Br. J. Surg. 1992, Vol. 79, June, 539-542
D. R. Farley, J. H. Donohue, D. M. Nagorney, H. A. Carpenter*, J. A. Katzmannt and D. M. IlstrupJ Department of Surgery and Sections of *Medical Pathology, tlmmunopathology and SBiostatistics, M a yo Clinic and M a yo Foundation, Rochester, Minnesota, USA Correspondence to .I Dr J. H. Donohue, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
Early gastric cancer Early gastric cancer comprises more than 30 per cent of gastric carcinomas treated in Japan but remains an uncommon entity in the western hemisphere. A retrospective review of 48 patients with early gastric cancer undergoing operative treatment between 1965 and 1984 was carried out. The mean patient age was 70 years, in 31 men and I 7 women. Preoperative diagnosis was made in 88 per cent of patients undergoing oesophagogastroduodenoscopy with biopsy but upper gastrointestinal radiography was diagnostic in only 20per cent. Surgical management consisted of subtotal gastrectomy (86 per cent), total gastrectomy (10 per cent) and wide local excision ( 4 per cent). The operative mortality and morbidity rates were 0 and 38 per cent, respectively. Mean follow-up was 7.7 years, with 44 per cent of patients still alive. Multivariate analysis disclosed only a healthy. Eastern Cooperative Oncology Group score ( P = 0.002) and a diploid DNA tumour pattern ( P = 0.05) as signijicant prognostic variables of survival. The overall survival rate ofpatients with early gastric cancer (70per cent at 5 years) was equivalent to that of an age- and sex-matched control population.
Over the past five decades the incidence of gastric cancer in the USA has declined steadily to approximately 24 000 new cases per year’. Despite advances in diagnosis and therapeutic treatment, the overall 5-year survival rate of 15 per cent has remained constant. In those with gastric cancer, there is a subset of patients with early gastric cancer who have an excellent prognosis (nearly 100 per cent 5-year survival). Early gastric cancer, as defined in 1962 by the Japanese Society of Gastroenterological Endoscopy, is a gastric adenocarcinoma confined to the mucosa or submucosa irrespective of lymph node involvement. Although common in Japan and the focus of intense study, early gastric cancer remains a rare entity in the USA. Few reports from the western hemisphere have appeared since the earliest clinical review of superficial spreading gastric cancer (pathologically the same entity as early gastric cancer) published in 1962‘. The present study determined the incidence, clinical presentation, treatment and outcome of patients with early gastric cancer and compared findings with those of other published reports.
Patients and methods From 1965 to 1984 the Mayo Clinic tumour registry recorded 2397 operative resections for gastric cancer. Review of all pathological reports identified 71 patients with the diagnosis of early gastric cancer. All available specimens (64) were re-examined by the study pathologist (H.A.C.) and 48 patients were confirmed to have gastric adenocarcinoma confined to the mucosa or submucosa. Sixteen patients were excluded after review because of the absence of carcinoma in 14 instances (benign mucosal biopsy, four; dysplasia, four; benign adenoma, three; benign gastric ulcer, two; Barrett’s oesophagus, one), one advanced gastric carcinoma, and one gastric lymphoma. Specimens were evaluated for histological grade (Broders’) and Lauren classification4. The DNA content of paraffin-embedded tissue was measured by flow cytometry using the method of Gonchoroff et ~ 1 . ~ . Performance status was estimated by the criteria of the Eastern Cooperative Oncology Group (ECOG)h: 0 is asymptomatic; 1 is symptomatic, fully ambulatory; 2 is symptomatic, in bed for less than half of the day; 3 is symptomatic, in bed for more than half of the day but not bedridden; and 4 is bedridden. Patient histories were reviewed to document the clinical presentation, diagnostic evaluation, operative therapy and postoperative course. Patient status was determined by follow-up examination or telephone contact. Analysis of discrete and continuous variables was performed using the log rank test’ and Cox’s proportional
W7-1323/92/060539-04 8 1992 Butterworth-Heinemann Ltd
hazards model’. Estimates of survival for the study group and an age- and sex-matched control population (1970 North Central USA) were compared using the method of Kaplan and Meier9. Multivariate associations of survival were investigated using the model of Cox’.
