203 Endoscopy 3 (1979) 203-206
Evaluation of histological classification in early gastric cancer (An analysis of 300 cases) K. Elster, W. Carson, A. Wild, A. Thomasko
Summary Using the Lauren approach of histological classifi-
cation, 300 cases of early gastric cancer (EGC) were analysed with regard to their age distribution,
to predisposing lesions, including gastritis, and survival rate. The average age of onset for EGC of the diffuse type is 56, ten years earlier than for the intestinal type. There was a significantly high per-
centage of EGC of the diffuse type without gastritis. On the other hand, gastritis in pernicious anaemia falls in the high-risk group. The survival rate in our cases is 98%, corrected for age. The results show that it is of utmost importance to differentiate between the histological types of gastric carcinoma; for there may be indeed a difference in pathogenesis and aetiology.
Zusammenfassung Unter Anwendung der Lauren-Klassifikation mit der Abgrenzung der histologischen Typen diffus" und intestinal" wurden 300 Magenfriihkarzinome, im Hinblick auf Altersverteilung, pradis-
ponierende Faktoren, einschließlich der Gastritis und der 5- Jahresheilungsrate analysiert.
Der Altersgipfel für den diffusen Typ lag bei 56 Jahren, 10 Jahre friiher als beim intestinalen Typ. Statistisch signifikant war der hohe Prozentsatz von Friihcarcinomen mit dem histologischen diffusen Typ in einer Schleimhaut ohne Entziindungs-
zeichen. Die Perniziosa-Konstellation" der Gastritis stellt jedoch einen Risikofaktor dar. Die 5Jahresheilungsrate 215 verwertbarer Falle lag bei 98%, nach Alterskorrektur. Die Ergebnisse weisen
auf die Bedeutung und Notwendigkeit bei der Key-Words: Early gastric carcinoma, Lauren classification, gastritis
Abgrenzung der histologischen Typen des Magencarcinoms bei derartigen Untersuchungen hin; denn offensichtlich bestehen Unterschiede in der Pathogenese und Atiologic.
Since the advent of better quantitative and qualitative endoscopic procedures the diagnosis of early gastric cancer (EGC) has been made more and more frequently. Since the founding of the Bayreuth Pathology Institute nine years ago we diagnosed 300 cases of EGC on resected stomachs, using the Japanese definition. The morphological prediag-
according to the findings of Lauren (5) and Ming (6) in their work with advanced stomach cancers. The first type is characterized by expanding growth of a tumor with well-defined boundaries. The basic histologic structure is usually adenocarcinoma (Fig. I).
nosis was made by biopsy in 96% (2). Of these diagnoses by biopsy, 82% were made
In the second or diffuse type there are scattered cells and cell groups (Fig. 2). This type presents morphologically a signet ring cell carcinoma or a poorly differentiated tubular
on the first biopsy and 14% on follow-up.
adenocarcinoma, and may frequently be a mixture of both types.
Histological types We divided our cases into the two histolog-
ical types of intestinal and diffuse cancer,
Age distribution
The significance of this differentiation is reflected in the age distribution. The diffuse
0013-726 X179 1500-0203 $ 02.00 © 1979 Georg Thieme Publishers
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Department of Pathology, Municipal Hospital, Bayreuth
204
K. Elster, W. Carson, A. Wild, A. Thomasko
age age at the onset of disease is 56 years with
the diffuse carcinoma, about 10 years earlier than the age of the average patient with the intestinal type. In the same manner, the peak
incidence for the diffuse type is about 10 years earlier than that for the intestinal type. These statistics agree with those for the ad-
expectancy, that older people are more frequently gastroscoped, and that therefore the absolute number of gastric cancers in old age is higher.
Correlation with gastritis An interesting finding is that there are significant differences in the incidence of a so-
MAN r Fig. 1
Adenocarcinoma, highly differentiated with
"expanding" growth. Early gastric carcinoma II b (m) intestinal type
called accompanying gastritis".
In
early
cancer of the diffuse type there was normal
mucosa in 13% of the cases. Even in the intestinal type 7% of the cases showed no gastritis in the mucosa surrounding the tumor. Still higher percentages are seen if we
regard the mucosa of the fundus (Tab. 2).
