[A case of extrahepatic bile duct metastasis from gastric cancer].

A 56-year-old man was admitted with obstructive jaundice. Abdominal computed tomography and endoscopic retrograde cholangiopancreatography showed circumferential stenosis with irregular wall in lower bile duct, but the cytology of biliary brushing was no malignancy. The patient was given a diagnosis of gastric carcinoma with bone and skin metastasis. He died 2 months after the first hospital admission and autopsy was performed. The histological findings of gastric and bile duct tumor revealed signet ring cell carcinoma. The immunohistological findings of both tumors were identical. We definitively diagnosed this case as metastasis of gastric carcinoma to the bile duct.

Risk factors for delayed bleeding from endoscopic submucosal dissection of gastric neoplasms.

OBJECTIVE: Delayed bleeding is a major complication of endoscopic submucosal dissection (ESD) of gastric neoplasms. We aimed to clarify risk factors for delayed bleeding from ESD. MATERIAL AND METHODS: This study included 447 patients in whom 544 gastric neoplasms were resected by ESD between April 2006 and March 2011 in Yamaguchi University Hospital. We analyzed risk factors for delayed bleeding from ESD in relation to various clinical and pathological factors. RESULTS: En bloc resection rate was 95.4% (519/544), and curative resection rate was 87.8% (477/544). Delayed bleeding occurred in 7.0% (38/544) and perforation occurred in 1.8% (10/544) of patients. Univariate analysis revealed platelet count (Plt) <15 × 104/µl (p = 0.013), prothrombin time (PT) <70% (p = 0.044), resected size ≥ 50 mm (p = 0.038), and positive/indeterminate lateral margin (p = 0.012) to be risk factors for delayed bleeding. Multivariate analysis showed that Plt <15 × 104/µl (odds ratio [OR], 2.62; 95% confidence interval [CI]: 1.17-5.53, p = 0.020) and positive/indeterminate lateral margin (OR, 5.45; 95% CI: 1.39-17.95, p = 0.018) were independent risk factors for delayed bleeding. CONCLUSIONS: Low Plt, low PT, large resected size, and positive/indeterminate lateral margin were significant risk factors for delayed bleeding from ESD. Patients with these risk factors must be carefully observed for signs of delayed bleeding.

Fine-tuning the criteria for strip biopsy and endoscopic submucosal dissection improves the outcome of early gastric carcinoma treatment.

BACKGROUND AND AIM: Strip biopsy and endoscopic submucosal dissection (ESD) have been developed as a local treatment for early gastric cancer (EGC). However, the lesion criteria for the use of ESD, rather than strip biopsy, remain to be elucidated. METHODS: On the basis of reviews of literature and our observations concerning the outcome of strip biopsy, we set the criteria for selecting strip biopsy and ESD as follows. The indications for strip biopsy were lesions less than 10 mm in size and located in the anterior wall or greater curvature of the lower and middle stomach. ESD was indicated for all other lesions. The validity of the criteria was then analyzed prospectively in 156 patients. The rate of en bloc R0 resection and local recurrence were evaluated. RESULTS: Subsequently, 156 lesions were divided according to the criteria and were endoscopically resected by strip biopsy (n = 13) or ESD (n = 143). The en bloc R0 resection rates for the whole group and the strip biopsy and ESD groups was 93.5% (146/156), 92.3% (12/13), and 93.7% (134/143), respectively. None of the patients had suffered from local recurrence in either the strip biopsy or ESD groups. CONCLUSION: The validity of our criteria for selecting strip biopsy and ESD was verified. Our criteria exploit the advantages of both procedures and obtain better endoscopic therapy outcomes for EGC.

Usefulness of magnifying endoscopy with narrow-band imaging for determining gastric tumor margin.

