Endoscopic Resection is Infeasible for Early Gastric Cancers with Undifferentiated Components.

BACKGROUND/AIMS: Aim of this study is to find subgroup of early gastric cancer with lymph node metastasis for which successive further surgical operation is needed after endoscopic resection. METHODOLOGY: A total of 559 lesions of early gastric cancer, which had undergone curative gastrectomy, were enrolled in this study. We retrospectively investigated 10 clinicopathological factors predictive of lymph node metastasis by univariate and multivariate analysis. We showed the frequency of lymph node metastasis of subgroups in combination of independent factors selected by multivariate analysis. RESULTS: Lymph node metastases were detected in 57 lesions (10.2%). Univariate analysis revealed that lesion size > 30 mm, undifferentiated components, sm massive invasion, lymphatic invasion and venous invasion were factors significantly correlated with lymph node metastasis. By multivariate analysis, risk factors for lymph node metastasis were lesion size > 30 mm, undifferentiated components, sm massive invasion, and lymphatic invasion, with odds ratios of 2.17, 2.30, 5.88 and 8.24, respectively. In lesions with undifferentiated components, LNM were found in all subgroups. CONCLUSIONS: When we treat early gastric cancers contained undifferentiated components, even if they are predominantly differentiated-type intramucosal lesions, an additional surgical procedure should be considered or careful follow-up is required.

[Case of gastric cancer with recurrence of carcinomatous lymphangiosis of the lung 7.6 years after surgery and successfully treated with S-1/low-dose CDDP/Lentinan combination therapy].

A 78-year-old woman underwent gastrectomy for type 3 gastric cancer with pyloric stenosis, which was detected in November 1997. Thoracic and abdominal CT and other diagnostic procedures were conducted regularly for 5 years after surgery. The patient was recurrence-free and her clinical course was satisfactory. Starting in early May 2005, however, she began to experience respiratory difficulty at exertion, which exacerbated rapidly thereafter. Examination at a department of respiratory physiology led to a diagnosis of a recurrence of stomach cancer and carcinomatous lymphangiosis+lymphatic metastasis to the peritoneal cavity. She was referred to us for palliative care. The accentuated respiratory difficulty was eased with oxygen inhalation and opioid administration. With improvement in her respiratory condition, a combination of S-1 80 mg/day, CDDP 10 mg x once/week and Lentinan 1 mg x twice/week, was initiated. Within about 2 weeks, her respiratory difficulty was eliminated and after 4 weeks x 2 courses, the tumor images were no longer recognized in the thoracic and abdominal CTs. The combination therapy of S-1/low-dose CDDP/Lentinan is free of evident adverse effects and may be a potent therapeutic alternative as a palliative therapy for malignant stomach cancers in elderly patients or those in a poor systemic condition.

Retrospective analysis of the results of strip biopsies to determine the indication for endoscopic submucosal dissection for early gastric cancer.

OBJECTIVE: To determine the indication for endoscopic submucosal dissection, we retrospectively analyzed the results of strip biopsies for early gastric cancer. METHODS: We studied 374 lesions of 360 patients with early gastric cancer. The resection results were classified into complete local resection and incomplete resection. The relations among the resection results and maximum tumor diameter, tumor location, and 1-year recurrence were analyzed. RESULTS: Complete local resection was achieved by strip biopsy for 206 of the 374 lesions (55.1%). For the 168 lesions with incomplete resection, local recurrence was found in 22. The rate of complete local resection in strip biopsy was significantly low, and the rate of local recurrence was significantly high for lesions exceeding 2 cm in diameter as well as for lesions of the cardiac part and the angular part of the lesser curvature. CONCLUSIONS: Our strip biopsy results suggest that endoscopic submucosal dissection is needed for early gastric cancer lesions larger than 2 cm in diameter and for those located in the cardiac part and angular part of the lesser curvature.

En bloc resection for primary non-Hodgkin's lymphoma of the descending colon with massive extension into the neighboring organs.

A 79-year-old female who was surgically treated and received adjuvant chemotherapy for primary non-Hodgkin's lymphoma of the descending colon with massive extension into the pancreatic tail, spleen, and left kidney is herein reported. The patient had acute colonic obstruction and an urgent laparotomy was performed because endoscopic decompression using a transnasal ileus tube could not be done. We performed a left colectomy with an en bloc resection of the neighboring organs, followed by the creation of an end colostomy. The patient had no major postoperative complications and is well without any recurrence of lymphomas 6 months after surgery.

Clinical impact of strip biopsy for early gastric cancer.

