Advantages of 70-kV CT Angiography for the Visualization of the Adamkiewicz Artery: Comparison with 120-kV Imaging

BACKGROUND AND PURPOSE

Preprocedural identification of the Adamkiewicz artery is crucial in patients with aortic diseases. This study aimed to compare 70-kV CTA with conventional 120-kV CTA for the identification of the Adamkiewicz artery, examining differences in radiation dose and image quality.

MATERIALS AND METHODS

We retrospectively analyzed 2 equal groups of 60 patients who had undergone 70-kV or 120-kV CTA to detect the Adamkiewicz artery before aortic repair. Size-specific dose estimate, the CT number of the aorta, and the contrast-to-noise ratio of the anterior spinal artery to the spinal cord were recorded. Furthermore, detectability of the Adamkiewicz artery was evaluated by using a 4-point continuity score (3, definite to 0, undetectable).

RESULTS

There was significantly lower radiation exposure with 70-kV CTA than 120-kV CTA (median size-specific dose estimate, 23.1 versus 61.3 mGy, respectively; P < .001). CT number and contrast-to-noise ratio were both significantly higher in the 70-kV CTA group than the 120-kV group (999.1 HU compared with 508.7 HU, and 5.6 compared with 3.4, respectively; P < .001 for both). Detectability of the Adamkiewicz artery was not impaired in the 70-kV CTA group (90.0% versus 83.3% in the 120-kV group, P = .28). Moreover, the Adamkiewicz artery was detected with greater confidence with 70-kV CTA, reflected by a significantly superior continuity score (median, 3) compared with 120-kV CTA (median, 2; P = .001).

CONCLUSIONS

Seventy-kilovolt CTA has substantial advantages for the identification of the Adamkiewicz artery before aortic repair, with a significantly lower radiation exposure and superior image quality than 120-kV CTA.

Trajectories of endoscopic Barrett esophagus: Chronological changes in a community-based cohort

AIM

To elucidate longitudinal changes of an endoscopic Barrett esophagus (BE), especially of short segment endoscopic BE (SSBE).

METHODS

This study comprised 779 patients who underwent two or more endoscopies between January 2009 and December 2015. The intervals between the first and the last endoscopy were at least 6 mo. The diagnosis of endoscopic BE was based on the criteria proposed by the Japan Esophageal Society and was classified as long segment (LSBE) and SSBE, the latter being further divided into partial and circumferential types. The potential background factors that were deemed to affect BE change included age, gender, antacid therapy use, gastroesophageal reflux disease-suggested symptoms, esophagitis, and hiatus hernia. Time trends of a new appearance and complete regression were investigated by Kaplan-Meier curves. The factors that may affect appearance and complete regression were investigated by χ² and Student-t tests, and multivariable Cox regression analysis.

RESULTS

Incidences of SSBE and LSBE were respectively 21.7% and 0%, with a mean age of 68 years. Complete regression of SSBE was observed in 61.5% of initial SSBE patients, while 12.1% of initially disease free patients experienced an appearance of SSBE. Complete regressions and appearances of BE occurred constantly over time, accounting for 80% and 17% of 5-year cumulative rates. No LSBE development from SSBE was observed. A hiatus hernia was the only significant factor that facilitated BE development (P = 0.03) or hampered (P = 0.007) BE regression.

CONCLUSION

Both appearances and complete regressions of SSBE occurred over time. A hiatus hernia was the only significant factor affecting the BE story.

Diabetes mellitus carries a risk of gastric cancer: A meta-analysis

AIM: To investigate the association and quantify the relationship between diabetes mellitus (DM) and gastric cancer (GC) by an updated meta-analysis.

METHODS: The initial PubMed search identified 1233 publications. Studies not reporting GC or those not reporting actual number of GC were excluded. Twelve pertinent studies were retrieved from the PubMed database or from a manual search and considered for the meta-analysis. Pooled risk ratios and 95%CI were estimated by a random-effects model. Subgroup analysis was performed according to gender or geographical regions. Heterogeneity and publication bias were evaluated by I² and funnel plot analysis, respectively.

RESULTS: DM was significantly associated with GC with a RR of 1.41 (P = 0.006) (95%CI: 1.10-1.81). Subgroup analyses revealed that both sexes showed a significant association with GC, with a greater magnitude of risk in females (RR = 1.90; 95%CI: 1.27-2.85; P = 0.002) than in males (RR = 1.24; 95%CI: 1.08-1.43; P = 0.002). In addition, the link between DM and GC was significant in East Asian DM patients (RR = 1.77; 95%CI: 1.38-2.26; P < 0.00001) but not in Western DM patients (RR = 1.23; 95%CI: 0.90-1.68; P = 0.2). There was no evidence of publication bias, but the results indicated significant heterogeneity.

CONCLUSION: This updated meta-analysis has provided evidence of positive DM-GC associations. The limited information on potentially important clinical confounding factors in each study deserves further investigation.

[S-1 monotherapy achieved twenty-month survival for peritoneal lavage cytology-positive gastric cancer patient undergoing noncurative resection]

We report a gastric cancer patient with positive peritoneal lavage cytology (CY1) who achieved 20-month progression free survival by S-1 monotherapy. An 82-year-old male patient who underwent distal gastrectomy with residual disease for type 4 scirrhous gastric cancer manifesting pyloric stenosis, direct invasion to the pancreas, and CY1. He received S-1 monotherapy postoperatively. His ECOG performance status (PS) was 0. The initial treatment schedule was 100mg/day, twice daily for 4 weeks with a 2-week rest, repeated every 6 weeks. Grade 2 thrombocytopenia at the end of the 5th course of treatment required discontinuation of one course of treatment, and subsequent treatment was continued with a dose reduction to 80mg/day. Afterwards, although treatment was temporarily postponed for 2 weeks, the dose modification enabled him to receive S-1 for 20 months, leading to a relative dose intensity of 81%. There was no evidence of disease progression. The most severe adverse events were transient grade 3 neutropenia as well as leukocytopenia, anemia, and thrombocytopenia, grade 2 each, without gastrointestinal toxicities. His PS was not deteriorated. Although survivalrates of CY1 gastric cancer patients are still poor, our case suggests that S-1 monotherapy is effective against CY1, even for patients aged over 80, if the relative dose intensity is maintained by comprehensive patient management and appropriate dose modification.

A substantial incidence of silent short segment endoscopically suspected esophageal metaplasia in an adult Japanese primary care practice

AIM: To determine the incidence and characteristics of endoscopically suspected esophageal metaplasia (ESEM) in a primary adult care institution.

