Feasibility study of postoperative management based on ERAS of patients with gastrectomy

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Background: Although the usefulness of the postoperative management based on Enhanced Recovery After Surgery (ERAS) program of patents with colectomy is shown, there are a few papers concerning ERAS program for gastric cancer patients. The aim of the present study was to examined whether a new postoperative management based on ERAS was feasible for pts with gastrectomy.

Methods: From September 2009 to April 2010, we have adopted the new clinical pathway (CP) based on ERAS and oral rehydration therapy (ORT) for 30 consecutive gastric cancer patients who underwent curative gastrectomy. These pts began a oral rehydration solution (ORS) on the first postoperative day, and after the volume of ORS got 1,000 ml, we stopped intravenous transfusion. The incidence of adverse events, postoperative pt's activity score, which pt's daily activity was evaluated with, and total infusion volume of these pts were compared with 30 pts with the previous CP that were enrolled as a control group.

Results: There were no significant differences in the clinical and operative factors between the two groups. The post operative patient's activity score of ERAS group was significantly higher up to 7th postoperative day (POD). Total infusion volume was significantly little besides, in most cases, infusion therapy was substituted for ORT with OS-1 within 2 POD. There was no difference in the hospitalized days, and the incidence of adverse events were statistically no significance between two groups.

Conclusions: Our CP based on ERAS and ORT is feasible for patients with gastrectomy.

No significant financial relationships to disclose.

Factors influencing 3D-MRI diagnosis in preoperative breast cancer patients

620

Background: We presented 3D-MRI will be the useful breast imaging tool in diagnosing intraductal spread and tumor size in breast cancer patients. (ASCO 2008).To do breast conserving surgery, careful management was needed in cases with widely ductal spreading and multifocal lesion. This study was to evaluate factors influencing false negative diagnosis and multifocal types of 3D-MRI, retrospectively. Methods: From July 2000, pre-operative 3D-MRI was underwent 488 cases and images were obtained 479 cases (98%). These patients could be divided into three groups according to 3D-MRI images: pattern 1) localized type (273 cases), 2) widely enhanced type (106 cases) and 3) multi-focal type (100 cases). From April 2005, resected specimen was serially step cut and total specimens were microscopically evaluated. Tumor size in 3D-MRI was 1cm over smaller than resected specimens were defined false negative cases. Investigated factors influencing 3D-MRI were age, patterns of 3D-MRI images, presence of pre-operative chemotherapy, histological type, histological grade, microscopical invasive tumor size (mm) and presence of ductal spreading. Results: The rate of histological confirmed intraductal spread were seen in 58% (158/273cases), 89% (94/106 cases) of patients with 3D-MRI pattern 1) and 2), respectively. Tumor size was correlated between MRI and specimens, significantly (n = 162, r = 06706, p < 0.001). Factors influencing false negative diagnosis of 3D-MRI were presence of pre-operative chemotherapy (p < 0.05), presence of ductal spreading (p < 0.001) and patterns of 3D-MRI images (p < 0.05). In the cases with multi-focal 3D- images, there were only 11(11/41, 26%) cases with true multifocal lesions by total specimens examination. Selection for breast conserving surgery and margin width were based by 3D-MRI images. The proportion of breast-conserved surgery were obtained 90% (437/488 cases) and local failure seen only 6 cases (local failure rate 1.4%) in 3D-MRI guided surgery. (median follow up 52 months). Conclusions: These results suggest that MRI will be the useful breast imaging tool, but caution will be needed in cases with pre-operative systemic therapy, cases expected intraductal spread by imaging tools and cases with multi-focal 3D- images.

No significant financial relationships to disclose.

Factors influencing false negative diagnosis of 3D-MRI in pre-operative breast cancer patients

Abstract #4005

Introduction: We presented 3D-MRI will be the useful breast imaging tool in diagnosing intraductal spread and tumor size in breast cancer patients (ASCO 2008). But, false negative cases were very important in breast conserving surgery and careful management was needed in 3D-MRI guided surgery. This study was to review imaging diagnosis using 3D-MRI and to evaluate factors influencing false negative diagnosis of 3D-MRI, retrospectively. Material and methods: From July 2000, pre-operative 3D-MRI was underwent 433 cases of breast cancer patients. Images were obtained 426 cases (98%). Tumor size between 3D-MRI and resected specimens were evaluated retrospectively. Cases with tumor size difference between 3D-MRI and resected specimens less than 1cm were defined related cases and cases with tumor size in 3D-MRI was 1cm more smaller than resected specimens were defined false negative cases. Investigated factors influencing false negative diagnosis of 3D-MRI were age, patterns of 3D-MRI images, presence of pre-operative chemotherapy, histological type, histological grade, microscopical invasive tumor size (mm) and presence of ductal spreading. From April 2005, the entire specimen was serially step cut and evaluated. Results: Tumor diameter from nipple side to lateral margin were measured by MRI and specimens, tumor size was correlated between MRI and specimens, significantly (n=118, r=07186, P &lt; 0.001). On Multivariate analysis revealed that factors influencing 3D-MRI diagnosis were presence of ductal spreading (p=0.0002), patterns of 3D-MRI images (p=0.06) and presence of pre-operative chemotherapy (P=0.04). Factors influencing false negative diagnosis of 3D-MRI were presence of pre-operative chemotherapy (P&lt;0.05), presence of ductal spreading (P&lt;0.01) and infiltration of lymphocyte in the edge of ductal spreading (P&lt;0.05). Selection for breast conserving surgery and margin width were based by 3D-MRI images. The proportion of breast-conserved surgery were obtained 89% (380/426 cases) and local failure seen only 6 cases (local failure rate 1.4%) in 3D-MRI guided surgery. (6-94 months, median follow up 51 months).&#x2028; Conclusion: These results suggest that MRI will be the useful breast imaging tool in diagnosing intraductal spread and tumor size in breast cancer patients. But, caution will be needed in cases with pre-operative systemic therapy and cases expected ductal spreading by other imaging tools.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4005.

