Development and external validation of a nomogram for overall survival after curative resection in serosa-negative, locally advanced gastric cancer.

BACKGROUND: Few nomograms can predict overall survival (OS) after curative resection of advanced gastric cancer (AGC), and these nomograms were developed using data from only a few large centers over a long time period. The aim of this study was to develop and externally validate an elaborative nomogram that predicts 5-year OS after curative resection for serosa-negative, locally AGC using a large amount of data from multiple centers in Japan over a short time period (2001-2003). PATIENTS AND METHODS: Of 39 859 patients who underwent surgery for gastric cancer between 2001 and 2003 at multiple centers in Japan, we retrospectively analyzed 5196 patients with serosa-negative AGC who underwent Resection A according to the 13th Japanese Classification of Gastric Carcinoma. The data of 3085 patients who underwent surgery from 2001 to 2002 were used as a training set for the construction of a nomogram and Web software. The data of 2111 patients who underwent surgery in 2003 were used as an external validation set. RESULTS: Age at operation, gender, tumor size and location, macroscopic type, histological type, depth of invasion, number of positive and examined lymph nodes, and lymphovascular invasion, but not the extent of lymphadenectomy, were associated with OS. Discrimination of the developed nomogram was superior to that of the TNM classification (concordance indices of 0.68 versus 0.61; P < 0.001). Moreover, calibration was accurate. CONCLUSIONS: We have developed and externally validated an elaborative nomogram that predicts the 5-year OS of postoperative serosa-negative AGC. This nomogram would be helpful in the assessment of individual risks and in the consideration of additional therapy in clinical practice, and we have created freely available Web software to more easily and quickly predict OS and to draw a survival curve for these purposes.

Inverse correlation between NKG2D expression on CD8+ T cells and the frequency of CD4+CD25+ regulatory T cells in patients with esophageal cancer.

Although malignant diseases are known to be associated with immune suppression, detailed mechanisms of this phenomenon are still unknown. NKG2D is an activating cell surface receptor expressed by natural killer (NK) cells and CD8+ T cells, and it has been reported that NKG2D engagement is extremely important for T cell activation. In the current study, NKG2D expression on CD8+ T cells and the frequency of CD4+ CD25+ regulatory T (Treg) cells were determined by multicolor flow cytometry to investigate one of the mechanisms responsible for immune evasion in esophageal cancer patients. NKG2D expression on CD8+ T lymphocytes in esophageal cancer patients was significantly lower than in those of normal controls. NKG2D expression in T3/T4 esophageal cancer was significantly lower than that in T1/T2 esophageal cancer. CD8+ T cells from patients with lymph node metastasis expressed significantly lower NKG2D than those without lymph node metastasis. Moreover, significantly lower NKG2D expression was observed in stage III/IV cancer in comparison with stage I/II. The frequency of CD4+CD25+ Treg cells in esophageal cancer patients was significantly higher than those in normal controls. NKG2D expression on CD8+ T cells was significantly inversely correlated with the frequency of CD4+CD25+ Treg cells in esophageal cancer patients. Our data indicates that decreased NKG2D expression on CD8+ T cells is correlated with disease severity. Decreased NKG2D expression and an increase in Treg cells may be one of the key mechanisms responsible for immune evasion in esophageal cancer.

Continuous infusion of 5-fluorouracil with versus without low-dose, consecutive administration of cisplatin in advanced colorectal cancer. A prospective randomized phase II study.

