Young-Il Min

A new strategy for the application of CA19-9 in the differentiation of pancreaticobiliary cancer: analysis using a receiver operating characteristic curve

OBJECTIVES:Clinicians might be misled in interpreting an elevated CA19-9 when differentiating pancreaticobiliary cancer from benign clinical conditions such as acute cholangitis or cholestasis, because in these conditions, the concentration of CA19-9 may also be elevated. The aims of our study were to calculate new individual cutoff values for CA19-9 according to clinical situations using a receiver operating characteristic (ROC) curve and to define a new strategy for interpreting CA19-9 in pancreaticobiliary cancer.METHODS:One hundred sixty patients with pancreatic diseases (cancer 90, benign disease 70), 322 patients with biliary tract diseases (biliary cancer 152, benign disease 170), and 20,035 asymptomatic controls were enrolled in the present study. An ROC curve was described by plotting the sensitivity on the y-axis against 1-specificity on the x-axis for each of several cutoff values.RESULTS:The area under the ROC curve was significantly greater for pancreatic cancer than for biliary cancer (p < 0.05). For patients with pancreatic cancer, CA19-9 proved to be useful. At a cutoff value of 37 U/ml, sensitivity and specificity were 76.7% and 87.1%, respectively. For patients with biliary cancer, CA19-9 was not helpful. However, when patients with biliary disease were divided into two groups according to the presence of cholangitis or cholestasis, CA19-9 proved to be more useful for the group without cholangitis or cholestasis than for the group with cholangitis or cholestasis (p < 0.05). In the former group, the sensitivity and specificity of CA19-9 were 77.6% and 83%, respectively, at the cutoff value of 37 U/ml. For the latter group, the sensitivity and specificity of CA19-9 were 74% and 41.5% respectively, whereas the specificity reached 87% at 300 U/ml. CA19-9 in diagnosing pancreatic cancer was useful regardless of accompanying acute pancreatitis or cholestasis. The serum concentration of CA19-9 in asymptomatic individuals was 9.42 ± 9.95 U/ml. Only 1 of 157 patients with a concentration of CA19-9 above 37 U/ml was found to have gallbladder cancer. The positive and negative predictive values were 0.65% and 0.78%, respectively.CONCLUSIONS:The use of CA19-9 for the differentiation of pancreaticobiliary cancer should be applied individually, depending on the clinical situation.

Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence

BACKGROUND Percutaneous transhepatic cholangioscopy (PTCS) has a major role in the treatment of hepatolithiasis. The aims of this study were to evaluate immediate and long-term results of PTCS treatment and to elucidate the risk factors for recurrence of stones or cholangitis. METHODS A retrospective study was conducted of patients with hepatolithiasis who underwent PTCS treatment. A total of 92 patients underwent PTCS treatment and 68 were followed for 24 to 60 months (median 42 months). RESULTS Complete clearance of stones was achieved in 74 (80%) patients. The rate of complete clearance was significantly lower in patients with severe intrahepatic strictures compared with that for those with no strictures (14 of 24, 58% vs. 16 of 16, 100%, p < 0.01) and those with mild to moderate strictures (14 of 24, 58% vs. 44 of 52, 85%, p < 0.05). Patients with severe intrahepatic strictures had a higher recurrence rate than those with no or mild strictures (100% vs. 28%, p < 0.01). In addition the recurrence rate in patients with advanced biliary cirrhosis (Childs class B or C) was higher than in those with no or mild (Childs class A) cirrhosis (89% vs. 29%, p < 0.01). In patients with type I and II hepatolithiasis (Tsunoda classification), stones recurred in 2 (12%) patients at 28 and 32 months after successful stone removal, without further recurrence afterwards. The recurrence rate in patients with type III and IV hepatolithiasis increased gradually up to 50% at 60 months of follow-up. CONCLUSIONS Severe intrahepatic stricture was the only factor that affected the immediate success rate of PTCS in the treatment of hepatolithiasis. Several risk factors including severe biliary stricture, advanced biliary cirrhosis and Tsunoda type III and IV affected the long-term results.

