Differences in Attitudes and Practices of Cancer Pain Management between Medical Oncologists and Palliative Care Physicians.

This study aimed to evaluate whether there are differences in the attitudes and practices of cancer pain manage-ment between medical oncologists and palliative care physicians. An online nationwide survey was used to collect responses from board-certified medical oncologists and palliative care physicians in Japan. The survey questionnaire comprised 30 questions. The differences in responses between medical oncologists and palliative care physicians were examined. Out of the 1,227 questionnaires sent, 522 (42.5%) were returned. After apply-ing the exclusion criteria, 445 questionnaires (medical oncologists: n = 283; palliative care physicians: n = 162) were retained for analysis. Among the questions about potential barriers to optimal cancer pain man-agement, both medical oncologists and palliative care physicians considered the reluctance of patients to take opioids due to fear of adverse effects as the greatest barrier. Significantly different ratings between medical oncologists and palliative care physicians were observed on 5 of the 8 questions in this area. Significantly differ-ent ratings were observed for all questions concerning pain specialists and their knowledge. For effective cancer pain management, it is important to account for differences in attitudes and practice between medical oncolo-gists and palliative care physicians.

Multicenter Prospective Study on the Safety of Upper Gastrointestinal Endoscopic Procedures in Antithrombotic Drug Users.

BACKGROUND: The Japan Gastroenterological Endoscopy Society updated its guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment in July 2012. However, the safety of endoscopic procedures in antithrombotic drug users has not been fully investigated. AIMS: To evaluate the safety of upper gastrointestinal endoscopic procedures in antithrombotic drug users. METHODS: From September 2013 to September 2015, patients who were taking antithrombotic drugs and who underwent upper gastrointestinal endoscopic procedures were prospectively enrolled at five hospitals. Incidences of bleeding and thrombosis during endoscopic procedures were evaluated. RESULTS: A total of 270 patients [221 for endoscopic mucosal biopsy and 49 for endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) were enrolled. The bleeding rate was 0.9% for endoscopic mucosal biopsy and 22% for EMR/ESD, respectively. The bleeding rate after endoscopic mucosal biopsy was not significantly high, even if antithrombotic drugs were continued (0 vs. 1%, P > 0.99), while it was significantly higher among multiple antithrombotic drug users than single drug users (5.9 vs. 0%, P < 0.05). The bleeding rate after EMR/ESD was also higher among multiple antithrombotic drug users than single drug users, but was not significantly different (33 vs. 14%, P = 0.17). Moreover, there were no differences in bleeding rates according to the cessation or continuance of antithrombotic drugs (20 vs. 25%, P = 0.74). There were no thromboembolisms in all cases. CONCLUSIONS: Upper gastrointestinal endoscopic procedures performed under the new guidelines appear acceptable. However, endoscopic procedures among multiple antithrombotic drug users show a greater potential for bleeding.

Optimal Bowel Preparation Method to Visualize the Distal Ileum via Small Bowel Capsule Endoscopy.

Small bowel capsule endoscopy (SBCE) is a convenient and minimally invasive method widely used to evaluate the small intestine. However, especially in the distal ileum, visualization of the intestinal mucosa is frequently hampered by the remaining intestinal contents, making it difficult to detect critical lesions. Although several studies have reported on the efficacy of bowel preparation before SBCE, no standardized protocol has been established. Herein, we determined the optimal preparation method for better visualization of the distal ileum using SBCE. We retrospectively analyzed 259 consecutive patients who had undergone SBCE between July 2009 and December 2019, divided into three groups: Group A (no preparation except overnight fasting), Group B (ingestion of 1-2 L polyethylene glycol 4 h before colonoscopy after overnight fasting and performing SBCE immediately after colonoscopy), and Group C (ingestion of 0.9 L magnesium citrate [MC] before SBCE after overnight fasting). The visibility of the intestinal mucosa in the first 10 min and at the last 10 min during the period of observation of the distal ileum was examined using a scoring system and compared. The visibility of the images captured by SBCE was assessed based on the scoring of the degree of bile/chyme staining, residual fluid and debris, brightness, bubble reduction, and visualized mucosa. The status of intestinal collapse was also assessed. In the first 10 min of observation of the distal ileum, no significant differences were detected among the groups. In the last 10 min, significantly better images were acquired in Group C in terms of bile/chyme staining, brightness, bubble reduction, and visualized mucosa. Bowel preparation using a low-dose MC solution 2 h before SBCE provided significantly higher-quality images of the distal ileum. Further optimization, such as the timing of initiating the preparation, is necessary to determine the optimal regimen for bowel preparation prior to SBCE.

