Significant prognostic factors in patients with node-negative gastric cancer

BACKGROUND

We evaluated the influence of several clinicopathological variables on 5 year survival of patients with node-negative gastric cancer.

PATIENTS AND METHODS

Clinical characteristics were retrieved from the records of all patients who underwent gastric resection between 1985 and 1995 at the Department of General Surgery, Sendai National Hospital, and follow-up data were obtained from our tumor registry. Pathological characteristics were determined from a detailed review of all available histopathological slides. The results of a retrospective analysis of clinicopathological data of 339 patients having no lymph node metastasis were compared with those of 358 patients with lymph node metastasis. Univariate and multivariate analyses of patients with node-negative gastric cancer were performed to evaluate the prognostic significance of clinicopathological features (age, gender, gross type, histological type, depth of invasion and location).

RESULTS

The 5 year survival rate for patients with node-negative gastric cancer was 92.5%. Node-negative gastric cancers were characterized by a smaller tumor, expansive and medullary histological type, and less frequency of lymphatic invasion and vascular permeation. In multivariate analysis, the statistical significant prognostic factors were tumor size (P = 0.0185), vascular permeation (P = 0.0011) and cancer-stromal relationship (P = 0.0291).

CONCLUSION

Tumor size, vascular microinvasion and cancer-stromal relationship are the most reliable predictors of 5 year survival for patients with node-negative gastric cancer.

c-erbB-2, p53 protein expression and steroid hormone receptors in breast carcinomas: an immunohistochemical study

p53, c-erbB-2 protein, steroid hormone receptors, and their correlation with clinicopathologic features were investigated in 70 primary breast carcinomas. All markers were measured immunohistochemically on paraffin sections. Altered p53 expression was found in 27.1% of cases and was associated with negative estrogen receptor status. p53 immunostaining was correlated weakly with histologically lymphatic vessel invasion of carcinoma. c-erbB-2 protein overexpression was seen in 48.6% of cases. A trend was observed in the correlation between c-erbB-2 immunostaining and regional lymph node metastases. Estrogen receptor status was not associated with any histologic or clinical parameters, whereas progesterone receptor status was associated with lymph node metastasis and histologically lymphatic vessel invasion of cancer. PgR status, p53 and c-erbB-2 immunostaining may prove to be an additional criterion in histologic diagnosis of breast cancer.

Emergency abdominal surgery for small bowel perforation secondary to metastatic lung cancer

Emergency surgery for bowel perforation caused by metastases from lung cancer is rare. Two cases of small bowel perforation due to metastasizing lung cancer are reported. Both patients were admitted as a surgical emergency case. One of the two patients presented herein survived and was discharged from the hospital. Perforated small bowel due to metastatic lung cancer is a highly fatal event that occurs in the late phases of the disease. Despite the poor prognosis, early and appropriate therapy will occasionally yield successful surgical palliation. Patients with known lung cancer who develop abdominal complaints should be examined thoroughly and treated quickly.

[Mitral valve replacement under cardiopulmonary bypass which complicated by multiple sclerosis: a case report]

The 60-year-old women who complicated by multiple sclerosis was referred to our hospital under diagnosis of mitral valve stenosis and tricuspid valve regurgitation. The mitral valve replacement and the tricuspid valve annuloplasty were performed under cardiopulmonary bypass. In the state of multiple sclerosis, even an operation by general anesthesia could become a cause of abrupt change, but by appropriate management during and after surgery, the post operative course was uneventful without any complications, and the patient discharged on the 35th post operative day.

Early gastric cancer in the young: clinicopathological study

BACKGROUND

Thirty-four cases of early gastric carcinoma in patients under 50 years of age treated in the period from 1985 to 1995 were reviewed.

METHODS

These constituted 3.7% of 923 cases of gastric cancer in patients of all ages that were treated at Sendai National Hospital during the same 10-year period. Data were compared with those of 194 patients 50 years of age or older.

RESULTS

The incidence of gastric cancer in men and women was almost the same in both groups. Tumours tended to be located distally in the stomach. Macroscopically, depressed lesions were more common in younger patients. Significant differences were observed in depth of invasion, histological type and histological growth patterns.

CONCLUSIONS

The distinctive histological features of early gastric cancer in younger patients were a diffuse type of cancer with infiltrative tumours in the mucosal layer. The prognosis of younger patients was similar to that of older patients.

[A case of unresectable pancreatic cancer responding to MTX/5-FU sequential therapy]

A 66-year-old woman was admitted to our hospital complaining of abdominal pain and jaundice. Upper gastrointestinal series and computed tomography revealed pancreatic cancer. Pancreatectomy could not be performed because of portal invasion and multiple liver metastasis. Cholecystectomy, choledochojejunostomy and gastrojejunostomy were performed. The patient was treated with methotrexate (MTX) 100 mg/m2 i.v. followed one hour later with 5-fluorouracil (5-FU) 700 mg/m2. Leucovorin rescue of 10 mg po was given 24 hours after MTX administration. Treatment was repeated every 14 days. As a result, the size of a primary tumor of the pancreas was reduced (42%) on computed tomography, and the CEA level decreased to 27.8 ng/ml from 84 ng/ml. No side effects were observed. The patient continued to receive chemotherapy at our outpatient clinic for 20 months. She died of exacerbation of carcinomatous peritonitis 23 months after initial admission. Therefore, we conclude that MTX/5-FU sequential therapy seems beneficial to manage advanced pancreatic carcinoma from the viewpoint of antineoplastic activity as well as quality of life.

