Article pp.133-153 du Vol.11 n°2 (1981)

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D i o g n o s i s / O i o g n o s l i c EDITORIAL

Progress of gastric carcinoma diagnosis and long term surgical

results of early carcinoma

Tsutomu KIDOKORO (*), Yasuo HAYSASHIDA, Motomichi URABE, Shinsuke WATANABE, Katsujiro MAEKAWA and Kazuhide KUMAGAI

Juntendo University School of Medicine, The First Surgical Department, 2-1-1, Hondo, Bunkyo-ku, Tokio (Japan)

Le cancer gastrique superficiel :

progr6s du diagnostic et r6sultats chirurgicaux 61oign6s

1. R E C E N T P R O G R E S S OF E N D O S C O P I C A L T E C H N I C I N D I A G N O S I S O F G A S T R I C C A N C E R

Early gastric cancers account for about 14 % of all resectable gastric cancer cases in Japan.

Table I shows the comparative study of both data from W,I-IO CC Monograph No. 2 and the one of our clinic.

The difference between these two are mainly based on a circumstance to pick up gastric cancer patients together with an ability of gas.tric cancer diagnosis.

In Japan diagnostic technic of G.I. tract pro- gressed considerably within these 15 years, particularly X ray diagnosis and endoscopic diagnosis are so advanced and generalised overall Japan that early gastric cancer is now numerously detected every year not only in university but also in smaller clinics as well.

In this paper macroscopic feature of early gastric cancer is classified in accordance with the classification proposed by Japan Endoscopic Society 1962.

TABLE I

FREQUENCY OF EARLY GASTRIC CANCER CASES IN ALL RESECTABLE GASTRIC CANCER

CASES IN JAPAN

AII resected cases . . . Early cancer . Advanoed

cancer . . . . Unknown . . .

(Japan) luntendo Univ.

1963-1966 1969-1978

5 706 795 (13,9 % 4 286

625

1 233 437 (35,4 % 796

0

Address for reprint : Tsutomu Kidokoro, J u n t ~ d o University School of Medicine, The First Surgical Dept., 2-1-1, Hondo, Bunkyo-ku, Tokio (Japan).

Key-words : cancer, early gastric cancer, endoscopy, gastrocamera stomach, tong term survey, surgery, vital staining.

Mots-cl~s : cancer, cancer gastrique superficiol, chirurgie, colorations vitales, gastrocam6ra, endoscopic, estomac, survie post-chirurgicale.

Acta Endoscopica Tome XI - N ~ 2 - I98I 133

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This classification is divided in three groups, that is p r o t r u d e d ,type (type I), superficial type (type I I ) and excavated type (type I I I ) . T y p e I I is subdivided into three groups, namely slightly elevated type ( I I a), flat type ( I I b) and slightly depressed type ( I I c). C o m b i n e d type is repre- sented in connection of each of these types, such as I I a + I I c, I I c + I I I , and so on.

1) M i n u t e C a n c e r

Dr. Yoshida in o u r clinic studied on minute gastric cancer wi,th reference to chronic gastritis

as a background of cancer 9 His study was based on 293 lesions of 273 early gastric cancers including 14 cases of multiple early gastric cancers.

I n this study minute cancer is defined as one in which diameter of cancer is less than 0.5

• cm.

Table I I and table I l l represent size of early cancer in relation to .the depth of infiltration and the macroscopic ,type of early gastric cancer classified in accordance with the classification of Japan Endoscopic Society in 1962 respectively.

TABLE II

SIZE OF EARLY GASTRIC CANCER IN RELATION TO THE DEPTH OF CANCER INFILTRATION IN MY CLINIC

Minute

cm2 cancer 0.52-1.02 1.1~-3.02 3.12-5.02 5.12 Total

m . . .

s m . . .

21 (13.5 %)

1 (0.7 %)

22 (7,5 %)

21 (13.5 %)

9 (6.6 %) (10.2 %) 30

57 (36.5 %)

55 (40.1%) (38.2 %) 112

43 (27.6 %)

33 (24.1%)

76 (25.9 %)

14 (9.0 %)

39 (28.5 %)

53 (18.1%)

156 137 293

TABLE' I I I

SIZE OF EARLY GASTRIC CANCER IN RELATION TO MACROSCOPIC TYPE OF CANCER IN OUR CLINIC

(CLASSIFIED BY IAPAN ENDOSCOPIC SOCIETY 1964)

c m 2

I, lla, I I a + I l c . . . IIb . . . IIc, I l c + I I I , III . . .

Minute cancer 3 (3.9 %)

11 (68.8 %)

8 (4 %)

0 . 5 2 - 1 . 0 2

(16.9 %) 13 2 (12.5 %)

15 (7.5 %)

1.12-3.02 36 (46.8 %)

3.12-5.02 15 (19.5 %)

1 (6.3 %)

5.1 2 I0 (13.0 %)

2 (12.5 %)

76 60 41

(38.0 %) (30.0 %) (20.5 %)

22 30 112 76 53

(7.5 %) (10.2 %) (38.2 %) (25.9 %) (18.1%)

Total 77 16 200

134 T o m e X I - N ~ 2 - 1981 A c t a E n d o s c o p i c a

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Minute cancers except one lesion revealed the depth of cancer invasion limited to mucosa, whereas in cases of early cancer with 0.5-"

- - 1 . 0 2 cm 2 dimension sm cases are increased to 9 out of 30 cases, and as increasing size of lesion more and more sm cases are increased.

As concerned the macroscopic type of minute early cancer, generally, abounds in flat type and depressed or excavated type come after.

A clue .to find out such minute lesions is analysed in our clinic and most of them are found by multisectional examination of stomach resected due to coexistent lesion, and several lesions are found and diagnosed as minute cancer preoperatively. In cases of tiny cancer of 0.5'-'

- - 2 . 0 .2 cm 2 width of invasion correct diagnosis

will become more easier in accordance with the size of lesion (table IV).

TABLE IV

ABILITY OF ENDOSCOPIC DIAGNOSIS IN OUR CLINIC

Type Protruted of early or

cancer elevated

Minute 0

cancer .. XX 0.52-1.02 . OOOOO

XX

1.12-2.0-" . . OOOOO

OOOOO OOO

[at Depressed or cxcavated 0 0 0 XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O0 X o -- Correctly diagnosed eadoscopically.

X = Misdiagnosed or overlooked.

A case of minute cancer coexistent with a linear ulcer will be shown in this paper.

A 35 years old male had suffered from epigastralgy for several years, and examination of the stomach was done every year. Recently linear ulcer was diagnosed by X ray and endoscopic examination and a minute cancer

type I I c was found. Fiberscope picture revealed a minute cancer type I I c at .the anterior wall of body, a linear ulcer scar could be seen on the posterior wall corresponding to the minute cancer (fig. 1). Undervisual biopsy proved this lesion to be a tubular adenocarcinoma.

