A case of malignant peritoneal mesothelioma successfully treated with systemic chemothrapy

A 64-year-old man with a 2-month history of abdominal distension was admitted for transient cerebral ischemic attack. A CT scan revealed massive ascites. Laparoscopy showed multiple whitish nodules on the visceral peritoneum and the omentum. Peritoneal biopsy revealed tumor cells consistent with malignant peritoneal mesothelioma (MPeM). Pemetrexed in combination with cisplatin was administered because it has been reported to be active in patients with MPeM. However his disease progressed. As second-line therapy paclitaxel was tried which yielded a complete response (CR). Eighteen months later he developed abdominal pain of the right upper region where a CT scan showed a mass with surrounding inflammation. As third-line therapy, gemcitabine was administered and again resulted in a CR. He is alive at 3 years from first presenting. Searches for case studies published in medical journals on MPeM were carried out, and 59 cases were analyzed in comparison with this case.     

Effects of physical exercise prescribed by a medical support team on elderly lower extremity osteoarthritis combined with metabolic syndrome and/or type 2 diabetes

Aim: The aims of the present study were to investigate the effectiveness of exercise intervention provided by a medical support team specializing in lifestyle‐related diseases in the treatment of elderly lower extremity osteoarthritis and to examine the influence of bodyweight decrease on changes in the evaluation indexes. Methods: Participants were 61 patients (57 women and 4 men, aged 68.3 ± 9.6 years) with lower extremity osteoarthritis (109 total diseased joints) and either one or more of the following diseases: obesity, metabolic syndrome and type 2 diabetes. Indexes relating to metabolic diseases, orthopedic disorders, lifestyle activity level and health‐related quality of life (HRQOL) were obtained before and after exercise intervention. Results: The numbers of patients with obesity, metabolic syndrome, type 2 diabetes, gonarthrosis and coxarthrosis were 56, 49, 32, 56 and 9, respectively. The mean intervention period was 4.7 ± 1.6 months (2–10.8 months). Indexes relating to metabolic diseases and orthopedic disorders, activity level and HRQOL were all significantly improved after intervention (P < 0.05). Bodyweight decreased by 10.3% and showed a correlation with other evaluated items. Five explanatory variables were extracted through multiple regression analysis that bodyweight reduction rate was set as the criterion variable: changes of bodyweight, body mass index, percent body fat, glycated hemoglobin and total energy expenditure per bodyweight. Conclusion: The exercise intervention provided by our medical support team clearly improved indexes relating to metabolic diseases and orthopedic disorders. In addition, decreased bodyweight was related to improvements in metabolic factors, motor function and HRQOL. Geriatr Gerontol Int 2012; 12: 446–453.     

Reproducibility of three-dimensional coordinate systems based on craniofacial landmarks

Abstract Objectives: To propose a method for evaluating the reproducibility of anatomical coordinate systems based on craniofacial skeletal landmarks and to tentatively evaluate four systems created on preoperative cone-beam computed tomography (CBCT) data obtained from mandibular prognathism patients in order to confirm the utility for actual patients' data. Materials and Methods: In three-dimensional images of 10 patients obtained by a CBCT with a large field of view, six dentists set four coordinate systems that were created in different ways, twice by plotting some landmarks situated in the superior portion of the maxillofacial skeletons. The 95% confidence ellipse of six objective landmarks related to the jaw and teeth (upper incisor, left upper first molar, lower incisor, left lower first molar, menton, and left gonion) were three-dimensionally drawn for each coordinate system. The ellipsoid volume was calculated to evaluate the reproducibility of the coordinate systems. Results: The reproducibility could be evaluated for each coordinate system using the method proposed. The coordinate systems that were created by landmarks situated at greater distances from each other showed relatively small ellipsoid volume in comparison to those with shorter distances between landmarks. Conclusion: Anatomical coordinate systems with larger distances between the landmarks used were stable when landmarks related to the jaw and teeth were assigned as objective landmarks. The method proposed here was effective in terms of the reproducibility evaluation of a coordinate system.     

