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A 53-year-old man presented with massive right hydrothorax just after introduction of continuous ambulatory peritoneal dialysis (CAPD). Because the glucose concentration of pleural fluid was markedly high compared with that of serum, we diagnosed pleuroperitoneal communication. Thoracoscopic surgery was performed and thinning of the diaphragm was found. We sutured the diaphragm to repair the thin portion and performed pleurodesis with 50% glucose solution. He restarted CAPD 1 month post-operatively and continued at home without pleural effusion. Eight months post-operatively, he experienced dyspnea again and chest X-ray showed right hydrothorax. Although the cause of recurrent hydrothorax is unknown, it may be that not only surgical repair but also more intense pleurodesis is needed.

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BACKGROUND/AIMS: Recent advances in diagnostic techniques have led to the detection of an increasing number of early gastric cancers in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for these cancers. METHODOLOGY: The clinicopathologic characteristics of 35 patients with early gastric cancer in the upper third of the stomach who underwent three different types of gastrectomies were reviewed retrospectively from hospital records between January 1992 and August 1999. RESULTS: Patients undergoing limited proximal gastrectomy with esophagogastrostomy reconstruction had shorter operation times and less blood loss than those for patients undergoing total gastrectomy or proximal gastrectomy with jejunal interposition. No lymph node metastasis was identified in any of these patients. Heartburn due to reflux esophagitis was seen in a few patients of each group, but they were successfully treated by antacids. The extreme reduction in food intake volume was more frequently experienced in patients with total gastrectomy than those with both proximal gastrectomies. When mortality due to other disease was excluded, all patients survived without recurrence. CONCLUSIONS: A limited proximal gastrectomy with esophagogastrostomy reconstruction decreased surgical risk and realized preservation of maximal function.

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BACKGROUND: Because bromodeoxyuridine (BrdU) is incorporated into DNA synthesizing (S-phase) cells, the blood supply of liver tumors can be traced by injecting BrdU into either the hepatic artery or portal vein. It also is possible to study the delivery of anti-cancer drugs acting during S-phase when they are injected by these routes. The blood supply of and drug delivery to liver tumors were examined using BrdU in patients with 19 metastatic liver cancers and 8 hepatocellular carcinomas. METHODS: At the time of hepatic resection, 200 mg of BrdU was injected by the various routes or 200 mg of BrdU suspended in 2 ml of a lipid contrast medium was injected into the hepatic artery by a reported method 2 weeks before hepatectomy. The liver tumors resected were stained immunohistochemically with an avidin-biotin-peroxidase complex method using anti-BrdU monoclonal antibody. RESULTS: BrdU injected into the hepatic artery or portal vein was incorporated into the metastatic liver tumor. After intraarterial infusion BrdU suspension, the delivery of BrdU was enhanced. The nuclei of hepatocellular carcinomas that received BrdU from the hepatic artery or portal vein incorporated BrdU. CONCLUSIONS: Metastatic liver cancers had both arterial and portal blood supplies. Hepatocellular carcinomas also had, not only an arterial, but also a portal blood supply. In both primary and secondary hepatic cancers, the delivery of anti-cancer agents acting during S-phase using the lipid contrast medium administration method was excellent.

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Seventy-nine patients undergoing hepatic resection without manipulation of the vena cava were divided into three groups. Group 1 consisted of 32 patients in whom hepatic hilar vascular exclusion was not performed. Group 2 (20 patients) had vascular inflow exclusion performed at the operative site only (right or left unilateral exclusion). Group 3 (27 patients) had total inflow exclusion during hepatic resection. There were no significant differences between the groups in blood loss or blood transfusion requirement. On the third day after operation, the serum glutamic-pyruvic transaminase level in group 3 was significantly higher than that in group 1 (P less than 0.01). Vascular inflow exclusion may not be essential for successful hepatic resection.

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For 4 patients with peritoneal carcinomatosis who had severe abdominal pain and vomiting, intra-arterial infusion chemotherapy, via the superior mesenteric artery was performed. After the treatment, all patients were free of their symptoms and began to eat again. Severe complications such as superior mesenteric arterial thrombosis did not occur. It is concluded that our treatment is clinically useful because the quality of life of these patients at the end stage was improved.

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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.

