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Therefore, the number of reports about liver metastasis from gastric cancer has been few. So far, various systemic chemotherapies or intrahepatic arterial infusion HAI has been performed, but prolonged survival has generally not been achieved. However, new anticancer drugs S-1, CPT, and taxanes have recently been widely used for advanced gastric cancer in many institutes in Japan, and some gastric cancer patients with liver metastasis are effectively treated by chemotherapy and remain alive for a long time after the therapy.
In this study, a retrospective clinicopathologic evaluation of gastric cancer cases with synchronous liver metastasis and hepatectomy cases including metachronous liver metastasis was performed. Among these cases, there were 77 with synchronous liver metastasis. The mean age was The number of patients with no stage IV factors except H factor was 44; their mean age was There were 17 cases that underwent hepatectomy for liver metastasis, including 5 cases with metachronous liver metastasis, from to Their mean age was For this study, clinicopathological examinations were undertaken according to the 14 th Japanese Classification of Gastric Carcinoma [ 6 ].
Moreover, in hepatectomy cases, two clinical variables, such as partial resection or anatomic hepatic resection segmentectomy or lobectomy and synchronous or metachronous metastasis, were added. The disease-specific survival rate was calculated with the Kaplan-Meier method.
The significance of any difference between the survival curves was determined using the log-rank test. The Cox proportional hazards model was used in the multivariate analysis of the factors determined to be significant for disease-specific survival on univariate analysis. The number of patients who had no Stage IV factors except H1 was 44 The number of synchronous P 1 and M1 factors, and CY 1 was 1 each. Seven clinicopathological factors INF, ly, N factor, gastrectomy, grade of lymph node dissection, the number of metastatic nodules in the liver within 3 or not , and HAI were significantly different between the patients with only H factor and the patients with multiple Stage IV factors Table 1.
The numbers of gastrectomy only, gastrectomy plus postoperative systemic chemotherapy, and preoperative chemotherapy cases were 17, 12, and 5 cases, respectively. HAI was given to 14 cases, systemic chemotherapy only was given to 8 cases, hepatectomy was performed in 3 cases, hepatectomy plus HAI was performed for 3 cases, and best supportive care BSC was given to 12 cases. Chemotherapy status was unknown in 3 cases 1 case underwent gastrectomy, 2 cases did not undergo gastrectomy.
All 6 hepatectomy cases underwent gastrectomy and systemic chemotherapy.
Of the 17 HAI cases including 3 hepatectomy cases, 15 cases underwent systemic chemotherapy, but 2 cases did not undergo systemic chemotherapy. Multivariate analysis showed that histology [HR 2. Multivariate analysis showed that histology [HR 3. On histology, the survival curve of the differentiated type cases was significantly higher than that of the undifferentiated type cases. For systemic chemotherapy, the survival curve of cases that underwent systemic chemotherapy was significantly higher than that of cases that did not undergo systemic chemotherapy.
Seventeen cases underwent HAI. Of these cases, three underwent hepatectomy. For the macroscopic type of primary site, there were 2 type 1 cases, 6 type 2 cases, 8 type 3 cases, and 1 type 5 case. There were no type 4 cases. For the T factor, there were 1 T3 case, 13 T4a cases, and 3 T4b cases.
For the P factor, there was only 1 P1 case. Three cases had distant lymph node metastasis, and no cases had distant organ metastasis. On histology, there were 7 tub1 cases, 3 tub2 cases, 1 pap case, 5 por1 cases, and 1 por2 case. For the number of metastatic nodules, 9 had within 3, and 8 had 4 or more.
All HAI cases underwent gastrectomy. For the gastrectomy, 9 patients underwent distal gastrectomy, and 8 patients underwent total gastrectomy. For the lymph node dissection, 8 patients underwent D0 or D1, 8 patients underwent D2, and 1 patient underwent D3. Fifteen patients underwent systemic chemotherapy, and 2 patients underwent only HAI. The range of the duration of HAI was months, with a mean of 7.