Results Presentation There were 31 men and 17 women in the study population with a mean age of 70 (range 47-84) years. All patients were symptomatic on presentation. The physical signs and symptoms included epigastric pain (30 patients), anorexia and weight loss (19), nausea (19), melaena (12), vomiting (eight), fatigue (eight), dysphagia (four) and fever (two). Diagnostic evaluation A variety of diagnostic procedures was used over the study period. Forty patients underwent contrast examinations (barium upper gastrointestinal radiography) or oesophagogastroduodenoscopy with biopsy (Table 2 ). Eight patients with persistent symptoms of dyspepsia, despite medical therapy, underwent laparotomy without either evaluation. Of 22 patients undergoing both procedures, endoscopy with biopsy was diagnostic in 19 while only six barium studies were diagnostic ( P < 0.01) (Table 1 ). Operative treatment Operative management varied from wide local excision in two elderly women to total gastrectomy in five patients with proximally located neoplasms. The types of gastric resection and anastomotic reconstruction are summarized in Table 2. The Table 1 Preoperarive evaluation of 48patients with early gastric cancer
Interpretation
Upper, gastrointestinal radiography
Oesophagogastroduodenoscopy and biopsy
Diagnostic Suspicious Benign Negative Total
6 10 12 2 30
28 4 0 0 32
539
Early gastric cancer: D. R. Farley e t al.
Table 2 Operative managemenr of 48patients with early gastric cancer No. of
Gastric resection Wide local excision Subtotal gastrectomy Radical subtotal gastrectomy Total gastrectomy Reconstruction Gastrotomy Billroth I Billroth I1 Oesophagojejunostomy Other
n
5-year survivors
2 30 11
1 21 7
5
4
2
I
17 18
10
5
15 4
6
3
carcinoma. Three patients have died from metastatic tumour progression. The remaining 24 patients died from causes unrelated to their gastric cancer. Tumour recurrence occurred in four women with pathologically diverse carcinomas (Table 4 ) . Biopsy-proven pulmonary metastases were documented in two patients 5 years after resection. The remaining two women died 4 years after resection from biopsy-proven intra-abdominal carcinomatosis. Patient survival at 5 and 10 years was equivalent to that of an age- and sex-matched population (Figure 2). The disease-specific survival rate was 92 per cent at both 5 and 10
Table 3 Univariate analysis
of clinical and pa~hological factors correlating with survival in 48 patients with early gastric cancer
5-year survival rate (YO) P t
n
Clinical factors Age (years) > 68
23
25 31:17
5 lb (2.3 kg)) Yes 29
;75; 0
i
0.62
No Abdominal pain before operation Yes
66 74
i
0.17
21 18
19 30
18 70 66 Gastrointestinal haemorrhage before operation Yes 14 No 34 71 67 No
Pathological factors Tumour location Antrum Body Cardia Gastro-oesophagealjunction Pylorus Histological grade 1/11 III/IV Depth of invasion Mucosa Submucosa Lauren classification Diffuse Intestinal Mixed Nodal involvement Yes
No DNA ploidy status Diploid Tetraploid Aneuploid Indeterminate
21
76
21
2 3
5; 50 100
16 32
56 75
21 27
67 71
1
19
27 2
7 41
1 1
1 i i
:; 50
1
71 68
i
0.52 0.47
0.16
0.18
0.24
0.47
0.77
23
6 54 50
13
6 ~
Patient outcome The mean follow-up of all patients was 7.7 (range 4-24) years. Twenty-one patients remain alive, one with recurrent
0.25
loo
20
A 0 AB B
mean(s.d.) proximal margin of resection was 53(3.2) cm, and that of the distal margin 5.1(3.l)cm. No synchronous nongastric neoplasms were discovered at the time of abdominal exploration.
