Tae-Sung Sohn

Indication for endoscopic mucosal resection in early signet ring cell gastric cancer

BackgroundThe aim of this study was to compare the clinicopathological characteristics of an early signet ring cell carcinoma (SRC) with an early undifferentiated carcinoma (mucinous, poorly differentiated adenocarcinoma) and early differentiated carcinoma (well or moderately differentiated tubular adenocarcinoma, papillary adenocarcinoma) and find indications for endoscopic mucosal resection (EMR) in early SRC.Methods1520 patients with early gastric cancer (EGC), who underwent a curative gastrectomy, were analyzed retrospectively. Among them, 388 patients with SRC were compared with 253 patients with undifferentiated carcinoma (UDC) and 879 with a differentiated carcinoma (DC).ResultsSRC was more common in young female patients than UDC. SRC had a tendency to be confined to the mucosa, with smaller size than UDC. The lymph node metastasis rate for SRC was lower than that for UDC, but similar to that of DC. Multivariate analysis revealed lymph node metastasis (LNM) to be associated with the depth of invasion, tumor size, histological type, and lymphatic involvement. SRC had no LNM in the case of a mucosal tumor, smaller than 2cm, and in the absence of lymphatic involvement. The prognosis of SRC was more favorable than UDC.ConclusionsEarly SRC has different characteristics from early UDC. In view of the lower rate of lymph node metastasis and better prognosis, we suggest that EMR can be performed on patients with early SRC limited to the mucosa, less than 2cm in size, and with no lymphatic involvement.

Patterns of failure in gastric carcinoma after D2 gastrectomy and chemoradiotherapy: a radiation oncologist's view

The risk of locoregional recurrence in resected gastric adenocarcinoma is high, but the benefit of adjuvant treatment remains controversial. In particular, after extended lymph node dissection, the role of radiotherapy is questionable. Since 1995, we started a clinical protocol of adjuvant chemoradiotherapy after D2 gastrectomy and analysed the patterns of failure for 291 patients. Adjuvant chemotherapy consisted of five cycles of fluorouracil and leucovorin, and concurrent radiotherapy was given with 4500 cGy from the second cycle of chemotherapy. With a median follow-up of 48 months, 114 patients (39%) showed any type of failure, and the local and regional failures were seen in 7% (20 out of 291) and 12% (35 out of 291), respectively. When the recurrent site was analysed with respect to the radiation field, in-field recurrence was 16% and represented 35% of all recurrences. Our results suggest that adjuvant chemoradiotherapy has a potential effect on reducing locoregional recurrence. Moreover, low locoregional recurrence rates could give a clue as to which subset of patients could be helped by radiotherapy after D2 gastrectomy. However, in order to draw a conclusion on the role of adjuvant radiotherapy, a randomised study is needed.

Employment status and work-related difficulties in stomach cancer survivors compared with the general population

Little was known about work situation and work-related difficulties, including housework after stomach cancer diagnosis. We aimed to compare employment status and work-related difficulties between stomach cancer survivors and the general population. We enrolled 408 stomach cancer survivors from two hospitals 28 months after diagnosis and 994 representative volunteers from the general population from 15 geographic districts. Working was defined as being employed (including self-employed) and nonworking as being retired or a homemaker. Nonworking was significantly higher among stomach cancer survivors (46.6%) than in the general population (36.5%). Compared with the general population, the survivors had more fatigue in performing both housework (adjusted odds ratio (aOR)=2.08; 95% confidence interval (95% CI)=1.01–4.29) and gainful work (aOR=4.02; 2.55–6.33). More cancer survivors had reduced working hours (aOR=1.42; 95% CI=4.60–28.35) and reduced work-related ability (aOR=6.11; 95% CI=3.64–10.27) than did the general population. The association of nonworking with older age and being female was significantly more positive for survivors than for the general population. Among survivors, poorer Eastern Cooperation Oncology Group Performance Status and receiving total gastrectomy were positively associated with nonworking. Stomach cancer survivors experienced more difficulties in both housework and gainful employment than did the general population. Our findings on stomach cancer survivors’ work-related difficulties and the predictors of nonworking will help physicians guide patients towards more realistic postsurgical employment plans.