Minimally invasive video-assisted thoracoscopic lobectomy for better clinical outcomes in peripheral T1NO lung cancer

It is an unresolved issue whether various thoracotomies affect clinical outcomes. In addition, a wide variety of technical approaches of video-assisted thoracic surgery depend on the facility. We reviewed 152 consecutive patients with clinical T1N0M0 lung cancer that underwent three types of lobectomy with systematic mediastinal lymphadenectomy in a single institute: 46 conventional thoracotomies (OPEN), 50 anterolateral small thoracotomies mainly using the thoracoscope as a light guide (ASSIST), and 56 minimum thoracotomies in which only a thoracoscope view was used (PURE). Total discharge from the chest drainage tube, length of hospital stay, and post-thoracotomy pain were significantly less in PURE than in OPEN and ASSIST. The results of mediastinal lymphadenectomy were equivalent. The 3-year survival rates were also similar among the three groups. We conclude that good clinical outcomes, especially reduced post-thoracotomy pain, seemed to correlate with the lesser degree of destruction of the chest wall with the identical quality as an acceptable cancer operation in PURE.

A phase II study of single-agent docetaxel in patients with metastatic esophageal cancer

BACKGROUND

To evaluate the activity and toxicity of docetaxel in patients with metastatic esophageal cancer.

PATIENTS AND METHODS

Eligible patients had histologically confirmed carcinoma of the esophagus with measurable metastatic sites according to Response Evaluation Criteria in Solid Tumors (RECIST). Patients were either chemotherapy-naïve or previously treated with one regimen of chemotherapy. Docetaxel 70 mg/m(2) was administered intravenously over 1-2 h, every 21 days.

RESULTS

Of 52 patients enrolled in this study, three were excluded because they did not receive docetaxel due to worsening condition after enrollment. Thirty-six patients had received prior platinum-based chemotherapy. The majority of patients (94%) had squamous cell carcinoma. Ten of 49 evaluable patients [20%; 95% confidence interval (CI) 10-34%] showed a partial response. Of the 10 partial responses, six patients had received prior platinum-based chemotherapy. Grade 3 or 4 neutropenia was noted in 43 of 49 patients (88%), and nine of 49 patients (18%) developed febrile neutropenia. Twenty-eight of 49 patients (57%) required lenograstim. Grade 3 anorexia and fatigue occurred in nine (18%) and six (12%) patients, respectively. Median survival time was 8.1 months (95% CI 6.6-11.3) and the 1-year survival rate was 35% (95% CI 21-48%).

CONCLUSIONS

Docetaxel as a single agent is effective in esophageal cancer, but careful management of neutropenia is needed.

Phase II evaluation of protracted infusion of cisplatin and 5-fluorouracil in advanced squamous cell carcinoma of the esophagus: a Japan Esophageal Oncology Group (JEOG) Trial (JCOG9407)

BACKGROUND

Surgery for advanced esophageal carcinoma has its limits as regards aggressiveness and therapeutic effect, therefore effective multimodality treatment is required to obtain better survival. The objective of this study was to evaluate whether daily continuous infusion of CDDP could achieve a higher clinical response rate with less toxicity than its drip infusion in the previous phase II study that we had conducted.

METHODS

Patients with primary extensive or relapsed esophageal carcinoma after esophagectomy, which had distant organ metastasis and histologically proven SCC, were eligible for this study. A dose of 20 mg/m(2) of cisplatin and 800 mg/m(2) of 5-fluorouracil was given by continuous infusion for 24 h on days 1-5. This treatment was repeated every 4 weeks for up to four cycles. A total of 36 men and six women with a median age of 64 (range 39-75) years were registered and 36 patients were eligible.

RESULTS

The overall response rate of the registered patients was 33.3% (12/36) and the median response duration was 175 days. Median survival time was 201.5 days and the 1-year survival rate was 27.8%. Change from bolus to continuous infusion of cisplatin affected neither the type nor the degree of toxicity.

CONCLUSION

Daily continuous infusion of cisplatin was not associated with higher response or lower toxicity than those seen with the high-dose bolus or multibolus treatment regimens. We conclude that this regimen in this setting is not worthy of further phase III trials. JEOG is now evaluating other drug combination regimens.

Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy

BACKGROUND

Whether video-assisted thoracic surgery (VATS) improves postoperative pulmonary function is still controversial. We compared postoperative pulmonary function after VATS lobectomy and standard lobectomy.

METHODS

Eleven patients who had undergone standard lobectomy and 10 patients who had undergone VATS lobectomy were studied. Arterial blood gas analyses were performed on the 4th, 7th, and 14th postoperative days. Pulmonary function, including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1.0), and peak flow rate (PFR) were measured on the 7th and 14th postoperative days (early phase), and approximately 1 year after surgery (late phase).

RESULTS

Pulmonary function, as assessed with arterial oxygen partial pressure (PaO2) (p = 0.054), arterial oxygen saturation (O2SAT) (p = 0.063), FVC (p = 0.10), and FEV1.0 (p = 0.08), was better after VATS lobectomy than after thoracotomy on the 7th postoperative day. PFR was significantly better after VATS on both the 7th and 14th postoperative days (p = 0.008 and p = 0.03, respectively).

CONCLUSIONS

VATS lobectomy had advantages on early postoperative pulmonary function. We conclude that VATS lobectomy is a beneficial alternative to standard thoracotomy, especially for patients with poor pulmonary reserve.

Evaluation of the accuracy of preoperative staging in thoracic esophageal cancer

BACKGROUND

Exact clinical staging before treatment of esophageal cancer has become increasingly important in the evaluation and comparison of the results of different treatment modalities, including surgery, chemotherapy, and radiotherapy.

