Preoperative Staging Of Gastric Cancer Research Articles

Endoscopic ultrasonography Versus Helical Computed Tomography for Preoperative staging of Gastric Cancer

Endoscopic ultrasonography Versus Helical Computed Tomography for Preoperative staging of Gastric Cancer

3003: Effect of transabdominal ultrasound in preoperative staging of gastric cancer

3003: Effect of transabdominal ultrasound in preoperative staging of gastric cancer

Staging of gastric cancer with 16-channel MDCT

Early detection and accurate preoperative staging of gastric cancer are clinically important because the prognosis and choice of an optimal therapeutic approach are directly related to the stage of a neoplasm at time of presentation. Multidetector row computed tomography is a potentially powerful tool for noninvasive gastric evaluation. When thin collimation is used, near-isotropic imaging of the stomach is possible. Proper air distention of the stomach is used with virtual gastroscopic images; the technique is able to evaluate endoluminal lesions of the stomach and assist in early detection of gastric cancer. Adequate water-filled dynamic multiplanar reformatted images allow the radiologist to choose the optimal imaging plane to accurately evaluate depth of tumor invasion of the gastric wall and perigastric fat plane infiltration, identify a thin fat plane between a tumor and adjacent organs, avoid partial volume averaging effects, and better differentiate lymph nodes from small perigaskric vessels. Thus, the combination of air distention and hydrodistention of the stomach and dynamic contrast-enhanced multidetector row computed tomography with near-isotropic imaging offer improved diagnosis and staging of gastric cancers.

Usefulness of endoscopic ultrasonography in preoperative TNM staging of gastric cancer

To evaluate the value of endoscopic ultrasonography (EUS) in the preoperative TNM staging of gastric cancer. Forty-one patients with gastric cancer (12 early stage and 29 advanced stage) proved by esophagogastroduodenoscopy and biopsies preoperatively evaluated with EUS according to TNM (1997) classification of International Union Contrele Cancer (UICC). Pentax EG-3630U/Hitachi EUB-525 echo endoscope with real-time ultrasound imaging linear scanning transducers (7.5 and 5.0 MHz) and Doppler information was used in the current study. EUS staging procedures for tumor depth of invasion (T stage) were performed according to the widely accepted five-layer structure of the gastric wall. All patients underwent surgery. Diagnostic accuracy of EUS for TNM staging of gastric cancer was determined by comparing preoperative EUS with subsequent postoperative histopathologic findings. The overall diagnostic accuracy of EUS in preoperative determination of cancer depth of invasion was 68.3% (41/28) and 83.3% (12/10), 60% (20/12), 100% (5/5), 25% (4/1) for T1, T2, T3, and T4, respectively. The rates for overstaging and understaging were 24.4% (41/10), and 7.3% (41/3), respectively. EUS tended to overstage T criteria, and main reasons for overstaging were thickening of the gastric wall due to perifocal inflammatory change, and absence of serosal layer in certain areas of the stomach. The diagnostic accuracy of metastatic lymph node involvement or N staging of EUS was 100% (17/17) for N0 and 41.7% (24/10) for N+, respectively, and 66% (41/27) overall. Misdiagnosing of the metastatic lymph nodes was related to the difficulty of distinguishing inflammatory lymph nodes from malignant lymph nodes, which imitate similar echo features. Predominant location and distribution of tumors in the stomach were in the antrum (20 patients), and the lesser curvature (17 patients), respectively. Three cases were found as surgically unresectable (T4 N+), and included as being correctly diagnosed by EUS. EUS is a useful diagnostic method for preoperative staging of gastric cancer for T and N criteria. However, EUS evaluation of malignant lymph nodes is still unsatisfactory.

