Usefulness of endoscopic aspiration mucosectomy as compared with strip biopsy for the treatment of gastric mucosal cancer

BACKGROUND

Several techniques are available for the endoscopic treatment of gastric intramucosal cancers, but their advantages and disadvantages have not been adequately evaluated. We compared the therapeutic usefulness of endoscopic aspiration mucosectomy with that of strip biopsy.

METHODS

Between May 1995 and May 1997, we performed strip biopsy (May 1995 through February 1996) or endoscopic aspiration mucosectomy (March 1996 through May 1997) in a consecutive series of patients with intestinal-type intramucosal cancer. Parameters of assessment included the following: size of removed specimens, en bloc resection rate, time required for resection, duration of hospitalization, and complications.

RESULTS

Forty-nine patients with gastric intramucosal cancers underwent endoscopic aspiration mucosectomy and 44 underwent strip biopsy. The two groups were similar with respect to age, gender, and lesion macroscopic appearance, size, and site. The mean longest diameter of the resected specimens was significantly greater with endoscopic aspiration mucosectomy (20.3 +/- 3.4 mm) than with strip biopsy (15. 8 +/- 4.4 mm) (p < 0.001). The rate of en bloc resection (resection of an entire lesion in one procedure) was significantly higher with endoscopic aspiration mucosectomy (61.2%, 30 of 49) than with strip biopsy (36.4%, 16 of 44) (p < 0.05). The number of specimens obtained by piecemeal resection was slightly, but not significantly, higher with strip biopsy (2.4 +/- 1.7) than with endoscopic aspiration mucosectomy (2.0 +/- 1.7). The time required for treatment was similar for each procedure. The duration of hospitalization was significantly shorter with endoscopic aspiration mucosectomy (12.8 +/- 5.3 days) than with strip biopsy (15.9 +/- 74 days) (p < 0.05). As for complications, the rate of bleeding was 20. 5% (9 of 44) with strip biopsy and 10.2% (5 of 49) with endoscopic aspiration mucosectomy; bleeding was controlled in all cases by treatment with a heater probe.

CONCLUSIONS

Endoscopic resection of large gastric intramucosal tumors is easier with endoscopic aspiration mucosectomy compared with strip biopsy. Endoscopic aspiration mucosectomy is a useful procedure for en bloc resection.

The management of bleeding peptic ulcer in the elderly with heater probe thermocoagulation

BACKGROUND/AIMS

The aim of this study was to compare the clinical characteristics of bleeding peptic ulcers in the elderly with those in younger patients, retrospectively.

METHODOLOGY

Between 1986 and 1994, 274 patients with bleeding peptic ulcers were treated with heater probe endoscopically. They were divided into 2 groups: 48 in the elder group (70 years of age or older) and 226 in the younger group (<70). We evaluated the rate of concomitant disease, rebleeding rate, incidence of emergency surgery, mortality and blood transfusion requirement between the 2 groups.

RESULTS

The incidence of concomitant disease was significantly higher in the elderly group (83.3%) than in the younger group (33.3%) (p<0.01). The rate of rebleeding (younger group 23.5% vs. elderly group 31.3%), the incidence of emergency surgery (5.8% vs. 6.3%, respectively) and the rate of mortality due to hemorrhage (2.2% vs. 4.2%, respectively) were similar in the 2 groups. There was no significant difference in the mean volume of blood transfused.

CONCLUSIONS

It was revealed that aggressive endoscopic hemostasis improved the mortality rate and the incidence of emergency surgery in elderly patients as well as in younger patients, provided that their general condition was monitored carefully.

[Two regimens of combined 5'-deoxy-5-fluorouridine and cisplatin showing different dose intensities--investigation based on relative performances]

Patients with inoperable gastric cancer were given either of two regimens of combined 5'-deoxy-5-fluorouridine and cisplatin with different dose intensities. The results were compared based on ratios of the actual and the scheduled total doses of the regimens [relative performance (RP)]. The overall response rates and survival curves between the regimens showed no differences, but the incidences of severe adverse drug reactions was higher with regimen A, which had a higher dose intensity. Furthermore, survivals with regimen A were no different between the responding and non-responding patients, whereas the survivals of responding patients under regimen B were significantly longer than those of non-responding patients. Average RP were 0.87 with regimen A and 0.93 with regimen B. The mean RP of responding and non-responding patients were 0.94 and 0.84, respectively, with regimen A, and 0.99 and 0.89 with regimen B. Regarding survivals in both the RP = 1.0 and the RP < 1.0 groups, no difference was observed with regimen A. However, with regimen B, the RP = 1.0 group exhibited significantly better survival curves. Furthermore, survivals of the RP = 1.0 group under regimen B were much more favorable than in the RP = 1.0 group under regimen A. The above findings show that a regimen with an appropriate dose intensity has a favorable survival effect on patients.

