• Journal of Gastric Cancer
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• v.8 no.3
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• pp.136-140
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• 2008

Purpose: Stage IV early gastric carcinoma (EGC) is a rare disease. We report here on 10 cases of EGC that showed metastasis in more than 15 lymph nodes. Materials and Methods: A total of 8354 cases of gastric carcinoma in patients who underwent surgical procedures between January 2001 and January 2007 at Samsung Medical Center were studied, and 10 cases were classified as stage IV EGC. We investigated their clinicopathologic characteristics. Results: There were 5 males and 5 females. Their ages at operation ranged from 46 to 76 years with a mean age of 61. All of the 10 patients had undergone curative resection for gastric cancer. The pathological diagnosis confirmed that all of the patients had tumor confined to the submucosa. The median size of the tumors was 5.3cm and the mean number of dissected nodes was 45.5 with a mean number of 22.2 involved nodes. Six cases were classified as the diffuse type and 4 were classified as the intestinal type by Lauren's classification. Histologically, 3 cases were signet ring cell carcinoma, 3 were poorly differentiated, 2 were moderately differentiated and 2 were well differentiated adenocarcinoma. Endolymphatic invasion was found in 9 cases. The median follow-up was 31 months. Adjuvant chemotherapy was done in 9 patients, and the patient who did not receive chemotherapy died by cerebrovascular accident. 2 patient had recurrence of gastric cancer and 7 survived without recurrence. Conclusion: More cases should be collected and further studies on the molecular and cellular tumor characteristics are required to characterize these tumors that show aggressive lymphatic spread.

• Journal of Gastric Cancer
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• v.8 no.3
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• pp.154-159
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• 2008

Purpose: Although most surgeons generally administer prophylactic antibiotics for more than three days, the optimal duration of antimicrobial prophylaxis in elective gastric surgery is still open to debate. The aim of this study was to determine if the duration of prophylactic antibiotic use can affect the recovery of patients after elective gastric surgery. Materials and Methods: A total of 93 patients with gastric cancer were enrolled in this study, between January 2007 and December 2007. Patients were excluded if they had an infection at the time of surgery or they underwent an emergency operation. The first antibiotics were commonly given from just prior to the operation. The patients were divided into three groups according to the operation periods: those who received antibiotics only on the day of operation (arm A), those who received antibiotics for up to 3 days (arm B), and those who received antibiotics for more than 5 days postoperatively (arm C). The antibiotic that was used was second generation cephalosporin. Results: The rate of surgical site infection was 12.9% (n=4) in arm A, 16.1% (n=5) in arm B and 19.4% (n=6) in arm C, respectively (P=0.788). No relationship was observed between the duration of prophylaxis and the rate of fever or the neutrophil counts during postoperative 7 days (P=0.119, P=0.855). Conclusion: The prophylactic effect of antibiotics on recovery, with the antibiotics being received only on the day of the operation, is as effective as receiving antibiotics for a longer duration after gastric cancer surgery.

• Journal of Gastric Cancer
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• v.5 no.4 s.20
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• pp.288-294
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• 2005

Purpose: Superficially spreading (SS) early gastric cancer (EGC) is characterized by wide horizontal extension without deep vertical invasion. It is a relatively rare form of EGC, and it's clinicopathological (C-P) characteristics are not evident. This study aimed to clarify their C-P characteristics. Materials and Methods: We defined SS EGC as invading less than the submucosal layer that measured more than 60 mm in diameter or wider than $5{\times}5cm \;(25cm^2)$ in width. The C-P characteristics and prognosis were compared between 69 patients with SS EGC and 319 patients with the common type EGC (EGC except SS type). Results: For SS EGC lymph node metastases, Lauren's diffuse type, lymphatic invasion were significantly higher than in common type EGC. In patients with SS EGC, all of the metastatic lymph nodes were anatomically distributed within the paragastric region, with fewer along the left gastric artery and common hepatic artery. In 6 cases of SS EGC with resection marqins less than 10 mm, there was no death during the follow-up period (4 to 13 years after operation) if margins were not involved. Age (>58 yrs), tumor site (upper 1/3), lymph node metastasis, submucosal invasion were statistically significant poor prognostic factor in univariate survival analysis. In multivariate survival analysis, age and lymph node metastasis were independent prognostic factors. However, tumor diameter or width was not a significant prognostic factor. Conclusion: Although SS EGC has histologically distinct properties, gastrectomy with free surgical margins and appropriate lymph node dissection $(D1+{\beta})$ could be a suitable treatment.

