Shigeru Takegawa

Continuous hyperthermic peritoneal perfusion for the treatment of peritoneal dissemination in gastric cancers and subsequent second-look operation

A total of 31 patients with gastric cancer showing peritoneal dissemination received continuous hyperthermic peritoneal perfusion (CHPP) in combination with the administration of cisplatin (CDDP) and mitomycin C (MMC). The authors developed a new special device named the peritoneal cavity expander (PCE) for sufficient perfusion and direct temperature measurement in the peritoneal cavity. As complications of CHPP three patients presented with bone marrow suppressions (leukocytes ⩽ 3000/mm3 and/or platelets ⩽ 30,000/mm3): one, leakage of intestinal anastomosis; one, intestinal perforation; and one, acute renal failure. But none of them was lethal. Twelve of 31 patients who had received CHPP during the initial operation underwent second‐look operation (SLO) for the assessing the effects of CHPP and for resecting residual or recurrent tumors. Among 12 patients who received SLO complete response (CR) was observed in four patients, partial response (PR) in one, no change (NC) in three, and progressive disease (PD) in four, with the overall response rates (%CR + %PR) standing at 41%. Two‐year survival rate of the complete and partial responders was 50%, which was significantly higher than 0% of the other responders (NC + PD). The survival curves of the two groups were significantly different (P < 0.05, generalized Wilcoxon test). These results supported that CHPP was well tolerated and effective for the treatment of patients with peritoneal dissemination in gastric cancer when combined with anti‐cancer drugs having synergism with hyperthermia. Since the outcome of SLO was one of prognostic factors it was important to follow up these patients by SLO.

A clinicopathologic study on multiple gastric cancers with special reference to distal gastrectomy

Simultaneous multiple gastric cancer was seen in 49 (5.8%) of 852 resected stomachs. Patients with multiple cancers were older than those with single gastric cancers (P < 0.01) and the incidence of multiple gastric cancer was significantly higher in male patients than in female patients (P < 0.05). The incidence rates of multiple carcinomas were 9.6% of early gastric carcinomas and 4.0% of advanced gastric carcinomas. With regard to histologic type, the incidence rate of the differentiated type was 71% and the incidence rate of the undifferentiated type was 29%. In 68 serially resected stomachs, 5 (7.4%) new multiple cancers were detected microscopically, whereas 4 (5.9%) had already been diagnosed grossly. The incidence rate of multiple carcinoma increased to 13.2% by this procedure. The cases that were cut serially showed that most of the multiple cancers were located distally from the F‐line presenting the line along which intestinal metaplasia appeared. This study suggests that the surgeon is required to resect the area including the F‐line at the time of distal gastrectomy so as not to leave another cancer in the gastric remnant.

A malignant granular cell tumor of the stomach: Report of a case

We report herein what to our knowledge is the first documented case of a malignant granular cell tumor of the stomach. A 64-year-old woman was admitted to our hospital for investigation of gastric submucosal tumor. Endoscopy disclosed a large hemispherical mass located on the lesser curvature at the gastric antrum with a normal mucosal surface, and computed tomography (CT) revealed a solid tumor about 7 cm in diameter with clear margins. A laparotomy was carried out under the preoperative diagnosis of leiomyosarcoma of the stomach. A tumor was found in the gastric antrum, with extragastric extension to the hepatic hilum, and a distal partial gastrectomy was performed. However, a follow-up CT scan performed 21 months postoperatively revealed a solid tumor of about 10 cm in diameter with clear margins, situated between the liver and the transverse colon. This was subsequently diagnosed as local recurrence and a resection was carried out. Microscopic examination of both the first and second specimens showed that the tumor cells were large and polygonal, with medullary proliferation and finely granular eosinophilic cytoplasm. Mitotic figures were also present. Thus, the lesion was diagnosed as a malignant granular cell tumor of the stomach from the clinical and pathological findings.

