Search

Laparoscopic and endoscopic cooperative surgery(LECS)for gastric gastrointestinal stromal tumor(GIST)has become a popular surgery with both curability and functional preservation. In this study, we examined the outcomes of 14 patients who underwent classical LECS or CLEAN-NET in our hospital. Until March 2022, classical LECS was performed in patients with intraluminal growth tumors or tumors close to the gastroesophageal junction. After April 2022, classical LECS was performed in patients with intraluminal growth tumors without ulceration, and CLEAN-NET was performed in patients with ulceration or intramural growth tumors. There were 10 males and 4 females with a median age of 80.5 years. Intraluminal growth tumor were 8 patients, close to the gastroesophageal junction tumor were 3, and intramural growth tumor were 4, respectively. Five of these patients had tumors with ulceration. Classical LECS was performed in 10 patients and CLEAN-NET in 4 patients, and the median operative time was 165.5 minutes. All patients underwent R0 resection, and no postoperative complications or recurrences were observed. LECS was performed safely, and it is important to select the surgical procedure according to the tumor site and growth type.

Purpose: The effect of a history of gastrectomy on patients undergoing hepatectomy is unclear. We investigated the relationship between postoperative complications of Clavien-Dindo grade III or higher and a history of gastrectomy in patients undergoing hepatectomy., Methods: The subjects of this retrospective analysis were 474 consecutive patients who underwent hepatectomy at our institute for hepatic malignancy, classified into groups of those with or without a history of gastrectomy and those with or without postoperative complications. We compared the clinicopathological factors between the groups., Results: There were no hospital deaths. Gastrectomy history was identified in 22 patients (4.6%) and was significantly associated with advanced age, low body mass index, male sex, decreased serum albumin level, decreased hemoglobin level, low PNI, low CONUT score, high incidence of postoperative complications, and longer hospital stay. Multivariate analyses revealed that the independent risk factors for postoperative complications were gastrectomy history, an albumin-bilirubin score of 2/3, primary liver cancer, high serum creatinine level, advanced age, and prolonged operation time., Conclusions: Gastrectomy history was an independent predictor of postoperative complications in patients undergoing hepatectomy for hepatic malignancies. Patients with a history of gastrectomy were likely to suffer postoperative bile leakage and pneumonia., (© 2021. Springer Nature Singapore Pte Ltd.)

S-1 plus cisplatin is the standard chemotherapy for recurrent gastric cancer. While depression and delirium are frequent in cancer patients, hypomania during chemotherapy is rare. We describe a rare case of hypomania during S-1 plus cisplatin treatment for recurrent gastric cancer. A 66-year-old woman, with no previous psychiatric disorder, received S-1 plus cisplatin for recurrent gastric cancer. She showed peculiar behavior. Physical examination, urine, blood and imaging findings were normal. There was no gastric cancer progression. During psychiatric consultation, she behaved inappropriately. However, she behaved normally while performing daily activities. She manifested a persistently elevated, expansive or irritable mood, clearly different from her usual non-depressed state, meeting hypomania diagnostic criteria. Her condition did not require chemotherapy discontinuation or additional medication. During the second and subsequent S-1 plus cisplatin cycles, symptoms were stable. Cancer patients often have adjustment disorders, depression and delirium, but rarely hypomania. Our patient showed no significant changes in blood biochemistry and brain and whole body imaging. While S-1 plus cisplatin-induced hypomania cannot be excluded, hypomanic symptoms did not improve during the chemotherapy rest period, nor was there deterioration during subsequent cycles, suggesting drug-induced mania to be unlikely. Possible onset mechanisms include manic defense phenomena, common with stressful life events. There are no reports of recurrent gastric cancer patients experiencing hypomania during S-1 or S-1 plus cisplatin therapy, i.e. our patient represents a rare course. Clinicians should recognize psychosis or mood disorders during gastric cancer treatment. Further accumulation of such rare cases might elucidate pathological mechanisms underlying hypomania in cancer patients.

