Successful treatment of mediastinal pancreatic pseudocyst and pancreatic pleural effusion with endoscopic pancreatic duct drainage: A case report

An 81‐year‐old man with chronic pancreatitis was being treated with a protease inhibitor. He developed an acute exacerbation of chronic pancreatitis and dyspnea. Contrast‐enhanced computed tomography showed disruption of the main pancreatic duct, a cystic lesion connecting the mediastinum to the main pancreatic duct, and left pleural effusion. We diagnosed a pancreatic pseudocyst, mediastinal pancreatic pseudocyst, and pancreatic pleural effusion. Endoscopic retrograde pancreatography showed leakage of contrast medium from the pancreatic body; furthermore, a cystic cavity extending to the mediastinum through a pancreatic duct fistula was visualized. An endoscopic transpapillary nasopancreatic drainage tube was placed in the cystic cavity. Computed tomography showed that the mediastinal pseudocyst and pleural effusion had disappeared. Endoscopic transpapillary pancreatic duct drainage may be useful when a connection between the main pancreatic duct and a mediastinal pseudocyst is confirmed by imaging.

A Prospective Study of Neoadjuvant Gemcitabine Plus Nab-paclitaxel in Patients with Borderline-resectable Pancreatic Cancer

Objectives Neoadjuvant therapy followed by radical resection improves the borderline-resectable pancreatic cancer (BRPC) prognosis; however, the optimal therapeutic regimen remains unclear. Gemcitabine plus nab-paclitaxel (GnP) showed a high anti-tumor effect in primary lesions in a prospective study for metastatic disease. However, evidence concerning its feasibility is still lacking in patients with BRPC. We therefore evaluated the tolerability of neoadjuvant GnP (NAC-GnP) for BRPC. Methods This single-center prospective study evaluated 10 patients with BRPC who were treated with two cycles of NAC-GnP. The primary endpoint was feasibility for NAC-GnP. Treatment feasibility was defined as a successful outcome in at least eight patients. Results Ten patients who had BRPC in contact with the celiac artery (n=5), superior mesenteric artery (n=3), or hepatic artery (n=2) were enrolled. The median age was 75 (range, 40-82) years old. Grade 3 anorexia and grade 2 pneumonia occurred in one patient each, so treatment was feasible in eight patients. The median primary tumor reduction and response rates were 33% (range, 0-68%) and 60%, respectively. Six of eight patients who had abnormal CA19-9 levels at the time of enrolment showed a decrease in CA19-9 levels, with a median decrease of 72%. Five patients underwent radical resection, including R0 resection in four. Postoperative grade IIIa Clavien-Dindo complications occurred in one patient (upper gastrointestinal bleeding and pancreatic fistula). Conclusion Two-cycle NAC-GnP is a feasible treatment for patients with BRPC. Further studies on NAC-GnP in patients with BRPC are warranted.

Gastroduodenal Stenting with a Flexible Stent Demonstrates Favorable Clinical Effectiveness despite Gradual Expansion: A Multicenter Prospective Study

AIMS

This study aimed to evaluate the effectiveness and safety of stenting with a flexible braided self-expandable metal stent (SEMS) for unresectable malignant gastric outlet obstruction (GOO).

METHODS

Palliative stenting was prospectively carried out at seven university hospitals between October 2017 and August 2020. All procedures were performed using a flexible branded SEMS of the same brand. The primary endpoint was clinical success rate at 7 days after stenting. Secondary endpoints were procedural success rate, adverse events, recurrent gastric outlet obstruction (RGOO), and patient survival time.

RESULTS

Sixty patients were enrolled. The procedural and clinical success rates were 100% and 90%, respectively. RGOO occurred in 15 cases (25%). Adverse events other than RGOO were found in seven cases (12%). The 50% survival time was 75.5 days (range: 52-97 days). Median expansion rates at 1, 3, and 7 days after stenting were 55%, 65%, and 75%, respectively.

CONCLUSIONS

A flexible braided stent woven with relatively thin wires was used for malignant GOO. Despite a gradual expansion with slightly lower expansile force, the stent functioned sufficiently well and showed favorable results. Clinical Trials Registry ID: UMIN000029496.

Management of common bile duct stones in a pregnant woman by percutaneous biliary drainage followed by elective endoscopic stone removal after delivery

A woman in her 30s who was 12 weeks pregnant with her third child presented with jaundice. Blood tests showed elevated hepatobiliary enzymes and direct bilirubin. Abdominal ultrasonography showed dilatation of the common bile duct and strong echo with a 9 mm acoustic shadow in the distal bile duct. She was diagnosed with common bile duct stone disease and biliary drainage was considered necessary. Percutaneous transhepatic biliary drainage (PTBD) was performed considering the effect on both the fetus and the mother, and the procedure was successful without any complications. The PTBD tube was left in place until delivery at 36 weeks 6 days of gestation and endoscopic stone removal was performed 14 days after delivery. The patient was discharged 18 days after delivery without any complications. In pregnant women with common bile duct stones, palliative PTBD followed by elective endoscopic stone removal after delivery can be considered a treatment strategy.