METHODS

The accuracy of preoperative tumor staging by using an esophagography, esophagoscopy, percutaneous and endoscopic ultrasonography, and computed tomography was assessed in 224 patients with resectable esophageal cancer. The results of tumor staging by these tests were compared prospectively with the pathologic stage of the esophagectomy specimens with respect to the T and N categories defined by the International Union Against Cancer TNM classification.

RESULTS

For the T category, the overall accuracy was 80%. For the N category, overall accuracy was 72%, with a sensitivity of 78%, a specificity of 60%, and a positive predictive value of 78%. Overall, the accuracy of stage grouping was 56%.

CONCLUSIONS

Either the T or N categories can be predicted reliably by clinical staging techniques. However, the preoperative stage grouping might not be valid in resectable, localized esophageal cancer.

Undifferentiated carcinoma with lymphoid infiltration of the esophagus: a case report

This paper reports a surgically treated case of undifferentiated carcinoma with lymphoid infiltration of the esophagus. Histologically, most of the tumor consisted of undifferentiated carcinoma (non-small cell type) with lymphoid infiltration and a small portion showed features of poorly differentiated squamous cell carcinoma. Carcinoma with lymphoid infiltration in the stomach, breast or nasopharynx has a good prognosis, but in the esophagus this histological type is extremely rare and its characterization is unclear. This is only the sixth report to date of undifferentiated carcinoma with lymphoid infiltration of the esophagus.

Port site recurrence of unexpected gallbladder carcinoma after a laparoscopic cholecystectomy: report of a case

Unexpected gallbladder carcinoma was identified in a 71-year-old woman after she underwent a laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis. A subsequent laparotomy for a resection of the liver bed and a dissection of the lymph nodes around the hepatoduodenal ligament was done. Two and a half years later, the patient developed subcutaneous metastasis at the epigastric trocar site through which the gallbladder was removed. A third operation was thus performed, revealing no evidence of peritoneal dissemination, liver metastasis, or lymph node metastasis, and the abdominal wall mass was resected. The histological findings confirmed the diagnosis of metastatic carcinoma of the gallbladder. We recommend that when planning LC, the possibility of malignancy should thus be kept in mind. However, if there is any sign which does not completely exclude malignancy, such as a contracture or wall thickness of the gallbladder, LC should be performed by the abdominal wall lifting method and using a protective bag for the removal of the gallbladder.

[Histological effect of arterial embolization chemotherapy for metastatic liver tumors from colorectal cancer--report of cases of hepatectomy after arterial embolization chemotherapy]

To evaluate the histological effect of arterial embolization chemotherapy (AEC) for the metastatic liver tumors from colorectal cancer, 5 lesions were examined in 4 patients who were treated with surgery after AEC. In addition, to compare the histological changes of the metastatic liver tumors, we histologically examined 7 lesions in 5 patients who were treated with surgery alone as a historical control. For the patients with AEC, anti-cancer agents and lipiodol were administered by selected hepatic arterial infusion with fragments of sponzel. In a group of AEC, all metastatic liver tumors were detected after resection of the primary tumors. The range of tumor size in these lesions was from 2.5 to 4.2 cm in diameter. Otherwise, in a group of non-AEC, the size of tumors ranged from 2 to 5 cm in diameter. In angiography, tumor stainings were detected in 2 lesions, and in all lesions no accumulation of lipiodol was detected by CT scan. The overall response rate at the surgery was 7 to 33% (average 23%) in a group of AEC. In addition, in 2 lesions, about 60% of the lesions were necrotic tissues, and more than 90% of the tumor lesions in 3 lesions were histologically necrosis. Within these lesions, encapsulation of the metastatic tumors was observed in 3 lesions. Otherwise, in a group of non-AEC, 50-70% of the tumor lesions were histologically detected as necrosis, and in one lesion, encapsulation was observed. These evidences suggest the histological effect of AEC may be evaluated when more than 70% of tumor necrosis in lesions is observed. In conclusion, the treatment was effective in 3 cases and not effective in one case.

A randomized trial of surgery with and without chemotherapy for localized squamous carcinoma of the thoracic esophagus: the Japan Clinical Oncology Group Study

OBJECTIVE

To determine whether postoperative adjuvant chemotherapy confers a survival benefit on patients with esophageal squamous cell carcinoma undergoing radical surgery, we undertook a cooperative, prospective randomized controlled trial.

METHODS

A total of 205 patients underwent transthoracic esophagectomy with lymphadenectomy at eleven institutions between December 1988 and July 1991. These patients were prospectively randomized into two groups (100 patients underwent surgery alone and 105 patients had additional two courses of combination chemotherapy with cisplatin (70 mg/m2) and vindesine (3 mg/m2). The two groups did not differ with respect to sex, age, location of tumor, and distributions of pT, pN, pM, or p stage.

RESULTS

The 5-year survival was 44.9% in the surgery alone group and 48.1% in the surgery plus chemotherapy group. The relative risk was estimated to be 0.89 (95% confidence interval, 0.61 to 1.31) in the surgery plus chemotherapy group compared with the surgery alone group. No significant differences in survival were detected between the two groups, even with lymph node stratification.

CONCLUSION

Postoperative adjuvant chemotherapy with cisplatin and vindesine has no additive effect on survival in patients with esophageal cancer compared with surgery alone.

