Significance of background coloration in endoscopic detection of early esophageal squamous cell carcinoma

Endoscopic diagnostics of early squamous cell carcinoma (SCC) in the laryngo-esophageal region have dramatically improved together with development of less invasive endoscopic treatment. It is essential for gastrointestinal endoscopists to detect lesions when they are still endoscopically treatable, especially in this region since surgical approach can still be extremely invasive. Pioneers have found some notable fundamental alterations in early SCC and created several classifications. Inoue [Dig Endosc 2001;13(suppl): 40-41] proposed the intrapapillary capillary (IPCL) classification, which focused on the microvascular change of the mucosal surface. One of the significances of this classification is that it clearly distinguished the lesions that require further pathological evaluation by categorizing the diameter change of the IPCLs. On the other hand, Arima et al. [Esophagus 2005;2:191-197] advocated the alteration of microvessels as well as change of the vascular arrangement in the area. Most recently, the Japan Esophageal Society constructed a new classification uniting these two exemplary classifications as the 'Japanese Classification of Magnifying Endoscopy for Early Squamous Cell Carcinoma'. This classification was intended to be simple and easily applicable in general clinical practice. Brownish color change between the IPCLs has reported to be one of the useful findings in distinguishing early SCC from benign changes such as inflammatory change and low-grade intraepithelial neoplasia. Nevertheless, the exact cause of this phenomenon remains unclear. We recently examined the association of color change with hemoglobin (Hb) in cancer tissue, since NBI exclusively detects the wavelength of Hb in superficial vessels in the gastrointestinal tract. This review article also describes our examination of a distinct finding in esophageal cancer, namely, 'background coloration'.

Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) permits removal of colorectal epithelial neoplasms en bloc, but a substantial risk of procedure-related perforation has been reported. We sought to unravel the clinicopathological factors associated with the clinical outcomes of ESD for colorectal epithelial neoplasms in a large series.

PATIENTS AND METHODS

ESD was done in 278 patients with 292 colorectal tumors that fulfilled the inclusion criteria. The criteria for ESD were: lesion greater than 20 mm in size, lesion with fibrotic scarring, locally residual colorectal lesion, or invasive carcinoma with slight submucosal penetration. Resection was assessed as en bloc or piecemeal, complete (en bloc with tumor-free lateral and basal margins) or incomplete. Complications including perforation and bleeding were assessed, and factors related to each were analyzed using logistic regression. Patients underwent multiple follow-up endoscopic examinations (mean 4.6; median 4; range 2 - 9; total number 1010).

RESULTS

En bloc resection was achieved in 90.1 % of lesions (263/292) and resection was deemed to be complete in 233 (79.8 %). Right-side colonic location and the finding of fibrosis were the significant contributors to incomplete resection. Perforation was seen in 24 cases (8.2 %), and was associated with large tumor size and the presence of fibrosis. When the contributive factors for each were combined, the risks of incomplete resection and perforation were substantially increased.

CONCLUSION

The present study provides useful information for predicting risks for incomplete resection and complication in colorectal ESD.

Concentrations of alpha- and beta-defensins in plasma of patients with inflammatory bowel disease

BACKGROUND

Impaired production/release of defensins, representative endogenous antimicrobial peptides, is associated with the pathogenesis of inflammatory bowel disease (IBD).

MATERIAL AND METHODS

Employing in house radioimmunoassay, we examined concentrations of the major forms alpha-defensins, human neutrophil peptides (HNP) 1-3 and human beta-defensin (HBD)-2 in plasma of 55 IBD patients consisting of 29 patients with ulcerative colitis (UC) and 26 with Crohn's disease (CD) and 57 controls.

RESULTS

The circulating HNP 1-3, but not HBD-2, levels in IBD patients were significantly higher than those in controls. Plasma HNP 1-3 concentrations in CD patients significantly correlated with Crohn's disease activity index, peripheral white blood cell counts, serum CRP values and TNF-alpha levels.

CONCLUSIONS

Elevation of circulating alpha-defensins levels is suggestive of their physiopathological roles in IBD. Plasma HNP 1-3 concentrations may be an indicator for CD activity and their association with CRP and TNF-alpha supports a possible association with the inflammatory process.

Endoscopic submucosal dissection for early gastric cancer: a large-scale feasibility study

OBJECTIVE

Endoscopic submucosal dissection (ESD) has the advantage over conventional endoscopic mucosa resection, permitting removal of early gastric cancer (EGC) en bloc, but long-term clinical outcomes remain unknown. A follow-up study on tumour recurrence and survival after ESD was conducted.

