A new model to estimate duration of survival in patients with hepatocellular carcinoma with BCLC intermediate stage.

It is difficult to determine whether an individual therapy contributes to the elongation of survival because of the difficulty of organizing clinical research in patients who receive multiple treatments in HCC. We aimed to establish a new model of survival prediction in patients with intermediate stage HCC to establish standards in the recent and coming multi-MTA era. This analysis was prepared using a data set of 753 patients diagnosed HCC prior to 2017. Multiple regression analysis showed age, naïve or recurrence, the size of the largest tumor nodule, the number of nodules, total bilirubin, albumin and α-fetoprotein as independent predictors of survival. A Weibull model had the best fit and, based on these predictors, we established a new predicted survival model. The survival duration can be predicted the proposed model; EXP (4.02580 + (- 0.0086253) × age + (- 0.34667) × (naïve/recurrence) + (- 0.034962) × (number of nodules) + (- 0.079447) × (the size of the largest nodule) + (- 0.21696) × (total bilirubin) + 0.27912 × (albumin) + (- 0.00014741) × (α-fetoprotein)) × (- natural logarithm(0.5))^0.67250. This model is useful for the planning and evaluating the efficacy of recent sequential therapies in multi-MTA era.

Objective Response by mRECIST to Initial Lenvatinib Therapy Is an Independent Factor Contributing to Deep Response in Hepatocellular Carcinoma Treated with Lenvatinib-Transcatheter Arterial Chemoembolization Sequential Therapy.

Objective: There is limited information regarding the benefits of Lenvatinib-transcatheter arterial chemoembolization (LEN-TACE) sequential therapy for unresectable hepatocellular carcinoma (u-HCC). We compared the efficacy and safety of LEN-TACE sequential therapy to LEN monotherapy and investigated the factors contributing to the LEN-TACE sequential therapy deep response. Methods: We enrolled a multicenter cohort of 247 patients with u-HCC treated with LEN between 2018 and 2020. Propensity score matching identified 63 matching pairs of patients with well-balanced characteristics. We retrospectively compared the clinical outcomes, including overall survival (OS), progression-free survival (PFS), and incidence of adverse events (AEs), between the LEN-TACE and LEN monotherapy groups. Additionally, we evaluated the tumor response, change in albumin-bilirubin (ALBI) score, factors affecting PFS and OS, and independent predictors contributing to the LEN-TACE sequential therapy deep response. In this study, at eight weeks after resumption of LEN after initial TACE, "deep response" was defined as achieving complete response or partial response (PR) on modified Response Evaluation Criteria in Solid Tumors (mRECIST), and at least a 30% decrease in the sum of diameters of target lesions, taking the baseline sum diameters as the reference. Results: The OS and PFS in the LEN-TACE group were significantly higher than those in the LEN monotherapy group (p = 0.002 and p = 0.037, respectively). The incidence of AEs related to LEN was not significantly different between the two groups. In LEN-TACE sequential therapy, the objective response rate was 61.9%, and the disease control rate was 74.6%, according to the mRECIST criteria. No significant change in the ALBI score was observed during sequential LEN-TACE therapy. Multivariable analyses revealed that deep response was independently associated with the outcome of the initial response to LEN by mRECIST: PR (odds ratio: 5.176, 95% confidence interval: 1.528-17.537, p < 0.001). Conclusions: LEN-TACE sequential therapy may provide more clinical benefits than LEN monotherapy in u-HCC patients who responded to initial LEN treatment. Objective response according to mRECIST to initial LEN is an independent factor contributing to LEN-TACE sequential therapy deep response.

Association of serum creatinine-to-cystatin C ratio with skeletal muscle mass and strength in nonalcoholic fatty liver disease in the Iwaki Health Promotion Project.

