Staging Of Gastric Carcinoma Research Articles

Comparative Study of Transabdominal Ultrasonography and Multidetector Row Computed Tomography in Preoperative Staging of Gastric Carcinoma

Comparative Study of Transabdominal Ultrasonography and Multidetector Row Computed Tomography in Preoperative Staging of Gastric Carcinoma

Gastric carcinoma: typing, staging, lymph node and resection margin status on gastrectomy specimens.

To determine the extent and stage of gastric carcinoma on gastrectomy specimens in terms of type, grade, location, depth of invasion, resection margins and lymph node status. Descriptive study. Section of Histopathology, Department of Pathology, Aga Khan University, Karachi during 2005 and 2006. A 100 consecutive gastrectomy specimens received during the study period, in which resection was done for gastric carcinoma were included. Exclusion criteria were gastrectomy performed for gastrointestinal stromal tumor (GIST) and gastric lymphoma. Specimens were examined according to standard techniques. The reporting incorporated all relevant parameters including gross examination, tumor location, type and grade, depth of invasion, surgical resection margins and lymph node status. Staging was done according to the TNM staging system. Restults: Fifty three (53%) tumors were located in the distal part of the stomach and 35 (35%) in the proximal part. In 12 (12%) cases, tumor was diffusely involving the entire stomach. Histologically, the tumors were signet ring type in 63 (63%) cases and intestinal type in 37 (37%). At least one peripheral resection margin was positive in 29 (29%) cases. Sixty six (66%) cases were T3, 30 (30%) were T2, 3 (3%) were T1 and one case (1%) was T4. Twenty four cases (24%) were N0, 35 (35%) were N1, 27 (27%) were N2 and 14 (14%) were N3. Gastric cancer was at very advanced stage in these patients with full thickness involvement of the gastric wall and positive lymph nodes. It is thus essential to detect and surgically treat these cancers in an early stage. Better surgical techniques are required to ensure negative peripheral resection margins and removal of adequate number of lymph nodes, so that proper staging can be performed.

Assessment of lymphovascular invasion in gastric carcinoma; do they always indicate lymph node metastasis?

Background: Stomach cancer is one of the leading causes of cancer death. The grading and staging of this cancer plays an important prognostic role. Lymphovascular invasion predicts poor outcome in gastric cancer. Among the others, lymphovascular invasion provides useful information for the clinical management of patients with gastric cancer. Nevertheless, data about lymphovascular invasion in early-stage and in lymph node-positive gastric cancer are lacking. Hence, significance of lymphovascular invasion to metastatic lymph nodes impacting nodal status in gastric cancer has been studied in this study.Materials and methods: This is a retrospective analysis of twenty nine (29) histologically confirmed gastric carcinoma cases received in the department of Pathology at NMCTH dating from October 2014 to September 2016.Results: There was male preponderance to gastric carcinoma with male to female ratio of 2.2:1. The age varied from 31- 84 years. There were 17 cases (59%) of intestinal type and 11 cases (38%) of diffuse type of gastric carcinoma and 1 case (3%) of adeno-neuroendocrine carcinoma. Microscopic evaluation for depth of invasion showed tumor invasion till the subserosal connective tissue layer (69%) suggesting pT3 stage. lymphovascular invasion was identified in 21 cases (72%). There was statistically significant correlation (p value 0.01) between lymphovascular invasion and nodal status (N0) status. Conclusion: Presence of lymphovascular invasion is considered as poor prognostic marker in case of gastric adenocarcinoma. Pathologist have been reporting their presence or absence in each gastrectomy reports related to gastric carcinoma.This study has established a significant relation between presence of lymphovascular invasion and nodal staging of gastric carcinoma.

Hierarchical and Complex System Entropy Clustering Analysis Based Validation for Traditional Chinese Medicine Syndrome Patterns of Chronic Atrophic Gastritis.

