Clinical significance of additional gastrectomy after non-curative endoscopic submucosal dissection for early gastric cancer: a retrospective single-center study

Purpose@#Additional surgery is recommended for patients after a non-curative endoscopic submucosal dissection (ESD) to prevent residual cancer (RC) or lymph node metastasis (LNM). We aimed to evaluate the clinicopathologic characteristics of patients who underwent an additional gastrectomy after a non-curative ESD procedure and identify the risk factors of RC and LNM. @*Methods@#We retrospectively assessed the clinicopathological factors of 73 patients who underwent additional gastrectomy following a non-curative ESD between January 2009 and December 2019 at our center. @*Results@#RC and LNM rates after additional gastrectomy were 9.6% and 8.2%, respectively. Invasion deeper than 500 μm (P = 0.045), positive horizontal resection margin (P < 0.001), and positive ESD margin (P = 0.001) were identified as statistically significant factors in univariate analysis for RC, but not in multivariate analysis. Lymphatic invasion was the only risk factor found to be significant in both univariate and multivariate analyses (P = 0.005 and P = 0.012). @*Conclusion@#Additional gastrectomy is necessary to prevent RC or LNM after non-curative ESD. Lymphatic invasion was also associated with LNM in patients who underwent an additional gastrectomy after a non-curative ESD, and in such cases, active treatment is required.

External Validation of a Gastric Cancer Nomogram Derived from a Large-volume Center Using Dataset from a Medium-volume Center

PURPOSE: Recently, a nomogram predicting overall survival after gastric resection was developed and externally validated in Korea and Japan. However, this gastric cancer nomogram is derived from large-volume centers, and the applicability of the nomogram in smaller centers must be proven. The purpose of this study is to externally validate the gastric cancer nomogram using a dataset from a medium-volume center in Korea. MATERIALS AND METHODS: We retrospectively analyzed 610 patients who underwent radical gastrectomy for gastric cancer from August 1, 2005 to December 31, 2011. Age, sex, number of metastatic lymph nodes (LNs), number of examined LNs, depth of invasion, and location of the tumor were investigated as variables for validation of the nomogram. Both discrimination and calibration of the nomogram were evaluated. RESULTS: The discrimination was evaluated using Harrell's C-index. The Harrell's C-index was 0.83 and the discrimination of the gastric cancer nomogram was appropriate. Regarding calibration, the 95% confidence interval of predicted survival appeared to be on the ideal reference line except in the poorest survival group. However, we observed a tendency for actual survival to be constantly higher than predicted survival in this cohort. CONCLUSIONS: Although the discrimination power was good, actual survival was slightly higher than that predicted by the nomogram. This phenomenon might be explained by elongated life span in the recent patient cohort due to advances in adjuvant chemotherapy and improved nutritional status. Future gastric cancer nomograms should consider elongated life span with the passage of time.

Gastric carcinosarcoma

Gastric carcinosarcoma is an uncommon biphasic malignant tumor. We report the case of 59-year-old man with a history of melena and dizziness. Endoscopic findings showed a fungating mass that originated from the posterior wall of upper body. Radical total gastrectomy with Roux-en-Y esophagojejunostomy was performed. In the resected specimen, immunohistochemical studies for epithelial and mesenchymal markers showed positive reactions. The mass invaded the submucosa without regional lymph node metastasis. Adjuvant chemotherapy with TS-1 (Taiho Pharmaceutical Co. Ltd, Japan) was performed after surgery despite early clinical stage due to aggressive features of carcinosarcoma.

In which group of gastric cancer patients is the preoperative neutrophil-to-lymphocyte ratio a significant prognostic factor?

