Long-term comparison of boomerang-shaped jejunal interposition and Billroth-I reconstruction after distal gastrectomy.

BACKGROUND: Billroth-I (BI) is a simple, physiological method of reconstruction following distal gastrectomy. In actuality, postoperative QOL is by no means favorable due to the high incidence of post-gastrectomy syndrome. The aim of this study is to assess the safety and efficacy of boomerang-shaped jejunal interposition (BJI) after distal gastrectomy. METHODS: Sixty-six patients with early gastric cancer underwent the BI procedure (n = 33) or BJI (n = 33) after distal gastrectomy, following which they were compared for 5 years. Tumor characteristics, operative details, postoperative complications and complaints, number of meals, and body weight were analyzed. Patients were followed up by endoscopy every 12 months. RESULTS: There were no significant differences in the incidence of postoperative complications. The incidence of heartburn (30 vs. 0 %, P = 0.0009) and oral bitterness (33 vs. 6 %, P = 0.0112) were significantly lower in the BJI cases. Endoscopic findings revealed significantly lower incidences of reflux esophagitis (24 vs. 0 %, P = 0.0051) and remnant gastritis (70 vs. 3 %, P < 0.0001) in the BJI group. The incidence of food stasis was low in both groups (12 vs. 15 %). In the BJI group, 30 patients (90 %) were eating 3 meals/day within 12 months, whereas in the BI group, 16 patients (48 %) were still eating 5 meals/day at 12 months or later. CONCLUSIONS: BJI is as safe as BI, but is better in terms of improvement in bile reflux and food intake without stasis. This procedure, therefore, appears to be a useful method for reconstruction after distal gastrectomy.

Comprehensive analysis of genes involved in the malignancy of gastrointestinal stromal tumors.

BACKGROUND: During tumorigenesis of gastrointestinal stromal tumors (GISTs), the most frequent changes are reported to be gain-of-function mutations in the C-KIT proto-oncogene. However, we speculated that additional genetic alterations are required for the progression of GISTs. PATIENTS AND METHODS: Using 15 cases diagnosed with GISTs, we searched for novel indicator genes by microarray analyses using an Oligo GEArray(R) PI3K-AKT Signaling Pathway Microarray Kit. In addition, we analyzed the mutational status of C-KIT and the proliferation status indicated by the Ki-67 index. RESULTS: The tumor localizations of the 15 GISTs were as follows: 8 in the stomach; 2 in the small intestine; 2 in the mesentery; 1 in the duodenum; 1 in the rectum; and 1 in liver. Regarding the C-KIT gene analysis, mutations in exon 11 were detected in 11 out of 13 patients. In 1 out of the 13 patients, mutations were detected in both exons 11 and 13. No genetic abnormalities were identified in 1 patient. The Ki-67 labeling indices were significantly lower for the low-risk and intermediate-risk groups than for the high-risk group (p=0.0440). No specific genes were overexpressed in the >1% Ki-67 group. Regarding the primary lesion sites, the following 6 genes were overexpressed in tumors in the stomach: RBL2, RHOA, SHC1, HSP90AB1, ACTB and BAS2C. CONCLUSION: Gene analysis is currently only useful for diagnostic assessment and predicting therapeutic effects. However, it may be possible for new malignancy-related factors to be identified by comparing and investigating gene expression levels and other factors using such analyses.

Performance of integrated FDG PET/contrast-enhanced CT in the diagnosis of recurrent colorectal cancer: Comparison with integrated FDG PET/non-contrast-enhanced CT and enhanced CT.