• Journal of Gastric Cancer
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• v.5 no.4 s.20
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• pp.222-227
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• 2005

Purpose: There are several reports suggested the usefulness of serum tumor markers, AFP, CEA and CA19-9 as prognostic factors or indicators for recurrence in gastric cancer. This clinical study was peformed to evaluate positive rate of tumor markers according to site of recurrence in gastric cancer. Materials and Methods: From the database of patients who underwent radical gastrectomy for gastric cancer between January 1999 and January 2004, 52 patients who showed recurrence were included in this retrospective study. Serum levels of tumor markers were measured at the time of preoperative diagnosis of the gastric cancer and at the time of postoperative recurrence during follow up, respectively. Results: The overall positivity of tumor markers at the time of recurrence was found to be significantly higher than that of prior to surgery in the recurred group for the single test as well as the combination tests. For the peritoneum, the most common recurrent site, the positivity of CA19-9 was higher at the time of recurrence. And the significant positivity of CEA at the time of recurrence was detected in the liver cases. Conclusion: Having a preoperative positive tumor marker may identify the patient as having an increased chance of a recurrence. Although tumor markers continue to have limited diagnostic significance in gastric cancer, CA19-9 may be useful as a predictor for peritoneal recurrence of the gastric cancer, and CEA for recurrence to liver.

• Journal of Gastric Cancer
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• v.6 no.2
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• pp.109-113
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• 2006

Purpose: Various minimally invasive surgical techniques, such as an endoscopic mucosal resection and a laparoscopic gastrectomy, are becoming common practice for some cases of early gastric cancer (EGC) defined in terms of the depth of invasion being limited to the mucosa or submucosa. However, there are rare cases of early gastric cancer with massive lymph-node metastasis. Materials and Methods: From 6 university hospitals of Korea, 2,772 EGC cases were resected during the various period of analysis (1,432 cases of mucosal cancer and 1,340 of submucosal cancer). Results: As control data, we used the data from a single institute, CHA University Hospital. There were nine cases of early gastric cancer (9/2,772, 0.32%) with N3 lymph node metastasis defined by more than 15 lymph nodes being metastasized according to the UICC-TNM classification (pT1N3, stage IV). Two cases were mucosal cancer (2/1,432, 0.1 4%), and seven cases were submucosal cancer (7/1,340, 0.52%). Metastasized lymph nodes varied in number from 18 to 52. There were three male and six female patients with a mean age of 57. This is a totally reversed sex ratio compared to the usual gastric cancer or EGC. Among the total of 9 EGC patients, there were 5 who had superficial spreading carcinomas with surface areas larger than $25\;cm^2$. This is a significantly higher proportion compared to the general EGC population. When we compared the tumor size according to the LN status, the N3 group was definitely larger than the other groups. 78% of the pT1N3 cases showed lymphatic invasion, which is very high compared to the 4.7% in general EGC cases. Among the 9 cases, 6 patients had too short a follow-up period to evaluate the correct prognosis, but there was one patient with a non-curative resection and two patients with early recurrence. Although the sample size is small and the follow-up period is short, we can expect a very poor prognosis when we consider the common prognosis of EGC that is widely known and accepted. Conclusion: From these results, we can a conclude that the risk factors for pT1N3 gastric cancer are female patients, submucosal invasion, larger tumor size, and lymphatic invasion. However rare, the existence of pT1N3 gastric cancer needs to be taken into consideration, especially during the diagnosis. Furthermore, minimally invasive treatment for EGC needs to be chosen with great precaution. Since the prognosis of pT1N3 gastric cancer is expected to be poor, aggressive adjuvant chemotherapy may be necessary. (J Korean Gastric Cancer Assoc 2006;6:109-113)

• Journal of Gastric Cancer
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• v.7 no.4
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• pp.185-192
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• 2007