BACKGROUND: The impact of EMR (strip biopsy method) on the selection of subsequent treatment for early gastric cancer was analyzed retrospectively. METHODS: A total of 163 consecutive patients with gastric epithelial tumors (186 lesions) underwent strip biopsy. On the basis of pretherapeutic findings, the indications for strip biopsy were classified into 4 groups: benign-malignant borderline group (93 lesions), curative indication group (65), diagnostic indication group (22), and palliative indication group (6). The clinical impact of the strip biopsy result on the subsequent treatment strategy was assessed. RESULTS: Of the lesions in the benign-malignant borderline group, 36.6% were intramucosal cancer. In the curative indication group, the results of strip biopsy differed from the pretherapeutic findings for 7.7% of the lesions. Strip biopsy was effective treatment for all lesions in the benign-malignant borderline group and for 92.3% of those in the curative indication group. Strip biopsy avoided unnecessary surgery in 50% of patients in the diagnostic indication group and 16.7% of those in the palliative indication group. After the strip biopsy results were explained, 50% of the patients in the palliative indication group reversed their initial decision and opted for surgery. Strip biopsy results reversed the decision for surgery, which had been based on inaccurate pretherapeutic information, in 20% of cases of early gastric cancer. CONCLUSIONS: Strip biopsy has a major clinical impact, because it provides an accurate diagnosis, aids in the selection of an appropriate treatment strategy, and reduces unnecessary surgery.

Cutaneous metastasis from pancreatic adenocarcinoma: a case report and a review of the literature.

We treated a 77-year-old Japanese man with cutaneous metastases from pancreatic adenocarcinoma. Physical examinations revealed reddish, non-tender and firm nodules in left axilla. Laboratory examination showed a remarkable elevation in the tumor markers of CA 19-9, DUPAN-2 and SPAN-1. Abdominal computed tomography showed a low-density mass in the tail of the pancreas, and histological examination of nodule in the axilla revealed a metastatic adenocarcinoma. The immunohistochemistry of CA 19-9 in the excised nodule was positive. Cutaneous metastasis from pancreatic adenocarcinoma is usually rare, and the prognosis is poor, as the disease is usually advanced.

Prognostic value and interobserver agreement of endoscopic ultrasonography for superficial squamous cell carcinoma of the esophagus: a prospective study.

BACKGROUND AND AIMS: Submucosal invasion of superficial esophageal cancer (SEC) is related to the prognosis. We prospectively analyzed outcomes of SEC in patients staged by endoscopic ultrasonography (EUS). PATIENTS AND METHODS: We staged 31 endoscopically diagnosed SEC cases using a 20/15-MHz thin probe. The EUS tumor stage was classified as EUSM (limited within mucosa), EUS-SM (with submucosal invasion), or EUS-MP over (invading the muscularis propria or deeper). Lymph node metastasis and 2-yr survival were analyzed according to the EUS tumor stage in 29 squamous cell carcinoma cases. Interobserver agreement of the EUS stage was tested between the examiner and a blind reviewer. RESULTS: Lymph node metastasis was significantly frequent in the EUS-SM group (8 of 18 cases [44.4%]) compared with the EUS-M group (1 of 10 cases [10%]) (p = 0.03). Patient survival at 2 yr after initial therapy was 72.2% in the EUS-SM group and 90% in the EUS-M group. Death from cancer was noted only in the EUS-SM group (three cases). The accuracy rates of EUS tumor staging were 74.1% by the examiner and 66.7% by the blind reviewer, with moderate interobserver agreement (kappa = 0.46). CONCLUSIONS: Thin-probe EUS can classify SEC into two groups: the EUS-M group with excellent outcome and the EUS-SM group with a significant risk of lymph node metastasis.

Epstein-Barr virus association is rare in esophageal squamous cell carcinoma.

BACKGROUND: A critical role of Epstein-Barr virus (EBV) in carcinogenesis of nasopharyngeal squamous cell carcinoma and gastric adenocarcinoma is strongly suspected. We analyzed the possible EBV association for Japanese squamous cell carcinoma (SCC)-dominant esophageal cancer cases. METHODS: We retrospectively screened 36 surgically resected esophageal cancer lesions from 36 patients mainly with SCC using in situ hybridization (ISH) for EBV-encoded small RNA1 (EBER-1). EBV DNA analysis using real-time quantitative polymerase chain reaction (Q-PCR) was performed for three recent cases. RESULTS: We found no EBER-1-positive cancer cell in any tested esophageal cancer lesion. There were many EBER-1-positive tumor-infiltrating lymphocytes in the basaloid SCC lesion and a small number of positive lymphocytes in the other five advanced SCC lesions (14.7% of SCC). One SCC lesion with a highcopy number of EBV DNA had EBER-1-positive lymphocytes. CONCLUSIONS: EBV is rarely associated with esophageal SCC, and may appear through tumorinfiltrating lymphocytes in some advanced lesions.

Pancreatic arteriovenous malformation treated by transcatheter embolization.

Arteriovenous malformation of the pancreas is a rare condition that may cause upper gastrointestinal bleeding. A 58-year-old man with an arteriovenous malformation of the pancreas is described. The patient had recurrent episodes of melena. The diagnosis was confirmed by angiographic study and color Doppler ultrasonography. Therapeutic embolization of the arteriovenous malformation was successfully carried out. In conclusion, transcatheter arterial embolization should be chosen for the patient with the pancreatic arteriovenous malformation.