The Expression of Programmed Death-Ligand 1 on Immune Cells Is Related to a Better Prognosis in Biliary Tract Cancer

Background/Aims@#Programmed death-ligand 1 (PD-L1) expression in tumor cells is associated with a poor biliary tract cancer (BTC) prognosis; tumor-infiltrating immune cells in the tumor microenvironment are associated with a better prognosis. The effect of PD-L1 expression on immune cells on survival is unclear. We investigated the relationship between PD-L1 expression in immune cells and BTC prognosis. @*Methods@#PD-L1 expression was evaluated using an anti-PD-L1 22C3 mouse monoclonal primary antibody, and its relationships with clinical characteristics and prognosis were analyzed using the Cox proportional hazard model to investigate the prognostic performance of PD-L1 in BTC. @*Results@#Among 144 analyzed cases, patients with positive PD-L1 expression in tumor cells and negative PD-L1 expression in immune cells showed poorer overall survival rates than those exhibiting other expressions (tumor cells: hazard ratio [HR]=1.023, p<0.001; immune cells: HR=0.983, p=0.021). PD-L1 expression in tumor cells was an independent predictor of poor overall survival (HR=1.024, p<0.001). In contrast, PD-L1 expression in immune cells was a predictive marker of good prognosis (HR=0.983, p=0.018). @*Conclusions@#PD-L1 expression in immune cells may be used as an independent factor to evaluate the prognosis of patients with BTC.

Machine-Learning Model for the Prediction of Hypoxaemia during Endoscopic Retrograde Cholangiopancreatography under Monitored Anaesthesia Care

Purpose@#Hypoxaemia is a significant adverse event during endoscopic retrograde cholangiopancreatography (ERCP) under monitored anaesthesia care (MAC); however, no model has been developed to predict hypoxaemia. We aimed to develop and compare logistic regression (LR) and machine learning (ML) models to predict hypoxaemia during ERCP under MAC. @*Materials and Methods@#We collected patient data from our institutional ERCP database. The study population was randomly divided into training and test sets (7:3). Models were fit to training data and evaluated on unseen test data. The training set was further split into k-fold (k=5) for tuning hyperparameters, such as feature selection and early stopping. Models were trained over k loops; the i-th fold was set aside as a validation set in the i-th loop. Model performance was measured using area under the curve (AUC). @*Results@#We identified 6114 cases of ERCP under MAC, with a total hypoxaemia rate of 5.9%. The LR model was established by combining eight variables and had a test AUC of 0.693. The ML and LR models were evaluated on 30 independent data splits. The average test AUC for LR was 0.7230, which improved to 0.7336 by adding eight more variables with an l 1 regularisation-based selection technique and ensembling the LRs and gradient boosting algorithm (GBM). The high-risk group was discriminated using the GBM ensemble model, with a sensitivity and specificity of 63.6% and 72.2%, respectively. @*Conclusion@#We established GBM ensemble model and LR model for risk prediction, which demonstrated good potential for preventing hypoxaemia during ERCP under MAC.

Response to Neoadjuvant Therapy and Prognosis in Patients with Resectable Pancreatic Cancer: A Propensity Score Matching Analysis

Background/Aims@#Controversy regarding the effectiveness of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma (PDAC) still exists. Here, we aimed to identify the potential benefits of neoadjuvant therapy followed by surgery for resectable PDAC. @*Methods@#We reviewed radiologically resectable PDAC patients who received resection with curative intent at a tertiary hospital in South Korea between January 2012 and August 2019. A total of 202 patients underwent curative resection for resectable PDAC: 167 underwent surgical resection first during this period, and 35 received neoadjuvant chemotherapy/chemoradiation therapy followed by surgery. Resectable PDAC patients were subdivided, and 1:3 propensity score matching (PSM) was performed to reduce selection bias. @*Results@#Compared with the group that received surgery first, the group that received neoadjuvant treatment followed by surgery had significantly smaller tumors (22.0 mm vs 27.0 mm, p=0.004), a smaller proportion of patients with postoperative pathologic T stage (p=0.026), a smaller proportion of patients with lymphovascular invasion (20.0% vs 40.7%, p=0.022), and a larger proportion of patients with negative resection margins (74.3% vs 51.5%, p=0.049). After PSM, the group that received neoadjuvant therapy had a significantly longer progression-free survival than those in the group that underwent surgery first (29.6 months vs 15.1 months, p=0.002). Overall survival was not significantly different between the two groups after PSM analysis. @*Conclusions@#We observed significantly better surgical outcomes and progression-free survival with the addition of neoadjuvant therapy to the management of resectable PDAC. However, despite PSM, there was still selection bias due to the use of different regimens between the groups receiving surgery first and neoadjuvant therapy. Large homogeneous samples are needed in the future prospective studies.