Purpose: RUNX3, a novel tumor suppressor, is frequently inactivated in gastric cancer. In the present study, we examined the pattern of RUNX3 expression in gastric cancer cells from gastric cancer specimens and the impact of its alteration on clinical outcome. Materials and Methods: A total of 124 samples of both gastric cancer and normal tissue were obtained from 124 patients who underwent curative gastrectomy at the Seoul Medical Center from January 2001 to December 2005. RUNX3 expression was determined by immunohistochemical staining, and the results were analyzed. Statistical analysis wabased on clinicopathological findings and differences in survival rates. Results: The mean age of the patients was 61 years, and the male:female ratio was 1.9:1. The expression rate of RUNX3 was 59.7% (74/124). The expression rate was higher in differentiated gastric cancers (nucleus: 9.1%, cytoplasm: 57.6%) than in the undifferentiated types (nucleus: 5.2%, cytoplasm: 46.6%) (P=0.133). The 5-year survival rates according to RUNX3 expression determined from cancer tissue were 88.9% for the nucleus $\pm$ cytoplasm(+) group of patients, 76.1% for the cytoplasm only (+) group of patients, and 65.3% for the RUNX3 negative expression group of patients (P=0.626). Only UICC TNM staging showed statistical significance related to the survival rate, as determined by multivariate analysis. Conclusion: The RUNX3 expression rate was higher in differentiated gastric cancer than in the undifferentiated types without significance. Although RUNX3 expression predicted better survival, based on multivariate analysis, the finding was not statistically significant. More cases should be further evaluated.

• Journal of Gastric Cancer
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• v.7 no.4
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• pp.193-199
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• 2007

Purpose: Combined resection of an invaded organ in advanced gastric cancer (AGC) with infiltration of adjacent organs is essential to achieve R0 resection. However, when the tumor invades the head of the pancreas or duodenum, R0 resection interferes with the lower resectability and results in a higher morbidity. Wereviewed these cases retrospectively and considered the proper extent of the surgical resection. Materials and Methods: We retrospectively analyzed cases where patients underwent surgery for gastric adenocarcinoma at the Department of Surgery, Presbyterian Medical Center, between January 1998 and December 2003. Among the 45 patients who were suspected to have pancreatic head or duodenum invasion by a primary tumor or metastatic lymph nodes based on the operative findings, we included 22 patients without incurable factors. The patients were classified into three groups: 4 patients that underwent a combined resection (PD group), 12 patients that underwent a palliative subtotal gastrectomy (STG group) and 6 patients that underwent bypass surgery only (GJ group). We analyzed the clinicopathological features, operative data and results. Results: The patients of the PD group achieved R0 resection by PD with D3 Dissection in all Patients. A pancreatic fistula was observed in one patient (morbidity 25%). There was no surgery-associated mortality (mortality 0%). All patients of the PD group were in stage IV. However, the 2-year survival rate (SR) was 75% and the 5-year SR was 50%. Six patients of the STG group underwent surgery with marginal resection and the other six patients of the STG group had a positive distal resection margin. The 2-year SR was 41.7% and the 5-year SR was 16.7%. Most of the patients of group GJ were of old age (mean age: $72.7{\pm}8.6$ years) or had chronic diseases. The 2-year SR was 0%. Conclusion: Combined resection of the pancreas and duodenum in AGC with pancreatic head invasion is relatively safe with moderate morbidity and a lower mortality. One can expect long-term survival if combined resectionis performed in cases without incurable factors.

• Investigative Magnetic Resonance Imaging
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• v.12 no.2
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• pp.178-187
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• 2008

Purpose : To evaluate and compare the diagnostic accuracy of MRI and ultrasound(US) for estimation of invasion depth of gastric carcinoma by correlation with histopathologic findings in vitro and to find out the best MR pulse sequence for detection and accurate delineation of tumor. Materials and Methods : Resected specimen of total or subtotal gastrectomy from 53 patients with gastric carcinoma were done of imaging studies of MRI and US. And US was examined by using high frequency linear transducer for tumor invasion depth by a radiologist. In each case, both imaging findings of MRI and US were evaluated independently for tumor detection and invasion depth by consensus of two radiologists and were compared the diagnostic accuracy between two imaging modalities according to the histopathologic findings. MR imaging with five MR pulse sequences, spin echo T1 and in- and out-of phase gradient echo T1 weighted images, FSE and SSFSE T2 weighted images, were performed. Five MR pulse sequences were evaluated and compared on the point of detection and accurate distinction of tumor from surrounding normal tissue. Results : In EGC, diagnostic accuracy of US(77%) was superior than that of MRI(59%) but no statistically significant difference was noted between two imaging modalities(p=0.096). In AGC, both imaging modalities of MRI and US showed relatively high diagnostic accuracy as 97% and 84% respectively. Diagnostic accuracy of MRI was statistically better than that of US at the significant level(p<0.001). The best MR pulse sequence among five in each specimen was FSE T2WI(75.5%, 40/53) in both EGC and AGC. In AGC, FSE T2WI showed excellent imaging quality by showing very high ratio (93.5%, 29/31) of accurate delineation of tumor. Conclusion : MRI and US show relatively high diagnostic accuracy in the evaluation of tumor invasion depth of resected specimen in AGC. The most excellent pulse sequence of MRI for the evaluation of tumor invasion depth is FSE T2WI on the point of detection and accurate delineation of tumor in both EGC and AGC.

