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Gajendra S, Sharma R. Cytomorphological evaluation of non-haematopoietic malignancies metastasizing to the bone marrow. AMERICAN JOURNAL OF BLOOD RESEARCH 2023; 13:1-11. [PMID: 36937461 PMCID: PMC10017595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/25/2022] [Indexed: 03/21/2023]
Abstract
Bone marrow (BM) is one of the rare but important site of metastasis of solid tumors. The key steps of metastasis include invasion, intravasation, circulation, extravasation, and colonization. Tumor cells may express some adhesion molecules that promote the transmigration to the marrow space and link them to the marrow stroma with subsequent engraftment. It is important to detect the bone marrow metastasis for initial clinical staging, therapeutic selection, prognostic risk stratification, assessment of response to therapy and predicting relapse. Prognosis of non-hematopoietic malignancies with BM metastasis is dismal. Due to occulting and atypical clinical manifestations, bone marrow metastases can be easily missed or misdiagnosed, leading to higher mortality rates. The important factors on which the prognosis of patients with bone marrow metastases depends are primary tumor site, performance status, platelet count, and therapeutic regimens (systemic chemotherapy or palliative/supportive care). Further, in cases with BM metastasis with unknown primary sites, misdiagnosis can lead to delayed initiation of therapy and increased mortality. BM metastasis is seen in less than 10% of patients with metastatic cancer and is common in lung, breast or prostate carcinoma. Bone marrow metastasis can be presented as the initial presentation with hematological changes and may be misdiagnosed as a primary haematopoietic disorder. Leucoerythoblastic blood picture is the most common peripheral blood smear finding indicating BM metastasis, may be an indicator of associated BM fibrosis. Bone marrow aspiration and biopsy with immunohistochemistry (IHC) is an easy, cost effective and gold standard method of detection of BM metastasis. BM biopsy is superior to bone marrow aspirate for detection of metastasis. Morphology of metastatic cells is as per the primary site of tumor. Immunohistochemistry is a useful adjunct to morphology in reaching a definitive diagnosis even in case with carcinoma unknown primary (CUP) and also in diagnosing case of unsuspected malignancies. Though bone marrow is not among the most common site of involvement in CUP, which are liver, bone, lymph nodes and lung. But BM, if involved, the site of origin is determined using the immunohistochemistry panel applied to the metastatic deposits based on the morphology The aim of the review is to discuss the hematological findings of non-haematopoietic malignancies metastasizing to the bone marrow, emphasizing on histomorphology with IHC and its significance in establishing primary diagnosis in clinically unsuspected cases.
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Affiliation(s)
- Smeeta Gajendra
- Department of Laboratory Oncology, All India Institute of Medical Sciences, Dr. BRA IRCHNew Delhi 110029, India
| | - Rashi Sharma
- Department of Pathology and Laboratory Medicine, Medanta - The MedicitySector 38, Gurgaon, India
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2
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Zhu Z, Shi L, Dong Y, Zhang Y, Yang F, Wei J, Huo M, Li P, Liu X. Effect of crosstalk among conspirators in tumor microenvironment on niche metastasis of gastric cancer. Am J Cancer Res 2022; 12:5375-5402. [PMID: 36628284 PMCID: PMC9827080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/16/2022] [Indexed: 01/12/2023] Open
Abstract
In Traditional Chinese medicine, the metaphoric views of the human body are based on observations of nature guided by the theory of "Yin-Yang". The direct meanings of yin and yang are the bright and dark sides of an object, which often represent a wider range of opposite properties. When we shifted our view to gastric cancer (GC), we found that there are more distinctive Yin and Yang features in the mechanism of GC development and metastasis, which is observed in many mechanisms such as GC metastasis, immune escape, and stem cell homing. When illustrating this process from the yin-yang perspective, categorizing different cells in the tumor microenvironment enables new and different perspectives to be put forward on the mechanism and treatment of GC metastasis.
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Affiliation(s)
- Zhongbo Zhu
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Lijuan Shi
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Yawei Dong
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Yanmei Zhang
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Fan Yang
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Jingjing Wei
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Minfeng Huo
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Peiqing Li
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
| | - Xiping Liu
- Key Laboratory of Gansu Provincial Prescription Mining and Innovative Translational Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China,Gansu Provincial Traditional Chinese Medicine New Product Creation Engineering Laboratory, Gansu University of Chinese MedicineLanzhou 730000, Gansu, P. R. China
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Fujita K, Okubo A, Nakamura T, Takeuchi N. Disseminated carcinomatosis of the bone marrow caused by granulocyte colony-stimulating factor: A case report and review of literature. World J Gastrointest Oncol 2022; 14:2077-2084. [PMID: 36310701 PMCID: PMC9611438 DOI: 10.4251/wjgo.v14.i10.2077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/08/2022] [Accepted: 08/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Disseminated carcinomatosis of the bone marrow (DCBM) is a widespread metastasis with a hematologic disorder that is mainly caused by gastric cancer. Although it commonly occurs as a manifestation of recurrence long after curative treatment, the precise mechanism of relapse from dormant status remains unclear. Granulocyte colony-stimulating factor (G-CSF) can promote cancer progression and invasion in various cancers. However, the potential of G-CSF to trigger recurrence from a cured malignancy has not been reported.
CASE SUMMARY A 55-year-old Japanese woman was diagnosed with Ewing sarcoma localized on the fifth lumbar vertebrae 6 years after curative gastrectomy for T1 gastric cancer. After palliative surgery to release nerve compression, pathological diagnosis of the resected specimen was followed by curative radiation and chemotherapy. During treatment, G-CSF was administered 32 times for severe neutropenia prophylaxis. Eight months after completing definitive treatment, she complained of severe back pain and was diagnosed as multiple bone metastases with DCBM from gastric cancer. Despite palliative chemotherapy, she died of disseminated intravascular coagulation 13 d after the diagnosis. Immunohistochemical examination of the autopsied bone marrow confirmed a diffuse positive staining for the G-CSF receptor (G-CSFR) in the relapsed gastric cancer cell cytoplasm, whereas the primary lesion cancer cells showed negative staining for G-CSFR. In this case, G-CSF administration may have been the key trigger for the disseminated relapse of a dormant gastric cancer.
CONCLUSION When administering G-CSF to cancer survivors, recurrence of a preceding cancer should be monitored even after curative treatment.
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Affiliation(s)
- Kengo Fujita
- Department of Medical Oncology, Ina Central Hospital, Nagano 396-8555, Japan
| | - Ayaka Okubo
- Department of Medical Oncology, Ina Central Hospital, Nagano 396-8555, Japan
| | - Toshitsugu Nakamura
- Department of Diagnostic Pathology, Ina Central Hospital, Nagano 396-8555, Japan
| | - Nobumichi Takeuchi
- Department of Medical Oncology, Ina Central Hospital, Nagano 396-8555, Japan
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Huang L, Zhao Y, Shi Y, Hu W, Zhang J. Bone Metastasis From Gastric Adenocarcinoma-What Are the Risk Factors and Associated Survival? A Large Comprehensive Population-Based Cohort Study. Front Oncol 2022; 12:743873. [PMID: 35402215 PMCID: PMC8989732 DOI: 10.3389/fonc.2022.743873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 02/28/2022] [Indexed: 01/19/2023] Open
Abstract
Background While bone metastasis is not common in gastric adenocarcinoma (GaC), it can have important impacts on prognosis. This large cohort study aimed at exploring factors associated with bone metastasis in GaC and investigating the time-dependent cumulative mortalities and prognostic factors in GaC patients with bone metastasis at the population level. Methods Data on patients with GaC diagnosed in 2010–2016 were retrieved from a large population-based database. We explored factors associated with bone metastasis using the multivariable-adjusted logistic model. We then calculated the time-dependent cancer-specific mortalities in GaC patients with bone metastasis using the cumulative incidence function and compared mortalities across subgroups using Gray’s test. We further assessed factors associated with mortality using the multivariable-adjusted Fine–Gray subdistribution hazard model. Results Together 11,072 eligible patients with metastatic GaC were enrolled, which comprised 1,511 (14%) people with bone metastasis and 9,561 (86%) with other metastasis, encompassing 6,999 person-years of follow-up. Bone metastasis was more frequently detected in 2014 or later, in younger patients, in patients with gastric cardia cancers, in people with signet-ring cell carcinoma, and in those with poorly differentiated/undifferentiated cancers; it was less commonly observed in black patients. Bone metastasis was associated with more frequent brain and lung metastases. The median survival of patients with bone metastasis was 4 months; the 6-month and 3-year cancer-specific cumulative mortalities were 56% and 85%, respectively. In patients receiving chemotherapy, American Indians/Alaskan Natives, patients with gastric antrum/pylorus cancers, and those with positive lymph nodes had higher mortality risks, while those undergoing resection had lower mortality hazards. Conclusion In GaC patients, bone metastasis was associated with various clinicopathologic factors including age, ethnicity, tumor location, histology, differentiation, and metastasis to other sites. Patients with bone metastasis had poor prognosis which was associated with ethnicity, tumor location, lymph node involvement, and treatment. Our findings provide important hints for tailed patient management and for further mechanistic investigations.
