BACKGROUND Endoscopic resection,especially endoscopic submucosal dissection(ESD),is increasingly performed in elderly patients with early gastric cancer,and lesions beyond the expanded indications are also resected en...BACKGROUND Endoscopic resection,especially endoscopic submucosal dissection(ESD),is increasingly performed in elderly patients with early gastric cancer,and lesions beyond the expanded indications are also resected endoscopically in some patients.It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.AIM To assess the efficacy and feasibility of gastric ESD for elderly patients,and define high-risk lesions and prognostic indicators.METHODS Among a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014,179 sessions(15.3%)were performed in patients aged≥80 years,and 172 of these sessions were done in patients with a final diagnosis of gastric cancer.These patients were studied retrospectively to evaluate short-term outcomes and survival.The short-term outcomes included the rates of en bloc resection and curative resection,complications,and procedurerelated mortality.Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010.Fisher’s exact test was used to statistically analyze risk factors.Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test.Survival rates at each time point were based on Kaplan-Meier estimation.Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test.To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting,we used the least absolute shrinkage and selection operator(LASSO)Cox regression model including factors curative/noncurative,age,gender,body mass index,prognostic nutritional index,Charlson comorbidity index(CCI),Glasgow prognostic score,neutrophil-to-lymphocyte ratio,and antithrombotic agent use.We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation.P<0.05 was considered statistically significant.RESULTS The en bloc dissection rate was 97.1%,indicating that a high quality of treatment was achieved even in elderly patients.As for complications,the rates of bleeding,perforation and aspiration pneumonitis were 3.4%,1.1%and 0.6%,respectively.These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients.A dissection incision>40 mm,lesions associated with depressions,and lesions with ulcers were risk factors for post-ESD bleeding,and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients(P<0.05).Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding.The overall survival(OS)did not differ significantly between curative and noncurative ESD(P=0.69).In patients without additional surgery,OS rate was significantly lower in patients with a high CCI(≥2)than in those with a low CCI(≤1)(P<0.001).CONCLUSION Gastric ESD is feasible even in patients aged≥80 years.Observation without additional surgery after noncurative ESD is reasonable,especially in elderly patients with CCI≥2.展开更多
Portal vein tumor thrombus (PVTT) frequently occurs with the progression of hepatocellular carcinoma (HCC) and is an important factor in determining the prognosis of HCC.In many cases of HCC with advanced PVTT,treatme...Portal vein tumor thrombus (PVTT) frequently occurs with the progression of hepatocellular carcinoma (HCC) and is an important factor in determining the prognosis of HCC.In many cases of HCC with advanced PVTT,treatment is difficult because the tumor has considerable extension into the liver,and portal hypertension is a frequent complication.The standard therapy for unresectable HCC with advanced PVTT is sorafenib therapy in patients with good hepatic function.However,the outcomes of sorafenib therapy are not completely satisfactory,making the development of another therapy an urgent task.Therefore,this review aims to summarize non-operative treatments for HCC with advanced PVTT and discuss future perspectives based on those therapies,including therapies still being developed.展开更多
文摘BACKGROUND Endoscopic resection,especially endoscopic submucosal dissection(ESD),is increasingly performed in elderly patients with early gastric cancer,and lesions beyond the expanded indications are also resected endoscopically in some patients.It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.AIM To assess the efficacy and feasibility of gastric ESD for elderly patients,and define high-risk lesions and prognostic indicators.METHODS Among a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014,179 sessions(15.3%)were performed in patients aged≥80 years,and 172 of these sessions were done in patients with a final diagnosis of gastric cancer.These patients were studied retrospectively to evaluate short-term outcomes and survival.The short-term outcomes included the rates of en bloc resection and curative resection,complications,and procedurerelated mortality.Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010.Fisher’s exact test was used to statistically analyze risk factors.Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test.Survival rates at each time point were based on Kaplan-Meier estimation.Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test.To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting,we used the least absolute shrinkage and selection operator(LASSO)Cox regression model including factors curative/noncurative,age,gender,body mass index,prognostic nutritional index,Charlson comorbidity index(CCI),Glasgow prognostic score,neutrophil-to-lymphocyte ratio,and antithrombotic agent use.We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation.P<0.05 was considered statistically significant.RESULTS The en bloc dissection rate was 97.1%,indicating that a high quality of treatment was achieved even in elderly patients.As for complications,the rates of bleeding,perforation and aspiration pneumonitis were 3.4%,1.1%and 0.6%,respectively.These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients.A dissection incision>40 mm,lesions associated with depressions,and lesions with ulcers were risk factors for post-ESD bleeding,and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients(P<0.05).Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding.The overall survival(OS)did not differ significantly between curative and noncurative ESD(P=0.69).In patients without additional surgery,OS rate was significantly lower in patients with a high CCI(≥2)than in those with a low CCI(≤1)(P<0.001).CONCLUSION Gastric ESD is feasible even in patients aged≥80 years.Observation without additional surgery after noncurative ESD is reasonable,especially in elderly patients with CCI≥2.
文摘Portal vein tumor thrombus (PVTT) frequently occurs with the progression of hepatocellular carcinoma (HCC) and is an important factor in determining the prognosis of HCC.In many cases of HCC with advanced PVTT,treatment is difficult because the tumor has considerable extension into the liver,and portal hypertension is a frequent complication.The standard therapy for unresectable HCC with advanced PVTT is sorafenib therapy in patients with good hepatic function.However,the outcomes of sorafenib therapy are not completely satisfactory,making the development of another therapy an urgent task.Therefore,this review aims to summarize non-operative treatments for HCC with advanced PVTT and discuss future perspectives based on those therapies,including therapies still being developed.
