[A case of inoperable scirrhous gastric cancer that responded remarkably to a combination of TS-1+paclitaxel and showed complete loss of ascites]

Complete loss of malignant ascites by combination chemotherapy of TS-1+paclitaxel was experienced. The case was a 56-year-old woman who was diagnosed with inoperable scirrhous gastric cancer with malignant ascites. The administered regimen of chemotherapy was TS-1 100 mg/day (80 mg/m2) for 2 weeks. Paclitaxel 60 mg/day (50 mg/m2) on day 1 and 8 of TS-1 intake, followed by 2-weeks rest. Partial response was confirmed by gastrography and gastrofiberscope after 3 courses were performed. Furthermore, computed tomography (CT) showed complete loss of malignant ascites. Adverse reactions were grade 3 leukopenia and grade 2 nausea, vomiting and diarrhea. This result indicates the possibility of combination chemotherapy of TS-1+paclitaxel becoming an effective option in treating inoperable scirrhous gastric cancer.

[A case of effective weekly paclitaxel administration for primary lesion of schirrous gastric cancer]

We report a case of advanced schirrous gastric cancer with carcinomatous peritonitis. Chemotherapy with TS-1 was applied during the first 4 weeks, but the tumor did not respond to this therapy. Next, paclitaxel (TXL) was administered at a weekly dose of 90 mg/body/day for 3 weeks followed by a week interval of rest. Remarkable mass reduction of primary tumor was observed after 3 courses of treatment, and the symptom derived from primary tumor was relieved without significant side effects. The clinical course for schirrous gastric cancer with carcinomatous peritonitis is still miserable for patients, although many attempts have been made to improve its prognosis. A weekly paclitaxel regimen appears to be one of the promising treatment for schirrous gastric cancer.

[Two cases of non-curatively resected scirrhous gastric cancer that responded well to weekly paclitaxel therapy]

We report 2 cases in which the weekly administration of paclitaxel proved to be effective for patients with scirrhous gastric cancer who underwent a curability C operation. Weekly paclitaxel therapy was observed to effectively treat peritoneal and retroperitoneal dissemination. After this treatment the tumor markers decreased markedly. This weekly paclitaxel therapy was observed to cause no adverse effects, and thanks to the treatment the patients were able to consume normal meals. These patients could also be sufficiently treated as outpatients. Weekly paclitaxel therapy is thus considered to be effective for the treatment of advanced scirrhous gastric cancer with peritoneal and retroperitoneal dissemination.

[Two advanced gastric cancer patients who showed malignant ileus soon after administration of combination therapy of preoperative intra-peritoneal chemotherapy and gastrectomy]

Forty-eight patients with serosa-invaded advanced gastric cancer were administered to pre-operative intra-peritoneal chemotherapy to prevent peritoneal recurrence. There were no severe adverse effects from the intra-peritoneal chemotherapy. Of these patients, 2 showed malignant ileus shortly after intra-peritoneal chemotherapy and gastrectomy, and needed laparotomy because of dilatation of duodenum stump and liver dysfunction. The intestines and mesothelium showed diffuse thickness and hardness. We report the clinicopathological features of these cases and therapeutic limitation of intra-peritoneal chemotherapy.

[A case responding to weekly paclitaxel (TXL) therapy as third line chemotherapy for scirrhous type gastric cancer]

A 67-year-old female was admitted to our hospital in May, 2001 for examination. She was diagnosed with advanced gastric cancer that was inoperable due to peritoneal dissemination. Seventeen courses of sequential MTX and 5-FU therapy, and 2 courses of TS-1 plus CDDP were carried out. A partial response (PR) and prolonged NC were obtained after these chemotherapies. However, pleural effusion and ascites appeared again, and we diagnosed progressive disease. As a third line chemotherapy for this patient, paclitaxel (TXL) was administered. Treatment consisted of two 3-week courses of paclitaxel 70 mg per m2 on day 1 of each week, with a 1-week break between the courses. Two weeks after the start of this therapy, pleural effusion and ascites had completely disappeared. Paclitaxel is considered to be promising for advanced gastric cancers, as second or third line chemotherapy with paclitaxel for patients with inoperable gastric cancer seems to be effective in improving QOL.

[A case of stomach cancer in which TS-1 neoadjuvant therapy was effective against multiple hepatic metastasis, allowing a radical cure A surgery]

It is believed that multiple hepatic metastases from stomach cancer are highly refractory, and resistant to clinical treatment. In the present study, TS-1 neoadjuvant therapy administered orally in a single course brought about CR in the hepatic metastatic foci and PR in the primary foci, thus enabling grade A radical extirpation in a case of advanced stomach cancer. The patient continued to be treated on an ambulatory basis. His peri- and post-operative courses were satisfactory and the treatment was completed without the development of adverse effects.

[Complete response in a case of advanced scirrhous type 3 gastric cancer of with bulky N2 para-aorta lymph node metastases treated by combined chemotherapy of TS-1 and CDDP]

A 54-year-old patient with scirrhous type 3 gastric cancer having bulky N2 and para-aorta lymph node metastases was treated by combined chemotherapy of TS-1 and CDDP. Before treatment, CEA was 28.4 mg/ml. TS-1 (120 mg/day) administered for 14 days followed by 14 days rest was one course. CDDP (80 mg/m2) was administered by 24 hour continuous intravenous infusion at day 8 after the start of TS-1. After 2 courses of treatment, the level of CEA decreased to 1.4 mg/ml and the primary legion with lymph node metastases had decreased significantly. After 5 courses, endoscopic examination revealed complete disappearance of the primary tumor with no cancer cells detected by endoscopic biopsy. A CT scan also showed complete disappearance of all lymph node metastases. No severe adverse effects (NCI-CTC grade 3 of 4) were observed with this therapy. TS-1/CDDP chemotherapy is considered very effective for scirrhous gastric cancer with far advanced lymph node metastases.

Phase II study of sequential high-dose methotrexate and fluorouracil combined with doxorubicin as a neoadjuvant chemotherapy for scirrhous gastric cancer

BACKGROUND

The prognosis of scirrhous gastric cancer remains poor when it is treated with surgical resection alone or chemotherapy alone. A phase II study of sequential high-dose methotrexate and fluorouracil, combined with doxorubicin, as a neoadjuvant chemotherapy was conducted in an attempt to evaluate the efficacy of this regimen in improving the survival of patients with scirrhous gastric cancer.

