Significance of the Expression of CyclinD1 and Ki67 Antigen in Nasopharyngeal Carcinoma

Objective: To detect the expression of cyclinD1 and Ki67 in nasopharyngeal carcinoma (NPC) and their correlation with the biological behaviors and prognosis. Methods: 56 cases of biopsy specimens of NPC which had been embedded with para?n in 1996 in our hospital were collected and immunostained with cyclinD1 and Ki67 monoclonal antibodies by means of the streptavidin peroxides method. The patients were followed up periodically, and then their biological behaviors and prognosis were statistically analyzed. Results: The percentage of cyclinD1 and Ki67 positive cells in the NPC specimens ranged from 0–54% and 0–31% respectively. The staining was nuclear. Of the 56 cases, 30 cases (56.6%) highly expressed cyclinD1 or Ki67 HPI and 26 cases (46.4%) lowly expressed cyclinD1, while only 16 cases (28.6%) showed Ki67 HPI (high proliferated index) and 40 cases (71.4%) showed Ki67 LPI (low proliferated index). Patients who lowly expressed cyclinD1 or highly expressed Ki67 had a higher radiosensitivity and a better prognosis. Conclusion: CyclinD1 and Ki67 immunohistochemical staining is considered to be useful, not only as an independent factor of radiosensitivity and prognosis respectively, but also as a means of determining the optimum treatment for each individual patient with NPC.

Effect of lymphadenectomy extent on advanced gastric cancer located in the cardia and fundus

AIM： To analyze the prognostic impact of lymphade-nectomy extent in advanced gastric cancer located in the cardia and fundus. METHODS： Two hundred and thirty-six patients with advanced gastric cancer located in the cardia and fundus who underwent D2 curative resection were analyzed retrospectively. Relationships between the numbers of lymph nodes （LNs） dissected and survival was analyzed among different clinical stage subgroups. RESULTS： The 5-year overall survival rate of the entire cohort was 37.5%. Multivariate prognostic variables were total LNs dissected （P 〈 0.0001; or number of negative LNs examined, P 〈 0.0001）, number of positive LNs （P 〈 0.0001）, T category （P 〈 0.0001） and tumor size （P = 0.015）. The greatest survival differences were observed at cutoff values of 20 LNs resected for stage Ⅱ（p = 0.0136）, 25 for stage Ⅲ（P 〈 0.0001）, 30 for stage Ⅳ（P = 0.0002）, and 15 for all patients （P = 0.0024）. Based on the statistically assumed linearity as best fit, linear regression showed a significant survival enhancement based on increasing negative LNs for patients of stages Ⅲ （P = 0.013） and Ⅳ（P = 0.035）. CONCLUSION： To improve the long-term survival of patients with advanced gastric cancer located in the cardia and fundus, removing at least 20 LNs for stage Ⅱ,25 LNs for stage Ⅲ, and 30 LNs for stage N patients during D2 radical dissection is recommended.

Relationship between cell adhesion molecules expression and the biological behavior of gastric carcinoma

