Endoscopic mucosal resection for early gastric cancer.

Progress in the detection of early gastric cancer has made endoscopic mucosal resection (EMR) possible for the treatment of gastric cancer instead of only conventional surgical resection. The most commonly employed modalities include strip biopsy, double snare polypectomy, and resection with combined use of highly concentrated saline and epinephrine, and resection using a cap. The indications should be strictly limited to the differentiated IIa type (the slightly elevated type) that is smaller than 2 cm, or the differentiated IIc type (slightly depressed type) without ulcer formation and smaller than 1 cm. Both of these entities are thought to have a negligible risk of lymph node metastasis. Prognosis after this treatment is comparable that of surgical resection for early gastric cancer in completely resected cases. EMR also permits local resection in elderly patients with various complications who would be at risk for conventional surgical operations. EMR should be encouraged for treatment of gastric cancer if the indications are strictly chosen.     

Gastric cancer presenting a variety of macroscopic and histopathological findings

A 68-year-old man was admitted to hospital because of nausea and vomiting. Examination of the upper digestive tract led to a total gastrectomy. A histopathological examination revealed a Borrmann type 3 advanced cancer in the prepyloric antrum that showed a moderately differentiated adenocarcinoma. Found on the anterior wall of the middle corpus was an advanced cancer, mimicking a type IIc early cancer, that was poorly differentiated with dispersed signet ring cells. Between these two advanced cancers, another superficially extended cancer, consisting of a type IIa and IIb early cancer, was found. The type IIa cancer, located on the posterior wall of the angle, was a papillary adenocarcinoma and the type IIb cancer on the lesser curvature of the antrum was moderately differentiated. Therefore this patient displayed not only a type IIa and a type IIb cancer, but also a Borrmann type 3 cancer and an advanced cancer, mimicking type IIc, that were linked into one large lesion. Although the present case was not determined as being a multiple gastric cancer, it suggests the likelihood of a multicentric generation, growth, and extension of synchronous multiple cancers, in view of the variety of macroscopic and histopathological findings presented.     

Analysis of Early Gastric Cancer Cases Collected from Major Hospitals and Intitutes in Japan

An analysis of 17,212 lesions from 15,933 patients with earlygastric cancer collected from 110 major hospitals and institutesin Japan is presented. The percentage of patients with early gastric cancer was highamong persons in their 60s and 50s. The sex ratio (F/M) was0.5 but it was higher for younger people than for old people.Regarding distribution of the types of early gastric cancer,the depressed group (Types IIe, III) accounted for 73.9% andthe elevated group (Types I, IIa) accounted for 15.3%. The elevated group was more frequent in the older age group.In regard to the type and invasion, slight invasion was prominentin types lIb and IIa, while deep invasion was prominent in IIa+ IIc. The metastatic rate was 18.4% for IIa + IIc, 11.8% forI and 11% for IIe. The frequency of lymph node metastasis was+4% in intramucosal cancer, 18.9% in submucosal cancer and 11.4%in total. The type in which multiple cancers were most frequentwas lIb, followed by IIa. The percentage of differentiated adenocarcinoma was 91.9% inthe elevated group and was found more often among the aged. Undifferentiated adenocarcinoma occurred more often among theyoung. The relationship between site and histology, locationand invasion, location and lymph node metastasis etc. were alsoinvestigated. We believe that these results should be very usefulfor detection and treatment of early gastric cancer. The rate of detection of small cancer is increasing year byyear. This increase can be explained by the progress and widespreadapplication of endo-scopy, which will continue to play a largerole in diagnosis and treatment of gastric cancer.     

Initial radiographic findings of early gastric cancer detected in health check programs and human "dry dock" collective health checks and treated by endoscopic mucosal resection