Advantages of Japanese response criteria for estimating the survival of patients with primary gastric cancer

BACKGROUND: We conducted a retrospective study to investigate the adequacy of the Efficacy Criteria for Primary Lesions in the Japanese Classification of Gastric Cancer (Japanese criteria) for evaluating the anti-tumor efficacy of chemotherapies and the relationship between tumor regression and the prognosis of gastric cancer.METHODS: The data for 90 patients with inoperable ad-vanced gastric cancer who received various chemotherapies, consisting of fluorinated pyrimidines and cisplatin, were retrospectively analyzed. Based on the Japanese criteria, we investigated the efficacy of the chemotherapies and the relationship between the response in primary lesions and survival. We also compared the efficacy of chemotherapies evaluated by the Japanese criteria to that evaluated by the WHO criteria.RESULTS: All 90 patients were evaluable by the Japanese criteria. The overall response rate was 53.3% (Partial response [PR] in 48 patients and no change + progressive disease [NC + PD] in 42 patients). The primary lesions were classified as measurable (a-lesions) in 27 patients, evaluable but not measurable (b-lesions) in 31 patients, and diffusely infiltrating (c-lesions) in 32 patients. Overall median survival time (MST) was 9.4 months. The MSTs of the responders and non-responders were 12.6 and 7.8 months, respectively. In contrast, by the WHO criteria, 49 patients (54.4%) were evaluable; the other 41 patients had gastric primary lesions alone but were not measurable by WHO criteria. The overall response rate was 67.3% (33/49), and overall MST was 9.4 months. The MSTs of the responders evaluated by both sets of criteria were both 12.6 months.CONCLUSIONS: We suggest that the Japanese criteria are useful for evaluating the anti-tumor effect of gastric cancer chemotherapies and that prospective studies to reconfirm their usefulness are warranted in Japan, and in Western countries.

Pilot study of combined treatment with continuous infusion of 5-fluorouracil, mitomycin C, and cisplatin (FMP) in patients with inoperable advanced gastric cancer

We investigated combined chemotherapy with 5-fluorouracil (600 mg/m2/day, day 1-5, c.i.v.), mitomycin-C (6 mg/m2, day 6), and cisplatin (60 mg/m2, day 7) for inoperable advanced gastric cancer, including those with poor performance status (PS). Overall response rates were 62.5% (20/32), 59.1% (12/22) for PS 0-2 and 70.0% (7/10) for PS 3-4. Median survival was 7.2 months, 8.7 for PS 0-2; and 6.3 for PS 3-4. There was no serious toxicity or any treatment-related death. This therapy is useful, even for poor PS.

Prediction of response to 5'-deoxy-5-fluorouridine (5'-DFUR) in patients with inoperable advanced gastric cancer by immunostaining of thymidine phosphorylase/platelet-derived endothelial cell growth factor

BACKGROUND

No reliable method is available for predicting the response to chemotherapy in patients with gastric cancer. The anticancer drug 5'-deoxy-5-fluorouridine (5'-DFUR) is converted into 5-fluorouracil (5-FU) by thymidine phosphorylase (dThdPase). We studied the relation between the expression of dThdPase in tumor tissue and the response to treatment with 5'-DFUR to determine if this enzyme can be used to predict the response to chemotherapy.

METHODS AND MATERIALS

We performed endoscopic biopsy and studied the expression of dThdPase by immunostaining with anti-dThdPase monoclonal antibody in 41 patients with inoperable advanced gastric carcinomas before they received multiple-drug chemotherapy, including 5'-DFUR. The relation between the expression of dThdPase and the response to chemotherapy was studied. We also studied the characteristics of positive cells against anti-dThdPase monoclonal antibody.

RESULTS

The response rate among patients whose tumors were positive for dThdPase expression (56.8%, 21/37) was higher than that among patients whose tumors were negative for dThdPase expression (0%, 0/4; p = 0.048). Spindle-shaped cells darkly expressing dThdPase were sporadically seen surrounding cancer nests in some patients. Multiple-antibody immunostaining suggested that these spindle-shaped cells were perivascular mesenchymal cells. The response rate was 82.4% (14/17) among patients with spindle-shaped cells strongly positive for dThdPase, as compared with 29.2% (7/24) among those with spindle-shaped cells weakly positive or negative for dThdPase (p = 0.00131). The expression of spindle-shaped cells darkly stained with dThdPase was the factor most strongly related to the response to chemotherapy (odds ratio = 35.513, p = 0.0027).

