High frequency of bone recurrence as an initial recurrence site after radical surgery in T1N3 gastric cancer: a propensity score matching analysis.

PURPOSE: T1 gastric cancer (GC) with seven or more metastatic lymph nodes is extremely rare, and very few clinical studies have been conducted to evaluate the clinicopathological features of their recurrence. METHODS: We retrospectively analyzed the outcomes of T1 GC and T2-4 GC patients who had multiple nodal metastases after radical surgery from 2006 to 2020. Propensity score matching was performed to compare the two groups of patients. RESULTS: After propensity score matching, 18 of 22 patients in the T1 group and 36 of 144 patients in the T2-4 group were selected. Recurrence occurred in six patients (33.3%) in the T1 group. In the T1 group, the most common site of initial recurrence was bone (15.0%). The prevalence of bone recurrence was significantly higher in the T1 group than in the T2-4 group (P = 0.02). The median interval time between radical surgery and bone recurrence was 24 months, and the median survival time after bone recurrence was 14 months. CONCLUSION: Bone recurrence was more frequently identified as an initial recurrence site in T1 GC cases with multiple metastases after radical surgery compared with that in T2-4 GC cases. Careful attention should be paid to postoperative bone recurrence in the long-term postoperative course of these patients.

Billroth-I reconstruction using an overlap method in totally laparoscopic distal gastrectomy: propensity score matched cohort study of short- and long-term outcomes compared with Roux-en-Y reconstruction.

BACKGROUND: Delta-shaped anastomosis is an established procedure for intracorporeal Billroth-I reconstruction (B-I). However, this procedure has several technical and economic problems. The aim of the current study was to present the technique of B-I using an overlap method (overlap B-I), which is a side-to-side intracorporeal gastroduodenostomy in laparoscopic distal gastrectomy (LDG), and to evaluate the short- and long-term outcomes of this overlap B-I procedure. METHODS: We retrospectively reviewed the medical records of 533 patients who underwent LDG with overlap B-I (n = 247) or Roux-en-Y reconstruction (R-Y) (n = 286). Patients with overlap B-I were propensity score matched to patients with R-Y in a 1:1 ratio. Short- and long-term outcomes of the two procedures were compared after matching. RESULTS: In the total cohort, anastomosis-related complications occurred in 2.4% of patients with overlap B-I, and 3.2% of those with R-Y (P = 0.794). Morbidity rate, including anastomosis-related complications, and postoperative course were comparable after overlap B-I performed by qualified versus general surgeons. Of 247 patients with overlap B-I, 169 could be matched. After matching, morbidity rate and postoperative course were comparable between the two procedures. Median operation time was significantly shorter for overlap B-I (205 min) than R-Y (252 min; P < 0.001). The incidence of readmission due to gastrointestinal complications was significantly lesser after overlap B-I (2.4%) compared with R-Y (21.9%; P < 0.001). The main causes of readmission after R-Y were bowel obstruction (7.3%) and gallstones (8.0%). Regarding the development of common bile duct (CBD) stones, 11 patients (3.8%) who underwent R-Y were readmitted due to CBD stones, whereas no patients who underwent B-I developed CBD stones. CONCLUSIONS: Overlap B-I is feasible and safe, even when performed by general surgeons. B-I was superior to R-Y concerning operation time and readmission due to gastrointestinal complications.

Safety of laparoscopic distal gastrectomy for gastric cancer when performed by trainee surgeons with little experience in performing open gastrectomy.

PURPOSE: This study aimed to evaluate the surgical outcomes and clinical safety of laparoscopic distal gastrectomy (LDG) when performed by trainee surgeons with little prior experience in performing open gastrectomy, under the guidance of trainer surgeons. METHODS: From January 2008 until March 2015, 17 trainee surgeons and 5 trainer surgeons performed LDGs to treat 371 patients with clinical stage T1-T3 gastric cancer. Of these patients, 140 and 231 underwent LDG performed by trainee surgeons and trainer surgeons, respectively. We retrospectively analyzed the surgical outcomes of the two groups. RESULTS: Trainee surgeons required significantly longer operation times than the trainer surgeons, with respective mean operation times of 262 and 223 min (p < 0.001). However, the mean blood loss volumes, average numbers of retrieved lymph nodes, postoperative complications, and postoperative hospital stay lengths did not differ significantly between LDGs performed by trainee surgeons and trainer surgeons. CONCLUSIONS: The study findings suggest that, under the guidance of trainer surgeons, trainee surgeons with little experience with open gastrectomy and even without prior experience with LDG can perform radical surgeries safely.

Early gastric cancer with diffuse heterotopic gastric glands and granular cell tumors mimicking advanced gastric cancer.