Magnitude of Combination Therapy of Radical Resection and External Beam Radiotherapy for Patients With Carcinomas of the Extrahepatic Bile Duct and Gallbladder

The present study sought to identify the therapeutic efficacy of adjuvant external beam radiotherapy (EBRT) for carcinomas of the extrahepatic bile duct (EHBD) and gallbladder. Twenty-one patients with pathologically verified EHBD carcinoma and 18 patients with gallbladder carcinoma were analyzed retrospectively by Cox regression analysis for predictors of survival. The overall 5-year survival rates after resection were 33% for EHBD carcinoma and 56% for gallbladder carcinoma. The overall 5-year survival rate for EHBD carcinoma was 60% in 8 patients without microscopic residual disease (R0), 15% in 9 patients with microscopic residual tumor (R1), and 0% in 4 patients with macroscopic residual tumor (R2). The overall 5-year survival rate of gallbladder carcinoma patients was also decreased with R status equal to 73%, 40%, and 0% for R0, R1 and R2, respectively. Adjuvant radiotherapy significantly improved the 5-year survival rate in 7 patients with R1 disease of EHBD carcinoma (P= .035), compared with survival in 2 patients who underwent resection alone. However, no significant difference was noted in the 5-year survival rate between the resection plus EBRT group and the resection alone group for gallbladder carcinoma. Multivariate analysis revealed that histopathologic grade (G) was an independent predictor of survival for EHBD carcinoma and that direct invasion of liver parenchyma was a predictor of survival for gallbladder carcinoma. This study suggests that curative resection provides the best survival for patients with EHBD and gallbladder carcinoma, and that radiotherapy may play a beneficial role in controlling local–regional residual EHBD carcinoma tumors. However, new strategies for adjuvant therapy are needed to improve survival in patients with gallbladder carcinoma.

Primary hepatic leiomyosarcoma in a woman after renal transplantation: Report of a case

In contrast to malignant lymphomas or skin cancer, smooth muscle tumors including leiomyosarcoma are rarely associated with transplant recipients. We herein present a 33-year-old woman with end-stage renal disease who received a transplant at 27 years of age. Four years after the transplantation, at age 31, she underwent a mastectomy because of primary right breast cancer, which was found to be a 5-mm-sized mucinous carcinoma with no regional lymph node metastasis. Six years after the transplantation, a liver tumor was unexpectedly discovered. An explorative laparotomy revealed a well-encapsulated tumor occupying the posterior portion of the right lobe of the liver. The patient underwent a posterior segmentectomy. Histologically, the tumor possessed intermingling fascicles of spindle cells with eosinophilic cytoplasm and elongated nuclei. Based on an immunohistochemical examination, the tumor cells were positive for the muscle-associated antibody. In addition, RNA probes for Epstein-Barr virus were negative based on in situ hybridization. The histologic, immunohistochemical findings were considered to be diagnostic for leiomyosarcoma, which is a low-grade malignancy. Two years after surgery, the patient is doing well with no recurrence of liver tumors or breast cancer.

Flow-Cytometric Analysis of Colorectal Cancer with Hepatic Metastases and Its Relationship to Metastatic Characteristics and Prognosis

Studying the DNA ploidy patterns of 52 primary tumors, diploid tumors accounted for 48.1% and aneuploid tumors for 51.9%. Out of 31 patients with liver metastases, 35.5% had diploid tumors and 64.5%, aneuploid tumors. Heterogeneity (difference in DNA ploidy pattern between the primary lesion and liver metastases) was found in 20% of the patients examined. In 28 of the patients, the liver metastases were unresectable, and their prognoses were such that the 1- and 2-year survival rates from the diploid tumors were 42.9 and 14.3%, respectively, while 1-year survivors from aneuploid tumors died within 2 years. In resected cases of hepatic metastases, the DNA ploidy pattern of the metastatic lesions did not correlate with the metastasis period, extent of spread or number of lesions. The recurrence rate of aneuploid tumors in the residual livers was 50%, which was slightly higher than the rate of 36.4% for diploid tumors. The prognoses in patients with diploid tumors were significantly better than those in patients with aneuploid tumors: 5-year survival was 71.1% in diploid tumor patients, compared with 21% in aneuploid tumor patients.

Massive hemorrhage in a patient with intestinal Behçet's disease: report of a case.

Abstract Major gastrointestinal bleeding is a rare manifestation of intestinal Behçets disease. We report herein the case of a 64-year-old man with intestinal Behçets disease complicated by myelodysplastic syndrome who suffered massive hemorrhage. Colonoscopy demonstrated ulceration of the entire colon from the cecum to the rectum, characterized by punched-out ulcers. Angiography demonstrated apparent extravasation of contrast material in the terminal ileum, and embolization was not successful. Continued and massive bleeding necessitated surgical resection of the involved segment of ileum; however, massive bleeding recurred. Re-endoscopy showed oozing hemorrhage from the multiple colon ulcerations. Intra-arterial prednisolone injection therapy was given, following which the melena gradually subsided and completely stopped within a few days.

