Multicenter prospective trial of total gastrectomy versus proximal gastrectomy for upper third cT1 gastric cancer

BACKGROUND

The appropriate surgical procedure for patients with upper third early gastric cancer is controversial. We compared total gastrectomy (TG) with proximal gastrectomy (PG) in this patient population.

METHODS

A multicenter, non-randomized trial was conducted, with patients treated with PG or TG. We compared short- and long-term outcomes between these procedures.

RESULTS

Between 2009 and 2014, we enrolled 254 patients from 22 institutions; data from 252 were included in the analysis. These 252 patients were assigned to either the PG (n = 159) or TG (n = 93) group. Percentage of body weight loss (%BWL) at 1 year after surgery, i.e., the primary endpoint, in the PG group was significantly less than that of the TG group (- 12.8% versus - 16.9%; p = 0.0001). For short-term outcomes, operation time was significantly shorter for PG than TG (252 min versus 303 min; p < 0.0001), but there were no group-dependent differences in blood loss and postoperative complications. For long-term outcomes, incidence of reflux esophagitis in the PG group was significantly higher than that of the TG group (14.5% versus 5.4%; p = 0.02), while there were no differences in the incidence of anastomotic stenosis between the two (5.7% versus 5.4%; p = 0.92). Overall patient survival rates were similar between the two groups (3-year survival rates: 96% versus 92% in the PG and TG groups, respectively; p = 0.49).

CONCLUSIONS

Patients who underwent PG were better able to control weight loss without worsening the prognosis, relative to those in the TG group. Optimization of a reconstruction method to reduce reflux in PG patients will be important.

Neck Location on the Outer Convexity is a Predictor of Incomplete Occlusion in Treatment with the Pipeline Embolization Device: Clinical and Angiographic Outcomes

BACKGROUND AND PURPOSE

With the increasing use of the Pipeline Embolization Device for the treatment of aneurysms, predictors of clinical and angiographic outcomes are needed. This study aimed to identify predictors of incomplete occlusion at last angiographic follow-up.

MATERIALS AND METHODS

In our retrospective, single-center cohort study, 105 ICA aneurysms in 89 subjects were treated with Pipeline Embolization Devices. Patients were followed per standardized protocol. Clinical and angiographic outcomes were analyzed. We introduced a new morphologic classification based on the included angle of the parent artery against the neck location: outer convexity type (included angle,  <160°), inner convexity type (included angle,  >200°), and lateral wall type (160° ≤ included angle  ≤200°). This classification reflects the metal coverage rate and flow dynamics.

RESULTS

Imaging data were acquired in 95.3% of aneurysms persistent at 6 months. Complete occlusion was achieved in 70.5%, and incomplete occlusion, in 29.5% at last follow-up. Multivariable regression analysis revealed that 60 years of age or older (OR, 5.70; P = .001), aneurysms with the branching artery from the dome (OR, 10.56; P = .002), fusiform aneurysms (OR, 10.2; P = .009), and outer convexity-type saccular aneurysms (versus inner convexity type: OR, 30.3; P < .001; versus lateral wall type: OR, 9.71; P = .001) were independently associated with a higher rate of incomplete occlusion at the last follow-up. No permanent neurologic deficits or rupture were observed in the follow-up period.

CONCLUSIONS

The aneurysm neck located on the outer convexity is a new, incomplete occlusion predictor, joining older age, fusiform aneurysms, and aneurysms with the branching artery from the dome. No permanent neurologic deficits or rupture was observed in the follow-up, even with incomplete occlusion.

Predictors of Cerebral Aneurysm Rupture after Coil Embolization: Single-Center Experience with Recanalized Aneurysms

BACKGROUND AND PURPOSE

Recanalization after coil embolization is widely studied. However, there are limited data on how recanalized aneurysms rupture. Herein, we describe our experience with the rupture of recanalized aneurysms and discuss the type of recanalized aneurysms at greatest rupture risk.

MATERIALS AND METHODS

A total of 426 unruptured aneurysms and 169 ruptured aneurysms underwent coil embolization in our institution between January 2009 and December 2017. Recanalization occurred in 38 (8.9%) of 426 unruptured aneurysms (unruptured group) and 37 (21.9%) of 169 ruptured aneurysms (ruptured group). The Modified Raymond-Roy classification on DSA was used to categorize the recanalization type. Follow-up DSA was scheduled until 6 months after treatment, and follow-up MRA was scheduled yearly. If recanalization was suspected on MRA, DSA was performed.

RESULTS

In the unruptured group, the median follow-up term was 74.0 months. Retreatment for recanalization was performed in 18 aneurysms. Four of 20 untreated recanalized aneurysms (0.94% of total coiled aneurysms) ruptured. In untreated recanalized aneurysms, class IIIb aneurysms ruptured significantly more frequently than class II and IIIa (P = .025). In the ruptured group, the median follow-up term was 28.0 months. Retreatment for recanalization was performed in 16 aneurysms. Four of 21 untreated recanalized aneurysms (2.37% of total coiled aneurysms) ruptured. Class IIIb aneurysms ruptured significantly more frequently than class II and IIIa (P = .02).

CONCLUSIONS

The types of recanalization after coil embolization may be predictors of rupture. Coiled aneurysms with class IIIb recanalization should undergo early retreatment because of an increased rupture risk.

An artificial impact on the asteroid (162173) Ryugu formed a crater in the gravity-dominated regime

The Hayabusa2 spacecraft investigated the small asteroid Ryugu, which has a rubble-pile structure. We describe an impact experiment on Ryugu using Hayabusa2's Small Carry-on Impactor. The impact produced an artificial crater with a diameter >10 meters, which has a semicircular shape, an elevated rim, and a central pit. Images of the impact and resulting ejecta were recorded by the Deployable CAMera 3 for >8 minutes, showing the growth of an ejecta curtain (the outer edge of the ejecta) and deposition of ejecta onto the surface. The ejecta curtain was asymmetric and heterogeneous and it never fully detached from the surface. The crater formed in the gravity-dominated regime; in other words, crater growth was limited by gravity not surface strength. We discuss implications for Ryugu's surface age.

Thoracic aortic aneurysm is an independent factor associated with diffuse idiopathic skeletal hyperostosis

Aims

Although we often encounter patients with an aortic aneurysm who also have diffuse idiopathic skeletal hyperostosis (DISH), there are no reports to date of an association between these two conditions and the pathogenesis of DISH remains unknown. This study therefore evaluated the prevalence of DISH in patients with a thoracic aortic aneurysm (AA).

Patients and Methods

The medical records of 298 patients who underwent CT scans for a diagnosis of an AA or following high-energy trauma were retrospectively examined. A total of 204 patients underwent surgery for an AA and 94 had a high-energy injury and formed the non-AA group. The prevalence of DISH was assessed on CT scans of the chest and abdomen and the relationship between DISH and AA by comparison between the AA and non-AA groups.

Results

The prevalence of DISH in the AA group (114/204; 55.9%) was higher than that in the non-AA group (31/94; 33.0%). On multivariate analysis, the factors of AA, male gender, and ageing were independent predictors of the existence of DISH, with odds ratios of 2.9, 1.9, and 1.03, respectively.

Conclusion

This study revealed that the prevalence of DISH is higher in patients with an AA than in those without an AA, and that the presence of an AA significantly influenced the prevalence of DISH. Cite this article: Bone Joint J 2018;100-B:617-21.

