Is curative gastrectomy justified for gastric cancer with cytology positive as the only stage IV factor?

AIMS: The prognosis of patients with gastric cancer and stage IV factors is poor. However, several recent studies have identified that curative surgery followed by S-1 chemotherapy for cytology positive (CY1) only patients contributed to a better prognosis. This study was designed to compare the prognosis between curative and palliative gastrectomy followed by chemotherapy in CY1 only stage IV gastric cancer. METHODS: Between 2001 and 2016, 1507 patients underwent gastrectomy for gastric cancer. Of these, 51 consecutive patients with only CY1 factor who underwent gastrectomy followed by chemotherapy were enrolled in this study. RESULTS: (1) Twenty three (45%) patients underwent curative D2 or D2+ gastrectomy, and the remaining 28 (55%) patients underwent palliative gastrectomy, followed by S-1 based or another historical recommended chemotherapy postoperatively. (2) Compared with patients undergoing palliative gastrectomy, patients undergoing curative gastrectomy had a significantly better prognosis (P = 0.042; median survival time: curative vs. palliative, 22.6 months vs. 11.8 months) and a lower incidence of recurrences (P = 0.091). Two- and five-year overall survival rates of patients following curative gastrectomy were 48.2% and 18.2%, respectively. A multivariate analysis showed that venous invasion [P = 0.006; hazard ratio (HR), 3.70 (95% CI: 1.27-9.43)] and curative gastrectomy [P < 0.005; HR, 0.28 (95% CI: 0.12-0.87)] were independent prognostic factors. CONCLUSION: Curative gastrectomy followed by chemotherapy might be justified to improve the prognosis of patients with only CY1 Stage IV gastric cancer.

[A Case of GIST with Extensive Peritoneal Dissemination Controlled over Long-Term by Low-Dose, Intermittent Administration of Imatinib after Weight Loss Surgery].

A 67-year-old man presented with abdominal pain and fever. Many abdominal tumors were detected by enhanced computed tomography(CT). The largest tumor, measuring 20 cm, had perforated the ileum and formed an abscess. Emergency surgery was performed to remove multiple tumors in the peritoneal cavity as much as possible. Immunostaining showed c-kit and CD34 positivity, and the tumors were diagnosed as gastrointestinal stromal tumor(GIST). During postoperative imatinib therapy for the residual tumor, low-dose intermittent administration was required due to side effects, but the disease was controlled for over 91months. For advanced GIST with peritoneal dissemination, 200mg/day imatinib or intermittent administration after volume reduction surgery might be effective depending on the patient's general condition.

[A Case of Resection for Metastatic Osseous Tumor from Rectal Cancer].

A 67-year-old male was referred to our hospital for further investigation of fecal occult blood. We diagnosed him with rectal cancer with osseous metastasis. Chemo-and radiation therapy were administered following resection of the rectal cancer. There were no other lesions except for the osseous metastasis remaining after these interventions. The osseous lesion was then resected. There have no signs of recurrence for 1 year and 9 months since the last operation. We report a case of successful resection of osseous metastasis from rectal cancer.

[Endovascular trapping using a tandem balloon technique for a spontaneous vertebrovertebral fistula associated with neurofibromatosis type 1].

We report a rare case of a young man who had spontaneous left vertebrovertebral fistula associated with neurofibromatosis Type 1. His complaints were severe pain in the left neck and numbness in the left upper extremity. Cervical MR images showed a large abnormal flow void to the left of the spinal canal. An angiogram demonstrated a fusiform aneurysm and a high flow arteriovenous fistula in the left vertebral artery that drained into the internal vertebral plexus and formed a large venous varix. The occipital artery, the thyrocervical artery and the contralateral vertebral artery were associated with the fistula. The arteriovenous fistula was treated by endovascular coil embolization, using a tandem balloon technique. For this fistula, exhibiting the combination of high flow and multiple associated arteries, the flow control technique during the coil embolization, using tandem balloons in both the subclavian artery and the distal portion of the fistula of the vertebral artery, was safe and feasible for preventing coil migration.

Self-expandable Metallic Stents Contribute to Reducing Perioperative Complications in Colorectal Cancer Patients with Acute Obstruction.