Utility of endoscopic transpapillary pancreatic cyst drainage for intraductal papillary mucinous neoplasm infection

A 61-year-old woman with intraductal papillary mucinous neoplasm (IPMN) infection, who was treated with antibiotics, developed IPMN reinfection with febrile epigastric pain and was febrile. CT showed that the diameter of the IPMN had grown and hardened, with thickening of the cyst wall. Endoscopic retrograde pancreatography was then performed and a nasopancreatic cyst drainage tube was placed into the cyst. Symptoms and inflammatory findings improved considerably 17 days after endoscopic drainage. Few reports and evidence have been found regarding IPMN infections, and the frequency of onset, route of infection and optimal drainage method remain unknown. This study indicated that endoscopic transpapillary pancreatic cyst drainage was effective and is highly recommended for IPMN infection.

Effectiveness of introducing a 20-gauge core biopsy needle with a core trap in EUS-FNA/B for diagnosing pancreatic cancer

Background

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) is a standard method for pathological diagnosis of pancreatic solid lesions. The EchoTip ProCore 20G® (PC20), a 20-gauge biopsy needle with a forward-bevel core trap, has been available in Japan since 2015.

Methods

We compared the efficacy of the PC20 with that of the EchoTip ProCore 22G® (PC22) and Acquire 22G® (AC22) in EUS-FNA/B for diagnosing pancreatic cancer. This retrospective study included 191 patients with pancreatic cancer who underwent EUS-FNA/B using the PC20, PC22, or AC22 at our facility from April 2013 to October 2019. We investigated the patients’ clinical characteristics and the diagnostic accuracy and safety of each needle.

Results

A sufficient stroke length of puncture was secured in all patients. The maximum length under EUS was shorter with the AC22 (22.1 ± 2.2 mm) than PC20 (30.6 ± 0.7 mm, p < 0.01) and PC22 (30.3 ± 0.8 mm, p < 0.01). The histological accuracy was 96.4% with the PC20 but only 58.8% with the PC22 (adjusted p (p-adj) < 0.0001) and 75.0% with the AC22 (p-adj = 0.06). The diagnostic accuracy of the combination of histology and cytology was 96.4% with the PC20, while it was 72.1% with the PC22 (p-adj < 0.0001) and 91.7% with the AC22 (p-adj > 0.99). One patient (0.9%) in the PC20 group developed mild pancreatitis, but no adverse events occurred with the other needles.

Conclusions

The PC20 showed better diagnostic capability than the PC22. The diagnostic efficacy was similar between the PC20 and AC22. The high histological accuracy of the PC20 could be advantageous for lesions in which histological assessment is critical.

Gastropathy associated with lanthanum phosphate deposition that was endoscopically tracked for 3 years. A case report

Background

With the recent increased use of lanthanum carbonate, several cases of lanthanum phosphate deposition to gastric mucosa in dialysis patients have been reported. However, the endoscopic appearance of the early-stage lesion and the over-time alterations of endoscopic findings due to the progression of lanthanum phosphate deposition remain unclear.

Case presentation

An 80-year-old man receiving dialysis and taking lanthanum carbonate as a phosphate binder over a 4-year period underwent upper gastrointestinal endoscopy four times beginning 1 year after initiation of treatment. The first endoscopic examination (after 1 year of exposure to lanthanum carbonate) revealed rough mucosa with a few areas of white granular mucosa. Over the 3 years of endoscopic follow-up, the white granular mucosa spread and multiple erosions appeared. Histopathological findings of biopsy specimens from an erosion showed extensive infiltration by histiocytes containing deposits. Scanning electron microscopy-energy dispersive X-ray spectroscopy (SEM-EDX) revealed that the presence of the deposits containing phosphorus and lanthanum in the gastric mucosa.

On the basis of these results, the patient was diagnosed with gastropathy associated with lanthanum phosphate deposition.

Conclusions

Over a 3-year period, endoscopic findings associated with lanthanum deposition gradually changed and expanded from the early stage.

Utilization of a new technology of 3D biliary CT for ERCP-related procedures: a case report

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is still performed using two-dimensional (2D) X-ray images. The success rate and risk of complications are considered operator-dependent. We explored performing an ERCP-related procedure with 3D-computed tomography (CT) biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction.

Case presentation

The patient was a 66-year-old man who underwent rectal resection and postoperative chemotherapy for rectal cancer. A liver metastasis caused obstructive jaundice and acute cholangitis, necessitating emergency hospitalization. A 3.5 cm mass in the hilar region of the biliary tree caused type IV biliary obstruction according to the Bismuth-Corlette classification of hilar cholangiocarcinoma. ERCP and biliary drainage were performed repeatedly, but had no effect. Given that selective bile duct drainage had proven extremely difficult with the conventional procedures, three-dimensional (3D) images were created from preoperative CT image data using a 3D image reconstruction system (SYNAPSE VINCENT version 5, FUJIFILM Corporation, Tokyo, Japan). Using the 3D images for preoperative planning and intraoperative reference, biliary drainage and stent placement were successfully performed without complications. Postoperatively, the patient had no further cholangitis or need for stent replacement up to his death.