Though epigastralgy was relieved by conser- vative therapy, gastrectomy with dissection of regional lymphnode was performed.

Resected stomach revealed a long linear ulcer running from lesser curvature towards the posterior wall with remarkable shortening of the lesser curvature, and on the anterior wall adjacent to the linear ulcer a minute cancer of depressed type (II c) could be seen (fig. 2).

Generally speaking, histologically most of tiny gastric cancers less than 1.0 .2 cm z are proved to be well differenciated adenocarcinoma. My data showed all minute cancers were well-differenciated adenocarcinoma, and the larger the lesion grows the more frequently the case of poorly differenciated adenocarcinoma increases.

2) M u l t i p l e e a r l y g a s t r i c c a n c e r

F o r diagnosis of earIy gastric cancer we should not be ignorant to multiple cancer of stomach, as multiple cancer is more frequent in early cancer cases, compared with advanced ones.

In our clinic multiple early cancers were 27 cases among 437 early cancer cases accounting for 6.2 % , whereas early gastric cancers were found coexistent with advanced ones in 20 cases out of 746 advanced cases accounting for 2.8 % , and multiple advanced cancers were only 0.3 % (table VI).

The number of early cancers in relation to spread of the lesion are shown in table VII.

Minute cancers and small cancers within the range of 0 . 6 " - - 1 . 0 ' - ' cm'-' spread occupied 36.7 % and 15.0 % of all multiple early cancers respectively, and sum of them reached as high as 51.7 % of multiple early cancers.

And when relatively small cancers ranged between 1.12 cm'-' to 2.0 ~ cm'-' spread is added to these minute and small cancers less than 1.02 cm 2, it reaches as high as 70.0 % of all multiple early cancers.

Acta Endoscopica T o m e X I - N o 2 - 1981 135

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Figure 1

A gastrocamera picture which was taken by U turn technique for convenience of seeing the upper part of the stomach.

The axis of gastrocamera can be seen in the middle of this picture. A small depression indicated with arrows at the anterior wall shows a type II c early cancer, and at the posterior wall apart from this depression a linear ulcer scar can be seen.

Image de gastrocam6ra prise en cardiovision r6trograde pour examen de la partie proximale de I'estomac.

L'axe de la gastrocam6ra est reconnaissable au milieu de I'image. On peut observer une petite d6pression de la face anterieure correspondant a u n cancer superficiel de type I1 c (marqu6 d'une fl~che) en regard d'une cicatrice d'ulc6re lin6aire de la face post6rieure.

Figure 2

A resected stomach of the same patient. Remarkable shortening of the lesser curvature as the result of a long linear ulcer running across the lesser curvature can be seen.

A minute gastric cancer type II c is pointed with arrow.

Piece op6ratoire du m6me malade. R6traction marqu6e de la petite courbure cons6cutive & un long ulc~re lin6aire dispos6 en travers de celle-ci. Le mini-cancer type II c est indiqu6 par une fl~che.

Figure 3

Distribution of 76 lesions of 27 multiple early gastric cancer cases. Dotted lines with letter F indicate the border line between the fundic gland area and the antral gland area.

Distribution de 76 I~sions dans 27 cas de cancers gastriques multiples. Les lignes pointill6es marqu6es par la lettre F, indiquent les limites entre les zones de muqueuses & glandes de type fundique et de type antral.

Figure 4

The picture in which congo red dye spray method was applied by endoscope.

Dark blue stained area is the fundic area with parietal cells and red colored mucosa shows the antral portion.

Image endoscopique de coloration de muqueuse au rouge-congo. La zone color6e en bleu sombre d61imite la r6gion fundique & cellules pari6tales et la r6gion antrale rest6e rouge.

136 T o m e X I - N o 2 - 1981 A c t a E n d o s c o p i c a

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Figure S

A 63 years old female (early gastric cancer II c, sm) Methylen blue solution was sprayed through fiberscope and details of the mucosa surrounding a crater at the anterior wall o the stomach can be seen clearly.

Femme de 63 ans (cancer gastrique superficiel, type II c, sous-muqueux). L'instillation directe de bleu de m~thyl6ne par vole endoscopique d6finit clairement les d~tails du plissement muqueux au voisinage du crat&e ulc~reux de la face ant~rieure de I'estornac.

Figure 6

A 63 years old female (early gastric cancer II c, sin).

Upper half is a picture of a resected stomach of the same patient, and downward picture shows histological view of this lesion which proved to be a poorly differenciated adenocarcinoma (IOOX, HE).

Femme de 63 ans (cancer gastrique superficiel, type II c, sous-muqueux). La partie sup6rieure montre la piece de r6section chirurgicale et la pattie inf6rieure I'aspect histologique de cet ad6nocarcinome peu diff6renci6 (100 X, HE).

Figure 7

A type II c early gastric cancer on the lesser curvature of the gastric body.

A clip was settled by endoscope a few days before operation, and this clip served as a guide to recognise a resection line in the course of operation.

Cancer gastrique superficiel, type II c de la petite courbure du corps gastrique.

Une agrafe a 6t6 pos6e par vole endoscopique que',qu~s jours avant I'intervention destin6e & servir de rep6re au chirurgien Iors du choix de la limite de r~section.

A c t a E n d o s c o p i c a T o m e X I - N o 2 - 1 9 8 1 127

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T A B L E V

c m 2

Well differenciated adenocarcinoma . . . Poorly differenciated

adenocarcinoma . . .

Minute

c a D c e r

22

0.52-1.02

23 7

1.12-3.0 ~

78 34

o o

3.1--5.0-

34 42

5.12

25 28

Total

TABLE VI

MULTIPLE CANCER OF TIdE STOMACH : RESECTED SPECIMEN

Multiple early ca . . . Early ca. with advanced ca . . . Multiple advanced ca . . .

Multiple ca . . .

27 / Early ca.

20 / Advanoed ca.

2 / Advanced ca.

49 / Resect,ed gastric ca.

437 746 746

1 233

6.2 % 2.8 % 0.3 %

4.0 %

T A B L E V I I

cm2 I < 0.52 Number of .

cancers . . . 22 (36.7 %)

o o

0.6--1.0-

9 (15.0 %)

1.12-2.02

11 (18.3 %)

2.12_3.0 `2

7 (11.7 % )

2 ')

3.1 -4.0-

4 (6.7 %)

4.12-5.02

1 (1.7 %)

> 5.12

6 (10.0 %)

Total

60

So when one early gastric cancer is f o u n d in any region of the s t o m a c h b y e x a m i n a t i o n , you should r e m i n d the possibility of coexistence a n o t h e r minute o r small early gastric cancer in a n o t h e r p a r t of the stomach.

N e x t distribution of 76 lesions of 27 multiple early gastric cancer cases were studied (fig. 3).

