Non-surgical treatment of gastric emphysema with intraabdominal free gas and hepatic portal venous gas: Lessons from a rare case.

We herein describe a case of an 83-year-old man who presented with epigastralgia, vomiting, and abdominal distention. The physical abdominal examination revealed mild tenderness. Computed tomography revealed intramural gastric gas spread throughout the stomach, intraabdominal free gas, and hepatic portal venous gas. We diagnosed gastric emphysema with intraabdominal free gas and hepatic portal venous gas. We selected a wait-and-watch approach because physical examination did not show any peritoneal signs, although the radiological examinations showed remarkable findings. As a result, he received conservative therapy with fasting, intravenous infusion of antibiotics, and gastric decompression by nasogastric intubation. The patient was relieved of the symptoms, and follow-up computed tomography showed that all the abnormal gas disappeared soon after the treatment. In conclusion, the intramural gastric gas even with both intraabdominal free gas and hepatic portal venous gas does not always require surgical intervention. In case clinicians including general surgeons and physicians encounter intraabdominal free gas with hepatic portal venous gas, gastric emphysema should be considered in the different diagnosis. Lack of knowledge may lead to misdiagnosis, which may result in unnecessary surgical intervention.

[A patient with advanced remnant gastric cancer responding completely to S-1 monotherapy].

A 74-year-old man with anemia visited our hospital. When he was 42 years old, he was diagnosed with duodenal ulcer and underwent gastrectomy with Billroth II construction. A gastrointestinal endoscopic examination revealed an ulcerative lesion at the remnant stomach, and the pathological examination of the biopsy specimen showed moderate to poorly differentiated adenocarcinoma. Abdominal CT scan revealed liver and para-aortic lymphnode metastases. He received daily oral administration of S-1 at a dose of 100 mg/body, bid, 4 weeks on and 2 weeks off. After 4 courses of S-1, CT scan showed a complete response of the liver and also para-aortic lymphnode metastasis. He underwent total remnant gastrectomy with D2 dissection. Histological examination revealed no residual cancer cells in the surgically removed stomach and lymphnode, and he was diagnosed a complete pathological response (Grade 3). He refused adjuvant S-1, but is in good health without recurrence 2 years after the operation.

Complete cure of metastatic gastric cancer treated with combination chemotherapy using S-1.

A 65-year-old man had gastric cancer with liver and lung metastases, and received three cycles of FLEP (5-fluorouracil, leucovorin, etoposide, cisplatin) chemotherapy on June, 2001. The primary lesion became scar ulceration and adenocarcinoma tissue was recognized by biopsy pathologically. The lung metastases and lymph node metastases disappeared. The metastatic liver lesion decreased more than 95% in size and was judged partial response. Thereafter he received only oral administration of 100mg S-1 (70mg/m2). The metastatic liver lesion was shown to have disappeared on CT of the abdomen and was judged complete response, on June, 2002. Since then, he was receiving S-1 and continued to be complete response for two and half years until June, 2004. The clinical trial of S-1 as an adjuvant therapy for patients with advanced gastric cancer, who underwent curative resection, is ongoing in a multicenter study. Although the outcome is still unknown, the effect of S-1 for adjuvant chemotherapy may be also promising. We think that S-1 is useful as an adjuvant therapy and maintenance therapy of prior treatment including surgical resection.

[Complete response of recurrent gastric cancer to chemotherapy with TS-1 and CPT-11--a case report].

A 58-year-old man with gastric cancer who had undergone distal gastrectomy on February 8, 2001 was revealed to have anorexia, and was diagnosed with a local recurrence in anastomosis by upper GI examination in August 2003. In September 2003, he was given combination chemotherapy with TS-1 50 mg/m2 (days 1-14) and CPT-11 80 mg/m2 (days 1, 8) every 3 weeks. A complete response (CR) was confirmed by endoscopy in December 2003. At present, he has been receiving chemotherapy with only TS-1 50 mg/m2 as a maintenance therapy and continuing CR. However, a trial of combination therapy with TS-1 plus CPT-11 is ongoing, and this combination chemotherapy may well achieve a high response rate. Because the adverse events of this chemotherapy have been mild and tolerable in some of our cases, this regimen is considered very useful.

FLEP chemotherapy for alpha-fetoprotein-producing gastric cancer.