Intestinal tuberculosis with abdominal complications: radiologic and pathologic features

AbstractBackground: To investigate radiologic and pathological features of intestinal tuberculosis with abdominal complications. Methods: Twenty-two patients with 23 surgically proven complications (nine intestinal obstructions, eight perforations, three fistulae, and three intestinal bleeds) were analyzed. Medical records, radiologic studies, and pathologic examinations were reviewed with special emphasis on searching for the common features in each group of complication. Results: The most important single feature in seven of the nine patients with intestinal obstruction was the presence of stricture. In the remaining two patients, bowel adhesion was a primary cause of obstruction. In eight patients with intestinal perforation, both obstruction and ulcerations in the dilated proximal loop were the important features in six, and multiple deep ulcerations without obstruction was a primary cause in the remaining two. The common features in three patients with fistulae were focal or multiple strictures, severe adhesions, and fibrotic bowel wall. Intestinal bleeding originated from diffuse mucosal ulcerations. The abdominal complications occurred during antituberculous therapy in 10 of the 22 patients. Conclusion: Understanding the radiologic and pathologic features of intestinal tuberculosis with complications help in making an appropriate clinical decision for the treatment strategy. Close observation is necessary, especially in those patients who are acutely ill during antituberculous medical therapy.

Primary colon lymphoma in Korea: A KASID (Korean Association for the Study of Intestinal Diseases) study

Although almost all primary colorectal lymphomas are of B-cell lineage in Western countries, primary colorectal T-cell lymphomas are not uncommon in the East. The aim of this study was to review the clinical characteristics and treatment outcomes of primary colorectal lymphomas, with special emphasis on the differences between T-cell and B-cell lymphomas. Ninety-five cases of primary colorectal lymphomas that satisfied Dawsons criteria were identified from the clinical databases of 13 university hospitals in Korea. The mean age at the time of presentation was 51.1 years and the male:female ratio was 64:31. The clinical information, including endoscopic and histological characteristics, was retrospectively analyzed. Of the primary colorectal lymphomas, 78 cases (82.1%) were of B-lineage and 17 cases (17.9%) were of T-cell lineage. Patients with T-cell lymphomas presented at a younger age than patients with B-cell lymphomas (42.8 vs 52.9 years, respectively; P= 0.016). The most common presenting symptom was abdominal pain (87.1%) for B-cell lymphomas, whereas hematochezia or night fever was more common for T-cell lymphomas (52.9% and 35.3%, respectively). The most common endoscopic type was fungating mass (54.0%) for B-cell lymphomas and ulcerative/ulcero-infiltrative lesions (80.0%) for T-cell lymphomas. Intussusception was more common in B-cell lymphomas than in T-cell lymphomas (30.8% vs 5.9%, respectively; P= 0.035), but perforation was more common in T-cell lymphomas than in B-cell lymphomas (23.5% vs 3.8%, respectively; P= 0.005). The prognosis was significantly worse for T-cell lymphomas than for B-cell lymphomas (P= 0.002). Primary colorectal T-cell lymphomas are characterized by multifocal ulcerative lesions in relatively young patients, a high rate of hematochezia, fever, or perforation, and a poor prognosis even for cases of localized disease.

Efficacy of neoadjuvant chemoradiotherapy in resectable esophageal squamous cell carcinoma--a single institutional study.

