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

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

Comparison of Laparoscopic Cholecystectomies between the Two 5-year Intervals

PURPOSE: The laparoscopic cholecystectomy has become a common procedure for treating gallbladder disease. The objectives of this study was to evaluate the learning curve by reviewing 145 patients treated with laparoscopic cholecystectomy, between Group A (From January 1991 to December 1995) and Group B (From January 1996 to December 2000). METHODS: We retrospectively analyzed 145 laparoscopic cholecystectomies performed at the Department of General Surgery, National Medical Center, from January 1991 to December 2000. The sex, age, operation time, associated disease, previous operation history, hospital stay, and pathology were reviewed. RESULTS: The ratio of Females to males was 1.9:1, and their age ranged from 18 to 80 years with the majority in their fifties and sixties. Most of the operative indications were cholelithiasis. The mean operative time was 89 minutes, which varied between 40 and 180 minutes, and the average admission time was five days. The operation times of Group A and Group B were statistically significant with respect to learning curve (p value<0.000). A linear regression test of the operation time and operation cases was also significant. The postoperative analgesic injection and hospital stay were improved in Group B, but had no statistical significance. A conversion to open cholecystectomy was done in four cases due to bleeding, severe adhesion, or clip migration of the cystic duct during surgery. CONCLUSION: The laparoscopic cholecystectomy was a safe and effective treatment for gallbladder disease, and wepredict that the operation time will become shorter with more experience.

Extrahepatic Biliary Precancerous Lesions associated with Choledochal Cyst / 한국간담췌외과학회지

BACKGROUND: Carinoma arising from the choledochal cyst is rare but well known complication, the mechanism of which is, however, still unclear. This study is intended to analogize the mechanism of carcinogenesis in choledocahl cyst from the changes in the cyst epithelium according to the age groups. MATERIALS AND METHODS: This retrospective study included 19 cases of choledochal cysts and was performed by comparing 6 cases of group I patients(age less than 20) to 13 cases of group II patients(age 20 or more).The records of both group patients were reviewed for demographic and clinical features. Histopathologic findings and immunoreactivities for p53 were comparatively analyzed. RESULTS: In group I, epithelial changes of chronic inflammation, regeneration atypia, hyperplasia, intestinal metaplasia and dysplasia were found in 6, 4, 5, 1 and 3 cases, respectively. In group II, there were 12 chronic inflamation, 5 regeneration atypia, 7 hyperplasia, 1 intestinal metaplasia, and 11 dysplasia including 4 high grade and 7 low grade dysplasia. There were also 3 carcinomas arising from the cyst in group II. p53 immunoreactivities were only found in those with dysplasia and carcinoma. CONCLUSIONS: Intestinal metaplasia presents in only 2 cases. On the other hand, dysplasia is one of the predominant findings in the epithelium of the cysts. These findings suggest carcinogenesis in choledochal cyst presumably follow de novo pathway(repeated injury/regeneration - dysplasia - carcinoma) rather than metaplasia - dysplasia - carcinoma sequence.

Clinical Analysis of Patients with Gastrectomized Stage IV Stomach Cancer / 대한암학회지

PURPOSE: The prognosis of stage IV stomach cancer patients is very poor and the effectiveness of radical surgery including extended lymphadenectomy and combined resection in these patients is still controversial. The purposes of this retrospective study were to identify the prognostic factors and to evaluate the effectiveness of extended lymphadenectomy and combined resection in stage IV stomach cancer paients. MATERIALS AND METHODS: Of 585 patients who were operated for stomach cancer at the NMC from Jan. 1987 to Oct. 1993, 154 patients of stage IV stomach cancer (121 patients who had distant metastasis and 33 patients who had not) were identified. We analyzed data of these 154 patients to find the characteristic clinicopathological features, the prognostic factors and the proper extent of surgical treatment. RESULTS: Comparing with stage I, II and III groups, larger tumor size, higher proportions of Borrmann type IV and undifferentiated carcinoma and higher rates of lymph node metastasis and combined resection were noticed in stage IV stomach cancer group. In combined resection, pancreas tail was mainly resected due to tumor invasion but spleen was mainly resected for the completeness of lymph node dissection. In multivariate analyses, peritoneal metastasis and postoperative residual tumor were independent prognostic factors. The overall 5-year survival rate was 14.6%. Stage IV stomach cancer patients without distant metastasis had better 5-year survival rate than that of those who had distant metastasis (34.3% vs 7.9%, p=0.00001). CONCLUSIONS: Radical procedures including extended lymphadenectomy and combined resection of the invaded organs should be considered in the stage IV stomach cancer patients without distant metastasis.

