Combined resection of invaded organs in patients with T4 gastric carcinoma

BACKGROUND

To understand the efficacy of gastrectomy combined with the resection of other organs and to refine the indications for this type of surgery, the records of 156 patients with carcinoma of the stomach directly invading adjacent organs or structures (T4 gastric carcinoma) were analyzed retrospectively.

METHODS

The patients were divided into three groups, as follows: in group A, curative resection was performed by the combined resection of invaded organs or structures; in group B, although combined resection was performed, curative resection could not be performed because of the extent of lymph node metastasis, liver metastasis, and/or peritoneal metastasis; in group C, combined resection was not performed.

RESULTS

In patients with peritoneal or liver metastasis, there was no significant difference in prognosis among the three groups. In patients without peritoneal and liver metastasis, the prognosis of group A was significantly better than that of group B or group C, irrespective of the extent of lymph node metastasis or the number of invaded organs. In these group A patients, the 5-year survival rates of those with localized tumors and no lymph node metastasis, those with localized tumors and lymph node metastasis, those with infiltrating tumors and no lymph node metastasis, and those with infiltrating tumors and lymph node metastasis were 100%, 56.2%, 57.1%, and 13.6%, respectively.

CONCLUSIONS

Combined resection of involved organs should be carried out with curative intent in patients with localized gastric cancer or infiltrating gastric cancer without lymph node metastasis.

Significant correlation between micrometastasis in the lymph nodes and reduced expression of E-cadherin in early gastric cancer

BACKGROUND

E-cadherin has been recognized as an important factor associated with tumor metastasis. However, the relationship between micrometastasis in the lymph nodes and the expression of E-cadherin in the primary tumor in gastric cancer remains unclear.

METHODS

Two consecutive sections of 4522 lymph nodes from 162 patients with early gastric cancer were prepared for simultaneous hematoxylin and eosin (H&E) and cytokeratin (CK) staining. Sections of primary tumors from 135 of these patients were prepared for E-cadherin immunostaining.

RESULTS

The incidence of lymph node involvement was significantly increased, from 6.8% (11/162 patients) by H&E staining, to 27% (43/162 patients) by CK immunostaining (P < 0.0001). Micrometastasis in the lymph node was found in 32 of 151 (21%) patients who had no lymph node metastasis evidenced by H&E staining. Micro-lymph node metastasis was frequently found in tumors with a diameter more than 1.0 cm, of those that were poorly differentiated, deeply invaded, showed lymphatic on vascular invasion, and in those that showed reduced expression of E-cadherin. Loss of expression of E-cadherin in the primary tumor was closely correlated with micro-lymph node metastasis. Patients with tumors with micro-lymph node metastasis detected by CK immunostaining had a significantly lower 5-year survival rate (P < 0.01) than those without such metastases.

CONCLUSION

Tumors more than 1.0 cm in diameter and those that exhibit poor differentiation, deep invasion (i.e., to the submucosa), lymphatic or vascular invasion, and reduced expression of E-cadherin are risk factors for lymph node metastasis in early gastric cancer. Thus, it is recommended that cancers confined to the mucosa (m-cancers) that are more than 1.0 cm in diameter should not be treated with limited surgery without lymphadenectomy.

Quantification of TECTA and DFNA5 expression in the developing mouse cochlea

TECTA and DFNA5 are the mouse orthologues of the human deafness-associated genes TECTA and DFNA5. To determine how expression of these genes is regulated during development, relative mRNA abundance was examined in mice by non-radioactive RT-PCR. TECTA mRNA was detected on embryonic day 15 (E15), increased to its highest level on postnatal day 3 (P3) and then dramatically decreased by P15. Low levels persisted (adulthood, P45 to 67) with mean mRNA abundance after P15 less than 25% of P3 levels. DFNA5 mRNA expression was constant throughout these time points. These results imply that TECTA is transcribed at a particularly high level during tectorial membrane morphogenesis. In contrast, DFNA5 is present in both the developing and mature cochlea.

False-positive magnetic resonance image in the diagnosis of small acoustic neuroma

A patient presented with sudden hearing loss on her first visit to our department. Gadolinium-DTPA-enhanced magnetic resonance imaging (MRI) of the posterior cranial fossa portrayed an intracanalicular tumour image (2-3 mm), and the pure tone average (PTA) and speech discrimination score (SDS) values were 65 dB and 60 per cent, respectively. Surgical intervention to remove the suspected tumour was scheduled by the translabyrinthine approach. Intracanalicular observations by the retrolabyrinthine approach revealed limited oedema on the inferior vestibular nerve with vascular dilation. The tumour image disappeared two years after the operation. Surgical findings and the post-operative course advocate that gadolinium-DTPA-enriched MRI image of an intracanalicular lesion such as arachnoiditis might produce a false-positive result.

Prognostic factors in patients with advanced gastric cancer treated by noncurative resection: a multivariate analysis

BACKGROUND/AIMS

The relationship between prognostic factors and survival time after noncurative gastric resection in patients with advanced gastric cancer was examined by a retrospective review of data on 364 patients.

METHODOLOGY

There were 168 patients without metastasis to the liver or peritoneum (group A), 127 with peritoneal metastasis and no liver metastasis (group B), 50 with liver metastasis and no peritoneal metastasis (group C) and 19 with synchronous liver and peritoneal metastases (group D). Patients were primarily treated with the following 3 drugs: the fluorinated pyrimidines, cisplatin, and mitomycin C.

RESULTS

Patients in group D had a very poor prognosis as compared with the other groups. Multivariate analysis using the Cox's proportional hazard model adjusted for sex, age, and other covariants indicated that lymph node metastasis, lymph node dissection, and fluorinated pyrimidines for group A, cisplatin for group B, and lymph node dissection for group C were independent prognostic factors. An analysis of patients excluding cases who died within 30 days after surgery revealed that lymph node dissection for group A, lymph node dissection and cisplatin for group B, and lymph node dissection for group C were independent prognostic factors.

CONCLUSIONS

Treatment protocol specific for the residual disease may improve the survival of patients with advanced gastric cancer treated by noncurative resection.

Postoperative morbidity and mortality after gastrectomy for gastric carcinoma

BACKGROUND/AIMS

Surgical technique and postoperative care for gastric cancer have significantly improved in recent years. However, whether postoperative morbidity or mortality rates after gastrectomy for gastric cancer were reduced or not in recent years was unclear. In this study, we analyzed the chronological changes of postoperative morbidity and mortality rates, and we analyzed risk factors for postoperative morbidity and mortality in patients undergoing gastrectomy for carcinomas of the stomach.

METHODOLOGY

A total of 887 patients with gastric cancer were gastrectomized in our hospital between January 1985 and December 1996. The patients were divided into three groups on the basis of chronology. The first group included patients treated over the period 1985 to 1988 (n = 324); the second group, 1989 to 1992 (n = 300); and the third group, 1993 to 1996 (n = 263). Postoperative morbidity rates and mortality rates were compared among the three groups. Also, significant risk factors affecting postoperative morbidity and in-hospital mortality were analyzed by the multiple logistic regression analysis.

RESULTS

Postoperative complications were detected in 95 patients (10.7%) and in-hospital mortality rate was 2.4% (21/887). Postoperative morbidity rates were 10.5%, 11%, and 10.6% in the first, second, and third groups, respectively and postoperative mortality rates were 2.5%, 2%, and 2.7%, respectively. These postoperative morbidity and mortality rates were not different between the groups (P = 0.979 and P = 0.866). The most common postoperative complication was anastomotic leakage (56/95, 58.9%). Significant risk factors affecting in-hospital mortality were Stage IV (P = 0.006) and noncurative gastric resection (P = 0.004). However, the extent of lymph node dissection, combined resection, or the existence of preoperative complications were not significant risk factors of in-hospital mortality by multiple logistic regression analysis.

CONCLUSIONS

These results indicate that patients with far-advanced gastric cancer might have a high risk of postoperative mortality. In noncurative operations for patients with advanced gastric cancer, unnecessary lymph node dissection or combined resection should be avoided.

Correlation between spontaneous apoptosis and the expression of angiogenic factors in advanced gastric adenocarcinoma

The aim of this study was to investigate whether angiogenic factors influence the occurrence of spontaneous apoptosis in advanced gastric cancer. The apoptotic indices (AIs) of 97 tumors from 97 patients with advanced gastric cancer (pT3, pN0, pM0, Stage II) were analyzed by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick end labeling (TUNEL) method. Intratumoral microvessel densities (IMVDs) of tumors stained with anti-CD34 monoclonal antibody were quantified under x 200 magnification using computer-assisted image analysis. The expressions of angiogenic factors, such as vascular endothelial growth factor (VEGF), thymidine phosphorylase (dThdPase), transforming growth factor-alpha (TGF-alpha), and p53 were analyzed immunohistochemically and compared with IMVDs and AIs. The mean IMVD of the 97 tumors was 365/mm2 (range 147-990/mm2). The mean AI of tumors was 2.1% (range 0-11.3%). A significant inverse correlation between the AIs and the IMVDs was shown (p = -0.278, P = 0.0064). The mean IMVDs of tumors with high expressions of dThdPase, TGF-alpha, or p53 were significantly higher than those of tumors with low expressions of these factors. The mean AI of tumors with high expressions of dThdPase was significantly lower than that of tumors with low expressions of dThdPase (P = 0.023). However, no significant correlations were detected between AIs and the expression levels of VEGF, TGF-alpha, or p53. In gastric cancer, dThdPase may play an important role in tumor progression by increasing microvessels and by suppressing apoptosis of cancer cells.

