Clinical and pathological prognostic factors involved in gastrointestinal stromal tumors (gist) of gastric origin

BACKGROUND: This study wants to identify clinical and pathologic prognostic factors of resected gastric gastrointestinal stromal tumors (GIST). METHODS: Twenty-nine patients with c-Kit positive gastric GIST who underwent surgical resection at the Brazilian National Cancer Institute (INCA) between 1983 and 2004 were reviewed retrospectively. Prognostic significance of clinical and pathological variables was investigated. The endpoints were overall survival and disease free survival. RESULTS: Median follow-up was 35 months. Five-year estimate survival rate was 53%. Univariate analysis for overall survival identified size 13.5 cm (p=0.01) and recurrence (p=0.03) as prognostic factors. Size 13.5 cm and recurrence were independent factors (p=0.01 and p=0.03 respectively) in multivariate analysis. Univariate analysis for disease free survival identified size 13.5 cm (p=0.04) and grade (p=0.04) as prognostic factors but only size 13.5 cm was an independent factor in multivariate analysis. CONCLUSION: Size 13.5 cm and recurrence were identified as independent prognostic factors for overall survival. Only size 13.5 cm was an independent prognostic factor for disease free survival.OBJETIVO: Identificar os fatores prognósticos clínicos e anatomopatológicos nos portadores de tumor estromal gastrointestinal (GIST) gástrico submetidos à ressecção cirúrgica. MÉTODO: Estudo retrospectivo realizado no Instituto Nacional do Câncer (INCA), incluindo 29 casos de GIST gástrico c-Kit positivo submetidos à ressecção cirúrgica entre 1983 e 2004. Variáveis clínicas e anatomopatológicas foram investigadas quanto ao significado prognóstico, correlacionando-as com sobrevida global e sobrevida livre de doença. RESULTADOS: O acompanhamento mediano foi de 35 meses. A sobrevida global, estimada em cinco anos, foi de 53%. As variáveis tamanho tumoral maior que 13,5 cm e presença de recidiva tiveram implicação prognóstica na sobrevida global conforme análise univariada (p=0,01 e p=0,03, respectivamente). A análise multivariada evidenciou que tamanho tumoral maior que 13,5 cm e presença de recidiva representaram fatores prognósticos independentes relacionados à sobrevida global (p=0,01 e p=0,03, respectivamente). As características tamanho tumoral maior que 13,5 cm e índice mitótico influenciaram significativamente (p=0,04 e p=0,04) a sobrevida livre de doença (análise univariada), porém apenas tamanho tumoral maior que 13,5 cm apresentou-se como fator prognóstico independente (p=0,04) relacionado à sobrevida livre de doença, quando utilizada a análise multivariada. CONCLUSÕES: O tamanho tumoral e a presença de recidiva representaram fatores prognósticos independentes relacionados à sobrevida global. Apenas o tamanho tumoral apresentou impacto adverso independente na sobrevida livre de doença.INCAUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaINCA Seção de Cirurgia Abdômino-PélvicaUFRJINCA Serviço de Anatomia PatológicaUniversidade Gama FilhoHospital dos Servidores do Estado Serviço de Anatomia PatológicaUNIFESP, EPMSciEL

Synchronous advanced gastric adenocarcinoma and advanced esophageal squamous cell carcinoma

CONTEXT: Synchronous associations of esophageal and gastric cancers are not a common finding, especially with differing histological types and both tumors in advanced forms. A case with such an association is presented, in which an unusual therapy was proposed: palliative gastrectomy and esophageal intubation. CASE REPORT: A 75-year-old white man was referred to our service complaining of malaise and weight loss for one year and dysphagia and vomiting for 2 months. The patient had sought out medical consultation as a result of the latter two complaints.CONTEXTO: A associação sincronicamente de cânceres do esôfago e estômago não é um achado comum, especialmente com tipos histológicos diferentes e ambos os tumores avançados. Um caso com essa associação é relatado e proposta uma terapia: gastrectomia paliativa e prótese esofágica. RELATO DE CASO: Um paciente do sexo masculino, branco, de 75 anos, foi referido ao nosso serviço queixando-se de mal-estar e perda ponderal por um ano e vômitos por dois meses, motivo pelo qual procurou ajuda médica.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Discipline of Surgical GastroenterologyUniversidade São Paulo Discipline of Surgical GastroenterologyUNIFESP, EPM, Discipline of Surgical GastroenterologySciEL

