Prevalence of Malnutrition in Hospitalized Patients: a Multicenter Cross-sectional Study

BACKGROUND: Malnutrition is associated with many adverse clinical outcomes. The present study aimed to identify the prevalence of malnutrition in hospitalized patients in Korea, evaluate the association between malnutrition and clinical outcomes, and ascertain the risk factors of malnutrition. METHODS: A multicenter cross-sectional study was performed with 300 patients recruited from among the patients admitted in 25 hospitals on January 6, 2014. Nutritional status was assessed by using the Subjective Global Assessment (SGA). Demographic characteristics and underlying diseases were compared according to nutritional status. Logistic regression analysis was performed to identify the risk factors of malnutrition. Clinical outcomes such as rate of admission in intensive care units, length of hospital stay, and survival rate were evaluated. RESULTS: The prevalence of malnutrition in the hospitalized patients was 22.0%. Old age (≥ 70 years), admission for medical treatment or diagnostic work-up, and underlying pulmonary or oncological disease were associated with malnutrition. Old age and admission for medical treatment or diagnostic work-up were identified to be risk factors of malnutrition in the multivariate analysis. Patients with malnutrition had longer hospital stay (SGA A = 7.63 ± 6.03 days, B = 9.02 ± 9.96 days, and C = 12.18 ± 7.24 days, P = 0.018) and lower 90-day survival rate (SGA A = 97.9%, B = 90.7%, and C = 58.3%, P < 0.001). CONCLUSION: Malnutrition was common in hospitalized patients, and resulted in longer hospitalization and associated lower survival rate. The rate of malnutrition tended to be higher when the patient was older than 70 years old or hospitalized for medical treatment or diagnostic work-up compared to elective surgery.

A Promising Method for Tumor Localization during Total Laparoscopic Distal Gastrectomy: Preoperative Endoscopic Clipping based on Negative Biopsy and Selective Intraoperative Radiography Findings

PURPOSE: Precise localization of tumors and creation of sufficient proximal resection margins are complicated processes during total laparoscopic distal gastrectomy (TLDG) for clinical T1/T2 gastric cancers. Various solutions to this problem have also yielded many disadvantages. In this study, we reviewed a preoperative endoscopic clipping method based on the results of negative biopsy and selective intraoperative radiography. MATERIALS AND METHODS: A retrospective review of 345 consecutive patients who underwent TLDG and preoperative endoscopic clipping for tumor localization was conducted. During preoperative endoscopy, the endoscopists performed negative biopsies just 1–2 cm selectively above the tumor's upper limit. After confirming the biopsy results, endoscopic metal clips were applied just proximal to the negative biopsy site the day before surgery. Selective intraoperative tumor localization using portable abdominal radiography was performed only when we could not ensure a precise resection line. RESULTS: Negative biopsy was performed in 244 patients. Larger tumor size (P=0.008) and more distally located tumors (P=0.052) were observed more frequently in the negative biopsy group than in the non-negative biopsy group. The non-negative biopsy group had significantly higher frequencies of differentiated tumor types than the negative biopsy group (P=0.003). Of the 244 patients who underwent negative biopsies, 6 had cancer cells in their biopsy specimens. We performed intraoperative radiography in 12 patients whose tumors had difficult-to-determine proximal margins. No tumors were found in the proximal resection margins of any patients. CONCLUSIONS: Our tumor localization method is a promising and accurate method for securing a sufficient resection margin during TLDG.

Correlation between HER2 Overexpression and Clinicopathological Characteristics in Gastric Cancer Patients Who Have Undergone Curative Resection

PURPOSE: At present, a human epidermal growth factor receptor 2 (HER2)-based concept of tumor biology has been established, and trastuzumab (Herceptin(R); Genentech/Roche, San Francisco, CA, USA), a monoclonal humanized antibody directed against HER2, is a pivotal agent for the management of HER2 positive (HER2+) metastatic breast cancer. It is also known that HER2 has a predictive value in gastric cancer; however, its association with the prognosis of this disease remains uncertain. The purpose of this study was to evaluate both the relationship between HER2 overexpression in the tumors of gastric cancer patients, and the prognosis of these patients who have had curative resection. MATERIALS AND METHODS: A total of 139 consecutive patients with gastric cancer who underwent surgery at the Kosin University Gospel Hospital between October 2011 and March 2012 were included in this retrospective study. All tumor samples were examined for HER2 expression by immunohistochemistry. A retrospective review of the medical records was conducted to determine the correlation between the presence of HER2 overexpression and clinicopathological factors. RESULTS: The HER2+ rate was 15.1%. HER2 overexpression was associated with histological grade (P=0.044) and Lauren classification (P=0.036). There was no significant difference in the 2-year overall survival between HER2+ and HER2- patients (P=0.396). Multivariate analysis showed that HER2 was not an independent prognostic factor. CONCLUSIONS: HER2 overexpression in tumors was associated with histological grade and Lauren classification in gastric cancer patients with curative resection. However, HER2 was not an independent prognostic factor for gastric cancer in our study.

