Hwoon-Yong Jung

Degree of Healing and Healing-Associated Factors of Endoscopic Submucosal Dissection-Induced Ulcers After Pantoprazole Therapy for 4 Weeks

Background There is no consensus regarding the degree of healing of endoscopic submucosal dissection (ESD)-induced ulcers and the optimal duration of proton pump inhibitor (PPI) treatment. Aim To evaluate the degree of healing and the factors associated with healing of ESD-induced ulcers after PPI therapy for 4xa0weeks. Methods Fifty-six patients who underwent complete ESD for adenoma or early gastric cancer were enrolled. All patients underwent follow-up endoscopy to evaluate the degree of ulcer healing after pantoprazole therapy (40xa0mg per day) for 4xa0weeks. We evaluated change in size of ESD-induced ulcers between baseline and 4xa0weeks, and correlated relevant factors with degree of healing of small and large ulcers. Results At follow-up, 28 (50%) patients had large ulcers (areaxa0>xa010xa0mm2). Ulcer size at 4xa0weeks was closely correlated with initial ulcer size (Pxa0<xa00.001) and abruptly increased when initial ulcer size was larger than 4xa0cm. Comorbidity, procedure time, and initial specimen size were significantly associated with healing rate, but multivariate analysis showed that initial ulcer size was the only significant parameter (Pxa0<xa00.015). Conclusions Healing degree of ESD-induced ulcers at 4xa0weeks is dependent on initial ulcer size, indicating that duration of treatment with PPI should be dependent on initial ulcer size.

Verrucous carcinoma of the esophagus

A 66-year-old man with chronic dysphagia and chronic cough of 2 years duration was admitted to the Veterans Administration Medical Center. Ann Arbor. MI in October 1983. complaining of progression in dysphagia for both solids and liquids, and 20-lb weight loss during the 2 months before admission. Approximately 27 years before, he sustained extensive battery acid bums to his face, neck, upper part of the thorax, pharynx, and esophagus during a motor vehicle accident. He underwent multiple reconstructive and skin graft operations during the next 4 years. An esophageal stricture resulting from the caustic injury subsequently required frequent dilatations. He continued to be a heavy smoker and alcohol drinker until recently. On physical examination he was a cachectic, dehydrated man in moderate discomfort. There were confluent scars across his face neck and upper chest. Chest examination revealed coarse rales in the right upper lobe and bilateral basilar rhonchi. The remainder of the physical examination was unremarkable. The laboratory studies revealed Hb 13 g/dl, hematocrit 39.6%. white blood cell count 28.600/mm and normal serum electrolytes. A chest radiograph revealed cavitating infiltrates in the right upper lobe. A PPD was negative and no acid-fast bacilli were found in the sputum. The sputum cytology showed malignant cells. A barium swallow (Fig. 1) revealed a large polypoid mass in the proximal esophagus almost completely obstructing the lumen. The contrast medium extravasated through an esophageal perforation and filled a mediastinal abscess cavity on the right side. A large diverticulum of the proximal esophagus was also filled with the contrast medium. Computed tomography of the chest (Fig. 2) showed right upper lobe infiltrates with cavity formation and a mediastinal abscess on the right side. Fine needle aspiration of the right upper lobe lesion yielded purulent exudate and budding yeast consistent with aspiration pneumonia. A laryngoscopic examination revealed a paralyzed right vocal cord. Bronchoscopy revealed no intrabronchial mass. Esophagoscopy showed a large cauhflower-like mass occluding the esophageal lumen at 17 cm from the incisors. Biopsy revealed verrucous squamous cell carcinoma of the esophagus (Fig. 3). Initial treatment consisted of antibiotics and nutritional support requiring a feeding gastrostomy tube. Due to combination of severe chronic obstructive pulmonary disease, mediastinal abscess, and marked debilitation, he was considered a poor surgical candidate. The patient refused chemotherapy. His general condition continued to deteriorate and on December 8. 1983 he died due to respiratory arrest. No autopsy was performed.

Narrow-band imaging and white-light endoscopy with optical magnification in the diagnosis of dysplasia in Barrett’s esophagus: results of the Asia-Pacific Barrett’s Consortium

