Multiple duodenal epithelial tumors in a patient with polymerase proofreading-associated polyposis in POLE variant

Polymerase proofreading-associated polyposis (PPAP) is a rare disease with autosomal-dominant inheritance caused by germline variants in the POLE and POLD1 genes. PPAP has been reported to increase the risk of multiple cancers, including colon, duodenal, and endometrial cancers. Herein, we report a case in which multiple duodenal tumors led to the detection of a POLE mutation. A 43-year-old woman underwent esophagogastroduodenoscopy (EGD). Multiple duodenal tumors were detected, and all lesions were treated endoscopically. The patient had a history of multiple colorectal cancers and endometrial cancer along with a family history of cancer; hence, genetic testing was performed, and POLE variant, c.1270C > G (p.Leu424Val) was detected. Hereditary colorectal cancer syndromes should be considered in patients with colorectal cancer who have multiple cancers or a family history of cancer, and multigene panel sequencing is useful in confirming the diagnosis. In addition, duodenal tumors frequently coexist in patients with PPAP-carrying POLE variants, while the endoscopic treatment for duodenal tumors becomes safe and useful with several new approaches. Therefore, surveillance EGD is necessary in such patients for the early detection and treatment of duodenal tumors.

Short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery for superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND AIMS

This retrospective study aimed to compare the short- and long-term outcomes of endoscopic submucosal dissection and laparoscopic and endoscopic cooperative surgery in patients with superficial non-ampullary duodenal epithelial tumors.

PATIENTS AND METHODS

We investigated consecutive patients with SNADETs > 10 mm in size who underwent ESD (ESD group) or LECS (LECS group) between January 2015 and March 2021. The data was used to analyze the clinical course, management, survival status, and recurrence between the two groups.

RESULTS

A total of 113 patients (100 and 13 in the ESD and LECS groups, respectively) were investigated. The rates of en bloc resection and curative resection were 100% vs. 100% and 93.0% vs. 77.0% in the ESD and LECS groups, respectively, with no significant difference. The ESD group had shorter resection and suturing times than the LECS group, but there were no significant difference after propensity score matching. There were also no differences in the rates of postoperative adverse event (7.0% vs. 23.1%; P = 0.161). The 3-year overall survival (OS) rate was high in both the ESD and LECS groups (97.6% vs. 100%; P = 0.334). One patient in the ESD group experienced recurrence due to liver metastasis; however, no deaths related to SNADETs were observed.

CONCLUSION

ESD and LECS are both acceptable treatments for SNADETs in terms of a high OS rate and a low long-term recurrence rate, thereby achieving a comparable high rate of curative resection. Further studies are necessary to compare the outcomes of ESD and LECS for SNADETs once both techniques are developed further.

Mortality risk factors and fulminant sub-phenotype in anaerobic bacteremia: a 10-year retrospective, multicenter, observational cohort study

PURPOSE

During the last decade, the incidence of anaerobic bacteremia (AB) has been increasing. Patients with AB may develop complex underlying diseases, which can occasionally be accompanied by fatal or fulminant outcomes. However, the risk factors for AB-related mortality remain unclear. Herein, we sought to elucidate the risk factors for AB-related mortality.

METHODS

In this multicenter, retrospective, observational study, we enrolled patients with culture-proven AB from six tertiary hospitals in Japan, between January 2012 and December 2021. Data on patient and infection characteristics, laboratory findings, treatment, and outcome were collected, and their associations with mortality were analyzed.

RESULTS

A total of 520 participants were included. The 30-day mortality in the study cohort was 14.0% (73 patients), and malignant tumors were frequently observed comorbidities in 48% of the entire cohort. Multivariable logistic regression analysis showed a Charlson comorbidity score of > 6, serum creatinine level of > 1.17 mg/dL, and hypotension to be independent risk factors for 30-day mortality in AB (odds ratios [ORs] 2.12, 2.25, and 5.12, respectively; p < 0.05), whereas drainage significantly reduced this risk (OR, 0.28; p < 0.0001). Twelve patients (2.3% of the whole cohort and 16.4% of the deceased patients) presented with extremely rapid progression leading to fatal outcome, consistent with "fulminant AB."

CONCLUSIONS

This study identified acute circulatory dysfunction and performance of drainage as independent predictive factors for 30-day AB-related mortality and revealed the existence of a fulminant AB sub-phenotype. Our findings could serve as a practical guide to predict the clinical outcomes of AB.

