[A case report of 16-year-old gastric cancer patient with a rapid recurrence after curative gastrectomy]

A 16-year-old female patient with gastric cancer was recently treated at our institute. She had macroscopically curative surgery, but relapsed to die 7 months after surgery due to peritoneal dissemination. We experienced three teen-agers over past 45 years, who were 0.019% of all cases treated in our institute. Histological type of these cases was undifferentiated adenocarcinoma, exposing to serosa. Though they had suffered abdominal discomfort for long time, proper diagnosis was not done due to their young age. Even the teen-ager who has abdominal complaints should be subjected to a thorough examination of gastrointestinal tract. Oncogene analysis should be done for the familial strain of gastric cancer.

[Multi-variate analysis of prognostic factors in gastric cancer with Cox' proportional hazard model]

A total of 8,993 cases of gastric cancer which were undergone gastrectomy at Cancer Institute Hospital, Tokyo were subjected to the multi-variate analysis of prognostic factors in gastric cancer. Relative ratio of hazard risk indicated the rank of importance in prognostic factors as the following order: Hepatic metastasis, radicality of surgery, macroscopic tumor type, serosal involvement, number of involved lymph node, and grade of lymph node metastasis. Difference in the results of analysis was observed between mono- and multi-variate analysis in the following categories: site of primary lesion, type of resection, and chemotherapy. These results suggested the importance of multimodality therapy to achieve the absolute curative surgery for advanced cancer, and also the importance of multi-variate analysis for the proper evaluation of prognostic factors.

[Meta-analysis of 10 postoperative adjuvant chemotherapies for gastric cancer in CIH]

Six adjuvant chemotherapy protocols with 10 chemotherapy regimens were subjected to meta-analysis with an aim to clarify the survival benefits of adjuvant chemotherapy in gastric cancer. All adjuvant chemotherapies were compared with surgery alone, in cases from 1959 to 1982 in the Cancer Institute Hospital, Tokyo in the setting of controlled randomized study; and 1,177 gastric cancer patients with curative surgery were entered the studies. Pooled odds ratio and its 95% confidence interval was 0.63(0.51-0.78). The results suggested the survival benefits of adjuvant chemotherapy with mitomycin C and/or 5-fluorouracil in gastric cancer.

[The changes in the treatment of early gastric cancer--endoscopic mucosal resection and limited (nerve preserving) operation]

We have been trying to perform endoscopic mucosal resection (ER) since 1987, and limited operation since 1985 (nerve preserving operation since 1991) for early gastric cancer. 205 patients were performed ER from 1978 to 1990, 78 patients were performed limited operation from 1985 to 1993. We perform ER according to the indication as follows: 1) differentiated IIa type, size approximately 2 cm, 2) differentiated IIc type, size approximately 1cm, Ul(-), 3) undifferentiated IIc type, size approximately 5mm, Ul(-). And the indication of limited operation is the patients with intramucosal cancer and tumor size approximately 2cm. Up to date, we have never experienced recurrence of these patients undergone ER or limited operation. As to QOL, these therapy will be expected to improve QOL of early gastric cancer patients, especially per os and body weight loss after surgery.

[Indication for the lymph node dissection of gastric cancer based on the pattern analysis small of lymphatic spread]

A total of 8,230 cases of gastric cancer treated at CIH were subjected to the analysis of the pattern of lymphatic spread with an aim of getting indication for the lymph node dissection of Small gastric cancer. Modified dissection (D1-alpha) is indicated for the patients with following conditions: 1) every elevated or flat type mucosal cancer, 2) excavated (IIc) type mucosal cancer less than 10mm in diameter, 3) elevated or flat type submucosal cancer less than 10mm in diameter, 4) excavated submucosal cancer less than 5mm in diameter. Extended dissection (D2 + alpha) is indicated for small cancer which exposed to serosa. Cancer in the upper thirds needs total gastrectomy or cardiectomy according to the state of #5 and 6 nodes, with complete dissection of #1 to 11 nodes associated with sampling of #16 nodes. Total gastrectomy with complete dissection of #1 to 11 nodes and sampling of #16 nodes is indicated for the advanced small cancer in the middle thirds, and total gastrectomy with complete dissection of #1 to 13 nodes and sampling of #14, 16 nodes is indicated for cancer in the lower thirds.

[The treatment and clinical issue of gastric cancer with infiltrating the adjacent organs]

We discussed the advances and clinical issue including complications in the treatment of gastric cancer infiltrating the adjacent organs. Recent years, the proportion of the patients with gastric cancer infiltrating the adjacent organs are decreasing, but there isn't remarkable advances in the treatment result of them. That is due to the fact that about one half of them has distant metastasis, such as peritoneal dissemination or liver metastasis. Whatever the survival rate of the patients who was performed combined resection is better than unresected cases. The postoperative complications of the combined resection cases is two times as much as the uncombined resected cases. Therefore we should perform combined radical resection for the patients without distant metastasis, and for the patients with distant metastasis, we should perform palliative surgery for the purpose of improving QOL.

