Acceptance and Preference of Computed Tomographic Colonography and Colonoscopy: Results of a Nationwide Multicenter Comparative Questionnaire Survey in Japan.

Objectives: To investigate patient acceptance and preference for computed tomographic colonography (CTC) over colonoscopy. Methods: Participants were recruited from a nationwide multicenter trial in Japan to assess the accuracy of CTC detection. They were scheduled to undergo colonoscopy after CTC with common bowel preparation on the same day. Some were administered sedative drugs during colonoscopy, depending on the referring clinician and participant's preferences. The participants were requested to complete a questionnaire to evaluate the acceptability of bowel preparation, examinations, and preference for future examinations. Results: Of the 1,257 enrolled participants, 1,180 (mean age: 60.6 years; women: 43.3%) completed the questionnaire. Sedative drugs were not administered in 687 participants (unsedated colonoscopy group) and were administered intravenously during colonoscopy in 493 participants (sedated colonoscopy group). Before propensity score matching, the mean participants' age, percentages of asymptomatic participants, insufflation of gas during colonoscopy, and number of participants with a history of abdominal/pelvic operation significantly differed between the groups. After propensity score matching, 912 participants from each group were included in the analysis. In the unsedated colonoscopy group, CTC was answered as significantly easier than colonoscopy (p<0.001). Conversely, CTC was significantly more difficult than colonoscopy in the sedated colonoscopy group (p<0.001). In the unsedated colonoscopy group, 48% preferred CTC and 22% preferred colonoscopy for future examinations, whereas in the sedated colonoscopy group, 26% preferred CTC and 38% preferred colonoscopy (p<0.001). Conclusions: CTC has superior participant acceptability compared with unsedated colonoscopy. However, our study did not observe the advantages of CTC acceptance over sedative colonoscopy.

Assessment of postoperative common bile duct stones after endoscopic extraction and subsequent cholecystectomy.

BACKGROUND: Common bile duct stones (CBDSs) occasionally cause serious diseases, and endoscopic extraction is the standard procedure for CBDS. To prevent biliary complications, cholecystectomy is recommended for patients who present with gallbladder (GB) stones after endoscopic CBDS extraction. However, CBDS can occasionally recur. To date, the occurrence of CBDS after endoscopic CBDS extraction and subsequent cholecystectomy is not fully understood. Hence, the current study aimed to evaluate the incidence of postoperative CBDSs. METHODS: This retrospective observational study included consecutive patients who underwent postoperative endoscopic retrograde cholangiography after endoscopic CBDS extraction and subsequent cholecystectomy between April 2012 and June 2021 at our institution. After endoscopic CBDS extraction, a biliary plastic stent was inserted to prevent obstructive cholangitis. Endoscopic retrograde cholangiography was performed to evaluate postoperative CBDSs after cholecystectomy until hospital discharge. The outcomes were the incidence of postoperative CBDSs and CBDSs/sludge. Moreover, the predictive factors for postoperative CBDSs were evaluated via univariate and multivariate analyses. RESULTS: Of eligible 204 patients, 52 patients (25.5%) presented with postoperative CBDSs. The incidence rate of CBDS/sludge was 36.8% (n = 75). Based on the univariate analysis, the significant predictive factors for postoperative CBDSs were ≥ 6 CBDSs, presence of cystic duct stones, and ≥ 10 GB stones (P < 0.05). Moreover, male sex and < 60-mm minor axis in GB might be predictive factors (P < 0.10). Based on the multivariate analysis, ≥ 6 CBDSs (odds ratio = 6.65, P < 0.01), presence of cystic duct stones (odds ratio = 4.39, P < 0.01), and ≥ 10 GB stones (odds ratio = 2.55, P = 0.01) were independent predictive factors for postoperative CBDSs. CONCLUSIONS: The incidence of postoperative CBDS was relatively high. Hence, patients with predictive factors for postoperative CBDS must undergo imaging tests or additional endoscopic procedure after cholecystectomy.