Objectives: Chronic atrophic gastritis (CAG) is the precancerous stage of gastric carcinoma. Traditional Chinese Medicine (TCM) has been widely used in treating CAG. This study aimed to reveal core pathogenesis of CAG by validating the TCM syndrome patterns and provide evidence for optimization of treatment strategies. Design: This is a cross-sectional study conducted in 4 hospitals in China. Hierarchical clustering analysis (HCA) and complex system entropy clustering analysis (CSECA) were performed, respectively, to achieve syndrome pattern validation. Results: Based on HCA, 15 common factors were assigned to 6 syndrome patterns: liver depression and spleen deficiency and blood stasis in the stomach collateral, internal harassment of phlegm-heat and blood stasis in the stomach collateral, phlegm-turbidity internal obstruction, spleen yang deficiency, internal harassment of phlegm-heat and spleen deficiency, and spleen qi deficiency. By CSECA, 22 common factors were assigned to 7 syndrome patterns: qi deficiency, qi stagnation, blood stasis, phlegm turbidity, heat, yang deficiency, and yin deficiency. Conclusions: Combination of qi deficiency, qi stagnation, blood stasis, phlegm turbidity, heat, yang deficiency, and yin deficiency may play a crucial role in CAG pathogenesis. In accord with this, treatment strategies by TCM herbal prescriptions should be targeted to regulating qi, activating blood, resolving turbidity, clearing heat, removing toxin, nourishing yin, and warming yang. Further explorations are needed to verify and expand the current conclusions.

Label-free imaging for T staging of gastric carcinoma by multiphoton microscopy.

Gastric cancer is one of the most common malignancies worldwide. The accurate diagnosis of tumor invasion depth is critical for therapeutic strategy and prognosis. Without fluorescent labelling, multiphoton microscopy (MPM) imaging could directly reveal tissue architecture based on two-photon excited fluorescence (TPEF) and second harmonic generation (SHG). In this study, we aimed to explore the feasibility of MPM imaging to assess the gastric tumor morphology and infiltration. Unstained slides of 18 fresh gastric tissues with different T staging were examined by multiphoton microscopy. Morphological and quantitative analyses were both conducted. The nuclear area was defined as the area of nuclear boundary. Collagen content was defined as the ratio of SHG pixels to all pixels. Gastric normal and tumor tissues under different T stages visually presented with cellular and subcellular features on fluorescent imaging. The nuclear areas of normal and cancerous cells were 32.01 ± 2.89 and 58.41 ± 6.06μm2 (P < 0.001), respectively. Collagen content was quantified as 0.087 ± 0.012 in normal mucosa but 0.020 ± 0.007 in cancerous mucosa (P < 0.001). All results were in accord with the paired H&E-stained slides. Our findings suggested the convincing potential of MPM for judging T staging of gastric cancer. Without staining intervention, TPEF and SHG of MPM imaging could objectively and quantitatively indicate the subcellular and molecular changes during carcinogenesis. With the advancement of deep penetration, self-focus imaging and three-dimensional (3D) visualization, label-free MPM imaging compacted with endoscopy could be further introduced to realize the real-time in vivo assessment of tumor invasion clinically.

Clinical characteristics of distal gastric cancer in young adults from Northeastern Brazil

BackgroundIt has been suggested that distal gastric carcinoma (GC) in younger patients has a more aggressive outcome than in older patients, however this is a controversial issue. The aim of this study was to compare clinicopathological features between younger and older patients with GC in Northeastern Brazil.MethodsA total of 207 patients with distal GC (41 patients ≤45 years, considered younger group, and 166 > 45 years, considered older group) were evaluated prospectively during a 6 year period.ResultsThe mean patient age in the young group was 37.41 years old and 64.43 years in the older group. No significant difference was found regarding gender, area of residence, history of alcohol consumption, chronic tobacco smoking. Prevalence of first-degree GC history was 12.5% (7.3% in younger group vs. 13.9% in older; p < 0.46). The most frequent symptom was gastric pain and weight loss. Diffuse infiltrative cancer was more frequently seen in younger patients (70.70% vs. 33.70%, respectively; p < 0.01), as was histologically less differentiated tumors (63.40% vs. 33.10%; p < 0.01) and stage IV of GC (48.80% vs. 30.70%; p < 0.015). Five-year survival, evaluated in 82 patients, was lower in younger patients (p = 0.045); however, after adjusting for stage of GC in the multivariate analysis, this association did not remain significant. Family history of GC and gender had no impact on survival.ConclusionsYounger patients showed higher prevalence of diffuse type of Lauren and lower survival that was attributed to higher rate of advanced stage of GC. Gastric cancer screening strategies should also be considered in younger individuals, especially in areas of high prevalence. Further studies are warranted to determine risk factors associated with gastric cancer in young adults.

