Predictors of permanent stoma creation in patients with mid or low rectal cancer: results of a multicentre cohort study with preoperative evaluation of anal function.

AIM: Preoperative factors predictive of permanent stoma creation were investigated in a long-term follow-up of patients with mid or low rectal cancer. METHOD: We included patients who underwent radical resection for mid or low rectal cancer with available data for preoperative anal function measured by manometry and Faecal Incontinence Severity Index questionnaire between January 2005 and December 2015 in three tertiary referral hospitals. A permanent stoma was defined as a stoma present until the patient's last follow-up visit or death. Preoperative factors that predicted permanent stoma creation were analysed. RESULTS: Over a median follow-up of 57.4 months (range 12-143 months), a permanent stoma was created in 144/577 (25.0%) patients, including 89 (15.4%) who underwent abdominoperineal resection, one (0.2%) who underwent Hartmann's operation without reversal, 15 (2.6%) with a diverting ileostomy at the time of initial sphincter-preserving surgery without undergoing stoma reversal, and 39 (6.8%) who underwent permanent ileostomy formation after sphincter-preserving surgery. Patients with permanent stoma creation had a shorter tumour distance from the anal verge (P < 0.001), larger tumour size (P = 0.020) and higher preoperative Faecal Incontinence Severity Index score (P = 0.020). On multivariable analysis, tumour distance from the anal verge predicted permanent stoma formation (relative risk 0.53 per centimetre increase; 95% confidence interval 0.46-0.60; P < 0.001) but preoperative anal function did not. CONCLUSION: Tumour distance from the anal verge was the only preoperative determinant of permanent stoma creation in rectal cancer patients. These data may help mid and low rectal cancer patients understand the need for permanent stoma.

The impact of social media on citation rates in coloproctology.

AIM: This study aimed to investigate the association between Twitter exposure and the number of citations for coloproctology articles. METHOD: Original articles from journals using Twitter between June 2015 and May 2016 were evaluated for the following characteristics: publishing journal; article subject; study design; nationality, speciality and affiliation of the author(s); and reference on Twitter. Citation data for these articles were retrieved from Google Scholar (https://scholar.google.com) in January 2018. We performed a univariate analysis using these data followed by a multivariate, logistic regression analysis to search for factors associated with a high citation level, which was defined as accrual of more than five citations. RESULTS: Out of six coloproctology journals listed on the InCites JCR database, three (Diseases of the Colon & Rectum, Colorectal Disease and Techniques in Coloproctology) used Twitter, where 200 (49.5%) out of a total of 404 articles had been featured. Citation rates of articles that featured on Twitter were significantly higher than those that did not (11.4 ± 9.2 vs 4.1 ± 3.1, P < 0.001). In multivariate analysis, Twitter exposure (OR 8.6, P = 0.001), European Union nationality (OR 2.4, P = 0.004), Colorectal Disease journal (OR 3.3, P = 0.005) and systematic review articles (OR 3.4, P = 0.009) were associated with higher citation levels. CONCLUSION: Article exposure on Twitter was strongly associated with a high citation level. Medical communities should encourage journals as well as physicians to actively utilize social media to expedite the spread of new ideas and ultimately benefit medical society as a whole.

Isolation of internal and external sphincter progenitor cells from the human anal sphincter with or without radiotherapy.

