Outcome after Simultaneous Resection of Gastric Primary Tumour and Synchronous Liver Metastases: Survival Analysis of a Single-center Experience in China

Background: The optimal surgical strategy for the treatment of synchronous resectable gastric cancer livermetastases remains controversial. The aims of this study were to analyze the outcome and overall survival ofpatients presenting with gastric cancer and liver metastases treated by simultaneous resection. Materials andMethods: Between January 1990 and June 2009, 35 patients diagnosed with synchronous hepatic metastasesfrom gastric carcinoma received simultaneous resection of both primary gastric cancer and synchronous hepaticmetastases. The clinicopathologic features and the surgical results of the 35 patients were retrospectively analyzed.Results: The 5-year overall survival rate after surgery was 14.3%. Five patients survived for more than 5 yearsafter surgery. No mortality has occurred within 30 days after resection, although two patients (5.7%) developedcomplications during the peri-operative course. Univariate analysis revealed that patients with the presenceof lymphovascular invasion of the primary tumor, bilateral liver metastasis and multiple liver metastasessuffered poor survival. Lymphovascular invasion by the primary lesion and multiple liver metastases weresignificant prognostic factors that influenced survival in the multivariate analysis (p=0.02, p=0.001, respectively).Conclusions: The presence of lymphovascular invasion of the primary tumor and multiple liver metastases aresignificant prognostic determinants of survival. Gastric cancer patients without lymphovascular invasion andwith a solitary synchronous liver metastasis may be good candidates for hepatic resection. Simultaneous resectionof both primary gastric cancer and synchronous hepatic metastases may effectively prolong survival in strictlyselected patients.     

手术治疗胃癌肝转移的预后分析

目的：探讨手术治疗胃癌肝转移的预后因素．方法：对25例患者临床病理特征及生存应用多元分析其与预后的关系。结果：20例行同时性肝切除，5例行异时性肝切除，1、3、5年生存率分别为84．0％，28．0％，21．0％。肝转移灶数目（孤立和多灶），转移灶分布（单叶和多叶），肝切除方式，原发灶组织学类型，淋巴结转移及脉管瘤栓与预后相关，多元分析显示多灶肝转移，原发灶淋巴结转移、脉管瘤栓是其预后独立危险因素。结论：对出现孤立转移灶、原发灶无淋巴结转移且无脉管瘤栓的胃癌肝转移患者应手术切除以获得更好的预后。     

Survival benefit of combined curative resection of the stomach (D2 resection) and liver in gastric cancer patients with liver metastases

BackgroundThe benefit of surgical resection of liver metastases from gastric cancer has not been well established. The aim of this study was to evaluate the rationale for hepatic resection in patients with hepatic metastases from gastric cancer.MethodsAmong 10 259 patients diagnosed with gastric adenocarcinoma in the Yonsei University Health System from 1995 to 2005, we reviewed the records of 58 patients with liver-only metastases from gastric cancer who underwent gastric resection regardless of hepatic surgery.ResultsThe overall 1-year, 3-year, and 5-year survival rates of 41 patients who underwent hepatic resection with curative intent were 75.3%, 31.7%, and 20.8%, respectively, and three patients survived >7 years. Of the 41 patients, 22 had complete resection and 19 had palliative resection. Between the curative and palliative resections, survival rates after curative intent were not different. The number of liver metastasis (solitary or multiple) was a marginally significant prognostic factor for survival.ConclusionsSurgery for liver metastases arising from gastric adenocarcinoma is reasonable if complete resection seems feasible after careful preoperative staging, even if complete resection is not actually achieved. Hepatic resection should be considered as an option for gastric cancer patients with hepatic metastases.     

