Hitoshi Ojima

Comparison between positron emission tomography and computed tomography in the use of the assessment of esophageal carcinoma.

The role and potential value of positron emission tomography (PET) scanning in certain tumors has been widely investigated in recent years. The authors retrospectively assessed the performance of 18‐F‐fluorodeoxyglucose (FDG)‐PET in the assessment of esophageal squamous cell carcinoma (SCC).

The incremental effect of positron emission tomography on diagnostic accuracy in the initial staging of esophageal carcinoma

The purpose of the current study was to assess whether [18F]fluorodeoxyglucose positron emission tomography (FDG‐PET) provides incremental value (e.g., additional information on lymph node involvement or the presence of distant metastases) compared with computed tomography (CT) in patients with esophageal carcinoma.

Adjuvant chemotherapy of S-1 versus gemcitabine for resected pancreatic cancer: a phase 3, open-label, randomised, non-inferiority trial (JASPAC 01)

BACKGROUND Although adjuvant chemotherapy with gemcitabine is standard care for resected pancreatic cancer, S-1 has shown non-inferiority to gemcitabine for advanced disease. We aimed to investigate the non-inferiority of S-1 to gemcitabine as adjuvant chemotherapy for pancreatic cancer in terms of overall survival. METHODS We did a randomised, open-label, multicentre, non-inferiority phase 3 trial undertaken at 33 hospitals in Japan. Patients who had histologically proven invasive ductal carcinoma of the pancreas, pathologically documented stage I-III, and no local residual or microscopic residual tumour, and were aged 20 years or older were eligible. Patients with resected pancreatic cancer were randomly assigned (in a 1:1 ratio) to receive gemcitabine (1000 mg/m(2), intravenously administered on days 1, 8, and 15, every 4 weeks [one cycle], for up to six cycles) or S-1 (40 mg, 50 mg, or 60 mg according to body-surface area, orally administered twice a day for 28 days followed by a 14 day rest, every 6 weeks [one cycle], for up to four cycles) at the data centre by a modified minimisation method, balancing residual tumour status, nodal status, and institutions. The primary outcome was overall survival in the two treatment groups, assessed in the per-protocol population, excluding ineligible patients and those not receiving the allocated treatment. The protocol prespecified that the superiority of S-1 with respect to overall survival was also to be assessed in the per-protocol population by a log-rank test, if the non-inferiority of S-1 was verified. We estimated overall and relapse-free survival using the Kaplan-Meier methods, and assessed non-inferiority of S-1 to gemcitabine using the Cox proportional hazard model. The expected hazard ratio (HR) for mortality was 0.87 with a non-inferiority margin of 1.25 (power 80%; one-sided type I error 2.5%). This trial is registered at UMIN CTR (UMIN000000655). FINDINGS 385 patients were randomly assigned to treatment between April 11, 2007, and June 29, 2010 (193 to the gemcitabine group and 192 to the S-1 group). Of these, three were exlcuded because of ineligibility and five did not receive chemotherapy. The per-protocol population therefore consisted of 190 patients in the gemcitabine group and 187 patients in the S-1 group. On Sept 15, 2012, following the recommendation from the independent data and safety monitoring committee, this study was discontinued because the prespecified criteria for early discontinuation were met at the interim analysis for efficacy, when all the protocol treatments had been finished. Analysis with the follow-up data on Jan 15, 2016, showed HR of mortality was 0.57 (95% CI 0.44-0.72, pnon-inferiority<0.0001, p<0.0001 for superiority), associated with 5-year overall survival of 24.4% (18.6-30.8) in the gemcitabine group and 44.1% (36.9-51.1) in the S-1 group. Grade 3 or 4 leucopenia, neutropenia, aspartate aminotransferase, and alanine aminotransferase were observed more frequently in the gemcitabine group, whereas stomatitis and diarrhoea were more frequently experienced in the S-1 group. INTERPRETATION Adjuvant chemotherapy with S-1 can be a new standard care for resected pancreatic cancer in Japanese patients. These results should be assessed in non-Asian patients. FUNDING Pharma Valley Center, Shizuoka Industrial Foundation, Taiho Pharmaceutical.

