Is Endoscopic Therapy Safe for Upper Gastrointestinal Bleeding in Anticoagulated Patients With Supratherapeutic International Normalized Ratios?

The management of upper gastrointestinal bleeding (UGIB) in anticoagulated patients with supratherapeutic international normalized ratios (INRs) presents a challenge. The purpose of the study was to evaluate the safety of endoscopic therapy for UGIB in anticoagulated patients with supratherapeutic INR in terms of rebleeding and therapeutic outcomes. One hundred ninety-two anticoagulated patients who underwent endoscopic treatment for UGIB were enrolled in the study. Patients were divided into 2 groups based on the occurrence of rebleeding within 30 days of the initial therapeutic endoscopy: no-rebleeding group (n = 168) and rebleeding group (n = 24). The overall rebleeding rate was 12.5%. Bleeding from gastric cancer and bleeding at the duodenum were significantly related to rebleeding in a univariate analysis. Multivariate analysis determined that presenting symptoms other than melena (hematemesis, hematochezia, or others) (odds ratio, 3.93; 95% confidence interval, 1.44-10.76) and bleeding from gastric cancer (odds ratio, 6.10; 95% confidence interval, 1.27-29.25) were significant factors predictive of rebleeding. Supratherapeutic INR at the time of endoscopic therapy was not significantly associated with rebleeding in either univariate or multivariate analysis. Significant differences in bleeding-related mortality, additional intervention to control bleeding, length of hospital stay, and transfusion requirements were revealed between the rebleeding and no-rebleeding groups. There were no significant differences in therapeutic outcomes between patients with INR within the therapeutic range and those with supratherapeutic INR. Supratherapeutic INR at the time of endoscopic therapy did not change rebleeding and therapeutic outcomes. Thus, we should consider endoscopic therapy for UGIB in anticoagulated patients, irrespective of INR at the time of endoscopic therapy.

Clinical predictors associated with proton pump inhibitor-induced hypomagnesemia.

There is increasing evidence and case reports regarding proton pump inhibitor (PPI)-induced hypomagnesemia. Our study aimed to clarify the relationship between PPI use and serum magnesium levels and to specify high-risk patients. We retrospectively studied 112 consecutive patients aged 20 years or older who were treated with PPI for ≥30 days and whose serum magnesium levels were available for the PPI treatment period. We compared the mean level of serum magnesium of the enrolled patients with PPI treatment with matched controls. There were no significant differences between the matched PPI users (n = 105) and nonusers (n = 210) in the magnesium levels (0.85 ± 0.09 vs. 0.86 ± 0.16 mM, P = 0.297). In a subgroup analysis of a PPI user group, hypomagnesemia could be observed in 32 patients but not in 80 patients. In multivariate analyses, PPI use for >1 year, age less than 45 years, and concurrent cisplatin or carboplatin use were significantly associated with PPI-induced hypomagnesemia {P = 0.042, odds ratio [OR; 95% confidence interval (CI)]: 5.388 [1.056-27.493]; P = 0.007, OR [95% CI]: 4.710 [1.523-14.571]; P = 0.007, OR [95% CI]: 13.404 [2.066-86.952], respectively} after adjusting for confounders. This study shows that long-term PPI use is associated with hypomagnesemia in hospitalized adult patients. Therefore, serum magnesium levels should be checked before the initiation of PPI treatment and during the treatment period in patients, particularly those concurrently using platinum-based chemotherapy or who are expected to use PPI for long periods.

Early gastric cancer with mixed histology predominantly of differentiated type is a distinct subtype with different therapeutic outcomes of endoscopic resection.