Comparative Analysis of Clinicopathologic Features and Tumor Suppressor Genes Expression According to Growth Patterns in Colorectal Carcinomas

PURPOSE: Growth patterns of colorectal carcinomas can be divided into polypoid growth (PG) and nonpolypoid growth (NPG). This study was intended to find characteristic clinicopathologic features and the expression status of p53, p21, and p16 with relation to growth patterns in colorectal carcinomas. METHODS: Sixty-one surgically resected colorectal carcinomas including 43 PG and 18 NPG carcinomas were reviewed in this study. Immunohistochemical stains for p53, p21, and p16 were done, and the results were analyzed with respect to growth patterns, and other prognosic parameters. RESULTS: PG carcinomas were significantly correlated with adenoma (p=0.0001), and with favorable histology group (p=0.04). On the contrary, NPG carcinomas were significantly correlated with unfavorable histology group (p=0.04). In NPG carcinomas, the frequency of positive expression of p53 was higher and the expression of p16 was lower than that of PG carcinomas. But there was no statistical significance (p=0.150, 0.210 respectively). The expression of p21 has no difference between NPG and PG carcinomas (p=0.953). CONCLUSIONS: As a result, it can be thought that the tendency of higher expression of p53 and lower expression of p16 in NPG carcinomas than in PG carcinomas may suggest more aggressive biologic behavior of NPG carcinomas.

Mammographic and Clinical Correlation of Axillary Lymph Nodes

BACKGROUND: The purpose of this study was to determine the cause of the axillary abnormalities seen in mammography and to evaluate the imaging characteristics of benign lymphadenopathy and lymphadenopathy associated with malignancy. METHODS: One hundred ninety-three (193) abnormalities seen mammographically were retrospectively reviewed and correlated with clinical diagnoses and pathologic results found in the medical records of patients treated from August 1997 to July 1998 at the National Medical Center. For each abnormality, the length, the margins and the presence of microcalcifications were noted. RESULTS: One hundred seventy-eight (178) patients had benigh lymphadenopathy and twelve patients had metastatic breast cancer. The mean lengths of lymph nodes in benign lymphadenopathy & metastatic breast cancer were 13.7 mm and 22 mm, respectively (p=0.0002). Fatty infiltrations of benign lymphadenopathy were seen 157 patients (88.2%) while eleven patients with metastatic breast cancers had nonfatty infiltration and one patient had fatty infiltration. Among the patient with benign lymphadenopathy circumscribed margins were observed in 167 patients (93.8%), microlobulated margins in 7 patients (3.9%), and obscured margins in 4 patients (2.2%), while among the patients with metastatic breast cancer circumscribed margins were seen in 6 patients, obscured margins in 3 patients, spiculated margins in 2 patients, and a microlobulated margin in 1 patient. No microcalcifications were found in lymph nodes. CONCLUSIONS: For benign lymphadenopathy the size of the abnormality was less than 13.7 mm and it had circumscribed margin and fatty center. On the other hand; homogenously dense (nonfatty) axillary lymph nodes were strongly associated with malignancy when axillary lymph nodes were longer than 22 mm with ill-defined or spiculated margins; therefore, a biopsy should be done to confirm malignancy in such cases.

A case of Small Cell Carcinoma of the Gallbladder / 한국간담췌외과학회지

Small cell carcinoma of the gallbladder is a rare neoplasm with a high malignant potential, representing about 4% of all carcinomas in this organ. It predominantly develops in older women with cholelithiasis and deaths usually occur within a few months after the diagnosis. We report a case with a small cell carcinoma of the gallbladder with literature review. A case of 74-year-old woman with fever and abdominal pain for days was temporarily diagnosed as empyema of the gallbladder and received emergency cholecystostomy. 15 days later, she underwent cholecystectomy. Pathological examination of the gallbladder revealed small cell carcinoma. Of the immunohistochemical stains for neuroendocrine and other tumor markers, this tumor was positive for cytokeratin, NSE, lysozyme, gastrin,p53 and p16 and negative for CEA, chromogranin, synaptophysin, somatostatin, serotonin and ACTH. The small cell was partially originated from the common premobial cell with bidirectional differentiation. She died of cancer cachexia 2 months after initial operation.

