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A 32-year-old woman was admitted our hospital due to epigastric discomfort. The patient diagnosed as having scirrhous carcinoma of the stomach by upper gastrointestinal scope. Peritoneal dissemination and ovarian metastasis were confirmed by the diagnostic laparoscopy. Therefore, combination chemotherapy with S-1 and intraperitoneal chemotherapy(ip)with docetaxel (DTX) was started. After 2 courses chemotherapy, laparoscopy was performed again. Peritoneal dissemination was scarred, but biopsy showed altered AE1/AE3 positive cells, and increased left ovarian metastasis, so systemic chemotherapy was changed to DCS chemotherapy and added DTX ip. After 4 courses chemotherapy and 7 months after the first diagnosis, subtotal gastrectomy, hysterectomy and bilateral adnexectomy were performed because the cytology and tumor marker remained within normal range. In histopathological diagnosis, the effect of chemotherapy was Grade 2 at the primary site and Grade 3 at the metastatic site. Nine years have passed since the initial diagnosis and she has no relapse with postoperative adjuvant chemotherapy.

Background/aims: The prognosis of some patients with gastric tumors that have infiltrated adjacent organs may be improved by operations that include complete removal of these structures. However, such a radical operation raises concerns about operative risk., Methodology: We performed a retrospective analysis of 55 patients whose gastric primary tumors invaded adjacent organs to evaluate the effect of combined removal on postoperative survival. Prognostic factors were also determined by the univariate and multivariate analysis., Results: Cumulative 5-year survival of patients who underwent complete removal of invaded organs was significantly higher than that of patients who did not undergo complete removal of invaded organs or gastrectomy alone. No significant difference was noted between groups in mortality at 30 days after operation. Univariate and multivariate analysis seeking prognostic factors revealed that completeness of the combined removal of invaded organs was among the predictors of outcome., Conclusions: In conclusion, our study suggested that complete removal of invaded organs simultaneously with gastrectomy can prolong postoperative survival of patients with gastric cancer directly invading adjacent organs.

Background/aims: A new dosage formulation consisting of an anti-cancer drug bound to activated carbon particles was developed for a local injection against early gastric cancer so that the dosage formulation yields chemotherapeutic effects selectively to the lymph node metastases as well as to the primary lesion., Methodology: As a pilot study, the new dosage formulation, total of 50-200 mg of methotrexate only or total of 200 mg of methotrexate plus 8 mg of mitomycin C, was injected into the primary lesions and the adjacent gastric wall of 8 patients with early gastric cancer, guided by a gastrofiberscope before gastrectomy. The surgically resected specimens were examined histologically for the therapeutic effects on the primary lesion and its nodal metastasis., Results: The therapeutic effects were seen in 2 of 4 lymph node metastases (50%) and 5 of 8 of the primary lesions (63%), as confirmed histologically with degeneration and/or necrosis., Conclusions: Preoperative local injection of the new dosage formulation will be useful to give chemotherapeutic effects on the potential metastases in the regional nodes as well as to the primary lesion.

Background/aims: Extensive gastrectomy, defined as gastrectomy with complete omentectomy and extended lymphadenectomy, improves the survival of gastric cancer patients with peritoneal metastases, even though peritoneal metastasis is considered the end-stage of cancer. MMC-CH, a new dosage formulation of mitomycin C, extended the survival of rabbits with peritoneal carcinomatosis as compared to aqueous mitomycin C., Methodology: We retrospectively reviewed 114 patients who underwent gastrectomy for gastric cancer with peritoneal metastases., Results: Six patients survived for more than 5 years after the therapy out of 63 patients treated with MMC-CH therapy and extensive gastrectomy for gastric cancer with P1, i.e., metastases to the adjacent peritoneum but no metastasis to the distant peritoneum, or P2, i.e., a few metastases to the distant peritoneum. However, there were no 5-year survivors in patients with P3, i.e., numerous metastases to the distant peritoneum, or in patients treated with incomplete omentectomy, limited lymphadenectomy and no MMC-CH therapy., Conclusions: The results imply that gastric cancer patients with P1 or P2 have a possible chance to survive more than 5 years when treated with MMC-CH therapy and extensive gastrectomy.

A splenectomy or distal pancreaticosplenectomy is often performed simultaneously with total gastrectomy in the treatment of gastric carcinoma to facilitate dissection of the lymph nodes around the splenic artery and splenic hilus. However, the negative impact of splenectomy and pancreaticosplenectomy has also been reported. A retrospective analysis was performed to evaluate the outcomes of distal pancreaticosplenectomy and total gastrectomy, splenectomy and total gastrectomy, and gastrectomy alone in the patients with advanced gastric carcinoma without distant metastasis. Prognostic factors were examined. No significant differences existed in 5-year survival in the patients who underwent gastrectomy with splenectomy, gastrectomy with distal pancreaticosplenectomy, or gastrectomy alone. Neither splenectomy, nor distal pancreaticosplenectomy were prognostic factors. However, distal pancreaticosplenectomy was an independent predictor of pancreatic fistula. In conclusion, the addition of distal pancreaticosplenectomy or splenectomy to total gastrectomy for gastric cancer increases the risk of severe complications, but does not improve survival.

The development of clinical practice guidelines for the systematic treatment of cancer is being promoted as a way to assist clinicians and patients. In this paper, the advantages and disadvantages of developing clinical practice guidelines for both clinicians and patients are discussed. Physicians may regard guidelines to be unrealistic, and some may even consider guidelines to be a challenge to their autonomy. However, the advantages of guidelines for the patients and clinicians exceed any disadvantages. The development of guidelines should therefore be promoted, although with consideration of both the many advantages and disadvantages for clinicians and patients.