Quantitative Analysis of Conebeam CT for Delineating Stents in Stent-Assisted Coil Embolization

BACKGROUND AND PURPOSE

Innovative techniques and device-related advances have improved the outcomes of neuroendovascular treatment. 3D imaging has previously used 2 × 2 binning, but 1 × 1 binning has recently been made available. The aim of this study was to evaluate the quantitative ability of conebeam CT for stent delineation and to investigate its effectiveness in the clinical environment.

MATERIALS AND METHODS

Four acquisition groups of 3D MIP images acquired using conebeam CT with varying conditions (acquisition time, 10 or 20 seconds and binning, 1 × 1 or 2 × 2) were compared. Two methods of analysis were performed, a phantom study and an analysis of 28 randomly selected patients. The phantom study assessed the contrast-to-noise ratio and full width at half maximum values in conebeam CT images of intracranial stent struts. In the clinical subjects, we assessed contrast-to-noise ratio, full width at half maximum, and dose-area product.

RESULTS

In the phantom study, the contrast-to-noise ratio was not considerably different between 10- and 20-second acquisition times at equivalent binning settings. Additionally, the contrast-to-noise ratio at equivalent acquisition times did not differ considerably by binning setting. For the full width at half maximum results, equivalent acquisition times differed significantly by binning setting. In the clinical analyses, the 10-second/1 × 1 group (versus 20 second/2 × 2) showed a higher contrast-to-noise ratio (P < .05) and a dose-area product reduced by approximately 70% (P < .05), but the difference in full width at half maximum was not significant (P = .20).

CONCLUSIONS

For stent-assisted coil embolization, quantitative assessment of conebeam CT showed that 10 second/1 × 1 was equivalent to 20 second/2 × 2 for imaging deployed intracranial stents. Furthermore, the 10-second/1 × 1 settings resulted in a much smaller DAP.

Modulation of Aneuploidy in Leishmania donovani during Adaptation to Different In Vitro and In Vivo Environments and Its Impact on Gene Expression

Aneuploidy is usually deleterious in multicellular organisms but appears to be tolerated and potentially beneficial in unicellular organisms, including pathogens. Leishmania, a major protozoan parasite, is emerging as a new model for aneuploidy, since in vitro-cultivated strains are highly aneuploid, with interstrain diversity and intrastrain mosaicism. The alternation of two life stages in different environments (extracellular promastigotes and intracellular amastigotes) offers a unique opportunity to study the impact of environment on aneuploidy and gene expression. We sequenced the whole genomes and transcriptomes of Leishmania donovani strains throughout their adaptation to in vivo conditions mimicking natural vertebrate and invertebrate host environments. The nucleotide sequences were almost unchanged within a strain, in contrast to highly variable aneuploidy. Although high in promastigotes in vitro, aneuploidy dropped significantly in hamster amastigotes, in a progressive and strain-specific manner, accompanied by the emergence of new polysomies. After a passage through a sand fly, smaller yet consistent karyotype changes were detected. Changes in chromosome copy numbers were correlated with the corresponding transcript levels, but additional aneuploidy-independent regulation of gene expression was observed. This affected stage-specific gene expression, downregulation of the entire chromosome 31, and upregulation of gene arrays on chromosomes 5 and 8. Aneuploidy changes in Leishmania are probably adaptive and exploited to modulate the dosage and expression of specific genes; they are well tolerated, but additional mechanisms may exist to regulate the transcript levels of other genes located on aneuploid chromosomes. Our model should allow studies of the impact of aneuploidy on molecular adaptations and cellular fitness.IMPORTANCE Aneuploidy is usually detrimental in multicellular organisms, but in several microorganisms, it can be tolerated and even beneficial. Leishmania-a protozoan parasite that kills more than 30,000 people each year-is emerging as a new model for aneuploidy studies, as unexpectedly high levels of aneuploidy are found in clinical isolates. Leishmania lacks classical regulation of transcription at initiation through promoters, so aneuploidy could represent a major adaptive strategy of this parasite to modulate gene dosage in response to stressful environments. For the first time, we document the dynamics of aneuploidy throughout the life cycle of the parasite, in vitro and in vivo We show its adaptive impact on transcription and its interaction with regulation. Besides offering a new model for aneuploidy studies, we show that further genomic studies should be done directly in clinical samples without parasite isolation and that adequate methods should be developed for this.

In vitro selection of miltefosine resistance in promastigotes of Leishmania donovani from Nepal: genomic and metabolomic characterization

In this study, we followed the genomic, lipidomic and metabolomic changes associated with the selection of miltefosine (MIL) resistance in two clinically derived Leishmania donovani strains with different inherent resistance to antimonial drugs (antimony sensitive strain Sb-S; and antimony resistant Sb-R). MIL-R was easily induced in both strains using the promastigote-stage, but a significant increase in MIL-R in the intracellular amastigote compared to the corresponding wild-type did not occur until promastigotes had adapted to 12.2 μM MIL. A variety of common and strain-specific genetic changes were discovered in MIL-adapted parasites, including deletions at the LdMT transporter gene, single-base mutations and changes in somy. The most obvious lipid changes in MIL-R promastigotes occurred to phosphatidylcholines and lysophosphatidylcholines and results indicate that the Kennedy pathway is involved in MIL resistance. The inherent Sb resistance of the parasite had an impact on the changes that occurred in MIL-R parasites, with more genetic changes occurring in Sb-R compared with Sb-S parasites. Initial interpretation of the changes identified in this study does not support synergies with Sb-R in the mechanisms of MIL resistance, though this requires an enhanced understanding of the parasite's biochemical pathways and how they are genetically regulated to be verified fully.

Endovascular Treatment of Unruptured Paraclinoid Aneurysms: Single-Center Experience with 400 Cases and Literature Review

BACKGROUND AND PURPOSE

Paraclinoid aneurysms have been increasingly treated endovascularly. The natural history of these aneurysms has gradually been elucidated. The purpose of this study was to assess the safety and efficacy of endovascular treatment for these aneurysms.

MATERIALS AND METHODS

We performed a retrospective review of 377 patients with 400 paraclinoid aneurysms treated between January 2006 and December 2012. Their clinical records, endovascular reports, and radiologic and clinical outcomes were analyzed. Because aneurysms ≥7 mm are at higher risk of rupture, we classified aneurysms as small (<7 mm) or large (≥7 mm).

RESULTS

Overall, 115 of the 400 aneurysms (28.8%) were large (≥7 mm). Thromboembolic complications were found significantly more often with large aneurysms than with small ones (7.4% vs 1.0%, P = .001). Hemorrhagic complications were found only with small aneurysms (0.7%). The 6-month morbidity rates were similar for small (1.0%) and large (0.8%) aneurysms. Immediate angiographic outcomes were similar (P = .37), whereas recurrences and retreatment occurred more frequently with large aneurysms (P = .001 and P = .007, respectively). Multivariate analysis showed that aneurysm size was the only independent predictor for recurrence (P = .005). Most recurrences (81%) were detected by scheduled angiography at 6 months.

CONCLUSIONS

Aneurysm size influenced the type of complication (thromboembolic or hemorrhagic) and the recurrence rate. Given the approximately 1% annual rupture rate for aneurysms ≥7 mm, analysis of our data supports the rationale of using prophylactic endovascular treatment for unruptured paraclinoid aneurysms ≥7 mm.

Phase III study comparing oxaliplatin plus S-1 with cisplatin plus S-1 in chemotherapy-naïve patients with advanced gastric cancer

BACKGROUND

We evaluated the efficacy and safety of S-1 plus oxaliplatin (SOX) as an alternative to cisplatin plus S-1 (CS) in first-line chemotherapy for advanced gastric cancer (AGC).

