[A Hematogenous Metastasis from Scirrhous Gastric Cancer to the Uterus]

A 46-year-old woman was referred to our hospital because of nausea. Endoscopy revealed scirrhous gastric cancer, and abdominalcomputed tomography revealed peritonealdissemination. She was diagnosed with Stage IV gastric cancer and treated with S-1 plus CDDP combination chemotherapy. After 4 courses of chemotherapy, the primary tumor and peritoneal dissemination were considered clinically stable, but the uterus grew rapidly. She was diagnosed as having uterine metastasis based on cervicaland endometrialsmear class V cytology. As the chemotherapy was not effective for the uterine lesions, totalhysterectomy and bilateralsal pingo-oophorectomy were performed. Histological findings showed a poorly differentiated cancer with vascular emboli. Uterine metastases are an important consideration in women with scirrhous gastric cancer, and we recommend palliative hysterectomy for chemotherapy-resistant metastases if the primary tumor and other metastases are controlled.

[Primary Breast Cancer in a Man]

A 76-year-old man noticed a tumor under his right nipple. Mammography revealed an irregularly shaped nodule in the right breast. Ultrasonography showed a 20mm irregularly shaped nodule in the central area. MRI showed an 18mm irregularly shaped nodule in the central area with skin invasion. On core needle biopsy, the tumor was diagnosed as an invasive ductal carcinoma of the right breast. The patient underwent a mastectomy and axillary lymph node dissection. Histopathologically, the patient was diagnosed with invasive ductal carcinoma(scirrhous carcinoma). The tumor was positive for both ER and PgR, and the HER2 score was 1. The Ki-67 index was 20-30%. Male breast carcinoma accounts for approximately 1.0% of all breast carcinomas. The most common complaint is elastic, hard nodules with no pain. Postoperative therapy for male breast cancer is similar to that for female cancer. This patient underwent a mastectomy and lymph node dissection. After surgery, tamoxifen was administered as adjuvant therapy. There has been no evidence of recurrence for 4 months after the surgery.

[A case report of scirrhous gastric cancer with peritoneal dissemination treated effectively with various chemotherapy regimens after laparoscopic distal subtotal gastrectomy]

We report a 44-year-old male patient who was diagnosed with scirrhous gastric cancer with peritoneal dissemination using laparoscopy. The patient underwent a non-curative resection with laparoscopic distal subtotal gastrectomy. In addition, we placed a port into the patient's abdomen for intraperitoneal chemotherapy administration. Postoperatively, we administered capecitabine (per os)+ paclitaxel (intraperitoneally) and, after 2 cycles, the oral anticancer agent 5-FU was given. The patient died of peritonitis carcinomatosa 25 months after the operation. The combined therapies contributed to improve the quality of life, specifically oral ingestion, for 2 years.

[Synchronous male bladder cancer and breast cancer - a case report]

A 74-year-old man complained of blood in his urine over a 1-week period beginning in early October 2013, and was examined in the urology department of our hospital. A thorough examination revealed bladder cancer, and surgery was planned after two cycles of preoperative gemcitabine plus cisplatin chemotherapy. A chest computed tomography (CT) performed to evaluate the response to chemotherapy revealed a mass in the right breast. The patient had previously complained about the same site, and mammography and ultrasonography had suggested the possibility of a malignant mammary gland tumor. The results of aspiration cytology were Class V, and based on that finding, a diagnosis of cancer of the right breast was made. In February 2014, we performed a mastectomy, while preserving the pectoral muscles, along with sentinel node biopsy, total cystectomy, urethrectomy, pelvic lymph node dissection, and ureteroileal anastomosis. The histopathological diagnosis of the right breast tumor was invasive ductal carcinoma[scirrhous carcinoma, ly (+), v (-), g (+), f (+), s (+), nuclear grade 1=atypia 2+mitosis 1, EIC (-), ICT (-), NCAT (-)]. A micrometastatic tumor measuring approximately 1mm was observed in the sentinel lymph node. The breast disease was classified as pT1N1mi(sn)M0, Stage IIA, and the tumor was ER (+), PgR (+), HER2/neu (2+), and FISH (-). The bladder cancer was diagnosed as urothelial carcinoma, non-papillary, invasive G2>G3, pT2a; no pelvic lymph node metastases were detected, and it was classified as pT2aN0M0, Stage II. Synchronous male breast cancer and bladder cancer is a very rare condition, and we report the case with a review of the literature.

[The case of a long-surviving patient with breast cancer and brain metastases treated using multidisciplinary therapy]

We present the case of a 55-year-old-woman who was diagnosed with left breast cancer, and underwent a left mastectomy and left axillary lymph node resection. The histopathological examination indicated scirrhous carcinoma and lesser papillotubular carcinoma[estrogen receptor-negative (ER-), progesterone receptor-negative(PgR-), and human epidermal growth factor receptor 2-positive, grade 3 (HER2, 3+)] with lymph node metastases. Adjuvant chemotherapy consisting of epirubicin and cyclophosphamide (EC) followed by paclitaxel was administered. During the therapy, the patient noticed a mass on her left chest wall. It was diagnosed as a locally recurrent tumor. A computed tomography (CT) scan indicated supraclavicular lymph node metastasis. The patient underwent radiotherapy and was administered chemotherapy with TS-1 and trastuzumab. Brain metastases were found 24 months postoperatively, and the patient underwent surgery and wholebrain radiotherapy. After these, systemic capecitabine and trastuzumab chemotherapy was administered. The therapy was subsequently changed to capecitabine and lapatinib. There have been no subsequent metastatic tumors, and good control has been achieved for a long time after the detection of brain metastases.

[A case of metastatic gastric cancer from breast cancer treated with proximal gastrectomy]

We report a case of a 72-year-old woman with breast cancer who developed significant stenosis due to gastric cardia metastasis. The patient had undergone radical mastectomy for breast cancer when she was 53 years old and had developed postoperative recurrent diseases in the sternum and lung when she was 62 years old. Nineteen years after mastectomy, computed tomography (CT) scans showed gastric cardia metastasis. As symptoms of cardiac stenosis gradually developed, we performed proximal gastrectomy. The specimen was histologically diagnosed as estrogen receptor( ER)-positive scirrhous carcinoma that had metastasized from the breast cancer. The patient resumed oral intake of food after surgery. Surgical treatment might be useful to improve the quality of life of patients with metastatic gastric tumor.