BACKGROUND: Safety of endoscopic resection (ER) for early gastric cancers (EGC) with mixed histology predominantly of differentiated type has not been securely established, since those lesions tend to exhibit lymph node metastasis, compared to pure differentiated type. The purpose of this study was to evaluate clinicopathologic characteristics, therapeutic outcomes, and risk for lymph node metastasis in predominantly differentiated mixed EGC treated by ER. METHODS: A total of 1,016 patients with 1,039 EGCs underwent ER between January 2007 and June 2013. Enrolled lesions were divided into groups of either pure differentiated (n = 1,011) or predominantly differentiated mixed (n = 28), according to the presence of mixed histology predominantly of differentiated type in ER specimen. RESULTS: Mixed histology predominantly of differentiated type was diagnosed in 2.7% of lesions. Larger size, mid-third location, and moderately differentiated histology on forceps biopsy were independent risk factors for the predominantly differentiated mixed histologic type of EGC in multivariate analysis. En bloc resection rate tended to be lower, and complete and curative resection rates were significantly lower in the predominantly differentiated mixed group. The rate of lymph node metastasis in the lesions with additional operation tended to be higher, in this mixed histology group. CONCLUSIONS: Larger size, mid-third location, and moderately differentiated histology on forceps biopsy carry the significant risk for mixed histology predominantly of differentiated type. EGC with predominantly differentiated mixed histologic type affects therapeutic outcomes and consequent clinical course accompanied by possibly higher risk for lymph node metastasis. The safety of ER for predominantly differentiated mixed EGC should be validated by further prospective investigation.

Pre-treatment neutrophil to lymphocyte ratio as a prognostic marker to predict chemotherapeutic response and survival outcomes in metastatic advanced gastric cancer.

BACKGROUND: Several studies have shown that the neutrophil to lymphocyte ratio (NLR) in peripheral blood is a prognostic factor of various cancers. However, there is limited information on the clinical and prognostic significance of NLR in patients with metastatic advanced gastric cancer (AGC). Therefore, we examined whether the NLR can be used as a prognostic marker for predicting chemotherapeutic response and survival outcomes in metastatic AGC patients who are receiving palliative chemotherapy. METHOD: A total of 268 patients diagnosed with metastatic AGC were enrolled. NLR was calculated from complete blood cell count taken before the first chemotherapy treatment. Patients were divided into two groups according to the median value of NLR: a high NLR group and a low NLR group. RESULT: The median follow-up period was 340 days (range 72-1796 days) and median NLR was 3.06 (range 0.18-18.16). The high NLR group (NLR >3.0) contained 138 patients and the low NLR group (NLR ≤3.0) contained 130 patients. Low NLR group patients had a significantly higher chemotherapeutic disease control rate (90.0 % vs. 80.4; P = 0.028), and longer progression-free survival (PFS) and overall survival (OS) than the high NLR group patients (186 vs. 146 days; P = 0.001; 414 vs. 280 days; P < 0.001, respectively). In multivariate analysis, NLR showed a significant association with PFS (HR 1.478; 95 % CI 1.154-1.892; P = 0.002) and OS (HR 1.569; 95 % CI 1.227-2.006; P < 0.001). CONCLUSION: Pretreatment NLR is a useful prognostic marker in patients with metastatic AGC who are undergoing palliative chemotherapy.

Prediction of survival by tumor area on endosonography after definitive chemoradiotherapy for locally advanced squamous cell carcinoma of the esophagus.

BACKGROUND: Definitive chemoradiotherapy (CRT) is a reasonable approach for patients with locally advanced esophageal cancer who are not surgical candidates. This study was performed to investigate whether endosonography (EUS) assessment of tumor area response is a useful prognostic marker in patients with squamous cell carcinoma (SCC) of the esophagus who receive definitive CRT. METHODS: A total of 33 patients who received definitive CRT for locally advanced esophageal SCC were enrolled. The maximal transverse cross-sectional area of the tumor was measured before and after definitive therapy. EUS response was defined as a ≥50% reduction of the tumor area after definitive CRT. RESULTS: Based on EUS evaluation, there were 20 nonresponders (60.6%) and 13 responders (39.4%). The median progression-free survival (PFS) was significantly longer in EUS responders than EUS nonresponders (p = 0.005). However, there was no statistical significance in overall survival according to EUS response (p = 0.120). During multivariate analysis, EUS response to definitive CRT was the only significant factor associated with PFS (p = 0.045), whereas EUS response to definitive CRT was not associated with overall survival (p = 0.221). CONCLUSIONS: A reduction of the maximal cross-sectional tumor area measured by EUS correlates with a superior prognosis in patients with locally advanced SCC of the esophagus after definitive CRT.

Clinicopathologic factors and outcomes of histologic discrepancy between differentiated and undifferentiated types after endoscopic resection of early gastric cancer.

