Clinical significance of dispersion imaging by shear wave elastography in the treatment and diagnosis of pancreatic cancer.

BACKGROUND AND AIM: Recently, dispersion imaging by shear wave elastography has been developed to visualize a tissue viscosity-related factor by measuring the dispersion slope. However, clinical significance of dispersion imaging in the field of pancreatic cancer is unknown. This study aimed to investigate the clinical significance of dispersion imaging in the treatment and diagnosis of pancreatic cancer. METHODS: We measured shear wave dispersion slope (SWD) (m/s/kHz) and shear wave elasticity (SWE) (kPa) in patients with pancreatic ductal adenocarcinoma (PDA). The primary endpoint was the relationship between the changes in SWD and SWE values before and after chemotherapy and the response to chemotherapy. Secondary endpoints included SWD and SWE values in relation to differences between PDA and non-PDA sites and histopathological scores of stroma, inflammation, fibrosis, and necrosis in endoscopic ultrasound-guided fine-needle aspiration specimens. RESULTS: Fifty-six patients were included, 30 of whom underwent chemotherapy. There was no relationship between the changes of SWD and SWE values and chemotherapy responses. In 56 patients, the median SWD value was 12.20 m/s/kHz (interquartile range [IQR]: 10.88-13.61) at PDA sites and 13.57 m/s/kHz (IQR: 12.28-16.20) at non-PDA sites (P = 0.005). The median SWE value was 8.18 kPa (IQR: 7.00-9.74) at PDA sites and 6.14 kPa (IQR: 5.40-6.77) at non-PDA sites (P < 0.001). Histopathological evaluation revealed that inflammation scores were correlated with SWD values (rs  = 0.42, P < 0.001). CONCLUSIONS: Dispersion imaging in pancreatic cancer would be useful for diagnosis and assessing inflammation.

Clinical and imaging features of interstitial lung disease in cancer patients treated with trastuzumab deruxtecan.

BACKGROUND: Interstitial lung disease/pneumonitis (ILD/pneumonitis) has been identified as a drug-related adverse event of special interest of trastuzumab deruxtecan (T-DXd), but there were a few reports of T-DXd-related ILD/pneumonitis in clinical practice. METHODS: Between May 25, 2020 (the launch of T-DXd in Japan) and February 24, 2022, there were 287 physician-reported potential ILD/pneumonitis cases from the Japanese post-marketing all-case surveillance. By February 27, 2022, an independent adjudication committee assessed 138 cases and adjudicated 130 cases as T-DXd-related ILD/pneumonitis. The clinical features and imaging characteristics of these cases were evaluated. RESULTS: The majority of adjudicated T-DXd-related ILD/pneumonitis cases were grade 1 or 2 (100/130, 76.9%). The most common radiological pattern types observed were organizing pneumonia patterns (63.1%), hypersensitivity pneumonitis patterns (16.9%), and diffuse alveolar damage (DAD) patterns (14.6%). Eleven cases (8.5%) from 130 resulted in death; the majority of these (8/11, 72.7%) had DAD patterns. The overall proportion of recovery (including the outcomes of recovered, recovered with sequelae, and recovering) was 76.9%, and the median time to recovery was 83.5 days (interquartile range: 42.25-143.75 days). Most cases (59/71, 83.1%) that were treated with corticosteroids were considered responsive to treatment. CONCLUSIONS: This is the first report to evaluate T-DXd-related ILD/pneumonitis cases in clinical practice. Our findings are consistent with previous reports and suggest that patients with DAD patterns have poor outcomes. Evaluation of a larger real-world dataset may further identify predictors of clinical outcome.

Efficacy of a novel ultra-sharp dilation device for dilating bare metal stent mesh in patients with hilar malignant biliary obstruction.

The placement of additional stents in patients with hilar malignant biliary obstruction can be challenging when a metal stent already exists because occasionally, the catheter and delivery system of the additional stent cannot pass through the mesh of the formerly placed stent. We studied ten consecutive patients with hilar malignant biliary obstruction who underwent mesh dilation using a novel ultra-sharp dilation device (ES dilator) to assess the efficacy and safety of the ES dilator for mesh dilation. Mesh dilation using the ES dilator was successful in eight patients (8/10; 80.0%), which was the same rate as that of patients with pre-dilation using a Soehendra biliary dilation catheter (4/5, 80.0%) and patients without pre-dilation (4/5, 80.0%). In the two patients with dilation failure, the angle of the hilar bile duct branch was too steep to permit the passage of a stiff dilation device. Nonetheless, stent placement was uncomplicated in all mesh-dilated patients (8/8, 100.0%), and no adverse events related to the ES dilator were observed. The efficacy of an ultra-sharp dilation device appears promising for metallic stent mesh dilation, especially in patients where conventional methods are unsuccessful. However, additional data are necessary to confirm our findings.