0~0002
71:65
Blood group
Figure 1 Location of early gastric cancer in 48 patients. The majority of tumours were located in the gastric antrum and body
i
0.05
~~~
ECOG, Eastern Cooperative Oncology Group. *Expected 5-year survival rate for healthy age- and sex-matchedcontrols: age > 68 years, 64 per cent; age 3 N ) fared poorly (5-year survival rate 36.3 per cent). This survival advantage may relate to nearly all mucosal early gastric cancers being diploid, a finding described by other^'^,^^. Improved survival occurs in patients with diploid tumours, but it is unclear whether this advantage is the result of other concurrent factors or independent of other variables. A greater incidence of synchronous and metachronous nongastric malignancies has been reported for patients with early gastric cancer. Green et al.I4 found that nearly one-third of patients subsequently developed cancers at other sites. Eight of 109 patients of Itoh et al. died from a non-gastric malignancy". In this study, cardiovascular disease was the most common cause of death and second primary tumours were not noted. Four patients developed recurrence of gastric cancer and three died from metastatic disease. Early gastric cancer was found in only 2 per cent of 2397 patients undergoing gastric resection for cancer during a 20-year period. The reasons for this are the stringent histological criteria for early gastric cancer, the nature of surgical practice in the USA and the common failure to diagnose gastric cancer at an early stage. Bringaze et al.", Oleagoitia et al." and Ohta et aL3 have documented higher prevalences of early gastric cancer among patients with gastric carcinoma, ranging from 5 to 33 per cent. The aggressive screening measures adopted in Japan have resulted in a marked increase in the prevalence of early gastric cancer. Some Japanese institutions have reported greater than 50 per cent of all gastric cancers as early3'. Although
541
Early gastric cancer: D. R . Farley et al.
earlier evaluation of dyspeptic patients might increase the detection of early gastric carcinoma, the low incidence of this cancer in western countries makes mass screening economically
’.
The crude 5- and 10-year survival rates of 70 and 58 per cent were substantially lower than the 90-95 per cent survival rates reported for Japanese patient^"*^^^^^^^^. This may be a factor of patient age, since the survival in patients with early gastric cancer was equivalent to an age- and sex-matched control population. Green et a / . have shown that the survival rate of patients with early gastric cancer is equivalent to that in age-matched control^'^. The finding of an improved survival rate for patients with good performance status has not previously been reported.
experience in a United States Medical Center. Am J Med 1988; 85: 658-61.
14. 15. 16. 17. 18.
19. 20.
References 1. 2. 3. 4.
5.
6.
7. 8. 9. 10. 11.
12. 13.
542
Boring C C , Squires TS, Tong T. Cancer statistics, 1991. C A 1991; 41: 19-36. Friesen G, Dockerty MB, ReMine WH. Superficial carcinoma of the stomach. Surgery 1962; 51: 300-12. Broders AC. Carcinoma in situ contrasted with benign penetrating epithelium. J Am Med Assoc 1932: 99: 1670-3. Lauren P. The two histological main types of gastric carcinoma: diffuse and so-called intestinal-type carcinomas. An attempt at histo-clinical classification. Acta Pathol Microbiol Scand 1965; 64: 31-49. Gonchoroff NJ, Ryan JJ, Kimlinger T K et a / . Effect of sonication on paraffin-embedded tissue preparation for DNA flow cytometry. Cytometry 1990; 11: 642-6. Minna JD, Pass H, Glatstein E, Ihde DC. Cancer of the lung. In: Vincent T, DeVita JR, Hellman S, Rosenberg SA, eds. Cancer Principles and Practice of Oncology. Philadelphia: JB Lippincott, 1989: 591-705. Peto R, Peto J. Asymptomatically efficient rank variant procedures (with discussion). J R Statist Soc [Ser A ] 1972; 135: 185-207. Cox DR. Regression models and life tables (with discussion). J R Statbt Soc [Ser B ] 1972; 34: 187-220. Kaplan EL, Meier P. Non-parametric estimation from incomplete observations. J Am Stat Assoc 1958; 53: 457-81. Bringaze WL 111, Chappius CW, Cohn I et a / . Early gastric cancer: a 21-year experience. Ann Surg 1986; 204: 103-7. Carter KJ, Schaffer HA, Ritchie WP. Early gastric cancer. Ann Surg 1964; 199: 604-9. Goldstein F , Kline TS, Kline IK et al. Early gastric cancer in a United States hospital. Am J Gastroenterol 1983; 78: 715-19. Green PHR, O’Toole K M , Slonim D et a / . Increasing incidence and excellent survival of patients with early gastric cancer:
21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32.