By multisectional e x a m i n a t i o n of the resected s t o m a c h the b o r d e r l i n e between the fundic area and the a n t r u m were decided. I n t e r m e d i a t e zone b e t w e e n fundic m u c o s a and antral m u c o s a was included in the antral portion, as m o s t of cancers were seen in the antral p o r t i o n and

atrophic antral mucosa seems to be closely related with cancer.

I n fig. 3 the d o t t e d lines m a r k e d with the letter F on the anterior and pas,terior sides indicate the borderline between the fundic a r e a and the antrum.

W i t h the e x c e p t i o n of 2 lesions, all of the lesions were located in the a n t r u m and the inter- m e d i a t e zone.

This fact serves not only to l o o k for multiple early cancers, but also for decision of resection's line during operation, n a m e l y this d a t a shows

138 T o m e X I - N ~ 2 - 1981 A c t a E n d o s c o p t . c a

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that by surgery of antral early cancer the antral portion of the stomach should be removed as wide as possible, and when a part of antral portion has to be kept careful survey is neces- sary.

Here I will show a method to determine borderline of the fundus and the antrum using dye spray method.

After intravenous injection of 1 % histamine solution, congo-red solution is applied endosco- pically. Hydrochloride secreted from parietal cell of the fundic area changes the color of congo-red dark blue, on the contrary color of the antrum does not change and thus the borderline of the fundus and the antrum can be clearly shown (fig. 4).

To ascertain this borderline during operation an endoscopic clipping method is applied imme- diately after dye spray procedure.

Using this method we can certify the borderline of the fundus and the antrum easily from the serosal surface during operation.

3) O u r usual m e t h o d f o r e n d o s c o p i c diagnosis of early gastric cancer

When X ray examination revealed suspicious of cancer, endoscopic biopsy is mandatory to confirm cancerous tissue. We apply this undervisual biopsy firs{ to ascertain cancer, secondly to confirm the spread of cancer exactly as to serve for determination of the gastrectomy area.

This method is most useful for diagnosis of type I I b or II c early cancer.

For diagnosis of the gastric polyp polypoid cancer should be excluded carefully. For this purpose endoscopic polypectomy with multisectional examination of the polyp is usually done. By this multisectional examination we can diagnose not only existence of cancer but also depth of cancer invasion is fully recognised to serve for determination of surgical indication.

I will express new endoscopic technic which are useful for surgeon to help the surgical procedure.

a) Dye spray method (fig. 5).

The dye spray method is classified in direct and indirect method, which is to demonstrate

minute ups and downs by marking contrast with dye applied to the gastric mucosa.

The direct method refers to local application of a dye by injecting .through the biopsy channel of endoscope under visual control. This is the most common technique.

In the indirect method, a dye is administered orally prior to endoscopy. This serves not only for making contrast, but also for giving addi- tional information, since it has been proved that methylenblue is absorded by cancer cells and some of the cells with intestinal metaplasia.

Fig. 5 shows a fiberscopic picture of an ulcerative lesion on the anterior wall of gastric body. In the middle of picture shallow depression covered with white fur can be seen, converging folds are prominent and fine view of surrounding mucosa is evident.

The dye is distributed in ,the lower portions between folds and even in the interareolar furrous in some area and the detailed observation was thereby possible.

Despite rugal tips end at the ulcer margin without clubbling or irregular thinning which is the typical sign of malignancy, biopsy specimen from the ulcer margin proved a tubular adenocarcinoma.

Thus radical gastrectomy with regional lymphnode dissection was performed (fig. 6).

Comparing fiberscopic finding with resected stomach, we can analyse the converging rugal feature of fiberscope correspondent with those of resected stomach.

b) Endoscopic clip-on technique.

In fact in the course of surgical operation, we are sometimes embarrasser with the determination of border of mucosal invasion of early cancer.

Recently we tried to apply this technique to acknowledge the border of mucosal spread of cancer which is ascertained by endoscopy several days later.

In fact in the course of surgical operation sometimes embarrassed with the determination of border of mucosal invasion of early cancer.

If clips were applied several days before by endoscopic procedure, we could recognise the

Acta Endoscopica Tome X I - N ~ 2 - 1981 139

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border of cancer invasion easiiy by touching these clips from the serosal surface of stomach (fig. 7).

2. L O N G T E R M R E S U L T S

In this chapter endresul,ts of early gastric cancer in our clinic are presented. At first defini- tion of early gastric cancer will be explained according to the macroscopic classification of early gastric cancer from Japan Endoscopic Society proposed by Tasaka [4] in 1962 as shown previously.

For ,the purpose to evaluate the operative data of gastric cancer through all over Japan equally,

<< The general rules for the gastric cancer study in surgery and pathology >> were proposed by Japanese Research Society for Gastric Cancer in 1962 [3].

In this paper several words are used according to this rule. For instance <~ R >> means the width of lymphnode dissection, and when gastrectomy is performed without any lymphnode dissection, this type of operation is called

<<R0 ~.

And when dissection of lymphnode was performed as far as the first group, second group

and third group of lymphnode, each type of operation is called R,, R2 and R:~ respectively.

<~ Ow (+)~> or << ow (--)>~ deal with the histological finding of resected stomach with or without presence of cancerous tissue at the proximal resection line respectively.

Endresults of early gastric cancer and analysis of recurrent cases in our clinic are shown according to this rule.

1) M A T E R I A L A N D M E T H O D O F A N A L Y S I S

431 cases of early gastric carcinoma were resected in our clinic during the period of

11 years from April 1967 to March 1978.

Out of these, 20 cases of multiple gastric cancers were excluded. In the remaining 411 cases detailed pathohistological examination were done in 367 cases. These cases consisted of 184 m cancers and 183 sm cancers. The cases resected more than five years ago were 225 consisting of 114 ms and 111 sms.

Of these 225 cases, 2 cases escaped from the follow-up study. Eight cases were known to alive for 4 years but information was not available about their 5th year. Excluding these 10 cases, 95.6 % of the cases provided data as shown in table VIII.

T A B L E VIII

POSTOPERATIVE DEATH IN EARLY GASTRIC CANCER CASES

m

No. of cases

114

, s m . . . 1 1 1 ,

Total 225

Not followed

10

Died of recurrence within 5 years

Operative death

Died of other disease

15

Cause of death unknown

In 114 m cases, 4 cases were excluded because of incomplete follow-up. Death within 30 days after surgery was dealt as operative

death and this occured in 2 cases. Seven cases died of other diseases and one case died of unknown cause. Three cases died of recurrence.

140 Tome X I - N ~ 2 - 1981 Acta Endoscopica

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It should be noted in these figures that recurrence of early gastric carcinoma is rare whereas other diseases occupy a large portion of causes of death. In this study, we calculated the five- year survival rate as follows.

First of all immediate postoperative dea,th and untreatable cases are excluded from the number of calculation, and death by other diseases or unknown cause are added to death by recurrence taking a possibility of death by recurrence into consideration.

2) R E S U L T

a) Recurring rate within 5 years a[ter operation

The rate of recurrence within postoperative 5 years were calculated from the data in our clinic (table IX).