PATIENTS AND METHODS

In this randomized, open-label, multicenter phase III study, patients were randomly assigned to receive SOX (80-120 mg/day S-1 for 2 weeks with 100 mg/m(2) oxaliplatin on day 1, every 3 weeks) or CS (S-1 for 3 weeks with 60 mg/m(2) cisplatin on day 8, every 5 weeks). The primary end points were noninferiority in progression-free survival (PFS) and relative efficacy in overall survival (OS) for SOX using adjusted hazard ratios (HRs) with stratification factors; performance status and unresectable or recurrent (+adjuvant chemotherapy) disease.

RESULTS

Overall, 685 patients were randomized from January 2010 to October 2011. In per-protocol population, SOX (n = 318) was noninferior to CS (n = 324) in PFS [median, 5.5 versus 5.4 months; HR 1.004, 95% confidence interval (CI) 0.840-1.199; predefined noninferiority margin 1.30]. The median OS for SOX and CS were 14.1 and 13.1 months, respectively (HR 0.958 with 95% CI 0.803-1.142). In the intention-to-treat population (SOX, n = 339; CS, n = 337), the HRs in PFS and OS were 0.979 (95% CI 0.821-1.167) and 0.934 (95% CI 0.786-1.108), respectively. The most common ≥grade 3 adverse events (SOX versus CS) were neutropenia (19.5% versus 41.8%), anemia (15.1% versus 32.5%), hyponatremia (4.4% versus 13.4%), febrile neutropenia (0.9% versus 6.9%), and sensory neuropathy (4.7% versus 0%).

CONCLUSION

SOX is as effective as CS for AGC with favorable safety profile, therefore SOX can replace CS.

CLINICAL TRIAL NUMBER

JapicCTI-101021.

Surpass flow diverter in the treatment of intracranial aneurysms: a prospective multicenter study

BACKGROUND AND PURPOSE

Incomplete occlusion and recanalization of large and wide-neck brain aneurysms treated by endovascular therapy remains a challenge. We present preliminary clinical and angiographic results of an experimentally optimized Surpass flow diverter for treatment of intracranial aneurysms in a prospective, multicenter, nonrandomized, single-arm study.

MATERIALS AND METHODS

At 24 centers, 165 patients with 190 intracranial aneurysms of the anterior and posterior circulations were enrolled. The primary efficacy end point was the percentage of intracranial aneurysms with 100% occlusion on 6-month DSA. The primary safety end point was neurologic death and any stroke through a minimum follow-up of 6 months.

RESULTS

Successful flow-diverter delivery was achieved in 161 patients with 186 aneurysms (98%); the mean number of devices used per aneurysm was 1.05. Clinical follow-up (median, 6 months) of 150 patients (93.2%), showed that the primary safety end point occurred in 18 subjects. Permanent neurologic morbidity and mortality were 6% and 2.7%, respectively. Morbidity occurred in 4% and 7.4% of patients treated for aneurysms of the anterior and posterior circulation, respectively. Neurologic death during follow-up was observed in 1.6% and 7.4% of patients with treated intracranial aneurysms of the anterior and posterior circulation, respectively. Ischemic stroke at ≤30 days, SAH at ≤7 days, and intraparenchymal hemorrhage at ≤7 days were encountered in 3.7%, 2.5%, and 2.5% of subjects, respectively. No disabling ischemic strokes at >30 days or SAH at >7 days occurred. New or worsening cranial nerve deficit was observed in 2.7%. Follow-up angiography available in 158 (86.8%) intracranial aneurysms showed 100% occlusion in 75%.

CONCLUSIONS

Clinical outcomes of the Surpass flow diverter in the treatment of intracranial aneurysms show a safety profile that is comparable with that of stent-assisted coil embolization. Angiographic results showed a high rate of intracranial aneurysm occlusion.

An arthroscopic check valve release improves knee intrameniscal cyst symptoms in adolescent: a case report

Intrameniscal cysts begin with the flow of synovial fluid from a meniscal tear in one direction, enlarging probably as a result of an on-and-off valve mechanism of the tear flap. The current available literature focuses primarily on the necessity for surgery, however a large meniscus resection to remove cysts may place an additional burden on menisci, leading ultimately to knee joint degenerative changes. In this article, we present a rare case of intrameniscal cysts with an isolated horizontal meniscal tear in an adolescent, and describe a new arthroscopic procedure for treating this type of intrameniscal cyst. We performed arthroscopic partial release of the meniscal tear check-valve mechanism, preventing further intrameniscal cyst expansion. The patient's clinical symptoms improved, and this procedure may also be useful in treating intrameniscal cysts with an isolated horizontal meniscal tear and can be considered as an option to preserve meniscal function and minimize degenerative arthritis in young athletes.

Highly sensitive nanoscale spin-torque diode

Highly sensitive microwave devices that are operational at room temperature are important for high-speed multiplex telecommunications. Quantum devices such as superconducting bolometers possess high performance but work only at low temperature. On the other hand, semiconductor devices, although enabling high-speed operation at room temperature, have poor signal-to-noise ratios. In this regard, the demonstration of a diode based on spin-torque-induced ferromagnetic resonance between nanomagnets represented a promising development, even though the rectification output was too small for applications (1.4 mV mW(-1)). Here we show that by applying d.c. bias currents to nanomagnets while precisely controlling their magnetization-potential profiles, a much greater radiofrequency detection sensitivity of 12,000 mV mW(-1) is achievable at room temperature, exceeding that of semiconductor diode detectors (3,800 mV mW(-1)). Theoretical analysis reveals essential roles for nonlinear ferromagnetic resonance, which enhances the signal-to-noise ratio even at room temperature as the size of the magnets decreases.

High-density lipoprotein cholesterol subfractions and lecithin: cholesterol acyltransferase activity in collegiate soccer players

Many of the published data on the lipid profile of athletes is based on studies of endurance athletes. The data on soccer players are rare. The purpose of this study was to examine serum high-density lipoprotein cholesterol subfractions and lecithin:cholesterol acyltransferase activity in collegiate soccer players. 31 well-trained male collegiate soccer players were divided into 2 groups: 16 defenders and 15 offenders. They were compared with 16 sedentary controls. Dietary information was obtained with a food frequency questionnaire. The subjects were all non-smokers and were not taking any drug known to affect the lipid and lipoprotein metabolism. The offenders had significantly higher high-density lipoprotein cholesterol, high-density lipoprotein2 cholesterol, and apolipoprotein A-I than the defenders and controls, whereas the defenders had the significantly higher high-density lipoprotein2 cholesterol than the controls. Both groups of athletes had significantly higher lecithin:cholesterol acyltransferase activity than the controls. The results indicate that favorable lipid and lipoprotein profile could be obtained by vigorous soccer training.

Therapeutic efficacy of acotiamide in patients with functional dyspepsia based on enhanced postprandial gastric accommodation and emptying: randomized controlled study evaluation by real-time ultrasonography

BACKGROUND

Improvement in subjective symptoms has been reported in functional dyspepsia (FD) patients administered with acotiamide. Improvement was confirmed in meal-related symptoms, such as postprandial fullness, upper abdominal bloating, and early satiety. We examined the mechanism underlying the effects of acotiamide on gastric accommodation reflex (GAR) and gastroduodenal motility in FD patients.

