[A resected case of advanced gastric cancer after treatment with low-dosage TS-1].

We report a case of advanced gastric cancer that responded well to low-dosage TS-1. A 72-year-old woman was diagnosed as having unresectable advanced gastric cancer with ascites and hydronephrosis in the right kidney. She was treated with chemotherapy using a low-dosage of TS-1 (80 mg/body/day) administered perorally for 4 weeks followed by a drug-free 2 weeks, in six-week cycles. However, she developed weight loss, appetite loss, and stomatitis. We therefore reduced the dosage of TS-1 from 80 mg/body/day to 60 mg/body/day. The ascites and hydronephrosis gradually improved during the following 3 months, whereupon she could undergo total gastrectomy. The postoperative findings showed no ascites and no peritoneal dissemination. The postoperative pathological findings showed that the cancer cells were localized to within the mucosa, and there were no cancer cells in the greater and lesser omentum. Three weeks after the operation, TS-1 was resumed at 60 mg/body/day. However, 3 months later,ascites and metastasis to the abdominal skin developed, and she died 9 months after the operation.

Clinical examination of the water-soluble vitamin levels in blood during peripheral parenteral nutrition.

The water-soluble vitamin (included vitamin B1, B6, B12 and C) preparations are not always replenished when peripheral parenteral nutrition (PPN) is used in Japan. We evaluated the need for administration of vitamins preparation during PPN, and involved analysis of the blood levels of water-soluble vitamins in patients receiving perioperative PPN before and after gastrectomy. Patients were examined as two set of groups as follows; 18 patients who did not receive water-soluble vitamin preparations during PPN, the Unsupplemented Group, and 22 patients who received such preparations during PPN, the Supplemented Group. Consequently, in the Unsupplemented Group, the blood vitamin B1 level during the early postoperative period was significantly lower than the preoperative level, but in the Supplemented Group, it was significantly higher than the preoperative level. In the Supplemented Group, the blood vitamin B12 level during the early postoperative period was markedly higher than the preoperative level. And in both groups, the blood vitamin C level remained below the lower limit of the criterion range throughout the perioperative period. These results suggested that administration of water-soluble vitamins during PPN was needed to avoid potential vitamin deficiencies after surgery and to prevent a potential onset of severe metabolic complications from any deficiencies.

[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.

Surgery and clinicopathological features of gastric adenocarcinoma involving the esophago-gastric junction.

To clarify the optimal operative procedure for gastric adenocarcinoma involving the esophago-gastric junction (EGJ), we investigated 49 cases with an upper gastric cancer invading the esophagus who underwent surgical treatment in our department during the period from 1991 to 2000. According to Siewert's classification, there were 21 cases with a type II tumor, and 28 cases with a type III tumor. Twenty-five cases underwent surgery through an abdominal approach only. The remaining 24 cases were operated on via a left thoraco-abdominal approach. Eight (33%) of 24 cases who underwent extended lymphadenectomy through a left thoraco-abdominal approach had lower mediastinal lymph node metastasis. Metastasis was observed in cases with cancer invasion more than 2 cm from the EGJ. There were 6 cases with a T1 tumor, 6 with a T2 tumor, 27 with a T3 tumor, and 10 with a T4 tumor. Incidences of lymph node metastasis were 0% for T1, 67% for T2, 81% for T3, and 80% for T4. Proximal gastrectomy was performed in 6 cases at the early stage and in 10 cases at the advanced stage with distant metastasis (M1). Total gastrectomy was done in 33 cases at the advanced stage, and 3 of these 33 cases had metastasis to the parapyloric lymph nodes. We performed combined resection of the body and tail of the pancreas and the spleen in 7 cases. One of these 7 cases had direct invasion to the pancreas and 6 cases had remarkable metastasis to the lymph nodes along the splenic artery. Splenectomy preserving the pancreas was done in 24 cases. The incidences of metastasis of the lymph nodes along the splenic artery and the splenic hilum were 25% and 17%, respectively. We performed partial resection of the diaphragm surrounding the esophageal hiatus in 15 cases through a left thoraco-abdominal approach. Six cases had metastasis to the diaphragm and nine cases had direct invasion to the diaphragm. Tumors were stage I in 8 cases, II in 5 cases, III in 13 cases and IV in 23 cases, and the curability was categorized as A in 8 cases, B in 20 and C in 21. The overall 5-year-survival rate was 25%, and the rates according to cancer stage were 86% for stage I, 40% for stage II , 21% for stage III and 0% for stage IV. The 5-year survival rates of cases at stage II and III were 33% for cases using the left thoraco-abdominal approach and 28% for cases with the abdominal approach. Based on these results, we recommend distal esophagectomy with total gastrectomy, and occasional combined resection of the spleen and the diaphragm through a left thoraco-abdominal approach for advanced gastric adenocarcinoma involving the EGJ.

A patient with advanced gastric cancer, underwent curative gastrectomy and partial resection of metachronous hepatic metastases, is surviving for 13 years to date.

We have reported a successful case of curative partial liver resection of metachronous liver metastasis from advanced gastric cancer. The patient was 56 years old and has undergone total gastrectomy with D2 lymph node dissection (2 type, well-differentiated adenocarcinoma, H0P0n0se, Stage 2). At 18 months later, follow-up ultrasound detected liver metastasis in the right posterior segment. Together with other imaging modalities, it was diagnosed as a solitary lesion without any other recurrence, and we performed partial resection of the right posterior segment. During the operation, there was no sign of any other recurrence (no peritoneal dissemination, no lymph node metastasis, and no other liver metastasis). Two Mitomycin-C (MMC) intravenous injections were given as postoperative chemotherapy. Usually, surgery for liver metastasis from gastric cancer is very rare as a curative therapy, because it is difficult to predict the effectiveness of the operation. In the present case, we decided on the operation since there was no sign of any other recurrence. It has now been 13 years to date since the partial liver resection and the patient remains free from recurrence.