[Acute tumor lysis syndrome in the setting of advanced gastric cancer].

A 69-year-old man was admitted with right flank pain. The patient was diagnosed with advanced gastric cancer with multiple metastases in the liver and abdominal lymph nodes and underwent chemotherapy. Three days following the initial administration of S-1 plus cisplatin, the patient developed tumor lysis syndrome (TLS) with increased LDH, hyperuricemia, hyperkalemia, and elevated creatinine. Although rare, TLS following chemotherapy for solid tumors is a potentially fatal complication, and high physician awareness is required, especially in patients with risk factors, such as bulky disease.

[Mass-forming autoimmune pancreatitis caused after resection of an IgG4-related renal pelvic lesion].

A 64-year-old man was found to have a 15-mm tumor in the pancreatic tail by CT angiography 1 year after resection of a left renal pelvic tumor. Clinically, the tumor was preoperatively suspected to be autoimmune pancreatitis. However, surgical resection was performed under a diagnosis of pancreatic ductal cancer, because atypical epithelial cells were detected by endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Pathological examination of the tumor revealed a mass-forming autoimmune pancreatitis. Mass-forming autoimmune pancreatitis is often difficult to preoperatively differentiate from pancreatic carcinoma. Response to steroid treatment and the detection of extrapancreatic lesions may contribute to an accurate diagnosis, thereby avoiding unnecessary surgery.

Narrow-band imaging magnification predicts the histology and invasion depth of colorectal tumors.

BACKGROUND: There are several reports concerning the differential diagnosis of non-neoplastic and neoplastic colorectal lesions by narrow-band imaging (NBI). However, there are only a few NBI articles that assessed invasion depth. OBJECTIVE: To determine the clinical usefulness of NBI magnification for evaluating microvessel architecture in relation to pit appearances and in the qualitative diagnosis of colorectal tumors. DESIGN: A retrospective study. SETTING: Department of Endoscopy, Hiroshima University, Hiroshima, Japan. PATIENTS AND MAIN OUTCOME MEASUREMENTS: A total of 289 colorectal lesions were analyzed: 12 hyperplasias (HP), 165 tubular adenomas (TA), 65 carcinomas with intramucosal to scanty submucosal invasion (M-SM-s), and 47 carcinomas with massive submucosal invasion (SM-m). Lesions were observed by NBI magnifying endoscopy and were classified according to microvessel features and pit appearances: type A, type B, and type C. Type C was divided into 3 subtypes (C1, C2, and C3), according to the detailed NBI magnifying findings of pit visibility, vessel diameter, irregularity, and distribution. These were compared with histologic findings. RESULTS: Histologic findings of HP and TA were seen in 80.0% and 20.0%, respectively, of type A lesions. TA and M-SM-s were found in 79.7% and 20.3%, respectively, of type B lesions. TA, M-SM-s, and SM-m were found in 21.6%, 29.9%, and 48.5, respectively, of type C lesions. HPs were observed significantly more often than TAs in type A lesions, TAs were observed significantly more often than carcinomas in type B lesions, carcinomas were observed significantly more often than TAs in type C (P < .01). TA, M-SM-s, and SM-m were found in 46.7%, 42.2%, and 11.1% of type C1 lesions, respectively. M-SM-s and SM-m were found in 45.5% and 54.5%, respectively, of type C2 lesions. SM-m was found in 100% of type C3 lesions. TAs and M-SM-s were observed significantly more often than SM-m in type C1 lesions, and SM-m were observed significantly more often than TAs and M-SM-s in type C3 lesions (P < .01). CONCLUSIONS: NBI magnification findings of colorectal lesions were associated with histologic grade and invasion depth.

Evaluation of microvessels in colorectal tumors by narrow band imaging magnification.

