Hitoshi Shimao

Usefulness of endoscopic aspiration mucosectomy as compared with strip biopsy for the treatment of gastric mucosal cancer

BACKGROUND Several techniques are available for the endoscopic treatment of gastric intramucosal cancers, but their advantages and disadvantages have not been adequately evaluated. We compared the therapeutic usefulness of endoscopic aspiration mucosectomy with that of strip biopsy. METHODS Between May 1995 and May 1997, we performed strip biopsy (May 1995 through February 1996) or endoscopic aspiration mucosectomy (March 1996 through May 1997) in a consecutive series of patients with intestinal-type intramucosal cancer. Parameters of assessment included the following: size of removed specimens, en bloc resection rate, time required for resection, duration of hospitalization, and complications. RESULTS Forty-nine patients with gastric intramucosal cancers underwent endoscopic aspiration mucosectomy and 44 underwent strip biopsy. The two groups were similar with respect to age, gender, and lesion macroscopic appearance, size, and site. The mean longest diameter of the resected specimens was significantly greater with endoscopic aspiration mucosectomy (20.3 +/- 3.4 mm) than with strip biopsy (15. 8 +/- 4.4 mm) (p < 0.001). The rate of en bloc resection (resection of an entire lesion in one procedure) was significantly higher with endoscopic aspiration mucosectomy (61.2%, 30 of 49) than with strip biopsy (36.4%, 16 of 44) (p < 0.05). The number of specimens obtained by piecemeal resection was slightly, but not significantly, higher with strip biopsy (2.4 +/- 1.7) than with endoscopic aspiration mucosectomy (2.0 +/- 1.7). The time required for treatment was similar for each procedure. The duration of hospitalization was significantly shorter with endoscopic aspiration mucosectomy (12.8 +/- 5.3 days) than with strip biopsy (15.9 +/- 74 days) (p < 0.05). As for complications, the rate of bleeding was 20. 5% (9 of 44) with strip biopsy and 10.2% (5 of 49) with endoscopic aspiration mucosectomy; bleeding was controlled in all cases by treatment with a heater probe. CONCLUSIONS Endoscopic resection of large gastric intramucosal tumors is easier with endoscopic aspiration mucosectomy compared with strip biopsy. Endoscopic aspiration mucosectomy is a useful procedure for en bloc resection.

Survival after surgical treatment of early gastric cancer: surgical techniques and long-term survival.

Background and aimsRecent results from long-term follow-up of a large number of patients who have undergone gastric resection for early gastric cancer (EGC) have not yet been fully evaluated.Patients and methodsA total of 848 patients who had undergone gastric resection for EGC (262 female, 586 male; mean age 58.0 years; range 20–86 years) were studied with respect to surgical technique, long-term survival and prognostic factors on the basis of current TNM classification.ResultsDeath related to recurrence occurred in only eight patients (0.9%). Hematogenous metastasis to the liver or bone represented the most common pattern of recurrence, developing in six of the eight recurrences (75%). The 5-year and 10-year cancer-related survival rates were 98.6% and 94.8%, respectively. The 5-year and 10-year overall survival rates were 95.2% and 85.0%, respectively. Lymph node metastasis represented an independent prognostic factor when analyzed on the basis of cancer-related survival.ConclusionThe present findings indicate that long-term survival of patients who undergo gastric resection for EGC is extremely good and that lymph node metastasis represents an independent prognostic factor when analyzed according to cancer-related survival. Future developments for the treatment of EGC are expected to improve quality of life for patients after gastric resection.

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.

