[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.

[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.

[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.

[Cell cycle analysis of endometrial cancer cells in vitro treated with growth factor and steroid hormone]

The aim of this study was to overtake the mechanism of the control system in endometrial cancer cell line in vitro. Ishikawa cell (IK cell) and HEC-1 cell (HEC cell) derived from endometrial cancers were cultured with serum free medium (SFM-101). IK cell possessed Estrogen receptor (ER), Progesterone receptor (PR), Epidermal growth factor (EGF) and its receptor (EGFR). HEC cell had PR, EGF, and EGFR, however HEC cell did not keep ER. EGF stimulated the growth of IK cell, but the growth of HEC cell was not stimulated by EGF. S phase cells were increased by EGF in IK cell, but were not increased by EGF in HEC cell. The growth of IK cell was stimulated significantly by EGF and Estradiol-17 beta (E2) +EGF than control. However, E2+EGF did not stimulate the growth of IK cell than EGF significantly. Danazol (D) and D+EGF inhibited the growth of IK cell significantly than control. S phase cells were decreased by the treatment of D and D+EGF. From our results, EGF stimulated the growth of ER positive endometrial cancer cell, but EGF did not stimulate ER negative endometrial cancer cell. E2+EGF and EGF stimulated the growth of IK cell as a same. However, D inhibited the growth of IK cell that was stimulated by EGF.

[In vitro chemosensitivity test using collagen gel matrix for human gastric carcinomas]

The usefulness of an in vitro human tumor culture system using a specialized collagen gel matrix derived from pig skin was retrospectively evaluated as a chemosensitivity test for human gastric carcinomas. Seven xenograft tumors derived from human gastric cancers were examined by this system (CGM assay) and compared with the data obtained by a nude mice assay (NM assay) and a succinic dehydrogenase inhibition test (SDI test). Xenograft tumors had three-dimensional growth on the collagen gel matrix like that in vivo. There was increasing cell kill with rising cytotoxic drug concentration. When drug sensitivity was evaluated as effective based on an inhibition rate of 40% or more in the CGM assay, drug sensitivity as measured by the CGM assay corresponded with that measured by the NM assay for all xenograft tumors but not the SDI test. This system could be applied for chemosensitivity test of scirrhous gastric carcinomas. It was suggested that the CGM assay may be more like an in vivo like chemosensitivity test and clinically useful testing for the patients with gastric cancer, including scirrhous one.

Antigenic analysis of recent H1N1 influenza viruses with monoclonal antibodies

Antigenic analysis of recently isolated H1 influenza viruses was performed using haemagglutination inhibition (HI) assay with monoclonal antibodies to the haemagglutinin (HA) subunit. Tests using monoclonal antibodies against the HA of the A/England/333/80 (H1N1) and A/Yamagata/120/86 (H1N1) viruses revealed that the major antigenic drift occurred in 1985 or 1986 and A/Dunedin/6/83-like virus became a major strain after 1986.

Epitope changes on the haemagglutinin molecule of recently isolated H1N1 influenza viruses

We have studied changes of epitopes on the haemagglutinin molecule (HA) of H1N1 influenza viruses isolated between 1977 and 1986. For this purpose monoclonal antibodies (MAbs) were raised against the HA of the influenza A/England/333/80 and A/Yamagata/120/86 strain viruses. In order to define the amino acid residues responsible for the change of epitopes, we prepared several HA cDNAs modified by site-directed mutagenesis and cloned them into a simian virus 40 expression vector (SVHA). The substitution of glycine with serine at position 125c (suffix indicates presence in H1 but not in H3 subtype HAs) on the HA of the influenza A/USSR/90/77 strain virus resulted in the loss of epitope 110 (epitopes were named after MAbs) and created new epitopes 139 and 15, which were observed on the HA of A/England/333/80 and a few isolates from 1983. These new epitopes disappeared from the HA in some of the isolates in 1983 and most of the isolates in 1984 and 1986. The disappearance of epitopes 139 and 15 seems to be associated with the loss of epitope W18, which was identified on the HA of A/USSR/90/77. We suggested previously that amino acid residue 189 was involved in epitope W18. We therefore expressed an HA protein with two amino acid substitutions at positions 189 and 125c and found that the conversion of glutamine to lysine at position 189 in SVHA-67 prevented the expression of epitopes 139 and 15.

