Primary gastric lymphoma

This is a population-based review of 153 cases of primary gastric lymphoma. Sixty-seven (43 per cent) were histologically reviewed using the Kiel classification. There were no significant differences between reviewed and unreviewed cases. Ninety-seven per cent of all cases were of the non-Hodgkin's type. The annual incidence was constant at 1.2 per cent of gastric malignancies. The mean age was 60 years and the male to female ratio 1:8. Presenting symptoms were similar to those of gastric cancer. Twenty-one per cent had a palpable mass but one-third of these were amenable to a potentially curative resection. Some 66 per cent were resectable and 58 per cent had a macroscopic clearance of tumour. TNM stage and absolute tumour size were significant prognostic factors (P less than 0.005 and P less than 0.05 respectively) but the Kiel classification was not. The overall 5 year survival was 24 per cent. Apart from 10 patients whose only anti-tumour treatment was radiotherapy (5 year survival 36.9 per cent) no patient who did not have curative surgery survived 5 years. The 5 year survival for curative resection was 34 per cent and for curative resection plus radiotherapy was 43.5 per cent (45 and 73.4 per cent for the node negative cases respectively). A laparotomy is essential; 'curative' surgery possibly with adjuvant radiotherapy offers the best hope for cure.     

Clinicopathological features of patients with Borrmann type IV gastric carcinoma

Background: To determine whether there is a specific pattern of clinicopathological features that could be used to distinguish ­Borrmanntype IV gastric carcinoma from other types of gastric carcinoma. Methods: We retrospectively analysed the clinicopathological features of patients with Borrmann type IV carcinoma of the stomach.The results were compared with the features of patients who had other types of gastric carcinoma. Results: The incidence of Borrmann type IV gastric carcinomawas 11.0% (199 patients). A poorly differentiated tumour was found in 120 out of 199 patients (60.3%) with Borrmanntype IV gastric carcinoma. The positive lymph node metastasis was found in 150 out of 199 patients (75.4%) with Borrmanntype IV gastric carcinoma (P < 0.0001).The incidence of serosal invasion (91.5%) and peritoneal dissemination (37.7%) was significantly higher in these patients. Of the patients with Borrmann type IV gastric carcinoma,161 patients (80.9%) were classified as either stage IIIor IV at initial diagnosis. The curative resection rate of patientswith Borrmann type IV gastric carcinoma was lower than that of patients with other types of gastric carcinoma (P < 0.001).The survival rate was higher in patients with a curative resection(P < 0.001). The 5‐year survival rate of patients with Borrmann type IV tumour was lower than that of patients with other types of gastric carcinoma (P < 0.001).The 5‐year survival rates were 90.9% for stage I patients with Borrmann type IV gastric carcinoma and 39.5%, 18.6% and8.7% for stages II, III and IV, respectively (P < 0.001). Conclusion: Improving the prognosis for patients with Borrmanntype IV gastric carcinoma requires early detection and a curative resection.     

Extensive surgery for carcinoma of the gallbladder

BACKGROUND: The purpose of this study was to clarify the efficacy of, and define the indications for, extensive surgery for gallbladder carcinoma. METHODS: Between 1979 and 1994, 116 patients with gallbladder carcinoma underwent operation. Radical resection was performed in 80 patients. RESULTS: In 68 patients with stage III or IV disease, extensive resection including extended right hepatectomy (n = 40), pancreaticoduodenectomy (n = 23) and/or portal vein resection (n = 23) was employed to achieve complete tumour excision. The hospital mortality rate was 18 per cent. The postoperative 3- and 5-year survival rates were 44 and 33 per cent respectively in the patients with stage III disease (n = 9), and 24 and 17 per cent respectively in patients with stage IV (M0) disease (n = 29). In contrast, the postoperative survival rate for the 30 patients with stage IV (M1) disease (7 per cent at 3 years and 3 per cent at 5 years) was worse than that for patients with stage III and stage IV (M0) disease (P = 0.009 and P = 0.062 respectively). CONCLUSION: Radical resection should be undertaken for stage III and stage IV (M0) gallbladder cancer. Although portal vein resection and/or pancreaticoduodenectomy did not contribute to long-term survival, better survival was obtained than that for the unresected patients.     

