Choong Nam Shim

Clinical Predictors Associated With Proton Pump Inhibitor-Induced Hypomagnesemia

There is increasing evidence and case reports regarding proton pump inhibitor (PPI)-induced hypomagnesemia. Our study aimed to clarify the relationship between PPI use and serum magnesium levels and to specify high-risk patients. We retrospectively studied 112 consecutive patients aged 20 years or older who were treated with PPI for ≥30 days and whose serum magnesium levels were available for the PPI treatment period. We compared the mean level of serum magnesium of the enrolled patients with PPI treatment with matched controls. There were no significant differences between the matched PPI users (n = 105) and nonusers (n = 210) in the magnesium levels (0.85 ± 0.09 vs. 0.86 ± 0.16 mM, P = 0.297). In a subgroup analysis of a PPI user group, hypomagnesemia could be observed in 32 patients but not in 80 patients. In multivariate analyses, PPI use for >1 year, age less than 45 years, and concurrent cisplatin or carboplatin use were significantly associated with PPI-induced hypomagnesemia {P = 0.042, odds ratio [OR; 95% confidence interval (CI)]: 5.388 [1.056–27.493]; P = 0.007, OR [95% CI]: 4.710 [1.523–14.571]; P = 0.007, OR [95% CI]: 13.404 [2.066–86.952], respectively} after adjusting for confounders. This study shows that long-term PPI use is associated with hypomagnesemia in hospitalized adult patients. Therefore, serum magnesium levels should be checked before the initiation of PPI treatment and during the treatment period in patients, particularly those concurrently using platinum-based chemotherapy or who are expected to use PPI for long periods.

Prognostic value of neutrophil-to-lymphocyte ratio in patients treated with concurrent chemoradiotherapy for locally advanced oesophageal cancer.

BACKGROUND We performed a retrospective analysis of Asian patients with locally advanced oesophageal cancer to test the hypothesis that an elevated neutrophil-to-lymphocyte ratio is associated with a poor survival rate after definitive concurrent chemoradiotherapy. METHODS In total, 138 patients diagnosed with locally advanced oesophageal cancer (TNM classification of malignant tumours stage II or III) who were treated with definitive concurrent chemoradiotherapy between January 2005 and December 2010 were retrospectively analysed. Definitive concurrent chemoradiotherapy was performed using two different chemotherapy regimens. RESULTS The median follow-up duration was 39.5 months (range 1.1-93.4). The median progression-free survival was 14.0 months, and the median overall survival was 19.9 months. Compared with the low (<2.0) neutrophil-to-lymphocyte ratio group (n=43, 31.2%), the high (≥2.0) neutrophil-to-lymphocyte ratio group (n=95, 68.8%) exhibited significant decreases in the durations of both progression-free survival and overall survival. Using multivariate analysis, an elevated neutrophil-to-lymphocyte ratio was also significantly associated with decreased progression-free survival (HR 1.799; 95% CI, 1.050-3.083; P=0.032) and overall survival duration (HR 2.115; 95% CI, 1.193-3.749; P=0.010). CONCLUSIONS The pretreatment neutrophil-to-lymphocyte ratio is a useful prognostic marker in patients with locally advanced oesophageal cancer treated with definitive concurrent chemoradiotherapy.

Impact of tumor location on clinical outcomes of gastric endoscopic submucosal dissection

AIM To determine whether there is a correlation between the location of the lesion and endoscopic submucosal dissection (ESD) outcome. METHODS From January 2008 to December 2010, ESD of 1443 gastric tumors was performed. En bloc resection rate, complete resection rate, procedure time and complication rate were analyzed according to the tumor location. RESULTS The rates of en bloc resection and complete resection were 91% (1318/1443) and 89% (1287/1443), respectively. The post-ESD bleeding rate was 4.3%, and perforation rate was 2.7%. Tumors located in the upper third of the stomach were associated with a longer procedure time and significantly higher rates of incomplete resection, piecemeal resection, and perforation than tumors below the upper third of the stomach. Posterior wall lesions had significantly longer procedure times and higher rates of incomplete resection and piecemeal resection than lesions in other locations. In multivariate analysis, posterior wall lesions and upper third lesions were significantly associated with incomplete resection and perforation, respectively. In post-ESD bleeding analysis, location was not a significant related factor. CONCLUSION More advanced endoscopic techniques are required during ESD for lesions located in the upper third or posterior wall of the stomach to decrease complications and improve therapeutic outcomes.