We evaluated the feasibility of using serum creatinine-to-cystatin C ratio in the assessments of muscle mass and strength in nonalcoholic fatty liver disease. In a community-based cross-sectional study, skeletal muscle mass and handgrip strength were assessed in 641 Japanese adults. Low skeletal muscle mass index and low handgrip strength were defined as indicated in the sarcopenia diagnostic criteria of the Japan Society of Hepatology. Nonalcoholic fatty liver disease was defined as fatty liver on ultrasonography in the absence of other causes of steatosis. The creatinine-to-cystatin C ratio was useful for identifying the participants with low skeletal muscle mass index, with an area under the receiver-operating characteristic curve of 0.84 [95% confidence interval (CI), 0.77-0.91] in men and 0.72 in women (95% CI, 0.65-0.78), and those with low handgrip strength, with an area under the receiver-operating characteristic curve of 0.96 (95% CI, 0.93-0.99) in men and 0.79 (95% CI, 0.66-0.92) in women. Moreover, the creatinine-to-cystatin C ratio correlated with skeletal muscle mass index (r = 0.511, p<0.001) and handgrip strength (r = 0.657, p<0.001), whereas it did not correlate with exacerbation of hepatic steatosis. In this study, creatinine-to-cystatin C ratio correlated with muscle mass and strength in nonalcoholic fatty liver disease regardless of hepatic steatosis.

Hepatic Macrophages Express Melanoma Differentiation-Associated Gene 5 in Nonalcoholic Steatohepatitis.

The activation of innate immune system is essential for the pathogenesis of nonalcoholic steatohepatitis (NASH). Among pattern recognition receptors, it is well-characterized that toll-like receptors (TLRs) are deeply involved in the development of NASH to reflect exposure of the liver to gut-driven endotoxins. In contrast, it has not been elucidated whether retinoic acid-inducible gene-I (RIG-I)-like receptors (RLRs) are similarly implicated in the disease progression. In the present study, we examined the expression of melanoma differentiation-associated antigen 5 (MDA5), known to be a member of RLRs, in a diet-induced murine model of NASH. The liver tissues were collected from C57BL/6 J mice at 1, 3, and 6 weeks after choline-deficient L-amino acid-defined high-fat diet (CDAHFD), and the expression of MDA5 was analyzed by western blotting, immunofluorescence (IF), and real-time quantitative PCR (qPCR). The results of western blotting showed that hepatic expression of MDA5 was increased at 3 and 6 weeks. In IF, MDA5-positive cells co-expressed F4/80 and CD11b, indicating they were activated macrophages, and these cells began to appear at 1 week after CDAHFD. The mRNA expression of MDA5 was significantly upregulated at 1 week. Additionally, we performed IF using liver biopsy specimens collected from 11 patients with nonalcoholic fatty liver diseases (NAFLD), and found that MDA5-positive macrophages were detected in eight out of eleven patients. In an in vitro study, MDA5 was induced upon stimulation with lipopolysaccharide in murine bone marrow-derived macrophages and THP-1 cells. Our findings suggest that MDA5 may be involved in the inflammation of NASH.

Leptin/adiponectin ratio correlates with hepatic steatosis but not arterial stiffness in nonalcoholic fatty liver disease in Japanese population.

BACKGROUND AND AIMS: Cardiovascular disease (CVD) is a leading cause of mortality in nonalcoholic fatty liver disease (NAFLD). The aim of this study was to investigate the relationship of leptin-to-adiponectin (L/A) ratio with hepatic steatosis and arterial stiffness in NAFLD. METHODS: The subjects were 871 Japanese adults who participated in a health survey. Dietary intake, body composition, lipid profile, serum interleukin-6 (IL-6), leptin, and adiponectin were analyzed. NAFLD was defined as fatty liver on ultrasonography in the absence of other causes of steatosis. Arterial stiffness was evaluated by the brachial-ankle pulse wave velocity (baPWV). RESULTS: The subjects with NAFLD had a greater body mass index (BMI) and body fat percentage (BFP); a higher intake of daily energy (kcal) and carbohydrates; and a higher prevalence of hypertension, diabetes, and hyperlipidemia. The subjects with NAFLD had higher serum leptin and lower serum adiponectin concentrations and a higher L/A ratio than subjects without NAFLD. The L/A ratio increased with increasing severity of steatosis. The L/A ratio showed positive correlations with BMI and BFP, and a negative correlation with age. Women had higher L/A ratio and BFP levels than men regardless of the presence or absence of NAFLD. There was a weak positive correlation between baPWV and severity of steatosis. BaPWV was strongly correlated with age, while no relation was found between baPWV and L/A ratio. IL-6 level was correlated with baPVW and age, while the correlation between Il and 6 level and L/A ratio was very weak. The L/A ratio was correlated with triglycerides and the ratio of total cholesterol to high-density lipoprotein-cholesterol. CONCLUSION: L/A ratio and arterial stiffness were associated with the severity of steatosis, whereas there was no correlation between L/A ratio and arterial stiffness in NAFLD. These findings suggest that not only leptin and adiponectin but also other factors might be involved in the pathogenesis for atherosclerosis in NAFLD.