Sentinel lymph nodes with technetium‐99m colloidal rhenium sulfide in patients with esophageal carcinoma

The authors assessed the detection of sentinel lymph nodes in patients with esophageal squamous cell carcinoma (SCC) using technetium‐99m colloidal rhenium sulfide. They studied whether an analysis of sentinel lymph nodes using cytokeratin (CK) immunohistochemistry increased the accuracy of staging.

Predictive value of blood flow in the gastric tube in anastomotic insufficiency after thoracic esophagectomy.

Anastomotic insufficiency is considered to be one of the most serious complications associated with esophageal reconstruction. The purposes of this study were to identify (1) the relationship between anastomotic insufficiency and tissue blood flow (TBF) in the gastric tube in the perioperative period, and (2) the effects of intravenous prostaglandin E1 (PGE1) on TBF in the gastric tube. The study group consisted of 44 patients who were to undergo esophagectomy for esophageal cancer. Intraoperative and postoperative TBF on the serosal side of the gastric tube were measured by laser-Doppler tissue blood flowmetry. The TBF of the Leakage(+) group (n=5) was poorer than that of the Leakage(−) group (n=39) during the intraoperative and postoperative periods. There was a significant difference in TBF between the two groups at postoperative day (POD) 3. There was a tendency in the PGE1(+) group (n=18) to exhibit richer blood flow through the anastomosis than the PGE1(−) group (n=26), intraoperatively, but the difference was not significant. Two of five Leakage(+) cases were also in the PGE11(+) group. There was no relationship between intraoperative medication with PGE1 and incidence of leakage. The TBF of three-field lymph node dissection and reconstruction of the retrosternal route group (n=21) was poorer than that of the two-field lymph-node dissection and reconstruction of the posterior mediastinal route group (n=23). The TBF in the gastric tube after esophagectomy may be a predictor of anastomotic insufficiency. However, PGE1 treatment in the intraoperative period alone is not effective in preventing anastomotic insufficiency.RésuméLa fistule anastomotique après anastomose oesophagienne est une des complications les plus sévères. Les buts de cette étude ont été d’identifier: (1) dans la période postopératoire, les rapports entre la fistule anastomotique et le débit sanguin des tissus (DST) du tube gastrique, (2) les effets de la prostaglandine E1 (PGE1) administrée en intraveineux sur le DST du tube gastrique. Le groupe d’étude a comporté 44 patients ayant eu une œsophagectomie pour cancer de l’œsophage. Le DST a été mesuré au niveau de la séreuse du tube gastrique par une débitométrie sanguine au laser-Doppler en peropératoire et en postopératoire. Le DST mesuré en peropératoire et en postopératoire a été plus faible dans le groupe avec fistule (+) (n=5) que dans le groupe sans fistule (−) (n=39). Au jour postopératoire 3, la différence observée du DST des deux groupes a été significative. On a noté une tendance dans le groupe PGE1(+) (n=18) à un débit plus élevé à travers l’anastomose que dans le groupe PGE1(−) (n=26), en peropératoire, mais cette difference n’était pas significative. Deux des cinq cas de fistule (+) étaient dans le groupe PGE1(+). Il n’y avait aucun rapport entre la prise de PGE1 peropératoire et l’incidence de fistule. Le DST après oesophagectomie par trois champs et reconstruction par voie rétrosternale (n=21) était moins bon que celui de l’oesophagectomie par deux champs et reconstruction par voie médiastinale postérieure (n=23). Le DST du tube gastrique après oesophagectomie pourrait être un facteur prédictif de fistule anastomotique. Cependant, le traitement par PGE, pendant la période peropératoire seul n’est pas efficace dans la prévention de fistule anastomotique.ResumenLa complicación más grave de las reconstrucciones esofágicas es la insuficiencia o fuga anastomótica. Los objetivos de este trabajo fueron: (1) establecer las relaciones existentes, durante el periodo perioperatorio, entre la insuficiencia o fuga anastomótica y el flujo sanguíneo tisular (TBF) del tubo gástrico, (2) averiguar los efectos de la administración intravenosa de prostaglandina E1 (PGE1) en el TBF del tubo gástrico. Estudiamos 44 pacientes esofagectomizados por cáncer. Utilizando un flujómetro sanguíneo textura! tipo Laser-Doppler se midió, en el periodo tanto intra como postoperatorio, el TBF en la serosa del tubo gástrico. Durante estos periodos el TBF, en el grupo insuficiencia o fuga anastomótica (+) n=5 fue menor que en el grupo sin insuficiencia (−) n=39. Se constató al tercer día del postoperatorio (POD) una diferencia muy significativa del TBF entre ambos grupos. Se registró en el grupo PGE1 (+) (n=18) en relación con el grupo PGE1 (−) (n=26) una tendencia no significativa por lo que a un mayor flujo sanguíneo textural, a través de la anastomosis, se refiere. Dos de las 5 insuficiencias anastomóticas se registraron en el grupo PGE1 (+). No hubo relación alguna entre la administración intraoperatoria de PGE1 y la frecuencia de la dehiscencia. El TBF en tres áreas ganglionares tras disección y reconstrucción retroesternal (n=21) fue menor, que en dos áreas anglionares tras disección y reconstrucción mediastínica posterior (n=23). El TBF del tubo gástrico es un factor pronóstico válido de la dehiscencia o fuga anastomótica. El tratamiento intraoperatorio con PGE, no es eficaz en la prevención de la misma.

