Surgical treatment for gastric carcinomas with concomitant hepatic metastasis

BACKGROUND/AIMS

We have reviewed our experience with gastric cancer patients having synchronous liver metastasis in an attempt to clarify how to treat such patients.

PATIENTS AND METHODS

In 116 patients with gastric cancer metastatic to the liver, evaluations were executed to find an effective treatment. Fourteen received gastrectomy plus hepatic resection (Group A), 68 gastrectomy alone (Group B), and 34 non-resected (Group C).

RESULTS

The average survival time was 15.0 months in Group A, 7.2 months in Group B and 3.6 months in Group C, with a statistical difference between Group B and Group C (p < 0.05). In Group A patients, the mean survival time was 21.5 months in those undergoing potentially curative surgery for the carcinoma without incurable factors other than liver metastasis. The survival time was 6.3 months in those undergoing noncurative gastrectomy and hepatectomy because of evidence of incurable metastatic spread, the value being similar to that following gastrectomy alone in Group B patients. In Group B, adjuvant chemotherapy led to a significant increase in survival (p < 0.05).

CONCLUSIONS

Hepatectomy combined with gastrectomy seems to be effective as an active measure to lengthen survival for patients of gastric carcinoma and concomitant liver metastasis only when other incurable factors were not evident at operation. Noncurative gastrectomy followed by adjuvant chemotherapy is recommended in the presence of various incurable factors.

Transforming growth factor-beta 1 induces apoptosis in gastric cancer cells through a p53-independent pathway

BACKGROUND

Apoptosis is induced by various anticancer agents or radiation through the tumor suppressor gene p53-dependent pathway and is also induced by other factors, including transforming growth factor-beta 1 (TGF-beta 1). In this study, the authors investigated whether TGF-beta 1 would induce apoptosis in gastrointestinal cancer cells, and its relation to the status of the p53 gene.

METHODS

The induction of apoptosis by TGF-beta 1 was determined in 12 gastrointestinal cancer cell lines using DNA ladder formation. Status of the p53 gene was examined by sequencing of cDNA from p53 mRNA and expressions of TGF-beta 1 mRNA and TGF receptors I and II mRNAs were determined by Northern blot analysis and the reverse transcriptase-polymerase chain reaction analysis, respectively.

RESULTS

Of 12 cell lines, wild-type p53 was present in 3 lines, point mutation was detected in 7 lines, and p53 mRNA was absent in 2 lines. TGF-beta 1 was expressed in all 12 lines, but both TGF receptors I and II were expressed in only 6 lines. Addition of TGF-beta 1 induced DNA ladder formation only in KATOIII cells, with deleted p53 mRNA, but expressed TGF receptors I and II.

CONCLUSIONS

These findings show that TGF-beta 1 induces apoptosis in gastric cancer cells through TGF-beta receptors I and II and a p53-independent pathway.

Multidrug resistance-associated protein expression in clinical gastric carcinoma

BACKGROUND

We examined the relationship between the expression of a multi-drug resistance-associated protein (MRP) and the biologic factors regarding invasion and metastasis of human gastric cancer.

METHODS

In 75 patients with gastric cancer, the expression of MRP was immunohistochemically investigated and the expression of MRP mRNA was also detected using reverse transcription PCR (RT-PCR). Sensitivity to the anticancer agents, cisplatin (CDDP), doxorubicin (DXR), etoposide (VP-16), and mitomycin C (MMC) was examined using the MTT {3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl[2H]-tetra-zolium bromide} assay. The relation between MRP expression and development, invasion, and metastasis of cancer was analyzed, and overexpression of the tumor suppressor gene p53 was investigated, immunohistochemically.

RESULTS

Immunohistochemically detected MRP positive tumors were noted in 34 of 75 excised tumors (45%), and confirmed by RT-PCR. There was no significant relation between MRP expression and clinicopathologic features or prognosis. Positive p53 staining was evident in 16 of 34 MRP positive tumors (47%) and 18 of 41 negative ones (44%), and there was no significant correlation between MRP and abnormal p53 expression. The MTT assay showed that MRP positive gastric cancer tissue was less sensitive to CDDP, DXR, and MMC compared with MRP negative ones. A similar tendency was noted with VP-16.

