Efficacy of a gastroscope for cecal intubation during colonoscopy in patients with severe sigmoid adhesion

BACKGROUND

Cecal intubation during colonoscopy is difficult to achieve in patients with severe sigmoid adhesions. This retrospective observational study assessed the efficacy of using a gastroscope for colonoscopy in patients with severe sigmoid adhesions. Furthermore, the ability of computed tomography (CT) to predict the possibility of cecal intubation using a gastroscope was examined.

METHODS

A total of 1,626 patients who underwent colonoscopy for total colon observation by one endoscopist were enrolled. Cecal intubation rate and other procedure-related outcomes were evaluated. We also investigated whether identification of the sigmoid colon pathway by CT was involved in cecal intubation rate using a gastroscope.

RESULTS

Of the enrolled patients, cecal intubation by colonoscope was not feasible in 19 patients (1.2%) because of severe sigmoid adhesions. Cecal intubation was possible in 13 patients (68.4%) using a gastroscope, and the cecal intubation rate of peritoneal carcinomatosis (0%, p < 0.01) was significantly lower than that of other causes such as a diverticulum (100%) and history of gynecologic surgery (80%). The identifiable case of the sigmoid colon pathway by horizontal section on CT showed significantly higher cecal intubation rate compared to those of unidentifiable cases (92.3% vs. 16.7%, p < 0.01).

CONCLUSION

Using a gastroscope is effective in performing cecal intubation during colonoscopy in patients with severe sigmoid adhesions. However, in patients with sigmoid adhesions caused by peritoneal carcinomatosis, cecal intubation may be difficult, even when a gastroscope is used. The ability of CT to identify the sigmoid colon pathway may predict success of cecal intubation.

Endoscopic fenestration for benign complete anastomotic obstruction following rectal surgery

Video 1Endoscopic fenestration for benign complete anastomotic obstruction after rectal surgery.

Long-term outcomes after endoscopic submucosal dissection for differentiated-type early gastric cancer that fulfilled expanded indication criteria: A prospective cohort study

BACKGROUND AND AIM

Endoscopic resection for early gastric cancer (EGC) is widely performed. However, there is still a paucity of strong evidence regarding long-term outcomes after endoscopic submucosal dissection (ESD) for the expanded indication criteria of the Japanese guidelines (ver. 2010).

METHODS

Endoscopic submucosal dissection was performed in patients with EGC that met the expanded indication criteria: (i) cT1a, differentiated-type EGC of 2 to 5 cm, ulcer negative or (ii) cT1a, differentiated-type EGC of ≤3 cm, ulcer positive. Patients whose pathological examination fulfilled the curative resection criteria were then enrolled in this cohort study: negative vertical margin, negative lymphovascular invasion, and (i) pT1a, differentiated-type, and ulcer negative; (ii) pT1a, differentiated-type, ≤3 cm, and ulcer positive; or (iii) pT1b1 (<500-μm submucosal invasion), differentiated-type, and ≤3 cm. Patients with only a positive horizontal margin as a noncurative factor were included for follow-up.

RESULTS

From September 2003 to February 2012, a total of 356 patients underwent ESD, and 214 were enrolled in the survival analysis. One hundred twenty patients (56%) had >2 cm in diameter and ulcer-negative lesions, and 94 (44%) had ≤3 cm and ulcer-positive lesions. The vital status at 5 years after ESD was confirmed in all (100%) patients. No local or metastatic recurrence was detected; however, 26 metachronous gastric cancers developed, and 1 patient died of metachronous gastric cancer. The 5-year disease-specific and overall survival rates were 99.5% (95% confidence interval [CI], 97.2%-100%) and 93.9% (95% CI, 89.8%-96.4%), respectively.

CONCLUSION

ESD for EGC that fulfills the expanded criteria is feasible and shows favorable long-term outcomes.

Effects of antithrombotic drugs on the results of fecal immunochemical test in colorectal neoplasms screening

Fecal immunochemical test (FIT) is widely used as a colorectal cancer screening tool. Antithrombotic drugs may affect the screening performance of FIT for colorectal tumors. The aim of this study was to clarify the effect of antithrombotic agents on FIT accuracy in screening for colorectal neoplasms. This retrospective study enrolled a total of 758 patients who underwent both FIT and total colonoscopy. The effect of antithrombotic drugs on FIT accuracy in detecting colorectal neoplasms (CN), including colorectal cancer (CRC), advanced adenoma (AA), and non-advanced adenoma (NAA), was examined. Of the 758 patients, 144 (19%) received antithrombotic drugs (administration group). In administration group, 61/144 (42%) cases had CN [CRC:14, AA:15, NAA:32] and 217/614 (35%) cases had CN (CRC:43, AA:56, NAA:118) in non-administration group. The prevalence of CN was not significantly different between the two groups (p = 0.1157). There was no significant difference in sensitivity or specificity of the detection of all types of CN with or without taking antithrombotic drugs. Neither the positive predictive value nor negative predictive value of FIT was affected by antithrombotic drug administration. Taking antithrombotic drugs may not have a large impact on sensitivity, specificity, positive predictive value, or negative predictive value of FIT in screening for CN.

Skeletal Muscle Depletion: A Risk Factor for Pneumonia following Gastric Endoscopic Submucosal Dissection in Elderly Patients

INTRODUCTION

Endoscopic submucosal dissection (ESD) is an effective treatment for gastric neoplasms in elderly patients; however, it involves several adverse events, including pneumonia. This study aimed to investigate whether skeletal muscle depletion (SMD) was associated with the development of pneumonia in elderly patients who underwent gastric ESD.

METHODS

This retrospective observational cohort study included 157 patients (≥80 years) who had undergone gastric ESD. The skeletal muscle cross-sectional area was measured by CT, and the value of the third lumbar vertebra skeletal muscle index (L3 SMI) was evaluated. The SMD was defined as an L3 SMI value ≤38.0 cm2/m2 for women and ≤42.0 cm2/m2 for men. Pneumonia was also diagnosed using CT to identify all included patients.

RESULTS

Among 157 patients, 66 (42.0%) showed SMD. In the SMD group, the incidence of pneumonia was 21.2%, whereas it was 7.7% in the non-SMD group (p = 0.018). The longest hospitalization duration was 19 days. Antibiotics were administered in 61.9% of the patients. Procedure time was not significantly different between the groups (72 ± 54 min vs. 62 ± 44 min, p = 0.201). On multivariate analysis, SMD was an independent risk factor for the development of pneumonia (odds ratio = 3.16, 95% confidence interval, 1.18-8.50, p = 0.023).

CONCLUSIONS

SMD was not a rare entity in patients aged ≥80 years with gastric neoplasms. SMD was a significant risk factor for pneumonia related to gastric ESD in elderly patients.

Narrow band imaging under less-air condition improves the visibility of superficial esophageal squamous cell carcinoma

Background

The current virtual chromoendoscopy equipment cannot completely detect superficial squamous cell carcinoma (SCC) in the esophagus, despite its development in the recent years. Thus, in this study, we aimed to elucidate the appropriate air volume during endoscopic observation to improve the visibility of esophageal SCC.

Methods

This retrospective study included a total of 101 flat type esophageal SCCs identified between April 2017 and January 2019 at the Department of Gastrointestinal Oncology, Osaka International Cancer Institute. Video images of narrow band imaging (NBI) under both less-air and standard-air conditions were recorded digitally. Videos were evaluated by five endoscopists. Relative visibility between less-air and standard-air conditions of the brownish area, brownish color change of the epithelium, and dilated intrapapillary capillary loop (IPCL) were graded as 5 (definitely better under less-air condition) to 1 (definitely worse under less-air condition), with 3 indicating average visibility (equivalent to standard-air observation).

