Gastric Pseudotumoral Lesion Caused by a Fish Bone Mimicking a Gastric Submucosal Tumor

Gastric complications following unintentional foreign body ingestion are extremely rare. Here, we report the case of a 59-year-old healthy woman who presented with nonspecific abdominal pain and an apparent gastric submucosal tumor that was incidentally detected by gastrofiberscopy. The patient underwent laparoscopic surgery, which revealed an intact gastric wall with no tumor invasion, deformity, or evidence of a gastric submucosal lesion. However, an impacted fish bone was found.

Down-regulation of survivin suppresses uro-plasminogen activator through transcription factor JunB

Survivin, a member of the inhibitors of apoptosis protein family, is expressed during development and in various human cancers. However, the clinical relevance of survivin in cancer is still a matter of debate. Genes induced by hepatocyte growth factor (HGF) were screened using cDNA microarray technology in the stomach cancer cell lines, NUGC3 and MKN28. The levels of JunB, survivin, and uro-plasminogen activator (uPA) were up-regulated in cells treated with HGF in a dose-dependent manner. HGF-induced up regulation of JunB, survivin, and uPA was inhibited by pre-treatment with a MEK inhibitor (PD 98059). HGF-induced up-regulation of uPA was repressed by survivin knockdown. HGF enhanced the binding activity of JunB to the survivin promoter in control cells, but not in the JunB-shRNA cells. Transfection with survivin-shRNA resulted in a decrement of cell proliferation, as determined with MTT assays. In an in vitro invasion assay, significantly fewer cells transfected with survivin shRNA than control cells were able to invade across a Matrigel membrane barrier. In conclusion, survivin appeared to play an important role in the up-regulation of uPA induced by HGF via JunB and might contribute to HGF-mediated tumor invasion and metastasis, which may serve as a promising target for gastric cancer therapy.

Clinical Outcomes according to Primary Treatment in Gastric Cancer Patients with Peritoneal Seeding

PURPOSE: Peritoneal seeding of gastric cancer is known to have a poor prognosis. With the diagnosis of peritoneal seeding, there is no effective treatment modality. Gastrectomy with chemotherapy or primary chemotherapy is basically one of major options for this condition. This study was conducted to compare the clinical outcomes of these treatments and to identify the better way to improve the prognosis of patients with peritoneal seeding. MATERIALS AND METHODS: Between 2001 and 2007, gastric cancer patients with peritoneal seeding by preoperative or intraoperative diagnosis were reviewed retrospectively. The enrolled patients were divided as primary gastrectomy and primary chemotherapy group. Clinicopathologic characteristics and clinical outcomes of groups were analyzed and compared. RESULTS: Fifty-four patients were enrolled. 21 patients belonged to the group of primary gastrectomy and 33 patients were to the primary chemotherapy group. Among 33 patients of the primary chemotherapy group, 17 patients were received only chemotherapy and 16 patients were received gastrectomy due to the good responses of primary chemotherapy. The 3 years survival rates were 14% in primary gastrectomy group, 55% in patients who received gastrectomy after primary chemotherapy, and 0% in patients with primary chemotherapy only. CONCLUSIONS: Although this study had many limitations, some valuable information was produced. In terms of survival benefits for the gastric cancer patients with peritoneal seeding, primary gastrectomy and additional gastrectomy after primary chemotherapy revealed the better clinical outcomes. But, prospective randomized clinical study and multi-center study are should be performed to decide proper treatment for gastric cancer patients with peritoneal seeding.

Erratum to: Clinical Outcomes according to Primary Treatment in Gastric Cancer Patients with Peritoneal Seeding

No abstract available.

