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1.  Endoscopic ultrasonography for gastric submucosal lesions 
Gastric submucosal tumors (SMTs) are a rather frequent finding, occurring in about 0.36% of routine upper GI-endoscopies. EUS has emerged as a reliable investigative procedure for evaluation of these lesions. Diagnostic Endoscopic ultrasonography (EUS) has the ability to differentiate intramural tumors from extraluminal compressions and can also show the layer of origin of gastric SMTs. Tumors can be further characterized by their layer of origin, echo pattern and margin. EUS-risk criteria of their malignant potential are presented, although the emergence of EUS-guided fne needle aspiration (EUS-FNA) has opened new indications for transmural tissue diagnosis and expanded the possibilities of EUS in SMTs of the stomach. Tissue diagnosis should address whether the SMT is a Gastrointestinal stromal tumour (GIST) or another tumor type and evaluate the malignant potential of a given GIST. However, there seems to be a lack of data on the optimal strategy in SMTs suspected to be GISTs with a negative EUS-FNA tissue diagnosis. The current management strategies, as well as open questions regarding their treatment are also presented.
PMCID: PMC3139278  PMID: 21772939
Endoscopic ultrasound; Gastric submucosal tumors; EUS-guided fne needle aspiration; Gastrointestinal stromal tumours
2.  Two cases of mucinous adenocarcinoma of the stomach mistaken as submucosal tumor 
A gastric carcinoma with the endoscopic features resembling submucosal tumor (SMT) is rare, and reportedly account for only 0.1% to 0.63% of all resected gastric carcinomas. The preoperative diagnosis of SMT-like gastric carcinoma is challenging, and thus, diagnosis is usually made intraoperatively or postoperatively. Furthermore, mucinous adenocarcinoma is an uncommon histologic subtype of gastric carcinoma characterized as an elevated lesion resembling SMT due to abundant mucin pools in submucosa. Here, we report two cases in which a gastric mucinous adenocarcinoma was mistaken as a SMT.
PMCID: PMC3566470  PMID: 23396274
Submucosal tumor; Gastric neoplasms; Adenocarcinoma; Mucinous
3.  Laparoscopic resection for 125 gastroduodenal submucosal tumors 
The present study aims to elucidate the treatment strategies of laparoscopic resection for gastroduodenal submucosal tumors (SMTs).
Data of 125 gastroduodenal STMs were collected retrospectively resected from August, 2004 to February, 2013. Surgical outcomes according to tumor locations, pathologic results and survival data for gastrointestinal stromal tumors (GISTs) were collected and analyzed.
There were 55 male and 70 female patients with mean age 57.9 ± 12.7 years old. Mean tumor size of gastric SMTs was 2.7 ± 1.64 cm (range, 0.4-8.5 cm). GIST was the most common (n = 70, 56%). Regarding the tumor location, all the fundic lesions were GISTs and leiomyoma was occurred 58.8% of cardiac lesions. Ectopic pancreas and schwannomas were mostly located at body portion, 73% and 80%, respectively. SMTs located at duodenal bulb comprise 4 GISTs and 3 carcinoids. Surgical results comparing between lesions located at cardia, near-pylorus and else had no difference in operation time, hospital stay and complications. In terms of outcome of GIST, all patients underwent curative resection except one case of peritoneal sarcomatosis. There was one recurrence in a high risk group following resection. The cumulative 5-year disease free survival rate was 93.5% in all GISTs. There were two postoperative complications, one gastric outlet obstruction and one leakage following wedge resection.
Laparoscopic wedge resection is a safe and feasible procedure for the small to medium sized gastroduodenal SMTs even their locations are near cardia or pylorus.
PMCID: PMC3996721  PMID: 24783179
Stomach neoplasms; Gastrointestinal stromal tumor; Laparoscopy
4.  Laparoscopic-endoscopic cooperative surgery for gastric submucosal tumors 
AIM: To assess the feasibility, safety, and advantages of minimally invasive laparoscopic-endoscopic cooperative surgery (LECS) for gastric submucosal tumors (SMT).
METHODS: We retrospectively analyzed 101 consecutive patients, who had undergone partial, proximal, or distal gastrectomy using LECS for gastric SMT at Peking Union Medical College Hospital from June 2006 to April 2013. All patients were followed up by visit or telephone. Clinical data, surgical approach, pathological features such as the size, location, and pathological type of each tumor; and follow-up results were analyzed. The feasibility, safety and effectiveness of LECS for gastric SMT were evaluated, especially for patients with tumors located near the cardia or pylorus.
