Nobue Futawatari

Laparoscopy-assisted distal gastrectomy for early gastric cancer: experience with 111 consecutive patients.

BackgroundLaparoscopy-assisted distal gastrectomy (LADG) is gaining wider acceptance for the treatment of early gastric cancer. However, firm evidence supporting its safety and usefulness is scant, and no study has compared the outcomes of various procedures for LADG. We examined the surgical outcomes of LADG performed using different methods for lymph node dissection.MethodsBetween September 1998 and January 2005, we performed LADG in 111 patients with early gastric cancer. In the 55 patients treated initially, group 2 lymph node dissection was performed through a small, 7-cm-long incision (minilaparotomy). In 43 of these patients, hand-assisted laparoscopic surgery (HALS) was done. In the 56 patients treated more recently, lymph node dissection was performed laparoscopically. In 31 of these patients, the celiac branches of the vagus nerve were preserved. Clinical outcomes of these procedures were compared.ResultsIn the first 55 patients, HALS significantly shortened the operation time (277 vs 243 min, p < 0.05). In the latter 56 patients, LADG with preservation of the celiac branches of the vagus nerve was associated with a longer operation time (283 vs 228 min, p < 0.01) and higher blood loss (150 vs 92 g, p < 0.05) than with LADG without celiac branch preservation. There were no differences among the various operative procedures in postoperative course, including the length of the postoperative hospital stay or the rate of complications.ConclusionsLADG is a safe and technically feasible procedure for the treatment of early gastric cancer. Laparoscopic lymph node dissection provided a good visual field and was easier to perform and required less time when the celiac branches of the vagus nerve were not preserved, with no negative effect on outcome.

Clinical Experience of Laparoscopy-Assisted Proximal Gastrectomy with Toupet-Like Partial Fundoplication in Early Gastric Cancer for Preventing Reflux Esophagitis

BACKGROUND Laparoscopy-assisted proximal gastrectomy (LAPG) has become prevalent for early gastric cancer in the upper stomach, but standard esophagogastrostomy is sometimes complicated with reflux esophagitis. Clinical outcomes are described here in patients with reconstruction by esophagogastrostomy with Toupet-like partial fundoplication (TPF) in LAPG. STUDY DESIGN From November 2005 through December 2008, LAPG was performed in 36 patients with early gastric cancer, 26 (72.2%) of whom could have reconstruction with the TPF because the remnant stomach was sufficiently large. RESULTS In LAPG with TPF, mean operation time was 293 minutes, mean blood loss was 119 g, and the mean number of dissected lymph nodes was 25.1. Regarding postoperative complications, anastomotic leakage occurred in two patients. More than 1 year after operation, 3 (15.0%) of the 20 patients had heartburn and 6 (30.0%) had reflux esophagitis (Los Angeles classification grade A, n=2; grade B, n=4); proton pump inhibitors were effective in these patients. CONCLUSIONS Esophagogastrostomy with TPF could be a simple, safe, and useful technique for reconstruction after LAPG in patients with early gastric cancer, and its clinical usefulness is worthwhile for the prospective validation.

Technique of esophagojejunostomy using transoral placement of the pretilted anvil head after laparoscopic gastrectomy for gastric cancer

BACKGROUND During esophagojejunostomy using a circular stapler after laparoscopy-assisted gastrectomy, placement of the anvil head via the transabdominal approach proved difficult. The authors report on a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretilted anvil head via the transoral approach. METHODS Between November 2007 and December 2008, esophagojejunostomy was performed using the transoral, pretilted anvil head in 27 patients after laparoscopy-assisted gastrectomy. The anesthesiologist introduced the anvil while observing its passage through the pharynx. During the anastomosis, we kept the jejunum fixed in position with a silicone band Lig-A-Loops, thereby preventing the intestine from slipping off the shaft of the stapler. RESULTS Esophagojejunal anastomosis using the transoral anvil head was achieved successfully in 26 patients; for 1 patient, passage of the anvil head was difficult owing to esophageal stenosis. No other complications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred during passage. No postoperative complications occurred, except for 1 patient who developed anastomotic stenosis, in whom mild relief was achieved using a bougie. CONCLUSION Esophagojejunostomy using the transoral pretilted anvil head is a simple and safe technique.