Successful treatment by on-demand glecaprevir and pibrentasvir for hepatitis C flare during R-CHOP in patients with diffuse large B-cell lymphoma: a case report.

BACKGROUND: In patients with hepatitis C virus (HCV) and malignant lymphoma, hepatitis C flare during R-CHOP can result in discontinuation of treatment. However, appropriate therapeutic strategies for managing hepatitis C flare during R-CHOP have not been established, and this issue is complicated by conflicting results regarding the use of direct-acting antivirals in patients with uncontrolled malignancies. CASE PRESENTATION: We report the first case of effective and safe treatment with on-demand 8-week glecaprevir and pibrentasvir for hepatitis C flare during R-CHOP in a patient with diffuse large B-cell lymphoma (DLBCL). The patient completed five additional courses of R-CHOP without hepatic toxicity. A complete response of DLBCL and a sustained virological response were observed at 24 weeks after glecaprevir and pibrentasvir completion. CONCLUSION: On-demand, direct-acting antivirals could be a novel strategy for managing hepatitis C flare during R-CHOP.

Time to diagnosis and clinical characteristics in pediatric brain tumor patients.

PURPOSE: We aimed to identify factors that affect the time to diagnosis in pediatric brain tumors and investigate the effect of time to diagnosis on clinical outcome. METHODS: A retrospective study of children with brain tumors aged less than 18 years diagnosed at the University of Tsukuba Hospital over a period of 7 years was conducted. RESULTS: Eighty-five consecutive patients, with a mean age of 9.1 years, were included in the study. The median interval from symptom onset to diagnosis was 45 days (range 0-1673); median interval from symptom onset to first presentation was 31.0 days; and median interval from first presentation to diagnosis was 13.5 days. Germinoma had the longest interval from symptom onset to first presentation, and from first presentation to diagnosis. Patients presenting with endocrine disorder had a significantly longer interval from symptom onset to first presentation (p = 0.019); those with visual disturbance (p = 0.016) or endocrine disorder (p = 0.030) had significantly longer intervals from first presentation to diagnosis. CONCLUSION: Pediatric brain tumor patients with germinoma and presenting symptoms of endocrine disorder or visual disturbance have a longer time to diagnosis. Although improved prognosis is not clearly related to a shorter time to diagnosis, we believe that early diagnosis can lead to improved treatment and better quality of life. A detailed medical history and neuroimaging studies at the earliest time possible are important for early diagnosis.

Effect of Pancreatic Mass Size on Clinical Outcomes of Endoscopic Ultrasound-Guided Fine-Needle Aspiration.

BACKGROUND: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has high diagnostic accuracy for pancreatic diseases. However, the effect of mass size on diagnostic accuracy has yet to be determined, especially for small pancreatic lesions. We aimed to determine the effect of pancreatic mass size on the diagnostic yield of EUS-FNA. METHODS: We searched the database in Hokkaido University Hospital between May 2008 and December 2016 and identified solid pancreatic lesions examined by EUS-FNA. All lesions were stratified into five groups based on mass sizes: groups A (< 10 mm), B (10-20 mm), C (20-30 mm), D (30-40 mm) and E (≥ 40 mm). The sensitivity, specificity, diagnostic accuracy and adverse event rate were retrospectively evaluated. RESULTS: We analyzed a total of 788 solid pancreatic lesions in 761 patients. The patients included 440 males (57.8%) with a mean age of 65.7 years. The sensitivities in groups A (n = 36), B (n = 223), C (n = 304), D (n = 147) and E (n = 78) were 89.3%, 95.0%, 97.4%, 98.5% and 98.7%, respectively, and they significantly increased as the mass size increased (P < 0.01, chi-squared test for trend). The diagnostic accuracies were 91.7%, 96.4%, 97.7%, 98.6% and 98.7%, respectively, and they also significantly increased as the mass size increased (P = 0.03). Multivariate analysis showed that pancreatic mass size was associated with diagnostic accuracy. The adverse event rates were not significantly different among the five groups. CONCLUSIONS: The sensitivities and diagnostic accuracies of EUS-FNA for solid pancreatic lesions are higher for lesions ≥ 10 mm in size, and they are strongly correlated with mass size.

