Clinicopathologic differences between early gastric remnant cancer and early primary gastric cancer in the upper third of the stomach.

BACKGROUND/AIMS: This study was designed to clarify the clinicopathologic characteristics and survival in early gastric remnant cancer and compare with early primary cancer in the upper third of the stomach. METHODOLOGY: Twenty-five patients with early gastric remnant cancer, who underwent resection at Kanagawa Cancer Center and First Department of Surgery, Yokohama City University between 1974 and 1996 were evaluated in this study. Various clinicopathologic characteristics, such as age, sex, symptoms, size of tumor, depth of invasion, lymph node metastasis, cell differentiation, and survival were investigated and early gastric remnant cancer was compared with early primary cancer in the upper third of the stomach. RESULTS: According to the macroscopic type, protruded type such as I or II type accounted for a great majority in early gastric remnant cancer, while II c depressed type was common in early primary cancer in the upper third of the stomach, comprising 64.2% of all cases. Pathological examination disclosed that well-differentiated carcinoma and mucosal carcinoma were more frequently observed in early gastric remnant cancer than in early primary cancer in the upper-third of the stomach. The 5-year survival rate was 83.5% for early primary cancer in the upper-third of the stomach. In contrast, no patients experienced recurrence after operation for early gastric remnant cancer. CONCLUSIONS: From the view point of clinicopathological evaluation, gastric remnant cancer is a special from of gastric cancer. A follow-up program is important in order to detect early gastric remnant cancer. A low incidence of lymph node metastasis suggests that endoscopic mucosal resection of the tumor or limited operation could be performed under strict indication.

Effect of trypsin inhibitor on reflux oesophagitis after total gastrectomy in rats.

OBJECTIVE: To characterise alkaline reflux oesophagitis after total gastrectomy in rats from the standpoints of cell proliferation and apoptosis and from its macroscopic and microscopic findings, and to evaluate the preventive and curative effects of camostat mesilate, a trypsin inhibitor. DESIGN: Open laboratory study. SETTING: University hospital, Japan. ANIMALS: 70 male Wistar rats. INTERVENTIONS: Total gastrectomy with Billroth II anastomosis (n = 30) and with Roux-en-Y anastomosis (n = 30) were used to establish reflux oesophagitis. Camostat mesilate was given for prevention and cure. The remaining 10 animals had a sham operation. MAIN OUTCOME MEASURES: Trypsin activity of the oesophagus, macroscopic and microscopic findings, bromodeoxyuridine (BrdU) and apoptotic cell labelling indices. RESULTS: Reflux oesophagitis was more common and extensive after Billroth II than Roux-en Y anastomosis. The BrdU labelling index was increased in oesophagitis, while the apoptotic index did not change. Camostat mesilate was effective in both preventing and treating oesophagitis. CONCLUSION: Trypsin has an important role in the development of reflux oesophagitis after total gastrectomy.

Small cell carcinoma of the esophagus: a case report.

Primary small cell carcinoma of the esophagus, which is similar in appearance and behavior to its counterpart of the lung, is a rare tumor. We describe a 77 year-old woman whose esophagram revealed a well-defined mass in the lower third of the thoracic esophagus. A biopsy specimen showed an infiltration of small malignant cells. The individual cells were oval- or spindle-shaped with hyperchromatic nuclei and scant cytoplasm. Synaptophysin staining was positive. The mass was diagnosed as a small cell carcinoma of the esophagus. She underwent an esophagectomy with esophagogastric anastomosis. We discuss the treatment of small cell carcinoma of the esophagus.

Helicobacter pylori of the remnant stomach and its eradication.