The Capabilities of Ultrasound Diagnosis in Assessment of Gastric Carcinoma of Different Localization and Stage

Objective: To evaluate the diagnostic possibilities of transabdominal ultrasonography for various localizations of gastric carcinoma (GC). Materials and Methods: The study included 101 patient with GC, the stage T1 in 5, the stage of T2 – in 12, the stage of T3 – in 39 and the stage of T4 – in 45 cases respectively. The stomach tumor in 37 (36.6%) cases was localized mainly in the antrum, 35 (34.6%) – in the body, 12 (11.9%) in the cardia and fundus, in 13 (12.9%) cases it had a total, in 4 (4.0%) - subtotal character. Ulcerating infiltrating forms (UIF) of GC was diagnosed in 71 cases, diffuse infiltrating forms (DIF) in 23 cases. All patients underwent preoperative X-ray, virtual gastroscopy techniques, multidetector computed tomography and transabdominal ultrasonography (USG). Results: The intestinal histological form of GC was detected in 7 cases – with USG in 6 cases. The UIF of GC with the help of USG was diagnosed in 69 (97,2%) cases, DIF – in 23 (100%) cases of T2-T4 stages. The results of USG and CT was coincided in all cases of T3 and in 92,7% of T4 stages of GC. Conclusions: The combined use of ultrasonography and gastroscopy will increase the detection of early intestinal type of GC. USG is the best, cheap, independent method for diagnosing a diffusely infiltrative form of GC, especially of the antrum. At stage T3, he is not inferior to CT in assessing the localization and prevalence of GC, and at stage T4, the difference between them is negligible.

1013 - Incidence, Survival, and Predictors of Lymph Node Metastasis in Early Stage Gastric Signet Ring Cell Carcinomas in the United States

1013 - Incidence, Survival, and Predictors of Lymph Node Metastasis in Early Stage Gastric Signet Ring Cell Carcinomas in the United States

PBX1 attributes as a determinant of connexin 32 downregulation in Helicobacter pylori-related gastric carcinogenesis.

AIMTo clarify the mechanisms of connexin 32 (Cx32) downregulation by potential transcriptional factors (TFs) in Helicobacter pylori (H. pylori)-associated gastric carcinogenesis.METHODSApproximately 25 specimens at each developmental stage of gastric carcinogenesis [non-atrophic gastritis, chronic atrophic gastritis, intestinal metaplasia, dysplasia and gastric carcinoma (GC)] with H. pylori infection [H. pylori (+)] and 25 normal gastric mucosa (NGM) without H. pylori infection [H. pylori (-)] were collected. After transcriptional factor array analysis, the Cx32 and PBX1 expression levels of H. pylori-infected tissues from the developmental stages of GC and NGM with no H. pylori infection were measured by real-time polymerase chain reaction (RT-PCR) and Western blot analysis. Regarding H. pylori-infected animal models, the Cx32 and PBX1 mRNA expression levels and correlation between the gastric mucosa from 10 Mongolian gerbils with long-term H. pylori colonization and 10 controls were analyzed. PBX1 and Cx32 mRNA and protein levels were further studied under the H. pylori-infected condition as well as PBX1 overexpression and knockdown conditions in vitro.RESULTSIncremental PBX1 was first detected by TF microarray in H. pylori-related gastric carcinogenesis. The identical trend of PBX1 and Cx32 expression was confirmed in the developmental stages of H. pylori-related clinical specimens. The negative correlation of PBX1 and Cx32 was confirmed in H. pylori-infected Mongolian gerbils. Furthermore, decreased PBX1 expression was detected in the normal gastric epithelial cell line GES-1 with H. pylori infection. Enforced overexpression or RNAi-mediated knockdown of PBX1 contributed to the diminished or restored Cx32 expression in GES-1 and the gastric carcinoma cell line BGC823, respectively. Finally, dual-luciferase reporter assay in HEK293T cells showed that Cx32 promoter activity decreased by 30% after PBX1 vector co-transfection, indicating PBX1 as a transcriptional downregulator of Cx32 by directly binding to its promoters.CONCLUSIONPBX1 is one of the determinants in the Cx32 promoter targeting site, preventing further damage of gap junction protein in H. pylori-associated gastric carcinogenesis.