AIM: We aimed to isolate and propagate internal and external anal sphincter progenitor cells from the human anal sphincter, with or without radiotherapy, for tailored cell therapy of faecal incontinence. METHODS: Sphincter progenitor cells were isolated from normal internal and external anal sphincters collected from 10 patients with rectal cancer who had undergone abdominoperineal resection with (n = 6) or without (n = 4) preoperative chemoradiotherapy. The isolated cells and differentiated muscle fibres were identified using immunofluorescence assay, western blotting and reverse transcription polymerase chain reaction (RT-PCR). The proliferation of progenitor cells with and without radiotherapy was compared by quantitative 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. RESULTS: The immunofluorescence assay before differentiation confirmed that the internal anal sphincter progenitor cells expressed CD34 and neural-glial antigen 2 (NG2), whereas the external anal sphincter progenitor cells expressed CD34 and PAX7. After differentiation, the internal anal sphincter progenitor cells expressed desmin, calponin and α-smooth muscle actin, whereas the external anal sphincter progenitor cells expressed desmin, myogenic factor 4 and myosin heavy chain. The differential expression profiles of both cell types were confirmed by western blotting and RT-PCR. MTT assays showed that the viability of internal and external anal sphincter progenitor cells was significantly lower in the radiotherapy group than that in the nonradiotherapy group. CONCLUSIONS: This study describes the differential harvest internal and external sphincter muscle progenitor cells from human anal sphincters. We confirm that radiotherapy decreases the viability of internal and external anal sphincter progenitor cells.

Effects of depth of neuromuscular block on surgical conditions during laparoscopic colorectal surgery: a randomised controlled trial.

There have been few objective evaluations of the effects of deep neuromuscular blockade on intra-operative conditions. In this prospective randomised controlled study, we evaluated the effects of deep neuromuscular block on surgical conditions during laparoscopic colorectal surgery. Patients were randomly allocated using a computer-generated randomisation code to either moderate (train-of-four count 1-2 maintained and antagonised with neostigmine) or deep (post-tetanic count 1-2 maintained and reversed with sugammadex) levels of neuromuscular blockade. The primary outcome measure was the number of abrupt increases in intra-abdominal pressure intra-operatively. Secondary outcome variables were intra-operative restoration of spontaneous breathing, number of surgical requests for additional neuromuscular blockade, surgical rating of operating conditions and patient satisfaction. The surgeon who rated the surgical conditions score and investigator who checked the postoperative variables were blinded to patient allocation. In total, we recruited 70 patients of whom 64 (32 in each group) were analysed. Increases in intra-abdominal pressure (14/32 vs. 6/32; p = 0.031), intra-operative restoration of spontaneous breathing (16/32 vs. 2/32; p < 0.001) and request for additional neuromuscular blockade (21/32 vs. 8/32; p = 0.001) were more frequent in the moderate compared with the deep group. In patients undergoing elective laparoscopic colorectal surgery, deep neuromuscular blockade provided better surgical conditions than moderate neuromuscular blockade, as measured by a reduction in the incidence of intra-abdominal pressure alarms.

MRI findings of young male soldiers with atraumatic anterior knee pain.

The purpose of this study is to investigate abnormal magnetic resonance image (MRI) findings of young active males with atraumatic anterior knee pain (AKP). Targeting young male soldiers, we prospectively gathered and analyzed 157 knee MRIs from patients with atraumatic AKP (AKP group) and 53 knee MRIs from patients without knee pain (control group). Abnormalities of the patellofemoral (PF) joint and extensor mechanism on MRI were more common in the AKP group than the control group (48% vs 13%, P < 0.001). The overall prevalence of medial plica (34% vs 13%, P = 0.004) and the prevalence of the thick medial plica (9% vs 0%, P = 0.023) were considerably higher in the AKP group. The cartilaginous sulcus angle in the AKP group without abnormalities on MRI was significantly higher than both the AKP group with abnormalities and the control group (145° vs 141° vs 142°, respectively, P = 0.001). Our results suggest that careful assessment of young, active males with atraumatic AKP is warranted regarding PF joint abnormalities, particularly the presence of medial plica and/or subtle abnormalities of the articular geometry. The results from the present study could be used for the management of patients with AKP.

Changes of knee joint and ankle joint orientations after high tibial osteotomy.