Is There a Role for Palliative Gastrectomy in Patients with Stage IV Gastric Cancer?

Patients with metastatic gastric cancer are currently not considered operative candidates and are most often offered systemic therapy. Palliative resection of the primary tumor has been considered irrelevant to the outcome and has been recommended only for palliation of symptoms. We have examined the role of palliative gastrectomy and its impact on survival in patients with stage IV gastric cancer at initial diagnosis between 1990 and 2000. A total of 105 patients with stage IV disease were identified during this period; 81 of them (77.1%) had no resection, and 24 (22.9%) underwent palliative gastric resection. Mean survival in those without resection who received chemotherapy (with or without radiation) treatment was 5.9 months (95% confidence interval 4.2–7.6). For those with resection and adjuvant therapy, mean survival time was 16.3 months (95% confidence interval 4.3–28.8 months). Kaplan-Meier survival analysis showed significantly better survival in those with resection and adjuvant therapy (log-rank test, P = 0.01). Mortality and morbidity rates associated with palliative resection were 8.7% and 33.3%, respectively, which did not differ statistically from the 3.7% and 25.3% in patients who underwent curative gastrectomy during same period of time. However, the length of hospitalization (22 versus 16 days) was significantly higher compared with those without stage IV disease. These data suggest that palliative resection combined with adjuvant therapy may improve survival in a selected group of patients with stage IV gastric cancer. Palliative gastrectomy plus systemic therapy should be compared with systemic therapy alone in a randomized trial.     

Preoperative staging of carcinoma of the bronchus: can computed tomographic scanning reliably identify stage III tumours?

BACKGROUND--The aim of preoperative computed tomographic (CT) assessment of patients with carcinoma of the bronchus is to stage the tumour accurately, and forewarn the surgeon of any possible local extrapulmonary extension of tumour in patients considered to have potentially resectable disease. The ability of CT scanning to differentiate between conventionally resectable lung cancer (TNM stages I and II), locally advanced but resectable lung cancer (TNM stage IIIa), and locally advanced but unresectable lung cancer (TNM stage IIIb) was determined in a group of patients accepted for surgery. METHODS--Computed tomographic scans of 110 patients who underwent thoracotomy for intended resection of carcinoma of the bronchus, including 52 cases with stage III and 58 cases with stage I or II disease, were reviewed and the CT features and radiological interpretations correlated with the surgical and pathological findings. RESULTS--Thirteen CT scans were judged not to have been of diagnostic quality: of the remaining 97 cases 45 had stage III lung cancer, of whom 30 had successful resections, and 52 had stage I or stage II tumours. There was no difference in the frequencies of CT observations--including contiguity of tumour and mediastinum or chest wall, apparent mediastinal or chest wall invasion, proximity of tumour to the carina, mediastinal nodal enlargement, pulmonary collapse or consolidation and pleural effusion--in patients with stage I/II disease and patients with stage III disease. Similar results were found when the same observations were compared in all patients with resected disease and those with unresectable tumour. Sensitivity and specificity of CT was 27% and 96% respectively for tumour unresectability, 50% and 89% for mediastinal invasion, 14% and 99% for chest wall invasion, and 61% and 76% for mediastinal nodal metastases. Only 19 of 45 stage III tumours were correctly identified as being stage III and resectable or unresectable. CONCLUSIONS--In patients being considered for thoracotomy for resection of lung cancer, CT scanning used as the sole method of staging is of limited value for differentiating between stage I/II and stage III tumours. Patients should not be denied the opportunity for curative surgery on the basis of equivocal CT signs.     

