Clinical characteristics of diabetic ketoacidosis in users and non-users of SGLT2 inhibitors

AIM

This study investigated the clinical characteristics of diabetic ketoacidosis (DKA) and compared the DKA characteristics between patients treated with and without SGLT2 inhibitors.

METHODS

Data were collected from patients aged ≥ 18 years admitted for DKA at nine centres in Korea between September 2014 and April 2017. The electronic medical records of these subjects were retrospectively reviewed. Based on their history of medications taken before admission, subjects were classified as either users or non-users of SGLT2 inhibitors and their clinical characteristics of DKA were compared.

RESULTS

During the study, the main subtype of DKA episodes (n = 523) was identified as type 2 diabetes (51%). Average hospitalization duration was 11 days, and average intensive care unit (ICU) time was 2.5 days. The in-hospital mortality rate was 3%, but no users of SGLT2 inhibitors died during DKA treatment. In patients taking SGLT2 inhibitors (n = 15), DKA manifested at 124 days, on average, after starting the inhibitors (range: 7-380 days). Also, SGLT2 inhibitors users had significantly lower plasma glucose levels (413 mg/dL) compared with non-users (554 mg/dL), and longer ICU stays (4 vs. 2 days; P = 0.019).

CONCLUSION

In this report of recent data on the clinical features of DKA in Korea, patients using SGLT2 inhibitors needed longer treatment in ICUs compared with non-users and had lower levels of blood glucose, whereas DKA associated with SGLT2 inhibitors was rare.

Landscape of Elderly Suicide in South Korea: Its Trend According to Age, Gender, and Educational Attainment

South Korea has one of the highest suicide rates in the world, and the most alarming suicide rate is among its elders. This study aims to understand the social, historical, and cultural context of the Korean older adults and examine suicide trends based on that understanding. The results show that the suicide risk increases with age, the male suicide rate outweighs that of females, and the suicide rate decreases with educational attainment. In addition, several suggestions for reducing elderly suicide rate are addressed, including differentiating the existing social services for elders by age and expanding suicide prevention programs beyond schools to communities so that all people in need can access them.

Comparative study on the effectiveness of a corticosteroid injection for carpal tunnel syndrome in patients with and without Raynaud's phenomenon

AIMS

The aim of this study was to compare the efficacy of a corticosteroid injection for the treatment of carpal tunnel syndrome (CTS) in patients with and without Raynaud's phenomenon.

PATIENTS AND METHODS

In a prospective study, 139 patients with CTS were treated with a corticosteroid injection (10 mg triamcinolone acetonide); 34 had Raynaud's phenomenon and 105 did not (control group). Grip strength, perception of touch with a Semmes-Weinstein monofilament and the Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at baseline and at six, 12 and 24 weeks after the injection. The Cold Intolerance Severity Score (CISS) questionnaire was also assessed at baseline and 24 weeks after the injection.

RESULTS

The two groups had similar baseline BCTQ scores, but the scores in the Raynaud's phenomenon group were significantly higher than those in the control group at 12 and 24 weeks after the injection. Throughout the 24-week follow-up, there were no significant differences in the mean grip strength between the groups, whereas the mean Semmes-Weinstein monofilament sensory index for the control group was significantly higher than that of the Raynaud's phenomenon group. The mean CISSs were not significantly different between the groups at baseline and at 24 weeks. After 24 weeks, 11 patients (32%) in the Raynaud's phenomenon group and 16 (15%) in the control group required carpal tunnel decompression (p = 0.028). Multivariable analysis indicated that concurrent Raynaud's phenomenon (odds ratio (OR) 2.6) and severe electrophysiological grade (OR 2.1) were independently associated with a failure of treatment after a corticosteroid injection.

CONCLUSION

Although considerable improvements in symptoms will probably occur in patients with Raynaud's phenomenon who have CTS, they have higher risk of poor functional outcomes and failure of treatment than those without Raynaud's phenomenon. Cite this article: Bone Joint J 2017;99-B:1637-42.

Effects of metabolic syndrome on the functional outcomes of corticosteroid injection for De Quervain tenosynovitis

Metabolic syndrome is a constellation of medical conditions that arise from insulin resistance and abnormal adipose deposition and function. In patients with metabolic syndrome and De Quervain tenosynovitis this might affect the outcome of treatment by local corticosteroid injection. A total of 64 consecutive patients with De Quervain tenosynovitis and metabolic syndrome treated with corticosteroid injection were age- and sex-matched with 64 control patients without metabolic syndrome. The response to treatment, including visual analogue scale score for pain, objective findings consistent with De Quervain tenosynovitis (tenderness at first dorsal compartment, Finkelstein test result), and Disability of the Arm, Shoulder, and Hand score were assessed at 6, 12, and 24 weeks follow-up. Treatment failure was defined as persistence of symptoms or surgical intervention. Prior to treatment, patients with metabolic syndrome had mean initial pain visual analogue scale and Disability of the Arm, Shoulder, and Hand scores similar to those in the control group. The proportion of treatment failure in the metabolic syndrome group (43%) was significantly higher than that in the control group (20%) at 6 months follow-up. The pain visual analogue scale scores in the metabolic syndrome group were higher than the scores in the control group at the 12- and 24-week follow-ups. The Disability of the Arm, Shoulder, and Hand scores of the metabolic syndrome group were higher (more severe symptoms) than those of the control group at the 12- and 24-week follow-ups. Although considerable improvements in symptom severity and hand function will likely occur in patients with metabolic syndrome, corticosteroid injection for De Quervain tenosynovitis is not as effective in these patients compared with age- and sex-matched controls in terms of functional outcomes and treatment failure.

LEVEL OF EVIDENCE

III.

Effect of metabolic syndrome on the outcome of corticosteroid injection for carpal tunnel syndrome

Diffuse peripheral nerve impairment is common in metabolic syndrome: in patients with metabolic syndrome and carpal tunnel syndrome this might affect the outcome of treatment by local corticosteroid injection. A total of 55 consecutive patients with carpal tunnel syndrome and metabolic syndrome treated with corticosteroid injection (10 mg triamcinolone acetonide) were age and sex matched with 55 control patients without metabolic syndrome. Grip strength, perception of touch with Semmes-Weinstein monofilaments and Boston Carpal Tunnel Questionnaires were assessed at the baseline and at 6, 12 and 24 weeks follow-up. The two groups had similar pre-operative grip strength and Boston Carpal Tunnel Questionnaire scores. The Boston Carpal Tunnel Questionnaire symptom and function scores of the metabolic syndrome group were significantly greater than the control group at 12 and 24 weeks follow-up. Except for significantly greater grip strength at the 12-week follow-up in the control group, there were no significant differences in grip strength between the groups. Semmes-Weinstein monofilament sensory index for the control group was significantly greater than that of the metabolic syndrome group throughout the 24-week follow-up. After 24 weeks, five patients (13%) in the control group and 13 patients (27%) in the metabolic syndrome group had had carpal tunnel surgery. Patients with metabolic syndrome are at risk for poor functional outcome and failure of treatment after corticosteroid injection for carpal tunnel syndrome.

