Two cases of gastric cancer with elevated serum levels of KL-6

BACKGROUND

The serum level of Krebs von den Lungen-6 (sKL-6) is a biomarker of interstitial pneumonia and has been reported to be elevated in patients with cancers. However, there have been few cases of gastric cancer (GC) with elevated sKL-6 that were treated by chemotherapy. We herein report two cases of GC with elevated sKL-6 that were treated with oxaliplatin plus S-1 (SOX) chemotherapy and discussed the resulting changes in sKL-6.

CASE PRESENTATION

The first patient was a 79-year-old woman complaining of loss of appetite. Esophagogastroduodenoscopy (EGD) showed a type-3 tumor in the gastric antrum and biopsy specimens showed adenocarcinoma. Computed tomography (CT) showed multiple liver metastases. sKL-6 was elevated to 1,292 U/ml, but a CT revealed no obvious lesions of the lungs, including interstitial pneumonia. The tumor was diagnosed as GC with liver metastases and elevated sKL-6. Respiratory function data were normal. SOX therapy using oxaliplatin and S-1 was performed. After 3 courses of SOX therapy, CT showed reductions of the liver metastases as well as the primary tumor, and sKL-6 was decreased to 201 U/ml. After the 44 courses, sKL-6 was slightly elevated. Chest CT showed interstitial pneumonia and chemotherapy was stopped. The patient is still alive without any metastasis 72 months later. The second patient was a 69-year-old woman complaining of upper abdominal pain. EGD revealed a type-3 tumor in the gastric antrum showing adenocarcinoma with HER2-positive pathology. CT showed multiple node metastases around the abdominal aorta. sKL-6 was elevated to 2,239 U/ml, but a respiratory function test showed no abnormalities, and CT of the lungs showed no obvious lesions. The tumor was diagnosed as GC with distant node metastases and elevated sKL-6. The patient received SOX therapy combined with trastuzumab. After 6 courses, the size of the primary tumor and multiple node metastases were reduced, and sKL-6 was decreased to 284 U/ml.

CONCLUSIONS

These two cases suggest that sKL-6 may be important not only as an indicator of interstitial pneumonia in chemotherapeutic courses, but also as a tumor marker in GC patients with multiple metastases.

A case report of adenosquamous carcinoma of the esophagogastric junction

BACKGROUND

Many types of tumors can arise in the esophagogastric junction (EGJ). Squamous cell carcinoma (SCC) arising from the esophageal epithelia, adenocarcinoma arising from the gastric mucosa, or Barrett's esophageal mucosa are frequently observed in the EGJ. However, adenosquamous carcinoma (ASC) has been rarely observed in this area. We herein report a rare case of ASC of the EGJ.

CASE PRESENTATION

An 81-year-old man visited our hospital complaining of dysphagia. Esophagogastroduodenoscopy detected an elevated tumor in the gastric cardia. Biopsy specimens taken from the tumor showed SCC. Computed tomography revealed a tumor located in the EGJ and node metastases surrounding the EGJ. The tumor was diagnosed as SCC, overhanging in the stomach, of the EGJ. The patient underwent a proximal gastrectomy with a lower esophagectomy and node dissection for the metastases surrounding the EGJ, and esophagogastrostomy in the lower mediastinum. Histopathologic examination showed the tumor consisted of SCC and adenocarcinoma. The adenocarcinoma consisted of nests scattered in the SCC. We observed adenocarcinoma component in 35% of the tumor and epithelial spread of SCC in the lower esophagus. Thus, we diagnosed the tumor as ASC of the EGJ. Eight metastatic nodes were dissected; both SCC and adenocarcinoma were observed in seven.

CONCLUSIONS

In the present case, SCC may be originated from the squamous epithelia of the lower esophagus and grew into the stomach, and the adenocarcinoma may have differentiated from SCC through the infiltration.

Lung adenocarcinoma initially presenting as Trousseau's syndrome treated successfully with pembrolizumab: A case report

A 60-year-old woman was urgently admitted to our hospital because of vertigo and left hemiplegia. Laboratory examination showed thrombocytopenia, high levels of D-dimer and carcinoembryonic antigen. Brain magnetic resonance imaging (MRI) revealed multiple bilateral cerebral infarctions. Chest computed tomography (CT) showed an irregularly shaped tumor in the upper lobe of the left lung and mediastinal node swelling. The histopathological findings revealed adenocarcinoma negative for anaplastic lymphoma kinase fusion gene, sensitive epidermal growth factor receptor mutations. A diagnosis of lung adenocarcinoma initially presenting as arterial thromboembolism was made, and she was treated with direct oral anticoagulant (DOAC). Subsequently, pembrolizumab therapy was initiated because tumor cells were positive for programmed cell death protein 1 (PD-L1;60%), and resulted in reduction of the tumor with normalization of the platelet count and d-dimer. The treatment has been continued for over one year without any recurrence of the disease or thromboembolism.

High incidence of other primary malignancies in patients with synchronous multiple gastric cancers "a multi-center retrospective cohort study"

This study evaluated the relationship between synchronous multiple gastric cancer and other primary malignancies. During 2002–2013, 1094 consecutive surgically treated gastric cancer patients were enrolled. Preoperatively, we performed total colonoscopy and whole-body computed tomography. When malignancies in other organs were suspected, detailed organ-specific examinations were performed. Synchronous multiple gastric cancer occurred in 102 patients (9.3%)which was frequently observed in patients with preoperative other primary malignancies (p < 0.001). Preoperative other primary malignancy was an independent risk factor for synchronous multiple gastric cancer (p = 0.001; hazard ratio: 2.145, 95% confidence interval: 1.354–3.399) and an independent prognostic factor of overall survival in patients undergoing gastrectomy with curative intent (p = 0.021; hazard ratio: 1.481, 95% confidence interval: 1.060–2.070). Thus, patients with preoperative other primary malignancies have a high risk of synchronous multiple gastric cancer. Careful preoperative examination is recommended to improve survival.

Prevalence and management of colorectal neoplasia in surgically treated esophageal cancer patients

AIMS

The existence of other primary tumors during the treatment of esophageal cancer patients has been an important issue. Our aim is to investigate the prevalence and management of colorectal neoplasia (CRN) in surgically treated esophageal cancer patients.

METHODS

Between 2002 and 2008, 93 patients with esophageal cancer were surgically treated. Seventy-three patients underwent subtotal esophagectomy and 20 underwent lower esophagectomy for esophageal cancer. Colonoscopy was available for detecting CRN before and after surgery.

RESULTS

Eighty-nine (95.7%) of the 93 patients were screened by colonoscopy preoperatively or within a year from the operation. Thirty-nine patients (43.8%) with CRN were synchronously identified: adenoma in 34 (38.2%) and adenocarcinoma in 5 patients (5.6%). Eleven adenomas with high grade-dysplasia and 8 adenomas with low grade-dysplasia were removed endoscopically. Three superficial adenocarcinomas were endoscopically removed before surgery, and 2 adenocarcinomas were surgically removed. Seventy-four patients (83.1%) were followed using colonoscopy, and 11 subsequent CRN, including 2 superficial adenocarcinomas, were endoscopically detected in 8 patients (10.8%). The size of esophageal cancer was larger in the patients with than without CRN (p = 0.036). The body mass index in esophageal cancer patients with CRN tended to be higher than in those without CRN (p = 0.065).

