meeting report of the 76th congress of the japanese gastric cancer association

Gastric Cancer (2004) 7: 185–195DOI 10.1007/s10120-004-0307-2 ” 2004 by

International andJapanese Gastric

Cancer Associations

Special article

Meeting report of the 76th Congress ofthe Japanese Gastric Cancer Association

Nobuaki Kaibara, Yoshihide Otani, Haruhiro Inoue, Yoshihiko Maehara, Michio Kaminishi, Wataru Yasui,Yutaka Takahashi, Hiroki Yamaue, Yoshitaka Yamamura, Masahiro Hiratsuka, Shigeaki Yoshida,Takanori Hattori, Wasaburo Koizumi, Kentaro Sugano, Tsukasa Tsunoda, Kosei Hirakawa,Sumio Matsumoto, and Toshiro Konishi

for gastrointestinal tract cancer was introduced in 1999in Japan. Already 127 out of 458 member institutesof the JGCA which answered a JGCA questionnairehave started using SN biopsy or planned to introduce itin clinical practice. Y. Kitagawa emphasized, at the endof his presentation, that large-scale clinical trials wereindispensable to confirm the feasibility of SN biopsy.T. Fujimura, of Kanazawa University, presented theiroriginal method of “lymphatic basin dissection”, usingintraoperative endoscopic lymphatic mapping (IELM).Y. Uenosono, Kagoshima University, referred tothe appropriate size of radioactive colloids as tracers forSN detection. H. Hayashi, of Chiba University, notedthe advantages of a combined dye and radioactive col-loid method for laparoscopic SN biopsy. I. Miyashiro,Osaka Medical Center for Cancer and CardiovascularDiseases, presented the procedure and results of adye method using indocyanine green (ICG). The finalspeaker, H. Nimura, of Jikei University, presenteda method of SN detection by infrared ray, whichmade ICG-stained green nodes in fat tissue morevisible.

After these presentations, five updated subjects ofinterest for SN biopsy were discussed by six speakers:(1) the appropriate stage of gastric cancer for an SNbiopsy indication, (2) selection of tracers — radioactivecolloid or dye, (3) timing of and method for the injec-tion of tracers under the lesion, (4) methods forcollecting radioactive or dye-stained LNs — simpleisolation of the node from fat tissue, or lymphaticbasin dissection, (5) diagnosis of positive nodes —microscopic observation of H&E-stained orcytokeratin-immunostained sections, or reverse tran-scription-polymerase chain reaction (RT-PCR).

In the last part of the discussion, the necessity formulticenter trials in order to advance the clinical appli-cation of SN biopsy in gastric cancer surgery in Japanwas reconfirmed by all speakers and by the audienceat the symposium. Two protocols were presented for

Introduction

The 76th Congress of the Japanese Gastric Cancer As-sociation (JGCA) was held at the Yonago ConventionCenter “Big Ship,” Tottori, March 4–6, 2004. Althoughthe JGCA annual meeting usually takes place in Febru-ary, we postponed the meeting to early March to avoidtraffic congestion due to heavy snow in the region.Ironically, after exceptionally fine weather in February,snow fell in March, and flights from all over Japan weredisrupted. Nevertheless, 1800 physicians and research-ers attended the congress, and 664 papers (the largestnumber in the history of the congress) were presented.

We set the main theme as “Cooperation in Asia”, andorganized two international symposia to promote betterunderstanding of gastric cancer disease in Asiancountries. We also invited two distinguished doctorsfor special lectures: Professor Hideaki Tahara, Instituteof Medical Science, University of Tokyo, Japan for“Dendric cells; biology and their potential in cancerimmunotherapy”, and Professor Stephen B. Howell,University of California, San Diego, California, UnitedStates, for “Copper transporters mediate uptake andefflux of the platinum drugs.”

Discussions about some of the main topics of thecongress are summarized below by the chairpersons ofeach session.

Special symposium 1. Frontline of sentinel lymph nodebiopsy for gastric cancer (chaired by S. Kitano, OitaUniversity, and Y. Otani, Keio University, Tokyo)The sentinel node (SN) is the lymph node (LN) thatreceives the first lymph flow from a malignant tumor,and SN biopsy specimens are taken to determinewhether standard lymphadenectomy can be avoided inpatients with clinically node-negative cancer.

Six speakers made presentations. Y. Kitagawa, KeioUniversity, explained the historical background and thecurrent status of SN biopsy for gastric cancer. SN biopsy

186 N. Kaibara et al.: Report of 76th Congress of JGCA

randomized controlled trials for the feasibility test ofSN biopsy for gastric cancer. One was the JCOG 0302(Japan Clinical Oncology Group, http://www.jcog.jp/)protocol and the other was the Japanese Societyof Sentinel Node Navigation Surgery (http://web.sc.itc.keio.ac.jp/surgery/snns/) protocol. It is be-lieved that the common use of SN biopsy procedureswill make the SN biopsy a valuable tool for gastriccancer surgery, especially for function-preserving sur-gery for early gastric cancer. (Reported by Y. Otani.)

Special symposium 2. Latest advances in endoscopicmucosal resection (chaired by S. Yoshida, NationalCancer Center Hospital East, and H. Inoue, ShowaUniversity Northern Yokohama Hospital)In this symposium, the latest advances in endoscopicmucosal resection (EMR) were presented, and theprocedural refinements were precisely discussed.Conventional EMR is, in principle, based upon snarestrangulation of the target mucosa. With this method,the size of specimens was limited to 2 to 3cm, with anunclear resection margin, and, therefore, histopatho-logical evaluation of the resected specimen oftenremained unsatisfactory. Regardless of the tumor size,single-fragment resection is considered to be essentialfor accurate histopathological analysis, particularly toexpand the criteria.

In 1995, Ono and Hosokawa developed the “insula-tion-tip (IT) knife technique”, later termed “endoscopicsubmucosal dissection (ESD)”. Their procedure con-sists of two parts; marginal cutting of the lesion, fol-lowed by submucosal dissection of the isolated mucosa.With ESD, theoretically, lesions of any size can beresected as a single fragment and can be precisely evalu-ated by pathologists regarding the microscopic charac-teristics of the superficial cancer. Although ESD has agreat advantage for a large-block resection, some prob-lems remain for ordinary endoscopists. The proceduremay take a very long time, with a relatively high risk ofcomplications, such as massive bleeding and perfora-tion. H. Ono, Shizuoka Cancer Center, in his presenta-tion, emphasized the significance of one-block resectionand recent technical improvements. The concept ofone-block resection by ESD has now become accepted,and is generally recommended to all endoscopists, butthe original IT knife procedure still demands high tech-nical skills. Any easy techniques and devices that willmake ESD technically feasible for all endoscopists areawaited.