First of all, 4 cases of immediate postoperative death and 10 cases of untreatable cases were excluded from 225 cases of early gastric cancer, whereas death by other diseases or unknown cause totalled 17 cases was added to death by recurrence. Then the recurrent death within 5 years totalled 22 cases (10.4 % ) of 211 early gastric cancers and the five-year survival rate was 89.6 % .

In 108 cases of m excluded postoperative death and untreatable cases, death by recurrence occurred in three cases which is 2.7 % of the cases tolerated surgery. Death by other diseases and by unknown cause occured in 7 and 1 case which accounted for 6.5 % and 1.8 % , respectively. The lotalled 10.2 % , but death by recurrence was 2.7 % . If death by unknown cause is added, death by recurrence was 3.7 % , whereas 6.5 % died of other diseases.

In sm cases, in similar calculation, the five- year survival rate was 89.3 % . Death by recurrence, other diseases, and unknown cause was 1.9 % , 7.8 % and 1.8 % , respectively.

TABLE IX

FIVE-YEAR SURVIVAL RATE OF EARLY GASTRIC CARCINOMA

No. of Died of Died of other Died of Total

cases recurrence disease unknown cause

m . . . 108 3 (2.7 %) 7 (6.5 %) 1 (1.13 %) 11 (10.2 %)

sm . . . . 103 2 (1.9 % 8 (7.8 %) 1 (l.0 %) 11 (10.7 %)

Total .. 211 5 (2.4 %) 15 (7.1%) 2 (1.0 %) 22 (10.4 %)

b) Detail of recurrence

In table X are shown the details of type of recurrent lesions and their preoperative data of original lesions ; depth of invasion, macroscopic classification, extent of lymphnode dissection and the lenghts of survival.

In case no. J 166, the lesion was a I I c and sm, but it was operated as a benign ulcer

without sufficient preoperative survey because of hemorrhage which required emergency surgery. Lymphnode dissection was R0. The patient died of local recurrence at 4 years and 2 months postoperatively. Histopathological study at initial surgery had revealed presence of cancerous tissue at the proximal resection line [ow ( + ) ] . Irrespective of the fact that cancer was partly left behind the resection line, the patient could thus well survive for more than 4 years.

Acta Endoscopica Tome X I - N + 2 - 1981 141

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TABLE X

DETAILS OF RECURRENCE Case

(*) J 166 . . . . 1230 . . . . J 276 1541 ^.^.^.^. 1 855 . . . .

Depth of invasion

rft

m m s m

Macroscopic type

IIc I I c + I I I I l c + I I I

IIc IIc

Extent of dissection

R0 R2 R2 RI R3

Survival period 4 y 2 m 4 y l m 4 y 3 m 2 y 8 m 4 y 4 m

Form of recurrence

Local recurrence

Liver metastasis and carcinomatous peritonitis

Metastasis to liver and other organs Metastasis to liver and other organs Lymphatic metastasis and hematogenous remote metastasis

(*) J 166 : o w ( + ) .

In cases no. J 2 3 0 , J 2 7 6 and J 5 4 1 , the lesions were <~ m >~ of I I c or I I c + I I I type.

The patients died of recurrence at 2 years and 8 months to 4 years and 3 months after surgery, all associated with liver metastasis. Considering of the time of recurrence and that the lesions were intramucosal at surgery, it is probable that liver metastasis occured first and then they spread over peritoneal cavity or into other organs via blood stream. In cases of ow ( - - ) , which cancerous tissue is proved completely r e m o v e d at the examination of proximal resection line, therefore, hematogenous liver metastasis seems the most important route of metastasis.

T h e case no. J 855, an sm of I I c type, died of recurrence at 4 years and 4 months. Despite the fact that dissection up to the third group of nodes was performed in this case, recurrence was a combination of hematogenous and lymphatic metastasis.

c ) D e t a i l s o f d e a t h b y c a u s e s o t h e r t h a n r e c u r r e n c e

In ,table X I are shown causes of 18 non-cancer deaths. Cardiovascular diseases were attributable in the a g e d ; 3 C V A s and 2 heart problems.

T w o pa, tients committed suicide; which occupied a rather high percentage of causes of deaths. E v e n in early cancer cases, therefore, a careful psychological management as in advanced cases would be important. T h e other cases were

2 liver diseases, 1 operative complication-insuf- ficiency of anastomosis, 2 malignancies of other organs and 3 u n k n o w n causes. A .total of 18 patients died of those causes unrelated to recurrence, whereas: only 5 patients died of recurrence.

TABLE XI

DETAILS OF NON-RECURRENT DEATH

CVA . . . 3

Heart disorder . . . 2

Suicide . . . 2

Liver disease . . . 2

Operative complication . . . 1

Malignancy of other organs . . . 2

Unknown . . . 3 15

3 ) D I S C U S S I O N

By early gastric carcinoma as mentioned previously, is meant cancer limited to the mucosa or submucosa at most, and it is a fact that prognosis of such cancer is quite favorable.

Besides, macroscopic appearance of resected specimen can tell .the possibility of early stage cancer with a considerable certainty. Further- more, the relationship between the macroscopic

142 T o m e X I - N o 2 - 1981 T o m e X I - N ~ 2 - 1981

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appearance of the resected specimen and X-ray or endoscopic finding has been well studied with abundan,t meterials.

Furthermore nowadays we have various me- thods for diagnosis of minute changes of gastric mucosa including dye spray method. Conse- quently, preoperative diagnosis of early gastric carcinoma and its macroscopic type is now possible with considerable accuracy.

Among our cases in which preoperative diagnosis was early cancer, only 17 % of them were later found by histological study to have invaded beyond the submucosal layer falling into the category of advanced cancer.

Progress of endoscopic diagnosis enabled not only early diagnosis of gastric cancer, but also contributed to the simplification of operations technique.

Preoperative endoscopic clip-on technique is an indispensable method for determination of the resection line of the stomach by the operation of early cancer, particularly when the lesion spreads to higher portion of the stomach.

The classification of early gastric carcinoma does not involve the problem of lymphnode metastasis. According to the conventional common sense, cancer with metastasis tends to recur with poor prognosis. However, end results of early gastric carcinoma are excellent, in spite of the fact that lymphnode metastasis is not infrequent, e.g., 4.9 % and 18.6 % in

<, m >> and <, sm >> cancers respectively in our series (table XII).

TABLE XII

LYMPHNODE METASTASIS IN EARLY GASTRIC CARCINOMA

- - I

m . . .

s m . . . .

Total ..

n ( - - )

175 149 324

n ( + ) 9 (4.9 %) 34 (18.6 %) 43 (11.7 %)

Total 184 183

367

m --- c a n c e r i n v a s i o n i s l i m i t e d t o m u c o s a . s m = c a n c e r i n v a s i o n i s l i m i t e d t o s u b m u c o s a .

The metastases are however, limited mainly to the lymphnodes adjacent to the tumor.

