Pathology and prognosis of gastric carcinoma. Findings in 10,000 patients who underwent primary gastrectomy.

BACKGROUND: Despite recent advances in diagnosis and treatment, gastric carcinoma remains a major cause of death in the world. METHODS: The clinicopathologic profile of 10,000 consecutive patients who underwent primary gastrectomy during 1962-1989 were reviewed and prognostic factors influencing survival in those with gastric carcinoma were analyzed in 7031 patients. RESULTS: Incidence of gastrectomy for carcinoma has increased steadily and the rate of early carcinoma exceeded that of advanced carcinoma in the recent period of 1985-1989. Five-year and 10-year survival rates were 46.1% and 35.2% in 3868 patients with advanced carcinoma, and 88.8% and 77.3% in 3163 patients with early carcinoma, respectively. In patients with advanced carcinoma, significantly poorer survival rates were noticed for patients older than 70 years of age, those who underwent total gastrectomy, tumors involving the entire stomach or greater than 10 cm in diameter, a macroscopic diffusely infiltrative pattern, adenosquamous histologic type, positive surgical resection margins, or lymph node metastasis. None of the above poor prognostic features were identified in patients with early gastric carcinoma group except for those older than 70 years of age. Although lymph node metastases were present in 10% of early gastric carcinomas, this feature did not impart a poor prognosis. Patients with advanced carcinoma grossly resembling an early carcinoma had an intermediate prognosis, suggesting the existence of a developmentally midstage lesion between early and advanced carcinoma. CONCLUSIONS: The study illustrates that the most important role for clinicians treating with gastric carcinoma should be early detection and aggressive surgery for resectable tumors, followed by detailed pathologic examination.

[Solid and cystic tumor of the pancreas with prominent calcification].

A case of a solid and cystic tumor of the pancreas is presented. The immunohistochemical study of the resected tumor revealed alpha 1-antitrypsin and neuron specific enolase positive malignant cells proliferating pseudopapillary around fibrovascular stroma. Prominent calcification was characteristic in the present case.

Distribution of beta-human chorionic gonadotropin-positive cells in noncancerous gastric mucosa and in malignant gastric tumors.

The authors examined the localization and behavior of beta-human chorionic gonadotropin (HCG)-positive cells in human gastric noncancerous mucosa and in gastric malignant tumors, using immunohistochemistry and the anti-beta-HCG antibody. The beta-HCG-positive cells were located mainly in the antral mucosa and were generally restricted to the neck portion of the pyloric glands, although a few were present in fundic glands of the gastric body. The beta-HCG-immunoreactive cells were found in gastric carcinomas in 53% of the 92 cases examined. These cells were observed more often in advanced carcinomas that were histologically poorly differentiated than in early carcinomas or in well-differentiated tumors, but this prevalence had no statistical significance. The presence of the beta-HCG-positive cells in the gastric carcinomas suggested no appreciable prognostic significance, even quantitatively. In the syncytiotrophoblast-like tumor cells seen in four gastric tumor samples with histologic features of a choriocarcinoma, immunoreactivity to the beta-HCG was striking. There was, however, no recognizable dominance in the number of beta-HCG-reactive cells in the noncancerous mucosa around the tumor.

Recurrence in early gastric cancer.

In a retrospective study of 503 cases of early gastric cancer, 17 of the patients had died of a recurrence of the gastric cancer and 72 had died of unrelated causes. The cumulative recurrence mortality rates were 2.2% at 9 years for mucosal cancer and 8.4% at 8 years for submucosal cancer. The recurrence patterns of early gastric cancer were hematogenic metastasis to the liver, lung, or bone (nine cases), recurrence from lymph nodes (three cases), and recurrence in the residual stomach (five cases). Submucosal cancers with a macroscopically elevated appearance, lymph node metastasis, and evidence of vessel invasion were the high-risk cancers for hematogenic recurrence, and adjuvant chemotherapy should be prescribed. Two cases of lymph node recurrence were attributed to inadequacy of lymph node dissection. Because metastasis to the group 2 lymph nodes was noted in 1.5% of cases of early gastric cancer and a macroscopic diagnosis of nodal status was inaccurate, complete dissection should be performed regardless of identification of metastasis. Five cases of recurrence in the residual stomach were attributed to overlooked lesions of multiple carcinoma and were detected at an advanced stage. Careful and regular postoperative follow-up is required to detect these recurrences at an early stage.

Prognostic value of immunohistochemically identified CEA, SC, AFP, and S-100 protein-positive cells in gastric carcinoma.

Gastric tissues from 85 patients with advanced carcinoma were studied immunohistochemically for localization of carcinoembryonic antigen (CEA), secretory component (SC) and alpha-fetoprotein (AFP), and for S-100 protein-positive cells. Our objective was to determine if these factors could serve as prognostic indicators. Forty patients died of recurrence or metastases within 2 years (Group I), and the remaining 45 survived 10 years or longer (Group II) after resection. CEA-positive cells were present in 93% and 89% of Groups I and II, respectively. In case of staining for CEA, positive results were seen not only in the malignant cells but also in the stroma in 35% of Group I but none in Group II. The immunohistochemical status of SC was not essentially different between Groups I and II; the positive staining was recognized in 50% and in 57%, respectively. Gastric carcinomas rarely reacted to AFP. S-100 protein-positive cells, which play an important role in local immunity, were often present in Group II (47%) but rarely in Group I (10%). Thus, in addition to the various prognostic factors available to the surgical pathologist, the presence of CEA and the appearance of S-100 protein-positive cells in tumor tissue will aid in predicting the prognosis of patients with advanced gastric carcinoma.