Optimal sequential therapy using tyrosine kinase inhibitors as the first-line treatment in patients with metastatic renal cell carcinoma: A nationwide multicenter study

Objective:The purpose of the study was to identify the best sequence of therapy beginning with a tyrosine kinase inhibitor(TKI)as the first-line therapy for patients with metastatic renal cell carcinoma(mRCC)in terms of overall survival(OS),progression-free survival(PFS),and rates of discontinuation and adverse effects during the treatment period.Methods:This is a retrospective,nationwide multicenter study of patients with mRCC after diagnosis at 10 different tertiary medical centers in Korea from January 1992 to December 2017.We focused on patients at either“favorable”or“intermediate”risk according to the International mRCC Database Consortium criteria,and they were followed up(median 335 days).Finally,a total of 1409 patients were selected as the study population.We generated a Cox proportional hazard model adjusted for covariates,and the different therapy schemes were statistically tested in terms of OS as well as PFS.In addition,frequencies of discontinuation and adverse events were compared among the therapy schemes.Results:Of the primary patterns of treatment sequences(24 sequences),“sunitinib epazopanib”and“sunitinibeeverolimuseimmunotherapy”showed the most beneficial results in both OS and PFS with significantly lower hazards than“sunitinib”,which is the most commonly treated agent in Korea.Considering that the“TKIeTKI”structure showed relatively higher discontinuation rates with higher adverse effects,the overall beneficial sequence would be“sunitinibeeverolimuseimmunotherapy”.Conclusion:Among several sequential therapy starting with TKIs,“sunitinibeeverolimuse immunotherapy”was found to be the best scheme for mRCC patients with“favorable”or“intermediate”risks.

Different oncological features of colorectal cancer codon-specific KRAS mutations:Not codon 13 but codon 12 have prognostic value

BACKGROUND Approximately 40%of colorectal cancer(CRC)cases are linked to Kirsten rat sarcoma viral oncogene homolog(KRAS)mutations.KRAS mutations are associated with poor CRC prognosis,especially KRAS codon 12 mutation,which is associated with metastasis and poorer survival.However,the clinicopathological characteristics and prognosis of KRAS codon 13 mutation in CRC remain unclear.AIM To evaluate the clinicopathological characteristics and prognostic value of codonspecific KRAS mutations,especially in codon 13.METHODS This retrospective,single-center,observational cohort study included patients who underwent surgery for stage I-III CRC between January 2009 and December 2019.Patients with KRAS mutation status confirmed by molecular pathology reports were included.The relationships between clinicopathological characteristics and individual codon-specific KRAS mutations were analyzed.Survival data were analyzed to identify codon-specific KRAS mutations as recurrence-related factors using the Cox proportional hazards regression model.RESULTS Among the 2203 patients,the incidence of KRAS codons 12,13,and 61 mutations was 27.7%,9.1%,and 1.3%,respectively.Both KARS codons 12 and 13 mutations showed a tendency to be associated with clinical characteristics,but only codon 12 was associated with pathological features,such as stage of primary tumor(T stage),lymph node involvement(N stage),vascular invasion,perineural invasion,tumor size,and microsatellite instability.KRAS codon 13 mutation showed no associations(77.2%vs 85.3%,P=0.159),whereas codon 12 was associated with a lower 5-year recurrence-free survival rate(78.9%vs 75.5%,P=0.025).In multivariable analysis,along with T and N stages and vascular and perineural invasion,only codon 12(hazard ratio:1.399;95%confidence interval:1.034-1.894;P=0.030)among KRAS mutations was an independent risk factor for recurrence.CONCLUSION This study provides evidence that KRAS codon 13 mutation is less likely to serve as a prognostic biomarker than codon 12 mutation for CRC in a large-scale cohort.