Conclusions

We report the first case of an ERCP-related procedure with 3D biliary imaging for preoperative simulation and intraoperative reference in a patient with malignant biliary obstruction. The 3D image reconstruction is useful for preoperative planning and could contribute to an increased success rate, decreased complications, a shorter operation time, and reduced radiation exposure to the operator.

P1245 Huge left atrial myxoma masks mitral regurgitation

A 61-year-old gentleman, he had shortness of breath while few weeks and getting worse, was presented to our hospital. His oxygen saturation was 94 %(O2 5L) and no crackles or rales were heard. His electrocardiogram was sinus tachycardia, and chest X-ray showed cardiomegaly and BNP level was elevated (260.3pg/mL). Transthoracic echocardiography (TTE) revealed huge mass(57 × 39mm) occupying left atrium (LA), the mass was flexible in cardiac cycle and prolapsing from LA to left ventricle, it seems like cardiac myxoma. We suspected mitral stenosis (MS) caused by the mass (peak trans mitral flow velocity 3.1m/s), mitral regurgitation(MR) was not significant, and moderate tricuspid regurgitation with pulmonary hypertension (peak systolic pressure 61 mmHg). We performed transesophageal echocardiography(TEE) and CT angiography revealed the mass at fossa ovalis, we decided surgery of removing the mass considering the risk of mitral annulus obstruction and embolism. Intraoperative findings, after taken off the mass, TEE showed moderate to severe MR not detected preoperative TEE. Additionally, it revealed the mitral annulus enlargement(42 × 38mm by 2D TEE) and may gradually induced by prolapsing the mass. Finally, surgery for mitral valve was performed and postoperative TTE showed no MR. The mass was diagnosed cardiac myxoma by pathology.

MS is relatively common in patients with prolapsing LA myxoma , and it improves after removing the mass. In this case, mitral valve was no degeneration but enlarged mitral annulus and significantly MR had revealed after removing the mass. Keep in mind that there is possibility to underestimate of MR associated with LA myxoma. To take care of mitral valve complex sufficiently in such case, and to detect these findings at preoperative echocardiography, then more useful assessment for surgery.

Abstract P1245 Figure. Huge Left Atrial Myxoma Masks MR

Assessment of preoperative pancreatic biopsy, cytological/histological review of cell-block-specimens obtained by endoscopic ultrasound-guided fine-needle aspiration: Laboratory-based study

BACKGROUND

Pancreatic cancer is among the most lethal cancers worldwide due to the limited availability of techniques for early detection of signs and symptoms. Reportedly, it is the fourth-leading cause of cancer-related mortality among Japanese adults. With the advent of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosing pancreatic cancer, the rate of the cytological and histological diagnoses of cell-block-specimens has significantly increased in Japan.

METHODS

The cytological specimens of 165 patients with pancreatic lesions obtained using EUS-FNA between January 2010 and July 2016 at the Kyorin University Hospital were investigated. The clinical course of 153 patients was assessed from their clinical records, which included information on their imaging diagnosis, laboratory data, final clinical diagnosis and treatment; moreover, the accuracy of the cytological/histological examination and clinical diagnosis at our hospital were analysed.

RESULTS

The number of cells in cell-block-specimens was too small to estimate data. However, cytological specimens were sufficient to observe the findings of suspected malignancy such as necrosis. Biopsy was deemed necessary for diagnosis using both histological and cytological specimens.

CONCLUSION

EUS-FNA can be used not only to diagnose benign or malignant types of pancreatic cancers but also to assess the sensitivity of molecular target drugs and chemotherapy methods. Therefore, both histological and cytological diagnoses are required to enhance diagnostic precision both in our hospital and at other institutions.

Pharmacokinetic-pharmacodynamic comparison of ceftriaxone regimens in acute cholangitis

The most important factors determining the prognosis of patients with acute cholangitis (AC) are prompt biliary drainage and appropriate choice of antibiotics. This study was performed to evaluate whether dividing the number of doses based on the PK-PD theory contributes to better clinical outcome in the management of acute cholangitis. We measured ceftriaxone levels in blood and bile in 21 cases diagnosed with moderate-to-severe AC. Eleven cases were administered 2 g of ceftriaxone once-daily (group A) and 10 cases were given 1 g of ceftriaxone twice-daily (group B). The theoretical effect of ceftriaxone was evaluated by pharmacokinetic-pharmacodynamic (PK-PD) parameters. Clinical efficacy was evaluated by body temperature, white blood cell count and serum levels of C-reactive protein. Minimum level of ceftriaxone in serum (in mg/L) in groups A and B at 24 h after the first dose was 9.1 and 9.2, whereas that in bile was 2.9 and 2.5, respectively. The minimum inhibitory concentration (MIC) of ceftriaxone for all isolated bacteria was below the minimum serum and biliary concentration of ceftriaxone 24 h after the first administration (except for Enterococcus species). The MIC for isolated bacterial strains was <16 mg/L, which is the PK-PD breakpoint for ceftriaxone at 2 g/day. Both regimens showed clinical efficacy and did not contradict the effect predicted based on PK-PD.

