Naoya Saito

Proximal gastrectomy and jejunal pouch interposition for the treatment of early cancer in the upper third of the stomach: Surgical techniques and evaluation of postoperative function

BACKGROUND Limited surgery for the treatment of early gastric cancer located in the upper third of the stomach should be based on a well-balanced reduction in the extent of lymph node dissection and gastric resection while assuring a favorable quality of life and prognosis after operation. METHODS We have used interposition of a double jejunal pouch between the esophagus and the remnant stomach after performing proximal gastrectomy. To assure anastomosis and hemostasis during this operation, we currently use a surgical stapler with a vaginoscope and our new edge clamps. This method has been used in 12 patients to date. RESULTS On histopathologic examination the 12 cases comprised 11 early cancers (seven mucosal and four submucosal cancers) and one subserosal cancer. There was no evidence of lymph node metastasis of postoperative complications such as anastomotic leakages or hemorrhage, demonstrating the low-risk nature of this procedure. CONCLUSIONS The evaluation of postoperative quality of life, in terms of clinical signs and symptoms and dietary status, yielded favorable results. Thus our method has the important advantage of allowing good organ preservation.

Distinct Expression of CDX2 and GATA4/5, Development-Related Genes, in Human Gastric Cancer Cell Lines

CDX2 is a tumor‐suppressor homeobox gene involved in colon carcinogenesis, but its role in gastric cancer is unknown. Although GATA4, −5 and, −6 transcription factors have distinct functions in the regulation of gastrointestinal epithelial cell differentiation, there have been no reports regarding GATA4/5/6 alterations in gastrointestinal carcinomas. By using a semiquantitative reverse transcription–polymerase chain reaction assay, we studied the expression of gut development–related genes CDX2/1 and GATA4/5/6 in 11 human gastric cancer cell lines. The expression of CDX2 appeared to progressively decrease with the transition from well differentiated to poorly differentiated cancer cell lines. CDX1 was below detectable levels in all cell lines. The expression of GATA4 and GATA5 was undetectable in four and six cell lines, respectively, whereas the majority of the cell lines expressed GATA6 abundantly. These results suggest that CDX2 and GATA4/5 may be associated with the carcinogenesis of the stomach. Mol. Carcinog. 28:184–188, 2000.

The use of endoscopic ultrasound in determining the depth of cancer invasion in patients with gastric cancer

SummaryEndoscopic ultrasonography (EUS) was performed in 110 patients with gastric cancer to examine the depth of cancer invasion. The normal gastric wall has a five-layer structure on EUS. In 19 lesions, changes on EUS were limited to the first and/or second layers, suggesting that invasion was limited within the mucosa. In 91 lesions, changes were evident in the third or deeper layers. Alterations in the EUS appearance could be divided into two types: type A, with destruction of the layered structure and type B with thickening of the layers. The amount of interstitial tissue in cancer was classified as medullary or intermediate in 90% of type A, and as scirrhous in 82% of type B tumor. The EUS diagnosis of invasion was 95% accurate for stage M cancers, 75% for SM, 64% for PM, 100% for SS, 79% for SE, and 100% for SI lesions. The overall accuracy was 81%. Accompanying fibrosis and metastatic perigastric nodes were the main reasons for overestimating the extent of disease.

Treatment of primary multiple early gastric cancer: from the viewpoint of clinicopathologic features.

Abstract. The treatment of multiple early gastric cancer was investigated through the clinicopathologic assessment of 61 cases of primary multiple early gastric cancer (82 accessory lesions) treated by surgical resection over a 15-year period. These cases accounted for 11.7% of all cases of early gastric cancer resected during the same period. The 61 patients included 48 men (mean age 64 years) and 13 women (61 years). Of the 82 accessory lesions, 41 (50%) were located in the same region as the main lesion. The most frequent combination of macroscopic types of the main lesion and the accessory lesion was depressed type/depressed type (28 cases). The main lesion was of the well differentiated type in 39 (64%) of the 61 cases; the accessory lesion was also well differentiated in 37 of the 39 cases. Of the 82 accessory lesions, 29 (35%) had been overlooked preoperatively; most of them were located in the middle third of the stomach and included 17 depressed and 10 flat lesions, most of which measured no more than 1 cm. Cases of multiple early gastric cancer are characterized by the predominance of male patients of advanced age (>60 years), a combination of the same macroscopic type of the main and accessory lesions, and well differentiated carcinoma. Lymph node metastasis and vascular invasion are equally or less frequent than in cases of solitary early gastric cancer. The postoperative crude survival rate in patients with multiple gastric cancer is similar to that in those with solitary gastric cancer. Therefore we believe that multiple early gastric cancer does not require extended operative procedures. Endoscopic treatment may be indicated if each lesion fits the criteria for treatment and careful follow-up is ensured.

