A case of recurrent massive thickening of the gastric wall caused by pancreatitis of the gastric ectopic pancreas: Detailed pathogenesis based on imaging.

A 40-year-old Japanese male presented with epigastric pain and loss of appetite at a general hospital three years ago. Computed tomography revealed massive thickening of the gastric wall, and gastroscopy revealed diffuse erythema and edematous thickening of the gastric mucosa. Thereafter, epigastric pain and gastric wall thickening recurred frequently, causing an inability to intake food. Conservative treatment was marginally effective; therefore, a distal gastrectomy was performed. Postoperatively, the patient resumed food intake without complications. Histopathological examination of the surgical specimen revealed Heinrich type 1 gastric ectopic pancreas (EP) with pancreatitis. In this case, the gastric wall's massive thickening was caused by gastric EP's pancreatitis. Although there are some reports of pancreatitis of gastric EP, there are no detailed reports of endoscopic findings, including endoscopic ultrasonography and the disease progression. Recurrent pancreatitis of EP leads to forming a septum within the gastric wall, resulting in a hematoma. Eventually, irreversible narrowing of the gastric lumen may occur, as observed in the present case. We consider this an important case report presenting detailed pathogenesis supported by endoscopic and pathohistological findings of surgical specimens. Our study will help in the early diagnosis and better management of the condition.

A Case Series of Radiation-induced Hemorrhagic Gastroduodenitis.

Objective We examined the clinical course and treatment method of a case series of radiation-induced hemorrhagic gastroduodenitis with clinical signs. Methods This was a single-center retrospective observational study. Patients We included seven patients with radiation-induced hemorrhagic gastroduodenitis treated at our hospital between April 2014 and May 2020. Results One male patient each had cancer of the head of the pancreas, bile duct cancer, hepatocellular carcinoma, and ureteral cancer, whereas two women had recurrent endometrial cancer and one woman had recurrent cervical cancer. The onset occurred 3-5 months after the end of radiation treatment. Endoscopic examinations showed a red edematous mucous membrane in a fragile condition stretching from the antrum of the stomach to the duodenum, with telangiectasia and ulcer. For endoscopic hemostasis, five patients underwent argon plasma coagulation (APC), which was successful in three patients. Two of these were being administered an antithrombotic at the time. One case resistant to conservative treatment required repeated transfusion for recurring hemorrhaging over a short period of time and therefore underwent surgical treatment. Thereafter, the postoperative course was favorable. Conclusions Actively attempting hemostasis through APC and surgery is effective for treating radiation-induced hemorrhagic gastroduodenitis. The use of an antithrombotic agent might lead to a risk of repeated hemorrhaging. Therefore, repeated hemostasis through APC is crucial.

Massive Ascites Caused by Primary Diffuse Large B-cell Lymphoma of the Jejunum: A Case of a Rare Initial Symptom.

A 74-year-old man presented with abdominal swelling. Computed tomography revealed massive ascites and localized thickening of the small intestinal wall. Enteroscopy showed ulcerative lesions along the circumference of the jejunum. Histological examination showed dense proliferation of large lymphoid atypical cells, and immunohistochemistry showed CD20 and CD10 positivity, CD3 negativity, and Ki67 labeling index >80%. Cytology of the ascitic fluid revealed large lymphoid cells. These findings suggest that small intestine primary diffuse large B-cell lymphoma (DLBCL) caused the ascites. Massive ascites as an initial symptom of primary DLBCL of the jejunum is rare. Herein, we describe this unusual presentation.

Prevalence and Clinical Implications of the Mirror and TV Signs in Advanced Alzheimer's Disease and Dementia with Lewy Bodies.

OBJECTIVE: To explore the prevalence and clinical implications of the mirror and TV signs in the moderate to advanced stages of Alzheimer's disease (AD) and dementia with Lewy bodies (DLB). METHODS: We retrospectively examined the prevalence of clinical and psychiatric symptoms including the mirror and TV signs in 200 subjects with AD and 200 with DLB and evaluated the relationships among the symptoms. RESULTS: The mirror sign was found in 3.0% of AD and 4.5% of DLB subjects. The TV sign was found in 1.5% of AD and 4.0% of DLB subjects. The prevalence of the mirror and TV signs was not significantly different between the AD and DLB groups. Visual hallucination, visual illusion, misidentification of person, and sleep talking were significantly more frequent in DLB than in AD subjects. The mirror sign was significantly associated with lower Mini-Mental State Examination scores, whereas the TV sign was significantly associated with the misidentification of person. CONCLUSIONS: Both the mirror and TV signs were rare even in the moderate to advanced stages of AD and DLB. The mirror sign may be independent from other delusional misidentification syndromes (DMSs). Being associated mainly with global cognitive decline, the mirror sign is unlikely attributed to any specific cognitive impairment or the dysfunction of localized brain areas. In contrast, the TV sign was significantly more often coexistent with the misidentification of person, suggesting that the TV sign may partly share common neuropsychological mechanisms with DMSs.