CONCLUSIONS

We noted that esophageal cancer is frequently associated with synchronous and/or metachronous colorectal cancer and adenomas. Colonoscopy is useful to detect and manage CRN before and after esophagectomy, although a few limitations exist.

Relationships of obesity and diabetes mellitus to other primary cancers in surgically treated gastric cancer patients

BACKGROUND

Other primary cancers (OPC) have been reported in gastric cancer (GC) patients. Recent studies have shown relationships of obesity and diabetes mellitus to cancer development in several organs. The purpose of this study was to investigate the relationships of obesity and diabetes mellitus (DM) to the prevalence of OPC in GC patients.

METHODS

We reviewed 435 GC patients who were treated surgically and followed their outcomes after surgery. Patients with body mass index (BMI) ≥ 25 kg/m(2) were defined as obese. Fasting plasma glucose (FPG) and HbA1c levels were examined before surgery.

RESULTS

OPC was observed in 109 GC patients (25.1%): 40 (9.2%) with synchronous OPC and 76 (18.2%) with metachronous OPC. The most common OPC was colorectal cancer (22.8%). OPC was frequently observed in patients with DM (p = 0.0022), and DM was an independent risk factor for the occurrence of OPC (odds ratio, 2.215; 95% confidence interval, 1.2007-4.0850; p = 0.011). Synchronous OPC was frequently observed in patients with obesity (p = 0.025), and obesity was an independent risk factor for the occurrence of synchronous OPC (odds ratio, 2.354; 95% confidence interval, 1.1246-4.9279; p = 0.023). Metachronous OPC was frequently observed in patients with DM (p = 0.0071), and DM was an independent risk factor for the occurrence of OPC (odds ratio, 2.680; 95% confidence interval, 1.0291-6.9780; p = 0.044).

CONCLUSION

There is a need to be aware of the possibility of OPC in GC patients with DM/obesity. They should undergo intensive screening for OPC before and after gastrectomy.

Prevalence of synchronous colorectal neoplasms in surgically treated gastric cancer patients and significance of screening colonoscopy

BACKGROUND AND AIM

The existence of other primary tumors during the treatment and management of gastric cancer (GC) is an important issue. The present study investigated the prevalence and management of synchronous colorectal neoplasms (CRN) in surgically treated GC patients.

METHODS

Of 381 surgically treated GC patients, 332 (87.1%) underwent colonoscopy to detect CRN before surgery or within a year after surgery.

RESULTS

CRN were synchronously observed in 140 patients (42.2%). Adenoma was observed in 131 patients (39.4%). Endoscopic resection was done in 18 patients with adenoma. Colorectal cancer (CRC) was observed in 16 patients (4.8%), superficial CRC in 13 and advanced CRC in three patients. Endoscopic resection of superficial CRC was carried out in seven patients, whereas simultaneous surgical resection of CRC was done in nine patients. CRN were more frequently observed in men. CRC was more frequently observed in GC patients with distant metastasis, albeit without significance. The overall survival of GC patients with CRN or CRC was poorer than that of patients without CRN or CRC.

CONCLUSION

Synchronous CRN were commonly associated with GC and screening colonoscopy should be offered to patients with GC.

Helicobacter heilmannii sensu stricto-related gastric ulcers: A case report

A spiral bacterium (SH9), morphologically different from Helicobacter pylori (H. pylori), was found in a 62-year-old woman’s gastric mucosa. Gastroscopic examination revealed multiple gastric ulcers near the pyloric ring; mapping gastric biopsy showed mild mononuclear infiltration with large lymphoid follicles in the antrum, without corpus atrophy. Urea breath test and H. pylori culture were negative, but Giemsa staining of biopsies revealed tightly coiled bacteria that immunostained with anti-H. pylori antibody. Sequencing of SH9 16S rRNA and the partial urease A and B subunit genes showed that the former sequence had highest similarity (99%; 1302/1315 bp) to Helicobacter heilmannii (H. heilmannii) sensu stricto (H. heilmannii s.s.) BC1 obtained from a bobcat, while the latter sequence confirmed highest similarity (98.3%; 1467/1493 bp) to H. heilmannii s.s. HU2 obtained from a human. The patient was diagnosed with multiple gastric ulcers associated with H. heilmannii s.s. infection. After triple therapy (amoxicillin, clarithromycin, and lansoprazole) with regimen for eradicating H. pylori, gastroscopy showed ulcer improvement and no H. heilmannii s.s. upon biopsy.

Reduced expression of αGlcNAc in Barrett's oesophagus adjacent to Barrett's adenocarcinoma--a possible biomarker to predict the malignant potential of Barrett's oesophagus

AIMS

Gastric gland mucin contains O-glycans exhibiting terminal α1,4-linked N-acetylglucosamine residues (αGlcNAc). Recently we demonstrated that mice deficient in αGlcNAc in gastric gland mucin develop gastric adenocarcinoma spontaneously, indicating that αGlcNAc is a tumour suppressor for gastric cancer. However, the role of αGlcNAc in Barrett's oesophagus (BO) remains unknown. In this study, we investigated whether reduced αGlcNAc expression in BO is associated with development of Barrett's adenocarcinoma (BAC).

METHODS AND RESULTS

Thirty-five BO lesions adjacent to BAC were examined by immunohistochemistry for αGlcNAc, MUC6 and CDX2. As controls, 35 BO lesions without BAC obtained from patients with oesophageal squamous cell carcinoma were also analysed. Expression of αGlcNAc relative to its scaffold MUC6 in BO adjacent to BAC was reduced significantly compared to control BO. Decreased αGlcNAc expression in BO adjacent to BAC was particularly significant in patients with smaller tumour size (<20 mm) and minimal invasion of tumour cells to the superficial muscularis mucosae. There was also a significant inverse correlation between αGlcNAc and CDX2 expression in BO adjacent to BAC.

CONCLUSIONS

Decreased expression of αGlcNAc compared with MUC6 in BO is a possible hallmark in predicting BAC development.

[Juvenile gastric polyposis in a patient with antiphospholipid syndrome]

We report a case of juvenile gastric polyposis associated with antiphospholipid syndrome. A 42-year-old woman was admitted with a chief complain of fatigue. Six years earlier, antiphospholipid syndrome was diagnosed and treated with aspirin. Two years earlier, gastric polyps were endoscopically observed, the number and size of which subsequently increased. Juvenile gastric polyposis was diagnosed on the basis of the pathological features of the biopsy specimens. Bleeding was repeatedly identified from the polyposis. Total gastrectomy was performed because of worsening anemia and hypoalbuminemia.

[A case of squamous cell carcinoma of the esophagogastric junction with bulky no.7-metastatic node successfully treatedby chemoradiation followed by surgery]

The patient was a 59-year-old man showing an ulcerative tumor. He had squamous cell carcinoma diagnosed by biopsy specimens, found in the esophagogastric junction by esophagogastroduodenoscopy. Abdominal CT showed a No.7 nodeswelling( 40mm in diameter), and the metastatic tumor directly invaded the pancreas(cStage IVa). We scheduled surgery followed by chemoradiotherapy, because it was difficult to remove the metastatic node completely. Two courses of chemotherapy consisting of 5-FU and CDDP were performed, and 2 Gy/day-irradiation(total amount of 40 Gy)was performed over 20 days. After chemoradiation, the tumor changed to a superficially depressed lesion, and the metastatic huge node was shrunk. Thirty-five days after chemoradiation, transhiatal a lower esophagectomy with proximal gastrectomy was performed. Histopathologic findings after surgery showed no cancer remnant in the primary site and the node(pCR). Three years later, the patient is well without recurrence. Although there was no evidence of preoperative chemoradiation limited in squamous cell carcinoma of the esophagogastric junction, surgery followed by chemoradiotherapy may be an effective treatment in advanced cases, such as the present one.