OBJECTIVE: We sought to determine (1) whether change in the tibial plateau inclination (TPI) after high tibial osteotomy (HTO) is different from change in the knee joint line orientation (KJLO) relative to the ground; (2) whether, in varus knee OA patients before and after HTO, these radiographic measures are different from those in normal control; and (3) whether the postoperative values of the TPI and KJLO relative to the ground are associated with short term clinical outcome scores after HTO. DESIGN: Fifty patients who underwent HTO and 75 normal controls were assessed with four radiographic measures. We compared the measures before HTO with those after HTO and with those of the normal controls, then examined associations between the postoperative radiographic measures and clinical outcome scores 1-year after HTO. RESULTS: After HTO, TPI increased 9.0°, whereas KJLO relative to the ground only increased 4.1°, with a compensatory change of the ankle joint line orientation. However, the postoperative KJLO relative to the ground in the HTO group was significantly different from that of the normal controls (mean difference, 4.9°; P < 0.001). In the multiple regression analyses, the postoperative radiographic measures were not associated with outcome clinical scores 1 year after HTO. CONCLUSION: After HTO the relative KJLO changed significantly less than did the anatomical geometry of the proximal tibia. Although the KJLO after the HTO was still significantly different from that of normal knees, its value did not adversely affect clinical outcome scores 1 year after HTO.

Semi-quantitative HPV viral load in patients with ASC-US cytology: viral load correlates strongly with the presence of CIN but only weakly with its severity.

OBJECTIVES: This study was performed to evaluate the prognostic significance of human papillomavirus (HPV) viral load, expressed in relative light units (RLUs), in patients with atypical squamous cells of undetermined significance (ASC-US) cytology. METHODS: A total of 349 ASC-US cases with HPV infection, detected using Hybrid Capture 2, were diagnosed histologically. A colposcopically directed punch biopsy was performed on acetowhite areas. Endocervical curettage biopsy and random cervical punch biopsy in four quadrants were performed in unsatisfactory colposcopy cases. In negative colposcopy cases, random cervical punch biopsy in four quadrants was performed. RESULTS: Case with no cervical intraepithelial neoplasia (CIN), CIN1 and CIN2+ (CIN2/CIN3) accounted for 162, 135 and 52 cases, respectively. The mean age showed no difference among the three groups (P = 0.510). There was a significant correlation between RLU values and the presence of CIN (P < 0.001), but less so with its severity: the median RLU values for negative, CIN1 and CIN2+ cases were 42.68, 146.45 and 156.43, respectively, with widely overlapping confidence intervals. The cut-off values of RLU to detect CIN1+ and CIN2+ were 6.73 and 45.64, respectively. CONCLUSIONS: The HPV viral load in ASC-US cases showed a significant correlation with the presence of CIN and less so with its severity, and showed large overlap of viral loads between grades of CIN. In ASC-US cases, RLU was not an accurate predictor of immediate high-grade CIN.

Effects of magnesium sulphate on coagulation after laparoscopic colorectal cancer surgery, measured by rotational thromboelastometry (ROTEM® ).

We investigated the effects of magnesium sulphate on blood coagulation profiles using rotational thromboelastometry in patients undergoing laparoscopic colorectal cancer surgery. Patients were randomly allocated to the magnesium group (n = 22) or control group (n = 22). The magnesium group received intravenous magnesium sulphate (50 mg.kg(-1) followed by a continuous infusion of 15 mg.kg(-1) .h(-1) ), whereas the control group received the same volume of isotonic saline. Mean (SD) postoperative serum magnesium levels were 1.60 (0.13) mmol.l(-1) in the magnesium group compared with 0.98 (0.06) mmol.l(-1) in the control group (p < 0.001). All maximum clot firmness values of ROTEM analysis were significantly lower on the third postoperative day in the magnesium group compared with the control group (p < 0.05). We conclude that ROTEM analysis demonstrated that intra-operative administration of intravenous magnesium sulphate reduces blood hypercoagulability in patients undergoing laparoscopic colorectal cancer surgery.

Attitudes and practices of Korean gynecologists towards hormone replacement therapy in endometrial cancer survivors.

