Article pp.26-24 du Vol.8 n°2 (1978)

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V o u s a v e z p u l i f e

RESUMES SI~LECTIONNI~S

Follow up studies on development and course of gastric cancer

Yanao O G U R O

Internal Medicine Department, National Cancer, Center Hospital Gastroenterological Endoscopy, 1977, 19, 738-739 We have classified endoscopic follow up

studies of the gastric cancer into two methods.

One is a retrospective study, and the other is a prospective study. Under retrospective study, it is defined as a follow up study on proven gastric cancer by surgery, collecting preceding endoscopic films. According to this method, changes of macroscopical features can be followed, but it is impossible to clarify their malignancies at their initial pictures or to comfirm the time when they change to the cancer. At a retrospective study, almost all initial pictures are worse or misdiagnosed and without biopsy.

We have experienced 93 lesions of retrospective study of the gastric cancer for long period. Out of them, elevated types, interme- diate types and U I ( - - ) types of the gastric cancer were 36 lesions and depressed types and U I ( + ) types of the gastric cancer were 57 lesions. As for stage of cancer, 46 lesions were the advanced and 47 lesions were the early. On initial features, flat lesions were 39, scar were 23, polyp was none and gastric ulcer were 7. We called flat lesions as no finding, atrophic types of gastritis, erosive types, scar ? and II b ? all together. Based on these fre-

quencies, we cannot conclud that malignant changes from flat lesions were higher than from the polyp or gastric ulcer, because flat lesions were very common.

We have experiened 10 cases of positive changed biopsy out of 379 cases of prospective study. In our prospective studied group, we selected only following cases as followed with periodic and exact biopsy for more than 2 years. As far as each lesions, 3 (3.4 % ) cases of positive changed biopsy result were detected out of 88 cases of the gastric polyp prospectively followed, i (8.3 % ) from 12 of the group III of the gastric atypical epithelial lesion, 5 ( 2 . 1 % ) from the gastric ulcer and none from 18 atrophic gastritis. It is very difficult to differentiate whether false negative or malignant change when biopsy result changes from negative to positive. The former is a failure of biopsy and the latter is a case of cancerous cange from the benign lesion. But in our groups, there were very few possibilities of false negative, because enough, exact, periodic and long term biopsies were performed.

We believe that there were some cases changed from the benign to the cancer in these positive changed cases.

Process of human gastric cancer

Y. K O H L I and S. T A K E D A Dept. of Medicine, Kyoto Pref. Univ. Med.

Gastroenterological Endoscopy, 1977, 19, 740-741 With the recent advances of diagnostic abi-

lities of gastric cancer in x-ray and endoscopy, we have been able not only to diagnose almost

all cases of early gastric cancer, but also to presumpt its pathological pattern from the x-ray film a n d / o r endoscopic picture.

Acta Endoscopica Tome VIII - N ~ 2 - 1978 X X I

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In this paper, we would like to discuss the developmental process of gastric cancer with its time course from the retrospective and prospective point of views.

MATERIALS AND METHODS Among 932 cases of resected gastric cancer in our university hospital, including 287 cases of early gastric cancer, 6l cases have been retrospectively followed up over 3 months by endoscopy and/or x-ray. Furthermore, 3 cases are prospectively followed up by endoscopy, because of the refusal of the patient to his surgical treatment. Using these cases, process of gastric cancer was studied by endoscopy and the initial pattern of gastric cancer was presumpted.

Secondly, the boubling time of mucosal gastric cancer was estimated, using 13 cases followed up over 3 months by x-ray.

RESULTS AND DISCUSSION The obtained results are shown in Figure 1.

Protruded type (II a) of early gastric cancer

has been unchanged in its size and shape during about 61 months in mean observation time, which is longer than that of depresed one. After developing to I I a + I I c type, however, it grows rapidly to advanced one during 6.5 to 12 months.

On the contrary, among various depressed types of early gastric cancer, II c or II c + II a type shows more rapid growth to advanced one, but I I c + III, I I I + I I c or III type does slower growth and almost unchanged in its size and shape during about 40 months.

