Preliminary trial of adjuvant surgery for advanced gastric cancer.

In patients with stage IV gastric cancer, systemic chemotherapy is the key treatment. Combination chemotherapy (cis-diamminedichloride platinum plus S-1 and docetaxel plus S-1) results in long-term survival in clinical practice. In selected cases, additional (adjuvant) surgery may result in further long-term survival. This study aimed to evaluate the efficacy of adjuvant surgery following the response to chemotherapy for advanced gastric cancer. Based on response to chemotherapy, the indications for adjuvant surgery (surgery after the response to chemotherapy) are that resection is expected to be curative rather than palliative, provided that no other distant metastases occur. The study included 20 advanced gastric cancer patients who had undergone gastrectomies after the response to the combination chemotherapy of docetaxel and S-1, between September 2003 and December 2008 at Hiroshima University Hospital. At a median follow-up of 980 days, the median overall survival was 855 days. A 2- and 3-year survival was observed in 80 and 54.9% of patients, respectively, following macroscopic curative surgery. In the palliative group, the median overall survival was 510 days, but a 3-year survival was not observed. In the partial response group, the median overall survival was 865 days and a 3-year survival was observed in 37% of patients. One-year survival was not observed in the stable disease group. The patient survival in the partial response group was statistically more prolonged than in the stable disease group. The median overall survival in patients with liver metastasis was 865 days, while that in patients with peritoneal dissemination was 510 days. In conclusion, adjuvant surgery may be effective in gastric cancer patients diagnosed as stage IV by means of liver or distant lymph node metastasis, except in cases of peritoneal dissemination.

[Effectiveness of high-dose, intermittent 5'-DFUR therapy for advanced gastric cancer].

We report a case of advanced gastric cancer with multiple liver metastases and peritoneal dissemination. The patient was effectively treated with high-dose 5'-DFUR. A 52-year-old patient with advanced gastric cancer and multiple liver metastases, who showed a high serum level of CEA and CA19-9 underwent simple D1 gastrectomy. Thereafter, he received per os 1,200 mg/day of 5'-DFUR intermittently (5 days a week) and TAI every four months postoperatively. The serum levels of both CEA and CA19-9 fell dramatically to within the normal range and were maintained thereafter until the present. The size and number of the liver metastases dramatically decreased, judging from CT and angiography findings.

Prognostic value of peritoneal lavage cytology and chemotherapy during surgery for advanced gastric cancer.

BACKGROUND: The prognostic value of intra-operative peritoneal lavage cytology and chemotherapy was evaluated retrospectively. METHOD: Lavage cytology was performed in 257 patients. Prognosis was investigated in 85 of pT3 and pT4 patients with radical gastrectomy. Intra-operative chemotherapy was selected according to the cytology and exploration of the peritoneal cavity. For patients forecasted to have peritoneal recurrence, intraperitoneal injection of cisplatin was performed. RESULTS: No free cancer cells (cy(-)) were found in pTis, pT1 and pT2. In pT3 and pT4, cy(-) were 82.8% of the cases without macroscopic metastasis (P(-)), and the presence of free cancer cells (cy(+)) were 89.3% of the cases with macroscopic metastasis (P(+)). Intraperitoneal injection was performed in about 60% of P(-)/cy(+) and P(+) cases. Five-year survival rate of P(-)/cy(-) was 41.7% and that of P(-)/cy(+) was 33.3%. All of P(+) died within 3 years. CONCLUSION: Patients of P(-)/cy(+) probably had microscopic residual disease and might benefit from intraperitoneal chemotherapy.

Improvement of oral ingestion in patients with inoperable esophageal cancer treated with radiotherapy, chemotherapy and insertion of a self-expanding nitinol stent.

Radiotherapy, chemotherapy and self-expanding nitinol stent insertion were performed in patients with inoperable esophageal cancer to improve oral ingestion. Twelve patients underwent radiotherapy and chemotherapy. A stent was inserted in patients with dysphagia after radiotherapy and chemotherapy. Patients' capacity for oral ingestion was classified into three categories: grade I patients were able to ingest enough food; grade II patients could ingest food but required nutritional support; and grade II patients found it impossible to ingest anything. After radiotherapy and chemotherapy, the number of grade I patients increased from three to five but seven patients remained in grades II and III. Four grade II and III patients were treated with stents, after which dysphagia was reduced to grade I. In the grade I patients after treatment with radiotherapy and chemotherapy, the duration of grade I was on average 167 days and survival was 191 days. In the patients subjected to stent insertion, grade I lasted 65 days and survival was 149 days. Before the introduction of the stent, grade II patients died, on average, after 91 days. After the introduction of self-expanding nitinol stents, all patients could ingest enough food and were discharged.

Long-term outcome of renal transplantation in hepatitis B surface antigen-positive patients in cyclosporin era.

The impact of hepatitis B virus (HBV) infection on the outcome of renal transplantation (Tx) has been controversial. To determine the indication of renal Tx in patients infected by HBV, we investigated the long-term outcome of renal transplant patients with hepatitis B surface antigen (HBsAg). We analyzed 980 patients, including 18 HBsAg carriers, who underwent renal Tx and were immunosuppressed with cyclosporin in our institute. Fourteen out of 18 patients (77.8%) showed hepatic dysfunction after an average period of 17.8 months (range 1-65) after Tx. Four out of 14 patients (28.5%) with hepatic dysfunction died of liver failure due to fulminant hepatitis with functioning grafts between 15 and 71 months after Tx. The remaining 10 patients with hepatic dysfunction are alive up to the time of last follow-up; however, 5 of them lost their grafts because of rejection between 44 and 92 months after Tx. Their liver function improved after withdrawal of cyclosporin. Only 4 patients did not develop chronic liver disease and have had functioning grafts for between 44 and 147 months. One patient died of subarachnoid hemorrhage 22 months after Tx. HBe antigen, antibody and HCV antibody status were not related to the occurrence of liver dysfunction after Tx. Four HBV-DNA-positive patients showed deteriorated liver function. Three patients with chronic active hepatitis confirmed by the biopsy were treated with interferon. Interferon improved liver function in 2 patients, however, 1 patient died of liver failure despite interferon therapy. Our data suggested that the presence of HBsAg is often associated with chronic liver disease leading to liver failure regardless of HBe and HCV status after Tx. The indication of renal Tx in patients with HBsAg should be determined carefully giving consideration to these results.

[Nutritional management of patients with cirrhosis after hepatectomy].

Nutritional management for the patients with cirrhosis after hepatectomy was studied. Based on the experimental results, 1-1.5g/kg/day of branched chain amino acid (BCAA) enriched solution with 30 kcal/kg/day of glucone was given to the cirrhotic patients after hepatectomy for 10-14 days. Sodium and total fluid volume were strictly restricted. Elemental diet for liver failure (ED-H) was started to give within 7 days after surgery for 6-21 days. High relationships were observed between preoperative nutritional status such as prealbumin and retinol binding protein (RBP) and incidence of postoperative complications, suggesting that postoperative nutritional supply was very important. Changes of albumin, hepaplastin test and prothrombin time were rather good and the BCAA to aromatic amino acids molar ratio was maintained high when nutritional management was performed. Overall one and two year survival rates were 74% (20/27) and 36% (5/14), respectively. No significant difference was seen between the prognoses of the patients with and without liver dysfunction. Immediate postoperative nutritional management must be essential to get over critical stage safely and long-term nutritional supply may be necessary to get better prognosis.