LEVEL OF EVIDENCE

Treatment benefits III.

Supplementary tibial fixation in anterior cruciate ligament reconstruction - Direct cortical fixation using spiked washer screw vs. post-tie using washer screw

We compare clinical outcomes of two different supplementary tibial fixation in anterior cruciate ligament (ACL) reconstruction using free tendon Achilles allograft. Eighty subjects underwent ACL reconstruction using Endobutton CL for femoral fixation and Bio-interference screw for tibial fixation. Supplementary tibial fixation was performed as direct -cortical fixation using spiked washer screw (group I) or as post-tie using washer screw (group II). -Lachman test, pivot shift test, IKDC classification, Lysholm score, and side-to-side difference (SSD) were evaluated. Thirty six in group I and thirty five in group II could follow up for at least 2 years. At the last follow-up, 7 in group I and 1 in group II showed 2+ or 3+ in Lachman test (p = 0.027). Mean SSD was 2.4mm in group I and 1.4mm in group II (p = 0.048). Post-tie using washer screw was more effective than direct cortical fixation using spiked washer screw to restore stability. Level of evidence : Therapeutic Level I ; Randomized controlled clinical trial.

The risk of lymph node metastases in 3951 surgically resected mucosal gastric cancers: implications for endoscopic resection

BACKGROUND AND AIMS

Endoscopic resection for mucosal gastric cancer (MGC) is highly recommended in the absence of lymph node metastasis (LNM). We aimed to clarify the risk factors for LNM in MGC and to investigate the association of LNM with the indication criteria for endoscopic submucosal dissection (ESD).

METHODS

A retrospective cohort study was performed on 3951 patients with MGC who underwent radical gastrectomy at the Samsung Medical Center in Seoul, Republic of Korea, between September 1994 and September 2010.

RESULTS

Of the patients with MGC, 101 (2.60%) were positive for LNM. Multivariate analysis, followed by univariate analysis, revealed the following risk factors for LNM in MGC: large tumor size, undifferentiated tumor type, lymphatic invasion, perineural invasion, and associated ulceration in the tumor (hazard ratio 1.25, 7.49, 20.65, 23.45, and 4.07, respectively). Patients without LNM had significantly increased survival and/or recurrence-free survival rates than patients with LNM (188.4/209.8 months vs 169.5/188.0 months; P = .029/.004, respectively). Only 3 of 1065 patients (0.3%) who met the absolute indication criteria for ESD had LNM. Of those who met the expanded indication criteria for ESD, 11 of 2678 patients (0.4%) had LNM. LNM also was found in 2 patients who had a differentiated tumor <0.5 cm without ulceration.

CONCLUSION

The risk for LNM was very low when patients with MGC met the absolute and/or expanded criteria for endoscopic resection, which meant the indication criteria for ESD was safe and acceptable. However, although the risk for LNM is very low, it should not be considered negligible in endoscopic resection.

Association of heart rate with albuminuria in a general adult population: the 2011 Korea National Health and Nutrition Examination Survey

BACKGROUND

Albuminuria is associated with increased risk of multiple adverse health outcomes, such as progressive renal failure, cardiovascular disease and death. However, in the general population, it is uncertain whether albuminuria is associated with elevated heart rate, which is an independent and powerful risk factor for cardiovascular disease.

AIM

To investigate whether an elevated heart rate is an independent factor associated with albuminuria in the general adult population of Korea.

METHODS

A cross-sectional analysis was carried out on 5198 Korean adults aged 19 years or older who participated in the fifth (2011) Korea National Health and Nutrition Examination Survey (KNHANES V-2).

RESULTS

The prevalence of albuminuria showed an increasing trend throughout the whole range of heart rate, even after adjusting for confounders (P = 0.002). The increment was most profound at the heart rate of 70-75 and >76 beats per minute (b.p.m.; P = 0.011). In multiple logistic regression analysis, age (P < 0.001), hypertension (P < 0.001), diabetes (P < 0.001), hypertriglyceridaemia (P = 0.025), estimated glomerular filtration rate (P = 0.028) and heart rate (P = 0.023) were independently associated with the presence of albuminuria in Korean adults. Compared with participants with heart rate ≤ 64 b.p.m., the odds ratio (95% CI) for albuminuria was 1.50 (1.15-1.96) for those with heart rate ≥ 76 b.p.m.

CONCLUSIONS

The prevalence of albuminuria is independently associated with heart rate in the general adult population of Korea.

Preoperative smoking cessation can reduce postoperative complications in gastric cancer surgery

BACKGROUND

Despite the close link between cigarette smoking and the development of gastric cancer, little is known about the effects of cigarette smoking on surgical outcomes after gastric cancer surgery. The aim of this study was to investigate whether preoperative smoking status and the duration of smoking cessation were associated with short-term surgical consequences in gastric cancer surgery.

METHODS

Among 1,489 consecutive patients, 1,335 patients who underwent curative radical gastrectomy at the Samsung Medical Center between January and December 2009 were included in the present study. The smoking status was determined using questionnaires before surgery. Smokers were divided into four groups according to the duration of smoking cessation preoperatively (<2, 2-4, 4-8, and >8 weeks). The primary endpoint was postoperative complications (wound, lung, leakage, and bleeding); secondary endpoints were 3-year recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Five hundred twenty-two patients (39.1 %) were smokers. Smokers had a significantly higher overall incidence of postoperative complications than nonsmokers (12.3 vs. 5.2 %, P < 0.001, respectively), especially in impaired wound healing, pulmonary problems, and leakage. Smokers also had more severe complications than nonsmokers. After adjusting for other risk factors, the odds ratio (95 % CI) for the development of postoperative complications in the subgroups who stopped smoking <2 weeks, 2-4, 4-8, and >8 weeks preoperatively were 3.35 (1.92-5.83), 0.99 (0.22-4.38), 2.18 (1.00-4.76), and 1.32 (0.70-2.48), respectively, compared with the nonsmokers. There were no significant differences in 3-year RFS (P = 0.884) and OS (P = 0.258) between smokers and nonsmokers.

CONCLUSIONS

Preoperative smoking cessation for at least 2 weeks will help to reduce the incidence of postoperative complications in gastric cancer surgery.