Pyogenic liver abscess secondary to gastric perforation of an ingested toothpick:A case report

BACKGROUND Liver abscess due to foreign body-induced gastrointestinal tract perforation is a rare event that could be misdiagnosed due to low suspicion.Less than 100 cases have been reported to date.CASE SUMMARY We report a case of a 53-year old female patient with pyogenic liver abscess secondary to ingestion of a toothpick with penetration through the lesser curvature of the stomach.The patient presented with persistent epigastric pain.Abdominal computed tomography demonstrated the presence of a linear radiopaque object associated with abscess formation in the left liver lobe.Inflammatory changes in the lesser curvature of the stomach indicated gastric wall penetration by the object.As the abscess was refractory to antibiotic treatment,laparoscopic liver resection was performed to remove the foreign body and adjacent liver parenchyma.Following surgery,symptoms fully resolved without any sequelae.CONCLUSION This rare case demonstrates the importance of considering foreign body penetration as a cause of pyogenic liver abscess,particularly in abscesses of unknown origin that are resistant to antibiotic therapy.Clinical suspicion,early diagnosis,and prompt removal of the foreign body could lead to improved outcomes in these patients.

Intraperitoneal chemotherapy for gastric cancer:A contemporary perspective

StageⅣgastric cancer and peritoneal metastasis Gastric cancer is one of the most common malignancies worldwide and is a leading cause of cancer-related deaths(1).Over the past few decades,advances in surgical techniques and chemotherapy have improved the prognosis for patients with gastric cancer.

Increased incidence of indeterminate pancreatic cysts and changes of management pattern: Evidence from nationwide data

Background:Pancreatic cysts are common.However,most studies are based on data collected from individual centers.The present study aimed to evaluate the changes of management patterns for pancreatic cystic lesions(PCLs)by analyzing large epidemiologic data.Methods:Between January 2007 and December 2018,information regarding pancreatic cystic lesions was acquired from the nationwide Health Insurance Review and Assessment Service database in Korea.Results:The final number of patients with pancreatic cysts was 165277 among the total claims for reimbursement of 855983 associated with PCLs over 12 years.The total number of claims were increased from 19453 in 2007 to 155842 in 2018 and the prevalence increased from 0.04%to 0.23%.For 12 years,2874(1.7%)had pancreatic cancer and 8212(5.0%)underwent surgery,and 36 had surgery for twice(total 8248 pancreatectomy).After ruling out claims from the first 3 years of washout period,the incidence increased from 9891 to 24651 and the crude incidence rate of PCLs expanded from 19.96 per 100000 to 47.77 per 100000.Compared to specific neoplasm codes(D136 or D377),the use of pancreatic cyst code(K862)has been remarkably increased and the most common since 2010.The annual number of pancreatectomies increased from 518 to 861 between 2007 and 2012,and decreased to 596 until 2018.The percentage of pancreatic cancer in patients who received pancreatectomy increased from 5.6%in 2007 to 11.7%in 2018.Conclusions:The incidence of PCLs is rapidly increasing.Among PCLs,indeterminate cyst is increasing outstandingly.A trend of decreasing in the number of resections and increasing cancer rates among resected cysts may be attributed to the updated international guidelines.

Intra-arterial lipo-prostaglandin E1 infusion for arterial spasm in liver transplantation:A case report

BACKGROUND Hepatic artery obstruction is a critical consideration in graft outcomes after living donor liver transplantation.We report a case of diffuse arterial vasospasm that developed immediately after anastomosis and was managed with an intra-arterial infusion of lipo-prostaglandin E1(PGE1).CASE SUMMARY A 57-year-old male with hepatitis B virus-related liver cirrhosis and hepatocellular carcinoma underwent ABO-incompatible living donor liver transplant.The grafted hepatic artery was first anastomosed to the recipient’s right hepatic artery stump.However,the arterial pulse immediately weakened.Although a new anastomosis was performed using the right gastroepiploic artery,the patient’s arterial pulse rate remained poor.We attempted angiographic intervention immediately after the operation;it showed diffuse arterial vasospasms like‘beads on a string’.We attempted continuous infusion of lipo-PGE1 overnight via an intra-arterial catheter.The next day,arterial flow improved without any spasms or strictures.The patient had no additional arterial complications or related sequelae at the time of writing,1-year post-liver transplantation.CONCLUSION Angiographic evaluation is helpful in cases of repetitive arterial obstruction,and intra-arterial infusion of lipo-PGE1 may be effective in treating diffuse arterial spasms.