CONCLUSIONS

MRP expression relates to the chemosensitivity of tumor cells against some anticancer drugs and is independent of known factors related to the development, invasion, and metastasis of human gastric cancers.

Vasoacting agents flavone acetic acid and hydralazine given in combination enhance antitumor effects under condition of hyperthermia

The combined effects of flavone acetic acid (FAA), hydralazine (HYD) and hyperthermia on B16 melanoma cells and solid tumor were examined in vitro and in vivo. In vitro, hyperthermia did not enhance the cytotoxicity of the combined use of FAA and HYD. In vivo, growth inhibition of B16 melanoma solid tumor by FAA (150 mg/kg) combined with HYD (5.0 mg/kg) could not be differentiated from that by FAA or HYD alone. Increased antitumor effect was recognized when FAA combined with HYD was used under conditions of hyperthermia. FAA combined with HYD significantly reduced tumor blood flow compared to FAA alone or HYD alone. We thus conclude that the significant reduction in tumor blood flow may play an important role in the enhanced antitumor effects of the combined treatment with FAA, HYD, and hyperthermia.

Apoptosis in tumors and normal tissues induced by whole body hyperthermia in rats

Apoptosis in tumor and normal tissues was examined in rats treated with whole-body hyperthermia (WBH; 41.5 degrees C for 2 h). WBH alone produced 0.5 day of tumor growth delay (TGD) in a fibrosarcoma and 5.8 days of TGD in the Ward colon carcinoma. This difference in WBH-induced TGD indicates that the fibrosarcoma is relatively resistant to WBH, whereas the Ward colon carcinoma is relatively heat sensitive. A quantitative histological assay for apoptosis demonstrated that the extent of apoptosis in the fibrosarcoma reached a maximum level of 19% 4 h after WBH and returned to the control level by 24 h. In contrast, WBH induced apoptosis with a peak value of 43% at 8 h in the Ward colon carcinoma, and the apoptotic level remained elevated above the control level until 48 h after WBH. Within normal tissues, the spleen and the lymph nodes showed WBH-induced apoptosis; however, the highest level of WBH-induced apoptosis as well as the most prolonged increase in apoptotic levels occurred in the thymus. The WBH-induced apoptosis in the thymus remained elevated above the control level until 48 h after WBH. Within the entire gastrointestinal tract, the small intestine was the most sensitive to WBH. Apoptotic cells were observed in the small bowel mucosa following WBH exposure. We also noted a minor WBH-induced increase in the apoptotic level in the bone marrow. Except for the case of the thymus, increased apoptotic levels in the normal tissues declined after peak levels at 4 h, and apoptosis above control levels was not seen beyond 12 h following WBH. Thus, within the normal tissues, WBH-induced apoptosis declined to basal levels within 12-48 h. These data indicate that both the extent and the kinetics of WBH-induced apoptosis differ between the two tumors and, meaningfully, between tumor and normal tissues. The extent and duration of apoptosis seem to correlate with tumor response to WBH.

Beta-adrenergic stimulation induces ST-segment elevation in dogs with healing myocardial infarction

There is controversy with regard to the mechanism of the exercise-induced ST-segment elevation in myocardial infarction. The purpose of the present study was to investigate the mechanism of ST-segment elevation through pharmacologic interventions. Transmural anterior myocardial infarction was produced by gelatin sponge embolization of the left anterior descending artery in seven closed-chest dogs. One and four weeks after myocardial infarction, the dogs underwent the following three interventions: right atrial pacing, norepinephrine infusion (3.75, 7.5, and 15 micrograms/min) with the pacing, and methoxamine injection (2.5 and 5.0 mg) with the pacing. All dogs had transmural infarction with a mean infarct size of 12.0 +/- 4.2% of the left ventricular weight. Right atrial pacing did not induce significant changes in ST-segment. Norepinephrine induced a marked elevation of ST-segment at leads V1 to V4, while methoxamine did not. Norepinephrine induced a significant increase in left ventricular ejection fraction, while methoxamine produced a marked decrease in the ejection fraction and an increase in ventricular volume. The mean percent radial shortening of the non-infarct ventricular wall showed a significant increase with norepinephrine, but a decrease with methoxamine. In conclusion, myocardial ischemia and wall motion abnormality may be excluded as possible mechanisms of ST-segment elevation and an enhanced beta-adrenergic mechanism in the non-infarct myocardium is suggested to be responsible for ST-segment elevation.