Treatment of a GIST patient with modified dose of sunitinib by measurement of plasma drug concentrations

In this study we report the pharmacokinetics and severe adverse effects of sunitinib in a woman with a gastrointestinal stromal tumor (GIST). A 60-year-old woman with small intestinal GIST developed severe thrombocytopenia (1.7×10(4)/μl) following 1 week of treatment with sunitinib at 50 mg/day. Although the dose of sunitinib was reduced to 25 mg/day, platelet levels remained low. On day 7, the trough concentration of sunitinib plus SU12662 was 46.1 ng/ml and the area under the curve (AUC) was 1,393.0 ng·h/l. The dose was again reduced to 12.5 mg/day. However, the day after resumption of treatment, the patient developed symptoms of left heart failure due to myocardosis caused by sunitinib. Sunitinib has been reported to inhibit platelet-derived growth factor receptor (PDGFR) phosphorylation at concentrations over the range of 50-100 ng/ml (sunitinib plus SU12662) in vivo. In this case, the plasma concentration was sufficient to inhibit PDGFR at 25 or 50 mg/day. However, thrombocytopenia appeared at both dosages. Although the results in this case did not suggest a correlation between thrombocytopenia and plasma concentration, the degree of thrombocytopenia was decreased by reduction of the dose. In conclusion, the findings reported here indicate that the plasma concentration of sunitinib plus SU12662 is an important indicator to reduce adverse effects.

How much length of the distal esophagus is removed by transhiatal approach for squamous cell carcinoma and Barrett's adenocarcinoma in Japanese patients?

BACKGROUND/AIMS

The removed length of the esophagus by transhiatal distal esophagectomy (THDE) for patients with squamous cell carcinoma (SCC) and Barrett's adenocarcinoma (BAC) in the distal/abdominal esophagus was investigated.

METHODOLOGY

Twenty six patients with carcinoma mainly located in the distal/ abdominal esophagus were treated by THDE: SCC (Group-S, n=17) and BAC (Group-A, n=9). The length of the mobilized esophagus (D1) and that of the removed esophagus (D2) were measured. After surgery, we measured the distance between the stapled line of the esophagogastrostomy and the diaphragmatic hiatus (D3). The ratio of D3 to the distance between the bronchial bifurcation and the hiatus (D3-ratio) was calculated.

RESULTS

The mean D1, D2 and D3 were 91.2mm, 65.2mm and 63.2mm, respectively. There were no differences among D1, D2 and D3 between Group-S and Group-A. The mean D3-ratio was 51.9%, and there was no difference between Group-S and Group-A. No postoperative mortality was observed, although postoperative complications were observed in 2 patients (7.7%). After THDE, no local recurrence was observed, node recurrence in 4 (15.4%) and distant metastasis in 7 (26.9%). Five-year survival rate after THDE was 70.1%. Seven patients (26.9%) complained of heartburn and only one of Group-S frequently felt heartburn. In endoscopic findings, most of the patients with heartburn were classified as Grade M.

CONCLUSIONS

Approximately 65mm of the distal esophagus and approximately 50% of the distance between the bronchial bifurcation and the hiatus was safely removed by THDE for SCC and BAC of the distal/abdominal esophagus, in spite of limited cases.

Pseudo-Meigs syndrome caused by sigmoid colon cancer metastasis to the ovary

We present a patient with pseudo-Meigs syndrome (PMS) secondary to sigmoid colon cancer metastasis to the ovary with elevated serum levels of carcinoembryonic antigen, CA19-9, and CA-125 who showed a marked change in pleural effusion before and after surgery. We have to consider PMS associated with colon cancer in patients with pleural effusion/ascites and ovarian tumors.

Fatal interstitial pneumonia associated with oxaliplatin-based therapy in a patient with metastatic rectal cancer

Oxaliplatin in combination with 5-fluorouuacil and leucovorin (FOLFOX) is one of the most commonly used first-line chemotherapies for patients with advanced or metastatic colorectal cancer. Pulmonary toxicity, including interstitial pneumonia (IP)/peumonitis, is a very rare complication. We report a case of fatal IP associated with FOLFOX therapy in a patient with metastatic rectal cancer. A 74-year-old man with rectal adenocarcinoma and associated liver metastases underwent palliative surgery and 21 cycles of modified FOLFOX6 therapy. After starting the 22nd therapy cycle, the patient developed a high fever with non-productive cough. Chest X-ray demonstrated diffuse ground-glass opacities in both lungs, and computed tomography showed severe disorder of the bilateral lung architecture. On the basis of a lymphocyte stimulation test (DLST), oxaliplatin-induced IP was diagnosed. Intravenous administration of high-dose methylprednisolone was started, but the symptoms and radiological findings were not improved. The patient died of respiratory failure 16 days after the last administration of oxaliplatin. Although IP is a rare but potentially fatal complication of oxaliplatin-based treatment in colorectal cancer patients, clinicians should pay careful attention to the clinical respiratory symptoms and radiographic findings in colorectal cancer patients receiving FOLFOX therapy.

Synthesis and Physical Properties of π -Conjugated Polymers Containing Mesogenic Group

Novel side chain type liquid crystalline polymers, polythiophene and poly(aryleneethynylene) [PAE], containing a mesogenic group in the side chain were synthesized. Polythiophene derivatives were obtained by dehalogenative polycondensation with zero-valence nickel complex under mild condition. PAE type polymers were obtained by coupling dihalo aromatic compound with diethynyl aromatic compound. Their thermal properties were examined by differential scanning calorimetry, optical microscopy and X-ray diffractometry. All polymers exhibited a smectic or nematic mesophase depending upon the polymer backbone and pendant mesogenic group. Polythiophene derivatives exhibited electrochemical activity. Annealing polythiophene derivatives led to a lower oxidation potential and a higher conductivity. The degree of the orientation of the polymer backbone was supported by polarized UV-vis measurement. An effective conjugated length became longer by introducing thiophene rings into the polymer backbone. A high quantum yield of fluorescence was observed for PAE type polymers.

Induction of high endothelial venule-like vessels expressing GlcNAc6ST-1-mediated L-selectin ligand carbohydrate and mucosal addressin cell adhesion molecule 1 (MAdCAM-1) in a mouse model of "Candidatus Helicobacter heilmannii"-induced gastritis and gastric mucosa-associated lymphoid tissue (MALT) lymphoma

BACKGROUND

"Candidatus Helicobacter heilmannii" induce chronic gastritis, which eventually leads to gastric B-cell type mucosa-associated lymphoid tissue (MALT) lymphoma. This study was performed using an animal model of infection with "Candidatus Helicobacter heilmannii" to elucidate how this chronic inflammation is induced or maintained.

