Signet-ring cell carcinoma arising from a fundic gland polyp in the stomach

Fundic gland polyps (FGPs) are currently the most common type of gastric polyps and are usually benign. However, although rare, gastric adenocarcinoma of FGP has been recently proposed as a new variant of gastric adenocarcinoma. Here we report the first case of a 49-year-old woman with focal signet ring cell carcinoma that arose from an FGP of the stomach. The tumor was completely excised by endoscopic snare polypectomy. FGPs should therefore be evaluated for malignant changes although they occur rarely, if the FGP has an erosive or irregular surface.

Clinical significance of intensive endoscopic screening for synchronous esophageal neoplasm in patients with head and neck squamous cell carcinoma

OBJECTIVES

Patients with head and neck squamous cell carcinoma (HNSCC) often develop second primary tumors in the upper aerodigestive tract. Early detection of synchronous esophageal squamous cell neoplasm (ESCN) is important because the prognosis of HNSCC can be affected by the statuses of second primary tumors.

METHODS

In a prospective study, 308 patients with HNSCC were screened for synchronous ESCN between May 2010 and April 2012. All patients underwent conventional white-light endoscopic examination with Lugol chromoendoscopy and narrow band image.

RESULTS

The median age was 61 years (range, 26-87 years), and the male-to-female ratio was 4.2:1. Two hundred and thirty-four patients (76.0%) were current or ex-smokers, 207 patients (67.2%) had a history of alcohol consumption and 56 patients (18.2%) had previous history of cancer. Synchronous ESCN was detected in 22 patients (7.1%), and most patients were at an early stage. The locations of index HNSCC in these patients were as follows: hypopharynx (n = 12), larynx (n = 6), oropharynx (n = 2) and oral cavity (n = 2). Synchronous ESCN was detected in 25.5% (12/47) of hypopharyngeal cancer and in 27.8% (15/54) of HNSCC involving the pyriform sinus. Multivariate analysis showed that smoking (current smoker vs. never smoker, Odds Ratio [OR] 8.3, p = 0.028), a history of cancer (OR 5.0, p = 0.002) and pyriform sinus involvement (OR 9.2, p < 0.0001) increased the risk of developing synchronous ESCN.

CONCLUSIONS

Patients with HNSCC, especially those who are current smokers, have a history of cancer and have pyriform sinus involvement, should undergo intensive endoscopic screening to detect synchronous ESCN.

Comparison of clinical outcomes associated with pull-type and introducer-type percutaneous endoscopic gastrostomies

Background/Aims

Percutaneous endoscopic gastrostomy (PEG) is a method of providing enteral nutrition using endoscopy. The PEG techniques differ according to the insertion method, and include the pull type, push type, and introducer type. The aim of this study was to compare the clinical outcomes associated with the pull-type and introducer-type PEG insertion techniques, which included the adverse events, at our tertiary care center in Korea.

Methods

We retrospectively reviewed 141 cases that had undergone PEG insertion at our center from January 2009 to June 2012. The indications for PEG insertion and the acute and chronic complications caused by each type of PEG insertion were analyzed.

Results

The indications for PEG insertion in our cohort included neurologic disease (58.7%), malignancy (21.7%), and other indications (19.6%). Successful PEG insertions were performed on 136 cases (96.5%), and there were no PEG-associated deaths. Bleeding was the most frequent acute complication (12.8%), and wound problems were the most frequent chronic complications (8.8%). There were no statistically significant differences between the pull-type and introducer-type PEG insertion techniques in relation to complication rates in our study population.

Conclusions

PEG insertion is considered a safe procedure. The pull-type and introducer-type PEG insertion techniques produce comparable outcomes, and physicians may choose either of these approaches according to the circumstances.

Pneumonia after endoscopic resection for gastric neoplasm

BACKGROUND

Pneumonia following endoscopic procedures may affect the clinical course and prolong hospital stay.

AIM

To investigate the incidence and risk factors for pneumonia after endoscopic resection (ER) for gastric neoplasm.