Indication and meaning of hepatic resection for metastatic liver tumors from gastric cancer

To clarify the efficacy and indication of hepatectomy in gastric cancer metastasis to the liver, we studied 26 liver metastases patients undergoing hepatectomy. The cumulative 5-year survival rations were 25.3%. A survival analysis showed that prognoses of patients n(-) or T2 group were statistically better than other group. Three patients underwent a repeat liver resection from gastric metastasis and survived for about thirty months. There was an example using chemotherapy which made a liver tumor removal operation possible to the patient who had multiple liver metastases. In conclusion, liver resection is a beneficial option and multimodal therapy including a repeat liver resection and systemic chemotherapy, may be important for improving the prognosis of patients with liver metastases from gastric cancer.     

Multivariate prognostic study on large gastric cancer

BACKGROUND: Although many authors investigate the prognostic factors of gastric cancer, there are few comprehensive studies on the prognosis of patients with large gastric cancer. The aim of this study was to clarify the prognostic factors of large gastric cancer using multivariate analysis. METHODS: The study included 95 patients who underwent gastrectomy for gastric cancer measuring 10 cm or more in diameter. We examined 24 clinicopathologic factors based on patient, operation, and tumor findings. Survival rates were analyzed by the Kaplan-Meier and Mantel-Cox method, and multivariate analysis was done using the Cox proportional hazards model. RESULTS: Overall 5-year survival rate was 22%, and median survival period was 15 months. The 5-year survival rate was influenced by the tumor size, gross type, serosal invasion, extragastric lymph node metastasis, liver metastasis, peritoneal dissemination, stage of disease (I, II vs. III, IV), resection margin, and operative curability (R0 vs. R1, R2). Of these, independent prognostic factors were three tumor findings: serosal invasion (absent vs. present, odds ratio 3.06, P < 0.01), extragastric lymph node metastasis (absent vs. present, odds ratio 2.13, P < 0.05), and liver metastasis (absent vs. present, odds ratio 3.77, P < 0.05). The survival was not significantly associated with any of the patient factors or operation factors including the extent of lymph node dissection. CONCLUSION: In patients with large gastric cancer, independent prognostic factors were serosal invasion, extragastric lymph node metastasis, and liver metastasis. Prognosis after gastectomy was determined by these tumor factors and was not associated with the patient or operation factors.     

40例胃癌肝转移的手术治疗及预后

目的 分析胃癌肝转移患者的手术治疗效果及影响预后的因素,以探讨其手术指征。 方法 回顾性分析2010年1月1日至2012年1月1日于我院胃肠外科行原发灶+肝转移灶切除的40例胃癌合并肝转移患者的临床资料,分析其手术效果并用Log-rank检验及Cox风险比例模型分别对胃癌肝转移患者的主要临床病理因素与预后的关系进行单因素和多因素分析。 结果 40例患者均顺利完成手术,其中行R0切除30例,R1切除10例,无R2切除者。术后并发症发生率为15.0% （6/40）,无术后大出血及死亡病例。1年、2年及3年总生存率分别为37.5% （15/40）、10.0% （4/40）、0,中位生存期为10.5个月。单因素分析显示原发灶病理类型、原发胃癌侵犯浆膜、胃周淋巴结转移、血管癌栓、神经侵犯、转移灶分布、转移灶直径、肝转移类型、肝切除方式和手术根治程度与预后相关。多因素分析显示原发胃癌侵犯浆膜、血管癌栓、神经侵犯、转移灶直径和手术根治程度为预后的独立影响因素。 结论 原发胃癌未侵犯浆膜、无血管癌栓、无神经侵犯、肝转移灶直径＜5 cm和R0切除者可能是胃癌肝转移行原发灶+肝转移灶切除术的受益人群,亦可能是较佳的手术适应证。     

Prediction of survival time after curative surgery for advanced gastric cancer.

