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A case of esophageal carcinoma that had invaded to the cardia was treated with intracavitary irradiation. The residual tumor was present at the cardia after radiotherapy. This result demonstrates that intracavitary irradiation is not necessarily effective for cases with invasion to the cardia of the stomach. Operation is recommended for such cases to obtain local control.
From 1964-1978 458 patients were operated for carcinoma of the cardia or esophagus at the surgical clinic, Krankenhaus Nordwest, Frankfurt/M. Indication, preoperative treatment and operative procedures are discussed. In 117 cases, an abdominal thoracic resection or a resection of the cardia was performed. In a higher frequency of incurable cases an esophageal endoprosthesis was implanted. The lethality rate was 20,5% after resection. Nearly half of the operated patients survived for two years. 36% of the patients were still alive five years following abdominal thoracic resection and 21% following cardia resection. Despite a relatively high surgical risk, resection seemed to be the appropriate procedure as proven by the good long term results.
The prognostic relevance of DNA stem line ploidy was ascertained by comparative DNA analysis performed by flow cytometry (FCM) and by Feulgen image cytometry (ICM) of histologic slides on paraffin-embedded resection material from 221 carcinomas of the cardia and stomach. While flow cytometric detection of DNA stem line aneuploidy was rather insecure in smaller or diffuse carcinomas, the methodological restrictions of ICM were seen in a reduced measuring accuracy varying from one case to the other. This resulted in a lower security in distinguishing mere peridiploidy from real hyperdiploid DNA aneuploidy. Despite the difference of methodology, the results were principally concurring. The assessment of DNA stem line ploidy offered no appreciable information about the prognosis of Lauren's diffuse carcinomas. For intestinal carcinomas, however, there was a significant positive correlation between DNA stem line aneuploidy and the evidence of regional nodal metastases, which might explain to a considerable extent the significantly unfavorable clinical course of tumor cases with recorded DNA aneuploidy. The correlation between DNA stem line ploidy, nodal status, and clinical outcome was distinctly less strong in intestinal carcinomas of the cardia than in those of the stomach, because nodal metastatic spread of cardia carcinomas is strongly influenced by local conditions of lymph drainage and the special mechanical strain.
Our experiments were performed on dogs in which the central end of the left thoracic vagus had been sutured to the peripheral end of the left phrenic nerve. In such preparations, the activity of motor units of the re-innervated left hemidiaphragm indicated the activity of the vagal efferent fibres. After the left hemidiaphragm had been transformed into subcutaneous muscle, we studied, (using electromyography in the unanesthetized dog), the discharge of vagal fibres which originally supplied the lower oesophageal sphincter (cardia). The present paper only deals with fibres showing low frequency tonic discharge. 1. For some fibres (VIC type ; N = 42), the spontaneous firing rate (1.5 less than f less than 4.5 spikes/s) is suddenly enhanced just after the buccopharyngeal stage of swallowing (12 less than f less than 16 spikes/s). The this discharge stops abruptly just before the end of oesophageal peristalsis and starts again 2 to 3 seconds later at a low frequency (15 less than f less than 4.5 spikes/s). 2. Other fibres (VEC ; N = 18), which also have a slow discharge frequency (1 less than f less than 3 spikes/s) stop firing soon after the onset of swallowing and remain silent until the end of oesophageal peristalsis. At this time, i.e. when the bolus enters the stomach, the discharge starts again with an increased frequency (5 less than mean frequency less than 9 spikes/s). 3. The behaviour of the tonic vagal fibres during swallowing, as well as their low discharge frequency, strongly suggest that these fibres originally controlled the smooth muscle of the lower oesophageal sphincter and excited either an inhibitory (VIC = vagal inhibitory fibres of cardia) or an excitatory control (VEC = vagal excitatory fibres of cardia) upon this area.