INTRODUCTION: Heterotopic gastric grands (HGGs) are gastric grands that are observed in the submucosa and are considered to be paracancerous lesions or precursors of gastric cancer (GC). Granular cell tumors (GCTs) are benign neural origin tumors. Gastrointestinal GCTs are rare and gastric GCTs are seldom seen. We report the case of a patient who was diagnosed with early GC with diffuse HGGs affecting the whole stomach and two GCTs mimicking advanced GC. PRESENTATION OF CASE: The patient is a 71-year-old male with epigastric discomfort. Gastrointestinal endoscopy revealed an ulcerated lesion at the mid-gastric body. A biopsy specimen indicated adenocarcinoma. Moreover, gastrointestinal endoscopy revealed a submucosal tumor at the posterior wall and multiple transparent protuberances across the entire stomach. Computed tomography demonstrated diffuse gastric wall thickening with lymphadenopathies. Total gastrectomy was performed under the preoperative diagnosis of advanced GC with lymph node metastases. The pathological diagnosis was adenocarcinoma invading submucosal stroma without lymph node metastasis, two GCTs, and diffuse HGGs affecting whole stomach. DISCUSSION: Preoperative diagnosis of GC depth or range associated with HGGs is often difficult. Although diffuse HGGs are sometimes observed, there is no previous report of a case of HGGs with whole gastric wall thickening observed by computed tomography. As a result, this case was overdiagnosed as advanced GC. Although the relationship between GCTs and HGGs or GC is unclear, there is no case report of GCTs accompanied by HGGs or GC. CONCLUSION: This case report suggested that cautious preoperative assessment for GC co-occurring with HGGs is required.

Double mapping with subareolar blue dye and peritumoral green dye injections decreases the false-negative rate of dye-only sentinel node biopsy for early breast cancer: 2-site injection is more accurate than 1-site injection.

BACKGROUND: The optimum sentinel node biopsy (SNB) mapping method for breast cancer remains to be determined. No matter which mapping agents are used, 2-site injection may be superior to 1-site injection in limiting the false-negative rate. METHODS: We examined whether a double-mapping method with subareolar injection of blue dye and peritumoral injection of green dye would decrease the false-negative rate of dye-only SNB in 145 patients with early breast cancer. RESULTS: The identification rate for blue-dyed and/or green-dyed (including mixed color-dyed) lymph nodes was 96.6% (140/145). Sensitivity and specificity were 95.1% (39/41) and 100% (99 of 99), respectively. Accuracy was 98.6% (138/140) with a false-negative rate of 4.9% (2/41). There were 4 patients in whom nodes of each color were found, but nodes of only 1 color were shown to be positive. The primary tumors of these 4 patients and of the 2 patients with false-negative results were located in the upper-outer quadrant of the breast. When only blue-dyed or green-dyed nodes (including mixed color-dyed nodes) were counted, the false-negative rates were 10.3% (4/39) for the subareolar mapping technique and 10.0% (4/40) for the peritumoral mapping technique. CONCLUSIONS: The double-mapping method based on subareolar and peritumoral injections decreases the false-negative rate of dye-only SNB for early breast cancer. Variations in lymphatic channels may exist in the lateral half of the breast and thus may influence identification of positive sentinel nodes. This finding should be taken into account in cases of multicentric breast cancer.

Long-term quality of life after laparoscopically assisted distal gastrectomy for gastric cancer.

OBJECTIVE: To investigate whether laparoscopically assisted distal gastrectomy (LADG) contributes to long-term quality of life as compared to open gastrectomy in patients with early-stage gastric cancer. MATERIALS AND METHODS: Quality of life was self-reported using a 15-item questionnaire with five options for each question. The responses obtained from 47 LADG patients and 33 conventional open gastrectomy patients were compared. All patients underwent Billroth I gastrectomy for early gastric cancer between September 1999 and October 2002. RESULTS: Patients who underwent LADG showed better results than those who underwent the open procedure with regard to satisfaction with the operation (87.2% vs. 57.6%; P < 0.01). However, the rate of late complications such as delayed gastric emptying was higher in the LADG group than in the open group (40.4% vs. 18.2%; P < 0.05). No differences were observed between the LADG and open groups with regard to appetite loss, heartburn, diarrhea, or difficulty in swallowing. CONCLUSION: LADG has an equivocal effect on long-term quality of life. Satisfaction with the surgical procedure was greater in patients who underwent the LADG method; however, complications that impaired the quality of life were also seen. The usefulness of LADG should be assessed in view of the immediate and relatively short-term outcomes and their effect on long-term quality of life.

[Two cases of gastric cancers with lung metastases responding to weekly administration of paclitaxel].

