A case report of early rectal carcinoma, IIa + IIc type, with no invasion of the submucosa

A 66-year-old woman was admitted to the Hakodate Chuo Hospital because of abdominal discomfort. A barium enema study revealed a deformity of the middle Houston's valve of the rectum and granular lesions at the Rb region of the rectum. A colonoscopic examination showed the IIa + IIc type of early rectal carcinoma. A resected specimen also revealed IIa + IIc type early rectal carcinoma, 8 X 13 mm in diameter, and well-differentiated adenocarcinoma with no invasion of the submucosa. Infiltration into the lymphatic vessels and regional lymph node metastasis were not encountered. The deformity of the rectal Houston's valve was checked by a barium enema study. It should be emphasized that early detection of colorectal carcinoma with no invasion of the submucosa, requires careful barium enema studies and colonoscopic examination.     

67例早期胃癌临床病理特征及预后分析

目的：研究早期胃癌患者的临床病理特征及预后因素.方法：回顾性分析我院67例早期胃癌根治术标本的肿瘤直径、浸润深度、肉眼分型、组织学分型、淋巴结数目、淋巴结转移等资料.并对患者进行随访及预后分析.结果：早期胃癌发病高峰为40-59岁,以男性多见.大体分型以凹陷型、浅表型为主,组织学分型以管状腺癌为主,12例伴胃周淋巴结转移,5年生存率为95%,粘膜内癌不伴有胃周淋巴结转移者5年生存率为100%.结论：提高早期胃癌的检出率,降低胃癌死亡率.     

Risk of Lymph Node Metastases from Early Gastric Cancer in Relation to Depth of Invasion: Experience in a Single Institution

Background: An accurate assessment of potential lymph node metastasis is important for the appropriate treatment of early gastric cancers. Therefore, this study analyzed predictive factors associated with lymph node metastasis and identified differences between mucosal and submucosal gastric cancers. Materials and Methods: A total of 518 early gastric cancer patients who underwent radical gastrectomy were reviewed in this study. Clinicopathological features were analyzed to identify predictive factors for lymph node metastasis. Results: The rate of lymph node metastasis in early gastric cancer was 15.3% overall, 3.3% for mucosal cancer, and 23.5% for submucosal cancer. Using univariate analysis, risk factors for lymph node metastasis were identified as tumor location, tumor size, depth of tumor invasion, histological type and lymphovascular invasion. Multivariate analysis revealed that tumor size >2 cm, submucosal invasion, undifferentiated tumors and lymphovascular invasion were independent risk factors for lymph node metastasis. When the carcinomas were confined to the mucosal layer, tumor size showed a significant correlation with lymph node metastasis. On the other hand, histological type and lymphovascular invasion were associated with lymph node metastasis in submucosal carcinomas. Conclusions: Tumor size >2 cm, submucosal tumor, undifferentiated tumor and lymphovascular invasion are predictive factors for lymph node metastasis in early gastric cancer. Risk factors are quite different depending on depth of tumor invasion. Endoscopic treatment might be possible in highly selective cases.     

Treatment of early gastric cancer by endoscopic double snare polypectomy (EDSP)

The indication for EDSP was studied in 75 patients with early gastric cancer diagnosed endoscopically which had been obtained over a period of 11 years (1979 to 1985) at the Cancer Institute Hospital, Tokyo and the following results were obtained. EDSP consists of two procedures using double channel fiberscope; a sessile or depressed lesion pulled upward by one snare cautery (standard EDSP) is transformed into a subpedunculated one, which allows another snare cautery of pseudostalk, and it is excised by using coagulation current. EDSP was performed in 53 cases of IIa type and 22 cases of IIc type. Excision by one snare cautery was possible in 90.9% (40/44) of IIa lesion measuring less than 2 cm and in 100% (14/14) of IIc lesion measuring less than 1 cm, the total being 85.3% (64/75). There was no residual cancer in 41 cases of IIa lesion (93.2%) and 17 cases (85.0%) of IIc lesion with two recurrent cancers confirmed by follow-up endoscopy. Residual cancer was found in 6 cases (9.1%) which were operated on. The results mentioned above show the usefulness of EDSP and selection of case without lymph node metastasis permitting complete excision by one snare cautery is of much importance. EDSP is indicated for IIa lesion of differentiated type measuring less than 2 cm, IIc lesion of differentiated type without ulceration measuring less than 1 cm and IIc lesion of undifferentiated type without ulceration measuring less than 0.5 cm that is not located in the fundic gland area.     