A prospective phase II study of neoadjuvant chemoradiotherapy (CRT) for resectable esophageal squamous cell carcinoma was conducted from May 1993 to March 1996. A total of 88 patients fitted the eligibility criteria and were treated with two courses of induction chemotherapy (cisplatin 60 mg/m2/day on day 1 and 5-fluorouracil (5-FU) 1 000 mg/m2/day on days 2-6) with concurrent hyperfractionated radiotherapy (48 Gy/40 fractions/4 weeks) followed by esophagectomy or definitive CRT comprising 4 cycles of cisplatin/5-FU and hyperfractionated radiotherapy (additional 12 Gy) with intracavitary brachytherapy (9 Gy). Clinical response and downstaging were achieved in 83% and 42% of the patients, respectively. With a median follow-up of 77 months, median survival time was 18 months with a 5-year survival rate of 23%. The clinical responses to CRT and surgery were independent prognostic factors for overall survival. Among the intended surgery group (n=52), 41 (79%) patients underwent surgery and 36 had a resection with a pathologic complete response rate of 43%. When compared with a matched historical control (n=40), there was a significant survival benefit in the multimodality arm (p=0.04). This multimodality therapy was feasible and its efficacy was promising, especially when surgical resection was performed. The therapeutic benefit of neoadjuvant CRT remains to be assessed in large well-designed randomized trials, one of which is ongoing at our institution.

Cystic Fibrosis Transmembrane Conductance Regulators (CFTR) in Biliary Epithelium of Patients with Hepatolithiasis

Cystic fibrosis transmembrane conductance regulator (CFTR) has been considered to be involved in the regulatory pathway of biliary mucin secretion. We investigated expression of CFTR protein and mRNA in 24 livers with hepatolithiasis, in 6 with cholangiocarcinoma, and in 12 histologically normal livers. According to the histologic features of chronic proliferative cholangitis, hepatolithiasis was subdivided into inflammatory cell infiltration predominant (N = 14) and fibrosis predominant (N = 10). The mean signal density of CFTR in overall hepatolithiasis and in histologically normal livers was 1.23 ± 0.15 and 1.01 ± 0.13, respectively (P > 0.05). The CFTR protein (1.60 ± 0.18) and mRNA (1.09 ± 0.15) in inflammatory cell infiltration predominant patients were significantly higher (CFTR protein, 1.01 ± 0.13; mRNA, 0.75 ± 0.11) than in control subjects (P < 0.05), whereas those in fibrosis-predominant patients (CFTR protein, 0.72 ± 0.15; mRNA, 0.55 ± 0.13) were less than in control subjects (P < 0.05). CFTR protein (1.27 ± 0.17) in patients with cholangiocarcinoma was not different from that of control subjects (1.01 ± 0.13). CFTR expression in hepatolithiasis patients was rather heterogeneous but was closely related to the histology of bile ducts.

ENDOSCOPIC LIGATION BY DETACHABLE SNARE FOR THE HEMOSTASIS OF COLONIC BLEEDING FOLLOWED BY SUCCESSFUL LIVER TRANSPLANTATION

A 40‐year‐old male patient with liver cirrhosis developed hematochezia resulting in hepatic encephalopathy. Colonoscopic examination revealed a large, approximately 4.0 cm‐sized villous adenoma in the sigmoid colon which showed diffuse blood oozing. We succeeded in the control of bleeding from the lesion only with a detachable snare. The patient recovered from hepatic encephalopathy and may have an opportunity for liver transplantation. Fortunately, the patient regained normal liver function after a successful liver transplantation.

The clinical implication of glucocorticoid receptor β expression in patients with inflammatory bowel disease

Background/Aims: Glucocorticoid is mainly used for the treatment of inflammatory bowel disease (IBD). However, such a treatment occasionally shows refractory cases and a long-term use causes serious side effects. It would be very useful if we could predict the responsiveness before treatment. Recently, it is reported that glucocorticoid response is related to the expression of human glucocorticoid receptor (hGR). Thus, we investigated the expression rates and clinical implication of hGR in patients with IBD. Methods: The mRNA of peripheral blood mononuclear cells was obtained from 24 patients with ulcerative colitis (UC), 12 patients with Crohns disease (CD), and 17 controls. The cDNA was confirmed using specific primers for hGR and hGR . Results: The expression of hGR mRNA was detected in all patients and controls. In contrast, hGR mRNA was detected in 14 patients (10 in UC, 41.7% and 4 in CD, 33.3%) and 7 controls (41.2%). Seven patients were glucocorticoid-resistant and underwent an operation (hGR positive: 3, hGR negative: 4). There was no significant difference in the treatment duration and dosage between the hGR positive and negative groups. However, the hGR negative group had a significant decrease in the colitis activity after glucocorticoid treatment. Conclusions: The expression of hGR mRNA might provide helpful information about glucocorticoid responsiveness in patients with IBD.

