Sumitaka Arima

Evaluation of malignancy and the prognosis of esophageal cancer based on an immunohistochemical study (p53, E-cadherin, epidermal growth factor receptor).

The subjects in this study consisted of 40 preoperative untreated esophageal squamous cell carcinoma patients. While p53 did not significantly correlate with the clinicopathological factors, E-cadherin significantly correlated with lymphatic invasion, vascular invasion, the depth of invasion, the degree of lymph node metastasis, the histological stage, and the number of lymph node metastases. Epidermal growth factor receptor (EGFR) significantly correlated with age, the depth of invasion, and the number of lymph node metastases. The 5-year cumulative survival rate was 45.7% in the p53-positive cases and 61.9% in the p53-negative cases, with no significant difference, and 87.8% in the E-cadherinpositive cases and 19.1% in the-negative cases, and the difference was significnat. The prognosis was significantly poor in EGFR-positive subjects: the 5-year survival rate was 38.6% in EGFR-positive cases and 68% in-negative cases. The 5-year survival rate in E-cadherin-negative, EGFR-positive cases was 0%, while it was 91.7% in the reverse pattern, and this difference was significant. These findings suggest that both E-cadherin and EGFR are important prognostic factors, and a more precise prognosis can thus be obtained by combining them. Such a combined technique may be very useful as an indicator for grading the biological malignancy of esophageal cancer.

The clinical characteristics and outcome of intraabdominal abscess in Crohn’s disease

BackgroundWe aimed to elucidate the incidence and natural course of abdominal abscess complicating Crohn’s disease (CD).MethodsOf 352 patients with CD who were observed at our hospital between 1985 and October 2001, we studied 35 patients (9.9%) with abscesses in the mid-abdominal region (the abdominal wall, peritoneal cavity, retroperitoneum, and subphrenic region).ResultsThe cumulative incidence of complication with an abscess was 9% and 25%, respectively, 10 and 20 years after CD onset. Of the 35 CD patients with abscess, 60% had had surgery by the time of the present study. The age when the abscess developed was 30.1 ± 8.1 years, and the duration of illness from the onset of CD until development of an abscess was 10.8 ± 6.3 years (range, 0–29 years). The location of involvement was: abdominal wall, n = 14 (40%); peritoneal cavity, n = 10 (29%); retroperitoneum or iliopsoas, n = 9 (26%); and subphrenic region, n = 2 (6%). In terms of location of abscess, it occurred most often on the right side (65.7%). Almost all abscesses occurred near the site of an anastomosis. Diseased segments of the bowel responsible for abscess formation were categorized radiographically as showing mild stenosis (6.5%), intermediate stenosis and/or simple fistula (41.9%), and severe stenosis and/or multiple fistulas (51.6%). Conservative treatment (including drainage of abscess) alone was effective in 7 patients (20%) and surgery was needed in 28 patients (80%). During the 5.3-year follow-up after treatment for the abdominal abscess, 9 of the 35 patients (26%) had recurrence of an abscess, mostly within 3 years.ConclusionsAbscess formation was noted in about 10% of patients with CD, with 46% of abscesses occurring in a diseased bowel segment near an anastomotic site. Of the diseased bowel segments responsible for abscess formation, half had neither severe stenosis nor multiple fistulas. Almost all patients underwent surgery for the abscess, and, in more than a quarter of the patients, there was recurrence within a few years after surgery.

