[Symptoms of Cancer Patients and Kampo Formulas Effective for Them].

Patients with cancer exhibit various symptoms induced by cancer itself and its therapy leadingto fatigue; however, their vital energy can be restored by administration of Kampo, which is a traditional Japanese herbal medicine. Restoration and maintenance of mental and physical energy are important for successful cancer treatment. For this purpose, appropriate use of Kampo formulas, such as"Ho-zai", formulas to vitalize fatigued patients (eg, Hochu-ekki-to, Juzen-taiho-to, Ninjin-yoeito), "Hojin-zai", formulas to restore energy (eg, Gosha-jinki-gan), and"Kuoketsu-zai ", formulas to resolve stagnant blood flow (eg, Keishi-bukuryo-gan, Tokaku-joki-to, Toki-shakuyaku-san) are administered in combination. Consequently, basic autonomic functions, such as appetite, sleep, defecation, and urination normalize and the nutritional and mental conditions are restored. These favorable changes in the patients' condition allow completion of the standard cancer therapy course, resultingin an improved outcome of cancer therapy and successful treatment. Kampo therapy can be administered as the final treatment option for patients with last-stage cancer who do not have any other effective therapy options. If patients with cancer are administered Kampo formulas, their vital energy is restored, and they develop a will to fight the cancer. As a result, communication becomes easier.

Simultaneous endoscopic submucosal dissection for synchronous double early gastric cancer.

BACKGROUND: This study aims to evaluate the safety and efficacy of simultaneous endoscopic submucosal dissection (ESD) for synchronous double early gastric cancers. METHODS: We retrospectively evaluated 832 single gastric cancers from 789 patients treated by single ESD (single group) and 124 synchronous double cancers from 62 patients treated by simultaneous ESD (simultaneous group). RESULTS: The overall rate of en bloc resection and curative resection was comparable between the two groups. Procedure time was significantly longer in the simultaneous group than in the single group (131.0 ± 66.5 and 94.8 ± 64.1 min, respectively, P < 0.001). White blood cell count on the day after ESD was significantly higher in the simultaneous group (9310 ± 2774/µl) than in the single group (8633 ± 2341/µl) (P = 0.032). Length of fasting period after ESD was 1.1 ± 0.5 days in the single group and 1.4 ± 1.1 days in the simultaneous group (P = 0.082). Complications were more frequent in the simultaneous group than in the single group (11.3 vs. 5.4 %, respectively), but the difference was not significant (P = 0.082). Complication rate per one lesion did not differ between the two groups (5.6 vs. 5.4 %, respectively, P = 0.914). Multivariate analysis showed procedure time longer than 150 min was independently predictive for complications of simultaneous ESD (P < 0.042, odds ratio = 6.094). Large tumors, upper portion location and tumors not in the standard guideline criteria were significantly associated with long procedure time. CONCLUSIONS: Simultaneous ESD for synchronous early gastric cancer can be a feasible and safe option, and it can reduce hospital stay. These results need to be validated by further studies.

Safety, efficacy, and long-term outcomes for endoscopic submucosal dissection of early esophagogastric junction cancer.

BACKGROUND: Early esophagogastric junction (EGJ) cancer is currently being treated in the same way as early gastric cancer, by endoscopic submucosal dissection (ESD), but long-term outcomes are still unknown. Our aim was to retrospectively evaluate the safety and efficacy of ESD in treating early EGJ cancer and compare risk factors in curative and non-curative resection cases. METHODS: Forty-four cases of early EGJ cancer, defined as a Siewert's type II tumor, in 44 patients with a mean age of 70.0 years and a male/female ratio of 90.9:9.1 % were treated by ESD between January 2004 and June 2010. There were 30 standard indication cases; the remaining 14 cases were expanded indication cases. RESULTS: Mean resected specimen and tumor sizes were 35 and 17 mm, respectively, and median procedure time was 121 min, with no bleeding or perforation complications. All cases were resected en bloc with an 84.1 % curative resection rate (37/44). The curative resection rates in the standard and expanded indication cases were 90.0 % (27/30) and 71.4 % (10/14), respectively. There were no significant differences in tumor location, tumor morphology, tumor size, histology of biopsy specimens, or standard versus expanded indication cases with regard to risk factors for curative and non-curative resections. However, submucosal invasion, positive tumor margins, lymphovascular invasion, and some components of poorly differentiated adenocarcinomas in just the submucosal layer were significantly more common in the non-curative resection cases. CONCLUSIONS: ESD was a safe, effective, and minimally invasive treatment for early EGJ cancer. For tumors without any submucosal invasion findings, therefore, ESD is an acceptable treatment option, in addition to also being suitable for diagnostic purposes in evaluating the need for surgery.

