Diagnostic variation and outcome for high-grade gastric epithelial dysplasia

HYPOTHESIS: High-grade dysplasia (HGD) of the gastric epithelium is associated with high prevalence of invasive carcinoma, and distinction by endoscopic biopsy is difficult. DESIGN: Cohort study, 1996 to 2003. SETTING: Tertiary care center. PATIENTS: Consecutive sample of 22 patients with initial diagnosis of gastric HGD by endoscopic biopsy. Biopsy specimens were separately reviewed by 3 experienced pathologists. Clinical management was individually decided. MAIN OUTCOME MEASURES: Strength of interpathologist agreement (kappa) and final pathological diagnosis. RESULTS: The diagnosis was revised to intramucosal carcinoma in 14% to 32% of patients or suspicious for invasive carcinoma in 23% to 41%. The strength of agreement between any 2 pathologists for distinguishing between dysplasia and invasive carcinoma was fair (kappa = 0.35-0.36). A diagnosis of intramucosal carcinoma or suspicious for invasive carcinoma by 2 pathologists correlated strongly with subsequent detection of invasive carcinoma. Three patients underwent gastrectomy for HGD, and invasive carcinoma was detected in all (2 patients, T1 N0; 1 patient, T2 N0). Six patients had invasive carcinoma on endoscopic surveillance at a median of 15 months (range, 3-34 months) after diagnosis of HGD and underwent endoscopic mucosal resection (2 patients, T1 NX), gastrectomy (2 patients, T1 N0), or no resection (2 patients). Another patient had metastatic gastric adenocarcinoma despite having a diagnosis of only HGD by endoscopy. Seven patients (32%) died of unrelated causes, without invasive carcinoma, at a median of 19 months (range, 1-38 months). Three patients were alive with persistent HGD at 26 to 61 months. Two patients had no dysplasia on follow-up. CONCLUSIONS: Experienced pathologists often disagreed in distinguishing invasive carcinoma from HGD in gastric biopsy specimens. One third of patients with gastric HGD died of causes unrelated to cancer. Invasive carcinoma was detected in 67% of the remainder.     

Oesophageal resection for high-grade dysplasia in Barrett's oesophagus

BACKGROUND: The aims of this study were to evaluate the prevalence of invasive cancer in patients with high-grade dysplasia in Barrett's oesophagus and to verify whether a second endoscopy with multiple biopsies could improve the accuracy of preoperative diagnosis. In addition, the mortality, morbidity and survival rates in patients with high-grade dysplasia having oesophageal resection were recorded. METHODS: Fifteen patients were observed from 1982 to 1998; the first seven patients were offered primary oesophageal resection after diagnosis. The other eight patients underwent a second endoscopy with a median of 12 biopsies examined. All later underwent oesophageal resection. RESULTS: Invasive adenocarcinoma was found in five patients, with a minimal difference between the first and second periods (two of seven versus three of eight). There were no perioperative deaths. Early morbidity was observed in eight patients and late morbidity in four. The actuarial survival rate was 79 per cent at 5 years. The Karnofsky status was unchanged from preoperative values in 13 of 15 patients after a median follow-up of 46 months. CONCLUSION: These patients with high-grade dysplasia had a 33 per cent probability of harbouring invasive oesophageal carcinoma but even a second endoscopy failed to identify patients with invasive tumour. Oesophagectomy was performed with no deaths and remains a rational treatment in patients fit for surgery.     

