Comprehensive diagnostic ability of endocytoscopy compared with biopsy for colorectal neoplasms: a prospective randomized noninferiority trial.

BACKGROUND AND STUDY AIMS: Endocytoscopy enables observation at 450-fold magnification during gastrointestinal endoscopy, allowing on-site "optical biopsy." We compared the accuracies of endocytoscopy and standard biopsy for the diagnosis of colorectal neoplasms. PATIENTS AND METHODS: We performed a randomized, controlled, open-label trial of patients with colorectal lesions (≥ 5 mm) detected during colonoscopy in a tertiary referral center. We randomly assigned the 203 detected lesions of 170 eligible patients to either the endocytoscopy or standard biopsy group. An on-site endoscopist assessed the histopathology of the endocytoscopy group lesions according to the endocytoscopic findings, whereas a pathologist later assessed standard biopsy group lesions by microscopic examination of the biopsy specimens. We calculated the diagnostic accuracies in both groups with reference to the final histopathology of the resected specimens. The primary endpoint was to determine whether the diagnostic accuracy of endocytoscopy for neoplastic lesions was noninferior to that of standard biopsy (with a predefined noninferiority margin of 10%). Analyses were by intention-to-treat and per-protocol. The study is registered, number UMIN000003923. RESULTS: Overall, 102 lesions in the endocytoscopy group and 101 in the standard biopsy group were available for primary outcome analysis. There were no complications. The diagnostic accuracy of endocytoscopy for the discrimination of neoplastic lesions was 94.1% (95% confidence interval 87.6% to 97.8%), whereas that of standard biopsy was 96.0% (90.2% to 98.9%), which is within the noninferiority margin (absolute difference -1.9%, -8.6% to +5.0%). CONCLUSIONS: Endocytoscopy is noninferior to standard biopsy for the discrimination of neoplastic lesions. With its advantage of providing an on-site diagnosis, endocytoscopy could provide a novel alternative to standard biopsy in routine colonoscopy.

Differentiation, maturation, and proliferation of macrophages in the mouse yolk sac: a light-microscopic, enzyme-cytochemical, immunohistochemical, and ultrastructural study.

Primitive macrophages first appear in the blood islands of the mouse yolk sac on the ninth day of gestation. After the tenth day of fetal life, these cells differentiate into fetal macrophages and become mature, with the development of intracellular organelles. They appear in the mesenchymal layer and further immigrate into the extraembryonic coelom. The fetal macrophages do not show any cytochemical peroxidase or 5'-nucleotidase activity, and they possess a marked proliferative capacity. Promonocytes or monocytes that have an incomplete ultrastructure emerge in the blood islands of the yolk sac a day after the occurrence of the fetal macrophages. These events suggest that fetal macrophages differentiate from primitive macrophages before the development of promonocytes or monocytes in the mouse yolk sac; they actively proliferate and are colonized into the embryonic tissues. These results also indicate that the ontogeny of the monocyte/macrophage is different in the early embryo compared with its later developmental stages.

Development, differentiation, and maturation of fetal mouse yolk sac macrophages in cultures.

The development and differentiation of macrophages in the fetal mouse yolk sac were studied morphologically in four different culture experiments. In the culture of mouse embryos with yolk sac, the development of fetal macrophages was demonstrated to precede that of promonocytes and monocytes in the yolk sac. In vitro differentiation of the fetal macrophages was consistent with the results of our previous in vivo observation indicating that fetal macrophages were differentiated from primitive macrophages, but not from the monocytic cell series. Differentiation of primitive macrophages into fetal macrophages, before the development of promonocytes and monocytes, was reproduced in the culture of cell suspensions from the fetal mouse yolk sacs, with a mouse bone marrow stromal cell clone (ST2) particularly with those at 8 days of gestation. In the soft agar or liquid culture of yolk sac cells with LP3-conditioned medium, monocyte-macrophage colonies were effectively induced, but not fetal macrophage colonies. The results provide evidence for the existence, in yolk sac hematopoiesis, of two distinct macrophage populations: a fetal macrophage population and a monocyte-derived macrophage population. The data indicate an obvious difference in development and differentiation between the two populations and the temporal precedence of fetal macrophages appearing before monocyte-macrophages.

