Analysis of Clinical Features and Factors Predictive of Malignancy in Intraductal Papillary Mucinous Tumor of the Pancreas: Multi-center Analysis in Korea / 한국간담췌외과학회지

BACKGROUND/AIMS: Despite of increasing numbers of reports on intraductal papillary mucinous tumor (IPMT), there is still difficulty in its' diagnosis, treatment and prediction of prognosis. The purpose of this multicenter study was to evaluate the clinico-pathological features of IPMT in Korea and suggest the prediction criteria of malignancy in IPMT. METHODS: We retrospectively reviewed the clinico-pathological data of 208 patients who underwent operations with IPMT between 1993 and 2002 at 28 institutes in Korea. RESULTS: Of the 208 patients with a mean age of 60.5+/-9.7 years, 147 were men and 61 were women. 124 patients underwent pancreatoduodenectomy, 42 distal pancreatectomy, 17 total pancreatectomy, 25 limited pancreas resection. Benign cases were 128 (adenoma (n=62), borderline (n=66)) and malignant cases were 80 (non-invasive (n=29), invasive (n=51)). A significant difference in 5-year survival was observed between benign and malignant group (92.6% vs. 65.3%; p=0.006). Of the 6 factors (age, location, duct dilatation, tumor appearance, main duct type, and tumor size) that showed the statistical difference in univariate analysis between benign and malignant group, we found three significant factors (tumor appearance (p=0.009), tumor size (p=0.023), and dilated duct size (p=0.010)) by multivariate analysis. CONCLUSION: Although overall prognosis of IPMT is superior to ordinary pancreatic cancer, more curative surgery is recommended in malignant IPMT. Tumor appearance (papillary), tumor size (> or =30 mm) and dilated duct size (> or = 12 mm) can be used as preoperative indicators of malig-nancy in IPMT.

Abnormal Fragile Histidine Triad Gene Expression in Gastric Cancer

PURPOSE: Genomic alterations and abnormal expression of the fragile histidine triad (FHIT) gene in gastric cancer were examined to determine whether the FHIT gene is actually a frequent target for alteration during gastric carcinogenesis. MATENRIALS AND METHODS: To correlate DNA and RNA lesions of the FHIT gene with the effect on FHIT protein expression, in 40 gastric cancers, we investigated the FHIT gene for loss of heterozygisity (LOH), aberrant transcripts, and protein expression. RESULTS: Allelic loss at D3S1300 was detected in 7 of 38 (19%) informative cases. Aberrant transcripts were observed in 20 of 40 (50%) cases. Significant reduction of FHIT protein expression was observed in 22 of 40 (55%) cases. Aberrant FHIT transcription was shown to be associated with loss of FHIT protein expression. However, aberrent FHIT transcripts themselves were not associated with any clinicopathological parameters, such as age, sex, tumor site, or clinical stage. Moreover, there was no association between the presence of LOH at D3S1300 and the expression of aberrant FHIT transcripts. CONCLUSION: The high frequency of aberrant FHIT transcripts, the significant rate of LOH at D3S1300, and the altered expression of the FHIT protein indicate that alterations of the FHIT gene can play an important role in gastric carcinogenesis.

A Case of Malignant Melanoma Presenting as a Breast Mass / 한국유방암학회지

Malignant melanomas arising in the skin, buccal mucous membranes. and retina are encountered frequently. A malignant melanoma characteristically disseminates widely but infrequently metastasizes to the breast, and primary melanoma of the breast is even rarer. Primary melanomas can arise in the glandular tissue of the breast. We report a case of malignant melanoma either primary in the breast or metastatic from an unknown primary that presented initially as a left breast mass without a detectable cutaneous lesion.