Objective: Postoperative survival of patients with Borrmann type IV gastric carcinoma is significantly worse than that in patients with other Borrmann types of gastric carcinomas. The most common pattern of recurrence in patients with Borrmann type IV gastric carcinoma is peritoneal metastasis. We examined the predictors of developing peritoneal metastasis., Methods: We retrospectively analyzed the relationship between peritoneal metastasis and Borrmann type IV gastric carcinoma. We also examined the dependence of the peritoneal metastasis on clinicopathological findings., Results: Borrmann type IV was an independent prognostic factor of survival by multivariate analysis, and regional lymph node metastasis was an independent predictor of peritoneal metastasis in patients with Borrmann type IV gastric carcinoma., Conclusion: Because type of lymph node dissection was not associated with developing peritoneal metastasis, early detection of cancer without lymph node metastasis may be the only means of improving survival in patients with Borrmann type IV gastric cancer.

Background: The long-term survival of 200 patients with gastric cancer who underwent radical gastrectomy was analyzed with respect to the number and anatomical extent of lymph node metastasis. All of the patients received intra-lymph node injection of fine activated carbon particle solution (CH40) during surgery., Methods: The average number of resected lymph nodes increased in line with the anatomical level of lymph node dissection; 32.5 per patient in D1, 42.3 in D2, 3 and 66.3 in D4. The percentage of blackened lymph nodes without metastasis (42.4%) was slightly higher than that of lymph nodes containing metastasis (37.2%), but the difference was not statistically significant. Of the 200 patients, 61 (30.5%) had microscopic evidence of metastatic lymph node involvement. Twenty-two patients had between one and three metastatic lymph nodes, 19 had between four and nine and 20 patients had more than nine. The 5-year survival rate was 93.1% in patients without lymph node metastasis, 71.9% in patients with 1-8 metastatic nodes, 36.1% in patients with 4-9 nodes and 19.2% in patients with > 9 nodes., Results: The 5-year survival rate according to the anatomical extent of metastatic lymph nodes was 93.1% in n0, 63.1% in n1, 37.9% in n2, 27.8% in n3 and 0% in n4. The number of metastatic lymph nodes and also their anatomical extent were identified as independent prognostic factors for survival by multivariate analysis., Conclusion: The number and anatomical extent of metastatic lymph nodes have similar impacts on prognosis in gastric cancer.

Background: It remains unknown whether extended surgery improves the survival rate of patients with gastric cancer. This study was a review of combined pancreaticosplenectomy with total gastrectomy for gastric cancer., Methods: The clinicopathological details of 190 patients who underwent combined pancreaticosplenectomy with total gastrectomy between 1969 and 1996 were compared retrospectively with those of 206 patients who underwent total gastrectomy with splenectomy alone., Results: There was no statistical difference in the survival rate when pancreaticosplenectomy was added to total gastrectomy. The mortality rate was similar, but the morbidity rate was higher in patients who had pancreaticosplenectomy. Six patients who had direct pancreatic invasion and two thought to have involved lymph nodes along the splenic artery survived for more than 5 years after operation. In the latter group, the metastatic lymph nodes along the splenic artery could have been resected without pancreatectomy., Conclusion: Since a combined pancreaticosplenectomy adds no survival advantage to total gastrectomy for gastric cancer, this procedure should no longer be regarded as routine.

Background/aims: The omentum is the site where peritoneal metastases occur most frequently. It has not been shown whether complete resection of the omenta during gastrectomy improves the survival of gastric cancer patients with macroscopic peritoneal metastases., Methodology: We retrospectively analyzed 126 patients who underwent gastrectomies for gastric cancer with peritoneal metastases but without hematogenous metastases. The 126 patients were stratified according to their grade of peritoneal metastases into three groups: the P1 patients (patients with peritoneal metastases in the adjacent peritoneum but not in the distant peritoneum); the P2 patients (patients with a few peritoneal metastases in the distant peritoneum); and the P3 patients (patients with many metastases in the distant peritoneum). In each group, the survival and clinicopathological characteristics were compared between patients treated by complete resection of the greater omentum and the lesser omentum plus extensive lymphadenectomy during gastrectomy, versus patients treated by incomplete resection of the omenta and non-extensive lymphadenectomy during gastrectomy., Results: Complete omentectomy and extensive lymphadenectomy during gastrectomy improved survival significantly only in the P1 patients. Other clinicopathological characteristics did not differ between them., Conclusion: Complete omentectomy and extensive lymphadenectomy is recommended in patients with peritoneal metastases in the adjacent peritoneum but not in the distant peritoneum.

Little is known about the clinicopathologic features of mp colorectal cancer, defined as a cancer where the depth of invasion is limited to within the mucosa, the submucosa and the proper muscle. This study was designed to determine the clinicopathologic features of mp colorectal cancers. From 1973 to 1993, 83 mp colorectal cancer and 66 sm colorectal cancer patients were treated in our department and were enrolled in this study. During the same period, 66 patients with sm colorectal cancer defined as a cancer where the depth of invasion is limited to within the mucosa and the submucosa, were treated. The clinicopathologic findings of these patients were determined retrospectively from their hospital records. Clinicopathologic differences in sm and mp colorectal cancers were compared with sm and mp gastric cancers. The incidence of mp colorectal cancer increased from 7.9% in 1973-1977 to 16.2% in 1988-1993. An advanced macroscopic appearance, a larger tumor size, lymph node metastasis and lymph vessel invasion were more predominant in mp than sm colorectal cancer. Multivariate analysis demonstrated that these clinicopathologic factors were not statistically independent prognostic factors for mp colorectal cancer patients. There was no statistical difference in postoperative survival between sm and mp colorectal cancer patients. Mp colorectal cancer should be defined as early colorectal cancer, because the postoperative survival rate does not differ between mp and sm colorectal cancers, and the clinicopathologic differences between these two are negligible.