[A case of rectal submucosal tumor diagnosed with the coexistence of gastrointestinal neuroendocrine tumor G1 and adenocarcinoma following endoscopic submucosal dissection].

In a 67-year-old man, colonoscopy confirmed the presence of a 5-6mm submucosal tumor in the upper rectum (Ra);the tumor showed a tendency to grow with the size appearing to be 9-10mm at re-examination that was performed 1 year thereafter. No findings on computed tomography indicated metastasis. A neuroendocrine tumor (NET) was suspected, and endoscopic submucosal dissection was performed. The patient was pathologically diagnosed with coexistence of NETG1 and a well-differentiated adenocarcinoma. Few reports have described the coexistence of relatively low-grade NETG1 and an adenocarcinoma in the Ra, and such an occurrence is considered rare. The patient has shown no recurrence at 3 years and 2 months postoperatively.

Preference and Experience of Colonic Examination for Participants Presenting to Hospitals with a Positive Fecal Immunochemical Test Result.

PURPOSE: Patients who test positive on the fecal immunochemical test (FIT) for colorectal cancer (CRC) are referred for colonoscopy for further diagnostic evaluation. Colonoscopy is not a perfect method and may be a challenge for some FIT-positive patients. Computed tomographic colonography (CTC) is an alternative method that is less invasive and allows examination of the whole colon. The study objective was to evaluate the preference of FIT-positive patients for either colonoscopy or CTC for CRC examination. PATIENTS AND METHODS: Individuals older than 40 years with a positive FIT test at eight Japanese hospitals between December 2012 and July 2015 were invited to participate. Participants were given detailed information regarding colonoscopy and CTC before deciding on either examination. They completed questionnaires before the procedure regarding their preference and after the procedure regarding their experience. RESULTS: The pre- and post-questionnaires of 846 and 834 participants, respectively, were analyzed. Participants preferred colonoscopy over CTC (colonoscopy, 72%; CTC, 28%). The possibility of obtaining biopsy samples and removing colorectal polyps during the procedure was the main reason for colonoscopy selection. Patients selected CTC to reduce discomfort but reported that CTC bowel preparation was more burdensome than colonoscopy bowel preparation. The overall experience of the examination did not differ between the groups. CONCLUSION: Colonoscopy is the standard examination for FIT-positive patients. However, when given a choice, almost one-third of participants chose CTC because they thought it would be a more "comfortable" examination. Clinicians should therefore be aware of patients' potential preference for noninvasive colorectal examinations.

Accuracy of CT Colonography for Detection of Polypoid and Nonpolypoid Neoplasia by Gastroenterologists and Radiologists: A Nationwide Multicenter Study in Japan.

OBJECTIVES: The objective of this study was to assess prospectively the diagnostic accuracy of computer-assisted computed tomographic colonography (CTC) in the detection of polypoid (pedunculated or sessile) and nonpolypoid neoplasms and compare the accuracy between gastroenterologists and radiologists. METHODS: This nationwide multicenter prospective controlled trial recruited 1,257 participants with average or high risk of colorectal cancer at 14 Japanese institutions. Participants had CTC and colonoscopy on the same day. CTC images were interpreted independently by trained gastroenterologists and radiologists. The main outcome was the accuracy of CTC in the detection of neoplasms ≥6 mm in diameter, with colonoscopy results as the reference standard. Detection sensitivities of polypoid vs. nonpolypoid lesions were also evaluated. RESULTS: Of the 1,257 participants, 1,177 were included in the final analysis: 42 (3.6%) were at average risk of colorectal cancer, 456 (38.7%) were at elevated risk, and 679 (57.7%) had recent positive immunochemical fecal occult blood tests. The overall per-participant sensitivity, specificity, and positive and negative predictive values for neoplasms ≥6 mm in diameter were 0.90, 0.93, 0.83, and 0.96, respectively, among gastroenterologists and 0.86, 0.90, 0.76, and 0.95 among radiologists (P<0.05 for gastroenterologists vs. radiologists). The sensitivity and specificity for neoplasms ≥10 mm in diameter were 0.93 and 0.99 among gastroenterologists and 0.91 and 0.98 among radiologists (not significant for gastroenterologists vs. radiologists). The CTC interpretation time by radiologists was shorter than that by gastroenterologists (9.97 vs. 15.8 min, P<0.05). Sensitivities for pedunculated and sessile lesions exceeded those for flat elevated lesions ≥10 mm in diameter in both groups (gastroenterologists 0.95, 0.92, and 0.68; radiologists: 0.94, 0.87, and 0.61; P<0.05 for polypoid vs. nonpolypoid), although not significant (P>0.05) for gastroenterologists vs. radiologists. CONCLUSIONS: CTC interpretation by gastroenterologists and radiologists was accurate for detection of polypoid neoplasms, but less so for nonpolypoid neoplasms. Gastroenterologists had a higher accuracy in the detection of neoplasms ≥6 mm than did radiologists, although their interpretation time was longer than that of radiologists.