Clinical Significance of IGFBP-3 Methylation in Patients with Early Stage Gastric Cancer

BACKGROUND: IGFBP-3 is a multifunctional protein that inhibits growth and induces apoptosis of cancer cells. Hypermethylation of the promoter represses expression of the IGFBP-3 gene. We undertook this study to assess the impact of IGFBP-3 methylation on survival of early stage gastric cancer patients. METHODS: Of the 482 tissue samples from gastric cancer patients who underwent curative surgery, IGFBP-3 methylation was tested in 138 patients with stage IB/II gastric cancer. We also analyzed IGFBP-3 methylation in 26 gastric cancer cell lines. IGFBP-3 methylation was evaluated by methylation-specific polymerase chain reaction (MethyLight). Statistical analyses, all two-sided, were performed to investigate the prognostic effects of methylation status of the IGFBP-3 promoter on various clinical parameters. RESULTS: Hypermethylation of IGFBP-3 was observed in 26 (19%) of the 138 stage IB/II gastric cancer patients. Clinicopathological factors such as age, Lauren classification, sex, tumor infiltration, lymph node metastasis, and histologic grade did not show a statistically significant association with the methylation status of the IGFBP-3 promoter. Patients with a hypermethylated IGFBP-3 promoter had similar 8-year disease-free survival compared with those without a hypermethylated IGFBP-3 promoter (73% vs 75%, P = .78). In subgroup analyses, females, but not males, seemed to have poorer prognosis for DFS and OS in the subset of patients with IGFBP-3 methylation as compared with those without IGFBP-3 methylation (8-year DFS: 55.6% vs 71.6%, P = .3694 and 8-year overall survival: 55.6% vs 68.4%, P = .491, respectively) even with no statistical significance. CONCLUSIONS: The status of IGFBP-3 methylation as measured by methylation-specific polymerase chain reaction proposed the modest role for predicting survival in specific subgroups of patients with early-stage gastric cancer who undergo curative surgery. However, this needs further investigation.

Pulsed laser-assisted focused electron-beam-induced etching of titanium with XeF2: enhanced reaction rate and precursor transport

In order to enhance the etch rate of electron-beam-induced etching, we introduce a laser-assisted focused electron-beam-induced etching (LA-FEBIE) process which is a versatile, direct write nanofabrication method that allows nanoscale patterning and editing. The results demonstrate that the titanium electron stimulated etch rate via the XeF2 precursor can be enhanced up to a factor of 6 times with an intermittent pulsed laser assist. The evolution of the etching process is correlated to in situ stage current measurements and scanning electron micrographs as a function of time. The increased etch rate is attributed to photothermally enhanced Ti-F reaction and TiF4 desorption and in some regimes enhanced XeF2 surface diffusion to the reaction zone.

Ultrasonically activated shears versus electrocautery in open gastrectomy for gastric cancer: a randomized controlled trial

BACKGROUND

Use of ultrasonically activated shears (UAS) is gaining popularity in open surgery but without concrete evidence. We conducted a prospectively randomized study to assess the efficacy of ultrasonic dissection in open gastrectomy for gastric cancer.

METHODS

Patients with gastric cancer who were to undergo gastrectomy with D2 lymph node dissection were enrolled and assigned to either the conventional surgery group (n = 125) or the UAS group (n = 128).

RESULTS

The mean operating time was significantly reduced in the UAS group (89.3 ± 15.6 min) when compared to the conventional group (97.8 ± 17.2 min; p < 0.001). However, we did not find any significant difference in operative blood loss, the amount of postoperative abdominal drainage, or the rate of postoperative complications between the groups. A multivariate analysis for operating time revealed that the use of UAS, female gender and BMI less than 25 were significantly associated with reduced operating time. The operating time was significantly longer in the conventional group than in the UAS group (B 7.786; 95 % CI 4.103-11.468; p < 0.001). In the subgroup analysis, the use of UAS significantly reduced the operating time, especially in male patients, regardless of the BMI status.

CONCLUSIONS

The use of UAS in gastrectomy for gastric cancer was a safe and efficient method, especially in terms of reducing operating time for male patients.

Lymphoepithelioma-like carcinoma: a distinct type of gastric cancer

BACKGROUND

Lymphoepithelioma-like carcinoma (LELC) is a rare type of gastric carcinoma and has histologic features of intense lymphocytic infiltration. In this study, we attempted to analyze the clinicopathologic characteristics and survival outcome of patients with LELC compared with those with non-lymphoepithelioma-like carcinoma (NLELC).

METHODS

We studied 4282 patients who underwent gastrectomies to treat gastric cancer at the Department of Surgery of the Samsung Medical Center in Seoul, between January 2008 and December 2010. The clinicopathologic features and clinical outcomes of patients with LELC (n = 46) were compared with those with NLELC (n = 4236). In situ hybridization for Epstein-Barr virus (EBV) positivity was performed on the tissue of patients with LELC (n = 46) and NLELC (n = 1247).

RESULTS

The patients with LELC are male predominant and had more upper locations, more indeterminate Lauren classifications, lower T stages, less lymphatic invasion, and more positive EBV in situ hybridization compared with those of the NLELC group (80.4% versus 6.5%). Age, histologic type, Lauren type, the location of the tumor, the depth of the invasion, lymph node metastasis, and venous invasion were independent prognostic factors; however, the LELC type itself was not predictive of outcome. The 5-y survival rate of the LELC group (97.7%) was better than that of the NLELC group (89.4%); however, this difference was not statistically significant (P = 0.127).

CONCLUSIONS

The results of our study suggest that LELC is a less advanced disease than NLELC in terms of depth of invasion and lymphatic invasion at diagnosis. However, our study does not examine LELC as an independent prognostic factor of gastric cancer. Further studies are needed to explore its associations with EBV and a distinct pathway of carcinogenesis from NLELC.

Effect of triclosan-coated sutures on surgical site infection after gastric cancer surgery via midline laparotomy

PURPOSE

Surgical site infection (SSI) after open abdominal surgery is still a frequently reported nosocomial infection. To reduce the incidence of SSI, triclosan-coated sutures with antiseptic activity (Vicryl Plus) were developed. The aim of this study was to analyze the effect of Vicryl Plus on SSI after gastric cancer surgery via midline laparotomy.

METHODS

A total of 916 patients who underwent gastric cancer surgery at Samsung Medical Center between December 2009 and September 2011 were prospectively collected. We examined the occurrence of SSI (primary endpoint), assessments of wound healing (secondary endpoint). They were evaluated postoperatively on days 3, 7, and 30.

RESULTS

Of the 916 patients, 122 were excluded postoperatively by screening (out of the study protocol, adverse events, etc.). The remaining 794 patients were enrolled and monitored postoperatively. The cumulative SSI incidence was 11 cases (1.39%; 95% confidence interval [CI], 0.77-2.50) on day 30. Seromas were most frequently detected in wound healing assessments, with a cumulative incidence of 147 cases (18.51%; 95% CI, 15.98-21.39) on day 30.

CONCLUSION

The use of triclosan-coated sutures (Vicryl Plus) for abdominal wall closure can reduce the number of SSIs in gastric cancer surgery.

Clinical significance of skip lymph node metastasis in gastric cancer patients

PURPOSE

Given the recent increase in the incidence of early gastric cancer, there is greater interest in identifying a minimally invasive therapy. The purpose of this study was to analyze the patterns of lymph node metastasis in patients with gastric cancer and to elucidate the clinical significance of skip metastasis.

METHODS

We retrospectively analyzed patterns of lymph node metastasis (LNM) and clinicopathologic factors related to skip metastasis.