Kombiniertes laparoskopisch-endoskopisches Vorgehen beim Magencarcinom

Abstract. The purpose of this review is to outline the laparoscopic-endoscopic procedures that we perform for early gastric cancer. These procedures were applied to 29 patients. Preoperative work-up included gastric endoscopy, barium X-ray examination, endoscopic ultrasonography, and histological examination, and surgery was performed in patients diagnosed as having mucosal gastric cancer for which endoscopic mucosal resection (EMR) was difficult. Laparoscopic wedge resection of the stomach using the lesion-lifting method, by which a wedge resection is made while pulling up the full-thickness gastric wall, was carried out in the 16 patients with lesions of the anterior wall, lesser curvature, and greater curvature of the stomach. On pathological examination of resected specimens, the surgical margin and lymphatic or venous invasion were negative in all these patients. The histological depth of the lesions was m (mucosal cancer) in 15 patients and sm1 (slight cancer infiltration into the submucosal layer) in one. This one patient later underwent gastrectomy but no lymph node metastases were found. Oral nutrition was resumed for a mean (± SD) of 2.9 ± 0.8 days after operation, and the duration of hospitalization after operation was 12.3 ± 3.4 days. The 13 patients with lesions of the posterior wall of the stomach and near the cardia or the pylorus received laparoscopic intragastric mucosal resection. Laparotomy was required in 1 of these patients due to intraoperative hemorrhage. The surgical margins were negative in all 12 patients in whom laparoscopic intragastric mucosal resection was successful. Lymphatic or venous invasion was positive in 2, both of whom had sm1 cancer lesions of both of these patients were located in the cardiac region, total gastrectomy was avoided, and careful observation is continued. Oral nutrition was resumed 4.0 ± 1.6 days after operation, and the duration of hospitalization after operation was 12.0 ± 3.5 days. In addition, no postoperative complication was noted after either procedure, and all patients have been recurrence free for a follow-up period of 460 months. Selected properly, these laparoscopic endoscopic procedures are considered to be curative and minimally invasive treatments for early gastric cancer.Zusammenfassung. In dieser Darstellung sollen die laparoskopisch-endoskopischen Verfahren beschrieben werden, die bei uns zur Therapie des Magenfrühcarcinoms durchgeführt werden. Die Kombinationsverfahren wurden in 29 Fällen durchgeführt. Bei Patienten mit einem Mucosacarcinom des Magens, bei denen eine Mucosaresektion (EMR) als zu schwierig erschien, wurde präoperativ eine Endoskopie, eine Röntgen-Kontrastmittel-Darstellung des Magens mit Barium, eine endoskopische Ultraschalluntersuchung sowie eine histologische Untersuchung durchgeführt. Die laparoskopische tangentiale Resektion der Magenwand („Wedge-Resektion“) mit der sog. „lesion-lifting“-Methode, bei der die gesamte Magenwand einschließlich des Tumors angehoben und anschließend reseziert wird, wurde bei 16 Patienten mit Läsionen sowohl an der Vorderwand als auch an der kleinen und großen Kurvatur des Magens durchgeführt. Bei allen Patienten wurden die Resektate histologisch untersucht. In allen Fällen waren die Resektionsränder tumorfrei und es gab keine lymphatische oder venöse Tumorinfiltration. Die histologische Aufarbeitung ergab bei 15 Patienten das Tumorstadium T1m und bei einem Patienten T1sm. Bei diesem Patienten wurde anschließend eine Gastrektomie durchgeführt. Ein Lymphknotenbefall fand sich nicht. Alle Patienten waren nach im Median 2,9 ± 0,8 Tagen postoperativ voll oral enteralisiert. Die postoperative Hospitalisationsdauer betrug 12,3 ± 3,4 Tage. Bei 13 Patienten mit Tumorlokalisation im Bereich der Magenhinterwand, der Kardia oder des Pylorus, wurde eine laparoskopische intragastrale Mucosaresektion durchgeführt. Bei einem der Patienten war wegen einer intraoperativen Blutung eine Laparotomie erforderlich. Bei allen 12 Patienten, bei denen die laparoskopische intragastrale Mucosaresektion durchgeführt wurde, waren die Resektionsränder tumorfrei. Eine lymphatische oder venöse Tumorinfiltration wurde in 2 Fällen mit Tsm-Stadium nachgewiesen. Bei beiden Patienten war die Läsion nahe der Kardia lokalisiert, so daß auf eine totale Gastrektomie verzichtet wurde. Beide Patienten wurden sorgfältig nachbeobachtet. Der postoperative orale Kostaufbau war nach 4 ± 1,6 Tagen und die postoperative Hospitalisationsdauer nach 12 ± 3,5 Tagen abgeschlossen. Der postoperative Verlauf war komplikationslos. Die Gesamtheit der Patienten ist nach einer Follow-up-Periode von im Median 36,3 Monaten tumorfrei. Bei strenger Indikationsstellung können die endoskopisch-laparoskopischen Eingriffe als kurative und minimal-invasive Behandlungsmöglichkeit des Magenfrühcarcinoms angesehen werden.

