Ji Min Choi

Clinical implications of pre-existing adenoma in endoscopically resected early gastric cancers

Background Although gastric adenoma is widely accepted as a precursor of gastric cancer, pre-existing adenoma is not always detected in gastric cancer patients. Objective To investigate the clinical characteristics of early gastric cancer (EGC) arising from adenoma, compared with those of EGC without pre-existing adenoma. Methods Patients who underwent endoscopic resection for EGC at a single tertiary hospital were divided into two groups based on the presence (ex-adenoma group) or absence (de novo group) of pre-existing adenoma on pathologic specimens. Clinicopathologic characteristics, endoscopic features and long-term outcomes were analyzed. Results Of 1,509 patients, 236 (15.6%) were included in the ex-adenoma group. Mean age (P = 0.003) and Helicobacter pylori infection rate (P = 0.040) were significantly higher in the ex-adenoma than in the de novo group. Mean endoscopic size was significantly larger, elevated lesions were more prevalent (both P < 0.001), and carcinomas were more differentiated in the ex-adenoma group than in the de novo group (P = 0.037). The degree of atrophy (P = 0.025) or intestinal metaplasia (P < 0.001) was more advanced in the ex-adenoma group. Synchronous gastric neoplasia was significantly more prevalent in the ex-adenoma group (P < 0.001), whereas metachronous cancer recurrence rate was not significantly different between the two groups. Conclusions EGCs with pre-existing adenoma show a greater association with H. pylori–related chronic inflammation than those without, which could explain the differences in the characteristics between groups. Potential differences in carcinogenic mechanisms between the groups were explored.

Surveillance strategy according to age after endoscopic resection of early gastric cancer.

BackgroundWhether surveillance strategy after curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) differs in young patients is unclear. This study aimed to evaluate the risk of metachronous and extragastric recurrence in young patients with EGC after curative ESD.MethodsWe retrospectively enrolled 1237 consecutive patients who underwent curative ESD for EGC from 2005 to 2014 at a single tertiary hospital. The patients were divided into group 1 (<50xa0years of age, nxa0=xa086), group 2 (age 50–74, nxa0=xa0985), or group 3 (≥75xa0years of age, nxa0=xa0166). The clinical characteristics and outcomes were compared among the three age groups.ResultsGroup 1 had more frequent Helicobacter pylori infection (Pxa0<xa00.001), less frequent intestinal metaplasia (Pxa0=xa00.021), and more frequent undifferentiated tumors (Pxa0=xa00.039). Although the 5-year risk of developing metachronous recurrence appeared to be lower in group 1 (2.7%) than in groups 2 (8.6%) or 3 (8.7%), the risk became quite similar at the 7-year follow-up (6.4, 12.7, and 8.7% for groups 1, 2, and 3, respectively; Pxa0=xa00.409 by log-rank test). Extragastric recurrences developed in only 2 cases in group 2 (0.2%).ConclusionsSurveillance for metachronous and extragastric recurrence after curative ESD in patients <50xa0years of age should not be different from that in patients ≥50xa0years of age. Endoscopic surveillance for metachronous recurrence should be continued for longer than 5xa0years, even in young patients.

Long-Term Effects of Helicobacter pylori Eradication on Metachronous Gastric Cancer Development

Background/Aims Gastric mucosal atrophy and intestinal metaplasia due to Helicobacter pylori infection are the main precursor lesions of gastric cancer. The aim of this study was to evaluate the long-term effects of H. pylori eradication on the progression of precancerous lesions to metachronous cancer after endoscopic resection of early gastric cancer (EGC). Methods Patients who underwent endoscopic resection of EGC were retrospectively reviewed. Changes in precancerous lesions and development of metachronous cancer were compared according to H. pylori eradication and final infection status. Results In total, 565 patients were followed for over 5 years after endoscopic resection of EGC. The grade of atrophy on corpus was significantly lower in the H. pylori-eradicated group than in the persistent group during follow-up (p=0.029). In patients <70 years of age, the cumulative incidence rate of metachronous cancer was significantly lower in the H. pylori-eradicated group than in the persistent group (p=0.018). Age was an independent risk factor for metachronous cancer development. Conclusions H. pylori eradication might prevent the development of metachronous cancer in patients <70 years of age by delaying the progression of precancerous lesions after endoscopic resection of EGC.

