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 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 »  References
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  Table of Contents  
Year : 2014  |  Volume : 51  |  Issue : 1  |  Page : 15-17

Staging laparoscopy in gastroesophageal and gastric adenocarcinoma: First experience from Pakistan

1 Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
2 Department of Surgery, Civil Hospital, Karachi, Pakistan

Date of Web Publication18-Jun-2014

Correspondence Address:
A B Bhatti
Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.134603

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 » Abstract 

Context: Current NCCN guidelines do not consider staging laparoscopy mandatory for detection of metastasis in gastroesophageal junction (GEJ) and gastric cancer. Aims: To determine the rate of detection of metastasis on staging laparoscopy in GEJ and gastric cancer in Pakistani population and determine the prognostic significance of cytology versus biopsy positive metastatic disease. Settings and Design: Retrospective study conducted from January 2005 to June 2013. Materials and Methods: Demographics, clinicopathological characteristics and laparoscopic findings of 149 patients were compared. Statistical Analysis Used: Categorical variables were represented as frequencies and percentages and significance was determined using Chi square test. Overall survival was calculated from the date of staging laparoscopy to the date of death/last follow-up. Survival for cytology versus biopsy positive metastatic disease was calculated using Kaplan Meier curves and significance determined with Log rank test. Results: Overall, metastases were detected in 40% of patients on staging. Laparoscopy detected metastasis in significantly high number of gastric cancers (48% versus 28%) (P = 0.01). Peritoneal nodules were more frequent with gastric tumors (40% versus 23%) and also were more likely to be malignant (58% versus 35%). Expected one year survival in patients with positive cytology (peritoneal washing/ascitic fluid) was significantly higher than patients with a positive peritoneal nodule biopsy (29% versus 0) (P = 0.04). On univariate analysis this was the only significant factor for increased risk of death (P = 0.03, HR = 2.5, CI = 1.04-5.98). Conclusions: Staging laparoscopy detects metastatic disease in a significant number of patients deemed non metastatic on preoperative imaging. Prognostically, cytology positive metastatic cancer may be different from biopsy positive cancer.

Keywords: Gastric cancer, gastroesophageal cancer, laparoscopy, staging

How to cite this article:
Bhatti A B, Haider S, Khattak S, Syed A A. Staging laparoscopy in gastroesophageal and gastric adenocarcinoma: First experience from Pakistan. Indian J Cancer 2014;51:15-7

How to cite this URL:
Bhatti A B, Haider S, Khattak S, Syed A A. Staging laparoscopy in gastroesophageal and gastric adenocarcinoma: First experience from Pakistan. Indian J Cancer [serial online] 2014 [cited 2022 Dec 7];51:15-7. Available from:

 » Introduction Top

Staging laparoscopy has a well-established role in detecting small peritoneal deposits that are missed on computed tomography, endoscopic ultrasound and occasionally positron emission tomography (PET). [1] According to current NCCN guidelines, laparoscopy is optional in GEJ adenocarcinomas and should be considered in gastric cancers. Gastroesophageal junction (GEJ) cancers have been identified as a separate entity with their distinct anatomical location, lymphatic drainage and metastatic potential. In fact it has been recommended that they should be grouped as esophageal carcinoma. [2] Recently, studies have reported better survival for patients with cytology positive disease versus macroscopic metastasis. [3] There are no reports from Pakistan and very limited literature from Indian subcontinent on the role of staging laparoscopy in upstaging of GE junction and gastric cancers. The objective of this study was to share our experience with metastatic detection on staging laparoscopy for GE junction and gastric adenocarcinomas in Pakistani population and determine the survival difference in cytology positive versus biopsy positive metastatic cancer.