Background and Objectives: As there is no consensus regarding the prognosis of patients with signet cell carcinoma of the stomach compared with other types of gastric cancer, we retrospectively studied the clinicopathologic features and prognosis of signet cell carcinoma in comparison with other types of gastric cancer., Methods: Gastrectomies were performed because of gastric cancer in 1,498 patients between 1970 and 1994. Of the 154 patients diagnosed with signet ring cell carcinoma, 94 had early and 60 had advanced gastric carcinoma. The percentage of patients with an early carcinoma was significantly higher among those with signet ring cell carcinoma compared with those with other gastric carcinoma histologies., Results: The survival of the total group of patients with signet ring cell carcinoma was significantly better than that of patients with other types of gastric carcinoma (P < 0.05). Survival of the subset of patients with early signet ring cell carcinoma was also improved compared with patients with other types of gastric carcinoma (P < 0.05). However, patients with advanced signet ring cell carcinoma had a poor prognosis similar to that of patients with other types of gastric carcinoma.

Background: Mortality resulting from gastric carcinoma is decreasing. This is mainly due to vigorous endoscopic screening and the consequent higher incidence of early detection of the disease. In this study, to evaluate the effect of surgical treatment on the prognoses of patients with gastric carcinoma, the survival of 1579 patients who underwent gastrectomy between 1970 and 1994 was retrospectively analyzed., Methods: The patients were divided into 5 groups at 5-year intervals. Postoperative survival was compared among the groups., Results: Postoperative survival was significantly improved in the later groups for patients with Stage I, II, III, and IV disease. A multivariate analysis of prognostic factors revealed that the time period during which the gastrectomy was performed was an independent predictor of survival., Conclusions: It was concluded that survival has been improved by recent advances in the surgical approach to gastric carcinoma.

Background/aims: Despite the increased frequency of early gastric cancer, little is known about the clinicopathological features of early gastric cancers complicated by lymph node metastasis. This study was designed to determine whether the number of involved lymph nodes is associated with prognosis in patients with early gastric cancer., Methodology: Fifty one patients with node-positive early gastric cancer were reviewed retrospectively from hospital records. The patients were divided into two groups according to the number of positive nodes: a) 40 patients with 1-4 positive nodes, b) 11 patients with 5 or more positive nodes., Results: The patients with 5 or more positive nodes showed poorer prognosis than patients with less than 5 positive nodes., Conclusions: Early gastric cancer patients with 5 or more positive nodes show a poorer prognosis than early gastric cancer patients with less than 5 positive nodes. Since surgery alone cannot completely cure patients with early gastric cancer complicated by 5 or more positive nodes, intensive postoperative chemo-immunotherapy should be administered to these patients.

Background/aims: Little is known about the most appropriate surgical procedure for gastric cancer in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for gastric cancer in the upper third of the stomach., Methodology: The clinicopathological characteristics of 115 node-positive gastric cancers in the upper third of the stomach were reviewed retrospectively and compared with those of 111 node-negative gastric cancers in the upper third of the stomach., Results: Node-positive gastric cancers showed higher rates of peritoneal metastasis (p < 0.005), larger tumor sizes (p < 0.005), deeper tumor penetration (p < 0.005), higher rates of diffuse type in histology (p < 0.025), and more advanced histological stages (p < 0.005), than node-negative gastric cancers. Patients with node-positive gastric cancer demonstrated a poorer survival rate than those with node-negative gastric cancer (p < 0.005). Lymph node metastasis along the lower stomach was observed in cases of gastric cancer which had invaded beyond the muscularis propria of the stomach but not in those confined within the muscularis propria. No lymph node metastasis in the splenic hilum was found in association with gastric cancer when the depth was limited to the mucosa or the submucosa., Conclusion: The appropriate surgical procedures for the treatment of gastric cancer in the upper third of the stomach are as follows: a) proximal gastrectomy without splenectomy for gastric cancer when the depth is limited to the mucosa or the submucosa, b) proximal gastrectomy with splenectomy for gastric cancer when the depth of invasion extends to the muscularis propria, c) total gastrectomy with splenectomy for gastric cancer when the depth of invasion extends beyond the muscularis propria.

Purpose: To determine the chronologic changes in the clinicopathologic features of gastric cancer patients., Patients and Methods: The clinicopathologic findings of 1,795 patients with gastric cancer were examined retrospectively from hospital records obtained between 1969 and 1995. The patients were divided into three generations on the basis of chronologic order. The first generation included patients treated over the period 1969 to 1977; the second generation, 1978 to 1986; and the third generation, 1987 to 1995., Results: The chronologic changes in the clinicopathologic findings for all gastric cancers included increases in the superficial type based on macroscopic appearance (P < .005), small-sized tumor (P < .025), superficial depth of invasion (P < .005), and earlier histologic stages (P < .005), in addition to a decrease in lymph node metastasis (P < .005). Overall, the postoperative survival rate has improved over time in gastric cancer patients, with 5-year survival rates of 36.0%, 53.3%, and 68.6% in the first, second, and third generations, respectively. In stages 1,2, and 3, the survival rate in the third generation was the highest of the three generations, whereas in stage 4, the survival rate did not differ between the three generations. Patients who underwent a D2 dissection showed a higher survival rate than those with D1 or D3 dissections, but there was no statistical difference in the survival of patients with D1, D2, and D3 dissections when stage 4 patients were excluded., Conclusion: The chronologic changes in gastric cancer patients over the past 27 years have included an increase in the incidence of earlier-staged gastric cancers, which has had a significant impact on the improved postoperative survival rate.

A new dosage formulation consisting of anticancer drugs bound to carbon particles was developed for treating cancers of the upper digestive tract, and is designed to distribute higher levels of anticancer drug to the regional lymph nodes and at the injection site, as compared to a drug in aqueous solution form. Thirteen patients with histologically proven carcinoma (8 with superficial esophageal cancer and 5 with early or proper muscle layer-infiltrating gastric cancer), in whom surgical treatment was contraindicated, received intra- and peritumoral injection of the new dosage formulation (total dose of 35-100 mg of peplomycin or 250-500 mg of methotrexate) guided by esophago- or gastro-fiberscope. Eleven of these 13 patients are currently alive, 12-64 months after therapy, or they died without evidence of recurrence 12-98 months after the treatment. One patient has remained cancer-free for 37 months after a second course of the therapy given to treat a recurrence found 26 months after the first treatment. Another patient has a recurrent tumor 9 months after the therapy and is now going to undergo a second course of treatment. Side effects were not severe and well-tolerable.

