Chang-Min Cho

Factors related to lymph node metastasis and the feasibility of endoscopic mucosal resection for treating poorly differentiated adenocarcinoma of the stomach

BACKGROUND AND AIMnEndoscopic mucosal resection (EMR) is currently not accepted as an alternative treatment to surgery in early gastric cancer (EGC) of the undifferentiated histologic type. The present retrospective analysis examined the correlation of various histologic factors with the presence of lymph node metastasis (LNM).nnnPATIENTS AND METHODSnA retrospective analysis on 234 patients with poorly differentiated EGC who underwent radical gastrectomy with D2 lymph node dissection was undertaken. Several clinicopathologic factors were investigated to identify predictive factors for LNM: age, sex, type of operation, tumor location, tumor size, gross type, ulceration, lymphatic invasion, and depth of invasion.nnnRESULTSnOf the 234 lesions with poorly differentiated EGC, half (n = 116) already showed submucosal invasion in the resection specimen; 25.9 % of those (30/116) were limited to the upper third (SM1). Of the lesions confined to the mucosa, LNM was found in 3.4 % (4/118). With minor submucosal infiltration (SM1), the LNM rate was lower (0/30) in our patient population. Only with SM2/3 infiltration did the LNM rate sharply rise to around 30 %. The cut-off for submucosal infiltration depth was 500 microm (0/32 LNM), above which LNM rates were substantial (31.2 %; 24/77). There was limited correlation between the SM1-3 classification and actual measurement of submucosal infiltration depth. In a multivariate analysis, tumor size ( P = 0.033), depth of invasion ( P = 0.004), and lymphatic invasion ( P < 0.001) were associated with LNM.nnnCONCLUSIONnPoorly differentiated EGC confined to the mucosa or with minimal submucosal infiltration (<or= 500 microm) could be considered for curative EMR due to the low risk of LNM. Given the limited case number of subgroups, these findings should be confirmed by more data from other centers, which should also focus on local recurrence after EMR in poorly differentiated EGC.

The feasibility of endoscopic submucosal dissection for rectal carcinoid tumors: comparison with endoscopic mucosal resection.

BACKGROUND AND STUDY AIMSnRectal carcinoid tumors are often found incidentally during screening colonoscopy and can be resected using various endoscopic techniques. This study aimed to compare the safety and efficacy of endoscopic submucosal dissection (ESD) with endoscopic mucosal resection (EMR) for rectal carcinoid tumors.nnnPATIENTS AND METHODSnBetween January 2003 and June 2009, 74 patients (74 lesions) underwent either EMR (n = 28) or ESD (n = 46) for rectal carcinoid tumors. The rate of endoscopic complete resection, pathological complete resection, procedure complications, and tumor recurrence were analyzed retrospectively.nnnRESULTSnThe endoscopic complete resection rate was significantly higher in the ESD group (46 lesions, 100 %) compared with the EMR group (25 lesions, 89.3 %) ( P = 0.049). The pathological complete resection rate was higher in the ESD group (38 lesions, 82.6 %) compared with the EMR group (18 lesions, 64.3 %); however, this difference was borderline significant ( P = 0.067). Overall complication rate was not significantly different between the EMR group (3.6 %) and the ESD group (6.3 %). There was one case of remnant lesion in the EMR group, which was managed by ESD, and no recurrence has been detected in either the EMR or ESD groups.nnnCONCLUSIONnThis study suggests that ESD might be a feasible treatment technique for small rectal carcinoid tumors. It showed superior efficacy and comparable safety to EMR.

Solid-pseudopapillary tumor of the pancreas.

Background Solid-pseudopapillary tumor (SPT) of the pancreas is a low-grade malignancy, which has been infrequently observed in adolescent and young adult females since first report by Frantz in 1959. In this article, we describe our experience of 8 cases of SPT with the clinical features, diagnosis, treatments, and outcomes. Methods We retrospectively reviewed the medical records and images of 8 patients who underwent surgery for SPT between January 1995 and December 2004. Results Seven females and 1 male with the mean age of 29 years (range, 10 to 64) at presentation were identified. Three patients presented palpable abdominal mass, 2 with abdominal pain, and the remainder with no specific symptom. The mean diameter of the tumors was 7.9u2009cm (range, 4.0 to 10.0). Four were located in the tail, 3 in the body, and 1 in the head. Surgical procedure included distal pancreatectomy with/without splenectomy in 7 patients and Whipple operation in 1 with no surgical morbidity and mortality. All were alive without evidence of recurrence after mean follow-up of 26.4 months (range, 1 to 66). Conclusions SPT of the pancreas is an unusual neoplasm and typically occurs in young females presenting well-demarcated pancreatic masses, which are amenable to cure by complete surgical resection.

Failure of Helicobacter pylori eradication and age are independent risk factors for recurrent neoplasia after endoscopic resection of early gastric cancer in 283 patients.

Whether the incidence of metachronous gastric dysplasia and cancer could be decreased by eradication of Helicobacter pylori after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC).

Endoscopic incision of a septum in a case of spontaneous intramural dissection of the esophagus.

Intramural dissection of the esophagus is a rare esophageal disorder that is characterized by a long laceration between the esophageal mucosa and submucosa but without perforation. It reveals characteristic radiologic and endoscopic features. The etiology of intramural dissection of the esophagus remains uncertain. The most common presenting symptoms are sudden retrosternal pain, hematemesis, odynophagia, dysphagia, and back pain. Conservative management is usually thought to be adequate. We report a case of spontaneous intramural esophageal dissection, in which the symptom of dysphagia did not improve with the conservative management, and an endoscopic incision of the septum between true and false lumens using a needle-type diathermy knife was done safely and effectively.

