Hiroyoshi Mieno

Endoscopic treatment of gastric cancer

SummaryWe analyzed 445 cases of early gastric cancer to confirm which were associated with lymph-node metastases. Overall, gastric cancers less than 2 cm in size, without an ulcer or ulcer scar, or protuberant or mixed morphology could be expected to be free of lymph-node metastases. In these patients with early gastric cancer without lymph-node metastasis, local treatment using surgical endoscopy could effectively eradicate the disease. Laser irradiation was performed in 44 cases and mucosal resection in 18 cases. All early gastric cancers less than 2 cm in size, with the exception of those located in the prepylorus or high on the posterior wall of the body of the stomach were eradicated by laser irradiation. Mucosal resection was used to ablate cancers less than 1 cm in size and with the exception of 1 case, total clearance was obtained. We conclude that early gastric cancer without lymph-node metastases can be eradicated by surgical endoscopic treatment.

The concepts, procedures, and problems related in endoscopic laser therapy of early gastric cancer

SummaryWe report 34 cases of early gastric cancer in which endoscopic laser therapy was performed at the Kitasato University Hospital. The problems encountered were the size and location of the tumor, the presence of lymphatic metastasis or concomitant disorders, and technical problems associated with the irradiation procedure. Of the 34 cases, 22 cases were considered as completely cured (no malignancy was detected after laser therapy), 11 cases were incompletely cured (malignant cells were detected after laser therapy), and 1 case was undetermined.

Multifocal granular cell tumors of the gastrointestinal tract : Immunohistochemical findings compared with those of solitary tumors

Granular cell tumors (GCT) are infrequently found in the gastrointestinal tract (GIT), and only four previous reports have described lesions occurring simultaneously in different sites. The present case of 11 GCT, located in the esophagus, stomach, colon and pericolic adipose tissue, occurred in a 50‐year‐old Japanese woman. All GCT appeared histologically benign and there was no sign of recurrence at 3 years after surgery. Immunohistochemical analysis and comparison between this case of multifocal GCT and six cases of solitary benign GCT of the GIT, which were taken from the files of the Department of Pathology at Kitasato University (1986–2000), demonstrated the follow‐ing:  (1) all diffusely expressed S‐100, DCC and bcl‐2, and (2) median labeling indices for Ki‐67, cyclin D1, p53 (Pab1801), and p21WAF1/CIP1 of 4%, 24%, 1% and 28%, respectively, for the multifocal tumors, and 3.5%, 23%, 1% and 29%, respectively, for the solitary lesions, with no significant difference between the two groups. Thus, the expression of cyclin D1 and p21WAF1/CIP1 may be involved in the tumorigenesis of both types of GCT. The present case emphasizes the need to evaluate the entire GIT when a single GCT is identified. Multifocal lesions should be treated conservatively by local excision because, as with the solitary tumors, they exhibit a benign biological behavior, consistent with their low Ki‐67 immunoreactivity.

Adenocarcinoma complicating Barrett's esophagus: an analysis of cell proliferation

In Japan, cases of Barretts esophagus with concurrent adenocarcinoma are relatively rare. We report herein a case of long-segment Barretts esophagus-associated adenocarcinoma in a 72-year-old Japanese man. The surgical specimen showed that an ulcerating tumor, measuring 5.5 x 3.9 cm, was present in the lower esophagus adjacent to the esophagogastric junction, the background lower esophagus having an erythematous appearance. Histologically, the ulcerating tumor was a well-to-moderately differentiated tubular adenocarcinoma, with a small area of signet ring cell carcinoma invading the adventitia. In addition, the esophageal epithelium was replaced by columnar epithelium (9.5 cm in length) with multifocal dysplastic changes. Immunohistochemically, the number of Ki-67-positive cells gradually increased, moving from the normal gastric mucosa (mean Ki-67 labeling index [mKLI], 2.6%) through Barretts epithelium (mKLI, 12.9%), low-grade dysplasia (mKLI, 16.9%), and high-grade dysplasia (mKLI. 23.7%) to invasive carcinoma, in that order, with labeling higher in the invasive tubular adenocarcinoma elements (mKLI, 40.5%) than in areas of signet ring cell carcinoma (mKLI, 20.4%). Findings in our patient suggest that increased cellular proliferation plays an integral part, in the progression of Barretts metaplasia to adenocarcinoma. The collection of further cases for analysis will be necessary to confirm this hypothesis.

Laser Therapy for Early Upper Gastrointestinal Carcinoma

An invasive procedure generally is the first choice of therapy for the treatment of gastric cancer. The development of improved microimaging and innovative engineering, however, has established a new field of endoscopic laser therapy. This article discusses the use of high-power and low-power lasers in the treatment of early gastric cancer.