METHODS

Patients were eligible if they had potentially resectable scirrhous gastric cancer with adequate organ functions and no prior treatment. The treatment schedule consisted of methotrexate (1 g/m2, day 1) fluorouracil (1.5 g/m2, day 1), leucovorin (15 mg/m2, days 2-4), and doxorubicin (30 mg/m2, day 15), repeated at a 28-day interval, and followed by radical surgery.

RESULTS

A total of 20 eligible patients were registered. Objective responses in the neoadjuvant chemotherapy segment were observed in 3 of the 20 (15%) patients. No complete remission was observed. The neoadjuvant chemotherapy was associated with grade 3 or 4 neutropenia in 14 of the 20 (70%) patients. The median time from the initial therapy to the operative day was 82 days. Thirteen of the 20 (65%) patients underwent curative resection. No treatment-related deaths occurred. However, the 2-year survival rate in this treatment program (25%) did not show any superiority over that in historical controls.

CONCLUSIONS

Sequential high-dose methotrexate and fluorouracil, combined, with doxorubicin, as a neoadjuvant chemotherapy for scirrhous gastric cancer did not improve the survival rate in spite of improving the curative resection rate.

[Complete response in an elderly patient with advanced gastric scirrhous cancer treated with combined chemotherapy of TS-1 and CDDP]

A 79-year-old male was diagnosed as having a scirrhous cancer of the stomach. Carcinomatous peritonitis was suspected on abdominal CT examination and the CA19-9 showed a high level of 95 U/ml. The patient was treated with combined chemotherapy of TS-1 and CDDP. TS-1 (100 mg/day) was administered for 14 days followed by 14 days rest as one course. CDDP was administered in 24-h continuous intravenous infusion on day 8. This treatment was done every 4 weeks regularly. After 5 courses, X-ray and endoscopy examinations revealed disappearance of cancerous lesions in the stomach with an improvement in the extensibility. No cancer cell were confirmed by endoscopic biopsy, nor did a CT-scan detect carcinomatous peritonitis. The CA19-9 decreased within the normal limit. Ten months after chemotherapy was started, the patient was very healthy without a recurrence of cancer. This combined chemotherapy has administered in 8 courses, and during this period no high grade toxicities (WHO grade 3 or 4) occurred. This TS-1/CDDP chemotherapy was effective for scirrhous gastric cancer and might be administered safely even for aged patients.

[A case in which TS-1, an orally-administered 5-FU chemotherapeutic agent, showed marked effectiveness against scirrhous type gastric cancer with multiple organ metastases]

A 67-year-old woman with anorexia and weight loss was referred to our hospital with a diagnosis of type 4 gastric cancer. Since metastases to the liver, left adrenal gland, and Douglas' pouch were detected in addition to ascites and bilateral hydronephrosis, the tumor was judged unresectable and systemic chemotherapy with TS-1 was begun. Symptoms began to improve after the first course, and the patient was discharged and followed as an outpatient. An upper GI series showed improvement of the primary lesion, and cancer cells became undetectable under biopsy. At the end of the third course, computed tomography confirmed that metastases to the liver, the lymph nodes, and the adrenal gland had disappeared. The ascites diminished significantly, and hydronephrosis began to ameliorate. The effectiveness of the drug continued until the end of the eleventh course, and the patient is currently in her seventeenth month as an outpatient. This case shows the effectiveness of TS-1 against scirrhous type gastric cancer, a cancer generally considered resistant to chemotherapy. Furthermore, treatment on an outpatient basis has greatly improved her quality of life.

[A case of gastric cancer with paraaortic lymph node metastasis responding to preoperative chemotherapy and surviving 4 years and 4 months after total gastrectomy]

A 68-year-old woman was admitted to our hospital because of type 4 gastric cancer associated with paraaortic lymph node metastasis. Considered surgically incurable, she was placed on preoperative chemotherapy consisting of Methotrexate (MTX) 50 mg (day 1), CDDP 10 mg (day 2-6), 5-FU 500 mg (day 1-6) and Leucovorin (LV) 60 mg (day 2-6). Because of severe nausea and leucopenia, she could receive only 1 course of the chemotherapy. CT on January 7, 1997 (5 weeks after the chemotherapy) showed that the gastric wall thickness and the paraaortic lymph nodes swelling had decreased remarkably. She underwent total gastrectomy on January 13, 1997 (pT2, pN2, pM1 (LYM), stage IV, TNM classification). As an outpatient, she was treated with UFT-E 300 mg/day (continuous until the present) and MTX 50 mg (day 1), 5-FU 500 mg (day 1) and LV 60 mg (day 2-3) once two weeks (total 27 cycles). Four years and 4 months after surgery, although peritoneal recurrence was suspected, she has been managed at our outpatient clinic.

[A case of long surviving advanced recurrent breast cancer with multiple bone metastases responding to treatment with 5'-DFUR combined with MPA]

The patient was a 69-year-old woman who had undergone right standard radical mastectomy on August 8, 1991, and was treated with chemo- and hormonal therapy of ADM, UFT and TMA. Three years later she showed multiple bone metastases with elevation of CEA, and 5'-DFUR 1,200 mg/day and MPA 800 mg/day were administered. Two years later her CEA levels were decreased, 5'-DFUR was discontinued and MPA 1,200 mg/day only was continued. Two months later a side effect of MPA, her body weight gain, was observed, and the dosage of MPA was reduced from 1,200 mg/day to 800 mg/day. Then the side effect was resolved. Bone scintigraphy and MRI showed that bone metastatic lesions were reduced 6 years after 5'-DFUR and MPA therapy. It is suggested that this combination therapy may be useful for advanced recurrent breast cancer patients with multiple bone metastases.