BACKGROUND/AIMS: Many authors have reported that Helicobacter pylori (H. pylori) is one of the major causes of gastritis and peptic ulcer. This study was conducted to evaluate the incidence of H. pylori infection and the curative effects of amoxicillin and omeprazole on H. pylori in the remnant stomach. METHODOLOGY: Biopsy specimens were obtained from 70 patients who underwent gastrectomy for gastric cancer. H. pylori was subsequently diagnosed by CLO test and culture of H. pylori. Gastritis was assessed by the scoring of four characteristic pathological parameters. Patients with positive H. pylori were eligible for the eradication study. Amoxicillin, 750 mg per day for 2 weeks, and omeprazole, 20 mg per day for 8 weeks, were administered to them. Endoscopic reexamination was performed 12 weeks after the initiation of treatment. RESULTS: The overall positive rate of H. pylori was 37.1%; 39.6% in Billroth I reconstruction, 0% in Billroth II reconstruction, and 55.6% in pylorus preserving gastrectomy, respectively. The positive H. pylori rate of Billroth II reconstruction was significantly low. However, there was no association of positive rate of H. pylori with time. There was no significant difference of gastritis scores between H. pylori infected patients and non-infected patients. The eradication rate was 70.0%. CONCLUSIONS: H. pylori was present in 37.1% of patients who underwent gastrectomy. Gastritis was not significantly severe in H. pylori infected patients. The treatment with amoxicillin and omeprazole was effective for these patients.

Serum CA 19-9, SLX, STN and CEA levels of the peripheral and the draining venous blood in gastric cancer.

BACKGROUND/AIMS: This study was conducted to elucidate the relationship between the seropositive rates of Carcinoembryonic antigen (CEA), Sialyl Le(a) (CA 19-9), Sialyl Le(x) (SLX) and Sialyl Tn (STN) and the clinicopathological variables. The correlation of serum levels of these antigens between the peripheral venous blood and the venous blood draining from the tumor was also evaluated. METHODOLOGY: The subjects were 113 patients with gastric cancer, who underwent gastrectomy at the First Department of Surgery, Yokohama City University, between 1991 and 1996. Serum levels of CA 19-9, SLX, STN and CEA in the peripheral blood and the draining venous blood were measured. RESULTS: The positive rates for CA 19-9, SLX, STN and CEA were closely correlated with tumor stage, lymph node metastasis, and depth of invasion. Although the seropositive rates for CA 19-9, SLX, STN, and CEA in the draining venous blood were lower than those in the peripheral blood, a close correlation for serum levels of 4 antigens between the peripheral venous blood and the draining venous blood was observed in advanced cancer. CONCLUSIONS: These results suggest that these antigens may be drained by the lymphatic route as well as the hematogenous route. Further studies must be performed to elucidate the mechanism of these antigens entering into the peripheral blood by devising a technique for collecting the lymph.

Sialyl Tn antigen expression is associated with the prognosis of patients with advanced colorectal cancer.

BACKGROUND/AIMS: One of the main problems in multimodal cancer treatment is the lack of prognostic parameters for the individual patient. This study was conducted to clarify the prognostic factors in patients with advanced colorectal cancer. METHODOLOGY: We examined DNA ploidy, Ki-67-derived growth fraction and the expression of CA 19-9, Sialyl Tn (STN) and carcinoembryonic antigens (CEA), along with standard clinicopathological variables including age, sex, tumor location, tumor size, cell differentiation, depth of invasion, and lymph node metastasis in 78 patients with advanced colorectal carcinoma, who underwent curative surgical resection. In addition, we determined the prognostic significance of these parameters. RESULTS: Forty-six patients (59.0%) showed aneuploidy and 32 (41.0%) showed diploidy. The Ki-67 labeling index ranged from 13.9-40.3% with a mean of 24.9%. The index was not correlated with standard clinicopathological variables. There was no significant correlation between seropositive rates for CEA, CA 19-9, or STN and standard clinicopathological variables except for age. In tumor tissue, the positive rates for these antigens were 62.8% for CA 19-9, 67.1% for STN, and 96.2% for CEA. There was no significant correlation between positive rates and clinicopathological variables. The expression of STN in serum had the strongest association with survival, followed by lymph node metastasis and expression of STN in tissue. CONCLUSIONS: We conclude that not only lymph node metastasis but also STN expression are important prognostic factors in patients with advanced colorectal carcinoma who undergo curative surgical resection.