BACKGROUND/AIM: The self-expandable metallic stent (SEMS) is an excellent non-invasive tool for emergent bowel obstruction. This study was designed to evaluate the clinical usefulness of the SEMS for avoiding perioperative complications. PATIENTS AND METHODS: We analyzed a total of 47 consecutive patients who had a bowel obstruction due to colorectal cancer at initial diagnosis between 2012 and 2017 from hospital records. RESULTS: Perioperative complications occurred in 30% (14/47) of patients. Univariate and multivariate logistic regression analyses identified an age of more than 75 years [p=0.037, OR=6.84 (95% CI=1.11-41.6)] and the absence of an SEMS treatment [p=0.028, OR=18.5 (95% CI=1.36-250.0)] as independent risk factors for perioperative complications. Pneumonia (12.7% (6/47)) was the most common complication. There were no pneumonia patients (0% (0/15)) who were treated with the SEMS. In contrast to patients with the non-SEMS treatment, 18.7% (6/32) of all patients and 35.7% (5/14) of elderly patients had pneumonia. CONCLUSION: The SEMS is a safe and effective treatment for avoiding perioperative complications, particularly pneumonia, and may be a crucial strategy in elderly patients with acute obstruction due to colorectal cancer.

Ectopic gastrointestinal variceal bleeding with portal hypertension.

Massive gastrointestinal bleeding from gastrointestinal varices is one of the most serious complications in patients with portal hypertension. However, if no bleeding point can be detected by endoscopy in the predilection sites of gastrointestinal varices, such as the esophagus and stomach, ectopic gastrointestinal variceal bleeding should be considered as a differential diagnosis. Herein, we report a case of ectopic ileal variceal bleeding in a 57-year-old woman, which was successfully diagnosed by multi-detector row CT (MDCT) and angiography and treated by segmental ileum resection. To date, there have been no consensus for the treatment of ectopic ileal variceal bleeding. This review was designed to clarify the clinical characteristics of patients with ectopic ileal variceal and discuss possible treatment strategies. From the PubMed database and our own database, we reviewed 21 consecutive cases of ileal variceal bleeding diagnosed from 1982 to 2017. MDCT and angiography is useful for the rapid examination and surgical resection of an affected lesion and is a safe and effective treatment strategy to avoid further bleeding.

Survival and clinical evaluation of salvage operation for cervical lymph node recurrence in esophageal cancer.

BACKGROUND/AIMS: Although extended lymphadenectomy for thoracic esophageal cancer is widely practiced in Japan, solitary supraclavicular lymph node recurrence (SCLR) has often become a problem. This study was designed to evaluate the survival and clinical benefit of salvage cervical lymphadenectomy. METHODOLOGY: Between 1989 and 2001, 153 patients underwent esophagectomy for esophageal cancers. SCLR was identified in 5 (3.7%) patients and these five patients were examined retrospectively. RESULTS: Surgical treatment was performed intensively for all patients. Two patients showed longterm survival for 7 years 3 months and 4 years, respectively. Four patients belonged to the good prognostic group but the other patient had poor prognosis from the viewpoint of both the pathological metastatic lymph node number and disease-free interval (DFI). There were no local recurrences but were a recurrent laryngeal nerve palsy in three patients associated with treatment. CONCLUSIONS: Salvage cervical lymphadenectomy for SCLR should be performed positively by selecting each case carefully. Indication must be weighed against increased morbidity considering such indicators as the extent of metastatic lymph node numbers and DFI.

Prognostic and clinical evaluation of patients with T2 gastric cancer.

BACKGROUND/AIMS: Little is known about the clinicopathological features of intermediate-stage T2 gastric cancer, defined as tumors invading the muscularis propria or subserosa. METHODOLOGY: Of 808 patients with gastric cancer, 210 patients (25.9%) who underwent gastrectomy for T2 gastric cancer were selected for this retrospective study. The clinicopathologic findings of these patients were analyzed retrospectively from their hospital records. RESULTS: Of all 808 patients with gastric cancer, 73 patients (9.0%) had tumors invading the muscularis propria (mp). The remaining 137 patients (16.9%) had tumors invading the subserosa (ss). Compared with ss gastric cancer, mp gastric cancer was associated with smaller tumor size, an absence of lymphatic spreading, and hematogenous and late recurrence [disease-free interval: 654.5 days (mp) vs. 365.5 days (ss)]. Univariate analysis of cases with curative operations showed that lymphatic invasion, and lymph node metastasis were significant prognostic factors in patients with T2 gastric cancer. Further examination by multivariate analysis demonstrated that pN2 or higher as classified by both the JCGC (Japanese Classification of Gastric Cancer) and the TNM lymph node staging systems was a predictor of poor prognosis. CONCLUSIONS: JCGC and TNM lymph node staging systems were the most reliable prognostic factors for T2 gastric cancer. Close follow-up should be required for patients with stage pN2 or higher gastric cancer. Long-term follow-up should be required for mp cancers, in particular.

Postoperative complications following gastrectomy for gastric cancer during the last decade.

