A Japanese Family Meeting the Clinical Diagnostic Criteria for MEN1 with a MEN1 Variant of Uncertain Significance

Multiple gastroenteric, pancreatic, and pituitary neuroendocrine neoplasms (NENs) were diagnosed in a 74-year-old man with a history of primary hyperparathyroidism (PHPT). Germline testing demonstrated a variant of MEN1 (c.1694T>A, p.L565Q), whose pathogenicity was classified as a variant of uncertain significance (VUS) according to the ACMG/AMP guidelines. The same germline variant was detected in the patient's son and daughter, who also showed PHPT or hypercalcemia and met the clinical diagnostic criteria for multiple endocrine neoplasia type 1 (MEN1). During surveillance of the son, multiple pancreatic tumors suggestive of NENs were detected. The pathogenicity of the current MEN1 variant was re-evaluated as likely pathogenic, based on additional family data.

Endoscopic ultrasound-guided infectious liver cyst drainage associated with autosomal dominant polycystic kidney disease in which percutaneous approach is impossible

A man in his 70s on maintenance dialysis for autosomal dominant polycystic kidney disease was admitted with epigastralgia and a fever lasting for 1 week. Computed tomography showed a thickened liver cyst measuring 121 mm in the caudate lobe, suggesting infection. Percutaneous drainage was impossible because multiple liver cysts and ascites entered the puncture route. Endoscopic ultrasound (EUS) revealed a huge liver cyst with debris-like echoes. Transgastric EUS-guided drainage was performed, and internal and external drainage was performed without adverse events. After the procedure, the symptoms quickly improved, and the external drain was removed after 12 days. The internal drainage stent remained in place, and the patient was discharged from the hospital 53 days after the EUS-guided drainage. EUS-guided drainage is an effective alternative treatment for infected liver cysts where a percutaneous approach is impossible.

Impact of a new dedicated sheath device for tissue sampling of biliary stricture on pathological diagnostic yield: Retrospective study

Background and study aims Endoscopic transpapillary biliary forceps biopsy (TBFB) is a common method for obtaining specimens from biliary lesions. Its diagnostic yield is unsatisfactory; to overcome this disadvantage, a dedicated sheath has been developed. This study aimed to evaluate the outcomes of conventional TBFB and TBFB with a novel sheath device. Patients and methods Consecutive patients who underwent TBFB between January 2020 and December 2021 were retrospectively evaluated. The rate of obtaining adequate samples, failed attempts at forceps insertion into the bile duct, and sensitivity were compared between the two groups. Results Ninety-two patients who underwent 115 endoscopic retrograde cholangiopancreatographies (76 in the conventional group vs. 39 in the dedicated sheath group) were included. The rates of obtaining adequate samples, failed attempts of the forceps into the bile duct, and sensitivity were 72.4% vs. 89.7% ( P = 0.03), 28.3% vs. 0% ( P < 0.01), and 66.7% vs. 88.9% ( P = 0.02), respectively. Conclusions TBFB with the novel sheath device contributed to improved sensitivity for diagnosis of biliary stricture without insertion of forceps outside the bile duct.

Endoscopic ultrasound-guided tissue acquisition for focal liver lesions in the caudate lobe: a report of seven cases

The caudate lobe of the liver is located deep within the body and surrounded by major blood vessels, such as inferior vena cava, portal vein, and hepatic veins. Thus, percutaneous biopsy is technically challenging. Herein, we report seven patients with focal liver lesions in the caudate lobe who underwent endoscopic ultrasound-guided tissue acquisition (EUS-TA). Their median age was 56 (25-79) years, consisting five males and two females, and the median lesion size was 44 (19-77) mm. Transgastric EUS-TA was performed in all patients. The needles used were 22G and 25G in six patients and one patient, and the median procedure time was 18 (13-30) min. In all patients, adequate specimens were collected, and pathological diagnosis was possible (three intrahepatic cholangiocarcinoma, two metastatic tumors from pancreatic cancer, one hepatocellular carcinoma, and one focal nodular hyperplasia). No adverse events associated with the procedure were observed. EUS-TA can be the first choice for tissue acquisition of the caudate lobe lesions.

Endoscopic ultrasound-guided hepaticogastrostomy versus hepaticogastrostomy with antegrade stenting in patients with unresectable malignant distal biliary obstruction: a propensity score-matched case-control study

BACKGROUND AND AIMS

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a rescue procedure when endoscopic retrograde cholangiopancreatography fails. Peritonitis and recurrent biliary obstruction (RBO) are adverse events (AEs) associated with EUS-HGS. Antegrade stenting across a malignant distal biliary obstruction (MDBO) followed by EUS-HGS (EUS-HGAS) creates two biliary drainage routes, potentially reducing peritonitis and prolonging time to RBO (TRBO). We compared the outcomes of the two techniques.

METHODS

Data of consecutive patients with MDBO who underwent attempted EUS-HGS or EUS-HGAS across five institutions from January 2014 to December 2020 were retrospectively analyzed. A matched cohort of the patients was obtained using one-to-one propensity score matching. The primary outcome was TRBO, and secondary outcomes included AEs except for RBO and overall survival (OS).

