Size discrepancy between endoscopic size and pathologic size is not negligible in endoscopic resection for early gastric cancer

Background

Accurate tumor size measurement is critical for selecting proper candidates for endoscopic resection (ER) of early gastric cancer (EGC). However, size discrepancy between endoscopic size and pathologic size often occurs during ER for EGC.

Objective

The purposes of this study were to investigate the clinicopathological characteristics related to size discrepancy and the clinical implications of size discrepancies in terms of therapeutic outcomes.

Methods

Between April 2006 and June 2013, a total of 820 patients with 826 EGCs underwent ER. Enrolled lesions were categorized into the following three groups based on size discrepancy between endoscopic size and pathologic size: well-estimated (N = 308), underestimated (N = 215), or overestimated (N = 303) lesions. The well-estimated group was defined as lesions with a ratio of endoscopic size to pathologic size from 0.7 to 1.3.

Results

The overall median size discrepancy was 5.0 mm (interquartile range 2.0–9.0). Size, location, macroscopic type, primary tumor stage, and histology differed significantly between the three groups. Larger size [odds ratio (OR) 5.07, 95 % confidence interval (CI) 3.38–7.59, p < 0.001], flat/depressed type (OR 1.71, 95 % CI 1.15–2.55, p = 0.008), and undifferentiated histology (OR 2.24, 95 % CI 1.31–3.83, p = 0.003) were independent risk factors for endoscopic size underestimation in multivariate analysis. Smaller size (OR 10.95, 95 % CI 4.64–25.87, p < 0.001) was the only independent predictor for endoscopic overestimation of size. Significantly lower complete resection and curative resection rates were detected in the underestimated group compared with the well-estimated group, while the complete resection rate in the overestimated group tended to be higher than in the well-estimated group. There was no significant difference of curative resection rate between the overestimated and the well-estimated groups.

Conclusions

Larger size, flat/depressed type, and undifferentiated histology of EGC carry a significant risk for endoscopic underestimation of lesion size, which results in the lower rates of complete and curative resections for EGC. Further studies to reduce size discrepancy are warranted.     

CD151 Overexpression is Associated with Poor Prognosis in Patients with pT3 Gastric Cancer

Introduction

CD151, a transmembrane protein of the tetraspanin family, is implicated in the regulation of cell-substrate adhesion and cell migration. Overexpression of CD151 has been reported in several cancers and controls MET-dependent neoplastic growth by enhancing receptor signaling. However, association of CD151 overexpression with MET or tumor progression has not been reported in gastric cancer.

Materials and Methods

We conducted immunohistochemical analysis of CD151 overexpression in 491 pT3 gastric carcinomas and analyzed the relationship with MET overexpression and prognostic significance.

Results

CD151 was highly expressed in 119 gastric carcinomas (24.2 %) and was significantly associated with higher pN stages. Patients with CD151-positive gastric cancer showed shorter overall (p = 0.003) and disease-free survival (p = 0.001) compared with patients with CD151-negative gastric carcinoma. CD151 overexpression was an independent prognostic factor for overall survival [hazard ration (HR) 1.335; 95 % CI 1.005–1.775; p = 0.046] and disease-free survival (HR 1.903; 95 % CI 1.348–2.685; p < 0.001). Co-overexpression of CD151 and MET was observed in 30 (6.1 %) gastric cancers and was more frequent in advanced pN stages than in other groups. Moreover, co-overexpression of CD151 and MET was a strong independent prognostic factor for overall survival (HR 3.163; 95 % CI 1.958–5.108; p < 0.001) and disease-free survival (HR 3.834; 95 % CI 2.145–6.852; p < 0.001).

Conclusion

CD151 overexpression is an independent prognostic factor and could be a potential molecular therapeutic target in patients with advanced gastric cancers. Further studies are needed to establish the biological significance of CD151/MET co-overexpression and the potential of targeting both molecules as a therapeutic strategy.     

External Validation of Online Predictive Models for Prediction of Cancer-specific Mortality and All-cause Mortality in Patients with Urothelial Carcinoma of the Urinary Bladder

Purpose

The objective of the study was to validate the previously reported lookup Table and Bladder Cancer Research Consortium (BCRC) nomogram in predicting cancer-specific mortality (CSM) and all-cause mortality (ACM) after radical cystectomy using an external cohort from South Korea.

Methods

The study comprised 409 patients. Discrimination was quantified with the concordance index. The relationship between the model-derived and actual CSM and ACM was graphically explored within calibration plots. Clinical net benefit was evaluated by decision curve analysis.