Conventional versus underwater endoscopic resection for superficial non-ampullary duodenal epithelial tumours

BACKGROUND AND OBJECTIVE

Several endoscopic resection methods have been developed as less invasive treatments for superficial non-ampullary duodenal epithelial tumours. This study aimed to compare outcomes of conventional endoscopic mucosal resection and underwater endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours, including resection depth and rate of the muscularis mucosa contained under the lesion.

METHODS

This single-centre retrospective cohort study conducted from January 2009 to December 2021 enrolled patients who underwent conventional endoscopic mucosal resection and underwater endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours and investigated their clinicopathological outcomes using propensity score matching.

RESULTS

Of the 285 superficial non-ampullary duodenal epithelial tumours, 98 conventional endoscopic mucosal resections and 187 underwater endoscopic mucosal resections were included. After propensity score matching, 64 conventional endoscopic mucosal resections and 64 underwater endoscopic mucosal resections were analysed. The R0 resection rate was significantly higher in underwater endoscopic mucosal resection cases than in conventional endoscopic mucosal resection cases (70.3% vs. 50.0%; P = 0.030). In the multivariate analysis, a lesion diameter > 10 mm (odds ratio 7.246; P = 0.001), being in the 1st-50th treatment period (odds ratio 3.405; P = 0.008), and undergoing conventional endoscopic mucosal resection (odds ratio 3.617; P = 0.016) were associated with RX/R1 resection. Furthermore, in underwater endoscopic mucosal resection cases, the R0 rate was significantly higher for lesions diameter ≤10 mm than >10 mm, and was significantly higher in the 51st-treatment period than in the 1st-50th period. Conventional endoscopic mucosal resection and underwater endoscopic mucosal resection cases showed no significant difference in resection depth and muscularis mucosa containing rate.

CONCLUSIONS

Underwater endoscopic mucosal resection may be more acceptable than conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumours ≤ 10 mm. A steep early learning curve may be acquired for underwater endoscopic mucosal resection. Large multicentre prospective studies need to be conducted to confirm the effectiveness of underwater endoscopic mucosal resection.

Value of the Tumor-Stroma Ratio and Structural Heterogeneity Measured by a Novel Semiautomatic Image Analysis Technique for Predicting Survival in Patients With Colon Cancer

BACKGROUND

The tumor-stroma ratio and intratumor stromal heterogeneity have been identified as prognostic factors for several carcinomas. Recent advancements in image analysis technologies and their application to medicine have enabled detailed analysis of clinical data beyond human cognition.

OBJECTIVE

This study aimed to investigate the tumor-stroma ratio and intratumor stromal heterogeneity measured using a novel objective and semiautomatic method with image analysis.

DESIGN

A retrospective cohort design.

SETTINGS

Single institution.

PATIENTS

This study included patients who underwent curative colectomy for colon cancer.

MAIN OUTCOME MEASURES

The survival analyses between tumor-stroma ratio or intratumor stromal heterogeneity high and low groups after colectomy were assessed in multivariate analyses.

RESULTS

Two hundred patients were divided into 2 groups based on the median tumor-stroma ratio and intratumor stromal heterogeneity values. The 5-year overall survival and relapse-free survival rates after colectomy significantly differed between the high and low tumor-stroma ratio or intratumor stromal heterogeneity groups. Multivariate analysis identified low tumor-stroma ratio (HR: 1.90, p = 0.03) and high intratumor stromal heterogeneity (HR: 2.44, p = 0.002) as independent poor prognostic factors for relapse-free survival. The tumor-stroma ratio and intratumor stromal heterogeneity correlated with the duration from curative surgery to recurrence. Furthermore, postoperative recurrence within 2 years was predicted with higher accuracy by using the tumor-stroma ratio or intratumor stromal heterogeneity than by using the pathological stage. In a validation cohort, interobserver agreement was assessed by 2 observers, and Cohen's κ coefficient for the tumor-stroma ratio (κ value: 0.70) and intratumor stromal heterogeneity (κ value: 0.60) revealed a substantial interobserver agreement.

LIMITATIONS

This study was limited by its retrospective, single-institution design.

