Laparoscopic splenectomy with peginterferon and ribavirin therapy for patients with hepatitis C virus cirrhosis and hypersplenism.

BACKGROUND: This study aimed to evaluate whether laparoscopic splenectomy (Lap-Sp) contributes to the completion and curability of combined peginterferon and ribavirin (peg-IFN + RIB) therapy for cirrhotic patients with pancytopenia due to hypersplenism. METHODS: From December 2004 to September 2007, 21 patients underwent Lap-Sp before treatment with peg-IFN + RIB. All the patients were Child-Pugh class A or B with a mean platelet count of 5.7 x 10(4)/mm(3) and a mean leukocyte count of 2,830/mm(3). The hepatitis C virus (HCV) genotype was 1b for 18 patients and 2b for 3 patients. Of the 21 patients, 17 had a viral load exceeding 100 KIU/ml, and 4 had a load of less than 100 KIU/ml. RESULTS: All the patients underwent Lap-Sp without severe complications. The average hospital stay was 12.7 days (range, 6-23 days). Platelet counts increased from a mean of 5.7 +/- 2.2 x 10(4)/mm(3) preoperatively to 19.6 +/- 7.6 x 10(4)/mm(3) postoperatively and remained above 7.0 x 10(4)/mm(3) during the subsequent peg-IFN + RIB therapy. The full course of therapy was completed for nine patients, with five obtaining a sustained virologic response and one obtaining a biologic response. The five patients who obtained a sustained virologic response had either HCV type 2b or 1b with a low viral load (<100 KIU). At this writing, treatment is ongoing for the remaining 12 patients. CONCLUSIONS: Laparoscopic splenectomy allows patients with HCV cirrhosis and hypersplenism to receive full-dose peg-IFN + RIB therapy. Patients with HCV, genotype 2 or 1b and a low viral load, and hypersplenism may be good candidates for Lap-Sp.

Characteristics of gastric cancer in patients over 80-years-old.

BACKGROUND/AIMS: The number of elderly gastric cancer patients undergoing surgery is rapidly increasing because of the current aging society. To determine an effective surgical treatment method, the clinicopathological characteristics of such patients should therefore be clarified. METHODOLOGY: Between 1979 and 2005, 2010 patients with gastric cancer underwent curative surgery in our institute. Clinicopathological characteristics of 109 patients in the elderly group (> or = 80-years-old) were compared with those of 1901 patients in the young group (< 80-years-old). RESULTS: In the elderly group, cancers of the lower third of the stomach and differentiated types, and less-invasive surgery were common. The 5-year survival rate specific to gastric cancer was not significantly different between groups, but the overall 5-year survival rate including causes other than gastric cancer was significantly different (p<0.01) at 82% in the elderly group and 67% in the young group. CONCLUSIONS: In the medical care of elderly gastric cancer patients, it is necessary to accurately determine the specific clinicopathological characteristics, and subsequently, an effective surgical treatment method.

[Questionnaire survey to investigate correspondence of medical doctors and dentists in Japan for antithrombotic therapy at surgeries or biopsy].