type is found more frequently in the first decades and less so in later decades of life,
and the intestinal type occurs with ever
increasing frequency from the middle age to later life (Fig. 3). Correspondingly, the aver-
These results may make the aetiological correlation of tumor and chronic atrophic gasat least for the diffuse tritis questionable type. This is all the more remarkable since benign lesions such as peptic ulcer are associated with a high percentage of changes like
Fig. 2 with
ekgi
Signet ring-cell carcinoma scattered cells and cell
groups. Early gastric carcinoma II b (m) diffuse type
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
vanced cancers published by Lauren (5). However, it is noticeable that the diagnosis of both types of EGC is made a decade later, respectively (Tab. 1). This may perhaps be explained by the fact that there is a longer life
Evaluation of histological classification in early gastric cancer
50-
205
diffuse type - intestinal type
40-
30-
10Age distribution of two histological types in 300 early gastric Fig. 3
cancers. (17 cases of mixed type are not included) Table
10-
20-
o-30-
50-
40-
60-
70- age
1
Mean age Peak
O
Intestinal Type Diffuse Type Intestinal Type Diffuse Type
Advanced Carcinoma (n = 1344) (1945-1964 Lauren)
Early Gastric Cancer
55.4 47.7
66.0 56.0
60-69 50-59
70-75 60-65
(n =
300)
(1969-1978, own cases)
Mean age and peak age in diffuse and intestinal type. Comparison between early gastric cancer and advanced carcinoma.
chronic atrophic gastritis, with and without
changes in the gastric stump are at least partly
intestinal metaplasia (1). A collective evaluation of chronic atrophic gastritis as a precancerous lesion is therefore not only problematic, but may be dangerous with respect to the therapeutic consequences (7).
a factor in the pathogenesis of malignancies of the stomach. The coincidence of benign hyperplasiogenic polyps with tumors can not
Lesions with high risk
Analysis of stomach at risk yields another probable reason to consider a different pathogenesis for the two types. The cancer to be expected in patients with pernicious anaemia would be of the intestinal type. This is associated with chronic atrophic gastritis of
the entire mucosa of the fundus. Quantitatively speaking, this may be termed precancerous". The resected stomach may be seen
yet be explained, and there is likewise no answer regarding the question of Ménétrier's syndrome in our small number of cases. Deviations from single circumscribed findings seem to be of great therapeutic and prognostic importance. Lesions covered by our study are double early cancers, early gastric cancer together with a borderline lesion, multicentric
localisation, that is, various cancerous foci relatively far apart, and finally, the tumor spreading without continuous infiltration, a fact one can recognize only after microscopic
under the same aspect, albeit with some reser-
examination. The last two types of lesions most frequently develop recurrences in the
vations, for it is thought that the atrophic
gastric stump (3).
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
20
206
K. Elster: Evaluation of histological class fication in early gastric cancer
Table 2
early gastric carcinoma Diff.-Type (n = 122) Int.-Type (n = 151)
chronic atrophic gastritis with or without intestinal metaplasia
65
severe superficial gastritis
14
(9)
10
(8)
mild or moderate superficial gastritis
60
(40)
74
(62)
normal
12
(8)
18
(15)
151
(100)
122
(100)
18
(15)
Frequency and severity of gastritis in tumor-distant fundic mucosa
One of our case findings demonstrated how
important it
is
that, whenever biopsy has
References 1
revealed a signet ring cell carcinoma, the sur-
geon should resect with a great margin of safety, not only proximally, but also into the duodenum.
2
3
Elster, K., S. Reiss, K. Heinkel: Histotopographische Untersuchungen tiller die intestinale Metaplasie im Karzinomund Ulkusmagen Z. Gesamte Inn. Med. 15 (1960) 1035 Elster, K.: Biopsie und Cytologie (in der Diagnostik und Therapie chirurgischer Erkrankungen) Langenbecks Arch. Chir. 345 (Kongregbericht 1977) 313 Elster, K., A. Thomasko: Klinische Wertung der histologi-
In spite of this finding, which may adversely affect the prognosis, the cumulative
schen Typen des Magenfrühkarzinoms Eine Analyse von 300 Fällen. Leber, Magen, Dann 8, Nr. 6 (1978) 319 4 Elster, K., E. Seifert: Magenfriihkarzinom. In: Th. Gheorghiu (Hrsg.): Das gastroenterologische Kompenchum. Witzstrock, Baden-Baden Brüssel Kiiln New York (1979)
survival rate from the 215 cases which we
5
Survival rate
followed up, corrected for age, was 98% (+ 2% 8%). There were no significant differ-
ences between the two histological types under discussion (4). The value of such an analysis of early gas-
tric cancer lies not only in the aspect of the clinical morphology and its practical meaning for diagnosis, therapy and prognosis, but also especially in the deepening of our knowledge of the pathogenesis.
Lauren, P.: The two histological main types of gastric carcinoma: diffuse and so-called intestinal type carcinoma.
