Long-term results of surgery for early gastric cancer

BACKGROUND: Gastrectomy for early gastric cancer is widely accepted as an adequate therapeutic method. Recent developments of less invasive procedures require the identification of patients who will benefit from such an approach. METHODS: A retrospective study was undertaken of 238 patients with early gastric cancer who underwent gastrectomy from 1977 to 1999. Clinicopathological data relating to survival were evaluated. RESULTS: Analysis of 33 node-positive patients (14 per cent) revealed a tumour diameter greater than 20 mm (P = 0.011), depressed macroscopic type (P < 0.05), diffuse histological type (P < 0.001), poor tumour differentiation (P < 0.001) and infiltration of the submucosal layer (P < 0.002) as factors associated with lymph node metastasis. Multivariate analysis found diffuse histological type to be an independent risk factor. The overall 5-year survival rate was 87 per cent, and was significantly better in patients who underwent radical lymphadenectomy than in those who had regional lymph node dissection (92 versus 78 per cent; P < 0.01). Similarly, patients younger than 65 years had a more favourable 5-year survival rate (90 per cent) than older ones (77 per cent). Multivariate analysis with the Cox proportional hazards model confirmed patient age and type of lymphadenectomy as independent prognostic factors. CONCLUSION: The findings suggest that extended lymph node dissection may be beneficial for some patients with early gastric cancer, although randomized clinical trials are needed to evaluate this observation further.     

Clinicopathological significance of microscopic abscess formation at the invasive margin of advanced low rectal cancer

BACKGROUND: The aim of this study was to evaluate the clinicopathological significance of microscopic abscess formation (MAF) at the invasive front of advanced low rectal cancer. METHODS: The clinicopathological features of 226 consecutive patients with low rectal cancer, who underwent curative resection between May 1997 and December 2002, were analysed. RESULTS: Fifty-seven (25.2 per cent) of the 226 tumours had MAF and 169 (74.8 per cent) did not. Patients with tumours showing MAF were more likely to have extended surgery than those without MAF: 47 versus 31.4 per cent respectively underwent non-sphincter-preserving surgery (P=0.029) and 82 versus 60.9 per cent underwent lateral lymph node dissection (P=0.003). The incidence of lymph node metastases was lower in patients with MAF (30 versus 53.3 per cent; P=0.002). Univariable analysis of disease-free survival revealed that depth of invasion (P<0.001), lymph node status (P<0.001), histological type (P=0.035), lymphatic invasion (P<0.001), venous invasion (P<0.001), perineural invasion (P<0.001), focal dedifferentiation (P<0.001) and MAF (P<0.001) were significant prognostic factors. Multivariable analysis showed that lymph node status (P<0.001), perineural invasion (P=0.002), venous invasion (P=0.033) and MAF (P=0.012) remained independent prognostic factors. CONCLUSION: MAF may reflect indolent tumour behaviour and a more favourable outcome in patients with advanced low rectal cancer.     

Does reoperation predispose to postoperative wound infection in women undergoing operation for breast cancer?

Reoperations for breast cancer predispose to a higher risk of postoperative wound infections than primary procedures. We accomplished a retrospective chart review of 320 women who underwent multiple breast cancer procedures between 10/97 and 8/02. The mean number of procedures was 2.4 (range, 2-5). The overall incidence of wound infection was 6.1 per cent. Wound infections developed, on average, 12 days after surgery (range, 2-30). There was a statistically significant difference in the incidence of wound infection comparing the initial procedure versus the subsequent operation (1.6% vs. 9.4%, P < 0.001). This was also seen with reoperation after an operative biopsy compared to operation after a core biopsy (11.1% vs. 9.7%, P < 0.01). The incidence was increased to 22.0 per cent when the initial operation involved lymph node dissection (sentinel lymph node biopsy or complete axillary lymph node dissection). Wire localization did not increase the incidence of postoperative wound infections, and prophylactic antibiotics were associated with a decreased incidence of wound infection in the reoperative setting. The incidence of wound infection is increased with reoperation after operative biopsy compared to operation after core biopsy and is further increased when the initial biopsy involved lymph node dissection.     

Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer

BACKGROUND: Lateral lymph node metastases occur in some patients with low rectal cancer and may cause local recurrence after total mesorectal excision. The aims of this study were to identify risk factors for lateral node metastases in patients with pathological tumour (pT) stage 3 or pT4 low rectal adenocarcinoma, and to evaluate the prognostic significance of lateral node metastases. METHODS: A retrospective analysis was performed of the outcome of 237 patients with pT3 or pT4 low rectal adenocarcinoma who underwent R0 resection with systematic lateral node dissection. RESULTS: Lateral lymph node metastases were found in 41 patients (17.3 per cent). Increased risk of lateral lymph node metastases was associated with a distal tumour margin close to the anal margin, histological type other than well or moderately differentiated adenocarcinoma, and the presence of mesenteric lymph node metastases. Patients with lateral node metastases had a significantly shorter postoperative survival (5-year survival rate 42 versus 71.6 per cent; P < 0.001) and an increased risk of local recurrence (44 versus 11.7 per cent; P < 0.001) compared with those without lateral node metastases. CONCLUSION: Tumour site, histological type and the presence of mesenteric lymph node metastasis are factors predicting the risk of lateral node metastasis. The poor prognosis of patients with lateral lymph node metastases after systematic lateral dissection suggests the need for adjuvant therapy.     

Therapeutic Value of Lymph Node Dissection in Advanced Gastric Cancer with Macroscopic Duodenum Invasion: Is the Posterior Pancreatic Head Lymph Node Dissection Beneficial?

Background  In advanced gastric cancer (AGC) with duodenum invasion, the posterior pancreatic lymph nodes are susceptible to metastasis because of their proximity to the duodenum. The therapeutic value of lymph node dissection in this area for AGC with macroscopic duodenum invasion remains unclear. Methods  Patients who had undergone curative gastrectomy for lower-third AGC from 1970 to 2004 at the Cancer Institute Hospital were recruited for this study. Clinicopathological data were collected retrospectively, and compared between cases of AGC with duodenum invasion (AGC-DI group) and AGC without duodenum invasion (AGC-nDI group). In the AGC-DI group, the therapeutic value of lymph node dissection was evaluated using a therapeutic index (multiplication of the frequency of metastasis to the station by the 5-year survival rate of patients with metastasis to that station). Results  The AGC-DI group generally had tumors of higher pathological stage, which might account for the poorer 5-year survival rate compared with that of the AGC-nDI group (50.1% versus 68.5%; P = 0.0002). The incidence of lymph node metastasis was higher in the AGC-DI group than that in the AGC-nDI group, including nodes in the posterior pancreatic head (23.9% versus 7.0%, P < 0.0001). In the AGC-DI group, posterior pancreatic head lymph node dissection was of therapeutic value (4.19) equivalent to dissection of second-tier lymph nodes. Conclusions  The dissection of posterior pancreatic head lymph nodes might be effective in AGC with macroscopic duodenum invasion since this has therapeutic value equivalent to that of second-tier lymph node dissection and might improve patients’ long-term outcomes.     

Risk factors for complications following resection of large gastric cancer.

