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Background: In this study, the accuracy of preoperative staging for gastric stump cancer, which has not been thoroughly investigated since the condition is rare, was investigated using computed tomography and gastroscopic imaging., Methods: Between February 1994 and April 2018, 49 patients with gastric stump cancer, following subtotal or total gastrectomy, were reviewed retrospectively. Preoperative diagnoses of clinical T and clinical N categories were compared with post-operative pathological diagnoses (pT and pN categories). Positive predictive values, accuracy, sensitivity and specificity were also evaluated., Results: The overall accuracy of T staging was 40.8%. The positive predictive value for cT3/T4 was 96.3%, whereas the positive predictive value for cT1/T2 was 72.7%. The overall accuracy for N staging was 61.2%. The positive predictive value of lymph node positive patients was 73.3%. The positive predictive value and sensitivity of over stage II were 96.6% and 84.8%, respectively., Conclusions: The accuracy of preoperative diagnosis using both computed tomography and gastroscopy imaging may be feasible for T3/T4 advanced gastric stump cancer, whereas diagnosing T1/2 gastric stump cancer must be carefully considered due to high misdiagnosis rates, relating to depth., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

HIK1083 and trefoil factor 2 (TFF2) are known to be expressed in gastric-type carcinoma (GAS), but they do not reliably mark all GASs, and focal expression can be missed in biopsy specimens. We aimed to investigate whether claudin-18 and alpha-methylacyl-CoA racemase (AMACR) could be surrogate markers to separate GAS from other types of endocervical adenocarcinoma (ECA) and to compare their usefulness with that of HIK1083 and TFF2. Claudin-18 and AMACR immunohistochemistry was performed, and the results were compared with that of TFF2 and HIK1083, using whole sections of 75 ECAs (22 GASs and 53 non-GASs) and 179 ECAs with tissue microarrays (TMAs). TMAs were built to simulate the assessment of immunohistochemical stains in small biopsies. Any membranous (claudin-18) or cytoplasmic/membranous (AMACR, TFF2, HIK1083) staining of >5% of tumor cells was considered positive. Of 75 ECAs with whole sections, claudin-18 was significantly more frequently expressed in GASs (21/22) compared with non-GASs (8/53) (P<0.01). In ECAs with TMAs, claudin-18 expression was significantly frequent in GASs (15/23, 65.2%) than in non-GASs (3/152, 2.0%; all usual-type) (P<0.01). All claudin-18-positive GASs showed intense staining except 1 case. Claudin-18 shared the same degree of sensitivity and specificity with HIK1083 and TFF2. Three clear cell carcinomas were positive for claudin-18, but none showed intense staining. AMACR was expressed in a subset of ECAs and showed no impact in distinguishing between GAS and other ECAs. Our results suggest that claudin-18 is a promising surrogate marker to separate GAS from other types of ECA, including clear cell carcinoma., Competing Interests: Conflicts of Interest and Source of Funding: Supported in part through the NIH/NCI Cancer Center Support Grant P30 CA008748 (R.A.S., K.J.P.). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The Japan Clinical Oncology Group has recently conducted large scale clinical trials with findings that have revealed pivotal strategies for the treatment of resectable gastric cancer surgery. These findings include the fact that D3 lymphadenectomy does not improve survival rates when compared to D2 lymphadenectomy, and it is not recommended for resectable gastric cancer. Also, a transhiatal approach is recommended, instead of the left thoraco-abdominal approach, for the treatment of adenocarcinoma of the esophago-gastric junction or gastric cardia which has invaded ≤ 3 cm of the esophagus. Gastrectomy with splenectomy and bursectomy had been recommended as a part of the D2 lymphadenectomy. However, the results of the recent clinical trials revealed that splenectomy should be avoided in total gastrectomy with D2 lymphadenectomy for proximal gastric cancer and that bursectomy should be avoided in gastrectomy with D2 lymphadenectomy for resectable gastric cancer. Both splenectomy and bursectomy were found to be unable to improve survival, but instead increased operative morbidity. These trials revealed that the above-mentioned invasive and aggressive procedures did not provide sufficient survival benefits and that gastric cancer surgery may be trending from an "invasive to less invasive" and "aggressive to more conservative" approach.