Mesothelial cells differentiate into fibroblast-like cells under the scirrhous gastric cancer microenvironment and promote peritoneal carcinomatosis in vitro and in vivo

Peritoneal metastases are one reason for the poor prognosis of scirrhous gastric cancer (SGC), and myofibroblast provides a favorable environment for the peritoneal dissemination of gastric cancer. The aim of this study was to determine whether myofibroblast originates from peritoneal mesothelial cells under the influence of the tumor microenvironment. Immunohistochemical studies of peritoneal biopsy specimens from patients with peritoneal lavage cytological (+) status demonstrate the expression of the epithelial markers cytokeratin in fibroblast-like cells entrapped in the stroma, suggesting that these cells stemmed from local conversion of mesothelial cells. To confirm this hypothesis in vitro, we co-incubated mesothelial cells with SGC or non-SGC to investigate morphology and function changes. As we expected, mesothelial cells undergo a transition from an epithelial phenotype to a mesenchymal phenotype with loss of epithelial morphology and decrease in the expression of cytokeratin and E-cadherin when exposed to conditioned medium from HSC-39, and the induction of mesothelial cells can be abolished using a neutralizing antibody to transforming growth factor-beta1 (TGF-β1) as well as by pre-treatment with SB431542. Moreover, we found that these mesothelial cells-derived cells exhibit functional properties of myofibroblasts, including the ability to increase adhesion and invasion of SGC. In summary, our current data demonstrated that mesothelial cells are a source of myofibroblasts under the SGC microenvironment which provide a favorable environment for the dissemination of gastric cancer; TGF-β1 produced by autocrine/paracrine in peritoneal cavity may play a central role in this pathogenesis.

[A case of metastatic breast cancer with bilateral hydronephrosis effectively treated with capecitabine]

A 54-year-old female was diagnosed with invasive ductal carcinoma (pT3N1M0, Stage IIIA, estrogen receptor positive [ER (+)], progesterone receptor positive [PgR (+)], human epidermal growth factor receptor type 2 [HER2] score 0) and was treated by preoperative chemotherapy with weekly paclitaxel followed by 5-fluorouracil(5-FU) plus epirubicin plus cyclophosphamide regimen(FEC). Partial mastectomy with axillary dissection was performed. The pathological examination disclosed that the tumor was scirrhous carcinoma, and a pathological partial response was achieved by chemotherapy. Multiple bone metastases were detected 18 months after the surgery during treatment with letrozole as adjuvant therapy. Retroperitoneal metastases with hydronephrosis and a lung metastasis were detected 28 months after the surgery, even though exemestane and zoledronate were administrated after detection of the bone metastases. Chemotherapy with capecitabine was started and she recovered from hydronephrosis 4 months after the start of treatment. After 32 months from the first treatment with capecitabine, the patient is presently alive without hydronephrosis due to continued chemotherapy.

A novel transforming growth factor beta receptor kinase inhibitor, A-77, prevents the peritoneal dissemination of scirrhous gastric carcinoma

PURPOSE

Transforming growth factor beta receptor (TGFbeta-R) is reported to correlate with the malignant potential of scirrhous gastric carcinoma. The aim of the current study is to clarify the possibility of molecular target therapy with a TGFbeta-R inhibitor, A-77, for the treatment of peritoneal dissemination of scirrhous gastric cancer.

EXPERIMENTAL DESIGN

Three scirrhous gastric cancer cell lines and two fibroblasts were used. For in vivo experiments, the A-77 was administered i.p. to mouse models of peritoneal dissemination. The influences of A-77 on the adhesion ability, invasion ability, and the expression of adhesion molecules were examined in vitro.

RESULTS

The A-77 administration resulted in a significantly (P < 0.01) better prognosis for the mice with peritoneal dissemination (median survival time, 51 days), compared with the control (median survival time, 25 days). A-77 therefore significantly (P < 0.01) decreased the weight and number of metastatic nodes. The adhesive ability and invasion ability of cancer cells were significantly decreased by A-77. A-77 decreased the expression of alpha(2), alpha(3), and alpha(5) integrins in gastric cancer cells. The histologic findings showed the degree of fibrosis to be less in the tumors treated by A-77. A-77 decreased the growth of fibroblast and invasion-stimulating activity of fibroblasts on cancer cells.

CONCLUSION

The TGFbeta-R inhibitor, A-77, decreased the expression of integrins in cancer cells and the proliferation of fibroblasts, which resulted in the decreased adhesive and invasive abilities of scirrhous gastric cancer cells to peritoneum. A-77 is thus considered to be useful for the inhibition of peritoneal dissemination of scirrhous gastric carcinoma.

Establishment and characterization of a cell line (NABCA) derived from metastatic lymph nodes of breast scirrhous carcinoma

We successfully established a breast scirrhous carcinoma cell line (designated as NABCA) derived from metastatic tumors of the lymph node. The cells grew as multi-layered cultures without contact inhibition. The population doubling time was approximately 66 h. G-band karyotype of NABCA revealed 66% diploid, XX. Surprisingly, the cells had a number of secretory granules and straight microvilli as a brash border. In heterotransplantation, the cells produced a tumor resembling the original tumor. The NABCA is sensitive to Adriamycin (doxorubicin; KYOWA HAKKO KOGYO, Tokyo, Japan) and Taxol (paclitaxel; Bristol-Myers KK, Tokyo, Japan). This cell line is useful for studying the mechanism of lymphatic metastasis and susceptibility of anticancer drugs in human breast scirrhous cancer.

[A case of scirrhous gastric cancer with peritoneal metastases successfully treated by combined chemotherapy of biweekly paclitaxel and TS-1 followed by curative resection]

The patient was a 50-year-old male with advanced gastric cancer. Laparoscopy showed peritoneal metastases. We thought a complete resection would be difficult, so he was given neoadjuvant chemotherapy combined with paclitaxel (200 mg, day 1, 15) and TS-1 (120 mg/day, for days 1-14 with a 2-week rest). After 3 courses of this neoadjuvant chemotherapy, the tumor decreased in size. Laparoscopy showed no peritoneal metastasis, and thus a total gastrectomy with splenectomy and D 2 lymph node dissection was performed. The pathological diagnosis was sig, LM, type 4, pT 3 (SE), sci, INFgamma, ly 0, v 0, pN 0, pPM (-), pDM (-), and the antitumor efficacy of this therapy was Grade 0 histologically. Combined chemotherapy of biweekly paclitaxel and TS-1 was thought to be an effective neoadjuvant chemotherapy for advanced gastric cancer in this case.

[A case of progressive gastric carcinoma accompanied by disseminated carcinomatosis of bone marrow due to bone metastasis with DIC recovery by joint administration of 5-FU and paclitaxel]

A 54-year-old male visited our hospital with the chief complaint of anorexia. Based on various tests, a diagnosis of scirrhous gastric carcinoma accompanied by bone metastasis and liver metastasis was made. As DIC developed following hospital admission, 5-FU and PTX therapy (5-FU at 600 mg/m(2), 24-hour continuous infusion, day 1-5 and PTX at 80 mg/m(2), iv, day 8, 15, 22) were administered. Although primary foci, bone metastasis, and liver metastasis were observed by image diagnostic procedures, recovery from DIC was achieved. 5-FU+PTX therapy is considered to be effective for DIC due to bone metastasis of gastric carcinoma.