Diagnosis of laterally spreading tumors (LST) in the rectum and selection of treatment: characteristics of each of the subclassifications of LST in the rectum.

BACKGROUND: In recent years, endoscopic submucosal dissection (ESD) has often been used for the treatment of laterally spreading tumors (LST) of the rectum. The present study was carried out with the aim of clarifying the characteristics of each of the subtypes of LST in the rectum that are often treated by ESD. PATIENTS AND METHODS: This study involved 141 rectal LST that were initially treated at our hospital between March 2005 and December 2010 and whose endoscopic images and histopathological specimens could be re-examined. The LST were divided into LST-G-H (homogeneous type), LST-G-MIX (nodular mixed type), LST-NG-F (flat type) and LST-NG-PD (pseudo-depressed type) type lesions, and tumor diameter and depth of invasion of each of these tumor types were investigated. RESULTS: Regarding the depth of invasion, the proportion of submucosa-massive (SM-m) lesions was high in the LST-NG-PDtumors, even among tumors measuring <20 mm in diameter; both the rate of cancer and proportion of SM-m lesions were significantly higher in the LST-NG-PD tumors than in the LST-NG-F tumors (P < 0.05). In both LST-NG-MIX and LST-NG-PD tumors, the proportion of SM-m lesions was significantly higher in the lower rectum than in the upper rectum (P < 0.05). CONCLUSION: For LST of the rectum (particularly of the lower rectum), it is necessary to carefully select the treatment considering LST subclass and tumor diameter from the standpoint of the presence of malignancy, quality of life, and prognosis of patients.

Clinical characterization of gastric lesions initially diagnosed as low-grade adenomas on forceps biopsy.

AIM: The aim of this study was to elucidate characteristics of gastric lesions that are initially diagnosed as low-grade adenomas and to establish appropriate treatment. METHODS: We retrospectively reviewed 231 lesions initially diagnosed as gastric adenomas. All forceps biopsy samples were histologically diagnosed as category 3 low-grade adenomas according to the revised Vienna Classification. All patients underwent endoscopic resection with endoscopic findings and post-resection diagnoses evaluated subsequently. RESULTS: Sixty-three lesions were initially diagnosed as depressed adenomas, and 168 lesions were diagnosed as protruding adenomas. The depressed lesions were significantly smaller (11.6 ± 5.0 mm) than the protruding lesions (17.0 ± 10.8 mm) (P < 0.001). Diagnoses reclassified to category 4 mucosal high-grade neoplasia (i.e. high-grade adenoma, adenocarcinoma in adenoma and adenocarcinoma) were more frequent among depressed lesions (52.4%) than among protruding lesions (31.0%) (P = 0.004). Multivariate analysis of all 231 lesions showed that lesion size larger than 20 mm (P < 0.001) and depressed appearance (including central depression) (P < 0.001) were significant independent factors suggesting cancer. For the 168 protruding lesions, lesion size larger than 20 mm (P < 0.001) and central depression (P < 0.001) were significant independent factors suggesting cancer. For the 63 depressed lesions, lesion size larger than 15 mm (P = 0.016) and a moth-eaten appearance (P = 0.017) were significant independent factors in the pre-treatment diagnosis of cancer. CONCLUSIONS: Adenocarcinoma lesions were often found in depressed lesions and protruding lesions with central depression. Endoscopic resection for total biopsy is recommended, even if forceps biopsy indicates low-grade adenoma, as pre-treatment biopsy may be inadequate for an accurate histological diagnosis.