Gastric cancer with invasion limited to the muscularis propria

The clinicopathological features of 84 muscularis propria (mp) gastric cancers, defined as gastric cancer invading the muscularis propria of the stomach, were reviewed retrospectively, and compared with 267 early gastric cancers (m/sm cancer) and 333 gastric cancers invading beyond the subserosal layer (ss-si cancer). There were statistical differences in tumor size, histological growth pattern, cancer-stromal relationship, lymph node metastasis, lymphatic invasion, vascular permeation and operative procedure between mp gastric cancer and early gastric cancer or ss-si gastric cancer. The mp tumors were significantly larger than the early cancer tumors but significantly smaller than the ss-si tumors (P < 0.0001), and mp cancer had more frequent lymph node metastasis (50%) than did early gastric cancer (10%) but less frequent lymph node metastasis than did ss-si cancer (84%; P < 0.0001). Histologically, infiltrative and scirrhous types were more common in the mp cancer group than in the early cancer group. The frequency of vascular permeation in the mp cancer group was almost the same as that in the early cancer group. Univariate analysis revealed that the significant prognostic factors were nodal involvement (P = 0.0213) and lymphatic invasion (P = 0.0364). Multivariate analysis of the mp-invaded cancer cases, however, revealed that lymph node metastasis was not a significant prognostic factor, although it was more important than was lymphatic invasion. Multivariate analysis also revealed that the prognosis of our mp gastric cancer patients was affected most by vascular permeation, followed by tumor size.

Clinicopathologic prognostic features in patients with gastric cancer associated with esophageal or duodenal invasion

BACKGROUND

We evaluated the influence of several clinicopathologic variables on 5-year survival of patients with gastric cancer associated with esophageal or duodenal invasion, and determined the significance of resection line involvement.

PATIENTS AND METHODS

A review of the database for gastric adenocarcinoma at Sendai National Hospital between January 1985 and December 1995 identified 923 patients who underwent gastric cancer resection. Of these patients, 37 were reported to have tumour infiltration of the esophagus or duodenum on histological examination of the resected specimens. Univariate and multivariate analyses of patients with esophageal or duodenal invasion were performed to evaluate the prognostic significance of clinicopathologic features. Then the patients were divided into two groups based on the results of microscopic examination: a tumour wedge-positive group for resection margins of less than 5 mm in width and a tumour wedge-negative group for resection margins of more than 5 mm in width. There were 8 patients in the narrow (margin-positive) group and 29 patients in the wide margin (margin-negative) group, respectively.

RESULTS

Univariate analysis revealed that the significant prognostic factors were nodal involvement (p=0.0004) and gross type (p=0.0031). Multivariate analysis of the esophagus or duodenum-invaded cancer cases, however, revealed that only nodal involvement was a significant prognostic factor. There were statistical correlations between these groups (margin-positive and margin-negative groups) and the Borrmann type of tumour and tumour size. The survival rate was worse in patients with tumour line involvement.

CONCLUSIONS

Multivariate analysis revealed that the prognosis of patients with esophageal or duodenal invasion was affected only by nodal involvement independently. The risk of surgical margin involvement was high in cases of a large Borrmann type-4 tumour and infiltrative carcinoma.

Poorly differentiated, solid-type adenocarcinoma of the stomach

Data of 58 cases of poorly differentiated, solid-type adenocarcinoma of the stomach treated at our hospital between 1985 and 1995 were reviewed and compared to data of 146 cases of non-solid-type carcinoma in order to determine whether there are distinguishable clinicopathological features between these two types of carcinoma. Significant differences were observed with respect to tumor size, stage, macroscopic appearance, depth of invasion, histologic growth pattern, lymph node metastasis, microscopical lymphatic invasion and vascular permeation. Patients in the solid-type cancer group tended to have smaller tumors; the disease was in the early stage in 48% of the patients, and total gastrectomy was performed in only 20 of the 58 patients. Nodal involvement, lymphatic invasion and vascular permeation were also less common in patients with solid-type cancer. The overall survival rate of patients with solid-type carcinoma was higher than that of patients with non-solid-type carcinoma, though no significant differences were observed when corrected for stage. Our results suggest that poorly differentiated solid-type carcinoma of the stomach should be regarded as a distinct type of adenocarcinoma that has a good prognosis. The significant prognostic factors for this type of gastric cancer are lymphatic invasion and tumor location.

Malignant fibrous histiocytoma: a method to control intraoperative hemorrhage by clamping the feeding arteries

Malignant fibrous histiocytoma (MFH), also referred to in the past as malignant fibrous xanthoma and fibroxanthosarcoma, is a tumor of mesenchymal tissue origin. A case of retroperitoneal MFH was reported. In this paper, we describe a method of hemostasis and intraoperative control of hemorrhage during resection of retroperitoneal MFH by snaring the feeding arteries. The patient was successfully operated on using this technique.

Signet ring cell carcinoma of the stomach: a clinicopathological comparison with the other histological types

A retrospective analysis was carried out on 93 patients with signet ring cell carcinoma of the stomach operated on between 1985 and 1995, to review the clinicopathologic characteristics from the database of gastric cancer at Sendai National Hospital. The results were compared with those for 590 patients with other types of gastric carcinoma. Women were afflicted as commonly as men in the signet ring cell carcinoma group. These patients tended to be younger and to have larger tumors. The histological type was commonly scirrhous and infiltrative. The survival of patients with signet ring cell carcinoma was worse than that of patients with other types of gastric cancer but the difference was not statistically significant. Patients with early signet ring cell carcinoma had a good prognosis, similar to that of the other groups. However, prognosis of patients with advanced signet ring cell carcinoma was poor compared with patients with other types of this disease. In multivariate analysis, the statistical significant prognostic factors were vascular microinvasion and tumor location. These findings suggest that signet ring cell carcinoma of the stomach should be regarded as a distinct type of gastric cancer.