Endoscopic Evaluation of Neoadjuvant Chemotherapeutic Efficacy in Gastric Cancer before Gastrectomy Might be as Useful as Histological Assessment after Gastrectomy.

BACKGROUND: Neoadjuvant chemotherapy for advanced gastric cancer is expected to improve prognoses. However, as there is no method to evaluate neoadjuvant chemotherapeutic efficacy before gastrectomy, some patients at high risk for a poor prognosis undergo gastrectomy. The aim of the present study was to investigate whether endoscopy could be useful for assessing the efficacy of neoadjuvant chemotherapy. METHODS: In this retrospective study, we analyzed the data of 41 patients who received neoadjuvant chemotherapy followed by gastrectomy at our institution to investigate whether responsiveness to neoadjuvant chemotherapy, as assessed with endoscopy, can serve as a surrogate marker for histological grades 1b or higher in the Japanese Classification of Gastric Carcinoma (JCGC) scheme. RESULTS: There were 32 (78.0%) responders and 9 (22.0%) nonresponders to neoadjuvant chemotherapy, as observed in endoscopic evaluations. Among the endoscopic responders, 24 (75.0%) had cancer of histological grade 1b or higher, and 15 (46.9%) had cancer of grade 2 or higher. Among the endoscopic nonresponders, 1 (11.1%) patient had histological grade 1b cancer. Compared with endoscopic nonresponders, endoscopic responders were more likely to show a histological response (chi-square test: p = 0.0005 for JCGC grade 1b or higher; p = 0.0099 for JCGC grade 2 or higher). CONCLUSIONS: Most endoscopic responders showed JCGC histological responses. Evaluation of neoadjuvant chemotherapeutic efficacy by endoscopy in gastric cancer may be useful before gastrectomy. As this was a retrospective study, further investigations are required. The protocol was approved by the ethics review committee at Osaka Medical College (No. 2422) and was registered in the University Hospital Medical Information Network Clinical Trial Registry (UMIN000033088).

Massive Bleeding from a Small Intestinal Submucosal Tumor-like Arterial Malformation: An Unclassifiable Vascular Lesion Revealed by a Detailed Pathological Evaluation.

A 53-year-old woman presented with repeated copious bloody stool. Small bowel capsule endoscopy revealed a submucosal tumor (SMT)-like lesion, with erosion of the surface, in the first third of the small bowel. Balloon-assisted small intestinal endoscopy also revealed a pulsatile SMT-like lesion with an exposed vessel on the surface. This unknown lesion was surgically resected. The histopathological findings of the resected SMT-like lesion showed a dilated artery with thrombosis blockage and recanalization. Since this case could not be classified as any of the small intestinal vascular lesion patterns endoscopically, its classification will require the accumulation of further cases.

Superficial non-ampullary duodenal cancer identified by small-bowel capsule endoscopy: a case report (with video).

Herein, we report for the first time a case of a surficial superficial non-ampullary duodenal cancer causing obscure intestinal bleeding that was identified by small-bowel capsule endoscopy and treated by endoscopic mucosal resection. A 73-year-old man underwent upper gastrointestinal endoscopy to identify the cause of anemia. Although conventional duodenoscopy revealed a flat, elevated 5-mm lesion with a central recess and "milk-white mucosa" at the inferior duodenal angulus, capsule endoscopy revealed a white nodular 5-mm lesion with central recess at the duodenum slightly to the anal side from the major duodenal papilla. Pathohistological examination revealed a low-grade well-differentiated tubular adenocarcinoma growing locally in the mucosal layer. Although capsule endoscopy detected a nodular lesion, conventional endoscopy revealed a flat, elevated lesion. The cause of this difference in endoscopic findings is considered to be the degree of extension of the intestinal mucosa. In contrast, "milk-white mucosa" as a typical finding of superficial duodenal tumor in conventional endoscopy could be identified as a white mucosal color tone in capsule endoscopy. Conventional endoscopic findings of irregular surface structure in the lesion suggested malignancy. Pathohistologically, the ductal structure of the adenocarcinoma was also distorted. Unfortunately, it was difficult to suggest that the lesion was adenocarcinoma based on the endoscopic findings alone.