Analysis of Clinical Predictive Factors Affecting the Outcome of Second-Line Chemotherapy for Gemcitabine-Refractory Advanced Pancreatic Cancer

Background/Aims@#The benefit of second-line chemotherapy (SL) after failed first-line chemotherapy (FL) in patients with advanced pancreatic cancer has not yet been established. We evaluated the clinical characteristics affecting the benefits of SL compared to best supportive care (BSC), identified the prognostic factors, and ultimately devised a model of clinical parameters to assist in making decision between SL and BSC after the failure of gemcitabine-based FL. @*Methods@#The records of patients who received gemcitabine-based FL for advanced pancreatic cancer at Yonsei University Hospital between January 2010 and December 2015 were retrospectively reviewed. Significant clinical parameters were assessed for their potential as predictive factors. @*Results@#SL patients received a longer duration of FL compared with BSC patients with median duration being 16.0 weeks (range, 8.0 to 26.0 weeks) and 8.0 weeks (range, 4.0 to 16.0 weeks), respectively (p<0.001). When the SL group was stratified by their modified overall survival (mOS) (longer and shorter than 6 months), we found significant differences for several clinical factors, namely, metastasis to the peritoneum (p<0.001), number of metastases (p<0.001), thrombotic events (p=0.003), and level of carbohydrate antigen 19-9 (CA19-9; p=0.011). In multivariate analysis, more than one site of metastasis, occurrence of thrombotic event during FL, and a CA19-9 level above 90 U/mL were significant independent prognostic factors for mOS in the SL group (p<0.05). When an attempt was made to devise a prognostic nomogram, Harrell’s C-index of the final prognosis prediction model was 0.62. @*Conclusions@#SL may be beneficial for patients without peritoneal metastasis or thrombotic events who have a single metastasis and a level of CA19-9 less than 90 U/mL. This prognostic nomogram can be used to predict mOS before the administration of SL after the failure of gemcitabine-based FL.

The Epidemiology and Trends of Primary Total Ankle Arthroplasty and Revision Procedure in Korea between 2007 and 2017

Background@#The aim of this study was to investigate the surgical trends of primary total ankle arthroplasty (TAA) and revision procedure in Korea from 2007 to 2017 using national population-based data. @*Methods@#We reviewed the National Health Insurance data of Korea from 2007 to 2017. The data included diagnosis codes, procedure codes, prescriptions, medical costs, and other demographic data. Trends of primary diagnosis for primary TAA were evaluated. Annual trends and incidences per 100,000 person-years of primary TAA and revision procedures as well as compound annual growth rate (CAGR) during the study period were analysed. Surgical trends according to patients' age, hospital grades, and insurance systems were also evaluated. @*Results@#Primary diagnosis for primary TAA was mostly degenerative arthritis (6,501 cases; 90.5%). From 2007 to 2017, the total number of cases of primary TAA and revision procedures was 7,183 and 585, respectively. The number of cases in 2007 of primary TAA was 313; there were no cases of revision. The number of cases in 2017 of primary TAA were 986 and of revision were 108. The CAGR during this period was 28.6% for primary TAA and 44.6% for revision procedures. Incidences per 100,000 person-years in 2017 were 1.91 for primary TAA and 0.21 for revision procedures. The average cost paid by patients themselves was USD 813 (19%) and by the National Health Insurance Service was USD 3,480 (81%). @*Conclusion@#The incidence of primary TAA and revision procedures steadily increases in Korea during the 11-year study period.