胃癌骨转移的临床特点

据文献报道胃癌伴有骨转移发生率为0.46% ～38% ,胃癌伴骨转移的高危因素包括:年轻患者、病理为低分化腺癌、Borrmann Ⅲ型、浸润深度T 3 和T 4、伴多发淋巴转移和胃体部肿瘤。转移途径半数以上为非门脉系统。胃癌伴骨转移而无肝转移病例占69% ,骨转移与淋巴转移区站转移有密切关联,距胃原发病灶3 cm以上存在淋巴转移者,其骨转移发生率为27% 。核素扫描为骨转移提供了诊断途径和可靠的依据,HCG 、CEA 肿瘤标志物检测对诊断骨转移有所帮助,治疗以放化疗为主。骨转移预后较差,大多生存期< 6 个月。      

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.     

胃癌淋巴结转移规律的临床研究

目的：探讨胃癌淋巴结转移规律和胃癌根治术的淋巴结清扫范围。方法：将采集不同部位的淋巴结,依据国际TNM分期标准和组站分类法,全部数据进行统计学处理。结果：本组胃癌淋巴结转移率67．3％,早期和进展期胃癌转移率分别为14．3％和79．8％。肿瘤浸润深度T1者,淋巴结转移主要局限于N1,T2者淋巴结转移N3者5．4％,T3者淋巴结转移N3的9．5％。结论：胃癌淋巴结转移通常从原发病灶开始,通过淋巴网沿着淋巴管由近及远地向外扩散,肿瘤的大小或浸润深度不同,淋巴结转移的差异性有显著意义（P＜0．01）。     

Endoscopic resection with local injection of HSE (ERHSE) in early gastric carcinomas

We have developed a new therapeutic method of endoscopic resection with local injection of HSE (ERHSE) for the early gastric carcinomas. ERHSE was performed for a total of seventy eight lesions of seventy five cases. Seventy eight early gastric carcinomas consisted of IIc (35), IIa (32), I (6), IIa + IIc (4) and IIc + IIa (1). Ten cases out of 75 underwent gastrectomy, because the invasion of carcinoma was detected in the submucosa or to the resected margin. No evidence of local recurrence has been obtained in the sixty five cases treated by this method.     

The expression of thymidylate synthase and thymidine phosphorylase in the early-stage of gastric cancer

The immunohistochemical expression of thymidylate synthase (TS) and thymidine phosphorylase (TP) was investigated in 116 of early gastric cancer, in order to know whether or not these reflect malignity in an early stage. The materials conditioned on early gastric cancer with submucosal invasion and over 1 cm2 in size, were 57 with and 59 without lymph node metastasis. They were divided into two by the depth of invasion. The expressions of TS and TP in these group were compared with corresponding histopathological findings. Overall expressions of TS and TP were 54.3% and 34.5%, respectively. The TS-expression was not related with the depth of invasion and lymph node metastasis. The TP-expression, however, showed significant difference between with and without lymph node metastasis, and was so on the depth of submucosal invasion in the group without the nodal metastasis. Multivariate analysis showed that mucosal spread bordering 4 cm2 in size (p = 0.024) and lymphatic permeation (p = 0.099) in TS-expression, and lymph node metastasis (p = 0.041), submucosal invasion (p = 0.076) and venous permeation (p = 0.111) in TP-expression were the noticeable factors regarding to their high expression rates. Although these results were considered not to exceed gastric resection on the prognosis, they might be applicable as one of the indicators in postoperative follow-up on the minor resection of early gastric cancer such as EMR or local resection.     

淋巴结转移阴性早期胃癌的临床病理特点及预后分析

目的:探讨淋巴结转移阴性早期胃癌的临床病理特点及其预后因素,为临床治疗提供理论依据。方法:回顾性分析1983年1 月～2003年12月河北医科大学附属邢台人民医院肿瘤外科收治132 例淋巴结转移阴性早期胃癌患者的临床病理特征与预后的关系。结果:淋巴结转移阴性与淋巴结转移阳性早期胃癌在肿瘤直径和浸润深度组间有显著性差异（P<0.05）。 两者在性别、年龄、家族史、肿瘤数目、肿瘤部位、大体类型和组织学类型分组中有显著性差异（P>0.05）。 本组获随访126 例,6 例失访,随访率为95.5% 。3 年生存率为91.3%（115/126）,5 年生存率为84.9%（107/126）。 单因素分析经Kaplan-Merier 分析筛选出浸润深度与淋巴结转移阴性早期胃癌预后关系密切（P=0.001）。 结果表明浸润深度是淋巴结阴性早期胃癌的独立预后因素。黏膜内癌患者的生存率与黏膜下癌者比较,差异有统计学意义（P<0.05）。 结论:浸润深度是淋巴结转移阴性早期胃癌的独立预后因素。术前或术中正确评估早期胃癌的淋巴结转移状态是选择合理的治疗方案和改善预后的重要条件。      