A systematic review of the accuracy and utility of peritoneal cytology in patients with gastric cancer

Background There is lack of uniformity in the utilization of peritoneal cytology in gastric cancer management. the identification of intraperitoneal free cancer cells (IFCCs) is believed to confer poor prognosis. However, while some of these patients are palliated, others may undergo more aggressive therapies. in this review, we aimed to identify and synthesize findings on the use of peritoneal cytology in predicting peritoneal recurrence and overall survival in curative gastric cancer patients.Methods Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. We determined the accuracy, sensitivity, and specificity of peritoneal cytology in predicting peritoneal recurrence based on four techniques-conventional cytology, immunoassay, immunohistochemistry, and reverse transcriptase-polymerase chain reaction. Recurrence rates and overall survival rates for curative patients were determined, based on positivity or negativity for IFCCs.Results Twenty-eight articles were included. All four techniques showed wide variations in accuracy, sensitivity, and specificity in predicting peritoneal recurrence. Recurrence rates for patients positive for IFCCs ranged from 11.1 to 100%, while those negative for IFCCs had recurrence rates of 0-51%. Overall survival was significantly reduced for patients with positive IFCCs. Short follow-up periods and possible duplication of results may limit result interpretation.Conclusion the presence of IFCCs appears to increase the risk of peritoneal recurrence and is associated with worse overall survival in gastric cancer patients. Further incorporation of peritoneal cytology in clinical decision-making in gastric cancer depends on the development of a consistently accurate and rapid IFCC detection method.Canadian Cancer SocietyOntario Ministry of Health and Long-Term CareUniv Toronto, Dept Surg, Toronto, ON, CanadaSunnybrook Hlth Sci Ctr, Sunnybrook Res Inst, Toronto, ON M4N 3M5, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilDalhousie Univ, Dept Surg, Halifax, NS B3H 4H2, CanadaQueens Univ, Dept Community Hlth & Epidemiol, Kingston, ON, CanadaSunnybrook Hlth Sci Ctr, Dept Anat Pathol, Toronto, ON M4N 3M5, CanadaUniv Toronto, Div Surg Oncol, Sunnybrook Hlth Sci Ctr, Odette Canc Ctr, Toronto, ON, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilCanadian Cancer Society: 019325Web of Scienc

A systematic review and meta-analysis of the utility of EUS for preoperative staging for gastric cancer

Background Accurate preoperative staging is important in determining the appropriate treatment of gastric cancer. Recently, endoscopic ultrasound (EUS) has been introduced as a staging modality. However, reported test characteristics for EUS in gastric cancer vary. Our purpose in this study was to identify, synthesize, and evaluate findings from all articles on the performance of EUS in the preoperative staging of gastric cancer.Methods Electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1 January 1998 to 1 December 2009. All search titles and abstracts were independently rated for relevance by a minimum of two reviewers. Meta-analysis for the performance of EUS was analyzed by calculating agreement (Kappa statistic), and pooled estimates of accuracy, sensitivity, and specificity for all EUS examinations, using histopathology as the reference standard. Subgroup analyses were also performed.Results Twenty-two articles met our inclusion criteria and were included in the review. EUS pooled accuracy for T staging was 75% with a moderate Kappa (0.52). EUS was most accurate for T3 disease, followed by T4, T1, and T2. EUS pooled accuracy for N staging was 64%, sensitivity was 74%, and specificity was 80%. There was significant heterogeneity between the included studies. Subgroup analyses found that annual EUS volume was not associated with EUS T and N staging accuracy (P = 0.836, 0.99, respectively).Conclusion EUS is a moderately accurate technique that seems to describe advanced T stage (T3 and T4) better than N or less advanced T stage. Stratifying by EUS annual volume did not affect EUS performance in staging gastric cancer.Canadian Cancer SocietyMinistry of Health and Long Term CareCIHRHanna Family Chair in Surgical OncologySunnybrook Hlth Sci Ctr, Sunnybrook Res Inst, Toronto, ON M4N 3M5, CanadaSunnybrook Hlth Sci Ctr, Div Surg Oncol, Toronto, ON M4N 3M5, CanadaOdette Canc Ctr, Toronto, ON M4N 3M5, CanadaInst Clin Evaluat Sci, Toronto, ON, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilSunnybrook Hlth Sci Ctr, Div Gastroenterol, Dept Med, Toronto, ON M4N 3M5, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilCanadian Cancer Society: 019325Web of Scienc