Role of strictureplasty in surgical treatment of Crohn’s disease

Background. The aim of this study was to review early and late results of strictureplasty for patients affected by Crohn’s disease.Methods. We reviewed 103 patients with obstructive Crohn’s disease undergoing 293 strictureplasties (Heineke-Mikulicz, 235; Finney, 22; Jaboulay, 35; side-to-side isoperistaltic strictureplasty, 1). Mean age at surgery was 31.4 years. Forty-four patients had at least one previous surgery, and synchronous other surgical procedures were performed in 62 patients. For 41 patients with strictureplasty alone, 154 strictureplasties were done. The site and number of strictures treated by strictureplasty were as follows: duodenum (2), small intestine (265), ileocecal region (6), colon (4), recurrence at previous anastomosis (11), and recurrence at previous strictureplasty (5). The mean number of structureplasties per patient was 2.8. Reoperation has been used as the definitive end-point for recurrence, and the long-term outcome of strictureplasty was examined.Results. There was no operative mortality. Septic complications related to strictureplasty developed in 4 patients and reoperation was needed in 2 patients (1.9%). Mean duration of follow-up was 80.3 months. For all patients, the 5- and 10-year reoperation rate was 45.0% and 61.9%, respectively. Forty-five patients (43.7%) required further operation for recurrence, of whom 21 patients (20.4%) had recurrence at the site of strictureplasty, which was restricture in 14 patients and perforating disease in 7 patients. Perforating disease for recurrence was more frequent at the site treated by the Finney or Jabouley procedure compared with Heineke-Mikulicz.Conclusions. It is considered that, in the long term, strictureplasty is safe and useful for preserving the intestine in the surgical treatment of Crohn’s disease if strictures are carefully selected.

A Clinicopathological Investigation of "Tumor Nodules" in Colorectal Cancer

PurposeTumor nodules (tn) have been histologically identified within the fatty tissue or the detached fatty tissue around dissected lymph nodes, or else picked up as lymph nodes from resected specimens with no lymph node components. The TNM classification of malignant tumors provides a description of how to deal with tn, but there has so far been no description within the Japanese classification of colorectal carcinoma. The aim of this study was to determine whether we should regard tn as metastatic lymph nodes from the viewpoint of prognosis.MethodsA total of 544 patients who underwent a resection of colorectal adenocarcinoma between 1985 and 1995 were reviewed.ResultsTumor nodules were found in 54 (17.6%) of 307 colon cancer patients, and in 41 (17.3%) of 237 rectal cancer patients. We classified the curability A patients into four groups for both colon and rectal cancer; positive lymph nodes with tn (Group A), negative lymph nodes with tn (Group B), positive lymph nodes without tn (Group C), and negative lymph nodes without tn (Group D). The prognosis was not significantly different between Groups A, B, and C, but it was significantly different between Group D and Groups A, B, and C (P < 0.01) in both the colon and the rectum.ConclusionFrom the viewpoint of prognosis, it thus appears justifiable to regard tn as lymph node metastasis.

Assessment of blood flow in the small intestine by laser Doppler flowmetry: Comparison of healthy small intestine and small intestine in Crohn's disease

Blood flow and blood distribution were investigated in 40 patients with normal small intestine and the relation between blood flow and the morphological features of Crohns disease was examined in 11 patients with Crohns disease by laser Doppler flowmetry from the serosal side during surgery. In normal small intestine, blood flow was measured at six points: upper, middle, and lower small intestine, each of the mesenteric borders, and the antimesenteric surface. In Crohns disease, macroscopically normal tissue and affected lesions were observed in detail by intraoperative endoscopy after blood flow measurement. The blood flow values in the normal small intestine gradually decreased from the upper to the lower small intestine. As the level of inflammation progressed in Crohns disease the blood flow values gradually decreased; the exudative stage of Crohns disease (aphthoid ulcer) showed blood flow values that were slightly below those in macroscopically normal tissue. These results are the first to demonstrate decreased blood flow in affected lesions in Crohns disease and changes in blood flow according to the degree of inflammation in vivo.

AN EVALUATION OF MALIGNANCY AND PROGNOSTIC FACTORS BASED ON MODE OF LYMPH NODE METASTASIS IN ESOPHAGEAL CARCINOMA

This study was conducted to evaluate lymph node metastasis as a key prognostic factor in esophageal cancer. Metastatic lesions in lymph nodes were grouped by histological morphology as intracapsular or extracapsular, and the significance of lymph node metastasis was evaluated by relating metastatic lesions to clinical pathologic factors and patient prognosis. In our hospital, 46 of 81 patients who underwent resection of esophageal cancer developed lymph node metastasis. These 46 patients were enrolled in a study analyzing the relationship between the metastatic mode and the clinicopathological factors. The frequency of extracapsular metastasis was significantly high in patients with a profound depth of cancer, three or more metastases, distant metastasis (n3 and n4), or severe lymphatic invasion. The prognosis was significantly worse in patients with extracapsular metastasis, and this tendency was also seen even in patients with three or more metastases, limited metastasis (n1 and n2), or mild lymphatic invasion (ly0 and ly1). These findings suggest that the metastatic mode reflects the degree of esophageal cancer progression and is an important prognostic factor.

