Overt bone metastasis and bone marrow micrometastasis of early gastric cancer.

Recently we encountered two cases of early gastric cancer (EGC) with bone metastasis after surgery. As they were not accompanied by overt liver, lung, or peritoneal metastasis, we examined the clinical significance of bone metastasis in EGC and its mechanisms by a review of the literature. We found only 10 cases of EGC complicated with overt bone metastasis in the English literature, so we also examined the Japanese reports of such cases. The main histologic type of cases of bone metastasis from EGC was the diffuse type, and there were long intervals between surgery and overt bone metastasis. One reason for such long intervals may have been the tumor dormancy. Two types of dormancy, dynamic and static, and two types of postoperative overt metastases, that of micrometastatic origin (normograde metastatic process) and that of bone marrow origin (retrograde metastatic process), were considered. We speculated that there may be specific routes by which the cancer cells infiltrate the bone marrow directly from EGC or lymph node metastasis. The procedures for diagnosing bone micrometastasis using monoclonal antibodies have recently been improved, but their accuracy rates are still not universally accepted. New, more reliable examinations are required to improve the survival rates of EGC.

Intra-abdominal bronchogenic cyst with gastric attachment: report of a case.

We report a rare case of an intra-abdominal bronchogenic cyst. An abnormal lesion was detected on an ultrasonogram, done as part of a physical checkup, in an 81-year-old woman. Computed tomography and magnetic resonance imaging showed a cystic mass attached to the lesser curvature of the stomach. Initially, we suspected a congenital cyst without malignant components; however, as the patient wished to have the lesion removed, we performed a minilaparotomy. The cystic lesion was firmly attached to the lesser curvature by fibrous tissue. Microscopic examination subsequently revealed the 26-mm mass to be a benign bronchogenic cyst with a bronchial element. We compared our findings with those of 50 previously reported cases of intraabdominal bronchogenic cysts. None of these patients was older than ours, and lesions attached to the esophagus or stomach were extremely unusual. Bronchogenic cysts are difficult to diagnose preoperatively based on imaging findings, but surgery may be indicated if malignant components are suspected, or if the lesion is enlarging or causing symptoms.

Evaluations of interferon-γ/interleukin-4 ratio and neutrophil/lymphocyte ratio as prognostic indicators in gastric cancer patients.

BACKGROUND AND OBJECTIVES: Th2-dominant immunity and high neutrophil/lymphocyte ratios (NLRs) have been reported to reflect tumor progression, and so we examined whether the Th1/Th2 ratio and NLR can act as prognostic indicators or not. METHODS: Peripheral blood samples were taken within 1 week before and 14 postoperative days after curative gastrectomy using 157 gastric cancer cases for the measurement of both ratios. The proportions of Th1 cells (interferon γ-producing CD4 T cells), Th2 cells (interleukin-4-producing CD4 T cells) were counted by two-color flow cytometry analysis. RESULTS: There were significant differences in 5-year survival both between the high and low Th1/Th2 ratio groups, and between the high and low NLR groups. The pattern classifications before and after surgery in the Th1/Th2 ratio showed strongly significant differences in 5-year survival. NLR was especially influenced by tumor size, and there was a negative linear correlation between the two ratios before surgery. CONCLUSIONS: The Th1/Th2 ratio may be a good prognostic indicator and may also be a promising marker for estimating the effectiveness of surgery. NLR may also be a good prognostic indicator and may be a valid marker of tumor recurrence, and it appeared that some interaction between lymphocytes and neutrophils had occurred.

The distribution and intracellular location of Fas and Fas Ligand following gastric carcinogenesis: Fas Ligand expressing gastric carcinoma cells can inhibit local immune response.

Previous reports indicated that Fas Ligand (FasL) in gastric carcinoma might support tumour cells to evade host immune attack. However, the mechanism induced by the Fas/FasL system has not yet been described on the basis of comparison of normal and malignant tissues in terms of the features of regional location of Fas and FasL. By using immunostaining methods, we studied the distribution and regional location of Fas and FasL in gastric epithelial cells (GECs), gastric carcinoma cells (GCCs), normal gastric stroma-infiltrating lymphoid cells (NGILs) and tumour-infiltrating lymphoid cells (TILs) in 59 tissue specimens of human gastric carcinoma. The expression of Fas within the entire GECs was higher than that in all GCCs (P < 0.0001); however, the expression of Fas in NGILs was lower than that in TILs (P < 0.0001). The expression of FasL showed no significant difference between GECs and GCCs, or between NGILs and TILs. When we analyzed the Fas/FasL expression on cytomembrane (CM) in GECs and GCCs, Fas-in-CM was detected in 79.4% and 33.33% (P < 0.05), compared with 3.03% and 56.67%, respectively, for FasL-in-CM (P < 0.001). Our results suggest that there is indeed a possible mechanism to assist cancer cells to evade host immune attack, and this mechanism depends on the dynamic state of Fas/FasL expression, that is, Fas showed a tendency to be expressed within the cells, whereas FasL showed a tendency to be expressed on the cell membrane following carcinogenesis.