PURPOSE: Several recent studies have reported on the clinical importance and prognostic significance of neutrophil-to-lymphocyte ratio (NLR) in gastric cancer. The objective of this study was to identify the subgroups of patients with gastric cancer for which the preoperative NLR was prognostically significant.METHODS: Data from 870 patients who were among those who had undergone surgery for gastric cancer between August 2005 and December 2013 were evaluated. Receiver operating characteristic curve analysis was used to determine the cut-off value for NLR. The patients were classified into high-NLR (NLR≥1.7) and low-NLR (NLR<1.7) groups, and survival analysis of subgroups of gastric cancer patients was performed.RESULTS: Univariate analysis identified age, gender, tumor location, tumor histology, tumor, node, metastasis (TNM) stage, and NLR as significant prognostic factors. Multivariate analysis identified age, TNM stage, and NLR as significant prognostic factors. In subgroup analysis, NLR was a significant prognostic factor except group of TNM stage I, II with age younger than 70 years.CONCLUSION: Except group of TNM stage I, II with age younger than 70 years, careful postoperative follow-up is warranted for those patients with elevated NLR.

Time-Dependent Effects of Prognostic Factors in Advanced Gastric Cancer Patients

PURPOSE: This study aimed to identify time-dependent prognostic factors and demonstrate the time-dependent effects of important prognostic factors in patients with advanced gastric cancer (AGC). MATERIALS AND METHODS: We retrospectively evaluated 3,653 patients with AGC who underwent curative standard gastrectomy between 1991 and 2005 at the Korea Cancer Center Hospital. Multivariate survival analysis with Cox proportional hazards regression was used in the analysis. A non-proportionality test based on the Schoenfeld residuals (also known as partial residuals) was performed, and scaled Schoenfeld residuals were plotted over time for each covariate. RESULTS: The multivariate analysis revealed that sex, depth of invasion, metastatic lymph node (LN) ratio, tumor size, and chemotherapy were time-dependent covariates violating the proportional hazards assumption. The prognostic effects (i.e., log of hazard ratio [LHR]) of the time-dependent covariates changed over time during follow-up, and the effects generally diminished with low slope (e.g., depth of invasion and tumor size), with gentle slope (e.g., metastatic LN ratio), or with steep slope (e.g., chemotherapy). Meanwhile, the LHR functions of some covariates (e.g., sex) crossed the zero reference line from positive (i.e., bad prognosis) to negative (i.e., good prognosis). CONCLUSIONS: The time-dependent effects of the prognostic factors of AGC are clearly demonstrated in this study. We can suggest that time-dependent effects are not an uncommon phenomenon among prognostic factors of AGC.

Preoperative neutrophil-to-lymphocyte ratio is a prognostic factor for overall survival in patients with gastric cancer

PURPOSE: Preoperative neutrophil-to-lymphocyte ratio (NLR) reflects patients' inflammation status, clinical stage, and survival in various malignancies. However, only a limited amount of information on the clinical importance and prognostic significance of NLR in gastric cancer has been reported. The objective of this study is to assess the prognostic values of preoperative NLR in patients with gastric cancer. METHODS: During the period between August 1, 2005 and December 31, 2011, we collected data from 601 patients among those who had undergone surgery for gastric cancer at the Department of Surgery, Konkuk University Medical Center. We classified the subjects into high NLR (NLR > or = 1.7) group and low NLR (NLR or = 1.7), and old age (> or = 70 years) are significant, independent prognostic factor for overall survival in patients with gastric cancer.

Intra-abdominal fibromatosis after gastrectomy for gastric cancer

Intra-abdominal fibromatosis (IAF) may arise either sporadically or in association with familial adenomatous polyposis. The characteristics of fibromatosis are slow-growth, benign histological features, and aggressive local invasion. Surgery remains a reasonable first treatment option. Here, we report 2 cases of a phenomenon rarely described in published literature, IAF after gastrectomy for gastric cancer. Intra-abdominal masses were found during the routine follow-up period in a 50-year-old man who had received a radical subtotal gastrectomy for early gastric cancer. Two mesenteric masses were detected in the upper abdomen by CT and were excised completely along with segments of the jejunum. Another intra-abdominal mass was found in 60-year-old man who had received a radical total gastrectomy for advanced gastric cancer. A 4.2-cm-sized mass was detected in the periumbilical region by follow-up CT and was excised completely along with a segment of the ileum.

