Prospective comparison of diagnostic performance of magnifying endoscopy and biopsy for sessile serrated adenoma/polyp.

Background: Magnifying narrow-band imaging (M-NBI) has recently improved the accuracy of endoscopic diagnosis of gastrointestinal tumors, including colorectal polyps. However, it can be difficult to distinguish between sessile serrated adenoma/polyps (SSA/Ps) and other polyps, especially hyperplastic polyps (HPs), by histological biopsy, because diagnostic features of SSA/Ps can be detected around the colon crypt bases. We aimed to evaluate the accuracy of endoscopic diagnosis of SSA/Ps using M-NBI compared with histological biopsy. Methods: We prospectively enrolled patients diagnosed with SSA/Ps by preoperative endoscopy and assessed the diagnostic accuracy. The primary outcome was the diagnostic accuracy of endoscopy and biopsy. Results: Between August 2015 and October 2017, 295 lesions were resected by polypectomy or endoscopic mucosal resection, and 79 endoscopically resected specimens that were endoscopically diagnosed as SSA/P underwent biopsy for histological examination. Two lesions were excluded because the specimens were too small for histological examination. Finally, 77 endoscopically resected specimens and 77 biopsy specimens were included in the analysis. Histopathological examination showed 67 SSA/Ps, 8 HPs, and 2 adenomas. The sensitivity, specificity and accuracy of endoscopic M-NBI diagnosis for SSA/Ps were 95.7%, 95.5% and 95.6%, respectively. The sensitivity, specificity and accuracy of histological diagnosis of a single biopsy specimen were 71.6%, 90.0% and 74.0%, respectively. The McNemar test showed significant differences between biopsy and endoscopy diagnoses (P=0.001). Conclusion: This study shows that biopsy may be avoided by using M-NBI in patients with suspected SSA/Ps.

Underwater endoscopic mucosal resection: a new endoscopic method for resection of rectal neuroendocrine tumor grade 1 (carcinoid) ≤ 10 mm in diameter.

Background and study aims Rectal neuroendocrine tumors grade 1 (NET G1; carcinoid) ≤ 10 mm in diameter often extend into the submucosa, making their complete histological resection difficult using endoscopic techniques. Endoscopic submucosal resection with a ligation device (ESMR-L) and endoscopic submucosal dissection (ESD) are commonly used to overcome these difficulties. We also previously reported that underwater endoscopic mucosal resection (UEMR) could facilitate resection of rectal NET G1. This study aimed to evaluate the safety and efficacy of UEMR for removing rectal NET G1 ≤ 10 mm in diameter. 6 consecutive patients with rectal NET G1 ≤ 10 mm in diameter underwent UEMR at our hospital. The rate of en bloc resection was 100 %, and the rate of R0 resection was 83 %. The median procedure time was 8 min (range 5 - 12 min). No perforations or delayed bleeding occurred in this study. In conclusion, UEMR allows the safe and reliable resection of rectal NET G1 ≤ 10 mm in diameter with comparable results to ESMR-L or ESD, including high en bloc and R0 resection rates with no increase in significant adverse events. A multicenter trial is required to confirm the validity of the present results.

Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis.

BACKGROUND AND STUDY AIMS: Cold snare polypectomy (CSP) for small colorectal polyps has lower incidence of adverse events, especially delayed postpolypectomy bleeding (DPPB). However, few data are available on comparisons of the incidence of DPPB of CSP and hot polypectomy (HP). The aim of this study was to evaluate the incidence of DPPB after CSP and compare it with that of HP. A propensity score model was used as a secondary analysis. PATIENTS AND METHODS: This was a retrospective cohort study conducted in a single municipal hospital. We identified 539 patients with colorectal polyps from 2 mm to 11 mm in size who underwent CSP (804 polyps in 330 patients) or HP (530 polyps in 209 patients) between July 2013 and June 2015. RESULTS: There were no cases of DPPB in the CSP group. Conversely, DPPB occurred in 4 patients (1.9 %) after HP, resulting in a significant difference between the CSP and HP groups (0.008 % vs 0 %, P  = 0.02). Propensity score-matching analysis created 402 matched pairs, yielding a significantly higher DPPB rate in the HP group than CSP group (0.02 % vs 0 %, P  = 0.04). However, significantly more patients in the CSP group had unclear horizontal margins that precluded assessment (83 vs 38 cases, P  < 0.001). The retrieval failure rate was significantly higher in the CSP group than in the HP group (3 % vs 0.7 %, P  = 0.01). CONCLUSIONS: DPPB was less frequent with CSP than HP, as selected by the propensity score-matching model. Our findings indicate that CSP is recommended polypectomy in daily clinical setting. However, special care should be taken during polyp retrieval and horizontal margin assessment, and these issues could be taken into account in follow-up after CSP.