PURPOSE: We examined correspondence of doctors and dentists at the time of surgeries or biopsy in patients treated with antithrombotics by questionnaire survey. METHODS: We investigated management of antithrombotic therapy at dental extraction, biopsy or polypectomy under an endoscope, an operation of a cataract, pacemaker implantation by questionnaire survey for doctors and dentists in 64 national hospital organization hospitals (NHO-hospital) and doctors in 163 hospitals participated in the Japan Multicenter Stroke Investigators' Collaboration (J-MUSIC) study. We compared the results between NHO-hospitals and J-MUSIC hospitals. RESULT: The doctor questionary survey got an answer from 103 institutions (63%) out of the 163 J-MUSIC hospitals and 26 institutions (40%) out of 64 NHO-hospitals. The dental extraction under continuation of warfarin therapy in patients with past history of stroke and non-valvular atrial fibrillation or mechanical heart valves was accepted in 35% and 45%, respectively. They were 58% and 69%, respectively in J-MUSIC hospitals and were significantly higher than those in NHO-hospital (p = 0.031 and p = 0.023, respectively). There were no significant differences in antithrombotic management strategies in correspondence to the biopsy, polypectomy or pacemaker implantation between the two groups of hospitals. Continuation of the antithrombotic therapy at surgery to cataracta was more frequent in J-MUSIC hospitals than in NHO-hospitals (nonvalvular atrial fibrillation 48% vs 22% p = 0.015, mechanical heart valve 51% vs 30% p = 0.059). Experience of stroke due to transient withdrawal of warfarin (69% vs 27%, p = 0.0005) and antiplatelet (59% vs 31%, p = 0.022) therapies were more frequently seen in the J-MUSIC hospitals than in the NHO-hospitals. The dentist questionary survey got an answer from 30 institutions (44%) out of the NHO-hospitals. The acceptance rates of dental extraction under continuation of warfarin or antiplatelet therapies were 53% and 60%, respectively. CONCLUSION: It is suggested that constant consensus is provided with a medical institution as for the biopsy, polypectomy, and pacemaker implantation without a difference being seen in both medical institution groups. However, acceptance rate under antithrombotic therapy at dental extraction or surgery for cataracta was higher in the J-MUSIC hospitals than in the NHO-hospitals, which may be due to lack of the consensus to antithrombotic therapy for those surgeries and higher rate of doctors' experience of stroke after withdrawal of antithrombotic therapy in J-MUSIC hospitals.

Second primary cancer after surgery for colorectal cancer without lymph node metastasis.

BACKGROUND/AIMS: Colorectal cancer patients without lymph node metastasis usually show a favorable prognosis with low recurrence rates; however, there is an increased risk of the development of a second primary cancer. Understanding the features of a second primary cancer is important to establish an effective postoperative follow-up program for colorectal cancer without lymph node metastasis. METHODOLOGY: The clinicopathological data on 801 patients with Dukes' A and Dukes' B colorectal cancer were examined in respect to second primary cancer. RESULTS: In patients with Dukes' A cancer, the incidences of recurrence and second primary cancer were similar. When tumor invasion was limited within subserosa in Dukes' B patients, the incidence of a second primary cancer was almost two-thirds that of recurrence. More than half of the second primary cancers again developed from the colorectum, followed by stomach and lung. CONCLUSIONS: When colorectal cancer patients without lymph node metastasis show tumor invasion limited within the subserosa, postoperative follow-up should monitor a balance of recurrence with a second primary cancer.

Influence of prophylactic apical node dissection of the inferior mesenteric artery on prognosis of colorectal cancer.

BACKGROUND/AIMS: Middle ligation (ML) of the inferior mesenteric artery (IMA) maintains adequate blood supply to an anastomosis and has no risk of autonomic nerve injury. If apical node dissection of the IMA improves the prognosis, ML and prophylactic dissection of the apical node without division of the IMA above the colic artery may also result in an additional prognostic improvement in patients with sigmoid colon or rectal cancer. METHODOLOGY: Four hundred and one patients with either Dukes' B or Dukes' C colorectal cancer were clinicopathologically examined. In order to evaluate the influence of the prophylactic dissection of the apical node on the prognosis, the two groups of ML with and without apical node dissection were compared. RESULTS: The 5-year survival rates in the groups of ML and ML with apical node dissection were 90% and 91%, respectively, in 218 Dukes' B patients. The 5-year survival rates in the groups of ML and ML with apical node dissection were 73% and 71%, respectively, in 183 Dukes' C patients. There were no significant differences between the two groups in both Dukes' B and Dukes' C patients. CONCLUSIONS: When ML is adopted for patients with sigmoid colon or rectal cancer, additional dissection of the apical node is not needed.