RESULTS: The 101 patients included 43 (42.6%) men and 58 (57.4%) women, with mean age of 51.2 ± 13.1 years (range, 14-76 years). The most common symptom was belching. Almost all (n = 97) patients underwent surgery with preservation of the cardia and pylorus, with the other four patients undergoing proximal or distal gastrectomy. The mean distance from the lesion to the cardia or pylorus was 3.4 ± 1.3 cm, and the minimum distance from the tumor edge to the cardia was 1.5 cm. Tumor pathology included gastrointestinal stromal tumor in 78 patients, leiomyoma in 13, carcinoid tumors in three, ectopic pancreas in three, lipoma in two, glomus tumor in one, and inflammatory pseudotumor in one. Tumor size ranged from 1 to 8.2 cm, with 65 (64.4%) lesions < 2 cm, 32 (31.7%) > 2 cm, and four > 5 cm. Sixty-six lesions (65.3%) were located in the fundus, 21 (20.8%) in the body, 10 (9.9%) in the antrum, three (3.0%) in the cardia, and one (1.0%) in the pylorus. During a median follow-up of 28 mo (range, 1-69 mo), none of these patients experienced recurrence or metastasis. The three patients who underwent proximal gastrectomy experienced symptoms of regurgitation and belching.
CONCLUSION: Laparoscopic-endoscopic cooperative surgery is feasible and safe for patients with gastric submucosal tumor. Endoscopic intraoperative localization and support can help preserve the cardia and pylorus during surgery.
PMCID: PMC3769911  PMID: 24039367
Laparoscopic-endoscopic cooperative surgery; Gastric submucosal tumor; Minimally invasive surgery; Laparoscopy; Endoscopy
5.  Gastric calcifying fibrous tumor removed by endoscopic submucosal dissection 
The World Health Organization describes calcifying fibrous tumors (CFTs) as rare, benign lesions characterized by hypocellular, densely hyalinized collagenization with lymphoplasmacytic infiltration. These tumors rarely involve the gastrointestinal (GI) tract. A routine endoscopic upper gastrointestinal screen detected a 10-mm submucosal tumor (SMT) in the lesser curvature of the lower corpus of the stomach of an apparently healthy, 37-year-old woman with no history of Helicobacter pylori infection. Endoscopic ultrasonography (EUS) localized the internally isoechoic, homogeneous SMT mainly within the submucosa. Malignancy was ruled out using endoscopic submucosal dissection (ESD). A pathological examination confirmed complete resection of the SMT, and defined a hypocellular, spindle-cell tumor with a densely hyalinized, collagenous matrix, scattered lymphoplasmacytic aggregates as well as a few psammomatous, dystrophic calcified foci. The mass was immunohistochemically positive for vimentin and negative for CD117 (c-kit protein), CD34, desmin, smooth muscle actin (SMA) and S100. Therefore, the histological findings were characteristic of a CFT. To date, CFT resection by ESD has not been described. This is the first case report of a gastric calcifying fibrous tumor being completely resected by ESD after endoscopic ultrasonography.
PMCID: PMC3773860  PMID: 24044047
Calcifying fibrous tumor; Endoscopic submucosal dissection; Submucosal tumor; Endoscopic ultrasonography
6.  Magnetic Resonance Imaging Zygapophyseal Joint Space Changes (Gapping) in Low Back Pain Patients following Spinal Manipulation and Side Posture Positioning: A Randomized Controlled Mechanisms Trial with Blinding 
The purpose of this study was to quantify lumbar zygapophyseal (Z) joint space separation (gapping) in low back pain (LBP) subjects after spinal manipulative therapy (SMT) or side-posture positioning (SPP).
This was a controlled mechanisms trial with randomization and blinding. Acute LBP subjects (N=112, four n=28 MRI protocol groups) had 2 magnetic resonance imaging (MRI) appointments (initial enrollment [M1] and following 2 weeks of chiropractic treatment [M2]; receiving 2 MRI scans of the L4/L5 and L5/S1 Z joints at each MRI appointment. After the first MRI scan of each appointment, subjects were randomized (M1 appointment) or assigned (M2 appointment) into SPP (non-manipulation), SMT (manipulation), or control MRI protocol groups. After SPP or SMT, a second MRI was taken. The central anterior-posterior (A-P) joint space was measured. Difference between most painful side A-P measurements taken post- and pre-intervention was the Z joint “gapping difference.” Gapping differences were compared (ANOVA) among protocol groups. Secondary measures of pain visual analog scale (VAS), verbal numeric pain rating scale (VNPRS), and function Bournemouth questionnaire (BQ) were assessed.