[A case of advanced gastric cancer with malignant ascites responding to weekly paclitaxel therapy]

A 54-year-old woman with scirrhous gastric cancer in the upper third area was admitted to our hospital. She was diagnosed with advanced gastric cancer that was inoperable due to peritoneal metastasis, so weekly paclitaxel (PTX) therapy was carried out. After 2 courses, malignant ascites completely disappeared and bilateral hydronephrosis improved. After 4 courses, no ascites or hydronephrosis were seen. Only neutropenia (grade 2) and alopecia (grade 1) were observed as adverse events during the therapy, but no major adverse events were noted. We also investigated the concentration of paclitaxel in ascites. Two hours after intravenous injection of PTX, the concentration of PTX in ascites rose over the reported cytotoxic dose of PTX, and this available concentration was maintained after 48 hours. Weekly paclitaxel therapy is suggested to be one of the safe and useful treatments for advanced gastric cancer with malignant ascites.

[Palliative chemotherapy and CUP-syndrome: medical intentions versus patients' attitudes in decision making]

The following case report is about a 55 year old male patient with CUP-syndrome. After developing a malignant bowel obstruction he received five cycles of a palliative chemotherapy with oxaliplatin and irinotecan. The focus is on medical intentions and goals concerning palliative chemotherapy and on discussing patients' attitudes towards chemotherapy. Communication is identified as fundamental skill in shared decision making. On the one hand it improves Patients' satisfaction and palliative care and on the other hand it reduces psychological and existential suffering. In tumors of unknown primary site regimens with different combinations of Platin, Taxol, Etoposide, Irinotecan and Gemcitabine showed responses up to 46% and a survival benefit with an overall median survival up to 12 months and even long term survival.

Randomized controlled trial of the effect of hysterectomy or LNG-IUS use on bone mineral density: a five-year follow-up

A 72-year-old female with scirrhous-type advanced gastric cancer was treated with TS-1/CDDP as neoadjuvant chemotherapy. TS-1 (80 mg/m(2)/day) was orally administered for 3 weeks and CDDP (60 mg/m(2)) was administered by intravenous drip on day 8. Partial response (PR) was obtained after the first course, and total gastrectomy was performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and a few regional lymph node metastases (3/67). The patient has now been in good health without a recurrence for 1 year and 9 months after surgery.

Transtubal Spread of Serous Adenocarcinoma of the Endometrium: An Underrecognized Mechanism of Metastasis

Most endometrial carcinomas metastasize by invading myometrial lymphatics and spreading to regional lymph nodes. However, uterine serous carcinomas (USCs) metastasize frequently to peritoneal surfaces even when only minimally invasive. This study examines the methods of spread and the role of retrograde transtubal spread. Eighty-seven USCs treated by hysterectomy were identified. Primary peritoneal cases and cases with significant ovarian involvement were excluded. Eighty (92%) cases were pure serous, and the remainder had at least 25% serous histology. Fifty-four of 87 (62%) had extrauterine spread at hysterectomy, most commonly to peritoneal surfaces and sometimes to the pelvic lymph nodes. Twenty-six of 54 (48%) cases had no lymphatic/vascular (LV) invasion and 18/54 (33%) had no myometrial invasion. Eleven of these 54 (20%) patients with metastases lacked both myometrial and LV invasion, and the metastases involved the peritoneal surface more often than the lymph nodes (p<0.001). Three of the 11 cases had tumor clusters in the fallopian tube lumen. Another 13 cases also had clusters of tumor within the fallopian tube lumen, and all 16 cases had peritoneal spread (p<0.001). Extrauterine spread correlated highly with LV invasion (p<0.001) but not with the presence or depth of myometrial invasion. Retrograde transtubal implantation as well LV invasion are two important mechanisms by which USC spreads; all cases with tumor clusters in the fallopian tube lumen had peritoneal spread. This explains the phenomenon whereby patients with serous carcinomas confined to the endometrium and lacking LV invasion have widespread metastases to the peritoneum.

A synergic inhibitory-effect of combination with selective cyclooxygenase-2 inhibitor and S-1 on the peritoneal metastasis for scirrhous gastric cancer cells

An inhibitory-effect of a selective cyclooxygenase-2 (COX-2) inhibitor on peritoneal metastasis of scirrhous gastric carcinoma was investigated in vivo. Peritoneal metastasis had developed after intraperitoneal inoculation of scirrhous gastric cancer cells, OCUM-2MD3, in nude mice. COX-2 inhibitor and/or S-1 were administered orally in nude mice with peritoneal metastasis. Oral administration of COX-2 inhibitor and S-1 significantly prolonged survival rates of these nude mice, compared with either alone. These findings suggested that combining S-1 and COX-2 inhibitor administration obtain a synergistic inhibitory-effect on the peritoneal metastasis of scirrhous gastric carcinoma.

[Proptosis as the first sign of recurrent scirrhous breast carcinoma]

OBJECTIVE

To inform clinicians of a metastatic orbital neoplasm that frequently masquerades as an orbital inflammatory syndrome.

CASE REPORT

The case of a 61-year-old woman, diagnosed and treated seven years ago for a scirrhous breast carcinoma is presented. She complained of blurred vision and proptosis of the left eye and these symptoms were the first manifestation of tumor relapse.

DISCUSSION

When orbital inflammation is detected in an adult female patient, a full medical history must be obtained and physical examination performed, as orbital metastases have been reported to be the initial manifestation of malignancy in 30 to 50% of cases.

[Intraperitoneal chemotherapy in gastric cancer patients with peritoneal dissemination]

Peritoneal dissemination is one of the non-curative factors in gastric cancer and colon cancer. Although many treatments have been conducted for peritoneal dissemination, no standard chemotherapy has yet been established. For sometime we had used continuous hyperthermic peritoneal perfusion (CHPP)for peritoneal dissemination in gastric cancer and colon cancer. CHPP has a marked survival benefit for scirrhous type gastric cancer patients without liver metastasis. Patients with prophylactic CHPP have significantly better prognoses than those without prophylactic CHPP, and therapeutic CHPP has a survival benefit for gastric cancer patients with slight to moderate peritoneal dissemination (P 1-2). But CHPP has no significant prognostic benefit for gastric cancer patients with severe peritoneal dissemination (P 3). Therefore, a new cancer treatment is needed for those patients. On the other hand, many kinds of anticancer agents, including cisplatin, via intraperitoneal (ip) administration have been tried thus far for peritoneal dissemination therapy. Especially, intraperitoneal taxane anticancer agent is very effective for the treatment and local control of severe peritoneal dissemination in gastric cancer. A phase I/II study of taxane anticancer agents via ip administration should be tried in gastric cancer patients with peritoneal dissemination.