[A case of desmoplastic malignant mesothelioma]

A 43-year-old man was admitted to Nara Medical University Hospital because of right-sided chest pain. Computed tomographic examination revealed a right pleural effusion and diffuse pleural thickening. Malignant mesothelioma was diagnosed from the results of a percutaneous pleural biopsy, and the patient then underwent right pleuro-pneumonectomy. The resected specimen was examined by light and electron microscopy, which revealed scattered sarcoma-like malignant cells with some epithelial differentiation, in abundant extracellular collagen with storiform derangement. Therefore, desmoplastic malignant mesothelioma (mixed type) was diagnosed. This is a rare histological subgroup of malignant mesotheliomas. The patient died 2 months after the operation, due to multiple and rapidly growing metastases. After lung tissue was dissolved, ferruginous (asbestos) bodies were counted, and the results were consistent with occupational exposure to asbestos (413 asbestos bodies per 5 g of lung tissue).

Surface-coil magnetic resonance imaging of the internal auditory canal and the inner ear. Preliminary report

Parasagittal surface-coil magnetic resonance imaging of the internal auditory canal and the inner ear was performed. We used T2-weighted fast spin-echo sequences to visualize the inner ear and the individual nerves in the internal auditory canal with high contrast in a short acquisition time. Computer-assisted quantitative measurement of the nerves was performed to estimate the cross-sectional areas and the diameters of the nerves. The average diameters of the facial nerve, the cochlear nerve, and the vestibular nerve of normal-hearing individuals were, respectively, 1.1 +/- 0.2 mm (mean +/- SD), 1.2 +/- 0.2 mm, and 1.5 +/- 0.2 mm. In the cerebellopontine angle, the average diameter of the eighth nerve was 1.8 +/- 0.2 mm. Two patients with unilateral and bilateral hearing loss were also presented. In the patient with unilateral deafness, the cochlear nerve of the diseased side was not identified and the eighth cranial nerve diameter was smaller than that of the normal side. In the patient with bilateral deafness, fibrosis of the inner ear and atrophy of the eight nerve were demonstrated in the ear with posttraumatic deafness. The present method may represent a new approach to the assessment of pathologic processes involving the inner ear and the nerves in the internal auditory canal.

[Reproductive toxicity of iodixanol, a new non-ionic, iso-tonic contrast medium in rats and rabbits]

The reproductive toxicity of iodixanol, a non-ionic isotonic contrast medium, was investigated in rats and rabbits. Iodixanol was administered intravenously to male rats at doses of 0.3, 1.0 or 2.0 gI/kg/day for 80 days or more until successful copulation. Female rats were treated with iodixanol at the same dose levels for at least 14 days prior to and in the early stage of pregnancy. No remarkable adverse effects on fertility were noted at any dose level. Increased water consumption and swollen paws/face were observed among male rats receiving > 1.0 gI/kg/day. In addition, decreased food consumption was observed in males of the 2.0 gI/kg/day group. In female rats, no remarkable adverse effects were noted at any dose level. Iodixanol elicited no evidence of teratogenicity when administered during the fetal organogenesis period to pregnant rats and rabbits at doses of 0.3, 1.0 or 2.0 gI/kg/day. No remarkable changes were observed in rat or rabbit fetuses, nor in dams of any dose group. In a perinatal and postnatal dosing study in rats using doses of 0.3, 1.0 or 2.0 gI/kg/day, iodixanol did not adversely affect the reproductive performance of the treated parent animals and pre- and postnatal development of their offspring.

[Two-color flow cytometry analysis of lymphocyte subsets in patients with acute myocardial infarction and post-myocardial infarction syndrome]