Continuous Use of Thienopyridine May Be as Safe as Low-Dose Aspirin in Endoscopic Resection of Gastric Tumors

Background/Aims Current guidelines recommend withholding antiplatelets for 5–7 days before high-risk endoscopic procedures. We investigated whether this reduces post-endoscopic submucosal dissection (ESD) bleeding. Methods Gastric ESD cases with antiplatelets were retorospectively reviewed. Withholding antiplatelets for 5–7 days before ESD was defined as cessation and 0–4 days as continuation. The rate and risk of post-ESD bleeding according to the types and cessation of antiplatelets were assessed. Results Among the 215 patients (117 adenoma and 98 early gastric cancer), 161 patients were on single (94 aspirin, 56 thienopyridine, and 11 other agents), 51 on dual, and 3 on triple antiplatelets. Post-ESD bleeding rates were 12.8% in aspirin users, 3.6% in thienopyridine, 27.5% in dual, 33.3% in triple therapy, and 9.7% in the cessation and 15.0% in the continuation group. Multiple antiplatelets (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.01 to 5.76) and specimen size ≥ 5.5 cm (OR, 2.84; 95% CI, 1.04 to 7.73) were the risk of bleeding, while continuation of thienopyridine (OR, 0.23; 95% CI, 0.05 to 1.09) and antiplatelets (OR, 1.83; 95% CI, 0.68 to 4.94) did not increase the risk of bleeding. Conclusions Continuing thienopyridine and aspirin did not increase the risk of post-ESD. Multiple antiplatelet therapy and a large specimen size were independent risk factors of post-ESD bleeding.

Effects of Helicobacter pylori eradication for metachronous gastric cancer prevention: a randomized controlled trial

BACKGROUND AND AIMSnWhether eradication of Helicobacter pylori reduces the incidence of metachronous gastric cancer (MGC) is still debatable. We aimed to evaluate the long-term effect of H pylori eradication on the development of MGC after endoscopic gastric tumor resection.nnnMETHODSnWe undertook an open-label, prospective, randomized controlled trial at a tertiary hospital in Seoul, Korea. Participants were recruited during April 2005 to February 2011 and followed until December 2016. We assigned 898 patients with H pylori infection treated with endoscopic resection (ER) for gastric dysplasia or early gastric cancer to receive (nxa0=442) or not receive (nxa0=456) eradication therapy using a random-number chart. Eradication group patients received oral omeprazole 20 mg, amoxicillin 1 g, and clarithromycin 500 mg twice daily for a week, whereas control group patients received no H pylori treatment. The primary outcome was the incidence of MGC (intention-to-treat analysis).nnnRESULTSnThe 877 patients who attendedxa0≥1 follow-up examination (eradication group, 437; control group, 440) were analyzed. Median follow-up was 71.6 months (interquartile range, 42.1-90.0). MGC developed in 18 (4.1%) eradication and 36 (8.2%) control group patients (log-rank test, Pxa0= .01). In our yearly analysis, the effect of eradication showed a significant difference in 5 years after allocation (log-rank test, Pxa0= .02). The adjusted hazard ratio for the control group was 2.02 (95% CI, 1.14-3.56; Pxa0= .02), compared with the eradication group.nnnCONCLUSIONSnH pylori eradication significantly reduces the incidence of MGC after ER of gastric tumors and should be considered for H pylori-positive gastric tumor patients treated with ER. (Clinical trial registration number: NCT01510730.).

