[A case of advanced gastric cancer with multiple liver, lung, and lymph node metastases treated with S-1, CDDP, and trastuzumab].

The patient was a 58-year-old man diagnosed with type 2 advanced gastric cancer located at the fundus with multiple liver, lung, and lymph node metastases(Stage IV). Examination of an endoscopically obtained biopsy specimen revealed poorly differentiated adenocarcinoma (por), which stained positive for human epidermal growth factor receptor 2 (HER2) on immunohistochemistry. We started chemotherapy with S-1 plus cisplatin (CDDP) plus trastuzumab. The treatment was effective, as the tumor had reduced in size by 22.5% and 36.2%(partial response[PR])after 3 and 6 courses, respectively. Adverse events related to the treatment were limited to grade 1 fever, nausea, vomiting, and diarrhea. The patient's chief complaints of right upper abdominal pain and abdominal fullness remarkably improved after treatment initiation. Although the therapy was effective against the multiple liver metastases and could be continued for 11 courses, the lymph nodes metastases did not respond to therapy (progressive disease [PD]), and the patient died 9 months after the start of treatment. Chemotherapy with S-1 pus CDDP plus trastuzumab may be effective for HER2-positive advanced gastric cancer with liver metastasis.

Therapeutic strategy using extracorporeal life support, including appropriate indication, management, limitation and timing of switch to ventricular assist device in patients with acute myocardial infarction.

The appropriate indication for, management of and limitations to extracorporeal life support (ECLS) and the timing of a switch to a ventricular assist device (VAD) remain controversial issues in patients with acute myocardial infarction (AMI) complicated with cardiogenic shock or cardiopulmonary arrest. To evaluate and discuss these issues, we studied patients with AMI treated with ECLS and compared deceased and discharged patients. Thirty-eight patients with AMI who needed ECLS [35 men (92.1 %), aged 59.9 ± 13.5 years] were enrolled in this study. Of these 38 patients, 34 subsequently underwent percutaneous coronary intervention (PCI), and four subsequently received coronary artery bypass grafting (CABG). Fourteen patients (36.8 %) were discharged from the hospital. The outcome was not favorable for those patients with deteriorating low output syndrome (LOS) and the development of leg ischemia, hemolysis and multiple organ failure during ECLS. Levels of creatine kinase, creatine kinase-MB (CK-MB), lactate dehydrogenase, serum creatinine (Cr) and amylase after the patient had been put on ECLS and fluctuation of the cardiac index, blood pressure, arterial blood gas analysis and CK-MB and Cr levels during ECLS were indicators to switch from the ECLS to VAD. In the case of patients with no complication associated with ECLS, 4.6-5.6 days after initiation of ECLS was assumed to be the threshold to decide whether to switch from ECLS to VAD. Patients with AMI who suddenly developed refractory pulseless ventricular tachycardia or ventricular fibrillation without deteriorating LOS and who underwent successful PCI or CABG, and who prevented the complications associated with ECLS, showed a high probability of recovering with ECLS.

Factors predicting mortality in emergency abdominal surgery in the elderly.

OBJECTIVE: This study aimed to investigate clinical features of abdominal emergency surgery in elderly patients, and to determine factors predicting mortality in these patients. METHODS: The study population included 94 patients aged 80 years or older who underwent emergency surgery for acute abdominal diseases between 2000 and 2010. Thirty-six patients (38.3%) were male and fifty-eight patients (61.7%) were female (mean age, 85.6 years). Main outcome measures included background of the patient's physical condition (concomitant medical disease, and performance status), cause of disease, morbidity and mortality, and disease scoring system (APACHE II, and POSSUM). Prognostic factors affecting mortality of the patient were also evaluated by univariate analysis using Fisher's exact test and Mann-Whitney U-test, and by multivariate analysis using multiple logistic regression analysis. RESULTS: Of the 94 patients, 71 (75.5%) had a co-existing medical disease; most patients had hypertension (46.8%). The most frequent surgical indications were acute cholecystitis in 23 patients (24.5%), followed by intestinal obstruction in 18 patients (19.1%). Forty-one patients (43.6%) had complications during hospital stay; the most frequent were surgical site infection (SSI) in 21 patients (22.3%) and pneumonia in 12 patients (12.8%). Fifteen patients died (overall mortality, 16%) within 1 month after operation. The most common causes of death were sepsis related to pan-peritonitis in 5 patients (5.3%), and pneumonia in 4 patients (4.3%). Multiple logistic regression analysis showed that time from onset of symptoms to hospital admission and the POSSUM scoring system could be prognostic factors for mortality. CONCLUSIONS: Mortality in elderly patients who underwent emergency surgery for acute abdominal disease can be predicted using the disease scoring system (POSSUM) and on the basis of delay in hospital admission.

