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1.  Impact of a surgical intensivist on the clinical outcomes of patients admitted to a surgical intensive care unit 
An intensivist is a key factor in the mortality of patients admitted to the intensive care unit (ICU). The aim of this study was to evaluate the effect of an intensivist on clinical outcomes of patients admitted to a surgical ICU.
During the study period, the surgical ICU was converted from an open ICU to an intensivist-directed ICU managed by an intensivist who was board certified in both general surgery and critical care medicine. We compared consecutive patients admitted to the surgical ICU before and after implementing the intensivist-directed care. The primary outcome was ICU mortality, and secondary outcomes were hospital mortality, 90-day mortality, length of hospital stay, ICU-free days, ventilator-free days, and ICU readmission rate.
A total of 441 patients were included in this study: 188 before implementation of the intensivist and 253 after implementation. Clinical characteristics were not different between the two groups. ICU mortality decreased from 11.7% to 6.3% (P = 0.047) after implementation, and 90-day mortality also decreased significantly (P = 0.008). The adjusted hazard ratio of the intensivist for ICU mortality was 0.43 (95% confidence interval, 0.22-0.87; P = 0.020). ICU-free days (P = 0.013) and the hospital length of stay (P = 0.032) were significantly improved after implementing the intensivist-directed care. Before implementation period, 16.0% of patients were readmitted, compared with only 9.9% after implementation (P = 0.05).
Implementing intensivist-directed care in the surgical ICU was associated with significant improvements in ICU mortality and significant clinical outcomes.
PMCID: PMC4062451  PMID: 24949324
Intensive care units; Critical illness; Specialization; General surgery; Mortality
2.  Large tubular colonic duplication in an adult treated with a small midline incision 
Tubular colonic duplication presenting in adults is rare and difficult to diagnose preoperatively. Only a few cases have been reported in the literature. We report a case of a 29-year-old lady presenting with a long history of chronic constipation, abdominal mass and repeated episodes of abdominal pain. The abdominal-pelvic computed tomography scan showed segmental bowel wall thickening thought to be small bowel, and dilatation with stasis of intraluminal content. The provisional diagnosis was small bowel duplication. She was scheduled for single port laparoscopic resection. However, a T-shaped tubular colonic duplication at sigmoid colon was found intraoperatively. Resection of the large T-shaped tubular colonic duplication containing multiple impacted large fecaloma and primary anastomosis was performed. There was no perioperative complication. We report, herein, the case of a T-shaped tubular colonic duplication at sigmoid colon in an adult who was successfully treated through mini-laparotomy assisted by single port laparoscopic surgery.
PMCID: PMC3294114  PMID: 22403754
Colonic duplication; Congenital abnormalities; Adult; Laparoscopy
3.  Predicting tumor response after preoperative chemoradiation using clinical parameters in rectal cancer 
AIM: To evaluate the clinical parameters and identify a better method of predicting pathological complete response (pCR).
METHODS: We enrolled 249 patients from a database of 544 consecutive rectal cancer patients who underwent surgical resection after preoperative chemoradiation therapy (PCRT). A retrospective review of morphological characteristics was then performed to collect data regarding rectal examination findings. A scoring model to predict pCR was then created. To validate the ability of the scoring model to predict complete regression.
RESULTS: Seventy patients (12.9%) achieved a pCR. A multivariate analysis found that pre-CRT movability (P = 0.024), post-CRT size (P = 0.018), post-CRT morphology (P = 0.023), and gross change (P = 0.009) were independent predictors of pCR. The accuracy of the scoring model was 76.8% for predicting pCR with the threshold set at 4.5. In the validation set, the accuracy was 86.7%.
CONCLUSION: Gross changes and morphological findings are important predictors of pathological response. Accordingly, PCRT response is best predicted by a combination of clinical, laboratory and metabolic information.
PMCID: PMC3247696  PMID: 22219601
Rectal cancer; Preoperative chemoradiotherapy; Downstaging; Tumor regression; Validation
4.  Compliance and Effective Management of the Hand-Foot Syndrome in Colon Cancer Patients Receiving Capecitabine as Adjuvant Chemotherapy 
Yonsei Medical Journal  2009;50(6):796-802.
Physicians and oncology nurses must continue to update their knowledge on treatment and treatment-related side effects, while searching for effective methods to prevent or manage side effects. The objective of our study was to describe the incidence and response to treatment of the hand-foot syndrome (HFS) and the compliance with treatment of patients with stage IIB, IIIA, IIIB, and IIIC colon cancer that were treated with capecitabine alone as adjuvant therapy.
