A case of small-cell esophageal cancer with chronic renal failure undergoing hemodialysis safely treated with cisplatin and etoposide.

A 54-year-old male undergoing hemodialysis was admitted to our hospital because of difficulty in swallowing. Esophagography and esophageal endoscopy revealed an irregular ulcerated lesion in the cervical esophagus. It was diagnosed as a small-cell esophageal cancer from the biopsy sample. Computed tomography showed a tumor infiltrating the trachea and a few lymph node metastases in the cervix, upper mediastinum, and abdomen. The patient was started on chemotherapy with cisplatin (CDDP) and etoposide (VP-16), which had been reported to be effective for small-cell lung cancer. The patient was treated with CDDP (80 mg/m(2)) on day 1 and VP-16 (100 mg/m(2)) on days 1, 3, and 5, every 4 weeks. On the days of chemotherapy, hemodialysis was started as soon as possible after completion of administration of the agents. No severe side effects were observed. After 4 courses of therapy, the patient achieved a partial response.

Postoperative recurrence of an IPMN of the pancreas with a fistula to the stomach.

We report on a case of a 74 year old man who was diagnosed with a recurrence of non-invasive carcinoma of intraductal papillary mucinous neoplasm (non-invasive IPMN) by postoperative gastroscopy (GS). A pylorus preserving pancreatico duodenectomy for IPMN in the pancreatic head was performed. A histopathological study revealed non-invasive adenocarcinoma. At first, the local recurrence of the tumor around the superior mesenteric artery circumference was diagnosed and disappeared with gemcitabine. Later, the GS showed the elevated lesion with mucin hypersecretion in the remnant stomach. The lesion had a central dip and a fistula common to the pancreas was confirmed on fisterography. We diagnosed a recurrence of IPMN and administered chemotherapy again. However, he died of his original illness. There are no reports of postoperative recurrence of IPMN checked by GS. It should be remembered that the elevated lesion of the remnant stomach is considered as one of the recurrent patterns of IPMN.

Ncx (Enx, Hox11L.1) is required for neuronal cell death in enteric ganglia of mice.

BACKGROUND/PURPOSE: Ncx (Enx, Hox11L.1)-deficient (Ncx-/-) mice develop mega-ileo-ceco-colon with a larger number of neuronal cells in the enteric ganglia. We investigated mechanisms related to this abnormality and directed our attention to the effects on gastrointestinal tract functions. METHODS: The number of NADPH diaphorase or cuprolinic blue-positive neuronal cells in the enteric ganglia was examined during growth of the mice. Neuronal cell death of enteric ganglia was assayed by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling. Function of the gastrointestinal tract was determined by measuring excretion time of the barium chloride given into the stomach. RESULTS: The number of neuronal cells decreased in control mice older than 2 weeks, and neuronal cell death was evident in the ganglia. However, the number of neuronal cells did not decrease in Ncx-/- mice, and cell death was rare. Excretion time of barium chloride was prolonged in all Ncx-/- mice examined and was improved by the administration of an inhibitor of nitric oxide synthase. CONCLUSIONS: Ncx participates in cell death of enteric neurons. Motor abnormality of the gastrointestinal tract in Ncx-/- mice may be attributed to the large number of neuronal cells.

Endoscope-assisted thoracoscopic technique for esophageal bronchogenic cyst which presented elevated CA125.

A 26-year-old male was admitted to our hospital with a complaint of mild dysphagia. Preoperative examinations revealed a cystic lesion at the lower esophagus, thought to be a bronchogenic cyst. The patient underwent successful thoracoscopic tumor extirpation, assisted by endoscopy, without undergoing major thoracotomy. Thoracoscopic surgery is recommended for this entity, but the muscle layer is often injured. Endoscopic ultrasonography was very useful, as it could detect damage to the proper muscle layer of the esophagus near the tumor. Thus, we could predict preoperatively that the defect in the muscle layer, which must be closed, would be caused by the surgery. Additionally, endoscopy easily facilitated the detection of the regional defect and the border of the proper muscle layer, and also could be used as a stent during wall suturing. This technique enabled us to avoid postoperative stenosis of the esophagus. Furthermore, our case presented a high level of CA125. The preoperative serum CA125 value was 93.8 U/ml and intratumoral CA125 concentration was 1,690,000 U/ml. Serum CA125 decreased to 16.5 U/ml after surgery. In this paper, we present a new strategy of the treatment for bronchogenic cyst and a review the literature.

Prediction of lymph node status in patients with superficial esophageal carcinoma: analysis of 160 surgically resected cancers.

BACKGROUND: The ability to predict lymph node metastasis in cases of superficial esophageal carcinoma before surgery would allow the identification of specific patients who do not require additional surgical resection after endoscopic local resection. METHODS: From 1980 to 2002 a total of 160 patients with superficial esophageal carcinoma, Tis or T1 tumors, underwent subtotal esophagectomy with lymph node dissection. On the basis of clinicopathologic data the risk factors for lymph node metastases are discussed. RESULTS: Patients with tumors that showed submucosal invasion, a nonflat shape, and lymphatic invasion had a higher risk for lymph node metastasis than the other patients. Multivariate analysis showed that the tumor depth and the macroscopic shape of the tumor were independent risk factors for lymph node metastases. CONCLUSIONS: Esophagectomy with lymph node dissection is recommended for patients with submucosal cancer. Local tumor resection can be recommended for patients with mucosal cancer without lymphatic invasion.

[The operation of Barrett's esophagus].