Short- and long-term outcomes of a novel transpapillary dilation technique using a diathermic dilator for severe benign bile duct stricture.

Endoscopic dilation for severe benign biliary stricture using mechanical dilation devices is occasionally ineffective. Hence, diathermic dilation has recently been gaining attention as a salvage procedure. We evaluated the short- and long-term outcomes of diathermic dilation for severe benign biliary stricture that could not be dilated using conventional mechanical dilation. Thirteen consecutive cases with severe benign biliary stricture that underwent diathermic dilation using 6-Fr electrocautery dilator were enrolled. Short- and long-term outcomes were analyzed. Diathermic dilation was successful in 13 cases (100%), whereas stent was successfully placed in 12 cases (92.3%). Adverse events occurred in two cases (15.4%): mild hemobilia and cholangitis. Recurrence of bile duct stricture was observed in five out of 12 cases (41. 7%) in the 1115-day median follow-up period. Finally, eight cases achieved stent-free state (61.5%) and have remained stent-free without any episode of cholangitis and abnormal liver function test. Diathermic dilation using 6-Fr electrocautery dilator is a promising salvage procedure for severe benign biliary stricture when the conventional dilation technique has been ineffective.

Hyper-vascular giant cavernous malformation in a child: a case report and review.

INTRODUCTION: Giant cavernous malformation (GCM) in children is a rare vascular anomaly, and its natural history is unclear. Despite their giant size, intraparenchymal GCMs are low-flow vascular malformations. Herein, we report a case of hyper-vascular intraparenchymal GCM with an AV shunt in a child. CASE: A 3-year-old boy had had an enlarged head since infancy. Magnetic resonance (MR) images on admission showed a strikingly enhanced mass lesion, 6 cm in size. A 4-vessel CAG demonstrated a hyper-vascular mass with an AV shunt. After transarterial embolization, the patient underwent total excision of the mass. The tumor bled easily, during surgery the patient lost 400 cm3 in blood. Histopathological examination confirmed the diagnosis of cavernous hemangioma. CONCLUSION: The differential diagnosis of intraparenchymal, strikingly-enhanced tumors with an AV shunt include hyper-vascular GCMs. Consideration of potential for bleeding during the operation is also important.

The efficacy and safety of the internal medication therapy of the triple drugs for chronic subdural hematoma: Retrospective analysis.

The recurrence of chronic subdural hematoma (CSDH) after surgical treatment is a severe problem with no effective prevention method. This retrospective study aimed to investigate factors associated with CSDH recurrence after burr hole surgery and hematoma changes on computed tomography before surgery to examine prevention methods for recurrence. A total of 166 hematomas were enrolled in this study, with 139 patients undergoing burr hole surgery for CSDH. Among these patients, 17 (12 %) had recurrence. Propensity score matching was performed based on postoperative drug therapy, including goreisan, carbazochrome sodium sulfonate hydrate, and tranexamic aid, resulting in 39 matched cases in 0-2 and 3 drug therapy groups. The recurrence rates were 18 % for the 0-2-drug therapy group and 3 % for the 3-drug therapy group. Univariate analysis revealed that the use of 0-2 drugs was associated with a higher risk of CSDH recurrence (odds ratio [OR], 8.31; 95 % confidence interval [CI], 0.97-71.17; p = 0.05) compared to the use of 3 drugs. Multivariate regression analysis further confirmed that 0-2 drug therapy after surgery was associated with an increased risk of CSDH recurrence (OR, 11.06; 95 % CI, 1.16-105.4; p = 0.037). Additionally, 36 hematomas were evaluated before surgery, with hematoma changes such as lower density and new trabecular formation detected in 14 CSDHs (39 %). Multivariate regression analysis showed that 3-drug therapy was associated with more cases of hematoma change than 0-2-drug therapy (OR, 13.9; 95 % CI, 1.09-177.65; p = 0.043). The 3-drug therapy was effective in reducing the recurrence of hematoma after burr hole surgery and promoted hematoma thrombosis.

Transvenous Embolization for Isolated Superior Petrosal Sinus Dural Arteriovenous Fistula.