AIM: To evaluate the relationship between the expression of cell adhesion molecules (CAMs) and the biological behavior of gastric carcinoma. METHODS: Expression of syndecan-1, E-cadherin and integrin β3 were evaluated by immunohistochemical study in a total of 118 gastric carcinomas and 20 non- tumor gastric mucosas. RESULTS: The expressions of syndecan-1 and E-cadherin were significantly lower in gastric carcinoma compared to non-tumor gastric mucosa, and the low expression rates were positively correlated to the tumor invasion depth, vessel invasion, lymph node metastasis and distant metastasis (P < 0.01 in all cases). However, the expression of integrin β3 was significantly higher in gastric carcinoma compared to non-tumor gastric mucosa, and the high expression rates were positively correlated to the tumor invasion depth, vessel invasion, lymph node metastasis and distant metastasis (P < 0.01 in all cases). In addition, the three protein expressions were correlated to the tumor growth pattern (P < 0.01, P < 0.01, and P < 0.05 respectively), but not correlated to tumor differentiation (P > 0.05, P > 0.05 and P > 0.05 respectively). Positive correlation was observed between the expressions of syndecan-1 and E-cadherin, but they which were negatively correlated to the expression of integrin β3 (P < 0.01 in all cases). Univariate analysis demonstrated that the mean survival time and 5-year survival rate were lower in the cases with low expressions of syndecan-1 and E-cadherin and high expression of integrin β3 (P < 0.01, in all cases). COX multivariate analysis showed that the expression level of syndecan-1 could be an independent prognostic index of gastric carcinoma (P < 0.01), whereas E-cadherin and integrin β3 could not be independent indexes (P > 0.05, P > 0.05 respectively). CONCLUSION: The low expression of syndecan-1 and E-cadherin and the high expression of integrin β3 are significantly correlated with the invasion and metastasis of gastric carcinoma, and they are highly correlated with each other. Therefore they may serve as important prognostic markers of gastric carcinoma.

Early prediction of major depression in chronic hepatitis C patients during peg-interferon α-2b treatment by assessment of vegetative-depressive symptoms after four weeks

AIM: To study the predictive value of the vegetative- depressive symptoms of the Zung Depression Rating Scale for the occurrence of depression during treatment with peg-interferon α-2b of chronic hepatitis C (CHC) patients. METHODS: The predictive value of vegetative- depressive symptoms at 4 wk of treatment for the occurrence of a subsequent diagnosis of major depressive disorder (MDD) was studied in CHC patients infected after substance use in a prospective, multi- center treatment trial in Belgium. The presence of vegetative-depressive symptoms was assessed using the Zung Scale before and 4 wk after the start of antiviral treatment. RESULTS: Out of 49 eligible patients, 19 (39%) developed MDD. The area under the ROC curve of the vegetative Zung subscale was 0.73, P = 0.004. The sensitivity at a cut-point of > 15/35 was 95% (95% CI: 74-100). The positive predictive value equalled 44% (95% CI: 29-60). CONCLUSION: In this group of Belgian CHC patients infected after substance use, antiviral treatment caused a considerable risk of depression. Seven vegetativedepressive symptoms of the Zung scale at wk 4 of treatment predicted 95% of all emerging depressions, at a price of 56% false positive test results.

Prognostic analysis of patients with pancreatic head adenocarcinoma less than 2cm undergoing resection

AIM:To investigate the differences in clinicopathological features between patients with pancreatic cancer greater or less than 2 cm situated over the pancreatic head and the prognostic factors for survival of patients with pancreatic cancer<2 cm over the pancreatic head. METHODS:From 1983 to 2006,159 patients with histologically proven pancreatic adenocarcinoma(PAC) at the pancreatic head undergoing curative resection at the Department of Surgery,Chang Gung Memorial Hospital,Taipei,Taiwan were reviewed,comprising 123 cases of large(L)-PAC(tumor>2 cm)and 36 cases of small(S)-PAC(tumor≤2 cm).We compared the clinicopathological characteristics and prognosis of L-PAC and S-PAC patients.The clinicopathological characteristics of S-PAC were investigated to clarify the prognosis predictive factors of S-PAC. RESULTS:One hundred and fifty-nine PAC patients, aged 16-93 years(median,59.0 years)with a tumor at the pancreatic head undergoing intentional curative resection were investigated.The S-PAC and L-PAC patients had similar demographic data,clinical features,and tumor markers(a similar positive rate of carcinoembryonic antigen and carbohy- drate antigen 19-9).There were also similar rates of lymph node metastasis,portal vein invasion,stage distribution,tumor differentiation,positive resection margin,surgical morbidity and mortality observedbetween the two groups.During a follow-up period ranging from 1.0 to 122.7 mo(median,10.9 mo), S-PAC and L-PAC patients had a similar prognosis after resection(P=0.4805).Among the S-PAC patients group,patients with higher albumin level(>3.5 g/dL) had more favorable survival than those with lower albumin levels,which was the only favorable predictive prognostic factor.Meanwhile,early-staged(stageⅠ,Ⅱ) S-PAC patients tended to have a more favorable outcome than late-stage(stageⅢ,Ⅳ)S-PAC patients, but this was not statistically significant. CONCLUSION:S-PAC patients should not be regarded as early PAC.Only higher albumin level(>3.5 g/dL) and early stage disease(stageⅠ,Ⅱ)were the favorable prognosis factors for S-PAC patients.