Initial Experience with Endoscopic Ultrasound.

Since its introduction in early 1990s, endoscopic ultrasound (EUS) has become integral to the diagnosis and staging of various luminal, extraluminal gastrointestinal (GI) and certain non-GI lesions. There is no data on EUS experience in Bangladesh. The aim of this paper is to evaluate the initial recent experience and clinical impact of EUS. All EUS procedures data were recorded prospectively from July 2013 to December 2014. These included patients' demographics, referral details, provisional diagnosis, management plan before and after EUS & indications of procedures. EUS-FNA data recorded included details regarding site, number of passes and histological diagnosis. Two hundred & four EUS procedures were carried out over one and half years. Male female ratio was 1.4:1, mean age was 46.4 ± 20 years. Of these procedures 148 (72.5%) were referrals from physicians and 56 (27.5%) were from surgeons. Most common indications were pancreatobiliary pathologies, esophageal & gastric pathologies. Pancreatobiliary lesions (n = 165, 80.9%) included patients with (A) Benign pathologies: Microliths in Gall baldder (n = 6), Gall stones (n = 12), Biliary ascarrisis (n = 22), Choledocholithiasis (n = 42), Acute Pancreatitis (n = 9), Chronic Pancreatitis (n = 15), Pancreatic pseudocysts(n = 4) (B) Malignant Pathologies : GB Carcinoma (n = 4), Cholangiocarcinoma (n = 29), Ca- pancreas (n = 9), Periampullary carcinoma (n = 12). Esophageal lesion was 9.3% (n = 19) of total procedures. Forty seven percent (n = 9) of EUS procedures on esophagus were for staging of esophageal malignancy, 10. 5% (n = 2) for restaging or recurrence after chemoradiation and 21% (n = 4) for submucosal lesions. Fifteen EUS procedures were carried out for gastric lesions, seven were for staging of gastric carcinoma, four were for assessment of submucosal lesions (e.g. GIST, lipoma or external compression), 02 for assessment of polyps and two for gastric ulcers.In clinical impact & outcome study, changes in diagnosis, management, avoidance of investigations and usefulness of EUS were evaluated. Diagnosis was changed in 34.4% (64/186) & management was changed in 45%(92/204). Additional investigation was avoided in 57.8% (118/204). This is the first report of Bangladesh experience of EUS to date. EUS is safe, accurate, cost effective & very useful tool for diagnosis and management of G.I. disorders.

Presence of Barrettʼs Esophagus Is Associated with Earlier Stage Gastric Cancer

Introduction: Adenocarcinoma of the esophagus, gastroesophageal junction (GEJ) and gastric cardia is increasing in incidence in the United States (US) while non-GEJ/cardia gastric carcinoma (GC) appears to be decreasing. Barrett's esophagus (BE) is the precursor lesion for esophageal and GEJ adenocarcinoma, but its association with non-cardia GC, if any, has not been well-characterized. Methods: We performed a retrospective analysis of patients with histologically confirmed non-cardia GC who also had endoscopic data available from 2008-2016 at a single NYC academic center. Age at diagnosis, race/ethnicity, smoking and alcohol status, presence of histologically confirmed BE, GC stage, GC location, and Helicobacter pylori status were recorded. Statistical analysis was performed in STATA. Results: 108 patients [67.6% men/32.4% women] met inclusion criteria. Mean age at diagnosis of GC was 70.1+/-11.0 years. 8.3% (n=9/108) had concomitant BE confirmed on histopathology (6 men/3 women). Compared to the overall cohort, there was no difference in age at GC diagnosis (66.7 +/- 3.5 years), or in race/ethnicity among patients with BE. These patients had earlier stages of GC (77.8% (n=7/9) stage 0 or 1; 22.2% (n=2/9) missing; 0% stage >2) at presentation compared to those without BE (40.4% (n=40/99) stage 0 or I, 41.4% (n=40/99) stage >2, and 17.2% (n=17/99) missing), Fischer's exact test p=0.02. H. pylori was only present in 7.4% (n=8/108) of patients overall and was not significantly associated with the presence or absence of BE (p=0.59). 44.4% (n=4/9) patients with BE were current/former smokers, while 55.6% (n=5/9) reported current/former alcohol use (compared to 42.6% and 26.9%, respectively in the overall cohort). In these 9 patients with concomitant BE, 4 had GC located in the body/fundus (44.4%), 4 in the incisura (44.4%), and 1 in antrum (11.1%). No BE had concomitant dysplasia or adenocarcinoma. Conclusion: In this multi-racial/ethnic cohort with histopathologically confirmed non-GEJ, non-cardia GC, we found an association between the presence of BE and earlier stage (0 or 1) gastric cancer. Further investigation into these findings and confirmation in a larger cohort is needed.