BACKGROUND: Histologic discrepancies among specimens obtained by forceps biopsy and endoscopic resection (ER) between the differentiated and undifferentiated types often occur in early gastric cancer (EGC). This study aimed to evaluate the predictive clinicopathologic characteristics and clinical implications of histologic discrepancies in EGC. METHODS: From August 2005 to March 2012, 596 lesions from 579 patients underwent ER for EGC. The lesions studied were diagnosed as the differentiated histologic type from forceps biopsy specimens. The lesions were grouped according to the occurrence of histologic discrepancy between the differentiated and undifferentiated types in specimens obtained by ER as concordant (n = 570) or discordant (n = 26). The main outcome measures were en bloc resection, complete resection, and curative resection rates. RESULTS: The histologic discrepancy rate was 4.4% among the studied lesions. Larger size, lesion location in the mid third of the stomach, easy friability, exudates, and submucosal invasion shown on endoscopic ultrasound were significantly related to histologic discrepancy in the univariate analysis. In the multivariate analysis, lesion location in the mid third of the stomach [odds ratio (OR) 5.34, 95% confidence interval (CI) 1.59-19.13] and easy friability (OR 29.26, 95% CI 2.30 to >999.9) were significant factors associated with histologic discrepancy. The complete resection and curative resection rates were significantly lower and the additional operation rates after ER were significantly higher in the discordant group. CONCLUSIONS: The EGCs with histologic discrepancy between the differentiated and undifferentiated types changed the therapeutic outcomes of ER. Easily friable lesions located in the mid third of the stomach carry a significant risk for histologic discrepancy in undifferentiated histology when ER of EGCs is performed.

Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy?

BACKGROUND: Anastomotic leaks are a life-threatening complication of gastrectomies with high mortality after surgical reintervention. Endoscopic therapy using fibrin glue injection, endoclip, and other devices is an alternative to surgical intervention for anastomotic leaks. Recently, self-expanding metal stents (SEMS) were introduced to treat anastomotic leaks. The purpose of this study was to assess the clinical characteristics and therapeutic outcomes of SEMS and nonstent endoscopic therapy (NSET) for treatment of anastomotic leaks after total gastrectomy with the aim of assisting endoscopists in choosing a treatment method. METHODS: Between July 2002 and March 2013, 13 patients treated with SEMS and 14 patients treated with NSET for anastomotic leaks after total gastrectomy were enrolled onto the study. Enrolled patients received 16 SEMS placement sessions and 21 NSET sessions. RESULTS: No significant differences in baseline characteristics or clinical characteristics related to leakage were detected in patients with SEMS compared to NSET. The successful sealing rate at the first attempt by SEMS was significantly better than that of NSET (80.0 vs. 28.6 %, P = 0.036), whereas the successful sealing rate after multiple endoscopic treatments was not statistically different (80.0 vs. 64.3 %, P = 0.653). The main reason for reintervention with SEMS was complications and with NSET was nonseal (P = 0.004). Clinical outcomes including length of hospital stay, endoscopic treatment-related mortality, and all-cause mortality were not significantly different between the 2 groups. CONCLUSIONS: In terms of efficacy by single effort, SEMS was superior to other methods for treating anastomotic leaks after total gastrectomy. However, complications with SEMS should be considered when choosing an endoscopic treatment method.

Safety and patient satisfaction of early diet after endoscopic submucosal dissection for gastric epithelial neoplasia: a prospective, randomized study.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a standard treatment for gastric neoplasia limited to the mucosa without lymph node metastasis. However, there are neither standardized guidelines nor studies on the best time to start oral intake after ESD. The aim of this study was to compare patient satisfaction, safety, length of hospital stay, and economic feasibility between an early post-ESD diet and the conventional immediate fasting protocol. METHODS: A total of 130 patients with 156 gastric epithelial neoplasias who underwent ESD by a single expert endoscopist were consecutively and prospectively enrolled. Enrolled patients were randomized to an early diet group or a control group. The early diet group started meals as a clear liquid diet on day 0, and a soft diet and general diet in sequence on day 1. The fasting group was fasted for 2 days. Patients in both groups underwent second-look endoscopy within 2 days following ESD and follow-up endoscopy after 2 months. RESULTS: In the course of the study, ten patients were excluded. The total number of patients in the early diet group and control group was 63 and 57, respectively. Mean age was 62 years (±9.4). There were no significant differences in clinicopathologic conditions or endoscopic results such as procedure time or size of lesions between the two groups. There were no significant differences in abdominal pain score, rate of post-ESD bleeding or healing rate of ESD-induced ulcer between the two groups. However, the early diet protocol led to significantly higher patient satisfaction (p = 0.001), lower hospital costs (p < 0.001), and shorter hospital stay (p < 0.001) than the conventional fasting protocol. CONCLUSIONS: An early post-ESD diet protocol provides higher patient satisfaction, is more cost effective, decreases hospital stay, and does not influence complication rates such as post-ESD bleeding, abdominal pain, or ulcer healing compared with the conventional fasting protocol.