Correlation between expression of platelet-derived endothelial cell growth factor (thymidine phosphorylase) and microvessel density in early-stage human colon carcinomas

Platelet-derived endothelial cell growth factor may play a role in tumor development through its angiogenic action. To clarify the relationship between expression of platelet-derived endothelial cell growth factor and microvessel density in the development of human colon carcinoma, we examined 80 early-stage colon carcinomas using microscopy and immunohistochemistry. Localization of platelet-derived endothelial cell growth factor was assessed by immunocytochemistry, while microvessel count was evaluated by either HE staining or Factor VIII immunostaining. Among the examined carcinomas, 35 were classified as m carcinomas including carcinoma in situ, whereas 45 were sm carcinomas. Fifteen (42.9%) of the 35 m and 30 (66.7%) of the 45 sm carcinomas demonstrated high vascular density, whereas 20 (57.1%) m and 15 (33.3%) sm carcinomas showed moderate or low vascular density. Vascular density was higher in sm carcinomas than in m carcinomas and there was a significant correlation between depth of invasion and vascular density. Of the 45 highly vascularized carcinomas, 44 expressed platelet-derived endothelial cell growth factor. There was a statistically significant correlation between the frequency of platelet-derived endothelial cell growth factor expression and microvessel density (P = 0.012). These data demonstrate that microvessel density may be associated with the depth of cancer invasion and that platelet-derived endothelial cell growth factor may play an important role in the early stage of colon cancer development through angiogenesis.

Small cell carcinoma of the esophagus: a case report

This article reports a case of primary undifferentiated small cell carcinoma of the esophagus with lymph node metastasis which invaded the stomach wall. The patient was treated with chemotherapy alone, consisting of CDDP and VP-16. The patient had a complete response to chemotherapy, with no evidence of disease for nine months, after six courses of the regimen. Small cell carcinoma of the esophagus is an aggressive tumor with an extremely poor prognosis. Because its characteristics are similar to small cell carcinoma of the lung, small cell carcinoma of the esophagus should be treated by multi-drug chemotherapy including CDDP, with or without radiation as the first line treatment. This chemotherapy regimen may achieve a long disease-free survival time.

[Granisetron versus granisetron plus methylprednisolone in the prevention of chemotherapy induced nausea and vomiting--in adjuvant chemotherapy, including CDDP against gastric cancer]

CDDP is one of the most effective drugs in chemotherapy for gastric cancer. We compared the antiemetic effect of a combination of granisetron and methylprednisolone with that of granisetron administered alone. Twenty postgastrectomy-patients who were to receive moderately emetogenic chemotherapy, including CDDP, were enrolled in randomized fashion to evaluate the efficacy and toxicity of two antiemetic regimens. The following antiemetic regimens were used: 3 mg of granisetron given intravenously before chemotherapy (11 patients) or a combination of granisetron and 250 mg of methylprednisolone in the same manner (9 patients). Granisetron combined with methylprednisolone tender to be more effective than granisetron alone. The adverse effects were very mild. Their efficacy against delayed emesis is still not entirely satisfactory.

[Chemotherapy for peritoneal dissemination in gastric cancer under ureteral catheterization]

The treatment of peritoneal dissemination of gastric cancer is mainly chemotherapy, but it use is often limited by ileus, hydronephrosis and jaundice. We employed a ureteral catheter for 6 patients with hydronephrosis due to peritoneal dissemination. Chemotherapy (CDDP + ADM + 5-FU or MTX + 5-FU) was administered in 5 patients. After ureteral catheterization, renal function was kept within normal ranges, so chemotherapy was performed safely. One of five patients became CR and the effect of the treatment was satisfactory (PR: 1, NC: 2). Thus, chemotherapy after ureteral catheterization may be effective for patients with peritoneal dissemination and hydronephrosis.

Drug sensitivity testing for clinical samples from oesophageal cancer using adhesive tumour cell culture system

A total of 83 specimens of surgically resected tumours from 78 patients with oesophageal cancer were assayed for drug sensitivity using an adhesive tumour cell culture system (LifeTrac CSA assay). Seventyone of 83 specimens had a sufficient number of cells to permit growth in culture and 57 of 71 (80%) were evaluable for drug response. Cells (3 x 10(3) ml-1 well-1) were cultured for 14 days and exposed to drugs on days 3-8. Growing cells were confirmed as cancer cells by immunohistochemical staining. IC90 values against several anti-cancer drugs were determined and population distributions of IC90 for each drug served as the basis for judging sensitivity. The 10th percentiles of IC90 (microgram ml-1) for CDDP, 5-FU, DOX, CPM, MTX, VP16, IFOS, VDS, BLM and CDDP + 5-FU were 0.3, 0.16, 0.005, 0.9, 0.006, 0.09, 0.8, 0.006, 0.04 and 0.15 + 0.09 respectively. The population distribution of IC90 against each drug showed a specific pattern that was very similar among histopathological gradings and stages of the disease. This system appeared to be a clinically applicable drug sensitivity test for human oesophageal cancer.

Proliferation of osteoclast-like giant cells in a metastatic bone tumor from stomach cancer: report of a case and analysis of the autopsy findings

A 70-year-old man who had undergone esophagectomy with reconstructive surgery using a portion of the stomach 5 years earlier for esophageal cancer was admitted to our hospital after a routine endoscopy and histological examination of a biopsy specimen revealed poorly differentiated adenocarcinoma in the stomach. A gastrectomy and intrathoracic esophagojejunostomy was performed on January 20, 1993; however, the patient suffered a cerebral infarction and died of septic shock on April 9, 1993. At autopsy, metastatic tumors were macroscopically observed in various organs, including a bone tumor measuring 1.0 cm in diameter in the L4 vertebra. To clarify the origin of the bone tumor, we conducted histological and immunohistochemical examinations. Histological examination revealed a mixture of osteoclast-like giant cells (OGCs) and poorly differentiated adenocarcinoma cells, although no histologic features of OGCs were observed either in a primary site or in any of the multiple metastatic lesions. On immunohistochemistry, adenocarcinoma cells in the bone stained positively for the carcinoembryonic antigen (CEA), whereas no staining for CEA was observed in the OGCs which demonstrated negative staining for all the antigens of epithelial markers. These findings led us to conclude that this bone tumor had metastasized from the stomach cancer and that the OGCs may have originated from mesenchymal cells reacting to the adenocarcinoma cells.

