Takeshi Nakachi

Prognostic Significance of Immunohistochemically Detected Blood and Lymphatic Vessel Invasion in Colorectal Carcinoma: Its Impact on Prognosis

BackgroundThe prognostic significance of blood vessel invasion (BVI) and lymphatic vessel invasion (LVI) is unclear. Because of the absence of specific markers for venous and lymphatic vessels, earlier studies could not reliably distinguish between BVI and LVI.MethodsBy immunostaining for podoplanin and CD34 antigen, we retrospectively investigated LVI and BVI in 419 tissue specimens of colorectal carcinoma. We performed univariate and multivariate analysis of the clinicopathologic features, frequency of recurrence, and outcome of patients with or without LVI and BVI.ResultsThe use of hematoxylin and eosin (H&E) staining to identify BVI and LVI yielded a false positive rate of 9.1% and false negative rate of 12.6%. The incidence of BVI was significantly higher among tumors with LVI than tumors without LVI (P <.001). In logistic multivariate analysis, only LVI (P < .001) was associated with lymph node metastasis and BVI (P = .015) was associated with distant recurrence. Calculating the prognostic relevance, both two invasion types correlated with decreased survival in univariate analysis (both P <.001). In multivariate analysis, BVI (P =.024), lymph node status (P =.003) and tumor stage (P <.001) remained statistically significant factors for survival.ConclusionsOur results suggest that immunohistologic evaluation of BVI and LVI could be useful in colorectal carcinoma indicating the risk of lymph node metastasis and recurrence, thereby contributing to prognostic evaluation.

The perioperative granulocyte/lymphocyte ratio is a clinically relevant marker of surgical stress in patients with colorectal cancer.

PURPOSE This study was to assess the clinical relevance of the blood granulocytes to lymphocytes (G/L) ratio as an early marker of surgical stress in patients with colorectal cancer. METHODS Thirty-three patients with colorectal cancer were prospectively to undergo laparoscopic-assisted (n=12) or open (n=21) surgical resection. Granulocyte and lymphocyte counts were used to calculate the G/L ratios in blood samples from all patients before the operation and post-operatively on days 1, 3 and 7. Additionally, serum inflammatory cytokines, interleukin (IL)-1β, IL-6, IL-8, tumour necrosis factor (TNF)-α, granulocyte colony-stimulating factor (G-CSF) and macrophage (M)-CSF were assayed as markers of surgical stress. RESULTS Seven of 33 patients developed unexpected complications. Serum IL-6 (P<0.0001), G-CSF (P=0.0257), and M-CSF (P<0.0001) were higher on day 1 vs before the operation. Similarly, the G/L ratios were higher on days 1-3 vs before the operation (P<0.0001) and then gradually decreased together with the surgical stress levels. The G/L ratios and the numbers of granulocytes and lymphocytes in the blood showed no correlation with serum IL-1β or TNF-α. In contrast, the G/L ratios and the numbers of granulocytes in the blood showed significant correlation with IL-6 (Rs=0.710, P<0.0001, Rs=0.653, P<0.0001, respectively), with G-CSF (Rs=0.626, P<0.0001, Rs=0.578, P<0.0001), with M-CSF (Rs=0.470, P<0.0001, Rs=0.372, P<0.0001). However, the number of lymphocytes showed inverse correlation with IL-6 (Rs=-0.493, P<0.0001), G-CSF (Rs=-0.440, P<0.0001) and M-SCF (Rs=-0.443, P<0.0001). CONCLUSION The G/L ratio appears to be a simple and clinically relevant parameter for the assessment of perioperative stress in patients undergoing colorectal surgery.

The Use of Autologous Fibrin Glue for the Treatment of Postoperative Fecal Fistula Following an Appendectomy: Report of a Case

We herein report a case of postoperative fecal fistula following an appendectomy which was successfully treated by the use of autologous fibrin glue. An 82-year-old man had acute appendicitis and underwent an appendectomy. Later, a fecal fistula developed and he underwent drainage treatment twice. After 4 weeks of drainage and during the third recurrence, the remaining fistula was successfully treated using autologous fibrin glue, instead of surgery, due to potential complications and the risks of associated with advanced age. No recurrence has been observed for 5 months. In conclusion, autologous fibrin gluing for fecal fistula was found to be a safe, economical, and effective treatment. A search of Medline from 1980 until 2002 revealed no other report of this treatment for postoperative fecal fistula following an appendectomy.

Gastric tube perforation after esophagectomy for esophageal cancer.

We searched for cases of perforation of the gastric tube after esophagectomy for esophageal cancer by reviewing the literature. Only 13 cases were found in the English literature, and serious complications were seen in all cases, especially in cases of posterior mediastinal reconstruction. However, in the Japanese literature serious complications were also frequently seen in retrosternal reconstruction. Gastric tubes are at a higher risk of developing an ulcer than the normal stomach, including an ulcer due to Helicobacter pylori infection, insufficient blood supply, gastric stasis, and bile juice regurgitation. H. pylori eradication and acid-suppressive medications are important preventive therapies for ordinary gastric ulcers, but for gastric tube ulcers the effects of such treatments are still controversial. We tried to determine the most appropriate treatment to avoid serious complications in the gastric tubes, but we could not confirm an optimal route because each had advantages and disadvantages. However, at least in cases with severe atrophic gastritis due to H. pylori infection or a history of frequent peptic ulcer treatment, the antesternal route is clearly the best. Many cases of gastric tube ulcers involve no pain, and vagotomy may be one of the reasons for this absence of pain. Therefore, periodic endoscopic examination may be necessary to rule out the presence of an ulcer.

