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This technical report provides useful information on the current status and issues of quality control in 125 I seed source strength measurement for Permanent Prostate Brachytherapy in Japan.With the spread of 125 I seed brachytherapy, the traceability of source strength measurements with the single-seed assay was established in Japan. This allows medical facilities to measure reference air kerma rate of 125 I seeds with their own well-type of ionization chamber. However, it is difficult to maintain the traceability chain because the 125 I reference air kerma rate standards have been hardly utilized by medical facilities so far. Meanwhile, some serious incidents of contamination of the different source strengths and dead seeds were reported in Japan.To address the specific issues in Japan, JASTRO Brachytherapy Subcommittee established a working group (WG) in 2021. The goal of this WG is to investigate the management methods of source strength measurement used in medical facilities, and to discuss the ideal and practicable methods of source management such as verifying the number of seeds and source strength. Initially, a questionnaire survey was conducted to facilities offering 125 I seed brachytherapy in Japan. Sixty-seven out of 95 facilities responded (response rate 70.5%). This survey revealed that 41% of facilities did not perform either confirmation of the number of seeds or measurement of source strength. There are several reasons why the source strength was not measured in those facilities. For example, 125 I seeds are provided under the sterilized conditions; quality assurance by source suppliers is reliable; and there is not sufficient staff.The single-seed assay is regarded as an internationally standardized and the most reliable measurement method. Therefore, it is an essential measurement technique to ensure traceability of source strength measurements. However, our survey found that most Japanese facilities do not perform single-seed assays. Meanwhile, some facilities have performed batch assay as an alternative method, in which all of the multiple sources in a batch are measured while loaded into sterilized cartridges. Although the measurement by the batch assay is less accurate than the one by the single-seeded assay, the batch assay does not require re-sterilization of the source and can be performed quickly. It might be useful to detect unexpected errors such as differences in the number of sources and abnormalities in source strength.In this report, we will introduce several methods of source strength measurement that have been implemented in medical facilities. The quality assurance of 125 I seed sources in prostate interstitial brachytherapy should be provided not only by the source suppliers but also by the medical facilities that use sources to treat patients. We hope that medical facilities will refer to this technical report and use it as an aid to quality assurance in their own facilities.

In the point dose verification of intensity-modulated radiation therapy (IMRT), we compared the commonly used method of measuring absolute dose (absolute method) with the measurement method by the American Association of Physicists in Medicine Task Group 119, which describes the point dose verification for IMRT using the ratio of reference irradiation and measured ionization. The target was 66 plans for head and neck cancer, 46 plans for lung cancer with 6 MV X-ray, and 31 plans for prostate cancer with 10 MV X-ray. They were treated with volumetric-modulated arc therapy (VMAT). Each plan was evaluated by the absolute method and the TG119 method using 3D-array. The average and 2SD of the verification results for head and neck cancer, lung cancer, and prostate cancer were 0.129±2.185%, 0.963±2.125%, and 0.259±2.019% by the absolute method, and 0.952±2.039%, 1.704±2.080%, and 0.524±1.274% by the TG119 method. The ratio between the average of the TG119 method and the absolute method corresponded to the error of reference irradiation dose. Considering that the measurement method is simple, the TG119 method enables more stable point dose verification of VMAT.

Malignant gliomas have a poor prognosis despite advances in surgical procedures, radiotherapy, and the emergence of new treatments have improved outcomes. One of these new treatments is gene therapy, which has been developed as a new therapeutic strategy. Recently, new methods and approaches have been developed. Gene therapy involves the introduction of genes or cells into a glioma, or the human body, to treat gliomas; various genes such as cancer-suppressing genes, immunomodulation cytokine-related genes, and suicide genes are used in this treatment. Viral therapy is a treatment that oncolytic viral replicates in tumor cells to destroy tumors. Various viral genes can also be used as therapeutic genes. Currently, the most well-studied and accumulated viruses are adenoviruses and HSV-1. Various clinical trials have been conducted using gene therapy and viral therapy, some of which are scheduled to be approved in the near future. Gene therapy and viral therapy have dramatically improved and have developed progressively since their first clinical use.

We assessed the clinical features in surgery cases of female spontaneous pneumothorax by comparing them with male patients. One hundred six patients ( female/male:16/90)who had undergone surgery for spontaneous pneumothorax between January 2003 and August 2013 was retrospectively studied. Patient background, pneumothorax classification and treatment were assessed. No significant difference was found in patient background and treatment. In pneumothorax classification, the frequency of secondary pneumothorax in females was significantly greater than that in males (p<0.001). Additionally, in females, the number of bulla identified during surgery was significantly fewer and the number of recurrences before surgery was more frequent than that in males.