The development of stomach cancer is closely associated with chronic inflammation, and the Wnt/beta-catenin signaling pathway is activated in most cases of this cancer. High-mobility group A (HMGA) proteins are oncogenic chromatin factors that are primarily expressed not only in undifferentiated tissues but also in various tumors. Here we report that HMGA1 is induced by the Wnt/beta-catenin pathway and maintains proliferation of gastric cancer cells. Specific knockdown of HMGA1 resulted in marked reduction of cell growth. The loss of beta-catenin or its downstream c-myc decreased HMGA1 expression, whereas Wnt3a treatment increased HMGA1 and c-myc transcripts. Furthermore, Wnt3a-induced expression of HMGA1 was inhibited by c-myc knockdown, suggesting that HMGA1 is a downstream target of the Wnt/beta-catenin pathway. Enhanced expression of HMGA1 coexisted with the nuclear accumulation of beta-catenin in about 30% of gastric cancer tissues. To visualize the expression of HMGA1 in vivo, transgenic mice expressing endogenous HMGA1 fused to enhanced green fluorescent protein were generated and then crossed with K19-Wnt1/C2mE mice, which develop gastric tumors through activation of both the Wnt and prostaglandin E2 pathways. Expression of HMGA1-enhanced green fluorescent protein was normally detected in the forestomach, along the upper border of the glandular stomach, but its expression was also up-regulated in cancerous glandular stomach. These data suggest that HMGA1 is involved in proliferation and gastric tumor formation via the Wnt/beta-catenin pathway.

Purpose: We herein report a case with synchronous multiple liver metastases from gastric carcinoma surviving disease-free for more than 10 years after hepatic resection., Methods: A 64-year-old male admitted to our hospital because of constitutional wariness. Preoperative diagnosis was type 1 gastric cancer at the lower third of the stomach and multiple metastases of both hepatic lobes. After we performed distal gastrectomy with regional lymphadenectomy and wedge hepatic resection for eight metastatic liver tumors, he received 5-fluoropyrimidine and platinum-based adjuvant chemotherapy during the early postoperative period., Results: The pathologic examination revealed moderately differentiated gastric adenocarcinoma with regional lymph node metastasis and multiple liver metastases. The postoperative course was uneventful and the patient is doing well without disease recurrence after more than 10 years following surgery., Conclusion: To the best of our knowledge, this patient is the longest disease-free survivor after liver resection for synchronous multiple liver metastases from advanced gastric cancer. In this modern era of developing liver surgery and adjuvant chemotherapy, combination therapy of aggressive surgery and early postoperative adjuvant chemotherapy for advanced gastric cancer with liver metastasis may allow long-term survival in selected patients.

The detection of gastric premalignant lesions, atrophic gastritis, corpus atrophic gastritis, and intestinal metaplasia, using several potential markers was examined in Costa Rica. Depending on the lesion investigated, from a total of 223 dyspeptic patients, 58 (26.0%), 31 (13.9%), or 23 (10.3%) were histologically diagnosed with atrophic gastritis, corpus atrophic gastritis, or intestinal metaplasia, respectively. Sera were used for the measurement of pepsinogen (PG) and Helicobacter pylori CagA antibody (CagA-ab) levels by ELISA, and human genomic DNAs were used for the genotyping of interleukin (IL)-1beta (-511 and +3954), IL-10 (-1082 and -592), and IL-1RN intron 2 by PCR and RFLP. Multivariate analysis was done adjusting for sex, age, and H. pylori seropositivity. Low PG levels (L-PG; PG I < or = 70 microg/L + PG I/II < or = 3), very low PG levels (VL-PG; PG I < or = 30 microg/L + PG I/II < or = 2), and CagA-ab were individually associated with all premalignant lesions whereas IL-1beta +3954T-carrier and IL-1RN homozygous 2 allele were associated with intestinal metaplasia. VL-PG, for corpus atrophic gastritis detection, was the single marker with the highest combination of test characteristics, sensitivity (77.4%), specificity (80.7%), positive predictive value (39.3%), negative predictive value (95.7%), and seropositivity rate (27.4%), expected to improve after periodic measurements. Combined examinations of VL-PG and CagA-ab improved the specificity (92.7%) and positive predictive value (62.2%), with similar sensitivity (74.2%) and negative predictive value (95.7%). In conclusion, corpus atrophic gastritis detection with periodic measurements of serum PG, alone or in combination with CagA-ab status, to identify high gastric cancer risk, seems to be the method best suited for mass screening in Costa Rica.

