Cholangioscopic diagnosis of hemobilia: an unusual case of left hepatic portal hypertension by plasma cell tumor.

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[Successful R0 Resection of Hilar Cholangiocarcinoma Invading the Inferior Vena Cava through Left Trisegmentectomy with Combined Resection of the Portal Vein and Inferior Vena Cava after Gemcitabine/Cisplatin Combination Chemotherapy-A Case Report].

A 65-year-old woman was admitted to our institution with sonography results indicating a caudate lobe mass. CT showed a large low-density mass in the caudate lobe, extensively involving the inferior vena cava and main portal vein. Moderately differentiated adenocarcinoma was found on transcutaneous biopsy. We therefore regarded this tumor as a severe locally advanced hilar cholangiocarcinoma and initiated gemcitabine/cisplatin combined chemotherapy. The tumor gradually reduced in size. However, after 28 courses of treatment, CT showed persistent tumor invasion in the left trunk of the portal vein and inferior vena cava invasion in succession in the middle; the tumor had not yet invaded the left hepatic vein. Owing to myelosuppression and general malaise, it was difficult to continue chemotherapy. After 32 courses of treatment, the patient underwent a left trisegmentectomy with combined resection of the portal vein and inferior vena cava. Postoperative microscopic findings revealed no apparent invasion of the tumor in the inferior vena cava, thus suggesting successful R0 resection. The patient is alive without recurrence 18 months postoperatively.

Metastatic primary pulmonary leiomyosarcoma to the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration.

A 77-year-old female patient consulted our hospital for an abnormal shadow observed on chest X-ray. Computed tomography revealed the shadow of a mass in the right lower lung lobe and two shadows of masses in the pancreatic head and body. 18F-fluorodeoxyglucose-positron emission tomography showed an intense uptake only in the fields corresponding to these three masses. Each mass was diagnosed as leiomyosarcoma by transcutaneous needle biopsy of the pulmonary mass and endoscopic ultrasound-guided fine-needle aspiration of the pancreatic masses. The primary site was the lung because the pulmonary lesion was solitary, and no tumor was found in other organs. In English language literature, a case of primary pulmonary leiomyosarcoma with metastasis solely to the pancreas has not yet been reported to the best of our knowledge.

Molecular biomarker identification for esophageal adenocarcinoma using endoscopic brushing and magnified endoscopy.

BACKGROUND: Barrett's esophagus (BE) is a predisposing factor for esophageal adenocarcinoma (EAC); however, the precise mechanism underlying this association remains unclear. The identification of biomarkers that are associated with an increased risk of BE progression to EAC would facilitate diagnosis and early treatment. Toward this goal, we aimed to identify biomarkers associated with BE and EAC in patients. METHODS: In conjunction with high-resolution magnified endoscopy with narrow-band imaging (ME-NBI), we obtained brushing samples from the long-segment BE (LSBE) or short-segment BE (SSBE) of patients with EAC or without EAC (control). To identify candidate biomarker genes, microarray analysis was performed for a training set of 28 American samples. To confirm the microarray results, expression levels of the 16 candidate biomarkers were evaluated by real-time polymerase chain reaction analysis, using samples collected from an additional 53 American patients. In addition, we also performed a functional analysis for these genes using Gene Ontology (GO) enrichment analysis. RESULTS: Among the 16 genes identified as differentially expressed by microarray analysis, the GO analysis indicated matrix metalloproteinase (MMP) family associated with 'collagen metabolic process' and 'multicellular organismal macromolecule metabolic process' as the two top biological processes. Brushing samples of patients with EAC showed up-regulated expression of decay-accelerating factors (DAF and CD55) and topoisomerase type Iiα (TOP2A), and down-regulated expression of the sodium channel epithelial 1 beta subunit (SCNN1B). CONCLUSIONS: The up-regulation of CD55 and TOP2A, and the down-regulation of SCNN1B were common to the brushing samples and might serve as molecular biomarkers for identifying EAC in patients with SSBE. TRIAL REGISTRATION: University Hospital Medical Information Network (UMIN) (000004004).

Chemotherapy-induced neutropenia as a prognostic factor in patients with pancreatic cancer treated with gemcitabine plus nab-paclitaxel: a retrospective cohort study.

OBJECTIVES: Chemotherapy-induced neutropenia (CIN) is a common adverse event of chemotherapy. Several reports have suggested that CIN could be an important prognostic factor in chemotherapy of various cancers. However, whether CIN is a prognostic factor in unresectable pancreatic cancer (PC) treated with gemcitabine plus nab-paclitaxel (GnP) is unknown. The primary endpoint of this study was to compare overall survival (OS) between patients with severe CIN (grade ≥ 3) and those with absent/mild CIN (grade ≤ 2) in unresectable PC cases treated with GnP as first-line chemotherapy. METHODS: A retrospective, cohort study was conducted using data from a computerized database. A total of 290 patients with pathologically confirmed PC treated with GnP as first-line chemotherapy were analyzed (severe CIN: ≥ grade 3, n = 174; absent/mild CIN: ≤ grade 2, n = 116). RESULTS: The median OS was longer in the severe CIN group than in the absent/mild CIN group (19.2 months vs 11.3 months, respectively; P < 0.001). After adjustment, severe CIN was an independent predictive factor for OS (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.38-0.74; P < 0.001). After adjustment by time-varying covariates, severe CIN was still a significant prognostic factor for OS (HR, 0.79; 95% CI 0.69-0.91, P = 0.001). CONCLUSION: The present results show that severe CIN is an independent and useful prognostic factor in PC patients treated with GnP.