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Affiliation(s)
- Lei Huang
- Department of Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yajie Zhao
- Department of Geriatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Medical Center on Aging of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Shi
- Department of Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiguo Hu
- Department of Geriatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Medical Center on Aging of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Department of Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,State Key Laboratory of Oncogenes and Related Genes, Shanghai Jiao Tong University, Shanghai, China
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Wu C, Lin X, Li Z, Chen Z, Xie W, Zhang X, Wang X. A Diagnostic Nomogram Based on 18F-FDG PET/CT for Bone Metastasis of Gastric Cancer. Front Cell Dev Biol 2022; 9:783466. [PMID: 34970546 PMCID: PMC8712756 DOI: 10.3389/fcell.2021.783466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/20/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose: To develop an effective diagnostic model for bone metastasis of gastric cancer by combining 18F-FDG PET/CT and clinical data. Materials and Methods: A total of 212 gastric cancer patients with abnormal bone imaging scans based on 18F-FDG PET/CT were retrospectively enrolled between September 2009 and March 2020. Risk factors for bone metastasis of gastric cancer were identified by multivariate logistic regression analysis and used to create a nomogram. The performance of the nomogram was evaluated by using receiver operating characteristic curves and calibration plots. Results: The diagnostic power of the binary logistic regression model incorporating skeleton-related symptoms, anemia, the SUVmax of bone lesions, bone changes, the location of bone lesions, ALP, LDH, CEA, and CA19-9 was significantly higher than that of the model using only clinical factors (p = 0.008). The diagnostic model for bone metastasis of gastric cancer using a combination of clinical and imaging data showed an appropriate goodness of fit according to a calibration test (p = 0.294) and good discriminating ability (AUC = 0.925). Conclusions: The diagnostic model combined with the 18F-FDG PET/CT findings and clinical data showed a better diagnosis performance for bone metastasis of gastric cancer than the other studied models. Compared with the model using clinical factors alone, the additional 18F-FDG PET/CT findings could improve the diagnostic efficacy of identifying bone metastases in gastric cancer.
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Affiliation(s)
- Chunhui Wu
- Department of Nuclear Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoping Lin
- Department of Nuclear Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhoulei Li
- Department of Nuclear Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhifeng Chen
- Department of Nuclear Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenhui Xie
- Department of Nuclear Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiangsong Zhang
- Department of Nuclear Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoyan Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Fujita I, Toyokawa T, Makino T, Matsueda K, Omote S, Horii J. Small early gastric cancer with synchronous bone metastasis: A case report. Mol Clin Oncol 2020; 12:202-207. [PMID: 32064095 PMCID: PMC7016521 DOI: 10.3892/mco.2020.1985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 12/02/2019] [Indexed: 12/30/2022] Open
Abstract
Bone metastasis during the early stages of gastric cancer is rare, and synchronous bone metastasis is even less common. The present report outlines a case of a small early gastric cancer, which was detected due to bone metastasis. A 63-year-old man was referred to Fukuyama Medical Center with back pain and anorexia of 2 weeks' evolution. MRI revealed multiple metastatic lesions in the thoracic and spinal bone. Fluorodeoxyglucose positron emission tomography revealed focal uptake in the lesser curvature of the stomach and in the spinal bone, pelvic and thigh bone, but uptake was not detected in the stomach. Esophagogastroduodenoscopy revealed a 10 mm slightly elevated lesion with a central depression in the middle-third of the stomach. Endoscopic ultrasonography confirmed that the tumor was confined to the mucosa. A biopsy specimen acquired from the gastric lesion indicated signet-ring cell carcinoma, and the specimen acquired from the lumbar spine revealed cell aggregation such as that found in signet-ring cell carcinoma. The patient received first-line chemotherapy with S-1 and cisplatin, and second-line chemotherapy with nab-paclitaxel. However, the patient died 120 days after consultation at Fukuyama Medical Center.
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Affiliation(s)
- Isao Fujita
- Department of Gastroenterology, National Hospital Organization, Fukuyama Medical Center, Fukuyama, Hiroshima 720-8520, Japan
| | - Tatsuya Toyokawa
- Department of Gastroenterology, National Hospital Organization, Fukuyama Medical Center, Fukuyama, Hiroshima 720-8520, Japan
| | - Takafumi Makino
- Department of Gastroenterology, National Hospital Organization, Fukuyama Medical Center, Fukuyama, Hiroshima 720-8520, Japan
| | - Katsunori Matsueda
- Department of Gastroenterology, National Hospital Organization, Fukuyama Medical Center, Fukuyama, Hiroshima 720-8520, Japan
| | - Shizuma Omote
- Department of Gastroenterology, National Hospital Organization, Fukuyama Medical Center, Fukuyama, Hiroshima 720-8520, Japan
| | - Joichiro Horii
- Department of Gastroenterology, National Hospital Organization, Fukuyama Medical Center, Fukuyama, Hiroshima 720-8520, Japan
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7
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Patan S, Benzar T, Sanford G, Kavanaugh M. Advanced metastatic gastric adenocarcinoma identified within the placenta: a case report with literature review. J Gastrointest Oncol 2020; 11:127-132. [PMID: 32175115 DOI: 10.21037/jgo.2019.09.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
We present an extremely rare case of a multiparous women age 32 in her 35th week of gestation who was admitted to our hospital for evaluation of back pain and was incidentally found to have metastatic gastric adenocarcinoma, diagnosed from a routine placental specimen. The coexistence of gastric carcinoma with pregnancy is a rare event, accounting for 0.026% to 0.1% of all pregnancies. To the best of our knowledge, the world literature contains only eight known cases of metastatic gastric cancer to the placenta-the present case is the ninth. An uncommon finding, in this case, was the extensive spread of cancer to bone marrow and leptomeninges.
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Affiliation(s)
- Shajadi Patan
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Taras Benzar
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Gabrielle Sanford
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Mindie Kavanaugh
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Harvey PR, Coupland B, Mytton J, Evison F, Patel P, Trudgill NJ. Outcomes of pneumatic dilatation and Heller's myotomy for achalasia in England between 2005 and 2016. Gut 2019; 68:1146-1151. [PMID: 30606814 DOI: 10.1136/gutjnl-2018-316544] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 11/25/2018] [Accepted: 11/30/2018] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Achalasia is a disorder characterised by failed relaxation of the lower oesophageal sphincter. The aim of this study was to examine, at a national level, the long-term outcomes of achalasia therapies. METHODS Hospital Episode Statistics include diagnostic and procedural data for all English National Health Service-funded hospital admissions. Subjects with a code for achalasia who had their initial treatment between January 2006 and December 2015 were grouped by treatment; pneumatic dilatation (PD) or surgical Heller's myotomy (HM). Procedural failure was defined as time to a further episode of the same therapy or a change to a different therapy. Up to three PDs were permitted without being considered a therapy failure. RESULTS 6938 subjects were included; 3619 (52.2%) were men and median age at diagnosis was 59 (IQR 43-75) years. 4748 (68.4%) initially received PD and 2190 (31.6%) HM. The perforation rate following PD was 1.6%. Mortality at 30 days was 0.0% for HM and 1.9% for PD, and <8% after perforation following PD. Factors associated with increased mortality after PD included age quintile 66-77 (OR 4.55 (95% CI 2.00 to 10.38), p<0.001), >77 (9.78 (4.33 to 22.06), p<0.001); Charlson comorbidity score >4 (2.87 (2.08 to 3.95), p<0.001); previous HM (2.47 (1.33 to 4.62), p<0.001); and repeat PD 1-3 (1.58 (1.15 to 2.16), p=0.005), >3 (1.97 (1.21 to 3.19), p=0.006). Durability of up to 3 PD and HM over 10 years of follow-up was 86.2% and 81.9%, respectively (p<0.001). DISCUSSION The efficacy of PD for achalasia appears to be greater than HM over 10 years. There was no mortality associated with HM, but 1.9% of subjects died within 30 days of PD. Mortality was associated with increasing age, comorbidity, previous HM and repeat PD.
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Affiliation(s)
- Philip R Harvey
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals, West Bromwich, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Ben Coupland
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jemma Mytton
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity Evison
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Prashant Patel
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals, West Bromwich, UK
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Choi B, Lee EJ, Shin MK, Park YS, Ryu MH, Kim SM, Kim EY, Lee HK, Chang EJ. Upregulation of brain-derived neurotrophic factor in advanced gastric cancer contributes to bone metastatic osteolysis by inducing long pentraxin 3. Oncotarget 2018; 7:55506-55517. [PMID: 27458153 PMCID: PMC5342432 DOI: 10.18632/oncotarget.10747] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 07/11/2016] [Indexed: 12/23/2022] Open
Abstract
The brain-derived neurotrophic factor (BDNF) activates its receptor, tropomyosin receptor kinase B (TrkB; also called NTRK2) that has been shown to promote the malignant progression of several cancers. In this study, we investigated the clinical and biological significance of the BDNF/TrkB axis in the progression of human gastric cancer. The increased co-expression of the BDNF/TrkB axis was significantly correlated with bone metastatic properties in advanced gastric cancers. BDNF acting via TrkB receptors increased the levels of long pentraxin 3 (PTX3) that was related to bone metastatic status of gastric cancer by enhancing gastric cancer–osteoblastic niche interactions. In bone metastatic gastric cancer, PTX3 knockdown using small interfering RNA significantly inhibited BDNF-induced interactions of cancer cells with osteoblasts. Moreover, BDNF-derived PTX3 induction supported subsequent osteoclastogenesis, and this effect was significantly reversed by PTX3 silencing. These findings suggest that a functional interaction between BDNF/TrkB and PTX3 enhances the osteolysis of bone metastatic gastric cancer, thereby providing potential prognostic factors for the development of bone metastasis of gastric cancer.