Pharmacokinetics of intraoperative intrapleural cisplatin chemotherapy of various osmolarities in cases of esophageal cancer

Intraoperative intrapleural (i.pl.) cisplatin (CDDP) treatment during thoracotomy was performed for esophageal cancers. Three patients underwent isotonic (308 mOsm/l) CDDP treatment. Hypotonic CDDP treatments with a 154 mOsm/l solution and a 62 mOsm/l solution were administered to 4 and 9 patients, respectively. The maximum concentrations (Cmax) of both total and filterable platinum in the plasma after injection of the hypotonic solution were significantly higher than those after injection of the isotonic solution. The area under the curve of concentration versus time (AUC) of the plasma of the 62 mOsm/l solution was significantly higher than that of the 154 mOsm/l and isotonic solution. Although higher levels of the Cmax may increase side-effects, the hypotonic condition of the i.pl. fluid and increased AUC in the plasma may escalate the accumulation of platinum in i.pl. cancer cells. These results suggest that hypotonic i.pl. CDDP is tolerable and may be useful for treatment of the incipient phase of pleural carcinomatosis and for prophylaxis of postoperative recurrence.

Bax expression as a prognostic marker of postoperative chemoradiotherapy for patients with esophageal cancer

Postoperative chemoradiotherapy was introduced to improve the survival of patients with esophageal squamous cell carcinoma (ESCC). However, considerable number of patients still die of cancer recurrence despite curative operation plus chemoradiotherapy. This indicates that some ESCCs are chemoradio-resistant. To prevent unnecessary treatment and to improve the effect of post-operative adjuvant therapy, it seems to be important to investigate biological markers of chemoradio-sensitivity in ESCC. Loss of Bax expression has been reported to be associated with poor response to chemotherapy in breast cancer, and Bax promotes apoptosis in cells. Abnormal expression of Bax may play an important role in chemoradio-sensitivity in malignant tumors. In this study, we retrospectively investigated the prognostic significance of the expressions of Bax and p53 in patients with ESCC. Immunoreactivities of Bax and p53 were evaluated in 141 surgically resected ESCC by using monoclonal antibodies. Prognoses of 141 patients with or without postoperative chemoradiotherapy were compared among groups with high and low expressions of Bax or p53. High immunoreactivities of Bax and p53 were detected in 49 cases (33.1%) and in 70 cases (47.3%), respectively. Loss of Bax expression was detected more frequently in p53-positive tumors. Bax expression correlated with favorable prognosis (P=0.016) in 57 patients with postoperative chemoradiotherapy. However, in 84 patients without adjuvant therapy, the prognostic significance of Bax was minimal. Moreover, in patients with or without postoperative chemoradiotherapy, p53 expression did not correlate with the prognosis. Bax expression may be a good marker for chemoradio-sensitivity in patients with ESCC.

Prediction of survival period for patients with postoperative recurrence after curative resection for advanced gastric carcinoma

BACKGROUND/AIMS

Although many studies have attempted to clarify the prognostic indicators for gastric carcinoma, there have been few studies regarding the factors that correlate with the survival period of patients with postoperative recurrence.

METHODOLOGY

Among 504 advanced gastric adenocarcinoma patients who had undergone curative gastrectomy, 188 patients who had died of recurrence were used in this study.

RESULTS

Univariate analysis indicated that age, the presence of lymph node metastasis and blood vessel invasion, the number of positive lymph nodes, and gastrectomy significantly correlated with the survival period. Multivariate analysis indicated that the length of the survival period was independently influenced by the number of positive lymph nodes and blood vessel invasion. The survival time of patients with less than 3 positive lymph nodes and no accompanying blood vessel invasion was significantly longer than that of other patients.

CONCLUSIONS

The number of positive lymph nodes and the presence of blood vessel invasion are the most important factors predicting the survival period of patients with postoperative recurrence after curative resection for advanced gastric carcinoma.

Mutated p53 in tumors, mutant p53 and p53-specific antibodies in the circulation in patients with gastric cancer

The accumulation of mutated p53 in tumor cells results in the presence in the circulation of mutant p53 (p53m) and the production of p53-specific antibodies (p53Ab). We examined the relationships among these phenomena and analyzed their clinical implications in 62 patients with gastric cancer at various stages. Expression of p53 in tumors was studied by an immunohistochemical method and circulating p53m and p53Ab were quantitated with commercially available enzyme-linked immunosorbent assay kits. The detectable expression of p53 in tumors and circulating p53Ab was recognized in 28 (45.2%) and 7 (11.3%) of the 62 patients, respectively. The number of patients with higher levels of circulating p53m increased with the progression of the depth of cancer invasion. Patients with any positive findings for the three p53-related parameters had a poorer prognosis, and the difference was statistically significant in patients with p53Ab. When survival was analyzed in terms of the combination of the three p53-related parameters (detectable expression of p53 in tumor cells, high levels of p53m and p53Ab in the circulation), a significantly poorer prognosis was associated with an increase in the number of positive parameters. Analysis of p53 in tumor cells, together with analysis of circulating p53m and p53Ab, could improve the accuracy of prognosis in patients with gastric cancer.

Cisplatin combined with prostaglandin E1 chemotherapy in rat peritoneal carcinomatosis

Cisplatin intraperitoneal (i.p.) chemotherapy is frequently performed for patients with peritoneal carcinomatosis. However, cisplatin penetrates only the surface of the peritoneal tumor and has serious side effects on renal cells. Thus, cisplatin i.p. chemotherapy had been limited to use for these patients. Prostaglandin E1 (PGE1) has been used for reducing the toxic effects of anticancer drugs because of its cytoprotective effects and has been reported to enhance tumoricidal activity of anticancer drugs. In our study, the effects of PGE1 on the rat peritoneal carcinomatosis model treated with cisplatin i.p. chemotherapy were evaluated. Cisplatin (5 mg/kg) was given in an i.p. administration to 70 tumor-free rats. PGE1 was administered to 35 rats through the tail vein at an infusion rate of 0.1 microg/kg/min (1 ml/hr), and the remaining 35 rats were injected with physiological saline. Forty rats were given an i.p. injection of 1 x 10(7) AH100B cells. Ten days after injection, cisplatin (5 mg/kg) was administered with PGE1 to 20 and the remaining 20 were injected with physiological saline. The accumulation of platinum in the tissues and apoptotic renal cells were analyzed. The maximum concentrations of platinum in the kidneys of PGE1 untreated rats (tumor-free: 10.11 microg/g; tumor-bearing: 11.45 microg/g) did not differ from those of platinum in the kidneys of PGE1-treated rats (tumor-free: 10.28 microg/g; tumor-bearing: 13.28 microg/g). The number of apoptotic renal cells was significantly reduced by PGE1 administration in both tumor-free and tumor-bearing rats. Moreover, PGE1 increased the maximum platinum concentration in tumor masses (5.31 microg/g) of the treated group compared with that in tumor mass of the control group (2.72 microg/g, p = 0.009). These results indicate that PGE1 may increase the anticancer effect of cisplatin by increasing tumor platinum concentration and may reduce the chance of cisplatin-induced renal failure. Intraperitoneal cisplatin chemotherapy combined with PGE1 treatment may have a therapeutic benefit for patients with peritoneal carcinomatosis.

Limited operation for patients with T1 esophageal cancer

BACKGROUND/AIMS

Transhiatal esophagectomy without thoracotomy has been introduced as a minimally invasive operation to prevent postoperative complications in patients with relatively early-stage esophageal cancer who have preoperative pulmonary or cardiovascular complications or who are in a high age bracket. However, this procedure for patients with esophageal cancer remains controversial, especially as regards curative surgery because complete intrathoracic lymphadenectomy cannot be performed in this operation. Thus, cancer recurrence after this operation has been considered to be high. To evaluate the benefits of this less invasive surgery for patients with T1 esophageal cancer, the prognoses of patients who underwent transhiatal esophagectomy without thoracotomy were compared with those of patients who underwent traditional esophagectomy with thoracotomy.

METHODS

Between 1989 and 1998, 33 patients with T1 esophageal cancer were operated on in our hospital. We introduced transhiatal esophagectomy without thoracotomy in 19 patients who were over 70 years old or who had preoperative complications (transhiatal group). The remaining 14 patients were treated with the transthoracic procedure (transthoracic group). These 33 patients were followed up at our hospital until the end of 1999. The postoperative complications and prognoses in the two groups were compared.