Gapping differences were significant at the first (adjusted, p=0.01; SPP=0.66 +0.48mm; SMT=0.23 +0.86; control=0.18 +0.71) and second (adjusted, p=0.0005; SPP=0.65 +0.92mm, SMT=0.89 +0.71; control=0.35 +0.32) MRI appointments. VNPRS differences were significant at first MRI appointment (p=0.04) with SMT showing the greatest improvement. VAS and BQ improved after two weeks of care in all groups (both p<0.0001).
SPP showed greatest gapping at baseline. After two weeks, SMT resulted in greatest gapping. SPP appeared to have additive therapeutic benefit to SMT.
PMCID: PMC3756802  PMID: 23648055
Manipulation; Spinal; Zygapophyseal Joint; Chiropractic; Low Back Pain; Lumbar vertebrae
7.  Second Malignant Tumors After Treatment of Nasopharyngeal Carcinoma 
Skull Base  2002;12(2):87-91.
The purpose of this study was to identify the histopathology, location, and latency interval for the development of second malignant tumors (SMT) after successful treatment for nasopharyngeal carcinoma (NPC). Of 55 patients, four developed SMT after successful treatment of NPC in a single institutional series for an incidence of 7%. An additional 31 patients with SMT after treatment for NPC were identified from the literature. At minimum, all patients were treated with radiotherapy to the primary site. The histopathology of SMT included sarcoma (69%), squamous cell carcinoma (17%), adenocarcinoma (6%), meningioma (6%), and lymphoma (3%). SMT occurred at various sites in the head and neck, but most (51%) arose in the sinonasal cavity. For the entire group, the mean latency interval between treatment for NPC and the development of SMT was 11.8 years. These findings indicate that the development of SMT in patients achieving long-term survival after treatment for NPC may be radiation induced. Long-term follow-up for these patients is important to assess for this potentially late complication.
PMCID: PMC1656915  PMID: 17167655
Nasopharyngeal carcinoma; second malignant tumors
8.  Changes in Pain Sensitivity following Spinal Manipulation: a Systematic Review and Meta-Analysis 
Spinal manipulation (SMT) is commonly used for treating individuals experiencing musculoskeletal pain. The mechanisms of SMT remain unclear; however, pain sensitivity testing may provide insight into these mechanisms. The purpose of this systematic review is to examine the literature on the hypoalgesic effects of SMT on pain sensitivity measures and to quantify these effects using meta-analysis. We performed a systematic search of articles using CINAHL, MEDLINE, PsycINFO, and SPORTDiscus from each databases’ inception until May 2011. We examined methodological quality of each study and generated pooled effect size estimates using meta-analysis software. Of 997 articles identified, 20 met inclusion criteria for this review. Pain sensitivity testing used in these studies included chemical, electrical, mechanical, and thermal stimuli applied to various anatomical locations. Meta-analysis was appropriate for studies examining the immediate effect of SMT on mechanical pressure pain threshold (PPT). SMT demonstrated a favorable effect over other interventions on increasing PPT. Subgroup analysis showed a significant effect of SMT on increasing PPT at the remote sites of stimulus application supporting a potential central nervous system mechanism. Future studies of SMT related hypoalgesia should include multiple experimental stimuli and test at multiple anatomical sites.
PMCID: PMC3349049  PMID: 22296867
Manual therapy; Spinal manipulation; Pain; Experimental pain
9.  Synchronous Early Gastric Cancer Resembling Submucosal Tumor at the Fundus 
Gut and Liver  2007;1(2):171-174.
Concern about detecting gastric carcinoma in its early stages has increased the incidence of detecting multiple synchronous gastric carcinomas. Although gastric carcinomas may present with various gross features, those showing the features of submucosal tumor (SMT) are rare. We report on a case of synchronous gastric carcinomas comprising one lesion with typical features of superficial early gastric carcinoma and the other with atypical features that mimicked SMT. Even though synchronous gastric carcinoma is rare, it may be worthwhile to make a pathological diagnosis of coexisting SMT using endoscopic-ultrasound-guided fine-needle aspiration or endoscopic mucosal resection.
PMCID: PMC2871622  PMID: 20485635
Synchronous cancer; Early gastric carcinoma; Submucosal tumor
10.  An uncommon malignant cutaneous squamomelanocytic tumor 
The intermingling of two malignant neoplasms within the same cutaneous tumor is rare. No consensus has been reached for a clear definition and categorization. In the current study, we describe a cutaneous neoplasm; a squamomelanocytic tumor (SMT) with histological features combining those of a squamous cell carcinoma (SCC) and a malignant melanoma (MM). This is the second report of an oculocutaneous SMT, and concerns a subject with a 20-year history of solar lentigo coexisting with solar keratosis in the primary lesion. This type of tumor is quite rare, with a distinct cytological architecture and immunohistochemical features, and the differential diagnosis of SMT may be considered. However, the histogenesis, biological behavior and malignant potential of SMTs remain a matter of speculation. With regard to the treatment, complete surgical resection and close follow-up are recommended.