Health and Prevention Enhancement (H-PEACE): a retrospective, population-based cohort study conducted at the Seoul National University Hospital Gangnam Center, Korea

Purpose The Health and Prevention Enhancement (H-PEACE) study was designed to investigate the association of diagnostic imaging results, biomarkers and the predisease stage of non-communicable diseases (NCDs), such as malignancies and metabolic diseases, in an average-risk population in Korea. Participants This study enrolled a large-scale retrospective cohort at the Healthcare System Gangnam Center, Seoul National University Hospital, from October 2003 to December 2014. Findings to date The baseline and follow-up information collected in the predisease stage of NCDs allows for evaluation of an individual’s potential NCD risk, which is necessary for establishing personalised prevention strategies. A total of 91u2009336 health examinees were included in the cohort, and we repeatedly measured and collected information for 50.9% (n=46u2009484) of the cohort members. All participants completed structured questionnaires (lifestyle, medical history, mini-dietary assessment index, sex-specific variables and psychiatric assessment), doctors’ physical examinations, laboratory blood and urine tests and digital chest X-ray imaging. For participants with available data, we also obtained information on specific diagnostic variables using advanced diagnostic tests, including coronary CT for coronary calcium scores, colonoscopy and brain MRI. Furthermore, 17u2009455 of the participants who provided informed consent and donated blood samples were enrolled into the Gene-environmental interaction and phenotype study, a subcohort of the H-PEACE, from October 2013, and we analysed genome-wide single-nucleotide polymorphism array data for 6579 of these blood samples. Future plans The data obtained from this cohort will be used to facilitate advanced and accurate diagnostic techniques related to NCDs while considering various phenotypes. Potential collaborators can access the dataset after receiving approval from our institutional review board. Applications can be submitted on the study homepage (http://en-healthcare.snuh.org/HPEACEstudy).

Ablation of residual gastric tumor by argon plasma coagulation after endoscopic resection

BackgroundFor residual gastric tumors (RT) found at the treated sites after endoscopic resections (ER), additional treatment options are additional ER, surgery or argon plasma coagulation (APC). Long-term efficacy of APC as the curative modality for RT has not been fully elucidated. This study aimed to investigate the efficacy and long-term outcome of APC for RT with relevant tumor factors.MethodsEighty-two patients who received ER for gastric adenocarcinoma or adenoma and were subsequently treated with APC for RT were reviewed retrospectively. Characteristics of the tumors curatively ablated with single-session of APC and the non-curatively ablated were compared by multiple logistic regression analysis. Overall rate of curative ablation and follow-up duration was calculated.ResultsInitial tumor size <20xa0mm [odds ratio for second residual recurrence (OR) 0.16; 95xa0% confidence interval (CI) 0.039–0.63], en-bloc resection (OR 0.16; 95xa0% CI 0.039–0.72), histologic complete resection (OR 0.14; 95xa0% CI 0.028–0.66) and RT with flat or depressed type (OR 0.20; 95xa0% CI 0.051–0.77) were significantly associated with curative ablation of RT by single-session of APC. Anterior wall or lesser curvature location showed a tendency toward curative APC, but not reached statistical significance (OR 0.36; 95xa0% CI 0.11–1.16). A total of 60 patients (73.2xa0%) achieved curative ablation after single-session of APC. Eleven among the patients (nxa0=xa022) with second or more residual recurrence achieved curative ablation with one or two more additional sessions of APC. Overall rate of curative ablation was 86.6xa0% (71/82). From the last APC, the final curative ablation group (nxa0=xa071) has been followed up for 49.7xa0±xa037.4xa0months.ConclusionsEn-bloc resection, histologic complete resection, RT with flat or depressed type and initial tumor size less than 2xa0cm can be predictors of favorable clinical outcome of APC as an additional treatment for RT. For selected patients with RT, APC and close monitoring could be a reasonable alternative to immediate resection.