PURPOSE: To investigate the attitudes of Korean gynecologists towards prescribing hormone replacement therapy (HRT) after treatment for endometrial cancer. MATERIALS AND METHODS: A questionnaire, addressing attitudes towards HRT and treatment strategies for patients previously treated for endometrial cancer, was distributed to 163 Korean gynecologists. RESULTS: Of the 163 gynecologists that were sent this questionnaire, 98 (60.1%) responded. Among the respondents, 81 (82.7%) had previously prescribed HRT to patients with endometrial cancer. Of the latter, 75 (92.6%) had prescribed HRT to patients with Stage I, and more than half to patients with Stage II, endometrial cancer. Of the respondents who had prescribed HRT, 33 (40.7%) did so without regard for cancer-cell type and 33 (40.7%) began patients on HRT more than two years after endometrial cancer treatment. Tibolone was the most commonly prescribed drug (61.9%). The most common reason not to prescribe HRT was fear of cancer recurrence (38.1%). CONCLUSION: Most of the Korean gynecologists surveyed had experience prescribing HRT to endometrial cancer patients. Although HRT is not actively recommended, HRT given post-therapy to endometrial cancer patients is considered acceptable.

Adjuvant capecitabine chemotherapy using a tailored-dose strategy in elderly patients with colon cancer.

BACKGROUND: This study was conducted to analyze the feasibility of adjuvant capecitabine therapy using a tailored-dose escalation strategy in elderly patients with colon cancer (CC). METHODS: CC patients (≥ 70 years of age) who received adjuvant capecitabine were enrolled. The starting dosage of capecitabine was 2000 mg/m(2)/day (days 1-14, every 3 weeks). On the second cycle, the dosage was escalated to 2500 mg/m(2)/day if the patient tolerated the first cycle. Dose intensity (DI), toxicity, and the change in quality of life (QoL) were evaluated. RESULTS: Of 82 patients enrolled, 67 completed eight cycles. Dose escalation to 2500 mg/m(2)/day was possible in 56 patients, and this dosage was maintained in 24 patients until the completion of chemotherapy (eight cycles). Forty-one patients completed therapy with a DI ≥ 1333 mg/m(2)/day [relative dose intensity (RDI) ≥ 80%]. Toxic effects were tolerable and the QoL was not compromised during treatment. Creatinine clearance < 50 ml/min and Charlson-Age comorbidity index ≥ 8 were related to a reduced capecitabine dosage (RDI < 80%). CONCLUSIONS: A tailored-dose escalation strategy was feasible in elderly CC patients receiving adjuvant capecitabine chemotherapy. Decreased renal function and an increased number of comorbidities were independently predictive of reduced administration of the capecitabine dose.

Comparative study of NOTES rectosigmoidectomy in a swine model: E-NOTES vs. P-NOTES.

BACKGROUND AND STUDY AIMS: Several reports have demonstrated the safety of pure natural-orifice transluminal endoscopic surgery (P-NOTES) using transanal endoscopic microsurgery (TEM) and embryonic NOTES (E-NOTES; laparoscopic surgery through the umbilicus). This study was performed to compare the safety and applicability of NOTES rectosigmoidectomy between E-NOTES and P-NOTES in a swine model. PATIENTS AND METHODS: E-NOTES was conducted through a single port using laparoscopic instruments (n = 11). P-NOTES was performed using TEM with transgastric endoscopic assistance (n = 11). Gastrotomies were created using a needle knife and the balloon dilatation technique, and closed using T-anchors. Blood samples were collected to evaluate changes in systemic cytokine levels during the preoperative and postoperative periods; operative outcomes were also evaluated and compared between the groups. The necropsy findings were recorded after sacrifice at 1 week after the procedure. RESULTS: The mean operative time for P-NOTES was significantly longer than that for E-NOTES (239 vs. 103 minutes, P < 0.001). The mean distance from the anal verge to colorectal anastomosis in the P-NOTES group was significantly less than that in the E-NOTES group (2.9 vs. 17.6 cm, P < 0.001). On necropsy, the complication rate of P-NOTES was higher than that of E-NOTES, but without statistical significance (54.5 % vs. 18.2 %, P = 0.091). The differences in changes in TNF-α, C-reactive protein, interleukin-6, and interleukin-1ß between P-NOTES and E-NOTES were not significant. CONCLUSIONS: E-NOTES rectosigmoidectomy in the swine model is safe, but remains challenging for use in pelvic dissection. P-NOTES rectosigmoidectomy using TEM may be a promising tool for pelvic dissection, but the transgastric approach involves a high degree of risk.

