Clinicopathological Assessment of Gastric Xanthoma as Potential Predictive Marker of Gastric Cancer.

BACKGROUND/AIMS: Gastric xanthomas are frequently observed in the stomach as small yellowish plaques or nodules. A close relationship among Helicobacter pylori infection, atrophic gastritis, and xanthomas has been reported. We assessed the clinicopathological features of gastric cancer with or without xanthomas. METHODS: A total of 91 patients who were diagnosed as having early gastric cancer were enrolled. We evaluated the gastritis status using scores for gastritis and atrophy, positivity of H. pylori infection, the prevalence rate of xanthomas, and the clinicopathological features of gastric cancer. RESULTS: Gastric xanthomas were observed in 72.5% of early gastric cancer cases. Scores for gastritis and atrophy were significantly higher in the xanthoma-positive group than those in the xanthoma-negative group. A higher prevalence of differentiated-type adenocarcinoma was found in the xanthoma-positive group. Among the cases with multiple gastric xanthomas, the prevalence of males was significantly higher than that of females. CONCLUSION: A high prevalence rate of gastric xanthomas in gastric cancer cases was shown. Xanthomas were highly associated with age, the severities of gastritis and atrophy, and differentiated-type adenocarcinoma. Regardless of the eradication of H. pylori, xanthomas may be useful predictive markers for the development of differentiated-type adenocarcinoma.

Efficacy of hybrid endoscopic submucosal dissection (ESD) as a rescue treatment in difficult colorectal ESD cases.

BACKGROUND AND AIM: Endoscopic submucosal dissection (ESD), which provides a higher en bloc resection rate than conventional endoscopic mucosal resection (EMR), is considered to be a useful treatment option for large colorectal tumors. However, colorectal ESD is not widely used because of its technical difficulty, risk of complications and time required. To overcome these drawbacks, a simpler modified technique, ESD with snaring (hybrid ESD), has been developed. The aim of the present study was to retrospectively compare the safety and efficacy of hybrid ESD and conventional ESD for colorectal tumors. METHODS: Between September 2008 and June 2016, ESD was carried out on 137 lesions and hybrid ESD on 27 lesions. All hybrid ESD cases were carried out as a rescue treatment in difficult ESD cases. We retrospectively investigated procedure time, and the rates of en bloc resection, perforation, bleeding, and local recurrence. RESULTS: In the hybrid ESD group, procedure time was shorter compared with the ESD group (108 ± 59.5 min vs 122 ± 72.2 min), but the en bloc resection rate was lower (66.7% vs 94.2%). However, there were no significant differences in procedure time, or in rates of en bloc resection, perforation and bleeding between the two groups. Local recurrence did not develop in any of our cases. CONCLUSIONS: Hybrid ESD as a rescue treatment in difficult ESD cases may be less effective for en bloc resection of large colorectal tumors. Indication for hybrid ESD may be limited to scheduled treatment from the outset and emergency cases with patients who present unstable vital signs during ESD.

A rare case of fibrohistiocytic hepatic inflammatory pseudotumor with cholecystocholangitis showing positive IgG4 staining.

Inflammatory pseudotumor (IPT) is a rare benign mass characterized by infiltration of inflammatory cells and proliferation of fibrous tissues. Consistent with increasing knowledge about IgG4-related disease (RD), it has been implicated in the etiology of hepatic IPT, which is pathologically classified into two categories with respect to the proportion of IgG4-positive plasma cells: fibrohistiocytic- and lymphoplasmacytic-type. A 66-year-old man was admitted for treatment of cholecystocholangitis. Incidentally, abdominal computed tomography (CT) revealed an ambiguous low-density mass within segment 4 (S4) of the liver. Magnetic resonance imaging (MRI) showed the typical images of hepatic IPT within S4. Together with CT and MRI imaging, we suspected hepatic IPT, and had the opportunity to biopsy the S4 lesion during surgery for cholecystitis. Histopathological examination of liver tissue showed diffuse fibrous tissues, dense lymphoplasmacytic infiltration, and obliterative phlebitis with no evidence of malignancy. Despite infiltration of IgG4-positive plasma cells, these histological findings corresponded with fibrohistiocytic-type hepatic IPT. Similarly, in the resected gallbladder, relatively abundant IgG4-positive cells were observed, but not entirely consistent with IgG4-RD criteria. Although IgG4 immunostaining can be useful for the classification of hepatic IPT, the present histological tissues were borderline condition defined by IgG4-RD criteria. This rare case of hepatic IPT suggests a future focus on the borderline histological features of IgG4-RD.

