A prospective and crosssectional study on 65 elderly patients with lower gastric cancer undergoing radical gastrectomy with D2 lymphadenectomy at Military Hospital 103 from January 2018 to April 2020. In all the cases, D2 lymph node dissection was performed according to Guidelines of the Japanese Gastric Cancer Association.
Trang 1RESEARCH ON CLINICAL AND PARACLINICAL
CHARACTERISTICS OF LOWER THIRD GASTRIC CANCER IN
THE ELDERLY AT MILITARY HOSPITAL 103
Ho Chi Thanh 1 , Truong Duc Tuan 1 , Lai Ba Thanh 1
SUMMARY
Objectives: To investigate clinical and paraclinical features of lower third gastric cancer in
the elderly patients at Military Hospital 103 Subjects and methods: A prospective and
cross-sectional study on 65 elderly patients with lower gastric cancer undergoing radical gastrectomy with D2 lymphadenectomy at Military Hospital 103 from January 2018 to April 2020 In all the cases, D2 lymph node dissection was performed according to Guidelines of the Japanese
Gastric Cancer Association Results: The mean age was 70.03 ± 7.435 years; the average
disease detective time was 57 ± 2.767 months; common symptoms were epigastric pain (96.9%), weight loss (47.7%), gastrointestinal bleeding (26.1%), gastric outlet obstruction (18.5%) The incidence of comorbidities was 41.54%, anemia 56.9% 96.9% was diagnosed by gastroscopy, 76.2% by gastric X-ray Diagnostic accuracy of abdomen and lymph node metastasis on abdominal CT scanner reached 73.1% and 24.3%, respectively whereas these
rates on PET-CT were 86.66% and 66.66%, respectively Conclusions: The study indicated
that clinical symptoms of gastric cancer in the elderly were atypical, with short duration of detection There was a significant association between the prevalence of patients with combined diseases, anemia, prolonged day of preoperative treatment (p < 0.05)
* Keywords: Gastric cancer; Lower third gastric cancer; Elderly patient
INTRODUCTION
Gastric cancer is the leading common
malignancy among gastrointestinal cancer
[1] Recently, global life expectancy has
increased, so the proportion of elderly
patients with stomach cancer continues
to increase According to research by
Tomaiuolo P et al in the US from 2003 to
2007, the average age of gastric cancer
patients is 70, of which 24% of patients
aged 65 to 74; 27% of patients aged 75
to 84 and 12% over 85 years [5] Japan is
the country which has the highest average life expectancy in the world and also the highest incidence of gastric cancer, there are approximately 60% of patients diagnosed with gastric cancer aged > 65 [6] Obviously, radical surgery to treat stomach cancer in the elderly is a challenge for the surgeon [7] What are the differences between clinical symptoms and diagnosis of gastric cancer in the elderly, the status of chronic diseases, results of treatment, incidence
of accidents and postoperative complications?
1
Department of Abdominal Surgery, Military Hospital 103, Vietnam Military Medical University
Corresponding author: Ho Chi Thanh (hochithanhbv103@gmail.com)
Date received: 15/6/2020
Trang 2SUBJECTS AND METHODS
1 Subjects
Patients > 60 years of age, diagnosed
with lower adenocarcinoma of the stomach,
undergoing radical surgery to remove the
lower part of the stomach with D2 lymphoma
following the 4th Japanese Gastric Cancer
Society guidelines (JGCA ver 4) [8] at the
Center of Abdominal Surgery, Military
Hospital 103
2 Methods
- Prospective, descriptive and cross
sectional study
- Patients were examined and taken conventional examiniation
- Patients were examined and treated for combined diseases
- Complications of gastric cancer such as anemia, gastrointestinal bleeding, nourishment in patients with pyloric stenosis and cachexy
* Data processing: By SPSS 22.0
software
- The data were recorded according to consistent medical records from admission time to the date of surgery
- Clinical and paraclinical characteristics were taken at the time of admission
RESULTS
Table 1: General characteristics
Gender
Disease duration
* Clinical symptoms:
Epigastric pain: 63 patients (96.9%); anorexia: 50 patients (76.9%); weight loss: 31 patients (47.7%); palpable mass in the abdomen: 12 patients (18.5%); gastrointestinal bleeding: 17 patients (26.1%); pyloric stenosis: 12 patients (18.5%)
Trang 3Table 2: Imaging tests
Test
Table 3: Blood tests
* Comorbidities:
Hypertension: 15 patients (23.07%); cardiac diseases: 6 patients (9.23%); diabetes:
5 patients (7.69%); COPD: 3 patients (4.61%); prostate hypertrophy: 3 patients (4.61%); no comorbidites: 38 patients (58.46%)