Natural history of urothelial dysplasia of the bladder

Urothelial dysplasia is the putative precursor of urothelial carcinoma in situ (CIS) and invasive urothelial carcinoma of the urinary tract. Urothelial dysplasia is frequently identified in patients with urothelial CIS and cancer. However, very little is known about the clinical presentation and natural history of urothelial dysplasia in the absence of urothelial CIS or invasive cancer. The authors studied 36 patients with isolated urothelial dysplasia at the Mayo Clinic between 1969 and 1984. None of these patients had previous or concurrent urothelial CIS or invasive cancer, and none received treatment for dysplasia. The histopathologic features of urothelial dysplasia were examined, and long-term clinical follow-up was obtained. Progression was defined as the development of urothelial CIS or carcinoma. The male-to-female ratio was 2.6:1, and the mean patient age at the time of diagnosis was 60 years (range 25-79). Urothelial dysplasia has a predilection for the posterior wall. Eleven patients had urinary irritative symptoms, 10 had hematuria, 3 had both irritative symptoms and hematuria, and 12 were found to have dysplasia incidentally. The mean follow-up was 8.2 years (range 0.1-25.5). Seven (19%) of 36 patients developed biopsy-proven progression, including 4 with CIS and 3 with invasive cancer, and 1 of them died of bladder cancer. The intervals from diagnosis to progression ranged from 6 months to 8 years (mean 2.5 years). One of the remaining 29 patients had positive cytologic results 2.5 years after the initial diagnosis of dysplasia. The authors conclude that urothelial dysplasia is a significant risk for the development of CIS and invasive urothelial carcinoma, and patients with urothelial dysplasia should be followed up closely.     

Histologic appearances of endoscopic gastric mucosal biopsies 10--20 years after partial gastrectomy.

Fifty-six symptomatic patients, who had had a partial gastrectomy 10--24 years previously for benign disease, were examined by endoscopy and multiple mucosal biopsies. No patient had a completely normal gastric mucosa. Varying degrees of gastritis, intestinal metaplasia, foveolar hyperplasia and dysplasia were seen. Seventeen patients (30%) had extensive areas of dysplasia associated with acute or chronic inflammation. Severe dysplasis, however, was detected in only one case. In five patients a "diffuse type" carcinoma of the gastric stump was found. While it is generally accepted that significant dysplasia (moderate or severe dysplasis) is premalignant, the degree of risk is unknown. This makes management of individual patients difficult.     

Management of gastric remnant carcinoma based on the results of a 15-year endoscopic screening program.

SUMMARY BACKGROUND DATA: Partial gastrectomy for benign peptic ulcer disease is associated with an increased risk of adenocarcinoma of the gastric remnant, especially in patients who are at least 15 years' postgastrectomy. Increasing evidence of mucosal dysplasia is noted on random gastric biopsy and may serve as a histologic marker in the identification of early cancer of the gastric stump. METHODS: From an initial group of 233 patients who underwent gastrectomy for benign peptic ulcer disease between 1960 and 1975, 163 patients began yearly flexible gastroscopy and random mucosal biopsy. Routine histologic studies identified either normal or dysplastic epithelium as well as adenocarcinoma. An average of eight biopsies were taken per endoscopic study. All endoscopic studies were performed by surgical residents under the supervision of one surgical attending. RESULTS: From July 1980 to June 1995, 145 patients completed annual gastroscopy and random biopsy. A total of 2287 endoscopic studies were performed. Fifteen patients were found to have severe dysplasia. Nine (60%) had associated microscopic evidence of adenocarcinoma. Four additional patients had macroscopic adenocarcinoma on endoscopic examination. All 13 patients with cancer were asymptomatic. Six patients continue surveillance who display moderate-to-severe dysplasia alone. The 13 patients with carcinoma underwent completion gastrectomy (R2 nodal dissection) with no evidence of cancer found beyond the gastric wall. These patients averaged 29 years since their original partial gastrectomy. OBJECTIVE: A prospective screening program for gastric remnant cancer was begun to assess the ability to discover early neoplastic changes on random biopsy and to make treatment decisions regarding the efficacy of completion gastrectomy after discovery of carcinoma. CONCLUSIONS: Aggressive annual screening using flexible endoscopy and multiple random biopsy may discover cancer in the gastric remnant and can lead to completion curative gastrectomy in asymptomatic people. Patients who are at least 20 years postpartial gastrectomy for benign disease should be considered for annual endoscopic surveillance.     