Early gastric cancer with lanthanum deposition mucosa by endoscopic submucosal dissection: a case report and literature review.

Lanthanum carbonate is used to prevent hyperphosphatemia in dialysis patients with chronic renal failure and generally recognized as poorly absorbed by the gastrointestinal tract. However, some clinical cases of lanthanum deposition in the stomach have been shown. In addition, few endoscopic images of lanthanum deposition have been reported, particularly with respect to early-stage gastric cancer. A 64-year-old man with 22 years history of dialysis was treated with lanthanum carbonate for 3 years. With screening esophagogastroduodenoscopy, he was diagnosed with intramucosal gastric cancer, surrounded by the specific endoscopic images of the lanthanum deposition, and underwent endoscopic submucosal dissection. Histopathologically, massive accumulations of macrophages containing fine, granular, eosinophilic materials were observed in the lamina propria. These eosinophilic depositions were present in the lamina propria of the non-tumor region, but not in that of the tumor region. The histological features were further identified as lanthanum phosphate deposition by scanning electron microscopy. This case indicates the clinical significance of lanthanum deposition associated with gastric cancer. It is further required to evaluate more endoscopic images of the gastric mucosa, especially intramucosal cancer, with lanthanum deposition.

Linked color imaging enhances endoscopic detection of sessile serrated adenoma/polyps.

BACKGROUND AND STUDY AIMS: Although new image-enhanced endoscopy (IEE) technologies such as blue laser imaging (BLI), BLI-bright, and linked color imaging (LCI) have been developed, their utility for the detection of sessile serrated adenoma/polyps (SSA/Ps) is still unclear. This study aimed to evaluate the utility of BLI, BLI-bright, and LCI for SSA/P detection in still image examinations and in a prospective randomized controlled trial (RCT). PATIENTS AND METHODS: A group of 6 expert and non-expert endoscopists read 200 endoscopic still images containing SSA/P lesions using white light image (WLI), BLI, BLI-bright, and LCI. Color differences were calculated using the color space method. A prospective RCT of tandem colonoscopy with WLI and LCI was performed. Patients with SSA/P and those with a history of SSA/P that had been endoscopically removed were enrolled and randomly allocated to WLI-LCI or LCI-WLI groups. Additional endoscopic detection rates for SSA/P were compared between the 2 groups. RESULTS: LCI showed the highest SSA/P detection rate among the 4 modes for both expert and non-expert endoscopists. The detection rate with LCI for the 6 expert endoscopists (mean 98.3 ±â€Šstandard deviation 2.0 %) was significantly higher than that with WLI (86.7 ±â€Š6.0 %, P  < 0.01). Likewise, the detection rate with LCI for the 6 non-expert endoscopists (92.3 ±â€Š2.9 %) was significantly higher than that with WLI (72.7 ±â€Š11.5 %, P  < 0.01). The color difference of SSA/P with LCI was the highest among the 4 modes, and was significantly higher than with WLI (median 15.9, (interquartile range 13.7 - 20.6) vs. 10.2, (7.6 - 14.2); P  < 0.0001). In the RCT, a total of 44 patients (WLI-LCI 22 vs. LCI-WLI 22) underwent colonoscopy. The additional detection rate for SSA/P in the second inspection in the WLI-LCI group (21.6 %, 8/37) was significantly higher than in the LCI-WLI group (3.2 %, 1/31; P  = 0.02). The small, flat, non-mucus and isochromatic SSA/Ps in the transverse colon were detected more frequently in the second inspection with LCI. CONCLUSIONS: LCI was the most sensitive mode for SSA/P detection among WLI, BLI, BLI-bright, and LCI in the still image examinations. Our RCT strongly suggests that LCI is superior to conventional WLI for SSA/P detection during colonoscopy. UMIN000017599.