Table 4: Relationship between comorbidities and pre-operative days of treatment
Pre-operative days of treatment Comorbidities
n
Mean ± SD (day)
Min - max (day)
p value
Table 5: Relationship between anemia and pre-operative days of treatment
Pre-operative days of treatment
Mean ± SD (day)
Min - max (day)
p value
Trang 4DISCUSSION
* General features:
The average age: 70.03 ± 7.435 years;
highest: 89 years old; male/female ratio:
3.06 The average time of illness was
2.57 ± 2.767 months, of which 66.1% was
under 3 months, 24.6% from 3 - 6 months,
9.2% over 6 months (table 1) This result
is consistent with the domestic research
on gastric cancer that morbidity rate in
men is higher than women The duration
of illness in this study is shorter than other
authors: Trinh Hong Son (5.7 months) [1],
Pham Duy Hien (9 months) [2] It is likely
that clinical symptoms of the elderly are
atypical and transient, making it difficult
to detect by gastroscopy Research by
Nashimoto A revealed that 20% of
patients with gastric cancer are over
80 years old
* Clinical symptoms:
Abdominal pain in epigastrium: 96.9%,
anorexia: 76.9%, weight loss: 47.7%,
palpable mass in the abdomen: 18.5%
(table 2) According to Pham Duy Hien,
atypical epigastric abdominal pain constituted
75 - 85%, unexplained weight loss was
present in 80 - 85% which are signs of
advanced cancer [2]
Gastric outlet obstruction is a late
complication, seen in 12 patients (18.5%),
gastrointestinal bleeding in 17 patients
(26.1%) According to Nguyen Van Van,
gastrointestinal bleeding can occur at an
early stage of gastric cancer but it is easily
overlooked, until anemia is detected [3]
According to Trinh Hong Son, pyloric stenosis
makes up 23.5% and gastrointestinal
bleeding occupies 11.1% [1]
* Laboratory testing:
100% of patients were performed gastroscopy and biopsy before surgery, the accurate diagnosis of gastroscopy
was 96.9% (table 3) Abdominal X-ray was
done in 32.3%, with accurate diagnosis
of 76.2% According to Pham Duy Hien, Trinh Hong Son, the correct diagnosis of X-ray was 73.2%, 90% [1, 2]
Abdominal CT-scan is a highly appreciated method of diagnosing the extent of gastric cancer damage before surgery There were 41 patients who were performed abdominal CT scan, which allows the accurate diagnosis of position
of damage and the size of tumor being 73.17%, the status of abdominal lymph
node being 24.39% (table 3) To enhance
the detection and diagnosis ability of tomography for stomach cancer, it is necessary to stretch the stomach by keeping the patients well-supplied with water However, diagnosis of precise pre-operative staging of CT-scan is limited, especially the diagnosis of metastatic lymph node status According to Weiser MR, with lymph node less than 5 mm in size, the diagnostic rate of CT-scan was 1%, lymph nodes from 5 - 9 mm increased the diagnostic rate to 45%, with lymph nodes
≥ 10 mm this rate was 70% [9] According
to Kuntz C et al, the correct diagnosis rate
of multidisciplinary CT-scan was 53% for early stage gastric cancer and 92% for advanced stomach cancer [10]
PET/CT-scan was performed in 15 patients The correct diagnosis rate of the size and tumor invasion was 86.66% and that of lymph node metastasis was 66.66% and no distant metastasis was found
(table 3) According to Yun M et al,
Trang 5accurate rates of PET/CT scan for
diagnosis of lymph node metastases N1
was 56%, N2: 72% and N3: 95% [11]
PET/CT images allows higher accuracy
than CT-scan, but high cost is a limitation
of this technique
* Blood test:
Average red blood cell was 3.9 ±
0.819 T/L, hemoglobin: 115.1 ± 27.650 g/L
According to the World Health Organization,
anemia occurs when hemoglobin less than
130 g/L in males and less than 120 g/L in
females In our study, there were 37
patients with anemia (56.9%) (table 4)
According to Pham Duy Hien, blood
leakage and black stools can appear at
early stage [7] The average protein was
68.6 ± 7.955 g/L, the average albumin
was 36.9 ± 4.656 These are two indicators
that reflect the nutritional status of the
patient In general, the protein and albumin
index in the elderly is lower than normal in
combination with gastric cancer affecting
patients’ nutritional status
The average CEA was 11.4 ±
42.088 ng/mL; average CA19.9 was
56.5 ± 202.332 U/mL and the average
CA72.4 was 8.6 ± 30.811 U/mL CA72.4
is a glycoprotein that can be detected in
stomach, pancreas, colorectal, ovarian and
breast cancers Normal concentrations
