Current status and application of endoscopic submucosal dissection for early gastric cancer / 中国肿瘤临床

Owing to technological developments in endoscopic treatment with continued development and application of newer en-doscopic equipment, as well as improved health consciousness among patients, a greater number of patients are being diagnosed with early gastric cancer (EGC). Both laparotomy and laparoscopic surgery can achieve satisfactory results in the treatment of EGC. Pa-tients undergoing endoscopic treatment for EGC showed improved quality of life postoperatively with lower complication rates. Endo-scopic submucosal dissection (ESD) is being widely used to treat EGC, with an overall 5-year survival rate of 90%. Patients undergoing ESD showed better perioperative outcomes in terms of lesser physical trauma, higher safety, excellent patient compliance, and lower treatment costs. ESD may gradually replace conventional surgery as the primary treatment for EGC. This paper focuses on the clinical application of ESD in the management of EGC.

Function-Preserving Surgery in Gastric Cancer

The rising incidence of early gastric cancer has enabled the development of function-preserving gastrectomy with the focus on post gastrectomy quality of life and adherence to sound oncologic principles. It is concurrent with the growing popularity of minimally invasive surgery; and both are commonly used together. The different kinds of function-preserving gastrectomy included in this review are: pylorus-preserving and proximal gastrectomy, vagus nerve preservation, sentinel node navigation, and various endoscopic & minimally-invasive techniques. In this article the indications, techniques, oncologic safety, functional benefit, and outcomes of each kind of function-preserving gastrectomy are discussed.

Estallido respiratorio de neutrófilos por las técnicas del nitroazul tetrazolio (NBT) y dihidrorodamina (DHR) en niños con sospecha clínica de enfermedad granulomatosa crónica (EGC)

Introducción: El estallido respiratorio (ER) de neutrófilos es fundamental para la defensa contra infecciones, proceso ausente o ineficaz en la EGC, una inmunodeficiencia primaria (IDP) diagnosticada mediante la prueba del NBT. Actualmente se destacan las técnicas por citometría de flujo como la DHR, realizada únicamente en el Instituto de Investigaciones en Ciencias de la Salud (IICS), habiendo sido aplicada sólo en niños sanos. Objetivo: Evaluar el ER de neutrófilos por las técnicas NBT y DHR en niños con sospecha clínica de EGC y describir sus características clínico-demográficas. Materiales y Métodos: Se incluyeron 36 niños de ambos sexos, menores de 17 años de edad, remitidos al IICS entre el 2014-2015 por médicos especialistas. Se extrajo sangre para evaluación del ER de neutrófilos y se aplicó un cuestionario. Resultados: La mediana de edad fue de 4 años, 56% varones. Predominaron los pacientes hospitalizados, la sepsis y forunculosis cutánea fueron las manifestaciones clínicas más frecuentes y un 72% presentó recurrencia de infecciones con mediana de 3 episodios/año. El promedio para el IE de neutrófilos fue de 38,1±13,7 en el ensayo DHR, y 87±17% de activación para la prueba del NBT. En 8 pacientes los valores fueron inferiores al considerado normal y en un niño se confirmó EGC, observándose un patrón de herencia ligada al X. Conclusión: La evaluación del ER de neutrófilos permitió detectar un caso de EGC, determinándose el patrón hereditario mediante la técnica DHR por primera vez en el país. Es esencial el empleo de herramientas diagnósticas disponibles en niños con sospecha clínica de IDPs, para la detección y tratamiento oportunos que mejoran su calidad de vida y reducen la mortalidad.

Introduction: The neutrophil`s respiratory burst (RB) is essential for the defense against infections, this process is absent or ineffective in the CGD, a primary immunodeficiency (PID) diagnosed by the NBT test. Techniques that used flow cytometry such as DHR, performed only at the Instituto de Investigaciones en Ciencias de la Salud (IICS), currently stand out, having been applied only to healthy children. Objective: To evaluate the neutrophil`s RB using the NBT and DHR techniques in children with clinical suspicion of CGD and to describe their clinical and demographic characteristics. Materials and methods: 36 children of both sexes, with less than 17 years of age, that were referred to the IICS by specialists physicians between the years 2014-2015 were included. A blood sample was obtained to evaluate the neutrophil`s RB and a questionnaire was applied. Results: The median age was of 4 years and 56 % were males. Predominantly the patients were hospitalized, being sepsis and cutanueos furunculosis the most frequent clinical manifestations and a 72 % presented recurrent infection with a median of 3 episodes/year. The average for the neutrophil´s stimulation index (EI) was 38,1±13,7 with the DHR test, and 87±17% of activation for the NBT test. In 8 patients the values obtained were below the ones considered as normal and in one child CGD was confirmed, in which an X-linked inheritance pattern was observed. Conclusion: The evaluation of the neutrophil`s RB allowed the detection of one case of CGD, and the inheritance pattern was determined by the DHR test for the first time in our country. The use of available diagnostic tools in children with clinical suspicion of PID is essential for the appropriate detection and treatment that improve the quality of life and reduce mortality.

