Prediction of lymph node metastasis in early gastric signet-ring cell carcinoma:A real-world retrospective cohort study

BACKGROUND Signet-ring cell carcinoma(SRCC)was previously thought to have a worse prognosis than other differentiated gastric cancer(GC),however,recent studies have shown that the prognosis of SRCC is related to pathological type.We hypothesize that patients with SRCC and with different SRCC pathological components have different probability of lymph node metastasis(LNM).AIM To establish models to predict LNM in early GC(EGC),including early gastric SRCC.METHODS Clinical data from EGC patients who had undergone gastrectomy at the First Affiliated Hospital of Nanjing Medical University from January 2012 to March 2022 were reviewed.The patients were divided into three groups based on type:Pure SRCC,mixed SRCC,and non-signet ring cell carcinoma(NSRC).The risk factors were identified through statistical tests using SPSS 23.0,R,and EmpowerStats software.RESULTS A total of 1922 subjects with EGC were enrolled in this study,and included 249 SRCC patients and 1673 NSRC patients,while 278 of the patients(14.46%)presented with LNM.Multivariable analysis showed that gender,tumor size,depth of invasion,lymphovascular invasion,ulceration,and histological subtype were independent risk factors for LNM in EGC.Establishment and analysis using prediction models of EGC showed that the artificial neural network model was better than the logistic regression model in terms of sensitivity and accuracy(98.0%vs 58.1%,P=0.034;88.4%vs 86.8%,P<0.001,respectively).Among the 249 SRCC patients,LNM was more common in mixed(35.06%)rather than in pure SRCC(8.42%,P<0.001).The area under the ROC curve of the logistic regression model for LNM in SRCC was 0.760(95%CI:0.682-0.843),while the area under the operating characteristic curve of the internal validation set was 0.734(95%CI:0.643-0.826).The subgroups analysis of pure types showed that LNM was more common in patients with a tumor size>2 cm(OR=5.422,P=0.038).CONCLUSION A validated prediction model was developed to recognize the risk of LNM in EGC and early gastric SRCC,which can aid in pre-surgical decision making of the best method of treatment for patients.

Differential analysis of lymph node metastasis in histological mixed-type early gastric carcinoma in the mucosa and submucosa

AIM To investigate the relationship between histological mixed-type of early gastric cancer(EGC) in the mucosa and submucosa and lymph node metastasis(LNM).METHODS This study included 298 patients who underwent gastrectomy for EGC between 2005 and 2012. Enrolled lesions were divided into groups of pure differentiated(pure D), pure undifferentiated(pure U), and mixed-type according to the proportion of the differentiated and undifferentiated components observed under a microscope. We reviewed the clinicopathological features, including age, sex, location, size, gross type, lymphovascular invasion, ulceration, and LNM, among the three groups. furthermore, we evaluated the predictors of LNM in the mucosa-confined EGC.RESULTS Of the 298 patients, 165(55.4%) had mucosa-confined EGC and 133(44.6%) had submucosa-invasive EGC. Only 13(7.9%) cases of mucosa-confined EGC and 30(22.6%) cases of submucosa-invasive EGC were observed to have LNM. The submucosal invasion(OR = 4.58, 95%CI: 1.23-16.97, P = 0.023), pure U type(OR = 4.97, 95%CI: 1.21-20.39, P = 0.026), and mixedtype(OR = 5.84, 95%CI: 1.05-32.61, P = 0.044) were independent risk factors for LNM in EGC. The rate of LNM in mucosa-confined EGC was higher in the mixedtype group(P = 0.012) and pure U group(P = 0.010) than in the pure D group, but no significant difference was found between the mixed-type group and pure U group(P = 0.739). Similarly, the rate of LNM in the submucosa-invasive EGC was higher in the mixedtype(P = 0.012) and pure U group(P = 0.009) than in the pure D group but was not significantly different between the mixed-type and pure U group(P = 0.375). Multivariate logistic analysis showed that only female sex(OR = 5.83, 95%CI: 1.64-20.70, P = 0.028) and presence of lymphovascular invasion(OR = 13.18, 95%CI: 1.39-125.30, P = 0.020) were independent risk factors for LNM in mucosa-confined EGC, while histological type was not an independent risk factor for LNM in mucosa-confined EGC(P = 0.106).CONCLUSION for mucosal EGC, histological mixed-type is not an independent risk factor for LNM and could be managed in the same way as the undifferentiated type.