MATERIALS AND METHODS

BALB/c mice were infected with the "Candidatus Helicobacter heilmannii" isolate SH4. The animals were examined at 8, 26, 54, and 83 weeks after the infection. The stomach of the animals was resected and immunostained for peripheral lymph node addressin (PNAd) and mucosal addressin cell adhesion molecule 1 (MAdCAM-1), "Candidatus Helicobacter heilmannii," and CD45R/B220. An in vitro binding assay with L- and E-selectin·IgM chimeric proteins was performed. Real-time polymerase chain reaction was used to evaluate transcripts of N-acetylglucosamine-6-O-sulfotransferases (GlcNAc6STs), which direct the expression of the PNAd and MAdCAM-1.

RESULTS

Chronic gastritis developed in the infected animals, and its severity increased with the duration of the infection. B-cell type MALT lymphoma developed in some animals at 54 and 83 weeks after infection. PNAd- and MAdCAM-1-expressing high endothelial venule (HEV)-like vessels were induced in infected animals which developed chronic gastritis and MALT lymphoma. The number of HEV-like vessels increased as chronic inflammation progressed. The induced HEV-like vessels were bound by L- and E-selectin·IgM chimeric protein. mRNA expressions of GlcNAc6ST-1 and MAdCAM-1 increased in the infected animals.

CONCLUSIONS

HEV-like vessels expressing GlcNAc6ST-1-mediated L-selectin ligand carbohydrate and MAdCAM-1 may play a crucial role in the pathogenesis of "Candidatus Helicobacter heilmannii"-induced chronic gastritis and MALT lymphoma.

Endotoxin-induced lung injury in α-galactosylceramide-sensitized mice is caused by failure of interleukin-4 production in lung natural killer T cells

Administration of bacterial lipopolysaccharide (LPS) known as endotoxin into α-galactosylceramide (α-GalCer)-sensitized mice causes severe lung lesions but few hepatic lesions in lethal shock, and interferon (IFN)-γ is suggested to play a pivotal role in preparation of the lung lesions. In order to clarify the mechanism of how α-GalCer sensitization causes lung lesions exclusively in mice, we examined the differential responsiveness of lungs and livers to α-GalCer sensitization. Although lung and liver natural killer T (NK T) cells both produced IFN-γ in response to α-GalCer, IFN-γ signalling was triggered only in the lungs of α-GalCer-sensitized mice. Lung NK T cells did not produce interleukin (IL)-4 in response to α-GalCer and it did not induce the expression of suppressor of cytokine signalling 1 (SOCS1) in the lungs. Conversely, IL-4 produced by liver NK T cells led to the expression of SOCS1 in the livers of the mice. Neutralization of IL-4 reduced SOCS1 expression in the livers and exacerbated LPS-induced hepatic lesions. IL-10 was produced by liver NK T cells but not lung NK T cells. However, IL-10 was produced constitutively by alveolar epithelial cells in normal lung. Lung NK T cells and liver NK T cells might express CD8 and CD4, respectively. Based on the fact that IL-4 inhibited IFN-γ signalling in the livers of α-GalCer-sensitized mice via SOCS1 expression and signal transducer and activator of transcription 1 (STAT-1) activation, no inhibition of the IFN-γ signalling in the lungs caused LPS-induced lung lesions in α-GalCer-sensitized mice. The detailed mechanism of development of the lung lesions in α-GalCer-sensitized mice is discussed.

Metformin attenuates production of nitric oxide in response to lipopolysaccharide by inhibiting MyD88-independent pathway

Metformin is reported to ameliorate inflammation in diabetic patients. The effect of metformin on lipopolysaccharide-induced nitric oxide production was studied by using RAW 264.7 macrophage-like cells. The action of metformin was analyzed by dividing lipopolysaccharide signaling into the MyD88-dependent and -independent pathways. Metformin significantly reduced the expression of an inducible type of nitric oxide synthase and inhibited lipopolysaccharide-induced nitric oxide production. On the other hand, metformin did not inhibit lipopolysaccharide-induced tumor necrosis factor-alpha production. The expression levels of interferon-beta protein and mRNA, which is a key molecule in MyD88-independent pathway, were significantly inhibited by metformin. Compound C, a specific AMP-activated protein kinase inhibitor, did not affect the inhibitory action of metformin. Metformin was suggested to inhibit lipopolysaccharide-induced nitric oxide production via inhibition of interferon-beta production in MyD88-independent pathway. Metformin might exhibit an anti- inflammatory action on diabetic complications as well as the antidiabetic action.

Esophageal cancer associated with other primary cancers--historical comparison of clinicopathologic features in 359 esophageal cancer patients

BACKGROUND/AIMS

We historically investigated the clinicopathologic features of esophageal cancer associated with other primary cancers (OPC), and discussed differences between the last decade and the previous period.

METHODOLOGY

A total of 359 patients with esophageal cancer treated between 1981 and 2006 were enrolled. They were divided into 2 groups; 213 patients between 1981 and 1996 (Group-A), and 146 patients between 1997 and 2006 (Group-B).

RESULTS

Between Group-A and Group-B, there was a significant difference in the frequency of OPC (15.5% vs. 32.2%, p < 0.001). Regarding the site of OPC, there was a significant difference in the frequency of head and neck cancers (p < 0.001). There was a significant difference in the frequency of metachronous OPC between Group-A and Group-B (5.6% vs. 18.5%, p < 0.001). Antecedent OPC was more frequently observed in Group-B than Group-A (3.3% vs. 11.0%, p < 0.01), and subsequent OPC was also more frequently observed in Group-B than Group-A (2.8% vs. 7.5%, p < 0.05). Although the 5-year survival rate after esophagectomy of the patients without OPC was better in Group-B than Group-A (31.5 % vs. 52.7 %; p < 0.01), there was no difference in that of the patients with OPC between Group-A and Group-B, (40.7% vs. 54.2%).

CONCLUSION

Metachronous as well as synchronous OPC in esophageal cancer patients were more frequent in the recent period than in the previous period. We should consider antecedent, synchronous, and subsequent OPC in esophageal cancer patients.

Gastric schwannoma exhibiting increased fluorodeoxyglucose uptake

This is the first case of gastric schwannoma that exhibited increased accumulation of [(18)F] fluorodeoxyglucose (FDG) on positron emission tomography (PET) imaging. The patient was a 60-year-old woman in whom esophagogastroduodenoscopy showed a submucosal tumor, about 25 mm in size, in the upper body of the stomach, with ulceration at the top of the tumor. Endoscopic ultrasonography revealed a well-defined hypoechoic mass located in the proper muscle layer of the stomach. The specimen taken from the tumor showed only inflammatory degenerative tissue. Abdominal computed tomography revealed a tumor in the upper body of the stomach. FDG-PET showed FDG uptake (standardized uptake value [SUV] max 5.8) coincident with the tumor. Hence, the tumor was diagnosed initially as a gastrointestinal stromal tumor of the stomach. Laparoscopic partial gastrectomy was performed. Pathological examination showed that the tumor consisted of spindle cells with large nuclei, and mitosis was absent. The Ki-67 labeling index of the tumor cells was 4%. Immunohistochemically, the tumor cells showed a positive reaction for S-100 protein, whereas they were negative for KIT, CD 34, and alpha-smooth muscle actin protein. The tumor was diagnosed as a benign gastric schwannoma. Gastric schwannoma should be included in the differential diagnosis of submucosal tumors of the stomach with FDG uptake.

