The pattern of postoperative quality of life following minimally invasive gastrectomy for gastric cancer: a prospective cohort from Korean multicenter robotic gastrectomy trial

Purpose

Quality of life (QOL) has become important in the trend of emphasizing patient satisfaction. This study aimed to evaluate the QOL in patients who underwent laparoscopic or robotic gastrectomy for gastric cancer.

Methods

A prospective trial was performed involving patients who underwent laparoscopic or robotic gastrectomy for primary gastric cancer at 11 hospitals in Korea. Within this comparative trial, QOL, postoperative pain, and long-term complications were exanimated. The quality-of-life questionnaire (QLQ)-C30 and QLQ-STO22 developed by the European Organization for Research and Treatment of Cancer were used for the QOL survey. We compared the data after dividing it into several types of characteristics as follows; device (robotic or laparoscopic), operation type, pathological stage, and sex. Biased components were extracted by logistic regression analysis. Propensity score matching was applied to the data set with the biased components.

Results

In total, 434 patients (211 for laparoscopic surgery and 223 for robotic surgery) were enrolled, out of which 321 patients who responded to both preoperative and postoperative surveys were selected for analysis. Robotic gastrectomy was not different from laparoscopic gastrectomy with respect to postoperative QOL. Distal gastrectomy showed better scores than total gastrectomy in terms of role functioning, social functioning, fatigue, nausea/vomiting, pain, dyspnea, constipation, financial difficulties, dysphagia, eating restrictions, anxiety, taste, and body image. Male patients showed better scores on the 19 scales compared to female patients.

Conclusion

Robotic and laparoscopic approaches for gastric cancer surgery did not differ from each other with respect to QOL. Distal gastrectomy resulted in better QOL than total gastrectomy.

[The Short-term Outcome and Safety of Laparoscopic Colorectal Cancer Resection in Very Elderly Patients]

Background/Aims

Due to the recent increase in elderly population, laparoscopic surgery is more frequently performed in the elderly. This study aimed to compare the short-term outcomes of laparoscopic colorectal cancer surgery between the very elderly group (VEG), categorized as those with age over 80 years and the elderly group (EG), categorized as those with age 65 to 79 years.

Methods

We retrospectively compared 48 very elderly patients with 96 elderly patients (1:2 matched) who underwent laparoscopic resection for colorectal cancers at our institution between March 2010 and December 2014. The clinicopathologic parameters, surgical characteristics and short term outcomes were compared.

Results

There was no statistically significant difference in clinicopathologic characteristics between VEG and EG. Postoperative pain score (7 points vs. 6 points, p=0.264), time to first flatus (3 days vs. 3 days, p=0.335), hospital stay (15 days vs. 16.5 days, p=0.361), complication rates (47.9% vs. 26.0%, p=0.147) and major complication rate (25% vs. 20.8%, p=0.681) were not statistically different between the two groups. Before surgery, VEG had higher rate of neurologic underlying disease, such as dementia or cerebrovascular disease, than EG (25.0% vs. 7.3%, p=0.007).

Conclusions

There was no significant difference in the clinicopathologic characteristics, short-term outcomes, and complication rates for laparoscopic colorectal resection between VEG and EG, except delirium. Age over 80 years may be relevant for the application of laparoscopic colorectal cancer resection.

Long-Term Survival of a Patient with Adenocarcinoma of the Esophagogastric Junction with a Portal Vein Tumor Thrombosis Who Underwent Palliative Total Gastrectomy: A Case Report

Portal vein tumor thrombosis (PVTT) with advanced gastric cancer is very rare; when it occurs, it exhibits aggressive growth and carries a poor prognosis. In addition, definitive treatment has not been established due to insufficient data. Herein, we report a case of PVTT associated with an adenocarcinoma of the esophagogastric junction that was successfully controlled by means of a palliative total gastrectomy without surgical resection of the PVTT and administration of palliative continuous doxifluridine.