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As the model of an anti-cancer agent acting at DNA synthesizing phase, BrdU was infused for metastatic liver cancers into the portal vein and/or the hepatic artery. After administration, the liver tumors were resected, and immunohistochemical staining was performed using anti-BrdU monoclonal antibody. Two of 6 portal group tumors were stained. All 4 arterial and 3 arterio-portal group tumors were stained. Therefore, it was proved that metastatic liver tumors had both arterial and portal blood supply. But areas to which BrdU was delivered were only peripheral, and the inmost area was 2 mm from the tumor surface. After the intra-arterial infusion of BrdU suspended in lipiodol, the delivery of BrdU was highly enhanced and 4 of 6 tumors were stained even to the deepest areas. However, one tumor of which the major part was necrotic and one tumor which produced mutin were not stained at all. It was interesting that after intra-arterial administration of BrdU suspended in lipiodol, BrdU was also found in the cytoplasm of normal liver cells.

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In order to deliver a high concentration of CDDP in tumor tissue, we attempted to infuse CDDP intra-arterially for preoperative patients with resectable gastric cancer. Thirty-two patients (21 males and 11 females) were treated. The concentration of platinum was measured in cancer tissue, normal mucosa, lymph nodes without metastasis at the greater curvature. These were gathered operatively and in serum just before operation. The serum concentration of free-CDDP was also measured. Student's-t test was performed with the data. After intra-arterial injection of 60 mg CDDP, the mean concentration of platinum in cancer tissue was 1.11 +/- 0.45 microgram/g and after intravenous injection of 40 mg CDDP that was 0.30 +/- 0.11 microgram/g. After intra-arterial injection of 40 mg CDDP, the mean concentration of platinum in cancer tissue was 0.64 +/- 0.12 microgram/g, which was significantly higher than in normal gastric mucosa (0.27 +/- 0.06 micrograms/g) or serum (0.37 +/- 0.10 micrograms/ml) (p less than 0.025). The mean concentration of platinum in cancer tissue was higher than in the lymph nodes (0.45 +/- 0.10 micrograms/g), but there was no significant difference. In sera the concentrations of free-CDDP were all under the detectable limit. It was concluded that intra-arterial injection therapy of CDDP was an effective method to maintain a high concentration of CDDP in gastric cancer tissue.

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To compare the pharmacological advantage of intra-arterial, intraportal and intravenous administration of anticancer drug for metastatic liver tumor, BrdU was administered to rabbits with metastatic liver tumor of VX2 from various routes and taken up into the nuclei of tumor cells. Both one-shot injection and continuous infusion (30 min) of BrdU was performed from celiac artery, portal vein or peripheral vein. In some rabbits, the portal vein or the celiac artery was ligated to form one blood supply to the liver. After the administration of BrdU, the liver was removed. The samples were stained by the immunohistochemical procedure using monoclonal antibody to BrdU. The result was that the drug uptake of small metastatic liver tumor by both arterial and portal one-shot injection was good, and the uptake following intra-arterial injection of BrdU was superior to its intraportal injection in large metastatic tumor. However, only peripheral cells of large tumor took up BrdU after intra-arterial injection and inner cells of large tumor did not take up BrdU after any continuous infusions. The intraportal and intravenous administration of BrdU without ligation of celiac artery had the same effect as its intra-arterial administration.

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We had 84 patients with unresectable metastatic liver cancer from May, 1980 to December 1987 in the National Matsudo Hospital. Eighteen of them had no treatment; 26 of them had serial transarterial embolization (TAE) with or without infusion of anti-cancer drug dispersed in lipiodol; 7 of them had only serial trans-arterial infusion (L-TAI) of an anticancer drug suspended in lipiodol. A significant survival advantage of patients with TAE or L-TAI was noted when compared with no treatment, but there was no difference between the survival rate of patients with TAE and L-TAI. There were some 82 patients with unresectable metastatic liver cancer from October 1984 to March 1988 in Kyto Prefectural University of Medicine Hospital. Thirteen of them had L-TAI using one anti-cancer drug (one-drug group); 8 of them had L-TAI using two drugs (two-drug group); 22 of them had L-TAI with three drugs (three-drug group). The survival rate of the three-drug group was superior to the one- and two-drug groups. It was concluded that TAE was not necessary for metastatic liver cancer, but L-TAI must be undertaken, because combined cancer chemotherapy enhanced the effect of L-TAI.

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