Lymph node ratio is a critical prognostic predictor in gastric cancer treated with S-1 chemotherapy.

BACKGROUND: S-1 is an oral anticancer drug widely used in postoperative adjuvant therapy for patients in Japan with stage II/III gastric cancer. Candidates for more intense adjuvant treatments need to be identified, particularly among patients with stage III cancer. METHODS: Univariate and multivariate analyses were conducted for patients with stage II/III gastric cancer who underwent surgery and received S-1 postoperatively between 2000 and 2010. RESULTS: Factors indicating poor prognosis identified by univariate analysis include male sex (P = 0.022), age ≥67 years (P = 0.021), intestinal-type histology (P = 0.049), lymph node ratio ≥16.7 % (P < 0.0001), open surgery (P = 0.039), as well as the 13th JGCA stage (P < 0.0001) and the 14th JGCA/7th International Union Against Cancer (UICC) stage (P < 0.0001). Multivariate analysis revealed that lymph node ratio ≥16.7 % and intestinal-type histology were significant as predictors of prognosis, independent from the pathological stages. Based on these and other findings, stage IIIC cancer on the 14th JGCA/7th UICC stage system in combination with the lymph node ratio could identify patients with extremely high risk for recurrence CONCLUSIONS: Our current findings suggest that lymph node ratio ≥16.7 % in combination with the new staging system could be a useful prognostic indicator in advanced gastric cancer. Because these high-risk patients cannot be identified preoperatively by any diagnostic tool, further improvement in postoperative adjuvant therapy is warranted.

Preoperative dual-phase 3D CT angiography assessment of the right hepatic artery before gastrectomy.

PURPOSES: In the current study, we evaluated the efficacy of dual-phase three-dimensional (3D) CT angiography (CTA) in the assessment of the vascular anatomy, especially the right hepatic artery (RHA), before gastrectomy. METHODS: The study initially included 714 consecutive patients being treated for gastric cancer. A dual-phase contrast-enhanced CT scan using 32-multi detector-row CT was performed for all patients. RESULTS: Among the 714 patients, 3D CTA clearly identified anomalies with the RHA arising from the superior mesenteric artery (SMA) in 49 cases (6.9 %). In Michels' classification type IX, the common hepatic artery (CHA) originates only from the SMA. Such cases exhibit defective anatomy for the CHA in conjunction with the celiac-splenic artery system, resulting in direct exposure of the portal vein beneath the #8a lymph node station, which was retrospectively confirmed by video in laparoscopic gastrectomy cases. Fused images of both 3D angiography and venography were obtained, and could have predicted the risk preoperatively, and the surgical finding confirmed its usefulness. CONCLUSION: Preoperative evaluations using 3D CTA can provide more accurate information about the vessel anatomy. The fused images from 3D CTA have the potential to reduce the intraoperative risks for injuries to critical vessel, such as the portal vein, during gastrectomy.

Survival outcome of laparoscopic gastrectomy for clinical early (cT1) gastric cancer.

PURPOSES: Laparoscopy-assisted gastrectomy (LAG) for clinical early (cT1) gastric cancer (EGC) is superior to open gastrectomy in terms of the short-term outcome; however, long-term survival outcome remains elusive. METHODS: Four hundred and ninety-one cT1 EGC patients who underwent LAG between 1998 and 2010 were registered to evaluate the survival outcome, including 237 patients who were observed for at least 5 years (long-term, L group), while 221 patients who were observed for at least 2-5 years (intermediate term, I group). RESULTS: There were 17 deaths, including 7 patients who developed recurrence (5 in pT1 and 2 in pT4a). Two fatal cases with pStage IIB were uniquely T1N3b. Six out of the 7 recurrences occurred within 2 years after surgery. The 237 patients in the L group included 6 of the recurrent deaths (2.5 %), while the 221 patients in the I group included 1 recurrent death (0.9 %). Recurrent sites of pathological T1 cases were the liver (n = 2), lung (n = 1), ovary (n = 1), and bone (n = 1), and no peritoneal or local recurrence was found. CONCLUSIONS: Collectively, the survival outcome of EGC by LAG was excellent and LAG was acceptable as a therapeutic procedure for EGC.

Is PET-CT suitable for predicting lymph node status for gastric cancer?

BACKGROUND/AIMS: To verify the value of PET-CT for predicting lymph node status of gastric cancer preoperatively. METHODOLOGY: 78 gastric cancer patients accepted PET-CT preoperatively, the results of lymph node status were compared with the postoperative pathology. CT was used as control. RESULTS: The accuracy of PET-CT and CT in N category was 55.1% vs. 54.4%, respectively. The sensitivity, specificity, accuracy, positive predicting value (PPV), and negative predicting value (NPV) of PET-CT in predicting position of positive lymph node were 31.0%, 97.2%, 61.5%, 92.9%, and 54.7%, respectively. While for CT, were 60.5%, 83.3%, 70.6%, 82.1%, and 62.5%, respectively. For tier 1 lymph node metastasis, the sensitivity, specificity, accuracy, PPV, and NPV of PET-CT were 31.6%, 95.0%, 64.1%, 85.7%, and 59.4%, respectively. While for CT, were 60.0%, 78.8%, 69.1%, 75.0%, and 65.0%, respectively. The sensitivity of CT was significantly better (p = 0.031). For tier 2 or tier 3 lymph node metastasis, the sensitivity, specificity, accuracy, PPV, and NPV of PET-CT were 12.0%, 98.1%, 70.5%, 75.0%, and 70.3%, respectively. While for CT, were 22.7%, 93.5%, 70.6%, 62.5%, and 71.7%, respectively, without significance. CONCLUSIONS: PET-CT is not sensitive enough to predict the regional lymph node status of gastric cancer preoperatively.