BACKGROUND: Although there is a low mortality rate after gastrectomy in Japan, most studies include many early gastric cancers. There have been few studies on the morbidity after gastrectomy for advanced gastric cancer. The aim of this study was to clarify the characteristics and risk factors for postoperative complications after resection of large gastric cancers based on three clinical factors: patient, operation and tumour. METHODS: A retrospective study was carried out on 97 patients with a gastric tumour measuring 10 cm or more in diameter. Postoperative complications were recorded and the patients were divided into two groups: 38 with complications and 59 without. Patient, operative and tumour findings were compared between the two groups. RESULTS: Overall morbidity and mortality rates were 39 and 7 per cent respectively. The most frequent complication was pleural effusion (17 per cent), followed by anastomotic leakage (14 per cent), abdominal abscess (12 per cent), wound infection (12 per cent), pancreatic leakage (8 per cent) and peritonitis (6 per cent). Risk factors associated with postoperative complications were operating time (400 versus 337 min, P < 0.01), blood loss (1338 versus 782 ml, P < 0.01), pancreatic invasion (26 versus 8 per cent, P < 0.05) and raised serum carcinoembryonic antigen (CEA) level (5 ng/ml or greater) (36 versus 17 per cent, P < 0.05), independent of patient age, nutritional status, type of gastrectomy, splenectomy or pancreatectomy, extent of lymph node dissection, tumour location, size and stage of disease. CONCLUSION: Even in Japan, the morbidity of gastrectomy for large gastric cancer is high and associated with operating time, blood loss, pancreatic invasion and serum CEA level.     

Prediction of mediastinal lymph node metastasis in medullary thyroid carcinoma

BACKGROUND: Mediastinal lymph node metastases can be life threatening owing to their proximity to vital organs. Reliable identification of mediastinal metastasis is of utmost importance for timely mediastinal lymph node dissection, although suitable clinicopathological variables for their detection in patients with thyroid cancer have yet to be identified. METHODS: This was an analysis of 83 consecutive patients with radiological suspicion of mediastinal metastasis who underwent trans-sternal mediastinal lymph node dissection for node-positive medullary thyroid carcinoma between November 1994 and March 2003. RESULTS: Univariate analysis revealed that extrathyroidal extension (P < 0.001), distant metastasis (P = 0.001), the preoperative serum calcitonin level (P = 0.001), operation type (P = 0.004), contralateral cervicolateral metastasis (P = 0.016) and bilateral nodal metastasis (P = 0.031) were significantly associated with mediastinal involvement. Only extrathyroidal extension remained significant in a multivariate logistic regression analysis of mediastinal lymph node metastasis. Prediction of mediastinal metastasis by extrathyroidal extension was best at reoperation, with a specificity of 97 per cent and a positive predictive value of 88 per cent. CONCLUSION: Mediastinal lymph node dissection should be considered in patients undergoing reoperation for node-positive medullary thyroid carcinoma who have extrathyroidal extension and cervical lymph node metastases.     

Right hemicolectomy does not confer a survival advantage in patients with mucinous carcinoma of the appendix and peritoneal seeding

BACKGROUND: Traditionally epithelial malignancies of the appendix with or without carcinomatosis have been treated by right hemicolectomy. Recent accumulation of a large number of patients with this disease has enabled a re-evaluation of this surgical judgement. METHODS: Clinical data on 501 patients with epithelial malignancy of the appendix were collected prospectively. All patients had peritoneal seeding at the time of referral and were treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy. The main independent variable for statistical analysis was the surgical procedure used to resect the primary cancer (appendicectomy alone versus right hemicolectomy). Nineteen other clinical and pathological variables were considered as control variables. The endpoint for all analyses was survival. RESULTS: Median follow-up after the initial diagnosis was 4 years. The rate of regional lymph node positivity was 5.0 per cent. When the incidence of lymph node metastasis was determined by histological type, it was statistically significantly higher in intestinal (66.7 per cent) than in mucinous (4.2 per cent) tumours (P < 0.001). The presence of lymph node metastases had no influence on prognosis (P = 0.155). The surgical procedure (appendicectomy alone versus right hemicolectomy) had an influence on patient survival by univariate analysis (P < 0.001), but not by multivariate analysis (P = 0.258). CONCLUSION: Right hemicolectomy does not confer a survival advantage in patients with mucinous appendiceal tumours with peritoneal seeding. These data suggest that right hemicolectomy should be avoided unless metastatic involvement of the appendiceal or distal ileocolic lymph nodes is documented by biopsy, or the resection margin is inadequate.     