[Past and future of gastric cancer treatment in Japan]

History of gastric cancer treatment in Japan during about 100 years was described. Not only development of surgery, but also influence of European medicine and improvement of diagnosis were studied. History and activity of Cancer Institute Hospital (C.I. H.) and Japanese Research Society for Gastric Cancer (J.R.S.G.C.) were also described.

Phosphocholine-bonded galactosylceramides having a tri-unsaturated long-chain base from the clam worm, Marphysa sanguinea

Seven glycosphingolipids were obtained in the pure state from the clam worm, Marphysa sanguinea, by preparative HPLC with a reversed-phase column in a recycling mode. Their structures were elucidated based on detailed analyses of 1H- and 13C-NMR spectra of the intact compounds. The position and the geometry of double bonds in the long-chain base (LCB) were determined by the two-dimensional NMR (COSY, NOESY, and HMBC) analyses. All compounds are phosphocholine-bonded monogalactosylceramides and two of them have tri-unsaturated long-chain bases.

[Left upper abdominal evisceration for advanced gastric cancer]

To evaluate the clinical significance of the surgical procedure of left upper abdominal evisceration (LUAE), we analysed the prognosis of patients who received LUAE in the Cancer Institute Hospital from 1980 to 1990 using pair matching analysis. Survival benefits were observed in the patients with the tumor located in the upper or middle part of the stomach, and especially in those with Borrmann type 4 gastric cancer. Even in cases of peritoneal dissemination, patients who received LUAE survived longer than those with conventional total gastrectomy. These results indicated that LUAE should be a standard surgical approach for Bormann type 4 gastric cancer.

[The accuracy and clinical issue of preoperative diagnosis of gastric cancer]

We discussed the accuracy and clinical issue of preoperative diagnosis for 764 patients with gastric cancer from 1987 to 1990. The accuracy of diagnosis, location, tumor size, wall invasion, involved lymph node were 81.8, 80.5, 62.2, 82.5% respectively. The clinicopathological characteristics of the regions which we missed preoperative diagnosis are infiltrating type and scirrhous type in diagnosis of tumor size, and large tumor in diagnosis of wall invasion. Especially in the case of early gastric cancer, we missed diagnosis of wall invasion of the regions with clinicopathological characteristics as follows: depressed type, undifferentiated type and ulceration in lesions. Now it is difficult to diagnosis wall invasion before surgery, so we have to be careful to determine the indication of endoscopic resection or limited operation for early gastric cancer, especially with clinicopathologic characteristics stated as above.

[Progress of the treatment of gastric cancer in Cancer Institute Hospital, Tokyo]

From 1946 to 1990, a total of 10,485 cases of gastric cancer patients were treated at the Cancer Institute Hospital (CIH), Tokyo. During the past 46 years, CIH contributed to various aspects of surgical treatment of gastric cancer; extensive radical surgery for advanced cancer, safe reconstruction methods after total gastrectomy, modified surgery for early stage cancer, and multimodality therapy for moderately advanced cancer. Five-year survival rate was 20% for all cases in 1940s, and 66.5% for 1980s. Improvement in the treatment results could be attributed to the relative increase in the number of early stage cancers, the increase in the rate of curative surgery (R0), and incorporation of multi-modality therapy before or after curative surgery. Stage-oriented therapy is mandatory for further improvement in the treatment results and the patient's quality of life after surgery.

[Treatment of recurrent gastric cancer]

The recurrence rate of resected gastric cancer was 31.9%. The rate was in creasingly higher in proportion to the lack of radicality. The most common type of recurrence was peritoneal dissemination, followed by hematogeneous metastasis, local recurrence, and distant lymph node metastasis. The treatments for recurrence were surgery (9.3%) and chemotherapy (16.1%). Systemic chemotherapy (intravenous iv) was common, and local chemotherapy (intraarterial ia, intraperitoneal ip) was rate. The efficacy of systemic chemotherapy (iv) for recurrent gastric cancer without local recurrence was suggested. The efficacy of local chemotherapy (ia) was suggested for peritoneal dissemination and local recurrence.