Results

The mean (standard deviation) visibility score of the brownish area, brownish color change of the epithelium, and dilated IPCLs under less-air condition were 3.94 (0.58), 3.73 (0.57), and 4.13 (0.60), respectively, which were significantly better than that under standard-air condition (p < 0.0001). Esophageal SCC evaluated as ≥ 4 in the mean visibility score of the brownish area, brownish color change of the epithelium, and dilated IPCLs accounted for 50% (51/101 lesions), 34% (34/101 lesions), and 67% (68/101 lesions), respectively.

Conclusions

The present results suggested that NBI with less air might improve the visibility of flat type esophageal SCC compared with NBI with standard air. Less-air NBI observation may facilitate the detection of flat type esophageal SCC.

Trial registration

The present study is a non-intervention trial.

Does cold snare polypectomy completely resect the mucosal layer? A prospective single-center observational trial

BACKGROUND AND AIM

The true incidence of incomplete muscularis mucosa resection with cold snare polypectomy (CSP) is unknown. We examined the incidence of incomplete muscularis mucosa resection both with and without cold snare defect protrusion (CSDP).

METHODS

We prospectively enrolled patients undergoing polypectomy for 4 to 9mm nonpedunculated polyps. We evaluated the presence of CSDP immediately following CSP and biopsied the CSDP or the center of the mucosal defect without CSDP. The presence of the muscularis mucosa and any residual polyp in the biopsies was evaluated histologically. The primary outcome was the incidence of incomplete mucosal layer resection defined as the presence of muscularis mucosa or residual polyp in the biopsies.

RESULTS

From August 2017 to October 2018, 188 patients were screened, and 357 polyps were included. CSDP was detected in 122/355 (34%) evaluated mucosal defects. Excluding five lesions requiring hemostasis immediately following CSP, 352 mucosal defects were biopsied. After excluding 102 biopsies containing normal mucosa, we evaluated 250 biopsies. The overall incidence of incomplete mucosal layer resection was 63% (159/250), 76% (68/90) with CSDP and 57% (91/159) without CSDP (P < 0.01). Both univariate and multivariate analyses showed that size (≥ 6 mm), resection time (≥ 5 s), and serrated lesions were risk factors for CSDP.

CONCLUSIONS

Cold snare defect protrusion (CSDP), which was present with 36%, was a good indicator for incomplete mucosal layer resection. Even in nonCSDP polypectomies, 57% of the mucosal layer was not removed completely. Thus, CSP should be used for intra-epithelial lesions only, and careful pretreatment evaluation is recommended.

Endoscopic appearance of esophageal xanthoma

Background and study aims  Esophageal xanthomas are considered to be rare, and their endoscopic diagnosis has not been fully elucidated. The aim of the present study was to determine the characteristics of the endoscopic appearance of esophageal xanthomas. Patients and methods  This was a retrospective study of consecutive patients with histologically diagnosed esophageal xanthomas at a referral cancer center in Japan. The endoscopic appearance, by magnifying or image-enhanced endoscopy, and histological findings of esophageal xanthomas were investigated. Results  Seven patients (six men and one woman) were enrolled. All of the patients had a solitary lesion, and the median size was 2 mm (range, 1 - 5 mm). Conventional white-light endoscopy showed the lesions as flat areas with yellowish spots in four cases and slightly elevated yellowish lesions in three cases. Magnifying endoscopy, performed in six patients, revealed the lesions as areas with aggregated minute yellowish spots with tortuous microvessels inside. Magnifying narrow-band imaging contrasted the yellowish spots and microvessels better than white-light endoscopy. In all lesions, histological examination showed that the yellowish spots corresponded to papillae filled with foam cells. The foam cells were strongly immunopositive for CD68, and in all lesions, CD34-positive intrapapillary capillaries surrounded the aggregated foam cells. The different morphologies of the flat and slightly elevated lesions corresponded to different densities of papillae filled with foam cells. Conclusions  Magnifying endoscopy revealed minute yellowish spots with tortuous microvessels inside. These correspond well with histological findings and so may be useful in the diagnosis of esophageal xanthomas.

Endoscopic full-thickness resection of gastric gastrointestinal stromal tumor: a Japanese case series

Background:

Gastrointestinal stromal tumors (GISTs) are potentially malignant and are indicated for resection. The standard treatment for resectable GISTs is surgery, although endoscopic resection has been reported outside Japan. This study retrospectively analyzed the results of endoscopic resection of GISTs in Japan.

Method:

We identified patients with GISTs treated only by endoscopic resection in our institute between January 2016 and December 2018, and analyzed their clinical and pathological characteristics.

Results:

During the study period, 8 GISTs were resected only by endoscopy: 7 were located in the upper third of the stomach and 1 in the middle. All were intraluminal growth type. Median (range) tumor diameter was 20 (10-35) mm. All tumors were resected en bloc with a median (range) operation time of 67.5 (50-166) min. Complete perforation occurred in 5 cases, but the serosa remained in 2 and the outer layer of the muscularis propria remained in 1. The defect was endoscopically closed with clip-and-endoloop purse-string suturing (n=3), simple endoclipping (n=2), or over-the-scope clipping (n=2), and 1 did not require closure because the outer longitudinal muscle was preserved. Oral feeding was commenced on postoperative day (POD) 3 (median; range 2-4), and the patient was discharged on POD 6 (median; range 4-11). No serious adverse event developed after the procedures.

Conclusion:

Endoscopic resection for selected cases of small intraluminal GISTs is feasible, making it a viable alternative treatment option to laparoscopic surgery.

Efficacy of autofluorescence imaging for flat neoplasm detection: a multicenter randomized controlled trial (A-FLAT trial)

BACKGROUND AND AIMS

Colorectal flat (nonpolypoid) lesions can be overlooked during colonoscopy. This study evaluated the efficacy of updated autofluorescence imaging (AFI) for detecting colorectal flat neoplasms.

METHODS

This was a prospective, multicenter, randomized controlled trial in 9 Japanese tertiary institutions. Patients undergoing colonoscopy because of positive fecal immunochemical tests, surveillance after polypectomy, or investigation of minor symptoms were enrolled and randomly assigned to either the white-light imaging (WLI) or the AFI group. Primary outcome measurement was number of flat neoplasms per patient.

RESULTS

From November 2015 to June 2017, 817 patients were enrolled. After excluding 15 patients, 802 were finally analyzed (404, WLI; 398, AFI). Patients' backgrounds (sex, age, indication of colonoscopy, experience of endoscopists) and quality of colonoscopy (bowel preparation, sedative use, cecal insertion rate, insertion and withdrawal time) were not different between groups. Number of flat neoplasms in each patient was significantly higher in the AFI than in the WLI group (.87 [95% confidence interval [CI], .78-.97] vs .53 [95% CI, .46-.61]), whereas overall and polypoid neoplasm detection was not significantly different between the groups (1.33 [95% CI, 1.22-1.45] vs 1.14 [95% CI, 1.03-1.24], .46 [95% CI, .40-.53] vs .60 [95% CI, .53-.68]). Flat neoplasms were more frequently detected in the right-sided colon with AFI (.61 [95% CI, .54-.70] vs .30 [95% CI, .25-.36]) but not in the left-sided colon and rectum (.26 [95% CI, .21-.32] vs .23 [95% CI, .19-.28]).

CONCLUSIONS

Updated AFI improves the detection of flat colorectal neoplasms in the right-sided colon compared with WLI. (Clinical trial registration number: UMIN000019355.).

Efficacy of vonoprazan in prevention of bleeding from endoscopic submucosal dissection-induced gastric ulcers: a prospective randomized phase II study

BACKGROUND

Vonoprazan, potassium-competitive acid blocker, is expected to reduce incidence of delayed bleeding after gastric endoscopic submucosal dissection (ESD); however, preliminary data to design a large-scale comparative study are lacking. This study aimed to assess the efficacy of vonoprazan in preventing delayed bleeding after gastric ESD.