Recently, the treatment of advanced gastric cancer by continuous infusion of 5-fluorouracil (5-FU) with low-dose cisplatin (CDDP) has improved efficacy without severe toxicities. The possible effectiveness of 5-FU+low-dose CDDP for colorectal cancer (CRC) is intriguing. One hundred fifty-five patients with far-advanced CRC including at least one measurable lesion were enrolled in a prospective randomized clinical trial funded by the Japanese Foundation for Multidisciplinary Treatment of Cancer. These patients were assigned to the two arms to assess the value of low-dose CDDP when added to a continuous intravenous infusion of 5-FU at a dose of 300 mg/m(2)/24 hrs in a one-week cycle consisting of 5 days of treatment and 2 days of rest for at least 12 weeks. CD-DP was given intravenously at a dose of 3 mg/m(2) on days 1-5 and days 8-12, and then at a dose of 7 mg/m(2) twice a week. Three patients were excluded from the trial. The response rate in the 5-FU+low-dose CDDP arm (n=75) was significantly higher than that in the 5-FU arm (n=77) (25.3% vs. 11.7%; P = 0.037). There was no significant difference in the median overall survival time between the 5-FU+low-dose CDDP arm and the 5-FU arm (479 and 491 days, respectively). Grades 3/4 toxicities occurred infrequently in both arms. The quality of life was almost the same between the arms. Low-dose CDDP improved the response rate while keeping toxicities within clinically acceptable limits. However, this combined treatment did not confer a survival advantage over treatment with continuous infusion of 5-FU alone for patients with far-advanced CRC; that might be attributable to the short CDDP administration setting of 12 weeks.

Predictive value of Ki-67 and argyrophilic nucleolar organizer region staining for lymph node metastasis in gastric cancer.

Proliferative activities in 91 primary gastric carcinomas and 36 corresponding metastatic perigastric lymph nodes were investigated using Ki-67 labeling percentage and an argyrophilic nucleolar organizer region (AgNOR) count. Tumors with a high proliferative activity often metastasized to lymph nodes, and the proliferative activities of the primary lesion and the perigastric lymph node metastases were similar. A significant correlation was recognized between the Ki-67 labeling percentage and the AgNOR count (r = 0.744; P less than 0.001). The Ki-67 labeling percentage and AgNOR count proved to be useful predictors of nodal metastasis regardless of tumor size, depth of invasion, and histological type. Even when tumors are smaller (less than 7 cm) or the stage of the disease is early (pT1, 2), the formation of metastasis increased with an increased Ki-67 labeling percentage or AgNOR count. The combination analysis of depth of invasion with Ki-67 labeling percentage or AgNOR count gives a more precise prediction of nodal metastasis, compared with histological analysis alone.

Liver adenosquamous carcinoma invading the esophagogastric junction - a case-report and a review of the literature.

A case of adenosquamous carcinoma of the liver involving the esophago-gastric junction is reported. The preoperative diagnosis of a submucosal tumor of the cardia of the stomach was made following a barium meal study, gastrofiberscopy, ultrasonography, and computed tomography. At surgery, a tumor was found measuring 6x5 cm in diameter and involving the left lobe of the liver, lower esophagus and cardia of the stomach, and the origin of the tumor was unclear. Post-operative histopathology revealed that the tumor contained two different malignant components of glandular and squamous cells. An adenosquamous carcinoma originating in the liver was suspected, since the cancer cells did not involve the esophago-gastric mucosa and were mainly located in the S2 of the liver. Despite aggressive adjuvant chemotherapy, the patient died of a recurrence in the liver seven months later. This seems to be the first documentation of adenosquamous carcinoma of the liver invading the esophago-gastric junction.

Patients with multiple gastric cancers have poorer prognosis than patients with single gastric cancer.

The postoperative survival of patients with multiple gastric cancers (MGC) was evaluated in a comparison with that of patients with single gastric cancer (SGC). During the past 30 years, 2,405 patients with gastric cancer underwent gastrectomy in our clinic. Of these patients, 2,241 (93.2%) had SGC and 164 (6.8%) had MGC. The survival of patients With MGC was significantly poorer than that of patients with SGC. The incidence of deaths caused by gastric cancer, by malignancies in organs other than the stomach and by nontumorous diseases other than malignancies was greater in each case in patients with MGC. While, there was no single, independent factor that explained the poorer prognosis of patients with MGC, the significantly greater age of patients with MGC might be responsible for an increased incidence of occurrence not only of other malignancies but also of nontumorous diseases associated with aging.