METHODS

Thirty-four FD patients (mean age, 40.4 years) were examined ultrasonographically before and after 14-18 days of acotiamide (100 mg t.i.d.) or placebo administration. To assess GAR, expansion rate in cross-sectional area of the proximal stomach was measured after every 100-mL ingestion, using a straw, of up to 400 mL of a liquid meal (consommé soup, 13.1 kcal; 400 mL) in a supine position. Next, we measured gastric emptying rate (GER), motility index (MI, antral contractions), and reflux index (RI, duodenogastric reflux) to assess gastroduodenal motility. Patients also completed a survey based on the seven-point Likert scale both before and after drug administration.

KEY RESULTS

Of the 37 cases, 19 and 18 were administered with acotiamide and placebo A respectively, significant difference was observed in GAR between the acotiamide and placebo groups (21.7%vs 4.4%) after 400 mL ingestion. GER significantly accelerated after treatment in the acotiamide group (P = 0.012), no significant differences were observed in MI and RI between the two groups. Improvement rates were 35.3 and 11.8% for the acotiamide and placebo groups.

CONCLUSIONS & INFERENCES

Acotiamide significantly enhances GAR and GER in FD patients. Acotiamide may have therapeutic potential for FD patients.

Prospective randomized trial of preoperative enteral immunonutrition followed by elective total gastrectomy for gastric cancer

BACKGROUND

Perioperative enteral immunonutrition is thought to reduce postoperative morbidity in patients undergoing major gastrointestinal surgery. This study assessed the clinical effects of preoperative enteral immunonutrition in well nourished patients with gastric cancer undergoing total gastrectomy.

METHODS

Well nourished patients with primary gastric cancer, fit for total gastrectomy, were randomized to either a control group with regular diet, or an immunonutrition group that received regular diet supplemented with 1000 ml/day of immunonutrients for 5 consecutive days before surgery. The primary endpoint was the incidence of surgical-site infection (SSI). Secondary endpoints were rates of infectious complications, overall postoperative morbidity and C-reactive protein (CRP) levels on 3-4 days after surgery.

RESULTS

Of 244 randomized patients, 117 were allocated to the control group and 127 received immunonutrition. SSIs occurred in 27 patients in the immunonutrition group and 23 patients in the control group (risk ratio (RR) 1.09, 95 per cent confidence interval 0.66 to 1.78). Infectious complications were observed in 30 patients in the immunonutrition group and 27 in the control group (RR 1.11, 0.59 to 2.08). The overall postoperative morbidity rate was 30.8 and 26.1 per cent respectively (RR 1.18, 0.78 to 1.78). The median CRP value was 11.8 mg/dl in the immunonutrition group and 9.2 mg/dl in the control group (P = 0.113).

CONCLUSION

Five-day preoperative enteral immunonutrition failed to demonstrate any clear advantage in terms of early clinical outcomes or modification of the systemic acute-phase response in well nourished patients with gastric cancer undergoing elective total gastrectomy.

REGISTRATION NUMBER

ID 000000648 (University Hospital Medical Information Network (UMIN) database).

Phase II trial of preoperative S-1 plus cisplatin followed by surgery for initially unresectable locally advanced gastric cancer

BACKGROUND

The aim of this study was to evaluate the efficacy and feasibility of preoperative chemotherapy with S-1 plus cisplatin in patients with initially unresectable locally advanced gastric cancer.

METHODS

We enrolled patients with initially unresectable locally advanced gastric cancer because of severe lymph node metastases or invasion of adjacent structures. Preoperative chemotherapy consisted of S-1 at 80 mg/m(2) divided in two daily doses for 21 days and cisplatin at 60 mg/m(2) intravenously on day 8, repeated every 35 days. If a tumor decreased in size, patients received 1 or 2 more courses. Surgery involved radical resection with D2 lymphadenectomy.

RESULTS

Between December 2000 and December 2007, 27 patients were enrolled on the study. No CR was obtained, but PR was seen in 17 cases, and the response rate was 63.0%. Thirteen patients (48.1%) had R0 resections. There were no treatment related deaths. The median overall survival time (MST) and the 3-year overall survival (OS) of all patients were 31.4 months and 31.0%, respectively. Among the 13 patients who underwent curative resection, the median disease-free survival (DFS) and the 3-year DFS were 17.4 months and 23.1%, respectively. The MST and the 3-year OS were 50.1 months and 53.8%, respectively. The most common site of initial recurrence after the R0 resection was the para-aortic lymph nodes.

CONCLUSIONS

Preoperative S-1 plus cisplatin can be safely delivered to patients undergoing radical gastrectomy. This regimen is promising as neoadjuvant chemotherapy for resectable gastric cancer. For initially unresectable locally advanced gastric cancer, new trials using more effective regimens along with extended lymph node dissection are necessary.

Impaired gastric response to modified sham feeding in patients with postprandial distress syndrome

BACKGROUND

Impaired vagal function has been reported to be important in some patients with functional dyspepsia (FD). However, the pathophysiologic mechanisms influencing the cephalic phase of vagal activity in FD are incompletely understood. The aim of this study was to investigate the gastric response to modified sham feeding (MSF) on ultrasound and cardiovascular autonomic function in FD patients.

METHODS

Nineteen patients with postprandial distress syndrome (PDS, 11 men and eight women; mean age: 48.2 years) and 26 healthy subjects (HS, 13 men and 13 women; mean age: 45.0 years) were studied prospectively. Firstly, cardiovascular autonomic function was assessed by spectral analysis of RR interval variability. Antral contraction was then evaluated by ultrasonography after MSF was performed to stimulate the cephalic phase of vagal activity.

KEY RESULTS

Spectral analysis of RR interval variability showed that the high-frequency component was significantly smaller in the patients than in the HS (P<0.01). The frequency of antral contraction in response to MSF over 15 min was also significantly lower in the PDS patients than in the HS. The 15-min integrated antral contractile response (area under the contraction vs time curve) was significantly smaller in the PDS patients than in the HS (P<0.01). Univariate analysis revealed a modest correlation between the high-frequency component of RR interval variability and the area under the contraction vs time curve (n=46, r=0.49, P<0.01).

CONCLUSIONS & INFERENCES

Autonomic abnormalities affecting the cephalic phase of vagal activity may be important in the pathogenesis of FD.

Randomized controlled trial comparing Billroth-I and Roux-en-Y reconstruction in distal gastrectomy for gastric cancer

65

Background: In distal subtotal gastrectomy for gastric cancer, Billroth-I (B-I) reconstruction has been performed predominantly in Japan, while increasing number of surgeons chose Roux-en-Y (R-Y) reconstruction recently. To evaluate the safety and superiority of R-Y we conducted a multi-institutional prospective randomized controlled trial.

Methods: Gastric cancer patients who underwent distal gastrectomy were randomized to B-I or R-Y intraoperatively. The primary endpoint was the ratio of body weight loss 1 year after surgery, the secondary endpoints were the incidence of delayed gastric emptying (DGE) and postoperative morbidity.

Results: Between Aug 2005 and Dec 2008, a total of 332 patients were enrolled and 163 patients were assigned to B-I and 169 patients to R- Y. The patient's characteristics were well balanced between the two groups. The operation time was significantly longer in R-Y than B-I (median 180 min in B-I vs 214 min in R-Y, p < 0.0001). The postoperative morbidity was 14 patients (8.6%) in B-I and 23 (13.6%) in R-Y (p = 0.14), the incidence of DGE was 7 (4.3%) in B-I vs 16 (9.5%) in R-Y (p = 0.06), and the hospital stay after surgery was 14.1days in B-I vs 16.4 days in R-Y (p = 0.02). There was no hospital death in the two groups. The body weight loss at 1 year after surgery compared to preoperation was -5.4kg (-9.1%) in B-I vs -6.2kg (-9.8%) in R-Y (p = 0.11).