METHODS: Eight hundred and thirty two consecutive individuals (mean age, 67.6 years) undergoing upper gastrointestinal endoscopy between January 2009 and December 2010 were included in this study. The diagnosis of ESEM was based on the criteria proposed by the Japan Esophageal Society, and was classified as long segment ESEM (3 cm or more) or short segment ESEM (< 3cm). Short segment ESEM was further divided into circumferential and partial types. Age, gender, hiatus hernia, esophagitis, gastroesophageal reflux disease (GERD)-suggested symptoms, and antacid medications were recorded as background factors. Esophagitis was graded according to the Los Angeles classification. Hiatus hernia was divided into absent and at least partially present.

RESULTS: Long and short segment ESEM were found in 0 and 184 (22.1%) patients, respectively (mean age of short segment ESEM patients, 68.3 years). Male gender and hiatus hernia were shown to be significant factors affecting short segment ESEM by both univariate (P = 0.03 and P = 9.9x10^-18) and multivariate [Odds ratio (OR) = 1.45; P = 0.04, and OR = 43.3; P = 1.5x10^-7)] analyses. Two thirds of patients with short segment ESEM did not have GERD-suggested symptoms. There was no correlation between short segment ESEM and GERD-suggested symptoms.

CONCLUSION: The incidence of short segment ESEM in our community practice seems higher than assumed in Asian countries. As GERD-suggested symptoms are a poor predictor of ESEM, endoscopists should bear in mind that silent short segment ESEM does exist and, in fact, was found in the majority of our patients.

Statins and gastric cancer risk

BACKGROUND/AIMS

Statin is the most promising agent in the improvement of blood lipid profiles, and a substantial risk reduction of subsequent cardiovascular events leads to a rapid increase in current prescription rates. However, statin use or a lower total cholesterol has been associated with an increased cancer risk, although some deny such an association. Whether a positive statin-cancer association exists or not remains a matter of debate because such a causal association, if any, may offset anticipated cardioprotective benefits from statins. So far, no statin-cancer association in gastric cancer has been systematically highlighted in the literature.

METHODOLOGY

Original studies concerning the effect of statins on gastric cancer incidence were searched in PubMed Central published between 1993 and 2008. A manual search was additionally performed though reference lists in the retrieved manuscripts. Pooled gastric or upper gastrointestinal cancer risk ratio (RR) with 95% confidence interval (CI) was independently calculated by random effects model, provided by the Cochrane Library software Review Manager 5.

RESULTS

Six publications were considered finally eligible, three were for gastric cancer risk and three were for upper gastrointestinal cancer risk. Statin use proved no significant increase (RR; 1.37, 95% CI; 0.57-3.25) in gastric cancer risk, nor was there any evidence of increased risk (RR; 1.20, 95% CI; 0.94-1.53) even in upper gastrointestinal cancer.

CONCLUSIONS

These results suggest that statins had no short-term effect on gastric or upper gastrointestinal cancer incidence. Further investigation of long-term associations between statin use and gastric cancer is warranted.

Successful type-oriented endoscopic resection for gastric carcinoid tumors: A case report

The standard treatment in Japan for gastric carcinoid has been gastrectomy with lymphadenectomy. This report describes the possibility of endoscopic treatment as an appropriate option for gastric carcinoid fulfilling certain conditions. A 46 year old woman underwent endoscopic mucosal resection for two 3 mm gastric carcinoids. The patient had hypergastrinemia with pernicious anemia and type A chronic atrophic gastritis, suggesting that the tumors were type I in Rindi's classification. Both tumors were located in the mucosal layer with no cellular polymorphism and were chromogranin A positive. Neither tumor recurrence in the stomach nor distant metastases have been documented during the 5 years of follow-up. Although many type I gastric carcinoids may be clinically indolent, reports on successful endoscopic treatment for this carcinoid have been scanty in the literature in Japan, presumably because of the hitherto surgical treatment stance for the disease. This report discusses how the size, number, depth and histological grading of the type I gastric carcinoid could allow the correct identification of a benign or malignant propensity of an individual tumor and how endoscopic resection could be a treatment of choice when these factors render it feasible. This stance could also obviate unnecessary surgical resection for more benign tumors.

[Our experiences of best supportive care for gastric cancer patients]

BACKGROUND

The literature contains only a small number of reports concerning best supportive care(BSC)in gastric cancer. With the progress of social healthcare systems supporting medical care at home, the quality and performance of BSC at present are different from those in the mid-1990s, when the previous reports were published. We evaluated the quality and performance of BSC in gastric cancer patients in collaboration with visiting nurses.

PATIENTS AND METHODS

This study comprised 17 gastric cancer patients receiving BSC between March 2005 and April 2009. Baseline characteristics were age, sex, performance status, and main disease site at entry. Except for one patient who died of other than gastric cancer, types of nutritional support whenever needed during the BSC period were divided into two categories; drip infusion through peripheral vein (peripheral group, n=7) and parenteral or enteral nutrition through a central venous catheter or gastrostomy (hyperalimentation group, n=9). The main outcome measures were overall survival and survival according to the type of nutritional support, as well as quality and performance of BSC.

RESULTS

Mean age and mean PS were 76 years old and 2. 9, respectively, with incidences of > or =75 years old and PS> or =3 accounting for 71% and 59%, respectively. Overall MST was 175 days, which was longer than earlier reported. MST of the hyperalimentation group (190 days)was significantly (p<0.04) longer than that of the peripheral group. Fourteen patients (88%) could stay at home during at least part of the BSC period, and among them, 10 patients received home visiting care by a doctor and/or nurse, and 7 patients (70%) died at home. Eight patients (89%) in the hyperalimentation group received home care visits.

CONCLUSIONS

These results suggest that home care hyperalimentation by visiting nurses prolongs BSC patient survival in gastric cancer. Domiciliary care realizes hyperalimentation and provides comprehensive home-care during BSC period.

Pharmacogenetics of irinotecan: An ethnicity-based prediction of irinotecan adverse events

Irinotecan is now regarded as the most active drug for the treatment of colorectal cancer. However, one of the most difficult issues oncologists face is deciding the optimal dose for an individual patient, as each individual shows different outcomes even at the same dose with regard to treatment related adverse events, ranging from no toxicity to a lethal event. Inherited genetic polymorphism of a single gene or multiple genes (haplotype or linkage disequilibrium) involved in SN-38 glucuronidation, a predominant route of irinotecan detoxification, is now recognized as a significant factor that can alter the incidence of side effects. Attempts to explore such inherited genetic variability have been focused on elucidating interindividual as well as interethnic differences. Genotyping studies in relation to adverse events in an individual or in a group of similar ethnicity should contribute to establishing individual-oriented or ethnicity-oriented irinotecan treatment regimens. This review highlights current single- or multi-tired approaches for the elucidation of genetic predispositions of patients to severe toxicities, especially among Asians. The purpose of this is to contribute to minimizing toxicity by dose modifications, with the consequent aim of maximizing dose intensity and efficacy, an ultimate goal of irinotecan-individualized therapy.