Role of surgery, its results and complications, in the combined treatment of primary gastric non-Hodgkin lymphoma

During ten years 580 patients have been treated for gastric tumour in our department, 510 of them were operated on. Resection could be performed in 296 cases. 17 resections, 5.7 per cent of all were performed because of primary non-Hodgkin gastric lymphoma. No gastric lymphoma was found among the non-resected patients. The preoperative histological diagnosis was correct only in 8 cases. MALT origin could be proved in 5 patients. Synchronous adenocarcinoma and lymphoma was diagnosed in 2 patients. Staging was decided according to Lugano classification. There were six stage I, four stage II, and seven stage IV patients. 8 subtotal and 9 total gastrectomy was performed, 5 were extended and 2 were combined. R0 resection could be carried out in five stage I, two stage II and in one stage IV patient. We lost 2 patients in the postoperative period. Patients were treated with adjuvant chemotherapy (VEP, CHOP) except for 2 patients with low grade MALT lymphoma. The likelihood of one-year survival is 73 per cent, average two-year survival is 63 per cent. When the tumour is operable by total gastrectomy we suggest to perform splenectomy as well, despite of the fact that some postoperative complications can be related to it. We think it is reasonable to perform palliative resection in cases of locally extended stage IV tumours, which affect the patient's quality of life: to cease the pain, passage troubles, bleeding and to improve the conditions for adjuvant treatment.     

Pre-operative carcino-embryonic antigen and survival in patients with colorectal cancer

The relationship between pre-operative levels of carcino-embryonic antigen (CEA), resectability of the primary tumour, the extent of tumour spread and subsequent survival was studied in 333 patients with colorectal cancer. Twenty-five per cent of patients undergoing 'curative' resection had elevated CEA levels compared with fifty-six per cent of patients receiving palliative treatment. Twenty-five per cent of patients with Dukes B or C tumours had elevated pre-operative CEA levels compared with seventy per cent of patients with stage D disease. In patients undergoing 'curative' resection there was no correlation between pre-operative CEA levels and subsequent survival. In patients undergoing palliative resection, elevated pre-operative CEA levels were associated with poor survival. Although pre-operative levels of CEA reflect the extent of the underlying disease process, estimations of pre-operative CEA levels are of limited value in predicting patients with a poor prognosis following curative resection for colorectal carcinoma.     

Retrospective analysis of prognostic factors after liver resection and transplantation for cholangiocellular carcinoma

BACKGROUND: Cholangiocellular carcinoma is an uncommon primary liver cancer, which may be mixed with hepatocellular carcinoma. A retrospective analysis was undertaken to evaluate the results of surgical treatment and to identify prognostic factors. METHODS: Between 1978 and 1996, 162 patients underwent surgery for cholangiocellular carcinoma: liver resection (n = 95), liver transplantation (n = 24) and exploratory laparotomy with and without drainage (n = 43). Univariate and multivariate analyses of prognostic factors were performed. RESULTS: Overall survival was 47 per cent at 1 year, 28 per cent at 2 years and 13 per cent at 5 years. Survival rates for patients with resectable tumours were 64, 43 and 21 per cent respectively, and for those who underwent liver transplantation 21, 8 per cent and zero respectively. Univariate analysis showed that the following variables had an effect on survival: age, jaundice, liver resection, T, N and M stage in the tumour node metastasis classification, Union Internacional Contra la Cancrum (UICC) tumour stage, tumour-free margins, vascular infiltration, tumour number, tumour size and serum level of carcinoembryonic antigen. Multivariate analysis identified jaundice, N and M category, and UICC tumour stage as independent prognostic factors. CONCLUSION: The data underscore the importance and prognostic value of the UICC tumour classification for cholangiocellular carcinoma. The prognosis of mixed tumours is no different. Liver resection remains the treatment of choice; transplantation offers no solution for otherwise unresectable tumours.     