Endoscopic submucosal dissection and gastrectomy for early gastric cancer: a Meta-Analysis / 中国内镜杂志

Objective To compare the difference of the effects and safety of endoscopic submucosal dissection (ESD) and surgery for early gastric cancer. Methods We searched the Pubmed, CBM, Embase, Cochrane Library, CNKI, CQVIP and WanFang data from January 1990 to June 2016 studies comparing endoscopic resection with gastrectomy for treatment of early gastric cancer. We selected the eligible studies according the including and excluding criteria. The quality of the included studies was assess using the Newcastle-Ottawa Scale (NOS), then using Revman 5.3 to make the Meta analysis. Result The meta-analysis enrolled 12 studies with 4331 patients, all of the studies were retrospectively analyzed. The result of the meta-analysis showed that there were no significant difference regarding the recurrence rate [(22/2586, 0.85%) vs (6/1134, 0.53%), P = 0.370] and five-year survival rate [(852/909, 93.72%) vs (707/746, 94.77%), P = 0.340] between endoscopic resection and gastrectomy. Gastrectomy was associated with higher en bloc resection rate, which were 100.00% and 92.23% respectively. However, gastrectomy was also related to longer operative time (SMD = -3.04, 95%CI: -3.64 ~ -2.45, P = 0.000) and hospital stay (SMD = -2.53, 95%CI: -3.73 ~ -1.32, P = 0.000). The postoperative complication was also higher than endoscopic, which were (45/816, 5.50%) vs (101/686, 14.72%) respectively. Conclusion There were no significant difference regarding recurrence rate and five-year survival rate between endoscopic and gastrectomy. While the en bloc resection rate was lower than gastrectomy, endoscopic offers a shorter hospital stay, shorter operative time with minimal invasive and fewer operating and postoperative complications than gastrectomy. Endoscopic should be recommended as a standard treatment for early gastric cancer with indications.

Función del sistema NADPH oxidasa en la formación de trampas extracelulares de los neutrófilos (NETs) / Role of nadph oxidase system in the neutrophil extracelular Traps (NETs) formation

Las trampas extracelulares de los neutrófilos son estructuras fundamentalmente compuestas de cromatina y proteínas granulares, que una vez liberadas constituyen un mecanismo de defensa que tiene la capacidad de atrapar y destruir microorganismos patógenos. El proceso que libera estas estructuras es conocido como NETosis y en el caso que provoque muerte celular, esta es diferente a la apoptosis y a la necrosis. Si bien no se conocen todos los eventos moleculares involucrados en la formación de las NETs, se sabe que dependiendo del estímulo, las especies reactivas del oxígeno son esenciales para que ocurra la descondensación de la cromatina y se lleve a cabo el proceso de NETosis(AU)

Neutrophil extracellular traps (NETs) are structures mainly composed of chromatin and granule proteins that once released constitute a defense mechanism due to their ability to trap and destroy pathogen microorganisms. The process by which these structures are released is known as NETosis and in case this may lead to cell death is different to apoptosis and necrosis. Although all the molecular events involved in the formation of NETs are poorly understood, it is known that depending on the stimulus, reactive oxygen species (ROS) are essential to the chromatin decondensation and subsequent NETs formation(AU)

Fas and FasL expression in leukocytes from Chronic Granulomatous Disease patients / Expresión de Fas y FasL en leucocitos de pacientes con Enfermedad Granulomatosa Crónica

Chronic Granulomatous Disease (CGD) is a primary immunodeficiency characterized by defects in superoxide (O2-) production, which result from mutations in one of the four NADPH oxidase components, predisposing to bacterial and fungal infections. Besides the O2-defect, it has been described that neutrophils from CGD patients are resistant to cell death, a phenomenon that has been connected to chronic inflammation and predisposition to autoimmune diseases. A diminished expression of Fas and its counterpart FasL, molecules known to play a major role in cell death, has been described in lymphocytes depleted of O2-reactive oxygen species (ROS), suggesting an involvement of ROS in Fas/FasL expression. In this work, Fas and FasL expressions were analyzed in T cells and neutrophils from two CGD families, previously known to harbor two different molecular defects: absence of either p47-phox or p67-phox. We found that T lymphocytes from CGD patients express low levels of Fas and FasL, while a diminished FasL expression was observed on neutrophils from a CGD A470 patient. These defects may contribute to understand altered cell death in CGD patients.