Effect of lymph node micrometastases on prognosis of gastric carcinoma

AIM： To evaluate the relationship between lymph node micrometastases and prognosis of patients with gastric carcinoma and to evaluate the significance of the new assessment of nodal status in determining the pN categories in the 5th edition of the UICC TNM classification.METHODS： A total of 850 lymph nodes from 30 patients with gastric carcinoma who underwent gastrectomy with lymphadenectomy were assessed by reverse transcription polymerase chain reaction assay in addition to histologic examination. Cytokeratin-20 gene marker was used in this assay.RESULTS： Routine examination by HE staining confirmed metastasis in 233 lymph nodes from 20 patients. All these 233 lymph nodes were oltokeratin-20 positive. Moreover, lymph node micrometastases were detected in an additional 67 lymph nodes in 12 of these 20 patients. Lymph node micrometastases were also detected in t0 lymph nodes from 2 of 10 patients who had no obvious metastases identified by HE staining. Totally, lymph node micrometastases were identified by the reverse transcription polymerase chain reaction assay in 77 （12.5%） lymph nodes from 14 （46.7%） patients with gastric carcinoma. Of 27 patients who underwent curative resection, 7 （25.9%） were up-staged （from Ⅰ B stage to Ⅱ stage in 1 patient, from IB stage to ⅢA stage in 1 patient, from Ⅱ stage to ⅢA stage in 1 patient, from ⅢA stage to ⅢB stage in 1 patient, from ⅢA stage to Ⅳ stage in 1 patient, from ⅢB stage to Ⅳ stage in 2 patients）. In a median follow-up of 32 （range 8-36） too, Kaplan-Meier survival analysis showed significant improvements in median survival （22.86 ± 3.17 mo, 95% CI： 16.64-29.08 mo vs 18.00 ± 7.4 mo, 95% CI： 3.33-32.67 mo） of patients with negative lymph node micrometastases over patients with positive lymph node micrometastases （log-rank, P 〈 0.05）.CONCLUSION： Lymph node micrometastases have a significant impact on the current staging system of gastric carcinoma, and are significant risk factors for prognosis of patients with gastric carcinoma.

Effect of neoadjuvant chemoradiotherapy on prognosis and surgery for esophageal carcinoma

AIM:To investigate the role of neoadjuvant chemoradiotherapy in prognosis and surgery for esophageal carcinoma by a meta-analysis.METHODS:PubMed and manual searches were done to identify all published randomized controlled trials(RCTs) that compared neoadjuvant chemoradiotherapy plus surgery(CRTS) with surgery alone(S) for esophageal cancer.According to the test of heterogeneity,a fi xed-effect model or a random effect model was used and the odds ratio(OR) was the principal measure of effects.RESULTS:Fourteen RCTs that included 1737 patients were selected with quality assessment ranging from A to C(Cochrane Reviewers' Handbook 4.2.2).OR(95% CI,P value),expressed as CRTS vs S(values>1 favor CRTS arm),was 1.19(0.94-1.48,P=0.28) for 1-year survival,1.33(1.07-1.65,P=0.69) for 2-year survival,1.76(1.42-2.19,P=0.11) for 3-year survival,1.41(1.06-1.87,P=0.11) for 4-year survival,1.64(1.28-2.12,P=0.40) for 5-year survival,0.82(0.39-1.73,P<0.0001) for rate of resection,1.53(1.33-2.84,P=0.007) for rate of complete resection,1.78(1.14-2.78,P=0.79) for operative mortality,1.12(0.89-2.48,P=0.503) for all treatment mortality,1.33(0.94-1.88,P=0.04) for the rate of adverse treatment,1.38(1.23-1.63,P=0.0002) for local-regional cancer recurrence,1.28(0.85-1.58,P=0.60) for distant cancer recurrence,and 1.27(0.86-1.65,P=0.19) for all cancer recurrence.A complete pathological response to chemoradiotherapy occurred in 10%-45.5% of patients.The 5-year survival benefi t was most pronounced when chemotherapy and radiotherapy were given concurrently(OR:1.45,95% CI:1.26-1.79,P=0.015) instead of sequentially(OR:0.85,95% CI:0.64-1.35,P=0.26).CONCLUSION:Compared with surgery alone,neoadjuvant chemoradiotherapy can improve the long-term survival and reduce local-regional cancer recurrence.Concurrent administration of neoadjuvant chemoradiotherapy was superior to sequential chemoradiotherapy.