Prognosis and surgical management of patients with palpable inguinal lymph node metastases from melanoma

BACKGROUND: The appropriate management of melanoma metastatic to inguinal lymph nodes remains controversial. The aim of this study was to identify disease- and treatment-related factors that influence the outcome of patients undergoing therapeutic groin dissection for clinically detectable melanoma lymph node metastases. METHODS: A retrospective analysis was performed on data collected from the case records of patients who had a therapeutic inguinal lymph node dissection performed between 1984 and 1998. RESULTS: Some 132 patients were suitable for inclusion. Sixty patients had superficial inguinal lymph node dissection (SLND) and 72 had combined superficial inguinal and pelvic lymph node dissection (CLND). There was no difference in postoperative morbidity or major lymphoedema between SLND and CLND. The overall survival rate was 34 per cent at 5 years. On univariate analysis, age (P = 0.003), the number of involved superficial lymph nodes (P = 0.001) and the presence of extracapsular spread (P = 0.003) were found to have a significant impact on survival. The presence or absence of pelvic lymph node metastases in patients who had CLND was a significant prognostic factor for survival (5-year survival 19 versus 47 per cent; P = 0.015). CONCLUSION: The prognosis of patients with clinically detectable melanoma metastases to the groin is variable and related to the biological characteristics of each case. CLND provided additional prognostic information and optimal regional control with no increased morbidity compared with SLND.     

Evaluation of the necessity for gastrectomy with lymph node dissection for patients with submucosal invasive gastric cancer

BACKGROUND: When cancer cells are found in the submucosal layer of an endoscopically resected specimen, patients are recommended to undergo gastrectomy with lymph node dissection. If it were possible to identify those patients in whom the risk of lymph node metastasis was negligible, it might be possible to avoid surgery. METHODS: Among those who underwent gastrectomy for gastric cancer from 1980 to 1999, 1091 patients with a cancer invading the submucosa were studied. Clinicopathological factors (sex, age, tumour location, macroscopic type, size, ulceration, histological type, lymphatic-vascular involvement and degree of submucosal penetration) were investigated for their possible association with lymph node metastasis. RESULTS: Lymph node metastases were found in 222 patients (20.3 per cent). Univariate analysis showed that larger tumour size (more than 30 mm), undifferentiated histological type, lymphatic-vascular involvement and massive submucosal penetration had a significant association with lymph node metastasis. Tumour size, histological type and lymphatic-vascular involvement were independent risk factors for lymph node metastasis. By combining these three factors with submucosal penetration of less than 500 microm, 117 patients could be selected as having a minimal risk of lymph node metastasis (95 per cent confidence interval 0-3.1 per cent). CONCLUSION: Lymphadenectomy may not be necessary for patients with gastric cancer invading the submucosa who fulfil the above conditions     

Prediction of lateral pelvic node involvement in low rectal cancer by conventional computed tomography

BACKGROUND: The clinical significance of lateral pelvic lymphatic spread in rectal cancer remains unknown. The present study aimed to assess the accuracy of preoperative computed tomography (CT) for prediction of lateral node involvement in patients with low rectal cancer and to determine the prognostic significance of extended lateral node dissection. METHODS: A total of 109 patients with primary low rectal cancer were enrolled in this prospective cohort study. The preoperative CT findings were compared with the histopathological results and with follow-up data. RESULTS: CT diagnosed lateral lymph node status with high accuracy (sensitivity 95 per cent, specificity 94 per cent), in marked contrast to mesorectal node status. Of 68 patients who had R0 resection without lateral node dissection, only two developed pelvic wall recurrence during median follow-up of 4.1 years. Metastatic nodes in the lateral pelvic region were significantly larger than those in the mesorectum (P < 0.001). CONCLUSION: CT accurately predicted lateral lymph node status in low rectal cancer, allowing preoperative identification of patients who might benefit from extended lateral node dissection.     