Background/aim: The outcome after hepatectomy and non-surgical treatment of liver metastases from gastric and colorectal malignancies are reported., Methodology: Between April 1988 and March 1994, 176 patients with metastatic liver cancer were treated at the First Department of Surgery, Kyoto Prefectural University of Medicine Hospital., Results: All patients received multi-disciplinary treatment, and 51 underwent hepatectomy. The survival after hepatectomy for metastatic liver cancer from a colorectal primary was better than that for gastric cancer. The survival after hepatic arterial infusion (HAI) therapy for metastases from gastric cancer was better than that for colorectal cancer., Conclusion: Surgical resection may be the best treatment for liver metastases from colorectal cancer. HAI may be a better option for liver metastases from gastric cancer.

The clinicopathologic features of patients with 47 synchronous multifocal early gastric cancers were reviewed retrospectively from hospital records between 1969 and 1994. These patients were then compared to 587 patients with solitary early gastric cancers. Accessory lesions were missed preoperatively in 15 of the 47 patients with multifocal early gastric cancers. Multifocal early gastric cancer was significantly more common in slightly older patients (multifocal versus single: 65.19 +/- 10.65 years versus 59.22 +/- 11.7 years (p = 0.004). Elevated lesions and the intestinal type of cancer were found more frequently in multifocal early gastric cancers than in solitary cancers (p < 0.005). The tumor location was higher in multiple early gastric cancers than in solitary cancers (p < 0.05). The postoperative survival did not differ between the two groups. We conclude that when planning the surgical treatment of early gastric cancers in the elderly, the whole stomach should be evaluated before and during the operation, and after the resected stomach examined.

A distal pancreatectomy is often performed simultaneously with splenectomy and total gastrectomy in the treatment of gastric carcinoma to facilitate dissection of the lymph nodes around the splenic artery. However, the morbidity of partial pancreatectomy is high. Patients undergoing pancreaticosplenectomy in conjunction with total gastrectomy are subject to leaks from the pancreatic stump, which may cause further complications. We performed a retrospective analysis to evaluate the end results of simultaneous distal pancreatectomy with total gastrectomy. The effect of distal pancreatectomy on survival was studied by examination of the records of 174 patients who underwent splenectomy and total gastrectomy for gastric carcinoma. Of these, 93 underwent distal pancreatectomy. Prognostic factors were determined and were examined in relation to the post-operative complications. There was no significant difference in the 5-year survival of the patients who did or did not undergo distal pancreatectomy. There was no correlation between any prognostic factor and distal pancreatectomy. In contrast, distal pancreatectomy was independently associated with post-operative complications. In this retrospective study, the addition of distal pancreatectomy to splenectomy at total gastrectomy for patients with gastric cancer did not affect survival but was associated with severe complications.

The clinicopathological features of 37 early gastric cancers mimicking advanced gastric cancer were reviewed retrospectively, and were compared with 596 other early gastric cancers and 126 mp gastric cancers, defined as gastric cancer invading the muscularis propria of the stomach. A greater tumour size (P < 0.005), submucosal invasion (P < 0.005), lymph node and lymph vessel invasion (P < 0.005) and vascular invasion (P < 0.025) were found more frequently in early gastric cancers mimicking advanced gastric cancers than in other early gastric cancers. There were no significant differences in the clinicopathological findings between early gastric cancers mimicking advanced gastric cancers and mp gastric cancers. Patients with early gastric cancers mimicking advanced gastric cancers showed a lower survival rate than patients with other early gastric cancers, but a higher survival than those with mp gastric cancers. The macroscopic appearance of an advanced gastric cancer was an indicator of massive submucosal invasion and lymph node metastasis in early gastric cancer. As early gastric cancers mimicking advanced gastric cancers showed similar clinicopathological findings to mp gastric cancers, these cancers should be treated as mp gastric cancers.

Background: Since the majority of patients with early gastric cancer show long-term survival after surgery, a special attention must be directed to preserving gastric function in these patients. Little is known about the protocol of surgical treatment appropriate for early gastric cancer patients. This study was designed to determine the appropriate surgical procedure for early gastric cancer., Methods: The clinicopathologic features of 52 patients with node-positive early gastric cancer were reviewed retrospectively from hospital records between 1969 and 1994 and were compared with those of 582 patients with node-negative early gastric cancer. Nodal status of positive nodes in the 52 cases was investigated., Results: Depth of invasion, lymph vessel invasion, and tumor size were associated with lymph mode metastasis. Node-positive patients with early gastric cancer had a poorer survival rate than node-negative patients (P < 0.05). Patients with five or more positive nodes and positive nodes distant from the common hepatic artery showed an extremely poor prognosis., Conclusions: The surgical procedures most appropriate for the treatment of early gastric cancer are as follows: (1) local gastric resection without lymphadenectomy for mucosal cancers of < 2 cm in diameter and for elevated submucosal cancers of < 1 cm in diameter, (2) gastrectomy with dissection of the perigastric nodes, the nodes along the left gastric artery and the common hepatic artery, for the treatment of other early gastric cancers.

While proximal gastrectomy is often performed for early gastric cancer in Japan, it remains unclear whether or not proximal gastrectomy should be performed for advanced gastric cancer. This study was designed to determine the operative indications for proximal gastrectomy in patients with gastric cancer in the upper third of the stomach. A total of 1691 patients with gastric cancer were reviewed retrospectively from hospital records during the period from 1969 to 1994, and the clinicopathologic characteristics of 82 patients who underwent proximal gastrectomy were compared with those of 150 patients who underwent total gastrectomy. Lymph node metastasis along the lower part of the stomach was observed in gastric cancers which had invaded beyond the muscularis propria of the stomach, but not in those confined to the muscularis propria. Three patients with gastric cancer that had invaded beyond the muscularis propria and metastasized to nodes along the lower part of the stomach were cured by total gastrectomy. However, there was no difference in the postoperative survival rates of the patients treated with proximal gastrectomy and those treated with total gastrectomy, irrespective of tumor stage and depth of invasion. Thus, proximal gastrectomy should be performed for gastric cancer when the depth of invasion is confined to the muscularis propria of the stomach.

