残胃癌的病因及预防对策分析

目的总结残胃癌的临床特征,分析其病因及预防对策。方法选择1999年2月至2010年2月因胃良性病而住院行胃大部切除术的患者进行随访观察,将术后发生残胃癌（残胃癌组）和未发生残胃癌（残胃组）病例的临床特征进行分析,对两组的一般情况、长期吸烟史,以及术后胆汁反流率、幽门螺杆菌（Helicobacter pylori,Hp）感染率等进行比较,以进一步分析残胃癌可能的病因及预防对策。结果共有89例患者获得完整随访资料,其中32例发生残胃癌,57例无残胃癌发生。两组在年龄、性别、原发病及第一次手术方式的差别均无统计学意义（均P〉0.05）。术后残胃癌组与残胃组胆汁反流率比较为87.5%vs.57.9%,P〈0.01;Hp感染率比较为84.4%vs.56.1%,P〈0.01;长期吸烟史比较为62.5%vs.40.4%,P〈0.05。长期吸烟史与无吸烟史胆汁反流率比较55.7%vs.32.1%,P〈0.05。结论单因素考察证实,远端胃大部切除术后胆汁反流、Hp感染、长期吸烟史是发生残胃癌的高危因素,BillrothⅡ式手术不是发生残胃癌的独立风险因子,吸烟可促进胆汁反流的发生,控制胆汁反流、Hp感染和戒烟有望降低发生残胃癌的风险。     

Early gastric cancer – excellent prognosis after curative resection in 87 patients irrespective of submucosal infiltration, lymph-node metastases or tumor size

BACKGROUND AND AIMS: Despite a decreasing incidence of primary gastric carcinoma over the last decade, the incidence of early gastric cancer has remained unchanged. Some aspects of the surgical treatment (e.g., extent of resection, lymphadenectomy) are still controversially discussed in the literature. PATIENTS/METHODS: Between May 1986 and July 1999, 87 patients were operated upon due to primary early gastric adenocarcinoma. All patients data were analyzed retrospectively. RESULTS: Of 626 patients with primary gastric carcinoma, 87 (13.9%) had an early carcinoma (54 men, 33 women; median age 61 years). In all patients, curative (R0-) gastrectomy could be performed, total in 62 patients (71.4%) and subtotal in 25 patients (28.6%). Postoperative morbidity was 23% and mortality 4.5%. Mucosal tumors were found in 34 (39.1%) and submucosal in 53 (60.9%) patients. Multicentricity was present in eight cases (9.1%). Twelve patients (13.8%) had lymph-node metastases. The 5-year survival rate was 88.8%. The submucosal infiltration, the lymph-node infiltration, the histological type, and the tumor size had no statistically significant impact on prognosis. CONCLUSION: Radical resection of early gastric cancer cured most of the patients, irrespective of lymph-node metastases or tumor size. Multicentricity, increasing incidence of proximal cancers, and low mortality suggest that total gastrectomy may be indicated. Patients with early gastric cancer may benefit from D2-lymphadenectomy, but this has to be assessed in further randomized studies, in particular for those with small mucosal tumors.     

Early experience with laparoscopic radical gastrectomy for advanced gastric cancer

Use of the laparoscopic approach for the management of gastric cancer is still in the developmental phase. The authors present their experience with laparoscopic radical gastrectomy for advanced gastric cancer. Between September 1997 and August 1999, four laparoscopic gastrectomies for gastric carcinoma were performed on two male and two female patients (mean age, 61.5 years). One D2 total radical gastrectomy and three D2 subtotal distal gastrectomies were performed, using a totally laparoscopic approach. Mean operative time was 210 minutes. There were no intraoperative complications. All four patients recovered uneventfully from surgery and began oral feeding on the third postoperative day. Median postoperative stay was 7 days (range, 6-9). All patients were alive 8 months to 3 years after the operation, with no cancer recurrences. This series shows that laparoscopic radical gastrectomy for moderately advanced cancers can produce good results in terms of safety and oncologic adequacy.     