How useful is preoperative imaging for tumor, node, metastasis (TNM) staging of gastric cancer? A meta-analysis

Background Surgery is the fundamental curative option for gastric cancer patients. Imaging scans are routinely prescribed in an attempt to stage the disease prior to surgery. Consequently, the correlation between radiology exams and pathology is crucial for appropriate treatment planning.Methods Systematic searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 1, 2009. We calculated the accuracy, overstaging rate, understaging rate, Kappa statistic, sensitivity, and specificity for abdominal ultrasound (AUS), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) with respect to the gold standard (pathology). We also compared the performance of CT by detector number and image type. A meta-analysis was performed.Results for pre-operative T staging MRI scans had better performance accuracy than CT and AUS; CT scanners using >= 4 detectors and multi-planar reformatted (MPR) images had higher staging performances than scanners with <4 detectors and axial images only. for pre-operative N staging PET had the lowest sensitivity, but the highest specificity among modalities; CT performance did not significantly differ by detector number or addition of MPR images. for pre-operative M staging performance did not significantly differ by modality, detector number, or MPR images.Conclusions the agreement between pre-operative TNM staging by imaging scans and post-operative staging by pathology is not perfect and may affect treatment decisions. Operator dependence and heterogeneity of data may account for the variations in staging performance. Physicians should consider this discrepancy when creating their treatment plans.Canadian Cancer SocietyOntario Ministry of Health and Long-Term CareHanna Family Chair in Surgical OncologySunnybrook Hlth Sci Ctr, Sunnybrook Res Inst, Toronto, ON M4N 3M5, CanadaSunnybrook Hlth Sci Ctr, Dept Med Imaging, Toronto, ON M4N 3M5, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilQueens Univ, Dept Community Hlth & Epidemiol, Kingston, ON, CanadaUniv Toronto, Div Biostat, Dalla Lana Sch Publ Hlth, Toronto, ON, CanadaInst Clin Evaluat Sci, Toronto, ON, CanadaSunnybrook Hlth Sci Ctr, Div Surg Oncol, Odette Canc Ctr, Toronto, ON M4N 3M5, CanadaUniv Toronto, Dept Hlth Policy Management & Evaluat, Toronto, ON, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilCanadian Cancer Society: 019325Web of Scienc

A systematic review of the accuracy and indications for diagnostic laparoscopy prior to curative-intent resection of gastric cancer

Background Despite improved preoperative imaging techniques, patients with incurable or unresectable gastric cancer are still subjected to non-therapeutic laparotomy. Diagnostic laparoscopy (DL) has been advocated by some to be essential in decision-making in gastric cancer. We aimed to identify and synthesize findings on the value of DL for patients with gastric cancer, in this era of improved preoperative imaging.Methods Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from January 1, 1998 to December 31, 2009. We calculated the change in management and avoidance of laparotomy based on the addition of DL and laparoscopic ultrasound (LUS). the accuracy, agreement (kappa), sensitivity, and specificity of DL in assessing tumor extent, nodal involvement, and the presence of metastases with respect to the gold standard (pathology) were also calculated.Results Twenty-one articles were included. DL showed moderate to substantial agreement with final pathology for T stage, but only fair agreement for N stage. for M staging, DL had an overall accuracy, sensitivity, and specificity ranging from 85-98.9%, 64.3-94%, and 80-100%, respectively. the use of DL altered treatment in 8.5-59.6% of cases, avoiding laparotomy in 8.5-43.8% of cases. LUS provided additional benefit in 5.8-7.2% of cases.Conclusions Despite evolving preoperative imaging techniques, diagnostic laparoscopy continues to be of substantial value in staging patients with gastric cancer and in avoiding unnecessary laparotomy. the current data support DL for all patients with advanced gastric cancer.Canadian Cancer SocietyOntario Ministry of Health and Long-Term CareHanna Family Chair in Surgical OncologyUniv Toronto, Dept Surg, Toronto, ON, CanadaSunnybrook Hlth Sci Ctr, Sunnybrook Res Inst, Toronto, ON M4N 3M5, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilDalhousie Univ, Dept Surg, Halifax, NS B3H 4H2, CanadaQueens Univ, Dept Community Hlth & Epidemiol, Kingston, ON, CanadaUniv Toronto, Sunnybrook Hlth Sci Ctr, Div Surg Oncol, Odette Canc Ctr, Toronto, ON, CanadaUniversidade Federal de São Paulo, Dept Surg, São Paulo, BrazilCanadian Cancer Society: 019325Web of Scienc