[Peritoneal dissemination of scirrhous type 4 gastric cancers]

We examined 198 cases of primary scirrhous type 4 gastric cancer at our department from 1984 to 2003. Of these, 139 cases underwent gastrectomy. The essential cause of inoperability was peritoneal dissemination with malignant abdominal abscises. The incidence of peritoneal dissemination was 48.2% of all resected cases. The 5-year survival rate of all resected cases was 12% and that of non-resectable cases was 0%. One of the 59 nonresectable cases who responded remarkably to treatment by TS-1/paclitaxel combination chemotherapy obtained survival of 12 months. Six cases with peritoneal dissemination were treated by chemotherapy with cisplatin and etoposide infused intra-peritoneally and 2 of them were diagnosed as P 0 after 4 weeks. One case with type 4 gastric cancer who had right hydronephrosis and malignant abdominal ascites underwent curative resection after successful treatment with TS-1. We have selected the way of conventional chemotherapy for inoperable type 4 gastric cancers, but the prognosis is still poor. It is thought necessary to improve survival by newly developed anticancer agents such as TS-1, etoposide and taxanes. Immuno-cellular therapy with autologous tumor cell stimulated lymphocyte may be examined as a neo-adjuvant therapy as well as chemotherapy.

Development and biological analysis of peritoneal metastasis mouse models for human scirrhous stomach cancer

The number of published studies on peritoneal dissemination of scirrhous gastric carcinoma is very small as a result of the unavailability of highly reproducible animal models. Orthotopic implantation of HSC-44PE and HSC-58 (scirrhous gastric carcinoma-derived cell lines) cells into nude mice led to dissemination of the tumor cells to the greater omentum, mesenterium, peritoneum and so on, and caused ascites in a small number of animals. Cycles of isolation of the ascitic tumor cells and orthotopic inoculation of these cells were repeated in turn to animals. This was to isolate highly metastatic cell lines with a strong capability of inducing the formation of ascites (44As3 from HSC-44PE; 58As1 and 58As9 from HSC-58). All three cell lines induced tumor formation at the site of orthotopic injection, and caused fatal cancerous peritonitis and bloody ascites in 90-100% of the animals approximately 3-5 weeks after the inoculation. When the parent cells were implanted, the animals became moribund in approximately 12-18 weeks, however, none of the animals developed ascites. Complementary DNA microarray and immunohistochemical analyses revealed differences in the expression levels of genes coding for the matrix proteinase, cell adhesion, motility, angiogenesis and proliferation between the highly metastatic- and parent-cell lines. The usefulness of this model for the evaluation of drugs was assessed by analyzing the stability of the metastatic potential of the cells and the reproducibility. Animals intravenously treated with CPT-11 and GEM showed suppressed tumor growth and significantly prolonged survival. The metastatic cell lines and the in vivo model established in the present study are expected to serve as a model of cancerous peritonitis developing from primary lesions, and as a useful means of clarifying the pathophysiology of peritoneal dissemination of scirrhous gastric carcinoma and the development of drugs for its treatment.

[A case of anthracycline and taxane-resistant breast cancer with life-thereatening multiple liver metastases responding to oral combination chemotherapy by UFT, cyclophosphamide and medroxyprogesterone acetate]

A 53-year-old woman presented with an advanced right breast cancer together with skin manifestations and massive axillary lymph node metastases, as well as distant metastases in the lung and the liver. The patient received surgery after 6 courses of chemotherapy with epirubicine and intravenous cyclophosphamide (80/600 mg/m2). A weekly paclitaxel regimen (80 mg/m2) was started because the tumor markers increased soon after surgery. Despite chemotherapy, no response was confirmed, then weekly docetaxel (35 mg/m2) was started. Although the tumor markers decreased after administration of docetaxel, severe liver disfunction appeared and did not improve after cessation of docetaxel. Computed tomography (CT) revealed numerous metastatic nodules in the bilateral lobes of the liver. UFT (400 mg/day) and cyclophosphamide (100 mg/day) were administered for 4 weeks followed by 2 weeks cessation and then combined with continuous medroxyprogesterone acetate (800 mg/day). Liver function tests were normalized 3 months after, and the massive metastatic liver tumors disappeared completely. Lung metastasis also subsided. In spite of these good responses, tumor markers did not normalize and skin nodules appeared around the surgical site. Administration was stopped 36 weeks after initiation of the treatment.

[A case of advanced breast cancer markedly responding to chemo-endocrine therapy with only slight alopecia]

We report a case of good response to chemo-endocrine therapy with slight alopecia. A 55-year-old woman was diagnosed as advanced breast cancer with T4c, N3, M1, Stage IV, who was left cervical node-positive. She received 4 cycles of CTF (cyclophosphamide 100 mg/body/day 1-14, THP 30 mg/body/days 1,8, and 5-FU 750 mg/body/days 1, 8 4 wq) therapy in addition to oral tamoxifen (20 mg/body) administration. After this treatment, the primary tumor was markedly reduced (PR), and only slight alopecia was observed. Generally, 3 cycles of CAF (CEF) therapy induced severe alopecia (grade 3). But this CTF regimen caused grade 1 alopecia. Most women have strong resistance to alopecia. It seems that the quality of life for breast cancer patients was affected by the extent of the alopecia. Therefore, CTF therapy should be considered effective for advanced breast cancer patients while reducing the extent of alopecia.

[A case of non-curatively resected scirrhous gastric cancer successfully treated over 2 years with weekly administration of paclitaxel]

We report a patient with far-advanced gastric cancer treated by weekly administration of paclitaxel (TXL) over 2 years. The patient was a 66-year-old female with peritoneal metastasis and remarkable lymph node metastasis of scirrhous gastric cancer. She underwent a non-curative resection with total gastrectomy and splenectomy in May 2002. Postoperative chemotherapy with TS-1 (80 mg/body) was performed. Due to grade 4 neutropenia and grade 2 anorexia, this treatment could not be continued. Three months after surgery, the tumor marker (CA19-9) had elevated to an abnormal level. Alternatively, TXL was administered at a weekly dose of 70 mg/m2 for 3 weeks followed by 6 weeks rest from September 2002. The tumor marker (CA19-9) gradually decreased to the normal level. Because of the long rest interval, 10 courses of treatment could be continued, and the patient has been alive over 2 years with the cancer controlled. There have been few effective chemotherapies for gastric cancer with peritoneal metastasis. Weekly paclitaxel therapy is considered to be effective for the treatment of advanced scirrhous gastric cancer with peritoneal metastasis.

[Weekly paclitaxel administration and intraabdominal CBDCA injection possibly beneficial treatment for recurrent breast cancer associated with metastatic ovarian cancer and peritoneal dissemination after operation--a case report]

A 46-year-old woman who had received mastectomy for breast cancer 6 years earlier complained of abdominal distension. Computed tomography and ultrasonography revealed massive ascites and ovarian swelling of both sides. She was diagnosed as having primary ovarian cancer and peritoneal dissemination, and underwent a total hysterectomy as well as ovarectomy on both sides. After surgery, she received a sequential chemotherapy, ie, intraabdominal injection of carboplatin (CBDCA 300 mg/m2) and div administration of paclitaxel (PTX 180 mg/m2) as a standard regimen for advanced ovarian cancer. However, detailed histological examinations showed that the ovarian cancer had metastasized from her breast cancer. It is well-known that breast cancer easily metastasizes to the bone, liver, pleura and lymph node, but rarely to the ovarium or peritoneum when chemotherapy is conducted. Therefore, no standard therapy has been established for breast cancer metastasizing to the ovarium. Our patient received 4 cycles of weekly administration of PTX (PTX 80 mg/m2, 3 consecutive weeks, 1-week break), followed by oral administration of doxifluridine+anastrozole on an outpatient basis. No evidence of recurrence of breast cancer has been noted 1 year after surgery. This result suggests that weekly administration of PTX and intraabdominal injection of CBDCA might be beneficial in the treatment of recurrent breast cancer associated with metastatic ovarian cancer and peritoneal dissemination after operation.