Surgical outcome after incomplete endoscopic submucosal dissection of gastric cancer.

Endoscopic resection of early gastric cancer is a relatively new and attractive treatment, but occasionally fails to remove all cancer lesions completely. This study aimed to elucidate clinicopathological factors that could be helpful in predicting residual tumour in the surgical specimen after incomplete endoscopic submucosal dissection (ESD).

Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer

Endoscopic submucosal dissection is gaining popularity in the treatment of early gastric cancer. This study aimed to identify clinicopathological factors predictive of lymph node metastasis in patients with the poorly differentiated early gastric cancer to assess the feasibility of using endoscopic submucosal dissection for these cancers.

Clinical Practice Guideline for Accurate Diagnosis and Effective Treatment of Gastrointestinal Stromal Tumor in Korea

Despite the rarity in incidence and prevalence, gastrointestinal stromal tumor (GIST) has emerged as a distinct pathogenetic entity. And the clinical management of GIST has been evolving very rapidly due to the recent recognition of its oncogenic signal transduction pathway and the introduction of new molecular-targeted therapy. Successful management of GIST requires a multidisciplinary approach firmly based on accurate histopathologic diagnosis. However, there was no standardized guideline for the management of Korean GIST patients. In 2007, the Korean GIST study group (KGSG) published the first guideline for optimal diagnosis and treatment of GIST in Korea. As the second version of the guideline, we herein have updated recent clinical recommendations and reflected changes in diagnosis, surgical and medical treatments for more optimal clinical practice for GIST in Korea. We hope the guideline can be of help in enhancing the quality of diagnosis by members of the Korean associate of physicians involving in GIST patientss care and subsequently in achieving optimal efficacy of treatment.

Long-Term Surgical Outcome of 1057 Gastric GISTs According to 7th UICC/AJCC TNM System: Multicenter Observational Study From Korea and Japan.

AbstractThe aim of this study was to evaluate the treatment and prognosis of gastric gastrointestinal stromal tumors (GISTs) according to the 7th UICC/AJCC tumor-node-metastasis (TNM) system and the modified National Institutes of Health (NIH) risk classification. The study cohort consisted of 1057 patients with gastric GIST who underwent surgery between January 2000 and December 2007 from 13 institutions in Korea and 2 in Japan. Clinicopathologic characteristics, surgical outcomes, recurrence, and 5-year recurrence-free survival were evaluated.The mean age of the patients was 58.6 years. Thirty patients (2.8%) had distant metastasis preoperatively. Median tumor size was 4.0 cm. Complete resection (R0 resection) was achieved in 1018 patients (96.3%). Eighty-six patients (8.1%) had postoperative complications, and 2 patients (0.2%) died within 30 days after surgery. According to the 7th UICC/AJCC TNM system, 5-year recurrence-free survival rates were 95% to 99% in stage I, 94.1% in stage II, 74.1% in stage IIIA, 48.6% in stage IIIB, and 50.0% in stage IV patients. On survival analysis of high-risk patients according to the TNM system, the 5-year recurrence-free survival rates were 91.6% in stage II, 74.1% in stage IIIA, and 48.6% in stage IIIB patients. Independent factors of recurrence following surgery for gastric GIST were gender, tumor size, mitotic count, and radicality on multivariate analysis.The treatment outcome and prognosis of gastric GIST in Korea and Japan seem more favorable compared to those in Western countries. Compared to the modified NIH risk classification, the 7th UICC/AJCC TNM system is more reflective of the 5-year recurrence-free survival of patients with gastric GIST.