RESULTS

Among 360 patients, 283 (176 and 107 in the HGS and HGAS groups, respectively) were eligible. The matched cohorts included 81 patients in each group. AEs developed in 10 (12.3%) and 15 (18.5%) patients (p=0.38) in the HGS and HGAS groups, respectively. RBO occurred in 18 and 2 patients in the HGS and HGAS groups, respectively (p<0.001). TRBO was significantly longer in the HGAS group (median 194 vs. 716 days; hazard ratio [HR]=0.050, 95% confidence interval [CI]=0.0066-0.37, p<0.01). However, there was no significant difference in OS between the groups (median 97 vs. 112 days; HR=0.97, 95% CI=0.66-1.4, p=0.88).

CONCLUSIONS

EUS-HGAS extended TRBO compared with EUS-HGS, while AEs, except for RBO and OS, did not differ. The longer TRBO of EUS-HGAS could benefit patients with longer life expectancy.

Long-term Follow-up of Small Nonfunctioning Pancreatic Neuroendocrine Tumors Diagnosed Using Endoscopic Ultrasound-guided Fine-needle Aspiration

Objective Clinical practice guidelines in Japan recommend surgery for all nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs), regardless of their size or associated symptoms. Because pancreatic resection is highly invasive, follow-up for small NF-PNETs is often chosen in clinical practice. However, the natural history of NF-PNET remains poorly understood. We aimed to examine the natural history of pathologically confirmed NF-PNET. Methods This single-center retrospective case series investigated NF-PNETs that were pathologically diagnosed using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) at our hospital between 2014 and 2018. Patients who were followed up without treatment due to their general condition or their wish were included in the study. Patients' background characteristics, imaging findings, pathological findings, and long-term prognoses were investigated using medical records. Results Overall, 26 patients were diagnosed with NF-PNET by EUS-FNA during the observation period. Of these, 9 patients (3 men and 6 women; median age: 64 years old) were followed up without treatment. All of these patients were asymptomatic, and localization was noticed in 3 cases in the head, body, and tail (1 each), with a median size of 12 (range: 4-18) mm. Neuroendocrine tumor (Grade 1 [G1]) was pathologically diagnosed in all patients with EUS-FNA. The median observation period was 63 (range: 26-90) months. Tumor growth and distant metastasis were not observed in any of the nine patients who remained asymptomatic. Conclusion Follow-up is a feasible option for asymptomatic NF-PNET ≤20 mm in size with a pathological grade of G1.

A case of synchronous IgG4-associated pleuritis and type 1 autoimmune pancreatitis

A 50-year-old man presented to the emergency department with left chest pain, epigastralgia, and low-grade fever for several days. A CT scan showed left pleural effusion, ground-glass opacities in the lower lobes of both lungs, and a capsule-like rim in the pancreas. ERCP showed narrowing of the main pancreatic duct. EUS-FNA was performed, but pathological findings showed no IgG4-positive cells. A thoracoscopic biopsy was performed, and pathological findings showed many IgG4-positive cells. A diagnosis of autoimmune pancreatitis and IgG4-associated pleurisy was made according to international diagnostic criteria. After that, oral steroid therapy was started, and left pleural effusion and pancreatic enlargement improved.

Discordant microsatellite instability findings in two samples from a patient with biliary cancer that responded to pembrolizumab

Microsatellite instability (MSI) is a key marker to predict response to immune checkpoint inhibitors; however, only 1-2% of biliary cancers have this genomic feature. In a patient with hilar biliary cancer, MSI was examined in two cancer specimens (forceps biopsy from the biliary stricture and endoscopic ultrasound-guided fine-needle aspiration biopsy [EUS-FNAB] from the adjacent lymph node). We observed discordant results, as high frequency of MSI was found only in the forceps biopsy. Although the FNAB sample was 10 times larger than that of the forceps biopsy, the tumor concentration was much lower, which is a possible reason for the discordance. Besides, immunohistochemistry of four mismatch-repair (MMR) proteins showed proficient MMR expressions. The tumor became refractory to gemcitabine, cisplatin, and S-1 but responded well to pembrolizumab. Caution is needed for sample selection and for interpretation of the test's results, to avoid missing rare chance for effective molecular target agents.

Optimization of endoscopic ultrasound-guided tissue sample acquisition for commercially available comprehensive genome profiling

BACKGROUND AND AIM

Optimal tumor samples are crucial for successful analysis using commercially available comprehensive genomic profiling (CACGP). However, samples acquired by endoscopic ultrasound-guided tissue acquisition (EUS-TA) are occasionally insufficient, and no consensus on the optimal number of needle passes required for CACGP exists. This study aimed to explore the optimal number of needle passes required for EUS-TA to procure an ideal sample fulfilling the prerequisite criteria of CACGPs.