Materials and Methods
Between September 2005 and September 2006, 84 patients fulfilled the inclusion criteria and were included in this retrospective analysis of prospectively collected data.
The treatment compliance rate was 90.5% (76 out of the 84 patients). The HFS developed in 65 patients (77.4%). Thirty-three patients (50.7%) had grade 1 HFS, 22 patients (33.8%) had grade 2 HFS and 10 patients (15.5%) had grade 3 HFS, as their most severe episode. For Grade 1 patients, the dose was maintained, and skin barrier cream and moist exposed burn ointment (MEBO) were applied. For Grade 2 patients, either the dose was maintained or 25% of the dose was reduced; MEBO and supportive care were provided. For Grade 3 patients, one cycle of chemotherapy was interrupted followed by dose adjustment; MEBO and supportive care were provided.
HFS is manageable if both patients and oncology care teams are educated about HFS associated with capecitabine. The HFS is treated by patient education, preventive management, ointment application, conservative management, dose reduction, and interruption of chemotherapy administration.
PMCID: PMC2796406  PMID: 20046420
Colon neoplasm; capecitabine; compliance; side effects; hand erythema; foot erythema
5.  Intra-operative Measurement of Surgical Lengths of the Rectum and the Peritoneal Reflection in Korean 
Journal of Korean Medical Science  2008;23(6):999-1004.
The lengths of the surgical rectum and peritoneal reflection were important factors in treatment modality of rectal tumor. To evaluate the surgical length of rectum, we measured the length of the peritoneal reflections, sacral promontory and termination of the taenia coli from the anal verge by rigid sigmoidoscope in 23 male and 23 females during operation. The mean lengths of the sacral promontory were 16.5± 2.2 cm and 16.1±2.2 cm in the males and females, respectively. As for the peritoneal reflection, the results were anterior (8.8±2.2 cm, 8.1±1.7 cm), lateral (10.8±2.7 cm, 11.4±1.9 cm) and posterior (13.8±2.5 cm, 14.0±1.9 cm), respectively. There were no statistically significant differences between male and female. And only height had a correlation with the length of sacral promontory both in male and female (p=0.015 and p=0.018, respectively). For all the estimated lengths, the length of the sacral promontory had a correlation with the lengths of the anterior (p<0.001 and p=0.001) and posterior (p<0.001 and p<0.001) peritoneal reflections in males and females, respectively. We suggest that the intra-operative lengths of the rectum and peritoneal reflection will be useful information for treatment modality of rectal tumor clinically in Korean.
PMCID: PMC2610666  PMID: 19119443
Rectum; Sacral Promontory; Peritoneal Reflection
6.  Anal Canal Carcinoma: Experience from a Single Korean Institution 
Yonsei Medical Journal  2007;48(5):827-832.
The clinical features, treatment modality approaches in clinical practice, and prognostic factors for anal canal carcinoma patients were retrospectively analyzed.
Materials and Methods
Between October 1994 and December 2005, 50 patients with anal canal cancer were treated at Samsung Medical Center, Seoul, Korea.
After a median follow up of 37.8 months (range, 6.6 - 136.1 months), the 5-year and 10-year survival rates for the 38 patients with early and locally advanced squamous and cloacogenic carcinoma (squamous cell carcinoma and cloacogenic carcinoma) were 74.8% and 66.5%, respectively. The 5-year survival and disease-free survival rates (DFS) of the 31 patients who received chemoradiation therapy (CRT) were 83.6% and 74.3%, respectively. The overall and DFS could not be determined for the adenocarcinoma group due to the small number of cases (n = 8). Univariate analysis showed that tumor size (p = 0.04) and inguinal node status (p = 0.04) significantly influenced patient survival in patients with squamous cell and cloacogenic carcinomas. Furthermore, univariate analysis also showed that, inguinal node status influenced patient survival in the adenocarcinoma group. Multivariate analysis showed that inguinal node metastasis is a single independent prognostic variable for survival (p = 0.04) in patients with squamous cell and cloacogenic carcinomas.
Combined CRT has been adopted as standard treatment with outcomes that are comparable to those reported in randomized clinical trials. Due to the rarity and complexity of anal canal carcinoma, interdepartmental cooperation is required for disease treatment. Thus, proper treatment of patients should incorporate a team-approach and should be available to as many patients as possible.