Clinical aspects of rifampicin-associated pseudomembranous colitis

Pseudomembranous colitis (PMC) is known to develop after antibiotic administration, but antituberculosis agents are rarely associated with this disorder. We report 6 cases of PMC after rifampicin administration; the clinical manifestations, laboratory findings, imaging findings, and clinical course are described. The median age of patients was 68 years (range, 54 to 82u2009y). All patients were diagnosed with active pulmonary tuberculosis by sputum smear and culture, and 2 suffered from type 2 diabetes mellitus. The average interval between initiation of antituberculosis therapy and the onset of diarrhea was 19.8 days. The anatomic distribution of PMC included the rectum and sigmoid colon in 5 cases and up to the hepatic flexure in 1 case. All patients were cured with medical treatment, which include discontinuation of rifampicin and oral metronidazole and vancomycin. PMC recurred in 1 patient after retreatment with rifampicin. Our findings suggest that patients who are treated with antituberculosis agents, who develop acute diarrhea during or after therapy, should be evaluated for PMC.

Where has the tumor gone? The characteristics of cases of negative pathologic diagnosis after endoscopic mucosal resection

BACKGROUND AND STUDY AIMSnDiscrepancies can occur between the histopathological findings from forceps biopsy and endoscopic mucosal resection (EMR), and occasionally in embarrassing cases tumorous tissue is not found at EMR. The aim of the present study was to evaluate the clinical, endoscopic, and histological features of gastric tumors in patients with pathololgically negative findings at EMR.nnnPATIENTS AND METHODSnWe retrospectively reviewed data from all patients with gastric tumor treated with EMR or endoscopic submucosal dissection (ESD) between August 1999 and April 2007 at our institution, and enrolled into the study patients with no tumor tissue found at mucosal resection. Their biopsy and EMR specimen slides were reviewed by a single pathologist. Patient characteristics, including demographic and clinical features, and the endoscopic appearance of mucosal lesions were evaluated.nnnRESULTSnOut of 633 patients treated with EMR or ESD, 20 patients (3.2 %) were included. The mean +/- SD maximal dimension of the mucosal lesions was 6.40 +/- 2.19 mm (range 3 - 10). Mean number of forceps biopsy fragments was 3.80 +/- 1.96 and mean sampling ratio was 2.08 +/- 1.07 mm/fragment. Before resection, histological findings from forceps biopsy were: 13 low grade dysplasias (65.0 %), 2 high grade dysplasias (10.0 %), and 5 intramucosal carcinomas (25.0 %).nnnCONCLUSIONSnIn the case of pathologically negative findings at EMR, tumors might have been small enough to have been removed by the previous forceps biopsy. However, the possibility of sampling error or of a different location should be considered. Furthermore, appropriate communication between endoscopists and pathologists is essential.

Clear Cell Hepatocellular Carcinoma with Spontaneous Regression of Primary and Metastatic Lesions

The prognosis of advanced hepatocellular carcinoma (HCC) tends to be poor. Spontaneous regression of this lesion is extremely rare. In this report, we describe a case of HCC which spontaneously regressed along with a metastatic lesion of the chest wall. A huge HCC in the right lobe, the largest diameter of which was about 15×12 cm, developed in a 72-year-old man. He and his family refused further treatment. Three months after the diagnosis, metastasis to the chest wall was detected. We prescribed a painkiller for him in order to alleviate chest pain. Fourteen months after the diagnosis, the tumor size of the primary lesion was downsized to 3×4 cm in diameter. A biopsy taken from the chest wall proved to be clear cell HCC (CHCC). Since then, the metastatic lesion has also disappeared. Here, we report this unusual histologically proven CHCC with literature reviews.

Gastrointestinal bleeding in adult patients with Henoch-Schönlein purpura.

We investigated the clinical and endoscopic features of gastrointestinal lesions in adults with Henoch-Schönlein purpura (HSP) causing gastrointestinal bleeding. The study included 24 adult HSP patients with gastrointestinal hemorrhage who underwent both upper gastrointestinal endoscopy and colonoscopy. The controls were 27 adult HSP patients without gastrointestinal hemorrhage. Patients with gastrointestinal bleeding showed higher frequencies of purpura on the upper extremities and trunk, and of elevated serum C-reactive protein (CRP). The rate of concurrent lesions in both the upper and lower gastrointestinal tracts was 91.7 %. The second portion of duodenum and terminal ileum were most frequently and severely involved. Leukocytoclastic vasculitis was detected in severe lesions and was significantly associated with mucosal ischemic changes. Most lesions (95.7 %) dramatically improved after corticosteroid therapy. This study suggests that both upper and lower gastrointestinal examinations are necessary for proper evaluation of gastrointestinal bleeding in patients with HSP.

A Case of Primary Pancreatic Non-Hodgkin's Lymphoma

Primary pancreatic lymphoma is rare, comprising 0.2~4.9% of all pancreatic malignancies and less than 1% of cases of non-Hodgkins lymphoma. Many patients are diagnosed with lymphoma after radical resection. We report a rare presentation of diffuse large B cell lymphoma, appearing as a primary tumor of the pancreas. A 61-year old female was admitted to the hospital with the complaint of right upper abdominal pain. Computed tomography of the abdomen showed a well defined mass located at the head of the pancreas. A frozen section of pancreas, during laparotomy, revealed lymphoma. The patient received 6 cycles of chemotherapy and is currently in complete remission. This case underscores the importance of differentiating primary lymphoma from the more common adenocarcinoma of the pancreas as treatment and prognosis differ significantly. Primary pancreatic lymphoma should be considered in the differential diagnosis of pancreatic tumors and an attempt to obtain a tissue diagnosis is always necessary before proceeding to radical surgery, especially on young patients.