[Successful combination therapy with 5'-DFUR and MPA for breast cancer with spinal and vertebral metastases]

We report a case of breast cancer with spinal and vertebral lesions. A 49-year-old premenopausal woman with a left breast tumor was admitted to our hospital for acute weakness of the lower limbs and dysuria. She could neither stand nor walk. The tumor in the left breast was 5.0 cm in diameter with skin ulcer, and it was diagnosed as breast cancer. Magnetic resonance (MR) image showed multiple vertebral and spinal metastases from breast cancer. Chemotherapy, consisting of cyclophosphamide, doxorubicin and 5-fluorouracil (CAF) was initiated. Her symptoms dramatically changed for the better. She became able to walk and urinate. We performed palliative mastectomy after 3 cycles of CAF therapy. Histopathological findings of breast tumor showed scirrhous carcinoma. Although the estrogen and progesterone receptor status of primary tumor was negative, chemo-endocrine therapy, consisting of medroxyprogesterone acetate (MPA) and doxifluridine (5'-DFUR) was given as daily therapy, and vertebral and spinal lesions were reduced. Her condition has remained stable for 4 years. For patients with metastatic breast cancer, complete remission is uncommon, and disease stabilization is a reasonable goal of successful therapy. In this respect, therapy with CAF, followed by MPA and 5'-DFUR, was successful in the patient.

[Weekly paclitaxel therapy is useful for gastric carcinoma as second-line chemotherapy]

The patient was a 58-year-old man who suffered from non-resectable gastric cancer, staged intraoperatively for peritoneal dissemination and paraaorta lymph node metastasis at another hospital in December 2002. He was initially treated with TS-1 as an outpatient. However, he was readmitted on March 4, 2003 for hematuria, general fatigue, jaundice and dyspnea. He was diagnosed with gastric cancer duodenum invasion, obstructive jaundice and lymphangitis carcinomatosa, and began weekly TXL as second-line chemotherapy on March 26. TXL (70 mg/ m2) was infused once a week for 3 weeks followed by a 1-week interval as one cycle. One week after the first infusion therapy, the jaundice and dyspnea were greatly improved. CT scan showed the lymphangitis carcinomatosa had disappeared and paraaorta lymph node metastasis was reduced to 60% after one cycle of the treatment. The toxic events were leukopenia (grade 1) and alopecia (grade 1).

[A case of scirrhous carcinoma of the stomach with malignant pleural and peritoneal carcinomatosis responding to the local administration of docetaxel (TXT)]

We report the case of a 34-year-old woman who underwent total gastrectomy for scirrhous carcinoma in the stomach (T4, N0, H0, CY1, P1, Stage IV). Despite adjuvant chemotherapy with TS-1 and/or CDDP, ascites caused by peritoneal carcinomatosis increased four months after gastrectomy. Therefore, intraperitoneal administration of docetaxel (TXT) at a dosage of 45 mg/m2 was applied. This therapy successfully maintained her good quality of life by inhibiting the increase of ascites without any severe adverse side effects for more than six months. When the left effusion from pleural carcinomatosis appeared nine months after the surgery, the intrathoracic administration of TXT succeeded in inhibiting the increase of pleural effusion over five months or more. In this case, intraperitoneal and intrapleural administrations of TXT were effective and temporarily improved the patient's quality of life without any side effects. We thought that the local administration of TXT was a useful treatment without severe toxicities for malignant pleural effusion and ascites in scirrhous carcinoma of the stomach.

Management protocol for scirrhous gastric cancer

BACKGROUND

The prognosis for patients with scirrhous gastric cancer (SGC) is extremely poor. However, the management protocol for this type of cancer has not been well discussed. In this study, we retrospectively evaluated the management of SGC and we introduced a new treatment protocol for SGC.

PATIENTS AND METHODS

Between 1991 and 2001, 58 patients with SGC were treated. Thirty-nine, who underwent gastrectomy, were divided into 3 sub-groups according to peritoneal metastasis (P) and peritoneal washing cytology (CY) status [P(-)/CY(-), P(-)/CY(+), and P(+)/CY(+)]. The survival rates of these 3 sub-groups were compared with patients who did not have a gastrectomy (n=19), retrospectively. From 2002, we started a new treatment protocol for SGC. Laparoscopic diagnosis of P or CY and intraperitoneal chemotherapy (IPC) were performed before performing laparotomy on 10 patients with SGC.

RESULTS

The 5-year survival rate of the 19 patients in P(-)/CY(-) was 11.6%. The survival rates of patients with P(-)/CY(+) or patients with P(+)/CY(+) were no different from patients who did not have gastrectomy (pleural effusion or ascites negative). In 10 patients who were treated with the new protocol, 7 with P(-)/CY(-) underwent gastrectomy after IPC and 3 with P(+)/CY(+) underwent repeated IPC.

CONCLUSION

Gastrectomy may not have prognostic benefit for patients with SGC with CY(+). Thus, we recommend laparoscopic diagnosis of peritoneal metastasis or peritoneal cytology before performing laparotomy on these patients.

[A case of effective weekly paclitaxel administration for primary lesion of schirrous gastric cancer]

We report a case of advanced schirrous gastric cancer with carcinomatous peritonitis. Chemotherapy with TS-1 was applied during the first 4 weeks, but the tumor did not respond to this therapy. Next, paclitaxel (TXL) was administered at a weekly dose of 90 mg/body/day for 3 weeks followed by a week interval of rest. Remarkable mass reduction of primary tumor was observed after 3 courses of treatment, and the symptom derived from primary tumor was relieved without significant side effects. The clinical course for schirrous gastric cancer with carcinomatous peritonitis is still miserable for patients, although many attempts have been made to improve its prognosis. A weekly paclitaxel regimen appears to be one of the promising treatment for schirrous gastric cancer.

[Two cases of non-curatively resected scirrhous gastric cancer that responded well to weekly paclitaxel therapy]

We report 2 cases in which the weekly administration of paclitaxel proved to be effective for patients with scirrhous gastric cancer who underwent a curability C operation. Weekly paclitaxel therapy was observed to effectively treat peritoneal and retroperitoneal dissemination. After this treatment the tumor markers decreased markedly. This weekly paclitaxel therapy was observed to cause no adverse effects, and thanks to the treatment the patients were able to consume normal meals. These patients could also be sufficiently treated as outpatients. Weekly paclitaxel therapy is thus considered to be effective for the treatment of advanced scirrhous gastric cancer with peritoneal and retroperitoneal dissemination.