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??Correlation analysis of Helicobacter pylori infection to the clinicopathological features of gastric cancer:An analysis of 125 patients LIU Kai, ZHANG Wei-han, YANG Kun, et al. Department of Gastrointestinal Surgery, West China Hospital of Sichuan University , Chengdu 610041, China
Corresponding author: HU Jian-kun, E-mail: hujkwch@126.com
Abstract Objective To investigatethe clinicopathological features of gastric cancer based on Helicobacter pylori (Hp) status. Methods The clinical data of 125 patients who underwent gastrectomy for gastric cancerbetween May 2013 and May 2014 in the Department of Gastrointestinal Surgery, West China Hospital of Sichuan University were analyzedretrospectively. 14C urea breath test (14C-UBT) was applied to define the status of Hp. Patients were divided into two groups (HP positive and HP negative).The differences of clinicopathological characteristics were compared between two groups. Results The outcome of 14C-UBT showed there were 62 patients (49.6%) with Hppositive and 63 patients (50.4%) negative. For patients with HP positive, the proportion of lower third gastric cancer was higher (69.4%vs.49.2%), while the middle third gastric cancer was lower (6.5%vs.20.6%)(P=0.047). The proportion of tubular adenocarcinoma and the expressive rate of Her-2 were higher in HP positive patients than that of patients without Hp infection(53.2%vs.30.2%, P=0.009) (52.1%vs.25.5%, P=0.005). However, in the current study there was no significant difference on tumor size, depth of tumor invasion, lymph nodes metastasis, distant metastasis and grade of histological type between two groups.The expression of Her-2 in gastric cancer patients had independent correlation with Hp positive by Logistic regression analysis [P=0.006??Exp(B)=0.314??95%CI(0.137-0.720)].Conclusion Hp may have relationship with the tumor location and expression of Her-2 in gastric cancer patients, while the correlation to tumor stage and prognosis is needed to be further investigated.     

The prevalence of Helicobacter pylori infection in gastric cancer and gastric stump cancer

In 1994, the International Agency for Research in Cancer recognized Helicobacter pylori (Hp) as "a definitive cause of human cancer". The present study aimed at determining the prevalence of Hp infection in the gastric cancer developed on the background of a disordered stomach as compared with gastric stump cancer. The prevalence of Hp infection was a twice higher in the patients with gastric cancer than in those with gastric stump cancer, and in both cases much lower than that reported in the literature. Possible explanation would be the much older mean age of the patients, the protective role of gastrectomy, and the multifactorial etiopathogenesis in both gastric and gastric stump cancers.     

Differences between Biopsy- or Specimen-related Laurén andWorld Health Organization Classification in Gastric Cancer

The extent of stomach resection in gastric cancer depends on tumor size, tumor location, depth of invasion, and the histological allocation to intestinal or diffuse type according to Laurén. As the latter is based on preoperative findings we performed a retrospective histomorphological study to quantify the differences between biopsy-related and surgical specimen-related Laurén classification. Additionally the World Health Organization (WHO) classification of preoperative endoscopic biopsies and surgical specimens were compared. Preoperative biopsies and resected tumor specimens from 100 patients with primary gastric carcinoma were retrospectively classified according toLaurén and WHO. The reclassification was independently performed by three pathologists who were not aware of the previous diagnoses. In 74% the Laurén classification of pre- and postoperative specimens was identical, whereas 26% of the cases showed a disagreement. Out of 48 tumors with preoperative diagnosis of an intestinal type, 10 tumors (20.8%) exhibited a diffuse growth pattern in the gastrectomy specimens; and 16% of the cases showed a disagreement of the pre- and postoperative histopathological type according to the WHO classification. Preoperative biopsy-related and surgical specimen-related Laurén classification differ in about one-quarter of the cases. Mostly, the preoperative diagnosis of an intestinal tumor type must be corrected into a diffuse or mixed type according to Laurén. Since this may have consequences for the surgical strategy, the extent of surgical resection, rebiopsies, and reconfirmation of an intestinal type should be performed at least in those cases with any doubts of this classification.     