Gastric-type endocervical adenocarcinoma (GAS) is a recently described diagnostic entity originally characterized as a tumor with (1) voluminous cytoplasm that is (2) clear or pale eosinophilic, and (3) cells showing distinct cell borders. Since the initial tumor description there has been accumulating experience that the neoplasm, in addition to classic features, may show a wide spectrum of morphologic appearances. This paper describes and illustrates cases of GAS with focal or diffuse findings that include: densely eosinophilic cytoplasm, foamy cytoplasm, goblet cells, glands with elongated, stratified nuclei, glands with small cuboidal cells, glands with flattened cells, papillary growth, single cell infiltration and infiltration with microcystic elongated and fragmented pattern. All these patterns may bring up a differential diagnosis with other cervical malignancies such as usual, intestinal, endometrioid, clear cell, serous, and mesonephric adenocarcinoma. The paper describes the patterns of immunostaining of respective lesions that may aid in the diagnostic process and summarizes the main points of the differential diagnosis. GAS is associated with somatic and germline STK11 mutations and TP53 mutations but is invariably negative for human papilloma virus when tumor only is tested. It shows variation in incidence between countries. Awareness of the spectrum of morphologic appearances in GAS is important for accurate and confident diagnosis. Correct identification of GAS is important due to its propensity for ovarian and other distant metastases, markedly worse prognosis as compared with usual endocervical adenocarcinoma, and its relative resistance to chemotherapy.

Recently, exosome‑encapsulated microRNAs (miRNAs) have been attracting attention as stable and minimally invasive biomarkers in cancer patients. The aim of the present study was to clarify the value of plasma exosomal microRNA‑23b (miR‑23b) as a diagnostic and prognostic biomarker in gastric cancer (GC) patients at each tumor stage. We first selected recurrence specific exosomal miRNA by miRNA microarray from 6 GC patients (stage I) with or without recurrence, and 3 healthy volunteers. In this analysis, miR‑23b demonstrated the most significant change. Subsequently, we validated the usefulness of miR‑23b as a biomarker using the plasma exosome samples collected from 232 GC patients and 20 healthy volunteers. miR‑23b levels were evaluated by Taqman microRNA assays. Exosomal miR‑23b levels of GC patients were significantly lower than those of the healthy controls. A significant association was revealed between the plasma exosomal miR‑23b levels and the expression of miR‑23b in primary tumor tissues. Concerning the pathological condition, miR‑23b demonstrated a significant association with tumor size, depth of invasion, liver metastasis and TNM stage. The overall survival (OS) rates of low‑miR‑23b patients were significantly worse than those of high‑miR‑23b patients at stage I, II, III and IV. The disease‑free survival (DFS) rates of low exosomal miR‑23b patients were significantly worse than those of high‑miR‑23b patients at stage I, II and III. Cox multivariate analysis indicated that exosomal miR‑23b was an independent prognostic factor for OS and DFS at each tumor stage. Our results revealed that exosomal miR‑23b has potential as minimally invasive predictive biomarker for the recurrence and prognosis of GC in patients at all stages.

Purpose: Laparoscopic pylorus-preserving gastrectomy (LPPG) is performed to preserve function in treating early gastric cancer. However, gastric stasis is a potential complication of LPPG that could decrease postoperative quality of life, possibly due to gastric edema of the pyloric cuff caused by venous stasis. We introduced an infrapyloric vein (IPV)-preserving LPPG (iLPPG) procedure to prevent pyloric cuff edema and thus minimize the incidence of gastric stasis and investigated the early clinical outcomes of iLPPG., Methods: We reviewed 150 patients with gastric cancer who underwent LPPG between August 2011 and June 2013 at the Cancer Institute Hospital and analyzed postoperative complications, incidence of gastric stasis (requiring starvation longer than 72 h or an invasive treatment), and transient delayed gastric emptying (TDGE)., Results: Of the 150 patients, 56 underwent iLPPG and 94 underwent conventional LPPG without preservation of the IPV (cLPPG). Morbidity rates were 5.4% in the iLPPG group and 23.4% in the cLPPG group (P = 0.003). The incidence of both gastric stasis and TDGE was significantly lower in the iLPPG group than in the cLPPG group (0 vs. 8.5%, P = 0.03 and 0 vs. 7.4%, P = 0.046, respectively). Median postoperative stay was significantly shorter in the iLPPG group compared to the cLPPG group (9 vs. 11 days, P < 0.001, respectively)., Conclusions: Preservation of the IPV might prevent the incidence of postoperative gastric stasis after LPPG, resulting in a shorter postoperative stay.

Background: The measurement of a single abdominal image on computed tomography (CT) can provide an estimate of the total body skeletal muscle. We evaluate the change of the area of the psoas major muscle (PMMA) in a CT which was performed routinely after gastrectomy in gastric cancer., Methods: A total of 119 gastric cancer patients who underwent gastrectomy were enrolled for the study. A CT image at the top of the iliac crest level was obtained at the following times: 3 postoperative months (POM), 6 POM, 1 postoperative year (POY), 2 POY, 3 POY, and 5 POY. We analyzed the change rate of PMMA after gastrectomy and before or after recurrence., Results: PMMA change after gastrectomy was approximately between -8 and -10% over the 5-year observation period. PMMA in the R2 (macroscopic residual tumor)/recurrence group was lower than that in the no recurrence group, and a significant difference was observed at 2 POY (-21.7 ± 3.6% vs. -7.9 ± 2.3%, p < 0.01). PMMA after freshly diagnosed recurrence had decreased significantly by 14.1 ± 1.8% (p < 0.01)., Conclusions: Evaluation of PMMA change by CT after gastrectomy could assist in the diagnosis of the progression of cancer state in gastric cancer patients., (© 2017 S. Karger AG, Basel.)