Melanoma Differentiation-Associated Gene 5 Positively Modulates TNF-α-Induced CXCL10 Expression in Cultured HuH-7 and HLE Cells.

The molecular mechanisms of innate immunity are closely associated with the development of non-alcoholic fatty liver disease (NAFLD). TNF-α is a key cytokine involved in the pathogenesis of metabolic inflammation like NAFLD. Melanoma differentiation-associated gene 5 (MDA5) is a member of the intracellular RNA helicase family proteins that play a pivotal role in an antiviral immune response. Previous studies have demonstrated that TNF-α induces the expression of MDA5 in some types of cells. However, the correlation between TNF-α and the expression of MDA5 in hepatocytes remains unknown. In the present study, we used two human hepatocellular carcinoma cell lines, HuH-7 and HLE, and examined the expression of MDA5 in these cells upon stimulation with TNF-α. The expression of MDA5 induced by TNF-α was analyzed by quantitative real-time RT-PCR and western blotting. Next, RNA interference against MDA5 was performed and the expressions of CXCL10 and STAT1 were examined. We found that the expression of MDA5 had increased upon stimulation with TNF-α in a concentration-dependent manner. Gene silencing against MDA5 suppressed the expression of TNF-α-induced CXCL10 in both cells. In HLE cells, gene silencing of MDA5 impaired STAT1 phosphorylation 24 h after stimulation with TNF-α. On the other hand, TNF-α-induced STAT1 phosphorylation was not detected in HuH-7 cells. These results indicated that MDA5 positively modulated the TNF-α-induced expression of CXCL10 in both STAT1-dependent and -independent manner and may be associated with metabolic inflammation in the liver.

Lifestyle Factors Rather Than Helicobacter pylori Infection or Estradiol Level are Associated With Osteopenia in Japanese Men.

Although decreased calcium absorption, decreased bone formation, alcohol drinking, and smoking have been considered as causes of osteopenia in men, the cause is unknown in half of the cases. Many reports highlighted the association between Helicobacter pylori infection and osteoporosis, mainly in East Asia and Japan. To identify relevant factors of osteoporosis in men, we examined estrogen and calcium intakes and other lifestyle factors together with gastric mucosal atrophy caused by Helicobacter pylori infection. This study is a cross-sectional study design of 268 healthy men who underwent general medical examinations. Multivariate analysis was performed, with age, body mass index, smoking habit, drinking habit, exercise habit, estradiol level, calcium intake, and Helicobacter pylori infection and its associated gastric mucosal atrophy as the independent variables and the presence of osteopenia as the dependent variable. The adjusted odds ratio was 0.74 (95% Confidence Interval [0.29, 1.90], p = .531) and 1.31 (95% Confidence Interval [0.54, 3.21], p = .552), when Helicobacter pylori infection was positive without and with gastric mucosal atrophy, respectively. Helicobacter pylori infection and gastric mucosal atrophy were not significant factors. Low body mass index, smoking habit, and low calcium intake were significantly associated with decreased bone density. In conclusion, Helicobacter pylori infection was not a significant risk, whereas low body mass index, current smoking, and lower calcium intake had a significant influence on the development of osteopenia in men.

Daidzein Intake Is Associated with Equol Producing Status through an Increase in the Intestinal Bacteria Responsible for Equol Production.

Equol is a metabolite of isoflavone daidzein and has an affinity to estrogen receptors. Although equol is produced by intestinal bacteria, the association between the status of equol production and the gut microbiota has not been fully investigated. The aim of this study was to compare the intestinal bacteria responsible for equol production in gut microbiota between equol producer and non-producer subjects regarding the intake of daidzein. A total of 1044 adult subjects who participated in a health survey in Hirosaki city were examined. The concentration of equol in urine was measured by high-performance liquid chromatography. The relative abundances of 8 bacterial species responsible for equol production in the gut microbiota was assessed using 16S rRNA amplification. There were 458 subjects identified as equol producers. The proportion of equol production status and the intake of daidzein increased with age. Daily intake of daidzein was larger in equol-producer. The intestinal bacteria, which convert daidzein to equol were present in both equol producers and non-producers. However, the relative abundance and the prevalence of Asaccharobacter celatus and Slackia isoflavoniconvertens were significantly higher in equol producers than those in equol non-producers. The intestinal bacteria that convert daidzein to equol are present in not only the equol producers but also in the non-producers. The daidzein intake is associated with the equol production status through an increase of A. celatus and S. isoflavoniconvertens in the gut microbiota.

