Gastric cancer remains a significant problem in terms of global health, and is the most common cancer in Korea. Surgery is the only potentially curative treatment for localized gastric cancer, but most cases present at an advanced stage. Randomized trials have demonstrated that chemotherapy for advanced gastric cancer improves the quality of life and extends survival, by 4~6 months, compared with best supportive care alone. Single agents with a proven activity in a first-line setting include 5-fluorouracil (5-FU), doxorubicin, mitomycin C, cisplatin, taxanes (docetaxel and paclitaxel) and oral fluoropyrimidines (capecitabine and TS-1). Based on the results from several large scale randomized trials, FP (5-FU/cisplatin) and ECF (epirubicin/cisplatin/5-FU) combinations are the most widely used regimen against advanced gastric cancer. Phase II studies of the FP and ECF combination reported a 40~51% response rate in previously untreated patients, and this regimen also produced a significantly higherresponse rate than the FAM (5-FU/doxorubicin/ mitomycin) and FAMTX (5-FU/doxorubicin/methotrexate) regimens, respectively. However, significant treatment related-toxicities and discomfort were reported from ECF, which prevents this combination from becoming the standard treatment regimen. While no one combination chemotherapy regimen is accepted as the standard for advanced gastric cancer, FP is currently considered a suitable reference regimen worldwide. New agents, such as taxane, irinotecan and oxaliplatin, combined with old agents, such as cisplatin and 5-FU, are currently under evaluation to further improve treatment outcomes. Also, oral 5-FU prodrugs are replacing the cumbersome 5-FU long-term infusion due to its convenience and superior toxicity profile. However, the low complete response rate and short response duration are still the main obstacles in the chemotherapy for gastric cancer. Only large scale comparative clinical trials will give clues to improve the results of gastric cancer treatments.
Citations
Borrmann type IV gastric cancer is often diagnosed only at an advanced stage, resulting in a prognosis poor. We performed a retrospective study of the clinical characteristics of Borrmann type IV gastric cancer and the prognostic factors affecting the survival rate in such patients.
Of 4,063 patients with all gastric cancers, 370 (9%) with Borrmann type IV gastric cancer were analyzed.
The clinical characteristics of these patients included a higher incidence rate in young females, and higher rates of serosa exposure, metastasis to lymph nodes and early peritoneal dissemination. Of patients presenting with peritoneal seeding, those resected had a higher survival rate than those that were not. A univariate analysis showed that the prognostic factors affecting the survival rate following a curative resection were the location, occupied area and depth of the primary tumor, as well as the presence of lymph node metastasis and the tumor stage. A multivariate analysis indicated that the tumor location and stage were significant independent prognostic factors after a curative resection for Borrmann type IV gastric cancer.
In conclusion, the early diagnosis and treatment of patients with Borrmann type IV gastric cancer are essential for the better survival of these patients. Even in patients with advanced tumors, a noncurative palliative resection may improve the prognosis.
Citations
There has been no definitive randomized study to identify the optimal therapeutic regimen for treating squamous cell carcinoma of tonsil. The purpose of this study was to retrospectively evaluate the treatment outcome according to various combinations of surgery, radiation therapy and chemotherapy.
Fifty-six patients with tonsillar carcinoma, who were treated at Seoul National University Hospital from March 1985 to August 2001, were the subjects of this study. Twenty-one patients received surgery followed by radiation therapy (SRT), 16 patients underwent radiation therapy alone (RT), and 19 patients received neoadjuvant chemotherapy and radiation therapy (CRT). The median radiation dose was 66.6 Gy for the SRT group and 70.2 Gy for the RT and CRT groups. Surgery comprised extended tonsillectomy and modified radical neck dissection of the involved neck. Cisplatin and 5-fluorouracil were used every three weeks for 3 cycles in the SRT group. The median follow-up was 73.2 months.
The distribution of T-stage was 4 cases of T1, 14 cases of T2, 1 case of T3 and 2 cases of T4 staging in the SRT group, 2 cases of T1, 6 cases of T2, 5 cases of T3 and 3 cases of T4 staging in the RT group and 0 cases of T1, 7 cases of T2, 9 cases of T3 and 3 cases of T4 staging in the CRT group. The distribution of N-stage was 5 cases of N0, 2 cases of N1, 13 cases of N2 and 1 case of N3 staging in the SRT group, 6 cases of N0, 5 cases of N1, 5 cases of N2 and 0 cases of N3 staging in the RT group, and 2 cases of N0, and 7 cases of N1, 9 cases of N2 and 1 case of N3 staging in the CRT group. The five-year overall survival rate (OSR) for all patients was 78%. The five-year OSR was 80% for the SRT group, 71% for the RT group, and 80% for the CRT group (p=ns). The five-year disease-free survival rate was 93% for the CRT group and 71% for the RT group (p=0.017). Four patients developed local failure and one patient failed at a regional site in the RT group, and one patient failed at a primary site in the CRT group. The five-year DFS was 84% for patients who had undergone neck dissection and 76% for patients who had not undergone neck dissection (p=ns). Treatment-related complications of grade 3 or 4 occurred in 15 patients, and the incidence of complication was not different between each of the treatment methods.
