[A Case of Medullary Carcinoma of Transverse Colon Which Resected by Laparoscopic Colectomy].

A 59-year-old woman's father and paternal grandmother died of colorectal cancer and her paternal uncle died of pancreatic cancer. She was positive for fecal occult blood and underwent colonoscopy. The colonoscopy revealed a type 0-Ⅱa+ Ⅱc lesion in the transverse colon suspected to be submucosal deep invasion, and the biopsy revealed poorly differentiated adenocarcinoma. Contrast-enhanced CT showed no regional lymphatic metastasis or distant metastasis. She was diagnosed with transverse colon cancer, T1N0M0, cStage Ⅰ, and laparoscopic partial colectomy and D2 lymphadenectomy were performed. Histopathological examinations showed medullary carcinoma, pT2(MP), Ly1a, V0, BD1, Pn1a, pPM0, pDM0, pN0. She had 2 of the items in the revised Bethesda Guideline, and was suspected of having Lynch syndrome(LS). There is no definitive diagnosis of LS because she did not want MSI or other genetic testing. However, the surveillance should be required not only for recurrence of colon cancer but also for occurrence of LS-related tumors.

[Early Gastric Cancer with Many Enlarged Lymph Nodes as Sarcoid Reaction - A Case Report].

The patient was a 57-year-old man. Upper gastrointestinal endoscopy revealed a 0- II c lesion at the anterior wall of the greater curvature in the lower third of the stomach, and the biopsy of this tumor gave the diagnosis of tubular adenocarcinoma. Abdominal contrast-enhanced computed tomography revealed many enlarged regional and non-regional lymph nodes. Because there was no definite evidence of lymph node metastasis, distal gastrectomy with D2 was performed. Histopathological examinations found the sarcoid reaction(SR)in lymph nodes, but could not demonstrate any cancer cells. SR is the epithelioid cell granuloma in lymph nodes found in patients without systemic sarcoidosis but with cancer. Early gastric cancer with SR is rare, with only 22 reported cases in Japan. SR is considered as one of the differential diagnoses when we find many enlarged lymph nodes in patients with early gastric cancer.

[Surgical management of eight cases of bronchiectasis].

Few reports are currently available on the surgical management of bronchiectasis. We report our experience with 8 cases of bronchiectasis. The indications of pulmonary resection were recurrent pneumonia and/or hemoptysis in spite of medical treatment and the extent mainly limited to the unilateral lung. With the exception of one patient, who died from postoperative pneumonia, all patients showed improvement in symptoms. However, in two cases, hemoptysis recurred; these patients had cystic bronchiectasis, Pseudomonas aeruginosa infections and minimal disease in the contralateral lung, which accounted for the recurrence of hemoptysis. A few reports indicated that cystic bronchiectasis and incomplete resection were adverse prognostic factors and that Pseudomonas aeruginosa infections were related to the development of new bronchiectasis. However, according to some other reports, these factors were not adverse prognostic factors. It is thought that the analysis of many cases is required to determine the indication of lung resection and the appropriate type of resection for bronchiectasis; however, it is difficult to conduct randomized control studies. Since the accumulation of case reports is also considered to be important, we report our series of cases.

Potassium oxonate, an enzyme inhibitor compounded in S-1, reduces the suppression of antitumor immunity induced by 5-fluorouracil.

S-1 is an oral formulation combining tegafur (FT), 5-chloro-2,4-dihydroxypyridine (CDHP), and potassium oxonate (Oxo) in a molar ratio of 1:0.4:1. We examined whether Oxo reduces the immunosuppression induced by 5-fluorouracil (5-FU) in the rat. The body weight of rats treated with S-1 (FT + CDHP + Oxo) for seven consecutive days was significantly higher than that of rats treated with a combination of FT plus CDHP (FT + CDHP) for a similar period. The number of peripheral leukocytes was significantly higher in the S-1-treated rats (S-1 group) than that in the FT + CDHP-treated rats (FT + CDHP group). There was no apparent difference between the two treated groups in phenotypic changes of CD3-, CD45-, CD4-, or CD8-positive cells from the spleen or mesenteric lymph nodes. However, the natural killer activities of both spleen cells and mesenteric lymph node cells were significantly higher in the S-1 group than in the FT + CDHP group. Interleukin (IL)-2 production by spleen cells stimulated with concanavalin A was significantly lower in the FT + CDHP group than in the S-1 group. Although IL-2 production by mesenteric lymph node cells in the S-1 group was lower than that in untreated rats, it was higher than that in the FT + CDHP group. These findings suggest that Oxo in S-1 may reduce the suppression of antitumor immunity induced by 5-FU.