Flow Cytometric Measurement of DNA Index and BrdUrd Labeling Index in Endoscopic Biopsy Specimens of Colorectal Carcinoma

We compared values of the DNA Index (DI) and bromodeoxyuridine (BrdUrd) labeling index (BULI) of biopsy specimens with those of resected specimens from 12 patients with colorectal cancer, to evaluate the cell cycle by flow cytometry (FCM). From each patient, 4 biopsy specimens were endoscopically removed. Also, small pieces of tissue, 0.5 cm in diameter, were taken from 4 different sites of the resected tumor. Both kinds of specimens were labeled in vitro with BrdUrd. Their DI and BULI values were evaluated from the DNA/BrdUrd bivariate scatter diagram by FCM. It was found that the coefficients of variation (CVs) for endoscopic biopsy specimens were siginificantly lower than those for resected specimens, 4.2 ± 1.3 (Mean ± S. D.) and 5.4 ± 1. 7, respectively. In 8 cases without intratumoral DI heterogeneity, there was a good correlation in the values of DI between the biopsy and resected specimens (r = 0.99, p < 0.01). A significant correlation was also found in the BULI values between the two types of specimens (r = 0.73, p < 0.01). These results suggested that 4 biopsy specimens were enough to estimate DI and BULI by FCM and that DI and BULI values determined by flow cytometry could be useful for decision‐making about the therapeutic modality for preoperative patients.

A Long Surviving Case of Remnant Stomach Cancer with Paraaortic Lymph-node Metastasis. A Patient with Three Primary Cancers Including Remnant Stomach Cancer Gallbladder Cancer and Breast Cancer.

大動脈周囲リンパ節 ((16) b1 inter) 転移陽性であったが切除術後4年5か月の現在再発徴候を認めず健在の1症例を経験した.本症例は64歳の女性で, 残胃癌と同時性に胆嚢癌を切除し, その1年1か月後に右乳癌を切除しえた.既往歴では左乳切 (詳細不明) と胃切除 (巨大皺襞症) がある.残胃癌は肝転移や腹膜播種を認めず, 組織学的には膠様腺癌で漿膜に露出し第4群リンパ節転移陽性で, 残胃全摘膵体尾部脾合併切除兼R2郭清術, また, 胆嚢癌は粘膜内に限局する乳頭腺癌で所属リンパ節転移を認めず, 拡大胆嚢摘除術兼R2郭清術, さらに, 乳癌は1cmの浸潤性乳管癌でリンパ節転移や遠隔転移を認めず, 非定型乳房切除術が施行された.進行した残胃癌は予後不良とされるが, 再建法と進行度に応じた積極的な合併切除とリンパ節郭清を選択することで長期生存の可能性が生じるものと思われた.また担癌患者を診察する際には, 術前術後の他臓器原発癌に留意することが肝要である.

Clinicopathological study of peritoneal dissemination in the gastric cancer.

P2以上の腹膜播種を有する胃癌58例 (初回40例, 再発18例) について播種を肉眼的に小結節散布型 (TB型), 結節散在型 (ND型), びまん型 (DF型), その他に分類して臨床病理学的に検討した.また切除, 持続温熱腹膜灌流 (CHPP) の予後に及ぼす影響につき検定した.雛はBorrmann3, 4型 (84%), por (71%), ssγ以上 (96%), sci (71%), INFγ(82%), ly2+ly3(70%), v0十v1(94%) である症例が多く, 再発例では初回例に比べTB型, DF型が有意に多かった (p<0.05).予後は初回例と再発例の間, および播種の各肉眼型の間では差は認められなかった.切除例は非切除例に比べ予後は良好であり (p<0.01), CHPP施行例は非施行症例に比べ予後は良好であった (p<0.05).TB型, ND型では同様に切除例, CHPP施行例の方が予後良好であったが, DF型では差は認められなかった.以上より腹膜播種を有する胃癌でも切除やCHPPにより特にTB型, ND型において予後が改善されると考えられた.