3.2. CLIMA ESCOLAR
3.2.2. CLIMA SOCIAL ESCOLAR: CONCEPTO E IMPORTANCIA
About 75.0% of early gastric carcinomas were well differentiated while the remaining 25.0% were moderately differentiated. Also about 37.2% of advanced tumours were well differentiated while 30.2% and 32.6% respectively were moderately and poorly differentiated. These findings seem to suggest a possible association between the histologic grade and depth of invasion of the tumour with most early carcinomas and a significantly smaller number of advanced carcinomas being well differentiated.
Moreover, there were no poorly differentiated early gastric carcinomas in the series.
6.7 PATTERNS OF METASTASIS
In all, a total of 37 cases were assessed. Of these, table 8 shows that 22 cases (59.5%) had lymph node metastasis while 3 cases (8.1%) had omental metastasis. There was 1 case each (2.7%) with metastasis to the liver and umbilicus. Metastasis was absent in 27.0% of cases. Neither the specific group nor the total number of lymph nodes involved in each case could be assessed. No lymph nodes were included in the tissues sent in cases which showed omental and hepatic metastases. The only case
with umbilical metastasis was a biopsy specimen Table 10 shows that a total of 21(63.6%) out of the 33 cases of advanced gastric carcinoma showed evidence of metastatic spread as opposed to 3 (75.0%) of the 4 cases of superficial carcinomas.
Eighteen cases (54.5%) of advanced carcinomas had evidence of metastasis to the peri-gastric lymph nodes while 2 cases (6.0%) and 1 case (3.0%) each showed metastasis to the omentum and liver respectively. All cases of metastasis from superficial carcinomas were to peri-gastric lymph nodes.
6.8 ASSOCIATED INCIDENTAL FINDINGS 6.8.1 Helicobacter pylori
A total of 79 (81.4%) out of the 97 cases reviewed for the study showed evidence of chronic gastritis in the surrounding, apparently non neoplastic gastric tissue. Table 9 shows that out of these 79 cases, forty-three (54.4%) had histological evidence of helicobacter pylori infection. No H. pylori was found in the absence of chronic gastritis. The association between chronic gastritis and the presence of H. pylori was found to be statistically significant with a p-value of 0.000.
6.8.1.1 H. pylori, Patients’ Age and Sex
H. pylori was detected in all age groups. Table 9 shows that H. pylori was found in 6(33.3%) of patients younger than 40 years and 37(46.8%) of those 40 years and older. It was present in 33.3% of patients in the 20-29 year age group and 30.0% of those in the 30-39 year age group. H. pylori was also found in 60.0%, 41.4% and
45.8% of patients in the 40-49, 50-59 and 60-69 year age groups respectively while it was detected only in 40.0% of those in the 70-79 year age group. It was present in the only case above 80 years old. There was, however, no significant relationship between the presence of H. pylori and the patients’ age (p=0.298).
H. pylori was found in 39.6% of males and 50.0% of females. There was also no significant relationship between the patient’s sex and the presence of H. pylori (p=0.306)
6.8.1.2 H. pylori and Histological Type of Gastric Carcinoma
Table 9 also shows that H. pylori was found in 60% of patients with diffuse carcinoma and in 41.9% of patients with the intestinal type carcinoma. However, no significant association was found between H. pylori and the Lauren’s histological type of the carcinoma (p= 0.292).
6.8.1.3 H. pylori, Gross Growth Pattern and Topography of Gastric Carcinoma According to table 9, H. pylori was found in 46.7% of excavated tumours, 39.7% of fungating types, 66.7% of ulcerative tumours and 66.7% of diffusely infiltrating tumours. However, there was no significant association between the gross growth pattern of the tumours and the presence of H. pylori (p=0.494).
It was also found in 45.7% of antro-pyloric tumours, 25.0% of cardia tumours, 42.9% of corporal tumours and 40.0% of fundal tumours. There was no significant
association between the topographical location of the tumours and the presence of H. pylori (p=0.871).
