[Perivesical abscess secondary to ruptured appendicitis : a case report].

A 38 year-old man was referred to our hospital for high fever and lower abdominal pain. The laboratory data showed his inflammatory state with a few puss cells in the urine analysis. Computed tomography (CT) scan and magnetic resonance imaging (MRI) scan demonstrated perivesical abscess and the cystoscopy on the day just before the operation revealed no abnormal findings in the bladder mucosa. In the operation, under the preoperative diagnosis of pyourachus, the appendix with the tip open was found inside the abscess cavity. Therefore, appendectomy and partial cystecomy were carried out. On the grounds of the pathological findings ; remarkable inflammatory change in the perivesical fatty tissue and slight inflammatory lesions in the subserous layer of the appendix, in addition to the clinical course and the retrospective findings of the preoperative MRI scan : existence of a tubular structure connecting with the abscess cavity, the final diagnosis was made as perivesical abscess secondary to ruptured appendicitis. This case is reported with a brief discussion as to the diagnosis and treatment.

Impact of lymphovascular invasion in patients with stage I gastric cancer.

BACKGROUND: Patients with stage I gastric cancer often suffer from tumor recurrence despite a generally favorable operative outcome. It is therefore important to determine the prognostic factors in order to improve such outcomes. METHODS: Between April 1985 and March 2000, a total of 1,880 patients with histologically proven stage I gastric cancer were included in this study. Operative outcomes (survival time, prognostic factors, pattern of recurrence) were evaluated in these patients. RESULTS: Multivariate analysis in patients with all stage I gastric cancer revealed that depth of invasion, lymph node metastasis, and lymphovascular invasion independently influenced prognosis. Moreover, advanced age was selected as an independent prognostic factor in patients with stage IA, and lymphovascular invasion in patients with stage IB gastric cancer by multivariate analyses. The 5-year survival rates in stage T1N1 patients with moderate to severe lymphovascular invasion, T2N0 with moderate to severe lymphovascular invasion, and II were 95.1%, 83.5%, and 76.9%, respectively. There was a significant difference in survival time between stage T1N1 and II (P = .0189) but not between stage T1N1 and T2N0 or stage T2N0 and II. CONCLUSION: T2N0 gastric cancer patients with moderate to severe lymphovascular invasion may be suitable candidates for adjuvant chemotherapy.

[Efficacy of low-dose CDDP and CPT-11 for patients with intestinal type of gastric adenocarcinoma].

BACKGROUND: Preclinical studies have shown that irinotecan (CPT-11) and cisplatin (CDDP) can act synergistically. Several chemotherapy regimens combining CPT-11 and CDDP for advanced gastric cancer have been reported to demonstrate high response rates and high incidence of severe toxicity. PURPOSE: We conducted a combination chemotherapy regimen of low-dose CDDP and CPT-11 to prolong the time to progression with less toxicity. PATIENTS AND METHODS: Seven patients with histologically-confirmed intestinal type of gastric adenocarcinoma were enrolled in this study. All patients were male, and their age at diagnosis ranged from 52 to 76 with a mean age of 64.8. Six patients received combination chemotherapy with CPT-11 and CDDP after the gastrectomy (stage I b: 1, II : 3, III b: 1, IV: 1). Only chemotherapy was administered in one patient because of a far advanced primary lesion and metastatic tumors. Low-dose CDDP (20 mg/body) and CPT-11 (65 mg/m(2)) were administered intravenously once every two weeks. RESULTS: The overall response rate was 43% including 1 complete response and 2 partial responses. One patient had grade 3 myelosuppression. Other adverse reactions were mild. CONCLUSION: The combination of low-dose CDDP and CPT-11 has mild therapeutic toxicities and may achieve a prolonged median survival time in patients with intestinal- type gastric adenocarcinoma.

Phase I study of biweekly docetaxel and S-1 combination chemotherapy for advanced gastric cancer.

