Kazuaki Okuyama

Evaluation of treatment for gastric cancer with liver metastasis.

In 161 cases of gastric cancer with liver metastasis but without peritoneal dissemination, evaluations were executed to find effective treatment. The most favorable results with best prognosis were obtained in the group receiving gastrectomy + hepatectomy + chemotherapy, followed by gastrectomy + chemotherapy, and gastrectomy alone. The most unfavorable outcome was in nonresected cases. Chief chemotherapy to be used after gastrectomy was FML (5‐fluorouracil (5‐FU) + mitomycin C [MMC] + lentinan) continuous intra‐arterial infusion. Hepatectomy was found to be effective as an active measure for tumor reduction in cases of liver metastasis so far as the metastatic lesions are only a few scattered ones in both lobes.

The treatment of lymph node metastasis from esophageal cancer by extensive lymphadenectomy

During the period between 1965 and the end of 1988, 560 patients with esophageal cancer were surgically treated in our University hospital. In an attempt to improve patient survival, three-field lymphadenectomy of the bilateral neck, mediastinum and abdomen was performed in 117 patients treated since 1983. The present study was undertaken to reveal the substantial rate of lymph node metastasis in esophageal cancer and to decide if three-field lymphadenectomy is mandatory or not for surgery of esophageal cancer. Despite the increased radicality of the operation, the mortality and morbidity rates decreased in the 1980s compared to the earlier periods, the operative death being 12.5 per cent in the 1960s, vs. 2.0 per cent in the 1980s. Moreover, the mortality rate of the patients receiving the three-field lymphadenectomy was as low as 2.6 per cent. The metastatic rate of cervical nodes in the patients receiving three-field lymphadenectomy was 32.5 per cent, while that of mediastinal and abdominal nodes was 47.0 per cent and 46.0 per cent respectively. The metastatic rate in the mediastinum was high in the bilateral recurrent nerve lymph nodes, bifurcation nodes and paraesophageal nodes, while in the abdomen, it was high in the bilateral paracardial nodes. Recurrent nerve paralysis, which had been rarely seen was observed in 12.0 per cent of the patients. Metastasis from esophageal cancer is often seen in the cervical nodes, however, the clinical importance of three-field lymphadenectomy will be decided by the data of patient survival in the near future.

A comparison between ultrasonography and mammography, computed tomography and digital subtraction angiography for the detection of breast cancers.

Ultrasound (US) was compared with mammography (MMG), computed tomography (CT), and digital subtraction angiography (DSA) in its effectiveness to detect breast cancer masses and metastatic axillary nodes. Forty-seven breast cancer patients who all underwent MMG, US, CT, and DSA preoperatively in our institution between 1986 and 1990 were studied. US was able to detect tumors in all cases regardless of tumor size, whereas DSA detected T1-size tumors and MMG detected T2-size tumors in 40% and 64.7% of cases, respectively, being specifically inferior to US. It was found that MMG was least likely to detect papillotubular carcinoma, although microcalcification alone without a tumor mass on MMG improved detectability from 46.2% to 76.9%, according to the histological type. CT was found to be most sensitive to axillary node metastases (81.8%), followed by US (72.7%), but DSA was significantly unfavorable (42.9%). Thus, we concluded that US was superior to MMG, CT, and DSA for detecting breast cancer masses, but that CT was more advantageous than US, while DSA was of little value for evaluating axillary nodal status.

Anatomic study of the bronchial arteries with special reference to their preservation during the radical dissection of the upper mediastinum lymph nodes

BACKGROUND The anatomy of the bronchial arteries was studied, with special reference to their preservation during the radical dissection of the upper mediastinum lymph nodes. METHODS The bronchial arteries of 71 cadavers were studied macroscopically by use of the surgical field of right thoracotomy. The small branches difficult to identify macroscopically were described by x-ray imaging with digital subtraction angiography. Their anatomic relationship to the adjacent organs was observed microscopically. RESULTS The bronchial arteries arising from the intercostal arteries (the intercostobronchial arteries) were observed in 66 of 71 cases. By use of the surgical field of right thoracotomy the intercostobronchial arteries were easily found and preserved. All cadavers also had other bronchial arteries arising from the aorta. These were difficult to preserve because of the depth of the surgical field and the location of their course in the dissected area. Bronchial arteries had established connection with each other via the vascular network in the tracheal proper sheath. India ink injected into the intercostobronchial arteries was observed in the tracheal proper sheath and the submucosa of the trachea. CONCLUSIONS Saving the blood supply to the trachea is possible with careful preservation of the intercostobronchial arteries and the tracheal proper sheath during radical dissection of the upper mediastinum.