Clinicopathological features and prognosis of gastric cancer in young European adults

BACKGROUND: The aims of this study were to define the clinicopathological features and prognosis of gastric cancer in young European adults. METHODS: Between 1990 and 2004, 603 patients with gastric cancer were enrolled in a prospective database. The findings for 51 (8.5 per cent) patients aged 45 years or less were compared with those of 457 aged between 46 and 75 years. RESULTS: In the younger group there were significantly more women (57 versus 36.3 per cent; P = 0.004), Laurén diffuse-type carcinomas (73 versus 42.7 per cent; P < 0.001), N2-3 lymph node metastases (59 versus 38.9 per cent; P = 0.005), stage IV disease (49 versus 35.7 per cent; P = 0.085) and resections that were non-curative (36 versus 18.5 per cent; P = 0.007) than in the older patients. Actuarial survival rates in younger patients at 5 and 10 years after resection were 40 and 32 per cent respectively, similar to those in older patients (P = 0.540). Unfavourable prognostic factors associated with poor 5-year survival were the degree of gastric wall invasion (T3-4 versus T1-2; P < 0.001), lymph node invasion (positive versus negative; P < 0.001), disease stage (III-IV versus I-II; P < 0.001) and curability of resection (non-curative versus curative; P < 0.001). CONCLUSION: Gastric cancer in young adults tends to be more advanced; however, when matched for stage, the prognosis does not differ from that of older patients.     

High incidence of in-transit metastases after sentinel node biopsy in patients with melanoma

BACKGROUND: The occurrence of in-transit metastases in patients with a tumour-positive sentinel node varies greatly between centres and it has been suggested that the incidence is high in this patient group. METHODS: The incidence of in-transit metastases in 61 patients who had lymph node dissection because of a tumour-positive sentinel node was compared with that in 60 patients who had palpable nodal metastases dissected. RESULTS: The incidence of in-transit metastases was 23 per cent in patients with a positive sentinel node and 8 per cent in those with palpable nodes (P = 0.027). CONCLUSION: Sentinel node biopsy was associated with a higher risk of in-transit metastases. This finding does not support the routine use of sentinel node biopsy in the management of melanoma.     

肝内胆管细胞癌淋巴结转移与预后的关系

目的 探讨淋巴结转移对肝内胆管细胞癌（ICC）患者预后的影响。方法 对随访到的132例自1996年12月至2003年6月在我院手术治疗的ICC患者的临床资料进行回顾性分析,采用Kaplan-meier法对确定的单因素进行生存率分析,采用χ^2检验对各样本率之间进行比较,采用Logistic回归进行多因素分析,采用Log-rank法对单因素进行生存分析评价。结果 肝十二指肠韧带淋巴结转移出现在所有术前29例以及术后48例淋巴结转移患者中,未发现“跳跃式”淋巴结转移。随访到的58例已死亡患者中,有36例经证实死于淋巴结转移,淋巴结转移是ICC患者术后主要死亡原因之一。Logistic回归统计学分析显示,肿瘤分化程度（χ^2=4．071,P=0．044）以及浸润型胆管细胞癌与淋巴结转移的发生密切相关（χ^2=3．872,P=0．037）。98例行根治性手术患者中,46例行淋巴结清扫与52例未行淋巴结清扫患者中位生存期分别为20个月和13个月,差异有统计学意义（χ^2=9．82,P〈0．01）。结论 肝十二指肠韧带淋巴结可能为ICC的前哨淋巴结。对肝十二指肠韧带淋巴结转移的预防和积极治疗,可望提高ICC患者的生存率。     