Background/aims: Whether gastric cancer in young patients differs in any way from gastric cancer in older patients has been a controversial issue. This study was designed to determine the clinicopathological features of gastric cancer in young patients., Material and Methods: The clinicopathological features of 86 young patients with gastric cancer, defined as 39 years of age or younger, were reviewed retrospectively from hospital records between 1969 and 1993. They were then compared with 1134 middle-aged patients with gastric cancer between 40 and 69 years old., Results: The incidence of gastric cancer in young patients declined from 6.34% of all gastric cancer patients 20 years ago to 4.49% in the most recent decade. The histopathological findings for gastric cancer in young patients were aggressive features, including an undifferentiated type, a scirrhous type, and an infiltrating type (defined as infiltrating growth and an indistinct border from the surrounding tissues). There were no statistical differences in tumor staging and survival between the 2 groups., Conclusion: Gastric cancer in young patients decreased in overall incidence, but possesses aggressive histopathological features different from older patients. Furthermore, the tumor staging and prognosis for young patients was similar to middle-aged patients.

Background: Splenectomy often is performed simultaneously with total gastrectomy for gastric carcinoma to facilitate dissection of splenic hilar lymph nodes. Splenectomy, however, should be avoided as frequently as possible because of its important role in the reticuloendothelial system and because of its sometimes severe complications. We evaluated the end results of simultaneous splenectomy with total gastrectomy., Methods: The effect of splenectomy on survival was examined by retrospective analysis of 245 patients undergoing total gastrectomy for gastric carcinoma. Of these, 154 underwent splenectomy, and 91 did not. Prognostic factors for patients undergoing total gastrectomy were determined. The relationship to postoperative complications also was analyzed., Results: No significant differences overall were found between the 5-year survival of the patients undergoing total gastrectomy with or without splenectomy. No correlation to any prognostic factor was seen with splenectomy. In contrast, splenectomy was independently associated with postoperative complications., Conclusions: In this retrospective study simultaneous splenectomy at total gastrectomy for gastric cancer did not have an effect on the survival rate of patients undergoing total gastrectomy, and it sometimes caused severe complications.

The clinicopathological features of 380 elderly patients 70 years of age or older with gastric cancer were reviewed retrospectively from hospital records between 1969 and 1993. They were then compared with 1134 middle-aged patients between 40 and 69 years. The elderly constituted 18.4% of all gastric cancer patients 20 years ago but now comprise 24.4% of all patients in the most recent decade, despite the overall decrease in the rate of gastric cancer. The distinguishing histological features of gastric cancer in the elderly were an intestinal type of cancer, expansive tumour growth and synchronous multiplicity of the lesions. Elderly patients had a similar rate of tumour extension but had poorer survival as compared with the middle-aged patients. Post-operative death within 30 days after surgery was also higher in the elderly than in the middle-aged patients.

A total gastrectomy was performed in 49 patients with early gastric cancer, and the effectiveness of this procedure was evaluated by reviewing the hospital files of the patients. The reasons for this total gastrectomy were as follows: (1) lymph node dissection for 22 patients, (2) surgeon's choice in reconstruction for 10 patients, (3) modification of the surgery from subtotal to total gastrectomy for seven patients, (4) synchronous multiple cancers for seven patients, and (5) cancer in a stomach remnant for three patients. Of 49 patients, 42 had the cancerous lesions in the upper portion of their stomachs. Lymph node involvement occurred in 5 patients, but not in the supra- or infrapyloric lymph nodes. Postoperative complications such as anastomotic leakage, reflux esophagitis and pancreatic fistula occurred in five, four, and two patients, respectively. Postoperative death, including two patients who died within 30 days after the surgery, occurred in 5 patients. Our study showed that total gastrectomy resulted in excessive unnecessary surgery in 39 out of 49 patients (79.6%). We conclude that a total gastrectomy should not be performed on patients with early gastric cancer except for synchronous multiple cancers and for cancers in a stomach remnant.

A new dosage formulation (MTX-CH), composed of fine activated carbon particles absorbing methotrexate (MTX), distributes concentrated MTX for long periods of time to the regional lymph nodes as well as to the injection site, in animal experiments. MTX-CH would enhance the therapeutic effects not only on the primary lesion but also on the lymphatic metastasis. As clinical trials, (A) in five patients with early gastric cancer, MTX-CH at 50 to 200 mg/person of MTX was injected endoscopically in and around the primary lesion before operation. Surgically removed specimens showed that three out of the 5 primary lesions had disappeared or were necrotic, and the remaining two lesions had shrunk. (B) Three patients with contraindication to surgery received the endoscopic injection of MTX-CH. The MTX-CH injected at 250 to 1,500 mg/person into and around the primary lesion of relatively early gastric cancer resulted in the complete disappearance of the primary lesions for 14 to 24 months up to the present time without enlargement of the lymph nodes. It was thought that local injection of MTX-CH will be effective therapy, especially for gastric cancer with potential lymphatic metastasis in patients with contraindications to surgery.