PMCID: PMC2628150  PMID: 17963341
Anal canal cancer; neoplasm; chemotherapy; radiotherapy
7.  Immunohistochemical Detection of p53 Expression in Patients with Preoperative Chemoradiation for Rectal Cancer: Association with Prognosis 
Yonsei Medical Journal  2014;56(1):82-88.
The expression of p53 in patients with rectal cancer who underwent preoperative chemoradiationand and its potential prognostic significance were evaluated.
Materials and Methods
p53 expression was examined using immunohistochemistry in pathologic specimens from 210 rectal cancer patients with preoperative chemoradiotherapy and radical surgery. All patients were classified into two groups according to the p53 expression: low p53 (<50% nuclear staining) and high p53 (≥50%) groups.
p53 expression was significantly associated with tumor location from the anal verge (p=0.036). In univariate analysis, p53 expression was not associated with disease-free survival (p=0.118) or local recurrence-free survival (p=0.089). Multivariate analysis showed that tumor distance from the anal verge (p=0.006), ypN category (p=0.011), and perineural invasion (p=0.048) were independent predictors of disease-free survival; tumor distance from the anal verge was the only independent predictor of local recurrence-free survival. When the p53 groups were subdivided according to ypTNM category, disease-free survival differed significantly in patients with ypN+ disease (p=0.027) only.
Expression of p53 in pathologic specimens as measured by immunohistochemical methods may have a significant prognostic impact on survival in patients with ypN+ rectal cancer with preoperative chemoradiotherapy. However, it was not an independent predictor of recurrence or survival.
PMCID: PMC4276781  PMID: 25510750
p53; rectal cancer; immunohistochemistry
8.  Transanal natural orifice transluminal endoscopic surgery total mesorectal excision in animal models: endoscopic inferior mesenteric artery dissection made easier by a retroperitoneal approach 
We report the performance of natural orifice transluminal endoscopic surgery (NOTES) low anterior resection in animals using transanal total mesorectal excision (TME) with laparoscopic assistance and endoscopic inferior mesenteric artery (IMA) dissection.
Four pigs weighing 45 kg each, and one dog weighing 25 kg, underwent surgery via a transanal approach. The rectum was occluded transanally using a purse-string suture, approximately 3-4 cm from the anal verge. The rectal mucosa was incised circumferentially just distal to the purse-string. A SILS or GelPOINT port was inserted transanally. Transanal TME was assisted by laparoscopy and proceeded up to the peritoneal reflection. More proximal dissection, including IMA dissection, was performed along the retroperitoneal avascular plane by endoscopy alone and facilitated by CO2 insufflation. The IMA was clipped and divided endoscopically. The mobilized rectosigmoid were exteriorized transanally and transected. A colorectal anastomosis was performed using a circular stapler with a single stapling technique.
Endoscopic dissection of the IMA was successful in all five animals. The mean operation time was 125 minutes (range, 90-170 minutes). There were no intraoperative complications or hemodynamic instability. The mean length of the resected specimen was 14.4 cm (range, 12-16 cm).
A NOTES retroperitoneal approach to the IMA with CO2 insufflation and intact peritoneal covering overcame the difficulties of retraction and exposure of endoscopic dissection in animals.
PMCID: PMC4091439  PMID: 25025019
Natural orifice transluminal endoscopic surgery; Retroperitoneal approach; Total mesorectal excision; Inferior mesenteric artery
9.  Alcohol dehydrogenase, iron containing, 1 promoter hypermethylation associated with colorectal cancer differentiation 
BMC Cancer  2013;13:142.
The aberrant methylation of CpG islands in the promoter is associated with colorectal cancer (CRC) carcinogenesis. In our previous study, the promoter of alcohol dehydrogenase, iron containing, 1 (ADHFE1) was most highly methylated in CRC compared to normal colorectal mucosa. In this study, we examined the expression and function of the ADHFE1 in CRC.
We examined the promoter methylation and mRNA expression of ADHFE1 with 5-aza-2′-deoxycytidine (5-Aza-2-dC) in 12 CRC cell lines, 124 paired CRC and adjacent normal mucosa, and 59 advanced adenomas. To confirm methylation of ADHFE1, we performed bisulfite genomic sequencing in 3 CRC cell lines, 6 paired CRC and adjacent normal mucosa. ADHFE1 protein expression was studied using western blot and immunohistochemistry, respectively in the 36 and 243 paired CRC and adjacent normal tissue. We transfected the DLD-1 with pcDNA3.1 vector containing ADHFE1 and examined the expression of differentiation marker, such as ALP, CEA and Cdx2. We examined the ADHFE1 expression at distinct developmental stages in mouse embryos.