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Affiliation(s)
- Bongkun Choi
- Department of Biomedical Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Cell Dysfunction Research Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Jin Lee
- Department of Biomedical Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Cell Dysfunction Research Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Kyung Shin
- Department of Biomedical Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Cell Dysfunction Research Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Soo Park
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Hee Ryu
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Min Kim
- Department of Biomedical Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Cell Dysfunction Research Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Young Kim
- Department of Biomedical Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Cell Dysfunction Research Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyung Keun Lee
- Department of Ophthalmology and Corneal Dystrophy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Ju Chang
- Department of Biomedical Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Cell Dysfunction Research Center, University of Ulsan College of Medicine, Seoul, Korea
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Wang X, Tan Y, Lv L, Zhu H, Chu Y, Li C, Liu D. Peroral endoscopic myotomy versus pneumatic dilation for achalasia in patients aged ≥ 65 years. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:637-641. [PMID: 27649684 DOI: 10.17235/reed.2016.4488/2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM Both peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) has proved to be effective for treating achalasia in patients aged ≥ 65 years. However little is known about the comparison between POEM and PD. The aim of the study was to compare the safety and efficacy of POEM and PD for the treatment of achalasia in these patients. METHODS We retrospectively reviewed the medical records of patients aged 65 years-old or more who received POEM or PD for the treatment of achalasia at our hospital from January 2010 to December 2015, they were divided into the POEM group and the PD group. Demographics and data about safety and efficacy were collected retrospectively and compared between the two groups. RESULTS A total of 31 patients were enrolled, and 21 of them received POEM, while the other 10 received PD. The treatment success (Eckardt score ≤ 3) rate of POEM and PD at 3, 6, 12, 24 and 36 months after the treatment were comparable (p > 0.05). Treatment failure was noticed in 3 cases, 1 of them was in the POEM group and the other 2 in the PD group, there was no significant difference (p > 0.05). Multivariate analysis showed that sigmoid-type achalasia was a predictive factor of treatment failure. No severe complications were observed during operation and periodical follow-up. CONCLUSION Short-term and intermediate efficacy of POEM and PD for treating achalasia in patients aged ≥ 65 years was comparable. A large scale, randomized study with long-term follow-up is necessary in order to make a definitive conclusion.
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Affiliation(s)
- Xuehong Wang
- the Second Xiangya Hospital of Central South University
| | - Yuyong Tan
- Gastroenterology, The Second Xiangya Hospital of Central South University, China
| | - Liang Lv
- the Second Xiangya Hospital of Central South University
| | - Hongyi Zhu
- the Second Xiangya Hospital of Central South University
| | - Yi Chu
- The Second Xiangya Hospital of Central South University
| | - Chenjie Li
- the Second Xiangya Hospital of Central South University
| | - Deliang Liu
- Gastroenterology, The Second Xiangya Hospital of Central South Unive, China
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11
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Mikami J, Kimura Y, Makari Y, Fujita J, Kishimoto T, Sawada G, Nakahira S, Nakata K, Tsujie M, Ohzato H. Clinical outcomes and prognostic factors for gastric cancer patients with bone metastasis. World J Surg Oncol 2017; 15:8. [PMID: 28061855 PMCID: PMC5216595 DOI: 10.1186/s12957-016-1091-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 12/23/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bone metastasis due to gastric cancer is rare, and the clinical features have not been fully evaluated. We investigated the clinical features, treatment outcomes, and prognostic factors in gastric cancer patients with bone metastasis. METHODS We retrospectively collected data on 34 consecutive patients who were diagnosed radiologically with bone metastasis due to gastric cancer. We estimated the overall survival after the diagnosis of bone metastasis using the Kaplan-Meier product-limit method and evaluated which clinicopathological factors were associated with prognostic factors for survival using univariate and multivariate Cox proportional hazards regression models. RESULTS The treatment for the primary tumor was surgery in 16 patients (47.1%) and chemotherapy in 18 patients (52.9%). The median serum alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) levels at the time of bone metastasis were 375.5 and 249 IU/L, respectively. Ten patients (29.4%) were diagnosed with bone metastasis and gastric cancer at the same time. The 6-month survival rate after the diagnosis of bone metastasis was 63.8%, and the median survival time was 227.5 days. Multivariate analysis revealed that metachronous metastasis (p = 0.035) and extraosseous metastasis (p = 0.028) were significant risk factors for poor survival. CONCLUSIONS The prognosis of gastric cancer with bone metastasis was poor, and metachronous metastasis and extraosseous metastasis were shown to be poor prognostic factors. Serum ALP, LDH, and tumor markers are not always high, so aggressive diagnosis using appropriate modalities such as bone scan, MRI, or PET-CT may be necessary in routine practice even in asymptomatic patients.
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Affiliation(s)
- Jota Mikami
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan.
| | - Yutaka Kimura
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Onohigashi, Sayama City, 589-8511, Osaka, Japan
| | - Yoichi Makari
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
| | - Junya Fujita
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
| | - Tomoya Kishimoto
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
| | - Genta Sawada
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
| | - Shin Nakahira
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
| | - Ken Nakata
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
| | - Masaki Tsujie
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
| | - Hiroki Ohzato
- Department of Surgery, Sakai City Medical Center, 1-1-1 Ebarajicho, Nishi-ku, Sakai City, 593-8304, Osaka, Japan
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Hanamura F, Shibata Y, Shirakawa T, Kuwayama M, Oda H, Ariyama H, Taguchi K, Esaki T, Baba E. Favorable control of advanced colon adenocarcinoma with severe bone marrow metastasis: A case report. Mol Clin Oncol 2016; 5:579-582. [PMID: 27900088 DOI: 10.3892/mco.2016.1029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/25/2016] [Indexed: 12/16/2022] Open
Abstract
Colorectal cancer (CRC) has a propensity to metastasize to the liver, lungs and regional abdominal lymph nodes, but rarely to the bone marrow. A 60-year-old man presented to the National Hospital Organization Kyushu Cancer Center with a 4-week history of persistent lower back pain, anorexia and difficulty defecating. Complete blood count revealed severe thrombocytopenia and erythroblastosis, suggesting a hematological malignancy. However, the bone marrow examination demonstrated involvement by a moderately to poorly differentiated adenocarcinoma, but no hematopoietic abnormalities. A computed tomography scan revealed thickening of the wall of the sigmoid colon, with para-aortic, hilar, mediastinal and supraclavicular lymphadenopathy. The patient was thus diagnosed with sigmoid colon adenocarcinoma with lymph node and bone marrow metastasis. Modified FOLFOX6 was promptly initiated, with concurrent therapy for disseminated intravascular coagulation (DIC). An increased number of thrombocytes was observed on day 6. After 3 cycles of treatment, the patient recovered from DIC and the levels of serum carcinoembryonic antigen and cytokeratin 19 fragment were decreased. Tumor biopsy during colonoscopy following recovery from DIC demonstrated poorly differentiated adenocarcinoma with mucin production, without mutations in the RAS, BRAF or PIK3CA genes, and a cytokeratin (CK) 7-negative, CK20-positive phenotype. The patient has been treated with chemotherapy for 150 days without disease progression. However, the efficacy of chemotherapy for rarely encountered bone marrow metastasis from CRC is poor. The present case was favorably maintained on chemotherapy and survived for 10 months.
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Affiliation(s)
- Fumiyasu Hanamura
- Department of Medical Oncology, Fukuoka Wajiro Hospital, Fukuoka 811-021, Japan; Department of Gastrointestinal and Medical Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Yoshihiro Shibata
- Department of Medical Oncology, Fukuoka Wajiro Hospital, Fukuoka 811-021, Japan
| | - Tsuyoshi Shirakawa
- Department of Gastrointestinal and Medical Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Miyuki Kuwayama
- Department of Gastrointestinal and Medical Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Hisanobu Oda
- Department of Gastrointestinal and Medical Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan; Department of Medical Oncology, Saiseikai Fukuoka General Hospital, Fukuoka 810-0001, Japan
| | - Hiroshi Ariyama
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Kenichi Taguchi
- Department of Cancer Biology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Taito Esaki
- Department of Gastrointestinal and Medical Oncology, National Hospital Organization Kyushu Cancer Center, Fukuoka 811-1395, Japan
| | - Eishi Baba
- Department of Comprehensive Clinical Oncology, Faculty of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
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Miller HJ, Neupane R, Fayezizadeh M, Majumder A, Marks JM. POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia. Surg Endosc 2016; 31:1636-1642. [PMID: 27534662 DOI: 10.1007/s00464-016-5151-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/21/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Achalasia is a rare motility disorder of the esophagus. Treatment is palliative with the goal of symptom remission and slowing the progression of the disease. Treatment options include per oral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LM) and endoscopic treatments such as pneumatic dilation (PD) and botulinum toxin type A injections (BI). We evaluate the economics and cost-effectiveness of treating achalasia. METHODS We performed cost analysis for POEM, LM, PD and BI at our institution from 2011 to 2015. Cost of LM was set to 1, and other procedures are presented as percentage change. Cost-effectiveness was calculated based on cost, number of interventions required for optimal results for dilations and injections and efficacy reported in the current literature. Incremental cost-effectiveness ratio was calculated by a cost-utility analysis using quality-adjusted life year gained, defined as a symptom-free year in a patient with achalasia. RESULTS Average number of interventions required was 2.3 dilations or two injections for efficacies of 80 and 61 %, respectively. POEM cost 1.058 times the cost of LM, and PD and BI cost 0.559 and 0.448 times the cost of LM. Annual cost per cure over a period of 4 years for POEM, and LM were consistently equivalent, trending the same as PD although this has a lower initial cost. The cost per cure of BI remains stable over 3 years and then doubles. CONCLUSION The cost-effectiveness of POEM and LM is equivalent. Myotomy, either surgical or endoscopic, is more cost-effective than BI due to high failure rates of the economical intervention. When treatment is being considered BI should be utilized in patients with less than 2-year life expectancy. Pneumatic dilations are cost-effective and are an acceptable approach to treatment of achalasia, although myotomy has a lower relapse rate and is cost-effective compared to PD after 2 years.