Prognostic significance of histological grade in clear-cell carcinoma of the ovary: a retrospective study of Korean Gynecologic Oncology Group.

BACKGROUND: This study was to investigate the prognostic significance of clinicopathologic characteristics in patients with clear-cell carcinoma (CCC) of the ovary. MATERIALS AND METHODS: Two hundred and one patients with CCC of the ovary were registered in the Korean Gynecologic Oncology Group. The Korean Gynecologic Pathology Study Group reviewed the pathological slides centrally, using a universal grading system. The prognostic significances of clinicopathologic factors were evaluated by multivariate analysis. RESULTS: Most of the patients were diagnosed at an early stage (stage I, 61.3%), and the overall 5-year survival rate was 57%. Early-stage disease showed a favorable prognosis, but advanced diseases showed poor prognosis. Stage of disease was the only significant prognostic factor on multivariate analysis (P < 0.001). However, universal grade and residual tumor also showed prognostic significance on the forward stepwise likelihood ratio test. There was no survival difference observed between patients treated with paclitaxel-based and those treated with platinum-based combination chemotherapy. CONCLUSIONS: The stage, residual tumor, and universal grade were significant prognostic factors in patients with CCC of the ovary. The universal grading system is applicable in determining prognosis of CCC of the ovary. Further clinical trials for optimal chemotherapy are in need.

Prognostic factors in FIGO stage IB-IIA small cell neuroendocrine carcinoma of the uterine cervix treated surgically: results of a multi-center retrospective Korean study.

BACKGROUND: To determine the clinical and pathologic prognostic factors in surgically treated patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB-IIA small cell neuroendocrine carcinoma of the uterine cervix (SCNEC). PATIENTS AND METHODS: We retrospectively reviewed a total of 68 patients with FIGO stage IB-IIA SCNEC surgically treated from January 1997 to December 2003 in Korea. RESULTS: Of the 68 patients, 43 had FIGO stage IB1 SCNEC, 15 had stage IB2, and 10 had stage IIA. Seven were treated with radical surgery alone; 11 with neoadjuvant chemotherapy (NACT) followed by radical surgery; 24 with radical surgery followed by adjuvant chemotherapy; and 26 with radical surgery followed by adjuvant radiation or chemoradiation. After a median follow-up of 44 months (range, 6-113 months), the 2-year and 5-year survival rates for all patients were 64.6% and 46.6%, respectively. Univariate and multivariate analysis showed that FIGO stage was predictive of poor prognosis. Patients who received NACT showed poorer prognosis than those who did not receive NACT. Adjuvant chemoradiation did not improve survival compared with adjuvant chemotherapy alone. CONCLUSIONS: FIGO stage may act as a surrogate for factors prognostic of survival. Primary radical surgery followed by adjuvant chemotherapy is the preferred treatment modality for patients with early stage SCNEC.

Association of cyclin D1 G870A polymorphism with uterine leiomyoma in women whose body mass index values are above 25 kg/m2.