In this session, some important technical refinementsof ESD were discussed. T. Oyama, Saku GeneralHosptial, advocated the practical usefulness of the“hook knife technique”. So far, they have performedESD in 312 patients, and single-fragment resection waspossible in 301 (96%). Perforation occurred in only 3

patients (0.96%). The hook knife is a technically sophis-ticated device, but it generally demands a longer timethan the IT knife method. T. Gotoda, National CancerCenter Hospital, Tokyo, reported their 3-year experi-ence of 708 patients. In 13% of the patients, it tookmore than 2 h to complete the procedure. They nowrecommend a combination use of the IT knife withsome other modalities (needle knife, distal attachment,and so on). A. Hosokawa, National Cancer Center Hos-pital East, also advocated a combination method, withthe IT knife and other, new, modalities, namely, “hole-to-hole and jerking and scratch method”. M. Kaise,Tokyo Jikeikai Medical University, presented a com-bined technique with marginal cutting and mucosal re-section, using a monofilament hard snare. H. Ono alsoreported a minor improvement of IT knife deviceswhich makes the original IT knife procedure mucheasier for ordinary endoscopists. Y. Oda, Hattori Gas-trointestinal (GI) Hospital, recommended, from aneducational point of view, that ESD should first be triedfor small and distally located lesions in the stomach,while ESD for large and proximally located lesionsshould be done by expert hands.

In this session, we confirmed that the use ofsome advocated modifications of the IT knife methodmakes ESD a more feasible and effective procedure.(Reported by H. Inoue.)

International symposium 1. Chemotherapy for gastriccancer in Asia (chaired by Y. Maehara, Kyushu Univer-sity, and M. Terashima, Fukushima Medical University)Gastric cancer remains the most common cause of can-cer death in Asia. The treatment outcome has beenmuch improved during the past few decades, mainly dueto earlier diagnosis. However, the prognosis of patientswith advanced or recurrent gastric cancer still remainspoor. 5-Fluorouracil (5-FU) has been a key chemo-therapeutic agent in the treatment of advanced or recur-rent gastric cancer. Despite several phase III studies, astandard chemotherapeutic regimen has not been estab-lished worldwide. In the 1980s, the FAM regimen wasemployed as standard chemotherapy. In recent years,new anticancer agents have been introduced and arebeing tested as single agents, or in combinations. Theseinclude the taxanes, irinotecan (CPT-11), oxaliplatin,capecitabine, and S1. Therapeutics with molecular-targeted agents such as tyrosine kinase inhibitors will betested in the near future.

Y.H. Kim, Korea University, and Y.J. Bang, SeoulNational University, reported a review of gastric cancerchemotherapy in Korea. In a randomized phase IIIstudy, 5-FU � cisplatin (CDDP) (FP) was comparedwith 5-FU alone or FAM treatment, and FP had ahigher response rate and longer time to progression. To

N. Kaibara et al.: Report of 76th Congress of JGCA 187

improve the response rate with combination treatment,5’DFUR � CDDP; and capecitabine � CDDP wereinvestigated. Capecitabine � CDDP was highly active,with a response rate of 54.8%, with manageabletoxicities. Epirubicin, CDDP, and UFT plus leucovorinwere tested, and a significant response rate of 54%, withtolerable toxicity, was obtained. Currently, a phase IIItrial comparing SKI-2053R � 5-FU versus CDDP �5-FU is ongoing.

K.M. Chu, University of Hong Kong, presented areview and outline of the prospects of gastric cancerchemotherapy in Hong Kong, and Li.-T. Chen, NationalHealth Research Institute, Taipei, reviewed chemo-therapy in Taiwan; a two-stage sequential approach(HDFL/cisplatin followed by docetaxel and irinotecan)and salvage biweekly OXFL46 seemed promising, withprolonged overall survival.

H. Baba, Kyushu University; A. Ohtsu, NationalCancer Center Hospital East; and H. Takiuchi, OsakaMedical University, reported the final results of a phaseIII study comparing 5-FU vs 5-FU � CDDP (FP) vsUFT � mitomycin C (MMC), conducted by the JapanClinical Oncology Group (JCOG). The overall survivalof patients treated with FP was not different from thatof patients receiving 5-FU alone. Newer regimens arebeing evaluated in terms of survival advantage, in threerandomized controlled trials: 5-FU vs CPT-11 � CDDPvs S-1 as a JCOG study; S-1 vs S-1 � CDDP; and 5-FU/leucovorin vs S-1 as company-sponsored postmarketingstudies. These ongoing randomized trials in Japan willclarify the true impact of the newer-generationregimens for advanced gastric cancer.

After these presentations, the question of what wasthe current standard chemotherapy for gastric cancer inAsia was discussed. The current status of chemotherapyusing new anticancer agents, such as irinotecan, thetaxanes, oxaliplatin, and S-1 were also discussed.Finally, we discussed the problems that needed to beovercome in order to perform international clinicaltrials of chemotherapy for advanced gastric cancerin Asian countries in future. (Reported by Y.Maehara.)

International symposium 2. Gastric cancer surgery inAsia (chaired by K. Maruyama, International Medicaland Welfare University, and M. Kaminishi, Universityof Tokyo)The prevalence of gastric cancer is still high in Asiancountries. It is reported that gastric cancer is the secondleading cause of cancer-related death in Japan, Korea,China, and Turkey, and it is the fourth leading cause ofcancer-related death in Hong Kong and Taiwan. Thepresent status of and future aspects of treatment forgastric cancer in various countries and regions werepresented.

Surgery plays the central role in potentially curativetreatment. Reported survival rates after surgery dependon the proportion of patients with early gastric cancer inthe study, and the scope of lymphadenectomy. D2 lym-phadenectomy has been the gold standard for treatmentof advanced gastric cancer, and the results of D2 lym-phadenectomy from Korea and Shanghai showed a60%–65% 5-year survival rate. Furthermore, compara-tive studies of D1 and D3 gastrectomy for advancedgastric cancer (T2–4) from Turkey and Taipei revealeda better prognosis after D3 gastrectomy. In contrast towestern countries, D2 or more extended radical surgeryhas been performed as a standard treatment for ad-vanced gastric cancer at specialized institutions in Asiancountries.