Atypical teratoid/rhabdoid tumor(AT/RT)is a rare and lethal childhood cancer. Although radiation therapy in children less than three years of age is generally deferred because of its neural toxicity, recent studies have shown that multimodal therapies, including radiation therapy, are effective in pediatric patients with AT/RT less than three years of age. We treated four infant AT/RT patients and investigated the impact of radiation therapy and genetic classification on the prognosis. The mean age at the time of the operation was 9.3 months and all patients were female. All patients underwent surgical resection. Of the four patients, two received combined irradiation and chemotherapy. Specifically, one patient received conformal craniospinal radiation therapy and the other received craniospinal irradiation with proton beams. Immunohistochemical analyses of tumor specimens revealed that the two patients were positive for ASCL1, a regulator of Notch signaling. Patients who received radiation therapy and exhibited ASCL1-positive tumors had a better prognosis. We conclude that radiation therapy may prolong survival in AT/RT patients who are less than 3 years of age. However, further study is required to evaluate long-term functional outcomes.

A 62-year-old man with high fever and in a state of disorientation was transferred to our hospital. One year before this transfer, he had undergone total arch replacement surgery for thoracic aortic dissection. On admission to our hospital, head MRI revealed multiple brain abscesses in the territory of the vertebral-basilar artery, and chest CT showed gas around the aortic graft, in particular, at the origin of the left subclavian artery. We diagnosed him with brain abscesses in the left vertebral-basilar artery resulting from an infected aortic graft. We immediately began administration of intravenous antibiotics. Although his blood, urine, and cerebrospinal fluid cultures were negative, fortunately, the brain abscesses and ectopic gas disappeared. Since reports of only antibiotic use for treating brain abscesses due to aortic graft infection are rare, the appropriate duration of antibiotic administration has not been established yet. Therefore, careful observation is required in this case.

The behavior of a physician when confirming the death of a patient is thought to greatly affect the bereaved family. The required aspects of a physician's behavior after a patient's death are rarely included in physician education. Therefore, the few physicians who confirm the death of a patient should be conscious of the grief of the family members. A questionnaire survey was administered to nurses of a palliative care unit, and the findings showed that the behavior of an attending physician was different from that of other physicians when confirming death. We have prepared a manual that specifies the expected behavior of physicians confirming the death of patients to ensure that physicians other than the attending physician are also conscious of subsequent grief care for the bereaved family.

For aging, people having malignant disease are increasing. And surgical resection is an important part in the treatment of pulmonary metastasis from colorectal cancer. We analyzed the treatment outcome and prognostic factors affecting survival in our subset of patients. We have experienced 64 operations of metastatic lung tumors from colorectal cancer for 23 years since January 1988. Various factors affecting prognosis are studied based on 5-year survival in this report. Overall 5-year survival rate was 38.7%. The disease-free intervals more than 2 years, a solitary metastatic pulmonary lesion and the serum level of prethoracotomy carcinoembryonic antigen (CEA) were significantly affecting factors on the prognosis. Furthermore, sequential study for 23 years couldn't demonstrate the prognostic improvement by the advance of the thoracoscopic technology or the development of the new anti-cancer drugs, though the treatment of patients with pulmonary metastases from colorectal cancer continues to evolve. The role of pulmonary metastasectomy is very important to reduce the volume of metastatic lesions for the better prognosis.

Synovial sarcomas compromise between 5 to 10% of all soft tissue sarcomas in adults. Synovial sarcoma commonly occurs in the vicinity of the large joints and cranial metastasis is rare. Here, we describe a case with intracranial metastases of a synovial sarcoma. A 41-year-old woman was admitted to our department with sensory aphasia. She had a history of a left inguinal synovial sarcoma and underwent surgery and chemotherapy for primary and metastatic lesions. Head MRI revealed three gadolinium-enhancing lesions in the left frontal, parietal and parietotemporal lobe. Gross total resection was achieved in the left parietotemporal lesion and pathological diagnosis was synovial sarcoma. Two weeks after surgery, she received cyber-knife radiosurgery and her neurological deficit was almost completely resolved. Intracranial metastatic synovial sarcoma is rare. Surgical resection and stereotaxic radiosurgery was very effective in the present case.