18F-2-Deoxy-2-Fluoro-D-Glucose Positron Emission Tomography: Computed Tomography for Preoperative Staging in Gastric Cancer Patients

PURPOSE: The use of 18F-2-deoxy-2-fluoro-D-glucose positron emission tomography-computed tomography as a routine preoperative modality is increasing for gastric cancer despite controversy with its usefulness in preoperative staging. In this study we aimed to determine the usefulness of preoperative positron emission tomography-computed tomography scans for staging of gastric cancer. MATERIALS AND METHODS: We retrospectively analyzed 396 patients' positron emission tomography-computed tomography scans acquired for preoperative staging from January to December 2009. RESULTS: The sensitivity of positron emission tomography-computed tomography for detecting early gastric cancer was 20.7% and it was 74.2% for advanced gastric cancer. The size of the primary tumor was correlated with sensitivity, and there was a positive correlation between T stage and sensitivity. For regional lymph node metastasis, the sensitivity and specificity of the positron emission tomography-computed tomography were 30.7% and 94.7%, respectively. There was no correlation between T stage and maximum standardized uptake value or between tumor markers and maximum standardized uptake value. Fluorodeoxyglucose uptake was detected by positron emission tomography-computed tomography in 24 lesions other than the primary tumors. Among them, nine cases were found to be malignant, including double primary cancers and metastatic cancers. Only two cases were detected purely by positron emission tomography-computed tomography. CONCLUSIONS: Positron emission tomography-computed tomography could be useful in detecting metastasis or another primary cancer for preoperative staging in gastric cancer patients, but not for T or N staging. More prospective studies are needed to determine whether positron emission tomography-computed tomography scans should be considered a routine preoperative imaging modality.

Amylase, lipase, and volume of drainage fluid in gastrectomy for the early detection of complications caused by pancreatic leakage / 대한외과학회지

PURPOSE: Pancreatic leakage is a serious complication of gastrectomy due to stomach cancer. Therefore, we analyzed amylase and lipase concentrations in blood and drainage fluid, and evaluated the volume of drainage fluid to discern their usefulness as markers for the early detection of serious pancreatic leakage requiring reoperation after gastrectomy. METHODS: From January 2001 to December 2007, we retrospectively analyzed data from 24,072 patient samples. We divided patients into two groups; 1) complications with pancreatic leakage (CG), and 2) no complications associated with pancreatic leakage (NCG). Values of amylase and lipase in the blood and drainage fluid, volume of the drainage fluid, and relationships among the volumes, amylase values, and lipase values in the drainage fluid were evaluated, respectively in the two groups. RESULTS: The mean amylase values of CG were significantly higher than those of NCG in blood and drainage fluid (P < 0.05). For lipase, statistically significant differences were observed in drainage fluid (P < 0.05). The mean volume (standard deviation) of the drained fluid through the tube between CG (n = 22) and NCG (n = 236) on postoperative day 1 were 368.41 (266.25) and 299.26 (300.28), respectively. There were no statistically significant differences between the groups (P = 0.298). There was a correlation between the amylase and lipase values in the drainage fluid (r = 0.812, P = 0.000). CONCLUSION: Among postoperative amylase and lipase values in blood and drainage fluid, and the volume of drainage fluid, the amylase in drainage fluid was better differentiated between CG and NCG than other markers. The volume of the drainage fluid did not differ significantly between groups.