Serial changes in lymphocyte subsets were analyzed in 37 patients with acute myocardial infarction (AMI), in 2 patients with postmyocardial infarction syndrome (PMIS), and in healthy subjects (control group) using two-color flow cytometry to investigate cellular immunity after AMI and PMIS. Peripheral blood lymphocyte subsets were measured on admission and at weeks 2, 4, 8, and 16 after the onset of AMI. The white blood cell count was significantly higher on admission and at week 2 in the AMI group compared with the control group. The percentage of CD4-positive helper T cells was significantly higher on admission and at weeks 2 and 4 in the AMI group compared with the control group, and the percentage of CD8-positive suppressor T cells was significantly lower in the AMI group at week 2 than in the control group. The ratio of helper-to-suppressor T cells peaked 2 weeks after the AMI and then decreased gradually. There were no significant changes in the CD4/CD8 ratio, the percentage of cytotoxic T cells, or the percentage of inducer T cells, throughout the observation period. There were no significant differences in the percentage of T cells, B cells, CD4-positive T cells, CD8-positive T cells, and natural killer cells between AMI patients and control subjects. The percentage of activated CD4- and CD8-positive cells was higher in the AMI group at weeks 4 and 8 than in the control group. There was no significant correlation between changes in lymphocyte subsets and infarct size. The percentage of activated CD8-positive cells was consistently higher in the PMIS group compared with the control and AMI groups. The percentage of cytotoxic T cells in one of the PMIS patients was significantly higher than in the AMI group. There were no significant differences in the proportions of other subsets between PMIS and AMI patients. The changes in lymphocyte subsets observed in patients with AMI suggested that immunological competence was enhanced in these patients. Abnormalities in humoral immunity, such as the appearance of anticardiac antibody, have been observed in patients with PMIS. Our results suggest that PMIS is also associated with changes in cellular immunity.

Male reproductive toxicity study of nefiracetam in rats

Sprague-Dawley male rats were administered nefiracetam orally at daily doses of 500 and 1500 mg/kg/day for 4 or 9 weeks. Although the copulation index was not affected by nefiracetam treatment, the fertility index was extremely low in the 1500 mg/kg/day group for both treatment periods. This high dose group consistently exhibited decreased testicular weights. Epididymal and prostate weights were also reduced in the 1500 mg/kg/day group after both 4- and 9-week treatments and in the 500 mg/kg/day group after the 9-week treatment. Severe degenerative changes such as degeneration of germ cells, loss of germ cells and atrophy of seminiferous tubules were observed in all rats of the 1500 mg/kg/day groups after both 4 and 9 weeks of treatment. Retention of spermatids in stage IX, X and XI seminiferous tubules was also noted after the 4- and 9-week treatments at 500 mg/kg/day. The testicular sperm head counts were markedly decreased following the 4- and 9-week treatments at 1500 mg/kg/day, and mildly reduced after the 4-weeks treatment at 500 mg/kg/day. From these results it is concluded that histopathological examination and the testicular sperm head count method are highly useful for detecting testicular toxicity and that testicular lesions caused by nefiracetam can be detected after 4 weeks of exposure.

Cyclosporin A and FK506 reverse anthracycline resistance by altering the cell cycle

We investigated the effect of cyclosporin A (CsA) or FK506 on the cytotoxicity of anthracyclines against a human laryngeal cancer cell line, KB cells, and a multi-drug resistance cell line, VJ-300 cells. CsA and FK506 enhanced the cytotoxicity of anthracyclines, especially in the VJ-300 cells. The intracellular concentrations of epirubicin (EPIR), daunomycin (DM), adriamycin (ADM) and THP-adriamycin (THP) were increased by the addition of CsA or FK506 in VJ-300, but not in KB cells. The intracellular accumulation of EPIR was most increased when CsA or FK506 was concomitantly administered with the drug. We also asked whether CsA or FK506 might influence the cycle of KB or VJ-300 cells. The population of cells in each phase of the cell cycle was little changed in both KB and VJ-300 cells when 0.3 microM ADM was administered for 24 h. Both CsA and FK506 significantly increased the ADM-induced accumulation of VJ-300 cells in G2M phase, in comparison with findings with KB cells. Thus, the reversal of MDR by CsA or FK506 is related to increased intracellular concentrations of cytotoxic drugs and, as a result, the increased G2M accumulates in MDR cells. Among of antrhacyclines, EPIR was most effective when concomitantly combined with CsA or FK506 in VJ-300 cells.