[A case of hepatic metastasis of gastric cancer responding to TS-1, administered for two consecutive weeks and one week rest]

We have treated a case of hepatic metastasis of gastric cancer that has responded well to TS-1. The patient was a 68-year-old male, who underwent distal gastrectomy for gastric cancer. After surgery 5'-deoxy-5-fluorouridine (5'-DFUR) 800 mg/day was administered orally for two months. Grade 4 diarrhea appeared, so administration of 5'-DFUR was discontinued. Afterward the patient was followed with no chemotherapy. Liver metastasis (S6, 3 cm in diameter) was found at twelve months after surgery. 5'-DFUR (800 mg/day) was administered orally everyday. Grade 3 diarrhea appeared and metastasis showed NC after four weeks. 5'-DFUR administration was discontinued. Seventeen days later TS-1 (80 mg/day) was administered orally everyday for 2 weeks, followed by 1 week rest, as one course. Two courses of TS-1 administration resulted in a marked reduction of the liver metastasis, for a PR (75% reduction). After 3 courses, the liver metastasis showed CR. The patient is alive without recurrence after 12 courses. This TS-1 administration regimen was effective and tolerable for a patient with liver metastasis from gastric cancer.

[A case of nonresectable scirrhous type gastric cancer treated by hypertensive subselective chemotherapy with pharmacokinetic modulating chemotherapy]

There have been few effective chemotherapeutic regimens for scirrhous type gastric cancer. A 62-year-old male patient was admitted to our hospital because of anorexia and abdominal discomfort. Gastroendoscopy showed a type 4 advanced gastric cancer in the upper gastric body. Histologic study of biopsy specimens from the tumor revealed poorly differentiated adenocarcinoma. Examination by computed tomography and ultrasonography revealed swollen paraaortic lymph nodes and peritonitis carcinomatosa. The patient was diagnosed as having a nonresectable scirrhous type gastric cancer with peritonitis carcinomatosa and paraaortic lymph node metastasis. This patient was treated weekly with an intraarterial 5-FU (500 mg) and MTX (100 mg) including AT-II by a subcutaneously implanted port system placed into the thoracic aorta. Furthermore, he was administered tegafur/uracil (400 mg/day) 5 days weekly as a pharmacokinetic modulating chemotherapy (PMC). After eight courses of treatment of PMC, paraaortic lymph node swelling and ascites decreased. This chemotherapy produced a partial response in the peritonitis carcinomatosa and paraaortic lymph nodes. This chemotherapy was repeated preoperatively. We reconsidered this case to show indications for operation. The patient died suddenly of acute heart failure before the operation. This therapy was considered an effective treatment for nonresectable gastric cancer.

Intestinal perforation due to metastasis of breast carcinoma, with special reference to chemotherapy: a case report

We report a case of small-bowel perforation due to metastatic carcinoma of the breast during chemotherapy. Partial resection of the small intestine and primary anastomosis were performed. Although the patient made a good recovery from panperitonitis, she died of the disease on the 55th postoperative day. Since perforation during chemotherapy results in an extremely poor prognosis, special caution during chemotherapy is needed for patients with possible gastrointestinal involvement with tumor.

[A case of nonresectable scirrhous type gastric cancer successfully treated by low-dose cisplatin (CDDP), 5-fluorouracil (5-FU) and pirarubicin (THP)]

There have been few effective chemotherapeutic regimens for scirrhous type gastric cancer. Recently, the usefulness of combined cancer agent chemotherapy based on the concept of biochemical modulation has been reported. For example sequential MTX and 5-FU therapy, low-dose CDDP plus 5-FU, and the like. In this paper, we report the usefulness of low-dose CDDP plus 5-FU therapy in combination with pirarubicin (THP) for inoperable scirrhous type gastric cancer. A 32-year-old man who was suffering from scirrhous type gastric cancer with pyloric stenosis was treated with this regimen. Eight weeks after the start of therapy, his gastric capacity and lumen diameter had clearly increased, and he was taking ordinary meals. Ascites had also completely disappeared. CR has now been continued about 7 months. This regimen is considered to be promising for scirrhous type gastric cancers with a poor prognosis.

Scirrhous cancer of the stomach which survived for more than five years after neoadjuvant chemotherapy with UFT (uracil and tegafur) and cisplatin

A 68-year-old man was diagnosed as having a scirrhous cancer of the stomach. Carcinomatous peritonitis was suspected on abdominal CT examination. Three courses of uracil and tegafur (UFT)/cisplatin (CDDP) chemotherapy were administered. The primary foci were reduced in size, then total gastrectomy was performed. Histological findings revealed a poorly differentiated adenocarcinoma with scirrhous invasion into the subserosa. Histological efficacy of the chemotherapy was judged to be grade 2. The patient has been alive without disease for more than five years after total gastrectomy. Neoadjuvant chemotherapy with UFT and CDDP may have contributed to the favorable clinical outcome in this patient.

[Clinical study of selective intra-arterial infusion chemotherapy using trans-radial arterial approach in 4 cases of advanced breast cancer]

We administered neoadjuvant chemotherapy by a selective intra-arterial infusion method using a trans-radial approach in patients with advanced breast cancer (stage III and stage IV). The trans-radial approach uses the arterial flow, based on the Seldinger technique. In this method, the radial artery is cannulated, and epirubucin is infused into the artery that carries blood from the subclavical artery to the breast. We have used this method in 4 cases thus far. Two of the patients received a single intra-arterial infusion of epirubicin. The other 2 patients were catheterized before they received chemotherapy by intra-arterial infusion. This technique decreased the pain or discomfort caused by the catheterizations during chemotherapy in all 4 cases. However, the currently available catheters are not always able to approach the artery flowing into the breast, thus the protocol will need to be refined.

[A case of multiple liver metastases from breast cancer successfully treated with intra-arterial administration of docetaxel]

Docetaxel is an excellent agent with a high antitumor effect for the treatment of advanced/recurrent breast cancer. A 55-year-old female with metastatic liver tumors from breast cancer showed a remarkable response to intra-arterial administration of docetaxel (20 mg/week, or 40 mg/2 weeks). Since CT and MRI imaging revealed multiple metastases in the liver, intra-arterial chemotherapy was selected. No critical side effect was found during this chemotherapy. A CT scan 3 months after chemotherapy showed a partial response. We conclude that this intra-arterial chemotherapy using docetaxel will be safe and useful for liver metastases from breast cancer.