METHODS

In this single-center randomized phase II trial, a modified screened selection design was used with a threshold non-bleeding rate of 89% and an expected rate of 97%. In this design, Simon's optimal two-stage design was first applied for each parallel group, and efficacy was evaluated in comparison with the threshold rate using binomial testing. Patients were randomly assigned in a 1:1 ratio to receive either vonoprazan 20 mg (VPZ group) or lansoprazole 30 mg (PPI group) for 8 weeks from the day before gastric ESD. The primary endpoint was the incidence of delayed bleeding, defined as endoscopically confirmed bleeding accompanied by hematemesis, melena, or a decrease in hemoglobin of ≥ 2 g/dl.

RESULTS

Delayed bleeding occurred in three of 69 patients (4.3%, 95% CI 0.9-12.2%, p = 0.047) in the VPZ group, and four of 70 (5.7%, 95% CI 1.6-14.0%, p = 0.104) in the PPI group. As only vonoprazan showed significant reduction in delayed bleeding compared with the threshold rate, it was determined to be efficacious treatment.

CONCLUSIONS

Vonoprazan efficaciously reduced the delayed bleeding rate in patients with an ESD-induced gastric ulcer. A large-scale, randomized, phase III study is warranted to definitively test the effectiveness of vonoprazan compared with proton pump inhibitors.

Impact of age at diagnosis of head and neck cancer on incidence of metachronous cancer

Background

Metachronous cancer in patients with head and neck cancer (HNC) is common and is associated with a poor prognosis. We aimed to evaluate the incidence of metachronous cancer at different sites according to age at diagnosis of index HNC.

Methods

We collected data on 2011 patients with oral cancer, oropharynx cancer, hypopharyngeal cancer, and laryngeal cancer as index cancers using the Osaka International Cancer Institute Cancer Registry database between 2005 and 2016. Among these, we analyzed 1953 patients after excluding 5 patients who were not followed-up and 53 patients with simultaneous multiple index cancers. We evaluated the cumulative incidence of metachronous cancer in the esophagus, lung, and other sites according to age at diagnosis of the index HNC using the Kaplan–Meier method. Multivariate logistic regression analysis was performed to identify factors that influenced the incidence of metachronous cancers following HNC.

Results

The cumulative incidence of metachronous esophageal cancer in young patients (< 65 years) was significantly higher than that in old patients (≥ 65 years) (12.1% vs 8.5% at 5 years, and 16.5% vs 11.2% at 10 years; p = 0.015). On the other hand, the cumulative incidence of the other cancers in young patients was significantly lower than that in old patients (7.8% vs 12.2% at 5 years, and 13.9% vs 15.3% at 10 years; p = 0.017). The cumulative incidence of lung cancer was not significance according to age at diagnosis of the index HNC. In the multivariate analysis, histological type (squamous cell carcinoma) and lesion location (hypopharynx and larynx) were independently associated with metachronous cancers. Moreover, age at diagnosis of the index HNC (< 65 years), histological type (squamous cell carcinoma) and lesion location (hypopharynx) were significant predictors of metachronous esophageal cancer incidence and lesion location (hypopharynx) was a significant predictor of metachronous lung cancer incidence.

Conclusion

Risk stratification of metachronous cancers with age and other predictors may help to properly manage patients with HNC.

Trial registration

The present study is a non-intervention trial.

Natural history of early gastric cancer: series of 21 cases

Background and study aims  While knowledge of the natural history of early gastric cancer (EGC) may be useful in relevant clinical situations, few relevant reports are available. Therefore, we investigated the progression of EGC. We gathered data regarding 114 cases of EGC from 2005 to 2015 from a hospital cancer registry and analyzed 21 lesions that fulfilled five inclusion criteria. Deep progression was defined as submucosal invasion by a mucosal tumor and proper muscle invasion by a submucosal tumor. Lateral progression was defined as ≥ 20 % increase in size. During median follow-up of 23 months, one of 18 mucosal tumors showed deep progression and six showed lateral progression. Of three submucosal tumors, two showed deep progression and three showed lateral progression. Our study suggests that a certain proportion of mucosal cancers can lie dormant for several years. Further large-scale studies in a multicenter setting should overcome the limitations of this study.

Differences in Clinical Course of Intraprocedural and Delayed Perforation Caused by Endoscopic Submucosal Dissection for Colorectal Neoplasms: A Retrospective Study

BACKGROUND

Although the use of endoscopic submucosal dissection (ESD) as a minimally invasive treatment for large superficial colorectal neoplasms is increasing, colorectal ESD remains technically challenging. As perforation in the colorectum is generally considered to be associated with a higher risk of complications, the aim of this study was to investigate the characteristics of perforation caused by colorectal ESD.

METHODS

This retrospective study included 635 lesions treated with colorectal ESD, between February 2011 and December 2015, in a tertiary cancer center. We evaluated and compared the clinical course and short-term outcomes of the intraprocedural perforation group with those of the delayed perforation and no perforation groups.

RESULTS

Perforation occurred in 45 (7.1%) of the 635 cases. Thirty-six cases were intraprocedural perforation (5.7%), all of which were successfully closed with endoclips during the procedure. Nine cases of delayed perforation occurred (1.4%). No emergency surgery was performed in the intraprocedural perforation group; however, 5 of 9 cases underwent emergency surgery in the delayed perforation group (56%, p < 0.0001). There were statistically significant differences between the intraprocedural and delayed perforation groups with regard to the hospitalization period, fasting period, abdominal pain scale, peak white blood cell (WBC) count, and peak C-reactive protein (CRP), and between the intraprocedural and no perforation groups with regard to the location of the lesion, hospitalization period, fasting period, abdominal pain scale, peak WBC, peak CRP, and en bloc resection rate.

CONCLUSIONS

While intraprocedural perforation due to colorectal ESD can be managed conservatively, delayed perforation can lead to serious adverse events.

Line-assisted complete closure for a large mucosal defect after colorectal endoscopic submucosal dissection decreased post-electrocoagulation syndrome

BACKGROUND AND AIM

The incidence of post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) can be decreased by closing mucosal defects. However, large mucosal defects after colorectal ESD cannot be closed endoscopically. We established line-assisted complete clip closure (LACC), a novel technique for large mucosal defects after colorectal ESD. We evaluated the prophylactic efficacy of LACC for preventing PECS.

METHODS

Sixty-one consecutive patients on whom LACC after colorectal ESD was attempted from January 2016 to August 2016 were analyzed. After exclusion of patients with incomplete LACC and adverse events during ESD, 57 patients comprised the LACC group. In contrast, 495 patients who did not undergo closure of a mucosal defect comprised the control group. Propensity score matching was used to adjust for patients' backgrounds. Treatment outcomes were evaluated between the groups.

RESULTS

Median resected specimen size in the LACC-attempted group was 35 mm (range, 20-72 mm), and LACC success rate was 95% (58/61). Median procedure time of LACC was 14 min. In the LACC group, incidence of PECS was only 2%, and no delayed bleeding or perforation occurred. Propensity score matching created 51 matched pairs. Adjusted comparisons between the LACC and control groups showed a lower incidence of PECS (0% vs 12%, respectively; P = 0.03) and shorter hospitalization (5 vs 6 days, respectively; P < 0.001) in the LACC group.

CONCLUSION

This study suggests that LACC can effectively reduce the incidence of PECS, although further large-scale studies are warranted.

