An endocrine cell carcinoma with gastric-and-intestinal mixed phenotype adenocarcinoma component in the stomach.

A 77-year-old man complained of bodyweight loss, and a Borrmann 3 type lesion was observed endoscopically in the anterior wall of angular region of the stomach. The endocrine cell carcinoma (ECC) having the cytoplasmic staining of chromogranin A (CgA) was detected pathologically in the biopsy samples. The patient underwent distal gastrectomy plus systemic lymph node (LN) dissection (D2 LN dissection), and pathological examination revealed ECC invading the subserosa, and no LN metastasis (pT2N0M0). None of the gastric and intestinal endocrine cell marker expression was apparent in the ECC cells. The lesion also contained a moderately differentiated type tubular adenocarcinoma component, which was judged to be gastric-and-intestinal mixed (GI type) phenotype, using gastric and intestinal exocrine cell markers. After the surgery, he left the hospital and started oral doxifluridine (600 mg/day). The patient now (March 2008, about 19 months since the surgery) continues this chemotherapy with no recurrence. In conclusion, we experienced ECC with a GI type adenocarcinoma component. The ECC cases with the GI type adenocarcinoma component may have a relatively good prognosis, being similar to the results of advanced gastric cancers from the viewpoint of gastric and intestinal phenotypic expression.

Phosphoinositide 3-kinase inhibitor (wortmannin) inhibits pancreatic cancer cell motility and migration induced by hyaluronan in vitro and peritoneal metastasis in vivo.

In order to block peritoneal metastasis of pancreatic cancer cells, we have attempted to block the signal transduction pathway involving hyaluronan (HA), Src, phosphoinositide 3-kinase (PI3K) and Akt. We examined the effects of Src, PI3K and Akt inhibitors on pancreatic cancer cell motility, invasion and metastasis. The pancreatic cancer cell line SW1990, known to cause peritoneal metastasis efficiently in nude mice, was used in this study. SW1990 cells were stimulated by HA to induce Akt phosphorylation. Then, the inhibitory effects of PI3K and Src kinase inhibitors were examined. Cell motility and cell migration assays were adopted to assess the cancer cell motility and its migration capability. We also examined the therapeutic efficacies of PI3K inhibitor wortmannin on peritoneal metastasis of SW1990 cells in the nude mouse model. Stimulation of SW1990 cells by HA markedly induced the Src-PI3K-Akt signaling, thus enhancing cancer cell motility and its migration. Significantly, we found that wortmannin could exert marked inhibition of the peritoneal metastasis of SW1990 in nude mice in vivo. These findings indicate that the PI3K-Akt signaling pathway plays an essential role in peritoneal metastasis and PI3K inhibitors such as wortmannin can be novel modalities to prevent peritoneal metastasis of invasive cancers such as pancreatic cancer.

Palliative Percutaneous Jejunal Stent for Patients with Short Bowel Syndrome.

Gastrointestinal obstruction is a common preterminal event in patients with gastric and pancreatic cancer who often undergo palliative bypass surgery. Although endoscopic palliation with self-expandable metallic stents has emerged as a safe and effective alternative to surgery, experience with this technique remains limited. In particular, a proximal jejunal obstruction requires more technical expertise than a duodenal obstruction. Palliative treatment modalities include both surgical and nonsurgical approaches. In this report, we describe the successful placement of self-expandable metallic stents at the proximal jejunum using a combination of percutaneous endoscopic, intraoperative, and transstomal stenting. Usually endoscopy is not indicated in cases of proximal jejunal obstruction, but some cases may require palliative endoscopy instead of bypass operation.

Granulocyte-colony stimulating factor producing rectal cancer.