Chemosensitivity test is useful in evaluating the appropriate adjuvant cancer chemotherapy for stage III non-scirrhous and scirrhous gastric cancers

A total of 183 cases with gastric cancer was retrospectively analyzed in terms of their chemosensitivity as determined by the 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl-2H tetrazolium bromide (MTT) assay and their survival rates after surgery. After the patients were stratified into scirrhous or non-scirrhous carcinoma groups, they were tested for stage III or IV gastric cancer. In these four cohorts, the patients were categorized into sensitive and insensitive groups determined by the MTT assay. The sensitive group was treated with at least one drug that had been shown to be effective in the MTT assay, and the insensitive group was given a drug that had been shown to be ineffective in the MTT assay. In stage III gastric cancer, the sensitive group showed a favorable survival compared to the insensitive group in scirrhous and non-scirrhous carcinoma, while this difference was diminished in stage IV gastric cancer. There were no survival benefits in the sensitive group in stage III gastric cancer, when they were not treated with adjuvant cancer chemotherapy. These results suggested that MTT assay would be useful in evaluating the appropriate adjuvant cancer chemotherapy for stage III scirrhous and non-scirrhous gastric cancer.

Tranilast and cisplatin as an experimental combination therapy for scirrhous gastric cancer

We examined the effect of Tranilast on the reduction of the administered dose of cisplatin using a scirrhous gastric cancer model. Scirrhous gastric cancer cell line, OCUM-2M, and gastric fibroblasts, NF-10, were used. The IC50 values of CDDP to OCUM-2M cells were decreased by Tranilast in vitro. The combination treatment with Tranilast and CDDP decreased the xenografted tumor size. The combination therapy decreased fibrosis and mitosis, and increased apoptosis. These findings suggest that Tranilast increased the CDDP response on scirrhous gastric cancer. The combination treatment with Tranilast and CDDP may be useful as a new therapy for scirrhous gastric carcinoma.

[A case of stage IV breast cancer showing long-term complete response to combination therapy with 5'-DFUR and MPA]

We report a 62-year-old woman with supraclavicular lymph node, pleural and bone metastases from breast cancer showing a long-term complete response to combination therapy with 5'-DFUR and MPA. A large amount of pleural effusion was drained followed by administration of ADM, which improved the amount of effusion. Treatment with CAF and TAM decreased tumor size, but CAF was abandoned due to severe leukopenia. Mastectomy was performed for local control. However, levels of tumor markers increased progressively. Administration of CMF was tried, but tumor markers continued to increase. Therefore, combined chemoendocrine therapy with 5'-DFUR and MPA was undertaken. Levels of tumor markers normalized and a complete response was obtained 13 months after starting this combination therapy. There are no further metastatic lesions evident, and this status has been consistently maintained for more than three years (six years and five months after diagnosis of breast cancer). There were no significant side effects of this combination therapy except for mild weight gain and moon face. This combination regimen with 5'-DFUR and MPA is considered useful as a second-line treatment for advanced breast cancer.

Extended surgery--left upper abdominal exenteration plus Appleby's method--for type 4 gastric carcinoma

BACKGROUND

The prognosis after surgical treatment for type 4 gastric cancer, including linitis plastica, remains poor. The most frequent recurrence mode is retroperitoneal involvement. To remove the tumor and microinvasion surrounding the stomach, extended surgery, left upper abdominal exenteration plus the Appleby's method (LUAE + Apl), has been performed for type 4 cancers since 1983.

PATIENTS AND METHODS

A total of 54 patients with type 4 cancer underwent extended surgery (LUAE + Apl) over the past 11 years. In the LUAE + Apl surgical procedure, the whole stomach, pancreas body and tail, spleen, gallbladder, transverse colon, and left adrenal were removed en bloc. The results of this treatment are reported and the most beneficial application of this procedure (group A) is evaluated and compared with findings in similar patients who underwent common surgery between 1973 and 1983 (group B).

RESULTS

As postoperative complications, pancreatic fistula (30%; control 19%), liver dysfunction (15%; 14%), anastomosis failure (6%; 9%), and infection (4%; 1%) were observed (NS). In group A, one patient died of liver dysfunction and another of multiple organ failure due to major pancreatic fistula. In stage III, the 5-year survival rate of group A (40%) was better than that of group B (20%; p < 0.05). In stage IV, the 5-year survival rate of group A (5%; 3% in group B) was not improved.

CONCLUSION

LUAE + Apl improved the survival of patients with scirrhous cancer in stage III, but it was not effective for those in stage IV. To improve the survival of patients in stage IV, a new concept of treatment and supportive therapy needs to be used.

Tranilast (N-(3,4-dimethoxycinnamoyl) anthranilic acid) down-regulates the growth of scirrhous gastric cancer

BACKGROUND

Fibroblasts have been reported to play an important role in the proliferation of scirrhous gastric cancer cells. It would be an effective cancer therapy to reduce the cancer-stimulating activity of fibroblasts. The aim of the present investigation was to define the efficacy of Tranilast (N-(3,4-dimethoxycinnamoyl) anthranilic acid), a drug used clinically for the treatment of excessive proliferation of fibroblasts, on the growth of scirrhous gastric carcinoma both in vitro and in vivo.

MATERIALS AND METHOD

The human scirrhous gastric cancer cell line, OCUM-2M, and the human gastric fibroblasts, NF-8, were used. OCUM-2M cells on the upper well and NF-8 cells in the lower well were co-incubated with Tranilast at the required concentrations in vitro. The in vivo effect of Tranilast was examined by measuring the size and the apoptotic index of coinoculated tumor by OCUM-2M cells and NF-8 cells.

RESULTS

The proliferation of OCUM-2M cells was significantly stimulated by co-culture with NF-8 cells. Tranilast significantly suppressed the proliferation of NF-8 cells and subsequently decreased the growth of OCUM-2M cells in vitro. Furthermore, Tranilast depressed gastric carcinoma growth and induced cancer cell apoptosis through its effect in blocking the growth-interactions between fibroblasts and scimbous gastric cancer cells in vivo.