RESULTS

We were able to reduce the operation time using the transhiatal procedure. Even though no significant difference was detected, there were fewer postoperative pulmonary complications with this procedure (11%) than with the transthoracic procedure (21%). The incidences of in-hospital mortality did not differ between the two groups. Cancer recurrence was detected in 5 of 19 patients (26%) in the transhiatal group and in 5 of 14 patients (36%) in the transthoracic group; no difference was observed (P=0.562). The 5-year survival rate (58%) of the transhiatal group was no different from that of the transthoracic group (62%, P=0.69).

CONCLUSIONS

Complete intrathoracic lymphadenectomy cannot be performed along with transhiatal esophagectomy; however, the prognoses of patients who were treated with this procedure were no different from those of patients who were treated with transthoracic esophagectomy. Thus, transhiatal esophagectomy without thoracotomy might be a justifiable operation for compromised patients with T1 esophageal cancer.

An elevated serum level of transforming growth factor-beta 1 (TGF-beta 1) significantly correlated with lymph node metastasis and poor prognosis in patients with gastric carcinoma

BACKGROUND

Overexpression of transforming growth factor beta s (TGF-beta s), multifunctional polypeptides, have been reported in the tissue of various types of carcinomas, including gastric carcinoma. To our knowledge, serum levels of TGF-beta 1 have not previously been examined in patients with gastric carcinoma as a possible indicator of prognosis.

METHODS

Preoperative serum levels of TGF-beta 1 were measured in 111 patients with gastric carcinoma by an enzyme-linked immunosorbent assay.

RESULTS

An elevated level of TGF-beta 1 was significantly correlated with lymph node metastasis and poor prognosis. Moreover, the preoperative serum levels of TGF-beta 1 in patients with peritoneal recurrence were significantly higher than those in patients both with lymph node recurrence and without recurrence.

CONCLUSION

The serum level of TGF-beta 1 might be useful for predicting recurrence patterns and prognosis in patients with gastric carcinoma.

Nuclear profiles of cancer cells reveal the metastatic potential of gastric cancer

Nuclear profiles have been reported as useful prognostic predictors in various cancers. Data from computerized morphometry are objective and can be quickly derived using conventional microscopic analysis, but image analysis of nuclear features has only rarely been applied to investigations of gastric cancer. The aim of this study was to evaluate the correlation between one of these morphological nuclear features and the clinicopathological parameters in patients with gastric cancer. The morphometric nuclear feature (nuclear area) was analysed in 400 patients with gastric cancer. In each case, 300 cancer nuclei on routine haematoxylin and eosin-stained slides were analysed through the use of a computer-assisted image analysis system which traced the nuclear profiles (magnificationx400) on a computer monitor. The morphometric data were compared with the patients' clinicopathological status and survival rate. The mean nuclear area (NA) of cancer cells from 400 cases of gastric cancer was 47.2 microm(2). The NAs of cancer cells from tumours with microvessel invasion (lymphatic or venous invasion), lymph node metastasis or hepatic metastasis at the time of operation were significantly larger than those of cancer cells from tumours without such invasion or metastases. Cytokeratin (CK) immunostaining was performed on 2577 lymph nodes from 91 patients with advanced gastric cancer (pT3, pN0, pM0, stage II) to detect micrometastases. CK-positive lymph nodes were detected in 350 of 2577 lymph nodes (13. 6%) and in 62 of 91 patients (68.1%). The mean NA of cancer cells from 62 tumours with micrometastases (44 microm(2)) was larger than that of cancer cells from 29 tumours without micrometastases (38.8 microm(2), p=0.043), and a significant positive correlation was detected between the NAs of cancer cells from 91 tumours and the number of micrometastatic lymph nodes of 91 patients (rho=0.278, p=0. 008). Cancer cells with large NA correlated strongly with haematogenous and lymph node recurrence or relapse after gastrectomy and the NA of cancer cells was identified as an independent prognostic factor in gastric cancer. Nuclear morphometry is an objective, reproducible, and technically uncomplicated procedure. The NA of cancer cells correlates closely with the metastatic potential of gastric cancer. Nuclear morphometry may therefore be useful for the selection of patients who are at risk of haematogenous or lymph node metastatic recurrence after surgery.

Nuclear profiles of cancer cells reveal the metastatic potential of gastric cancer

Nuclear profiles have been reported as useful prognostic predictors in various cancers. Data from computerized morphometry are objective and can be quickly derived using conventional microscopic analysis, but image analysis of nuclear features has only rarely been applied to investigations of gastric cancer. The aim of this study was to evaluate the correlation between one of these morphological nuclear features and the clinicopathological parameters in patients with gastric cancer. The morphometric nuclear feature (nuclear area) was analysed in 400 patients with gastric cancer. In each case, 300 cancer nuclei on routine haematoxylin and eosin-stained slides were analysed through the use of a computer-assisted image analysis system which traced the nuclear profiles (magnificationx400) on a computer monitor. The morphometric data were compared with the patients' clinicopathological status and survival rate. The mean nuclear area (NA) of cancer cells from 400 cases of gastric cancer was 47.2 microm(2). The NAs of cancer cells from tumours with microvessel invasion (lymphatic or venous invasion), lymph node metastasis or hepatic metastasis at the time of operation were significantly larger than those of cancer cells from tumours without such invasion or metastases. Cytokeratin (CK) immunostaining was performed on 2577 lymph nodes from 91 patients with advanced gastric cancer (pT3, pN0, pM0, stage II) to detect micrometastases. CK-positive lymph nodes were detected in 350 of 2577 lymph nodes (13. 6%) and in 62 of 91 patients (68.1%). The mean NA of cancer cells from 62 tumours with micrometastases (44 microm(2)) was larger than that of cancer cells from 29 tumours without micrometastases (38.8 microm(2), p=0.043), and a significant positive correlation was detected between the NAs of cancer cells from 91 tumours and the number of micrometastatic lymph nodes of 91 patients (rho=0.278, p=0. 008). Cancer cells with large NA correlated strongly with haematogenous and lymph node recurrence or relapse after gastrectomy and the NA of cancer cells was identified as an independent prognostic factor in gastric cancer. Nuclear morphometry is an objective, reproducible, and technically uncomplicated procedure. The NA of cancer cells correlates closely with the metastatic potential of gastric cancer. Nuclear morphometry may therefore be useful for the selection of patients who are at risk of haematogenous or lymph node metastatic recurrence after surgery.

Combined analysis of p53 and retinoblastoma protein expressions in esophageal cancer

BACKGROUND

p53 gene mutation and abnormal p53 protein expression, also loss of the retinoblastoma gene and protein expression are frequently associated with esophageal squamous cell carcinoma (ESCC). Recently, the prognostic significance of the combined analysis of p53 protein and retinoblastoma protein (pRB) has been reported in non-small cell lung cancer. However, in ESCC, the prognostic significance of the combined analysis of these proteins remains unclear. In this study, we immunohistochemically analyzed the p53 protein and pRB expressions in surgically resected ESCC, and we evaluated the prognostic significance of the combination of these proteins.

METHODS

We analyzed p53 protein and pRB expressions immunohistochemically in 191 surgically resected ESCC cases. Overexpression of p53 and loss of pRB were considered abnormal.

RESULTS

Overexpression of p53 protein was detected in 79 patients (41%) and decreased pRB nuclear staining occurred in 82 (43%). The Kaplan-Meier survival curve showed that absence of pRB expression was significantly associated with shortened survival (p = 0.001), whereas expression of p53 was not significantly associated with survival. Moreover, p53 and pRB status individually were not independent prognostic factors in multivariate survival analysis. With respect to pRB and p53, the tumors could be grouped into four categories: p53-/pRB+ (31%); p53-/pRB- (27%); p53+/pRB+ (26%); and p53+/pRB- (16%). Favorable prognosis was observed in patients with p53-/pRB+ tumors. Multivariate analysis showed p53-/pRB+ status to be an independent prognostic factor.

CONCLUSIONS

The combination of p53 protein loss and pRB expression was associated with good prognosis in patients with ESCC.

Detection of loss of heterozygosityat microsatellite loci in esophageal squamous-cell carcinoma

Microsatellite alterations at 3 genetic loci (chromosomes 2p, 3p and 17p) were analyzed in 25 tumors (20 primary tumors and 5 metastatic lymph nodes) from 20 patients after surgical treatment for esophageal cancer. DNA samples from tumors were compared with control DNA from lymphocytes obtained from the peripheral blood of the individual patients. Microsatellite alterations [microsatellite instability (MSI) and loss of heterozygosity (LOH)] were detected in 15% of 20 primary tumors with marker D2S123 (chromosome 2p), 55% with marker D3S1067 (chromosome 3p) and 50% with marker TP53 (chromosome 17p). The 3-year disease-free survival rate of the 10 patients who had tumors without alterations or with an alteration at only 1 of 3 microsatellite loci was 75% and it was better than that of the 10 patients who had tumors with alterations at 2 or 3 microsatellite loci (48%, p = 0.049). This finding suggests that esophageal cancer with alterations at multiple microsatellite loci might have strong malignant potential. However, MSI was only detected in one of 20 patients, which suggests that MSI might not play an important role in the development of this cancer. Three of 5 metastatic lymph nodes showed no LOH even though primary tumors of these patients exhibited LOH with 1 or 2 markers, and 1 metastatic lymph node had LOH that was detected with D3S1067 even though the primary tumor of this patient had no LOH with all markers. Thus, clonal heterogeneity might exist in esophageal squamous-cell carcinomas.