A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video).

BACKGROUND: Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer, although it is not widely used in the colorectum because of technical difficulty. OBJECTIVE: To examine the current status of colorectal ESDs at specialized endoscopic treatment centers. DESIGN AND SETTING: Multicenter cohort study using a prospectively completed database at 10 specialized institutions. PATIENTS AND INTERVENTIONS: From June 1998 to February 2008, 1111 colorectal tumors in 1090 patients were treated by ESD. MAIN OUTCOME MEASUREMENTS: Tumor size, macroscopic type, histology, procedure time, en bloc and curative resection rates and complications. RESULTS: Included in the 1111 tumors were 356 tubular adenomas, 519 intramucosal cancers, 112 superficial submucosal (SM) cancers, 101 SM deep cancers, 18 carcinoid tumors, 1 mucosa-associated lymphoid tissue lymphoma, and 4 serrated lesions. Macroscopic types included 956 laterally spreading tumors, 30 depressed, 62 protruded, 44 recurrent, and 19 SM tumors. The en bloc and curative resection rates were 88% and 89%, respectively. The mean procedure time ± standard deviation was 116 ± 88 minutes with a mean tumor size of 35 ± 18 mm. Perforations occurred in 54 cases (4.9%) with 4 cases of delayed perforation (0.4%) and 17 cases of postoperative bleeding (1.5%). Two immediate perforations with ineffective endoscopic clipping and 3 delayed perforations required emergency surgery. Tumor size of 50 mm or larger was an independent risk factor for complications, whereas a large number of ESDs performed at an institution decreased the risk of complications. LIMITATIONS: No long-term outcome data. CONCLUSIONS: ESD performed by experienced endoscopists is an effective alternative treatment to surgery, providing high en bloc and curative resection rates for large superficial colorectal tumors.

A case of small undifferentiated intramucosal gastric cancer with lymph node metastasis.

Early gastric cancer (EGC) has a favorable prognosis after surgical gastrectomy. For intramucosal EGC with little risk of lymph node metastasis, endoscopic mucosal resection (EMR) is an accepted treatment method. Herein we document a noteworthy case of small undifferentiated gastric cancer with nodal metastasis. A 60-year-old Japanese woman underwent gastrectomy with D2 lymph node dissection for the treatment of EGC in the lower gastric body. Histological examination revealed that signet-ring cell carcinoma was located in approximately one-third of the superficial portion of the mucosal layer, with a tumor size of 13 mm. No lymphatic invasion, venous invasion, or fibrosis was observed in the submucosal layer. This case had nodal metastasis and was finally diagnosed as stage IB (T1N1M0) according to the Japanese Classification of Gastric Carcinoma (JCGC). The patient is alive without recurrence 6 years after treatment.

Risk factors for metachronous gastric cancer in the remnant stomach after early cancer surgery.