This study was carried out to define independent prognostic factors influencing survival time and to examine the survival time of patients with advanced gastric cancer treated by curative resection. Six hundred and forty-eight patients were identified of whom 275 patients died of tumor recurrence during follow-up. Univariate analysis using Mantel-Cox analysis, indicated that tumor size, tumor location, gross appearance, degree of gastric wall invasion, lymph node metastasis and operative procedures were significant factors related to survival time (P less than 0.01 to P less than 0.05). Multivariate analysis using the Cox proportional hazard model adjusted for sex, age and other factors, suggested that tumor size (P less than 0.01, relative risk = 1.79), degree of gastric wall invasion (P less than 0.01, rr = 1.24) and lymph node metastasis (P less than 0.01, rr = 2.39) were the most independent prognostic factors statistically, although these three prognostic factors were inter-related. When the tumor is less than 5 cm and there is no serosal invasion or lymph node metastasis, then a longer survival time can be expected (88.7% at 5-years). If the tumor size exceeds 10 cm and there is invasion into neighboring structures and lymph node metastases, then survival time will be short (11.9% at 4-years).     

Rational Operation for Primary Gastric Carcinoma with Liver Metastasis

OBJECTIVE To investigate the prognosis of advanced gastric carcinoma patients with liver metastasis, and provide a foundation for rational operations. METHODS The operations and prognosis of 102 primary gastric carcinoma patients with liver metastasis were studied retrospectively. RESULTS In gastric carcinoma patients with H1 metastasis who underwent a resection operation, the 6-month, 1- and 2-year post-operative survival rates were 61%, 42% and 7%. There was a statistically significant difference in survival between resected and non-resected patients （P=0.000） in gastric carcinoma cases with H2 metastasis, resection operations resulted in 54%, 16% and 8% respective survival rates, with no significant difference compared to patients not receiving a resection （P=0.132）. Gastric carcinoma patients with H3 metastasis who received a resection operation showed 25%, 13% and 0% respective survivals with no significantly better prognosis compared to the non-resected cases （P=0.135）. There was no statistically significant difference in survival between the cases with or without peritoneal metastasis （P=0.152）. CONCLUSION A resection operation provides a better prognosis for gastric carcinoma patients with H1 metastasis independent of peritoneal metastasis, but resection has no benefit for gastric carcinoma cases with H2 or H3 metastasis. Peritoneal metastases are not the significant influencing factor for the prognosis of gastric cancer with liver metastasis.     

Ovarian metastases resection from extragenital primary sites:outcome and prognostic factor analysis of 147 patients

ABSTRACT: BACKGROUND: To explore the outcomes and prognostic factors of ovarian metastasectomy intervention on overall survival from extragenital primary cancer. METHODS: Patients with ovarian metastases from extragenital primary cancer confirmed by laparotomy surgery and ovarian metastases resection were retrospectively collected in a single institution during an 8-year period. A total of 147 cases were identified and primary tumor sites were colorectal region (49.0%), gastric (40.8%), breast (8.2%), biliary duct (1.4%) and liver (0.7%). The pathological and clinical features were evaluated. Patients' outcome with different primary tumor sites and predictive factors for overall survival were also investigated by univariate and multivariate analysis. RESULTS: Metachronous ovarian metastasis occurred in 92 (62.6%) and synchronous in 55 (37.4%) patients. Combined metastases occurred in 40 (27.2%). Bilateral metastasis was found in 97 (66%) patients. The median ovarian metastasis tumor size was 9 cm. Thirty nine (26.5%) patients with massive ascites 1000 mL on intraoperative evaluation. With a median follow-up of 48 months, the median OS after ovarian metastasectomy for all patients was 8.2 months (95% CI 7.2-9.3 months). In univariate analyses, extragenital primary cancer site from gastrointestinal cancer compared to that of breast cancer (8.0 months vs. 41.0 months, P=0.000), from gastric cancer compared to that of colorectal cancer (7.4 months vs. 8.8 months, P=0.036), synchronous metastases (8.1 months vs. 10.2 months, P=0.027), local invasion (8.0 months vs. 13.7 months, P=0.007), massive intraoperative ascites ([greater than or equal to] 1000 mL) (6.0 months vs. 9.9 months, P=0.005), combined metastasis (5.9 months vs. 10.2 months, P=0.001) were identified as significant poor prognosis factors. In multivariate analyses combined metastasis (RR, 1.72; 95% CI, 1.09-2.69, P=0.018), locally invasion (RR, 1.62; 95% CI, 1.03-2.54, P=0.038) and massive intraoperative ascites (RR, 1.58; 95% CI, 1.02-2.49, P=0.04) were independent factors for predicting unfavorable overall survival. CONCLUSION: Ovarian metastases are more commonly seen to originate from primary gastrointestinal tract. The prognosis of ovarian metastasis is dismal and the benefit of ovarian metastatectomy is limited. Those with combined metastasis outside ovaries, locally invasion and massive intraoperative ascites were independent factors for predicting unfavorable overall survival. The identification of the primary tumor is required to plan for adequate treatment for this group of patients.     