[Awake pronation of surgical patients with cervical spinal lesions]

Positioning of patients with cervical spinal lesions under general anesthesia may lead to serious neurological complications. The authors attempted awake pronation in eighteen patients to minimize the risks. In all patients, cervical instability or cervical spinal cord compression was diagnosed, and posterior fusion or laminoplasty under general anesthesia was planned. Naso-tracheal intubation was performed by broncho-fiberoptic scope under topical anesthesia and light sedation. After tracheal intubation, pronation was completed while patients were still awake. Twelve patients could change their position almost by themselves, and needed only a little assistance of the medical staff. After the patients settled in appropriate position, general anesthesia was induced. Neurological status was assessed before and after the intubation, and just before the induction of general anesthesia, to prove the absence of complications. Operations were accomplished without major troubles in all patients. During post anesthetic interviews, eight patients had memory of the positioning, but none of them had any complaints about the procedure. Awake pronation may be useful to minimize the risk of neurological complications related to positioning of surgical patients, and also need less assistance by medical staff.

Nuclear accumulation of p53 protein in gastric cancer strongly correlates with enlargement of nuclear area of cancer cells

The nuclear area (NA) of cancer cells have been reported to be a useful prognostic indicator in various tumors. However, this image analysis of cancer nucleus has only rarely been applied to gastric adenocarcinoma. Moreover, it remains to be shown what types of biological factors influence this nuclear feature. In this study, we analyzed the area of cancer nuclei in tumors from 97 patients with advanced gastric cancer (t3, n0, stage II) by using hematoxylin and eosin stained slides with a computer-assisted image-analysis system. The morphometric data were compared with clinicopathological and biological status of the tumors. The mean NA of 50 tumors with venous invasion (50 microm2) was significantly larger than that of 47 tumors without venous invasion (38 microm2, p<0.0001). There was a significant correlation between the NAs of cancer cells and the p53 labeling indices of tumors (p=0.0012) and Ki-67 labeling indices of tumors (p=0.0324). However, no significant correlation was detected between the NAs of cancer cells and other factors, such as, tumor size, DNA ploidy pattern, expression of vascular endothelial growth factor (VEGF), or microvessel density of tumors. The five-year survival rate of 49 patients with large nuclear area (NA > or =41 microm2, 63%) was significantly lower than that of 48 patients with small nuclear area (NA <41 microm2, 78%, p=0.043). Data from computerized morphometry are objective and can be obtained rapidly by conventional microscopic analysis. The NA of cancer cells in advanced gastric cancer appears to predict the ability to invade the microvessels in the gastric wall. This nuclear morphological feature strongly correlated with p53 accumulation in the nuclei of gastric adenocarcinoma.

Pharmacokinetics of hypotonic cisplatin chemotherapy administered into the peritoneal and the pleural cavities in experimental model

The pharmacokinetics of intraperitoneal (i.p.) and intrapleural (i.pl.) hypotonic cisplatin (CDDP) were compared under the same experimental conditions. The same dose of CDDP was administered in hypotonic (62 mOsm/L) and isotonic (308 mOsm/L) solutions to the peritoneal and pleural cavities of Ehrlich carcinoma cell bearing mice. The intracellular amount of platinum increased for more than 60 minutes after an i.pl. injection of the hypotonic solution of CDDP, whereas it increased for up to 30 minutes after an i.p. injection. Although hypotonic conditions augmented the amount of platinum taken-up by Ehrlich cells, the amount was significantly greater in the pleural cavity than in the peritoneal cavity. In Donryu rats, the levels of platinum in the i.p. and i.pl. fluids decreased rapidly after injection of hypotonic solution as compared with isotonic solution. The extent of this decrease was greater in the peritoneal cavity than in the pleural cavity. In the hypotonic condition, the area under the curve of concentration versus time (AUC) for platinum of i.pl. fluid was greater than that of i.p. fluid. When i.p. and i.pl. hypotonic CDDP were administered, the osmolarity of the fluid returned rapidly to the isotonic level, with equilibration in 30 or 180 minutes respectively. The lower osmolarity continued for a longer duration in the pleural cavity than in the peritoneal cavity. These results indicate that the pleural cavity may require a smaller amount of CDDP to achieve the same effect on intracellular uptake of platinum than the peritoneal cavity.

Clinical significance of retinoblastoma protein (pRB) expression in esophageal squamous cell carcinoma

BACKGROUND AND OBJECTIVES

The goal was to evaluate the clinicopathological significance of retinoblastoma gene product (pRB) expression in esophageal squamous cell carcinoma.

METHODS

We investigated abnormal pRB expression in tumors in 191 patients using an immunohistochemical method in conjunction with anti-RB protein antibody. Surgically resected esophageal squamous cell carcinomas were examined by immunohistochemical analysis for altered pRB expression.

RESULTS

Decreased pRB nuclear staining indicating loss of RB function occurred in 82 (43%) of the cases studied. The incidence of decreased pRB expression was higher in tumors with invasion to the adventitia (50%) than in tumors without invasion to the adventitia (33%, P = 0.0188). In addition, the incidence of decreased pRB expression was higher in tumors with lymph node metastasis (50%) than in those without (34%, P = 0.0346). The 3-year survival rates of 82 patients who had tumors with decreased pRB expression (30%) was significantly lower than that of 109 patients who had tumors with normal pRB expression (52%, P = 0.0032). However, in the multivariate survival analysis, pRB expression was not an independent prognostic factor for patients with esophageal squamous cell carcinoma.

CONCLUSIONS

Abnormal pRB expression appears to be closely associated with tumor development. However, the existence of tumors with hyperphosphorylated RB protein (inactivated form) in pRB-positive tumors, such as those in the present study, should be considered. Thus, discrimination of this hyperphosphorylated form of RB protein from the unphosphorylated RB protein is needed.

Prognostic benefit of extended radical lymphadenectomy for patients with gastric cancer

BACKGROUND

The therapeutic value of extensive gastric lymphadenectomy in gastric cancer is controversial. We retrospectively investigated the effect of extended lymphadenectomy on survival in 882 patients with gastric cancer.

MATERIALS AND METHODS

From 882 patients who underwent gastrectomy, D0 or D1 lymphadenectomy was performed on 137 patients, D2 lymphadenectomy on 524 and D3 lymphadenectomy on 221. Curative gastrectomy was performed on 771 patients and the 5-year survival rate of patients had undergone D0 or D1 lymphadenectomy (D1 group) and that of patients who had undergone D2 lymphadenectomy (D2 group) was compared with that of patients had undergone D3 lymphadenectomy (D3 group).

RESULTS

In each stage, the 5-year survival rates of patients who had undergone curative operations (n = 771) were compared among the D1, D2 and D3 groups. The 5-year survival rates were as follows: Stage I: n = 510, 89.3% (D1 group: n = 91, 85.8%; D2 group: n = 384, 90.3%; D3 group: n = 35, 88.1%; p = 0.539), Stage II: n = 83, 77.8% (D2 group: n = 35, 82.7%; D3 group: n = 48, 74.3%; p = 0.601), Stage III: n = 133, 50.2% (D2 group: n = 46, 39%; D3 group: n = 87, 56.1%; p = 0.027), Stage IV: n = 45, 8.9% (D2 group: n = 10, 0%; D3 group: n = 35, 11.4%; p = 0.588). Postoperative complications were detected in 10.4% of the cases and the in-hospital mortality rate was 2.4%. The postoperative morbidity rate of the D3 group (15.8%) was significantly higher than that of the other groups (D1 group: 7.3% and D2 group: 9%; p = 0.008). However, the in-hospital mortality rate of the D3 group (1.4%) was not different from that of the other groups (D1 group: 3.7% and D2 group: 2.5%; p = 0.374).

CONCLUSION

These results indicate that D3 lymphadenectomy might be performed as safely as D1 or D2 lymphadenectomy on patients with gastric cancer. In addition, D3 lymphadenectomy might provide a survival benefit for patients with Stage III or Stage IV gastric cancer.

Clinical significance of retinoblastoma protein (pRB) expression in esophageal squamous cell carcinoma

BACKGROUND AND OBJECTIVES

The goal was to evaluate the clinicopathological significance of retinoblastoma gene product (pRB) expression in esophageal squamous cell carcinoma.