A Case of Noncuratively Resected Gastric Cancer and Postoperative Chemotherapy with S-1 Monotherapy Resulting in Long-Term Survival for Over 8 Years

We report the case of a noncuratively resected gastric cancer patient who was successfully treated with S-1 monotherapy, resulting in long-term survival of 96 months. A 72-year-old woman underwent noncurative resection of subtotal gastrectomy for advanced gastric cancer with conglomerated lymph node metastasis and pancreatic invasion. She received chemotherapy with S-1 monotherapy postoperatively. S-1 (100 mg/day) was administered orally after breakfast and dinner for 28 days followed by a 14-day break for a total of 52 months. Regular checkups with esophagogastroduodenoscopy, abdominopelvic computed tomography, and fluorine-18-fluorodeoxyglucose positron emission tomography revealed no evidence of cancer 96 months after the operation. The patient was effectively treated with long-term administration of S-1 after noncurative gastrectomy for advanced gastric cancer.

Alcohol Consumption, High-Density Lipoprotein Cholesterol, Antithrombin III, and Body Mass Index Are Associated with Great Saphenous Vein Reflux in the Thigh

BACKGROUND

Venous valvular reflux is the main cause of chronic venous dysfunction. However, the etiology of valvular reflux is not completely understood. We conducted this study to investigate new risk factors for venous reflux of the great saphenous vein (GSV) in the thigh.

METHODS

We studied 139 consecutive patients (278 legs) who underwent Doppler ultrasonography at our hospital between March 2015 and February 2016 for leg discomfort with visible varicosities, edema, skin changes, or venous ulcer in the legs. Continuous variables included age, body mass index (BMI), hematological and blood chemistry parameters, smoking (pack-years), and alcohol consumption (days). Nominal variables included sex, comorbidities, smoking status, alcohol drinking status, and specific antibodies. The relationship of GSV reflux with pregnancy and number of children was investigated in 184 legs of 92 patients among 96 female patients.

RESULTS

On logistic regression analysis, independent factors determining GSV reflux were BMI (B = 0.126, P = 0.012), high-density lipoprotein (HDL) cholesterol level (B = 0.029, P = 0.025), duration of alcohol consumption (B = 1.237 E^-4, P = 0.016), and antithrombin III level (B = -0.036, P = 0.011).

CONCLUSIONS

In this study, the factors determining GSV reflux were higher HDL cholesterol level, longer duration of alcohol consumption, lower antithrombin III level, and higher BMI.

A Case of Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis Treated with Preoperative FOLFOX Chemotherapy Followed by Radical Subtotal Gastrectomy and D2 Lymph Node Dissection

We report the case of a 73-year-old female who was diagnosed with advanced gastric cancer. Esophagogastroduodenoscopy was used to diagnose Borrmann type 3 advanced gastric cancer located at the gastric antrum. A biopsy revealed poorly differentiated adenocarcinoma. Abdominopelvic computed tomography (CT) and ¹⁸F-fluorodeoxyglucose positron emission tomography-CT (FDG-PET-CT) scans demonstrated multiple lymph node metastases, including the para-aortic lymph nodes. Systemic chemotherapy with 5-fluoruracil (5-FU), oxaliplatin, and leucovorin (FOLFOX) was initiated. An abdominopelvic CT scan taken after 4 cycles of chemotherapy showed improvement in the ulceroinfiltrative gastric lesion and marked regression of several enlarged lymph nodes. Consequently, we performed a subtotal gastrectomy with D2 lymphadenectomy. The postoperative histopathological report was early gastric carcinoma with no lymph node metastasis in the 48 resected lymph nodes. Another 4 cycles of FOLFOX chemotherapy were performed after surgery. A FDG-PET-CT scan taken 12 months postoperatively showed no definite evidence of local recurrence or distant metastasis, and the previously noted retroperitoneal lymph nodes had disappeared. A FDG-PET-CT taken 16 months postoperatively showed multiple lymph node metastases, including the left supraclavicular lymph node. Despite 8 cycles of secondary chemotherapy with 5-FU, irinotecan, and leucovorin (FOLFIRI) and radiotherapy, the patient died 38 months after the operation.

