Portal de Periódicos da CAPES

Diagnosis of gastric carcinoma in Japan and western countries

1997; Elsevier BV; Volume: 350; Issue: 9075 Linguagem: Inglês

10.1016/s0140-6736(05)64181-5

1474-547X

Massimo Rugge, Mauro Cassaro, Fabio Farinati, Francesco Di Mario,

Metastasis and carcinoma case studies

With respect to Ronald Schlemper and colleagues' report1Schlemper RJ Itabashhi M Kato Y et al.Differences in diagnostic criteria for gastric carcinoma between Japanese and Western pathologists.Lancet. 1997; 349: 1725-1729Summary Full Text Full Text PDF PubMed Scopus (352) Google Scholar we would like to consider several issues that are closely related to our own experience. First, as a general rule of oncology, when the intraepithelial location of the cancer is not explicitly specified, invasiveness must be regarded as intrinsic to any epithelial malignant disease. It is noteworthy, however, that cytological atypia (another cancer attribute) may be undetectable even in metastatic lesions,2Riddell RH Premalignant and early malignant lesions in the gastrointestinal tract: definition terminology and problems.Am J Gastroenterol. 1996; 91: 864-872PubMed Google Scholar which strongly contradicts the sensitivity of cellular/nuclear abnormality in the histological diagnosis of cancer, whatever its location.1Schlemper RJ Itabashhi M Kato Y et al.Differences in diagnostic criteria for gastric carcinoma between Japanese and Western pathologists.Lancet. 1997; 349: 1725-1729Summary Full Text Full Text PDF PubMed Scopus (352) Google Scholar Second, it is accepted that invasive cancers represent the most advanced stage of a multistep sequential process and, in the gastrointestinal tract, this has been validated by clinical and molecular studies. Hence a spectrum of preinvasive neoplastic lesions theoretically also recognisable in the morphogenesis of intestinal-type gastric cancer and the terms gastric epithelial dysplasia or adenoma have been adopted to define such flat or raised lesions. A clear-cut border between dysplasia and invasive lesions may be hard to distinguish, especially in high-grade preinvasive lesions. According to Schlemper and colleagues, these are the cases in which the Japanese pathologists favour the diagnosis of full-blown cancer (by attaching particular importance to nuclear atypia). As a result of this practical Japanese approach (i) the diagnosis of cancer is consistently made on biopsy and endoscopic mucosal resection (EMR) samples (from the Japanese viewpoint, cases e,f,i,j,l,m,n,o,p,q,r); (ii) advanced gastric carcinoma is successfully prevented; but (iii) evidence of any invasiveness is consistently lacking from either the biopsy or the EMR specimens (cases h,k,m,n). Although this clinicopathological behaviour, which might be amaply justfied by several considerations (especially in high-risk areas); whãt we would highlight is that inconsistent diagnostic classifications lead to inconsistent guidelines for the clinical management of such lesions. The fallout on patient management concerns whether and when it is justified to surgically treat neoplastic lesions with no histological evidence of invasion. Leaving aside the EMR procedure, the main point is the timing of gastric resection in the absence of any invasive carcinomatous pattern.1Schlemper RJ Itabashhi M Kato Y et al.Differences in diagnostic criteria for gastric carcinoma between Japanese and Western pathologists.Lancet. 1997; 349: 1725-1729Summary Full Text Full Text PDF PubMed Scopus (352) Google Scholar, 3Sakamoto J Yasue M Do Japanese statistics on gastric carcinoma need to be revised?.Lancet. 1997; 349: 1711Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar Unquestionably, high-grade gastric epithelial dysplasia, detected as initial diagnosis or during the follow-up of low-grade dysplasia, must be removed. For low-grade lesions (ranging from mild to moderate gastric epithelial dysplasia), the high percentage of cases in whom no further dysplasia is detected (possibly regression), either after Helicobacter pylori eradication or with no therapy (73/123 of our patients with a mean follow-up of 46 months, range 12–160, unpublished data) would advise against any over-hasty surgical treatment. We emphasise that such a wait and monitor approach is ethical only with strict follow-up (in terms of endoscopic schedule and sampling method).4Rugge M Leandro G Farinati F et al.Gastric epithelial dysplasia: how clinico-pathologic background relates to management.Cancer. 1995; 76: 37Crossref Scopus (76) Google Scholar It is worth mentioning that, judging from our prospective follow-up study of gastric epithelial dysplasia (130 patients with follow-up longer than 12 months, Table 1), most patients did not develop gastric cancer after a mean follow-up of 40 months, and the prevalence of gastric cancer detected in the early stage was 78%.TableGastric cancers detected during prospective follow-up of gastric epithelial dysplasia (GED)initial diagnosisNo of patientsEGCAGCGC-nosMean time elapsed from the initial diagnosis to cancer detection (range)Mild Ged8930045 months (15–80)Moderate GED3462036 months (21–72)Severe GED750225 months (12–36)EGC=early gastric cancer, AGC=advanced gastric cancer, GC-nos=Gastric cancer of unknown pTNM stage. Open table in a new tab EGC=early gastric cancer, AGC=advanced gastric cancer, GC-nos=Gastric cancer of unknown pTNM stage.