doi:10.1111/j.1440-1746.2011.06759.

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 ndings, 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 13% 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.57 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.914 Therefore, the clinical proles 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 nal diagnosis was conrmed 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) 16261629 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

Y Bai and Z-S Li

Very young patients with gastric cancer

patients age, gender, symptoms, images of endoscopic examinations, endoscopic and pathologic ndings were all stored in this endoscopic database, which was described previously,8,14 and the alarm features refers to dysphagia, weight loss, GI bleeding and vomiting. All of the endoscopic reports were searched to identify very young patients with gastric cancer, the control group for these patients consisted of a cohort of consecutive patients, who were older than 35 years of age and were diagnosed with gastric cancer during the same study period. These patients were matched to the study group by their year of diagnosis. Clinical details extracted from the database included patient demographics, the indication for EGDs, symptoms, endoscopic ndings and biopsy results, histologic tumor type, and clinical follow-up. Patients with gastric carcinoid tumor, lymphoma, and gastrointestinal stromal tumor were excluded. Efforts were carried out to obtain clinical follow-up data: patients were interviewed at the time of return visits to the outpatient clinics; and patients with cell phones or home telephones were contacted by phone. Follow-up data were sought until the patient died. For patients who died, the date of death was obtained from their available family members and other proxies. Written informed consent was obtained from all patients before the EGDs. The ethical committee approval of this study was obtained from Shanghai Changhai Hospital Ethics Committee.

Table 1

Basic characteristics of the study population (n = 210) Study group No. of patients (%) Control group No. of patients (%) 59 (3692) 58 (3892) 62 (3689) 118 (56.2%) 92 (43.8%) 113 (53.8%) 97 (46.2%) 11 (5.2%) 199 (94.8%) P

Age (median, range) Male Female Gender Male Female Alarm features Present Absent Family history of GC Yes No GC, gastric cancer.

31 (1335) 30 (1935) 31 (1335) 84 (40.0%) 126 (60.0%) 72 (34.3%) 138 (65.7%) 40 (19.0%) 170 (81.0%)

< 0.05

< 0.01

< 0.01

< 0.05

Table 2 Anatomical distribution, endoscopic appearance and pathological ndings of young gastric cancer patients Distribution Study group (n = 210) 71 13 122 4 (33.8%) (6.2%) (58.1%) (1.9%) Control group (n = 210) 127 13 64 6 (60.5%) (6.2%) (30.5%) (2.9%) P < 0.01 1.000 < 0.01 NS NS < 0.01

Statistical analysis
Categorical data were compared by c2 test with continuity correction if appropriate. Continuous variables are expressed as median or mean standard deviation (SD) and ranges, and were compared with the Students t-test. Two-tailed P-values less than 0.05 were considered statistically signicant. Statistical analysis of the data was performed with Microsoft Excel, and SPSS 10.0 for Windows (Statistical Product and Service Solutions, Chicago, IL, USA).

Antrum Angle Body Fundus Tumor size (cm) Lauren classication Intestinal Diffuse Mixed Endoscopic appearance Borrmann I Borrmann II Borrmann III Borrmann IV NS, not signicant.

5.2 2.4 66 (31.4%) 134 (63.8%) 10 (4.8%) 4 32 90 84 (1.9%) (15.2%) (42.9%) (40.0%)

4.1 2.2 115 (54.8%) 83 (39.5%) 12 (5.7%) 3 37 77 93 (1.4%) (17.6%) (36.7%) (44.3%)

NS

Results
A total of 210 consecutive very young patients with gastric cancer were included; among these patients, the median age of these patients was 31 years (range: 1335), 60% were female, 34.3% patients presented alarm features, and 19% patients reported family history of gastric cancer. The characteristics of the entire patient population are shown in Table 1. The mean tumor size of gastric cancer in young patients was 5.2 cm, which was larger than that in old patients (4.1 cm), but the difference is not signicant. The anatomical distribution of these cancers is shown in Table 2. 33.8% of young patients had the gastric cancers located in the gastric antrum, which was signicantly lower than that in the elderly group (P < 0.01). However, 58.1% of the gastric cancers were located in the gastric body, which was signicantly higher than that in elderly group (P < 0.01). The endoscopic appearance of the two groups of patients was similar; few patients presented with Borrmann I or II lesions (17.1% and 19.0%, respectively), the majority of the lesions were Borrmann III or IV lesions (82.9% and 81%, respectively). The