Pleomorphic carcinoma is rare in the primary lung cancer with a poor prognosis. We reported a resected case of pleomorphic carcinoma of the lung with rapid progression. A 62-year-old male with a tumor shadow in the right lung which had not been noted 9 months before was referred to our hospital. The abnormal shadow was not noted 9 months ago. The tumor located in the right lower lobe and rapidly enlarged from 7.5 cm to 9.5 cm in a month. Right pneumonectomy was necessary, because of the intrapulmonary metastasis in the right upper lobe. Pathological findings showing spindle cells with massive necrosis, were consistent with a diagnosis of pleomorphic carcinoma. Only by 45 days after operation, local recurrence and metastases to the brain, right adrenal gland and small intestine were found, resulting in death at 67 days after operation.

Recent advances in endovascular techniques greatly improved the ability to treat complex cerebral aneurysms. However, patients with wide-necked cerebral aneurysms have posed a special challenge to conventional endovascular therapy. We report a novel method of embolizing wide-necked basilar apex aneurysms by employing a Y-configuration, double stent technique. A 40-year-old woman with a partially thrombosed basilar apex aneurysm transferred to our hospital after diagnosis of subarachnoid hemorrhage. Cerebral angiography revealed a wide-necked aneurysm which neck was incorporating the origins of both the posterior cerebral arteries. In treatment procedure, a microcatheter was inserted into the aneurysm followed by coiling of the upper half of the dome. Next, the first stent was deployed in the right P2 segment extending down to the mid basilar artery and the second stent was then deployed with half of the stent in the left P2 and the other half within the lumen of the previously placed stent. Finally, the microcatheter was withdrawn near the neck, and the rest of the aneurysmal dome was packed by additional coils. The result was favorable. Successful coil embolization of a wide-necked bifurcation aneurysm can be achieved by using the double stenting Y-configuration in this case. This result continues to provide highly encouraging support of this novel technique to treat a subset of complex, wide-necked aneurysms that until recently were considered poor candidates for endovascular therapies.

A 74-year-old-man (case 1) was admitted to our hospital because of dry cough, fever, and dyspnea on effort. His daughter-in-law, a 53-year-old-woman (case 2), was also admitted to our hospital on suspicion of hypersensitivity pneumonitis (HP). Their diagnoses of HP were established by radiological, serological, and histological examinations. It was necessary to differentiate between summer-type hypersensitivity pneumonitis (SHP) and bird breeder's lung due to their special environment. Several examinations, including immunological findings of BALF, returning-home provocation test, and antigen inhalation challenge test, enabled us to establish their diagnoses of SHP.

The patients were a 59-year-old man and 68-year-old man with previously-treated small cell lung cancer (extensive disease). Amrubicin (40 mg/m(2) and 45 mg/m(2)) was administered for 3 days after brain irradiation. Severe neutropenia continued for nine days from day 8 following administration. Although both patients had an infection, it improved by granulocyte-colony stimulating factor (G-CSF), and antibiotics, plus a blood transfusion. Particular attention for severe myelosuppression should be given to amrubicin therapy with previously-treated small cell lung cancer. However, a detailed blood test in course 1 and early administration of drugs such as G-CSF make this therapy feasible. In addition, to control the condition of patients, repeated administration of amrubicin with dose reduction is recommended.

A 52-year-old man undergoing distal gastrectomy for gastric cancer in July 1998 was found to have a 0-IIa type gastric tumor near EC junction in January 2005. Histological examination showed the tumor was moderately differentiated adenocarcinoma. As the tumor was diagnosed as mucosal cancer, endoscopic mucosal dissection was performed. But pathological findings showed the depth of cancer cell invasion into deep submucosal layer. Then total resection of remnant stomach was performed. Both tumors were diagnosed as EBV-associated carcinoma. It is speculated that the mucosa changing after initial operation would give risk to a new occurrence of EBV-associated remnant gastric carcinoma. And then follow up after operation is important. Although some cases of EBV-associated remnant gastric carcinoma is found for short period after the primary surgery, our case second primary cancer was found 7 year after primary surgery. Long term follow-up by Endoscopy seems to be important.