Comparable efficacy of endoscopic transpapillary gallbladder drainage and percutaneous transhepatic gallbladder drainage in acute cholecystitis.

BACKGROUND AND STUDY AIMS: Although endoscopic transpapillary gallbladder drainage (ETGBD) is reportedly useful in patients who have acute cholecystitis, its efficacy has not been compared to that of percutaneous transhepatic gallbladder drainage (PTGBD). We retrospectively compared the efficacy and safety of ETGBD and PTGBD in patients with acute cholecystitis. PATIENTS AND METHODS: We studied 75 patients who required gallbladder drainage for acute cholecystitis between January 2014 and December 2016. Using propensity score matching analysis, we compared the clinical efficacy and length of hospitalization in patients successfully treated with ETGBD and PTGBD. Moreover, we assessed the predictive factors for hospitalization period < 30 days using multivariate analysis. RESULTS: ETGBD and PTGBD were successfully performed in 33 patients (77 %) and 42 patients (100 %) ( P  < 0.001). Twenty-seven matched pairs were obtained after propensity score matching analysis. No significant differences were observed between patients treated with ETGBD and those treated with PTGBD with respect to improvement in white blood cell count and serum C-reactive protein level. The length of hospitalization in patients treated with ETGBD was significantly shorter than in those treated with PTGBD regardless of the need for surgery. Multivariate logistic regression analysis revealed ETGBD (odds ratio, 7.07; 95 % confidence interval 2.22 - 22.46) and surgery (odds ratio 0.26; 95 % confidence interval 0.09 - 0.79) as independent factors associated with hospitalization period. There were no significant differences in occurrence of complications in ETGBD and PTGBD procedure. CONCLUSIONS: ETGBD was shown to be as useful as PTGBD for treatment of acute cholecystitis and was associated with shorter hospitalization period. ETGBD can be an alternative treatment option for acute cholecystitis at times when PTGBD is not possible.

Validity of the Pre-endoscopic Scoring Systems for the Prediction of the Failure of Endoscopic Hemostasis in Bleeding Gastroduodenal Peptic Ulcers.

Objective Although several pre-endoscopic scoring systems have been used to predict the mortality or the need for intervention for upper gastrointestinal bleeding, their usefulness to predict the failure of endoscopic hemostasis in bleeding gastroduodenal peptic ulcers has not yet been fully investigated. In this study, we evaluated the usefulness of the Glasgow-Blatchford score (GBS), the clinical Rockall score (CRS), and the AIMS65 score in predicting the failure of endoscopic hemostasis in patients with bleeding gastroduodenal peptic ulcers. Methods We retrospectively evaluated 226 consecutive emergency endoscopic cases with bleeding gastroduodenal peptic ulcers between April 2010 and September 2016. The study outcome was the failure of first endoscopic hemostasis. The GBS, CRS, and AIMS65 scores were assessed for their ability to predict the failure of endoscopic hemostasis using a receiver-operating characteristic curve. Results Eight cases (3.5%) failed to achieve first endoscopic hemostasis. Surgery was required in six cases, and interventional radiology was required in two cases. The GBS was superior to both the CRS and the AIMS65 score in predicting the failure of endoscopic hemostasis [area under the curve, 0.77 (95% confidence interval, 0.64-0.90), 0.65 (0.56-0.74) and 0.75 (0.56-0.95), respectively]. No failure of endoscopic hemostasis was noted in cases in which the patient scored less than GBS 10 and CRS 2. Conclusion The GBS was the most useful scoring system for the prediction of failure of endoscopic hemostasis in patients with bleeding gastroduodenal peptic ulcers. The GBS was also useful in identifying the patients who did not require surgery or interventional radiology.