HETEROTOPIC OSSIFICATION AND PSAMMOMATOUS CALCIFICATION IN GASTRIC CARCINOMA

Two cases of heterotopic ossification occurring in a carcinoma of the stomach are reported. In one of these cases, bone formation is seen only in the regional metastasis, while in the other case, it is found in the primary tumor alone. In addition, there is seen in the former case a deposit of laminated psammoma bodies in the primary tumor and its regional metastasis. These two conditions are both so unusual for gastric carcinoma that only nine pertinent cases with heterotopic ossiflcation and two authentic cases with psammomatous calcification have been reported in the literature. The feature of these conditions la described and the pathogenesis discussed on the basis of personal Findings and a review of literature.

Clinicopathological study on 100 early gastric cancer cases.

SummaryClinicopathological study was given to 100 early gastric cancer cases. The cases included 50 intramucosal lesions (m-group) and 62 submucosal lesions (sm-group), and the share is 17% of whole cases treated surgically. The sex ratio is about 2:1 (male: female). According to the classification by location, the occurrence rate of lesion on anterior wall is 18.8%. This fact suggests the impotance of roentgenscopy by compression technique and double contrast in a prone position focussed on anterior wall. In addition, endoscopy is essential in order to detect minute cancers.The rates of metastasis of early gastric cancers is 2.4% of m-group and 16.1% of sm-group.No metastasis occurs in protruded or elevated type as far as cancer cells remain within the mucosa. Once cancer cells infiltrate into the submucosa, metastasis is oberserved in 36%.In the present cases, 9 (9%) out of 100 cases of early gastric cancers are the multiple cases. In order to avoid oversight of cancer foci, the portion of stomach to be remained after surgery should be throughly examined prior to operation and again under direct vision after gastric incision.

The postoperative recurrence of crohn's disease: An analysis of 37 patients with crohn's disease who underwent endoscopy during initial surgery

A total 37 patients with Crohns disease who underwent intraoperative endoscopy during resection of the affected intestine were evaluated in this study. The average age of the patients at surgery was 23.2 years. The residual lesions in the remaining intestine identified by intraoperative endoscopy were classified according to their pathologic profiles into three groups: A, B and C. In group A, comprising patients with longitudinal ulcers and/or a cobblestone appearance, 10 of 12 patients had recurrence. In 5 of these 10, the residual lesions were exacerbated and 2 required a further operation. The remaining 5 patients showed recurrence at the site of previous anastomosis and 2 of these 5 required additional surgery.In group B, comprising patients with small ulcers, aphthoid ulcers, or scars, and group C, comprising patients with no residual lesions, recurrence was observed in 13 of 16, and 3 of 9 patients, respectively. The recurrent lesions were all found proximal to, or at the site of previous anastomosis. Additional operations were performed on 3 of the group B patients. The findings of this study revealed that recurrence requiring additional surgery is more frequent at the site of anastomosis, regardless of the endoscopic appearance of the residual lesions.

The uptake of anticancer drugs by tumor tissues and lymph node and the effectiveness of postoperative adjuvant chemotherapy on survival time

Forty-one patients with advanced gastric cancer underwent gastrectomy and the correlation between tissue uptake of the adjuvant drug and the prognosis were studied. The patients were preoperatively administered Tegafur (Futraful, Taiho Pharmaceutical Co. Ltd, Japan) and samples of tissue were obtained intraoperatively. 5-FU levels in the tumor and lymph nodes were measured by gas chromato-massfragmentography (GCMF). The patients in whom the 5-FU uptake by the tissues was measured and who were given over 60 g of Tegafur as postoperative adjuvant chemotherapy, were divided into two groups; namely, one group in whom the 5-FU uptake by the tumor tissue and lymph nodes was over 0.05 μg/g and the other in whom the uptake was lower than 0.05 μg/g. There were no significant differences in the background factors of either group. Each survival rate was calculated by the Kaplan-Meier method, and the generalized Wilcoxon method was used for statistical analysis. There was no statistically significant correlation between the 5-FU uptake by the tumor and the prognosis, however the 5-year survival rate in the group whose 5-FU uptake of the lymph nodes was over 0.05 μg/g was statistically significant (p=0.018).