La Enfermedad Granulomatosa Crónica (EGC) es una inmunodeficiencia primaria caracterizada por un defecto en la producción de superóxido (O2-), que se genera como consecuencia de mutaciones en uno de los cuatro componentes del complejo NADPH oxidasa y predispone a infecciones por bacterias y hongos. Además de los defectos en la producción de O2-, se ha descrito que los neutrófilos de los pacientes con EGC exhiben una resistencia a la muerte celular, evento que se asocia con la inflamación crónica y predisposición a enfermedades autoinmunes. Se ha descrito que linfocitos en medios desprovistos de O2-especies reactivas del oxigeno (ROS), muestran reducida expresión de Fas y FasL, moléculas que juegan un papel relevante en el control de la muerte celular, sugiriendo la participación de los ROS su regulación. En este trabajo analizamos la expresión de Fas y FasL en linfocitos T y neutrófilos en dos familias portadores de dos defectos genéticos diferentes asociados con EGC: ausencia de p47-phox o de p67-phox. Evidenciamos una baja expresión de Fas y FasL en los linfocitos T de los pacientes con EGC, pero solo los neutrófilos de los pacientes con defecto de p47-phox, fueron incapaces de expresar FasL. Estos defectos pudieran contribuir a entender la alteración de la muerte celular observada en los pacientes con EGC.

Surgical Treatment for Patients Who Underwent Endoscopic Mucosal Resection (EMR)/Endoscopic Submucosal Dissection (ESD) of Early Gastric Cancer (EGC)

PURPOSE: To evaluate the necessity for additional surgical treatment after Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD), we analyzed the pathologic results of patients who underwent surgical treatment. METHODS: 140 consecutive patients underwent additional surgical treatment after EMR/ESD with en bloc resection between April 2005 and November 2009 at ASAN Medical Center. Additional surgical treatments were undergone for following conditions such as incomplete dissection (involvement of margin), undifferentiated-type histology (> or =2 cm) and submucosal cancer. RESULTS: One patient with deep margin involvement displayed advanced gastric cancer after gastrectomy. Three of 74 patients with clear resection margin were confirmed to have residual cancer at ESD site and 2 of 3 patients displayed advanced gastric cancer after surgery. In univariate analysis for metastasis of lymph node, deep submucosal invasion (over sm2 or 500microm) and the presence of lymphovascular invasion showed significant differences for lymph node metastasis. Especially, lymphovascular invasion was an important predictive factor for lymph node metastasis in multivariate analysis. In analysis for residual cancer, lateral margin involvement and large tumor (>3 cm) were risk factors. And, only lateral margin involvement showed significant risk in multivariate analysis. CONCLUSION: Although EMR/ESD were fully accomplished for resection margin, gastrectomy and lymph node dissection were positively necessary for patients with deepsubmucosal invasion (over sm2 or 500microm) and the presence of lymphovascular invasion to eliminate the possibility of residual cancer or more advanced gastric cancer or metastatic lymph nodes.

Detecção de genes do cluster egc em Staphylococcus aureus isolados de alimentos de origem animal / Detection of genes of egc cluster in Staphylococcus aureus isolated from foods of animal origin

Os objetivos deste estudo foram detectar, por PCR, genes codificadores de enterotoxinas estafilocócicas, pertencentes ao cluster egc (genes seg, sei, selm, seln e selo) em Staphylococcus aureus isolados em diferentes alimentos de origem animal, e relacionar sua presença com a fonte de isolamento. Quarenta e uma cepas de S. aureus de diferentes origens (carne de frango, leite cru, embutidos cárneos e queijo) foram avaliadas por PCR, por meio da amplificação de um fragmento de 3375pb (denominado egc parcial), que foi utilizado como marcador da presença do cluster, e fragmentos de cada um dos genes pertencentes ao cluster egc. Há presença de genes do cluster egc em isolados de S. aureus isoladas em alimentos de origem animal; entretanto, diferentes genótipos puderam ser observados em função da fonte de isolamento. A ocorrência de S. aureus isolados em carne de frango que possuíam todos os genes do cluster foi elevada; no entanto, nos isolados oriundos dos demais alimentos, essa ocorrência foi reduzida.

