Background: s/Aims: Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021. Methods: Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop. Results: In November 2021, the finalized draft was presented for public scrutiny during a formal hearing. Conclusions The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

Background/Aims: Atezolizumab plus bevacizumab (ATE+BEV) therapy has become the recommended first-line therapy for patients with unresectable hepatocellular carcinoma (HCC) because of favorable treatment responses. However, there is a lack of data on sequential regimens after ATE+BEV treatment failure. We aimed to investigate the clinical outcomes of patients with advanced HCC who received subsequent systemic therapy for disease progression after ATE+BEV. Methods: This multicenter, retrospective study included patients who started second-line systemic treatment with sorafenib or lenvatinib after HCC progressed on ATE+BEV between August 2019 and December 2022. Treatment response was assessed using the Response Evaluation Criteria in Solid Tumors (version 1.1.). Clinical features of the two groups were balanced through propensity score (PS) matching. Results: This study enrolled 126 patients, 40 (31.7%) in the lenvatinib group, and 86 (68.3%) in the sorafenib group. The median age was 63 years, and males were predominant (88.1%). In PS-matched cohorts (36 patients in each group), the objective response rate was similar between the lenvatinib- and sorafenib-treated groups (5.6% vs. 8.3%; P=0.643), but the disease control rate was superior in the lenvatinib group (66.7% vs. 22.2%; P<0.001). Despite the superior progression- free survival (PFS) in the lenvatinib group (3.5 vs. 1.8 months, P=0.001), the overall survival (OS, 10.3 vs. 7.5 months, P=0.353) did not differ between the two PS-matched treatment groups. Conclusions In second-line therapy for unresectable HCC after ATE+BEV failure, lenvatinib showed better PFS and comparable OS to sorafenib in a real-world setting. Future studies with larger sample sizes and longer follow-ups are needed to optimize second-line treatment.

Background/Aims: We examined the concordance rate among fasting plasma glucose (FPG), 2-hour post-challenge glucose (2hr PG), and hemoglobin A1c (HbA1c) in the diagnosis of diabetes in a population with a high-risk for type 2 diabetes mellitus (T2DM) in Korea. Methods: Among the participants from the Korean Diabetes Prevention Study, individuals with FPG ≥ 100 mg/dL, body mass index (BMI) ≥ 23.0 kg/m2, and no previous history of T2DM were consecutively enrolled after a 75 g glucose tolerance test. We analyzed the differences in the clinical characteristics in subjects with stage 1 (FPG, 100 to 109 mg/dL) and stage 2 (FPG, 110 to 125 mg/dL) impaired fasting glucose (IFG). Results: Of 1,637 participants, 27.2% had T2DM and 59.3% had IFG and/or impaired glucose tolerance (IGT). The mean age was 55.0 ± 8.1 years and the mean BMI was 26.3 ± 2.7 kg/m2. Based on FPG criteria, 515 (31.4%) and 352 (21.5%) subjects were classified as having stage 1 and stage 2 IFG, respectively. The 19.0% of stage 1 and 43.5% of stage 2 subjects showed 2hr PG levels in the diabetic range. Even for those in the normal FPG range, 63 (9.5%) participants showed a 2hr PG level of ≥ 200 mg/dL. Of 446 subjects with newly-diagnosed diabetes, 340 (76.2%) showed FPG levels < 126 mg/dL. Conclusions The oral glucose tolerance test should be actively considered for Korean adults who are overweight or obese with the IFG range (FPG, 100 to 125 mg/ dL) to allow for early detection of diabetes and prompt intervention.

Purpose: Alpha-fetoprotein (AFP) is a prognostic marker for hepatocellular carcinoma (HCC). We investigated the prognostic value of AFP levels in patients who achieved complete response (CR) to transarterial chemoembolization (TACE) for HCC. Materials and Methods: Between 2005 and 2018, 890 patients with HCC who achieved a CR to TACE were recruited. An AFP responder was defined as a patient who showed elevated levels of AFP (>10 ng/mL) during TACE, but showed normalization or a >50% reduction in AFP levels after achieving a CR. Results: Among the recruited patients, 569 (63.9%) with naïve HCC and 321 (36.1%) with recurrent HCC after complete resection were treated. Before TACE, 305 (34.3%) patients had multiple tumors, 219 (24.6%) had a maximal tumor size >3 cm, and 22 (2.5%) had portal vein tumor thrombosis. The median AFP level after achieving a CR was 6.36 ng/mL. After a CR, 473 (53.1%) patients experienced recurrence, and 417 (46.9%) died [median progression-free survival (PFS) and overall survival (OS) of 16.3 and 62.8 months, respectively]. High AFP levels at CR (>20 ng/mL) were independently associated with a shorter PFS [hazard ratio (HR)=1.403] and OS (HR=1.284), together with tumor multiplicity at TACE (HR=1.518 and 1.666, respectively). AFP non-responders at CR (76.2%, n=359 of 471) showed a shorter PFS (median 10.5 months vs. 15.5 months, HR=1.375) and OS (median 41.4 months vs. 61.8 months, HR=1.424) than AFP responders (all p=0.001). Conclusion High AFP levels and AFP non-responders were independently associated with poor outcomes after TACE. AFP holds clinical implications for detailed risk stratification upon achieving a CR after TACE.