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Affiliation(s)
- Heidi J Miller
- Department of Surgery, UH Case Medical Center, 11100 Euclid Ave, Lakeside 7th Floor, Cleveland, OH, 44121, USA.
| | - Ruel Neupane
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Mojtaba Fayezizadeh
- Department of Surgery, UH Case Medical Center, 11100 Euclid Ave, Lakeside 7th Floor, Cleveland, OH, 44121, USA
| | - Arnab Majumder
- Department of Surgery, UH Case Medical Center, 11100 Euclid Ave, Lakeside 7th Floor, Cleveland, OH, 44121, USA
| | - Jeffrey M Marks
- Department of Surgery, UH Case Medical Center, 11100 Euclid Ave, Lakeside 7th Floor, Cleveland, OH, 44121, USA
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Familiari P, Greco S, Volkanovska A, Gigante G, Cali A, Boškoski I, Costamagna G. Achalasia: current treatment options. Expert Rev Gastroenterol Hepatol 2016; 9:1101-14. [PMID: 26186641 DOI: 10.1586/17474124.2015.1052407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Achalasia is a rare esophageal motility disorder, characterized by impaired swallow-induced, lower esophageal sphincter (LES) relaxation and defective esophageal peristalsis. Unfortunately, there are no etiological therapies for achalasia. Patients present with dysphagia, chest pain and regurgitation of undigested food, often leading to weight loss. The currently available treatments have the common aim of relieving symptoms by decreasing the pressure of the LES. This can be achieved with some medications, by inhibiting the cholinergic innervation (botulinum toxin), by stretching (endoscopic dilation) or cutting (surgery) the LES. Recently, other therapeutic options, including per-oral endoscopic myotomy have been developed and are gaining international consensus. The authors report on the benefits and weaknesses of the different therapies and provide an updated approach to the management of achalasia.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit - Gemelli University Hospital Università Cattolica del Sacro Cuore, Rome, Italy
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15
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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Data analyses and perspectives on laparoscopic surgery for esophageal achalasia. World J Gastroenterol 2015; 21:10830-10839. [PMID: 26478674 PMCID: PMC4600584 DOI: 10.3748/wjg.v21.i38.10830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.
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16
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Iovino F, Orditura M, Auriemma PP, Ciorra FR, Giordano G, Orabona C, Bara F, Sergio R, Savastano B, Fabozzi A, Laterza MM, Ventriglia J, Petrillo A, Della Corte CM, DE Vita F. Vertebral carcinomatosis eleven years after advanced gastric cancer resection: A case report. Oncol Lett 2014; 9:1403-1405. [PMID: 25663920 PMCID: PMC4315078 DOI: 10.3892/ol.2014.2822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 10/29/2014] [Indexed: 01/16/2023] Open
Abstract
Bone metastasis is an uncommon event in advanced gastric cancer patients and bone metastases are rarely detected as isolated lesions. However, eleven years after treatment for locally advanced gastric cancer, including total gastrectomy followed by adjuvant chemotherapy, a 49-year-old female was admitted to the IX Division of General Surgery of the Second University of Naples (Naples, Italy) exhibiting severe progressive neurological symptoms. Magnetic resonance imaging indicated vertebral abnormalities, with evidence of marrow infiltration in several vertebral bodies; however, a contrast-enhanced computed tomography scan did not detect disease progression to other sites. Biopsy of the soft tissue at the level of the second lumbar vertebra (L2) revealed a metastatic lesion derived from gastric mucinous adenocarcinoma. The patient was initially treated with radiotherapy directed to the L2–L4 vertebral bodies to control the pain. Subsequently, systemic chemotherapy according to a FOLFOX-4 (leucovorin, fluorouracil and oxaliplatin) regimen commenced. However, after eight cycles, pulmonary progression of the disease occurred. Thus, palliative care was administered and the patient succumbed one month later. The late relapse of gastric cancer in the current patient may be associated with the theory of tumour dormancy.
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Affiliation(s)
- Francesco Iovino
- IX Division of General Surgery, Department of Anaesthetic, Surgical and Emergency Sciences, Second University of Naples, Naples I-80131, Italy
| | - Michele Orditura
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
| | - Pasquale Pio Auriemma
- IX Division of General Surgery, Department of Anaesthetic, Surgical and Emergency Sciences, Second University of Naples, Naples I-80131, Italy
| | - Francesca Romana Ciorra
- IX Division of General Surgery, Department of Anaesthetic, Surgical and Emergency Sciences, Second University of Naples, Naples I-80131, Italy
| | - Giovanni Giordano
- IX Division of General Surgery, Department of Anaesthetic, Surgical and Emergency Sciences, Second University of Naples, Naples I-80131, Italy
| | - Consiglia Orabona
- IX Division of General Surgery, Department of Anaesthetic, Surgical and Emergency Sciences, Second University of Naples, Naples I-80131, Italy
| | - Francesco Bara
- IX Division of General Surgery, Department of Anaesthetic, Surgical and Emergency Sciences, Second University of Naples, Naples I-80131, Italy
| | - Renato Sergio
- IX Division of General Surgery, Department of Anaesthetic, Surgical and Emergency Sciences, Second University of Naples, Naples I-80131, Italy
| | - Beatrice Savastano
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
| | - Alessio Fabozzi
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
| | - Maria Maddalena Laterza
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
| | - Jole Ventriglia
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
| | - Angelica Petrillo
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
| | - Carminia Maria Della Corte
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
| | - Ferdinando DE Vita
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine, Second University of Naples School of Medicine, Naples I-80131, Italy
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Turkoz FP, Solak M, Kilickap S, Ulas A, Esbah O, Oksuzoglu B, Yalcin S. Bone metastasis from gastric cancer: the incidence, clinicopathological features, and influence on survival. J Gastric Cancer 2014; 14:164-72. [PMID: 25328761 PMCID: PMC4199883 DOI: 10.5230/jgc.2014.14.3.164] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/25/2014] [Accepted: 08/26/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To evaluate the incidence, clinicopathological characteristics, treatment outcomes, prognostic factors, and survival of gastric cancer patients with bone metastases. MATERIALS AND METHODS Of 4,617 gastric cancer patients who were treated between 2001 and 2013, 176 patients with bone metastases were analyzed. RESULTS The incidence of bone metastasis was 3.8%. The most common histopathological subtype was adenocarcinoma (79%) with poor differentiation (60.8%). The median interval from the diagnosis to bone metastasis was 11 months. The median survival time after bone metastasis was 5.4 months. Factors that were associated with longer median survival times included the following: isolated bone metastasis (P=0.004), well-differentiated tumors (P=0.002), palliative chemotherapy (P=0.003), zoledronic acid treatment (P<0.001), no smoking history (P=0.007), and no metastatic gastric cancer at the time of diagnosis (P=0.01). On the other hand, high levels of lactate dehydrogenase (LDH) (hazard ratio [HR]: 1.86; P=0.015), carcinoembryonic antigen (CEA) (HR: 2.04; P=0.002), and carbohydrate antigen (CA) 19-9 (HR: 2.94; P<0.001) were associated with shorter survival times. In multivariate analysis, receiving zoledronic acid (P<0.001) and performance status (P=0.013) were independent prognostic factors. CONCLUSIONS Smoking history, poor performance status, poorly differentiated adenocarcinoma, and high levels of LDH, CEA, and CA 19-9 were shown to be poor prognostic factors, while receiving chemotherapy and zoledronic acid were associated with prolonged survival in gastric cancer patients with bone metastases.
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Affiliation(s)
- Fatma Paksoy Turkoz
- Ataturk Chest Disease and Chest Surgery Training and Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Mustafa Solak
- Hacettepe University Cancer Institute, Department of Medical Oncology, Ankara, Turkey
| | - Saadettin Kilickap
- Hacettepe University Cancer Institute, Department of Medical Oncology, Ankara, Turkey
| | - Arife Ulas
- Ankara Ataturk Training and Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Onur Esbah
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Berna Oksuzoglu
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Department of Medical Oncology, Ankara, Turkey
| | - Suayib Yalcin
- Hacettepe University Cancer Institute, Department of Medical Oncology, Ankara, Turkey
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18
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Kumar AR, Schnoll-Sussman FH, Katz PO. Botulinum toxin and pneumatic dilation in the treatment of achalasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Borges AA, Lemme EMDO, Abrahao LJ, Madureira D, Andrade MS, Soldan M, Helman L. Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response. Dis Esophagus 2014; 27:18-23. [PMID: 23551592 DOI: 10.1111/dote.12064] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Achalasia is a motor disorder characterized by esophageal aperistalsis and failure of lower esophageal sphincter relaxation. The cardinal symptoms are dysphagia, food regurgitation and weight loss. The most effective treatments are pneumatic dilation (PD) of the cardia and Heller esophageal myotomy with partial fundoplication. There is still controversy regarding which treatments should be initially done. The aims of this study were to evaluate clinical response and the variables related to good results in both treatments. Ninety-two patients with achalasia diagnosed by esophageal manometry were randomized to receive either PD or laparoscopic Heller myotomy with partial fundoplication. After the procedure, patients were followed up clinically and submitted to esophageal manometry and pH monitoring. Three months after treatment, 73% of the patients from PD group and 84% of the surgery group had good results (P = 0.19). After 2 years of follow-up, 54% of the PD group and 60% of the surgery group (P = not significant) were symptom free. Variables related to a good response to PD were a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment. Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment when compared with PD. The reflux rate was significantly higher in the PD group (27.7%) compared with the surgery group (4.7%), P = 0.003. We concluded that surgical treatment and PD for achalasia are equally effective even after 2 years of follow-up. The choice of treatment for achalasia should be based on the following parameters: treatment availability, rate of good results, complication rates, variables related to good responses and also the patient's wish.