Transoral endoscopic examination of head and neck region

Transoral endoscopy with narrow band imaging (NBI) is useful for early detection of head and neck (HN) cancer. However, the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx are difficult to observe using transoral endoscopy. Advanced cancers in these regions may be missed even when NBI is used. This report highlights a method of transoral endoscopic examination of the HN region. For observation of the oral cavity and oropharynx, it is important to observe these regions without using a mouthpiece. Wide opening of the mouth facilitates observation of the oral cavity and oropharynx. Moreover, visibility of the oropharynx, including the anterior wall, is dramatically improved, when the patient positions the tongue forward and says 'aaah.' This technique also facilitates observation of the dorsum of the tongue, which is difficult to observe from a tangential view when using a mouthpiece. To observe the hypopharynx, the Valsalva maneuver is very useful. Patient cooperation is important when observing the HN region thoroughly to gain clear endoscopic views. Narcotic drugs, such as pethidine hydrochloride, are ideal for conscious sedation and reduce the gag reflex while still allowing patient cooperation. From the oral cavity to the hypopharynx, including the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx, most of the HN region can be observed during routine examination using transoral endoscopy without any special devices.

Safety of cold snare polypectomy for duodenal adenomas in familial adenomatous polyposis: a prospective exploratory study

BACKGROUND

Cold snare polypectomy (CSP) to remove multiple duodenal adenomas (MDAs) in patients with familial adenomatous polyposis (FAP) could be an effective and less invasive method than more extensive surgery. The aim of the present study was to determine the safety of this procedure.

METHODS

This prospective exploratory study included 10 consecutive patients with FAP and MDAs who underwent CSP for as many as 50 duodenal adenomas. The primary outcome was the incidence of severe adverse events.

RESULTS

10 patients were enrolled and underwent 332 CSPs from June 2016 to January 2017. The median procedure time was 33 minutes (range 25 - 53), and the median number of polyps removed during a single session was 35 (range 10 - 50). Most of the removed polyps were ≤ 10 mm. None of the 10 patients experienced a severe adverse event. One patient developed arterial bleeding during the procedure, but it was easily managed using hemoclips.

CONCLUSIONS

CSP for MDAs in patients with FAP was safe. The long-term efficacy of this procedure should be investigated.

Impact of electrosurgical unit mode on post esophageal endoscopic submucosal dissection stricture in an in vivo porcine model

BACKGROUND AND AIM

 Strictures are a major complication of esophageal endoscopic submucosal dissection (ESD) for superficial esophageal carcinoma. Post ESD, stricture develops during the process of scar formation, which is related to inflammation caused by ESD. We planned a study to evaluate whether certain electrosurgical unit modes could attenuate strictures after esophageal ESD.

METHODS

 A total of 16 ESD, three-quarters of the esophageal circumference, were performed in four live pigs. A ball-tip Flush knife was used for mucosal incision. Submucosal dissection was performed using a Hook knife in monopolar mode and a ball-tip Jet B-knife in bipolar mode. Applied electrosurgical unit modes were FORCED COAG, SWIFT COAG, SPRAY COAG, ENDO CUT in monopolar mode, and FORCED COAG in bipolar mode. One month after ESD, the pigs were killed humanely and the severity of strictures and fibrosis was assessed.

RESULTS

 The resected site in the esophagus showed complete mucosal regrowth and scar formation in all pigs. The quotients of stricture following ENDO CUT, SWIFT COAG, FORCED COAG effect2, FORCED COAG effect3, FORCED COAG effect4, SPRAY COAG, and Bipolar FORCED COAG mode were 16 %, 28 %, 38 %, 33 %, 51 %, 39 %, and 47 %, respectively. The equivalent quotients of fibrosis were 7 %, 28 %, 31 %, 30 %, 35 %, 63 %, and 100 %, respectively. ENDO CUT mode was associated with the lowest mean quotients of stricture and fibrosis.

CONCLUSION

 ENDO CUT mode showed promising results to attenuate fibrosis and strictures after esophageal ESD.

Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas

BACKGROUND AND STUDY AIM

Underwater endoscopic mucosal resection (UEMR) was recently developed in a Western country. A prospective cohort study to investigate the effectiveness of UEMR was conducted in patients with small superficial nonampullary duodenal adenomas.

PATIENTS AND METHODS

Patients with duodenal adenomas ≤ 20 mm were enrolled. After the duodenal lumen had been filled with physiological saline, UEMR was performed without submucosal injection. Endoclip closure was attempted for all mucosal defects after UEMR. Follow-up endoscopy with biopsy was performed 3 months later. The primary end point was the complete resection rate, defined as neither endoscopic nor histological residue of adenoma at the follow-up endoscopy.

RESULTS

30 patients with 31 lesions were enrolled. The mean (SD) tumor size was 12.0 mm (7.3). The complete resection rate was 97 % (90 % confidence interval, 87 % - 99 %). The en bloc resection rate was 87 %. All mucosal defects were successfully closed by endoclips. No adverse events occurred except for one case of mild aspiration pneumonia.

CONCLUSIONS

UEMR is efficacious for the treatment of small duodenal adenomas, but further large-scale trials are warranted to confirm these results.

Multiple convex demarcation line for prediction of benign depressed gastric lesions in magnifying narrow-band imaging

BACKGROUND AND STUDY AIMS

 With magnifying narrow-band imaging (M-NBI) of the gastric mucosa, a characteristic demarcation line (DL) is occasionally found in non-cancerous depressed lesions. This DL forms multiple convex shapes along the edge of the epithelia of surrounding mucosa. We have termed this novel finding a multiple convex DL (MCDL). In this study, we clarified the prevalence of an MCDL in depressed gastric lesions detected in patients at high risk for gastric cancer and determined the diagnostic yield necessary to distinguish between cancer and non-cancer.

PATIENTS AND METHODS

 This was a post hoc analysis of a multicenter prospective trial. In total, 362 small (≤ 10 mm) depressed lesions were detected in 1353 patients. Presence or absence of a DL in target lesions was evaluated on M-NBI images. The proportion of MCDLs among lesions with a DL was evaluated.

RESULTS

Images of 347 lesions (39 cancerous and 308 non-cancerous) were evaluable. A DL was present in 252/347 lesions (73 %). When the cutoff value for the proportion of MCDLs needed to distinguish non-cancer from cancer was set at two-thirds, an MCDL was observed in 86/252 lesions (34 %). In 86 lesions with an MCDL, 83 (97 %) were non-cancerous. The sensitivity, specificity, positive predictive value, and negative predictive value of an MCDL for non-cancerous lesions were 38 %, 91 %, 97 %, and 19 %, respectively.

CONCLUSIONS

 Presence of an MCDL had high specificity and positive predictive value for non-cancerous lesions. Evaluating the shape of the DL is useful for differentiation between cancer and non-cancerous lesions.

Efficacy and Safety of Endoscopic Resection Followed by Chemoradiotherapy for Superficial Esophageal Squamous Cell Carcinoma: A Retrospective Study

OBJECTIVES

The reported 1- and 3-year overall survival rates after esophagectomy for stage I superficial esophageal squamous cell carcinoma (SESCC) are 95-97% and 86%, and those after definitive chemoradiotherapy (CRT) are 98% and 89%, respectively. This study was performed to elucidate the efficacy and safety of another treatment option for SESCC: endoscopic resection (ER) followed by CRT.

METHODS

We retrospectively reviewed the overall survival, recurrence, and grade ≥3 adverse events of consecutive patients who refused esophagectomy and underwent ER followed by CRT for SESCC from 1 January 2006 to 31 December 2012.

RESULTS

In total, 66 patients with SESCC underwent ER followed by CRT during the study period, and complete follow-up data were available for all patients. The median age was 67 (range, 45-82) years, and the median observation period was 51 (range, 7-103) months. Local and metastatic recurrences occurred in 2 (3%) and 6 (9%) patients, respectively, and 17 (26%) patients died. The 1-, 3-, and 5-year overall survival rates were 98%, 87%, and 75%, respectively. One of the 23 patients with mucosal cancer and 5 of 43 with submucosal cancer developed metastatic recurrences (P=0.65). Five of the 61 patients with negative vertical resection margin and 1 of 5 with positive vertical resection margin developed metastatic recurrences (P=0.39). None of the 30 patients without lymphovascular involvement developed metastatic recurrences; however, 6 of 36 patients with lymphovascular involvement developed metastatic recurrences (P=0.0098). Grade ≥3 adverse events occurred in 21 (32%) patients and all adverse events were associated with CRT, hematological adverse events in 13 (20%), and non-hematological adverse events in 9 (14%).