Abstract. Background: The purpose of this study was to evaluate the capacity of detection (detectability), by radiographic examination, of minute gastric cancer that was indicated for endoscopic mucosal resection (EMR). Methods: Fifty-five lesions in 55 patients with minute gastric cancer were endoscopically resected between 1992 and 2000 at the Foundation for Detection of Early Gastric Carcinoma. Of these 55 patients, 33 patients underwent indirect (with image intensifier and 100-mm roll film) and/or direct radiographic examination of the upper gastrointestinal tract as the initial screening examination, and subsequent upper gastrointestinal endoscopy. The remaining 22 patients underwent upper gastrointestinal endoscopy as the initial screening examination. As the first step, radiographic (indirect and direct) images were reviewed, and the abnormalities which had eventually led to the detection of the minute early gastric cancer (EGC) were reconfirmed. Then, they were analyzed in terms of the reproducibility of abnormal findings which enabled the detection of such a minute EGC, and in terms of whether they could be treated by EMR. The size, morphology, and location of the radiographically detected lesions were analyzed. Results: Seventeen lesions of EGC were detected in the group in which indirect radiography was initially performed. Of these 17 lesions, some abnormality corresponding to the site of the lesion was pointed out in 7 lesions (2 lesions of type IIa and 5 lesions of type IIc). On the other hand, the remaining 10 lesions (type IIa, 3; type IIc, 5; type IIa + IIc, 1; and type IIb, 1) were detected by endoscopy, which was carried out to confirm the other abnormalities in the indirect radiographic images. Sixteen lesions of EGC were detected in the group in which direct radiography was initially performed. Of these 16 lesions, some abnormality corresponding to the site of the lesion was pointed out in 8 lesions (4 lesions of type IIa and 4 lesions of type IIc). The remaining 8 lesions (3 lesions of type IIa and 5 lesions of type IIc) were not detected by direct radiography. Conclusion: Indirect and direct radiographic examination enabled the detection of approximately 50% of EGCs which could be treated by endoscopic resection. The significance of radiographic examination should not be underestimated, even in the detection of EGCs which can be endoscopically resected. Received: June 18, 2001 / Accepted: December 7, 2001     

Five cases of rectal cancer showing remarkable response to suppository administration of tegafur

Five cases of rectal cancer, one male and 4 females, were preoperatively treated with Tegafur suppositories at 1,500 mg per day, for 8 to 21 days (mean, 14 days). These tumors were 2 early cancers and 3 advanced cancers, the configuration of which were one IIa type, one IIa + IIc type and 3 Borrmann 2 types. Their size ranged from 1.3 to 4.2 cm in diameter. Curative resections were performed in all cases, and the examination of the resected specimen revealed marked effects of Tegafur as follows: 1) Reduction of tumor size, 2) disappearance of cancer wall, 3) degeneration of cancer cells and destruction of cancer glands accompanied by fibrous stroma with infiltration of lymphocytes and plasma cells, 4) formation of xanthogranulomatous tissue with foamy histiocytes, which were characteristic findings showing that cancer tissue had been present there. As a result, rectal cancer clearly showed remarkable response to suppository administration of Tegafur for only about two weeks, if the tumor cells were sensitive to the drug.     

A case of IIa + IIc type early carcinoma of the rectum, with no invasion of the submucosa

A case of a IIa + IIc type early carcinoma of the rectum is reported. A 62-year-old man, who had been checked by immunological latex agglutination faecal occult blood testing, underwent a colorectal examination at Hakodate Chu-o Hospital. A barium enema revealed a slightly elevated lesion with a central depression in the lower rectum. Colonoscopic examination showed a IIa + IIc type of early rectal carcinoma. Study of the resected specimen also confirmed a IIa + IIc type early rectal carcinoma, 17 x 15 mm in diameter. Histologically, a lesion was located within the mucosa and consisted of both a carcinoma and an adenoma. Immunological latex agglutination faecal occult blood testing was thought to be useful for mass screening detection of a colorectal carcinoma.     

Endoscopic diagnosis of gastric cancer of a benign appearance

From April, 1982 to March, 1987, we have performed 36,566 gastrofiberscopic examinations and have detected 793 gastric cancers among 7,618 biopsies. Of these 55 cancerous lesion (6.9%) diagnosed as benign at the time of endoscopic examinations were analyzed and the following results were noted. 1. Most such lesions were small in size and superficial in nature. 2. The gross appearances of the cancers were mainly IIc, IIc + III or IIa. 3. The lesions were most frequently located on the gastric angulus or the side with a lesser curvature. 4. Histologically, well differentiated adenocarcinomas were relatively frequent. 5. False-negative cases determined by endoscopic examination were not infrequent in cases of lesions involving an ulcer, or showed redness, erosion or a polyp.     