Indication of hepatic resection for metastatic liver tumors from gastric cancer

To clarify the benefit and indication of resection for metastatic liver tumors from gastric cancer, we reviewed the therapeutic outcomes at the Niigata University Medical Hospital and at a referred institution. From January 1982 to April 2004, thirty-nine patients with synchronous and 40 with metachronous liver metastases from gastric cancer had been treated. In synchronous cases, forty percent of the patients had many metastatic tumors in bilateral hepatic lobes and the majority of them had advanced gastric cancer with serosal invasion and widely spread of lymphatic metastases. On the other hand, over 70% of metachronous patients had unilobar or scattered bilobar metastases and only 20% of them accompanied other types of metastases. A survival analysis showed that the prognoses of patients undergoing hepatic resection were statistically better than other treatments in both synchronous and metachronous cases. And there was no evidence for the benefit of palliative gastrectomy. So we conclude that surgical treatment for hepatic metastases from gastric cancer is a beneficial option if all the lesions including the primary and lymphatic ones can be eradicated in limited candidates of synchronous cases and in more candidates of metachronous cases, especially unilobar and a few scattered bilobar metastases.     

Favourable long-term results after surgical removal of lung metastases of breast cancer

We retrospectively evaluated whether a surgical strategy benefits patients with operable lung metastasis of breast cancer. Between 1960 and 2000, 90 patients (mean age 55.1; range 32-77) with lung metastasis (79 solitary, 11 multiple) underwent surgery as follows: wedge resection (n = 10), segmental resection (n = 11), lobectomy (n = 68) and pneumonectomy (n = 1). The metastases were completely resected in 89% of them. One patient died due to surgical complications. The overall 5- and 10-year cumulative overall survival rates were 54% and 40%, respectively (median, 6.3 years). Fifteen patients survived without relapse for over 10 years. They were 24% of those who progressed for 10 years or more after lung surgery. The most significant prognostic factor was disease-free interval (DFI) and stage at breast surgery. The 10-year survival rates of those with >==3 and <3 years of DFI were 47% and 26%, respectively (P = 0.014). Survival times were significantly longer for patients with clinical stage I at breast surgery than those with stage II-IV (P = 0.013). Our data, although limited and highly selective, suggest that surgical approach to lung metastasis from breast cancer may prolong survival in certain subgroups of patients to a greater extent than systemic chemotherapy alone. Surgical approach to lung metastasis of breast cancer, if possible, should be a treatment of choice to a great extent.     

633例胃癌患者临床病理特征及生存分析

目的 对比不同Lauren分型胃癌的临床病理特征,对其进行生存分析,并筛选预后因子。方法 回顾性分析2007年1月1日—2008年6月30日在哈尔滨医科大学附属肿瘤医院接受手术治疗的胃癌患者的临床病理学资料,将收集到的633例胃癌患者分为肠型胃癌、弥漫型胃癌,对两组的临床病理特征及生存数据等进行统计分析。结果 对比弥漫型胃癌而言,肠型胃癌比例略高(51.66% vs. 48.34%),男性比例较高(2.94:1 vs. 2.03:1,P=0.035),更易发生于老年患者(发病年龄≥60岁比例54.43% vs. 35.94%,P＜0.001)。肠型胃癌预后明显好于弥漫性胃癌(中位生存时间:90.90个月 vs. 37.33个月,P=0.014)。多因素分析显示年龄≥60岁、CA199异常、肿瘤较大、分化较差、浆膜侵犯、初始淋巴结转移、姑息性手术、非幽门切除术是胃癌的不良预后因素。结论 Lauren分型可以较好的反应不同胃癌的临床病理学特征,并指导预后。     