Evaluation of Prognostic Values according to the New TNM Classification in Gastric Cancer

PURPOSE: In 2010, the new UICC/AJCC TNM classification for gastric cancer was declared. The new classification for gastric cancer has several changes from the 6th classification. We evaluated the prognostic values and differences according to the new UICC/AJCC TNM classification. METHODS: From 2000 to 2004, 1,196 patients who underwent curative resection with D1+beta or more lymph node dissection and with 15 or more lymph nodes retrieved were studied retrospectively. We analyzed clinical characteristics and survival outcomes retrospectively from medical records. RESULTS: According to UICC/AJCC 7th TNM classification, the 5-year survival rate (5YSR) of each group for depth of invasion and node metastasis were significantly different. The 5YSR of stage II in 6th classification was 82.4% and the 5YSR of stage IIa and IIb in 7th classification were 92.2% and 82.9%. The 5YSR of stage IIIa and IIIb in 6th classification were 56.3% and 33.0%. The 5YSR of stage IIIa, IIIb and IIIc in 7th classification were 72.7%, 48.4% and 26.1%. In our Cox regression multivariate analysis, N stage of the 6th UICC/AJCC TNM classification was the main independent prognostic factor. CONCLUSION: N stage of the 6th UICC/AJCC TNM classification is a more reliable prognostic factor than N stage of the 7th UICC/AJCC TNM classification. Further study should be performed to confirm the appropriateness of N stage TNM classification for gastric cancer.

Malignant Solitary Fibrous Tumor of Retroperitoneum Mimicking Gastric Submucosal Tumor / 대한소화기학회지

Solitary fibrous tumors (SFTs) are an uncommon neoplasm characterized by the proliferation of spindle cells. The diagnostic criteria of malignant solitary fibrous tumors (MSFTs) include high cellularity, high mitotic activity (4>10 HPF), pleomorphism, hemorrhage and necrosis. This tumor frequently involves the pleura and MSFTs of retroperitoneum mimicking gastric submucosal tumor are very rare. We report a rare case of MSFT that presented as a gastric submucosal tumor. A gastroscopic examination showed a large bulging mucosa in the gastric body. Abdominal computed tomography revealed a well-defined heterogeneous enhancing mass between the left hepatic lobe and gastric body. Surgical resection was performed and histologic features were consistent with a MSFT.

Inflammatory Pseudotumor of Splenic Hilar Node Mimicking Gastric Submucosal Tumor

Inflammatory pseudotumor (IPT) is an uncommon clinical condition characterized by proliferation of spindle cells, inflammatory cells, and small vessels. IPT has been reported in various anatomical sites, including the orbit, lung, liver, spleen, and so on. IPT of the lymph node is very rare. We recently experienced a 65-year-old woman diagnosed with IPT of the lymph node in the splenic hilar, or distal supra-pancreatic area, mimicking gastric submucosal tumor. The tumor was removed without event using the laparoscopic method. This lesion in the splenic hilum is extremely rare and has not been cited in the current literature. We describe such a rare case of IPT with a review of the literature.

Comparison of Clinical Characteristics between Open and Laparoscopic Surgery Groups in Gastric Gastrointestinal Stromal Tumor Patients

PURPOSE: The stomach is the most frequent site of gastrointestinal stromal tumor (GIST). Surgery remains the only curative treatment for GIST. Resection needs to ensure tumor free margin without lymphadenectomy. Thus partial gastric resection is the treatment of choice for gastric GIST. This study aims to review clinical characteristics between open and laparoscopic wedge resection group and evaluate safety and efficacy of laparoscopic wedge resection. METHODS: Between 1997 and 2008, 74 consecutive patients undergoing open or laparoscopic wedge resection of gastric GISTs were identified in a retrospectively collected database. Preoperative and postoperative variables were analyzed. RESULTS: Wedge resection with negative margin was performed in 74 patients. Laparoscopic wedge resection was performed 19 patients. Open wedge resection was performed in 55 patients. Mean tumor size of laparoscopic group was 2.7 cm (range 0.4~6.0) and open group was 4.4 cm (range 0.4~23.0). Mean operation time of laparoscopic group was 150.0 minutes (range 80~240), and open group was 164.6 minutes (range 75~360). Mean hospital stay of laparoscopic group was 7.11 days (range 3~19), and open group was 9.38 days (range 6~20). There were no significant survival differences between groups. CONCLUSION: A laparoscopic wedge resection of gastric GIST is associated with short hospitalization and not inferior to open wedge resection in terms of morbidity and mortality. The long-term outcomes between laparoscopic and open wedge resection group in our study were no significant survival differences. Long-term and prospective randomized study should be performed to confirm oncological safety of laparoscopic wedge resection.