Prognostic Discrepancy of the 6th and 7th UICC N Classification for Lymph Node Staging in Gastric Cancer Patients after Curative Resection

BACKGROUND

The validity of N classification of the 7th edition of the American Joint Committee on Cancer/Union Internationale contre le Cancer (AJCC/UICC) tumor-node-metastasis (TNM) staging system is still under debate. The purpose of this study was to evaluate the prognostic efficacy of the 7th edition of the AJCC/UICC TNM staging system (focusing on N stage), in comparison with the 6th edition, at a single Eastern institution.

METHODS

We analyzed 1,435 patients with gastric cancer who underwent curative resection performed from September 1998 to August 2003 at the Memorial Jin-Pok Kim Korea Gastric Cancer Center. We analyzed the survival rate of the patients according to the AJCC/UICC 6th and 7th editions, and compared each stage, focusing on N stage.

RESULTS

Significant differences in the 5-year survival rates were observed between the 6th and the 7th AJCC/UICC staging system. In the 6th edition staging system, the Kaplan-Meier curves discriminated each N stage significantly. In contrast, there was no difference in terms of survival curves for N stage according to the 7th edition, especially between N1 and N2: the Kaplan-Meier plots of survival curves between N1 (77.0%) and N2 (78.1%) stages overlapped significantly (p < 0.05).

CONCLUSION

Although the 7th UICC staging system is a more detailed and sophisticated system in the T category, there was no prognostic significance between the pN1 and pN2 stages according to our data. Therefore, we suggest establishing a new UICC staging system taking into consideration the application of the N stage.

A Case of Gastric Cancer with Situs Inversus Totalis

Situs inversus totalis (SIT) is a rare congenital anomaly that refers to a completely reversed location of the abdominal and thoracic organs. We report the case of 50-year-old man with gastric cancer and SIT who was diagnosed during a screening esophagogastroduodenoscopy. A chest X-ray, abdominopelvic computed tomography, and ¹⁸F-fluoro2-deoxyglucose-D-glucose-positron emission tomography scans revealed SIT. We performed a radical subtotal gastrectomy with D2 lymph node dissection. Advanced surgical skill is required to perform a precise lymphadenectomy in a patient with SIT by visualizing the exact mirror image of the anatomy during the operation. The patient had an uneventful intra- and postoperative course and was followed up at the outpatient department without any evidence of recurrence. In conclusion, surgery in a patient with gastric cancer and SIT can be safely performed by paying attention to the inverted anatomic structures during the operation.

Simultaneous robotic subtotal gastrectomy and right hemicolectomy for synchronous adenocarcinoma of stomach and colon

Simultaneous laparoscopy-assisted resection for synchronous stomach and colon cancers has been reported frequently; however, robot-assisted gastrectomy and colectomy for these conditions are rarely reported. We report the successful use of robotic surgery for synchronous cancers of the stomach and colon. A 71-year-old woman with no specific medical history was diagnosed with early gastric cancer at the gastric angle and right colon cancer after undergoing esophagogastroduodenoscopy and colonofiberoscopy. Abdomino-pelvic computed tomography revealed that the stomach and colon lesions were limited to the mucosa without any lymph nodes or distant metastasis, which suggested the clinical stage for both cancers as T1N0M0. We performed robot-assisted radical subtotal gastrectomy and simultaneous right hemicolectomy through six ports. All procedures were successful without any perioperative complications. A 36-month postoperative follow-up of the patient at the outpatient department revealed no evidence of recurrence. We consider that concurrent robot-assisted subtotal gastrectomy and colectomy are technically feasible and safe.