Surgical treatment of early gastric cancer

In Japan, R2-gastric resection which consists of gastrectomy, omentectomy and complete removal of Group 1 and 2 regional lymph nodes has been generally accepted as the procedure of choice in the treatment of early gastric cancer during the past 20 years. As a result, surgical treatment for early gastric cancer patients has achieved a very good survival rate, 97.7% and 96.2% 5 and 10 years, respectively, after surgery. To determine a new rationale for surgical treatment for early gastric cancer, the relationship between various prognostic factors and postoperative prognosis in 1,200 patients with early gastric cancer was studied. The survival rate for patients with a single focus of cancer in the stomach was significantly higher than that for patients with multiple foci. The incidence of recurrence was very low (2.8%) as a whole and most recurrence was found in patients who have had invasion into the submucosa with regional lymph node metastasis. The characteristic mode of recurrence was hematogenous metastasis to the liver and lung. The majority of causes of death were non-malignant disease and multiple primary malignant neoplasms. As to the survival rate in relation to the extent of lymph node dissection, no significant difference in survival rate was observed among the three procedures R0-, R1- and R2-resection in single cancer regardless of cancer invasion through the gastric wall. The survival rate for intramucosal carcinoma without lymph node metastases and with Group 1 lymph node metastases in both single and multiple cancer was 100%. In addition, 125 patients with intramucosal polypoid cancer (types I and IIa according to the macroscopic classification of early gastric cancer) showed no lymph node metastasis and had 100% survival. Therefore, from the present study a new rationale for surgical treatment for early gastric cancer is recommended as follows: 1) In general, R1-resection is indicated for intramucosal carcinoma and R2-resection for submucosal carcinoma. 2) Local resection of the tumor or R0-resection with preservation of the regional lymph nodes is thought to be sufficient for an intramucosal polypoid carcinoma less than 2.0 cm in diameter.     

160例胃癌卵巢转移的治疗及预后因素分析

目的:通过回顾性分析胃癌卵巢转移患者的临床资料,了解胃癌卵巢转移瘤切除术、患者临床病理特征与生存之间的关系,从而探索可能对其生存有益的治疗方法。方法:收集并整理2010年1月至2019年12月新疆医科大学附属肿瘤医院经组织病理学及影像学确诊的160例胃癌卵巢转移患者的资料,根据治疗方式将患者分为两组:卵巢转移瘤切除组（n=37,A组）及卵巢转移瘤未切除组（n=123,B组）。分析两组患者的临床病理特征、治疗方式与生存的关系。结果:A组的生存期明显优于B组（15.9个月vs 5.7个月,P＜0.001）,且此生存获益对青年女性更加明显（16.8个月vs 12.0个月,P＜0.001）,多因素分析显示卵巢转移瘤切除术［HR（95％CI）:2.524（1.597～3.988）,P＜0.001］、CA125升高［HR（95％CI）:0.630（0.433～0.917）,P＝0.016］是影响生存的独立预后因素。结论:对于胃癌卵巢转移患者,卵巢转移瘤切除术可延长生存期。转移瘤切除术、CA125水平是影响患者生存的独立预后因素。     