早期胃癌的淋巴结转移规律及预后分析

目的 分析早期胃癌的临床病理特征与预后之间的关系及早期胃癌的淋巴结转移规律.方法 对1994年1月～2005年10月手术治疗并有完整资料的255例早期胃癌的临床病理学资料进行回顾性分析.结果 255例患者的总5年生存率为91.4%.单因素分析显示,肿瘤浸润深度、脉管瘤栓和区域淋巴结转移与患者术后生存率有关;而性别、年龄...     

整合素β1、血管内皮生长因子与胃癌浸润转移的关系

目的探讨胃癌组织中整合素β1、血管内皮生长因子（VEGF）的表达与胃癌浸润、转移的关系。方法应用免疫组织化学技术检测63例胃癌组织中整合素β1、VEGF的表达,结合临床资料、病理分级、分期、分型对其进行统计学分析。结果胃癌组织中整合素β1的表达与病理分级及患者年龄、性别无关。整合素β1的阳性表达率在全层与黏膜下层间,全层与肌层间的表达差异有统计学意义（P〈0．05）,但肌层与黏膜下层间的表达差异无统计学意义（P〉0．05）。管状腺癌、乳头状腺癌、黏液腺癌、未分化腺癌中的阳性表达率分别为70．00％、55．56％、57．14％、64．86％,差异无统计学意义。在胃癌发生转移组中的表达（80．56％）明显高于未转移组（55．56％）,差异有统计学意义（P〈0．05）。VEGF在胃癌中的表达与性别、浸润深度及组织学分型均无关,但与有无转移有关,发生转移组的阳性表达率为86．11％（31／36）,未转移组有62．96％（17／27）表达阳性,两者间差异有统计学意义（P〈0．05）。结论整合素的表达与胃癌的浸润深度及有无淋巴结转移有关,浸润程度越深,阳性表达率越高;有淋巴结转移组明显高于无淋巴结转移组。VEGF的表达与胃癌是否伴有淋巴结转移有关,转移组的表达高于无转移组。     

Clinicopathological features of the superficial spreading type of early gastric cancer

Background. During a 10-year period (1986–1995), 59 of 538 patients with early gastric cancer (11.0%) had the superficial spreading type of gastric cancer. We attempted to elucidate the clinicopathological features and investigated the influence of those features on surgical procedures and patient prognoses. Methods. These 59 superficial spreading lesions were analyzed with respect to macroscopic type, lymph node (LN) metastasis, recurrent pattern, and method of surgical operation. In addition, the lesions were compared with those of 393 other patients with small-sized cancer. Results. In both groups, the IIc type macroscopic lesion occurred most frequently, and the depressed subtype occurred more frequently than the elevated subtype. There was no significant histologic difference between the groups. The incidence of LN metastasis was 8.7% in early gastric cancer, 7.1% in small-sized cancer, and 20.3% in superficial spreading cancer. The incidence of lymphovascular invasion was 24.4% in small-sized cancer and 50.8% in superficial spreading cancer. The incidences of LN metastasis and lymphovascular invasion were greater in superficial spreading cancer than in small-sized cancer. Despite extensive preoperative examination, determination of the tumor margin was impossible in 26 of the 59 patients with superficial spreading cancer. The incidence of recurrence was 2.0% in small-sized cancer and 5.1% in superficial spreading cancer. Conclusions. A wide resection with extensive lymph node dissection (D2 or more) seems to be an appropriate treatment for the superficial spreading type of early gastric cancer. Received for publication on Sept. 17, 1998; accepted on July 21, 1999     