BACKGROUND: Docetaxel and S-1 are novel antitumour chemotherapeutic agents with distinct toxicities. Here a phase I study of combined docetaxel and S-1 therapy for advanced gastric cancer is reported. PATIENTS AND METHODS: The study group comprised 21 patients who received at least two courses of treatment. Intravenous docetaxel was administered with dose escalation from 20-45 mg/m2 depending on the dose-limiting toxicity (DLT) on days 1 and 15, and oral S-1 (BSA < 1.25 m2, 80 mg/day; 1.25 < or = BSA < 1.50 m2, 100 mg/day; 1.50 m2 < or = BSA, 120 mg/day) was administered on days 1-7 and 15-21. RESULTS: The maximum tolerated dose of docetaxel was 45 mg/m2 and the DLT was defined as neutropenia. The recommended docetaxel dose was identified as 40 mg/m2. The response rate (including partial responses) was 57.1%. Five cases showed no change and four showed progressive disease after two courses of treatment. The mean survival rate was 15 months. CONCLUSION: A phase II clinical trial is required to confirm these results.

The influence of stage migration on the comparison of surgical outcomes between D2 gastrectomy and D3 gastrectomy (para-aortic lymph node dissection): a multi-institutional retrospective study.

BACKGROUND: The aim of this study was to determine the influence of stage migration on the outcomes of D2 gastrectomy compared with D3 gastrectomy in advanced gastric cancer. METHODS: A series of 580 advanced gastric cancer patients (430 D2 gastrectomy and 150 D3 gastrectomy) were registered. The incidence of stage migration and the surgical results of D2 and D3 gastrectomy were compared. RESULTS: The incidence of N-stage migration was 22.7% and that of pathological stage was 20.7%. Stage-specific survival times of simulated D2 gastrectomy and real D2 gastrectomy were equal. In patients with pN2 tumors measuring 50 to 100 mm in diameter, there was a significant difference in survival between D2 and D3 gastrectomy. However, no difference was observed between D2 and simulated D2 gastrectomy. CONCLUSIONS: Because there was a high incidence of stage migration in patients after D3 gastrectomy, it may be more feasible to validate comparisons between different levels of lymph node dissection in a randomized controlled trial.

Clinical significance of the metastatic lymph-node ratio in early gastric cancer.

The metastatic lymph-node ratio has important prognostic value in gastric cancer; this study focused on its significance in early gastric cancer. In total, 1,472 patients with early gastric cancer underwent curative gastrectomy between 1992 and 2001. Of these, 166 (11.3%) had histologically proven lymph-node metastasis. Prognostic factors were identified by univariate and multivariate analyses. Metastasis was evaluated using the Japanese Classification of Gastric Carcinoma (JGC) and the Union Internationale Contre le Cancer/Tumor, Node, Metastasis (UICC/TNM) Classification. The metastatic lymph-node ratio was calculated using the hazard ratio. The cut-off values for the metastatic lymph-node ratio were set at 0, <0.15, >or=0.15 to <0.30, and >or=0.30. The numbers of dissected and metastatic lymph nodes were correlated, but the number of dissected lymph nodes and the metastatic lymph-node ratio was not related. The JGC and UICC/TNM classification demonstrated stage migration and heterogeneous stratification for disease-specific survival. The metastatic lymph-node ratio showed less stage migration and homogenous stratification. The metastatic lymph-node ratio may be a superior method of classification, which provides also accurate prognostic stratification for early gastric cancer patients.

Lymph node status in patients with submucosal gastric cancer.

BACKGROUND: The aim of this study was to clarify the lymph node status in patients with submucosal gastric cancer. METHODS: Between April 1994 and December 1999, 615 patients with histologically proven submucosal gastric cancer who underwent curative resection were included in this study. The results of the surgery and predictive factors for lymph node metastasis were evaluated by univariate and multivariate analyses. The accuracy of the predictive factors was assessed in a second population of a further 186 patients. RESULTS: Lymph node metastasis was observed in 119 patients (19.3%). Multivariate analysis showed that pathologic tumor diameter (> or = 20 mm) and lymphatic invasion were independent predictive factors for lymph node metastasis. The incidence of lymph node metastasis without these 2 predictive factors was 1.8% (2 of 113), and it was 51.2% (85 of 166) with the 2 predictive factors, 9.5% (14 of 148) in tumors < 20 mm in diameter, and 5.3% (22 of 414) in tumors without lymphatic invasion. Among patients with a tumor < 20 mm in diameter, the incidence of lymph node metastasis was significantly reduced in those with a differentiated tumor: 4.2% (4 of 95). These results were almost identical to those observed in the second population. CONCLUSIONS: Lymph node status can be accurately predicted on the basis of pathologic tumor diameter < 20 mm, lymphatic invasion (absence), and histological type (differentiated) in patients with submucosal gastric cancer. Less extensive surgery for these patients might be reconsidered after confirmation of the reproducibility of the results of this study by an appropriately designed prospective clinical trial.