OESOPHAGEAL CANCER: OUTCOME OF MODERN SURGICAL MANAGEMENT

Many clinicians still associate oesophagectomy for oesophageal carcinoma with low cure rates, poor palliation and prohibitive peri-operative mortality. Surgical advances have rendered such perceptions inaccurate. A prospective study of all patients undergoing surgery for oesophageal cancer in an Australian teaching hospital between 1979 and 1993 has been undertaken. Selection. staging, pre-operative preparation, surgical technique and postoperative care were all carefully controlled. One hundred and thirty-seven patients were explored. Twenty-one were inoperable. One hundred and sixteen underwent resection with intent to cure. Hospital mortality for oesophagectomy was 1.7%. There were no cases of clinical anastomotic leakage. Eighty-nine per cent achieved excellent to good swallowing. The median survival for all cases was 14 months and the 5 year survival was 18%. Median survival for resected cases was 18 months and the 5 year survival was 26%. The long-term survival was related to postoperative stage of the disease but not to tumour type. Oesophagectomy for oesophageal cancer will restore good swallowing in 90% of cases. Operative mortality should be less than 5% and the overall 5 year survival 20–3096. Early tumours can often be cured (ca in situ 100%. stages I and II 50–60%), indicating the benefits of early detection. Poor survival in advanced disease (stage III 15%. stage IV 0%) on a background of low surgical mortality indicate the need for better staging and more effective adjuvant therapies.     

Clinical evaluation of schizophyllan adjuvant immunochemotherapy for patients with resectable gastric cancer —A randomized controlled trial—

Adjuvant immunochemotherapy using schizophyllan (SPG), an extract from the culture broth ofSchizophyllum commune Fries, was prescribed at random for 326 Japanese patients with resectable gastric cancer. The overall survival rates for 3 years did not differ between the SPG and control groups. In 62 patients with stage I gastric cancer and 67 with stage II, there was little difference in the 3-year survival rates. The survival rates for 100 patients with stage III were enhanced at p=0.0811 in the SPG group, as compared to the controls. The survival rates in 97 patients with stage IV cancer were much the same. These results warrant further application of this immunopotentiating drug for treating patients with resectable gastric cancer.     

Analysis of the Survival Period in Resectable Stage IV Gastric Cancer

Background: Patients with stage IV gastric cancer usually have a poor prognosis, but some patients with resectable cancer survive for more than 5 years. We aimed to study the correlation of protein expression and survival in resectable stage IV gastric cancer.Patients and Methods: Tissue samples of 42 patients with resectable stage IV gastric cancer were stained immunohistochemically for the mutant p53 protein and heat shock protein-27 (hsp27). The correlation between protein expression and clinicopathological factors was investigated. Furthermore, prognostic value of each factor was analyzed.Results: Univariate analysis showed that pN factors (Japanese classification, P = .028; International Union Against Cancer classification, P = .024), blood vessel invasion (P = .043), hsp27 overexpression (P = .019), and the index of p53 and hsp27 overexpression (P = .0026) had a prognostic influence. Only Lauren classification, however, revealed the prognostic influence in multivariate analysis (P = .046).Conclusions: These results suggest that immunostaining of tumor specimens for p53 and hsp27 and clinicopathological analysis may help predict the survival of patients with resectable stage IV gastric cancer.     

Colon and rectal carcinoma. Forty years and 1400 cases

One thousand four hundred cases of colorectal carcinoma were treated primarily at the Wake Forest University Medical Center between 1945 and 1985. The surgical approach was constant in all patients without obvious stage IV disease: wide resection, including at least the primary-level and intermediate-level lymph nodes. There were 812 women and 588 men in the series. Sixty-eight per cent of the 1400 cancers occurred in the rectosigmoid, but only 53 per cent of the last 300 cases were in this region. Initial staging showed 560 cases (40%) of local disease, 504 cases (36%) of regional disease, and 336 cases (24%) of distant disease. Cecal, ascending, hepatic, and transverse lesions were most often associated with stage IV disease. Among the 1115 patients with long-term follow-up, 44 per cent with stage I disease, 37 per cent with stage II disease, 24 per cent with stage III disease, and 6 per cent with stage IV disease had survived for 5 years or longer. There were no differences when 5-year survival was correlated with site. This review provided no evidence that wide resection leads to increased long-term survival.     

