Kazuhito Tsuchida

Prognostic value of extracapsular invasion and fibrotic focus in single lymph node metastasis of gastric cancer

BackgroundHistological findings of metastatic lymph nodes are important prognosticators in patients with gastric cancer. The aim of this study was to clarify the clinical significance of various pathological characteristics of the early phase of lymph node metastasis in patients with gastric cancer, by selecting patients with tumors that had single lymph node metastases, no serosal invasion, and no metastases to the peritoneum, liver, or distant organs.MethodsSeventy-eight patients were eligible and were entered in this study. These patients were subdivided according to the following histological characteristics of the one metastatic lymph node: size of the metastasis (i.e., amount of tumor cells [AT]), proliferating pattern (PP), intranodal location (IL), and the presence or absence of extracapsular invasion (ECI) and/or fibrotic focus (FF). Associations between clinicopathological factors, survival, and the nodal findings were examined.ResultsThere were no correlations between AT or PP and any clinicopathological factors. IL was significantly correlated with venous invasion and the pathological characteristics of the primary tumor. ECI and FF were observed significantly more frequently in pT2 than in pT1 cancer. Overall survival (OS) differed significantly according to depth of invasion, venous invasion, and the presence or absence of ECI or FF, although OS was not affected by AT, PP, or IL. The 10-year overall survival rates of patients with and without ECI were 50 % and 80 %, respectively, while these rates for patients with and without FF were 50 % and 79 %, respectively. Multivariate analysis revealed that ECI and FF were significant prognosticators of survival.ConclusionThese results strongly suggested that the presence of ECI or FF could affect the survival of patients with gastric cancer.

Indications for Staging Laparoscopy in Clinical T4M0 Gastric Cancer

BackgroundThis study was undertaken to determine the efficacy of the clinical indications for performing staging laparoscopy for locally advanced gastric cancer to detect peritoneal metastasis or positive cytology findings.MethodsThe study included 231 patients with T4 gastric cancer without hematogenous or clinically evident peritoneal metastasis. The clinicopathologic features, including T and N factors, were diagnosed by clinical staging. The relation between the clinicopathologic features and the presence of peritoneal metastasis or lavage cytology at surgery was analyzed.ResultsA total of 31 patients underwent staging laparoscopy; 200 others underwent open surgery as a primary treatment. Both peritoneal metastasis and lavage cytology were negative in 145 (62.8%) patients, whereas peritoneal metastasis or lavage cytology was positive in 86 patients (37.2%). When calculating diagnostic accuracy in the 23 patients who underwent open laparotomy after staging laparoscopy, the accuracy rate was 95.7%. A multivariate analysis showed that a tumor location involving three portions; macroscopic type 3, 4, or 5; and positive lymph node metastasis to all three is significantly correlated with either peritoneal metastasis or positive cytology. When patients had two or three factors among these three independent risk factors, peritoneal metastasis or positive cytology could be detected with 91.9% sensitivity and 46.7% positive predictive value.ConclusionsThe selection of T4 tumors based on clinically evaluable risk factors is therefore considered useful for detecting peritoneal metastasis efficiently and hence avoiding unnecessary staging laparoscopy.

Relationship between RegIV gene expression to outcomes in colorectal cancer

Regenerating islet‐derived family members (Reg) are superfamily of calcium‐dependant lectins that are expressed in the proximal gastrointestinal tract and ectopically at other sites in the setting of tissue injury. The regenerating islet‐derived family member 4 (RegIV) gene has been reported in various cancers, associating with diverse functions. This study examined the relation of the relative expression of RegIV gene to clinicopathological factors and outcomes in patients with colorectal cancer (CRC).

Gallbladder herniation into the lesser sac through the foramen of Winslow: report of a case.

We report a case of gallbladder hernia into the lesser sac through the foramen of Winslow. The patient was a 90-year-old woman, admitted to hospital with obstructive jaundice. Computed tomography (CT) showed a left-deviated and remarkably enlarged gallbladder dragging the liver, and a dilated intrahepatic bile duct. The deviated gallbladder was thought to compress the common bile duct, causing the obstruction. Laparoscopic examination revealed gallbladder herniation into the lesser sac without a floating gallbladder; thus, we performed laparoscopic cholecystectomy. Herniation of the gallbladder is the rarest of all internal hernias and most reported cases have involved a floating gallbladder. The case we report here is therefore considered especially unusual.

Prognostic factors in stage IB gastric cancer.

AIM To identify the subset of patients with stage IB gastric cancer with an unfavorable prognosis. METHODS Overall survival (OS) rates were examined in 103 patients with stage IB (T1N1M0 and T2N0M0) gastric cancer between January 2000 and December 2011. Univariate and multivariate analyses were performed to identify risk factors using a Cox proportional hazards model. RESULTS The OS rates of patients with T1N1 and T2N0 cancer were 89.2% and 94.1% at 5-years, respectively. Both univariate and multivariate analyses demonstrated that tumor location was the only significant prognostic factor. The OS rate was 81.8% at 5-years when the tumor was located in the upper third of the stomach and was 95.5% at 5-years when the tumor was located in the middle or lower third of the stomach (P = 0.0093). CONCLUSION These data may suggest that tumor location is associated with survival in patients with stage IB gastric cancer.