CT and PET in Stomach Cancer: Preoperative Staging and Monitoring of Response to Therapy

Stomach cancer is one of the leading causes of cancer mortality worldwide. Complete resection of a gastric tumor and adjacent lymph nodes represents the only potentially curative intervention. Computed tomography (CT) has remained the modality of choice for the preoperative staging of gastric cancer and for follow-up. A recently developed advanced CT technique that makes use of thin sections, optimal contrast material enhancement, and multiplanar reformation allows more accurate staging. However, CT may be limited in the identification of nonenlarged lymph node metastasis, peritoneal dissemination, and small hematogenous metastasis. Positron emission tomography (PET) with 2-[fluorine-18]fluoro-2-deoxy-d-glucose (FDG) has been recognized as a useful diagnostic technique in clinical oncology. FDG PET allows scanning of a larger volume than is possible with CT. Although FDG PET is not an appropriate first-line diagnostic procedure in the detection of stomach cancer and is not helpful in tumor staging, it may play a valuable role in the detection of distant metastases, such as those of the liver, lungs, adrenal glands, ovaries, and skeleton. FDG PET may also be helpful in the follow-up of patients undergoing chemotherapy, as it allows the identification of early response to treatment. Further studies are needed to determine the efficacy of FDG PET in the detection of local nodal metastases and peritoneal dissemination. Nevertheless, the combined use of CT and PET can be helpful in the preoperative staging of stomach cancer and in the therapeutic monitoring of affected patients.

Gastric Cancer Staging at Multi–Detector Row CT Gastrography: Comparison of Transverse and Volumetric CT Scanning

To prospectively evaluate the accuracy of multi-detector row computed tomography (CT) gastrography for preoperative staging of gastric cancer, with pathologic and surgical results as the reference standard. This study was approved by the institutional review board, and patients gave written informed consent. One hundred six patients (72 male, 34 female; mean age, 56 years) with endoscopically proved gastric cancer underwent unenhanced and contrast material-enhanced multi-detector row CT gastrography, with effervescent granules used as oral contrast material. Two experienced radiologists independently evaluated the depth of tumor invasion into the gastric wall (tumor staging), the involvement of regional lymph nodes (nodal staging), and the presence or absence of metastasis (metastatic staging) on transverse and volumetric CT images, which included images produced with multiplanar reformation and a virtual endoscopic technique. TNM staging of each tumor was compared with the pathologic and surgical results. Diagnostic accuracy in TNM staging was analyzed. Gastric cancer was detected in 92 (87%) of 106 study patients with transverse CT imaging and in 104 (98%) with volumetric CT imaging. The overall accuracy of the tumor staging was 77% with transverse CT imaging and 84% with volumetric CT imaging (P < .001). The overall accuracy for lymph node staging was 62% with transverse CT imaging and 64% with volumetric CT imaging (P = .057). For staging of metastases, there was no difference between transverse and volumetric CT imaging (86% for both) (P > .99). Multi-detector row CT gastrography with multiplanar reformation and virtual endoscopy, compared with transverse CT imaging, can improve the accuracy of preoperative staging of gastric cancer. This difference was significant for tumor staging but not for the staging of lymph nodes and metastases.

Loss of Ep-CAM (CO17-1A) expression predicts survival in patients with gastric cancer.

Preoperative staging of gastric cancer is difficult and not optimal. The TNM stage is an important prognostic factor, but it can only be assessed reliably after surgery. Therefore, there is need for additional, reliable prognostic factors that can be determined preoperatively in order to select patients who might benefit from (neo) adjuvant treatment. Expression of immunohistochemical markers was demonstrated to be associated with tumour progression and metastasis. The expression of p53, CD44 (splice variants v5, v6 and v9), E-cadherin, Ep-CAM (CO17-1A antigen) and c-erB2/neu were investigated in tumour tissues of 300 patients from the Dutch Gastric Cancer Trial, investigating the value of extended lymphadenectomy compared to that of limited lymphadenectomy). The expression of tumour markers was analysed with respect to patient survival. Patients without loss of Ep-CAM-expression of tumour cells (19%) had a significantly better 10-year survival (P<0.0001) compared to patients with any loss: 42% (s.e.=7%) vs 22% (s.e.=3%). Patients with CD44v6 (VFF18) expression in more than 25% of the tumour cells (69% of the patients) also had a significantly better survival (P=0.01) compared to patients with expression in less than 25% of the tumour cells: 10 year survival rate of 29% (s.e.=3%) vs 19% (s.e.=4%). The prognostic value of both markers was stronger in stages I and II, and independent of the TNM stage. Ep-CAM and CD44v6-expression provides prognostic information additional to the TNM stage. Loss of Ep-CAM-expression identifies aggressive tumours especially in patients with stage I and II disease. This information may be helpful in selecting patients suitable for surgery or for additional treatment pre- or postoperatively.