Sporadic nonampullary duodenal adenoma in the natural history of duodenal cancer: a study of follow-up surveillance.

OBJECTIVES: Although sporadic nonampullary duodenal adenoma (SNDA) is regarded as a precancerous lesion, its natural course is uncertain. The aim of this study was to evaluate the risk of development of adenocarcinoma in SNDA lesions initially diagnosed as showing low-grade dysplasia (LGD; category 3) or high-grade dysplasia (HGD; category 4.1). METHODS: We analyzed 68 SNDAs, diagnosed based on initial and subsequent biopsies, in 66 consecutive patients. Of these, 46 (43 LGD lesions, 3 HGD lesions) were followed up for ≥6 months without treatment (mean 27.7±16.9 months; range 6-72 months), including 8 lesions that were eventually resected during follow-up. Sixteen lesions (eight LGD lesions, eight HGD lesions) were resected immediately, either endoscopically or surgically, and six lesions were excluded because of a short follow-up (<6 months). The histopathological diagnoses and macroscopic changes were evaluated. RESULTS: Among the 43 LGD lesions followed up for ≥6 months, 34 (79.1%) showed no histopathological changes during follow-up, whereas the remaining 9 (20.9%) showed progression to HGD, including 2 (4.7%) that progressed eventually to noninvasive carcinoma (category 4.2). Macroscopically, 76.7% (33 of 43) of the LGD lesions showed no notable changes in size, 16.3% (7 of 43) became undetectable, 4.7% (2 of 43) reduced in size, and 2.3% (1 of 43) became larger in size. In contrast, all the three HGD lesions that were followed up for ≥6 months remained unchanged histologically, based on biopsy, and showed no notable macroscopic changes, although one of these HGD lesions resected endoscopically revealed evidence of noninvasive carcinoma. Although we diagnosed all lesions as HGD from biopsy samples, a high percentage of cancers (54.5%, 6 of 11) were diagnosed from resected specimens. A multivariate analysis identified HGD diagnosed at first biopsy and a lesion diameter of ≥20 mm as being significantly predictive of progression to adenocarcinoma. CONCLUSIONS: LGD lesions show a low risk of progression to adenocarcinoma, but some risk of progression to HGD, which warrants careful follow-up biopsy. However, HGD lesions and large SNDAs≥20 mm in diameter show a high risk of progression to adenocarcinoma. Therefore, they should be treated immediately.

Diagnosis of undifferentiated type early gastric cancers by magnification endoscopy with narrow-band imaging.

BACKGROUND AND AIMS: The diagnostic use of magnification endoscopy with narrow-band imaging (ME-NBI) to assess histopathologically undifferentiated-type early gastric cancers (UD-type EGCs) is not well elucidated. The purpose of this study was to examine the comparative relationship between ME-NBI images and histopathological findings in UD-type EGCs. METHODS: We analyzed 78 consecutive cases of UD-type EGCs ≤ 20 mm in diameter that underwent ME-NBI ≤ 2 weeks prior to resection. The ME-NBI images were compared with histopathological findings following either endoscopic submucosal dissection (ESD) or surgery. Applying the comparative results, we prospectively evaluated the success of identifying the lateral extent of UD-type EGCs resected by ESD in additional consecutive cases. RESULTS: Lesions with preserved but irregular surface microstructures (S-type based on ME-NBI) showed mucosal atrophy and corresponded histologically to the non-whole-layer type of intramucosal cancer (24/24, 100%). Lesions with an irregular microvasculature type (V-type, for example, corkscrew pattern) or mixed type upon ME-NBI corresponded histopathologically to the non-whole-layer type of intramucosal cancer (15/54, 27.8%), the whole-layer type of intramucosal cancer (27/54, 50.0%) or submucosal (sm) invasion cancer (12/54, 22.2%). Applying these comparative results, we used ME-NBI to successfully predict the lateral extent of cancer, which corresponded to the histopathological lateral extent in all 18 additional consecutive UD-type EGCs resected by ESD. CONCLUSIONS: ME-NBI images of UD-type EGCs were very closely related to the histopathological findings. Thus, ME-NBI can be useful in the pretreatment assessment of the histopathological patterns of cancer development and the lateral extent of such lesions.