Relationship of esophageal dysplasia to associated head and neck cancer in patients with esophageal carcinoma

To investigate the relationship between esophageal dysplasia and the development of both esophageal cancer (EC) and head and neck cancer (HNC), a clinicopathological study was performed in 113 patients with EC who underwent esophagectomy without any preoperative treatment. The incidence of dysplastic lesions in the resected esophagus was determined by a whole-organ stepwise cutting method. Synchronous or metachronous primary HNC was present in 25 patients, all of whom were male (Group A) and absent in both 70 male patients (Group B) and 18 female patients. A total of 628 dysplastic lesions were found in 79 patients; 67 of them were graded as carcinoma in situ (CIS) in 26 patients, 44 as severe dysplasia (SD) in 16 patients, 182 as moderate dysplasia (MOD) in 59 patients, and 335 as mild dysplasia (MID) in 58 patients. The incidence of CIS, SD and MOD was low in females, slightly increased in Group B, and markedly increased in Group A, and the differences between Group A and Group B and between Group A and females were statistically significant. There was a sex difference in smoking and alcohol consumption, only a few smokers or drinkers being female, whereas there was no significant difference between Groups A and B in smoking and alcohol consumption. CIS, SD or MOD in the esophagus appear to be closely related to both EC and HNC, and patients with EC associated with CIS, SD or MOD are at increased risk of developing HNC.

[Clinical effects of FUT-187 in reflux esophagitis after gastrectomy]

FUT-187 was orally administered to 38 patients with postgastrectomy reflux esophagitis for 4 weeks. The drug reduced the chief subjective symptoms of reflux esophagitis, such as heartburn, chest pain, precordial pain, and dysphagia for solids in 78.1% of patients. Redness, edema and erosion were also reduced in 53.3% of patients as determined endoscopically. Overall, FUT-187 exhibited an excellent therapeutic effect on the reflux esophagitis which was refractory to conventional treatments.

Alcohol consumption and risk of esophageal cancer in Japan: a case-control study in seven hospitals

In a multi-center case-control study, we evaluated the risk of esophageal cancer in the Japanese population. All patients and controls were inpatients in the surgical departments of seven hospitals nationwide. Patients eligible for the study were those newly diagnosed as having primary esophageal cancer. One control per case was selected from among patients admitted to the same hospital, and 141 male pairs were analyzed using logistic regression analysis. The results showed dose-response relation between the risk of esophageal cancer and both the quantity (g/week) and frequency (times/week) of alcohol drinking (P value for trend = 0.0001). Although a statistically significant risk increase was shown among moderate to heavy smokers (15 < or = cigarette/day < 25) (odds ratio, 4.35:95% confidence interval, 1.81-10.49), the dose-response for cigarette smoking was unclear (P value for trend = 0.07). No combined effect of alcohol drinking and cigarette smoking was found. A frequent intake of fruit was associated with a decreased risk (P value for trend = 0.02). After adjustment for alcohol consumption, cigarette smoking and fruit intake were found not to be associated with the risk, whereas a preference for high-temperature food and drink showed a statistically significant positive association (P value for trend = 0.02). Drinkers who consumed shochu most frequently showed a three-fold increased risk over that for beer consumers, although the association disappeared after adjusting for the amount of alcohol consumed. The present results confirm alcohol intake and a preference for high-temperature food to be associated with an increased risk of esophageal cancer and show the amount of alcohol consumed, rather than the type of alcoholic beverage, to be the main risk determinant.

[Limited surgery for early gastric cancer]

The prognosis of the resected "early gastric cancer" is very good, especially in mucosal cancer. In Japan, the surgery for the gastric cancer generally is subtotal gastrectomy combined with R2-lymph nodal dissection. But, some cases are free of lymph nodal metastasis, and might be cured without its dissection. We analyzed resected specimens of early gastric cancer pathologically, and assessed what cancers we could do the limited operation without impairing curability. Lymph nodal metastasis of the mucosal cancer developed 2.1% of all 291 mucosal cancers, and of the submucosal cancer, 15.7% of 229 cases. Lymph vessel permeation depicted 5.2% and 82.1%, respectively. As for the mucosal cancer, less than 10 mm in maximum diameter, there were no lymph vessel permeations nor lymph nodal metastasis. In these cases, the limited operation, especially the local resection and the endoscopic resection could be available without any fear of cancer residue. In contrast, the submucosal cancer was not considered the candidate of the limited surgery.

[A case of advanced gastric cancer responding to an FAP (5-FU, ADM, platinum compounds) combined chemotherapy]

An experience with an advanced gastric cancer patient with metastases to bilateral breasts, uterus, abdominal lymph nodes, bilateral axillary and supraclavicular lymph nodes, and bone marrow, responded extremely well to an FAP combined chemotherapy as reported here. The patients received four courses of 5-FU (370 mg/m2/day, for five days, continuous infusion), ADM (30 mg/m2 on day 1, i.v.) and CDDP (55 mg/m2 on day 1, i.v.) every 3 weeks in our hospital. This was followed by 7 months of outpatient therapy with 5-FU (550 mg/m2 on day 1, i.v.), ADM (30 mg/m2 on day 1, i.v.) and CBDCA (330 mg/m2 on day 1, i.v.) for every 4 weeks. The complete remission of the primary and metastatic lesions, that was confirmed by the histological examinations, was obtained after 10 months since the initial treatment started. The toxicity was generally moderate, however, the alopecia was severe. The patient has been living for 6 months without any signs of the recurrence after the complete remission obtained.