Analysis of the colonic mucosa associated microbiota (MAM) using brushing samples during colonic endoscopic procedures.

The mucosa-associated microbiota is an important component in human microbiota. The aim was to investigate mucosa-associated microbiota using brush samples during endoscopic procedures and compare with fecal microbiota. Seven patients who were planning to undergo a routine colonoscopy were recruited. Mucosal brushing samples were taken from 3 sites (terminal ileum, ascending and sigmoid colon), and a fecal sample was taken on the morning of colonoscopy. The samples were immediately placed in microcentrifuge tubes containing DNA stabilization reagent and analyzed using the next generation sequencer. The individual differences in microbiota were more evident than the differences of the sampling sites. Actinobacteria was more abundant and Bacteroidetes was less in the brush samples than those in the fecal samples. Taxonomic composition at the genus level and the proportion of genes responsible for some functions in the brushing samples tended to be different from those in the fecal samples. Bulleidia and Oribacteriumi were significantly more abundant and the proportions of genes responsible for transcription factors and phosphotransferase system were higher in ileal mucous than those in fecal samples. Brushing during colonoscopic procedure instead of using feces samples might be useful to analyze mucosa-associated microbiota.

[Duodenal obstruction after transarterial embolization for rupture of a pancreaticoduodenal artery aneurysm due to segmental arterial mediolysis:a case report].

A man in his 60s visited a local clinic because of repeated bouts of intermittent epigastric and back pain since July 2017. He was referred to our department because of suspected acute abdomen. Contrast-enhanced computed tomography revealed an aneurysm in the anterior inferior pancreaticoduodenal artery, and a retroperitoneal hematoma was observed. Although no extravascular leakage of contrast medium was observed, rupture of the aneurysm was suspected based on his vital signs, which indicated a state of shock. Emergency arteriography and coil embolization were performed. After coil embolization, the hematoma started to decrease, and no recurrent bleeding was observed. However, on hospitalization day 10, mucosal edema of the descending limb of the duodenum, thought to be an ischemic change, was observed along with gastrointestinal obstruction. A stomach tube was placed, and the patient was treated with central venous hyperalimentation for approximately 3 weeks. Because the gastrointestinal contrast radiography performed on hospitalization day 30 indicated improvement in the obstruction, liquid diet was started. Subsequently, the patient's gastrointestinal obstruction gradually improved. He was discharged on hospitalization day 47. The cause of the aneurysm in the anterior inferior pancreaticoduodenal artery was segmental arterial mediolysis (SAM). SAM is a degenerative arterial disease of unknown etiology that mainly develops in the bifurcations of the abdominal aorta. It requires immediate attention because the formation of aneurysms due to SAM can cause rupture and sudden intraperitoneal cavity bleeding. The prognosis for visceral artery aneurysms is poor, with a mortality rate of approximately 50% for cases involving pancreaticoduodenal artery aneurysm rupture. However, we believe that our experience is remarkable, as we saved our patient's life with conservative treatment involving coil embolization. Duodenal mucosal edema due to ischemic changes after coil embolization was observed, but this condition improved with conservative treatment.

Persistent monoarthritis of the temporomandibular joint region enhances nocifensive behavior and lumbar spinal Fos expression after noxious stimulation to the hindpaw in rats.

Effects of persistent temporomandibular joint (TMJ) inflammation on nociceptive responses of remote bodily areas of the rat were investigated. Monoarthritis of the TMJ region was evoked by the injection of complete Freund's adjuvant (CFA) into the left TMJ region. Rats without injection of CFA into the TMJ region served as controls (non-CFA group). Time spent on licking behavior evoked by the injection of formalin into the left hindpaw and withdrawal thresholds of mechanical stimulation to both sides of the hindpaw were measured during TMJ inflammation for 3 weeks. Furthermore, expression of Fos protein in the lumbar dorsal horn was immunohistochemically investigated following the injection of formalin into the hindpaw during TMJ inflammation. Formalin-evoked nocifensive behavioral activities were significantly enhanced at 10 and 14 days after CFA injection in the late phase, while the withdrawal threshold to mechanical stimulation was significantly decreased bilaterally at 8, 10 and 14 days after CFA injection. Both formalin-evoked licking behavior and mechanical withdrawal thresholds to bilateral hindpaw at 21 days after CFA injection were similar to those in the non-CFA group. The number of Fos-positive neurons in the lumbar dorsal horn ipsilateral to the formalin injection at 1 and 7 days after CFA injection into the TMJ were similar to those in the non-CFA group; however, those were significantly increased in the laminae I-II and V-VI of the lumbar dorsal horn at 14 days after CFA injection. TMJ inflammation for 7 and 14 days alone produced a small number of Fos-expressing neurons in the lumbar dorsal horn. These results provide evidence that persistent unilateral inflammation of the TMJ region causes an increase in behavioral hyperalgesia of the hindpaw, which is attributed to the modulation of neural activities, in part, in the lumbar dorsal horn, likely mediated by supraspinal neural mechanisms.