Endoscopic ultrasonography is valuable for identifying early gastric cancers meeting expanded-indication criteria for endoscopic submucosal dissection.

BACKGROUND: Endoscopic ultrasonography (EUS) has become a reliable method for predicting the invasion depth of early gastric cancer (EGC). This study evaluated the accuracy of EUS in identifying lesions meeting expanded-indication criteria for endoscopic submucosal dissection (ESD) and analyzed clinicopathologic factors influencing the diagnostic accuracy of EUS in assessing tumor invasion depth. METHODS: This study investigated 542 EGCs of 515 patients who underwent EUS pretreatment. The pretreatment EUS-determined diagnosis was compared with the final histopathologic evaluation of resected specimens, and the impact of various clinicopathologic parameters on diagnostic accuracy was analyzed. RESULTS: The diagnostic accuracy of EUS in identifying lesions meeting expanded-indication criteria for ESD was 87.8% (259/295) for differentiated adenocarcinoma (D-type) 30 mm in diameter or smaller, 43.5% (10/23) for D-type tumor larger than 30 mm in diameter, and 75% (42/56) for undifferentiated adenocarcinoma (UD-type) 20 mm in diameter or smaller. Using multivariate analysis, the diagnostic accuracy of EUS in predicting tumor invasion depth was determined to be decreased significantly by ulcerous change and large tumor size (diameter, ≥30 mm). CONCLUSION: For patients with EGC, D-type lesions 30 mm in diameter or smaller and UD-type lesions 20 mm in diameter or smaller can be diagnosed with high accuracy by EUS, but larger D-type lesions (diameter, >30 mm) should be considered carefully in terms of EUS-based treatment decisions. Findings of ulceration and large tumors are associated with incorrect diagnosis of tumor invasion depth by EUS.

Risk factors for delayed bleeding after endoscopic submucosal dissection for gastric neoplasm.

BACKGROUND: Delayed bleeding is one of the major complications of endoscopic submucosal dissection (ESD). The aim of this study is to determine the incidence rate and clinical factors associated with delayed bleeding, as well as the time interval between bleeding and ESD for gastric neoplasm. METHODS: We investigated 647 lesions in 582 consecutive patients undergoing ESD for gastric neoplasm. RESULTS: Delayed bleeding after ESD was evident in all 28 lesions from 28 patients (4.33% of all specimens, 4.81% of patients), and all achieved endoscopic hemostasis. Resected specimen width (≥40 mm) was the only significant factor associated with delayed bleeding on univariate and multivariate analysis. In early delayed bleeding (bleeding occurring on or before the fourth postoperative day), wide resected specimen and tumor location in the lower third of the stomach were significant risk factors. In late delayed bleeding (bleeding occurring after the fifth operative day), wide resected specimen, tumor location in the middle third of the stomach, hypertension, and high body mass index (≥25 kg/m(2)) were significant factors. Delayed bleeding in patients with tumors in the upper and middle third of the stomach (median 8.0 days; range 1-20 days) occurred significantly later as compared with patients who had tumors in the lower third (median 2.0 days; range 1-34 days). CONCLUSIONS: Risk factors for delayed bleeding, and the probable underlying mechanism involved, differed depending on the time elapsed between surgery and the bleeding episode.

Expansion of indications for endoscopic treatment of undifferentiated mucosal gastric cancer: analysis of intramucosal spread in resected specimens.

