Gastric Cancer with Bone Marrow Invasion at Presentation: Case-Report and Review of the Literature

A case of extensive bone marrow infiltration due to gastric cancer is reported. A 65-year old man with an acute episode of anemia (Hb 4.1 mg/dl) and dyspnea was admitted to the Medical Department of a general hospital. Bone marrow biopsy showed extensive paratrabecular infiltration of a poorly differentiated adenocarcinoma of gastric origin. The primary tumor in the stomach was confirmed, and the patient was referred to our Institute and treated with combination chemotherapy (FAMTX) for 6 cycles. Due to the disappearance of bone marrow infiltration, the patient was considered for curative resection of the primary gastric cancer. After 27 months the patient is alive and in clinical complete remission.

Feasibility of intraperitoneal Trastuzumab treatment in a patient with peritoneal carcinomatosis from gastric cancer

OBJECTIVES

This case report evaluates the feasibility and efficacy of intraperitoneal (IP) trastuzumab administration in gastric cancer (GC) patients with peritoneal carcinomatoses.

METHODS

Peritoneal metastasis is a common sign of advanced tumor stage, tumor progression or disease recurrence in patients with GC. Recently, the role of HER2 overexpression in GC, occurring in about 20% of cases, is correlated with a worse prognosis. We report the case of 61-years old female, admitted to our Hospital after curative surgery for GC with over-expression of HER2. Seven months after the start of first line chemotherapy treatment a pleuro-peritoneal disease progression occurred, documented by cytological exam; according to HER2 status, we decided to treat the patient with IP trastuzumab administration.

RESULTS

Between September and October 2012, the patient (ECOG performance status was 0), underwent to 6 cycles of IP trastuzumab. Trastuzumab was administered weekly at a dose of 150 mg for each cycle after paracentesis. The safety was good, no local complications (e.g. abdominal pain, peritonitis) occurred. The clinical revaluation evidenced a stable peritoneal disease.

CONCLUSIONS

To our knowledge this is the first report on Trastuzumab use to treat IP metastases from GC, with acceptable toxicity and local disease control.

MTHFR polymorphisms in gastric cancer and in first-degree relatives of patients with gastric cancer

Two common mutations, 677 C→T and a1298 A→C, in the methylenetetrahydrofolate reductase gene (MTHFR) reduce the activity of MTHFR and folate metabolism. Familial aggregation in a variable but significant proportion of gastric cancer (GC) cases suggests the importance of genetic predisposition in determining risk. In this study, we evaluate MTHFR polymorphisms in 57 patients with a diagnosis of GC, in 37 with a history of GC in first-degree relatives (GC-relatives), and in 454 blood donors. Helicobacter pylori (HP) infection was also determined. An increased risk was found for 677TT in GC patients with respect to blood donors (odds ratio (OR) = 1.98), and statistical significance was sustained when we compared sex–age-matched GC patients and donors (OR = 2.37). The 677TT genotype association with GC was found in women (OR = 3.10), while a reduction in the 667C allele frequency was present in both the sex. No statistically significant association was detected when 677–1298 genotype was stratified by sex and age. Men of GC-relatives showed a higher 1298C allele frequency than donors (OR = 4.38). Between GC and GC-relatives, HP infection frequency was similar. In conclusion, overall findings support the hypothesis that folate plays a role in GC risk. GC-relatives evidence a similar 677TT frequency to that found in the general population.

A new HLA-A*680106 allele identified in individuals with celiac disease from the Friuli area of northeast Italy

A novel human leukocyte antigen (HLA)-A*680106 antigen was identified in two Italian individuals by polymerase chain reaction sequencing-based typing.

Small-bowel neoplasms in patients undergoing video capsule endoscopy: a multicenter European study

BACKGROUND AND STUDY AIM

Small-bowel tumors account for 1% - 3% of all gastrointestinal neoplasms. Recent studies with video capsule endoscopy (VCE) suggest that the frequency of these tumors may be substantially higher than previously reported. The aim of the study was to evaluate the frequency, clinical presentation, diagnostic/therapeutic work-up, and endoscopic appearance of small-bowel tumors in a large population of patients undergoing VCE.

PATIENTS AND METHODS

Identification by a questionnaire of patients with VCE findings suggesting small-bowel tumors and histological confirmation of the neoplasm seen in 29 centers of 10 European Countries.

RESULTS

Of 5129 patients undergoing VCE, 124 (2.4%) had small-bowel tumors (112 primary, 12 metastatic). Among these patients, indications for VCE were: obscure gastrointestinal bleeding (108 patients), abdominal pain (9), search for primary neoplasm (6), diarrhea with malabsorption (1). The main primary small-bowel tumor type was gastrointestinal stromal tumor (GIST) (32%) followed by adenocarcinoma (20%) and carcinoid (15%); 66% of secondary small-bowel tumors were melanomas. Of the tumors, 80.6% were identified solely on the basis of VCE findings. 55 patients underwent VCE as the third procedure after negative bidirectional endoscopy. The lesions were single in 89.5% of cases, and multiple in 10.5%. Retention of the capsule occurred in 9.8% of patients with small-bowel tumors. After VCE, 54/124 patients underwent 57 other examinations before treatment; in these patients enteroscopy, when performed, showed a high diagnostic yield. Treatment was surgery in 95% of cases.

CONCLUSIONS

Our data suggest that VCE detects small-bowel tumors in a small proportion of patients undergoing this examination, but the early use of this tool can shorten the diagnostic work-up and influence the subsequent management of these patients.