The ADHFE1 promoter was hypermethylated in all CRC cell lines, 81.8% in CRCs, and 84.7% in advanced adenomas, with reciprocal change by 5-Aza-2-dC. The expression of ADHFE1 mRNA was down-regulated in all CRC cell lines and 96.3% in CRC tissues. The expression of ADHFE1 protein was down-regulated in 91.7% of CRC tissues. In the immunohistochemistry, normal epithelial cells at the crypt top showed very strong ADHFE1 expression, whereas they were much weaker at the crypt base. In CRC, the good differentiation was significantly associated with high ADHFE1 expression. The activity of differentiation marker, such as ALP and CEA, was higher in pcDNA3.1-ADHFE1 transfected CRC cells with consistent correlation with ADHFE1 protein than control. In mouse embryos, ADHFE1 in the large intestine was the first detected at E15.5. At E18.5, ADHFE1 was predominantly expressed in the top of the mature crypt epithelium.
It showed that the hypermethylation of ADHFE1 promoter in CRC is concordance with down-regulation of ADHFE1 mRNA and ADHFE1 protein. ADHFE1 has an important role of differentiation in CRC, as well as normal colorectal mucosa and embryonic developmental processes.
PMCID: PMC3618294  PMID: 23517143
ADHFE1; Promoter methylation; Colorectal cancer; Differentiation
10.  Oncologic Outcomes of Stage IIIA Colon Cancer for Different Chemotherapeutic Regimens 
Adjuvant chemotherapy is currently recommended for Stage IIIA colon cancers. This study aimed to elucidate the oncologic outcomes of Stage IIIA colon cancer according to the chemotherapeutic regimen based on a retrospective review.
From 1995 to 2008, Stage IIIA colon cancer patients were identified from a prospectively maintained database at a single institution. Exclusion criteria were as follows: rectal cancer, another malignancy other than colon cancer, no adjuvant chemotherapy and unknown chemotherapeutic regimen. One hundred thirty-one patients were enrolled in the study, and the clinicopathologic and the oncologic characteristics were analyzed. The number of males was 72, and the number of females was 59; the mean age was 59.5 years (range, 25 to 76 years), and the median follow-up period was 33 months (range, 2 to 127 months).
Of the 131 patients, fluorouracil/leucovorin (FL)/capecitabine chemotherapy was performed in 109 patients, and FOLFOX chemotherapy was performed in 22 patients. When the patients who received FL/capecitabine chemotherapy and the patients who received FOLFOX chemotherapy were compared, there was no significant difference in the clinicopathologic factors between the two groups. The 5-year overall survival and the 5-year disease-free survival were 97.2% and 94.5% in the FL/capecitabine patient group and 95.5% and 90.9% in the FOLFOX patient group, respectively, and no statistically significant differences were noted between the two groups.
Stage IIIA colon cancer showed good oncologic outcomes, and the chemotherapeutic regimen did not seem to affect the oncologic outcome.
PMCID: PMC3499427  PMID: 23185706
Stage IIIA; Colon neoplasm; Chemotherapeutic agent; Prognosis
11.  Outcome of total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis 
We evaluated the risk factors for late complications and functional outcome after total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC).
Pre- and postoperative clinical status and follow-up data were obtained for 55 patients who underwent TPC with IPAA between 1999 and 2010. The median follow-up duration was 4.17 years. Late complications were defined as those that appeared at least one month after surgery. For a functional assessment, telephone interviews were conducted using the Global Assessment of Functioning Scale. Twenty-eight patients completed the interview.
Late complications were found in 20 cases (36.3%), comprising pouchitis (n = 8), bowel obstruction (n = 5), ileitis (n = 3), pouch associated fistula (n = 2), and intra-abdominal infection (n = 2). The preoperative serum albumin level for patients with late complications was lower than for patients without (2.4 ± 0.5 vs. 2.9 ± 0.7, P = 0.04). Functional outcomes were not significantly associated with clinical characteristics, follow-up duration, operation indication, or late complications.
This study demonstrated that a low preoperative albumin level could be a risk factor for late complications of TPC with IPAA. Preoperative nutritional support, especially albumin, could reduce late complications. Functional outcomes are not related to late complications.
PMCID: PMC3433549  PMID: 22977759
Ulcerative colitis; Proctocolectomy; Complications
12.  Negative impact of pretreatment anemia on local control after neoadjuvant chemoradiotherapy and surgery for rectal cancer 
Radiation Oncology Journal  2012;30(3):117-123.
