Takao Machimura

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%.

Immunohistochemical studies of blood group-related antigens in human superficial esophageal carcinomas.

A total of 63 surgically resected esophageal carcinomas (including 49 superficial esophageal carcinomas) and histologically normal tissue adjacent to the superficial carcinoma (nontumorous epithelium) were examined immunohistochemically for the blood group antigens (BGA) A, B, H, Lewisa, Lewisb, Lewisx, and Lewisy. Deletion of an expected A, B or H antigen occurred in 12 (24.5%) of the 49 superficial carcinomas and three (21.4%) of the 14 advanced carcinomas. Incompatible expression of an unexpected A or B antigens occurred in only one case (1.6%) in the carcinoma. In the clinicopathologic study, there was a significant correlation between immunoreactivity of Lewisa and depth of cancer invasion (chi‐square test, P < 0.05). In the superficial carcinoma, there were significant correlations between immunoreactivity of Lewisx and lymph node status (chi‐square test, P < 0.05), immunoreactivity of Lewisy and prognosis (Z test, P < 0.05), and incompatible expression of Lewisb for tumor against nontumorous epithelium and histologic variation (chi‐square test, P < 0.01). The functional significance of alternations in BGA expression that may be associated with oncogenesis is not clear. However, immunohistochemical determination of BGA may be a more advantageous marker to predict the patients clinical course in superficial esophageal carcinoma.

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.

Survival Benefit of Screening for Early Esophageal Carcinoma in Head and Neck Cancer Patients

Abstract: Primary cancer of the head and neck was diagnosed in 676 cases. Systematic endoscopic screening of the upper gastrointestinal tract (including iodine staining of the esophagus) was performed within 1 month of diagnosing head and neck cancer in order to determine the possible presence of a second malignancy‐ We divided cases in which esophageal cancer was detected into a group in which the initially diagnosed head and neck cancer had been treated curatively and those in which the treatment had been non‐curative. A pathological diagnosis of primary esophageal cancer was obtained in 37 cases (5.5%). The incidence of esophageal cancer associated with cancer of the oral cavity or pharynx was significantly higher (10.9%) than in cases with an associated cancer of the larynx or paranasal sinus (1.9%, p<0.05). All but one of the 37 cases detected by screening were asymptomatic and had superficial carcinoma. Of these lesions, 19 Were mucosal carcinomas, 17 submucosal carcinomas and only one an advanced cancer. Twenty‐four of these 37 cases had died. The cause of death was head and neck cancer in 17, esophageal cancer in two and other causes in five. The 5‐year survival rate of cases in whom the initial head and neck cancer had been treated curatively was 46.7%.

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.

Endoscopic Mucosal Resection for Early Carcinomas of the Esophagus

Recently, the rate of detection of early and superficial esophageal cancer has increased particularly with the development of panendoscopy and endoscopic staining techniques in Japan. The intra-epithelial and intra-mucosal carcinomas not extending to the muscularis mucosae did not have vascular invasion or lymph node metastases. Thus we have employed endoscopic mucosal resection for these patients. In this paper, we explained the technique of endoscopic mucosal resection in detail, focusing on the endoscopic mucosal resection tube(EEMR-tube) method which we devised originally. This method was employed in more than 85 cases and 107 lesions of early esophageal cancers.

Treatment of So-Called Early Esophageal Carcinoma

Recently, in Japan, progress has been made in the diagnosis of esophageal carcinoma. Increasing numbers of superficial and early stage lesions are being detected. A preoperative diagnosis defines so-called early esophageal carcinoma as being a lesion having pT1, pNO, and pMO [1]. Based on our study of 32 cases in the past 10 years, we will discuss the different therapeutic modalities and their results. We will also provide an overview of the current status of the therapeutic approach for superficial esophageal carcinoma in Japan.

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.

Segmental Resection of the Duodenum for Early Cancer of Papilla of Vater

近年, 十二指腸乳頭部早期癌や良性疾患に対して, 根治的かつ縮小手術として, 膵温存の十二指腸下行脚分節切除, 部分切除の報告が散見される. 紹介した本術式は膵温存が可能で膵管, 胆管共通管を十二指腸壁外, 膵外で切離して十二指腸乳頭部を完全摘出でき, 十二指腸腔内の水平方向へ進展した腫瘍に対応できる. 今回, 我々は十二指腸乳頭部早期癌の2症例に膵温存十二指腸下行脚分節切除を行ったので文献的考察を含め報告する. 症例1は61歳の女性で, 非露出腫瘤型の早期癌の診断で上記手術を行い, H0, P0, M (-), pN0, pEM0, m, stage Iであった. 症例2は77歳の女性で, 露出腫瘤型の乳頭部早期癌の診断で手術を行い, 病理診断はH0, P0, M (-), pN0, pEM0, od, stage1であった. 2症例ともに術後若干の胃排泄遅延を認めたが, その後の食事摂取は良好であった. 本症例は今後, 長期の経過観察を要するが, 十二指腸乳頭部早期癌に対する根治術式として有用であると考えた.