Background: Associations between Helicobacter pylori gene diversity and gastric cancer have not been reported on in Costa Rica, despite its being one of the countries with the highest gastric cancer incidence and mortality rates in the world. The aim of this study was to determine the prevalence of H. pylori cagA and vacA genes and investigate whether it could be correlated with atrophic gastritis (AG) and gastric cancer (GC) in Costa Rica., Materials and Methods: Genomic DNAs from isolates of 104 patients classified into two groups: non-atrophic gastritis group (n = 68) and atrophic gastritis group (n = 36), were subjected to PCR-based genotyping of cagA and vacA genes and their correlation with clinical outcome was investigated. Total DNA extractions from gastric tissues of 25 H. pylori-infected gastric cancer patients were utilized for comparative purposes., Results: The presence of cagA (75.3%), vacA s1b (75.3%), and vacA m1 (74.2%) was detected, and colonization by strains with different vacA genotypes in the same stomach was found in 9.7% of the patients. Age- and sex-adjusted vacA s1b and vacA m1 were associated with GC while only vacA m1 was significantly associated with AG. A tendency for association between cagA and vacA s1b, and AG was reported., Conclusions: The prevalence status of the cagA and vacA (s1/m1) genes in Costa Rica seems to fall between that found in European/North American and East Asian countries, and both cagA and vacA seem to have clinical relevance in this country.

Background/aims: The detection of early gastric carcinoma (EGC) has increased worldwide in recent years due to advances in endoscopic techniques and equipment. The objectives of this study were to compare the clinicopathological findings of patients with N1 node-negative and positive EGC, and then consider the treatment options., Methodology: A total of 814 cases of gastric carcinoma in patients who underwent surgical procedures between 1981 and 1999 at Kochi Medical School were studied. In 375 patients with EGC, surgicopathological parameters were analyzed., Results: Lymph node metastasis was observed in 28 patients (7.4%) with EGC. EGC of the flat type with submucosal invasion, lymphatic permeation, and tumor size larger than 4 cm was associated with higher risk factors of lymph node metastasis. In this study, the location and histological classification of EGC were not related to lymph node metastasis. However, lymph node metastasis was not recognized in submucosal invasive gastric carcinomas less than 1 cm in size., Conclusions: In the EGC limited to the mucosa or smaller than 1 cm, when the tumor infiltrated the submucosal layer, it could be managed by less invasive surgery without standard lymphadenectomy, and gastrectomy with lymphadenectomy was necessary for patients with EGC who had a high risk of lymph node metastasis.

A 76-year-old man was admitted for treatment of gastric cancer that causing anorexia. Endoscopy showed the stenosis in the antrum of the stomach and multiple small nodules with erosion from the upper body to the corpus of the stomach. Total gastrectomy with Roux-en-Y reconstruction was performed. On the resected specimen, there were at least 28 nodules with erosion in the submucosal layer of the entire stomach. The lesions had no continuity with one another and were the same histological type, poorly differentiated adenocarcinoma. We diagnosed these lesions as intramural metastases of gastric cancer.

Reflux esophagitis is a serious postoperative complication for patients undergoing gastrectomy. We designed a new jejunal pouch-esophagostomy to prevent reflux after proximal gastrectomy. After proximal gastrectomy, ajejunal segment about 17 cm long was folded. Side-to-side jejuno-jejunostomy was made using a linear stapler with 100-mm staples along the length at the anti-mesenteric side. A 10-cm-longjejunal pouch with a 7-cm-long apical bridge was made. Esophago-jejuno end-to-side anastomosis (pouch-esophagostomy) was made with circular stapler at the right anterior wall the apical bridge. We add "partial posterior fundoplication" like wrapping using the apical bridge of the jejunal pouch. Patients with this new anti-reflux anastomosis showed no reflux on barium meal study even in the right anterior oblique deep Trendelenburg's position. Jejunal pouch reconstruction with partial posterior wrapping provides a satisfactory result with regard to preventing reflux esophagitis.

Background: We evaluated several risk factors for gastric cancer in Costa Rican regions having contrasting gastric cancer incidence rates, despite the small dimensions of the country., Methods: A total of 180 dyspeptic patients were classified into two groups according to the gastric cancer incidence (GCI) rate in their Costa Rican region: group A, with a high GCI rate (n = 91) and group B, with a low GCI rate (n = 89). Helicobacter pylori infection was detected by rapid urease test, Gram staining, and histological observation. Antral and corpus specimens were obtained to assess the grade of inflammation, topography of gastritis, gastric atrophy, and intestinal metaplasia by histological examination. Serum CagA antibody was measured by an antigen-specific enzyme-linked immunosorbent assay., Results: There was no significant difference in H. pylori prevalence between groups A (73%) and B (63%); however, serum CagA antibody was more frequently detected in group A (79%) than in group B (54%) [P = 0.02; odds ratio (OR), 2.68]. Among patients under 60 years of age, serum CagA antibody was even more frequently detected in group A (81%) than in group B (49%) (P < 0.01; OR, 4.50). The prevalence of corpus-predominant gastritis, atrophic gastritis, and moderate/severe grades of neutrophilic infiltration was higher in serum CagA antibody-positive patients than in CagA antibody-negative patients (P = 0.003, 0.04, and 0.002, respectively)., Conclusions: Infection with H. pylori possessing the cagA gene is associated with the development of severe gastric damage such as gastric atrophy, leading to gastric cancer, and probably influences the differences in GCI between Costa Rican regions.

