A foreign body granuloma after gastric perforation mimicking peritoneal dissemination of gastric cancer: report of a case.

This report presents the case of a 58-year-old man who was found to have foreign body granulomas (FBGs) that mimicked disseminated gastric cancer. The patient presented with a severe attack of acute upper abdominal pain, was admitted to the hospital, and thereafter underwent an immediate laparotomy due to a diagnosis of an upper gastrointestinal perforation. Follow-up endoscopy revealed an ulcer scar measuring 2 cm in size in the anterior wall of the middle stomach. The pathological examination of biopsy specimens taken around the scar revealed well to poorly differentiated adenocarcinoma. At the time of reoperation performed 2 months after the first operation, many small white granulomas were observed which were thought to be the result of peritoneal dissemination of the gastric cancer. However, both the cytology of the Douglas washing and pathological examination of frozen section specimens were negative for carcinoma, and therefore a distal gastrectomy was performed. The pathological examination revealed the presence of FBGs. In this rare case, the FBGs formed shortly after surgery and were difficult to distinguish from disseminated cancer.

[Super-elderly colon cancer with peritoneal dissemination effectively treated with modified FOLFOX6 chemotherapy--report of a case].

We reported a case of super-elderly colon cancer with peritoneal dissemination effectively treated with modified FOLFOX6 chemotherapy. A 80-year-old woman was referred to our hospital for abdominal distension in January 2007. Abdominal CT showed peritoneal dissemination and colonoscopy revealed transverse colon cancer. The patient's performance status (PS) score was 3. She had pleural effusion on the left side and massive acsites. After the general condition was improved, operation was performed for sub-ileus in March, but it became a probe laparotomy for severe peritoneal dissemination. We tried modified FOLFOX6 chemotherapy from April. The patient's pleural effusion decreased after 3 courses of chemotherapy and we could remove the thoracic tube. Massive acsites observed in abdominal CT disappeared after 5 courses of chemotherapy. The patient did not suffer from sub-ileus after around 8 courses of chemotherapy and she could then take food. The patient's PS score became 1, and she was discharged in September. Two more courses of chemotherapy were given on as an outpatient basis. The chemotherapy was changed to S-1 on the patient's request in November. As of February 2008, the patient's PS score was 0, and she has been under treatment as an outpatient.

[Complete response to CPT-11 and UFT/LV combination therapy in a case with simultaneous multiple lung metastases from colon cancer].

We report the complete response for one year of a patient with simultaneous multiple lung metastases from colon cancer who was treated using a combination of irinotecan (CPT-11) and uracil/tegafur (UFT)/Leucovorin (LV) using a schedule reported overseas. A 61-year-old woman was admitted to our hospital and diagnosed with ascending colon cancer and simultaneous multiple lung metastases. The patient underwent a right hemicolectomy and was treated with CPT-11 (150 mg/m(2)) on day 1 and oral UFT and oral LV on days 1-14. This treatment cycle was repeated every 3 weeks. A CT examination after 4 cycles of chemotherapy revealed a partial response of multiple lung metastases, and the next examination after 6 cycles revealed a complete response. The adverse effects observed during this chemotherapy regimen were leucopenia (grade 1), neutropenia (grade 2), vomiting (grade 2) and hair loss (grade 1). The patient is now receiving her 22nd cycle of chemotherapy, and her multiple metastases have shown a complete response for one year. The CPT-11 and UFT/LV combination therapy was well tolerated and was covered by the national health insurance system in Japan. This treatment may enable prolonged survival and improve quality of life in patients with metastatic colorectal cancer.

Surgery plus chemotherapy compared with surgery alone for localized squamous cell carcinoma of the thoracic esophagus: a Japan Clinical Oncology Group Study--JCOG9204.