OBJECTIVE: This study aimed at comparing the efficacy of FLEP chemotherapy in the treatment of stage IV AFP-producing gastric cancer and stage IV non-AFP-producing gastric cancer. METHODS: Between 1989 and 2002, 57 patients with stage IV inoperable gastric cancer were given a combination of chemotherapy with 5-fluorouracil (5-FU), leucovorin (LV), etoposide (VP-16) and cis-diamminedichloroplatinum (CDDP) (designated as FLEP). In the two groups classified histologically according to AFP positivity, the rate of response and conversion to surgery, disease-free and overall survival were compared. The disease-free and overall survival in the two groups was compared by a log-rank test. RESULTS: Patients of the AFP-producing group had a significantly better response rate (70 vs. 31.9%, p = 0.03) and a better conversion rate (40 vs. 12.8%, p = 0.04) than those of the non-AFP-producing group. Patients of the AFP-producing group also had a significantly better disease-free and overall survival (p = 0.02) than those of the non-AFP-producing group. AFP-producing gastric cancer was identified as an independent prognostic factor. CONCLUSION: FLEP chemotherapy was more effective for stage IV AFP-producing gastric cancer than in stage IV non-AFP-producing gastric cancer. Preoperative FLEP chemotherapy improved the prognosis of AFP-producing gastric cancer because of downstaging.

[A case report of colon cancer with liver and lung metastases responding to combination chemotherapy with l-LV, 5-fluorouracil and CPT-11].

A 58-year-old man who had colon cancer with liver and multiple lung metastases underwent ileocecal resection on May 10, 2002. MTT assay of 5-FU and CPT-11 was performed with resected material, with both medicines accepted for sensitivity. On June 4, he received combination chemotherapy with CPT-11 + 5-FU/l-LV. The liver metastasis disappeared and was judged CR from a CT of the abdomen. Almost all the multiple lung metastases had disappeared or were decreased in size. They were therefore judged NC from a CT of the chest. Moreover, CEA and CA19-9 decreased to within normal limits. While he was receiving bimonthly chemotherapy with only CPT-11 as a maintenance therapy, liver and lung metastases did not change. Combination chemotherapy with CPT-11 + 5-FU/l-LV is effective. The anticancer drug sensitivity examination is only one index, however. Considering adverse effects and medical costs, individualized therapy based on the sensitivity test for anticancer drugs should be performed.

Adjuvant therapy for resected gastric carcinoma.

Despite its continued decline over the past 40 years, gastric carcinoma is a common gastrointestinal cancer and a major health problem around the world. In Asian countries, such as Korea, Japan, Taiwan, and China, it remains one of the leading causes of cancer-related death. Similarly, it is a common malignancy in many South American countries, Eastern European countries, and many countries of the former Soviet Union. In North America, the incidence of gastric carcinoma is low; however, the incidence of proximal gastric carcinoma has risen over the past 15 years. In 2001, approximately 21,700 new cases and 12,800 deaths were estimated in the United States as a result of gastric carcinoma. In the United States, gastric cancer ranks 14th among all cancers in incidence rate and 10th in overall mortality rate. An early detection program has been established in Japan, where nearly 6,000,000 adults are screened annually. This type of mass screening for gastric cancer is not practiced elsewhere, however. Because the risk of relapse remains high for patients after a curative resection, there is a great need for effective adjuvant therapy for patients with gastric carcinoma.

Combination chemotherapy comprising 5-fluorouracil, leucovorin, etoposide, and cis-diamminedichloroplatinum for the treatment of advanced gastric cancer.

PURPOSE: The FLEP regimen (5-FU, LV, ETP, and CDDP) has been recommended as a combination chemotherapy to control advanced and recurrent gastric cancer. We performed a phase II study of this regimen in 49 patients with advanced gastric cancer. METHODS: The treatment regimen consisted of: 5-FU at 370 mg/m(2) (days 1-5, i.v. 24 h); LV at a dose of 30 mg (days 1-5, i.v. bolus); and ETP and CDDP each at 70 mg/m(2) (days 7 and 21, i.a. 2 h), which was repeated every five weeks. RESULTS: The overall response rate was 40.8% (20/49 patients) and the median survival time was 12.6 months (range 1.1-41.8). The adverse events were Grade 3/4 leukocytopenia (16.3%), Grade 3/4 thrombocytopenia (8.2%), Grade 3 nausea and/or vomiting (4.1%), and Grade 3 stomatitis (2.0%). CONCLUSIONS: Based on the encouraging response rate and prognosis, we recommend applying the FLEP regimen to patients with primary advanced gastric cancer.

Outcomes after emergency surgery for gastric perforation or severe bleeding in patients with gastric cancer.