CONCLUSION

Tranilast is a useful drug to reduce the proliferation of scirrhous gastric carcinoma.

Pilot study for preoperative administration of l-OHP to patients with advanced scirrhous type gastric cancer

A new DACH platinum complex, l-OHP, was developed by Kidani as an anticancer agent. A clinical trial took place in Europe which demonstrated its therapeutic efficacy for colorectal cancer. An effective treatment, especially chemotherapy for patients with a advanced scirrhous type gastric cancer, has not yet been established. An in vitro study showed that l-HOP inhibited cell growth in human gastric cancer cell lines. Our pilot study determined the efficacy of preoperative administration of l-OHP, 67 mg/m2 to 100 mg/m2, every 2-3 weeks, for two to three cycles, in five patients with this disease (Stage III and IV) roentogenoscopically and histologically. The platinum concentration in the tissues was also measured. By X-ray examination of the stomach at the time of pre- and post-administration of l-OHP, extension of the lesional gastric wall was observed. Histologically three Grade 2 responses and two Grade 1a responses were obtained according to the criteria presented by Japanese Research Society for Gastric Cancer. The mean platinum concentrations in the lesional tissues were 0.98 ppm and 0.5 ppm in the patients administered l-OHP for three and two cycles respectively. There was no toxicity that prevented surgery. These preliminary results showed the possibility that 1-OHP would be effective for patients with advanced scirrhous type gastric cancer as a neoadjuvant therapy.

Neoadjuvant chemotherapy in scirrhous cancer of the stomach using uracil and tegafur and cisplatin

We administered a mixture of uracil and tegafur (UFT)/cisplatin (CDDP) chemotherapy in 28 patients with scirrhous gastric cancer. In the regimen, UFT was orally administered at a dose of 200 mg/m2 twice a day. The CDDP was administered at a dose of 90 mg/m2 by 24-hour continuous infusion every 4 weeks. As a result, antitumor effects for primary gastric foci were achieved in 14 of the 28 patients (50%). Ascites from peritoneal dissemination disappeared completely in eight of 13 patients (62%). Total gastrectomy was performed in ten patients after 2 to 3 courses of chemotherapy. Histological response grades assessed on the resected specimen were Grade 2 in four, Grade 1b in three, Grade 1a in one and Grade 0 in two patients. Neoadjuvant chemotherapy is feasible against scirrhous gastric cancer and a subsequent prospective randomized trial should be prepared to clarify the survival benefit of the treatment.

[A case of recurrent breast cancer responding to long-term treatment with 5'-DFUR combined with MPA]

A 55-year-old woman with recurrent breast cancer treated with sequential mastectomies, chemo-and hormonal therapy of UFT, CPM and TAM, achieved remission. Six months later she was admitted with a diagnosis of carcinomatous pleurisy. A large pleural effusion was drained followed by administration of ADM, which improved her effusion and accompanying dyspnea. The effusion recurred but the patient desired outpatient treatment. Thus, we prescribed oral 5'-DFUR and MPA. One month later, her cough had improved and her sputum cytology was negative, while on chest radiograph the pleural effusion had decreased and the patch-like shadows in her right lung field had disappeared. She was considered as a case of PR. At one year and 3 months after starting concomitant 5'-DFUR and MPA the pleural effusion disappeared. The patient has received this outpatient treatment for 2 years without adverse reactions.

Recurrent breast cancer treated successfully with mitomycin-C and vinblastine after failure of both doxorubicin-containing regimen and paclitaxel--a case report

Cross-resistance is one of the chief obstacles in salvage therapy for refractory breast cancer. Although paclitaxel is one of the most promising drugs, it shows a response rate of 30% at most for patients with breast cancer resistant to doxorubicin, and no effective treatments for tumors refractory to both agents have been reported. We describe a 38-year-old woman with recurrent breast cancer, who was treated successfully with mitomycin-C and vinblastine after doxorubicin-based chemotherapy and paclitaxel failed. The combinations of mitomycin-C and microtubule inhibitors including vinca alkaloids and taxanes may have a potential application to refractory breast cancer.

[Chemotherapy of scirrhous gastric cancer]

Cancer chemotherapy plays a central role in the treatment of recurrent or unresectable scirrhous gastric cancers classified mainly as Borrmann type 4. Though we have no specifically effective drugs for scirrhous gastric cancer, 5-FU and its derivative, MMC, anthracyclines, CDDP, CQ and ACNU are known to be relatively effective single agents against this tumor. In an attempt to enhance the effect of single agents, several combined chemotherapy regimens have been devised and tested. These regimens included 5-FU + MMC, UFT + MMC, UFT + CDDP, MTX.5-FU, FAM, FAP, EAP and ELF regimen. At present, combined therapies using 5-FU and MTX or CDDP may be the most attractive of these combined regimens.

[A case of nonresectable gastric cancer treated by sequential methotrexate and 5-fluorouracil]

An advanced gastric cancer patient with multiple retroperitoneal lymph node metastases and bone metastases was treated with sequential MTX and 5-FU. Complete response was obtained against both gastric primary lesion and retroperitoneal lymph nodes observed endoscopically and by computed tomography. Partial response was obtained against bone metastases observed by bone scintigraphy. Side effects of the chemotherapy were not observed.

Intracavitary cisplatin chemotherapy experience with six dogs

Six dogs with a median age of 7 years (range = 5-14 years) were presented for signs referable to thoracic or abdominal effusion associated with neoplasia of the body cavities. Intracavitary cisplatin was administered at 50 mg/m2 every 4 weeks for a median of 2.5 treatments (mean = 3, range = 1-6). Three dogs with pleural mesothelioma had complete resolution of effusion for 289, 129, and greater than 306 days without evidence of tumor growth. Resolution of effusion occurred after one treatment in two dogs and after two treatments in one dog. In three dogs with carcinomatosis of unknown origin, complete responses was seen in two dogs after one treatment for 255 and greater than 807 days, respectively. Intracavitary chemotherapy with cisplatin was associated with palliation and control of malignant pleural and/or abdominal effusion in five of six dogs. Toxicity was minimal, and this method of therapy should be further explored in dogs with similar malignancies.