PURPOSE: The aim of our study was to evaluate the accuracy of integrated positron emission tomography and computed tomography (PET/CT) using (18)F-fluorodeoxyglucose (FDG) with IV contrast for depiction of suspected recurrent colorectal cancer and to assess the impact of PET/contrast-enhanced CT findings on clinical management compared with PET/non-contrast-enhanced CT and CT component. METHODS: One hundred seventy patients previously treated for colorectal cancer underwent PET/CT consisting of non-enhanced and contrast-enhanced CT for suspected recurrence. PET/contrast-enhanced CT, PET/non-contrast-enhanced CT and enhanced CT were interpreted by two experienced radiologists by consensus for each investigation. Lesion status was determined on the basis of histopathology, radiological imaging and clinical follow-up for longer than 6 months. RESULTS: Patient-based analysis showed that the sensitivity, specificity and accuracy of PET/contrast-enhanced CT were 93.2 (69/74), 95.8 (92/96) and 94.7% (161/170), respectively, whereas those of PET/non-contrast-enhanced CT were 89.2 (66/74), 94.8 (91/96) and 92.4% (157/170), respectively, and those of enhanced CT were 79.7 (59/74), 93.8 (90/96) and 87.6% (149/170), respectively. Sensitivity and accuracy differed significantly among the three modalities (Cochran's Q test: p = 0.0004 and p = 0.0001, respectively).The findings of PET/contrast-enhanced CT resulted in a change of management for 64 of the 170 patients (38%) and had an effect on patient management in 12 patients (7%) diagnosed by enhanced CT alone and 4 patients (2%) diagnosed by PET/non-contrast-enhanced CT. CONCLUSION: Integrated PET/contrast-enhanced CT is an accurate modality for assessing colorectal cancer recurrence and led to changes in the subsequent appropriate therapy.

PET/CT supports breast cancer diagnosis and treatment.

The application of positron emission tomography with (18)F fluoro-2-deoxy-D-glucose (FDG-PET) has remarkably improved the management of cancer patients. However, some caution is necessary in the interpretation of FDG-PET images. Because of its low spatial resolution, it is difficult to identify the anatomical location of radiotracer uptake and to distinguish between normal physiological accumulation and pathological uptake. A novel combined PET/CT system has been developed that improves the capacity to correctly localize and interpret FDG uptake. Although only a few studies have been conducted on the potential role of PET/CT in the management of breast cancer patients, the advantage of this modality compared with PET alone should be relevant for application in the field of breast cancer. In this review, we describe the clinical impact of PET/CT on breast cancer diagnosis compared with PET alone with respect to disease restaging, treatment monitoring, preoperative staging and primary diagnosis. In addition, the possible role of PET/CT with iodine contrast is noted for evaluation of intra-ductal spreading.

Depth of tumor invasion in locally advanced rectal cancer correlates with patients' prognosis: the usefulness of elastic stain for its measurement.

PURPOSE: The relationship between the prognosis and the extent of colorectal carcinoma (CRC) is still unclear. As a simple parameter of the local invasion of CRC, we assessed the extent of tumor invasion beyond the outer border of the muscularis propria (MP). METHODS: We examined 147 cases of CRC using a slight modification of the procedure established by the Japanese Society for Cancer of the Colon and Rectum. For the statistical analysis, the patients were divided into two groups, namely, a "shallow" group and a "deep" group, using a specific cut-off value (COV). A multivariate analysis to identify independent prognostic factors was performed. RESULTS: Significant differences in the 5-year survival rate were observed between the "shallow" and "deep" groups in 39 cases of rectal carcinoma (COV 4 mm; 72.4% vs. 30.0%, hazard ratio = 3.204), but not observed in 147 cases of CRC. In addition, the outcome for patients with "deep" cancer in the lower rectum was markedly worse than that for patients with "shallow" cancer (COV 4 mm; 81.8% vs. 12.5%, hazard ratio = 5.371). CONCLUSIONS: The depth of tumor invasion beyond the MP is thus considered to be an important prognostic factor for patients with T3/T4 rectal carcinoma, especially in the lower rectum. A careful follow-up is required for the patients with rectal carcinoma that has invaded more than 4 mm beyond the MP.

Sigmoid colon cancer with mediastinal lymph node metastases.

Mediastinal lymph node metastasis from colorectal cancer is rarely seen. We herein report on a 74-year-old man who was hospitalized with multiple brain metastases and mediastinal lymph node metastasis from an adenocarcinoma of the sigmoid colon. A preoperative brain magnetic resonance image showed multiple brain tumors, and a chest computed tomography (CT) scan indicated a mediastinal tumor. CT-guided aspiration biopsy cytology of the mediastinal tumor showed metastatic adenocarcinoma from a digestive tract tumor. Barium enema and sigmoid colonoscopy showed that the cancer was located in the sigmoid colon. Laparoscopic assisted sigmoidectomy with lymph node dissection was performed. Pathological findings of the specimen showed a moderately differentiated adenocarcinoma that invaded to the subserosa, but no evidence of lymph node metastasis was found. The patient was discharged 3 weeks after the operation and died 3 months later.

