Optimal Administration of Phosphorus Adsorbents When Using Medical Nutritional Supplements for Tube-fed Patients.

All medical enteral nutrition products contain phosphorus and when administered to patients with chronic kidney disease (CKD) and on dialysis, they lead to the risk of elevated serum phosphorus levels. Thus, serum phosphorus levels should be monitored, and phosphorus adsorbents should be used in cases of high serum phosphorus levels. In this study, we investigated the effect of phosphorus adsorbents on enteral nutrition, using Ensure Liquid®, a medical nutritional formula, for patients with CKD and those on dialysis. Additionally, we compared the effects of the simple suspension method, in which various phosphorus-adsorbing agents are suspended and mixed directly with the nutritional formula for tube administration (hereafter referred to as the "pre-mix method"), and the conventional method, in which only the phosphorus-adsorbing agents are administered separately from the nutritional formula for tube administration (hereafter referred to as the "normal administration method"). The administration of various phosphorus adsorbents using the pre-mix technique resulted in a phosphorus removal rate of 8-15% (approximately 12% on average). Therefore, through the pre-mix method, maintaining the phosphorus content of Ensure Liquid® below the daily phosphorus intake standard was possible for patients on dialysis. The pre-mix method via the simple suspension method of administering phosphorus adsorbent with Ensure Liquid® resulted in less drug adsorption to the injector and tube and a higher phosphorus removal rate than the normal administration method.

[A Case of Advanced Neuroendocrine Cell Carcinoma of the Stomach Treated with S-1 and Cisplatin Chemotherapy].

A 69-year-old man presented to our hospital because of epigastric pain. A type 2 lesion was seen in the lesser curvature of the antrum of the stomach. A moderately differentiated adenocarcinoma(human epidermal growth factor receptor 2-negative) was diagnosed by biopsy. Abdominal computed tomography showed a mass shadow 52mm in diameter in the pyloric region invading the surrounding organs, but no evidence of distant metastasis. Chemotherapy with S-1 and cisplatin(SP therapy)was initiated because of a diagnosis of locally advanced gastric cancer. After 2 courses of chemotherapy, the tumor shrinkage rate was 70%, confirming that treatment was effective. However, severe skin disorders developed, precluding the continuation of chemotherapy. Staging laparoscopy showed no evidence of peritoneal dissemination, but invasion into the superior mesenteric vein was noted. The tumor was resected by pancreaticoduodenectomy with partial resection of the venous wall. Pathological examination of the resected specimens provided a definite diagnosis of neuroendocrine cell carcinoma. As of 1 year and 7 months after surgery, there has been no observation of metastasis or recurrence. SP therapy was suggested to be a useful regimen for preoperative chemotherapy in patients with locally advanced neuroendocrine cell carcinoma.

Molecular detection of sentinel node micrometastases in patients with clinical N0 gastric carcinoma with real-time multiplex reverse transcription-polymerase chain reaction assay.

PURPOSE: Described is a novel real-time multiplex reverse transcription-polymerase chain reaction (RT-PCR) assay suitable for intraoperative detection of micrometastasis (MM) in sentinel nodes (SNs) dissected from patients with clinical N0 (cN0) gastric carcinoma. METHODS: One hundred three patients with gastric cancer, who were preoperatively diagnosed with cN0 and clinical T1 or T2, were enrolled. The patients underwent SN mapping followed by standard radical gastrectomy with lymph node dissection. In addition to all SNs, non-SNs (NSNs) within the SN lymphatic basin and NSN from a different lymphatic basin were randomly sampled. All SNs and NSNs were examined by routine histologic diagnosis and RT-PCR for the expression of cytokeratin (CK) 19, CK20, and carcinoembryonic antigen (CEA). RESULTS: The RT-PCR assay and histologic examination were performed in 512 SNs and 299 NSNs from 103 patients. Pathologic l lymph node metastasis was revealed in 13 (12.6%) of 103 patients. All metastatic lymph nodes were identified within SNs. SNs of these 13 patients had positive findings on RT-PCR. Twenty-eight (27.2%) of 103 patients had negative histopathology but positive findings on RT-PCR. In 7 patients (6.8%), SNs were negative but NSNs were positive on RT-PCR. RT-PCR-positive NSNs were present in the same station as corresponding SNs in 3 of these 7 patients and in the same basin as SNs in 4 patients. CONCLUSIONS: The real-time multiplex RT-PCR assay is a useful tool for the detection of MM in SNs and NSNs in patients with gastric cancer.

Molecular diagnosis and translymphatic chemotherapy targeting sentinel lymph nodes of patients with early gastrointestinal cancers.

The sentinel lymph node (SLN) is defined as the lymph node(s) that first receives lymphatic drainage from the site of the primary tumor. Recent progress in molecular techniques has demonstrated the presence of micrometastatic tumor cells in SLNs. Quantitative real-time RT-PCR assay, which enables rapid analysis, is currently being undertaken for intraoperative molecular diagnosis of SLNs. We developed an intraoperative real-time RT-PCR assay to detect micrometastasis in SLNs for early gastric cancer. All SLNs and randomly selected non-SLNs in 96 cT1 or cT2 gastric cancer patients were biopsied intraoperatively and examined by routine hematoxylin and eosin staining, immunohistochemistry with anticytokeratin antibody (AE1/AE3), and multimarker real-time RT-PCR assay including cytokeratin (CK) 19, CK20, and carcinoembryonic antigen. All patients with histopathologically verified metastasis in their SLNs demonstrated positive results by RT-PCR assay. Forty percent of patients with histopathologically negative SLNs showed positive SLNs by RT-PCR assay. RT-PCR assay revealed that 4 patients (4%) with negative SLNs had positive non-SLNs; however, these positive non-SLNs were identified within each SLN basin. We recently developed a new drug delivery system targeting SLNs with a phospholipid polymer, using 2-methacryloyloxyethyl phosphorylcholine conjugated with paclitaxel. Our preliminary data suggest that this novel drug delivery system may be feasible for translymphatic chemotherapy targeting SLNs of patients with cN0 early gastrointestinal cancer, who have the potential for occult metastasis in SLNs. Endoscopic resection of the primary tumor followed by translymphatic chemotherapy targeting SLNs may become a promising minimally invasive multidisciplinary therapy.