BACKGROUND: Many studies have shown that a polymorphism (G870A) in cyclin D1 (CCND1) is associated with carcinogenesis in a variety of cancers. Our aim was to determine if an association exists between the CCND1 G870A polymorphism and uterine leiomyoma in Korean women. METHODS: Blood samples of 331 cases and 204 controls aged 47.4 +/- 7.6 and 46.8 +/- 10.4 years (mean +/- SD), respectively, were collected. CCND1 genotyping was determined by PCR and restriction fragment length polymorphism. RESULTS: Allelic frequencies of cases (A, 0.53; G, 0.47) were not significantly different from those of controls (A, 0.49; G, 0.51) (P = 0.22). After adjustment for menarche age and BMI, multivariate logistic regression analysis showed that the AA genotype was not associated with increased risk for uterine leiomyoma [odds ratio (OR) = 1.38, 95% confidence interval (CI); 0.85-2.26, P = 0.19]. However, in stratification analysis of cases and controls with BMI >25 kg/m(2), allelic frequencies of cases (A, 0.56; G, 0.44) were significantly different from controls (A, 0.36; G, 0.64) (P = 0.005), and the AA genotype was associated with increased risk for uterine leiomyoma (OR = 3.61, 95% CI; 1.02-12.73, P = 0.046). Furthermore, the OR for AA compared with combined GG and AG genotypes was 3.16 (95% CI 1.01-9.92, P = 0.048). CONCLUSIONS: The A allele and AA genotype of CCND1 G870A polymorphism have a significant association with an increased risk of the uterine leiomyoma in obese Korean women.

Characteristics of recurrence in adult-type granulosa cell tumor.

Granulosa cell tumor (GCT) of the ovary is a very rare neoplasm, which is characterized by an indolent clinical course. Thus, the clinical characteristics, optimal treatment, and follow-up protocols are not well established. The goal of this study is to evaluate clinical findings, prognostic factors, and recurrent features of GCT in Korean patients. Between 1987 and 2005, 42 cases of GCT were diagnosed in our institution. There were 35 cases showing adult-type GCT, which were available for evaluation. All charts were reviewed, and the clinical data along with treatment results were retrospectively studied. Statistical analyses were performed for risk factors of recurrence and disease-free survival. GCT accounted for 3% of all ovarian malignancies in our institution during the study period. The median age was 45 years (range, 24-68 years). Abdominal and hormone-related symptoms were the main causes of first presentation. There were eight cases of recurrence including two cases of disease-related deaths during the median follow-up period of 177 months (range, 8-212 months). Factors affecting the recurrence involved residual tumor and stage, but residual tumor was the only significant factor of recurrence in multivariate analysis. The median time to relapse was 75 months (range, 55-137 months), and the liver was the most common extra-pelvic metastatic site followed by the intestine. Continuous long-term follow-up with pelvic and whole-abdominal surveillance is absolutely required. Active management including complete tumorectomy is the most important treatment modality in both primary surgeries and recurrent cases.

Retrospective multicenter study of a clinicopathologic analysis of pseudomyxoma peritonei associated with ovarian tumors (KGOG 3005).

The purpose of this study is to assess clinicopathologic features of pseudomyxoma peritonei (PMP) that has ovarian pathology and its relationship with the prognosis. From 1995 to 2004, the clinical records and follow-up data of 35 patients with PMP, which had primarily originated from the ovary, were collected from 11 institutes of gynecologic oncology in Korea and retrospectively analyzed. All patients had ovarian lesion histologically confirmed with PMP. The mean age at diagnosis was 53.7 years (range: 16-82 years). There were 25 (71.4%) patients with disseminated peritoneal adenomucinosis, 5 (14.3%) with peritoneal mucinous carcinomatosis with intermediate group, and 5 (14.3%) with peritoneal mucinous carcinomatosis. The clinical stages at diagnosis were IA in 2 patients, IIIB in 4, IIIC in 23, IV in 1, and unknown in 5. In preoperative tumor markers, the positive rates were 72% (CA125), 47.4% (CA19-9), and 84.6% (CEA). Thirty-four patients underwent surgical staging or cytoreduction, and then 27 patients (77%) received adjuvant chemotherapy that was given to patients in a nonuniform fashion. The 5-year survival for 35 patients was 87%. Survival rate was significantly lower in patients >50 years of age (P = 0.002). Our data showed that age of the patient is the only significant prognostic factor in PMP that has ovarian lesion.

Impact of diagnostic laparoscopy on the management of chronic pelvic pain.