The prognostic significance of resection of primary tumor in gastric and colorectal cancer patients with synchronous liver metastasis.

The significance of primary tumor resection in gastric and colorectal cancer patients with liver metastasis (H(+)) was evaluated in terms of operative mortality and survival rate by dividing the materials [293 gastric cancer and 80 colorectal cancer patients (53 colon and 27 rectum) with synchronous liver metastasis] into the following groups: Firstly, with or without peritoneal dissemination (P), secondly, with or without resection of the primary tumor and thirdly, with or without postoperative adjuvant chemotherapy. The following results were obtained: (1) The direct operative death rate of primary tumor resection, excluding death from other causes, showed an absence of statistically significant differences between the P0H(+) and P(+)H(+) gastric and colorectal cancer patients. (2) There was no significance in the prognosis between the primary tumor resection + postoperative chemotherapy group and the non-resectable group in the P(+)H(+) gastric and colorectal cancer patients, revealing no prognostic value of the primary tumor. (3) In the P0H(+) gastric and colorectal cancer patients, the primary tumor resection + postoperative chemotherapy group was significantly more favorable in prognosis than was the primary tumor resection alone group or the non-resectable group, showing the value of primary tumor resection.

Granular cell tumor of the esophagus —report of a case and review of the literature—

We report herein a case of a 46 year old man presenting with a gastric ulcer in whom an endoscopy happened to detect an elevated lesion in the lower esophagus. Endoscopic biopsy proved sufficient for determining the diagnosis of a granular cell tumor (GCT). Electron and microscopic studies suggest that GCT are derived from Schwann cells. Although commonly found in the tongue and skin, GCT are rarely seen in the gastrointestinal tract, especially in the esophagus. However, advances in endoscopic techniques will increase the opportunity of detecting GCT of the esophagus.

Protection against suture insufficiency in ante-thoracic esophagogastrostomy

In attempts to decrease suture insufficiency in case of antethoracic esophagogastrostomy, a gastric tube was so specially prepared that the short gastric vessels as well as the splenic vessels were severed very adjacent to the spleen. The anastomosis of the gastric tube thus prepared to the cervical esophagus was made using EEA-autosuture instruments. The suture insufficiency rate was thus markedly improved, with a value of aproximately 10 per cent. Even cases of suture insufficiency with minor leakage, control was complete with simple pressure with gauze.

Surgical Result of Esophageal Cancer Treated with Extended Lymph Node Dissection

The relapse rate of esophageal cancer is high, especially at the cervical and supra-clavicular nodes [1]. This makes it difficult to hope for an improvement of long-term survival of the patient. In order to have curative operation, we initiated extensive three-field lymph node dissection, including the lymph nodes in the neck, mediastinum, and abdomen [2].

A case of extragastric leiomyoblastoma with peduncle.

症例は65歳, 女性. 1988年7月, 胃粘膜下腫瘍の診断のもと開腹し, 胃体上部前壁に胃外有茎性腫瘤を認め, 術中迅速組織検査にて胃平滑筋芽細胞腫と診断され, 胃部分切除を施行した. 腫瘍の切除標本の大きさは, 3.5×2.5cmで一部に出血を伴っていた. 組織学的には, ヘマトキシリンーエオジン染色では, 核は異型性に乏しく, 核周囲に透明帯を有し, 胞体は好酸性であり, 鍍銀染色では, 一部にalveolar patternが認められた. 電子顕微鏡像ではdense patchを認め, 本腫瘍が平滑筋由来であることが示唆された. 今回集計しえた本邦における胃平滑筋芽細胞腫228例について検討したところ, 最大腫瘍径が5cm未満では手術時に転移, 直接浸潤を認めず, また予後の明らかな69例の10年生存率は88.8%であり, この内手術時に転移, 他臓器直接浸潤を示した13例の予後は5年生存率が71.3%, 10年生存率が47.5%であった.

Evaluation of Preoperative Stage of Esophageal Cancer by Endoscopic Ultrasonography

Esophagography and endoscopy have long been used for evaluation of patients with esophageal carcinoma. Recently these have been supplemented by computer tomography, magnetic resonance imaging, and endoscopic ultrasonography (EUS). Our institution has shown great interest in EUS because of its high degree of sensitivity in small lesions and its accuracy in the preoperative staging of esophageal carcinoma.