Pharmacogenetics of fluoropyrimidine and cisplatin. A future application to gastric cancer treatment

Chemotherapy plays an important role in the treatment of gastric cancer both in adjuvant or advanced settings. Recent randomized trials in Japan have proved that S-1, a novel fluoropyrimidine derivative, and cisplatin are the most promising agents. However, both the efficacy and toxicity of a given regimen vary widely among patients due to the inherited variability of genes that involve drug anabolism and catabolism. A narrow therapeutic index of antitumor agents, i.e. a given regimen being too toxic and/or less effective to some segment of patients, prevents the overall improvement of treatment outcomes. Pharmacogenetics, a research field elucidating genetic polymorphism in drug metabolizing enzymes, may contribute to identifying patients who benefit from chemotherapy or who will experience life-threatening toxicity. There are several crucial enzymes identified involving anabolism and the catabolism of fluoropyrimidine and cisplatin, including dihydropyrimidine dehydrogenase, thymidylate synthase, orotate phosphoribosyl transferase, glutathione S transferase, and excision repair cross complementary group. Various polymorphisms and ethnic variabilities of these genes have been elucidated. This review highlights variations within biological functions, detection systems, and possible clinical applications of these enzymatic polymorphisms. This knowledge provides a tool to determine an optimum regimen according to the patient's drug metabolizing characteristics. This stance will contribute to establishing individualized therapies for gastric cancer, which offers superior efficacy with a minimal chance of severe toxicity.

A three-year survivor case of gastric cancer with peritoneal dissemination--an outpatient with second-line weekly paclitaxel

This case report describes a three-year survivor case by weekly paclitaxel, who had peritoneal dissemination of gastric cancer resistant to methotrexate and 5-fluorouracil therapy. A 62-year-old female with massive ascites, abdominal pain, and difficulty in eating received a weekly paclitaxel schedule which consisted of a 1-hour infusion of paclitaxel (70 mg/m(2)) given once a week for three weeks followed by a 1-week rest, repeated every four weeks. Short course premedication was given 30 minutes prior to paclitaxel. The administrations could be performed on an outpatient basis with transient grade 3 neutropenia requiring no specific medication. Neither hypersensitivity reactions nor peripheral neuropathy developed. A dramatic disappearance of ascites and relief of abdominal pain, as well as a rapid recovery of food intake enabled the patient to be withdrawn from nutritional support through central venous catheter, indicating this schedule's contribution to improve her quality of life. A three-year survival from the commencement of weekly paclitaxel without evidence of relapse was confirmed. Weekly paclitaxel was based on the dose-dense concept, where cumulative paclitaxel exposures by frequent, repetitive administration have a more potent antitumor effect than higher dose 21-day schedule. Encouraging aspects in the weekly paclitaxel schedule in this report are that the survival time is considered to be satisfactorily long as compared with those of other case reports in the literature achieved by a convenient outpatient use with acceptable toxicities, leading to a comprehensive contribution to improve patient quality of life.

Nutritional comparisons between a pylorus-preserving gastrectomy with and without suprapyloric lymph node clearance: a preliminary report

BACKGROUND/AIMS

A pylorus-preserving gastrectomy (PPG) is a procedure for gastric cancer (GC) patients which attempts to control gastric emptying and to minimize postoperative nutritional disadvantages. The persistence of conflicting stances concerning qualifying candidates for PPG--a narrower or wider segment of patients--is attributable to a lack of decisive evidence concerning the precise nutritional impact of suprapyloric lymph node clearance.

METHODOLOGY

Forty-eight patients underwent a PPG with (30 patients; dissection group) or without (18 patients; preservation group) suprapyloric lymph node clearance between 2002 and 2004. Patients with mucosal GC located in the middle third of the stomach were assigned to the preservation group and the other early GC patients formed the dissection group. Those who were followed up more than one year postoperatively were selected from the preservation (8 patients) and the dissection (16 patients) groups, and changes in body weight, hemoglobin, total protein, and albumin were compared between the two groups. Baseline clinicopathological characteristics, surgically related events, and supportive medications were also compared between the two groups.

RESULTS

Dissection group patients received significantly longer surgery (p < 0.01) and a wider scope of lymphadenectomy (p < 0.0001) than preservation group patients. Other factors including the length of postoperative hospital stay and morbidity rate did not differ between the two groups. Percent changes in body weight, hemoglobin, total protein, and albumin, as well as postoperative profiles of each parameter were similar between the two groups.

CONCLUSIONS

These results suggest that suprapyloric lymph node clearance resulted in more traumatic surgery while it did not exacerbate postoperative nutritional status as compared with suprapyloric lymph node preservation. PPG is justifiable for submucosal GC or an even wider segment of patients by suprapyloric lymph node clearance without nullifying the anticipated nutritional benefit.

Enhanced efficacy of herpes simplex virus mutant HF10 combined with paclitaxel in peritoneal cancer dissemination models

BACKGROUND/AIMS

Oncolytic viral therapy is used worldwide. Many genetically engineered viruses have been evaluated for their potential as a new therapeutic agent for cancer. HF10, herpes simplex virus (HSV) type-1 clone, has remarkable anti-tumor effects, based on our previous research. In this study, we investigated the ability of HF10 to infect and lyse murine colon cancer cells, CT26, in vitro, and tested its efficacy in an immuno-competent animal model of colorectal cancer. Further, we attempted to evaluate HF10/paclitaxel combination therapy.

METHODOLOGY

In vitro, viral replication and cytotoxicity of HF10 against CT26 was observed. In vivo, BALB/c mice harboring carcinomatous peritonitis of CT26 cells were treated with HF10, paclitaxel or HF10 combined with paclitaxel.

RESULTS

HF10 is effective for peritoneal dissemination without ascites. The combination of HF10 and paclitaxel prolonged survival of mice bearing carcinomatous dissemination of CT26 compared with the controls, HF10 alone and paclitaxel alone. Paclitaxel did not suppress viral replication and cytotoxicity of HF10.

CONCLUSIONS

These results indicate that the combination of HF10 and paclitaxel had a remarkable effect as a cancer therapy and this method is applicable to almost all advanced cancers. This new combination therapy is a potentially epoch-making cancer therapy.

Oncolytic virus therapy--foreword

We are very pleased and proud to be able to publish this special issue of Current Cancer Drug Targets devoted to oncolytic virus therapy covering basic and clinical research on adenovirus, vaccinia virus, herpes virus, and Newcastle disease virus. In these papers, we welcome the world's top authorities in the field who have generously contributed their latest review articles for exclusive publication in this special issue. Moreover, this issue also includes a range of opinion from government drug organizations. Here we simply wish to bring together the newest knowledge and experience in the field of cutting-edge oncolytic virus therapy for researchers and every kind of cancer therapist. The Foreword presents a historical perspective on the development of oncolytic virus together with the encouraging results of recent clinical trials (e.g., H101 has been tested in clinical trial of nearly 250 patients and approved for human use by the Chinese FDA, while PV701 has been tried in over 110 patients, as described in our special issue).