PMCID: PMC3570222  PMID: 23407590
squamomelanocytic tumor; solar keratosis; solar lentigo; histogenesis
11.  False-Negative Results of Endoscopic Biopsy in the Diagnosis of Gastrointestinal Kaposi's Sarcoma in HIV-Infected Patients 
Kaposi's sarcoma (KS) is a rare endothelial neoplasm mainly involving the skin, but it is often associated with AIDS. Diagnosis of gastrointestinal (GI) tract KS, a common site of visceral involvement in AIDS, is important, but endoscopic biopsy carries a risk of false-negative results (FNRs) due to its submucosal appearance. This study sought to determine the rate and causes of FNR for endoscopic biopsy of GI-KS lesions. Endoscopic biopsy samples of 116 GI-KS lesions were reviewed retrospectively. All GI-KS lesions were confirmed to be resolved following KS therapy. FNRs were yielded for 41 of the lesions (35.3%). Among upper and lower GI sites, the esophagus was the only site significantly associated with FNRs (P < 0.01). Small size (<10 mm) and patches found on endoscopy were significantly associated with FNRs (P < 0.05). Findings of submucosal tumor (SMT) with ulceration were significantly associated with true-positive results (P < 0.05). In conclusion, FNRs were found in 35.3% of GI-KS lesions and were especially related to the site of the esophagus and endoscopic early stage (small size or patch appearance). An SMT with ulceration may be relatively easy to diagnose on endoscopic biopsy. Caution should be exercised when performing endoscopic biopsy of these lesions in AIDS patients and evaluating the histological features.
PMCID: PMC3513736  PMID: 23227427
12.  Metastasectomy for distant metastatic melanoma: Analysis of data from the first Multicenter Selective Lymphadenectomy Trial (MSLT-I) 
Annals of Surgical Oncology  2012;19(8):2547-2555.
For stage IV melanoma, systemic medical therapy (SMT) is used most frequently; surgery is considered an adjunct in selected patients. We retrospectively compared survival after surgery±SMT versus SMT alone for melanoma patients developing distant metastases while enrolled in the first Multicenter Selective Lymphadenectomy Trial.
Patients were randomized to wide excision and sentinel node biopsy, or wide excision and nodal observation. We evaluated recurrence site, therapy (selected by treating clinician), and survival after stage IV diagnosis.
Of 291 patients with complete data for stage IV recurrence, 161 (55%) underwent surgery±SMT. Median survival was 15.8 vs. 6.9 months and 4-year survival was 20.8% vs. 7.0% for patients receiving surgery±SMT vs. SMT alone (p<0.0001; HR 0.406). Surgery±SMT conferred a survival advantage for patients with M1a (median >60 months vs. 12.4 months; 4-year 69.3% vs. 0; p=0.0106), M1b (median 17.9 vs. 9.1 months; 4-year 24.1% vs. 14.3%; p=0.1143), and M1c (median 15.0 vs. 6.3 months; 4-year 10.5% vs. 4.6%; p=0.0001) disease. Patients with multiple metastases treated surgically had a survival advantage, and number of operations did not reduce survival in the 67 patients (42%) who had multiple surgeries for distant melanoma.
Our findings suggest that over half of stage IV patients are candidates for resection and exhibit improved survival over patients receiving SMT alone, regardless of site(s) and number(s) of metastases. We have begun a multicenter randomized phase III trial comparing surgery versus SMT as initial treatment for resectable distant melanoma.
PMCID: PMC3405182  PMID: 22648554
Stage IV melanoma; metastasectomy; MSLT-I; survival
13.  Glomus tumor in the stomach: Computed tomography and endoscopic ultrasound findings 
A 57-year-old man presented with intermittent dull abdominal pain after a period of 1 year. Abdominal computed tomography (CT) was performed. Except for the endoscopy, the work-up for possible medical causes remained inconclusive. An open-abdomen, partial surgical excision of the stomach was performed after the unsuccessful endoscopic resection. The pathology report revealed a glomus tumor of the stomach. Importantly, glomus tumors of the stomach are rare and are almost always benign. Therefore, the most important current role of imaging associated with the diagnostic approach and therapeutic plan for a glomus tumor is to differentiate it from other gastric submucosal tumors (SMTs). We report this case with representative radiologic findings, including CT and endoscopic ultrasound (EUS) reports, and also correlate them with clinical and pathologic presentations that can help in the early detection and differentiation of gastric SMTs from other SMTs. As such, the purpose of this report is to provide a better understanding of relevant CT and EUS features. Alternative treatments should be considered carefully according to the imaging results.