Isolated superior petrosal sinus dural arteriovenous fistula (SPSdAVF) is a rare condition for which transvenous embolization is a safe treatment, even if accessing the isolated sinus can be challenging. A 39-year-old female patient with dizziness and right facial palsy underwent magnetic resonance imaging, revealing a venous infarction at the posterior fossa and a dural arteriovenous fistula. Digital subtraction angiography showed an isolated SPSdAVF. The shunt point was posterior to the isolated superior petrosal sinus, and the shunt flowed only through the petrosal vein. Contrast-enhanced magnetic resonance imaging showed thrombosis at the anterior segment of the superior petrosal sinus. Transvenous embolization was successfully performed via the thrombosed anterior segment of the superior petrosal sinus without associated complications. This case shows that transvenous embolization through a thrombosed superior petrosal sinus is an alternative treatment option for isolated SPSdAVF.

Efficacy and Safety of Lumbar Drainage before Endovascular Treatment for Ruptured Intracranial Aneurysms.

Objective: Intraoperative rebleeding during endovascular treatment for ruptured intracranial aneurysms is associated with poor prognosis. Lumbar drainage is performed preoperatively to control intracranial pressure; however, it is associated with a risk of brain herniation or rebleeding because intracranial pressure may change rapidly. Therefore, this study aimed to examine the efficacy and safety of preoperative lumbar drainage. Methods: This retrospective study enrolled 375 patients who underwent endovascular treatment of ruptured intracranial aneurysms at our institution between April 2013 and March 2018. The incidence of rebleeding and clinical outcomes were compared between patients who did and did not undergo preoperative lumbar drainage. Results: Among the 375 patients with ruptured intracranial aneurysms, 324 (86.0%) and 51 (14.0%) patients did and did not undergo lumbar drainage, respectively. The incidence of rebleeding was 11/324 (3.4%) and 2/51 (3.9%) in lumbar drainage and nonlumbar drainage groups, respectively, with no statistical differences (p = 0.98). Of the rebleeding cases, 9/11 (81%) and 2/2 (100%) in lumbar drainage and nonlumbar drainage groups, respectively, were due to intraoperative bleeding, and 2/11 (19%) in the lumbar drainage group, the causes of the rebleeding were undetermined. The incidence of symptomatic vasospasm did not differ significantly between the groups (13.2% vs. 11.8%, P = 0.776), while the incidence of hydrocephalus (24.6% vs. 11.8%, P = 0.043) and meningitis (15.2% vs. 5.9%, P = 0.075) were slightly higher in the lumbar drainage group. Favorable clinical outcomes (modified Rankin Scale score <2) at discharge were less frequent in the lumbar drainage group (55.3% vs. 70.0%, P = 0.051). No significant differences were observed in the propensity score-matched analysis. Conclusion: Lumbar drainage before endovascular treatment for ruptured intracranial aneurysms is a safe procedure that does not increase the incidence of rebleeding.

Risk factors for recurrent biliary obstruction following endoscopic biliary stenting in patients with unresectable ampullary cancer: A multicenter retrospective study.

OBJECTIVES: Unresectable ampullary cancer (AC) is a rare disease entity. The risk factors for recurrent biliary obstruction (RBO) following endoscopic biliary stenting (EBS) for unresectable AC remain unknown. In this study we aimed to evaluate the cumulative RBO rate and to identify risk factors for RBO following palliative EBS in patients with unresectable AC. METHODS: This multicenter retrospective observational study enrolled consecutive patients with unresectable AC who had undergone palliative EBS between April 2011 and December 2021. The cumulative rate of and risk factors for RBO following palliative EBS were evaluated via multivariate analysis. RESULTS: The study analysis comprised 107 patients with a median age of 84 years (interquartile range 79-88 years). Plastic stents (PSs) and self-expandable metal stents (SEMSs) were placed in 53 and 54 patients, respectively. Functional success was accomplished in 104 (97.2%) patients. Of these, RBO occurred in 62 (59.6%) patients, with obstruction and complete/partial migration occurring in 47 and 15 patients, respectively. The median time to RBO was 190 days. Multivariate analysis showed that PS was associated with a higher rate of RBO compared to SEMS (hazard ratio [HR] 2.48; P < 0.01) and that the presence of common bile duct stones/sludge immediately after EBS was an independent risk factor for RBO (HR 1.99; P = 0.04). CONCLUSIONS: The use of SEMS compared to PS during EBS reduced the time to RBO in patients with unresectable AC. Common bile duct stones/sludge immediately after EBS was a risk factor for RBO.

Significance of Shear Wave Dispersion Slope Values Before Versus After Biliary Drainage in Patients With Obstructive Jaundice: A Single-Center Prospective Observational Cohort Study.

