Optimal cutoff value of preoperative CEA and CA19-9 for prognostic significance in patients with stage II/III colon cancer.

PURPOSE: This unicentric, retrospective cohort study aimed to identify the optimal cutoff values of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) for the prognosis in patients with stage II/III colon cancer. METHODS: After excluding 43 patients with CA19-9 levels < 0.2 U/mL, 588 were included. Receiver operating characteristic curves were constructed to determine the optimal cutoff values of CEA and CA 19-9 for disease relapse. RESULTS: The median CEA and CA19-9 values were 3.6 (interquartile range: 2.1-7.2 ng/mL) and 14.3 (interquartile range: 8.1-30.0) U/mL, respectively. The optimal cutoff values of CEA and CA19-9 were 5.4 ng/mL and 22.4 U/mL, respectively. A multivariate analysis of relapse-free survival (RFS) showed that cancer stage, CEA, and CA19-9 were significant independent factors. The RFS of patients with stages II and III colon cancer was significantly stratified by CEA (< 5.4/ ≥ 5.4 ng/mL) and CA19-9 (< 22.4/ ≥ 22.4 U/mL). Prognostication based on the reference values (< 5.0 ng/mL for CEA and < 37.0 U/mL for CA19-9) was less significant than that based on the optimal cutoff values. Both elevated CEA and CA19-9 had no value dependency on RFS: RFS curves were similar between extremely elevated CEA (≥ 54.0 ng/ml) and intermediate CEA (5.4-54.0 ng/ml) and between extremely elevated CA19-9 (≥ 224.0 U/ml) and intermediate CA19-9 (22.4-224.0 U/ml). CONCLUSION: The optimal cutoff values of preoperative CEA and CA19-9 for RFS were 5.4 ng/ml and 22.4 U/mL, respectively, in patients with stages II and III colon cancer. Further relapse risk stratification is possible using these values.

CA19-9 is a significant prognostic marker of patients with stage III gastric cancer.

BACKGROUND: Due to prognostic heterogeneity within a stage of gastric cancer (GC), identification of patients with a high risk for recurrence after resection is important. We aimed to identify the prognostic significance of preoperative serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels in patients with Stage I, II, and III GC who underwent R0 gastrectomy. METHODS: A total of 794 patients were included in this study after excluding 72 patients with CA19-9 <1.0 U/mL. Receiver operating characteristic curves were drawn to assess the optimal cut-off values of CEA and CA19-9 for disease recurrence. RESULTS: The optimal cut-off values of CEA and CA19-9 levels were 2.9 ng/mL and 46.3 U/mL, respectively. Multivariate analysis for relapse-free survival (RFS) showed that stage of GC, CA19-9 levels, postoperative adjuvant chemotherapy, and venous invasion were significant independent factors. The RFS and overall survival (OS) of patients with CA19-9 ≥ 46.3 U/mL were significantly lower than those with CA19-9 < 46.3 U/mL in Stage III GC. However, the RFS of GC patients with CA19-9 ≥ 463 U/mL tended to be better than those with CA19-9 levels between 46.3 and 463 U/mL. CONCLUSIONS: The RFS and OS of patients with CA19-9 ≥ 46.3 U/mL were significantly lower than those with CA19-9 < 46.3 U/mL in Stage III GC. However, there was no value dependency of extremely elevated CA19-9 on RFS. Further risk stratification can be obtained by measuring preoperative serum CA19-9 in stage III GC.

Chronological Changes in Appendiceal Pathology Among Patients Who Underwent Appendectomy for Suspected Acute Appendicitis.

BACKGROUND: Given recent advances in imaging and the development of diagnostic parameters, the rate of unnecessary appendectomy (i.e., negative appendectomy) has been decreasing. However, the incidence of acute appendicitis (AA) in elderly patients is rising due to the aging of society. We aimed to identify chronological changes in demographics and appendiceal pathology among patients who underwent appendectomy for suspected AA. METHODS: Data from 881 patients who underwent appendectomy for suspected AA between January 2006 and December 2017 were analyzed. The final diagnosis was based on intraoperative findings, pathological reports, and clinical course. Negative appendectomy was defined as the absence of appendiceal diseases including inflammation, fibrosis, and neoplasm. We compared demographics and appendiceal pathology between early (2006-2011) and late study phases (2012-2017). RESULTS: The mean age of patients with pathologically proven AA (n = 761) was significantly greater in the late phase than in the early phase (38.6 ± 19.8 years vs. 44.0 ± 20.3 years, p = 0.0002), and the ratio of patients with AA aged ≧ 75 years was also increased (from 5.6 to 8.6%, p = 0.1120). The incidences of complicated appendicitis (defined as perforated or gangrenous appendicitis) and appendiceal diverticulitis (AD) were increased in the late phase compared to those in the early phase (61.3% vs. 77.2% and 3.7% vs. 6.6%, respectively). The negative appendectomy rate was significantly reduced in the late phase compared to that in the early phase (10.0% vs. 2.5%, p < 0.0001). CONCLUSIONS: During a 12-year period, the mean age of patients with AA and the incidences of complicated appendicitis and AD increased, whereas the negative appendectomy rate decreased.

Esophageal reconstruction using a pedicled jejunum following esophagectomy for metastatic esophageal stricture from breast cancer in a patient with previous pancreatoduodenectomy.

A 71-year-old woman with dysphagia was diagnosed with thoracic esophageal squamous cell carcinoma by endoscopic biopsy at another hospital. She had previously undergone partial breast excision with axillary lymph node dissection for right breast cancer eleven years earlier and subtotal stomach-preserving pancreatoduodenectomy with Child's reconstruction for ampullary cancer ten years earlier. Gastrointestinal endoscopy showed a stricture due to a bulging submucosal tumor in the mid-thoracic esophagus. The tumor was diagnosed as an esophageal metastasis from breast cancer by endoscopic ultrasound-guided fine-needle aspiration biopsy. After six courses of fulvestrant, the tumor progressed, completely impeding her ability to swallow. An esophagectomy was planned in a one-stage operation because of the expectation of a prolonged survival and her strong hope of regaining oral intake. Unfortunately, she underwent emergent omental patch repair for perforation of the gastrojejunostomy site due to an anastomotic ulcer one day before the scheduled operation. Due to postoperative impairment of her performance status, she subsequently underwent a two-stage esophageal operation. In the first surgical stage, prone position thoracoscopic esophagectomy and cervical esophagostomy were performed and she was discharged with enteral nutrition on postoperative day 15. Sixty-one days after the first surgical stage, esophageal reconstruction was performed using a pedicled jejunum with microvascular anastomosis via the subcutaneous route. She was discharged without any complications 20 days after the second operation.

The impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux after intrathoracic esophagogastrostomy following transthoracic esophagectomy.

PURPOSE: The aim of this study was to evaluate the impact of cervical lymph node dissection on acid reflux and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy. METHODS: Thirty-one patients receiving transthoracic esophagectomy with gastric tube reconstruction by intrathoracic esophagogastrostomy were divided into the following two groups: a two-field lymph node dissection group (2F group) and a three-field lymph node dissection group (3F group). All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy at 1 year after surgery. The 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were compared between the 2 groups. RESULTS: No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) patients in the 3F group (p = 0.007). DGER was found in 2 patients (13%) in the 2F group and in 8 (53%) in the 3F group (p = 0.023). Four patients (25%) in the 2F group and 9 (60%) in the 3F group (p = 0.048) had reflux esophagitis. CONCLUSION: Cervical lymph node dissection increases acid reflux and DGER and can lead to an increase in the incidence of reflux esophagitis in patients undergoing intrathoracic esophagogastrostomy.