[The questionnaire survey to clarify correspondence of medical doctors and dentists in Fukuoka City, Japan, for warfarin therapy at the dental extraction].

PURPOSE: The questionnaire survey was performed in order to clarify correspondence of medical doctors and dentists working at hospital service for warfarin therapy at the dental extraction. METHODS: For 17 senior dentists in 17 hospitals and 142 senior physicians in 82 hospitals in Fukuoka City, we investigated using the questionnaire whether they supported dental extraction under warfarin therapy or not in patients having warfarin treatment with past history of cardioembolic stroke due to non-valvular atrial fibrillation (NVAF). Specialty and experience of stroke after withdrawal of warfarin were also asked in medical doctors. RESULT: The reply was obtained from 14 dentists (82.4%) and 66 doctors (46.5%). The number of dentists and doctors who pull out a tooth under warfarin treatment continuation were 12 persons (85.7%) and 32 persons (48.5%), respectively. The rates in doctors whose specialty was stroke, cardiovascular disease, and others were 78.6% (11/14), 36.0% (9/25), and 44.4% (12/27), respectively. The rate in stroke specialists was significantly higher than that in cardiovascular disease specialists (p = 0.019). The stroke specialists had experience of stroke after withdrawal of warfarin more frequently than the cardiovascular disease specialists (57.1% vs. 20.0%, p = 0.033). CONCLUSION: The rates of acceptance in tooth extraction under warfarin treatment continuation of the dentist were high in Fukuoka city, while that of the medical doctors were not. Rate of doctor's acceptance differed according to the specialties, and may be affected by experience of stroke after cessation of warfarin therapy.

[Surgical treatment for multiple colorectal metastases: efficacy of ablation therapy].

Either hepatic resection, microwave coagulonecrotic therapy (MCN), or a combination of liver resection and MCN was performed in 166 patients with liver metastases from colorectal cancer. In 53 patients who underwent liver resection, the 1-, 3-, and 5-year actual survival rates were 85.0%, 51.2%, and 42.2%, respectively. In 77 who underwent MCN, the 1-, 3-, and 5-year actual survival rates were 82.8%, 46.7%, and 36.0%, respectively. In 34 who underwent both liver resection and MCN, the 1-, 3-, and 5-year actual survival rates were 84.2%, 41.6%, and 21.1%, respectively. The survival rates among the three groups did not differ significantly. Of 166 patients with liver metastases, 44 showed multiple liver metastases (H3). Of 44 patients with multiple liver metastases, 27 underwent MCN (mean tumor diameter 27.2 mm, mean number of tumors 11.2), and the 1-, 3-, and 5-year actual survival rates were 73.1%, 31.3%, and 25.1%, respectively. Of 44 patients with multiple liver metastases, 17 underwent both liver resection and MCN (mean tumor diameter 41.9mm, mean number of tumors 8.1), and the 1-, 3-, and 5-year actual survival rates were 66.3% and 14.7%, respectively. To perform MCN more effectively in the treatment of liver metastases, surgical margins around tumors should be from 10 mm to 15 mm, and both the feeding artery and drainage vein should be coagulated before MCN.

[Assessment of goserelin treatment in adjuvant therapy for premenopausal patients with breast cancer in Japan-zoladex breast cancer study group trial-B].