Exploratory Analysis to Find Unfavorable Subset of Stage II Gastric Cancer for Which Surgery Alone Is the Standard Treatment; Another Target for Adjuvant Chemotherapy

The aim of the present study was to explore the unfavorable subset of patients with Stage II gastric cancer for whom surgery alone is the standard treatment (T1N2M0, T1N3M0, and T3N0M0). Recurrence-free survival rates were examined in 52 patients with stage T1N2-3M0 and stage T3N0M0 gastric cancer between January 2000 and March 2010. Univariate and multivariate analyses were performed to identify risk factors using a Cox proportional hazards model. The recurrence-free survival (RFS) rates of the patients with stages T1N2, T1N3, and T3N0 cancer were 80.0, 76.4, and 100% at 5 years, respectively. The only significant prognostic factor for the survival rates of the patients with stage pT1N2-3 cancer measured by univariate and multivariate analyses was pathological tumor diameter. The 5-year RFS rates of the patients with stage pT1N2-3 cancer were 60.0%, when the tumor diameters measured <30 mm, and 88.9% when the tumor diameters measured >30 mm (P = 0.0248). These data may suggest that pathological tumor diameter is associated with poor survival in patients with small T1N2-3 tumors. Because our study was a retrospective single-center study with a small sample size, a prospective multicenter study is necessary to confirm whether small tumors are risk factor for the RFS in T1N2-3 disease.Key words: Gastric cancer, Stage II, Adjuvant chemotherapyEvery year, more than 934,000 people develop gastric cancer worldwide. After lung cancer, gastric cancer is the second most frequent cancer-related cause of death.¹ Complete resection is essential to cure gastric cancer. Patients with stage II or stage III gastric cancer often develop tumor recurrence, even after complete curative resections.In 2007, the Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer (ACTS-GC) phase III trial demonstrated that S-1 is effective as adjuvant chemotherapy in Japanese patients who have undergone curative D2 gastrectomy for advanced gastric cancer.² In general, patients eligible for ACTS-GC were those diagnosed with pathological stages II and III. However, patients classified with pathological (p) stages T1N2M0, T1N3M0, and T3N0M0—which are classified as part of stage II—were excluded from the ACTS-GC trial. Because in the prior phase III studies comparing surgery alone and adjuvant chemotherapy, patients with stages T1N+ and T2-3/N0 cancer had excellent prognoses with 5-year overall survival (OS) rates of more than 80% from surgery alone,^3,4 these patients were excluded from receiving adjuvant chemotherapy. Japanese Gastric Cancer Association (JGCA) guidelines clearly state that the standard treatment for these patients is surgery alone.⁵Therefore, patients with stage II gastric cancer have been divided into two groups: one for whom the standard treatment is surgery alone, and the other for whom the standard treatment is surgery and adjuvant chemotherapy with S-1. Before the advent of ACTS-GC, survival rates were poorer in the latter group than in the former. However, treatment with adjuvant chemotherapy with S-1 has reversed this trend. Now, patients in the latter group receiving S-1 adjuvant chemotherapy have 5-year OS rates of 84.2%.⁶ Therefore, it may be old rationale that dictates that patients in the former group should be excluded from receiving adjuvant chemotherapy, because the 5-year OS rates are now more than 80% by S-1 adjuvant chemotherapy in the latter group. Five-year OS rates of 80% would not be obtained by surgery alone. Among those patients with stage II gastric cancer assigned to the surgery alone group, some may have a poor prognosis and be good candidates for adjuvant chemotherapy. The aim of the present study was to explore the unfavorable subset of patients among those with stage II gastric cancer for whom surgery alone is the standard treatment (T1N2M0, T1N3M0, and T3N0M0).     

Priority of Lymph Node Dissection for Siewert Type II/III Adenocarcinoma of the Esophagogastric Junction

Objective

The purpose of this study was to clarify the priority of nodal dissection in Siewert types II and III adenocarcinoma of the esophagogastric junction (AEG).

Methods

The priority of nodal dissection was evaluated based on the therapeutic value index calculated by multiplying of the frequency of metastasis to each station and the 5-year survival rate of patients with metastasis to that station.

Results

A total of 176 patients (95 type II and 81 type III) were examined. Among the lymph nodes that had a metastatic incidence exceeding 10 %, the stations showing the first to fourth highest index were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the node at the root of the left gastric artery (No. 7) in the total cohort, as well as in each type. The next station was the lower thoracic paraesophageal lymph node (No. 110), followed by the nodes along the proximal splenic artery (No. 11p) in type II, whereas it was the nodes along the proximal splenic artery (No. 11p) followed by the para-aortic nodes (No. 16a2), the nodes at the celiac artery (No. 9), and the nodes around the splenic hilum (No. 10) in type III.

Conclusions

These results suggest that the highest priority nodal stations to be dissected were the paracardial and lesser curvature nodes (Nos. 1, 2, and 3) and the nodes at the root of the left gastric artery (No. 7), regardless of the Siewert subtype, but the subsequent priority was different depending on the subtype.