Therefore, radical dissection is possible and good end results can be expected with exception of rare cases associated with early distant metastasis such as to the liver. In this paper such rare cases of recurrence are analysed. In our series 5 cases died of recurrence, and local recurrence is seen only in one case.

Residual 4 cas~s died of distant metastasis irrespective of gastrectomy with extensive lymphnode dissection. Even if early gastric cancer is concerned, when lymphnode metastasis had been proved by histopathological examination or in occasional cases of sm, sufficient postoperative chemotherapy may be indicated.

Excluding rare cases of recurrence, surgery of gastric cancer at early stages gives quite favorable result as shown in this paper, detection of early gastric cancer is most important for eli- mination of gastric cancer.

Finally I will show 2 collected data of long term results of early gastric cancer in Japan.

In 19'69, Hayashida [1] collected data of 2 364 cases of early cancer from all over Japan and reported end results over 5 years in 368 cases. 1972, Honda [2] collected the end results over 10 years.

C O N C L U S I O N S

With progress of endoscopic technique early cancer cases are increasing year by year in Japan.

In our clinic lesions from 1.13 cm .to 2.02 cm width are diagnosed correctly in 30 cases out of 31 cases, whereas minute cancers less than 0.5 cm by diameter are correctly diagnosed only 4 Cases out of 11 cases.

Thus dye spray method is widely applied in Japan to demonstrate minute change of the gastric mucosa clearly and this method serves to correct diagnosis of early cancer.

Particular use of endoscopic clipon method contributes to show the lesions border, and this clip can be palpated from the serosal surface on the stomach which enables the operator to feel

A c t a E n d o s c o p i c a T o m e X I - N ~ 2 - 1981 143

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the b o r d e r of lesion without gas.trostomy in the c o u r s e of operation.

Multiple cancer of s t o m a c h is analysed and the m e t h o d h o w to determine the resection line of s t o m a c h is discussed. N e x t long term results of early gastric cancer are p r e s e n t e d according to the d a t a of m y clinic.

431 cases of early gastric c a r c i n o m a were resected in our clinic during the p e r i o d of 11 years f r o m A p r i l 1967 to M a r c h 1978.

Of these, the cases resected m o r e than five years ago were 225 consisting of 114 ms and

111 sms.

D e a t h by recurrence o c c u r e d in 5 cases which is 2.4 % of the cases tolerated surgery. D e a t h b y o t h e r diseases a n d b y u n k n o w n cause o c c u r e d in 15 cases and 2 cases, respectively, which is a c c o u n t e d for 7 . 1 % and 1.0 % of the cases tolerated surgery. D e t a i l s of recurrence are analysed.

REFERENCES 1. HAYASHIDA T., KIDOKORO T. - - End results

of early gastric cancer collected from 22 i~astitutions, I to choh. Stomach in Intestine, 1969, 4, 1077-1085.

2. HONDA T. - - Ten years results of early gastric cancer. Gastroenterological endoscopy, 1977, 19, 613-629.

3. lapanese Research Society :for Gastric Cancer : The general rules for the gastric cancer study in surgery and pathology, 9th ed. Kanehara Co., 1974.

4. T A S A K A S. - - Early gastric cancer, collected data in ]apan. Gastroenterological endoscopy, 1962, 4, 4-14.

5. KIDOKORO T. - - Frequency of resection, metastasis and five-year survival rate of early gastric carcinoma in a surgical olinic. Early Gastric Cancer, lapanese Association, 1971, p. 45-49, University of Tokyo Press.

6. ASHIZAWA S., KIDOKORO T. - - Endoscopic color atlas of gastric diseases 1970, p. 1-223, Bun- kodo Co. Press, 1970.

1. P R O G R E S RI~'CENTS

D E S T E C H N I Q U E S E N D O S C O , P I Q U E S D A N S L E D I A G N O S T I C

D U C A N C E R D E L ' E S T O M A C Les cancers gastriques superficiels reprdsentent au Japon environ 40 % des cancers gastriques rOsdquables.

TABLEAU I

FRI~QUENCE DU CANCER GASTRIQUE SUPERFICIEL PARMI L'ENSEMBLE DES LESIONS RESEQUABLES AU ]APON

Total des cas r6s6qu6s . . . Cancers super-

ficiels . . . Cancers invasifs

Inconnus . . .

Univ.

Japon luntendo

1963-1966 1969-1978 5 7O6

795 (13,9 %) 4 286

625

1 233

437 (35,4 %) 796

0

L e tableau 1 fournit les r~sultats de IYtude comparative de nos rdsultats personnels et de ceux provenant de la monographie n ~ II CC- OMS.

La diff6rence entre ces deux s~ries r~side principalement dans les circonstances de recru- tement des patients porteurs de cancer gastrique et l'aptitude gt poser le diagnostic.

A u Japon, les techniques d'exploration du tractus digestif ont consid~rablement progressO ces 15 derniOres ann~es, particuliOrement les mdthodes radiologiques et endoscopiques. Elles sont tellement avancdes et g~n~ralis~es dans la totalitd du pays, que le cancer gastrique superficiel est actueUement d~tect6 d~ grande

~chelle ehaque annde, non seulement dans les centres hospitaliers universitaires mais dgalement dans les cliniques de moindre importance. Les donn~es macroscopiques du cancer superficiel reprises dans cette ~tude, sont classifi(es selon les catdgories proposdes par la Socidtd Japonaise d'Endoscopie en 1962.

144 Tome Jr - N ~ 2 - 1981 Acta Endoscopica

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Cette classification comporte 3 groupes, savoir le type saillant (type I), le type superficiel (type I1) et le type excavd (type liD. Le type H est subdivisd en 3 groupes, c'est-gt-dire le type ldg&ement surdlevd (II a), le type plat (II b) et le type l@Orement d@rimd (II c). L e s formes eombindes sont reprdsentdes darts des catdgories de types associds, tels que : l l a + H c, H e

+ III, etc.

1) L e s mini-cancers

Dans notre institution clinique, le D ~ Yoshida a dtudis les mini-cancers gastriques dans le cadre de la gastrite chronique, consid&~e comme terrain pr~-canc&eux.

Son gtude est basde sur 293 lgsions parmi 273 cancers gastriques superficiels comportant 14 cas de localisations ndoplasiques multiples.

Dans cette ~tude le <~ mini-cancer >> est ddfini comme une ldsion cancdreuse de diamOtre infd- rieur gt 0,5 • 0,5 cm.

Les tableaux 11 et I I I ]ournissent les dimen- sions des cancers superfl'ciels en relation avec la prolondeur de l'infiltration et le type macro- scopique de cancer superficiel selon la classifi- cation de la Soci3t3 Endoscopique Japonaise (1962).