Novel risk stratification for metachronous recurrence after curative endoscopic submucosal dissection for early gastric cancer

BACKGROUND AND AIMSnThis study stratified the risk of developing metachronous gastric cancer (MGC) after curative endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) to enable customization of endoscopic surveillance for MGC.nnnMETHODSnA total of 1115 patients who underwent curative ESD based on the expanded criteria for differentiated EGC from 2005 to 2014 at a single tertiary hospital were enrolled in this retrospective cohort study. They were followed up with annual endoscopy for a median of 50.1 months. Helicobacter pylori and histologic intestinal metaplasia (IM) were evaluated. The Kaplan-Meier method and Cox regression analysis were used for risk stratification.nnnRESULTSnThree risk groups were identified: group 1 comprised patients with a synchronous neoplasm; group 2 comprised male patients with corpus IM; and group 3 comprised male patients without corpus IM or female patients. The 5- and 7-year cumulative risks (95% confidence interval [CI]) for metachronous recurrence were 15.1% (95% CI, 7.7-22.5) and 26.1% (95% CI, 14.9-37.3), respectively, in group 1; 5.6% (95% CI, 3.1-8.1) and 9.3% (95% CI, 5.4-13.2), respectively, in group 2; and 3.8% (95% CI, 1.6-6.0) and 4.9% (95% CI, 2.4-7.4), respectively, in group 3 (Pxa0< .001 by log-rank test). The incidence of MGCs increased constantly even after 5 years in groups 1 and 2 but not in group 3. There was not enough evidence to show an association between H pylori eradication and metachronous recurrence in the data.nnnCONCLUSIONSnMeticulous annual endoscopic surveillance for MGC for more than 5 years is recommended for patients with synchronous neoplasm. Endoscopic surveillance may also be extended beyond 5 years in male patients with corpus IM.

Clinical efficacy of endoscopic ultrasonography for decision of treatment strategy of gastric cancer

BackgroundAccurate preoperative tumor staging of gastric cancer is indispensable with expansion of indications for laparoscopic surgery and endoscopic resection. It is important to distinguish mucosal cancer (T1a) in smaller lesion and differentiate early gastric cancer (EGC) in larger lesion considering endoscopic resection indication and laparoscopic surgery indication. We evaluated the clinical outcomes of endoscopic ultrasonography (EUS) for the decision of treatment strategy of gastric cancer compared with pathological staging.MethodsThe patients who underwent EUS and surgical or endoscopic resection for gastric cancer were retrospectively reviewed between September 2005 and February 2016. The depth of tumor invasion (T staging) by EUS was compared with the pathological staging after endoscopic or surgical resection.ResultsA total of 6084 patients were finally analyzed. The accuracy rates for T1a and EGC were 75.0 and 89.4%, respectively. The overall accuracy of T staging by EUS was 66.3% when divided by T1a, T1b, and over T2. The accuracy of EUS prior to endoscopic resection was 75.1% in absolute indication and 73.1% in expanded criteria, respectively. The accuracy rates for T1a with lesion ≤u20092xa0cm in miniprobe EUS and EGC with lesion >u20092xa0cm in conventional EUS were 84.6 and 83.2%, respectively. In multivariate analysis, presence of ulcer, large tumor size, and radial EUS were associated with overestimation, and small tumor size and miniprobe were associated with underestimation in T staging.ConclusionsEUS showed the high accuracy of 84.6% for T1a in lesion ≤u20092xa0cm in miniprobe EUS and 83.2% for EGC in lesion >u20092xa0cm in conventional EUS, respectively. EUS can be a complementary diagnostic method to determine endoscopic or surgical treatment modality.

Long-term outcome of group D patients with negative serum anti-Helicobacter pylori antibody and positive serum pepsinogen test in healthy Koreans: Long-term outcome of group D patients

The aim of this study was to assess the clinical characteristics and long‐term outcomes of group D patients (negative H. pylori antibodies and positive pepsinogen level).