Treatment of liver toxicity in women undergoing adjuvant chemotherapy for breast cancer: A phase III, monocentric, prospective, randomised trial of ursodeoxycolic acid (UDCA) vs no treatment

9060

Background: Liver toxicity during adjuvant chemotherapy (CT) represents one of the causes of treatment delay and dose reduction, with impairment of dose intensity and of final results. UDCA, a hydrophilic bile acid, has been reported to be effective in cholestasis. Aim: to evaluate the efficacy of UDCA (12 mg/kg/die) plus CT discontinuation vs CT discontinuation alone in the treatment of liver toxicity. Methods: The study provided two arms of randomization: discontinuation of CT and administration of UDCA at the dosage of 12 mg/kg/day or discontinuation of CT. CT was resumed at normalization of liver tests. Pts with liver metastases, acute or chronic hepatopathy, heart or kidney failure, or PS<70 were excluded. During a 3 year period, 118/305 pts developed CT-induced hepatotoxicity and were enrolled into the study. Logistic multiple models and Fisher test or χ2 test and the Mann-Whitney test were used. Results: Out the 118 pts, 66% were treated with CMF, 29% with Anthracyclines alone or in sequence with CMF and 5% with Anthracyclines and Taxanes. Liver toxicity occurred respectively in 37 pts after the 1st cycle, in 35 after the 2nd, in 15 after the 3rd, in 19 after the 4th, in 9 after the 5th and in 3 after the 6th. CT was definitely stopped in 8% of pts. CT was delayed of 1 week in 53%, of 2 wks in 31% and of 3 or more in 16%. 95% of pts had a hepatocytolitic damage and nobody purely cholestatic. G1 toxicity was observed in 34%, G2 in 57%, G3 in 9%. Pts were randomized in two groups of 59 pts each. UDCA group: 3 pts (5%) stopped CT and 11 (19%) had dose reduction. Control group: 6 pts (10%) stopped CT and 7 (12%) had dose reduction. No statistically significant difference between UDCA group and control group was noted both for dose reduction (p = 0.31) and for CT stop (p = 0.30), even if twice as many pts of the control group had to stop CT (6/59). No correlation between alcohol use and liver damage was noted. Conclusions: Most cases of liver toxicity are of low or intermediate grade. No statistically significant difference was found between UDCA and control, even if there was a positive trend in reducing liver toxicity, that can have a positive impact on the final results of adjuvant CT.

No significant financial relationships to disclose.

Neoadjuvant chemotherapy (CT) and postoperative chemoradiation (PCRT) in locally advanced, resectable, gastric cancer (LAGC). Preliminary results of a pilot study

15078

Background: Curative surgery is achieved in fewer than 50% of patients (pts) in LAGC. PCRT has shown significant improvement in disease control and survival but a limited impact on metastatic disease. To improve this results, a combined modality approach, including IORT, was planned. Methods: Pts with resectable LAGC (stage T3–4 and/or N+) were eligible. EGDS, EUS, abdomen CT were used for staging. 3 cycles of ECF (Epirubicin 50mg/mq, q 3wks; Cisplatin 60mg/mq, q 3wks and 21-day c.i. 5-FU 200mg/mq/day) were planned before radical surgery. IORT (10–15 Gy) included the high risk area defined at surgery. Postop RT included gastric area, anastomosis, duodenal stump and draining lymph node stations. RT (41.4–45 Gy in 23–25 fractions) and concurrent c.i. 5-FU (200 mg/mq/day) were administered. An oral caloric intake >= 1500 Kcal was provided. Results: From June 2001 to December 2006, 22 pts (13 M and 9 F), median age 64 yrs (41–74), with uT3N1 (21pts) and uT2N1 (1pt), entered the study. Tumor location was proximal in 10, lower in 8 and middle in 4 pts, respectively. All pts underwent the planned neoadjuvant ECF with a median of 3 cycles (range 3–5). Toxicity was moderate (<= grade 3) without toxic deaths: nausea and vomiting in 3%, mucositis in 3%, hematological in 7%. Twenty/22 pts underwent surgery (in progress in 2 pts) and 15 (75%) had R0 resection. Tumor downstaging was reported in 9/20 (45%) pts (8 pT2, 1pT1). IORT with 12.5 Gy (10–15 Gy) was given to 12 pts and 12 pts had PCRT. Eight pts were excluded from PCRT for postop complications (2 pts), disease progression (3 pts) or pN3 (3 pts). All 12 pts completed RT with a median dose of 41.4 Gy (41.4–56Gy), but 3 (25%) required RT interruption and 5 pts (40%) also definitive 5-FU interruption (overall PCRT compliance of 60%). Major toxicity from PCRT consisted of G3 asthenia and anorexia, requiring parenteral nutrition. Conclusions: Neoadjuvant CT confirmed feasible in LAGC and resulted in a substantial downstaging with a favourable R0 resection rate. Combined modality approach with IORT and PCRT appears attractive, but limited compliance to PCRT was observed. A definitive evaluation and data on disease control and survival will be reported.

No significant financial relationships to disclose.

Proteins specifically hyperexpressed in a coeliac disease patient with aberrant T cells

An aberrant T cell population is the basis for diagnosis of refractory coeliac disease and determines the risk of enteropathy-associated T cell lymphoma. This disease is serious with a poor survival. Pathogenetic mechanisms sustaining aberrant T cell proliferation remain unknown. Recently, alemtuzumab has been proposed as a promising new approach to treat these patients. Only few single cases have been tested at present; nevertheless, in all the cases a clinical improvement was observed. However, whether intraepithelial lymphocytes have been targeted effectively by alemtuzumab is still debated. This study reports, using two-dimensional difference gel electrophoresis (2D DIGE), hyperexpressed proteins associated specifically with aberrant T cells found in a patient with coeliac disease by comparison of the protein expression of this sample with that of patients with coeliac disease and polyclonal T cells or with control subjects. The data demonstrated a significantly higher expression of IgM, apolipoprotein C-III and Charcot-Leyden crystal proteins in a duodenal biopsy specimen of the patient with clonal T cells compared with that of other patients. These preliminary results allow hypothesizing different clinical effects of alemtuzumab in patients with coeliac disease and aberrant T cell proliferation, because as well as the probable effect on T cells, alemtuzumab could exert its effect by acting on inflammatory associated CD52(+) IgM(+) B cells and eosinophil cells, known to produce IgM and Charcot-Leyden crystal proteins, that we demonstrated to be altered in this patient. The results also emphasize the possible association of apolipoprotein with aberrant T cell proliferation.