We describe here a new technique for performing the large anastomosis between the jejunal pouch and the remnant stomach in patients undergoing proximal gastrectomy with jejunal pouch interposition. The biangulation method described in this report is a simpler technique than the existing triangulation anastomosis technique, requiring only two applications of a linear stapler. One row of staples forms the posterior wall of the anastomosis and the other forms the anterior wall. When used for jejunal pouch reconstruction after proximal gastrectomy in 12 cases of early gastric cancer, no evidence of anastomotic leakage or stenosis was apparent from barium meal studies or endoscopic examination. We find this biangulation technique to be a simple and safe procedure that is ideal for anastomoses of large diameter.

Aim: To examine the paclitaxel concentrations in plasma and ascites after its intravenous administration in patients with ascites due to peritonitis carcinomatosa resulting from advanced gastric cancer., Methods: Two patients with ascites due to peritonitis carcinomatosa resulting from gastric cancer were included in this study. The paclitaxel concentrations in plasma and ascites were investigated for 72 h in case 1 and 168 h in case 2 after intravenous administration., Results: The paclitaxel concentration in plasma peaked immediately after administration, followed by rapid decrease below the threshold value of 0.1 micromol (85 ng/mL) within 24 h. In contrast,the paclitaxel concentration in ascites increased gradually for 24 h after administration to a level consistent with the level found in plasma. After 24 h the level of paclitaxel in ascites and plasma became similar, with the optimal level being maintained up to 72 h following administration., Conclusion: The concentration of paclitaxel in ascites is maintained within the optimal level for the treatment of cancer cells for up to 72 h after intravenous administration. Paclitaxel is a promising drug for the treatment of malignant ascites of gastric cancer.

Background/aims: Gastric carcinoma (GC) is one of the most common malignant tumors of the digestive tract and the incidence of adenocarcinoma of the upper one-third of the stomach has increased recently worldwide. The objective of this study was to analyze the clinicopathological variables in patients with GC and examine preoperative diagnosis and the medical treatment strategy of Type 1 GC., Methodology: Nine hundred and eighty-one patients with GC who underwent surgical resection between 1981 and 2002 at Kochi Medical School were studied. Thirty-five patients with Type 1 GC were compared with non-Type 1 GC patients on postoperative surgicopathological parameters, and changing trends were evaluated., Results: The characteristics of patients with Type 1 GC were different from those of patients with non-Type 1 GC: Their tumors were more often in the upper one-third of the stomach (37% vs. 15%), lesions were histologically differentiated in 80% (vs. 56%), and there were more superficial lesions surrounding Type 1 GC (80% vs. 8%). The absolute value and the rate of Type 1 GC increased significantly from the first half to the second half of the study., Conclusions: Our findings showed that when Type 1 GC is discovered, physicians should investigate the mucosa around the main neoplasm carefully. The current series suggested that Type 1 GC are associated frequently with superficial lesions, making local resections more difficult, and that Type 1 GC was similar clinicopathologically to carcinoma of the gastric cardia and had different etiologies contributed to its tumorgenesis, compared with non-Type 1 GC, and Type 1 GC may become the key which solves the problem of carcinoma at the gastric cardia.

Background: The characteristics of stage II gastric cancer according to the Japanese Classification of Gastric Cancer (JCGC) were examined and the high-risk factors predicting poor prognosis were detected., Patients and Methods: In total, 107 patients, who underwent clinically curative gastrectomy with D2 lymphadenectomy for stage II gastric cancer, were included. Survival curves of the depth of invasion, lymph node metastasis, the ratio of involved: resected lymph nodes and chemotherapy treatment were compared., Results: The survival curves were related to tumor invasion depth and lymph node metastasis. The ratio of involved resected lymph nodes was a good prognostic indicator compared to the classification of regional lymph node metastasis (N classification). Survival rates with adjuvant chemotherapy were slightly higher than without adjuvant chemotherapy, but the difference was not significant., Conclusion: pT2pN1 (stage II) gastric cancers according to the JCGC, especially pSSpN1 cases, included stage IIIB and IV gastric cancers according to the International Union Against Cancer / American Joint Committee on Cancer (UICC/AJCC); therefore, the prognosis of these might be poor. With pSSpN1 cases, according to the JCGC, anticancer chemotherapy equivalent to that required for stage III gastric cancer cases is necessary.