Scirrhous colonic metastasis from ductal carcinoma of the breast: report of a case

Metastasis of breast cancer to the colon is rare. We report a case of a 49-year-old female who presented with a stenotic tumor of the descending colon five years after treatment of breast cancer with mastectomy and pedicled transverse rectus abdominis musculocutaneous flap. Laparotomy showed a diffusely infiltrated tumor over the descending colon. Anterior resection with loop ileostomy was performed, and the pathology showed that the colonic wall and the mesentery were diffusely infiltrated with poorly differentiated adenocarcinoma, which stained strongly for cytokeratin 7. The histologic diagnosis is consistent with colonic metastasis from ductal carcinoma of breast origin. In a patient with a history of breast cancer, colonic metastasis from the breast primary cancer should be considered, especially if the colonic lesion is scirrhous in nature. The incision for laparotomy and the probable stoma site should be planned carefully in females after breast reconstructive surgery.

[A case of stomach cancer in which TS-1 neoadjuvant therapy was effective against multiple hepatic metastasis, allowing a radical cure A surgery]

It is believed that multiple hepatic metastases from stomach cancer are highly refractory, and resistant to clinical treatment. In the present study, TS-1 neoadjuvant therapy administered orally in a single course brought about CR in the hepatic metastatic foci and PR in the primary foci, thus enabling grade A radical extirpation in a case of advanced stomach cancer. The patient continued to be treated on an ambulatory basis. His peri- and post-operative courses were satisfactory and the treatment was completed without the development of adverse effects.

[Complete response in a case of advanced scirrhous type 3 gastric cancer of with bulky N2 para-aorta lymph node metastases treated by combined chemotherapy of TS-1 and CDDP]

A 54-year-old patient with scirrhous type 3 gastric cancer having bulky N2 and para-aorta lymph node metastases was treated by combined chemotherapy of TS-1 and CDDP. Before treatment, CEA was 28.4 mg/ml. TS-1 (120 mg/day) administered for 14 days followed by 14 days rest was one course. CDDP (80 mg/m2) was administered by 24 hour continuous intravenous infusion at day 8 after the start of TS-1. After 2 courses of treatment, the level of CEA decreased to 1.4 mg/ml and the primary legion with lymph node metastases had decreased significantly. After 5 courses, endoscopic examination revealed complete disappearance of the primary tumor with no cancer cells detected by endoscopic biopsy. A CT scan also showed complete disappearance of all lymph node metastases. No severe adverse effects (NCI-CTC grade 3 of 4) were observed with this therapy. TS-1/CDDP chemotherapy is considered very effective for scirrhous gastric cancer with far advanced lymph node metastases.

[A case in which TS-1, an orally-administered 5-FU chemotherapeutic agent, showed marked effectiveness against scirrhous type gastric cancer with multiple organ metastases]

A 67-year-old woman with anorexia and weight loss was referred to our hospital with a diagnosis of type 4 gastric cancer. Since metastases to the liver, left adrenal gland, and Douglas' pouch were detected in addition to ascites and bilateral hydronephrosis, the tumor was judged unresectable and systemic chemotherapy with TS-1 was begun. Symptoms began to improve after the first course, and the patient was discharged and followed as an outpatient. An upper GI series showed improvement of the primary lesion, and cancer cells became undetectable under biopsy. At the end of the third course, computed tomography confirmed that metastases to the liver, the lymph nodes, and the adrenal gland had disappeared. The ascites diminished significantly, and hydronephrosis began to ameliorate. The effectiveness of the drug continued until the end of the eleventh course, and the patient is currently in her seventeenth month as an outpatient. This case shows the effectiveness of TS-1 against scirrhous type gastric cancer, a cancer generally considered resistant to chemotherapy. Furthermore, treatment on an outpatient basis has greatly improved her quality of life.

[A case of gastric cancer with paraaortic lymph node metastasis responding to preoperative chemotherapy and surviving 4 years and 4 months after total gastrectomy]

A 68-year-old woman was admitted to our hospital because of type 4 gastric cancer associated with paraaortic lymph node metastasis. Considered surgically incurable, she was placed on preoperative chemotherapy consisting of Methotrexate (MTX) 50 mg (day 1), CDDP 10 mg (day 2-6), 5-FU 500 mg (day 1-6) and Leucovorin (LV) 60 mg (day 2-6). Because of severe nausea and leucopenia, she could receive only 1 course of the chemotherapy. CT on January 7, 1997 (5 weeks after the chemotherapy) showed that the gastric wall thickness and the paraaortic lymph nodes swelling had decreased remarkably. She underwent total gastrectomy on January 13, 1997 (pT2, pN2, pM1 (LYM), stage IV, TNM classification). As an outpatient, she was treated with UFT-E 300 mg/day (continuous until the present) and MTX 50 mg (day 1), 5-FU 500 mg (day 1) and LV 60 mg (day 2-3) once two weeks (total 27 cycles). Four years and 4 months after surgery, although peritoneal recurrence was suspected, she has been managed at our outpatient clinic.

[A case of long surviving advanced recurrent breast cancer with multiple bone metastases responding to treatment with 5'-DFUR combined with MPA]

The patient was a 69-year-old woman who had undergone right standard radical mastectomy on August 8, 1991, and was treated with chemo- and hormonal therapy of ADM, UFT and TMA. Three years later she showed multiple bone metastases with elevation of CEA, and 5'-DFUR 1,200 mg/day and MPA 800 mg/day were administered. Two years later her CEA levels were decreased, 5'-DFUR was discontinued and MPA 1,200 mg/day only was continued. Two months later a side effect of MPA, her body weight gain, was observed, and the dosage of MPA was reduced from 1,200 mg/day to 800 mg/day. Then the side effect was resolved. Bone scintigraphy and MRI showed that bone metastatic lesions were reduced 6 years after 5'-DFUR and MPA therapy. It is suggested that this combination therapy may be useful for advanced recurrent breast cancer patients with multiple bone metastases.

[A case of hepatic metastasis of gastric cancer responding to TS-1, administered for two consecutive weeks and one week rest]

We have treated a case of hepatic metastasis of gastric cancer that has responded well to TS-1. The patient was a 68-year-old male, who underwent distal gastrectomy for gastric cancer. After surgery 5'-deoxy-5-fluorouridine (5'-DFUR) 800 mg/day was administered orally for two months. Grade 4 diarrhea appeared, so administration of 5'-DFUR was discontinued. Afterward the patient was followed with no chemotherapy. Liver metastasis (S6, 3 cm in diameter) was found at twelve months after surgery. 5'-DFUR (800 mg/day) was administered orally everyday. Grade 3 diarrhea appeared and metastasis showed NC after four weeks. 5'-DFUR administration was discontinued. Seventeen days later TS-1 (80 mg/day) was administered orally everyday for 2 weeks, followed by 1 week rest, as one course. Two courses of TS-1 administration resulted in a marked reduction of the liver metastasis, for a PR (75% reduction). After 3 courses, the liver metastasis showed CR. The patient is alive without recurrence after 12 courses. This TS-1 administration regimen was effective and tolerable for a patient with liver metastasis from gastric cancer.