Chemotherapy, whether neoadjuvant or adjuvant,has become an important tool for the treatment ofhighly advanced gastric cancer following the recent de-velopment of new anticancer agents. However, therewere many debates on the selection of drugs and theeffectiveness of chemotherapy. No definite regimenshave been established. The necessity for global co-operation in randomized controlled trials of surgery andchemotherapy was postulated.

Of note, the proportion patients with early gastriccancer has been increasing in many countries, resultingin increasing interest in limited and less invasive treat-ment. Laparoscopic gastrectomy has been adopted inJapan and Korea, and favorable results have been re-ported. However, there are still some disadvantages,such as technical difficulties, few long-term results,time-consuming operation, high cost (because of the useof many instruments and expensive equipment), andlack of establishment of training systems. Further im-provement to overcome these difficulties is mandatoryfor standardization of this procedure. The application ofthe SN concept in gastric surgery is being reviewed. Acombination of laparoscopic surgery and SN navigationmay provide much less invasive treatment than thatpreviously used for early gastric cancer. (Reported byM. Kaminishi.)

Symposium 1. Molecular biology of gastric cancer andits clinical implications (chaired by W. Yasui, HiroshimaUniversity, and M. Mori, Kyushu University)Recent advances in molecular biology have uncoveredthe precise mechanism of the development and progres-sion of gastric cancer. Various genetic and epigeneticalterations are accumulated in the course of multistepstomach carcinogenesis. These alterations includemutation and loss of heterozygosity (LOH) of tumorsuppressor genes, microsatellite instability (MSI), andgene silencing by promoter hypermethylation. In thissymposium, we discussed the significance of molecularanalysis from the clinical viewpoint, especially in terms


of diagnostics and new approaches to search for novelgenetic markers.

The silencing of tumor suppressor genes by promoterhypermethylation participates in carcinogenesis. K.Hibi, Nagoya University, reported the detection of pro-moter methylation in the serum of cancer patients andits use for diagnosis. Promoter methylation of the p16,HLTF, and CDH13 genes was examined in gastriccancer tissues by methylation-specific PCR, and in 68%of patients, the tissues showed hypermethylation of atleast one gene. Hypermethylation of the p16 promoterwas detected in the serum of 15% of patients withp16 methylation in the tumor. The examination ofcombinations of suitable gene promoters will be valu-able to screen for gastric cancer in the serum. It isof clinical importance to clarify the relation betweenmolecular characteristics and sensitivity to anticancerdrugs. M. Yashiro, Osaka City University, examinedLOH in the APC, p53, DPC4, PTEN, and CDH1 genes,as well as MSI, in advanced gastric cancer, and studiedthe relationship of these parameters to sensitivity totreatment with CDDP and 5-FU (FP therapy). A highfrequency of MSI and/or LOH of the p53 gene wereassociated with sensitivity to FP therapy, indicating thatthese parameters may be good markers for chemosensi-tivity. As to abnormalities of the p53 and PTEN genes,E. Oki, Kyushu University, demonstrated that LOH ofthe PTEN gene was associated with p53 mutation and apoor prognosis.

Detection of cancer cells in the peritoneal cavity hascrucial clinical implications; however, routine cytologyis not sensitive. H. Taniguchi, Osaka University,reported the usefulness of the detection ofcarcinoembryonic antigen (CEA) and cytokeratin 20mRNAs, by real-time RT-PCR, using a LightCycler, inpreoperative peritoneal lavage fluid. For patients whomgenetic markers were positive by PCR but negative bycytology preoperatively, MMC and CDDP wereadministered intraperitoneally, and 60% of patients hadbecome negative by PCR at surgery. This strategy isapplicable for selecting suitable adjuvant therapy.

Using genomic science, including the global analysisof gene expression and bioinformatics, the individualcharacteristics of each cancer can be determined pre-cisely, and this is directly connected to personalizedmedicine. A better knowledge of the molecular bases ofgastric cancer may lead to new approaches to diagnosisand treatment. Multiple-color spectral karyotyping(SKY) is a useful tool to identify novel chromosomalaberrations. Y. Yamashita, Kyoto Prefectural Univer-sity, examined the chromosomal state of gastric cancerby SKY. Complex karyotyping in all chromosomescould be analyzed, and many breakpoints (including8q24, 1q13, and 20q11.2) and various rearrangements(including 8q24.1/13q14 and 8q24.1/11q13) were identi-

fied. This information is valuable for isolating novelgenes that participate in stomach carcinogenesis andnew genetic markers for cancer diagnosis. Serial analy-sis of gene expression (SAGE) is a powerful techniquethat allows global analysis of gene expression in a quan-titative manner, without prior knowledge of the se-quence of the genes. N. Oue, Hiroshima University,reported that REGIV (regenerating gene type IV) wasidentified by comparing the gene expression profile ofscirrhous-type gastric cancer with that of normal gastricepithelia. RegIV was found to be secreted by cancercells, and RegIV inhibited apoptosis, suggesting thatRegIV may serve as a novel biomarker and therapeutictarget for gastric cancer. (Reported by W. Yasui.)

Symposium 2. New agents for gastric cancer chemo-therapy (chaired by M. Fujii, Nihon University, Tokyo,and Y. Takahashi, Kanazawa University)The emergence of new chemotherapeutic agents, suchas S1, CPT-11, and the taxanes, increases the responserate in patients with far advanced and unresectable gas-tric cancer. Therefore our next questions are how to usethese drugs and how to select among them.

B. Nakata, Osaka City University, reported a phase Istudy of low-dose CDDP (days 1, 2, 3, 4, and 5, everyweek) combined with S-1 (80mg/m2, 4 weeks on and 2weeks off) with measurements of serum 5-FU concen-tration, and the recommended dose (RD) of CDDP at4 mg/m2. Y. Takahashi, Kanazawa University, reporteda randomized controlled phase II trial of tailored CPT-11 (which employed individualized doses by limitingthe toxicity to grade 2) combined with S-1 (80mg/m2, 2weeks on and 2 weeks off) vs S-1 (80 mg/m2, 4 weeks onand 2 weeks off); the results showed varied individual-ized doses of CPT-11, ranging from 25 mg/m2 to 125 mg/m2 (RD determined by phase I study). These two trialsare like “chronic chemotherapy”; in other words, usinglower doses or tailored doses and obtaining longer sur-vival by repeating drug regimens over longer periods oftime, with less toxicity.