The aim of this study was to detect, through PCR usage, the genes which encodes staphylococcal enterotoxins and which belongs to egc cluster (seg, sei, selm, seln and selo) in S. aureus isolated from different foods of animal origin and correlate their presence with the strain origin. Forty-one strains of S. aureus from different sources (chicken meat, raw milk, sausage meat and cheese) were evaluated through PCR by amplifying a fragment of 3375bp (called partial egc), which was used as a marker for the presence of cluster, and fragments of individual genes belonging to egc cluster. There is presence of the egc cluster in strains of S. aureus isolated from foods of animal origin, however, different genotypes could be observed depending on the isolation source. The occurrence of strains isolated from chicken meat that had all the genes of the cluster was high; however, in the strains isolated from the other foods, such occurrence has been reduced.

LC-MS/MS for Simultaneous Determination of Four Major Active Catechins of Tea Polyphenols in Rat Plasma and Its Application to Pharmacokinetics / 中草药·英文版

Objective To develop a liquid chromatography technique coupled with tandem mass spectrometry(LC-MS/MS)for simultaneous determination of four active catechins EGCC,ECG,EGC,and EC of tea polyphenols(TP)in rat plasma in order to further study its multi-component pharmacokinetics.Methods Following a single step liquid-liquid extraction of plasma samples with ethyl acetate,the four catechins were separated on a Hypersil ODS C18 column using an isocratic mobile phase composed of methanol-water(30:70).The detection using a mass spectrometer was performed under negative ESI in the MRM mode.The analytes were identified by reference to both MRM and tR values and quantified using peak area internal standard method.Results The method was shown to be specific without interference from matrix,metabolites,and impurities present in TP raw material and to be sensitive with LOD and LOQ of 1.5 and 10 ng/mL(EGCG)as well as 0.75 and 5 ng/mL(ECG,EGC,and EC).A good linearity was obtained over a wide range of 10-10000 ng/mL for EGCG and 5-5000 ng/mL for other three catechins(r > 0.996).The method was validated to be reproducible and reliable,as evidenced by intra-batch and inter-batch precision of less than 10% and 11%,accuracy of 97.13%-106.05% and 99.22%-103.14%,respectively.The recovery of extraction ranged from 72.74% to89.13%,matrix effect from 88.76% to 105.97% for four cateckins.The method was successfully used to study the pharmacokinetics of TP iv administered to rats at a dose of 100 mg/kg.Conclusion This method is shown to completely meet requirements for the multi-component pharmacokinetic study of TP in rats.

Clinicopathologic Characteristics of Stage IV Early Gastric Cancer

PURPOSE: Stage IV early gastric carcinoma (EGC) is a rare disease. We report here on 10 cases of EGC that showed metastasis in more than 15 lymph nodes. MATERIALS AND METHODS: A total of 8354 cases of gastric carcinoma in patients who underwent surgical procedures between January 2001 and January 2007 at Samsung Medical Center were studied, and 10 cases were classified as stage IV EGC. We investigated their clinicopathologic characteristics. RESULTS: There were 5 males and 5 females. Their ages at operation ranged from 46 to 76 years with a mean age of 61. All of the 10 patients had undergone curative resection for gastric cancer. The pathological diagnosis confirmed that all of the patients had tumor confined to the submucosa. The median size of the tumors was 5.3cm and the mean number of dissected nodes was 45.5 with a mean number of 22.2 involved nodes. Six cases were classified as the diffuse type and 4 were classified as the intestinal type by Lauren's classification. Histologically, 3 cases were signet ring cell carcinoma, 3 were poorly differentiated, 2 were moderately differentiated and 2 were well differentiated adenocarcinoma. Endolymphatic invasion was found in 9 cases. The median follow-up was 31 months. Adjuvant chemotherapy was done in 9 patients, and the patient who did not receive chemotherapy died by cerebrovascular accident. 2 patient had recurrence of gastric cancer and 7 survived without recurrence. CONCLUSION: More cases should be collected and further studies on the molecular and cellular tumor characteristics are required to characterize these tumors that show aggressive lymphatic spread.