 » Materials and Methods Top

This study included a retrospective cohort of patients who underwent staging laparoscopy for gastroesophageal junction (GEJ) or gastric adenocarcinoma between the year January 2005 to December 2012 and were followed till June 2013. Patients deemed metastatic without cytological or histopathological evidence were excluded. Patients with locally advanced but resectable tumors (Stage II and III) with absence of metastases on preoperative imaging underwent laparoscopy. Computed tomography in all patients, endoscopic ultrasound in patients with GEJ tumors and positron emission tomography scan (PET) scan was performed selectively in patients with high suspicion of metastatic disease. Patients were divided into 1) Gastroesophageal junction (GEJ) carcinoma and, 2) Gastric carcinoma based on their preoperative endoscopic and imaging findings and staged according to American Joint Committee on Cancer AJCC 7 th edition.

The two groups were compared for demographics, pre-op clinical stage, grade and laparoscopy findings. Primary outcome of interest was rate of detection of cytology/biopsy proven metastasis. Secondary outcome was survival difference between cytology and biopsy positive metastatic disease. Patients positive on both cytology and biopsy were excluded from survival analysis. Overall survival was calculated by subtracting the date of death from the date of laparoscopy. T-test for interval and chi square test was used for categorical variables. Survival was calculated with Kaplan Meier survival curves and Log rank test was used to determine significance. Univariate analysis was performed to identify factors for multivariate analysis.

 » Results Top

Patient characteristics

A total of 149 patients were included in the study with 60 GEJ carcinoma and 89 primary gastric carcinoma. Male to female distribution was 3:1 (112/37). Median age was 55 (28-72) and 52 (20-79) years for GEJ and gastric cancers respectively and not significantly different (P = 0.09). Significant difference was present between GEJ and gastric carcinomas with respect to grade and clinical stage at presentation. Gastric tumors were more likely to present in stage II (65% versus 30%) (P < 0.0001) but have a poorly differentiated histology (75% versus 38%) (P < 0.0001).

Laparoscopic findings

Significant difference was present with respect to nodal enlargement, presence of peritoneal nodules and positivity of peritoneal nodules between the two groups. There was a significantly high rate of nodal enlargement in gastric cancers (61% versus 43%) (P = 0.02). Peritoneal nodules were detected more frequently in patients with gastric malignancy (40% versus 23%) (P = 0.02). The number of peritoneal nodules that were positive for malignancy on histopathology was higher in patients with gastric cancer (58% versus 36%) (P = 0.04). No significant difference was present between the two groups with respect to positive cytology both for peritoneal washings and ascitic fluid. Staging laparoscopy detected metastatic disease in a significantly high number of patients with primary gastric adenocarcinoma versus GEJ adenocarcinoma (48% versus 28%) (P = 0.01). The overall rate of metastatic detection was 40%.


No difference in expected one year survival was observed between metastatic gastric and GEJ adenocarcinoma i.e., 25% and 28% respectively (P = 0.9). Presence of peritoneal nodules significantly affected survival (12% versus 38%) (P = 0.04). A statistically significant difference in one year expected survival was observed between patients deemed metastatic on cytology (Peritoneal washings + ascitic fluid) versus biopsy of peritoneal nodules. Patients with positive cytology had a one year expected survival of 29% versus 0% for patients with biopsy positive disease (P = 0.04) [Figure 1]. On univariate analysis this was the only significant factor and biopsy positive metastatic disease was associated with an increased risk of death when compared with cytology positive disease (P = 0.03, HR = 2.5, CI = 1.04-5.98).
Figure 1: Expected 1 year survival for patients with cytology versus biopsy positive metastatic disease

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 » Discussion Top

A significantly high number of patients with gastric carcinoma had enlarged lymph nodes, peritoneal nodules and malignancy in peritoneal nodules when compared with GEJ carcinoma. The study underscores the prognostic role of cytology positive versus biopsy positive disease with latter being more aggressive. Limitations of the current study are relatively small number of patients with metastatic disease potentially affecting the statistical significance of study variables.