Lymph node metastasis in early gastric cancer: how can surgeons perform limited surgery?

BACKGROUND

In Japan, the standard treatment policy for all potentially curable patients with gastric cancer is radical resection, including extensive lymph node dissection. The extent of lymph node dissection remains a controversial issue in the management of early gastric cancer. A recent trend in the surgical treatment of early gastric carcinoma has been to limit surgery such that a complete cure is achieved and the patient's quality of life is improved. However, approximately 10% of early gastric cancers are reported to be node positive and little is known about the protocol of surgical treatment most appropriate for the treatment of early gastric cancer. In this study, we examined the clinicopathological features that could distinguish node-positive cancer from node-negative cancer.

PATIENTS AND METHODS

The clinicopathological features of 26 patients with node-positive early gastric cancer were reviewed from the database of gastric cancer at the Department of Surgery, Sendai National Hospital. They were compared with those of 239 patients with node-negative cancer.

RESULTS

Tumor size, macroscopic appearance, depth of cancer invasion, histological growth pattern and lymphatic invasion were associated with lymph node metastasis. Node-positive patients with early gastric cancer had a poorer survival rate than node-negative patients (P<0.05).

CONCLUSION

Limited surgery, such as local resection without lymphadenectomy, can be performed for elevated or flat type cancer, or tumor <2 cm in diameter. Lymphadenectomy is recommended to achieve higher possible cure rates for other early gastric cancers.

[Prospective controlled study on the usefulness of Carmofur as a postoperative adjuvant chemotherapy for colorectal cancer]

A prospective controlled study, the 7th cooperative study of the Japanese Foundation for Multidisciplinary Treatment, was conducted to evaluate the usefulness of concomitant therapy with MMC + HCFU as a postoperative adjuvant therapy in patients with colorectal cancer who had undergone curative resection for a period of 2 years and 11 months from February, 1986. The Dukes B and C patients with colorectal cancer classified by macroscopic examination who had an intravenous MMC 6 mg/m2 on the day of operation and followed by oral HCFU for 12 months from 2 weeks after operation (Group X) were compared with patients who had operation only (Group Y). Some 978 patients with colon cancer and 713 patients with rectal cancer were enrolled in the study, 85 (5.0%) of whom were not eligible. The 5-year survival rate of Group X in colon cancer was 79.3% and that of Group Y was 76.4%: thus the survival rate of Group X was slightly better than that of Group Y, but no significant difference was found between the two groups. Subset analysis revealed that the survival rate of Group X in advanced cancer of stage III b + IV, according to the General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus in Japan, was 62.4% and that of Group Y was 46.2%. Thus, the survival rate of Group X was significantly better than that of Group Y (logrank test: p = 0.035, generalized Wilcoxon test: p = 0.025). The disease-free survival rate was not significantly different between the groups with colon cancer and rectal cancer. The above results suggest that HCFU is useful for patients with a high risk of recurrence who had advanced colon cancer (stage III b + IV). However, additional prospective studies are required to verify them.

[Combination use of second generation cephem and isepamicin for the treatment of post-surgical infection of the lower digestive tract]

Effects of combination use of a second generation cephem and an aminoglycoside antibiotic isepamicin (ISP), for the treatment of post-surgical infections of the lower digestive tract were examined from a laboratory and clinical perspective. Thirty-three out of total 35 cases were included in the analysis of the test, while the other 2 cases did not meet the criteria for analysis. ISP was administered in combination with one of the second generation cephems among cefotiam (CTM), cefmetazole (CMZ), or cefuroxime (CXM) for 26 cases of wound infection and 7 cases of peritonitis. The overall efficacy rate was 88%; 92% in wound infection and 71% in peritonitis individually. There was no significant difference in efficacy among different groups. Bacteriological study showed the combination use of any one of the second generation cephems and ISP was very effective in all 14 cases of infections with a single species of bacterium, the efficacy rate was 100%. It was also effective in 9 out of 10 cases with mixed infections of 2 species of bacteria (90%), but effectiveness was diminished in only 6 out of 9 cases with mixed infections of 3 species (67%). Sixty-nine strains were isolated from the 35 cases, more than half of which (44 strains) were Gram-negative; 14 strains of E. coli (20%), 13 strains of E. faecalis (13%) and 6 strains of P. aeruginosa (9%). The MIC50 and MIC90 were, respectively, 1.56 micrograms/ml and 100 micrograms/ml for ISP, 6.25 micrograms/ml and 100 micrograms/ml for CTM, 12.5 micrograms/ml and 100 micrograms/ml for CMZ, and 25 micrograms/ml and 100 micrograms/ml for CXM. The MICs in any combination uses decreased synergistically according to ISP concentration. Adverse events were observed in 3 out of 35 cases, but they were not severe. The results indicated that the combination use of a second generation cephem and ISP was useful and should be one of the choices for the treatment of post-operative infections of the lower digestive tract.