The Clinicopathologic Characteristics of Neuroendocrine Tumor of the Stomach

PURPOSE: The goal of this study was to review the clinicopathologic characteristics of neuroendocrine tumor (NET) of the stomach. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 13 patients who were diagnosed with neuroendocrine tumor from January 1999 to August 2007 at Kosin Medical Center; 4,159 gastric cancer patients were treated surgically during the same time. The average follow up period was 14.3 months. RESULTS: The majority of 13 patients were men (male-female ratio: 11:2) and the average age of patients with NET was 59.4 years (range: 42~72 years). The presenting symptoms were mostly epigastric pain and soreness. The tumor was limited to the mucosa or submucosa in two cases, and the tumor extended beyond the muscle layer in 11 cases. The mean size of the tumor was 7.0 cm, ranging from 0.7 cm to 15 cm. The type of the NEC (according to the WHO classification) was type 3 for eight patients, type 4 for four patients and type 1 for one patient. Regional lymph node metastasis was noted in 11 patients. Four cases showed recurrence of disease and the site of recurrence included liver in two patients, multiple organs (including the peritoneum and lung) in one patient and multiple organs (including liver, pancreas and duodenum) in one patient. The recurrent cases were type 3 and type 4 and the average survival period of the recurrent patients was 12.8 months. CONCLUSION: The majority of neuroendocrine tumors of the stomach were at an advanced stage at the time of diagnosis. These tumors frequently recurred in the liver and they have a poor prognosis.

Experience of Biliary Atresia-Long-term Survival

Biliary atresia (BA) is an uncommon neonatal surgical disease that has a fatal outcome if not properly treated. The survival rates of the patients with native liver after Kasai's operation in countries outside Japan are not so good. We reviewed the results of 22 cases of biliary atresia treated in Kosin University Hospital between October 1987 and March 2001. There were 13 males and 9 females aged from 21 to 106 days (mean 52 days). There were 3 cases of Type I (13.6%), and 3 of Type II (13.6%), and 16 Type III (72.7%). The operative methods were resection of the common bile duct remnant and cyst followed by Roux-en-Y hepaticojejunostomy in 3 cases for Type I BA; Kasai I in 15 cases, Kasai II in 1 case, and Ueda's operation in 3 cases for Types II and III BA. There was no death within the first 30 days after operation. We were able to follow 21 of the 22 patients (95.4%) for more than 5 years. The actual 5 year survival rate (YSR) was 40.9%. One Type I case received a living-related liver transplantation at 6 years of age because of the multiple intrahepatic stones and liver cirrhosis. Five YSR after biliostomy group (Kasai II and Ueda op.) was 75% (3/4) while that of Kasai I was 20% (3/15). One case had no bile duct in the resected fibrotic plaque on microscopic review and died 8 months after Kasai I operation, would have been a strong candidate for early liver transplantation. From the above result, our conclusions are as follows; (1) early liver transplantation should be considered for cases of no bile duct after pathologic examination of the resected specimen, (2) measures to prevent postoperative cholangitis and prevention of postoperative liver cirrhosis are needed, (3) liver transplantation program should be available for failed cases.

Analysis of the Relationship between Nutritional Status and Hospitalization Days after Surgery in Gastric Cancer Patients

PURPOSE: Protein and energy malnutrition are common in patients with stomach cancer. Nutritional assessment is very important because malnutrition has been shown to be associated with increased morbidity and mortality in stomach cancer. Therefore, this study analyzed the relationship between the nutritional status and the number of hospitalization days in stomach cancer patients. METHODS: The study subjects were 89 patients with stomach cancer, who were admitted to the General Surgery Department during August 2001 to December 2001. The initial nutrition status was assessed using biochemical, anthropometric, and subjective global assessment (SGA) data along with the number of hospitalization days. RESULTS: The study was showed that the mean age was 55.9, the gender ratio was 1.3 : 1 and the mean hospitalization days were 15.59 and there was no statistically significant difference. The weight changes during 1 month before surgery, weight change during 6 month before surgery, usual body weight, and serum albumin level were associated with the nutritional status. The Pearson's correlation test revealed statistically significant relationships between the number of hospitalization days and the MAC (mid-arm circumference), MAMC (mid arm muscle circumference), and serum albumin level. Moreover, according the logistic regression test, MAMC was most associated with the number of hospitalization days. According to stomach cancer stage, only the serum triglyceride level was showed a statistically significant association. However, the Pearson's correlation test revealed the MAC and serum albumin level to be associated with the number of hospitalization days. CONCLUSION: A nutritional assessment should be carried out in cancer patients pre-operatively. Moreover, the number of hospitalization days after surgery should decrease with adequate nutritional support. These results show that MAMC is most adequate data for assessing the nutritional status and could play a key role in decreasing the number of hospitalization days after surgery with adequate nutritional support. In addition, monitoring of the laboratory levels, such as albumin, triglyceride, and transferring, could be helpful in decreasing the number of hospitalization days. However, the other laboratory parameters, such as cholesterol, zinc, and total lymphocyte count, were not associated with the number of hospitalization days.

