Kee Don Choi

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.

Multiple synchronous early gastric cancers: High-risk group and proper management

BACKGROUNDnMultiple early gastric cancers (MEGCs) may be easily missed on preoperative gastroscopy because the lesions are predominantly small and flat. This may increase the risks of gastric remnant lesions and recurrence. We aimed to define high-risk group of MEGC and suggest proper management of missed lesion after partial gastrectomy.nnnMETHODSnA total of 117 patients with MEGCs and 2182 with solitary EGC who underwent gastrectomy between 2008 and 2010 were retrospectively analyzed to determine their clinicopathologic characteristics. We also assessed their family history, the presence of Helicobacter pylori infection, and of precancerous lesions; and the results of microsatellite instability and immunohistochemical staining of the primary (largest) lesion for p53, human epidermal growth factor receptor [HER1], and HER2 were also reviewed.nnnRESULTSnMEGCs occurred more frequently in elderly males and in patients with adenoma, atrophic gastritis, or a family history of gastric cancer. These patients had more favorable pathologic findings, including less deep invasion, better differentiation, more intestinal type, and less frequent lymphovascular/perineural invasion than patients with solitary EGCs. The mean size of MEGCs was smaller (2.44 cm vs 3.36 cm) but there was no difference in the number of metastatic lymph nodes. Most accessory lesions were confined to the mucosal layer, with their average diameter was 1.82 cm.nnnCONCLUSIONSnA careful preoperative gastroscopy should be performed in patients at high risk of MEGCs and more cautious postoperative endoscopic surveillance of the remnant stomach is required. For missed foci on remnant stomach, endoscopic resection can be a good option if it meets the criteria.

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.