Hepatocellular carcinoma (HCC) has extremely poor prognosis. Immunotherapy has emerged as a new treatment for a number of cancers. Adoptive immunotherapy is one of the important cancer immunotherapy, which relies on the various lymphocytes including cytotoxic T lymphocytes, natural killer (NK) and cytokine induced killer cells. Also, there has been advance in techniques of NK cell activation to more effectively kill the cancer cells. Of note, recently the blocking antibodies targeting programmed cell death protein 1 (PD-1) have shown promising results in diverse cancers including HCC. We report our recent experience of a patient accompanying advanced HCC with extrahepatic metastases. Disease progression had occurred after sorafenib administration, while the patient showed local tumor control and tumor marker decrease by NK cell immunotherapy combined with PD-1 inhibitor therapy. Though, there was no definite survival advantage due to impaired liver function, which might be caused by treatment related toxicities as well as cancer progression.
Antibodies, Blocking ; Carcinoma, Hepatocellular ; Cell Death ; Cytokine-Induced Killer Cells ; Disease Progression ; Humans ; Immunotherapy ; Immunotherapy, Adoptive ; Killer Cells, Natural ; Liver ; Lymphocytes ; Neoplasm Metastasis ; Prognosis ; Programmed Cell Death 1 Receptor ; T-Lymphocytes, Cytotoxic

OBJECTIVE: Gynecologic oncologists are uncertain about the safety of tibolone application in cervical adenocarcinoma (AC) patients. This study examined the possible adverse effects of tibolone on the survival of cervical AC patients. METHODS: Medical records of 70 cervical AC patients with International Federation of Gynecology and Obstetrics stages IA to IB were reviewed. A bilateral salpingo-oophorectomy was performed in all patients, and survival outcomes between tibolone users (n=38) and non-users (n=32) were compared. RESULTS: A comparison of the tibolone users with non-users revealed similar clinicopathological variables. Progression-free survival (P=0.34) and overall survival (P=0.22) were similar in the users and non-users. The risks of progression (hazard ratio [HR], 1.71; 95% confidence interval [CI], 0.46–6.37; P=0.43) and death (HR, 1.59; 95% CI, 0.06–45.66; P=0.79) were also similar in both groups. CONCLUSION: Tibolone has no adverse effect on the survival of cervical AC patients and can be administered safely to this population. These findings may be helpful in improving the quality of life of cervical AC patients.
Adenocarcinoma* ; Disease-Free Survival ; Gynecology ; Humans ; Medical Records ; Obstetrics ; Prognosis ; Quality of Life ; Uterine Cervical Neoplasms

OBJECTIVE: To evaluate the potential effects of previous abdominal surgery on post-operative outcome and incidence of complications after total laparoscopic hysterectomy (TLH). METHODS: Between June 2008 and December 2016, 331 patients who underwent TLH were retrospectively reviewed. Participating patients were divided into 2 groups according to previous abdominal surgery. We compared the 2 groups based on estimated blood loss, operation time, hospital stay, surgery-related complications, and conversion to laparotomy rates. RESULTS: Group 1 included patients without a history of abdominal surgery (n=186), group 2 included patients with a history of abdominal surgery (n=145). The complication rate was 3.2% in group 1 and 2.8% in group 2. Other post-operative outcome and complications such as estimated blood loss, hospital stay and conversion to laparotomy rates did not differ significantly between groups. Adhesiolysis was significantly more common in group 2 (P < 0.001) and operation time was significantly longer in the group 2 (P=0.004). The rate of conversion to laparotomy was higher in group 2, but this difference was not significant (P=0.115). Group 2 patients were divided into subgroups according to the number of surgery. In subgroups analysis of group 2, there were 70 patients who had one previous abdominal surgery and 75 patients who had 2 or more previous surgeries. Moreover, there were significant differences in adhesiolysis (P=0.004) and conversion to laparotomy (P=0.034). There were no significant differences in other complications observed upon subgroup analysis. CONCLUSION: TLH can be conducted successfully regardless of previous abdominal surgery. Patients with previous abdominal surgery are suitable and feasible candidates for TLH.
Humans ; Hysterectomy* ; Incidence ; Laparoscopy ; Laparotomy ; Length of Stay ; Postoperative Complications ; Retrospective Studies