Namely, peptic ulceration in I I c lesion is considered to be palying an important role as the elimination factor against cancerous growth. Actually, the douling time of II c + III or I I I + II c type is longer than that of II c or II c + II a type. Namely, in this se- ries, the doubling time of II c + III or I I I + II c type and II c or II c + II a type are estimated to be 989-3462 days and 577-1154 days, respectively.

Finally, from these retrospective studies, abnormal redness, discoloration, spotty ero- sion or disappearance of areal pattern is considered to be one of endoscopical initial findings of early gastric cancer.

...Mode of development of gastric cancer observed by endoscopy...

Toshihiko SAITO

D e p t . o f I n t e r n a l M e d i c i n e , T o k y o M e d i c a l College, T o k y o , Japan G a s t r o e n t e r o l o g i c a l E n d o s c o p y , 1977, 19, 742-743

The following presentation is a hypothesis of gastric cancer's developing procedures and developing course of time. This assumption has been made by comparing twelve cases of early cancer, six cases of advanced cancer, which were obtained from retrospective follow-up study, and one case of early cancer, one case of advanced cancer, which were obtained from prospective follow-up study.

I. The assumption of gastric cancer's developing procedures may be shown as follows :

a) Early cancer Type I

Type I I b developes into early cancer Type I.

Type II b developes into Type I through Type II c.

b) Advanced cancer Type Borrmann's Type II

Type I I b developes into Type Borr- mann's II through Type II c.

Type I I b developes into Type Borr- mann's II through Type I I c and through Type II a + II c.

XXII Tome VIII - N o 2 - 1978 Acta Endoscopica

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c) Advanced cancer Type Borrmann's III Type I I b developes into Type Borr- mann's III through Type II c.

Type I I b developes into Type Borr- mann's III through Type II c and through Type II c + III (also Type III + II c).

II. Malignant Cycle

It is assumed that Type II c is not accompanied with ulceration and also thay Type II c is lesion of initial stage prior to malignant cycle.

III. The assumption of gastric cancer's developing course of time

a) Mucosal cancer Type II c which inclu- des groupe of U1 II accompanied with ulceration and unaccompanied with ulceration develop,'s slowly.

b) Submucosal invasive cancer of Type I and Type II c may develope more rapidly than mucosal cancer Type II c dose.

c) In case of Type Borrmann's II (groupe of unaccompanied with ulceration), Type II b developes quickly into advanced cancer.

d) When comparing the development duration of Type II c into advanced cancer, Type Borrmann's III (U1 II accompanied with ulceration) developes more slowly than Type Borr- mann's II (group of unaccompanied with ulceration) does.

In assuming of gastric cancer's developing procedures and the course of developing time, it is necessary to consider that some biological factors of patients and their tumor immunities may responsible for the duration and procedures of cancer development.

Growth patterns of gastric carcinoma

Kazuhide T A K E Z O E

Dept. of Surgery, A o y a m a Hospital For Tokyo, Metropolitan Officials, T o k y o Gastroenterological Endoscopy, 1977, 19, 744-745

Endoscopic retrospective or prospective studies on growth patterns of gastric carcinoma during the period of 6 months to 7 years were possible with 57 lesions in 56 cases. In these cases, the lesions were initially overlooked, misdiagnosed, or were not operated for various reasons until the last time of observation.

In 28 cases in which the final diagnosis was superficial carcinoma, only 3 2 . 1 % of them showed apparent progressive growth, whereas growing tendency was evident in 89.7 % of 29 advanced cases. Concerning the speed of growth, there were cases, in which the lesions were vague at the time of the first examination but became obvious superficial cancers within 3 years or so. On the other hand, the cases, in which the initial diagnoses were superficial cancers showing apparent enlargement later either into larger superficial cancers or advanced ones, the changes occured mostly after 2 years. Most of those cases which were advanced cancers from the beginning showed consi-

derable increase in size within one year. These findings would suggest that some lesions stay at superficial stages for a fairly long period of time until they start to regrow while the other lesions continuously grow from the beginning.