p53 gene in human esophageal cancer (EC) and cancer of gastric cardia was analyzed. Southern blotting hybridization revealed that five of 35 of EC sample were found to contain abnormal structure of p53 gene, including 2 deletions and 3 rearrangements; two of 27 adjacent non-tumor tissues also contain abnormal structure of p53 gene (7.4%), among them one case was fragment deletion and another case was rearrangement. PCR-direct sequencing technique was used to detect p53 point mutation within exon and intron 5 through 9. Fifteen of 30(50%) of esophageal squamous cell carcinomas contained mutation of p53 gene. Five of 11(45%) adjacent non-tumor tissues also contained mutation of p53 gene. An esophageal adenocarcinoma showed p53 mutation. Three of 4 carcinoma of gastric cardia showed p53 mutation. Mutation spectrum in EC: 8 of 22 cases (36.4%) of p53 mutation were G:C to A: T transition, 6 of 22 cases (27.3%) of p53 mutation were frameshift mutation, including 13.6% (3/22) insertion and 9.1% (2/22) deletion mutation. Some new sites of p53 mutation in human EC were identified. The results suggest that the p53 gene plays an important role in carcinogenesis of human esophagus and gastric cardia.
From April 1983 to September 1992, we performed surgical treatment for 751 consecutive cases of carcinoma of the esophagus and gastric cardia. 709 patients had complete resection. Among them 314 were carcinoma of the esophagus, the rest were of the gastric cardia. The total resectability was 94.4%. In 55 cases the carcinoma of the esophagus was excised from the left thorax. 185 cases had an excision of Ivor-Lewis esophagogastrectomy. In 52 cases it was excised through right thorax, the left neck and the upper abdomen. The carcinoma of gastric cardia was excised from left thorax in 254 cases, from abdomen in 141 cases. Among 709 cases, there were 73 cases with complications including that in the lungs in 26 cases (35.6%). There was no death within 30 days or during the stay in hospital after the operation. The authors hold that the key to reduce operative mortality is to prevent anastomotic leaking. Proper operative approaches should be chosen carefully according to the different position of the pathologic changes so as to gain a thorough operative exposure. The technique of anastomosis is of the key importance. The anastomosis with extending the esophageal mucosa may prevent leaking effectively. Besides, it is necessary to effectively deal with post-operative complications in time, especially when there is a massive bleeding while carrying on drainage in the thoracic cavity during the early postoperative-stage. Bleeding should be staunched in time inside the thorax again.
The highest incidences of esophageal and gastric cardia cancer in the world occur in northern China. Chinese scientists have developed esophageal balloon cytology screening to detect these cancers, but traditional cytology is sometimes inadequate to find some early, curable lesions. Several studies suggest that quantitative fluorescence image analysis (QFIA) of DNA ploidy and nuclear morphology may be able to improve upon traditional cytology results. In October 1987, esophageal balloon cytology was performed on 1331 adults in Linxian, China, and all samples were evaluated both by traditional cytology and QFIA. From 1987 to May 1991, 62 new squamous esophageal cancers and 44 new adenocarcinomas of the cardia were identified in this cohort. Proportional hazards models were used to evaluate the relationship of cytological diagnoses and six QFIA variables to subsequent cancer risk. These models showed significant trends for increasing esophageal cancer risk, with increasing values in five of the QFIA variables and with increasing severity of the traditional cytological diagnoses. A comparison of models with only cytology variables versus models with both cytology and QFIA variables indicated that the QFIA provided an important additional predictive value. Persons with both cytological dysplasia and high cellular DNA were 8 times more likely to develop esophageal cancer than were individuals with neither of these conditions. For cardia cancer, associations between QFIA variables or cytological diagnoses and later cancer were more limited. This study suggests that the QFIA variables evaluated here are independent predictors of squamous esophageal cancer and that combining QFIA with traditional cytology can improve prediction of esophageal cancer risk.