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.

Carcinomatosis matters: clinical outcomes and prognostic factors for clinical success of stent placement in malignant gastric outlet obstruction.

BACKGROUND: Although carcinomatosis is not a contraindication to stenting in selected patients with malignant gastric outlet obstruction (GOO), associate factors for clinical success rate of self-expandable metallic stent (SEMS) placement in GOO patients with carcinomatosis have not been fully characterized. METHODS: We analyzed a total 228 patients who were scheduled for SEMS placement for malignant GOO in tertiary-care academic medical center. All patients were treated with an uncovered or covered SEMS by using the over-the-wire placement procedure. We retrospectively evaluated clinical outcomes of SEMS placement. RESULTS: Technical success was achieved in all patients. Patients were categorized into two groups according to the presence of carcinomatosis. Clinical success rates of patients without carcinomatosis group and with carcinomatosis group were 93.9 % (92 of 98) and 80.8 % (105 of 130), respectively (P = 0.004). In subgroup analysis of patients with carcinomatosis, the clinical success rate was lower in patients with ascites (64.8 %) than in those without ascites (92.1 %, P < 0.001). Multivariate logistic regression model revealed that carcinomatosis without ascites did not decrease clinical success rate compared with absence of carcinomatosis; meanwhile, carcinomatosis with ascites showed lower clinical success rates compared with absence of carcinomatosis (adjusted odds ratio 0.163, 95 % confidence interval 0.058-0.461). In addition, poor performance status [Eastern Cooperative Oncology Group (ECOG) status ≥ 3, adjusted odds ratio 0.178, 95 % confidence interval 0.078-0.409] was also an independent poor predictive factor for clinical success of SEMS placement. CONCLUSIONS: In palliation for malignant GOO, the status of carcinomatosis with ascites and poor performance status (ECOG status ≥ 3) are significant predictive factors for poor clinical success of SEMS placement.

Prevalence of rheumatoid factor and parameters associated with rheumatoid factor positivity in Korean health screening subjects and subjects with hepatitis B surface antigen.

OBJECTIVES: The purpose of this study is to assess the prevalence and titer of rheumatoid factor (RF) in Korean health screening subjects and consecutive subjects with hepatitis B surface antigen (HBsAg) and to examine the factors influencing RF positivity. METHODS: This study was performed in 37,660 patients (23,269 men, 14,391 women) without arthralgia, who participated in a health checkup program in 2009. RESULTS: Approximately 3.7% of health screening subjects (3.3% of males and 4.4% of females) were positive for RF. Among subjects with HBsAg (n = 1,494) and antibody for hepatitis C virus (HCV) (n = 132), 11.8 and 10.6% were RF positive, respectively. There was a significant difference in the RF-positive rate between males and females. The RF-positive rate had a significant linear-by-linear association with aging, but there was no significant relationship between RF positivity and aging among subjects with HBsAg or anti-HCV antibody. Presence of HBsAg and anti-HCV antibody, positive C-reactive protein (CRP), and female sex were factors strongly associated with RF positivity. CONCLUSIONS: The rate of RF positivity in health screening adults and subjects with HBsAg in Korea can be estimated to be 3.7 and 11.8%, respectively. Clinicians should consider hepatitis B or C virus infection status, CRP positivity, and sex when interpreting RF-positive results.

Seasonal trends of diagnosis of childhood malignant diseases and viral prevalence in South Korea.