Surgical Results for Perforated Gastric Cancer

PURPOSE: Perforated gastric cancer (PGC) is rare and occurs in 1~4% of all gastric cancers. Possible dissemination of tumor cells at the time of perforation of the gastric carcinoma has been a matter of concern. The intraoperative determination of what kind of operation should be done and how extensive the lymphnode dissection should be still remains controversial. The purpose of this study is to evaluate the factors influencing the survival and to determine the optimal treatment for PGC. MATENRIALS AND METHODS: A total of 42 patients were operated on for a perforated gastric carcinoma at Soonchunhyang University Chunan Hospital from 1983 to 2000. the age and the sexes of the patients, the location of perforation, the diameter of perforation, the histologic type of the tumor, the depth of wall invasion, the absence or presence of lymph node metastasis / distant metastasis, the stage of disease, the type of operation, and the outcomes were examined. Statistically significant differences were analyzed by using Fisher's exact test. RESULTS: The stage distributions according to the UICC classification were 1 case of stage I, 6 cases of stage II, 17 cases of stage III, and 11 cases of stage IV. An emergency gastrectomy was done in 26 patients (61.9%), with a 5-yr survival rate of 44%. The survival of patients was significantly influenced by the depth of wall invasion, the lymphnode metastasis, distant metastasis, the stage of disease, and the type of operation. CONCLUSION: an emergency gastrectomy is the treatment of choice for most patients with resectable PGC. Choosing more a optimistic surgical approach for potentially curative cases of PGC should be one way to increase the patient's survival rate.

Analysis of Factors Influencing Morbidity and Mortality after Pancreaticoduodenectomy

PURPOSE: The surgical morbidity and mortality after a pancreaticoduodenectomy has been decreasing but still remains high. The most serious complications are pancreatic leakage, gastrointestinal or intra-abdominal hemorrhage, and an intraabdominal abscess. The less serious complications are delayed gastric emptying and wound problems. The aim of this study was to evaluate the risk factors for morbidity and mortality after a pancreaticoduodenectomy. METHODS: Among 90 patients who underwent pancreaticoduodenectomy from Feb. 1992 to Dec, 2000. 68 patients whose hospital records could be reviewed thoroughly were enrolled in this study. The postoperative morbidity and mortality after a pancreaticoduodenal resection were evaluated in terms of the patient's age, combined disease, laboratory values, biliary drainage, transfusion, types of pancreaticojejunostomy, pancreatic duct size, consistency, and the administration of octreotide. Univariate and multivariate analysis were performed with a chi-square test and multiple logistic regression test. RESULTS: Postoperative complications were observed in 43 cases (63.2%). Wound complications were noted in 13 cases (19.1%), gastric emptying disturbance in 10 cases (14.7%), bleeding in 9 cases (13.2%), an abscess in 4 cases (5.9%), and leakage in 22 cases (32.4%). Nine cases (13.2%) had died. The causes of death were sepsis due to leakage in 3 cases, bleeding in 3 cases, and others causes in 3 cases. Univariate analysis showed that diabetes mellitus was significantly (P<0.05) related to delayed gastric emptying. In multivariate analysis, transfusion was significantly (P<0.05) related to wound infections and mortality. Old age ( 65 years) was significantly related to leakage and delayed gastric emptying. CONCLUSION: Pancreaticoduodenectomy is still associated with a high mortality and morbidity rate even though there has been significant progress in the field of pancreatic surgery and postoperative follow-up. Old age and transfusions appeared to be the main risk factors for morbidity and mortality after a pancreaticoduodenectomy in this study. In addition to these factors, better anticipation and management of the postoperative complications is essential for improving the surgical outcome.

Clinical Correlation of c-erbB-2, p53, bcl-2, and c-myc Expression in Patients with Breast Cancer / 한국유방암학회지

PURPOSE: Breast cancer is a common malignant tumor in Korean women. Various oncogenes have been demonstrated in malignant tumor cells. There were many reports on the relationship between the prognosis and the tumor markers, particularly c-erbB-2, p53, bcl-2, and c-myc. However, this relationship is controversial. The aim of this study was to perform immunohistochemical staining for the c-erbB-2, p53, bcl-2, and c-myc antigenic protein in breast cancer patients, to evaluate the expression rate of each antigen, and to compare the correlations with the patients' prognosis. METHODS: The medical records of 80 patients who were diagnosed with breast cancer and who were treated with a mastectomy between January 1993 and December 1996 at Soonchunhyang University Chunan Hospital were selected according to the condition of the paraffin block fixation. The prognostic factors were investigated. The immunohistochemical expression of c-erbB-2, p53, bcl-2, and c-myc was examined and compared with the survival rate using a Kaplan-Meier estimate and a log rank test. RESULTS: Eighty patients (79 females, 1 male) were included in this study, with a mean (SD) age of 48.2 (10.6) years and follow-up duration of 59.9 (24.9) months. The overall mortality was 41.3 (33/80)% and the mean (SD) survival time was 77 (4) months. The overall 5-year survival rate was 63.3%. Among the study variables, the tumor stage was a significant predictor of survival showing a significantly low survival rate in tumor stage III. The tumor size and lymph node metastasis were significantly associated with the survival rate in patients with breast cancer. CONCLUSION: c-erbB-2, p53, bcl-2, and c-myc might be useful prognostic factors, even though a statistical significance was not achieved.