PMCID: PMC3587493  PMID: 23482388
Glomus tumor; Stomach; Diagnosis; Therapy
14.  A rare case of xanthogranuloma of the stomach masquerading as an advanced stage tumor 
Xanthogranuloma of the stomach is an extremely rare disease, and this lesion has only been found to coexist with early gastric cancer in 2 cases in the literature.
Case presentation
We report a case of xanthogranuloma of the stomach combined with early gastric cancer that mimicked an advanced stage tumor. A 65-year-old female was referred to our hospital because of epigastralgia. During a physical examination, a defined abdominal mass was palpable in the region of the left hypochondrium. Imaging studies revealed an advanced gastric cancer, which was suspected of having infiltrated the abdominal wall. Total gastrectomy and resection of the regional lymph node and abdominal wall were performed. Histopathologic examination of the resected specimen demonstrated xanthogranuloma combined with early gastric cancer.
Xanthogranuloma presenting as a form of SMT (submucosal tumor) of the stomach is an extremely rare disease, and diagnosing it preoperatively is difficult. Further accumulation and investigation of this entity is necessary.
PMCID: PMC3142508  PMID: 21722385
xanthogranuloma; early gastric cancer
15.  Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications 
Surgical Endoscopy  2013;27:3271-3279.
Endoscopic submucosal dissection (ESD) is a well-established method for the treatment of gastrointestinal epithelial tumors. However, the treatment of gastric subepithelial tumors (SETs) that originate from the muscularis propria layer still depends primarily on surgical techniques. We evaluated the appropriate indications for ESD in the treatment of SETs that originate from the muscularis propria layer.
Thirty-five patients with gastric SETs that originate from the muscularis propria layer who underwent ESD were enrolled, and the charts were retrospectively reviewed to investigate the parameters predictive complete resection and complications.
The mean age of the patients was 54.15 ± 9.3 years, and the male/female ratio was 2:3. Twenty-eight of the 35 SETs (85.7 %) were movable, and 15 (45.7 %) had a positive rolling sign. The most frequent location of the SETs was high body (n = 14). The most common pathological diagnoses were leiomyoma (60 %) and gastrointestinal stromal tumor (28.6 %). The complete resection rate was 74.3 %. A positive rolling sign (p = 0.022) and small tumor size (≤20 mm; p = 0.038) were significantly associated with complete resection. Two patients (6.1 %) developed perforations that required surgical treatment; their SMTs were neurogenic tumors with fixed lesion. Tumor mobility was significantly associated with perforation (p = 0.017).
The ESD method appears to be relatively safe for use in the complete resection of SETs that originate from the muscularis propria layer. Small tumor size (≤20 mm) and a positive rolling sign are appropriate indications for ESD.
PMCID: PMC3751271  PMID: 23519491
Subepithelial tumor; Muscularis propria; Endoscopic submucosal dissection
16.  Distribution of Cavitations as Identified with Accelerometry during Lumbar Spinal Manipulation 
This project determined the location and distribution of cavitations (audible sounds producing vibrations) in the lumbar zygapophyseal (Z) joints that were targeted by spinal manipulative therapy (SMT).
This randomized, controlled, clinical study assessed 40 healthy subjects (20 male, 20 female), 18–30 years of age, that were block randomized into SMT (Group 1, n=30) or side-posture positioning only (Group 2, control, n=10) groups. Nine accelerometers were placed on each patient (7 on SPs/sacral tubercles of L1–S2 and 2 placed 3 cm left and right lateral to the L4/L5 interspinous space). Accelerometer recordings were made during side-posture positioning (Groups 1 and 2) and SMT (Group 1 only). The SMT was delivered by a chiropractic physician with 19 years of practice experience and included 2 high-velocity, low-amplitude thrusts delivered in rapid succession. Comparisons using chi-square or McNemar’s test were made between number of joints cavitating from: Group 1 vs. Group 2, up-side (contact side for SMT) vs. down-side, and Z joints within the target area (L3/L4, L4L5, L5/S1) vs. outside the target area (L1/L2, L2/L3, sacroiliac).
Fifty-six cavitations were recorded from 46 joints of 40 subjects. Eight joints cavitated more than once. Group 1 joints cavitated more than Group 2 joints (p<0.0001), up-side joints cavitated more than down-side joints (p<0.0001), and joints inside the target area cavitated more than those outside the target area (p<0.01).
Most cavitations (93.5%) occurred on the up-side of SMT subjects in segments within the target area (71.7%). As expected, SMT subjects cavitated more frequently than side-posture positioning only subjects (96.7% vs. 30%). Multiple cavitations from the same Z joints had not been previously reported.