Hepatitis C virus-related hepatocellular carcinoma and B-cell lymphoma patients show a different profile of major histocompatibility complex class II alleles

Comparison of human leukocyte antigen (HLA) frequencies in patients with hepatitis C virus (HCV)-associated hepatocellular carcinoma (HCC) and in patients with HCV-associated non-Hodgkin's lymphoma (NHL) has not been addressed previously. To this aim, we investigated the distribution of HLA class II alleles in two selected groups of HCV-infected patients. Group 1 included 50 patients with HCV-associated NHL; group 2 included 29 patients with HCV-associated HCC. A control group included 144 hospitalized patients without NHL or HCC and who were negative for HCV, hepatitis B virus, and human immunodeficiency virus antibodies. Polymerase chain reaction sequence DRB1 and DQB1 specific-primer methods were used. DRB1*1101/DQB1*0301 haplotype, which mainly favors the spontaneous clearance of HCV infection, was lower in HCC subjects than in controls, whereas HLA-DRB1*1104/DQB1*0301, was higher in NHL patients. These findings suggest different pathogenic pathways in HCC and in NHL development. In patients with HCV-associated HCC, a major protective role of DQB1*0301 allele, rather than DRB1*11, was found, probably because of a better HLA class II-associated virus clearance. By contrast, the same allele as HLA-DRB1*04 showed an increase in HCV-associated NHL. These data suggest that NHL and HCC development may be associated to a different response with respect to chronic HLA class II-restricted antigen presentation (perhaps a switch toward CD4+Th2 response in NHL?) or, alternatively, that these alleles could be in linkage disequilibrium to unrelated gene(s), or are in synergy with other immunomodulatory genes that may confer increased risk for NHL.

Utility of combined use of plasma levels of chromogranin A and pancreatic polypeptide in the diagnosis of gastrointestinal and pancreatic endocrine tumors

BACKGROUND

Chromogranin A (CgA) is considered the most accurate marker in the diagnosis of gastro-entero-pancreatic (GEP) endocrine tumors. Pancreatic polypeptide (PP) has also been proposed to play this role, but then not used due to its low sensitivity. The aim of the present study was to determine whether the assessment of PP would improve the diagnostic reliability of CgA in patients with GEP tumors.

PATIENTS AND METHODS

Both markers were assessed in 68 patients [28 functioning (F), 40 non functioning (NF)]. Twenty-seven patients disease-free (DF) after surgery, and 24 with non-endocrine tumors (non-ETs) were used as control groups.

RESULTS

CgA sensitivity was: 96% in F, 75% in NF, 74% in pancreatic, and 91% in gastrointestinal (GI) tumors. Specificity was 89% vs DF, and 63% vs non-ETs. PP sensitivity was: 54% in F, 57% in NF, 63% in pancreatic, and 53% in GI tumors. Specificity was 81% vs DF, and 67% vs non-ETs. By combining the two markers a significant gain in sensitivity vs CgA alone was obtained: overall in GEP tumors (96% vs 84%, p = 0.04), in NF (95% vs 75%, p = 0.02), and in pancreatic (94% vs 74%, p = 0.04). More specifically, a 25% gain of sensitivity was obtained in the subgroup of NF pancreatic tumors (93% vs 68%, p = 0.04).

CONCLUSION

The combined assessment of PP and CgA leads to a significant increase in sensitivity in the diagnosis of GEP tumors, particularly in pancreatic NF.

Somatostatin receptor scintigraphy versus chromogranin A assay in the management of patients with neuroendocrine tumors of different types: clinical role

BACKGROUND

Current diagnosis and staging of neuroendocrine tumors (NETs) are significantly improved by the introduction of the chromogranin A (CgA) assay in plasma or serum as a tumor marker, and by the use of somatostatin receptor scintigraphy (SRS) for tumor localization. However, the clinical role of CgA assay compared with SRS in the management of NETs has not been well elucidated.

PATIENTS AND METHODS

Sixty-three consecutive patients with a histological diagnosis of NET underwent plasma CgA assay and SRS for tumor staging (23 cases), evaluation of tumor response (18 cases) and evaluation of tumor recurrence on follow-up (22 cases). Twenty-one patients had well-differentiated neuroendocrine tumors (WDNETs: 18 gastroenteropancreatic tumors and three lung NETs); 22 patients had well-differentiated neuroendocrine carcinomas (WDNECs: 17 gastroenteropancreatic carcinomas, two lung neuroendocrine carcinomas and three neuroendocrine carcinomas of unknown origin) and 20 patients had poorly differentiated neuroendocrine carcinomas (PDNECs: 14 extra-pulmonary small-cell carcinomas and six Merkel cell carcinomas). Almost all (58 of 63) NETs were non-functioning. The quantitative determination of CgA was performed in plasma using an enzyme immunoassay with a cut-off value fixed at 34 U/l. Scintigraphies with indium 111-DTPA-octreotide ((111)In-pentetreotide) included whole-body images and single photon emission computed tomography (SPECT) scans of the chest and abdomen.

RESULTS

SRS results were compared with CgA findings and final clinical data. The overall sensitivity of SRS and CgA, based on the final clinical data, was 77% and 55%, respectively, whereas the specificity of both SRS and CgA was 94%. Concerning tumor type, SRS accuracy was 95% for WDNETs, 86% for WDNECs and 60% for PDNECs; CgA accuracy was 76% for WDNETs, 68% for WDNECs and 50% for PDNECs. With regard to disease extent, SRS sensitivity was 100% for limited disease and 72% for advanced disease; CgA sensitivity was 43% for limited disease and 57% for advanced disease.

CONCLUSIONS

In our NET series, SRS proved to be more sensitive than CgA, with equivalent specificity. Tumor differentiation influences the sensitivity of SRS and CgA analysis. In addition, the plasma CgA level is related to tumor secretory activity. Nevertheless both SRS and CgA should be considered useful tools in the diagnostic work-up of NET patients.

Digestive neuroendocrine tumours: diagnosis and treatment in Italy. A survey by the Oncology Study Section of the Italian Society of Gastroenterology (SIGE)

BACKGROUND

New insights in the diagnosis and treatment of digestive neuroendocrine tumours have prompted a renewed interest in these rare and complex diseases.

AIM

To establish how many new cases of digestive neuroendocrine tumours were diagnosed, and how they were treated, at gastroenterological centres across Italy during a two-year period (1997-1998).

METHODS

The 12 centres taking part filled in a data collection form reporting type of tumour, methods of diagnosis and therapeutic strategies adopted in each case. Data were collected and analysed by the authors of the present report.