RESULTS

Among 2963 patients with gastric cancer, 997 patients (33.6%) were detected as having LNM, and 27 patients (2.7%) with skip metastasis were detected among 997 patients with LNM. Skip metastasis were detected more frequently in the elderly. Compared with the N1 group, the skip metastasis group showed lower frequency of vascular invasion, and compared with the stepwise N2 group, the skip metastasis group showed smaller tumor size and a significantly higher incidence of negative lymphatic, vascular, and perineural invasion.

CONCLUSIONS

Currently there is no way to predict N2 station LNM including skip metastasis, D2 LN dissection for gastric cancer is thought to be the appropriate treatment, even during early stage disease. Minimally invasive therapy should be performed cautiously in consideration of possible skip metastasis.

Complications leading reoperation after gastrectomy in patients with gastric cancer: frequency, type, and potential causes

Purpose

Reoperations after gastrectomy for gastric cancer are performed for many types of complications. Unexpected reoperations may cause mental, physical, and financial problems for patients. The aim of the present study was to evaluate the causes of reoperations and to develop a strategic decision-making process for these reoperations.

Materials and Methods

From September 2002 through August 2010, 6,131 patients underwent open conventional gastrectomy operations at Samsung Medical Center. Of these, 129 patients (2.1%) required reoperation because of postoperative complications. We performed a retrospective analysis of the patients using an electronic medical record review. Statistical data were analyzed to compare age, sex, stage, type of gastrectomy, length of operation, size of tumor, and number of lymph node metastasis between patients who had been operated and those who had not.

Results

The variables of age, sex, tumor stage, type of gastrectomy, length of operation, and number of lymph node metastases did not differ between the 2 groups. However, the mean tumor size in the reoperation group was greater than that in the non-reoperation group (5.0±3.7 [standard deviation] versus 4.1±2.9, P=0.007). The leading cause of reoperation was surgical-site infection (n=49, 0.79%). Patients with intra-abdominal bleeding were operated on again in the shortest period after the initial gastrectomy (6.3±4.2 days). Patients with incisional hernia were not reoperated on until after 208.3±81.0 days, the longest postoperative period.

Conclusions

Tumor size was the major variable leading to reoperation after gastrectomy for gastric cancer. The most common complication requiring the reoperation was a surgical site-related complication.

Changes in postoperative recurrence and prognostic risk factors for patients with gastric cancer who underwent curative gastric resection during different time periods

BACKGROUND

Current rates of survival for gastric cancer patients are much improved compared with those of the past. The purpose of our study was to analyze the survival of gastric cancer patients according to time period and to examine how different prognostic factors are related to changing survival rates.

METHODS

We analyzed data from 7,757 patients who underwent curative gastrectomy after diagnoses of gastric cancer at Samsung Medical Center from 1994 to 2006. Clinicopathologic characteristics and prognostic factors were analyzed retrospectively, with patients divided into period I, from 1994 to 2001, and period II, from 2002 to 2006.

RESULTS

The 5-year, disease-free survival rate of patients with gastric cancer increased significantly from 76.7 % during period I to 85.9 % during period II (p < 0.001). The prognosis of the patient who underwent surgery during period I was worse than that of the patient in period II. When multivariate analyses were performed for each time period, independent prognostic factors for period I included patient age >60 years, tumor located in the whole stomach, tumor size, stage, vascular invasion, perineural invasion, and adjuvant chemotherapy. For period II, tumor size, vascular, and adjuvant chemotherapy were no longer independent prognostic risk factors.

CONCLUSIONS

The disease-free survival of gastric cancer improved and prognostic factors changed over time. Active, concurrent chemoradiotherapy together with radical gastric resection performed by an expert surgeon seemed to contribute to the improvement in the survival rates of gastric cancer.

Recapitulation of previous genome-wide association studies with two distinct pathophysiological entities of gastric cancer in the Korean population

Gastric cancer (GC) is the most common malignancy. The incidence rates remain remarkably high in East Asians. Although genome-wide association studies in the Han Chinese and Japanese populations have so far yielded susceptibility loci for GC, these findings need to be validated in an independent ethnic group. To identify the potential heterogeneity by histological classified subtypes (intestinal and diffuse), we examined the previously reported associations in the Korean population. PRKAA1 at 5p13.1 was found to be more strongly associated with intestinal type (odds ratio, OR=1.39, 95% CI (confidence interval) =1.22-1.58, P=3.77 × 10(-7)) than diffuse type. In addition, PSCA at 8q23.3 was significantly replicated in diffuse type (OR=1.49, 95% CI=1.32-1.67, P=2.43 × 10(-11)) but far less significant in intestinal type. In conclusion, these findings could bring additional insights into the etiologic heterogeneity in gastric carcinogenesis mechanisms.

Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer

BACKGROUND

Endoscopic submucosal dissection is gaining popularity in the treatment of early gastric cancer. This study aimed to identify clinicopathological factors predictive of lymph node metastasis in patients with the poorly differentiated early gastric cancer to assess the feasibility of using endoscopic submucosal dissection for these cancers.

METHODS

The records of patients with poorly differentiated early gastric cancer who had undergone gastric cancer surgery between January 2002 and December 2009 were reviewed. Associations between clinicopathological factors and the presence of lymph node metastasis were analysed by univariable and multivariable logistic regression analysis.

RESULTS

Some 1005 patients were included in the analysis. Univariable analysis indicated that lymph node metastasis was associated with sex, ulceration, tumour size, depth of invasion, macroscopic type, lymphatic invasion and venous invasion. Logistic regression revealed that lymph node metastasis was significantly associated with sex, tumour size, depth of tumour invasion and lymphatic involvement. In the group with none of these risk factors (men with mucosal tumour no larger than 2 cm in size, with no lymphatic involvement), lymph node metastasis was present in four (3·2 per cent) of 124 patients.

CONCLUSION

In the present study 3·2 per cent of patients who were negative for all identified risk factors had lymph node metastasis. The use of endoscopic submucosal dissection should be considered carefully in the treatment of poorly differentiated early gastric cancer.

Impact of body mass index on surgical outcomes in radical total gastrectomy

BACKGROUND/AIMS

In this study, the authors evaluated the impact of body mass index (BMI) on surgical outcomes in patients undergoing total gastrectomy for upper third early gastric cancer.

METHODOLOGY

Sixty-one consecutive patients with upper third early gastric cancer that underwent radical total gastrectomy from May 2009 to December 2009 were included in this prospective cohort study. Patients were stratified by BMI (in accordance with the WHO guidelines) into a normal group (18.5-24.9kg/m2), and an overweight group (≥25.0kg/m2). These two groups were compared with respect to stomach specimen weight (g), operative time (min), number of lymph nodes harvested, length of postoperative hospital stay (day), and postoperative complication rate (%).

RESULTS

Thirty-seven (61%) patients had a normal weight and 24 (39%) were overweight. According to multivariate analysis, the only factor correlated with BMI was the weight of stomach extirpated en bloc with omentum, and the weight of stomach extirpated en bloc with omentum was also significantly correlated with operative time. However, BMI was not found to be significantly correlated with postoperative complications.