Successful late management of spontaneous esophageal rupture using T-tube mediastinoabdominal drainage

BACKGROUND Spontaneous esophageal rupture is extremely rare, and early symptoms of the disease are similar to those of emergency diseases of the chest and abdomen. The diagnosis and treatments are often delayed, resulting in an unfavorable outcome in some cases. METHODS We performed improved T-tube drainage for spontaneous esophageal rupture in 5 patients between 1995 and 1999. Our improved method was a modified procedure of the reported method of Abbott et al, as follows: a T-tube was inserted into the esophagus. A separate stab incision was made in the abdominal wall, and the long limb of the T-tube was brought out through this incision ensuring that the course of the T-tube intra-abdominally was short and straight, with some slack to allow for postoperative abdominal distension. An advantage of this method was that it facilitated healing of the fistula after removal of the T-tube. RESULTS All patients were treated with a satisfactory outcome. CONCLUSION This improved T-tube drainage was technically very easy and safe method for spontaneous esophageal rupture in severe cases.

Lymphoepithelial Cyst of the Pancreas: Report of a Case

A lymphoepithelial cyst (LEC) is an extremely rare benign lesion of the pancreas. During a medical check-up, a 77-year-old man without any symptoms was found to have a cyst in the body of the pancreas. His serum carbohydrate antigen 19-9 level was slightly elevated. Computed tomography showed a multilocular, low-attenuating cyst on the superior surface of the pancreatic body. Thus, we performed distal pancreatectomy with splenectomy. Histological examination revealed that the cyst wall was lined with squamous epithelium and surrounded by abundant mature lymphoid tissue. Keratinous substances were present in the cyst. An LEC of the pancreas is associated with a good prognosis and, although unusual, it should be considered in the differential diagnosis of pancreatic cystic lesions. Minimal resection of the cyst should be performed whenever possible, and extensive surgery avoided. For patients with a high surgical risk, fine-needle aspiration biopsy may be considered.