METHOD

ESD was performed for patients with EGC that fulfilled the expanded criteria: mucosal cancer without ulcer findings irrespective of tumour size; mucosal cancer with ulcer findings <or=3 cm in diameter; and minute submucosal invasive cancer <or=3 cm in size. 551 patients with 589 EGC lesions were enrolled. The patients underwent ESD and then received periodic endoscopic follow-up and metastatic surveys for 6-89 months (median, 30 months). The main outcome measures were resectability (en bloc or piecemeal resection), and curability (curative or non-curative). Complications were assessed, and factors related to each were analysed statistically. The overall and disease-free survival rates were estimated.

RESULTS

En bloc resection was achieved in 94.9% (559/589), and larger lesions were at higher risk of piecemeal resection. 550 of 581 lesions (94.7%) were deemed to have undergone curative resection. En bloc resection was the only significant contributor to curative ESD. Patients with non-curative resection developed local recurrence more frequently. The 5-year overall and disease-specific survival rates were 97.1% and 100%, respectively.

CONCLUSION

Precise assessment of curability with successful one-piece resection may reduce tumour recurrence after ESD. The prognosis of EGC patients treated by ESD is likely to be excellent, though further longer follow-up studies are warranted.

Relationship between period of survival and clinicopathological characteristics in patients with colorectal liver metastasis

AIM

Cancer death in the early period after hepatectomy still occurs in patients with colorectal liver metastasis (CLM). We examined the relationship between clinicopathological parameters and survival periods in 130 CLM patients who underwent hepatectomy.

PATIENTS/METHODS

Patients were divided into four groups: Group 1 (5-year survivors without tumor relapse), Group 2 (survivors at 2-5 years), Group 3 (cancer death at 2-5 years), and Group 4 (cancer death within 2 years).

RESULTS

A short surgical margin was frequent in Group 4 compared to Group 1 (31 vs. 78%, P<0.05). Primary node-positive status, absence of fibrous pseudo-capsular formation, higher Clinical Risk Score, and tumor recurrence within 12 months were frequent in Group 4 (P<0.05). Multivariate analysis revealed a short surgical margin (HR; 3.5) and early tumor relapse (HR; 5.9) as independently significant related parameters (P<0.05).

CONCLUSIONS

Sufficient surgical margins and careful follow-up for early tumor relapse may be important for improving postoperative outcomes for CLM patients.

Endoscope disinfection using chlorine dioxide in an automated washer-disinfector

Although 2% glutaraldehyde is often the first-line agent for endoscopic disinfection, its adverse reactions are common among staff and it is less effective against certain mycobacteria and spore-bearing bacteria. Chlorine dioxide is a possible alternative and an automated washer-disinfector fitted with this agent is currently available. This study was conducted to evaluate the effectiveness of chlorine dioxide in endoscopic disinfection after upper gastrointestinal examination. In vitro microbicidal properties of chlorine dioxide solutions were examined at high (600 ppm) and low (30 ppm) concentrations against various microbes including Pseudomonas aeruginosa, Helicobacter pylori, Mycobacterium avium-intracellulare and Bacillus subtilis in the presence or absence of bovine serum albumin (BSA). Immediately following endoscopic procedures and after application to the automated reprocessor incorporating chlorine dioxide at 30 ppm for 5 min, endoscopic contamination with infectious agents, blood, H. pylori ureA gene DNA and HCV-RNA was assessed by cultivation, sensitive test tape, polymerase chain reaction (PCR) and reverse transcriptase-PCR analysis, respectively. Chlorine dioxide at 30 ppm has equivalent microbicidal activity against most microbes and faster antimicrobial effects on M. avium-intracellulare and B. subtilis compared with 2% glutaraldehyde, but contamination with BSA affected the microbicidal properties of chlorine dioxide. Endoscopic contamination with microbes, blood and bacterial DNA was eliminated after application of the automated reprocessor/chlorine dioxide system. Thus, chlorine dioxide is a potential alternative to glutaraldehyde. The use of automated reprocessors with compatibility to chlorine dioxide, coupled with thorough pre-cleaning, can offer effective, faster and less problematic endoscopic disinfection.

Ghrelin enhances gastric motility through direct stimulation of intrinsic neural pathways and capsaicin-sensitive afferent neurones in rats

BACKGROUND

Ghrelin may stimulate gastric motility via the vagal nerve pathway. However, the mechanism of ghrelin-induced changes in gastrointestinal motility has not yet been clearly defined. The present study was designed to investigate whether ghrelin accelerates gastric emptying via capsaicin-sensitive afferent neurones and directly affects the enteric neuromuscular function.

METHODS

Gastric emptying of nutrient solids was assessed after intravenous administration of saline or ghrelin in conscious rats. The effects of ghrelin on gastric emptying were also examined in rats pretreated with capsaicin. Gastric emptying and intestinal transit of non-caloric liquids were evaluated using 51Cr solution. The effects of ghrelin on spontaneous contractile activities of isolated strips from stomach and jejunum were also investigated and the influence of ghrelin on motor responses to carbachol and electrical field stimulation was examined.