A Case of 47-Years-Old Female with Obstructive Jaundice and Weight Loss / 대한소화기암학회지

Serine protease inhibitor Kazal-type 1 (SPINK1) is a gene expressed from pancreatic acinar cell which its mutation is known to be associated with chronic pancreatitis (CP) and pancreatic cancer. We report a case of a 47-years-old female with nausea and weight loss with yellow discoloration of skin. Initial imaging and endoscopic study led us to an impression of chronic pancreatitis with pancreatic cancer with common bile-duct dilation. Biopsy result was confirmed with pancreatic adenocarcinoma and additional imaging revealed lymph node and bone metastasis. Our genetic analysis revealed 194+2T>C mutation of SPINK1. Biliary obstruction was successfully decompressed by stent insertion and underwent chemotherapy and radiotherapy. Although there is accumulating evidence of association between SPINK1 mutation and CP, the relationship between SPINK1 mutation and pancreatic cancer in CP patient is an emerging concept. Genetic analysis should be considered in patients with young age especially when diagnosed with both CP and pancreatic cancer.

Irreversible Electroporation in Patients with Pancreatic Cancer :Angel and Devil / 대한소화기암학회지

Pancreatic cancer has a very poor prognosis. Complete surgical resection remains the only current curative treatment. Locally advanced pancreatic cancer (LAPC) is considered as unresectable because of involvement of celiac and/or mesenteric vessels. The treatment of LAPC is a challenge. Current guidelines suggest systemic therapy. However, the majority of patients will never experience conversion to surgical resection. Thus, in these patients, ablation is an alternative therapy for local control, which causes local destruction while ideally avoiding injury to surrounding healthy tissue. Irreversible electroporation (IRE) is an energy delivery system, effective in ablating tumors by inducing irreversible membrane destruction of cells. IRE demonstrated to be safe in previous studies. However, it is not free from complications, even serious. Here, we reported two cases of the IRE in LAPC patients.

Distal Femoral Medial Opening Wedge Osteotomy for Post-Traumatic, Distal Femoral Varus Deformity

Restoration of neutral mechanical alignment of the lower limb is an important factor in the treatment of unicompartmental arthrosis. Traditionally, medial opening wedge high tibial osteotomy has been widely performed to correct varus malalignment with unicompartmental arthrosis. However, an ideal indication for the high tibial osteotomy is the knee with metaphyseal tibial varus malalignment. The basic principle of corrective osteotomy is performing an osteotomy at the center of the deformity to prevent abnormal joint line obliquity. If pathologic distal femoral varus deformity is the cause of genu varum, the osteotomy should be performed in the distal femur. Reports of medial opening wedge distal femoral osteotomy (DFO) to correct varus malalignment are rare. We present a case of this very rare and challenging condition in a 47-year-old male, which was successfully treated by medial opening wedge DFO.

Bleeding Complications and Clinical Safety of Endoscopic Retrograde Cholangiopancreatography in Patients with Liver Cirrhosis

PURPOSE: Patients with liver cirrhosis are considered to be at risk for additional adverse events during endoscopic retrograde cholangiopancreatography (ERCP). The present study was designed as a propensity-score matched analysis to investigate whether cirrhotic liver increases the risk of bleeding complications in patients undergoing ERCP. MATERIALS AND METHODS: In total, 8554 patients who underwent ERCP from January 2005 to December 2015 were retrospectively analyzed. To adjust for the imbalance between patients with and those without liver cirrhosis, 1:3 propensity score matching was performed according to age and sex. RESULTS: Liver cirrhosis was identified in 264 (3.1%) patients. After propensity score matching, a total of 768 patients were included in each of the cirrhotic (n=192) and non-cirrhotic groups (n=576). Post-procedure bleeding (10.9% vs. 4.7%, p=0.003) was more frequently observed in patients with liver cirrhosis than in those without. In multivariate analyses, liver cirrhosis was identified as an independent risk factor associated with post-ERCP bleeding (p=0.003) after further adjustment for prothrombin time, antiplatelet/coagulant, duration of ERCP, and stent insertion. Child-Pugh (CP) class C was found to be associated with an increased incidence of post-ERCP bleeding in patients with cirrhosis (odds ratio 6.144, 95% confidence interval 1.320–28.606; p=0.021). CONCLUSION: The incidence of post-ERCP bleeding in patients with liver cirrhosis was higher than that in patients without liver cirrhosis. In particular, CP class C cirrhosis was significantly associated with post-ERCP bleeding.