Results

Of the 409 patients, 147 (35.9 %) had died from various causes. One hundred two deaths were attributable to bladder cancer. For CSM at 5 years, the bootstrap-corrected concordance indices of the American Joint Committee on Cancer (AJCC) staging system, lookup Table, and BCRC nomogram were 71.8 % (95 % confidence interval [CI] 66.9–76.5), 73.0 % (95 % CI 67.9–78.0), and 76.2 % (95 % CI 71.6–80.9), respectively. For ACM at the same time point, the discrimination accuracies of these models were 70.7 % (95 % CI 66.7–74.6), 72.8 % (95 % CI 68.5–76.9), and 76.2 % (95 % CI 72.3–80.2), respectively. The calibration plots tended to exaggerate both survival outcomes in all models. When compared to the lookup Table as well as the AJCC staging system, the BCRC nomogram performed well across a wide range of threshold probabilities using decision curve analysis.

Conclusions

The BCRC nomogram was characterized by higher accuracy and larger potential clinical benefit compared to the lookup Table. However, there is a great need for additional models that consider outcomes of patients for whom the existing models do not apply.     

Clinical importance of the updated Oxford classification in allograft IgA nephropathy

With the recent update to the Oxford classification for allograft IgA nephropathy (IgAN), additional investigations on the clinical significance of the updated components are warranted. We performed a retrospective cohort study at two tertiary hospitals. Kidney transplant recipients diagnosed with allograft IgAN were included in the study after additional review by specialized pathologists. We applied the updated Oxford classification and determined the MEST‐C scores of the patients. The main study outcome was death‐censored graft failure within 10 years after the establishment of allograft IgAN diagnosis and was assessed using the Cox regression analysis. Three hundred thirty‐three allograft IgAN patients were reviewed: 100 patients with confirmed native IgAN and 233 patients with other, clinical, or unknown primary causes for end‐stage renal disease (ESRD). The updated Oxford classification for allograft IgAN demonstrated prognostic value for graft failure, and patients with multiple MEST‐C components had worse outcomes. M, E, S, and C were significantly associated with the prognosis of recurred IgAN and T was the only independent prognostic parameter for allograft IgAN without confirmed native IgAN. Therefore, we suggest reporting MEST‐C scores in allograft biopsies and careful interpretation of the results according to the primary cause of ESRD.     

Survey for the Opinion of Medical Students and Medical Staff on a Financial Incentive System for Deceased Organ Donation in an Asian Country

BackgroundFinancial incentives for deceased organ donation are associated with many controversial ethical issues. This study examines the perspectives of medical students and staff members on financial incentives for the families of brain-dead organ donors.MethodologyA structured survey form was used between December 7, 2017 and January 28, 2018 to elicit opinions on financial incentives for the families of brain-dead organ donors. Forty-three medical staff members and 81 medical students participated in the survey voluntarily. The opinions on the financial incentive system and the relationship between willingness to give information about organ donation to families and a financial incentive system were assessed.ResultsThe majority of the participants (81.4%) had positive thoughts on organ donation. More than half of the participants (60.5%) thought that the financial incentive system did not erode the ethical purity of organ donation. As charge doctors, most respondents (84.6%) were willing to give information about organ donation to family members in the presence of financial incentives. However, the percentage decreased significantly to 60.5% when financial incentive was no longer factored into consideration (P < .001).LimitationThe study population is small, and the participants are not representative of the general population.ConclusionThe opinions of medical students and medical staff on financial incentives for deceased organ donation were generally positive. Financial incentives proved to be a potential influencing factor as an option of organ donation to be given to families.     

Effectiveness of Antithymocyte Globulin Induction Dosing Regimens in Kidney Transplantation Patients: A Network Meta-analysis

BackgroundAntithymocyte globulin (ATG) is an induction therapy in kidney transplantation, but our knowledge about the relation between outcomes and ATG regimens is limited. We compared ATG effectiveness in kidney transplantation according to dosage and administration schedule.MethodsReports from 1970 until May 2018 in CENTRAL, MEDLINE, EMBASE, and Science Citation Index Expanded were searched. We performed direct and indirect network meta-analysis using Bayesian models and generated rankings for ATG dosage and injection number variations by generation mixed treatment comparison.We compared ATG dose and schedule in kidney transplantation in relation to all-cause death, graft failure, antibody-mediated rejection, T-cell mediated rejection, biopsy-proven acute rejection, and bacterial and viral infection.ResultsTen studies (N = 1065) were analyzed by forming 6 groups: ATG alternate doses, 9 mg/kg, 6 mg/kg, and 4.5 mg/kg; single dose, 6 mg/kg, and 4.5 mg/kg; and control. Compared to placebo, ATG regimen variations were not associated with significant differences in survival, viral infection, renal function, or graft survival. ATG regimens 9 and 4.5 mg alternate dosing tended to reduce biopsy-proven acute rejection but without statistical significance. According to the highest rank probability, the 9 mg alternate dosing group had the highest tendency for cytomegalovirus and bacterial infections but without statistical significance.ConclusionsThe rejection frequency tended to be lower for the 9 and 4.5 mg alternate dosing groups. Infections occurred at a higher rate in the 9 mg alternate dosing group, but the differences in the risk of infection among the groups with different ATG regimens were not statistically significant.     