Background: The feasibility of gastrectomy with standard lymphadenectomy for patients over 85 years of age is not known. This study investigated short- and long-term outcomes and the tolerability of gastrectomy with standard lymphadenectomy for patients over 85 years with gastric cancer., Methods: Altogether, 77 patients aged over 85 years underwent gastrectomy with lymphadenectomy for gastric cancer at the Cancer Institute Hospital, Japan from May 2000 to February 2012. Postoperative short-term outcomes and survivals were analyzed retrospectively. Standard lymphadenectomy was defined according to the Japanese Gastric Cancer Association guidelines. Lymphadenectomy without splenectomy during total gastrectomy was called "reduced" lymphadenectomy., Results: Distal gastrectomy was performed in 51 patients, total gastrectomy in 20, remnant total gastrectomy in 5, and proximal gastrectomy in 1 patient. Gastrectomy with standard lymphadenectomy was initially planned for 50 (64.9 %) patients and completed in 42 (54.5 %) patients. The other 8 patients underwent reduced lymphadenectomy because they required R1 or R2 resection. There were no deaths. The morbidity rate was 55.8 % overall and 54.8 % with standard lymphadenectomy. The most frequent complication was intestinal hypoperistalsis (29.9 %). The mean postoperative hospital stay was 19 days (range 10-70 days). The median overall survival time was 46.8 months., Conclusion: Coupled with comprehensive postoperative medical care due to the relative high morbidity risk, gastrectomy with standard lymphadenectomy for gastric cancer may be acceptable for relatively healthy patients over 85 years of age. Decisions to reduce the extent of lymphadenectomy during gastrectomy should not be based on advanced age alone.

Introduction: The feasibility, safety, and improved quality of postoperative life following laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with a hand-sewn anastomosis via a mini-laparotomy for early gastric cancer (EGC) have been previously established. Here we describe the surgical procedure of totally laparoscopic pylorus-preserving gastrectomy (TLPPG) using an intracorporeal delta-shaped anastomosis technique, and the short-term surgical outcomes of 60 patients with EGC in the middle stomach are reported., Methods: After lymphadenectomy and mobilization of the stomach, intraoperative gastroscopy was performed in order to verify the location of the tumor, and then the distal and proximal transecting lines were established, 5 cm from the pyloric ring and just proximal to Demel's line, respectively. Following transection of the stomach, a delta-shaped intracorporeal gastrogastrostomy was made with linear staplers., Results: There were no intraoperative complications or conversions to open surgery. Mean operation time and blood loss were 259 min and 28 mL, respectively. Twelve patients (20.0%) experienced postoperative complications classified as grade II using the Clavien-Dindo classification, with the most frequent complication being gastric stasis (6 cases, 10.0 %). The incidence of severe complications classified as grade III or above was 1.7%; only one patient required reoperation and intensive care due to postoperative intraabdominal bleeding and subsequent multiple organ failure., Conclusion: TLPPG with an intracorporeal delta-shaped anastomosis was found to be a safe procedure, although it tended to require a longer operating time than the well-established LAPPG with a hand-sewn gastrogastrostomy.

Background: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. Surgical resection with a free margin is the gold standard treatment for these lesions., Objective: The aim of this study was to evaluate the feasibility of performing laparoscopic resection for gastric GIST from the viewpoint of operative and long-term oncological outcomes., Methods: Between 2005 and 2011, a total of 78 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a retrospective single-center study. Patient and tumor characteristics, surgical procedures, risk classification, postoperative complications, mortality, recurrence, and survival time were collected from a database, and the descriptive statistics were estimated., Results: Patients (N = 78; 32 males and 46 females) with a median age of 63 years (range 31-82) were evaluated. The tumors were located at the cardia (10.3%), upper stomach (59.0%), middle stomach (23.1), and lower stomach (7.7%). The mean size of the tumors was 34.7 ± 12.1 mm. The laparoscopic procedures included wedge resection (92.3%), such as laparoscopy and endoscopy cooperative surgery (51.3%), and gastrectomy (7.7%). All cases exhibited a pathologically negative margin. The mean operative time was 147.5 ± 63.8 min, and the mean estimated amount of blood loss was 17.8 ± 47.9 ml. The mean length of hospitalization was 9.4 ± 12.8 days. The incidence of perioperative complications higher than grade III was 2.6%, including two cases of anastomotic leakage. Regarding risk classification, low, intermediate and high were observed in 61, 6, and 11 cases, respectively. During a mean follow-up period of 45.3 ± 18.5 months, one patient experienced local recurrence in the omentum. Meanwhile, four patients died due to other diseases; all other patients survived., Conclusions: Adequate oncologic resection was achieved in all cases. Laparoscopic surgery is a feasible option for gastric GISTs <5 cm.