Gastrointestinal cancer risk in patients with a family history of gastrointestinal cancer / 대한소화기학회지

BACKGROUND/AIMS: This study was performed to evaluate the relationship between family history of gastrointestinal (GI) cancers and incidence of any GI cancer in the Korean population. METHODS: Between January 2015 and July 2016, 711 GI cancer patients and 849 controls in 16 hospitals in Korea were enrolled. Personal medical histories, life styles, and family history of GI cancers were collected via questionnaire. RESULTS: There was a significant difference in the incidence of family history of GI cancer between GI cancer patients and controls (p=0.002). Patients with family history of GI cancer tended to be diagnosed as GI cancer at younger age than those without family history (p=0.016). The family members of GI cancer patients who were diagnosed before 50 years of age were more frequently diagnosed as GI cancer before the age of 50 years (p=0.017). After adjusting for major confounding factors, age (adjusted odds ratio [AOR] 1.065, 95% confidence interval [CI]; 1.053–1.076), male gender (AOR 2.270, 95% CI; 1.618–3.184), smoking (AOR 1.570, 95% CI; 1.130–2.182), and sibling's history of GI cancer (AOR 1.973, 95% CI; 1.246–3.126) remained independently associated with GI cancers. CONCLUSIONS: GI cancer patients tended to have a first relative with a history of concordant GI cancer. Personal factors (old age and male) and lifestyle (smoking) contribute to the development of GI cancer, independently. Individuals with high risk for GI cancers may be advised to undergo screening at an earlier age.

Clinical Value of Contrast-Enhanced Harmonic Endoscopic Ultrasonography in the Differential Diagnosis of Pancreatic and Gallbladder Masses

BACKGROUND/AIMS: Recent studies have revealed that contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) is beneficial in the differential diagnosis of malignant neoplasms of the pancreas and gallbladder from benign masses, in terms of the evaluation of microvasculature and real-time perfusion. In this study, we aimed to prove the clinical value of CEH-EUS in the differential diagnosis of pancreatic and gallbladder masses by direct comparison with that of conventional EUS. METHODS: We reviewed the sonographic images and medical information of 471 patients who underwent conventional EUS and CEH-EUS for the diagnosis of pancreatic and gallbladder masses at a single medical center (Severance Hospital, Seoul, Korea) between March 2010 and March 2016. RESULTS: The enhancement pattern of CEH-EUS of the pancreatic solid masses showed higher sensitivity and specificity in differentiating pancreatic adenocarcinoma and neuroendocrine tumors (82.0% and 87.9% for pancreatic adenocarcinoma and 81.1% and 90.9% for neuroendocrine tumors, respectively), and the area under the receiver operating characteristic curves was higher than that of conventional EUS. The enhancement texture of CEH-EUS of the gallbladder masses showed a higher sensitivity in differentiating malignant masses than that of conventional EUS; however, the difference between the areas under the receiver operating characteristic curves was not statistically significant. CONCLUSIONS: CEH-EUS can complement conventional EUS in the diagnosis of pancreatic and gallbladder masses, in terms of the limitations of the latter.