Severe dysplasia in children with familial adenomatous polyposis: rare or simply overlooked?

Background/Purpose

Because severe dysplasia and carcinoma in children with familial adenomatous polyposis (FAP) younger than 18 years is rare, earlier surgical intervention is not common. The purpose of this study is to report the prevalence of dysplasia and carcinoma among children with FAP in our institution.

Methods

From 1998 through 2004, children 18 years or younger with FAP that underwent total proctocolectomy at a large children's hospital were retrospectively reviewed.

Results

Eleven children underwent surgery for FAP. The mean age at surgery was 13 ± 3.2 years. Approximately half of the patients who underwent preoperative endoscopy had evidence of dysplasia. Nine (82%) patients had dysplasia on preoperative biopsy and/or operative specimen, and 3 (27%) of these patients had severe dysplasia or carcinoma in situ. Four of the 5 patients without symptoms had evidence of dysplasia. No patients had invasive carcinoma.

Conclusion

We observed a higher incidence of severe colonic dysplasia in young children with FAP compared with the current literature. A significant number of patients with dysplasia at surgery had no symptoms and no evidence of dysplasia on preoperative endoscopic biopsies. These data suggest that earlier intervention in children with FAP may be beneficial and should be investigated further.     

Gastric dysplasia. A histological follow-up study

To evaluate the clinical and biological significance of gastric dysplasia, we reviewed the histology of all available specimens of gastric mucosa in 85 patients in whom dysplasia had been previously diagnosed. The initial diagnosis of dysplasia was mild (Dy I) in 23 cases, moderate (Dy II) in 41 cases, and severe (Dy III) in 21 cases. The length of follow-up varied from 3 months to 11 years, with an average of 42 months. The follow-up of cases with Dy I and Dy II suggests that both lesions progress slowly and in most instances will remain stable or regress. In 18 cases, a carcinoma was found--17 in the group of Dy III and one in the group of Dy II. Of the 18 carcinomas, nine were at an early stage. Our data suggest that severe dysplasia is a reliable marker of high risk of gastric cancer and represents a strong indication for a gastrectomy.     

胃癌术后复发的再手术治疗

目的 探讨胃癌术后复发的早期发现、早期诊断和再手术治疗问题,提高胃癌5年生存率.方法 回顾性分析1994～1997年17例胃癌术后复发再手术病例.结果 胃癌术后复发71%发生于2年之内,早期发现依赖于术后定期胃镜检查,再次手术获根治性切除者生存14个月～4年,获姑息性切除者生存6个月～22个月.结论 对胃癌术后复发病人再次手术行根治性切除者,可延长病人生存时间,术后定期纤维胃镜检查有助于早期发现和早期诊断.     

Photodynamic therapy for carcinoma in situ of the anus

HYPOTHESIS: Photodynamic therapy (PDT) for carcinoma in situ of the anus is an alternative to surgical excision in patients who are seropositive for human immunodeficiency virus (HIV). DESIGN: Before-after trial.Settings Tertiary referral center. PATIENTS: Twelve HIV-seropositive patients who were actively being treated for AIDS with high-grade dysplasia on anal Papanicolaou test results had site-directed biopsies of acetowhitening foci immediately after application of dilute acetic acid. Biopsy results showed that 5 patients had anal carcinoma in situ. These patients were given the photosensitizer delta-aminolevulinic acid orally. Four to 4.25 hours later, the entire anal circumference was treated with PDT. All 5 patients, after being treated with PDT, had repeated Papanicolaou tests at monthly intervals. If acetowhitening occurred at the fifth month, site-directed biopsy was done. MAIN OUTCOME MEASURES: Anal cytologic examination by Papanicolaou test and site-directed biopsy if acetowhitening was found at 5 months in order to determine effectiveness of PDT in downstaging cytologic findings. RESULTS: All patients had a consistent downgrading of cytologic findings during the 5 months of follow-up. Papanicolaou test results showed 2 patients had no dysplasia, 2 had mild dysplasia, and 1 had moderate dysplasia. Moderate dysplasia was confirmed by site-directed biopsy results. No complications of PDT occurred, but all 5 patients developed various abnormalities in liver function test results that returned to baseline values within 2 weeks; this also has been noted in patients ingesting delta-aminolevulinic acid who are presumably HIV seronegative. CONCLUSION: In a group of patients who are at high risk for recurrence irrespective of initial treatment, PDT can be used as a successful alternative to surgical excision for anal carcinoma in situ.     