Rare MDM4 gene amplification in colorectal cancer: The principle of a mutually exclusive relationship between MDM alteration and TP53 inactivation is not applicable

MDM4, a homolog of MDM2, is considered a key negative regulator of p53. Gene amplification of MDM4 has been identified in a variety of tumors. MDM2 or MDM4 gene amplification is only associated with the wild-type TP53 gene in retinoblastomas, thus the amplification of the two genes is mutually exclusive. Previously, we demonstrated that MDM2 amplification and TP53 alteration were not mutually exclusive in colorectal cancer, and we identified a subset of colorectal cancer patients without alterations in either the TP53 or the MDM2 gene. In this study, we investigated the gene amplification status of MDM4 in the same set of colorectal cancer cases. Unexpectedly, MDM4 amplification was rare, detected in only 1.4% (3 out of 211) of colorectal cancer cases. All the three gene-amplified tumors also harbored TP53-inactivating mutations. This contradicts the simple mutually exclusive relationship observed in retinoblastomas. Surprisingly, two of the three MDM4-amplified tumors also demonstrated MDM2 amplification. Paradoxically, the MDM4 protein levels were decreased in the tumor tissue of the gene-amplified cases compared with levels in the matched normal mucosa. We speculate that MDM4 might play a role in colorectal carcinogenesis that is not limited to negative regulation of p53 in combination with MDM2. The functional significance of MDM4 is still unclear and further studies are needed.

Exploratory Analysis to Find Unfavorable Subset of Stage II Gastric Cancer for Which Surgery Alone Is the Standard Treatment; Another Target for Adjuvant Chemotherapy.

The aim of the present study was to explore the unfavorable subset of patients with Stage II gastric cancer for whom surgery alone is the standard treatment (T1N2M0, T1N3M0, and T3N0M0). Recurrence-free survival rates were examined in 52 patients with stage T1N2-3M0 and stage T3N0M0 gastric cancer between January 2000 and March 2010. Univariate and multivariate analyses were performed to identify risk factors using a Cox proportional hazards model. The recurrence-free survival (RFS) rates of the patients with stages T1N2, T1N3, and T3N0 cancer were 80.0, 76.4, and 100% at 5 years, respectively. The only significant prognostic factor for the survival rates of the patients with stage pT1N2-3 cancer measured by univariate and multivariate analyses was pathological tumor diameter. The 5-year RFS rates of the patients with stage pT1N2-3 cancer were 60.0%, when the tumor diameters measured <30 mm, and 88.9% when the tumor diameters measured >30 mm (P = 0.0248). These data may suggest that pathological tumor diameter is associated with poor survival in patients with small T1N2-3 tumors. Because our study was a retrospective single-center study with a small sample size, a prospective multicenter study is necessary to confirm whether small tumors are risk factor for the RFS in T1N2-3 disease.

Long-term survival results of the patients who were enrolled to the feasibility study of laparoscopy-assisted distal gastrectomy for c-stage I gastric cancer.

166 Background: We introduced laparoscopy-assisted distal gastrectomy (LADG) as multi-institutional feasibility study, and already reported that the overall morbidity rate was 1.6% in the study (Gastric Cancer 2012). The aim of this study is to evaluate the long-term survival results of the patients who were enrolled to the study and finished 5-year follow-up. Methods: A total of 165 c-stage I gastric cancer patients who were registered from Kanagawa Cancer Center were included to the study. The Kaplan-Meier method was used to evaluate overall survival and recurrence-free survival. Results: Median follow-up period of the patients was 1901 days. The reconstruction methods were either B-I (n=150), R-Y (n=14), or B-II (n=1). The accuracy for preoperative diagnosis of stage I was 87.2% (144/165). Among 14 patients with p-stage II/III excluding T3N0/T1N2-3, eight patients received postoperative adjuvant chemotherapy. The recurrence rates by pathological stage were 0% (0/123) for stage IA, 4.7% (1/21) for stage...

A Case of Stercoral Perforation of the Ascending Colon.

宿便性大腸穿孔はS状結腸から直腸に好発するまれな疾患であり, その他の部位での発生は極めてまれである. 今回, 上行結腸に発生した宿便性大腸穿孔を経験したので報告する. 症例は77歳の男性. 右気胸のため入院し胸腔ドレナージ中に腹部違和感に続く急激な腹痛が出現. 画像上, 腹腔内遊離ガス像と糞塊による上行結腸の著明な拡張を認めたため緊急開腹術を施行した. 上行結腸は糞塊により拡張し, 前壁の一部は薄く数か所で穿孔し糞便の流出を認めた. 憩室および通過障害をきたす病変は認めなかった. 周囲の汚染が比較的軽度であったため, 右結腸切除を行い1期的に再建した. 上行結腸前壁には1cm以下の類円形の穿孔と潰瘍病変を多数認めた. 病理学的に穿孔部周囲には全層性に炎症細胞浸潤を伴う高度の虚血性変化を認め, 圧迫壊死を示唆する所見で, 宿便性大腸穿孔と診断した. 術後経過は一時的譫妄を除き良好で, 術後15日目に退院した.