The Early Experience with a Laparoscopy-assisted Pylorus-preserving Gastrectomy: A Comparison with a Laparoscopy-assisted Distal Gastrectomy with Billroth-I Reconstruction

PURPOSE: Pylorus-preserving gastrectomy (PPG), which retains pyloric ring and gastric function, has been accepted as a function-preserving procedure for early gastric cancer for the prevention of postgastrectomy syndrome. This study was compared laparoscopy-assisted pylorus-preerving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGB I). MATERIALS AND METHODS: Between November 2006 and September 2007, 39 patients with early gastric cancer underwent laparoscopy-assisted gastrectomy in the Department of Surgery at Korea Cancer Center Hospital. 9 of these patients underwent LAPPG and 18 underwent LADGBI. When LAPPG was underwent, we preserved the pyloric branch, hepatic branch, and celiac branch of the vagus nerve, the infrapyloric artery, and the right gastric artery and performed D1+beta lymphadenectomy to the exclusion of suprapyloric lymph node dissection. The distal stomach was resected while retaining a 2.5~3.0 cm pyloric cuff and maintaining a 3.0~4.0 cm distal margin for the resection. RESULTS: The mean age for patients who underwent LAPPG and LADGBI were 59.9+/-9.4 year-old and 64.1+/-10.0 year-old, respectively. The sex ratio was 1.3:1.0 (male 5, female 4) in the LAPPG group and 2.6:1.0 (male 13, female 5) in the LADGBI group. Mean total number of dissected lymph nodes (28.3+/-11.9 versus 28.1+/-8.9), operation time (269.0+/-34.4 versus 236.3+/-39.6 minutes), estimated blood loss (191.1+/-85.7 versus 218.3+/-150.6 ml), time to first flatus (3.6+/-0.9 versus 3.5+/-0.8 days), time to start of diet (5.1+/-0.9 versus 5.1+/-1.7 days), and postoperative hospital stay (10.1+/-4.0 versus 9.2+/-3.0 days) were not found significant differences (P>0.05). The postoperative complications were 1 patient with gastric stasis and 1 patient with wound seroma in LAPPG group and 1 patient with left lateral segment infarct of liver in the LADGB I group. CONCLUSION: Patients treated by LAPPG showed a comparable quality of surgical operation compared with those treated by LADGBI. LAPPG has an important role in the surgical management of early gastric cancer in terms of quality of postoperative life. Randomized controlled studies should be undertaken to analyze the optimal survival and long-term outcomes of this operative procedure.

Comparison of Laparoscopy-assisted Distal Gastrectomy with Open Distal Gastrectomy for Early Gastric Cancer

PURPOSE: Laparoscopy-assisted distal gastrectomy (LADG) is gaining wider acceptance as a minimally invasive treatment for early gastric cancer. Generally; LADG, with extraperigastric lymph node dissection, is considered a technically more complicated procedure for gastric cancer than a conventional open distal gastrectomy (CODG). LADG, with extraperigastric lymph node dissection, for gastric cancers has previously been described, but the safety, efficacy and clinical benefits of these types of surgery are still unclear. To evaluate the short-term surgical validity, surgical outcome of a LADG, with extraperigastric lymph node dissection, was compared with that of a CODG in early gastric cancer patients. METHODS: A retrospective study of 80 patients with early gastric cancer (EGC), who underwent a LADG, with extraperigastric lymph node dissection, between September 2004 and August 2006, at Keimyung University Dongsan Medical Center, was performed. Over the same period, conventional open gastrectomies were performed in 97 patients, confirmed to have EGC from their pathology. Various clinicopathological parameters were evaluated from the medical records. RESULTS: The baseline characteristics, including gender, age, body mass index (BMI) and tumor size, were similar between the two groups. In the LADG group, the operation time was longer (P=0.000), but the blood loss was less (P=0.000) than in the CODG group. The postoperative recovery in the LADG group was faster, as reflected by the shorter time to pass gas and the shorter hospital stay, which resulted in significantly lower serum white blood cell count amylase and C-reactive protein levels on day 1. Pathological examinations showed the surgery to be equally radical in the two groups. CONCLUSION: According to this study; LADG, with extraperigastric lymph node dissection, is a safe and technically feasible procedure for the treatment of early gastric cancer. The LADG procedure provides several advantages to that of a conventional open distal gastrectomy; less inflammatory reactions, a rapid return of gastrointestinal function and a shorter hospital stay, with no decrease in the operative curability.