Killian-Jamieson diverticulitis with cervical cellulitis: report of a case

A Killian-Jamieson (K-J) diverticulum is an uncommon hypopharyngeal diverticulum related to the better-recognized Zenker's diverticulum. Cervical cellulitis due to K-J diverticulitis is also highly exceptional. We report the case of a 53-year-old woman with cervical cellulitis caused by K-J diverticulitis. The cellulitis was cured by the administration of an antibiotic agent. The patient underwent a resection of the K-J diverticulum 2 months after the cellulitis was cured. The cervical diverticulum was judged to be a K-J diverticulum because the diverticulum prolapsed laterally just below the cricopharyngeus muscle on the esophagogram. The left recurrent laryngeal nerve adhered to the proximity of the orifice of the diverticulum. The recurrent laryngeal nerve was carefully preserved before the resection of the diverticulum. Accurate differential diagnosis between K-J and Zenker's diverticula is necessary before surgery to preserve the recurrent laryngeal nerve.

Postoperative suppression of inflammatory cytokines after distal gastrectomy in elderly patients

PURPOSE

Surgical procedures are being performed on elderly people with increasing frequency, but accordingly, postoperative complications and mortality rates are higher than for younger patients. We conducted this study to establish if cytokine responses after distal gastrectomy in elderly patients differ from those in younger patients.

METHODS

Twenty-one patients undergoing distal gastrectomy were divided into two groups based on age: the elderly group consisted of 10 patients aged >/=75 years, and the younger group consisted of 11 patients aged <65 years. Blood samples were collected from the patients preoperatively, and then on postoperative days (PODs) 1, 3, and 7, for analysis of interleukin (IL)-6, IL-8, IL-10, soluble tumor necrosis factor receptors (sTNF-R), and IL-1 receptor antagonist (IL-1ra); and also to measure TNF-alpha and IL-1beta after incubation with Escherichia coli lipopolysaccharide.

RESULTS

The IL-6 concentration and TNF-alpha on POD 1 were both significantly lower in the elderly group than in the younger group (P = 0.0058 and P = 0.022, respectively).

CONCLUSION

Cytokine profiles after distal gastrectomy in elderly patients differ from those in younger patients, with lower pro-inflammatory and inflammatory cytokine responses evident in the elderly.

Novel mechanism of U18666A-induced tumour necrosis factor-alpha production in RAW 264.7 macrophage cells

U18666A is a cholesterol transport-inhibiting agent that is used widely to mimic Niemann-Pick type C disease. The effect of U18666A on tumour necrosis factor (TNF)-alpha production in mouse macrophage cell line, RAW 264.7 cells and peritoneal macrophages was examined. U18666A induced TNF-alpha mRNA expression 48 h after the treatment, and TNF-alpha production 48 and 72 h after stimulation in RAW 264.7 cells. U18666A accumulated intracellular free cholesterol in the culture of normal medium but not cholesterol-free medium. U18666A also induced reactive oxygen species (ROS) generation in normal medium but much less in cholesterol-free medium. Anti-oxidant N-acetyl-L-cysteine (NAC) abolished U18666A-induced TNF-alpha production. U18666A led to the phosphorylation of p38 mitogen-activated protein kinase 24 and 48 h after the stimulation and the p38 activation was inhibited in presence of cholesterol-free medium or NAC. A p38 inhibitor reduced U18666A-induced TNF-alpha production. Taken together, U18666A was suggested to induce TNF-alpha production in RAW 264.7 cells via free cholesterol accumulation-mediated ROS generation.

The mechanism of development of acute lung injury in lethal endotoxic shock using alpha-galactosylceramide sensitization

The mechanism underlying acute lung injury in lethal endotoxic shock induced by administration of lipopolysaccharide (LPS) into alpha-galactosylceramide (alpha-GalCer)-sensitized mice was studied. Sensitization with alpha-GalCer resulted in the increase of natural killer T (NK T) cells and the production of interferon (IFN)-gamma in the lung. The IFN-gamma that was produced induced expression of adhesion molecules, especially vascular cell adhesion molecule-1 (VCAM-1), on vascular endothelial cells in the lung. Anti-IFN-gamma antibody inhibited significantly the VCAM-1 expression in alpha-GalCer-sensitized mice. Very late activating antigen-4-positive cells, as the counterpart of VCAM-1, accumulated in the lung. Anti-VCAM-1 antibody prevented LPS-mediated lethal shock in alpha-GalCer-sensitized mice. The administration of LPS into alpha-GalCer-sensitized mice caused local production of excessive proinflammatory mediators, such as tumour necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6 and nitric oxide. LPS caused microvascular leakage of proteins and cells into bronchoalveolar lavage fluid. Taken together, sensitization with alpha-GalCer was suggested to induce the expression of VCAM-1 via IFN-gamma produced by NK T cells and recruit a number of inflammatory cells into the lung. Further, LPS was suggested to lead to the production of excessive proinflammatory mediators, the elevation of pulmonary permeability and cell death. The putative mechanism of acute lung injury in LPS-mediated lethal shock using alpha-GalCer sensitization is discussed.

Lipopolysaccharide augments the in vivo lethal action of doxorubicin against mice via hepatic damage

The effect of lipopolysaccharide (LPS) on the in vivo lethal action of doxorubicin (DOX) against mice was studied. DOX killed LPS-pretreated mice much earlier than untreated mice, and exhibited a stronger toxic action against LPS-pretreated mice. DOX-induced lethality in LPS-pretreated mice was due to severe hepatic damage, but there were no significant lesions in the heart, kidney and lung. Hepatic lesions were accompanied by caspase 3-positive cells and fragmented DNA-positive cells, suggesting the involvement of apoptosis. DOX induced the production of a high level of interferon (IFN)-gamma and tumour necrosis factor (TNF)-alpha in LPS-pretreated mice, but not in non-treated mice. The DOX-induced lethality was prevented significantly by anti-IFN-gamma antibody, but not anti-TNF-alpha antibody. Administration of recombinant IFN-gamma in place of LPS augmented definitively the DOX-induced lethality. LPS augmented the DOX-induced lethality in TNF-alpha-deficient mice. Taken together, LPS was suggested to enhance DOX-induced IFN-gamma production and augment the in vivo lethal action via hepatic damage.

Clinicopathologic features and histochemical analyses of proliferative activity and angiogenesis in small cell carcinoma of the esophagus

BACKGROUND

We investigated clinicopathologic features in patients with esophageal small cell carcinoma (SCEC), and its proliferative activity and angiogenesis.

METHODS

Ten patients with SCEC from 335 esophageal carcinoma patients were analyzed clinicopathologically. For analyses of cell proliferation, apoptosis, and angiogenesis of SCEC, Ki-67 immunostaining, the TUNEL method, and CD31 and CD68 immunostaining were used.

RESULTS

Esophagectomy was performed in nine patients, while one with extensive SCEC was treated by repeated chemotherapy and radiotherapy. Four patients received chemotherapy both before and after surgery, one only before surgery, and four only after surgery. Cisplatin and etoposide were given to five patients, while irinotecan and cisplatin were given to three. Five survived more than 18 months, and two more than 36 months. One of these two had limited SCEC treated by surgery and chemotherapy, whereas the other had extended SCEC treated by repeated chemotherapy and radiotherapy. The microvessel count and the Ki-67 labeling index of SCEC were higher than those of squamous cell carcinoma (P = 0.0033 and P = 0.0005, respectively). Between SCEC with and without preoperative chemotherapy, the Ki-67 labeling index was lower (P = 0.027) and the apoptotic index was higher in the treated SCEC (P = 0.014). Between SCEC patients who survived more or less than 18 months, the microvessel count was lower in those who survived more than 18 months (P = 0.049).