As regards the morphological changes, the 7 cases in which the final diagnoses were superficial cancers, the macroscopic types were virtually unchanged for the observation period of 2 to 3 years. Among advanced cases, 10 lesions of Borrmann II cancer developed mostly from I I c or I I c like lesions, but some of them originated from II a or II b. Three cases of Borrmann III were from II c or II c like lesions.

We encountered a peculier case of Borr- mann II cancer of Stage IV which was un- resectable. Two years later it became like an ulcer scar and the patient is still alive at present after 7 years.

Acta Endoscopica Tome Vlll - N ~ 2 - 1978 X X I I I

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Retrospective follow-up studies on the growth of gastric cancer

Shigeru HISAMICHI, M.D.

Cancer Detection Center o[ Miyagi Cancer Society, Sendai, Japan Gastroenterological Endoscopy, 1977, 19, 746

The purpose of this study is to analyse the initial endoscopic figures, the natural courses and the speed of development of human gastric cancer by using the endoscopic findings. Our materials are 41 cases with gastric cancer who had been followed for more than one year.

The all gastrofiberscopic films of these cases must have good recordability especially at the locations of the cancer lesions and were studied retrospectively. The cases consisted of 27 of early gastric cancer and 14 of advanced cancer, but were expected from the cases of so-called malignant cycle.

Results :

(1) The initial endoscopic figures which are small polypoid lesion, redness, small excavated lesion, etc., of gastric mucosal appearance and their natural courses of development of gastric cancer are shown in Fig. 1.

(2) The average observation periods of the course to early cancer from the initial endoscopic study are longer than the course of development to advanced cancer from early cancer.

Developmental process of gastric cancer

Tozo HOSOI

Department o[ Internal Medicine School of medicine Juntendo University Gastroenterological Endoscopy, 1977, 19, 748

The course of gastric cancer development was studied, based on 54 cases of gastric cancer which had been followed up over 6 months by X-ray or endoscopy.

Retrospective and prospective analyses of the 54 cases revealed following results.

1) Type II a and II c early cancer tend to

grow up slowly in contrast with the fairly rapid growths of type I and II a + II c early cancer. 2) A kind of type II c early cancer, ill-defined and unaccompanied ulcer appears to develop most rapidly. 3) In every type of cancer, the growth is slow in its early stage and becomes rapid in its later stage.

Le diagnostic du cancer de I'estomac

G. M I L L E R , M. K A U F M A N N , Ph. G E R T S C H Praxis, 1977, 18, 545-551

Le diagnostic du cancer prdcoce de l'estomac est un des grands probl~mes de la gastro- entdrologie. Les Japonais pratiquent avec suc- c~s une d6tection pr6coce basde sur des examens de masse. Pour l'Europe, ce proc6d~

serait trop on6reux. Les examens doivent donc 6tre faits de faqon s61ective.

Dans ce but il faut que chaque syndrome douloureux de l'6pigastre persistant plus de

XXIV Tome VIII - N ~ 2 - 1978 Acta Endoscopica

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15 jours soit examin6 attentivement par le m6decin de famille, par le radiologue, par le gastroent6rologue.

Le premier pas sera l'examen radiologique.

Radiologue et gastroent6rologue doivent avoir une technique parfaite et savoir inter- pr6ter les images en recherchant un cancer pr&oce.

Chaque image suspecte doit &re contrSlde par un endoscopiste exp6riment6 qui effectuera de nombreuses biopsies. Si l'histologie est

ndgative, on effectuera un deuxi6me examen et de nouvelles biopsies. Si celles-ci restent n6gatives, et que subsiste la suspicion de cancer, il ne faut pas h6siter fi effectuer une rd- section gastrique.

L'estomac r6s6qu6 sera examin6 par un pathologue spdcialis6 dans le cancer pr&oce de l'estomac.