Clinicopathological Characteristics of Patients Who Received Additional Gastrectomy after Endoscopic Resection due to Gastric Cancer

PURPOSE: Recently, early gastric cancer has increased in Korea. Thus, endoscopic resection and laparoscopic gastrectomy has increased in early gastric cancer patients. But, endoscopic resection of early gastric cancer has many problems such as poor long-term survival data, diverse endoscopic techniques, ambiguous follow-up strategy, nonuniform pathologic interpretation and so on. We studied patients that received additional gastrectomy after EMR/ESD. We analyzed clinicopathological characteristics states before and after EMR/ESD. METHODS: From 1998 to 2008, 56 patients received additional gastrectomy after EMR/ESD due to gastric cancer. We analyzed tumor characteristics, endoscopic resection type, reasons for gastrectomy, post-operative characteristics, etc., retrospectively from medical records. RESULTS: The ratio of male to female was 2:1. Six patient tumors were larger than 2 cm in size. Forty-five patients received EMR and 12 patients received ESD. Common macroscopic feature of endoscopic findings were superficial elevated and superficial depressed between 10 mm and 20 mm. Forty patients received immediate gastrectomy due to incomplete endoscopic resection. Sixteen patients received additional gastrectomy during follow-up period after EMR/ESD. The most common reason of immediate gastrectomy was positive resection margin. The most common reason of follow-up gastrectomy was cancer recurrence. Three patients had advanced gastric cancer in follow up gastrectomy group. Two patients died due to gastric cancer in immediate gastrectomy group and follow-up gastrectomy group. CONCLUSION: Active effort for surgical treatment is needed when the gastric cancer characteristics of patients is inadequate for endoscopic resection. Uniform pathologic interpretation is essential for confirming completeness of endoscopic resection. Treatment and follow-up strategy after endoscopic resection is important due to recurrence and new cancer occurrence. Long-term and prospective randomized study should be performed to confirm safety and difficulty of endoscopic resection.

Annual Change of Clinicopathologic Characteristics after Radical Gastrectomy due to Gastric Cancer

PURPOSE: Recently, early gastric cancer has increased in Korea. Thus, endoscopic treatment and laparoscopic gastrectomy has increased in early gastric cancer patients. We studied periodic change and characteristics in gastric cancer patients. Thus, we analyzed annual change of clinicopathological characteristics and long-term survival results of gastric cancer patients after radical gastrectomy over 10 years. METHODS: From 1995 to 2004, 2,387 patients underwent radical gastrectomy due to gastric cancer. We analyzed annual characteristics, sex, age distribution, cancer location, depth of invasion, lymph node metastasis, UICC stage and 5-year survival rates, retrospectively from medical records. RESULTS: The number of gastric cancer patient has increased annually. The ratio of male to female was 2:1. Gastric cancer was most common and increased annually in the 60~79-year age group. Early gastric cancer increased annually. The 5-year survival rate was 93% in stage Ia, 89% in stage Ib, 72% in stage II, 51% in stage IIIA, 38% in stage IIIb and 22% in stage IV. Multivariate analysis revealed that UICC stage (or depth of invasion and lymph node metastasis) and cancer location were the main independent prognostic factors. CONCLUSION: Prognosis is improved due to increase of early gastric cancer. So, we should attempt diagnosis early and treat early gastric cancer. Active treatment is recommended even for the elderly gastric cancer patients. And care should be taken with respect to morbidity and mortality.

Metachronous Four Primary Malignancies in Gastro-intestinal Tract / 대한소화기학회지

Multiple primary malignancy was reported firstly by Billroth in 1889. Recently, multiple primary malignancies are considered to increase due to improved survival rate of cancer patients, advanced diagnostic tools, and increased use of chemotherapy and radiotherapy. In Korea, several cases of triple primary malignancies were reported. However, four primary malignancies in gastro-intestinal tract was rarely reported. Recently, we experienced a 70 year-old male who was diagnosed with metachronous four primary malignancies in rectum, ascending colon, stomach, and ampulla of Vater. We report this rare case of metachronous four primary malignancies with a review of literature.