PMCID: PMC3215819  PMID: 21986305
17.  Quantification of Cavitation and Gapping of Lumbar Zygapophyseal Joints during Spinal Manipulative Therapy 
The purpose of this study was to use previously validated methods to quantify and relate 2 phenomena associated with chiropractic spinal manipulative therapy (SMT): 1) cavitation and 2) the simultaneous gapping (separation) of the lumbar zygapophyseal (Z) joint spaces.
This was a randomized, controlled, mechanistic clinical trial with blinding. Forty healthy subjects (18 to 30 years of age) without a history of low back pain participated. Seven accelerometers were affixed to the skin overlying the spinous processes of L1-L5 and the S1 and S2 sacral tubercles. Two additional accelerometers were positioned 3 cm left and right lateral to the L4/L5 inter-spinous space. Subjects were randomized into: Group 1–side-posture SMT (n=30) or Group 2–side-posture positioning (SPP, n=10). Cavitations were determined by accelerometer recordings during SMT and SPP (left-side=up-side for both groups); gapping (gapping difference) was determined by the difference between pre- and post-intervention MRI joint space measurements. Results of mean gapping differences were compared.
Up-side SMT and SPP joints gapped more than down-side joints (0.69 vs. −0.17mm, p<0.0001). SMT up-side joints gapped more than SPP up-side joints (0.75 vs. 0.52mm, p=0.03). SMT up-side joints gapped more in males than females (1.01 vs. 0.49mm, p<0.002). Overall, joints that cavitated gapped more than those that did not (0.56vs. 0.22mm, p=0.01). No relationship was found between the occurrence of cavitation and gapping with up-side joints alone (p=0.43).
Z joints receiving chiropractic SMT gapped more than those receiving side-posture positioning alone, Z joints of males gapped more than those of females, and cavitation indicated that a joint had gapped, but not how much a joint had gapped.
PMCID: PMC3501577  PMID: 22902194
spinal manipulation; zygapophyseal joints; facet joints; cavitation; chiropractic
18.  Prediction of Risk of Malignancy of Gastrointestinal Stromal Tumors by Endoscopic Ultrasonography 
Gut and Liver  2013;7(6):642-647.
The accurate preoperative prediction of the risk of malignancy of gastrointestinal stromal tumors (GISTs) is difficult. The aim of this study was to determine whether tumor size and endoscopic ultrasonography (EUS) features can preoperatively predict the risk of malignancy of medium-sized gastric GISTs.
Surgically resected, 2 to 5 cm gastric GIST patients were enrolled and retrospectively reviewed. EUS features, such as heterogeneity, hyperechoic foci, calcification, cystic change, hypoechoic foci, lobulation, and ulceration, were evaluated. Tumors were grouped in 1 cm intervals. The correlations of tumor size or EUS features with the risk of malignancy were evaluated.
A total of 75 patients were enrolled. The mean tumor size was 3.43±0.92 cm. Regarding the risk of malignancy, 51 tumors (68%) had a very low risk, and 24 tumors (32%) had a moderate risk. When the tumors were divided into three groups in 1 cm intervals, the proportions of tumors with a moderate risk were not different between the groups. The preoperative EUS features also did not differ between the very low risk and the moderate risk groups.
Tumor size and EUS features cannot be used to preoperatively predict the risk of malignancy of medium-sized gastric GISTs. A preoperative diagnostic modality for predicting risk of malignancy is necessary to prevent the overtreatment of GISTs with a low risk of malignancy.
PMCID: PMC3848548  PMID: 24312703
Gastrointestinal stromal tumors; Endosonography; Tumor size; Malignant risk
19.  Moderators and predictors of response to cognitive-behavioral therapy augmentation of pharmacotherapy in obsessive-compulsive disorder 
Psychological medicine  2010;40(12):2013-2023.
Cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (EX/RP) is efficacious as a treatment for obsessive-compulsive disorder (OCD). However, about half of patients have a partial or poor response to EX/RP treatment. This study examined potential predictors and moderators of CBT augmentation of pharmacotherapy, to identify variables associated with a poorer response to OCD treatment.
Data were drawn from a large randomized-controlled trial that compared the augmenting effects of EX/RP to stress management training (SMT; an active CBT control) among 108 participants receiving a therapeutic dose of a serotonin reuptake inhibitor (SRI). Stepwise regression was used to determine the model specification.
Pre-treatment OCD severity and gender were significant moderators of outcome: severity affected SMT (but not EX/RP) outcome; and gender affected EX/RP (but not SMT) outcome. Adjusting for treatment type and pre-treatment severity, significant predictors included greater comorbidity, number of past SRI trials, and lower quality of life. Significant moderators, including their main-effects, and predictors accounted for 37.2% of the total variance in outcome, comparable to the impact of treatment type alone (R2=30.5%). These findings were replicated in the sub-group analysis of EX/RP alone (R2=54.0%).