Cyclin D1 and cyclin E2 are differentially expressed in gastric cancer

Cell cycle regulators cyclin D1 and cyclin E2 function in G1/S transition by activating downstream cyclin-dependent kinases. Deregulated expression of these cyclins has been reported in various cancers. However, little is known about their clinical significance in gastric carcinoma. We aimed to explore that whether there is differential expression of these cyclins in clinically distinct gastric cancer patients. In this study we recruited a total of 92 subjects including 20 controls and 72 cases of histopathologically proven gastric carcinoma. Expression profiling at transcript level was done by semiquantitative RT-PCR and of protein by immunohistochemistry. Receiver operator characteristics analysis was done for determining diagnostic utility of cyclin D1 and cyclin E2. We demonstrate that cyclins D1 and E2 are frequently overexpressed in early stages of gastric carcinoma. Interestingly, expression of cyclins D1 and E2 significantly correlates with different clinical parameters such as gender, histological type (intestinal and diffuse), tumor location (proximal, middle, and distal), tumor differentiation (differentiated and undifferentiated), tumor invasion (serosal, lymphatic, and venous) and tumor metastasis (lymph node, peritoneal, ascites, and liver). Cyclin D1 has significantly higher sensitivity and specificity as diagnostic biomarker than cyclin E2. Our results suggest that overexpression of cyclin D1 and cyclin E2 is an early event in gastric carcinogenesis. The differential expression of these cyclins may be useful as diagnostic biomarkers for early detection of gastric carcinoma.

Gastric Medullary Carcinoma: A Rare Case Report.

A case of 64-year-old female patient with early stage gastric medullary carcinoma has been presented, along with a review of the literature.

Prediction of T stage in gastric carcinoma by enhanced CT and oral contrast-enhanced ultrasonography.

BackgroundThe aim of this study is to explore the values of enhanced CT and oral contrast-enhanced ultrasonography on preoperative T stage in gastric carcinoma.MethodsForty patients with gastric carcinoma, including 27 males and 13 females, were confirmed by endoscopy, operation, and pathology. The median age of these patients was 49 years old (25 to 73 years). There were 19 cases of well-differentiated adenocarcinoma, 13 cases of poorly differentiated adenocarcinoma, 5 cases of signet ring cell carcinoma, and 4 cases of mucinous adenocarcinoma by pathology. All these patients were examined by both enhanced CT and ultrasound examination simultaneously 1 week before surgery. T staging in all these gastric carcinomas was carried out by enhanced CT or oral contrast-enhanced ultrasonography, respectively, or by both of them. The statistical difference between T stage by imaging and pathological T stage was analyzed.ResultsIn this study, there were 5 cases with T1 stage, 9 cases with T2 stage, 20 cases with T3 stage, and 6 cases with T4 stage by pathology; 5 cases with T1 stage, 7 cases with T2 stage, 22 cases with T3 stage, and 6 cases with T4 stage by enhanced CT imaging with an accuracy of 75.00%; 6 cases with T1 stage, 7 cases with T2 stage, 22 cases with T3 stage, and 5 cases with T4 stage by ultrasonography examination, with an accuracy of 77.50%; and 4 cases with T1 stage, 10 cases with T2 stage, 19 cases with T3 stage, and 7 cases with T4 stage by both enhanced CT imaging and ultrasonography examination, with an accuracy of 85.00%. The accuracy of T staging in gastric carcinoma by both enhanced CT and ultrasound was higher than that either by enhanced CT or by ultrasound, respectively (P < 0.05). The anastomosis degree of the gastric carcinoma between enhanced CT and ultrasonography was κ = 0.404.ConclusionsCombination diagnosis of enhanced CT and oral contrast-enhanced ultrasonography is helpful to improve the accuracy of T staging of gastric carcinoma before operations.

