Tomokazu Matsuyama

Beneficial Effects of Immediate Enteral Nutrition After Esophageal Cancer Surgery

Abstract This study was conducted to determine the effects of immediate enteral nutrition (EN) on nutritional status, immunological competence, and the suppression of excessive inflammatory responses in patients following esophageal cancer surgery. Twenty-four patients who underwent the same elective operation for thoracic esophageal carcinoma were randomized into an immediate enteral nutrition (IEN) group who received EN from postoperative day (POD) 1 and a parenteral nutrition (PAN) group. Both groups received comparable volumes and calories on the same POD. Laboratory studies were carried out preoperatively and on PODs 1–7. Other nutritional and immunological assessments were repeated on PODs 1 and 7. Plasma concentrations of nitrate and nitrite were also measured. All of the patients in the IEN group tolerated enteral feeding well. There were no significant differences in the results of nutritional assessments, lymphocyte function, or plasma nitrate and nitrite levels between the two groups. The IEN group showed a significantly earlier recovery of the total lymphocyte count. The serum levels of total bilirubin and C-reactive protein were significantly attenuated in the IEN group. These results indicate that immediate EN may have beneficial effects on immunological competence and the suppression of excessive inflammatory responses in patients following esophagectomy. Patients undergoing radical esophageal surgery who are subjected to severe surgical stress might benefit the most from early EN.

Expression of Hypoxia-Inducible Factor-1α Protein Predicts Survival in Patients with Transitional Cell Carcinoma of the Upper Urinary Tract

Hypoxia-inducible factor-1 (HIF-1), identified as one of the transcription factors, has been found to play an essential role in oxygen homeostasis. HIF-1 is a heterodimer composed of HIF-1α and HIF-1β. Increased levels of HIF-1α have been reported during the carcinogenesis and progress of several tumors. We investigated the prognostic importance of HIF-1α expression in transitional cell carcinoma of the upper urinary tract. In 127 cases of transitional cell carcinoma of the upper urinary tract, we examined its expression (using immunohistochemistry and in situ hybridization), and also its relation to the expression of p53 oncoprotein, as well as to proliferating cell nuclear antigen (PCNA) immunoreactivity, microvessel density, clinicopathologic parameters, and clinical outcome. A positive expression of HIF-1α protein was recognized in 55.1% of samples, the expression being apparent within the nucleus in tumor cells. HIF-1α protein expression correlated with grade, growth pattern, p53 oncoprotein expression, and PCNA index, but not with stage. Furthermore, a significant correlation was found between HIF-1α protein expression and both overall and disease-free survival rates in the univariate and multivariate analyses (in all tumors and in invasive tumors). A positive expression of HIF-1α mRNA was recognized in 69.6% of 125 samples which were available, the expression being apparent within the cytoplasm in tumor cells. The positive expression of HIF-1α mRNA by in situ hybridization correlated significantly with HIF-1α protein expression by immunohistochemistry. HIF-1α mRNA expression only correlated with pattern of growth (P = 0.0078). In conclusion, the detection of HIF-1α protein would seem to be of value in informing the prognosis of transitional cell carcinoma of the upper urinary tract.

Expression of hypoxia-inducible factor-1α in esophageal squamous cell carcinoma

Hypoxia‐inducible factor‐1 (HIF‐1) is a transcription factor that plays an important role in tumor growth and metastasis by regulating energy metabolism and inducing angiogenesis. Elevated levels of HIF‐1α, a subunit of HIF‐1, are noted in various malignant tumors, but it is unclear whether this is so in esophageal carcinoma. The purpose of this study was to evaluate the implications of HIF‐1α expression in esophageal squamous cell carcinoma. In 215 patients with esophageal carcinoma, we examined immunoreactivity for HIF‐1α protein, vascular endothelial growth factor (VEGF) protein and p53 protein. In 38 patients, we examined the expression of HIF‐1α messenger ribonucleic acid (mRNA) (using the semiquantitative reverse transcriptase‐polymerase chain reaction [RT‐PCR]). A positive HIF‐1α protein expression was recognized in 95% of the patients, and was strongly apparent within both the nuclei and/or cytoplasm of tumor cells. The proportion of patients in the ‘high score’ group for HIF‐1α protein expression increased significantly with increasing VEGF protein expression. Immunoreactivity for HIF‐1α protein was found to have a significant effect on disease‐free survival rate in our univariate analysis, but no effect on overall survival rate. In RT‐PCR, HIF‐1α mRNA scores correlated significantly with scores for HIF‐1α protein expression, but not with any clinicopathologic factor or either of the survival rates. The detection of HIF‐1α protein and mRNA would appear to offer limited information as to progression and prognosis in esophageal carcinoma. (Cancer Sci 2005; 96: 176–182)

Influences of thoracic duct blockage on early enteral nutrition for patients who underwent esophageal cancer surgery