[Effect of UFT on nuclear DNA distribution of gastric and colorectal carcinomas]

To evaluate the effect of UFT on nuclear DNA distribution of carcinoma, we measured the DNA content of biopsy specimens and resected specimens obtained from 18 patients by microfluorometry. The tumors consisted of 7 gastric and 11 colorectal carcinomas. Five patients who received administration of 400mg of UFT (400mg of tegafur) were classified as the chemotherapy group and another 13 patients were classified as the control group. 1) DNA indices of biopsy specimens and resected specimens of the same patients showed almost the same values both in the control group (r = 0.81) and in the chemotherapy group (r = 0.89) (p less than 0.05). 2) S and S + G2M fractions of resected specimens showed almost the same values as compared with those of corresponding biopsy specimen in the control group. However, in the chemotherapy group S and S + G2M fractions of resected specimens showed a tendency to be higher than those of corresponding biopsy specimen (0.05 less than p less than 0.1). This study indicates that the biopsy specimens are sufficient for DNA analysis and that UFT-induced DNA change may be increase of S and S + G2M fraction.

[A clinicopathological studies on gastrointestinal leiomyosarcomas, with special reference to prognosis]

Twenty-five cases of gastrointestinal leiomyosarcomas were subjected to clinico-pathological studies in an attempt to correlate the prognosis with tumor size, mitosis, cellularity and DNA ploidy pattern. Leiomyosarcomas greater than 5cm in diameter had poorer prognosis. Those with mitotic index larger than 3.0/mm2, cellularity larger than 3.0/0.0004mm2, DNA aneuploidy had poorer prognosis. By multiple regression analysis, mitotic index was useful for the prediction of tumor recurrence in earlier postoperative period, but cellularity, tumor size were useful for the prediction of recurrence in later postoperative period. As for the type of tumor recurrence, hematogenous metastasis was observed in 7 cases, peritoneal dissemination in 2 and local recurrence in 4. Four cases with local recurrence had all hematogenous metastasis. Two cases of gastric leiomyosarcomas developing local recurrence were greater than 10cm in diameter and gastric local resection was done for them. One case was diagnosed benign leiomyoma in the rectum histologically, but after trans-anal tumor resection local recurrence and metastasis to the lung occurred. We must pay attention to the surgical margin and the surface of tumor dissection during of the tumor, especially in larger tumors. Aggressive surgical resection is efficient for the treatment of recurrent tumors.

Human chorionic gonadotropin in gastric carcinoma. A useful marker for bone metastasis

Twenty patients with bone metastases from gastric carcinoma resected during the 13 years from 1974 through 1987 were investigated in relation to the serum and tissue carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG). The incidence of bone metastases was 2.1% (20/933). The serum AFP, CEA and hCG positive rates were found to be 14.3, 42.9 and 69.2% for patients with bone metastases and 18.3, 19.4 and 14.1% for those without bone metastases, respectively. In addition, the tissue AFP, CEA and hCG positive rates were 11.1, 100 and 77.8% for such patients with bone metastases, and 8.0, 80.8 and 21.1% for those without bone metastases. Only the serum and tissue hCG positive rate was significantly higher for the patients with bone metastases than those without bone metastases. The bone metastatic lesions were investigated for tissue hCG in four cases, and found to be positive in all the four bone lesions. In four of the patients with metachronous bone metastases, serum hCG levels were elevated before or at the time when bone metastases were diagnosed. Furthermore, serum hCG levels fell in response to chemotherapy or tumor resection. On the contrary, the serum AFP or CEA levels did not correlate with the clinical course in patients with bone metastases. These results indicate that the measurement of the tissue and serum hCG in patients with gastric carcinomas could be of extreme value in the search for bone metastases and the serum hCG level could be a useful marker for the prediction of bone metastases in gastric carcinoma.