A 52-year-old man suffering from a pure-type primary gastric small cell carcinoma was treated with surgery and combination chemotherapy. The small cell carcinoma, approximately 6.5 cm in diameter, was situated in the posterior wall of the antrum and there were no distant metastases. Total gastrectomy and regional lymph node dissection was carried out. Histological examination revealed a solid pattern of proliferation of small cells with hyperchromatic, round nuclei and scant cytoplasm. Neoplastic cells infiltrated into the subserosal layer with severe lymphatic and vascular invasion. Regional lymph node cells were mostly replaced by tumor cells that stained positive for Grimelius, neuron-specific enolase (NSE), and synaptophysin. Accumulations of electron-dense core granules in the small neoplastic cells were seen by electron microscopy. Following surgery, the patient was treated with adjuvant chemotherapy consisting of cisplatin and etoposide. The patient is alive and recurrence free 3 years after surgical operation. We review 107 published cases of primary gastric small cell carcinoma, an extremely rare disease first reported in 1976. Small cell carcinoma is an aggressive, malignant tumor. Intensive chemotherapy is essential for patient survival even when curative surgical resection is carried out.

Aim: To review the cases reported in the literature, examined their clinicopathological features, and evaluated the efficacy of different therapeutic modalities for this rare condition., Methods: A search of the MEDLINE database revealed 16 cases of pericarditis carcinomatosa (PC) originating from GC reported in the literature between 1982 and 2005. Additional detailed data were obtained from the authors of these studies for subsequent clinicopathological investigation. We have also described about a case study from our own clinic., Results: The mean age of cases with pericarditis carcinomatosa originating from GC was 54 years. Females were diagnosed at a younger age (46.3 years) compared to males (58 years). The mean survival period after diagnosis was 4.5 mo. No statistical differences in the length of survival time were found between different therapeutic modalities, such as drainage, and local and/or systemic chemotherapy after drainage. However, three cases who underwent systemic chemotherapy survived for more than 10 mo. Cases that developed metachronous cardiac tamponade for more than 2 years after the diagnosis of GC generally survived for a longer period of time, although this was not statistically significant. Multivariate analysis revealed that low levels of carcinoembryonic antigen (CEA), and CEA and/or cancer antigen 19-9 (CA 19-9) were associated with longer survival., Conclusion: Cases with low levels of CEA, and CEA and/or CA 19-9 should undergo systemic chemotherapy with or without local chemotherapy after drainage.

Background/aims: The present phase I study was planned to define the toxicities, maximum tolerated dose (MTD), and pharmacokinetics of the combination of paclitaxel and cisplatin in patients with advanced or recurrent gastric cancer, and to recommend a dose for the phase II study., Methodology: Patients were required to have performance status of 0 to 1, to be between 15 and 74 years of age, and to have adequate organ function. The cisplatin was administered at a fixed dose of 25mg/m2 and paclitaxel was administered at four dose levels (60, 70, 80, and 90mg/m2). Plasma sampling was performed to characterize the pharmacokinetics and pharacodynamics of paclitaxel., Results: All of the 15 patients entered were assessable for toxicity and response and were subject to analysis of dose-limiting toxicity (DLT) and MTD. Neutropenia (grade 4, for 3 days or more; n=2) indicated DLT at dose level 4 (90mg/m2). The MTD for this regimen was 90mg/m2/week of paclitaxel for 3 weeks. Tumor response occurred in 7 of the 15 patients and the overall response rate was 57.1%. The pharmacokinetic profiles of paclitaxel were similar to those observed after the administration of each dose as a single agent., Conclusions: Our study demonstrated that the level 3 dosage (80mg/m2 of paclitaxel and 25mg/m2 of cisplatin) is recommended for this combination chemotherapy. This phase I study showed favorable antitumor activity and fewer adverse reactions relative to other types of chemotherapy.

The surgical outcome of most early gastric cancer (EGC) is usually satisfactory. Some cases show bone metastasis even though the depth of cancer invasion is confined to the mucosa. The most frequent site for recurrence of EGC is the liver. Cases of EGC with bone metastasis are reviewed to clarify the clinicopathological characteristics of EGC giving rise to bone metastasis. Possible mechanisms and risk factors underlying this rare condition are proposed. Forty-six cases of bone metastasis from EGC are reviewed from published reports and meeting proceedings in Japan. This investigation suggests that risk factors for bone metastasis from EGC include depressed-type signet-ring cell carcinoma, poorly differentiated carcinoma, and/or the likely involvement of lymph node metastasis, even though the cancer is confined to the gastric mucosa. The risk factors do not include recurrence of EGC in the liver. We speculate that the mechanism of bone metastasis from EGC is via lymphatic channels and systemic circulation. Post-operative follow-up of cases should consider the development of bone metastasis from EGC. We propose the use of elevated alkaline phosphatase levels for the detection of bone metastasis and recommend bone scintigraphy in positive cases.