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Affiliation(s)
- A A Borges
- Esophagus Unit, Gastroenterology Division, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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20
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Basheer A, Daniel J, Padhi S. Compressive myeloradiculopathy from bony metastasis as the initial presentation of poorly differentiated adenocarcinoma stomach - a case report. Australas Med J 2013; 6:515-9. [PMID: 24223069 DOI: 10.4066/amj.2013.1859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Carcinoma of the stomach rarely disseminates to bone. We report a case of compressive myeloradiculopathy from extensive metastases to the spine, which on evaluation originated from adenocarcinoma of the stomach. Magnetic resonance imaging of the spine showed osteolytic and osteosclerotic metastases. Gastrointestinal endoscopy revealed ulcerative growth in the stomach that on biopsy showed poorly differentiated adenocarcinoma. This case is unique in that the initial presentation of gastric cancer itself was bony metastases without any gastrointestinal symptoms or liver involvement. Moreover, metastases were osteosclerotic as well, which is against the general belief that gastric cancer produces only osteolytic secondaries.
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Affiliation(s)
- Aneesh Basheer
- Department of Medicine, Pondicherry Institute of Medical Sciences
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Abstract
PURPOSE The proposed guideline for performing endoscopic resection of early gastric carcinoma (EGC) in Paris classification is a well-differentiated carcinoma with maximum involvement Sm1. Signet ring cell carcinomas (SRC) are excluded from this recommendation. Authors from Eastern countries have proposed extending this resection to include selected undifferentiated EGC. Via an analysis of a series of cases of signet ring carcinoma, we will discuss whether it is possible to resect EGC with signet ring cells in Europe. METHODS We retrospectively included patients with histological classification pT1 of EGC showing SRC. Data was extracted from the hospital gastrectomy register. Lymphadenomectomy D1.5 was performed on all patients. Histology results were retrospectively obtained from the electronic patient file. RESULTS Twelve patients (mean age = 55.4, four women, eight men) underwent surgery, without previous chemotherapy, between 2000 and 2012, for EGC with SRC. Mean size of the lesions was 20.2 mm (5-35 mm). Seven lesions were located in the antrum, five in the fundus. In the case of nine patients, histology showed no lymphovascular involvement. None of these nine patients presented lymph node metastases (LNM). Five patients had intramucosal carcinoma, four were classified as Sm1, one patient was Sm2, and one patient was Sm3. On surgery, the three patients with lymphovascular invasion showed LNM. CONCLUSION Endoscopic resection of EGC with SRC does not systematically imply complementary treatment by surgery, although criteria for endoscopic resection are difficult to determine because of the lack of data in Europe.
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Park JM, Song KY, O JH, Kim WC, Choi MG, Park CH. Bone recurrence after curative resection of gastric cancer. Gastric Cancer 2013; 16:362-9. [PMID: 22961057 DOI: 10.1007/s10120-012-0193-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 08/14/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Standard follow up for bone recurrence has not yet been established for gastric cancer after surgical resection. The aim of this study was to investigate the incidence of and related risk factors for bone recurrence after surgical resection of gastric cancer. METHODS A cohort of 3035 gastric cancer patients after curative resection was reviewed. We analyzed the patients who had bone scintigraphy before the surgery as well as during the follow-up period. The incidence of and the risk factors for bone recurrence after surgical resection of gastric cancer were investigated. RESULTS In a total of 1683 patients analyzed, bone recurrence was detected in 30 patients (1.8%). The incidence of bone recurrence was significantly higher in advanced gastric cancers than in early lesions (3.5 vs. 0.4%, p < 0.01). The most common recurrence site was the spine, followed by pelvic bone and rib. Most patients had multiple bone metastases. The median time for recurrence was 28 months (range 4-111) from the surgery. In univariate analysis, the recurrence rate was higher in the tumors with large size, undifferentiated pathology, location in the body, and advanced stage. In multivariate analysis, lymph node metastasis (N2/N3 vs. N0/N0I) was the most predictable risk factor for bone recurrence [hazard ratio [HR] 1.44 (95% confidence interval [CI] 1.217-1.694)] and depth of invasion (T2-4 vs. T1) was also independently associated with bone recurrence. CONCLUSIONS The incidence of bone recurrence was low after curative surgery in patients with gastric cancer. Intensive follow up with bone scintigraphy seems to be unnecessary in these patients.
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Affiliation(s)
- Jae Myung Park
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, # 505, Banpo-Dong, Seocho-Gu, Seoul, 137-701, Korea.
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Ishigami S, Arigami T, Uchikado Y, Setoyama T, Kita Y, Sasaki K, Okumura H, Kurahara H, Kijima Y, Harada A, Ueno S, Natsugoe S. IL-32 expression is an independent prognostic marker for gastric cancer. Med Oncol 2013; 30:472. [PMID: 23479179 DOI: 10.1007/s12032-013-0472-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 01/15/2013] [Indexed: 12/16/2022]
Abstract
A strong link between inflammation and gastrointestinal cancer has been demonstrated. Interleukin (IL)-32 is a recently described pro-inflammatory cytokine characterized by the induction of nuclear factor kappa B (NF-κB) activation. We investigated whether IL-32 expression has clinical significance in gastric cancer. A total of 182 gastric cancer patients who received curative gastrectomy were enrolled in our study. IL-32 expression was detected by immunohistochemistry, and the correlation between clinicopathological features and IL-32 expression was analyzed. Tumor depth and lymph node metastases developed more frequently in IL-32-positive gastric cancer patients than those who were negative for IL-32 expression (p < 0.01). Lymphatic- and venous invasion in the IL-32-positive group were more severe than in cancer cells lacking IL-32 expression (p < 0.05). Multivariate analysis demonstrated that IL-32 is one of the prognostic markers (p < 0.03) for gastric cancer, in addition to nodal involvement and tumor depth. IL-32 positivity significantly affected clinicopathological factors. Thus, IL-32 expression in gastric cancer may serve as a preferential metastatic condition that allows cells to escape host antitumor immunity. Pro-inflammatory cytokines induce immunosuppression in a paracrine manner, thereby facilitating the metastasis of tumor cells.
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Affiliation(s)
- Sumiya Ishigami
- Digestive Surgery Surgical Oncology, Kagoshima University School of Medicine, 8-35-1 Sakuragaoka, Kagoshima 890-8520, JAPAN.
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Hekmat S, Ghaedian T, Barati H, Movahed M. Solitary metastasis of gastric cancer to fibula: a case report. IRANIAN JOURNAL OF RADIOLOGY 2012; 9:161-4. [PMID: 23329984 PMCID: PMC3522377 DOI: 10.5812/iranjradiol.3564] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 01/31/2012] [Accepted: 02/15/2012] [Indexed: 12/17/2022]
Abstract
Gastric cancer is one of the most common and most fatal neoplasms in human. Its skeletal metastasis is less frequent, particularly when solitary. The objective of this article is to represent a case of solitary fibular metastasis from this cancer not reported before based on Medline search.
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Affiliation(s)
- Sepideh Hekmat
- Department of Nuclear Medicine, Hasheminejad Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Sepideh Hekmat, Hasheminejad Hospital, Tehran, Iran. Tel.: +98-9123049589, Fax: +98-2188644471, E-mail:
| | - Tahereh Ghaedian
- Department of Nuclear Medicine, Hasheminejad Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Barati
- Department of Nuclear Medicine, Hasheminejad Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansour Movahed
- Department of Nuclear Medicine, Hasheminejad Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Gockel I, Sgourakis G, Drescher DG, Lang H. Impact of minimally invasive surgery in the spectrum of current achalasia treatment options. Scand J Surg 2012; 100:72-7. [PMID: 21737381 DOI: 10.1177/145749691110000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Minimally invasive Heller myotomy has evolved the "gold standard" procedure for achalasia in the spectrum of current treatment options. The laparoscopic technique has proved superior to the thoracoscopic approach due to improved visualization of the esophagogastric junction. Operative controversies most recently include the length of the myotomy, especially of its fun-dic part, with respect to the balance between postoperative persistent dysphagia and development of gastroesophageal reflux, as well as the type of the added antireflux procedure. Peri-operative mortality should approach 0%, and favorable long-term results can be achieved in > 90%.
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Affiliation(s)
- I Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany.
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26
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Kwon JY, Yun J, Kim HJ, Kim KH, Kim SH, Lee SC, Kim HJ, Bae SB, Kim CK, Lee NS, Lee KT, Park SK, Won JH, Hong DS, Park HS. Clinical outcome of gastric cancer patients with bone marrow metastases. Cancer Res Treat 2011; 43:244-9. [PMID: 22247710 PMCID: PMC3253867 DOI: 10.4143/crt.2011.43.4.244] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 07/19/2011] [Indexed: 01/27/2023] Open
Abstract
Purpose The prognosis of gastric cancer patients with bone marrow metastases is extremely poor. The current study was conducted to evaluate the clinical outcomes of advanced gastric cancer patients with bone marrow metastases. Materials and Methods We retrospectively reviewed the medical records of 26 advanced gastric cancer patients with bone marrow metastases who were treated at Soonchunhyang University Hospital between September 1986 and February 2009. Results The median age was 46 years (range, 24 to 61 years). All patients had poorly differentiated adenocarcinoma, including 17 signet ring cell carcinomas. The majority of the patients had thrombocytopenia, anemia, and elevated lactate dehydrogenase levels. Sixteen patients (61.5%) received palliative chemotherapy (median, 4 cycles; range, 1 to 13 cycles). The median overall survival after detection of bone marrow metastases for the cohort of patients was 37 days (95% confidence interval, 12.5 to 61.5 days). The median overall survival after detection of bone marrow involvement was 11 days in the best supportive care group (range, 2 to 34 days) and 121 days (range, 3 to 383 days) in the palliative chemotherapy group (p<0.001). The causes of death were tumor progression (11 patients, 45%), brain hemorrhage (6 patients, 25%), infection (5 patients, 21%), and disseminated intravascular coagulation (1 patient, 4%). There were no chemotherapy-related deaths. Conclusion Palliative chemotherapy could be considered in advanced gastric cancer patients with bone marrow metastases as a treatment option.
