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.
Journal of military pharmaco-medicine no5-2020 RESEARCH ON CLINICAL AND PARACLINICAL CHARACTERISTICS OF LOWER THIRD GASTRIC CANCER IN THE ELDERLY AT MILITARY HOSPITAL 103 Ho Chi Thanh1, Truong Duc Tuan1, Lai Ba Thanh1 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 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 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? Department of Abdominal Surgery, Military Hospital 103, Vietnam Military Medical University Corresponding author: Ho Chi Thanh (hochithanhbv103@gmail.com) Date received: 15/6/2020 Date accepted: 22/6/2020 147 Journal of military pharmaco-medicine no5-2020 - Patients were examined and taken conventional examiniation SUBJECTS AND METHODS Subjects - Patients were examined and treated for combined diseases 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 - 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 Methods - Prospective, descriptive and cross sectional study - Clinical and paraclinical characteristics were taken at the time of admission RESULTS Table 1: General characteristics General characteristics Number of patients (n) Rate (%) Male 49 75.38 Female 16 24.61 Gender BMI 19.95 ± 2.647 Disease duration < months 43 66.2 - < months 16 24.6 ≥ months 9.2 Mean (months) 2.57 ± 2.767 * 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%) 148 Journal of military pharmaco-medicine no5-2020 Table 2: Imaging tests Number of tests Test Accurate diagnosis Unclear imaging n % n % n % Gastroscopy 65 100.0 63 96.9 3.1 Gastric X-ray 21 32.3 16 76.2 23.8 Abdominal CT 41 63.07 30 73.17 10 24.39 PET/CT 15 23.07 13 86.66 10 66.66 Table 3: Blood tests Mean ± SD Min - max RBC (T/L) 3.9 ± 0.819 1.60 - 5.60 HGB (g/L) 115.1 ± 27.650 50 - 158 Protein (g/L) 68.6 ± 7.955 52 - 85 Albumin (g/L) 36.9 ± 4.656 27 - 46 CEA (ng/mL) 11.4 ± 42.088 0.59 - 257 CA19.9 (U/mL) 56.5 ± 202.323 - 1,200 CA72.4 (U/mL) 8.6 ± 30.811 0.52 - 186.2 * Comorbidities: Hypertension: 15 patients (23.07%); cardiac diseases: patients (9.23%); diabetes: patients (7.69%); COPD: patients (4.61%); prostate hypertrophy: 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 n Mean ± SD (day) Min - max (day) No 38 7.8 ± 4.601 - 25 Yes 27 10.1 ± 6.463 - 35 65 8.8 ± 5.523 - 35 Comorbidities Total p value 0.012 Table 5: Relationship between anemia and pre-operative days of treatment Pre-operative days of treatment n Mean ± SD (day) Min - max (day) Hb ≥ 110 44 7.9 ± 5.830 - 35 Hb < 110 21 10.7 ± 4.371 - 23 65 8.8 ± 5.523 - 35 Anemia (g/L) Total p value 0.038 149 Journal of military pharmaco-medicine no5-2020 DISCUSSION * 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 months, 24.6% from - months, 9.2% over 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] 150 * 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 mm in size, the diagnostic rate of CT-scan was 1%, lymph nodes from - 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, Journal of military pharmaco-medicine no5-2020 accurate 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 days, the latest was 35 days It can be seen from table 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 151 Journal of military pharmaco-medicine no5-2020 CONCLUSIONS 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 Trịnh Hồng Sơn Nghiên cứu nạo vét hạch điều trị ung thư dày Luận án Tiến sĩ Y học Trường Đại học Y Hà Nội 2001 Phạm Duy Hiển Ung thư dày Nhà xuất Y học Hà Nội 2007 Nguyễn Văn Vân, Nguyễn Đình Hối Bệnh ung thư dày Nhà xuất Y học Hà Nội 1975 Bray F, Ferlay JI, Soerjomataram Global Cancer Statistics 2018: GLOBOCAN Estimates of incidence and mortality worldwide 152 for 36 cancers in 185 countries CA Cancer J Clin 2018:1-31 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 Matsuki A, et al Surgical treatment for gastric cancer in extremely aged patients Journal of Aging Science 2014; 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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... [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... Japanese Gastric Cancer Association Japanese gastric cancer treatment guidelines (ver 4) Gastric Cancer 2016:1-19 Weiser MR, C Colon K Diagnosis and staging of gastric cancer Cancer of the upper