Critical Pathway for Colorectal and Gastric Cancer

PURPOSE: The critical pathway (CP) is to standardize the clinical practice of specialists working to optimize care. The objective of this study was to develop a critical pathway for the surgical treatment of patients with colorectal or gastric cancer and to evaluate the results of the CP. METHODS: Twenty-one patients with colorectal cancer, who were managed according to the CP between August 2005 and November 2005, were compared with 18 patients for whom this pathway had not been used between June 2004 and September 2004. Forty-eight patients with gastic cancer, who were managed according to the CP between June 2005 and September 2005, were compared with 49 patients for whom this pathway had not been used daring the same period in 2004. The length of stay and the cost per patients were compared between the CP group and the non-CP group. RESULTS: For patients with colorectal cancer, the postoperative hospital length of stay in the CP group was significantly shorter (9.0 vs. 12.3 days, P<0.001), but for patients with gastric caner, there was no difference (10.6 vs. 11.4, P=0.134). The mean hospital charges were won5,037,816 and won5,263,508 for colorectal cancer and for gastric cancer, respectively, and won4,808,602 and won4,674,329, for the CP and the non-CP groups, respectively, but these differences were not significant. CONSLUSIONS: The critical pathway in colorectal and stomach surgery decreased the length of stay and might regulate hospital charges. Such a pathway could be easily designed and implemented at hospitals and could standardize clinical practice.

DNMT3b Promoter Polymorphism and Risk of Gastric Cancer in the Korean Population

PURPOSE: DNA methylation is an important epigenetic factor in tumorigenesis. We hypothesized that polymorphism of the promoter of the DNA methyltransferase 3b (DNMT3b) genes, which are responsible for regulating the methylation status of tumor suppressor genes, are associated with increased risk of gastric cancer. MATERIALS AND METHODS: In this hospital-based case-control study, to determine the role of this polymorphism of the promoter of DNA methyltransferase 3b (DNMT3b) genes in gastric cancer, we genotyped 176 cases and 70 control subjects. To determine the genotype, we used a polymerase chain reaction restriction fragment length polymorphism assay. We compared alleles and genotypes between the two groups and revealed an association of DNMT3b promoter polymorphism with increased risk of gastric cancer in the Korean population. RESULTS: Genotype frequencies were 14.8% (Cytosine-Cytosine), 71.6% (Cytosine-Thymine), and 13.6% (Thymine- Thymine) in the case patients and 40.0% (Cytosine-Cytosine), 42.9% (Cytosine-Thymine), and 17.1% (Thymine-Thymine) in the control subjects, respectively. Compared with CC homozygotes, CT heterozygotes had a 4.523-fold increased risk (OR, 2.13; 95% CI, 2.324~8.803), and the TT homozygotes had a 2.154-fold elevated risk (OR, 1.42; 95% CI, 0.899~5.165). For the T variant genotype (CT+TT), there was a 3.846-fold increased risk (OR, 1.88; 95% CI, 2.040~7.251). However, no significance was observed in the genotype distributions of both polymorphisms according to histopathology, stage of stomach cancer. The Ssame results were observed with Helicobacter infection. CONCLUSION: DNMT3b promoter polymorphism, especially the T variant genotype, is associated significantly with thean increased risk of gastric cancer.

Proximal Variation of the Long Thoracic Nerve would be Vulnerable to Injury during an Axillary Dissection

Herein, our experience of a rare variation of the long thoracic nerve during an axillary dissection in a female patient with a breast ductal carcinoma in situ (DCIS) is reported. Her long thoracic nerve was duplicated and united at its proximal and distal parts, respectively. She was a 45-year old female, with microcalcification on her left breast, which had been diagnosed as a DCIS by a stereotactic core needle biopsy. Due to the diffuse distribution of lesions, a mastectomy was performed, with immediate reconstruction using a transverse rectus abdominis muscle (TRAM) free flap. After the mastectomy, an axillary dissection was performed for anastomoses of the free flap to the thoracodorsal vessels, at which point the duplicated variation of the proximal part of the long thoracic nerve was found. This variation is very rare, and would be vulnerable to injury during an axillary dissection. Therefore, surgeons should take care to avoid injury to such a nerve during axillary surgery.

Use of Complementary and Alternative Medicine by Gastric Cancer Patients

PURPOSE: Complementary and alternative medicine (CAM) has recently been spotlighted, and CAM can be defined as methods for treating diseases or ways to maintain physical health that out lie outside the boundaries of conventional medicine. We have conducted research to determine the status of CAM usage among Korean gastric cancer patients and their attitudes toward it, to determine what better can be done about CAM. METHODS: We surveyed those patients in St. Mary Hospital who were diagnosed to gastric cancer and who volunteered to participate in this study. The survey consists of 38 questions and each question covered personal characteristics information as to whether they have used CAM, whether they were satisfied after taking CAM and their intentions for re-use. RESULTS: A total of 195 patients answered the survey. 80 patients (41%) experienced CAM for the purpose of remedying their gastric cancer. The top leading CAM was dietary supplement for 52% of the patients, ginseng for 26% of the patients and Chinese herbal medicine for 10.8% of the patients. 54 patients (67.5%) were satisfied with the results of the CAM and they said that it had an effect on fatigue (45%). The statistics showed positive correlation between the level of education and the CAM users (P=0.001). CONCLUSION: The percentage of patients using CAM among the gastric cancer patients was high, up to 41%. Most of these patients wanted more information and discussion with their physicians about CAM therapies. The interesting thing was that most of the CAM was oral medicine. Based on our findings, research on the safety and effectiveness of CAM is required.