Clinical Experiment of Mutant Herpes Simplex Virus HF10 Therapy for Cancer

We reviewed our clinical trial using mutant herpes simplex virus "HF10". We have evaluated the safety and effect of HF10 against recurrent breast cancer since 2003 and also applied HF10 to non-resectable pancreatic cancer since 2005. An oncolytic herpes simplex virus type 1, mutant HF10, has been isolated and evaluated for anti-tumor efficacy in syngeneic immunocompetent mouse models. From long time before clinical trial, we have found that the mutant virus can have remarkable potential to effectively treat cancer in experimental studies using animals, and that all of the surviving mice acquire resistance to rechallenge of the tumor cells. A number of studies have shown that HF10 is effective and safe for use in localized or peritoneally disseminated malignant tumors of non-neuronal origin in animals. Pilot studies using HF10 have been initiated in patients with metastatic breast cancer. For each patient, 0.5 ml HF10 diluents at various doses were injected into test nodule, and 0.5 ml sterile saline was injected into a second nodule. All patients were monitored for local and systemic adverse effects, and the nodules were excised 14 days after viral injection for histopathological studies. All patients tolerated the clinical trial well. While no adverse effects occurred, there was cancer cell death and 30-100% regression histopathologically in recurrent breast cancer. As mentioned above, intratumoral injection of mutant herpes simplex virus HF10 for recurrent metastatic breast cancer was safe and effective. Also a trial for non-resectable pancreatic cancer being carried out on the basis of the above result has proved to be innocuous and has been in progress to assess the clinical benefit and enhance the potentiality of HF10 against cancer.

Laparoscopy-assisted pylorus-preserving gastrectomy with quality controlled lymph node dissection in gastric cancer operation

BACKGROUND

Pylorus-preserving gastrectomy (PPG) with extensive lymph node dissection is useful for treatment of early gastric cancer with preservation of function. This technique could be improved by using laparoscopy-assisted gastrectomy.

STUDY DESIGN

Between September 2000 and September 2004, 109 patients with T1 gastric cancer underwent surgical treatment; 72 underwent laparoscopy-assisted PPG (LAPPG) and 37 underwent conventional PPG (CPPG). Total numbers of dissected lymph nodes, retrieval at each lymph node station, intraoperative blood loss, and operation times were used as measures of the quality of lymph node dissection to compare the procedures. Continuous data are summarized as mean +/- SE.

RESULTS

Operation times with the LAPPG procedure (279 +/- 6 minutes) were significantly, but only 20 minutes, longer than with CPPG (259 +/- 8 minutes) (p = 0.047), although estimated blood loss for LAPPG patients (153 +/- 13 mL) was not significantly different for those undergoing CPPG (184 +/- 13 mL, p = 0.13). Mean total number of dissected lymph nodes was 32.3 +/- 1.6 in the LAPPG group and 28.5 +/- 2.2 in the CPPG group (p = 0.16). There was no significant difference in the number of lymph nodes retrieved for any of the nodal stations between the LAPPG and CPPG procedures.

CONCLUSIONS

Clinical outcomes of surgical treatment were comparable for gastric cancer patients who underwent LAPPG and those treated with CPPG in terms of station-dependent lymph node dissection and estimated blood loss.

The useful combination of a higher frequency miniprobe and endoscopic submucosal dissection for the treatment of T1 esophageal cancer

BACKGROUND

There are few published data on the discrimination ability of endoscopic ultrasonography (EUS) among each subdivision of T1 cancer, and overdiagnosis is an unsolved problem that eventually causes overtreatment. The purpose of this study was to verify whether our treatment strategy incorporating EUS realizes a tailored patient management of T1 esophageal cancer.

METHODS

This study comprised 20 esophageal cancer patients undergoing 12- to 20-MHz miniprobes for T staging and a 7.5-MHz dedicated echoendoscope for N staging. Initial therapy constituted endoscopic submucosal dissection (ESD) for endosonographically node-negative, mucosal, or slight submucosal cancers and a primary esophagectomy with three-field lymphadenectomy for deeper cancers. If the ESD specimen revealed no cancer involvement of the muscularis mucosa, the patients entered a follow-up program; otherwise, they were advised to undergo a subsequent esophagectomy and three-field lymphadenectomy.

RESULTS

Perfect discrimination accuracy was achieved among T1, T2, and T3 cancers. Whether cancer depth was up to the slight submucosal layer or deeper was correctly differentiated in 12 of 14 T1 cancers (86%). EUS categorized all patients correctly into candidates for either ESD or surgery. The pathological cancer depth of the resected specimens revealed that no patients experienced unnecessary overtreatment.

CONCLUSIONS

A higher frequency miniprobe is useful for the detailed evaluation of cancer depth, contributing to decision making for treatment options of T1 esophageal cancer. A miniprobe and echoendoscope in combination with ESD provide an appropriately tailored management plan on an individual basis, avoiding unnecessary treatment or indicating radical surgery.

Safety of a paraaortic node dissection for selected advanced gastric cancer patients

BACKGROUND/AIMS

Comprehensive evaluations of a superextended (D3) dissection concerning its benefits as well as potential disadvantages have been scanty in the English literature.

METHODOLOGY

The patient selection criteria for a D3 dissection were pre- and intraoperatively > or = T3 and/or > or = N2 diseases, no paraaortic node involvement, no distant or peritoneal metastases, and a negative peritoneal lavage cytology. A D3 dissection involved a node clearance up to the third tier including the middle paraaortic region. Twenty-seven patients were entered into our D3 dissection strategy in a prospective manner between 1997 and 2000, and were divided into 2 groups: pathologically meeting the D3 criteria (D3 criteria fit; 12 patients) and pathologically proved to have less advanced disease (less advanced/D3; 15 patients). Data from age-matched 53 patients who underwent a D2 dissection between 1991 and 1996 were collected and also divided according to the current D3 criteria. Surgical invasiveness, morbidity and mortality, nutritional parameters, and survival were compared between D2 and D3 patients. Additionally, positive paraaortic node patients with a D3 dissection (4 patients) were used for preliminary survival comparison.

RESULTS

A D3 dissection resulted in longer surgery and more blood loss, but morbidity and mortality, and nutritional impairment were similar to those of a D2 dissection. A more promising survival rate by a D3 dissection over a D2 dissection was observed only in the D3 fit patients but not in the less advanced disease patients. On the contrary, survivals of the positive paraaortic node patients were pessimistic despite the R0 resection.