PET scan has been performed frequently in recent years and has better results than other imaging modalities for detection of metastasis. [4] In the present study, nearly 17% patients with laparoscopy detected metastasis had a pre-laparoscopy negative PET scan. It is believed that cytology positive disease represents stage IV disease and management should be palliative. [5] Gold and colleagues reported no difference in the survival of patients treated with therapeutic surgical resection in known cytology positive versus gross metastatic disease. [6] However, recent reports have suggested slightly better survival for patients with cytology positive disease. [3] Patients with Stage IV disease received palliative treatment in the current study irrespective of whether they had cytology or biopsy positive disease and a significant difference in survival was observed.

Laparoscopy detected occult metastatic disease has poor prognosis. One year overall survival of 39% and a median disease specific survival of 10 months with palliative chemotherapy has been reported. [7] It has also been shown that clearance of cytology positive disease with chemotherapy may result in significant improvement in disease specific survival. [8] In the present study one year overall survival of 25% and 28% was observed for patients with gastric and GEJ carcinoma respectively. The metastatic detection rate was better for gastric cancers. Factors like difference in behavior of GEJ cancers, anatomical location or selective use of EUS might be responsible. It is possible that EUS detected metastatic disease in some patients and avoided a laparoscopy. A significantly poor survival in patients with peritoneal nodules irrespective of their benign or malignant nature might represent patients who had metastasis but peritoneal biopsy was inadequate. A case can be made for multiple biopsies from different quadrants of abdomen in particular in patients with diffuse metastasis to improve the sensitivity of staging laparoscopy.

Staging laparoscopy plays an important role in upstaging these cancers due to its ability to detect small peritoneal and visceral metastasis. The study also demonstrates that cytology positive disease may have better prognosis than biopsy positive metastatic disease and further evaluation of this finding with larger sample size is warranted. Furthermore, whether single peritoneal biopsy from suspicious nodule is adequate to obtain diagnosis of metastasis in diffuse peritoneal disease or multiple biopsies from different quadrants should be taken is unclear.

 » References Top

1.Yano M, Tsujinaka T, Shiozaki H, Inoue M, Sekimoto M, Doki Y, et al. Appraisal of treatment strategy by staging laparoscopy for locally advanced gastric cancer. World J Surg 2000;24:1130-6.  Back to cited text no. 1
2.Hu B, El Hajj N, Sittler S, Lammert N, Barnes R, Meloni-Ehrig A. Gastric cancer: Classification, histology and application of molecular pathology. J Gastrointest Oncol 2012;3:251-61.  Back to cited text no. 2
3.Lee SD, Ryu KW, Eom BW, Lee JH, Kook MC, Kim YW. Prognostic significance of peritoneal washing cytology in patients with gastric cancer. Br J Surg 2012;99:397-403.  Back to cited text no. 3
4.Tourani SS, Cabalag C, Link E, Chan ST, Duong CP. Laparoscopy and peritoneal cytology: Important prognostic tools to guide treatment selection in gastric adenocarcinoma. ANZ J Surg 2013. [Epub ahead of print].  Back to cited text no. 4
5.Bentrem D, Wilton A, Mazumdar M, Brennan M, Coit D. The value of peritoneal cytology as a preoperative predictor in patients with gastric carcinoma undergoing a curative resection. Ann Surg Oncol 2005;12:347-53.  Back to cited text no. 5
6.Gold JS, Jaques DP, Bentrem DJ, Shah MA, Tang LH, Brennan MF, et al. Outcome of patients with known metastatic gastric cancer undergoing resection with therapeutic intent. Ann Surg Oncol 2007;14:365-72.  Back to cited text no. 6
7.Sarela AI, Miner TJ, Karpeh MS, Coit DG, Jaques DP, Brennan MF. Clinical outcomes with laparoscopic stage M1, unresected gastric adenocarcinoma. Ann Surg 2006;243:189-95.  Back to cited text no. 7
8.Mezhir JJ, Shah MA, Jacks LM, Brennan MF, Coit DG, Strong VE. Positive peritoneal cytology in patients with gastric cancer: Natural history and outcome of 291 patients. Ann Surg Oncol 2010;17:3173-80.  Back to cited text no. 8


  [Figure 1]

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