CONCLUSIONS

Tumor-stroma ratio and intratumor stromal heterogeneity calculated using image analysis software have potential as imaging biomarkers for predicting the survival of patients with colon cancer after colectomy. See Video Abstract at http://links.lww.com/DCR/C114 .

VALOR DE LA PROPORCIN DE ESTROMA TUMORAL Y LA HETEROGENEIDAD ESTRUCTURAL MEDIDOS POR UNA NUEVA TCNICA DE ANLISIS DE IMGENES SEMIAUTOMTICA PARA PREDECIR LA SUPERVIVENCIA EN PACIENTES CON CNCER DE COLON

ANTECEDENTES:La proporción de estroma tumoral y la heterogeneidad del estroma intratumoral han sido identificados como factores pronósticos para varios tipos de carcinomas. Los avances recientes en cuanto a las tecnologías de análisis de imágenes y sus aplicaciones en la medicina, han permitido un análisis detallado de los datos clínicos más allá del conocimiento humano.OBJETIVO:Investigar la relación del estroma tumoral y la heterogeneidad del estroma intratumoral calculados mediante un nuevo método objetivo y semiautomático para el análisis de imágenes.DISEÑO:Diseño de cohorte retrospectivo.AJUSTES:Institución única.PACIENTES:Pacientes sometidos a colectomía curativa por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:Los análisis de supervivencia entre la relación del estroma tumoral o la heterogeneidad del estroma intratumoral entre los grupos con valores altos y bajos tras la colectomía, fueron evaluados en análisis multivariados.RESULTADOS:Fueron divididos 200 pacientes en dos grupos basados en la mediana de la proporción con respecto a los valores del estroma tumoral y la heterogeneidad del estroma intratumoral. Las tasas de supervivencia general a los 5 años y de supervivencia libre de recaídas después de la colectomía, difirieron significativamente entre los grupos con índice de estroma tumoral o heterogeneidad del estroma intratumoral altos y bajos. El análisis multivariante identificó una proporción de estroma tumoral baja (cociente de riesgos instantáneos: 1.90, p = 0.03) y una heterogeneidad estromal intratumoral alta (cociente de riesgos instantáneos: 2.44, p = 0.002) como factores independientes de mal pronóstico para la supervivencia libre de recaídas. La proporción de estroma tumoral y la heterogeneidad del estroma intratumoral se correlacionaron con la duración de la recurrencia desde la cirugía.Además, la recurrencia posoperatoria dentro de los 2 años se predijo con mayor precisión mediante el uso del índice de estroma tumoral o la heterogeneidad del estroma intratumoral que mediante el uso del estadio patológico. En una cohorte de validación, la concordancia interobservador fue evaluada por dos observadores, y el coeficiente Kappa de Cohen para la proporción de estroma tumoral y la heterogeneidad estromal intratumoral reveló una concordancia interobservador sustancial (valor Kappa: 0.70, 0.60, respectivamente).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo de una sola institución.CONCLUSIONES:La proporción del estroma tumoral y la heterogeneidad del estroma intratumoral calculadas mediante software de análisis de imágenes tienen potencial como biomarcadores de imagen para predecir la supervivencia de los pacientes con cáncer de colon tras la colectomía. Consulte Video Resumen en http://links.lww.com/DCR/C114 . (Traducción-Dr. Osvaldo Gauto ).

Additional 30-Second Observation of the Right-Sided Colon for Missed Polyp Detection With Texture and Color Enhancement Imaging Compared with Narrow Band Imaging: A Randomized Trial

INTRODUCTION

The efficacy of texture and color enhancement imaging (TXI) in the novel light-emitting diode endoscopic system for polyp detection has not been examined. We aimed to evaluate the noninferiority of the additional 30-second (Add-30-s) observation of the right-sided colon (cecum/ascending colon) with TXI compared with narrow band imaging (NBI) for detecting missed polyps.

METHODS

We enrolled 381 patients ≥40 years old who underwent colonoscopy from September 2021 to June 2022 in 3 institutions and randomly assigned them to either the TXI or NBI groups. The right-sided colon was first observed with white light imaging in both groups. Second, after reinsertion from hepatic flexure to the cecum, the right-sided colon was observed with Add-30-s observation of either TXI or NBI. The primary endpoint was to examine the noninferiority of TXI to NBI using the mean number of adenomas and sessile serrated lesions per patient. The secondary ones were to examine adenoma detection rate, adenoma and sessile serrated lesions detection rates, and polyp detection rates in both groups.