Diagnostic Performance and Patient Acceptance of Reduced-Laxative CT Colonography for the Detection of Polypoid and Non-Polypoid Neoplasms: A Multicenter Prospective Trial.

Purpose To evaluate the diagnostic accuracy and patient acceptance of reduced-laxative computed tomographic (CT) colonography without computer-aided detection (CAD) for the detection of colorectal polypoid and non-polypoid neoplasms in a population with a positive recent fecal immunochemical test (FIT). Materials and Methods Institutional review board approval and written informed consent were obtained. This multicenter prospective trial enrolled patients who had positive FIT results. Reduced-laxative CT colonography and colonoscopy were performed on the same day. Patients received 380 mL polyethylene glycol solution, 20 mL iodinated oral contrast agent, and two doses of 20 mg mosapride the day before CT colonography. The main outcome measures were the accuracy of CT colonography for the detection of neoplasms 6 mm or larger in per-patient and per-lesion analyses and a survey of patient perceptions regarding the preparation and examination. The Clopper-Pearson method was used for assessing the 95% confidence intervals of per-patient and per-lesion accuracy. Survey scores were analyzed by using the Wilcoxon and χ2 tests. Results Three hundred four patients underwent both CT colonography and colonoscopy. Per-patient sensitivity, specificity, positive predictive value, and negative predictive value of CT colonography for detecting neoplasms 10 mm or larger were 0.91 (40 of 44), 0.99 (255 of 258), 0.93 (40 of 43), and 0.98 (255 of 259), respectively; these values for neoplasms 6 mm or larger were 0.90 (71 of 79), 0.93 (207 of 223), 0.82 (71 of 87), and 0.96 (207 of 215), respectively. Per-lesion sensitivities for detection of polypoid and non-polypoid neoplasms 10 mm or larger were 0.95 (40 of 42) and 0.67 (six of nine), respectively; those for neoplasms 6 mm or larger were 0.90 (104 of 115) and 0.38 (eight of 21), respectively (P < .05 for both). Patient acceptance of preparation and examination with CT colonography was significantly higher than that with colonoscopy, and 62% (176 of 282) of patients would choose CT colonography as the first examination if they have a positive FIT result in the future. Conclusion Reduced-laxative CT colonography without CAD is accurate in the detection of polypoid neoplasms 6 mm or larger but is less accurate in the detection of non-polypoid neoplasms. Reduced-laxative CT colonography has high patient acceptance and is an efficient triage examination for patients with a positive FIT. © RSNA, 2016 Online supplemental material is available for this article.

Iatrogenic Colonic Perforation due to Computed Tomographic Colonography.

Although the complications of computed tomographic colonography (CTC) are very rare, CTC is associated with potential risk of colonic perforation. In the present report we describe two cases of colonic perforation secondary to CTC. In the first case with ascending colonic carcinoma, insertion of a rigid double-balloon catheter caused direct rectal wall perforation. In the second case with obstructive colonic carcinoma, pneumoperitoneum developed due to automated carbon dioxide insufflation. Both patients were asymptomatic after examination and recovered without any complications. Based on the findings of the current cases, we recommend that a soft-tip catheter be used for CTC, and suggest that colonic perforation can occur even with automatic insufflation, depending on patient characteristics.