La clef du diagnostic pr~coce du cancer gastrique est la collaboration 6troite entre le m6decin de famille, le gastroentdrologue, le radiologue, l'endoscopiste et le pathologue.

Comparaison du cancer gastrique au d6but en Angleterre et au Japon

D.M.D. EVANS, J.L. CRAVEN, F. M U R P H Y , and B.K. C L E A R Y Gut, 1978, 19, 1-9

Avant l'introduction de l'endoscopie, sur 720 cas de cancer gastrique, quatre &aient diagnostiquds avant que le cancer ait atteint la musculeuse, soit 0,5 % . Depuis l'utilisation de l'endoscopie et biopsie per-endoscopique, 10 d'une s6rie de 101 cas de cancer gastrique ont 6t6 diagnostiqu& ~t ce stade de << ddbut >>, soit un taux de 10 %.

Les caract6ristiques cliniques morphologi- ques et histologiques de ces cancers au ddbut sont tout ~ fait comparables ~a ceux ddcrits

par les Japonais sous le terme de (< early gastric cancers >> et r6v61ent une remarquable similitude.

Les r6sultats de cette 6tude sugg6rent qu'une forte proportion des cancers de l'estomac en Angleterre pourraient &re diagnostiquds ~ un stade pr6coce grfice /t l'emploi d'investigations plus intensives chez des patients souffrant de troubles dyspeptiques, en particulier, en utili- sant les techniques radiologiques, l'endoscopie et les biopsies per-endoscopiques.

L'dvolution des cancers

C. L A G A R D E , B. HOERNI, M. D U R A N D Collection de monographies de cancdrologie

Editions Masson, 120, boulevard Saint-Germain, 75280 Paris Cedex 06

La pr6occupation majeure de l'endoscopiste devient de plus en plus le d6pistage, le diagnostic et parfois m~me le traitement du cancer.

L'endoscopie est de loin actuellement la meilleur technique d'exploration en canc6ro- logie.

Cependant l'endoscopiste ne doit pas de- venir un simple technicien. I1 doit rester un m6decin, un sp6cialiste capable de suivre son malade de bout en b o u t ; l'endoscope ne doit

&re pour lui que le prolongement de son ~eil et de sa main.

A c t a E n d o s c o p i c a T o m e V I I I - N O 2 - 1 9 7 8 XXV

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C'est pourquoi il nous a semblE important de presenter ici l'excellent ouvrage de C. Lagarde, B. Hoerni, M. Durand, consacrE /t l'Evolution des cancers.

Qu'il s'agisse de d6pister, de mesurer l'extension de la dissemination, ou de surveiller l'Evolution d'un cancer trait6, l'endoscopiste a besoin de connaltre le mode de propagation et de dissemination topographique, ainsi que la chronologie d'6volution du cancer en cause.

C'est pourquoi les auteurs ont divis6 leur ouvrage en deux parties:

la topographie, - - la chronologie.

La topographie envisage essentiellement l'origine et les diverses voies de propagation rant au niveau de /'extension locale qu'au niveau des propagations lymphatique et san- guine.

Un inventaire pr6th6rapeutique dans lequel sont expos6s les diff6rents moyens d'exploration de /a lesion cancEreuse, vient clore cette premi6re partie.

L a chronologie de l'Evolution tumorale est ensuite abord6e sous deux aspects essentiels : spontanEment et apr~s traitement.

Deux chapitres : pronostic et survie et gu6- rison terminent cet ouvrage. L'impression d'en- semble qui se dEgage de ce travail est essentiellement celle du choix d'un langage clair et concis. I1 permet aux non initiEs que sont souvent les endoscopistes d'appr6hender d'une mani6re plus concrete l'Evolution de la maladie cancEreuse.

A une 6poque off nous voulons tous faire des diagnostics prEcoces et des protocoles de surveillance des Etats prEcancEreux et des cancers traitEs, la lecture de ce manuel riche de 500 rEfErences nous parah indispensable.

F. V I C A R I

XXVI T o m e V I I I - N ~ 2 - 1 9 7 8 A c t a E n d o s c o p i c a