• Journal of Yeungnam Medical Science
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• v.39 no.3
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• pp.235-243
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• 2022

Background: Intrahepatic cholangiocarcinoma (ICC) of the left liver often shows left-sided lymph node (LN) metastasis. If gastric lesser curvature is extensively dissected, it can induce an iatrogenic injury to the extragastric vagus nerve branches that control motility of the pyloric sphincter and lead to gastric stasis. To cope with such LN dissection-associated gastric stasis, we performed pyloroplasty preemptively. The objective of this study was to analyze our 20-year experience of preemptive pyloroplasty performed in 10 patients. Methods: We investigated clinical sequences of 10 patients with ICC who underwent preemptive pyloroplasty following left hepatectomy and extended left-sided LN dissection. Incidence of gastric stasis and oncological survival outcomes were analyzed. Results: All 10 patients were classified as stage IIIB due to T1-3N1M0 stage according to the 8th edition of American Joint Committee on Cancer staging system. The overall patient survival rate was 51.9% at 1 year, 25.9% at 2 years, and 0% at 3 years. Seven patients showed uneventful postoperative recovery after surgery. Two patients suffered from gastric stasis, which was successfully managed with supportive care. One patient suffered from overt gastric paresis, which was successfully managed with azithromycin administration for 1 month. Conclusion: We believe that preemptive pyloroplasty is an effective surgical option to prevent gastric stasis in patients undergoing extensive left-sided LN dissection. Azithromycin appears to be a potent prokinetic agent in gastroparesis.

• Journal of Gastric Cancer
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• v.9 no.4
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• pp.231-237
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• 2009

Purpose: The aim of this study was to evaluate the significance of palliative gastrojejunostomy for treating patients with unresectable stage IV gastric cancer, and as compared with laparotomy for treating patients with incurable gastric cancer. Materials and Methods: We retrospectively studied 167 patients who could not undergo resection without obstruction at Korea University Hospital from 1984 to 2007. They were classified into two groups, one that underwent palliative gastrojejnostomy (the bypass group, n=62) and one that underwent explo-laparotomy (the O&C group, n=105), and the clinical data and operative outcomes were compared according to the groups. Results: For the clinical characteristics, there were no differences of age, gender and liver metastasis between the bypass group and the explo-laparotomy group, but there was a significant different for the presence of peritoneal metastasis (P=0.001). There was no difference between two groups for the postoperative mortality and morbidity. For the postoperative outcomes, the duration of the hospital stay (29.25 vs 16.67) and the frequency of re-admission were not different, but the median overall survival (4.3 months vs. 3.4 months, respectively) was significantly different. By multivariate analysis, the presence of peritoneal metastasis was identified as the independent prognostic factor for incurable gastric cancer. Conclusion: A prophylactic bypass procedure is not effective for improving the quality of life and prolonging the life expectancy of unresectable stage IV gastric cancer patients without obstruction.

• Radiation Oncology Journal
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• v.21 no.1
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• pp.27-34
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• 2003

Purpose : To evaluate the efficacy of radiotherapy, and the factors affecting survival in patients of extrahepatic bile duct cancer, by analyzing the results of postoperative radiotherapy Materials and Methods : Between October 1991 and July 2001, 21 patients with extrahepatic bile duct cancer, who received radiotherapy after a radical resection, were retrospectively reviewed. The patients' ages ranged from 39 to 75 years, with a median of 61 years, and a male to female ratio of 16 to 5. The numbers of patients with proximal and distal bile duct cancer were 14 and 7, respectively. From the postoperative pathological examination, 19 of the patients were found to have microscopic residues, and 7 to be lymph node positive. Patients with AJCC stages I, II and III were 10, 10 and 1, respectively. The total radiation dose administered was 4,500$\~$6,300 cGy, with a median dose of 5,040 cGy. The follow up period was 20$\~$81 months, with a median of 57.5 months. Results : The overall and disease free survival rates at 3 and 5 years were 41.0 and 29.3$\%$, and 41.6 and 29.7$\%$, respectively. The influences of age, sex, tumor location, differentiation, microscopic residue, neural invasion, 7 and N stage, the stage itself, the dose of radiation and chemotherapy, on survival were evaluated. The T stage and the stage itself were found to be significant from a univariate analysis (p<0.05), but the degree of significance was limited by the small number of patients. A recurrence occurred in 12 patients (57.1$\%$), 5 in locoregional sites, 4 in distant sites and 3 in a combination of locoregional and distant sites, and the sites of distant metastasis were the liver, 6, and the bone, 1 Grade 2 or 3 acute leucopenias occurred in 2 patients and grade 2 chronic peptic ulcers occurred in 4, who were all recovered by conservative management. Conclusion : Postoperative radiotherapy is feasigbls in extrah데atic bile duct cancer, with tolerable toxicity, but prospective studies, with a large patient enrollment, are needed for the evaluation of the effects of postoperative radiotherapy and the related prognostic factors.