Cecal adenocarcinoma with prominent rhabdoid feature: report of a case with immunohistochemical, ultrastructural, and molecular analyses.

Colorectal adenocarcinoma with rhabdoid phenotype is extremely rare, and only 1 case of adenocarcinoma showing rhabdoid dedifferentiation has been reported. The authors present another case of cecal adenocarcinoma with prominent rhabdoid feature in a 66-year-old man. The 13-cm sized tumor consisted mainly of rhabdoid cells and partly of adenocarcinoma, and transition from adenocarcinoma to rhabdoid areas was noted. Ultrastructural analysis revealed intracytoplasmic aggregates of intermediate filaments in the rhabdoid cells. Adenocarcinoma cells were diffusely immunoreactive to cytokeratin 7 and AE1/3, but occasionally positive for vimentin. The rhabdoid cells were negative for cytokeratin 7, weakly/focally immunoreactive to AE1/3, and diffusely positive for vimentin. These results suggested that the rhabdoid cells were dedifferentiated adenocarcinoma. Analysis of the rhabdoid cells with molecular techniques is also presented.

Relative and combined performance of mammography and ultrasonography for breast cancer screening in the general population: a pilot study in Tochigi Prefecture, Japan.

BACKGROUND: Breast cancer screening by mammography is thought to be effective in reducing breast cancer mortality while ultrasonography is not accepted as a population screening modality, although the latter has been suggested to be useful in detection of cancer in the dense breast, relatively more typical for a younger woman. METHODS: Mammography with medio-lateral oblique view was offered on trial in 1999-2000 for 3453 female residents in Tochigi prefecture who also underwent clinical breast examination and ultrasonography. The municipalities that provided cancer screening were informed of the final diagnosis for women with positive findings in the screening trial by doctors who performed the diagnostic evaluation. Linkage was also made between the list of participants in the trial and registrations at Tochigi Cancer Registry for breast cancer cases diagnosed during 1999-2001. RESULTS: Thirteen cases with breast cancer were identified during a 2-year follow-up period: 10 were diagnosed subsequent to positive finding in the trial; two were negative in the trial and diagnosed 23 and 24 months after, respectively; and one had a positive finding at the trial but was undiagnosed at first and then diagnosed 18 months after the trial. Among the 11 cases judged as positive in the trial, four were judged only by mammography while three were judged only by ultrasonography. Those mammography alone-detected cases were relatively young, at 36, 40, 47 and 54 years of age, respectively, while the ultrasonography alone-detected cases were aged 50, 55 and 68, respectively. CONCLUSIONS: Combined screening with mammography and ultrasonography may be feasible. A larger study is required to evaluate relative performance of mammography and ultrasonography in detail by characteristics of examinees and their breasts.

The relationship between FDG uptake in PET scans and biological behavior in breast cancer.

BACKGROUND: Positron emission tomography (PET) is a non-invasive imaging modality used in the diagnosis and staging of breast cancer. However, several factors can affect fluoro-deoxyglucose (FDG) uptake by a tumor. To clarify the parameters that most affect FDG accumulation in tumors, the relationship between standardized uptake values (SUVs) and clinicopathological factors and immunohistopathological analysis was investigated in breast cancer. MATERIAL AND METHODS: PET studies were performed preoperatively on 37 patients with breast carcinoma. SUVs were counted at one hour (early phase) and at two hours (delayed phase) after FDG injection. The relationships between SUVs and 13 clinical, pathological and immunohistchemical factors were studied. RESULTS: A significant association was found between FDG accumulation and early and delayed phase mitotic counts (p=0.0018 and 0.0010, respectively), Ki67 positive cell percentage (p=0.0098 and 0.0062, respectively), and nuclear grade (p=0.0232 and 0.0195, respectively). On the other hand, nodal status weakly correlated with the delayed phase (p=0.0907). However, other clinicopathological parameters and immunohistopathological status, which included tumor size, age, histology, estrogen receptor, progesterone receptor and Her2/neu overexpression, did not correlate significantly with FDG uptake. CONCLUSION: Mitotic count and Ki67 reflect cellular aggressiveness. These parameters were strongly correlated with tracer uptake. Thus our data suggested that the biological behavior of breast cancer is reflected in the variation of FDG uptake by the tumor. However, whether FDG uptake is a true prognostic and predictive factor remains to be confirmed in larger studies over an extended period of time.