BACKGROUND: Granulocyte-colony stimulating factor (G-CSF)-producing cancer has been reported to occur in various organs, especially the lung. However, G-CSF-producing colorectal cancer (CRC) has never been reported in the English literature. CASE PRESENTATION: A 57-year-old man was admitted for the surgical removal of a rectal cancer. Some hepatic tumors in the liver were revealed concurrently, and their appearance suggested multiple liver metastases. Low anterior resection was performed. with the help of histopathological examination and immunohistochemical studies, we diagnosed this case to be an undifferentiated carcinoma of the rectum. After the operation, the white blood cell (WBC) count increased gradually to 81,000 cells/microL. Modified-FOLFOX6 therapy was initiated to treat the liver metastases, but there was no effect, and peritoneal dissemination had also occurred. The serum level of G-CSF was elevated to 840 pg/mL (normal range, <18.1 pg/mL). Furthermore, immunohistochemistry with a specific monoclonal antibody against G-CSF was positive; therefore, we diagnosed this tumor as a G-CSF-producing cancer. The patient died from rapid growth of the liver metastases and peritoneal dissemination 2 months after surgery. CONCLUSION: This is the first case of G-CSF-producing rectal cancer, and its prognosis was very poor.

Complete extragastric growth in a giant gastrointestinal stromal tumor: report of a case.

Gastrointestinal stromal tumors (GISTs) are characterized by remarkable variability in their differentiation potential, but most of these lesions do not display convincing smooth muscle or neuronal differentiation. Here we report the case of a 65-year-old woman who underwent a perfect resection of a large submucosal tumor that displayed extragastric growth. The specimen was revealed to be an elastic soft tumor, 18 x 25 x 11 cm in size. Histologically, the tumor consisted of spindle-shaped cells, with a mitotic rate of 12 per 10 high-power fields. Immunohistochemically, the tumor showed positive staining for CD34 and c-kit but negative staining for alpha-smooth muscle actin, Desmin, and s-100 protein. From these findings, the tumor was diagnosed as an uncommitted type of GIST with high-grade malignancy. This case needs careful and long-term follow-up to monitor for signs of local recurrence or distant metastasis.

Successful paclitaxel-based chemotherapy for an alpha-fetoprotein-producing gastric cancer patient with multiple liver metastases.

BACKGROUND: Alpha-fetoprotein (AFP)-producing gastric cancer is known to frequently cause multiple liver metastases and to have an extremely poor prognosis. CASE PRESENTATION: A 64-year-old Japanese man admitted to our hospital was diagnosed with gastric cancer with liver metastases. He underwent a total gastrectomy with splenectomy, and pathological stage IV disease according to the classification proposed by the Japanese Gastric Cancer Association was assigned. The histological diagnosis was poorly differentiated adenocarcinoma, and tumor production of AFP was confirmed by immunohistochemical staining. Following surgery, the patient received combination chemotherapy consisting of TS-1 and paclitaxel. Initially, AFP levels decreased dramatically and computed tomography (CT) revealed regression of liver metastases. However, multiple new liver metastases appeared and serum AFP levels increased after 5 months. A regimen of 5-FU plus paclitaxel followed by paclitaxel monotherapy was used next. Serum AFP levels once again decreased and CT showed regression or disappearance of liver metastases. The patient currently has a very good quality of life, and is receiving weekly paclitaxel monotherapy as an outpatient. No progression of liver metastases has been observed to date. CONCLUSION: We consider this rare case to have significant value with respect to treatment of AFP-producing gastric cancer with multiple liver metastases, and propose that combining surgery with chemotherapeutic agents such as paclitaxel may lead to a better prognosis in such cases.

Expression of alpha6 integrin subunit is associated with malignancy in gastric gastrointestinal stromal tumors.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common non-epithelial neoplasms of the gastrointestinal tract. The aim of this study was to investigate the clinicopathological and immunohistochemical features of gastric GISTs and to evaluate the degree of integrin expression in order to determine the need for surgery or predict the prognosis for GIST patients. MATERIAL/METHODS: Clinicopathological findings were obtained from patients' records. Specimens from 32 cases of gastric GIST were analyzed with immunohistochemical methods. The c-kit negative examples among the original 48 patients with gastric submucosal and muscle layer tumors were excluded from the study. RESULTS: There was a significant correlation between p53 protein expression and tumor malignancy. The positive staining for proliferating cell nuclear antigen was observed in all patients, and the mean tumor proliferation index for benign and malignant groups were 3.0% and 16.3%, respectively. alpha5beta1 integrin and alpha6 integrin subunit were expressed from moderately to strongly in tumor cells, and alpha 6 integrin subunit expression correlated significantly with whether tumors were classified as benign or malignant. However, there were no significant differences between the survival of GIST patients and integrin expression, mitotic rate, tumor size, or tumor malignancy. CONCLUSIONS: Malignant GISTs show significant expression of alpha6 integrin subunit. It may be useful in supporting other parameters, such as p53, MI, and tumor size. We suggest that alpha6 integrin subunit expression may be useful as an indication for surgery and also as one of several prognostic factors.

