Esophageal intramural metastasis from an adenocarcinoma of the gastric cardia: report of a case

We report herein the rare case of a 65-year-old man found to have esophageal intramural metastasis from cancer of the gastric cardia. Endoscopic examination initially revealed an infiltrating ulcerative tumor of the gastric cardia involving the esophagogastric junction, as well as a submucosal tumor of the lower esophagus. A total thoracic esophagogastrectomy with lower mediastinal lymphadenectomy was performed, and the resected specimen demonstrated that both the cardia and esophageal tumors were adenocarcinomas with the same cellular differentiation. As lymphatic invasion and metastases to the paracardial and mediastinal lymph nodes were observed, the esophageal submucosal tumor was considered to be an intramural metastasis from the carcinoma of the gastric cardia resulting from extensive lymphatic spread. The patient died of recurrent disease 9 months after the resection. This case report serves to demonstrate that intramural metastasis may be a local indicator of the systemic spread of disease in patients with gastric carcinoma, as it is in esophageal carcinoma.

Selective targeting and photodynamic destruction of intimal hyperplasia by scavenger-receptor mediated protein-chlorin e6 conjugates

BACKGROUND

Photosensitizers, such as Photofrin II or Chloroaluminum-sulfonated phthalocyanine accumulate at sites of arterial injury. We have exploited this property to develop a model of photodynamic therapy (PDT) for intimal hyperplasia. The fluorescent probe [maleylated-bovine serum albumin (mal-BSA) conjugated with Texas-red] can be selectively targeted to intimal macrophages and smooth muscle cells recruited during formation of hyperplasia via a receptor-mediated mechanism.

METHODS

In this study, the photosensitizer chlorin e6 (Cle6) was conjugated to mal-BSA in a rat model of intimal hyperplasia, then tested the efficacy of the ligand conjugation to photosensitizer (mal-BSA/Cle6) in PDT of intimal hyperplasia. Arterial wall injury was produced by a balloon catheter pulled through the abdominal aorta of the rat to create a model of intimal hyperplasia. Fluorescent compounds were injected two weeks after injury.

RESULTS

Four hours after injection, the intensity of fluorescence achieved with injection of mal-BSA/Cle6 was higher for intimal hyperplastic lesions as compared to control areas. BSA-Cle6 unconjugated did not demonstrate such delivery. Two weeks after balloon injury, the injured aorta was irradiated externally with an argon pumped dye laser four hours following the photosensitizer injection. We employed two total radiant exposures: 20 J/cm2 and 40 J/cm2. Forty-eight hours after PDT, the arteries were examined histologically. Intimal hyperplastic cells were significantly reduced by PDT in the mal-BSA/Cle6 injected group (40-100%) versus the Cle6 group (0-20%).

CONCLUSIONS

Mal-BSA/Cle6 is taken up efficiently by a scavenger pathway, localizes in areas of intimal hyperplasia, and functions as a photosensitizer for PDT.

[A basic study of photodynamic therapy of experimental hepatoma with ME 2906]

We have studied effects of photodynamic diagnosis (PDD) and photodynamic therapy (PDT) in hepatoma as confirmed by the existence of hepatoma when using a new photosensitizer mono-L-aspartyl chlorin e6. Japanese white rabbits were selected to perform abdominal incision under intravenous anesthesia and transplant VX2 tumor cells into the liver left lobe for the hepatoma model. Hepatoma of 1 cm in diameter (at one week after transplantation) was used experimentally to radiate a semiconductor laser (664 nm, 200 J/cm2) for treatment.

The effects of serum on cellular uptake and phototoxicity of mono-L-aspartyl chlorin e6 (NPe6) in vitro

Previous reports showed that the photosensitizer mono-L-aspartyl chlorin e6 (NPe6) binds to serum proteins. However, the influence of this binding on the cellular uptake and photodynamic therapy (PDT) phototoxicity of NPe6 is still undefined. In this paper, we studied how serum in medium affected the P388 cellular uptake and PDT phototoxicity of NPe6 in vitro. This was assessed by (1) detection of the red shift (654 nm Q band peak of absorption) induced by protein binding NPe6; (2) detection of intracellular concentration of NPe6 by HPLC and (3) measurements of the cell survival ratio after PDT by MTT assay. The 654 nm Q band peak of NPe6 shifted to 665 nm after binding of NPe6 and serum proteins. The protein-bound NPe6 cannot be uptaken by cells, thus there was no PDT phototoxicity. Nevertheless, phototoxicity recovered when the concentration of NPe6 excessed the serum protein binding ability or there was free serum protein in the medium. These data suggested that the cellular uptake of NPe6 is inhibited by serum components in the medium, and that only free NPe6 is accumulated by P388 cells even during relatively long incubations. The cytotoxicity of PDT mainly depends on the free NPe6 level in the medium.