Prognostic role of lymph node metastasis in early gastric cancer

Objective： To clarify the relationship between clinicopathological features and lymph node metastasis and to propose the potential indications of lymph node metastasis for prognosis in early gaswic cancer （EGC） patients. Methods： We retrospectively observed 226 EGC patients with lymph node resection, and analyzed the associations between lymph node metastasis and clinicopathological parameters using the chi-square test in univariate analysis and logistic regression analysis in multivariate analysis. Overall survival analysis was determined using the Kaplan-Meier and log-rank test. We conducted multivariate prognosis analysis using the Cox proportional hazards model. Results： Of all the EGC patients, 7.5% （17/226） were histologically shown to have lymph node metastasis. The differentiation, lymphovascular invasion and depth of invasion were independent risk factors for lymph node metastasis in EGC. The 5- and 10-year survival rates were significantly lower in patients with lymph node metastasis than in those without and the patients also had shorter progress-free survival time. Lymph node metastasis and tumor size were independent prognostic factors for EGC. The status of the lymph nodes was a significant factor in predicting recurrence or metastasis after surgery. Conclusions： The undifferentiated carcinoma and lymphovascular and/or submucosal invasion were associated with a higher incidence of lymph node metastasis in EGC patients, whom need to perform subsequent D2 lymphadenectomy or laparoscopic lymph node dissection and more rigorous follow-up or additional chemotherapy/radiation after D2 gastrectomy for poor prognosis and high recurrence/metastasis rate.

Controversies in the diagnosis and management of early gastric cancer

Early diagnosis and treatment is the key to improving the prognosis of gastric cancer. The past decades have wimessed the rapid advances in the diagnosis and management of early gastric cancer （EGC）： endoscopy has played an increasingly important role, whereas laparoscopic techniques have also been introduced for EGC treatment. In China, the proportion of EGC is gradually increasing, and this condition will soon become a hot research topic. In this article, we will elucidate some major controversies in the diagnosis and management of EGC.

Upgrading the definition of early gastric cancer: better staging means more appropriate treatment

Since Murakami defined early gastric cancer(EGC) as a "carcinoma limited to the gastric mucosa and/or submucosa regardless of the lymph node status", several authors have focused on the most influential histopathological parameters for predicting the development of lymph node metastases by considering the lymph node status as an important prognostic factor. A few authors have also considered the depth of invasion as one of the keys to explaining the existence of subgroups of patients affected by EGC with poor prognoses. In any case, EGC is still considered an initial phase of tumor progression with good prognosis. The introduction of modern endoscopic devices has allowed a precise diagnosis of early lesions, which can lead to improved definitions of tumors that can be radically treated with endoscopic mucosal resection or endoscopic submucosal dissection(ESD). Given the widespread use of these techniques, the Japanese Gastric Cancer Association( JGCA) identified in 2011 the standard criteria that should exclude the presence of lymph node metastases. At that time, EGCs with nodal involvement should have been asserted as no longer fitting the definition of an early tumor. Some authors have also demonstrated that the morphological growth pattern of a tumor, according to Kodama's classification, is one of the most important prognostic factors, thereby suggesting the need to report it in histopathological drafts. Notwithstanding the acquired knowledge regarding the clinical behavior of EGC, Murakami's definition is still being used. This definition needs to be upgraded according to the modern staging of the disease so that the appropriate treatment would be selected.

THE EXPRESSION OF BCL-2 AND BAX PROTEINS IN GASTRIC CARCINOMA AND PRECANCEROUS LESIONS

Objective To investigate the variance of expression of bcl-2 and bax genes in the genesis or gastric carcinoma as well as their relationship. Methods Thirty-five cases of early-stage gastric carcinoma and Twenty-four cases ot chronic atrophic gastritis were studied by immunohistochemical method. Results There were no statistical differences of bcl-2 expression levels between gastric carcinoma and atypical hyperplasia or paracancerous intestinal- epithelial metaplasia(IEM) (P>0.05).There were statistical differences of bcl-2 expression between normal epithe- lial tissues (or non-cancerous IEM) and the other three groups(P<0.05), but no statistical difference between the normal epithelial and the non-cancerous IEM group was observed(P>0.05). The expressions or bax protein were found in the normal epithelial and the other groups in varying degrees,but there were no statistical differences be- tween either two of the groups (P>0.05). The bcl-2/bax ratio was higher in early-stage gastric carcinoma,atypical hy- perplasia and paracancerous intestinal-metaplasia than in the non-cancerous intestinal-metaplasia (P<0.05) and nor- mal epithelial tissues(P<0.01). Conclusion The abnormal expression of bcl-2 protein and bax protein,especially the increased bcl-2/bax ratio, probably play an important role in the course of carcinogenesis or gastric carcinoma.