PURPOSE: The aim of this study was to pathologically investigate the developmental pattern of undifferentiated mucosal gastric cancer and to determine safe surgical margins for curative resection by endoscopic resection. RESULTS: Intramucosal cancer spread, or the width of the proliferative zone, was pathologically investigated in 47 cases of undifferentiated mucosal gastric cancer of size 20 mm or smaller without ulceration (scars). The 47 cases comprised 40 IIc and 7 IIb cases. The IIc cases consisted of 5 (12.5%) of intermediate-layer type (cancer localized at the intermediate layer of the mucosa), 31 (77.5%) of superficial type, and 4 of whole-layer type (10%). The IIb cases consisted of six of intermediate-layer type (85.7%) and one of superficial type (14.3%). The width of the proliferative zone in the 40 IIc cases ranged from 0 to 2,390 microm (average 605.5 microm). There was no significant correlation between width of proliferative zone and background mucosa. With regard to lesion size, average width was 243.6 microm in cases with longest diameter 5 mm. CONCLUSIONS: In endoscopic treatment of undifferentiated mucosal gastric cancer of size 20 mm or smaller without ulceration (scars), the lateral safety margin should be 3 mm or more.

Therapeutic outcomes of endoscopic submucosal dissection of undifferentiated-type intramucosal gastric cancer without ulceration and preoperatively diagnosed as 20 millimetres or less in diameter.

AIM: The aim of the present study was to examine therapeutic outcomes of endoscopic submucosal dissection (ESD) of undifferentiated-type intramucosal gastric cancer and the problems of diagnosis. METHODS: We reviewed 58 patients with preoperatively diagnosed undifferentiated-type intramucosal early gastric cancer (EGC) without ulceration with a diameter of 20 mm or smaller (expanded-indication lesion) who underwent ESD at the Cancer Institute Hospital between September 2003 and August 2008. RESULTS: The overall rates of one-piece resection and complete resection were 98% and 90% respectively, and the median operation time was 70 min. Bleeding was seen in 8.6% and perforation in 3.4%. The curative resection rate was low at 79%. Factors responsible for non-curative resection were most commonly submucosal invasions. If limited to pathologically diagnosed expanded-indication lesions, the curative resection rate was 98%. The difference in tumor size between a macroscopic diameter and a histological diameter was within +/-5 mm in 96% of expanded-indication lesions, with none of these cases having a histological diameter that exceeded the macroscopic diameter by more than 5 mm. CONCLUSION: ESD was technically feasible for expanded-indication lesions of undifferentiated-type EGC. We achieved a high rate of curative resection by the markings at sites 5 mm beyond the preoperatively determined lesion area. Factors responsible for non-curative resection were most commonly submucosal invasions. We should diagnose the depth of such lesions more carefully.

Early esophageal cancer can be detected by screening endoscopy assisted with narrow-band imaging (NBI).

BACKGROUND/AIMS: Iodine staining of the esophagus has been shown to be useful in detecting esophageal cancer. Narrow band imaging (NBI), a new endoscopic lighting system, visualizes the microvasculature of the gastrointestinal (GI) mucosa. To evaluate the detectability of early esophageal cancer by screening endoscopy assisted with NBI as compared with that assisted with iodine staining. DESIGN: A prospective comparative study. Setting A single endoscopy unit. PATIENTS: Forty-nine consecutive patients, consisting of 40 males and 9 females with a mean age of 67, most of whom were at high risks for esophageal cancer (heavy drinker and smoker, history of cancer especially of head and neck, etc.). INTERVENTION: Following conventional endoscopic observation, the esophagus was observed with NBI for possible cancerous lesions. Dark-brown areas on NBI were defined as NBI-positive areas. Esophageal mucosa was subsequently stained with 1.5% iodine, and both findings were compared. Finally, the areas discolored by iodine stain were biopsied for histological evaluation. MAIN OUTCOME MEASUREMENTS: The sensitivity, specificity, and positive predictive value (PPV) of endoscopic detection of esophageal cancer. RESULTS: Squamous cell carcinoma was detected in 5 out of 118 areas. Esophageal cancers detected were all both NBI-positive and discolored by iodine staining. Sensitivity, specificity, and PPV of NBI-positive areas for cancer were 100%, 59%, and 9.8%, respectively. On the other hand, the discolored areas with iodine staining for cancer were 100%, 4.4%, and 4.4%, respectively. NBI observation was significantly superior to iodine staining for detecting esophageal cancer (p < 0.02). LIMITATION: In this study, the endoscopist engaged was not blinded and the assessment was not standardized. CONCLUSIONS: Esophageal endoscopy assisted with NBI was more useful for detecting early esophageal cancer than that assisted with iodine staining.