[The analysis of prognosis of patients with gastric cancer with the nodal stage(N, n) and the number of involved lymph nodes]

Now we use the nodal grade (N, n) as a prognostic indicator in patients with gastric cancer according to the general rules for the gastric cancer study. But there are both of patients with good and poor prognosis in the same nodal grade. Then we analyzed the survival of patients with gastric cancer based on the nodal grade and the number involved lymph nodes, and discussed the new prognostic indicator with both of them. We classified the three groups based on the number of involved nodes as follows: 0.1-4.5-. There is the differences in survival between each pair of groups statistically. The relationship between the nodal grade (N, n) and the number of lymph node metastasis is that the survival of patients with involved nodes more than five is equal to the survival of the patients with high nodal grade and involved nodes 1-4. Therefore it suggest that the new grading consisting of them will be more better prognostic indicator.

[Prognostic factors of the gastric cancer patients without distant metastasis]

From 1946 to 1990, 10,485 patients with gastric cancer were been surgically treated in the Cancer Institute Hospital, Tokyo. Retrospectively, we analyzed prognostic factors, especially in those without distant metastasis. Prognosis of the patients with tumors which invaded the proper muscle layer improved dramatically (from 70% to 90%). However, patients who had advanced tumors with serosal invasion did not show good survived (from 20% to 40%). To improve the prognosis of patients with serosal positive gastric cancer, a new and effective prophylactic therapy for peritoneal recurrence is needed.

Excitation-contraction uncoupling and muscular degeneration in mice lacking functional skeletal muscle ryanodine-receptor gene

Contraction of skeletal muscle is triggered by the release of Ca2+ from the sarcoplasmic reticulum (SR) after depolarization of transverse tubules. The ryanodine receptor exists as a 'foot' protein in the junctional gap between the sarcoplasmic reticulum and the transverse tubule in skeletal muscle, and is proposed to function as a calcium-release channel during excitation-contraction (E-C) coupling. Previous complementary DNA-cloning studies have defined three distinct subtypes of the ryanodine receptor in mammalian tissues, namely skeletal muscle, cardiac and brain types. We report here mice with a targeted mutation in the skeletal muscle ryanodine receptor gene. Mice homozygous for the mutation die perinatally with gross abnormalities of the skeletal muscle. The contractile response to electrical stimulation under physiological conditions is totally abolished in the mutant muscle, although ryanodine receptors other than the skeletal-muscle type seem to exist because the response to caffeine is retained. Our results show that the skeletal muscle ryanodine receptor is essential for both muscular maturation and E-C coupling, and also imply that the function of the skeletal muscle ryanodine receptor during E-C coupling cannot be substituted by other subtypes of the receptor.

cDNA cloning and regional distribution of a novel member of the opioid receptor family

We have cloned a cDNA for a novel member of the opioid receptor family, designated as ROR-C, from the rat cerebrum cDNA library using the probe derived from the delta-opioid receptor subtype cDNA. The deduced amino acid sequence of ROR-C shows high homology with those of ROR-A (rat delta-opioid receptor subtype), ROR-B (rat mu-subtype) and ROR-D (rat kappa-subtype). RNA blot hybridization and in situ hybridization analysis revealed that ROR-C mRNA is expressed in discrete regions of the rat central nervous system.

How extensive should lymph node dissection be for cancer of the thoracic esophagus?

From 1985 to 1992, 171 patients with cancer of the thoracic esophagus underwent esophagectomy with systematic dissection of regional lymph nodes including cervical nodes. The hospital mortality rate was 5.3%. The dissected nodes were classified into four groups: the deep cervical (C), upper mediastinal and cervical paratracheal (U), middle and lower mediastinal (L), and upper perigastric (G) groups. The U group mainly consisted of nodes beside the recurrent laryngeal nerves. The phase of cancer infiltration of lymph nodes was evaluated by the total number and the distribution of involved nodes. Of cases with nodal involvement, only 37% were in the late phase, in which more than seven nodes or in which the U, L, and G groups were all involved. Of cases in the earliest phase in which only one node was involved, 93% had either the U or G group involved. The C group of nodes was infrequently involved until the late phase. Cancer had metastasized to the U and G groups across a considerable anatomic distance even in earlier phases. Outcomes of the cases with nodal involvement not in the late phase were satisfactory; the cumulative survival was 60% at 3 years and 54% at 5 years. Systematic nodal dissection would benefit even cases with nodal involvement, unless the disease is in the late phase. Nodes beside the recurrent nerves and upper perigastric nodes should be dissected with higher priority, though they are located anatomically distant.