Effectiveness of Positron Emission Tomography in the Pre-operative Staging of Gastric Cancer

PURPOSE: The aim of this study was to examine the usefulness of positron emission tomography (PET)-computed tomography (CT) in the pre-operative staging of gastric cancer. MATERIALS AND METHODS: Between February 2006 and August 2008, PET-CT and CT were performed on 70 patients diagnosed with gastric cancer by gastrofiberscopic biopsy. The sensitivities, specificities, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT and CT imaging for the detection of gastric cancer TNM staging were compared. RESULTS: The detection rates for the primary tumor were as follows: PET-CT, 81.4% (57/70); and CT, 42.9% (30/70). For both early gastric cancer (EGC) and advanced gastric cancer (AGC), PET-CT was more accurate than CT in detecting the lesions. As the size of the tumor exceeded 3 cm, the detection rate increased. The sensitivities, specificities, PPV, and NPV of PET-CT for lymph node staging were 55.6%, 81%, 86.2%, and 45.9%, while the sensitivities, specificities, PPV, and NPV of CT were 40.0%, 85.7%, 85.7% and 40%, respectively. One case of multiple liver metastasis and two cases of dual primary cancer (rectal and pancreatic cancers) were detected by PET-CT. PET-CT also had a higher detection rate for all histologic types of primary tumors. PET-CT was more accurate than CT in detecting primary gastric cancer lesions. The detection of nodal metastasis by PET-CT was similar to CT; small-sized tumors or EGC detection rates were not high. However, PET-CT provided additional information to detect distant metastases and dual primary cancers and reduced unnecessary laparotomies to detect peritoneal seeding or carcinomatosis. CONCLUSION: It would be useful to make a pre-operative diagnosis of gastric cancer and determine treatment if PET-CT were added to other routine pre-operative studies.

Gastric Adenocarcinoma with Coexistent Hepatoid Adenocarcinoma and Neuroendocrine Carcinoma: A Case Report

This report represents a very rare case of a gastric adenocarcinoma that was coexistent with hepatoid adenocarcinoma and neuroendocrine carcinoma. A 77-year-old man was admitted to our hospital due to a huge ulcerofungating mass identified at the proximal body of the stomach. After a pathological diagnosis of the tumor as a poorly differentiated adenocarcinoma was made, the patient underwent a total gastrectomy with lymph node dissection. Microscopically, the tumor consisted of three morphologically distinct components-tubular adenocarcinoma, hepatoid adenocarcinoma and neuroendocrine carcinoma. The hepatoid adenocarcinoma component resembled a hepatocellular carcinoma and produced alpha-fetoprotein. The neuroendocrine carcinoma component was positive for chromogranin and synaptophysin immunostains. This is an example of the diverse morphological and immunophenotypical differentiation of gastric carcinomas.

Different Clinical Outcomes of Stage IV Gastric Cancer according to the Curability of Surgery

PURPOSE: This study was conducted to evaluate the survival differences between curative stage IV and non-curative stage IV gastric cancers after gastrectomy. METHODS: Stage IV gastric cancer patients who received gastrectomy were selected from our surgical data-base from 1995 to 2004. These patients were separated into two groups according to the curability by surgery. We analyzed the survival differences between curative stage IV patients and non-curative stage IV patients. Survival analysis was performed by Kaplan-Meier survival analysis. RESULTS: During a 10-year period, gastrectomy was performed in 2,214 patients. 224 patients were diagnosed as stage IV. 144 patients were male and 80 patients were female. 97 patients received total gastrectomy. 127 patients received subtotal gastrectomy. 173 patients were diagnosed with curative stage IV and 51 patients were non-curative stage IV. Overall 3-year and 5-year survival rates of stage IV gastric cancer patients in this study were 31.5% and 18.4%. 3-YSR of curative and non-curative stage IV were 36.0% and 16.7% respectively (P-value=0.0204). 5-YSR of curative and non-curative stage IV was 21.9% and 4.2% (P-value=0.0169). CONCLUSION: Significant survival differences were found between curative and non-curative stage IV. Although direct tumor extension or distant metastasis exists, gastrectomy with combined resection was important to improve prognosis if it is possible to resect. When it comes to the matter of survival rate, the subclassification of stage IV gastric cancer should be considered for further management.