Stage-dependent approach to stomach cancer

Accurate staging by unambiguously defined, comparable criteria is essential for a phase-adjusted therapeutic concept to cope with gastric carcinoma. Decision-making on gastrectomy or subtotal gastric resection has to depend primarily on tumour localisation and prognosis by histological classification according to Laurén. Between January 1, 1980, and May 1, 1988, operations for gastric carcinoma were performed on 203 patients at the Surgical Department of Charité, with gastric resection being applied to 144 of them. Postoperative lethality amounted to nine per cent. Indications were established in 66 cases for gastrectomy and in 78 patients for subtotal gastric resection. Two-year survival rates were 52 per cent for the intestinal cell type and 35 per cent for the diffuse type. Prognosis can be improved by radical resection and extensive lymph node removal at the first two lymph node stages. Resection of other infiltrated organ regions may quite often prove necessary for oncological radicality. Splenectomy will be chosen for stomach carcinomas localised in the upper and medium thirds or in tumour stages III and IV.     

血栓调节蛋白在胃癌组织中的表达

目的 研究血栓调节蛋白（ＴＭ）的胃癌组织中的表达。方法 应用免疫组织化学ＡＢＣ法对４０例手术切除胃癌标本进行ＴＭ表面的研究。结果 １８例肠型胃癌中,１５例ＴＭ表达阳性（８３．３％）,２２例弥漫型胃癌中,１１例ＴＭ表达阳性（５０．０％）;６０岁以上病人是２３例,其中１９例ＴＭ表达阳性（８２．６％）,６０岁以下病人１７例,其中７例ＴＭ表达阳性（４１．２％）,肠型胃癌ＴＭ的表达明显高于弥漫型胃癌（Ｐ〈０     

Increased epithelial cadherin expression among Japanese intestinal-type gastric cancers compared with specimens from American patients of European descent

The different patterns of gastric cancer in the Far East and West have evolved to the extent that it has been suggested that the disease in Japan is biologically less aggressive than in the West. We studied paraffin-embedded, formalin-fixed tissue blocks from Japanese patients and American patients of European descent who had undergone gastrectomy for gastric cancer not involving the gastroesophageal junction. Specimens were staged (T stage), graded (Lauren classification), and biomarker expression (epithelial cadherin [E-cadherin], c-erbB2, Ki67, and p53) was quantified using immunohistochemistry without knowledge of the country of origin. E-cadherin was expressed in 49 per cent of malignant cells from Japanese specimens compared with 27 per cent of malignant cells from American specimens (P = 0.04). The expression of E-cadherin on diffuse cancers from the two countries was similar (34.4 in Japanese vs 41.5 in American, P = 0.92). E-cadherin expression, however, was significantly higher among intestinal cancers from the two countries: 56.3 per cent of cells from intestinal or mixed cancers from Japan (n = 32) expressed E-cadherin compared with 22.2 per cent of American specimens (n = 12; P = 0.008).-c-erbB2 was expressed on a higher proportion of malignant cells from American specimens (30% vs 22%; P = 0.20). E-cadherin expression, a favorable prognostic factor, is more common in Japanese intestinal-type gastric cancer not involving the gastroesophageal junction. If the biology of gastric cancer in the Far East is less aggressive than that in the United States, it is likely that treatments need to be individualized.     