We report a gastric cancer patient with positive peritoneal lavage cytology (CY1) who achieved 20-month progression free survival by S-1 monotherapy. An 82-year-old male patient who underwent distal gastrectomy with residual disease for type 4 scirrhous gastric cancer manifesting pyloric stenosis, direct invasion to the pancreas, and CY1. He received S-1 monotherapy postoperatively. His ECOG performance status (PS) was 0. The initial treatment schedule was 100mg/day, twice daily for 4 weeks with a 2-week rest, repeated every 6 weeks. Grade 2 thrombocytopenia at the end of the 5th course of treatment required discontinuation of one course of treatment, and subsequent treatment was continued with a dose reduction to 80mg/day. Afterwards, although treatment was temporarily postponed for 2 weeks, the dose modification enabled him to receive S-1 for 20 months, leading to a relative dose intensity of 81%. There was no evidence of disease progression. The most severe adverse events were transient grade 3 neutropenia as well as leukocytopenia, anemia, and thrombocytopenia, grade 2 each, without gastrointestinal toxicities. His PS was not deteriorated. Although survivalrates of CY1 gastric cancer patients are still poor, our case suggests that S-1 monotherapy is effective against CY1, even for patients aged over 80, if the relative dose intensity is maintained by comprehensive patient management and appropriate dose modification.

Systemic chemotherapy is the treatment recommended for prolonged survival in cases of metastatic gastric cancer. There have been a number of clinical reports of surgical resection of liver metastasis in selected patients with gastric cancer. Here, we report on a case of treatment of far advanced gastric cancer with synchronous multiple liver metastases with prompt S-1 in combination with fractional cisplatin sandwiched between twostage surgery. Metastases including peritoneal dissemination and extensive lymph node involvement were absent so it was feasible to completely remove all of the macroscopic liver metastases. Each step of the chemotherapy progressed satisfactorily and histological examination after the hepatectomy yielded a pathologically complete response of liver metastases from the gastric cancer. This strategy provides a promising treatment for far advanced gastric cancer with a limited number of synchronous liver metastases. The referral to surgical oncology is a crucial step for the documentation of pathological complete response.

The radical treatment of gastric cancer is complete resection of the tumor by surgery. For advanced gastric cancer, a multidisciplinary approach has been attempted to improve patient prognosis. Potentially resectable and curable advanced gastric cancer is treated with routine surgery, followed by postoperative adjuvant chemotherapy. For highly advanced gastric cancer, extended radical surgery or preoperative adjuvant chemotherapy have been attempted. Laparoscopic gastrectomy for advanced gastric cancer has not been widely used because of the difficult surgical technique involved, but enhanced magnification in the surgical field is expected to improve the accuracy of the lymph node dissection procedure. In future, the significance of currently available treatments should be investigated. The key treatment for advanced gastric cancer at present is surgery.

Background/aims: The anastomosis performed during laparoscopy-assisted pylorus-preserving gastrectomy (PPG) is usually handsewn; however, the technique is sometimes difficult because it is done through a small incision and the level of skill of each operator may vary. The present study describes a triangulating stapling technique used during an anastomosis in laparoscopy-assisted pylorus-preserving gastrectomy., Method: The 80-mm stapler was used 3 times for the triangulating stapling technique. The posterior walls, including the stay sutures, were joined by firing the stapler, and the anterior stomach ends were stapled in an everting fashion using two firings of the stapler. Both the anterior staple lines should overlap in the middle. Patient demographics and the operative data were examined., Results: The triangulating stapling technique was performed during laparoscopy-assisted PPG in 9 patients. The median time for the anastomosis during laparoscopy-assisted PPG using the triangulating stapling technique was 19.0 min (16.0-31.0). Postoperative complications, including gastric stasis and anastomotic failure, were not found in any of the present patients., Conclusion: The triangulating stapling technique using a linear stapler is a safe and reliable technique to perform and can be easily conducted in a short time. We therefore consider it a useful anastomosis method for laparoscopy-assisted pylorus-preserving gastrectomy, even by unskilled surgeons., (Copyright © 2010 S. Karger AG, Basel.)