BACKGROUND: Early gastric cancer patients have a good prognosis after radical resection. However, if the patients have a gastric remnant after the surgery, the risk of metachronous gastric cancer remains. The aim of this study was to clarify the risk factors for metachronous gastric cancer after partial gastrectomy for early gastric cancer. METHODS: Data on a series of 1281 consecutive gastrectomy patients with pathologically confirmed early gastric cancer from 1991 to 2007 in Shikoku Cancer Center were analyzed retrospectively. RESULTS: The gastric remnants of 868 patients were periodically surveyed by endoscopic examination. Among those surveyed cases, 26 patients were diagnosed as having metachronous gastric cancer in the gastric remnant. They underwent curative resection by remnant gastrectomy (n = 13 patients) or endoscopic mucosal resection (n = 13 patients). Multivariate analysis showed that male sex, older age, submucosal invasion, and proximal gastrectomy were independent risk factors. CONCLUSIONS: Our data suggested that more intensive endoscopic follow-up is needed for the remnant stomach in patients with these risk factors to detect metachronous gastric cancer at its early stage.

High orotate phosphoribosyltransferase gene expression predicts complete response to chemoradiotherapy in patients with squamous cell carcinoma of the esophagus.

OBJECTIVE: Chemoradiotherapy (CRT) is a possible alternative to surgery for esophageal cancer. As complete response (CR) to CRT is essential for a good prognosis, potential biomarkers predictive of CR were explored. METHODS: Endoscopic tumor biopsies were obtained from 41 patients with stage II-III esophageal squamous cell carcinoma before 5-fluorouracil/cisplatin-based definitive CRT. cDNA was derived from RNA isolated from microdissected tumor cells. mRNA expression levels of 10 genes involved in CRT or tumor biology were measured using quantitative real-time RT-PCR. RESULTS: Expression levels of orotate phosphoribosyltransferase (OPRT) and dihydrofolate reductase mRNA were significantly higher in the CR group compared with the non-CR group (p = 0.0206 and 0.0191, respectively). Matrix metalloproteinase 9 mRNA expression was significantly lower in the CR group (p = 0.0436). CR rates were significantly higher in patients with node-negative disease and high expression levels of OPRT and dihydrofolate reductase genes (p = 0.0448, 0.0104 and 0.0104, respectively). No significant difference in CR rates was observed for other variables. Multivariate analysis revealed that high OPRT gene expression was an independent predictive factor of CR (p = 0.0192). It was also significantly associated with good prognosis (p = 0.0450). CONCLUSION: High OPRT gene expression may be a predictive factor of CR to 5-fluorouracil/cisplatin-based CRT in esophageal cancer.

A case of early colorectal cancer with rectal varices treated with endoscopic variceal ligation.

Rectal varices are ectopic varices that occur in patients with portal hypertension and cause abrupt gastrointestinal bleeding. Endoscopic variceal ligation is a minimally invasive treatment used for patients with bleeding from rectal varices. Endoscopic treatment of colorectal tumors accompanied by rectal varices has been rarely reported. It is very important to control bleeding during treatment. The patient was a 76-year-old man who had a chief complaint of bloody stools. A flat-elevated-type neoplastic lesion measuring about 20 mm was found above the rectal varices. After performing endoscopic variceal ligation for rectal varices around the lesion, the lesion was resected en bloc by endoscopic submucosal dissection. Bleeding was controlled during the procedure; the patient was discharged 7 days after the endoscopic treatment, and there was no postoperative bleeding. Colonoscopy performed 90 days after the procedure showed scar formation in the wound area and no remnant lesion. The implementation of preoperative endoscopic variceal ligation enabled us to control bleeding during endoscopic treatment in a case of early colorectal cancer accompanied by rectal varices.

A multicenter observational study on the clinicopathological features of gastric cancer in young patients.