Objective: The advent and utility of new endoscopic imaging modalities for predicting the histology of Barrett’s esophagus (BE) in real time with high accuracy appear promising and could potentially obviate the need to perform random biopsies where guidelines are poorly adhered to. We embarked on evaluating the performance characteristics of white-light endoscopy with magnification (WLE-z), narrow-band imaging with magnification (NBI-z) and a combination of both modalities. Design: This was a prospective online study with 28 endoscopists from 11 countries (Asia-Pacific region) participating as assessors. In total, 35 patients with BE were assessed using 150 slides from WLE-z and NBI-z randomly arranged using a simple classification with corresponding histology. The overall Accuracy (Acc), Sensitivity (Sn), Specificity (Sp), Positive Predictive Value (PPV), and Negative Predictive Value (NPV) of WLE-z, NBI-z and a combination of both were calculated. Results: The overall Acc for WLE-z and NBI-z images was 87.1u200a% and 88.7u200a%, respectively. When images from the two modalities were placed side by side, the Acc increased to 90.3u200a%. The Sn, Sp, PPV, and NPV of WLE-z were 48u200a%, 92u200a%, 45u200a%, and 93u200a% while with NBI-z, these improved to 89u200a%, 89u200a%, 56u200a%, and 98u200a%, respectively. When both imaging modalities were viewed together, they improved further to 93u200a%, 90u200a%, 61u200a%, and 99u200a%. Conclusion: The high NPV (99u200a%) when both WLE-z and NBI-z were used simultaneously indicates that areas with regular appearance that are diagnosed with confidence can effectively be left alone and not biopsied when performed at a skilled resourced center. This approach could potentially lead to a paradigm shift of how patients with BE are assessed.

Role of surgical resection in complete responders on FDG-PET after chemoradiotherapy for locally advanced esophageal squamous cell carcinoma.

To determine the role of surgery in complete responders on FDG‐PET after CRT and the prognostic significance of metabolic response in locally advanced esophageal squamous cell carcinoma.

Biofeedback therapy for female patients with constipation caused by radical hysterectomy or vaginal delivery.

Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy.

The effect of eradication of Helicobacter pylori on gastric cancer prevention in healthy asymptomatic populations

Although many epidemiologic studies have evaluated the effect of Helicobacter pylori eradication on gastric cancer, the effect is still uncertain in general populations. We evaluated whether H. pylori eradication would affect the incidence of gastric cancer in healthy asymptomatic populations.

The incidence and locational predilection of metachronous tumors after endoscopic resection of high-grade dysplasia and early gastric cancer.

BackgroundThe incidence of metachronous lesions after endoscopic resection (ER) of high-grade dysplasia (HGD) has not been evaluated, and optimal surveillance strategy remains vague. This study aimed to evaluate the incidence and characteristics of metachronous tumors including HGD and early gastric cancer (EGC) arising after ER.PatientsThe medical records of 2779 patients with 2981 lesions (445 patients with HGD and 2334 patients with EGC) who underwent ER and surveillance endoscopy at Asan Medical Center between April 1999 and December 2011 were retrospectively reviewed, and clinicopathological features of metachronous tumors were analyzed.ResultsNinety-six metachronous lesions (17 HGD and 79 EGC) occurred in 92 patients during median 42xa0months of follow-up period (range 26–58xa0months). The 5-year and 10-year overall cumulative incidences of metachronous tumors were 4.6 and 10.5xa0%, respectively, and were on steady rise up to 10xa0years. The 5- and 10-year cumulative incidences of metachronous lesions were 4.1 and 8.4xa0% in HGD group and 4.7 and 11.3xa0% in EGC group (Pxa0=xa00.578), respectively. The size of metachronous tumors was significantly smaller than initial lesion (2.3 vs. 1.9xa0cm, Pxa0=xa00.039). Lower third of the stomach was most frequent site for both initial and metachronous lesions (77.1 and 70.8xa0%, respectively) and age was the significant predicting factor for metachronous tumors.ConclusionsCumulative incidence of metachronous tumors after ER of HGD was comparable to the incidence after ER of EGC. Surveillance endoscopy can be considered at least for 10xa0years, with special attention on the lower third of the stomach.

Abstract 2874: A prospective study of a repeat endoscopic biopsy to identify HER2-positive tumors following an initial HER2-negative endoscopic biopsy in unresectable or metastatic gastric cancer patients: GASTHER1 study