Clinical Correlation of c-erbB-2, p53, bcl-2, and c-myc Expression in Patients with Breast Cancer

PURPOSE: Breast cancer is a common malignant tumor in Korean women. Various oncogenes have been demonstrated in malignant tumor cells. There were many reports on the relationship between the prognosis and the tumor markers, particularly c-erbB-2, p53, bcl-2, and c-myc. However, this relationship is controversial. The aim of this study was to perform immunohistochemical staining for the c-erbB-2, p53, bcl-2, and c-myc antigenic protein in breast cancer patients, to evaluate the expression rate of each antigen, and to compare the correlations with the patients' prognosis. METHODS: The medical records of 80 patients who were diagnosed with breast cancer and who were treated with a mastectomy between January 1993 and December 1996 at Soonchunhyang University Chunan Hospital were selected according to the condition of the paraffin block fixation. The prognostic factors were investigated. The immunohistochemical expression of c-erbB-2, p53, bcl-2, and c-myc was examined and compared with the survival rate using a Kaplan-Meier estimate and a log rank test. RESULTS: Eighty patients (79 females, 1 male) were included in this study, with a mean (SD) age of 48.2 (10.6) years and follow-up duration of 59.9 (24.9) months. The overall mortality was 41.3 (33/80)% and the mean (SD) survival time was 77 (4) months. The overall 5-year survival rate was 63.3%. Among the study variables, the tumor stage was a significant predictor of survival showing a significantly low survival rate in tumor stage III. The tumor size and lymph node metastasis were significantly associated with the survival rate in patients with breast cancer. CONCLUSION: c-erbB-2, p53, bcl-2, and c-myc might be useful prognostic factors, even though a statistical significance was not achieved.

Clinical Results and Histologic Change on Animal Model with Modified Uncut Roux Reconstruction after Gastrectomy

PURPOSE: The uncut Roux operation prevents the Roux stasis syndrome by preserving neuromuscular continuity between the proximal jejunum and the Roux limb, but this technique has an unacceptably high incidence of dehiscence of the staple lines with subsequent reflux gastritis or esophagitis. The authors designed a modified uncut procedure to avoid dehiscence of the staple lines. The aim of this study was to review whether this technique might be useful by examining the histologic change on animal study and the postoperative radiologic study of patients with modified uncut reconstruction. METHODS: Between February 1997 and December 2000, the UGI study was reviewed in 213 patients undergoing the modified uncut Roux reconstruction at Soonchunhyang University Hospital, Chunan, Korea, at 2 and 8 weeks after operation, to evaluate the incidence of dehiscence and the leakage of staple lines. Animal study included ten pigs, 5 underwent conventional uncut Roux procedure with staple, while the other 5 received reinforcing whole layer suture with black silk on the staple lines. The animals then underwent a second operation at 15 days after operation to evaluate histologic change and dehiscence of staple lines. RESULTS: Dehiscence and leakage were not found in any of the 213 patients undergoing modified uncut Roux reconstruction. In the animal study, 2 of 5 cases (40%) receiving conventional uncut Roux reconstruction had dehiscence, whereas dehiscence was absent in all 5 cases receiving modified uncut Roux reconstruction and these 5 animals showed more marked infiltration of inflammatory cells, vascular formation and more severe fibrosis on histologic examination. CONCLUSION: The conventional uncut Roux procedure suffer dehiscence of the staple lines with subsequent reflux gastritis or esophagitis. Therefore, modified uncut Roux reconstruction might prevent a jejunal leakage in the case of staple line dehiscence and might prevent dehiscence of staple lines.