Although the patients with more advanced T stage were included in the RT and CRT groups, the OSR was not statistically different according to the treatment methods. In the radical radiation therapy group, the addition of neoadjuvant chemotherapy showed an improvement in the disease-free survival. Because of the retrospective nature of our study and the small number of patients, this study cannot draw any definite conclusions, but it suggests that radiation therapy with chemotherapy can be a good alternative option for squamous cell carcinoma of tonsil. Controlled randomized study is necessary to confirm this hypothesis.
Citations
DNA-PKcs is one of the DNA repair genes. It was recently found that hyperplasia and dysplasia of the intestinal mucosa and the production of aberrant crypt foci were developed in DNA-PKcs-null mice, and this suggests a suppressive role for DNA-PKcs in tumorigenesis.
To investigate the possible relationship between the clinico-pathologic characteristics and the survival of gastric cancer patients, the expression status of DNA-PKcs was determined in 279 consecutive gastric cancers. Immunohistochemical analysis was performed to evaluate the expression levels of DNA-PKcs protein by using the tissue array method.
Out of 279 consecutive gastric cancers, 63 cases (22.6%) showed the loss of DNA-PKcs expression. The loss of DNA-PKcs expression was significantly associated with advanced cancer (p<0.001), lymphatic invasion (p=0.001), lymph node metastasis (p=0.009), and advanced pTNM stage (p=0.009). Univariate survival analysis revealed that patients with the loss of DNA-PKcs expression had significantly poorer survival than those patients with intact DNA-PKcs expression (p=0.004). Moreover, the loss of DNA-PKcs expression was identified to correlate with a lower survival in the subgroup of stage I gastric cancer patients (p=0.037).
The loss of DNA-PKcs expression was found in 23% of human gastric cancers and this was identified to significantly correlate with poor patient survival, especially for stage I gastric cancer patients.
Citations
The purpose of this study was to evaluate the clinicopathological significance of the microvessel density and macrophage and mast cell counts in invasive breast carcinomas.
45 invasive breast carcinomas were immunohistochemically stained with the endothelial antigen, CD34, and macrophage marker, CD68. 0.1% toluidine blue was used to highlight mast cells. The microvessel and mast cell counts were performed at ×200 magnification and the macrophages at ×400 magnification.
With the 45 invasive breast carcinomas, there were no statistically significant associations between the mast cell, macrophage and microvessel counts and the tumor size and lymph node status. ER and PR negative mast cells infiltrated more than in cases of positive stati, with statistical significance (p-value=0.010 and 0.005, respectively). The macrophage counts were negatively correlated with the PR status (p-value=0.030). With respect to the c-erbB-2 status, there was no significance correlation with the mast cell, macrophage and microvessel counts. The mast cell counts showed significantly positive correlation with the microvessel counts in the invasive breast carcinomas (p-value=0.015). In a comparison of the macrophage counts with the microvessel counts, a positive tendency for both parameters, but without statistical significance (p-value=0.310).
Increasing numbers of mast cells and macrophages were recruited in invasive breast carcinomas, which contribute to angiogenesis. The microvessel density in invasive breast carcinomas had no statistically significant association with the tumor size, lymph node status, and histological grade, presence of DCIS component, estrogen/progesterone receptor status and cerbB-2 status. The evaluation of angiogenesis using these methods is not thought to provide an independent clinicopathological factor in invasive breast carcinomas.
Citations
The outcome and prognostic factors of brainstem glioma were evaluated following radiotherapy methods.
Between 1986 and 2001, 45 childhood patients with diffuse brainstem glioma were treated. There were 26 boys and 19 girls, with a median age of 7 years (range 3~18). The histopathological diagnoses were confirmed in 13 patients, which revealed a low-grade glioma in four patients, and high-grade glioma in the other nine. Before 1993, radiation therapy using a regime of 1.8 to 2.0 Gy once a day was performed in 16 cases; thereafter, a regimes of 1.1 or 1.5 Gy twice a day was given in 15 and 14 cases, respectively. Nine patients were treated with adjuvant chemotherapy. The response to the treatment was evaluated by the MRI findings 4 weeks after radiotherapy.