Clinicopathological analysis of poorly differentiated adenocarcinoma of the stomach.

BACKGROUND/AIMS: Our aim was to investigate clinicopathological characteristics of a medullary cancer infiltration with scanty stroma type (por1) and a diffuse cancer infiltration with scirrhous stroma type (por2) of poorly differentiated gastric adenocarcinoma, especially differences in lavage cytodiagnosis, lymph node metastasis pattern and nuclear DNA ploidy between them. METHODOLOGY: Age and gender of 168 patients (46: por1, 122: por2) and clinicopathological characteristics such as tumor site, lymph node metastasis, vascular invasion and serosal involvement were compared. Lymph node metastasis patterns were classified into 1) marginal, 2) nodular, 3) diffuse, and 4) massive types. The whole abdominal cavity was intra-operatively washed with 200 ml of saline, Papanicolaou-stained and used for lavage cytodiagnosis. Nuclear DNA ploidy pattern of carcinoma was determined using flow cytometry. RESULTS: Lymph node metastasis rate was significantly higher in por2, especially in those with positive serosal invasion. Positive rate of lavage cytodiagnosis was significantly higher in por2 (38.9%), than that in por1 (9.1%). There were more hematogeneous recurrences in por1 more peritoneal disseminated recurrences in por2. Survival rate was better in por1. CONCLUSIONS: There were differences in lymph node metastasis, lavage cytodiagnosis and recurrence pattern between por1 and por2 even in poorly differentiated adenocarcinoma. These characteristics should be understood when selecting post-operative chemotherapy and also during follow-up.

The detection of microscopically disseminated cancer cells in the abdominal cavity by intraoperative lavage cytology combined with an immunocytochemical method in gastric cancer.

This study was conducted to clarify the possible role of the immunocytochemical examination of intraoperative lavage cytology in gastric cancer. The expression of CA19-9, STN, SLX and CEA in tissues were examined in 70 patients with advanced gastric cancer who underwent gastric resection. The tissue sections were processed with the hematoxylin and eosin staining and immunostaining using the avidin-biotin-peroxidase complex (ABC) method. Fifty one patients underwent the lavage cytology. The cytologic samples were stained by the conventional Papanicolau method and ABC immunocytochemical method. Expression of CEA was detected at obviously higher frequency than those of the 3 carbohydrate antigens. The method combined with 4 antibodies increased the detection rate to 97.2%. Conventional lavage cytology was positive in 16 out of 51 patients. The diagnosis of class III in four patients was changed to class V through the immunocytochemical examination. The immunocytochemical examination of lavage cytology is very useful to verify the microscopically disseminated cancer cells in gastric cancer.

Clinicopathologic differences between gastric remnant cancer and primary cancer in the upper third of the stomach.

BACKGROUND: The prognosis of gastric remnant cancer is considered to be poor compared with that of primary cancer. MATERIALS AND METHODS: This study was conducted to elucidate the differences of clinicopathologic findings and treatment results between 59 patients with gastric remnant cancer (GRC) and 579 patients with primary proximal gastric cancer (PGC). RESULTS: There was no significant difference in the incidence of lymph node metastasis between GRC and PGC. However, changes in the metastatic pattern to lymph nodes were observed in GRC. In GRC, the tumor easily invaded the neighboring organs due to the adhesions around the remnant stomach, resulting in a low resectability with curative intent. The 5-year survival rate after curative resection for advanced GRC was 50.9%. GRC patients without serosal invasion had a good prognosis. CONCLUSION: Although the survival rate after curative resection for GRC patients was similar to that of PGC, GRC patients without serosal invasion had a better prognosis. Therefore, early detection is an important way to improve overall survival in GRC.