Green PHR, O’Toole K M , Weinberg LM et al. Early gastric cancer. Gastroenterology 1981; 81: 247-56. Fielding JWL, Ellis DJ, Jones BG et a / . Natural history of ‘early’ gastric cancer: results of a 10-year regional survey. Br Med J 1980; 281: 965-7. Paulino F , Roselli A. Early gastric cancer: report of twenty-five cases. Surgery 1979; 85: 171-6. Itoh H , Oohata Y, Nakamura K et a/.Complete ten-year postgastrectomy follow-up of early gastric cancer. Am J Surg 1989; 158: 14-16. Oleagoitia J M , Echevarria A, Santidrian JI et al. Early gastric cancer. Br J Surg 1986; 73: 804-6. Thompson G, Somers S, Stevenson G W . Benign gastric ulcer: a reliable radiologicdiagnosis? A m JRoentgenoll983; 141: 331-3. Sano T, Okuyama Y, Kobori 0 et al. Early gastric cancer. Endoscopic diagnosis of depth of invasion. Dig Dis Sci 1990; 35: 1340-4. Kodama Y, Sugimachi K , Soejimz K et a / . Evaluation of extensive lymph node dissection for carcinoma of the stomach. WorldJSurg 1981; 5: 241-8. Sowa M , Kato Y, Nishimura M et al. Surgical approach to early gastric cancer with lymph node metastasis. World J Surg 1989; 13: 630-6. Mori M , Kitigawa S, Iida M et al. Early carcinoma of the gastric cardia. Cancer 1987; 59: 1758-66. Lawrence M, Shiu MH. Early gastric cancer. Twenty-eight year experience. Ann Surg 1991; 213: 327-34. Carmalt HL, Gillett DJ, Lin BPB. Early gastric cancer. Aust N Z J Surg 1990; 60: 865-9. Endo M, Habu H. Clinical studies of early gastric cancer. Hepatogastroenterology 1990; 37: 408- 10. Ichiyoshi Y, Toda T, Minamisouo Y et al. Recurrence in early gastric cancer. Surgery 1990; 107: 489-95. de Aretxabala X, Yonemura Y, Sugiyama K et a / . DNA ploidy in early gastric cancer and its relationship to prognosis. Br J Cancer 1988; 58: 81-4. Inokuchi K , Kodama Y, Sasaki 0 et al. Differentiation of growth patterns of early gastric carcinoma determined by cytophotometric DNA analysis. Cancer 1983; 51: 1138-41. Nanus DM, Kelsen D P , Niedzwiecki D et al. Flow cytometry as a predictive indicator in patients with operable gastric cancer. J Clin Oncol 1989; 7: 1105-12. Ohta H, Noguchi Y , Takagi K er al. Early gastric carcinoma with special reference to macroscopic classification. Cancer 1987; 60: 1099-106. Evans D M D , Craven JL, Murphy F et al. Comparison of ‘early gastric cancer’ in Britain and Japan. Gut 1978; 19: 1-9.