In vitro chemosensitivity test of human gastric carcinomas using collagen gel matrix

We retrospectively evaluated the usefulness of an in vitro human tumor culture system using a specialized collagen gel matrix derived from pig skin as a chemosensitivity test for human gastric carcinomas, especially for scirrhous gastric carcinomas. Seven xenograft tumors derived from human gastric cancers were examined by using this system and the results were compared with the data obtained from a nude mouse assay. Xenograft tumors exhibited three-dimensional growth on the collagen gel matrix like that in vivo. The drug sensitivity as measured by this assay at 10 times therapeutic peak plasma concentrations of the drugs corresponded with that measured by the nude mouse assay for all xenograft tumors. The correlation coefficients were 0.873 for cisplatin, 0.919 for etoposide, 0.880 for mitomycin C and 0.932 for adriamycin. In the case of scirrhous gastric carcinoma, the drug sensitivity could be measured successfully in all 12 patients. This in vitro assay system has advantages as a chemosensitivity test because of its convenience, rapidity, and in vivo-like three-dimensional tumor growth. This system should contribute to the development of chemotherapy for scirrhous gastric carcinomas.

Tumor reduction surgery and long-term survival in advanced ovarian cancer: a DACOVA study

Three hundred sixty-one patients with FIGO stage III and IV ovarian cancer were treated with cis-platinum combination chemotherapy in a Danish multicenter trial. Primary surgery was performed at 58 different departments; 32% of the patients were operated at a department associated with an oncologic center, 50% at a general gynecologic department, and 18% at a general surgical department. Complete pathologic response and long-term survival were similar for patients operated on in the different departments. Patients who underwent radical surgery or optimal debulking had a 10% risk of progression during chemotherapy and a 5-year survival of 46%. Patients who underwent suboptimal debulking and exploratory laparotomy had a 40% risk of progression during chemotherapy and a 5-year survival of 14%. Complete pathologic response showed an insignificant difference between radical surgery and optimally tumor reduction (57% versus 41%) and a significant difference between suboptimal tumor reduction and exploratory laparotomy (19% versus 6%). Patients secondarily tumor reduced had a survival rate superior to that of patients not secondarily tumor reduced (25% versus 4% at 4 years).

[A carcinoma of the right breast arising after a mastectomy in primary malignant lymphoma of the left breast]

In 1987, a 51-year-old woman visited our hospital, having noticed a painless 1.5 x 1.5 cm tumor of the left breast. On biopsy, it was pathologically diagnosed as being a primary malignant lymphoma of the breast. Thus we performed a modified radical mastectomy (Patey's method), in combination with chemotherapy (Cyclophosphamide, Vincristine, Prednisolone). Two years after the operation, a tumor of the right breast, 1.0 x 1.0 cm in size, was noticed. At this time, since an excised specimen was pathologically determined as being a scirrhous carcinoma, we performed a modified radical mastectomy (Auchincloss' method), followed by chemotherapy (Tegafur).

[Two cases of advanced breast cancer with distant metastasis showing long-term survival with multidisciplinary treatment including intra-arterial infusion chemotherapy]

Two cases of advanced breast cancer are reported that have had no recurrence for more than five years after multidisciplinary treatment including intra-arterial infusion chemotherapy. The first case is a 62-year-old housewife who had brain metastases. The primary lesion and distant metastases were completely responsive to irradiation combined with chemoendocrine therapy. The other one is a 38-year-old housewife with ovarian metastasis that was revealed after oophorectomy. In this case chemoendocrine therapy was added without irradiation after intra-arterial infusion chemotherapy. These cases indicate that intra-arterial infusion chemotherapy can be recommended as a component of multidisciplinary treatment even in advanced breast cancer with distant metastasis.

[Effect of sequential MTX/5-FU therapy for a case of disseminated intravascular coagulation syndrome associated with recurrence of gastric cancer--a case report]

Although a 39-year-old male received the curative operation of total gastrectomy for advanced scirrhous carcinoma of the stomach, recurrence of cancer was occurred soon after the surgery, accompanied by hemorrhagic diathesis from DIC. The abdominal CT scan examination revealed the rapid enlargement in the size of the several lymphnodes around the abdominal aorta, and the blood chemistry tests showed marked increase of the serum CEA value. The sequential chemotherapy with intermediate dose of MTX and 5-FU in conjunction with OK-432 was started to treat the case. This chemotherapy was carried out once a week for 5 times and consequently DIC was led to the perfect remission. Furthermore, CEA level decreased within normal range, and the size of the enlarged lymphnodes at paraaortic area diminished remarkably. Although he complained of nausea and loss of appetite during the treatment, no severe adverse effects such as granulocytopenia, diarrhea, or loss of hair were observed. The successful result in this patient suggests that sequential therapy of intermediate dose of MTX and 5-FU with administration of OK-432 may be effective in the treatment of advanced scirrhous carcinoma of the stomach.

[A study of complete responders in cases of metastatic breast cancer treated with combination chemotherapy]

Twenty-eight patients with a metastatic breast cancer who have achieved a complete remission from a combination chemotherapy that included doxorubicin have been analyzed to ascertain the factors which affect the duration of the response and the survival time. The median duration of a complete remission was 26 months. Relapses occurred in 17 patients (61%), of which the median duration of the response was 18 months and 71% of the relapses occurred at the sites of the prior dominant disease. Most of the patients suffered a relapse while they were receiving maintenance chemotherapy. The number of metastasized organs were one or two in 89% of the patients. The dominant sites of the disease were mainly the visceral (61%) and soft tissue (29%), and the duration of survival was found to be longer in patients with a visceral metastasis. In the group of patients who experienced a recurrence 2 years or more after their operation showed a statistically longer remission and survival time than those who experienced a recurrence within 2 years. The duration of survival from the start of chemotherapy was 45.5 months for complete responders and 21 months for partial responders. This difference was statistically significant (p less than 0.001), though no difference was found between partial responders and "no-change" patients (18.5 months). The tendency towards a relapse at the site of the initial involvement and while receiving maintenance therapy suggests that the majority of patients with a metastatic breast cancer who achieved a complete remission with this combination chemotherapy still have a substantial subclinical residual tumor. Maintenance treatment should be investigated to ascertain the procedures and duration of therapy. Thus, these results have indicated that it is necessary to achieve a complete remission in order to obtain a long term survival.