CONCLUSIONS

A D3 dissection is an invasive procedure but can be performed as safely as a D2 dissection. Our results provide a starting point for a D3 challenge; however, paraaortic node positive patients should be excluded from a D3 dissection.

Performance of outpatient regimen of S-1 in combination with fractional cisplatin for advanced or recurrent gastric cancers: a phase I study

BACKGROUND

We designed an outpatient regimen consisting of fractional cisplatin in combination with S-1, a novel oral fluoropyrimidine derivative for the treatment of recurrent or advanced gastric cancer and conducted a phase I study to determine the dose limiting toxicities (DLTs) and recommended dose (RD).

METHODS

Escalating dosages of cisplatin (15, 20, and 25 mg/m(2), as levels 1, 2, and 3, respectively) were administered over 2 h on days 1, 8, and 15, with a fixed dose of S-1 for 3 consecutive weeks (days 1-21), repeated every 5 weeks. National Cancer Institute common toxicity criteria(NCI-CTC) grade 2 toxicities required treatment delay. Primary first cycle DLTs were defined as NCI-CTC grade 3 or 4 toxicities (except for hemoglobin levels, nausea, and vomiting).

RESULTS

Nine patients were initially enrolled, and DLTs did not appear; however, one level-3 patient experienced grade 3 anemia. An additional three patients were enrolled in level 3 to confirm the toxicity profiles, and none experienced DLTs. Toxicity evaluations throughout a total of 62 cycles revealed that grade 1 or 2 hematological toxicities were common, although mostly transient, with recovery without specific treatment. One patient each in levels 1 and 3 required hospitalization due to grade 3 toxicities in the later cycles. Mean dose intensities for S-1 and cisplatin were both more than 91%. There were no treatment-related deaths. The preliminary response rate was 44%.

CONCLUSIONS

It was concluded that the RD of cisplatin in this regimen was 25 mg/m(2) (level 3). S-1 in combination with fractional cisplatin is a promising regimen that allows repeated drug administration, in an outpatient setting, for advanced or recurrent gastric cancers. A phase II study of the RD is now under way.

Concepts, rationale, and current outcomes of less invasive surgical strategies for early gastric cancer: data from a quarter-century of experience in a single institution

Previously proposed criteria of less invasive surgery for early gastric cancer (EGC) were based mainly on the pathological analyses of the resected specimens; however, preoperative and intraoperative information are also obviously essential for decision making on stage-dependent patient management. Furthermore, most indications and treatment options have not been systematically integrated or evaluated by treatment outcomes. We investigate in this report the rationality of less invasive surgery employed for EGC. Distribution analyses of positive nodes were investigated among 684 patients with primary solitary EGC (379 mucosal and 305 submucosal) who underwent curative resection between 1976 and 2000. Clinicopathological factors highlighted and analyzed included clinical (preoperative and intraoperative) and pathological (postoperative) cancer depth and nodal involvement, gross form, histological type, and maximum cancer diameter, as well as postoperative morbidity and mortality. The scope of lymphadenectomy can be reduced to a modified D1 for clinically mucosal, node-negative, nonpalpable gastric cancer, or for clinically submucosal, node-negative gastric cancer < or = 1.5 cm for intestinal type, or < or = 1.0 cm for diffuse type. Otherwise, a modified D2 lymphadenectomy is sufficient. Local resection can be recommended for clinically mucosal, node-negative gastric cancer without apparent ulceration < or = 4 cm if adjacent lymph nodes are proved cancer negative by a frozen section examination. If the gastric cancer has spread beyond the above criteria, a pylorus-preserving gastrectomy (PPG) can be recommended for tumors located in the middle or lower third of the stomach, provided the distal margin of the cancer is at least 4.5 cm from the pyloric ring. The PPG can be accompanied by a modified D1 or a modified D2 lymphadenectomy according to the respective dissection criteria. Results of these less invasive strategies showed reduced morbidity and mortality, as well as no recurrence or cancer-related deaths. These results suggest that each of our criteria for less invasive surgery for EGC is realistic, well stratified, and satisfactory.

Efficacy of triple therapy plus cetraxate for the Helicobacter pylori eradication in partial gastrectomy patients

In the present study, we aimed to establish an additional standardized protocol with a higher H. pylori eradication rate in the remnant stomach. Fifty-five H. pylori-positive patients were randomly allocated to one of three regimens: LAC--lansoprazole, amoxicillin, and clarithromycin b.i.d. for 7 days (n = 17); LAC+CET--LAC b.i.d. plus cetraxate q.i.d. for 7 days (n = 20); and LEFT--LAC for 7 days in a horizontal body position on the left side for 30 min (n = 18). Patient compliance and side effects were checked via interviews. H. pylori eradication was successful in 75, 72, and 41% in LAC+CET, LEFT, and LAC, respectively. The eradication rate was significantly higher in LAC+CET than in LAC (P = 0.024) but not in LEFT (P = 0.058). Adverse events that occurred in each group were almost all mild ones. Cetraxate plus LAC for 1 week is a safe and effective regime for the eradication of H. pylori in patients after partial gastrectomy.

Accuracy of linear-array EUS for preoperative staging of gastric cardia cancer

BACKGROUND

The feasibility of a less invasive operation for early stage cancer of the gastric cardia with a low frequency of lymph node involvement has been previously demonstrated by us. Precise discrimination among mucosal, submucosal, and advanced cancers, as well as accurate evaluation of the proximal tumor margin are prerequisites for such stage-specific treatment. EUS is considered the most reliable staging modality. However, there is no EUS study specifically of cardia cancer.

METHODS

Forty-five patients with gastric cardia cancer who underwent gastrectomy with at least first-tier lymphadenectomy were retrospectively analyzed. The results of preoperative linear-array echoendoscopy (7.5 MHz) with respect to cancer depth, lymph node involvement, and esophageal invasion were compared with postoperative histopathologic findings.

RESULTS

Overall diagnostic accuracy for depth of invasion was 71%. Sensitivity for T1, T2, and T3 lesions was 100%, 31% and 75%, respectively. Overstaging of T2 cancers was the main diagnostic error. Mucosal (pT1-m) and submucosal (pT1-sm) cancers were correctly discriminated in 81% of patients. Diagnostic accuracy for lymph node involvement was 80%. EUS had positive and negative predictive values of 90% and 80%, respectively, for esophageal invasion.

CONCLUSIONS

For gastric cardia cancer, the linear-array echoendoscope yielded satisfactory results with respect to depth of invasion, lymph node involvement, and esophageal invasion evaluation. The information obtained is useful to the performance of stage-specific treatment.