Laparoscopy-assisted distal gastrectomy for early gastric cancer with complete situs inversus: report of a case.

We herein report our experience in performing a laparoscopy-assisted distal gastrectomy involving standard lymph node dissection for a patient with early gastric cancer and situs inversus. A superficial elevated lesion was found on the posterior wall of the antrum. The preoperative diagnosis was cStage IA (cT1, cN0, cH0, cP0, cM0). A laparoscopy-assisted distal gastrectomy with standard lymph node dissection (D1 + β) for early gastric cancer was successfully performed by shifting the monitor to the right and left, and by applying sufficient care and time. The course of blood vessels was not abnormal except for the right/left inversion. Billroth I reconstruction was performed through a delta-shaped anastomosis. The postoperative course was favorable and the patient was discharged on postoperative day 12. Based on a histopathological examination, a 5.0 × 5.0-cm, mucosal, poorly differentiated adenocarcinoma (pT1, pN0, sH0, sP0, sM0, Stage IA) was diagnosed.

Laparoscopic versus open distal gastrectomy for early gastric cancer in Japan: long-term clinical outcomes of a randomized clinical trial

PurposeWe report the long-term clinical outcomes of a randomized clinical trial comparing laparoscopy-assisted distal gastrectomy (LADG) with open DG (ODG).MethodsBetween 2005 and 2008, 63 patients with clinical T1 (cT1) gastric cancer were randomly assigned to undergo either LADG or ODG. Long-term clinical outcomes included prospective questionnaire-based symptoms and survival.ResultsBased on the responses to the prospective questionnaires, patients who underwent LADG reported greater satisfaction and were more likely to favor the procedure than those who underwent ODG. The most notable difference in symptoms was related to wound pain and diarrhea. After ODG, wound pain reduced in intensity but persisted throughout the follow-up. Surprisingly, diarrhea was more frequent after LADG than after ODG, possibly due to overeating, because symptoms elicited by overeating, such as vomiting after a meal or heartburn, were also more frequent after LADG. In terms of long-term survival, there were no cases of recurrence in either group.ConclusionsLADG was associated with less wound pain during long-term follow-up after surgery, whereas symptoms related to overeating were common. Based on our findings and the patients’ reported satisfaction, we recommend LADG for cT1 gastric cancer as an effective procedure with excellent long-term survival.

Early gastric cancer frequently has high expression of KK-LC-1, a cancer-testis antigen

AIM To assess cancer-testis antigens (CTAs) expression in gastric cancer patients and examined their associations with clinicopathological factors. METHODS Eighty-three gastric cancer patients were evaluated in this study. Gastric cancer specimens were evaluated for the gene expression of CTAs, Kitakyushu lung cancer antigen-1 (KK-LC-1), melanoma antigen (MAGE)-A1, MAGE-A3 and New York esophageal cancer-1 (NY-ESO-1), by reverse transcription PCR. Clinicopathological background information, such as gender, age, tumor size, macroscopic type, tumor histology, depth of invasion, lymph node metastasis, lymphatic invasion, venous invasion, and pathological stage, was obtained. Statistical comparisons between the expression of each CTA and each clinicopathological background were performed using the χ2 test. RESULTS The expression rates of KK-LC-1, MAGE-A1, MAGE-A3, and NY-ESO-1 were 79.5%, 32.5%, 39.8%, and 15.7%, respectively. In early stage gastric cancer specimens, the expression of KK-LC-1 was 79.4%, which is comparable to the 79.6% observed in advanced stage specimens. The expression of KK-LC-1 was not significantly associated with clinicopathological factors, while there were considerable differences in the expression rates of MAGE-A1 and MAGE-A3 with vs without lymphatic invasion (MAGE-A1, 39.3% vs 13.6%, P = 0.034; MAGE-A3, 47.5% vs 18.2%, P = 0.022) and/or vascular invasion (MAGE-A1, 41.5% vs 16.7%, P = 0.028; MAGE-A3, 49.1% vs 23.3%, P = 0.035) and, particularly, MAGE-A3, in patients with early vs advanced stage (36.5% vs 49.0%, P = 0.044), respectively. Patients expressing MAGE-A3 and NY-ESO-1 were older than those not expressing MAGE-A3 and NY-ESO-1 (MAGE-A3, 73.7 ± 7.1 vs 67.4 ± 12.3, P = 0.009; NY-ESO-1, 75.5 ± 7.2 vs 68.8 ± 11.2, P = 0.042). CONCLUSION The KK-LC-1 expression rate was high even in patients with stage I cancer, suggesting that KK-LC-1 is a useful biomarker for early diagnosis of gastric cancer.