Paper accepted 5 January 1992
Br. J. Surg., Vol. 79, No. 6, June 1992
D. R. Farley, J. H. Donohue, D. M. Nagorney, H. A. Carpenter*, J. A. Katzmannt and D. M. IlstrupJ Department of Surgery and Sections of *Medical Pathology, tlmmunopathology and SBiostatistics, M a yo Clinic and M a yo Foundation, Rochester, Minnesota, USA Correspondence to .I Dr J. H. Donohue, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
Early gastric cancer Early gastric cancer comprises more than 30 per cent of gastric carcinomas treated in Japan but remains an uncommon entity in the western hemisphere. A retrospective review of 48 patients with early gastric cancer undergoing operative treatment between 1965 and 1984 was carried out. The mean patient age was 70 years, in 31 men and I 7 women. Preoperative diagnosis was made in 88 per cent of patients undergoing oesophagogastroduodenoscopy with biopsy but upper gastrointestinal radiography was diagnostic in only 20per cent. Surgical management consisted of subtotal gastrectomy (86 per cent), total gastrectomy (10 per cent) and wide local excision ( 4 per cent). The operative mortality and morbidity rates were 0 and 38 per cent, respectively. Mean follow-up was 7.7 years, with 44 per cent of patients still alive. Multivariate analysis disclosed only a healthy. Eastern Cooperative Oncology Group score ( P = 0.002) and a diploid DNA tumour pattern ( P = 0.05) as signijicant prognostic variables of survival. The overall survival rate ofpatients with early gastric cancer (70per cent at 5 years) was equivalent to that of an age- and sex-matched control population.
Over the past five decades the incidence of gastric cancer in the USA has declined steadily to approximately 24 000 new cases per year’. Despite advances in diagnosis and therapeutic treatment, the overall 5-year survival rate of 15 per cent has remained constant. In those with gastric cancer, there is a subset of patients with early gastric cancer who have an excellent prognosis (nearly 100 per cent 5-year survival). Early gastric cancer, as defined in 1962 by the Japanese Society of Gastroenterological Endoscopy, is a gastric adenocarcinoma confined to the mucosa or submucosa irrespective of lymph node involvement. Although common in Japan and the focus of intense study, early gastric cancer remains a rare entity in the USA. Few reports from the western hemisphere have appeared since the earliest clinical review of superficial spreading gastric cancer (pathologically the same entity as early gastric cancer) published in 1962‘. The present study determined the incidence, clinical presentation, treatment and outcome of patients with early gastric cancer and compared findings with those of other published reports.
Patients and methods From 1965 to 1984 the Mayo Clinic tumour registry recorded 2397 operative resections for gastric cancer. Review of all pathological reports identified 71 patients with the diagnosis of early gastric cancer. All available specimens (64) were re-examined by the study pathologist (H.A.C.) and 48 patients were confirmed to have gastric adenocarcinoma confined to the mucosa or submucosa. Sixteen patients were excluded after review because of the absence of carcinoma in 14 instances (benign mucosal biopsy, four; dysplasia, four; benign adenoma, three; benign gastric ulcer, two; Barrett’s oesophagus, one), one advanced gastric carcinoma, and one gastric lymphoma. Specimens were evaluated for histological grade (Broders’) and Lauren classification4. The DNA content of paraffin-embedded tissue was measured by flow cytometry using the method of Gonchoroff et ~ 1 . ~ . Performance status was estimated by the criteria of the Eastern Cooperative Oncology Group (ECOG)h: 0 is asymptomatic; 1 is symptomatic, fully ambulatory; 2 is symptomatic, in bed for less than half of the day; 3 is symptomatic, in bed for more than half of the day but not bedridden; and 4 is bedridden. Patient histories were reviewed to document the clinical presentation, diagnostic evaluation, operative therapy and postoperative course. Patient status was determined by follow-up examination or telephone contact. Analysis of discrete and continuous variables was performed using the log rank test’ and Cox’s proportional
W7-1323/92/060539-04 8 1992 Butterworth-Heinemann Ltd
hazards model’. Estimates of survival for the study group and an age- and sex-matched control population (1970 North Central USA) were compared using the method of Kaplan and Meier9. Multivariate associations of survival were investigated using the model of Cox’.