ABSTRACT: The shear wave dispersion (SWD) slope has become available in the clinical practice and is related to tissue viscosity. However, clinical evaluation using SWD was not yet performed for obstructive jaundice. We aimed to evaluate the change of SWD values between before and after biliary drainage in patients with obstructive jaundice. This prospective observational cohort study evaluated 20 patients with obstructive jaundice who underwent biliary drainage. The SWD and liver elasticity values were measured before versus after biliary drainage, comparing between days -5 and 0 (day 0), days 1 and 3 (day 2), and days 6 and 8 (day 7). The mean ± SD values of SWD measured at day 0, day 2, and day 7 were 15.3 ± 2.7, 14.2 ± 3.3, and 13.3 ± 2.4 m/s/kHz, respectively. Dispersion slope values were decreased significantly from day 0 to day 2, from day 2 to day 7, and from day 0 to day 7 ( P < 0.05). Liver elasticity levels and serum hepatobiliary enzymes were additionally decreased significantly over time after biliary drainage. The correlations between SWD and liver elasticity values were strong ( r = 0.91, P < 0.01). In conclusion, t he SWD values decreased significantly over time after biliary drainage concomitant with liver elasticity.

Efficacy of redox nanoparticles for improving survival of transplanted cells in a mouse model of ischemic stroke.

The success of cell transplantation therapy for ischemic stroke is hindered by the low cell survival rate in poststroke brain, due in part to high free radical production and ensuing oxidative stress. We have developed redox nanoparticles to eliminate reactive oxygen species. In this study, we tested the protective efficacy of these redox nanoparticles in cell culture and a mouse model of ischemic stroke. Induced human dental pulp stem cells were subjected to oxygen-glucose deprivation and reoxygenation to recapitulate ischemia and reperfusion in the penumbra surrounding a cerebral infarct. Cell viability using WST-8 assay, apoptosis using TUNEL, free radicals using MitoSOX, and inflammatory cytokines using ELISA kit were measured in the presence and absence of redox nanoparticles after oxygen-glucose deprivation and reoxygenation. The scavenging activity of redox nanoparticles against reactive oxygen species was detected by electron spin resonance. Moreover, induced cells were transplanted intracerebrally into to the distal middle cerebral artery occlusion model with and without redox nanoparticles, and the survival rate measured. Cell viability was enhanced, while apoptosis, free radical generation, and inflammatory cytokine expression levels were reduced in cultures with redox nanoparticles. Further, reduced redox nanoparticles were detected in the cytoplasm, indicating free radical scavenging. Addition of redox nanoparticles also improved the survival rate of transplanted cells after 6 weeks in vivo. These redox nanoparticles may increase the applicability and success of induced stem cell therapy for ischemic stroke patents by promoting long-term survival.

Effects of activation of an alcohol metabolic gene, cigarette smoking, and alcohol intake on the incidence of metachronous gastric cancer in patients who underwent endoscopic resection for gastric cancer: A multicenter retrospective pilot study.

Background and Aim: Metachronous gastric cancer (GC) frequently occurs in patients who have undergone endoscopic resection (ER) for GC. We evaluated the risk for development of metachronous GC following ER for GC based on genetic polymorphisms for alcohol dehydrogenase-1B (ADH1B) and aldehyde dehydrogenase-2 (ALDH2), as well as alcohol consumption and smoking habits. Methods: We studied 77 patients who underwent ER for GC (median follow-up of 84 months). Genotyping of ADH1B/ALDH2 was performed using saliva sampling. Histories of alcohol consumption and smoking before and after ER and Helicobacter pylori eradication were documented. Results: Multivariate analyses revealed that homozygous slow-metabolizing ADH1B (hazard ratio [HR] = 2.38, P < 0.13), heavy smoking (HR = 2.36, P < 0.09), and cigarette smoking after ER (HR = 2.47, P < 0.10) were not independently associated with the risk of secondary GC development. We analyzed the cessation status of the 38 patients who were classified as heavy smokers before ER based on their smoking habits after the ER and divided them into a cessation group (n = 27, non-smokers after ER) and a non-cessation group (n = 11). Cumulative incidence curves of secondary GC in the cessation and non-cessation groups revealed 5-year incidence rates of 19.0% and 45.0%, respectively (P = 0.02). Conclusion: Continued cigarette smoking, at a high level, may be an important risk factor for the development of metachronous GC. Advice for smoking cessation should be given.