BACKGROUND: Narrow band imaging (NBI) uses optical filters for sequential green and blue illumination and narrows the bandwidth of spectral transmittance. OBJECTIVE: We determined the clinical usefulness of NBI magnification for evaluation of microvascular architecture and qualitative diagnosis of colorectal tumors. DESIGN: This study was a retrospective study. SETTING: Department of Endoscopy, Hiroshima University, Hiroshima, Japan. PATIENTS AND MAIN OUTCOME MEASUREMENTS: A total of 189 colorectal lesions were analyzed. Each lesion was observed by NBI magnifying endoscopy and classified according to microvascular features (ie, thickness and irregularity). Microvessel thickness was classified as invisible, thin, or thick, and microvessel irregularity was classified as invisible, regular, mildly irregular, or severely irregular. NBI endoscopic images were compared with histologic findings. RESULTS: With respect to microvessel thickness, invisible microvessels were found significantly more often in hyperplasia lesions, and thick microvessels were found significantly more often in carcinoma with submucosal massive invasion (sm-m) (P < .01). With respect to microvessel irregularity, invisible microvessels were found significantly often in hyperplasia lesions, and severely irregular microvessels were found significantly often in sm-m lesions (P < .01). Accuracy of diagnosis of sm-m on the basis of thick and severely irregular lesions was 100%. CONCLUSION: Microvascular features determined by NBI magnification are associated with histologic grade and depth of submucosal invasion. These results indicate that NBI magnification is useful for the prediction of histologic diagnosis and selection of therapeutic strategies of colorectal tumors.

Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization.

BACKGROUND: Endoscopic submucosal dissection (ESD) has been positively applied to and gradually standardized for early stomach cancer, particularly in Japan. However, because it is technically difficult to perform ESD of the colon, ESD is not a commonly used technique. OBJECTIVE: The aim of this study was to evaluate the possibility of standardizing colorectal ESD. SETTING: ESD was performed at the Department of Endoscopy, Hiroshima University Hospital. DESIGN: Time required for ESD, rate of complete en bloc resection, complication, and postoperative local persistence and recurrence were investigated retrospectively in 70 cases of colorectal neoplasia, wherein the lesion was more than 20 mm in diameter. INTERVENTIONS: All lesions were resected by ESD. RESULTS: The average (+/-SD) time required for ESD was 70.5+/-45.9 minutes (range, 15-180 minutes), and the histologic rate of complete en bloc resection was 80.0% (56/70). With regard to complication, 1.4% of cases of postoperative hemorrhage (1/70) and 10.0% of cases of perforation (7/70) were observed in total. The rate of perforation was investigated with respect to the type of knife used for ESD and the period after the induction of ESD. The rate of perforation markedly decreased with the practice of the technique. Moreover, the rate of perforation was high when an insulated-tip diathermic knife was used; practicing this technique was insufficient to reduce the rate of perforation. The average duration of follow-up was 614+/-289.5 days, and no case of local persistence and recurrence or metastasis was observed. LIMITATIONS: The ESD technique depends on the level of each skill of each colonoscopist. CONCLUSIONS: With regard to ESD of the colon, complication, eg, perforation, could be decreased by sufficient practice and selection of an appropriate knife. It is suggested that, in the near future, ESD will be standardized for the colon.

Optical biopsy of GI lesions by reflectance-type laser-scanning confocal microscopy.

BACKGROUND: Laser-scanning confocal microscopy (LCM) is a new, noninvasive method of optical imaging that may be able to provide an instant microscopic image of untreated tissue under endoscopy. OBJECTIVE: The aim of this study was to compare LCM images and histologic images of GI lesions to clarify the usefulness of LCM in diagnosing neoplastic lesions. DESIGN: This study was a feasibility study. SETTING: The Department of Endoscopy, Hiroshima University Hospital. PATIENTS AND MAIN OUTCOME MEASUREMENTS: The study materials were GI lesions resected endoscopically at our institute. Twenty-two areas of 15 untreated specimens from the esophagus (normal mucosa, n=1; dysplasia, n=1), stomach (normal mucosa, n=3; cancer, n=5), and colon (normal mucosa, n=3; adenoma, n=8; cancer, n=1) were examined. LCM images and images of hematoxylin and eosin-stained sections were compared. A prototype probe LCM system that is equipped with a semiconductor laser that oscillates at 685 nm and that analyzes reflected light was used. RESULTS: Smooth nuclei of cells were visualized by LCM in the normal esophageal-mucosa specimen. Irregular nuclei were visualized in 3 of 5 gastric-cancer specimens and in cells around the crypt of the colonic-cancer specimen. Nuclei were visualized in 5 of 8 colonic-adenoma specimens. Nuclei were not visualized in 2 of 3 normal gastric-mucosa specimens or in normal colonic-mucosa specimens. CONCLUSIONS: LCM provides instant microscopic images, and, with further technical improvement, in the future this novel method will aid in immediate diagnosis under endoscopy without the need for tissue biopsy.