胃癌组织及区域淋巴结MUC1、CD44v6、nm23表达与胃癌侵袭转移及预后的关系

背景与目的:研究证实胃癌浸润深度和淋巴结转移是多基因及其蛋白表达产物协调作用的结果,寻找与胃癌转移相关的分子生物学标志物有助于胃癌的研究。本实验旨在探讨胃癌组织及区域淋巴结中MUC1、CD44v6、nm23表达与胃癌侵袭转移及预后的关系。方法:采用SP免疫组织化学方法对110例胃癌组织及613枚区域淋巴结中的MUC1、CD44v6、nm23基因蛋白的表达进行检测。结果:①胃癌组织中的MUC1蛋白阳性表达在低分化癌组、浸润型组、T3+T4组、淋巴结转移组、Ⅲ～Ⅳ期组、生存期<5年组分别为84.6%、88.1%、87.3%、91.7%、94.4%、95.5%,CD44v6分别为79.5%、74.6%、79.4%、81.7%、87.0%、87.9%,nm23分别为38.5%、32.2%、30.2%、25.0%、25.9%、18.2%。MUC1和CD44v6表达低分化癌组显著高于高、中分化癌组(78.9%vs57.7%),浸润型组高于局限型组(72.6%vs54.9%),T3+T4组高于T2组(72.3%vs46.8%),淋巴结转移组高于无淋巴结转移组(68.0%vs46.0%),TNMⅢ～Ⅳ期组高于Ⅰ～Ⅱ期组(67.9%vs44.6%),生存期<5年组高于≥5年组(59.1%vs31.8%),各组间差异均具有显著性(P<0.01或P<0.05)。而nm23除分化程度、Borrmann分型不同的两组之间差异无显著性外,T3+T4组低于T2组(51.1%),有淋巴结转移组低于无淋巴结转移组(56.0%),TNMⅢ～Ⅳ期组低于Ⅰ～Ⅱ     

早期胃癌组织中上皮钙粘蛋白表达与淋巴结微转移及临床病理的关系

背景与目的:早期胃癌淋巴结微转移问题日益受到关注,胞浆角蛋白(cytokeratin,CK)染色是识别上皮源性恶性肿瘤细胞的重要方法,本研究拟探讨早期胃癌原发灶上皮钙粘蛋白(epithelial cadherin,E-cad)的表达情况与淋巴结内出现微转移之间的关系及临床意义.方法:用免疫组织化学染色的方法对162例早期胃癌患者的4 522枚淋巴结进行苏木精-伊红(HE)和胞浆角蛋白(cytokeratin,CK)染色,并对其中135例患者的原发灶切片进行E-cad染色,结合临床病理资料和随访结果进行分析.结果:HE染色发现的淋巴结转移率为6.8%(11/162),而CK染色发现的淋巴结转移率为26.5%(43/162),二者差异有统计学意义(P＜0.001).在151例HE染色未见淋巴结转移的患者中通过CK染色发现了32例(21.2%)有淋巴结微转移,且淋巴结微转移多见于原发灶直径大于1.0 cm,组织分化不良,肿瘤浸润较深的(如浸及粘膜下层),淋巴管和血管受累,以及E-cad低表达标本(P＜0.05).原发灶E-cad的低表达率为57.0%(77/135),与淋巴结出现微转移有密切关系,有淋巴结微转移患者的5年生存率比没有微转移者明显低(P＜0.01).结论:肿瘤直径大于1.0 cm,组织分化不良,较深的浸润,淋巴管或血管受累,以及E-cad低表达是早期胃癌患者出现淋巴结转移的高危因素.     

Time trends of surgical treatment and the prognosis for Japanese patients with gastric cancer

The incidence of gastric cancer is much higher in Japan than in other countries even though diagnostics and treatments of such patients have improved. The objective of this study was to present an overview of the past, present and future of surgical treatment for our patients with gastric cancer. We analysed data on 2152 Japanese men and women with gastric cancer who underwent surgical resection from 1965 to 1995 at Kyushu University in Fukuoka, Japan, based on a univariate and the multivariate analysis. We focused on time trends of surgical treatment and the postoperative outcome. Over the years, there have been favourable changes in the numbers of patients with early gastric cancer. In all cases of gastric cancer, the rate of 18% in the first six year period (group 1) was 57% in the last 5 year period (group 6). Size of the tumour was smaller, well-differentiated tumour tissue was more common, and lymphatic involvement was less frequent. Lymph node metastasis, liver metastasis and peritoneal dissemination all decreased. Extensive lymph node dissection was more frequently done and the rate of curative resection (curability A and B) increased. With increases in identifying the early stage of cancer and better perioperative care, mortality rates 30 days after the surgery greatly decreased. Multivariate analysis revealed that the 10 factors of depth of invasion, lymph node metastasis, lymph node dissection, tumour size, liver metastasis, peritoneal dissemination, lymphatic invasion, vascular invasion, lesion in the whole stomach and lesion in the middle stomach were independent factors for determining the prognosis. Detection of the tumour in an early stage, standardized surgical treatment, including routine lymph node dissection, close follow-up schedules and better perioperative management are expected to increase survival time for patients with this malignancy.     