BACKGROUND/AIMS: The reduction in the incidence of severe postoperative complications has resulted in a significant increase in the survival of patients with gastric cancer. METHODOLOGY: A total of 879 patients undergoing gastrectomy for gastric cancer during the last decade were retrospectively evaluated for postoperative complications, mortality and associated risk factors. RESULTS: The most frequent complications were anastomotic leakage (3.0%) and wound infection (2.8%) followed by the development of pancreatic fistulae (2.2%) and intra-abdominal abscesses (1.5%). Multiple logistic regression analysis identified various independent risk factors including the extent of lymph node dissection (D1D2 vs. D3) for anastomotic leakage (RR 3.6, P<0.05), splenectomy or distal pancreatosplenectomy for pancreatic fistulae (RR 27.4, P<0.0001) and operative time (360 min < or =) for intra-abdominal abscess (RR 4.8, P<0.05). In total, fourteen patients (1.6%, n=879) died from postoperative complications, with 5 patients dying following non-curative gastrectomy (5.6%, n=90). The complications most associated with death were anastomotic leakage (4 patients) and pneumonia (2 patients). CONCLUSIONS: In view of the potential risk of complications, we should carefully evaluate the indications for aggressive lymph node dissection and/or combined resection of neighboring organs as well as non-curative gastrectomy.

Prognostic value of lymph node staging in gastric cancer.

BACKGROUND/AIMS: The latest TNM classification (5th edition) changed the definition of nodal staging from the anatomical localization to the total number of metastatic lymph nodes. This study was designed to evaluate and compare the prognostic significance of nodal staging between the two widely known staging systems, the TNM classification (TNM) and Japanese Classification for Gastric Cancer (JCGC). METHODOLOGY: A total of 582 patients who underwent curative gastrectomy with extended lymphadenectomy for gastric cancer were reviewed retrospectively from hospital records. Based on the localization of metastatic nodes according to the JCGC and the total positive node number according to TNM, the patients were divided into subgroups and their prognoses compared. RESULTS: Lymph node metastasis was found in 189 of the 582 patients (32.5%). Both nodal staging systems were found to be significant prognostic factors by multivariate analysis. A prognostic analysis of the patients by subdivision with the two staging systems indicated that the nodal staging system in TNM was more homogenous than that of the JCGC. CONCLUSIONS: The nodal staging system of the TNM classification is superior to that of the Japanese Classification of Gastric Cancer, because it is simple, reproducible and homogeneous.

Postoperative clinical evaluation following pylorus-preserving gastrectomy.

BACKGROUND/AIMS: Recent pathological study demonstrated that extended lymphadenectomy is not always necessary for patients with early gastric cancer. METHODOLOGY: Twenty-eight patients underwent pylorus-preserving gastrectomy. The clinicopathological findings of patients with pylorus-preserving gastrectomy were compared to those of 58 patients with conventional distal gastrectomy. RESULTS: There were no significant differences in surgical duration, blood loss, blood chemistry, food intake, and body weight loss. Regarding abdominal symptoms, early dumping syndrome was significantly higher in distal gastrectomy than in pylorus-preserving gastrectomy (35.6% vs. 12.0%, p<0.05). Remnant gastritis was also significantly higher in distal gastrectomy (57.1% vs. 27.7%, p<0.05). However, food residue tended to be more frequently seen in pylorus-preserving gastrectomy (33.3% vs. 61.1%, p=0.052). Based on questionnaire results, the rate of patient satisfaction with their surgical outcome tended to be lower in pylorus-preserving gastrectomy than in distal gastrectomy (84.0% vs. 95.6%, p=0.098). The tendency was more pronounced in patients over 70 years old (77.8% vs. 100%, p=0.065). CONCLUSIONS: Pylorus-preserving gastrectomy is superior to conventional distal gastrectomy in the prevention of dumping syndrome and reflux gastritis. However, since delayed emptying is frequently seen post pylorus-preserving gastrectomy, this procedure is not recommended for older patients under simplistic indications.

[Neurologist and emergency neuroendovascular revascularization -training programs for endovascular procedures-].

Emergency neuroendovascular revascularization is a reperfusion therapy for acute stroke. The operator for this therapy has to obtain a license as a specialist in endovascular procedures. For neurologists wishing to acquire this license, there are two kinds of training programs: full-time training and concurrent training. Full-time training was chosen by the first author of this review, while concurrent training will be performed by staff in the author's department. The advantage of full-time training is the acquisition of a lot of experience of various diseases that are treated with endovascular procedures and managed in the periprocedural period. However, full-time training has the disadvantages of a requirement to discontinue medical care of neurological diseases except for stroke and employment at a remote institution. The advantages and disadvantages of concurrent training are the reverse of those of full-time training. Neither training system can succeed without cooperation from Departments of Neurology in neighboring universities and the institutional Department of Neurosurgery. It is particularly important for each neurologist to establish a goal of becoming an operator for recanalization therapy alone or for all fields of endovascular procedures because training will differ for attainment of each operator's goal.