Dysplasia in the human esophagus: clinicopathological study on 500 esophagi at autopsy

To clarify the relation between esophageal carcinoma and dysplasia, the pathology and epidemiology of 500 cases where clinically overt esophageal carcinoma had not been the direct cause of death were studied at autopsy. There were 297 men and 203 women. Four hundred and eighty-five patients had had malignant disease, of which 91 fulfilled the criteria for multiple primary malignancies. For all cases, cigarette and drinking habits were examined in patient records. All the esophagi were examined at autopsy by microscopy. Carcinoma in situ was found in six cases (1.2%). Dysplasia was observed in 73 (14.6%) and was graded mild in 58, moderate in 25 and severe in seven. The incidence of dysplasia was frequent in men than in women. Carcinoma in situ and severe dysplasia were more frequent where there was a history of habitual smoking and drinking, and were often associated with multiple primary cancers, mainly in the head and neck region. Predisposing factors for high grade dysplasia of the esophagus are gender, smoking, drinking, head and neck cancer and multiple primary cancers, corresponding to those of clinical esophageal carcinoma.

[Effect of medroxyprogesterone acetate on the cell kinetics in primary breast cancer]

Effect of medroxyprogesterone acetate (MPA) on the breast cancer cell kinetics was investigated by flow cytometry on paraffin-embedded tissues. Nuclear DNA contents were measured in 67 primary cases. MPA, 1,2000 mg/day, was administered orally for two weeks in 12 cases (MPA group) and the remaining cases (n-MPA group) served as the controls, until the day before operation. The DNA histograms were compared between both groups. The mean percentage of G0 + G1 phase was higher and that of S-phase and G2 + M phase, lower, in the MPA group than those in the n-MPA group. Especially in estrogen receptor positive and premenopausal cases, a significant difference was present between both groups. These results suggest that MPA could inhibit DNA synthesis with a delay of the cell cycle progression in human breast cancer.

[Intraperitoneal administration of recombinant interferon-beta for prevention in peritoneal metastasis of gastric cancer]

Recombinant interferon-beta (IFN-beta) shows a high anti-tumor effect on cancerous ascites, has little local irritative action and can safely be administered intraperitoneally. A randomized trial was conducted to evaluate the efficacy of intraperitoneal administration of IFN-beta for the purpose of preventing peritoneal metastasis of gastric cancer. The subjects selected were patients under 75 years of age who were macroscopically positive for serosal invasion and had undergone curative operation. Comparison was made by the envelope method between the cases given IFN-beta i.v. at 6 x 10(6) units continuously for 14 days from the day of operation and from 1 week after operation. MMC, 20 mg (i.v.) on the day of operation and 5-FU, 200 mg (p.o.) for 1 year from 2 weeks after operation were administered, respectively, in the two groups. The number of cases registered from March, 1987 to September, 1988 was 33, with 17 in the administration group and 16 in the control group. No difference was noted between the two groups in 3-year survival rate and disease free survival rate. As to the recurrence involving the peritoneum, however, there was a difference between the two groups, with 1 out of 6 cases in administration group and 3 out 4 cases in control group. Intraperitoneal chemotherapy can be an effective adjuvant therapy for gastric cancer, if cases are selected.

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

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

[Two autopsy cases associated with a latent superficial carcinoma of esophagus]

To clarify the histogenesis of squamous cell carcinoma of esophagus, 307 esophagus resected from autopsied cases have been thoroughly examined. These specimens were dyed with Lugol solution and entirely blocked to study subserial sections. Among these specimens, two subclinically superficial squamous cell carcinomas were found. First case uncovered was that of a woman who had died of a carcinoma of uterus. Microscopic examination revealed a small carcinoma in situ, located in the cervical portion of the esophagus, though this lesion showed no associated dysplasia. The other case was that of an old man who had died of a massive hemorrhage from a gastric ulcer, associated with carcinomas of the lip, liver, and prostate. The esophageal lesion was an intramucosal carcinoma located in the mid esophagus that was encountered with moderate dysplasia. These examples are not only quite rare as being multiple primary carcinomas but they also suggest two possible types of cancer development of the esophagus: one that progresses from normal mucosa, and the other from dysplastic mucosa.

[The relation of dysplasia and squamous cell carcinoma of the esophagus]

It remains controversial whether epithelial dysplasia of the esophagus is a precancerous lesion or not. Forty resected specimens of the esophagus without preoperative irradiation were totally examined to clarify the relationships between dysplasia and squamous cell carcinoma of the esophagus. The entire subserial sections of each esophagus were stained by hematoxylin and eosin for histopathological observations. Diagrams were provided to examine the distribution of dysplasia in the esophagus. Epithelial dysplasia was classified into mild, moderate and severe. Of 32 cases (80%) with dysplasia, 29 (73%) showed mild dysplasia, 23(58%) moderate and 10 (25%) severe dysplasia. The lesions of moderate or severe dysplasia were mainly seen at the mid-esophagus, and this predominant sites were the same as the esophageal cancer. The patients with moderate or severe dysplastic changes were younger than the patients with esophageal cancer. It was possible that moderate or severe dysplasia was closely associated with precancerous lesions.

[The clinicopathologic analysis of autopsied breast cancer]

In 46 patients with recurrent breast cancer, the chronological change of pathomorphologic findings and its relationship with the clinical courses were studied with the comparison between the materials obtained at the time of operations and autopsies. Histologically, 24 cases (52.2%) showed undifferentiated change with time, and 22 cases (47.8%), no change. There were no cases with differentiation. The cases with undifferentiated change progressed acutely with no response to treatment, resulting in poor prognosis. Some of these cases showed metastatic behavior similar to leukemia, malignant lymphoma or small cell carcinoma of lung. It was suggested that the chronological and histological change was to some extent related to the clinical course.