BACKGROUND: Several studies have reported a seasonal trend in the diagnosis of childhood cancer suggesting seasonal factors such as infection. The present study aimed to analyze the diagnosis pattern of childhood malignant diseases using public health data, and to compare this pattern with seasonal viral infection trends. METHOD: Using the open data source of the Health Insurance Review and Assessment Service, we extracted data regarding all patients under 21 years of age and who had any cancer, aplastic anemia or myelodysplastic syndrome between September 2009 and December 2013. The positive detection rates of 11 viruses was collected from the surveillance data of Korea Centers for Disease Control and Prevention, and seasonality analysis were conducted with both data. RESULTS: In total, 9085 patients were diagnosed with malignant disease during the study period; there were about 175 new cases per month on average. Monthly stacked time series by year showed an apparent seasonal variation with the highest monthly average in January as 236, and the lowest in September as 120. In winter, significantly more patients were diagnosed with acute lymphoblastic leukemia, acute myeloid leukemia, neuroblastoma, and Hodgkin's lymphoma than in other seasons. There was a temporal correlation with the diagnostic trends of several diseases and the prevalence of recent human parainfluenza virus. CONCLUSION: This study tentatively suggests that the diagnosis of childhood malignancy follows a seasonal trend in Korea, and has a possible correlation with viral prevalence in several diseases. Further long-term analysis of epidemiological data is needed to explore possible causality.

Endoscopic submucosal dissection for undifferentiated-type early gastric cancer: do we have enough data to support this?

Although endoscopic submucosal dissection (ESD) is now accepted for treatment of early gastric cancers (EGC) with negligible risk of lymph node (LN) metastasis, ESD for intramucosal undifferentiated type EGC without ulceration and with diameter ≤ 2 cm is regarded as an investigational treatment according to the Japanese gastric cancer treatment guidelines. This consideration was largely based on the analysis of surgically resected EGCs that contained undifferentiated type EGCs; however, results from several institutes showed some discrepancies in sample size and incidence of LN metastasis. Recently, some reports about the safety and efficacy of ESD for undifferentiated type EGC meeting the expanded criteria have been published. Nonetheless, only limited data are available regarding long-term outcomes of ESD for EGC with undifferentiated histology so far. At the same time, endoscopists cannot ignore the patients' desire to guarantee quality of life after the relatively non-invasive endoscopic treatment when compared to conventional surgery. To satisfy the needs of patients and provide solid evidence to support ESD for undifferentiated EGC, we need more delicate tools to predict undetected LN metastasis and more data that can reveal predictive factors for LN metastasis.

Clinicopathologic characteristics associated with complications and long-term outcomes of endoscopic papillectomy for adenoma.

PURPOSE: Endoscopic papillectomy (EP) is currently employed for the treatment of ampullary adenoma. This study aimed to evaluate the clinical, endoscopic, and histologic characteristics related to complications and long-term outcomes of EP. MATERIALS AND METHODS: Thirty-nine patients underwent EP for ampullary adenoma. Patients were grouped according to the occurrence of procedure-related complications: no complication group (n=28) and complication group (n=11). RESULTS: The overall complication rate was 28.2%. The most common complication was EP-related pancreatitis (n=7). Amylase (p=0.006) and lipase levels (p=0.007), 24 hours after EP, were significantly higher in the complication group, however, these levels did not differ at earlier times. As the tumor progressed from adenoma to cancer, the complete resection was significantly lessened (p=0.032). The duration of antiprotease injection during the hospital stay was significantly longer (p=0.017) and the transfusion requirements were significantly higher (p=0.018) in the complication group. During a median follow-up of 15 months, three lesions (10.3%) recurred among patients with complete resection (n=29) and five lesions (12.8%) recurred among enrolled patients. One patient with progressive recurrence from low-grade dysplasia to adenocarcinoma was noted during a follow-up of 22 months. CONCLUSION: If symptoms are present, amylase and lipase levels, 24 hours after EP, could help predict possible EP-related pancreatitis. Histologic diagnosis through resected specimens may result in complete resection. Patients with complications need a longer duration of antiprotease injection during their hospital stay and more transfusions. The recurrence rate was not significantly high in completely resected cases, however, there was a possibility of progressive recurrence.