CONCLUSIONS

The expression of dThdPase in stromal spindle-shaped cells may be a useful index in predicting the response to 5'-DFUR in patients with gastric cancer.

[Effects of Helicobacter pylori eradication therapy on the healing process of peptic ulcers]

The advent of H2-receptor antagonists (H2RA) and proton pump inhibitors (PPI) has particularly revolutionized the treatment of peptic ulcer disease. Most cases can now be successfully controlled by medical treatment with H2RA and PPI, but a high rate of ulcer recurrence remains an important problem. The quality of ulcer healing (QOUH) has therefore received increasing attention, and various investigators have attempted to define the conditions required for nonrecurrence. Ulcer scars with a good QOUH are considered to have a very low risk of recurrence. Recent studies have confirmed that recurrence of peptic ulcer can be suppressed markedly by eradication of Helicobacter pylori (H. p). Moreover, various types of endoscopic examinations (conventional observation, dye-contrast endoscopy, magnifying endoscopy, endoscopic ultrasonography, pharmacoendoscopy) have confirmed that the QOUH after eradication of H. p is better than that after conventional anti-ulcer therapy. H. p eradication therapy may become treatment of first choice for peptic ulcers.

A prospective randomized study of amoxycillin and omeprazole with and without metronidazole in the eradication treatment of Helicobacter pylori

A combination of amoxycillin and omeprazole is often used to treat Helicobacter pylori infection. A three-drug regimen comprising metronidazole, amoxycillin and omeprazole has been proposed as an alternative therapy. In a prospective, randomized, comparative study, we evaluated these two regimens with respect to safety and efficacy in patients with H. pylori infection. Sixty patients with peptic ulcer (gastric, 32 patients; duodenal, 28 patients) who had a history of ulcer recurrence were randomly assigned to dual therapy with amoxycillin (500 mg three times daily for 2 weeks) and omeprazole (20 mg once daily for 8 weeks) or to triple therapy with metronidazole (500 mg twice daily for 2 weeks) plus amoxycillin and omeprazole, given in the same dosages as dual therapy. Forty-eight patients completed the protocol; treatment was discontinued because of side effects in nine patients, and three patients dropped out of the study. On the basis of all patients treated, the rate of H. pylori eradication was significantly higher for triple therapy 20/23 cases, 87.0%; 95% confidence interval (CI), 0.664-0.972) than for dual therapy 13/25, 52.0%; 0.313-0.722; P < 0.05). On an intention-to-treat basis, the difference between the groups in the rate of H. pylori eradication was marginally significant (P = 0.06 [0.028-0.512]). Side effects were reported by five patients receiving triple therapy (skin rash, one; nausea, two; headache, one; abdominal pain, one), and four patients receiving dual therapy (skin rash, two; abdominal pain, one; diarrhoea, one). All side effects resolved spontaneously after termination of treatment. There was no significant difference in safety between the two regimens. Triple therapy with metronidazole, amoxycillin, and omeprazole was significantly more effective for the eradication of H. pylori than dual therapy with amoxycillin and omeprazole alone. The safety of these regimens was similar, and triple therapy was found to be clinically acceptable.

Enhanced cellular proliferation and p53 accumulation in gastric mucosa chronically infected with Helicobacter pylori

This study evaluated whether the increased risk of development of gastric carcinoma due to chronic Helicobacter pylori infection could be linked with elevated cell proliferative activity and expression of p53 and bcl-2. Forty-eight patients undergoing therapy for H pylori-positive gastroduodenal ulcers were separated into not eradicated (NE; n = 23) and eradicated (E; n = 25) groups 6 months after the treatment. Serum pepsinogen (PG) I:II ratios and histologic changes in the gastric corpus and the antrum, assessed according to the modified Sydney System, as well as epithelial cell proliferation (mitosis, Ki67, and proliferating cell nuclear antigen [PCNA]), and expression of oncoproteins (p53 and bcl-2) were examined before and at 3 months and 6 months after treatment for H pylori. Chronic persistent H pylori infection was associated with a low PG I:II ratio, increased inflammation and activity score, and elevated cell proliferation, as evidenced by the Ki67 and PCNA labeling indexes and the mitotic index in the NE group. Scattered accumulation of p53 protein continued to be observed in the NE group after treatment but was significantly decreased in the E group. We conclude that persistent H pylori infection causes gastritis, with epithelial degeneration and regeneration that result in accentuation of epithelial cell proliferation and accumulation of p53 protein, presumably heightening the genetic instability consistent with the development of carcinoma.

