Utility of weekly docetaxel combined with preoperative radiotherapy for locally advanced esophageal cancer from pathological analysis

Esophageal squamous cell cancer (ESCC) is a high-grade carcinoma that is treated with multidisciplinary approaches, including chemoradiotherapy (CRT) followed by surgery. Despite some success with these therapies, overall survival remains poor. In order to investigate a newer CRT regimen, we designed a comparative study to evaluate preoperative CRT using docetaxel (DOC) or 5-Fluorouracil and cisplatin (FU+CDDP [FP] therapy) for treatment of resectable ESCC. In a retrospective review of patients with resectable, locally advanced ESCC, 95 patients received preoperative CRT between 2001 and 2007. CRT was administered using either FP (n = 40) or DOC (n = 55). Pathological response and clinical outcomes were compared between the two groups. Hazard ratios and time-to-event analyses were used to assess outcomes; the ratios were controlled by multivariate logistic regression analysis of potential prognostic factors, and survival was presented with Kaplan-Meier curves. In the FP group, a significant curative effect was observed on the basis of pathological examination of postoperative lesions. However, the DOC group presented a significantly better prognosis on the basis of cumulative survival rates. Logistic regression analysis revealed that the presence of five or more lymph node metastases was an independent predictor of reduced survival. Patients with lymph node metastasis exhibited a better prognosis in the DOC group than those in the FP group. Preoperative CRT for locally advanced esophageal cancer using DOC results in similar or better long-term outcomes compared with FP-based CRT. Therefore, CRT using DOC is a promising therapy option for esophageal cancer.

Correlation between loss of Bcl-XL expression and improved prognosis in advanced esophageal cancer treated by preoperative chemoradiotherapy

We investigated the clinical significance of the apoptosis- related molecule expression of tumor cells in patients with advanced esophageal cancer treated with preoperative chemoradiotherapy (CRT). Preoperative CRT reduced Bcl-X(L) expression in a significant proportion of the group responding to CRT but not in the group resisting CRT, although Bcl-2 expression was reduced in both groups. The mean survival time of the patients with cancers that lost Bcl-X(L) following CRT was significantly longer compared to those with cancers expressing Bcl-X(L). These results suggested that CRT reduced Bcl-X(L) expression, and this decrease closely correlated with the prolonged survival of advanced esophageal cancer patients treated with preoperative CRT.

Circulating micrometastases of esophageal cancer detected by carcinoembryonic antigen mRNA reverse transcriptase-polymerase chain reaction: clinical implications

In some patients without distant metastases according to conventional preoperative investigations, relapse occurs in distant organs within a few years after radical resection of esophageal cancer. Various attempts have been made to detect micrometastases that are not found by conventional techniques. A quantitative real-time reverse-transcriptase polymerase chain reaction was used to detect messenger RNA for carcinoembryonic antigen in 147 blood samples from 49 patients scheduled for radical resection of esophageal cancer at Juntendo University Hospital between September 2003 and June 2004. The number of circulating cancer cells was assessed and the clinical significance of detecting such micrometastases was analyzed. Multivariate analysis showed that positivity of this assay was significantly associated with pT1 or pT2 disease and stage III or stage IV disease. Patients with more than 40-50 carcinoembryonic antigen mRNA copies among 10(4) normal cells on quantitative analysis had a higher recurrence rate. The number of tumor cells circulating in the blood may have more influence on the prognosis of esophageal cancer than the presence of tumor cells.

Normal esophageal mucosae adjacent to esophageal adenocarcinomas in both Japanese and U.S. patients have a field defect of methylation changes

4636

Background: Esophageal mucosae that reside next to gross cancer are often without histological premalignant changes. We hypothesized that DNA hypermethylation could be detected in “normal” tissues adjacent to esophageal adenocarcinomas (EAC). Methods: A cohort of patients from Japan (J, n=14) and the United States (US, n=41) with locally advanced EAC were evaluated for methylation status. Esophagectomy specimens provided a source of paired normal and tumor tissues. After DNA extraction, methylation specific PCR was used to evaluate the promoters of APC, p16 and MGMT in all samples. Methylation frequency was calculated for each patient and expressed as a percentage of total. Results: Age, gender, pathologic stage and epigenetic analyses of primary tumors were similar in each cohort. Methylation frequency of tumors was: APC (66% US; 70% J). p16 (39% US; 20% J). MGMT (63% US; 75% J). In adjacent histologically “normal” esophageal mucosae, the percentage of patients with methylation at 0, 1, 2 or 3 genes was 79%, 14%, 0%, 7% for the J group and 56%, 44%, 10% and 2% for the U.S. group. In both cohorts, the majority of the normal samples had no methylation changes. In over half of the total cohort, however, there was at least one gene in the adjacent histologically “normal” tissue positive for DNA hypermethylation. Very few samples in either group, however, had more than one gene methylated in histologically “normal” esophageal mucosae. In general, the same methylation pattern present in the “normal” tissue persisted in the primary malignancy. Conclusions: Histologically negative esophageal mucosae adjacent to cancer frequently show at least one hypermethylated gene in a multiple gene panel. These data suggest that for patients with EAC, regardless of nationality, there is a field defect of promoter hypermethylation changes in adjacent esophageal mucosae. These events reflect those of the primary malignancy, and are probably early and cumulative during carcinogenesis.

No significant financial relationships to disclose.

Prognostic significance of disseminated cancer cells in bone marrow in patients with squamous cell carcinoma of the esophagus using quantitative RT-PCR for CEA mRNA

20004

Background: The clinical significance of disseminated cancer cells in bone marrow has not been elucidated in esophageal cancer. The aim of this study was to evaluate the relation between quantity of disseminated cancer cells in bone marrow and clinical characteristics, including prognostic significance, in patients with squamous cell carcinoma of the esophagus using real time reverse transcriptase polymerase chain reaction (RT-PCR) for CEA (carcinoembryonic antigens) mRNA. Methods: Bone marrow samples were obtained from the 4th or 5th right rib on thoracotomy from consecutive 65 operative patients with esophageal squamous cell cancer, who received esophagectomy with lymph node dissection. After total RNA extraction, they were investigated by quantitative real time RT-PCR for CEA. We also performed qualitative analyses to confirm the results at least twice. We adopted quantitative results when qualitative analyses showed positive. Results: In bone marrow CEA mRNA was detected in 14 out of the 65 patients (21.5%). There were no significant differences in clinicopathological findings between positive and negative group for bone marrow CEA. However, after a short median follow-up of 12 months (3–19 months), 6 of 14 (42.9%) patients with positive CEA group had been dead compared to 4 out of 51 (7.8%) patients with negative CEA group. The survival time of both group showed a significant difference (p=0.0282). However, there was no relationship between the amount of cancer cells in bone marrow and patients’ survival. Conclusions: Disseminated cancer cells in bone marrow using quantitative RT-PCR for CEA mRNA may be a significant predictor for highly malignant squamous cell carcinoma of the esophagus.