In 2 cases, the effect could not be determined, because these cases underwent hepatectomy synchronously Table 4. The response rate was The response rate to this regimen was With respect to prognosis, the 1-year survival rate was In H1-only cases, the 1-year survival rate was On the other hand, for the prognosis of systemic chemotherapy-only cases, the 1-year survival rate was The clinicopathological characteristics of cases who underwent hepatectomy are summarized in Table 5. All 12 gastric cancer cases with synchronous liver metastasis underwent gastrectomy plus hepatectomy.
Five cases underwent hepatectomy for metachronous liver metastasis. One patient underwent hepatectomy twice for synchronous metastasis and metachronous metastasis after 24 months. For the macroscopic type of primary site, there were 11 type 2 cases, 4 type 3 cases, 1 type 4 case, and 1 type 5 case. Two cases had distant lymph node metastasis. All 17 hepatectomy cases had within 3 metastatic nodules.
There were no cases with distant organ metastasis.
On histology, 4 were tub1, 6 were tub2, 2 were pap, 3 were por, and 2 were por1. The primary tumor size of all hepatectomy cases except 1, which was type 4 cancer, was less than mm. The clinicopathological characteristics of cases who underwent hepatectomy. All hepatectomy cases underwent gastrectomy. For gastrectomy, 10 patients underwent distal gastrectomy, and 7 patients underwent total gastrectomy. For the lymph node dissection, 3 patients underwent D1, 12 patients underwent D2, and 2 patients underwent D3.
For the hepatectomy, 12 patients underwent partial resection, 3 patients underwent left lateral segmentectomy, 1 patient underwent extended right posterior segmentectomy, and 1 patient underwent left lobectomy after HAI. Three patients underwent partial resection and radiofrequency ablation RFA. Four patients did not receive systemic chemotherapy. Five patients underwent hepatectomy combined with HAI. For residual tumor, there were 7 R0 cases and 10 R2 cases. All 5 metachronous metastasis cases underwent R0 surgery. All 3 cases with multiple Stage IV factors underwent R2 surgery.
The duration after first surgery was from 4 to 24 months, and the average duration was Cases who underwent hepatectomy for liver metastasis from gastric cancer. On the prognosis of hepatectomy cases, the 1-year survival rate was There was no significant difference between partial resection and systemic resection Table 7. For stromal volume, the survival curve of medullary type cases was significantly higher than those of intermediate and scirrhous types. For lymph node metastasis, the survival curves of N0, N1, and N2 cases were significantly higher than of N3 cases. With respect to the number of Stage IV factors, the survival curve of H1-only cases was significantly higher than that of multiple Stage IV factor cases.
For residual tumor, the survival curve of R0 cases was significantly higher than that of R2 cases. The survival curve of metachronous metastasis was significantly higher than that of synchronous metastasis. All three cases that underwent RFA were alive more than three years after surgery.
The prognosis of gastric cancer cases with liver metastasis is extremely poor because most patients with gastric cancer with concomitant liver metastases are excluded as candidates for curative surgery accompanied by hepatic resection due to incurable simultaneous factors, such as peritoneal dissemination, widespread lymph node metastases, and direct invasion to adjacent structure. Moreover, many cases have multiple metastatic lesions in both lobes of the liver. In the present study, H1-only cases accounted for only 44 cases Histology, systemic chemotherapy, and HAI were independent prognostic factors.
Differentiated histological type, systemic chemotherapy, and HAI were associated with a good prognosis in gastric cancer patients with liver metastasis. Moreover, all HAI cases underwent gastrectomy, and 14 of 17 cases were H1-only cases. Therefore, gastrectomy and H1-only were thought to be absolutely necessary for a good prognosis.
Lymph nodes near the tumor are generally removed during surgery so that they can be checked for cancer cells. Researchers are exploring the use of chemotherapy before surgery to help shrink the tumor and after surgery to help kill residual tumor cells. Chemotherapy is given in cycles with intervals of several weeks depending on the drugs used.