The influence of positive peritoneal cytology on survival in patients with pancreatic adenocarcinoma

The American Joint Committee on Cancer (AJCC) staging system for pancreatic adenocarcinoma classifies positive peritoneal cytology as stage IV disease. Data are limited with respect to the prevalence of positive peritoneal cytology and its influence on survival in patients with resectable, locally advanced, and metastatic disease. Four hundred sixty-two patients underwent staging laparoscopy for pancreatic adenocarcinoma between January 1995 and December 2005. Kaplan-Meier survival comparisons were performed to evaluate the significance of positive peritoneal cytology on overall survival (OS) in resected patients and patients with locally advanced and metastatic disease. Of the 462 patients, 47% (217/462) underwent a pancreatic resection. The 21% (95/462) with locally advanced disease and 32% (150/462) with metastatic disease did not undergo resection. Peritoneal cytology was positive in 17% (77/462), and was associated with stage of disease (metastatic, 37%; locally advanced, 11%; resected, 5%; P=0.01). Positive cytology was not associated with OS in patients with metastatic disease or locally advanced disease, but was in resected patients (median, 16 months vs. 8 months; P<0.001). Node-positive disease was present in 8 of 10 patients resected with positive cytology (2 years OS, 12% positive cytology vs. 23% negative; P=0.006). In this study, patients who underwent resection in the presence of positive peritoneal cytology and absence of other identifiable metastatic disease had a similar survival as other patients with stage IV disease. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006 (poster presentation).     

Late results of postoperative long term cancer chemotherapy for advanced carcinoma of the stomach

Postoperative long term cancer chemotherapy (PLCC) with the combination of Mitomycin-C, FT-207^*, a furanyl analog of 5-fluorouracil, and PSK^**, an immunopotentiator, was prescribed for patients with advanced gastric cancer. Five year survival rates for all stage III and stage IV patients were 52.8 and 19.3 per cent in the PLCC group. The rates were 26.7 and 2.2 per cent in the control groups (p<0.05). In curative cases of stage IV, the 5-year survival rate was 50.0% in the PLCC group while the rate was 11.1% in the controls. Mean survival time of patients with peritoneal dissemination or hepatic metastases was 12.8 and 10.9 months, respectively, for the PLCC group, in contrast to the lower 6.4 and 4.3 months for the controls. Thus, the 5-year survival rate of advanced gastric cancer patients in stage III and stage IV was markedly improved when these patients were treated with the protocol. Our findings clearly show that adjuvant chemotherapy should be administered for a long period postoperatively in order to achieve a significant improvement in patients with gastric cancer.     

Primary gastric lymphoma. Problems in staging and management

A retrospective review of 28 patients with primary gastric lymphoma was performed to determine the optimal treatment modality. The presenting signs and symptoms resembled peptic ulcer disease or gastric carcinomas. The majority of the lymphomas were of the diffuse histiocytic subtype. There was a 75 percent resectability rate in those patients operated on. Palliative resection produced a 5 year duration of survival of 28 percent and curative resection, 43 percent. Eighteen patients underwent a subtotal gastrectomy, and a total of 10 patients presented with stage I disease. The longest median duration of survival at last follow-up was 32 months for patients with stage IB disease compared with a median duration of survival of 8 months for those with stage III disease. Adjuvant radiotherapy and chemotherapy may improve survival after a curative resection is performed if there is serosal penetration or nodal involvement.     

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.     

Prognostic significance of peritoneal tumour cells identified at surgery for colorectal cancer

Background:

The prognostic significance of intraperitoneal tumour cells (IPCs) in colorectal cancer is not clear. This study aimed to determine whether detection of IPCs could be used a prognostic marker for selecting patients at high risk of recurrence.

Methods:

The study included 226 patients with colorectal cancer who underwent elective resection. Clinical variables, including the presence of IPCs, were analysed for their prognostic significance.

Results:

Thirty‐three patients (14·6 per cent) were positive for IPCs. Univariable analysis indicated that the presence of IPCs was a significant prognostic factor in patients with stage III colorectal cancer; the 5‐year disease‐specific survival rate was 14 per cent in IPC‐positive patients versus 79 per cent in those without IPCs (P < 0·001). Multivariable analysis showed that IPC positivity was the most robust prognostic factor in stage III disease (hazard ratio 2·2; P = 0·003), whereas nodal category (N1 or N2) showed no significant association with prognosis. In addition, IPCs were associated with haematogenous recurrence (P = 0·004) rather than peritoneal or local recurrence (P = 0·077) in patients with stage III disease.

