Min Hsiung Huang

Gastric substitution for resectable carcinoma of the esophagus: An analysis of 368 cases

Between 1974 and 1984, 1,188 patients with esophageal malignancies were treated in the Division of Thoracic Surgery of Veterans General Hospital, Taipei. The rate of resectability was 42.6%. Since 1974, the stomach has been used as esophageal substitute, and through 1984, a total of 368 patients were collected. The routes of reconstruction included retrosternal (77.2%), posteromediastinal (7.1%), and intrathoracic (15.7%). The rates of postoperative complications and surgical mortality in these 368 patients were 26.3% and 6.5%, respectively. Leakage of anastomosis was the most frequent complication. The incidence of stricture of esophagogastrostomy was 25.5%. All strictures were relieved by esophageal dilations. An average of 3.9 esophageal dilations were performed per patient (range, 1 to 15). Radical lymph node dissection was not routinely performed in our series. The actuarial 2-year and 5-year survival rates were 26.4% and 7.6%, respectively. Among 76 patients undergoing cervical esophagogastrostomy and surviving for more than 1 year, late complications occurred as follows: acid/bile regurgitation, 46.1%; postprandial fullness of abdomen, 38.2%; dumping syndrome, 13.2%; distended stomach with dyspnea, 11.8%; aspiration pneumonia, 6.6%; and gastric ulcer, 6.6%. Moreover, compared with patients without pyloroplasty, those with pyloroplasty were found to have a higher incidence of bile regurgitation (55.5% versus 8.6%), dumping syndrome (33.3% versus 6.9%), aspiration pneumonia (16.7% versus 3.4%), and gastric ulcer (22.2% versus 1.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis of esophageal squamous cell carcinoma : Analysis of clinicopathological and biological factors

OBJECTIVES:Esophageal squamous cell carcinoma (ESCC) is rather common among the Chinese, but the therapeutic outcome is dismal. Knowledge of the prognostic factors in cancerous patients may influence therapeutic strategy. However, systemic analyses of clinicopathological and biological factors for patients with ESCC are few, and the results are controversial.METHODS:Between 1985 and 1996, 117 patients undergoing en bloc esophagectomy and gastric substitution were enrolled. None had neoadjuvant treatment. Postoperative adjuvant therapy was provided for patients at and beyond stages IIa. Clinical responses were followed routinely. Flow cytometry was used to measure DNA ploidy and synthesis-phase fraction (SPF) of the resected esophageal tissues from all patients. Immunohistochemistry was also used to examine the expression of proliferating cell nuclear antigen (PCNA), epidermoid growth factor receptor (EGFR), HER-2/neu, and p53 in the pathological sections. Clinical correlation was evaluated by χ2 with Fishers exact test, and survival by log-rank test.RESULTS:The overall survival rates were 74% for 1 yr, 48% for 3 yr, and 38% for 5 yr. TNM tumor staging, the number of diseased lymph nodes (N ≤ 3 or N > 3), degree of cell differentiation, DNA ploidy, SPF, and lymphovascular invasion were more useful than biological markers, such as PCNA, EGFR, HER-2/neu, and p53, for the prognosis of ESCC. Multivariate analysis revealed significant correlation of tumor staging and number of diseased lymph nodes with patient survival after surgery.CONCLUSIONS:En bloc esophagectomy may provide a rather satisfactory survival rate for patients with early stage ESCC. However, for patients with distant lymph node metastasis and those with more than three lymph nodes involved, radical surgical resection, even combined with postoperative chemoradiotherapy, cannot improve survival. The prognostic value of biological markers, including PCNA, EGFR, HER-2/neu, and p53, however, is limited.

Prognostic significance of HER-2/neu overexpression in stage I adenocarcinoma of lung.

BACKGROUND Even with early diagnosis and adequate resection, the 5-year survival rate for stage I lung cancer patients is around 60% to 70%. Overexpression of HER-2/neu protein is associated with poor prognosis in lung cancers. In this study, we evaluated the expression of HER-2/neu in cancer cells of lung and assessed their clinicopathologic and prognostic significance. METHODS From 1986 to 1995, clinical data on 42 consecutive patients who underwent complete surgical resection for stage I lung adenocarcinoma were collected. Expression of HER-2/neu in paraffin-embedded tumor samples was determined by immunohistochemistry and scored with a semiquantitative method. RESULTS Twenty-one of 42 patients were positive for HER-2/neu overexpression in tumor. Compared with patients with low HER-2/neu expression, patients with HER-2/neu overexpression had a significantly higher incidence of early tumor recurrence (p = 0.014). Survival was also significantly better in patients without HER-2/neu overexpression than in those with HER-2/neu overexpression (p = 0.0047). By univariate analysis, HER-2/neu overexpression and poor cell differentiation are two important factors correlated with poor prognosis. CONCLUSIONS Expression of HER-2/neu oncoprotein in stage I lung adenocarcinoma can predict the tumors aggressiveness. Early tumor recurrence was frequently detected in patients with HER-2/neu overexpression. We recommend an individualized therapeutic strategy based on the level of HER-2/neu oncoprotein in the tumor cells.