Ludloff's medial approach for open reduction of congenital dislocation of the hip. A 20-year follow-up

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff's medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff's medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

LUDLOFF’S MEDIAL APPROACH FOR OPEN REDUCTION OF CONGENITAL DISLOCATION OF THE HIP

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff’s medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi.

At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented.

We conclude that Ludloff’s medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

[A comparative study of the effect of granisetron and a combination of granisetron plus steroids on cancer chemotherapy induced emesis]

Effects of 40 micrograms/kg of granisetron monotherapy (K group) and concurrent therapy with a steroid (KS group) on acute and delayed emesis induced by cancer chemotherapy which included CDDP at a dose of 60 mg/m2 or more were compared in random clinical trials under the central registration method. In KS group, either 500 mg of methylprednisolone succinate or 8 mg of dexamethasone phosphate was given prior to granisetron administration. Clinical symptoms such as vomiting, nausea and anorexia were better in KS group than in K group, on any day from day 1 to day 7, and there was a statistically significant difference on day 1 and day 2. The cumulative total control rate throughout the period of seven days was also significantly higher in KS group. KS group was rated higher in the final clinical evaluation based on doctor's impressions, but there was no significant difference between the two groups. Augmented antiemetic effect of granisetron by concurrent therapy with a steroid was most notably demonstrated in male patients under 60 years of age. The antiemetic effect at the acute stage was proven to influence the final clinical effectiveness, thus suggesting the importance of antiemetic therapy of acute emesis. Adverse reactions were seen in two out of 122 patients (1.6%). They were slight headache and moderate diarrhea in 1 case each, both of which disappeared soon, confirming the high safety profile of granisetron.

[Combination chemotherapy with tegafur-uracil (UFT) and cisplatin (CDDP) for advanced gastric cancer. UFTP Study Group]

An early phase II study of tegafur-uracil (UFT) combined with cisplatin (CDDP) was conducted in patients with advanced gastric cancer. UFT was administered orally for 28 consecutive days at a dose of 400 mg/m2 and CDDP was injected intravenously for 3 day at a dose of 30 mg/m2 over 8 hours every 4 weeks. This treatment cycle was repeated every 4 weeks. Sixteen patients were enrolled in this study and 14 patients could be evaluated for clinical response and toxicity. Based on the results of extramural review, 6 of 14 patients achieved a partial response and the response rate was 42.9%. High grade toxicities (WHO grade 3 or 4), specifically anorexia, nausea and vomiting, diarrhea, and leukocytopenia, were seen in 5, 2, 3 and 2 patients, respectively. The overall median survival time was 347 days (11.4 months) for evaluated patients. Although these results are preliminary, this regimen does appear to be effective in terms of tumor response and survival. Larger patient numbers in a Phase II study and further studies to evaluate survival are awaited.

The use of a hydroxyapatite block for innominate osteotomy

We used hydroxyapatite blocks to keep open Salter innominate osteotomies in 19 children (21 hips), avoiding the need for an autograft taken from the anterior superior iliac spine. Our results were satisfactory, with less deformation of the iliac bone, and a reduction of both blood loss and operating time.

The use of a hydroxyapatite block for innominate osteotomy

We used hydroxyapatite blocks to keep open Salter innominate osteotomies in 19 children (21 hips), avoiding the need for an autograft taken from the anterior superior iliac spine. Our results were satisfactory, with less deformation of the iliac bone, and a reduction of both blood loss and operating time.

A phase II study of combination therapy with 5'-deoxy-5-fluorouridine and cisplatin in the treatment of advanced gastric cancer with primary foci

BACKGROUND

5'-Deoxy-5-fluorouridine (5'-DFUR, doxifluridine) is a recently developed prodrug of oral 5-fluorouracil (5-FU), which is used clinically in Japan for the treatment of gastric, colorectal, and breast cancer. 5-FU has been reported to act synergistically with cisplatin (CDDP) in experimental and clinical studies. The authors conducted a multicenter Phase II study of combination therapy with 5'-DFUR and CDDP to evaluate the therapeutic usefulness of this regimen in the treatment of unresectable and advanced gastric cancers with primary foci. None of the patients had previously undergone chemotherapy. Their ages ranged from 27 to 75 years and performance status was grade 0 to 3.