Relationship between Helicobacter pylori infection and histologic features of gastritis in biopsy specimens in gastroduodenal diseases, including evaluation of diagnosis by polymerase chain reaction assay.

We investigated the relationship between Helicobacter pylori infection and the histologic features of gastritis in gastroduodenal disease, and evaluated the diagnostic usefulness of the polymerase chain reaction (PCR) assay for the detection of H. pylori before and after eradication therapy. Endoscopic biopsy specimens from 81 patients with gastroduodenal disease were examined for the presence of H. pylori by culture and histologic examination. Histologic features of gastritis were classified according to the updated Sydney System, and results of the PCR assay were compared with those of histologic examination, using histologic scores. The density of H. pylori was significantly correlated with polymorphonuclear neutrophil activity and chronic inflammation. These findings suggest that the grades of infiltration of polymorphonuclear neutrophil cells and chronic inflammatory cells correspond to the density of H. pylori infection assessed by the updated Sydney System. Patients with positive results on PCR assay and negative results on histologic examination may have a low density of H. pylori because of severe atrophy in the gastric mucosa. Differences in results for the PCR assay and histologic examination were found in 2 of 12 patients in the detection of H. pylori after eradication therapy. According to the results of the PCR assay and histologic features before and after eradication, the gastric tissue-based PCR assay for H. pylori after eradication may be too sensitive to judge successful eradication of H. pylori.

Infantile osteopetrosis complicating neuronal ceroid lipofuscinosis.

An autopsy case of infantile osteopetrosis complicating neuronal ceroid-lipofuscinosis is reported. Autopsy revealed generalized sclerosis and thickening of cortical and spongy bones, formation of mineralized cartilagenous tissues, and narrowing of the marrow cavities associated with decreased hematopoietic cell components. Around the thickened bone trabecles, osteoclasts lacked a ruffled border and clear zone along the cell membrane facing the bone matrix surface. The brain was markedly atrophic with neuronal cell loss and focal gliosis, and the remaining neuronal cells accumulated brown granular pigments, which were confirmed histochemically and electron-microscopically to be ceroid and lipofuscin. In the cerebral medulla, the development of myelin sheaths was extremely poor. Also, the occurrence of Lex type glycolipids and GM3 and the apparent absence of cerebroside and cerebroside sulfate were proved by biochemical analysis, suggesting that the brain was still in a stage of embryonic development or still in the process of differentiation. Except for one suggestive case, this is the first case of complicating neuronal ceroid-lipofuscinosis in infantile osteopetrosis.

Gastrointestinal lesions in an adult patient with Henoch-Schönlein purpura.

A 28 year-old man was admitted because drug toxication, due to a high dose of antipsychotic drugs, presented purpuric rash on both legs, lower abdominal pain, arthralgia, and fresh-bloody stool. Colonoscopy observed numerous small ring-like petechiae in the rectum and in the sigmoid colon. Upper gastrointestinal endoscopy found a few petechiae in the antrum of the stomach and in the duodenal second portion. He was treated with coagulation factor X III after admission. After 38 days, there was no abnormal mucosa in the colorectum, the duodenal second portion, or the antrum of the stomach. The disappearance of gastrointestinal lesions correlated with the course of the illness. Gastrointestinal tracts should be thoroughly observed in patients with Henoch-Schönlein purpura.

Histological findings after placement of a self-expanding stent in rectal carcinoma with complete obstruction--case report.

Patients with acute obstruction due to colorectal carcinomas frequently require emergency surgery. However, such emergency procedures are associated with various complications, a high mortality rate and a poor prognosis. If the obstruction could be immediately relieved, the patient could later undergo an elective operation with a much better prognosis. Recently, expanding metallic stents have been used to treat obstruction due to colorectal carcinoma. In the case reported here, we initially inserted a colonoscopic retrograde bowel drainage tube per anus to achieve decompression. We then placed a self-expanding metallic stent, since we anticipated a prolonged preoperative period due to high fever, congestive heart failure, cerebral infarction, and persistent high blood sugar concentrations. The patient had no complications for 57 days after placement of the stent, and eventually underwent an elective operation. Histologically, the side of the cancerous lesion compressed by the stent was thin and consisted solely of a serosal layer. Implantation of a metallic stent is safe for the treatment of acute malignant obstruction. Stent placement is indicated not only as a palliative treatment for inoperable or recurrent cases, but also as a preoperative procedure before elective surgical resection.