Prognostic significance of bcl-2 and p53 expression in colorectal carcinoma

Objective: This study was designed to detect the expression of bcl-2 and p53 proteins in colorectal carcinomas and to determine their association with the patient survival and stage of the diseases. Methods: Immunohistochemistry method was used to detect the expression of bcl-2 and p53 proteins in 93 cases of colorectal carcinoma. The stain results were obtained by analyzing the clinic-pathological characteristics of patients. Results: Fifty-seven percent (53/93) of the colorectal carcinomas were bcl-2 protein positive. The positive rate of bcl-2 protein in lymph node involvement cases was lower (15/37) than the cases without node involvement (38/58, P<0.01). The positive rate of p53 protein was 43% (40/93) in colon-rectum carcinomas. No significant correlation was observed between p53 protein expression and clinic-pathological manifestations (P>0.05) but the survival was significantly worse (P=0.0001) in the p53 protein positive cases. Neither bcl-2 nor p53 alone was correlated with stage of the disease. When combined bcl-2/p53 status was analyzed, a group with bcl-2(+) and p53(?) had the best prognosis. This group was significantly associated with earlier Dukes’ stages (P=0.1763). In multivariate Cox regression analysis, lymph node involvement and p53 protein expression were two independent factors correlated with survival time. Conclusion: The expression of bcl-2 and p53 represent biological characteristics of colorectal carcinomas. Assessment of both bcl-2 and p53 status may be valuable in predicting the prognosis of patients.

Prognostic factors and time-related changes influence results of colorectal liver metastases surgical treatment:A single-center analysis

AIM:To analyze the prognostic factors involved in survival and cancer recurrence in patients undergoing surgical treatment for colorectal liver metastases(CLM) and to describe the effects of time-related changes on survival and recurrence in these patients.METHODS:From January 1994 to January 2006,236 patients with CLM underwent surgery with the aim of performing curative resection of neoplastic disease at our institution and 189(80%) of these patients underwent resection of CLM with curative intention.Preoperative,intraoperative and postoperative data,including primary tumor and CLM pathology results,were retrospectively reviewed.Patients were divided into two time periods:a first period from January 1994 to January 2000(n = 93),and a second period from February 2000 to January 2006(n = 143).RESULTS:Global survival at 1,3 and 5 years in patients undergoing hepatic resection was 91%,54% and 47%,respectively.Patients with preoperative extrahepatic disease,carcinoembryonic antigen(CEA) levels over 20 ng/dL,more than four nodules or extrahepatic invasion at pathological analysis had worse survival.Tumor recurrence rate at 1 year was 48.3%,being more frequent in patients with preoperative and pathological extrahepatic disease and CEA levels over 20 ng/dL.Although patients in the second time period had more adverse prognostic factors,no differences in overall survival and recurrence were observed between the two periods.CONCLUSION:Despite advances in surgical technique and better adjuvant treatments and preoperative imaging,careful patient staging and selection is crucial to continue offering a chance of cure to patients with CLM.