Macroscopic intraoperative diagnosis of serosal invasion and clinical outcome of gastric cancer: risk of underestimation

Data on 715 Japanese patients with gastric cancer were studied retrospectively with regard to the relationship between macroscopic and microscopic diagnoses of serosal invasion and clinicopathological factors affecting the accuracy of the macroscopic diagnosis. Although there was no macroscopic evidence of serosal invasion intraoperatively (S0 or S1), there was histological evidence of cancer cells on the serosal surface in 69 patients (9.7%). In these serosal invasion-positive cases, the tumors were larger; were located more commonly in the upper third, lesser and greater curvatures of the stomach; were Borrmann type 3 or type 4 tumors, and of an undifferentiated histologic type with an infiltrative growth pattern more commonly, and had more extensive lymphatic and vascular vessel invasion and lymph node metastasis (P < 0.01). Total gastrectomy was done more often for the serosal invasion-positive group, but the extent of lymph node dissection was comparable. Cases of a noncurative resection because of a positive surgical margin were more frequent in the serosal invasion-positive group (8/69 vs. 14/646, P < 0.01), and most had undifferentiated and infiltrative cancers. The 10-year survival rates were 49.2% and 85.5% for patients with and without serosa invasion, respectively. These findings clearly show that the serosal surface, especially in cases of the undifferentiated or infiltrative type of gastric cancer, must be closely inspected intraoperatively.

[DNA ploidy pattern and p53 overexpression in gastric cancer]

DNA ploidy pattern was determined by flow cytometry and p53 overexpression was investigated immunohistochemically in 145 primary gastric cancers. Aneuploid patterns were found in 78 (65%) and diploid patterns in 67 (46%). Metastasising to lymph nodes was observed more frequently in cases with aneuploid tumors, as compared to those with diploid tumors (p < 0.01). DNA ploidy patterns were related to overexpression of p53. The incidences of overexpression of p53 in aneuploid tumors and diploid ones were 65% and 33%, respectively (p < 0.05). Thus, we suggest that gastric carcinomas with the aneuploid pattern have mutation of tumor suppressor gene p53 and high potential to metastasize to lymph nodes.

Clinicopathologic characteristics and outcome of adenocarcinoma of the human gastric cardia in comparison with carcinoma of other regions of the stomach

BACKGROUND

Carcinoma arising in the cardioesophageal junction is a distinct clinical entity compared with tumors located in other regions of the stomach. This study was done to analyze the biologic characteristics of carcinoma of the gastric cardia compared with other gastric carcinomas.

STUDY DESIGN

Clinicopathologic features and postoperative prognosis of 68 cases of carcinoma of the cardia were evaluated, in comparison with findings of tumors in other regions of the stomach.

RESULTS

From 1975 to 1992, 68 (6.5 percent) of 1,042 patients with carcinoma of the stomach had adenocarcinoma of the cardia. Carcinoma of the cardia was characterized by a more advanced stage compared with carcinoma of other regions of the stomach. The incidence of early stage carcinoma (limited to the submucosal layer) was 11.8 percent in the cardia, 15.8 percent in the upper one-third, and 42.2 percent in the remaining middle and lower thirds of the stomach. When compared to carcinoma in other regions of the stomach, tumors of the cardia had a significantly poorer prognosis and there was a higher incidence of lymph node and hepatic metastasis. The five-year survival rates in patients with adenocarcinoma in the cardia, the upper one-third, and the remaining middle and lower thirds of the stomach were 35.3, 43.7, and 61.9 percent, respectively. Especially for patients with stage II and stage III disease, the prognosis was significantly worse with adenocarcinoma of the cardia than with carcinomas of the other regions of the stomach.

CONCLUSIONS

Early detection is crucial to improve the survival of patients with carcinoma of the gastric cardia. Extended dissection of lymph nodes and aggressive postoperative chemotherapy in an attempt to prevent hepatic metastasis are highly recommended.

Clinicopathological features of patients who died with second primary cancer after curative resection for gastric cancer

The appearance of a second cancer in patients who had undergone curative operation for the first gastric cancer is one of the crucial problems for the clinician. We analysed data on 910 patients with gastric cancer treated with curative resection, with respect to the risk factors for second primary cancer and the prognosis. Of 910 patients, 69 (7.6%) died with a second primary cancer. In patients with a second primary cancer, there were more men and age was more advanced, compared to the survivors. The gastric tumor was larger, the serosal invasion was more prominent and lymphatic involvement was more frequent. The postoperative 5-year survival for patients with a second primary cancer was 60.9%, the 10-year rate was 31.9% and the 15-year was 19.6%. Multivariate analysis revealed that risk factors for a second primary cancer was advanced age, male sex and a larger tumor. Our findings suggest that during the follow-up of patients with gastric cancer treated by curative resection and risk factors, a second primary cancer may occur in other organs, in addition to a recurrence of the first cancer.