This is the first randomized-controlled study to examine moderators and predictors of CBT augmentation of SRI pharmacotherapy. Although effect sizes for individual predictors tended to be small, their combined effect was comparable to that of treatment. Thus, future research should examine whether monitoring for a combination of these risk factors and targeting them with multi-modular strategies can improve EX/RP outcome.
PMCID: PMC3953340  PMID: 20416137
20.  Invasive Ductal Carcinoma Arising from an Ectopic Pancreas in the Gastric Wall: A Long-Term Survival Case 
Case Reports in Oncology  2012;5(1):69-73.
A case of invasive ductal carcinoma of an ectopic pancreas in the stomach in a 74-year-old woman is presented. A 4.0 cm gastric submucosal tumor (SMT) was resected surgically. Histologically, the tumor showed cystic tissue consisting of an ectopic pancreas with foci of a moderately differentiated tubular adenocarcinoma. In this tumor, small pancreatic tissues, acini, Langerhans islets, and ductular cells were detected in the gastric SMT. The patient has experienced long-term survival. The incidence of pancreatic cancer of an ectopic pancreas is rare, and the etiology of this disease is discussed in the literature.
PMCID: PMC3355652  PMID: 22611364
Ectopic pancreas; Pancreas cancer; Gastric wall
21.  Gastric Lipoma Presenting with Massive Upper Gastrointestinal Bleeding 
A case of massive upper gastrointestinal bleeding in a 37-year-old female is presented showing a submucosal mass in the gastric body. At laparotomy a pedunculated submucosal mass was found located on the posterior wall at the junction of the body and antrum of the stomach, 8 cm from the pylorus. Pathology confirmed that it was a 4 cm benign gastric lipoma with a bleeding central ulcer. Gastric lipomas are rare, benign, typically submucosal tumors occurring in the gastric antrum. They are usually asymptomatic but can become symptomatic depending on size, location, and if there is ulceration of the lesion. These lesions may be mistaken as malignant tumors or present with upper GI bleeding or intussusception. The diagnosis can be made using a combination of upper endoscopy, endoscopic ultrasound, CT, and MRI with surgical excision being the definitive treatment of choice. We hope that this case highlights the fact that these lesions can present with massive upper GI haemorrhage and should be included in the diagnosis when appropriate.
PMCID: PMC3864169  PMID: 24363942
22.  A case of neuroendocrine tumor G1 with unique histopathological growth progress 
A gastric neuroendocrine tumor (NET) is generated from deep within the tissue mucosal layers. In many cases, NETs are discovered as submucosal tumor (SMT)-like structures by forming a tumor mass. This case has a clear mucosal demarcation line and developed like a polyp. A dilated blood vessel was found on the surface. The mass lacked the yellow color characteristic of NETs, and a SMT-like form was evident. Therefore, a nonspecific epithelial lesion was suspected and we performed endoscopy with magnifying narrow-band imaging (M-NBI). However, this approach did not lead to the diagnosis, as we diagnosed the lesion as a NET by biopsy examination. The lesion was excised by endoscopic submucosal dissection. The histopathological examination proved that the lesion was a polypoid lesion although it was also a NET because the tumor cells extended upward through the normal gland ducts scatteredly. To our knowledge, there is no previous report of NET G1 with such unique histopathological growth progress and macroscopic appearance shown by detailed examination using endoscopy with M-NBI.
PMCID: PMC3870915  PMID: 24368937
Neuroendocrine tumor G1; Demarcation line; Polypoid growth; Magnifying narrow-band imaging; Submucosal tumor
23.  AIDS-Related EBV-Associated Smooth Muscle Tumors: A Review of 64 Published Cases 
The number of reported cases of smooth muscle tumor (SMT) arising in patients with AIDS has been increasing since the mid-1990s. The aim of this study is to characterize the epidemiology, clinical manifestations, pathologic features, prognosis and, management of Epstein-Barr virus-related SMT (EBV-SMT) in patients with AIDS. An English language literature search identified 53 articles including 64 reported cases of EBV-SMT. The majority of these reports involved patients who were young, severely immunosuppressed, and had multifocal tumors. The central nervous system was the most common site to be involved. Histologically, tumors had smooth muscle features and were immunoreactive for muscle markers and all but two tumors demonstrated the presence of EBV by either immunohistochemistry, in situ hybridization, and/or PCR. While mitoses and/or necrosis were used to separate leiomyoma from leiomyosarcoma, these features did not correlate with clinical outcome. Treatment included primarily resection, and less often radiotherapy, chemotherapy and highly active antiretroviral therapy (HAART). Overall, EBV-SMTs appear to have variable aggressiveness and clinical outcome and may exhibit a more favorable prognosis compared to conventional leiomyosarcoma. Tumor-related death from EBV-SMT occurred in only 4 of 51 patients.