CONCLUSIONS

This study suggested that an elevated BMI was significantly associated with increased weight of stomach extirpated en bloc with omentum, which was found to elongate operative times.

The predictors and clinical impact of positive resection margins on frozen section in gastric cancer surgery

Purpose

The aim of this study is to compare the characteristics of tumor and prognosis, depending on the status of resection margin involvement, on the frozen section diagnosis in gastric cancer.

Materials and Methods

This study was conducted retrospectively, in 83 margin-positive patients on the frozen section diagnosis, who underwent gastrectomy from July 1995 to September 2006. The control group was selected by matching the age, gender, TNM stage and status of adjuvant chemoradiotherapy, among those who had shown clear resection margins. The characteristics of tumor and patient survival are investigated, and they were analyzed between the two groups.

Results

The tumor size was significantly larger in the study group than that of the control group (P=0.037). There was significant difference between the two groups in location of the tumors (P=0.003). Multivariate analysis indicated that only the location and Lauren's classification are independent factors, which affected the resection margin involvement. Median survival was 41.0±11.5 months in the study group and 93.0±30.3 months in the control group (P=0.049). In the survival analysis, it was investigated that TNM stage and the resection margin involvement of the frozen section diagnosis were the critical variables.

Conclusions

When the tumor is located at the middle or the upper third, or the Lauren's indeterminate type, they are highly likely to show the resection margin involvement on the frozen section diagnosis, and it can, therefore, have negative effects on the prognosis. It is considered as good to perform more extensive resection as possible, during the initial resection.

Tumor size predicts survival in mucinous gastric carcinoma

BACKGROUND

Mucinous gastric carcinoma (MGC) is a distinct histologic subtype of gastric cancer. However, the prognostic significances of the current TNM staging system and histology in MGC have not been studied.

METHODS

206 patients who underwent R0 resection for MGC were classified by tumor size (<3 cm as T1; ≥ 3-5 cm as T2; ≥ 5-9 cm as T3; and ≥ 9 cm as T4). Immunohistochemistry for EGFR and HER2 was also performed.

RESULTS

Tumor sizes ranged from 1.2 to 21.0 cm (median 6.2 cm). Large tumor size (≥ 5 cm) was significantly associated with older patient age, deeper invasion depth, and more frequent lymph node metastasis (P < 0.05). Tumor size was a significant prognostic factor in both univariate (P < 0.001) and multivariate (P < 0.04) analyses. However, depth of invasion was not significant in multivariate analyses. A modified staging system based on tumor size predicted survival more accurately than did the conventional TNM staging system. We verified our results in an independent validation cohort of 123 MGC patients. Overexpression of either EGFR or HER2 was rare.

CONCLUSIONS

In MGCs, tumor size is an independent prognostic factor and a modified TNM system based on tumor size predicted survival accurately.

Circular stapler size and risk of anastomotic complications in gastroduodenostomy for gastric cancer

BACKGROUND

A Billroth I reconstruction with a mechanically sutured anastomosis is commonly performed in gastric cancer patients. Some surgeons prefer to use large circular staplers during suturing to minimize risks for anastomotic stricture and gastric stasis after surgery. The effect of stapler size on anastomotic complications has not been validated.

METHODS

This study was conducted with 1,031 patients who underwent gastrectomy and Billroth I reconstruction at Samsung Medical Center in Seoul, Korea, between January 2007 and October 2008. Patients were assigned to group A (384 patients) or group B (647 patients) depending on the size of the circular stapler that the surgeon selected for mechanical anastomosis. A 25 mm circular stapler was used for patients in group A, and a 28 or 29 mm circular stapler was used for patients in group B. Postoperative complications were analyzed retrospectively.

RESULTS

The incidence of complications (e.g., gastric stasis, anastomotic stricture, and bleeding) did not differ significantly between groups. Age greater than 60 years was the only significant risk factor for anastomotic complications identified in univariate and multivariate analyses.

CONCLUSIONS

Stapler size was unrelated to complications, such as stricture and gastric stasis. Age was the only significant risk factor for anastomotic complications after gastroduodenostomy.

Clinical significance of gastritis cystica profunda and its association with Epstein-Barr virus in gastric cancer

BACKGROUND

Gastritis cystica profunda (GCP) is a relatively rare disorder characterized by hyperplastic and cystic down growth of gastric glands into the submucosa. In the current study, the authors attempted to clarify the clinical and pathologic features of GCP in patients with gastric cancer.

METHODS

The records of 10,728 patients with gastric cancer who underwent gastric cancer surgery were reviewed. The clinicopathologic features of patients who had GCP (n = 161) were compared with the features of patients without GCP (n = 10,567). In situ hybridization to determine Epstein-Barr virus (EBV) positivity was performed in cancer tissues from patients with (n = 119) and without (n = 503) GCP.

RESULTS

GCP was associated significantly with older age, male gender, proximal tumor location, differentiated histology and Lauren intestinal type compared with non-GCP. GCP also was present more frequently in remnant and multiple gastric cancers. Patients who had GCP presented with earlier tumor stages in terms of depth of invasion and lymph node metastasis, and they had less lymphatic and perineural invasion than patients without GCP; however, the presence of GCP was not an independent prognostic factor. The EBV-positive rate was significantly higher in the GCP group (31.1%) than in the non-GCP group (5.8%).

CONCLUSIONS

Patients with gastric cancer who had GCP had clinicopathologic features that differed from the features observed in patients without GCP. GCP was associated significantly with EBV-positive gastric cancers, and its possible role as a premalignant lesion needs to be clarified.

Synthesis and electroplating of high resolution insulated carbon nanotube scanning probes for imaging in liquid solutions

High resolution and isolated scanning probe microscopy (SPM) is in demand for continued development of energy storage and conversion systems involving chemical reactions at the nanoscale as well as an improved understanding of biological systems. Carbon nanotubes (CNTs) have large aspect ratios and, if leveraged properly, can be used to develop high resolution SPM probes. Isolation of SPM probes can be achieved by depositing a dielectric film and selectively etching at the apex of the probe. In this paper the fabrication of a high resolution and isolated SPM tip is demonstrated using electron beam induced etching of a dielectric film deposited onto an SPM tip with an attached CNT at the apex.

Nutritional risk index as a predictor of postoperative wound complications after gastrectomy

AIM: To investigate the correlation between the nutritional risk index (NRI) and postoperative wound complications.

METHODS: From January 2008 through June 2008, 669 patients who underwent curative gastrectomy for gastric cancer were included in a retrospective study. Medical records of consecutive patients were collected and analyzed to determine postoperative wound complication rates. The NRI was assessed on the fifth postoperative day and other possible risk factors for the incidence of wound complications were analyzed to identify the factors affecting postoperative wound complications. Patients with other postoperative complications were excluded from the study.