Surgical Treatment and Prognosis for Gastric Cancer in the Elderly

PURPOSE: The number of elderly patients who undergo surgery for gastric cancer has increased in recent years due to a life expectancy. To prevent fatal complications and increase the survival rate in gastric cancer patients, this study endeavored to clarify the risk factors contributing to postoperative complications in elderly patients undergoing a radical gastrectomy. METHODS: Between January 1997 and December 1998, 176 patients underwent a gastrectomy for gastric cancer. For this review, the patients were divided into two groups; 30 patients over 70 years of age (older group) and 102 patients below 70 years of age (younger group), were prepared. A retrospective study was performed to examine the factors related to the high rate of complications and to compare the operative and general complications. RESULTS: The incidences of preoperative combined disease were 56.6% in the older group and 31.3% in the younger group (p<0.05), but no significant difference in the incidence of postoperative complications (36.6% versus 38.2%) was found between the two groups. The most common postoperative complications were wound infections, pulmonary disorders, and intraabdominal infections. CONCLUSION: Despite the increased rate of preoperative combined disease in older patients, patients over 70 years are able to tolerate a radical gastrectomy for gastric cancer when optimal perioperative management is provided and blood loss is reduced.

Expression of E-Cadherin and alpha-Catenin in Patients with Colorectal Cancer

PURPOSE: E-cadherin plays a crucial role in cell-cell adhesion in epithelial tissues. The function of E-cadherin is thought to be regulated by its associated cytoplasmic proteins including alpha-catenin. Recent studies have shown a correlation between decreased E-cadherin and alpha-catenin expression and tumor invasion and metastasis. METHODS: We conducted an immunohistochemical staining of epithelial (E)-cadherin and alpha-catenin expression in 129 tissue samples taken from colorectal cancer patients undergoing surgical treatment by the avidin-biotin-peroxidase complex method. We classified tumors into three types according to the expression modality. Cancer cells with strong expression at the cell-cell boundaries were defined as two positive (++);, when the expression was positive, but not concentrated at the cell-cell boundaries and weak, they were defined as one positive (+);, and when the tumor showed no staining, they were defined as negative (-). The relationships between these three expression types and the clinicopathological features of colorectal cancer were investigated. RESULTS: The expression type of E-cadherin and alpha-catenin was two positive (++) in 5 and 20 of the cancer tissue specimens, one positive (+) in 66 and 56, and negative (-) in 58 (45%) and 53 (41.1%). Negative expression of E-cadherin and alpha-catenin were significantly correlated with tumor differentiation, Dukes'stage, and lymph node metastasis of the colorectal cancer patients (P<0.05). CONCLUSION: The expression type of E-cadherin is signifi-cantly corretated to that of alpha-catenin, and the loss of their expression indicates the invasion and metastasis of colorectal cancer. To predict tumor invasion and metastasis in colorectal carcinoma, it is useful to investigate both the expression of E-cadherin and of alpha-catenin.

Perforated Early Gastric Cancer: A case report

An exceedingly rare case of perforated early gastric cancer is reported. A 68-year-old man developed peritonitis due to perforation of early gastric cancer. An emergency radical operation was performed and was followed by an uneventful recovery. Histologic examination of the surgical specimen showed type III early gastric cancer composed of a signet ring cell carcinoma. Five years after surgery, the patients was alive with no evidence of tumor recurrence. The rarity of this complication in early gastric cancer is discussed, and a review of the literature is presented.

Expression of MMP-2 (Matrix Metalloproteinase Type 2) and TIMP-2 (Tissue Inhibitor of Metalloproteinase Type 2) in Color

