Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer.

BACKGROUND/AIMS: The aim of this study was to evaluate the risk factors of perforation during endoscopic submucosal dissection (ESD). METHODOLOGY: ESD was performed using a Flex knife in 64 patients with a total of 67 gastric tumors. Perforation occurred at the sites of a total of 4 lesions (5.9% [4/67]) for which conservative treatment had been effective. We evaluated several possible risk factors for perforation following ESD, such as tumor size, the location of the lesion, the operation time, and other clinical factors. RESULTS: All the perforations occurred in the posterior wall of the gastric upper or middle body. In an analysis adjusted for age and sex, the tumor size (odds ratio (OR), 1.017; 95% confidence interval (CI), 1.004-1.030), the location of the lesion in an upper region (OR, 10.64; 95%CI, 1.160-10.00) and the operation time (OR, 1.017; 95%CI, 1.013-1.295) were significantly associated with the incidence of perforation. All perforations were transient, resolving within 7 days, and did not require surgical treatment. CONCLUSIONS: A large tumor size, the location of the lesion in an upper region, and a long operation time are risk factors for perforation following ESD.

Allergic reactions to oxaliplatin in a single institute in Japan.

Allergic reactions to oxaliplatin can be severe and are an important cause of discontinuation of treatment. A retrospective review was performed for 105 patients who received FOLFOX regimens between May 2005 and June 2007. Twenty-five cases (23.8%) of allergic reactions were identified, including 9 late onset reactions (8.6%) and 16 immediate reactions (15.2%). Severe allergy (Grades 3 and 4) occurred in seven patients (6.7%). Re-introduction of FOLFOX was attempted for seven immediate onset patients with a severity grade of 1 or 2, and three of these patients (42.9%) showed relapse of allergy. In approximately 10% of the patients, FOLFOX had to be discontinued due to allergy before the disease became refractory to the regimen. Our experience indicates that allergy to oxaliplatin may be a significant concern and that methods are required for suppression of this allergy.

Gastric surgery is not a risk factor for the development or progression of Barrett's epithelium.

BACKGROUND/AIMS: Barrett's epithelium is currently believed to be related to acid gastroesophageal reflux. The aim was to determine the role of pancreatic-biliary reflux in the genesis of Barrett's epithelium. METHODOLOGY: The study population comprised 1055 cases (606 men and 449 women; median age, 67 years) who had undergone an upper endoscopy at the Gastroenterology Division of Yokohama City University Hospital between August 2005 and July 2006. The study population was composed of 869 cases with intact stomachs and 186 cases with distal-gastrectomies. The presence and the progression of Barrett's epithelium were diagnosed based on the Prague C & M Criteria. The correlations of clinical factors, including distal-gastrectomy, with the presence and the progression of Barrett's epithelium were examined. RESULTS: The study demonstrated that 42.2% of the total population was diagnosed to have Barrett's epithelium and, in 12.6% of the cases with Barrett's epithelium, the progression of Barrett's epithelium was observed during the median 72 month followup. A distal gastrectomy was not significantly correlated with either the incidence or progression of Barrett's epithelium. CONCLUSIONS: This lack of association between gastric surgery and Barrett's epithelium suggests that pancreatic-biliary reflux with limited acid is not sufficient for the genesis of Barrett's epithelium.

Reduction therapy of alanine aminotransferase levels prevent HCC development in patients with HCV-associated cirrhosis.

BACKGROUND: To find a way to prevent the development of hepatocellular carcinoma (HCC) from hepatitis C virus-associated liver cirrhosis (HCV-LC), an analysis of the HCV-LC patients who had received reduction therapy of the alanine aminotransferase (ALT) levels was performed. PATIENTS AND METHODS: Seventy-four consecutive HCV-LC patients of Child Stage A were followed for >10 years for the development of HCC. They were divided into two groups: in group A, the reduction therapy for the ALT levels was aggressively performed, while in group B, the reduction therapy was not performed aggressively. The patients were subdivided into three sub-groups according to their serum ALT levels. In groups A and B, the high ALT group was comprised, respectively, of nine and five patients whose annual average serum ALT levels were persistently high (> or =80 IU), while the low ALT group was comprised of 19 and 20 patients whose annual average serum ALT levels were persistently low (<80 IU). The remaining eleven and ten patients had annual average serum ALT levels which fluctuated and were unclassified (unclassified group). RESULTS: In group B, 65.7% of the patients had developed HCC in 13 years, in contrast to only 41.0% of group A (p=0.039). In group A, the median HCC development time was 12.8 years, in contrast to only 3.8 years in group B (p=0.0013). Multivariate analysis demonstrated that the mode of reduction therapy and ALT levels were the significant factors affecting HCC development. CONCLUSION: The chances of surviving for more than ten years without developing HCC for HCV-LC patients

Ursodiol use is possibly associated with lower incidence of hepatocellular carcinoma in hepatitis C virus-associated liver cirrhosis.