International experts consensus guidelines on robotic liver resection in 2023

The robotic liver resection(RLR)has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system,however,controversies still exist.Based on the foundation of the previous consensus statement,this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice.The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine(EBM).Relevant literature was reviewed and analyzed by the evidence evaluation group.According to the WHO Handbook for Guideline Development,the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022,a total of 14 recommendations were generated.Among them were 8 recommendations formulated by the GRADE method,and the remaining 6 recommendations were formulated based on literature review and experts’opinion due to insufficient EBM results.This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.

活动衬垫和固定衬垫全膝关节置换治疗膝骨性关节炎的早期临床结果比较(英文)

背景:虽然活动衬垫膝关节假体在体外的研究中显示具有更好的关节运动学表现、更低的磨损率,但是否具有更好的体内临床效果仍有争议。目的:对比观察活动衬垫型和固定衬垫型膝关节假体在置换后1年时膝关节活动度和临床效果。设计、时间及地点:回顾性病例对比分析。2003-11/2006-07首尔国立大学盆唐医院关节重建中心。对象:共纳入接受全膝关节置换488例患者669膝。244例患者341膝采用了固定衬垫型假体,244例患者328膝采用活动衬垫型假膝。方法:所有手术皆由一位固定医师(TKKim)完成。采用髌旁内侧入路,术中不翻转髌骨,而将髌骨向外侧脱位进行显露。以间隙测量器作为间隙撑开工具并进行间隙的准确测量,根据测量结果进行软组织松解平衡,直到达到下述标准:屈曲间隙大于伸直间隙不超过3.0～4.0mm或伸直间隙大于屈曲间隙不超过1.0～2.0mm,对于内翻畸形膝关节,外侧间隙大于内侧间隙2.0～3.0mm是可以接受的。常规行髌骨置换,所有假体都采用骨水泥固定。主要观察指标:以角尺测量患者置换前后膝关节屈曲挛缩程度和最大屈曲度。置换前后膝关节的疼痛和功能状态采用AKS评分、髌股关节评分、WOMAC评分和SF-36系统评分进行评价。结果:两组患者在性别、年龄、身高、体质量和体质量指数方面差异没有显著性。置换后两组在PF膝前痛评分、WOMAC疼痛评分和SF-36躯体疼痛评分方面两组差异无显著性(P>0.05);固定衬垫组平均AKS疼痛评分略高于活动衬垫组(48.5±3.2,47.5±4.8,P=0.010)。置换后两组患者的屈曲畸形得到了很好的矫正(P=0.341),两组的膝关节活动度差异没有显著性(P=0.412)。置换后所有反映膝关节功能的评价指标两组间差异均无显著性(P>0.05)。结论:活动衬垫型膝关节假体置换后在膝关节活动度、疼痛缓解以及膝关节功能方面与固定衬垫型膝关节假体相比并没有显著性优势。手术技术是获得置换后良好临床效果的关键。

Characteristics of gastric cancer in peptic ulcer patients with Helicobacter pylori infection