Conclusions: The advantage of R- Y reconstruction compared to B-I was not proved in terms of postoperative morbidity either the body weight loss 1 year after surgery.

No significant financial relationships to disclose.

An integrated analysis of two phase II trials (JCOG0001 and JCOG0405) of preoperative chemotherapy followed by D3 gastrectomy for gastric cancer (GC) with extensive lymph node metastasis (ELM)

90

Background: GC with ELM (bulky N2 metastasis and / or para-aortic lymph node metastases [PAN]) is commonly regarded unresectable, while in JCOG combined modality treatment has been tested since 2000 (JCOG0001 and JCOG0405). Both trials met their primary endpoints (i.e., 3 year-survival of 27.3% in JCOG0001 and R0 resection of 82.4% in JCOG0405). The survival and the toxicity profile were quite different between the trials despite the similar eligibility with an outstanding 3-year survival of 58.8% in JCOG0405. This study is conducted to explore if survival is still better in JCOG0405 after adjusting baseline factors and if there is a subset of patients (pts) who benefit more from either treatment.

Methods: Eligibility criteria for both included histologically proven gastric adenocarcinoma; bulky nodal involvement around major branched arteries to the stomach and/or PAN; cM0 (except PAN); negative lavage cytology; not linitis plastica type; PS of 0 or 1. Pts received two or three cycles of induction chemotherapy of IP: irinotecan (70 mg/m2 on day 1 and day 15) and cisplatin (80 mg/m2 on day 1) in JCOG0001, or SP: S1 (80 mg/m2 from day 1 to 21) and cisplatin (60 mg/m2 on day 8) in JCOG0405, followed by D3 gastrectomy. Multivariate analysis for overall survival adjusting baseline factors and treatment (IP/SP) was performed with a Cox regression model. Interaction tests were also carried out between baseline factors and treatment.

Results: After adjusting baseline factors, SP was superior than IP for overall survival (HR=0.335: 0.184 – 0.612). There was only interaction effect between treatment and the status of lymph node metastases (bulkyN+/PAN- vs bulkyN-/PAN+ vs bulkyN+/PAN+; p=0.1306).

Conclusions: SP was shown to be the favorable treatment for GC with ELM by multivariate analysis, while poor prognosis in pts having both bulky N+ and PAN+ may necessitate further treatment improvement.

No significant financial relationships to disclose.

A randomized controlled phase III trial to evaluate the effect of preoperative enteral immunonutrition on the surgical site infection after total gastrectomy (OGSG0507)

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Background: To investigate the effect of preoperative enteral immunonutrion on the incidence of surgical site infection (SSI) after total gastrectomy for gastric cancer, we conducted a prospective randomized controlled trial.

Methods: Eligibility criteria included: (1) histologically proven adenocarcinoma of stomach, (2) scheduled total gastrectomy, (3) aged less than 80 years, (4) not malnourished, (5) possible to ingest liquid diet, (6) written informed consent. Eligible patients (pts) wereassigned to the immunonutrition (I) group or the control (C) group. In the C group pts freely accessed to regular diet until surgery. In the I group, pts were supplemented with 1,000 ml/day of immunonutrient enriched with arginine, omega-3 fatty acids and RNA (Impact) in addition to the regular diet for 5 days before surgery. The primary endpoint was the incidence of SSI and the secondary endpoints were other infectious complications and serum CRP level on POD 3 or 4.

Results: From 02/2004 to 12/2009, 240 gastric cancer patients (pts) who underwent gastric surgery were enrolled. 125 pts assigned to the I group and 115 pts assigned to the C group. Age, sex, body weight, serum albumin and general nutritional status were well balanced between the two groups. 223 pts underwent total gastrectomy, 6 pts proximal gastrectomy, 4 pts distal gastrectomy, and 7 pts simple laparotomy. In terms of tumor status, there were no significant difference between the groups in histological type, T stage, and lymph node metastasis. 104 of 125 pts assigned to the I group tolerated a daily intake 1,000 ml of Impact for 5 days. The incidence of SSI was 26 (20.8%) in the I group and 24 (20.9%) in the C group (R.R: 1.00, 95% C.I: 0.61-1.63). Postoperative morbidity was 36 (28.8%) in the I group and 30 (26.1%) in the C group. There was no difference in days of hospital stay after surgery between the groups.

Conclusions: The oral administration of immunonutrient for 5 days before surgery did not contributed to the reduction of infectious complications after total gastrectomy in gastric cancer pts.

No significant financial relationships to disclose.

Randomized controlled trial of omental bursectomy for resectable cT2-3 gastric cancer

72

Background: Omental bursectomy, a traditional surgical procedure to dissect the peritoneal lining covering the pancreas and the anterior plane of the transverse mesocolon, has often been performed against resectable gastric cancer. We have conducted a multi- institutional randomized controlled trial to elucidate the safety and usefulness of this procedure.

Methods: Patients with cT2 or cT3 gastric adenocarcinoma were intraoperatively randomized to radical gastrectomy plus D2 lymphadenectomy either with or without bursectomy. The primary endpoint was overall survival (OS). The planned sample size was 464, with an alpha error of 0.05 and statistical power of 80% to detect a 10% margin of non-inferiority for the non-bursectomy group. The first interim analysis was conducted on Sep 2008, and we decided the preliminary data release according to Korn's proposal (J Clin Oncol. 2005).

Results: Between Jul 2002 and Jan 2007, a total of 210 patients were randomized to either the bursectomy group or the non-bursectomy group. Background characteristics were well balanced. Intraoperative blood loss was greater in the bursectomy group than in the non-bursectomy group (median, 475 mL vs. 350 mL, p=0.047), while other surgical factors did not vary significantly. The overall morbidity rate was 14%, the same between two groups. The hospital mortality rate was 0.95%; one patient per group. In the first interim analysis, the 3-year OS were 86% in bursectomy group and 79% in non-bursectomy group, and the hazard ratio was 1.55 (95% CI: 0.84-2.84). The non-bursectomy group had more patients with peritoneal recurrences than the bursectomy group (14% vs. 8%).

Conclusions: Experienced surgeons could safely perform a D2 gastrectomy with an additional bursectomy. First interim analysis suggested the survival advantage of omental bursectomy for cT2-3 gastric cancer patients. Final analysis will be conducted in 2012.

No significant financial relationships to disclose.

Effects of intermittent Pringle's manoeuvre on cirrhotic compared with normal liver

BACKGROUND

Although patients with liver cirrhosis are supposed to tolerate ischaemia-reperfusion poorly, the exact impact of intermittent inflow clamping during hepatic resection of cirrhotic compared with normal liver remains unclear.

METHODS

Intermittent Pringle's manoeuvre was applied during minor hepatectomy in 172 patients with a normal liver, 59 with chronic hepatitis and 97 with liver cirrhosis. To assess hepatic injury, delta (D)-aspartate aminotransferase (AST) and D-alanine aminotransferase (ALT) (maximum level minus preoperative level) were calculated. To evaluate postoperative liver function, postoperative levels of total bilirubin, albumin and cholinesterase (ChE), and prothrombin time were measured.

RESULTS

Significant correlations between D-AST or D-ALT and clamping time were found in each group. The regression coefficients of the regression lines for D-AST and D-ALT in patients with normal liver were significantly higher than those in patients with cirrhotic liver. Irrespective of whether clamping time was 45 min or less, or at least 60 min, D-AST and D-ALT were significantly lower in patients with cirrhosis than in those with a normal liver. Parameters of hepatic functional reserve, such as total bilirubin, prothrombin time, albumin and ChE, were impaired significantly after surgery in patients with a cirrhotic liver.