3409 Safety and usefulness of percutaneous transhepatic cholecystoscopic examination (ptccs) in highrisk surgical patients manifesting acute cholecystitis.

Backgrounds: The aim of the present study is to identify the diagnostic and therapeutic usefulness of percutaneous transhepatic cholecystoscopic examination (PTCCS) in high-risk surgical patients manifesting acute cholecystitis. Methods: Between the January 1992 and June 1998, 33 consecutive patients who underwent percutaneous transhepatic cholecystostomy (PC) and subsequent PTCCS for the management of acute cholecystitis and evaluation of gallbladder lesion were included. Results: PC and subsequent PTCCS were successfully accomplished in all of 33 patients. During PTCCS, minor complication (2 of minor bleeding during elctrohydraulic lithotripsy, 2 of tube dislodgement and 1 of bile leakage to peritoneum) occurred in five patients. PTCCS revealed 26 cases of gallstones, 3 cases of sludge ball, 3 cases of gallbladder carcinoma and 1 case of clonorchiasis as associated gallbladder lesion with acute cholecystitis. Three cases of the gallbladder cancer (one case of fundal cancer concealed by stone and two cases of neck cancer) were not predicted radiologically and were incidentally found during PTCCS. For 26 patients with gallstones, PTCCS and concomitant stone removal were successfully carried out in one to four consecutive sessions (mean 2.2 sessions). Gallstones recurred in three (3/22, 14%) patients during the mean follow-up period of 27months. All of them remain asymptomatic. Conclusion: PC and PTCCS may be justified in the management of acute cholecystitis in selected patients of high surgical risk.

7218 The prevalence and relationship of esophageal hiatal hernia and reflux esophagitis in korean.

Backgrounds/Aims: The prevalence of esophageal hiatal hernia and reflux esophagitis are known to be low in the Orient compared with those of the West. We inspected prospectively the prevalence of esophageal hiatal hernia and reflux esophagitis and analyze mutual relationship of esophageal hiatal hernia and reflux esophagitis. Methods:We performed this study at the health promotion center (group A) and outpatient department (group B) among Asan Medical Center in Korea from March to August 1999. Esophageal hiatal hernia was diagnosed endoscopically if the distance from Z-line to diaphragmatic pinch cock action area was 2cm or more. The severity of hiatal hernia was determined by 3cm. Reflux esophagitis was diagnosed when mucosal hyperemia, erosion, ulcer lesion was noted at the distal esophagus. The severity of reflux esophagitis was assessed by Los Angeles (LA) classification. Results: 1) The number of group A and B was 6,401 and 2,740, respectively. The median age and male to female ratio of each group was 47, 48 and 1.8:1, 1:1, respectively. 2) The prevalence of hiatal hernia and reflux esophagitis was 10.8%, 5.8% in group A and 9.9%, 7.2% in group B. 3) Grade I and grade II of hiatal hernia occupied 85.4%, 14.6% in group A, and 82.7%, 17.3% in group B. 4) The stage of reflux esophagitis based on LA classification was as follows. A was 64.2%, B was 33.2%, C was 2.1%, D was 0.5% in group A, A was 65.3%, B was 26.5%, C was 4.6%, D was 4.1% in group B. 5) The prevalence of reflux esophagitis was significantly higher when hiatal hernia was present in both groups (p 25) in both groups. Significant risk factor for reflux esophagitis was hiatal hernia in both groups. Conclusions: The prevalence of hiatal hernia was about 10% in Korean. The prevalence of reflux esophagitis was significantly higher when hiatal hernia was present and more severe.