H. Nomura, Osaka Medical College, reported the sig-nificance of chemosensitivity tests and their evaluation,and recommended the use of 5-FU, CDDP, and CPT-11as first-line combination treatment. W. Ichikawa,Saitama Medical School, reported on prediction of theefficacies of S-1 and CPT-11, based on thymidylate syn-thetase (TS) and dihydropyrimidine dehydrogenase(DPD) levels. This study suggested that we shouldselect S-1 for patients with lower TS levels and S-1combined with CPT-11 for those with higher TS levels.These reports indicate the importance of tailoredchemotherapy based on various chemosensitivity tests,including drug-related enzymes and genes.

H. Narahara, Osaka Medical Center, reported goodfeasibility and antitumor effects with their clinical trials


of CPT-11 (50 mg/m2, days 1, 8, and 15) combined withdocetaxel (50mg/m2; day 1) and CPT-11(80mg/m2; days1 and 15) combined with S-1 (80mg/m2; 3 weeks on and1 week off), and recommended the latter regimen asfirst-line therapy. Y. Emi, Hiroshima, Red Cross Hospi-tal and K.Yoshida, Hiroshima University, reportedfavorable results with weekly paclitaxel (80mg/m2) assecond-line therapy, which showed less toxicity thanconventional regimens, with better effects, includingprolonged stable disease. T. Doi, National CancerCenter Hospital East, Chiba, reported a summary of2778 patients treated with a single drug (S-1; 80mg/m2;4 weeks on and 2 weeks off). Toxicities, including grade3 and higher, were observed in only 5% of patients,excluding hemoglobin reduction (12%). The responserate was 38%. Median survival time and time to pro-gression (TTP; time to progressive disease [PD]) were369 days and 137 days, respectively. The 1-year and2-year survival rates were 52% and 23%, respectively.

The results of these six reports suggest that new drugssuch as S-1, CPT11, and the taxanes showed higherresponse rates, with less toxicity, than conventionaldrugs in treating gastric cancer. Unfortunately, there isstill no standard chemotherapy for gastric cancer. How-ever, it is expected that, in the near future, some goodcandidate regimens will be decided on for first- andsecond-line therapies, from among the ongoing clinicaltrials that include these new drugs. (Reported by Y.Takahashi.)

Symposium 4. New strategy of immunotherapy for gas-tric cancer (chaired by S. Saji, Gifu University, and H.Yamaue, Wakayama Medical University)Cancer immunotherapy has entered a new era, allowingus to understand well the immune mechanism, includingthe precise sequences of cancer-related antigen pep-tides, and the mechanism of antigen presentation bydendritic cells (DCs). Eight speakers reported on newstrategies of immunotherapy for patients with gastriccancer; two speakers focused on antibody studies, andfive speakers clarified the anticancer effects of peptide-pulsed DCs. Also, J. Cai, Hebei Medical University,China, reported that gene transduction of DCs has beensuccessfully performed with a retroviral vector, and sug-gested that immunogene therapy may be an effectivetool for the treatment of gastric cancer.

First, K. Kono, Yamanashi University, reported on anew aspect of Herceptin, which recognizes the HER-2antigen expressed in various tumor cells, includinggastric cancer cells. Herceptin exerts anticancereffects by antibody-dependent cellular cytotoxicity(ADCC); however, in this report, HER-2 specificcytotoxic T-lymphocytes (CTL) augmented their MHC-restricted activity, and HER-2 restricted cytolytic

activity when CTLs were treated with Herceptin invitro. J. Sakamoto, Kyoto University, reported anotherantibody in a phase I clinical study. His group has devel-oped a new monoclonal antibody, huA33, which recog-nizes the cancer-related antigen A33, which is widelydistributed in gastrointestinal cancer tissues. Thirteenpatients with gastric cancer received huA33 in a phase Iclinical trial, and no toxicity was observed, except forone patient with mild fever (grade 1). However, oneshould consider that there are differences in the expres-sion of the A33 antigen in primary tumor sites andmetastatic sites.

Next, the symposium focused on cancer vaccination,using peptide-pulsed DCs. K. Mimura, Yamanashi Uni-versity, reported that CTLs which recognized HER-2peptides could be generated from peripheral bloodmononuclear cells obtained from gastric cancer pa-tients; N. Tokunaga, Okayama University, reported theclinical efficacy of treatment with p53 protein-pulsedDCs injected into gastric cancer tissues as neoadjuvantimmunotherapy. Two speakers demonstrated novel ap-proaches in DC therapy. Y. Ueda, Kyoto PrefecturalUniversity, used OK432 as an agent for the in vitromaturation of DCs. DCs expressed CD83 on their cellsurfaces on stimulation with interleukin (IL)-4 andOK432, and OK432-stimulated DCs secreted variouscytokines, including tumor necrosis factor (TNF)-α,and granulocyte-macrophage-colony-stimulating factor(GM-CSF). S. Kashimura, Fukushima Medical Univer-sity, reported the clinical benefits of a combination ofimmunotherapy, using DCs, with chemotherapy, usinga taxane. The final topic was reported by K. Okita,Sapporo Medical University. His group clarified a rela-tionship between gastric cancer cells and monocytes inthe process of metastasis, as well as a relationship be-tween metastasis and chemokines, including RANTES(Regulated on Activation, Normal T Expressed andSecreted) a chemokine that is a physiological ligand forthe HIV-1 coreceptors CCR3 and CCR5. RANTESmay be a useful molecular target for the inhibition ofcancer metastasis.

In summary, we discussed new strategies of immuno-therapy for gastric cancer; this could be a promisingapproach for the treatment of patients with advancedgastric cancer. (Reported by H. Yamaue.)

Panel discussion 1. Diagnosis and management of gas-trointestinal stromal tumors (GIST) (chaired by A.Yanagisawa, Kyoto Prefectural University of Medicine,and Y. Yamamura, Aichi Cancer Center)Most gastrointestinal mesenchymal tumors (GIMTs),which characteristically reveal a smooth protrusion ofgastrointestinal wall lined by intact mucosa, had beenconsidered to derive from smooth muscle and were gen-erally classified as leiomyomas and leiomyosarcomas.


Through various immunohistochemical studies, amajority of these tumors has come to be classifiednowadays as gastrointestinal stromal tumors (GISTs).The etiology of GISTs has been elucidated throughmutation analysis of the KIT protooncogene. Recentprogress in the understanding of GISTs has led to con-fusion among Japanese clinicians and investigators re-garding the diagnostic criteria of this disease entity. Itwas more than appropriate, therefore, that GIST wasselected as one of main subjects to be discussed at thiscongress.

