Synchronous Multiple Early Gastric Cancer Research Articles

Endoscopic features of synchronous multiple early gastric cancers: Findings from a nationwide cohort.

We investigated the factors associated with synchronous multiple early gastric cancers and determined their localization. We analyzed 8191 patients who underwent endoscopic submucosal dissection for early gastric cancers at 33 hospitals in Japan from November 2013 to October 2016. Background factors were compared between single-lesion (n=7221) and synchronous multi-lesion cases (n=970) using univariate and multivariate analyses. We extracted cases with two synchronous lesions (n=832) and evaluated their localization. Significant independent risk factors for synchronous multiple early gastric cancer were older age (≥75 years old) (OR=1.257), male sex (OR=1.385), severe mucosal atrophy (OR=1.400), tumor localization in the middle (OR=1.362) or lower region (OR=1.404), and submucosal invasion (OR=1.528 (SM1), 1.488 (SM2)). Depressed macroscopic type (OR=0.679) and pure undifferentiated histology OR=0.334) were more common in single early gastric cancers. When one lesion was in the upper region, the other was more frequently located in the lesser curvature of the middle region. When one lesion was in the middle region, the other was more frequently located in the middle region or the lesser curvature of the lower region. When one lesion was in the lower region, the other was more frequently located in the lesser curvature of the middle region or the lower region. Factors associated with synchronous multiple early gastric cancer included older age, male sex, severe mucosal atrophy, tumor localization in the middle or lower region, and tumor submucosal invasion. Our findings provide useful information regarding specific areas that should be examined carefully when one lesion is detected.

Endoscopic Screening for Missed Lesions of Synchronous Multiple Early Gastric Cancer during Endoscopic Submucosal Dissection.

To evaluate the value of endoscopic screening during endoscopic submucosal dissection (ESD) in the detection of synchronous multiple early gastric cancer (SMEGC) and the risk factors for missed diagnosis of SMEGC. We conducted gastric endoscopic screening during ESD operation in 271 patients with early gastric cancer (EGC) referred for ESD, and endoscopic follow-up within 1 year after the operation. The detection and characteristics of SMEGC were analyzed in three stages: before ESD, during ESD operation, and within 1 year after ESD. SMEGC was detected in 37 of 271 patients (13.6%). Among them, 21 patients with SMEGC (56.8%) were diagnosed before ESD, 9 (24.3%) were diagnosed with SMEGC by endoscopic screening during ESD operation, and 7 (18.9%) were found to have EGC lesions in the stomach during postoperative endoscopic follow-up within 1 year. The preoperative missed detection rate of SMEGC was 43.2%, and the rate of missed detection could be reduced by 24.3% (9/37) with endoscopic screening during ESD operation. Missed SMEGC lesions were more common in flat or depressed type and smaller in size than the lesions found before ESD. The presence of severe atrophic gastritis and age ≥60 years were significantly correlated with SMEGC (P < 0.05), while multivariate analysis showed that age ≥60 years was an independent risk factor (OR = 2.63, P < 0.05) for SMEGC. SMEGC lesions are apt to be missed endoscopically. Special attention should be paid to small, depressed, or flat lesions in detecting SMEGC, especially in elderly patients or (and) patients with severe atrophic gastritis. Endoscopic screening during ESD operation can effectively reduce the missed diagnosis rate of SMEGC.

Clinicopathological features, risk of lymph node metastasis and survival outcome of synchronous multiple early gastric cancer