[A case of advanced gastric cancer with carcinomatosa peritonitis effectively treated by 5-FU and low-dose CDDP therapy]

A 66-year-old woman was admitted to our clinic for appetite loss and abdominal distension in August 1995. Endoscopic study revealed an advanced gastric cancer in the upper body of her stomach. Abdominal CT study revealed massive ascites and para-aortic lymph nodal involvement. Cytological study of the ascites revealed class V. She was diagnosed to be in the terminal stage of gastric cancer with carcinomatosa peritonitis. Combination chemotherapy with 5-fluorouracil (5-FU) and low-dose cisplatin (CDDP) was given by continuous intravenous injection of 5-FU 500 mg/day, and intermittent intravenous injection of CDDP 30 mg/week was performed for reduction of the ascites and her complaint. Endoscopic study 6 weeks after starting chemotherapy could not find crater of the gastric cancer but only a shallow ulcerative lesion. The biopsy specimen of that lesion was group III. No ascites and over 50% reduction of the para-aortic lymph node were found by the abdominal CT study. This state persisted over 4 weeks. No myelo-suppression, renal dysfunction or any severe side effect were observed during chemotherapy. Her performance status improved from 3 to 1.

[Aortic valve replacement with the Toronto stentless porcine valve in a patient with clipping for cerebral arterial aneurysm]

A 48-year-old man, who had a cerebral arterial aneurysm, was admitted in our institution for operation of aortic valve stenosis. At first, he underwent clipping for cerebral arterial aneurysm under precise management of his hemodynamic condition. After the clipping operation, we performed aortic valve replacement with the Toronto stentless porcine valve because no anticoagulant therapy was ideal for patient with cerebrovascular disease and larger effective orifice area was preferable for stenotic aortic annulus. By means of echocardiography, mean pressure gradient of the aoric valve decreased from 42 mmHg to 22 mmHg after the valve operation. He was discharged from the hospital on the 23rd postoperative day, and he has been doing well without thromboembolic events and bleeding complications for five postoperative months. This experience suggest that the Toronto stentless porcine valve might be one of the valve of choice for patients with aortic valve disease and cerebrovascular disease.

[Aortic valve replacement due to Libman-Sacks endocarditis combined with infectious endocarditis]

A 40-year-old female had a history of fever, arthralgia, proteinuria, and dyspnea on effort twenty years ago, and was diagnosed as SLE, renal failure, and aortic regurgitation. She also suffered from pyelonephritis and sepsis due to the infection of E. coli. Preoperative examination revealed non-active phase of SLE. Echocardiography and aortography showed massive aortic regurgitation and operation was recommended. Operative findings showed fresh vegetation on the aortic leaflets, and aortic valve replacement (Tekna-Edwards 19 mm) was performed. Histological findings of the vegetation showed Libman-Sacks endocarditis and infectious endocarditis. Predonisolone was infused intravenously to prevent the acute deterioration of SLE after the operation. She was discharged from the hospital three weeks after the operation.

[Clinical study of ambulatory cancer chemotherapy for advanced colorectal cancer]

To evaluate ambulatory cancer chemotherapy, the clinical response, toxicities and survival time were analysed among 32 patients with non-curative or recurrent colorectal cancer who were treated by l-Leucovorin (l-LV) plus 5-fluorouracil for the past four years. Twenty-nine patients were treated with 5-FU (370 mg/m2) plus l-LV (10-100 mg/m2) for 5 consecutive days and a 23-day interval between treatments. Three patients were treated with l-LV (250 mg/m2) administered as a two-hour infusion and 5-FU (600 mg/m2) intravenous push midinfusion weekly for 6 weeks of an 8-week cycle. Partial response (PR) was observed in 9 patients (28%), no change (NC) in 18. One-year survival ratio was 61% and 4 of 32 patients survived at the end of this study. The median survival time was 14 months. Although stomatitis, nausea/vomiting, diarrhea, leukopenia and pigmentation were noted, no severe side effects were observed. These results suggested that l-LV plus 5-FU therapy might be a useful ambulatory cancer chemotherapy for patients with advanced colorectal cancer.

[Cooperative study of surgical adjuvant chemotherapy for colorectal cancer. Cooperative Study Group of Surgical Adjuvant Chemotherapy for Colorectal Cancer in Japan]

With the cooperation of 357 institutions nationwide, during the two years from January 1984 to December 1985, curative resection cases of colorectal cancer were divided into two groups and treated in the following method: A group with chemotherapy received MMC 12 mg/m2, on the day of operation, followed by 6 mg/m2 every two months, 6 times. From the second week after operation, 800 mg/body/day of FT was administered for one year. The other was a control group with operation only. In this study, targetting those cases in which recurrence was observed within 5 years, among eligible cases histologically curative resection, recurrence forms were examined by prognostic factors and usefulness of adjuvant chemotherapy after operation. Regarding the recurrence of liver metastasis, in the case of colon cancer, the effect of chemotherapy was observed in highly positive cases of lymph node metastasis and positive cases of lymphatic vessel invasion. In rectal cancer, it was noticed in Dukes C cases. For the local recurrence of rectal cancer, it was observed in Dukes C and cases of relative curative resection. Chemotherapy tended to inhibit recurrence within one year after the operation in both liver metastasis and local recurrence.

[A successful repair of the aortic dissection (DeBakey type I) with ischemic complications of the kidney and lower extremities]

A 65-year-old male was referred to our institution under diagnosis of aortic dissection which passed 1 month after the onset. An aortography revealed DeBakey type I aortic dissection with the left renal artery involvement and the very narrow true lumen of the abdominal aorta compressed by the pseudolumen, especially at the orifice of the right renal artery. On the 3rd day of admission, the patient manifested SVC syndrome, oliglia and pulselessness of the femoral artery bilaterally, that indicated ischemia of the kidney and the lower extremities. An emergency operation was performed, and the ascending aorta was replaced using open distal anastomotic technique for the distal site of the aorta under deep hypothermia and retrograde cerebral perfusion method. The ischemic symptoms and SVC syndrome were disappeared promptly after operation. Postoperative CTscan showed the narrow true lumen of the abdominal aorta expanded remarkably. The postoperative course was uneventful and the patient discharged on the 54th postoperative day.