ADENOSQUAMOUS LUNG CARCINOMA:CLINICAL CHARACTERISTICS,SURGICAL TREAMENT AND PROGNOSIS

Objective.The effectiveness of surgical resection of adenosquamous carcinoma of the lung remains poorly defined because of the histology’s relatively low frequency, the failure in most published series to separate adenosquamous carcinoma from the other variants of non-small cell lung carcinoma.To define the effectiveness of surgical treatment of adenosquamous carcinoma,we have retrospectively reviewed our hospital experience over a 12-year period. Methods.Retrospectively reviewed 22 cases of adenosquamous carcinoma who were surgically treated,except one patient,in the PUMCH from Jan.1985 to Aug.1997.This series constitutes the 19% of a total of 1 245 patients with all types of surgical treatment for the primary lung cancer during the same time. Results.The adenosquanous carcinoma was mostly presented in the old patients with a mean age of 60 years and mostly located in the peripheral of lung(n=20).The overall 5-year survival was 23%.Those with stage Ⅰ tumors survival was only 18%(n=13), stage Ⅱ 5%. The survival in stage Ⅲ tumors was not longer than 25 months and in stage Ⅳ survival was not longer than 12 months. Conclusion.Our results suggest that adenosquamous carcinoma of lung was a virulent tumor,which exhibited highly aggressive biological behavior with early lymph nodes metastasis(46%) and its prognosis was worse than that of both squamous cell carcinoma and adenocarcinoma.

Factors related to lymph node metastasis and surgical strategy used to treat early gastric carcinoma

AIM:The prognosis of early gastric carcinoma (EGC) is generally excellent after surgery. The presence or absence of lymph node metastasis in EGC is an important prognostic factor. The survival and recurrence rates of node-negative EGC are much better than those of node-positive EGC. This study examined the factors related to lymph node metastasis in EGC to determine the appropriate treatment for EGC.METHODS: We investigated 748 patients with EGC who underwent surgery between January 1985 and December 1999 at the Division of Gastroenterologic Surgery, Department of Surgery, Chonnam National University Hospital. Several clinicopathologic factors were investigated to analyze their relationship to lymph node metastasis: age, sex, tumor location, tumor size, gross type, histologic type, depth of invasion, extent of lymph node dissection, type of operation,and DNA ploidy.RESULTS:Lymph node metastases were found in 75 patients (10.0%). Univariate analysis showed that male sex, tumor size larger than 2.0cm, submucosal invasion of tumor, histologic differentiation, and DNA ploidy pattern were risk factors for regional lymph node metastasis in EGC patients. However, a multivariate analysis showed that three risk factors were associated with lymph node metastasis:large tumor size, undifferentiated histologic type and submucosal invasion. No statistical relationship was found for age, sex, tumor location, gross type, or DNA ploidy in multivariate analysis. The 5-year survival rate was 94.2% for those without lymph node metastasis and 87.3% for those with lymph node metastasis, and the difference was significant (P<0.05).CONCLUSION: In patients with EGC, the survival rate of patients with positive lymph nodes is significantly worse than that of patients with no lymph node metastasis. Therefore,a standard D2 lymphadenectomy should be performed in patients at high risk of lymph node metastasis: large tumor size, undifferentiated histologic type and submucosal invasion.

Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

AIM： To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh （CTP） and model for end-stage liver disease （MELD） score to predict that outcome. METHODS： We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint. RESULTS： Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD （12.8 ＋ 3.9 vs 12.6 ＋ 4.7, P = 0.9） or in the mean CTP （7.6 ± 1.2 vs 7.7 ± 1.7, P = 0.8） between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures （MELD： 22.4 ± 8.7 vs 15.2 ± 6.4, P = 0.0007; CTP： 9.9 ± 1.8 vs 8.5 ± 1.8, P = 0.008）. The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them （AUC = 0.755 ± 0.066 for MELD vs AUC = 0.696 ± 0.070 for CTP, P = 0.3）. CONCLUSION： The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.