P53 expression in gastric adenocarcinoma: clinicopathological correlation and prognostic significance

BACKGROUND: To study the expression of p53 protein in gastric adenocarcinoma and its relationship to clinicopathological parameters such as, age, sex, infiltration of the gastric wall (T), histological type of Lauren's classification, histological differenciation, lymph node involvement, stage (TNM) and patient longevity. METHODS: Forty-five patients with the diagnosis of gastric carcinoma submitted to a sub-total gastrectomy or a total gastrectomy in the Surgical Oncology Department at the Santa Casa de Misericórdia Hospital in Maceió, Alagoas and the University Hospital of the Federal University of Alagoas, Brazil during the period of January 1991 to May 2002 were analysed.The expression of the p53 protein was evaluated by an immunohistochemistry method, and compared to age, sex, infiltration of the gastric wall, histological type, histological differenciation, lymph node involvement, stage (TNM) and patient longevity. RESULTS: In the total number of patients, 27 were male (60%). The age range of all patients was 26 - 75 years (mean = 53.9 years). Forty patients (88.9%) were classified as well differenciated. As far as infiltration of the gastric wall, 28 patients (62.2%) were classified as having deep infiltration. In 25 patients (55.6%) the lymph nodes were free of disease. The histological study revealed that 29 patients (64.4%) were classified as the intestinal type of Lauren's classification. The stage (TNM) showed that 33 patients (73.3%) presented an advanced tumor. In the immunohistochemistry analysis, 18 patients (40%) were considered positive.The follow-up varied between 63 to 3920 days, with the average time being 1020.4 days. The statistical method of univariate analysis of Mantel identified the variables: age, stage, lymph node involvement and the tumor infiltration of the gastric wall as prognostic factors related to the patient with a significant statistical longevity (p<0.05). Multivariate analysis showed that only lymph node involvement was an independent prognostic factor. CONCLUSION: The author concluded that 18 (40%) of the total number of 45 patients with gastric carcinoma showed an immunohistochemistry reaction. There was no significant statistical relationship between expression of p53 protein and prognostic factors studied. Expression of p53 protein was not an independent prognostic factor.OBJETIVO: Avaliar a expressão da proteína p53 no adenocarcinoma gástrico e correlacioná-la com variáveis clínicas e anatomopatológicas, tais como: idade, sexo, infiltração da parede gástrica (T), tipo histológico (Laurén), grau de diferenciação histológica, comprometimento linfonodal, estadiamento (TNM) e sobrevida. MÉTODO: Foram analisados os registros médicos e reestudadas as lâminas de peças cirúrgicas de 45 doentes com adenocarcinomas gástricos submetidos à gastrectomia parcial e total no Serviço de Cirurgia Oncológica da Santa Casa de Misericórdia de Maceió-AL e no Hospital Universitário da Universidade Federal de Alagoas, no período de 1991 a 2002. A expressão da proteína p53 foi avaliada pelo método imunohistoquímico com o anticorpo monoclonal DO-7 e comparada com idade, sexo, infiltração na parede gástrica, tipo histológico, grau de diferenciação, comprometimento linfonodal, estadiamento e sobrevida. RESULTADOS: Dos 45 doentes, 27 eram do sexo masculino (60%). A média das idades foi 53,9 anos (26 - 75 anos), e mediana de 57 anos. Em 40 doentes (88,9%) o tumor foi classificado como bem diferenciado. Quanto à infiltração na parede gástrica, em 28 doentes (62,2%) foram classificados como profundos. Em 25 doentes (55,6%) não havia comprometimento linfonodal. O estudo histológico revelou que 29 doentes (64,4%) apresentavam tumores classificados como tipo intestinal de Laurén. O estadiamento TNM demonstrou que 33 (73,3%) doentes apresentavam tumores avançados. Quanto à expressão da p53, 18 doentes (40%) foram considerados positivos. O tempo médio de seguimento foi de 1020,4 dias (63 - 3920 dias) e mediana de 798 dias. Trinta e um (68,9%) doentes evoluíram para óbito. As variáveis: idade, estadiamento, comprometimento linfonodal e infiltração do tumor na parede gástrica, foram fatores prognósticos relacionados à sobrevida com significado estatístico (p<0,05). Não houve correlação estatística significativa da proteína p53 com as variáveis estudadas. A análise estatística multivariada identificou apenas o comprometimento linfonodal como fator prognóstico independente. CONCLUSÕES: Os autores concluíram que dezoito (40%) dos doentes expressaram a reação imunohistoquímica para p53. Não houve correlação estatística significativa da expressão da proteína p53 com os fatores prognósticos estudados. A expressão da proteína p53 não foi fator prognóstico independente.Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM)Hospital Escola Dr. José Carneiro Santa Casa de Misericórdia Seção de Oncologia(UFAL)(UNCISAL) Escola de Ciências Médicas de Alagoas.Santa Casa de Misericórdia de Maceió - AL Seção de Cirurgia OncológicaUNIFESP, EPMSciEL