METHODS

Subjects who underwent ER for gastric neoplasm at the Asan Medical Center from January 1997 to March 2013 were included. To investigate risk factors, control patients were randomly selected from these subjects.

RESULTS

Of the 7,149 subjects who underwent ER for gastric neoplasm, 44 (0.62 %) developed pneumonia. The median age of these 44 patients was 68 years (range 31-82 years), and the male to female ratio was 3:1. Twenty-five of the pneumonia patients (56.8 %) were smokers, and 8 (18.2 %) had underlying pulmonary diseases. The median procedure time was 23 min (range 2-126 min), and pathologic diagnoses included adenocarcinoma (n = 29), dysplasia (n = 10), and hyperplastic polyp (n = 5). Compared with the control group, smoking (current smoker vs. never smoker, odds ratio [OR] 2.366, p = 0.021), total procedure time (OR 1.011, p = 0.048), and hemostasis time (OR 1.026, p = 0.028) were risk factors for the development of pneumonia. In multivariate analysis, age >65 years (OR 2.073, p = 0.031), smoking (current smoker vs. never smoker, OR 2.324, p = 0.023), and hemostasis time (OR 1.025, p = 0.038) were independent risk factors. All patients recovered from pneumonia, and the duration of hospital stay did not differ between patients with pneumonia and the control group (p = 0.077).

CONCLUSIONS

Whereas old age, smoking, and longer hemostasis time are risk factors for pneumonia, its incidence after ER is not associated with clinically significant adverse outcomes.

Endoscopic resection as a possible radical treatment for duodenal gangliocytic paraganglioma: a report of four cases

Gangliocytic paraganglioma (GP) is a rare, benign tumor which is usually found in the duodenum. We here report four recent cases of GP, with successful endoscopic resection in three cases, including a lesion on the ampulla of Vater. In all cases, each lesion had a stalk that facilitated removal using an endoscopic approach. Endoscopic mucosal resection is a feasible and safe treatment if the location, depth, and lymph node status are all favorable and is also helpful for definite diagnosis of unknown duodenal mass. To avoid morbidity resulting from open surgical resection, careful inspection for the peduncle of the GP will help determine the feasibility of endoscopic resection.

Potential-based methodology for active sound control in three dimensional settings

This paper extends a potential-based approach to active noise shielding with preservation of wanted sound in three-dimensional settings. The approach, which was described in a previous publication [Lim et al., J. Acoust. Soc. Am. 129(2), 717-725 (2011)], provides several significant advantages over conventional noise control methods. Most significantly, the methodology does not require any information including the characterization of sources, impedance boundary conditions and surrounding medium, and that the methodology automatically differentiates between the wanted and unwanted sound components. The previous publication proved the concept in one-dimensional conditions. In this paper, the approach for more realistic conditions is studied by numerical simulation and experimental validation in three-dimensional cases. The results provide a guideline to the implementation of the active shielding method with practical three-dimensional conditions. Through numerical simulation it is demonstrated that while leaving the wanted sound unchanged, the developed approach offers selective volumetric noise cancellation within a targeted domain. In addition, the method is implemented in a three-dimensional experiment with a white noise source in a semi-anechoic chamber. The experimental study identifies practical difficulties and limitations in the use of the approach for real applications.

Meta-analysis of first-line triple therapy for helicobacter pylori eradication in Korea: is it time to change?