Endoscopic Ultrasonography (EUS) in Preoperative Staging of Gastric Cancer in a Clinical Observational Study of 1,199 Patients: Demand and Reality

Endoscopic Ultrasonography (EUS) in Preoperative Staging of Gastric Cancer in a Clinical Observational Study of 1,199 Patients: Demand and Reality

Gastric cancer by multidetector row CT: preoperative staging

The role of computed tomography (CT) in the preoperative staging of gastric cancer, even if controversial, may be fundamental for evaluating the local extent and nodal involvement of the disease, especially in locally advanced cases. However, previous results of CT staging have not been satisfactory for predicting the invasive depth of the tumor or possible nodal metastases. Recently introduced multidetector row CT (MDCT) and three-dimensional (3D) imaging are expected to overcome the limitations in cancer staging by offering rapid and accurate information for space perception, detailed hemodynamics, and real-time 3D processing of volumetric data sets. In particular, virtual endoscopic imaging may be helpful for detecting early gastric cancer. In our experience, T and N stagings of gastric cancer were improved with 3D MDCT when using volume rendering and virtual endoscopic imaging compared with conventional axial two-dimensional (2D) CT (accuracy of T staging with 3D vs. 2D CT images, 84% vs. 77%; accuracy of N staging, 63% vs. 61% with 3D vs. 2D images, respectively). In particular, the detection rate of early gastric cancer was markedly increased up to 96% when using 3D MDCT. Therefore, we believe that 3D MDCT of the stomach may enhance the performance of CT in the preoperative evaluation of patients who have gastric cancer by offering easy early detection of lesions and accurate tumor staging through the 3D imaging process.

Promoter hypermethylation of p16 gene in pre- and post-operative plasma of patients with gastric adenocarcinoma

Objective: To detect promoter hypermethylation of p16 gene in matched pre- and post-operative plasma of patients with gastric adenocarcinoma for evaluating the effectiveness of therapeutic intervention. Methods: Tissue samples, pre- and post-operative plasma of 84 patients were collected. Plasma of 15 healthy people was collected as control. After sodium-bisulfite treatment, extracted DNA was amplified for p16 promoter by methylation-specific polymerase chain reaction (MSP). The PCR products were detected by both gel-ethidium bromide electrophoresis and high performance liquid chromatogram (HPLC). Results: Among 84 patients, p16 hypermethylation was detected in 26 (31.0%) cancer tissues and 2 (0.02%) tumor-adjacent tissues and 12 (14.3%) pre-operative plasma, while negative in plasma of healthy people. For positive plasma cases, the paired tumor tissues were confirmed to be methylated. Within available 30 pairs of matched pre- and post-operative plasma, 6 pre-operative plasma was positive, and only 1 of 6 plasma remained hypermethylated after surgery. The results detected by HPLC exactly matched those by gel-electrophoresis. Conclusion: The alteration of status of p16 hypermethylation in post-operative plasma is considered the consequences of surgical intervention. Although p16 hypermethylation has no role in pre-operative staging of gastric cancer, detecting hypermethylated p16 in plasma could be utilized in monitoring patients after surgery.

Progressive CT system technology and experience improve the perceived preoperative stage of gastric cancer

Our goals were to measure the accuracy of specialist helical computed tomography (CT) in the preoperative staging of gastric cancer, to determine the relative benefit of progressive CT system technology, and to determine the magnitude of any learning curve in radiological interpretation. One hundred patients (median age, 70 years; range 27-86 years; 68 male) underwent a preoperative CT (73 helical [hCT], 27 multislice [mCT]), performed by a single specialist radiologist, followed by surgery within 3 weeks. The strength of the agreement between the perceived CT stage and the histopathological stage was determined for each CT system and also for four serial cohorts of 25 patients, by the weighted Kappa statistic (Kw). The Kw values for T, N, M1 liver, and M1 peritoneal stage were 0.40, 0.18, 0.36, and 0.09 for hCT, compared with 0.57, 0.67, 0.66 (all P < 0.001), and 0.24 (P = 0.06) for mCT. Serial Kw for T and N stages improved from 0.26 and -0.14 in the first quartile of patients to 0.61 and 0.73 (P < 0.001) in the last quartile of patients. The role of CT in the preoperative staging of gastric cancer is becoming stronger as CT technology improves.