[Anesthetic management of Seckel syndrome: a case report]

Seckel syndrome is a rare syndrome of chromosome aberration, in which bird-headed dwarfism, microcephalus and other minor deformities are recognized. A 24-year-old male patient with Seckel syndrome underwent both abdominal and orthopaedic surgeries in 1 year under general anesthesia. The first operation was an emergent operation under preshock state and enterostomy was performed. The second was arthrodesis of the hip joint. Before the second operation, laryngeal CT, tomography and fiberscopy revealed stenosis just below his vocal cord. During the second operation, the anesthesia was unsatisfactory with inhalation of nitrous oxide and sevoflurane and intravenous vecuronium, because of intraoperative abnormal hypertension. But the recovery from the anesthesia was prompt. Although we experienced no difficulty in intubation except for intraoperative abnormal hypertension, preoperative laryngeal and renal examinations are necessary in the anesthetic management of this syndrome.

[Immunohistochemical study of the endomyocardial biopsy of systemic lupus erythematosus]

The mechanisms of cardiac involvement in systemic lupus erythematosus (SLE) were studied using immunohistochemical staining of endomyocardial biopsy specimens from 14 patients with SLE and normal coronary arteriograms. All 14 specimens showed mild interstitial edema, 11 showed mild cardiac fibrosis, and another two cases showed moderate cardiac fibrosis with myocardial derangements. Four specimens showed moderate cell infiltration in the interstitium. Area of fibrosis, diameter of myocardium and area of interstitial edema were increased in the SLE patients compared to the control cases. Immunofluorescence showed IgG and fibrinogen deposition in the membrane of cardiac myocytes and in the interstitium. Immunohistochemistry found no B lymphocytes in any of the seven SLE cases. T lymphocytes were observed in all seven SLE cases, and OKT 8 lymphocytes were increased significantly in the interstitial tissue as compared with OKT 4 lymphocytes. At endomyocardial biopsy, all 14 patients were receiving corticosteroid therapy and had low activity disease. The results suggest that cardiac tissue damage was associated with immunological abnormalities and might progress silently under conditions in which the disease activity was suppressed by corticosteroid therapy.

Growth pattern and p53 overexpression in patients with early gastric cancer

BACKGROUND

The growth pattern of early gastric carcinoma, based on a volumetric analysis, reflects well biologic characteristics of the tumor. The penetrating growth (Pen) type tumor has an unfavorable prognosis, compared with a superficially spreading (Super) type. Abnormality of the p53 suppressor gene plays an important role in alteration of cells leading to development of cancer. p53 point mutations are present even in an early stage of carcinoma.

METHOD

In 159 patients with early gastric carcinoma, overexpression of p53 was studied immunohistochemically, using a monoclonal antibody (PAb 1801), and the relationship between growth pattern and p53 overexpression was analyzed.

RESULTS

Early gastric carcinoma was grouped into 43 of the Super type, 37 of the expansively penetrating growth (Pen-A) type, 16 of the infiltratively penetrating growth (Pen-B) type, and 63 of the Small mucosal type limited to the mucosal layer. The Pen-A type tumors were characterized by the highest incidence of p53 positive expression and poorest postoperative course. Between the Pen-A type and the Super type, there were significant differences in the incidence of the p53 positive expression (43% vs. 16%), the frequency of recurrence (16% vs. 7%), and disease free interval (574 days vs. 2926 days).

CONCLUSION

The authors' observations show that the p53 gene plays an important role in expansion of gastric carcinoma, even in the early stages.

Surgical treatment and prognosis for patients with gastric cancer lesions larger than ten centimeters in size

In 323 of 1,620 patients with gastric cancer, the lesion was > or = 10 cm in maximum diameter. Studies were done with respect to clinicopathologic features and the prognosis. Patients with tumors > or = 10 cm were younger and women patients were more numerous compared to those with tumors < 10 cm. Tumors were more advanced and noncurative resection was usually done for these patients. A multivariate analysis showed that serosal invasion, liver metastasis, lymph node metastasis, operative curability, tissue differentiation, and extended lymph node dissection to be independent prognostic factors. This retrospective study showed that patients with a larger tumor are at an increased risk for tumor advancement and that they will benefit from curative resection and extended lymph node dissection.