Clinical study of upper gastrointestinal bleeding associated with low-dose aspirin in Japanese patients.

BACKGROUND/AIMS: The aim of this study was to clarify the prevalence and various clinical factors of upper gastrointestinal bleeding (UGIB) associated with low-dose aspirin (LDA) treatment. METHODOLOGY: There were 6,807 patients who were under treatment with LDA at our hospital between January 2003 and November 2007. They had kept taking the LDA or started treatment in the study period and kept taking the whole period of observation. Esophagogastroduodenoscopy (EGD) was performed 453 patients of these patients, and 71 were diagnosed as LDA-associated UGIB. We examined the prevalence and various clinical factors of UGIB associated with LDA treatment. RESULTS: The occurrence rate of UGIB was 0.209 UGIB per 100 patient-years at least. The multivariate odds ratio of LDA-associated UGIB was 3.318 (95% confidence interval (CI) 1.650-6.671, p = 0.0008) for a history of peptic ulcer, 0.086 (95% CI: 0.011-0.652, p = 0.0176) for the use of a proton pump inhibitor (PPI) with LDA, and 0.253 (95% CI: 0.113-0.569, p = 0.0009) for the use of a histamine type 2 receptor antagonist (H2RA) with LDA. CONCLUSIONS: Our results suggest that a history of peptic ulcer significantly increases the risk of LDA-associated UGIB. Regular use of a PPI or a H2RA effectively decreases the risk.

Re-epithelialization of squamous epithelium for a radiation-induced rectal ulcer while giving an ecabet sodium enema.

The present patient developed a severe rectal ulcer more than 1 month after having received external beam radiation therapy for prostate cancer. Surveillance endoscopy every 3 months demonstrated healing of this rectal ulcer using a novel therapy. He was given enemas with ecabet sodium, which provides physical protection and promotes healing by increasing prostaglandin E(2), and this process induced squamous metaplasia that halted the progression of the ulcer of radiation proctitis as a late-phase reaction. Intrapapillary capillary loops were visualized with magnified narrow band imaging at the healing ulcer site as seen via the esophagus and, moreover, demonstrated histologically.

Comparison of the diagnostic utility of the ultrathin endoscope and the conventional endoscope in early gastric cancer screening.

Currently, transnasal esophagogastroduodenoscopy using an ultrathin endoscope is being widely carried out as a screening test for early gastric cancer. We compared the diagnostic utility of ultrathin esophagogastroduodenoscopy with that of conventional esophagogastroduodenoscopy in detecting 42 lesions of early gastric cancer that had a diameter of

[Therapeutic strategy for hemorrhagic radiation proctitis--the optimum condition of argon plasma coagulation (APC)].

AIM: This study was performed to clarify the optimum condition of argon plasma coagulation (APC) to treat hemorrhagic radiation proctitis. SUBJECTS: Among 25 patients with hemorrhagic radiation proctitis treated in the Cancer Institute Hospital between December 2000 and May 2004, 18 were followed-up for more than 6 months. The clinical courses of these 18 patients were analyzed retrospectively. METHODS: Proctoscopic findings of the hemorrhagic lesions were categorized as type-A (localized dilated veins, n = 6) , type-B (diffuse dilated veins, n = 6), and type-C (dilated veins associated with ulcers orerosions, n = 6). APC was applied for 5-10 seconds with the power of 40 W and the argon flow of 1.0 l/min (high power APC), or for 1-2 seconds with the power of 40 W and the argon flow of 0.6 l/min (low power APC). RESULTS: Type-A and B patients were successfully treated with either low or high power APC without any serious complications. But some type-C patients treated with high power APC showed serious complications such as proctovaginal fistula or prolonged ulceration. No recurrence patients were 89% (16/18) during the mean follow up period of 18 +/- 9.9 months. CONCLUSION: APC therapy for hemorrhagic radiation-proctitis was useful, but the pathologic healing process and consequence were different by rectal mucosal weakness. It is necessary for the therapeutic strategy to be put up and down according to proctoscopic findings. As for the optimum condision APC short cauterization by low power setting was more recommended.