Tumor recurrence in patients with early gastric cancer: a clinicopathologic evaluation

We conducted a retrospective study on 711 patients with early gastric cancer. Twenty-two patients (4.0%) developed recurrent disease and 21 died of recurrence during this study. One hundred and sixty-three patients died of unrelated or unknown causes. The recurrence patterns of 22 patients were as follows: hematogeneous metastasis to the liver in 11 patients, peritoneal dissemination in 3, recurrence in the remnant stomach in 3, and in the distant lymphonodes in 1. The mean survival period of patients with recurrent disease was 50.4 months, and 7 of these patients (31.8%) died more than 5 years after surgery. A retrospective clinicopathologic evaluation of the 22 patients and 526 patients without recurrence revealed significant differences between the two groups with respect to mean age at the time of surgery (62.5 years in the recurrent group vs 57.3 years in the nonrecurrent group), tumor size (41.2 vs 30.6 mm), depth of invasion (submucosal cancer: 19 vs 256), lymphnode metastasis (11 vs 48), lymphatic (11 vs 89) and venous (7 vs 18) invasion, and operative curability (curability B: 8 vs 48). Three patients with intramucosal cancer who died of hematogenous and/or peritoneal recurrence within 7 years after surgery had neither lymphnode metastasis nor lymphatic or venous invasion, suggesting that new techniques are needed for prediction of recurrent disease in patient with early gastric cancer.

Splenectomy in cancer gastrectomy: recommendation of spleen-preserving for early stages

BACKGROUND

The prognostic significance of splenectomy in cancer gastrectomy was reevaluated, in terms of postoperative survival rate, retrospectively.

MATERIALS AND METHODS

The cumulative survival rates between a splenectomized group (n = 272) and a nonsplenectomized group (n = 192) were compared.

RESULTS

The five-, ten- and fifteen-year survival rates were significantly higher in the nonsplenectomized group in total. When the cancer was classified, according to intraoperative gross findings of the degree of serosal invasion, penetration into adjacent organs and metastases, the five-year cumulative survival rate for Stage I and II patients was significantly higher in the nonsplenectomized group. No significant difference was found between the two groups of Stage II in any of the one- to fifteen-year survival rates. The one-year survival rate for Stage IV patients in the splenectomized group was higher than that in the nonsplenectomized group.

CONCLUSIONS

The splenectomy should be limited to the Stage III or IV patients with some specific findings.

Down-regulatory role of surface CD4 molecules on autoreactive helper T cells during B cell activation

MS202 is an IL-2-dependent Th2 clone reactive to auto-MHC class II antigens as previously reported. It expresses CD4, TCR-alphabeta, Thy 1.2 and H-2k on the cell membrane, as well as CD40 ligand. In order to investigate a functional role of surface CD4 molecules on Th2 cells during B cell activation, we attempted to establish a CD4- variant subclone derived from the CD4+ MS202, and its effect on B cell activation was examined. Briefly, MS202 was incubated with ethyl methanesulfonate to induce mutation followed by extensive treatment with anti-CD4 MoAb and complement. MS1.1.2, a representative subclone of resulting cell lines, was shown to lack CD4 molecules on the cell membrane, although it possessed almost the same amount of surface molecules other than CD4 compared with the original MS202 by analysis with flow cytometry. Interestingly, MS1.1.2 induced the maturation of B cells into IgM-producing cells more potently than MS202. This differentiative effect was markedly greater on activated B cells than resting B cells; each population was prepared from splenic B cells by a gradient separation method, but after treatment with anti-IgM antibodies, resting B cells responded to MS1.1.2, resulting in the secretion of a comparative amount of IgM. Furthermore, the effect of MS 1.1.2 on DNA synthesis of activated B cells was much greater than that of MS202. The present results suggest that surface CD4 molecules on Th2 cells may not be substantially required for B cell activation, and rather mediate a down-regulation signal to B cells.

Tumor spread and outcome of treatment in primary esophageal small cell carcinoma

BACKGROUND

The most effective treatment for patients with esophageal small cell carcinoma has not yet been established because of the overall extremely poor prognosis regardless of the mode of treatment. The role of esophagectomy has been controversial in the management of patients with this disease.

METHODS

The clinicopathologic characteristics of 13 patients with primary esophageal small cell carcinoma were retrospectively studied and the prognostic significance of various factors with respect to esophagectomy were evaluated.