A 57-year-old woman visited a physician with complaints of anorexia and pollakiuria. Because a pelvic tumor and ascites were detected, she was referred to our department. Douglas pouch puncture revealed adenocarcinoma cells. Further examination showed an advanced gastric cancer with peritoneal dissemination. The cancer was judged to be unresectable. Chemotherapy with a combination of TS-1 and CDDP was performed before the operation. After 2 courses of the chemotherapy, her complaints disappeared, although abdominal CT confirmed remaining peritoneal dissemination. After 7 courses of chemotherapy, abdominal CT showed that the peritoneal dissemination had disappeared. Total gastrectomy and lymph node dissection were performed. Histological findings of the stomach revealed complete disappearance of cancer cells in the stomach and the regional lymph nodes. We confirmed that the TS-1/CDDP therapy resulted in a complete response to advanced gastric cancer and peritoneal dissemination. We recommend that chemotherapy be continued until the peritoneal dissemination disappears.

Thoracoscopic clipping of the thoracic duct was successfully performed for the treatment of postoperative chylothorax. Chylothorax occurred in a 67-year-old man following an esophagectomy for esophageal cancer. Following unsuccessful conservative therapy for 3 weeks, we performed thoracoscopic surgery to examine the thoracic duct and found a leaking point of chylous fluid. The thoracic duct was successfully clipped resulting in complete elimination of the effusion immediately after surgery. Generally, chylothorax complicated by an esophagectomy has been managed by medical treatment first, followed by surgical intervention in case of uncontrollable pleural effusion. We think you should try this method at first in case chylothorax was able to be treated with not thoracotomy but thoracoscopic surgery: minimal invasiveness.

Lung cancer invading neighboring anatomical structures such as the chest wall, pericardium, diaphragm, and left atrium are categorized as T3 or T4, which is regarded as locally advanced lung cancer. The purpose of this study was to evaluate results of surgical treatment of T3-4N0-2M0 non-small cell lung cancer according to involved organs. From 1981 to April 2005, 148 patients with lung cancer invading neighboring organs were surgically treated in our hospital. The 5-year survival was 41.4% in all cases. According to 5-year survival of clinical characteristics, the chest wall (parietal pleura) group (45.5%) had a significantly better prognosis compared with the left atrium (0%, p = 0.03) and diaphragm (0%, p = 0.04) groups. T3N0 (50.3%), IIB (55.4%), IIIA (44.6%), and complete resection groups (49.0%) showed a significantly better prognosis compared with T3N2 (27.9%, p = 0.01), III B (0%, p < 0.0001), and incomplete resection groups (13.9%, p < 0.0001), respectively. These results indicate that the prognosis of patients with N2 disease or incomplete resection remains poor in regardless with the type of involved organs.

We report a case of peritoneal cancer dissemination with Type 4 gastric cancer, successfully treated with combination chemotherapy with TS-1. The patient was a 59-year-old female, who complained of abdominal distension with pain, weight loss, and poor appetite. She was diagnosed as unresectable Type 4 gastric cancer, T3N2MOHOP1CY1M0, Stage IV with massive ascites (cytology: Class V). After 2 courses of combined chemotherapy with TS-1 and cisplatin (CDDP), primary tumor reduction was confirmed and no cancer cells were detected from a pathological investigation with biopsied specimens by endoscopy. As additional therapy for remained ascites, intraperitoneal administration of paclitaxel and docetaxel was performed, resulting in a remarkable decrease of ascites with cytological disappearance of cancer cells. The patients underwent total gastrectomy with lymph node dissection, pathological diagnosis of primary site and lymph nodes showed grade 2 effect, and no cancer cells were detected in ascites and peritoneum, microscopically. While she died of peritoneal recurrence after the surgery, the case suggested the clinical advantage of controlling the advanced cancer-bearing state by combination chemotherapy with TS-1, instead of surgery.