PMCID: PMC3062098  PMID: 21437186
24.  Transgenic Tobacco Overexpressing Brassica juncea HMG-CoA Synthase 1 Shows Increased Plant Growth, Pod Size and Seed Yield 
PLoS ONE  2014;9(5):e98264.
Seeds are very important not only in the life cycle of the plant but they represent food sources for man and animals. We report herein a mutant of 3-hydroxy-3-methylglutaryl-coenzyme A synthase (HMGS), the second enzyme in the mevalonate (MVA) pathway that can improve seed yield when overexpressed in a phylogenetically distant species. In Brassica juncea, the characterisation of four isogenes encoding HMGS has been previously reported. Enzyme kinetics on recombinant wild-type (wt) and mutant BjHMGS1 had revealed that S359A displayed a 10-fold higher enzyme activity. The overexpression of wt and mutant (S359A) BjHMGS1 in Arabidopsis had up-regulated several genes in sterol biosynthesis, increasing sterol content. To quickly assess the effects of BjHMGS1 overexpression in a phylogenetically more distant species beyond the Brassicaceae, wt and mutant (S359A) BjHMGS1 were expressed in tobacco (Nicotiana tabacum L. cv. Xanthi) of the family Solanaceae. New observations on tobacco OEs not previously reported for Arabidopsis OEs included: (i) phenotypic changes in enhanced plant growth, pod size and seed yield (more significant in OE-S359A than OE-wtBjHMGS1) in comparison to vector-transformed tobacco, (ii) higher NtSQS expression and sterol content in OE-S359A than OE-wtBjHMGS1 corresponding to greater increase in growth and seed yield, and (iii) induction of NtIPPI2 and NtGGPPS2 and downregulation of NtIPPI1, NtGGPPS1, NtGGPPS3 and NtGGPPS4. Resembling Arabidopsis HMGS-OEs, tobacco HMGS-OEs displayed an enhanced expression of NtHMGR1, NtSMT1-2, NtSMT2-1, NtSMT2-2 and NtCYP85A1. Overall, increased growth, pod size and seed yield in tobacco HMGS-OEs were attributed to the up-regulation of native NtHMGR1, NtIPPI2, NtSQS, NtSMT1-2, NtSMT2-1, NtSMT2-2 and NtCYP85A1. Hence, S359A has potential in agriculture not only in improving phytosterol content but also seed yield, which may be desirable in food crops. This work further demonstrates HMGS function in plant reproduction that is reminiscent to reduced fertility of hmgs RNAi lines in let-7 mutants of Caenorhabditis elegans.
PMCID: PMC4029903  PMID: 24847714
25.  Prognostic analysis of gastric gastrointestinal stromal tumor with synchronous gastric cancer 
Many patients with gastric gastrointestinal stromal tumor (GIST) and synchronous gastric cancer have been described, most in single case studies. We retrospectively investigated the clinicopathologic features and prognostic effects of gastric GIST in patients with synchronous gastric cancer.
The study enrolled 170 patients with gastric GIST, who had undergone complete surgical resection (R0) from January 2000 to December 2011. Forty-two patients had synchronous gastric cancer (CA Group), whereas 128 did not (Non-CA Group). The clinicopathologic features and potential prognostic factors in the two groups were compared.
Patients in the CA Group had more obvious symptoms, but a lower rate of preoperative diagnosis of gastric GIST (P <0.05). The two groups differed significantly in gender, age, greatest tumor diameter, risk stratification, tumor-associated ulcers, and CD117 and CD34 expression (P <0.05 each). Univariate analysis showed that age, risk stratification, postoperative oral imatinib and synchronous gastric cancer were predictive factors of survival (P <0.05). Cox regression analysis showed that risk stratification, postoperative oral imatinib and synchronous gastric cancer were independent predictors of survival (P <0.05). Stratified analysis showed that the 5-year overall survival rate was lower in patients with synchronous gastric cancer than in those without synchronous gastric cancer.
Gastric GIST with synchronous gastric cancer had a lower rate of preoperative diagnosis, with correct diagnosis often missed. Survival, however, depended primarily on the gastric cancer.
PMCID: PMC3917900  PMID: 24479763
Gastrointestinal stromal tumor; Synchronous gastric cancer; Risk stratification; Prognosis

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