METHODS

Patients who underwent EUS-TA for solid masses between November 2019 and July 2021 were retrospectively studied. The correlation between the acquisition rate of an ideal sample and the number of needle passes mounted on a microscope slide was evaluated. Additionally, the factors predicting a successful analysis were investigated in patients scheduled for CACGP using EUS-TA-obtained samples during the same period.

RESULTS

EUS-TAs using 22- and 19-gauge (G) needles were performed in 336 and 57 patients, respectively. There was a positive correlation between the acquisition rate and the number of passes using a 22-G needle (38.9%, 45.0%, 83.7%, and 100% for 1, 2, 3, and 4 passes, respectively), while no correlation was found with a 19-G needle (84.2%, 83.3%, and 85.0% for 1, 2, and 3 passes, respectively). The analysis success rate in patients with scheduled CACGP was significantly higher with ideal samples than with suboptimal samples (94.1% vs 55.0%, P < 0.01).

CONCLUSIONS

The optimal estimated number of needle passes was 4 and 1-2 for 22- and 19-G needles, respectively.

Transgastric endoscopic ultrasound-guided fine needle biopsy for diagnosing gastrointestinal stromal tumor of the jejunum

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Genetic medicine in companion diagnostics of germline BRCA testing of Japanese pancreatic cancer patients

In 2021, Japan's national health insurance made germline BRCA (g.BRCA) testing available to unresectable pancreatic cancer (PC) patients as a companion diagnostic (CD) of the PARP inhibitor. This study investigated the incidence of the g.BRCA variant (g.BRCAv.) and the status of the genetic medicine associated with its testing. A total of 110 PC patients underwent the testing, five of whom (4.5%) had a deleterious g.BRCA2v. (all truncations) but no g.BRCA1v. The turnaround time (TAT) to the doctors was 13 days, and to the patients, 17 days. A higher incidence of a BRCA-related family history and a shorter TAT were seen in the g.BRCAv. patients, but they were insignificant (p = 0.085 and p = 0.059, respectively). Genetic counseling was not performed for three g.BRCA2v. patients because two of them had no accessible relatives and one died of the cancer before the genetic report was completed. Two families underwent generic counseling and testing based on the patient's genetic data. g.BRCAv. is recognized in a small fraction of PC cases, and the following genetic counseling is done more for the relatives than for the patients. TAT was constant and did not affect much on the genetic counseling, but the earlier testing is expected for patients with a deadly cancer.

Discordance of microsatellite instability and mismatch repair immunochemistry occurs depending on the cancer type

Microsatellite instability (MSI) and deficiency of mismatch repair (dMMR) are key markers for predicting the response of immune checkpoint inhibitors (ICIs) and screening for Lynch syndrome (LS). This study examined the incidences of and factors associated with the concordance of MSI and MMR in human cancers. A total of 518 formalin-fixed cancer tissues were analyzed for MSI and MMR immunohistochemistry (IHC). MSI was analyzed by a PCR-based method using Promega markers. Concordance with MMR expression and factors associated with concordance were analyzed. In 2 colorectal cancer samples, MMR IHC failed due to inadequate staining conditions. In the remaining 516 cancers, a high level of MSI (MSI-H) was identified in 113 cases, and dMMR was identified in 112. The concordance of MSI and MMR IHC was 98.3%. Only 9 cases (4 pancreatobiliary, 3 colorectal, and 2 endometrial cancers) were discordant. Of the 113 MSI-H cases, 4 (3.5%) were proficient MMR (pMMR); of the 403 microsatellite stability (MSS) cases, 5 (1.2%) were dMMR. The independent factors associated with MSI-H/dMMR included meeting Amsterdam II criteria, assay purpose, and sampling method. Multivariate analysis revealed that cancer type (gastrointestinal cancers or others) was associated with concordance of MSI and MMR IHC. Three LS cases with pancreatic or endometrial cancer demonstrated MSS and dMMR, and one biliary cancer showed MSI-H and pMMR. Discordance between MSI and MMR IHC occasionally occurs in pancreaticobiliary and endometrial cancers. When suspected, both MSI and MMR IHC should be done to judge the ICI indication and screen for LS.

Permanent endoscopic transpapillary gallbladder drainage using a novel spiral stent (IYO-stent)

BACKGROUND AND AIM

Endoscopic transpapillary gallbladder drainage (ETGBD) is widely performed. However, there is no consensus on the appropriate diameter, length, and shape of the stent that should be used in this procedure. In addition, there are limited data on the outcomes of permanent ETGBD. In our facility, a stent with a novel spiral structure (IYO-stent) is permanently placed in patients with acute cholecystitis who are not indicated for surgery. This study examined the efficacy and safety of the IYO-stent in cases of permanent ETGBD.

METHODS

We retrospectively examined patients who underwent permanent ETGBD using the IYO-stent from April 2018 to December 2020.

RESULTS

Eleven patients were included in this study. The technical success and the clinical success rate were 91%. One patient had a post-procedure adverse event (post-endoscopic sphincterotomy bleeding). Within the median observation period of 312 days (range: 109-742), late adverse events, including cholangitis (n = 1) and incomplete stent migration (n = 1), were observed. However, none of the patients experienced cholecystitis relapse.