Expression of MAGE genes and survival in patients with hepatocellular carcinoma.

The human melanoma antigen (MAGE) gene family encode tumor-specific antigens recognized by autologous cytotoxic T lymphocytes. Some of these antigens may be potentially useful for cancer-specific immunotherapy. The expression of MAGE genes has been reported not only in melanoma but also in various other malignant tumors. However, little is known about the expression of these genes in human hepatocellular carcinoma (HCC). We therefore analyzed, by means of a reverse transcription-polymerase chain reaction (RT-PCR), the expression of MAGE-1, MAGE-2, and MAGE-3 genes in 60 tissue samples resected from HCCs. The MAGE-1, MAGE-2, and MAGE-3 genes were expressed in 18 (30.0%), 9 (15.0%), and 15 (25.0%), respectively, of the 60 tumor-tissue samples. Nineteen (31.7%) samples expressed at least one of the three MAGE genes, and 8 (13.3%) expressed all three genes. In contrast, none of the MAGE genes was expressed in any of the 60 adjacent non-tumorous liver samples. The age of patients was significantly older in at least one MAGE-positive group (MAGE-positive groups) than in the MAGE-negative ones (p<0.05). The tumor size was significantly larger in MAGE-positive groups than in the negative ones (p<0.05). The serum alpha-fetoprotein level was significantly lower in MAGE-positive groups than in negative ones (p<0.05). Patients with tumors expressing at least one MAGE gene showed a better recurrence-free survival rate than those with tumors showing no MAGE gene expression (p<0.05). These results indicated that the MAGE genes were exclusively expressed in cancerous tissues of a considerable proportion of patients affected by HCC, and that some of these patients might be potential candidates for tumor-specific immunotherapy using the MAGE encoded antigens.

Correlation between cathepsin D expression and p53 protein nuclear accumulation in oesophageal squamous cell carcinoma.

AIM: The lysosomal protease cathepsin D has been reported to be associated with tumour progression in malignant tumours. Expression of the gene encoding cathepsin D is known to be stimulated by oestrogen in mammary cancer cells. Recent experiments revealed that a p53 DNA binding site is located in the promoter region of the cathepsin D gene. This fact indicates that cathepsin D expression may correlate with p53 protein expression. The purpose of this study is to evaluate the expression patterns of the cathepsin D and p53 proteins in oesophageal squamous cell carcinoma (SCC). METHODS: In 154 patients with oesophageal SCC, expression of the cathepsin D and p53 proteins was measured in tumours by means of immunohistochemistry using monoclonal antibodies against cathepsin D (clone, 1C11) and p53 (clone, BP53-12). RESULTS: Cathepsin D was detected in tumour cells, although it was not found in normal oesophageal epithelium adjacent to carcinoma. High cathepsin D expression (positive tumour cells > 10%) was detected in 76 of 154 cases (49%) and high p53 nuclear expression (positive tumour cells > 50%) was detected in 70 cases (46%). High cathepsin D expression was significantly associated with invasive tumour growth (p = 0.002), poor prognosis (p = 0.049), and nuclear accumulation of p53 protein (p = 0.001). Overexpression of both p53 and cathepsin D was seen in 45 of the 154 cases (29.2%). In addition, there was a positive correlation between the cathepsin D index (percentage of cathepsin D positive tumour cells) and Ki-67 labelling index (percentage of Ki-67 positive tumour cells) in 154 oesophageal SCCs (rho = 0.257; p = 0.009). However, in multivariate survival analysis, cathepsin D expression by the tumours was not an independent prognostic factor in patients with oesophageal SCC (p = 0.236). CONCLUSIONS: The expression of cathepsin D by cancer cells may play an important role in the invasive growth of oesophageal SCC. Overexpression of both p53 and cathepsin D was seen frequently in tumours; p53 gene abnormalities may correlate with cathepsin D overexpression in oesophageal SCC.