The purpose of operation in Barrett's esophagus is to protect against esophageal acid exposure. In Western countries antireflux surgery is positive because Barrett's esophagus is recognized as premalignancy. But in Japan many people have SSBE without intestinal metaplasia. Thus if cancer is not detected in Barrett's esophagus, it is difficult to accept surgery. Besides antireflux surgery is not always successful. So the extra-surgical treatment is more recommended than operation in Japan.

Evaluation of Ki-67 and p53 expression in primary and repeated liver metastases of GISTs.

There has been little research evaluating changes related to tumor cell proliferation between primary and metastatic tumors of gastrointestinal tumors in the same case. We herein report the case of a 50-year-old woman with a gastric gastrointestinal stromal tumor (GIST), who developed metastatic liver tumors three times in the 7 years after proximal gastrectomy for GIST. The primary and all the metastatic liver tumors, except the second, showed fascicular/storiform architecture and the short spindle cell type. The diffuse epithelioid cell proliferation was observed in the second metastatic liver tumor. Although the immunostaining pattern with respect to GIST differentiation markers had been preserved in the primary tumor as well as in all of the metastatic tumors, the latter showed weaker positivity of both Ki-67 and p53 than the primary GIST. The primary tumor showed diffuse positive p53, and the highest value of Ki-67 labeling index (LI) among them. The metastatic liver tumors showed focal, negative or sporadic positive appearances of p53, however, Ki-67 LI were scattering among them. Immunohistochemical assessment of Ki-67 LI and p53 might be useful for evaluating changes related to tumor cell proliferation between primary and metastatic tumors of GISTs.

High en bloc resection rate achieved by endoscopic mucosal resection with IT knife for early gastric cancer.

BACKGROUND/AIMS: Circumferential endoscopic mucosal resection (EMR) around lesions performed by an insulation-tipped diathermic knife (IT knife) increases en bloc resection rates, suggesting the possibility of expanding indications for EMR. METHODOLOGY: Clinical outcome of EMR performed by IT knife under general anesthesia was evaluated for 26 patients with 29 early gastric cancer. RESULTS: Successful en bloc resection rates obtained by the IT knife were 100, 87.5, 90.0 and 100% for lesions < or =10 mm in size, 11-20 mm, 21-30 mm, and > or =31 mm, respectively. They were significantly higher with the IT knife than those obtained by the conventional method (IT knife method: 93.1% vs. conventional method: 28.5%, p<0.0001). Two lesions were lateral margin positive, and in three cases invasion of lesions was observed as deep as the submucosa. Distal, total, and proximal gastrectomy with D2 lymphadenectomy, respectively, was provided in 3 cases; however, no lymph node involvement was found in any of the resected specimens. Bleeding and perforation were observed in 3 cases, respectively, however, no additional surgical treatment was required for these patients. CONCLUSIONS: EMR by means of the IT knife under general anesthesia can be performed safely and adequately. It is a useful treatment modality for early gastric cancer.

Inhibitory remnant stomach motility by duodenal distention after B-I gastrectomy.

BACKGROUND/AIMS: Although control of gastric motility is a highly regulated process, B-I gastrectomy causes accelerated gastric emptying. We found few reports so far concerned with the mechanical effect of balloon distention of the duodenum on the remnant stomach in B-I dogs. METHODOLOGY: Four weeks after conventional distal gastrectomy with B-I reconstruction procedure, a balloon was inserted into the duodenum, and strain gauge force transducers (SGTs) were sutured onto the wall of the gastric remnant and duodenal serosa in beagles. After a two-week postoperative recovery period, gastro-duodenal motility was measured with SGTs prior to distention, during distention, and after evacuation of the balloon. The motility index (MI) was calculated every 30 minutes. RESULTS: Upon duodenal distention with 4 mL of water, motility of gastric remnant was significantly inhibited, however, no reduction in duodenal MI was observed. The response was maintained for as long as duodenal distension continued. Ninety minutes after evacuation of the balloon, MI returned to predistension levels. Increased plasma levels of cholecystokinin (CCK) were observed upon distention of the duodenal balloon. CONCLUSIONS: Motility of the remnant stomach in B-I dogs was inhibited by duodenal distension. Increased levels of plasma CCK during distention might play a role in this feedback mechanism.

Elevation of preoperative serum C-reactive protein level is related to poor prognosis in esophageal squamous cell carcinoma.

BACKGROUND AND OBJECTIVES: An increased serum C-reactive protein (CRP) level was found in patients with various malignant tumors and was associated with poor prognosis. The aim of this study was to analyze the clinicopathological significance and the prognostic value of preoperative CRP levels in patients with esophageal squamous cell carcinomas. PATIENTS AND METHODS: The preoperative CRP level was measured by enzyme-linked immunosorbent assay (ELISA) in 150 patients with primary esophageal squamous cell carcinomas. All patients underwent radical surgery without any preoperative therapy. The patients were divided into two groups using a cut-off value of 1.0 mg/dl. The pathological classifications of the tumor were examined according to the TNM/UICC classification. The associations between the clinicopathological factors and CRP level were determined. The prognostic value of CRP was determined using Cox's proportional hazards model. RESULTS: Thirty-five patients (23%) showed high CRP levels (more than 1.0 mg/dl). Statistically significant differences in CRP levels were observed depending on tumor depth (P = 0.022) and TNM/UICC stage (P = 0.001). A high CRP level was associated with poor survival (P = 0.005) and was confirmed by multivariate analysis. CONCLUSIONS: A high CRP level is associated with tumor progression and poor survival in patients with esophageal squamous cell carcinoma.