Gastric atrophy and xanthelasma are markers for predicting the development of early gastric cancer.

BACKGROUND: The significance of gastric xanthelasma in relation to gastric cancer still remains unclear. We investigated whether gastric xanthelasma would be a useful marker for predicting the development of early gastric cancer. METHODS: A total of 1823 patients who underwent a medical health checkup were enrolled. We examined the relationship between gastric xanthelasma and various clinical features, and in an endoscopic follow-up study investigated whether the presence of gastric xanthelasma was predictive of the development of early gastric cancer. RESULTS: In the initial endoscopic examination, gastric xanthelasma was detected in 107 (5.9 %) of the 1823 patients. The presence of gastric xanthelasma was significantly associated with age ≥65 years, male gender, open-type atrophy, and the presence of diabetes mellitus (DM) (p < 0.0001, p < 0.0001, p < 0.0001, and p < 0.0001, respectively). During the endoscopic follow-up period, early gastric cancer was found in 29 (1.6 %) of the 1823 patients. Gastric cancer occurred in 15 (14.0 %) of 107 patients with gastric xanthelasma, whereas it occurred in 14 (0.8 %) of 1716 patients without (p < 0.0001). Multivariate analysis revealed that open-type atrophy and gastric xanthelasma were independently related to the development of gastric cancer (odds ratio 7.19 [2.50-20.83]; p = 0.0003 and 5.85 [2.67-12.82]; p < 0.0001, respectively). The presence of gastric xanthelasma was significantly predictive of gastric cancer development even in the selected high-risk groups with open-type atrophy or DM (p < 0.0001 or p < 0.0001, respectively). CONCLUSIONS: Gastric xanthelasma is a useful marker for predicting the development of gastric cancer.

A Case of Myelodysplastic Syndrome with Intestinal Behçet's Disease-Like Symptoms Treated by Prednisolone and Azacitidine.

BACKGROUND Intestinal Behçet's disease-like symptoms are rare complications of myelodysplastic syndrome and are often refractory to immunosuppressive therapies. We described a case of myelodysplastic syndrome complicated by Behçet's disease-like symptoms treated with prednisolone and azacitidine. CASE REPORT A 68-year-old Japanese woman was admitted to our hospital because of persistent high fever and lower abdominal pain. Oral ulcerations developed after admission, and multiple ulcers were found in her terminal ileum by endoscopic examination. She was diagnosed with myelodysplastic syndrome with trisomy 8 by bone marrow examination. Her symptoms diminished after administration of prednisolone, but relapsed afterwards. She began azacitidine therapy and her symptoms have been controlled for at least 10 months. CONCLUSIONS This case might suggest the possibility of azacitidine as a treatment option for myelodysplastic syndrome complicated by Behçet's disease-like symptoms.

Diabetes mellitus increases the risk of early gastric cancer development.

BACKGROUND: The significance of diabetes mellitus (DM) in gastric carcinogenesis still remains unclear. We investigated whether DM would be a risk factor for the development of early gastric cancer. METHODS: Factors related to the presence of gastric cancer were examined in patients undergoing medical health checkups. We then investigated whether DM was related to the development of early gastric cancer during an endoscopic follow-up study. RESULTS: Gastric cancer was detected in 14 (1.0%) of 1463 patients at the first endoscopic examination and was significantly associated with the severity of gastric atrophy and the presence of DM. During the follow-up period (range 36-108 months; mean 70.0 months), early gastric cancer was newly detected in 26 (1.8%) of the 1449 patients in whom gastric cancer had not been detected at the first examination. Gastric cancer was detected in 17 (1.3%) of 1301 patients without DM, and in 9 (6.1%) of 148 patients with DM (P < 0.0001). Multivariate analyses demonstrated that open-type gastric atrophy and DM were independently related to the development of early gastric cancer (P < 0.0001 and P = 0.020, respectively). Gastric cancer was identified in 14 (5.1%) of 274 patients who had open-type atrophic gastritis without DM, whereas it was identified in 8 (16.0%) of 50 patients who had both open-type atrophic gastritis and DM (P = 0.0042). CONCLUSION: DM increases the risk of early gastric cancer development.