HCFU and UFT were reported effective in adjuvant chemotherapy for colorectal cancer. This investigation was planned as a randomized study to compare the usefulness of combination therapies with mitomycin C (MMC)+HCFU and MMC+UFT as postoperative adjuvant chemotherapy in patients with colorectal cancer following curative resection, in terms of survival rate, recurrence rate, and adverse drug reactions. A total of 501 patients consisting of 252 patients with stage III/IV colon cancer (Colorectal Cancer Handling Rules, 4th Ed.) for which macroscopic curative resection was possible and 249 patients with stage II/III/IV rectal cancer (ibid, 4th Ed.) were registered from 40 participating institutions. The patients were randomly allocated to two groups with colon cancer and rectal cancer employed as stratification factors. Beginning on Day 14 after surgery, HCFU at 300 mg/day was administered to one group and UFT at 300 mg/day or 400 mg/day to another group, both orally and daily for one year. MMC 6 mg/m2 was administered intravenously to both groups on the day of surgery and the day following. Among the 501 patients, 496 patients (99%) were eligible. The 5-year survival rates were 77.1% for the MMC+ HCFU group and 79.2% for the MMC+UFT group, with the 5-year recurrence-free survival rates were 76.1% and 72.9%, respectively, neither showing a significant difference between the groups. Adverse drug reactions appeared in 23% of patients in the MMC+HCFU group and in 19% in the MMC+UFT group, with no serious reactions. One year after surgery the administration completion rates were good, at 82% for the MMC+HCFU group and 83% for the MMC+UFT group. No clear difference in effectiveness was noted between MMC+HCFU therapy and MMC+UFT therapy as postoperative adjuvant chemotherapy for colorectal cancer. The administration completion rates were good, and no serious adverse drug reactions were observed for either therapy. It was thus considered that both therapies could be administered safely, and both were useful as postoperative adjuvant chemotherapies for colorectal cancer. It is considered necessary to compare them with standard therapies in Western countries in the future.

Migration of an orthopedic fixation wire into the thoracic cavity is an uncommon complication. We present a 64-year-old male undergoing intra-thoracic migration of a Kirschner wire. The patient had undergone the treatment of sternoclavicular joint dislocation due to clavicular fracture. Four months after the operation, a chest X-ray revealed a metallic foreign body in the mediastinum. A chest computed tomography (CT) showed the object in the anterior mediastinum adjacent to the aortic arch. An emergency video-assisted thoracoscopic surgery was successfully performed to remove a 60-mm-long Kirschner wire migrated from the mediastinum to the thoracic cavity. The operating time was 45 minutes, and the blood loss was less than 50 ml. His postoperative course was uneventful and he was discharged at the 6th day after surgery. Prompt diagnosis and surgical removal are necessary to prevent serious complications.

The sentinel node (SN) is defined as the first draining node from the primary lesion, and it has proven to be a good indicator of the metastatic status of regional lymph nodes in solid tumors. Recently, the validity of the SN concept in gastric cancer has been demonstrated by a number of single institutional studies, and prospective multi-center trials are presently ongoing. The Gastric Cancer Surgical Study Group of the Japan Clinical Oncology Group (JCOG) organized a multi-center prospective study of SN mapping by the dye-guided method using subserosal injection of indocyanine green. If the JCOG study reveals favorable results, in terms of false-negative rates, the dye-guided method will be utilized as a routine practice for open surgery in a wide range of institutions. If not, we will need to consider introduction of radioguided method or add further technical improvements, even for open surgery. A study group in the Japan Society of Sentinel Node Navigation Surgery is also conducting a multi-center prospective trial of SN mapping by a dual tracer method with blue dye and radio-active colloid. Even if the SNNS study demonstrates acceptable detection rates and low false-negative rates, we need to conduct a feasibility study of laparoscopic SN mapping for gastric cancer as the next step. The results of these clinical trials should provide useful perspectives on the future direction of SN navigation surgery for gastric cancer.

The purpose of this study was to review perioperative managements from the clinical features and the postoperative course of lung cancer patients with interstitial pneumonia (IP). Twenty-two patients with IP were divided into 2 groups: the acute exacerbation (AE) group (6 patients) and the non-acute exacerbation (NAE) group (16 patients). There was no significant difference in the patient background between the 2 groups. In hematological examination, KL-6 levels were significantly higher in the AE group than in the NAE group. There was no significant difference in the respiratory function tests in the both groups, and the heart rate after 2 flights test was significantly higher in the AE group than in the NAE group. There was no significant difference in operation-related factors, tumor-related factors and the postoperative course in the both groups. No postoperative death occurred in our 22 patients probably due to adequate treatments of IP which was managed by our detailed manual. Long-term follow-up for lung cancer patients with IP undergoing surgical intervention is needed to prevent AE.

A 65-year-old man was admitted to our hospital because of massive hemoptysis. The patient had suffered from pneumonia since 1999, but he had refused to undertake further examinations. In 2002, the patient was transferred to our emergency room because of massive hemoptysis. Following endotracheal intubation, the patient underwent bronchial artery embolization. The X-ray and computed tomography (CT) films on admission revealed localized bronchiectasis in the left upper lung. Bronchoscopic findings revealed massive bleeding from the left upper bronchus. Bronchial arteriography of the left bronchial artery showed peripherally hypervascular finding in the left upper lobe. A segmentectomy of the left upper division was performed as a radical therapy for localized lesions with massive hemoptysis. The pathological diagnosis was secondary abnormal development of the bronchial artery. We speculated that massive hemoptysis had occurred probably due to infection in the focus.