RESULTS: On the 5th postoperative day, the NRI sh-owed a malnutrition rate of 84.6% among postoperative patients. However, postoperative wound complications occurred in only 66/669 (9.86%) patients. Of the patients with wound complications, 62/66 (94%) belonged to the malnourished group (NRI < 97.5), and 4/66 (6%) patients to the non-malnourished group (NRI ≥ 97.5). The only factor correlated with wound complications was the NRI on the 5th postoperative day (odds ratio of NRI ≥ 97.5 vs NRI < 97.5: 0.653; 95% confidence interval: 0.326-0.974; P = 0.014) according to univariate analysis as well as multivariate analysis.

CONCLUSION: This study suggests that malnutrition immediately after surgery may play a significant role in the development of wound complications.

Phase III trial comparing capecitabine plus cisplatin versus capecitabine plus cisplatin with concurrent capecitabine radiotherapy in completely resected gastric cancer with D2 lymph node dissection: the ARTIST trial

PURPOSE

The ARTIST (Adjuvant Chemoradiation Therapy in Stomach Cancer) trial was the first study to our knowledge to investigate the role of postoperative chemoradiotherapy therapy in patients with curatively resected gastric cancer with D2 lymph node dissection. This trial was designed to compare postoperative treatment with capecitabine plus cisplatin (XP) versus XP plus radiotherapy with capecitabine (XP/XRT/XP).

PATIENTS AND METHODS

The XP arm received six cycles of XP (capecitabine 2,000 mg/m2 per day on days 1 to 14 and cisplatin 60 mg/m2 on day 1, repeated every 3 weeks) chemotherapy. The XP/XRT/XP arm received two cycles of XP followed by 45-Gy XRT (capecitabine 1,650 mg/m2 per day for 5 weeks) and two cycles of XP.

RESULTS

Of 458 patients, 228 were randomly assigned to the XP arm and 230 to the XP/XRT/XP arm. Treatment was completed as planned by 75.4% of patients (172 of 228) in the XP arm and 81.7% (188 of 230) in the XP/XRT/XP arm. Overall, the addition of XRT to XP chemotherapy did not significantly prolong disease-free survival (DFS; P = .0862). However, in the subgroup of patients with pathologic lymph node metastasis at the time of surgery (n = 396), patients randomly assigned to the XP/XRT/XP arm experienced superior DFS when compared with those who received XP alone (P = .0365), and the statistical significance was retained at multivariate analysis (estimated hazard ratio, 0.6865; 95% CI, 0.4735 to 0.9952; P = .0471). CONCLUSION The addition of XRT to XP chemotherapy did not significantly reduce recurrence after curative resection and D2 lymph node dissection in gastric cancer. A subsequent trial (ARTIST-II) in patients with lymph node-positive gastric cancer is planned.

Adenocarcinoma derived from gastric hamartomatous polyps

Most hamartomatous polyps in the stomach occur in patients with adenomatous polyposis coli and dysplasia. The authors report a case of a 57-year-old man without prior history of polyposis coli who presented with adenocarcinomas derived from hamartomatous polyps in the stomach. The patient underwent a radical subtotal gastrectomy with Billroth I anastomosis. Pathology revealed adenocarcinomas with moderate differentiation without evidence of lymph node metastasis in 60 nodes. We report a case of gastric cancers arising from de novo gastric hamartomatous polyps.

Long-term results and prognostic factors of gastric cancer patients with only positive peritoneal lavage cytology

BACKGROUND AND OBJECTIVES

The purpose of the present study was to investigate clinicopathologic features of gastric cancer patients with only positive peritoneal cytology in the absence of overt peritoneal metastases, and which might distinguish patients with poorer prognosis.

METHODS

Between September 1994 and August 2006, clinicopathological features were retrospectively evaluated in 37 consecutive patients with gastric cancer who underwent a curative resection and had positive peritoneal cytology in the absence of overt peritoneal metastases. Survival including disease-free survival (DFS) and overall survival (OS), and recurrence patterns were analyzed according to clinicopathologic characteristics.

RESULTS

The median follow-up period was 16.1 months (range, 3-45 months). The median DFS and OS of patients after curative resection were 10 months (range, 1-33 months) and 15 months (range, 2-45 months), respectively. All patients had recurred, in 34 (92%) with peritoneal dissemination. The overall 1-, 2-, 3-, and 5-year survival rates for the 37 consecutive patients were 43.2%, 45.9%, 5.4%, and 0%, respectively. Multiple linear regression analysis revealed that Borrmann type IV was an independent predictor for poorer prognosis.

CONCLUSIONS

A Borrmann type IV carcinoma may be the candidates for intraperitoneal chemotherapy among advanced gastric cancer patients.

Validation of seventh edition AJCC gastric cancer staging modifications

BACKGROUND AND OBJECTIVES

The seventh edition of the AJCC has more detailed staging categories for gastric cancer than does the sixth edition. The aim of our study was to compare the prognostic accuracies of the sixth and seventh AJCC editions for gastric cancer patients.

METHODS

We analyzed survival rates by category using the sixth and seventh editions of the AJCC in 10,060 patients with gastric cancer who had undergone gastrectomy between 1994 and 2007 at Samsung Medical Center.

RESULTS

Significant differences in prognosis were seen when comparing the new stages of the seventh edition of the AJCC that are subgroups of stages IB, II, IIIA, and IV in the sixth edition. In particular, stage IV of the AJCC sixth edition is divided into stages IIB, IIIA, IIIB, IIIC and IV in the seventh edition, and the 5-year survival rates of these respective stages were 80.2%, 45.3%, 23.5%, 17.2%, and 10.1% (P < 0.001).

CONCLUSIONS

Each category of the AJCC sixth edition has been divided into multiple stages in the AJCC seventh edition, each with a different prognosis. The newly divided subgroups from AJCC sixth edition stage IV showed more accurate outcome classification based on AJCC seventh edition staging stratification.

Stapling technique for performing Billroth II anastomosis after distal gastrectomy

The circular stapling technique has been widely applied for gastrointestinal anastomosis in gastrectomies (open or laparoscopic) for distal gastric cancers. We describe this method for use in performing Billroth II anastomosis in distal gastrectomies. From 2002-2009, we report the results following the use of the circular stapling technique performed in 520 patients at a single institution. The median time of completing the anastomosis was shorter using the stapling technique compared to the hand-sewn technique. The use of the stapler resulted in two cases of minor intraluminal bleeding at the anastomotic site. The circular stapling method can be applied safely and more efficiently in performing Billroth II reconstruction after distal gastrectomy compared to the hand-sewn method in patients with gastric cancer.

The relationships between perioperative CEA, CA 19-9, and CA 72-4 and recurrence in gastric cancer patients after curative radical gastrectomy

BACKGROUND AND OBJECTIVES

The correlation between perioperative CEA, CA 19-9, and CA 72-4 and recurrence of gastric cancer has not been clarified. The aim of this study was to investigate the relationships between perioperative CEA, CA 19-9, and CA 72-4 and recurrence of gastric cancer.

METHODS

We retrospectively analyzed the relationships between the tumor markers CEA, CA 19-9, and CA 72-4 and recurrence of gastric cancer.