After radiotherapy, the neurological deficit improved in 42 of the 45 patients (93%). The MRI responses were as follows; partial response 22/39 (56%), minimal to no response in 16/39 (41%) and tumor progression in 1/39 (3%). The median time to disease progression was 7 months, and the median survival was 12 months; the overall survival rate at 1 year was 41%. There was no significant prognostic factor for overall survival. The progression-free survival was influenced by the tumor histology (low grade vs. high grade, p=0.05) in those patients whose pathology was confirmed.
The radiation therapy fractionation schedule did not influence the survival. Low grade histology was a possible favorable prognostic factor of progression-free survival in pediatric brainstem glioma patients.
Citations
In this study, we examined whether additional, delayed regional FDG PET scans could increase the accuracy of the lymph node staging of NSCLC patients.
Among 87 patients who underwent open thoracotomy or mediastinoscopic biopsy under the suspicion of NSCLC, 35 (32 NSCLC and 3 infectious diseases) who had visible lymph nodes on both preoperative whole body scan and regional FDG PET scan were included. The following 3 calculations were made for each biopsy-proven, visible lymph node: maximum SUV of whole body scan (WB SUV), maximum SUV of delayed chest regional scan (Reg SUV), and the percent change of SUV between WB and regional scans (% SUV Change). ROC curve analyses were performed for WB SUVs, Reg SUVs and % SUV Changes.
Seventy lymph nodes (29 benign, 41 malignant) were visible on both preoperative whole bodyscan and regional scan. The means of WB SUVs, Reg SUVs and % SUV Changes of the 41 malignant nodes, 3.71±1.08, 5.18±1.60, and 42.59±33.41%, respectively, were all significantly higher than those of the 29 benign nodes, 2.45±0.73, 3.00±0.89, and 22.71±20.17%, respectively. ROC curve analysis gave sensitivity and specificity values of 80.5% and 82.8% at a cutoff of 2.89 (AUC 0.839) for WB SUVs, 87.8% and 82.8% at a cutoff of 3.61 (AUC 0.891) for Reg SUVs, and 87.8% and 41.4% at a cutoff of 12.3% (AUC 0.671) for % SUV Changes.
Additional, delayed regional FDG PET scans may improve the accuracy of lymph node staging of whole body FDG PET scan by providing additional criteria of Reg SUV and % SUV Change.
Citations
Histone deacetylase inhibitors (HDIs) are emerging as potentially useful components in anticancer therapy. In this study, we tried to confirm the radiosensitizing effect of trichostatin A (TSA) on a panel of human carcinoma cell lines and elucidate its mechanism of interaction.
A549, HeLa and Caski cells were exposed to TSA for 18 hr prior to irradiation, and the cell survival then measured using a clonogenic assay. Western blot and flow cytometric analyses, for histone acetylation, and cell cycle and apoptosis, respectively, were also performed.
TSA increased the acetylation of histone H3. The pretreatment of TSA consistently radiosensitized all three cell lines. The SF2 (surviving fraction at 2 Gy) of TSA-treated cells was significantly lower than that of mock treated cells. The SER (sensitizer enhancement ratio) increased in all 3 cell lines, in concentration dependent manners. The TSA treated cells showed abrogation of radiation-induced G2/M arrest, in a concentration dependent manner.
The pretreatment of TSA enhanced the radiosensitivity of a panel of human carcinoma cells, which was attributed, in part, to the abrogation of radiation-induced G2/M arrest.
Citations
Lymph node involvement is the most important prognostic factor of rectal cancer. Cancer originating from sites other than the rectum rarely metastasizes to the mesorectal lymph node. We report a rectal cancer patient with a synchronous metastatic prostatic carcinoma to the mesorectal lymph node.
Citations
A 13 year-old girl with osteosarcoma and pulmonary tumor recurrence developed acute renal failure following high dose methotrexate (12 g/m2) therapy, she had previously tolerated high dose methotrexate and her renal and hepatic functions were normal. Briefly, 48 hours after beginning methotrexate infusion her methotrexate concentration and creatinine level were 1338.8 µM/L and 5.8 mg/dl, respectively. Grade IV oral mucositis and neutropenia with fever developed at 144 hours after MTX infusion. Hydration and alkalinization were continued and leucovorin rescue was intensified based on the plasma MTX concentrations. Plasma exchange was performed twice and hemodialysis 3 times without problems, but methotraxate and creatinine levels remained high, 91.9 µM/L, and 2.5 mg/dl, respectively. After 3 courses of hemodialysis carboxypeptidase-G2 (CPDG2) was administered at 50 U/kg, intravenously over 5 minutes. After 15 minutes of CPDG2 (Voraxaze™) infusion, her plasma MTX concentration was 0.91 µM/L and no rebound elevation or side effects developed. Thirteen days post-MTX infusion her renal function had normalized. We report here our experience of a dramatic methotrexate level reduction caused by CPDG2 administration.
Citations