Clinicopathological features of gastric carcinoma in younger and middle-aged patients: a comparative study.

Gastric carcinoma is relatively rare in patients under the age of 40. This study was undertaken to clarify the clinicopathological characteristics and surgical outcomes of gastric carcinoma in younger patients compared with those of middle-aged patients. The surgical results from 131 younger patients (aged < or = 40 years) and 918 middle-aged patients (aged 55-65 years) were compared retrospectively. Female gender, undifferentiated tumor type and lymphatic invasion were significantly more common in the younger patients. Survival time did not differ between the two groups. The depth of tumor invasion was the only prognostic factor in younger patients, whereas macroscopic appearance, tumor diameter, depth of invasion, lymph node metastasis, and venous invasion were all significant prognostic factors in middle-aged patients. Peritoneal recurrence was significantly more common in younger patients. A family history of gastric adenocarcinoma was observed in 25.9% of younger patients, but this did not affect survival outcomes. As depth of invasion affects prognosis independently, and peritoneal metastasis is the predominant pattern of recurrence, it is essential to establish an optimal prophylactic treatment for peritoneal metastasis to improve surgical outcomes in younger patients with advanced gastric cancer.

Clinicopathological properties of poorly-differentiated adenocarcinoma of the stomach: comparison of solid- and non-solid-types.

BACKGROUND: The purpose of this study was to clarify the clinicopathological and biological properties of the poorly-differentiated types of gastric carcinoma (solid-type and non-solid-type). PATIENTS AND METHODS: A total of 1,558 patients with primary gastric adenocarcinomas were enrolled in this study. The surgical results were compared. RESULTS: Patients with non-solid-type tumors tended to be younger females with peritoneal or lymph node metastases and lymphatic invasion, and with tumors that were ill-defined, of larger diameter and deeper. Those patients with differentiated tumors tended to have the opposite characteristics of those patients with non-solid-type tumors. Patients with solid-type tumors had intermediate characteristics. The survival in patients with non-solid-type tumors was poor compared to those with differentiated or solid-type tumors. There was a significant difference in the survival of stage III tumors with either solid- or non-solid-type tumors (p=0.0480). CONCLUSION: Therapeutic strategies should be based on the histological type of the tumor in patients with poorly-differentiated gastric adenocarcinoma.

Comparison of surgical results of D2 versus D3 gastrectomy (para-aortic lymph node dissection) for advanced gastric carcinoma: a multi-institutional study.

BACKGROUND: Curative gastrectomy is a promising approach for the treatment of gastric cancer; however, the optimal extent of lymph node dissection for advanced cancer remains controversial. The aim of this multi-institutional study was to evaluate the feasibility of D3 gastrectomy (para-aortic lymph node dissection) for advanced gastric cancer. The surgical results of D2 and D3 gastrectomy (para-aortic lymph node dissection) were retrospectively compared. METHODS: A series of 580 advanced gastric cancer patients were registered between 1992 and 2000. Of these, 430 underwent D2 gastrectomy and 150 underwent D3 gastrectomy. Survival time, prognostic factors, postoperative morbidity/mortality, and pattern of recurrence were compared. RESULTS: There was no significant difference in survival time between D2 and D3 patients. However, the survival times of D3 patients with tumor diameters measuring 50 to 100 mm or with pN1 disease were significantly longer than those of the corresponding D2 patients. Analysis of the survival of patients with tumor diameters measuring 50 to 100 mm revealed that D3 gastrectomy conferred a survival advantage only to patients with pN2 disease. The incidence of lymphatic recurrence was lower in D3 patients with 50- to 100-mm tumors than in the corresponding D2 patients. CONCLUSIONS: D3 gastrectomy might be beneficial in patients with advanced pN2 gastric cancer within the group with tumors measuring 50 to 100 mm. A randomized controlled trial of patients with 50- to 100-mm tumors should be performed to test the validity of this preliminary result.