METHODS

We investigated abnormal pRB expression in tumors in 191 patients using an immunohistochemical method in conjunction with anti-RB protein antibody. Surgically resected esophageal squamous cell carcinomas were examined by immunohistochemical analysis for altered pRB expression.

RESULTS

Decreased pRB nuclear staining indicating loss of RB function occurred in 82 (43%) of the cases studied. The incidence of decreased pRB expression was higher in tumors with invasion to the adventitia (50%) than in tumors without invasion to the adventitia (33%, P = 0.0188). In addition, the incidence of decreased pRB expression was higher in tumors with lymph node metastasis (50%) than in those without (34%, P = 0.0346). The 3-year survival rates of 82 patients who had tumors with decreased pRB expression (30%) was significantly lower than that of 109 patients who had tumors with normal pRB expression (52%, P = 0.0032). However, in the multivariate survival analysis, pRB expression was not an independent prognostic factor for patients with esophageal squamous cell carcinoma.

CONCLUSIONS

Abnormal pRB expression appears to be closely associated with tumor development. However, the existence of tumors with hyperphosphorylated RB protein (inactivated form) in pRB-positive tumors, such as those in the present study, should be considered. Thus, discrimination of this hyperphosphorylated form of RB protein from the unphosphorylated RB protein is needed.

Micrometastasis in lymph nodes and microinvasion of the muscularis propria in primary lesions of submucosal gastric cancer

BACKGROUND

It is important to clarify the clinicopathologic characteristics of micrometastasis in lymph nodes and microinvasion in primary lesions for the treatment options with regard to submucosal gastric cancer.

METHODS

We examined 1945 lymph nodes and 68 primary tumors resected from 79 patients with submucosal gastric cancer. Two consecutive sections were prepared for simultaneous staining with ordinary hematoxylin and eosin and immunostaining with anticytokeratin antibody (CAM 5.2), respectively.

RESULTS

The incidence of nodal involvement in 79 patients with submucosal gastric cancer increased from 13% (10/79 patients) by hematoxylin and eosin staining to 34% (27/79 patients) by cytokeratin immunostaining. Micrometastases in the lymph nodes were found in 17 of 69 patients (25%), with cancer-free nodes examined by hematoxylin and eosin. Microinvasion to the muscularis propria was found in 11 of 68 patients (16%) who were histologically diagnosed with submucosal gastric cancer. Survival analysis demonstrated a lesser 5-year survival in the patients with micrometastasis in lymph nodes (82%) and with microinvasion to muscularis propria (73%). A high incidence of nodal involvement was found in submucosal cancers of large size (> 2 cm; 43%), a depressed type (48%), lymphatic invasion (73%), and deeper submucosal invasion (submucosal 3, 53%). A higher incidence of microinvasion was found with the diffuse-type carcinoma (33%).

CONCLUSIONS

Cytokeratin immunostaining is useful for detecting micrometastasis and microinvasion in submucosal gastric cancer. Tumor size, macroscopic type, lymphatic invasion, and the depth of submucosal invasion are strongly associated with lymph node involvement.

Detection of telomerase activity in esophageal squamous cell carcinoma and normal esophageal epithelium

BACKGROUND/AIMS

Relatively little has been reported about the telomerase activity of esophageal squamous cell carcinoma or normal esophageal epithelium. In this study, we have evaluated whether telomerase activity is a useful marker for detecting malignancies in the esophagus.

PATIENTS/METHODS

Esophageal carcinomas and normal esophageal tissues adjacent to carcinomas were obtained from 52 surgically treated, unselected patients, and normal esophageal epithelium from 11 non-cancerous patients were obtained by means of biopsy. The telomeric repeat amplification protocol (TRAP) assay was used for detection of telomerase activity in these samples. The incidence of detection of telomerase activity in esophageal carcinoma was compared with that of telomerase activity in normal esophageal epithelium. Moreover, the clinicopathological characteristics of telomerase-positive tumors were compared with those of telomerase-negative tumors.

RESULTS

Of the 52 carcinomas, 40 (77%) had detectable telomerase activity. However, telomerase activity was detected in 45 of 52 (87%) normal tissue samples adjacent to carcinomas and in 8 of 11 (73%) normal esophageal epithelium from non-cancerous patients. In esophageal cancer, no significant difference was detected in the clinicopathological findings between the telomerase-positive and -negative cases.

CONCLUSION

These results indicate that not only esophageal squamous cell carcinomas but also normal esophageal epithelium show strong telomerase activity. Thus, telomerase activity may not be a good marker for the detection of carcinoma in the esophagus.

The expression of transforming growth factor-beta1 is significantly correlated with the expression of vascular endothelial growth factor and poor prognosis of patients with advanced gastric carcinoma

BACKGROUND

Transforming growth factors beta (TGFs beta) are involved in a variety of important cellular functions, including cell growth and differentiation, adhesion, migration, extracellular matrix formation, and immune function. Moreover, it has been reported that TGFs beta are correlated with angiogenesis. However, the role of TGF-beta as an angiogenic factor in gastric carcinoma is still unclear.

METHODS

TGF-beta1 expression was determined in 101 patients with gastric carcinoma by immunohistochemical procedures, and this expression was compared in the current study with both the expression of vascular endothelial growth factor (VEGF), which is thought to be the most potent angiogenic factor, and microvessel density, to evaluate the effect of TGF-beta1 on the angiogenesis of gastric carcinoma tissues.

RESULTS

TGF-beta1 expression was detected in 23 tumors (22.8%). TGF-beta1 expression was more frequent in differentiated than in undifferentiated gastric carcinoma. Furthermore, TGF-beta1 expression was significantly correlated with the depth of invasion and the stage of disease. There was a close correlation between TGF-beta1 expression and VEGF expression. There was no correlation between TGF-beta1 expression and microvessel density, whereas VEGF expression was significantly correlated with microvessel density. With regard to prognosis, the 5-year survival rate was 55.9% for patients with TGF-beta1 positive tumors and 67.0% in patients with TGF-beta1 negative tumors. Accordingly, the prognosis for patients with TGF-beta1 negative tumors was significantly better than that for patients with TGF-beta1 positive tumors. Multivariate analysis indicated that lymph node metastasis, tumor size, and TGF-beta1 expression were independent prognostic factors.

CONCLUSIONS

These results suggest that TGF-beta1 might be associated with tumor progression by indirectly stimulating angiogenesis through the up-regulation of VEGF expression in gastric carcinoma.

Immunohistochemical detection of occult metastases in paraaortic lymph nodes in advanced gastric cancer

Some Japanese surgeons have examined the utility of super-extended paraaortic lymphadenectomy (PAL) as part of the surgical treatment for advanced gastric cancer. However, therapeutic value of this PAL remains controvertial. The purpose of this study was to evaluate appropriate candidates who might benefit from PAL by the immunostaining with cytokeratin (CK) of the macroscopically intact paraaortic nodes. A total of 525 paraaortic nodes from 35 patients was serially sectioned and stained with hematoxylin-eosin (H&E) and CK staining. A total of 17 nodes (3.2%) from 7 patients (20.0%), among 525 macroscopically intact paraaortic nodes, was determined to be immunopositive for CK. In 4 patients, 8 H&E-positive nodes with metastases were all immunopositive and, in addition, 4 H&E-negative nodes were also immunopositive. Furthermore, 3 patients with H&E-negative nodes had five immunopositive nodes. Immunostaining with CK was useful for detection of occult metastases. Survival was prolonged in 3 of these 7 patients. The incidence of CK-positive nodes was significantly higher in patients with gross type of 3 or 4 gastric cancer and in patients with H&E-detected nodal metastasis within group 3 (N3) nodes. It seems that such patients would benefit from prophylactic PAL.

The expression of transforming growth factor-beta1 is significantly correlated with the expression of vascular endothelial growth factor and poor prognosis of patients with advanced gastric carcinoma

BACKGROUND

Transforming growth factors beta (TGFs beta) are involved in a variety of important cellular functions, including cell growth and differentiation, adhesion, migration, extracellular matrix formation, and immune function. Moreover, it has been reported that TGFs beta are correlated with angiogenesis. However, the role of TGF-beta as an angiogenic factor in gastric carcinoma is still unclear.

METHODS

TGF-beta1 expression was determined in 101 patients with gastric carcinoma by immunohistochemical procedures, and this expression was compared in the current study with both the expression of vascular endothelial growth factor (VEGF), which is thought to be the most potent angiogenic factor, and microvessel density, to evaluate the effect of TGF-beta1 on the angiogenesis of gastric carcinoma tissues.