In the present cases, the presence of four or more tumors was a significant poor prognostic factor on univariate analysis, but it was not an independent poor prognostic factor on multivariate analysis. Angiography is a study where contrast material is injected into a large artery in the groin. The primary tumor size of all hepatectomy cases except 1, which was type 4 cancer, was less than mm. The doctor will generally start by taking a complete history and performing a physical examination. In patients with acid reflux, where contents from the stomach back up into the esophagus, the cells that line the esophagus can change and begin to resemble the cells of the intestine.
Radiation therapy is the use of high-energy rays to damage cancer cells and stop them from growing. Radiation destroys the cancer cells only in the treated area. Some patients with very early cancer of the stomach that is involving only the superficial layers of the stomach wall, may undergo an endoscopic resection of the cancer without surgery using techniques such as endoscopic mucosal resection or endoscopic submucosal dissection.
Doctors are looking at the combination of surgery, chemotherapy and radiation therapy to see what combination would have the most beneficial effect. The liver is one of the largest organs in the body, located in the upper right portion of the abdomen. The liver has many important functions, including clearing toxins from the blood, metabolizing drugs, making blood proteins, and making bile which assists digestion.
Hepatocellular carcinoma is a cancer that arises in the liver.
It is also known as hepatoma or primary liver cancer. HCC is the fifth most common cancer in the world. This rise is thought to be because of chronic hepatitis C, an infection that can cause HCC. In the United States, most cancers that are found in the liver are ones that spread or metastasize from other organs. Cancers that commonly metastasize to the liver include colon, pancreatic, lung and breast cancer. Abdominal pain is the most common symptom of HCC and usually is present when the tumor is very large or has spread. Unexplained weight loss or unexplained fevers are warning signs in patients with cirrhosis.
Sudden appearance of abdominal swelling ascites , yellow discoloration of the eyes and skin jaundice , or muscle wasting suggests the possibility of HCC. Alcohol related liver disease is also a risk factor for the development of HCC. There are certain chemicals that are associated with liver cancer-aflatoxin B1, vinyl chloride and thorotrast. Aflatoxin is the product of a mold called Aspergillus flavus and is found in foods such as peanuts, rice, soybeans, corn and wheat. Also thorotrast is no longer used for radiologic tests, and vinyl chloride, is a compound found in plastics.
Hemochromatosis, a condition in which there is abnormal iron metabolism, is strongly associated with liver cancer. Individuals with cirrhosis from any cause such as the hepatitis virus, hemochromatosis and alphaantitrypsin deficiency are at increased risk of developing HCC. The diagnosis of HCC cannot be made by routine blood tests. Screening by a blood test for the tumor marker, alpha- fetoprotein AFP , and radiological imaging must be performed.
Some doctors advocate measurement of AFP and imaging every 6- 12 months in patients with cirrhosis in an effort to detect small HCC. Radiological imaging studies are very important and may include one or more of the following-ultrasound, CT scan MRI magnetic resonance imaging and angiography. Ultrasound examination of the liver is frequently the initial study if HCC is suspected. CT scan is a very common study used in the USA for the workup of liver tumors. The ideal study is multi-phase CT scan with the use of oral and IV contrast.
MRI can provide sectional views of the body in different planes. MRI can actually reconstruct images of the biliary tree and the arteries and veins of the liver. Angiography is a study where contrast material is injected into a large artery in the groin. X-ray pictures are then taken to evaluate the arterial blood supply to the liver. If the patient has HCC, a characteristic pattern is seen because of the newly formed abnormal small blood vessels that feed the tumor.