Of six presentations, one referred to GISTs asspindle-cell tumors and another referred to GISTs asGIMTs, reflecting the confusion as regards the defini-tion of GIST. The participants were asked to adhere, infuture, to the definition of GIST established at the pre-vious congress: a proliferative neoplasm of spindle cellsthat fulfills either of the following criteria; (1) immuno-histologically positive for either or both KIT proteinand CD34, (2) immunohistologically negative for themarkers of myoid or neural origin if neither KIT proteinnor CD34 is expressed.

Immunohistological examination of the tissue speci-mens is mandatory for the diagnosis of GIST. GISTtumor tissues are rarely accessible by endoscopicbiopsy; however, because they are lined with intactmucosa. In general, therefore, GIST is diagnosed asa submucosal tumor, and follow-up is performed by 3-to 6-monthly endoscopic examinations until the tumorreaches the size of 2cm (A. Sawaki, Aichi CancerCenter) to 4 cm (Y. Tatsutomi, Tokyo University).A. Sawaki reported that endoscopic ultrasound-guidedfine-needle aspiration biopsy (EUS-FNAB) was auseful tool for the preoperative diagnosis of the tumor.

When a diagnosis of GIST is obtained, surgery is thetreatment of choice. Although sporadic cases associatedwith LN metastases have been reported (T. Sato, Can-cer Institute Hospital, Tokyo), wedge resection withoutsystematic LN dissection is the recommended treatmentoption (H. Katai, National Cancer Center, Tokyo), andthis can now be performed safely by a laparoscopy-assisted approach.

Imatinib mesylate is indicated for the treatment ofunresectable/recurrent GIST. Although a completeresponse was rarely achieved, survival benefit wasobserved among patients who had stable disease, indi-cating that the treatment should be continued until dis-ease progression (T. Kanda, Niigata University, and H.Endo, National Cancer Center East, Kashiwa). Evi-dence is, so far, lacking as regards the value of this drugin the neoadjuvant setting.

Various studies of the diagnosis and management ofGIST are currently ongoing, and the audience was con-vinced that there will be more to come in the very nearfuture. (Reported by Y. Yamamura.)

Panel discussion 2. Current status and future prospectsof peritoneal cytology for gastric cancer patients (chairedby M. Hiratsuka, Itami City Hospital, and H. Nishidoi,Tottori Red Cross Hospital)In this panel discussion, several important topics relatedto peritoneal cytology for gastric cancer; in particular,novel molecular-based methods for detecting cancercells with high sensitivity, were presented and discussedby five distinguished surgeons in this research field.

I. Miyashiro, Osaka Medical Center for Cancer andCardiovascular Diseases, presented findings showingthe prognostic significance of conventional peritoneallavage cytology (PLC), with special reference to therelationship between the number of cancer cells de-tected in PLC and patient prognosis. This group clearlyshowed that the number of cancer cells in PLC served asan important prognostic indicator.

The following three speakers talked about molecular-based methods for the detection of cancer cells inperitoneal washings. Y. Kodera, of Nagoya University,reported their attempts to increase sensitivity for thedetection of peritoneal cancer cells, using a real-timePCR assay for CEA mRNA. They found that a real-time PCR assay for CEA mRNA in peritoneal washingswas more sensitive than conventional PLC. The sensi-tivity and specificity of the real-time RT-PCR assay(84% and 94%, respectively) were higher than thosefor conventional cytology (56% and 91%, respectively).M. Takahashi, Yokohama City Hospital, reported onthe prognostic significance of telomerase reverse tran-scriptase mRNA (hTERT-M) expression in the perito-neal washings of P0/cT3–4 gastric cancer patients. Theirgroup showed, by multivariate analysis, that hTERT-Mwas the most significant prognostic factor among vari-ous conventional prognostic factors analyzed. The re-ports of these two groups suggest that a real-time PCRassay for the expression of CEA mRNA or hTERTmRNA has potential as a new molecular-based methodfor the detection of peritoneal cancer cells, with higheraccuracy than conventional PLC. K. Mori, University ofTokyo, reported a novel approach for the selection ofmarker genes, using microarray technology. First, theytried to select the most useful marker genes, takingadvantage of microarray analysis of the expression of10 000 genes in the gastric cancer cells and peritonealwashings of early-stage patients. They found that fivegenes, i.e., CK20, FABP1, MUC2, TFF1, and TFF2,were the best marker genes. Secondly, they showed thata nested RT-PCR assay, performed on these fivemarker genes, for the detection of cancer cells in theperitoneal washings, was highly sensitive and specific.

T. Inada, of Tochigi Cancer Center, reported theirresults of chemotherapy with 5-FU for CY1 (positivecytology) gastric cancer patients. They found that theoverall 5-year survival rate of the CY1 patients was


11.7%, and, interestingly, the median survival time ofpatients with DPD-negative cancers (2.38 years) waslonger than that of those with DPD-positive cancers(1.43 years).

It is well established that information derived fromconventional PLC plays a very important role in treat-ment decision-making for gastric cancer patients, andtherefore, the development of new more accurate meth-ods for the detection of peritoneal cancer cells has beenawaited for a long time. In this panel discussion, verypromising results on the detection of peritoneal cancercells with a novel molecular-based method werepresented. The molecular-based method seems to besuperior to conventional PLC. However, the resultspresented in the panel discussion are still preliminary,and confirmatory studies definitely need to be donebefore this new method can be accepted as a standard ofcare. (Reported by M. Hiratsuka.)

Consensus meeting 2. Need for the implementation of anationwide fact-finding inquiry on endoscopic mucosalresection (EMR) for early gastric cancers (chaired byS. Yoshida, National Cancer Center Hospital East, andY. Ohtani, Keio University)Since 1987, when Tada and colleagues initially devisedthe “strip biopsy”, endoscopic mucosal resection(EMR) has been used widely in Japan as a standardtreatment for early gastric cancer. With recent technicalinnovations, large tumors or those with ulcer scars canbe targets of EMR, and the expansion of the EMRcriteria in the JGCA guidelines is being discussed.Nevertheless, the actual end results of EMR havebeen reported only at the institutional level, withpossible publication bias in the literature. The JGCA,therefore, organized an ad-hoc committee to survey theactual situation of EMR in Japan (EMR Committee).D. Saito, from the National Cancer Center Hospital,chairman of this committee, emphasized the importanceof a nationwide fact-finding inquiry in order to clarifythe following issues; (1) validity of the JGCA guide-lines, (2) adequacy of general rules concerning EMRprocedures, (3) efficiency of surveillance after the treat-ment, (4) actual therapeutic efficacy, or gastric cancerdeath rates in patients with long follow-up, and (5) theincidence of expected and unexpected complications.