Magnifying endoscopy with narrow band imaging for diagnosis of colorectal tumors.

BACKGROUND: Narrow band imaging (NBI) uses optical filters for red-green-blue sequential illumination and narrows the bandwidth of spectral transmittance. OBJECTIVE: This study aimed to clarify the clinical usefulness of NBI magnification in assessment of pit patterns for diagnosis of colorectal tumors. DESIGN: This was a retrospective study. SETTING: Department of Endoscopy, Hiroshima University Hospital. PATIENTS AND MAIN OUTCOME MEASUREMENTS: A total of 148 colorectal lesions, 16 hyperplasias, 84 tubular adenomas, and 48 early carcinomas were examined and diagnosed histologically. Mean size of lesions was 15.6+/-7.28 mm. Lesions were observed first under NBI magnification without chromoendoscopy and then under standard magnification with chromoendoscopy, and pit patterns were recorded. Results of NBI magnification were compared with those of standard magnification with chromoendoscopy to assess the clinical usefulness of NBI magnification for diagnosing colorectal neoplasia. RESULTS: Correspondence between the two diagnostic methods was 88% (14/16) for type II, 100% (2/2) for type IIIs, 98% (73/75) for type IIIl, 88% (7/8) for type IV, 78% (25/32) for type Vi, and 100% (3/3) for type Vn pit patterns. NBI depicted brownish change on the basis of surface capillaries in 6% (1/16) of hyperplasia and 99% (83/84) of tubular adenomas. This difference in color depiction was significant. LIMITATIONS: This study was performed in single center. CONCLUSIONS: Determination of pit patterns of colorectal neoplasias by NBI magnification was nearly the same as that by standard magnification with chromoendoscopy. Furthermore, NBI can distinguish neoplastic and nonneoplastic lesions without chromoendoscopy.

Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer.

BACKGROUND: In EMR of early gastric cancer (EGC), en bloc resection reduces the risk of residual cancer. Endoscopic submucosal dissection (ESD) now allows en bloc resection of large EGCs. OBJECTIVE: To retrospectively determine whether ESD is more advantageous than EMR for EGCs. DESIGN: EMR (825 lesions, 711 patients) or ESD (195 lesions, 185 patients) was performed. The en bloc resection rate, histologically complete resection rate, operation time, complications, and local recurrence rate were studied in relation to ulceration. SETTING: Hiroshima University Hospital. PATIENTS: Subjects comprised 896 patients in whom 1020 EGCs were resected endoscopically from 1990 to 2004. RESULTS: In cases without ulceration, en bloc and histologically complete resection rates were significantly higher with ESD than with EMR, regardless of tumor size. The frequency of ulceration did not differ significantly between groups. Average operation time was significantly longer for ESD than for EMR, regardless of tumor size. Also, regardless of ulceration, the incidence of intraoperative bleeding was significantly higher with ESD (22.6%) than with EMR (7.6%). Delayed bleeding did not differ. In cases with ulceration, the incidence of perforation was significantly higher with ESD (53.8%) than with EMR (2.9%). Local recurrences were treated by incomplete EMR (en bloc, 2.9%; piecemeal, 4.4%). No patient experienced recurrence after ESD. CONCLUSIONS: ESD increased en bloc and histologically complete resection rates and may reduce the local recurrence rate. Increased operation time and complication risks with ESD in comparison with EMR remain problematic. Special measures are necessary for ESD of ulcerated lesions to reduce the rates of perforation and incomplete resection.