A left lower lobectomy was successfully performed in a lung cancer patient with anatomical variation in which the left superior and inferior pulmonary veins were connected to the left atrium after forming an extrapericardial single trunk. This variation is surgically important because ligation and division of the left inferior pulmonary vein may result in blockage of upper lobe vein drainage at the time of a left lower lobectomy. The ligation of the pulmonary vein leads to severe lung edema, which may cause infection, respiratory distress, or postoperative complications that could be life-threatening. Surgeons must always pay attention to this variation when performing a left lower lobectomy.

We report an adult case of congenital lobar emphysema due to bronchial atresia. A 24-year-old man was referred to our department because of cough and fever. A chest roentgenogram on admission showed multiple cystic shadows in the left lower lung field. Chest computed tomography (CT) demonstrated multiple cysts with neveau and scattered infiltration in the left lingual segment and lower lobe. Surgical treatment was scheduled because of no improvement of the chest lesions. The interlobar fissure was not found between the upper and the lower lobes, but between the upper and the lingual divisions. Additionally, the lingual bronchus was not bifurcated from the upper bronchus, but from the lower bronchus. As inflammatory changes were extended to the lingual division and the lower lobe, a left lingual segmentectomy and a lower lobectomy with video-assisted thoracoscopic surgery were performed. His postoperative course was uneventful and he was discharged at the seventh day after surgery.

Metastatic carcinoma from primary lung cancer is usually recognized in the brain, adrenal glands, and bone. It is uncommon in the digestive system, particularly in the duodenum. We report a 63-year-old man who had undergone a left lower lobectomy for lung cancer. Anemia (Hb 6.9 g/dl) had been observed 2 months after surgery for primary lung cancer. Gastroduodenoscopy showed duodenal metastasis, and further examination demonstrated adrenal metastasis. Palliative treatment was selected and the patient died 5 months after surgery.

Recently the diagnosis of peripheral small-sized lung cancers has increased with the development of computed tomography. The vast majority of them are adenocarcinoma, whereas squamous cell carcinoma is rare. From 1981 to 2002, 1,054 patients underwent pulmonary resection for primary lung cancer in National Nishigunma Hospital. Among of them, 17 patients with peripheral small-sized (2 cm or less) squamous cell carcinoma underwent lobectomy and systemic nodal dissection were retrospectively reviewed. These were 15 men and 2 women, with a mean age of 68 years (range, 56-75). Regarding the pathologic stage, 15 patients were classified in stage IA, 1 in IIA, and 1 in IIIA. Among of them, only 1 patient with n 2 disease died of cancer at 17 months after surgery. Overall 5-year and 10-year survival rates of this disease were 84.4% and 73.8%, respectively. Based on the present data, we conclude that mediastinal nodal dissection would be unnecessary in the patients with peripheral small-sized squamous cell carcinoma of the lung.

Two adolescents with complex regional pain syndrome (CRPS) were treated safely and effectively by spinal cord stimulation (SCS). They complained of intractable pain resistant to conservative therapies. Whereas continuous epidural anesthesia temporarily reduced pain, SCS was more effective in alleviating chronic severe pain and improving the quality of life. With careful selection of patients, SCS therapy might be recommended even in young cases.

We used a novel combination chemotherapy of TS-1 and low-dose cisplatin (CDDP) with 4 gastric cancer patients with liver metastases (one far advanced and 3 recurrent patients). TS-1 was administered at 80 mg-120 mg/body/day, twice daily for 3 weeks followed by a 2-week interval as one cycle, and CDDP was administered at 6 mg/m2/day div, for 5 days followed by a 2-day interval (1 cycle for an inpatient) or at 6 mg/m2/day div, at 5 times for 2-3 weeks (1 cycle for an outpatient). Efficacy and toxicity were evaluated after 3-6 cycles of the regimen, as long as the patients tolerated the regimen without severe side effects. This regimen resulted in 1 complete response, 2 partial responses and 1 progressive disease, showing a 75% efficacy rate. One patient experienced grade 2 nausea from this regimen, which was ameliorated by means of prolonging the interval of CDDP-administration. Thus, the regimen is useful to maintain patients' quality of life without severe adverse effects, and has a high efficacy in gastric cancer patients with liver metastases.