A l'exception d'un cas, les mini-cancers prd- sentent un envahissement limit~ ~ la muqueuse, alors que dans les cas de cancer superficiel dont les dimensions sont : 0,5 e - 1,0 e cm ~, les cas d'envahissement sous-muqueux s'Ol~vent ?~ 9 sur 30, cette proportion des envahissements sous-muqueux s'accroit avec l'3largissement de la surface des 13sions.

TABLEAU II

DIMENSIONS DES CANCERS GASTRIQUES SUPERFICIELS EN RAPPORT AVEC LA PROFONDEUR DE L'INFILTRATION TUMORALE

(SI~RIE PERSONNELLE)

c m 2

m . . .

s m . . .

Mini-cancer 21 (13,5 %)

1 (0,7 %)

22 (7,5 %)

0.52-1.02 21 (13,5 %)

9 (6,6 %)

3O (10,2 %)

1.12-3.02 57 (36,5 %)

55 (40,1%)

112 (38,2 %)

3.12-5.02 43 (27,6 %)

33 (24,1%)

76 (25,9 %)

5.12 14 (9,0 %)

39 (28,5 %)

53 (18,1%)

Total 156 137

293

m ~ m u q u e a l ~ s m : s o u s - m u q u e u x .

T A B L E A U I I l

DIMENSIONS DES CANCERS GASTRIOUES SUPERFICIELS EN RELATION AVEC LE TYPE MACROSCOPIOUE (SI~RIE PERSONNELLE) (SELON LA CLASSIFICATION DE LA SOCIETE JAPONAISE D'ENDOSCOPIE - 1964)

cm 2 Mini-cancer 0 , 5 2 - 1 , 0 2 1,12-3,0 e 3,12-5,0 ~ 5,18 I, IIa, I I a + I I c . . .

IIb . . . IIc, IIc-I-III, III . . .

3 (3,9 %)

11 (68,8 %)

8 (4 %)

13 (16,9 %)

2 (12,5 %)

15 (7,5 %)

36 (46,8 %)

0 76 (38,0 %)

15 (19,5 %)

1 (6,3 %)

60 (50,0 %)

10 (13,0 %)

2 (12,5 %)

41 (20,5 %)

22 30 112 76 53

(7,5 %) (10,2 %) (38,2 %) (25,9 %) (18,1%)

Total

20O

Acta Endoscopica Tome XI - N ~ 2 - I981 145

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Sur un plan macroscopique, les mini-cancers superficiels se prdsentent en gdndral sous la forme plate, les formes ddprimdes ou excavdes viennent ensuite.

Une indication du mode de repdrage de ces mini-Idsions a dtd analysde dans notre service clinique. La majeure partie d'entre elles Jurent repdrdes sur piOces de gastrectomie par examen en coupes sdrides d'estomacs porteurs de ldsions coexistantes ; plusieurs Idsions furent cependant repdrdes et identifides comme mini-cancers avant l'intervention chirurgicale. Dans les cas de can- cers minuscules de 0 , 5 2 - 2,0 :~ cm", l'dvalua- tion correcte du degrd d'envahissement est laci- litde du fait des dimensions de la ldsion (ta- bleau IV).

TABLEAU IV POSSIBILITES

DU D I A G N O S T I C E N D O S C O P I Q U E (RESULTATS PERSONNELS) Type Saillant

de cancer ou superficiel sur61ev6 Mini-cancer O

X X 0,5-~-1,02 .. O O O O O

XX 1,12-2,0 z .. O O O O O

O O O O O O O O

Plat

XX

X

D6prim6

O U

excav6 0 0 0 X X X 0 0 0 0 0 0 0 0 0 0 0 0 0 X X X 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O 0 X O = diagnostic endoscopique correct.

X = diagnostic erron6 ou m6connu.

Nous rapportons ci-de~sous, un cas de mini- cancer associd t~ un ulcOre lindaire.

Un homme de 35 ans, soullrant d'~pigas- tralgies depuis plusieurs anndes, a subi un exa- men gastrique annuel. Un contrOle radiologique r&ent a mis en Ovidence un ulcOre lindaire, et l'exploration endoscopique a rdvdld un mini- cancer type II c. L'image endoscopique montre ce mini-cancer type H c sur la face antdrieure

du corps gastrique, I'ulcdration lindaire Otant situde sur la lace postdrieure en regard du mini- cancer (Jig. 1). Les biopsies dirigdes montrent que cette ldsion est un addno-carcinome tubu- laire.

En ddpit de la rdgression des dpigastralgies sous traitement mddical, une gastrectomie avec exdrOse des ganglions loco-rdgionaux rut e l f e c - tude.

L'examen de la piOce de rdsection rdvdla une longue ulcOration lindaire, localisde au versant postdrieur de la petite courbure et entra~nant un

#nportant raccourcissement de celle-ci avec en regard, sur le versant antdrieur adjacent d'ulc~re lindaire, un mini-cancer de type << ddprim~ >>

(II c) (fig. 2).

D'une maniOre gdndrale, l'examen histologique de la majoritO de ces minuscules cancers, de sur- face inldrieure it 1,0 ~ cm ~, montre des addno- carcinomes bien diHdrencids. Maintes donndes

~tablissent que tous ces mini-cancers sont des addno-carcinomes difl~rencids. Plus les ldsions grandissent, plus s'accro~t la proportion des addno-carcinomes peu diff~rencids.

2) C a n c e r s g a s t r i q u e s superficiels m u l t i p l e s Dans le diagnostic du cancer gastrique super- [iciel, il ne faut pas perdre de vue, que la lrdquence des cancers multiples de l'estomac est plus grande dans les formes superficielles que dans le groupe des cancers" invasifs.

Dans notre centre clinique, parmi 437 cas de cancers supe#iciels, 27 cas de localisations mul- tiples ont dtO mis en ~vidence (soit 6,2 % de la sdrie), ators que 20 % seutement des cas de cancers gastriques superlLwls ont Ot~ ddnombr~s parmi les 746 observations de cancers invasifs (soit 2,8 %). D a m ce demi-groupe, les cancers invasiJs multiples reprdsentent seulement 0,3 % (tableau VI).

La relation entre le hombre de cancers super- ficiels et l'Otendue de la ldsion est Journie dans le tableau VII.

L e s mini-cancers et les petites ldsions de surface variant de 0,6 ~ 1,0 ~ cm ~ repr~sentent respectivement 36,7 % et 15,0 % de l'ensemble des cancers superficiels multiples, la somme de ceux-ci s'dlevant it 51,7 % des cancers super- ficiels multiples.

1 4 6 Tome XI - N O 2 - 1981 Acta Endoscopica

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TABLEAU V

cm 2 Mini-cancer 0,52-1,02 1 , 1 2 - 3 , 0 2 3,12-5,02 5,12 T o t a l Addnocarcinome

bien diff&encid . . . Ad6nocarcinome

peu diff&enci6

22 0

23 78

34

34 42

25 28

TABLEAU VI

CANCERS G A S T R I O U E S MULTIPLES - PIECES DE RESECTION C H I R U R G I C A L E S

Cancers superficiels multiples . . . Cancers superficiels associ& aux cancers

invasifs . . . Cancers invasifs multiples . . . Cancers multiples . . .