A patient with stage IV type 4 advanced gastric cancer who had a complete pathological response to short-term treatment with S-1 alone.

An 81-year-old woman presented with dysphagia. Stage IV (cT3, cN3, cH0, cM1) type 4 advanced gastric cancer was diagnosed. The left adrenal gland and the paragastric, mediastinal, and abdominal para-aortic lymph nodes were enlarged. Ascites was present. The patient started to receive S-1 (100 mg/day), given orally for 4 weeks followed by 2 weeks of rest. During the first course of treatment, grade 2 anorexia, grade 2 vomiting, and grade 2 diarrhea developed. Treatment with S-1 was therefore discontinued on day 27. The tumor had shrunk and was severely deformed. There was marked narrowing of the pyloric antrum. Abdominal computed tomography revealed that ascites and enlargement of the left adrenal gland and paragastric lymph nodes had resolved. To ensure adequate oral intake and improve the patients quality of life, a total gastrectomy with a limited (D1) lymph node dissection was performed. The primary gastric tumor, resected lymph nodes, and a peritoneal-lavage specimen were all negative for tumor. Histologically, the tumor had a complete pathological response to S-1. Two years after surgery, the patient is alive, with no evidence of metastasis or recurrence.

Expression of KK-LC-1, a cancer/testis antigen, at non-tumour sites of the stomach carrying a tumour

Kita-Kyushu lung cancer antigen-1 (KK-LC-1) is a cancer/testis antigen (CTA) and predominant target for cancer immunotherapy. Our previous study indicated that KK-LC-1 was expressed in 82% of gastric cancers, and also in 79% of early stage of gastric cancers, with a correlation to Helicobacter pylori (H. pylori) infection. In addition, we found that KK-LC-1 was occasionally expressed at non-tumour sites of stomachs carrying tumours. Here, we investigated the characteristics of KK-LC-1 expression at non-tumour sites and the clinical utility of these phenomena. The gene expression of KK-LC-1 was detected at the non-tumour sites including pyloric glands. The most detectable corpus/gland subset had a KK-LC-1 expression rate of 77% in the pyloric gland of the lower corpus where H. pylori preferentially exists. KK-LC-1 expression rates were 67% or 32% with or without intestinal metaplasia, which also induced by H. pylori, respectively. Consequently, KK-LC-1 would be detected at the pre-cancerous condition of the stomach, and may be a useful marker to predict gastric cancer.

Detection of KK-LC-1 Protein, a Cancer/Testis Antigen, in Patients with Breast Cancer

Background: Kita-Kyushu lung cancer antigen-1 (KK-LC-1) is a cancer/testis antigen and predominant target for cancer immunotherapy. Its detection is only established based on gene expression. In this study, we established a monoclonal antibody against KK-LC-1 to detect its protein expression in formalin-fixed samples. Materials and Methods: The monoclonal antibody against KK-LC-1 was evaluated and the detection of KK-LC-1 between gene expression and protein expression was compared in patients with breast cancer. The monoclonal antibody clone 34B3, which we established, stained testicular germ cells positively. Results: The rates of detection of KK-LC-1 gene and protein expression were 11.8% and 52.9%, respectively. Protein expression was detected in all triple-negative breast cancer cases studied (n=8). Furthermore, KK-LC-1 was detected in all tumours without oestrogen receptor expression. Conclusion: This study indicated that KK-LC-1 expression was detected in breast cancer, especially in oestrogen receptor-negative subtypes.

Helicobacter Pylori Infection Induces Gastric Cancer and the Cancer/Testis Antigens Expression

Helicobacter pylori (HP) are known to induce gastritis, atrophy, intestinal metaplasia, dysplasia, and stomach malignancy. HP infection also induces cancer/testis antigens (CTAs) during or after gastric malignancy. This study aims to elucidate the relationship between HP and CTAs, especially melanoma antigen-A3 and Kitakyushu lung cancer antigen-1.