The diagnostic value of PET-CT for peritoneal dissemination of abdominal malignancies.

AIM: To evaluate the diagnostic value of PET-CT for predicting peritoneal metastasis of abdominal malignancies. METHODS: One hundred fifty four (154) cases of malignant tumor, including 141 cases of gastric cancer, 9 cases of colon cancer, 2 cases of ovary cancer, and 2 cases of pseudomyxoma, had accepted PET CT from Nov. 2002 to Jan. 2006. One hundred twenty three (123) had also accepted high speed spiral CT (HSSCT) as control. The results were compared with peritoneal lavage, pathological examination and clinical manifestation. RESULTS: The accuracy of PET-CT for peritoneal metastasis was 87.7%, with sensitivity 72.7%, specificity 93.6%, PPV 82.1% and NPV 89.6%. HSSCT showed an accuracy of 79.7%, sensitivity 47.4%, specificity 94.1%, PPV 78.3%, and NPV 80.0%. PET-CT had significantly better sensitivity than HSSCT (p < 0.05). For gastric cancer patients alone, PET CT had an accuracy of 87.9%, sensitivity 74.4%, specificity 93.1%, PPV 80.6% and NPV 90.5%, significantly better than HSSCT's 78.1, 39.4, 93.8, 72.2, and 79.2% (p < 0.01), respectively. In case of Cy1P0, PET-CT showed a seemingly better sensitivity of 53.3% vs. 13.3% of HSSCT, although not statistically significant because of the number of observations (p = 0.053). And in P1 cases, PET-CT and HSSCT manifested sensitivity of 84.2% vs 63.2%, respectively, without significance (p = 0.141). CONCLUSION: PET-CT is useful in predicting peritoneal metastasis of malignancies.

[The results of surgical treatment for pseudomyxoma peritonei].

The surgical results of 37 patients with pseudomyxoma pertonei are reported. Twenty eight patients received laparotomy and complete cytoreduction (CC-0) could be done in 6 patients. However, 13 patients received incomplete cytoreduction, and 9 patients underwent drainage of ascites and peritoneal washing. The Peritoneal Carcinomatosis Index (PCI) was less than 20 in CC-0 patients. CC-0 patients survived significantly better than patients with residual disease. Accordingly, peritoneal washing to remove free cancer cells should be aimed for complete cytoreduction of the solid mucinous nodules.

Preoperative administration of polysaccharide Kureha and reduced plasma transforming growth factor-ß in patients with advanced gastric cancer: A randomized clinical trial.

Systemic abrogation of TGF-ß signaling results in tumor reduction through cytotoxic T lymphocytes activity in a mouse model. The administration of polysaccharide-Kureha (PSK) into tumor-bearing mice also showed tumor regression with reduced TGF-ß. However, there have been no studies regarding the PSK administration to cancer patients and the association with plasma TGF-ß. PSK (3 g/day) was administered as a neoadjuvant therapy for 2 weeks before surgery. In total, 31 advanced gastric cancer (AGC) patients were randomly assigned to group A (no neoadjuvant PSK; n=14) or B (neoadjuvant PSK therapy; n=17). Plasma TGF-ß was measured pre- and postoperatively. The allocation factors were clinical stage (cStage) and gender. Plasma TGF-ß ranged from 1.85-43.5 ng/ml (average, 9.50 ng/ml) in AGC, and 12 patients (38.7%) had a high value, >7.0 ng/ml. These patients were largely composed of poorly-differentiated adenocarcinoma with pathological stage III/IV. All the six elevated cases in group B showed a significant reduction of plasma TGF-ß (from 21.6 to 4.5 ng/ml, on average), whereas this was not exhibited in group A. The cases within the normal limits of TGF-ß remained unchanged irrespective of PSK treatment. Analysis of variance showed a statistically significant reduction in the difference of plasma TGF-ß between groups A and B (P=0.019). PSK reduced the plasma TGF-ß in AGC patients when the levels were initially high. The clinical advantage of PSK may, however, be restricted to specific histological types of AGC. Perioperative suppression of TGF-ß by PSK may antagonize cancer immune evasion and improve patient prognosis in cases of AGC.