Clinical treatment of gastroduodenal bleeding

SummaryOur present study was conducted by cooperation between Departments of Internal Medicine and surgery of a hospital, which was highly significant because the results were comprehensive without a bias toward either department. The present report describes whether or not emergency operations have decreased because of progress in various conservative hemostatic methods for hemorrhagic ulcer and short-term and long-term prognoses after conservative therapy. Compared with the first 8-year period, the number of patients treated by conservative therapy increased with a definite decrease in that of emergency operations in the latter 8-year period. As for the results of conservative treatment, the rate of shortterm prognostic hemostasis was 81.3%. Of the long-term prognostic cases, ulcers recurred in 50%, accompanied by recurrent bleeding in 34.8%. These patients were again treated by conservative therapy, and hemostasis was successful in 95.7%. The mortality rate following conservative therapy was 13.7% in the first period and 11.0% in the latter period. The surgical mortality rate was 6.0% in the first period and 5.4% in the latter period. There was no surgical death among the patients undergoing palliative operation. Our therapeutic policy for hemorrhagic ulcer will be described based on these findings.

Follow-up problems of laser irradiation as a local treatment for gastric cancer

Between 1980 and 1993, laser irradiation was performed in 117 cases of early gastric cancer, in cases in which surgical treatment was difficult. The follow-up periods after irradiation were relatively short (mean, 20.5 months) because many of the patients were aged, and because many patients had some concurrent disease. When 79 cases (excluding cases followed for only very short periods) were evaluated, the cancer-free rate was low for the following groups: (1) those patients in whom tumour size was over 40 mm; and (2) in those where the ‘sm’ tumours were invading the submucosal layer. Six patients developed tumour recurrence after laser therapy. In all six of these cases, recurrence was detected within 1 year after the end of therapy.