BACKGROUND: The details of gastric cancer in young patients remain unclear because of the low prevalence of the disease. This study aimed to clarify the clinicopathological features and prognosis of gastric cancer in young patients. METHODS: From January 2007 to January 2016, patients in their 20s and 30s who were diagnosed with primary gastric cancer at 4 hospitals were enrolled. Their clinical characteristics and prognosis were evaluated. RESULTS: The total number of patients was 72. The median age was 36 years, and the ratio of males to females was 1:1. The dominant histological type was undifferentiated type (66/72, 92%). Helicobacter pylori (H. pylori) was positive in 81% (54/67). Although there were some asymptomatic patients in stages I-III, all stage IV patients had some clinical symptoms at the diagnosis. The percentage of stage IV was significantly higher in patients in their 20s than in those in their 30s (75% vs. 25%, P < 0.001). The Kaplan-Meier method showed that the overall survival of patients in their 20s was significantly lower than that of patients in their 30s (P = 0.037). CONCLUSIONS: A high rate of H. pylori infection was revealed in young gastric cancer patients. The patients in their 20s had a worse prognosis than those in their 30s. We should consider examining the H. pylori infection status for young patients as well as older patients to identify high-risk populations.

Change of clinical characteristics of ulcerative colitis in Japan: analysis of 844 hospital-based patients from 1981 to 2000.

BACKGROUND: Although the number of ulcerative colitis patients has increased rapidly in Japan, few reports have been published regarding their clinical aspects. We investigated the clinical characteristics and chronological change of ulcerative colitis in Japanese patients. METHODS: Patients diagnosed with ulcerative colitis during the period from 1981 to 2000 were registered and their clinical profiles were analyzed. The chronological changes in clinical aspects, such as onset age, sex distribution, severity, extent of disease, clinical course, and corticosteroid use, were also determined. RESULTS: A total of 844 patients were registered, composed of 431 men and 413 women, with a median onset age of 34 years. The proportion of mild colitis and proctitis was significantly larger in patients with an onset at over 60 years of age, relative to those with an onset at less than 30 years (P<0.016). The proportion of ulcerative colitis patients with old age onset (P=0.09), male sex (P<0.01), mild colitis (P<0.01), proctitis (P<0.01), one-attack-only type (P<0.01), and not-treated-with-corticosteroid (P<0.01) demonstrated a chronological increase from 1981 to 2000. CONCLUSIONS: The distinctive clinical features and chronological change were seen in Japanese ulcerative colitis patients in recent years. Our data can help understand clinical aspects of ulcerative colitis patients in Asia, where the incidence of ulcerative colitis is still increasing.

Identification of risk factors for lymph node metastasis of colorectal cancer.

BACKGROUND/AIMS: Although lymph node metastasis is widely considered to be the potent prognostic factor in colorectal cancer patients, the clinical risk factors for lymph node metastasis in these patients have been scarcely analyzed. METHODOLOGY: The clinical records of 2125 patients who underwent colonoscopy and were diagnosed with colorectal cancer were reviewed. RESULTS: Multivariate analysis revealed that an increase in T stage (odds ratio (OR); 2.54, 95% confidence interval (CI) 2.17-2.98), and tumors with high grade pathology (OR; 1.63, 95% CI 1.10-2.41) were identified as the independent predictive factors for the presence of lymph node metastasis. On the other hand, the presence of synchronous adenomas (OR; 0.78, 95% CI 0.65-0.95) was a predictor for being free of lymph node metastasis. Stratification of the risk according to age and gender revealed that a tumor located in the right colon indicated significant risk for patients less than 50 years old (OR; 2.23, 95% CI 1.01-4.95), whereas tumors with high grade pathology indicated a significant risk only in female patients (OR; 1.74, 95% CI 1.01-3.00). CONCLUSIONS: The significant risk factors for lymph node metastasis were elucidated, and may facilitate surgeons in deciding the best surgical procedure to implement and pathologists in treating resected specimens.

Higher incidence of gastric remnant cancer after proximal than distal gastrectomy.