CONCLUSIONS

ER followed by CRT provides survival comparable with that of esophagectomy or definitive CRT and has a low local recurrence rate. A particularly favorable outcome is expected for cancers without lymphovascular involvement.

Technical feasibility of line-assisted complete closure technique for large mucosal defects after colorectal endoscopic submucosal dissection

Background and study aims Complete closure of large mucosal defects after colorectal endoscopic submucosal dissection (C-ESD) is considered impossible in most cases because of the limited width of the open clip. We therefore invented a simple closure technique using clip-and-line, named "line-assisted complete closure (LACC)", and assessed its technical feasibility. Patients and methods Between January and February 2016, we performed LACC in 11 patients after C-ESD and included them in this retrospective feasibility study. Outcome measures were procedural success rate, procedure time, and post-procedural complications. Results The median size of the resected specimen was 36 mm (range 30 - 72 mm). Procedural success was achieved in 10 of 11 cases (91 %). Those 10 cases required a median of 9 endoclips (range 6 - 12) for complete closure. Median procedure time for LACC was 14 minutes (range 6 - 22). No complications were observed in any of the cases after the procedure. Conclusion LACC is a simple and feasible technique for complete closure of large mucosal defects after C-ESD.

Biochemical response to interferon therapy correlates with interferon sensitivity-determining region in hepatitis C virus genotype 1b infection

Biochemical responders maintain normal alanine aminotransferase levels after interferon (IFN) therapy despite persistent presence of hepatitis C virus (HCV) RNA in their sera. There have been few reports on predictive factors for biochemical response. A region associated with sensitivity to IFN was identified in the nonstructural protein 5 A of genotype 1b [aa 2209-2248; IFN sensitivity-determining region (ISDR)]. The substitutions in ISDR correlate with sustained response to IFN. In this report, we assessed the association of ISDR with biochemical response. The sequences of ISDR were determined in 62 patients with HCV genotype 1b treated by IFN in two randomized controlled trials. 30 patients had wild ISDR (identical to HCV-J), 20 intermediate ISDR (1-3 amino acid substitutions compared with HCV-J), and 12 mutant ISDR (four or more amino acid substitutions). All 12 patients with mutant ISDR had a sustained response, while only one of those with wild or intermediate ISDR had a sustained response (P < 0.0001). In the 49 patients other than sustained responders, the patients with intermediate ISDR obtained biochemical response significantly more frequently (52.6%, 10/19) than those with wild-type ISDR (20.0%, 6/30) (P < 0.05). Multivariate analysis indicated the number of substitutions in ISDR as the most important predictor for biochemical response (discriminant coefficient=1.08, P < 0.05) and sustained response (discriminant coefficient=6.13, P < 0.0001). In phylogenetic analysis, clustering of sustained responders and biochemical responders was observed. These results demonstrate that the substitutions in ISDR are the most important predictor for biochemical response to IFN in patients infected with genotype 1b as well as for sustained response.

[Clinical investigation of inhomogeneity of washout rate in dipyridamole stress thallium scintigraphy: implication of new parameter for the indication of coronary intervention]

OBJECTIVES

The standard deviation of the washout rate in dipyridamole stress thallium-201 myocardial single photon emission computed tomography (SPECT) was correlated with the severity of coronary artery lesions and the viability of ischemic myocardium to provide a new quantitative parameter for judging indications for coronary intervention therapy.

METHODS

Dipyridamole stress thallium-201 SPECT was performed in 233 patients for differential diagnosis of angina pectoris during the 40 months beginning in October 1995, and 57 patients were investigated who underwent coronary angiography within 6 months of the SPECT. The washout rate standard deviation (WRSD) in 720 fractions in the bull's-eye view of the SPECT was determined. The conventional washout rate extent score (WRES) and washout rate severity score (WRSS) on the washout rate map were also determined. Based on the coronary angiography findings, patients were divided into 3 groups: zero-vessel group (zero-vessel disease, n = 20), one-vessel group (one-vessel disease, n = 18), and multivessel group (two- or three-vessel disease, n = 19). The patients were also divided into 2 other groups: Int group (n = 21), who underwent coronary intervention therapy, and Med group (n = 36), in whom intervention therapy was not indicated.

RESULTS

All 3 parameters, WRSD, WRES and WRSS, showed significant differences between the 3 groups, and more coronary arteries affected by coronary artery stenosis were associated with higher WRSD (zero-vessel group: 5.4 +/- 1.5, one-vessel group: 7.0 +/- 3.7, multivessel group 11.4 +/- 6.7; p < 0.001), WRES (3.3 +/- 5.0, 15.5 +/- 18.1, 23.0 +/- 25.4; p < 0.01), and WRSS (1.4 +/- 2.8, 25.4 +/- 40.2, 84.8 +/- 114.5; p < 0.01). WRSD (Med group: 5.9 +/- 2.7, Int group: 11.3 +/- 6.4; p < 0.001), WRES (7.3 +/- 12.0, 24.7 +/- 24.9; p < 0.01), and WRSS (9.9 +/- 29.3, 82.9 +/- 108.2; p < 0.01) were all significantly higher in the Int group compared with the Med group. There were significant correlations between Gensini's score and WRSD (r = 0.51, p = 0.00005), WRES (r = 0.37, p = 0.005), and WRSS (r = 0.29, p = 0.03). The cutoff values for the indications for coronary intervention therapy were established for each of the 3 parameters as the maximum value of average sensitivity and specificity as follows: WRSD > 9.0 (sensitivity 0.62, specificity 0.89, positive predictive value 0.76, negative predictive value 0.24); WRES > 10.0 (0.62, 0.69, 0.54, 0.46, respectively); WRSS > 13.0 (0.62, 0.83, 0.68, 0.32, respectively). WRSD > 9.0 had the highest specificity and positive predictive value for judging indications.

CONCLUSIONS

A new quantitative parameter, WRSD > 9.0, suggests the presence of viable and curable ischemic myocardium as an indication for coronary intervention therapy.

An autopsy case of familial idiopathic dilatation of bilateral atria

A 59-year-old male patient was followed up for congestive heart failure. Echo cardiogram showed no abnormal findings other than a remarkable dilatation of the bilateral atria. The coronary arteries and left ventricular contraction were normal. Left ventricular endomyocardial biopsy showed no significant abnormal findings. Further, we examined his siblings using dynamic magnetic resonance imaging (MRI) and found that they all also had dilated bilateral atria. After several hospitalizations, the proband died from cardiogenic shock. Pathological findings showed nonspecific change in bilateral atria and ventricles. This is a very rare case of familial idiopathic dilatation of bilateral atria.

A case of aberrant pancreatic cancer in the jejunum

We report a case of aberrant pancreatic cancer of the jejunum in a 63 year-old man. The patient was admitted to our hospital with epigastric discomfort and vomiting due to obstruction of the jejunum. Laparotomy revealed a submucosal tumor on the jejunum with multiple liver metastases. Histological examination showed the tumor to be a well differentiated tubular adenocarcinoma originating from aberrant pancreatic tissues lacking islets. Only 1 case of aberrant pancreatic cancer in the jejunum has been previously reported in the literature.

Randomized controlled trial of lymphoblastoid interferon alpha for chronic hepatitis C (comparison of 9-MU and 6-MU doses). IFN Treatment Group of Affiliated Hospitals of the Third Department of Internal Medicine at Nagoya University School of Medicine

OBJECTIVE

We conducted a randomized controlled trial to compare the efficacy of two different dosages of lymphoblastoid interferon alpha (IFN) for the treatment of chronic hepatitis C.