OBJECTIVE: Goserelin (GOS) therapy in an adjuvant setting for estrogen receptor(ER)-positive premenopausal patients with breast cancer was assessed in a randomised comparative study. METHODS: ER positive premenopausal patients with n + or n 0 and T > or = 3 cm received tamoxifen (TAM) 20 mg/day, GOS 3.6 mg/4 weeks or GOS + TAM for 2 years, and the clinical efficacy and safety of these regimens were assessed. RESULTS: In the data analysis of total 207 patients, hazard ratios of disease free survival (DFS) and overall survival (OS) in the GOS group compared to the TAM group were 0.87 and 2.10,respectively. The incidence of adverse drug reactions was similar (42-55%) in all three groups. Since the number of patients in this study did not reach the target number, the efficacy could not be assessed from a statistical aspect. Therefore,meta-analysis with similar foreign studies(ZIPP) was implemented. The results of meta-analysis showed that the hazard ratios of DFS and OS in the GOS group compared to the non-GOS group were 0.83 and 0.85, respectively. CONCLUSION: Although the analysis of 207 patients did not show any statistically significant difference between each of the treatment groups, the results of meta-analysis showed a significant prolongation of DFS in the GOS group. Also high tolerability of GOS was suggested. From these results, GOS was considered highly useful in adjuvant therapy for ER-positive premenopausal patients with breast cancer.

Genomic screens for genes upregulated by demethylation in colorectal cancer: possible usefulness for clinical application.

Inactivation of tumor suppressor genes may result in clinically aggressive tumors and poor prognoses for cancer patients. This study was conducted to investigate the clinical significance of genomic screens for genes upregulated by demethylation in colorectal cancer. We performed a comprehensive survey of commonly inactivated genes in colorectal cancer through the functional reactivation of epigenetically silenced genes by 5-Azacytidine, using cDNA microarrays containing 12,814 genes. We then investigated the clinical significance of the identified gene in colorectal cancer patients. Among 41 candidate genes identified by this microarray analysis, 31 (76%) harbored CpG islands, and many of the genes were associated with cancer-testis antigens, Wnt inhibitors, growth factors, and cell cycle regulators. Subsequent analysis by quantitative RT-PCR confirmed the reliability of our microarray strategy. In order to elucidate the potential clinical significance of these identified genes, we selected one of these genes, apolipoprotein D (apo D), and investigated its mRNA expression in 63 colorectal cancer patients using quantitative real-time RT-PCR. The mean expression level of Apo D mRNA was significantly lower in cancerous tissues than in non-cancerous tissues (p < 0.01), and a lower expression of Apo D was significantly correlated with lymph node metastasis (p < 0.05), advanced stages (p < 0.05) and poorer overall survival (p < 0.05). These results indicated that a genomic screen for genes upregulated by demethylation may be a useful approach for the identification of genes that are of clinical significance in colorectal cancer patients.

Prophylactic lymph node dissection for early gastric cancer invading submucosa.

BACKGROUND/AIMS: Prophylactic lymph node dissection for gastric cancer patients was considered to prolong survival time and D2 lymph node dissection was a standard treatment for early gastric cancer invading submucosa without lymph node metastasis. We investigated the possibility of minimizing the extent of prophylactic lymph node dissection for early gastric cancer invading submucosa if there was no evidence of lymph node metastasis. METHODOLOGY: We analyzed data on 404 patients with early gastric cancer invading the submucosa who underwent gastrectomy from 1979 to 1998 in the National Kyushu Medical Center, Fukuoka, Japan. The postoperative survival rate of patients with standard D2 dissection was compared with cases of those with limited D2 dissection which was defined as confined as D2 dissection dissections No.7 (lymph nodes were those along the left gastric artery), No.8 (lymph nodes along the anterosuperior common hepatic artery) and No.9 (lymph nodes along the celiac artery). RESULTS: Of the 404 patients, 52 and 17 had lymph node metastasis in group 1 and group 2 nodes, respectively. Of 17 patients with lymph node metastasis in group 2, 14 (82.4%) had metastasis confined to No.7, 8 and 9 of group 2 nodes. The 5-year survival rate of patients with submucosal cancer without lymph node metastasis was 94.4% after limited D2 dissection and 97.3% after standard D2 dissection, respectively. CONCLUSIONS: The appropriate prophylactic lymph node dissection for early gastric cancer invading the submucosa without lymph node metastasis was considered to be minimized to limited D2 dissection.

Distribution of synchronous and metachronous multiple colorectal cancers.