Although anemia is considered to be a contributor to intra-tumoral hypoxia and tumor resistance to ionizing radiation in cancer patients, the impact of pretreatment anemia on local control after neoadjuvant concurrent chemoradiotherapy (NACRT) and surgery for rectal cancer remains unclear.
Materials and Methods
We reviewed the records of 247 patients with locally advanced rectal cancer who were treated with NACRT followed by curative-intent surgery.
The patients with anemia before NACRT (36.0%, 89/247) achieved less pathologic complete response (pCR) than those without anemia (p = 0.012). The patients with pretreatment anemia had worse 3-year local control than those without pretreatment anemia (86.0% vs. 95.7%, p = 0.005). Multivariate analysis showed that pretreatment anemia (p = 0.035), pathologic tumor and nodal stage (p = 0.020 and 0.032, respectively) were independently significant factors for local control.
Pretreatment anemia had negative impacts on pCR and local control among patients who underwent NACRT and surgery for rectal cancer. Strategies maintaining hemoglobin level within normal range could potentially be used to improve local control in rectal cancer patients.
PMCID: PMC3496845  PMID: 23170290
Anemia; Rectal cancer; Neoadjuvant therapy; Concurrent chemoradiotherapy
13.  Epigenomic Analysis of Aberrantly Methylated Genes in Colorectal Cancer Identifies Genes Commonly Affected by Epigenetic Alterations 
Annals of Surgical Oncology  2011;18(8):2338-2347.
Determination of the profile of genes that are commonly methylated aberrantly in colorectal cancer (CRC) will have substantial value for diagnostic and therapeutic applications. However, there is limited knowledge of the DNA methylation pattern in CRC.
Materials and Methods
We analyzed the methylation profile of 27,578 CpG sites spanning more than 14,000 genes in CRC and in the adjacent normal mucosa using beadchip array-based technology.
We identified 621 CpG sites located in promoter regions and CpG islands that were significantly hypermethylated in CRC compared to normal mucosa. The genes on chromosome 18 showed promoter hypermethylation most frequently. According to gene ontology analysis, the most common biologically relevant class of genes affected by methylation was the class associated with the cadherin signaling pathway. Compared to the genome-wide expression array, mRNA expression was more likely to be down-regulated in the genes demonstrating promoter hypermethylation, even though this was not statistically significant. We validated 10 CpG sites that were hypermethylated (ADHFE1, BOLL, SLC6A15, ADAMTS5, TFPI2, EYA4, NPY, TWIST1, LAMA1, GAS7) and 2 CpG sites showing hypomethylation (MAEL, SFT2D3) in CRC compared to the normal mucosa in the array studies using pyrosequencing. The methylation status measured by pyrosequencing was consistent with the methylation array data.
Methylation profiling based on beadchip arrays is an effective method for screening aberrantly methylated genes in CRC. In addition, we identified novel methylated genes that are candidate diagnostic or prognostic markers for CRC.
PMCID: PMC3393129  PMID: 21298349
14.  Transanal Endoscopic Microsurgery for the Treatment of Well-Differentiated Rectal Neuroendocrine Tumors 
Recently, an increase in well-differentiated rectal neuroendocrine tumors (WRNETs) has been noted. We aimed to evaluate transanal endoscopic microsurgery (TEM) for the treatment of WRNETs.
Between December 1995 and August 2009, 109 patients with WRNETs underwent TEM. TEM was performed for patients with tumors sizes of up to 20 mm and without a lymphadenopathy. These patients had been referred from other clinics after having been diagnosed with WRNETs by using a colonoscopic biopsy; they had undergone a failed endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) and exhibited an involved resection margin and remaining tumor after ESD or EMR, regardless of the distance from the anal verge. This study included 38 patients that had more than three years of follow-up.
The mean age of the patients was 51.3 ± 11.9 years, the mean tumor size was 8.0 ± 3.9 mm, and no morbidity occurred. Thirty-five patients were asymptomatic. TEM was performed after a colonoscopic resection in 13 cases because of a positive resection margin, a residual tumor or a non-lifting lesion. Complete resections were performed in 37 patients; one patient with a positive margin was considered surgically complete. In one patient, liver metastasis and a recurrent mesorectal node occurred after five and 10 years, respectively.
TEM might provide an accessible and effective treatment either as an initial or as an adjunct after a colonoscopic resection for a WRNET.