Decrease of Estradiol and Several Lifestyle Factors, but Not Helicobacter pylori Infection, Are Significant Risks for Osteopenia in Japanese Females.

BACKGROUND: The primary cause of osteoporosis in women is increased bone resorption and decreased bone density associated with reduced estrogen secretion. Several studies have demonstrated a relationship between Helicobacter pylori infection and osteoporosis regardless of estrogen levels. This study examined the relationship between H. pylori infection and osteopenia together with estrogen levels, calcium intake, and several lifestyle factors. METHODS: This study included 473 healthy women who underwent a general health examination. Multivariate analysis was performed, with age, body mass index (BMI), smoking habit, drinking habit, exercise habit, schooling duration, estradiol levels, birth history, calcium intake, schooling duration, smoking habit, drinking habit, exercise habit, and H. pylori infection as independent variables and the presence of osteopenia as a dependent variable. RESULTS: The adjusted OR for osteopenia with H. pylori infection was 0.95 (95% CI 0.55-1.63, p = 0.84). In contrast, osteopenia was significantly associated with age, low BMI, lesser schooling period, low estradiol levels, and low calcium intake. CONCLUSIONS: H. pylori infection was not a significant risk for osteopenia by the multivariate analysis, which included the primary confounding factors. Significant factors, such as estradiol and calcium intake, should be assessed together to study the association of H. pylori infection and osteopenia.

Biliary drainage improves the predictive value of modified Glasgow Prognostic Scores in inoperable pancreatic cancer.

OBJECTIVE: To assess the influence of biliary drainage to cholangitis on modified Glasgow Prognostic Score (mGPS) in patients with pancreatic cancer. METHODS: mGPS was calculated before and after biliary drainage in 47 consecutive patients with inoperable pancreatic cancer who were receiving chemotherapy. Biliary drainage was indicated for malignant obstructive jaundice that prevented the administration of chemotherapy. To elucidate mGPS values, serum levels of CRP and albumin were measured at the time of diagnosis (before biliary drainage). Overall survival was evaluated and risk factors, which contribute to overall survival, were examined. RESULTS: Biliary drainage was performed in 15 patients. Using values obtained before biliary drainage, there were no significant differences in median survival time between patients with a mGPS of 0 and those with a mGPS of 1 or 2 (10.7 vs. 9.4 months; p = 0.757). However, using values obtained after biliary drainage, median survival time was significantly higher in patients with a mGPS of 0 than in those with a mGPS of 1 or 2 (11.4 vs. 4.7 months; p = 0.002). Multivariate analysis revealed that a mGPS of 1 or 2 (HR: 3.38; 95% CI: 1.35-8.46, p = 0.009), a carbohydrate antigen 19-9 >1000 U/mL (2.52; 1.22-5.23, p = 0.013), a performance status of 2 (7.68; 2.72-21.28, p = 0.001), carcinoembryonic antigen level >10 ng/mL (2.29; 1.13-4.61, p = 0.021) were independently associated with overall survival. CONCLUSION: mGPS values obtained after biliary drainage appear to be a more reliable indicator of overall survival in patients with inoperable pancreatic cancer.

Perforated emphysematous cholecystitis managed by endoscopic transpapillary gallbladder drainage.

An 88-year-old woman with dementia was diagnosed as having perforated emphysematous cholecystitis with localized peritonitis. Because she was at high risk for surgery, gallbladder drainage was required before surgery. Endoscopic transpapillary gallbladder drainage instead of percutaneous transhepatic biliary drainage was performed because bile could leak from the puncture site to free space around the perforated gallbladder. After the insertion of a nasobiliary drainage tube, the gallbladder was drained and cleaned with saline solution. Subsequently, a nasobiliary drainage tube was replaced with a double-pigtail stent because she was at high risk of dislodging the nasobiliary drainage tube. Although clinical improvement was observed, she was treated conservatively without surgery. She was followed up for 6 months without developing cholecystitis. For perforated cholecystitis without developing panperitonitis, endoscopic transpapillary gallbladder drainage would be an effective option as a bridge to surgery for the initial treatment and as an alternative to surgery for long-term management for a later treatment. This is the first reported case of perforated emphysematous cholecystitis with localized peritonitis treated with endoscopic transpapillary gallbladder drainage.