RESULTS

The TXI and NBI groups consisted of 177 and 181 patients, respectively, and the noninferiorities of the mean number of adenomas and sessile serrated lesions per patients in the second observation were significant (TXI 0.29 [51/177] vs NBI 0.30 [54/181], P < 0.01). The change in adenoma detection rate, adenoma and sessile serrated lesions detection rate, and polyp detection rate for the right-sided colon between the TXI and NBI groups were not different (10.2%/10.5% [ P = 0.81], 13.0%/12.7% [ P = 0.71], and 15.3%/13.8% [ P = 0.71]), respectively.

DISCUSSION

Regarding Add-30-s observation of the right-sided colon, TXI was noninferior to NBI.

Functional Analysis and Clinical Importance of ATP1A1 in Colon Cancer

BACKGROUND

Na+/K+-ATPase α1 subunit (ATP1A1) exhibits aberrant expression in various types of cancer. Moreover, its levels in specific tissues are associated with the development of cancer. Nevertheless, the mechanism and signaling pathways underlying the effects of ATP1A1 in colon cancer (CC) have not been elucidated, and its prognostic impact remains unknown.

METHODS

Knockdown of ATP1A1 expression was performed in human CC cell lines HT29 and Caco2 using small interfering RNA. The roles of ATP1A1 in various biological processes of cells (i.e., proliferation, cell cycle, apoptosis, migration, and invasion) were assessed. Microarray analysis was utilized for gene expression profiling. Samples obtained from 200 patients with CC who underwent curative colectomy were analyzed through immunohistochemistry.

RESULTS

ATP1A1 knockdown suppressed cell proliferation, migration, and invasion and induced apoptosis. The results of the microarray analysis revealed that the upregulated or downregulated gene expression in ATP1A1-depleted cells was related to the extracellular signal-regulated kinase 5 (ERK5) signaling pathway [epidermal growth factor receptor (EGFR), mitogen-activated protein kinase kinase 5 (MAP2K5), mitogen-activated protein kinase 7 (MAPK7), FOS, MYC, and BCL2 associated agonist of cell death (BAD)]. Immunohistochemical analysis demonstrated a correlation between ATP1A1 expression and pathological T stage (p = 0.0054), and multivariate analysis identified high ATP1A1 expression as an independent predictor of poor recurrence-free survival in patients with CC (p = 0.0040, hazard ratio: 2.807, 95% confidence interval 1.376-6.196).

CONCLUSIONS

ATP1A1 regulates tumor progression through the ERK5 signaling pathway. High ATP1A1 expression is associated with poor long-term outcomes in patients with CC.

Predictive values of immune indicators on respiratory failure in the early phase of COVID-19 due to Delta and precedent variants

Background

Immune response indicators in the early phase of COVID-19, including interferon and neutralizing responses against SARS-CoV-2, which predict hypoxemia remains unclear.

Methods

This prospective observational study recruited patients hospitalized with COVID-19 (before emergence of omicron variant). As the immune indicators, we assessed the serum levels of IFN-I/III, IL-6, CXCL10 and VEGF, using an ELISA at within 5 days after the onset of symptoms, and serum neutralizing responses using a pseudovirus assay. We also assessed SARS-CoV-2 viral load by qPCR using nasal-swab specimens and serum, to assess the association of indicators and viral distribution.

Results

The study enrolled 117 patients with COVID-19, of which 28 patients developed hypoxemia. None received vaccine before admission. Serum IFN-I levels (IFN-α and IFN-β), IL-6, CXCL10, LDH and CRP were significantly higher in patients who developed hypoxemia. A significant association with nasopharyngeal viral load was observed only for IFN-I. The serum levels of IFN-α, IL-6, CXCL10 were significantly associated with the presence of RNAemia. Multivariable analysis showed higher odds ratio of IFN-α, with cut-off value of 107 pg/ml, in regard to hypoxemia (Odds ratio [OR]=17.5; 95% confidence interval [CI], 4.7-85; p<0.001), compared to those of IL-6, >17.9 pg/ml (OR=10.5; 95% CI, 2.9-46; p<0.001).