Morphological Features of Metastatic Gastrointestinal Stromal Tumors after Gleevec Treatment: Two Cases Report

We report two patients with metastatic gastrointestinal stromal tumors (GISTs) with a focus on the morphological features related to Gleevec treatment. In case 1, a 50-year-old woman presented with a 1.8 cm metastatic GIST in the liver after resection of a gastric GIST. Majority of the metastatic tumor showed fibrosis and hyalinization after 8 weeks of Gleevec treatment. CD117-positive cells were present in approximately 1% of the overall tumor. In case 2, a 2 cm and 14 cm metastatic liver masses were found in a 54-year-old man who had a rectal GIST. After 4 weeks of Gleevec treatment, metastatic tumors showed a decrease in size on CT scan. The metastatic tumors showed a decrease in number of tumor cells. The hemorrhage, cystic changes, necrosis, and fibrosis made up approximately 90% of the tumor. The morphological features related to Gleevec treatment are important for correct diagnosis and evaluation of tumor response and prognosis.

Prognosis of Gastrointestinal Stromal Tumors Arising in the Stomach and Small Intestine: A Retrospective Study of 126 Cases from a Single Institution

BACKGROUND: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor in the gastrointestinal tract. As all GISTs have the potential for aggressive clinical behavior, the guidelines for defining the risk of aggressive behavior have been developed and they have been recently revised to precisely assess these patients' prognosis. METHODS: We analyzed 94 gastric and 32 small intestinal GISTs to compare the patients' survival with the risk stratification (original and revised). RESULTS: For gastric GISTs, 10 mitoses/50HPF was an important cutoff value for the risk of metastasis (1.3% vs 29.4%, respectively), whereas 16.7% of all the small intestinal GISTs with less than 5 mitoses/50HPF metastasized. The small intestinal GISTs showed higher frequencies of mucosal invasion and coagulation necrosis than did the gastric ones. Gastric GISTs had a significantly lower incidence of metastasis/recurrence than did the small intestinal ones in the same risk group. On multivariate analysis, the anatomic location (small intestine), the tumor size (>10 cm) and the mitotic count (>10/50HPF) were independent prognostic factors for a shorter disease-free survival for patients with GISTs. The mitotic count was more important than tumor size for both gastric and small intestinal GISTs. CONCLUSION: Small intestinal GIST is a more aggressive tumor than gastric GIST and the mitotic count is the most important prognostic factor for GISTs.

Prognostic Factors of Advanced Gastric Cancer Patients without Lymph Node Metastasis

PURPOSE: This study was conducted to identify prognostic factors in gastric cancer without lymph node metastasis and to specifiy which prognostic factors can be available in detail according to the depth of invasion. MATERIALS AND METHODS: This retrospective study was based on the medial records of 268 gastric cancer patients who received resectional therapy from 1990 to 1999. The patients who revealed pT2NOMO, pT3NOMO, pT4NOMO on postoperative pathologic reports were enrolled. The survival rate was analyzed according to clinicopathologic and therapeutic factors. RESULTS: According to the depth of invasion, the number of patients with pT2a, pT2b, pT3 and pT4 were 86 (32.1%), 56 (20.9%), 108 (40.3%), and 18 (6.7%) respectively. Age, depth of invasion, histological type, Borrmann type, and Lauren classification were statistically significant in the univariate analysis, and the age, the depth of invasion, and Lauren classification were independent prognostic factors identified by multivariate analysis. On multivariate analysis of subgroups according to the depth of invasion, the independent prognostic factors were age, Borrmann type, and Lauren classification in pT2, and age, Lauren classification , and vascular invasion in pT3. The prognostic factors of pT4 patients could not be analyzed due to limited sample size. CONCLUSION: In advanced gastric cancer patients without lymph node metastasis, age, the depth of invasion, and Lauren classification should be checked to predict prognosis. In patients with pT2 lesion among the above patients, the Borrmann type should be added in check-list.