Prognostic factors of T4 gastric cancer patients undergoing potentially curative resection.

AIM: To investigate the prognostic factors of T4 gastric cancer patients without distant metastasis who could undergo potentially curative resection. METHODS: We retrospectively analyzed the clinical data of 71 consecutive patients diagnosed with T4 gastric cancer and who underwent curative gastrectomy at our institutions. The clinicopathological factors that could be associated with overall survival were evaluated. The cumulative survival was determined by the Kaplan-Meier method, and univariate comparisons between the groups were performed using the log-rank test. Multivariate analysis was performed using the Cox proportional hazard model and a step-wise procedure. RESULTS: The study patients comprised 53 men (74.6%) and 18 women (25.4%) aged 39-89 years (mean, 68.9 years). Nineteen patients (26.8%) had postoperative morbidity: pancreatic fistula developed in 6 patients (8.5%) and was the most frequent complication, followed by anastomosis stricture in 5 patients (7.0%). During the follow-up period, 28 patients (39.4%) died because of gastric cancer recurrence, and 3 (4.2%) died because of another disease or accident. For all patients, the estimated overall survival was 34.1% at 5 years. Univariate analyses identified the following statistically significant prognostic factors in T4 gastric cancer patients who underwent potentially curative resection: peritoneal washing cytology (P < 0.01), number of metastatic lymph nodes (P < 0.05), and venous invasion (P < 0.05). In multivariate analyses, only peritoneal washing cytology was identified as an independent prognostic factor (HR = 3.62, 95% CI = 1.37-9.57) for long-term survival. CONCLUSION: Positive peritoneal washing cytology was the only independent poor prognostic factor for T4 gastric cancer patients who could be treated with potentially curative resection.

Hemodialysis is an independent predictor of coronary in-stent restenosis after paclitaxel eluting stent implantation.

OBJECTIVE: A drug eluting stent is often used for high-risk patients with complications such as diabetes mellitus (DM) and hemodialysis (HD), however the factors to predict restenosis after paclitaxel-eluting stent (PES) placement have not been reported to date. METHODS: Between May 2007 and August 2009, 165 consecutive patients (231 stents) received PES in our hospital. Stent diameter and length were determined by the use of intravascular ultrasound (IVUS). All patients continued to take 2 types of anti-platelet agents (aspirin and Clopidogrel or Ticlopidine). Ninety percent of the subjects received a follow-up coronary angiogram 6 months later. RESULTS: Underlying diseases were hypertension in 75%, hyperlipidemia in 78% and DM in 60% (15% on insulin), and 14% of the subjects received HD. Eighty-three percent of the patients had orally taken Statin, 85% ACE/ARB and 68% had beta blockers. Mean length and diameter of PES were 21.6 ± 7.2 mm and 2.9 ± 0.3 mm, respectively. Target lesion revascularization (TLR) rate 6 months after PES placement was 14.6% overall. In HD patients TLR was 43%, hypertension 15.0%, hyperlipemia 12.4%, DM with oral medication 12.5%, DM with insulin 12.0%, respectively. In multivariate analysis, HD was an independent risk factor for TLR (p=0.0001, OR: 6.61, 95% C.I.: 2.34-18.6). CONCLUSION: HD had the greatest influence on TLR after PES even though risk factors were well controlled. It is necessary to develop new PCI techniques and stents that are useful for HD patients.

Carcinoma of the papilla of Vater following treatment of pancreaticobiliary maljunction.

Pancreaticobiliary maljunction (PBM) is frequently associated with biliary cancer due to reflux of pancreatic enzymes into the choledochus, and even after surgery to correct the PBM such patients still have a risk of residual bile duct cancer. Here, we report the case of a 59-year-old female with carcinoma of the papilla of Vater which developed 2.5 years after choledochoduodenostomy for PBM. During the postoperative follow-up period, computed tomography obtained 2 years after the first operation demonstrated a tumor in the distal end of the choledochus, although she did not have jaundice and laboratory tests showed no abnormalities caused by the previous operation. As a result, carcinoma of the papilla of Vater was diagnosed at an early stage, followed by surgical cure. For early detection of periampullary cancer in patients undergoing surgery for PBM, careful long-term follow-up is needed.