CONCLUSION

Permanent ETGBD with IYO-stent is an effective treatment for the patients with acute cholecystitis who are not indicated for surgery.

A case of hemobilia caused by pancreatic metastasis of renal cell carcinoma treated with a covered metallic stent

We present the case of an 86-year-old man who had undergone left nephrectomy for renal cell carcinoma (clear cell carcinoma) 22 years ago. He visited the emergency department complaining of right hypochondrial pain and fever. He was eventually diagnosed with acute cholangitis. Abdominal contrast-enhanced computed tomography showed multiple tumors in the pancreas. The tumor in the pancreatic head obstructed the distal bile duct. Endoscopic retrograde cholangiopancreatography detected bloody bile juice flowing from the papilla of Vater. Therefore, he was diagnosed with hemobilia. Cholangiography showed extrinsic compression of the distal bile duct; a 6 Fr endoscopic nasobiliary drainage tube was placed. Endoscopic ultrasound showed that the pancreas contained multiple well-defined hypoechoic masses. Endoscopic ultrasound-guided fine-needle aspiration was performed using a 22 G needle. Pathological examination revealed clear cell carcinoma, and the final diagnosis was pancreatic metastasis of renal cell carcinoma (RCC) causing hemobilia. A partially covered metallic stent was placed in the distal bile duct. Consequently, hemobilia and cholangitis were resolved.

Endoscopic Transpapillary Gallbladder Drainage in a Patient with Billroth-II Reconstruction

Endoscopic transpapillary gallbladder drainage (ETGBD) is an established procedure and is listed in the Tokyo guidelines 2018. Although there are many reports of ETGBD in normal anatomy cases, it is rarely performed for patients with a surgically altered anatomy. We herein report the case of a patient who underwent ETGBD with Billroth-II reconstruction. ETGBD could be an effective treatment option even for patients with a surgically altered anatomy.

A case of bile duct diverticulum with repeated acute cholangitis due to diverticular stone fall

A 34-year-old man presented to the emergency department with a chief complaint of epigastric pain. Endoscopic ultrasound detected a 5 mm stone in the common bile duct. After endoscopic sphincterotomy, the black stones and debris were removed with balloon catheter. Abdominal ultrasonography detected no gallbladder stones; hence, the patient was followed up. However, 3 months later, the patient again developed acute cholangitis caused by common bile duct stones and underwent endoscopic stone removal. Cholangiography under balloon occlusion revealed a left hepatic duct diverticulum with an internal defect. Intraductal ultrasonography showed a hyperechoic lesion with acoustic shadow in the diverticulum, suggesting a stone or debris. Therefore, the patient was considered to have had repeated acute cholangitis because of the presence of falling diverticular stones. The patient underwent left hemihepatectomy plus segmentectomy 1 and cholecystectomy. Histopathologically, it was a true diverticulum without internal epithelial atypia. Many debris were seen in the diverticulum. Gallbladder stones were not observed. Eventually, the patient was discharged from the hospital with no postoperative complications and no recurrence of cholangitis after 20 months.

Comparative Study of an Ultrasound-guided Percutaneous Biopsy and Endoscopic Ultrasound-guided Fine-needle Aspiration for Liver Tumors

Objective Both a percutaneous biopsy and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) have been widely performed for liver tumors. However, no studies have compared these two biopsy methods. Method A retrospective study was conducted using medical records for patients who underwent a liver tumor biopsy from 2012 to 2019. The cases were classified into two groups for a comparison: an ultrasound-guided percutaneous biopsy group (percutaneous group) and an EUS-FNA group (EUS group). Results A total of 106 patients (47 in the percutaneous group and 59 in the EUS group) were included. The final diagnosis was malignant in 100 cases and benign in the remaining 6 cases. While the median lesion diameter was 62 mm in the percutaneous group, it was significantly smaller (34 mm) in the EUS group (p <0.01). The EUS group had more left lobe tumors than right lobe tumors. All cases of caudate lobe tumor (four cases) underwent EUS-FNA. The sensitivity, specificity, and accuracy of the procedure were 95%, 100%, and 96% in the percutaneous group and 100%, 100%, and 100% in the EUS group, respectively showing no significant difference. Adverse events were reported in 17% of the percutaneous group, which was significantly lower than in the EUS group (2%; p <0.01). Conclusion A percutaneous biopsy and EUS-FNA have equivalent diagnostic qualities for liver tumors, although EUS-FNA tends to be associated with fewer adverse events. A complete understanding of the characteristics of each procedure is essential when choosing the best biopsy method for each particular case.