PMCID: PMC3440489  PMID: 22993706
Well-differentiated rectal neuroendocrine tumors; Transanal endoscopic microsurgery; Colonoscopic resection; Treatment
15.  Metastasis of Neuroendocrine Tumors Are Characterized by Increased Cell Proliferation and Reduced Expression of the ATM Gene 
PLoS ONE  2012;7(4):e34456.
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare group of tumors with a wide spectrum of clinical behavior. However, there are no known clinically relevant biomarkers to predict metastasis.
Experimental Design
To investigate differential gene expression signatures of metastatic vs non-metastatic NETs, we studied cell cycle regulatory genes in 19 metastatic and 22 non-metastatic colorectal NETs by PCR arrays. Immunohistochemistry (IHC) and quantitative real-time RT-PCR were performed to verify the results and another set of 38 GEP-NETs were further studied for validation.
We first delineated six candidate genes for metastasis including ATM, CCND2, RBL2, CDKN3, CCNB1, and GTSE1. ATM was negatively correlated with metastatic NETs (p<0.001) with more than 2-fold change compared to non-metastatic NETs. Overexpression of ATM protein by IHC was strongly correlated with high ATM mRNA levels and low Ki-67 labeling index. Patients with ATM-negativity by IHC showed significantly decreased overall survival than patients with ATM-positivity (median OS, metastatic vs non-metastatic NETs; 2.7 years vs not reached; p = 0.003) and 85.7% of metastatic NETs were ATM-negative. In another validation set of GEP-NETs, decreased mRNA of ATM gene was associated with metastasis and remained significant (p = 0.023).
ATM down-regulation was strongly associated with metastatic NETs when compared with non-metastatic NETs and ATM may be a potential predictive marker for metastasis as well as a novel target in metastatic GEP-NETs.
PMCID: PMC3317775  PMID: 22485171
16.  Pancreatic serous cystadenocarcinoma with invasive growth into the colon and spleen 
Serous cystic neoplasms of the pancreas are almost always benign lesions. However, there are some case reports of malignant serous neoplasms of the pancreas. It is very difficult to distinguish malignant and benign tumors. Indeed, only clinicopathologic findings of locoregional invasion and metastasis represent a malignancy. We report a serous cystadenocarcinoma of the pancreas that was initially considered to be colon cancer. Post-operatively, the tumor was confirmed to be a malignant serous cystic tumor of the pancreas. One year later, the patient remains disease-free.
PMCID: PMC3204548  PMID: 22066125
Pancreas; Cystadenocarcinoma; Colon; Spleen
17.  Palliative radiotherapy in patients with a symptomatic pelvic mass of metastatic colorectal cancer 
To evaluate the palliative role of radiotherapy (RT) and define the effectiveness of chemotherapy combined with palliative RT (CCRT) in patients with a symptomatic pelvic mass of metastatic colorectal cancer.
From August 1995 to December 2007, 80 patients with a symptomatic pelvic mass of metastatic colorectal cancer were treated with palliative RT at Samsung Medical Center. Initial presenting symptoms were pain (68 cases), bleeding (18 cases), and obstruction (nine cases). The pelvic mass originated from rectal cancer in 58 patients (73%) and from colon cancer in 22 patients (27%). Initially 72 patients (90%) were treated with surgery, including 64 complete local excisions; 77% in colon cancer and 81% in rectal cancer. The total RT dose ranged 8-60 Gy (median: 36 Gy) with 1.8-8 Gy per fraction. When the α/β for the tumor was assumed to be 10 Gy for the biologically equivalent dose (BED), the median RT dose was 46.8 Gy10 (14.4-78). Twenty one patients (26%) were treated with CCRT. Symptom palliation was assessed one month after the completion of RT.
Symptom palliation was achieved in 80% of the cases. During the median follow-up period of five months (1-44 months), 45% of the cases experienced reappearance of symptoms; the median symptom control duration was five months. Median survival after RT was six months. On univariate analysis, the only significant prognostic factor for symptom control duration was BED ≥40 Gy10 (p < 0.05), and CCRT was a marginally significant factor (p = 0.0644). On multivariate analysis, BED and CCRT were significant prognostic factors for symptom control duration (p < 0.05).
RT was an effective palliation method in patients with a symptomatic pelvic mass of metastatic colorectal cancer. For improvement of symptom control rate and duration, a BED ≥ 40 Gy10 is recommended when possible. Considering the low morbidity and improved symptom palliation, CCRT might be considered in patients with good performance status.