Chemosensitivity of gastric-cancer using adhesive tumor-cell culture system

A total of 91 specimens of surgically resected tumors from 80 patients with gastric cancer were assayed for chemosensitivity using an adhesive tumor cell culture system (Life Trac ATCCS assay). Seventy-eight specimens of 91 had sufficient number of cells to grow in culture and 64 (82%) were evaluable excluding 8 low growth and 6 fungus contaminations. Cells (3x10(3)/ml/well) were cultured for 14 days and exposed to drugs on days 3-8. The growing cells were confirmed as cancer cells by immunohistochemical staining using monoclonal antibody to cytokeratin, epithelial membrane antigen and vimentin. IC90 value against (ADM, CDDP, CPM, 5-FU, MMC, MTX, VP-16, CBDCA and MMC+5-FU+MTX) was determined and population distribution of IC90 for each drug was obtained to serve as basic data for judging sensitivity. The 10th percentile of IC90 (mug/ml) was 0.01, 0.43, 1.23, 0.23, 0.01, 0.005, 0.14, 1.56 and 0.009+0.05+0.003 and median of IC90 was 0.02, 0.99, 2.31, 0.30, 0.06, 0.01, 0.39, 3.19 and 0.02+0.10+0.005, respectively. Population distribution of IC90 against each drug showed a specific pattern. Profiles of IC90 against various anticancer drugs differed in individual patients. Chemosensitivity of lymph node metatases seemed to be more resistant than that of their primary tumors. The ATTCS test was found to be useful as a sensitivity test for anti-cancer agents because of its reliability and excellent quantification.

[Clinical study of ambulatory cancer chemotherapy for recurrent breast cancer]

To evaluate ambulatory cancer chemotherapy, the clinical response, toxicities and survival time were analysed among 12 outpatients with recurrent breast cancer who were treated by sequential methotrexate (MTX)/5-FU therapy for the past 2 years. In this study, MTX (70 mg/m2, i.v.) and 5-FU (370 mg/m2, d.i.v.) were given on days 1 and 15 every 4 weeks, the 5-FU being given one hour after the MTX. Partial response (PR) was observed in 3 patients (25%), no change (NC) in 9. One-year survival ratio was 59%, and 7 out of 12 patients survived at the end of this study. The median disease free interval was 7.3 months, and 3 cases survived for more than one year without disease. Although nausea/vomiting, stomatitis, leukopenia and alopecia were noted, no severe side effects were observed. These results suggested that sequential MTX/5-FU therapy might be a useful ambulatory cancer chemotherapy for patients with recurrent breast cancer.

[An early phase II clinical study of RP56976 (docetaxel) in patients with breast cancer]

An early phase II clinical study of RP56976 (docetaxel), a new anticancer agent of plant origin, was conducted in patients with breast cancer at 20 Japanese collaborative institutions. Docetaxel was administered at two or more doses of 60 mg/m2 by intravenous infusion with dose-free intervals of 3-4 weeks, and the efficacy and safety was evaluated. Of the 51 patients enrolled, 50 patients completed the scheduled course of treatment. Two patients showed a complete response (CR) and 19 showed a partial response (PR) with a response rate of 42.0%. The response rates based on the efficacy for metastatic lesions in soft tissue, liver and lung, were 46.2% (18/39), 37.5% (3/8), and 38.5% (5/13), respectively. Of the 50 patients who completed the study, 48 patients had previously been treated for the present malignancy. Forty-seven patients had previously been treated with chemotherapy and showed a response rate of 40.4% (19/47). The response rate in those who had received chemotherapy composed of anthracyclines and other agents was 44.1% (15/34). Grade 3 or more severe leukopenia and neutropenia developed in 43 patients (84.3%) and 48 patients (94.1%), respectively. Other adverse reactions which occurred in a Grade 3 or more severe form included nausea/vomiting (1 patient), anorexia (5 patients), diarrhea (4 patients), fatigue (2 patients), and alopecia (20 patients). Except for alopecia, most adverse reactions were generally transient and reversible without any specific treatment.

[Early phase II study of KW-2307 in advanced or recurrent breast cancer. KW-2307 Cooperative Study Group (Breast Cancer Section]

A multi-institutional early phase II study of KW-2307 (vinorelbine), a new vinca alkaloid derivative, in advanced or recurrent breast cancer was conducted in 15 nationwide hospitals. KW-2307 was intravenously administered once weekly at doses of 15 to 25 mg/m2. Sixty-five among the enrolled 69 patients were eligible. Response rates were 11.8% (2/17) with 15 mg/m2, 28.0% (7/25) with 20 mg/m2 and 17.4% (4/23) with 25 mg/m2, and the overall response rate was 20.0%. Once-weekly intravenous administration of 20 mg/m2 was estimated to be the optimal dose of KW-2307 from the results. The major side effect was leucopenia, which was the dose-limiting factor in this study. Other subjective or objective side effects included anorexia, nausea-vomiting, phlebitis, fever, general fatigue and stomatitis, but none of them was serious.