CONCLUSIONS

Esophagectomy may be indicated for limited SCEC combined with chemotherapy. SCEC has high proliferative activity and rich neovascularization, and its proliferative activity may be suppressed by chemotherapy.

Gastric small cell carcinoma successfully treated by surgery and postoperative chemotherapy consisting of cisplatin and S-1: report of a case

We herein report a case of gastric small cell carcinoma (GSCC), which was successfully treated by surgery and postoperative chemotherapy consisting of cisplatin (CDDP) and the fluoropyrimidine S-1. The patient was a 63-year-old man in whom a gastric tumor had been endoscopically detected. The type 1 tumor was located in the gastric body. An abdominal computed tomogram showed many metastasized nodes around the stomach. A total gastrectomy with regional node dissection was performed. The removed tumor was histologically and histochemically diagnosed to be a GSCC with node metastases. Furthermore, washing peritoneal cytology histologically revealed the presence of carcinoma cells. Metastasis was histologically observed in 17 of 24 dissected nodes. After surgery, CDDP was intravenously administered and S-1 was orally administered for 1 year. Consequently, the patient is now well without any recurrence 45 months after surgery. We reviewed 52 Japanese patients with GSCC/endocrine cell carcinoma (EC) reported between 2001 and 2005 with reference to chemotherapy. Chemotherapy using S-1 was performed for 11 of the 52 patients. Four of the 11 patients, including the present case, who were treated with S-1 survived for over 2 years after surgery, although the GSCC/EC of the four patients were staged as III or IV. Therefore, chemotherapy consisting of CDDP and S-1 may provide a survival benefit for patients with GSCC/EC.

Lipopolysaccharide and interferon-gamma enhance Fas-mediated cell death in mouse vascular endothelial cells via augmentation of Fas expression

The effect of interferon (IFN)-gamma and/or lipopolysaccharide (LPS) on Fas-mediated cell death with anti-Fas agonistic antibody in vascular endothelial cells was examined using a mouse END-D cell line. Anti-Fas agonistic antibody exhibited cytotoxic actions on END-D cells. Fas-mediated cell death was enhanced by LPS or IFN-gamma. The combination of IFN-gamma and LPS significantly enhanced cell death compared to IFN-gamma or LPS alone. IFN-gamma and LPS augmented cell surface expression of Fas, but not tumour necrosis factor (TNF) receptor 1. Inhibitors of p38 mitogen-activated protein kinase (MAPK) prevented augmentation of Fas expression in IFN-gamma and LPS-treated END-D cells. IFN-gamma and LPS-treated END-D cells did not become susceptible to TNF-alpha or nitric oxide-mediated cytotoxicity. IFN-gamma and LPS thus appear to augment selectively Fas expression via activation of p38 MAPK and enhance Fas-mediated cell death in END-D cells. Furthermore, administration of IFN-gamma and LPS into mice induced in vivo expression of Fas on vascular endothelial cells and Fas ligand (FasL) on peripheral blood leucocytes. The relationship between enhancement of Fas-mediated cell death by IFN-gamma and LPS and the development of vascular endothelial injury is discussed.

Modified Irinotecan/5FU/Leucovorin therapy in advanced colorectal cancer and predicting therapeutic efficacy by expression of tumor-related enzymes

OBJECTIVE

To evaluate the efficacy and safety of a regimen using Irinotecan, 5FU and Leucovorin for patients with advanced or recurrent colorectal cancer.

MATERIAL AND METHODS

Irinotecan (75 mg/m(2)) was administered biweekly, while 5FU (600 mg/m(2)) and Leucovorin (250 mg/m(2)) were administered weekly, for 6 weeks.

RESULTS

The 21 consecutive patients subjected to this regimen showed a good response rate (43%) with minimal toxicity (incidence of grade 3/4: leukopenia and neutropenia, 5%, respectively, and vomiting, 10%). The mean survival time of all 21 patients was 15.7 months. This regimen could be a valid option for patients with advanced colorectal cancer, especially those seeking a good QoL (quality of life) for the remainder of their lives. We evaluated the expression of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), thymidine phosphorylase (TP) and orotate phosphoribosyl transferase (OPRT) mRNAs, and sialyl Lewis X on formalin-fixed, paraffin-embedded colorectal tumor samples. Expression of TS mRNA or sialyl Lewis X was negatively correlated with the response from chemotherapy. Patients with low DPD mRNA expression in the tumor showed a significant longer survival than those with high expression. In patients with high TP mRNA expression, there was a tendency towards a high incidence of leukopenia.

CONCLUSIONS

Some predictive factors elucidated in this study could contribute to the progress of the tumor-biology based, individualized chemotherapy for colorectal cancer patients.

Efficacy of S-1 for patients with peritoneal metastasis of gastric cancer

BACKGROUND

This study was designed to examine the efficacy and compliance of S-1 for the patients with peritoneal metastasis of gastric cancer.

METHODS

Sixteen consecutive patients with peritoneal metastasis of gastric cancer were treated with S-1. Their survival was compared with that of the historical control group (25 patients). Thymidylate synthase, dihydropyrimidine dehydrogenase, thymidine phosphorylase and orotate phosphoribosyl transferase mRNA expression in the tumor were evaluated.

RESULTS

The median survival time of S-1-treated patients was 550 days, which was significantly longer than that of the historical control group (215 days). We elucidated some factors to prolong the survival of the patients treated with S-1 for peritoneal metastasis: peritoneal metastasis without other distant metastases, the combination of S-1 treatment and gastrectomy, and low expression of thymidine phosphorylase mRNA in primary tumors.

CONCLUSIONS

S-1 showed a surprisingly long-term survival with minimum toxicity in patients with peritoneal metastasis of gastric cancer.

Usefulness of preoperative endobronchial ultrasound for airway invasion around the trachea: esophageal cancer and thyroid cancer

BACKGROUND

It is important to confirm preoperative tracheobronchial invasion to enable the selection of the most appropriate treatment.

OBJECTIVE

This study was performed to compare the usefulness of computed tomography (CT), magnetic resonance image (MRI) and bronchoscopy by endobronchial ultrasonography (EBUS) for the assessment of invasion of thyroid or esophageal cancer in cases with suspected tracheobronchial invasion.

METHODS

In cases with suspected contact between the tumor and tracheobronchial wall, CT, MRI and EBUS indicated deformity of the tracheobronchial wall due to the adjacent mass. The final diagnosis was based on surgical and histological results, and/or clinical follow-up.

RESULTS

Fifty-four patients were included in this study. Based on the findings of CT, MRI and EBUS, invasion was suspected in 29, 28 and 25 patients, respectively. Seventeen patients did not undergo surgery based on the results of CT, MRI and bronchoscopy with EBUS. Final diagnosis was intact trachea or bronchial adventitia in 26 patients and invasion in 28 patients. The sensitivity and specificity of CT, MRI and EBUS for invasion were 59 and 56, 75 and 73, and 92 and 83%, respectively. The accuracy of EBUS was significantly greater than that of CT in the present study (p = 0.0011). The accuracy of EBUS was significantly different from that of CT and MRI in the surgically treated patients (p = 0.005 and p = 0.032, respectively).