A novel method of prophylaxis and treatment for peritoneal carcinomatosis--mitomycin C bound to activated carbon particles (MMC-CH)--was tested in patients with advanced gastric cancer in a prospective randomized study. Activated carbon particles are taken up selectively by lymphatic tissues, which seem to be a primary site of peritoneal carcinomatosis in the peritoneal cavity, and adsorb a large amount of anticancer agent mitomycin C, which is subsequently released slowly and for a protracted period. A group of 113 patients who underwent radical resection for gastric cancer with definite serosal involvement were entered in this trial. Those in the control group received no intraperitoneal anticancer drugs. Patients in the MMC-CH group were given 50 mg mitomycin C as MMC-CH, which was dispersed throughout the peritoneal cavity just before surgical closure. No other anticancer drugs were given to these patients after surgery. The 2- and 3-year survival rates for the MMC-CH group were 42% and 38%, respectively; and the rates for the control group were 28% and 20%, respectively. The difference in survival between the two groups was significant at 2 and 3 years (p < 0.05). For the survival of patients with macroscopic peritoneal carcinomatosis, there was no difference between these two groups. For the survival of patients who underwent histologically curative resection, 2- and 3-year survivals for the MMC-CH group were 66% and 66%, respectively and for the control group 35% and 20%, respectively. The difference between the two groups was statistically significant (p < 0.01) at both 2 and 3 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-two patients with early gastric cancer received injections of activated carbon particles (CH-40) to identify during surgery the location of non-palpable tumours present in the upper portion of the stomach. A few days before surgery, 0.2 ml of CH-40 was injected endoscopically into the gastric muscle adjacent to the cancer. In 20 of the 22 patients, the CH-40-stained area was recognized as a blackened patch on the serosal surface of the stomach which indicated the location of the non-palpable cancer tissue. The surgical margin for gastrectomy was defined as the proximal margin of the carbon-stained area and gastrectomies were performed on the 22 patients. CH-40 injection made it possible to choose the extent of lymph node dissection.

We studied the efficacy of the intra-lymph nodal injection of the activated carbon particle absorbed mitomycin C (MMC-CH40) for gastric cancer. Ninety-five patients with gastric cancer underwent gastrectomy with D1 or D2 lymph node dissection. Of these, 38 patients were treated with intra-lymph nodal injection of MMC-CH 40 (MMC-CH 40 group). The other 57 patients were classified into the control group. The survival of MMC-CH group was significantly higher than that of the control group using generalized Wilcoxon method. However, since the percentage of stage IV was higher in the control group than in MMC-CH 40 group, the survivals of subgroups of stage I-III were compared. Although the percentage of the early gastric cancer was higher in the control group of stage I-III (n = 35) than in the MMC-CH group of stage I-III (n = 38), the survival curves of MMC-CH group were higher than in the control group. The difference in survival between the two groups was significant at 8 months after surgery. These results indicate that this new therapy improves survival in patients with stage I-III gastric cancer.

Although standard radical gastrectomy for gastric cancer, including lymph node dissection of compartments I and II, has been commonly utilized in Japan, new trends in gastric cancer surgery recently have been developed. In the treatment of early gastric cancer, endoscopic and limited surgeries have become more prevalent, whereas for advanced gastric cancer, super extended radical gastrectomy (SERG) and aggressive adjuvant therapy have been applied. Limited surgery includes wedge resection of the stomach, pylorus-preserving gastrectomy, vagus-preserving gastrectomy, and proximal gastrectomy. The purpose of these more limited techniques is usually to improve quality of life after surgery. Since Takahashi's lymph node staining method using fine activated carbon particles (CH40) made possible systematic para-aortic lymph node dissection, SERG has increased in popularity. The survival rate of patients with para-aortic lymph node metastases who underwent SERG was higher than that of patients who underwent extended radical gastrectomy.

In our department, curative operations were performed for 32 patients with advanced gastric cancer from April 1989 to August 1990. Preoperative intra-arterial injection therapy with etoposide (100 mg), pirarubicin (20 mg) and cisplatin (20 mg) was given 18 patients. Recurrence and survival rate were investigated. The survival rate of patients with preoperative intra-arterial injection therapy 45 months after operation was 59.2%, while that of patients without preoperative intra-arterial injection therapy was 75.8%. There were no significant differences between these two groups. Three lymph node recurrences were seen in patients with preoperative intra-arterial injection therapy (recurrence rate, 16.7%). Four recurrences were observed in patients without preoperative injection therapy (peritoneal dissemination 2, liver 1, local 1; recurrence rate, 28.6%). We earlier reported that preoperative intra-arterial cisplatin (40 or 60 mg) injection therapy may reduce the incidence of lymph node recurrence and liver metastasis but may not be effective to prevent postoperative peritoneal recurrence, while no peritoneal dissemination was observed in patients with preoperative intra-arterial EAP I injection therapy. Thus, it was concluded that further study of combination and dose of anti-cancer drug may improve effectiveness of preoperative intra-arterial injection therapy for gastric cancer.

We investigated the correlations between resection margin involvement by carcinoma and a number of clinicopathological features in patients with gastric cancer and esophageal invasion. From January 1968 to December 1988, 1,040 patients with carcinoma of the stomach underwent gastric resection. Thirty-nine patients had tumor infiltration of the esophagus on histological examination of the resected specimens. The patients were divided into two groups on microscopic examination: those in whom the resection margin was less than 5 mm wide, and those in whom it exceeded 5 mm microscopically. There were 6 and 33 patients in the narrow and wide margin groups, respectively. There were statistically significant differences in tumor size, depth of cancer invasion, and macroscopic appearance between the two groups. The risk of resection margin involvement was high in tumors with the following features: large Borrmann type 4 tumor (macroscopic appearance and size) and infiltrative carcinoma (depth of invasion).

An aberrant left hepatic artery, arising from the left gastric artery (LHLG), either as an accessory or replacing the left hepatic artery, is occasionally seen in patients with gastric cancer. Resection of LHLG, as part of the gastrectomy procedure, may cause liver dysfunction. The surgical records of a group of 141 patients who had undergone gastrectomy for gastric cancer following preoperative angiography were reviewed. Twenty-eight of the patients had an LHLG preoperatively; in 15 the artery was severed during surgery and in the remainder it was preserved. Postoperative liver function was assessed by measuring changes in lactate dehydrogenase, glutamic oxaloacetic transaminase, and glutamic pyruvic transaminase activities. The greatest changes in liver function were observed in patients in whom the LHLG has been severed; the changes in liver function among patients whose LHLGs were preserved were similar to those in patients who had no LHLG. Notably, the wider the area fed by the LHLG, the greater was the change in liver function. The observed liver dysfunctions were transient, however, and normal function resumed within 7 days after operation.