An attempt at a histo-clinical classification. Acta Pathol. Microbiol. Scand. 64 (1965) 31 6 Ming, S.-C.: Gastric carcinoma. A pathobiological classification. Cancer 39 (1977) 2475 7 Rtisch, W., K. Elster: Gastrointestinale Prakanzerosen. In: Th. Gheorghiu (Hrsg.): Das gastroenterologische Kompendium. Witzstrock, Baden-Baden Brüssel Köln New York (1977)
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
total
(43)
Evaluation of histological classification in early gastric cancer (An analysis of 300 cases) K. Elster, W. Carson, A. Wild, A. Thomasko
Summary Using the Lauren approach of histological classifi-
cation, 300 cases of early gastric cancer (EGC) were analysed with regard to their age distribution,
to predisposing lesions, including gastritis, and survival rate. The average age of onset for EGC of the diffuse type is 56, ten years earlier than for the intestinal type. There was a significantly high per-
centage of EGC of the diffuse type without gastritis. On the other hand, gastritis in pernicious anaemia falls in the high-risk group. The survival rate in our cases is 98%, corrected for age. The results show that it is of utmost importance to differentiate between the histological types of gastric carcinoma; for there may be indeed a difference in pathogenesis and aetiology.
Zusammenfassung Unter Anwendung der Lauren-Klassifikation mit der Abgrenzung der histologischen Typen diffus" und intestinal" wurden 300 Magenfriihkarzinome, im Hinblick auf Altersverteilung, pradis-
ponierende Faktoren, einschließlich der Gastritis und der 5- Jahresheilungsrate analysiert.
Der Altersgipfel für den diffusen Typ lag bei 56 Jahren, 10 Jahre friiher als beim intestinalen Typ. Statistisch signifikant war der hohe Prozentsatz von Friihcarcinomen mit dem histologischen diffusen Typ in einer Schleimhaut ohne Entziindungs-
zeichen. Die Perniziosa-Konstellation" der Gastritis stellt jedoch einen Risikofaktor dar. Die 5Jahresheilungsrate 215 verwertbarer Falle lag bei 98%, nach Alterskorrektur. Die Ergebnisse weisen
auf die Bedeutung und Notwendigkeit bei der Key-Words: Early gastric carcinoma, Lauren classification, gastritis
Abgrenzung der histologischen Typen des Magencarcinoms bei derartigen Untersuchungen hin; denn offensichtlich bestehen Unterschiede in der Pathogenese und Atiologic.
Since the advent of better quantitative and qualitative endoscopic procedures the diagnosis of early gastric cancer (EGC) has been made more and more frequently. Since the founding of the Bayreuth Pathology Institute nine years ago we diagnosed 300 cases of EGC on resected stomachs, using the Japanese definition. The morphological prediag-
according to the findings of Lauren (5) and Ming (6) in their work with advanced stomach cancers. The first type is characterized by expanding growth of a tumor with well-defined boundaries. The basic histologic structure is usually adenocarcinoma (Fig. I).
nosis was made by biopsy in 96% (2). Of these diagnoses by biopsy, 82% were made
In the second or diffuse type there are scattered cells and cell groups (Fig. 2). This type presents morphologically a signet ring cell carcinoma or a poorly differentiated tubular
on the first biopsy and 14% on follow-up.
adenocarcinoma, and may frequently be a mixture of both types.
Histological types We divided our cases into the two histolog-
ical types of intestinal and diffuse cancer,
Age distribution
The significance of this differentiation is reflected in the age distribution. The diffuse
0013-726 X179 1500-0203 $ 02.00 © 1979 Georg Thieme Publishers
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Department of Pathology, Municipal Hospital, Bayreuth
204
K. Elster, W. Carson, A. Wild, A. Thomasko
age age at the onset of disease is 56 years with
the diffuse carcinoma, about 10 years earlier than the age of the average patient with the intestinal type. In the same manner, the peak
incidence for the diffuse type is about 10 years earlier than that for the intestinal type. These statistics agree with those for the ad-
expectancy, that older people are more frequently gastroscoped, and that therefore the absolute number of gastric cancers in old age is higher.
Correlation with gastritis An interesting finding is that there are significant differences in the incidence of a so-
MAN r Fig. 1
Adenocarcinoma, highly differentiated with
"expanding" growth. Early gastric carcinoma II b (m) intestinal type
called accompanying gastritis".
In
early
cancer of the diffuse type there was normal
mucosa in 13% of the cases. Even in the intestinal type 7% of the cases showed no gastritis in the mucosa surrounding the tumor. Still higher percentages are seen if we
regard the mucosa of the fundus (Tab. 2).