PMCID: PMC3130661  PMID: 21600018
metastatic colorectal cancer; pelvic recurrence; palliative radiation therapy; concurrent chemoradiotherapy
18.  Routine chest computed tomography as a preoperative work-up for primary colorectal cancer: is there any benefit in short-term outcome? 
The aim of this study was to assess the role of pre-operative chest computed tomography (CT) compared with abdominopelvic CT (AP-CT) and chest radiography (CXR) for detecting pulmonary metastasis in patients with primary colorectal cancer (CRC).
We retrospectively analyzed the data of 619 patients with primary CRC who simultaneously received a preoperative chest CT (chest CT group), AP-CT with hilar extension, and CXR (CXR group).
In the chest CT group, there were 297 (48.0%) normal, 198 (32%) benign, 96 (15.5%) indeterminate, 26 (4.2%) metastasis, and two lung cancers. Eighteen patients (2.9%) in the CXR group who had no pulmonary metastasis were diagnosed with pulmonary metastasis on a chest CT. The sensitivity and accuracy were 83.9% and 99.0% in the chest CT group, respectively, and 29.0% and 91.5% in the CXR group, respectively (P < 0.0001 and P = 0.0003).
Chest CT appears to improve the accuracy of pre-operative staging in patients with CRC and is useful for the early detection of pulmonary metastasis as a baseline study for abnormal lung nodules.
PMCID: PMC3204704  PMID: 22066056
Colorectal neoplasm; Metastases; Computed tomography; Chest X-ray
19.  Treatment Outcomes of Anorectal Melanoma 
An anorectal melanoma (AM) is a very rare tumor. However, sufficient data supporting effective surgical options for the disease do not exist. This retrospective review aimed to analyze treatment outcomes for an AM.
From June 1999 to December 2008, we retrospectively reviewed a prospectively collected consecutive series of 19 patients who had undergone a surgical resection for an AM at a single institute. Surgical method and clinicopathological factors were analyzed.
The median age was 61.4 years (range, 46 to79 years). Main symptoms were an anal mass, hematochezia, perianal pain, tenesmus, fecal incontinence, and bowel habit change. The average duration of symptoms before diagnosis was 7.8 months (range, 1 to 36 months). S-100 and HMB-45 were positive in all patients, even in non-melanin pigmentation. There were 12 abdominoperineal resections (APRs) and 7 wide local excisions (WEs). The APR showed longer overall survival when compared with the WE (64.1 months vs. 10.9 months, P < 0.001). No patients who underwent a WE survived more than 13 months.
A high index of suspicion is necessary to establish the diagnosis for an AM in patients with anal symptoms, and S-100 and HMB-45 can be useful markers for an AM. Even with the small number of cases and the short follow-up, our data suggest that an APR for an AM may provide longer survival than a WE.
PMCID: PMC3053498  PMID: 21431094
Anorectal melanoma; Wide excision; Abdominoperineal resection; Immunohistochemical markers
20.  Oxaliplatin-Induced Chronic Peripheral Neurotoxicity: A Prospective Analysis in Patients with Colorectal Cancer 
Oxaliplatin-induced chronic peripheral neurotoxicity (OXCPN) manifests as a loss of sensation and dysesthesia in the distal extremities, which may impair daily activities and increase in incidence with the amount of oxaliplatin delivered. The variation in the reported incidence and severity of OXCPN may be a consequence of differences in the baseline characteristics of patients.
Materials and Methods
This was a prospective study (, NCT00977717) in which OXCPN was recorded for all consecutive colon cancer patients treated at Samsung Medical Center (Seoul, Korea) with oxaliplatin-based combination chemotherapy. The primary endpoint was the incidence of severe OXCPN (grade 2 lasting for >7 days, or grade 3). The association of severe OXCPN and pretreatment parameters was evaluated using a multivariate regression model.
Between Jan 2008 and Feb 2010, 100 patients treated with adjuvant folinic acid/fluorouracil plus oxaliplatin (FOLFOX) and 266 patients treated with capecitabine plus oxaliplatin (XELOX) or FOLFOX for advanced disease were registered into our study. The median cumulative dose of oxaliplatin was 796 mg/m2 (range, 85 to 1,583 mg/m2). Severe OXCPN was observed in 126 (34%) patients. Overall, 43 patients discontinued chemotherapy due to toxicity: 23 without severe OXCPN and 20 with severe OXCPN. In univariate analysis, severe OXCPN was frequently observed in patients with age ≥55 years (p<0.01), stage II or III (p<0.01), adjuvant setting (p=0.01), FOLFOX (p<0.01), performance status of 0 (p=0.02), and those with no prior chemotherapy (p<0.01). In a multivariate regression model, the number of chemotherapy cycles and the cumulative oxaliplatin dose were not associated with the development of severe OXCPN.