Long survival of a woman with a huge leiomyosarcoma of the duodenum after pancreaticoduodenectomy and transverse colectomy: a case report.

A woman with a huge leiomyosarcoma of the duodenum that had invaded the pancreas and transverse colon is living and well 10 years after pancreaticoduodenectomy combined with resection of the transverse colon. Malignant potential of the tumor was determined by the mitotic rate and nuclear deoxyribonucleic acid content. The mass exceeded 10 cm yet was characterized by low mitotic activity and a near-diploid pattern. The long survival is attributed to the extensive surgery and low-grade malignancy of the tumor.

A prospective pilot study of extended (D3) and superextended para-aortic lymphadenectomy (D4) in patients with T3 or T4 gastric cancer managed by total gastrectomy.

BACKGROUND: Japanese surgeons have been actively performing extended lymphadenectomy (D2, removal of perigastric nodes and nodes along the left gastric, common hepatic, celiac and splenic arteries; or D3, D2 plus removal of nodes in the hepatoduodenal ligament, in the retropancreatic space and along the vessels of the transverse mesocolon). In recent years interest has expanded to superextended lymphadenectomy (D4) of nodes around abdominal aorta (para-aortic lymph nodes from aortic hiatus to aortic bifurcation). Because the therapeutic value of this D4 procedure remains controversial, we initiated a prospective study to compare D3 and D4 lymphadenectomy. METHODS: Seventy patients with T3 or T4 gastric cancer and without macroscopic metastasis to the para-aortic nodes treated by potentially curative total gastrectomy were randomized to D4 (group A, n = 35) and D3 (group B, n = 35) lymphadenectomies. RESULTS: Metastases to para-aortic nodes were found in 4 patients. Postoperative survival after D4 resection was not statistically significant between the groups. Postoperative morbidity for group A was greater. In group A 4 patients had postoperative retention of intra-abdominal fluid (lymphorrhea) and 4 others had prolonged diarrhea. One patient in each group died of postoperative complications. CONCLUSIONS: Surgical treatment of microscopic disease in grossly normal para-aortic lymph nodes may generate occasional long-term survivors. Selecting appropriate candidates who might benefit from D4 resections needs to be refined. On the basis of this study, a nationwide study should be considered.

Less invasive surgery for early gastric cancer based on the low probability of lymph node metastasis.

BACKGROUND: Less invasive treatment is the current trend in many surgical fields. Most patients with early gastric cancer do not have lymph node metastasis. Thus extensive resection of the stomach and extended lymph node dissection do not appear to be necessary. METHODS: In a retrospective study, 890 consecutive patients with early gastric cancer who had undergone standard gastrectomy were assessed for depth of invasion, gross appearance, and maximum diameter of the tumor to examine the possibility of limiting the extent of lymph node dissection. A variety of limited gastrectomies have been developed and now include endoscopic mucosal resection, wedge resection, segmental gastrectomy, limited proximal gastrectomy, and distal hemigastrectomy. RESULTS: A retrospective study revealed that extensive lymph node dissection did not improve the survival of patients with early gastric cancer. Endoscopic mucosal resection was suitable for cancers of the depressed type of less than 1 cm in diameter and the elevated type of less than 2 cm in diameter. Wedge, segmental, or limited proximal gastrectomy was suitable for the elevated type of 2 to 3 cm in diameter. The elevated type of more than 3 cm in diameter and the depressed type of 1 to 3 cm in diameter sometimes involved metastasis to group 1 nodes. The depressed type of more than 3 cm in diameter sometimes involved metastasis to group 2 nodes. Thus such cases should be treated by gastrectomy with dissection of potentially metastatic lymph nodes. CONCLUSIONS: Limitation of the extent of gastrectomy and lymph node dissection may be possible, depending on the gross appearance and size of the tumor.