Intestinal perforation due to metastasis of breast carcinoma, with special reference to chemotherapy: a case report

We report a case of small-bowel perforation due to metastatic carcinoma of the breast during chemotherapy. Partial resection of the small intestine and primary anastomosis were performed. Although the patient made a good recovery from panperitonitis, she died of the disease on the 55th postoperative day. Since perforation during chemotherapy results in an extremely poor prognosis, special caution during chemotherapy is needed for patients with possible gastrointestinal involvement with tumor.

Differential gene expression profiles of scirrhous gastric cancer cells with high metastatic potential to peritoneum or lymph nodes

Scirrhous gastric cancer is often accompanied by metastasis to the peritoneum and/or lymph nodes, resulting in the highest mortality rate among gastric cancers. Mechanisms involved in gastric cancer metastasis are not fully clarified because metastasis involves multiple steps and requires the accumulation of altered expression of many different genes. Thus, independent analysis of any single gene would be insufficient to understand all of the aspects of gastric cancer metastasis. In this study, we performed global analysis on differential gene expression of a scirrhous gastric cancer cell line (OCUM-2M) and its derivative sublines with high potential for metastasis to the peritoneal cavity (OCUM-2MD3) and lymph nodes (OCUM-2MLN) in a nude mice model. By applying a high-density oligonucleotide array method, expression of approximately 6800 genes was analyzed, and selected genes were confirmed by the Northern blot method. In our observations in OCUM-2MD3 cells, 12 genes were up-regulated, and 20 genes were down-regulated. In OCUM-2MLN cells, five genes were up-regulated, and five genes were down-regulated. The analysis revealed two functional gene clusters with altered expression: (a) down-regulation of a cluster of squamous cell differentiation marker genes such as small proline-rich proteins [SPRRs (SPRR1A, SPRR1B, and SPRR2A], annexin A1, epithelial membrane protein 1, cellular retinoic acid-binding protein 2, and mesothelin in OCUM-2MD3 cells; and (b) up-regulation of a cluster of antigen-presenting genes such as MHC class II (DP, DR, and DM) and invariant chain (II) in OCUM-2MLN cells through up-regulation of CIITA (MHC class II transactivator). We then analyzed six gastric cancer cell lines by Northern blot and observed preferential up-regulation of trefoil factor 1, alpha-1-antitrypsin, and galectin 4 and down-regulation of cytidine deaminase in cells prone to peritoneal dissemination. Genes highly correlated with invasion or peritoneal dissemination of gastric cancer, such as E-cadherin or integrin beta4, were down-regulated in both of the derivative cell lines analyzed in this study. This is the first demonstration of global gene expression analysis of gastric cancer cells with different metastatic potentials, and these results provide a new insight in the study of human gastric cancer metastasis.

Borrmann's type IV gastric cancer: clinicopathologic analysis

OBJECTIVE

To determine whether there is a specific pattern of clinicopathological features that could distinguish Borrmann's type IV gastric cancer from other types of gastric cancer.

DESIGN

A retrospective study of patients with advanced gastric cancer treated between 1985 and 1995.

SETTING

The Department of Surgery, Sendai National Hospital, a 716-bed teaching hospital.

PATIENTS

The clinicopathologic features of 88 patients with Borrmann's type IV carcinoma of the stomach were reviewed from the database of gastric cancer. The results were compared with those of 309 patients with other types of gastric carcinoma.

MAIN OUTCOME MEASURES

Gender, age, tumour size, depth of invasion, histologic type, cancer-stromal relationship, histologic growth pattern, nodal involvement, lymphatic and vascular invasion, type of operation, cause of death and 5-year survival.

RESULTS

Women were afflicted as commonly as men in the Borrmann's type IV group. These patients tended to be younger and to have larger tumours involving the entire stomach than patients with other types of cancer. Histologic type was commonly diffuse and scirrhous, and serosal invasion was prominent with infiltrative growth. Nodal involvement and lymphatic invasion were more common in patients with Borrmann's type IV than in those with other types of gastric cancer. The disease was advanced in most instances and a total gastrectomy was performed in 55% of the patients. The survival rate of patients with Borrmann's type IV tumour was lower than for patients with other types of gastric cancer (p < 0.005, log-rank test).

CONCLUSIONS

In Borrmann's type IV gastric cancer, early detection and curative resection are crucial to extend the patient's survival. Aggressive postoperative chemotherapy is recommended when a noncurative resection is performed.

[A case of multiple liver metastases from breast cancer successfully treated with intra-arterial administration of docetaxel]

Docetaxel is an excellent agent with a high antitumor effect for the treatment of advanced/recurrent breast cancer. A 55-year-old female with metastatic liver tumors from breast cancer showed a remarkable response to intra-arterial administration of docetaxel (20 mg/week, or 40 mg/2 weeks). Since CT and MRI imaging revealed multiple metastases in the liver, intra-arterial chemotherapy was selected. No critical side effect was found during this chemotherapy. A CT scan 3 months after chemotherapy showed a partial response. We conclude that this intra-arterial chemotherapy using docetaxel will be safe and useful for liver metastases from breast cancer.

[A case of stage IV breast cancer showing long-term complete response to combination therapy with 5'-DFUR and MPA]

We report a 62-year-old woman with supraclavicular lymph node, pleural and bone metastases from breast cancer showing a long-term complete response to combination therapy with 5'-DFUR and MPA. A large amount of pleural effusion was drained followed by administration of ADM, which improved the amount of effusion. Treatment with CAF and TAM decreased tumor size, but CAF was abandoned due to severe leukopenia. Mastectomy was performed for local control. However, levels of tumor markers increased progressively. Administration of CMF was tried, but tumor markers continued to increase. Therefore, combined chemoendocrine therapy with 5'-DFUR and MPA was undertaken. Levels of tumor markers normalized and a complete response was obtained 13 months after starting this combination therapy. There are no further metastatic lesions evident, and this status has been consistently maintained for more than three years (six years and five months after diagnosis of breast cancer). There were no significant side effects of this combination therapy except for mild weight gain and moon face. This combination regimen with 5'-DFUR and MPA is considered useful as a second-line treatment for advanced breast cancer.