CONCLUSION

Patients with liver cirrhosis had a smaller increase in aminotransferase levels following portal triad clamping than those with a normal liver. However, hepatic functional reserve in those with a cirrhotic liver seemed to be affected more after intermittent inflow occlusion.

Effects of intermittent Pringle's manoeuvre on cirrhotic compared with normal liver

BACKGROUND

Although patients with liver cirrhosis are supposed to tolerate ischaemia-reperfusion poorly, the exact impact of intermittent inflow clamping during hepatic resection of cirrhotic compared with normal liver remains unclear.

METHODS

Intermittent Pringle's manoeuvre was applied during minor hepatectomy in 172 patients with a normal liver, 59 with chronic hepatitis and 97 with liver cirrhosis. To assess hepatic injury, delta (D)-aspartate aminotransferase (AST) and D-alanine aminotransferase (ALT) (maximum level minus preoperative level) were calculated. To evaluate postoperative liver function, postoperative levels of total bilirubin, albumin and cholinesterase (ChE), and prothrombin time were measured.

RESULTS

Significant correlations between D-AST or D-ALT and clamping time were found in each group. The regression coefficients of the regression lines for D-AST and D-ALT in patients with normal liver were significantly higher than those in patients with cirrhotic liver. Irrespective of whether clamping time was 45 min or less, or at least 60 min, D-AST and D-ALT were significantly lower in patients with cirrhosis than in those with a normal liver. Parameters of hepatic functional reserve, such as total bilirubin, prothrombin time, albumin and ChE, were impaired significantly after surgery in patients with a cirrhotic liver.

CONCLUSION

Patients with liver cirrhosis had a smaller increase in aminotransferase levels following portal triad clamping than those with a normal liver. However, hepatic functional reserve in those with a cirrhotic liver seemed to be affected more after intermittent inflow occlusion.

Phase II study of neoadjuvant chemotherapy and extended surgery for locally advanced gastric cancer

BACKGROUND

Locally advanced gastric cancer with extensive lymph node metastasis is usually considered unresectable and so treated by chemotherapy. This trial explored the safety and efficacy of preoperative chemotherapy followed by extended surgery in the management of locally advanced gastric adenocarcinoma.

METHODS

Patients with gastric cancer with extensive lymph node metastasis received two or three 28-day cycles of induction chemotherapy with irinotecan (70 mg/m(2) on days 1 and 15) and cisplatin (80 mg/m(2) on day 1), and then underwent gastrectomy with curative intent with D2 plus para-aortic lymphadenectomy. Primary endpoints were 3-year overall survival and incidence of treatment-related death.

RESULTS

The study was terminated because of three treatment-related deaths when 55 patients had been enrolled (mortality rate above 5 per cent). Two deaths were due to myelosuppression and one to postoperative complications. Clinical response and R0 resection rates were 55 and 65 per cent respectively. The pathological response rate was 15 per cent. Median overall survival was 14.6 months and the 3-year survival rate 27 per cent.

CONCLUSION

This multimodal treatment of locally advanced gastric cancer provides reasonable 3-year survival compared with historical data, but at a considerable cost in terms of morbidity and mortality.

Phase II feasibility study of adjuvant S-1 plus docetaxel for stage III gastric cancer patients after curative D2 gastrectomy (OGSG 0604)

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Background: Although an adjuvant chemotherapy with S-1 has become the standard treatment for stage II-III gastric cancer (GC) patients (pts) after curative D2 gastrectomy in Japan, the survival benefit for stage III pts obtained by S-1 is considered to be modest. S-1 plus docetaxel has shown a good response rate of 56% with prolonged median overall survival (OS) of 14.3 months in pts with advanced GC. This phase II study evaluated the feasibility and safety of adjuvant S-1 plus docetaxel for stage III GC pts after R0 resection. Methods: Patients with curatively resected pathological stage III GC receiving D2 dissection, age 20–80 years, performance status < 1, no prior adjuvant treatment, adequate organ function, and informed consent were given S-1 (80 mg/m2/day) orally for consecutive 2 weeks plus docetaxel (40 mg/m2) intravenously on day 1, repeated every 3 weeks. The treatment was started within 45 days after gastrectomy, and repeated for 4 cycles, followed by S-1 monotherapy until 1 year after surgery. Study endpoints included feasibility of the 4 cycles of S-1 plus docetaxel as primary, and safety, progression free survival (PFS), and OS as secondary. Sample size was set to be 50, which was determined to reject the feasibility of 50% under the expectation of 75% with power of 90% and two-sided α of 5%. Results: Fifty-three pts, 42 males and 11 females with a median age of 65 years, were enrolled between 5/2007 and 8/2008. Pathological stages included IIIA in 36 pts and IIIB in 17 pts. Planned 4 cycles of treatment were delivered to 41 out of 53 pts, with the feasibility of 77.4% (95% CI 63.8–87.7%, P<0.001). Reasons for discontinuation were recurrent cancer in 1 pt, adverse events in 10, and miscellaneous in 1, respectively. Grade 4 neutropenia was observed in 28% of pts with grade 3 febrile neutropenia in 9%. Non-hematological toxicities of grade 3 or more involved fatigue in 6%, anorexia in 9%, and nausea in 6%. No treatment-related deaths occurred. Conclusions: Adjuvant S-1 plus docetaxel was well-tolerated and showed good compliance. Although follow-up is ongoing on survival, this regimen could be a candidate of future phase III trial seeking for the optimal adjuvant chemotherapy for stage III GC pts after curative D2 gastrectomy.

No significant financial relationships to disclose.

Updated result on the 2.5-year follow-up of GC0301/TOP-002: Randomized phase III study of irinotecan plus S-1 (IRI-S) versus S-1 alone as first-line treatment for advanced gastric cancer (AGC)

4544

Background: IRI-S had longer in median survival time (MST) than S-1 alone, and was well tolerated in previously untreated AGC, but not statistically significant. Considering 68 patients (pts) were censored, further follow-up was needed to confirm the OS with more precision (Imamura et al. ASCO-GI 2008). We now present updated results of OS and exploratory analysis with the prolonged 2.5 year follow-up data. Methods: Treatments Arm A (oral S-1 80 mg/m2/day from Day 1 to 28, q6w), or Arm B (IRI-S; oral S-1 80 mg/m2/day from Day 1 to 21 and intravenous irinotecan 80 mg/m2 on Days 1 and 15, q5w) were continued until disease progression or unacceptable toxicities were observed. The primary endpoint was to compare OS between groups. This updated result was regarded as exploratory position. Results: Although the MST of Arm A was 319 days (95%Cl: 286–395) and of Arm B was 389 days (95%Cl: 324–459), Arm B didn’t show statistically significant superiority to Arm A (log-rank test p=0.54; hazard ratio (HR) =0.93). The 1-year survival was 45.0% in Arm A and 52.0% in Arm B, and the 2-year survival was 22.5% and 18.0%, respectively. Response rate was significantly different (Arm A/B, 26.9%/41.5%; chi-square test p=0.04) in 187 patient evaluated by RECIST criteria. Time to treatment failure was also favored in Arm B (median=138 days) compared to Arm A (111 days; log-rank test p=0.16; HR=0.85). In subset analyses, two groups showed possibility of clinical benefit in Arm B. The HR of diffuse type group was 0.71 (95%Cl: 0.52–0.96), and of PS1, 2 group was 0.63 (95%Cl: 0.42–0.95). As post protocol treatment, 45.6% of Arm A patients received an irinotecan-based regimen, and the MST of them was 496 days (95%Cl: 395–573). Conclusions: IRI-S did not show statistically significant superiority to S-1 alone in OS with this follow-up data. Post protocol treatment, effective treatment after S-1 failure might have affected survival. According to exploratory analyses, IRI-S may have clinical benefit in early-term of treatment, group of the diffuse type and that of PS1, 2. We need more considering predictive factors, because the gastric cancer is heterogeneous adenocarcinoma.