M. Tada, Saitama Cancer Center, reported thetreatment results of “strip biopsy”, based on his 2100cases during the past 15 years. He concluded that thetherapeutic efficacy of the procedure was proven, with-out any severe complications or gastric cancer death, forpatients meeting the criteria of the guidelines, thoughlocal recurrence that was treated with re-strip biopsyhad been detected in 7% of the patients. Also, he re-ferred to the difficulty of complete follow up of thepatients for a long time after the treatment. T. Gotoda,

National Cancer Center Hospital, and M. Fujishiro,Tokyo University Hospital, showed that their results forthe treatment of more than 600 lesions exceeding thecriteria of the guidelines were satisfactory, as long asthey completed single-fragment resection for the histo-logically differentiated type of mucosal cancer, usingan endoscopic submucosal dissection (ESD) technique,with which the complete resection rate was more than90%. T. Gotoda also emphasized the importance ofcareful follow up after multiple-fragment EMR, par-ticularly in lesions that did not meet the criteria of theguidelines, because the risk of treatment failure (in-cluding cancer death) is not low after histologicalunderdiagnosis of the resected specimens. He pointedout that the mooted nationwide inquiry could be usefulfor urging the government to set up adequate fundingfor the cost of ESD. M. Fujishiro emphasized the impor-tance of prospective registration, because several es-sential data parameters, such as bleeding volume andoperation time, cannot be checked by retrospectiveinvestigation.

T. Doi, National Cancer Center Hospital East, pro-posed an Internet registration system and outlined aregistration form to be used for the immplementation ofa nationwide inquiry on EMR. He commented that thedevelopment of such a prospective investigation wouldbe indispensable, because, in 2005, we will face anamendment of the Pharmaceutical Business Law bywhich we are required to carry out investigational clini-cal trials for newly developed endoscopic instruments tobe approved by the government.

In the general discussion, consensus on the followingpoints was obtained: (1) a nationwide fact-finding in-quiry on EMR for early gastric cancer should be carriedout; (2) to confirm the feasibility of Internet registra-tion, by the end of this year, 13 member institutionsof the EMR Committee register data on all patientstreated by EMR during the calendar year of 2001,and assess the feasibility of the system in 2005. (3)If the system works well, nationwide prospectiveregistration should start in 2006. (Reported by S.Yoshida.)

Workshop 2. Micrometastasis of gastric cancer (chairedby T. Hattori, Shiga University of Medical Science, andY. Kato, Osaka City University)Micrometastasis seems to be a prognostic factor for gas-tric cancer, but its clinical significance has not been fullyelucidated. M. Ikeguchi, Tottori University, reportedthat it was uncertain whether cancer cells appearing inperipheral blood as a result of surgical procedures led toreal metastasis. M. Miyagi, Kurume University, and K.Oyama, Fukushima Medical University, emphasizedthe importance of detecting micrometastasis in sentinelLNs. For the detection of micrometastasis, M. Ikeguchi


and K. Oyama, employed an RT-PCR method, and T.Ishii, Osaka University, reported a new transcription-reverse transcription concerted reaction (TRC) system.H. Akiyama, Yokohama City University, pointedout the necessity for diagnosing micrometastasis inparaaortic LNs for their successful resection. Y.Mochizuki, Aichi Cancer Center, reported an animalexperiment carried out to assess the effectiveness ofomentectomy and paclitaxel chemotherapy to controlmicrometastasis in the abdominal cavity.

The diagnosis of micrometastasis is now possible,as shown by the speakers at this workshop, but themanagement of micrometastasis appears to be the nextproblem to be overcome. (Reported by T. Hattori.)

Workshop 3. Palliative care for advanced gastric cancer(chaired by H. Shiozaki, Kinki University, Osaka, andW. Koizumi, Kitasato University, Kanagawa)In this session, six presenters spoke about their institu-tional experience and problems with the treatmentor palliative care of patients with advanced/recurrentgastric cancer.

For pain control, it was reported that gastric cancerpatients needed more opioids than patients withother digestive cancers. Half of the gastric cancerpatients needed additional sedative treatment for paincontrol.

One of the greatest problems with gastric cancer atthis stage is the frequent obstruction of the gastrointes-tinal tract, which interferes with oral intake. Feedingtechniques, such as percutaneous endoscopic gastros-tomy (PEG), or percutaneous transesophageal gastros-tomy (PTEG) were useful for maintaining nutrition.Endoscopic stenting for stricture and laparoscopicgastrojejunostomy were also helpful in some patients.However, the decision to undertake palliative surgery inpatients with obstructive peritonitis carcinomatosa isdifficult, because, though it certainly improves qualityof life in some patients, it may lead only to surgicalcomplications and pain in other patients.

The clinical significance of providing care for mentalproblems was also reported in this session. Anxietyand depression are major mental problems in patientswith recurrence, and a psycho-oncological approachshould be considered in these patients. (Reported byW. Koizumi.)

Workshop 4. Helicobacter pylori and gastric cancer(chaired by K. Sugano, Jichi Medical School, andY. Kinoshita, Shimane University)A strong link between Helicobacter pylori infection andgastric carcinogenesis has now been well established bya number of epidemiological, experimental, and clinicalstudies. Based on this premise, different aspects of therelationship between H. pylori and gastric cancer were

discussed in this workshop. Unique data, showing thatADP-ribosylation was associated with H. pylori infec-tion, were reported by N. Yoshihiro, Chiba University.As H. pylori has mono-ADP-ribosyltransferase activity,N. Yoshihiro’s group assume that this property ofH. pylori may play a part in gastric carcinogenesis.Although they found that ADP-ribosylated proteinswere increased in gastric cancer tissues, the ADP-ribosylated proteins were mostly poly-ADP-ribosylated, indicating that this increase was not dueto the bacterial enzyme but was due to an intrinsichost reaction. Thus, the role of the mono-ADP-ribosyltransferase activity of H. pylori in gastriccarcinogenesis is still unresolved.

N. Uemura, International Medical Center of Japan,Tokyo, presented two sets of data showing the effectof H. pylori infection on the development of gastriccancer. The major part of the internationally acclaimeddata he presented at this workshop has been publishedpreviously in two papers, but, in this talk, he presentedupdated follow-up data, showing that a few patients intheir H. pylori- eradicated group had developed gastriccancer. Therefore, it is now realized that H. pylori eradi-cation may retard the development of gastric cancer,but eradication is not sufficient to prevent the risk ofcancer progression in high-risk patients who have al-ready developed early gastric cancer.