Transabdominal ultrasonography in preoperative staging of gastric cancer

To investigate the value of transabdominal ultrasonography (US) in the preoperative staging of gastric cancer. A total of 198 patients with gastric cancer underwent preoperatively transabdominal US, depth of tumor infiltration was assessed in 125 patients, and lymph node metastasis was assessed in 106 patients. The staging accuracy of transabdominal US was 55.6%, 75.0%, 87.3% and 71.1% in T1, T2, T3 and T4 carcinomas, respectively. The overall accuracy was 77.6%. The detection rate for pancreatic invasion and liver invasion was 77.4%, 71.4%, respectively. The sensitivity, specificity, accuracy of transabdominal US in assessment of lymph node metastasis were 77.6%, 64.1%, 72.6%, respectively. Various shapes such as round, ovoid, spindle were encountered in benign and malignant lymph nodes. Majority of both benign and malignant lymph nodes were hyperechoic and had a distinct border. Benign lymph nodes were smaller than malignant lymph nodes in length and width (P = 0.000, 0.005). Irregular shape, fusional shape, infiltrative signs, inhomogenous echo were seen mainly in malignant lymph nodes (P = 0.045, 0.006, 0.027, 0.006). Transabdominal US is useful for preoperative staging in gastric cancer, although it is difficult to differentiate benign from malignant lymph nodes.

The Diagnostic Accuracy of Preoperative T-staging of Gastric Cancer Using EUS and CT

Purpose: Preoperative staging of gastric cancer is crucial because the treatment modality and the prognosis depend upon the stage of gastric cancer. Current treatment modalities for early gastric cancer have focused on the quality of life. Endoscopic ultrasonography (EUS) and abdominal computed tomography (CT) are commonly used diagnostic tools to evaluate the invasiveness (T stage) of the primary tumor. The purpose of this paper is to evaluate the sensitivity and the specificity of preoperative EUS and CT in comparison with postoperative pathology. Materials and Methods: From October 2001 to October 2002, EUS and abdominal CT were performed simultaneously on 75 patients who underwent radical gastric surgery for the treatment of gastric cancer. Through analyzing the clinical T stage and the pathologic T stage, We evaluated the diagnostic sensitivities and specificities of endoscopic ultrasonography and abdominal computed tomography. Results: The male-to-female sex ratio was 1 : 0.6 (males: 47, females: 28). The mean age was 55.4 years in males (range: ) and 54.4 years in females (range: ). The clinical T stage based on EUS included 22 T1mm, 7 T1sm, 22 T2, and 24 T3. The clinical T stage based on CT included 20 Tx, 23 T2, and 32 T3. The permanent pathologic report confirmed 23 T1mm, 10 T1sm, 17 T2, 24 T3, and 1 T4. The sensitivity and specificity of EUS were , respectively. However, the sensitivity and specificity of abdominal CT were , respectively. Conclusion: Our data suggest that EUS is a very useful diagnostic tool for evaluating the T stage of gastric cancer because EUS has higher specificity than abdominal CT. Therefore, EUS may have a significant role as a preoperative diagnostic modality in patients undergoing minimally invasive surgery.

Preoperative staging of gastric cancer by endoscopic ultrasound: the prognostic usefulness of ascites detected by endoscopic ultrasound.