BACKGROUND AND AIM: Magnifying endoscopy with narrow-band imaging (ME-NBI) enhances images of the irregular mucosal structures and microvessels of gastric carcinoma, and could be useful for determining the margin between cancerous and non-cancerous mucosa. We evaluated the usefulness of ME-NBI for determining the tumor margin compared with indigocarmine chromoendoscopy (ICC). METHODS: The subjects were 110 patients (with 118 lesions) who underwent endoscopic submucosal dissection for gastric tumors. They were randomized into ME-NBI and ICC groups. Marking was carried out by electrocautery with the tip of a high-frequency snare at the tumor margins determined by each observation. The distance from the marking dots to the tumor margin was measured histopathologically in the resected specimens. Marking was diagnosed as accurate if the distance was less than 1 mm. RESULTS: Of the 118 gastric lesions, 55 were allocated to the ME-NBI group, and 63 to the ICC group. Seventeen lesions in the ME-NBI group and 18 lesions in the ICC group were excluded because the distance from the marking dots to the tumor margin was immeasurable histopathologically. Thirty-eight lesions in the ME-NBI group and 45 lesions in the ICC group were evaluated. The rate of accurate marking of the ME-NBI group was significantly higher than that of the ICC group (97.4% vs 77.8%, respectively; P-value = 0.009). CONCLUSION: Magnifying endoscopy with narrow-band imaging can identify gastric tumor margins more clearly than ICC.

Three-day antibiotic treatment for acute cholangitis due to choledocholithiasis with successful biliary duct drainage: A single-center retrospective cohort study.

OBJECTIVES: Given that the optimal antibiotic treatment duration for acute cholangitis with successful biliary drainage remains unknown, this study aimed to validate whether antibiotic treatment duration could be reduced to ≤3 days among patients presenting the same. METHODS: This retrospective study included patients who presented with mild to moderate acute cholangitis due to choledocholithiasis who had undergone successful biliary drainage through endoscopic retrograde cholangiopancreatography (ERCP). After that, 30-day mortality rates and 3-month recurrence rates following short-course antibiotic treatment (SCT, ≤3 days) and long-course antibiotic treatment (LCT, ≥4 days) were compared. RESULTS: A total of 96 patients were analyzed, among whom 22 (22.9%) received SCT, and 74 (77.1%) received LCT. The SCT and LCT groups had a median antibiotic treatment duration of 1.5 (range 1-3) and seven (range 4-17) days, respectively. Moreover, the SCT and LCT groups exhibited no significant differences in cholangitis grades, 30-day mortality rates (0%, 0/22 and 2.7%, 2/74, respectively), 3-month recurrence rates, length of hospitalization, and acute bacteremic cholangitis rates. CONCLUSIONS: This study suggests that antibiotic treatment for ≤3 days may be adequate for patients with mild to moderate acute cholangitis due to choledocholithiasis who had undergone successful biliary drainage.

Gastric adenocarcinoma of fundic gland type with signet-ring cell carcinoma component: A case report and review of the literature.

A depressed lesion was found at a gastric angle of 76-year-old Japanese woman by esophagogastroduodenoscopy. Four years prior, she was diagnosed with a Helicobacter pylori infection but no eradication was performed. The pathological diagnosis of biopsy specimens was signet-ring cell carcinoma. Endoscopic submucosal dissection (ESD) was performed. Histopathological examination of the ESD specimen revealed proliferation of well-differentiated tubular adenocarcinoma mimicking fundic gland cells at the deep layer of the lamina propria mucosae. These tumor cells expressed focally pepsinogen-I, diffusely MUC6, and scattered H+/K+ ATPase according to immunohistochemistry. Therefore, we diagnosed this tumor as gastric adenocarcinoma of fundic gland type (GA-FG). Adjacent to the GA-FG, proliferation of signet-ring cell carcinoma which diffusely expressed MUC 2 and MUC 5AC was observed. Intestinal metaplasia was focally observed in the surrounding mucosa of the signet-ring cell carcinoma. To the best of our knowledge, this is the first case report of GA-FG with a signet-ring cell carcinoma component. The origin of signet-ring cell carcinoma, i.e., whether it accidentally arose from a non-neoplastic mucosa and coexisted with the GA-FG or dedifferentiated from the GA-FG is unclear at present. We expect the accumulation of similar cases and further analysis to clarify this issue.