Impact of tumor location on clinical outcomes of gastric endoscopic submucosal dissection.

AIM: To determine whether there is a correlation between the location of the lesion and endoscopic submucosal dissection (ESD) outcome. METHODS: From January 2008 to December 2010, ESD of 1443 gastric tumors was performed. En bloc resection rate, complete resection rate, procedure time and complication rate were analyzed according to the tumor location. RESULTS: The rates of en bloc resection and complete resection were 91% (1318/1443) and 89% (1287/1443), respectively. The post-ESD bleeding rate was 4.3%, and perforation rate was 2.7%. Tumors located in the upper third of the stomach were associated with a longer procedure time and significantly higher rates of incomplete resection, piecemeal resection, and perforation than tumors below the upper third of the stomach. Posterior wall lesions had significantly longer procedure times and higher rates of incomplete resection and piecemeal resection than lesions in other locations. In multivariate analysis, posterior wall lesions and upper third lesions were significantly associated with incomplete resection and perforation, respectively. In post-ESD bleeding analysis, location was not a significant related factor. CONCLUSION: More advanced endoscopic techniques are required during ESD for lesions located in the upper third or posterior wall of the stomach to decrease complications and improve therapeutic outcomes.

Tumour size is related to the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection: a retrospective single centre study.

BACKGROUND: Endoscopic submucosal dissection is applied in selected cases of signet ring cell early gastric cancer. However, factors related to curability of signet ring cell early gastric cancer with this method have not been fully evaluated. Our aim was to evaluate factors related to incomplete resection in signet ring cell early gastric cancer with endoscopic submucosal dissection. METHODS: A retrospective analysis was performed on a total of 126 consecutive patients with signet ring cell early gastric cancer who had undergone endoscopic submucosal dissection at the Severance Hospital in Korea, between March 2007 and March 2012. The clinical outcomes were reviewed and factors related to incomplete resection were analysed. RESULTS: Multivariate analysis showed that large tumour size was the only significant factor related to incomplete resection (P=0.006; hazard ratio, 1.040; 95% confidence interval, 1.101-1.084). In addition, large tumour size was the only significant factor related to endoscopic size underestimation (P<0.001; hazard ratio, 1.391; 95% confidence interval, 1.221-1.586). The rate of endoscopic size underestimation was significantly higher in tumours with a size ≥20mm (P<0.001). CONCLUSIONS: To improve the curability of signet ring cell early gastric cancer with endoscopic submucosal dissection, larger tumours (especially tumour with a size ≥20mm) should be resected with a larger margin.

Prognostic value of neutrophil-to-lymphocyte ratio in patients treated with concurrent chemoradiotherapy for locally advanced oesophageal cancer.

BACKGROUND: We performed a retrospective analysis of Asian patients with locally advanced oesophageal cancer to test the hypothesis that an elevated neutrophil-to-lymphocyte ratio is associated with a poor survival rate after definitive concurrent chemoradiotherapy. METHODS: In total, 138 patients diagnosed with locally advanced oesophageal cancer (TNM classification of malignant tumours stage II or III) who were treated with definitive concurrent chemoradiotherapy between January 2005 and December 2010 were retrospectively analysed. Definitive concurrent chemoradiotherapy was performed using two different chemotherapy regimens. RESULTS: The median follow-up duration was 39.5 months (range 1.1-93.4). The median progression-free survival was 14.0 months, and the median overall survival was 19.9 months. Compared with the low (<2.0) neutrophil-to-lymphocyte ratio group (n=43, 31.2%), the high (≥2.0) neutrophil-to-lymphocyte ratio group (n=95, 68.8%) exhibited significant decreases in the durations of both progression-free survival and overall survival. Using multivariate analysis, an elevated neutrophil-to-lymphocyte ratio was also significantly associated with decreased progression-free survival (HR 1.799; 95% CI, 1.050-3.083; P=0.032) and overall survival duration (HR 2.115; 95% CI, 1.193-3.749; P=0.010). CONCLUSIONS: The pretreatment neutrophil-to-lymphocyte ratio is a useful prognostic marker in patients with locally advanced oesophageal cancer treated with definitive concurrent chemoradiotherapy.