To determine clinicopathological features, risk of lymph node metastasis (LNM) and survival outcome in synchronous multiple early gastric cancer (MEGC) patients. A total of 338solitary early gastric cancer (SEGC) and 26 MEGC patients who underwent surgical resection were retrospectively reviewed. The clinicopathological features and predictive factors for MEGC patients were evaluated. Also, we analyzed risk factors for LNM and compared survival difference between SEGC and MEGC patients. The frequency of multiple synchronous lesions was 7.1% in early gastric cancer (EGC) patients. The main and minor lesions were mostly confined to the same third of the stomach (84.6%, 22/26), and the most common location was the lower third of the stomach. With regard to the number of coexisting lesions, most of the patients had two lesions and more than three lesions were not common. Tumor size≤2cm (OR:2.684, 95%CI:1.131-6.368, P<0.05) and the presence of atrophic gastritis (OR:2.418, 95%CI:1.052-5.555, P<0.05) were independent risk factors for synchronous MEGC. There was no significant statistical difference between SEGC and MEGC for LNM (17.5% vs 23.1%, P=0.311). The number of coexisting lesions was not associated with the risk of LNM in EGC. In addition, the survival outcome of MEGC patients was similar to that of SEGC (5-year RFS rate, 96.0% vs 93.7%, P=0.329;5-year OS rate, 96.0% vs 88.3%, P=0.479). Meticulous endoscopic examination at the initial diagnosis of MEGC was very important, especially for those with precancerous lesions such as atrophic gastritis. In terms of treatment methods, endoscopic resection may be equally suitable for synchronous MEGC if the lesions fulfilled its indication criteria.

Tu1198 CLINICAL ANALYSIS OF ESD FOR THE SYNCHRONOUS MULTIPLE PRIMARY EARLY CANCERS IN ESOPHAGUS AND STOMACH

Objective: With the improvement of endoscopic diagnosis and treatment, the discovery rate of the synchronous multiple primary early cancers in esophagus and stomach is gradually increased, while the traditional surgery bringing serious damages. Endoscopic submucosa dissection (ESD) has become the first treatment option of early cancer or precancerous lesions in the digestive tract partly. This study intends to explore the feasibility, safety and effectiveness of ESD in the treatment of the synchronous multiple early gastric cancer or precancerous lesions in esophageal and stomach. From January 2008 to December 2016, data of 12 patients with early esophageal cancer and early gastric cancer treated by ESD in Endoscopy Center of Zhongshan Hospital, Fudan University were reviewed. We analyzed the patient's history, the size of esophageal and gastric lesions, pathological results, the results of complete or curative resection and so on. Among the 12 patients here described, all diagnosed with synchronous multiple primary early cancers in esophagus and stomach. There were 9 male cases. The mean age was (67 ± 10.6.) years. Mean size was (2.2 ± 1.1) cm in esophageal when 3 lesions located in the upper esophagus, 8 in the middle ， and 1 in the lower. The average size of gastric lesions was (2.1 ± 1.3) cm with 5 lesions in the antrum, 2 in the gastric angle and 5 in cardia. Lesions were removed by ESD in 10 cases at the same time and were removed by stage in 2 case. The complete resection rate was 100% (10/10). Postoperative pathological results showed that there were esophageal precancerous lesions with gastric precancerous lesions in 4 cases, esophageal precancerous lesions with early gastric cancer in 2 cases,early esophageal cancer with gastric precancerous lesions in 3 cases and early esophageal cancer with early gastric cancer in 3 case. 12 patients with 24 lesions were consistent with endoscopic indications, when curative resection rate was 100% (10/10). Postoperative esophageal stricture occurred in 2 cases, which were improved after dilation. Median follow-up time was 30 (8-115)months, when 9 patients survived and 3 patients died. However, the cause of death was not associated with treatment of this disease. Simultaneous endoscopic treatment for esophageal and gastric lesions is rarely reported. There are still many issues that need to be discussed, including whether lesions should be removed at the same time or by stage; which lesion should be removed first; if choosing removed by stage, how long the internal time should be and so on. Howere, ESD is a minimally invasive endoscopic surgery, which can be used as a method of treating synchronous multiple primary early cancers in esophagus and stomach.Tabled 1Clinical data of patients with synchronous multiple primary early cancers in esophagus and stomach treated with ESDNO.sexageesophagus locationsize(cm)pathologic diagnosisinvasionthe basal level and marginesophagus locationsize(cm)pathologic diagnosisinvasionthe basal level and marginpatient simultaneous resectionadditional treatmentcomplicationfollow time(m)prognosis1male65upper0.8low-grade intraepithelial neoplasiam1negativeantrum3high-grade intraepithelial neoplasiam1negativeyesnono84survival2male52middle2high-grade intraepithelial neoplasiam1negativeangle1.5high-grade intraepithelial neoplasiam1negativeyesnono115survival3male60middle1.5high-grade intraepithelial neoplasiam1negativeangle5high-grade intraepithelial neoplasiam1negativenonoesophageal stricture95survival4male84middle3early esophageal cancerm1negativecardia1.5early gastric cancerm2negativeyesnono39die5male78middle3high-grade intraepithelial neoplasiam1negativeantrum1.5high-grade intraepithelial neoplasiam1negativeyesnono27die6male68upper4high-grade intraepithelial neoplasiam1negativecardia1.5early gastric cancerm3negativenonoesophageal stricture30survival7female71upper1early esophageal cancersm1negativecardia1.5early gastric cancerm3negativeyesnono35survival8male84middle3high-grade intraepithelial neoplasiam1negativeantrum1early gastric cancerm3negativeyesnono30survival9female58middle1.4early esophageal cancerm3negativecardia1.5high-grade intraepithelial neoplasiam1negativeyesnono25survival10male59lower0.8early esophageal cancerm2negativeantrum0.6high-grade intraepithelial neoplasiam1negativeyesnono18survival11male57middle3early esophageal cancersm1negativecardia3high-grade intraepithelial neoplasiam1negativeyesnono10die12female68middle2.5early esophageal cancerm3negativeantrum4early gastric cancersm1negativeyesnono8survival Open table in a new tab