Proton pump inhibitor (PPI)-based triple therapy consisting of PPI, amoxicillin, and clarithromycin, is the recommended first-line treatment for Helicobacter pylori infection. However, the eradication rate of triple therapy has declined over the past few decades. We analyzed the eradication rate and adverse events of triple therapy to evaluate current practices in Korea. A comprehensive literature search was performed up to August 2013 of 104 relevant studies comprising 42,124 patients. The overall eradication rate was 74.6% (95% confidence interval [CI], 72.1%-77.2%) by intention-to-treat analysis and 82.0% (95% CI, 80.8%-83.2%) by per-protocol analysis. The eradication rate decreased significantly from 1998 to 2013 (P < 0.001 for both intention-to-treat and per-protocol analyses). Adverse events were reported in 41 studies with 8,018 subjects with an overall incidence rate of 20.4% (95% CI, 19.6%-21.3%). The available data suggest that the effectiveness of standard triple therapy for H. pylori eradication has decreased to an unacceptable level. A novel therapeutic strategy is warranted to improve the effectiveness of first-line treatment for H. pylori infection in Korea.

Fetal shielding combined with state of the art CT dose reduction strategies during maternal chest CT

PURPOSE

Custom bismuth-antimony shields were previously shown to reduce fetal dose by 53% on an 8DR (detector row) CT scanner without dynamic adaptive section collimation (DASC), automatic tube current modulation (ATCM) or adaptive statistical iterative reconstruction (ASiR). The purpose of this study is to compare the effective maternal and average fetal organ dose reduction both with and without bismuth-antimony shields on a 64DR CT scanner using DASC, ATCM and ASiR during maternal CTPA.

MATERIALS AND METHODS

A phantom with gravid prosthesis and a bismuth-antimony shield were used. Thermoluminescent dosimeters (TLDs) measured fetal radiation dose. The average fetal organ dose and effective maternal dose were determined using 100 kVp, scanning from the lung apices to the diaphragm utilizing DASC, ATCM and ASiR on a 64DR CT scanner with and without shielding in the first and third trimester. Isolated assessment of DASC was done via comparing a new 8DR scan without DASC to a similar scan on the 64DR with DASC.

RESULTS

Average third trimester unshielded fetal dose was reduced from 0.22 mGy ± 0.02 on the 8DR to 0.13 mGy ± 0.03 with the conservative 64DR protocol that included 30% ASiR, DASC and ATCM (42% reduction, P<0.01). Use of a shield further reduced average third trimester fetal dose to 0.04 mGy ± 0.01 (69% reduction, P<0.01). The average fetal organ dose reduction attributable to DASC alone was modest (6% reduction from 0.17 mGy ± 0.02 to 0.16 mGy ± 0.02, P=0.014). First trimester fetal organ dose on the 8DR protocol was 0.07 mGy ± 0.03. This was reduced to 0.05 mGy ± 0.03 on the 64DR protocol without shielding (30% reduction, P=0.009). Shields further reduced this dose to below accurately detectable levels. Effective maternal dose was reduced from 4.0 mSv on the 8DR to 2.5 mSv on the 64DR scanner using the conservative protocol (38% dose reduction).

CONCLUSION

ASiR, ATCM and DASC combined significantly reduce effective maternal and fetal organ dose during CTPA. Shields continue to be an effective means of fetal dose reduction.

Risk factors and clinical outcomes of gastric cancer identified by screening endoscopy: a case-control study

BACKGROUND AND AIM

A customized screening program for gastric cancer would optimize the benefits of screening endoscopy. This study investigated the risk factors for gastric cancer detected during screening and factors affecting clinical outcomes.

METHODS

From April 2000 to December 2010, subjects who underwent screening endoscopy at Asan Medical Center were included. To investigate risk factors, age- and sex-matched control group was selected. The clinical outcomes of gastric cancer identified during screening (screening group) were compared with age, sex, and date of diagnosis-matched subjects who were diagnosed with gastric cancer in the outpatient clinic (outpatient group).