Intestinal endometriosis combined with colorectal cancer: a case series.

BACKGROUND: Intestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract. CASE PRESENTATION: This case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4). CONCLUSIONS: Therefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

Mucinous Balls Tangled With Mesothelial Cells and MUC2-Positive Cancer Cells in the Ascites of Pseudomyxoma Peritonei.

Pseudomyxoma peritonei (PMP) is characterized by extensive mucinous ascites following rupture of mucinous neoplasms of an intra-abdominal origin, and contain secreted gel-forming mucins such as MUC2 and MUC5AC. We encountered a 66-year-old Japanese man complaining of abdominal distension. Ascites at the site was gelatinous upon gross examination, and needle aspirate smears showed histiocytes and many mucinous balls wrapped in spindle cells, which were positive for vimentin, pan-cytokeratin, and podoplanin. The cell block showed several adenocarcinoma clusters, which were positive for MUC2, MUC5AC, CK20, and CDX-2, and negative for CK7. From these findings, a diagnosis of PMP arising from colon cancer was indicated. Cytoreductive surgery was performed, and the cystic diverticulum was found to be infiltrated by tumor cells in the sigmoid colon that caused PMP. Mucinous balls surrounded by mesothelial cells and MUC2-positive adenocarcinoma cells are useful clues in the diagnosis of PMP. Diagn. Cytopathol. 2016;44:628-631. © 2016 Wiley Periodicals, Inc.

Predictors of lymph node metastasis in T1 colorectal carcinoma: an immunophenotypic analysis of 265 patients.

BACKGROUND: The appropriateness of endoscopic resection in patients with T1 colorectal carcinomas is unclear. Highly precise predictors of lymph node metastasis are required to optimize the outcomes of treatments for T1 colorectal carcinomas. OBJECTIVE: The purpose of this work was to identify predictors of lymph node metastasis by examining the clinicopathologic significance of immunophenotypes found in T1 colorectal carcinomas. DESIGN: This was a retrospective study. SETTINGS: The study was conducted at a university hospital. PATIENTS: Included were 265 patients with T1 colorectal carcinoma who underwent radical surgery. INTERVENTIONS: Patients with T1 colorectal carcinoma were managed. MAIN OUTCOME MEASURES: Immunophenotypes were associated with various clinicopathologic parameters, and CD10 expression was strongly associated with lymph node metastasis. RESULTS: The levels of MUC2, MUC5AC, and CD10 expression were individually significantly associated with tumor location, growth pattern, histologic type, invasive potential, and metastatic potential. The incidence of lymph node metastasis was significantly associated with each of the 5 following parameters: depth of submucosal invasion (p = 0.005), tumor budding (p < 0.001), lymphatic invasion (p < 0.001), MUC2 expression (p = 0.006), and CD10 expression (p < 0.001). Multivariate analysis showed that CD10 expression (OR, 9.2 [95% CI, 2.5-39.8]; p = 0.001) and lymphatic invasion (OR, 6.3 [95% CI, 2.5-17.7]; p < 0.001) were independently associated with lymph node metastasis. LIMITATIONS: This study was limited by its small sample size, intraobserver variation attributed to immunohistochemical staining, and potential selection bias because surgically resected specimens were collected instead of endoscopically resected specimens. CONCLUSIONS: We suggest that CD10 expression is closely associated with lymph node metastasis in T1 colorectal carcinoma.

Pathological factors related to lymph node metastasis of submucosally invasive gastric cancer: criteria for additional gastrectomy after endoscopic resection.

BACKGROUND: There are currently no universally accepted indications and criteria for additional gastrectomy after endoscopic resection of submucosally invasive cancer. The purpose of the present study was to establish accurate indications and criteria for such additional gastrectomy on the basis of lymph node metastasis risk. METHODS: We investigated 130 submucosally invasive gastric cancers and analyzed the pathological risk factors for lymph node metastasis. The tumors were evaluated for pathological factors in the area of invasion, and factors were compared between the cases with lymph node metastasis and those without. RESULTS: Univariate logistic regression analysis showed that tumor minor axis length, depth of invasion, histological classification of the area of submucosal invasion, absence of lymphoid infiltration, ulceration or scar in the lesion, and lymphatic and venous invasion are statistically significant risk factors for lymph node metastasis. Multivariate logistic regression analysis showed that the absence of lymphoid infiltration and the presence of lymphatic invasion are statistically significant as risk factors for lymph node metastasis. CONCLUSIONS: We present a scoring system on the basis of the pathological criteria tested in this study. Our findings enable more accurate identification of patients who should undergo additional gastrectomy after endoscopic resection.