Management of Primary Chest wall Tuberculosis

Primary tuberculosis of the chest wall is rare and its clinical presentation may resemble pyogenic abscess or tumour. The diagnosis is difficult, since smears or cultures of aspirate frequently fail to show tubercle bacilli. Seven cases of primary chest-wall tuberculosis treated between 1973 and 1992 are described. All presented with a progressively enlarging mass. The diagnosis was based on bacteriologic and histologic findings, but definitive diagnosis was obtained before treatment in only two cases. Satisfactory results were obtained with surgical debridement and specific chemotherapy in six cases and with chemotherapy alone in one case. From this limited experience, we suggest that primary chest-wall tuberculosis should initially be treated with a combination regimen of antituberculous chemotherapy, which should take more than 9 months. If the lesion progressively enlarges or secondary infection occurs, however, adequate surgical debridement is also required.

Detection of Epstein-Barr virus in esophageal squamous cell carcinoma in Taiwan

Objective:Recently, an association between viral infection and the development of esophageal carcinoma has been reported, particularly the human papilloma virus (HPV) and Esptein-Bar virus (EBV). However, geographic variation in carcinogenesis is realized. In this study, we investigate the viral carcinogenesis and the biologic effect of viral infection on esophageal squamous cell carcinoma (ESCC) in Taiwan.Methods:To determine the association of viral infection (EBV and HPV) with ESCC, we applied polymerase chain reaction (PCR), immunohistochemistry, and in situ hybridization (ISH) to examine 119 surgical specimens from different sites of esophagus in 31 ESCC patients. Additionally, an immunoperoxidase method was used to detect EBV latent membrane protein-1 (LMP-1), p53, CD45RO (UCHL-1), Fas ligand (Fas L), and RNA ISH with oligonucleotide sequences was used to detected interleukin-6 (IL-6) mRNA.Results:By PCR, EBV DNA was detected in 11 cases (35.5%). Expression of EBERs in ESCC was further confirmed with ISH. Nonetheless, no LMP-1 expression was detected. On the other hand, human papillomavirus (HPV) was identified in only one case (3.2%) of ESCC. Furthermore, HPV was located by ISH in the distant normal region rather than in tumor cells. In EBV-positive cases, accumulation of p53 protein was detected in 10 lesions (91%); CD45RO+ lymphocytes together with expressions of FasL and IL-6 were respectively identified in 100%, 63.6%, and 54.5% of 11 EBV-positive lesions. Interestingly, in the EBV-negative cases (n = 20), p53 protein was detected in 40% of lesions; CD45RO 30%; FasL 50%, and IL-6 10%.Conclusion:In this study, no correlation was found between the presence of EBV in ESCC and the patients’ age, sex, as well as survival. Although our results indicate that EBV could be associated with ESCC, the clinical role of EBV in ESCC remains to be determined.

Management for patients with advanced T4 epidermoid carcinoma of the esophagus

Available data concerning the treatment of patients with advanced T4 esophageal carcinoma are limited. A consecutive series of 42 patients with advanced T4M0 epidermoid carcinoma of the esophagus were studied from June 1987 to July 1992. The aim of this study was to evaluate the efficacy of various therapeutic modalities, and further evaluate the therapeutic options. The various therapeutic modalities included the following: Group I, feeding jejunostomy or endoesophageal intubation, 6 patients; Group II, palliative subtotal esophagectomy only, 8 patients; Group III, bypass procedures without tumor resection, 9 patients; Group IV, nutritional support and then treatment with irradiation (n = 8) or concurrent radio‐chemotherapy (n = 4), 12 patients; Group V, subtotal esophagectomy, followed by aggressive concurrent radiochemotherapy, 7 patients. The total prescribed irradiation dose was 60 Gy (10 Gy/5 fractions/week). A combination regimen of chemotherapy consisted of cisplatin, 5‐fluorouracil, and leucovorin (PFL regimen).

Primary Pulmonary Malignant Hemangiopericytoma Associated With Coagulopathy

A 34-year-old woman with a massive pulmonary malignant hemangiopericytoma and coagulopathy as a paraneoplastic syndrome is reported. Although coagulopathy may appear as a paraneoplastic syndrome and cause treatment to be more complicated and difficult, it can also be a useful marker to monitor the results of operation and tumor recurrence. This unusual case shows that primary pulmonary malignant hemangiopericytoma deserves aggressive surgical intervention with complete resection even under the circumstances of coagulation abnormality.

Flow-cytometric DNA content analysis of oesophageal carcinoma. Comparison between tumour and sequential non-tumour mucosae

The DNA content in oesophageal carcinoma and in sequential non-tumour mucosa was evaluated in 35 patients with oesophageal carcinoma, to explore the hypotheses that DNA distribution pattern and S-phase fraction can reflect malignant potential and that DNA aneuploidy can provide an early-warning signal of developing cancer. DNA flow cytometry was performed on 129 specimens from the tumours and on 119 specimens from non-tumour mucosa. Control specimens from gastric fundus had normal diploid DNA content and low S-phase fraction. Aneuploidy was found in 94.3% of the carcinoma specimens and intratumoral heterogeneity in 54.3%. Of the non-tumour specimens, 43.7% showed aneuploidy and none multiple aneuploidy. Pattern III distribution was present in 8.6% of the tumour specimens but not in non-tumour mucosa, where the incidence of aneuploidy rose with closeness to the tumour (p < 0.001). S-phase fraction was smaller in non-tumour than in tumour specimens (p < 0.0001). The study indicated that histologically tumour-free oesophageal mucosa may have a high malignant potential in patients with oesophageal carcinoma. The relative instability of such mucosa, with aneuploid cells and low S-phase fraction, may facilitate transition to abnormally proliferating cells in response to environmental signals. Cigarette smoking and alcohol may increase the risk of multicentric cancer development.