Postoperative chemotherapy including intraperitoneal and intradermal administration of the streptococcal preparation OK-432 for patients with gastric cancer and peritoneal dissemination: a prospective randomized study

We studied the effects on survival time of postoperative immuno-chemotherapy, including the streptococcal preparation OK-432, in patients with gastric cancer and synchronous peritoneal dissemination. The patients were prospectively randomized and a valid statistical assessment could be made for 109. Patients randomized to group B received therapy that is widely used in Japan to treat patients with gastric cancer: mitomycin C (MMC) and UFT, a combination of tegafur and uracil in a molar ratio of 1:4, for 1 year. Patients randomized to group A received the same drugs as were given to group B patients plus OK-432 i.p. for 7 days, beginning on postoperative day 0, and OK-432 by intradermal injection for 1 year, at 2-week intervals. There were no differences between the two groups in any known prognostic factor or in the dose of any drug administered except for OK-432. There was no difference in the toxicity rate between the groups. In this negative trial, there was no improvement in survival time with the addition of OK-432 to MMC and UFT for patients with gastric cancer and peritoneal dissemination.

[The efficacy of intra-arterial infusion chemotherapy in patients with non-resectable liver metastasis from colorectal cancer--a randomized study comparing FAM versus FEM]

The efficacy of FAM (5-FU, ADM, MMC) chemotherapy was compared with that of FEM (5-FU, EPIR, MMC) chemotherapy, in which the EPIR dose was about 1.3 times the ADM dose, by hepatic arterial infusion. Twenty-one patients with unresectable hepatic metastasis from colorectal cancer were the subjects of this multi-institutional randomized study. The response rate in evaluable 15 patients was 0% (0/6) in FAM group and 22% (2/9) in FEM group, with a 50% survival time of 15.3 months in FAM group and 15.1 months in FEM group. The major toxicities were gastrointestinal, together with hepatic dysfunction, both of which were not serious. Total incidence of > or = grade 2 toxicities was 50% (3/6) in FAM group and 80% (8/10) in FEM group. There was no statistical difference between the two groups in response rate, 50% survival time and toxicities. The clinical results of FAM and FEM were therefore considered equal, and an expected improvement in efficacy by increasing the EPIR dose was not confirmed. However, two patients in FEM group showed an objective response not observed in FAM group; one of them showed CR and survived about 3 years. These findings seem to suggest the efficacy of FEM hepatic arterial infusion chemotherapy for treatment of unresectable hepatic metastasis from colorectal cancer.

[A randomized trial of intrahepatic infusion chemotherapy for unresectable colorectal liver metastases. Sendai Study Group]

A prospective, controlled randomized trial of hepatic arterial infusion of 5-fluorouracil (5-FU), adriamycin (ADM) and mitomycin C (MMC) [FAM group] versus 5-FU, epirubicin (EPIR) and MMC [FEM group] in patients with unresectable liver metastasis from colorectal cancer is reported. No objective response was observed in FAM group (n = 6), while two objective responses, 1 complete and 1 partial (22.2%), were achieved in FEM group (n = 9). There was no significant difference in the 50% survival period between the two groups (468 days in FAM group (n = 8) versus 462 days in FEM group (n = 10). Long survival over 2 years was observed in FEM group, but not in FAM group. Toxicities were recorded in 50% (3/6) of FAM group, and 80% (8/10) of FEM group, but they were mild and well tolerated. In conclusion, although there was no significant difference in clinical effects between the two groups, the use of EPIR instead of ADR in combination with 5-FU and MMC might be favorable for intrahepatic infusion chemotherapy because responders and long-term survival were exclusively observed in FEM group.

[Adjuvant chemotherapy using cyclophosphamide for breast cancer. National Hospital Collaborative Group for Study of Breast Cancer Treatment]

The total dosage and therapeutic value of Cyclophosphamide (CPA) administered as adjuvant chemotherapy for breast cancer were studied. The subjects were those under 65 years of age who were diagnosed as Stage II breast cancer and underwent curative operation at any of 10 national hospitals from May, 1978 to April, 1981. CPA at dose of 100mg was administered orally every day. Comparison was made between the long-term administration group (L) of patients receiving a total of 25 g/m2 over 18 months and the short-term administration group (S) receiving a total of 6 g/m2 over 6 months, in terms of survival rate (SV) and disease-free survival rate (DFV). Cases selected as the subjects were randomly allotted to the two groups by means of the envelope method. The number of cases registered was 316. Of them, 308 cases were eligible for the study. Thirty-eight cases (23.6%) in L and 15 cases (10.2%) in S dropped out due to side effects and other reasons. No difference was observed between the two groups in background factors such as age, menopausal status, type of operation, histological diameter of tumor, histological type and metastasis to lymph nodes. Results of a 10-year follow-up revealed no difference in SV and DFV between the two groups. Excluding the drop-out cases, however, DFV was significantly high in L. There was no difference in DFV between the two group in terms of menopausal status. DFV was significantly high in L, if one includes cases with metastasis to lymph nodes. DFV was high in L, even when a group with no more than 3 metastatic lymph nodes and the group with not less than 4 were included. It is of little value to administer CPA to all Stage II cases for a long period of time. CPA may be indicated for cases showing metastasis to lymph nodes.

