A prospective pancreatographic study of the prevalence of pancreatic carcinoma in patients with diabetes mellitus

BACKGROUND: The correlation between diabetes mellitus and pancreatic carcinoma is well documented, but no criteria have been established for the efficient selection of a high-risk group among patients with diabetes mellitus. METHODS: Eighty-seven patients were selected prospectively from outpatients with diabetes and underwent endoscopic retrograde pancreatography (ERP) according to the authors' original criteria, including the onset of diabetes after age 55 years, deterioration of diabetes or loss of body weight despite strict medical control, elevation of serum amylase and/or CA19-9 levels, and pancreatobiliary abnormalities on routine ultrasonography. The patients were divided into two groups according to the time from the onset of diabetes to ERP: Patients in Group A had recent-onset diabetes (within 3 years), and Group B patients had diabetes for > 3 years. RESULTS: A total of 86 patients (excluding 1 patient with unsuccessful ERP who had undergone previous Billroth-2 gastrectomy) were enrolled. There were 33 males and 53 females, age 40-90 years, with a mean age of 65.1 years. ERP demonstrated pancreatic carcinoma, although it was advanced disease in all patients, at an extremely high rate of 7.0% (6 of 86 patients) with no serious complications. The prevalence of pancreatic carcinoma in Group A (13.9%; 5 of 36 patients) was significantly greater compared with Group B (2.0%; 1 of 50 patients; P = 0.0442). ERP with an indwelling balloon catheter and subsequent pancreatic juice sampling was performed in 49 patients, yielding positive cytology in 1 patient with pancreatic tail carcinoma, whereas measurements of carcinoembryonic antigen and CA19-9 levels in pancreatic juice were of no use in the diagnosis of pancreatic carcinoma. CONCLUSIONS: Selective ERP in patients with diabetes who were at high risk did not lead to the early diagnosis of pancreatic carcinoma, although this study showed that the 3-year period after the onset of diabetes was critical. A more aggressive diagnostic approach within this period in diabetic patients with the authors' criteria may contribute to the earlier diagnosis of pancreatic carcinoma.     

Radiation therapy for small-cell lung cancer: results of the 1995-1997 patterns of care process survey in Japan

The Patterns of Care Study (PCS) conducted a nationwide audit survey in order to establish the national practice process of radiation therapy for small-cell lung cancer (SCLC) and examined the influence of institutional stratification on the process of care in Japan. The PCS randomly sampled institutions and patients using a two-stage cluster method and surveyed the process of radiation therapy for 174 stage I-III SCLC patients according to the category of institution, stratified as follows: A1, academic institutions treating > or = 300 patients a year; A2, <300 patients; B1, non-academic institutions treating > or = 120 patients a year; and B2, <120 patients. Karnofsky performance status distributions showed significant variance by stratification of institutions (P=0.013). Patients treated on an outpatient basis accounted for 32% in A1, 23% in A2, 8% in B1, but only 5% in B2 (P=0.007). A photon energy > or = 10 MV was used for 87% of patients in A1, 69% in A2, 54% in B1 and 23% in B2 (P=0.001). Contralateral hilus was irradiated for 11% of patients in A1, 17% in A2, 29% in B1 and 3% in B2 (P=0.001). Field size reduction during the treatment course was done for 77% of patients in A1, 54% in A2, 60% in B1 and 42% in B2 (P=0.007). Ninety-two percent of patients received combined chemotherapy and radiation therapy, and the most frequently used drugs were etoposide (91%) and cisplatin (69%). The results of clinical studies on SCLC had favorably penetrated into the clinical practice. However, the stratification of institutions significantly affected the process of radiation therapy in Japan.     

Clinical characteristics of hepatocellular carcinoma with an extensive lymph node metastasis at diagnosis

Lymph node metastasis is reported to occur only rarely in patients with hepatocellular carcinoma (HCC). However, we have encountered patients with HCC with extensive lymph node metastases. Here we report the clinical characteristics of HCC associated with extensive lymph node metastasis at diagnosis. Ten patients with HCC in whom extensive lymph node metastases were observed at the initial medical examination were studied. The degree of disease progression was documented with ultrasonography and dynamic computed tomography. Primary liver lesions were classified in the following three types according to imaging characteristics: type A, massive type with portal vein tumor thrombus; type B, multinodular, nonencapsulated type; and type C: multinodular, encapsulated type. In patients with types A and B HCC, a large number of lymph node metastases was observed, whereas a small number of isolated metastases was observed in patients with type C. All patients with types A and B HCC died within 7 months (median survival, 4 months), whereas those with type C survived for 4 years or more after treatment with transcatheter arterial chemoembolization and surgery. A relationship exists between the type of primary HCC lesions and the pattern of lymph node metastasis. Long-term survival may be expected for patients with isolated lymph node metastases.     