Biopsy can be performed if there is some question as to the diagnosis of HCC or if the doctor feels the management may be changed by the biopsy results. The prognosis depends on the stage of the tumor and the severity of the associated liver disease. There are some factors that predict poor outcome. This may include injection of anti-cancer chemicals into the body through a vein or through chemoembolization. The technique of chemoembolization is a procedure where chemotherapeutic drugs are given directly into the blood vessels that supply the tumor and small blood vessels are blocked so that the drug stays within the area of the tumor.
Ablation tissue destruction therapy in the form of using radiofrequency waves, alcohol injection into the tumor or proton beam radiation to the tumor site are other options for treatment. There is no data to indicate that any one of these treatment is better than another. Surgery is only available to patients with excellent liver function who have tumors less than cm that are confined to the liver. Many patients may have recurrence of HCC in another part of the liver.
Liver transplantation is a treatment option for patients with end-stage liver disease and small HCC. There is however a severe shortage of donors in the USA. The pancreas makes pancreatic juices, which help digest food in the small intestines, and hormones, including insulin. It is located behind the stomach in the back of the abdomen. The duct of the pancreatic gland opens into the first portion of the small intestine called the duodenum through a nipple like opening called the ampulla.
Early pancreatic cancer usually does not cause symptoms and is therefore known as the "silent" disease.
As the tumor gets larger, the patient may have one or more of the following:. It is not known exactly why certain people get pancreatic cancer. Research shows that there are certain risk factors that increase the chance of getting pancreatic cancer. Smoking is a risk factor. Alcohol consumption, a diet rich in animal fat and chronic pancreatitis may also be risk factors.
People with a condition called hereditary pancreatitis are also at increased risk for getting pancreatic cancer. Family history of pancreatic cancer is also an important risk factor as are certain inherited and genetic conditions. In addition to taking a complete history and performing a physical examination, the doctor may perform certain endoscopic and radiologic tests such as a CT scan, MRI or ultrasound. Endoscopic ultrasound may also be performed. This test may help in finding small tumors that may be less than cms one inch. A biopsy of an abnormal area of the pancreas may be performed in certain cases by inserting a needle into the pancreas under ultrasonic guidance.
ERCP endoscopic retrograde cholangiopancreatogram , a special x-ray study of the pancreatic duct and the common bile duct may also be used to make the diagnosis. For this test, a flexible tube with a light and a camera at the end is passed through the mouth into the stomach and then the small intestines. A dye is then injected into the pancreatic duct and the bile duct to look for abnormal filling or obstruction of these ducts by the tumor.
During this procedure, biopsies can be taken using a brush that is inserted into the bile duct. The biopsy specimens are then examined under a microscope to look for cancer cells. Cancer of the pancreas is really only curable if it is found in the early stages. Surgery, radiation and chemotherapy are possible treatment options. Surgery may be done to remove all or part of the pancreas and surrounding tissues if needed.
Radiation therapy can be used to damage the cancer cells and prevent them from growing. Radiation maybe used in certain trials after surgery to help kill any remaining cancer cells. Chemotherapy will not cure pancreatic cancer but may have some effect on slowing the rate of progression of the tumor or to improve the patient's quality of life.
Many new drugs are being investigated for chemotherapy of pancreatic cancer and patients with this disease may have an opportunity to participate in one of the research trials for chemotherapeutic treatment of pancreatic cancer. Pain control may be a difficult problem in patients with pancreatic cancer. Oral pain medication may be used, or patients may be referred for a nerve block which is performed by injecting alcohol into the bundle of nerves celiac plexus near the pancreas to decrease pain signals from the pancreatic cancer to the brain.
Find an ACG member gastroenterologist with a specialized interest in liver disease. Basics Resources Esophageal Cancer Carcinoma Overview The esophagus is a tube that connects the mouth and throat with the stomach "food pipe". Symptoms Very small tumors at an early stage do not generally cause symptoms.
Stomach Cancer Gastric Cancer Overview The stomach is part of the digestive system and connects the esophagus to the small intestine. Symptoms Patients may not have any symptoms in the early stages and often the diagnosis is made after the cancer has spread. The most common symptoms include: