Pathological characteristics of gastric cancer that develop hematogenous recurrence, with special reference to the site of recurrence

The pathologic characteristics of gastric cancer in 57 patients with hematogenous recurrence were pathologically analyzed by the site of recurrence. In recurrence of gastric cancer that developed in the liver, macroscopic observation revealed that cancers of Borrmann type 2 and 3 were most frequent. Microscopic examination revealed that the rate of occurrence of the medullary type of differentiated or poorly differentiated adenocarcinoma were high and that there were relatively frequent invasion by cancerous cells of the blood vessel that were closely related to the hematogenous metastasis. On the other hand, with respect to recurrence of gastric cancer that had developed in the lung or bone, Borrmann type 3 and 4, respectively, were more frequently observed. In these cases, microscopic analysis revealed that these cancers were poorly differentiated adenocarcinomas. In gastric cancer with bone recurrence, the rate of recurrence of the scirrhous type of tumor were higher than that of other types. It is important, for the management of patients after gastric cancer surgery, to predict possible hematogenous recurrence and its site by evaluation of the pathologic characteristics of the gastric cancer.

Proximal gastrectomy as the surgical procedure of choice for upper gastric carcinoma

To assess the efficacy of proximal gastrectomy in the treatment of upper gastric carcinoma, we analyzed clinical data from patients with lesions confined to the upper third of the stomach (group 1) and from patients with lesions which, while primarily located in the upper portion of the stomach, showed spread to the body of the stomach (group 2). Patients in group 2 showed more metastatic lymph node involvement, particularly of the infrapyloric lymph nodes, which were not included in lymphadenectomy accompanying proximal gastrectomy. None of the group 1 patients demonstrated metastasis to the infrapyloric lymph nodes. The postoperative 5-year survival rate in curatively operated group 1 patients was not significantly different between those treated by proximal gastrectomy and those subjected to total gastrectomy. We conclude that proximal gastrectomy is indicated in patients with upper gastric carcinoma when it is confined to the upper third of the stomach.

Prediction of the prognosis of liver cirrhosis in Japanese using Cox's proportional hazard model

Data on 155 patients with liver cirrhosis were analyzed, using Cox's proportional hazard model. Twenty variables were screened, using a multiple linear regression analysis in a stepwise manner and 6 were considered to reflect the prognosis of cirrhotics. Three of the 6 variables were significantly prognostic, i.e. ascites, atrophy of the right lobe of the liver seen on liver scintigram and the concentration of serum albumin. The prognostic index (PI) for each patient was calculated by adding all the products of scores of these three variables with the corresponding coefficient: PI = 0.895 X ascites (absent = 0, present = 1) + 0.983 X atrophy of right lobe of the liver on the liver scintigram (absent = 0, present = 1) + (-0.561) X serum albumin (g/dl). According to the PI, the subjects were separated into three groups; group 1: PI less than -1.9, group 2: -1.9 less than or equal to PI less than -0.6, group 3: PI greater than or equal to -0.6. The global 5- and 10-year survival rates of each group were 80% and 65% in group 1, 50% and 30% in group 2 and 12% and 0% in group 3, respectively. Four of the 14 deaths in group 1, 8 of 47 in groups 2 and 10 of 24 in group 3 were caused by hepatocellular carcinoma. Our observations suggest that advanced stage cases of cirrhosis are at a high risk concerning development of hepatocellular carcinoma.

Prognostic significance of lymph vessel involvement in gastric cancer

We studied the prognostic significance of lymph vessel involvement in the gastric wall in 226 patients with advanced gastric cancer. There was no close correlation between the gross morphology of the cancer and the incidence of lymph vessel invasion. However, the more severe the degree of lymph vessel involvement, the higher was the incidence of lymph node metastasis. Severe lymph vessel invasion was found most frequently in poorly differentiated adenocarcinoma of the medullary type. Among patients with scirrhous carcinoma there were some in whom lymph vessel involvement was overlooked on routine histologic examination. Because the depth of lymph vessel invasion of the gastric wall was significantly related to the clinical course, we consider this to be of supplementary predictive value.

[High-risk population of gastric cancer patients]

Atrophic gastritis with intestinal metaplasia cannot be regarded as a form of precancerous change, but it is of profound significance in the development of gastric carcinoma. It would be reasonable to infer that those subjects who have atrophic gastritis with intestinal metaplasia to any great extent represent a high-risk population for gastric cancer. Environmental factors, especially dietary habits, are implicated in the etiology of gastric carcinoma. Intake of high concentrations of sodium chloride is assumed to promote the development of carcinoma of the stomach. Cigarette smoking is also one of the risk factors in the pathogenesis of gastric cancer, supposedly acting as an initiator in gastric tumorigenesis. Although a controversy exists as to whether gastric resection for benign ulcers enhances the subsequent development of gastric carcinoma, it appears likely that an increased amount of long-term duodenogastric reflux after partial gastrectomy results in a higher incidence of carcinoma in the stomach remnant.

Preoperative radiotherapy and intra-abdominal metastasis of the lymph node in the surgical treatment of carcinoma of the thoracic esophagus

Esophagectomy was performed upon 84 patients treated surgically for squamous cell carcinoma of the thoracic esophagus from 1965 to 1985 at the Tottori School of Medicine. Forty-four of these patients received preoperatively a total of 30 to 40 grays of cobalt 60 (2 grays per day) to the primary lesions, and 40 patients did not receive preoperative radiation therapy. A decreased tendency in the occurrence of metastasis to the intrathoracic lymph nodes was observed histologically in the group exposed preoperatively to radiation. A significant decrease in the occurrence of metastasis to the intrathoracic regional nodes in patients with carcinoma of the middle part of the thoracic esophagus was observed (p less than 0.02). A significant increase in the occurrence of metastasis to the intra-abdominal lymph nodes was observed in the patients receiving radiation therapy (p less than 0.01). The results indicate that preoperative radiotherapy for carcinoma of the thoracic esophagus may increase the risk of metastasis to the intra-abdominal lymph nodes.

Alpha-fetoprotein-producing pancreatic carcinoma: case report and review of the Japanese literature

An autopsy was performed of a patient who succumbed to pancreatic carcinoma and in whom an unusually high level of serum alpha-fetoprotein (AFP) (84,000 ng/ml) was obtained. An immunohistochemical approach, utilizing the peroxidase-antiperoxidase method, proved that AFP was confined within pancreatic carcinomatous cells of the primary lesion and liver metastases. No AFP-positive cells were ever observed in the hepatocytes adjacent to the metastatic lesions in the liver. It may be inferred that, in this particular case, the carcinomatous cells themselves synthesize AFP. The sites of production of AFP in AFP-positive pancreatic carcinoma were discussed in a review of the literature.

Relationship between area of serosal invasion and prognosis in patients with gastric carcinoma

We examined the relationship between the spatial extent of invasion of the gastric serosa in patients with gastric carcinoma and their postoperative 5-year survival rate. At the time of surgical resection of gastric cancer, intraperitoneal free cancer cells were detected by lavage of the Douglas cavity in 135 of 309 (44%) patients with gross evidence of serosal invasion. Examination of the relationship between the presence of intraperitoneal free cancer cells and serosal area invaded by the tumor revealed that only 22% of cases with an area of serosal invasion 10 cm2 or less were positive for free cancer cells, but such cells were found in 72% of cases with an area of serosal invasion greater than 20 cm2. The 5-year survival rate was 31% in patients with an area of serosal invasion of less than 10 cm2, whereas the rate was only 8% in patients with an area of serosal invasion greater than 20 cm2. Not only the presence of serosal invasion by a tumor but also the spatial extent of the invasion are significant factors that influence the prognosis of patients with gastric carcinoma.

Immunological evaluation after splenectomy for hairy cell leukemia--a case report

Immunocompetence is generally reduced in patients with hairy cell leukemia (HCL), and splenectomy is advocated by many authorities as being the initial treatment of choice for HCL. A 46-year-old Japanese man with HCL underwent a splenectomy and was studied, with respect to immunological parameters, pre- and post-operatively. Preoperative analysis of the T cell subsets showed decreases in the proportions of OKT3 positive cells, OKT4 positive cells and OKT8 positive cells; a decrease in the OKT4/OKT8 ratio; and a markedly reduced lymphocyte blastic response in peripheral blood. After splenectomy, the increase in the proportion of OKT4 positive cells was greater than in that of OKT8 cells and the lymphocyte blastic response was also improved. The patient's post-operative course has been uneventful and immunological improvement is still recognizable now, 1 year after splenectomy.

Relationship between area of serosal invasion and prognosis in patients with gastric carcinoma

We examined the relationship between the spatial extent of invasion of the gastric serosa in patients with gastric carcinoma and their postoperative 5-year survival rate. At the time of surgical resection of gastric cancer, intraperitoneal free cancer cells were detected by lavage of the Douglas cavity in 135 of 309 (44%) patients with gross evidence of serosal invasion. Examination of the relationship between the presence of intraperitoneal free cancer cells and serosal area invaded by the tumor revealed that only 22% of cases with an area of serosal invasion 10 cm2 or less were positive for free cancer cells, but such cells were found in 72% of cases with an area of serosal invasion greater than 20 cm2. The 5-year survival rate was 31% in patients with an area of serosal invasion of less than 10 cm2, whereas the rate was only 8% in patients with an area of serosal invasion greater than 20 cm2. Not only the presence of serosal invasion by a tumor but also the spatial extent of the invasion are significant factors that influence the prognosis of patients with gastric carcinoma.

Induction of diffuse necrotizing enterocolitis by anticancer chemotherapy

Fulminant, necrotizing colitis is a frequent, and generally fatal, complication of severe granulocytopenia, occurring during the treatment of hematological malignancies. In these cases, the patient complains of severe peritonitis, including nausea, vomiting, abdominal pain, diarrhea or melena, and a high temperature. Here, a rare case of anticancer chemotherapy-induced diffuse necrotizing enterocolitis throughout the entire intestinal tract is presented, which developed in a patient who did not have a hematologic malignancy but who had colon cancer, the only clinical symptom of which was watery stools, without any evidence of peritoneal irritation. Full attention should be paid to progressive diarrhea in patients with malignancies during anticancer chemotherapy.

[Clinicopathological study of gastric cancer with bone metastasis]

Fifty-eight patients with bone metastasis from gastric cancer, of whom 33 patients were resected cases and 25 were autopsies, were investigated. The incidence of bone metastasis of gastric cancer was 13.4% (33/246) among autopsies and was higher than that (1.5%, 33/2242) among resected cases. We attempted to clarify the factors related to bone metastasis by clinicopathological study. Bone metastasis had a tendency to occur in invasive cancer such as Borrmann types three or four. Histological examination revealed that 86% (50/58) of bone metastasis was poorly differentiated adenocarcinoma and that the stroma was scirrhous type in almost all cases. We measured serum alkaline phosphatase in patients with bone metastasis of recurrent gastric cancer, and found that the levels were relatively related to the condition of bone metastasis. However, the prognosis of patients with bone metastasis was not good and the mean survival time was about 5 months after the appearance of symptoms. In our department, we employ total body hyperthermia in such cases. This method has proved relatively effective for bone metastasis, as reflected by bone scintigram and changes in serum alkaline phosphatase values. As there is no reliable method of treatment for bone metastasis of gastric cancer, the present approach may be worth trying.

Malignant lymphoma associated with reactive lymphoreticular hyperplasia of the stomach--a case report

We report a case of early malignant lymphoma of the stomach, associated with reactive lymphoreticular hyperplasia. This case seems to prove that there is some evidence of sarcomatous change in reactive lymphoreticular hyperplasia.

Clinical evaluation of total-body hyperthermia combined with anticancer chemotherapy for far-advanced miscellaneous cancer in Japan

One hundred sixty-eight patients with miscellaneous far-advanced cancer received a total of 444 extracorporeally induced total-body hyperthermia (TBHT) treatments in seven Japanese hospitals. Overall, a regression of malignancy was observed in 39 of 132 evaluable patients (29.5%) and the most favorable results were obtained for patients with lung cancer. Irrespective of whether the tumors were primary or secondary lesions or recurrences, favorable results were obtained in patients whose tumors were in the lung, liver, lymph nodes, and soft tissue. No relationship was found between an objective response to TBHT and histologic types of the tumors. There was no clear relationship between an objective tumor response and the nature of the simultaneous chemotherapy during hyperthermia. Antitumor effects were not evaluable in 36 patients (21.4%). Of these 36 patients, 33 died before evaluation could be made; 24 died of various complications and 9 died of cachexia without complication. The mortality increased in proportion to the reduction of the performance status of patients before TBHT. These results indicate that TBHT should be used as therapy for patients whose tumors are in the lung, liver, lymph node, and soft tissue and then only on patients in generally good condition.

[Prognosis of gastric cancer patients with special reference to the area of serosal cancerous invasion]

The area of serosal cancerous invasion and intraperitoneal free cancer cells were examined in 360 gastric cancer cases. The positivity rate of intraperitoneal free cancer cells was 20% in the group with under 20 cm2 of serosal invasion, 59% with 20 cm2 to 30 cm2, and 76% over 30 cm. The postoperative survival rate was significantly lower in the group with free cancer cells than in the group without them. Prognosis was better in case with the area of serosal invasion was smaller. Hematogenous metastasis was frequent under 20 cm2, but over 20 cm2, peritoneal metastasis predominated.

Decreased interleukin 1 activity in culture supernatant of lipopolysaccharide stimulated monocytes from patients with liver cirrhosis and hepatocellular carcinoma

Immunoregulatory function of peripheral blood monocytes was studied in patients with hepatocellular carcinoma (HCC) and liver cirrhosis (LC), by assaying interleukin 1 (IL-1) and prostaglandin E2 (PGE2) in the culture supernatant of lipopolysaccharide-stimulated monocytes. IL-1 activity of the monocyte culture supernatant without indomethacin was decreased in patients with HCC and LC, compared with that of controls. The activity was lower in patients with HCC than that in those with LC. The PGE2 content of the culture supernatant of monocytes from patients with LC and HCC was increased, compared to normal controls. To avoid the effect of PGE2 on the IL-1 assay, we cultured the monocytes with addition of indomethacin and assayed IL-1 activity in the culture supernatant. As a result, monocyte IL-1 production was increased in patients with HCC and LC, compared with normal controls. The decrease in IL-1 activity of the supernatant without indomethacin of patients with LC and HCC was considered to be due to increased secretion of PGE2 by the monocytes. Therefore, monocytes from patients with HCC and LC had an increased capacity of secreting both IL-1 and PGE2 over normal controls, but the effect of the suppressor function (PGE2 secretion) dominated in these patients.

[Intrahepatic-artery infusion of cis-diamminedichloroplatinum (II) and 5-fluorouracil in primary or metastatic liver cancer]

Eight hepatocellular cancer patients and eighteen metastatic liver cancer patients were treated with intrahepato-arterial infusion of CDDP (cis-diamminedichloro-platinum II) plus 5-FU (5-fluorouracil); CDDP (0.8-1.0 mg/kg) was given once every 7 or 10-14 days, while 5-FU (250-100 mg/day) was infused daily. A partial response was obtained in 5 of 8 patients with primary liver cancer and in 9 of 14 evaluable patients with metastatic liver cancer. However, severe complications due to bone marrow suppression were observed in 4 patients, 3 of whom died of septicemia and one of enterocolitis. This combined intra-hepato-arterial chemotherapy exerts a synergistic anticancer effect on malignant liver tumors, although the bone marrow suppression associated with it remains to be overcome.

Experimental study of antitumor effect of methyl-B12

We examined the antitumor effect of vitamin B12 (methyl-B12) using C3H/He, C57BL/6 and BALB/C mice for animals and MH134 hepatoma ascites cells, Lewis lung cancer cells and Ehrlich ascites tumor cells for tumor cells. At 1.0-10 micrograms/ml, methyl-B12 enhanced PHA- and Con-A-induced lymphocyte blastoformation of C3H/He mice. The growth of MH134 tumors on the backs of C3H/He mice were suppressed by the 7-day administration of 50 or 100 micrograms/day i.p. and their survival was longer than that of untreated mice. However, methyl-B12 administration did not positively affect the survival of C3H/He mice that had been irradiated with 60Co 300 R on the day before tumor cell inoculation. The growth of Ehrlich ascites tumor cells inoculated into BALB/C mice was also reduced at 17 and 19 days after tumor inoculation by administration of methyl-B12 50 micrograms/day i.p. and the mice survived longer than the untreated mice.