Carcinoembryonic Antigen (CEA) in the Gallbladder Bile (b-CEA) of Gastric Carcinoma Patients with Long-term Follow up

PURPOSE: Despite numorous reports on the relationship between the level of carcinoembryonic antigen (CEA) in gall bladder bile and liver metastasis in colorectal cancer, no similar studies have been carried out for gastric carcinomas. We, therefore, undertook the present study to establish the relationship between the gall bladder bile CEA and liver metastasis as well as the post-operative survival rate in gastric carcinoma patients with curative resections. MATERIALS AND METHODS: In 373 gastric cancer patients (252 males, 121 females, age 21~76 years) operated on at Kosin University Hospital between 1989~1996, the CEA concentration in the gall bladder bile was determined during the operation and the value was related to the rates of post-operative survival and liver metastasis during follow-up period. RESULTS: The overall rate of patient survival decreased gradually with increase in TNM stage. The 13-year post-operative survival rates for stages Ia, Ib, II, IIIa, and IIIb were 95.7%, 92.5%, 79.9%, 50.9%, and 43.3%, respectively, and the 10-year survival rate for stage IV was 22.6%. The patients with a high (> or =10 ng/ml) biliary CEA showed a significantly lower rate of survival than those with a low (0.10), but in those with high TNM stages (III and IV), the survival rate was significantly lower in the high CEA group (25.9%) than in the low CEA group (57.8%) (P<0.05). CONCLUSION: These result suggest that the gall bladder bile CEA level obtained in an advanced-staged gastric cancer operation may be used in predicting the post-operational survival rate and in sorting out patients with a high risk for cancer recurrence, especially in the liver area.

Hepatoid Adenocarcinoma of the Stomach: A Clinical Analysis of Fourteen Cases

PURPOSE: Hepatoid adenocarcinomas of the stomach are gastric carcinomas with both adenocarcinomatous and hepatocellular differentiations. Their incidence is rare, and they usually produce large amounts of alpha-fetoprotein (AFP). They have a specific pathologic feature, frequently occur together with liver metastasis and have a poor prognosis. This study was undertaken to understand the characteristics of clinical feature. METHODS: Fourteen hepatoid adenocarcinoma cases of gastric cancer were analyzed among 3243 patients who were treated for gastric cancer at our center between Jan 1996 and August 2003 (0.43%). RESULTS: There were 13 males and one female patient, with a median age of 59 years, ranging from 40 to 75. Ten tumors were located in the antrum, 2 in the body and 2 in the fundus. The size of the tumors varied from 2.3 to 11.0 cm. Direct invasions to adjacent organ were (4 to the pancreas and 1 to the colon). Four cases had visible lymph node enlargement at the time of the operation, ranging (from 3.5 to 6.0 cm). During the operation, 2 patients were found to have metastasis to the liver, 1 to the retroperitoneum, and 1 was positive on peritoneal washing cytology. The preoperative serum CEA levels were elevated in 7 patients, and 5 in 8 patients showed very high preoperative serum AFP levels ranging from 34.5 to 3724 ng/ml. All patients underwent a gastrectomy, and a hepatectomy in cases of liver metastasis. Pathological staging revealed one in stage Ib, four in stage II, one in stage IIIb and eight in stage IV. Immunohistochemical stainings was performed on all patients. Ten cases were positive for AFP. During follow up, eight patients died due to tumor (mean survival time: 10.6 months). Five had liver metastasis and 3 a recurrence in the peritoneum. The 6 remaining patients are still alive. CONCLUSION: 1. Hepatoid adenocarcinomas are rare and preoperatively diagnosis. The preoperative diagnostic methods of pathological consideration and preoperative serum AFP levels of all gastric cancer patients are recommended. 2. Hepatoid adenocarcinomas of the stomach have frequent and early postoperative liver metastasis and a poor prognosis, not only in advanced gastric caner but also in early cancer. Therefore, a possibly curative resection and more aggressive study for liver metastasis are recommended as being mandatory, and more sufficient treatment for these cases should be investigated.