RESULTS

Lymph node metastases and distant metastases were found at the time of presentation in 92.3 and 46.2%, respectively. Two of nine patients treated by surgical resection for local-regional disease survived >5 years after radical esophagectomy with a projected 5-year survival rate of 22.2%. The remaining 4/13 patients were treated by nonsurgical modalities, but died of the disease within 10 months. A significant difference (P < 0.05) was detected between the survival curves of the two groups of patients.

CONCLUSION

Radical esophagectomy may be an effective treatment modality in improving survival and the odds of a cure in patients with local-regional small cell carcinoma of the esophagus.

Tumor spread and outcome of treatment in primary esophageal small cell carcinoma

BACKGROUND

The most effective treatment for patients with esophageal small cell carcinoma has not yet been established because of the overall extremely poor prognosis regardless of the mode of treatment. The role of esophagectomy has been controversial in the management of patients with this disease.

METHODS

The clinicopathologic characteristics of 13 patients with primary esophageal small cell carcinoma were retrospectively studied and the prognostic significance of various factors with respect to esophagectomy were evaluated.

RESULTS

Lymph node metastases and distant metastases were found at the time of presentation in 92.3 and 46.2%, respectively. Two of nine patients treated by surgical resection for local-regional disease survived >5 years after radical esophagectomy with a projected 5-year survival rate of 22.2%. The remaining 4/13 patients were treated by nonsurgical modalities, but died of the disease within 10 months. A significant difference (P < 0.05) was detected between the survival curves of the two groups of patients.

CONCLUSION

Radical esophagectomy may be an effective treatment modality in improving survival and the odds of a cure in patients with local-regional small cell carcinoma of the esophagus.

Increased serum CA125 levels in plasma cell dyscrasias

We report 2 cases of plasma cell dyscrasia presenting with significantly elevated serum CA125 levels. The serum levels of CA125 from these patients correlated well with their serum M-protein levels. One patient had an IgG-kappa type extramedullary plasmacytoma with the culture supernatant from lymph node plasma cells showing a considerably high level of CA125 activity. The serum IgG fraction purified using a protein A column was devoid of any detectable CA125 activity, negating that the serum IgG M-protein from this patient might respond with a false-positive result in the CA125 immunoradiometric assay. The other patient had an IgG-lambda type plasma cell leukemia with the culture supernatant from peripheral mononuclear cells also showing a high level of CA125 activity. These observations may suggest that in plasma cell dyscrasias the CA125 antigen is spontaneously produced by tumor cells.

Evaluating the rational extent of dissection in radical esophagectomy for invasive carcinoma of the thoracic esophagus

To define the rational extent of dissection in radical esophagectomy for esophageal cancer, survival was studied according to nodal status in 154 patients undergoing extended radical esophagectomy. The incidence of cervical metastasis in patients with upper or middle esophageal tumors did not differ between those with favorable (grade N < or = 4) or unfavorable (grade N > or = 5) lymph node status, at 28.6% vs 20%, respectively. On the other hand, in patients with lower esophageal tumors, the incidence of cervical metastasis was significantly lower in those with favorable grade (grade N < or = 4) node status than in those with unfavorable grade (grade N > or = 5) node status, at 6.5% vs 46.7%, respectively. Survival did not differ in patients with upper or middle esophageal tumors according to whether they had regional (n = 42) or distant (n = 15) lymph node metastases, the 5-year survival rates being 11.6% vs 25%, respectively. However, in patients with lower esophageal tumors, none of 10 patients with distant node metastases survived for more than 4 years, whereas the survival rate was 43.7% at 5 years for 36 patients with regional node metastases. These results show that cervical lymphadenectomy should only be performed as part of radical esophagectomy in those patients with upper or middle esophageal cancer.

Points to be considered for conducting toxicokinetic studies under GLP and for validating analytical methods

Issues discussed by TK Working Group of the JPMA for the implementation of ICH guideline for toxicokinetics (TK) are summarized. 1) A unique management system may be needed for toxicokinetic studies, when TK measurements are conducted in a center for pharmacokinetics and metabolism studies, i.e. in a separate location or by an independent organization from those for toxicity studies. 2) TK measurement should be conducted in compliance with the protocols and validated SOPs for analytical methods. 3) Every time when study conditions in toxicity studies and/or TK measurement are changed, the analytical method should be more or less revalidated. The present paper will discuss some practical issues to be involved in such situations, and possible countermeasures for them.