Abstract P4-02-01: Analytical validation of an automated digital scoring protocol for Ki67: International multicenter collaboration study

Background/Goal: Ki67 expression has been a valuable prognostic marker in breast cancer, but has not seen broad adoption due to lack of standardization between institutions. Automation could represent a solution. Here we tested 3 automated digital image analysis (DIA) platforms including an open source platform to: (i) Investigate the reproducibility of Ki67 measurement across platforms with supervised classifiers performed by the same operator and by multiple operators. (ii) Compare accuracy of the 3 DIA platforms against outcome (prognostic potential). (iii) Assess inter-laboratory reproducibility of a calibrated DIA tool to evaluate Ki67 in breast cancer among 10 participating labs of the International Ki67 in Breast Cancer Working Group (IKWG).

Methods: The Mib-1 antibody (Dako) was used to detect Ki67 (dilution 1:100). HALO (H) (IndicaLabs), QuantCenter (QC) (3DHistech), QuPath (QP) (open-source software) digital image analysis (DIA) platforms were used to evaluate Ki67 expression. As a ground truth, we evaluated Ki67 LI with meticulous manual tissue segmentation using the Spectrum Webscope (SW) (Aperio). Calibration was performed using 30 ER+ breast cancer cases from phase 3 of the IKWG initiative where blocks were centrally cut and stained for Ki67. The inter-laboratory analysis was done with 10 participating laboratories divided into 2 groups where members within the same group were given the same set of images. The outcome cohort consisted of 149 breast cancer cases from the Yale Pathology archives in tissue microarray format. Intra-class correlation coefficient (ICC) was used to measure reproducibility with the pre-specified criterion for success being to exceed 0.80. Kaplan-Meier analysis supported with log-rank test was performed to assess prognostic potential.

Results: All 3 DIA platforms showed excellent inter-platform reproducibility (ICC: 0.933, CI: 0.879-0.966). Also, excellent reproducibility was found between all DIA platforms and the reference standard Ki67 values of SW (QP ICC: 0.970, CI: 0.936-0.986; H ICC: 0.968, CI: 0.933-0.985; QC ICC: 0.964, CI: 0.919-0.983). The intra-DIA reproducibility was also excellent for all platforms (QP ICC: 0.992, CI: 0.986-0.996; H ICC: 0.972, CI: 0.924-0.988; QC ICC: 0.978, CI: 0.932-0.991). Comparing each DIA against outcome, the hazard ratios were similar (QP=3.309, H=3.077, QC=3.731). The inter-operator reproducibility was particularly high (ICC: 0.962-0.995). As QP is open source software and also showed the lowest intra-DIA platform variability, we selected the QP platform to investigate inter-laboratory reproducibility among 10 IKWG labs. The different-section ICC across the 10 labs was 0.974 (CI: 0.954 - 0.986). The same-section ICC estimate was 0.984 (CI: 0.971-0.992) for group 1 and 0.978 (CI: 0.956-0.989) for group 2.

Conclusions: Our results showed outstanding reproducibility both within and between DIA platforms. We also found the platforms essentially indistinguishable with respect to prediction of breast cancer patient outcome. Automated Ki67 evaluation using a calibrated, open-source DIA platform (QuPath) met the pre-specified criterion of success in the multi-institutional setting. Assessment of clinical utility is planned.

Citation Format: Acs B, Leung SC, Pelekanou V, Bai Y, Martinez-Morilla S, Toki M, Chang MC, Gholap A, Jadhav A, Hugh JC, Bigras G, Laurinavicius A, Augulis R, Levenson R, Todd A, Piper T, Virk S, van der Vegt B, Hayes DF, Dowsett M, Nielsen TO, Rimm DL. Analytical validation of an automated digital scoring protocol for Ki67: International multicenter collaboration study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-02-01.

A Multicenter Phase II Study of Gemcitabine plus S-1 Chemotherapy for Advanced Biliary Tract Cancer

BACKGROUND

Gemcitabine (GEM) plus cisplatin (CDDP) chemotherapy has been used worldwide as the standard first-line treatment for advanced biliary tract cancer (BTC). A phase II trial has also suggested promising activity of GEM plus S-1 chemotherapy against advanced BTC. The aim of this study was to evaluate the efficacy and safety of GEM plus S-1 chemotherapy in patients with advanced BTC.