METHODS

Eighty-four patients with chronic hepatitis C were enrolled and randomly assigned into the two groups; group A was treated with 6 million units (MU) and group B with 9 MU daily for the first 2 wk, and then thrice weekly for an additional 14 or 22 wk.

RESULTS

Eighty patients were evaluated (39 patients in group A and 41 in group B); 14 patients in group A (35.9%) and 15 in group B (36.6%) obtained sustained response. The percentages of patients who became negative for HCV RNA at the end of the second wk differed slightly between the groups, without statistical significance (56.4% and 68.3%). When assessed in detail, patients with genotype 1 and < 1 Meq/ml of viral load became negative for HCV RNA significantly more frequently in group B (eight of eight) than in group A (three of seven) (p < 0.05) at the end of the second week, whereas the sustained response rate was similar between the groups (five of eight and four of seven). Predictors of sustained response by multivariate analysis were low viral load (< 1.0 Meq/ml) and negativity of HCV RNA at the end of the second wk of IFN.

CONCLUSIONS

The results indicated that there was no difference in sustained response rate between the 6-MU and 9-MU doses. The earlier disappearance of HCV RNA, at the end of the second wk or at least by the end of the fourth week, is an essential condition for sustained response.

Involvement of protein kinase C in the stimulation of sodium-dependent phosphate transport by parathyroid hormone in osteoblast-like cells

The rat osteosarcoma cell line UMR-106 has an osteoblast-like phenotype and possesses parathyroid hormone (PTH)-responsive dual signal transduction systems [adenosine 3',5'-cyclic monophosphate-dependent protein kinase (PKA) and calcium-protein kinase C (Ca-PKC)]. These cells transport inorganic phosphate (Pi) by a Na(+)-dependent carrier under stimulation by PTH. The present study aimed to clarify PTH-responsive signal transduction mechanisms in the regulation of Na(+)-dependent Pi transport by PTH in UMR-106 cells. Exposure of these cells to 10(-7) mol/l PTH induced a significant increase in Pi uptake within 30 min of incubation and it became maximal after 2 h. Parathyroid hormone (10(-9)-10(-7) mol/l) stimulated Pi uptake dose dependently. Activation of PKC by 12-O-tetradecanoyl phorbol-13-acetate (TPA) also increased Pi uptake in time- and dose-dependent manners similar to PTH. In contrast, neither PKA activation by 10(-4) mol/l forskolin or by 10(-4) mol/l dibutyryladenosine 3',5'-cyclic monophosphate nor calcium ionophore treatment with 10(-7) mol/l A23187 or with 10(-7) mol/l ionomycin during 3-h incubations affect Pi uptake, except its increase by 10(-4) mol/l forskolin at a 3-h incubation. These agents had no influence on Pi uptake even in combined treatments with TPA. The PTH-induced increase in Pi uptake was abolished almost completely by pretreating cells with PKC inhibitors, 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine dihydrochloride (H-7) (50 mumol/l) or staurosporin (10 and 50 nmol/l), and by down-regulating PKC with a prolonged TPA treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Biochemical improvement of chronic hepatitis C after gastrointestinal bleeding

Although chronic hepatitis C is frequently complicated by iron overload, it remains unclear whether iron cytotoxicity is involved in the disease process. Five patients with chronic hepatitis C showed rapid reduction of serum aminotransferase activity after gastrointestinal bleeding. Posthemorrhagic reduction of liver enzyme levels lasted for more than one week. Anemia was associated with a reduction of serum ferritin concentration. Considering the short half-lives of circulating liver enzymes, reduced release of enzymes, that is inactivation of cell lysis, is the likely cause of the improved biochemical indices. Reactive iron, which is cytotoxic for patients infected by HCV, may be rapidly incorporated into hemoglobin when erythropoiesis is stimulated. Our observation also suggests that intensive iron removal by phlebotomy is a safe, economic treatment for patients with chronic hepatitis C.

Protein kinase C is crucial for the stimulation of sodium-dependent phosphate transport by parathyroid hormone-related peptide in osteoblast-like cells

In the present study, we investigated the role of parathyroid hormone-related peptide (PTHrP)-responsive dual signal transduction systems in the regulation of sodium-dependent phosphate (Pi) transport by PTHrP in UMR-106 cells. Exposure of the cells to 10(-7) M human (h) PTHrP-(1-34) induced a significant increase in Pi uptake within 15 min of incubation. The peptide stimulated Pi uptake dose-dependently at the range of 10(-11)-10(-7) M. Activation of protein kinase C (PKC) by 12-O-Tetradecanoyl phorbol-13-acetate (TPA) also increased Pi uptake in time- and dose-dependent manners similar to PTHrP. In contrast, neither activation of adenylate cyclase by 10(-5) M forskolin nor calcium ionophore treatment with 10(-7) M A23187 affect Pi uptake. These agents failed to influence on Pi uptake even in combined treatment with TPA. The PTHrP-induced increase in Pi uptake was strongly inhibited by pretreating cells with PKC inhibitors, 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine dihydrochloride (H-7) (50 microM), and by down-regulating PKC with a prolonged TPA pretreatment. These results indicate that the messenger system mediated by PKC, rather than adenylate cyclase or cytosolic calcium, plays a crucial role in the regulation of sodium-dependent Pi transport by PTHrP in the osteoblast-like cells.

Characterization of a chymotrypsin-like hydrolytic activity in the opossum kidney cell

To characterize a chymotrypsin-like hydrolytic activity in the cell surface membranes of intact opossum kidney (OK) cells, we partially purified a protease from the membrane fractions of OK cells using Suc-Leu-Leu-Val-Tyr-MCA (Suc, succinyl; MCA, 4-methylcoumaryl-7-amide), a synthetic substrate for chymotrypsin, as the substrate. The semipure enzyme showed seryl chymotrypsin-like characteristics such as preferential hydrolysis of Suc-Leu-Leu-Val-Tyr-MCA and inhibition by phenylmethylsulfonyl fluoride, diisopropylfluorophosphate, and chymostatin. However, it clearly differed from alpha-chymotrypsin in its weak ability to hydrolyze Suc-Ala-Ala-Pro-Phe-MCA and in its high molecular mass (250-300 kDa). The enzyme also had an endopeptidase-like activity in that it cleaved human parathyroid hormone(1-84) at the Leu(37)-Gly(38) and Arg(52)-Lys(53) bonds. These results suggest that a high molecular mass chymotrypsin-like endopeptidase with unique characters is present in the membrane fractions of OK cells.

Unusual inferior vena cava obstruction causing extensive thrombosis: an intravascular endoscopic observation

A 28-year-old, previously healthy man was referred to our hospital three months after the appearance of lumbago, leg pains and fever. Routine examinations were normal. Phlebography demonstrated occlusion of the common femoral veins by thrombosis. Inferior vena cavography and magnetic resonance image showed that the inferior vena cava (IVC) became gradually narrower from the level of 11th thoracic vertebra. An intravascular endoscopic study gave the same morphological findings; the endothelial surface was found to be intact. We concluded that the stenosis of the IVC was the primary lesion and was the essential pathological condition. The massive thrombosis appeared to have occurred secondarily.