A case of lymph node metastasis following a curative endoscopic submucosal dissection of an early gastric cancer

Currently in Japan, differentiated gastric submucosal invasive cancers <500 μm (SM1) with negative lymphovascular involvement are included in expanded pathological criteria for curative endoscopic treatment. This is based on a retrospective examination of surgical resection cases in which patients suitable for such expanded criteria were determined to have a negligible risk of lymph node metastasis. We performed endoscopic submucosal dissection on a 65-year-old male with early gastric cancer in April 2005, and pathology revealed a well-differentiated adenocarcinoma, 21 × 10 mm in size, SM1 invasion depth and negative lymphovascular invasion as well as tumor-free margins, so the case was diagnosed as a curative resection. This case, however, resulted in lymph node metastasis that was diagnosed by endoscopic ultrasonography with fine-needle aspiration biopsy in May 2009. Distal gastrectomy with D2 lymph node dissection was then performed, confirming lymph node metastasis from the original gastric cancer.     

Two rare cases of node-positive differentiated gastric cancer despite their infiltration to sm1, their small size, and lack of lymphatic invasion into the submucosal layer

Early gastric cancer without lymph node metastasis has been reported after the analysis of many cases, and a consensus has been reached about this condition. We report two cases of node-positive differentiated sm1 gastric cancer without lymphatic invasion into the submucosal layer. Case 1 was a 73-year-old man who underwent EMR for 0-IIc early gastric cancer (EGC) on the gastric angle, with a histological diagnosis of tub1. Pathological examination revealed a 0-IIc lesion that was 12 mm in size and sm1 in invasion depth without lymphatic-vascular invasion. However, the infiltration in the submucosal layer was relatively wide. The patient subsequently underwent distal gastrectomy with D2 lymph node dissection. Pathological examination revealed level 2 lymph node metastasis. Case 2 was a 62-year-old woman who underwent ER for a 0-I+IIc-type EGC on the greater curvature of the antrum, with a histological diagnosis of tub1. Pathological examination revealed a 0-I+IIc-type lesion that was 15 mm in size and sm1 in depth. Lymphatic invasions in the muscularis mucosa were found, but none were seen in the submucosal layer. Two years later, follow-up computed tomography (CT) showed a lymph node swelling in the infrapyloric region. Distal gastrectomy with D2 dissection was then performed, and pathological examination revealed level 1 lymph node metastasis. Although the lesions in both patients satisfied the criteria of Gotoda et al. for minimal risk of nodal involvement, lymph node metastasis was observed in these patients. Curative surgery with lymph node dissection is thus required in patients with wide infiltration of the submucosal layer or lymphatic invasion in the muscularis mucosa.     

Is the new UICC staging system of gastric cancer reasonable? (Comparison of 5-year survival rate of gastric cancer by old and new UICC stage classification).

In the new UICC TNM system for gastric cancer approved in 1985, a T1 lesion with lymph node (LN) metastasis is classified as stage, Ib; in the old TNM system this was classified as stage III. This is contradictory to a general rule of the UICC TNM system, whereby cancer with LN metastasis is classified as stage II or III. Two thousand and sixty-three patients with less than T4 gastric cancer who were treated at Seoul National University Hospital from 1970 to 1986 were analysed for significant prognostic factors. Survival curves were subsequently analysed according to the number of LN metastases and the depth of invasion. As a result of multivariate study for clinical and pathological features such as age, tumour location, gross appearance, histological type, depth of tumour invasion and regional lymph node metastasis, we confirmed that only two factors--regional lymph node metastasis and depth of gastric wall invasion--are significant. We showed that when the LN variable is classified according to the number of LN metastases (0 group, 1-3 group, > 3 group) like the UICC TNM classification of colorectal cancer, the survival curves are similar to those reported by the Japanese Research Society for Gastric Cancer. The authors propose the modification of the UICC TNM classification system according to depth of invasion and the number of LN metastases, whereby a T1 lesion with LN metastasis is classified as stage IIa instead of stage 1b.     

Endoscopic mucosal resection for early gastric cancer.

Progress in the detection of early gastric cancer has made endoscopic mucosal resection (EMR) possible for the treatment of gastric cancer instead of only conventional surgical resection. The most commonly employed modalities include strip biopsy, double snare polypectomy, and resection with combined use of highly concentrated saline and epinephrine, and resection using a cap. The indications should be strictly limited to the differentiated IIa type (the slightly elevated type) that is smaller than 2 cm, or the differentiated IIc type (slightly depressed type) without ulcer formation and smaller than 1 cm. Both of these entities are thought to have a negligible risk of lymph node metastasis. Prognosis after this treatment is comparable that of surgical resection for early gastric cancer in completely resected cases. EMR also permits local resection in elderly patients with various complications who would be at risk for conventional surgical operations. EMR should be encouraged for treatment of gastric cancer if the indications are strictly chosen.