In a previous study of patients with hepatitis C virus (HCV)-associated liver cirrhosis (HCV-LC), we showed that increased liver inflammation, as assessed by higher serum alanine aminotransferase (ALT), was associated with increased risk for the development of hepatocellular carcinoma (HCC). This suggested that suppression of inflammation might inhibit HCC development in HCV-LC. Several agents have been suggested to possess chemopreventive potential against the development of HCC in chronic HCV-associated liver disease, including herbal medicines, such as Stronger-Neo-Minophagen C (glycyrrhizin) and Sho-saiko-to (TJ-9). Ursodiol [ursodeoxycholic acid (UDCA)], a bile acid widely used to treat cholestatic liver diseases, also possesses anti-inflammatory properties in liver disease. We hypothesized that suppression of liver inflammation, as assessed by decreases in serum ALT, might inhibit HCC occurrence in patients with HCV-LC. In this study, the preventive effect of UDCA on HCC was examined in patients with early-stage HCV-LC. One hundred two patients with HCV-LC (Child stage A) were treated with anti-inflammatory drugs, Stronger-Neo-Minophagen C,Sho-saiko-to, or UDCA, with the goal of lowering the average serum ALT level to <80 IU. Iftheaverage ALT level did not remain <80 IU after treatment with one agent, multiagent therapy was initiated. The patients were followed up for >5 years and were retrospectively subdivided into two groups: 56 UDCA users (group A) and 46 UDCA nonusers (group B). The mean +/- SD dosage of UDCA administered in group A was 473.7 +/- 183.0 mg/d. The average duration of UDCA administration in group A was 37.3 +/- 15.9 months over the 5-year study period. The cumulative incidence of HCC was recorded. The 5-year incidence of HCC in group A was 17.9% (10 of 56) and was significantly lower than that in group B (39.1%, 18 of 46; P = 0.025). The risk for HCC incidence, calculated by a logistic regression model, showed that the administration of UDCA significantly decreased hepatocarcinogenesis (P = 0.036). The herbal medicines used were comparable in dosage and treatment duration in the UDCA and non-UDCA groups. In conclusion, UDCA might prevent HCC development in HCV-LC. Interestingly, because the serum ALT trends over time were nearly the same in both groups, the chemopreventive effectiveness of UDCA was not accompanied by greater reductions in ALT compared with the UDCA nonusers.

Sustained low alanine aminotransferase levels can predict the survival for 10 years without hepatocellular carcinoma development in patients with hepatitis C virus-associated liver cirrhosis of child stage A.

An analysis was performed of the patients with hepatitis C virus-associated liver cirrhosis (HCV-LC) who never developed hepatocellular carcinoma (HCC) for 10 years after the histological diagnosis of LC. Seventy-four consecutive HCV-LC patients of Child stage A were observed for >10 years prospectively for the development of HCC with frequent ultrasonography and magnetic resonance imaging or computed tomography. Of the 63 patients who fulfilled the study, 48 patients were treated and 15 were nontreated because of their stable state. They were subdivided into three groups according to their serum alanine aminotransferase (ALT) levels: the high ALT group comprised of 23 patients whose annual average serum ALT level was persistently high (>/=80 IU); the low ALT group comprised of 28 patients whose annual average serum ALT level was persistently low (<80 IU), and the unclassified ALT group comprised of 12 patients. In the low ALT group, as high as 71.4% of patients had never developed HCC for 10 years, in contrast to only 17.4% in the high ALT group (p < 0.001). In the 30 patients who never developed HCC for 10 years, 20 patients belonged to the low ALT group, in contrast to only 4 belonging to the high ALT group. Sustained low ALT levels were important to survive for 10 years without developing HCC in the HCV-LC patients of Child stage A.