Acute left ventricular failure with pulmonary edema following pericardiocentesis for cardiac tamponade--a case report

We describe the complications of pericardiocentesis and their management in an 18 year-old man. This patient was admitted because of dyspnea and was found on echocardiogram to have cardiac tamponade with coexisting left ventricular dysfunction. He developed acute left ventricular failure with severe pulmonary edema immediately after pericardiocentesis. This complication may have been caused by an abrupt increase in venous return to the failing left ventricle following the release of the pericardial compression. Therefore, pericardial fluid must be drained with caution in pericardiocentesis, especially in cardiac tamponade patients with left ventricular dysfunction, and hemodynamics should be monitored both during and after this procedure.

Reconstruction of the lips, oral commissure, and full-thickness cheek with a composite radial forearm palmaris longus free flap

Reconstruction of the lower and upper lips, commissure, and full-thickness cheek defects using a composite radial forearm palmaris longus free flap with secondary commissuroplasty is described. This flap is useful for reconstruction of the total lower lip as well as larger defects that include full-thickness cheek and the commissure.

Lymphatic advancement to peritoneal dissemination and liver metastasis in gastric cancer patients

Lymph node metastasis is a risk factor for the occurrence of peritoneal dissemination and liver metastasis in patients with gastric cancer. We analysed data on 893 Japanese patients with serosally invasive gastric cancer, with respect to the relation between lymph node metastasis and peritoneal dissemination or liver metastasis. All these patients were treated in our clinics. Lymph node metastasis was evident in 746 patients, and in these patients the tumors were larger, lymphatic and vascular involvement were prominent and rates of peritoneal dissemination and liver metastasis were higher. In 147 patients with no evidence of lymph node metastasis, peritoneal dissemination was seen in 3.4% of cases and there was no liver metastasis. In cases of peritoneal dissemination and in those with liver metastasis, the rate of lymphatic involvement was higher than when there was vascular involvement. Peritoneal dissemination and liver metastasis are likely to be concomitant with lymph node metastasis in cases of serosally invasive gastric cancer. It seems apparent that lymphatic spread leads to peritoneal dissemination and liver metastasis in patients with gastric cancer.

Exercise-induced ST-segment elevation and hemodynamic responses one month after myocardial infarction

Changes in hemodynamics and plasma norepinephrine levels during supine bicycle exercise after myocardial infarction were measured to investigate the mechanism of exercise-induced ST-segment elevation. Seventy-eight patients were divided into groups which showed either ST elevation (STE), ST depression (STD), or no ST changes (STU). Most of the STE group had anterior myocardial infarction (90.6%) and single-vessel disease (76.7%). The STE group achieved a significantly higher workload (119.5 +/- 4.0 watts, mean +/- SEM) than the STD group (82.3 +/- 2.8, p < 0.01). Heart rate and cardiac output at maximal workload were significantly higher in the STE group (136.6 +/- 3.4 beats/min, 7.44 +/- 0.28 l/min/m2) than in the STD group (110.0 +/- 3.9, 4.83 +/- 0.36, p < 0.01). Pulmonary artery pressures were less elevated in STE than STD patients. Plasma norepinephrine levels increased significantly at maximal workload in STE patients, as compared to the other groups. In conclusion, the STE group achieved a higher exercise level associated with augmented sympathetic activity, which may be a possible mechanism of exercise-induced ST elevation after myocardial infarction.

Apoptosis in normal tissues induced by 5-fluorouracil: comparison between bolus injection and prolonged infusion

The induction of apoptosis in normal tissues was histopathologically examined in rats treated with 5-fluorouracil (5-FU). 5-FU was administered by either bolus intravenous injection or 72-hr prolonged intravenous infusion (PIF). Bolus injection and PIF of 5-FU induced different kinetic profiles of apoptosis in the thymus, spleen and ileum. The bolus injections of 5-FU induced a greater extent of apoptosis in these tissues, compared to PIF 5-FU. These data indicate that the kinetics and extent of apoptosis induced by 5-FU depends on the schedule of the 5-FU administration, and that 5-FU-induced toxicity may be related to 5-FU-induced apoptosis in normal tissues.