Results Presentation There were 31 men and 17 women in the study population with a mean age of 70 (range 47-84) years. All patients were symptomatic on presentation. The physical signs and symptoms included epigastric pain (30 patients), anorexia and weight loss (19), nausea (19), melaena (12), vomiting (eight), fatigue (eight), dysphagia (four) and fever (two). Diagnostic evaluation A variety of diagnostic procedures was used over the study period. Forty patients underwent contrast examinations (barium upper gastrointestinal radiography) or oesophagogastroduodenoscopy with biopsy (Table 2 ). Eight patients with persistent symptoms of dyspepsia, despite medical therapy, underwent laparotomy without either evaluation. Of 22 patients undergoing both procedures, endoscopy with biopsy was diagnostic in 19 while only six barium studies were diagnostic ( P < 0.01) (Table 1 ). Operative treatment Operative management varied from wide local excision in two elderly women to total gastrectomy in five patients with proximally located neoplasms. The types of gastric resection and anastomotic reconstruction are summarized in Table 2. The Table 1 Preoperarive evaluation of 48patients with early gastric cancer
Interpretation
Upper, gastrointestinal radiography
Oesophagogastroduodenoscopy and biopsy
Diagnostic Suspicious Benign Negative Total
6 10 12 2 30
28 4 0 0 32
539
Early gastric cancer: D. R. Farley e t al.
Table 2 Operative managemenr of 48patients with early gastric cancer No. of
Gastric resection Wide local excision Subtotal gastrectomy Radical subtotal gastrectomy Total gastrectomy Reconstruction Gastrotomy Billroth I Billroth I1 Oesophagojejunostomy Other
n
5-year survivors
2 30 11
1 21 7
5
4
2
I
17 18
10
5
15 4
6
3
carcinoma. Three patients have died from metastatic tumour progression. The remaining 24 patients died from causes unrelated to their gastric cancer. Tumour recurrence occurred in four women with pathologically diverse carcinomas (Table 4 ) . Biopsy-proven pulmonary metastases were documented in two patients 5 years after resection. The remaining two women died 4 years after resection from biopsy-proven intra-abdominal carcinomatosis. Patient survival at 5 and 10 years was equivalent to that of an age- and sex-matched population (Figure 2). The disease-specific survival rate was 92 per cent at both 5 and 10
Table 3 Univariate analysis
of clinical and pa~hological factors correlating with survival in 48 patients with early gastric cancer
5-year survival rate (YO) P t
n
Clinical factors Age (years) > 68
23
25 31:17
5 lb (2.3 kg)) Yes 29
;75; 0
i
0.62
No Abdominal pain before operation Yes
66 74
i
0.17
21 18
19 30
18 70 66 Gastrointestinal haemorrhage before operation Yes 14 No 34 71 67 No
Pathological factors Tumour location Antrum Body Cardia Gastro-oesophagealjunction Pylorus Histological grade 1/11 III/IV Depth of invasion Mucosa Submucosa Lauren classification Diffuse Intestinal Mixed Nodal involvement Yes
No DNA ploidy status Diploid Tetraploid Aneuploid Indeterminate
21
76
21
2 3
5; 50 100
16 32
56 75
21 27
67 71
1
19
27 2
7 41
1 1
1 i i
:; 50
1
71 68
i
0.52 0.47
0.16
0.18
0.24
0.47
0.77
23
6 54 50
13
6 ~
Patient outcome The mean follow-up of all patients was 7.7 (range 4-24) years. Twenty-one patients remain alive, one with recurrent
0.25
loo
20
A 0 AB B
mean(s.d.) proximal margin of resection was 53(3.2) cm, and that of the distal margin 5.1(3.l)cm. No synchronous nongastric neoplasms were discovered at the time of abdominal exploration.