Low expression levels of microRNA-124-5p correlated with poor prognosis in colorectal cancer via targeting of SMC4.

A component of polycomb repressor complex 2, enhancer of zeste homolog 2 (EZH2), plays an important role in tumor malignancy and metastasis, while milk fat globule-epidermal growth factor-factor 8 (MFGE8) plays a key role in tumor progression and prognosis. MicroRNAs (miRs) are also critically involved in various physiological and pathological processes. We here evaluated the relationship between overall survival (OS) in colorectal cancer patients and the expression of onco-miRs and miRs, which may target EZH2 and MFGE8. Plasma and formalin-fixed paraffin-embedded (FFPE) samples were obtained from 71 colorectal cancer patients. The expression levels of miRs complementary to EZH2 and MFGE8 mRNA and cancer malignancies were evaluated. The miRs analyzed were as follows: miR-16, miR-21, miR-26a, miR-34a, miR-98, miR-101-3p, miR-101-5p, miR-124-5p (also known as miR-124*), miR-126-3p, miR-126-5p, miR-210, miR-217, and miR-630. The plasma expression levels of MFGE8 in completely resected patients were significantly lower than those in unresectable patients. Lower miR-26a expression levels were correlated with a higher probability of OS. Higher miR-124-5p expression levels in plasma and FFPE samples were correlated with a higher probability of OS. The transfection of mimic miR-124-5p into WiDr and COLO201 cells inhibited the expression of structural maintenance of chromosomes 4 (SMC4) mRNA. Our results indicate that miR-124-5p may target the tumorigenesis gene, SMC4, which suggests that expression levels of miR-124-5p in plasma and FFPE samples; therefore, the expression of MFGE8, miR-26a, and miR-124-5p in plasma may be used as biomarkers to determine the prognosis of colorectal cancer patients.

FDG-PET Findings of Intraductal Oncocytic Papillary Neoplasms of the Pancreas: Two Case Reports.

Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas is a rare pancreatic tumor. To date, there have been three case reports of IOPN which showed strong positivity on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), raising the possibility of distinguishing IOPNs from other intraductal papillary mucinous neoplasms (IPMNs) using FDG-PET. However, all three cases had large tumors, approximately 10 cm in diameter, and there are no case reports of FDG-PET findings of small IOPNs, i.e. tumors the average size of malignant IPMNs (3-5 cm). We report two cases with IOPN of average size with FDG-PET findings. Computed tomography (CT) showed a multilocular cystic lesion 4 cm in diameter with a mural nodule 1 cm in diameter (case 1) and a cystic lesion 5 cm in diameter with a papillary mural nodule 4 cm in diameter (case 2). FDG-PET showed abnormal uptake at the same location as the pancreatic tumor revealed by CT in both cases. The maximum standardized uptake values of the lesions were 3.4 and 4.2, respectively. Surgical resection was performed and the tumor was diagnosed as IOPN with carcinoma in situ (case 1) and IOPN with minimal invasion (case 2). FDG-PET may be useful for diagnosing malignancy in IOPN, as it is in IPMN. However, in our two cases, strong accumulation was not observed in the IOPNs, which were within the average size range of malignant IPMNs.

[Computed tomography colonography for 5 cases of pneumatosis cystoides intestinalis].

Computed tomography colonography (CTC) was performed in 5 patients with pneumatosis cystoides intestinalis (PCI). The virtual colonoscopy view of CTC as well as total colonoscopy (TCS) findings showed polypoid lesions in the colon, and multiplanar reconstruction images of the colon revealed in the polypoid lesions of the colon. We confirmed the diagnosis of PCI in all cases. CTC also detected the PCI lesions in the subserosa of the colonic wall which were not detected by TCS. Accurate evaluation of the extent of PCI involvement was obtained by CT air-contrast enema images. CTC is useful for detection of PCI lesions, assessment of the exact site and final diagnosis for PCI.