细胞因子信号转导抑制因子1基因甲基化状态与胃癌幽门螺杆菌感染的关系

目的检测胃癌组织细胞因子信号转导抑制因子（SOCS-1）启动子区甲基化状态,初步探讨其甲基化状态与胃癌幽门螺杆菌（Hp）感染的关系。 方法选取2016年9月至2018年9月接受根治性手术的胃癌患者63例（胃癌组）,另选取同期行胃黏膜病理切片检查的胃黏膜息肉患者67例（对照组）,检测两组胃黏膜组织中SOCS-1基因甲基化状态,实时荧光定量PCR（RT-PCR）法及免疫印迹法检测病理组织SOCS-1 mRNA及蛋白表达水平,快速尿素酶试验检测Hp感染情况,分析胃癌组织SOCS-1甲基化与Hp感染相关性。 结果与对照组相比,胃癌组患者Hp感染阳性率升高（74.60% vs 11.94%,χ²=52.234,P<0.001）,SOCS-1启动子区CpG岛异常甲基化发生率升高（80.95% vs 5.97%,χ²=74.491,P<0.001）。Hp感染阳性胃癌患者的SOCS-1甲基化比例显著增高（95.74% vs 4.26%,χ²=26.261,P<0.001）,Hp感染阳性是SOCS-1甲基化的危险因素（OR=1.576,95% CI：1.126~2.205,P=0.035）。SOCS-1甲基化与胃癌分化程度低、TNM分期、淋巴结转移有关（χ²=11.530、9.380、11.581,均P<0.01）。与Hp感染阴性组相比,Hp感染阳性组SOCS-1 mRNA和蛋白表达量显著降低（P<0.05）。 结论Hp感染可能与SOCS-1 DNA启动子区甲基化密切相关,并通过影响SOCS-1甲基化促进胃癌发生、发展。     

Is extensive lymphadenectomy necessary for surgical treatment of intramucosal carcinoma of the stomach?

This study was undertaken to elucidate those histological and gross features associated with gastric carcinoma that can be adequately treated by gastrectomy with less aggressive lymphadenectomy. The frequency of metastasis to the lymph nodes was analyzed in 514 cases of resected, solitary, gastric carcinomas. The frequency of metastasis to the lymph nodes increased in proportion to the increase in the extent of penetration by the cancer into the gastric wall. Lymph nodes were not involved in cases of intramucosal carcinoma of the intestinal type, by Laurén's histological classification. By contrast, metastasis to the lymph nodes was observed in cases of intramucosal carcinoma of the diffuse type, by Laurén's classification. We conclude that extensive lymphadenectomy is not mandatory for patients with intramucosal carcinoma of the stomach of the protruded type, since the lymph nodes do not become involved in this type of gastric carcinoma.     

Microsatellite instability in Japanese vs European American patients with gastric cancer

BACKGROUND: The stage-stratified survival following gastrectomy for gastric cancer is far better in Japan than in the United States. The process of carcinogenesis may differ in gastric cancers from Japan and the United States, accounting for prognostic differences, as patients of Asian descent treated in United States also exhibit superior survival in comparison with non-Asian patients. HYPOTHESIS: The phenotype of gastric cancer differs between Japanese and American patients. DESIGN: Retrospective case-case (blinded) study. SETTING: University hospitals in Japan and the United States. PATIENTS AND METHODS: We compared the frequency of microsatellite instability (MSI) at 7 loci from formalin-fixed paraffin-embedded gastrectomy specimens, between cases of gastric cancer at Hitachi General Hospital (N = 18) and in US patients of European descent treated in Orange County, Calif (N = 20). Microsatellite instability, Lauren classification, and T stage were determined without knowledge of the country of origin of the specimens. MAIN OUTCOME MEASURE: The frequency of MSI in Japanese vs European American gastric cancer specimens. RESULTS: The frequency of MSI in Japanese gastric carcinoma specimens was higher than in specimens from American patients of European descent (39% vs 20%, respectively). In contrast, a high frequency of MSI was demonstrated in only 3 European American specimens (15% of all specimens in this group). Tumors from Japanese and American men were more likely to demonstrate MSI than those from women (50% vs 5.6%, respectively; P =.004). Among advanced-stage tumors, Japanese specimens were significantly more likely to demonstrate MSI (55%) than European American specimens (7.1%; P =.02). Specimens from Japan and America demonstrating MSI were equally likely to be from men, involve the gastroesophageal junction, and demonstrate intestinal histologic abnormalities. CONCLUSIONS: Advanced gastric cancers from Japan are more likely to demonstrate MSI. These data warrant a study of larger numbers of patients to assess whether differences in MSI expression correlates with prognostic differences between gastric carcinoma in patients in Japan vs the United States.     

Adenocarcinoma of the gastroesophageal junction in Japan: relevance of Siewert's classification applied to 177 cases resected at a single institution

Background: There had been a lack of international consensus about the definition of cancer of the gastric cardia until Siewert’s classification was approved at a consensus conference during the second International Gastric Cancer Congress held in 1997.