Peritoneal carcinomatosis of colorectal origin:Incidence,prognosis and treatment options

Peritoneal carcinomatosis (PC) is one manifestation of metastatic colorectal cancer (CRC). Tumor growth on intestinal surfaces and associated fluid accumulation eventually result in bowel obstruction and incapacitating levels of ascites, which profoundly affect the quality of life for affected patients. PC appears resistant to traditional 5-fluorouracil-based chemotherapy, and surgery was formerly reserved for palliative purposes only. In the absence of effective treatment, the histori-cal prognosis for these patients was extremely poor, with an invariably fatal outcome. These poor outcomes likely explain why PC secondary to CRC has received little attention from oncologic researchers. Thus, data are lacking regarding incidence, clinical disease course, and accurate treatment evaluation for patients with PC. Recently, population-based studies have revealed that PC occurs relatively frequently among patients withCRC. Risk factors for developing PC have been identi-fied:right-sided tumor, advanced T-stage, advanced N-stage, poor differentiation grade, and younger age at diagnosis. During the past decade, both chemother-apeutical and surgical treatments have achieved prom-ising results in these patients. A chance for long-term survival or even cure may now be offered to selected patients by combining radical surgical resection with intraperitoneal instillation of heated chemotherapy. This combined procedure has become known as hy-perthermic intraperitoneal chemotherapy. This edito-rial outlines recent advancements in the medical and surgical treatment of PC and reviews the most recent information on incidence and prognosis of this disease. Given recent progress, treatment should now be considered in every patient presenting with PC.

Surgical treatment and prognosis of cancers of hepatic flexure of colon invading the duodenum in 65 patients

Objective： The aim of the study was to discuss surgical treatment of right colon carcinoma of hepatic flexure invading the duodenum. Methods： The 65 patients with right colon carcinoma of hepatic flexure invading the duodenum, treated in our department from 1987 to 2007, were included in this study. Their clinicopathological data were retrospectively reviewed and analyzed. All the cases were divided into three types （local invasion, regional invasion, and cancer with internal fistula） according to duodenal defect, including local invasion （ 2.0 cm）, wide invasion （ 2.0 cm） and the presence of internal fistula. Results： The 25 patients with local invasion underwent en bloc resection of the duodenal wall. Pedicled ileal flap was used to cover the large duodenal defect measuring 2.0–3.0 cm in 5 patients. Dudenojejunostomy was used to reconstruct the large defect measuring more than 5 cm in 3 patients. Conservative resection of right-sided colon was performed in 18 patients with wide invasion. Four patients underwent pancreaticoduodenectomy combined with right hemicolectomy for colon cancer involving the pancreatic head. Ten cases underwent duodenal diverticularization. One patient with anastomotic leakage healed within 3 weeks. Other patients were cured without postoperative complications. The total 3-and 5-year survival rates after surgery were 53.8% and 9.2%, respectively. Conclusion： The surgical procedure to be performed is usually decided according to the cancer location, extent, and duodenal defect and invasion, which are important for prolonging life time, improving of quality of life and prognosis in these patients.

Multidisciplinary approach to understand the pathogenesis of gastric cancer

Gastric carcinoma remains a common disease worldwide with a dismal prognosis. Therefore, it represents a very important health problem. It occurs with a high incidence in Asia and is one of the leading causes of cancer death in the world. Although the incidence and mortality of gastric carcinoma are decreasing in many countries,gastric cancer still represents the second most frequent malignancies in the world and the fourth in Europe. The 5-year survival rate of gastric carcinoma is low. The etiology and pathogenesis are not yet fully known. The study of gastric cancer is important in clinical medicine as well as in public health. Over the past 15 years,integrated research in molecular pathology has clarified the details of genetic and epigenetic abnormalities of cancer-related genes in the course of the development and progression of gastric cancer. Gastric cancer, as all cancers, is the end result of the interplay of many risk factors as well as protective factors. Although epidemiological evidence indicates that environmental factors play a major role in gastric carcinogenesis, the role of immunological, genetic, and immunogenetic factors are thought to contribute to the pathogenesis of gastric carcinoma. Among the environmental factors,diet and Helicobacter pylori are more amenable to intervention aimed at the prevention of gastric cancer.The aim of the present paper is to review and include the most recent published evidence to demonstrate that only a multidisciplinary approach will lead to the advancement of the pathogenesis and prevention of gastric cancer. On the immunogenetic research it is clear that evidence is accumulating to suggest that a genetic profile favoring the proinflammatory response increases the risk of gastric carcinoma.