Impact of grade of dysplasia in villous adenomas of Vater's papilla

Therapeutic strategies for villous adenoma of the papilla of Vater remain controversial. This study evaluates the accuracy of preoperative histopathologic diagnosis and the impact of the grade of dysplasia on recurrence as well as on potential alteration of the surgical approach. A series of 32 patients with an adenoma of Vater's papilla who underwent local resection or pylorus-preserving pancreaticoduodenectomy between January 1990 and August 2000 were reviewed retrospectively. Multiple endoscopic biopsies had been performed preoperatively. The histopathology of the preoperatively obtained biopsy specimens and subsequent surgical specimens were evaluated for grade of dysplasia by two pathologists and correlated with the clinical course after operative treatment. Altogether, 3 of 11 patients (27%) with a low-grade (LG) dysplasia adenoma and 6 of 21 patients (29%) with a high-grade (HG) dysplasia adenoma in the initial endoscopic biopsy specimens exhibited invasive carcinoma at the postoperative histologic examination (NS). Recurrence was not observed in the 6 patients from the LG dysplasia adenoma group following local resection and benign postoperative histology. In contrast, recurrence of villous adenoma was discovered in 2 of 12 patients (17%) and development of invasive carcinoma in 5 of 12 patients (42%) from the preoperative HG dysplasia group (p <0.05). The overall risk of carcinoma after primary diagnosis of an HG dysplasia adenoma was 44% (14/32). Adenoma of the papilla of Vater including HG dysplasia appears to be associated with a high risk of exhibiting invasive carcinoma postoperatively and a high rate of recurrence. Therefore pylorus-preserving pancreaticoduodenectomy should be offered to patients with an HG dysplasia adenoma.     

Barrett's esophagus with high-grade dysplasia: an indication for esophagectomy?

Between 1982 and 1991, 19 patients (17 men and 2 women) with Barrett's esophagus, 10 of whom were in a surveillance program, were found to have high-grade dysplasia without evidence of invasive carcinoma. Median age was 66 years (range, 30 to 79 years). Heartburn was the most common presenting symptom. Esophagoscopy at the time of high-grade dysplasia diagnosis demonstrated normal Barrett's mucosa in 10 patients (53%), shallow ulcers in 3, slight mucosal irregularities in 2, small mucosal nodules in 2, stricture in 1, and shallow ulcer with stricture in 1. Eighteen patients underwent esophagectomy. There were no operative deaths. Nine patients (50%) had invasive carcinoma. Postsurgical stage was stage 0 in 9 patients, stage I in 6, stage IIA in 2, and stage IIB in 1. Median follow-up was 34 months (range, 2 to 116 months). Recurrent cancer developed in 2 patients. Overall 5-year survival was 66.7%; 5-year survival for patients with stage 0 disease was 100% and for stage I and II disease, 35.7%. We conclude that high-grade dysplasia in an indication for esophageal resection because of the high rate of associated early invasive carcinoma and that resection can be done safely with the expectation of excellent long-term survival. Because of these findings, we continue to recommend endoscopic surveillance in all patients with Barrett's esophagus.     