PATIENTS AND METHODS

The eligibility criteria were as follows: histologically-proven BTC, unresectable or recurrent disease, ECOG performance status (PS) 0-1 regardless of previous treatment. Gemcitabine was administered intravenously at the dose of 1,000 mg/m² over 30 min on days 1 and 8, and S-1 was administered orally at doses of 60/80/100 mg/day based on the BSA, from day 1 to day 14, every 3 weeks. The primary endpoint was the response rate according to RECIST, ver. 1.1, and the secondary endpoints were the frequency/severity of toxicities, progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 38 patients were enrolled between August 2008 and November 2011. There were 19 men and 19 women, with a median age of 66 years (range=44-81 years). Seven patients had a previous history of first-line or adjuvant chemotherapy after surgery. The PS was 0 and 1 in 30 and 7 patients, respectively. The treatment response was classified as partial response in 6 patients (15.8%) and as stable disease in 18 patients (47.4%). The median PFS and OS were 5.8 and 15.9 months, respectively. The toxicity was generally mild, and the most common grade 3/4 toxicities were leukopenia (31.6%), neutropenia (36.8%), nausea/vomiting (2.6%), and diarrhea (2.6%). There was one treatment-related death due to interstitial pneumonia.

CONCLUSION

Our study revealed that gemcitabine plus S-1 chemotherapy was well-tolerated and exhibited favorable antitumor activity in patients with advanced BTC.

Abstract P3-07-06: Objective measurement of HER2 (ERBB2) intracellular and extracellular domain spatial co-localization stratifies benefit from adjuvant trastuzumab

Background: The ASCO/CAP guidelines consider chromogen-based immunohistochemistry (IHC) as the primary assay to determine HER2 status in breast cancer. U. S. Food and Drugs Administration (FDA) approved HER2 antibody assays target the protein's intracellular domain (ICD). Studies suggest that quantitative, domain-specific measurement of HER2 might predict benefit from trastuzumab therapy, further classifying traditional HER2-positive breast cancer. Here we define a method of simultaneous, objective measurement of HER2 ICD and extracellular (ECD) domains, and determine its effect on trastuzumab benefit in the adjuvant setting.

Methods: We measured co-expression of HER2 ICD and ECD using a proximity ligation assay (PLA) and quantitative immunofluorescence (QIF) in a HER2 standardization tissue microarray (TMA) with CLIA-lab defined HER2 status. Previously validated, standardized HER2 antibodies were used to detect ICD and ECD (CB11 and SP3, respectively). We determined the relationship between HER2 PLA scores, HER2 clinical status and domain-specific scores. Finally, we measured HER2 ICD/ECD PLA in 180 patients from a clinical trial of adjuvant chemotherapy followed by trastuzumab (HeCOG 10/05). Median cut-point was used to stratify patients according to HER2 PLA scores. Cut-points for HER2 ICD and ECD were obtained using Joinpoint software. All statistical tests were two-sided.

Results: In the standardization TMA, HER2 PLA levels were associated to HER2 CLIA status (P&lt;0.0001). There was a good correlation between HER2 PLA scores and HER2 ICD and ECD (R2=0.57 and R2=0.54, respectively). In trastuzumab-treated patients from HeCOG 10/05, a similarly good correlation was observed between HER2 PLA scores and HER2 ICD and ECD (R2=0.41 and R2=0.3, respectively). In univariate analysis, HER2 PLA-low status was associated with ER-positive status (P=0.005). There was no association with age, histological grade, tumor size, lymph node status and TNM stage. Although all tumors were HER2-positive, HER2 PLA-high status was significantly associated with longer 5-year disease-free survival (DFS) (log-rank P=0.036, HR=0.32, 95% CI: 0.132-0.935). HER2 PLA status was superior to ICD status (log-rank P=0.67) and numerically comparable to ECD status (log-rank P=0.049, HR=0.31, 95% CI: 0.144-0.997) to predict benefit from adjuvant trastuzumab, as previously published by our group. HER2 PLA-high status was independent predictor of better outcome in a Cox proportional hazards model including age, histological grade, ER status, tumor size, lymph node status and TNM stage.

Discussion: Using an objective, quantitative HER2 assay for synchronous, domain-specific measurement, we stratified benefit from adjuvant trastuzumab treatment in patients from a prospective cohort. Our results further support the concept that benefit from HER2 ECD-targeted therapies might be modulated by the presence of truncated HER2 protein variants and that tyrosine kinase inhibitors (ICD-directed) may be advantageous for a subset of HER2-positive patients. Furthermore, this technique that uses two antibodies has the potential to increase both sensitivity and specificity of the IHC assay to predict response to HER2 pathway inhibitors.

Citation Format: Carvajal-Hausdorf DE, Toki M, Schalper KA, Pusztai L, Psyrri A, Kalogeras KT, Kotoula V, Fountzilas G, Rimm DL. Objective measurement of HER2 (ERBB2) intracellular and extracellular domain spatial co-localization stratifies benefit from adjuvant trastuzumab. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-06.