Follow-up result of endoscopic mucosal resection for gastric adenoma and early gastric cancer / 대한내과학회지

BACKGROUND: Endoscopic mucosal resection (EMR) is now widely accepted as a useful treatment method for gastric adenoma and early gastric cancer (EGC) because of its minimal invasiveness and satisfactory post-procedure results. The purpose of this study is to define the follow-up results and usefulness of EMR. METHODS: We analyzed 54 cases from June 2000 through September 2004. Endoscopy with histological examination was carried out every 3 months for 1 year after EMR. RESULTS: The patients consisted of 42 men and 12 women, and the mean age was 60 years old. The histological results were 42 gastric adenoma and 12 EGC cases. There were 9 cases that had the histological diagnosis changes after EMR. Complete resections was performed for 48 cases and the en block resections were 33 of 34 cases (97%) and piecemeal resections were done in 15 of 20 cases (75%). Recurrence was seen in 4 cases (7.1%), and the mean recurrence period was 7 months. There were 3 gastric adenomas of 42 cases (7.1%), one case of EGC of 12 cases (8.3%), one en block resection of 34 cases (2.9%) and three piecemeal resections of 20 cases (15%). CONCLUSIONS: EMR is a safe and useful treatment method for gastric adenoma and EGC. However, EMR has some limitations that EGC may have lymph node metastases or multiple tumors. So, periodic follow-up is very important. As we acquire more clinical experience, EMR may be accepted as the standard treatment method for gastric adenoma and EGC.

Preoperative Predictive Factors of Lymph Node Metastasis in Early Gastric Cancer

PURPOSE: Early gastric cancer (EGC) is defined as gastric cancer confined to the mucosa or submucosa, regardless of lymph node (LN) metastasis. LN metastasis is the most important factor in the treatment of EGC. If LN metastasis is predicted before or during surgery, function preserving surgery, such as endoscopic mucosal resection, laparoscopic partial gastrectomy, and pylorus preserving gastrectomy, without radical LN dissection, can be applied. This study was undertaken to determine the factors affecting LN metastasis and to aid in planning therapeutic approaches for such patients. METHODS: A retrospective study was performed on 1, 203 patients with EGC, who had undergoing a gastrectomy, with lymphadectomy, between 1990 and 2003 at the Keimyung University, Dongsan Medical Center. We analyzed tumor size, depth of invasion, macroscopic, and histologic types and lymph node metastasis using preoperative endoscopy and radiological findings. RESULTS: The incidence of EGC of all gastric cancer has increased annually. Of the 1, 203 patients, 54.2% and 45.8% had mucosal and submucosal cancers, respectively. The incidences of LN metastasis were 4.0% and 23.0% in mucosal and submucosal cancers, respectively. There was no LN metastasis in mucosal cancer, with a tumor size of less than 1 cm (0/169). In the elevated and flat types, the size of the tumors were between 1 and 2 cm, and there was no LN metastasis (0/40), (0/28), but with the depressed type there was an LN metastasis rate of 6.1%. In the well differentiated type, there were 0.5 (1/193) and 12.9% (11/85) LN metastasis in the mucosal and submucosal cancers, respectively. CONCLUSION: A gastrectomy without LN dissection can be applied for EGC less than 1 cm in size and to all well differentiated types of mucosal cancer. Also, it can be applied to elevated and flat EGC types less than 2 and 1 cm in size in mucosal cancer and less than 1 cm sized in submucosal cancers, respectively. A conventional gastrectomy, with LN dissection, is recommended in other EGC types.

Prognosis of Early Gastric Cancer: Impact of Lymph Node Metastasis

PURPOSE: Early gastric cancer (EGC) is defined as gastric cancer confined to the mucosa or submucosa, regardless of lymph node (LN) metastasis. The prognosis of EGC is more favorable than that of advanced gastric cancer. Due to the variety of prognosis of EGC, in relation to LN metastasis, this study was undertaken to determine the impact of LN metastasis on the survival of patients with EGC, and to aid in planning therapeutic approaches for such patients. METHODS: A retrospective study of 517 patients with EGC, who had undergoing a gastrectomy with lymphadenectomy, between 1990 and 1999 was performed. Stages were classified using the UICC TNM classification (1997). RESULTS: LN metastasis was observed in 67 cases (13.0%). 6.7% (17/288) of the EGC within the mucosa, and 19.0% (50/281) within the submucosa, had LN metastasis. The overall Five-year survival rates (5YSR) of 517 EGC patients was 95.5%, and for the EGC patients in N0, N1, N2 and N3 groups were 98.3, 82.2, 27.8 and 0%, respectively (P<0.001). The 5YSRs for patients with mucosal and submucosal cancers were 98.9 and 92.4%, respectively (P= 0.023), and was poorer in those EGC patients with tumor sizes above 5 cm than in those below 5 cm (5YSR 96.3 and 86.7%, respectively. P=0.020). However, the survival rates for EGC patients did not differ significantly based on the gross and histological types. The 5YSR for EGC patients with stage IA, IB, II and IV were 98.3, 82.1, 40.0 and 33.3%, respectively (P<0.001). LN metastasis and depth of invasion were found to be significant risk factor from the multivariate analysis. CONCLUSION: Based on the results of this study, the significant prognostic factors of EGC were LN metastasis and depth of invasion. Although the prognosis of EGC is favorable, it depends upon the prognostic factors.

