Background: A large proportion of patients attending open access endoscopy have histological and gross pathological findings that are potentially premalignant. The proportion of these patients who go on to develop malignancies and the timescale over which this occurs are uncertain. Aims: This study aims to discover the incidence of gastric cancers in this "high risk" group and to examine the potential for their early diagnosis and treatment. Patients: A total of 1753 patients attended open access endoscopy. From these, 166 patients with dysplasia, intestinal metaplasia, atrophic gastritis, foveolar hyperplasia, regenerative changes, polyps, or ulcers who agreed to undergo annual surveillance endoscopy were studied. Methods: Patients were endoscoped annually. Additionally, patients with ulcers were re-examined at two monthly intervals until ulcer healing. Cancers detected were treated by gastrectomy. Results: Twenty two of 1753 patients attending open access endoscopy had gastric cancer (1.3%). In the study population, 14 cancers were detected over 10 years (8.4 %). These were of an earlier stage than those detected at open access (stage I and II 67% v 23%; p<0.05) and five year survival was significantly higher (50% v 10%; p=0.006). In atrophic gastritis and intestinal metaplasia the risk of malignancy was 11%. Conclusions: In patients with atrophic gastritis or intestinal metaplasia, annual surveillance can detect most new tumours at an early stage with a major improvement in survival. Potential benefits of such a surveillance programme are large and warrant further investigation in a multicentre randomised controlled trial.
This randomised, double-blind, placebo-controlled study was designed to evaluate the ability of the orally administered matrix metalloproteinase inhibitor, marimastat, to prolong survival in patients with non-resectable gastric and gastro-oesophageal adenocarcinoma. Three hundred and sixty-nine patients with histological proof of adenocarcinoma, who had received no more than a single regimen of 5-fluorouracil-based chemotherapy, were randomised to receive either marimastat (10 mg b.d.) or placebo. Patients were treated for as long as was tolerable. The primary endpoint was overall survival with secondary endpoints of time to disease progression and quality of life. At the point of protocol-defined study completion (85% mortality in the placebo arm) there was a modest difference in survival in the intention-to-treat population in favour of marimastat (P=0.07 log-rank test, hazard ratio=1.23 (95% confidence interval 0.98 -1.55)). This survival benefit was maintained over a further 2 years of follow-up (P=0.024, hazard ratio=1.27 (1.03 -1.57)). The median survival was 138 days for placebo and 160 days for marimastat, with 2-year survival of 3% and 9% respectively. A significant survival benefit was identified at study completion in the pre-defined sub-group of 123 patients who had received prior chemotherapy (P=0.045, hazard ratio=1.53 (1.00 -2.34)). This benefit increased with 2 years additional follow-up (P=0.006, hazard ratio=1.68 (1.16 -2.44)), with 2-year survival of 5% and 18% respectively. Progression-free survival was also significantly longer for patients receiving marimastat compared to placebo (P=0.009, hazard ratio=1.32 (1.07 -1.63)). Marimastat treatment was associated with the development of musculoskeletal pain and inflammation. Events of anaemia, abdominal pain, jaundice and weight loss were more common in the placebo arm. This is one of the first demonstrations of a therapeutic benefit for a matrix metalloproteinase inhibitor in cancer patients. The greatest benefit was observed in patients who had previously received chemotherapy. A further randomised study of marimastat in these patients is warranted.
have improved the proportion of cancers that are diagnosed at a potentially curative stage to 63% and are reporting 5-year survival rates of 70% for R0 resections [1,2]. The centralization of services, earlier diagnosis, and more successful surgery has greatly increased the number of patients requiring follow-up. In a unit performing 50 R0 resections a year, approximately 150 patients will be undergoing follow-up at 5 years, and 200 at 10 years. In Japan and other countries in Eastern Asia where large units perform over 500 gastrectomies per year, with the majority for early-stage disease, the problems of follow-up are increased by at least an order of magnitude.There are three main reasons for follow-up: to detect problems associated with the operation, to collect outcome data, and to detect recurrent disease. Many units actively investigate patients in order to detect recurrences at an earlier and asymptomatic stage, in the hope that this will lead to improved outcomes. The evidence for this, however, is weak and several surgeons have questioned the use of scarce resources in intensive follow-up.In colorectal cancer, several randomized controlled trials (RCTs) and metaanalyses have demonstrated improved survival in patients undergoing intensive followup [3], and national bodies such as the American Society of Clinical Oncology (ASCO) and the Association of Coloproctology of Great Britain and Ireland have issued guidelines on the follow-up of colorectal cancer [4,5]. ASCO guidelines are also available for other cancers, such as breast [6] and lung [7], but for gastric cancer they are notable by their absence. Even the Japanese Gastric Cancer Association (JGCA) guidelines, which are proscriptive in the diagnosis and surgical treatment of gastric cancer, offer no guidance on follow-up [8]. This lack of guidance is unsurprising, given the paucity of high-quality evidence and the complete lack of RCTs. In the absence of national protocols, surgical units have adopted widely disparate regimes, Abstract Although there is broad agreement in the staging, classification, and surgery for gastric cancer, there is no consensus regarding follow-up after gastrectomy. Follow-up varies from investigations on clinical suspicion of relapse to intensive investigations to detect recurrences early, assuming that this improves survival and quality of life. Advanced gastric cancers recur mainly by locoregional recurrence or distant metastasis. Local recurrences detected at endoscopy or on computed tomography (CT) are invariably incurable. For early gastric cancers, endoscopy can detect new primaries, but the incidence of these tumors is low, and many thousands of procedures are required to detect each operable case. CT is much better at detecting liver metastasis and, although these are usually multiple and unresectable, there are several reports of good survival following liver resection for isolated metastasis. Tumor markers have been used with some success to detect subclinical recurrences and could be used to target more invasive...
PODH is a common complication following hybrid esophagectomy and MIO. Given the high mortality from emergency repair, careful thought is needed to identify surgical techniques to prevent PODH forming when minimal access esophagectomy are performed. Upper GI surgeons need to have a low index of suspicion to investigate and treat patients for this complication.
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