The utility of MRI for pre-operative T and N staging of gastric carcinoma: a systematic review and meta-analysis.

To perform a meta-analysis and literature review regarding the diagnostic accuracy of MRI for pre-operative tumour depth invasion (T) and regional lymph node invasion (N) staging of gastric carcinoma (GC). Articles were identified through systematic search of Medline, PubMed, Cochrane Library, Web of Science, Springerlink and several Chinese databases. The study quality was assessed by the quality assessment for studies of diagnostic accuracy. 2 reviewers independently extracted and assessed the data from 11 eligible studies. A meta-analysis was then carried out. Subgroup and sensitivity analyses were also performed. 11 studies (439 patients) were finally included in the current review. Among these studies, the significant evidence of heterogeneity was only discovered for specificity in T4 stage (I(2) = 59.8%). Pooled sensitivity and specificity of MRI to diagnose T stage tumour (T3-4 vs T1-2) were 0.93 [95% confidence interval (CI), 0.89-0.96] and 0.91 (95% CI, 0.87-0.95), respectively. Pooled estimates of sensitivity and specificity of MRI to diagnose N stage tumour (N0 vs N+) were 0.86 (95% CI, 0.80-0.92) and 0.67 (95% CI, 0.54-0.79), respectively. Subgroup analyses showed that diffusion-weighted imaging was more helpful for T staging. The present systematic review suggests that MRI has a good diagnostic accuracy for pre-operative T staging of GC and should be widely used in clinical work. However, the ability for N staging is relatively poor on MRI. In the pre-operative staging of GC, MRI was a useful tool and may enhance accuracy for the T staging of advanced GC.

High expression of astrocyte elevated gene-1 is associated with clinical staging, metastasis, and unfavorable prognosis in gastric carcinoma.

More and more evidence has demonstrated that astrocyte elevated gene-1 (AEG-1) is tightly associated with progression, metastasis, and unfavorable prognosis in many malignancies. However, the potential biological role of AEG-1 in gastric carcinoma (GC) has not been thoroughly delineated. In the current study, we found that AEG-1 mRNA and protein levels in GC tissues were significantly higher than those in normal gastric mucosa (P < 0.05). Simultaneously, statistical analysis displayed a significant correlation of high AEG-1 mRNA and protein expressions with differentiation status, TNM staging, invasive depth, and lymph node metastasis (P < 0.05). Most importantly, expressions of AEG-1 mRNA and protein in high clinical staging and metastatic GC tissues were dramatically higher than those in low clinical staging and non-metastatic GC tissues (P < 0.05). Stepwise investigation confirmed that the survival time of the patients with high AEG-1 level was shorter than those with low AEG-1 level or negative AEG-1 staining. Taken altogether, our data presented herein suggest that AEG-1 may be a novel predictor for metastasis and prognosis of the patients with GC.

Node-extranodal soft tissue stage based on extranodal metastasis is associated with poor prognosis of patients with gastric cancer