Diagnosis and treatment of early gastric cancer

SummaryBackgroundBecause of the high incidence of gastric cancer among the Japanese, group examination for gastric cancer was proposed and the double contrast technique was developed as a method of X-ray diagnosis.MethodsThe endoscope has developed from the early gastrocamera to the fiberscope and to the latest electroscope using CCD. Owing to the advancement of the diagnostic methods, early gastric cancer has been discovered throughout Japan in remarkably higher numbers, from a mere 217 in 1961 to the cumulative number of 24,847 until 1980.ResultsAmong the 1180 patients with gastric cancer who underwent surgery in our hospital between 1971 and 1989, 364 had early phase gastric cancer limited to the mucosa and their relative survival rate was 100.3% during the first 10 years. On the other hand, the survival rate of the patients with cancer that reached the serous membrane was as low as 22.2%. The survival rate greatly depends on the presence or absence of lymph node metastasis. Among all cases of gastric cancer, the 10-year survival rate of the 828 patients without lymph node metastasis was 97.6%, whereas that of the 213 patients with lymph node metastasis was 38.7%. If early gastric cancer can be detected before lymph node metastasis, a radical cure of the cancer is possible solely by local excision or by treatments using an endoscope without the need of purgation of lymph nodes. 613 patients with early gastric cancer were examined for lymph node metastasis. There was no lymph node metastasis in patients having the elevated type cancer with the major bosselation diameter smaller than 2.5 cm and those having the depressed type cancer with the major depression diameter smaller than 2.0 cm that does not show ulcerative changes. These 44 patients underwent non-invasive treatments. The results of the endoscopic laser treatment were as follows; the removal of cancer tissue was not complete after the first treatment of 5 of 14 patients with cancer tissues of 21 to 40 mm, (35.7%); the removal was not complete in 4 of 19 patients with cancer tissues of 11 to 20 mm (21.0%); all of the patients with cancer tissues of 10 mm or less were completely cured. The 43 patients who received endoscopic mucosal resection, all with cancer tissues of 10 mm or less, were cured, except for 2 patients with cancer near the pylorus ring. On average, however, the removal of cancer tissue was not complete in 30% of the patients.ConslusionsAlthough the basic treatment of early gastric cancer is the surgical one, less invasive endoscopic treatments are effective in limited cases. However, a thorough examination should be done beforehand in each case as to whether the endoscopic treatment is appropriate and, after treatment, careful observation of the progress is required.ZusammenfassungGrundlagenWegen der hohen Inzidenz des Magenkarzinoms in Japan, wurde vorgeschlagen, Gruppenuntersuchungen auf Magenkarzinom durchzuführen. und die Doppel-Kontrast Röntgentechnik wurde entwickelt.MethodikDas Endoskop hat sich von der frühen Gastrokamera zum Fiberskop und zum neuesten Elektroskop mit CCD weiterentwickelt. Aufgrund des Fortschritts in den Diagnosemethoden ist die Zahl der Früherkennungen von Magenkarzinomen in ganz Japan von nur 217 Fällen im Jahr 1961 auf eine kumulative Zahl von 25.847 bis zum Jahr 1980 angestiegen.ErgebnisseVon den 1180 Patienten mit Magenkarzinom, die zwischen 1971 und 1989 in unserem Spital operiert wurden, waren 364 Fälle von auf die Mukosa begrenztem Magenfrühkarzinom. Die relative Überlebensrate dieser Patienten war während der ersten 10 Jahre 100,3%. Andererseits hatten Patienten mit serosainfiltrierendem Karzinom nur eine Überlebensrate von 22,2%. Die Überlebensrate hängt sehr stark vom Vorhandensein oder Fehlen von Lymphknotenmetastasen ab. Von allen Magenkarzinomfällen hatten die 838 Patienten ohne Lymphknotenmetastasen eine 10-Jahres-Überlebensrate von 97.6%, während sie bei den 213 Patienten mit Lymphknotenmetastasen nur 38,7% betrug. Wenn das Magenfrühkarzinom vor dem Lymphknotenbefall erkannt wird, ist eine Radikalsanierung des Karzinoms allein durch lokale Exzision oder durch endoskopische Behandlung möglich, ohne daß die Lymphknoten entfernt werden müssen. 613 Patienten mit Magenfrühkarzinom wurden auf Lymphknotenmetastasen untersucht. Patienten mit der polypösen Form des Karzinoms mit einer Haupterhebung von im Durchmesser weniger als 2.5 cm sowie Patienten mit nicht ulzerierendem, schüsselförmigem Karzinom und einer Hauptdepression von weniger als 2.0 cm Durchmesser hatten keine Lymphknotenmetastasen. Diese 44 Patienten wurden einer nichtinvasiven Behandlung unterzogen. Die Ergebnisse der endoskopischen Laserbehandlung waren folgende: Bei 5 der 14 Patienten mit 21 bis 40 mm Krebsgewebe wurde bei Erstbehandlung keine vollständige Entfernung erreicht (35,7%), bei 4 von 19 Patienten mit 11 bis 70 mm Krebsgewebe war die Entfernung ebenfalls nicht vollständig (21,0%): eine Heilung wurde bei allen Patienten mit 10 mm Krebsgewebe oder weniger erzielt. Die 43 Patienten mit Krebsgewebe von 10 mm oder weniger, bei denen die Mukosa endoskopisch entfernt wurde, wurden alle geheilt, ausgenommen 2 Patienten mit Karzinom nahe dem Pylorus-Ring. Im Durchschnitt war jedoch bei 30% der Patienten die Entfernung des Krebsgewebes unvollständig.SchlußfolgerungenObwohl das chirurgische Vorgehen die grundlegende Behandlungart des Magenfrühkarzinoms ist, sind doch weniger invasive endoskopische Methoden bei begrenzten Fällen wirksam. Zuvor sollte jedoch in jedem einzelnen Fall eine gründliche Untersuchung durchgeführt werden, um klarzulegen, ob die endoskopische Behandlung angemessen ist, und nach der Behandlung sind die Fortschritte sorgfältig zu beobachten.

Endoscopic Surgery for Gastric Cancer

Application of endoscopic treatment for early gastric cancer seem to have been widely accepted in the recent years. To establish the indication of endoscopic therapy for early gastric cancer, results of 2072 surgery were reviewed:survival rate, complication, and lymph node metastasis. Local treatment by surgical endoscopy can eradicate early gastric cancer without lymph node metastasis. 631 cases of operated single early gastric cancer were studied to confirm which type of early gastric cancer has no lymph node metastasis.

An example of the detection of an esophageal carcinoma in its very early stage by urinary xanthopterin determination.

Neopterin (NP) has been used as a biochemical marker of the activated state of cell-mediated immunity and to monitor and screen for some clinical disorders1–4. In previous papers 5–6, we reported that xanthopterin (XP) also reflects the same type of immune status as well as various types of liver disease. In the course of our study on the determination of urinary pteridines, one of the authors (M.T.) happened to find that his urinary XP level was higher than the normal range. Although his other tumor indicators such as CEA, SCC and CA19-9 showed normal values, an abnormality was found in the squamous cells of his esophagus after endoscopic inspection. In the present paper we compare longitudinal changes in his urinary excretion levels of XP and NP for a period of eleven months before and after surgery.