type is found more frequently in the first decades and less so in later decades of life,
and the intestinal type occurs with ever
increasing frequency from the middle age to later life (Fig. 3). Correspondingly, the aver-
These results may make the aetiological correlation of tumor and chronic atrophic gasat least for the diffuse tritis questionable type. This is all the more remarkable since benign lesions such as peptic ulcer are associated with a high percentage of changes like
Fig. 2 with
ekgi
Signet ring-cell carcinoma scattered cells and cell
groups. Early gastric carcinoma II b (m) diffuse type
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
vanced cancers published by Lauren (5). However, it is noticeable that the diagnosis of both types of EGC is made a decade later, respectively (Tab. 1). This may perhaps be explained by the fact that there is a longer life
Evaluation of histological classification in early gastric cancer
50-
205
diffuse type - intestinal type
40-
30-
10Age distribution of two histological types in 300 early gastric Fig. 3
cancers. (17 cases of mixed type are not included) Table
10-
20-
o-30-
50-
40-
60-
70- age
1
Mean age Peak
O
Intestinal Type Diffuse Type Intestinal Type Diffuse Type
Advanced Carcinoma (n = 1344) (1945-1964 Lauren)
Early Gastric Cancer
55.4 47.7
66.0 56.0
60-69 50-59
70-75 60-65
(n =
300)
(1969-1978, own cases)
Mean age and peak age in diffuse and intestinal type. Comparison between early gastric cancer and advanced carcinoma.
chronic atrophic gastritis, with and without
changes in the gastric stump are at least partly
intestinal metaplasia (1). A collective evaluation of chronic atrophic gastritis as a precancerous lesion is therefore not only problematic, but may be dangerous with respect to the therapeutic consequences (7).
a factor in the pathogenesis of malignancies of the stomach. The coincidence of benign hyperplasiogenic polyps with tumors can not
Lesions with high risk
Analysis of stomach at risk yields another probable reason to consider a different pathogenesis for the two types. The cancer to be expected in patients with pernicious anaemia would be of the intestinal type. This is associated with chronic atrophic gastritis of
the entire mucosa of the fundus. Quantitatively speaking, this may be termed precancerous". The resected stomach may be seen
yet be explained, and there is likewise no answer regarding the question of Ménétrier's syndrome in our small number of cases. Deviations from single circumscribed findings seem to be of great therapeutic and prognostic importance. Lesions covered by our study are double early cancers, early gastric cancer together with a borderline lesion, multicentric
localisation, that is, various cancerous foci relatively far apart, and finally, the tumor spreading without continuous infiltration, a fact one can recognize only after microscopic
under the same aspect, albeit with some reser-
examination. The last two types of lesions most frequently develop recurrences in the
vations, for it is thought that the atrophic
gastric stump (3).
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
20
206
K. Elster: Evaluation of histological class fication in early gastric cancer
Table 2
early gastric carcinoma Diff.-Type (n = 122) Int.-Type (n = 151)
chronic atrophic gastritis with or without intestinal metaplasia
65
severe superficial gastritis
14
(9)
10
(8)
mild or moderate superficial gastritis
60
(40)
74
(62)
normal
12
(8)
18
(15)
151
(100)
122
(100)
18
(15)
Frequency and severity of gastritis in tumor-distant fundic mucosa
One of our case findings demonstrated how
important it
is
that, whenever biopsy has
References 1
revealed a signet ring cell carcinoma, the sur-
geon should resect with a great margin of safety, not only proximally, but also into the duodenum.
2
3
Elster, K., S. Reiss, K. Heinkel: Histotopographische Untersuchungen tiller die intestinale Metaplasie im Karzinomund Ulkusmagen Z. Gesamte Inn. Med. 15 (1960) 1035 Elster, K.: Biopsie und Cytologie (in der Diagnostik und Therapie chirurgischer Erkrankungen) Langenbecks Arch. Chir. 345 (Kongregbericht 1977) 313 Elster, K., A. Thomasko: Klinische Wertung der histologi-
In spite of this finding, which may adversely affect the prognosis, the cumulative
schen Typen des Magenfrühkarzinoms Eine Analyse von 300 Fällen. Leber, Magen, Dann 8, Nr. 6 (1978) 319 4 Elster, K., E. Seifert: Magenfriihkarzinom. In: Th. Gheorghiu (Hrsg.): Das gastroenterologische Kompenchum. Witzstrock, Baden-Baden Brüssel Kiiln New York (1979)
survival rate from the 215 cases which we
5
Survival rate
followed up, corrected for age, was 98% (+ 2% 8%). There were no significant differ-
ences between the two histological types under discussion (4). The value of such an analysis of early gas-
tric cancer lies not only in the aspect of the clinical morphology and its practical meaning for diagnosis, therapy and prognosis, but also especially in the deepening of our knowledge of the pathogenesis.
Lauren, P.: The two histological main types of gastric carcinoma: diffuse and so-called intestinal type carcinoma.
An attempt at a histo-clinical classification. Acta Pathol. Microbiol. Scand. 64 (1965) 31 6 Ming, S.-C.: Gastric carcinoma. A pathobiological classification. Cancer 39 (1977) 2475 7 Rtisch, W., K. Elster: Gastrointestinale Prakanzerosen. In: Th. Gheorghiu (Hrsg.): Das gastroenterologische Kompendium. Witzstrock, Baden-Baden Brüssel Köln New York (1977)
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
total
(43)