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Affiliation(s)
- Ji Yeon Kwon
- Division of Hematology and Oncology, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Korea
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27
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SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
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28
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Katzka DA, Castell DO. Review article: an analysis of the efficacy, perforation rates and methods used in pneumatic dilation for achalasia. Aliment Pharmacol Ther 2011; 34:832-9. [PMID: 21848630 DOI: 10.1111/j.1365-2036.2011.04816.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pneumatic dilation has re-emerged as a first line treatment for achalasia, but conclusions are limited by the relatively small numbers of patients studied and the lack of long term follow-up. AIM To summarise and analyse 29 available studies evaluating pneumatic dilation for achalasia with focus on efficacy, rate or perforation and dilation technique. METHODS A literature search for all studies, in which pneumatic dilation was performed for treatment of achalasia, was conducted. Studies, in which clear endpoints of efficacy of single dilation sessions over a period of years, were chosen. RESULTS The response for a single dilation session was 66% at 1 year and 59, 53, 50 and 25% at 2, 3, 5 and 10 years respectively. Use of a Rigiflex dilator and multiple dilations during the initial treatment improved efficacy. Overall perforation rate was only 2% (24/1358) of which only 1% required surgery. Use of multiple dilations led to increased perforation risk. The method of dilation used with regard to balloon size, pressure used, dilation times and single or multiple dilations varied in almost every study. CONCLUSIONS Pneumatic dilation is safer than commonly thought and efficacious, although multiple dilations will be needed over a lifetime in most patients. Standardisation of the technique should be attempted.
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Affiliation(s)
- D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
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Kopelman Y, Triadafilopoulos G. Endoscopy in the diagnosis and management of motility disorders. Dig Dis Sci 2011; 56:635-54. [PMID: 21286936 DOI: 10.1007/s10620-011-1584-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/14/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer). AIMS The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders. METHODS We performed a literature review in PubMed. RESULTS Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist. CONCLUSIONS This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.
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Affiliation(s)
- Yael Kopelman
- Stanford University School of Medicine, Stanford, CA, USA
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30
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Overt bone metastasis and bone marrow micrometastasis of early gastric cancer. Surg Today 2011; 41:169-74. [PMID: 21264750 DOI: 10.1007/s00595-010-4389-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 07/30/2010] [Indexed: 02/07/2023]
Abstract
Recently we encountered two cases of early gastric cancer (EGC) with bone metastasis after surgery. As they were not accompanied by overt liver, lung, or peritoneal metastasis, we examined the clinical significance of bone metastasis in EGC and its mechanisms by a review of the literature. We found only 10 cases of EGC complicated with overt bone metastasis in the English literature, so we also examined the Japanese reports of such cases. The main histologic type of cases of bone metastasis from EGC was the diffuse type, and there were long intervals between surgery and overt bone metastasis. One reason for such long intervals may have been the tumor dormancy. Two types of dormancy, dynamic and static, and two types of postoperative overt metastases, that of micrometastatic origin (normograde metastatic process) and that of bone marrow origin (retrograde metastatic process), were considered. We speculated that there may be specific routes by which the cancer cells infiltrate the bone marrow directly from EGC or lymph node metastasis. The procedures for diagnosing bone micrometastasis using monoclonal antibodies have recently been improved, but their accuracy rates are still not universally accepted. New, more reliable examinations are required to improve the survival rates of EGC.
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31
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13-year follow-up of a prospective comparison of the long-term clinical efficacy of temporary self-expanding metallic stents and pneumatic dilatation for the treatment of achalasia in 120 patients. AJR Am J Roentgenol 2011; 195:1429-37. [PMID: 21098206 DOI: 10.2214/ajr.10.4407] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this article is to compare the efficacy of self-expanding metallic stents and pneumatic dilation for the long-term clinical treatment of achalasia. SUBJECTS AND METHODS Patients diagnosed with achalasia (n = 120) were allocated for treatment with pneumatic dilation (n = 30; group A) or a temporary self-expanding metallic stent with a diameter of 20 mm (n = 30; group B), 25 mm (n = 30; group C), or 30 mm (n = 30; group D). Data on clinical symptoms, complications, and long-term clinical outcomes were collected, and follow-up was performed at 6 months and at 1, 3-5, 5-8, 8-10, and more than 10 years after surgery. RESULTS Pneumatic dilation and stent placement were technically successful in all patients. The follow-up at more than 10 years revealed that the clinical remission rate in group D (83.3%) was higher than that in groups A (0%), B (0%), and C (28.6%), and the overall cumulative clinical failure rate in group D (13%) was lower than that in groups A (76.7%), B (53.3%), and C (26.7%). Patients in group D exhibited reduced dysphagia scores and lower esophageal sphincter pressures and had normal levels of barium height and width during the follow-up periods, whereas these markers increased with time in the other groups. The duration of primary patency in group D was also longer than that in groups A, B, and C. CONCLUSION A temporary self-expanding metallic stent with a diameter of 30 mm has superior clinical efficacy for the treatment of achalasia compared with pneumatic dilation or self-expanding metallic stents with diameters of 20 or 25 mm.
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32
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Novais PA, Lemme EMO. 24-h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy. Aliment Pharmacol Ther 2010; 32:1257-65. [PMID: 20955445 DOI: 10.1111/j.1365-2036.2010.04461.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The most effective treatment for achalasia is pneumatic dilation or myotomy. The best option is still controversial and incidence of complications could help choosing. Gastro-oesophageal reflux (GER) is the most frequent complication after treatment for achalasia. The 24-h pH monitoring (24-h pH) is the best method to evaluate true GER. AIM To analyse the 24-h pH patterns after treatment, correlating with therapeutic success. METHODS Untreated patients with achalasia were randomized to pneumatic dilation or laparoscopic Heller myotomy with fundoplication (LHM+Fp) and evaluated with clinical/manometric results and 24-h pH. RESULTS Ninety-four patients were analysed pre-treatment and 85 post-treatment. Clinical success was 73.8% in pneumatic dilation group and 88.3% in LHM+Fp group (P = 0.08). The incidence of GER was 31% in pneumatic dilation, and 4.7% in LHM+Fp (P = 0.001). The occurrence of hypotensive lower oesophageal sphincter (LES) was 53.3% in patients who developed GER and 28.6% in patients with 24-h pH suggesting fermentation (P = 0.019). The rates of dysphagia resolution in patients with 24-h pH of GER and fermentation were respectively 86.7% and 85.7% (P = 0.89). CONCLUSIONS True GER 24-h pH is more frequent after pneumatic dilation for achalasia, and it is associated with a hypotensive LES. A 24-h pH suggestive of fermentation or true GER is not associated with worse clinical/manometric results.
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Affiliation(s)
- P A Novais
- Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Brazil.
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Reynoso JF, Tiwari MM, Tsang AW, Oleynikov D. Does illness severity matter? A comparison of laparoscopic esophagomyotomy with fundoplication and esophageal dilation for achalasia. Surg Endosc 2010; 25:1466-71. [PMID: 20976492 DOI: 10.1007/s00464-010-1415-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 09/03/2010] [Indexed: 01/25/2023]
Abstract
INTRODUCTION There is scarce evidence regarding optimal treatment options for achalasia in patients with varying illness severity risk. The objective of this study was to evaluate and compare outcomes with laparoscopic esophagomyotomy with fundoplication (LM) and esophageal dilation (ED) for hospitalized patients with different illness severity. METHODS The University HealthSystem Consortium (UHC) is an alliance of more than 100 academic medical centers and nearly 200 affiliate hospitals. UHC's Clinical Data Base/Resource Manager (CDB/RM) allows member hospitals to compare patient-level risk-adjusted outcomes for performance improvement purposes. The CDB/RM was queried for patients with achalasia who underwent LM (n=1,390) or ED (n=492) during a 3-year period between 2006 and 2008. RESULTS Overall esophageal perforation rates were significantly higher for ED (0.4% LM vs. 2.4% ED; p<0.001). Patients undergoing LM with minor/moderate illness severity showed higher morbidity (9.42% LM vs. 5.15% ED; p<0.05). However, LM patients in this illness severity group showed significantly lower 30-day readmission rate (0.38% LM vs. 7.32% ED; p<0.001) and length of stay (2.23±1.78 LM vs. 4.88±4.42 days ED; p<0.001), but comparable cost ($9,539 LM vs. $8990 ED; p>0.05). In the major/extreme illness severity group mortality was comparable (1.37% LM vs. 2.44% ED; p>0.05). Overall morbidity was significantly greater in LM (50.48% LM vs. 19.57% ED; p<0.001). However, the length of stay was significantly increased in the ED group (8.96±7.86 LM vs. 11.72±11.05 days ED; p=0.04). CONCLUSION In hospitalized patients with minor/moderate illness severity, laparoscopic myotomy for achalasia showed comparable or better outcomes than ED. For major/extreme illness severity, dilation showed comparable or better profile for hospitalized achalasia patients. These results highlight the importance and impact of illness severity on outcomes of achalasia patients.
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Affiliation(s)
- Jason F Reynoso
- Department of Surgery, University of Nebraska, University of Nebraska Medical Center, Omaha, NE, USA.