Impact of Physician Delay on Postoperative Outcome of Patients with Acute Appendicitis

BACKGROUND: It is controversial whether the delay of surgery for acute appendicitis by physician results in higher morbidity. Our present study explores this problem of physician delay on the postoperative outcome of patients with acute appendicitis. MATERIAL AND METHODS: Among 432 patients admitted for the presumptive diagnosis of acute appendicitis between Jan., 1995 and Dec., 1997, 358 patients with pathologically proven acute appendicits were analyzed. Physician delay from the hospital admission to the surgery was evaluated in relation to the stage of the disease at operation and postoperative outcome. RESULTS: Postoperative complications occurred signifficantly higher in advanced appendicitis group, than in simple appendicitis group. Postoperative oral consumption started significantly later and hospital days are significantly prolonged in those group. Both patient and physician delays significantly affect the stage of the disease. The finding that physician delay correlated with the stage, however, was denied by multivariate analysis. CONCLUSION: On the contrary to the patient delay, physician delay does not affect the stage of the acute appendicitis nor lead to increased incidence of postoperative complication. Physician delay to clarify the diagnosis is a reasonable strategy and it does not affect the outcome adversely.

Significance of Lymph Node Metastasis in Early Gastric Cancer

One hundred thirty four early gastric cancer cases were analyzed to determine the clinicopathologic features influencing lymph node metastasis. Subtotal gastrectomy for 122 patients and total gastrectomy for 12 patients were carried on including lymph node dissection of node groups 1 and 2. The mean duration of the follow-up was 44.2 months. In this review, the only pathologic feature influencing lymph node metastasis was depth of invasion. The rate of lymph node metastasis was significantly higher in submucosal cancer(30.3%) than mucosal cancer(8.6%)(Chi-Square test, P=0.0009). The lymph node metastasis was the only independent prognostic factor of early gastric cancer(P=0.0006), and raise the question whether the present definition of early gastric cancer is still of value. Most important result of our study is that 20.9% of the early gastric cancer had pathologically proven lymph node metastasis, and have worse prognosis than the cases without metastasis. In stead of the currently used early gastric cancer, we propose superficial cancer for carcinoma confined to mucosa or submucosa on endoscopic finding, and to save the term of early gastric cancer for the cases in which the invasion limited to the mucosa or submucosa without lymph node metastasis.

Significance of CEA Levels in Peripheral Venous Blood, Drainage Venous Blood, and Gallbladder Bile in Perdiciting Hepatic Metastases of Colorectal Cancer

Despite major diagnostic advances, 10-30% of hepatic metastases of colorectal carcinoma remain undetected. In this study, CEA levels of peripheral (p-CEA), drainage venous blood(d-CEA) and gallbladder bile(b-CEA) in patients with colorectal cancer were determined to examine the significance of their CEA levels in predicting hepatic metastases. From January 1993 through May 1996, p-CEA, d-CEA and b-CEA were obtained in 50 colorectal carcinoma patients without gallbladder pathology. Synchronous hepatic metastases were found in 5 patients(Hm group) and 45 cases had no hepatic metastasis. Among the 27 cases who followed up over 2 years, metachronous hepatic metastases(Hr group) were found in 6 cases and remaining 21 cases had no metastases(Ho group). Elevation of p-CEA, d-CEA, and b-CEA was significantly correlated with lymph node metastases and hepatic metastasis. The b-CEA levels were significantly correlated with p-CEA(r=0.533926, p 40 ng/ml had hepatic metastases(5 synchronous, 6 metachronous). However it is impossible to establish the possible of b-CEA because of high false positive and negative rate in predicting metachronous hepatic metastases. In conclusion, it is suggested that d-CEA could be highly sensitive indicator for selecting high-risk patients of metachronous hepatic metastases of colorectal cancer.