Synchronous and Metachronous Colon Cancers in Patients with Gastric Cancer: Report of 2 Cases

Colorectal cancer is the most common synchronous or metachronous cancer in patients with gastric cancer. I report two cases of synchronous and metachronous colon cancer with gastric cancer. Case 1: A 70-year-old man was admitted to our hospital for the treatment of gastric cancer, which had been diagnosed during esophagogastroduodenoscopy (EGD) screening. The recommended preoperative testing was colonofiberscopy (CFS). The CFS revealed a 3-cm ulcerofungating mass, located 20 cm from the anal verge. The pathological report showed a well-differentiated adenocarcinoma. Consequently, we performed radical total gastrectomy and low anterior resection simultaneously. There was no recurrence during the 40-month follow-up of this individual on an out-patient basis. Case 2: A 71-year-old man who was treated with laparoscopically assisted distal gastrectomy (LADG) due to early gastric cancer underwent regular follow-up examination with EGD and abdominopelvic computed tomography. A CFS performed 5 years after the LADG revealed a polypoid mass in the sigmoid colon. The pathological report showed a villous adenoma with adenocarcinoma in situ. The patient underwent a colonofiberscopic mucosectomy. At 36 months after the endoscopic mucosectomy, the patient remained free of recurrence.

Who may benefit from robotic gastrectomy?: A subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy

AIMS

Robotic gastrectomy for gastric cancer has been proven to be a feasible and safe minimally invasive procedure. However, our previous multicenter prospective study indicated that robotic gastrectomy is not superior to laparoscopic gastrectomy. This study aimed to identify which subgroups of patients would benefit from robotic gastrectomy rather than from conventional laparoscopic gastrectomy.

METHODS

A prospective multicenter comparative study comparing laparoscopic and robotic gastrectomy was previously conducted. We divided the patients into subgroups according to obesity, type of gastrectomy performed, and extent of lymph node dissection. Surgical outcomes were compared between the robotic and laparoscopic groups in each subgroup.

RESULTS

A total of 434 patients were enrolled into the robotic (n = 223) and laparoscopic (n = 211) surgery groups. According to obesity and gastrectomy type, there was no difference in the estimated blood loss (EBL), number of retrieved lymph nodes, complication rate, open conversion rate, and the length of hospital stay between the robotic and laparoscopic groups. According to the extent of lymph node dissection, the robotic group showed a significantly lower EBL than did the laparoscopic group after D2 dissection (P = 0.021), while there was no difference in EBL in patients that did not undergo D2 dissection (P = 0.365).

CONCLUSION

Patients with gastric cancer undergoing D2 lymph node dissection can benefit from less blood loss when a robotic surgery system is used.

A Case of Malignant Gastrointestinal Stromal Tumor Initially Misdiagnosed as Malignant B-Cell Lymphoma

Errors that occur in anatomic pathology influence the treatment strategy of patients with malignancy. There are four general types of error with three subtypes in the category of defective interpretation. The first subtype is a false-negative diagnosis or undercall of the extent or severity of the lesion, the second is a false-positive diagnosis, and the third is misclassification. We herein report a 65-year-old female patient with malignant gastrointestinal stromal tumor that was diagnosed after reevaluation of the lesion at our hospital – and treated with proximal gastrectomy – after initial diagnosis as malignant B-cell lymphoma on esophagogastroduodenoscopy biopsy of a small gastric fundic mass and subsequent treatment with six cycles of CHOP chemotherapy with aggravation of the mass at another hospital.

A Giant Retroperitoneal Liposarcoma Encasing the Entire Left Kidney and Adherent to Adjacent Structures: A Case Report

Retroperitoneal liposarcoma is a rare tumor. The dimension and weight of liposarcoma are variable; those over 20 kg are called ‘giant liposarcoma’. Herein, we report giant retroperitoneal liposarcoma measuring 45 cm in diameter and 25 kg in weight encasing the entire left kidney and adherent to adjacent structures. A 71-year-old woman presented for a regular checkup. Image study revealed a huge mass probably indicative of retroperitoneal liposarcoma encasing the entire left kidney and adherent to adjacent structures. We performed an organ-preserving surgical removal. The pathologic report was liposarcoma. At postoperative month 16, a follow-up CT revealed a locally recurrent tumor. The patient underwent surgical removal of the newly discovered mass. After the second surgery, the patient underwent regular follow-up CT for approximately 12 months, and to date, there has been no evidence of tumor recurrence. High-grade liposarcoma shows sensitivity to radiation therapy. However, the toxic effect of radiation therapy limits this option by treatment modality. The use of chemotherapy is also controversial. As a result, complete resection is the gold standard treatment. Here, we report a giant retroperitoneal liposarcoma encasing the entire left kidney and adherent to adjacent structures, describe successful organ-preserving surgical removal and discuss prognosis.