• Radiation Oncology Journal
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• v.15 no.2
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• pp.113-119
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• 1997

Purpose : Radical gastrectomy is main treatment of gastric cancer. But the result is not satisfactory with surgery alone. Most of pattern of failure remain locoregional recurrence. To improve 5 year survival postoperative chemotherapy with or without radiotherapy has been used. We analyzed patients with stage III and IV stomach cancer who had radical operation and received postoperative radiation therapy combined with or without chemotherapy retrospectively. Material and Method : From March 1985 to June 1993, 68 patients treated with curative resection and received postoperative adiuvant radiotherapy with 36Gy or more were evaluated. Median age was 60 years(range 28-66 yrs) . Patients were followed from 3 to 133 months with median follow up of 48 months. Thirty seven patients had non signet ring adenocarcinoma, 29 signet ring cell, 2 other cell. Patients with stage IIIA, IIIB, IV disease were 19, 25 and 24 respectively Chemotherapy was given to all patients except two. Results : Five-year overall survival and disease-free survival rate were 36.6% and 33.6%, respectively. Prognostic factor affecting survival were assessed. High ratio of jnvolved/dissected Iymph node, signet ring histology showed Poor Prognosis with statistical significance. Presence of residual tumor after surgery, stageIV. split course of radiation therapy, age, number of involved Iymph node, number of Iymph node dissection and grade of tumor affected survival without statistical significance, Type of chemotherapy did not affect survival. Recurrence was documented in 34 patients. High recurrence was seen in omentum and peritoneum with 23.5%, and remnant stomach, anastomosis site, A-loop and I-loop had also high recurrence with 13.2%. In field locoregional recurrence was 20.7% and total distant metastases were 39.7%. Total intraabdominal failure was 47.1% and extraabdominal failure was 13.2%. Treatment toxicity was considered to be acceptable. 22.1% of patients had grade 3 and only 1 patient had grade 4 leukopenia. Six Patients(8.8%) had weigh loss more than 10%. Conclusion : Treatment toxicity was acceptable with combined treatment with chemotherapy and radiotherapy. Locoregional recurrence was relatively low compared to distant failure with addition of irradiation. Peritoneal and omental seeding was high Five-rear surival was increased with combined modality. Radiation may eradicate minimal residual disease and improve survival, To evaluate role of radiation Prospective randomized study employing chemotherapy alone and chemotherapy plus radiation is necessary. Futhermore to reduce intraabdominal failure, role of intraabdominal chemotherapy in addition to combined chemotherapy plus radiation has to be explored.

• Journal of Gastric Cancer
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• v.6 no.4
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• pp.250-256
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• 2006

Purpose: Recently, interest in peroxisome-proliferator-activated receptors (PPAR) has increased, although clinical studies of the effect of $PPAR-{\gamma}$ expression on gastric cancer have not been reported yet. In this study, we investigated the role of $PPAR-{\gamma}$ expression in gastric cancer patients. Materials and Methods: One hundred twenty-eight (128) samples of both gastric cancer and normal tissues were obtained from 128 patients who had undergone at a curative gastrectomy at Seoul Medical Center from Jan. 2001 to Dec. 2005. $PPAR-{\gamma}$ expression was determined by using immunohistochemical staining, and the results were analyzed. The statistical analysis was based on clinicopathological findings and the differences in survival rates. Results: The mean age of the patients was 6n, and the male : female ratio was 1.9 : 1. $PPAR-{\gamma}$ expression was significantly higher in cancer tissues than in normal tissue (81.3% vs. 57.0%, p<0.001). There was insignificant difference between well and moderately differentiated types and poorly differentiated types in terms of the expression of $PPAR-{\gamma}$ (87.0% vs. 74.6%, P=0.074). In the univariate analysis the survival rate was significantly increased when $PPAR-{\gamma}$ was expressed in normal tissue (P=0.003). In the multivariate analysis, only the UICC TNM staging had significance related to the survival rate. Conclusion: The rate of $PPAR-{\gamma}$ expression was higher in cancer tissue than it was in normal tissue from gastric cancer patients. In the univariate analysis, $PPAR-{\gamma}$ expression in normal tissue had significance with respect to survival, but the multivariate analysis showed no such significance. Thus, we should further evaluate more cases to determine whether or not such a significance exists.