0~0002
71:65
Blood group
Figure 1 Location of early gastric cancer in 48 patients. The majority of tumours were located in the gastric antrum and body
i
0.05
~~~
ECOG, Eastern Cooperative Oncology Group. *Expected 5-year survival rate for healthy age- and sex-matchedcontrols: age > 68 years, 64 per cent; age 3 N ) fared poorly (5-year survival rate 36.3 per cent). This survival advantage may relate to nearly all mucosal early gastric cancers being diploid, a finding described by other^'^,^^. Improved survival occurs in patients with diploid tumours, but it is unclear whether this advantage is the result of other concurrent factors or independent of other variables. A greater incidence of synchronous and metachronous nongastric malignancies has been reported for patients with early gastric cancer. Green et al.I4 found that nearly one-third of patients subsequently developed cancers at other sites. Eight of 109 patients of Itoh et al. died from a non-gastric malignancy". In this study, cardiovascular disease was the most common cause of death and second primary tumours were not noted. Four patients developed recurrence of gastric cancer and three died from metastatic disease. Early gastric cancer was found in only 2 per cent of 2397 patients undergoing gastric resection for cancer during a 20-year period. The reasons for this are the stringent histological criteria for early gastric cancer, the nature of surgical practice in the USA and the common failure to diagnose gastric cancer at an early stage. Bringaze et al.", Oleagoitia et al." and Ohta et aL3 have documented higher prevalences of early gastric cancer among patients with gastric carcinoma, ranging from 5 to 33 per cent. The aggressive screening measures adopted in Japan have resulted in a marked increase in the prevalence of early gastric cancer. Some Japanese institutions have reported greater than 50 per cent of all gastric cancers as early3'. Although
541
Early gastric cancer: D. R . Farley et al.
earlier evaluation of dyspeptic patients might increase the detection of early gastric carcinoma, the low incidence of this cancer in western countries makes mass screening economically
’.
The crude 5- and 10-year survival rates of 70 and 58 per cent were substantially lower than the 90-95 per cent survival rates reported for Japanese patient^"*^^^^^^^^. This may be a factor of patient age, since the survival in patients with early gastric cancer was equivalent to an age- and sex-matched control population. Green et a / . have shown that the survival rate of patients with early gastric cancer is equivalent to that in age-matched control^'^. The finding of an improved survival rate for patients with good performance status has not previously been reported.
experience in a United States Medical Center. Am J Med 1988; 85: 658-61.
14. 15. 16. 17. 18.
19. 20.
References 1. 2. 3. 4.
5.
6.
7. 8. 9. 10. 11.
12. 13.
542
Boring C C , Squires TS, Tong T. Cancer statistics, 1991. C A 1991; 41: 19-36. Friesen G, Dockerty MB, ReMine WH. Superficial carcinoma of the stomach. Surgery 1962; 51: 300-12. Broders AC. Carcinoma in situ contrasted with benign penetrating epithelium. J Am Med Assoc 1932: 99: 1670-3. Lauren P. The two histological main types of gastric carcinoma: diffuse and so-called intestinal-type carcinomas. An attempt at histo-clinical classification. Acta Pathol Microbiol Scand 1965; 64: 31-49. Gonchoroff NJ, Ryan JJ, Kimlinger T K et a / . Effect of sonication on paraffin-embedded tissue preparation for DNA flow cytometry. Cytometry 1990; 11: 642-6. Minna JD, Pass H, Glatstein E, Ihde DC. Cancer of the lung. In: Vincent T, DeVita JR, Hellman S, Rosenberg SA, eds. Cancer Principles and Practice of Oncology. Philadelphia: JB Lippincott, 1989: 591-705. Peto R, Peto J. Asymptomatically efficient rank variant procedures (with discussion). J R Statist Soc [Ser A ] 1972; 135: 185-207. Cox DR. Regression models and life tables (with discussion). J R Statbt Soc [Ser B ] 1972; 34: 187-220. Kaplan EL, Meier P. Non-parametric estimation from incomplete observations. J Am Stat Assoc 1958; 53: 457-81. Bringaze WL 111, Chappius CW, Cohn I et a / . Early gastric cancer: a 21-year experience. Ann Surg 1986; 204: 103-7. Carter KJ, Schaffer HA, Ritchie WP. Early gastric cancer. Ann Surg 1964; 199: 604-9. Goldstein F , Kline TS, Kline IK et al. Early gastric cancer in a United States hospital. Am J Gastroenterol 1983; 78: 715-19. Green PHR, O’Toole K M , Slonim D et a / . Increasing incidence and excellent survival of patients with early gastric cancer:
21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32.