Dysplasia in Barrett's esophagus. A clinicopathologic study of six patients

To evaluate the consequences of dysplasia in Barrett's esophagus, six patients with esophageal mucosal biopsies showing dysplastic Barrett's mucosa in the absence of clinically evident esophageal carcinoma were identified and their clinicopathologic features reviewed. The patients, four men and two women, averaged 60 years and had long histories of gastroesophageal reflux. Four patients had high-grade dysplasia; two had low-grade. Dysplastic Barrett's mucosa appeared to arise most commonly from specialized-type Barrett's mucosa. After a mean follow-up of 29 months, four patients, all with high-grade dysplasia, had esophageal resections. Three of the four were found to have invasive adenocarcinoma, which extended through the esophageal wall in two patients. The fourth patient had a noninvasive adenomatous polyp ("Barrett's adenoma"), an infrequently described form of dysplasia in Barrett's esophagus. The two patients with low-grade dysplasia had developed no clinical indications of carcinoma. The results confirm that dysplastic Barrett's mucosa, particularly the high grade, is a morphologic marker for adenocarcinoma. Biopsy surveillance of patients with Barrett's esophagus is histologically feasible, but prospective studies are required to prove its effectiveness.     

Gastric carcinoma resected 95 months after being diagnosed: Report of a case

It is usually assumed that patients with gastric carcinoma will almost certainly die within 5 years if they do not receive treatment. We report herein a rare case of curative gastrectomy being performed 95 months after gastric carcinoma was diagnosed. A 37-year-old Japanese man had an upper gastrointestinal endoscopy with biopsy which revealed moderately differentiated adenocarcinoma of the stomach. This was diagnosed as type 11c early gastric carcinoma with ulceration but he refused surgery. At 45 years of age, 95 months later, he presented to our hospital with melena, at which time lesions in an identical location had enlarged to Borrmann type 3 advanced gastric carcinoma. Thus, a total gastrectomy with regional lymph node dissection was performed. Although there was no liver or peritoneal metastasis, the regional lymph nodes were involved; however, the patient recovered well and is still alive without any further recurrence roughly 4 years postoperatively. The natural history of gastric carcinoma and the malignant cycle are discussed following the presentation of this case.     

Can a failed ileal pouch anal anastomosis be left in situ?

OBJECTIVE: Failure after ileal pouch-anal anastomosis (IPAA) is reported with a frequency of 10-20%. The failed IPAA can be excised or defunctioned. Indications for excision and further management of an indefinitely diverted pouch are poorly described. The aim of the present investigation was to investigate pouch-related problems and the histopathological pattern of the pouch mucosa in this group of patients. METHOD: In a cohort of 620 patients having IPAA with a median follow-up of 14 years, 56 patients with failure were identified. The patients with defunctioned pouches were assessed with regard to pouch-related problems and endoscopy with biopsies was performed. Biopsies were stained with haematoxylin-eosin, PAS for neutral mucins and Alcian blue/high iron diamine for sialomucins/sulphomucins. Morphological changes were grouped into three types modified according to Veress and assessed for dysplasia. RESULTS: Twenty-two patients with an indefinitely diverted pouch were found. The follow-up time after surgery for failure was 10 years. Thirteen patients completed the follow-up. Except for two patients with pelvic/perineal pain, there were no clinical problems. The majority of patients displayed mild to moderate macroscopic signs of inflammation. Morphologically, findings ranged from a preserved mucosal pattern to intense inflammatory reaction. No case of dysplasia or carcinoma was found. CONCLUSION: Most patients with an indefinitely diverted pouch had no complaints regarding the pouch. There was no case of dysplasia. Indefinite diversion may be preferable to pouch excision, especially given the associated morbidity.     