Usefulness of endoscopic ultrasound-guided fine needle aspiration for splenic parenchyma in patients suspected of having primary splenic malignant lymphoma

Background and study aims  The diagnosis of malignant lymphoma (ML) is sometimes difficult, especially in patients with primary splenic malignant lymphomas (psML) which have no lymph nodes capable of acting as the biopsy target. We carried out endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for "splenic parenchyma" in patients suspected of having a psML, even without any obvious neoplastic lesions in the spleen. Patients and methods  A retrospective study using medical records was conducted of eight patients suspected of having a psML that received EUS-FNA for the splenic parenchyma between January 2016 and January 2019. Data analyzed included clinical background, EUS-FNA procedure (puncture needle/route), diagnostic ability (pathological/flow cytometry [FCM]), and complications. Results  EUS-FNA was performed from the stomach in all eight cases, and no patients had complications. As a result of splenic parenchymal biopsy found on EUS-FNA, 75 % of patients (6/8) were histologically diagnosed with MLs, monoclonality of B-cells was identified in all cases (8/8) with FCM, and all patients (8/8) were definitively diagnosed with psMLs. Conclusion  EUS-FNA for "splenic parenchyma" is useful for patients with spML, even if they have no obvious neoplastic lesions in the spleen.

Can the location of the mural nodule indicate benign or malignant in branch duct-type intraductal papillary mucinous neoplasm of the pancreas?

BACKGROUND/OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are classified into main duct (MD)-type IPMNs, branch duct (BD)-type IPMNs, and mixed type IPMNs. While MD-type IPMN has a high risk of malignancy and should therefore be considered for resection if the patient is fit, BD-type IPMN needs to be carefully judged for surgical indication. The decision to resect BD-type IPMN is often based on international consensus Fukuoka guidelines 2017, but further investigation is required. In this study, we focused on whether the location of the mural nodule (MN) could be an indicator of malignancy.

METHODS

We enrolled 17 cases who had been diagnosed BD-type IPMNs which were surgically resected from January 2016 to December 2019. These cases were classified into benign and malignant group. Subsequently, a clinicopathological study was conducted based on the localization of MN (MN-central type or MN-peripheral type).

RESULTS

Although MN was found in 57% (4/11) in the benign group, 88% (7/8) was noted in the malignant group, indicating the presence of MN to be more common in the malignant group. Those with MN consisted of 6 cases of MN-central type and 5 cases of MN-peripheral type. All cases of central type were malignant compared to only one case of the peripheral group being confirmed on histology as cancer.

CONCLUSION

BD-IPMN with central mural nodule should be considered high risk for malignancy.

A case of pancreatic mixed acinar-neuroendocrine carcinoma successfully diagnosed with endoscopic ultrasound-guided fine needle aspiration

Mixed acinar-neuroendocrine carcinoma (MAEC) of the pancreas is a rare entity, and obtaining a preoperative diagnosis is difficult. We report a case of pancreatic MAEC successfully diagnosed with EUS-FNA. The case was a 72-year-old male with upper abdominal pain. Abdominal CT showed an irregular, hypovascular tumor of pancreatic tail. EUS-FNA was performed using a 22G needle. Immunostaining revealed positive results for the acinar marker trypsin and the neuroendocrine markers chromogranin A and synaptophysin. The possibility for MAEC was considered. He underwent distal pancreatectomy and splenectomy. Immunohistochemical examination of the tumor cells showed a wide range of positivity for bcl-10 and trypsin as well as for chromogranin A and synaptophysin, but negative results for CA19-9 and AFP. Considering that ≥ 30% tumors were positive for both acinar and neuroendocrine markers, the patient was diagnosed with MAEC.

Usefulness of endoscopic nasobiliary drainage-guided ERCP in patients with surgically altered anatomy (with video)

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is one of the most challenging endoscopic procedures. Although single- or double-balloon endoscopes have been widely used, reaching the papilla of Vater (hepaticojejunostomy/pancreaticojejunostomy site) is often difficult. For patients in whom treatment cannot be completed in a single session, we placed endoscopic nasobiliary drainage (ENBD) at the end of the procedure; in the second session, the scope was inserted following ENBD placement. Patients and methods  Three patients with surgically altered anatomy and who underwent ENBD-guided ERCP were retrospectively examined using the medical records. Results  There were two men and one woman, with an average age of 75 years. The surgical procedure were distal gastrectomy and Roux-en-Y reconstruction in all patients. The diagnosis were choledocholithiasis in two and bile duct stricture in one. Average time to reach the papilla was 50 minutes (range, 21-102) for the first ERCP and was shortened to 11 minutes (range, 5-17) for the second session under an indwelling ENBD. Treatment was successful in all patients without complications. Conclusion  ENBD-guided ERCP in patients with surgically altered anatomy was a useful method that facilitated scope insertion and shortened the procedure time.

A case of primary pancreatic schwannoma diagnosed by endoscopic ultrasound-fine needle aspiration

Pancreatic schwannoma is difficult to diagnose preoperatively. A 79-year-old man was found to have a 9-mm pancreatic mass on abdominal ultrasonography. On EUS, there was a 9-mm, clearly demarcated, round, solid, hypo-echoic mass in the pancreatic body. The differential diagnosis included a pancreatic neuroendocrine tumor, a solid-pseudopapillary neoplasm, and an atypical pancreatic cancer. EUS-FNA was performed with a 22G needle. On pathology examination, spindle-shaped tumor cells were seen proliferating in bundles. On immunostaining, the lesion was negative for c-kit, CD34, and α-SMA but positive for S-100 protein. The MIB-1 index was < 2%. Based on the above findings, the lesion was diagnosed as a benign pancreatic schwannoma. We, therefore, decided to follow the patient with careful observation rather than resecting the lesion surgically. The tumor has not changed significantly after 3 years of follow-up. EUS-FNA is useful for the diagnosis of pancreatic schwannoma. If the tumor can be determined to be benign preoperatively, unnecessary surgery can be avoided. EUS-FNA should be actively implemented for pancreatic tumors that are difficult to diagnose definitively on imaging.