[Microcarcinoma of the pancreas: report of a case]

A 53-year-old man complaining of vertigo initially consulted a nearby hospital. While undergoing a medical examination, which included abdominal ultrasonography and a CT scan, a dilatation of the pancreatic duct was found. The patient was then admitted to our hospital for a more thorough examination. Laboratory findings revealed an elevated elastase-1 level and a DM-pattern of 75 g-OGTT. ERP showed a localized constriction in the main pancreatic duct and diffuse dilatations of the distal main duct. A cytologic examination revealed no malignant cells in the pancreatic juice. Even so, though a carcinoma was not confirmed, a pancreaticoduodenectomy was performed, since a carcinoma of the pancreas head was suspected. A histological examination of the resected specimen uncovered a nonfunctioning islet cell carcinoma, 8 mm in diameter. This case was considered fortunate, in that an early stage pancreatic cancer, adjacent to the main duct, had been detected by imaging diagnoses.

[Arterial infusion chemotherapy and embolization in unresectable hepatocellular carcinoma using an intraarterial catheter]

We performed arterial infusion chemotherapy and embolization on 22 patients with unresectable hepatocellular carcinoma via an intraarterial catheter, which was inserted in the hepatic artery under laparotomy. The administration frequency of intraarterial chemotherapy on a patient was 1 to 155 with a median of 17, while that of embolization was 1 to 6 with a median of 2.5. The maximal and average durations of a catheter in place were 15 and 4 months, respectively. The survival rates were 50% in one year, 18% in two years, and 12% in three years. Insertion technique and management of the catheter are relatively safe and easy, so catheterization of the hepatic artery would enable us to develop new treatment modalities.

Small cell carcinoma of the esophagus: report of a case treated with chemotherapy

A 54-year-old man with small cell carcinoma of the esophagus and extensive metastases to the liver and bone is presented herein. Ectopic hormone production and a high level of serum NSE (neuron specific enolase), as revealed by biochemical and radioimmunoassay, suggested that this tumor was derived from the cells of the APUD (amine precursor and dehydroxylation) series. He was treated with a combination chemotherapy, resulting in a prompt remission with significant palliation lasting five months. Small cell carcinoma of the esophagus is as responsive to chemotherapy as small cell carcinoma of the lung. Although this is an uncommon tumor, recognition is important because of its responsiveness to chemotherapy and the potential for significant palliation of symptoms without surgical intervention.

[Early breast cancer in terms of modes of growth and extension]

The modes of growth and extension of breast cancer have been evaluated in operated specimens. It has been found that in patients with a cancer in the duct, the outcome was more closely related to the degree of the extraductal infiltration than the size of the tumor. If early breast cancer is defined as a cancer associated with a 10-year survival rate of 90% or more then lesions of the intraductal type with an extraductal infiltration of less than 1/4 of the entire tumor extension fall into this category.

[A malignant fibrous histiocytoma of the breast]

We have experienced treating a 49-year-old female with a malignant fibrous histiocytoma (MFH) arising from the right mammary gland. Nine months after surgery, lung metastasis occurred but the lung lesion proved to be resectable. Our findings suggested that the primary lesion had originated from a phyllodes tumor. MFH arising from the mammary gland is an extremely rare tumor, and only 12 such cases have been reported including that of our patient.

[Organ specificity and common factors in latent tumors]

Materials displaying latent tumors were obtained from autopsy cases and from surgically removed organs at our hospital during the past 20 years. Organ specificity and the common factors of these latent tumors indicated the following: a high incidence of latent tumors was found in the small organs and/or endocrine organs (prostate, thyroid, pancreas). In addition, it was found that these tumorous organs are of sufficient interest for clinicopathologic study (stomach, esophagus). Latent tumors show an increasing tendency to manifestation at an advanced age. Further, shade of difference between females and males has been noted in comparing clinically manifested tumors. Also latent tumors occasionally coexist with multiple primary neoplasms in the same and indifferent organs. The histological characteristics of latent tumors is frequently associated with thickened capsules and fibrosis. It has been speculated that the appearances of a reaction are local autoimmune mechanisms and the hosts suppressive effects against the proliferation of tumors. The biological behaviour of latent and clinical tumors should be considered different.

[The relationship between dysplasia and squamous cell carcinoma of the esophagus and the consumption of alcohol and tobacco]

Forty-nine cases of esophagectomy and 242 autopsied cases were studied to delineate the pattern of the genesis of esophageal carcinoma. Severe dysplastic lesions found to be commonly associated with carcinoma of the esophagus, but with the exception of one case, these lesions were not associated with other carcinomas. They were more frequent in the cases of multiple primary cancer. This suggests that squamous carcinoma of the esophagus develops from severe dysplasia in a very similar manner to a carcinoma of the cervix uteri. Almost all cases of multiple primary cancers of the oropharynx and the esophagus had a history of heavy smoking and alcoholic drinking habits; so, in some manner, alcohol and tobacco consumption appear to increase the susceptibility of the squamous mucosa to a malignant transformation.

[Intracavitary administration of recombinant interferon in cancer patients with malignant effusions]

Interferon-beta (IFN-beta), 6 X 10 units/body, was administered intraperitoneally and intrapericardially daily to five recurrent cancer patients with malignant effusion. Two of them showed complete response with a disappearance of effusion and cytological negative. However, three patients showing a decrease in effusion and cytological negative were regarded as no change because of the short duration of the response (less than four weeks). Intracavitary administrations of IFN-beta were well tolerated, and no serious side effects were observed. Autopsies showed that all intestines with disseminated metastasis maintained organic elasticity and had neither ileus-like construction nor progressive adhesions. IFN-beta showed not only anticancer effects on malignant effusion, but protection against GI tract constriction through moderate control of the growth of connective tissue.