Metachronous gastric carcinoma from a gastric tube after radical surgery for esophageal carcinoma.

BACKGROUND: Cases of metachronous gastric carcinoma arising from a gastric tube used for reconstruction have been increasing in long-term survivors of esophageal cancer in recent years. We investigated the characteristics of gastric tube carcinoma to determine the most appropriate approach to managing it. METHODS: Between 1980 and 1997, 508 patients underwent radical esophagectomy for esophageal carcinoma at Keio University Hospital. Reconstruction was performed with a gastric tube in 414 (81.5%) of them, and 8 of them developed a metachronous carcinoma in the gastric tube. The clinical and pathologic characteristics of the gastric tube carcinomas were evaluated in this study. RESULTS: Gastric cancer was detected during follow-up endoscopic examinations or in an upper gastrointestinal series in seven patients. All of the cancers were diagnosed as adenocarcinoma histopathologically. Endoscopic mucosal resection was performed in two patients, partial resection of the residual stomach was performed in three patients. One patient was treated by endoscopic mucosal resection as palliative therapy, since he had severe pulmonary emphysema. Total resection of the gastric tube was attempted in 2 advanced cases but was unsuccessful because of direct invasion of other organ by the cancer. The 5 patients who underwent curative resection are alive with no subsequent recurrence. CONCLUSIONS: Since early diagnosis permits less invasive treatment and curative treatment is difficult in advanced cases, strict postoperative examinations are important after radical esophagectomy to ensure early detection of metachronous gastric carcinoma arising from gastric tubes used for reconstruction.

Significance of metastasis detected by molecular techniques in sentinel nodes of patients with gastrointestinal cancer.

The clinical significance of micrometastasis in sentinel nodes (SNs) may differ in various organs. In particular, the prognostic value of SN micrometastases detected by reverse transcriptase-polymerase chain reaction (RT-PCR) is still controversial. We investigated the diagnostic and therapeutic significance of nodal molecular metastasis detected by nested RT-PCR for cytokeratin (CK) 19 mRNA in gastrointestinal cancer. In 51 cases with GI tract cancer treated by standard curative resection, SNs were identified by a radio-guided method. In 10 of 51 patients, 25 SNs and 3 non-SNs were histologically negative and RT-PCR positive. Three non-SNs with positive CK19 mRNA were randomly sampled from the same basin where histologically positive SNs were identified. Immunohistochemical analysis of six additional step sections obtained at 30- micro m intervals with use of an anticytokeratin antibody showed clearly recognizable histological metastases in 4 of 25 histologically negative/RT-PCR-positive SNs (16%). In one case of esophageal squamous cell carcinoma with nodal micrometastasis identified by CK19 RT-PCR, extranodal local recurrence in the SN basin (left supraclavicular basin) was observed 6 months postoperatively. These findings suggest that nodal micrometastasis detected by nested RT-PCR has some clinical significance in GI cancer. Molecular assessment of the SN may be a valuable tool to complement routine histological examination for GI cancers.

Intraoperative lymphatic mapping and sentinel lymph node sampling in esophageal and gastric cancer.

Recent studies for SN mapping of esophageal and gastric carcinoma show that the SN concept is valid even for upper GI cancers with multidirectional and complicated lymphatic flow. The relatively high incidence of anatomic skip metastasis can be attributed to aberrant distribution of SNs. An individualized and minimally invasive surgical approach can be applicable to management of esophageal and gastric carcinoma based on SN status. Although there are several issues to be resolved, this novel procedure has the potential for great benefit to improve quality control in the treatment of upper GI cancer. Well-designed clinical trials of lymphatic mapping for upper GI cancer will be essential to determine whether this technique is widely applicable in the management of these tumors.

[Infectious complications after esophageal surgery].

The incidence of wound infection, which is an intrasurgical field infection, is lower than the incidence of pneumonia, which is an extrasurgical field infection, after esophageal cancer surgery. Several trials predicting postoperative infectious complications have been reported. One measured the phytohemagglutinin- and concanavalin A-induced proliferation of peripheral blood mononuclear cells in patients; one measured the white blood cell (WBC) count 2 h after surgery and the decrease in WBC count on first postoperative day; and another showed that the decrease in serum IgG2 level can predict the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) infections. Useful strategies for managing infectious complications have also been reported. Applying mupirocin calcium hydrate ointment to the nasal cavity decreases the incidence of MRSA infections. Autologous blood collection reduces the need for allogeneic transfusion in patients undergoing resection of esophageal cancer, and avoidance of allogeneic transfusion may reduce the risk of postoperative infection. The total exposure to preoperative chemoradiotherapy should be limited to 40 Gy or less to prevent postoperative pneumonia.