Gastric Schwannoma Mimicking Malignant Gastrointestinal Stromal Tumor Exhibiting Increased Fluorodeoxyglucose Uptake

A schwannoma is a kind of neurogenic tumor that rarely occurs in the gastrointestinal tract. Gastric schwannomas make up 0.2% of all gastric neoplasms. Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors and up to 60-70% of GIST occur in the stomach. Schwannoma and GIST are similar in clinical features, so they are difficult to differentiate preoperatively. Differential diagnosis of these two submucosal tumors is important because of the malignant potential of GIST and the relatively benign course of gastric schwannomas. We report a 49-year-old woman who was diagnosed after operation with a gastric schwannoma, which was suspected a malignant GIST by fluorine-18-fluorodeoxyglucose positron emission computed tomography imaging.

Spin dynamics in Na(4-x)Ir₃O₈ (x = 0.3 and 0.7) investigated by ²³Na NMR and μSR

We report (23)Na nuclear magnetic resonance (NMR) and zero-field (ZF) and longitudinal-field (LF) muon spin relaxation (μSR) measurements of the depleted hyperkagome compounds Na(4-x)Ir3O8 (x  =  0.3 and 0.7), which undergo an insulator-semimetal transition as a function of x. The (23)Na spin-lattice relaxation rates, T1(-1), follow a T(2.5) power law behavior at accessible temperatures of T  =  120-350 K. A substantial temperature dependence of T1(-1) indicates the presence of gapped excitations at elevated temperatures through the transition to a semimetallic phase. ZF-μSR results reveal that hole-doping leads to a melting of quasi-static order to a dynamically fluctuating state. The very slow muon depolarization rate which varies hardly with temperature indicates that spins are close to an itinerant limit in the largest doping x  =  0.7. The dynamic relaxation rates extracted from the LF-μSR spectra show a three-dimensional diffusive transport. Our combined NMR and μSR results suggest the occurrence of intriguing spin and charge excitations across the insulator-semimetal transition.

Metachronous Liver Metastasis Resulting from Early Gastric Carcinoma after Subtotal Gastrectomy Following Endoscopic Resection: A Case Report

Hepatic metastasis of early gastric cancer (EGC) following subtotal gastrectomy with lymphadenectomy is rare. We report the case of a 61-year-old male patient who was diagnosed with EGC that was initially treated using endoscopic submucosal dissection (ESD) and subsequently underwent laparoscopic subtotal gastrectomy. Histopathological examination of the patient's ESD specimen showed a moderately differentiated tubular adenocarcinoma invading the submucosa without lymphatic invasion. The deep margin of the specimen was positive for adenocarcinoma, and he subsequently underwent laparoscopic distal gastrectomy. The patient developed liver metastasis 15 months after the operation and then underwent liver resection. Histology of the resected specimen confirmed the diagnosis of two foci of metastatic adenocarcinoma originating from stomach cancer. Immunohistochemical analysis of the specimen demonstrated overexpression of human epidermal growth factor receptor 2. The patient was treated with trastuzumab in combination with chemotherapy consisting of capecitabine and cisplatin. Twenty-four months after the operation, the patient remained free of recurrence.