Clinical Analysis According to p21(Waf1/Cip1) and p27(Kip1) Expression in Gastric Cancer

PURPOSE: The p21(Waf1/Cip1) protein inhibits the cell cycle by inhibiting the phosphorylation at the G1-->S check point, and the p27(Kip1) protein similarly performs the suppressor function by controlling the p27-mediated G1 arrest. In this study, we analysed the clinical status and survival rates in correlations with p21 and p27 expression patterns in gastric cancer. MATERIALS AND METHODS: Between 1993 and 1997, 192 patients who underwent surgeries in Catholic Medical Center were analysed retrospectively in this study. Immunohistochemical staining was performed and if the nuclei of the tumor cells were stained, we assumed those as positive results. Statistical analysis was based on clinicopathological findings and differences in survival rates. RESULTS: The expression rate of p27 was 28.1% and 15.6% in p21 each. The ratio of T1-2(80.0%) was significantly high in p21 (+), but the ratio of T3-4 (50.6%) was slightly high in p21 (-). There was no statistical significance regarding other factors. The results in p27 was not much different from expression rate of p21 in T-stage. In addition, p27 expression in diffuse type (91.3%) was higher than in intestinal type (62.7%) by Lauren's classification (P <0.05). Also, there was no statistical significance in other factors. In the correlation of p21 and p27, p27 was positive when p21 was positive (53.5%). Conversely, p27 was negative when p21 was negative (76.5%, p <0.05). In the p21 and p27 combination test, there was higher rate of T1-2 (87.5%) in p21 (+)/p27 (+), and higher rate of T3-4 (58.1%) in p21 (-)/p27 (-) (P <0.05). Results showed higher rate of intestinal type (100%) in p21 (+)/p27 (+), and diffuse type (87.0%) was dominant in p21 (-)/p27 (-) (P <0.05) by Lauren's classification. Moreover, there was no statistical significance in the 5-year survival rate in the expression of p21 and p27, and the 5-year survival rate was highest in the case of p21 (+)/p27 (+) without statistical significance. CONCLUSION: In our study, p21(Waf1/Cip1) and p27(Kip1) expressed similar patterns. The expression of p21(Waf1/Cip1) and p27(Kip1) affected the degree of invasiveness of the tumor, and. Combined examination result revealed the correlation of p21(Waf1/Cip1) and p27(Kip1) with Lauren's classification and depth of invasion of the tumor. However, we assumed that little difference between the survival rates depending on expression of p21(Waf1/Cip1) and p27(Kip1) has limited their value as predictable prognostic indicators.

Perforated Duodenal Diverticulum after Distal Subtotal Gastrectomy and Billorth II Gastrojejunostomy

A 69-year old man presented with severe epigastric pain for 1 day. He had early gastric cancer at the antrum and underwent a distal subtotal gastrectomy and Billorth II gastrojejunostomy one month later without any post-operative complications. Radiologic examination revealed a large amount of retroperitoneal free air formation. Because of unremitting pain and unstable vital sign, exploratory laparotomy was followed. During the operation, a perforated duodenal diverticulum at the posterior wall of the 2nd portion of the duodenum was identified. He underwent diverticulectomy and primary closure. He was discharged on the 18th post operative day and has been followed up without any evidence of comlpication for several months.

Clinical Characteristics and Prognosis of Gastrointestinal Stromal Tumors of Stomach

PURPOSE: Gastrointestinal stromal tumorsm (GISTs) are the most common mesenchymal tumors that arise anywhere in the tubular GI tract. The prognosis for GSTIs is important because f GISTs may metastasiwx in the liver or the abdominal cavity in an early stage. For the reason we examined the tumor size, the mitotic number, ki 67, p53, and c-kit mutation as independent prognostic factor for GISTs. MATERIALS AND METHODS: A retrospective study was conducted in 76 patients who had been re-evaluated for confirmation of diagnosis between Jan 1998 and Dec. 2001. at Catholic University of medicine. RESULTS: There were significant difference between the tumor size, mitotic indices, ki 67, c-kit mutations and the 5-years survival rates. Tumor size (> or = 5 cm) and mitotic index (> or = 5/50 HPF) were statistically related to a significantly poor prognosis (P=0.017 and P=0.042, respectively). c-kit mutations in exon 11 were found in 7 cases c-kit mutation was observed more frequently in high risk patients, and there was a significant difference between c-kit mutation and survival (P=0.037). Elevated ki 67 was noted in 34 out of the 76 cases. High risk patients showed elevated ki67 index more frequently and there was significant relation with the survival rate (P=0.0417). CONCLUSION: We think that tumor size, mitotic index, Ki 67 and c-kit mutation are as independent prognostic factors for GISTs, but more research is needed.