Modulation of cisplatin sensitivity and resistance by buthionine sulfoximine and cyclosporin A in human esophageal cancer cells

We established a 2.4-fold cisplatin (CDDP)-resistant human esophageal cancer cell line (TE2R) from the parent TE2 line. CDDP accumulation was reduced in TE2R. The Na+, K+-ATPase inhibitor ouabain inhibited CDDP accumulation in TE2 but not TE2R, suggesting that TE2R may have alterations in the Na+, K+-ATPase and defective CDDP uptake mechanism. Buthionine sulfoximine (BSO) enhanced CDDP sensitivity of both cell lines and cyclosporin A (CsA) modified CDDP resistance in TE2R. These effects were associated with increased CDDP accumulation. Thus, BSO and CsA may be useful for modulation of CDDP sensitivity or resistance in esophageal cancer.

Photodynamic therapy with a diode laser for implanted fibrosarcoma in mice employing mono-L-aspartyl chlorin E6

The authors performed photodynamic therapy (PDT), avoiding any hyperthermic effects, using a newly developed diode laser and photosensitizer, mono-L-aspartyl chlorin e6 (NPe6), of Meth-A fibrosarcoma implanted in mice and achieved tumor therapeutic benefit. The photodynamic light treatment was performed 5 h following the photosensitizer administration. With 5.0 mg/kg NPe6 and light doses of 50, 100, 150 and 200 J/cm2, the tumor cure rates were 20, 50, 70 and 90%, respectively. With 100 J/cm2 laser exposure and NPe6 doses of 1.25, 2.5, 5.0, 7.5 and 10.0 mg/kg, the tumor cure rates were 0, 20, 50, 70 and 90%, respectively. A charge-coupled device (CCD) camera system was employed to measure the NPe6 fluorescence intensity correlating with the residual amount of the photosensitizer at deferent depth from the tumor surface. The ratios of the NPe6 fluorescence intensity at 3 mm from the tumor surface following 50, 100, 150 and 200 J/cm2 laser exposure to no laser exposure were 0.73, 0.36, 0.22 and 0.16, respectively. With samples sectioned at 1 mm depth, after 50 J/cm2 and the same photosensitizer dose (5 mg/kg) this ratio was 0.19. These results suggest that a certain increase in the tumor tissue level of NPe6 and a certain increase of laser light dose reaching deeper layer of tumor caused an increase in percent cure. In addition, the effectiveness of PDT depends on the total laser dose reaching deeper layers of tumors. Furthermore, the effectiveness of PDT tends to correlate with the amount of NPe6 photobleaching by PDT.

Carcinomas involving the esophagogastric junction (EGJ-Ca). A reevaluation of the criteria

The present study aims to elucidate more clearly the definition and criteria for carcinomas involving the esophagogastric junction (EGJ-Ca) from a practical viewpoint based on the concept that an EGJ-Ca is a separate surgical disease entity different from either a lower-esophageal or an upper-gastric carcinoma. Among a series of 397 cases of upper-gastric carcinoma and EGJ-Ca resected during a 31-year period between 1963 and 1993, 79 patients with EGJ-Ca (EGJ-Index ranging between 250 and 750) were selected according to lesions with the central point confined within the EGJ-zone 20 mm each proximal and distal to the EGJ-line. Selected for the control group were 97 patients with upper-gastric carcinoma that was strictly confined within the upper third segment of the stomach without involving the EGJ-line upward or the middle third segment downward and with the central point of lesions outside the EGJ-zone. The comparative analysis indicated that an EGJ-Ca might be well defined not only by the EGJ-Index, but also by the EGJ-zone and the localization of the central points of lesions confined within the EGJ-zone. The definition and criteria for EGJ-Ca were thus modified from those of the previous proposal and proposed in this study with three main factors: (1) the EGJ-Index, (2) the EGJ-zone, and (3) the localization of the central point of lesions.

The relationship between quantitative changes in collagen and formation of wrinkles on hairless mouse skin after chronic UV irradiation

Female albino hairless mice were irradiated chronically with sub-erythemal doses of UVB radiation. Collagen extracted from the irradiated or non-irradiated dorsal skin of mice was fractionated into neutral salt-soluble (NSC), acid-soluble (ASC) and insoluble fractions (ISC). An age-related exponential decrease in the content and proportion of acid-soluble collagen was found in each group. The contents and the proportions of ASC from irradiated mice were always significantly lower than those from age-matched control animals. Age-related slight decreases were observed in the contents (per fresh weight of tissues) of NSC, ISC and total collagen in the control group but decreases in these collagen contents after UVB irradiation were marked. A dramatic decrease in ASC occurred nearly concomitantly with wrinkle formation in the irradiated mice. The decrease of acid-soluble skin collagen in irradiated mice may play a role in the formation of wrinkles on hairless mouse dorsal skin.