RESULTS

In patients with early gastric cancer, the recurrence sensitivity of postoperative CEA, CA 19-9, and CA 72-4 was 40.0, 5.6, and 2.8%, respectively. And in patients with advanced gastric cancer, the recurrence sensitivity of postoperative CEA, CA 19-9, and CA 72-4 was 100.0, 68.2, and 51.3%, respectively. Multivariate analyses showed that an increase in postoperative CEA in early gastric cancer was an independent prognostic factor of recurrence. In patients with advanced gastric cancer, age >60 years, stage III, and postoperative CEA increase and CA 72-4 increase were independent prognostic factors of recurrence.

CONCLUSIONS

For patients with advanced gastric cancer, CEA, CA 19-9, and CA 72-4 are considered useful for follow-up tests. Although, CEA is considered useful for follow-up test for patients with early gastric cancer, but CA19-9 and CA72-4 are less useful due to their low sensitivity.

Early gastric cancer arising from heterotopic gastric mucosa in the gastric submucosa

The incidence of heterotopic gastric mucosa located in the submucosa in resected stomach specimens has been reported to be 3.0 to 20.1%. Heterotopic gastric mucosa is thought to be a benign disease, which rarely becomes malignant. Heterotopic gastric mucosa exists in the gastric submucosa, and gastric cancer rarely occurs in heterotopic gastric mucosa. Since tumors are located in the normal submucosa, they appear as submucosal tumors during endoscopy, and are diagnosed through endoscopic biopsies with some difficulty. For such reasons, heterotopic gastric mucosa is mistaken as gastric submucosal tumor. Recently, two cases of early gastric cancer arising from heterotopic gastric mucosa in the gastric submucosa were treated. Both cases were diagnosed as submucosal tumors based on upper gastrointestinal endoscopy, endoscopic ultrasound, and computed tomography findings, and in both cases, laparoscopic wedge resections were performed, the surgical findings of which also suggested submucosal tumors. However, pathologic assessment of the surgical specimens led to the diagnosis of well-differentiated intramucosal adenocarcinoma arising from heterotopic gastric mucosa in the gastric submucosa.

Impact of MET amplification on gastric cancer: possible roles as a novel prognostic marker and a potential therapeutic target

Identification of critical genes which play pivotal roles in controlling tumor growth and survival will establish the basis for developing therapeutic targets. With the aim of establishing personalized medicine for treatment of solid tumors, we focused on MET amplification in gastric cancer patients, given the extreme sensitivity to c-Met inhibitor in MET amplified gastric cancer cell lines. We tested MET amplification and activation of c-Met in various gastric cancer cell lines and tissue samples from 482 gastric cancer patients who underwent curative surgery. Gastric cancer cell lines with MET amplification by quantitative real-time PCR (qPCR) and FISH predicted sensitivity to PHA-665,752, a selective c-Met kinase inhibitor. Of the 472 patients who had DNA sample available for qPCR analysis, 100 patients (21.2%) had a MET copy number greater than 4.0 copies and demonstrated poorer survival following curative surgery with statistical significance (5-year OS; 50.0 vs. 59.1%; MET amplification (+) vs. MET amplification (-); P = 0.0134). These results suggest that the increased MET copy number measured by qPCR plays an important role in determining prognosis in gastric cancer patients. However, the predictive role of MET amplification for treatment response should be further explored in upcoming clinical trials.

Frequency and predictive factors of lymph node metastasis in mucosal cancer

Purpose

The incidence of lymph node metastasis has been reported to range from 2.6 to 4.8% in early stage gastric cancer with mucosal invasion (T1a cancer). Lymph node metastasis in early stage gastric cancer is known as an important predictive factor. We analyzed the prediction factors of lymph node metastasis in T1a cancer.

Materials and Methods

A total of 9,912 patients underwent radical gastrectomy due to gastric cancer from October 1994 to July 2006 in the Department Of Surgery at Samsung Medical Center. We did a retrospective analysis of 2,524 patients of these patients, ones for whom the cancer was confined within the mucosa.

Results

Among the 2,524 patients, 57 (2.2%) were diagnosed with lymph node metastasis, and of these, cancer staging was as follows: 41 were N1, 8 were N2, and 8 were N3a. Univariate analysis of clinicopathological factors showed that the following factors were significant predictors of metastasis: tumor size larger than 4 cm, the presence of middle and lower stomach cancer, poorly differentiated adenocarcinoma and signet-ring cell carcinoma, diffuse type cancer (by the Lauren classification), and lymphatic invasion. Multivariate analysis showed that lymphatic invasion and tumor larger than 4 cm were significant factors with P<0.001 and P=0.024, respectively.

Conclusions

The frequency of lymph node metastasis is extremely low in early gastric cancer with mucosal invasion. However, when lymphatic invasion is present or the tumor is larger than 4 cm, there is a greater likelihood of lymph node metastasis. In such cases, surgical treatments should be done to prevent disease recurrence.

The clue of Interstitial Cell of Cajalopathy (ICCpathy) in human diabetic gastropathy: the ultrastructural and electrical clues of ICCpathy in human diabetic gastropathy

Recent studies of diabetic animal models suggest an important role of ICC in the pathogenesis of gastropathy. The aim of this study was to characterize the ultrastructural features of ICC and record the electrical properties in the stomach of patients with type 2 DM. Gastric specimens were obtained from 13 diabetic patients and 6 control subjects with gastric cancer that underwent gastrectomy. All specimens were taken from disease-free areas. The samples were processed for both electron microscopic and electrophysiologic examination. The characteristic ultrastructural changes of the ICC were observed in both the nucleus and cytoplasm in patients with type 2 DM. Wrinkling of the nuclear envelope and changes in the cytoplasm such as dilatation of the endoplasmic reticulum, an increase of autophagic vacuoles, were more frequently observed in the diabetic patients. Apoptosis characterized by nuclear karyorrhexis or pyknosis was observed only in the diabetic patients. Slow waves were recorded in the circular muscle of stomach. In diabetic patients, the mean resting membrane potential was higher and amplitude was lower than controls. These changes of electrical activities of slow waves were accompanied with ultrastructural changes of ICC, particularly the characteristic nuclear changes. In human diabetic patients, the characteristic ultrastructural changes of ICC such as preapoptosis, accompanied with electrical dysrhythmia of slow waves, were observed. These results show several evidence converging to support that degeneration of the ICC may be associated with the pathogenesis of diabetic gastropathy.

Surgical outcome after incomplete endoscopic submucosal dissection of gastric cancer

BACKGROUND

Endoscopic resection of early gastric cancer is a relatively new and attractive treatment, but occasionally fails to remove all cancer lesions completely. This study aimed to elucidate clinicopathological factors that could be helpful in predicting residual tumour in the surgical specimen after incomplete endoscopic submucosal dissection (ESD).

METHODS

Patients who underwent gastrectomy because of incomplete ESD between August 2004 and August 2008 were analysed. Clinicopathological characteristics were reviewed retrospectively from prospectively collected medical records. Patients were classified into groups with and without residual tumour. Pathology results following gastrectomy were compared with those of incomplete ESD.