Frequent somatic mosaicism of NEMO in T cells of patients with X-linked anhidrotic ectodermal dysplasia with immunodeficiency.

Somatic mosaicism has been described in several primary immunodeficiency diseases and causes modified phenotypes in affected patients. X-linked anhidrotic ectodermal dysplasia with immunodeficiency (XL-EDA-ID) is caused by hypomorphic mutations in the NF-κB essential modulator (NEMO) gene and manifests clinically in various ways. We have previously reported a case of XL-EDA-ID with somatic mosaicism caused by a duplication mutation of the NEMO gene, but the frequency of somatic mosaicism of NEMO and its clinical impact on XL-EDA-ID is not fully understood. In this study, somatic mosaicism of NEMO was evaluated in XL-EDA-ID patients in Japan. Cells expressing wild-type NEMO, most of which were derived from the T-cell lineage, were detected in 9 of 10 XL-EDA-ID patients. These data indicate that the frequency of somatic mosaicism of NEMO is high in XL-ED-ID patients and that the presence of somatic mosaicism of NEMO could have an impact on the diagnosis and treatment of XL-ED-ID patients.

Study of clinicopathological factors associated with the occurrence of synchronous multiple gastric carcinomas.

BACKGROUND: Multiple gastric carcinomas often arise in gastric mucosa with chronic gastritis, particularly severe intestinal metaplasia. In regard to such characteristics, several clinicopathological risk factors for multiple carcinomas have been reported, but no clinically useful criteria are available at present for assessing the onset of multiple gastric carcinomas. If the risk for multiple gastric carcinomas could be accurately assessed, efficient and accurate surveillance could be performed following minimally invasive therapies. METHODS: In the present study, we investigated clinicopathological differences between 94 cases of multiple early gastric carcinomas and 285 cases of solitary early gastric carcinoma. We tested 379 specimens of gastric carcinomas that had been surgically resected at the Department of General and Gastroenterological Surgery of Osaka Medical College, Japan, from April 1999 to December 2006. RESULTS: Univariate analysis of clinicopathological factors in the present study showed that multiple gastric carcinomas were significantly correlated to old age (> or =65 years), well- and moderately differentiated histological type, mucin phenotype (intestinal type), distribution of atrophic mucosa in the stomach (severe), degree of intestinal metaplasia in the surrounding mucosa (severe), and heterotopic glandular cysts. Multivariate analysis using the stepwise method identified age (> or =65 years) and degree of intestinal metaplasia in the surrounding mucosa (severe) as significant independent risk factors for multiple gastric carcinomas. CONCLUSION: While other studies have shown risk factors for multiple gastric carcinomas, the present study is unique in showing risk assessment criteria based on a combination of risk factors for multiple gastric carcinomas.

Tryptophol induces death receptor (DR) 5-mediated apoptosis in U937 cells.

Tryptophol is a natural component isolated from vinegar produced from the boiled extract of black soybean. We have reported that tryptophol induces apoptosis in U937 cells via activation of caspase-8 followed by caspase-3. Tryptophol, however, did not affect human peripheral blood lymphocytes (PBL). In this study, we found that tryptophol enhances formation of a death-inducing signaling complex including death receptor (DR) 5. Cell viability and induction of apoptosis by tryptophol was reduced by transfection with decoy receptor (DcR) 1. These results indicate that tryptophol induces apoptosis through DR5 and that the resistance of PBL to tryptophol-induced apoptosis might be due to competition from DcR1.

Isolation of tryptophol as an apoptosis-inducing component of vinegar produced from boiled extract of black soybean in human monoblastic leukemia U937 cells.