Intestinal Obstruction due to Complete Transmural Migration of a Retained Surgical Sponge into the Intestine.

A 56-year-old woman with a history of gynecological surgery for cervical cancer 18 years previously was referred to our hospital for colicky abdominal pain, nausea and vomiting. Intestinal obstruction was diagnosed by contrast-enhanced computed tomography (CT) which showed dilation of the small intestine and suggested obstruction in the terminal ileum. In addition, CT showed a thick-walled cavitary lesion communicating with the proximal jejunum. (18)F-fluorodeoxyglucose positron emission tomography showed abnormal uptake at the same location as the cavitary lesion revealed by CT. The patient underwent laparotomy for the ileus and resection of the cavitary lesion. At laparotomy, we found a retained surgical sponge in the ileum 60 cm from the ileocecal valve. The cavitary tumor had two fistulae communicating with the proximal jejunum. The tumor was resected en bloc together with the transverse colon, part of the jejunum and the duodenum. Microscopic examination revealed fibrous encapsulation and foreign body giant cell reaction. Since a retained surgical sponge without radiopaque markers is extremely difficult to diagnose, retained surgical sponge should be considered in the differential diagnosis of intestinal obstruction in patients who have undergone previous abdominal surgery.

[A case of extrahepatic portal vein aneurysm with massive thrombosis].

A 59-year-old woman, who was given a diagnosis of portal vein aneurysm at another hospital 2 years previously, visited our institution complaining of abdominal pain in November 2005. Abdominal imaging including computed tomography and ultrasonography demonstrated that the portal vasculature had dilated to 5 cm in maximum dimension and its center was at the junction of the superior mesenteric vein and the splenic vein. Moreover, a large thrombus was seen in the portal vein, the superior mesenteric vein and the splenic vein. She was conservatively followed-up with warfarin. After 6 months, angiography revealed cavernous transformation around the portal vein was found with collateral flow toward the liver. At the time of writing the patient's condition is stable with neither extension of the thrombus nor constriction of the esophageal varices.

[Telangiectatic focal nodular hyperplasia accompanied with hemorrhage and necrosis during the course: report of a case].

A tumor, which was 10 cm in diameter, was found in the lateral segment of the liver of a 42-year-old man in October, 2004. The lesion was clinically diagnosed as focal nodular hyperplasia (FNH). In March, 2006, the patient admitted our hospital complaining epigastralgia, back pain, and fever. Hemorrhage and necrotic region was revealed within the tumor, hence lateral segmentectomy was carried out. The lesion was pathologically diagnosed as a telangiectatic FNH (T-FNH). A possibility that hemorrhage or necrosis may be induced within a T-FNH during its progress should be taken into consideration.

[Undifferentiated pleomorphic sarcoma detected in the descending colon: report of a case].

Undifferentiated pleomorphic sarcoma was a well-known tumor that usually involves the soft tissues. However, in the alimentary tract, it was seldom reported. A 55-year-old man was admitted to our hospital with lower abdominal pain. Endoscopic examination showed a protruding tumor occupied the lumen of the descending colon. Because of the colon obstruction by the tumor, a left hemicolectomy with en bloc lymph node dissection was performed. Main occupied lesion of the tumor was mesenterium and submucosa, with no epithelial dysplasia. Also, dissemination of the tumor was recognized in the mesenterium and greater omentum. Based on histological and immunohistological studies, the tumor was diagnosed as undifferentiated pleomorphic sarcoma.

Reactive lymphoid hyperplasia of the liver: a case report and review of literature.