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Li YD, Cheng YS, Li MH, Chen NW, Chen WX, Zhao JG. Temporary self-expanding metallic stents and pneumatic dilation for the treatment of achalasia: a prospective study with a long-term follow-up. Dis Esophagus 2010; 23:361-7. [PMID: 20353447 DOI: 10.1111/j.1442-2050.2010.01048.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The present study compares the efficacy of a self-expanding metallic stent (SEMS, diameter of 30 mm) and pneumatic dilation for the long-term clinical treatment of achalasia. A total of 155 patients diagnosed with achalasia were allocated for pneumatic dilation (n= 80, group A) or a temporary, 30-mm diameter SEMS (n= 75, group B). The SEMSs were placed under fluoroscopic guidance and removed by gastroscopy 4-5 days after placement. Data on clinical symptoms, complications, and long-term clinical outcomes were collected, and follow-up observations were performed at 6 months and at 1, 3-5, 5-8, 8-10, and >10 years, postoperatively. Pneumatic dilation and stent placement were technically successful in all of the patients. There were no significant differences in technique success, 30-day mortality, or complications between the two groups. The clinical remission rate in group A was significantly lower than that in group B at 1, 1-3, 3-5, 5-8 and, >10 years (P < 0.05), while the cumulative clinical failure rate in group A (66%, 53/80) was higher than that in group B (92%, 6/75). The mean primary patency in group B was significantly longer than that in group A (4.2 vs 2.1 years, respectively; P < 0.001). A temporary, 30-mm diameter SEMS was associated with a better long-term clinical efficacy in the treatment of patients with achalasia as compared with treatment with pneumatic dilation.
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Affiliation(s)
- Y-D Li
- Department of Diagnostic and Interventional Radiology, The Sixth Affiliated People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Horisoko E, Tsushima Y, Taketomi-Takahashi A, Tokunaga M, Endo K. Essential pre-treatment imaging examinations in patients with endoscopically-diagnosed early gastric cancer. BMC Med Inform Decis Mak 2010; 10:33. [PMID: 20534137 PMCID: PMC2906417 DOI: 10.1186/1472-6947-10-33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 06/09/2010] [Indexed: 12/29/2022] Open
Abstract
Background There have been no reports discussing which imaging procedures are truly necessary before treatment of endoscopically-diagnosed early gastric cancer (eEGC). The aim of this pilot study was to show which imaging examinations are essential to select indicated treatment or appropriate strategy in patients with eEGC. Methods In 140 consecutive patients (95 men, 45 women; age, 66.4 +/- 11.3 years [mean +/- standard deviation], range, 33-90) with eEGC which were diagnosed during two years, the pre-treatment results of ultrasonography (US) and contrast-enhanced computed tomography (CT) of the abdomen, barium enema (BE) and chest radiography (CR) were retrospectively reviewed. Useful findings that might affect indication or strategy were evaluated. Results US demonstrated useful findings in 13 of 140 patients (9.3%): biliary tract stones (n = 11) and other malignant tumors (n = 2). Only one useful finding was demonstrated on CT (pancreatic intraductal papillary mucinous tumor) but not on US (0.7%; 95% confidential interval [CI], 2.1%). BE demonstrated colorectal carcinomas in six patients and polyps in 10 patients, altering treatment strategy (11.4%; 95%CI, 6.1-16.7%). Of these, only two colorectal carcinomas were detected on CT. CR showed three relevant findings (2.1%): pulmonary carcinoma (n = 1) and cardiomegaly (n = 2). Seventy-nine patients (56%) were treated surgically and 56 patients were treated by endoscopic intervention. The remaining five patients received no treatment due to various reasons. Conclusions US, BE and CR may be essential as pre-treatment imaging examinations because they occasionally detect findings which affect treatment indication and strategy, although abdominal contrast-enhanced CT rarely provide additional information.
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Affiliation(s)
- Eri Horisoko
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
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Tratamiento quirúrgico de la acalasia: ¿mejor que las dilataciones? GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:653-61. [DOI: 10.1016/j.gastrohep.2009.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 02/13/2009] [Indexed: 01/22/2023]
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Kilic A, Schuchert MJ, Pennathur A, Gilbert S, Landreneau RJ, Luketich JD. Long-term outcomes of laparoscopic Heller myotomy for achalasia. Surgery 2009; 146:826-31; discussion 831-3. [PMID: 19789044 DOI: 10.1016/j.surg.2009.06.049] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Accepted: 06/12/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND Short-term outcomes of laparoscopic Heller myotomy (LHM) for achalasia have been excellent, although the long-term durability of this operation remains to be established. The aim of this study was to evaluate the long-term outcomes of LHM. METHODS A single-institution review of patients undergoing LHM between 1992 and 2003 with > or =5 years follow-up. Failure was defined as symptom recurrence requiring reoperation. Univariate and multiple regression analysis were performed to identify preoperative variables predictive of long-term success. RESULTS A total of 46 patients underwent LHM with Toupet (n = 42) or Dor (n = 4) fundoplication. At a mean follow-up of 6.4 years, 37 (80%) patients remained free from failure. Mean time to symptom recurrence in those failing LHM was 21.3 months (range, 0.5-77). Causes of failure included nonfunctioning end-stage esophagus (n = 4), fibrotic narrowing at the gastroesophageal junction (n = 4), and tight wrap (n = 1). Univariate analysis identified high preoperative lower esophageal sphincter pressure (LESP), no prior therapy, short duration of symptoms, and absence of sigmoidal esophagus as predictors of long-term success (P < or = .044 each). High LESP remained the only predictor of long-term durability in multiple regression analysis (P = .043). Reoperations included redo myotomy (n = 2), esophagectomy (n = 6), or both (n = 1). At final follow-up, 44 (96%) patients reported significant symptom improvement compared with pre-LHM severity. CONCLUSION LHM is associated with an 80% long-term success rate. Successful LHM may be predicted by high LESP, no prior therapy, short symptom duration, or absence of sigmoidal esophagus. In this series, failures of LHM underwent reoperation (redo myotomy or esophagectomy) with good results.
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Affiliation(s)
- Arman Kilic
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Namikawa T, Hanazaki K. Clinicopathological features of early gastric cancer with duodenal invasion. World J Gastroenterol 2009; 15:2309-13. [PMID: 19452571 PMCID: PMC2684595 DOI: 10.3748/wjg.15.2309] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The incidence of early gastric cancer (EGC) with duodenal invasion is extremely low, although advanced gastric cancer that arises in the antrum occasionally invades the duodenum. We investigated the clinicopathological features of EGC with duodenal invasion and provided strategies for clinical management. A Medline search was performed using the keyword “early gastric cancer” and “duodenal invasion”. Additional articles were obtained from references within the papers identified by the Medline search. We revealed that EGC with duodenal invasion was of the superficial spreading type of tumor. Tumors > 60 mm in size invaded the duodenum more extensively, and the distance of duodenal invasion from the pyloric ring was further in the elevated type than in the depressed type of tumor. There was no significant difference between the length of duodenal invasion and the histological type of the tumor. Gastric cancer located adjacent to the pyloric ring, even if cancer invasion was confined to the mucosa or submucosa, was more likely to invade the duodenum. The present study reveals that the elevated type of EGC is associated with more extensive duodenal invasion when the tumor size is > 60 mm, thus highlighting the importance of identification of duodenal invasion in these cases. We also reveal that sufficient duodenal resection with a cancer-free distal surgical margin should be performed in cases of duodenal invasion.
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Zhao JG, Li YD, Cheng YS, Li MH, Chen NW, Chen WX, Shang KZ. Long-term safety and outcome of a temporary self-expanding metallic stent for achalasia: a prospective study with a 13-year single-center experience. Eur Radiol 2009; 19:1973-80. [PMID: 19296113 PMCID: PMC2705705 DOI: 10.1007/s00330-009-1373-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Accepted: 12/22/2008] [Indexed: 02/06/2023]
Abstract
To prospectively evaluate the long-term clinical safety and efficacy of a newly designed self-expanding metallic stent (SEMS) in the treatment of patients with achalasia. Seventy-five patients with achalasia were treated with a temporary SEMS with a 30-mm diameter. The SEMSs were placed under fluoroscopic guidance and removed by gastroscopy 4–5 days after stent placement. Follow-up data focused on dysphagia score, technique and clinical success, clinical remissions and failures, and complications and was performed at 6 months, 1 year, and within 3 to 5 years, 5 to 8 years, 8 to 10 years, and >10 years postoperatively. Stent placement was technically successful in all patients. Complications included stent migration (n = 4, 5.33%), chest pain (n = 28, 38.7%), reflux (n = 15, 20%), and bleeding (n = 9, 12%). No perforation or 30-day mortality occurred. Clinical success was achieved in all patients 1 month after stent removal. The overall remission rates at 6 months, 1, 1–3, 3–5, 5–8, 8–10, and >10 year follow-up periods were 100%, 96%, 93.9%, 90.9%, 100%, 100%, and 83.3%, respectively. Stent treatment failed in six patients, and the overall remission rate in our series was 92%. The median and mean primary patencies were 2.8 ± 0.28 years (95% CI: 2.25–3.35) and 4.28 ± 0.40 years (95% CI: 3.51–5.05), respectively. The use of temporary SEMSs with 30-mm diameter proved to be a safe and effective approach for managing achalasia with a long-term satisfactory clinical remission rate.
