Akihito Torii

Peritoneal washing cytology: prognostic value of positive findings in patients with gastric carcinoma undergoing a potentially curative resection.

Free cancer cells in the abdominal cavity exfoliated from a tumor are considered to be responsible for peritoneal dissemination, the most frequent pattern of failure in gastric carcinoma patients treated with curative surgery.

Prognostic value and clinical implications of disseminated cancer cells in the peritoneal cavity detected by reverse transcriptase-polymerase chain reaction and cytology.

Free cancer cells exfoliated from the cancer‐invaded serosa contribute to peritoneal dissemination, the most frequent pattern of recurrence in gastric carcinoma patients. This study was designed to evaluate the prognostic relevance of such free cells in peritoneal washes detected by reverse transcriptase‐polymerase chain reaction (RT‐PCR) and cytology. RT‐PCR analysis with primers specific for carcinoembryonic antigen and conventional cytologic examination by Papanicolaou staining were performed on peritoneal washes, collected at laparotomy from 148 gastric carcinoma patients. Prognostic analyses were performed with 1) death due to cancer recurrence and 2) peritoneal dissemination as endpoints. RT‐PCR was found to be more sensitive than cytologic examination for detection of free cancer cells in the peritoneal washes, with a higher detection rate for each of the T categories in the tumor‐node‐metastasis (TNM) classification. Five patients with synchronous or recurrent peritoneal dissemination were found among 17 patients with positive RT‐PCR and negative cytologic results. Both positive cytologic results and positive RT‐PCR results had significant influences over the survival of patients with advanced gastric carcinomas (n = 75, p < .002). Detection of free cancer cells in peritoneal washes, most reliably by RT‐PCR, is promising as a predictor of peritoneal dissemination in patients with gastric carcinoma. Int. J. Cancer (Pred. Oncol.) 79:429–433, 1998.

Adenocarcinoma of the gastroesophageal junction in Japan: relevance of Siewert’s classification applied to 177 cases resected at a single institution☆

BACKGROUND There had been a lack of international consensus about the definition of cancer of the gastric cardia until Siewerts classification was approved at a consensus conference during the second International Gastric Cancer Congress held in 1997. STUDY DESIGN A review of the prospective gastric cancer database at Aichi Cancer Center from 1983 to 1992 identified 1,913 gastric carcinoma patients who underwent gastrectomy. These patients were classified retrospectively according to the Siewert classification, and 177 patients who fell into one of the three types form the basis of this study. Survival analyses were performed after stratifying patients by clinicopathologic variables. RESULTS There were 33 patients with type II and 144 with type III, although none had type I, a type frequently observed in the west. No evidence of a change in the frequency of types II or III cancers (approximately 9.3% overall) among gastric carcinoma patients was observed over the 10-year period. Clinical staging of gastric carcinoma by the TNM classification was found to reflect accurately the prognosis of these patients. There were no longterm survivors among the few patients with metastasis to the perigastric nodes of the distal stomach. CONCLUSIONS A striking difference in the distribution of types of adenocarcinoma of the gastroesophageal junction was observed in Japan compared with previously reported western data. A subgroup of carcinoma of the proximal stomach identified as types II and III may not require proximal gastrectomy from the viewpoint of sufficient lymphadenectomy.

The number of metastatic lymph nodes : A promising prognostic determinant for gastric carcinoma in the latest edition of the TNM classification

BACKGROUND The number of metastatic regional lymph nodes determines the new pN categories in the 5th edition of the TNM classification. STUDY DESIGN Our retrospective study was conducted to compare the new method of defining lymph node status with the conventional classification, consisting of the anatomic extent of lymph node metastases, a well-established prognostic factor. The study was based on clinical data for 493 patients with gastric carcinomas who underwent potentially curative operations and had histologically confirmed nodal metastases. These patients were stratified into 1) n categories according to the Japanese Classification of Gastric Carcinoma, 2) the new pN categories, and 3) the pN categories determined by the number of metastatic perigastric nodes resected by standard D1 gastrectomy. Survival data were analyzed for each group. RESULTS The number of metastatic nodes after D2 lymphadenectomy reflected prognosis well and was shown by multivariate analysis to be a strong independent prognostic factor. When the classification was performed limited to the metastatic perigastric nodes, stage migration was evident, but the variable remained competent as a prognostic indicator. CONCLUSIONS The number of metastatic nodes is a promising determinant in the new international stage classification.

Detection of Carcinoembryonic Antigen‐expressing Free Tumor Cells in Peritoneal Washes from Patients with Gastric Carcinoma by Polymerase Chain Reaction

Cytological examination of peritoneal washes is a useful predictor of peritoneal recurrence in gastric carcinoma patients. In the present study, even more sensitive detection of free cancer cells could be achieved through amplification of Carcinoembryonic antigen (CEA) mRNA by means of the reverse transcriptase‐polymerase chain reaction (RT‐PCR). CEA was first confirmed to be present in all the gastric cancer cell lines examined, irrespective of the differentiation degree, and absent in blood and mesothelium, indicating the specificity of this approach for detection of carcinoma cells in peritoneal lavage fluid. In sensitivity tests, CEA RT‐PCR proved to be capable of detecting 10 carcinoma cells per sample. Peritoneal washes of 15 of 48 gastric carcinoma patients, including all 10 patients with positive cytology results, proved positive for CEA mRNA. None of the 5 patients with benign disease was positive. Moreover, a close association with the depth of cancer invasion was established. The results indicate that the assay is more sensitive for detection of free carcinoma cells in the peritoneal cavity than conventional cytology. This is the first study to suggest the feasibility of the RT‐PCR method for prediction of peritoneal recurrence in gastric cancer patients.