Significance of long-term follow-up of early gastric cancer.

BACKGROUND: Therapeutic outcomes for most patients with early gastric cancer are favorable. However, mortality among these patients remains a concern. Improvements in therapeutic outcomes are being sought by studying the timing and causes of death. Here, the results of surgery were evaluated to assess the appropriate treatment and follow-up schedule for early gastric cancer. METHODS: A total of 1169 patients with early gastric cancer underwent curative gastrectomy between 1992 and 1999. Survival time, prognostic factors, cause of death, and time of death were evaluated retrospectively. RESULTS: Multivariate analysis of disease-specific survival identified lymph node metastasis as an independent prognostic factor. The anatomical extent of lymph node metastasis and the number of metastatic lymph nodes influenced the rate of recurrence. Multivariate analysis of overall survival identified age as a prognostic factor. A total of 91 patients (7.8%) from the study group died: 56 from comorbid diseases, 21 from gastric cancer, and 14 from other second primary cancers. Death from gastric cancer was frequently observed within 5 years of surgical resection, whereas death from other diseases usually occurred after 5 years. Patients who died as a result of diseases other than gastric cancer tended to be older. CONCLUSIONS: Appropriate lymph node dissection is necessary for patients with early gastric cancer, particularly those with risk factors associated with lymph node metastasis. Meticulous follow-up protocols that can detect second primary cancers, together with the development of treatments for comorbid diseases, are required to improve survival.

Surgical outcomes in patients with T4 gastric carcinoma.

BACKGROUND: There is controversy about the best therapeutic surgical approach for treatment of patients with T4 gastric cancer. STUDY DESIGN: We used univariate and multivariate analyses to review the surgical outcomes and prognostic factors of 117 patients who underwent surgery for T4 gastric carcinoma. RESULTS: Curative resection was performed in 38 (32.4%) patients, with the pancreas being the most frequently resected organ. The 5-year survival rate was 16.0% and the median survival time (MST) was 11 months for all 117 registered patients. The 5-year survival rates and MSTs in patients after curative and noncurative resection were 32.2% versus 9.5% and 20 months versus 8 months, respectively. These values differed considerably between the two groups (p < 0.0001). Curability was an independent prognostic factor among all registered patients, including those who underwent noncurative resection. A relatively small tumor diameter (< 100 mm) and few lymph node metastases (six or fewer metastatic lymph nodes) were independent prognostic factors when curative resection could be performed. Postoperative morbidity and mortality were acceptable after curative combined resection. CONCLUSIONS: We recommend the use of aggressive combined resection of adjacent organs, with extended lymph node dissection, for patients with T4 gastric carcinoma in whom curative resection can be used; that is, those with few metastatic lymph nodes (six or less) and a relatively small tumor diameter (100 mm). But noncurative resection should be avoided in patients with T4 gastric cancer.

[Effect of hepatic arterial infusion chemotherapy for liver metastasis from gastric cancer].

We performed hepatic arterial infusion (HAI) chemotherapy for 4 patients with advanced gastric cancer who had undergone curative resection except for liver metastasis. The main antineoplastic drugs were 5-fluorouracil (5-FU), mitomycin C (MMC) and cisplatin (CDDP). A catheter was inserted into the hepatic artery by interventional radiological techniques in 3 patients and operatively in 1 patient. The response rate for 4 patients was 75% (CR2, PR1, PD1). The adverse events were Grade 3/4 nausea and/or vomiting in 2 cases. The HAI chemotherapy was effective and useful for patients with advanced gastric cancer who had no unresectable lesions except for liver metastasis.