[Randomized controlled study on chemotherapy with 5-FD, ADM plus CDDP in advanced gastric carcinoma]

The clinical effects of combination chemotherapy with 5-FU, ADM plus CDDP for advanced carcinoma of the stomach were evaluated in a prospective randomized and controlled study. Seventy-seven patients from 18 major hospitals were randomly divided into A group and B group using the envelope method. A group was treated with protocol I (5-FU 270-300 mg/m2 iv from the 1st day to the 5th day and ADM 25 mg/m2 iv on the 5th day), and B group was treated with protocol II (5-FU, ADM plus CDDP 70 mg/m2 iv on the 1st day). These protocols were repeated every 3 weeks and repeated 3 courses in principle. Thirty-three cases from A group and 32 cases from B group were available for evaluation. The prognostic factors were compared between A and B group. No difference could be observed between the two groups. No cases from A group were interpreted as PR, while 6 cases (19%) from B group were recognized on PR after 3 courses. The response rate of the overall 19 cases from A group was 0%, while that of the overall 18 cases from B group was 33%. The statistical difference was observed between the two groups. However, no significant difference for the 50% survival time was observed between the two groups. One patient showing PR survived for 28 months. Gastrointestinal disturbances were observed in 60% and leukopenia plus thrombocytopenia in 40% of each group. Frequency and grade of the side effects were not significantly different between A and B group.

[Treatment with UFT as surgical adjuvant chemotherapy in carcinoma of large intestine. Cooperative Study Group of Surgical Adjuvant Chemotherapy for Colorectal Cancer in Japan]

The therapeutic results of the method II of the second study of the Cooperative Study Group of Surgical Adjuvant Chemotherapy for Colorectal Cancer in Japan were retrospectively reviewed and the relations of the 3-year survival rate to the dose of UFT per body weight as well as per kg of the patient and discontinuation of the treatment with UFT were investigated. The dose per day of UFT was randomly divided into group C (treated with UFT 600 mg/body/day) and group D (treated with UFT 400 mg/body/day for 12 months) by the envelope method. The 3-year survival rate of the patients whose body weight was 50 kg or more was higher than in the patients weighting less than 50 kg. The 3-survival rate of the patients treated with UFT from 8 to less than 12 mg/kg was the highest, while that of the patients treated with UFT of more than 12 mg/kg was the lowest. However, no statistical difference was observed between the two groups. The same results were observed in carcinoma of the colon and rectum, respectively. The findings indicated that the administration of excess amount of UFT was not effective. The relation between the 3-year survival rate and discontinuation of treatment with UFT was investigated at 6, 9 and 12 months after administration with UFT. The prognostic background factors of the C-group and the D-group were compared, but no difference was observed between the 2 groups at 9 months after administration. The 3-year survival rate of the patients treated continuously with UFT was higher than that of discontinued administration. The difference was especially evident in carcinoma of the colon, and good results were observed in cases treated continuously than in discontinued cases in both C- and D-groups.

[Adjuvant chemotherapy for gastric cancer--the third study. First report: central randomization by telephone method and analysis of patients' background factors]

JFMTC conducted the third adjuvant chemotherapy study for gastric cancer patients after curative surgery from 1982 to 1983. Patients were randomly allocated to one of the three arms by telephone method controlled at the headquarters of the foundation. This method resulted in the marked reduction of ineligible cases (253 cases, 6.0% of 4,236 cases), compared with those in the first study (18.3%). Main reasons of ineligibility were the violation of entry criteria due to the misjudgment of noncancer, duplicate cancers and operative curability. Telephone method for random allocation seems to contribute to the improvement in the data quality of a clinical trial.

Modulation of plasma glucose levels by thyrotropin-releasing hormone administered intracerebroventricularly in the rat

Thyrotropin-releasing hormone (TRH), but not histidyl-proline diketopiperazine (cyclo[His-Pro]), induced transient hyperglycemia associated with hyperglucagonemia and marked hyperinsulinemia when placed intracerebroventricularly (i.c.v.) in anesthetized rats. This TRH-induced hyperglycemia was prevented by acute adrenalectomy. However, adrenalectomy did not prevent TRH-induced hyperinsulinemia or hyperglucagonemia. In streptozotocin-induced diabetic rats, i.c.v. administration of TRH caused progressive and pronounced hyperglycemia. i.c.v. TRH-induced hyperinsulinemia was abolished by vagotomy and by systemic administration of hexamethonium or atropine. These results suggest that TRH induces hyperglycemia mediated by stimulation of the sympathetico-adrenal system and hyperinsulinemia by stimulation of the vagus nerve, and that the rapid decline of plasma glucose levels following transient hyperglycemia is due to hyperinsulinemia.

[The serum and tissue concentrations of tegafur, 5-fluorouracil and uracil in patients with gastric and colorectal cancers after oral administration of UFT]

Fifteen patients with stomach cancer and colorectal cancer were orally administered 600 mg of UFT before operation and the concentration of tegafur, 5-fluorouracil (5-FU) and uracil in the tissues and serum were measured by chemical assay. The mean 5-FU levels in tumor and lymph node were higher than those in normal tissues and were maintained in tumor for long time. Uracil level in tumor tissue was higher than in normal tissue with or without administration of UFT. Positive correlation between the concentration of uracil and 5-FU in the colorectal tumor with the correlation coefficient of 0.87 (p less than 0.01) was obtained.