Enhancement of CDDP cytotoxicity by caffeine is characterized by apoptotic cell death.

Through the use of STKM-1 human stomach cancer cells, we investigated the enhancement of the anti-tumor effect and the apoptosis induction of the CDDP and caffeine combination. Even when the concentration of CDDP was low, CDDP significantly decreased the proliferation of STKM-1 human stomach cancer cells, thus confirming the synergistic effect of the CDDP and caffeine group. The apoptotic labeling index of the CDDP plus caffeine combination was significantly higher than that of the CDDP group. In conclusion, caffeine enhanced the effect of CDDP by not only inhibiting DNA repairs but also inducing apoptosis.

Gastric emptying after pylorus-preserving gastrectomy in comparison with conventional subtotal gastrectomy for early gastric carcinoma.

It is well known that surgical intervention on the stomach will greatly alter gastric function and gastric emptying. In this study, we evaluated the difference in postoperative gastric remnant emptying following pylorus-preserving gastrectomy (PPG) and conventional subtotal gastrectomy (CDG) using sulfamethizole capsule food. The subjects comprised 18 patients who underwent PPG and 23 who underwent CDG for early gastric carcinoma. While delayed gastric emptying was observed early after PPG, 1 year after PPG it was markedly accelerated compared with that measured in the early postoperative period. However, it was slower than that in the CDG patients. On the other hand, rapid gastric emptying was observed early after CDG and did not change with time. These findings stress that although PPG results in stasis in the early postoperative period, it seems to prevent unduly rapid emptying.

A case of malignant peritoneal mesothelioma showed complete remission with chemotherapy.

A 71-year-old woman presented with an abdominal mass and ascites and was subsequently admitted to our hospital in June 1995. Further examination revealed that the mass was malignant and, as a result, surgery was indicated. However, the mass demonstrated widespread peritoneal dissemination, which therefore could not be resected, and pathological findings suggested a malignant peritoneal mesothelioma. The patient showed a remarkable response to combined chemotherapy with an accompanying intraperitoneal injection of cisplatin and etoposide and an intravenous injection of caffeine. However, owing to side effects, this regimen was discontinued. The patient was administered a combination drug of uracil and tegafur (UFT) in addition to intraperitoneal injection of cisplatin as an outpatient. By the 223rd day after surgery, the tumor mass and ascites had completely disappeared according to the CT. Hence chemotherapy was judged to have resulted in complete remission. Such a marked response to chemotherapy is rare in an advanced malignant peritoneal mesothelioma such as the present case. Eight months later, the tumor recurred in the pleura. Another regimen of chemotherapy with cisplatin and CPT-11 was performed. However, this treatment proved ineffective. The patient subsequently died of respiratory failure in January 1997 due to the mesothelioma. This is a case report of complete remission of malignant peritoneal mesothelioma by combined chemotherapy.

Postoperative functional evaluation of pylorus-preserving gastrectomy for early gastric cancer compared with conventional distal gastrectomy.

BACKGROUND: Malnutrition, gallbladder dysfunction, dumping syndrome, reflux esophagitis, and gastritis of the remnant stomach are unfavorable sequelae in patients undergoing gastrectomy. Operative procedures should be improved to ensure such patients a satisfactory quality of life. METHODS: After operation, gallbladder function, reflux gastritis, gastric emptying, and caloric intake were evaluated in 20 patients with early gastric cancer undergoing pylorus-preserving gastrectomy (PPG) and 25 patients undergoing conventional distal gastrectomy (CDG). RESULTS: The resting gallbladder area increased significantly after CDG. In contrast, after PPG the gallbladder area showed no significant change and the contraction rate decreased slightly. After CDG, emptying was much more rapid for the first 30 minutes after ingestion of a meal. Although delayed emptying was observed early after PPG, the rate of emptying increased with time. Gastric pH was lower and gastric mucosal injury was milder in patients undergoing PPG. These results are attributed to preserved pyloric function. The caloric intake and changes in body weight after operation were similar in both the CDG and PPG groups. CONCLUSIONS: PPG has advantages over CDG in terms of gallbladder function, the condition of the remnant stomach, and gastric emptying, PPG should be used in carefully selected patients with early gastric cancer to improve their quality of life.