[Six cases of anaplastic pancreatic carcinoma diagnosed by endoscopic ultrasound-guided fine needle aspiration]

Anaplastic pancreatic carcinoma is a rare form of pancreatic cancer with an extremely poor prognosis. Its diagnosis is often based on surgical specimens and few reports have described the use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for diagnosis. In this study, we examined six patients (mean age, 70.5 years;sex ratio, 1:1) who were diagnosed with anaplastic pancreatic carcinoma using EUS-FNA. The carcinomas were located in the pancreatic head, body, and tail in one, three, and two patients, respectively. The mean tumor diameter was 49.2mm. Five patients opted for best supportive care due to poor performance status and one underwent chemotherapy (GEM+nab-PTX). The median survival was 40.5 (14-98) days. The characteristic imaging findings of anaplastic pancreatic carcinoma, including central necrosis, marginal contrast enhancement, cystic findings, and internal calcification, were frequently observed in the patients. Anaplastic pancreatic carcinoma can also be diagnosed using biopsy tissue;however, a pathologist's consultation is required to differentiate the disease based on imaging findings for an accurate diagnosis.

Optimal timing for precutting in cases with difficult biliary cannulation

BACKGROUND AND STUDY AIMS

 In endoscopic retrograde cholangiopancreatography (ERCP), precutting is widely used when achieving biliary cannulation is difficult. However, no consensus has been reached with regard to the best time to initiate precutting.

PATIENTS AND METHODS

 We retrospectively examined 63 patients who underwent precutting for naïve papilla with difficulty in biliary cannulation between 2009 and 2016. The outcomes of the early precut group (≤ 20 min from cannulation until initiating precutting) and the late precut group (> 20 min) were compared.

RESULTS

 Of the 63 patients, 17 (27 %) were in the early precut group and 46 (73 %) were in the late precut group; median time until the initiating precutting was 28 minutes (7 - 50). No significant difference was observed between the two groups in terms of clinical features (age, sex, and indication for ERCP), precutting method, and rate of pancreatic duct stent placement. Significantly higher rates of successful biliary cannulation were observed in the early precut group (16/17; 94 %) than in the late precut group (32/46; 70 %) ( P  < 0.05). In 13 patients in whom precutting was commenced after 40 minutes, the rate of successful biliary cannulation was very low at 53 % (7/13). No significant difference was found between the two groups in terms of incidence of complications (pancreatitis in 5 patients and bleeding in 1 patient).

CONCLUSION

 In actual clinical practice, precutting is commenced approximately 30 minutes after cannulation; however, to successfully achieve biliary cannulation, precutting is recommended to be performed within 20 minutes. Precutting is effective when little inflammation and swelling of the ampulla of Vater is observed. This study was limited in that it was single-center, retrospective and had a small subject sample.

Life-threatening emphysematous liver abscess associated with poorly controlled diabetes mellitus: a case report

Background

Emphysematous liver abscesses are defined as liver abscesses accompanied by gas formation. The fatality rate is extremely high at 27%, necessitating prompt intensive care.

Case presentation

The patient was a 69-year-old Japanese man with type 2 diabetes. He visited the emergency outpatient department for fever and general malaise that had been ongoing for 2 weeks. Abdominal computed tomography revealed an abscess 5 cm in diameter accompanied by gas formation in the right hepatic lobe. Markedly impaired glucose tolerance was observed with a blood sugar level of 571 mg/dL and a glycated hemoglobin level of 14.6%. The patient underwent emergency percutaneous abscess drainage, and intensive care was subsequently initiated. Klebsiella pneumoniae was detected in both the abscess cavity and blood cultures. The drain was removed 3 weeks later, and the patient was discharged.

Conclusion

Emphysematous liver abscesses are often observed in patients with poorly controlled diabetes, and the fatality rate is extremely high. Fever and malaise occasionally mask life-threatening infections in diabetic patients, necessitating careful examination.