PURPOSE: We performed a multicenter randomized controlled trial to determine whether postoperative adjuvant chemotherapy improves outcome in patients with esophageal squamous cell carcinoma undergoing radical surgery. PATIENTS AND METHODS: Patients undergoing transthoracic esophagectomy with lymphadenectomy between July 1992 and January 1997 at 17 institutions were randomly assigned to receive surgery alone or surgery plus chemotherapy including two courses of cisplatin (80 mg/m2 of body-surface area x 1 day) and fluorouracil (800 mg/m2 x 5 days) within 2 months after surgery. Adaptive stratification factors were institution and lymph node status (pN0 versus pN1). The primary end point was disease-free survival. RESULTS: Of the 242 patients, 122 were assigned to surgery alone, and 120 to surgery plus chemotherapy. In the surgery plus chemotherapy group, 91 patients (75%) received both full courses of chemotherapy; grade 3 or 4 hematologic or nonhematologic toxicities were limited. The 5-year disease-free survival rate was 45% with surgery alone, and 55% with surgery plus chemotherapy (one-sided log-rank, P =.037). The 5-year overall survival rate was 52% and 61%, respectively (P =.13). Risk reduction by postoperative chemotherapy was remarkable in the subgroup with lymph node metastasis. CONCLUSION: Postoperative adjuvant chemotherapy with cisplatin and fluorouracil is better able to prevent relapse in patients with esophageal cancer than surgery alone.

Possible indication for surgical treatment of squamous cell carcinomas of the esophagus that involve the stomach.

BACKGROUND: The caudal spread of esophageal squamous cell carcinoma (ESCC) frequently involves the stomach. An extended surgical treatment may provide a tumor-free margin; however, its clinical benefit has not been elucidated. METHODS: Sixty-three of 582 patients with ESCC (11%) had massive gastric involvement and underwent esophagectomy with combined resection of the stomach and other organs. The mode of gastric involvement was classified as direct invasion from primary tumor (PT invasion) or invasion from metastatic lymph nodes (LN invasion). RESULTS: In addition to the removal of either the proximal (83%) or the whole (17%) stomach, 46 patients (73%) underwent the combined resection of adjacent organs, including the diaphragm, pancreas, liver, lung, and pericardium. This surgical treatment resulted in a high rate (83%) of curative resection and a low rate (8%) of operative mortality. Postoperative survival rates were 53%, 33%, and 25% at 1, 2, and 5 years, respectively. The first tumor recurrence was frequently in the abdominal paraaortic lymph nodes (41%) and the liver (28%), followed by the mediastinal lymph nodes, local recurrence, the lung, and other organs. The mode of gastric involvement strongly affected clinical outcome, with a 5-year survival rate of 36% for those with PT invasion but of only 7% with LN invasion (P <.0086). No significant difference was seen in the number and location of metastatic lymph nodes between the 2 groups; however, the size of the largest metastatic lymph node was significantly smaller with PT invasion than with LN invasion (12 mm vs 37 mm in diameter; P <.0001). CONCLUSION: Surgical treatment of ESCC involving the stomach was considered safe and successful. A favorable prognosis can be expected for gastric invasion from the primary tumor but not from metastatic lymph nodes.

The risk of second malignancy after adjuvant chemotherapy for stomach cancer.

BACKGROUND: Although many trials have been conducted to evaluate the feasibility and effectiveness of adjuvant chemotherapy (ACT) for patients with stomach cancer, the benefits of ACT remain unclear. Moreover, some authors have reported that ACT increased the incidence of second malignancy. The risk of second malignancy was evaluated in patients who underwent treatment for stomach cancer in the past 20 years at Osaka Medical Center for Cancer and Cardiovascular Diseases.METHODS: The study population consisted of 1925 patients who underwent gastrectomies for stomach cancer between the years 1978 and 1992 and who received follow-up examinations to check for second malignancies. They included 1114 patients who underwent surgery only (group A) and 811 who underwent surgery and received chemotherapy (group B). The observed incidence of second malignancy (O) was compared with the expected incidence (E), calculated by the person-year method, using data from the Cancer Registry in Osaka.RESULTS: The average follow-up period was 7.99 years. The total number of patients with a second malignancy was 127 (men, 97; women, 30); 72 patients had the second malignancy in digestive organs; 27 in respiratory organs; and 28 in other organs. The relative risks of a second malignancy in group A and B patients were 1.05 and 1.02 (differences between the two groups were not significant). The relative risks of a second malignancy in patients who received ACT with 5-fluorouracil, Tegafur and Uracil, and FT207 were 0.79, 1.01, and 1.06, respectively (differences between the groups were not significant).CONCLUSION: The risk of second malignancy after chemotherapy for stomach cancer was not high in comparison with the expected incidence. Adjuvant chemotherapy did not increase the risk of a second malignancy.