No significant financial relationships to disclose.

Allelic loss analysis of early-stage flat-type colorectal tumors

BACKGROUND

Flat-type colorectal tumors are rare, but are known for their unusual flat morphology and aggressive clinical behavior despite their small size. To identify distinct genetic alterations, loss of heterozygosity (LOH) analysis was performed on microdissected tissues.

MATERIALS AND METHODS

DNA was extracted from multiple microdissected foci in 43 cases of early-stage flat-type colorectal tumors and LOH analysis was performed on 2q, 4q, 5q, 12q, 14q, 15q, 17p, 18q, 18p and 22q.

RESULTS

LOH patterns were detected in one of two forms: (i) homogeneous LOH throughout the microdissected foci, which indicated the early acquisition of LOH; and (ii) heterogeneous LOH, which were detected in a part of analyzed foci. Homogeneous and heterogeneous LOH were most frequently detected on 17p (92%) followed by 18q (81%), 18p (81%), 5q (61%), 22q (51%), 14q (44%), 15q (41%), 2q (39%), 12q (36%) and 4q (32%). Homogeneous LOH was detected most frequently on 17p (68%) followed by 18p (53%), 18q (53%), 22q (34%) and 12q (27%). The average fractional allelic loss (FAL) for heterogeneous and homogeneous LOH was 0.57 and the average FAL for homogeneous LOH was 0.37.

CONCLUSIONS

Early flat-type colorectal tumors frequently shows the early occurrence of multiple LOH including 17p, 18p, 18q and 22q, which is coupled with additional LOH of other loci either simultaneously or in the early clonal progression phase. The extent and sequences of LOH may be the mechanisms responsible for the aggressive clinical behaviors of these tumors.

[Surgery for cancer of the esophagus in elderly patients]

Esophageal cancer has a fulminant biological characteristic, and shows a higher rate of lymph node metastasis than other gastrointestinal malignancies. The distribution of lymphatic spread is wide from cervical to abdominal field, and 3-field lymph node dissection is a standard procedure in esophageal cancer surgery. However, the morbidity and mortality rate following esophageal resection is higher than that of other gastrointestinal or thoracic surgery. The most serious postoperative complication of esophageal surgery in elderly patients is a pulmonary problem. In order to reduce postoperative pulmonary complications, we try to preserve bronchial artery, pulmonary branches of the vagal nerve, in addition to definite preservation of bilateral recurrent laryngeal nerve. Our survival rate and mean survival period in elderly patients with esophageal cancer was fairly good. To achieve a high survival rate and reduce postoperative morbidity and mortality in elderly patients, preoperative assessment of pulmonary function and quality control of surgical procedure is essential.

[Esophageal cancer surgery; importance of surgical quality control]

In esophageal cancer, the rate of lymphatic metastasis is higher than any other gastrointestinal cancer. The morbidity and mortality rate of esophageal surgery is still high. In order to reduce high morbidity and mortality rate, esophageal cancer surgery is recommended to be performed at a high-volume hospital in Europe and United States. In Japan, "3-field lymph nodes dissection surgery" has been established for complete lymphatic clearance, and the overall survival has improved. This surgical procedure is now recognized as a standard surgery for advanced esophageal cancer by "Japan Esophageal Society". However, even in Japan, the morbidity and mortality rate of esophageal cancer surgery is higher than gastric or colonic cancer surgery. For rationale of esophageal cancer surgery, we have to continue to improve our surgical quality such as preserving bronchial artery or pulmonary branches of the vagal nerve.

Flavopiridol as a radio-sensitizer for esophageal cancer cell lines

Flavopiridol is a synthetic flavone that has shown an antitumor effect against several cancers. Here, we investigated the in vitro effect of flavopiridol alone and the combined effect of low-dose flavopiridol plus radiation on esophageal squamous cell carcinoma cell lines. Esophageal squamous cell carcinoma cell lines (TE8, TE9 and KE4) were exposed to flavopiridol (0.05-400 nmol/L) for 48 h. Growth inhibition was evaluated by MTT assay, cell cycle distribution was determined by flow cytometry, and cyclin D1, Bcl-2 and Rb protein expression was detected by Western blotting. The effect of 0.05 nmol/L flavopiridol as a radio-sensitizer was determined by clonogenic assay. The IC50 was approximately 110-250 nmol/L. Exposure to 0.05 nmol/L flavopiridol for 48 h increased the G2/M population, while 300 nmol/L increased the G1 population. At a concentration of 300 nmol/L, nuclear fragmentation and chromatin condensation were observed in all three cell lines. Exposure to 300 nmol/L flavopiridol decreased the levels of cyclin D1 and Rb protein in all three cell lines and Bcl-2 protein was also decreased in TE8 and KE4 cells. Moreover, exposure to 0.05 nmol/L flavopiridol slightly decreased the levels of cyclin D1, Rb and Bcl-2 protein in KE4 cells. Flavopiridol treatment (0.05 nmol/L) enhanced the radio-sensitivity in all three cell lines. Low-dose flavopiridol augmented the response of esophageal squamous cell carcinoma cell lines to radiation. Administration of a low dose of flavopiridol could be a potent new therapeutic approach for improving the efficacy of radiotherapy against esophageal cancer.