Variation in MT expression in early-stage depressed-type and polypoid-type colorectal tumours

Metallothionein (MT) expression is observed in various carcinomas, but its role is not fully understood. To clarify the clinicopathological significance of MT, 87 colorectal adenomas and 128 early-stage carcinomas were immunohistochemically analysed for MT expression. The degree of MT immunostaining of a specimen was graded according to the proportion of MT-positive cells; negative (<5%) and positive (focally 5-50%, diffusely >50%). MT expression significantly decreased with tumour development. For carcinomas, MT-positivity was significantly associated with depth of invasion (T1 60% versus T2 33%; P<0.01), vascular involvement (positive 35% versus negative 61%; P<0.01) and morphology (polypoid 62% versus depressed 26%; P<0.01). Regarding MT-positive distribution, the diffuse-positive rate in MT-positive polypoid lesions was 28%, while MT-positive depressed lesions were all diffusely stained (P<0.01). In conclusion, our results suggested that decreasing MT expression is an early event in colorectal carcinogenesis and may reflect local invasion. Furthermore, MT-positive distribution may reflect genetic differences between the polypoid and depressed-type.     

A case of postoperative liver metastasis from gastric cancer which responded well to weekly chemotherapy with paclitaxel

We report a case of postoperative liver metastasis from gastric cancer showing a remarkable response to weekly administration of paclitaxel (TXL). The patient was a 50-year-old woman who underwent total gastrectomy. One month later, liver metastasis and a small amount of ascites were detected by CT scan. Therefore, the patient was administered weekly TXL. TXL (80 mg/m2) was infused over 1 hour after short premedication on an outpatient basis. Administration was continued for 3 weeks followed by 1 week rest. Liver metastasis and ascites disappeared 3 months after administration. The toxic events were leukopenia (grade 1) and alopecia (grade 1). No major adverse effects were observed.     

A case of colon metastasis to the lung treated successfully with combined chemotherapy of CPT-11 and 5'-DFUR

We administered pharmacokinetic modulating chemotherapy (PMC, oral tegafur/uracil [UFT] plus fluorouracil infusion) together with irinotecan hydrochloride (CPT-11) in a patient with rectal cancer, who had multiple lung metastases at 2 years and 7 months after surgery. However, because the patient showed resistance, we attempted combination therapy with CPT-11 and doxifluridine (5'-DFUR) on an outpatient basis, which resulted in NC after 9 months. During this period, the therapy was performed safely without any observable adverse reactions such as diarrhea or myelosuppression. This case suggests the efficacy of combination therapy with CPT-11 and 5'-DFUR, which was expected since this is an established treatment for progressive recurrent colon cancer.     

Hepatic arterial infusion of high-dose 5-FU to liver metastases--case reports of 6 patients with abnormal laboratory data on liver function

Six patients with metastatic liver cancer (H3) and abnormal laboratory data for liver function underwent intra-hepatic arterial infusion (H.A.I.) therapy of high dose 5-FU (1 g/body/day, 6 days/week, 1q for 2 patients, 2q for 4 patients, with at least a one week interval). No serious side effects were observed in any case. Even in 2 cases with suspicious partial obstruction of the portal vein, no remarkable change in liver function was observed after high dose 5-FU H.A.I. therapy. Four patients who received 12 g of 5-FU showed a reduction in the abnormal data after a short transient rise in some cases. In 2 cases the reduction rate was high and the laboratory data were normalized in 3 months. A long PR was obtained in these cases. The other 2 cases, on the other hand, showed a low reduction rate and the liver function relapsed in a week. Tumor markers also returned to previous levels in a short period. These findings together imply that the reduction rate of abnormal liver function data might predict the efficacy of high dose 5-FU H.A.I. therapy.