Billroth-I reconstruction using an overlap method in totally laparoscopic distal gastrectomy: propensity score matched cohort study of short- and long-term outcomes compared with Roux-en-Y reconstruction.

BACKGROUND: Delta-shaped anastomosis is an established procedure for intracorporeal Billroth-I reconstruction (B-I). However, this procedure has several technical and economic problems. The aim of the current study was to present the technique of B-I using an overlap method (overlap B-I), which is a side-to-side intracorporeal gastroduodenostomy in laparoscopic distal gastrectomy (LDG), and to evaluate the short- and long-term outcomes of this overlap B-I procedure. METHODS: We retrospectively reviewed the medical records of 533 patients who underwent LDG with overlap B-I (n = 247) or Roux-en-Y reconstruction (R-Y) (n = 286). Patients with overlap B-I were propensity score matched to patients with R-Y in a 1:1 ratio. Short- and long-term outcomes of the two procedures were compared after matching. RESULTS: In the total cohort, anastomosis-related complications occurred in 2.4% of patients with overlap B-I, and 3.2% of those with R-Y (P = 0.794). Morbidity rate, including anastomosis-related complications, and postoperative course were comparable after overlap B-I performed by qualified versus general surgeons. Of 247 patients with overlap B-I, 169 could be matched. After matching, morbidity rate and postoperative course were comparable between the two procedures. Median operation time was significantly shorter for overlap B-I (205 min) than R-Y (252 min; P < 0.001). The incidence of readmission due to gastrointestinal complications was significantly lesser after overlap B-I (2.4%) compared with R-Y (21.9%; P < 0.001). The main causes of readmission after R-Y were bowel obstruction (7.3%) and gallstones (8.0%). Regarding the development of common bile duct (CBD) stones, 11 patients (3.8%) who underwent R-Y were readmitted due to CBD stones, whereas no patients who underwent B-I developed CBD stones. CONCLUSIONS: Overlap B-I is feasible and safe, even when performed by general surgeons. B-I was superior to R-Y concerning operation time and readmission due to gastrointestinal complications.

[A case of undifferentiated colon cancer responding to FOLFIRI therapy].

We report a case of undifferentiated colon cancer treated with FOLFIRI therapy. A 69-year-old male had suffered from descending colon cancer. He underwent a left hemicolectomy with D3 dissection. Histopathologically, the tumor was undifferentiated carcinoma, and the cytology of ascites was positive. Peritoneal disseminations occurred soon after surgery, and these tumors did not respond to FOLFOX4 therapy. FOLFIRI therapy was employed, and it reduced the size of these tumors once. However, the therapy failed to control the tumor progression 2 months later. Although we started bevacizumab and S-1, the patient died 11 months after the operation. The present case demonstrates the efficacy of FOLFIRI therapy for undifferentiated colon cancer.

A case of primary extraskeletal osteosarcoma of the breast.

BACKGROUND: Primary sarcomas of the breast are rare and account for less than 1% of all primary breast malignancies. We experienced a case of extraskeletal osteosarcoma of the breast that had a unique clinical course and remarkable findings of mammography and magnetic resonance imaging (MRI). A review of the case reports published in the past few decades showed no reports of a case in which a calcified lesion was followed up three different times on mammography, making this a valuable case report. CASE PRESENTATION: A 52-year-old woman noticed a right breast mass and underwent a breast examination. Mammography showed a 1.5-cm coarse calcified lesion in the upper outer portion of the right breast. Because fine-needle aspiration (FNA) revealed no suspicion of malignancy, she was followed up. Sixteen months later, the tumor grew progressively to 4.5 cm in size with new calcifications that were fine and irregular in shape and density surrounding an enlarged, coarse calcified lesion. Contrast-enhanced magnetic resonance imaging (MRI) showed a high signal intensity in the periphery of the tumor. Extirpation of the tumor was indicated. The pathological findings were extraskeletal osteosarcoma. She underwent additional resection and latissimus dorsi flap reconstruction at the Department of Orthopedic Surgery. CONCLUSION: The present case suggests that mammography findings of a tumor with coarse calcifications that are not typical of benign lesions may be extraskeletal osteosarcoma. A diagnosis must be made as early as possible in order to improve the prognosis of this disease.

Double mapping with subareolar blue dye and peritumoral green dye injections decreases the false-negative rate of dye-only sentinel node biopsy for early breast cancer: 2-site injection is more accurate than 1-site injection.

