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Background: The incidence of paraaortic lymph node metastasis (N4) in relation with the site of the tumour, and survival in patients with gastric cancer who underwent gastric resection and superextended lymphadenectomy (D4), have been analyzed., Methods: The frequency of paraaortic lymph node metastasis was studied in 132 patients who underwent gastrectomy with D4 lymphadenectomy during the period June 1988 - December 2000. Six patients with plastic linitis and 3 with carcinoma of the gastric stump were excluded from the analysis., Results: In personal experience the most frequent postoperative morbidity were respiratory complication (7.6%) and pancreatic fistula (6.8%). Among the 132 patients the total number of dissected nodes was 6362 and the mean number of dissected nodes per case was 48.2. The total number of retrieved lymph nodes from the paraaortic station was 755 with a mean number 5.7 per patients. N4 nodal involvement was found in 25 (19%) of 132 patients: 14 (36%) patients with carcinoma located in the proximal third, 5 (13%) with tumour located in the middle third and 6 (11%) with carcinoma of the distal third of the stomach. The median survival time and the overall cumulative 5-year survival rate for curatively (R0) resected patients were 74 months and 52% respectively., Conclusions: The presence of metastasis in paraaortic lymph nodes in 19% of our patients, the low morbidity and mortality, the good survival after superextended lymphadenectomy, suggest that this lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 in 36% of cases).

Background: To assess an additional prognostic value of Goseki histological classification to TNM staging system in adenocarcinoma of the cardia., Methods: Sixty-one patients curatively resected for advanced (T2, T3 and T4) cardia cancer at the I Division of General Surgery, University of Verona were classified in four different grades according to Goseki. Survival curves were estimated with Kaplan-Meier method and compared by the log-rank test. Multivariate analysis was performed by Cox regression model. c2 test was used to compare Goseki to Lauren classification and grading. After discharge from hospital all patients were followed with a mean follow-up of 39.5 months., Results: Lauren classification and grading were significantly related to tubular differentiation (p<0.01). Kaplan-Meier estimates of survival showed a better 5-year outcome for tumors with good tubular differentiation (19%), even though the difference with poor tubular differentiated tumors was not statistically significant (p'0.06). Diffuse type carcinomas and tumors with poor cytological differentiation showed a worse prognosis at univariate analysis (p<0.01). Multivariate analysis showed no additional prognostic significance of any of the histological classification analyzed. Only T (p<0.02; RR 2.2; IC 1.2-4) and N (p<0.01; RR 5; IC 2.4-11) were independent prognostic factors., Conclusions: In adenocarcinoma of the cardia, Goseki classification did not add any information to Lauren classification and to TNM staging system.

Background: In order to improve the accuracy in the assessment of depth of tumor invasion, we performed an ultrasound examination of the resected specimen intraoperatively just after removal by the surgeon (Intraoperative Ultrasonography (IUS). This prospective blind study reports the results obtained with the IUS in the staging of T in a group of 281 patients who underwent curative gastrectomy for gastric cancer., Methods: After the removal by the surgeon, the portion of the stomach harboring the tumor was submitted to ultrasonography with a linear 7.5 Mhz probe. An echo-free standoff pad was placed between the probe and the organ; a second echo-free standoff pad was interposed between the stomach and the support surface. The diagnosis of depth of invasion was based on the degree of disruption of the five-layer sonographic structure of the gastric wall., Results: The IUS staging of T corresponded to the pathological diagnosis in 256 out of 281 cases (overall accuracy 91.1%). The sensitivity in the different classes of T was, respectively, 91.2 in T1m cases, 83.3 in the T1sm cases, 89.6 in the T2 cases, and 93.5% in the T3 cases., Conclusion: The IUS on the resected specimen has a high degree of accuracy in the assessment of depth of tumor invasion and seems to be an important advance in the clinical staging of gastric cancer., (Copyright 2001 Wiley-Liss, Inc.)