The translational aspect of complementary and alternative medicine for cancer with particular emphasis on Kampo.

Complementary and alternative medicine (CAM) including Japanese Kampo is known to have anticancer potential. An increasing number of cancer survivors are using CAM for disease prevention, immune system enhancement, and symptom control. Although there have been abundant previous clinical reports regarding CAM, scientific investigations aimed at acquiring quantifiable results in clinical trials, as well as basic research regarding CAM, have only recently been undertaken. Recent studies suggest that CAM enhancement of immune function is related to cytokines. This review provides a translational aspect of CAM, particularly Hozai in Kampo from both scientific and clinical points of view for further development of CAM for cancer treatment.

[PPI: new strategies for GERD].

Proton pump inhibitor (PPI) is the first-line drug for GERD and is far more effective than H2-receptor antagonist (H2RA). H2RA suppresses mainly nocturnal gastric acid secretion from parietal cells, while PPI blocks acid production at nighttime as well as daytime when acid refluxes often occur. PPI-test is a therapeutic diagnosis and can reliably distinguish GERD from other diseases presenting similar symptoms. Initial therapy of GERD should be started with a full dose of PPI. However, most of the GERD patients need maintenance therapy. The maintenance dose of PPI should be individualized with a titration technique ('New Step-down therapy'). A small number of GERD patients resistant to PPI therapy may be due to nocturnal acid breakthrough (NAB) or rapid metabolism of PPI (extensive metabolizer for CYP2C19).

Extensive 0-IIc (undifferentiated carcinoma) lesion around a gastric adenoma: a case report.

A 73-year-old woman underwent esophagogastroduodenoscopy (EGD) at a local hospital, which revealed a flat elevated lesion, approximately 15 mm in diameter, in the posterior wall of the lower gastric body. At our hospital, a repeat EGD and biopsy led to a diagnosis of moderately dysplastic adenoma. The patient requested endoscopic submucosal dissection (ESD). Histopathology revealed a gastric adenoma with negativity for tumor at the vertical margin; however, the horizontal margin was positive for cancer with an undifferentiated carcinoma surrounding the adenoma. EGD was repeated, and a discolored area was found around the ESD scar. Biopsy revealed an undifferentiated carcinoma. Laparoscopic distal gastrectomy was performed, and postoperative histopathology also revealed an undifferentiated carcinoma (50 mm in diameter) surrounding the ESD scar; this lesion was an undifferentiated adenocarcinoma that was colocalized with and spread out to surround the original adenoma. This case is important for consideration of the pattern of development and progression of superficial spreading gastric cancer.

Natural history of gastric cancer-a case followed up for eight years: early to advanced gastric cancer.

We experienced a case of gastric cancer that was prospectively followed up for 8 years. With severe heart disease, the patient did not wish surgery or anticancer drug treatment. After informed consent was obtained, he was followed up for 8 years. He received upper gastrointestinal endoscopy every year, which revealed IIc early gastric cancer, and biopsy showed well differentiated adenocarcinoma. A flat and mildly depressed lesion with redness was observed on endoscopy, exhibiting typical morphology of IIc-type early gastric cancer. The appearance of IIc M cancer was observed macroscopically from 2000 to 2003. Four years later, surface irregularity with ulceration appeared. Then, the whole lesion was elevated, which suggested submucosal invasion, and the tumor exhibited the morphology of IIa + IIc or type 3. The ulcer became deeper and elevated boundaries were formed. Horizontal expansion of the flat lesion was mild, while invasion to deeper layers was predominant. Eventually, he died of heart failure. Estimated M cancer was observed for about 3 years, followed by invasion to deeper layers. Taken together, this is a valuable case that followed up the manner of invasion to deeper layers over time from early to advanced gastric cancer.