Evaluation of scoring models for identifying the need for therapeutic intervention of upper gastrointestinal bleeding: A new prediction score model for Japanese patients.

BACKGROUND AND AIM: Multiple scoring systems have been developed to predict outcomes in patients with upper gastrointestinal bleeding. We determined how well these and a newly established scoring model predict the need for therapeutic intervention, excluding transfusion, in Japanese patients with upper gastrointestinal bleeding. METHODS: We reviewed data from 212 consecutive patients with upper gastrointestinal bleeding. Patients requiring endoscopic intervention, operation, or interventional radiology were allocated to the therapeutic intervention group. Firstly, we compared areas under the curve for the Glasgow-Blatchford, Clinical Rockall, and AIMS65 scores. Secondly, the scores and factors likely associated with upper gastrointestinal bleeding were analyzed with a logistic regression analysis to form a new scoring model. Thirdly, the new model and the existing model were investigated to evaluate their usefulness. RESULTS: Therapeutic intervention was required in 109 patients (51.4%). The Glasgow-Blatchford score was superior to both the Clinical Rockall and AIMS65 scores for predicting therapeutic intervention need (area under the curve, 0.75 [95% confidence interval, 0.69-0.81] vs 0.53 [0.46-0.61] and 0.52 [0.44-0.60], respectively). Multivariate logistic regression analysis retained seven significant predictors in the model: systolic blood pressure <100 mmHg, syncope, hematemesis, hemoglobin <10 g/dL, blood urea nitrogen ≥22.4 mg/dL, estimated glomerular filtration rate ≤ 60 mL/min per 1.73 m2 , and antiplatelet medication. Based on these variables, we established a new scoring model with superior discrimination to those of existing scoring systems (area under the curve, 0.85 [0.80-0.90]). CONCLUSION: We developed a superior scoring model for identifying therapeutic intervention need in Japanese patients with upper gastrointestinal bleeding.

Humoral hypercalcemia due to gastric carcinoma secreting parathyroid hormone-related protein during chemotherapy: a case report.

Humoral hypercalcemia due to a gastric carcinoma-secreting parathyroid hormone-related protein (PTHrP) is a rare disease associated with poor prognosis. A 61-year-old male with gastric cancer who had been receiving chemotherapy showed serum hypercalcemia and an elevated level of serum PTHrP with a suppressed intact parathyroid hormone level. Computed tomography revealed stable disease 4 weeks prior, and the laboratory examination revealed no adverse effects 2 weeks prior. The biopsy at the time of diagnosis was immunohistochemically positive for PTHrP later. Despite intensive care, the patient died of multiorgan failure on the 14th day after admission. In case of undifferentiated gastric cancer, the possibility of humoral hypercalcemia of malignancy caused by gastric cancer should be considered even when the patient is receiving chemotherapy.

[Disappearance of a gastric lesion following modified FOLFOX6 chemotherapy in a patient with metastatic colorectal cancer: a case report and literature review].

A 48-year-old man with colorectal cancer and right inguinal lymph node metastasis had previously undergone radiotherapy and chemotherapy (uracil/tegafur/leucovorin) after a colostomy in another hospital before being referred to us. Esophagogastroduodenoscopy (EGD) revealed the presence of a gastric metastatic lesion. After three courses of treatment with a modified regimen of leucovorin plus 5-fluorouracil plus oxaliplatin-6 (mFOLFOX6), EGD revealed that the gastric lesion had disappeared; computed tomography revealed that the size of the primary tumor and inguinal lymph node metastasis were markedly reduced. Subsequently, he underwent rectal resection of the primary tumor and continued treatment with mFOLFOX6 in combination with bevacizumab. We reviewed 29 similar cases from the literature, and determined that surgical resection of the tumor and appropriate chemotherapy can lead to long-term survival for patients with gastric metastases from colorectal cancer. Furthermore, positive CK20 and CDX2 expression and negative CK7 expression were useful adjuncts in the immunohistochemical diagnosis of gastric metastases from colorectal adenocarcinoma.

[Salvage gastrectomy and radiotherapy for R-CHOP-refractory gastric malignant lymphoma].