BACKGROUND: The optimum sentinel node biopsy (SNB) mapping method for breast cancer remains to be determined. No matter which mapping agents are used, 2-site injection may be superior to 1-site injection in limiting the false-negative rate. METHODS: We examined whether a double-mapping method with subareolar injection of blue dye and peritumoral injection of green dye would decrease the false-negative rate of dye-only SNB in 145 patients with early breast cancer. RESULTS: The identification rate for blue-dyed and/or green-dyed (including mixed color-dyed) lymph nodes was 96.6% (140/145). Sensitivity and specificity were 95.1% (39/41) and 100% (99 of 99), respectively. Accuracy was 98.6% (138/140) with a false-negative rate of 4.9% (2/41). There were 4 patients in whom nodes of each color were found, but nodes of only 1 color were shown to be positive. The primary tumors of these 4 patients and of the 2 patients with false-negative results were located in the upper-outer quadrant of the breast. When only blue-dyed or green-dyed nodes (including mixed color-dyed nodes) were counted, the false-negative rates were 10.3% (4/39) for the subareolar mapping technique and 10.0% (4/40) for the peritumoral mapping technique. CONCLUSIONS: The double-mapping method based on subareolar and peritumoral injections decreases the false-negative rate of dye-only SNB for early breast cancer. Variations in lymphatic channels may exist in the lateral half of the breast and thus may influence identification of positive sentinel nodes. This finding should be taken into account in cases of multicentric breast cancer.

Long-term quality of life after laparoscopically assisted distal gastrectomy for gastric cancer.

OBJECTIVE: To investigate whether laparoscopically assisted distal gastrectomy (LADG) contributes to long-term quality of life as compared to open gastrectomy in patients with early-stage gastric cancer. MATERIALS AND METHODS: Quality of life was self-reported using a 15-item questionnaire with five options for each question. The responses obtained from 47 LADG patients and 33 conventional open gastrectomy patients were compared. All patients underwent Billroth I gastrectomy for early gastric cancer between September 1999 and October 2002. RESULTS: Patients who underwent LADG showed better results than those who underwent the open procedure with regard to satisfaction with the operation (87.2% vs. 57.6%; P < 0.01). However, the rate of late complications such as delayed gastric emptying was higher in the LADG group than in the open group (40.4% vs. 18.2%; P < 0.05). No differences were observed between the LADG and open groups with regard to appetite loss, heartburn, diarrhea, or difficulty in swallowing. CONCLUSION: LADG has an equivocal effect on long-term quality of life. Satisfaction with the surgical procedure was greater in patients who underwent the LADG method; however, complications that impaired the quality of life were also seen. The usefulness of LADG should be assessed in view of the immediate and relatively short-term outcomes and their effect on long-term quality of life.

Breast cancer in Japanese men: does sex affect prognosis?

BACKGROUND: Breast cancer has received much less investigative attention in Asian men than in Caucasian men. We examined whether the prognosis of Japanese men with breast cancer differs from that of Japanese women with the disease. METHODS: The clinicopathological features of 14 Japanese men with breast cancer were reviewed and age- and stage-matched case-control analysis of these men and 140 female patients was performed. RESULTS: Disease-free survival (p=0.94) and overall survival (p=0.62) did not differ significantly between the sexes. Five-year disease-free survival was 77% for the men and 75% for the women, and the 5-year overall survival was 92% for the men and 86% for the women. The disease recurred in 2 men but none died of breast cancer, although 3 died of other causes during the median follow-up period of 7 years. There were no significant differences in p53 mutation (p=0.20) or erbB-2 oncoprotein overexpression (p=0.33) between the men and women studied. CONCLUSION: Survival rates of Japanese male and female breast cancer patients are similar when age and stage of the disease are taken into consideration. However, comorbid disease mortality is likely the major contributor to clinical outcome in Japanese male breast cancer.

[Two cases of gastric cancers with lung metastases responding to weekly administration of paclitaxel].

We report two cases of gastric cancer with multiple lung metastases responding well to weekly administration for 3 weeks followed by a week discontinuation of paclitaxel (80 mg/m2). Case 1, a 73-year-old man, was diagnosed as multiple lung metastases 1 year and 4 months after total gastrectomy for Borrmann 1 type gastric cancer (7.5 x 6.5 cm, pap, P0 cy(-) H0 mpn2, stage III A, ly2, v2). After 8 weekly administrations of paclitaxel 110 mg (80 mg/m2), the lung tumor diminished from 5 cm to a linear scar in size, and dyspnea needing inhalation of oxygen at home disappeared. Case 2, another 73 year-old man with multiple lung metastases at 7 months after distal gastrectomy for Borrmann 3 type gastric cancer (4 x 3.5 cm, muc, P0 cy(-) H0 sen2, stage III B, ly1, v0) received weekly paclitaxel 110 mg (80 mg/m2). Lung tumors disappeared after 27 administrations of paclitaxel, and CT scans have showed CR for 8 months until now after 44 administrations. Therefore, we recommend weekly administration of paclitaxel for lung metastases from gastric cancer.

Adenocarcinoma of aberrant pancreas in the jejunum: report of a case.