Study Design: A review of the prospective gastric cancer database at Aichi Cancer Center from 1983 to 1992 identified 1,913 gastric carcinoma patients who underwent gastrectomy. These patients were classified retrospectively according to the Siewert classification, and 177 patients who fell into one of the three types form the basis of this study. Survival analyses were performed after stratifying patients by clinicopathologic variables.

Results: There were 33 patients with type II and 144 with type III, although none had type I, a type frequently observed in the west. No evidence of a change in the frequency of types II or III cancers (approximately 9.3% overall) among gastric carcinoma patients was observed over the 10-year period. Clinical staging of gastric carcinoma by the TNM classification was found to reflect accurately the prognosis of these patients. There were no longterm survivors among the few patients with metastasis to the perigastric nodes of the distal stomach.

Conclusions: A striking difference in the distribution of types of adenocarcinoma of the gastroesophageal junction was observed in Japan compared with previously reported western data. A subgroup of carcinoma of the proximal stomach identified as types II and III may not require proximal gastrectomy from the viewpoint of sufficient lymphadenectomy.     

CDH1 truncating mutations in the E-cadherin gene: an indication for total gastrectomy to treat hereditary diffuse gastric cancer

BACKGROUND: Approximately 1% to 3% of all gastric cancers are associated with families exhibiting an autosomal dominant pattern of susceptibility. E-cadherin (CDH1) truncating mutations have been shown to be present in approximately 30% of families with hereditary diffuse gastric cancer (HDGC) and are associated with a significantly increased risk of gastric cancer and lobular breast cancer. METHODS: Individuals from a large kindred with HDGC who were identified to have a CDH1 mutation prospectively underwent comprehensive screening with stool occult blood testing, standard upper gastrointestinal endoscopy with random gastric biopsies, high-magnification endoscopy with random gastric biopsies, endoscopic ultrasonography, CT, and PET scans to evaluate the stomach for occult cancer. Subsequently, they each underwent total gastrectomy with D-2 node dissection and Roux-en-Y esophagojejunostomy. The stomach and resected lymph nodes were evaluated pathologically. RESULTS: Six patients were identified as CDH1 carriers from a single family. There were 2 men and 4 women. The mean age was 54 years (range, 51-57 years). No patient had any signs or symptoms of gastric cancer. Exhaustive preoperative stomach evaluation was normal in each case, and the stomach and adjacent lymph nodes appeared normal at surgery. However, each patient (6 of 6, 100%) was found to have multiple foci of T1 invasive diffuse gastric adenocarcinoma (pure signet-ring cell type). No patient had lymph node or distant metastases. Each was staged as T1N0M0. Each patient recovered uneventfully without morbidity or mortality. CONCLUSIONS: CDH1 mutations in individuals from families with HDGC are associated with gastric cancer in a highly penetrant fashion. CDH1 mutations are an indication for total gastrectomy in these patients. This mutation will identify patients with cancer before other detectable symptoms or signs of the disease.     

Synchronous multiple gastric adenocarcinoma: a clinical case

The Authors present a case of synchronous double gastric carcinoma in a 75-year-old man. Synchronous multiple gastric carcinoma (SMGC) constitutes 4% to 10% of all gastric cancers. It exhibits several clinicopathological characteristics that differ from those of solitary cancers: SMGC occurs in older people (men more than women); early carcinoma is observed more frequently in SMGC than in solitary cancers; the rate of intestinal type lesions is higher in multiple than in single gastric carcinoma. With regard to the pathogenesis of multiple gastric cancer, the theory proposing a multicentric or independent origin rather than the local or distant spread of one cancer (multifocality) has been favored.     