Pylorus-Preserving Gastrectomy for Early Gastric Cancer

BACKGROUND: The physical results after a pylorus-preserving gastrectomy (PPG) for early gastric cancer were evluated. METHODS: From August 1996 to March 1998, sixteen (16) patients underwent a PPG, and 17 patients underwent a conventional distal gastrectomy with Billroth I anastomosis (DG). The patients undergoing the PPG and theDG procedures were assessed for 1 year following their surgical procedure. Changes in body weight, food intake volume, and abdominal symptoms, which were determined from questionaires, gastric-emptying tests using the acetaminophen method, and gastroscopic findings, were compared between the two groups. RESULTS: There were no significant differences in the body weight ratio and the amount of food taken in a meal between the two groups. Patients who had a PPG had fewer postoperative abdominal symptoms than those who underwent a DG. After a DG, emptying was much more rapid. Gastroscopy revealed that the mucosa of the stomach remnant after a PPG was less abnormal than it was after a DG, but food stasis was more frequent after a PPG. CONCLUSION: A PPG is a more physiological operation than a conventional DG and should be used in carefully selected patient with early gastric cancer to improve their quality of life.

Primary Gastric Small Cell Carcinoma / 대한암학회지

Small cell carcinoma is derived from APUDcells of any parts of the body. Usually the cases are discovered in the lungs and have poor prognosis. Small cell carcinoma has been increasingly reported in various organ outside the lungs, such as the larynx, thymus, esophagus, stomach, pancreas, uterine cervix, and prostate. Primary small cell carcinoma of the stomach is extremly rare. The histology of the tumor was similar to that of ordinary small cell carcinoma of the lung, and the secretory granules were identified by electron microscopy. We report a patient with gastric pure small cell carcinoma who treated by a radical total gastrectomy and chemotherapy.

Clinical Study of Primary Gastric Lymphoma and Analysis of Prognostic Factors

BACKGROUND: The stomach is the most common extra nodal site for non-Hodgkin's lymphoma: primary gastric lymphomas are uncommon, constituting only 1% to 5% of malignant gastric lesions. METHODS: To elucidate the clinicopathologic features of this lymphoma, we retrospectively analyzed 33 patients with primary gastric lymphoma who had been treated at our hospital from Jan. 1986 to Dec. 1995. RESULTS: Primary gastric lymphomas were 1.2% of all gastric cancers. The mean age 46 years (range 25 to 68 years). There were 23 men and 10 women. The most frequent chief complaint was epigastric pain. The most common location was the gastric antrum and body. According to the working formulation, the malignancy grades were 4 low, 26 intermediate, and 3 high. The overall 5-year survival rate was 60%. Survival of five years according to the TNM stage of the disease was as follows: stage 1, 88%; stage II, 71%; stage III, 33%; and stage IV, 29%. Patient with stage I, II disease had a 5-survival rate of 80% versus 35% for stage III, IV disease (p<0.05). Tumor serosal involvement and 5-year survival was follows: no perigastric serosal involvement, 93%; serosal infiltration, 33% (p=0.0016). In cases undergoing a subtotal gastrectomy, 5-year survival rate was 70%, whereas patients undergoing a total gastrectomy had a 5-year survival rate of 30% (p<0.05). Those with tumors smaller than 7 centimeters had a 5-year survival rate of 66% versus 38% for larger neoplasms (p=0.09). CONCLUSIONS: By univariate analysis, the stage, operation methods, and serosa involvement were significant prognostic factors. However, in multivariate analysis, only the serosa involvement was significant prognostic factor.

Churg-Strauss Syndrome with Multiple Small Bowel Perforation: A case report

Churg and Strauss established the clinicopathologic features of allergic angiitis and granulomatosis. The condition is rare and is characterized by involvement of vessels of all sizes(including veins and venules), especially the pulmonary vessel. intra- and extravascular granuloma formation, eosinophil infiltration of tissue and an association with asthma and peripheral eosinophilia. Churg Strauss syndrome (CSS) involves the GI tract, the skin, the heart, the lungs etc. We report a case of CSS in 38 year old male patient, who presented acute peritonitis and who had had 4-year history of bronchial asthma. An emergency laparotomy revealed multiple impending perforations in small intestine. A skin lesion and neuropathy developed postoperatively. Microscopic exammination of the appendix and the skin lesion showed thrombs in the lumens of vessels, vasculitis and eosinophilic infiltration to the lesion and the vessel wall.

