Gastric Non-Hodgkin Lymphoma in a Helicobacter pylori-Infected Patient.

Primary gastric diffuse large B-cell lymphoma (PG-DLBCL) is a rare gastric malignant neoplasm. While the association between Heliobacter pylori infection and gastric mucosa-assisted lymphoid tissue lymphoma is well established, data supporting its association with DLBCL are less robust. Here we present a rare case of PG-DLBCL diagnosed with H. pylori. An 82-year-old man presented to clinic with complaints of worsening epigastric pain. He underwent an endoscopy which revealed 1 large nonbleeding gastric ulcer. Histopathological and immunohistochemical analysis confirmed PG-DLBCL. He was started on H. pylori eradication (HPE) and subsequently completed 6 cycles of R-mini-CHOP chemotherapy. Since then, the patient maintained clinical and radiological remission for more than a year without recurrence. PG-DLBCL is an aggressive Non-hodgkin lymphoma (NHL) that usually presents late. It has been shown that HPE without chemotherapy in DLBCL codiagnosed with H. pylori is not an effective strategy. Thus, the standard of care for patients would be HPE and chemotherapy as in our patient. More research is needed to better understand association between H. pylori and DLBCL.

Lumen-Apposing Metal Stent Used to Treat Malignant Esophageal Stricture.

Malignant esophageal strictures often require stent placement to alleviate dysphagia and improve quality of life. We present a novel application of a lumen-apposing metal stent to bypass a malignant esophageal stricture in the setting of altered gastric anatomy.

Migration of a Lumen-Apposing Metal Stent into the Colon.

The introduction of lumen-apposing metal stents (LAMS) has been an important development in the management of pancreatic fluid collections. Stent migration out of pancreatic fluid collections into the stomach has been reported, despite the special anti-migratory design of the bi-flanged stent. Data on stent migration rates remain sparse, with some studies suggesting a migration rate of 3.3-5%. There have been no reported cases of LAMS migration outside of the stomach. We describe the first reported case of a transgastric LAMS migrating from the stomach and passing into the colon.

Mincle suppresses Toll-like receptor 4 activation.

Regulation of Toll-like receptor responses is critical for limiting tissue injury and autoimmunity in both sepsis and sterile inflammation. We found that Mincle, a C-type lectin receptor, regulates proinflammatory Toll-like receptor 4 signaling. Specifically, Mincle ligation diminishes Toll-like receptor 4-mediated inflammation, whereas Mincle deletion or knockdown results in marked hyperresponsiveness to lipopolysaccharide in vitro, as well as overwhelming lipopolysaccharide-mediated inflammation in vivo. Mechanistically, Mincle deletion does not up-regulate Toll-like receptor 4 expression or reduce interleukin 10 production after Toll-like receptor 4 ligation; however, Mincle deletion decreases production of the p38 mitogen-activated protein kinase-dependent inhibitory intermediate suppressor of cytokine signaling 1, A20, and ABIN3 and increases expression of the Toll-like receptor 4 coreceptor CD14. Blockade of CD14 mitigates the increased sensitivity of Mincle(-/-) leukocytes to Toll-like receptor 4 ligation. Collectively, we describe a major role for Mincle in suppressing Toll-like receptor 4 responses and implicate its importance in nonmycobacterial models of inflammation.

TGF-ß Blockade Reduces Mortality and Metabolic Changes in a Validated Murine Model of Pancreatic Cancer Cachexia.

Cancer cachexia is a debilitating condition characterized by a combination of anorexia, muscle wasting, weight loss, and malnutrition. This condition affects an overwhelming majority of patients with pancreatic cancer and is a primary cause of cancer-related death. However, few, if any, effective therapies exist for both treatment and prevention of this syndrome. In order to develop novel therapeutic strategies for pancreatic cancer cachexia, appropriate animal models are necessary. In this study, we developed and validated a syngeneic, metastatic, murine model of pancreatic cancer cachexia. Using our model, we investigated the ability of transforming growth factor beta (TGF-ß) blockade to mitigate the metabolic changes associated with cachexia. We found that TGF-ß inhibition using the anti-TGF-ß antibody 1D11.16.8 significantly improved overall mortality, weight loss, fat mass, lean body mass, bone mineral density, and skeletal muscle proteolysis in mice harboring advanced pancreatic cancer. Other immunotherapeutic strategies we employed were not effective. Collectively, we validated a simplified but useful model of pancreatic cancer cachexia to investigate immunologic treatment strategies. In addition, we showed that TGF-ß inhibition can decrease the metabolic changes associated with cancer cachexia and improve overall survival.

An easily missed diagnosis: flank pain and nutcracker syndrome.

A 27-year-old woman presented to her primary care doctor's office with left flank pain. CT of the abdomen showed an isolated left renal vein thrombus. The clot was initially attributed to her oral contraceptive use; however, closer inspection of CT images revealed nutcracker phenomenon (compression of the renal vein between the superior mesenteric artery and abdominal aorta). Intravascular ultrasound imaging confirmed the diagnosis. Nutcracker syndrome is a rare condition, which if left untreated may cause damage to the left kidney. Although under diagnosed, there are several treatment options available ranging from simple surveillance to surgical resolution.