Radiation therapy of seminoma: 17-year experience at the Joint Center for Radiation Therapy

One hundred and sixteen patients with stage I and II primary testicular seminoma were treated at the Joint Center for Radiation Therapy (JCRT) between 1968 and 1984. Complete follow-up is available for 114 patients (98%) with a median follow-up time of 6 years. Actuarial relapse-free survival (RFS) and survival for the entire group at 10 years were 94 and 86%, respectively, with 27 patients still at risk beyond 10 years. Actuarial RFS and survival at 10 years by stage were 97 and 92% for stage I, 93 and 81% for stage IIa, 100 and 100% for stage IIb, but only 75 and 51% for stage IIc. The difference in actuarial survival between stage IIc patients and stage I, IIa and IIb patients was significant (p less than 0.01). These results indicate that radiation therapy is excellent treatment for stage I and II seminomas as long as the largest mass of disease is not greater than 5 cm (stage IIc). Patients with stage IIc seminoma are now treated with cisplatin-containing combination chemotherapy followed by radiation therapy to areas of bulk disease. Although the majority of patients with stage II disease in this series received mediastinal irradiation, this is no longer recommended at the JCRT.     

A case of primary early duodenal cancer

Reported is a case of a suprapapillary primary early duodenal cancer in a 50 year old male patient who had had a hemicolectomy 15 years earlier for a colon cancer. The patient had undergone upper gastrointestinal endoscopy during a mass screening for abnormalities in the gastro-intestinal tract, and a slightly depressed lesion of the IIa + IIc type, 25 x 20 mm in diameter, was discovered accidentally at the superior duodenal flexure. The subsequent biopsy revealed a well differentiated tubular adenocarcinoma. Thus, the patient underwent a subtotal gastrectomy and a partial duodenectomy with a lymph node dissection. The histology of the resected specimen was the same as that of the biopsy, but only the mucosa was involved. Adenomatous lesions of the colon are known to occasionally accompany upper gastro-intestinal tumor, so that periodic gastro-intestinal scrutiny follow-ups are mandatory.     

Endoscopic resection with local injection of HSE (ERHSE) in early gastric carcinomas

We have developed a new therapeutic method of endoscopic resection with local injection of HSE (ERHSE) for the early gastric carcinomas. ERHSE was performed for a total of seventy eight lesions of seventy five cases. Seventy eight early gastric carcinomas consisted of IIc (35), IIa (32), I (6), IIa + IIc (4) and IIc + IIa (1). Ten cases out of 75 underwent gastrectomy, because the invasion of carcinoma was detected in the submucosa or to the resected margin. No evidence of local recurrence has been obtained in the sixty five cases treated by this method.     

A case of superficial squamous cell carcinoma of the esophagus showing multicentric development

A 43-year-old male was admitted to the hospital with a complaint of mild dysphagia. A barium esophagogram showed an annular narrowing in the lower esophagus. Further, an endoscopic examination revealed erosive mucosa of the esophagus about 35 cm anal to the incisor. Lugol staining also revealed a geographical unstained lesion. The histologic diagnosis of a biopsy specimen indicated a squamous cell carcinoma and a total resection of the esophagus was performed. The operated material macroscopically showed a tumor of a superficially mixed type (IIa + IIc + IIb). The resected specimen histologically consisted of 18 squamous carcinomas that were separated with the normal squamous epithelium from each other. The major part of these lesions were limited to the epithelium, and only a few specimens microscopically showed an invasion of cancer nests in the propria mucosae. Great permeation of cancer cells into lymph vessels and the metastasis of one regional lymph node also were noted. Taken together, these findings indicated that the squamous cell carcinomas of this case seemed to have multicentrically developed from the normal esophageal mucosa.     

Evaluation of the prognostic factors in patients with stage-I and -II ovarian cancer treated by an operation + irradiation variant

The results of combined treatment (surgery and postoperative radiotherapy) in the group of 240 patients with stage I and II ovarian carcinoma were evaluated. The following factors were found to be important for prognosis: (I) removal of clinically detectable cancer sites during primary surgery (60.7% of 5-year survivals versus 19.4% of cases of surgery described by the surgeon as non-radical); (2) stage of tumor: 62.2% of survivals at stage I as compared with 28.3% at stage II; 73.9% at stage I without changes in the capsule of tumor against 56.9% in the other groups with the same stage; 45.5% at stage IIa versus 22.9% at stages IIb and IIc; (3) low differentiation of ovarian carcinoma which reduces curability to 44.9% in cases of stage I and IIa tumors. Five-year survival rates were higher, though statistically insignificant in those patients with stage Ia(i) and Ib(i) in whom intravaginal radium was applied (81.8%), and in those with stages Ia(ii), Ib(ii) and Ic in whom the whole abdomen was irradiated (64.5%). No statistically significant differences in relation to age, type of surgery, size of tumor identified during the first operation or type of teleradiotherapy (conventional roentgenotherapy or telecobalt therapy) were found.     