A case of occult contralateral breast cancer incidentally detected by contrast-enhanced MRI; report of a case with review of literature.

We encountered a case of occult contralateral breast cancer, previously undetected by conventional imaging such as mammography (MMG) and ultrasonography (US), but incidentally detected by contrast-enhanced magnetic resonance imaging (CE-MRI). We present it here with a review of the literature. A 67-year-old Japanese woman was referred to our hospital in October 2000 because of a 1.5 cm right breast lump detected in a medical checkup. MMG, US and fine needle aspiration cytology revealed a cancerous lesion during the right breast. No mass lesion was palpable nor was any detected by MMG or US in the left breast. Bilateral breast CE-MRI was performed for more detailed evaluation. Consequently, an occult contralateral breast cancerous lesion was detected incidentally by CE-MRI, with the images showing rapid initial enhancement of time to signal intensity curves. Before surgery, bilateral breast lesions were diagnosed as invasive ductal carcinoma by open biopsy. She underwent bilateral breast conserving surgery with bilateral axillary lymph node dissection. The postoperative course was uneventful and no recurrence has been noted as of January 18th, 2004. CE-MRI of the contralateral breast should be of value as a routine screen in those patients with a known or suspected malignancy in one breast considering the limits of breast cancer detection by such conventional modalities as MMG and US.

Survival and clinical evaluation of salvage operation for cervical lymph node recurrence in esophageal cancer.

BACKGROUND/AIMS: Although extended lymphadenectomy for thoracic esophageal cancer is widely practiced in Japan, solitary supraclavicular lymph node recurrence (SCLR) has often become a problem. This study was designed to evaluate the survival and clinical benefit of salvage cervical lymphadenectomy. METHODOLOGY: Between 1989 and 2001, 153 patients underwent esophagectomy for esophageal cancers. SCLR was identified in 5 (3.7%) patients and these five patients were examined retrospectively. RESULTS: Surgical treatment was performed intensively for all patients. Two patients showed longterm survival for 7 years 3 months and 4 years, respectively. Four patients belonged to the good prognostic group but the other patient had poor prognosis from the viewpoint of both the pathological metastatic lymph node number and disease-free interval (DFI). There were no local recurrences but were a recurrent laryngeal nerve palsy in three patients associated with treatment. CONCLUSIONS: Salvage cervical lymphadenectomy for SCLR should be performed positively by selecting each case carefully. Indication must be weighed against increased morbidity considering such indicators as the extent of metastatic lymph node numbers and DFI.

Prognostic and clinical evaluation of patients with T2 gastric cancer.

BACKGROUND/AIMS: Little is known about the clinicopathological features of intermediate-stage T2 gastric cancer, defined as tumors invading the muscularis propria or subserosa. METHODOLOGY: Of 808 patients with gastric cancer, 210 patients (25.9%) who underwent gastrectomy for T2 gastric cancer were selected for this retrospective study. The clinicopathologic findings of these patients were analyzed retrospectively from their hospital records. RESULTS: Of all 808 patients with gastric cancer, 73 patients (9.0%) had tumors invading the muscularis propria (mp). The remaining 137 patients (16.9%) had tumors invading the subserosa (ss). Compared with ss gastric cancer, mp gastric cancer was associated with smaller tumor size, an absence of lymphatic spreading, and hematogenous and late recurrence [disease-free interval: 654.5 days (mp) vs. 365.5 days (ss)]. Univariate analysis of cases with curative operations showed that lymphatic invasion, and lymph node metastasis were significant prognostic factors in patients with T2 gastric cancer. Further examination by multivariate analysis demonstrated that pN2 or higher as classified by both the JCGC (Japanese Classification of Gastric Cancer) and the TNM lymph node staging systems was a predictor of poor prognosis. CONCLUSIONS: JCGC and TNM lymph node staging systems were the most reliable prognostic factors for T2 gastric cancer. Close follow-up should be required for patients with stage pN2 or higher gastric cancer. Long-term follow-up should be required for mp cancers, in particular.