Hepatic copper accumulation in patients with primary biliary cirrhosis

Liver biopsy specimens from 18 patients with primary biliary cirrhosis were examined histochemically and by energy-dispersive x-ray microanalysis. Using two indices, we classified hepatic copper accumulation into three stages based on the Cu x-ray intensity of cuproproteins that had accumulated in hepatocyte lysosomes and on the binding ratio of postulated copper transfer proteins between the cytosol and lysosomes. Eight patients were in stage 1 with an initial accumulation of lysosomal cuproproteins, mediated by transfer proteins not saturated with copper. Two patients were in stage 2, in which transfer proteins were saturated with copper. The first two stages gave negative results for histochemical copper. The remaining eight patients were in stage 3, in which copper accumulation detected by histochemical included transfer proteins saturated with copper and large amounts of lysosomal cuproproteins. Five patients (one each in stages 1 and 2, and three in stage 3) underwent a second liver biopsy after treatment with 600 mg of ursodeoxycholic acid daily for 14 to 39 months. Results of blood chemistry tests improved, but liver histologic findings and copper accumulation were unchanged in all five patients. It seems likely that ursodeoxycholic acid does not affect the copper accumulation in hepatocyte lysosomes that reflects the state of cholestasis in patients with primary biliary cirrhosis.

Endothelin 1 hydrolysis by rat kidney membranes

Hydrolysis of endothelin 1 by rat kidney membranes was investigated using a reverse-phase HPLC and an automated gas-phase protein sequencer. Endothelin 1 was hydrolyzed into four major fragments which were detected by HPLC. Phosphoramidon, an inhibitor of neutral endopeptidase 24,11, almost completely suppressed the production of three fragments, but one fragment was not affected by the inhibitor. Analysis of N-terminal sequences of the degradation products revealed that the phosphoramidon-sensitive fragments were generated by cleavage at the Ser5-Leu6 bond of endothelin 1 that was identical with its cleavage site by purified rat endopeptidase 24,11, reported previously. The phosphoramidon-insensitive fragment was produced by cleavage at Leu17-Asp18, which was distinct from the sites by endopeptidase 24,11, but corresponded to that by a phosphoramidon-insensitive metallo-endopeptidase recently isolated from rat kidney membranes by us [(1992) Eur. J. Biochem. 204, 547-552]. Kinetic determination of endothelin 1 hydrolysis by the isolated enzyme yielded values of Km = 71.5 microM and kcat = 1.49 s-1, giving a ratio of kcat/Km = 2.08 x 10(4) s-1.M-1. The Km value was much higher and the kcat/Km value was much lower than those for rat endopeptidase 24,11 reported previously. Thus, endopeptidase 24,11 appears to hydrolyze endothelin 1 more efficiently than the isolated enzyme does. Both enzymes may play physiological roles in the metabolism of endothelin 1 by rat kidney membranes in vivo.

Parathyroid hormone degradation by opossum kidney cells via receptor-mediated endocytosis and lysosomal hydrolysis

The mechanisms involved in parathyroid hormone (PTH) degradation by proximal renal tubule cells were studied using an opossum kidney cell line possessing PTH receptors as an in vitro model system. One hour incubation of 5 nmol/l human (h) PTH-(1-84) with intact opossum kidney cells (4.0 x 10(6) cells) resulted in about 70% degradation and disappearance of hPTH-(1-84) from the medium, as determined by a two-site immunoradiometric assay. Preincubation with 100 nmol/l h[Nle8, Nle18, Tyr34]PTH-(1-34)amide for 6, 24, 48 and 72 h caused a 26, 47, 62 and 73% decrease, respectively, in PTH degradation by opossum kidney cells. Binding studies with 125I-labeled h[Nle8,Nle18,Tyr34]PTH-(1-34)amide as a radioligand showed that PTH receptor binding decreased with the time of pretreatment with the agonist. Pretreatments of the cells with monensin, an inhibitor of endocytosis, and the lysosomotropic agents such as chloroquine, ammonium chloride and leupeptin, inhibited degradation of hPTH-(1-84) by 87, 71, 76 and 72%, respectively. Concentrations of 5 nmol/l hPTH-(39-84) and hPTH-(39-68), which are known not to bind to PTH receptors appreciably, were not degraded by opossum kidney cells during 1 h incubations. Thus intact, biologically active PTH, but not its inactive fragments, is degraded by opossum kidney cells, by receptor-mediated endocytosis and lysosomal hydrolysis. A mechanism resembling the peritubular uptake of intact PTH by perfused kidneys reported previously appears to play a main role in PTH metabolism by cultured renal cells.

[Comparison of screening methods for diabetes mellitus, based on fasting glucose, HbA1C and fructosamine levels]

Screening methods for diabetes mellitus, based on fasting glucose (FPG), HbA1C and fructosamine (FRA) levels were compared with regard to their screening power. The subjects studied were 699 health examinees. A significant elevation of the mean level of each screening index was observed in diabetic subjects, but not in borderline cases compared with that of normal subjects. The FPG, HbA1C and FRA levels in diabetic subjects distributed over a wide range overlapping largely with the distributions of non-diabetic subjects. No appreciable difference in the screening power was observed between FPG and HbA1C but specificity was low in FRG for the comparable sensitivity level. In the screening methods based on the combination of two or more indices, elevation of the sensitivity was noted, but the specificity declined, resulting in an increase of re-examination rate. Among them, the combination of FPG and HbA1C indicated the highest sensitivity.

[Clinicopathological and immunohistochemical study on penetrating and superficial spreading type of early gastric cancers]

Specific type of early gastric cancer based on the cancer surface area and the degree of invasion were studied by measuring digital values of the cancer surface area in early gastric cancer patients. The results indicated that the pen and super type of early gastric cancer had many clinicopathological characteristics as compared with common type of early gastric cancer. An immunohistochemical study also revealed that the pen type of early gastric cancer had a high growth activity. Moreover, it was suggested that EGF was involved in its specific invasion and growth, and that EGF and TGF-beta affected its scirrhous growth. The possibility that the poorly differentiated pen type is an early lesion of linitis plastica type gastric cancer was also considered. From these findings, it was assumed that the immunological staining of EGF and TGF-beta in biopsy specimens might be useful in the diagnosis of the pen type of early gastric cancer and also in diagnosis of early lesion of linitis plastica type gastric cancer.

Production of tumor necrosis factor, interleukin 1, and interferon-gamma by peripheral blood mononuclear cells from patients with primary biliary cirrhosis

Since patients with primary biliary cirrhosis (PBC) have evidence of abnormal function of the immune system, we evaluated production of various cytokines by peripheral blood mononuclear cells (PBMCs) and monocytes from patients with this disease, using an enzyme-linked immunosorbent assay. The mean amounts of production of tumor necrosis factor alpha(TNF alpha), interleukin 1 beta (IL1 beta), and interferon-gamma (IFN-gamma) by PBMCs from patients with PBC tended to be increased in cultures in the presence of stimulating agents in comparison with controls, but there was no significant difference because of a wide scatter of results. Monocytes from PBC patients also tended to produce higher amounts of TNF alpha and IL1 beta than control monocytes did, although the percentage of monocytes in PBMCs was similar in PBC and controls. A significant correlation was found between TNF alpha production and IL1 beta production in PBC patients. The number of TNF alpha or IFN-gamma positive infiltrating mononuclear cells detected by immunohistochemical staining in liver biopsy sections correlated with the production of these cytokines by PBMCs in vitro. However, cytokine production did not correlate with serum biochemical or hepatic histologic findings, except for serum alkaline phosphatase values. In patients with type B chronic active hepatitis, IL1 beta and IFN-gamma production was similar to controls, while TNF alpha production tended to be enhanced. Thus the cytokines studied here may play some role in the pathogenesis of PBC.

Recombinant human alpha-interferon therapy for chronic non-A, non-B hepatitis: second report

Four million units per day of recombinant human alpha-interferon were administered three times weekly for 16 wk to 26 patients with chronic non-A, non-B hepatitis. The efficacy of therapy was assessed by comparing it with the results in the nontreated patients, or with our previous study in which we administered 2 million units per day of interferon. The treatment was discontinued in four patients 8 wk after start of therapy because there was no improvement in serum aminotransferase levels. The remaining 22 patients completed the treatment schedule, and their aminotransferase values showed significant decreases throughout the therapy and during the follow-up period, compared with their baseline levels or the nontreated group. After 3 months of follow-up, normal aminotransferase activities were seen in eight treated patients. In four of these patients, liver histology showed a marked improvement in inflammation and parenchymal cell necrosis. Percent change from pretreatment level of serum 2',5'-oligoadenylate synthetase activity was significantly higher in the aminotransferase-normalized group than in the nonnormalized group during therapy. The present study suggested that a higher dose of alpha-interferon could control the disease activity more effectively in patients with chronic non-A, non-B hepatitis.