RESULTS

TGF-beta1 expression was detected in 23 tumors (22.8%). TGF-beta1 expression was more frequent in differentiated than in undifferentiated gastric carcinoma. Furthermore, TGF-beta1 expression was significantly correlated with the depth of invasion and the stage of disease. There was a close correlation between TGF-beta1 expression and VEGF expression. There was no correlation between TGF-beta1 expression and microvessel density, whereas VEGF expression was significantly correlated with microvessel density. With regard to prognosis, the 5-year survival rate was 55.9% for patients with TGF-beta1 positive tumors and 67.0% in patients with TGF-beta1 negative tumors. Accordingly, the prognosis for patients with TGF-beta1 negative tumors was significantly better than that for patients with TGF-beta1 positive tumors. Multivariate analysis indicated that lymph node metastasis, tumor size, and TGF-beta1 expression were independent prognostic factors.

CONCLUSIONS

These results suggest that TGF-beta1 might be associated with tumor progression by indirectly stimulating angiogenesis through the up-regulation of VEGF expression in gastric carcinoma.

The expression of thymidine phosphorylase correlates with angiogenesis and the efficacy of chemotherapy using fluorouracil derivatives in advanced gastric carcinoma

The expression of thymidine phosphorylase (TP) and the density of microvessel in advanced gastric carcinoma were examined by immunohistochemistry to evaluate the significance of TP. The expression of TP was negative in 72 cases, positive in 54. The microvessel density correlated with the expression of TP. In total cases, patients with TP-positive tumours survived longer than those with TP-negative tumours. In patients treated with fluorouracil derivatives (FUs), the expression of TP significantly correlated with favourable prognosis and with unfavourable prognosis in those not treated with FUs. The patients with TP-positive tumours, the prognosis of patients treated with FUs was significantly better than that of those not treated with FUs. In patients with TP-positive tumours, treatment with FUs and lymph node metastasis were independent prognostic factors according to the Cox proportional hazards model. Depth of invasion and lymph node metastasis were independent prognostic factors in patients with TP-negative tumours. The determination of the expression of TP might be useful for predicting the efficacy of post-operative chemotherapy using FUs to prevent recurrence in advanced gastric carcinoma patients who undergo curative gastrectomy.

The expression of thymidine phosphorylase and its correlation with angiogenesis in gastric adenocarcinoma

BACKGROUND

It has been recently reported that thymidine phosphorylase (dThdPase) is identical to platelet-derived endothelial cell growth factor (PD-ECGF). dThdPase is known to be one of the angiogenic factors. Expression of dThdPase has been detected both in cancer cells and in stroma cells. However, the role of dThdPase, in cancer cells and in stroma cells regarding, neovascularization in gastric adenocarcinoma is still unclear. In this study, we analyzed the correlation between dThdPase activity and neovascularization in gastric cancer.

MATERIALS AND METHODS

We obtained fresh samples (tumors and adjacent normal mucosas) from 67 patients with gastric cancer who underwent gastrectomy between 1993 and 1994. The dThdPase activity was analyzed by the ELISA (enzyme-linked immunosorbent assay) method and by the immunohistochemical staining. Microvessel density (MVD) and vascular endothelial growth factor expression of tumors were analyzed by immunohistochemical staining.

RESULTS

The dThdPase activity of tumors (117 +/- 98 U/mg protein) was significantly higher than that of normal mucosas (46 +/- 36 U/mg protein, P < 0.0001). The expression of dThdPase was detected by immunostaining in stroma cells but not in mucosal cells in normal tissues. Based on the immunostaining results, 16 tumors expressed dThdPase both in cancer cells and stroma cells. The mean dThdPase activity and the mean MVD of these 16 tumors were significantly higher than those of 15 tumors with expression of dThdPase only in the stroma cells, and than those of 36 tumors with expression of dThdPase in neither the cancer cells or the stroma cells. The MVD of tumors strongly correlated with the dThdPase activity of tumors detected by the ELISA method (P < 0.0001).

CONCLUSIONS

The total amount of dThdPase produced by cancer cells and stroma cells may influence tumor angiogenesis in gastric cancer.

Neoangiogenesis and relationship to nuclear p53 accumulation and vascular endothelial growth factor expression in advanced gastric carcinoma

Recent studies have shown that tumor suppressor genes, particularly p53, may play a crucial regulatory role in the control of angiogenesis. Accordingly, we analyzed the correlation between p53 accumulation and the expression of vascular endothelial growth factor (VEGF) and microvessel counts in a series of human gastric adenocarcinomas by immunohistochemical staining. p53 expression was absent in 35 cases (29.7%), weak in 34 cases (28.8%), moderate in 35 cases (29.7%), and strong in 14 cases (11.8%). The prognosis of patients with both absent and weak expression of p53 was significantly better than that of patients with both moderate and strong expression of p53. VEGF expression was significantly associated with increased p53 expression. Moreover, increasing expression of p53 significantly correlated with an increase in microvessel counts. Nuclear p53 accumulation may correlate with tumor angiogenesis through VEGF upregulation in gastric carcinomas.

Clinical significance of the detection of thymidine phosphorylase activity in esophageal squamous cell carcinomas

In this study, we obtained fresh samples of tissue (tumors, adjacent normal mucosas, and metastatic lymph nodes) from 64 patients (metastatic lymph nodes were obtained from 16 patients) with esophageal cancer who underwent esophagectomy between 1993 and 1998. The thymidine phosphorylase (dThdPase) levels of tumors as determined by the ELISA method were compared with clinicopathological findings of tumors and were evaluated for their usefulness as a prognostic parameter for these patients. The dThdPase levels of tumors (221 +/- 21 U/mg protein) and metastatic lymph nodes (253 +/- 51 U/mg protein) were significantly higher than the dThdPase level of normal mucosas (53 +/- 7 U/mg protein, p < 0. 001). The dThdPase levels of tumors did not correlate with the histopathological grading of tumors, the depth of tumor invasion, and lymph node metastasis. The 3-year survival rate of 32 patients with a high level of dThdPase (42%) was not different from that of 32 patients with a low level of dThdPase (52%, p = 0.267). Moreover, the dThdPase level of tumors was not an independent prognostic factor for patients with esophageal cancer. These findings suggest that the level of dThdPase activity in esophageal cancers may not correlate with tumor progression and may not be a useful prognostic marker for patients with esophageal squamous cell carcinoma.

Administration in a hypotonic solution is preferable to dose escalation in intraperitoneal cisplatin chemotherapy for peritoneal carcinomatosis in rats

An animal model of intraperitoneal (i.p.) cisplatin chemotherapy using hypotonic solutions of sodium chloride has been developed as a treatment for peritoneal carcinomatosis. The concentrations of platinum in the plasma and in the i.p. fluid of Donryu rats were measured after i.p. injection of hypotonic (103 or 154 mosm/l) and isotonic (308 mosm/l) solutions that contained an equal amount of cisplatin. The maximum concentration (Cmax) and the area under the curve of concentration versus time (AUC) of platinum in the plasma increased proportionately with increases in the dose of cisplatin and they were significantly higher in rats given cisplatin in hypotonic solutions than in those given the drug in isotonic solution. The Cmax and AUC of total platinum were similar for the solution of 103 mosm/l with 2.5 mg/kg cisplatin and the isotonic solution with 5.0 mg/kg cisplatin. The Cmax and AUC of free platinum in the plasma did not increase with increases in the dose of cisplatin in isotonic solution but did increase after hypotonic injection. However, the solutions of lower osmolarity gave a decreased AUC of platinum in the i.p. fluid. Hypotonic conditions continued for 30 min at most after i.p. injection of hypotonic solutions. When the same dose of cisplatin was given to rats with tumors derived from AH100B carcinoma cells, the amount of platinum taken by i.p. solid tumors from the solution of 103 mosm/l was about twice that from the isotonic solution and was much the same as that taken up from the isotonic solution with twice the amount of cisplatin. These results indicate that hypotonic i.p. cisplatin chemotherapy might be preferable to escalation of the dose of i.p. cisplatin in the treatment of peritoneal carcinomatosis.

Mutated p53 protein expression and proliferative activity in advanced gastric cancer

BACKGROUND/AIMS

When the DNA of cells is damaged, wild-type p53 protein induces the expression of p21 (Waf1/Cip1/Sdi1), and regulates the progression of the cell cycle by inducing G1 arrest. Thus, wild type p53 or p21 protein negatively regulates cancer cell proliferation. However, in tumor with loss of expression of functional wild-type p53 protein by mutation or allelic deletion of the gene for p53, whether the proliferative activity of cancer cells might be accelerated or not is unclear. In this study, we investigated the correlation between the level of expression of mutated p53 protein and the proliferative activity of cancer cells in advanced gastric cancer.

METHODOLOGY

Ninety-seven samples from patients with gastric cancer that had invaded the serosa without lymph node metastasis (t3, n0, stage II) were investigated by immunohistochemical staining with a monoclonal antibody against p53 and against p21, and with the monoclonal antibody Ki-67. DNA ploidy patterns were analyzed by flow cytometry. The immunoreactivity against p53 and the proliferative activity of cancer cells were scored in terms of a labeling index (LI; percentage of immunostained cells) in each case. Moreover, the prognostic values for 93 surviving patients were evaluated by univariate and multivariate analysis.