Expression of vascular endothelial growth factor correlates with hematogenous recurrence in gastric carcinoma.

BACKGROUND: It has recently been reported that the microvessel density in a tumor correlates with hematogenous metastasis in gastric carcinoma. The aim of this study was to evaluate the relationship between the expression of vascular endothelial growth factor (VEGF), which was thought to be a potent angiogenesis-promoting factor, and hematogenous recurrence in advanced gastric carcinoma. METHODS: The expression of VEGF and the density of the microvessels were examined by immunohistochemistry in patients with advanced gastric carcinoma with serosal invasion who had undergone curative resection. RESULTS: The prognosis of patients with a VEGF-negative tumor was significantly better than that of patients with a VEGF-positive tumor. Multivariate analysis by Cox proportional hazards model showed that the expression of VEGF was an independent prognostic indicator. The expression of VEGF provided a significant estimate of relative risk for the development of hematogenous recurrence by multivariate logistic regression analysis. The microvessel count in VEGF-positive tumors was significantly higher than that in VEGF-negative tumors. CONCLUSIONS: VEGF is associated with hematogenous recurrence. Assessment of the expression of VEGF may therefore prove valuable in identifying patients with gastric carcinoma at high risk for recurrence who would benefit from adjuvant therapy.

Combined analysis of p53 and retinoblastoma protein expressions in esophageal cancer.

BACKGROUND: p53 gene mutation and abnormal p53 protein expression, also loss of the retinoblastoma gene and protein expression are frequently associated with esophageal squamous cell carcinoma (ESCC). Recently, the prognostic significance of the combined analysis of p53 protein and retinoblastoma protein (pRB) has been reported in non-small cell lung cancer. However, in ESCC, the prognostic significance of the combined analysis of these proteins remains unclear. In this study, we immunohistochemically analyzed the p53 protein and pRB expressions in surgically resected ESCC, and we evaluated the prognostic significance of the combination of these proteins. METHODS: We analyzed p53 protein and pRB expressions immunohistochemically in 191 surgically resected ESCC cases. Overexpression of p53 and loss of pRB were considered abnormal. RESULTS: Overexpression of p53 protein was detected in 79 patients (41%) and decreased pRB nuclear staining occurred in 82 (43%). The Kaplan-Meier survival curve showed that absence of pRB expression was significantly associated with shortened survival (p = 0.001), whereas expression of p53 was not significantly associated with survival. Moreover, p53 and pRB status individually were not independent prognostic factors in multivariate survival analysis. With respect to pRB and p53, the tumors could be grouped into four categories: p53-/pRB+ (31%); p53-/pRB- (27%); p53+/pRB+ (26%); and p53+/pRB- (16%). Favorable prognosis was observed in patients with p53-/pRB+ tumors. Multivariate analysis showed p53-/pRB+ status to be an independent prognostic factor. CONCLUSIONS: The combination of p53 protein loss and pRB expression was associated with good prognosis in patients with ESCC.

Clinicopathologic significance of the expression of mutated p53 protein and the proliferative activity of cancer cells in patients with esophageal squamous cell carcinoma.