It is possible that tumour-infiltrating granulocytes promote tumour progression.

Several lines of evidence indicate that tumour-infiltrating granulocytes (TIGs) promote tumour growth and progression. However, the prognostic significance of TIGs, the relationship between TIGs and Fas ligand (FasL) expressed on tumour cells remains unclear and warrants investigation. Using immunnostaining, we retrospectively investigated TIGs and FasL in 130 tissue specimens from gastric carcinoma. We analyzed the correlation among these markers, their association with clinicopathologic features and prognosis. The number of TIGs was significantly associated with FasL-expression (P=0.002). Further, TIGs were significantly associated with depth of tumour invasion, lymph node metastasis and tumour stage. Calculating the prognostic relevance, in multivariate analysis, TIGs [relative risk (RR)=1.014; 95% CI=1.002-1.027; P=0.015] and tumour stage were statistically significant factors for survival. Our results suggest that TIGs are conveniently measured by the immunostaining method, and possibly serve as an independent factor of prognosis in patients with gastric carcinoma. This is based on the fact that TIGs were significantly associated with tumour stage and shorter survival time.

[Review of our home parenteral nutrition (HPN) and home enteral nutrition (HEN) cases].

We reviewed our cases of HPN and HEN after percutaneous gastrostomy. We had 38 patients (26 men, 12 women) on HPN. Of them, 23 (17 men, 6 women) had an implantable subcutaneous infusion port. The average age of HPN cases was 69 (range 40-92) years, and 34 patients (89%) suffered from a malignant disease. The mean duration of HPN was 104 (range 2-543) days. Home anti-cancer chemotherapy was provided for 2 patients. Percutaneous gastrostomy was performed for 7 patients (4 men, 3 women) by endoscopy (PEG, 6 cases) and 1 patient needed an open laparotomy. Their average age was 60 (range 40-83) years. 5 patients with a malignant disease who were in HPN underwent gastrostomy for decompression drainage of a digestive tract obstruction. 2 patients had a benign disease and were on HEN for a long time. We experienced 2 cases of skin complications, one under HPN and the other under HEN, but no severe complication experienced. HPN and HEN contribute to improve the patients' QOL.

[Review of our home parenteral nutrition (HPN) and home enteral nutrition (HEN) cases].

We reviewed our cases of HPN and HEN after percutaneous gastrostomy. We had 38 patients (26 men, 12 women) on HPN. Of them, 23 (17 men, 6 women) had an implantable subcutaneous infusion port. The average age of HPN cases was 69 (range 40-92) years, and 34 patients (89%) suffered from a malignant disease. The mean duration of HPN was 104 (range 2-543) days. Home anti-cancer chemotherapy was provided for 2 patients. Percutaneous gastrostomy was performed for 7 patients (4 men, 3 women) by endoscopy (PEG, 6 cases) and 1 patient needed an open laparotomy. Their average age was 60 (range 40-83) years. 5 patients with a malignant disease who were in HPN underwent gastrostomy for decompression drainage of a digestive tract obstruction. 2 patients had a benign disease and were on HEN for a long time. We experienced 2 cases of skin complications, one under HPN and the other under HEN, but no severe complication experienced. HPN and HEN contribute to improve the patients' QOL.

[Current status of our home care].

We report a current status of our home care cases. Our home care has provided for 76 patients (46 men, 30 women) since July 1996. The average age was 73 (range 32-92) years old. The shortest period of home care was for 1 day, and the longest period of home care was achieved for 5 years and 5 months. 70 of the 76 patients suffered from malignant diseases. Of these patients, 53 patients were terminally ill cancer patients. 63 patients of the 76 had died, and over half of them (35 out of the 63 patients) had died at home. 14 of the 76 patients who were treated by other hospitals and clinics came to our hospital by means of referral, and we provided them our home care with the cooperation of these hospitals and clinics. No problems existed in our hospital with issues regarding discharge planning and nursing cooperation.