We evaluated retrospectively 33 patients with synchronous multiple primary lung cancers. These were 20 men and 13 women, with a mean age of 67 years (range, 51-79 years). In 27 cases, the tumors were located in the ipsilateral lung, and in 6 cases, they were in the bilateral lung. In patients with synchronous multiple primary lung cancers, combinations of adenocarcinoma and adenocarcinoma (12 cases, 36.4%), adenocarcinoma and others (6 cases, 18.2%) were most commonly observed histologically. Lobectomy was performed in 18, bi-lobectomy in 3, pneumonectomy in 4, lobectomy with partial resection in 6, and lobectomy with laser therapy or irradiation in 2 patients. Overall 5-year survival rate of this disease was 78.3%. Eight patients died within 1 year after surgical resection, and 2 of them died of treatment-related accident. Although optimal treatment of choice for synchronous multiple primary lung cancers remains an unresolved problem, we think that careful planning of the treatment for this disease including selection of surgical methods is much important.

Radical lymphadenectomy is the standard surgical approach even for early-stage gastric cancer with a relatively low incidence of lymph node metastasis because of the limited sensitivity of diagnostic imaging to detect micrometastasis in regional lymph nodes. The sentinel node (SN) concept is one topic among novel diagnostic procedures for micrometastasis. The SN is defined as the first draining node from the primary lesion and it would be the first site of micrometastasis. SN biopsy has been clinically validated and applied for the surgical treatment of malignant melanoma and breast cancer. Although the feasibility of this technique in other solid tumors including gastric cancer is still controversial, there are several reports demonstrating the diagnostic significance of SN mapping in early gastric cancer. We have established radio-guided SN mapping for early gastric cancer, and the diagnostic accuracy using this procedure in cT1N0 cases reached 98%. The radio-guided method allows us to detect the SN in endoscopic surgery quantitatively and reproducibly. Validation of the SN concept in gastric cancer in a multi-centric clinical trial is essential for clinical application of this procedure, including the establishment of a novel, minimally invasive approach for early-stage gastric cancer.

Purpose: We conducted a multi-center study to investigate the usefulness of a combination drug therapy with doxifluridine (5'-DFUR) and mitomycin C (MMC) in colorectal cancer patients with lung metastasis., Patient and Methods: Subjects were advanced/recurrent colorectal cancer patients with lung metastasis, who underwent concomitant drug administration with 533 mg/m2/day of 5'-DFUR orally and 4 mg/m2/day of MMC every 2 weeks intravenously., Results: Of 84 patients registered, 54 patients who were evaluable for tumor response showed results such as: complete response, one; partial response, 4; no change, 30; and progressive disease, 19, corresponding to a response rate of 9.3%. The median survival period of 54 patients was long at 473 days. The median administration days of 5'-DFUR was 201.5 days and the median number of MMC administrations was 14, indicating a long administration period of the combined therapy. The incidence of adverse drug reactions (ADRs) was 37.2% which included thrombocytopenia, 16.7%, and leukocytopenia, 11.5%; only a few ADRs were grade 3 or over., Conclusions: While combined therapy with 5'-DFUR and MMC resulted in a low response rate, the regimen suggested a survival effect in the patients.

In evaluations of adjuvant chemotherapy with oral anticancer agents, compliance in taking the drug as prescribed (compliance), adverse reactions, and feasibility are important factors in setting the dose. A weekday-on/weekend-off schedule, in which 600 mg/day of UFT was taken for 5 consecutive days and not taken on the following 2 days, was carried out as a postoperative adjuvant chemotherapy for one year in 87 patients with colorectal cancer who had undergone potentially curative resection. The prescribed dose and the dose of ingestion confirmed by physician interview were both highly consistent with the dose of ingestion according to the patients' self reports, with consistency rates of more than 94% for both. Relative performance (RP) yielded a value of 0.72, and individual dose intensity (IDI) yielded 0.8 on average. Female gender, low body weight, and low body surface area were factors that negatively affected feasibility. None of the adverse reactions was serious. Based on the feasibility and adverse reactions, the dosage of UFT should be set according to the body surface area at 375-425 mg/m2/day. When this schedule is used as one arm of a controlled study, it is suggested that the dose should be decided with 400 mg/m2 as a guideline.