Phosphorylation of the cytokinesis regulator ECT2 at G2/M phase stimulates association of the mitotic kinase Plk1 and accumulation of GTP-bound RhoA

The epithelial cell transforming gene 2 (ECT2) protooncogene encodes a Rho exchange factor, and regulates cytokinesis. ECT2 is phosphorylated in G2/M phases, but its role in the biological function is not known. Here we show that two mitotic kinases, Cdk1 and polo-like kinase 1 (Plk1), phosphorylate ECT2 in vitro. We identified an in vitro Cdk1 phosphorylation site (T412) in ECT2, which comprises a consensus phosphospecific-binding module for the Plk1 polo-box domain (PBD). Endogenous ECT2 in mitotic cells strongly associated with Plk1 PBD, and this binding was inhibited by phosphatase treatment. A phosphorylation-deficient mutant form of ECT2, T412A, did not exhibit strong association with Plk1 PBD compared with wild-type (WT) ECT2. Moreover, ECT2 T412A, but not phosphomimic T412D, displayed a diminished accumulation of GTP-bound RhoA compared with WT ECT2, suggesting that phosphorylation of Thr-412 is critical for the catalytic activity of ECT2. Moreover, while overexpression of WT ECT2 or the T412D mutant caused cortical hyperactivity in U2OS cells during cell division, this activity was not observed in cells expressing ECT2 T412A. These results suggest that ECT2 is regulated by Cdk1 and Plk1 in concert.

Detection of peptide-specific CTL-precursors in peripheral blood lymphocytes of cancer patients

Development of therapeutic vaccines is one of the major areas of tumour immunotherapy today. However, clinical trials of peptide-based cancer vaccines have rarely resulted in tumour regression. This failure might be due to an insufficient induction of cytotoxic T lymphocytes in the current regimes, in which cytotoxic T lymphocytes-precursors in pre-vaccination peripheral blood mononuclear cells are not measured. Initiation of immune-boosting through vaccination could be better than that of immune-priming with regard to induction of prompt and strong immunity. If this is also the case for therapeutic vaccines, pre-vaccination measurement of peptide-specific cytotoxic T lymphocytes-precursors will be important. In the present study, we investigated whether cytotoxic T lymphocytes-precursors reacting to 28 kinds of peptides of vaccine candidates (13 and 15 peptides for HLA-A24(+) and HLA-A2(+) patients, respectively) were detectable in pre-vaccination peripheral blood mononuclear cells of 80 cancer patients. Peptide-specific cytotoxic T lymphocytes-precursors were found to be detectable in peripheral blood mononuclear cells of the majority of cancer patients (57 out of 80 cases, 71%). The mean numbers of positive peptides were 2.0 peptides per positive case. Peripheral blood mononuclear cells incubated with positive peptides, not with negative peptides, showed significant levels of HLA-class-I-restricted cytotoxicity to cancer cells. The profiles of positive peptides entirely varied among patients, and were not influenced by the cancer origin. These results may provide a scientific basis for the development of a new approach to cancer immunotherapy, e.g.) cytotoxic T lymphocytes-precursor-oriented peptide vaccine.

[A case of advanced gastric cancer complicated with liver metastases responding remarkably to combined chemotherapy with 5-fluorouracil and low-dose cisplatin, with UFT and low-dose cisplatin for maintenance on an outpatient basis]

A 77-year-old man who had advanced gastric cancer with multiple liver metastases was treated by combined chemotherapy with 5-fluorouracil and low-dose cisplatin for 1 and half courses (1 course = 4 weeks). After this treatment, the primary gastric lesion was reduced, the liver metastases disappeared, and serum tumor marker levels decreased. After discharge, we administered a dose of 300 mg of UFT-E orally every day, and 10 mg of CDDP intravenously once weekly on an outpatient basis. The patient has survived with a good quality of life.

[A case of pulmonary metastases of breast cancer responding remarkably to combined chemotherapy with 5-fluorouracil and low-dose cisplatin]

A 46-year-old-woman underwent breast preserving mastectomy for advanced breast cancer. Seven months after operation, pulmonary metastases were found. The patient was admitted and treated with combined chemotherapy of 5-fluorouracil and low-dose cisplatin for 4 weeks. After discharge, UFT 300 mg orally every day and cisplatin 5 mg div once week were administered for 2 years on an outpatient basis. The result was disappearance of the pulmonary metastases. Five years after operation, the patient is alive without any sign of the pulmonary metastasis.

Locoregional cellular immunotherapy for patients with advanced esophageal cancer

The objectives of the present study were to determine the safety of locoregional administration of autologous lymphocytes stimulated with autologous tumor cells and interleukin (IL) 2 in vitro and to find laboratory markers to predict either clinical toxicity or clinical response. Eleven patients with advanced (n = 4) or recurrent (n = 7) esophageal cancers received the locoregional administration of these activated lymphocytes every 2 weeks for two to nine times (mean, 5.6 times), and mean numbers of the administered cells were 0.8 x 10(9) cells per treatment. The activated lymphocytes that were pretested for their surface markers and CTL activity were endoscopically injected into primary tumor sites (n = 4) or directly injected into metastatic lymph nodes (n = 2), pleural (n = 4) or ascitic (n = 1) regions. Grade 3 hypotension, grade 2 diarrhea, and grade 1 fever were observed in 1, 1, and 6 patients, respectively, and there was no adverse effect in the remaining three patients. The clinical outcome was as follows: one, complete response (CR); three, partial response (PR); two, stable response (SR); and five, progressive disease (PD). CTL activity in the administered cells was observed in 5 of the 11 patients (1 CR, 3 PR, and 1 PD) and was not observed in the remaining 6 patients (2 SR and 4 PD). Percentages of CD16+ cells in the peripheral blood of the responder group (CR+PR) significantly increased when compared with those before treatment or with those of the nonresponder group before as well as after treatment. Because the clinical toxicity was moderate and tolerable, this new method of locoregional immunotherapy will be applicable for use in treatment of patients with advanced and recurrent esophageal cancers. Both CTL activity in the administered cells and the percentages of CD16+ cells in the peripheral blood may be useful laboratory markers for predicting of clinical response.