RESULTS

Data refer to 98 patients, 22 with functioning and 76 with non-functioning digestive neuroendocrine tumours [50 carcinoids, 48 pancreatic endocrine tumour syndromes]. Primary tumours were localised in 96% (38% with metastases) of non-functioning and 81% (50% with metastases) of functioning tumours. These were surgically removed in >80% of patients in both groups. Somatostatin analogue treatment, with or without interferon, was administered in 35% of patients, while chemotherapy was used in 9% and 23% of functioning and non-functioning tumours, respectively. The imaging study always included a computed tomography scan (20% helical computed tomography). Magnetic resonance and somatostatin receptor scintigraphy were also performed, the former in 41% and 21% of the two (functioning and non-functioning tumour) groups, the latter in 45% and 30%.

CONCLUSIONS

The number of functioning digestive neuroendocrine tumours reported was lower than expected. Surgery plays a major role in the treatment of these tumours in all centres. Overall, in only a small number of patients was a multidisciplinary approach applied.

Percutaneous endoscopic gastrostomy (PEG) in palliative treatment of non-operable intestinal obstruction due to gynecologic cancer: a review

Percutaneous endoscopic gastrostomy (PEG) is a relatively simple method in achieving non-surgical gastric decompression in patients with upper gastrointestinal tract obstruction from metastatic pelvic and abdominal tumors.

Pre-malignant and malignant lymphoproliferations in an HCV-infected type II mixed cryoglobulinemic patient are sequential phases of an antigen-driven pathological process

Type II mixed cryoglobulinemia (MC) is a systemic vasculitis characterized by the presence in the serum of a monoclonal cryoprecipitable IgM with rheumatoid factor (RF) activity. Hepatitis C virus (HCV) has been recognized as its major etiologic factor. Because MC frequently evolves into overt B-cell non-Hodgkin's lymphoma (NHL), chronic HCV infection is hypothesized to lead to both benign and malignant lymphoproliferative disease. In this study, we investigated mutations in the V(H) and V(K) genes of the B-cell clone originating the overt B-cell lymphoma in a subject with MC. Mutational patterns were analyzed longitudinally in two bone marrow biopsies obtained at the stage of MC, as well as in multiple involved tissues (bone marrow, liver, and peripheral blood cells) at the stage of overt NHL. Hybridization of variable-diversity-joining (VDJ) PCR products with a probe specific for the neoplastic clone indicated that the lymphoma originated from one of the clones over-stimulated during MC. This clone producing an IgM highly homologous to a protein with RF specificity may explain the MC syndrome in the patient. Moreover, the presence of an IgH ongoing mutation process and the expression of an Ig antigen receptor significantly homologous to an anti-HCV protein support the hypothesis that the MC syndrome and the subsequent evolution to NHL are antigen-driven lymphoproliferative processes possibly sustained by HCV. Furthermore, the marked reduction in intra-clonal diversity in the last bone marrow biopsy obtained at the stage of overt NHL points out a minor dependence of the cells on the antigen-driven mechanism, although an intrinsic propensity of the neoplastic cell to undergo replacement mutations cannot be excluded.

Pharmacokinetics of oral etoposide in patients with hepatocellular carcinoma

Etoposide dosage in patients with liver dysfunction remains controversial. Since etoposide has a hepatic component to its clearance (CL) and shows a high degree of protein binding, hepatic impairment could affect etoposide disposition. However, the empiric recommendation that the dose of etoposide be decreased in such patients may reduce systemic exposure and be detrimental to its antitumor activity. To address these issues we studied the pharmacokinetics (PK) of etoposide in patients with hepatocellular carcinoma (HCC) and underlying cirrhosis (n = 17) treated with daily oral etoposide. Unbound etoposide was obtained by ultrafiltration. Etoposide concentrations (total and free drug) were measured by high-performance liquid chromatography (HPLC) and analyzed by noncompartmental equations. The patients had mild or moderate liver dysfunction. Albuminemia was in the normal range for all the patients. Creatininemia was normal in all but two patients. PK results (mean and range) showed that etoposide disposition was unchanged in patients with liver dysfunction. We found slightly high etoposide bioavailability [F, 61% (17-95%)] and clearance [CL, 1.1 (0.7-2.3)l h(-1) m(-2)] resulting in a normal degree of systemic exposure (AUC(oral) 27 microg h ml(-1)). Normal protein binding [PB 93.2% (84.4-98.1%)] contributed to a normal level of exposure to free drug (AUC(f, oral) 1.9 microg h ml(-1)). The distribution volume [V(SS) 8.4 (6.1-13.2) l/m2] and the effective half-life [t1/2eff, 5.1 (3.0-9.6) h] were normal. Median CL and protein binding did not differ in the seven patients with total bilirubin value of > 1.2 mg/dl as compared with the ten patients with total bilirubin levels of < or = 1.2 mg/dl (1.3 versus 1.01 h(-1) m(-2) and 92.5% versus 93.4%, respectively). In agreement with this PK finding, we observed no clinical evidence of increased toxicity in patients with hyperbilirubinemia as compared with patients with normal bilirubinemia (mean WBC decrease 38% versus 47%). The only case of severe (grade 4) hematological toxicity was observed in one patient with reduced glomerular filtration. Since the pharmacological effects of etoposide correlate with the level of systemic exposure to the free drug, our data suggest that no dose reduction is needed in patients with HCC. It is even possible to increase the dose intensity in patients with favorable PK parameters under appropriate hematological and therapeutic drug monitoring.

[Usefulness of chromogranin A determination in the diagnosis of neuroendocrine neoplasia]

Neuroendocrine gastroenteropancreatic tumor diagnosis is a very difficult and expensive procedure. This study compared Chromogranin A (CgA) to Neuron-specific enolase (NSE) in 55 patients affected by neuroendocrine tumors. Advanced local or metastatic neoplasia was found in 43 patients. Radical operation was performed in 12 patients. Seventeen cases of lung microcystoma, 23 cases of other intestinal tumors and 19 patients affected by irritable bowel syndrome were used as controls. CgA sampling demonstrated sensitivity of 73% and specificity of 66%, a positive predictive value of 77% and a negative predictive value of 61% while NSE sampling showed sensitivity of 100%, specificity of 36%, a positive predictive value of 15% and a negative predictive value of 100%. CgA values demonstrated a statistically significant difference between patients with neuroendocrine tumors and tumor-free resected patients (p = 0.0015), microcystoma patients (p = 0.0087), other types of neoplasia (p = 0.01) and irritable bowel syndrome patients (p = 0.0004). No significant difference was found among the same groups when NSE values were analyzed. The high diagnostic accuracy of CgA sampling renders it very useful in early neoplastic detection, even in cases of nonfunctioning neoplasms or absence of liver metastases. In addition, CgA sampling may be an effective screening test in patients with irritable bowel syndrome or with liver or lung metastases when there is no evidence of the primitive tumor.

