doi:10.1111/j.1440-1746.2011.06759.

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GASTROENTEROLOGY

jgh_6759

1626..1629

Endoscopic, clinicopathological features and prognosis of very young patients with gastric cancer
Yu Bai*,† and Zhao-Shen Li*,†
*Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, and †Center for Clinical Epidemiology and Evidence-Based Medicine, Second Military Medical University, Shanghai, China

Key words clinical presentation, gastric cancer, prognosis, upper gastrointestinal endoscopy. Accepted for publication 15 April 2011. Correspondence Professor Zhao-Shen Li, Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, China. Email: li.zhaoshen@hotmail.com

Abstract
Background and Aim: The number of clinical reports of very young (< 35 years) patients with gastric cancer are limited. We aimed to investigate the endoscopic and clinicopathological features and long-term prognosis of this unique group of patients. Methods: A prospective endoscopy database review of all consecutive very young patients with gastric cancer was performed. The gender, age, clinical features, endoscopic and pathologic findings, and long-term survival of these very young patients were analyzed and compared with those of elderly patients. Results: A total of 210 patients were included with a median age of 31 year, 60.0% was female, and 34.3% presented with alarm features, 19.0% reported family history of gastric cancer. 58.1% of these cancers were located in gastric body, 33.8% were located in the antrum. 63.8% of these cancers were found to be diffuse type; 18.1% of patients underwent curative surgical treatment, and the 5-year survival rate was 42.1%. Conclusions: The study describes that very young patients with gastric cancer were mainly females, who were less likely to present with alarm features, but had a high frequency of family history of gastric cancer; and the majority of these cancers were located in gastric body, and they had similar long-term prognosis compared with elderly counterparts if curative surgical resection was performed.

Introduction
Worldwide, gastric cancer is one of the most common digestive cancers, and it is the fourth most common cancer and the second leading cause of cancer-related death, with about 700 000 deaths annually.1 The prevalence of gastric cancer is still high in some Asian countries, especially in China, Japan, and Korea. For example, the overall age-adjusted incidence of gastric cancer in China is over 40/100 000/year.2 Typically, the average age of patients with gastric cancer at diagnosis is approximately 60 years; however, it is not uncommon to notice that about 1–3% of gastric cancer cases occur in patients < 30 years of age.3,4 Several reports have suggested that younger patients are often diagnosed with advanced stages and it has been observed that very young patients carry much worse prognosis than their elderly counterparts.5–7 A retrospective medical chart review of our endoscopic center also suggests very young patients have some unique epidemiological and clinicopathological features.8 Nonetheless, the reported clinical information concerning this issue is still controversial.9–14 Therefore, the clinical profiles of this special group of patients, including demographic and endoscopic characteristics, and longterm prognosis are not well known. To address these issues, in the present study, we aimed to characterize young Chinese patients with gastric cancer and to deter1626

mine whether this group of patients present any different clinical, endoscopic, pathological, and epidemiological features compared with older counterparts in a large endoscopic database.

Methods
A retrospective study was conducted, which included all consecutive patients diagnosed with gastric cancer at Digestive Endoscopy Center, Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China between 1985 and 2006. The population for the study included all patients described in a previous study.8 Basically, all the esophagogastroduodenoscopy (EGDs) were performed by experienced endoscopists. During the procedures of upper endoscopy, all the parts of the upper GI tract were carefully inspected, biopsy was taken for any lesion, which was suspected to be malignant on endoscopy; the final diagnosis was confirmed by pathological examination. All biopsy specimens were reviewed by experienced pathologists of the Department of Pathology of Changhai Hospital. Patients’ data were stored in a prospectively collected, standardized electronic endoscopy database (EIS [Endoscopy Information System], Angelwin, Beijing, China). The indication for EGDs,

Journal of Gastroenterology and Hepatology 26 (2011) 1626–1629 © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