OBJECTIVES We have previously reported the beneficial effects of immediate enteral nutrition (EN) after esophageal cancer surgery. This randomized control study was conducted to determine whether immediate EN is beneficial or not for patients whose thoracic ducts were ligated, as well as those whose thoracic ducts were preserved. PATIENTS AND METHODS Thirty-nine patients who underwent radical resection of the esophageal cancer entered this trial. After stratifying into two groups--patients whose thoracic ducts were preserved [D(+)] and those whose thoracic ducts were ligated [D(-)], they were randomly divided into two groups--the patients who received early EN and those who received parenteral nutrition (PN) followed by delayed enteral feeding. Thus, the number of patients in the D(+)-EN group, D(+)-PN group, D(-)-EN group and D(-)-PN group were 13, 12, 7 and 7, respectively. The mortality and morbidity rates, and several blood chemistries were compared between the EN groups and the PN groups. RESULTS Total lymphocyte count showed a significant early increase and serum c-reactive protein (CRP) was significantly decreased in the D(+)-EN group compared to the D(+)-PN group. However those differences were not observed between the D(-) groups. Serum total bilirubin was significantly decreased in the both EN groups compared to the PN groups. The mortality and morbidity rates were not different between the EN group and the PN group in the D(+) patients and also in the D(-) patients. CONCLUSIONS Patients whose thoracic ducts were ligated did not obtain any other benefit from early enteral feeding except for bilirubin metabolism. Early enteral feeding is not recommended for patients whose thoracic ducts are ligated during radical resection of a cancer in the thoracic esophagus.

Carcinosarcoma of the liver with an osteosarcomatous component

Abstract We report a case of hepatocellular carcinoma associated with mesenchymal differentiation, which was identified as a true carcinosarcoma based on thorough pathologic examination. A 48-year-old man presented with a giant mass in the lateral segment of the liver. It was resected by lateral segmentectomy combined with total gastrectomy. Microscopically, the tumor consisted of hepatocellular carcinoma, osteosarcoma, and undifferentiated sarcomatous components. The undifferentiated sarcomatous components were positive for cytokeratin, whereas the osteosarcomatous components were negative for cytokeratin and positive for S100. To our knowledge, this is only the second known case in which mesenchymal differentiation was immunohistochemically demonstrated in liver carcinosarcoma.

A case of esophageal stricture after corrosive esophagitis successfully treated by frequent endoscopic balloon dilation

A 14-year-old girl was admitted to our hospital for treatment of abdominal pain after an attempt to commit suicide by swallowing a caustic soda solution. Severe esophageal stricture following corrosive esophagitis occurred 2 weeks after admission. First, we tried to dilate the stenotic esophagus by using an esophageal bougie, but it was not effective and was also painful, and the treatment was stopped. Next, we tried endoscopic balloon dilation. This procedure was less painful and more effective for dilating the stenotic esophagus than was the bougie. At first, we used a pneumatic balloon and injected a steroid locally under the mucosal layer after dilation. The same procedure was continued in the outpatient clinic, but each interval of the procedures, about 3 weeks, was not changed for about 1 year. After 1 year of consecutive trials of frequent dilatation using a pneumatic balloon, the type of balloon was changed to a hydrostatic type. Three months after changing the type of balloon, treatment with tranilast, which was expected to be effective for prevention of restenosis, was started instead of steroid injection to the stenotic portion. After starting tranilast treatment, the interval of dilation became longer and the stricture itself gradually became dilated. Twenty-one months later, the interval of dilation was 3–4 months and oral intake had improved greatly. We therefore concluded that frequent endoscopic balloon dilation is effective for dilating stenosis after corrosive esophagitis. In addition, this case suggests that treatment with tranilast could be effective for preventing esophageal restenosis after balloon dilation.

Clinical Analysis of the Surgical Indication after Neoadjuvant Chemoradiotherapy for the Advanced Esophageal Cancer

はじめに: 進行食道癌の予後改善を目的に術前化学放射線療法 (CRT) が行われているが, その後の手術適応について判断に迷う例も少なくない. そこでCRT後の手術の安全性と手術例の予後規定因子より手術適応の明確化を試みた. 対象・方法: 1989年以降の当科入院食道癌患者のうちCRT後の切除例28例をCRT手術群, 術前無治療の切除例194例を対照手術群とした. CRT手術群と対照手術群で手術侵襲, 周術期免疫能, 在院死・合併症の頻度, 在院日数を比較した. CRT手術群の予後規定因子として有意な影響を示す因子から, 比例ハザードモデルにより独立した予後規定因子を求めた. 結果: CRT手術群はUt症例, 3領域郭清例を多く含み, 対照手術群に比べて手術時間・出血量ともに多く, 末梢血リンパ球数は9PODまで, リンパ球幼若化反応は1PODで低値を示した. 縫合不全の発生率, 在院死の頻度が有意に高かったが, 他の合併症・手術関連死の頻度, 術後在院日数に差はなかった. CRT手術群では, 手術的根治度と組織学的深達度が独立した予後規定因子となり, 対照手術群と異なる特徴を示した. 考察: CRT後の手術は, 侵襲が増大し免疫能の低下した条件下で行われるが, 安全性は許容範囲内と考えた. 早期再燃による在院死が多く, 予後規定因子である根治度Aの手術が可能な症例にのみ手術を行うべきである.