Endoscopic ultrasound (EUS) is the standard modality in local preoperative staging of gastric cancers and is reputedly able to detect ascites. However, the association between ascites detected by EUS and local tumor staging, peritoneal carcinomatosis, or survival after surgery is not well documented. To assess the accuracy, sensitivity, and specificity of EUS in the preoperative staging and detection of ascites in gastric cancers. We also try to correlate ascites with histologic staging, tumor differentiation, and survival rate of gastric carcinoma after surgery. The retrospective analysis was made in 57 consecutive patients with histologically confirmed gastric adenocarcinomas that underwent EUS before surgery. The accuracy of EUS was compared with the final surgical-pathologic findings. We estimated the prognostic usefulness by analyzing the clinicopathologic features of gastric adenocarcinomas and following up their survival rates. The overall T staging was 88% accurate by EUS. The accuracy for T staging was as follows: T1, 100%; T2, 33%; T3, 93%; and T4, 100%. About 50% of T2 cases were overstaged. The overall accuracy, sensitivity, and specificity of detecting lymph node metastasis by EUS were 79%, 79%, and 80%, respectively. One of the seven T1 cancers had regional lymph node metastasis, and it was missed by EUS, although the T classification was precisely staged based on finding submucosal invasion. A total of 22 patients (39%) had ascites detected by EUS; both the sensitivity and specificity of EUS in demonstrating ascites were 100% in our study. Ascites was significantly correlated with the depth of tumor invasion ( = 0.036), lymph node metastasis ( = 0.008), and poor cellular differentiation ( = 0.007), but it was not significantly correlated with macroscopic peritoneal carcinomatosis. The survival rate after surgical treatment was poor in those with gastric cancers with lymph node metastasis, ascites, or poorly differentiated tumors ( < 0.05). However, multivariate analysis showed that lymph node metastasis was the only significant prognostic predictor ( = 0.004). Endoscopic ultrasound is a valuable diagnostic tool in the local staging of gastric cancers and demonstration of ascites. Although the surgical treatment of gastric cancers with lymph node metastasis, ascites, or poor differentiation had poorer survival rate, only lymph node metastasis was proved to be a significant prognostic predictor in multivariate analysis.

Value of computed tomography in addition to ultrasound for preoperative staging of gastric cancer

Aim: The aim of this study was to assess the added value of computed tomography (CT) with ultrasound in identifying unresectable or incurable gastric cancer.Methods: One hundred and eighteen patients with various types of gastric cancer were preoperatively staged with ultrasound and CT between January 1999 and October 2000. Each individual was evaluated for ascites, liver metastasis and peritoneal metastases. The observations were compared to findings at surgery.Results: Both techniques were highly specific (93–99%) for all conditions except retroperitoneal invasion (85%). The sensitivities of ultrasound and CT were 64 and 36% for ascites, 50 and 62% for liver metastasis, 9 and 13% for peritoneal metastasis and 18 and 41% for retroperitoneal invasion. Ultrasonography was more sensitive than CT for detecting ascites, and CT was better for detecting retroperitoneal invasion.Conclusions: Both techniques allowed more accurate identification of liver metastasis and ascites than peritoneal metastasis and retroperitoneal invasion. In order to simplify scanning of patients with gastric cancer, we recommend that CT investigation should be done only in cases where the ultrasound findings are suspicious.

Carcinoma of stomach and duodenum: radiologic diagnosis and staging

Gastric carcinoma is one of the leading causes of cancer mortality worldwide. Accurate preoperative staging of gastric cancer is important in planning the most effective therapy toward cure or palliation. This article reviews the radiologic diagnosis and staging of gastric cancer.

Preoperative evaluation of gastric cancer: value of spiral CT during gastric arteriography (CTGA).

To evaluate the utility of dual-phase spiral computed tomography during gastric arteriography (CTGA) in the preoperative staging of gastric cancers. We performed CTGA in 21 patients with pathologically proven gastric cancers. CTGA findings were prospectively analyzed and correlated with surgical and pathologic findings. Dual-phase scans were performed at 10 s (early) and 60-100 s (delayed) after injection of 120 mL of contrast medium at an injection rate of 6 mL/s through a preset 5-Fr catheter positioned in the celiac trunk. Spiral CT scans were assessed for enhancing pattern of the normal gastric wall, tumor detectability, and accuracy of tumor staging. Normal gastric mucosa was clearly visible as two or three layers in all patients on early-phase scans and in eight patients on delayed-phase scans. The primary tumors were correctly detected with CTGA in seven (88%) of the eight early gastric cancers and in all 13 (100%) advanced gastric cancers. The accuracy of CTGA for T staging was 50% and 77% in early and advanced gastric cancers, respectively. The overall accuracy for tumor detection and T staging was 95% and 67%, respectively. The accuracy of CTGA for the degree of serosal invasion and regional lymph node metastasis was 77% and 76%, respectively. The CTGA technique improved tumor detection rate and accuracy of tumor staging, especially in early gastric cancer, and may be very useful in the preoperative staging of gastric cancer.

Hydro-dynamic CT preoperative staging of gastric cancer: correlation with pathological findings. A prospective study of 107 cases.