pathological ndings of these very young patients suggest a great proportion of the cancers (63.8%) were diffuse-type malignancy, which was signicantly higher than that in elderly patients (39.5%, P < 0.01). Among the 210 patients, only 38 (18.1%) patients received curative surgery. While the other 172 (81.9%) patients received non-operative management, including chemo-radiotherapy or palliative treatment, mainly due to distant metastasis. After curative surgery, the 5-year survival rate in the very young patients was 42.1%, while it was 46.7% in old patients who received curative surgery; there was no signicant difference in the survival rate between young patients and elderly patients who received curative surgery (P > 0.05). 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.
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Journal of Gastroenterology and Hepatology 26 (2011) 16261629 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd

Very young patients with gastric cancer

Y Bai and Z-S Li

Discussion
In general, gastric cancer remains a lethal disease with a dismal outcome, which caused about 700 000 deaths per year in the world.1 Though the majority of gastric cancer patients presents in their 50 to 60 years, it is reported a notable proportion of patients were below 50 years old. The clinical outcomes of young patients with gastric cancer remain controversial. Some studies indicated poorer prognosis in young patients.15 Other studies showed similar survival rates in young and elderly patients;1618 while some studies showed a better prognosis for young patients.19 Overall, there are few reports on this unique group of patients, and most of these studies are case series with limited number of patients, and most of these reports included patients less than 40 years old,1922 while our study included very young patients who were younger than 35 years old, and this may provide additional information to the management of this group of patients. The present study suggests very young patients with gastric cancer were mainly female with diffuse type malignancy, which were located in gastric body, and the long term prognosis was comparable with old patients with gastric cancer. As gastric cancer usually occurs in people over 50 years old, the incidence of gastric cancer in very young patients has not been extensively studied, from our institutions experience, about 4.2% (70/1632) of patients with gastric cancer who underwent surgical treatment were below 35 years old,23 which is comparable with other studies.20 Unlike elderly patients, young patients with gastric cancer showed a female predominance, the male/female ratio is 0.67 in young patients while it is 1.28 in old patients, which is in line with most previous reports.1520,23The reasons for this increasing frequency of females in young gastric cancer patients are still to be determined. In our series, only about one third of young patients presented with alarm features, which is signicantly lower than that of old patients; and this is consistent with our previous investigation showing that young upper GI cancer patients were less likely to present with alarm features,8 while some other studies reported a high prevalence of alarm symptoms at presentation.24,25 To early detect these young gastric cancer patients, it is suggested that even young patients without alarm symptoms should undergo endoscopy for early diagnosis of gastric cancer, or at least in areas with high prevalence of gastric cancer.26 Some Western series have reported positive family histories in < 10% of patients with gastric cancer; but we found 19% of our patients reported a positive family history of gastric cancer, and this nding is in accordance with Koea et al.s study,20 and they reported a positive family history in 19% of American young gastric cancer patients. We suppose this unique patient group may be identied according to the family history of gastric cancer and endoscopic screening for family members may be initiated. About 64% of young patients had diffuse-type malignancy, while in patients > 35 years old, only 40% have poorly differentiated cancers. Other investigators have described this lack of differentiation in young patients27 and the present case series also conrms that advanced pathology is more prevalent in young patients. Furthermore, the anatomic distribution of gastric cancer in younger patients is quite different from that in elderly patients. Among the younger patients, 60% of the cancers are located in the
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proximal stomach, but elderly patients are more likely to present with distal lesions. We observe that the long term survival rates in young patients managed with curative resections was similar to that in elderly patients. This suggests though younger patients were more likely to present with advanced staged disease and poor differentiation and diffuse lesions, the outcome of the patients with curative surgical resection was not worse compared with that of the old counterpart. In conclusion, the present study indicates 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.

Acknowledgments
Dr Bai Yu is supported by National Natural Science Foundation of China (Grant no. 30801087).

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