Predictive factors of lymph node metastasis in intramucosal poorly differentiated early gastric cancer and their impact on the laparoscopic surgery

Objective The aim of this study was to identify clinicopathological factors predictive of lymph node metastasis (LNM) in intramucosal poorly differentiated early gastric cancer (EGC), and further to expand the possibility of using laparoscopic surgery for the treatment of intramucosal poorly differentiated EGC.

Predictive biomarker and clinicopathological characteristics analysis for recurrence of early gastric cancer

Objective: The aim of this study was to identify the correlation between the clinicopathological characteristics and recurrence in early gastric cancer (EGC), what's more, we attempt to look for a predictive biomarker to predict and treat for re-currence of EGC. Methods: This study retrospectively analyzed 178 early gastric cancer patients who had the complete post-operative and follow-up medical records in the First Affiliated Hospital of Yangtze University (China) between January 1995 to December 2005. All of them were followed-up to December 2009 regularly. Computer tomography (CT), endoscopy, and single photon emission computed tomography (SPET-CT) were used to diagnose for recurrence of EGC. Immunohistochem-istry (IHC) and fluorescence in situ hybridization (FISH) were used for the detection of cerbB2. Chi-square test was applied to this study for statistics analysis. Results: Fourteen patients had recurrence. Eighteen patients were cerbB2-positive, including twelve recurrence patients and six norecurrence patients. Sex, tumor depth, and lymph node metastasis were related to the recurrence of EGC. Also, cerbB2-positive patients had the higher recurrence rate compared to the cerbB2-negative patients. Conclusion: Recurrence of EGC after curative resection can be predicted by using some clinicopathological characteristics. CerbB2 can be used as a predictive biomarker for recurrence of EGC.

完全机器人手术系统联合术中胃镜行保留幽门的中段胃切除在胃体癌的应用

目的探讨完全机器人手术系统联合术中胃镜行保留幽门的中段胃切除治疗中段胃体癌的可行性及安全性。方法采用描述性病例系列研究方法,回顾性收集并分析2023年5月至2023年9月期间中南大学湘雅二医院胃肠外科完成的7例完全机器人手术系统联合术中胃镜行双镜联合的保留幽门的中段胃体癌根治术的临床资料。术中胃镜钛夹定位病变位置,采用5孔法放置Trocar,完全机器人下行中段胃切除,行胃底胃体端端手工缝合。观察手术情况、围手术期情况和术后病理以及随访情况。计量资料采用平均数(范围)或M(范围)来表示,计数资料用频数表示。结果7例患者手术均成功实施完全机器人手术系统联合术中胃镜行双镜联合的保留幽门的中段胃体癌根治术,无中转开腹或术中输血。全组患者全组患者平均手术时间182(165~195)min,平均术中出血量45(40~60)ml,平均手术切口长度3.3(3.0~4.0)cm,平均术后排气时间为2.4(2.0~3.0)d,平均术后首次排便时间3.0(2.0~4.0)d,平均术后进流食时间为3.9(3.0~5.0)d,平均术后住院天数为7.6(7.0~9.0)d,平均术后拔出腹腔引流管时间为4.9(4.0~6.0)d,平均术后拔除尿管时间1.3(1.0~2.0)d,平均术后首次下床活动时间2.3(2.0~3.0)d,住院期间无严重手术相关并发症发生。电话随访患者术后6个月,全组术后切口愈合良好,无术后胃穿孔、术后吻合口出血、吻合口瘘、吻合口狭窄、无胃瘫或无病人出现严重营养不良,仅1例患者出现胃排空障碍导致的反酸、嗳气、腹胀轻微症状,其他患者均无严重餐后不适或胆汁反流性胃炎症状,主观整体营养评分均在A或B级,无病人发生肿瘤复发,转移或死亡,所有患者术后饮食、排便规律,生活质量满意。结论完全机器人手术系统联合术中胃镜行保留幽门的中段胃切除在胃体癌中具有独特优势,具有良好的安全性和可行性,且术后短期预后良好,有利于改善病人术后生活质量。