BACKGROUND AND OBJECTIVES: Free perforation and major bleeding in patients with gastric cancer are rare but serious conditions with potentially dangerous effects. To clarify the clinicopathologic characteristics of patients with these conditions and to determine the optimum management, we reviewed 16 cases of perforation and 13 cases of major bleeding in patients with gastric cancer who required emergency surgery. METHODS: We compared the clinical and histologic features of the patients with perforation and those with bleeding. Cox's multivariate regression analysis was used to compare survival rates between patients who underwent single-step surgery or a two-step radical procedure, between patients with stage I or II and stage III or IV cancer, between patients who underwent complete (R0) and incomplete (R1 or R2) resection, and between patients with bleeding and those with perforation. RESULTS: Many of the patients had advanced disease. There were no significant differences in clinicopathologic findings or survival between patients with gastric perforation and those with major bleeding. Patients who had major bleeding tended to have larger cancers. In the univariate analysis, gastrectomy (vs. no gastrectomy), R0 (vs. R1 or R2) resection, and lower stage (vs. higher stage) were highly correlated with improved survival time. CONCLUSIONS: Overall, patients with gastric cancers who underwent emergency gastrectomy had a poor prognosis, but it was better than that of patients who could not have gastrectomy because of the prXesence of advanced cancer. However, the survival rate was excellent in patients with early-stage cancer who underwent complete (R0) resection. We recommend complete resection when possible.

Brief review of advances in the treatment of gastric carcinoma in North America and Europe, 1995-2001.

Gastric carcinoma is widespread in many South American and Asian countries but may be especially deadly in the West, due to a lack of programs for early diagnosis. Advanced gastric carcinoma is incurable, and the median survival time of patients with advanced disease is only 6 to 9 months. We sought to examine investigative trends in the utilization of new agents in the treatment of advanced gastric carcinoma in North America and Europe. Representative published reports of phase II and III clinical trials of therapies for gastric carcinoma by investigators based in North America and Europe from January 1995 through December 2001 were identified by a computerized search of the PubMed literature database. Fluorouracil, cisplatin, leucovorin, methotrexate, doxorubicin, and mitomycin were considered "conventional" agents; all other drugs were considered "new" agents. Of the 42 reports identified by the literature search, 17 were by investigators in North America and 25 were by investigators in Europe. All reports by investigators in North America were phase II trials, compared with 64% of those studies in Europe; the other studies by European investigators were phase III trials (36%). Chemotherapeutic drugs we considered "new" for the purpose of this study were investigated in 64% of all trials in North America and Europe. Eighty-one percent (22/27) of the 27 trials in which new agents were studied were phase II studies. We conclude that new agents are being widely incorporated in the investigation of advanced gastric cancer in North America and Europe. This trend is likely to be continued as more new chemotherapeutic agents are developed for clinical testing.

Management of perforated gastric carcinoma: a report of 16 cases and review of world literature.

Perforated gastric carcinoma is rare; however, it is a serious condition associated with complications. To understand the proper management of this disease and to characterize its clinical course we reviewed available data on 16 patients with perforated gastric carcinoma. We collected data on the age and sex of the patients as well as operative findings and histological features of the primary tumor. The depth of invasion and presence of lymph node metastasis were also recorded. The Union Internationale Contre Cancer stage, extent of resection, and surgical method used were reviewed. We also reviewed published information on the management of perforated gastric carcinoma. The carcinoma was stage I in three cases, stage II in one case, stage III in three cases, and stage IV in nine cases. Many patients had distant metastases. Fourteen patients underwent gastrectomy. Two patients whose preoperative condition was poor died of surgery-related complications, but patients with early-stage carcinoma underwent an R0 resection (resection of the primary tumor with negative margins) and had minimal complications. We conclude that the outcome of patients who were able to undergo radical surgery was good and correlated with the stage of cancer. It is important to perform gastrectomy rather than repair the perforation first, and a proper lymphadenectomy should follow--thus a two-step surgery when necessary.

An evaluation of the effectiveness of extended lymph node dissection in patients with gastric cancer: a retrospective study of 1403 cases at a single institution.