The usefulness and safety of carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography in elderly patients: a prospective, double-blind, randomized, controlled trial

BACKGROUND/AIMS

Carbon dioxide (CO2) insufflation has been used in endoscopic retrograde cholangiopancreatography (ERCP). However, its usefulness and safety are controversial in elderly patients. Our aim was to assess the safety and usefulness of CO2 insufflation during ERCP in elderly patients.

METHODOLOGY

Between April 2010 and June 2011, a total of 60 patients 75 years old or older, who underwent ERCP, were randomized into the CO2 group (n = 30) and the air group (n = 30). Main outcomes were determined by assessing abdominal symptoms according to the Wong-Baker FACES Pain Rating Scale, calculating the volume of residual gas retention within the intestines on abdominal X-ray quantitatively and observing the cardiopulmonary states.

RESULTS

30 patients in the CO2 group and 30 patients in the air group were analyzed. Abdominal distension (P < 0.01), discomfort (P < 0.01) and nausea (P < 0.01) at 2 hours after ERCP were significantly reduced in the CO2 group. The gas volume scores immediately after ERCP (P < 0.01) and at 2 hours (P < 0.01) were significantly lower in the CO2 group.

CONCLUSIONS

CO2 insufflation instead of air insufflation is safe and useful for the prevention of post-ERCP abdominal symptoms in elderly patients.

[Managements for jaundice]

Jaundice is a yellowish pigmentation of skin and mucous membranes caused by hyperbilirubinemia, which itself has various causes. Jaundice related to malignant tumors is classified as obstructive jaundice. This disease proceeds from biliary tract obstruction and liver failure by progression of intrahepatic tumors, including metastases from other malignancies. Biliary tract cancer, pancreatic head cancer, or lymph nodes metastases from other sites of cancer are mainly responsible for the obstruction of the bile duct. In patients with obstructive jaundice, biliary drainage is often required in order to give treatments such as chemotherapy. In patients with biliary drainage, various complications arise, such as cholangitis due to obstruction ofa biliary stent, and bleeding from the ulcer due to a dislodged stent to the duodenum. It is crucial to manage those complications as oncologic emergencies. Jaundice of liver failure due to hepatic metastases is often observed in patients with gastrointestinal malignancies such as gastric cancer or colorectal cancer. Although chemotherapy is the usual application for those patients, useful anti-cancer agents are limited. It is crucial to diagnose and decide the best treatments as soon as possible for patients with very advanced hepatic metastases.

[Endoscopic treatment for hemorrhagic peptic ulcer in patients aged 70 years or more]

In this study on endoscopic hemostasis in patients aged 70 years or older with gastrointestinal ulcer bleeding, presence of shock, volume of transfusion over 6 units, and ulcer size over 3cm and solitary ulcer were significant risk factors for rebleeding. For 30-day mortality, concomitant disease and inpatient status were significant risk factors. Based on these results, we consider elderly patients with the above risk factors as high-risk patients for rebleeding or fatal outcome. The purpose of this study was to evaluate the efficacy of prevention of rebleeding such as by combined hemostatic methods and scheduled second-look endoscopy, and also to evaluate the offers of multidisciplinary approach such as interventional radiology for decreasing of mortality. Our conclusion is that we were able to reduce rebleeding rate and mortality after endoscopic hemostasis in high-risk patients and implement strategy to provide more careful endoscopic management with a multidisciplinary approach.

Molecular spin resonance in the geometrically frustrated magnet MgCr2O4 by inelastic neutron scattering

We measured two magnetic modes with finite and discrete energies in an antiferromagnetic ordered phase of a geometrically frustrated magnet MgCr2O4 by single-crystal inelastic neutron scattering, and clarified the spatial spin correlations of the two levels: one is an antiferromagnetic hexamer and the other is an antiferromagnetic heptamer. Since these correlation types are emblematic of quasielastic scattering with geometric frustration, our results indicate instantaneous suppression of lattice distortion in an ordered phase by spin-lattice coupling, probably also supported by orbital and charge. The common features in the two levels, intermolecular independence and discreteness of energy, suggest that the spin molecules are interpreted as quasiparticles (elementary excitations with energy quantum) of highly frustrated spins, in analogy with the Fermi liquid approximation.

[NSAID and its effect on prostaglandin]

Recently, the use of non-steroidal anti-inflammatory drug(NSAID) as an anti-inflammatory analgesic and antithrombotic has increased with the general aging of our society. Although it is understood that gastric mucosal injury is most-frequent side-effect of NSAID, there are actually a variety of mechanisms that NSAID has, some which are due to the depressed production of prostaglandin (PG). The main action of PG in the gastric mucosa is the regulation of gastric mucosa protecting mechanism and if PG is insufficient, the gastric mucosa is weakened. As endogenous PG decreases, there is a decrease in mucus production accompanied by a decrease in bicarbonate secretion, problems with, an increase of stomach motility, tissue restoration suppression and so on. As a result, it is considered that the defense mechanisms decrease and gastric mucosal injury occurs.