THE PRESENT STATUS OF SURGICAL TREATMENT OF GASTRIC CANCER IN CHINA

Gastric cancer remains one of the leading malignancies in China. The history of modern surgical treatment of gastric cancer could be dated back to the early fifties with an overall 5-year survival rate of around 10%. Remarkable progress has been achieved ever since in terms of operability, resectability and 5-year survival rate which ranges now from 30% to over 50% after radical resection. In regard to problems and future perspective, apart from the effort which should be redoubled in increasing the detection rate of EGC, the need to popularize the new international TNM staging system, to carry out in-depth studies on the biological behavior of gastric cancers and the role of the spleen in the evolution of gastric cancer, and to include new potential adjuvant measures in the therapeutic regimen of AGC are emphasized.

基于适配体的胃癌生物传感器研究与治疗策略

早期胃癌的及时诊断对指导治疗方式的选择及延长患者的生存期都具有重要意义。然而目前尚无灵敏、准确且方便的普筛工具,早期胃癌筛查仍依赖于内镜检查。通过消化内镜开展大规模筛查的成本较高,绝大部分国家和地区都无法承担。现阶段已有许多类型的生物标志物被证实具有预测和诊断肿瘤的能力。适配体作为寡核苷酸单链DNA或RNA,通过标签修饰、与各种新型材料偶联等方式,基于荧光、比色、电化学等多种检测策略,可以构建灵敏且可靠的生物传感器;同时分子量小、特异性强及自身生物学特性使其被广泛用于精准医疗领域。本文归纳与总结了基于适配体的胃癌诊断与治疗研究,以帮助研究者快速了解肿瘤适配体筛选思路、生物传感器构建与优化方法及治疗策略,为后续开发符合临床需求的胃癌适配体研究提供参考,辅助内镜检查的开展、诊治和随访。

内镜黏膜下剥离术与外科手术治疗早期胃癌的有效性及安全性的Meta分析

目的内镜黏膜下剥离术(ESD)与外科手术是早期胃癌(EGC)的常用治疗方法,但其相关风险及获益目前仍存在争议,该研究旨在比较两种治疗方法在治疗EGC的有效性、安全性等方面的差异。方法检索1990年1月-2016年6月发表在Pubmed、CBM、Embase、Cochrane Library、中国知网数据库、维普数据库及万方数据库的有关ESD与外科手术治疗EGC对比研究的所有中英文文献,根据纳入和排除标准对搜索的相关文献进行二次筛选,并对纳入的研究进行质量评价,采用Revman 5.3软件进行Meta分析。结果总共有12篇文献符合纳入标准,且均为回顾性队列研究,共涉及4 331个研究对象。Meta分析的结果显示:ESD与外科手术相比,复发率[(22/2 586,0.85%)vs(6/1 134,0.53%),P=0.370]及5年生存率[(852/909,93.72%)vs(707/746,94.77%),P=0.340]差异无统计学意义,虽然外科手术在整块切除率方面稍高于ESD组[(99/99,100.00%)vs(95/103,92.23%),P=0.020],但是外科手术组的手术时间[标准化均数差(SMD)=-3.04,95%CI:-3.64^-2.45,P=0.000]及住院时间(SMD=-2.53,95%CI:-3.73^-1.32,P=0.000)比ESD组延长,且术后并发症增多[(45/816,5.50%)vs(101/686,14.72%),P=0.000]。结论对于EGC的治疗,两种治疗方法在复发率及5年生存率方面无明显差异,虽然ESD组在整块切除率上不及外科手术组,但其具有创伤小、手术时间短、术中及术后并发症少、住院时间短且恢复快等显著优势,可作为EGC的首选治疗方法。