Prognosis and Treatment Outcomes of Gastric Cancer Patients with Hepatic Metastasis

PURPOSE: This study was conducted to evaluate the treatment outcomes and the prognosis for gastric cancer patients with hepatic metastasis. MATERIALS AND METHODS: This retrospective study was based on the medical records of 85 gastric cancer patients with hepatic metastasis (62 synchronous and, 23 metachronous) who received chemotherapy with or without resectional therapy from March 1990 to March 2006. The survival rate was analyzed according to clinicopathologic factors and therapeutic factors, such as whether or not a gastrectomy, a hepatic resection, and/or chemotherapy had been performed. RESULTS: The median survival of gastric cancer patients with hepatic metastasis was 11 months (synchronous: 11 months and metachronous: 17 months). The rates of gastrectomies and hepatic resections in the synchronous group were 24.1% and 16.1%, respectively. A 23.5% prevalence of extra-hepatic metastasis was observed. The median survivals of patients who underwent a gastrectomy with a hepatic resection, a gastrectomy alone, and non-surgical treatment were 60, 18, and 9 months, respectively (P<0.05). The disease-free median survival of the metachronous group was 8 (3~39) months. There was no difference in initial pathologic stage and frequency of hepatic metastasis after the gastrectomy in the metachronous group. In the synchronous group, extra-hepatic metastasis, a gastrectomy as the operative procedure, a hepatic resection as the operative procedure and the response to chemotherapy were statistically significant in the univariate analysis, and a hepatic resection as the operative procedure, the response to chemotherapy, and extra-hepatic metastasis were independant prognostic factors identified by the multivariate analysis. In the metachronous group, extra-hepatic metastasis, the response to chemotherapy and differentiation were statistically significant in the univariate analysis, and extra-hepatic metastasis was an independent prognostic factor identified by the multivariate analysis. CONCLUSION: An aggressive surgical therapy and effective chemotherapy are necessary in the treatment of gastric cancer patients with hepatic metastasis.

Hepatocyte Growth Factor/c-Met Signaling in Regulating Urokinase Plasminogen Activator in Human Stomach Cancer: A Potential Therapeutic Target for Human Stomach Cancer

BACKGROUND: Up-regulation of the hepatocyte growth factor (HGF), its transmembrane tyrosine kinase receptor (c-Met), and urokinase type plasminogen activator (uPA), is associated with the development and metastasis of various types of cancers. However, the mechanisms by which HGF/c-Met signaling mediates cancer progression and metastasis are unclear. METHODS: We investigated the roles of HGF/c-Met in tumor progression and metastasis in NUGC-3 and MKN-28 stomach cancer cell lines. RESULTS: Treatment with HGF increased c-Met phosphorylation in a dose-dependent manner, as well as increasing cell proliferation. HGF treatment also increased the protein level and the activity of uPA in NUGC-3 and MKN-28 cells. A monoclonal antibody against human uPA receptor (uPAR), mAb 3936, inhibited HGF-mediated tumor cell invasion in a dose-dependent manner. Down-regulation of uPA using uPA-shRNA induced a decrease in in vitro cell invasion in NUGC-3 cells. CONCLUSIONS: These results suggest that NUGC-3 and MKN-28 cells express functional c-Met, which may provide a therapeutic target for interfering with metastases of cancer cells by inhibiting uPA and uPAR-mediated proteolysis.

Two Cases of Jejunal Gastrointestinal Stromal Tumor Diagnosed by Capsule Endoscope / 영남의대학술지

Small bowel tumors have been difficult to diagnose because of low incidence and absence of specific symptoms. There are no efficient and accurate tests available for diagnosis. Capsule endoscopy is an efficient diagnostic tool for small bowel disease and obscure gastrointestinal bleeding. We diagnosed two cases of small bowel gastrointestinal stromal tumor (GIST) diagnosed by capsule endoscopy that were treated by surgery. A 68 year old male presented with abdominal pain. The capsule endoscopy showed fungating ulcer mass at the jejunum. A 55 year female presented with melena. The capsule endoscopy showed an intraluminal protruding mass with a superficial ulcer at the jejunum. Two cases were diagnosed with GIST after surgery. We report these two case diagnosed by capsule endoscopy and review the medical literature.