Risk of superficial squamous cell carcinoma developing in the head and neck region in patients with esophageal squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Multicentric squamous dysplasia in the esophagus can be visualized by Lugol chromoendoscopy as multiple Lugol-voiding lesions (LVLs). Narrow-band imaging combined with magnifying endoscopy (NBI-ME) facilitates the detection of superficial squamous cell carcinoma within the head and neck region (HNSCC). We investigated risk factors for superficial HNSCC in patients with esophageal squamous cell carcinoma (ESCC). STUDY DESIGN: Case-control study. METHODS: We studied 71 patients with synchronous or former ESCC. All patients underwent screening of the head and neck by NBI-ME and Lugol chromoendoscopy of the esophageal mucosa. The history of tobacco and alcohol use was documented. Genetic polymorphisms of aldehyde dehydrogenase type 2 (ALDH2) were identified by the sequence-specific primer polymerase chain reaction. Clinical factors related to superficial HNSCC were analyzed. RESULTS: All patients with superficial HNSCC were drinkers. On univariate analysis, multiple LVLs (odds ratio [OR], 56.92; 95% confidence interval [CI] 6.93-467.38; P < .001), ALDH2-2 allele (OR, 14.48; 95% CI, 1.8-116.56; P = .01), current smoker (OR, 4.25; 95% CI, 1.44-12.57; P = .009), and smoking index ≥ 1,000 (OR, 3.45; 95% CI, 1.19-9.99; P = .02) were associated with superficial HNSCC. On multivariate analysis, multiple LVLs (OR, 61.12; 95% CI, 5.4-691.64; P = .001), ALDH2-2 allele (OR, 16.19; 95% CI, 1.15-228.06; P = .04), and current smoker (OR, 8.02; 95% CI, 1.09-59.22; P = .04) were associated with superficial HNSCC. CONCLUSIONS: Patients with ESCC, particularly drinkers, current smokers, and those with the ALDH2-2 allele and multiple LVLs, have an increased risk of superficial HNSCC.

Comparison of staging between the old (6th edition) and new (7th edition) TNM classifications in advanced gastric cancer.

BACKGROUND: The aims of the present study were to compare staging between the old (6th edition) and new (7th edition) TNM classifications, and to evaluate the prognostic impact of extended lymph node dissection according to the new nodal staging in advanced gastric cancer. PATIENTS AND METHODS: A total of 609 patients with advanced gastric cancer who had undergone curative gastric resection combined with extended lymph node dissection were enrolled in the present study. Survival curves were analyzed according to staging based on the TNM 6th and 7th editions and the Japanese Classification of Gastric Carcinoma (JCGC) 14th edition. RESULTS: The 5-year survival rates and the consecutive stage survival with no significant differences were: IB 88%; II 74%; IIIA 53%; IIIB 39%; and IV 18% (IIIA vs. IIIB, p=0.1307) by the TNM 6th edition; IB 94%; IIA 85%; IIB 71%; IIIA 68%; IIIB 48%; IIIC 23%; and IV 13%; (IIB vs. IIIA, p=0.7665; IIIC vs. IV, p=0.4156) by the TNM 7th and JCGC 14th editions; N0 85%; N1 70%; N2 46%; N3 18%; and M1 13%; (N3 vs. M1, p=0.8640) by the TNM 6th edition; and N0 85%; N1 80%; N2 61%; N3a 46%; N3b 18%; and M1 13%; (N0 vs. N1, p=0.2735; N2 vs. N3a, p=0.0663; N3b vs. M1, p=0.8640) by the TNM 7th and JCGC 14th editions. CONCLUSION: The new classification according to the TNM 7th and the JCGC 14th editions does not always seem to be superior to the TNM 6th edition for the prognostic stratification of stages in patients who undergo curative resection for advanced gastric cancer. An extended lymph node dissection may be effective for N0-N3a, but not for N3b and M1 stages classified according to the new TNM 7th and JCGC 14th editions.

Trend in gastric cancer: 35 years of surgical experience in Japan.

AIM: To investigate the trend in gastric cancer surgery in the context of rapid therapeutic advancement in Japan and East Asia. METHODS: A retrospective analysis was performed on 4163 patients who underwent gastric resection for gastric cancer with histological confirmation between 1971 and 2007 at the surgical unit in Kitasato University Hospital, to determine the trend in gastric cancer requiring surgery. RESULTS: Gastric cancer requiring surgical resection increased in our hospital, but the incidence adjusted for population was constant during the observed period. Interestingly, the ratio of diffuse type/intestinal type gastric cancer was unexpectedly unchanged, and that of advanced/early gastric cancer (EGC) was, however, markedly reduced, while the actual incidence of potentially curative advanced gastric cancer tended to decrease. The incidence of EGC requiring surgery tended to increase as a whole, which is consistent with increased prevalence of endoscopic surveillance. As a result, overall survival and mortality of gastric cancer requiring gastric resection has recently markedly improved. CONCLUSION: In Japan, planned interventions may improve surgical gastric cancer mortality, but an unexpected trend of persistent existence of intestinal type cancer suggests the need for more robust medical intervention.