RESULTS

Ghrelin significantly accelerated gastric emptying of both nutrient solids and non-caloric liquids in conscious rats. The intestinal transit of non-caloric liquids was also enhanced by ghrelin. Pretreatment with capsaicin prevented the ghrelin-induced acceleration of gastric emptying of nutrient solids. Ghrelin did not modulate spontaneous and carbachol-induced contractions of strips of gastric body, gastric antrum and jejunum. However, electrical field stimulation-induced contractions were significantly enhanced by ghrelin in the gastric body.

CONCLUSIONS

The results suggest that the stimulatory effects of ghrelin on gastric motility are mediated by direct stimulation of the enteric neural pathway and capsaicin-sensitive afferent neurones.

Multiple lymphomatous polyposis of the colon originating from T-cells: a case report

Multiple lymphomatous polyposis is an unusual form of non-Hodgkin's lymphoma characterised by myriad polyps throughout the alimentary tract. Most multiple lymphomatous polyposis cases are derived from B-cell, and there has been little information on multiple lymphomatous polyposis of T-cell origin. A 67-year-old Japanese man presented with lower abdominal pain and diarrhoea of 4-week duration. Colonoscopy revealed numerous small umbilicated polyps and several raised erosions in the colorectum. Biopsy specimens showed diffuse proliferation of lymphoma cells negative for B-cell markers but positive for T-cell markers. Polymerase chain reaction using extracted chromosomal deoxyribonucleic acid from paraffin-embedded samples identified T-cell receptor gamma and delta gene recombination. The patient was treated with combined chemotherapy, leading to complete resolution of the lesions.

Impact of CagA status on serum gastrin and pepsinogen I and II concentrations in Japanese children with Helicobacter pylori infection

The study aimed to determine the association between cytotoxin-associated gene product (CagA), serum gastrin and pepsinogen levels in Japanese children infected with Helicobacter pylori. Three hundred children were enrolled in the study. H. pylori infection was assessed using an enzyme-linked immunosorbent assay, and CagA status was assessed using immunoblotting. Serum gastrin and pepsinogen concentrations were measured by radioimmunoassay. H. pylori seroprevalence was 12.3% (37/300) and CagA status was identified in 28/37 H. pylori-seropositive children (75.7%). Serum pepsinogen I and II levels were significantly higher in CagA-seropositive than CagA-seronegative children with H. pylori infection. There was no significant relationship between CagA seropositivity and serum gastrin levels. In conclusion, CagA status has a significant impact on serum pepsinogen levels, possibly through enhanced gastric mucosal inflammation.

Jejunal perforation in a patient with adult T-cell leukemia

We present a case of adult T-cell leukemia (ATL) with jejunal perforation at the site of intestinal involvement by ATL. A 39-year-old woman presented with sudden-onset abdominal pain. Physical examination showed generalized severe abdominal tenderness and intraabdominal free air was seen on radiographic examination. Under a diagnosis of peritonitis due to intestinal perforation, an emergency operation was performed. A pinhole-like perforation was found in the jejunum 80 cm distal to Treitz's ligament, and the patient underwent partial resection of the affected jejunum. Microscopic examination revealed diffuse infiltration of abnormal lymphocytes into the entire wall of the jejunum and mesenteric lymph nodes. A diagnosis of ATL was confirmed by the presence of antibody to human T-lymphotropic virus type 1 (HTLV-1) in the serum, a positive result for T-cell markers and the HTLV-1 proviral genome in the mononuclear cells in the specimens. The final diagnosis was thus lymphoma subtype of ATL. Combination chemotherapy was repeated until the patient died 14 months postoperatively. Emergent surgery followed by intense chemotherapy might improve survival in patients with ATL and perforated intestine.

Clinical and endoscopic features of adult T-cell leukemia/lymphoma with duodenal involvement

We describe three cases of adult T-cell leukemia/lymphoma (ATLL) with duodenal involvement and provide a review of the literature. The first case, a 74-year-old woman with acute subtype of ATLL, had multiple polypoid lesions from the bulbus extending into the descending portion of the duodenum. The second case, a 70-year-old man with lymphoma subtype of ATLL, had a polypoid tumor in the descending portion of the duodenum and multiple protruded lesions in the small and large intestines. The third case, a 67-year-old man with lymphoma subtype of ATLL, had a flat-elevated lesion in the descending portion of the duodenum, as well as a gastric ulcerated lesion. Biopsies from these lesions showed mucosal invasion of ATLL cells in each case. All patients received combination chemotherapy, which was successful in the first and third cases, accompanied by the disappearance of gastroduodenal lesions.