[Video assisted thoracic surgery for Mycobacterium avium complex pulmonary disease spread over multiple pulmonary lobe within one lung].

A 75-year-old woman with Mycobacterium avium complex (MAC) pulmonary disease who had been treated by drug therapy for 7 years was admitted on an emergency basis for hemoptysis. Through the previous 7 years, her sputum cultures had been positive for MAC, and her clinical symptoms and examinations, such as chest X-ray and computed tomography, revealed that her condition had worsened. The lesions spread over the right middle lobe, segment 3 (S3) in the right upper lobe, and segment 6 (S6) in the right lower lobe, however, no lesions were present in the left lung. Since we believed that the disease was localized unilaterally, surgical treatment was selected. The surgical procedures that were employed included right middle lobectomy, right S3 segmentectomy and partial resection of right S6 by thoracoscopy. Sixteen months postoperatively, the sputum culture is negative for MAC. Our procedure enabled the preservation of effective lung function and was successful in controlling MAC pulmonary disease. It is believed that surgery for MAC pulmonary disease should be evaluated in more patients to decide the appropriate surgical indication and procedure.

[Stromal bone formation by lung adenocarcinoma].

We report a case of lung adenocarcinoma with stromal bone formation. A 73-year-old woman was incidentally found to have a coin lesion in the left lower lung field on a chest roentgenogram and computed tomography showed a nodular lesion containing a few coarse high density areas in the left lower lobe. Since transbronchial cytology revealed adenocarcinoma, left lower lobectomy was performed. Histologically, the tumor was a papillary-tubular adenocarcinoma, and fragments of osseous tissue were found within abundant fibrous stroma. Bone formation in primary lung adenocarcinoma is a very rare condition, and only 7 other cases have been reported in the literature.

Prognostic value of lymph node staging in gastric cancer.

BACKGROUND/AIMS: The latest TNM classification (5th edition) changed the definition of nodal staging from the anatomical localization to the total number of metastatic lymph nodes. This study was designed to evaluate and compare the prognostic significance of nodal staging between the two widely known staging systems, the TNM classification (TNM) and Japanese Classification for Gastric Cancer (JCGC). METHODOLOGY: A total of 582 patients who underwent curative gastrectomy with extended lymphadenectomy for gastric cancer were reviewed retrospectively from hospital records. Based on the localization of metastatic nodes according to the JCGC and the total positive node number according to TNM, the patients were divided into subgroups and their prognoses compared. RESULTS: Lymph node metastasis was found in 189 of the 582 patients (32.5%). Both nodal staging systems were found to be significant prognostic factors by multivariate analysis. A prognostic analysis of the patients by subdivision with the two staging systems indicated that the nodal staging system in TNM was more homogenous than that of the JCGC. CONCLUSIONS: The nodal staging system of the TNM classification is superior to that of the Japanese Classification of Gastric Cancer, because it is simple, reproducible and homogeneous.

Postoperative complications following gastrectomy for gastric cancer during the last decade.

BACKGROUND/AIMS: The reduction in the incidence of severe postoperative complications has resulted in a significant increase in the survival of patients with gastric cancer. METHODOLOGY: A total of 879 patients undergoing gastrectomy for gastric cancer during the last decade were retrospectively evaluated for postoperative complications, mortality and associated risk factors. RESULTS: The most frequent complications were anastomotic leakage (3.0%) and wound infection (2.8%) followed by the development of pancreatic fistulae (2.2%) and intra-abdominal abscesses (1.5%). Multiple logistic regression analysis identified various independent risk factors including the extent of lymph node dissection (D1D2 vs. D3) for anastomotic leakage (RR 3.6, P<0.05), splenectomy or distal pancreatosplenectomy for pancreatic fistulae (RR 27.4, P<0.0001) and operative time (360 min < or =) for intra-abdominal abscess (RR 4.8, P<0.05). In total, fourteen patients (1.6%, n=879) died from postoperative complications, with 5 patients dying following non-curative gastrectomy (5.6%, n=90). The complications most associated with death were anastomotic leakage (4 patients) and pneumonia (2 patients). CONCLUSIONS: In view of the potential risk of complications, we should carefully evaluate the indications for aggressive lymph node dissection and/or combined resection of neighboring organs as well as non-curative gastrectomy.