Adhesion polypeptides are useful for the prevention of peritoneal dissemination of gastric cancer

We examined the effect of adhesion polypeptides on the adhesion and invasiveness of gastric cancer cell lines. We previously reported the establishment of an extensively peritoneal-seeding cell line, OCUM-2MD3, from a poorly seeding human scirrhous gastric carcinoma cell line, OCUM-2M. Both alpha2beta1 and alpha3beta1 integrin expression was markedly increased on OCUM-2MD3 cells compared with OCUM-2M cells, and the ability of OCUM-2MD3 cells to bind to the extracellular matrix (ECM) was also significantly higher than that of OCUM-2M cells. The adhesion polypeptides, YIGSR and RGD, and two RGD derivatives significantly inhibited the adhesion of OCUM-2MD3 cells to the submesothelial ECM, while not inhibiting the adhesiveness of OCUM-2M cells and two well differentiated human gastric cell lines, MKN-28 and MKN-74. The YIGSR and RGD peptides also significantly inhibited the invasiveness of OCUM-2MD3 cells. The survival of nude mice with peritoneal dissemination given YIGSR sequence intraperitoneally was obviously longer than that of untreated mice. The survival of mice treated with RGD was also improved, and this effect was increased using the RGD derivatives, poly(CEMA-RGDS) and CM-chitin RGDS. These polypeptides appear to block the binding of integrins, which are expressed on OCUM-2MD3 cells, to the submesothelial ECM, and consequently inhibit peritoneal implantation. The peritoneal injection of adhesion polypeptides may be a new therapy against the dissemination of scirrhous gastric cancer, and may be useful for the prevention of dissemination in high-risk patients.

[Enophthalmos caused by orbital metastasis of breast carcinoma]

BACKGROUND

Orbital metastatic disease usually leads to exophthalmos but rarely to enophthalmos. We report a case of a metastasis causing enophthalmos.

PATIENT

A 68-year-old woman had mastectomy for breast cancer six years prior to presentation. She complained of double vision when looking sideways. The right eye showed a motility reduction in all directions and a slight ptosis. She had 4 mm enophthalmos, and the eyelids were sunk into the orbit. There were no signs of optic nerve damage. Magnetic resonance imaging showed a retrobulbar mass surrounding the optic nerve and infiltrating the muscles. The space of the orbital fat was reduced. A biopsy confirmed the diagnosis of metastatic breast carcinoma. Histologically, the connective tissue was infiltrated by lymphocytes, and the nuclei of the tumor cells where aligned in a linear "indian file" pattern. 30% of the tumor cells contained the estrogen-receptor protein, 40% the progesterone-receptor protein. The CA-15/3 and CEA levels were elevated. The patient underwent orbital radiation with 50 Gy. During the following 2 months, the enophthalmos increased to 6 mm.

DISCUSSION

We suggest the following hypothesis as the cause of enophthalmos in orbital metastases: The tumor growth goes along with fibrosis. Subsequent shrinkage of the connective tissue pulls the eye back into the orbit. The ensuing elevation of tissue pressure leads to atrophy of the retrobulbar fat. The increase of tumor volume is too slow to compensate for the fat atrophy. Slowly progressive enophthalmos with reduced motility is nearly pathognomonic of metastatic scirrhous breast carcinoma. In rare cases, a diffusely infiltrating carcinoma of the gastrointestinal tract may cause a similar picture.

Surgically curable and incurable scirrhous carcinomas of the stomach

BACKGROUND AND OBJECTIVES

The purpose of this study was to identify a subgroup of patients with scirrhous carcinoma of the stomach who are more suitable for surgery by analysis of their clinicopathologic characteristics.

METHODS

Seventy-three patients with scirrhous gastric carcinoma who underwent gastrectomy between 1979 and 1994 were included in the study. Clinicopathological characteristics of 5-year survivors and nonsurvivors were compared. A multivariate analysis of various prognostic factors was performed.

RESULTS

The 5-year survival rate was 31.4%; 78% (28/36) of nonsurvivors died of malignant ascites and only 8% (3/36) died of hepatic or lung metastasis. When clinicopathologic parameters of 5-year survivors and nonsurvivors were compared, age, tumor size, macroscopic appearance, pT, pN, pM, stage, peritoneal lavage cytology, residual tumor, extent of gastric resection, operation time, volume of blood loss, and transfusion were significantly different. By the multivariate analysis, residual tumor, pathological depth of tumor infiltration, blood transfusion, and histological type were the independent prognostic factors.

CONCLUSIONS

The prognosis of scirrhous carcinoma of the stomach is mainly determined by the depth of penetration and curability. In order to obtain better survival, early detection of tumor while it is limited to T2 stage appeared most important. Aggressive surgery would be indicated for T3 tumors, but in the case of T4 tumors, extent of operation should be determined by other factors such as extent of nodal metastasis or presence of distant metastasis.

Transforming growth factor-beta and hepatocyte growth factor produced by gastric fibroblasts stimulate the invasiveness of scirrhous gastric cancer cells

Scirrhous gastric carcinoma is characterized by cancer cells that infiltrate rapidly in the stroma with extensive growth of fibroblasts. In the present study, we examined the effect of gastric fibroblasts on the invasiveness of a scirrhous gastric cancer cell line, OCUM-2D, using an invasion assay. Gastric fibroblast-derived conditioned medium (CM) significantly stimulated the invasiveness of OCUM-2D cells, as did transforming growth factor-beta (TGF-beta) and hepatocyte growth factor (HGF). The stimulating activity of gastric fibroblast-derived CM was inhibited significantly by anti-TGF-beta neutralizing antibody or anti-HGF neutralizing antibody. TGF-beta and HGF were detected in the gastric fibroblast-derived CM, and TGF-beta receptor and C-met (HGF receptor) were expressed on OCUM-2D cells. Thus, TGF-beta and HGF produced by gastric fibroblasts appear to affect the invasiveness of scirrhous gastric cancer cells. TGF-beta was also detected in the conditioned medium derived from OCUM-2D cells, though HGF was not. TGF-beta appears to affect the invasiveness of OCUM-2D cells in both paracrine and autocrine fashions.

Role of alpha 2 beta 1- and alpha 3 beta 1-integrin in the peritoneal implantation of scirrhous gastric carcinoma

We established a highly peritoneal-seeding cell line, OCUM-2MD3, from a poorly peritoneal-seeding cell line, OCUM-2M, of human scirrhous gastric carcinoma. The intraperitoneal inoculation of OCUM-2MD3 cells produced peritoneal dissemination in nude mice, whereas that of OCUM-2M cells did not. We then investigated the correlation between seeding potential and adhesion molecule beta 1-integrins or alpha 6 beta 4-integrin. alpha 2 beta 1- and alpha 3 beta 1-integrin expression on OCUM-2MD3 cells (91.6% and 93.6%) was increased compared with that of OCUM-2M cells (47.8% and 34.3%) by flow cytometric analysis, and the expression level of the other integrins was not different between the two cell lines. The binding ability of OCUM-2MD3 cells to matrigel, fibronectin, laminin and type I collagen was significantly increased, approximately seven times, three times, eight times, and three times greater than that of OCUM-2M cells respectively. The invasiveness of OCUM-2MD3 cells was also significantly increased 8-fold over OCUM-2M cells. The binding and invasive ability of OCUM-2MD3 cells was significantly decreased following the addition of anti-alpha 2 beta 1- and alpha 3 beta 1-integrin antibody, but not by anti-alpha 6 beta 1- and alpha 6 beta 4-integrin antibody. These results suggest that adhesiveness and invasiveness in peritoneal implantation of scirrhous gastric carcinoma might be closely associated with alpha 2 beta 1- and alpha 3 beta 1-integrin.