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Does the timing of adjuvant chemotherapy for gastric cancer influence patient outcome?

Polyvinyl chloride (PVC) is a widely used chemical for production of plastics. However occupational asthma (OA) caused by PVC has been reported only rarely. We report a 34-yr-old male wallpaper factory worker with OA due to PVC and nickel (Ni) whose job was mixing PVC with plasticizers. He visited the emergency room due to an asthma attack with moderate airflow obstruction and markedly increased sputum eosinophil numbers. A methacholine challenge test was positive (PC20 2.5 mg/mL). Bronchoprovocation tests with both PVC and Ni showed early and late asthmatic responses, respectively. Moreover, the fractional concentration of exhaled nitric oxide (FeNO) was increased after challenge with PVC. To our knowledge, this is the first case of OA in Korea induced by exposure to both PVC and Ni. We suggest that eosinophilic inflammation may be involved in the pathogenesis of PVC-induced OA and that FeNO monitoring can be used for its diagnosis.

The differential diagnosis between inactive carrier and active hepatitis is important in patients with chronic hepatitis B (CHB) virus infection. Serum cytokeratin (CK)-18 fragments (M30-antigen) are proposed as biomarkers of apoptosis.We investigated whether serum M30-antigen levels might help to characterize the various phases of CHB and predict the state of significant inflammation in patients with CHB.A total of 339 CHB patients who underwent liver biopsy, were included. Serum M30-antigen levels were compared between inactive carriers (n=21), patients with HBeAg-negative hepatitis (n=95), HBeAg-positive hepatitis (n=141) and liver cirrhosis (n=82).Serum M30-antigen levels were correlated significantly not only with AST (r=0.544, p0.001) and ALT (r=0.315, p0.001) and but also inflammatory grading score on liver biopsy (r=0.240, p0.001). Serum M30-antigen level in HBeAg-negative CHB was significantly higher than that of inactive HBV carrier (399.78 U/L vs 148.90 U/L, p0.001). Multivariate analysis showed that AST (p0.001), albumin (p=0.009) and M30-antigen (p=0.020) were the independent predictors of significant inflammation. Combined serum M30-antigen level (344 U/L) and AST (78 IU/L) measurement provided the most accurate identification of significant inflammation, showing 38.2% sensitivity, 96.1% specificity, 91.0% positive predictive value and 56.1% negative predictive value.Serum M30-antigen can be a predictive marker for distinguishing between inactive carrier and HBeAg-negative CHB. Serum M30 levels are associated with the presence of significant inflammation, especially in patients with normal or minimally elevated ALT in CHB patients.

Objectives The aim of this study was to determine the serum markers that predict significant inflammation in patients with chronic hepatitis B (CHB). Design and methods Between October 2005 and June 2009, 384 subjects with CHB were enrolled. Results Multiple logistic regression analysis identified the ALT, hyaluronic acid (HA) and procollagen III N-terminal peptide (PIIINP) as independent predictors of significant inflammation (grade ≥ 3). We constructed a formula for predicting significant inflammation. A significant inflammation (SI) score = 1.773 × ALT score + 1.599 × PIIINP score + 0.677 × HA score − 1.962. The area under receiver operating characteristic curve of the SI score was 0.831. The sensitivity, specificity, positive predictive value and negative predictive value of the SI score were 79.5%, 70.8%, 76.8% and 74.3%, respectively. Conclusions A simple scoring system including ALT, PIIINP and HA is an accurate non-invasive predictor of significant inflammatory activities in patients with CHB.