[Histopathological findings in autopsy cases of recurrent breast cancer]

In case of breast cancer subjected to postmortem examinations, histopathological changes were observed, and the effects of treatment were analyzed. Surgically obtained specimens of 36 cases of breast cancer could be compared with their postmortem specimens: in 14 cases (38.9%), tumor cells tended to be lowly differentiated, while the cells were unchanged in 22 (61.1%). There were no cases of differentiated tumor cells. Lowly differentiated cells were common in patients resistant to treatment who died shortly. Stromal tissues were sclerotic in eight cases (22.2%), medullated in three (8.3%), and unchanged in 25 (69.4%). Long-surviving cases tended to have the involvement of sclerosis.

[Clinicopathological studies on cases of multiple primary carcinomas of the esophagus associated with carcinoma of the hypopharynx and cervical esophagus]

Four cases of multiple primary carcinoma of the esophagus associated with dysplasia were found among seven patients with squamous cell carcinoma of the hypopharynx and cervical esophagus at the Shikoku Cancer Center Hospital. Two minute carcinomas were observed in these cases. One of them was too small to detect clinically despite the application of esophagoscopy with the Lugol's solution spraying method. All four patients had continued to smoke and consume alcoholic beverages (regularly) (habitually). These findings suggested that total esophagectomy is applicable to patients with hypopharyngoesophageal cancer, particularly those who continue to drink and smoke regularly.

[A case of breast cancer with lipid secretion]

Lipid-secreting carcinoma of the mammary gland is a very rare disease entity. We have experienced a 59-year-old woman diagnosed as having cancer of the left breast and treated by mastectomy. The excised material was found to be afflicted with common duct carcinoma partially involved in lipid secretion. This patient had a relapse and died three and a half years after the mastectomy. The autopsy material consisted mostly of lipid-secreting carcinoma. The pathogenesis of this disease and changes of histological figures are also discussed.

Enhanced antitumor effects of bleomycin and moderate hyperthermia by additional use of ethanol

The combined effects of moderate local hyperthermia, bleomycin and ethanol were investigated with Lewis lung carcinoma tumors in female C57BL/6 mice. Different combinations of treatments were performed on days 4 and 7 after tumor implantation. Combined treatment of 41 degrees C hyperthermia and bleomycin resulted in mild reductions of tumor growth. Hyperthermia plus bleomycin led to marked reduction in tumor growth under the condition of a 43 degrees C temperature. The antitumor effects of 41 degrees C hyperthermia combined with bleomycin were enhanced by the additional use of ethanol, and these effects were more remarkable than those of 43 degrees C hyperthermia and bleomycin. A possible application of these findings to clinical therapy for advanced esophageal cancer was discussed.

[Experimental studies on combined chemotherapy with hyperthermia and ethanol for advanced esophageal cancer. II. Effects of combined treatments on tumor growth in tumor-bearing mice]

The combined effects of local hyperthermia, bleomycin and ethanol were investigated using Lewis lung carcinoma (3LL) in female C57BL/6 mice and FM3A tumors in female C3H/He mice. The combined treatments were performed on days 4 and 7 or on days 4, 7 and 10 after tumor implantation. Hyperthermia at 43 degrees C for 60 min or 15 mg/kg of bleomycin resulted in mild reductions of tumor growth, respectively, whereas hyperthermia at 41 degrees C for 60 min alone did not show antitumor effects. Synergistic effects were observed with 43 degrees C hyperthermia and bleomycin. Furthermore the effects were enhanced by the combined use of ethanol (10% ethanol, 0.05 ml, i.t.). The antitumor effects of combined treatments of 41 degrees C hyperthermia and bleomycin were not so remarkable as those of 43 degrees C hyperthermia and bleomycin. In the combination of 41 degrees C hyperthermia, bleomycin and ethanol, marked increase of antitumor effects was observed particularly in 3LL tumor. A possible application of these findings to clinical therapy for advanced esophageal cancer was discussed.

[Histological classification and prognosis of mammary cancer-histological classification devised by the Japan Mammary Cancer Society and WHO classification]

Between 1966 and 1977, 427 patients with mammary cancer underwent surgery at the Shikoku Cancer Center Hospital. Using these subjects, the histological classification devised by the Japan Mammary Cancer Society was compared with the WHO classification. Since the WHO classification places 80.4% of all cases into the category of invasive duct carcinoma, the significance of the histological classification as a factor in predicting prognosis is reduced. Thus, some other subclassification is needed for practical application. We classified invasive duct carcinoma according to cellular atypism (CAT), structural atypism (SAT) and infiltration mode (INF), and examined their relationship to the 5-year survival rate; there was a positive correlation.

[Experimental studies on combined chemotherapy with hyperthermia and ethanol for advanced esophageal cancer. I. In vitro effects of combined treatments on 3H-TdR uptake of FM3A cells by microculture method]

The combined effects of hyperthermia, bleomycin and ethanol were investigated using FM3A tumor cells in vitro. Cytotoxicity of the heating was found at temperatures higher than about 41 degrees C, and remarkably increased at 43 degrees C. Cytotoxicity of ethanol was found at concentrations higher than 4% v/v, and remarkably increased at 8% v/v. Cytotoxicity of bleomycin was dependent on the dose but not so remarkable as those of the heating and ethanol. Cytotoxic effects of bleomycin were enhanced by the combined use of hyperthermia (41-43 degrees C). It was also enhanced by the combined use of low concentrations of ethanol (2-4%). On the other hand, a synergistic effect in cytotoxicity was observed, when the moderate hyperthermia was combined with low concentrations of ethanol. In the combination of low concentrations of ethanol, moderate hyperthermia and bleomycin, marked increase of cytotoxicity was observed. A possible application of these findings to clinical therapy for advanced esophageal cancer was discussed.