We isolated a novel apoptosis-inducing component, tryptophol, from vinegar produced from boiled extract of black soybean (black soybean vinegar). Compound-6 purified from an ethyl acetate extract of black soybean vinegar using high performance liquid chromatography (HPLC) induced fragmentation of DNA and the development of apoptotic bodies (characteristic physiological features of apoptosis) in U937 cells. By analysis of chemical structure, this active compound was identified as tryptophol. Tryptophol induced apoptosis involving caspase-8 and -3 activation, followed by cleavage of poly (ADP-ribose) polymerase (PARP), as shown by measurement of enzyme activity and immunoblot analysis. The cell viability of normal lymphocytes separated from human blood was less affected by tryptophol, and fragmentation of DNA was not induced in normal lymphocytes. These results indicate that tryptophol isolated from black soybean vinegar inhibited the proliferation of U937 cells by inducing apoptosis via a pathway involving caspase-8 followed by caspase-3, without affecting normal lymphocytes.

Neuroendocrine carcinoma of the liver associated with dermatomyositis: autopsy case and review of the literature.

Reported herein is an autopsy case of primary hepatic neuroendocrine carcinoma associated with dermatomyositis. A 71-year-old Japanese man, who was diagnosed with dermatomyositis 5 months before death, had multiple tumors within a non-cirrhotic liver. Histopathologically, the tumors were composed of small- and medium-sized round cells with clear cytoplasm arranged in nests, sheets or rosettes. Immunohistochemically, the tumor cells were positive for chromogranin A, neuron-specific enolase and CD56 and were negative for synaptophysin. This tumor was diagnosed as a primary hepatic neuroendocrine carcinoma with metastasis to the lung, gallbladder and lymph nodes around the pancreas and aorta; no primary lesions were detected in any other organ. The tumor cells were also positive for cytokeratin 7, cytokeratin 19 and epithelial membrane antigen but were negative for anti-hepatocyte antibody and AFP. These findings suggest that the tumor originated in intrahepatic bile duct epithelium. Various cancers have been reported in patients with dermatomyositis, but only seven cases of dermatomyositis associated with primary liver cancer have been reported. To the best of the authors' knowledge, this is the first report of dermatomyositis associated with primary hepatic neuroendocrine carcinoma.

A case of primary ductal adenocarcinoma of the lacrimal gland: histopathological and immunohistochemical study.

We encountered primary ductal adenocarcinoma of the lacrimal gland in a 67-year-old Japanese man. To the best of our knowledge, only three cases of primary ductal adenocarcinoma of the lacrimal gland have been reported in the literature. The patient was admitted because of visual disturbance, and a mass measuring about 3 cm in diameter was revealed in the right orbit. The mass was resected, and primary ductal adenocarcinoma of the lacrimal gland was diagnosed histopathologically. He died from recurrence at the primary site and metastasis to the brain, lungs, liver, common bile duct, and pancreas 2 years and 10 months after surgery although adjunctive orbital radiotherapy was given. Immunohistochemically, the characteristics of cancer cells were similar to those of salivary duct carcinoma, namely positivity for cytokeratin (CK) 7, 10, 17, 18, 19, and 34betaE12, and negativity for CK20. It was not clear whether the ductal adenocarcinoma originated from the ductal or acinar epithelium of the lacrimal gland, because the immunohistochemical features of both epithelia were identical.

X-linked ectodermal dysplasia and immunodeficiency caused by reversion mosaicism of NEMO reveals a critical role for NEMO in human T-cell development and/or survival.

X-linked ectodermal dysplasia and immunodeficiency (XL-EDA-ID) is an X-linked recessive disease caused by a mutation in the nuclear factor-kappaB (NF-kappaB) essential modulator (NEMO). Here we report an XL-EDA-ID patient with atypical features of very few naive-phenotype T cells and defective mitogen-induced proliferation of peripheral blood mononuclear cells (PBMCs). The patient's NEMO defect was diagnosed by flow cytometric analysis of intracellular NEMO staining. Specific cell lineages (monocytes and neutrophils) expressed reduced levels of NEMO, but 2 populations of T, B, and NK cells were detected with normal and reduced expression of NEMO. Genomic analysis revealed that duplication of a 4.4-kb sequence ranging from intron 3 to exon 6 caused the reduced expression of NEMO. Polymorphism analysis showed that the patient's B- and T-cell lines with reduced and normal expression of NEMO had the same X chromosome, indicating that the somatic mosaicism was not due to fetomaternal transfusion but was most likely due to postzygotic reversion. This XLEDA-ID case adds to our understanding of NEMO biology, indicating that NEMO is critical for T-cell development and/or survival in humans as well as in mice.