Factors related to clinically relevant fatigue in disease-free stomach cancer survivors and expectation–outcome consistency

BackgroundAlthough early detection and improved treatment have increased the number of long-term survivors, little is known about the prevalence and associations of clinically relevant fatigue (CRF) in disease-free stomach cancer survivors. Because no effective CRF management strategy yet exists, understanding CRF risk factors is important for developing treatment approaches.MethodsStomach cancer survivors (N = 374) completed a mailed survey that included the Brief Fatigue Inventory, Beck Depression Inventory, and the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire and its gastric module QLQ-STO22. We assessed sociodemographic, clinical, and symptom characteristics using multivariate logistic regression models to identify CRF-associated factors.ResultsApproximately half of disease-free stomach cancer survivors reported CRF, which was associated with female gender, low economic status, rural residence, current smoker, early tumor progress, current depression, and poor performance. Significant relationships of CRF with current depression and poor performance status remained robust after adjusting for potential confounders. Most functional and symptom scores of fatigued survivors deteriorated more than in non-fatigued survivors. Additionally, congruence between tumor progress and surgery type might influence CRF severity.ConclusionIn disease-free stomach cancer survivors, CRF is a common problem that is strongly associated with quality of life and other symptoms. Current depression, poor performance, and perceived understanding regarding postoperative condition are important CRF risk factors. Thus, CRF management in this population should focus on identifying these factors.

Factors Associated With Depression in Disease-Free Stomach Cancer Survivors

CONTEXT Depression in cancer survivors affects the rest of their lives in many ways. OBJECTIVES To estimate the prevalence of depression and identify associated factors in disease-free stomach cancer survivors. METHODS We enrolled 391 stomach cancer survivors who had been disease-free for at least one year after surgery from the cancer registries of two hospitals in Korea. Stomach cancer survivors were mailed a survey that included the Beck Depression Inventory, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, and the associated stomach module, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Stomach Cancer Module 22. RESULTS Forty-four percent of survivors suffered from depression, and more women (49%) than men (42%) had high depression scores (Beck Depression Inventory >13). In multiple logistic regression analysis, lower income (odds ratio [OR] 2.49; 95% CI 1.64-3.78), problems with care before treatment (OR 1.92; 95% CI 1.23-2.98), body image change (OR 2.23; 95% CI 1.41-3.53), and symptoms of fatigue (OR 3.11; 95% CI 1.49-6.52), dyspnea (OR 2.57; 95% CI 1.48-4.45), or insomnia (OR 4.51; 95% CI 1.88-10.83) were associated with depression. CONCLUSION The prevalence of depression was high in stomach cancer survivors even after the completion of treatment, especially among those with problems amenable to treatment, and we identified the associated factors. We suggest that stomach cancer survivors should be screened for depression after the end of treatment.

Clinical significance of skip lymph node metastasis in gastric cancer patients.

PURPOSE Given the recent increase in the incidence of early gastric cancer, there is greater interest in identifying a minimally invasive therapy. The purpose of this study was to analyze the patterns of lymph node metastasis in patients with gastric cancer and to elucidate the clinical significance of skip metastasis. METHODS We retrospectively analyzed patterns of lymph node metastasis (LNM) and clinicopathologic factors related to skip metastasis. RESULTS Among 2963 patients with gastric cancer, 997 patients (33.6%) were detected as having LNM, and 27 patients (2.7%) with skip metastasis were detected among 997 patients with LNM. Skip metastasis were detected more frequently in the elderly. Compared with the N1 group, the skip metastasis group showed lower frequency of vascular invasion, and compared with the stepwise N2 group, the skip metastasis group showed smaller tumor size and a significantly higher incidence of negative lymphatic, vascular, and perineural invasion. CONCLUSIONS Currently there is no way to predict N2 station LNM including skip metastasis, D2 LN dissection for gastric cancer is thought to be the appropriate treatment, even during early stage disease. Minimally invasive therapy should be performed cautiously in consideration of possible skip metastasis.