In our department, curative operations were performed for 49 patients with resectable advanced gastric cancer from Jan. 1988 to Feb. 1990. Among these patients, preoperative intra-arterial therapy using cisplatin (40 or 60 mg) was done for 17 patients. In this report, recurrence and survival rate of these patients were investigated. Survival rate of patients with preoperative intra-arterial injection therapy 42 months after operation was 56.15%, while that of patients without preoperative intra-arterial injection therapy was 56.62%. There were no significant differences between these two groups. And two peritoneal disseminations and one brain metastasis were seen in patients with preoperative intra-arterial injection therapy (recurrence rate, 17.6%), but no liver metastasis and local recurrence were noted. Seven recurrences were observed in patients without pre-operative intra-arterial CDDP injection therapy (local 3, liver 3, peritoneal dissemination 1, recurrence rate, 21.2%). We have already reported that much platinum accumulated in gastric cancer tissue and regional lymph nodes. This high accumulation of cisplatin can be the reason why no local recurrence was seen in patients with preoperative intra-arterial injection therapy. In conclusion, preoperative intra-arterial injection therapy using cisplatin may be an effective method to prevent postoperative local recurrence of resectable advanced gastric cancer.

The principles of lymphadenectomy for gastric cancer are discussed based on the 1010 gastric cancer patients who underwent gastrectomy with curative intent between 1970 and 1990. In 147 of these patients, regional lymphatic flow was examined by injecting activated carbon particles CH40. 1) One hundred and ninety patients (19.8%) with cancer invasion confined to the mucosa had lymph node metastases limited to the perigastric nodes (n1). 2) Two hundred and five patients (20.3%) had cancer invasion to the submucosa. For 99.0% of them the lymph node metastases were limited to compartment II (n2). 3) Three hundred and twenty-two patients (31.9%), with cancer invasion to the muscle layer or serosa and limited to the upper or middle third of the stomach, had lymph node metastases in compartment II and No. 12 (n 2 + No. 12). 4) Two hundred and ninety-three patients (29.0%) with cancer invasion to the muscle layer or serosa and limited to lower third of the stomach or to its extension, had lymph nodes metastases in compartment III (n3). 5) Consequent to observations on the regional lymph flow of the stomach by CH40, we now perform paraaortic lymph node dissection, when gastric cancer patients with serosal invasion have metastases lymph nodes No. 2, 7, 8a, 9, 11, 12 or No. 14V.

We report our study on the correlation between the types of anastomosis and the incidence of anastomotic stricture formation in the upper gastro-intestinal tract. Our experience with balloon dilatation is also reported. We examined the incidence of stricture formation among patients who had an anastomosis between the esophagus and stomach following subtotal esophagectomy for esophageal cancer, and esophagojejunostomy following proximal or total gastrectomy for gastric cancer in the past 17 years. Among 283 patients undergoing esophagojejunostomy, 7 cases of stricture (excluding 3 cases of cancer recurrence) were observed (conventional anastomosis 1.8%; stapling anastomosis 4.6%). There were 17 cases of stricture among 56 patients who had anastomosis between the esophagus and stomach following subtotal esophagectomy (conventional anastomosis 28.6%; stapling anastomosis 50.0%). One month or more after the operation, the diameter of the esophagojejunostomy was estimated using a barium study. The mean diameter of the anastomosis using the stapling method was 11.9 +/- 2.9 mm, whereas the mean diameter of serosubmucosal single layer hand-sewn anastomosis (Jourdan's) was 19.8 +/- 2.2 mm, and that of vertical mattress hand-sewn anastomosis was 19.0 +/- 2.0 mm. Balloon dilatation was used in 29 patients with anastomotic stricture of the upper gastro-intestinal tract (esophageal cancer, 19 patients, gastric cancer, 10 patients). With repeated dilatation, we were able to obtain satisfactory efficacy for benign strictures and there were no severe complications. We believe that balloon dilatation is an easy, safe and effective therapy for anastomotic stricture of the upper gastro-intestinal tract.

Attempts to prevent peritoneal carcinomatosis after surgery for gastric cancer by intraperitoneal administration of anticancer drugs have not been successful, largely because the drugs are not retained in the peritoneal cavity. We have assessed the prophylactic efficacy of a delayed-release preparation--mitomycin adsorbed onto activated charcoal (M-CH). 50 patients with gastric cancer and serosal infiltration were randomly assigned intraperitoneal treatment with M-CH (50 mg mitomycin intraoperatively) or no anticancer prophylaxis (control). Survival rates for the 3 years of follow-up were significantly higher among the 24 M-CH recipients (1 was lost to follow-up) than among the 25 controls (p less than 0.01). There were significant differences in survival between the groups at 1.5 years after randomisation (difference 34.6% [95% confidence interval 8.5-60.8%]; p less than 0.01) and at 2.0, 2.5, and 3.0 years (41.7% [14.2-69.1%]; p less than 0.005). The concentration of mitomycin was significantly higher in peritoneal exudate than in plasma for 24 h after drug administration. Side-effects were slight and well tolerated. Thus, peroperative intraperitoneal treatment with M-CH seems to improve survival after gastrectomy for gastric cancer, presumably by a prophylactic effect on peritoneal recurrence.

Activated carbon particles are taken selectively up by lymphatics when injected into the tissues and visualize regional lymph nodes colored black. Furthermore, carbon particles adsorb a large amount of the anticancer agent mitomycin C (MMC) on their surface and release the drug reversibly. Using these properties of activated carbon particles, we have applied it for lymph node dissection and chemotherapy of lymph node metastasis. After injection of carbon particles, regional lymph nodes of the stomach were found to be black; blackened lymph nodes extending widely from perigastric to para-aortic nodes were identified from other structures. Four hundred and twenty-four patients with gastric cancer were treated with this method for lymph node metastasis during 1984-1988. Involved nodes were generally colored in high incidence, about 70% of involved ones except for highly positive nodes, which was the same as noninvolved nodes. In highly positive nodes, the colored incidence was decreased to about 48%. The cumulative 5-year survival rate of the patients treated with this series was 74.6%, which was significantly higher than the figures without this method.