6.8.2 Gastric Glandular Atrophy
Table 10 shows the pattern of gastric glandular atrophy in patients with gastric carcinoma. Seventeen (21.5%) patients had gastric atrophy in the presence of chronic gastritis. On the other hand there were no cases of gastric atrophy in the absence of chronic gastritis.
6.8.2.1 Age of Patients and Occurrence of Gastric Atrophy
Gastric atrophy was found only in patients 40 years and older, occurring in 17(21.5%) of such cases (p=0.03). Gastric atrophy was found in 2(11.8%) cases in the 40-49 year age-group and 4(23.5%) cases in the 50-59 year age-group. The highest number of cases was found in the 60-69 year age-group with 6(35.3%) cases while there were 5(29.4%) cases in the 70-79 year age-group. There was only one case (5.9%) of mild atrophy. Moderate and severe atrophy each accounted for 11(64.7%) and 5(29.4%) cases respectively (figure 4).
6.8.2.2 Gastric Atrophy, Chronic Gastritis, Histological Type and Topography of Gastric Carcinoma
Table 10 shows that glandular atrophy was found in 24.6% of intestinal-type tumours and none of the diffuse type tumours (p=0.268). Glandular atrophy was also found in 19.8% of antro-pyloric tumours, 25.0% of fundal tumours and none of
cardia or corporal tumours. Glandular atrophy was found in 17 patients (21.5%) with gastritis but not in the absence of gastritis. The association between gastric glandular atrophy and chronic gastritis was also found to be statistically significant with a p-value of 0.03.
6.8.3 Intestinal Metaplasia
Table 11 shows the pattern of intestinal metaplasia in patients with gastric carcinoma. Thirty-seven patients (46.8%) with evidence of chronic gastritis had intestinal metaplasia while only one patient (5.6%) had intestinal metaplasia in the absence of any histological evidence of chronic gastritis (p=0.001).
6.8.3.1 Age and Occurrence of Intestinal Metaplasia
Table 11 shows that intestinal metaplasia was present only in 2 patients (11.1%) younger than 40 years but in 36 patients (45.6%) older than 40 years with a p value of 0.007. Figure 5 also shows the age distribution of intestinal metaplasia with 2 cases in the 30-39 year age-group and 6 cases in the 40-49 year age-group. Intestinal metaplasia was not found in patients younger than 30 years of age. The 50-59 year age-group had the highest frequency with 12 cases while there were 8 and 9 cases respectively in the 60-69 and 70-79 year age-groups respectively. It was present in the only case in the 80-100 year age-group. Both cases in the 30-39 year age-group were complete intestinal metaplasia. However, with advancing age the frequency of incomplete metaplasia increases accounting for more than 50% of the cases in each age-group.
6.8.3.2 Intestinal Metaplasia, Chronic Gastritis, Histological Type and Topography of Gastric Carcinoma.
According to table 11 intestinal metaplasia was found in only 30% of diffuse carcinomas and 40.7% of intestinal-type tumours (p=0.582). Intestinal metaplasia was also found in 40.7% of antropyloric tumours, 42.9% of corporal tumours, 66.7%
of fundal tumours and none of cardia tumours (p=0.440). Thirty-seven patients (46.8%) with associated gastritis and only 1 patient (5.6%) without chronic gastritis had evidence of intestinal metaplasia (p=0.001).
Although each of these associated incidental findings do not individually show any significant association with Lauren’s histological type of gastric carcinoma, logistic regression analysis, however, shows a significant relationship between gastric carcinoma of Lauren’s type and the presence of H. pylori, chronic gastritis, gastric atrophy and intestinal metaplasia, with a value of 0.000 (p<0.0001).