which was significantly higher than that in elderly patients (39. symptoms.4 66 (31.01 1. but the difference is not significant.9%) (15.7% in old patients who received curative surgery. weight loss. 60% were female.8%) were diffuse-type malignancy.1%. of patients (%) 59 (36–92) 58 (38–92) 62 (36–89) 118 (56. The ethical committee approval of this study was obtained from Shanghai Changhai Hospital Ethics Committee. These patients were matched to the study group by their year of diagnosis. endoscopic and pathologic findings were all stored in this endoscopic database.1% and 19.2%) 92 (43. including chemo-radiotherapy or palliative treatment. and clinical follow-up.5%) (2.0 for Windows (Statistical Product and Service Solutions. Follow-up data were sought until the patient died. the 5-year survival rate in the very young patients was 42.1%) (1.2%) 199 (94.05 < 0.3%) 138 (65. the median age of these patients was 31 years (range: 13–35).0%) 72 (34.9% and 81%.3%) NS Results A total of 210 consecutive very young patients with gastric cancer were included. who were older than 35 years of age and were diagnosed with gastric cancer during the same study period. The endoscopic appearance of the two groups of patients was similar.4%) 134 (63.8%) 113 (53. gastric cancer. Statistical analysis of the data was performed with Microsoft Excel. few patients presented with Borrmann I or II lesions (17.01 NS NS < 0. Written informed consent was obtained from all patients before the EGDs.8%) 97 (46.5%) (6. Among the 210 patients.0%) 4.2%) (42.5%) 12 (5.01).0%) < 0.1 cm). symptoms. 33.8% of young patients had the gastric cancers located in the gastric antrum.1 Ϯ 2. and patients with cell phones or home telephones were contacted by phone. the indication for EGDs.2%) (58. 1627 Journal of Gastroenterology and Hepatology 26 (2011) 1626–1629 © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd .8%) (6.01 Statistical analysis Categorical data were compared by c2 test with continuity correction if appropriate. 34. 31 (13–35) 30 (19–35) 31 (13–35) 84 (40.Y Bai and Z-S Li Very young patients with gastric cancer patients’ age. Continuous variables are expressed as median or mean Ϯ standard deviation (SD) and ranges.9%) (40. which was described previously. range) Male Female Gender Male Female Alarm features Present Absent Family history of GC Yes No GC.3% patients presented alarm features. The characteristics of the entire patient population are shown in Table 1. histologic tumor type. Antrum Angle Body Fundus Tumor size (cm) Lauren classification Intestinal Diffuse Mixed Endoscopic appearance Borrmann I Borrmann II Borrmann III Borrmann IV NS. 58. Clinical details extracted from the database included patient demographics. For patients who died.2%) 11 (5. Chicago. the majority of the lesions were Borrmann III or IV lesions (82.4%) (17.2%) (30. of patients (%) Control group No.14 and the alarm features refers to dysphagia.01 < 0. P < 0. After curative surgery. While the other 172 (81.05). All of the endoscopic reports were searched to identify very young patients with gastric cancer.2 cm. endoscopic findings and biopsy results.1%) patients received curative surgery.2 115 (54.9%) patients received non-operative management. However.01). while it was 46.05 Table 2 Anatomical distribution.0%) 126 (60.7%) 40 (19. USA).8%) 83 (39. only 38 (18.9%) P < 0. IL. which was significantly higher than that in elderly group (P < 0. there was no significant difference in the survival rate between young patients and elderly patients who received curative surgery (P > 0. GI bleeding and vomiting.7%) 3 37 77 93 (1.01 < 0.0%.01). Table 1 Basic characteristics of the study population (n = 210) Study group No.000 < 0.7%) (44. and SPSS 10. the control group for these patients consisted of a cohort of consecutive patients. Two-tailed P-values less than 0.2 Ϯ 2.0%) 170 (81. But the 5-year survival rate in both the very young and old patients without surgery was 0% and all these patients died within 12 months after diagnosis. among these patients. The anatomical distribution of these cancers is shown in Table 2.6%) (36.8%) 10 (4.05 were considered statistically significant. which was larger than that in old patients (4. images of endoscopic examinations. endoscopic appearance and pathological findings of young gastric cancer patients Distribution Study group (n = 210) 71 13 122 4 (33.8%) P Age (median.8%) 4 32 90 84 (1.5%. gender. respectively). and were compared with the Student’s t-test. respectively). and gastrointestinal stromal tumor were excluded.1% of the gastric cancers were located in the gastric body. mainly due to distant metastasis. which was significantly lower than that in the elderly group (P < 0. The pathological findings of these very young patients suggest a great proportion of the cancers (63. Patients with gastric carcinoid tumor. the date of death was obtained from their available family members and other proxies.8.9%) Control group (n = 210) 127 13 64 6 (60. not significant. Efforts were carried out to obtain clinical follow-up data: patients were interviewed at the time of return visits to the outpatient clinics. 5. lymphoma. and 19% patients reported family history of gastric cancer. The mean tumor size of gastric cancer in young patients was 5.