胃癌骨转移的临床特点

据文献报道胃癌伴有骨转移发生率为0.46% ～38% ,胃癌伴骨转移的高危因素包括:年轻患者、病理为低分化腺癌、Borrmann Ⅲ型、浸润深度T 3 和T 4、伴多发淋巴转移和胃体部肿瘤。转移途径半数以上为非门脉系统。胃癌伴骨转移而无肝转移病例占69% ,骨转移与淋巴转移区站转移有密切关联,距胃原发病灶3 cm以上存在淋巴转移者,其骨转移发生率为27% 。核素扫描为骨转移提供了诊断途径和可靠的依据,HCG 、CEA 肿瘤标志物检测对诊断骨转移有所帮助,治疗以放化疗为主。骨转移预后较差,大多生存期< 6 个月。      

A case of a perforation indicative of early gastric cancer with various macroscopic findings and a collective review of the relevant Japanese literature

A case of perforated early gastric cancer and a collective review of the relevant Japanese literature is reported. A 83-year-old woman with free air discovered by an abdominal X-ray, was referred to our hospital. On operating, a perforated ulcer was found within and lesions, indicative of a IIc + III type early gastric cancer. Macroscopically, there was an elevated lesion at the antrum of the stomach as well. Histologically, these lesions were connected and moderately differentiated adenocarcinoma. Another lesion was also found at the anterior wall and diagnosed as IIb type gastric cancer.     

Testicular seminoma: analysis of treatment and failure for stage II disease

Seventy-three patients with seminoma testis stage II have been retrospectively analyzed with regard to prognostic factors and value of prophylactic mediastinal irradiation and chemotherapy. Although survival differences were seen between stage IIa, IIb and IIc, these were not statistically significant. Neither was there a significant difference between IIc patients with tumors greater than 10 cm and less than 10 cm in diameter. The incidence of HCG-producing seminomas in the present series was 16%. No significant difference in survival nor relapse rate was found between HCG-producing and HCG-non-producing seminomas. Prophylactic mediastinal irradiation did not influence the survival nor the relapse rate and may therefore be omitted. In the present series there was no significant improvement neither in relapse rate nor survival in patients receiving pre-irradiation chemotherapy. However, the total number of patients is small and optimal pre-irradiation chemotherapy still have to be defined.     

早期胃癌的浸润深度与淋巴结转移关系

目的：探讨早期胃癌的浸润深度、肿瘤大小与淋巴结转移之间的相关性。方法：收集103例外科手术切除的早期胃癌,统计不同时期早期胃癌的检出率,分析其临床及病理特点。结果：103例早期胃癌中黏膜内癌（M）31例,仅有1例（3％）淋巴结转移,黏膜下癌（SM）有63例,淋巴结转移率为17％,其中SM1：16．1％,SM2：34％,SM3：35％;肿瘤最大直径超过2cn的淋巴结转移率（20％）较直径≤2cm者（8．8％）高;肉眼类型中Ⅱ型最多见,并淋巴结转移率也最高;组织类型中高分化腺癌最多,其次为低分化腺癌;且低分化腺癌淋巴结转移率高。结论：早期胃癌的淋巴结转移与肿瘤的浸润深度、肿瘤的大小、肉眼所见及组织类型有关。     

A clinicopathological study of early gastric cancers with a diameter larger than five centimeters

Out of a total of 1,112 resected early gastric carcinomas, 181 that were larger than 5 cm in diameter have been pathologically investigated. Of these, intramucosal and submucosal carcinomas amounted to 68 (37.6%) and 113 (64.4%), respectively. The incidence of their location, shown as a percentage, was 37.8% in the antrum, 57.4% in the corpus, and 4.8% in the fundus (11% in the anterior wall, 13.2% in the posterior wall, 68.1% in the lesser curvature, and 7.7% in the greater curvature). Grossly, the incidence of a type IIc carcinoma was 46.5% and that of a IIc + III type was 20.5%, respectively. Microscopically, in the intramucosal cases, signet ring cell carcinomas were the most frequent histological type, whereas in the invasive submucosal cases, the carcinomas were the intestinal metaplastic type. Lymphatic invasions, venous invasions, and lymph nodal metastases amounted to 32.6%, 6.1%, and 11.6%, respectively. In the early gastric carcinomas, the larger the tumor size, the more likelihood of a signet ring cell carcinoma than a intestinal metaplastic type, and it appeared that a signet ring cell carcinoma had infiltrated the propria mucosae for a longer time when compared to either an intestinal metaplastic type carcinoma or a poorly differentiated tubular adenocarcinoma.     