• Radiation Oncology Journal
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• v.16 no.1
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• pp.17-25
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• 1998

Purpose : Although local recurrence rates of stomach cancer after radiocal surgery have been reported in the range of $30-70\%$, the role of postoperative adjuvant therapy has not been established. We report the result of radiotherapy in resected stomach cancer with positive surgical margin to elucidate the role of postoperative radiotherapy. Materials and Methods : From June 1991 to August 1996, twenty five patients with positive surgical margins after radical gastrectomy were treated with postoperative radiotherapy and chemotherapy. Median dose of radiation was 55.8Gy and the range was 44.6-59.4Gy. Second cycle of chemotherapy was delivered concurrently with radiation and total number of six cycles were delivered. Twenty three had adenocarcinoma and the other two had leiornyosarcoma. The numbers of patients with stage I B, II, III A, III B, and IV were 1, 2, 11, 10 and 1 respectively. Positive margins at distal end of the stomach were in 17 patients and proximal in 5. The other three patients had positive margin at the sites of adjacent organ invasion Minimum and median follow-up periods were 12 months and 18 months, respectively, Results : Twenty-four of 25 patients received prescribed radiation dose and RTOG grade 3 toxicity of UGI tract was observed in 3, all of which were weight loss more than $15\%$ of their pretreatment weight. But hematemesis. melena, intestinal obstruction or grade 4 toxicity were not found. Locoregional failure within the radiation field was observed in 7 patients, and distant metastasis in 10 patients. Sites of locoregional recurrences involve anastomosis/remnant stomach in 3, tumor bed/duodenal stump in 3, regional lymph node in 1 patient Peritoneal seeding occurred in 6, liver metastases months and median disease free survival time was 26 months. Stages andradiation dose were not significant prognostic factors for locoregional in 2, and distant nodes in 2 patients. Four year disease specificsurvival rate was $40\%$ and disease free survival was $48\%$. Median survival was 35 failures. Conculsion : Although all patients in this study had positive surgical margins, locoregional failure rate was $28\%$, and 4 year disease specific survival rate was $40\%$. Considering small number of patients and relatively short follow-up period, it is not certain that postoperative radiotherapy lowered locoregional recurrences. but we could find a Possibility of the role of postoperative radiotherapy in Patients with high risk factors.

• Radiation Oncology Journal
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• v.9 no.1
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• pp.93-102
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• 1991

To evaluate the role of postoperative pelvic radiation therapy in rectal cancer, a retrospective analysis was done on 189 patients with modified Astler-Coiler stages B2+3, Cl , and C2+3 who were treated from February 1979 to June 1980. Forty-seven patients were staged as B2+3,17 as Cl, and 125 as C2+3. As a curative resection,41 received low anterior resection,143 received abdomino-perineal resection, and five received pelvic exenteration. The survival and disease-free survival rates of the total patients at five year were $45.3\%\;and\;44.1\%$, respectively. The stage was an important prognostic factor for survival and disease-free survival: the survival rates at five year were $63.4\%$ in stage B2+3, $62.4\%$ in C1, and $37.2\%$ in C2+3 (p<0.005): the disease-free survival rates at five year were $55.7\%$ in B2+3, $65.7\%$ in C1, and $30.4\%$ in C2+3, respectively (p<0.01). The liver was the most frequently involved organ of recurrence followed by the lung and the perineum. The patients who received low anterior resection achieved better disease-free survival but were more prone to late radiation bowel morbidities than those who received abdominoperineal resection. Postperative Pelvic radiation therapy Proved to be effective in locoregional disease control but did not prevent the appearance of distant metastasis, which was of major concern in advanced stages. Patterns of treatment failure, and factros relating to radiation morbidity are discussed, and therapeutic options for better results are proposed.

