The mucosa of the gastric remnant harboring malignancy. Histologic findings in the biopsy specimens of 504 asymptomatic patients 15 to 46 years after partial gastrectomy with emphasis on nonmalignant lesions

Abstract

Endoscopic bioptic screening of 504 asymptomatic postgastrectomy patients, 15 to 46 years after initial surgery, revealed ten gastric stump cancers of which six turned out to be early cancers; three of the early carcinomas were found during follow-up after prior severe dysplasia. At first endoscopy mild dysplasia was found in 58, moderate dysplasia in 11, and severe dysplasia in none of the patients. Follow-up biopsies in 177 patients showed mild dysplasia in 30, moderate dysplasia in six, and severe dysplasia in six patients. Regression of severe dysplasia was not observed. Both progression and regression of mild and moderate dysplasia occurred. At the first endoscopy the frequency of atrophy, intestinal metaplasia, cystic dilatation of glands, and foveolar hyperplasia in the stomal biopsy specimens was 45%, 35%, 54%, and 47%, respectively; during follow-up, 47%, 48%, 56%, and 56% respectively. These four lesions were significantly more frequent in the biopsy specimens of patients with gastric carcinoma or dysplasia than in the other patients and they were present in the environment of the tumor in all the surgical specimens of the six early cancers detected by the screening. Preoperatively a combination of these four lesions could be demonstrated in only those early gastric cancer patients, in whom more than eight stomal biopsy specimens were taken. Of 34 patients with severe atrophy in three or more stomal biopsy specimens taken at the same time, two manifested early stump cancer during follow-up. Severe dysplasia is a marker of malignancy and demands close follow-up; the value of mild and moderate dysplasia is less clear. The combination of atrophy, especially severe atrophy, intestinal metaplasia, cystic dilatation, and foveolar hyperplasia in the biopsy specimens of a single patient may also point to increased cancer risk. It is advisable to obtain multiple biopsy specimens of the anastomosis, also because early gastric cancer may occur without a suspect macroscopic appearance.