Gastric cancer with metastasis to the gingiva

The present case report describes a gastric cancer which showed unusual metastasis in the oral region. A 56-year-old male patient underwent total gastrectomy and splenectomy due to advanced gastric cancer in the upper third of the stomach. Fifteen months later, he presented with anorexia and gingival swelling of durations of approximately 3 and 1 month, respectively. The gastric tumor was histologically a signet ring cell and a poorly differentiated cancer with a moderate degree of vascular invasion. Biopsy specimens from the gingival tumor revealed a signet ring cell cancer. Other metastatic sites were the brain, limb bones and abdominal lymph nodes. A bone scintigram revealed an abnormal uptake in the limb bones, while it did not exhibit any abnormality in the oral region. Correlation between the histology of the gingival tumor with that of the gastric cancer, as well as the absence of a gingival tumor at the time of prior gastrectomy, led to a diagnosis that the gingival tumor was a metastasis from gastric cancer. Gastric cancer metastasizing to the oral region, either the osseus or the oral soft tissue, is very rare. Although it cannot be proved without an autopsy, negative findings in the mandible by bone scanning in the present case suggest that direct gingival metastasis can be considered, rather than mandibular metastasis involving the gingiva. Hematogenous spread could be a mechanism of metastasis for this unusual tumor.

[Successful downstaging by a low-dose, fractional administration of irinotecan hydrochloride (CPT-11) in combination with cisplatin in peritoneal lavage cytology positive, 5-fluorouracil refractory advanced gastric cancer patients]

A 46-year-old Japanese female with advanced gastric cancer with positive peritoneal cytology and who was refractory to methotrexate plus 5-FU sequential chemotherapy received low-dose, fractional irinotecan hydrochloride (CPT-11) in combination with cisplatin. This regimen could be repeated biweekly on an outpatient basis and was well tolerated. After 8 cycles of administration, a negative change in peritoneal cytology subsequently enabled a total gastrectomy, splenectomy, and cholecystectomy with a D3 lymph node dissection. The rationale for a low-dose, fractional administration of CPT-11 in combination with cisplatin is the synergistic antitumor activity obtained through the ability of SN-38 to potentiate cisplatin-induced cytotoxicity, as well as the increased therapeutic efficacy of a protracted CPT-11 administration over more intense treatment schedules. As far as we are aware, this case report demonstrates for the first time that a low-dose, fractional administration of CPT-11 with cisplatin can successfully produce a negative change in peritoneal lavage cytology, and potentiates a R0 resection in a 5-FU resistant advanced gastric cancer patient. This suggests that this combination could be an effective regimen for potentially disseminated, 5-FU resistant patients.

A seasonal variation in the onset of postoperative adhesive small bowel obstruction is related to changes in the climate

BACKGROUND

Postoperative small bowel obstruction following abdominal procedures is more common in patients who have undergone laparotomy. However, little is known about the influence of climate on the incidence of postoperative small bowel obstruction.

METHODS

To evaluate whether seasonal climatic variations are a risk factor for postoperative small bowel obstruction, hospital-based, retrospective case series was designed from medical records of 230 patients suffering from postoperative small bowel obstruction admitted to the Tokyo University Branch Hospital. Detailed analysis of weather charts from the Japanese Meteorological Agency and review of medical records for selected patients who were diagnosed with postoperative small bowel obstruction. The obstruction was diagnosed by abdominal X-ray imaging, clinical examination, and patient interviews.

RESULTS

A total of 233 patients diagnosed with postoperative small bowel obstruction were identified. Analysis of the medical records of these 233 patients revealed that the variables associated with an increased risk of postoperative small bowel obstruction included low ambient temperatures of 5-10 degrees C, an increase in air humidity by 40-50% and air pressure of 1010-1015 hPa.

CONCLUSION

The typical winter weather in Tokyo is characterised by low temperatures, low humidity and moderate air pressure. These winter climate conditions could be correlated with an increased incidence of postoperative small bowel obstruction in Tokyo during our period.

Indications for a pylorus-preserving gastrectomy for gastric cancer with proper muscle invasion

HYPOTHESIS

Our previous demonstrations of the feasibility of a pylorus-preserving gastrectomy with a wider-scope lymphadenectomy for early gastric cancer (GC) have raised the possibility of applying pylorus-preserving gastrectomy to a broader segment of GC patients, such as those having GC with invasion extending into the proper muscle layer (GCpm).

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENTS

This study comprised 107 patients with solitary primary GCpm located in the middle or lower third of the stomach.

INTERVENTION

All patients underwent gastrectomy, using at least the former D2 dissection of the American Joint Committee on Cancer.

MAIN OUTCOME MEASURES

Patterns and sites of nodal involvement were analyzed in relationship to other clinicopathologic characteristics, including preoperative and intraoperative evaluations of tumor depth (cT), nodal involvement (cN), and serosal involvement. The conditions required were serosal negativity and measurements less than or equal to cT2 cN0 with histologic proof of node negativity, or if positive, the positive nodes had to be confined to the first or selective second tier. The selective second-tier nodes were defined as those along the left gastric, common hepatic, and celiac arteries.

RESULTS

The factors favoring node negativity were serosal negativity, cN0, or both. For tumors that were serosal-negative and less than or equal to cT2 cN0 to meet the above conditions, a tumor in the middle third of the stomach had to be less than or equal to 2 cm in the maximum diameter, and that in the lower third could be any size. No patients with serosal negativity and cT2 cN0 GCpm less than or equal to 2 cm in diameter died of cancer or had positive nodes beyond the selective second tier.

CONCLUSIONS

Considering the required distance between the pyloric ring and distal margin of the tumor to avoid a positive resection margin, pylorus-preserving gastrectomy with a selective second-tier node dissection is optimal for tumors that are serosal negative, less than or equal to cT2 cN0, and less than or equal to 2 cm in maximum diameter when located in the middle or lower third of the stomach.

Utility of [13C] urea breath test for Helicobacter pylori detection in partial gastrectomy patients

Many reports on the diagnostic efficacy of the [13C] urea breath test ([13C] UBT) for the detection of Helicobacter pylori in the residual stomach have shown negative results. We previously reported on the utility of [13C] UBT and conducted an evaluation to establish a standardized protocol with a shorter sampling time for [13C] UBT in partial gastrectomy patients. Sixty-two patients who had undergone partial gastrectomy were included. The [13C] UBT protocol included ingestion of 100 mg [13C] urea, use of mouthwash, and the body in a horizontal position on the left side. The sensitivity of [13C] UBT was 95.7%. Thirty minutes and a cutoff of 2.0 per thousand were found to be optimal for the test, with the body position horizontal on the left side. In the present protocol [13C] UBT appears to be a reliable and convenient tool with the same accuracy rate as other routine tests in patients with a remnant stomach.