• Journal of Gastric Cancer
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• v.7 no.4
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• pp.200-205
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• 2007

Purpose: The aim of this study was to analyze the post operative outcome of reconstruction with using the stomach after performing total pharyngolaryngoesophagectomy in patients with hypopharyngeal cancer or cervical esophageal cancer. Materials and Methods: We conducted a retrospective chart review of 23 patients who underwent gastric pull up for esophageal substitution at the Department of Surgery, Yonsei University College of Medicine, between January 1991 and December 2006. All the patients had transhiatal esophagectomy performed without thoracotomy. Results: There were seventeen males and six females with a median age of 58.1 years (range: 40-70 years). 19 cases were hypopharyngeal cancer, 13 cases had cancer in the pyriform sinus, 15 cases had cancer in the postcricoid area and one case had cancer in the glottic area. The rest were cervical esophageal cancers. The pathologic result was squamous cell carcinoma in all cases. The median total follow-up period was 33 months (range: 1-62 months) and there were two (8.6%) postoperative deaths: one was due to carotid rupture and the other was due to hepatic failure with liver metastasis. The complications were leakage in 1 patient (4.4%), pneumothorax in 1 patient (4.4%) and pneumonia in 1 patient (4.4%). Conclusion: The use of stomach for esophageal reconstruction has many benefits for treating hypopharyngeal cancer or cervical esophageal cancer, So, we made sure there was a sufficient length for the anastomosis after pharyngolaryngoesophagectomy and a rich blood supply from the stomach. There was a low incidence of the leakage at the anastomotic site, along with a low incidence of stenosis and bleeding.

• Radiation Oncology Journal
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• v.27 no.4
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• pp.210-217
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• 2009

Purpose: To assess the influence of cyclooxygenase-2 (COX-2) expression on the survival of patients with a combination of rectal cancer and lymph node metastasis. Materials and Methods: The study included rectal cancer patients treated by radical surgery and postoperative radiotherapy at the Dong-A university hospital from 1998 to 2004. A retrospective analysis was performed on a subset of patients that also had lymph node metastasis. After excluding eight of 86 patients, due to missing tissue samples in three, malignant melanoma in one, treatment of gastric cancer around one year before diagnosis in one, detection of lung cancer after one year of diagnosis in one, liver metastasis in one, and refusal of radiotherapy after 720 cGy in one, 78 patients were analyzed. The immunohistochemistry for COX-2 was conducted with an autostainer (BenchMark; Ventana, Tucson, AZ, USA). An image analyzer (TissueMine; Bioimagene, Cupertino, CA, USA) was used for analysis after scanning (ScanScope; Aperio, Vista, CA, USA). A survival analysis was performed using the Kaplan Meier method and significance was evaluated using the log rank test. Results: COX-2 was stained positively in 62 patients (79.5%) and negatively in 16 (20.5%). A total of 6 (7.7%), 15 (19.2%), and 41 (52.6%) patients were of grades 1, 2, and 3, respectively for COX-2 expression. No correlation was found between being positive of COX-2 patient characteristics, which include age (<60-year old vs. $\geq$60), sex, operation methods (abdominoperineal resection vs. lower anterior resection), degrees of differentiation, tumor size (<5 cm vs. $\geq$5 cm), T stages, N stages, and stages (IIIa, IIIb, IIIc). The 5-year overall and 5-year disease free survival rates for the entire patient population were 57.0% and 51.6%, respectively. The 5-year overall survival rates for the COX-2 positive and negative patients were 53.0% and 72.9%, respectively (p=0.146). Further, the 5-year disease free survival rates for the COX-2 positive and negative patients were 46.3% and 72.7%, respectively (p=0.118). The 5-year overall survival rates were significantly different (p<0.05) for the degree of differentiation, N stage, and stage, whereas the 5-year disease free survival rates were significant for N stage and stage. Conclusion: Being positive for and the degree of COX-2 expression did not have a significant influence on the survival of rectal cancer patients with lymph node metastasis. However, N stage and stage did significantly influence the rateof survival. Further analysis of a greater sample size is necessary for the verification of the effect of COX-2 expression on the survival of rectal cancer patients with lymph node involvement.