Early Gastric Cancer: Diagnosis, Surgical Treatment and Follow-Up of 45 Cases

Aims and background

The 5-year survival rate of early gastric cancer (EGC) is 85%-100% after “curative” resection, as compared to 20%-30% in advanced gastric cancer (AGC). Because of this relatively high cure rate, the interest in the diagnosis and therapy of EGC has been steadily increasing. The present study, based on 45 EGCs, is aimed at a critical evaluation of the diagnostic procedures and surgical options.

Methods and results

Forty-five patients with early gastric cancer (27 men and 18 women; median age, 62 years; range, 28-84) were diagnosed and operated on. They represented 22.5% of all patients with gastric cancer (200) treated in the period July 1987 to January 1998. Forty-one patients were from the northeastern part of Italy. The most frequent symptom was epigastric pain (84%). Barium upper gastrointestinal radiography findings were strongly suggestive of malignancy in 41 cases (91%). Preoperative histopathological diagnosis of adenocarcinoma was performed in 43 cases (95.5%). In two cases (4.5%) severe epithelial dysplasia (associated with ulcer) was the first diagnosis, but the final diagnosis on the basis of the resected specimens was a well differentiated adenocarcinoma. The primary surgical procedure included i) subtotal distal resection (37 cases) with Billroth II (33) and Billroth I (4) reconstructions; ii) total gastrectomy (3) for proximal neoplastic extension; iii) proximal gastric resection (2) for cardial cancer; iv) degastro-total gastrectomy (3) for cancer of the stump. Two patients, previously treated with conservative surgery, underwent degastro-total gastrectomy for neoplastic microfocal extension to the margin of resection and for early anastomotic recurrence, respectively. Mural infiltration was limited to the mucosa and submucosa in 27 and 18 cases, respectively. Lymph node metastases were found in three mucosal and five submucosal tumor cases, involving either the first or the second echelon. No operative deaths or postsurgical complications occurred in this series. In the follow-up period (median, 36 months; range, 3-120) four patients died due to other causes; one developed liver metastases, another developed oropharyngeal cancer and two died of biopsy-proven lung cancer without evidence of gastric cancer recurrence.

Conclusions

The clinical presentation of EGC is aspecific. Preoperative endoscopy with biopsy remains the most sensitive diagnostic procedure. For treatment, subtotal distal gastric resection with lymphadenectomy is the “gold standard” but in some instances total gastrectomy may be indicated. Accurate pathological examination establishes the depth of infiltration, as well as the superficial extension of tumors and the lymph node status. Although the prognosis of EGC is favorable, a medium-term follow-up should be planned.

Evaluation of the risk for metachronous colorectal neoplasms following intestinal polypectomy: a clinical, endoscopic and pathological study

BACKGROUND/AIMS

Surveillance programs are recommended for patients with previous intestinal polypectomy because of the high rate of adenomatous recurrences and risk of subsequent colorectal cancer. The parameters to identify patients at higher risk and the length and schedules of follow-up have not yet been established. We considered some clinical, endoscopic and pathological parameters in order to assess the probability of developing new colorectal neoplasms and eventually to schedule proper surveillance programs.

METHODOLOGY

Patients with removed adenomas were enrolled into a clinico-endoscopic follow-up, comprehensive of two colonoscopies the first at 1 year and the second at 3 years. We evaluated the risk of new neoplasms dividing the patients into four groups according to the number and size of the adenomas removed and the parameters considered.

RESULTS

Of 164 patients enrolled 156 completed the study. We had an overall 21.3% of adenomatous recurrences at 1 year and 12.8% at 3 years. Most of the adenomas removed were tubular and small in size (< 1 cm). The percentage of patients who had adenomas with advanced pathological features was 1.82% at 1 year and 0.64% at 3 years. The increase in number and size of the adenomas removed on the initial colonoscopic examination was the only one parameter statistically significant, X(2)1 (trend) 5.11; p<0.05 at the first follow-up and X(2)1 (trend) 4.87; p<0.05 at the second follow-up.

CONCLUSIONS

Patients with previous single adenoma showed few recurrences of extremely benign histological features. Since they do not require short-term endoscopic examination, it would be reasonable to defer the next colonoscopy for at least another 5 years. During follow-up, patients with multiple polyps had adenomas with advanced pathological features so it was useful to follow-up at 1 year. The tendency for advanced pathological features of removed polyps was not seen at 3 years, suggesting the importance of long-term follow-up, but with longer intervals.

[Percutaneous endoscopic gastrostomy (PEG) in upper gastrointestinal tract occlusion in gynecologic oncology]

BACKGROUND AND AIMS

Intestinal obstruction is a frequent cause of death in patients suffering from gynecological cancer, who have undergone multiple treatment in the form of surgery and/or chemotherapy and/or radiotherapy. The usual form of rescue treatment consists in the use of a nasogastric tube to administer support and analgesic treatment. Surgical gastrostomy is not a viable proposition in these extremely weak patients with large masses compressing and displacing the stomach. Percutaneous endoscopic gastrostomy (PEG), a technique first introduced for nutritional purposes, can be beneficially used to achieve decompression in these patients.

METHODS

PEG was performed in a total of 67 patients who had already undergone multiple treatment for abdominal-pelvic neoplasia with upper gastrointestinal obstruction, who could no longer be operated and who had a life expectancy of less than sixty days. In three cases positioning was not possible owing to the lack of transillumination of the gastric and abdominal wall. 54/64 patients had previously undergone at least two operations.

RESULTS

Esophagogastric lesions were found in 29% of patients, some of which were attributed to the nasogastric tube. Symptomatic wellbeing was obtained in 76.5% a few days after PEG. PEG remained in situ from 4 to 472 days. Slight peristomal infection was observed in 9% of cases. In seven cases it was necessary to add octreotide owing to the reappearance of symptoms.