BACKGROUND/AIMS: Synchronous and metachronous multiple colorectal cancers are not rare occurrences. Since features of colorectal cancer depend on tumor location, we focused attention on the tumor distribution of synchronous and meta-chronous lesions in colorectal cancer. METHODOLOGY: The records of 1812 patients with colorectal malignancies (either invasive colorectal cancer or high grade dysplasia) were clinicopathologically analyzed. RESULTS: In one hundred and twenty patients with colorectal malignancies there were synchronous or metachronous lesions. The distribution of synchronous malignancies showed a significant shift from the proximal to the distal site, while in metachronous malignancies, the distribution of second tumors showed a significant shift from the distal to the proximal site. CONCLUSIONS: Our findings suggest that different types of cancer lesions do exist, hence careful and meticulous examinations are important.

Features of second primary cancer in patients with gastric cancer.

BACKGROUND: In order to improve the prognosis of gastric cancer patients, the timely identification of second primary cancers is considered to be a crucial clinical problem. METHODS: We analyzed the clinicopathological data of 2250 patients with gastric cancer with regard to both synchronous and metachronous second primary cancers. RESULTS: Of 2250 patients, 95 (4.2%) had a second primary cancer. Both colorectal and lung cancer were frequently detected, followed by cancer in the liver, esophagus and breast. Regarding the time of detection for such second cancers, 65% of colorectal cancers were detected synchronously, while more than 80% of lung cancers were detected metachronously. The prognosis of gastric cancer patients with a second primary cancer was more negatively influenced by a second primary cancer than by a primary gastric cancer. CONCLUSION: Since gastric cancer patients may develop synchronous and metachronous second cancers in other organs, effective preoperative and postoperative diagnostic modalities both for second primary cancers, as well as for the recurrence of gastric cancer, need to be developed.

A loop formation of Meckel's diverticulum: a case with obstruction of the ileum.

An adult case of obstruction of the ileum caused by a loop formation of Meckel's diverticulum is described. The patient, having severe abdominal pain and vomiting, was diagnosed as having ileus. A roentgenogram with a contrast medium showed severe obstruction at the mid part of the ileum. From findings of elective laparotomy, adhesion between the inflammatory end of Meckel's diverticulum and the corresponding mesenterium had formed a loop, which had clasped the distal part of ileum. We here warn that Meckel's diverticulum forming a loop is a cause of obstruction of the ileum in adults.

The role of adenoma for colorectal cancer development: differences in the distribution of adenoma with low-grade dysplasia, high-grade dysplasia, and cancer that invades the submucosa.

BACKGROUND: The purpose of this study was to elucidate the role of adenoma in the early stage of colorectal cancer development, we focused on the clinicopathologic relationship between adenoma with low-grade dysplasia (ALGD), adenoma with high-grade dysplasia (AHGD), and cancer that invades the submucosa in the colorectum. METHODS: We clinicopathologically examined a total of 553 adenomas and 58 cancers that invaded the submucosa. The tissues were excised from 479 patients who underwent total colonoscopy. RESULTS: The percentage of ALGD was 79.9% in the proximal colon, 70.5% in the distal colon, and 48.3% in the rectum, respectively. The percentages of AHGD and cancer were 14.5% and 5.6% in the proximal colon, 21.3% and 8.2% in the distal colon, and 35.4% and 16.3% in the rectum, respectively. In contrast with the distribution of ALGD, the distribution of both AHGD and cancer shifted from the proximal to the distal site, with a statistical significance (P <.01). When the distribution of adenoma was compared according to tumor size, both large- and small-sized AHGD showed a similar cancer distribution, however, both large- and small-sized ALGD showed different distributions. CONCLUSION: An important role of AHGD for cancer development in the colorectum may relate to the similar distribution between AHGD and cancer; however, the different distributions observed between ALGD, AHGD, and cancer suggested that ALGD has only a slight association with the development of cancer.