RESULTS

The mean p53 LI was 24% (range: 0-82.4%) and the mean Ki-67 LI was 23.1% (range: 0-70.7%) in 97 tumors. The expression of p21 protein was detected in 30 of 97 tumors (30.9%) and DNA aneuploidy was detected in 36 of 97 tumors (37.1%). There was significant correlation between the p53 LI and the Ki-67 LI (r = 0.61, t = 7.456, p < 0.001) in 97 tumors. Although, no significant difference was detected, the mean p53 LI (18.3%) of 30 tumors with expression of p21 protein was lower than that of 67 tumors without expression of p21 protein (26.6%, p = 0.096). However, no significant correlation between expression of p21 protein and Ki-67 LI was observed. The p53 LI was not an independent prognostic factor in 93 surviving patients by multivariate survival analysis (p = 0.069). However, the 5-year survival rate of 50 patients with a low level of p53 LI (p53 LI (< or = 10%, 78.3%) was significantly better than that of 43 patients with a high level of p53 LI (p53 LI > 10%, 62.1%, p = 0.045).

CONCLUSIONS

Accumulation of mutated p53 protein might suppress the expression of p21 protein in gastric adenocarcinoma, and cancer cells with overexpression of mutated p53 protein might have a high proliferative activity.

Clinical significance of spontaneous apoptosis in advanced gastric adenocarcinoma

BACKGROUND

Spontaneous apoptosis has been detected in gastric carcinoma. However, the clinicopathological significance of this remains unclear. The objective of this study was to investigate the correlation between spontaneous apoptosis and the clinicopathologic and biologic characteristics of advanced gastric carcinoma. In addition, the prognostic significance of spontaneous apoptosis of tumors was evaluated.

METHODS

The occurrence of apoptotic cell death (apoptotic index [AI]) in 97 patients with advanced gastric carcinoma was analyzed by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick end labeling method. The Ki-67 labeling index (LI), expression of p53 and p21, DNA ploidy pattern, microvessel density (MVD), density of dendritic cells (DCs) in tumors, and degree of lymphocytic infiltration (LI) of the tumors were compared with the AI for each patient. In addition, the prognostic significance of AI was evaluated in these patients.

RESULTS

The mean AI of the 97 tumors was 2.05% (range, 0-11.31%). Statistical analyses revealed significant correlations between the AIs and the Ki-67 LIs (P = 0.0004) and between the AIs and the density of DCs (P = 0.0007), as well as an inverse correlation between the AIs and the intratumoral MVD (P = 0.0064). In addition, the AI of 47 tumors with high grade LI (2.94+/-2.51%) was significantly higher than that of 50 tumors with low grade LI (1.22+/-0.93%) (P<0.0001). However, the authors failed to find a significant correlation between the AIs and expression of p53 and p21 and the DNA ploidy pattern. In 93 surviving patients, the 5-year survival rate of 45 patients who had tumors with high AIs (> or =1.47; 82%) was significantly better than that of 48 patients who had tumors with low AIs (<1.47; 60%) (P = 0.0264).

CONCLUSIONS

The findings of the current study suggest that the tumors with low neovascularization and high local immunoreactivity may regulate their progression by apoptosis. Moreover, less extensive apoptosis in gastric adenocarcinoma may contribute to disease progression and could be correlated with a poorer prognosis.

De-epithelialised anterior (anterolateral and anteromedial) thigh flaps for dead space filling and contour correction in head and neck reconstruction

Anterior (anterolateral and anteromedial) thigh flaps based on the descending branch of the lateral circumflex femoral vessels provide a long vascular pedicle and a large flap without sacrificing main vessels and muscles. Twenty-eight de-epithelialized anterior thigh flaps were transferred for reconstruction of head and neck defects following tumour ablation. Two flaps were lost in patients that had previously undergone high-dose radiotherapy following free tissue transfer. Vascularised fibula, vascularised iliac bone and other tissues were combined with anterior thigh flaps in 13 cases utilising the distal end or derivative branches of the vascular pedicle. Salivary fistula was seen in only one case, although there were many minor and major complications. In five cases, double skin flaps were harvested from the ipsilateral thigh. One of these flaps was used for coverage of intraoral defects, while the other was placed in the submandibular area to fill dead space. Compared with other methods, this multi-flap method is considered to be most suitable for dead space filling and contour correction.

The expression of vascular endothelial growth factor and proliferative activity of cancer cells in gastric cancer

BACKGROUND/AIMS

Vascular endothelial growth factor (VEGF) is one of the most important factors for angiogenesis in various malignant tumors. However, the clinicopathological and biological significance of the expression of VEGF in gastric cancer remains unclear. In this study, we investigated the relationship between the expression of VEGF and the clinicopathological and biological status of advanced gastric cancer, all of the same stage.

PATIENTS/METHODS

The expression of VEGF was immunohistochemically examined using the polyclonal antibody A-20 in tumors from 97 patients with invasion of the serosa but no lymph-node metastasis (t3, n0, stage II). The results were compared with clinicopathological and biological status (microvessel density and proliferative activity) of tumors.

RESULTS

Expression of VEGF was detected in 27 of 97 tumors (28%). The mean microvessel density (MVD) of 27 VEGF-positive tumors (458/mm2) was higher than that of 70 VEGF-negative tumors (331/mm2, P=0.0001). However, the proliferative activity expressed as the Ki-67 labeling index (LI; percentage of immunostained cancer cells) of 27 VEGF-positive tumors (13.8%) was significantly lower than that of 70 VEGF-negative tumors (26.7%, P=0.0002). In 48 tumors with low proliferative activity of cancer cells (Ki-67 LI < or =18%), 20 (42%) tumors expressed VEGF, and these tumors had a high MVD (4461/mm2). In the 93 surviving patients, the 5-year survival rate of the 25 patients with VEGF-positive tumors (64%) was not different from that of the 68 patients with VEGF-negative tumors (73%, P=0.4296).

CONCLUSION

Advanced gastric carcinoma with low proliferative activity may produce VEGF and may have high angiogenic potential in order for the tumor itself to grow. However, the prognosis of patients with such tumors was not unfavorable.

Soluble CD44 variant 6 as a prognostic indicator in patients with colorectal cancer

The expression of CD44v6 is well known as a useful marker of tumor progression and prognosis in colorectal cancer. In this study, we evaluated the serum levels of soluble CD44 splice variants containing exon v6 (sCD44v6) and examined the histological expression of CD44v6 in patients with colorectal cancer. Serum samples were obtained from 44 primary colorectal cancer patients before surgery. We used enzyme-linked immunosorbent assay to determine the serum levels of sCD44v6. The expression of CD44v6 was examined by immunohistochemical staining of the primary tumors obtained from the same patients. Both the serum concentration of sCD44v6 and the expression of CD44v6 were significantly associated with lymph node metastasis (p < 0.05). Furthermore, the serum level of sCD44v6 was higher in those patients with CD44v6-positive tumor tissues (154.4 +/- 34.8 ng/ml) than in those with CD44v6-negative ones (130.7 +/- 32.3 ng/ml; p < 0.05). The 5-year survival rate was significantly lower in patients with high serum levels of sCD44v6 (52.4%) than in those with low levels of sCD44v6 (78.0%; p < 0.05), and it was also significantly lower in patients with CD44v6-positive cancer (42.1%) than in those with CD44v6-negative cancer (84%; p < 0. 01). We concluded that preoperative elevation in the serum levels of sCD44v6 might be a prognostic indicator for patients with colorectal cancer.

Serum level of a soluble receptor for interleukin-2 as a prognostic factor in patients with gastric cancer

Increased levels of a soluble receptor for interleukin-2 (sIL-2R) have been found in the serum from patients with a variety of malignancies. Levels of sIL-2R have not previously been examined in a large group of patients with gastric cancer as a possible indicator of prognosis. Serum levels of sIL-2R were measured preoperatively by an enzyme-linked immunosorbent assay in 121 patients with gastric cancer. The preoperative levels of sIL-2R in patients with gastric cancer were significantly higher than those in normal controls. An elevated level of sIL-2R was significantly correlated with certain clinicopathologic features, which included depth of invasion, lymph node metastasis, lymphatic vessel invasion, blood vessel invasion and clinical stage. The postoperative survival time of patients with elevated levels of sIL-2R was significantly shorter than that of patients with normal levels. Furthermore, a multivariate analysis using Cox's proportional hazards model showed that the combination of levels of carcinoembryonic antigen and sIL-2R was an independent indicator of prognosis. Thus, the serum level of sIL-2R might be a useful prognostic indicator in patients with gastric cancer.

Less invasive surgery for early gastric cancer based on the low probability of lymph node metastasis

BACKGROUND

Less invasive treatment is the current trend in many surgical fields. Most patients with early gastric cancer do not have lymph node metastasis. Thus extensive resection of the stomach and extended lymph node dissection do not appear to be necessary.

