Methotrexate-associated lymphoproliferative disorder in the stomach and duodenum: a case report.

BACKGROUND: Methotrexate-associated lymphoproliferative disorder (MTX-LPD) can present as a benign lymphoid proliferation or a malignant lymphoma in patients taking MTX. Almost 50% of MTX-LPD cases show spontaneous remission after withdrawal of MTX treatment. Studies have suggested that the hyper-immune state of rheumatoid arthritis, the immunosuppressive state associated with MTX, and the carcinogenicity of the Epstein-Barr virus might contribute to MTX-LPD development. Although most cases of MTX-LPD occur at extranodal sites, few cases of MTX-LPD affecting the stomach and duodenum have been reported. To our knowledge, no other study has reported on the endoscopic observations of dramatic withdrawal and appearance of multiple digestive tract lesions in a short period of time. Herein, we report the clinical course and imaging findings of our case, which may be useful for understanding the pathological condition of MTX-LPD. CASE PRESENTATION: We describe the case of a 70-year-old woman with MTX-LPD of the stomach and duodenum. Disease regression was temporarily achieved after cessation of MTX treatment; however, it subsequently recurred, and complete response was only achieved after six cycles of rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone (R-CHOP) chemotherapy. CONCLUSIONS: The first-choice therapy for patients taking MTX who develop suspected MTX-LPD should be the withdrawal of MTX treatment. Even after remission is achieved, patients should be kept under careful observation, and if the disease recurs, chemotherapy should be commenced promptly.

Case of primary hepatic gastrinoma: Diagnostic usefulness of the selective arterial calcium injection test.

Gastrinomas mainly occur in the duodenum and pancreas. Primary hepatic gastrinoma is rare and difficult to diagnose because the liver is a frequent site of metastatic gastrinomas. Clinical factors were assessed in a 28-year-old man with diarrhea and heartburn who was hospitalized for recurrent duodenal ulcers. Abdominal ultrasound, endoscopic ultrasound and computed tomography (CT) could not detect a tumor in the duodenum or pancreas. His gastrin level was 846 pg/mL and magnetic resonance imaging showed a mass 12 mm in diameter in the right robe of the liver. A selective intra-arterial calcium injection (SACI) test and 68-gallium edotreotide positron emission tomography CT (Ga-DOTATOC PET-CT) were therefore performed. Calcium gluconate injection into the proper hepatic artery resulted in a marked increase in serum gastrin concentration in the right hepatic vein, with Ga-DOTATOC PET-CT showing uptake only by the liver mass. Following a diagnosis of primary hepatic gastrinoma, the tumor was resected. A histopathological examination indicated gastrinoma. Six months postoperatively, he has no symptoms, is not taking proton-pump inhibitors and his gastrin level remains within the normal range. The SACI test and the clinical course of this patient strongly suggest that the tumor was a primary hepatic gastrinoma. The SACI test is helpful in the diagnosis of primary hepatic gastrinoma.

[Signet ring cell carcinoma of the bile duct: a case report].

A 72-year-old man was admitted with obstructive jaundice. Computed tomography revealed a 4cm tumor with multiple cystic components obstructing the common bile duct. Endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography and intraductal ultrasonography demonstrated the tumor, which derived from the lower bile duct, grew into the bile duct lumen. Peroral cholangioscopy revealed distended tumor vessels on the surface of the tumor. Signet ring cell carcinoma of the bile duct was diagnosed by biopsy. The patient died 3 months after the first hospital admission despite chemotherapy.

Transoral surgery for superficial head and neck cancer: National Multi-Center Survey in Japan.

Head and neck cancers, especially in hypopharynx and oropharynx, are often detected at advanced stage with poor prognosis. Narrow band imaging enables detection of superficial cancers and transoral surgery is performed with curative intent. However, pathological evaluation and real-world safety and clinical outcomes have not been clearly understood. The aim of this nationwide multicenter study was to investigate the safety and efficacy of transoral surgery for superficial head and neck cancer. We collected the patients with superficial head and neck squamous cell carcinoma who were treated by transoral surgery from 27 hospitals in Japan. Central pathology review was undertaken on all of the resected specimens. The primary objective was effectiveness of transoral surgery, and the secondary objective was safety including incidence and severity of adverse events. Among the 568 patients, a total of 662 lesions were primarily treated by 575 sessions of transoral surgery. The median tumor diameter was 12 mm (range 1-75) endoscopically. Among the lesions, 57.4% were diagnosed as squamous cell carcinoma in situ. The median procedure time was 48 minutes (range 2-357). Adverse events occurred in 12.7%. Life-threatening complications occurred in 0.5%, but there were no treatment-related deaths. During a median follow-up period of 46.1 months (range 1-113), the 3-year overall survival rate, relapse-free survival rate, cause-specific survival rate, and larynx-preservation survival rate were 88.1%, 84.4%, 99.6%, and 87.5%, respectively. Transoral surgery for superficial head and neck cancer offers effective minimally invasive treatment. Clinical trials registry number: UMIN000008276.

Prophylactic injection of hypertonic saline-epinephrine oral to the papilla for prevention of postsphincterotomy bleeding.