Clinical significance of bone marrow micrometastases in esophageal cancer

Using the reverse transcriptase-polymerase chain reaction (RT-PCR), we investigated the clinical significance of bone marrow micrometastases in patients with esophageal cancer. Bone marrow samples from 57 patients with esophageal cancer, who underwent esophagotomy, were investigated by specific RT-PCR for carcinoembryonic antigens (CEA). A total of 40 out of 57 patients (70.1%) were positive for CEA mRNA in the bone marrow. Among curatively resected cases, 34 of 50 patients (68.0%) were positive for CEA. Ten of 13 T1 patients (76.9%) were positive for CEA. Although the CEA-positive rate was high, there was no significant correlation between CEA positivity and any clinical characteristics. Among the 40 CEA-positive patients, 50% have shown recurrence so far. Detection of cancer cells in the bone marrow by RT-PCR may not always correspond to the malignant potential or other characteristics of the tumor. CEA-positive 'micrometastases' might actually represent isolated circulating tumor cells without much biological significance.

Reduced low-density-lipoprotein cholesterol causing low serum cholesterol levels in gastrointestinal cancer: a case control study

Several epidemiological studies suggested an inverse relation between serum cholesterol level and cancer mortality. We analyzed the relation between gastrointestinal cancers and serum cholesterol levels. A total of 631 patients were recruited as cancer-bearing cases, comprising 181 esophageal cancers, 251 gastric cancers and 199 colorectal cancers. A case-control analysis was conducted on the serum TC, HDL-C, LDL-C and TG levels. TC and LDL-C were significantly lower in cancer-bearers by approximately 15 mg/dl. Furthermore, analyses by cancer site also showed significantly lower TC and LDL-C levels in cancer-bearers than in controls for all three sites. In this analysis, early stage cancer-bearers showed a significant decrease in TC levels by approximately 11 mg/dl compared with controls, and also a similar decrease in LDL-C levels. These results suggest that low TC levels are not related to cancer stage. Furthermore, findings of no significant differences in HDL-C and TG between cancer-bearing cases and controls in addition to a specific decrease in LDL-C in cancer-bearers suggest that hypocholesterolemia observed in these cases stems from low LDL-C. However, cancer-bearers and controls showed a similar distribution of TC and LDL-C levels. We should be aware that latent cancer bearers may be present among subjects with hypocholesterolemia.

Mutation of the p53 gene predicts lymph node metastases in Japanese patients with esophageal carcinoma: DNA and immunohistochemical analyses

We evaluated the clinicopathologic significance of p53 gene mutations, including a comparison of DNA analysis and immunohistochemical examination, in Japanese patients with esophageal squamous cell carcinoma, a highly aggressive cancer. Genomic DNA isolated from 76 tumors without preoperative treatment was subjected to polymerase chain reaction and sequencing. Associations were sought between p53 mutations and clinicopathologic characteristics. Cases also were investigated immunohistochemically to detect abnormal p53 protein accumulation. Overexpression of p53 protein occurred in 51 cases (67.1%), while gene mutations in the examined exons were found in only 14 (18.4%). By multivariate analysis, p53 mutation predicted detection of eight or more lymph node metastases. Mutations of the p53 gene may not only participate in the initiation of esophageal cancer, but also may promote lymph node metastasis. Unlike gene mutations, p53 protein overexpression did not predict nodal metastasis extent.

Successfully treated case of cervical abscess and mediastinitis due to esophageal perforation after gastrointestinal endoscopy

Perforations of the esophagus are uncommon complications of flexible gastrointestinal endoscopy. Perforations after endoscopy are likely to occur in the cervical esophagus, where fiber insertion is difficult anatomically. The diagnosis should be made as soon as possible, because mediastinitis and sepsis frequently develop following esophageal perforations. The surgical strategies are dependent on the location of the perforations and the condition of the patients. For a successful outcome, surgery is a preferred treatment for most perforation cases, and non-operative treatment, such as antibiotics, parental nutrition, and no food intake by mouth, should be applied carefully.

Histopathologic effects of neoadjuvant therapies for advanced squamous cell carcinoma of the esophagus: multivariate analysis of predictive factors and p53 overexpression

In 97 patients (60, chemotherapy; 22, chemoradiotherapy; 15, radiotherapy), histopathologic effects were evaluated microscopically, and histologic response rates were compared among three neoadjuvant treatment modalities. Predictive factors for neoadjuvant therapies were analyzed by logistic regression, including the results of p53 immunohistochemical staining. In the chemoradiotherapy group, the pathologic response rate was 86.4%, and was significantly higher than that for chemotherapy (P < 0.0001) or for radiotherapy (P = 0.0031). In patients with normal p53 protein expression, the histopathologic response rate to chemotherapy was 20.0%, a higher rate than that for patients with abnormal p53 overexpression. In the chemoradiotherapy or radiotherapy group, however, the response rates were almost the same, irrespective of p53 oncoprotein status. From multivariate analysis, the neoadjuvant treatment modality itself was identified as the most powerful predictive factor for the effect. Chemoradiotherapy had the most powerful effect on advanced esophageal cancer, and p53 status did not influence the clinical outcome in this group.

Outcomes of extended lymph node dissection for squamous cell carcinoma of the thoracic esophagus

Patients with thoracic esophageal carcinoma who underwent extended lymph node (LN) dissection were studied to assess the state of LN metastasis and evaluate its outcome in terms of a prognostic benefit. Pertaining to LN metastasis, it was found that depending on the location of a primary tumor, the area of choice, in which metastasis tends to develop predominantly, showed some variation. However, irrespective of the location of the tumor, the predominant growth of positive nodes was found to locate among three fields, namely the neck, mediastinum and abdomen even in patients with a single metastatic node. This suggests that extended LN dissection including the neck, mediastinum and abdomen should be considered mandatory, if a complete removal of the tumors for carcinoma of the thoracic esophagus is to be desired. Multivariate analysis revealed importance of LN dissection as a prognostic factor. A cumulative survival rate in the patients with lymphadenectomy through right thoracotomy was statistically better than that in the patients who underwent blunt extraction of the esophagus without lymphadenectomy. Furthermore, extensiveness of LN dissection could effectively serve as a prognostic factor. Consequently, three-field LN dissection yields a prognostic benefit to improve a long term survival in patients with carcinoma of the thoracic esophagus.