AIM:To evaluate the incidence and clinical characteristics of gastric cancer(GC) in peptic ulcer patients with Helicobacter pylori(H.pylori) infection.METHODS:Between January 2003 and December 2013, the medical records of patients diagnosed with GC were retrospectively reviewed.Those with previous gastric ulcer(GU) and H.pylori infection were assigned to the Hp GU-GC group(n = 86) and those with previous duodenal ulcer(DU) disease and H.pylori infection were assigned to the Hp DUGC group(n = 35).The incidence rates of GC in the Hp GU-GC and Hp DU-GC groups were analyzed.Data on demographics(age, gender, peptic ulcer complications and cancer treatment), GC clinical characteristics [location, pathological diagnosis, differentiation, T stage, Lauren's classification, atrophy of surrounding mucosa and intestinal metaplasia(IM)], outcome of eradication therapy for H.pylori infection, esophagogastroduodenoscopy number and the duration until GC onset were reviewed.Univariate and multivariate analyses were performed to identify factors influencing GC development.The relative risk of GC was evaluated using a Cox proportional hazards model.RESULTS:The incidence rates of GC were 3.60%(86/2387) in the Hp GU-GC group and 1.66%(35/2098) in the Hp DU-GC group.The annual incidence was 0.41% in the Hp GU-GC group and 0.11% in the Hp DUGC group.The rates of moderate-to-severe atrophy of the surrounding mucosa and IM were higher in the Hp GU-GC group than in the Hp DU-GC group(86% vs 34.3%, respectively, and 61.6% vs 14.3%, respectively, P < 0.05).In the univariate analysis, atrophy of surrounding mucosa, IM and eradication therapy for H.pylori infection were significantly associated with the development of GC(P < 0.05).There was no significant difference in the prognosis of GC patients between the Hp GU-GC and Hp DU-GC groups(P = 0.347).The relative risk of GC development in the Hp GUGC group compared to that of the Hp DU-GC group,after correction for age and gender,was 1.71(95%CI:1.09-2.70;P=0.02).CONCLUSION:GU patients with H.pylori infection had higher GC incidence rates and relative risks.Atrophy of surrounding mucosa,IM and eradication therapy were associated with GC.

Early rehabilitation programs after laparoscopic colorectal surgery:Evidence and criticism

During the past several decades,early rehabilitation programs for the care of patients with colorectal surgery have gained popularity.Several randomized controlled trials and meta-analyses have confirmed that the implementation of these evidence-based detailed perioperative care protocols is useful for early recovery of patients after colorectal resection.Patients cared for based on these protocols had a rapid recovery of bowel movement,shortened length of hospital stay,and fewer complications compared with traditional care programs.However,most of the previous evidence was obtained from studies of early rehabilitation programs adapted to open colonic resection.Currently,limited evidence exists on the effects of early rehabilitation after laparoscopic rectal resection,although this procedure seems to be associated with a higher morbidity than that reported with traditional care.In this article,we review previous studies and guidelines on early rehabilitation programs in patients undergoing rectal surgery.We investigated the status of early rehabilitation programs in rectal surgery and analyzed the limitations of these studies.We also summarized indications and detailed protocol components of current early rehabilitation programs after rectal surgery,focusing on laparoscopic resection.

Current applications of adipose-derived stem cells and their future perspectives

Adult stem cells have a great potential to treat various diseases. For these cell-based therapies, adipose-derived stem cells(ADSCs) are one of the most promising stem cell types, including embryonic stem cells(ESCs) and induced pluripotent stem cells(iPSCs). ESCs and iPSCs have taken center stage due to their pluripotency. However, ESCs and iPSCs have limitations in ethical issues and in identification of characteristics, respectively. Unlike ESCs and iPSCs, ADSCs do not have such limitations and are not only easily obtained but also uniquely expandable. ADSCs can differentiate into adipocytes, osteoblasts, chondrocytes, myocytes and neurons under specific differentiation conditions, and these kinds of differentiation potential of ADSCs could be applied in regenerative medicine e.g., skin reconstruction, bone and cartilage formation, etc. In this review, the current status of ADSC isolation, differentiation and their therapeutic applications are discussed.