Aims: To determine the significance of superextended lymphadenectomy (D4) in patients with gastric cancer. The incidence of para-aortic lymph node metastases (N4) was analysed as well as its relationship to the site of the tumour., Patients and Methods: The frequency of para-aortic lymph node metastases was assessed in 110 patients who underwent gastrectomy with D4 lymphadenectomy during the period from June 1988 to October 1999; five patients with plastic linitis and three with carcinoma of the gastric stump were excluded from the study., Results: The postoperative mortality rate was 2.7% (n = 3) and the postoperative morbidity rate was 29.1% (n = 32). In our experience the most frequent postoperative complications were pancreatic fistulas (7.3%) and respiratory complications (6.4%). Among the 110 patients, the total number of dissected nodes was 5245 and the mean number of dissected nodes per case was 47.7. The total number of retrieved lymph nodes from the para-aortic station level was 639, with a mean number of 5.8 per patient. N4 nodal involvement was found in 20 (18.2%) out of 110 patients: 12 (33%) patients with a carcinoma located in the proximal third, two (6%) with a tumour located in the middle third and six (15%) with a carcinoma of the distal third of the stomach., Conclusion: The presence of para-aortic lymph node involvement in 18.2% of the patients suggests that D4 lymphadenectomy should be considered in the curative surgical treatment of advanced gastric cancer, especially if located in the proximal third of the stomach (N4 + in 33% of the patients).

The aim of the study was to verify the long term results obtained in primary gastric lymphoma with a strategy consisting in surgery as first-line treatment. Over the period from January 1988 to December 1999, 44 patients with histologically proven primary gastric lymphoma underwent surgical treatment in the First Department of General Surgery of the University of Verona. Tumours were staged according to the Ann Arbor classification and divided, according to the Kiel classification, into high- and low-grade lymphoma. Patients received adjuvant chemotherapy depending on the grade of malignancy and/or completeness of resection. Of the 44 patients, 40 (90.9%) underwent curative resections, i.e. with complete macroscopic and microscopic tumour removal (R0), consisting in total gastrectomy in 34 cases and subtotal gastrectomy in 6. Twenty-five of 40 patients had stage IE and 15 stage IIE tumours. Adjuvant chemotherapy was given to 33 patients (30 high-grade lymphomas and 3 low-grade lymphomas with N2 metastases). The overall cumulative 10-year survival rate in patients who underwent R0 resection was 79% without any significant differences in 10-year survival between patients with high- and low-grade malignancy (both 79%; P = 0.582) or between patients with or without lymph node metastases (91% and 70%, respectively; P = 0.426). In conclusion, the present investigation suggests that surgery yields prolonged complete remission in a high percentage of patients affected by gastric lymphoma irrespective of histopathologic grade of the disease and nodal involvement.

Background: The aim of the present study was to evaluate the incidence of abdominal lymph node involvement of adenocarcinoma of the gastric cardia in relationship with the site and depth of tumor invasion., Methods: From July 1988 to April 1998, 79 patients with adenocarcinoma of the gastric cardia underwent surgical curative resection and D2 lymphadenectomy at the 1st Department of General Surgery of Verona University. Among these 79 patients, 16 had an adenocarcinoma of the distal esophagus (type I), 26 patients had an adenocarcinoma of the anatomic cardia (type II) and 37 had a subcardial adenocarcinoma (type III). The frequency of lymph node involvement in each of the lymph nodes as classified by the JRSGC were analyzed., Results: In type I carcinoma positive lymph nodes occurred in 20% of pT1, 33% of pT2 and 100% of pT3. Positive nodes along the lower half of the stomach were never found. In type II carcinoma positive lymph nodes occurred in 57% of pT1, 86% of pT2 and 83% of pT3. Metastasis along the greater curvature in 18% of advanced cancers were found. In type III carcinoma positive lymph nodes occurred in 83% of pT2, 94% of pT3 and in 100% of pT4. Nodes along greater curvature were involved in 21% of advanced cases and also infrapyloric lymph nodes involved in 13% of cases. The type II and III advanced tumors had involved paraortic lymph node in 33% of cases., Conclusions: These results suggest that for tumors of the cardia an extended lymphadenectomy is necessary to ensure the removal of all metastatic nodes.