Animal studies, presented by M. Tatematsu, AichiCancer Center, also demonstrated that H. pylori has aprofound effect on the promotion of gastric carcinogen-esis. He emphasized that high salt intake increasedthe risk of gastric carcinogenesis. In this animal model,earlier, compared with later, eradication of H. pyloriwas more effective in preventing gastric cancer deve-lopment. Together with Uemura’s data, this findingsuggests that we should consider starting H. pylorieradication programs in younger age groups.

Two studies, by N. Onoda, Osaka City University,and T. Miyashita, Kanazawa University, dealt with theproblems of H. pylori infection after gastrectomy. N.Onoda showed a discrepancy between endoscopic gas-tritis and histologic gastritis in the remnant stomach,and indicated that H. pylori infection was responsiblefor the histological gastritis, while duodenal regurgita-tion was more relevant in the endoscopic gastritis. T.Miyashita presented findings that H. pylori tended toshow spontaneous disappearance after gastrectomy. Heindicated that, although eradication of H. pylori aftergastrectomy may be effective for preventing remnantcancer development, this eradication required deliber-ate consideration, because in his group had experienceof patients who developed stomal ulcer after successfulH. pylori eradication. The topics presented in this work-shop represent only part of the large issue of the role ofH. pylori in gastric cancer. Therefore, we should keep


focusing our attention on the progress of this issue bycontinuing to hold workshops or symposiums in thecoming JGCA meetings. (Reported by K. Sugano.)

Workshop 5. Carcinoma of the cardia (chaired by Y.Kato, Cancer Institute, Tokyo, and T. Tsunoda,Kawasaki Medical School, Kurashiki)The optimal surgical approach for carcinoma of thecardia has been controversial, even with the introduc-tion of new anastomotic instruments. Some authorshave advocated the use of a left thoracotomy and lap-arotomy, while others have recommended laparotomyalone. Since 1996, when Siewert and Stein publishedtheir article entitled “Carcinoma of the cardia: carci-noma of the gastroesophageal junction — classification,pathology and extent of resection”, many surgeons havechosen to use this classification, because its clinical useis very simple and easy. When the tumor center or morethan two-thirds of the tumor mass is located more than1cm above the anatomical gastroesophageal junction,the tumor is classified as an adenocarcinoma of thedistal esophagus (type I). When the tumor center ortumor mass is located within 1cm orally or 2 cm aborallyof the anatomical gastroesophageal junction, the tumoris classified as a true carcinoma of the cardia (type II).Adenocarcinomas of the gastroesophageal junction thathave their tumor center or more than two-thirds ofthe tumor mass located more than 2cm below theanatomical gastroesophageal junction are classified assubcardial tumors (type III). For a type I tumor, a radi-cal transhiatal esophagectomy plus two-field LN dissec-tion should be adopted. For type II and III tumors,an extended total gastrectomy with D2 LN dissectionshould be adopted.

Siewert’s classification of carcinoma of the cardia wasapproved at a consensus conference during the SecondInternational Gastric Cancer Congress held in 1997, andis commonly used. However, there are some unresolvedpractical problems.

The concept of Siewert’s classification is based on thepattern of lymphatic spread, and the classification is notrelevant with regard to a safe resection margin of theesophagus. Most surgeons today accept that extendedlymphadenectomy may improve the prognosis in pa-tients with carcinoma of the cardia who have a limitednumber of positive LNs. However, in our workshop,five speakers reported that no patients with positiveLNs in the lower posterior mediastinum had survivedfor 2 years after operation. The speakers at this work-shop reported that recurrence at the resection marginreduced the survival rate. Thus, it seems that the mostimportant point at issue is the resection margin, which isdirectly related to the surgical approach; with or with-out thoracotomy, or a subtotal esophagectomy using atranshiatal blunt esophagectomy approach or a gastrec-

tomy plus resection of the lower part of the esophagus(extended total gastrectomy).

Siewert’s classification is made according to the loca-tion of the tumor center, but a huge or invasive tumorcan be far from the gastroesophageal junction. Basi-cally, it is unreasonable to select an operative procedureor approach from the viewpoint of the tumor center.Moreover, as we discussed in this workshop, the inva-sive pattern differs among histological types. For ex-ample, poorly differentiated or signet-ring cell typeshows more “skip lesions” far from the tumor marginthan other histological types. To select the optimalsurgical procedure for individuals, more precise datashould be obtained.

In the first place, as discussed at our workshop, whatis the gastroesophageal junction? Is it the mucosal junc-tion, vascular junction, luminal junction, or muscularjunction? Furthermore, it is difficult to make such ananalysis when the gastroesophageal junction has beendestroyed by cancer invasion. Therefore, the methodfor classifying the gastroesophageal junction should bestated when carcinoma of the cardia is discussed.

Because there are still many unresolved problemswith carcinoma of the cardia, as mentioned, we shoulddiscuss it again in the near feature. (Reported byT. Tsunoda.)

Workshop 6. Intraperitoneal chemotherapy for gastriccancer (chaired by K. Hirakawa, Osaka City University,and Y. Yonemura, Shizuoka Cancer Center)Peritoneal metastasis is fatal in patients with gastriccancer and is rarely cured. The treatment optionsfor peritoneal dissemination from gastric cancer areextremely limited. Some surgeons have removed theperitoneal dissemination by surgery. However, thisoperative procedure, peritonectomy, should be carriedout along with chemo-hyperthermic peritoneal perfu-sion (CHPP) to totally eliminate peritoneal metastasis,as micrometastases may spread all over the peritonealsurface. Intraperitoneal chemotherapy, with or with-out hyperthermia, has been investigated in sometrials, although the results remain controversial andunsatisfactory.