BACKGROUND: Many investigators have reported that extended lymph node dissection (D2 dissection) is probably an effective procedure. However, the theory that D2 dissection leads to an improvement in survival has not been confirmed in randomized trials. We attempted to confirm the effectiveness of D2 dissection with gastrectomy for gastric cancer. MATERIALS AND METHODS: Gastric cancer patients (1403) underwent curative resection by D1 (991 patients) or D2 (412 patients) dissection with gastrectomy. Survival rates calculated for all patients and subdivided for stage, depth of invasion, and lymph node metastasis were compared between the two groups. The diagnosis of lymph node metastasis was compared between macroscopic and histological findings. RESULTS: There was no significant difference in the survival of patients overall. However, in the patients with stage II, T1 or T2, or N1 disease, the survival of the D2 group was significantly better than that of the D1 group. The false positive rates of lymph node metastasis were 53.3% in the N1 group, 26.2% in the N2 group, and 9.2% in the N3 group. In a considerable proportion of the N1 and N2 patients, histological findings proved more or fewer metastases than macroscopic diagnosis. CONCLUSIONS: Metastatic lymph nodes should be resected as far as possible. D2 dissection with gastrectomy is recommended for T1, N1 or T2, N1 disease, particularly in younger patients.

Evaluation of serum CEA and CA19-9 levels as prognostic factors in patients with gastric cancer.

BACKGROUND: This clinicopathological study evaluated the utility of serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 as predictors of locoregional recurrence and long-term disease-free survival in patients with gastric cancer.METHODS: During the period January 1989 to December 1994, 485 patients with primary gastric cancer were evaluated. Gastrectomies were performed in 434 patients. Prognostic factors were analyzed by the Kaplan-Meier method and multivariate analysis, using Cox regression.RESULTS: Elevated serum CEA and CA19-9 levels were observed in 92 of the 485 patients (19.0%), and in 95 of the 435 patients (21.8%), respectively, and both markers were elevated in 29 of these 435 patients (6.7%). Elevated serum CEA and CA19-9 levels correlated well with lymph node metastasis, lymphatic invasion, vessel invasion, stage grouping, depth of invasion, and curability. Patients with elevated serum CEA levels were at significantly higher risk of having all recurrence factors than were those with normal serum CEA levels. Patients with elevated serum CA19-9 levels were at significantly higher risk of having peritoneal metastases and distant metastases than were those with normal serum CA19-9 levels. A significant difference in the cumulative survival curves of patients was demonstrated between those with elevated and those with normal serum CEA or CA19-9 levels, even for patients at the same disease stage (stage III). Patients with elevated levels of both markers had a significantly worse prognosis than patients in whom the levels of both markers were normal. In patients who underwent gastrectomy, elevated serum CEA levels either preoperatively or within 3 weeks after gastrectomy were associated with significantly worse prognosis than were normal levels. When the cutoff level of serum CEA was increased to 10 ng/ml, serum CEA, age, lymph node metastasis, and surgical stage grouping were selected as independent prognostic factors by multivariate analysis of 14 prognostic factors, using Cox regression.CONCLUSION: Serum CEA and CA19-9 levels provide additional prognostic information in patients with primary gastric cancer. In particular, an elevated serum CEA level provides additional prognostic information and is a useful indicator of curability in patients who undergo gastrectomy. Serum CEA level is an independent prognostic factor in patients with primary gastric cancer.

Clinicopathological features of the superficial spreading type of early gastric cancer.

BACKGROUND: During a 10-year period (1986-1995), 59 of 538 patients with early gastric cancer (11.0%) had the superficial spreading type of gastric cancer. We attempted to elucidate the clinicopathological features and investigated the influence of those features on surgical procedures and patient prognoses.METHODS: These 59 superficial spreading lesions were analyzed with respect to macroscopic type, lymph node (LN) metastasis, recurrent pattern, and method of surgical operation. In addition, the lesions were compared with those of 393 other patients with small-sized cancer.RESULTS: In both groups, the IIc type macroscopic lesion occurred most frequently, and the depressed subtype occurred more frequently than the elevated subtype. There was no significant histologic difference between the groups. The incidence of LN metastasis was 8.7% in early gastric cancer, 7.1% in small-sized cancer, and 20.3% in superficial spreading cancer. The incidence of lymphovascular invasion was 24.4% in small-sized cancer and 50.8% in superficial spreading cancer. The incidences of LN metastasis and lymphovascular invasion were greater in superficial spreading cancer than in small-sized cancer. Despite extensive preoperative examination, determination of the tumor margin was impossible in 26 of the 59 patients with superficial spreading cancer. The incidence of recurrence was 2.0% in small-sized cancer and 5.1% in superficial spreading cancer.CONCLUSIONS: A wide resection with extensive lymph node dissection (D2 or more) seems to be an appropriate treatment for the superficial spreading type of early gastric cancer.