A case of a 53-year-old female patient with reactive lymphoid hyperplasia (RLH), clinically designated as pseudolymphoma of the liver is described in this article. The patient was admitted to our hospital for further evaluation of hepatic tumors incidentally discovered at another hospital. Various diagnostic methods, including ultrasonography (US), computerized tomography (CT), magnetic resonance imaging (MRI) and hepatic angiography displayed three small lesions in the liver with outstanding findings consistent with hepatocellular carcinoma (HCC). Surgical resection was performed and the three lesions were microscopically diagnosed as RLH of the liver. The lesions comprised a massive infiltration of lymphoid cells with follicles and hyalinized inter-follicular spaces. Immunohistochemical examination revealed that infiltrating lymphocytes had no prominent nuclear atypia and polyclonality. RLH of the liver is a very rare condition and only twelve cases have been reported in the English literature. Majority of the reported cases were middle-aged women and about half of them had some immunologic abnormalities such as autoimmune thyroiditis, Sjogren's syndrome, primary immunodeficiency, primary biliary cirrhosis. Since they are often clinically misdiagnosed as HCC, surgery is the choice of treatment for these patients. Although their pathology resembles malignant lymphoma, the clinical course is completely benign. The authors propose that RLH of the liver can be discriminated from HCC by its clinical features.

Tumor-associated antigen recognized by the 22-1-1 monoclonal antibody encourages colorectal cancer progression under the scanty CD8+ T cells.

PURPOSE: The receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is a novel tumor-associated antigen. Although evidence suggests that RCAS1 suppresses immunity by inducing tumor-infiltrating lymphocyte (TIL) apoptosis, RCAS1 function in humans is controversial. RCAS1 overexpression leads to the generation of the Tn glycan antigen (N-acetyl-D-galactosamine, GalNAc) recognized by the 22-1-1 monoclonal antibody. The objective of this study is to examine Tn glycan antigen function in colorectal cancer and to determine its relationship to CD8+ T cells and prognosis. EXPERIMENTAL DESIGN: Immunohistochemical analyses examined Tn expression in tumor cells and CD8 on TILs in 146 surgically resected colorectal cancer. RESULTS: Of 146 samples, 68 tumors (47%) were Tn+; 72 tumors (49%) were CD8+. Using Cox multivariate analysis and the Kaplan-Meier method, Tn and CD8 positivity were determined to be mutually independent prognostic factors (P = 0.0266 and 0.0210, respectively). Tn+ patients with CD8+ TILs exhibited better survival than Tn+/CD8- patients (P = 0.0129). For CD8- patients, Tn positivity was associated with decreased survival from that seen in Tn- patients (P = 0.0097), suggesting that Tn exerts a function independent of CD8+ T cells in tumor progression. In all patients and cases with synchronous liver metastases (n = 29), the Tn+/CD8- survival rate was significantly lower than that seen for other groups (P = 0.0001 and 0.0063, respectively). The average number of liver metastases in Tn+/CD8- cases also increased (mean, 8.2 tumors; P = 0.0032). Multivariate analysis identified Tn+/CD8- status and Dukes' staging as independent prognostic factors (P = 0.0016 and < 0.0001, respectively). CONCLUSIONS: Tn may encourage invasion and innidiation through a mechanism independent of CD8+ T cells. Thus, Tn+/CD8- status is a risk factor for multiple liver metastases development and an independent negative prognostic factor for colorectal cancer.

A novel aspartate protease gene, ALP56, is related to morphological features of colorectal adenomas.

BACKGROUND AND AIMS: The recently identified aspartate protease gene ALP56 is up-regulated in human malignant tumors, including colorectal cancers, but the relationship remain unclear between ALP56 gene expression and clinicopathological findings, as well as when genetic alterations in ALP56 occur during the colorectal adenoma-carcinoma sequence. We therefore investigated expression of ALP56 mRNA in various human colorectal tissues. MATERIALS AND METHODS: We examined 18 colorectal adenomas 22 cancers, and 24 adjacent normal mucosal samples from patients undergoing conventional resection or endoscopic mucosal resection. Expression of ALP56 mRNA was determined by quantitative reverse-transcription polymerase chain reaction. RESULTS: Up-regulation of ALP56 gene transcription was observed in both adenomas and cancers compared to normal mucosa. ALP56 expression in exophytic adenomas was significantly greater than in flat adenomas. CONCLUSION: ALP56 may contribute to colorectal adenoma formation and to an exophytic growth pattern in these adenomas.