Conclusions

This study demonstrated that serum IFN-α levels in the early phase of SARS-CoV-2 infection strongly predict hypoxemic respiratory failure in a manner different from that of the other indicators including IL-6 or humoral immune response, and instead sensitively reflect innate immune response against SARS-CoV-2 invasion.

Standard Endoscopic Mucosal Resection vs Precutting Endoscopic Mucosal Resection Using Novel Disk-Tip Snare for Colorectal Lesions

INTRODUCTION

SOUTEN (KANEKA Co., Tokyo, Japan) is a unique snare with a disk tip. We analyzed the efficacy of precutting endoscopic mucosal resection with SOUTEN (PEMR-S) for colorectal lesions.

METHODS

We retrospectively reviewed 57 lesions of 10-30 mm treated with PEMR-S at our institution from 2017 to 2022. The indications were lesions that were difficult for standard EMR due to size, morphology, and poor elevation by injection. Various therapeutic results of PEMR-S such as en bloc resection, procedure time, and perioperative hemorrhage were analyzed, and the results of 20 lesions of 20-30 mm with PEMR-S were compared to those of lesions with standard EMR (2012-2014) using propensity score matching. Additionally, the stability of the SOUTEN disk tip was analyzed in a laboratory experiment.

RESULTS

The polyp size was 16.5 ± 4.2 mm and the non-polypoid morphology rate was 80.7%. Histopathological diagnosis included 10 sessile-serrated lesions, 43 low-grade and high-grade dysplasias, and 4 T1 cancers. After matching, the en bloc resection and histopathological complete resection rates of lesions of 20-30 mm between PEMR-S and standard EMR (90.0% vs. 58.1%, p = 0.03 and 70.0% vs. 45.0%, p = 0.11). The procedure time (min) was 14.8 ± 9.7 and 9.7 ± 8.3 (p < 0.01). The en bloc resection (%) and procedure time of expert/non-expert were 89.7/85.7 (p = 0.96) and 6.1 ± 2.2/18.5 ± 7.2 (p < 0.01). The perioperative bleeding and hemostasis success rates with SOUTEN were 43.9% and 96.0%. In the experiment, the SOUTEN disk tip was fixed stably compared to other EMR snares.

CONCLUSIONS

PEMR-S achieved high en bloc resection of colorectal lesions of 20-30 mm though it leaded to long procedure time.

Obscure gastrointestinal bleeding from a large jejunal lipoma treated using an endoscopic unroofing technique with double balloon enteroscopy: a case study

Small intestinal lipomas are rare, but may cause obscure gastrointestinal bleeding. The endoscopic unroofing technique excises only the upper third of the lipoma and allows both histological confirmation and complete treatment with minimal risk of perforation. We present a rare case of obscure gastrointestinal bleeding caused by a jejunal lipoma. A 75-year-old man on antiplatelet therapy presented to our department with melena and anemia. Computed tomography revealed he had a 45-mm jejunal submucosal tumor with fat attenuation. Endoscopic resection using an endoscopic unroofing technique with double balloon enteroscopy was successfully performed. The tumor was confirmed to be a lipoma.

Analysis of Texture and Color Enhancement Imaging for Improving the Visibility of Non-polypoid Colorectal Lesions

INTRODUCTION

An endoscopic system using 5-color light-emitting diodes (LEDs) (EVIS X1; Olympus Co., Tokyo, Japan), which includes texture and color enhancement imaging (TXI), has been released. In this study, we analyzed the effects of TXI on the visibility of non-polypoid colorectal lesions and its diagnostic accuracy.

METHODS

We reviewed 101 non-polypoid lesions from 26 patients observed with white light imaging (WLI), narrow band imaging (NBI), and TXI. One representative image of each mode was evaluated by 6 endoscopists using a polyp visibility score of 4 (excellent) to 1 (poor). We calculated the color difference (CD) values for each lesion in the three modes. For tumor characteristics, one representative image of TXI and NBI magnification was evaluated by 3 experts according to a NBI classification.

RESULTS

The least squares means [95% confidence interval] of polyp visibility score of TXI (3.42 [3.06-3.77]) was significantly higher than that of WLI (2.85 [2.49-3.20], p < 0.001) but not that of NBI (3.33 [2.98-3.69], p = 0.258). The CD value of TXI (13.3 ± 6.3) was higher than that of WLI (9.7 ± 6.0, p < 0.001) but not that of NBI (13.1 ± 6.8, p = 0.81). For sessile serrated lesions, the CD value of TXI (11.1 ± 4.4) tended to be lower than that of NBI (12.6 ± 6.0, p = 0.07). The diagnostic accuracy and confidence level of magnification for NBI were significantly better than those for TXI (87.1 vs. 80.5%, p = 0.027, 87.5 vs. 62.7%, p < 0.001, respectively).