BackgroundThe purpose of this study was to evaluate the effect of Node-Extranodal soft tissue（pNE） stage based on Extranodal Metastasis (EM) on recurrence and survival in patients with gastric cancer (GC). Materials and methodsA total of 642 patients were divided into two groups according to statue of EM. Clinicopathologic features were compared among the two groups, the log-rank test was used to assess statistical differences between the groups. Independent prognostic factors were identified by the Cox proportional hazards regression model. According to the number of EMs, EM was incorporated into the pN stage of gastric carcinoma. The 5-y overall survival (OS) and disease free survival (DFS) rates were 48.1% and 17.4%, 44.5% and 14.3% between the two groups. Patients with EM had a deeper tumor invasion and more number of lymph node metastases. Peritoneal dissemination and distant metastasis were more frequent with EM. EM is an independent risk factor for distance recurrence (odds ratio = 1.605), and it is the highest risk factor for peritoneal recurrence (odds ratio = 2.448). Multivariate analysis showed that depth of tumor invasion (P = 0.025), lymph node metastasis (P <0.001), and EM (P = 0.006) were independent factors associated with OS. Furthermore, EM (P = 0.0039) was also an independent prognostic factor for DFS. The differences in prognostic prediction between the seventh edition of the pN classification and the pNE classification were directly compared. We found the pNE classification (hazard ratio = 1.730, P <0.001) was more appropriate for predicting the OS of GC patients after curative surgery, and the −2 loglikehood of the pNE staging (4533.991) is smaller than the value of pN. ConclusionsEM was closely associated with cancer aggressiveness and the presence of EM was a significant independent predictor of reduced DFS and OS in GC patients. EM is an independent risk factor for distance recurrence, especially for peritoneal recurrence, the selection of postoperative adjuvant therapy in systemic (intravenous or intra-arterial) and regional (intraperitoneal) based on EM may be a reasonable approach. The lymph node imaging techniques such as injecting nanocarbon during surgery should be applied. As an important prognostic factor, EM should be incorporated into N stage according to its number retrieved in postoperative samples.

Gastric Cancer: The Role of Diffusion Weighted Imaging in the Preoperative Staging

Purpose: Evaluate the role of diffusion-weighted-imaging (DWI) in the diagnosis and staging of gastric carcinoma. Materials and methods: A total of 31 patients with gastric adenocarcinoma, which underwent preoperative staging with 3Tesla Magnetic Resonance Imaging (MRI), were enrolled. Two radiologists evaluated the tumor staging in DWI. Results were compared to postsurgical pathologic findings. Results: The T factor accuracy of conventional MRI and DWI was 73% and 80% respectively; while the N staging accuracy of conventional MRI and DWI was 80% and 93%, respectively. Conclusion: DWI and apparent diffusion coefficient (ADC) values showed to be useful in preoperative staging of gastric cancer.

Chromosome 8q as the most frequent target for amplification in early gastric carcinoma.

Early gastric carcinoma (GC) is considered to be a curable cancer, as it progresses to the advanced stage following varying durations. Understanding the early stage of GC may provide an insight into its pathogenesis and contribute to reducing the mortality rate of this disease. To investigate the genomic aberrations associated with 22 cases of early GC, high-density microarray comparative genomic hybridization was performed in the present study. The most notable finding was copy number gains (log2 ratio >0.25) on the long arm of chromosome 8, which occurred in 77.3% (17/22) of GC cases, and the delineated minimal common region was 8q22.1-q24.3. More specifically, two amplified (log2 ratio >1) loci in the 8q22.1-q24.3 region were detected in 18.2% (4/22) of GC cases. The first loci covered a region of 102.4–107.9 kb, mapping on 8q22.3-q23.1, and comprised the transcription factor CP2-like 3 gene. The second loci, spanning 128.7–145.7 kb on 8q24.21-q24.3, comprised the representative oncogene of myelocytomatosis. Furthermore, the following possible target genes that were not previously considered to play a pathogenic role in GC were identified: Plasmacytoma variant translocation 1, cysteine/histidine rich 1, kinesin family member C2, forkhead box H1, protein phosphatase 1 regulatory subunit 16A, glutamic-pyruvate transaminase, LOC113655 and RecQ protein-like 4. In the present study, previous findings showing that 8q mutations accumulate early during the multistage pathogenesis of GC were confirmed and expanded upon. The confirmation of previously reported 8q gains and the identification of novel target genes at 8q22.1-q24.3 amplified chromosomal sites should aid in improving our understanding of the molecular mechanisms underlying the tumorigenesis of early GC.