[Evaluation of CA72-4 as a tumor marker in patients with gastric cancer].

The clinical efficacy of CA72-4 for gastric cancer was studied in comparison with CEA and CA19-9. These 3 markers were examined simultaneously, preoperatively in 156 cases of gastric cancer. The positive rate of CA72-4 was higher than of CA19-9 and was equivalent to CEA. There was no significant difference between differentiated and undifferentiated carcinoma in these 3 markers. However, the positive rates of CEA and CA72-4 were significant higher in the cases with lymph node metastasis and curative grade B, C. The combination assay of CEA and CA72-4 was valuable because the tumor markers were considered to be independent of each other. Cases positive for both CEA and CA72-4 simultaneous were significantly more frequent among the cases with lymph node metastasis and in the serosa-invasive cases. In conclusion, CA72-4 is more important than CA19-9 as a tumor marker in gastric cancer patients.

The granulocyte/lymphocyte ratio as an independent predictor of tumour growth, metastasis and progression: Its clinical applications.

Several investigators have suggested that the granulocyte/lymphocyte (G/L) ratio is a good indicator for the evaluation of the condition of a tumour-bearing host, although its prognotic significance is unclear. To further investigate the clinical applications of the G/L ratio, we injected 1x105 and 1x106 Lewis lung carcinoma cells (3LLc) into the feet of 4-week-old C57BL/6 mice separated into groups A, B, C and D (1x105 cells) and E, F, G and H (1x106 cells). For the observation of tumour metastasis and G/L ratio, the mice in groups A-D were sacrificed on days 11, 14, 17 and 21 after inoculation with the 3LLc cells, and the mice in groups E-H on days 7, 11, 14 and 17. The results suggest that in mice the number of granulocytes increases with time after 3LLc cell injection (P<0.05). We also retrospectively investigated the correlation between G/L ratio, clinicopathologic features and prognosis in 62 patients with gastric carcinoma. There was a significant correlation between the G/L ratio and tumour weight (r=0.746, P<0.05), as well as a significant difference between the G/L ratio and the extent of metastases (P<0.05). Additionally, the G/L ratio was significantly associated with lymph node metastasis and higher tumour stage, tumour progression (P=0.017) and 5-year survival (P=0.013). In conclusion, the G/L ratio is associated with tumour progression and shorter survival. The close correlation between G/L ratio and tumour stage or lymph node status suggests that it could be used to predict tumour metastasis, prognosis and overall survival in patients with gastric carcinoma before they undergo surgical treatment.

Spinal destruction induced by chronic contained rupture of an abdominal aortic aneurysm: report of a case.

We report a case of spinal destruction caused by chronic contained rupture of an abdominal aortic aneurysm (AAA). The patient was a 73-year-old man who had undergone coronary artery bypass grafting, sigmoidectomy for colon cancer, and axillofemoral bypass with AAA resection within months of each other, 3 years earlier. Abdominal computed tomography and magnetic resonance imaging showed destruction of the 12th thoracic and 1st lumbar vertebrae. The possibility of a metastatic spine tumor prompted us to consult the orthopedic surgeons, who recommended a spinal percutaneous needle aspiration biopsy. However, the cardiovascular surgeons diagnosed chronic contained rupture of an inflammatory AAA. The patient gradually improved with antimicrobial treatment, but died of disseminated intravascular coagulation the following year. The definitive diagnosis was confirmed by autopsy. We report this case for its educational value, considering the serious consequences that might have occurred had we attempted to biopsy the lesion.

Acute myelogenous leukemia suddenly developing just after surgery for advanced gastric cancer: report of a case.

We report a case of acute myelogenous leukemia (AML) developing just after surgery for advanced gastric cancer, before adjuvant chemotherapy was started. Immature white blood cells were recognized in the peripheral blood from postoperative day (POD) 1. The patient's clinical status and bone scintigraphy showed no evidence of bone metastasis. Acute myelogenous leukemia was diagnosed by an aspiration biopsy of the bone marrow. If the AML had developed later and had become remarkable during or after adjuvant chemotherapy, the differential diagnosis between de novo and therapy-related leukemia would have been very difficult. Most leukemias that develop during the course of chemotherapy or radiotherapy, or both, are indisputably considered to be therapy-related. Thus, we report the clinical course of this patient with reference to the related literature to warn surgeons of the possibility of this unusual manifestation.