Objective: We conducted a phase I trial of escalating doses of weekly paclitaxel (Taxol) in combination with a fixed systemic administration of 5-fluorouracil (5-FU) in patients with advanced or metastatic gastric cancer., Methods: Patients with advanced or recurrent gastric cancer were treated with escalating doses of weekly paclitaxel as a 60 min intravenous (i.v.) infusion, along with a fixed dose of continuous 5-FU infused over 5 days. Plasma sampling was performed to characterize the pharmacokinetics and pharmacodynamics of paclitaxel., Results: Eighteen patients received combination therapy at four dose levels of weekly Taxol, ranging from 60 to 90 mg/m2/week. Dose-limiting toxicities > grade 3 were observed at the 90 mg/m2/week dose level. Toxicities included anemia, neutropenia, thrombocytopenia, nausea and alopecia. Two episodes of grade 4 neutropenia occurred in two of the three patients receiving this dose. At each dose level, pharmacological studies documented the persistence of significant serum paclitaxel levels over 24 h after drug administration. The maximum tolerated dose (MTD) for this regimen was 90 mg/m2/week of paclitaxel for 3 weeks plus 600 mg/m2/day of continuous 5-FU for 5 days., Conclusions: The combination of weekly paclitaxel and 5-FU demonstrated an acceptable toxicity profile and feasible pharmacokinetic results suggesting its practical applicability. Based on these findings, the recommended dose and schedule for phase II study of combination chemotherapy is paclitaxel 80 mg/m2/week x 3 over 4 weeks, and continuous 5-FU 600 mg/m2/day x 5 days every 4 weeks.

Background/aims: A pancreatic fistula is a potentially fatal complication in digestive tract surgery. The aim of this study was to review the prevention and treatment of pancreatic fistula as performed by our department., Methodology: Three hundred and seventeen patients with gastric neoplasm and 34 patients with pancreatic neoplasm who underwent surgical resection between 1981 and 2001 at Kochi Medical School were studied. Comparative analysis of the incidence of pancreatic fistulae and the mortality rate was carried out according to an operation type and time., Results: Among the 317 patients who underwent total gastrectomy due to gastric neoplasm, 30 (9.5%) showed pancreatic fistulae. The incidence of pancreatic fistulae in patients who underwent distal pancreatectomy for pancreatic neoplasm was 29.4%. The mortality rate of patients who underwent total gastrectomy was 4.4% and there was a tendency for mortality rate to decrease in the second decade compared to the first. The mortality rate of patients who underwent distal pancreatectomy was 5.9%., Conclusions: Mortality rate tended to decrease with advanced operative procedures, however, the incidence of pancreatic fistulae did not decrease. In pancreatic fistulae, it was found that the type of treatment was important. Intraoperative and postoperative drainage management for pancreaticosplenectomy will likely become much more important.

Thymidine phosphorylase (TP) is known to be more concentrated in human cancer tissues than in adjacent normal tissue based on findings using enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry. However, the ultrastructural localization of TP in cancer tissues has not previously been demonstrated. We investigated the localization of TP in gastric cancer and colorectal cancer tissue by ELISA, immunohistochemistry, and immunoelectron microscopy. Between April 1997 and May 2000, we obtained surgically resected specimens from 42, 46, and 36 cases of advanced gastric, colon, and rectal cancer, respectively. ELISA demonstrated that the TP level was higher in cancer tissues than in adjacent normal tissue. Immunohistochemically, cancer cells were positive for the enzyme in some cases. However, in a number of cases immunopositive inflammatory cells were also present in cancerous tissues. At the electron microscope level, TP was diffusely distributed in the cytoplasm of cancer cells and in the mitochondria of the neutrophil in gastric cancer tissue. In rectal cancer tissues, cytoplasmic granules in macrophages in cancer tissues were immunoreactive for the TP. These findings suggest that TP is produced by macrophages and exists in neutrophils and cancer cells.