Clinical Analysis of Endoscopic Submucosal Dissection for the Synchronous Multiple Primary Early Cancers in Esophagus and Stomach: 12 Cases Report.

With the improvement of endoscopic diagnosis, the discovery rate of the synchronous multiple primary early cancers in esophagus and stomach is gradually increased, while the traditional surgery bringing serious damages. Endoscopic submucosal dissection (ESD) has become the first treatment option of early cancer in the digestive tract partly. This study intends to explore the feasibility, safety, and effectiveness of ESD in the treatment of the synchronous multiple early gastric cancer or precancerous lesions in the esophagus and stomach. From January 2008 to December 2016, data of 12 patients with early esophageal cancer and early gastric cancer treated by ESD in the Endoscopy Center of Zhongshan Hospital, Fudan University were reviewed. We analyzed the patient's history, the size of esophageal and gastric lesions, pathological results, the results of complete or curative resection, and so on. Among the 12 patients described in this study, all were diagnosed with synchronous multiple primary early cancers in the esophagus and stomach. Lesions were removed by ESD in 10 cases at the same time and were removed by stage in 2 cases. The complete resection rate was 100% (24/24), and the curative resection rate was 100% (24/24). Postoperative esophageal stricture occurred in 2 cases, which improved after dilation. Median follow-up time was 30 (8-115) months, when 9 patients survived and 3 patients died. However, the cause of death was not associated with treatment of this disease. ESD is a minimally invasive endoscopic surgery, which can be used as a method of treating synchronous multiple primary early cancers in the esophagus and stomach.

Clinicopathologic characteristics and relevance of main and minor lesions of synchronous multiple early gastric cancer and gastric high grade intraepithelial neoplasia