The purpose of this article is to review the incidence and characteristic of first recurrence in a group of 182 patients who underwent curative surgery with extended lymphadenectomy (> or = D2). The median follow up was 46.4 months (range 14-111). The incidence of relapses was 3.3% in the early gastric cancer and 50.8% in the advanced cancer. First recurrence site was systemic in 69.4% of cases and locoregional in 22.6%. The major site of systemic recurrences were peritoneal surface (64.8%), liver (29.5%), and other extra abdominal metastases (5.7%). In 8% of the cases it was not possible to find the site of recurrence. Surgical resection was possible in only 2 out of 14 cases of local recurrence. The incidence of recurrence were directly correlated with the depth of tumor invasion (T1: 3.3%; T2: 20.6%; T3: 61.5%; T4: 70%) and node metastases (NO: 8.3%; N1+: 44.4%; N2+: 64.3%). In advanced cases the incidence of relapses after D1 lymphadenectomy was significantly higher than after D2 lymphadenectomy: 28.6% vs 5.5% in NO cases and 65.6% vs 49.3% in N+ cases. In conclusion it seems that extended lymphadenectomy is associated with a lower incidence of recurrences after curative surgery.

The expression of 67-KDa laminin receptor (LR) was investigated in a group of 75 patients who underwent curative gastrectomy for advanced gastric cancer, with special reference to the possible role in the tumor progression and in the overall survival. In 56 out of these 75 patients also the prognostic significance of proliferative activity was investigated using the monoclonal antibody Ki-67. The tumor LR expression and the Ki-67 labeling index (Ki-67 LI) were immunohistochemically determined in paraffin-embedded sections using the avidin-biotin immunoperoxidase method. The cumulative 5-years survival rate was 75.1% for patients without expression of LR, 52.6% for those with positive LR expression. Significant association between LR expression and depth of tumor invasion (p = 0.022) was found. By univariate analysis the presence of laminin receptor seemed to be associated with an higher risk of death (RR1.73-95% C.I. 0.71-4.20), but this effect disappeared after controlling for depth of tumor invasion. There was no significant relationship between the Ki-67 LI and wall invasion (p = 0.80) or nodal status (p = 0.73). The cumulative 5-year survival rates (95% CI) were 61.0% (35.3-79.2) in patients with Ki-67 index < 10%, 52.4% (29.7-70.9) with Ki-67 index = 10%-40%, 52.9% (27.6-73.0) with Ki-67 index > 40% and the differences were not statistically significant (p = 0.93). Also in multivariate analysis the proliferative activity did not independently affect survival (p = 0.98). An interaction between Ki-67 index and age was found and Ki-67 index > 40% was significantly associated with a poor prognosis in patients over 70 years old old (p = 0.002). In conclusion, tumor expression of laminin receptor could be correlated with gastric cancer aggressiveness, however its prognostic significance is already provided by depth of tumor invasion. The proliferative activity, determined with the monoclonal antibody Ki-67, does not seems to influence the survival except in elderly patients (> or = 70 years old).

The correct staging is of crucial importance in the choice of surgical treatment in patients affected by stomach carcinoma. In an attempt to achieve a greater accuracy in the diagnosis of depth of tumor invasion, we propose to perform ultrasonography of the gastric wall during surgery (in vitro ultrasonography). Immediately after removal by the surgeon, the portion of the stomach containing the tumor is submitted to ultrasonography with a linear 7.5-MHz probe. To obtain good ultrasonographic images it was necessary to interpose an echo-free standoff pad between the probe and the gastric wall and between the latter and support surface. On completion of ultrasonography, the surgical specimen was sent to the pathologist, who was unaware of the diagnosis formulated on the basis of in vitro ultrasonography (VUS). The VUS diagnosis of T corresponded to the pathological diagnosis in 87/93 cases (93.5% accuracy). In the early cancers the diagnosis was correct in 24/28 cases (85.7%); in the advanced cancers the diagnosis was correct in 63/65 cases (96.9%). In comparison with the results of the other preoperative and intraoperative techniques the accuracy of in vitro ultrasonography in diagnosing the depth of tumor invasion was clearly superior. We feel that VUS may become a basic instrument in T staging and an aid to the surgeon in deciding the extent of the resection and of lymphadenectomy in patients with gastric cancer.