Tumour size is related to the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection: A retrospective single centre study

BACKGROUND Endoscopic submucosal dissection is applied in selected cases of signet ring cell early gastric cancer. However, factors related to curability of signet ring cell early gastric cancer with this method have not been fully evaluated. Our aim was to evaluate factors related to incomplete resection in signet ring cell early gastric cancer with endoscopic submucosal dissection. METHODS A retrospective analysis was performed on a total of 126 consecutive patients with signet ring cell early gastric cancer who had undergone endoscopic submucosal dissection at the Severance Hospital in Korea, between March 2007 and March 2012. The clinical outcomes were reviewed and factors related to incomplete resection were analysed. RESULTS Multivariate analysis showed that large tumour size was the only significant factor related to incomplete resection (P=0.006; hazard ratio, 1.040; 95% confidence interval, 1.101-1.084). In addition, large tumour size was the only significant factor related to endoscopic size underestimation (P<0.001; hazard ratio, 1.391; 95% confidence interval, 1.221-1.586). The rate of endoscopic size underestimation was significantly higher in tumours with a size ≥20mm (P<0.001). CONCLUSIONS To improve the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection, larger tumours (especially tumour with a size ≥20mm) should be resected with a larger margin.

Prediction of Survival by Tumor Area on Endosonography after Definitive Chemoradiotherapy for Locally Advanced Squamous Cell Carcinoma of the Esophagus

Background: Definitive chemoradiotherapy (CRT) is a reasonable approach for patients with locally advanced esophageal cancer who are not surgical candidates. This study was performed to investigate whether endosonography (EUS) assessment of tumor area response is a useful prognostic marker in patients with squamous cell carcinoma (SCC) of the esophagus who receive definitive CRT. Methods: A total of 33 patients who received definitive CRT for locally advanced esophageal SCC were enrolled. The maximal transverse cross-sectional area of the tumor was measured before and after definitive therapy. EUS response was defined as a ≥50% reduction of the tumor area after definitive CRT. Results: Based on EUS evaluation, there were 20 nonresponders (60.6%) and 13 responders (39.4%). The median progression-free survival (PFS) was significantly longer in EUS responders than EUS nonresponders (p = 0.005). However, there was no statistical significance in overall survival according to EUS response (p = 0.120). During multivariate analysis, EUS response to definitive CRT was the only significant factor associated with PFS (p = 0.045), whereas EUS response to definitive CRT was not associated with overall survival (p = 0.221). Conclusions: A reduction of the maximal cross-sectional tumor area measured by EUS correlates with a superior prognosis in patients with locally advanced SCC of the esophagus after definitive CRT.

Is endoscopic therapy safe for upper gastrointestinal bleeding in anticoagulated patients with supratherapeutic international normalized ratios

The management of upper gastrointestinal bleeding (UGIB) in anticoagulated patients with supratherapeutic international normalized ratios (INRs) presents a challenge. The purpose of the study was to evaluate the safety of endoscopic therapy for UGIB in anticoagulated patients with supratherapeutic INR in terms of rebleeding and therapeutic outcomes. One hundred ninety-two anticoagulated patients who underwent endoscopic treatment for UGIB were enrolled in the study. Patients were divided into 2 groups based on the occurrence of rebleeding within 30 days of the initial therapeutic endoscopy: no-rebleeding group (n = 168) and rebleeding group (n = 24). The overall rebleeding rate was 12.5%. Bleeding from gastric cancer and bleeding at the duodenum were significantly related to rebleeding in a univariate analysis. Multivariate analysis determined that presenting symptoms other than melena (hematemesis, hematochezia, or others) (odds ratio, 3.93; 95% confidence interval, 1.44–10.76) and bleeding from gastric cancer (odds ratio, 6.10; 95% confidence interval, 1.27–29.25) were significant factors predictive of rebleeding. Supratherapeutic INR at the time of endoscopic therapy was not significantly associated with rebleeding in either univariate or multivariate analysis. Significant differences in bleeding-related mortality, additional intervention to control bleeding, length of hospital stay, and transfusion requirements were revealed between the rebleeding and no-rebleeding groups. There were no significant differences in therapeutic outcomes between patients with INR within the therapeutic range and those with supratherapeutic INR. Supratherapeutic INR at the time of endoscopic therapy did not change rebleeding and therapeutic outcomes. Thus, we should consider endoscopic therapy for UGIB in anticoagulated patients, irrespective of INR at the time of endoscopic therapy.