Intraoperative neurophysiological monitoring in spinal surgery

Recently, many surgeons have been using intraoperative neurophysiological monitoring(IOM) in spinal surgery to reduce the incidence of postoperative neurological complications, including level of the spinal cord, cauda equina and nerve root. Several established technologies are available and combined motor and somatosensory evoked potentials are considered mandatory for practical and successful IOM. Spinal cord evoked potentials are elicited compound potentials recorded over the spinal cord. Electrical stimulation is provoked on the dorsal spinal cord from an epidural electrode. Somatosensory evoked potentials assess the functional integrity of sensory pathways from the peripheral nerve through the dorsal column and to the sensory cortex. For identification of the physiological midline, the dorsal column mapping technique can be used. It is helpful for reducing the postoperative morbidity associated with dorsal column dysfunction when distortion of the normal spinal cord anatomy caused by an intramedullary cord lesion results in confusion in localizing the midline for the myelotomy. Motor evoked potentials(MEPs) consist of spinal, neurogenic and muscle MEPs. MEPs allow selective and specific assessment of the functional integrity of descending motor pathways, from the motor cortex to peripheral muscles. Spinal surgeons should understand the concept of the monitoring techniques and interpret monitoring records adequately to use IOM for the decision making during the surgery for safe surgery and a favorable surgical outcome.

Preoperative biliary drainage in hilar cholangiocarcinoma: When and how?

Hilar cholangiocarcinoma is a tumor of the extrahepatic bile duct involving the left main hepatic duct, the right main hepatic duct, or their confluence. Biliary drainage in hilar cholangiocarcinoma is sometimes clinically challenging because of complexities associated with the level of biliary obstruction. This may result in some adverse events, especially acute cholangitis. Hence the decision on the indication and methods of biliary drainage in patients with hilar cholangiocarcinoma should be carefully evaluated. This review focuses on the optimal method and duration of preoperative biliary drainage(PBD) in resectable hilar cholangiocarcinoma. Under certain special indications such as right lobectomy for Bismuth type ⅢA or Ⅳ hilar cholangiocarcinoma, or preoperative portal vein embolization with chemoradiation therapy, PBD should be strongly recommended. Generally, selective biliary drainage is enough before surgery, however, in the cases of development of cholangitis after unilateral drainage or slow resolving hyperbilirubinemia, total biliary drainage may be considered. Although the optimal preoperative bilirubin level is still a matter of debate, the shortest possible duration of PBD is recommended. Endoscopic nasobiliary drainage seems to be the most appropriate method of PBD in terms of minimizing the risks of tract seeding and inflammatory reactions.

Noninvasive Parameters and hepatic fibrosis scores in children with nonalcoholic fatty liver disease

AIM:To evaluate the noninvasive parameters and hepatic fibrosis scores in obese children with nonalcoholic fatty liver disease(NAFLD).METHODS:A total of 77 children diagnosed with NAFLD via liver biopsy were included and divided into 2 subgroups according to the histopathologic staging of hepatic fibrosis:mild(stage 0-1)vs significant fibrosis(stage 2-4).Clinical and laboratory parameters were evaluated in each patient.The aspartate aminotransferase(AST)/alanine aminotransferase(ALT)ratio,AST/platelet ratio index(APRI),PGA index,Forns index,FIB-4,NAFLD fibrosis score,and pediatric NAFLD fibrosis index(PNFI)were calculated.RESULTS:No clinical or biochemical parameter exhibited a significant difference between patients with mild and significant fibrosis.Among noninvasive hepatic fibrosis scores,only APRI and FIB4 revealed a significant difference between patients with mild and significant fibrosis(APRI:0.67±0.54 vs 0.78±0.38,P=0.032 and FIB4:0.24±0.12 vs 0.31±0.21,P=0.010).The area under the receiving operating characteristic curve of FIB4 was 0.81,followed by Forns index(0.73),APRI(0.70),NAFLD fibrosis score(0.58),AST/ALT ratio(0.53),PGA score(0.45),and PNFI(0.41).CONCLUSION:APRI and FIB4 might be useful noninvasive hepatic fibrosis scores for predicting hepatic fibrosis in children with NAFLD.