METHODS

In a retrospective study, 890 consecutive patients with early gastric cancer who had undergone standard gastrectomy were assessed for depth of invasion, gross appearance, and maximum diameter of the tumor to examine the possibility of limiting the extent of lymph node dissection. A variety of limited gastrectomies have been developed and now include endoscopic mucosal resection, wedge resection, segmental gastrectomy, limited proximal gastrectomy, and distal hemigastrectomy.

RESULTS

A retrospective study revealed that extensive lymph node dissection did not improve the survival of patients with early gastric cancer. Endoscopic mucosal resection was suitable for cancers of the depressed type of less than 1 cm in diameter and the elevated type of less than 2 cm in diameter. Wedge, segmental, or limited proximal gastrectomy was suitable for the elevated type of 2 to 3 cm in diameter. The elevated type of more than 3 cm in diameter and the depressed type of 1 to 3 cm in diameter sometimes involved metastasis to group 1 nodes. The depressed type of more than 3 cm in diameter sometimes involved metastasis to group 2 nodes. Thus such cases should be treated by gastrectomy with dissection of potentially metastatic lymph nodes.

CONCLUSIONS

Limitation of the extent of gastrectomy and lymph node dissection may be possible, depending on the gross appearance and size of the tumor.

Expression of vascular endothelial growth factor correlates with hematogenous recurrence in gastric carcinoma

BACKGROUND

It has recently been reported that the microvessel density in a tumor correlates with hematogenous metastasis in gastric carcinoma. The aim of this study was to evaluate the relationship between the expression of vascular endothelial growth factor (VEGF), which was thought to be a potent angiogenesis-promoting factor, and hematogenous recurrence in advanced gastric carcinoma.

METHODS

The expression of VEGF and the density of the microvessels were examined by immunohistochemistry in patients with advanced gastric carcinoma with serosal invasion who had undergone curative resection.

RESULTS

The prognosis of patients with a VEGF-negative tumor was significantly better than that of patients with a VEGF-positive tumor. Multivariate analysis by Cox proportional hazards model showed that the expression of VEGF was an independent prognostic indicator. The expression of VEGF provided a significant estimate of relative risk for the development of hematogenous recurrence by multivariate logistic regression analysis. The microvessel count in VEGF-positive tumors was significantly higher than that in VEGF-negative tumors.

CONCLUSIONS

VEGF is associated with hematogenous recurrence. Assessment of the expression of VEGF may therefore prove valuable in identifying patients with gastric carcinoma at high risk for recurrence who would benefit from adjuvant therapy.

A prospective pilot study of extended (D3) and superextended para-aortic lymphadenectomy (D4) in patients with T3 or T4 gastric cancer managed by total gastrectomy

BACKGROUND

Japanese surgeons have been actively performing extended lymphadenectomy (D2, removal of perigastric nodes and nodes along the left gastric, common hepatic, celiac and splenic arteries; or D3, D2 plus removal of nodes in the hepatoduodenal ligament, in the retropancreatic space and along the vessels of the transverse mesocolon). In recent years interest has expanded to superextended lymphadenectomy (D4) of nodes around abdominal aorta (para-aortic lymph nodes from aortic hiatus to aortic bifurcation). Because the therapeutic value of this D4 procedure remains controversial, we initiated a prospective study to compare D3 and D4 lymphadenectomy.

METHODS

Seventy patients with T3 or T4 gastric cancer and without macroscopic metastasis to the para-aortic nodes treated by potentially curative total gastrectomy were randomized to D4 (group A, n = 35) and D3 (group B, n = 35) lymphadenectomies.

RESULTS

Metastases to para-aortic nodes were found in 4 patients. Postoperative survival after D4 resection was not statistically significant between the groups. Postoperative morbidity for group A was greater. In group A 4 patients had postoperative retention of intra-abdominal fluid (lymphorrhea) and 4 others had prolonged diarrhea. One patient in each group died of postoperative complications.

CONCLUSIONS

Surgical treatment of microscopic disease in grossly normal para-aortic lymph nodes may generate occasional long-term survivors. Selecting appropriate candidates who might benefit from D4 resections needs to be refined. On the basis of this study, a nationwide study should be considered.

Combined analysis of tumour neoangiogenesis and local immune response in advanced gastric carcinoma

Neovascularization and host immune response are important in the growth and metastasis of solid tumours. Thus, microvessel density, and dendritic cell (DC) infiltration, which was thought to be an indicator of local immune function, were examined by immunohistochemistry and their prognostic significance was determined in patients with advanced gastric carcinoma. The 5-year survival rates in patients with both low microvessel counts and marked DC infiltration, in patients with either low microvessel counts or marked DC infiltration, and in patients with both high microvessel counts and slight DC infiltration were 82.6%, 68.6%, and 30.2%, respectively, the differences were statistically significant. Moreover, the multivariate analysis showed that combined analysis of microvessel counts and DC density was an independent prognostic indicator. Our findings indicate that combined analysis of tumour neoangiogenesis and local immune response might be useful for predicting prognoses of patients with advanced gastric carcinoma.

Computerized nuclear morphometry: a new morphologic assessment for advanced gastric adenocarcinoma

OBJECTIVE

To evaluate the correlation between the morphologic nuclear features and clinicopathologic parameters in patients with advanced gastric cancer.

SUMMARY BACKGROUND DATA

Nuclear profiles have been reported as useful prognostic predictors in various cancers. Data from computerized morphometries are objective and quickly derived using conventional microscopic analysis. However, this image analysis of nuclear features has rarely been applied to investigations of gastric adenocarcinoma. Moreover, it remains to be shown what types of biologic factors influence the nuclear features.

METHODS

Morphometric nuclear features (nuclear area, perimeter, and shape) were analyzed in 202 patients with serosal-invaded gastric cancer (stage II and III) who underwent curative gastrectomy. In each case, 300 cancer nuclei were analyzed on routine hematoxylin and eosin-stained slides through the use of a computer-assisted image analysis system by tracing the nuclear profiles (magnification x400) on a computer monitor. The morphometric data were compared with patient survival, clinicopathologic status, DNA ploidy pattern of tumors, expression of p53 protein, and proliferative activity of cancer cells.

RESULTS

Lymph node metastasis, lymphatic invasion, and venous invasion were more frequently detected in patients with large nuclear areas. Significant correlations were detected between the size of the nuclear area of cancer cells and the biologic factors of tumors, such as expression of p53, Ki-67 labeling index, and DNA ploidy pattern. The 5-year survival rate of the 100 patients in the large-nuclear group (nuclear area >45.3 microm2) was 47.6% and was significantly lower than the 74.4% rate of the 98 patients in the small-nuclear group (nuclear area < or =45.3 microm2). Moreover, the nuclear area was found to be an independent prognostic factor in the multivariate analysis.

CONCLUSIONS

Gastric cancer cells with a large nuclear area express mutated p53 protein and have high proliferative activity. Moreover, such cancer cells have high potential for invasion to the microvessels in the gastric wall. Thus, nuclear morphometry is a new and useful morphologic predictor for metastatic potential in advanced gastric cancer.

Relationship between the expression of vascular endothelial growth factor and the density of dendritic cells in gastric adenocarcinoma tissue

It has been reported that decreased numbers of dendritic cells (DCs) are correlated with poor prognosis in some types of malignancy, such as gastric cancer. However, factors that determine the density of DCs have not been characterized. It was recently reported that vascular endothelial growth factor (VEGF) inhibits the functional maturation of DCs from CD34+ precursors. In this study, we analysed the relationship between the expression of VEGF and the density of DCs in gastric carcinoma tissues by immunohistochemical staining. The extent of infiltration by DCs was graded from marked to slight on the basis of the mean densities of DCs. The prognosis of patients with marked infiltration was significantly better than that of patients with slight infiltration among patients who had undergone curative resection. Multivariate analysis showed that infiltration by DCs was an independent prognostic indicator. Furthermore, there was an inverse correlation between the density of DCs and the expression of VEGF Our results suggest that expression of VEGF might be associated with tumour progression and poor prognosis not only because VEGF stimulates angiogenesis, but also because it allows tumours to escape from attack by the immune system in patients with gastric carcinoma.

Levels of serum-soluble receptor for interleukin-2 in patients with colorectal cancer

The preoperative levels of serum-soluble receptor for interleukin-2 (IL-2R) were determined by an enzyme-linked immunosorbent assay in 38 patients undergoing surgery for colorectal cancer and 98 healthy controls. The levels of serum-soluble IL-2R in the patients with colorectal cancer were significantly higher than those in the normal controls (P < 0.05). Markedly elevated levels of serum-soluble IL-2R were recognized in patients with stage IV cancer, those with Dukes' stage D cancer, and those with liver metastasis. Moreover, the prognosis of patients with low levels of IL-2R (<531 U/ml) was significantly better than that of those with high levels (P < 0.05). These findings demonstrate that an elevated concentration of soluble IL-2R might be a useful indicator of liver metastasis and poor prognosis in patients with colorectal carcinoma.