We conducted a validation of the treatment of satellite nodules in the UICC TNM classification of 1997. Over the past 17 years (1981 to 1997), 29 patients underwent complete pulmonary resection for primary lung cancer accompanied by satellite nodules in the same lobe as the primary. All these patients were categorized as stage IIIB according to the current staging system. The five-year survival rate of all patients was 40% and the figure was unduly better for stage IIIB patients. The three-year survival rate of 20 patients having lymphatic involvement were 18%, but those of 9 patients without it was 89%. Outcome was significantly influenced on their presence or absence of lymph node metastases. The current staging system for patients with satellite lesions in the same lobe appears to be unacceptable because they provide the different influences on prognosis and selecting treatment modality according to the N status.

Various types of carcinoma cells have been shown to escape immune recognition by constitutive resistance to Fas receptor (Fas)-mediated apoptosis. The purpose of this study was to examine the sensitivity to Fas-mediated apoptosis of human head and neck squamous cell carcinoma (HNSCC) cells. We applied an anti-Fas monoclonal antibody (CH11) to HNSCC cell lines and monitored their cell death. All three HNSCC cell lines examined expressed Fas protein but not Fas-ligand mRNA. CH11 did not induce cell death (CH11-resistant) in any of the three HNSCC cell lines examined. Treatment with actinomycin D (ActD) converted the phenotypes of the CH11-resistant HNSCC cell lines from CH11-resistant to CH11-sensitive, suggesting that the resistance to CH11-induced apoptosis was dependent on RNA synthesis. Western blot analysis did not show any differences in expression of Bcl-2 between the non-treated and ActD-treated HNSCC cell lines. Expression of Bcl-XL, on the other hand, was greatly reduced in the ActD-treated HNSCC cell lines, implying that Fas signaling in the CH11-resistant HNSCC cell lines might be regulated by an Bcl-XL-inhibitable step.

Seven patients with pulmonary carcinoid including three with typical carcinoid and four with atypical carcinoid were reported. There were 3 males and 4 females, with an age range of 37 to 80 years. All patients with typical carcinoid had pathological stage I. Of the patients with atypical carcinoid, one patient had stage I, two stage IIIA and one stage IIIB. All but two patients underwent lobectomy and mediastinal lymph node dissection. Bronchoplastic operation or right pneumonectomy were performed in the two patients. All but one patient underwent absolute or relative curative operation. Only one patient died on the 4th postoperative day. One patient with atypical carcinoid died of cancer recurrence 4 years after surgery. One patient died of breast cancer. One patient underwent surgery for metachronous multiple lung cancer, and he is doing well without recurrence. In conclusion, a limited operation is thought to be acceptable only in patients with typical carcinoid in a peripheral lesion without lymph node metastasis. Lobectomy and mediastinal lymph node dissection is necessary for the atypical carcinoid case.

We have applied two different laparoscopic surgical techniques for early gastric cancer and have successfully treated 111 patients since March 1992. The indications are: 1) preoperative diagnosis of mucosal cancer; 2) lesion size of < 25 mm if the protruding type; and 3) lesion size < 15 mm and UI (-) if the depressed type. The first technique is laparoscopic wedge resection of the stomach using a lesion-lifting method (n = 93). The gastric wall around the cancerous lesion is exposed laparoscopically. The abdominal wall and gastric wall in the vicinity of the lesion are pierced using a 12-G sheathed needle. A small metal rod with a fine wire is introduced into the stomach through the outer sheath. By retracting the metal rod, the lesion can be lifted precisely (i.e., lesion-lifting method). Wedge resection at a sufficient distance from the metal rod is carried out using an endoscopic stapler. The second technique is referred to as laparoscopic intragastric mucosal resection (n = 18). Three balloon trocars are placed in the stomach laparoscopically. The stomach is then insufflated with CO2, and surgical instruments are introduced. The mucosal and submucosal layers around the lesion are resected with sufficient surgical margins. The selection of the laparoscopic technique depends on the site of the cancerous lesion. In our series of 111 patients, sufficient horizontal (mean 15 +/- 5 mm and 8 +/- 4 mm, respectively, using the first and second technique) and vertical surgical margins were achieved. There was no mortality and no major complications in patients undergoing either surgical technique. There have been two recurrences, both mucosal lesions found 2 years after the initial surgery, which were successfully treated with gastrectomy and laser irradiation. All patients have survived for 3 to 96 months, and there has been no trocar site recurrence. In conclusion, these laparoscopic procedures are curative and minimally invasive treatments for early gastric cancer.