Kuhn-Uk Lee

Validation of international consensus guidelines for the resection of branch duct‐type intraductal papillary mucinous neoplasms

Classifications of intraductal papillary mucinous neoplasm (IPMN) remain ambiguous, especially for the mixed type. Factors predicting malignancy remain unclear. The aim of this study was to evaluate the usefulness of factors predicting malignancy in the new international consensus guidelines for resection of branch duct‐type (BD)‐IPMN and to compare them with those in the previous version.

Intraoperative Transfusion: Is It a Real Prognostic Factor of Periampullary Cancer Following Pancreatoduodenectomy?

The purpose of this study was to clarify the prognostic significance of transfusion following pancreatoduodenectomy for periampullary cancers. We analyzed 357 periampullary cancers from 1985 to 1997 (ampullary cancer 130 cases, distal bile duct cancer 141 cases, pancreatic head cancer 86 cases). A total of 215 (60%) of the 357 patients have received intraoperative transfusion. The 5-year survival rate of 130 ampullary cancer patients was 59%; altogether, 76 patients (58%) underwent intraoperative transfusion. The 5-year survival rate of patients without intraoperative transfusion was 79%, whereas that of patients with a transfusion was 47% (p = 0.029). Following multivariate analysis, intraoperative transfusion was found to be an independent poor prognostic factor for those with ampullary cancer (relative risk 2.174). Among those with common bile duct cancer, the overall 5-year survival rate was 33%, and the 5-year survival rates for patients with (n = 87) or without (n = 54) transfusion were 25% and 38%, respectively, which did not reach statistical significance (p = 0.0717). For those with pancreatic head cancer, the overall 5-year survival rate was 16%, and there was no survival difference between transfused (n = 52) and untransfused (n = 34) patients. In the present study the reason was not clear, although intraoperative transfusion was an independent significant prognostic factor for ampullary cancer. Careful dissection to minimize intraoperative bleeding is mandatory during pancreatoduodenectomy for ampullary cancer.

Increased morbidity rates in patients with heart disease or chronic liver disease following radical gastric surgery.

The aim of this study was to investigate possible associations between (i) comorbid disease and (ii) perioperative risk factors and morbidity following radical surgery for gastric cancer.

Metastasis-Associated Protein S100A4 and p53 Predict Relapse in Curatively Resected Stage III and IV (M0) Gastric Cancer

Purpose: Pathologic stage is the most important predictive factor of relapse in gastric cancer after curative resection. However, patients with the same stage often have different risks of relapse. Here, we investigated whether the expressions of molecular markers can supplement the current staging system in terms of relapse prediction. Patients and Methods: One hundred and nine stage III or IV (M0) patients who had received curative gastrectomy followed by adjuvant 5-fluorouracil and cisplatin chemotherapy were included in this study. The expressions of molecular markers including p53, p27, COX-2, HER-2, EGFR, maspin, S100A4, E-cadherin, Sp1, and p97 were analyzed by immunohistochemistry in cancer and paired normal tissues. Results: The overall relapse rate was 58.7%, and pathologic stage was a significant predictive factor of relapse (42% in stage IIIA, 48% in IIIB, 76% in IV, p = 0.005). Of the 10 markers examined, p53 and S100A4 were expressed only in tumor tissues, and S100A4 expression was significantly associated with a higher relapse rate (85% vs. 53%, p = 0.008). In multivariate analysis including tumor stage, S100A4 and p53 expression were independent predictive factors of relapse (relative risk, 6.98; 95% confidence interval [CI], 1.608-30.342, 3.49; 95% CI, 1.328-9.186, respectively). On comparing patients who expressed S100A4 or p53 with those who expressed neither, relapse rates were 58% vs. 25% in stage III (p = 0.011) and 95% vs. 59% in stage IV (M0) (p = 0.003). Conclusion: In addition to staging system, the expressions of S100A4 and p53 were significant predictive factors of relapse in gastric cancer after curative resection and adjuvant chemotherapy.

The Role of Surgery After Incomplete Endoscopic Mucosal Resection for Early Gastric Cancer

PurposeEndoscopic mucosal resection (EMR) is a relatively new treatment option for early gastric cancer (EGC). However, cases of incomplete EMR resulting in a positive lateral margin or submucosal invasion (positive vertical margin) have been reported. We conducted this study to evaluate the role of surgery after incomplete EMR for EGC.MethodsWe analyzed 19 patients who underwent gastrectomy as a result of an incomplete EMR. The patients were divided into three groups according to the type of incomplete EMR: a positive lateral margin (LM) group (n = 9), a positive vertical margin (VM) group (n = 4), and a positive lateral and vertical margin (LM + VM) group (n = 6).ResultsThe positive residual tumor rate and the positive lymph node rate were 44.4% (4/9) and 0% (0/9) in the LM group, 50.0% (2/4) and 25.0% (1/4) in the VM group, and 83.3% (5/6) and 16.7% (1/6), LM + VM group, respectively. Curative resection was performed in all patients and there was no recurrence in 30.8 months of follow-up.ConclusionRadical surgery is recommended for patients with a positive lateral resection margin or submucosal invasion, or both, after EMR for EGC, because of the possibility of residual tumor or lymph node metastasis.

Laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy after palliative chemotherapy for advanced gastric cancer with isolated para-aortic lymph node metastasis

Prophylactic para-aortic lymphadenectomy is not recommended in curable advanced gastric cancer. However, there are few reports on therapeutic para-aortic lymphadenectomy after palliative chemotherapy in far advanced gastric cancer. We report three cases of laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy after palliative chemotherapy for the first time in Korea. Three gastric cancer patients with isolated para-aortic lymph node (PAN) metastasis showed partial response to capecitabine-based chemotherapy, and laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy was performed with curative intent. The mean total operation time was 365 minutes (range, 310 to 415 minutes), and the mean estimated blood loss was 158 mL (range, 125 to 200 mL). The mean number of retrieved PAN was 9 (range, 8 to 11), and all pathologic results showed no metastasis of para-aortic region. All patients recovered and were discharged without any significant complications.

Increasing Nodal Ratio is a Poor Prognostic Factor for Survival in Stage III–IV (M0) Gastric Cancer Patients Who Received Curative Surgery Followed by Adjuvant Chemotherapy: A Retrospective Study

OBJECTIVE The aim of this study is to evaluate the efficacy of adjuvant chemotherapy with 5-fluorouracil and cisplatin in gastric cancer patients and to assess prognostic factors affecting relapse and survival. METHODS We retrospectively reviewed the data of 153 patients with Stage III-IV (M0) gastric cancer. The patients were given adjuvant 5-fluorouracil/cisplatin chemotherapy after curative gastric resection with D2 dissection from November 1995 to November 2003. Chemotherapy consisted of cisplatin (60 mg/m(2) as 15 min i.v. infusion) and 5-fluorouracil (1200 mg/m(2) as 12 h continuous i.v. infusion for 4 days) in every 21 days up to six cycles. RESULTS During a median follow-up period of 72.9 months (range: 2.0-135.0 months), a total of 105 patients relapsed (locoregional 19.0% vs. systemic 81.0%). The median disease-free survival and overall survival were 19.8 and 32.2 months, respectively. Univariate analysis revealed T stage, TNM stage and lymph node ratio as prognostic factors for survival (P = 0.002, <0.0001 and <0.0001, respectively). After stepwise selection of the factors, multivariate analysis confirmed the impact of the lymph node ratio and T stage on overall survival and disease-free survival. CONCLUSIONS In patients with Stage III-IV (M0) gastric cancer, adjuvant 5-fluorouracil/cisplatin chemotherapy was tolerable, but did not seem to confer survival advantage. And the lymph node ratio was found as an independent prognostic factor in this population. This evidence suggests that the clinical trial using more active chemotherapeutic agents is mandatory.

Is neoadjuvant chemotherapy necessary for patients with initially resectable colorectal liver metastases in the era of effective chemotherapy

Backgrounds/Aims Hepatic resection has only guaranteed long-term survival in patients with colorectal liver metastasis (CRLM) even in the era of effective chemotherapy. The definite role of neoadjuvant chemotherapy (NCT) is to improve outcomes of unresectable CRLMs, but it its role has not been defined for initially resectable CRLMs (IR-CRLMs). Methods We reviewed the medical records of 226 patients, who had been diagnosed and treated for IR-CRLM between 2003 and 2008; the patients had the following pathologies: 10% had more than 4 nodules, 11% had tumors larger than 5 cm, and 61% had synchronous CRMLs. Among these patients, 20 patients (Group Y) were treated with NCT, and 206 (Group N) did not receive NCT according to their physicians preference. The median follow-up time was 34.1 months. Results The initial surgical plans were changed after NCT to further resection in 20% and to limited resection in 10% of 20 patients. Complication rates of Groups Y (30%) were indifferent from Group N (23%) (p=0.233), but intraoperative transfusions were more frequent in Group N (15%) than in Group Y (5%) (p=0.006). There was one case of hospital mortality (0.44%). Disease-free survival rates in Groups Y and N were 23% and 39%, respectively, and patient survival rates were 42% and 66% (p>0.05). By multivariate analysis, old age (≥60 years), differentiation of primary tumor (poorly/mucinous), resection margin involvement, and no adjuvant chemotherapy were associated with poor patient survival; the number of CRLMs (≥4) was associated with poor disease-free survival. Conclusions NCT had neither a positive impact nor a negative impact on survival, even with intraoperative transfusion, as observed on operative outcomes for patients with IR-CRLM. Further study is required to elucidate the role of NCT for treatment of patient with IR-CRLMs.