BACKGROUND: The aim of this study was to investigate the relation between the expression of mutated p53 protein and the proliferative activity of cancer cells in esophageal squamous cell carcinoma. In addition, the clinical and biologic significance of p53 status and the proliferative activity of cancer cells were evaluated in these patients. STUDY DESIGN: Samples of esophageal tumors from 94 patients were subjected to immunohistochemical staining with a monoclonal antibody against p53 and with the monoclonal antibody Ki-67. The immunoreactivity against p53 and the proliferative activity of cancer cells were compared with the clinicopathologic findings in each sample. Prognostic factors including p53 status and Ki-67 labeling index (LI; percentage of Ki-67-immunostained cells) were evaluated for 81 surviving patients by univariate and multivariate analysis. RESULTS: The mean Ki-67 LI of 50 p53-positive patients was higher than that of 44 p53-negative patients (p = 0.009). The Ki-67 LI increased according to the progression of tumors. Overexpression of mutated p53 protein was observed in 40.9% of tumors that invaded to the submucosa, and this percentage was not significantly changed in tumors with invasion to the adventitia. Metastases to the regional lymph nodes were observed in 3 of 22 patients with tumors that invaded to the submucosa, and these 3 tumors had both over-expression of mutated p53 protein and high Ki-67 LI. In 81 surviving patients, only lymph node metastasis (p = 0.045) and the curability of tumors (p < 0.001) were identified as independent prognostic factors by multivariate analysis. CONCLUSIONS: Overexpression of mutated p53 protein is detected in the early stage of esophageal cancer. This mutated p53 protein may not play an important role for tumor invasion. When tumor invasion is limited to the submucosa, cancer cells that overexpress mutated p53 protein may acquire high proliferative activity. Such cells might have considerable potential for metastasis to the lymph nodes.

Pharmacokinetics of intraoperative intrapleural cisplatin chemotherapy of various osmolarities in cases of esophageal cancer.

Intraoperative intrapleural (i.pl.) cisplatin (CDDP) treatment during thoracotomy was performed for esophageal cancers. Three patients underwent isotonic (308 mOsm/l) CDDP treatment. Hypotonic CDDP treatments with a 154 mOsm/l solution and a 62 mOsm/l solution were administered to 4 and 9 patients, respectively. The maximum concentrations (Cmax) of both total and filterable platinum in the plasma after injection of the hypotonic solution were significantly higher than those after injection of the isotonic solution. The area under the curve of concentration versus time (AUC) of the plasma of the 62 mOsm/l solution was significantly higher than that of the 154 mOsm/l and isotonic solution. Although higher levels of the Cmax may increase side-effects, the hypotonic condition of the i.pl. fluid and increased AUC in the plasma may escalate the accumulation of platinum in i.pl. cancer cells. These results suggest that hypotonic i.pl. CDDP is tolerable and may be useful for treatment of the incipient phase of pleural carcinomatosis and for prophylaxis of postoperative recurrence.

Immunohistochemical detection of occult metastases in paraaortic lymph nodes in advanced gastric cancer.

Some Japanese surgeons have examined the utility of super-extended paraaortic lymphadenectomy (PAL) as part of the surgical treatment for advanced gastric cancer. However, therapeutic value of this PAL remains controvertial. The purpose of this study was to evaluate appropriate candidates who might benefit from PAL by the immunostaining with cytokeratin (CK) of the macroscopically intact paraaortic nodes. A total of 525 paraaortic nodes from 35 patients was serially sectioned and stained with hematoxylin-eosin (H&E) and CK staining. A total of 17 nodes (3.2%) from 7 patients (20.0%), among 525 macroscopically intact paraaortic nodes, was determined to be immunopositive for CK. In 4 patients, 8 H&E-positive nodes with metastases were all immunopositive and, in addition, 4 H&E-negative nodes were also immunopositive. Furthermore, 3 patients with H&E-negative nodes had five immunopositive nodes. Immunostaining with CK was useful for detection of occult metastases. Survival was prolonged in 3 of these 7 patients. The incidence of CK-positive nodes was significantly higher in patients with gross type of 3 or 4 gastric cancer and in patients with H&E-detected nodal metastasis within group 3 (N3) nodes. It seems that such patients would benefit from prophylactic PAL.

Possible association between immunocompetence and enhanced risk of multicentric carcinogenesis in both the stomach and other organs in patients with gastric cancer.