Peppermint oil reduces gastric spasm during upper endoscopy: a randomized, double-blind, double-dummy controlled trial

BACKGROUND

GI endoscopy without general anesthesia causes a hyperperistaltic state in the stomach, which frequently necessitates the use of antispasmodic agents, such as hyoscine-N-butylbromide, but these drugs have side effects. Peppermint oil is harmless and acts locally to inhibit GI smooth muscle contraction.

METHODS

A randomized double-blind, double-dummy, controlled trial was conducted in 100 patients to compare the antispasmodic effects of hyoscine-N-butylbromide administered intramuscularly and a placebo solution administered intraluminally by means of the endoscope, and also the effects of a placebo solution administered intramuscularly with those of a peppermint oil solution administered intraluminally. The percent change in diameter of the pyloric ring before and after the administrations was defined as the opening ratio, and the percent change in diameter between the maximally and minimally opened pyloric ring states was defined as the contraction ratio. Time until disappearance of the contraction ring(s) in the gastric antrum and side effects of the drugs were also determined.

RESULTS

The opening ratio was significantly higher in the peppermint oil administration group than in the hyoscine-N-butylbromide injection group. The contraction ratio after peppermint oil administration was significantly lower than that after hyoscine-N-butylbromide injection. The time required for disappearance of the antral contraction ring(s) was shorter in the peppermint oil group (97.1 +/- 11.4) than in the hyoscine-N-butylbromide group (185.9 +/- 10.1 s; p < 0.0001). No significant side effects were associated with peppermint oil, whereas hyoscine-N-butylbromide injection produced side effects such as dry mouth, blurred vision, and urinary retention.

CONCLUSIONS

Peppermint oil solution administered intraluminally can be used as an antispasmodic agent with superior efficacy and fewer side effects than hyoscine-N-butylbromide administered by intramuscular injection during upper endoscopy.

Angiogenin in sera as an independent prognostic factor in gastric cancer

PURPOSE

The purpose of this study is to elucidate an increased expression of angiogenin (ANG) as a prognostic factor of gastric cancer (GC), against the background of our previous observations of the increased expression of ANG in the more progressed GC.

METHODS

We investigated serum ANG concentrations in 123 GC patients and 63 healthy volunteers as well as the distributions of ANG gene message in 52 GC tissues by in situ hybridization. The prognostic significance of ANG was investigated by the Cox proportional hazards model including variable selection and by survival analysis.

RESULTS

The mean serum ANG concentrations in GC patients (378.3+/-95.5 ng/ml) were significantly higher (P=0.0001) than those in the healthy volunteers (334.1+/-58.2 ng/ml). Either strong, moderate, weak, or no ANG gene message expression was seen in 25, 22, 4, and 1 patients, respectively, in GC cells as well as in interstitial cells in the vicinity of cancer cells, a finding in accord with our previous results of ANG protein localization. The variable selection method selected increased (> or =400 ng/ml) serum ANG concentration (P=0.02), undifferentiated histological type (P=0.01), cancer depth (P=0.001), and third-tier lymph node involvement (P=0.0005) as an independent prognostic factor by the Cox proportional hazards model. A significant correlation was seen between higher serum ANG concentrations (> or =400 ng/ml) and worse disease-free (P=0.003) or disease-specific (P=0.03) survivals. CONCLUSIONS. These results suggest that serum levels of ANG are an independent prognostic factor that could be a predictor of postoperative outcomes of GC patients.

Supra-additive antitumor activity of 5FU with tumor necrosis factor-related apoptosis-inducing ligand on gastric and colon cancers in vitro

We investigated supra-additive cytotoxic effects of 5-fluorouracil (5FU) on gastric and colon cancer cells with tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) in vitro. p53 wild- and mutant-type gastric and colon cancer cell lines were treated by 5FU alone, TRAIL alone, and a combination of 5FU and TRAIL, and cell viability after each treatment was determined by MTT assay. The p53 wild-type cells were more sensitive to 5FU alone or to TRAIL alone than p53 mutant-type cells. The cell growth inhibitory effects of the combined treatment were supra-additive and more significant in proportion to the increasing concentrations of TRAIL as compared with 5FU alone both in p53 wild- and mutant-type cells. Furthermore, TRAIL could cause a decrease in 5FU IC(50) to within the range of clinically relevant doses, particularly in p53 wild-type cells. This is the first demonstration of the supra-additive antitumor activity of 5FU with TRAIL on gastric cancer cells, giving evidence that TRAIL can reduce the requirement for 5FU that ultimately results in minimizing risks for systemic side effects while increasing the antitumor activity of 5FU, suggesting the clinical applicability of this combination for gastric and colon cancers.

Studies of 13C-urea breath test for diagnosis of Helicobacter pylori infection in patients after partial gastrectomy

BACKGROUND/AIMS

Many of the reports on the diagnostic efficacy of the 13C-urea breath test (13C-UBT) for the detection of Helicobacter pylori in the residual stomach have shown negative results. We conducted an evaluation to establish a standardized protocol and an appropriate cutoff value for 13C-UBT in partial gastrectomy patients.

METHODS

Forty-two patients undergoing partial gastrectomy were included. Three gastric biopsies from the anastomotic site and mid-to-high body were taken at panendoscopy for histology, culture and rapid urease test (RUT). The 13C-UBT protocol included ingestion of 100 mg 13C-urea, use of mouthwash, and the body in a horizontal position on the left side. Six breath samples were taken after ingestion.

RESULTS

The Delta 13CO2 values were significantly elevated in infected patients at all time points, and values were higher at 20 min and thereafter than at an earlier time point. The sensitivity of 13C-UBT was 96.3% with the cutoff of 2.0 per thousand at 40 min. The accuracy rates were highest with 13C-UBT, culture, RUT and histological tests, in that order.

CONCLUSION

Forty minutes and a cutoff of 2.0 per thousand were found to be optimal for the test, with the body position horizontal on the left side. In the present protocol 13C-UBT appears to be a reliable tool with the same accuracy rate as other routine tests in patients with a remnant stomach.

Activity and safety of a low dose, fractional administration of irinotecan hydrochloride (CPT-11) in combination with cisplatin for relapsed gastric cancer patients: a preliminary report

BACKGROUND

Irinotecan hydrochloride (CPT-11) in combination with cisplatin has emerged as a new therapeutic option for the treatment of advanced gastric cancer. So far, very few combination trials have been reported, and a relatively high frequency of grade 3/4 toxicities in previous trials has been a major problem. The purpose of this study was to elucidate the efficacy and safety of a low dose, fractional administration of CPT-11 and cisplatin that is principally based on recently acquired knowledge of the synergistic antitumor activities between these two agents.

METHODS

Five relapsed gastric cancer patients were treated every 2 weeks with a starting dose of CPT-11 (30 mg/m(2)) and a fixed dose of cisplatin (30 mg/m(2)). All patients were of performance status 0 and had received prior chemotherapy. Dose escalation of CPT-11 to 40 mg/m(2) or to 50 mg/m(2) was performed whenever possible. Responses, toxicities, and at-home ratio during chemotherapy were evaluated.