Postoperative clinical evaluation following pylorus-preserving gastrectomy.

BACKGROUND/AIMS: Recent pathological study demonstrated that extended lymphadenectomy is not always necessary for patients with early gastric cancer. METHODOLOGY: Twenty-eight patients underwent pylorus-preserving gastrectomy. The clinicopathological findings of patients with pylorus-preserving gastrectomy were compared to those of 58 patients with conventional distal gastrectomy. RESULTS: There were no significant differences in surgical duration, blood loss, blood chemistry, food intake, and body weight loss. Regarding abdominal symptoms, early dumping syndrome was significantly higher in distal gastrectomy than in pylorus-preserving gastrectomy (35.6% vs. 12.0%, p<0.05). Remnant gastritis was also significantly higher in distal gastrectomy (57.1% vs. 27.7%, p<0.05). However, food residue tended to be more frequently seen in pylorus-preserving gastrectomy (33.3% vs. 61.1%, p=0.052). Based on questionnaire results, the rate of patient satisfaction with their surgical outcome tended to be lower in pylorus-preserving gastrectomy than in distal gastrectomy (84.0% vs. 95.6%, p=0.098). The tendency was more pronounced in patients over 70 years old (77.8% vs. 100%, p=0.065). CONCLUSIONS: Pylorus-preserving gastrectomy is superior to conventional distal gastrectomy in the prevention of dumping syndrome and reflux gastritis. However, since delayed emptying is frequently seen post pylorus-preserving gastrectomy, this procedure is not recommended for older patients under simplistic indications.

Predictive value of the time-intensity curves on dynamic contrast-enhanced magnetic resonance imaging for lymphatic spreading in breast cancer.

PURPOSE: Dynamic contrast-enhanced magnetic resonance imaging (CE-MRI) has emerged as a promising diagnostic modality in various breast cancer treatments. However, little is known about the correlation between the pattern of time to signal intensity curves (TIC) on the CE-MRI and clinicopathologic features. This study was designed to investigate these correlations and evaluate the predictive value of TIC on CE-MRI in order to identify high-risk patients. METHODS: Between 2001 and 2003, 101 lesions were evaluated to detect malignancy on CE-MRI in 101 women who were suspected of having breast tumors based on either clinical findings or conventional imaging studies. Moreover, the clinicopathologic findings were compared with the pattern of TIC for the 69 surgically treated malignant lesions. RESULTS: In detecting malignancy, the sensitivity, specificity, and accuracy were 78.7%, 88.5%, and 81.2%, respectively, in the 101 breast lesions. Especially for the 69 surgically treated malignant lesions, in comparison with breast cancer tumors with the benign pattern of TIC, the breast cancer tumors with a malignant pattern were found more frequently in lymphatic invasion (P < 0.01) and lymph node metastasis (P < 0.005), although no statistical correlation regarding the histological type, tumor size, vascular invasion, extensive intraductal component, hormone receptor status, or pathological stage was noted between the two groups. According to a logistic regression model, lymph node metastasis was found to be a significant independent variable. CONCLUSION: The pattern of TIC could be used to predict lymphatic spreading associated with lymph node metastasis prior to surgery as well as to detect malignancy. Therefore, a more detailed evaluation should be made to identify the presence of lymphatic spreading in patients with a malignant pattern of TIC.

Phase I study of a combination of s-1 and weekly paclitaxel in patients with advanced or recurrent gastric cancer.