Prominent hypereosinophilia with disseminated intravascular coagulation as an unusual presentation of advanced gastric cancer.

A 78-year-old woman was admitted to our hospital complaining of anorexia and purpura of the extremities. She presented with prominent peripheral eosinophilia and disseminated intravascular coagulation (DIC). Despite receiving intensive therapy for DIC, her illness worsened. Esophagogastroduodenoscopy revealed advanced gastric cancer (AGC), and a bone marrow biopsy led to a diagnosis of disseminated carcinomatosis of the bone marrow caused by AGC. We initiated combination chemotherapy with S-1 and cisplatin, which lead to a significant improvement of the DIC and eosinophilia, and the patient was finally discharged. The primary symptoms of DIC and eosinophilia were both considered to be caused by AGC, and we successfully treated the patient's critical condition.

Dense-type crypt opening seen on magnifying endoscopy with narrow-band imaging is a feature of gastric adenoma.

BACKGROUND: Magnifying endoscopy with narrow-band imaging (ME-NBI) can visualize crypt openings (CO) as slit-like structures in gastric epithelial neoplasia. Visualization of numerous CO is characteristic of low-grade adenoma (LGA). The aim of the present study was to investigate whether visualization of CO by ME-NBI is useful for discriminating between LGA and early gastric cancer (EGC). PATIENTS AND METHODS: Fifty-one superficial elevated-type gastric neoplasias (10 LGA and 41 EGC) were retrospectively evaluated. The presence of CO and the number of CO were evaluated in endoscopic photos obtained at high-power endoscopic magnification by ME-NBI. The optimal cut-off value for the number of CO visualized to discriminate between LGA and EGC was determined by receiver operating characteristic curve analysis. RESULTS: The mean number of CO visualized was significantly larger in the LGA group than in the EGC group (31.2, 95% confidence interval [CI] 16.3-46.1 vs 6.3, 95% CI 3.6-9.0; P < 0.001). When the cut-off for the number of CO visualized was set at 20, the sensitivity, specificity, and accuracy of dense-type CO for discriminating between LGA and EGC were 90.0%, 87.8%, and 88.2%, respectively. CONCLUSION: Determining the number of CO visualized in superficial elevated-type gastric neoplasias by ME-NBI appears to be a useful method for discriminating between LGA and EGC.

Clinical characteristics of collagenous colitis with linear ulcerations.

BACKGROUND: The relationship between the thickness of subepithelial collagen bands (CB) and the development of linear ulcerations (LU) in collagenous colitis (CC) remains unclear. The aim of the present study was to compare the clinical and pathological features, including the thickness of CB, in CC patients with and without LU. PATIENTS AND METHODS: Twenty-five patients with CC diagnosed by pathological examination of biopsy specimens were analyzed. Eleven patients with LU (LU group) and 14 patients without LU (non-LU group) were compared. RESULTS: Ten patients in the LU group and seven in the non-LU group were taking lansoprazole (P = 0.038). Seven patients in the LU group and one in the non-LU group were taking non-steroidal anti-inflammatory drugs (NSAIDs) (P = 0.004). All LU were locatedin the transverse or left colon. Patients in the LU group were older than those in the non-LU group (P = 0.015). CB were significantly thicker in the LU group than in the non-LU group (mean ± SD, 40 ± 21 µm vs 20 ± 11 µm, P = 0.004). Multivariate analysis showed that NSAIDs use (odds ratio, 19.236; 95% confidence interval, 1.341-275.869) and CB thickness (odds ratio, 0.893; 95% confidence interval, 0.804-0.999) were independently associated with the development of LU. CONCLUSION: Use of lansoprazole and NSAIDs, thick CB, and advanced age are associated with the development of LU in CC patients.

Gastric xanthelasma may be a warning sign for the presence of early gastric cancer.