RESULTS

The response rate reached 40%. Toxicities were grade 1/2, and no grade 3/4 hematological toxicities or diarrhea were observed. Repeated subsequent treatments could be performed in an outpatient setting without treatment delay or cancellations, which resulted in an 83%-92% at-home ratio in four patients receiving five or more cycles of treatment. There were no treatment-related deaths.

CONCLUSION

A low dose, fractional administration of CPT-11 and cisplatin seems rational, encouraging, and safe, and compares well with other trials of the combination. Outpatient administration provides the patients with a better quality of life, suggesting a meaningful therapeutic option for relapsed gastric cancer patients in particular.

Supra-additive antitumor activity of 5FU with tumor necrosis factor-related apoptosis-inducing ligand on gastric and colon cancers in vitro

We investigated supra-additive cytotoxic effects of 5-fluorouracil (5FU) on gastric and colon cancer cells with tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) in vitro. p53 wild- and mutant-type gastric and colon cancer cell lines were treated by 5FU alone, TRAIL alone, and a combination of 5FU and TRAIL, and cell viability after each treatment was determined by MTT assay. The p53 wild-type cells were more sensitive to 5FU alone or to TRAIL alone than p53 mutant-type cells. The cell growth inhibitory effects of the combined treatment were supra-additive and more significant in proportion to the increasing concentrations of TRAIL as compared with 5FU alone both in p53 wild- and mutant-type cells. Furthermore, TRAIL could cause a decrease in 5FU IC(50) to within the range of clinically relevant doses, particularly in p53 wild-type cells. This is the first demonstration of the supra-additive antitumor activity of 5FU with TRAIL on gastric cancer cells, giving evidence that TRAIL can reduce the requirement for 5FU that ultimately results in minimizing risks for systemic side effects while increasing the antitumor activity of 5FU, suggesting the clinical applicability of this combination for gastric and colon cancers.

Indications of a minimized scope of lymphadenectomy for submucosal gastric cancer

BACKGROUND

A recent trend for less invasive surgery has increased consideration for a minimized scope of lymphadenectomy for submucosal cancer; however, feasibility criteria have not been precisely established.

METHODS

Patterns and sites of nodal involvement were retrospectively investigated in 294 patients with solitary submucosal gastric cancer in association with other clinicopathologic characteristics, including pre- and intraoperative evaluations of cancer depth (cT) and nodal involvement (cN).

RESULTS

Among the early (cT1) and node-negative (cN0) cancer, intestinal (< or =1.5 cm) and diffuse types (< or =1.0 cm) of submucosal cancer showed low incidences of nodal involvement (3%) confined to the first tier. When the cancer exceeded these cutoff diameters, positive nodes of the second tier were confined to three priority stations (left gastric, common hepatic, and celiac arteries) at an incidence of 2.3%. Perigastric and preferential dissection of these three node stations (modified D2 dissection) showed survival benefits identical to those of a conventional D2 dissection.

CONCLUSIONS

When submucosal cancer is evaluated as cT1cN0, a virtually sufficient minimized scope of lymphadenectomy is a D1 dissection for that within the cutoff diameter and a modified D2 dissection for that exceeding the cutoff diameter. These two types of dissection can even cover the infrequently observed node-positive stations and can realize no residual disease at surgery.

Distribution of angiogenin and its gene message in colorectal cancer patients and their clinical relevance

BACKGROUND

[corrected] The distribution of angiogenin (ANG) in normal colorectal and colorectal cancer tissues has not been precisely elucidated, while studies on the clinical significance of ANG have been scanty at best.

PATIENTS AND METHODS

We investigated the distribution of ANG and its gene message in 58 colorectal cancer and 58 corresponding normal colorectal tissue pairs by immunohistochemistry and in situ hybridization, the circulating ANG levels in sera by ELISA from 94 colorectal cancer patients and 52 healthy volunteers, as well as the clinical significance of ANG expression.

RESULTS

Strong, moderate and weak ANG immunoreactivity of cancer cells was observed in 22, 31 and 5 patients, respectively. ANG immunoreactivity was also observed in interstitial cells in the vicinity of and at the invasion front of cancer cells, as well as in normal superficial epithelial cells and in some interstitial cells. The distribution of the ANG gene message was coherent with the ANG protein localization. The mean serum ANG concentration was significantly (p =0.00005) higher in cancer patients as compared with that in the healthy volunteers and the degree of its elevation was more significant in the more progressed cancer subgroups. The degrees of ANG protein and mRNA expression correlated with serum ANG concentration (p<0.05). Survival analyses revealed a significant correlation between higher serum ANG concentrations (> or = 400ng/ml) and worse disease-free (p=0.003) or disease-specific (p=0.03) survivals.

CONCLUSION

These results suggest that ANG is expressed in colorectal cancer cells and in normal colorectal superficial cells as well as in interstitial cells and that serum levels of ANG reflect the degree of tissue ANG expression that could be a predictor of postoperative outcome.

Lymph node metastasis and preoperative diagnosis of depth of invasion in early gastric cancer

BACKGROUND

No reports have, to date, focused on the relationship between preoperative determination of the depth of invasion and lymph node metastasis. The present study, under the leadership of the Japanese Gastric Cancer Association, was designed to form a basis for decision making in limited treatment for early gastric cancer (EGC).

METHODS

From eight major hospitals in Japan, 2672 gastric cancers whose preoperative depth of invasion was mucosal(M-cancer), and 6209 EGCs, consisting of 3584 mucosal(m-) and 2625 submucosal(sm-) cancers, were collected by questionnaire. All registered patients underwent gastrectomy with D1 or more extensive lymphadenectomy between 1985 and 1998.

RESULTS

The accuracy of preoperative diagnosis of depth of invasion of M-cancers was 80.2% (2144/2672). However, of the total of 2432 M-cancers in which no nodal involvement was observed intraoperatively (N0), histological examination of the resected specimens confirmed that lymph node metastasis was absent in 2353 (96.8%). The frequencies of lymph node metastasis in early gastric, m-, and sm-cancers were 8.9%, 2.5%, and 17.6%, respectively. Node involvement was associated with a higher frequency of undifferentiated than differentiated histology, as well as with greater tumor size. The incidences of lymph node metastasis in m-cancers with a diameter of less than 4 cm, and in sm-cancers with a diameter below 1 cm were 1.3% (37/2837) and 4.9% (4/82), respectively. These metastases rarely extended beyond the first tier.

CONCLUSION

N0 and M-cancers, m-cancers less than 4 cm in diameter, and sm-cancers no larger than 1 cm in diameter may be appropriate indications for limited surgery.