Diagnostic Value of Endoscopic Ultrasonography in Symptomatic Patients with High and Intermediate Probabilities of Common Bile Duct Stones and a Negative Computed Tomography Scan

BACKGROUND/AIMS: When computed tomography (CT) does not indicate choledocholithiasis in highly suspicious patients, there is no definite consensus on the subsequent modality. Endoscopic ultrasonography (EUS) indicates fewer procedure-related complications than endoscopic retrograde cholangiopancreatography (ERCP) and has a lower cost than magnetic resonance cholangiopancreatography. Therefore, we aimed to investigate the diagnostic value of EUS in patients with suspected choledocholithiasis and negative CT findings. METHODS: Between March 2008 and November 2014, we retrospectively evaluated 200 patients with negative CT findings and high or intermediate probabilities of choledocholithiasis. All patients initially underwent EUS followed by ERCP as a confirmatory criterion standard. The primary outcome in these patients was the accuracy of EUS in the detection of choledocholithiasis. The secondary outcome was the clinical prediction of common bile duct (CBD) stones in this group. RESULTS: EUS indicated choledocholithiasis in 165 of the 200 patients, and ERCP confirmed choledocholithiasis in 161 patients (80.5%). The accuracy of EUS in the detection of choledocholithiasis was 94.0% (sensitivity, 97.5%; specificity, 79.5%; positive predictive value, 95.2%; negative predictive value, 88.6%). A multivariate analysis demonstrated that choledocholithiasis was strongly predicted by EUS detection of choledocholithiasis, an age >55 years and a clinical diagnosis of cholangitis. CONCLUSIONS: An EUS-first approach is recommended for patients with suspected CBD stones and negative CT findings.

Assessment of the Risk of Colorectal Cancer Survivors Developing a Second Primary Pancreatic Cancer

BACKGROUND/AIMS: We aimed to investigate the incidence of second primary pancreatic cancer (PC) after colorectal cancer (CRC) and to identify risk factors associated with subsequent PC. METHODS: The observed incidence of a subsequent PC in patients with CRC was standardized using a population with CRC from the Korean Central Cancer Registry (KCCR). The expected incidence rate of PC was obtained by assuming that the select group experienced the same cancer incidence as the corresponding general population in the KCCR. RESULTS: The registry included 4,822 patients with CRC aged 45 to 74 years, representing 16,725.1 person-years of follow-up. Thirteen patients (0.3%) were diagnosed with a subsequent PC, and the overall age-adjusted incidence of second primary PC was 269.6 per 100,000 cases. In contrast, the overall incidence of primary PC in the general population was 18.68 per 100,000 individuals. The standardized incidence ratio of subsequent PC was 14.44, which was significantly higher in patients with CRC than in the general population. Sex, diabetes mellitus, smoking, body mass index, and a history of receiving chemotherapy as a treatment for CRC did not increase the risk of subsequent development of PC. CONCLUSIONS: The risk of a second primary PC was higher in patients with CRC. Further studies are needed to identify the risk factors and generate a screening strategy for cancer survivors.

Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea

PURPOSE: Cholecystectomy in patients with an intact gallbladder after endoscopic removal of stones from the common bile duct (CBD) remains controversial. We conducted a case-control study to determine the risk of recurrent CBD stones and the benefit of cholecystectomy for prevention of recurrence after endoscopic removal of stones from the CBD in Korean patients. MATERIALS AND METHODS: A total of 317 patients who underwent endoscopic CBD stone extraction between 2006 and 2012 were included. Possible risk factors for the recurrence of CBD stones including previous cholecystectomy history, bile duct diameter, stone size, number of stones, stone composition, and the presence of a periampullary diverticulum were analyzed. RESULTS: The mean duration of follow-up after CBD stone extraction was 25.4+/-22.0 months. A CBD diameter of 15 mm or larger [odds ratio (OR), 1.930; 95% confidence interval (CI), 1.098 to 3.391; p=0.022] and the presence of a periampullary diverticulum (OR, 1.859; 95% CI, 1.014 to 3.408; p=0.045) were independent predictive factors for CBD stone recurrence. Seventeen patients (26.6%) in the recurrence group underwent elective cholecystectomy soon after endoscopic extraction of CBD stones, compared to 88 (34.8%) in the non-recurrence group; the difference was not statistically significant (p=0.212). CONCLUSION: A CBD diameter of 15 mm or larger and the presence of a periampullary diverticulum were found to be potential predictive factors for recurrence after endoscopic extraction of CBD stones. Elective cholecystectomy after clearance of CBD stones did not reduce the incidence of recurrent CBD stones in Korean patients.