27 / Cancers superficiels 20 / Cancers invasifs

2 / Cancers invasifs

49 / Cancers gastriques r6s6qu6s

437 746 746 1 233

6,2 % 2,8 % 0,3 % 4,0 %

TABLEAU VII

cm 2 .. < 0,52 0,62-1,0 e 1,12-2,02 2,12-3,02 3,12-4,02 4,1a-5,02 > 5,13 Total Nombre

de cancers 22 9 11 7 4 1 6 60

(36,7 %) (15,0 %) (18,3 %) (11,7 %) (6,7 %) (1,7 %) (10,0 %)

Lorsqu'on regroupe les cancers relativement petits, de surface variant de 1,1 ~ cm ~ d 2.0 ~ cm ~, et d'autre part, les mini-cancers et petits cancers de surface inf~rieure fi 1,0 ~ c m ~, l'ensemble re- pr6sente 70,0 % de t o u s l e s cancers superficiels multiples.

Ainsi, lorsqu'au cours d'une endoscopie, un cancer gastrique superficiel est mis en dvidence dans une r@ion de l' estomac, il faut avoir present gt l'esprit la possibilitd de coexistence d'un mini- cancer ou d'un petit cancer en un autre point de la surface muqueuse gastrique.

Dans une seconde dtape, nous avons dtudid la distribution de 76 l~sions parmi les 27 cancers superficiels multiples d#nombr~s (fig. 3).

L e s piOces de rdsections gastriques ]urent dtudides sur base de sections multiples rdalisdes de maniOre fi d6limiter les r@ions [undiques et antrales. La portion intermddiaire entre le Jundus et rantre Jut incluse dans la portion antrale tant et si bien que la majoritd des cancers ont dtd observds au niveau de l'antre et que l'atrophie de la muqueuse antrale semble ~troitement lide au cancer.

Sur la figure 3, les lignes en pointilld marquees par la lettre F au niveau des versants antdrieurs et post~rieurs, indiquent la limite entre les zones fundiques et antrales.

A l'exception de 2 16sions, toutes furent iden- tifides au niveau de l'antre et de la zone inter-

Acta Endoscoplca Tome XI - N ~ 2 - 1981 147

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mddiaire. Ce Jait rev~t une importance non seulement pour la recherche des cancers super- ficiels multiples, mais aussi lots de la ddlimitation du niveau de rdsection gastrique, puisqu'en cas de cancer gastrique antral super[iciel la rdsection de la portion antrale doit Otre aussi large que possible. Lorsque la gastrectomie ne l'emporte pas complOtement, une surveillance post-opd- ratoire attentive est indispensable.

A cet eJJet, une mdthode endoscopique de coloration de muqueuses permet de ddterminer les limites entre Jundus et antre.

AprOs injection I V d'une solution d'hista- mine d 1 % , une solution de rouge-congo est appliqu~e sur la muqueuse par voie endoscopi- que. Sous l'eJJet de la stimulation de la sdcrdtion chlorhydropeptique des cellules paridtales, la rdgion Jundique change de couleur et devient bleu sombre, alors qu'au contraire la coloration de l'antre demeure inchang~e et la limite entre les deux zones muqueuses devient parlaitement reconnaissable (Jig. 4).

Afin de fournir aux chirurgiens un rep&age per-opdratoire de ces Umites, des agra]es sont placdes par vo& endoscopique immddiatement aprOs coloration. Leur palpation d ventre ouvert, g~ travers la s&euse gastrique indique aux chi- rurgiens les ddlimitations Jixdes par l'endosco- piste.

3) Description de notre m6thode habituelle de diagnostic endoscopique du cancer gastrique superficiel

Lorsque l'examen radiologique rOvOle une Idsion suspecte, l'endoscopie-biopsie est ndces- saire pour dtablir le caract&e ndoplasique des tissus prdlevds. Nous appliquons la biopsie diri- g~e, d'abord pour ~tablir le cancer, ensuite pour confirmer exactement son dtendue, alin de Jaci- liter la ddtermination des limites de la gastrecto- mie. Cette mdthode est particuli&ement utile pour le diagnostic des cancers superficiels de type II b ou H c.

En ce qui concerne le diagnostic des polypes gastriques, le cancer de type polypo'ide doit dtre soigneusement exclu.

Pour cette raison, la polypectomie endosco- pique avec examen du polype en coupes sdrides est une attitude de routine. Par ces coupes s&i~es on peut diagnostiquer non seulement

l'existence d'un cancer mais aussi apprdcier sa pro[ondeur d'envahissement et dos lors l'Ova- luation d'une indication chirurgicale.

Les nouveaux procdd~s dOcrits ci-dessous servent d guider le chirurgien dans le choix de son proc~dd op&atoire.

a) M~thode de coloration de muqueuses (fig. 5).

Les proc~d~s de coloration sont classi]i~s en m~thodes directe et indirecte, destindes fi dOli- miter les portions sup&ieures et in]&ieures des zones muqueuses.

L e procdd~ direct consiste en l'application locale du colorant sous contrOle visuel par injec- tion directe dans le canal ~ biopsie de l'endo- scope. C'est la technique la plus commune.

Darts la m~thode indirecte, le colorant est administr~ par voie orale avant l'endoscopie.

Ceci sert non seulement ~ r~aliser un contraste, mais dgalement gl fournir des informations sup- pldmentaires puisqu'il a ~tO dtabli que le bleu de MdthylOne est absorbd par les cellules cancd- reuses et certaines cellules en mdtaplasie intes- tinale.

La figure 5 montre l'image endoscopique d'une ldsion ulcdreuse de la lace ant&ieure du corps gastrique. A u milieu de l'image, une d~- pression peu prolonde couverte d'un enduit fibri- neux blanchdtre peut ~tre observOe, vers laquelle convergent des plis saillants. Les lines structures de la muqueuse voisine sont bien visibles. Le colorant est distribud au niveau des creux entre les plis et de m~me dans les travOes interarOo- laires de certaines rOgions dont l'observation ddtaillde est ainsi rendue possible.

En d~pit de l'absence d'un amincissement irr~gulier ou de renJlements en ~ massues ~>

I'extr~mit~ des plis vers les berges de l' ulc&ation, signes habituellement caract&istiques d'une ma- lignitd, les biopsies des berges de cet ulcOre ont montr~ qu'il s'agit d'un ad~no-carcinome tubulaire. Aussi, une gastrectomie radicale avec rdsection des ganglions loco-rdgionaux a ~t~

elfectu~e (Jig. 6).

La comparaison entre les donndes de la fibro- scopie et de la piOce de r~section gastrique montre que l'analyse de la convergence des plis en endoscopie correspond ~ l'aspect de la piOce opdratoire.