Sa1919 Prognostic Value of Neutrophil to Lymphocyte Ratio in Patients Treated With Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer

a b s t r a c t Background: We performed a retrospective analysis of Asian patients with locally advanced oesophageal cancer to test the hypothesis that an elevated neutrophil-to-lymphocyte ratio is associated with a poor survival rate after definitive concurrent chemoradiotherapy. Methods: In total, 138 patients diagnosed with locally advanced oesophageal cancer (TNM classification of malignant tumours stage II or III) who were treated with definitive concurrent chemoradiother- apy between January 2005 and December 2010 were retrospectively analysed. Definitive concurrent chemoradiotherapy was performed using two different chemotherapy regimens. Results: The median follow-up duration was 39.5 months (range 1.1-93.4). The median progression-free survival was 14.0 months, and the median overall survival was 19.9 months. Compared with the low (<2.0) neutrophil-to-lymphocyte ratio group (n = 43, 31.2%), the high (≥2.0) neutrophil-to-lymphocyte ratio group (n = 95, 68.8%) exhibited significant decreases in the durations of both progression-free sur- vival and overall survival. Using multivariate analysis, an elevated neutrophil-to-lymphocyte ratio was also significantly associated with decreased progression-free survival (HR 1.799; 95% CI, 1.050-3.083; P = 0.032) and overall survival duration (HR 2.115; 95% CI, 1.193-3.749; P = 0.010). Conclusions: The pretreatment neutrophil-to-lymphocyte ratio is a useful prognostic marker in patients with locally advanced oesophageal cancer treated with definitive concurrent chemoradiotherapy.

Mo1172 Impact of Statin Therapy on the Long-Term Outcome After Radical Gastrectomy for Gastric Cancer

Background/Aims: Although several experimental and epidemiological studies suggest that statins may have antineoplastic properties, the impact of statin use on patient survival after a curative resection of gastric cancer is unknown. The aim of this study was to investigate whether the use of statins was associated with recurrence or survival after radical gastrectomy in stage II and III gastric cancer. Methods: We conducted matched case-control study of 65 statin user cases and 176 statin non-user cases after radical gastrectomy from January 2006 to December 2009. The controls were matched to cases by age, sex, stage, and operation month. In comparison of baseline characteristics, tumor differentiation, Laurens classification and Charlson comorbidity index showed statistically differences between two groups or subgroup analysis. Therefore, after adjustment of these different factors we performed Cox regression to identify the association between statin use and gastric cancer outcomes. Results: Recurrence free survival (RFS) between statin user and non-user was similar (adjusted hazard ratio of cancer recurrence or death = 1.518, 95% confidence interval (CI) = 0.761 to 3.03; p = 0.236). Overall survival (OS) was also similar between two groups (adjusted hazard ratio of death = 1.169, 95% CI = 0.57 to 2.397; p = 0.669). We also divided the statin user group into two groups according to the duration of statin use by six months. And then, we compared with three groups which were statin non-user, statin user less than 6 months and statin user more than 6 months. Statin user less than 6 months was associated increased recurrence risk (adjusted hazard ratio of cancer recurrence or death = 1[statin non-user as reference], 3.165 [less 6 months group, 95% CI = 1.337 to 7.491] and 0.368 [more 6 months group, 95% CI = 0.099 to 1.374]; p = 0.008), whereas statin user more than 6 months was showed statistically significant improved OS (adjusted hazard ratio of death = 1[statin non-user as reference], 2.405 [less 6 months group, 95% CI = 1.056 to 5.477] and 0.168 [more 6 months group, 95% CI = 0.032 to 0.881]; p = 0.006). Conclusions: Statin use was not associated with improved RFS and OS in patients after curative resection of stage II, III gastric cancer. However, subgroup analysis demonstrated that long-term statin use more than 6 months was associated with increased survival outcome. Our result firstly suggests antitumor activity of statin treatment with regard to post-operative period of gastric cancer, which has to this day not been fully elucidated.