Concomitant Statin Use Has a Favorable Effect on Gemcitabine-Erlotinib Combination Chemotherapy for Advanced Pancreatic Cancer

PURPOSE: Erlotinib-gemcitabine combined chemotherapy is considered as the standard treatment for unresectable pancreatic cancer. This study aimed to determine the clinical factors associated with response to this treatment. MATERIALS AND METHODS: This retrospective study included 180 patients with unresectable pancreatic cancer who received ≥2 cycles of gemcitabine-erlotinib combination therapy as first-line palliative chemotherapy between 2006 and 2014. "Long-term response" was defined as tumor stabilization after >6 chemotherapy cycles. RESULTS: The median progression-free survival (PFS) and overall survival (OS) were 3.9 and 8.1 months, respectively. On univariate analysis, liver metastasis (p=0.023) was negatively correlated with long-term response. Locally advanced stage (p=0.017), a history of statin treatment (p=0.01), and carcinoembryonic antigen levels <4.5 (p=0.029) had a favorable effect on long-term response. On multivariate analysis, a history of statin treatment was the only independent favorable factor for long-term response (p=0.017). Prognostic factors for OS and PFS were significantly correlated with liver metastasis (p=0.031 and 0.013, respectively). A history of statin treatment was also significantly associated with OS after adjusting for all potential confounders (hazard ratio, 0.48; 95% confidence interval, 0.26-0.92; p=0.026). CONCLUSION: These results suggest that statins have a favorable effect on "long-term response" to gemcitabine-erlotinib chemotherapy in unresectable pancreatic cancer patients. Statins may have a chemoadjuvant role in stabilizing long-term tumor growth.

A Comparison between Clinical Results of Selective Bundle and Double Bundle Anterior Cruciate Ligament Reconstruction

PURPOSE: The purpose of this study was to compare the clinical outcomes of arthroscopic anatomical double bundle (DB) anterior cruciate ligament (ACL) reconstruction with either selective anteromedial (AM) or posterolateral (PL) bundle reconstruction while preserving a relatively healthy ACL bundle. MATERIALS AND METHODS: The authors evaluated 98 patients with a mean follow-up of 30.8±4.0 months who had undergone DB or selective bundle ACL reconstructions. Of these, 34 cases underwent DB ACL reconstruction (group A), 34 underwent selective AM bundle reconstruction (group B), and 30 underwent selective PL bundle reconstructions (group C). These groups were compared with respect to Lysholm and International Knee Documentation Committee (IKDC) score, side-to-side differences of anterior laxity measured by KT-2000 arthrometer at 30 lbs, and stress radiography and Lachman and pivot shift test results. Pre- and post-operative data were objectively evaluated using a statistical approach. RESULTS: The preoperative anterior instability measured by manual stress radiography at 90° of knee flexion in group A was significantly greater than that in groups B and C (all p<0.001). At last follow-up, mean side-to-side instrumented laxities measured by the KT-2000 and manual stress radiography were significantly improved from preoperative data in all groups (all p<0.001). There were no significant differences between the three groups in anterior instability measured by KT-2000 arthrometer, pivot shift, or functional scores. CONCLUSION: Selective bundle reconstruction in partial ACL tears offers comparable clinical results to DB reconstruction in complete ACL tears.

A Comparison of Gastrointestinal Toxicities between Intensity-Modulated Radiotherapy and Three-Dimensional Conformal Radiotherapy for Pancreatic Cancer