OBJECTIVE: Prophylactic trans-catheter arterial balloon occlusion (PTABO) before cesarean section of placenta previa totalis has been introduced to prevent massive hemorrhage. The purpose of this study is to evaluate the clinical usefulness of PTABO in cases of suspected placental adhesion and to examine antepartal risk factors and perinatal outcomes in women with placental adhesion. METHODS: Between January 2012 and December 2015, 77 patients who had undergone ultrasonography for evaluation of placenta previa were enrolled in this study. Seventeen of these patients with suspected placental adhesion by ultrasonography and Pelvic MRI underwent PTABO before cesarean section and another 59 patients underwent cesarean section without PTABO. Antepartal risk factors and peripartum maternal and neonatal outcomes were compared between patients with PTABO and those without PTABO. RESULTS: More advanced maternal age, longer in gestational weeks at delivery, and more common previous cesarean section history were observed in the PTABO group. Placenta adhesion, abnormal Doppler findings, and frequency of transfusion were more common in the PTABO group. However there was no significant difference in estimated blood loss, hospital days, and neonatal outcome. It had occurred 3 cases of hysterectomy and 1 case of uterine artery embolization after cesarean section in the PTABO group. CONCLUSION: Close surveillance of antepartum risk factors for placental adhesion using ultrasonography and pelvic magnetic resonance imaging is important to prevention of massive hemorrhage during cesarean section. PTABO before cesarean section might result in reduced blood loss and requirement for transfusion during the operation.
Balloon Occlusion* ; Cesarean Section ; Female ; Hemorrhage ; Humans ; Hysterectomy ; Iliac Artery* ; Magnetic Resonance Imaging ; Maternal Age ; Peripartum Period ; Placenta ; Placenta Previa ; Postpartum Hemorrhage ; Pregnancy ; Risk Factors ; Ultrasonography ; Uterine Artery Embolization

OBJECTIVES: There is little research on the practice and effectiveness of electroconvulsive therapy (ECT) in Korea. This study investigated the practice pattern, effectiveness, and safety of ECT. METHODS: This chart review study included electronic medical records of 180 patients treated with ECT between January 2007 and December 2013 at the Asan Medical Center. Symptomatic improvement was assessed using Clinical Global Impression (CGI) scale. Treatment response was defined as CGI improvement scale score of 2 or less. Re-hospitalization was used as an indicator of recurrence. Safety was assessed by spontaneous reports from patients. RESULTS: One hundred and eighty patients underwent 1539 sessions of modified ECT. Their most frequent diagnosis was major depressive disorder (n=74, 41.1%). The most common indication for ECT was poor response to medication (n=177, 75.3%). Treatment response rate was 66.9% in acute phase group and 63.8% in the patients with poor response to medication. The recurrence rate at six months after the end of the course was 29.6%. Memory impairment or amnesia was the most common adverse effect. CONCLUSION: There was a remarkable improvement following ECT in patients who responded poorly to medications, and most adverse effects were tolerable and temporary. The present study suggests that ECT could be a useful treatment option.
Amnesia ; Chungcheongnam-do ; Depressive Disorder, Major ; Diagnosis ; Electroconvulsive Therapy* ; Electronic Health Records ; Humans ; Korea ; Memory ; Recurrence

Most esophageal lipomas are discovered incidentally and are small and asymptomatic. However, large (>4 cm) lipomas may cause various symptoms, including dysphagia, regurgitation, or epigastric discomfort. We present a 45-year-old woman with intermittent sudden choking and globus pharyngeus. Upper gastrointestinal endoscopy and endoscopic ultrasound revealed an approximately 10.0×1.5 cm pedunculated subepithelial tumor in the upper esophagus, identified as the cause of her symptoms. A thoracic computed tomography scan revealed a fat attenuated longitudinal mass along the upper esophagus, suggestive of a lipoma. Endoscopic resection of the lesion was performed with a detachable snare to relieve her symptoms, and the pathologic findings were consistent with a lipoma.
Airway Obstruction* ; Deglutition Disorders ; Endoscopy ; Endoscopy, Gastrointestinal ; Esophagus ; Female ; Humans ; Lipoma* ; Middle Aged ; SNARE Proteins ; Ultrasonography