Limiting vein puncture to three needle passes in subclavian vein catheterization by the infraclavicular approach.

PURPOSE: With central venous catheterization, each additional vein puncture raises the risk of complications. We assessed the rate of failure and complications using a limiting rule whereby the number of needle passes for subclavian vein catheterization was restricted to three. METHODS: A prospective clinical trial was conducted between September 2001 and December 2003 in a university hospital surgical department. Two hundred and thirty-two adult patients were enrolled to undergo subclavian vein catheterization under non-emergency conditions. The patients were subjected to right subclavian vein catheterization by the infraclavicular approach. Vein puncture failure was defined as such if venipuncture was not accomplished after three attempts. Any arterial puncture was judged to be a failure immediately. RESULTS: Vein puncture failure occurred in nine patients (3.9%), and included two arterial punctures (0.9%). No other complications, such as pneumothorax, hemothorax, plexus lesion, mediastinal hematoma or bleeding, or air embolism, were observed. In multivariate analyses, a close to average body mass index (weight in kilograms divided by the square of the height in meters, odds ratio 0.74; 95% confidence interval 0.56-0.97; P = 0.028) was associated with a low risk of failure. CONCLUSION: Limiting the number of needle passes to three may therefore prevent mechanical complications. A low body mass index was predictive of vein puncture failure.

A new method for constructing an ileal J pouch without an enterotomy.

The conventional methods of making an ileal J pouch require an enterotomy to introduce a linear stapler. We devised a new surgical technique that removes any need for this enterotomy by using both circular and linear staplers. We applied this method to two patients who underwent a total colectomy for ulcerative colitis and succeeded in making a J pouch without difficulty. This procedure may represent an improved method of making a J pouch.

Treatment of peritoneal carcinomatosis using carboplatin-loaded hydroxyapatite particles.

UNLABELLED: The anti-tumor effects and tissue distribution of carboplatin (CBDCA) incorporated into hydroxyapatite (HAP) particles was studied. MATERIALS AND METHODS: Seven days after the intraperitoneal (i.p.) implantation of AH130 tumor cells into Donryu rats, the animals were randomized into four groups: group I was treated with saline i.p.; Group II, with CBDCA i.v.; group III with CBDCA i.p.; and group IV with HAP-CBDCA i.p. RESULTS: The survival rate of group IV was better than that of the other groups (p < 0.05). The area under the ascitic platinum concentration-time curve and tissue concentrations of platinum in the omentum after 24 hours of treatment were higher in group IV than in groups II or III (p < 0.05). The platinum concentrations in the kidneys of group IV were lower than in group III (p < 0.05). CONCLUSION: The HAP-CBDCA combination enhances the anti-tumor effects of the drug and reduces the nephrotoxicity in rats with peritoneal carcinomatosis.

A novel colonic J-pouch procedure.

The conventional methods for making a J-pouch require a stab wound to introduce a linear stapler. We devised a novel procedure that removes any need for this stab wound. With our method, the bowel is first evaginated and a side-to-side anastomosis is created with a linear stapler and the intestine is then returned to a normal position.

An anti-stray stylet for subclavian catheterization by the infraclavicular approach.