BACKGROUND AND AIM: The significance of gastric xanthelasma in relation to gastric disease still remains unclear. We investigated the prevalence and significance of gastric xanthelasma in patients with atrophic gastritis and gastric cancer. METHODS: A total of 3238 patients who underwent endoscopic examinations of the upper gastrointestinal tract were enrolled. We retrospectively investigated the presence of gastric xanthelasma, the severity of gastric atrophy, and the presence of gastric cancer, and examined the relationship between gastric xanthelasma and various clinicopathological features. RESULTS: Gastric xanthelasma was detected in 249 (7.7%) of the 3238 patients and was significantly associated with age ≥ 65 years, male gender, open-type atrophy, and the presence of gastric cancer (P < 0.0001, P = 0.0002, P < 0.0001 and P < 0.0001, respectively). Multivariate analysis revealed that the presence of gastric cancer was independently related to the presence of gastric xanthelasma (odds ratio 6.19 [3.95-9.70], P < 0.0001). Age/sex/atrophy-matched control analysis demonstrated that the presence of gastric xanthelasma was significantly associated with the presence of gastric cancer (P < 0.0001). Moreover, the presence of xanthelasma in the upper region of the stomach was significantly associated with gastric cancer (P = 0.002). Gastric xanthelasma was observed in 50 (47.6%) of 105 patients with gastric cancer. CONCLUSION: Gastric xanthelasma may serve as a warning sign for the presence of gastric cancer.

Cap-polyposis-like gastropathy with hypoproteinemia treated with H. pylori eradication.

We herein report the case of a 43-year-old man with distinct gastropathy and hypoproteinemia treated with H. pylori eradication therapy. Most reported cases of protein-losing gastropathy are divided into Ménétrier's disease (MD) and diffuse varioliform gastritis (DVG). Our patient presented with leg edema due to marked hypoalbuminemia, which we ascribed to distinct gastropathy with novel endoscopic findings resembling cap polyposis in the colon, apparently different from both MD and DVG. H. pylori eradication therapy promptly induced the normalization of laboratory data and mucosal healing. Our case together with two previously published similar cases may contribute to establishing an association between cap-polyposis-like-gastropathy with hypoproteinemia and H. pylori.

[A case of α-fetoprotein-producing hepatoid adenocarcinoma of the stomach with spontaneous rupture of multiple liver metastases].

An 85-year-old man with epigastric pain and anorexia was admitted to our hospital. His serum α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist II (PIVKA II) levels were markedly elevated. Gastrointestinal endoscopy revealed a large mass near the fundus, and computed tomography revealed multiple liver tumors. Intraperitoneal bleeding followed rupture of a liver tumor and was successfully stopped by transarterial embolization; however, regrowth of multiple tumors followed, resulting in liver failure and death within a short period. Autopsy revealed hepatoid adenocarcinomas originating in the stomach that had metastasized to the liver. Hepatoid adenocarcinomas are hypervascular, rapidly growing tumors that may result in the spontaneous rupture of metastatic liver lesions. Transarterial embolization may be a feasible option for the treatment of these ruptured tumors.

Risk factors associated with recurrent hemorrhage after the initial improvement of colonic diverticular bleeding.

We elucidated risk factors contributing to recurrent hemorrhage after initial improvement of colonic diverticular bleeding. 172 consecutive hospitalized patients diagnosed with colonic diverticular bleeding were analyzed. Recurrent hemorrhage after initial improvement of colonic diverticular bleeding is main outcome measure. We analyzed factors contributing to recurrent hemorrhage risk in univariate and multivariate analyses. The length of the observation period after improvement of colonic diverticular bleeding was 26.4 +/- 14.6 months (range, 1-79 months). The cumulative recurrent hemorrhage rate in all patients at 1 and 2 years was 34.8% and 41.8%, respectively. By univariate analysis, age > 70 years (P = 0.021), BMI > 25 kg/m2 (P = 0.013), the use of anticoagulant drugs (P = 0.034), the use of NSAIDs (P = 0.040), history of hypertension (P = 0.011), history of smoking (P = 0.030) and serum creatinine level > 1.5 mg/dL (P < 0.001) were found to be significant risk factors for recurrent colonic diverticular bleeding. By multivariate analysis, age > 70 years (Hazard ratio (HR), 1.905, 95% confidence interval (CI), 1.067-3.403, P = 0.029), history of hypertension (HR, 0.493, 95% CI, 0.245-0.993, P = 0.048) and serum creatinine level > 1.5 mg/dL (HR, 95% CI, 0.288-0.964, P = 0.044) were shown to be significant independent risk factors. Close observation after the initial improvement of colonic diverticular bleeding is needed, especially in elderly patients or patients with history of hypertension or renal deficiency.

[A case of diffuse cystic malformation in which submucosal tumor-like advanced gastric cancer was identified during 10-year follow-up].