Synchronous triple primary cancers occurring in the stomach, kidney, and thyroid

We report an unusual case of synchronous triple primary cancer of the stomach, kidney, and thyroid in a 50-year-old male patient. Initial esophagogastroduodenoscopy with biopsy for the medical check-up revealed poorly differentiated adenocarcinoma. We performed an abdominal/pelvic computed tomography scan for staging and incidentally found a 1.7-cm exophytic hypervascular mass in the left kidney. Thyroid ultrasonography showed suspicious malignant nodules suspicious with multiple lymph nodes (LNs) metastasis in the right side of the neck. Subsequent fine needle aspiration biopsy of a nodule and a LN was performed. Cytologic report revealed papillary thyroid carcinoma with lateral LNs metastasis. Our integrate oncology team performed radical subtotal gastrectomy, partial nephrectomy, and total thyroidectomy with modified radical neck dissection. The postoperative pathologic finding was well-differentiated gastric adenocarcinoma (T1N0M0; stage 1A), renal cell carcinoma (T1aN0M0; stage 1), and papillary thyroid carcinoma (T4bN1bM0; stage 4B). He received postoperative a radio-active iodine ablation and is doing well with no recurrence.

Two cases of advanced gastric carcinoma mimicking a malignant gastrointestinal stromal tumor

Gastric cancer that mimics a submucosal tumor is rare. This rarity and the normal mucosa covering the protuberant tumor make it difficult to diagnosis with endoscopy. We report two cases of advanced gastric cancer that mimicked malignant gastrointestinal stromal tumors preoperatively. In both cases, the possibility of cancer was not completely ruled out. In the first case, a large tumor was suspected to be cancerous during surgery. Therefore, total gastrectomy with lymph node dissection was performed. In the second case, the first gross endoscopic finding was of a Borrmann type II advanced gastric cancer-like protruding mass with two ulcerous lesions invading the anterior wall of the body. Therefore, subtotal gastrectomy with lymph node dissection was performed. Consequently, delayed treatment of cancer was avoided in both cases. If differential diagnosis between malignant gastrointestinal stromal tumor and cancer is uncertain, a surgical approach should be carefully considered due to the possible risk of adenocarcinoma.

Factors related to morbidity in elderly gastric cancer patients undergoing gastrectomies

Purpose

The prevalence of gastric cancer in the elderly is increasing. The purpose of this study was to clarify factors related to morbidity following gastric cancer surgery in elderly patients.

Materials and Methods

For this study, data from 411 patients who underwent curative gastrectomies with lymph node dissections between March 2010 and January 2013 were retrospectively studied using a prospectively designed database. Patients were divided into 2 groups (<70 years vs. ≥70 years). For each group, perioperative factors were analyzed to determine if they were associated with postoperative morbidity and mortality.

Results

Comorbidities were more prevalent in the elderly group (≥70 years). Intraoperative and postoperative transfusions were also more frequently required in the elderly group. There was no significant difference in the number of retrieved lymph nodes between the 2 groups (44.3 vs. 46.6 nodes). In a comparison of the elderly versus non-elderly groups, the postoperative morbidity rates were 22.7% versus 8.9% (P<0.001) and the postoperative mortality rates were 4.2% versus 0% (P=0.002), respectively. Of the possible non-surgical complications, pulmonary problems were predominately found in the elderly group (P<0.001). Surgical complications were evenly distributed between the 2 groups (P=0.463). Postoperative morbidity was significantly associated with older age and postoperative transfusion. Multivariate analysis showed that higher body mass index (BMI) and postoperative transfusion were important factors associated with postoperative complications in the elderly group.

Conclusions

Pulmonary complications were frequently problematic in elderly patients. Higher BMI and postoperative transfusion were significant risk factors for postoperative complications in elderly patients with gastric cancer.