A forty-year-old female consulted a hospital complaining of epigastralgia. She underwent endoscopy, which showed irregular shaped ulceration with fold convergence; the biopsy specimen revealed poorly differentiated adenocarcinoma. She underwent subtotal gastrectomy and lymph node dissection. Histological findings revealed the signet-ring-cell cancer confined to the mucosa and no lymph node metastasis. The serum carcinoembryonic antigen was elevated 2 years and 11 months after operation. Bone scintigraphy demonstrated multiple accumulation and bone biopsy of the sacrum revealed the metastatic gastric cancer. She underwent chemotherapy and radiation, however, later complained of nausea, vomiting, and diminished visual acuity. Brain computed tomography revealed multiple brain metastasis. She died 3 years and 6 months after her operation. We reviewed the 39 reported cases of early gastric cancer with bone metastasis in Japan, which suggests that signet-ring-cell carcinoma and poorly differentiated carcinoma have a possibility of bone metastasis even though the early gastric cancer is confined to the mucosa.

Background: Smoking and alcoholic beverage drinking habits as well as a family history of cancer are well known risk factors for the multifocal occurrence of squamous cell carcinoma of the esophagus and the head and neck region. However, the role of these risk factors in multiple gastric carcinoma remains to be clarified. The purpose of this study was to examine the risk factors for multiple gastric carcinoma., Methods: The smoking and drinking habits as well as the family history of 157 patients with synchronous multiple gastric carcinoma and 157 patients with solitary gastric carcinoma who were similar with regard to gender, age, stage of the tumor, and year of admission were investigated. The risk of a multiple occurrence of gastric carcinoma also was elevated using the odds ratio (OR)., Results: The ORs of a multifocal occurrence of gastric carcinoma in patients who currently smoked and drank alcoholic beverages were 1.1 and 0.8, respectively, although the ORs were not related to the quantity of smoking or drinking. In patients with a close relative with gastric carcinoma the OR was 2.1 (95% confidence interval [CI], 1.3-3.7). In those patients with > or =2 close relatives with gastric carcinoma, the OR increased to 5.1 (95% CI, 1.2-21.1). Conversely, no significant elevation in the ORs was recognized regarding a family history of other cancers., Conclusions: In this study, a family history of gastric carcinoma was found to be clearly associated with the multifocal occurrence of gastric carcinoma; however, no significant correlation between the multifocal occurrence of gastric carcinoma in these patients and their smoking and drinking habits was recognized.

In order to provide a high dose of cis-diammine dichloro platinum (CDDP) into the regional lymph nodes and surrounding organs during operation, "intraoperative local infusion chemotherapy (ILIC)" was devised and has been applied to advanced gastric cancer patients. The aims of this method are 1) to reduce the possibility of metastasis by affecting the cancer cells before flowing out; 2) to administer drugs to the cancer cells which evade surgical resection; 3) to administer drugs to the lymphatic flow; and 4) to reduce the systemic side effects. After the laparotomy, the part of the stomach for gastrectomy was isolated from the blood supply, applying clamps to the proximal and distal parts of the stomach and hemostats to feeding blood vessels. Through a feeding artery to the tumor, 50 mg of CDDP was injected. Twenty-four patients underwent ILIC from June 1986 to December 1993. The 5-year survival rate was significantly better in the ILIC group compared to the control group which was selected by the matched pair method. The newly devised ILIC chemotherapy is a promising way to improve the prognosis of advanced gastric cancer patients. A randomized prospective study should be undertaken.

This study describes the distribution of spiral and coccoid forms of Helicobacter (H.) pylori within the surface mucous gel layer (SMGL) on human gastric mucosae. Gastric mucosae infected with H. pylori were obtained from surgically removed stomachs of 14 cases of gastric cancer. The glycocalyx of the spiral and coccoid forms of H. pylori was examined for specific lectin labeling. Coccoid forms were identified in 11 of these cases (78.6%). The SMGL, which was from 50 to 100 microns in thickness, contained H. pylori throughout its entire thickness. Variously-sized vacuole-like clear areas were present near H. pylori. The glycocalyx on both the spiral and coccoid forms was similar in its staining with the 8 types of lectins tested. However, the staining pattern of the lectins varied among different samples. The numerous fibrillae-like filaments radiated from the surface of the bacteria and appeared to link the bacteria to the surface mucous cells or the surrounding mucus. These fibrillae-like filaments were not specifically stained by the lectin reactions, suggesting absence of sugar molecules.