Surgical Treatment for Esophageal Cancer

Esophageal cancer is one of the most difficult malignancies to cure. The prognosis remains unsatisfactory despite significant advances in surgical techniques and perioperative management. The optimal treatment strategy for localized esophageal cancer has not yet been established. Surgical resection remains the mainstay of treatment for esophageal cancer, and curative resection is the most important surgery. Extended esophagectomy with three-field lymphadenectomy provides the highest quality of tumor clearance and prolongation of patient survival. There has been intense effort in developing novel strategies to treat patients with resectable esophageal cancer. Various combined-modality approaches have been attempted to improve treatment outcomes. Definitive chemoradiotherapy has an impact on long-term survival in patients with resectable esophageal cancer. Accordingly, there are three main combined-modality approaches: esophagectomy with adjuvant chemotherapy or chemoradiotherapy; primary definitive chemoradiotherapy with or without salvage esophagectomy, and preoperative chemoradiotherapy followed by planned esophagectomy. Recently, owing to the remarkable advances in optical technology, minimally invasive esophagectomy using endoscopic instruments has been introduced into esophageal cancer surgery. This article reviews recent changes in the treatment of esophageal cancer surgery, and considers the role of esophagectomy.

Treatment of multiple liver metastasis from gastric carcinoma

BackgroundThe efficacy of operative resection of liver metastasis from colorectal cancer has been established. However, a treatment for liver metastasis from gastric cancer has not yet been established. In this study, we evaluated the efficacy of hepatic arterial infusion for synchronous hepatic metastasis from gastric cancer.Patients and methodsThis study consisted of 37 patients [HAI group; 18 and non-HAI group; 19] with synchronous multiple liver metastases from gastric cancer at Gunma Prefecture Saiseikai-Maebashi Hospital. We retrospectively analyzed the efficacy of HAI.ResultsResponse rate (CR + PR) of HAI was 83%. However, HAI treatment did not affect any improvement in the survival rate.ConclusionHAI is an effective treatment for control of liver metastasis specifically. The factor effective for an improvement in the survival rate was possibly that of gastrectomy.

Factors Predicting Long-term Responses to Splenctomy in Patients with Idiopathic Thrombocytopenic Purpura

BackgroundIdiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder for which appropriate diagnostic treatments are uncertain. The response to splenectomy varies from 60% to 90%, and the remaining patients relapse and require further treatment. Therefore, it is important to predict the outcome of splenectomy before and after surgery. The objective of this study was to evaluate the efficacy of splenectomy in patients diagnosed with ITP.Materials and MethodsFrom 1988 to 2004, we splenectomized 32 patients with ITP; 17 underwent laparoscopic splenectomy (LS) and 15 underwent conventional open splenectomy (OS). For analysis, patients were separated retrospectively into two groups: the “responding group,” those who showed good outcomes with splenectomy, and the “non-responding group,” those who did not show good outcomes with splenectomy. Blood samples were examined before and immediately after surgery (day 0) and on postoperative days (POD) 1, 3, 5, and 7.ResultsThe median follow-up was 8.3 years (range: 1–16 years). The overall 5- and 10-year survival rates after splenectomy were 96.9% (one death). The responding group included 24 patients (75%), and the non-responding group included 7 (21.9%). Platelet counts in the responding group increased gradually until POD 7, and although platelet counts in the non-responding group were almost constant until POD 5, they subsequently decreased until POD 7. Average platelet counts in the responding and non-responding groups were 269 and 124 × 109/l on POD 7, respectively (P < 0.05). The pre- to post-surgery ratio of platelet counts were almost the same as the result of the actual data. Platelet counts during the long-term follow-up for the responding and non-responding groups were related to those noted on discharge.ConclusionsA high platelet count on POD 7 was associated with a good response to splenectomy, but age at surgery, the time interval between diagnosis and splenectomy, and prior responses to corticosteroid were not. We suggest that long-term outcomes of splenectomy can easily be predicted by platelet counts on POD 7.