Osamu Chino

Endoscopic mucosal resection for early gastric cancer

Progress in the detection of early gastric cancer has made endoscopic mucosal resection (EMR) possible for the treatment of gastric cancer instead of only conventional surgical resection. The most commonly employed modalities include strip biopsy, double snare polypectomy, and resection with combined use of highly concentrated saline and epinephrine, and resection using a cap. The indications should be strictly limited to the differentiated IIa type (the slightly elevated type) that is smaller than 2 cm, or the differentiated IIc type (slightly depressed type) without ulcer formation and smaller than 1 cm. Both of these entities are thought to have a negligible risk of lymph node metastasis. Prognosis after this treatment is comparable that of surgical resection for early gastric cancer in completely resected cases. EMR also permits local resection in elderly patients with various complications who would be at risk for conventional surgical operations. EMR should be encouraged for treatment of gastric cancer if the indications are strictly chosen.

Clinical analysis of reflux esophagitis following esophagectomy with gastric tube reconstruction

BackgroundRecently, the rate of postoperative long-term survival has increased in cases of esophageal cancer. We report on our analysis of postoperative reflux esophagitis (RE) at Tokai University.MethodsWe enrolled 48 patients who underwent gastric tube reconstruction after esophagectomy. The diagnosis of RE was confirmed by endoscopy.ResultsOf the 48 patients, 28 (58.3%) were found to have RE. Among the 28 patients with RE, only four (14.3%) reported symptoms. The distribution of the severity of RE according to the Los Angeles classification in the patients was as follows: grade M, 1 (3.6%); grade A, 2 (7.1%); grade B, 6 (21.4%); grade C, 17 (60.7%); and grade D, 2 cases (7.1%). Barretts epithelium was detected in 9 of the 28 patients (31%) with RE and in 3 of the 20 (15%) patients with no evidence of RE.ConclusionsTo detect the presence of RE as well as monitor for recurrence and development of metachronous cancer, we consider it important to perform endoscopy regularly over the long term. As Barretts epithelium is frequently encountered, care should be exercised to detect the specialized columnar epithelium showing dysplastic changes.

Endoscopic Criteria for Invasive Depth of Superficial Esophageal Cancer

Abstract: The therapeutic strategy for superficial esophageal cancer should be determined by the depth of invasion. Therefore, we endeavored to develop reliable criteria for endoscopic evaluation of the invasive depth of superficial esophageal cancer. Two hundred and fifty nine superficial squamous cell carcinoma cases were enrolled in this study, designed to investigate the relationship between endoscopic classification and the depth of invasion, and also between lesion size and depth of invasion. Almost all 0‐1, 0‐1+0‐llc, O‐llc+0‐lla and 0‐111 lesions invaded the submucosal layer, although 0‐lla and O‐llb lesions were limited to the mucosal layer. The 0‐llc type of lesion showed a wide range of invasive depths from M1 to SM3; in M1 cases with minimal depression the surface appears entirely smooth; in M2 cases the depressed surface is uniformly granular; and M3 cases have slightly larger granules. With submucosal cancer, the depressed surface showed some irregularity and variability in granule size. In the 0‐llc type, 100% of lesions under 10 mm and 80% of those under 30 mm in greatest dimension were mucosal cancer. The accuracy of our criteria for endo‐scopically evaluating the depth of invasion was 80.2%. The accuracy rate, in terms of assignment to group Ml and M2, M3 and SM1, or SM2 and SM3, was 90.6%.

Clinical Pathological Analysis of Surgically Resected Superficial Esophageal Carcinoma to Determine Criteria for Deciding on Treatment Strategy

We performed a clinical pathological study of conventionally resected superficial esophageal carcinomas since this type of lesion has been increasing, in order to develop criteria of determination for therapeutic strategies. Pathological studies were performed on specimens obtained by radical surgical resection in 133 cases of superficial esophageal cancer. Evaluation was performed in terms of the gross classification of the lesion type, depth of invasion, lymph node metastasis, vascular invasion, size of the lesion, outcome, etc. In 0-I, 0-IIc+0-IIa, and 0-III type submucosal cancer lesions the rate of metastasis to lymph nodes was more than 40%, but in 0-IIa and 0-IIb mucosal cancer cases no lymph node metastasis was observed. 0-IIc type lesions showed a wide range of invasiveness, ranging from m1 to sm3. In cases with m1 or m2 invasion, no lymph node or lymph-vessel invasion was recognized, but in m3, sm1, sm2, and sm3 cases lymph node metastasis was recognized in 12.5%, 22.2%, 44.0% and 47.4%, respectively. In 47% of lesions with a greatest dimension of less than 30 mm invasion was limited to the mucosa. Seventy-two percent of m1 and m2 cases were 30 mm in size or less. Lymph node metastasis was recognized in only 16.7% of cases less than 30 mm in size, but in cases of lesions 30 mm or more the rate of lymph node metastasis was 35.8%. 0-IIb and 0-IIa type lesions are indications for endoscopic esophageal mucosal resection (EEMR), while 0-I, 0-IIc+0-IIa, and 0-III lesions should be candidates for radical surgical resection. In the 0-IIc category, lesions in which the depression is relatively flat and with a finely granular surface are indications for EEMR, but those cases in which the surface of depression shows granules of varying sizes should be treated with radical surgical resection. Cases of 0-IIa type 30 mm or larger in greatest dimension which have a gently sloping protruding margin shoulder or reddening should be treated with caution, but EEMR can be performed first and subsequent therapeutic strategy decided on, based on the pathological findings of the specimen.

