J. W. L. Fielding

Improving outcomes in gastric cancer over 20 years

BackgroundGastric cancer has in the past proven to be a difficult disease to cure. Surgery is the most effective treatment, although the extent of lymphadenectomy undertaken is controversial. This paper examines trends in the detection and treatment of gastric cancer, the move toward targeted surgery, and their impact on survival.MethodsFrom 1982 to 2001, 430 patients with gastric cancer were under the care of a single surgeon at the same institution. Copies of the operation records, discharge summaries, and histology reports were retained and subsequently reviewed.ResultsThirty-six patients were excluded from the analysis. Two hundred and five patients (52%) had potentially curative surgery for adenocarcinoma and 189 had incurable disease. During the 20-year period, overall 5-year survival increased significantly, from 15% to 41% (P < 0.01). The number of curative procedures also increased significantly, from 33% to 73% (P1 < 0.001) as disease was detected earlier, and 5-year survival in these patients increased from 26% to 46%. Eighty-seven D1, 92 D2, and 26 targeted procedures were performed, with 30-day mortalities of 5%, 9%, and 5%, respectively. The 5-year survival was 47% for D1, 42% for D2, and 66% for targeted surgery.ConclusionThis paper demonstrates an improvement in the stage at which disease was detected and improvement in long-term survival for patients with gastric cancer. The development of targeted surgery has shown promising early results.

The influence of age on the surgical management of carcinoma ofthe stomach

The medical records of 31,808 patients with gastric cancer registered with the West-Midlands Cancer Registry between 1957-1981 were reviewed to determine the influence of age on presentation, stage assessment, management, survival and mortality rates. When analysed by stage, and excluding post-operative deaths, survival was similar in all age groups. This study confirms stage of disease to be the single most important prognostic factor. The inverse relationship between laparotomy and age implies inadequate assessment of stage in the elderly. The poor prognosis in unresected cases suggests that increased precise staging by laparotomy or laparoscopy will have minimal adverse effects. On the other hand this may result in increased resections and survival.

Radical surgery for early gastric cancer.

The role of radical surgery for early gastric cancer has become a topic of considerable debate. Despite excellent results from Japan and several retrospective and uncontrolled trials, results from two large prospective randomized trials appear to demonstrate no benefit from D2 compared to the D1 resections. These trials have prompted a move away from radical lymph-node dissection. We argue that this reasoning is flawed and based not on the lack of efficacy of the D2 resection but in an attempt to reduce post-operative mortality and morbidity. Post-operative complications are largely a result of distal pancreatectomy and splenectomy and the relative inexperience of surgeons performing the operations. By preserving these organs and concentrating surgery to specialized centres the complication rate of radical surgery can be significantly reduced to approximate that of non-radical surgery. Lymph-node metastasis to the N2 nodes in early gastric cancer has been shown to be as high as 23%. Non-radical surgery poses significant risks of leaving residual disease. Radical surgery must remain the operation of choice if non-curative surgery for a curable condition is to be avoided.

Radioimmunolocalization using the radiolabeled monoclonal anti-cea antibody 11-285-14 lacks diagnostic utility for the differentiation of pancreatic and bile duct cancer from chronic pancreatitis and sclerosing cholangitis

SummaryCEA expression was determined by immunohistochemistry in paraffin sections from cases of pancreatic cancer(n = 30), chronic pancreatitis(n = 10), cholangiocarcinoma(n = 12), and sclerosing cholangitis (n-4) using a new anti-CEA monoclonal antibody (11-285-14). CEA was expressed in 77% of pancreatic cancers and 80% of cholangiocarcinomas, but was not detected in any of the cases of sclerosing cholangitis. Although 60% of chronic pancreatitic tissues were positive, staining intensity was markedly reduced compared to cancers. Twenty-five patients with these conditions were therefore studied using radioimmunolocalization. Eleven of 12 pancreatic cancers were positively imaged, as were all three biliary tumors. However, positive scans were also obtained in 50% of the cases of chronic pancreatitis and sclerosing cholangitis. The overall sensitivity (68%) and specificity (63%) of radioimmunolocalization using the 11-285-14 antibody were not high enough to justify its use for diagnosis.

Stages I–IVA

The staging system used is based on the TNM system: it has been modified to identify those tumours that have been resected for palliation (stage IVA).

Overall Treatment and Survival

The overall pattern of gastric cancer presentation, treatment and outcome is described in this chapter. The results are described for all patients for the whole period and also by quinquennia or decades in order to evaluate changes occurring during the study period. Presentation is assessed by site and stage. The type of treatment is evaluated overall, by site and stage and by age group. Finally survival is considered for all patients, by site and stage, by age and by treatment and includes an analysis of the mortality in the first month after treatment.

Presentation and Investigations

Data relating to the type of presenting symptoms have been available only for the first four quinquennia, 1957–76, whereas for the duration of symptoms, data are available for the whole twenty five year period. When both type and duration of symptoms have been evaluated together only data for 1957–76 have been considered