A 66-year-old man with giant gastric folds had been followed up since February 2000. In March 2010, a submucosal tumor of 35mm was identified with endoscopy and a low echoic mass was identified with endoscopic ultrasonography. After histologic diagnosis by endosonography-guided fine needle aspiration biopsy, he underwent a total gastrectomy. Histologic examination of the resected specimen revealed a tumor 20mm in diameter consisting of well-to-moderately differentiated tubular adenocarcinoma in the thickened wall of the gastric greater curvature, which contained small cystic lesions in the lamina propria. Immunohistochemical staining showed thick gastric wall consisting of not only multiple cysts but also smooth muscle, elastic and collagen fibers. The histologic diagnosis was advanced gastric cancer accompanied by diffuse cystic malformation (DCM). Although it is a rare condition, DCM should be considered in the differential diagnosis of giant gastric folds and as a pre-cancerous lesion.

[Seven cases of gemcitabine-induced lung injury during treatment for pancreatic or biliary tract cancers].

Gemcitabine is an anti-cancer drug known to be safe and effective for pancreatic or biliary tract cancers, but lung injury is also known to be a rare side effect that sometimes becomes severe. Here we report seven cases of lung injury during gemcitabine treatment. Drug-induced lung injury was suspected in all cases. The male: female ratio was 5:2, and the average patient age was 71. Four had pancreatic cancers and three had biliary tract cancers. Gemcitabine had been administered an average 5.9 times at a dose of 1,141 mg. Patients showed a diffuse or patchy shadow mainly in the lower lung on computed tomography examination. Grades of adverse events were greater than 3 in all cases. Three patients died of the lung injury. Five cases had pulmonary emphysema, 2 had metastatic lung tumor as underlying pulmonary lesions, and these were assumed to have been important risk factors for drug-induced interstitial lung injury during gemcitabine treatment.

Mesoporous aluminosilicates assembled from dissolved LTA zeolite and triblock copolymer in the presence of tetramethylammonium hydroxide.

Zeolite Na-A crystals dissolved in a HCl solution were used as a single-source of silicon and aluminum for the synthesis of mesoporous aluminosilicates via a template-assisted method with an organic base tetramethylammonium hydroxide (TMAOH). Amphiphilic triblock copolymer Pluronic F127 (EO(106)PO(70)EO(106)) was used as template. Increasing the amount of TMAOH in the synthetic solution resulted in an increase in the aluminum content of the products. On the other hand, mesostructural periodicity was deteriorated with higher content of aluminum incorporated into the mesoporous framework. The samples with low Si/Al ratios less than 5 have wormhole-like pore structure, while the samples with Si/Al ratios more than 7 possess highly ordered mesoporous structure, a body-centered Im3m symmetry, with single crystal like morphology. The samples with Si/Al ratio of 7, which prepared at TMAOH molar concentration of 25 mM in the templating solution, possess BET surface area of 470 m(2)/g, pore size of 6.4 nm, and pore volume of 0.56 cm(3)/g. Aluminum atoms have successfully been incorporated in a tetra-coordinated position and remained stable even after calcination at 600 degrees C.

Synthesis of 3D pore mesostructured silica films by vapor infiltration of tetraethoxysilane.

Nonionic alkyl poly(oxyethylene) surfactants (Brij 56) films on a silicon substrate were treated with a tetraethoxysilane (TEOS) vapor. Mesostructured silica films were formed through a nano-phase transition under the infiltration of TEOS into the surfactant films. It was found that the calcined film had a 3D pore structure from the field emission scanning electron microscope (FE-SEM) observations in a different orientation. Grazing angle of incidence small angle X-ray scattering (GISAXS) measurement results showed that the symmetry of the film was an Fmmm space group oriented with the (010) plane parallel to the surface. The ordered structure of the films showed higher thermal stability than the films prepared by a conventional solvent-evaporation method.

[Case of moderately differentiated hepatocellular carcinoma with gastric metastasis].

A solitary liver nodule about 1cm in diameter was detected in a 68-year-old male HBV carrier during therapy for advanced lung cancer. A multiple IIc-like depressed lesion originating in the stomach soon became elevated as the liver lesion progressed. HE staining produced hepatoma-like histological findings for the tumors of the lung, liver and stomach, while immunohistochemical staining showed them to be positive for PIVKA-II and weakly positive for HP-1. Autopsy led to a diagnosis of a moderately differentiated hepatocellular carcinoma producing bile juice with metastasis to the lung and stomach. It is not clear why advanced metastasis in the lung occurred while the hepatocellular carcinoma in the liver was still small, but one possible explanation lies in the localization of the hepatic cancer: the tumor was located near a branch of the hepatic vein and vascular invasion may have caused early pulmonary metastasis via the hepatic venous flow.