II Consenso Brasileiro de Câncer Gástrico realizado pela Associação Brasileira de Câncer Gástrico

Background: Since the publication of the first Brazilian Consensus on Gastric Cancer (GC) in 2012 carried out by the Brazilian Gastric Cancer Association, new concepts on diagnosis, staging, treatment and follow-up have been incorporated. Aim: This new consensus is to promote an update to professionals working in the fight against GC and to provide guidelines for the management of patients with this condition. Methods: Fiftynine experts answered 67 statements regarding the diagnosis, staging, treatment and prognosis of GC with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree A consensus was adopted when at least 80% of the sum of the answers “fully agree” and “partially agree” was reached. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications. Results: Of the 67 statements, there was consensus in 50 (74%). In 10 declarations, there was 100% agreement. Conclusion: The gastric cancer treatment has evolved considerably in recent years. This consensus gathers consolidated principles in the last decades, new knowledge acquired recently, as well as promising perspectives on the management of this disease.Racional: Desde a publicação do primeiro Consenso Brasileiro sobre Câncer Gástrico em 2012 realizado pela Associação Brasileira de Câncer Gástrico (ABCG), novos conceitos sobre o diagnóstico, estadiamento, tratamento e seguimento foram incorporados. Objetivo: Promover uma atualização aos profissionais que atuam no combate ao câncer gástrico (CG) e fornecer diretrizes quanto ao manejo dos pacientes portadores desta afecção. Métodos: Cinquenta e nove especialistas responderam 67 declarações sobre o diagnóstico, estadiamento, tratamento e prognóstico do CG com cinco alternativas possíveis: 1) concordo plenamente; 2) concordo parcialmente; 3) indeciso; 4) discordo e 5) discordo fortemente. Foi considerado consenso a concordância de pelo menos 80% da soma das respostas “concordo plenamente” e “concordo parcialmente”. Este artigo apresenta apenas as respostas dos especialistas participantes. Os comentários sobre cada declaração, assim como uma revisão da literatura serão apresentados em publicações futuras. Resultados: Das 67 declarações, houve consenso em 50 (74%). Em 10 declarações, houve concordância de 100%. Conclusão: O tratamento do câncer gástrico evoluiu consideravelmente nos últimos anos. Este consenso reúne princípios consolidados nas últimas décadas, novos conhecimentos adquiridos recentemente, assim como perspectivas promissoras sobre o manejo desta doença