[Evaluation of cardiac load by measuring brain natriuretic peptide after thoracic esophagectomy and gastric tube in place].

A small dose of dopamine has been routinely infused for hemodynamic stabilization and diuresis in patients undergoing esophagectomy and gastric tube in place until the seventh postoperative day in our hospital. The timing of discontinuing infusion of dopamine was determined by our experience. However, there was no rationale to determine the timing of discontinuing it. Therefore, eight patients with ASA physical status I or II, undergoing esophagectomy and gastric tube in place were studied to evaluate postoperative cardiac load using brain natriuretic peptide, which is a biochemical detector of left ventricular dysfunction. There were no hemodynamic and cardiac events including myocardial ischemia and infarction in any patients. The postoperative course was uneventful in all patients. Serum BNP increased gradually and significantly until the third postoperative day with increasing urine volume. Serum BNP returned to the baseline level on the fourth postoperative day. However, serum BNP was still high in 3 patients on the sixth postoperative day in spite of dopamine. We conclude that cardiac overload was recognized until the third postoperative day.

Amebic liver abscess rupturing into the lesser omentum space.

A case of an amebic abscess localized in the lesser omentum is reported. There was no sign of a liver abscess in the imaging examination or the operative findings. However, it is likely that the amebic infection occurred after a liver abscess ruptured into the abdominal cavity. Early diagnosis and therapy are required when an abscess of unknown origin borders the liver, given the possibility of amebic abscess.

Clinical outcome of esophageal cancer patients with history of gastrectomy.

BACKGROUND: Surgery for thoracic esophageal cancer after gastrectomy involves a complicated reconstruction procedure. A surgeon's hesitation is further increased because the clinical outcome of surgical treatment of these patients has not been elucidated. OBJECTIVES: Among 948 thoracic esophageal cancer patients who underwent curative operation, 72 (7.6%) had a history of gastrectomy. Their clinico-pathological features and survival (follow-up average 881 days) were compared with those without gastrectomy. RESULTS: Esophagectomy for patients after gastrectomy was performed via right thoracotomy (66), left thoracotomy (4), and transhiatal resection (2), and reconstruction was done using the right-side colon (57) or jejunum (15). Compared to non-gastrectomized patients, gastrectomized patients were exposed to longer operation time (523 min vs. 460 min), but no significant difference was observed in operative mortality (4.2% vs. 2.5%) or blood loss (1,189 ml vs. 990 ml). Pathological examination showed no significant difference in depth of tumor invasion, lymph node metastasis, and TNM staging between gastrectomized and non-gastrectomized patients, while tumors were located at lower position in the gastrectomized patients (P = 0.046). The overall and cause-specific 5-year survival rates were 56% and 65% for gastrectomized esophageal cancer patients, which were significantly better than for non-gastrectomized patients (36% and 44%, P = 0.0235 and 0.024, respectively). Multivariate analysis showed gastrectomy as a marginally independent factor for a favorable prognosis (hazard ratio 1.832, P = 0.0324). With respect to tumor recurrence, hematogenic metastasis tended to be less frequent in gastrectomized patients than in non-gastrectomized patients. In gastrectomized patients, neither disease (peptic ulcer or gastric cancer) nor reconstruction (Billroth-I, Billroth-II, and Roux-Y) for gastrectomy affected the clinicopathological findings or post-operable survival. CONCLUSIONS: Surgical treatment of esophageal cancer patients after gastrectomy was complicated but tolerable, and should be considered as a reliable therapeutic modality because of favorable patient prognosis.