Benign esophageal schwannoma: Report of a case

We report herein the case of an otherwise asymptomatic 62-year-old woman who was found to have an incidental esophageal lesion during endoscopic follow-up of an unrelated disorder. An esophageal submucosal tumor was diagnosed, and the patient was subsequently monitored on a regular yearly basis. As the diameter of the tumor doubled over a 4-year period, the possibility of a malignant lesion could not be excluded, and she was admitted to our hospital for further investigations. Esophagography, endoscopy, endoscopic ultrasonography, and computed tomography confirmed a submucosal tumor, 35mm in length, in the thoracic midesophagus. A leiomyoma or leiomyosarcoma was suspected based on the known incidence of such tumors, and tumor enucleation was performed. Gross inspection revealed a solid tumor arising from the wall of the esophagus. Histopathologic examination showed intertwined bundles of spindle cells with spiral-like proliferation, and immunohistochemical studies were positive for S-100 protein, whereby a diagnosis of esophageal schwannoma was established. The patient experienced no postoperative complications, and her clinical course to date has been satisfactory. To date, 2 years 8 months after surgery, she has shown no sign of tumor recurrence and remains in good health.

MULTICENTRE COLLABORATIVE PROSPECTIVE STUDY OF ENDOSCOPIC TREATMENT OF EARLY GASTRIC CANCER

Aims:  The present study was conducted with the aims of elucidating the present state of endoscopic treatment, in particular endoscopic mucosal resection (EMR) of early gastric cancer, as well as any associated problems, and the prospects for further broadening of the indications for EMR.

Tumor volume: a novel prognostic factor in patients who undergo curative resection for gastric cancer

Abstract Background and aims: The present study evaluates the significance of tumor volume as a prognostic factor in gastric cancer. Patients/methods: Tumor volume was measured from serial tissue sections of 101 patients who had undergone curative resection for solitary carcinoma of the stomach using a computer graphics analysis program. These patients were analyzed with respect to survival based on uni- variate and multivariate analyses of clinicopathological factors, including tumor volume, to determine an independent prognostic factor. Results: Significant differences in survival were found with respect to depth of tumor invasion (P=0.001), status of lymph-node metastasis (P=0.018), tumor diameter (P=0.005), and tumor volume (P<0.0001) based on univariate analysis. However, multivariate analysis indicated only tumor volume as a valid factor in determining prognosis among the nine variables and was significantly associated with the prognosis (P=0.0005; relative risk 18.23; 95% confidence interval 3.52–94.37). Conclusion: The present findings indicate that tumor volume is an important prognostic factor in patients who undergo curative resection for gastric cancer and may be an alternative to conventional factors, thus providing a novel independent prognostic factor in gastric cancer.

A prospective study of endoscopic treatment for early gastric cancer in Japan: An interim report

Background: This prospective study was designed to clarify the present status and problems inherent in endoscopic treatment of early gastric cancer by endoscopic mucosal resection and other modalities in Japan and to investigate the possibility of extending the indications for endoscopic treatment.

Alpha-Fetoprotein-Producing Esophageal Adenocarcinoma: Report of a Case

Abstract Alpha-fetoprotein (AFP)-producing esophageal tumors are extremely rare. We report herein the case of a 51-year-old man found to have an AFP-producing adenocarcinoma arising from esophageal proper mucosa. The patient presented for investigation of dysphagia, and esophagogram and endoscopy revealed a lesion about 2 cm in size with a depressed center surrounded by low nodular protrusions in the lower esophagus. The preoperative serum AFP concentration was elevated to 52.4 ng/ml. A subtotal esophagectomy was performed, and macroscopic examination of the resected specimen revealed a superficial protruding lesion. Histopathological studies showed a poorly differentiated adenocarcinoma with a single lymph node metastasis. The tumor had infiltrated the submucosal layer, but there was no evidence of lymphatic or venous invasion. Immunohistochemical study revealed tumor cells positive for AFP. There were no findings of Barretts epithelium or any mucosal changes due to reflux esophagitis. An elevated AFP level 2 years after the operation led us to suspect tumor recurrence; however, diagnostic imaging studies showed no evidence of a recurrence or metastases. The serum AFP levels responded well to chemotherapy with transient decreased levels, but continued to rise until finally, 5 years after the operation, adenocarcinoma cells were detected in the pleural effusion. Thus, careful monitoring of the serum AFP levels at regular intervals could be a useful marker to indicate recurrence of esophageal carcinoma.

Endoscopic mucosal resection (EMR) for the management of poorly differentiated adenocarcinoma of the stomach: a patient who had recurrence and died 4 years after EMR.

Recent studies have explored the possibility of using endoscopic mucosal resection (EMR) to treat lesions with a relative indication for endoscopic therapy. We used EMR to manage poorly differentiated adenocarcinoma, a relative indication for endoscopic treatment, in a patient who requested such treatment and refused surgical intervention. We describe our experience with this patient, who died of tumor recurrence 4 years after the EMR. This case describes the problems of using EMR for the treatment of poorly differentiated adenocarcinoma.