Evidence for an initiation site for hen lysozyme folding from the reduced form using its dissected peptide fragments

We prepared two dissected fragments of hen lysozyme and examined whether or not these two fragments associated to form a native-like structure. One (Fragment I) is the peptide fragment Asn59-homoserine-105 containing Cys64-Cys80 and Cys76-Cys94. The other (Fragment II) is the peptide fragment Lys1-homoserine-58 connected by two disulfide bridges, Cys6-Cys127 and Cys30-Cys115, to the peptide fragment Asn106-Leu129. It was found that the Fragment I immobilized in the cuvette formed an equimolar complex with Fragment II (K(d) = 3.3x10(-4) M at pH 8 and 25 degrees C) by means of surface plasmon resonance. Moreover, from analyses by circular dichroism spectroscopy and ion-exchange chromatography of the mixture of Fragments I and II at pH 8 under non-reducing conditions, it was suggested that these fragments associated to give the native-like structure. However, the mutant Fragment I in which Cys64-Cys80 and Cys76-Cys94 are lacking owing to the mutation of Cys to Ala, or the mutant fragment in which Trp62 is mutated to Gly, did not form the native-like species with Fragment II, because the mutant Fragment I derived from mutant lysozymes had no local conformation due to mutations. Considering our previous results where the preferential oxidation of two inside disulfide bonds, Cys64-Cys80 and Cys76-Cys94, occurred in the refolding of the fully reduced Fragment I, we suggest that the peptide region corresponding to Fragment I is an initiation site for hen lysozyme folding.

Metastatic gastrinoma to the liver 20 years after primary resection

Gastrinoma is a rare endocrine tumor that is frequently associated with liver metastasis. The liver metastasis is usually seen simultaneously or soon after a primary operation. A 47-year-old woman who had had a total gastrectomy 20 years earlier developed liver metastasis. An interval of this length between surgery and metastasis is extremely rare. The total gastrectomy prevented the patient from developing the usual symptoms of hypergastrinemia that would have enabled early diagnosis of the metastasis. Laboratory examinations on admission revealed a high serum gastrin concentration (1500 pg/ml). Computed tomography showed an irregularly enhanced mass lesion with an uneven, low-density central area in the right anterior inferior segment of the liver. An extended right hepatectomy was performed. Intraoperative ultrasonography showed no abnormalities in the remnant pancreas. Examination of the cut surface of the specimen revealed a yellow, firm, elastic tumor, 55 mm in diameter. The interior of the tumor appeared necrotic. Histopathologically, the tumor was composed of cells with hyperchromatic, dysplastic nuclei arranged in a trabecular pattern with nest formation. Gastrin staining was positive. A histologic diagnosis of metastatic gastrinoma was made. The patient's gastrin concentration returned to normal and she was well at 2-year follow-up.

Natural history of sigmoid colon cancer: report of a patient observed for 4 years

We report a case of sigmoid colon cancer that was left untreated for a period of 4 years, because the patient declined treatment. A 59-year-old man was found to have an early carcinoma of the sigmoid colon measuring approximately 12 mm in diameter. The lesion, initially a flat cancer, increased in height and became sessile 4 months later. Subsequently, the central portion of the lesion became ulcerated, leaving an elevated ring along its periphery. The lesion eventually evolved into an ulcerated, invasive cancer. This sequence has not been observed with colonoscopy before.

Activated peritoneal macrophages inhibit the proliferation of rat ascites hepatoma AH-130 cells via the production of tumor necrosis factor-alpha and nitric oxide

OBJECTIVE

To study the effect of peritoneal macrophages on tumor cell proliferation, we cultured ascites hepatoma AH-130 cells with unstimulated, or lipopolysaccharide (LPS)- or interleukin (IL)-2-stimulated rat peritoneal macrophages, and examined the proliferation of AH-130 cells.

MATERIALS AND METHODS

Rat peritoneal macrophages isolated from male Wistar rats were co-cultured with AH-130 cells in the absence or presence of LPS or IL-2. After incubation, proliferation of AH-130 cells was analyzed using flow cytometry. In addition, the levels of tumor necrosis factor (TNF)-alpha and nitric oxide (NOx, nitrate + nitrite) in the culture supernatants were measured. Furthermore, anti-TNF-alpha antibody (10 microg/ml) and nitric oxide synthase inhibitor, N(G)-monomethyl-L-arginine (L-NMMA, 100 microM) were added to the coculture, and their effect on AH-130 cell proliferation was examined.

RESULTS

When AH-130 cells were co-cultured with unstimulated peritoneal macrophages, proliferation of AH-130 cells was not affected. In contrast, when AH-130 cells were cocultured with peritoneal macrophages in the presence of LPS (0.1-20 microg/ml) or IL-2 (1-200 U/ml), proliferation of AH130 cells was dose-dependently suppressed by LPS or IL-2. Moreover, LPS- or IL-2-stimulation increased the levels of TNF-alpha and NOx in the supernatants of AH-130 cell and macrophage co-culture, although LPS and IL-2 did not induce TNF-alpha and NOx production by AH-130 cells incubated without macrophages. Interestingly, anti-TNF-alpha antibody and L-NMMA significantly inhibited the suppression of AH-130 cell proliferation by LPS- or IL-2-stimulated macrophages (p < 0.05). Furthermore, exogenously added recombinant rat TNF-alpha (0.26-1300 ng/ml) or NO donor (GSNO, S-nitroso-L-glutathione) (0.1 - 10 mM) dose-dependently suppressed the proliferation of AH-130 cells in the absence of macrophages.

CONCLUSION

Together these observations suggest that when peritoneal macrophages are activated by LPS and IL-2, they suppress the proliferation of ascites hepatoma AH-130 cells via the production of TNF-alpha and nitric oxide.

[Outpatient treatment for gastrointestinal tract cancer in the Department of Surgery]

Recently, outpatient cancer treatment has been rapidly increasing in order to cut medical expenditures and promote the QOL of cancer patients. However, the efficacy of outpatient cancer treatment is still uncertain. When performing outpatient cancer treatment, one must have a clear idea of the expected effect, and provide appropriate treatment so that none of the expected benefit is sacrificed for the improved convenience.