Analyses of the APC and TGF-β Type II Receptor Genes, and Microsatellite Instability in Mucosal Colorectal Carcinomas

APC and transforming growth factor-β type II receptor (TGF-β RII) gene mutations, and microsatcllitc instability have been found in sporadic colorectal carcinomas. To clarify further the early alterations in colorectal carcinogenesis, we investigated these genetic changes in 23 protruding- and 24 superficial-type mucosal colorectal carcinomas. TGF-β RII gene mutations and microsatellite instability were rarely found in these lesions. Nevertheless, APC was mutated in 16 of the 47 (34.0%) mucosal colorectal carcinomas and was significantly more frequently mutated in protruding- (I) and superficial elevated-type (Ila) (14/32,43.8%) than in other superficial-type (IIa+IIc, IIb, IIc, and IIc+IIa) (2/ 15,13.3%) mucosal colorectal carcinomas (P<0.04). These results indicate that the APC gene may be involved from the beginning in the tumorigenesis of many early colorectal carcinomas, particularly of the protruding and superficial elevated types. However, there might be a distinct pathway for other superficial-type colorectal carcinomas, possibly not involving APC as an initial step of tumorigenesis.     

Two cases of histopathologically advanced (stage IV) early gastric cancers

We report two cases of early gastric cancer with distant metastases (stage IV). At our institute 1428 cases of primary gastric cancer were resected between 1980 and 1997; 536 were diagnosed as early gastric cancer based on the resected specimens (304 cases of mucosal cancer, Tis--TNM classification--and 232 of submucosal cancer, T1). 528 of these 536 cases were classified as histological stage I, six as stage II, none as stage III and two as stage IV. The incidence of stage IV early gastric cancer was 0.14% of all gastric cancers and 0.37% of the early gastric cancers. The two patients with stage IV early gastric cancer were women. Both tumors were defined as early cancer because they were confined to the submucosa. One was a type 0 IIc + III early cancer, histologically classifiable as a small, moderately differentiated adenocarcinoma (tub2 according to the Japanese Classification of Gastric Carcinoma, G2; TNM classification: ICD-O C16), size 10 x 8 mm; the other was a surface spreading type 0 IIc, classifiable as a signet-ring cell carcinoma (sig, G3), size 50 x 35 mm. Stage IV factors were N3 in the first and ovarian metastasis (Krukenberg tumor) in the second case.     

Recurrence of endometrial cancer and its pathological factors

The number of patients with uterine endometrial cancer has increased in recent years in Japan. The studies on the prognostic factors of endometrial cancer, however, have not been made in detail as compared with those on the prognostic factors of cervical cancers. We have therefore investigated retrospectively the prognoses of 94 cases with endometrial cancer treated in our clinic from 1973 to 1984. Out of 31 cases (32.9%) with recurrence, 13 cases were at the Stage I and II, and the recurrence ratios were 11.4% for Stage Ia, 18.2% for Stage Ib and 31.3% for Stage II. The prognosis of endometrial carcinoma appears to depend on the endocervical involvement of the cancer. Five prognostic factors for Stage I and II endometrial cancers analyzed here are as follows; (1) histologic differentiation (grade), (2) size (diameter) of the primary tumor, (3) myometrial invasion, (4) vascular invasion, (5) lymphnode metastasis. (1) The recurrence ratio was 15.0% in the well differentiated (Grade 1) group, 25.0% in the moderately differentiated (Grade 2) group, 27.3% in the poorly differentiated (Grade 3) group, and 12.5% in adenoacanthoma. (2) The ratio of recurrence was 2.9% with less than 3 cm diameter, 24% with 3-6 cm diameter, and 30% with greater than 6 cm diameter in tumor size. (3) The ratio of recurrence was 2.9% with less than 1/3, 24% with 1/3-2/3, and 30% with greater than 2/3 myometrial invasion. (4) The ratio of recurrence was 43.8% with vascular invasion, and 5.6% without it. (5) The ratio of recurrence was 75% with lymphnode metastasis, and 8.8% without it.(ABSTRACT TRUNCATED AT 250 WORDS)