- Open Access
Perforated gastric carcinoma: a report of 10 cases and review of the literature
© Roviello et al; licensee BioMed Central Ltd. 2006
- Received: 07 October 2005
- Accepted: 30 March 2006
- Published: 30 March 2006
Perforation is a rare complication of gastric carcinoma, accounting for less than 1% of all gastric cancer cases. The aim of the present study is to evaluate the prognostic value of perforation and to point out the surgical treatment options.
A total of 10 patients with perforated gastric carcinoma were retrospectively reviewed among 2564 consecutive cases of gastric cancer operated in three Centers belonging to the Italian Research Group for Gastric Cancer. The clinicopathological features including tumor stage and survival were analyzed and compared to literature data.
Incidence rate was 0.39%. All patients underwent emergency surgery, being performed gastrectomy in 6 patients (mortality 17%) and repair surgery in 4 patients (mortality 75%). The survival of patients was related to the stage of the disease, with 2 long-survival cases.
Perforation usually occurs in advanced stages of gastric cancer; nevertheless surgeons should not be always discouraged from a radical treatment of perforated gastric cancer, since perforation even occurs in early stages and seems not to be a negative prognostic factor itself. When possible, emergency gastrectomy should be performed, leaving repair surgery for unresectable tumors. A two-stage treatment is a good treatment option for frail patients with resectable tumors.
- Gastric Cancer
- Subtotal Gastrectomy
- Gastric Perforation
- Gastric Cancer Case
- Perforated Peptic Ulcer
Perforation of gastric carcinoma results in an acute abdominal syndrome due to the spilled gastric contents and the consequent peritonitis. It is a rare condition representing less than 1% of gastric cancer cases in the reports of the last years[1, 2] and up to 6% in reports dated before 1980 [3–5]; it has been reported that about 10–16% of all gastric perforations are caused by gastric carcinoma [6–9]. In most instances gastric carcinoma is not suspected as the cause of perforation prior to emergency laparotomy and the diagnosis of malignancy is often made only on postoperative pathologic examination. It is often difficult to recognize the kind of lesion that caused gastric perforation at the time of emergency surgery, particularly when pathologic evaluation of frozen sections is not available. The treatment should aim to manage both the emergency condition of peritonitis and the oncologic technical aspects of surgery: it may be hazardous to embark on a major procedure observing the principles of radical oncological surgery; on the other hand a limited procedure only may jeopardize long-term survival in a patient with potentially curable gastric malignancy. In order to further understand the optimal management of patients with perforated gastric cancer, we reviewed the clinicopathological features and surgical results in our experience, comparing data with the International literature.
We reviewed the medical records of 2564 patients with gastric cancer who had undergone surgical treatment in three Centers belonging to the Italian Research Group for Gastric Cancer (IRGGC): Dipartimento di Chirurgia Generale ed Oncologica, University of Siena, Istituto di Semeiotica Chirurgica, University of Verona and Divisione di Chirurgia 1, G.B. Morgagni Hospital, Forlì. Ten patients (0.39%) were treated for perforated gastric carcinoma. The clinicopathological features of all patients were analyzed on the basis of their medical records. Age and sex, preoperative diagnosis, location of perforation, depth of gastric wall invasion, absence or presence of lymph node metastasis, type of surgery, degree of lymph node dissection, UICC stage and outcome of the patients were examined. Overall survival from the time of primary operation was calculated using Kaplan-Meier estimates. A search of the literature was conducted in the Medline database; the terms "perforated", "perforation", "gastric cancer", "gastric ulcer" were associated for the search and English language journals only were selected.
Clinicopathological features of patients with perforated gastric cancer.
Number of Patients
Lauren histological type*
Lymph node metastasis*
Stage of disease
Lymph node dissection
Extended (D2, D3)
Limited (D0, D1)
Postsurgical survival data for patients with perforated gastric carcinoma.
Type of surgery
Cause of death or Comments
CHT – Alive with bone recurrence
CHT – Alive
Perforation is a rare complication of gastric cancer. In our series an incidence of less than 1% (0.39%) was observed comparable to the most recent studies[1, 2]. Preoperative diagnosis of malignancy is unusual, accounting for about 30% of cases[1, 2, 10]; the other patients are usually accepted for acute abdomen at the Emergency Units where generic preoperative diagnosis of gastroduodenal perforation is made. The only preoperative feature that may guide the surgeon is the age of the patient: perforated gastric carcinoma usually occurs in patients with a mean age of 65 years (68 years in our series) in contrast with the mean age of 51 years of the patients with perforated peptic ulcers [9–13]. Even during surgery the gastric ulcer is often diffucult to be characterized as benign or malignant by the surgeon. Therefore a biopsy and frozen section should be performed in all gastric perforations when a pathologist is available. Histologic determination is fundamental for the surgeon to choose the type of operation and to perform it with oncological criteria, for example considering adequate distance from the lesion and the resection margin. Malignant gastric perforation is more often a manifestation of advanced cancer with serosal invasion (55–82%) and lymph node metastasis (57–67%). Nevertheless, as confirmed by different observations[14, 15], gastric cancer can perforate at an early stage. Indeed at the pathologic examination of specimens, the process of gastric wall perforation is sustained by infectious and ischaemic factors due to the tumoral neovascularization which result in the shedding of the neoplastic tissue[3, 16].
It is still debated whether positive peritoneal cytology has an independent prognostic impact in gastric cancer. Several studies have noted free gastric cancer cells in the peritoneum to be associated with poor prognosis[17, 18]. However, viable free cancer cells have not been demonstrated in the peritoneal cavity of patients with perforated gastric cancer and the metastatic efficiency of gastric cancer cells possibly shed during perforation is uncertain in the presence of the peritonitis; different studies, included the present one, report of long-term survivors. When a curative operation can be performed, survival rates after gastric cancer perforation[1, 20] appear similar to survival rates observed in elective patients[21, 22]. Moreover, Gertsch et al. demonstrated how the only factor predicting long term survival is the TNM stage, while age or the size, the location, the depth of infiltration and the histologic grading of the tumor or a delay in treatment after perforation showed no correlation with long-term survival. Earlier, in 1997, Adachi et al. reviewed 155 cases of perforated gastric cancer collected from the Japanese literature finding that infiltrative gross type of the tumor, presence of serosal invasion, presence of lymph node metastasis, stage III-IV and curability of the tumor were the only negative prognostic factors influencing the 5-years survival rate, while age, sex, location, histologic type and type of lymph node dissection were not found to be significantly related to the long term survival. In another study of Gertsch et al., the Authors compared three groups of patients with perforated, bleeding and non-complicated gastric cancer, finding that perforation, as well as bleeding, does not significantly affect long term survival after gastrectomy.
Published series of patients with perforated gastric cancer.
Preoperative diagnosis (%)
N° Repair surgery
Survival range in resected cases 18–42 months
Survival range of patients with R0 resection, 15–41 months; with R1-R2 4–15 months
Survival range of patients with R0 resection, 14–108 months; with R1-R2 2 months
Mean survival, 5 months (range 1–18)
Range of survival, 1–18 months
Median survival, 108 months (range, 4–144)
Median survival stage I 50 months; III, 17 months; IV 4 months
5-years survival stage I-II, 76%; III-IV, 19%
5-years survival R0, 50%; 2-years survival R1-R2, 9%
Median survival stage I-II 75 months; III-IV, 4.8 months
See text and Table 2
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