[Basic and clinical study of adoptive immunotherapy using cytotoxic T lymphocyte (CTL) against cancers]

Cytotoxic T cells (CTL) have been known to be one of the effector cells responsible for regression of tumors. In tumor-bearing hosts, CTL insufficiently attack the tumor because the suppressor cells inhibit the induction and activation of CTL. In our in vitro study, CTL were induced from peripheral blood lymphocytes (PBL) of cancer patients. These CTL showed the specific cytotoxic activity against autologous tumor in one case and broad specificity against tumors in other cases. A patient with breast cancer was treated with adoptive immunotherapy of CTL because she had severe side effect from antineoplastics . Her breast cancer was histologically scirrhous type adenocarcinoma which was resistant to antineoplastics. Patient's PBL were cocultured with mitomycin C treated-autologous tumor, and they were proliferated with interleukin 2 or T-cell growth factor (TCGF). Then, these CTL were injected to this patient intravenously at the interval of one or two weeks. Before serial injection of CTL, antineoplastics was prescribed in order to inhibit the function of suppressor cells and cancer cells. The sizes of tumors were gradually reduced, suggesting clinical regression. We suggest that combined treatment of adoptive immunotherapy using CTL and antineoplastics (CTL therapy) is very useful in the treatment of cancer patients.

[Bone marrow necrosis in a patient with metastatic breast cancer in chemotherapy with chlorambucil, methotrexate and prednisone]

In this case report the clinical course of a female patient with metastatic breast cancer receiving a mild cytostatic regimen with chlorambucil, methotrexate and prednisone is described. She developed an unusual clinico-pathological syndrome with pancytopenia, fever and bone pain resulting from a bone marrow necrosis. The clinical course illustrates the great diagnostic difficulties and the potential benefit from rapid identification of this prognostically very poor event. Leading symptoms such as fever, bone pain, pancytopenia, an increase in the sedimentation rate, in lactate dehydrogenase and alkaline phosphatase in serum are often misinterpretated as tumor progression with bone or hepatic metastases and bone marrow carcinomatosis. An iliac crest aspirate and biopsy detects the diagnosis of a marrow necrosis. These symptoms should be kept in mind in order to avoid a diagnostic pitfall resulting from a misinterpretation of the morphological picture as necrotic metastasis in bone marrow or as an artefact. It is assumed that, in addition to the underlying malignant disease, cytostatic therapy with chlorambucil, methotrexate and prednisone triggers this event.

[Effect of combination chemotherapy of 5'-DFUR, cyclophosphamide and tamoxifen in a case of advanced breast cancer]

A patient with inoperable, advanced cancer in left breast and metastasis in the opposite axillary lymph nodes, received combination of 5'-DFUR, cyclophosphamide and tamoxifen. The daily dosages were: 1,200 mg/body, 100 mg/body, and 20 mg/body respectively, 5'-DFUR and cyclophosphamide were intermittently administered for two weeks followed by two weeks resting. The original foci began to respond after 3 weeks from the start of this therapy and disappeared in the 27th week. The metastatic foci disappeared in the 16th week, when the patient presented significant improvement from the aspect of quality of life with a good appetite. No serious side effects were observed except for leukocytopenia. This study indicated that the said combination is useful in treatment of advanced/recurrent breast cancer.

[Cooperative study of postoperative long-term adjuvant therapy of breast cancer. First study of a series--comparative study between postoperative tegafur administration and no adjuvant chemotherapy]

A prospective randomized study was performed in 22 institutions from July 1978, to evaluate the efficiency of long-term adjuvant chemotherapy with tegafur alone for primary breast cancer. Five hundred and eighty-seven eligible patients, classified into T1a, T2a, T3a, N0, N1a, N1b, and M0 were divided into two groups: Group A, radical mastectomy receiving no adjuvant chemotherapy; and Group B, radical mastectomy followed by 4 courses of adjuvant chemotherapy, each one consisting of daily administration of tegafur 600 mg p.o. for 8 weeks and 4 weeks rest. At the 66th month of median follow up time, there were no differences between the two groups on 5 year cumulative survival and disease free survival rate. In subgroup patients who have histologically 1-3 axillary involvements, there seemed to be a more meaningful prolongation of the disease-free interval in group B than in group A (logrank test; p = 0.11 generalized Wilcoxon test; p = 0.13).

[Chemoendocrine therapy of gastric "scirrhous" carcinoma]

An oral chemoendocrine treatment using Tamoxifen and FT-207 for female patients with gastric scirrhous carcinoma was developed at the National Cancer Center. The dose was oral Tamoxifen 20 mg/day b.i.d. combined with FT-207, 600 mg/day t.i.d. Since the results of the pilot trial were promising, a double-blind clinical study was performed in the National Cancer Center Hospital. In patients with non-curative surgery, the group of Tamoxifen and FT-207 had longer survival than those who received only FT-207 (p = 0.084) by the Generalized Wilcoxon's analysis. To confirm these results, a controlled clinical study is being undertaken with patients of both sexes, of scirrhous and non-scirrhous types, and in all after non-curative surgery.

[The role of thymidylate synthetase in sequential dose of MTX and 5-FU in the advanced scirrhous type gastric cancer]

The biochemical rationale for the potentiation of the effects of 5-FU by MTX is based on an increased PRPP level or MTX polyglutamate produced by MTX. The cytotoxic action of MTX results not only from inhibition of DHFR but also depends upon thymidylate synthetase (TS), a key enzyme in DNA synthesis. We obtained a monoclonal antibody to TS using a hydrophilic peptide consisting of 20 amino acids in the TS amino acid sequence and demonstrated by PAP that TS was detectable in poorly differentiated adenocarcinoma cells but not in well differentiated adenocarcinoma cells. Upon clinical application of sequential doses of MTX and 5-FU, the median survival durations were 318 days and 156 days for scirrhous-type gastric cancer patients and non-scirrhous-type gastric cancer patients respectively. These results suggest that immunohistochemistry with TS antibody is available as an indicator of the effect of this drug regimen.