Rational lymphadenectomy for early gastric cancer with submucosal invasion: A clinicopathological study

Among all the patients who underwent gastrectomy for primary solitary gastric cancer at our department from 1979 to 1994, 228 patients had gastric cancer that invaded the submucosal layer. These cases were thus examined clinicopathologically, including the extent of submucosal invasion. No lymph node metastasis was found in any of the cancers measuring less than 2 cm in diameter. Macroscopic type I lesions or various combined types (IIa 1 IIc, IIc 1 IIa, IIc 1 III) were more likely to infiltrate deeply and were also associated with a high incidence (18%–25%) of lymph node metastasis. No lymph node metastasis or vascular invasion was found in any simple type IIa lesions. The incidence of lymph node metastasis was 3% in simple type IIc cancers measuring 3 cm or less. In addition, submucosal microinvasion (sm1) simple type IIc cancers showed no accompanying lymph node metastasis or vascular invasion. We thus conclude that a full-thickness partial resection of the stomach, such as a laparoscopic local resection, is applicable to cancers measuring 3 cm or less provided that they are either simple macroscopic type IIa or simple type IIc sm1 cancers.

Monocyte function associated with intermittent lentinan therapy after resection of gastric cancer

The effect of lentinan administration on monocyte function in the peripheral blood were examined in 33 patients who underwent resection of gastric cancer. As parameters of monocyte function, IL-1 production, C3b receptor, Fc gamma receptor and monocyte ratio were determined every 4 weeks for a maximum of 24 weeks. Among patients who were taking combined therapy with lentinan, an increase in IL-1 beta production of more than 50% was found 8 weeks (2 months) after the initiation of therapy in 8 of 12 patients given 2 mg at 2-week intervals, and in 11 of 16 patients given the same dose at 4-week intervals. This increase was particularly clear in stage II or more advanced cases. There were no significant changes in the other parameters studied. It has been considered that lentinen is effective when administered once a week. The results of the present study, however, suggest that lentinan given every 4 weeks also stimulates monocyte function enough to maintain immunological activity.

Effect of lentinan on lymphocyte subsets of peripheral blood, lymph nodes, and tumor tissues in patients with gastric cancer.

The effect of lentinan on lymphocyte subsets of peripheral blood, lymph nodes, and tumor tissues in gastric cancer patients was investigated. A 2-mg dose of lentinan was administered to 12 patients intravenously twice, the first at 3–9 days before and the second the day before surgery. The results were then compared with a control group without lentinan administration comprising 12 patients. Regarding peripheral blood and lymph nodes without metastasis, lymphocyte subsets defined with anti-CD3, anti-CD4, anti-CD8, anti-Leu7, and anti-Leu11 were analyzed by flowcytometry. As for tumor tissues, lymphocyte subsets defined with anti-CD3, anti-CD4, anti-CD8, anti-Leu11, and anti-M3 were analyzed after immunohistochemical staining. There were no significant changes in the lymphocyte subsets of peripheral blood between the two groups. In the lymph nodes, the CD4 cell ratios increased; otherwise in regard to tumor-infiltrating lymphocytes (TILs), the number of CD4, Leu11 and LeuM3 cells showed a prominent increase. Therefore, lentinan was observed to produce different effects in accordance with the subjective organs.

Endoscopic evaluation of gastric cancer infiltrating the lower esophagus

SummaryEndoscopic and histopathological findings were compared in 74 patients with gastric cancer infiltrating the lower esophagus who had undergone gastrectomy to evaluate mode of esophageal infiltration. There were no early cancers. Cancer infiltration modes were histopathologically broken down into three types: superficial, whole layer, and deep layer. Endoscopic findings were broken down into five types for proximal infiltration. Endoseopy used for histological evaluation frequently revealed the protruded type to be whole layer and had a highly accurate diagnosis rate (94%); it revealed the histology of the other four types to be primarily superficial. Extent of cancer invasion was underestimated in giant-rugae tumors (40%), as endoseopy could barely detect the small nest of esophageal infiltrations. Lugol staining was useful in preventing underestimation. For flat cancer, which is poorly demarcated and is often accompanied by vascular invasion, preoperative evaluation is very difficult, requiring preoperative examination of a frozen section taken from the proximal edge of resected specimen.

Evaluation of gastric cancer by high-resolution three-dimensional CISS MR imaging in vitro

OBJECTIVE The objective of this study was to demonstrate the usefulness of high-resolution three-dimensional (3D) constructive interference in steady-state (CISS) MR imaging for evaluating mural invasion and the morphologic features of gastric cancers in vitro. MATERIALS AND METHODS High-resolution 3D-CISS MR images were obtained in three surgical specimens containing three different gastric cancers. RESULTS In early carcinoma, advanced carcinoma, and leiomyosarcoma, the depth of mural invasion at 3D-CISS MR imaging correlated well with the histopathologic stage. CONCLUSION High-resolution 3D-CISS MR imaging is a useful method for evaluating mural invasion and the macroscopic features of gastric cancers in vitro.

An Endoscopically Resected Case of Early Carcinoma of the Duodenal Bulb

We report here on a case of early carcinoma originating in the duodenal bulb. The patient was a 70‐year‐old woman who complained of nausea. A gastrointestinal endoscopy disclosed a lesion protruding from the duodenal bulb and a biopsy revealed adenocarcinoma. According to the results of the endoscopy, the tumor was subpedunculated and probably confined in the mucosal layer.