Churg-Strauss Syndrome with Multiple Small Bowel Perforation: A case report

Churg and Strauss established the clinicopathologic features of allergic angiitis and granulomatosis. The condition is rare and is characterized by involvement of vessels of all sizes(including veins and venules), especially the pulmonary vessel. intra- and extravascular granuloma formation, eosinophil infiltration of tissue and an association with asthma and peripheral eosinophilia. Churg Strauss syndrome (CSS) involves the GI tract, the skin, the heart, the lungs etc. We report a case of CSS in 38 year old male patient, who presented acute peritonitis and who had had 4-year history of bronchial asthma. An emergency laparotomy revealed multiple impending perforations in small intestine. A skin lesion and neuropathy developed postoperatively. Microscopic exammination of the appendix and the skin lesion showed thrombs in the lumens of vessels, vasculitis and eosinophilic infiltration to the lesion and the vessel wall.

Effectiveness of Routine Nasogastric Decompression in Elective Gastric Surgery

BACKGROUND : Prophylactic nasogastric decompression is used routinely after elective gastric surgery in spite of many disadvantages and complications - discomfort, pain, especially postoperative atelectasis. The aim of this study was to determine whether routine nasogastric decompression benefitted patients undergoing elective stomach operations. METHODS : Two hundreds forty patients were studied prospectively. All patients underwent elective gastric surgery from January 1994 to March 1996 by one surgeon at Gospel Hospital. In the intubated group, 120 consecutive patients were treated with a nasogastric tube (silastic, 16 French) just before or during the operation, it being removed on the 1st or the 2nd postoperative day. In the tubeless group, a nasogastric tube was not inserted at all in 120 consecutive patients. We compared the differences between two groups with respect to the mean duration of flatus passing, the incidence of postoperative pulmonary complication, leakage, reoperation, wound dehiscence, and operation mortality. RESULTS : The two groups showed no significant differences in age, sex and operation methods. Flatus passed earlier in the tubeless group, but the difference was statistically insignificant. The patients suffering from atelectasis were much larger in number in the intubated group (p<0.03). There were no significant differences in the incidence of anastomotic leakage, wound dehiscence, reoperation and operation mortality. CONCLUSIONS : The routine omission of nasogastric intubation was not associated with increased risks, such as leakage, wound dehiscence, reoperation, postoperative pulmonary complication, delayed flatus passing or diet intake, operative morbidity and motality. Conversely, the incidence of postoperative atelectasis was twice as high in the intubated group. We conclud that routine nasogastric intubation should be used only in specific cases and routine use of nasogastric intubation is not justified.

Morphological Transformation Region II (mtrII) of Human Cytomegalovirus / 대한암학회지

PURPOSE: Human herpesviruses have been associated with the etiology of several human cancers. The role of these viruses in carcinogenesis has not yet been clarified. This study focused on identifying and characterizing the transforming potential of cloned DNA fragments from human cytomegalovirus (HCMV). MATERIALS AND METHODS: Multiple DNA fragments of HCMV were applied to cells for transformation. Morphological transforming region II (mtrII) of HCMV strain Towne has been identified to a 3.0kb XbaI-BamHI DNA fragment which was retained in transformed cells. The transforming activity was induced by a 980 bp BaII-Xho I subfragment (pBS980) containing both promoter/ regulatory elements as well as three open reading frames (ORFs), i.e., 79ORF, 83ORF, and 34ORF. The ORFs have been evaluated for transforming potential in NIH3T3 cells. RESULTS: MtrII (pBS980) has BglII restriction enzyme site which divides into two subfragments, pBS440 and pBS540, the latter has whole 83ORF, 34ORF, and fragment of 79ORF, the former has only fragment of 79ORF. Among three ORFs, 83ORF and 34ORF were not functional in transformation, because in pBS540 these ORFs were not truncated. CONCLUSION: The 79ORF (79-aa transforming peptide) has allowed a better approach to determine the role of HCMV in human carcinogenesis.