Pulmonary thromboembolism after surgery for esophageal cancer: its features and prophylaxis

We attempt to clarify the problems of pulmonary thromboembolism (PTE), which occurs less frequently in Japan than in the West, regarding its special perioperative management and prophylaxis for PTE after esophagectomy. We studied 26 patients with PTE following esophagectomy among 1023 patients with esophageal cancer between 1984 and 1997. The presence of embolism was confirmed by pulmonary perfusion scintigraphy. The incidence, diagnosis, and other issues of PTE were all reviewed. The incidence of PTE was 2.5%, with patients showing a biphasic early and late onset. The main symptoms were dyspnea in 19 patients and tachycardia in 17. Scintigraphy demonstrated 154 lesions, 35.7% of which were located in the left lower lobe and 25.3% in the right lower lobe. Treatment mainly consisted of the administration of heparin and urokinase. Four of the 26 patients died. Intermittent pneumatic compression (IPC) with the administration of heparin has been used in our department since 1994 to prevent PTE and this has also helped to decrease the incidence from 3.2% to 0.7%. Because the incidence of PTE following esophagectomy is higher than expected, PTE should be considered whenever hypoxemia of some unknown cause is found. Both early diagnosis and treatment are essential. It is also important to prevent PTE by the use of IPC.

Usefulness of autologous blood transfusion for avoiding allogenic transfusion and infectious complications after esophageal cancer resection

BACKGROUND

A retrospective investigation was conducted to determine whether autologous blood collection could reduce allogenic transfusion after resection of esophageal cancer and whether allogenic transfusion influenced postoperative infection.

METHODS

Patients (n = 100) who met the criteria for hemoglobin, age, body weight, and serum protein donated 800 mL of autologous blood from May 1994 to December 1997. The control group (n = 248) was selected from patients who met the same criteria and did not donate autologous blood over the 10 years before the start of autologous blood collection.

RESULTS

Only three patients (3%) from the autologous group required allogenic transfusion versus 84 patients (33.7%) from the control group. Sixteen of the 26 patients who received more than 4 units of allogenic blood contracted postoperative infections compared with 25 of 165 patients who did not (P < .0001). Autologous blood transfusion significantly increased the probability of avoiding allogenic transfusion (odds ratio, 27.58), and allogenic transfusion was significantly related to postoperative infection (odds ratio, 1.19), according to logistic regression analysis.

CONCLUSIONS

Autologous blood collection reduces the need for allogenic transfusion in patients undergoing resection of esophageal cancer, and avoidance of allogenic transfusion may reduce the risk of postoperative infection.

Esophageal cancer and right aortic arch associated with a vascular ring

We report on the problems of diagnosis and surgical technique from the standpoint of mediastinal anatomy in patients with esophageal cancer and right aortic arch associated with a vascular ring. We propose that left thoracotomy plus sternotomy is the best approach to allow visualization of the bilateral recurrent laryngeal nerves.

A case of inflammatory breast cancer following augmentation mammoplasty with silicone gel implants

A 54-year-old-woman who underwent augmentation mammoplasty with silicone gel implants 30 years previously, visited our hospital with complaints of bloody nipple discharge, redness and itching of her right breast. Cancer of the right breast was diagnosed by dynamic magnetic resonance imaging (MRI) examination with Gadolinium (Gd)-DTPA enhancement. Radical mastectomy was subsequently performed. The histopathological findings demonstrated scirrhous and inflammatory breast cancer with invasion of dermal lymphatics.

Ratio of primary and secondary bile acids in feces: possible marker for colorectal cancer?

PURPOSE

Increases in fecal bile acids may play a role in colorectal carcinogenesis. The authors tested the hypothesis that high concentrations of primary and secondary bile acids are more common in patients with colon cancer than in patients with other gastrointestinal diseases.

METHODS

In this retrospective study the secondary bile acid deoxycholic acid and the primary bile acid cholic acid were measured in the feces by enzyme-linked immunoabsorbent assay in 63 patients with colorectal cancer, 24 patients with gastric cancer, 11 patients with biliary disorders, and 47 healthy volunteers.

RESULTS

Preoperatively, the mean deoxycholic acid values tended to be higher and the cholic acid values were significantly lower in patients with colorectal cancer than in healthy subjects. Patients with other gastrointestinal diseases had lower deoxycholic acid and cholic acid values than healthy subjects. In healthy subjects the deoxycholic acid to cholic acid ratio ranged from 0.10 to 2.86 (mean, 0.88), but in almost two-thirds, the ratio did not exceed 1. In contrast, the mean preoperative ratio in patients with colorectal cancer was 2.26 (range, 0.06-7.17; P < 0.0001) and tended to be higher in patients with advanced cancer and in those with sigmoid and rectal tumors. If 1.1 is taken as the upper limit of normal for deoxycholic acid to cholic acid ratio, 67 percent of patients with colorectal cancer had an abnormal value preoperatively.

CONCLUSION

A high deoxycholic acid concentration and deoxycholic acid to cholic acid ratio may be indicators of colorectal cancer. Further study is needed to improve sensitivity and specificity, perhaps by combining fecal bile acid measurements with other tests, and a large prospective trial may be warranted to determine whether these measurements have value in screening for this common cancer.

[Therapeutic strategy for adenocarcinoma in Barrett's esophagus: a study based on a comparison with squamous cell carcinoma]

The therapeutic strategy for adenocarcinoma in Barrett's esophagus is discussed based on a comparison with squamous cell carcinoma. The pattern and range of lymph node metastasis of adenocarcinoma in Barrett's esophagus is similar to that of squamous cell carcinoma, as is the pattern of recurrence. Chemotherapy is less effective, except for some reports on paclitaxel, but chemoradiation therapy is comparable in effect. The general tendency of a better prognosis for patients with carcinoma in Barrett's esophagus is the result of several factors, such as earlier detection of the disease, lower probability of lymph node metastasis, and distal location which permits less radical curative surgical procedures without cervical and superior mediastinal lymph node dissection. In principal the therapeutic strategy for adenocarcinoma in Barrett's esophagus should be determined like that for squamous cell carcinoma, taking into account the location of the lesion and the depth of invasion.