Persistent Nausea and Vomiting in Pregnancy

Question: A 23-year-old pregnant woman at 27 weeks gestation presented with 10 weeks of persistent nausea, emesis, and a 20-pound weight loss. On examination, she appeared ill and had epigastric tenderness. Laboratory assessment was notable for anemia (hemoglobin level, 7 g/dL). Hyperemesis gravidarum was entertained, but upper endoscopy revealed circumferential, edematous narrowing of the gastric antrum with ulceration (Figure A, arrow). Gastric biopsies were obtained (Figure B). Computed tomography showed intrauterine pregnancy (Figure C, thin arrow) and a thickened gastric wall (Figure C, thick arrow). What is the diagnosis? Look on page 323 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Gastric biopsy (Figure B) demonstrates adenocarcinoma with signet ring cells (arrows). The thick arrow in Figure C shows circumferential gastric thickening consistent with linitis plastica. The patient subsequently acknowledged her father perished with gastric cancer at age 45 years. Hereditary diffuse gastric cancer (HDGC) was confirmed by CDH-1 gene mutation testing. Vaginal delivery was expedited and chemotherapy initiated. Unfortunately, the patient succumbed to metastatic disease. Gastric cancer during pregnancy is rare, but should be considered in women with hyperemesis late in pregnancy. HDGC is an autosomal-dominant, inherited gastric cancer syndrome characterized by germline mutation of CDH-1 gene, which encodes for the cell-to-cell adhesion protein E-cadherin. It is a relatively rare cancer syndrome but may account for approximately 1% of all cases of gastric carcinoma in populations with a low incidence of gastric cancer such as the United States, Canada, and the United Kingdom.1Blair V. Martin I. Shaw D. et al.Hereditary diffuse gastric cancer: diagnosis and management.Clin Gastroenterol Hepatol. 2006; 4: 262-275Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar Diffuse-type gastric adenocarcinoma with signet-ring cells is the most common cancer in carriers of germline CDH-1 mutations. Genetic testing for mutations in the CDH-1 gene is widely available. However, only 30%–50% of families meeting diagnostic criteria carry a predisposing CDH-1 mutation.1Blair V. Martin I. Shaw D. et al.Hereditary diffuse gastric cancer: diagnosis and management.Clin Gastroenterol Hepatol. 2006; 4: 262-275Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar The revised International Gastric Cancer Linkage Consortium diagnostic criteria for CDH-1 mutation testing in HDGC include (1) 2 gastric cancer cases in family, 1 confirmed diffuse gastric cancer under age 50, (2) 3 confirmed diffuse gastric cancer cases in first- or second-degree relatives independent of age, (3) diffuse gastric cancer in an individual under age of 40, and (4) personal or family history of diffuse gastric cancer and lobular breast cancer, 1 diagnosed under the age of 50.2Fitzgerald R.C. Hardwick R. Huntsman D. et al.Hereditary diffuse gastric cancer: updated consensus guidelines for clinical management and directions for future research.J Med Genet. 2010; 47: 436-444Crossref PubMed Scopus (412) Google Scholar The other malignancy that occurs at increased frequency in HDGC families is lobular breast carcinoma. It is unclear why germline CDH-1 mutation predisposes predominantly to gastric cancer. There is a high lifetime risk for advanced gastric cancer in HDGC of approximately 70% in men and 80% in women by 80 years of age.3Pharoah P. Guilford P. Caldas C. Consortium TIGCLIncidence of gastric cancer and breast cancer in CDH1 (E-cadherin) mutation carriers from hereditary diffuse gastric cancer families.Gastroenterology. 2001; 121: 1348-1353Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar The risk for advanced gastric cancer is age-related and estimated to be <1% at 20 years and increasing to 4% at 30 years.3Pharoah P. Guilford P. Caldas C. Consortium TIGCLIncidence of gastric cancer and breast cancer in CDH1 (E-cadherin) mutation carriers from hereditary diffuse gastric cancer families.Gastroenterology. 2001; 121: 1348-1353Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar Because most patients have advanced stage gastric carcinoma at diagnosis, prophylactic gastrectomy is recommended in asymptomatic CDH-1 mutation carriers over the age of 20 years to prevent the development of this lethal cancer. If prophylactic gastrectomy is declined, intensive gastroscopic surveillance should be performed with the patient informed of the limitations for endoscopic detection of early lesions in HDGC.