Small bowel diverticulosis in patient with early gastric cancer

Jejunal and ileal diverticula are rare in adults. Duodenal diverticula are five times more prevalent than jejunoileal diverticula. Most patients are asymptomatic. However, chronic symptoms including intermittent abdominal pain, flatulence, diarrhea and constipation are seen in 10%-30% of patients. Gastric cancer is the second most common cancer in South Korea and here we report a case of early gastric cancer with multiple duodenal and jejunal diverticula. A 67-year-old woman was admitted to Konkuk University Medical Center with chronic diarrhea and weight loss of 19 kg over 2 months. Following gastroduodenoscopy, we identified adenocarcinoma of the lower body of the stomach. On abdominopelvic computed tomography, diverticula of duodenum and jejunum were found. Patient underwent distal gastrectomy and gastroduodenostomy with lymphadenectomy. She was discharged on the tenth postoperative day without complications.

Test Execution Variation in Peritoneal Lavage Cytology Could Be Related to Poor Diagnostic Accuracy and Stage Migration in Patients with Gastric Cancer

PURPOSE: Peritoneal lavage cytology is part of the routine staging workup for patients with advanced gastric cancer. However, no quality assurance study has been conducted to show variations or biases in peritoneal lavage cytology results. The aim of this study was to demonstrate a test execution variation in peritoneal lavage cytology between investigating surgeons. MATERIALS AND METHODS: A prospective cohort study was designed for determination of the positive rate of peritoneal lavage cytology using a liquid-based preparation method in patients with potentially curable advanced gastric cancer (cT2~4/N0~2/M0). One hundred thirty patients were enrolled and underwent laparotomy, peritoneal lavage cytology, and standard gastrectomy, which were performed by 3 investigating surgeons. Data were analyzed using the chi-square test and a logistic regression model. RESULTS: The overall positive peritoneal cytology rate was 10.0%. Subgroup positive rates were 5.3% in pT1 cancer, 2.0% in pT2/3 cancer, 11.1% in pT4a cancer, and 71.4% in pT4b cancer. In univariate analysis, positive peritoneal cytology showed significant correlation with pT stage, lymphatic invasion, vascular invasion, ascites, and the investigating surgeon. We found the positive rate to be 2.1% for surgeon A, 10.2% for surgeon B, and 20.6% for surgeon C (P=0.024). Multivariate analysis identified pT stage, ascites, and the investigating surgeon to be significant risk factors for positive peritoneal cytology. CONCLUSIONS: The peritoneal lavage cytology results were significantly affected by the investigating surgeon, providing strong evidence of test execution variation that could be related to poor diagnostic accuracy and stage migration in patients with advanced gastric cancer.

Hepatic Resection for Hepatic Metastases from Gastric Adenocarcinoma

PURPOSE: The effects of hepatic resection on patients with metastatic tumors from gastric adenocarcinomas are unclear. Therefore, we analyzed early clinical outcomes in patients who underwent surgical resection for hepatic metastases from gastric adenocarcinomas. MATERIALS AND METHODS: From January 2003 to December 2010, 1,508 patients with primary gastric cancers underwent curative gastric resections at the Korea Cancer Center Hospital. Of these patients, 12 with liver-only metastases underwent curative hepatic resection. Their clinical data were analyzed retrospectively. RESULTS: The median follow-up period was 12.5 months (range, 1~85 months); no operative mortalities or major complications were observed. Three patients underwent synchronous resections, and 9 underwent metachronous resections. In the latter group, the median interval between gastrectomy and hepatectomy for hepatic metastasis was 10.5 months (range, 5~47 months). The overall 1- and 5-year survival rates of these 12 patients were 65% and 39%, respectively, with a median overall survival of 31.0 months; 2 patients survived for >5 years. CONCLUSIONS: Hepatic resection can be a feasible procedure for treating hepatic metastases from gastric adenocarcinomas. Although this study was small and involved only selected cases, the outcomes of the hepatic resections were comparable and long-term (>5 years) survivors were identified. Surgical resection of the liver can be considered a feasible option in managing hepatic metastases from gastric adenocarcinomas.