In a retrospective study, we analyzed the association between the immunocompetence and multicentric carcinogenesis in both the stomach and organs other than the stomach in patients with single gastric cancer (SGC) and those with multiple gastric cancers (MGC). The incidence of primary cancers in other organs in patients with MGC (4/17, 23.5%) was significantly higher than that with SGC (15/202, 7.4%). Our analysis of the immunocompetence revealed a trend towards decreased activity of NK cells and of mitogen-induced blastogenesis in patients with MGC as compared to those with SGC. In patients with SGC, patients with primary cancers in other organs had significantly lower levels of both PHA-induced blastogenesis and CD4/CDs, and revealed a greater trend towards decreased activity of both NK cells and Con A-induced blastogenesis than patients without other primary cancers. These findings may suggest that immunocompetence plays a role in the enhanced multicentric carcinogenesis not only in the stomach but also in cancers of other organs.

Combined analysis of tumour neoangiogenesis and local immune response in advanced gastric carcinoma.

Neovascularization and host immune response are important in the growth and metastasis of solid tumours. Thus, microvessel density, and dendritic cell (DC) infiltration, which was thought to be an indicator of local immune function, were examined by immunohistochemistry and their prognostic significance was determined in patients with advanced gastric carcinoma. The 5-year survival rates in patients with both low microvessel counts and marked DC infiltration, in patients with either low microvessel counts or marked DC infiltration, and in patients with both high microvessel counts and slight DC infiltration were 82.6%, 68.6%, and 30.2%, respectively, the differences were statistically significant. Moreover, the multivariate analysis showed that combined analysis of microvessel counts and DC density was an independent prognostic indicator. Our findings indicate that combined analysis of tumour neoangiogenesis and local immune response might be useful for predicting prognoses of patients with advanced gastric carcinoma.

Expressions of thymidine phosphorylase (dThdPase) and vascular endothelial growth factor on angiogenesis in intestinal-type gastric carcinoma.

We examined the clinical and pathological significance of thymidine phosphorylase (dThdPase) and vascular endothelial growth factor (VEGF) in human gastric carcinomas, in terms of intratumoral microvessel density (IMVD), P53 expression, and patient prognosis in a total of 128 patients. Mean IMVD was significantly higher in the carcinomas with dThdPase or VEGF expression than in carcinomas without the expression. The simultaneous expression of dThdPase and VEGF was correlated with increased IMVD of human gastric carcinomas. VEGF expression was associated with P53 expression and poor patient prognosis, but dThdPase expression was not.

Nuclear accumulation of p53 protein in gastric cancer strongly correlates with enlargement of nuclear area of cancer cells.

The nuclear area (NA) of cancer cells have been reported to be a useful prognostic indicator in various tumors. However, this image analysis of cancer nucleus has only rarely been applied to gastric adenocarcinoma. Moreover, it remains to be shown what types of biological factors influence this nuclear feature. In this study, we analyzed the area of cancer nuclei in tumors from 97 patients with advanced gastric cancer (t3, n0, stage II) by using hematoxylin and eosin stained slides with a computer-assisted image-analysis system. The morphometric data were compared with clinicopathological and biological status of the tumors. The mean NA of 50 tumors with venous invasion (50 microm2) was significantly larger than that of 47 tumors without venous invasion (38 microm2, p<0.0001). There was a significant correlation between the NAs of cancer cells and the p53 labeling indices of tumors (p=0.0012) and Ki-67 labeling indices of tumors (p=0.0324). However, no significant correlation was detected between the NAs of cancer cells and other factors, such as, tumor size, DNA ploidy pattern, expression of vascular endothelial growth factor (VEGF), or microvessel density of tumors. The five-year survival rate of 49 patients with large nuclear area (NA > or =41 microm2, 63%) was significantly lower than that of 48 patients with small nuclear area (NA <41 microm2, 78%, p=0.043). Data from computerized morphometry are objective and can be obtained rapidly by conventional microscopic analysis. The NA of cancer cells in advanced gastric cancer appears to predict the ability to invade the microvessels in the gastric wall. This nuclear morphological feature strongly correlated with p53 accumulation in the nuclei of gastric adenocarcinoma.