Objective To investigate the clinicopathologic characteristics and relevance of main and minor lesions of synchronous multiple early gastric cancers (SMEGC) and gastric high grade intraepithelial neoplasia (GHGIN). Methods Thirty-two patients with SMEGC or/and GHGIN who were diagnosed and treated with endoscopic submucosal dissection in Nanjing Drum Tower Hospital from July 2012 to September 2016 were enrolled in this study. Their clinicopathologic characteristics were summed up, and the correlation between main and minor lesions on the size, location, endoscopic classification, pathologic type, invasion depth and vascular invasion were analyzed. Results Among the 32 patients, with mean age of 66.19±7.46 years, 90.62%(29/32) were male, 17 cases (53.3%) had family history of gastric cancer, 25 (78.13%) had smoking history, and 22 (68.75%) were alcohol users. There were 30 cases (93.75%) and 31 cases (96.88%) with mucosal atrophy and intestinal metaplasia, respectively. The size of main and minor lesions showed a positive correlation (r=0.4167, P=0.018). The endoscopic classification of major and minor lesions had no statistical significant consistency (P=0.314), but the pathologic type and invasion depth between major and minor lesions demonstrated a moderate significant positive correlation (P<0.05). The comparison of location between the main and minor lesions did not show correlation. However, it showed a significant correlation between major lesion which on the upper 1/3 of stomach and minor lesion on the lower 1/3 of stomach (r=0.463, P=0.003). Further more, when the main lesion was at posterior gastric wall, the minor lesions on lesser curvature were increased, which showed a positive correlation(r=0.417, P=0.009). Conclusion Old-age male with long-term smoking and alcohol history whose lesions combined with surrounding mucosa merger atrophy and intestinal metaplasia are considered as a high risk group in patients with SMEGC or/and GHGIN. Therefore, clinicians must keep high vigilant and make carefully observations on this group of patients during endoscopic examination, and consider the correlation between main and minor lesions to avoid misdiagnosis. Key words: Stomach neoplasms, multiple, synchronization; Early diagnosis; High grade intraepithelial neoplasia; Clinicopathologic characteristics

Predictive risk factors associated with synchronous multiple early gastric cancer.

The aim of this study was to elucidate the predictive risk factors of synchronous multiple early gastric cancer regardless of the treatment modality.Patients who underwent early gastric cancer treatment between July 2005 and June 2015 were retrospectively reviewed. In total, 1529 patients who were treated for early gastric cancer were included. We analyzed the patient's data to find predictive factors of synchronous multiple early gastric cancer compared to solitary early gastric cancer. Further analysis was performed to verify the difference between endoscopic and surgical treatment groups.Among the 1529 patients, synchronous multiple early gastric cancer was diagnosed in 68 (4.4%) patients. Significant differences in sex (P = .004), gross appearance (P = .038), depth of invasion (P = .007), and lymphovascular invasion (P = .039) were found between patients with solitary early gastric cancer and synchronous multiple early gastric cancer by univariate analysis. In multivariate analysis, male sex (odds ratio, 2.475; P = .011) and submucosal invasion (odds ratio, 1.850; P = .033) were independent predictive risk factors of synchronous multiple early gastric cancer. In addition, in multivariate analysis, significant differences in age, tumor size, longitudinal location, depth of invasion, and histology were found between patients groups depending on the mode of treatment.Male sex and submucosal invasion were predictive risk factors of synchronous multiple early gastric cancer. Patients with these factors should undergo more meticulous endoscopic surveillance.

Clinicopathologic Similarities of the Main and Minor Lesions of Synchronous Multiple Early Gastric Cancer.

The detection rate of early gastric cancer (EGC) is increasing due to improvements in diagnostic methods, but synchronous multiple EGC (SMEGC) remains a major problem. Therefore, we investigated the characteristics of and the correlation between the main and minor lesions of SMEGC. We retrospectively reviewed the medical records of patients with EGC between April 2008 and May 2013. The main lesion was defined as the one with the greatest invasion depth. If lesions had the same invasion depth, the tumor diameter was used to define the main lesion. Of 963 patients who had treatment for EGC, 37 patients with SMEGC were analyzed. The main and minor lesions showed a significant positive correlation of size (r = 0.533, P = 0.001). The main and minor lesions of SMEGC showed the same vertical and horizontal locations at 70.3% and 64.9%, respectively (P = 0.002 and P = 0.002). Macroscopic types were identical in 67.6% (P < 0.001), and 32.4% had identical macroscopic type and location. The main and minor lesions had identical characteristics of invasion depth, presence of lymphovascular invasion (LVI), and differentiation in 78.4%, 83.8%, and 83.8%, respectively. Differentiation, LVI, and invasion depth (microscopic characteristics) were simultaneously the same in 62.2%. The location, macroscopic type, and 3 microscopic characteristics were matched in 27%. The main and minor lesions of SMEGC have similar clinicopathologic characteristics. Therefore, the possibility of SMEGC should not be neglected in cases of EGC, considering an understanding of the characteristics and association of lesions.