Prognostic significance of the metastatic lymph node ratio in gastric cancer patients.

BACKGROUND: Lymph node metastasis is considered one of the most important prognostic factors in gastric cancer. However, the optimal system for accurate staging of lymph node metastasis for patients with gastric cancer remains controversial. This study was designed to investigate the prognostic significance of the metastatic lymph node ratio (MLR), which is calculated by dividing the number of metastatic lymph nodes by the total number of nodes harvested from patients with gastric cancer. METHODS: We retrospectively analyzed the clinical data of 186 consecutive patients diagnosed with gastric cancer who underwent curative gastrectomy at our hospital. The lymph node status was classified according to three systems:the International Union Against Cancer/American Joint Committee on Cancer (UICC/AJCC) system; the Japanese Gastric Cancer Association (JGCA) system; and an MLR-based system (MLR0: 0, MLR1: 0.01-0.19, MLR2: >or=0.2). The influence of the MLR on patient survival was determined using univariate Kaplan-Meier survival analysis, the generalized Wilcoxon test, and analysis with the multivariate Cox proportional hazards model. RESULTS: The 5-year survival rate of the patients with MLR0, MLR1, and MLR2 was 88.6%, 59.4%, and 13.4%, respectively. In addition to the MLR, the UICC/AJCC N category,JGCA n category, tumor stage (pT category), and tumor diameter significantly influenced the 5-year survival rate, as determined by univariate analysis. Multivariate analyses revealed that of the three factors used to stage lymph node involvement, MLR was the most significant prognostic factor. CONCLUSIONS: The MLR is an important and easy-to-assess prognostic factor that should be considered for staging lymph node metastasis in patients with gastric cancer.

Patient selection and therapeutic strategy for emergency percutaneous cardiopulmonary system in cardiopulmonary arrest patients.

BACKGROUND: To clarify the appropriate application and therapeutic strategy for the percutaneous cardiopulmonary system (PCPS) in patients in cardiopulmonary arrest (CPA), the effects of the duration of cardiopulmonary resuscitation (CPR), diagnosis of underlying diseases, subsequent intervention and complications were retrospectively investigated for the correlation between discharge or death of patients. The patients were treated under an identical therapeutic PCPS protocol. METHODS AND RESULTS: The 69 CPA patients [55 males (78.6%), 14 females; age, 55.0 +/-15.3 years; age range 15-79 years, 50 in-hospital CPA (I-CPA) and 19 out-of-hospital CPA (O-CPA) patients] were treated with emergency PCPS. The mean duration of CPR was 43.6 +/-37.4 min. Of 18 discharged patients (26.1%), 14 had I-CPA and 4 had O-CPA. Significant factors in the discharge of patients were confirmed diagnosis, subsequent treatment and prevention of complications associated with PCPS. CONCLUSIONS: Appropriate patient selection for PCPS in cases of O-CPA is likely to give a similar survival rate as for I-CPA. Patient selection and reversibility of the underlying disease and clinical state after starting PCPS affect the prognosis. Aggressive diagnosis and therapy for the underlying disease and prevention of complications associated with PCPS are essential factors in successful discharge of patients. Patients with an unknown etiology are not expected to fully recover, despite PCPS.

[A case of advanced gastric cancer successfully treated with S-1 and paclitaxel followed by curative resection].

A 59-year-old man diagnosed with Stage IV advanced gastric cancer due to pancreatic invasion(T4)and splenic hilum lymph node metastasis(N3)was initially treated with neoadjuvant chemotherapy using S-1 and CDDP. However, it was discontinued because the tumor marker increased after 1 course. Instead of S-1 and CDDP, S-1 and paclitaxel were then administered. After 4 courses, CT scan revealed reduced tumor size and the disappearance of splenic hilum lymph node swelling that indicated PR of the chemotherapy. Moreover, serum CEA was remarkably decreased to 77 ng/mL from 1,092 ng/mL. He could undergo subtotal gastrectomy(Billroth II)with lymph node dissection(D2)and cholecystectomy. Histopathological examination revealed Stage II (pT2(SS), pN1, CY0, ly1, v2)advanced gastric cancer that showed good effect of S-1 and paclitaxel. At this writing (October 2007), the patient has remained free of disease for more than 1 year and 6 months with good nutrition. Neoadjuvant chemotherapy using S-1 and paclitaxel for advanced gastric cancer seems to have been effective.