可切除结直肠癌肺转移的预后因素分析

目的 探讨结直肠癌肺转移根治性切除术后的预后影响因素.方法 回顾性分析行根治性切除术的60例结直肠癌肺转移患者的临床资料.结果 全组患者肺转移瘤切除术后和结直肠癌切除术后的5年生存率分别为43.7%和74.0%.单因素分析结果显示,肺转移瘤数目和无瘤间期与结直肠癌术后患者的总生存率有关(均P＜0.05),肺转移瘤切除前癌胚抗原(CEA)水平、肺转移瘸数目、有无肺门和纵隔淋巴结转移与肺转移瘤切除术后患者的生存率有关(均P＜0.05).多因素分析结果显示,肺转移瘤数目和无瘤间期是结直肠癌术后患者预后的独立影响因素(OR=2.691,95% CI为1.072～6.754;OR=0.979,95% CI为0.963～0.994),肺转移瘤数目、有无肺门和纵隔淋巴结转移是肺转移瘤切除术后患者预后的独立影响因素(OR=3.319,95% CI为1.274～8.648;OR=3.414,95% CI为1.340～8.695).结论 经过严格选择的结直肠癌肺转移患者,尤其是单发肺转移及无肺门和纵隔淋巴结转移的患者,行根治性切除术后可获得长期生存.     

Pathology and prognosis of gastric carcinoma: well versus poorly differentiated type

BACKGROUND: The most important parameters predicting outcome of patients with gastric carcinoma are the depth of wall invasion and the status of lymph node metastasis, but the prognostic significance of histologic type is unclear. The aim of this study was to clarify the prognostic value of two major histologic types of gastric carcinoma, that is well and poorly differentiated types. METHODS: Histopathologic findings and outcomes of 504 patients with gastric carcinoma were evaluated by well and poorly differentiated types. Well differentiated gastric carcinoma (WGC) included papillary and tubular adenocarcinomas, poorly differentiated medullary carcinoma, and well differentiated mucinous carcinoma; whereas poorly differentiated gastric carcinoma (PGC) included poorly differentiated scirrhous carcinoma, signet ring cell carcinoma, and poorly differentiated mucinous carcinoma. RESULTS: Patients with WGC were characterized by old age, male predominance, tumor location in the lower third of the stomach, small tumor size, and liver metastasis; whereas patients with PGC were distinguished by their tumor location in the middle third of the stomach, serosal invasion, lymph node metastasis, advanced stage, and peritoneal dissemination. The overall 5-year survival rate for patients with WGC was higher than that for patients with PGC (76% vs. 67%; P = 0.058), especially for patients with >/= 10 cm tumors (42% vs. 14%; P = 0.017). The 5-year survival rate for patients with serosa positive but node negative tumors was higher in WGC patients than in PGC patients (83% vs. 59%; P = 0.086); whereas the 5-year survival rate for patients with serosa negative but node positive tumors was lower in WGC patients than in PGC patients (63% vs. 88%; P = 0.008). Multivariate analysis indicated that among pathologic variables of the tumor, histologic type (WGC vs. PGC) was one of the independent prognostic factors. CONCLUSIONS: Histologic type is important for estimating the tumor progression and outcomes of patients with gastric carcinoma. In addition to the depth of wall invasion and status of lymph node metastasis, histologic type, including well or poorly differentiated type, should be evaluated in the management of gastric cancer.     

103例肝内胆管癌临床病理及诊治分析

  目的  研究分析肝内胆管癌（intrhepatic cholangiocarcinoma, ICC）的临床转移特点、治疗及预后。  方法  回顾性分析1989年1月至2009年12月本院收治的103例肝内胆管癌的临床资料, 分析根治手术与姑息手术、非手术治疗后患者预后的差异。  结果  103例肝内胆管癌患者1、3、5年总体生存率分别为66.1%, 30.1%, 18.4%, 中位生存时间20个月。根治手术组1、3、5年生存率分别为75.3%, 48.2%, 33.9%, 与姑息手术组（46.3%, 0, 0）、非手术组（7.7%, 0, 0）之间的差异有统计学意义。单因素分析表明患者的肿瘤直径、组织学分化程度、肿瘤单发或多发、门静脉、淋巴结、腹膜转移、手术方式为影响肝内胆管癌预后的危险因素。多因素分析显示组织学分化程度、有无门静脉转移、淋巴结转移、腹膜转移及手术方式是影响预后的独立因素。  结论  ICC淋巴结转移率高, 肝内复发是导致死亡的重要因素, 根治性手术切除是ICC最有效的治疗方法。组织学分化程度、门静脉转移、淋巴结转移、腹膜转移及手术方式是影响ICC患者预后的独立危险因素。      

Cerebral metastases from malignant melanoma.