ELISA determination of serum hyocholic acid concentrations in humans and their possible clinical significance

BACKGROUND/AIMS

Hyocholic acid (HCA), a bile acid isolated from pigs, has a different structure from the predominant bile acids from humans.

METHODOLOGY

We prepared an antiserum to HCA in rabbits and developed an enzyme-linked immunosorbent assay (ELISA), which we used to measure serum HCA in healthy subjects and patients with a variety of gastrointestinal and non-gastrointestinal diseases.

RESULTS

Patients with hepatic cirrhosis had a mean HCA concentration that was 120-fold greater than that in healthy subjects. Markedly elevated HCA levels were also present in patients with primary hepatoma or pancreatic cancer but not in patients with cancer of the breast, bile duct, duodenum, or stomach.

CONCLUSIONS

If these results are confirmed by further study, HCA measurement may prove clinically useful.

[A gastrointestinal radiographic study of 18 patients with esophageal adenocarcinoma arising from Barrett's epithelium]

Gastrointestinal radiographs were reviewed with pathological correlation in 18 patients with histologically proven esophageal adenocarcinoma arising from Barrett's epithelium. Comparison was also made with postoperative radiographs of resected esophageal specimens from 3 of the patients. Esophageal carcinoma could be observed in the gastrointestinal radiographs in 17 of the 18 patients. In 14 of the 17, the classification based on the gastrointestinal radiographs was consistent with the gross classification. In 10 of the 18 patients, rough mucosa was seen on gastrointestinal radiographs in the same area in which Barrett's epithelium was observed in the histopathological specimens. Sliding esophageal hiatus hernia was present in 12 of the 18 patients, a relatively high incidence. Regular granular or reticular shadows were observed on the mucosal surface of the esophagus on the postoperative radiographs of 3 patients. It is believed that a diagnosis of Barrett's epithelium can be made from gastrointestinal radiographs if these mucosal patterns are present. Although a definitive diagnosis of Barrett's epithelium based on upper gastrointestinal radiographs is considered difficult, the presence of rough mucosa in the esophagus around the carcinoma in combination with esophageal hiatus hernia are suggestive of esophageal adenocarcinoma arising from Barrett's epithelium.

Kinetic measurement of the interaction between a lysozyme and its immobilized substrate analogue by means of surface plasmon resonance

A method for evaluating the association and dissociation rate constants of interaction between a lysozyme and its substrate analogue, an immobilized p-aminophenyl-tri-N-acetyl-beta-chitotrioside, by means of surface plasmon resonance has been developed. Site-specific immobilization of p-aminophenyl-tri-N-acetyl-beta-chitotrioside, which is a product of p-nitrophenyl-tri-N-acetyl-beta-chitotrioside, on carboxymethyldextran linked to the surface of the cuvette of the instrument, IAsys, was carried out by catalysis with EDC/NHS. The kinetic parameters of the interaction between hen or human lysozyme and the immobilized substrate analogue indicated that a larger dissociation constant of the human lysozyme-immobilized substrate analogue complex depended on a smaller association rate constant. The kinetic parameters of the interaction between the immobilized substrate analogue and a mutant hen lysozyme, in which Arg14 and His15 are deleted, with higher activity than the wild type hen lysozyme were measured. It was suggested that the higher activity of the mutant lysozyme was due to faster removal of the substrate from the active site cleft and/or the formation of a stabler and better complex as to hydrolysis.

p53 gene mutation in 150 dissected lymph nodes in a patient with esophageal cancer

For thoracic esophageal cancer, we perform extended three field lymph node dissection, and have achieved nearly 50% of overall 5-year survival. However, patients sometimes develop lymph node recurrences in spite of having no lymph node metastases found by conventional histopathologic examination. In a patient with esophageal squamous cell carcinoma, we sequenced all the p53 cDNA translated regions (exon 2-10) of primary carcinoma, and confirmed one p53 nonsense mutation in exon 10. Then we extracted genomic DNA from 150 surgically dissected lymph nodes from that patient, and performed polymerase chain reaction analysis (PCR-RFLP) to detect the same p53 mutation in the lymph nodes. PCR-RFLP analysis showed the same p53 mutation in six lymph nodes. One node was located along the right recurrent laryngeal nerve, where no positive nodes was identified by conventional histopathologic examination. The p53 mutational diagnosis of metastatic cancer may be useful in detecting minimal residual disease.

A new choleretic effect of folinic acid

BACKGROUND/AIMS

In the chemotherapy of recurrent gastric cancer with 5-fluorouracil and folinic acid, an interesting phenomenon, the reduction of jaundice and improvement of liver function, was observed. The aim of this study was to investigate the mechanism of this phenomenon, and to confirm a choleretic effect of folinic acid.

METHODOLOGY

The bile duct of anesthetized rats was catheterized, and bile was collected. Bile volume and total bile acid production following intraperitoneal administration of folinic acid were determined and compared to those of control rats.

RESULTS

Both bile volume and total bile acid production increased following intraabdominal administration of folinic acid.

CONCLUSIONS

Folinic acid has a newly described pharmacologic effect of stimulating bile acid-dependent choleresis. It is possible that folinic acid may become a new drug for the treatment of jaundice or for the improvement of overall liver function.

[Successful management of aorto-esophageal fistula due to rupture of thoracic aortic aneurysm in an elderly patient]

Aorto-esophageal fistula due to ruptured thoracic aortic aneurysm is very rare but is associated with extremely high mortality. An 81-year-old woman was admitted due to repeated hematemesis. Endoscopic examination revealed ulceration with blood clot on the mid-esophagus and compression of an extra-esophageal mass. The thoracic CT scan revealed an aorto-esophageal fistula due to a ruptured descending thoracic aortic aneurysm. Surgery was performed on April 3, 1996. We report an aorto-esophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. The esophagus was reconstructed using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft. The postoperative course was uneventful and there have been no signs of mediastinal sepsis, graft infection or pyothorax 12 months postoperatively. We suggest that the resection of both the aneurysm and the esophagus as well as the immediate reconstruction of the esophagus by orthotopic gastric interposition to obliterate the retrosternal space are important technique in the management of intrathoracic infections.