RESULTS

Of 109 530 subjects, 327 were diagnosed with gastric cancer. The median age of the screening group was 63.6 years (interquartile range 56-71 years), and the male-to-female ratio was 2.4:1. When comparing with the control group, Helicobacter pylori seropositivity (odds ratio [OR] 2.933, P < 0.001), carcinoembryonic antigen (OR 8.633, P = 0.004), family history of gastric cancer (OR 2.254, P = 0.007), and drinking (OR 3.312, P < 0.001) were independent positive risk factors, and the use of aspirin a negative risk factor for gastric cancer (OR 0.445, P = 0.012) in multivariate analysis. Low-density lipoprotein cholesterol (hazard ratio [HR] 0.987, P = 0.005), cancer antigen 19-9 (HR 21.713, P < 0.001), resectability (HR 59.833, P < 0.001), and family history (HR 0.308, P = 0.009) were independent risk factors for death. The 5-year survival rate was significantly higher in the screening group than in the outpatient group (P < 0.001).

CONCLUSIONS

Early detection of gastric cancer by screening endoscopy while asymptomatic enhances patient outcomes, especially in high-risk groups.

Rapid onset of Stevens-Johnson syndrome and toxic epidermal necrolysis after ingestion of acetaminophen

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but life-threatening, severe cutaneous adverse reactions most frequently caused by exposure to drugs. Several reports have associated the use of acetaminophen with the risk of SJS or TEN. A typical interval from the beginning of drug therapy to the onset of an adverse reaction is 1-3 weeks. A 43-year-old woman and a 60-year-old man developed skin lesions within 3 days after administration of acetaminophen for a 3-day period. Rapid identification of the symptoms of SJS and TEN caused by ingestion of acetaminophen enabled prompt withdrawal of the culprit drug. After administration of intravenous immunoglobulin G, both patients recovered fully and were discharged. These two cases of rapidly developed SJS/TEN after ingestion of acetaminophen highlight the possibility that these complications can develop within only a few days following ingestion of over-the-counter medications such as acetaminophen.

Risk factors and clinical outcomes of gastric cancer identified by screening endoscopy: A case-control study

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Background: A customized screening program for gastric cancer would optimize the benefits of screening endoscopy. This study investigated the risk factors for gastric cancer detected during screening, and factors affecting clinical outcomes. Methods: From April 2000 to December 2010, subjects who underwent screening endoscopy at Asan Medical Center were included. To investigate risk factors, age and sex-matched control group were selected.The clinical outcomes of gastric cancer identified during screening (screening group) were compared with age, sex and date of diagnosis-matched subjects who were diagnosed with gastric cancer in the outpatient clinic (outpatient group). Results: Of 109,530 subjects, 327 were diagnosed with gastric cancer. The median age of the screening group was 63.6 years (interquartile range: 56-71 years), and the male to female ratio was 2.4:1. When comparing with the control group, H. pylori seropositivity (odds ratio [OR] 2.933, p<0.001), carcinoembryonic antigen (OR 8.633, p=0.004), family history of gastric cancer (OR 2.254, p=0.007), and drinking (OR 3.312, p<0.001) were independent positive risk factors, and the use of aspirin a negative risk factor for gastric cancer (OR 0.445, p=0.012) in multivariate analysis. Low density lipoprotein cholesterol (hazard ratio [HR] 0.987, p=0.005), cancer antigen 19-9 (HR 21.713, p<0.001), resectability (HR 59.833, p<0.001), and family history (HR 0.308, p=0.009) were independent risk factors for death. The 5-year survival rate was significantly higher in the screening group than in the outpatient group (p<0.001). Conclusions: Early detection of gastric cancer by screening endoscopy while asymptomatic enhances patient outcomes, especially in high risk groups.

Clinical outcomes associated with treatment modalities for gastrointestinal bezoars

Background/Aims

With technical and instrumental advances, the endoscopic removal of bezoars is now more common than conventional surgical removal. We investigated the clinical outcomes in a patient cohort with gastrointestinal bezoars removed using different treatment modalities.

Methods

Between June 1989 and March 2012, 93 patients with gastrointestinal bezoars underwent endoscopic or surgical procedures at the Asan Medical Center. These patients were divided into endoscopic (n=39) and surgical (n=54) treatment groups in accordance with the initial treatment modality. The clinical feature and outcomes of these two groups were analyzed retrospectively.