INTRODUCTION: Aberrant pancreas in the jejunum is a rare condition, and its malignant transformation is very unusual. CASE REPORT: We presented a case in which jejunal carcinoma occurred in the aberrant pancreas. A 76-year-old woman was admitted to our hospital due to repetitive vomiting after meals. Radiology showed high obstruction in the proximal jejunum. Laparotomy revealed that the obstruction was a submucosal tumor. Partial resection of the jejunum including the tumor was performed. Histology showed that the tumor was made up of well-differentiated adenocarcinoma originating from aberrant pancreatic tissues. CONCLUSION: This was the tenth case of aberrant pancreatic carcinoma in the jejunum reported in literature.

A multicenter phase II study of biweekly paclitaxel and S-1 combination chemotherapy for unresectable or recurrent gastric cancer.

PURPOSE: This Phase II study assessed the activity and safety of biweekly paclitaxel and oral S-1 as treatment for unresectable and recurrent gastric cancer. The maximum tolerated dose for this regimen had been established previously in a Phase I study performed in Japanese patients. PATIENTS AND METHODS: Chemotherapy was performed using two anticancer agents, S-1 and paclitaxel. Oral S-1 (80 mg/m(2)) was administered twice a day after meals for two consecutive weeks from Day 1 to 14, followed by a 2 week recovery period; paclitaxel (120 mg/m(2)) was administered intravenously, biweekly, on Days 1 and 15. The patient received cycles of this regimen every 4 weeks (q 28-day cycles). The primary end point was the response rate according to the Response Evaluation Criteria in Solid Tumors. RESULTS: A total of 39 patients (median age, 65 years) were enrolled; 13 other patients were screened, but found to be ineligible. All patients had unresectable and recurrent gastric cancer. The most common treatment-related Grade 3/4 adverse events were neutropenia (37.5%), appetite loss, diarrhea, decreased sodium (each 5%), and anemia, increased alanine aminotransferase, general fatigue, and dizziness (each 2.5%). Almost all the patients experienced alopecia. Intent-to-treat analysis showed a response rate of 43.6%. With a median follow-up of 14 months (range 8-21 months), median survival was 256 days and the median time to progression was 4 months. CONCLUSION: A combination regimen of biweekly paclitaxel and oral S-1 was well tolerated and showed promising activity against unresectable and recurrent gastric cancer.

Increased dihydropyrimidine dehydrogenase activity in breast cancer.

BACKGROUND AND OBJECTIVES: Although studies have focused on modulating the bioavailability of 5-FU through inhibition of dihydropyrimidine dehydrogenase (DPD) to improve efficacy of the drug, activity of this enzyme in breast cancer has not been thoroughly examined. We measured DPD activity in primary and metastatic lesions and benign breast tumors to evaluate the clinical significance of this enzyme in the treatment of breast cancer. METHODS: DPD activity was measured by catalytic assay and compared in 100 primary tumors (95 invasive carcinomas, 5 intraductal carcinomas), 26 uninvolved adjacent breast tissue specimens, 6 metastatic sites, and 7 intraductal papillomas. RESULTS: The enzyme level in the carcinomas was 4-fold that of adjacent uninvolved breast tissues (101 vs 23 pmol/min/mg protein, P < 0.001). Enzyme activity in intraductal papilloma (120 pmol/min/mg protein) was comparable to that in invasive carcinoma. There were no significant differences in DPD activity related to clinicopathologic features, but a tendency toward increased DPD activity was observed in progesterone receptor-negative breast cancer (P = 0.09). There was marginal correlation in enzyme activity between primary and metastatic lesions (P = 0.07). CONCLUSIONS: DPD activity is substantially upregulated in breast cancer tissue and is higher than that reported previously. The clinical implications of DPD inhibitors in patients being treated for breast cancer with oral fluoropyrimidine chemotherapy should be further investigated.

Postoperative follow-up of patients with early breast cancer: reappraisal of serum tumor markers.

The purpose of this study was to determine the most appropriate tests and procedures to detect disease progression effectively during the postoperative follow-up of patients with early breast cancer. We reevaluated our current surveillance protocol which involves the intensive follow-up of 643 patients with stage I disease. With the exception of one case of bone metastasis, all cases of recurrence (97%) were suspected from abnormal results detected during surveillance involving physical examination, serial determination of tumor markers, and chest roentgenography. Among 15 patients with asymptomatic distant metastasis, disease recurrence was suspected in 12 (80%) because of increased levels of serum tumor markers. No disease recurrence was detected by routine complete blood counts or automated chemistry studies alone. Our experience indicates that an effective follow-up regimen for patients with early breast cancer may include careful history-taking, physical examination, and the determination of serum tumor markers every 3-6 months for the first 3 years, then less frequently thereafter, and chest roentgenography every 6 months for 5 years, in addition to annual mammography. Serial determination of the tumor markers tumor polypeptide antigen, NCC-ST-439, and either carcinoembryonic antigen or carbohydrate antigen 15-3, seems to be of value for the selection of patients who should undergo radiologic exploration. The health benefits and cost-effectiveness of a follow-up focused on the measurement of serum tumor markers need to be evaluated in large prospective randomized trials.