Clinical analysis of multiple primary malignancies in the digestive system: A hospital-based study

AIM: To analyze the characteristics of multiple primary malignancies (MPMs) of digestive system; including incidence, types of tumor combinations, time intervals between development of multiple tumors, clinical course,and prognostic factors affecting survival and mortality.METHODS: Data from a total of 129 patients treated from January 1991 to December 2000 for pathologically proved MPMs, including at least one originating from the digestive system, were reviewed retrospectively.RESULTS: Among 129 patients, 120 (93.02%) had two primary cancers and 9 (6.98%) had three primary cancers. The major sites of MPMs of the digestive system were large intestine, stomach, and liver. Associated nondigestive cancers included 40 cases of gynecological cancers, of which 31 were carcinoma of cervix and 10cases of genitourinary cancers, of which 5 were bladder cancers. Other cancers originated from the lung, breast,nasopharynx, larynx, thyroid, brain, muscle, and skin.Reproductive tract cancers, especially cervical, ovarian,bladder, and prostate cancers were the most commonly associated non-GI cancers, followed by cancer of the lung and breasts. Forty-three cases were synchronous, while the rest (86 cases) were metachronous cancers. Staging of MPMs and treatment regimes correlated with the prognosis between survival and non-survival groups.CONCLUSION: As advances in cancer therapy bring about a progressively larger percentage of long-term survivors, the proportion of patients with subsequent primary lesions will increase. Early diagnosis of these lesions, based on an awareness of the possibility of second and third cancers, and multidiscipiinary treatment strategies will substantially increase the survival of these patients.

Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis

AIM: To investigate acute transient hepatocellular injury in patients with cholelithiasis and cholecystitis but no evidence of choledocholithiasis. METHODS: The medical records of patients with cholelithiasis who underwent cholecystectomy between July 2003 and June 2007 were retrospectively reviewed. Imaging studies to detect common bile duct (CBD) stones were performed in 186 patients, who constituted the study population. Biochemical liver tests before and after surgery, and with the presence or absence of CBD stones were analyzed. RESULTS: In 96 patients with cholelithiasis and cholecystitis without evidence of CBD stones, 49 (51.0%) had an alanine aminotransferase level elevated to 2-3 times the upper limit of normal, and 40 (41.2%) had an elevated aspartate aminotransferase level. Similar manifestations of hepatocellular injury were, as would be expected, even more obvious in the 90 patients with CBD stones. These markers of hepatocellular injury resolved almost completely within 2 wk to 1 mo after cholecystectomy. Compared to 59 patients with histologically less severe cholecystitis in the group undergoing urgent surgery (total 74 patients), the 15 patients with a gangrenous gallbladder had a higher mean level of total bilirubin (1.14 ± 1.27 mg/dL vs 2.66 ± 1.97 mg/dL, P < 0.001) and white cell count (9480 ± 4681/μL vs 12840 ± 5273/μL, P = 0.018).CONCLUSION: Acute hepatocellular injury in cholelithiasis and cholecystitis without choledocholithiasis is mild and transient. Hyperbilirubinemia and leukocytosis may predict severe inflammatory changes in the gallbladder.

Nonalcoholic fatty liver disease:Updates in noninvasive diagnosis and correlation with cardiovascular disease

Nonalcoholic fatty liver disease(NAFLD)refers to the accumulation of fat(mainly triglycerides)within hepatocytes.Approximately 20%-30%of adults in the general population in developed countries have NAFLD;this trend is increasing because of the pandemicity of obesity and diabetes,and is becoming a serious public health burden.Twenty percent of individuals with NAFLD develop chronic hepatic inflammation[nonalcoholic steatohepatitis(NASH)],which can be associated with the development of cirrhosis,portal hypertension,and hepatocellular carcinoma in a minority of patients.And thus,the detection and diagnosis of NAFLD is important for general practitioners.Liver biopsy is the gold standard for diagnosing NAFLD and confirming the presence of NASH.However,the invasiveness of this procedure limits its application to screening the general population or patients with contraindications for liver biopsy.The development of noninvasive diagnostic methods for NAFLD is of paramount importance.This review focuses on the updates of noninvasive diagnosis of NAFLD.Besides,we review clinical evidence supporting a strong association between NAFLD and the risk of cardiovascular disease because of the cross link between these two disorders.