An intensive chemotherapy combined with surgery, termed "intraoperative local infusion chemotherapy (ILIC)", was devised. The ILIC procedure is to infuse 50 mg of cisplatin through the feeding artery to the tumor, which has been isolated from blood flow by clamping the stomach and blood vessels, before radical surgery. An experiment in dogs showed considerable free Pt transfer into thoracic lymph after ILIC. Sum total Pt in the thoracic lymph after ILIC (294.5 micrograms/3 h) was 4.3 times that after IV administration (68.3 micrograms/3 h). In ILIC, AUC of free Pt in the thoracic lymph was about 5.8 times that in peripheral blood. ILIC was applied in 24 advanced gastric cancer patients, consisting of 6, 2, 4 and 12 in pTNM stage II, IIIA, IIIB and IV, respectively. Pt concentration of the tissues was high in the tumor (23.22 micrograms/g) and the regional lymph nodes (2.95 micrograms/g) compared to that in the serum (0.45 microgram/ml). The survival rate (Kaplan-Meier) in the ILIC patients was significantly higher than that of control patients (matched pair method) from among patients treated by surgery alone. No fatal complications were encountered in any patient treated by ILIC.

Purpose: To improve the prognosis of gastric cancer, radical surgical resection with extensive lymph node dissection plus intraoperative radiation therapy (IORT) was tried in our clinic. In addition, a new operative procedure was created to obtain wider irradiation field for total gastrectomy patients., Methods and Materials: A total of 183 gastric cancer patients who underwent radical gastrectomy with or without IORT from August 1983 to July 1992 were retrospectively evaluated. The patients were divided into two groups: group 1 consisted of 58 patients who underwent radical operation plus IORT. A single dose of 28 to 30 Gy was delivered around the celiac axis with an electron beam of 12 MeV. Group 2, our historical control group, which showed no difference in age, sex and stage, consisted of 120 patients who underwent only radical surgery. In addition, a new method of total gastrectomy with IORT after mobilization of the tail and body of the pancreas was devised to get wider irradiation field for advanced gastric cancer., Results: Of the Stage II gastric cancer patients, all the 11 patients of group 1 are alive, whereas in group 2, the 4-year and the 8-year survival rates were 60% and 48%, respectively. In Stage III patients, the 8-year survival rate of group 1 was 55% vs. 35% in group 2. As for Stage IV patients, the 5-year survival rate of group 1 was 12% and that of group 2 was 13%., Conclusion: Using this combined treatment modality of radical surgical operation+IORT, improved survival rates were obtained for Stage II and III gastric cancer patients. However, the method was ineffective for more advanced, Stage IV, patients. The wider irradiation field method used for total gastrectomy patients was safe and no complications were encountered.

The three-dimensional structure of the collagen networks in human gastric carcinoma was examined by scanning electron microscopy (SEM) after treatment with the cell-maceration method using a low temperature NaOH solution. Based on stromal content, the poorly differentiated adenocarcinoma can be divided into the medullary carcinoma area and the scirrhous carcinoma area. In the medullary carcinoma, the collagen sheath around the small tumor cell acinus formed spherical chambers (20-30 microns in diameter) with fenestrations (about 5 microns in diameter) connecting the chambers. The collagen sheath was composed of fine collagen fibrils (about 50 nm in diameter). In the scirrhous area, there was abundant fibrous stroma composed of thicker collagen fibrils (about 100 nm in diameter). Tiny tumor cell nests were sporadically seen in the fibrous stroma. These tumor nests were surrounded by collagen fibrils (about 50 nm in diameter). In the moderately differentiated tubular adenocarcinoma, the tumors were surrounded by spherical, ovoid or irregular shaped thick collagen sheaths (50-200 microns in diameter), which were composed of loosely packed 50 nm collagen fibrils. In well differentiated tubular adenocarcinoma, tumor glands were surrounded by spherical, ovoid or irregularly-shaped thick collagen sheaths (50-200 microns in diameter), composed of densely arranged fine collagen fibrils. In papillary carcinoma, the collagen sheaths were nipple-shaped. They were composed of very densely arranged fine collagen fibrils (about 50 nm in diameter).

A periodical and histological study on the histogenesis of experimental stomach carcinoma induced by N-methyl-N'-nitro-N-nitrosoguanidine in rats suggested that cancer progression occurred from the submucosal focus under the condition of existing adenomatous hyperplasia. This carcinoma manifested particular atypia, combined hyperplasia of the smooth muscle, indistinct borderline from the surrounding normal mucosa. These were considered to be specific histological findings in experimental carcinoma. In 3 of 273 gastrectomized patients with gastric carcinoma the same histological findings were obtained as in experimental gastric carcinoma; 35 patients had submucosal heterotopic glands similar to the experimentally induced rat foci or adenomatous hyperplasias seen in the experimental carcinoma. These results suggest the same histogenesis for human stomach cancer and the experimental carcinoma.