Treatment of esophageal cancer in patients over 80 years old

A total of 828 patients with esophageal cancer were treated at the Second Department of Surgery of Tokai University in the 20-year period from 1975 to June 1994, including 45 patients over 80 years old. We reviewed these elderly patients to assess the optimum therapeutic approach for such individuals. In recent years, the number of elderly patients with esophageal cancer has steadily been increasing. Advanced cancer is more common among this group, but early cancer has also been detected more frequently in recent years. Of the 45 elderly patients (80%) in our series, 36 were encountered in the last 10 years. As 28.9% of the patients had multiple cancers, a careful workup was necessary preoperatively. Since most patients (88.9%) had complications and were also in a poor general condition, limited surgery was recommended in consideration of the postoperative quality of life. The indications for endoscopic mucosal resection (EMR) may be able to be extended to submucosall (sml) cancer without lymph node swelling. Postoperative complications occurred in 60% of those undergoing surgical resection or esophageal bypass, although death only resulted in 1 case. The 5-year survival rate after surgical resection was 30.8%. These results therefore support the use of surgical treatment for selected elderly patients with esophageal cancer.

Assessment of the proliferative activity of superficial esophageal carcinoma using MIB-1 immunostaining for the Ki-67 antigen

Lymph node metastasis or vascular invasion may occur in superficial esophageal squamous cell carcinoma when it invades to or into the muscularis mucosae. Therefore, the correlation between histopathological characteristics and the proliferative activity of superficial esophageal carcinoma was investigated.

Technique of the double-channel ESD method performed with an EEMR tube

Endoscopic submucosal dissection (ESD) recently has been aggressively performed to treat superficial esophageal cancer; however, it is difficult to secure a good field of view for mucosal dissection, and the technique requires considerable skill. We have developed a double-channel ESD method using an endoscopic esophageal mucosal resection (EEMR) tube that makes it possible to perform the submucosal dissection with a good field of view while applying countertraction. Countertraction is achieved by maneuvering a fine grasping forceps inserted through the side channel of the EEMR tube, and the field of view of the submucosal dissection layer can be easily exposed. This technique can be performed while constantly observing the submucosal dissection layer with a stable field of view, and it is also easy to handle the blood vessels. Moreover, there is no disturbance of the field of view by the dissected mucosa.

Basaloid squamous carcinoma of the esophagus developed from achalasia: report of a case

A 57-year-old man, who had been diagnosed as having flask type, grade II achalasia of the esophagus at the age of 26, underwent Heller’s esophagomyectomy in a nearby hospital in 1971. A type 0-Is lesion measuring 2 cm in size was found on the middle thoracic esophagus in September 2002. A protruding tumor with a central depression, not stained with iodine, was detected by endoscopic examination. Standard subtotal esophagectomy with three-field lymph node dissection was performed. By histopathological examination, the esophageal lesion was classified as basaloid squamous carcinoma, extending to the middle part of the submucosa (T1b; sm2), without lymph node metastasis. The majority of the invasive carcinoma was composed of basaloid carcinoma, while a part showed as squamous cell carcinoma at the mucosal site. Achalasia of the esophagus is considered as a risk factor for squamous cell carcinoma by persistent mucosal inflammation caused by chronic stasis and food retention. Most of the reported carcinomas developing from esophageal achalasia are squamous cell carcinoma histologically. An extremely rare case of superficial basaloid squamous carcinoma with achalasia is presented.

Studies on Vascular Endothelial Cell Damage by Polidocanol in Relation to Concentration, Ethylene‐oxide Chain Length and Exposure Time

Abstract: In sclerotherapy for esophageal varices, the mechanism of intravariceal thrombus formation produced by a sclerosant (polidocanol, ethanolamine oleate, etc) is thought to be endothelial cell damage.

Clinicopathological significance of laminin-5γ2 chain expression in superficial esophageal cancer

The glycoprotein laminin 5γ2 chain (LN-5γ2) has recently become a focus of increased interest and investigation as a marker of invasion in gastrointestinal malignancies. We investigated the significance of LN-5γ2 expression as a prognostic factor in superficial esophageal cancer. The study population consisted of 87 patients who had undergone a transthoracic esophagectomy and three-field lymphadenectomy for the treatment of superficial esophageal cancer at Tokai University Hospital. Formalin-fixed, paraffin-embedded sections of the resected specimens were examined using immunohistochemical staining and hematoxylin and eosin staining to assess the correlations between the LN-5γ2 expression pattern and the clinicopathological factors (age, sex, T-factor, N-factor, ly-factor, v-factor, degree of differentiation, infiltrative growth pattern, tumor node metastasis classification of malignant tumors [TNM] stage, etc.) and the patient outcome. The expression pattern of LN-5γ2 was classified into an extracellular type (E type), characterized by the staining of extracellular matrix such as the basement membrane and the stroma (31 cases, 35.6%), and a cytoplasmic type (C type), characterized by the staining of the cytoplasm in the cancer cells (56 cases, 64.6%). The expression pattern was not correlated with any of the clinicopathological factors that were assessed. However, univariate analyses of the survival analysis data showed that the N-factor (P = 0.011), TNM stage (P = 0.011), and LN-5γ2 C type (P = 0.017) were prognostic factors. A multivariate analysis revealed that the N-factor (P = 0.049) and LN-5γ2 C type (P = 0.048) were prognostic factors. In the survival analysis, a univariate analysis of the 75 T1b cases also showed that the N-factor (P = 0.048), TNM stage (P = 0.048), and LN-5γ2 C type (P = 0.029) were prognostic factors, while a multivariate analysis showed that the LN-5γ2 C type (P = 0.035) was a prognostic factor. The C type expression of LN-5γ2, i.e. confined to the cytoplasm, was correlated with an unfavorable outcome among the patients with superficial esophageal cancer in the present series. Observation of the LN-5γ2 expression pattern may be useful for the diagnosis of highly malignant tumors.