Age and outcomes of primary percutaneous intervention for ST elevation myocardial infarction in a tertiary center are we there yet？

Background Primary percutaneous intervention （PPCI） is the treatment of choice for ST elevation myocardial infarction （STEMI） but robust evidence in the very elderly is lacking. We compared PPCI outcomes between different age quartiles （quartile I 〈 60 years, quartile 2 〉 60 to 〈 70 years, quartile 3 〉 70 to 〈 80 years, quartile 4 〉 80 years）. Methods Retrospective observational analysis of our Morriston Tertiary Cardiac Center （Abertawe Bro Morgannwg University Health Board） patients from 2005 to 2010 with STEMI who underwent PPCI. Resnlts Of 434 patients, 57 （13%） were in quartile 4 （〉 80 years）. In older age quartiles, patients were less likely to receive a drug eluting stent （DES, P = 0.001） or glycoprotein IlbAIIa inhibitor （GPI, P 〈 0.0001）. Increase in age was associated with reduced time to survival （13-coefficient： -0.192, t： -3,70, 95%CI： --4.91 to -1.50, P 〈 0.0001） as was the presence of cardiogenic shock 03-coefficient： -0.194, t = 3.77, 95%CI： -5.26 to -1.65, P 〈 0.0001）. Use of GPI was associated with increased time to survival （p-coefficient： 0.138, t = 2.82, 95%CI： 1.58-8.58, P = 0.005） but older age quartiles were less likely to receive GPI （P 〈 0.0001）. In-hospital mortality （1.8% quartile 1, 3.6% quartile 2, 10.9% quartile 3 and 12.3% quartile 4, P = 0.002） and 1-year mortality （5.4% quartile 1, 5.5% quartile 2, 16.8% quartile 3 and 24.6% quartile 4, P 〈 0.0001, respectively） was significantly higher in older age quartiles. Conclusions Increased short term and intermediate term mortality is seen in the very elderly after PPCI. Age and cardiogenic shock were prognostic factors. Intervention should not be based on age alone and awareness regarding prognostic factors can help improve management.

Hepatic portal venous gas: Physiopathology, etiology, prognosis and treatment

Hepatic portal venous gas (HPVG), an ominous radiologic sign, is associated in some cases with a severe underlying abdominal disease requiring urgent operative intervention. HPVG has been reported with increasing frequency in medical literature and usually accompanies severe or lethal conditions. The diagnosis of HPVG is usually made by plain abdominal radiography, sonography, color Doppler flow imaging or computed tomography (CT) scan. Currently, the increased use of CT scan and ultrasound in the inpatient setting allows early and highly sensitive detection of such severe illnesses and also the recognition of an increasing number of benign and non-life threatening causes of HPVG. HPVG is not by itself a surgical indication and the treatment depends mainly on the underlying disease. The prognosis is related to the pathology itself and is not influenced by the presence of HPVG. Based on a review of the literature, we discuss in this paper the pathophysiology, risk factors, radiographic findings, management, and prognosis of pathologies associated with HPVG.

