difference between PGA and DLA groups with respect to histological type of carcinoma was established, but residual tumour was more frequently associated with a diffuse type carcinoma (P less than 0.01). An overall tendency to poorer long-term prognosis in PGA was seen for all TNM stages, with and without residual tumour, except for TNM stage II with residual tumour, even though patients with PGA were younger than those with DLA. These differences in long-term prognosis, however, are based primarily on poorer short-term survival for PGA, particularly for TNM stages Ib and II without residual tumour. A significant risk of surgical management, particularly for early-stage tumours situated in the upper part of the stomach, has therefore been recognized. Surgeons should appreciate the higher surgical mortality rate for patients with PGA when curative treatment requires more risky surgical techniques.

[Early stomach cancer in comparison with advanced stomach cancer. Results of a prospective study of diagnosis and 5-year survival of 131 patients with early stomach cancer and 795 patients with advanced stomach cancer]. / Das Magenfrühkarzinom im Vergleich zum fortgeschrittenen Magenkarzinom. Ergebnisse einer prospektiven Studie zur Diagnostik und Fünfjahresüberleben von 131 Patienten mit Magenfrühkarzinom (EGC) und 795 Patienten mit fortgeschrittenem Magenkarzinom (AGC). Deutsche Magenkarzinom-TNM-Validierungs-Studiengruppe.

A multicentre prospective observational study with 22 surgical and 14 pathological units in West-Germany gathered data from 1420 patients with gastric cancer between April 1982 and October 1989, 131 patients with early gastric cancer (EGC) and 795 patients with a resectable advanced gastric cancer (AGC) were selected for comparison. Patients with EGC were younger than those with AGC (49% vs 37% younger than 60 years) and symptoms of an ulcer were found twice in comparison to AGC (40.7% vs 23.7%). EGC in comparison to AGC were frequently multifocal (9.2% vs 3.0%) and located in the middle and lower part of the stomach (83.9% vs 56.8%). Five-year-survival rates of mucosa carcinoma was 84% and of submucosal carcinoma 69% (p = 0.0741). WHO-typing of EGC and AGC were identical. But according to Laurén's classification there were more intestinal types with EGC than with AGC (60.3% vs 51.5%) and less diffuse or mixed types with EGC than with AGC (33.6% vs 44.0%). Five-year-survival rates of diffuse and intestinal types of EGC showed no significant difference (p = 0.19). Extended lymph node dissection was done in only one third of EGC and AGC. Five-year-survival rates of 36 EGC patients with and 95 EGC patients without extended lymph node dissection were 85% versus 72% (p = 0.0916). These results are a hint that systematic lymphadenectomy may have a beneficial effect on survival.

[Anxiety before gastrointestinal endoscopy--a significant problem?]. / Angst vor der gastrointestinalen Endoskopie--ein bedeutsames Problem?

98 consecutive patients (40 men, 58 women; mean age 49 [17-83] years) who had been referred for outpatient gastroscopy or colonoscopy were questioned beforehand regarding their anxiety about the procedure, its causes and how it could be dispelled. Two thirds of them (67%) stated that they felt anxiety about the investigation; almost half of them (46%) felt very great or "terrible" anxiety. 55% of the patients had been fully informed about the nature of the procedure. 69% of the women and 48% of the men had previously experienced gastroscopy or colonoscopy. The reasons for their anxiety were varied. One quarter of those questioned (24%) had had unpleasant experiences during previous endoscopies; others had been alarmed by rumours about endoscopy (22%), and some were less worried about the procedure itself than about what it might reveal (24%). Almost two thirds (63%) wanted a tranquilizing injection. Other methods for dispelling anxiety, such as detailed information about the procedure (21%), a calm, relaxed atmosphere (19%) or the presence of a relative at the endoscopy (7%) were claimed for in a limited way. However, 37% very much wanted to watch the endoscopy on the television monitor. The findings show that the number of patients who experience anxiety before undergoing endoscopy is alarmingly great, and that more energetic measures are necessary to relieve their fears and worries.

Has there been any improvement in the staging of gastric cancer? Findings from the German Gastric Cancer TNM Study Group.

This multicenter observational study examined the survival of 1420 patients with histologically proven carcinoma of the stomach. From April 1982 through October 1984, 1360 (95%) patients underwent surgery, 988 (72%) had resections, and 372 (28%) minor surgical procedures. The percentage of patients who have been followed until death or 3 to 5 years was 99.4%. Patients were staged preoperatively and intraoperatively and by pathologists using the old (1978) and new (1987) TNM stage groupings and 5-year survival was analyzed. Subgroups of patients who changed their stage group according to the new stage definitions were analyzed separately. Only age was an important prognostic factor for survival in Stage IA (P less than 0.05) and Stage IB (P less than 0.01). Residual tumor after surgery was most important for survival in Stage II (P less than 0.01) and Stage IIIA (P less than 0.001). This indicates that improvements of stage definitions for individual prognosis can only be achieved by adding data concerning the presence or absence of residual tumor (R classification).

[Radical treatment and prognosis: results of a multicenter surgical-pathologic TNM stomach cancer study]. / Radikalität und Prognose: Ergebnisse der multizentrischen chirurgisch-pathologischen Magencarcinom-TNM-Studie.

A multicentre observational study with 22 departments of surgery and 14 departments of pathology was started on April 1st, 1982 to validate TNM classification for patients with gastric carcinoma. 1417 patients with histologically proven gastric cancer entered the study. Follow-up is now 3-5 years. A subgroup of 138 patients (age under 65 years, no metastases M 0, curative resection R 0, only T 2-T 4-carcinomas and tumors situated only in the middle and lower third of the stomach) was studied. 65 had subtotal, 73 total resection. The 3 to 5 years cumulative survival time was at least not worse with subtotal in comparison to total resection.