Results

The median follow-up period was 13 months (interquartile range [IQR], 0 to 77 months) in 93 patients with a median age of 60 years (IQR, 50 to 73 years). Among the initial symptoms, abdominal pain was the most common chief complaint (72.1%). The bezoars were commonly located in the stomach (82.1%) in the endoscopic treatment group and in the small bowel (66.7%) in the surgical treatment group. The success rates of endoscopic and surgical treatment were 89.7% and 98.1%, and the complication rates were 12.8% and 33.3%, respectively.

Conclusions

Endoscopic removal of a gastrointestinal bezoar is an effective treatment modality; however, surgical removal is needed in some cases.

Clinical outcomes of colonic mucosal cancers with histologically positive or uncertain resection margin after endoscopic resection

BACKGROUND/AIMS

Although incomplete endoscopic resection of colonic neoplasms can lead to the development of interval invasive cancer, few studies have assessed clinical outcomes after histologically incomplete resection of colonic mucosal cancer. We aimed to evaluate the clinical outcomes of patients with histologically positive or uncertain resection margins after endoscopically complete resection of colonic mucosal cancer.

METHODOLOGY

We analyzed the clinical course of 38 patients (median 62 years, male:female = 27:11) who underwent endoscopically complete resection of colonic mucosal cancer, but who showed histologically positive or uncertain resection margins.

RESULTS

The median size of the 38 colonic mucosal cancers was 14 mm (range, 5-50 mm). Of these, 20 were resected by a piecemeal resection, and had uncertain histological resection margins. The remaining 18 patients underwent en-bloc resection; of these, 16 had uncertain resection margins and 2 had positive margins. Patients underwent a median of 2.3 follow-up endoscopies (range, 1-7) during a median follow-up time of 18.3 months (range, 3-75 months). No local or distant recurrence was detected.

CONCLUSIONS

Cautious followup without immediate additional treatment can be considered for patients who undergo endoscopically complete resection of colonic mucosal cancers, even when histological examination shows uncertain or positive resection margins.

Ginsenosides from Korean red ginseng inhibit matrix metalloproteinase-13 expression in articular chondrocytes and prevent cartilage degradation

Among the mammalian matrix metalloproteinases (MMPs), MMP-1, -3 and -13 are collagenases. Particularly, MMP-13 is important for the degradation of major collagens in cartilage under certain pathological conditions such as osteoarthritis. To establish a potential therapeutic strategy for cartilage degradation disorders, the effects of 11 ginseng saponins (ginsenosides Rb1, Rb2, Rc, Rd, Re, Rf, Rg1, Rg3, Rg5, Rk1 and F4) on MMP-13 induction were examined in a human chondrocyte cell line, SW1353. Among these, several saponins including ginsenoside Rc, Rd, Rf, Rg3 and F4 were found to inhibit MMP-13 expression in IL-1β-treated SW1353 cells at non-cytotoxic concentrations (1-50 μM). The most prominent inhibitors were ginsenosides F4 and Rg3. Ginsenoside F4 inhibited MMP-13 expression 33.5% (P<0.05), 57.9% (P<0.01) and 90.0% (P<0.01) at 10, 30 and 50 μM, respectively. Significantly, ginsenoside F4 was found to strongly inhibit activation of p38 mitogen-activated protein kinase in signal transduction pathways (86.6 and 100.0% inhibition at 30 and 50 μM, P<0.01). The MMP-13 inhibitory effect was also supported by the finding that ginsenosides F4 and Rg3 reduced glycosaminoglycan release from IL-1α-treated rabbit joint cartilage culture to some degree. Taken together, these results indicate that several ginsenosides inhibit MMP-13 expression in IL-1β-treated chondrocytes. Ginsenoside F4 and Rg3 blocked cartilage breakdown in rabbit cartilage tissue culture. Thus, it is suggested that certain ginsenosides have therapeutic potential for preventing cartilage collagen matrix breakdown in diseased tissues such as those found in patients with arthritic disorders.