Association of the primary tumor location with the site of tumor recurrence after curative resection of thoracic esophageal carcinoma.

The site of surgical failure in cases of thoracic esophageal cancer (TEC) may be affected by the vertical location of the cancer in this longitudinal organ, suggesting the need to select the mode of adjuvant therapy based on location. We classified 501 TECs (92% squamous cell carcinomas) that underwent curative surgery without preoperative treatment as 13% upper thoracic (Ut), 51% middle thoracic (Mt), and 36% lower thoracic (Lt) lesions. Recurrent disease was discovered in 180 (36%) of the patients during a postoperative survey, most frequently in the cervical nodes (19%), liver (18%), abdominal paraaortic nodes (17%), and upper mediastinal nodes (17%). Although postoperative survival rates were similar (5-year survival: Ut 51%, Mt 55%, Lt 54%), the tumor recurrence site was significantly affected by the TEC vertical location, with recurrence in the cervical and upper mediastinal nodes being most frequent for Ut and Mt cases and in the liver and abdominal paraaortic nodes for Lt cases. Insufficient surgical lymph node clearance could be assessed by the recurrence index (RI), defined as the frequency of metastasis at recurrence divided by that at surgery. The RI was significantly lower for the upper abdominal nodes (4%, 8/184) than the lower mediastinal nodes (15%, 19/123) or the upper mediastinal nodes (19%, 30/154). These findings indicated that regional tumor recurrence, corresponding to the surgical field, was more frequent in the Ut and Mt cases (53% and 51%) than the Lt cases (18%); and distant recurrence was more frequent in the Lt cases (62%) than in Ut or Mt cases (25% and 36%). Thus the vertical location of the thoracic esophageal cancer can be said to affected strongly the site of tumor recurrence after curative surgery. Regional radiotherapy might be expected to have an adjuvant effect on Ut/Mt tumors and systemic chemotherapy on Lt tumors.

Prognostic significance of the size of cancer nests in metastatic lymph nodes in human esophageal cancers.

BACKGROUND: Postoperative survival of patients with esophageal cancers after curative surgery is strongly affected by the presence of lymph node metastasis. The number and location of lymph node metastases have been evaluated and graded, but the clinical significance of their size has not been well investigated. METHODS: Of 322 esophageal cancer patients who underwent curative operations with radical lymph node dissection, 170 (53%) had lymph node metastasis. A total of 784 metastatic lymph nodes were obtained, and the area of the cancer nests was measured microscopically in the cross section. The data from each patient included the area of the largest cancer nest in the positive nodes (Nmax), classified as Na (<4 mm2), Nb (4-25 mm2), Nc (25-100 mm2), or Nd (>100 mm2). RESULTS: The 170 patients were classified according to the Nmax value: Na, 31 (18.2%); Nb, 35 (20.5%); Nc, 49 (28.8%); and Nd, 55 (32.4%). The 5-year survival rate was 77.7% in patients without lymph node metastasis and 35.4% in those with lymph node metastasis. When classified by Nmax, the 5-year survival rate was 77.8% for Na, 63.9% for Nb, 18.8% for Nc, and 12.8% for Nd. There was no significant difference in the survival rate between Na patients and those without lymph node metastasis. Nmax showed significant correlation with the primary tumor size, depth of tumor invasion, and number and location of metastatic lymph nodes, but not with histologic type or primary tumor location. In multivariate analysis, the Nmax value, the number of lymph node metastases and depth of tumor invasion were independent prognostic factors, while the location of the lymph node metastases was not statistically significant. CONCLUSIONS: The area of the largest cancer nest in the lymph nodes was one of the most significant prognostic factors for esophageal cancers. This estimation is objective and reproducible and may be of great importance when deciding the therapeutic modality for patients with esophageal cancers.