[Therapeutic treatment of Borrmann type 4 (scirrhous) gastric cancer-chemotherapy and histopathological studies]

Up to now, there has been no investigation documenting clearly the effectiveness of chemotherapy for Borrmann type 4 gastric cancer from a histopathological viewpoint. In this paper, we present a few representative cases of Borrmann type 4 gastric cancer in which microscopic examination revealed the therapeutic effectiveness (degradation of cancer cells) of neoadjuvant chemotherapy. Further, comparative studies will be needed to clarify the relationship between the assessed effectiveness of therapy by roentgenological and histopathological examination.

[Treatment methods for scirrhous carcinoma of the stomach--with special reference to total gastrectomy and chemotherapy in early postoperative period]

The problems existing in surgical treatment methods for scirrhous carcinoma of the stomach include the following: (1) highly advanced cases are frequent, (2) remnants of carcinoma in the proximal line of resection is frequent, and (3) peritoneal dissemination is frequent. Investigations were made on 76 cases of scirrhous carcinoma of the stomach in the care of our department, and the treatment methods in these cases were as follows: 1) Lymph node dissection: Lymphadenectomy of over R2 is performed. 2) Operative methods: When the cancer lesion is in A, AM, M, or MA, and when the proximal line of resection can be made in the excess of 5 cm from the tumor margin, than a sub-total gastrectomy is performed. For cancer lesions in areas other than the above, and for cancer lesions in the above but when the OW cannot be made to measure over 5 cm, a total gastrectomy is performed. In cases in which the cancer invasion extends beyond EGJ and when non-curative resection factors are absent, then an abdomino-thoracic approach is adopted. 3) Chemotherapy: There was some efficacy among the curative resected cases. Since most of the cases result in peritoneal dissemination, chemotherapy is applied during operation and during the early postoperative period.

[Cancer chemotherapy of scirrhous type gastric cancer and evaluation of chemotherapeutic efficacy]

At present, we evaluate the effects of cancer chemotherapy for gastric cancer using for criteria the general rules for gastric cancer study. Among these rules, the draft of criteria at evaluation of chemotherapy for scirrhous type gastric cancer is mentioned. Partial response (PR) is more than 100% in the rate of enlargement of the lesion area in an upright barium-filled picture. In our 53 cases, the effective rate was 3.8% [PR 2, NC 44(MR 2), PD 7]. It is sure that enlarged cases more than 100% are effective. But, in some cases enlarged less than 100%, we found certain effects clinically. We measured the area of upright barium-filled pictures in scirrhous type gastric cancer and normal control. The average control level was 200 cm2 (160-240) and that of scirrhous type gastric cancer was 108 cm2 (40-190). Thus about half of the patients cannot become PR. In this study, we attempted to evaluate the effects by improving the X-ray findings; for example wall rigidity, thickened folds and abnormal mucosal patterns in addition to the enlargement. As a result, we recognize that it is possible to evaluate by these findings. Also, the improved cases survive for a long time compared with the unchanged ones.

[A case report of patient with advanced stomach carcinoma of linitis plastica type responding to multi-immunotherapy and chemotherapy]

Multiple-drug (OK-432, PSK and SPG) immunotherapy and chemotherapy provided remission of symptoms for 36 months in a patient aged 21 years suffering scirrhous gastric carcinoma associated with carcinomatous peritonitis in which direct infiltration to the pancreas, retroperitoneum and the left colon was observed. A remarkable improvement with time was observed by endoscopic and roentgenographic observation, and a substantial improvement was also observed in the NK-cell ratios of lymphocyte subsets of the OKT series in relation to immunologic parameters. A tumor necrosis factor [TNF]-like substance was thought to have been induced by multiimmunotherapy in this case.

[Endocrine therapy of scirrhous carcinoma of the stomach]

Tissue localization of endogenous estrogens (estrone; E1, estradiol; E2, estriol; E3) progesterone was examined in scirrhous type of gastric cancer by the peroxidase-antiperoxidase (PAP) immunoperoxidase method. Twelve of 47 specimens showed positive estrogen staining, and 4 of 47 showed positive progesterone staining. The incidence of positive staining for these 4 substances was higher in male patients than in female patients. The number of specimens with positive E2 staining was the highest among E1, E2 and E3 staining. Prognosis of patients who had undergone curative surgery with positive estrogen staining were better than that of patients with negative estrogen staining. The existence of estrogen receptor (ER) and progesterone receptor (PgR) was also shown in 3 specimens and one specimen, respectively, from another 15 specimens with scirrhous type of gastric cancer by the dextran-coated charcoal assay. In a clinical test, Tamoxifen administered patients with scirrhous carcinoma following curative or noncurative gastrectomy showed better prognosis than non-Tamoxifen administered those.

[Chemotherapy of Borrmann type 4 gastric cancer]

In brief, the clinical course of patients with Borrmann type 4 gastric cancer is characterized by its marked tendency for peritoneal metastasis (P-factor). This paper dealt with the treatment of Borrmann type 4 gastric cancer from the viewpoint of the disease P-factor, and included the following topics; UFTM chemotherapy, pharmacokinetics of mitomycin C (i.v. vs i.p. use), case presentation, Port-A-catheter (implantable drug delivery system), suppression of collagen biosynthesis, prevention of the adverse effects of mitomycin C, neochemotherapy, and autopsy findings.

[Brain metastasis from breast cancer]

Thirty-seven patients with breast cancer who developed brain metastasis were analyzed. At the diagnosis of brain metastasis, all patients had widespread metastasis, and 36 patients were receiving chemotherapy. Thirty patients were treated by radiotherapy to the brain at doses of 4,000 rads. There were 6 CRs (20%) and 5 PRs (17%). The median survival time for all patients was 53 months (8-177+) from diagnosis of the primary tumor, 24 months (7-126+) from the first recurrence, and 6 months (1-47+) from diagnosis of brain metastasis. Patients who achieved CR or PR survived longer than non-responders (11+ months vs. 6 months: p less than 0.01). Several backgrounds factors were analyzed, and the results indicated that patients with better performance status survived significantly longer than those with poorer performance status (11 months vs. 4 months: p less than 0.001).