A retrospective study was undertaken of factors affecting survival in 129 patients with cerebral metastases from malignant melanoma referred to the Department of Radiation Oncology from June 1982 to January 1990. Their ages ranged from 19 to 83 years and the time interval from diagnosis of the primary tumour to development of cerebral metastases ranged from one month to 17 years. Cerebral metastases were apparently solitary in 59 (46%) and multiple in 70 (54%) patients respectively. Craniotomy with resection of tumour was performed in 49 patients, of whom 24 had a solitary cerebral metastasis as the only evidence of disease. Most patients (94%) received a course of radiotherapy. Median survival of the whole group after detection of cerebral metastases was 5 months (range less than 1-87+). Univariate analysis indicated that a solitary cerebral metastasis, absence of extracranial disease and tumour resection predicted improved survival, but only surgical intervention was of independent prognostic significance in a multivariate analysis. The effect of cranial irradiation on survival could not be assessed, but the dose of radiation did not influence survival. Of the 10 patients who survived for more than 2 years, eight had total resection of a solitary cerebral metastasis.     

Long-Term Survival in Two Cases of Resected Gastric Metastasis of Pulmonary Pleomorphic Carcinoma

We report two pulmonary pleomorphic carcinoma patients both of which underwent surgical resection of solitary gastric metastases. A 69-year-old man developed anemia 5 months after right upper lobectomy for pulmonary pleomorphic carcinoma and gastric metastasis was detected endoscopically. He underwent distal gastrectomy and has survived for 5 years without any other recurrence or metastasis. Preoperative abdominal computed tomography detected a submucosal gastric tumor in a 62-year-old man with left upper lobe pleomorphic carcinoma. A gastrointestinal stromal tumor was suspected. Left upper lobectomy was performed followed by partial gastrectomy with splenectomy. The histologic diagnosis was primary pulmonary pleomorphic carcinoma with gastric metastasis. He has survived for 4 years without any other recurrence or metastasis. Resection of gastric metastasis following complete pulmonary pleomorphic carcinoma resection may be indicated if the metastasis is solitary.     

Modified operation for an early stage gastric cancer

The standard operation for gastric cancer is carried out for advanced gastric cancer with serosal invasion accompanying patent disseminative metastasis to the peritoneum of the omental bursa and lymph node metastases. It consists of subtotal or total gastrectomy, omentobursectomy and extended lymph node dissection. An early stage cancer, which in Japan accounts for almost a half of the resectable cases of gastric cancer, shows no serosal invasion, and lymph node metastases are rare if the cancer remains intramucosal. Such cases represent about a half the cases of the early stage cancer. The diagnosis of the early stage cancer, especially if it remains intramucosal, is made by means of preoperative radiological and endoscopic examinations and intraoperative examination. Since 1977 we have been performing a modified operation as well for cases of the early stage cancer. The surgical procedure is as follows: reduction in the size of gastric resection by 2/3, pylorus-preserving gastrectomy and proximal gastric resection; preservation of the distal portion of the greater omentum and transverse incision of the upper abdomen instead of upper midline incision to prevent ileus due to intestinal adhesion to abdominal wound around umbilicus; sparing bursectomy; narrowing the area of lymph node dissection; sparing thoracotomy for cancer in the esophagogastric junction; sparing splenopancreatectomy; preservation of the hepatic branch of the vagal nerve and postoperative temporary oral administration of cholagogue to prevent postgastrectomy cholelithiasis. In addition, the primary lesion is isolated from the blood circulation by means of ligation of the drainage veins to diminish metastasis through the blood vessels (hepatic metastasis, etc.), which is the main cause recurrence after surgery for the early stage cancer. The results of this new surgery are satisfactory; the five-year postoperative survival rate is 100.0% and it reduced the time needed for surgery, anesthesia and blood transfusion.