Comparative Analysis of Growth Patterns in Colorectal Cancers that Invaded to

In this retrospective study, 49 patients who were treated by surgical resection of colorectal cancer, confuted to proper muscle and confirmed histologically from 1979 to 1996 were included. To examine the significance of growth pattern in terms of polypoid growth(PG)(n=26; m,sm 5, pm 21) and non-polypoid growth(NPG)(n=23; m,sm 3, pm 20), we analyzed several clinocopathologic variables by x2 test and unpaired t-test, 5-year survival rate by Kaplan-Meier method and Log-Rank statistics according to growth type comparatively: 1) In the PG tumor, muscle elevation(P<0.0117) and association with adenoma(P<0.0001) were more frequent than in the NPG. 2) The NPG type showed smaller size(P<0.0172) and higher rate of lymph node metastasis(P=0.025) and higher tendency of lymphatic invasion(P=0.07) and poor differentiation(P=0.0693) and deeper invasion(P=0.0972) and worse 5-year survival(P=0.0607). 3) Otherwise there was no difference in inflammation, fibrosis, and angioinvasion. 4) The mean thickness of Outer Longitudinal Muscle(OLM) was thicker in rectum than colon(rectum 1.62 mm, colon 0.74 mm, p<0.0059) and pm cancer was more in rectum than in colon(rectum 10.3%, colon 4.0% , p=0.0057). In the view of results, NPG in early colorectal cancer may suggest the possibility of de novo cancer. NPG type was smaller in the size but more aggressive in lymph node metastasis, lymphatic invasion, invasion depth, tumor differentiation, 5-year survival rate. So it needs more thorough follow up. The higher incidence of pm cancer in rectum than in colon, is probably due to thicker OLM of rectum than that of colon.

The Result of First Year Screening for Breast Cancer in National medical Center

Breast cancer is a major public health problem. 1 woman in 8 will have breast cancer develop during her lifetime in America. As in the United States, long-term increases in the incidence of breast cancer are being observed worldwide. The high incidence of breast cancer in the female population is provide the rationale for screening. The principal purpose of screening for breast cancer is to reduce mortality from the disease through early diagnosis and treatment. It is demonstrate that mortality from breast cancer can be reduced as much as 30% in a screened population. Thus the authors tried screening for breast cancer by mammography with education in breast self examination and classified mammographic parenchymal pattern of the breast in the National Medical Center. The results obtained were summarized briefly as follows:1) Between 1995-5 and 1995-7, 329 women over aged 35 in National Medical Center were invited for screening by mammography with education in breast self examination and mammographic parenchymal pattern of the breast. 2) 294(89.3 percentage) women in 329 were attended for screening and mammographic parenchymal pattern of the breast. 3) A group of 16 women(4.9 percentage) was called for further assessment. 4) 5 women(1.7 percentage) had suspicious lesions and proceeded to surgical biopsy; 4 lesions proved fibrocystic disease and 1 lesion proved fat necrosis and dystrophic calcification. 5) The mammographic parenchymal pattern of the breast showed the number of women according to classification: 20%, 23%, 50%, 7% for N1, P1, P2, DY type, respectively. 6) The malignant lesion was not detect. The results are not statistically significant. But periodic mammography screening of asymptomatic women shows that a satisfactory cancer detection can be achievable. Follow-up of women over aged 35 in the National Medical Center is continuing.

Splenic Preservation in Rats

Despite the recognized desirability of spenic salvage,forced splenectomy remains the rule in many operative situations,including trauma and pancreatic cancer. The aim of this study was to evaluate the phagocytic function,histologic finding and anatomic change when the perfusion of preserved spleen was done only through short gastric vessels after splenic vessel ligation. In this situation, we evaluate the necessity of mass reduction to improve the perfusion into the residual spleen by 2/3 patial splenectomy. We studied 41 Sprague-Dawley rats by subdiving them into 3 main groups.In HL(;Hilar ligation)group, splenic vessel ligation was done(n=18). In HLS(Hilar ligation + 2/3partial splenectomy), splenic vessel ligation and partial splenectomy were done(n=18), and the others(n=5) were used as a control group. The changes of anatomy,histologic findings, and phagocytic functions in the preserved splenic tissue were observed at 1hour,2weeks, and 5months postoperatively,based on results of the India ink technique for demonstrating phagocytic function and on results of regular histologic examination. In all rats,at least 1 upper short gastric vessel was noted without direct connection to splenic vessel.In HL group,at 2weeks postoperatively,the size and weight of the preserved spleens were severely decreased to 1/3 of those of control group(p=0.0002). But,after 5months,the size and weight recovered to about 70-80% of those of initial spleen parameters.In HLS group,the size and weight changes were not found.At 1hour postoperatively phagocytic activity decreased to 35% in the control group,10% at 2weeks and not improved at 5months in both groups.The white pulps didn't show any specific change. We concluded that in spite of splenic mass reduction,the white pulp did not change, and phagocytic function was not improved.Therefore,the splenic mass reduction is not essential for the recovery of phagocytic function at the preserved spleen.