TABLE 1: AGE AND SEX DISTRIBUTION OF PATIENTS WITH GASTRIC CARCINOMA
AGE GROUP SEX TOTAL (%)
MALE FEMALE
20-29 2 (66.7) 1 (33.3) 3 (3.1)
30-39 4 (40.0) 6 (60.0) 10 (10.3)
40-49 9 (60.0) 6 (40.0) 15 (15.5)
50-59 17 (58.6) 12 (41.4) 29 (29.9)
60-69 13 (54.2) 11 (45.8) 24 (24.7)
70-79 8 (53.3) 7 (46.7) 15 (15.5)
80-100 0 (0.0) 1 (100.0) 1 (1.0)
TOTAL 53 (54.6) 44 (45.4) 97 (100.0)
P=0.855
TABLE 2: TOPOGRAPHICAL DISTRIBUTION OF GASTRIC CARCINOMAS WITHIN THE STOMACH.
GROSS TOPOGRAPHY TOTAL
(%) ANTRUM
(%)
CARDIA (%)
CORPUS (%)
FUNDUS (%)
TYPE I 53(65.4) 1(25.0) 2(28.6) 2(40.0) 58(59.8)
TYPE II 21(25.9) 2(50.0) 5(71.4) 2(40.0) 30(30.9)
TYPE III 5(6.2) 0(0.0) 0(0.0) 1(20.0) 6(6.2)
TYPE IV 2(2.5) 1(25.0) 0(0.0) 0(0.0) 3(3.1)
TOTAL 81(83.5) 4(4.1) 7(7.2) 5(5.2) 97(100.0)
P=0.056
TABLE 3: GROSS MACROSCOPIC GROWTH PATTERNS OF GASTRIC CARCINOMA (BORRMAN’S CLASSIFICATION)
AGE-GROUP
GROSS GROWTH PATTERN
TOTAL (%) FUNGATING
(TYPE I) (%) EXCAVATED (TYPE II) (%) ULCERATIVE (TYPEIII) (%)
DIFFUSELY INFILTRATG (TYPEIV) (%)
20-29
1(50.0) 1(50.0) 0(0.0) 0(0.0) 2(5.4) 30-39
3(75.0) 0(0.0) 0(0.0) 1(25.0) 4(10.8) 40-49
2(33.3) 3(50.0) 1(16.7) 0(0.0) 6(16.2)
50-59
5(45.5) 6(54.5) 0(0.0) 0(0.0) 11(29.7) 60-69
4(50.0) 3(37.5) 0(0.0) 1(12.5) 8(21.6) 70-79
4(66.7) 2(33.3) 0(0.0) 0(0.0) 6(16.2)
TOTAL 19(51.4) 15(40.5) 1(2.7) 2(5.4) 37(100.0)
P=0.928
TABLE 4: HISTOLOGICAL TYPES OF GASTRIC CARCINOMA (WHO)
AGE-GROUP
WHO
TOTAL
MUCINOUS (%)
(%) PAPILLARY(%) SIGNET RING (%) TUBULAR(%) 20-29
0(0.0) 0(0.0) 1(33.3) 2(66.7) 3(3.1) 30-39
0(0.0) 2(20.0) 0(0.0) 8(80.0) 10(10.3) 40-49
0(0.0) 2(13.3) 0(0.0) 13(86.7) 15(15.50
50-59
5(17.2) 3(10.3) 4(13.8) 17(58.7) 29(29.9) 60-69
2(8.3) 0(0.0) 5(20.8) 17(70.8) 24(24.7) 70-79
4(26.7) 2(13.3) 0(0.0) 9(60.0) 15(15.5) 80-100
0(0.0) 0(0.0) 0(0.0) 1(100.0) 1(1.0)
TOTAL 11(11.3) 9(9.3) 10(10.3) 67(69.1) 97(100.0)
P=0.223
TABLE 5: HISTOLOGICAL TYPES OF GASTRIC CARCINOMA (LAUREN)
AGE GROUP
LAUREN
TOTAL (%)
DIFFUSE(%) INTESTINAL (%) MIXED(%)
20-29
1(33.3) 2(66.7) 0(0.0) 3(3.1)
30-39
0(0.0) 10(100.0) 0(0.0) 10(10.3) 40-49
0(0.0) 15(100.0) 0(0.0) 15(15.5)