Characteristics of the Serum Pepsinogen (PG) Test, and the Relationship between PG Test Results and Gastric Cancer Outcomes

Background and Aims: The serum pepsinogen (Pg) test is considered to be a high-risk marker for gastric cancer, so that it is intended that it will be gradually adopted for mass surveys in Japan. This manuscript examines the characteristics of the preoperative Pg test and the relationship between its results and the postoperative outcomes of gastric cancer cases in relation to the neutrophil/lymphocyte ratio (NLR) as a prognostic marker. Materials and Methods: Peripheral blood samples were taken within 1 week before gastrectomy for the Pg test and NLR. Results: The Pg test identified 128 (+) cases (59.0%) and 89 (–) cases (41.0%). In three of all cases, cancer had not been detected by an upper gastrointestinal series (UGI) in the previous year (every case showed Pg (+)). Five-year survival was 80.5% in the Pg (+) group, 60.7% in the Pg (–) group, 85.6% in the NLR (< 5.0) group, and 29.9% in the NLR (≥ 5.0) group, but 14.3% in the NLR (≥ 5.0) plus Pg (–) group, and 89.5% in the NLR (< 5.0) plus Pg (+) group. The differences in the 5-year survivals were statistically significant. Conclusions: A mass survey using the Pg test alone is inadequate, but the Pg test may be an important adjunct to the conventional methods. Gastric cancer with Pg (–) may have a higher potential for malignancy than cancer with Pg (+).

Pre-operative granulocyte/lymphocyte ratio as a predictive marker of post-operative complications in patients with colorectal cancer.

The aim of the present study was to assess the clinical relevance of the pre-operative granulocyte/lymphocyte (G/L) ratio as a predictive marker of post-operative complications in patients with colorectal cancer. In total, 85 patients (59 males and 26 females; mean age, 68.9 years) underwent surgery for colorectal cancer at the Department of Surgery, Ibraki Medical Center, Tokyo Medical University (Ami, Japan), and were divided into post-operative complication and non-complication groups. Clinical data, including age, gender, body mass index, tumor localization, tumor pathological type, cancer staging, surgery time, volume of surgical bleeding, pre-operative G/L ratio and further pre-operative laboratory data, including levels of albumin and C-reactive protein, Glasgow Prognostic Score, white blood cell count and levels of hemoglobin, creatine kinase, lactate dehydrogenase, carcinoembryonic antigen and carbohydrate antigen 19-9 were analyzed between these groups. The total post-operative complication rate was 18.8%. On univariate analysis, the amount of surgical bleeding and the pre-operative G/L ratio were significantly higher in the complication group than in the non-complication group (299.8±361.7 vs. 155.6±268.6 ml, P<0.05; and 6.73±10.38 vs. 3.49±2.78, P<0.05, respectively). Multivariate logistic regression analysis for the risk factors of post-operative complications, determined using univariate analysis, demonstrated that the amount of surgical bleeding and the pre-operative G/L ratio were independent risk factors of post-operative complications in patients with colorectal cancer. In conclusion, the G/L ratio may be a clinically relevant pre-operative predictive marker for post-operative complications.

Multifocal gastric cancer with a variety of histological findings coexisting with hyperplastic polyps: Report of a case

We report a case of multifocal gastric cancer with a variety of macroscopic and histological findings. A 65-year-old woman was admitted with upper abdominal pain. Her familial history was remarkable in that her mother had died of gastric cancer. The hematological and blood biochemical values were normal, but the serum was positive for Helicobacter pylori immunoglobulin G, and the serum pepsinogen test was also positive. Gastrointestinal fiberscopy showed many granulomatous lesions coexisting with pedunculated polypoid lesions and marked atrophic gastritis throughout the stomach. We performed total gastrectomy with regional lymph node dissection. There were four separate cancers and three hyperplastic polyps with entire intestinal metaplasia. The pathological findings of these multifocal gastric cancers varied, with coexisting differentiated and undifferentiated types, and early and advanced types. One of the pedunculated polypoid lesions was accompanied by papillary adenocarcinoma. Although multifocal gastric cancer is not uncommon, the present case is considered an extremely unusual example of gastric cancer.

Two Cases of Complete Response of Recurrent Gastric Cancer treated with Paclitaxel as Second Line Chemotherapy

症例1は72歳の男性で, 幽門側胃切除後肝門部リンパ節腫脹による黄疸, 傍大動脈リンパ節腫脹を認め, 低用量FP療法, TS-1 80mg内服を行うも奏効せず, Paclitaxel (60mg, 3週投与, 1週休薬) の投与を行ったところ, 5か月でcomplete response (以下, CR) を得た. CR後約半年間Paclitaxelを投与し, 長期にわたりCRを維持したが, Paclitaxel 投与中止後約4か月で多発性肝転移を来して不幸な転帰をたどった. 症例2は67歳の男性で, 胃全摘・膵尾側脾合併切除後, TS-1 80mg, CDDP 10mg/weekの投与をしていたが, 多発性肝転移, 傍大動脈リンパ節腫脹出現しPaclitaxel (60mg, 3週投与, 1週休薬) の投与を行った. 9か月後にはCRが得られた. 以後, biweekly投与で約2年7か月間投与を行った. 3年以上経過したが現在もCRを維持している. 今回, 症例1を通してPaclitaxel中止後の何らかの免疫監視機構の破綻などが示唆された. CRが得られた場合でも予後決定臓器への転移では, CR後も1年間は化学療法をすべきと思われた.