Carcinosarcoma of the esophagus with metastases showing osteosarcoma: a case report and review of the literature

Carcinosarcoma of the esophagus includes both carcinomatous and sarcomatous elements. The classification and histogenesis of carcinosarcoma is controversial. In a polypoid carcinosarcoma diagnosed in a resected esophagus the sarcomatous component was composed of dense interlacing bundles of spindle-shaped cells in the submucosa. Areas with transitional features between the two components were observed. Immuno-histochemical examination showed vimentin-positive cells in the sarcomatous areas. Subsequently, obtained autopsy specimens from the lung, kidney and iliac bone showed metastatic osteosarcoma composed of an interlacing pattern of bone or osteoid components. We suspected that the sarcomatous elements in the esophagus resulted from sarcomatous transformation of carcinoma cells, and that the metastatic lesions showed differentiation of neoplastic cells to the osteosarcoma.

[Difference between Japan and western countries in the treatment strategy for esophageal cancer]

The most conspicuous difference between Japan and Western countries in the treatment strategy for esophageal cancer is the attitude to lymph node dissection. Japanese surgeons have aimed at complete eradication of lymphatic spread of cancer cells and have reached the level of three-field lymph node dissection. In Western countries, however, surgeons rely more on chemotherapy or radiotherapy because they consider that most patients who present with esophageal cancer already have disseminated disease. Phase II studies of neoadjuvant chemotherapy and chemoradiotherapy have yielded encouraging results, and recently, positive reports on phase III studies of neoadjuvant therapy vs. surgery alone began to be announced. No such studies have included surgery with radical lymph node dissection. With the rapid advance in information technology, radical esophagectomy has gradually gained acceptance in the West, while many trials of neoadjuvant therapy have been carried out in Japan. Theoretically, the next step should be a phase III study of neoadjuvant therapy vs. surgery in which highly radical procedures such as three-field lymph node dissection are carried out.

Management of the pancreatic metastases from renal cell carcinoma: report of four resected cases

The pancreas is an uncommon site for metastasis from renal cell carcinoma. In most cases, pancreatic metastases occur as part of widespread nodal and visceral involvement, and there is thus evidence of metastatic disease elsewhere in the body. We present 4 cases with resectable pancreatic metastases arising from renal cell tumors without involvement of the regional lymph nodes at the operation. Three cases out of 4 were asymptomatic and the pancreatic metastases were detected by routine follow-up examination of renal cell carcinoma. Aggressive surgical treatment for the solitary metastatic lesion is advocated. Spread of renal cell carcinoma to the pancreas is, however, via the hematogenous route, and even solitary pancreatic metastasis may be one of the manifestations of the systemic metastasis of renal cell carcinoma. No pancreatic regional lymph nodes metastases were noted. Pancreatectomy should be undertaken to remove the tumor with adequate resection margins while preserving as much of the gland as possible. The prognosis of pancreatic metastases arising from a renal cell carcinoma is discussed with a review of the literature. Adjuvant chemo- and endocrine therapy should also be considered in these cases.

Case report: rupture of a gastric varix in liver cirrhosis associated with glycogen storage disease type III

Glycogen storage disease type III, or Cori's disease, is caused by a deficiency of amylo-1,6-glucosidase (debranching enzyme), which leads to the storage of an abnormal glycogen in the liver and in skeletal and heart muscle. Glycogen storage disease type III is usually characterized by hepatic symptoms, growth failure and myopathy. Even though liver cirrhosis is reported, portal hypertension is a rare complication of this disease. We describe the case of a glycogen storage disease type III patient who was diagnosed at 3 years of age and developed complications (liver cirrhosis and rupture of a gastric varix) at 31 years of age. We discuss the histological progression to cirrhosis of the liver and describe the liver enzyme profile at 3 and 31 years of age.

[Rational extent of lymph node dissection for carcinoma of the lower third of the thoracic ESOP-hagus of T2 or T3 stage with abdominal lymph node metastasis]

We discussed the rational extent of the lymph node dissection for carcinoma of the lower third of the esophagus of T2 or T3 stage with abdominal lymph node metastasis. Lymph node metastasis developed in 89.5% of patients. Cervical lymph node metastasis was seen in 35.8%. In the cases with positive abdominal lymph node, 40.9% of the patients had cervical node metastasis. The most frequent site of the positive node in the neck is the area along the right recurrent laryngeal nerve. On the stand point of removal of metastatic lymph node, neck dissection should be required. Three-field dissection yielded better survival rate than two-field dissection but statistical significance was not obtained. When the patients have cervical lymph node metastasis, they have greater possibility of developing blood borne metastasis. However, this observation does not deny the validity of the three-field dissection. Because this dissection may help reducing nodal spread and nodal recurrence. We have to wait for accumulation of the patients to analyze the definite extent of node dissection for T2 or T3 stage of carcinoma of the lower third of the esophagus with positive abdominal lymph node.

[Mediastinal lymph node metastasis from esophageal carcinoma: CT assessment with pathologic correlation]

Computed tomographic (CT) scans were performed in 179 patients with esophageal carcinoma to evaluate mediastinal lymph node metastasis. Histopathologic findings were compared with CT findings in a total of 7,218 resected lymph nodes. First, the criterion for lymph node metastasis on CT scans was 10 mm or more in long transverse diameter. The overall sensitivity and positive predictive value (PPV) were 19% (60 of 317 nodes) and 33% (60 of 180 nodes), respectively. Analysis of each of the eight subgroups of mediastinal nodes revealed that the PPV was more than 70% in node Nos. 105, 108, 110, and 112. In other subgroups, however, the PPV was less than 60%. Sensitivity was less than 50% in all eight subgroups. Second, the criterion for metastasis was 10 mm or more in short transverse diameter. The overall sensitivity and PPV were 8% (26 of 317 nodes) and 63% (26 of 41 nodes), respectively. Analysis of subgroups showed that the PPV in No. 106 nodes increased to 92%. In No. 106 nodes, use of a 5 mm criterion in long transverse diameter increased sensitivity to only 55%. Of the 317 histopathologically proven metastatic lymph nodes, 90 nodes (28%) were 10 mm or more in size, 112 (35%) were 5-10 mm, and 115 (36%) were less than 5 mm. Of the 6,901 non-metastatic lymph nodes, 473 nodes (7%) were 10 mm or more in size. Small (less than 5 mm in size) metastatic nodes were present in all eight subgroups. Among No. 107 and 109 nodes, large (10 mm or more in size) nonmetastatic nodes were prominent, resulting in low sensitivity and PPV. We conclude that CT does not provide an accurate assessment of metastatic versus non-metastatic mediastinal lymph nodes in patients with esophageal carcinoma.