50-59
4(13.8) 24(82.8) 1(3.4) 29(29.9) 60-69
5(20.8) 19(79.2) 0(0.0) 24(24.7) 70-79
0(0.0) 15(100.0) 0(0.0) 15(15.5) 80-100
0(0.0) 1(100.0) 0(0.0) 1(1.0)
TOTAL 10(10.3) 86(88.7) 1(1.0) 97(100.0)
P=0.434
FIGURE 1: SEX DISTRIBUTION OF GASTRIC CARCINOMA ACCORDING TO LAUREN’S SCHEME
mixed intestinal
diffuse
Lauren
50
40
30
20
10
0
frequency
female male
Sex
P=0.512
FIGURE 2: GROWTH PATTERNS OF GASTRIC CARCINOMA OF LAUREN’S TYPE
mixed intestinal
diffuse
Lauren
50
40
30
20
10
0
frequency
ulcerative schirrous fungating excavated Gross
P=0.709
FIGURE 3: LOCATION OF GASTRIC CARCINOMA OF LAUREN’S TYPE
mixed intestinal
diffuse
Lauren
80
60
40
20
0
frequency
fundus corpus cardia antrum Location
P=0.964
TABLE 6: HISTOLOGICAL DIFFERENTIATION OF GASTRIC CARCINOMA
AGE-GROUP
DIFFERENTIATION
TOTAL (%)
WELL(%) MODERATE (%) POOR(%)
20-29
1(33.3) 1(33.3) 1(33.3) 3(3.1) 30-39
4(40.0) 3(30.0) 3(30.0) 10(10.3) 40-49
8(53.3) 1(6.7) 6(40.0) 15(15.5) 50-59
10(34.5) 10(34.5) 9(31.0) 29(29.9) 60-69
11(45.8) 7(29.2) 6(25.0) 24(24.7) 70-79
5(33.3) 8(53.3) 2(13.3) 15(15.5) 80-100
1(100.0) 0(0.0) 0(0.0) 1(1.0)
TOTAL 40(40.3) 30(30.9) 27(27.8) 97(100.0)
P=0.592
TABLE 7: DEPTH OF INVASION OF THE STOMACH WALL BY GASTRIC CARCINOMA
GROSS
DEPTH
TOTAL (%) SUPERFICIAL
(%)
ADVANCED (%)
TYPE I
1(3.7) 26(96.3) 27(57.5)
TYPE II
2(12.5) 14(87.5) 16(34.0)
TYPE III
1(100.0) 0(0.0) 1(2.1)
TYPE IV
0(0.0) 3(100.0) 3(6.4)
TOTAL 4(8.5) 43(91.5) 47(100.0)
P=0.007
TABLE 8: PATTERN OF METASTASIS ACCORDING TO DEPTH OF TUMOUR INVASION
METASTATIC SITE
DEPTH
TOTAL (%)
SUPERFICIAL
(%) ADVANCED (%)
ABSENT
1(25.0) 12(36.4) 13(35.1) LIVER
0(0.0) 1(3.0) 1(2.7)
LYMPH
NODE 3(75.0) 18(54.5) 21(56.8)
OMENTUM
0(0.0) 2(6.0) 2(5.4)
TOTAL
4(10.8) 33(89.2) 37(100.0)
P=0.860
TABLE 9: PATTERN OF HELICOBACTER-LIKE ORGANISMS (HLO) ACCORDING TO SOME VARIABLES
HLO
Present Absent Total X2 P value
AGE
< 40 years
>40years 6(33.3)
37(46.8) 12(66.7)
42(53.2) 18
79 1.083 0.298
SEX
Male
Female 21(39.6)
22(50.0) 32(60.4)
22(50.0) 53
44 1.049 0.306
GROSS
Type I Type II Type III Type IV
23(39.7) 14(46.7) 4(66.7) 2(66.7)