We failed to find a significant association between patient characteristics at baseline and the development of severe OXCPN after oxaliplatin-based combination chemotherapy. Pharmacogenomic profiling using genome-wide association study in these patients is underway.
PMCID: PMC3021736  PMID: 21253319
Colorectal neoplasms; Oxaliplatin; Neurotoxicity
21.  Oncologic Outcome after Cessation or Dose Reduction of Capecitabine in Patients with Colon Cancer 
Oral capecitabine has been used as adjuvant therapy for colorectal cancer patients since the 1990s. Patient-initiated cessation or reduced use of capecitabine occurs widely for various reasons, yet the consequences of these actions are unclear. The present study sought to clarify treatment outcomes in such patients.
The study included 173 patients who had been diagnosed with stage II or III colon cancer according to the pathologic report after radical surgery at Samsung Medical Center from May 2005 to June 2007 and who had received capecitabine as adjuvant therapy. The patients were divided into groups according to whether the dose was reduced (I, dose maintenance; II, dose reduction) or stopped (A, cycle completion; B, cycle cessation). Recurrence and disease-free survival rates between the two groups each were analyzed.
Of the 173 patients, 128 (74.6%) experienced complications, most frequently hand-foot syndrome (n = 114). Reduction (n = 35) or cessation (n = 18) of medication was most commonly due to complications. Concerning reduced dosage, both groups displayed no statistically significant differences in recurrence rate and 3-year disease-free survival rate. Concerning discontinued medication use, the cycle completion group showed an improved recurrence rate (P = 0.048) and 3-year disease-free survival rate (P = 0.028).
The results demonstrate that maintaining compliance with capecitabine as an adjuvant treatment for colon cancer to preventing complications positively affects patient prognosis.
PMCID: PMC2998011  PMID: 21152231
Colon cancer; Capecitabine; Dose; Cycle; Disease-free survival
22.  En bloc Resection for Right Colon Cancer Directly Invading Duodenum or Pancreatic Head 
Yonsei Medical Journal  2009;50(6):803-806.
We undertook this study to analyze clinical features and surgical outcome of en bloc resections of the right side colon cancer directly invading duodenum and/or pancreatic head.
Materials and Methods
The records of all patients who underwent en bloc resection of duodenum and/or pancreas for right colon cancers were analyzed retrospectively. From September 1994 to September 2006, 1,016 patients underwent curative right hemicolectomy. Nine patients (0.9%) had en bloc resection of a right side colon cancer with duodenum or pancreatic head invasion.
The median operative time was 320 minutes (range, 200-420) and the median blood loss was 700 mL (range, 100-2,000). The mean size of tumor was 6.6 cm (range, 3.2-10.7). The mean preoperative carcinoembryonic antigen (CEA) was 10.6 ng/mL (range, 0.2-50.8). There was no 30 day perioperative mortality. The median disease-free survival was 23.5 months [95% confidence interval (CI) 5.2-41.8] and the median overall survival was 28.1 months (95% CI 9.7-46.5).
In patients with locally advanced right side colon cancer that directly invades the duodenum or pancreas can be safely resected with curative potential with minimum morbidity and mortality. Long term disease free survival can occur in a significant number of patients undergoing curative en bloc resection in this particular subset of patients.
PMCID: PMC2796407  PMID: 20046421
Colonic neoplasms; duodenectomy; pancreaticoduodenectomy; survival
23.  Chondrolipoma in the Pelvic Cavity: a Case Report 
Korean Journal of Radiology  2008;9(6):563-567.
A chondrolipoma is an extremely rare form of a benign mesenchymal tumor containing mature cartilage and fatty tissue. Chondrolipomas may be found in almost any part of the body, particularly in the connective tissue of the breast, head and neck area, as well as in the skeletal muscle. However, to the best of our knowledge, chondrolipomas located in the pelvic cavity have not been reported. In this case report, we describe a case of a chondrolipoma in the pelvis, and show that it has its own characteristic imaging findings, which included the composition of fatty tissue and calcification in most parts, as well as some focal areas of chondroid tissue based on the CT and MR findings.
PMCID: PMC2627234  PMID: 19039275
Chondrolipoma; Lipoma; Fatty tumor

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