Prevalence and risk factors for Barrett’s esophagus in Taiwan

BACKGROUND Barrett’s esophagus(BE)is a pre-malignant condition associated with the development of esophageal adenocarcinoma.The prevalence of BE in the general populations of Asian countries ranges from 0.06%to 1%.However,with lifestyle changes in Asian countries and adoption of western customs,the prevalence of BE might have increased.AIM To determine the current prevalence of BE in Taiwan,and to investigate risk factors predicting the presence of BE.METHODS This retrospective study was conducted at the Health Evaluation Center of Kaohsiung Veterans General Hospital in Taiwan.Between January 2015 and December 2015,3385 subjects undergoing routine esophagogastroduodenoscopy examinations as part of a health check-up at the Health Evaluation Center were included.Patient characteristics and endoscopic findings were carefully reviewed.Lesions with endoscopic findings consistent with BE awaiting histological evaluation were judged as endoscopically suspected esophageal metaplasia(ESEM).BE was defined based on extension of the columnar epithelium≥1 cm above the gastroesophageal junction and was confirmed based on the presence of specialized intestinal metaplasia(IM)in the metaplastic esophageal epithelium.Clinical factors of subjects with BE and subjects without BE were compared,and the risk factors predicting BE were analyzed.RESULTS A total of 3385 subjects(mean age,51.29±11.42 years;57.1%male)were included in the study,and 89 among them were confirmed to have IM and presence of goblet cells via biopsy examination.The majority of these individuals were classified as short segment BE(n=85).The overall prevalence of BE was 2.6%.Multivariate analysis disclosed that old age[odds ratio(OR)=1.033;95%confidence interval(CI):1.012-1.055;P=0.002],male gender(OR=2.106;95%CI:1.145-3.872;P=0.017),ingestion of tea(OR=1.695;95%CI:1.043-2.754;P=0.033),and presence of hiatal hernia(OR=3.037;95%CI:1.765-5.225;P<0.001)were significant risk factors predicting BE.The independent risk factor for the presence of IM in ESEM lesions was old age alone(OR=1.029;95%CI:1.006-1.053;P=0.014).CONCLUSION Current prevalence of BE among the general population in Taiwan is 2.6%.Old age,male gender,ingestion of tea and hiatal hernia are significant risk factors for BE.

Effects of Helicobacter pylori infection in gastrointestinal tract malignant diseases:From the oral cavity to rectum

Helicobacter pylori(H.pylori)has infected approximately fifty percent of humans for a long period of time.However,improvements in the public health environment have led to a decreased chance of H.pylori infection.However,a high infection rate is noted in populations with a high incidence rate of gastric cancer(GC).The worldwide fraction of GC attributable to H.pylori is greater than 85%,and a high H.pylori prevalence is noted in gastric mucosa-associated lymphoid tissue lymphoma patients.These results indicate that the majority of GC cases can be prevented if H.pylori infection is eliminated.Because H.pylori exhibits oral-oral or fecal-oral transmission,the relationship between this microorganism and other digestive tract malignant diseases has also attracted attention.This review article provides an overview of H.pylori and the condition of the whole gastrointestinal tract environment to further understand the correlation between the pathogen and the host,thus allowing improved realization of disease presentation.

Intraoperative Open-Cavity Implant for Accelerated Partial Breast Irradiation Using High-Dose Rate Multicatheter Brachytherapy in Japanese Breast Cancer Patients: A Single-Institution Registry Study

Background: Previous research has compared the efficacies of accelerated partial breast irradiation (APBI) and wholebreast irradiation (WBI). APBI immediately after surgery may provide more benefit after intraoperative insertion of catheters. Although balloon catheter-based APBI is available in the US, it is difficult in Japanese women, who have relatively small breasts. With the applicators being implanted during tumor removal, APBI can be started immediately after surgery. The aim of this study was to assess the safety and efficacy of APBI using the intraoperative open-cavity implant technique. Method: Patients (age≥40 years) with invasive breast cancer (diameter≤3 cm) were enrolled. Before lumpectomy, the insertion of applicators and delivery doses were simulated by computed tomography (CT). After confirmation of free margins and negative sentinel nodes (SNs) using frozen section analysis, applicators were inserted. Postoperative CT-based dose distribution analysis was performed using dose-volume histograms. APBI was started on the day of surgery, delivering 32 Gy in 8 fractions over the following 5-6 days, and it covered a distance of 2 cm from tumor margins. This observational study was approved by the institutional review board of our hospital. Results: From October 2008 to July 2012, 157 women (160 lesions) were enrolled (age 55.0 years, <40:9, SN+: 25, for patients’ request). The mean number of applicators used was 6.4 (2-15) and mean planning target volume was 35.8 cm3 (6.5-137.1 cm3). All radiotherapy-related toxicities were mild. However, 12 patients (7.5%) experienced wound breakdown because of surgical site infection. Two patients developed ipsilateral breast tumor recurrence (1 marginal, 1 at a distant site). Conclusions: Despite the small number of participants and a short follow-up period, our results suggest that this technique could be helpful in establishing clinical safety and efficacy.

Sentinel-Node-Driven Personalized Radiation Techniques Ranging from Partial Breast Irradiation to Regional Nodal Radiation after Breast-Conserving Surgery

Background: Breast-conserving surgery (BCS) followed by whole breast irradiation (WBI) has become the standard of care for treating patients with early-stage breast cancer. Recently, various radiation techniques followed by BCS have been reported. We have been investigating “personalized radiotherapy after BCS” ranging from accelerated partial breast irradiation (APBI) to WBI with regional nodal irradiation (RNI) based on the axillary node status. In this study, we compared different cohorts that received personalized radiotherapy. Method: Of 317 consecutive patients who underwent BCS followed by radiotherapy since November 2007, 187 who received APBI and 122 who received WBI were analyzed. Results: The local-only recurrence rate was 1.1% in the APBI group and 3.3% in the WBI group, and the regional-only recurrence rate was 1.1% for APBI and 0.8% for WBI. Conclusions: The clinical efficacy of APBI for local control after BCS was comparable to that of WBI ± RNI. Although this study was based on a small number of patients with a short follow-up period, the feasibility of breast-conserving therapy using multicatheter brachytherapy to achieve acceptable clinical outcomes was demonstrated.