Acute limb ischemia: surgical thromboembolectomy and the clinical course of arterial revascularization at ankle

Surgical thromboembolectomy for acute limb ischemia using Fogarty catheter is basically a blind procedure. Therefore, the complete removal of thromboemboli in all calf arteries is difficult even if completion angiography or radiological intervention is performed. The purpose of this study is to identify whether limb salvage could be achieved if at least one ankle artery was revascularized by surgical thromboembolectomy. We also observed the effectiveness of below-knee popliteal approach. Over 1 year, surgical thromboembolectomy via below-knee popliteal artery was performed on 18 acutely ischemic limbs in 14 consecutive patients. All patients were diagnosed based on clinical symptoms and computed tomography (CT) angiography. Surgical thromboembolectomy was terminated when a pulse was detected by a handheld vascular Doppler device in at least one ankle artery after closing the arteriotomy. Patients were observed during postoperative anticoagulation therapy. Of the 14 patients, 1 died and 1 underwent amputation due to the already necrotized lesion in the foot. After 1 week of anticoagulation therapy, two or more arterial pulses were detected at the ankles in all 15 limbs from the remaining 12 patients. During the 6 to 18 months of follow-up, all 15 limbs were salvaged successfully. In acute limb ischemia, successful limb salvage could be achieved by the revascularization of at least one ankle artery by surgical thromboembolectomy with concomitant anticoagulation therapy. Below-knee popliteal approach is an effective method and is worth for further study compared with other approaches.

Broadband electron spin resonance at low frequency without resonant cavity

We have developed a nonconventional broadband electron spin resonance (ESR) spectrometer operating continuously in the frequency range from 0.5 to 9 GHz. Dual antenna structure and the microwave absorbing environment differentiate the setup from the conventional one and enable broadband operation with any combination of frequency or magnetic field modulation and frequency or magnetic field sweeping. Its performance has been tested with the measurements on a 1,1-diphenyl-2-picrylhydrazyl (DPPH) sample and with the measurements on the single molecular magnet, V6, in solid state at low temperature.

A case of gastric adenocarcinoma presenting as meningeal carcinomatosis

Leptomeningeal carcinomatosis occurs in approximately 5% of patients with cancer. The most common cancers involving the leptomeninges are breast, lung cancer and melanoma. However, gastric adenocarcinoma has been rarely reported with leptomeningeal carcinomatosis. The presenting manifestations are usually headache, visual disturbances and seizures. We report a case of leptomeningeal metastasis that presented as a gastric cancer. A 49-year-old woman was admitted to our hospital with the symptoms of headache and melena for 10 days. The endoscopy showed a thickening of the folds of the stomach compatible with the diagnosis of a Borrman type IV gastric cancer. The biopsy revealed a signet ring cell carcinoma. The MRI of brain showed no abnormal findings; however, the patient complained of an intractable persistent headache, nausea and vomiting on admission day 6. The cytology examination of the cerebrospinal fluid supported the diagnosis of metastatic signet ring cell carcinoma.

Inhomogeneous low frequency spin dynamics in La(1.65)Eu(0.2)Sr(0.15)CuO(4)

We report Cu and La nuclear magnetic resonance measurements in the title compound that reveal an inhomogeneous glassy behavior of the spin dynamics. A low temperature peak in the La spin lattice relaxation rate and the "wipeout" of Cu intensity both arise from these slow electronic spin fluctuations that reveal a distribution of activation energies. Inhomogeneous slowing of spin fluctuations appears to be a general feature of doped lanthanum cuprate.

Structural determinants of a glucocorticoid receptor recognition element

Analysis of the relative inducibility of an extensive series of mutant glucocorticoid response elements (GREs) defines features critical to the constitution of an active GRE. Assuming that function as a GRE reflects binding of glucocorticoid receptor, our activity data are consistent with the recognition of the GRE as two hexamer half-sites, each half-site recognized by a single subunit of a receptor dimer, probably in a cooperative fashion. Integrity of both half-sites is necessary for an active element, and spacing of the half-sites is critical. The identity of 1 basepair within the hexamer half-site is unconstrained; the receptor probably makes no base-specific contacts at this position. In contrast, at other positions within the half-site, limited substitutions (if any) can be tolerated. These results along with data from certain insertion mutations suggest that the receptor recognizes each hexamer half-site as two separable subelements. A further implication is that the DNA-binding domain of the glucocorticoid receptor is composed of distinct subdomains, which interact with the subelements of the recognition sequence.