Green PHR, O’Toole K M , Weinberg LM et al. Early gastric cancer. Gastroenterology 1981; 81: 247-56. Fielding JWL, Ellis DJ, Jones BG et a / . Natural history of ‘early’ gastric cancer: results of a 10-year regional survey. Br Med J 1980; 281: 965-7. Paulino F , Roselli A. Early gastric cancer: report of twenty-five cases. Surgery 1979; 85: 171-6. Itoh H , Oohata Y, Nakamura K et a/.Complete ten-year postgastrectomy follow-up of early gastric cancer. Am J Surg 1989; 158: 14-16. Oleagoitia J M , Echevarria A, Santidrian JI et al. Early gastric cancer. Br J Surg 1986; 73: 804-6. Thompson G, Somers S, Stevenson G W . Benign gastric ulcer: a reliable radiologicdiagnosis? A m JRoentgenoll983; 141: 331-3. Sano T, Okuyama Y, Kobori 0 et al. Early gastric cancer. Endoscopic diagnosis of depth of invasion. Dig Dis Sci 1990; 35: 1340-4. Kodama Y, Sugimachi K , Soejimz K et a / . Evaluation of extensive lymph node dissection for carcinoma of the stomach. WorldJSurg 1981; 5: 241-8. Sowa M , Kato Y, Nishimura M et al. Surgical approach to early gastric cancer with lymph node metastasis. World J Surg 1989; 13: 630-6. Mori M , Kitigawa S, Iida M et al. Early carcinoma of the gastric cardia. Cancer 1987; 59: 1758-66. Lawrence M, Shiu MH. Early gastric cancer. Twenty-eight year experience. Ann Surg 1991; 213: 327-34. Carmalt HL, Gillett DJ, Lin BPB. Early gastric cancer. Aust N Z J Surg 1990; 60: 865-9. Endo M, Habu H. Clinical studies of early gastric cancer. Hepatogastroenterology 1990; 37: 408- 10. Ichiyoshi Y, Toda T, Minamisouo Y et al. Recurrence in early gastric cancer. Surgery 1990; 107: 489-95. de Aretxabala X, Yonemura Y, Sugiyama K et a / . DNA ploidy in early gastric cancer and its relationship to prognosis. Br J Cancer 1988; 58: 81-4. Inokuchi K , Kodama Y, Sasaki 0 et al. Differentiation of growth patterns of early gastric carcinoma determined by cytophotometric DNA analysis. Cancer 1983; 51: 1138-41. Nanus DM, Kelsen D P , Niedzwiecki D et al. Flow cytometry as a predictive indicator in patients with operable gastric cancer. J Clin Oncol 1989; 7: 1105-12. Ohta H, Noguchi Y , Takagi K er al. Early gastric carcinoma with special reference to macroscopic classification. Cancer 1987; 60: 1099-106. Evans D M D , Craven JL, Murphy F et al. Comparison of ‘early gastric cancer’ in Britain and Japan. Gut 1978; 19: 1-9.
Paper accepted 5 January 1992
Br. J. Surg., Vol. 79, No. 6, June 1992