[The problems of postoperative adjuvant chemotherapy in gastric cancer]

We studied the survival rate and state of recurrence of histologically curatively resected cases in the 1st (Method II) and the 2nd studies of the Cooperative Study Group of Surgical Adjuvant Chemotherapy for Gastric Cancer. The administration of MMC combined with Futraful was most effective, but there was no difference of survival rate between the patients in the 1st study given Futraful for 3 months and those in the 2nd study given the drug for 12 months. Irrespective of the kind of drug and term of administration, cases with stage I showing recurrence within 2 years after surgery accounted for ca. 50% of all stage I cases recurring within 5 years. In spite of histological malignancy, cases with stage II showing recurrence within 2 years after surgery accounted for ca. 65% of all stage II cases recurring within 5 years. As to the recurrent hazard rate for each recurrent type of case with stage III, all types showed a high peak between 0.5 and 1.5 years after surgery. The peritoneal metastatic hazard rate was the highest. The hazard rates for Groups B (MMC + Futraful) and C (Futraful) were lower than those for Group A (MMC). The above findings suggest the importance of postoperative adjuvant chemotherapy, which is performed repeatedly and intensively for 2 years in order to prevent recurrence.

[Cooperative study of surgical adjuvant chemotherapy of colorectal cancer (first report): Investigation of background factors and adverse effects. Cooperative Study Group of Surgical Adjuvant Chemotherapy of Colorectal Cancer in Japan]

In order to evaluate the efficacy of surgical adjuvant chemotherapy in patients undergoing gross curative resection for colorectal cancer (excluding m and sm cancer), a randomized controlled study was conducted from January, 1982 to October, 1983. Four hundred and ninety-one institutions participated in this study. The schedules for drug administration differed according to each district. In the Hokkaido and Shikoku districts, the patients were divided into the following two groups, one was a combination of ACNU and Futraful (FT) and the other was FT only. In the Chubu and Kinki districts, three groups were studied, namely those receiving a combination of ACNU and FT, those receiving FT only and those given no adjuvant chemotherapy. In the Tohoku and Kanto districts, a combination of MMC and FT and administration of FT only were studied. In the Chugoku and Kyushu districts, the patients were divided into a combination of ADM and FT, and FT only group. Among the 3,926 registered cases, 3,421 cases were valid for the study. As to the background factors, there were no significant differences among the groups in each district. There were no significant differences in one-year survival rates and one-year disease-free rates. No serious adverse effects were observed in any of the groups.

[Clinical study on serum immunosuppressive factors in gastric cancer patients--with special reference to preoperative ferritin levels and influence of surgical stress]

Serum ferritin values were measured preoperatively in 83 patients with gastric cancer and were found to be significantly higher than in normal subjects and mammary cancer patients. They were also significantly higher in healthy men than in women and in gastric cancer patients at stages I and IV than in those at stage III. There was no significant correlation between the serum ferritin value and various immunologic parameters. OK-432 serially administered pre- and postoperatively (A) and only postoperatively (B). The ferritin value increased markedly at one week postoperatively, reaching a peak at two weeks; at four weeks, it was reduced toward the value at one week. However, these changes in ferritin value showed no significant difference between groups A and B.

[Leiomyosarcoma of the rectum--a case report]

Tumors of smooth muscle origin are relatively uncommon in the rectum. Patients with leiomyosarcoma are very infrequently encountered. The patient was a 59-year-old Japanese male, who presented complaining of difficulty of defecation and melena. Rectal examination revealed an elastic hard and smooth-surfaced tumor of walnut size at 4 cm on the left antero-lateral wall. Needle biopsy was performed and the tumor was resected trans- sacrally. Histopathologically the tumor, was diagnosed to be leiomyosarcoma. Although the patient received no postoperative chemotherapy or irradiation, he is living without any symptoms or signs of recurrence 5 years and 6 months after the surgery.

[4 Cases of malignant mesenteric tumor]

Four patients with malignant mesenteric tumors are presented. The first was an 81-year-old male who had non-Hodgkin's lymphoma, the 2nd a 66-year-old male with leiomyosarcoma, the 3rd a 35-year-old male with well differentiated fibrosarcoma. All 3 of these patients underwent radical excision. The 4th patient was a 63-year-old male who underwent exploratory laparotomy only. Postmortem study showed leiomyosarcoma. Based on those and published experiences, we suggest that as soon as a diagnosis of mesenteric tumor has been established with CT scan, GI series etc., surgical removal and Chemotherapy should be performed.

[A case of metastasis of rectal cancer to the thyroid gland]

A 34-year-old male who showed a rectal mass upon irrigoradioscopy was admitted on October 6, 1979. Abdominoperineal amputation of the rectum was performed on October 11. Histopathological examination revealed that the tumor was adenocarcinoma of the well differentiated type, s, n0., stage II. The patient received chemotherapy and immunotherapy for 10 months postoperatively. In September 1981, enlargement of the thyroid gland associated with pain was noted and on January 12, 1982 total thyroidectomy was performed. Histologically, a diagnosis of well-differentiated adenocarcinoma, which was a metastasis from the rectal cancer, was made. On August 15, 1982, the patient died of generalized metastases.

[Clinical studies of cancer chemotherapy combined with angiotensin-II (ANG-II)]

The levels of anticancer drugs in tissue were measured by bioassay method in 28 patients with gastrointestinal cancer, who were treated with intravenous administration of 500 mg of 5-FU combined with ANG-II during surgery. The levels of 5-FU in the cancerous tissue of the stomach and the regional lymph nodes were higher in the cases who received 5-FU and ANG-II than in the cases received 5-FU alone. Based on this result, we carried out cancer chemotherapy combined with ANG-II for 15 patients with advanced cancer. The good clinical response was observed in 4 out of 15 cases (26.7%) including 2 complete (CR) and 2 partial responses (PR), respectively. According to Karnofsky's criteria of response, more than I-A response was observed in 5 out of 15 cases (33.3%). The major side effects of ANG-II therapy were nausea, vomiting and breast pain. The incidence of the side effects was 8.7% in total.