Retrospective analysis of the results of strip biopsies to determine the indication for endoscopic submucosal dissection for early gastric cancer.

OBJECTIVE: To determine the indication for endoscopic submucosal dissection, we retrospectively analyzed the results of strip biopsies for early gastric cancer. METHODS: We studied 374 lesions of 360 patients with early gastric cancer. The resection results were classified into complete local resection and incomplete resection. The relations among the resection results and maximum tumor diameter, tumor location, and 1-year recurrence were analyzed. RESULTS: Complete local resection was achieved by strip biopsy for 206 of the 374 lesions (55.1%). For the 168 lesions with incomplete resection, local recurrence was found in 22. The rate of complete local resection in strip biopsy was significantly low, and the rate of local recurrence was significantly high for lesions exceeding 2 cm in diameter as well as for lesions of the cardiac part and the angular part of the lesser curvature. CONCLUSIONS: Our strip biopsy results suggest that endoscopic submucosal dissection is needed for early gastric cancer lesions larger than 2 cm in diameter and for those located in the cardiac part and angular part of the lesser curvature.

Epstein-Barr virus upregulates phosphorylated heat shock protein 27 kDa in carcinoma cells using the phosphoinositide 3-kinase/Akt pathway.

Gastric cancer is the most common cancer in Japan and infection with Epstein-Barr virus (EBV) is responsible for about 10% of gastric cancers worldwide. Although EBV infection may be involved at an early stage of gastric carcinogenesis, the mechanisms underlying its involvement remain unknown. To investigate the role of EBV in gastric carcinogenesis, we performed proteomic analyses of an EBV-infected gastric carcinoma cell line NU-GC-3 (EBV(+)) and its uninfected control (EBV(-)). 2-DE was combined with MS to identify differentially expressed proteins. We found that EBV infection upregulated one of the phosphorylated heat shock protein 27 kDa (HSP27). The phosphorylated HSP27 isoform which increased in EBV(+) cells can be induced by both heat shock and arsenite. The increase of phosphorylated HSP27 in EBV(+) cells was reduced by treatment with the phosphoinositide 3-kinase (PI3K) inhibitors (LY294002 and wortmannin). In addition, we found increased levels of phosphorylated Akt in EBV(+) cells. These findings suggest that EBV infection upregulates the phosphorylation of HSP27 via the PI3K/Akt pathway. Thus, activation of the PI3K/Akt pathway may contribute to the establishment of a malignant phenotype in EBV-infected gastric carcinomas.

The long-term efficacy of Helicobacter pylori eradication therapy in patients with idiopathic thrombocytopenic purpura.

BACKGROUND AND AIM: A beneficial effect of Helicobacter pylori (H. pylori) eradication in patients with H. pylori-positive idiopathic thrombocytopenic purpura (ITP) has been reported by several investigators; however, it was not clear whether the recovered platelet count after H. pylori eradication was maintained for a long period. METHOD: Thirty-eight ITP patients who were examined for H. pylori infection were assessed. H. pylori-positive patients received a standard antibiotic therapy for H. pylori eradication. We investigated the long-term effect of H. pylori eradication on platelet recovery in patients with H. pylori-positive ITP. RESULTS: Of the 38 ITP patients, 26 (68.4%) were positive for H. pylori. The response rate of platelet recovery was 56.5% (13/23 patients). Twelve patients showed complete response (CR) and one showed partial response (PR). The mean platelet counts 6 months after eradication significantly increased from 31 x 10(9)/L to 129 x 10(9)/L in 23 H. pylori-eradicated patients (P < 0.001). The median platelet counts of responders 1, 2, 3, and 4 years after eradication were 168 x 10(9)/L (n = 10), 193 x 10(9)/L (n = 9), 168 x 10(9)/L (n = 7), and 243 x 10(9)/L (n = 4) after a mean follow-up of 25.8 months. CONCLUSION: Eradication therapy for H. pylori-positive patients with ITP was effective and a favorable effect was maintained for long periods.