of CA72.4 < 6.9 U/mL plays a role in
prognosis and assessment of disease
stage [12] Gwak HK surveyed 96 patients
which showed mean value of CEA being
1.9 ng/mL, CA19.9 being 9.9 ng/mL and
CA72.4 being 2.5 ng/mL The author
found that CA72.4 was significantly
related to lymph node involvement,
metastasis or stage of illness [13]
Compared to Gwak HK’s findings, our
results in all three tests were higher, which was appropriate due to lymph node metastasis and later stage, the relationship between stage of disease and test value, however, was made unclear due to limited number of tests
* Combined disease:
The incidence of comorbidities was observed in 27 patients (41.5%), the older the patients, the more susceptible to the combined diseases they are, of which hypertension, cardiovascular disease and diabetes are the most common In this study, the most prevalence of comorbidities was hypertension (23.07%), followed by stabilized heart disease (9.23%), diabetes (7.69%) and chronic obstructive pulmonary disease and hypertrophy of the prostate
(4.61%) (table 5) These findings are
consistent with Sakurai K’s, where comorbidities accounted for 74.1% with the highest rate of hypertension (41.1%) [4] Meanwhile the incidence of combined disease in Matsuk A’s study was 73.1%,
of which cardiovascular disease accounted for the majority (43.6%) [6]
* Pre-operation treatment:
The preoperative treatment day was
on average 8.8 ± 5.523 days, the earliest was 2 days, the latest was 35 days It can
be seen from table 6 and table 7, there was an association between pre-operative day of treatment and the comorbidities, anemia status (p = 0.012 and p = 0.038)
In cases of moderate and severe anemia, blood transfusions were required before surgery 20 patients (30.76%) received a maximum infusion of 1,200 mL of red blood cells Cachetic patients were combined with plasma infusion and nourishment before surgery, thus increasing the pre-operative treatment time
Trang 6CONCLUSIONS
Research on lower third gastric cancer
in the elderly, we found that clinical
symptoms are often faint, short duration
of the disease, with 41.54% of combined
diseases Upon admission, patients were
mostly in the advanced stage with late
complications: anemia 56.9%, gastrointestinal
bleeding 26.1%, pyloric stenosis 18.5%
The correct diagnosis rate of gastroscopy
and gastric X-ray were 96.9%, 76.2%,
respectively Abdominal CT-scan allows
the accurate diagnosis of injury sites and
the size of tumor being 73.17% whereas
the correct diagnosis rate of the size and
tumor invasion was 86.66%, lymph node
metastasis was 66.66% on PET/CT
There was a significant association in the
prevalence of patients with combined
diseases, anemia and prolonged day of
pre-operative treatment (p < 0.05)
REFERENCES
1 Trịnh Hồng Sơn Nghiên cứu nạo vét
hạch trong điều trị ung thư dạ dày Luận án
Tiến sĩ Y học Trường Đại học Y Hà Nội 2001
2 Phạm Duy Hiển Ung thư dạ dày Nhà
xuất bản Y học Hà Nội 2007
3 Nguyễn Văn Vân, Nguyễn Đình Hối
Bệnh ung thư dạ dày Nhà xuất bản Y học
Hà Nội 1975
4 Bray F, Ferlay JI, Soerjomataram
Global Cancer Statistics 2018: GLOBOCAN
Estimates of incidence and mortality worldwide
for 36 cancers in 185 countries CA Cancer J Clin 2018:1-31
5 Tomaiuolo P, et al Surgical treatment of gastric cancer in elderly patients Surgery in the multimodal management of gastric cancer Springer-Verlag, Italia 2012:139-147
6 Matsuki A, et al Surgical treatment for gastric cancer in extremely aged patients Journal of Aging Science 2014; 3(1):1-3
7 Sakurai K, et al The outcome of surgical treatment for elderly patients with gastric carcinoma Journal of Surgical Oncology 2015; 111:848-854
8 Japanese Gastric Cancer Association Japanese gastric cancer treatment guidelines (ver 4) Gastric Cancer 2016:1-19
9 Weiser MR, C Colon K Diagnosis and staging of gastric cancer Cancer of the upper gastrointestinal tract American Cancer Society 2002:237-251
10 Kuntz C, Herfarth C Imaging diagnosis for staging of gastric cancer Seminars in Surgical Oncology 1999; 17:96-102
11 Yun M, Lim JS, et al Lymph node staging of gastric cancer using 18F-FDG PET:
A comparative study with CT The Journal of Nuclear Medicine 2005; 46(10):1582-1588
12 Gireada A, Balescu I, Bacalbasa N Gastric cancer tumor markers revista medicalå românå 2015; 62:403-407
13 Gwak HK, Lee JH, Park SG Preliminary evaluation of clinical utility of CYFRA 21-1, CA72-4, NSE, CA19-9 and CEA in stomach cancer Asian Pacific Journal of Cancer Prevention: APJCP 2014; 15:4933-4938