55例早期胃癌的临床与病理分析

目的探讨早期发现EGC、评价预后及指导治疗的方法。方法收集该院2002年1月￣2004年12月手术治疗的胃癌数,统计EGC的检出率,并进行临床与病理分析。结果2002、2003、2004年EGC分别占该院同期手术胃癌数的5.26%、6.09%、11.11%。胃镜与病理检查符合率为92.73%。发病年龄高峰为50～59岁,男∶女=1.9∶1.0,症状及体症均缺乏特异性。EGC病灶主要分布在胃窦,肉眼分型多为Ⅱc和Ⅲ型,直径多<2cm。病理分型以低分化腺癌为主,多数浸润黏膜层。黏膜内癌和黏膜下癌的淋巴结转移率分别为11.34%和36.36%。术后化疗30例,占EGC患者的54.55%。结论EGC的检出率逐年增高,内镜加多点活检可明显提高EGC的诊断率。

54例早期胃癌术后临床病理分析

本文报告手术治疗早期胃癌54例,Ⅰ型5例;Ⅱ、Ⅲ各6例,Ⅱ19例、Ⅲ1例、Ⅱ+Ⅲ1例、Ⅱ+Ⅱ4例;Ⅲ型12例。54例均作R_2术式,7例有淋巴结转移,第1站转移率为12.96％,第站转移率为3.7％.随访率100％。5年生存率为94.5％,其中粘摸内癌5年生存率100％.粘膜下癌为87.5％。本文着重讨论早期胃癌诊断应重视癌前病变的纤维胃镜随访观察。对早癌的手术治疗.术前如能确定为粘膜内癌.可行R1术式。否则以R2术式为宜。

早期胃癌的胃镜及病理分析

目的分析早期胃癌的胃镜及病理特点,以提高早期胃癌的诊断率。方法总结该院1994￣2003年经手术证实为早期胃癌的64例患者的临床资料。结果64例早期胃癌病人术前胃镜均确诊为胃癌,其胃内分布以胃窦最多30例(46.9%),病理示管状腺癌最多32例(50.0%),病灶周围组织示萎缩性胃炎28例(43.8%),肠上皮化生26例(40.6%),中重度不典型增生26例(40.6%),幽门螺旋杆菌阳性58例(90.6%)。结论早期胃癌Ⅱ型病变多见,胃窦是好发部位,黏膜内癌与黏膜下癌发生淋巴转移的几率无明显差异(P>0.1),胃镜检查是早期胃癌确诊的重要手段,癌前病变及Hp与早期胃癌关系密切。

形似良性病变的早期胃癌的临床研究

目的总结形似良性病变早期胃癌临床特点，提高早期胃癌的诊断水平。方法回顾分析2001～2006年我院经手术切除和病理检查证实，且内镜下形态改变类似良性病变的早期胃癌25例。结果25例患者平均年龄为（58．59±9．35）岁，男女患病率无显著差异（P〉0．05）。21例（86．00％）患者有不同程度的临床症状。分化型癌19例，未分化型癌6例。黏膜内癌19例，黏膜下癌6例，均无淋巴结及远处转移。在内镜检查时发现可疑恶性病灶者18例，7例为内镜诊断良性病变由活检病理意外发现，漏诊率28％。有22例次接受色素染色后放大内镜、内镜荧光早期胃癌诊断仪（ISF）、智能电子分光内镜（FICE）检查等内镜精检，内镜精检和常规内镜检查的首次活检阳性率分别为81．8％和52．00％。大体形态以平坦型和凹陷型为主，内镜表现与良性息肉或炎性增生；局部黏膜发红或退色；局部黏膜粗糙或颗粒样或糜烂及良性溃疡相似。结论形似良性病灶早期胃癌易误认为良性病变，常规内镜首次活检阳性率低，应进行内镜精检并积极随访复查，避免延误诊断和治疗。

73例早期胃癌内镜特点分析

目的探讨早期胃癌(EGC)内镜特点及诊断方法的实用性。方法对73例EGC进行回顾性分析,对白光胃镜下黏膜异常表现,行色素胃镜及放大胃镜检查,根据腺管开口、微血管形态靶向活检送病理,病理明确癌变者行内镜下黏膜剥离术(ESD)或手术切除,术后病理作为最终诊断;记录整个检查过程中的所有表现及结果,综合分析。结果 73例发现病灶86处,其中9例有2处病变,2例有3处病变,白光胃镜下以0-Ⅱc型居多,占43.84%;腺管开口Ⅲ型23处、Ⅳ型44处,Ⅴ型19处;微血管形态规则型51处(59.30%)、不规则型29处(33.72%)、未发现微血管结构6处(6.98%)。普通白光胃镜与病理诊断完全符合率为60.46%(52/86)、基本符合率为72.09%(62/86),放大内镜与病理诊断完全符合率为93.02%(80/86)、基本符合率96.51%(83/86),两者相比差异有统计学意义(P<0.05)。结论 EGC内镜下具有特异性表现,根据这些表现可以加强对EGC识别能力,提高EGC诊治水平。

普通白光联合窄带成像放大内镜对早期胃癌浸润深度的诊断价值

目的:建立普通白光内镜(conventional white light endoscopy,C-WLE)联合窄带成像放大内镜(magnifying endoscopy with narrow-band imaging,ME-NBI)诊断早期胃癌(early gastric cancer,EGC)浸润深度的模型,提高EGC深度诊断的准确性。方法:回顾性分析2018年1月至2020年10月河北医科大学第四医院行黏膜下剥离术(endoscopic submucosal dissection,ESD)或手术治疗的241例EGC患者,用χ^(2)检验分析EGC黏膜下深层浸润的危险因素,应用Logistic回归模型分析EGC黏膜下深层浸润内镜下表现的独立危险因素,构建预测EGC浸润深度模型。结果:χ2检验结果表明黏膜皱襞变化、易出血、溃疡、边缘隆起、无血管区、扩张血管、微血管结构缺失、表面结构缺失是EGC黏膜下深层浸润的危险因素。Logistic多因素回归分析表明溃疡(OR=5.696,95%CI:1.656~19.590;P=0.006),边缘隆起(OR=5.363,95%CI:1.469~19.573;P=0.011),无血管区(OR=8.990,95%CI:2.522~32.042;P=0.001),扩张血管(OR=8.435,95%CI:3.323~21.408;P<0.001)为EGC黏膜下深层浸润的独立危险因素。将上述独立危险因素分别赋分为4分、4分、5分、5分,构建预测浸润深度的模型,AUC为0.802,最佳临界点为8分,诊断敏感度为71.4%,特异度为85.6%,准确率为82.5%。结论:依据C-WLE联合ME-NBI诊断EGC黏膜下深层浸润的独立危险因素构建的诊断模型有助于术前准确诊断EGC的浸润深度。

术后早期肠内营养对胃癌术后胃肠功能恢复和营养状况的影响

目的观察术后早期肠内营养对胃癌术后胃肠功能恢复以及和营养状况的影响。方法收集胃癌手术患者共90例,随机分为对照组45例和观察组45例。对照组于术后24 h开始进行肠外营养,观察组于术后24 h起进行肠内营养。比较2组排气和排便时间及肠鸣音恢复时间。检测2组腹胀发生情况。应用酶联免疫法(Elisa)测定2组前白蛋白(PA)、白蛋白(ALB)和生长激素(GH)水平。结果术后观察组患者的排气、排便以及肠鸣音恢复时间明显少于对照组(P<0.01)。术后24 h和48 h观察组的腹胀发生率显著低于对照组(P<0.01)。观察组患者胃肠功能恢复优良率为53.33%,对照组为28.89%,2组差异有统计学意义(P<0.05)。术后10 d,观察组患者血清PA、ALB和GH水平显著高于对照组(P<0.01)。结论胃癌术后早期肠内营养可促进胃肠功能恢复,改善机体营养状况。

内镜黏膜下剥离术治疗早期胃癌术后复发的相关因素分析

目的探讨内镜黏膜下剥离术(ESD)治疗早期胃癌(EGC)的术后复发情况及相关危险因素。方法回顾性分析2016年1月-2019年12月青海省人民医院消化内科实施ESD治疗且病理结果为EGC的258例患者的临床及随访资料,分析影响术后复发的相关因素。结果258例患者术后均获得长期随访,随访期间14例复发,复发率为5.4%,平均复发时间为(10.6±4.3)个月。经单因素和多因素统计分析,病变浸润深度为SM2或以上(OR=5.22,95%CI:1.257~21.648,P=0.023)、病变最大径≥4.0 cm(OR=5.23,95%CI:1.331~20.568,P=0.018)是影响ESD术后复发的独立危险因素。结论ESD治疗EGC临床疗效好,病变的浸润深度及大小是影响ESD术后复发的独立危险因素。