Clinical study of carcinoma of the penis

We reviewed six cases of carcinoma of the penis seen at our department during the last 12 years. The mean age and mean followup period were 56 +/- 11 years and 53 +/- 42 months, respectively. Inguinal lymphadenopathy was evident in all patients, one of whom was diagnosed as having nodal metastasis because of the persistence of adenopathy after antimicrobial therapy. Four patients, had Jackson Stage 1, 1 Stage 2 and 1 Stage 3 cancer. The patient with Stage 3 cancer underwent total penectomy and bilateral inguinal lymphadenectomy. He died of cancer 2 years after the operation. The 5 patients with stage 1 or 2 underwent partial penectomy without lymphadenectomy. Pathological examination showed moderately differentiated squamous cell carcinoma (SCC) in 2 patients with stage 2 and 3 cancer, well differentiated SCC in 3 and verrucous carcinoma in the other patient with stage 1 cancer. Prophylactic external radiation therapy to the groin was performed in 3 of the 4 patients with invasion to corpus spongiosum (pT2). Two of the 3 patients developed mild radiation dermatitis, and no major complications were observed. The 5 patients with clinically negative nodes showed no evidence of recurrence after surgery. As reported by others, inguinal node metastasis appears to worsen the prognosis of patients with carcinoma of the penis.     

Long-term follow-up of patients with familial adenomatous polyposis undergoing pancreaticoduodenal surgery

Adenomatous polyps and adenocarcinomas of the periampullary region are the most common upper gastrointestinal neoplasms encountered in familial adenomatous polyposis (FAP) patients. Tumors arising from the liver, biliary tract, and pancreas have also been reported. The purpose of this study was to review the clinical outcome of FAP patients after pancreaticoduodenal surgery for periampullary neoplasms. Of the 61 individuals participating in our prospective FAP registry, 8 underwent surgical resection of periampullary neoplasms between 1987 and 1998. The charts of these individuals were reviewed for clinical indications, type of pancreaticoduodenal surgery, postoperative complications, and outcome. Of the 8 patients identified, 7 had pancreaticoduodenectomy and 1 had duodenotomy with ampullectomy. The indications for surgery were periampullary cancer (3), severe dysplasia within a duodenal villous tumor (4), and solid-pseudopapillary tumor of the pancreas (1). At the time of pancreaticoduodenal surgery, patients ranged in age from 29–65 years, and all but one had undergone colorectal surgery, on average 16 years beforehand. Pancreatic ascites after a pylorus-sparing pancreaticoduodenectomy was the only surgical complication. At a median follow-up of 70.5 months (range 37–162), 2 patients had died, neither from their periampullary neoplasm. The patient treated by local excision subsequently developed gastric cancer arising from a polyp and went on to gastrectomy. Another patient developed confluent benign jejunal adenomas just beyond the gastroenteric anastomosis almost 12 years after pancreaticoduodenectomy for severe dysplasia of a duodenal villous adenoma. Pancreaticoduodenectomy is a safe and appropriate surgical option for FAP patients with duodenal villous tumors containing severe dysplasia or carcinoma. Postoperative morbidity was minimal and there was no perioperative mortality. Good long-term prognosis can be expected in completely resected patients although subsequent proliferative and/or neoplastic lesions may still be detected in the gastrointestinal tract with prolonged follow-up. Presented at the Forty-Second Annual Meeting of The Society of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation).     

Changing Patterns of Prognosticators During 15-Year Follow-Up of Advanced Gastric Cancer after Radical Gastrectomy and Adjuvant Chemotherapy: A 15-Year Follow-Up Study at a Single Korean Institute

Background We evaluated the long-term natural history of gastric cancer after radical gastrectomy and adjuvant chemotherapy through a 15-year follow-up study at a single institute. Methods Five hundred patients with advanced gastric adenocarcinoma who received radical gastrectomy and adjuvant chemotherapy were included in this long-term follow-up study. Patients were evaluated by imaging studies and upper gastrointestinal series or endoscopy every 6 months until the 10th year after surgery. Since then, the patients have been followed yearly in the same manner. Results The median follow-up period was 190.5 months. The recurrence rate in 5-year survivors was 10.8%. The dominant recurrence pattern was peritoneal carcinomatosis within 5 years and distant metastasis after 5 years post gastrectomy. Tumor stage was a clear-cut prognosticator within 5 years post gastrectomy, but was no longer informative in 5–10 years. At this period, only stage IV (IB–IIIB vs IVM0) was a significantly poor prognosticator. After 10 years, second primary cancer (seven cases) became as important an issue as recurrence of primary gastric cancer (six cases). Conclusions In patients with gastric carcinoma treated with radical gastrectomy and adjuvant chemotherapy, late recurrence after 5 years post gastrectomy was not rare. Prognosticators were varied depending on the length of time after surgery. Tumor factors including stage were prognosticators within 5 years post gastrectomy, but tumor factors except stage IV had no prognostic value after 5 years. In the 5–10 years post gastrectomy, only stage IV (IB–IIIB vs IVM0) was a poor prognosticator. Also, after 10 years, there were no prognosticators. Presented in part at the 42nd Annual Meeting of the American Society of Clinical Oncology, Atlanta, GA, USA. June 2–6, 2006 (abstract No. 4050).     