Expression of SART3 tumor-rejection antigen in gastric cancers

We previously reported SART3 as a tumor-rejection antigen recognized by histocompatibility leukocyte antigen (HLA)-A24-restricted cytotoxic T lymphocytes (CTLs). In this study, we investigated the expression of the SART3 antigen in gastric cancers, as a candidate for use in specific immunotherapy. The SART3 antigen was detected in 9 of 10 (90%) gastric cancer cell lines, 35 of 52 (67.3%) gastric cancer tissues, and 0 of 20 non-tumorous gastric tissues. SART3-derived peptides corresponding to positions 109- 118 and 315-323 induced HLA-A24-restricted and tumor-specific CTLs from peripheral blood mononuclear cells (PBMCs) of gastric cancer patients. These peptide-induced CTLs recognized HLA-A24(+) SART3(+) gastric cancer cells, but not HLA-A24(+) SART3(-) or HLA-A24(-) SART3(+) gastric cancer cells. Therefore, the SART3 peptides could be useful in specific immunotherapy of gastric cancer patients.

A cyclophilin B gene encodes antigenic epitopes recognized by HLA-A24-restricted and tumor-specific CTLs

We have studied Ags recognized by HLA class I-restricted CTLs established from tumor site to better understand the molecular basis of tumor immunology. HLA-A24-restricted and tumor-specific CTLs established from T cells infiltrating into lung adenocarcinoma recognized the two antigenic peptides encoded by a cyclophilin B gene, a family of genes for cyclophilins involved in T cell activation. These two cyclophilin B peptides at positions 84-92 and 91-99 induced HLA-A24-restricted CTL activity against tumor cells in PBMCs of leukemia patients, but not in epithelial cancer patients or in healthy donors. In contrast, the modified peptides at position 2 from phenylalanine to tyrosine, which had more than 10 times higher binding affinities to HLA-A24 molecules, could induce HLA-A24-restricted CTL activity against tumor cells in PBMCs from leukemia patients, epithelial cancer patients, or healthy donors. PHA-activated normal T cells were resistant to lysis by the CTL line or by these peptide-induced CTLs. These results indicate that a cyclophilin B gene encodes antigenic epitopes recognized by CTLs at the tumor site, although T cells in peripheral blood (except for those from leukemia patients) are immunologically tolerant to the cyclophilin B. These peptides might be applicable for use in specific immunotherapy of leukemia patients or that of epithelial cancer patients.

Polymorphisms in the 5'-flanking region of tumor necrosis factor-alpha gene in patients with rheumatoid arthritis

Polymorphisms in the 5'-flanking promoter/enhancer region of the tumor necrosis factor (TNF)-a gene were examined to study the genetic background of rheumatoid arthritis (RA). Four variant alleles, -1,031C/ -863A, -1,031C/-238A, -857T and -308A, were identified and examined in 387 RA patients and 575 healthy Japanese controls. The frequency of the -857T allele in RA patients was significantly higher than that in the controls. However, the HLA-DRB1 analysis in the same subjects showed that the DRB1*0405 allele, which is in linkage disequilibrium with the -857T, was more strongly associated with the disease susceptibility than the -857T allele. These results suggest that the susceptible gene to RA is more closely linked to the HLA-DRB1 locus than to the TNF-alpha locus.

A gene encoding antigenic peptides of human squamous cell carcinoma recognized by cytotoxic T lymphocytes

Except for melanomas, tumor antigens recognized by cytotoxic T lymphocytes (CTLs) are yet unidentified. We have identified a gene encoding antigenic peptides of human squamous cell carcinomas (SCCs) recognized by human histocompatibility leukocyte antigens (HLA)- A2601-restricted CTLs. This gene showed no similarity to known sequences, and encoded two (125- and 43-kilodalton [kD]) proteins. The 125-kD protein with the leucine zipper motif was expressed in the nucleus of the majority of proliferating cells tested, including normal and malignant cells. The 43-kD protein was expressed in the cytosol of most SCCs from various organs and half of lung adenocarcinomas, but was not expressed in other cancers nor in a panel of normal tissues. The three nonapeptides shared by the two proteins were recognized by the KE4 CTLs, and one of the peptides induced in vitro from peripheral blood mononuclear cells (PBMCs) the CTLs restricted to the autologous tumor cells. The 43-kD protein and this nonapeptide (KGSGKMKTE) may be useful for the specific immunotherapy of HLA-A2601(+) epithelial cancer patients.