The possibility that urinary pepsinogen I is a tumor marker of stomach cancer after total gastrectomy was examined. To decide the cutoff level of urinary pepsinogen I after total gastrectomy, urine samples from 15 patients who had undergone total gastrectomy for stomach cancer in the early or advanced stages and had been free from recurrence for more than 5 years were examined by pepsinogen I-specific radioimmunoassay. The mean concentration of urinary pepsinogen I was 17.5 +/- 7.4 ng/ml and the cutoff level of urinary pepsinogen after total gastrectomy was set at 32 ng/ml (mean + 2 SD). Twenty-two of 74 cases who had undergone total gastrectomy for stomach cancer were regarded as positive. And 20 of these 22 positive cases had definite clinical signs of recurrence of stomach cancer. There were only two false-positive cases. These results suggest that urinary pepsinogen I will be an useful tumor marker in detecting the recurrence of stomach cancer after total gastrectomy.

Preoperative intra-arterial injection therapy using etoposide, epirubicin and carboplatin (EAP II) was done for patients with resectable advanced gastric cancer. Twenty-six patients (14 males and 12 females) were treated. The concentrations of adriamycin (ADM) and platinum (Pt) were measured in cancer tissue, normal mucosa and regional lymph-nodes which were obtained operatively and in sera just before operation. But the concentration of etoposide was not measured, because when we used preoperative intra-arterial injection therapy using etoposide, epirubicin and cisplatin (EAP I), the mean concentration of etoposide was less than the detectable limit in all tissues and in sera. There were no significant differences among the mean concentrations of ADM in all tissues and in sera. And the mean concentration of ADM in cancer tissue was not higher than that of intra-arterial EAP I injection therapy. The mean concentration of platinum in sera was significantly lower than in cancer tissues, normal mucosa and lymph-nodes. And the mean concentrations of platinum in cancer tissues and lymph-nodes were higher than those of intra-arterial CDDP or EAP I injection therapy. It was concluded that preoperative intra-arterial EAP II injection therapy may be an effective method to improve the usefulness of preoperative intra-arterial injection therapy for gastric cancer.

In order to deliver a high concentration of anti-cancer drugs in tumor tissue, preoperative intra-arterial injection therapy using Etoposide (VP-16), Pirarubicin (THP-ADM) and Cisplatin (CDDP), was used for 22 patients with resectable advanced gastric cancer. The concentration of VP-16, Adriamycin (ADM) and platinum (Pt) were measured in cancer tissue, normal mucosa and lymphnodes without metastasis at the greater curvature, which were gathered operatively and in serum just before operation. Student's t test was performed with their data. The mean concentration of VP-16 was less than the detectable limit in all tissues and in serum. The mean concentration of ADM in cancer tissue was significantly higher than in normal gastric mucosa, in lymphnodes without metastasis, and in serum. The mean concentration of platinum in cancer tissue was higher than those in lymphnodes, normal mucosa, and serum, but no significant differences were noted among them. It was concluded that the intra-arterial injection of THP-ADM and CDDP was an effective method to maintain a high concentration of ADM and Pt in gastric cancer tissue. However, intra-arterial injection of VP-16 was not useful.

We examined the tissue localization of biotin-labeled murine monoclonal antibody (MAb) S202 directed against the human scirrhous gastric carcinoma cell line MK-01 in normal and tumor-bearing mice after intravenous (IV) administration. The biotin-labeled MAb proved to be stable in vivo under normal conditions, antibody titer being 1:256 at 4 hr after IV injection. At 24 hr after injection, the tumor was stained by the avidin-biotin-peroxidase complex (ABC) method. Biotin-labeled MAb was found to be suitable for detection of the xenografted tumor of nude mice. This study provides new information concerning the dynamics of the distribution of biotin-labeled MAb in vivo.

Surgical specimens from 2 patients with chronic ulcerative colitis accompanied with colon cancer were evaluated by immunoperoxidative staining using monoclonal antibodies A7 (against human colon cancer), S202 (against human gastric cancer), and anti-carcinoembryonic antigen (CEA). The three monoclonal antibodies were reactive with cancerous tissue, anti-CEA antibody and monoclonal antibody S202 reacted with dysplasia tissues, whereas monoclonal antibody A7 did not. Using high-iron diamine technique for mucosubstances (sialomucin and sulfomucin), cancer and dysplasia showed no secretory elements. Surrounding mucosa showed both sialomucin and sulfomucin secretion.

It is sometimes difficult to identify scirrhous carcinoma cells microscopically, since individually separated malignant cells grow into the fibrous tissue without glandular formation. In this study, we used anti-scirrhous carcinoma monoclonal antibody S202, which reacted strongly with 100% of scirrhous gastric cancer samples, in order to evaluate the precise depth to which cancer cells invaded in the stomach wall. The invasive carcinoma cells could be detected more clearly by immunohistochemical staining with S202 than by histological staining with hematoxylin-eosin. Furthermore, S202 was more useful than anti-CEA (carcinoembryonic antigen) antibody.

We used anti-scirrhous carcinoma monoclonal antibody (MAb) S202, which reacted strongly with scirrhous gastric cancer, to evaluate the depth of cancer cell invasion into the stomach wall. Sixty-eight scirrhous gastric cancer specimens were stained with the avidin-biotin peroxidase complex method using MAb S202. There were some discrepancies between the histological evaluation of the immunoperoxidase (IP) and hematoxylin-eosin (HE) staining regarding the depth of tumor invasion. In two of the 14 HE staining cases in which carcinoma had extended as far as the proper muscular layer, IP staining revealed that the lesions had actually penetrated this layer. As well, in two of the 18 HE staining cases in which carcinoma cells had not penetrated as far as the serosa, IP staining revealed that they had, in fact, reached the serosal surface. The invasive carcinoma cells were more easily discerned using IP staining with MAb S202 rather than using histological staining with HE. Thus, MAb S202 may be useful for precise identification of carcinoma cells.