Resection area of 15 mm as dividing line for choosing strip biopsy or endoscopic submucosal dissection for mucosal gastric neoplasm

BACKGROUND

Endoscopic mucosal resection (EMR) is effective treatment for mucosal gastric neoplasm. Endoscopic submucosal dissection (ESD), a novel EMR method, has been reported to enable en bloc resection more frequently than conventional EMR methods such as strip biopsy (SB). However, ESD requires more time than SB. A small lesion can be resected en bloc and effectively treated with SB.

GOAL

To evaluate using a 15 mm resection area as the dividing line between SB and ESD prospectively.

STUDY

SB was applied for resection area less than 15 mm (SB group) and ESD for 15 mm or larger resection (ESD group). We compared characteristics of lesions and outcomes of EMR between the 2 groups.

RESULTS

Ninety lesions were prospectively assigned to SB group (36 lesions) and ESD group (54 lesions). The average neoplasm size was 9.0+/-3.9 mm in the SB group and 19.1+/-11.3 mm in the ESD group (P<0.01). The average resection time was 11.7+/-5.8 minutes in the SB group and 128.9+/-102.8 minutes in the ESD group (P<0.01). The complete resection rate was 91.6% in the SB group and 83.3% in the ESD group (P=0.25). The complication rate was not significantly different between SB group and ESD group (11.1% vs. 16.7%, P=0.12). During follow-up (median 23+/-5 mo), 1 patient in each group, who had piecemeal resection at original EMR had recurrent neoplasm.

CONCLUSIONS

Gastric mucosal neoplasms which require only small (<15 mm) resection can be treated with SB, as effectively as with ESD.

A prospective randomized trial of either famotidine or omeprazole for the prevention of bleeding after endoscopic mucosal resection and the healing of endoscopic mucosal resection-induced ulceration

BACKGROUND

It has been reported that inhibitors of gastric acid secretion prevent bleeding after endoscopic mucosal resection for mucosal gastric neoplasm. However, uncertain whether an histamine2-receptor antagonist or proton-pump inhibitor is more effective.

AIM

To evaluate prospectively the effectiveness of famotidine or omeprazole for ulcer management after endoscopic mucosal resection.

METHODS

From July 2003 to October 2004, 57 patients were randomly assigned to famotidine or omeprazole for the management of endoscopic mucosal resection. Both drugs were given intravenously for the first 2 days, thereafter by mouth. The bleeding rates after endoscopic mucosal resection, the effects on the healing of endoscopic mucosal resection-induced ulceration, and cost-benefits were compared.

RESULTS

Twenty-eight patients received famotidine and 29 received omeprazole. No significant difference was observed between the two groups in patient characteristics. The bleeding rates after endoscopic mucosal resection were not significantly different (18% vs. 14%) between the groups. Similarly, no differences were seen in the size of the endoscopic mucosal resection-induced ulceration at 1, 30 and 60 days after resection between groups. The total costs of anti-secretory agents demonstrated a significant cost-benefit to those treated with famotidine (10,420 yen vs. 17,782 yen).

CONCLUSIONS

Famotidine is suggested as a better alternative to omeprazole for the management of endoscopic mucosal resection, as it showed a clear cost-benefit, and the healing results after endoscopic mucosal resection were similar for the two treatment strategies.

Identification of IFN-gamma-producing cells in IL-12/IL-18-treated mice

Both IL-12 and IL-18 have been characterized as effective IFN-gamma-inducing cytokines. Concomitant treatment with IL-12 and IL-18 has been shown to synergistically induce IFN-gamma and may be an effective therapy for treating cancer, allergy, and infectious diseases. To understand the mechanisms underlying the strong induction of IFN-gamma by IL-12/IL-18 in mice, we focused our studies on the IFN-gamma-producing cells in various lymphoid organs and tissues and utilized the intracellular cytokine staining method to detect such cells in situ. After combined treatment with IL-12 and IL-18, IFN-gamma-positive cells in C57BL/6 mice were detected in the liver (12.18%), spleen (0.68%), bone marrow (1.80%), and peritoneum (2.12%), but not in the thymus or lymph nodes (<0.05 and <0.08%, respectively). A two-color staining method revealed that the majority of IFN-gamma-producing cells in the liver were NK1.1(+) cells, while those in the spleen were mostly CD3(+) cells, and to a lesser degree NK1.1(+) cells. Both CD4(+) and CD8(+) cells in the liver and in the spleen produced IFN-gamma. The CD19(+) B cell population was not definitely shown to produce IFN-gamma in our induction experiments. NKT cells, which are a subpopulation of NK1. 1(+) CD3(+) cells, were diminished in the liver and did not seem to contribute to IFN-gamma production arising from IL-12/IL-18 treatment. Further in vitro experiments confirmed the responsiveness of hepatic mononuclear cells to IL-12/IL-18 stimulation. This study is the first to show the IFN-gamma-producing mechanisms of IL-12/IL-18 treatment at the phenotypic level.