Cancer of the cardia is traditionally discussed with cardiac cancer of the lower portion of the esophagus and upper gastric cancer invading the esophagus, and the specific characteristics of cancer of the cardia have never been clearly defined. We reviewed the outcome of 172 patients with adenocarcinoma of the cardia who had undergone radical surgery between 1949 and 1994 in the Division of Gastrointestinal Surgery of the Cancer Institute Hospital. The centers of the tumors were located within 2 cm above and below the boundary between the esophagus and the stomach, and their longitudinal diameter was less than 8 cm. We divided the patients into an early period (1949-1979; n = 79) and a late period (1980-1994; n = 93), and focused on the historical transition. There were no differences in patient gender or histology between the two periods. However, the late period was associated with fewer cases of esophageal invasion and shorter longitudinal diameter, as the age of the population advanced. The number of advanced cancers such as the localized and infiltrative type had decreased, and early cancer and early clinical stage had become more common, but despite the fact that the number of early cancers had increased, extended dissection, such as thoracic and paraaortic lymph node dissection, was performed more frequently. By clinical stage, the long-term outcome markedly improved in Stage I patient in the late period, and tended to improve in Stage II and III patients. This appears to have been attributable to the prevention of micrometastasis by extended dissection, although the number of early cancers is another major potential cause. There were no differences in the outcome of Stage IV patients between the two periods, and further advances in multimodality therapy must be awaited. The range of resection is basically proximal gastrectomy, and if there are adequate indications, the prognosis is favorable. In view of the status of lymphatic flow and lymph node metastasis, and long-term results, lateroaortic lymph node dissection is important. Since the number of early cancer patients has been increasing, if intraabdominal recurrence is prevented, intrathoracic lymph node dissection will contribute greatly to the outcome of such patients.
BACKGROUND: The divergent incidence patterns of gastric cardia and distal stomach cancer may suggest different etiologies. This study examined the role of cigarette smoking, alcohol drinking, and green tea consumption as risk factors for carcinoma by anatomic subsite of stomach. METHODS: Newly-diagnosed stomach carcinoma patients (n = 1124) and frequency-matched population controls (n = 1451) were interviewed in person. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. RESULTS: Excess risks associated with cigarette smoking and alcohol consumption were observed largely among men. The adjusted ORs for all stomach cancer combined were 1.35 (CI: 1.06-1.71) for current smokers, and 1.26 (CI: 0.86-1.84) for ex-smokers. For tumors of the distal stomach, statistically significant positive dose-response trends were found for the number of cigarettes smoked per day, the duration and pack-years of smoking, and inverse trends for years of stopped smoking. For tumors of the gastric cardia, however, a monotonic association was found only for the number of cigarettes smoked per day (P=0.06). Alcohol consumption was not related to the risk of cardia cancer, while a moderate excess risk of distal stomach cancer (OR: 1.55; CI: 1.07-2.26) was observed among heavy alcohol drinkers. Green tea drinking was inversely associated with risk of stomach cancer arising from either subsite, with ORs of 0.77 (CI: 0.52-1.13) among female heavy drinkers, and 0.76 (CI: 0.55-1.27) among male heavy drinkers. CONCLUSIONS: Our findings provide further evidence that cigarette smoking and, possibly, alcohol consumption increase the risk of stomach carcinoma, notably of the distal segment. An inverse association with green tea drinking was also observed.
OBJECTIVE: To determine the association of computed tomography (CT)-measured visceral adipose tissue (AT) and other measures of adiposity with fasting insulin in a biracial (African American and Caucasian) study population of young adults. RESEARCH METHODS AND PROCEDURES: The study population consisted of 251 young adults with normal glucose tolerance (NGT), ages 28-40 years, who were volunteers from the Birmingham, Alabama, and Oakland, California centers of the Coronary Artery Risk Development in Young Adults (CARDIA) study. RESULTS: In regression models with total adiposity measures (body mass index or dual-energy X-ray absorptiometry-measured percent fat), visceral AT (measured as a cross-sectional area in cm2) was generally a stronger predictor of insulin than overall adiposity in all race/gender groups (partial correlation coefficients ranging from 0.31 to 0.47) except for black men, in whom the associations were nonsignificant. Partial correlation coefficients between waist circumference and insulin, controlling for percent fat, were nearly identical to those between visceral AT and insulin in women and in white men. Analyses performed on 2060 NGT CARDIA subjects who were not in this study of visceral AT showed significant correlations of waist circumference with insulin in all race/gender groups, including black men, and that black men in the visceral AT study group were significantly leaner than other black male CARDIA subjects. DISCUSSION: We conclude that visceral AT was associated with fasting insulin in NGT participants in three of the four race/gender groups (black men excepted) and that waist circumference was a good surrogate for visceral AT in examining associations of central adiposity with fasting insulin.