METHODS

5'-DFUR (1400 mg/m2/d) was administered orally on days 1 through 4 and 15 through 18, and CDDP (80 mg/m2/d) was injected intravenously on day 5. This treatment cycle was repeated every 4 weeks. An independent panel of specialists evaluated the clinical response.

RESULTS

Fifty-one patients were studied. Clinical evaluation of response was possible in 43 patients who met the protocol requirements. The overall response rate was 50.0% (14 of 28, 95% confidence limits, 30.7%-69.4%) for patients with measurable lesions. The median duration of response was 5.2 months (156 days). The overall median survival time was 8.9 months (268 days) for evaluated patients. Therapeutic toxicity of World Health Organization (WHO) grade > or = 3 was manifested as anorexia and nausea or vomiting in 20.9% and 18.6% of the patients, respectively. However myelotoxicity and nephrotoxicity of WHO grades 3 and 4 occurred in less than 10% of the patient group. No drug-related mortality occurred.

CONCLUSIONS

Combined therapy with 5'-DFUR and CDDP is a safe and effective treatment regimen for advanced gastric cancers with primary foci which stresses the patient's quality of life, especially when used in an outpatient setting.

[UFTPM (UFT + CDDP + MMC) therapy for progressive stomach cancer. Research Association of Progressive Stomach Cancer]

We organized a cooperative research group consisting of 10 institutions and UFTPM therapy was given patients with unresectable and postoperatively relapsed stomach cancer. As the result, 20 cases were registered and the ratio of PR according to the criteria of stomach cancer chemotherapy was 4 out of 17 complete cases (23.5%), excluding 3 incomplete cases. The efficacy for the cases treated with more than 2 courses was 36.4% (4/11) and that for cases with 3 courses was 75% (3/4). One case with 3 courses was resectable and the cancer cells disappeared. Adverse effects of grade 3 or more according to the WHO criteria were observed in 20% of the cases.

An immunohistochemical study of c-erbB-2 protein in gastric carcinomas and lymph-node metastases: is the c-erbB-2 protein really a prognostic indicator?

An immunohistochemical study of the c-erbB-2 protein was conducted on formalin-fixed paraffin-embedded tissue sections from 136 primary gastric carcinomas and 50 metastatic lymph-node tumors obtained at gastrectomy. Expression of the protein was detected in 35 of 136 primary gastric carcinomas (25.7%) and 22 of 50 metastatic lymph nodes (44%). The staining pattern of tumor cells was classified as membranous or cytoplasmic. An immunohistochemical study using serially diluted antibody demonstrated that 82.6% of positive cases in metastatic lymph nodes showed c-erbB-2 immunoreactivity stronger than that in the primary tumors. Membranous staining was stronger than cytoplasmic staining. c-erbB-2 protein of the cytoplasmic as well as membranous types was confirmed to be a 185-kDa whole molecule by immunoblotting. Correlation between the expression of c-erbB-2 protein and clinical and histological parameters was investigated. No significant correlation between 5-year survival rate of patients and expression of c-erbB-2 protein was found. In the poorly differentiated carcinoma group possessing c-erbB-2 protein, overall survival was significantly shorter than in cases without protein expression (p < 0.01). We conclude that c-erbB-2 protein is not a useful prognostic indicator in gastric carcinomas.

Experimental and clinical studies on heater probe hemostasis for upper gastrointestinal bleeding with special reference to comparison with ethanol injection

The hemostatic effects in patients with upper gastrointestinal bleeding was evaluated using an endoscopic heater probe method and ethanol injection method. The heater probe method was effective in 94.4% of patients with few complications. The ethanol injection method was effective in 86.5% of patients. The heater probe method is considered to be an effective and safe technique in the treatment of upper gastrointestinal bleeding.

[Clinico-pathological study of autopsy cases of nonresected gastric cancer in the young and old]

To elucidate the difference between the natural history of gastric cancer in young and old patients, this study was carried out. Fifty-four cases were studied, representing the autopsy findings of gastric cancer patients who did not undergo operation. The characteristics of the gastric cancer in the young patients were as follows: had infiltrative macroscopical types, had histologically diffuse types, had deeper and wider infiltration, showed a severer invasion into the vessels, and, showed marked lymphatic disseminated, and distant metastasis. The elderly, in comparison, showed various types of gastric cancers. The extension of the cancer in the old group was significantly, less than in the young, even in the same diffuse type. The period from the onset to death was almost same in both groups. The age of the host seems one of the important factors influencing the natural history of gastric cancer.