Gastric motility after laparoscopically assisted distal gastrectomy,with or without preservation of the pylorus,for early gastric cancer,as assessed by digital dynamic x-ray imaging

This study aimed to evaluate the usefulness of digital x-ray imaging for measuring gastric motility in patients subjected to laparoscopically assisted distal gastrectomy without preservation of the pylorus (LADG) or laparoscopically assisted pylorus-preserving gastrectomy (LAPPG) for early gastric cancer. Between April 1998 and February 2002, 52 patients with preoperative stage IA gastric cancer underwent laparoscopically assisted distal gastrectomy, with 26 receiving LADG for tumors in the lower third of the stomach and 26 receiving LAPPG for tumors in the middle third of the stomach. The gastric emptying ratio at 15 min after the ingestion of the test meal was 61.8% ± 28.0% for LADG and 42.9% ± 18.0% for LAPPG (p < 0.01). The motility index was 2.65% ± 2.54% for LADG and 8.13% ± 2.46% for LAPPG (p < 0.001). In conclusion, LAPPG results in better motility than LADG for patients with early gastric cancer arising in the middle third of the stomach.     

内镜活检对胃癌组织学分类术前诊断的价值

目的 探讨内镜活检对胃癌组织学分类术前诊断的价值。方法 术前对141例胃癌患的内镜活检标本分别根据Lauren分类和世界卫生组织（WHO）分类判断组织学分类，并与手术标本结果对照。结果 内镜活检对胃癌Lauren分类术前诊断的准确率为76.6%。对肠型胃癌诊断的敏感性和特异性分别为85.4%和80.6%。而对弥漫型胃癌则分别为82.7%和80.3%，在59例术前诊断为肠型胃癌的病例中，18例（30.5%)在手术标本中呈弥漫性行生长，而在75例术前诊断为弥漫型胃癌的病例中，仅6例（8.0%)术后诊断为肠型胃癌，内镜活检对胃癌WHO分类术前诊断的准确率为87.2%，其中对乳头状/管状腺癌，黏液腺癌和印戒细胞癌的敏感性分别为91.9%。33.3%和66.7%。结论 内镜活检对胃癌组织学分类的术前诊断具有较高的临床应用价值。     

Role of glucocorticoid receptor in serosa-involved gastric carcinoma after gastrectomy

Glucocorticoid receptor (GR) was first found in the cytosol of gastric cancer tissue more than 15 years ago. At present, most gastric cancers are diagnosed at the advanced stage. To elucidate the role of GR in gastric cancer, the GR levels of the cancer tissue of 75 consecutive patients with grossly serosa-involved gastric carcinoma were determined by the dextran-coated charcoal method. The clinicopathologic characteristics and long-term survival duration were compared in patients with GR-positive and GR-negative cancer cells. We found that GR could be detected in the cytosol of cancer cells in 31 (41.3%) of the gastric cancer patients with a median concentration of 18.5 (range, 1.03–73.9) fmol/mg protein. No significant differences could be found in any clinicopathologic characteristic between the patients with GR-positive and GR-negative cancers. After multivariate analysis, gross Borrmann’s type, metastatic lymph node number, and GR positivity were the independent prognostic factors after gastrectomy for serosa-involved gastric carcinoma. GR-positive gastric cancer had a worse survival rate than GR-negative gastric cancer. Multimodality adjuvant therapies should be considered in patients with GR-positive serosa-involved gastric carcinoma. Supported by Taichung Veterans General Hospital, grant numbers TCVGH 914607C and 924603C (to C.-C.W.).     

Results of surgical treatment of early gastric cancer in 113 patients

From 1961 to 1978, 113 patients with early gastric cancer were treated surgically at Erlangen University. The lesions were located in the lower 1/3 of the stomach in 47% of the patients, in the corpus and fundus in 46%, and in the gastric stump after resection in 7%. Surgical techniques included subtotal distal resection, proximal resection, total gastrectomy, local excision and polypectomy, and their use depended on the circumstances. The tumors were classified as intestinal type carcinoma in 71% of patients and diffuse type carcinoma in 29%. The 5-year survival rates calculated by the actuarial method were 74% (observed) and 87% (age corrected). Tumors in the lower 1/3 of the stomach had a better prognosis than tumors of other regions. Tumors limited to the mucosa had a higher 5-year survival rate than those with invasion of the submucosa. In Europe, as in Japan, early gastric cancer has a much better prognosis than all other forms of gastric cancer.Presented at the XXVIIIth Congress of the Société Internationale de Chirurgie, San Francisco, California, U.S.A., September 2–8, 1979.