Survival Analyses in Breast Cancer According to Over-expression and Amplification of HER2 / 한국유방암학회지

PURPOSE: HER2 is a 185-kDa transmembrane protein, which shares a considerable homology with the epidermal growth factor receptor. The over-expression of HER2 has been reported to be associated with a poor clinical outcome in breast cancer. In clinical practice and research studies, immunohistochemistry (IHC) and fluorescence in-situ hybridization (FISH) have commonly been used for the detection of HER2. The aim of this study was to evaluate the prognostic significance of HER2 according to the results of IHC and FISH for HER2. METHODS: IHC and FISH were performed on the same breast cancer specimens from 388 Korean patients, with a mean follow-up duration of 59.8 months, with survival analyses were made according to the results of the HER2 detection methods; A0485 Ab (DAKO, Denmark) and the HER2 test kit (DAKO HerceptTest(TM), Denmark) for IHC, and the HER2 FISH kit (Vysis Inc., Downers Grove, Ill) for FISH were used. RESULTS: The IHC showed HER2 over-expression rates of 34.8% and 26.8% by the A0485 antibody and HercepTest, respectively. The rate of HER2 amplification by FISH in the same specimen was 25.8%. HER2 was confirmed as an independent prognostic factor by multivariate analyses regardless of the detection methods. In the survival analyses, according to the IHC results for HER2, only the 3+ scoring group in the positive results was associated with a poor survival. However, the positive group in the FISH test revealed a significantly worse survival than the FISH-negative group. CONCLUSION: For the prediction of survival of patients with breast cancer, the FISH test would be more useful than IHC, especially in the 2+ scoring IHC cases.

Survival Analyses in Breast Cancer According to Over-expression and Amplification of HER2 / 한국유방암학회지

PURPOSE: HER2 is a 185-kDa transmembrane protein, which shares a considerable homology with the epidermal growth factor receptor. The over-expression of HER2 has been reported to be associated with a poor clinical outcome in breast cancer. In clinical practice and research studies, immunohistochemistry (IHC) and fluorescence in-situ hybridization (FISH) have commonly been used for the detection of HER2. The aim of this study was to evaluate the prognostic significance of HER2 according to the results of IHC and FISH for HER2. METHODS: IHC and FISH were performed on the same breast cancer specimens from 388 Korean patients, with a mean follow-up duration of 59.8 months, with survival analyses were made according to the results of the HER2 detection methods; A0485 Ab (DAKO, Denmark) and the HER2 test kit (DAKO HerceptTest(TM), Denmark) for IHC, and the HER2 FISH kit (Vysis Inc., Downers Grove, Ill) for FISH were used. RESULTS: The IHC showed HER2 over-expression rates of 34.8% and 26.8% by the A0485 antibody and HercepTest, respectively. The rate of HER2 amplification by FISH in the same specimen was 25.8%. HER2 was confirmed as an independent prognostic factor by multivariate analyses regardless of the detection methods. In the survival analyses, according to the IHC results for HER2, only the 3+ scoring group in the positive results was associated with a poor survival. However, the positive group in the FISH test revealed a significantly worse survival than the FISH-negative group. CONCLUSION: For the prediction of survival of patients with breast cancer, the FISH test would be more useful than IHC, especially in the 2+ scoring IHC cases.

A Case of a Tailgut Cyst

The tailgut is a blind extension of the hindgut into the tail fold just distal to the cloacal membrane. Remnants of this structure may form a tailgut cyst. This is prone to infection and chronic fistula formation and has a long-term risk of malignancy. Non-recognition and incomplete treatment leads to morbidity. A twenty one year-old female patient visited our hospital with repeated perianal pain and discharge. Preoperative abdominopelvic MRI and endorectal ultrasonography revealed a retrorectal cyst suggestive of a tailgut cyst. She underwent a complete excision of the retrorectal mass through a presacral approach. She recovered uneventfully. This report includes the case and a brief review of tailgut cysts.

Tuberculous Pseudoaneurysm of the Descending Thoracic Aorta

The tuberculous aortic aneurysm is exceedingly rare. Kamen L. first described tuberculous aortic aneurysm in 1899. Since then, only about 40 cases have been reported in the literature 1945 to 2001, and among them only 19 cases have affected the thoracic aorta. The incidence and prevalence of tuberculosis is still reported to be far too high, and the demographic and geographic disease distribution has changed rapidly because of immigration and traveling from endemic areas, and also this is due to the increasing use of immunosuppression or because of HIV cases. Multi-resistant strains and comorbidities impair the effects of medical therapy and so this might result in surgical complications. The tuberculous aortic aneurysm generally occurs in the setting of disseminated tuberculosis, and it has a high mortality rate. This report describes a 35-year-old woman who had miliary pulmonary tuberculosis, and she underwent a surgical operation for tuberculous pseudoaneurysm of the thoracic aorta. Early detection and the proper surgical and medical combination therapy are essential for the optimal treatment of thoracic aortic pseudoaneurysm, as was done in this successful case.