Rees BI et al. Arch. 2008. The present study suggests very young patients with gastric cancer were mainly female with diffuse type malignancy. 42: 128–36. N Z J Surg. and the majority of these cancers were located in gastric body.23 which is comparable with other studies. the anatomic distribution of gastric cancer in younger patients is quite different from that in elderly patients. and this finding is in accordance with Koea et al. Early gastric carcinoma in Japanese patients under 30 years of age. In conclusion. it is reported a notable proportion of patients were below 50 years old. 46: 2690–3. but had a high frequency of family history of gastric cancer.1 Though the majority of gastric cancer patients presents in their 50 to 60 years. Ann. which is in line with most previous reports.8 while some other studies reported a high prevalence of alarm symptoms at presentation. and most of these reports included patients less than 40 years old.28 in old patients. only 40% have poorly differentiated cancers. Some studies indicated poorer prognosis in young patients. and most of these studies are case series with limited number of patients. Takahashi Y. Journal of Gastroenterology and Hepatology 26 (2011) 1626–1629 © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd . As gastric cancer usually occurs in people over 50 years old. 2000. Aust. Screening for gastric cancer in Asia: current evidence and practice. 188: 22–6. the incidence of gastric cancer in very young patients has not been extensively studied. Clinicopathological characteristics of gastric carcinoma in young and elderly patients: a comparative study.20 and they reported a positive family history in 19% of American young gastric cancer patients. Cortes-Gonzalez R. Wu MS. Mex. about 4. Outcome of oesophagogastric carcinoma in young patients.26 Some Western series have reported positive family histories in < 10% of patients with gastric cancer. Gut 2010. 1999. Yamagata M et al. 75: 22–6. the present study indicates that very young patients with gastric cancer were mainly females. the outcome of the patients with curative surgical resection was not worse compared with that of the old counterpart. Surg.Very young patients with gastric cancer Y Bai and Z-S Li Discussion In general. 1999. Ohiwa T et al. Bray F. Gastric carcinoma in patients under 35 years. Acknowledgments Dr Bai Yu is supported by National Natural Science Foundation of China (Grant no. Kakugawa Y et al. Surg. J. Early gastric cancer in the young: clinicopathological study. Med. 30801087). J. 1999. CA Cancer J. Teshima S et al. and this may provide additional information to the management of this group of patients.25 To early detect these young gastric cancer patients. Furthermore. We observe that the long term survival rates in young patients managed with curative resections was similar to that in elderly patients. J. but we found 19% of our patients reported a positive family history of gastric cancer. 2011. Wu CW et al. 2009. Br. Kuo HS. 64: 75–7. who were less likely to present with alarm features. from our institution’s experience. but microsatellite instability is uncommon in young age gastric cancers. while in patients > 35 years old. Alvarez JJ et al. Clin. Gastric cancer in young patients.15 Other studies showed similar survival rates in young and elderly patients. Moreno Paquentin E.2% (70/1632) of patients with gastric cancer who underwent surgical treatment were below 35 years old. Am. Lee HS. the male/female ratio is 0. Global cancer statistics. Other investigators have described this lack of differentiation in young patients27 and the present case series also confirms that advanced pathology is more prevalent in young patients. 69: 443–6.19–22 while our study included very young patients who were younger than 35 years old. Alteration of E-cadherin-mediated adhesion protein is common. 7: 515–19.15–20. 59: 722–8. Center MM et al. Coll.19 Overall. 48: 1552–5. which were located in gastric body. The clinical outcomes of young patients with gastric cancer remain controversial. Rev.20 Unlike elderly patients. Oncol. Takahashi N. Heslin MJ. 4 Lim S. Surg. or at least in areas with high prevalence of gastric cancer. Poorer prognosis in young patients with gastric cancer? Hepatogastroenterology 1999. Kim HS et al. 2 Leung WK. Extreme aggressiveness and lethality of gastric adenocarcinoma in the very young. 3 Mori M. and this is consistent with our previous investigation showing that young upper GI cancer patients were less likely to present with alarm features. Surg. References 1 Jemal A. only about one third of young patients presented with alarm features. Li ZS. About 64% of young patients had diffuse-type malignancy. and they had similar long-term prognosis compared with elderly counterparts if curative surgical resection was performed.67 in young patients while it is 1. Hepatogastroenterology 2001. 1985. Histopathology 2003. Gastric carcinoma in young adults. which is significantly lower than that of old patients. In our series. 144: 506–10. We suppose this unique patient group may be identified according to the family history of gastric cancer and endoscopic screening for family members may be initiated. there are few reports on this unique group of patients. which caused about 700 000 deaths per year in the world. 1999. 13 Kokkola A. 60% of the cancers are located in the 1628 proximal stomach. 8 Bai Y. 9: 279–87. Stabile BE. 10 Lo SS. Clark GW. 11 Bowrey DJ. Sugimachi K. 7 Quijano Orvañanos F. Zou DW et al. Among the younger patients. Sipponen P. This suggests though younger patients were more likely to present with advanced staged disease and poor differentiation and diffuse lesions. but elderly patients are more likely to present with distal lesions. and the long term prognosis was comparable with old patients with gastric cancer. Alarm features and age for predicting upper gastrointestinal malignancy in Chinese patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper gastrointestinal malignancy: an endoscopic database review of 102 665 patients from 1996 to 2006. 6 Eguchi T. 9 Yokota T. gastric cancer remains a lethal disease with a dismal outcome. 5 Smith BR. young patients with gastric cancer showed a female predominance. 72: 289–91. Postgrad. it is suggested that even young patients without alarm symptoms should undergo endoscopy for early diagnosis of gastric cancer.’s study.24. Gastroenterol. 61: 69–90. 12 Medina-Franco H.23The reasons for this increasing frequency of females in young gastric cancer patients are still to be determined.16–18 while some studies showed a better prognosis for young patients. Lancet Oncol.