Early Gastric Cancer Accompanied with a Giant Metastatic Abdominal Lymph Node

Lymph node metastasis is found in 10-15% of patients with early gastric cancer; however, metastatic nodes forming giant abdominal masses or distant metastases are extremely rare. A 51-year-old male, HBs Ag-positive patient presented with an incidentally found huge upper abdominal mass. Imaging studies showed a 7 cm-sized epigastric mass consistent with hepatocellular carcinoma. His serum -fetoprotein level was also significantly elevated (330.6 ng/ml). Endoscopic studies revealed a suspicious early gastric carcinoma located on the lesser curvature and the anterior wall of the antrum. He was operated on with a preoperative diagnosis of hepatocellular carcinoma coexisting with an early gastric carcinoma. However, the actual abdominal tumor was a metastatic lymph node resulting from a gastric carcinoma which was located around the hepatic artery. Accordingly, he underwent a subtotal gastrectomy with the D2 lymph node dissection and the removal of the metastatic node. Postoperatively, he did well without any complications. His serum -fetoprotein level decreased to 49.3 ng/ml one week after the surgery and was completely normalized 3 months later. To date, one year and 4 months after the operation, he is in good conditions without evidence of recurrence on endoscopic and imaging studies.

Endoscopic mucosal resection with a ligation device for early gastric cancer and precancerous lesions: comparison of its therapeutic efficacy with surgical resection

Endoscopic mucosal resection with a ligation device (EMR-L) has become important in the curative treatment of precancerous lesions and early gastric cancers (EGCs), but little is known of the long-term efficacy and survival rates of EMR-L compared with surgical resection. We analyzed the therapeutic efficacy and safety of EMR-L in cases of EGC and precancerous lesions and compared the results of EMR-L with those of gastrectomy in patients with EGC over the same periods. EMR-L was performed on 20 EGCs and 54 precancerous lesions including tubular adenomas with or without severe dysplasias in 74 patients. Macroscopic type, size and location of the lesion were determined by endoscope, and the depth of invasion in EGCs was determined by endoscopic ultrasonography and confirmed by pathologic examination of the resected specimens. All the EGC cases were endoscopically followed up for at least 18 months (range, 18-66 months). Patients were selected that underwent subtotal gastrectomy and the survival rates were compared with those that underwent EMR-L. Complete resection was made in a single EMR-L treatment session in 61 cases (82.4%; 91.5%, were precancerous lesions and 65% were EGCs). After a repeat trial of EMR-L, the total rate of complete resection of precancerous lesions and EGCs was 92.6% and 85.0%, respectively. The survival rate of EGCs showed that complete resection by EMR-L resulted in 2 and 5 year survival rates of 100% and 95%, which are comparable to those of surgery (100% and 100%). This study suggests that EMR-L is a technically simple, minimally invasive and highly safe and effective treatment modality for selective EGCs, and offers an alternative to surgical treatment.

A Comparative Retrospective Study of Mucosal and Submucosal Cancer in Early Gastric Cancer