IgM myeloma--its distinction from Waldenström's macroglobulinemia.

An autopsy case of multiple myeloma (MM) with marked elevation of serum IgM as an M-component, diagnosed as IgM myeloma, was described. Clinically, multiple bone lesions were found but neither lymphadenopathy, hepatosplenomegaly nor tumor mass formation in the gastrointestinal tract. Pathologically, the tumor cells proliferating in the bone lesions were mainly comprised of myeloma cells closely resembling mature plasma cells, though they contained immature cells as a minor cell population. At autopsy, slight infiltration of myeloma cells was confirmed in the lymph nodes, spleen and both kidneys, which is considered to be a terminal phenomenon that occurred in the clinical course of the case. From these findings, it appears reasonable that, though a monoclonal increase of serum IgM was found, this case differs from Waldenström's macroglobulinemia (WM) both clinically and pathologically and is rather situated within the category of MM. The occurrence of such a case is extremely rare, only 28 cases being reported in the literature, including 13 autopsy cases. The existence of IgM myeloma in the category of MM should be emphasized as a disorder distinct from WM.

B cell ontogeny in murine embryo studied by a culture system with the monolayer of a stromal cell clone, ST2: B cell progenitor develops first in the embryonal body rather than in the yolk sac.

A stromal cell clone, ST2, which can support both myelopoiesis and B lymphopoiesis of adult bone marrow was used as an in vitro microenvironment for investigating the ontogeny of the B cell progenitor in murine embryos. The B cell progenitor clonable on an ST2 layer first become detectable in the embryonal body rather than in the yolk sac around day 9.5 of gestation. As soon as it develops in the embryo, it enters the blood circulation and becomes detectable both in the developing fetal liver and the yolk sac of the 10 day embryo. On the other hand, mast cell and polymorphonuclear cell progenitors, which are also generated on the ST2 layer, develop first in the yolk sac and migrate to the fetal liver around day 10-11 of gestation. At the late stage of embryonal development, day 15-16 of gestation, the B cell progenitor enters the femur as vascularization of the femur starts. These results suggest that the localization of the committed stem cells for various hemopoietic cell lineages differs in the early embryo, although the localization of the pluripotent stem cells is yet to be determined.

Hepatic angiomyolipoma. A case report with review of the literature.

Hepatic angiomyolipoma in a 59-year-old woman is reported. The tumor was located at the lower edge of the left lobe of the liver, measured 3 x 2 x 2 cm, and appeared solid. Histologically, it consisted of abundant blood vessels of varying caliber, mature fat cells, and round, spindle-shaped or epithelioid interstitial cells. The latter were considered to be of smooth muscle origin, because myofilamentous structures were demonstrated ultrastructurally in the cytoplasm and because they were positive for desmin by the PAP method. Based on these findings, the diagnosis of angiomyolipoma was confirmed. A review of the literature revealed only 15 cases of hepatic angiomyolipoma. From a clinicopathological viewpoint, a comparison was made between hepatic angiomyolipoma and its more frequent renal counterpart. The hepatic tumor is considered to be a kind of hamartoma.

Nonsecretory myeloma: analysis of two patients by immunoperoxidase studies and plaque-forming cell assay.

We studied the production and secretion of immunoglobulin by tumor cells in two patients with nonsecretory myeloma, by means of an immunoperoxidase technique and plaque-forming cell assay. Immunoperoxidase staining of bone marrow cells revealed monoclonal proliferation of immunoglobulin-containing cells, and the plaque-forming cell assay of peripheral mononuclear cells and bone marrow cells showed secretion of monoclonal immunoglobulin from the myeloma cells. These observations suggest that the secreted protein disappears as a result of enhanced catabolism or rapid deposition. There has been speculation as to the existence of this type of nonsecretory myeloma, but there had been no evidence. We were able to demonstrate it with the plaque-forming cell assay.