New approaches to gastric cancer staging:Beyond endoscopic ultrasound,computed tomography and positron emission tomography

Currently, there is no single gold standard modality for staging of gastric cancer and several methods have been used complementarily in the each clinical situation. To make up for the shortcomings of conventional modalities such as endoscopic ultrasound, computed tomography and 18F-fluoro-2-deoxyglucose positron emission tomography, numerous attempts with new approaches have been made for gastric cancer staging. For T staging, magnifying endoscopy with narrow-band was evaluated to differentiate mucosal cancer from submucosal cancer. Single/double contrast-enhanced ultrasound and diffusion-weighted magnetic resonance imaging were also tried to improve diagnostic accuracy of gastric cancer. For intraoperative staging with sentinel node mapping, indocyanine green infrared and fluorescence imaging was introduced. In addition, to detect micrometastasis, real-time reverse transcription-polymerase chain reaction system with multiple markers was studied. Staging laparoscopy using 5-aminolevulinic acid-mediated photodynamic diagnosis and percutaneous diagnostic peritoneal lavage were also evaluated. However, most studies reporting new staging methods is preliminary and further studies for validation in clinical practice are needed. In this mini-review, we discuss new progress in gastric cancer staging. Especially, we focus on new diagnostic approach to gastric cancer staging beyond the conventional modalities and briefly review the remarkable clinical results of the studies published over the past three years.

Is endoscopic ultrasonography still the modality of choice in preoperative staging of gastric cancer?

The treatment option for gastric cancer is usually based on preoperative staging by imaging modalities. Endoscopic ultrasonography (EUS) and computed tomography (CT) have been used as the diagnostic modality of choice in preoperative staging of gastric cancer. Magnetic resonance imaging (MRI) has been employed in several studies, and (18F) 2-Fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) has emerged as a new promising imaging modality. The purpose of this article is to provide summarized information on preoperative staging using EUS, multi-detector row CT (MDCT), MRI and PET for gastric cancer. In T staging, both EUS and MDCT show high accuracy. MRI seemed to have better performance, but the number of MRI studies is limited. FDG-PET is not able to properly evaluate the depth of invasion. In N staging, the diagnostic accuracy of EUS, MDCT and MRI is not sufficient. In preoperative M staging, MDCT and FDG-PET showed similar diagnostic accuracies. FDG-PET/CT fusion could be expected to show better performance in the future. Physicians should keep in mind that each diagnostic modality has advantages and limitations and choose an appropriate diagnostic strategy tailored for each patient.

Sex-and gender-specific disparities in colorectal cancer risk

Colorectal cancer is one of the most common causes of cancer morbidity both in men and in women.However,females over 65 years old show higher mortality and lower 5-year survival rate of colorectal cancer compared to their age-matched male counterparts.The objective of this review is to suggest gender-based innovations to improve colorectal cancer outcomes in females.Women have a higher risk of developing right-sided(proximal) colon cancer than men,which is associated with more aggressive form of neoplasia compared to left-sided(distal) colon cancer.Despite differences in tumor location between women and men,most of scientific researchers do not consider sex specificity for study design and interpretation.Also,colorectal cancer screening guidelines do not distinguish females from male,which may explain the higher frequency of more advanced neoplasia when tumors are first detected and false negative results in colonoscopy in females.Moreover,socio-cultural barriers within females are present to delay screening and diagnosis.Few studies,among studies that included both men and women,have reported sex-specific estimates of dietary risk factors which are crucial to establish cancer prevention guidelines despite sex-and genderassociated differences in nutrient metabolism and dietary practices.Furthermore,anti-cancer drug use for colorectal cancer treatment can cause toxicity to the reproductive system,and gender-specific recurrence and survival rates are reported.Therefore,by understanding sex-and gender-related biological and socio-cultural differences in colorectal cancer risk,gender-specific strategies for screening,treatment and prevention protocols can be established to reduce the mortality and improve the quality of life.

Niche interactions in epidermal stem cells

Within the epidermis and dermis of the skin, cells secrete and are surrounded by the extracellular matrix(ECM), which provides structural and biochemical support. The ECM of the epidermis is the basement membrane, and collagen and other dermal components constitute the ECM of the dermis. There is significant variation in the composition of the ECM of the epidermis and dermis, which can affect "cell to cell" and "cell to ECM" interactions. These interactions, in turn, can influence biological responses, aging, and wound healing; abnormal ECM signaling likely contributes toskin diseases. Thus, strategies for manipulating cellECM interactions are critical for treating wounds and a variety of skin diseases. Many of these strategies focus on epidermal stem cells, which reside in a unique niche in which the ECM is the most important component; interactions between the ECM and epidermal stem cells play a major role in regulating stem cell fate. As they constitute a major portion of the ECM, it is likely that integrins and type Ⅳ collagens are important in stem cell regulation and maintenance. In this review, we highlight recent research-including our previous work-exploring the role that the ECM and its associated components play in shaping the epidermal stem cell niche.