A man in his seventies presented with a stomach abnormality that was revealed upon physical examination.Following workup, he was diagnosed with gastric diffuse large B-cell lymphoma (DLBCL)StageII1 (Lugano staging system for gastrointestinal lymphoma) with low risk as defined by the International Prognostic Index criteria.The entire stomach showed an intense, abnormal FDG uptake by FDG-PET evaluation.He was treated with rituximab plus CHOP (R-CHOP).The patient's body weight decreased by 12 kg during the treatment period.Post -treatment evaluation by gastroscopy and FDG-PET following 5 courses of R-CHOP therapy revealed a residual lesion in the stomach.Total gastrectomy was performed for R-CHOP refractory gastric DLBCL.The pathological diagnosis was DLBCL, and the pathological therapeutic effect was Grade 1a.Lymphoma cells were detected at the duodenal margin of the resected specimen, and an FDG-PET scan showed abnormal FDG uptake in the duodenal stump necessitating salvage chemotherapy (DeVIC therapy)and radiotherapy.The patient's body weight increased by 5 kg after gastrectomy and there were no signs of relapse for 14 months after the operation.Salvage therapy including gastrectomy may be effective for chemotherapy-resistant gastric DLBCL.

[A case of small intestinal lymphoma with ileus requiring surgery during chemotherapy].

Perforation, bleeding, and ileus are known complications of small intestinal lymphoma and can occur either at diagnosis or during the course of treatment. Surgery is an important component in the management of these gastrointestinal complications. However, there is no consensus regarding the indications for and timing of surgery in small intestinal lymphoma. We herein present our experience with a case of small intestinal lymphoma with ileus that required surgery during chemotherapy. A 69-year-old man developed abdominal pain. Computed tomography revealed lower right jaw lymphadenopathy, small intestinal wall thickening, and mesenteric lymphadenopathy. Malignant lymphoma (diffuse large B-cell type) was diagnosed on the basis of a lower jaw lymph node biopsy. The patient was initially administered chemotherapy. After the third cycle of chemotherapy, the patient developed small intestinal obstruction detected upon abdominal computed tomography. Because a stricture persisted despite medical treatment, we performed partial resection of the small intestine. The postoperative course was good, and the patient rapidly resumed chemotherapy. Currently, 6 months after the surgery, the patient is alive without any progression of the lymphoma. A multidisciplinary treatment strategy, including surgery, is desirable to achieve a safe but radical cure for small intestinal lymphoma.

Influence of endoscopic submucosal dissection on serum levels of pepsinogens in patients with early gastric cancer.

BACKGROUND: The serum levels of pepsinogens (PG) have been considered to be a useful marker for assessing the risk of metachronous gastric cancer in patients who undergo endoscopic submucosal dissection. However, the influence of endoscopic submucosal dissection (ESD) on serum levels of PG has not yet been examined. The aim of this study was to examine whether the level of PG after ESD can be used to predict the risk of metachronous cancer. PATIENTS AND METHODS: The study included of 100 consecutive patients who underwent ESD for gastric cancer at Hirosaki University Hospital from September 2009 to February 2011. Serum levels of PG I and II on the day before and after ESD were compared. Stool antigen test was also performed to examine the presence of Helicobacter pylori infection. RESULTS: The mean serum level of PG I before and after ESD was 34.3 ± 31.6 ng/mL and 70.5 ± 100.0 ng/mL (P < 0.001), respectively. PG I/II ratio before and after ESD was 2.40 ± 1.51 and 2.79 ± 1.70 (P < 0.001). The serum level of PG I and the PG I/II ratio were significantly changed after ESD, regardless of the use of proton pump inhibitor, Helicobacter pylori infection or the location of the tumor. CONCLUSIONS: ESD treatment modulates the serum level of PG I and significantly increases the PG I/II ratio. Serum levels of PG should be measured before the ESD procedure is performed to predict the risk of developing metachronous gastric cancer after ESD.

Successful treatment of gastric adenocarcinoma in a Meckel's diverticulum with pemetrexed plus carboplatin.

A 42-year-old man was found to have an adenocarcinoma arising from ectopic gastric mucosa in Meckel's diverticulum, as diagnosed with surgical pathology. Recurrence was recognized with massive ascites at 1 year and 6 months after surgery. Chemotherapy in the first and second lines was not effective. In the third line of chemotherapy, pemetrexed and carboplatin were both administered and this resulted in a good response for massive ascites. This palliative therapy was effective and safe.