CONCLUSION

EBUS is the most useful technique for determining the depth and extent of tumor invasion into the airway wall. The combination of MRI and EBUS will contribute to surgical planning in patients with esophageal and thyroid cancer.

Effect of weight loss using formula diet on renal function in obese patients with diabetic nephropathy

OBJECTIVE

To evaluate the effect and safety of treatment with low-calorie formula diet on renal function and proteinuria in obese patients with diabetic nephropathy.

DESIGN

Prospective study on safety and efficacy of a 4-week low-calorie (11-19 kcal/kg/day) normal-protein (0.9-1.2 g/kg/day) diet partly supplemented with formula diet.

SUBJECTS

In all, 22 obese patients with diabetic nephropathy (BMI: 30.4+/-5.3 kg/m(2), HbA1c: 7.1+/-1.4%, serum creatinine: 172.4+/-57.5 micromol/l, urinary protein: 3.3+/-2.6 g/day).

RESULTS

The mean body weight decreased by 6.2+/-3.0 kg. The mean systolic blood pressure, creatinine, blood urea nitrogen, urinary protein, and 8-hydroxydeoxyguanosine decreased significantly by 7.5+/-12.7 mmHg, 41.6+/-23.9 micromol/l, 1.50+/-1.61 mmol/l, 1.8+/-1.7 g/day, and 3.1+/-3.6 ng/mg creatinine, respectively. No patient had increased serum creatinine and urinary protein. Mean creatinine clearance (40.6+/-17.9 to 46.1+/-14.6 ml/s/1.73 m(2)) and serum albumin showed no significant changes. Delta serum creatinine and Delta urinary protein correlated with Delta body weight (r=0.62 and 0.49, respectively) and Delta visceral fat area (r=0.58 and 0.58, respectively), but did not correlate with Delta systolic blood pressure, Delta fasting blood glucose and Delta subcutaneous fat area.

CONCLUSION

These results suggested that weight reduction using formula diet might improve renal function and proteinuria safely for a short term in obese patients with diabetic nephropathy.

Perioperative blood transfusion and survival following curative hepatic resection for hepatocellular carcinoma

BACKGROUND/AIMS

The association between transfusion and recurrence after resection for hepatocellular carcinoma (HCC) is still under debate. The influences of perioperative blood transfusion on survival and recurrence after curative hepatic resection for HCC and prognostic factors in patients with blood transfusion were evaluated.

METHODOLOGY

Curative hepatectomy was performed in 210 patients (57%) with and 158 (43%) without perioperative blood transfusion. Prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model.

RESULTS

Multivariate analysis revealed that perioperative blood transfusion was an independent predictor for recurrence in patients with serum low albumin level (< 3.5 g/dL). In transfused group, stage IV, large tumor size (> or = 5 cm), high value of ICGR15 (> or = 20%), and old age (> or = 60 year) were independent factors of poor disease-free survival.

CONCLUSIONS

Perioperative blood transfusion promotes the recurrence of HCC after hepatic resection in patients with hypo-albuminemia. In transfused patients, establishment of strategy for recurrence based on pTNM staging, tumor size, ICGR15, and age may be required to improve survival.

Significance of macrophage chemoattractant protein-1 expression and macrophage infiltration in squamous cell carcinoma of the esophagus

OBJECTIVES

Macrophage chemoattractant protein-1 (MCP-1) is a chemokine-inducing infiltration of macrophages, which can play several roles in tumor growth and metastasis. We have attempted to clarify the relationship between MCP-1 expression and macrophage infiltration in esophageal squamous cell carcinoma (SCC).

METHODS

Paraffin-embedded sections of tissue samples taken from 56 patients with esophageal SCC after curative surgery were immunohistochemically stained for MCP-1, CC chemokine receptor 2 (CCR-2), and thymidine phosphorylase (TP). Macrophage recruitment in SCC was evaluated by monocytic count based on CD68 immunostaining. Microvessels immunostained for Factor VIII-related antigen were counted in SCC, and microvessel density (MVD) was determined. Ki-67 labeling index was calculated based on Ki-67 immunostaining, and an apoptotic index was calculated based on the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick end labeling.

RESULTS

MCP-1 was expressed in cancer cells of 31 SCC (55.4%) and in stromal cells mainly identified as macrophages of 16 SCC (28.6%). CCR-2 was expressed in stromal cells of all SCC and in vascular endothelial cells of 15 SCC (26.8%). There was a significant correlation between the expression of MCP-1 in cancer cells and of CCR-2 in stromal cells. TP was expressed in stromal cells in 76.7% of the SCC. Monocytic count, MVD, and Ki-67 LI in SCC with MCP-1 expression in cancer cells were higher than that without, and apoptotic index in SCC with MCP-1 expression in cancer cells were lower than that without. Furthermore, the monocytic count was positively correlated with MVD, while it was inversely correlated with apoptotic index. Clinicopathologically, MCP-1 expression in cancer cells was correlated with venous invasion, distant metastasis, and lymph node metastasis. Monocytic count in SCC with venous invasion, distant metastasis, or lymph node metastasis was higher than that without them. Five-year survival rate in the patients with high monocytic count or MCP-1 expression was worse than that with a low monocytic count or without MCP-1 expression.

CONCLUSIONS

These results suggest that MCP-1 expression and macrophage infiltration is associated with angiogenic promotion in esophageal SCC. MCP-1 expression may be interactively associated with macrophage infiltration in esophageal SCC; MCP-1 may play an important role in tumor angiogenesis through production of angiogenic factors, such as TP, by recruited macrophages in esophageal SCC. Furthermore, CCR-2 expression in vascular endothelial cells may participate partially in angiogenesis. Clinicopathologically, esophageal SCC patients with MCP-1 expression have no favorable prognosis.

Thoracoscopic enucleation of esophageal stromal tumor

Gastrointestinal stromal tumor is a rare entity, especially in the esophagus. We report a patient with a stromal tumor of the esophagus who underwent a thoracoscopic enucleation of the tumor. The patient was a 61-year-old man complaining of slight dysphagia. A submucosal tumor of the middle thoracic esophagus was found endoscopically. The tumor was approximately 4.0 cm in diameter measured by endoscopic ultrasonography. On 17 May 2001, thoracoscopic enucleation of the esophageal tumor was performed using a Kodama Di-suction. The Kodama Di-suction was useful for the thoracoscopic enucleation of the submucosal tumor of the esophagus, acting as both a dissector and a sucker. The patient's course was uneventful after surgery. Histopathologically the esophageal tumor revealed a high cellularity, consisting of spindle cells, and the tumor cells were immunohistochemically positive for CD34 and c-kit protein, but not for a-smooth muscle actin or S-100 protein. From these findings, the esophageal submucosal tumor was diagnosed as gastrointestinal stromal tumor, distinguished from leiomyoma.