PURPOSE: The matrix metalloproteinases (MMPs) have been implicated in proteolysis of basement membrane for initiation of metastatic cascade. Tissue inhibitors of metalloproteinases (TIMPs) are specific inhibitors of MMPs. The purpose of this study was to evaluate the expression of MMP-2 and TIMP-2 in human colorectal carcinomas. METHODS: The paraffin blocks of 140 colorectal carcinomas were recalled and immunostained with monoclonal antibodies specific for MMP-2 and TIMP-2. These antibodies were effective on formalin fixed, paraffin embedded sections. The rate of stain was estimated, and the relationships between the expression and the stage, the differentiation, lymph node metastasis, distant metastasis and the survival rate were assessed. RESULTS: MMP-2 was present in 31.4% of colorectal cancers. TIMP-2 was identified in 63.6% of tumors. The expression of MMP-2 was significantly associated with the presence of lymph-node metastasis, the stage, and the presence of distant metastasis. However the expression of TIMP-2 was not correlated with any risk factors. CONCLUSIONS: These results suggest that MMP-2 could predict the ability of cancer invasion and be used as a prognostic factor for the colorectal adenocarcinoma.

Clinical Analysis of Female Patients Under 20 Years of Age with Benign Breast Masses

BACKGROUND: Breast lesions in children and adolescents are rare and develop mainly in females. The management of breast masses in children and adolescents can be a perplexing problem for pediatricians and surgeons. It is well documented that breast lesions in females under 20 years of age rarely represent malignant disease. However, they frequently are a source of discomfort and anxiety for the patient, particularly when they do not resolve spontaneously. METHODS: To determine the frequency of different breast masses in females under 20 years of age on whom surgery was performed, we carried out a retrospective study of females under 20 years who were admitted to the Department. of Surgery of Soonchunhyang University Hospital for surgery between 1993 and 1995. RESULTS: The mean age was 17.9 years. A total of 44 surgical procedures were performed in 40 patients. The masses ranged in size from 0.8 cm through 7.0 cm. As to the location, the mass was in the right breast of 22 patients (50%) and in the left breast of 22 (50%). The most common location of the mass was in the right upper outer quadrant (13 patients, 29.5%). Of the 44 masses, fine-needle aspiration cytology was performed in 33 masses. Of them, 28 were fibroadenomas, 4 were fibrocystic disease, and 1 was a lipoma. Excisional biopsy was performed on 44 masses. Of them, 33 were fibroadenomas, 4 were fibrocystic disease, 5 was fibroadenoma and fibrocystic disease, 1 was a lipoma, and 1 was a lymphangioma. There were no malignancies. CONCLUSIONS: In female patients under 20 years of age, we suggest that benign breast should be studied for diagnosis, treatment, and histological feature.

Infra-red Thermography as a Predictor of Prognosis in Breast Cancer / 대한암학회지

PURPOSE: The purpose of this study is to analyze the usefulness of breast thermography in assessing the prognosis in breast cancer and to obtain correlative evidence between thermographic prognosis and prognostic factors for breast cancer. MATERIALS AND METHODS: Thermographic examinations were performed in a room maintained at 20C. The patient was undressed to the waist, with both arms elevated for 10 minutes prior to the examination in order to cool and equilibrate the breast skin at room temperature. Digital infrared thermographic system was used (NEC, San-ei, Therm Tracer 6T67). The thermographic prognosis was classified according to Dr. Hobbins (Sl good, S2=fair and S-poor) suggested by Dr. Hobbins. The results were analyzed by Chi-Squire. One hundred three patients of breast cancer were examined by digital infrared thermographic system between Jan 1992 and December 1996. RESULTS: The mean age was 48, with a range from 20 to 85. According to the TNM classification 25 (24%) were in stage I, 47 (46%) stage II, 29 (28%) stage III, and 2 (2%) stage IV. The tumor size ranged from 0.5 to 20 cm (mean 4 cm), On histologic examination, 43 (43.%) patients had metastasis in the axillary nodes, 40 (55%) patients was estrogen-receptor positive. The nuclear grade I was 46 (35%) patients, II 24 (28%) and III 16 (19%). The classification of thermographic prognosis were Sl in 47 cases (46%), 82 in 32 (31%) and 83 in 24 (23%). The classification of the thermographic prognosis was found to be statistically correlated with tumor size (p<0.0001), axillary node status (p<0.0001) and TNM tumor stage (p<0.0001). But nuclear grade and estrogen receptor were not statistically correlated with the thermographic prognosis. The correlation between thermographic prognosis and actual survival rate was not available. CONCLUSION: These results suggest that breast thermography would be useful as a predictor in breast cancer before surgery.