275 Outcome Over 5 Years of Minimally Invasive Treatment of Early Gastric Cancer Beyond Endoscopic Submucosal Dissection Ga Won Song*, Suk Pyo Shin, Weon-Jin Ko, Jun Hwan Yoo, Duk Hwan Kim, Kim Wonhee, Kwang Hyun Ko, Joo Young Cho, Ki Baik Hahm, Sung-Pyo Hong, Pil Won Park, Jun-Hyung Cho Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea (the Republic of); Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background/Aims: The aim of this study was to evaluate the long term outcomes of combined endoscopic submucosal dissection (ESD) with laparoscopic lymph node dissection (LLND) and endoscopic full-thickness resection (EFTGR) with laparoscopic regional lymph node dissection (hybrid natural orifice transluminal endoscopic surgery, hybrid NOTES) for early gastric cancer (EGC). Methods: This is a retrospective analysis at a single tertiary referral center. A total of 23 patients with EGC underwent combined ESD with LLND and hybrid NOTES for early gastric cancer beyond endoscopic submucosal dissection between February 2007 and August 2009. Then the patients received periodic endoscopic follow-up and metastatic surveys over 5 years. The main outcome measures were curability (curative or non-curative), recurrent rate, and survival rates. Results: The curative resection rate of all cases was 95.7% (ESD with LLND 90.0% vs. hybrid NOTES 100%, respectively). Incomplete resection was shown in 1 (tumor-positive vertical margin). Histologically, 11 cases were mucosal cancers, and 12 were submucosal cancers. And there were 12 undifferentiated cancers. The median tumor size was 3.4 cm (range, 1.25.7cm) in long diameter. The lymphovascular invasion was found in 3 cases with 1 lymph node metastasis. 5 patients underwent additional gastrectomy because of tumor-positive margins or treatment-related complications. During over 5 year follow-up periods, none showed local recurrence or lymph node metastasis. The 5 year overall survival rates and disease free survival of the patients was100% in both. Conclusion: Combined ESD with LLND and hybrid NOTES showed favorable long term clinical outcomes. They could be utilized as a bridge between ESD and gastrectomy in selected patients with a risk of lymph node metastasis. 276 Incidence and Risk Factors of Metachronous Gastric Cancer After Endoscopic Resection and Successful Helicobacter pylori Eradication: Results From a Large-Scale, Multicenter Cohort Study in Japan Genki Mori*, Takeshi Nakajima, Ichiro Oda, Kiyoshi Asada, Taichi Shimazu, Nobutake Yamamichi, Takao Maekita, Chizu Yokoi, Mitsuhiro Fujishiro, Takuji Gotoda, Masao Ichinose, Toshikazu Ushijima Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; Division of Epigenomics, National Cancer Center Research Institute, Tokyo, Japan; Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan; Department of Gastroenterology, University of Tokyo, Tokyo, Japan; Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan; Department of Gastroenterology and Hepatology, National Center for Global Health and Medice, Tokyo, Japan; Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan Introduction: A previous multicenter prospective randomized study from Japan showed that Helicobacter pylori (HP) eradication reduced the development of metachronous gastric cancer (MGC) after endoscopic resection (ER) for early gastric cancer (GC) from 40.5 to 14.1 cases per 1000 person-years. MGC is, however, still detected in a certain rate even after successful HP eradication, few studies have evaluated the incidence and risk factors of MGC. Aims: To clarify the incidence and risk factors of MGC in the cases after ER for early GC with successful HP eradication. Methods: Participants comprised 594 patients (485 men, 109 women; median age, 66 years; range, 36-79 years) who underwent ER for early GC and successful HP eradication in one of three institutions (National Cancer Center Hospital, The University of Tokyo Hospital and Wakayama Medical University Hospital) between 1999 and 2010. Annual endoscopic surveillance was performed after ER. HP infection was diagnosed using the C urea breath test, serology and culture of biopsy samples. Positive results in at least one of these three tests were considered as evidence of HP infection. The status of baseline gastric mucosal atrophy at the time of successful HP eradication was assessed endoscopically according to the Kimura-Takemoto classification. MGC was defined as a GC newly detected at least 1 year after successful HP www.giejournal.org Vol eradication. Results: Median follow-up period after successful HP eradication was 4.5 years (range, 1.0-11.4 years). During the follow-up period, 93 MGCs were detected in 79 patients. Kaplan-Meier analysis showed a linear increase in the cumulative incidence of MGC; the incidence of MGC was 29.9 cases per 1000 person-years (Fig. 1). Multivariate analysis by using Cox proportional hazard modeling revealed that male sex, open-type gastric mucosal atrophy, and multiple GCs before HP eradication were independent risk factors for MGC (Table 1). Conclusion: Careful and continuous surveillance endoscopy for MGC is required even after successful HP eradication, particularly in male patients, those with extensive gastric mucosal atrophy, and multiple GCs before HP eradication. Multivariate analysis for the risk of MGC ume 81, No. 5S : 2015 GASTROINTE Number STINAL E Hazard Ratio

It is known that rheumatoid arthritis (RA) patients show increased incidence of multiple myeloma (MM), despite its rarity. Only one case of MM with seronegative RA was reported in Korea, thus far. We report a case of MM with seropositive RA. The patient was a 66 year old female who had been diagnosed with seropositive RA 4 years ago. Over the last 1 month, the patient experienced general weakness and weight loss of 10 kg. It was found that her serum creatinine had increased and her urine analysis showed proteinuria. To evaluate renal failure and proteinuria, renal biopsy, bone marrow biopsy and electrophoresis were carried out. A diagnosis of myeloma cast nephropathy was made. We report this rare case of MM represented as acute renal failure during the treatment for RA, and include a review of the literature.

Background/Aims: The treatment for steroid-refractory acute graft versus host disease (GVHD) after allogeneic stem cell transplantation (allo-SCT) needs to be standardized. We report our clinical experience with etanercept for steroid-refractory acute GVHD. Methods: Eighteen patients who underwent allo-SCT and presented with steroid-refractory acute GVHD at Ajou University Hospital were studied retrospectively. They were given 25 mg of etanercept subcutaneously twice weekly for 4 weeks. The clinical responses were evaluated with regard to the severity of acute GVHD. Results: The median patient age was 43.5 years. Using nonparametric tests, etanercept had a down-grading effect on acute GVHD ( p = 0.005), although no patient experienced complete remission. Partial responses were seen in 80%, 17%, and 57% of grade II to IV patients, respectively. Skin and gut GVHD were well controlled with etanercept, whereas hepatic GVHD was not. Four patients died of fatal infections. No factors affecting the clinical outcome of etanercept were identified. Conclusions: Etanercept has a modest effect on steroid-refractory acute GVHD af ter allo-SCT, with tolerable side effects.