CONCLUSIONS

PEG is relatively easy to use and allows obstructive symptoms to be resolved in the majority of patients. Special medical skills are not required and the patient may be easily managed at home together with support therapy and pain management. Once PEG has been performed, it is possible to take fluids and semi-liquid foods, offering the patient a chance to taste flavours which have often been forgotten. PEG enables neoadjuvant chemotherapy to be performed in patients with previously untreated intestinal obstruction.

Hepatitis C virus, non-Hodgkin's lymphomas and hepatocellular carcinoma

In a case-control study in northeastern Italy hepatitis C virus infection seemed to increase by about 50-fold the risk of non-Hodgkin's lymphoma involving the liver and major salivary glands (i.e. larger than that for hepatocellular carcinoma) and by about fourfold the risk of lymphomas at other sites.

Palliative treatment of upper intestinal obstruction by gynecological malignancy: the usefulness of percutaneous endoscopic gastrostomy

The usefulness of percutaneous endoscopic gastrostomy (PEG) for decompression in patients with unresolving intestinal obstruction by gynecological malignancy is examined. Between April 1993 and August 1995, 34 consecutive patients with small-bowel obstruction by gynecological cancer, heavily pretreated with surgery and chemotherapy, were admitted to our prospective study. PEG was performed in 32/34 patients (94.1%). Failure in the placing of the tube occurred in 2 patients (5.9%). Twenty-seven patients (84.4%) experienced symptomatic relief after a few days from PEG and tolerated soft and liquid foods. All of these patients were discharged from the hospital and underwent parenteral nutrition at home. The median postoperative hospital stay was 7 days (range 3-45). No major complications due to PEG placement itself occurred in our patients. Only 4 patients (12.5%) had postprocedure nausea and vomiting that was unresponsive to the conventional therapy. The use of Octreotide (0.6 mg/24 hr) obtained relief from symptoms until death. The gastrostomy remained in place for a median of 74 days (range 5-210). Relief from symptoms after PEG placement and total parenteral nutrition permitted continuation of palliative chemotherapy in 8 patients (25%). We suggest percutaneous endoscopic drainage gastrostomy technique as the procedure of choice for long-term drainage of unresolving small bowel obstruction in patient with metastatic abdominal gynecologic malignancy.

Pharmacokinetics of vinorelbine in patients with liver metastases

BACKGROUND

The main elimination pathway of vinorelbine is hepatic metabolism, and the clearance of vinorelbine could be reduced in patients with liver metastases.

OBJECTIVES

To study the pharmacokinetics of vinorelbine in patients who have advanced breast cancer with or without liver metastases and to study the relationship between hepatic function and vinorelbine clearance.

PATIENTS AND METHODS

We studied 29 patients with advanced breast cancer: 19 with liver metastases and 10 control patients with extrahepatic metastases (mean age, 61 years; age range, 38 to 81 years). The vinorelbine dose was 30 mg/m2 as a short intravenous infusion; the dose was reduced by 50% in patients with bilirubin > 2 mg/dl. Patients were classified by ultrasonographic estimation of the liver volume replaced by tumor (%LVRT). Standard liver function tests and a monoethylglycinexylidide test (a quantitative liver function test based on lidocaine metabolite formation) were performed. Vinorelbine was assayed in plasma by HPLC with fluorescence detection. Vinorelbine determination was impossible in two patients with more than 75% LVRT because of interferences. Pharmacokinetic parameters were calculated with a noncompartimental method and compared by means of the Kruskal-Wallis test.

RESULTS

A lower vinorelbine clearance rate was observed in the five patients with more than 75% LVRT (22.9 L/hr/m2) compared with the 10 patients with no liver metastases (48.0 L/hr/m2) and the 12 patients with 25% to 75% LVRT (45.3 L/hr/m2). Terminal elimination half-life and apparent volume of distribution were not significantly different among groups. The monoethylglycinexylidide test had a significant correlation with vinorelbine clearance. (r2 = 0.70; p = 10(-4).

CONCLUSIONS

These results support vinorelbine dose reduction in patients with severe liver failure but not in patients with moderate secondary liver involvement. The monoethylglycinexylidide test may prove to be useful for vinorelbine dose individualization.

Gastroduodenal involvement in staging of nodal non-Hodgkin lymphomas: a clinical and endoscopic prospective study of 235 patients

OBJECTIVES

The gastrointestinal tract is often the site of involvement of non-Hodgkin lymphomas (NHL). The aim of this endoscopic prospective study was to verify the prevalence of the gastroduodenal involvement in patients in staging for NHL and to assess its impact on the choice of therapeutic strategies.

METHODS

Two hundred and thirty-five consecutive patients were included in the study. Upper gastrointestinal endoscopy was performed, and biopsy samples were taken on every mucosal lesion and on macroscopically illness-free duodenal and gastric mucosa. The samples were submitted to histological examination, and the clinical stage of NHL was reevaluated.

RESULTS

Sixty-one of the 235 patients exhibited histological involvement of gastric (40), duodenal (7), or both (14) mucosae. Endoscopic lesions were recorded in 51 patients, but the involved mucosa appeared macroscopically normal in 10 patients (16.3%). In 13 patients, the gastroduodenal involvement modified the clinical stage from I and II to III, indicating a different therapeutic approach. No difference was detected in the frequency of gastrointestinal involvement among the high, intermediate, and low grades of lymphoma malignancies. Thirty-five positive patients underwent a further endoscopic examination after the chemotherapy treatment. Although clinical remission was expected in all cases, 42.8% of them subsequently exhibited NHL.

CONCLUSIONS

Upper digestive endoscopy plus biopsy sampling plays a necessary diagnostic role, not only when major clinical signs (hemorrhage) are present, but also in earlier stages of NHL (I and II), when a reevaluation of the therapeutic strategy may be indicated. In stages III and IV of illness, it may also prove useful in evaluating the efficacy of chemotherapy.

Nonsteroidal antiinflammatory drugs for cancer pain: comparison between misoprostol and ranitidine in prevention of upper gastrointestinal damage

PURPOSE

The prophylactic strategy of nonsteroidal antiinflammatory drug (NSAID)-induced upper gastrointestinal (UGI) damage has largely been studied in arthritic patients, but not in cancer patients. The efficacy of misoprostol and ranitidine in the prevention of gastroduodenal damage in patients taking diclofenac for their cancer pain has been compared in this study.