BACKGROUND: Diagnostic laparoscopy is a useful tool, especially when there is no definite anatomical abnormality visible on imaging modalities. We assess the role and clinical impact of diagnostic laparoscopy in the management of women with chronic pelvic pain. METHODS: Clinical data of 3,068 cases of diagnostic laparoscopy performed for chronic pelvic pain from June 1994 to August 2005 were analyzed. We compared the diagnoses after diagnostic laparoscopy and those after pelvic examination and imaging modalities such as ultrasound or computed tomography (CT), and we then checked the final pathologic diagnoses after operation. RESULTS: Pelvic endometriosis was the most common (60.2%) laparoscopic finding in patients with chronic pelvic pain in this study, followed by normal pelvic findings (21.2%) and pelvic congestion (13.0%). Diagnostic laparoscopy had an influence on correcting previous plans based on imaging modalities in 42.7% of patients such as discarding unnecessary procedures or introducing new diagnostic or therapeutic plans. There were 3 cases of major complications requiring immediate correction. CONCLUSIONS: Diagnostic laparoscopy is a useful diagnostic tool for of women with chronic pelvic pain and can be used as a guideline for individualized treatment.

High incidence of loosening of the femoral component in legacy posterior stabilised-flex total knee replacement.

We have examined the results obtained with 72 NexGen legacy posterior stabilised-flex fixed total knee replacements in 47 patients implanted by a single surgeon between March 2003 and September 2004. Aseptic loosening of the femoral component was found in 27 (38%) of the replacements at a mean follow-up of 32 months (30 to 48) and 15 knees (21%) required revision at a mean of 23 months (11 to 45). We compared the radiologically-loose and revised knees with those which had remained well-fixed to identify the factors which had contributed to this high rate of aseptic loosening. Post-operatively, the mean maximum flexion was 136 degrees (110 degrees to 140 degrees) in the loosened group and 125 degrees (95 degrees to 140 degrees) in the well-fixed group (independent t-test, p = 0.022). Squatting, kneeling, or sitting cross-legged could be achieved by 23 (85%) of the loosened knees, but only 22 (49%) of the well-fixed knees (chi-squared test, p = 0.001). The loosened femoral components were found to migrate into a more flexed position, but no migration was detected in the well-fixed group. These implants allowed a high degree of flexion, but showed a marked rate of early loosening of the femoral component, which was associated with weight-bearing in maximum flexion.

Elevated Microsatellite Alterations at Selected Tetranucleotide Repeats (EMAST) and Microsatellite Instability in Patients with Colorectal Cancer and Its Clinical Features.

PURPOSE: Recently, a different type of microsatellite instability (MSI) instability designated 'elevated microsatellite alterations at selected tetranucleotide repeats' (EMAST) has been reported in several neoplasms, but its clinical implications remain unclear. We aimed to determine the relationships among EMAST, MSI and clinicopathologic characteristics, including oncologic outcomes, in colorectal cancer (CRC). MATERIALS AND METHODS: We evaluated 100 sporadic CRC cases subjected to surgery using five markers (MYCL1, D9S242, D20S85, D8S321, and D20S82) for EMAST and the Bethesda panel for MSI status. Immunohistochemical detection of hMSH3, c-erbB2, EGFR and thymidylate synthase was performed. Clinical characteristics and prognostic relevance were assessed. RESULTS: We identified 22 EMAST-positive tumors (22.0%) and 32 MSI-high (MSI-H) tumors (32.0%). EMAST was more frequent in colon cancer than rectal cancer (p=0.033), and associated with MSI-H phenotype (p<0.001), low expression of hMSH3 (p=0.004), and overexpression of thymidylate synthase (p=0.006). Among the 38 MSI-L tumors, only one (4.5%) showed EMAST. Long-term oncologic results in terms of overall and disease-free survival were similar between EMAST and non-EMAST tumors. CONCLUSION: EMAST is more closely related to MSI-H than MSI-L or MSS status. The clinical and molecular characteristics of EMAST were distinct in terms of tumor location, thymidylate synthase expression, MSI status and hMSH3 expression. Our preliminary findings support the utility of EMAST as a new potential classifier in CRC.