Solid-pseudopapillary tumor of the pancreatic tail

We report a case of the rare solid-pseudopapillary tumor of the pancreas. In contrast to other pancreatic tumors,the solid-pseudopapillary tumor has a favorable prognosis.The 60-year-old female patient we report on here was treated by left pancreatic resection combined with splenectomy for a non-metastasizing tumor of the pancreas. A solid-pseudopapillary tumor was found on histology. The patient had no signs of metastases at present.Since a microscopically invasive tumor growth is assumed,oncologically curative resection should be preferred vs the less radical enucleation. The rare solid-pseudopapillary tumor of the pancreas has a good prognosis after successful oncological resection.

Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion

AIM： To analyze the effectiveness of the endoscopic therapy and to identify prognostic factors for recurrent bleeding. METHODS： Retrospective study of patients with gas- trointestinal bleeding secondary to Dieulafoy＇s lesion （DL） from 2005 to 2011. We analyzed the demographic characteristics of the patients, risk factors for gastro- intestinal bleeding, endoscopic findings, characteristics of the endoscopic treatment, and the recurrence of bleeding. We included cases in which endoscopy de- scribed a lesion compatible with Dieulafoy. We exclud- ed patients who had potentially bleeding lesions such as angiodysplasia in other areas or had undergone other gastrointestinal endoscopic procedures. RESULTS： Twenty-nine patients with DL were identi- fied. Most of them were men with an average age of 71.5 years. Fifty-five percent of the patients received antiaggregatory or anticoagulant therapy. The most common location for DL was the stomach （51.7%）. The main type of bleeding was oozing in 65.5% of cases. In 27.6% of cases, there was arterial （spurting） bleeding, and 6.9% of the patients presented with an adherent clot. A single endoscopic treatment was ap- plied to nine patients （31%）, eight of them with adren- aline and one with argon, while 69% of the patients received combined treatment. Six patients （20.7%） presented with recurrent bleeding at a median of 4 d after endoscopy （interquartile range = 97.75）. Within these six patients, the new endoscopic treatment ob- tained a therapeutic success of 100%. The presence of arterial bleeding at endoscopy was associated with a higher recurrence rate for bleeding （50% vs 33.3% for other type of bleeding） rP = 0.024, odds ratio （OR） = 8.5, 95% CI = 1.13-63.87]. The use of combined en- doscopic treatment prevented the recurrence of bleed- ing （10% vs 44.4% of single treatment） （P = 0.034, OR = 0.14, 95% CI = 0.19-0.99）. CONCLUSION： Endoscopic treatment of DL is safe and effective. Adrenaline monotherapy and arterial （spurting） bleeding are associated with a high rate of bleeding recurrence.

Surgical Treatment and Prognosis of Synchronous Double Primary Lung Cancer： a Report of 31 Cases

OBJECTIVE The concept of double primary lung cancer （DPLC） has been generally accepted. Recently, an increasing incidence of synchronous DPLC has been reported, while the diagnostic standard and treatment strategies remain to be improved. This study was conducted to investigate effective surgical treatment and prognosis of synchronous DPLC. METHODS From January 1983 to April 2004, 31 patients with synchronous DPLC were operated in our department. Clinical data, such as surgical pattern, postoperative complications, and survival status, of all these patients were reviewed retrospectively. RESULTS The 31 patients with synchronous DPLC accounted for 0.67% of all the 4,649 patients operated for primary lung cancer in our department during the same period. Both tumors of the synchronous DPLC were resected with Iobectomy or pneumonectomy in 12 patients, while among the other 19 patients at least 1 tumor was treated with partial pulmonary resection. The postoperative morbidity was 29%（9/31）, including 1 case of respiratory insufficiency, 3 cases of atelectasis, 2 cases of atrial fibrillation, 1 case of haemoptysis, 1 case of pleural effusion, and 1 case of wound fat necrosis. No deaths occurred during the operations or within 30 days postoperatively. The postoperative 1 -, 3-, and 5-year survival rates were 52%, 29%, and 20%, respectively. CONCLUSION The incidence of synchronous DPLC is low. An aggressive and reasonable surgical approach can achieve a satisfactory outcome in patients with synchronous DPLC. The postoperative morbidity is low. Some patients might achieve long-term survival.