[Table: see text]

A randomized phase III trial to determine the efficacy of postoperative antimicrobial prophylaxis in gastric cancer surgery (OGSG0501)

e15576

Background: In Japan, antimicrobial prophylaxis (AMP) is typically administered for 3 to 4 days postoperatively in gastric cancer surgery. This far exceeds the recommended 24h or less laid out by the Centers for Disease Control (CDC) guidelines for the prevention of surgical-site infections, after a clean-contaminated operation. Methods: A multicenter randomized phase III trial was designed to evaluate the effect of postoperative AMP in gastric cancer surgery. Patients (pts) were required to have histologically proven gastric cancer which was curable by distal gastrectomy, be classifiable as ASA 1 or 2, and have adequate organ function. Pts were randomized to: (A) perioperative AMP (cefazolin 1g, at <30min before incision, every 3h intraoperative supplements) plus postoperative AMP (cefazolin 1g, twice daily for 2 postoperative days) or (B) perioperative AMP alone. Pts were stratified by institution and ASA. The primary endpoint was the incidence of surgical site infection (SSI). With 171 pts per arm, this study had 80% power to demonstrate non-inferiority with 5% margin of peri-AMP alone and 0.05 1-sided alpha. Results: 355 patients were recruited (A: 179, B: 176) in 7 centers between June 2005 and December 2007. The surgical-site infection rate was 9.0 percent (16 of 178) for peri-/post AMP and 4.5 percent (8 of 176) for peri-AMP alone, with no significant differences (Fisher's exact test: P=0.14, RR=1.98 [95%CI, 0.89–4.44]), but showing a significant non-inferiority (P<0.001). The remote site infection rate was 3.4 percent (6 of 178) for peri-/post AMP and 5.1 percent (9 of 175) for peri-AMP alone, with no significant differences (P=0.44, RR=0.66 [95%CI, 0.25- 1.70]). Conclusions: This multicenter randomized phase III trial confirms that postoperative AMP is unnecessary in patients undergoing distal gastrectomy for gastric cancer.

No significant financial relationships to disclose.

Multi-center, phase II study for combination therapy with paclitaxel/doxifluridine to treat advanced/recurrent gastric cancer showing resistance to S-1: Final results (OGSG 0302)

15025

Background: We report here results of phase II study for a combination therapy with paclitaxel/doxifluridine to treat advanced/recurrent gastric cancer showing resistance to S-1. S-1 is an oral fluoropyrimidine drug that combines tegafur, CDHP, and oxonic acid (Oxo), which has been most frequently used in Japan. Methods: Subject registration was started to employ 35 patients with advanced/recurrent gastric cancer, who were selected among those with measurable lesions fitting to RECIST, and with resistant to S-1 treatment (PS, 0–2; and patient’s ages ranged from over 20 to under 75 years). We employed dosages that Hyodo et. al. used in phase I study and recommended as a standard regimen including paclitaxel, 80 mg/m2, i.v. on days 1 and 8; and doxifluridine, 600 mg/m2, p.o. on days 1–14.. These were repeated every 3 weeks. Primary endpoint of present phase II study was: RR; and secondary endpoints were OS, PFS, and onset rate of adverse events. Results: From September, 2003 to March, 2005, 35 patients were registered: including 28 men; 7 women; median age of 66 years (range, 49–75 years); and PS levels were, zero with 21 and one with 14 patients. In 33 eligible patients, except 2, clinical usefulness was evaluated resulting in response rate of 18.2% (PR, 6; SD, 15; PD, 10; and NE, 2 patients). OS was 321 days, and PFS was 119 days. Severe adverse events were found in 3 patients to discontinue the present treatment though; other adverse events were relatively mild without no death due to the present therapy. Conclusions: Patients in the present study with advanced/recurrent gastric cancer were those resistant to S-1 treatment. Response rate was 18.2% increasing to 63.6% when SD was added. OS resulted in relatively long period of 321 days, while OS from initial time starting S-1 treatment was 619 days. This suggests that the present treatment is useful as the sequential therapy. Adverse events were controllable suggesting a high reliability of the present therapy. In conclusion, the present therapy with paclitaxel/doxifluridine could be a treatment of choice as an useful second line chemotherapy for patients undergone S-1 treatment.

No significant financial relationships to disclose.

Irinotecan plus S-1 (IRIS) versus S-1 alone as first line treatment for advanced gastric cancer: Preliminary results of a randomized phase III study (GC0301/TOP-002)

4525

Background: Irinotecan has single agent activity and combination activity with S-1 reportedly in phase I/II studies with advanced gastric cancer patients (pts). S-1, oral fluoropyrimidine, also has activity on gastric cancer. A multicenter, randomized phase III trial comparing IRIS to S-1 alone in advanced gastric cancer was conducted. Methods: Pts with previously untreated gastric cancer were randomized to Arm A (oral S-1 80 mg/m2/day from day 1 to 28 followed by a 14-day rest period), or Arm B (oral S-1 80 mg/m2/day from day 1 to 21 and intravenous irinotecan 80 mg/m2 on days 1 and 15 followed by a 14-day rest). Treatment was continued unless disease progression was observed. Inclusion criteria: PS (ECOG) of 0 to 2; adequate major organ functions. Primary endpoint was overall survival. Results: From June 2004 to November 2005, 326 pts were randomized to arm A (162 pts) and arm B (164 pts). Pts characteristics (arm A vs. arm B) were as follows: median age: 63 vs. 63 years, PS 0–1: 97% vs. 97%, and distribution of subtype of intestinal/diffuse/others: 44%/55%/1% vs. 41%/58%/1%. Among 187 RECIST-evaluable pts (93 vs 94) reviewed by independent review panel, best response rates were 26.9% for arm A and 41.5% for arm B(p=0.035). Among 319 toxicity-evaluable patients (161 vs 158), grade 3 or 4 toxicities for arm A vs arm B (% of pts) were as follows: neutropenia 9.3% vs 26.6%, diarrhea 5.6% vs 15.8%, anorexia 9.9% vs 15.8%, nausea 3.7% vs 7.0%, vomiting 0.6% vs 2.5%. Conclusions: IRIS is effective, and well tolerated in pts with advanced gastric cancer. Survival analysis is underway.

No significant financial relationships to disclose.