Serum alanine aminotransferase levels and survival after hepatectomy in patients with hepatocellular carcinoma and hepatitis C virus-associated liver cirrhosis.

We examined whether sustained alleviation of inflammation as monitored by serum alanine aminotransferase (ALT) levels was associated with longer survival in hepatectomized hepatocellular carcinoma (HCC) patients with hepatitis C virus-associated liver cirrhosis (HCV-LC). Thirty-four hepatectomized patients with HCV-LC and HCC as a single nodule, and for whom more than 5 years had elapsed after the hepatectomy, were studied. They had no histologic evidence of portal or hepatic vein invasion. They were subdivided into two groups according to their serum ALT levels in the 2 years after hepatectomy: the low ALT group comprised 13 patients whose serum ALT levels showed a sustained low level below 80 IU, and the high ALT group comprised 21 patients whose serum ALT levels showed several peaks or plateaus above 80 IU. The patients had been followed-up prospectively with frequent ultrasonography and magnetic resonance imaging or computed tomography for recurrence for > 5 years. The survival period, non-recurrence interval and number of recurrences were observed. Recurrences were treated with transcatheter chemoembolization in all cases. The cumulative survival rate in the low ALT group was significantly better than that in the high ALT group (P < 0.05). The 5-year survival in the low ALT group was as high as 92.3% (12 of 13) compared with 33.3% (7 of 21) in the high ALT group (P < 0.05). The cumulative non-recurrence rate in the low ALT group was also significantly better than that in the high ALT group (P < 0.01). The survival period correlated well with the interval until the first recurrence (r = 0.545, P = 0.006). There was a tendency for the number of recurrences in the low ALT group (1.5 +/- 0.4, mean +/- SE) to be fewer than that in the high ALT group (2.2 +/- 0.4), although this was not significant. Sustained alleviation of inflammation, as indicated by low ALT levels, provides a survival advantage mainly due to the longer non-recurrence interval, and possibly because of fewer recurrences, in hepatectomized HCC patients with HCV-LC.

[A case of advanced pancreatic cancer showing remarkable response to gemcitabine treatment].

A 46-year-old woman with a 3-month history of upper abdominal pain was referred to our hospital because of the presence of a pancreatic mass and multiple hepatic nodules on abdominal ultrasonography (US) and computed tomography (CT). We concluded that the patient had pancreatic cancer with multiple hepatic metastases on the findings of endoscopic retrograde cholangiopancreatography (ERCP) and fine needle aspiration biopsy of the hepatic nodule. The patient received gemcitabine treatment. Gemcitabine 1,000 mg/m2 was administered once a week for 3 weeks followed by a week of rest, this constituting 1 cycle of treatment. Partial responses (PR) of both pancreatic and hepatic lesions were observed after the first cycle of the gemcitabine treatment, and serum concentrations of CEA and CA19-9 remarkably decreased. We considered that clinical benefit was obtained because Karnofsky performance status improved and analgesic consumption decreased. Such effectiveness of the gemcitabine treatment lasted for the following 4 cycles. In general, chemotherapy has few effects on an advanced pancreatic cancer. We report a case of advanced pancreatic cancer that could obtain remarkable antineoplastic effect and clinical benefit with gemcitabine treatment.

[Examination of percutaneous microwave coagulation and radiofrequency ablation therapy for metastatic liver cancer].

Percutaneous microwave coagulation therapy (PMCT) and radio frequency ablation therapy (RFA) as treatments for metastatic liver cancer were examined. PMCT or RFA was administered for 18 metastatic liver cancer lesions (primary lesion: 11 colon rectal cancer, one esophagus cancer, one thyroid cancer, one pancreatic cancer, one pheochromocytoma) in 16 patients from July 1999 to March 2002. RFA was performed 1 time for 12 minutes in principle, using a Cool-tip RF system from Radionics. Patients had a mean age of 58.8 years and the mean diameter of the neoplasms was about 22 mm. Critical complications were not seen. The rate of partial recurrence was 35.3% as of March, 2002, in an average observation period of 7.3 months. On the other hand, with the medical treatment for the hepatocellular carcinoma provided during this period, the rate of partial recurrence was 14.8%. The treatment of metastatic liver cancer by PMCT and RFA is associated with a high rate of a recurrence as compared with hepatocellular carcinoma, and needs to be examined to discover ways of adaptation and improvement of the technology.