GOALS/BACKGROUND: Endoscopic injection of hypertonic saline-epinephrine (HSE) solution oral to the papilla effectively arrests uncontrolled bleeding after endoscopic sphincterotomy (ES). The aim of this study was to evaluate the efficacy of a prophylactic injection of HSE solution oral to the papilla before ES for prevention of post-ES bleeding. STUDY: Patients scheduled for ES were recruited into this study. Before ES, patients randomly underwent a single submucosal injection of HSE solution (1 mL) 1 to 2-cm oral to the papilla (injection group) or no injection (noninjection group). After ES, patients were prospectively evaluated for occurrence of post-ES complications such as bleeding, perforation, and pancreatitis between the groups. RESULTS: A total of 120 patients were randomized to the injection group (n=60) or the noninjection group (n=60). The 2 groups were similar with respect to all background variables. Bleeding occurred in 10 patients (8.3%), and the incidence of bleeding was significantly higher in the noninjection group (9/60) than in the injection group (1/60) (P=0.017). Retroperitoneal perforation occurred in 1 patient (injection group) (0.83%). Pancreatitis occurred in 10 patients (8.3%), and the incidence of pancreatitis tended to be higher in the noninjection group (8/60) than in the injection group (2/60) (P=0.095). CONCLUSIONS: Prophylactic injection of HSE solution oral to the papilla before ES is a simple and inexpensive method, and is effective for prevention of post-ES bleeding.

Epinephrine sprayed on the papilla for prevention of post-ERCP pancreatitis.

BACKGROUND: Epinephrine sprayed on the papilla may reduce papillary edema and thus prevent acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the efficacy of this technique for prevention of post- ERCP pancreatitis. METHODS: Patients scheduled for ERCP were recruited into this study. We randomized the patients to have 10 ml of either 0.02% epinephrine (epinephrine group) or saline (control group) sprayed on the papilla after diagnostic ERCP and prospectively analyzed the occurrence of post-ERCP pancreatitis between the groups. We recorded duct visualization, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration. RESULTS: There was no significant difference between the groups with regard to visualization of the bile duct and/or the main and accessory pancreatic ducts, presence of pancreatic acinarization, number of injections into the pancreatic duct, total volume of contrast used, and procedure duration. Overall, post-ERCP pancreatitis occurred in 4 of the 370 patients (1.1%). The incidence of pancreatitis tended to be higher in the control group (4/185) than in the epinephrine group (0/185) (P = 0.1230). CONCLUSIONS: Epinephrine sprayed on the papilla tended to prevent post-ERCP pancreatitis, although it was not statistically significant because of the low incidence of pancreatitis. Further studies on the efficacy of this technique in patients at high risk for pancreatitis, and on other volumes and/or concentrations of epinephrine, are warranted.

The prospect of endoscopic submucosal dissection for early anal canal squamous cell carcinoma.

Squamous cell carcinoma (SCC) of the anal canal is seldom diagnosed at an early stage. Chemoradiation therapy is a standard in Europe and the United States, though in squamous cell carcinoma there is no evidence-based therapy. In Japan, endoscopic submucosal dissection (ESD) is the standard minimally invasive treatment for early stage cancer of the digestive tract, including the colorectum. Therefore, if the lesion is diagnosed at an early stage, ESD may be selected for anal canal lesions. We experienced two cases of early stage anal canal cancer in which the diagnosis and the extent of the lesions were confirmed using magnifying endoscopy with narrow-band imaging (NBI), as well as performing ESD. Pathological examination showed the resected specimen to be SCC in situ; the horizontal and vertical margins were free of tumor; and in one case there was no lymphovascular invasion. In the other case it showed the tumor was contained within the epithelium; horizontal and vertical margins were free of tumor; The follow-up period is not long enough to assert that ESD for anal canal squamous cell carcinoma may be an option of minimally invasive therapy. However, if there is a possibility of lymphatic invasion as in one of our cases, we need to give serious consideration to ESD for these lesions, and careful follow-up is necessary even if the lesion is in situ.

Handcrafted two-channel colonoscope for grasping-forceps-assisted resection of giant pedunculated polyps.

BACKGROUND: Colonoscopic polypectomy of giant pedunculated polyps has an increased risk of bleeding and is technically difficult. To facilitate the removal of the polyps, we handcrafted a two-channel colonoscope and applied it for grasping-forceps-assisted resection. METHODS: We easily handcrafted a two-channel colonoscope by taping a plastic tube along the shaft of a standard colonoscope and used it for the technique in 10 patients with 12 giant pedunculated polyps. OBSERVATIONS: The colonoscope with forceps assistance proved to be satisfactory for handling detachable and polypectomy snares. Immediate bleeding occurred in one patient because the detachable snare could not be maneuvered over the polyp. In 3 patients, the plastic tube became mobile during the procedure because the tape that attached the tube became loose. No other complications occurred. CONCLUSIONS: A handcrafted two-channel colonoscope for grasping-forceps-assisted resection of giant pedunculated polyps is effective for the prevention of postpolypectomy bleeding and the reduction of technical difficulties.

Open-biopsy-forceps technique for endoscopic removal of distally migrated and impacted biliary metallic stents.

BACKGROUND: Endoscopic removal of distally migrated and impacted biliary metallic stents is technically challenging. An open-biopsy-forceps technique for endoscopic removal of these migrated stents is described. METHODS: The technique was used in 4 patients with distally migrated and impacted covered metallic stents. A closed biopsy forceps was advanced through the stent mesh and opened within the stent to form an "anchor." With endoscope withdrawal, the stent was dislodged easily from the duodenum to the stomach. After grasping an end of the stent with a snare, the stent was removed by complete withdrawal of the endoscope. OBSERVATIONS: In all patients, the impacted stent was removed successfully. Mean time for removal was 10.2 minutes. Although ulceration was evident in the duodenal wall where the distal stent end was impacted in all patients, no other complication or adverse event was observed. CONCLUSIONS: The open-biopsy-forceps technique is useful for endoscopic removal of distally migrated and impacted biliary metallic stents.