Prognostic factors of renal dysfunction induced by environmental cadmium pollution

To assess the influence of environmental cadmium (Cd) exposure on long-term outcome, a follow-up study was conducted from 1981-1982 to March 1991 on 3178 inhabitants living in the Cd-polluted Kakehashi River basin. The standardized mortality ratios of the urinary beta 2-microglobulin (beta 2-MG)-, protein-, and amino acid-positive subjects of both sexes and the urinary glucose-positive female subjects were higher than those of the subjects with urinary-negative findings or the general Japanese population during the observation period. After adjusting for age using Cox's proportional hazards model, significant associations were found between mortality and urinary indices. In multiple comparisons using all of the indices, urinary protein and beta 2-MG in the women and urinary protein in the men were the factors most contributing to the mortality rates. In the urinary protein-negative female group as well, a significant association was found between urinary beta 2-MG and mortality. These results suggest that the prognosis of subjects with Cd-induced renal dysfunction is unfavorable, with the mortality rate increasing even in the early stage of proximal tubular dysfunction. Urinary protein and urinary beta 2-MG are important prognostic factors, with the latter, in particular, considered to be useful as an early index predictive of premature mortality.

Isolation and characterization of a gene for a ryanodine receptor/calcium release channel in Drosophila melanogaster

The nucleotide sequence of a 25.7 kilobase Drosophila melanogaster genomic DNA segment containing a gene for a ryanodine receptor/calcium release channel homologue has been determined. Computer analysis and partial cDNA cloning revealed 26 exons comprising the protein-coding sequence in this gene. The predicted protein is homologous in amino acid sequence and shares characteristic structural features with the mammalian ryanodine receptors. In blot hybridization analysis, a approximately 16 kilobase RNA species was identified abundantly in a 6-12 h embryo as the transcript from this gene. In situ hybridization to polytene chromosomes indicated that this gene locates at band position 44F on the second chromosome.

Immunohistochemical study of c-erbB-2 oncoprotein expression in extramammary Paget's disease

Sections of formalin-fixed, paraffin-embedded tumor tissue from 20 patients with noninvasive extramammary Paget's disease and 2 patients with invasive extramammary Paget's disease were stained immunohistochemically by means of anti-c-erbB-2 product monoclonal antibody. Membrane staining of intraepidermal tumor cells was found in only 3 of 20 cases of noninvasive extramammary Paget's disease. In the 2 invasive cases, tumor cells of invasive lesions and metastases were positive while intraepidermal tumor cells were negative.

Psychological stress increases serotonin release in the rat amygdala and prefrontal cortex assessed by in vivo microdialysis

The effects of psychological stress on serotonin (5-HT) release were studied in the basolateral amygdaloid nucleus and the prefrontal cortex in conscious rats with in vivo microdialysis. Psychological stress, wherein emotional factors were predominantly involved, significantly increased extracellular 5-HT levels in these two areas. These findings suggest that activation of serotonergic neurons in these brain regions is involved in the emotional and/or cognitive states in animals.

[Correlations between estrogen receptor and prognostic factors of patients with breast cancer. The Kanto Cooperative Study Group of Adjuvant Chemoendocrine Therapy for Breast Cancer, Japan]

We investigated possible correlations between estrogen receptor (ER) and prognostic factors in 3,789 patients with stage II or stage IIIa breast cancer in Japan. The patients with ER-positive tumors showed a significantly better prognosis in the 5-year survival rate and the 5-year disease-free survival rate compared with the patients with ER-negative-tumor. Positivities increased with increasing patient age, with increasing tumor size, and lowering degree of cell differentiation, and no relation was observed between the positivities and tumor sites, obesity index, and lymph-node metastasis.

Urinary beta 2-microglobulin concentration and mortality in a cadmium-polluted area

A 9-y follow-up study of 3,178 persons who lived in a cadmium-polluted area was conducted to assess the influence of environmental cadmium exposure on long-term outcome. The standardized mortality ratios of the urinary beta 2-microglobulin-positive subjects (> 1,000 micrograms/g creatinine) of both sexes were higher than those of the general Japanese population, whereas the cumulative survival curves were lower than those of the urinary beta 2-microglobulin-negative group. A significant association was also found between urinary beta 2-microglobulin and mortality, using a Cox's proportional hazards model. Moreover, mortality rates increased in proportion to increases in the amount of urinary beta 2-microglobulin excreted. These results suggest that the prognosis for cadmium-exposed subjects with proximal tubular dysfunction is unfavorable. The mortality rate tended to become higher as the severity of renal dysfunction progressed.

cDNA cloning and pharmacological characterization of an opioid receptor with high affinities for kappa-subtype-selective ligands

The amino acid sequence of a rat opioid receptor, designated as ROR-D, has been deduced by cloning and sequencing the cDNA. The ROR-D expressed from the cDNA exhibits high affinities for ligands selective for the opioid receptor kappa-subtype and low affinities for ligands selective for the delta- and mu-subtypes. RNA blot hybridization analysis indicated that ROR-D mRNA is distributed in cerebrum and brainstem but not in cerebellum.