Mediastinal tracheostomy using a pectoralis major myocutaneous flap after resection of carcinoma of the esophagus involving the proximal part of the trachea

An operative procedure of mediastinal tracheostomy using a pectoralis major myocutaneous flap is presented. In this procedure, the terminal portion of the trachea penetrates through the center of a pectoralis major myocutaneous flap and the tracheal wall is completely wrapped with the muscular portion of the flap. Between 1981 and 1988, eight patients with carcinoma in the cervicothoracic segment of the esophagus underwent mediastinal tracheostomy after laryngoesophagectomy and extended resection of the proximal part of the trachea through sternal manubrectomy, because of invasion into the trachea. In five of eight patients, a pectoralis major myocutaneous flap was used to construct a tracheal stoma. A skin flap only, or both a skin flap and a muscle flap, was used in the other three. In four of eight patients, tracheal necrosis occurred, and rupture of the brachiocephalic artery occurred in one patient when the tracheal stoma had been constructed using both a skin flap and a muscle flap. However, neither skin breakdown nor bleeding from the major vessels occurred when using the myocutaneous flap. Therefore, it is concluded that the construction of the tracheal stoma using a pectoralis major myocutaneous flap is recommended for mediastinal tracheostomy after laryngoesophagectomy with extended resection of the proximal part of the trachea.     

Locoregional adoptive immunotherapy resulted in regression in distant metastases of a recurrent esophageal cancer

 Esophageal cancer is one of the most common malignant diseases. However, postoperative recurrences are still resistant to currently available radiochemotherapy. We recently reported a study on the initial clinical efficacy of locoregional adoptive immunotherapy for advanced esophageal cancer. We report here our clinical experience of remarked responses in distant metastatic lesions in a patient with recurrent cancer after receiving this immunotherapy. A male patient underwent curative surgery, and presented with multiple recurrent metastases in the supraclavicular lymph nodes (LNs), liver, and abdominal aortic LNs. Autologous tumor-activated lymphocytes (AuTLs) generated ex vivo were regionally injected into supraclavicular LNs every 2 weeks 13 times. Mean numbers of the administrated cells were 0.8 × 10⁹ cells/injection. AuTLs established from peripheral blood lymphocytes stimulated by autologous tumor cells with interleukin-2 were tested for their cytotoxicity before every treatment. During immunotherapy, Grade 2 diarrhea and fever were observed. The clinical partial responses were obtained in all lesions and were sustained for 11 months. Because clinical toxicity was tolerable, this immunotherapy might be useful for patients with far-advanced esophageal cancers. Received: June 19, 2002 / Accepted: September 26, 2002 Correspondence to:U. Toh     

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.     

Intraarterial cellular immunotherapy for patients with inoperable liver metastases of esophageal cancer

PURPOSE: We report 2 patients with refractory liver metastatic tumor after esophagectomy for advanced esophageal cancer, who responded markedly to locoregional cellular immunotherapy by repeated intraarterial infusions of autologous tumor cell-activated T lymphocytes (AuTL), even after they failed the standard chemotherapy of cisplatin (CDDP) and 5-fluorouracil (5-FU). METHODS: AuTL administrations were made through the hepatic artery via a subcutaneous reservoir located at the right upper leg. Six injections were administered to both patients, repeated at 2-week intervals. The total number of administered T cells reached 2.4 x 10(9) and 3.1 x 10(9), respectively. RESULTS: A 39% and 51% regression in each infused field, compared with the size of liver tumor before treatment, was observed by computed tomography (CT) scan in patient 1 and 2, respectively. The responses continued up to the 10th and 11th month after the intraarterial infusion, confirmed by follow-up CT scan. The adverse effects of intraarterial immunotherapy were tolerable, with grade 1-2 fever and nausea in each patient. CONCLUSIONS: Clinical regression of liver metastases of esophageal cancer was observed in both patients who received this intraarterial cellular immunotherapy. Liver metastases of esophageal cancer may be controlled effectively and safely by repeating the intraarterial AuTL infusion as a locoregional immunotherapy over a long period.     

Examination of dose verification in intensity modulated radiation therapy (IMRT) treatment planning using averaging dose in chamber volume

Since the year 2000, our hospital has been equipped with an intensity modulated radiation therapy (IMRT) facility. Before IMRT is administered, the absorbed dose is measured by the ionization chamber to provide verification for the IMRT procedure. In utilizing the current point dose evaluation, large discrepancies have been experienced when the measured dose is compared with the calculated dose. This discrepancy is due to the lack of uniformity in IMRT irradiation in comparison with that of the present method of dose distribution. In order to reduce the margin of error, the average dose of the ionization chamber calculated on a dose-volume histogram was compared with the measured dose. As a result, the margin of error was minimized to <2% in uniform areas and <4% in non-uniform areas.     

Combination immunotherapy using autologous tumor-stimulated lymphocytes and trastuzumab (Herceptin) for the patients with recurrent breast cancer

PURPOSE: We report two patients with refractory recurrent breast cancer (HER2/neu: +) postoperatively, who had failed response to the available conventional chemotherapy of CAF (cyclophosphamide, adriamycin, 5-fluorouracil) and docetaxel, etc. They markedly responded to the combination immunotherapy using intraperitumoral injections of autologous tumor cell-stimulated T lymphocyte (AuTL) and trastuzumab (Herceptin), an anti-HER2 monoclonal antibody. METHODS: AuTLs were administrated directly into the recurrent tumor by intraperitumoral injections biweekly and trastuzumab was infused systemically every week. The treatments were repeated for 6 and 11 injections in the patients, respectively. The total administered T cells had reached to 3.8 x 10(9) and 6.4 x 10(9), respectively. The dosage of trastuzumab was 2 mg/kg in each patient. RESULTS: The carcinomatous pleural effusion had disappeared and was well controlled in patient 1 and a marked regression in injected fields in comparison to the size of the recurrent tumor before treatment was observed in patient 2. The tumor marker proteins (CEA, CA15-3, TPA) had also decreased significantly. The adverse effects of the immunotherapy were tolerable with grades 1-2 infusion reaction of fever, tachycardia and hypotension, but no cardiac dysfunction was observed. CONCLUSIONS: Clinical responses of recurrent breast cancer were observed in two patients after receiving the intra-peritumoral AuTL injection plus trastuzumab immunotherapy. These results showed that refractory recurrent breast cancer may be controlled effectively and safely by repeating the cellular immunotherapy combined with trastuzumab and suggested utility of combining these agents in clinical trial.