Journal of Gastroenterology and Hepatology 26 (2011) 1626–1629 © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd 1629 . Clinicopathological comparison between young and old age patients with gastric adenocarcinoma. J. Curtiss C. Br. 2006. 10: 1023–32. Surg. Guoen F. Gastric carcinoma in young adults. Surg. J. Clin. 19 Katai H. Carcinoma of the stomach in the young adult. 15: 1464–9. 18 Santoro R. Salgado-Nesme N. Jianwei B et al. 20 Koea JB. 26: 139–43. J. 2004. Torres-Villalobos G et al. Cancer 2005. 25: 1668–73. 1988. Carboni F. Bołdys H. Oncol.Y Bai and Z-S Li Very young patients with gastric cancer 14 Bai Y. 2000. Gastrointest. Popiela T. Gastric cancer in young patients: demographic. 35: 61–7. Surg. Clinicopathological features and prognosis of gastric cancer in young European adults. 208: 593–6. and prognostic factors in 92 patients. Wanczura P et al. Akiyama H. de Virgilio C. Clinicopathologic characteristics of gastric cancer in a young patient population. Marek TA. Li C et al. Hepatol. 7: 346–51. 16 Matley PJ. Kim S. 2010. Ramos-De la Medina A. 393: 37–43. Clinicopathological features of gastric carcinoma in younger and middle-aged patients: a comparative study. Tamura PY. 2007. Sano T et al. Lepiane P et al. 2008. Surg. J. Clinicopathologic characteristics and prognosis for young gastric adenocarcinoma patients after curative resection. Gastrointest. 17 Kunisaki C. Endoscopy 2003. Nomura M et al. Dent DM. J. clinicopathological. Jpn. Surg. J. J. Gastric carcinoma in young adults. Zou DW et al. Gastric adenocarcinoma in patients 40 years of age or younger. Surg. Surg. Clinicopathological profile and long-term outcome in young adults with gastric cancer: 22 23 24 25 26 27 multicenter evaluation of 214 patients. 12: 1263–7. 15 Theuer CP. 8: 240–4. Oncol. Gastroenterol. 94: 737–42. Surg. Ann. Brennan MF. Tianhang L. Gao J. 1996. Surg. 13: 379–85. Distribution trends of colorectal adenoma and cancer: a colonoscopy database analysis of 11 025 Chinese patients. Kolodziejczyk P et al. 35: 43–52. Ann. Madden MV et al. The effect of perineural invasion on overall survival in patients with gastric carcinoma. Sasako M. Keese G et al. 21 Kulig J. Lai JF. Ann. Gastrointest. Karpeh MS. Langenbecks Arch. J. 2008. 2008. 1996. Am. Int. Bani-Hani KE. 172: 473–6. Even young patients with no alarm symptoms should undergo endoscopy for earlier diagnosis of gastric cancer. Oncol. Cancer 1960. Gastrointest.

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