Nutritional status after total and partial gastrectomy with Roux-en-Y reconstruction

Dietary intake and nutritional status were studied in two groups of patients after total gastrectomy (n = 10) and after partial gastrectomy (n = 10). All patients were reconstructed with a Roux-en-Y loop. Investigations were carried out 4-17 years after the operation. Eight patients in the group undergoing total gastrectomy and four patients undergoing partial gastrectomy had gastric carcinoma and were without recurrent disease 5-15 years after the operation. A clinical dietician conducted an anthropometric evaluation. All patients underwent an upper gastrointestinal endoscopy, clinical examination, [14C]triolein breath test and a blood chemistry profile. The median weight loss from operation to investigation was 2.1 kg in the partial gastrectomy group and 6.7 kg in the total gastrectomy group (n.s.). After partial gastrectomy three patients had a subnormal body mass index (n.s.). This was not found in the total gastrectomy group. Energy intake was below that recommended in seven patients in the partial gastrectomy group (three of them had a subnormal body mass index) and in two in the total gastrectomy group (n.s.) [14C]triolein breath testing revealed fat malabsorption in three patients after partial gastrectomy and in five patients after total gastrectomy (n.s.).     

Role of re-resection in early gastric stump carcinoma

Between 1971 and 1990, 26 patients were diagnosed as having an early carcinoma in the gastric remnant after ulcer surgery. Three patients with proximal tumour location were operated on with total gastrectomy. The surgical strategy in the remaining patients with tumour adjacent to the anastomosis was re-resection of at least 5-6 cm of the anastomotic area and restoration of gastrointestinal continuity with a Roux-en-Y loop. A margin of at least 2 cm from the carcinoma to the resection line was taken. There was no postoperative mortality. In three cases the preoperative endoscopic and histological judgement of tumour classification and stage was incorrect; when the surgical specimens were examined one patient was found to have advanced carcinoma and in the other two no malignancy could be found. Median follow-up was 15 years (range 3-19 years). During follow-up, six of the re-resected patients developed recurrences, all located in the gastric remnant. Four patients with recurrence underwent reoperation with total gastrectomy, one had exploratory laparotomy and one had no further surgery. No postoperative deaths occurred. Three of the six patients died from gastric carcinoma. We conclude that this surgical strategy failed to prevent local recurrence of an early form of gastric carcinoma, considered to be potentially curable in virtually all cases. Partial resection of the gastric remnant as the treatment of choice in patients with early gastric stump carcinoma cannot be recommended.     

Carcinoma of the surgically treated stomach. Our experience]

Between 1977 and 1991, 12 patients (11 males and 1 female; median age of 62.7 years) with gastric stump cancer were observed. All patients were previously operated for benign gastric (4) or duodenal (8) ulcer disease. Median duration interval between first operation and the diagnosis of gastric carcinoma was 22.0 years (range 7-39 years). Only in 5 patients total gastrectomy was carried out. Two out of these 5 patients are still alive at 2 and 24 months after surgery, while the median survival of remaining patients was about 9 months. The usefulness of close follow-up and digestive endoscopy in peptic ulcer patients who had surgical treatment is considered in order to detect an early gastric stump cancer.