Relationship between surgical procedure and spontaneous urination after rectal cancer surgery.

OBJECTIVE: The aim of this study was to determine the relationship between surgical procedures and spontaneous urination after rectal cancer surgery. METHODS: We reviewed the time of removal of the Foley catheter in 91 patients with middle and lower rectal cancer who had undergone curative surgery, either abdominoperineal resection (APR) or sphincter-preserving operation (SPO), without pelvic lymphadenectomy (PL). We also reviewed the time of catheter removal in 40 rectal cancer patients who had undergone one of four types of autonomic nerve preserving (ANP) operations. RESULTS: The mean time of removal of the catheter was 7.3 postoperative days (POD) in patients who underwent APR and 3.1 POD in patients who underwent SPO (p = 0.01). The mean time of removal in patients who underwent ANP for the entire plexus without PL (type 1a) was 6.7 POD. It was 5.6 POD in ANP for the entire plexus with PL (type 1b), 13.8 POD in ANP for bilateral pelvic plexus with PL (type 2) and 15.8 POD in ANP for unilateral pelvic plexus with PL (type 3). CONCLUSION: The type of operation and the volume of preserved nerves could be influential factors in the time to removal of the Foley catheter after rectal cancer surgery.

[A case of effective treatment of oral TS-1 and intravenous MMC administration for multiple metastases of gastric cancer].

A 49-year old man underwent distal gastrectomy (D3) for circumferential type 3 cancer at the gastric antrum and cholecystectomy in September 2002. During the surgery, multiple metastases were observed predominantly in the left lobe of the liver, and lateral segmentectomy was performed as non-curative (curability-C) resection leaving the small metastases in the right lobe of the liver. Based on the results of chemo-sensitivity tests (5-FU 15.0%, CDDP 34.0%, MMC 35.3%, TXT 0.0%), we started to administer TS-1 (100 mg/day for 4 weeks followed by a 2-week rest interval) and MMC (10 mg/body on day 1). Due to leukocytopenia, the regimen was changed to TS-1 (100 mg/day for 4 weeks followed by a 2-week rest interval) and MMC (4 mg/body every other week [day 1, 14]) from the second course. Levels of tumor markers dropped and liver metastatic lesions remarkably decreased in size by CT after the third course. In conclusion, a combination of TS-1/MMC may be regarded as one option for postoperative adjuvant chemotherapy for outpatients.

Correlation between survivin mRNA expression and lymph node metastasis in gastric cancer.

BACKGROUND: Correlations between the malignant potential and prognosis of cancer and abnormal control mechanisms of apoptosis have been discovered in a variety of cancers. Survivin is a member of the inhibiting apoptosis protein family that is abundant in embryonic and carcinoma tissues. We measured the expression of survivin mRNA in gastric cancer to determine whether levels of survivin mRNA expression could serve as an index of malignancy. METHODS: Expression of survivin mRNA was measured in samples of both gastric cancer and noncancerous tissue from 107 patients. Survivin mRNA was detected by the real-time polymerase chain reaction (PCR) method, and then the relationship between the survivin mRNA level and histological diagnosis was analyzed. RESULTS: Expression of survivin mRNA was observed in 105 of 107 cancerous tissues and in 101 of 107 noncancerous tissues. The Mean value of survivin mRNA expression in cancerous tissue was 5.18 +/- 1.30, significantly higher ( P < 0.01) than that in noncancerous tissue, at 4.21 +/- 1.48. No significant differences were found in the values of survivin mRNA expression according to histological classification or according to increasing depth of tumor invasion. However, survivin mRNA expression was significantly higher ( P < 0.01) in patients displaying lymph node metastasis (5.48 +/- 1.01) than in patients without the metastasis (4.70 +/- 1.55). CONCLUSIONS: These results indicate that increased survivin mRNA expression begins in the early stages of gastric carcinogenesis. Moreover, the level of survivin mRNA expression may indicate the potential for lymph node metastasis in patients with gastric cancer. Correlations between the malignant potential and prognosis of cancer and abnormal control mechanisms of apoptosis have been discovered in a variety of cancers. Survivin is a member of the inhibiting apoptosis protein family that is abundant in embryonic and carcinoma tissues. We measured the expression of survivin mRNA in gastric cancer to determine whether levels of survivin mRNA expression could serve as an index of malignancy.