Vasospasms of the radial artery after the transradial approach for coronary angiography and angioplasty.

We examined vasospasms of the radial artery after a transradial approach was used for coronary angiography or angioplasty. In forty-eight patients (39 males and 9 females), arteriography of the radial artery was initially performed just after the transradial approach was used for coronary angiography and/or angioplasty. Then, five months later, a second arteriography of the radial artery was obtained after a transbrachial approach was used for coronary angiography. First and second arteriographies were compared to evaluate vaso-spasms of the radial artery. In the present study, more than 75% stenosis in the radial artery, 25-75% stenosis, and less than 25% stenosis were tentatively defined as severe spasms, moderate spasms, and mild spasms, respectively. In arteriographic studies on the radial artery, twenty-four patients (50%) had severe radial artery spasms, eleven patients (23%) had moderate spasms, and thirteen patients (27%) had mild spasms. The diameters of both the proximal and distal radial arteries in the severe spasm group were significantly smaller than those in the mild and moderate spasm groups (proximal site: severe group 2.39 +/- 0.70 mm versus mild group 2.98 +/- 0.46 mm, P < 0.05, and moderate group 2.96 +/- 0.77 mm, P < 0.05, distal site: severe group 2.26 +/- 0.60 mm versus mild group 2.73 +/- 0.47 mm, P < 0.05, and moderate group 2.86 +/- 0.71 mm, P < 0.05). We concluded that vasospasms of the radial artery occurred in most patients after the transradial approach. Furthermore, severe radial spasms were strongly correlated with the size of the diameter of the artery.

Cyclic GMP production by ANP, BNP, and NO during worsening and improvement of chronic heart failure.

Cyclic GMP (cGMP) serves as an intracellular second messenger of atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and nitric oxide (NO) and its peripheral blood concentration is an index of its biological activity. It has been reported that the plasma concentration of cGMP is correlated with the concentrations of ANP and BNP and is related to the prognosis of chronic heart failure patients, but the relation with NO has not been studied. Therefore, we investigated the roles of ANP, BNP, and NO in relation to cGMP in the blood during worsening and improvement of chronic heart failure. The subjects were 25 patients who were hospitalized in our hospital for acute worsening of chronic heart failure. Plasma concentrations of NO, norepinephrine (NE), ANP, BNP, and cGMP were measured on acute worsening (admission) and improvement (discharge) of heart failure. The cGMP concentration on worsening showed a positive correlation with the NO concentration (r = (0.57, P < 0.01), but no correlations with ANP or BNP were observed. The cGMP concentration on improvement showed no correlation with the NO concentration, but a positive correlation with ANP (r = 0.69, P < 0.001) and BNP (r = 0.67, P < 0.001). No correlation was observed between the NO and NE concentrations. We also studied serious cases of NYHA IV and mild cases of NYHA II to III. The cGMP concentration in the serious group showed a positive correlation with the NO concentration but no correlations with ANP or BNP concentrations on worsening. However, in the mild group, the cGMP concentration during worsening showed positive correlations with both the NO and BNP concentrations. On improvement, the cGMP concentration showed no correlation with the NO concentration but positive correlations with both the ANP and BNP concentrations in both the severe and mild groups. The results suggest the possibility that cGMP is produced mainly by NO during worsening, and by ANP and BNP rather than NO during improvement of chronic heart failure.

A young girl with vasospastic angina associated with mutation in endothelial nitric oxide synthase gene--a case report.

A 13-year-old girl was successfully recuperated from cardiopulmonary arrest shortly after running 80 m in a competition. The electrocardiogram, echocardiogram and 123I-MIBG myocardial scintigraphic imaging indicated myocardial ischemia in the anteroseptal wall of the left ventricle. Coronary angiography during the recovery phase revealed no stenotic lesions, and spasms of the left anterior descending artery and the left circumflex artery could be provoked by acetylcholine. The endothelial nitric oxide synthase gene abnormality associated with coronary spasms was examined. The patient had the T-786 --> C, A-922 --> G, and T-1468 --> A mutations in the 5'-flanking region on one allele of the endothelial nitric oxide synthase gene. To the authors' knowledge, she represents the first case of life-threatening coronary spasms in childhood associated with mutations in the endothelial nitric oxide synthase gene.