Chromatic regulation inChlamydomonas reinhardtii alters photosystem stoichiometry and improves the quantum efficiency of photosynthesis

The work addressed the adjustment of the photosystem ratio in the green algaChlamydomonas reinhardtii. It is shown that green algae, much like cyanophytes and higher plants, adjust and optimize the ratio of the two photosystems in chloroplasts in response to the quality of irradiance during growth. Such adjustments are compensation reactions and helpC. reinhardtii to retain a quantum efficiency of oxygen evolution near the theoretical maximum. Results show variable amounts of PS I and a fairly constant amount of PS II in chloroplasts and suggest that photosystem stoichiometry adjustments, occurring in response to the quality of irradiance during plant growth, are mainly an adjustment in the concentration of PS I. The work delineates chromatic effects on chlorophyll accumulation in the chloroplast ofC. reinhardtii from those pertaining to the regulation of the PS I/PS II ratio. The detection of the operation of a molecular feedback mechanism for the PS I/PS II ratio adjustment in green algae strengthens the notion of the highly conserved nature of this mechanism among probably all oxygen evolving photosynthetic organisms. Findings in this work are expected to serve as the basis of future biochemical and mutagenesis experiments for the elucidation of the photosystem ratio adjustment in oxygenic photosynthesis.

Scanning electron microscopic analysis of acute photodynamic therapy for atherosclerotic plaques of rabbit aorta by using a pheophorbide derivative

The aim of this study was to demonstrate acute efficacy of photodynamic therapy on atheromas by using a pheophorbide derivative, PH-1126. Cholesterol-fed atherosclerotic rabbits were injected intravenously with 1 mg/kg of PH-1126. Twenty-four hours later, PH-1126 selectively accumulated in atherosclerotic plaques. Then, atherosclerotic lesions in the upper thoracic aorta were treated by irradiation with a krypton ion laser at a wave-length of 647 nm. At 6 h after photodynamic therapy, the treated aorta was examined by scanning electron microscopy. Numerous teardrop-shaped cells were observed on the endothelial surface of the plaque irradiated at a total energy of 100 J/cm2. These cells were larger than monocytes and macrophages, and resembled foam cells in size and shape. The body of the teardrop-shaped cell resembled pumice stone, mainly because of the presence of globular elements in the cytoplasm. A part of the cell appeared to remain in the subendothelial space. These findings suggest that the cells may be foam cells from the intimal layer of atherosclerotic plaque that were expelled into the aortic lumen. It may become possible to flatten atheroma in a long-term period after photodynamic therapy using PH-1126 as a potent photosensitizer.

Biphasic intra-abdominal desmoplastic small cell tumor in a patient with proximal spinal muscular atrophy

A case is reported of intra-abdominal desmoplastic small cell tumor (IDSCT) with biphasic histologic features in a patient with proximal spinal muscular atrophy. The tumor was composed of small epithelial cell nests with spindle cell sarcomatous areas. Both areas were surrounded by a desmoplastic stroma. Immunohistochemical studies revealed reactivity for low molecular weight cytokeratin, epithelial membrane antigen, vimentin, desmin and Leu-7 in both areas. Electron microscopic examination demonstrated paranuclear aggregates of intermediate filaments, zonula adherens and basement membrane-like material in the epithelial cells, while spindle cells in the tumor had fewer intracytoplasmic organelles. However, intermediate or transitional forms of both types of tumor cells were frequently observed. Although IDSCT are known to express multi-phenotypes immunohistochemically, attention should be paid to the broad spectrum of cell morphology in these tumors.

Intramural metastases from thoracic esophageal cancer: local indicators of advanced disease

The patterns of tumor spread and long-term survival of patients with (n = 54) and without (n = 270) intramural metastasis from esophageal cancer were investigated after either extended radical (n = 155) or less radical (n = 169) esophagectomy. The purpose was to evaluate whether extended radical esophagectomy has an impact on the long-term survival of patients with intramural metastases from the disease. The patients with intramural metastasis had significantly larger primary tumors (p < 0.01) and more frequent T4 tumors (p < 0.001), stage IV disease (p < 0.05), lymphatic invasion (p < 0.05), and lymph node metastasis (p < 0.01) than did those without intramural metastasis. The survival rates of patients with intramural metastases were significantly worse than those of patients without intramural metastases after resection (p < 0.001). No patient with intramural metastases survived more than 4 years after either extended or less radical esophagectomy, and there was no significant difference between the two survival curves. Therefore intramural metastases should be considered local indicators of advanced esophageal cancer, and radical esophagectomy may not be indicated for patients with intramural metastasis from the disease.