RESULTS

A total of 118 patients were included. The incidence of residual tumour in the surgical specimen was 24·6 per cent after incomplete ESD. Elevated/flat-type cancers, large tumours (at least 2 cm) and those limited to the mucosa had significantly higher incomplete ESD rates. Cancer limited to the mucosa and the presence of tumour in the lateral margin were associated with residual tumour in the surgical specimen (both P = 0·001).

CONCLUSION

Radical gastrectomy should be performed if pathological examination reveals a positive lateral resection margin after ESD.

Endoscopists' view on superficial spreading type of early gastric cancer--endoscopic resection or surgery?

OBJECTIVE

The superficial spreading type of early gastric cancer (EGC) possesses unique features different from other types of EGC. We aimed to elucidate the clinicopathological features of superficial spreading type of EGC.

MATERIAL AND METHODS

We analyzed 1455 EGC lesions from 1398 patients who had undergone surgical treatment at Samsung Medical Center from 2000 to 2002. Then the clinicopathological features of 224 superficial-spreading EGC lesions (15.4%) was compared to that of 1231 lesions of a common type of EGC.

RESULTS

In the superficial spreading type of EGC, the incidence of undifferentiated type and submucosal invasion were higher than those of common type of EGC (55.4 vs 38.0%, p < .01 and 58.5 vs 37.8%, p < .01, respectively). Lymph node metastasis and lymphovascular invasion were more frequent in superficial spreading type than in common type of EGC (19.2 vs 7.6%, p < .01 and 15.2 vs 7.4%, p < .01, respectively). There was no difference in recurrence rate or 5-year survival rate between the two groups.

CONCLUSION

Considering higher risk of submucosal invasion and lymph node metastasis in superficial spreading type, a careful consideration should be done before the application of endoscopic resection to the superficial spreading type of EGC.

Mucinous gastric cancer presents with more advanced tumor stage and weaker β-catenin expression than nonmucinous cancer

BACKGROUND

Mucinous gastric carcinoma (MGC) is a rare type of gastric cancer; its biological behavior is controversial. In this study, we attempted to clarify the clinical and pathological features as well as the prognostic significance of MGC. We also compared the expression patterns of CDX-2 and β-catenin between MGC and nonmucinous gastric carcinoma (NMGC).

METHODS

We reviewed the records of 9218 patients with gastric cancer who underwent gastric cancer surgery between January 1997 and December 2006. The clinicopathological features and clinical outcome of MGC (n = 197) were compared to NMGC (n = 9021). Immunohistochemical staining using the tissue array method was performed on MGC (n = 194) and NMGC (n = 89) tissues.

RESULTS

MGC had a larger size and a higher frequency of Borrmann type I findings in advanced cases than NMGC. In addition, MGC had deeper invasion, more lymph node and lymphatic involvement, a more advanced tumor stage, and lower 5-year survival rates than NMGC. Age, depth of invasion, lymph node metastasis, lymphatic invasion, and curability were independent prognostic factors; but the mucinous histological type itself was not predictive of outcome. β-Catenin immunoreactivity was statistically significantly weaker in MGC than NMGC; however, there was no difference in CDX-2 expression between the two groups.

CONCLUSIONS

MGC presents at a more advanced stage and was larger than NMGC. The poor prognosis of MGC was related to the more advanced tumor stage at diagnosis; the histological type was not an independent prognostic factor. The result of immunohistochemical staining suggests that MGC has a distinct pathway of carcinogenesis from NMGC.

Clinical significance of the discrepancy between preoperative and postoperative diagnoses in gastric cancer patients

BACKGROUND

Discrepancies between pre- and postoperative diagnoses can lead to dilemma for operative management adequacy.

PATIENTS AND METHODS

A total of 2,910 patients with gastric adenocarcinoma underwent curative surgery at the Samsung Medical Center between 2001 and 2003. Patients were divided into four groups: early gastric cancer (EGC)-EGC group that consisted of subjects who were diagnosed as having EGC pre- and postoperatively, advanced gastric cancer (AGC)-EGC group, EGC-AGC group, and AGC-AGC group. Clinicopathologic features and survival rates of groups were analyzed retrospectively.

RESULTS

Of the 2,910 patients, 1,491 (51.2%) patients were included in the EGC-EGC group, 132 (4.5%) in the AGC-EGC group, 120 (4.1%) in the EGC-AGC group, and 1,167 (40.1%) in the AGC-AGC group. The EGC-AGC group showed higher proportions of the followings than the EGC-EGC group: upper-third and middle-third tumor localizations, a tumor size from 2 to 5 cm, undifferentiated adenocarcinoma, Lauren's diffuse type, endolymphatic invasion, vascular invasion, and perineural invasion. Five-year survival rates were dependent on the final pathologic stages, not on the preoperative stages. Multivariate analysis revealed that age and American Joint Committee of Cancer stage were independent prognostic factors of patient survival.

CONCLUSION

A decision regarding minimally invasive treatment for EGC must be made having considered tumor location, size, and cellular differentiation, because of the possibility of an incorrect preoperative diagnosis.

Phase I study of intraperitoneal irinotecan in patients with gastric adenocarcinoma with peritoneal seeding

PURPOSE

The objectives of this phase I study were to determine the maximum-tolerated dose (MTD), dose-limiting toxicities (DLTs), and preliminary efficacy of intraperitoneally administered irinotecan (CPT-11) in gastric cancer patients with peritoneal seeding.

EXPERIMENTAL DESIGN

Gastric adenocarcinoma patients with surgical biopsy proven peritoneal seeding were enrolled at the time of surgery. Prior to IP chemotherapy, patients underwent palliative gastrectomy and CAPD catheter insertion in which CPT-11 was administered on postoperative day 1. The IP CPT-11 was initiated at 50 mg/m(2), which was escalated to 100, 150, 200, 250, and 300 mg/m(2). IP CPT-11 chemotherapy was repeated every 3 weeks.

RESULTS

Seventeen patients received a total of 56 cycles at five different CPT-11 dose levels. The DLTs were neutropenic fever, neutropenia, and diarrhea. At the dose level 2 (100 mg/m(2)), there were one DLTs in one of the first cohort of three patients, but no DLTs at the second cohort of this level. At the dose level 5 (250 mg/m(2)), two DLTs were detected in the first two patients; thus, the accrual was stopped resulting in the recommended dose of IP CPT-11 of 200 mg/m(2). Median progression-free survival was 8.6 months (95% CI, 5.9,11.2), and median overall survival was 15.6 months (95% CI, 8.4,22.8). Pharmacokinetic results of the study showed that the C (max) of peritoneal SN-38 was achieved earlier than that of plasma SN-38.

CONCLUSIONS

Intraperitoneally administered CPT-11 was feasible and tolerable. Further, phase II study of IP CPT-11 in gastric cancer patients with peritoneal seeding is warranted.