Significance of extended radical surgery for stage IV gastric cancer

Forty percent of patients with gastric cancer with direct infiltration to adjacent organs survived for more than 5 years after curative resection. Favorable results were obtained in cases in which combined resection of the body of the pancreas or the liver was performed due to cancer infiltration. However, patients who had undergone gastrectomy with combined colectomy or pancreatoduodenectomy showed a poor survival rate. The postoperative 5-year survival rate was 29% for patients who had presented with group 3 lymph node metastasis and undergone potentially curative surgery. Particularly, favorable results were obtained in cases with metastases confined to lymph nodes in the hepatoduodenal ligament. In dissection of the deepest nodes, lymph nodes in the hepatoduodenal ligament is the most important to remove in surgery for stage IV gastric cancer. We have performed gastrectomy combined with dissection of group 1 and 2 lymph nodes in the treatment of patients with gastric cancer with peritoneal metastasis. Results obtained so far revealed that only patients with a lesser extent of serosal invasion survived longer after operation. We are presently conducting a trial of hyperthermia combined with anticancer chemotherapy as a possible method for prolongation of survival of patients with peritoneal metastasis of gastric cancer.     

Extranodal metastasis is an indicator of poor prognosis in patients with gastric carcinoma

BACKGROUND: The aim of this study was to determine the clinical significance and prognostic impact of extranodal metastasis (EM) in gastric carcinoma. METHODS: The study included 1023 patients who underwent gastrectomy with lymphadenectomy for primary gastric carcinoma between January 1993 and December 1996. EM was defined as the presence of tumour cells in extramural soft tissue that was discontinuous with either the primary lesion or locoregional lymph nodes. RESULTS: EM was detected in 146 (14.3 per cent) of the 1023 patients and in 1060 (3.0 per cent) of the 35 811 nodules that were retrieved as 'lymph nodes' from adipose connective tissues. The incidence of EM was significantly higher in patients with tumours that were large (diameter 10 cm or more), infiltrative, deeply invading or undifferentiated and in those with lymph node, peritoneal or liver metastases, or lymphatic or vascular involvement. After curative operation overall survival was significantly worse for patients with EM than those without (P < 0.001). Multivariate analysis identified EM as an independent prognostic factor (hazard ratio 1.82 (95 per cent confidence interval 1.23 to 2.71); P = 0.003). CONCLUSION: EM is an independent prognostic factor and should therefore be included in the tumour node metastasis (TNM) staging system.     

Perineural invasion has a negative impact on survival of patients with gallbladder carcinoma

BACKGROUND: The clinical significance of perineural invasion of gallbladder carcinoma remains unclear. The aim of this study was to elucidate the incidence and mode of perineural invasion of gallbladder carcinoma and clarify its prognostic significance. METHODS: A clinicopathological study was conducted on 68 patients who underwent attempted curative resection for gallbladder carcinoma. According to the pathological tumour node metastasis (pTNM) classification of the Union Internacional Contra la Cancrum, there were five (7 per cent), nine (13 per cent), 20 (29 per cent) and 34 (50 per cent) patients with pT1, pT2, pT3 and pT4 disease respectively. Twenty patients (29 per cent) had pM1 disease, including involved para-aortic nodes, liver metastases and localized dissemination. RESULTS: The overall incidence of perineural invasion was 71 per cent (48 of 68 patients). Forty-four (96 per cent) of 46 patients with extrahepatic bile duct invasion had perineural invasion. Although several histological factors were associated with perineural invasion, multivariate analysis demonstrated that extrahepatic bile duct invasion was the only significant factor correlated with perineural invasion (odds ratio 99.0, P < 0.001). The perineural invasion index, defined as the ratio of the number of involved nerves to the total number of nerves examined, was significantly higher at the centre than in the proximal and distal parts of the tumour in the 46 patients with extrahepatic bile duct invasion (P < 0.001). The 5-year survival rate for patients with perineural invasion was significantly lower than that for patients with no invasion (7 versus 72 per cent; P < 0.001). Cox proportional hazard analysis identified perineural invasion (relative risk (RR) 5.3, P < 0.001) and lymph node metastasis (RR 2.5, P = 0.008) as significant independent prognostic factors. CONCLUSION: Perineural invasion is common in advanced gallbladder carcinoma and has a significant negative impact on patient survival.     