PATIENTS AND METHODS

Patients who needed high-dose (200 to 300 mg/d) diclofenac for cancer pain and without mucosal lesions at baseline gastroduodenal endoscopy were randomized to receive misoprostol (200 micrograms twice daily; M group) or ranitidine (150 mg twice daily; R group). UGI endoscopy was repeated after 4 weeks.

RESULTS

Twenty-three patients treated with misoprostol and 26 treated with ranitidine concluded the study. The M group showed a significantly (P < .02) lower incidence of gastroduodenal lesions (two patients; 8.7%) than the R group (10 patients; 38.5%). Gastric ulcers occurred in one (4%) misoprostol-treated patient and in six (23%) ranitidine-treated patients. Six of seven patients with ulcers were asymptomatic. Seventy-one percent and 86% of ulcers occurred in patients older than 60 years and in those who received greater than 3.1 mg/kg of diclofenac, respectively.

CONCLUSION

Misoprostol was significantly more effective than ranitidine in the prevention of gastroduodenal lesions in cancer patients receiving diclofenac.

Percutaneous endoscopic gastrostomy as a decompressive technique in bowel obstruction due to abdominal carcinomatosis

BACKGROUND AND STUDY AIMS

Percutaneous endoscopic gastrostomy (PEG) is a simple method of achieving nonsurgical gastric decompression in patients suffering from metastatic abdominal tumors and upper gastrointestinal tract obstruction. The aim of this prospective study was both to evaluate the efficacy of PEG for intestinal decompression in patients with disseminated abdominal cancer and to compare two catheters with different diameters.

PATIENTS AND METHODS

Over a one-year period, 22 consecutive female patients (mean age 53.7, range 29-73) were referred to us and a PEG was successfully placed in 21. In four patients with unsatisfactory endoscopic trans-illumination of the anterior abdominal wall, an ultrasound unit was used to identify an adequate site for PEG placement.

RESULTS

All patients experienced substantial symptomatic relief after a few days: vomiting and nausea completely resolved, and abdominal pain persisted in one patient only. No gastrostomy-related additional morbidity was noticed. We randomly inserted a 15-French or a 20-French tube: no statistically significant difference was noticed between the two in the symptomatic relief provided.

CONCLUSIONS

Our data support the hypothesis that PEG is an effective, safe, and well-tolerated method of achieving gastric decompression in cancer patients; ultrasound guidance was an interesting option in positioning a tube in difficult situations; a standard nutritional tube, namely 15 or 20 French in diameter, may be large enough to obtain excellent clinical results.

DNA flow cytometric evaluation of cell cycle distribution in ulcerative colitis: a proposed method for assessing severity of disease

The assessment of disease severity in ulcerative colitis depends mainly on subjective variables, and an objective method of assessing mucosal inflammation is needed. Determination of the synthetic phase of the cell cycle is an accurate expression of inflammatory activity in the colonic mucosa. The aim of the study was to find out if the proliferative index or the synthetic phase (S phase) of the colonic mucosa of patients with ulcerative colitis, as evaluated by DNA flow cytometry, is a reliable and reproducible marker of disease activity. Sixty consecutive patients with ulcerative colitis of different degrees of activity were entered into the study and submitted to colonoscopy plus multiple rectal biopsies. Disease severity was defined for each patient by means of a clinical, endoscopic, and histological score. Flow cytometry was used to calculate the proliferative index and the S phase of the cell cycle. A statistically significant correlation (p < 0.001) was found between all indices of severity. It is suggested that flow cytometric evaluation of the cell cycle in the rectal mucosa may be an efficient method of assessing severity of disease and efficacy of medical treatment in ulcerative colitis.

Effect of short- and long-term treatment with omeprazole on cell cycle distribution in the gastric mucosa. Results of a flow cytometric study

Omeprazole may exert an effect on gastric mucosal proliferation by inhibiting gastric acid secretion and increasing serum gastrin levels. It may also influence the kinetics of endocrine cells and the oxyntic mucosa. The aim of the present study was to evaluate the cell cycle in different gastric compartments following short- (1 month) and long-term (6 months) administration of two different dosages of omeprazole by means of a flow cytometric method. We also determined serum gastrin levels at the same time. No differences in cell cycle distribution of the antrum, body, and fundus were found in the two different dosage groups after 1 month of therapy, considering the synthetic phase (S-phase) of the cell cycle. A statistically significant increase in S-phase was reported after long-term therapy in the mucosa of the fundus and body of the stomach in both groups. Gastrin levels showed no clear correlation with cell cycle distribution variables. We postulate a proliferative adaptation of the oxyntic mucosa to long-term drug administration not mediated by gastrin influence.

Adjuvant Therapy for Primary Breast Cancer in a Female Patient Affected by Autoimmune Liver Disease: Does it Cure Breast Cancer and Primary Biliary Cirrhosis?

Polychemotherapy (CMF or CMF-like regimens) is the treatment of choice in premenopausal breast cancer patients with 1–3 positive nodes. In clinical practice, patients with abnormal biochemical tests of liver function are usually excluded from this potentially curative methotrexate-containing regimen in order to avoid worsening of hepatic damage. On the other hand, recent reports have shown a beneficial effect of methotrexate in a particular autoimmune liver disease such as primary biliary cirrhosis. We discuss the case of a female patient with breast cancer and primary biliary cirrhosis whose biochemical tests of liver function and the titer of antimitochondrial antibody persistently improved after treatment with 3 cycles of CMF. In conclusion, we suggest that the CMF regimen is potentially useful in patients with breast cancer and primary biliary cirrhosis.