三维颅面水平参考平面的确定方法

目的:比较在三维影像选取双侧耳点和双侧眶下点构建的不同水平面之间差异,分析不同水平面对双侧耳点和双侧眶下点位置的影响,为颅面部三维头影测量水平参考平面的确定提供依据。方法:选取32名正畸治疗前面部基本对称患者(颏下点离正中矢状面≤2 mm), 获取DICOM格式的大视野锥形束CT数据并导入到Dolphin软件,将鼻根点、蝶鞍点和枢椎齿突最高点构建正中矢状面,测量双侧耳点和双侧眶下点中随机三点构建的4种水平参考平面。分别定义为,平面1:水平面由右侧耳点和双侧眶下点构成;平面2:水平面由左侧耳点和双侧眶下点构成;平面3:水平面由双侧耳点与右侧眶下点构成;平面4:水平面由双侧耳点与左侧眶点构成。记录4个平面在三维空间当中的俯仰角、侧偏角和横滚角。间隔两周,一位研究者进行两次测量。计算组间相关系数(interclass correlation coefficient,ICC)比较两次测量结果的一致性,检验测量者自身的可靠性,进行单因素重复测量方差分析检验组内4个平面之间的差异,按年龄分为13~17岁组和≥18岁组。以枢椎齿突最高点为原点计算双侧耳点和双侧眶下点位置,应用圆周长公式分析头部转动对双侧耳点和双侧眶下点的影响。结果:单因素重复测量方差分析结果显示,不同三点构建的4种平面之间俯仰角、侧偏角和横滚角差异均无统计学意义(P=0.196、0.314、0.341)。头位转动对双侧耳点和双侧眶下点的影响分析结果为:1°俯仰角变化产生耳点约0.5 mm、眶下点约1.6 mm的变化;1°侧偏角变化产生耳点约1.1 mm、眶下点约1.5 mm的变化;1°横滚角变化产生耳点约1.2 mm、眶下点约0.7 mm的变化。结论:对于面部基本对称个体,应用三维头颅影像对双侧耳点和双侧眶下点中随机选取三个点构建的4种水平面之间差异无统计学意义;以双侧眶下点和右侧耳点构建的水平面可能最适合临床使用;头部不同方向的转动使双侧耳点和双侧眶下点产生不同位置的变化。     

Fixation of a Posteromedial Osteochondral Lesion of the Talus Using a Three-Portal Posterior Arthroscopic Technique

Fixation of a large osteochondral fragment on the posteromedial talus can be performed using medial malleolar osteotomy or an arthroscopic technique with a transmalleolar portal. However, osteotomy can be associated with some morbidity, such as longstanding pain and tenderness at the osteotomy site. Also, it requires longer immobilization. However, the transmalleolar portal damages the tibial articular cartilage, which can later cause pain. In young patients, it can injure the epiphyseal plate. We describe a posterior arthroscopic technique using 3 posterior portals that allow access to a posteromedial osteochondral lesion of the talus and fixation of the osteochondral fragment without malleolar osteotomy or transmalleolar drilling.     

Internal impingement of the shoulder in flexion

Contact of the rotator cuff to the superior glenoid with the arm in flexion has been described and postulated to be a source of rotator cuff disease. The goals of the current study were to document the existence of internal impingement in flexion arthroscopically and to determine its prevalence in patients with various diseases. Also, we attempted to determine the clinical significance of internal impingement in flexion by investigating the associations between internal impingement in flexion and the preoperative and intraoperative findings. A consecutive case series of 376 patients having arthroscopy of the shoulder were entered prospectively into this study. During arthroscopy, intraarticular lesions were evaluated and the presence of contact of the rotator cuff to the superior glenoid and the degree of flexion making the contact were noted. Statistical analysis was done with two dependent variables defined: the presence of internal impingement in flexion and the flexion degree making internal impingement in flexion. Of the 376 patients, 277 (74%) had internal impingement in flexion and 99 (26%) did not have internal impingement in flexion. There were no statistically significant differences in the prevalence of internal impingement in flexion according to the primary diagnoses. Statistical analysis revealed that the presence of internal impingement in flexion was associated with Type II superior labrum anterior posterior (SLAP) lesions and the presence of internal impingement of the rotator cuff to the superior glenoid in abduction and external rotation. There was a significant relationship between rotator cuff disease and decreasing angle of contact for internal impingement in flexion. This study showed that internal impingement in flexion is common in a cohort of patients having shoulder surgery, with an overall prevalence of 74%, and that internal impingement in flexion may contribute to the development of Type II SLAP lesions and rotator cuff disease.