The aim of this study was to evaluate the accuracy of dynamic CT in the preoperative staging of gastric cancer. One hundred seven patients affected by gastric cancer diagnosed by endoscopic biopsy were prospectively staged by dynamic CT prior to tumor resection. After an oral intake of 400-600 ml of tap water and an intravenous infusion of a hypotonic agent, 200 ml of non-ionic contrast agent were administered by power injector using a biphasic technique. The CT findings were prospectively analyzed and correlated with the pathological findings at surgery. The accuracy of dynamic CT for tumor detection was 80 and 99% in early and advanced gastric cancer, respectively, with overall detection rate of 96% (103 of 107). Three early (pT1) and one advanced (pT2) cancers were undetected. Tumor stage as determined by dynamic CT agreed with pathological findings in 83 of 107 patients with an overall accuracy of 78%. The accuracy of CT in detecting increasing degrees of depth of tumor invasion when compared with pathological TNM staging was 20% (3 of 15) and 87% (80 of 92) in early and advanced cancer, respectively. The sensitivity, specificity, and accuracy of CT in the preoperative staging (pT3-pT4 vs pT1-pT2) was 93, 90, and 91.6%, respectively. The sensitivity, specificity, and accuracy of CT in assessing metastasis to regional lymph nodes was 97.2, 65.7, and 87%, respectively. Computed tomography correctly staged liver metastases in 105 of 107 patients with an overall sensitivity of 87.5% and specificity of 99 %. The sensitivity of peritoneal involvement was 30% when ascites or peritoneal nodules were absent. Our findings show that dynamic CTcan play a role in the preoperative definition of gastric cancer stage. The results can be used to optimize the therapeutic strategy for each individual patient prior to surgery, thus avoiding unnecessary intervention and allowing careful planning of extended surgery in eligible patients.

Need for staging laparoscopy in patients with gastric cancer

AIMS: The aim of preoperative staging in gastric cancer is to correctly identify patients with advanced disease who should not be subjected to surgery and to allow the treatment of those who are admitted for operation to be planned accurately. This study assessed the impact of a policy of selective staging laparoscopy in patients deemed suitable for curative or palliative surgery, to ascertain whether the selective approach increased the frequency of abandoned or unplanned surgical procedures. METHODS: Fifty consecutive patients with gastric or type III gastro-oesophageal junction cancer staged by computed tomography (CT) alone, in whom surgery was felt to be appropriate for 'cure' or palliative symptom control, were studied. Specific CT, endoscopic and biochemical criteria were applied prospectively to select out a subgroup of 18 patients who also underwent preoperative staging laparoscopy. The overall accuracy of staging and operative outcomes were assessed. RESULTS: Using this selective approach the resection rate was 98 per cent, although three patients in each group had their planned procedure altered to a less radical (two in each group) or more radical (one in each group) resection (P = 0.23). Overall, 41 of 50 patients were staged correctly (accuracy 82 (95 per cent confidence interval 69-90) per cent) and 86 per cent of patients underwent the planned surgical procedure. The only abandoned operation occurred in the staging laparoscopy group. CONCLUSIONS: It is possible to plan a patient's operation accurately without the need for a staging laparoscopy in all cases.

Accuracy of endoscopic ultrasonography in the preoperative staging of gastric cancer

from anesthesia. Sham burn rats served as controls. Apoptosis was quantified by immunohistochemical staining (TUNEL) in paraffin-embedded sections and mucosal proliferation was determined by either bromodeoxyuridine (BrdU) incorporation or proliferative cell nuclear antigen binding (PCNA). Results were analyzed by Wilcoxon's rank sum analysis and t-test. Results: The apoptotic index (TUNEL positive cells/100 villous epithelial cells) in burned rats was higher than controls at 12 hours. At 24 and 48 hours, apoptosis was highest in the starved groups, with no difference between sham and burn. Burn and starvation were not additive (see figure). Mucosal proliferation (BrdU incorporation positive cells/100 crypt cells) was not different between groups at any time point. Conclusion: Burn and starvation cause an increase in apoptosis in the small bowel mucosa, however, the effects are not additive. Starvation appears to be the greater stimulus of small bowel mucosal apoptosis. These results provide strong support for early enteral feeding after injury to maintain mucosal integrity.