BACKGROUND/AIMS: Proximal gastrectomy has been widely accepted as a standard operation for early stage gastric cancer located in the upper third of the stomach. Therefore, cancer of the distal gastric remnant is now increasing. The aims of this study were to clarify and compare the incidences of gastric remnant cancer after proximal and distal gastrectomy. METHODOLOGY: Data on a consecutive series of 809 cases of gastrectomy performed for early gastric cancer from 1991 to 2003 in Shikoku Cancer Center were analyzed retrospectively with respect to the incidence of gastric remnant cancer. RESULTS: We performed distal gastrectomy in 624 patients and proximal gastrectomy in 47 patients during the study period. After those operations, the gastric remnants of 457 cases and 33 cases, respectively, were surveyed periodically by endoscopic examination at our hospital. Among those surveyed cases, 10 patients (2.2%) and 3 patients (9.1%) were diagnosed as having gastric remnant cancer, respectively. The gastric remnant cancer-free survival after proximal gastrectomy was significantly lower than that after distal gastrectomy. CONCLUSIONS: Because of the higher incidence of gastric remnant cancer after proximal gastrectomy, it is more important to survey the gastric remnant after proximal gastrectomy periodically by postoperative endoscopic examination.

Risk factors and indications for first surgery in Crohn's disease patients.

BACKGROUND/AIMS: Despite appropriate medical treatment, a large part of CD patients undergo surgery. In this study, we aimed to identify the risk factors and indications for first surgery in CD patients. METHODOLOGY: The clinical records of 289 consecutive Japanese CD patients treated at 23 hospitals between January 1981 and August 2003 were reviewed. Clinical factors, including gender, age at onset, year at onset, and disease extent were examined, in order to identify the risk factors for first surgery. In addition, indications for first surgery were investigated, and stratified by these risk factors. RESULTS: A total of 113 (39%) patients underwent surgery at least once. Female gender (RR, 1.62; 95% CI, 1.09-2.41), and disease affecting the ileum (RR, 2.06; 95% CI, 1.20-3.53) were identified as the independent risk factors for surgery. In addition, female CD patients were more likely to undergo first surgery due to the indication of perforation than male patients (25% vs. 6%, p=0.006). Recent clinical and demographic changes of Japanese CD patients, such as increases in female and aged patients, did not affect the surgical risk factors and indications. CONCLUSIONS: Female CD patients should be consulted with special attention to the high risk of surgery due to perforation.

[Clinical study of irinotecan plus infusional fluorouracil/l-leucovorin (FOLFIRI) in patients with fluoropyrimidine-resistant metastatic colorectal cancer].

The clinical efficacy and safety of irinotecan plus infusional fluorouracil/l-leucovorin (FOLFIRI) in patients with fluoropyrimidine-resistant metastatic colorectal cancer were studied retrospectively. 20 patients were treated with FOLFIRI at our hospital between October 2003 and November 2005. The objective overall response rate was 28% (5/18; 95% confidence interval, 9.7-54%). The disease control rate (CR+PR+SD) was 61%. The most frequent grade 3 to 4 adverse event was neutropenia, and it was seen in 50%. Non-hematological toxicities were mild. The median survival time was 11 months. The 1-year survival rate was 34%. This study showed the activity and safety of FOLFIRI in practice.

[A case of alpha-fetoprotein-producing minute mucosal gastric cancer].

The endoscopic examination of a 63-year-old man revealed a IIc lesion, 5 mm in diameter, in the lesser curvature of the gastric body. His serum alpha-fetoprotein (AFP) level was high at 14.3 ng/ml. Immunohistological studies on the biopsy specimens showed a positive reaction for AFP. Endoscopic ultrasonography revealed that the tumor was limited to the second layer of the gastric wall and this tumor was diagnosed as mucosal cancer. The final diagnosis was AFP-producing mucosal gastric cancer (AFPMGC). Cases of AFPMGC are rarely encountered. The present case suggested that even minute mucosal gastric cancer could produce AFP.

Clinical Characteristics of Seven Patients with Lanthanum Phosphate Deposition in the Stomach.