Risk Stratification for Serosal Invasion Using Preoperative Predictors in Patients with Advanced Gastric Cancer

PURPOSE: Although serosal invasion is a critical predisposing factor for peritoneal dissemination in advanced gastric cancer, the accuracy of preoperative assessment using routine imaging studies is unsatisfactory. This study was conducted to identify high-risk group for serosal invasion using preoperative factors in patients with advanced gastric cancer. MATERIALS AND METHODS: We retrospectively analyzed clinicopathological features of 3,529 advanced gastric cancer patients with Borrmann type I/II/III who underwent gastrectomy at Korea Cancer Center Hospital between 1991 and 2005. We stratified patients into low- (70%) groups, according to the probability of serosal invasion. RESULTS: Borrmann type, size, longitudinal and circumferential location, and histology of tumors were independent risk factors for serosal invasion. Most tumors of whole stomach location or encircling type had serosal invasion, so they belonged to high-risk group. Patients were subdivided into 12 subgroups in combination of Borrmann type, size, and histology. A subgroup with Borrmann type II, large size (> or =7 cm), and undifferentiated histology and 2 subgroups with Borrmann type III, large size, and regardless of histology belonged to high-risk group and corresponded to 25% of eligible patients. CONCLUSIONS: This study have documented high-risk group for serosal invasion using preoperative predictors. And risk stratification for serosal invasion through the combination with imaging studies may collaboratively improve the accuracy of preoperative assessment, reduce the number of eligible patients for further staging laparoscopy, and optimize therapeutic strategy for each individual patient prior to surgery.

Phenotypic Differences of Gastric Cancer according to the Helicobacter pylori Infection in Korean Patients

PURPOSE: Infection with Helicobacter pylori is an important risk factor for gastric cancer in humans. We compared the clinicopathologic features of gastric cancer patients based on H. pylori infection. MATERIALS AND METHODS: We prospectively studied 155 patients who had gastric cancer and underwent gastrectomies in 1 hospital in Korea. We examined H. pylori infections using the rapid urease test (RUT) with gastrectomy specimens and collected clinical and pathologic data. RESULTS: The number of H. pylori infections based on the RUT was 137 (88%). The H. pylori-negative group was significantly associated with AGC and tumor histology. H. pylori infection was significantly correlated with type I/IIa in EGC and type III/IV/V in AGC. AGC was significantly correlated with larger tumor size, lymphatic invasion, perineural invasion, and H. pylori infection based on univariate and multivariate analyses. CONCLUSIONS: We report the prevalence of H. pylori based on the RUT in gastric cancer patients. H. pylori infection influences the tumor histology, progression, and growth type of gastric cancer.

Phenotypic Differences of Gastric Cancer according to the Helicobacter pylori Infection in Korean Patients

PURPOSE: Infection with Helicobacter pylori is an important risk factor for gastric cancer in humans. We compared the clinicopathologic features of gastric cancer patients based on H. pylori infection. MATERIALS AND METHODS: We prospectively studied 155 patients who had gastric cancer and underwent gastrectomies in 1 hospital in Korea. We examined H. pylori infections using the rapid urease test (RUT) with gastrectomy specimens and collected clinical and pathologic data. RESULTS: The number of H. pylori infections based on the RUT was 137 (88%). The H. pylori-negative group was significantly associated with AGC and tumor histology. H. pylori infection was significantly correlated with type I/IIa in EGC and type III/IV/V in AGC. AGC was significantly correlated with larger tumor size, lymphatic invasion, perineural invasion, and H. pylori infection based on univariate and multivariate analyses. CONCLUSIONS: We report the prevalence of H. pylori based on the RUT in gastric cancer patients. H. pylori infection influences the tumor histology, progression, and growth type of gastric cancer.