Randomized clinical trial comparing level II and level III axillary node dissection in addition to mastectomy for breast cancer

BACKGROUND: In addition to mastectomy, level II and level III axillary node dissection procedures are performed widely in Japan. A randomized clinical trial was performed to determine which procedure was more effective. METHODS: One group of women had resection of the pectoralis minor muscle and dissection of level I, II and III axillary lymph nodes (level III dissection). In a second group, the pectoralis minor muscle was left intact and level III axillary lymph node dissection was not performed (level II dissection). A total of 1209 women with stage II breast cancer were enrolled in the study and randomly assigned to one of the two groups. RESULTS: The 10-year cumulative survival rate was 86.6 per cent after level II and 85.7 per cent after level III axillary dissection (hazard ratio (HR) 1.02; P = 0.931, log rank test). The 10-year disease-free survival rate was 73.3 and 77.8 per cent respectively (HR 0.94, P = 0.666). Overall survival and disease-free survival rates in the two groups were similar after both procedures. The duration of surgery was significantly shorter (P < 0.001) and blood loss was significantly less (P = 0.001) after level II dissection. In a survey of patients' symptoms on follow-up, no significant differences were found between the two procedures. CONCLUSION: The addition of pectoralis minor muscle resection and level III axillary lymph node dissection to mastectomy for stage II breast cancer did not improve overall or disease-free survival rates.     

Surgery for gastric cancer in patients with cirrhosis

To clarify the therapeutic strategies for gastric cancer surgery in the presence of cirrhosis, 39 patients with gastric cancer accompanied by liver cirrhosis were reviewed. Severe postoperative complications developed in 10 patients (25.6%), and there were 4 (10.3%) hospital deaths, 1 (2.6%) of which occurred within 1 month. Although extended lymph node dissection of D₂ or more was adopted for low-risk patients, 3 of 19 patients who underwent such extensive operations, most of which involved complete lymph node dissection in the hepatoduodenal ligament, died. Conversely, only 1 of 20 patients who underwent limited lymph node dissection of D₁ or less died. Postoperative massive ascites developed in 6 patients, 3 of whom died. The cumulative 5-year survival rate following curative resection was 63.7% for patients with early gastric cancer, and 13.9% for those with advanced gastric cancer. The most frequent cause of death was cirrhosisrelated, such as hepatic failure or hepatoma. In conclusion, extensive lymph node dissection for patients with gastric cancer accompanied by cirrhosis carried a risk of postoperative fatal massive ascites as lymphorrhea. Thus, lymph node dissection in the hepatoduodenal ligament should be avoided, except in patients with evident metastases, and as a rule, aggressive surgery should not be performed in cirrhotic patients.     

Cavernous transformation of the portal vein coinciding with early gastric cancer and cholelithiasis

A 71-year-old man who developed jaundice with a high-grade fever was admitted to our hospital. The episode was ascribed to cholecysto-choledocholithiasis. In the preoperative evaluation, a cavernous transformation of the portal vein and an early gastric cancer were found. The patient thereafter underwent an operation for those pathologies after the endoscopic removal of a choledochal stone; cholecystectomy, and a distal gastrectomy with regional lymph node dissection for gastric cancer. The proposed procedures of gastrectomy and cholecystectomy were completed without any major difficulty because no markedly enlarged collateral veins were found in the area where the regional lymph node dissection was carried out. Thanks to advances in imaging modalities, an asymptomatic cavernous transformation of the portal vein coinciding with gastric cancer such as that seen in the present case may be increasingly encountered in the future. The greatest caution, however, needs to be exerted at operation to minimize any unexpected bleeding and to avoid any interruption of the porto-portal shunts in such cases. Further, the reestablishment of the portal blood supply to the liver might be required in advanced cases of gastric cancer, where regional lymph node dissection may necessitate skeletonization of the hepatoduodenal ligament for curative purposes.