We report two cases of gastric cancer with multiple lung metastases responding well to weekly administration for 3 weeks followed by a week discontinuation of paclitaxel (80 mg/m2). Case 1, a 73-year-old man, was diagnosed as multiple lung metastases 1 year and 4 months after total gastrectomy for Borrmann 1 type gastric cancer (7.5 x 6.5 cm, pap, P0 cy(-) H0 mpn2, stage III A, ly2, v2). After 8 weekly administrations of paclitaxel 110 mg (80 mg/m2), the lung tumor diminished from 5 cm to a linear scar in size, and dyspnea needing inhalation of oxygen at home disappeared. Case 2, another 73 year-old man with multiple lung metastases at 7 months after distal gastrectomy for Borrmann 3 type gastric cancer (4 x 3.5 cm, muc, P0 cy(-) H0 sen2, stage III B, ly1, v0) received weekly paclitaxel 110 mg (80 mg/m2). Lung tumors disappeared after 27 administrations of paclitaxel, and CT scans have showed CR for 8 months until now after 44 administrations. Therefore, we recommend weekly administration of paclitaxel for lung metastases from gastric cancer.

Disparities in the survival improvement of recurrent breast cancer.

BACKGROUND: The therapeutic advances in breast cancer have improved the survival of patients with early disease; however, survival improvement of patients with recurrent disease remains ambiguous. In this retrospective study, we examined whether disparities in survival improvement exist in patients with recurrent breast cancer with distant metastasis. METHODS: The survival time of 126 patients who experienced recurrence at distant sites from 1990 through 1996 was compared to that of 195 patients who did from 1997 through 2003. RESULTS: A significant survival improvement was observed in the patients who experienced recurrence in the period of 1997-2003 in comparison to the other period in the subsets with estrogen receptor (ER)-positive disease, those who received adjuvant hormonal therapy, and those with a disease-free interval (DFI) of 24 months or more. However, no significant survival improvement was observed in each counterpart. The median survival time (MST) from the first relapse of patients with ER-positive disease in the recurrence period of 1997-2003 was 18.8 months longer than that in the recurrence period of 1990-1996 (46.6 months vs. 27.8 months). The MST of patients with a DFI of 24 months or more in 1997-2003 was 20.3 months longer than that in the other time period (47.2 months vs. 26.9 months). CONCLUSION: The survival of recurrent breast cancer has improved with disparities. The ER status and the DFI are associated with a survival improvement of women with recurrent breast cancer with distant metastases.

Increased dihydropyrimidine dehydrogenase activity in breast cancer.

BACKGROUND AND OBJECTIVES: Although studies have focused on modulating the bioavailability of 5-FU through inhibition of dihydropyrimidine dehydrogenase (DPD) to improve efficacy of the drug, activity of this enzyme in breast cancer has not been thoroughly examined. We measured DPD activity in primary and metastatic lesions and benign breast tumors to evaluate the clinical significance of this enzyme in the treatment of breast cancer. METHODS: DPD activity was measured by catalytic assay and compared in 100 primary tumors (95 invasive carcinomas, 5 intraductal carcinomas), 26 uninvolved adjacent breast tissue specimens, 6 metastatic sites, and 7 intraductal papillomas. RESULTS: The enzyme level in the carcinomas was 4-fold that of adjacent uninvolved breast tissues (101 vs 23 pmol/min/mg protein, P < 0.001). Enzyme activity in intraductal papilloma (120 pmol/min/mg protein) was comparable to that in invasive carcinoma. There were no significant differences in DPD activity related to clinicopathologic features, but a tendency toward increased DPD activity was observed in progesterone receptor-negative breast cancer (P = 0.09). There was marginal correlation in enzyme activity between primary and metastatic lesions (P = 0.07). CONCLUSIONS: DPD activity is substantially upregulated in breast cancer tissue and is higher than that reported previously. The clinical implications of DPD inhibitors in patients being treated for breast cancer with oral fluoropyrimidine chemotherapy should be further investigated.

Postoperative follow-up of patients with early breast cancer: reappraisal of serum tumor markers.

The purpose of this study was to determine the most appropriate tests and procedures to detect disease progression effectively during the postoperative follow-up of patients with early breast cancer. We reevaluated our current surveillance protocol which involves the intensive follow-up of 643 patients with stage I disease. With the exception of one case of bone metastasis, all cases of recurrence (97%) were suspected from abnormal results detected during surveillance involving physical examination, serial determination of tumor markers, and chest roentgenography. Among 15 patients with asymptomatic distant metastasis, disease recurrence was suspected in 12 (80%) because of increased levels of serum tumor markers. No disease recurrence was detected by routine complete blood counts or automated chemistry studies alone. Our experience indicates that an effective follow-up regimen for patients with early breast cancer may include careful history-taking, physical examination, and the determination of serum tumor markers every 3-6 months for the first 3 years, then less frequently thereafter, and chest roentgenography every 6 months for 5 years, in addition to annual mammography. Serial determination of the tumor markers tumor polypeptide antigen, NCC-ST-439, and either carcinoembryonic antigen or carbohydrate antigen 15-3, seems to be of value for the selection of patients who should undergo radiologic exploration. The health benefits and cost-effectiveness of a follow-up focused on the measurement of serum tumor markers need to be evaluated in large prospective randomized trials.