Conclusion:

The presence of IPCs is a significant prognostic factor in patients with stage III colorectal cancer. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

The clinical usefulness of preoperative CEA determination in gastric cancer

Between 1980 and 1984, preoperative serum carcinoembryonic antigen (CEA) was determined in 468 patients with gastric cancer to evaluate its clinical usefulness. The positive rate of preoperative CEA was 20.9 per cent in these 468 patients. A significantly higher CEA positive rate was obtained in those patients with liver metastasis (69.2 per cent), n_3–4 (40.0 per cent), stage IV gastric cancer (37.0 per cent) and Pap, Tub₁ histological type (26.3 per cent) (p<0.01). It is interesting that the positive rate of the 49 unresectable patients was 51.0 per cent, which was significantly higher than 17.4 per cent of the 419 resectable cases (p<0.01). CEA levels in 16 of the 39 patients with liver metastasis were more than 100 ng/ml. In contrast, serosal invasion and peritoneal metastasis were less correlated to the CEA positive rate. In the 419 resected cases, the 5 year survival rate in the higher CEA group of more than 50 ng/ml (35 cases) was 4.4 per cent, which was significantly lower than 64.0 per cent in the negative group (346 cases) (p<0.01). These results show that CEA determination in patients with gastric cancer is useful for the prediction of prognosis, as well as for a diagnostic tool to discover the presence of liver or lymph node metastasis.     

Primary tumor resection in patients with stage IV breast cancer: 10-year experience

The role of surgery in the management of stage IV breast cancer is controversial. Existing studies in Stage IV breast cancer have not closely evaluated the role of patient response to induction systemic therapy (IST) in its relationship to survival outcomes. We identified all patients with a diagnosis of de novo stage IV breast cancer who underwent surgery of their primary tumor from January 2008 to December 2018. Patients were grouped according to their response in the primary disease site into progression (progressive primary disease) or no progression (nonprogressive primary; comprising complete, partial and stable response). We identified a total of 45 stage IV breast cancer patients who underwent operative intervention of their primary breast tumor. Prior to surgical intervention, progression in the primary site during IST was identified in 13/42 patients (31%), of whom four patients also had progression in the distant disease. The 5-year survival was higher in the nonprogressive primary (74%) than the progressive primary disease group (52%) which did not reach statistical significance (p = 0.08). Age, pathologic tumor size, clinical nodal status, number of positive lymph nodes, and distant disease response to systemic therapy were significantly associated with survival. In this single institution experience, select patients with stage IV breast cancer at initial diagnosis who underwent resection of the primary tumor following systemic therapy achieved favorable overall and distant progression-free survival. Surgery is reasonable to consider for local palliation or in selected patients who have excellent response to systemic therapy and good performance status.     

Gastric cancer: a 25-year review

Between 1957 and 1981, 31,716 cases of gastric cancer were registered in the West Midlands, UK. The age-standardized incidence has shown a decrease from 17.42 per 100,000 population during the first quinquennium to 15.30 per 100,000 in the last. There was an apparent increase in the proportion of proximal lesions with a decrease in the proportion of distal, antral cancers. The stage of disease at diagnosis remained constant with 79 per cent of patients having stage IV disease. Less than 1 per cent presented with stage I disease. As a result, the curative resection rate was 21 per cent. The operative mortality rates for curative partial gastrectomy and total gastrectomy were 13 and 29 per cent respectively. Surgeons undertaking more than nine total gastrectomies annually had an overall mean operative mortality rate of 22 per cent. Overall age-adjusted survival at 5 years was 5 per cent. Survival at 5 years for stage I, II and III disease was 72, 32 and 10 per cent respectively. There was a significant increase in survival time for those treated by curative resection between 1972 and 1981 compared with the previous decade. The implications for the management of gastric cancer are discussed.