Hiroshi Yamashiro

A prospective pilot study of extended (D3) and superextended para-aortic lymphadenectomy (D4) in patients with T3 or T4 gastric cancer managed by total gastrectomy☆

BACKGROUND Japanese surgeons have been actively performing extended lymphadenectomy (D2, removal of perigastric nodes and nodes along the left gastric, common hepatic, celiac and splenic arteries; or D3, D2 plus removal of nodes in the hepatoduodenal ligament, in the retropancreatic space and along the vessels of the transverse mesocolon). In recent years interest has expanded to superextended lymphadenectomy (D4) of nodes around abdominal aorta (para-aortic lymph nodes from aortic hiatus to aortic bifurcation). Because the therapeutic value of this D4 procedure remains controversial, we initiated a prospective study to compare D3 and D4 lymphadenectomy. METHODS Seventy patients with T3 or T4 gastric cancer and without macroscopic metastasis to the para-aortic nodes treated by potentially curative total gastrectomy were randomized to D4 (group A, n = 35) and D3 (group B, n = 35) lymphadenectomies. RESULTS Metastases to para-aortic nodes were found in 4 patients. Postoperative survival after D4 resection was not statistically significant between the groups. Postoperative morbidity for group A was greater. In group A 4 patients had postoperative retention of intra-abdominal fluid (lymphorrhea) and 4 others had prolonged diarrhea. One patient in each group died of postoperative complications. CONCLUSIONS Surgical treatment of microscopic disease in grossly normal para-aortic lymph nodes may generate occasional long-term survivors. Selecting appropriate candidates who might benefit from D4 resections needs to be refined. On the basis of this study, a nationwide study should be considered.

Clinicopathologic differences between carcinoma in the gastric remnant stump after distal partial gastrectomy for benign gastroduodenal lesions and primary carcinoma in the upper third of the stomach

Background. This study evaluated the prognosis of patients with carcinoma in the gastric remnant stump after distal gastrectomy for benign disease (stump cancer).

Does the extent of lymph node dissection affect the postoperative survival of patients with gastric cancer and disseminating peritoneal metastasis

For patients with gastric cancer and either P, or P2 peritoneal metastasis, no definite consistent policy with respect to the extent of lymph node dissection has yet been established. In palliatively gastrectomized patients, we analyzed the relationship between the extent of lymphadenectomy and postoperative survival. In patients with P1, an R2 or R3 lymphadenectomy was associated with a significantly improved postoperative survival as compared to an Rl dissection, while this, however, was not the case in patients with P2. As this study was not intended to be a prospective randomized study, a definite conclusion should be avoided. However, our findings suggest that in patients with PI, surgery should not be confined to a resection of the primary lesion, but should also include an R2 or R3 lymphadenectomy.

Diagnostic accuracy of combination of assays for immunosuppressive acidic protein and carcinoembryonic antigen in detection of recurrence of gastric cancer

Two tumour markers, immunosuppressive acidic protein (IAP) and carcinoembryonic antigen (CEA), were assayed in gastric cancer patients. Levels of IAP and CEA were measured simultaneously in the preoperative and postoperative periods. The usefulness of the combined assay of these markers for detection of recurrence of cancer was investigated in terms of sensitivity, specificity and diagnostic accuracy. Sensitivity was not high (69.2%), but specificity and diagnostic accuracy were 96.7% and 86.9%, respectively. In cases with metastases in the liver, sensitivity (100.0%), specificity (100.0%) and diagnostic accuracy were high. In cases of peritoneal dissemination, these indices were low. The combination assay of IAP and CEA appears to be useful for detection of recurrence of gastric cancer, especially in patients with liver metastases.

Esophageal cancer associated with multiple cancerous lesions: clinicopathologic comparisons between multiple primary and intramural metastatic lesions.

SummaryDetailed histopathological examination of serial blocks and subserial sections of the entire resected esophagus in 111 patients who underwent esophagectomy for esophageal squamous cell carcinoma revealed 38 associated cancerous lesions apart from the main tumors, in 33 patients (29.7%). These associated lesions were divided into multiple primary lesions (MPLs; 27 lesions in 23 patients) and intramural metastatic lesions (IMLs; 11 lesions in 10 patients). Thirteen and fourteen MPLs were distributed on the proximal and distal sides, respectively, of the main tumor with the same mean distance of 2.6 cm. Three and 8 IMLs were located on the proximal and distal sides, respectively, with mean distances of 3.4 cm and 4.6 cm. With respect to the histological depth of cancer invasion, MPLs were all confined within the submucosal layer (superficial cancer) while IMLs varied from the submucosa to the adventitia. Histological findings indicate that MPLs may be associated with a possible increased multicentric carcinogenic potential in the non-cancerous epithelium of the esophagus of patients who have had an antecedent esophageal cancer, and that IMLs are developed by intramural lymphatic spread from the primary esophageal cancer. These results emphasize the need for careful attention to the choice of margins during the surgical resection of the esophagus.

Esophageal Cancer Associated with Multiple Primary or Intramural Metastatic Lesions

The presence of multiple primary [1] or intramural skip metastatic lesions [2], in addition to the main tumor are well recognized as specific features of invasive esophageal cancer. A detailed histological examination by serial blocks and subserial sections of the entire resected esophagus, as a routine procedure enabled us to detect the associated minute lesions that were barely identifiable macroscopically on the resected specimen. In the present study, we analyzed the clinicopathological findings of esophageal cancers associated with multiple cancerous lesions, apart from the main lesions, and we compared clinical features between multiple primary lesions (MPLs) and intramural metastatic lesions (IMLs).

Thermochemotherapy Using a Radiofrequency Capacitive Heating System in the Treatment of Unresectable Bile Duct and Pancreatic Cancers

非手術例を除く胆道癌非切除例4例と膵癌非切除例6例の計10例に対し, 8MHzのradiofrequency (RF) 誘電加温装置を用いて局所温熱化学療法を施行した.RF加温は腫瘍内温度42℃ ・30分を目標に週1回施行した.最高腫瘍内温度とRF最大出力との間には有意な正の相関が認められ, RF最大出力1,000W以上で腫瘍内温度は有効な42℃ 以上に上昇した.腫瘍縮小効果は5例に, P.S.の改善と血清腫瘍マーカー値の低下はおのおの6例に認められ, 膵癌の有痛例5例中3例に除痛効果が得られた.腫瘍縮小が得られた5例中3例が1年以上, うち1例が2年以上生存中である.温熱化学療法施行例の遠隔成績は従来の化学療法単独施行例の成績よりも良好であった.以上より, 切除不能胆道・膵癌に対する温熱化学療法は, 高い抗腫瘍効果とともにquality of lifeの改善が得られ, 有効な治療法になる可能性が示唆された.