• Radiation Oncology Journal
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• v.25 no.1
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• pp.16-25
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• 2007

[ $\underline{Purpose}$ ]: Breast conserving surgery (BCS) followed by chemotherapy (CTx.) and radiation therapy (RT) is widely performed for the treatment of early breast cancer. This retrospective study was undertaken to evaluate our interim results in terms of failure patterns, survival and relative risk factors. $\underline{Materials\;and\;Methods}$: From January 1999 through December 2003, 129 patients diagnosed with invasive breast cancer and treated with BCS followed by RT were subject to retrospective review. The median age of the patients was 45 years (age distribution, $27{\sim}76$ years). The proportions of patients according to their tumor, nodes, and metastases (TNM) stage were 65 (50.4%) in stage I, 41 (31.7%) in stage IIa, 13 (10.1%) in stage IIb, 9 (7.0%) in stage III, and 1 patient (0.8%) in stage IIIc. For 32 patients (24.8%), axillary node metastasis was found after dissection. BCS consisted of quadrantectomy in 115 patients (89.1%) and lumpectomy in 14 patients (10.6%). Axillary node dissection at axillary level I and II was performed for 120 patients (93%). For 7 patients (5.4%), only sentinel node dissection was performed with BCS. For 2 patients (1.6%) axillary dissection of any type was not performed. Postoperative RT was given with 6 MV X-rays. A tumor dose of 50.4 Gy was delivered to the entire breast area using a tangential field with a wedge compensator. An aditional dose of $9{\sim}16\;Gy$ was given to the primary tumor bed areas with electron beams. In 30 patients (23.3%), RT was delivered to the supraclavicular node. Most patients had adjuvant CTx. with $4{\sim}6$ cycles of CMF (cyclophosphamide, methotrexate, 5-fluorouracil) regimens. The median follow-up period was 50 months (range: $17{\sim}93$ months). $\underline{Results}$: The actuarial 5 year survival rate (5Y-OSR) was 96.9%, and the 5 year disease free survival rate (5Y-DFSR) was 93.7%. Local recurrences were noted in 2 patients (true: 2, regional node: 1) as the first sign of recurrence at a mean time of 29.3 months after surgery. Five patients developed distant metastases as the first sign of recurrence at $6{\sim}33$ months (mean 21 months). Sites of distant metastatic sites were bone in 3 patients, liver in 1 patient and systemic lesions in 1 patient. Among the patients with distant metastatic sites, two patients died at 17 and 25 months during the follow-up period. According to stage, the 5Y-OSR was 95.5%, 100%, 84.6%, and 100% for stage I, IIa, IIb, and III respectively. The 5Y-DFSR was 96.8%, 92.7%, 76.9%, and 100% for stage I, IIa, IIb, and III respectively. Stage was the only risk factor for local recurrence based on univariate analysis. Ten stage III patients included in this analysis had a primary tumor size of less than 3 cm and had more than 4 axillary lymph node metastases. The 10 stage III patients received not only breast RT but also received posterior axillary boost RT to the supraclavicular node. During the median 53.3 months follow-up period, no any local or distant failure was found. Complications were asymptomatic radiation pneumonitis in 10 patients, symptomatic pneumonitis in 1 patient and lymphedema in 8 patients. $\underline{Conclusion}$: Although our follow up period is short, we had excellent local control and survival results and reaffirmed that BCS followed by RT and CTx. appears to be an adequate treatment method. These results also provide evidence that distant failure occurs earlier and more frequent as compared with local failure. Further studies and a longer follow-up period are needed to assess the effectiveness of BCS followed by RT for the patients with less than a 3 cm primary tumor and more than 4 axillary node metastases.