Optimal initiation of Helicobacter pylori eradication in patients with peptic ulcer bleeding

AIM:To evaluate when Helicobacter pylori(H.pylori)eradication therapy(ET)should be started in patients with peptic ulcer bleeding(PUB).METHODS:Clinical data concerning adults hospitalizedwith PUB were retrospectively collected and analyzed.Age,sex,type and stage of peptic ulcer,whether endoscopic therapy was performed or not,methods of H.pylori detection,duration of hospitalization,and specialty of the attending physician were investigated.Factors influencing the confirmation of H.pylori infection prior to discharge were determined using multiple logistic regression analysis.The H.pylori eradication rates of patients who received ET during hospitalization and those who commenced ET as outpatients were compared.RESULTS:A total of 232 patients with PUB were evaluated for H.pylori infection by histology and/or rapid urease testing.Of these patients,53.7%(127/232)had confirmed results of H.pylori infection prior to discharge.In multivariate analysis,duration of hospitalization and ulcer stage were factors independently influencing whether H.pylori infection was confirmed before or after discharge.Among the patients discharged before confirmation of H.pylori infection,13.3%(14/105)were lost to follow-up.Among the patients found to be H.pylori-positive after discharge,41.4%(12/29)did not receive ET.There was no significant difference in the H.pylori eradication rate between patients who received ET during hospitalization a n d t h o s e w h o c o m m e n c e d E T a s o u t p a t i e n t s[intention-to-treat:68.8%(53/77)vs 60%(12/20),P=0.594;per-protocol:82.8%(53/64)vs 80%(12/15),P=0.723].CONCLUSION:Because many patients with PUB who were discharged before H.pylori infection status was confirmed lost an opportunity to receive ET,we should confirm H.pylori infection and start ET prior to discharge.

Clinicopathologic factors and molecular markers related to lymph node metastasis in early gastric cancer

AIM: To analyze predictive factors for lymph node metastasis in early gastric cancer.METHODS: We analyzed 1104 patients with early gastric cancer(EGC) who underwent a gastrectomy with lymph-node dissection from May 2003 through July 2011. The clinicopathologic factors and molecular markers were assessed as predictors for lymph node metastasis. Molecular markers such as microsatellite instability, human mut L homolog 1, p53, epidermal growth factor receptor(EGFR) and human epidermal growth factor receptor 2(HER2) were included. The χ2 test and logistic regression analysis were used to determine clinicopathologic parameters.RESULTS: Lymph node metastasis was observed in 104(9.4%) of 1104 patients. Among 104 cases of lymph node positive patients, 24 patients(3.8%) were mucosal cancers and 80 patients(16.7%) were submucosal. According to histologic evaluation, the number of lymph node metastasis found was 4(1.7%) for well differentiated tubular adenocarcinoma, 45(11.3%) for moderately differentiated tubular adenocarcinoma, 36(14.8%) for poorly differentiated tubular adenocarcinoma, and 19(8.4%) for signet ring cell carcinoma. Of 690 EGC cases, 77 cases(11.2%) showed EGFR overexpression. HER2 overexpression was present in 110 cases(27.1%) of 406 EGC patients. With multivariate analysis, female gender(OR = 2.281, P = 0.009), presence of lymphovascular invasion(OR = 10.950, P < 0.0001), diameter(≥ 20 mm, OR = 3.173, P = 0.01), and EGFR overexpression(OR = 2.185, P = 0.044) were independent risk factors for lymph node involvement.CONCLUSION: Female gender, tumor size, lymphovascular invasion and EGFR overexpression were predictive risk factors for lymph node metastasis in EGC.