BACKGROUND/AIMS: Concurrent chemoradiotherapy (CCRT) is considered the treatment option for locally advanced pancreatic cancer, but accompanying gastrointestinal toxicities are the most common complication. With the introduction of three-dimensional conformal radiotherapy (3-D CRT) and intensity-modulated radiotherapy (IMRT), CCRT-related adverse events are expected to diminish. Here, we evaluated the benefits of radiation modalities by comparing gastrointestinal toxicities between 3-D CRT and IMRT. METHODS: Patients who received CCRT between July 2010 and June 2012 in Severance Hospital, Yonsei University College of Medicine, were enrolled prospectively. The patients underwent upper endoscopy before and 1 month after CCRT. RESULTS: A total of 84 patients were enrolled during the study period. The radiotherapy modalities delivered included 3D-CRT (n=40) and IMRT (n=44). The median follow-up period from the start of CCRT was 10.6 months (range, 3.8 to 29.9 months). The symptoms of dyspepsia, nausea/vomiting, and diarrhea did not differ between the groups. Upper endoscopy revealed significantly more gastroduodenal ulcers in the 3-D CRT group (p=0.003). The modality of radiotherapy (3D-CRT; odds ratio [OR], 11.67; p=0.011) and tumor location (body of pancreas; OR, 11.06; p=0.009) were risk factors for gastrointestinal toxicities. CONCLUSIONS: IMRT is associated with significantly fewer gastroduodenal injuries among patients treated with CCRT for pancreatic cancer.

Parosteal Lipoma in the Metatarsus: A Case Report / 대한족부족관절학회지

We experienced a rare case of parosteal lipoma, which located on the periosteum of the foot 4th metatarsus. A 22-year-old woman visited the hospital with painful mass in her foot. Based on the assessment of plain radiographs, computed tomography scan, and magnetic resonance image, it was suspected as lipoma. Marginal excision was performed and parosteal lipoma was confirmed histologically. Any local recurrence and complications were not observed in 2 years after surgery.

Photodynamic Therapy Followed by Left Hepatectomy Used to Treat an Intraductal Papillary Mucinous Neoplasm of the Bile Duct / 대한내과학회지

Mucin-hypersecreting bile duct tumors, which closely resemble intraductal papillary mucinous neoplasms of the pancreas, are rare, and both the clinical features and management thereof are poorly understood. As the biliary tract and the pancreas share a common origin, the two diseases may exhibit homologous histopathological features. Certain intraductal papillary tumors of the bile duct are associated with production of large amounts of mucin that disturb bile flow and cause severe biliary dilatation, obstructive jaundice, and cholangitis. Herein, we report on a patient with an extensive intraductal papillary mucinous neoplasm of the bile duct, involving both the right and left intrahepatic ducts. The ducts were subjected to photodynamic therapy, followed by left hepatectomy. The surgical specimen revealed an adenocarcinoma with a negative resection margin. Photodynamic therapy of the intrahepatic ducts was well-tolerated in the present case, and may serve as a useful therapeutic option for selected patients with intraductal papillary mucinous neoplasms of the bile duct.

Prognostic Significance of Volume-Based FDG PET/CT Parameters in Patients with Locally Advanced Pancreatic Cancer Treated with Chemoradiation Therapy

PURPOSE: We investigated the prognostic role of volume-based parameters measured on 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) scans in patients with locally advanced pancreatic cancer (LAPC) treated with chemoradiation therapy (CRT). MATERIALS AND METHODS: We enrolled 60 patients with LAPC who underwent FDG PET/CT before CRT. Maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of primary pancreatic cancers were measured on FDG PET/CT scans. Treatment response was evaluated according to the Response Evaluation Criteria in Solid Tumors. Survival analysis was performed using the Kaplan-Meier method, and Cox proportional hazard models were used to determine independent prognostic factors. RESULTS: The progression-free survival (PFS), locoregional progression-free survival (LRFPS), and overall survival (OS) for this population were 6.2, 10.9, and 13.2 months, respectively. The overall treatment response rate was 16.7% at 4 weeks after CRT, and the disease control rate (DCR) was 80.0%. DCR was significantly higher in patients with low SUVmax, MTV, or TLG, and showed strong correlation with longer survival times. On univariate analysis, MTV and TLG were significant prognostic factors for PFS, LRPFS, and OS, together with pre-CRT and post-CRT CA19-9 levels. Multivariate analyses demonstrated that MTV together with the pre-CRT CA19-9 level were independent prognostic factors for PFS, LRPFS, and OS, as was TLG for LRPFS and OS. CONCLUSION: MTV and the pre-CRT CA19-9 level provided independent prognostic information in patients with LAPC treated with CRT. Volume-based PET/CT parameters may be useful in identifying which subgroup of patients would benefit from radiation therapy as a part of CRT.