Gastric emptying after gastric interposition for esophageal carcinoma: comparison between the anterior and posterior mediastinal approaches.

BACKGROUND/AIMS: Close observation and evaluation of the function of the transposed stomach after esophagectomy is essential. The present study uses the sulfamethizole capsule meal test to evaluate differences in gastric emptying between the anterior and posterior mediastinal approaches in patients undergoing esophagectomy. METHODOLOGY: Thirty-eight patients who underwent the esophagectomy and esophagogastrostomy for esophageal cancer were randomly divided into 2 groups: Group 1: anterior mediastinal approach, and Group 2: posterior mediastinal approach. Gastric emptying was studied using the sulfamethizole capsule meal test. Patients received sulfamethizole food capsules, 65 g of bread, and 150 ml of water. Plasma sulfamethizole levels were determined by high performance liquid chromatography (HPLC). RESULTS: Gastric emptying in both groups was significantly accelerated compared to healthy volunteers. Gastric emptying did not differ significantly between groups 1 and 2. CONCLUSIONS: The present data show that the sulfamethizole capsule meal test is an effective means of evaluating the emptying of the transposed stomach. Furthermore, when the stomach is used as an esophageal substitute following esophagectomy, gastric emptying does not differ according to the access route.

[A case of postbulbar duodenal ulcer due to adjuvant chemotherapy after gastrectomy for gastric cancer].

We encountered a rare case of postbulbar ulcer caused by adjuvant chemotherapy after gastrectomy. A 64 year-old woman, who received chemotherapy with CDDP-5-FU after gastrectomy, developed severe hematemesis. Endoscopic examination revealed a gigantic ulcer at the anal site of Vater's papilla. The ulcer was healed with PPI and soft diet.

Expression of CA19-9, SLX, STN and CEA in relatively early gastric carcinoma.

Expression and presence of the carbohydrate antigens CA19-9, SLX and STN, and CEA in tissues and serum were examined in 132 patients with early or propria muscle invaded gastric cancer. The seropositive rate was not different in patients with cancer or gastritis. In tumor tissue, the positive rate for these antigens was 28.8% in CA19-9, 9.1% in SLX, 47.0% in STN and 72.9% in CEA. Results showed that gastric cancers, even at an early stage, produce abnormal carbohydrate antigens not detected in normal tissues. However, transfer of antigens into the circulation was not observed in patients with early gastric cancer, suggesting the possibility that number of carcinoma cells may be involved in the transfer of antigens into blood.

Diagnosis of submucosal tumors by injecting a water soluble contrast medium: judgement of tumor developing pattern and endoscopic lumpectomy.

With the remarkable increases in the number of cases of endoscopical removal of submucosal tumors spurred by the application of high-frequency current, it has become more and more important to apply beforehand some reliable methods like ours to differentiate between tumors and other tumescent lesions due to extra-gastric pressure similar in configuration to tumors and also to confirm the development patterns of tumors either intra-gastric or extra-gastric. Such preparatory arrangements seem indispensable to minimize the risk of perforation incidental to the endoscopical treatment of tumors. To cope with another danger of major bleeding following tumor resection, securing on hand an effective hemostatic is indispensable as well. In our care of the patients after their undergoing endoscopical lumpectomies, we usually subject them to quiet rest and fasting for two or three days; then when they are to resume a regular diet, we endoscopically examine them before and after each meal to confirm the presence or absence of bleeding. In 12 subjects of this series treated with our routine and finally with lumpectomies for gastric submucosal tumors, no serious adverse reactions developed.