OBJECTIVE: A phase I study of weekly intravenous paclitaxel combined with a fixed dose of S-1, a dihydropyrimidine-dehydrogenase-inhibitory oral fluoropyrimidine, was conducted for patients with advanced or recurrent gastric cancer (ARGC). Endpoints of this study were to examine the toxicity profile OF this regimen and to determine the recommended dose (rd) of paclitaxel. METHODS: S-1 was fixed at a dose of 80 mg/m(2) per day and was administered for 2 weeks (days 1--14) followed by a 2-week rest. Two dose levels of paclitaxel (level 1: 60 mg/m(2), level 0: 50 mg/m(2)) were studied. Paclitaxel was infused over 1 h on days 1, 8, and 15. Plasma sampling was performed to characterize the pharmacokinetics and pharmacodynamics of paclitaxel in some patients. Fifteen patients were enrolled (6 patients in level 1, and 9 patients in level 0). Dose-limiting toxicities were defined as grade 4 hematological (including grade 3 febrile neutropenia) and grade 3 non-hematological (except anorexia, nausea, vomiting and depilation) toxicities. RESULTS: Three of 6 patients in level 1 developed grade 4 neutropenia or grade 3 febrile neutropenia, and 1 of them also showed grade 3 diarrhea, which settled the maximum-tolerated dose at this level. At level 0, 2 of 9 patients developed grade 4 neutropenia or grade 3 febrile neutropenia, and the RD of paclitaxel for this protocol was set at this level. Pharmacologic studies demonstrated the persistence of significant serum paclitaxel levels over 24 h after drug administration at both levels. Objective responses according to Response Evaluation Criteria in Solid Tumors were observed in 3 of 6 patients who had measurable disease. CONCLUSION: A combination of S-1 and weekly paclitaxel was feasible and well tolerated, and is suggested to produce a worthwhile response in ARGC. These results warrant further investigation, and a phase II study has already been started.

Elevated expression levels of NCOA3, TOP1, and TFAP2C in breast tumors as predictors of poor prognosis.

BACKGROUND: Amplification of DNA in certain chromosomal regions plays a crucial role in the development and progression of human malignancies, specifically when protooncogenic target genes within those amplicons are overexpressed. Comparative genomic hybridization studies have revealed frequent amplification at 20q in primary breast tumors. The aim of the current study was to identify specific genes in the 20q amplicon that were likely to have clinical significance. METHODS: The authors examined 38 primary breast tumors by using a quantitative real-time reverse transcription-polymerase chain reaction assay to determine expression levels of 18 potential targets for amplification events involving 20q. Potential correlations between elevated expression of the genes in question and clinicopathologic parameters or clinical outcomes were analyzed. RESULTS: Elevated expression of NABC1 was significantly associated with positive estrogen (P < 0.001) and progesterone (P = 0.027) receptors in breast tumors, and high expression of PTK6 was significantly correlated with positive estrogen receptor status (P = 0.022) and postmenopausal status (P = 0.008). Patients whose tumors showed elevated expression of NCOA3 (AIB1) had significantly shorter disease-free (P = 0.017) and overall (P = 0.0021) survival times after surgery than did other patients with breast tumors. Reduced disease-free survival, but not reduced overall survival, was associated with high expression of TOP1 (P = 0.035) and TFAP2C (P = 0.035). CONCLUSIONS: TOP1, TFAP2C, and (particularly) NCOA3 may be prognostic indicators for patients with breast tumors.

Comparison of intraductal spread on dynamic contrast-enhanced MRI with clinicopathologic features in breast cancer.

OBJECTIVE: Contrast-enhanced magnetic resonance imaging (CE-MRI) has emerged as a new diagnostic technology in various breast cancer treatments. However, little is known about the correlation between intraductal spread on CE-MRI and clinicopathologic features. This study was designed to evaluate these correlations for the surgical planning of breast cancer. METHODS: Twenty-six breast cancer lesions (in 26 female patients) treated by breast conserving surgery between March 2001 and March 2003 were evaluated retrospectively. CE-MRI was performed with a 1.5 T unit using a dedicated bilateral breast coil. RESULTS: In detecting intraductal spread of breast cancer, the sensitivity, specificity and accuracy of CE-MRI were 82.4%, 60.0% and 77.3%, respectively. On mammography (MMG), these were 21.1%, 100.0% and 42.3%, respectively. Therefore, CE-MRI has a higher sensitivity and accuracy, although with a lower specificity than MMG. Compared with breast cancer lesions without intraductal spread on CE-MRI, lesions with intraductal spread on CE-MRI were found more frequently in larger-sized tumors (P = 0.0088). CONCLUSION: Preoperative evaluation for intraductal spread by CE-MRI should be more useful than by MMG for breast cancer. When making the surgical decision regarding excision range, particular attention should be paid to this consideration for patients with larger-sized cancer tumors.