A retrospective study of surgical treatment for gastric cancer in our institute as a clinical hospital in Japan

15125

Background: Two European randomized controlled trials comparing D1 and D2 gastrectomy revealed a high operative mortality in the D2 group. Based on these reports, D1 gastrectomy is a standard treatment for western patients. In contrast, D2 gastrectomy is considered a standard and safe procedure in Japan. Moreover, the operative morbidity/mortality and the incidence of the major surgical complications were not different between D2and extended para-aortic lymphadenectomy in a prospective randomized controlled trial in Japan. We report a retrospective study of surgical treatment for gastric cancer in our institute as a clinical hospital in Japan. Methods: Patients who underwent gastrectomy between January 1998 and November 2006 in our institute were analyzed. Survival according to the staging by Japanese Classification of Gastric Cancer, the level of the dissection of lymph nodes, and all complications were studied. Results: A total 1342 patients underwent gastrectomy between January 1998 and November 2006 in our institute. The male/female ratio was 2.2 and the mean age was 64.7±11.4 years(range,27–94 years). The 5-year survival according to the staging by Japanese Classification of Gastric Cancer was 98.4%, 84.7%, 77.2%, 46.1%, 40.2% and 33.4% in the stage IA, IB, II, IIIA, IIIB, and IV, respectively. D0, D1, D2, and D3 or D4 gastrectomy was performed in 48, 200, 610, and 27 patients, respectively. Complications were identified in 295 patients(22%) involving 2 patients with treatment death(0.01%) and anastomotic leak, surgical site infection, pancreatic fistula, ileus, anastomotic stenosis, abdominal abcess, liver dysfunction, postoperative bleeding, pneumonia , DIC , peritonitis, and others were identified in 66, 51, 42, 28, 26, 23, 21, 14, 13, 4, 3, and 4 patients, respectively. We analyzed the D0/D1 and D2/D3/D4 dissection subgroups about complications. There was no significant difference in the incidence of complications between the two groups (p=0.093). Conclusions: Our data suggested that gastrectomy with D2 dissection has been a safe treatment with a good prognosis in our institute. D2 gastrectomy is considered a safe treatmemt without increasing surgical complications.

No significant financial relationships to disclose.

Esophageal cancer treatment in our institute from 1999 to 2005

15183

Background: 5 year survival rate of esophageal cancer in Japan reported to the Japanese Society for Esophageal Diseases from 1988 to 1994 (9,143 cases) was improved to 35.5% comparing to the rate of the beginning of 1980 which remained around 20%. This result was given by the increase of early cancer cases attributed to the progress of the ability of diagnosis, the improvement of the postoperative management, and the 3 field lymph node dissection introduced from the middle of 1980. Biological malignant potential and the modality of treatment for esophageal cancer in Japan differs from those in the United States. Methods: We studied clinicopathological characteristic and treatment results of 63 esophageal cancer patients in our institute from 1999 to 2005. Results: 63 patients consisted of 47 males and 16 females with mean age of 63.4±11.4. Out of 47 patients who underwent surgical treatment, 6 and 4 patients underwent neoadjuvant chemoradiotherapy and chemotherapy, respectively. 15 patients without surgical treatment consisted of 12 patients, including one patient after endoscopical mucosal resection, undergoing chemoradiotherapy, 2 patients undergoing chemotherapy, and 3 patients undergoing radiotherapy, respectively. Most common histological type was squamous cell carcinoma (55 patients), followed by adenocarcinoma (3 patients), small cell carcinoma(3 patients), others(2 patients), and unknown(1 patients). There was 1 surgical treatment-related death. The major complications were SSI (18 patients), anastomotic leakage(7 patients) and recurrent nerve palsy (5 patients). The 2-year survival rate of patients with surgical resection was 68.1%, while the rate of the unresectable patients was 38.9%.Since 2002, we have adopted posterior mediastinal route as a prime choice, rather than retrosternal route. The median amount of blood loss, rate of complications and duration of post operative hospital stay of each routes are 650/415(ml), 65/45(%), 35/22(day), respectively. These results suggested that posterior mediastinal route showed superiority comparing to restrosternal route. Conclusions: Backed by these outcomes, we will aim to establish a logical strategy for esophageal cancer therapy which could accompany fewer complications, respect quality of life and prolong survival time.

No significant financial relationships to disclose.

The prognosis of the patients with gastric cancer intraoperatively detected microscopical free abdominal cancer cells at Douglas cavity

14090

Background: The free abdominal cancer cells in the patients with gastric cancer probably result in peritoneal dissemination. In Japan, the detection of free abdominal cancer cells at Douglas cavity is usually examined immediately after lapalotomy for advanced gastric cancer, because this procedure is recommended in Japanese Classification of Gastric Carcinoma 1999 provided by Japanese Gastric Cancer Association. The patients detected free abdominal cancer cells are diagnosed as stage IV, even if they undergo the surgical curative operation. However some of them have relatively long survival. We investigated that the amount of free abdominal cancer cells or histological type might affect their prognosis. Methods: Surgeon collected 50ml of saline with which Douglas cavity was irrigated. Pathologist stained cells by Papanicolaou follwed by differential centrifugation (2000G for 5 minutes) of saline. Among all 492 patients who underwent surgery for gastric cancer in our institute between 2000 and 2004, 46 patients underwent the curative surgery except free abdominal cancer cells. We investigated the amount of free abdominal cancer cells and histological type as the factors to affect prognosis of these 46 patients. The log-rank test was used to evaluate the survival curves calculated by Kaplan-Maier method. Results: 5 or less and more than 5 cancer cells per 1 cm2 were microscopically detected in 22 (Group A) and 24 patients (Group B), respectively. The median survival time (MST) of Group A and B were 877 and 384 days, respectively (P=0.16). The two-year survival rates of Group A and B are 63.7% and 27.2%, respectively. The cancer cells diagnosed histologically as differentiated and undifferentiated type were detected in 13 (Group X) and 33 patients (Group Y), respectively. The MSTs of Group X and Y were 877 and 383 days, respectively (P=0.13). The two-year survival rates of Group X and Y are 82.1% and 28.9%, respectively. Conclusions: In patients who have advanced gastric cancer with free abdominal cancer cells, a larger number or undifferentiated type of cancer cells may reduce the survival periods of patients with curative resection.

No significant financial relationships to disclose.

The advantages of circular stapling instrument compared with Albert-Lembert suture for anastomosis of Billroth I gastrectomy for gastric cancer

14104

Background: In Japan, reconstruction with Billroth I using Albert-Lembert suture had been usually performed in distal gastrectomy for gastric cancer. However stapling instruments have within recent years gained wide acceptance not only in total gastrectomy but also in distal gastrectomy. We have introduced circular stapling instrument for anastomosis reconstructed with Billroth I since June 2001. Methods: 111 and 222 patients with gastric cancer underwent distal gastrectomy reconstructed with Billroth I using Albert-Lembert suture from June 1999 to May 2001 (Group A) and using circular stapling instrument from June 2001 to December 2003 (Group B) for anastmosis in our institute, respectively. Albert-Lembert suture was performed as end-to-end gastroduodenostomy followed by resection of proximal line stapled across with liner cutter instrument. The procedure of anastomosis using circular stapling instrument was as followed; the distal duodenum was clamped with the purse-string instrument, divided proximally, the anvil was attached, the purse-string was tied down, the circular stapler without anvil was inserted through a gastrotomy, brought out through a stab wound at the anastomosis site, the instrument was closed and fired, and gastrectomy involving the site of gastrotomy was closed with linear cutter instrument. The followed-up periods of all patients from surgery were more than 2 years. We retrospectively compared the incidence of anastomosis-related complications within 2 years from surgery consisting of anastomotic bleeding, leakage, and stenosis. P-values were calculated statistically using χ2-test. Results: Anastomotic bleeding occurred in 1 (0.45%) patient of Group B, but in none of Group A (P=0.48). Anastomotic leakage occurred in 2 patients (1.80%) of Group A, but in none of Group B (P=0.045). Anastomotic stenosis occurred in 2 patients (0.90%) of Group B, but in none of Group A (P=0.32). All complications were recovered and all patients left hospital in the safety. Conclusions: Our data indicated that circular stapling instrument for anastomosis of Billroth I gastrectomy for gastric cancer significantly reduced the incidence of anastomotic leakage compared with Albert-Lembert suture.

No significant financial relationships to disclose.