Synchronous multiple early gastric cancer diagnosed before treatment ; report of two cases

Recently, synchronous multiple early gastric cancers are being increasingly reported due to the aging of society and development of high-performance endoscopy techniques. We present two cases of synchronous multiple early gastric cancers in which the diagnosis was made before the treatment. In Case 1, three pedunculated lesions measuring approximately 10 mm in diameter and one depressed lesion measuring 20 mm in diameter were detected endoscopically in the gastric antrum, and examination of biopsy specimens revealed the diagnosis of cancer for all the lesions. Laparoscopic subtotal gastrectomy was performed, and histology of the resected tissue revealed intramucosal well-differentiated tubular adenocarcinoma in the three pedunculated lesions and intramucosal poorly differentiated adenocarcinoma in the depressed lesion. In Case 2, two depressed lesions measuring approximately 10 mm in diameter and one pedunculated lesion measuring 3 mm in diameter detected in the gastric body were treated by endoscopic submucosal resection. All the resected lesions were diagnosed histopathologically as intramucosal well-differentiated tubular adenocarcinomas. Histopathological examination revealed evidence of atrophic gastritis with intestinal metaplasia due to H. pylori infection in the background gastric mucosa in both the cases, and the mucin expression phenotype of the gastric cancer was the gastric phenotype in the three pedunculated lesions of Case 1 and the intestinal phenotype in all the three lesions in Case 2. We suggest that the possible presence of synchronous multiple cancerous lesions, e.g., well-differentiated adenocarcinoma located in the atropic gastric mucosa, should be investigated endoscopically in patients diagnosed as having early gastric cancer.

Characteristics and prognosis of synchronous multiple early gastric cancer

To assess the clinicopathologic characteristics, risk factors, and prognosis for synchronous multiple early gastric cancer (SMGC). A total of 146 patients with SMGC and 1194 patients with single gastric cancer who had undergone gastrectomy between 1989 and 2008 were retrospectively analyzed to determine their clinicopathologic characteristics and postoperative survival. Tumors were classified into groups on the basis of location and histology. Smoking habits were evaluated using the Brinkman index. Clinical and pathological factors were compared using either Fisher's exact test or Pearson's χ(2) test. Logistic regression analysis was performed to identify independent risk factors. Survival rate was calculated using the Kaplan-Meier method. SMGCs accounted for 10.9% of gastric cancer cases and occurred predominantly in elderly male patients with a family history of gastric cancer who were both smokers and drinkers. These tumors were typically macroscopically elevated and histologically differentiated. There were no significant differences between SMGC and single gastric cancer patients with respect to tumor location, tumor size, lymph node metastasis, the number of metastatic lymph nodes, venous invasion, or tumor stage (P = 0.052, P = 0.347, P = 0.595, P = 0.805, P = 0.559, and P = 0.408, respectively). Further, there was no significant difference in postoperative survival between the patient groups (P = 0.200). Of the 146 SMGC patients, a single patient had remnant cancer. A careful preoperative endoscopy is necessary for patients who are at high risk of SMGC, and minimally invasive treatment may be indicated in some cases.

The Clinicopathologic Features and Prognosis of Multiple Early Gastric Cancer

Purpose: Multiple early gastric cancer (MEGC) accounts for between 4.5% and 11.7% of all early gastric cancers (EGC). We investigated the treatment of MEGC from the viewpoint of the clinicopathologic features of the disease. Materials and Methods: 2,281 patients with EGC underwent gastric resection at the Department of Surgery, Severance Hospital during the 11 years between January 1994 and December 2004 and we carried out a retrospective analysis of these patients. Results: There were 91 cases of synchronous MEGC (4.0%) according to the diagnostic criteria of Moertel: there were 81 double, 9 triple and 1 quadruple lesions. Of the 102 accessory lesions, 64 (62.7%) were less than 10 mm in diameter and 83 (81.4%) were located in the same region as the main lesion. The most frequent histologic type of main lesion was a well differentiated adenocarcinoma, which was found in 52 cases (57.1%). There were 49 mucosal main lesions and 42 submucosal main lesions. Lymph node metastasis was detected in 6 cases (6.6%): 1 in mucosal lesions and 5 in submucosal main lesions Conclusion: Solitary EGC and MEGC had very similar clinopathological features and a similar prognosis. Therefore, we believe that the general EGC treatment guidelines can be applied for multiple EGC. It is important to evaluate the whole stomach before and during the operation and then after examining the resected specimen.