In this workshop, five speakers presented theirfindings on clinical outcome (one of them reported theresults of CHPP), and one speaker presented experi-mental findings. N. Ohashi, Nagoya University, demon-strated that the peritoneal micrometastases of gastriccancer cell lines in nude mice disappeared afterthe intraperitoneal administration of paclitaxel. Heconcluded that intraperitoneal chemotherapy withpaclitaxel might be useful as a prophylactic treatmentfor peritoneal micrometastasis. Next, two speakersreported the results of neoadjuvant intraperitonealchemotherapy. S. Fushida, Kanazawa University, noted


that laparoscopic intraperitoneal examination shouldbe done preoperatively for patients with a high riskof peritoneal metastasis. He demonstrated that pre-or postoperative intraperitoneal chemotherapy witha taxane prolonged the survival of patients who under-went gastrectomy. Y. Fujiwara, Osaka University,argued that, in CY0 patients with a positive moleculardiagnosis of peritoneal metastasis (made usingperitoneal lavage fluid obtained by laparoscopy) thedisease was susceptible to neoadjuvant intraperitonealchemotherapy with cisplatin and mitomycin. S.Katayanagi, Tokyo Metropolitan Komagome Hospital,pointed out the usefulness of repeat intraperitonealchemotherapy with CDDP, using an intraperitonealport after operation. K. Ohta, University of Tsukuba,stated that intraperitoneal chemotherapy was useful forpatients with P0CY1 or macroscopically resected P1disease, but that it should not be administered to pa-tients with unresectable P1. On the other hand, C.Kunisaki, Yokohama City University, reported disap-pointing results of CHPP in both the prophylactic andtreatment settings.

To summarize the workshop discussions, the clinicalusefulness of intraperitoneal chemotherapy was sug-gested in gastric cancer with intraperitoneal micro-or minimally disseminated disease. (Reported by K.Hirakawa.)

Video symposium. Progress of endoscopic surgeryfrom laparoscopy-assisted distal gastrectomy (LADG)(chaired by S. Matsumoto, Fujita Health University,Nagoya, and M. Ninomiya, Hiroshima City Hospital)The procedure of gastrectomy consists of three ele-ments; removal of the primary lesion, lymphadenec-tomy, and reconstruction. It is true that laparoscopicsurgery needs more hemostatic procedures than thoserequired in open surgery. Around 1990, the hemostaticmethods in laparoscopic surgery were confined to theuse of compression, endoclips, and electrocautery. Theadvent of ultrasonic cavitational shears has enabled safeand easy LN dissection, which has facilitated the devel-opment of LADG.

In this symposium, six panelists presented videos todemonstrate that the same quality of radical operationcould be achieved in LADG as in open surgery.

M. Ninomiya, Hiroshima City Hospital, in his open-surgery video, showed the detailed technique of auto-nomic nervous system preservation for early gastriccancer, while K. Kojima, Tokyo Medical and DentalUniversity, reported his laparoscopic procedure for thepreservation of the pancreatic, hepatic, and celiac auto-nomic nerve branches.

One of the important points in laparoscopic surgeryis to secure a good visual field. Y. Ohmura, OkayamaRosai Hospital, reported that the operative field for

lymphadenectomy could be effectively extended by el-evating the stomach toward the anterior abdominal wallwith Nylon strings placed around the corpus and thepylorus of the stomach. I. Uyama, Fujita Health Uni-versity, Nagoya, demonstrated D2 LN dissection withhand-assisted laparoscopic surgery (HALS). He saidthat, by retracting the spleen and the pancreas in totalgastrectomy, HALS could secure a good visual field forthe removeal of LNs along the splenic artery.

S. Kanaya, Himeji National Hospital, reported a gas-troduodenostomy method named “Delta anastomosis”using a linear stapler. Y. Kakeji, Kyushu University,Fukuoka, demonstrated that intracorporeal ligationand anastomosis are easily performed under thewith a three-dimensional view, using the “da Vinci”manipulator.

We concluded that laparoscopic surgery has con-stantly been improved in quality with the developmentof new devices and surgeons’ experience. (Reported byS. Matsumoto.)

Educational seminar. Critical pathways in the diagnosisprocedure combinations (DPC) era (chaired by T.Konishi, Kanto Medical Center NTT-EC, and H.Furukawa, Sakai Municipal Hospital)The Educational Seminar was held on the day beforethe start of the scientific sessions. Despite the very un-favorable weather, with sleet, more than 300 peopleparticipated in this seminar, reflecting the increasinginterest in the topics of “diagnosis procedure combina-tions” (DPC) and “critical pathways” (CP). At present,the DPC system is used at only 82 hospitals in Japan,but it is anticipated that the system will be introduced atall acute care facilities in the not-so-distant future, andthat its effects on the management of medical institu-tions will be huge. Additionally, CP are garnering atten-tion as an efficient tool with which to tackle this issue.

During the lecture part of the seminar, first of all, T.Konishi, one of the chairpersons, gave an overview ofthe current status of the introduction of CP for gastriccancer therapy in Japan. Then M. Kobayashi, KeioUniversity, Tokyo, explained the essence of the currentDPC, giving examples of the way in which the healthinsurance system calculates, reimbursement and out-lining the design of CP under the DPC system. M.Terashima, Fukushima Medical University, presentedthe objectives and utility of the introduction of CP forcancer chemotherapy; then he outlined the cost effectsof the 2004 DPC revision, based on an example from theclinical practice of chemotherapy for gastric cancer. Healso referred to a comparative analysis of the DPCsystem and a system based on reimbursement of theactual costs of treatment. H. Baba, Kyushu University,Fukuoka, touched on the national policies for theimprovement of safety in health care and showed the


importance of CP for risk management and improvedsafety. Finally, S. Takahashi, Shizuoka Cancer Center,reported on CP for gastric cancer surgery with differentpostoperative admission periods depending on the sur-geons; he also outlined the CP that their center used intheir electronic medical record system.

In the plenary discussion, S. Ohyama (Cancer Insti-tute Hospital, Tokyo), T. Noie (Kanto Medical CenterNTT-EC), H. Yamanaka (Kishiwada City Hospital,Osaka), and W. Takiyama (Hiroshima Asa MunicipalHospital) joined the speakers as panelists. They dis-cussed, among other topics, the role of CP in the era ofDPC, the need or lack of need for modifications of CP,and methods for establishing the use of CP. Many doc-tors from hospitals where DPC have already been intro-

duced, as well as those from hospitals where this systemhas not yet been used, also participated in the discus-sion. Consensus was achieved in that the introduction ofDPC and the use of CP must not affect the safetyof medical care. Examples of the increased efficiency ofmedical care, owing to DPC and CP leading to changesin the number of beds and the distribution of personnel,were also given. As a result, it was agreed that CP inresponse to DPC should not be introduced from themanagement point of view, but “should be promulgatedfor progress towards quality care, giving primary im-portance to safe health care for the patient, based onclinical guidelines and evidence, and being revisedaccording to the results of variance analysis.” (Reportedby T. Konishi.)

meeting report of the 76th congress of the japanese gastric cancer association

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