Proceedings: AACR Annual Meeting 2014; April 5-9, 2014; San Diego, CAnnBackground: The intratumoral heterogeneity of HER2 expression in gastric cancer (GC) is a major challenge when identifying patients who will benefit from HER2-targeting therapy. The aim of this study is to evaluate the significance of re-evaluation of the HER2 status by repeat endoscopic biopsy in GC patients with an initial, HER2-negative endoscopic biopsy.nnMethods: Patients with unresectable or metastatic gastric/gastroesophageal junction (GEJ) adenocarcinoma and who will receive first-line chemotherapy, were eligible if the HER2 was negative on the initial endoscopic biopsy. HER2 positivity was defined as immunohistochemistry (IHC) 3+ or IHC 2+/fluorescence in situ hybridization (FISH) + using the GC scoring system. A repeat endoscopic biopsy was performed in ≥6 different primary tumor sites immediately after obtaining initial HER2-negative results.nnResults: From May 2011 to April 2013, a total of 183 eligible patients were enrolled. Baseline characteristics at the time of the initial biopsy were as follows: tumor location, GEJ∼fundus/body/antrum/diffuse stomach=22(12.0%)/47(25.7%)/68(37.2%)/46(25.1%); Lauren classification, intestinal/diffuse/mixed=53(29.0%)/111(60.7%)/19(10.4%); and HER2 IHC score, 0/1/2=149(81.4%)/26(14.2%)/8(4.4%). The median number of biopsy pieces per patient was 5 (range, 1-15) and 10 (range, 1-15) on the initial and repeat biopsy, respectively (P<0.0001). There was no difference in the median ratio of the number of cancer-containing pieces/total pieces; 0.86 (range, 0.13-1) vs. 0.89 (range, 0.10-1) (P=0.679). As the repeat biopsy identified 16 patients with HER2-positive tumor, the rate of rescued HER2 positivity was 8.7% (95% CI 4.6-12.8%). Rescued HER2 positivity was associated with tumor location (diffuse stomach vs. others=0% vs. 11.7%, P=0.013), Bormann type (IV vs. others=0% vs. 11.7%, P=0.013), and the HER2 IHC score on the initial biopsy (0 vs. 1 vs. 2 = 6.7% vs. 15.4% vs. 25.0%, P=0.028). In multivariate analysis, the HER2 IHC score (1/2 vs. 0, odds ratio=3.78; P=0.016) was an independent predictive factor for rescued HER2 positivity.nnConclusions: Repeat endoscopic biopsy is recommended in order to check the HER2 status again even if the initial endoscopic biopsy is HER2 negative in metastatic or unresectable GC.nnNote: This abstract was not presented at the meeting.nnCitation Format: Sook Ryun Park, Young Soo Park, Baek-Yeol Ryoo, Chang Gok Woo, Hwoon-Yong Jung, Jeong Hoon Lee, Gin Hyug Lee, Min-Hee Ryu, Yoon-Koo Kang. A prospective study of a repeat endoscopic biopsy to identify HER2-positive tumors following an initial HER2-negative endoscopic biopsy in unresectable or metastatic gastric cancer patients: GASTHER1 study. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2874. doi:10.1158/1538-7445.AM2014-2874

Efficacy and Safety of UI05MSP015CT in Functional Dyspepsia: A Randomized, Controlled Trial

Background/Aims To evaluate the efficacy and safety of a controlled release, once-daily formulation of mosapride (UI05MSP015CT) in patients with functional dyspepsia (FD). Methods Patients with FD were randomly assigned (1:1) to receive either UI05MSP015CT (15 mg once a day, study group) or mosapride (5 mg three times a day, control group) and corresponding placebo for 4 weeks. The primary endpoint was a change in the gastrointestinal symptom score (GIS) evaluated at enrollment and after 4 weeks. Secondary endpoints were changes in the Nepean Dyspepsia Index-Korean version (NDI-K), rate of satisfactory symptom relief, and rate of adverse events. Results A total of 138 patients were enrolled (female, 73.9%; mean age, 44.0±15.4 years). After excluding patients who violated the study protocol, 59 and 58 patients from the study and control groups, respectively, were included in the per-protocol analysis. No difference was observed in drug compliance between the control and study groups (97.07%±4.52% vs 96.85%±6.05%, p=0.870). Changes in GIS scores were 9.69±6.44 and 10.01±5.92 in the study and control groups. The mean difference in GIS change between groups was 0.33 (95% confidence interval, 1.75 to 2.41), demonstrating non-inferiority of UI-05MSP015CT (p=0.755). The rate of satisfactory symptom relief was not different between the study and control groups (39.0% vs 56.9%, p=0.053). No differences in change in NDI-K score (14.3 vs 16.9, p=0.263) or rates of adverse events (12.9% vs. 4.4%, p=0.062) were observed between the study and control groups. Conclusions Once-daily mosapride is not inferior to conventional mosapride in efficacy and is safe in patients with FD.

Usefulness of endoscopic ultrasonography in endoscopic submucosal dissection.

. 2010; 25: 1747–1753.Endoscopic mucosal resection (EMR) is now firmly established asa treatment approach for gastric neoplasms, particularly earlygastric cancer (EGC). It is an organ-saving method that is lessinvasive than surgical resection. Moreover, it can provide a concisepathological diagnosis that allows prognosis to be predicted. Withthe aid of instrumental developments, such as an electrosurgicalknife, a more precise endoscope, and high-frequency electrosur-gical current generator, endoscopic submucosal dissection (ESD)enables dissection of deeper tissue layers. Further, ESD has beenreported to be superior to EMR for en bloc resection and localrecurrence rates.