BACKGROUND: The 5-year survival rate for early gastric cancer (EGC) now exceeds 90% and EGC is now recognized as a curable malignancy. The less extensive treatment has attracted interest. It is of vital importance to select a surgical method appropriate to each individual case. A retrospective study was undertaken to compare clinicopathologic features between mucosal (M) and submucosal (SM) cancers and to evaluate treatment modality for EGC. METHODS: We analyzed clinicopathologic data on 345 surgically treated patients with early gastric cancer between September 1983 and December 1996 at the Department of Surgery, Korea University College of Medicine: 183 patients with mucosal cancer and 162 patients with submucosal cancer. RESULTS: The rate of detection of EGC has been increasing as high as 25% since 1990. There were significant differences between M and SM cancers with regard to the location of the tumor, lymph node metastasis and histologic type. The SM cancer had lower 1/3 in location, more lymph node metastasis and more differentiated than M cancer. Nodal involvement was evident in 49 patients (14.2%): 6.6% (12/183) with M cancer and 22.8% (37/162) with SM lesions. The 5-year survival rate of all patients was 94.7%: 95.3% in M cancer and 94.0% in submucosal SM cancer. The 5-year survival rates for SM cancer were 96.1% in node-negative cases and 86.3% in node-positive cases with significance and M cancer had no survival difference. CONCLUSIONS: As early gastric cancer can be cured by surgery, the submucosal carcinomas in this series had no indications for less extensive treatment, such as endoscopic or laparoscopic limited surgery. These carcinomas should be subject to standard surgery with gastrectomy and combined dissection of lymph nodes.

Clinicopathologic Findings of Early Gastic Cancer / 대한암학회지

PURPOSE: The prognosis forearly gastric cancer (EGC) is generally excellent after curative gastrectomy alone. However, the EGC of young patients was generally more invasive and metastasizing, and the prognosis of them was poorer than those of the elderly. We performed a retrospective study to evaluate clinica1 and pathological factors influencing the prognosis of EGC. MATERIALS AND METHODS: The authors investigated 66 cases of EGC resected at Inha Hospital in Song-Nam, from January 1987 to December 1996. We analyzed 9 clinicopathologic factors: age, sex, macroscopic type, tumor size, depth of invasion, location, lymph node metastasis, Williss classification and Laurens classification. RESULTS: Out of 66 cases (42 males, 24 females) of EGC, the sex ratio (M: F) was 1.75: 1, and the mean age was 55.5 years in male and 54.3 in female. The age incidence revealed a greater prevalence on 6th decade (33.3%). The most common macroscopic type of EGC was IIb and its combined type (43 cases, 65.2%). In tumor size, 16 cases (24.2%) were between 2.0 and 2.9 cm, and 13 cases (19.6%) between 1.0 and 1.9 cm, 10 cases (15%) between 3.0 and 3.9 cm. The tumors smaller than 2.0 cm were 33.2% but greater than 5.0 cm were 18.8%. In male, mucosal lesions were more common (66.6%) than submucosal lesions (33.4%); but in female, the incidence of both types of lesions were the same. The submucosal lesion in female was the most frequent at 4th decade. The major location of EGC was antrum (51.5%). Lymph node metastases were found in 3 females and 1 male. By Williss classification, poorly differentiated adenocarcinoma and signet ring cell carcinoma were more common in female (29.2%, 25%) than in male (11.9%, 14.3%). By Laurens classification, the diffuse type was more common in female (50%) than in male (33.3%). This type was the most frequent in 4th decade female patients. However, none of the above data reached statistical significance. CONCLUSION: We found the generalized tendency, though not statistically confinned, that the young female patients of EGC frequently had larger and poorly differentiated, diffuse adenocarcinomas with more frequent lymph node metastasis than male. The authors emphasizes that a further study would be needed in young female patients of EGC on hormonal factors influencing its clinicopathologic findings.

The Endoscopie Findings of Superficial Flat Type Early Gastric Cancer (EGC IIb) / 대한소화기내시경학회지

Early gastric cancer(EGC) has been proved to be a malignant tumor with favorable prognosis in contrast to the advanced one, thus early diagnosis has always been the emphasis regardless its type. In particular, diagnosis of superficial flat type EGC(IIb) is extremely difficult on gross inspection. The aim of this study is to review the clinical features of the patients with EGC type IIb, with special reference to the endoscopic appearance of tumor. We reviewed the medical records and endoscopic findings of 13 patients which were thereafter surgically resected and pathologically proven EGC type IIb at SNUH from 1989 to 1993. The depressed lesion was observed most frequently in EGC type IIb. The endoscopic suggestion of EGC type IIb were given initially with mucosal bleeding and discoloration. In 3 cases (20%), tumor extended to the submucosa and in only 1 case, lymph node metastasis was found. Four patients(30.9%) had another coincidental EGC or peptic ulcer. Every possible effort is needed not to omit the resectable cancer when the mucosal bleeding and discoloration is observed. Careful observation is recommended not to overlook coincidental lesions.