35(60.3) 16(53.3) 2(33.3) 1(33.3)
58 30 6 3
2.400 0.494
HISTOLOGY
Diffuse Intestinal Mixed
6(60.0) 36(41.9) 1(100.0)
4(40.0) 50(58.1) 0(0.00)
10 86 1
2.463 0.292
TOPOGRAPHY
Antrum Cardia Corpus Fundus
37(45.7) 1(25.0) 3(42.9) 2(40.0)
44(54.3) 3(75.0) 4(57.1) 3(60.0)
81 4 7 5
0.709 0.871
GASTRITIS
Present
Absent 43(54.4)
0(0.0) 36(45.6)
18(100.0) 79
18 17.599 0.000
TABLE 10: PATTERN OF GASTRIC GLANDULAR ATROPHY ACCORDING TO SOME VARIABLES
ATROPHY
Present Absent Total X2 P value
AGE
< 40 years
>40years 0(0.0)
17(21.5) 18(100.0)
62(78.5) 18
79 4.697 0.03
SEX
Male
Female 7(13.2)
10(22.7) 46(86.8)
34(77.3) 53
44 1.507 0.220
GROSS
Type I Type II Type III Type IV
10(17.2) 4(13.3) 3(50.0) 0(0.0)
48(828) 26(86.7) 3(50.0) 3(100.0)
58 30 6 3
5.383 0.146
HISTOLOGY
Diffuse Intestinal Mixed
0(0.0) 17(19.8) 0(0.0)
10(100.0) 69(80.2) 1(100.0)
10 86 1
2.636 0.268
TOPOGRAPHY
Antrum Cardia Corpus Fundus
16(19.8) 0(0.0) 0(0.0) 1(20.0)
65(80.2) 4(100.0) 7(100.0) 4(80.0)
81 4 7 5
2.637 0.451
GASTRITIS
Present
Absent 17(21.5)
0(0.0) 62(78.5)
18(100.0) 79
18 4.697 0.030
TABLE 11: PATTERN OF INTESTINAL METAPLASIA ACCORDING TO SOME VARIABLES
INTESTINAL METAPLASIA
Present Absent Total X2 P value
AGE
< 40 years
>40years 2(11.1)
36(45.6) 16(88.9)
43(54.4) 18
79 7.305 0.007
SEX
Male
Female 20(37.7)
18(40.9) 33(62.3)
26(59.1) 53
44 0.102 0.750
GROSS
Type I Type II Type III Type IV
25(43.1) 11(36.7) 2(33.3) 0(0.0)
33(56.9) 19(63.3) 4(66.7) 3(100.0)
58 30 6 3
2.473 0.480
HISTOLOGY
Diffuse Intestinal Mixed
3(30.0) 35(40.7) 0(0.0)
7(70.0) 51(59.3) 1(100.0)
10 86 1
1.081 0.582
TOPOGRAPHY
Antrum Cardia Corpus Fundus
33(40.7) 0(0.0) 3(42.9) 2(40.0)
48(59.3) 4(100.0) 4(57.1) 3(60.0)
81 4 7 5
2.701 0.440
GASTRITIS
Present
Absent 37(46.8)
1(5.6) 42(53.2)
17(94.4) 79
18 10.484 0.001
FIGURE 4: DISTRIBUTION OF GASTRIC GLANDULAR ATROPHY AMONG THE DIFFERENT AGE GROUPS
80-100 70-79
60-69 50-59
40-49 30-39
20-29
Agegroup
25
20
15
10
5
0
frequency
severe moderate mild absent Atrophy
P=0.876
FIGURE 5: PATTERN OF INTESTINAL METAPLASIA AMONG THE DIFFERENT AGE GROUPS.