Objective To analyze the clinical characteristics and endoscopic features of patients with lanthanum deposition in the stomach. Patients We retrospectively reviewed seven patients with lanthanum deposition in the stomach who were diagnosed at Okayama Saiseikai General Hospital. We investigated the patient sex, age at diagnosis, medical and medication histories, gastrointestinal symptoms, complications, presence or absence of gastric atrophy, and outcome. We also investigated any changes in the endoscopic features if previous endoscopic images were available. Results Seven patients (six males and one female) had lanthanum deposition. The median age was 65 years (range, 50-79 years). All patients had been undergoing dialysis (continuous ambulatory peritoneal dialysis in one patient, hemodialysis in six patients). The dialysis period ranged from 16 to 73 months (median, 52 months). The patients had all been taking lanthanum carbonate for a period ranging from 5 to 45 months (median, 27 months). Gastric atrophy was noted in 6 patients (85.7%). One patient had difficulty swallowing, and 1 other patient had appetite loss. The other 5 patients were asymptomatic. Endoscopic features included annular whitish mucosa (n = 4), diffuse whitish mucosa (n = 3), and whitish spots (n = 2). Five patients underwent multiple esophagogastroduodenoscopy. The endoscopic features were unchanged in 2 patients, whereas the whitish mucosa became apparent and spread during the course in 3 patients. Conclusion We identified 7 patients with lanthanum deposition in the stomach. All patients showed whitish lesions macroscopically. Although the pathogenicity of gastric lanthanum deposition is uncertain, lanthanum-related lesions in the stomach progressed during continuous lanthanum phosphate intake in several patients.

[A case of gastric hamartomatous inverted polyp (submucosal tumor type) accompanied by gastric cancer].

Endoscopic examination of a 39-year-old woman revealed a flat-elevated submucosal tumor (SMT) in the upper third area of the stomach and a IIc lesion in the anterior wall of the lower third of the stomach. Endoscopic ultrasonography findings suggested an aberrant pancreas. Both lesions were resected by distal gastrectomy. Histological examination of the SMT revealed the dilated glands with cyst formation and proliferation of smooth muscle bundles in the submucosal layer, and it was diagnosed as a gastric hamartomatous inverted polyp. The IIc lesion was a signet ring cell carcinoma. Cases of gastric hamartomatous inverted polyps coexistent with gastric cancer have been rarely reported in Japan.

A phase I study of doxifluridine combined with weekly paclitaxel for metastatic gastric cancer.

PURPOSE: Based on the synergistic effect in preclinical studies, a phase I clinical trial for the combination of paclitaxel and doxifluridine (an intermetabolite of capecitabine) was performed to determine the recommended dose for the treatment of patients with metastatic gastric cancer. METHODS: The dose of paclitaxel was increased from 60 mg/m2 at level 1 to 90 mg/m2 at level 5. It was administered as a 1-h infusion on days 1 and 8. The dose of doxifluridine was fixed at 600 mg/m2 per day up to level 3, and escalated to 800 mg/m2 per day at levels 4 and 5. It was administered orally for 2 weeks. The treatment was repeated every 3 weeks. RESULTS: A total of 28 patients were enrolled. No dose-limiting toxicity (DLT) was observed at levels 1 and 2 (paclitaxel 70 mg/m2). A DLT of grade 4 neutropenia lasting for more than 4 days was observed in one patient at level 3 (paclitaxel 80 mg/m2). In addition, the first five of six patients in this group experienced grade 3 neutropenia during the first treatment cycle. A further six patients were added in order to confirm the safety of this dosage level, and no more DLTs except for grade 3 nausea in one patient were observed in the second cohort. No DLT was seen in three patients at level 4 (paclitaxel 80 mg/m2). DLTs (grade 3 neuropathy in one patient and a treatment delay of the second cycle for more than 1 week due to grade 3 neutropenia in another) were observed in two out of six patients at level 5 (paclitaxel 90 mg/m2), and this dose level was determined as the maximum tolerated dose. The tumor response rate was 42% (95% confidence interval 20-67%) in 19 patients with measurable lesions. CONCLUSIONS: The recommended dose was determined as 80 mg/m2 of paclitaxel (days 1 and 8) and 800 mg/m2) of doxifluridine (days 1-14) every 3 weeks. The results of this phase I study are encouraging and a phase II trial is thus warranted.