OBJECTIVE: Misplacement of subclavian vein catheters has been reported. We assessed the rate of misplacement of a subclavian vein catheter with and without a novel stylet. METHODS: A prospective, randomized, controlled clinical trial was conducted between September 2001 and June 2003 in a university hospital. Two hundred sixteen adult patients were enrolled to receive subclavian vein catheterization under non-emergency conditions. Patients were randomly assigned to undergo right subclavian vein catheterization with the stylet (n = 109, stylet group) or without the stylet (n = 107, control group). The rate of subclavian vein catheter misplacement was determined and risk factors for failure and complications were analyzed. RESULTS: There was no incidence of catheter misplacement in the stylet group, but this occurred in 12 patients in the control group in whom the catheter was misplaced into the ipsilateral internal jugular vein (0% versus 11.2%, P = 0.0003). In multivariate analyses, use of the stylet (odds ratio = 0.062, 95% confidence interval = 0.008 to 0.495, P = 0.009) and a close to average body mass index (odds ratio = 0.73, 95% confidence interval = 0.54 to 0.98, P = 0.038) were associated with low risks of complications and failure, respectively. CONCLUSIONS: This stylet is useful for decreasing the incidence of misplacement of subclavian vein catheters. Body mass index is predictive of failed vein puncture.

Keyhole procedure: a new technique for intestinal anastomosis with a large opening and less tissue trauma, using both circular and linear staplers.

BACKGROUND: We designed a new technique, termed the keyhole procedure, that uses a linear stapler to enlarge the anastomotic opening made with a circular stapler. The present study was performed to evaluate this technique in terms of maximum bursting pressure and area of anastomotic opening and compare it with conventional anastomosis using a circular stapler in an animal model. METHODS: Anastomoses were created by the new technique or by the conventional method in swine small intestine. Anastomosis integrity was assessed by the air leakage test. Anastomotic openings were photographed and measured with an image analyzer. RESULTS: It was found that the area of the anastomotic opening obtained with the new technique was more than 3 times that of the control (P <.001). There was no significant difference between the methods in maximum bursting pressure. CONCLUSIONS: The keyhole procedure provides a larger anastomotic opening than conventional anastomosis with a circular stapler, without impairing the integrity of anastomosis.

[Efficacy of intraperitoneal chemotherapy for advanced Borrmann type IV gastric carcinoma].

We report four patients with advanced Borrmann type IV gastric carcinoma, in whom intraperitoneal chemotherapy with low-dose CDDP and 5-FU plus MMC via a peritoneal port was effective against peritoneal metastasis. However, none of the four patients survived for a long period. During treatment, they were followed on an outpatient basis and received intraperitoneal chemotherapy biweekly with good control of peritoneal metastasis. The ratio of the outpatient follow-up period was more than 50% in all these patients. Intraperitoneal chemotherapy may be effective for controlling peritoneal metastasis of advanced Borrmann type IV gastric carcinoma, and contribute to maintaining the patient's quality of life.

Solitary intraperitoneal recurrence of alpha-fetoprotein-producing gastric carcinoma: report of a case.

A solitary recurrence of gastric carcinoma in the peritoneal cavity is extremely rare. We herein present a case of solitary intraperitoneal recurrence in a patient with alpha-fetoprotein (AFP)-producing gastric carcinoma. As far as we can determine, this is the first report of such a form of recurrence in a patient with gastric carcinoma who underwent a successful resection. A review of our eight patients who had AFP-producing gastric carcinoma showed a frequent association with hepatic metastasis and a poor prognosis as has been reported previously. Our patient received intra-arterial chemotherapy with low-dose cisplatin and 5-fluorouracil to prevent hepatic recurrence, but eventually developed multiple hepatic metastases after ceasing this therapy. Therefore, adjuvant intra-arterial chemotherapy may have altered the site of first recurrence in this patient.

Successful drainage of a mediastinal abscess via an esophago-mediastinal fistula complicating radiotherapy for esophageal cancer: a case report.

Radiotherapy is now commonly employed in patients with inoperable esophageal cancer which invased neighbor organs directly. A rare, but often fatal complication of radiotherapy is perforation with mediastinal abscess. We successfully treated a 65-year-old male patient who developed an esophageal cancer with trans-esophageal drainage and irrigation. This technique may also be useful in the treatment of patients with anastomotic leaks after esophagectomy or idiopathic esophageal rupture.