Sesterterpenoids and diterpenoids of the wax excreted by a scale insect, Ceroplastes pseudoceriferus

A new sesterterpene, (2Z,6Z,10E)-cericerene-15,24-diol (1), and its 30-hydroxytriacontanoate (2) were isolated from the wax exuded by the scale insect Ceroplastes pseudoceriferus, together with the acetates and 30-hydroxytriacontanoates of 3,15-dihydroxy- and 15, 20-dihydroxylabda-7,13-diene (3-6). The absolute configurations of the labdadiene alcohols were antipodal to the ordinary labdanes isolated from terrestrial plants.

Interobserver and intraobserver variation in endoscopic assessment of GERD using the "Los Angeles" classification

BACKGROUND

A new endoscopic classification of gastroesophageal reflux disease (GERD) has been proposed, and the term mucosal break has been introduced to describe mucosal damage. This new classification was evaluated by endoscopists with different levels of experience.

METHODS

Fifty endoscopic photographs for each of 20 randomly selected patients with GERD were assessed retrospectively by three groups of seven endoscopists classified by experience: group 1 (100 to 500 procedures), group 2 (500 to 3000), and group 3 (more than 3000). The new classification was modified by adding grade 0 to describe healed mucosal breaks, so that there were five grades. All photographs were assessed twice at an interval of more than 1 week, and kappa statistics were used to determine observer variation.

RESULTS

Interobserver variation within group 3 (kappa = 0.39, n = 21) and between groups 3 and 2 (kappa = 0.36, n = 49) was significantly different (p < 0.01) from that between groups 3 and 1 (kappa = 0.26, n = 49). Intraobserver variation in group 1 (kappa = 0.39, n = 7) was significantly different (p < 0.01) from that in group 2 (kappa = 0.51, n = 7) and group 3 (kappa = 0.54, n = 7).

CONCLUSIONS

Observer variation depends on level of endoscopic experience. Only experienced endoscopists should use the new classification for grading of GERD.

In vitro study using leukemia cell line panel to demonstrate rapid thymic T cell death due to contact with HIV-1 carrier cell clones

A rapid (within 1 h) and profound cytotoxic cell death of immature TdT+CD4+CD8+ and/or TdT+CD4+ thymic T cell type leukemia cell lines, and of normal thymocyte populations rich in TdT+CD4+CD8+ cells was induced by contact with some human immunodeficiency virus type-1 (HIV-1) carrier T cell clones. This cytotoxic reaction, without requiring a complete viral replication cycle in the thymic T cells, did not occur in any mature CD4+CD8+ and/or CD4+ T cells which are otherwise permissive for virus infection. Although it was not an antigen-specific cytotoxic reaction, the rapid and profound thymic T cell destruction was shown, at the individual clonal level, to be triggered specifically by the binding of CD4 molecules on thymic T cells with gp120/gp160 on HIV-1 carrier clones. The present study suggesting direct elimination of immature T cells by contact with some HIV-1-infected T cells, may provide a novel insight into the mechanism responsible for the mature CD4+ T cell depletion in HIV-1 infection.

Acquired cytotoxic activity of CD8+ HIV-1IIIB carrier immature T cell clones specific to CD4+CD8+ (parental) human T cell clones and normal thymocytes

By infecting human leukemia cell lines in vitro with HIV-1IIIB' a number of HIV-1 carrier clones were generated. Among them, 5 of 13 CD8+ HIV-1 carrier T cell clones were shown to acquire a rapid cytotoxic activity (within 1 hour) specific to TdT+CD4+CD8+ immature T cells including normal thymocytes. This novel cytotoxic reaction, without requiring virus infection and indicating a rapid T cell precursor elimination during active lymphopoiesis, suggests a mechanism responsible for mature CD4+ T cell depletion in HIV-1 infected individuals.

Comparative efficacy of acid reflux inhibition by drug therapy in reflux esophagitis

The advent of histamine H2 receptor antagonists (H2-RA) has allowed the treatment of reflux esophagitis (RE) to be controlled over a relatively long term. The authors have experienced some cases resistant to H2-RA, but it was revealed that these cases can be successfully treated with proton pump inhibitors. It has been suggested that esophagogastric dysmotility can lead to RE. RE has been treated for many years by using GI-prokinetic agents, which theoretically inhibit acid reflux and improve esophageal acid clearance. In order to compare the effects on acid reflux of an H2-RA (famotidine), a proton pump inhibitor (omeprazole) and a GI-prokinetic agent (cisapride), we measured the 24-hour pH in the esophagus and stomach simultaneously, before and after treatment in 17 patients with RE. It was found that the proton pump inhibitor was the most effective drug for inhibiting esophageal acidification, followed by famotidine and then cisapride. Furthermore, we found that cisapride often actually exacerbated acid reflux. The differences in inhibitory effects on acidification allowed us to draw conclusions regarding the treatment of RE. It was concluded that the stronger the inhibitory effect of a drug on acid secretion, the more useful it was in the treatment of RE. The GI-prokinetic drug did not inhibit acid reflux as much as we had expected.