148 Tome XI - N o 2 - 1981 Acta Endoscoplca

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b) Technique de mise en place endoscopique d' agraf es.

A u d~but, cette technique rut utilis~e pour re]ermer une ddhiscence muqueuse gastrique ou en vue d'obturer un vaisseau h~morragique au niveau d'un cratOre utc&eux gastrique.

R~cemment, nous avons tent~ d'appliquer cette m~thode pour reconna~tre les limites d'ex- tension muqueuse d'un cancer confirm~ par endoscopie quelques jours plus tard.

Inddniablement, en cours d'intervention le chirurgien est quelque]ois embarrassd pour d~li- miter les limites d'envahissement muqueux d'un cancer superficiel. Si quelques jours auparavant, les agra[es sont mises en place par voie endo- scopique, les limites d'extension du processus

~doplasique sont aisdment identifiables par palpation des agra[es d travers la sur[ace sdreuse de l'estomac (fig. 7).

2. R s A L O N G T E R M E DANS L E C A N C E R S U P E R F I C I E L Dans ce chapitre, nous analysons les r~sultats finaux des cancers gastriques super]iciels d~- hombres dans notre cUnique.

La d~finition primaire du cancer gastrique superficiel, s'accorde dvidemment avec la clas- sification macroscopique proposde par Tasaka 14] en 1962 d la Soci~t~ Japonaise d'Endoscopie et d~taill~e pr~c~demment.

A[in de permettre une ~valuation des donndes op~ratoires du cancer gastrique dans la totalit~

du Japon, ~ Les rOgles gdndrales d'~tude du cancer gastrique en chirurgie et pathologie ~> ont

~td propos~es en 1962, par ie Groupe Japonais de Recherches pour le cancer gastrique [3].

Dans ce travail, diff&ents termes sont utilis~s conJorm~ment ~ ces rkgles. Par exemple <~ R ~ signifie l'~tendue de la dissection des ganglions lymphatiques, et lorsque la gastrectomie est ac- complie sans rdsection ganglionnaire ce type d'op~ration est classd << RO >>.

Lorsque la dissection des ganglions lympha- tiques atteint le premier groupe, le second groupe, ou le troisiOme groupe ganglionnaires, chaque type d'intervention est d~nomm~ res- pectivement R~, Re et Ra.

<< O W ( + ) >> ou ~ O W ( - - ) ~> ddsignent sur le plan histologique les estomacs rds~quds, res- pectivement porteurs ou non, de tissu canc~reux au niveau de la tranche de section proximale.

L e s r~sultats finaux en termes de cancer gastrique superficiel et l'~valuation des cas de rdcidives dans notre clinique ont ~td soumis gt cette r~gle.

1) M A T I ~ R I E L E T MP.THODES D ' A N A L Y S E

A u cours de la p&iode de 11 arts, s'dtendant d'avril 1967 ~ mars 1978, 431 cas de cancers gastriques superficiels ont Ot~ l'objet d'une rd- section chirurgicale dans notre clinique. 20 cas de cancers gastriques multiples ont ~t~ exclus de ce groupe. Parmi les 411 cas restants, l'examen histopathologique ddtaill~ a ~td accompli chez 367 d'entre eux.

Ces cas comportaient 184 cancers muqueux et 183 cancers sous-muqueux. Parmi les 225 cas opdrds plus de 5 ans auparavant, 114 ~taient muqueux et 111 sous-muqueux.

Parmi ces 225 cas, 2 ont dchapp~ ~ la sur- veillance syst~matique. 8 patients ~taient en vie lors de la 4 c annde, mais les informations dispo- nibles ont fait d~faut au suiet de la 5 e annde.

En excluant ces 10 cas, 95,6 % des cas ont fourni les donndes reprises dans le tableau 8.

Sur 114 cas de cancers muqueux, 4 cas furent exclus en raison d'une suveillance incomplOte.

Un d~cOs end~ans les 30 jours aprOs intervention fur class~ comme une mort op~ratoire et ceci survint dans 2 cas.

7 cas dOcddOrent d la suite d'autres maladies et 1 cas mourut d'une affection de cause in- connue.

3 cas d~c~d~rent d la suite d'une r~cidive.

ll ]aut noter dans ces observations, la raretd de la r~cidive du cancer gastrique superfic&I alors que d'autres pathologies occupent une large proportion des causes de d~cds.

Dans cette ~tude nous avons calculd le taux de surv& ~ 5 ans, selon le proc~d~ suivant.

Acta Endoscopica Tome X I - N o 2 - 1981 149

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TABLEAU VIII

DECES POST-OPERATOIRES

DANS LES CAS DE CANCERS GASTRIQUES SUPERFICIELS

m

8 m .

Total . . . .

Nombre de cas

114 111

225

N o n

suivis

10

D6c6d&

par r&idive end6ans les

5 ans

D&~s post- op&atoires

Autres

c a u s e s

de decks

15

D6cbs de cause inconnue

m ---- n l u q u e u x . s m = s o u s - m u q u e u x .

En premier lieu, Ies d~cds imm~diatement post-opdratoires et les cas non traitables ]urent exclus du nombre total retenu, et les d~cds consdcuti[s h des affections diffdrentes et incon- nues Jurent ajoutds aux ddcOs par rdcidive tenant ainsi compte de la possibilitd d'une r~cidive m~connue.

2) R E S U L T A T S

a) T a u x de r6cidives end6ans les 5 ann6es post- op6ratoires

L e taux de rdcidives end3ans les 5 anndes post-op&atoires calculd sur la base de nos donndes personneUes est fourni dans le ta- bleau I X .

En premier lieu, 4 cas de ddcds post-op&a- toires immddiats et 10 cas non traitables ont gtd exclus des 225 cas de cancers gastriques superficiels, alors que les ddcds des affections diffdrentes ou inconnues totalisent 17 cas ajoutds aux ddcds par r3cidives.

Ainsi, le ds par rdcidive dans les 5 ans concerne 22 cas (10,4 % ) des 211 cancers gas- triques superficiels avec un taux de survie d 5 ans, 89,6 % .

Dans le groupe des 108 cas de cancers mu- queux, ~ l'exclusion des morts post-opdratoires et des cas intraitables, les d~c~s par rs ont concernd 3 observations soit 2,7 % des cas soumis ~ la chirurgie.

TABLEAU IX

TAUX DE SURVIE A 5 ANS DU CANCER GASTRIQUE SUPERF1C1EL

m . . . .

s m . . .

Total . .

Nombre de cas

108 103 21l

D~c~s pal" r6cidive

3 (2,7 %) 2 (1,9 %) 5 (2,4 %)

Autres causes de d&~s 7 (6,5 %) 8 (7,8 %)

15 (7,1%)

D&~s de causes incontaues

i (1,o %) I (1,0 %) 2 (1,0 %)

Total

11 (lO,2 %) 11 (10,7 %) 22 (10,4 %)

150 Tome XI - N O 2 - 198t Acta Endoscopica