A new macroscopic classification predicts prognosis for patient with liver metastases from colorectal cancer.

OBJECTIVE The authors defined a new macroscopic classification of liver metastases from colorectal cancer. SUMMARY BACKGROUND DATA There were different prognostic results after the same operative procedure for liver metastases with similar background factors. METHODS Eighty-one resected liver metastases were classified into simple nodular (SN) or confluent nodular (CN) types according to the characteristics of the cut surface of the tumor. RESULTS The 5-year survival rates after hepatectomy were 41.7% for the SN lesions (n = 39) and 23.1% for the CN lesions (n = 42). The difference between the survival curves was statistically significant (p = 0.0307). Multivariate analysis using Coxs proportional hazards model revealed that the macroscopic type (p = 0.023), the tumor diameter (p = 0.0001), and the presence of lymph node metastases (p = 0.0016) were statistically significant independent prognostic factors. CONCLUSION The new macroscopic classification may be valuable as a prognostic factor reflecting the biologic behavior of liver metastases.

Lack of Benefit of Combined Pancreaticosplenectomy in D2 Resection for Proximal-Third Gastric Carcinoma

AbstractOf the 2790 patients with gastric carcinoma who underwent surgery between January 1978 and December 1993, there were 224 who underwent a D2 resection for cancer of the proximal third of the stomach. Survival in these patients was retrospectively analyzed with special reference to the survival benefit of pancreaticosplenectomy (PS). The D2 resection involved a splenectomy in 129 patients, a PS in 38 patients, and neither in 57 patients, with 5-year survivals of 74%, 59%, and 91%, respectively. Although these differences in survival were attributable to the apparent deviation in the incidence of prognostic variables, no significant survival benefit of PS was observed for patients with the same clinical stage disease (stages II and III) or the same nodal status (n1 and n2). Because PS was associated with a significant increase in the incidence of anastomotic dehiscence and length of hospital stay, the dismal survival benefit implies that it should not be performed routinely with the D2 resection but should be employed only for lesions with direct invasion of the pancreas.

Lymph node status assessment for gastric carcinoma: Is the number of metastatic lymph nodes really practical as a parameter for N categories in the TNM classification?

Background and Objectives: The anatomical extent of nodal metastasis has been replaced by the number of metastatic nodes as a key indicator of prognosis (pN categories) in the fifth edition of Tumor Node Metastasis Classification for gastric carcinoma by the International Union Against Cancer. The rate of metastatic nodes among all the nodes harvested is also a good prognostic factor. The object of this study is to evaluate which of the three parameters for the assessment of nodal status is the most appropriate for use in the stage classification.

The role of radical gastrectomy with systematic lymphadenectomy for the diagnosis and treatment of primary gastric lymphoma

OBJECTIVE We evaluated the therapeutic efficacy of radical gastrectomy for primary B-cell lymphoma of the stomach and attempted to identify patients who could be adequately treated with surgery alone. SUMMARY BACKGROUND DATA Several recent gastric lymphoma reports have discussed the therapeutic benefits of various treatment strategies for stage IE and IIE lymphoma. However, few studies have been based on patients accurately staged by systematic lymphadenectomy with subsequent pathologic examination. METHODS A retrospective study was performed to evaluate the survival and biologic behavior of lesions in 60 patients with gastric lymphoma who were treated by radical gastrectomy alone. Tumors were classified according to the histopathologic concept of mucosa-associated lymphoid tissue (MALT)-derived lymphoma. RESULTS A low histopathologic grade was associated with a significantly lower incidence of nodal metastasis (p = 0.07) and less extensive infiltration of the gastric wall (p < 0.005) despite larger tumor size. A 5-year survival rate of >95% was attained with surgery alone for MALT lymphoma and for true stage IE lymphoma diagnosed by pathologic examination of up to N2 lymph nodes routinely performed after radical gastrectomy. CONCLUSIONS Surgery alone is adequate treatment for stage IE or pure MALT lymphoma, provided that the staging is performed after radical gastrectomy.

Metastatic gastric lymph node rate is a significant prognostic factor for resectable stage IV stomach cancer

BACKGROUND Stage IV gastric carcinoma is rarely curatively resected and almost invariably carries a poor prognosis. Several clinicopathologic factors are involved, but lymphatic spread of the cancer may significantly affect survival. STUDY DESIGN A retrospective study was designed to evaluate whether the nodal metastatic rate (number of lymph node metastases/number of resected lymph nodes) is a parameter of lymphatic spread and could provide a significant prognostic factor. Several prognostic factors were assessed by multivariate analysis in 153 stage IV gastric carcinoma patients with histopathologic data on nodal metastasis. RESULTS A significant difference in survival was observed in the stage IV cancer patients with total nodal or gastric nodal metastatic rates < 50% versus those with rates > 50%. Multivariate analysis revealed that a total nodal or gastric nodal metastatic rate > 50% was a highly significant prognostic factor. The gastric nodal metastatic rate can be used in patients who do not undergo an extended lymphadenectomy. CONCLUSIONS Lymphatic spread of gastric carcinoma expressed in terms of the total nodal or gastric nodal metastatic rate is a significant prognostic factor. The latter can be calculated without pathologic data derived from extended lymphadenectomy, and so it is universally applicable.