Stromal tumor of the pancreas with expression of c-kit protein: report of a case

We report on a case of a stromal tumor, similar to a gastrointestinal stromal tumor, originating from the pancreas. The patient was a 54-year-old woman, who was seen at the Kofu Municipal Hospital because of an abdominal tumor. On abdominal computed tomography and splenic arteriography, the tumor was detected in the pancreatic tail. The patient underwent distal pancreatectomy with splenectomy. Macroscopically, the cut surface of the tumor showed almost completely surrounded by the normal pancreatic tissue. Microscopically, the tumor composed of spindle-shaped cells that were immunoreactive for vimentin, CD34, and c-kit protein. Therefore, the tumor was diagnosed as a stromal tumor of the pancreas. The expression of c-kit protein suggests that this pancreatic stromal tumor may originate from primitive mesenchymal cells which can be a logical candidate for the origin of gastrointestinal stromal tumors and extra-gastrointestinal stromal tumors.

Basaloid-squamous carcinoma of the esophagus treated by preoperative chemotherapy: report of two cases

Basaloid squamous carcinoma (BSC) of the esophagus has been associated with a poor outcome after surgery. We herein report two patients with esophageal BSC treated by preoperative chemotherapy. Patient 1 was a 55-year-old man who presented with a tumor of the middle esophagus diagnosed as BSC. He was treated by chemotherapy using a combination of 5-fluorouracil (5-FU: 750 mg/m(2), 1st-5th day, 24-h continuous infusion) and cisplatin (CDDP: 75 mg/m(2), 1st day, drip infusion per 2 h) before surgery, because of lymph node metastases of the mediastinum and around the left gastric artery. Even though the metastatic nodes were reduced and an esophagectomy was performed, the patient died of recurrence 12 months after chemotherapy. Patient 2 was a 57-year-old man who demonstrated BSC of the esophagus with direct invasion to the discending aorta, who was treated by preoperative chemotherapy using the same regimen as that of patient 1. The esophageal tumor was reduced, and a curative esophagectomy was performed. The patient is now alive without recurrence 38 months after chemotherapy. In conclusion, preoperative chemotherapy using a combination of 5-FU and CDDP may thus be an effective treatment for patients with advanced BSC of the esophagus.

Small cell carcinoma of the esophagus with reference to alternating multiagent chemotherapy: report of two cases

We herein report the findings of two patients with small cell carcinoma of the esophagus (SCEC) who were treated with alternating chemotherapy using cisplatin and etoposide (PVP), and cyclophosphamide, adriamycin or epirubicin, and vincristine (CAV). Patient 1 was a 61-year-old woman with SCEC. Her serum level of pro-gastrin-releasing peptide (Pro-GRP) was elevated (79.8 pg/ml; normal range <46.0 pg/ml). The patient underwent an esophagectomy following PVP/CAV-therapy. Six months later her serum level of Pro-GRP became elevated, and multiple metastases to the liver and lung were detected. Two courses of PVP/CAV-therapy were performed, and these metastatic foci almost completely disappeared. The serum level of Pro-GRP was in the normal range. One year after surgery, multiple brain metastases and recurrence of liver metastases were detected, then the serum level of Pro-GRP became re-elevated. Two courses of PVP/CEV-therapy were performed, and the metastases to the brain and liver decreased in size. However, the brain metastases relapsed, and the patient died 21 months after the diagnosis. Patient 2 was treated with two courses of preoperative PVP/CAV-therapy; however, the patient died of multiple liver metastases 17 months after the diagnosis. In six previously documented patients and the two present patients who were treated with PVP/CAV-therapy, the primary or metastatic foci of SCEC decreased in size, and the mean survival of the patients was 19 months. In conclusion, PVP/CAV alternating chemotherapy is beneficial for prolonging the survival of SCEC patients; however, new chemotherapeutic modalities are still needed to further improve the prognosis of SCEC patients. Furthermore, the level of serum Pro-GRP in patients with SCEC may be both a diagnostic marker and a therapeutic monitor.

Cardiac myxoma: its origin and tumor characteristics

Cardiac myxoma is most common among primary cardiac tumors, and its origin and tumor characteristics have been gradually elucidated by recent advances in molecular biology. Prichard's structure in the interatrial septum which was reported to be a candidate for the origin of cardiac myxoma, was revealed to be age-related changes. In hereditary cardiac myxoma "Carney complex", chromosomal abnormalities involving chromosomes 2p, 12 and 17q have been reported, however, no genetic abnormalities of these locus were found in the development of sporadic cases. Cardiac myxoma has multiple differentiating potentials, and recently various amounts of cardiomyocyte-specific transcription factor genes were identified. This indicates that cardiac myxoma might arise from mesenchymal cardiomyocyte progenitor cells. Various cytokines and growth factors such as vascular endothelial growth factor, basic fibroblast growth factor, monocyte chemotactic protein-1 and interleukin-6 were involved in tumor growth and angiogenesis. Although cardiac myxoma usually presents as a benign neoplasm, reports suggesting its malignancy, including recurrence of the tumor, locally invasive myxoma, extension from the heart, and distant metastasis are increasing. These genetic and molecular approaches to cardiac myxoma may prompt the development of therapeutic modalities for treatment of malignancies and cardiac cell regeneration.

Food residue at endoscopy in patients who have previously undergone distal gastrectomy: risk factors and patient preparation

BACKGROUND AND STUDY AIMS

Food residue is often seen in the gastric remnant after partial gastrectomy, making it difficult to diagnose early cancer in the residual stomach. The aims of this study were to clarify the risk factors for the accumulation of food residue, and to study methods of preparation for endoscopy in patients who had undergone distal gastrectomy.

PATIENTS AND METHODS

374 endoscopic examinations of patients who had undergone distal gastrectomy for gastric cancer were compared with 2168 endoscopic examinations in patients without a history of gastrectomy. Relationships between the presence of food residue and a number of clinical factors, including patient preparation, were evaluated by univariate and multivariate analyses.

RESULTS

Food residue in the gastric remnant was observed in 70 examinations (18.7 %), a significantly higher proportion than that found in control patients (0.3 %). From multivariate analysis, underlying diseases (endocrine, metabolic, or connective tissue disease), Billroth type I reconstruction, and postoperative gastric retention were found to be independent risk factors for the accumulation of food residue. Diet preparation (a liquid diet plus aclatonium napadisilate) significantly decreased the incidence of food residue.

CONCLUSIONS

Our diet preparation method can be recommended as a preparation for upper gastrointestinal endoscopy in patients who have undergone distal gastrectomy, especially in patients with additional risk factors.

Small-intestinal sarcomatoid carcinoma with superior vena cava syndrome

A 56-year-old man was hospitalized because of swelling of the right upper extremity and anemia. A diagnosis of superior vena cava (SVC) syndrome caused by lymphogenous metastasis was made after chest computed tomography (CT) scan and biopsy of cervical lymph nodes were carried out. Standard examinations, such as abdominal CT scan and endoscopies of the upper and lower gastrointestinal tract, failed to find the primary lesion. However, selective angiography of the superior mesenteric artery (SMA) showed a clear stain of bleeding vessels in the small intestine. Laparotomy was performed, and immunohistochemical findings revealed sarcomatoid carcinoma in the small intestine (a rarely seen neoplasm). This aggressive carcinoma, which showed negative reactivity with CD34, CD117 (c-kit), and S-100 was clearly distinguished from other mesenchymal tumors, such as malignant gastrointestinal stromal tumor (GIST) and malignant fibrous histiocytoma (MFH).