The Outcomes of Curative Resection for Ampulla of Vater Cancer

INTRODUCTION: The prognosis of peri-ampullary cancer is poor because of its low respectability and high recurrence rate. Yet cancer of the Ampulla of Vater(AOV) has a relatively good prognosis. The aim of this study is to investigate the outcomes and to determine the factors that affect the survival rate of patients who underwent curative resection for AOV cancer. METHODS: From August 1988 to January 2008, 54 patients underwent curative resection for AOV cancer. We retrospectively reviewed the clinocopathologic data. The median follow up period was 45 months. RESULTS: Twenty-seven pancreaticoduodenectomies (PD) and 27 pyrolus-preserving pancreaticoduodenectomies (PPPD) were performed. There was no hospital mortality, but 25 out of 54 patients (47.3%) experienced postoperative complications. The 5-year overall survival (OS) rate was 53.97% and the 5-year disease free survival (DFS) rate was 51.75%. On multivariate analysis, the variables that affected the overall survival rate and the disease free survival rate was poor histologic differentiation (p<0.001). CONCLUSIONS: Although the AOV cancer is one of the periampullary cancers that have a very poor outcome, long-term survival and favorable outcomes can be achieved after a curative resection. In this study, poor-histologic differentiation was the only independent factor for a poor prognosis.

An Alternative Method for a Rapid Urease Test Using Back-table Gastric Mucosal Biopsies from Gastrectomy Specimen for Making the Diagnosis of Helicobacter pylori Infection in Patients with Gastric Cancer

PURPOSE: The rapid urease test is a rapid and reliable method for diagnosing Helicobacter pylori infection. However it requires gastric mucosal biopsies during endoscopy, and the test is not covered by national health insurance for patients with gastric cancer. So, we introduced an alternative method for a rapid urease test using back-table gastric mucosal biopsies from gastrectomy specimen. MATERIALS AND METHODS: Ninety gastric cancer patients underwent an anti H. pylori IgG ELISA test and gastrectomy. Just after gastrectomy, two gastric mucosal biopsies from the prepyloric antrum and lower body of the gastrectomy specimen were taken from the back table in the operative room, and these were fixed immediately with the rapid urease test kit, and the color change was monitored for up to 24 hours. In this study, H. pylori infection was defined as positive when the serology or rapid urease test showed positive results. RESULTS: The positive rate of the rapid urease test and serology was 91.1% and 77.8%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of the rapid urease test and serology were 94.3 and 80.5%, 100 and 100%, 100 and 100%, and 37.5 and 15%, respectively. The accuracy of the rapid urease test was higher than that of serology (94.4 vs. 81.1%, respectively). The rapid urease test showed a higher rate of detecting H. pylori infection than that of serology (McNemar's test, P=0.019). CONCLUSION: The result of the rapid urease test using back-table gastric mucosal biopsies from a gastrectomy specimen is comparable to the reference data of the conventional rapid urease test using gastric mucosal endoscopic biopsies. Therefore, it can be an alternative diagnostic method for H. pylori infection.

Survival Rates after Operation for Gastric Cancer: Fifteen-year Experience at a Korea Cancer Center Hospital

PURPOSE: Gastric cancer is the most common malignant tumor in Korea. We reviewed the cases at our institution to identify the survival rates and clarify the prognostic factors of patients with gastric cancer. MATERIALS AND METHODS: We conducted a retrospective study of 6,918 patients who had received a diagnosis of gastric cancer, and they underwent surgery at Korea Cancer Center Hospital during a 15-year period from 1991 to 2005. RESULTS: The overall 5-year survival rate was 66.8%. The univariate analysis revealed that age, location of tumor, gross type of tumor, the histology according to the WHO classification, the Lauren classification, depth of invasion (T stage), lymph node metastasis (N stage), distant metastasis (M stage), the type of surgery, the UICC TNM stage, postoperative complications, adjuvant chemotherapy, lymphatic invasion, venous invasion and perineural invasion were the significantly different factors of the survival rates. The multivariate analysis revealed that age , Borrmann type 4, the histology according to the WHO classification, depth of invasion (T stage), lymph node metastasis (N stage), distant metastasis (M stage), the type of surgery, UICC TNM stage, postoperative complications, adjuvant chemotherapy and lymphatic invasion were the independent prognostic factors. CONCLUSION: We have shown a statistically significant association between the survival rates after operation for gastric cancer and the clinicopathologic factors. Early diagnosis of gastric cancer, appropriate surgeryand adjuvant therapy might improve the quality of life and the survival rates of gastric cancer patients.