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Affiliation(s)
- Jun-Gong Zhao
- Department of Radiology, The Tenth Affiliated People's Hospital, Shanghai Tong Ji University, No. 301, Middle Yan Chang Road, Shanghai, China
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Tuset JA, Luján M, Huguet JM, Canelles P, Medina E. Endoscopic pneumatic balloon dilation in primary achalasia: predictive factors, complications, and long-term follow-up. Dis Esophagus 2008; 22:74-9. [PMID: 19021691 DOI: 10.1111/j.1442-2050.2008.00874.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pneumatic dilation (PD) has been widely used in the treatment of idiopathic achalasia with a 70-90% response. The aim of this study was to evaluate the effectiveness of PD and its predictive factors by means of clinical assessment. In addition, we evaluated its safety and the need for subsequent surgical intervention. Fifty-six patients were treated with a Witzel dilator. The response was evaluated at medium (1-5 years) and long term (>5 years). Diverse possible predictive factors to response were analyzed. After the first PD, 85.7% of the 56 patients improved and passed from clinical stage II-III to clinical stage 0-I (P < 0.005). After the second dilation, 84.6% of the patients (13) passed to clinical stage 0-I (P < 0.05). Only patients who were not young (>40 years) avoided a second dilation and/or surgery (P < 0.001). During the first 5 years of follow-up, 80% of patients maintained their response; this percentage decreased to 58% after 10 years. PD therapy of achalasia is a safe technique, with few adverse effects (4% perforations and 10% gastroesophageal reflux). It offers a medium-term response of 80% and long-term response of around 60%. Age was the only predictive response factor.
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Affiliation(s)
- J A Tuset
- Digestive Disease Unit, General University Hospital of Valencia, Valencia, Spain
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Chuah SK, Hu TH, Wu KL, Chen TY, Changchien CS, Lee CM. The role of barium esophagogram measurements in assessing achalasia patients after endoscope-guided pneumatic dilation. Dis Esophagus 2008; 22:163-8. [PMID: 19018853 DOI: 10.1111/j.1442-2050.2008.00888.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Only a few studies have been performed comparing subjective symptom improvements with objective improvement in esophageal emptying after pneumatic dilation (PD), and discrepancy existed. We evaluated whether esophagogram measurements adds to the traditional subjective symptoms scores in assessing achalasia patients after PD. We enrolled 32 new patients with achalasia who received endoscope-guided PD treatment between January 1998 and June 2004. Postdilation investigations were performed by using esophageal emptying on esophagogram prospectively in a blinded manner, along with symptom scores before and after PD at the initial investigation, 6 weeks later, and every 1 year thereafter. Our results showed that seven patients who noted complete relief showed less than 50% improvement in barium column height and esophageal diameter. There was no linear correlation between the degree of patient symptom improvement and esophageal emptying measured by esophagogram (r = 0.181, P = 0.322). A trend of association existed in the relationship between clinical remissions and initial post-PD esophageal emptying improvement (P = 0.067). In summary, the association between the post-PD symptom score improvement and degrees of esophageal emptying may be hampered by the small sample size in the current study. An additional objective parameter like esophagogram to the subjective symptom scores may be more optimal in assessing clinical remissions.
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Affiliation(s)
- S-K Chuah
- Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan
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Yi A, Shin JH, Song HY, Jung HY, Lee GH, Yoon CJ, Choi E, Kim KR, Kim JH. Esophageal achalasia: comparison of fluoroscopically-guided double vs. endoscopically-guided single balloon dilation. ACTA ACUST UNITED AC 2008; 33:177-82. [PMID: 17334874 DOI: 10.1007/s00261-007-9199-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE To compare the long-term clinical effectiveness of fluoroscopically guided double and endoscopically guided single balloon dilations in esophageal achalasia. MATERIALS AND METHODS Thirty-two fluoroscopically guided balloon dilations were performed in 21 patients (group A) and 48 endoscopically guided balloon dilations were performed in 37 patients (group B). The double balloon dilation technique (10 + 20-mm, 15 + 20-mm or 20 + 20-mm in diameter), with preceding single balloon dilation (10, 15, or 20-mm in diameter), was used in group A, whereas the single balloon dilation technique (30, 35, or 40-mm in diameter) with gradually increased internal pressure was used in group B. Technical success, clinical success, complications, and primary/secondary patency rates were compared between the two groups. RESULTS All procedures were technically successful without esophageal perforation. Clinical success was achieved in 97% (31/32) and 92% (44/48) of balloon dilations in groups A and B, respectively. The symptomatic improvement in dysphagia was significantly higher in group A than in group B. Incidence of complications was the same (18.8%) in both groups. Group A showed significantly longer primary and secondary patency periods than did group B (P < 0.05). CONCLUSION Fluoroscopically guided double balloon dilation has greater long-term effectiveness than endoscopically guided single balloon dilation in the treatment of esophageal achalasia.
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Affiliation(s)
- Ann Yi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-2dong, Songpa-gu, Seoul, 138-736, South Korea
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Kilic A, Schuchert MJ, Pennathur A, Landreneau RJ, Alvelo-Rivera M, Christie NA, Gilbert S, Abbas G, Luketich JD. Minimally invasive myotomy for achalasia in the elderly. Surg Endosc 2007; 22:862-5. [PMID: 18027037 DOI: 10.1007/s00464-007-9657-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 08/17/2007] [Accepted: 10/09/2007] [Indexed: 01/25/2023]
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Karanicolas PJ, Smith SE, Inculet RI, Malthaner RA, Reynolds RP, Goeree R, Gafni A. The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia. Surg Endosc 2007; 21:1198-206. [PMID: 17479318 DOI: 10.1007/s00464-007-9364-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Revised: 02/02/2007] [Accepted: 02/27/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND The two main treatment options for esophageal achalasia are laparoscopic distal esophageal myotomy (LM) and pneumatic dilatation (PD). Our objective was to compare the costs of these management strategies. METHODS We constructed a decision analytic model consisting of two treatment strategies for patients diagnosed with achalasia. Probabilities of events were systematically derived from a literature review, supplemented by expert opinion when necessary. Costs were estimated from the perspective of a third-party payer and society, including both direct and indirect costs. Future costs were discounted at a rate of 5.5% over a time horizon of 5 and 10 years. Uncertainty in the probability estimates was incorporated using probabilistic sensitivity analyses. We tested uncertainty in the model by modifying key assumptions and repeating the analysis. RESULTS From the societal perspective, the expected cost per patient was $10,789 (LM) compared with $5,315 (PD) five years following diagnosis, and $11,804 (LM) compared with $7,717 (PD) after 10 years. The 95% confidence interval of the incremental cost per patient treated with LM was ($5,280, $5,668) after five years, and ($3,863, $4,311) after 10 years. The incremental cost of LM was similar from the third-party payer perspective and in the secondary model analyzed. CONCLUSIONS Initial LM is a more costly management strategy under all clinically plausible scenarios tested in this model. Further research is needed to determine patients' preferences for the two treatment modalities, and society's willingness to bear the incremental cost of LM for those who choose it.
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Affiliation(s)
- Paul J Karanicolas
- Department of Surgery, The University of Western Ontario, London, Canada.
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Treatment of Esophageal Achalasia - Pneumatic Dilatation Vs Surgical Procedure. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0107-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone. Ann Surg 2006; 243:579-84; discussion 584-6. [PMID: 16632991 PMCID: PMC1570551 DOI: 10.1097/01.sla.0000217524.75529.2d] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Heller myotomy has been shown to be an effective primary treatment of achalasia. However, many physicians treating patients with achalasia continue to offer endoscopic therapies before recommending operative myotomy. Herein we report outcomes in 209 patients undergoing Heller myotomy with the majority (74%) undergoing myotomy as secondary treatment of achalasia. METHODS Data on all patients undergoing operative management of achalasia are collected prospectively. Over a 9-year period (1994-2003), 209 patients underwent Heller myotomy for achalasia. Of these, 154 had undergone either Botox injection and/or pneumatic dilation preoperatively. Preoperative, operative, and long-term outcome data were analyzed. Statistical analysis was performed with multiple chi and Mann-Whitney U analyses, as well as ANOVA. RESULTS Among the 209 patients undergoing Heller myotomy for achalasia, 154 received endoscopic therapy before being referred for surgery (100 dilation only, 33 Botox only, 21 both). The groups were matched for preoperative demographics and symptom scores for dysphagia, regurgitation, and chest pain. Intraoperative complications were more common in the endoscopically treated group with GI perforations being the most common complication (9.7% versus 3.6%). Postoperative complications, primarily severe dysphagia, and pulmonary complications were more common after endoscopic treatment (10.4% versus 5.4%). Failure of myotomy as defined by persistent or recurrent severe symptoms, or need for additionally therapy including redo myotomy or esophagectomy was higher in the endoscopically treated group (19.5% versus 10.1%). CONCLUSION Use of preoperative endoscopic therapy remains common and has resulted in more intraoperative complications, primarily perforation, more postoperative complications, and a higher rate of failure than when no preoperative therapy was used. Endoscopic therapy for achalasia should not be used unless patients are not candidates for surgery.
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Affiliation(s)
- C Daniel Smith
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Abstract
PURPOSE OF THIS REVIEW This article reviews the most notable results of esophageal interventions for dysphagia and bleeding published in 2005. RECENT FINDINGS Long-term rubber tube placement was shown to be an interesting treatment option for difficult esophageal strictures. Two studies demonstrated that only 50% of patients who had undergone pneumatic dilation for achalasia were dysphagia-free after long-term follow-up. It was shown that patients with dysphagia from esophageal cancer should be treated by intraluminal radiotherapy (brachytherapy), whereas stent placement was preferable in those with a poor prognosis. Temporary stent placement is an option in patients undergoing radiotherapy for inoperable esophageal cancer to increase the dysphagia-free period. Two studies were published on the successful use of silicone-covered plastic stents for sealing of leaks after surgery of the esophagus. The optimal treatment for bleeding varices was confirmed to be endoscopic band ligation. A meta-analysis demonstrated that adding sclerotherapy to band ligation for secondary prophylaxis of bleeding varices had no effect on clinical outcome. SUMMARY In 2005, new techniques for the treatment of complicated strictures were presented. In addition, expanding indications for stents were reported. Finally, endoscopic band ligation was confirmed to be the most optimal technique for the treatment of varices.
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Affiliation(s)
- Peter D Siersema
- Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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