Immunohistochemical studies of intrahepatic tumour necrosis factor alpha in chronic liver disease

To determine the intrahepatic production of tumour necrosis factor alpha (TNF alpha) in chronic liver disease three monoclonal antibodies were used against TNF alpha in immunohistochemical studies of liver tissue sections from patients with chronic liver disease. All three monoclonal antibodies stained infiltrating mononuclear cells. Monoclonal antibody II 7C2 also stained the cytoplasm or nucleus, or both, of a varied number of hepatocytes from nine patients with chronic hepatitis B virus infection, suggesting that the antigenic epitope related to hepatitis B core antigen (HBcAg) crossreacted with II7C2. The other two monoclonal antibodies, III2F3 and IV3E5, stained significantly larger numbers of mononuclear cells in cases of chronic active hepatitis B than in chronic persistent hepatitis B, or hepatitis B related liver cirrhosis. III2F3 stained significantly larger numbers of mononuclear cells in non-A, non-B chronic active hepatitis than in chronic persistent hepatitis B or hepatitis B related liver cirrhosis. These results indicate that TNF alpha is produced and secreted by infiltrating mononuclear cells in focal inflammatory areas of the liver, and suggest that TNF alpha may have a role in the inflammatory activity of chronic liver disease.

Tumor necrosis factor alpha production by peripheral blood mononuclear cells of patients with chronic liver disease

We investigated the production of tumor necrosis factor alpha by peripheral blood mononuclear cells of patients with chronic liver disease and its association with hepatitis activity. Tumor necrosis factor alpha production was measured with an enzyme-linked immunosorbent assay. Tumor necrosis factor alpha production by peripheral blood mononuclear cells stimulated with recombinant gamma-interferon of patients with chronic active hepatitis (5.8 +/- 4.0 units per ml, p less than 0.05) and patients with cirrhosis (4.1 +/- 2.1 units per ml, p less than 0.05) was significantly increased when compared with controls (2.5 +/- 1.6 units per ml). Tumor necrosis factor alpha production by peripheral blood mononuclear cells stimulated with a combination of recombinant gamma-interferon and recombinant interleukin 2 of patients with chronic persistent hepatitis (5.8 +/- 3.8 units per ml, p less than 0.05), patients with chronic active hepatitis (8.9 +/- 3.0 units per ml, p less than 0.001) and patients with cirrhosis (6.7 +/- 3.2 units per ml, p less than 0.05) was significantly increased in comparison with controls (3.3 +/- 1.8 units per ml). Tumor necrosis factor alpha production of patients with chronic active hepatitis was significantly higher than that of patients with chronic persistent hepatitis (p less than 0.05). There was a significant correlation (r = 0.5699, p less than 0.005) between tumor necrosis factor alpha production and histologic activity index in patients with chronic persistent hepatitis or chronic active hepatitis. These findings show that tumor necrosis factor alpha production is increased in chronic liver disease and that the increased tumor necrosis factor alpha production is related to hepatitis activity.

Pre-S proteins in chronic hepatitis B virus infection: markers of active viral infection

The role of large (pre-S1) and middle (pre-S2) proteins of HBsAg in hepatitis B virus (HBV) infection is not fully known. Therefore, we studied the expression of pre-S proteins in the liver and serum of 26 patients with chronic HBV infection, using immunoperoxidase staining and enzyme immunoassay. Pre-S1 and pre-S2 proteins were detected in a large number of patients in both liver and serum, irrespective of the disease activity. Serial sections showed that most cells positive for HBsAg were also positive for pre-S proteins. The localization of pre-S2 and HBsAg was similar, with cytoplasmic and membranous stainings of hepatocytes, whereas pre-S1 was expressed exclusively in cytoplasm. Serum levels of HBsAg, pre-S1, and pre-S2 of DNA polymerase-positive cases were significantly higher than those of DNA polymerase-negative cases. Membranous display of pre-S2 on hepatocytes was observed more often in DNA polymerase-positive patients, and their serum pre-S2 levels were significantly higher than those without it. The predominant localization of cytoplasmic HBcAg usually was associated with active, ongoing hepatitis. Its expression and DNA polymerase activity were significantly correlated. These results indicate that pre-S proteins in serum and the membranous display of pre-S2 on hepatocytes of patients with chronic HBV infection refect active viral replication, but their expression does not correlate with disease activity.

Interferon alpha and gamma positive mononuclear cells and HLA antigen expression on hepatocyte membrane in the liver in chronic type B and non-A, non-B hepatitis

To evaluate the role of local interferon on pathogenesis in chronic type B and non-A, non-B chronic hepatitis, we examined the cellular localization of interferon alpha and gamma, and the expression of HLA antigens in cryostat liver sections from 33 chronic carriers of HBs antigen and 10 patients with non-A, non-B chronic hepatitis, using an immunoperoxidase procedure with monoclonal antibodies. Infiltrating mononuclear cells were the main cell element staining positive for interferon alpha or gamma. Among type B chronic liver disease, the percentages of both interferon alpha- and gamma-positive mononuclear cells were highest in patients with chronic active hepatitis, and their levels were higher in patients who had serum HBe antigen, indicating that local expression of interferon closely correlates with activity of disease and virus replication. On the other hand, both the frequency of interferon alpha or gamma positive cells, and the intensity of HLA class I antigens on hepatocytes were much lower in patients with non-A, non-B, chronic active hepatitis in comparison with those with type B chronic active hepatitis. These findings suggested that locally produced interferons have role of varying degrees on the host defence mechanism in chronic hepatitis, reflecting disease activity and the etiology of the disease.

Hepatitis B core antigen-specific IFN-gamma production of peripheral blood mononuclear cells in patients with chronic hepatitis B virus infection

To evaluate the specificity of cellular immune response to hepatitis B virus (HBV) Ag in patients with chronic HBV infection, we have measured IFN-gamma production and proliferation of PBMC of 16 patients with chronic active hepatitis (CAH), 17 asymptomatic carriers of HBV (ASC), 6 anti-hepatitis B surface (HBs)-positive subjects, and 6 control individuals with ELISA procedure and [3H]thymidine incorporation. There was no significant increase in the mean proliferative response to recombinant HB surface and core Ag (rHBsAg and rHBcAg), nor was IFN-gamma production elicited with rHBsAg in any group. In contrast, PBMC of HBeAg-positive and anti-HBe-positive CAH patients, and anti-hepatitis B "e" Ag (HBe)-positive ASC showed significantly enhanced IFN-gamma production in response to HBcAg, whereas those of HBeAg-positive ASC and anti-HBs-positive subjects did not respond to HBcAg. The maximal response was observed in a 5-day culture with 500 ng/ml of rHBcAg when assessed by stimulation index value. Monocytes did not demonstrate an increased suppressor or helper activity for IFN-gamma production in these patients. T cell subset fractionation revealed that CD4+ cells were main population of IFN-gamma production specific for HBcAg and CD8+ cells did not suppress IFN-gamma production of CD4+ cells. Furthermore, CD4+ cells of HBeAg-positive ASC generated lesser amounts of IFN-gamma than HBeAg-positive CAH patients did. These results show that the measurement of IFN-gamma production is useful to determine cellular immune response to HBV Ag and suggest that IFN-gamma production depends on the helper activity of CD4+ T cells sensitized to HBcAg.