[Basal and postprandial blood gastrin in peptic ulcer. The physiopathological considerations in relation to different locations of the lesion]

A different pathophysiological mechanism is widely accepted for gastric and duodenal ulcer. In particular, the exact role of gastrin in the determinism of nonhormone-dependent peptic ulcer disease has been completely clarified. The aim of the present study was to analyse fasting and postprandial serum gastrin levels in 99 duodenal ulcer patients, 17 gastric ulcer patients and 11 subjects presenting an association of gastric and duodenal ulcer. The possible correlation between postprandial gastrin concentrations and basal and maximal acid output in the 3 groups of patients has also been investigated. Fasting serum gastrin levels do not appear different among the 3 classes of patients, while postprandial gastrin concentrations are statistically higher at 15 minutes in duodenal ulcer patients and in subjects with the association of gastric and duodenal ulcer as compared to gastric ulcer patients. Mean fasting and stimulated gastrin levels are higher in gastric ulcer females than in males during the entire test and with a statistically significant difference at 30 minutes. The concentrations of the hormone are not different in males of the 3 groups of patients at basal time, while they are statistically lower at 15 and 30 minutes in gastric ulcer males compared to those with duodenal ulcer and the association of the localization. Finally, positive correlation has been observed between B.A.O. and M.A.O. and postprandial gastrin concentration in the 3 groups of patients, while there is an inverse correlation between the previous parameters as regards sex, both in gastric and duodenal ulcer.

[Clinical usefulness of the blood gastrin curve after protein meal in duodenal ulcer]

Conflicting data are present in the literature on pathophysiological role of serum gastrin and peptic ulcer disease. The aim of this study was to evaluate, in duodenal ulcer patients, the possible correlation between post-prandial serum gastrin concentrations and some epidemiological (sex, family history, onset of the disease, blood group status, smoking habit, alcohol consumption) and clinical (effectiveness of therapy, bleeding episodes) factors. The gastrin levels were expressed in absolute values and as per cent increase of fasting serum gastrin concentrations. As regards sex, the per cent increase of fasting serum gastrin concentration was significantly higher in females (No. 16) than in males (No. 60) at 30 and 60 minutes (192.25% vs 116.52% and 105.42% vs 40.96% respectively; p less than 0.05 and p less than 0.005). Post-prandial serum gastrin concentrations, expressed as per cent increase, were higher in heavy drinkers (No. 14) and statistically significant at 120 minutes (40.57% vs 9.58%, p less than 0.025); as well as in smoker patients (No. 31), at 15, 30 and 60 minutes (227.59% vs 123.52%, 177.23% vs 101.62%, 0.025 and p less than 0.05). Post-prandial gastrin was unrelated to blood group status, onset of the disease, family history, effectiveness of medical treatment and bleeding episodes.

Gastric and duodenal ulcer in the same patient

No extensive endoscopic studies have been performed on the prevalence and the clinical outcome of association of gastric ulcer (GU) and duodenal ulcer (DU). The present investigation, partially retrospective and partially prospective, takes into account 715 patients with active ulcer demonstrated by endoscopy, followed-up for a mean period of 3.8-years; 23 of them (3.2%) were found to have synchronous or asynchronous gastric and duodenal ulcers. The following characteristics were investigated: age of onset of both diseases, ulcer family history, cigarette and alcohol consumption, nonsteroidal anti-inflammatory drugs abuse, serum pepsinogen group I, ABO and Lewis blood groups, healing and relapse rate under H2-blocker treatment. The first diagnosis (by either X-Ray or endoscopy) was DU in 500 subjects (70%), GU in 210 (29.3%) and synchronous gastric and duodenal ulcers in 5 (0.7%). After a median period of 10 years, 2.8% of DU patients developed a GU; after 2-12 yrs 1.9% of GU patients developed a DU. The clinical and biochemical findings of our GU/DU patients suggest that the two ulcers are related by chance.

IN CONCLUSION

asynchronous GU/DU patients do not seem to have a distinct disease in the large spectrum of ulcer disease. Larger studies must be planned on synchronous GU/DU with the aim of assessing whether or not it represents a particular type of ulcer disease.

Gastric ulcer and stomach aging: pathophysiology and clinical implications

138 consecutive patients with endoscopically and histologically confirmed benign gastric ulcer were investigated in order to evaluate the relationship between aging and parameters relating to gastric ulcer pathophysiology and natural history: prevalence in dyspeptic patients referred to an endoscopic unit, recurrences, gastric acid secretory capacity, peptic activity, incidence of precancerous and neoplastic changes. On the basis of our results, different populations of gastric ulcer patients seem to be identifiable: (1) young patients (aged under 40), with low prevalence and recurrence rates, with acid capacity above normal range, high peptic activity and no risk for precancerous or neoplastic changes, (2) middleaged subjects (41-50), with high prevalence and recurrence rates, high peptic activity and acid activity within the normal range, atrophic gastritis, intestinal metaplasia, dysplasia and low incidence of cancer, and (3) elderly patients (aged over 50), with lower prevalence and recurrence rates, frequent association with chronic atrophic gastritis, impaired acid and peptic secretion, in whom one may observe either an association of the ulceration with cancer or evolution of dysplasia into neoplasia. These observations confirm that elderly and middle-aged gastric ulcer patients should undergo routine follow-up, and that pathophysiological data should be taken into account before deciding upon antiulcer therapy.

Early and advanced gastric cancer during follow-up of apparently benign gastric ulcer: significance of the presence of epithelial dysplasia

One hundred and forty-four patients with apparently benign gastric ulcer were endoscopically followed up in order to evaluate the outcome of the lesion. Particular attention was given to: (a) detect possible delay in diagnosing gastric cancer; (b) ascertain the frequency of association with epithelial dysplasia; (c) establish the role of markers, such as serum pepsinogen group I (PGI), and gastric juice CEA in predicting gastric ulcer evolution. Endoscopic and bioptic check-ups were carried out during the first year at 3, 6 and 12 months after endoscopic healing of the ulcer, and then at every symptomatic recurrence. Ten patients (6.9%) were found to present histological evidence of malignancy (within 3 months in six cases, between 6 and 12 months in three cases, and after 41 months in the rest). Four cases were early gastric cancers, and six had shown dysplastic changes of the mucosa at the edge or scar of the ulcer. Serum PGI levels were not significantly different in gastric cancer patients, while gastric juice CEA levels were sharply increased compared to those of gastric ulcer patients: nine out of ten patients had values above normal range. These data suggest that: (a) there may be some delay in diagnosing gastric carcinoma, and gastric ulcer patients should be controlled routinely more than once; (b) the presence of dysplasia indicates the need for prolonged follow-up, because of the high risk of association with or evolution into gastric cancer, and because of the higher number of early gastric cancer detections that this protocol allows; (c) further support in monitoring patients "at risk" may be afforded by gastric juice CEA determination.