The peritrophic membrane of Drosophila melanogaster consists of four layers, each associated with a specific region of the folded epithelial lining of the cardia. The epithelium is adapted to produce this multilaminar peritrophic membrane by bringing together several regions of foregut and midgut, each characterized by a distinctively differentiated cell type. The very thin, electron-dense inner layer of the peritrophic membrane originates adjacent to the cuticular surface of the stomadeal valve and so appears to require some contribution by the underlying foregut cells. These foregut cells are characterized by dense concentrations of glycogen, extensive arrays of smooth endoplasmic reticulum, and pleated apical plasma membranes. The second and thickest layer of the peritrophic membrane coalesces from amorphous, periodic acid-Schiff-positive material between the microvilli of midgut cells in the neck of the valve. The third layer of the peritrophic membrane is composed of fine electron-dense granules associated with the tall midgut cells of the outer cardia wall. These columnar cells are characterized by cytoplasm filled with extensive rough endoplasmic reticulum and numerous Golgi bodies and by an apical projection filled with secretory vesicles and covered by microvilli. The fourth, outer layer of the peritrophic membrane originates over the brush border of the cuboidal midgut cells, which connect the cardia with the ventriculus.
BACKGROUND: Although Helicobacter pylori infection is a major risk factor for gastric cancer, it does not explain the full picture of stomach carcinogenesis. There have been few epidemiological studies, however, which examined both H. pylori and environmental factors simultaneously. The aims of this study were to estimate the association of environmental factors (smoking and dietary factors) with gastric cancer in consideration of H. pylori infection, and to investigate the effects of the interaction between environmental factors and H. pylori infection. METHODS: A multicenter, hospital-based, case-control study of gastric cancer was conducted at four hospitals in Nagano prefecture, Japan, between October 1998 and March 2002. For 153 newly diagnosed gastric cancer cases, two controls matched by age (within 3 years), sex, and residence area were randomly selected from the participants of a health check-up program during the same period in the same hospitals. We conducted a questionnaire survey and obtained blood samples. Consequently, 122 non-cardia gastric cancer cases and 235 controls were available for this analysis. RESULTS: Results. H. pylori infection was strongly associated with non-cardia gastric cancer after adjustment for possible confounding factors (odds ratio [OR], 8.2; 95% confidence interval [CI], 3.7-18.2). Cigarette smoking (OR, 2.8; 95% CI, 1.2-6.5) and frequent intake of miso (fermented soy bean) soup (OR, 2.1; 95% CI, 0.9-5.1) and rice (OR, 2.5; 95% CI, 1.0-6.1) were determined to be risk factors even after adjusting for possible confounding factors, including H. pylori infection. However, no statistically significant interaction between environmental factors and H. pylori infection was detected. CONCLUSION: This finding suggests that although H. pylori infection is clearly an important risk factor for gastric cancer, smoking cessation and dietary modification may be practical strategies for the prevention of non-cardia gastric cancer among both H. pylori-positive and -negative subjects in Japan.
BACKGROUND: Precise knowledge of the abdominal nodal spread of cardia adenocarcinoma in relation to the depth of invasion of the tumor and its longitudinal extension may be very important for the surgeon as a guide in choosing the type of resection and lymphadenectomy.METHODS: The frequency of node metastases in each abdominal station of the first and second tier was prospectively studied in 101 patients with type II and III cardia cancer (defined as approved by the consensus conference held during the second International Gastric Cancer Conference in Munich in April, 1997) who underwent total gastrectomy with D2 lymphadenectomy during the period January 1994 to April 1998. Lymph nodes were retrieved immediately after operation by the surgeon and assigned to the appropriate station according to the classification of the Japanese Research Society for Gastric Cancer.RESULTS: In early gastric cancer, of both type II and type III, lymph node involvement was limited to the perigastric nodes of the upper half of the stomach and to the lymph node station of the celiac trunk. In advanced cancers, whether of type II or type III, there was a fairly high frequency of metastases to the perigastric nodes of the lower half of the stomach; there was also high frequency of metastases at N2 stations, without differences in frequency between pT2 and pT3 tumors (staged according to the classification of the Japanese Research Society for Gastric Cancer).CONCLUSIONS: The results of our study provide evidence for the need to perform a total gastrectomy with D2 lymphadenectomy in all patients with advanced cardia cancer type II or type III. In early cancers, a less extensive resection (proximal gastrectomy) with D2 lymphadenectomy may be indicated.
