Early gastric cancer: is it a distinct clinical entity?

Of 199 patients with gastric cancer seen at The Montreal General Hospital between 1970 and 1981, 104 were considered to have had a curative resection, and 26 of these were early gastric cancers (EGC). The authors compared early gastric cancers with advanced, but resectable, gastric cancers to determine whether EGC is a distinct entity or a stage in the progressive evolution of gastric cancer. They found that depth of invasion was the primary determinant of outcome, but that there was no discrete cut-off point between the depth of invasion associated with early and with advanced gastric cancers. The pathological features normally associated with a favourable prognosis in gastric cancer, such as absence of lymph-node metastases, an expanding growth pattern, intestinal metaplasia, and well-differentiated histologic features correlated highly with depth of invasion but did not appear to change abruptly between EGC and advanced resectable lesions. The authors conclude that EGC is not a distinct pathological or clinical entity but a stage in the progressive growth of gastric cancer.

Gastric carcinoma: intestinal metaplasia and tumor growth patterns as indicators of prognosis.

We have reviewed 200 cases of gastric carcinoma treated between 1970 and 1980 to assess the value of intestinal metaplasia in the stomach and tumor growth patterns in determining prognosis. Intestinal metaplasia was found to be more frequently associated with early gastric tumors, expanding-type tumors, and tumors located in the antrum. The survival rate was 53% with intestinal metaplasia and 34% without. Sixty-three percent of expanding tumors with metaplasia survived. If the lymph nodes were not involved, the survival rate with metaplasia was 81%. We conclude that intestinal metaplasia and growth patterns are valuable in predicting outcome. Preoperative evaluation of gastric tumors should include multiple endoscopic mucosal biopsy specimens. If intestinal metaplasia is present, the improved possibility of survival should influence the surgeon in the choice of operative treatment.

Cholangiocarcinoma as a late complication of choledochoenteric anastomoses.

Two cases of cholangiocarcinoma developing several years after choledochoenteric anastomoses are reported. It is speculated that these may represent heretofore unrecognized late complications of this procedure. The intermittent chronic obstruction with bile stasis and recurrent inflammation may be causative factors in the development of cholangiocarcinoma after choledochoenterostomy.

Rational management of malignant colon polyps based on long-term follow-up.

We reviewed the long-term results of management of 38 patients with carcinoma in colorectal polyps. Of these, 16 patients demonstrated malignant invasion of the lamina propria but not the muscularis mucosa (group I), and 22 patients showed malignant invasion of the muscularis mucosa (group II). Primary therapy for group I patients consisted of polypectomy in 12, local excision in one, and colonic resection in three. One patient had a subsequent abdominal-perineal resection and was found to have no residual disease and no lymph node involvement. Follow-up of the group I patients showed that 11 were alive and well (mean 5.8 years) and five died of unrelated causes (mean 5.2 years). Of group II patients, 12 underwent polypectomy, six local excision, and four colectomy. Of these 22 patients, 11 underwent further operation, including nine major bowel resections and two local re-excisions. None of these 11 patients had either residual tumor or lymph node metastases. One patient died of complications after abdominal-perineal resection. Follow-up showed that 18/22 group II patients were alive and well 5 to 15 years later (mean 7.5 years); four died of unrelated causes (mean 3.2 years). We then reviewed another group of 220 patients who had undergone resection for invasive colon cancer to relate the presence or absence of lymph node metastases to the depth of malignant invasion in the bowel wall. We found that 44% of this entire group had lymph node involvement. Of 36 patients with tumor confined to the bowel wall, nodal metastases occurred in only 22%. Of eight patients with malignancy superficial to the muscularis propria, only one had nodal involvement. We conclude that colon cancer tends to progress in an orderly fashion and the risk of nodal metastases increases with the depth of invasion. Carcinoma in a polyp represents a very early stage of colon cancer. We therefore recommend polypectomy as primary treatment for pedunculated polyps containing carcinoma either superficial to or invading muscularis mucosa. If histologic review demonstrates incomplete excision, lymphatic invasion, or poor differentiation, patients with lesions invading the muscularis mucosa should undergo formal colonic resection.

A simple method for catheter fixation of the cystic duct during cholangiography.

The use of Weck hemoclips with an ureteral catheter has proved to be an extremely quick, simple and reliable method of carrying out cholangiography and may possibly merit the consideration of others.

Common bile duct exploration: indications and results.

To ascertain the best diagnostic indicators of choledocholithiasis and to decrease the incidence of retained stones in the common bile duct after exploration, the authors carried out a retrospective review of 110 consecutive patients who underwent common bile duct exploration for calculous biliary tract disease. Conditions that were most often associated with choledocholithiasis were cholangitis and clinically obvious jaundice. The serum bilirubin level was helpful in identifying patients with stones in the common bile duct only when the value was greater than 6 mg/dl (103 mumol/l), and alkaline phosphatase only when the value was more than 250 IU (normal 110 IU). When stones are felt in the duct at operation, the diagnosis of choledocholithiasis is certain; positive operative cholangiograms are highly reliable and the coexistence of small gallstones and a dilated cystic duct is suggestive. The retention of stones is best prevented by careful exploration followed by high-quality T-tube cholangiography performed at operation after the exploration is complete. Any missed stones found in this way should be removed by re-exploration at the time of the original operation. Stones left in the common bile duct are best extracted nonoperatively under radiologic control. This technique, while effective and safe, is associated with considerable morbidity.

Mortality and prognosis of obstructing carcinoma of the large bowel.

In a series of 760 patients with adenocarcinoma of the colon and rectum, 103 patients presented with acute obstruction requiring urgent surgical decompression. Obstructed patients were slightly older and had slightly more advanced tumors than the total group. Obstructing lesions of the left colon treated primarily by staged procedures had relatively low mortality and five year survival figures comparable to unobstructed cases. Obstructing lesions of the right colon had a much poorer absolute five year survival rate, mainly because of the high operative mortality associated with primary resection in our institution. Five year survival after curative resection in patients with obstructing tumors of the right colon was considerably less than in patients with nonobstructing tumors. A suggestion is made for consideration of proximal external bowel decompression in association with resection of the right colon.

Prognosis in colon cancer: a pathologic reassessment.

One hundred forty-eight cases of colon carcinoma were subjected to further pathologic study. Survival was correlated with stage and grade of the tumor and with the number of involved lymph nodes. In addition, cases were assessed as to the extent of local chronic inflammatory reaction about the lesion and the degree of sinus histiocytosis in draining lymph nodes. A correlation was possible between grading, staging, extent of lymph node involvement, and survival. A substantial difference in five-year survival was shown when local inflammatory reaction was present and when sinus histiocytosis was observed. The presence of both of these factors further improved survival. An adequate evaluation of these factors, both individually and in combination, should improve our ability to assess prognosis in colon cancer.

Bedside determination of left atrial pressure.

An investigation was conducted to assess the accuracy of left heart filling pressures determined by a right heart catheter introduced at the bedside. Twelve patients were studied after open cardiac surgery by simultaneously recording pressures from both sides of the pulmonary capillary bed with a direct left atrial catheter and a flow-directed pulmonary arterial catheter. The mean pulmonary artery "occluded" pressure was shown to be a highly reliable index of mean left atrial pressure in all cases. It was much more accurate than pulmonary end-diastolic pressure, especially in six patients with pre-existing pulmonary hypertension.