The Early Experience with a Laparoscopy-assisted Pylorus-preserving Gastrectomy: A Comparison with a Laparoscopy-assisted Distal Gastrectomy with Billroth-I Reconstruction

PURPOSE: Pylorus-preserving gastrectomy (PPG), which retains pyloric ring and gastric function, has been accepted as a function-preserving procedure for early gastric cancer for the prevention of postgastrectomy syndrome. This study was compared laparoscopy-assisted pylorus-preerving gastrectomy (LAPPG) with laparoscopy-assisted distal gastrectomy with Billroth-I reconstruction (LADGB I). MATERIALS AND METHODS: Between November 2006 and September 2007, 39 patients with early gastric cancer underwent laparoscopy-assisted gastrectomy in the Department of Surgery at Korea Cancer Center Hospital. 9 of these patients underwent LAPPG and 18 underwent LADGBI. When LAPPG was underwent, we preserved the pyloric branch, hepatic branch, and celiac branch of the vagus nerve, the infrapyloric artery, and the right gastric artery and performed D1+beta lymphadenectomy to the exclusion of suprapyloric lymph node dissection. The distal stomach was resected while retaining a 2.5~3.0 cm pyloric cuff and maintaining a 3.0~4.0 cm distal margin for the resection. RESULTS: The mean age for patients who underwent LAPPG and LADGBI were 59.9+/-9.4 year-old and 64.1+/-10.0 year-old, respectively. The sex ratio was 1.3:1.0 (male 5, female 4) in the LAPPG group and 2.6:1.0 (male 13, female 5) in the LADGBI group. Mean total number of dissected lymph nodes (28.3+/-11.9 versus 28.1+/-8.9), operation time (269.0+/-34.4 versus 236.3+/-39.6 minutes), estimated blood loss (191.1+/-85.7 versus 218.3+/-150.6 ml), time to first flatus (3.6+/-0.9 versus 3.5+/-0.8 days), time to start of diet (5.1+/-0.9 versus 5.1+/-1.7 days), and postoperative hospital stay (10.1+/-4.0 versus 9.2+/-3.0 days) were not found significant differences (P>0.05). The postoperative complications were 1 patient with gastric stasis and 1 patient with wound seroma in LAPPG group and 1 patient with left lateral segment infarct of liver in the LADGB I group. CONCLUSION: Patients treated by LAPPG showed a comparable quality of surgical operation compared with those treated by LADGBI. LAPPG has an important role in the surgical management of early gastric cancer in terms of quality of postoperative life. Randomized controlled studies should be undertaken to analyze the optimal survival and long-term outcomes of this operative procedure.

The Clinical Significance and Detection of Intraperitoneal Micrometastases by ThinPrep(R) Cytology with Peritoneal Lavage Fluid in Patients with Advanced Gastric Cancer

PURPOSE: Peritoneal lavage cytology is regarded as a useful diagnostic test for detecting intraperitoneal micrometastsis. However, there are currently no reports about cytological examination with ThinPrep(R) (CY), a newly introduced fluid-based diagnostic system, in patients with advanced gastric cancer (AGC). This study was performed to analyze the clinical significance of intraoperative peritoneal lavage for CY in AGC patients. MATERIALS AND METHODS: 424 AGC patients were suspected to have serosal exposure macroscopically during surgery and they underwent intraoperative peritoneal lavage for CY between 2001 and 2006 at Korea Cancer Center Hospital. The clinical data, pathological data and CY results were collected and analyzed retrospectively. RESULTS: The percentage of cytology positive results was 31.1%, and this was well correlated with the T-stage, N-stage and P-stage. The 3-year survival rates of CY0 and CY1 were 68.1% and 25.9%, respectively. According to the P-stage and CY, the 3-year survival rates were 71.1% in P0CY0, 38.9% in P0CY1, 38.5% in P1/2/3CY0 and 11.0% in P1/2/3CY1. Interestingly, both the P0CY1 and P1/2/3CY0 survival curves were similar figures, but they were significantly different from those of the other groups. Multivariate analysis indicated that CY was an independent, strong prognostic factor for survival, as well as sex, the T-stage, N-stage, P-stage, other metastasis and the serum CEA. CY1 was revealed as a risk factor for peritoneal recurrence in the curative resection group. CONCLUSION: The results certify indirectly that cytological examination using ThinPrep(R) is a very reliable diagnostic method for detecting intraperitoneal micrometastasis from the fact that it is not only a strong prognostic factor, but it is also a risk factor for peritoneal recurrence in AGC patients. Therefore intraoperative peritoneal lavage should be included in the routine intraoperative staging workup for AGC, and its result will provide a good target for the treatment of peritoneal micrometastasis.