BACKGROUND: Adenocarcinoma of the esophagus and cardia is a challenging disease for the surgeon. Delay in diagnosis, nodal involvement, and incompleteness of resection have an adverse effect on long-term prognosis. Efforts are currently oriented to identify patients who may benefit from extensive resection.METHODS: Between November 1992 and May 1998, 218 patients with histologically proven adenocarcinoma of the distal esophagus or cardia were referred to our Department. In 6 patients (10.2%) cancer was discovered during endoscopic surveillance for Barrett's metaplasia. Overall, 147 patients (67%) underwent resection. An Ivor-Lewis approach was used in 121 patients; of these, 51 underwent an extended mediastinal lymph node dissection.RESULTS: Median cumulative survival was 25.9 +/- 3.1 months in patients undergoing resection, and 7 +/- 1.3 months in patients having palliation ( P < 0.01). Survival was significantly higher in patients with negative nodes than in those with lymph node metastases (54 +/- 12.9 versus 17 +/- 2.8 months; P < 0.01). Six of the 51 patients (11.8%) undergoing extended lym-phadenectomy had metastatic upper mediastinal nodes. Additional serial sections and immunohistochemistry were performed in 46 patients. In 6 of 18 patients (33.3%) with negative nodes at conventional hematoxylin-eosin examination, immunohistochemistry demonstrated micrometastases in the lesser curvature, paracardial, peripancreatic, or lower mediastinal nodes. Three of these patients had recurrent disease within the first year of follow-up.CONCLUSIONS: Early diagnosis remains the prerequisite for curative treatment of adenocarcinoma of the esophagus and cardia. Endoscopic surveillance appears to be warranted in patients with Barrett's metaplasia. When a curative resection is attempted, extended lymphadenectomy improves tumor staging and may prevent local recurrences. Serial sections and immunohistochemistry provide additional accuracy in the staging of the disease and may prove useful to select patients for adjuvant therapy.
In 1984, a prospective cohort study, Coronary Artery Risk Development in Young Adults (CARDIA) was initiated to investigate life-style and other factors that influence, favorably and unfavorably, the evolution of coronary heart disease risk factors during young adulthood. After a year of planning and protocol development, 5,116 black and white women and men, age 18-30 years, were recruited and examined in four urban areas: Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota, and Oakland, California. The initial examination included carefully standardized measurements of major risk factors as well as assessments of psychosocial, dietary, and exercise-related characteristics that might influence them, or that might be independent risk factors. This report presents the recruitment and examination methods as well as the mean levels of blood pressure, total plasma cholesterol, height, weight and body mass index, and the prevalence of cigarette smoking by age, sex, race and educational level. Compared to recent national samples, smoking is less prevalent in CARDIA participants, and weight tends to be greater. Cholesterol levels are representative and somewhat lower blood pressures in CARDIA are probably, at least in part, due to differences in measurement methods. Especially noteworthy among several differences in risk factor levels by demographic subgroup, were a higher body mass index among black than white women and much higher prevalence of cigarette smoking among persons with no more than a high school education than among those with more education.