Characteristics of Metachronous Multiple Early Gastric Cancers after Endoscopic Mucosal Resection

Endoscopic mucosal resection (EMR) of early gastric cancer is a minimally invasive procedure. The incidence and characteristics of metachronous multiple gastric cancers were investigated in a retrospective study in patients with early gastric cancer after EMR treatment. A total of 143 patients with early gastric cancer who had undergone EMR treatment were periodically followed up with endoscopic examinations for 24 months or longer. The median period of endoscopic follow-up was 57 months (range 24 - 157 months). None of the patients died of gastric cancer, and there were no treatment-related deaths. Five patients died of other diseases. Of 20 patients (14 %) with metachronous multiple gastric cancers, 15 were treated by EMR. One patient with differentiated submucosal cancer and four with undifferentiated cancers underwent surgery. Sixteen patients (11 %) had synchronous multiple early gastric cancer lesions within 1 year of the initial EMR. About half of the multiple lesions were located in the same third of the stomach as the primary lesion, and most lesions were similar in macroscopic type to the primary lesions. Most multiple lesions were of the differentiated type. Annual endoscopic examinations can preserve the whole stomach in most patients with early gastric cancer after successful EMR.

SELECTION OF TREATMENT FOR MULTIPLE EARLY GASTRIC CANCER FROM THE CLINICOPATHOLOGICAL POINTS OF VIEW

In order to select treatment for synchronous multiple early gastric cancer, a clinicopathological study was conducted in 143 lesions of 61 patients with synchronous multiple early gastric cancer resected surgically at our department. Results were as follows: 1) The incidence of synchronous multiple early gastric cancer was 11.7% of all early gastric cancers, and many of the patients were elderly male. 2) Forty-one (50%) of 82 accessory lesions were located at the same segment. Most of the main and accessory lesions were same macroscopic type. 4) On 61 multiple cases, 39 main lesions were well differentiated type, of which 37 accessory lesions were the same. 5) Twenty-eight (34%) of 82 accessory lesions were preoperatively missed lesions including 16 lesions of type 0IIc and 10 lesions of type 0IIb most of which were ≤1.0cm in size and located at the middle part of the stomach. 6) The incidence of lymph node metastasis or vessel invasion of synchronous multiple early gastric cancer were both lower than those of solitary early gastric cancer. We conclude that endoscopic mucosal resection or modified operation can be selected for synchronous multiple early gastric cancer using each selection criteria for treatment for solitary early gastric cancer on condition that postoperative intensive examination of remnant stomach should be performed.

PREFERRED THERAPEUTIC CHOICE FOR SYNCHRONOUS MULTIPLE EARLY GASTRIC CANCER

This study was conducted to examine therapies for synchronous multiple early gastric cancer in terms of clinicopathological characteristics. Subjects were 184 patients with 232 lesions who underwent partial gastrectomy or total gastrectomy for early gastric cancer in a period from 1986 to 1993. Of these 184 patients, 37 patients (20.1%) had synchronous multiple early gastric cancer. Aged patients whose main lesion was differentiated and elevated lesion locating in the area C or A tended to have accessory lesions. Histologically, 89.2% of the acessory lesions had the same type as the main lesions had and in many cases, macroscopically, accessory lesion were much the same as the main lesions. Depressed and flat accessory lesions, measuring 5 mm or less, were prone to be overlooked on preoperative examination. It is inferred that multiple lesions might develop from the same background mucosa. We have to decide resection areas in surgery by considering the background mucosae not to pass over the accessory lesions. For the patients with high surgical risk, endoscopic mucosal resection (EMR) becomes a more curative therapy if we consider the chlinicopathological characteristics of multiple early gastric cancer on preoperative examination and strictly follow up after the operation.