Combined Cytoreductive Surgery and Early Postoperative Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Gastric Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Peritoneal seeding is the most common type of metastasis or recurrence and one of the poor prognostic factors in gastric cancer. Moreover, there are as yet no effective treatment modalities available. Recently some research groups suggested the benefit of combined cytoreductive surgery and intraperitoneal chemotherapy, but the related experiments remain in the trial stage. Therefore, we assessed the safety and evaluated the efficacy of combined cytoreductive surgery and early postoperative intraperitoneal chemotherapy (EPIC) in gastric cancer patients with peritoneal carcinomatosis of gastric cancer. MATERIALS AND METHODS: From Nov. 1997 to May. 2002, eighteen cases of combined cytoreduction and EPIC were performed in the Korea Cancer Center Hospital due to gastric cancer with peritoneal carcinomatosis. The control group consisted of 33 patients who had no resection without EPIC during the same periods. After combined cytoreductive surgery and EPIC, all patients received systemic chemotheraphy with the exception of 2 patients who could not tolerate the treatment. We retrospectively investigated the clinicopathologic features and analyzed the factors affecting the prognosis. Median follow-up period was 11.9 months (range 0.5~61 months). Statistical analysis was performed by SPSS 11.0 for Windows. A P-value less than 0.05 was considered as statistically significant. RESULTS: There was one case of the treatment-related mortality (5.5%) and seven cases of treatment-related complications (38%) in the combined cytoreductive surgery and intraperitoneal chemotherapy group. One-, 3- and 5-year survival rates of cytoreductive surgery plus EPIC were 57.6%, 25.9% and 13.0%, respectively, and those of the control group were 18.2%, 3% and 0%, respectively. Survival of the combined cytoreductive surgery plus EPIC group was better than that of the control group (p=0.0026). In multivariate analysis of prognostic factors affecting the survival, combined cytoreductive surgery plus EPIC (p=0.02) and systemic chemotherapy (p=0.019) were independent prognostic factors. CONCLUSION: Although a small number of cases were included in this study, combined cytoreductive surgery plus EPIC showed survival benefit and retained a comparable complication rate compared with the control group.

Imaging of Estrogen Receptors with Iodine-123- Iabeled Estradiol in Primary Breast Cancer Patients

PURPOSE: We evaluated the feasibility of non-invasive imaging of estrogen receptors (ER) in primary breast cancer with iodine-123-labeled ER specific ligand (17alpha,20E)-21-[123I] iodo-19-nonpregna-1,3,5-(10), 20-tetraene-3, 17-diol using conventional nuclear medicine technique. METHODS: Before they underwent surgical management, planar scintigraphy and single-photon emission computed tomography (SPECT) were performed in 18 patients with proven primary breast cancer, after single IV injection of 5~10 mCi I-123-estradiol. The results were compared with those of immunohistochemical staining against ER of the surgical specimens. RESULTS: Planar and SPECT imaging showed hot uptake in nine of eighteen (50%) breast cancer patients. The results of ER immunohistochemistry were all positive in these patients. In the 9 cases of negative scintigraphy, 8 showed negative staining results but one showed positive staining results. Therefore, the overall concordance rate of ER scintigraphy and ER immunohistochemistry was 94.4% (17/18). CONCLUSION: ER scintigraphy using I-123-estradiol is a highly predictable in vivo technique to detect ER-positive breast cancer preoperatively. It has potential application as a reliable diagnostic modality and indicator of hormone therapy for breast cancer patients.