OBJECTIVE: To test whether a higher fasting insulin concentration is associated with a lower rate of weight gain over six to seven years. DESIGN: Two longitudinal epidemiologic cohorts including blacks and whites. SUBJECTS: The Coronary Artery Risk Development in Young Adults (CARDIA) Study examined subjects aged 18-30 y in 1985-86 and 1992-93 (n = 3636), and the Atherosclerosis Risk in Communities (ARIC) Study examined subjects aged 45-64 y in 1987-89 and 1993-95 (n = 11179). MEASUREMENTS: In each study, fasting insulin at baseline and weight change during follow-up were measured in participants without diabetes. RESULTS: In whites and black men in CARDIA, there was a positive age-adjusted association between baseline insulin and weight change, although weight change was not entirely monotonic across the insulin quartiles. In these race-gender groups, the linear regression coefficients indicated that each 50 pmol/L increment of baseline insulin was associated (P < 0.05) with approximately 0.10 kg/y greater rate of weight gain (95% confidence intervals (CI) for this estimate in kg/y were 0.023-0.187 for white women, 0.015-0.150 for black men, and 0.011-0.158 for white men). The association was eliminated entirely with adjustment for baseline weight. In contrast, among whites and black women in ARIC, the association was negative, with the linear regression coefficients suggesting that each 50 pmol/L higher fasting insulin concentration was associated (P < 0.05) with a 0.03-0.10 kg/y lower rate of weight gain (95% CI for this estimate in kg/y were -0.133 to -0.061 for black women, -0.106 to -0.054 for white women, and -0.055 to -0.009 for white men). This finding was generally strengthened by adjustment for baseline body mass index (BMI). CONCLUSIONS: A higher fasting insulin concentration is associated modestly with a lower rate of weight gain in ARIC, but not in CARDIA.
BACKGROUND: The aim was to perform a prospective randomized study in patients with chronic gastro-oesophageal reflux treated either by total fundoplication or calibration of the cardia with posterior gastropexy. Late follow-up considered subjective and objective parameters, and related outcome to the presence of Barrett's oesophagus. METHODS: A total of 164 patients were randomized to fundoplication (n = 76) or calibration of the cardia (n = 88). They were evaluated by clinical questionnaire, upper gastrointestinal endoscopy with biopsies, oesophageal manometry and gastro-oesophageal reflux studies, including scintigraphy and 24-h oesophageal pH monitoring. RESULTS: There were no operative deaths. There was 95 per cent follow-up at a mean of 85 months. The mean recurrence rate for both operations was near 40 per cent at 10 years, but patients without Barrett's oesophagus had a recurrence rate after both operations of around 23 per cent compared with 83 per cent after 10 years for those with Barrett's oesophagus (P < 0.0001). Low-grade dysplasia developed in 13 per cent of the patients with Barrett's oesophagus. There were significant differences in all objective parameters in a comparison of patients with Visick I or II and those with Visick III or IV disease at the late assessment. CONCLUSION: Both total fundoplication and calibration of the cardia with posterior gastropexy had similar subjective and objective late results. However, results were significantly worse in patients with Barrett's oesophagus.
As the few randomized controlled trials available in the literature comparing botulinum toxin (BT) injection with established endoscopic treatment of achalasia cardia, i.e. pneumatic dilatation, showed conflicting results, we conducted a prospective randomized trial. Seventeen consecutive patients with achalasia cardia diagnosed during a period between December 1997 and February 2000 were randomized into two treatment groups [pneumatic dilatation by Rigiflex dilator (n=10), BT injection by sclerotherapy needle into four quadrants of lower esophageal sphincter (LES) (n=7) 80 units in five cases, 60 units in two cases] after dysphagia grading, endoscopy, barium esophagogram, and manometry, all of which were repeated 1 week after treatment. Patients were followed up clinically for 35.2+/-14 weeks. Chi-squares, Wilcoxon rank-sum test, Kaplan-Meier method and log-rank tests were used for statistical analysis. After 1 week, 6/7 (86%) BT-treated vs. 8/10 (80%) dilatation-treated patients improved (P=NS). There was no difference in LES pressure and maximum esophageal diameter in the barium esophagogram in the two groups before therapy. Both therapies resulted in significant reduction in LES pressure. The cumulative dysphagia-free state using the Kaplan-Meier method decreased progressively in BT-treated compared with dilatation-treated patients (P=0.027). Two patients with tortuous megaesophagus, one of whom had failed dilatation complicated by perforation previously, improved after BT. One other patient in whom pneumatic dilatation had previously failed improved in a similar manner. BT is as good as pneumatic dilatation in achieving an initial improvement in dysphagia of achalasia cardia. It is also effective in patients with tortuous megaesophagus and previous failed pneumatic dilatation. However, dysphagia often recurs during 1-year follow up.