Prognostic factors in adenocarcinoma of the gastric cardia: pathologic stage analysis and multivariate regression analysis

PURPOSE

To clarify the pathologic stages of adenocarcinoma of the gastric cardia in which the prognosis is worse than in adenocarcinoma of the middle or distal part of the stomach, and to determine prognostic factors in these stages by multivariate analysis.

PATIENTS AND METHODS

We analyzed 2,536 cases of surgically resected gastric adenocarcinoma of all pathologic stages. Four hundred seventy-two cases of gastric carcinoma, in which cumulative survival of gastric cardia was poor, were subjected to Cox regression analysis for prognostic factors, and to logistic regression analysis for factors influencing venous or lymphatic invasion.

RESULTS

The prognosis of adenocarcinoma of the gastric cardia was inferior when compared with similarly staged carcinomas of the middle or lower part of the stomach when there was invasion of proper muscle layer or subserosal layer, with no lymph node metastasis or with only adjacent (group 1) lymph nodes metastases (T2N0 or T2N1, according to the Japanese classification). In these stages, the prognostic factors were age, histologic type, venous invasion, and location of the tumor in the upper part of the stomach. Tumor location in the upper stomach was also a predictor for the presence of venous invasion.

CONCLUSION

The prognosis of adenocarcinoma of the gastric cardia is poor in patients with T2 tumors with no or few lymph node metastases. Additional treatment after surgery may be necessary to improve the survival of this population.

Abscesses caused by "dropped" stones after laparoscopic cholecystectomy for cholelithiasis: a report of three cases

While laparoscopic cholecystectomy is a standard therapeutic option for gallbladder stones, it is associated with a significant risk of injury to the gallbladder wall, which may result in the dispersion of free stones within the peritoneal cavity. However, the incidence and consequences of these dropped stones remains unclear. We report herein the cases of three patients in whom abdominal abscesses developed as a result of dropped stones during this procedure. Of particular interest was the relatively long interval from the procedure to the onset of symptoms and the unusual progression of the inflammation. These case reports strongly reinforce the risk of dropped stones during laparoscopic cholecystectomy.

Quick and simple distal pancreatectomy using the GIA stapler: report of 35 cases

A method for distal pancreatectomy using the multifire GIA-80 stapler (US Surgical, Nonvalk, Connecticut, USA) is reported that is quicker, associated with reduced blood loss and a lower incidence of pancreatic fistula than with other instruments such as the TA-55 stapler (Auto Suture, Ascot, UK). When performing total gastrectomy with distal pancreatectomy and splenectomy to complete a wide lymph node dissection in patients with advanced gastric cancer, this method of pancreatectomy can be useful.

Case report: gastrointestinal bleeding from a hepatocellular carcinoma invading the transverse colon

A 72-year-old woman with cirrhosis of the liver was treated repeatedly by transcatheter arterial embolization for multifocal hepatocellular carcinomas. She developed gastrointestinal bleeding secondary to direct invasion of the wall of the transverse colon. The diagnosis was made pre-operatively by colonoscopy and the patient was treated successfully. This rare complication of hepatocellular carcinoma was due to the protrusive type of growth exhibited by this tumour and may have been affected by the transcatheter arterial embolization.

Relief of jaundice by 5-fluorouracil and folinic acid in patients with recurrent gastric cancer

The aim of this study was to evaluate the effect of 5-fluorouracil (5-FU) and folinic acid on liver function and bile production in patients with recurrent gastric cancer and jaundice. Thirteen patients were studied for liver function and hyperbilirubinaemia, and six patients were studied for bile production retrospectively, who were treated with 5-FU [700 mg m(-2)] and folinic acid [20 mg m(-2)] for 4 days. Serum total bilirubin, aspartate aminotransferase (AST), gamma-glutamyl transferase (gamma-GT) and alkaline phosphatase (ALP) concentrations all improved with treatment (P<0.0001), and bile production increased significantly (P<0.0001) following treatment. 5-FU and folinic acid can significantly improve jaundice and liver function, and promote bile production. It is possible that 5-FU and folinic acid may become a new method for the relief of jaundice in patients with gastrointestinal tract malignancies.

Radical lymph node dissection for cancer of the thoracic esophagus

OBJECTIVE

The authors documented the localization and frequency of lymphatic spread in squamous cell carcinoma of the thoracic esophagus and evaluated the influence of radical systematic lymph node dissection on patient survival.

SUMMARY BACKGROUND DATA

From accumulated surgical experience, it was suggested that some of the patients with lymph nodal involvement from cancer could be cured by its clearance. However, it is only recently that cancer of the esophagus has been evaluated in terms of analyzing lymphatic spread and results of lymphadenectomy.

METHODS

Among 1298 patients admitted to the Toranomon Hospital between 1973 and 1993, 913 (70.3%) had resections, including curative and palliative procedures. For this study, 717 patients with TNM RO (resection with no residual tumor at operation in TNM classification) were analyzed. Survival was compared between groups of patients with less extensive thoracoabdominal (two-field) dissections and extensive collothoracoabdominal (three-field) dissections.

RESULTS

Comparative study revealed that 5-year survival rate for TNM RO patients after free-field dissection (55.0%) was significantly better (log rank test, p = 0.0013) than the rate after two-field dissection (38.3%). The results were particularly significant in subgroups with stage III and IV (because of nodal factor). Overall 5-year survival rate after all resections was 42.4%.

CONCLUSIONS

The role of radical lymph node dissection in cancer of the thoracic esophagus evaluated. Long-term survival was compared between two groups with two- and three-field dissection. It was concluded that survival rate was significantly better in patients with extensive three-field dissection.