CONCLUSION

TXI showed better visibility than WLI in terms of the endoscopist's score and CD value and may improve polyp detection.

Anoctamin 5 regulates the cell cycle and affects prognosis in gastric cancer

BACKGROUND

Anoctamin 5 (ANO5)/transmembrane protein 16E belongs to the ANO/ transmembrane protein 16 anion channel family. ANOs comprise a family of plasma membrane proteins that mediate ion transport and phospholipid scrambling and regulate other membrane proteins in numerous cell types. Previous studies have elucidated the roles and mechanisms of ANO5 activation in various cancer types. However, it remains unclear whether ANO5 acts as a plasma membrane chloride channel, and its expression and functions in gastric cancer (GC) have not been investigated.

AIM

To examine the role of ANO5 in the regulation of tumor progression and clinicopathological significance of its expression in GC.

METHODS

Knockdown experiments using ANO5 small interfering RNA were conducted in human GC cell lines, and changes in cell proliferation, cell cycle progression, apoptosis, and cellular movement were assessed. The gene expression profiles of GC cells were investigated following ANO5 silencing by microarray analysis. Immunohistochemical staining of ANO5 was performed on 195 primary tumor samples obtained from patients with GC who underwent curative gastrectomy between 2011 and 2013 at our department.

RESULTS

Reverse transcription-quantitative polymerase chain reaction (PCR) and western blotting demonstrated high ANO5 mRNA and protein expression, respectively, in NUGC4 and MKN45 cells. In these cells, ANO5 silencing inhibited cell proliferation and induced apoptosis. In addition, the knockdown of ANO5 inhibited G₁-S phase progression, invasion, and migration. The results of the microarray analysis revealed changes in the expression levels of several cyclin-associated genes, such as CDKN1A, CDK2/4/6, CCNE2, and E2F1, in ANO5-depleted NUGC4 cells. The expression of these genes was verified using reverse transcription-quantitative PCR. Immunohistochemical staining revealed that high ANO5 expression levels were associated with a poor prognosis. Multivariate analysis identified high ANO5 expression as an independent prognostic factor for 5-year survival in patients with GC (P = 0.0457).

CONCLUSION

ANO5 regulates the cell cycle progression by regulating the expression of cyclin-associated genes and affects the prognosis of patients with GC. These results may provide insights into the role of ANO5 as a key mediator in tumor progression and/or promising prognostic biomarker for GC.

NADPH Oxidase 2 Has a Crucial Role in Cell Cycle Progression of Esophageal Squamous Cell Carcinoma

BACKGROUND

NADPH oxidases (NOXs) are transmembrane proteins that generate reactive oxygen species. Recent studies have reported that NOXs are involved in tumor progression in various cancers. However, the expression and role of NOX2 in esophageal squamous cell carcinoma (ESCC) remain unclear. This study aimed to clarify the pathophysiologic role of NOX2 in patients with ESCC and cell lines.

METHODS

Two human ESCC cell lines (TE5 and KYSE170) were used for NOX2 transfection experiments, and the effects on cell proliferation, cell cycle, cell motility, and cell survival were analyzed. An mRNA microarray analysis was also performed to assess gene expression profiles. Additionally, NOX2 immunohistochemistry was performed on 130 primary ESCC tumor samples to assess the prognostic value of NOX2 in patients with ESCC.

RESULTS

NOX2 depletion significantly inhibited cell proliferation with the G₀/G₁ arrest and resulted in apoptosis in two cell lines. Microarray analysis revealed a strong relationship between NOX2 gene expression and the signaling pathway of cell cycle regulation by the B-cell translocation gene 2 (BTG2) family, including BTG2, CCNE2, E2F1, and CDK2 genes. Immunohistochemical staining revealed that high NOX2 protein expression was significantly associated with deeper tumor invasion and selected as one of the independent prognostic factors associated with the 5-year OS rate in patients with ESCC.

CONCLUSIONS

NOX2 expression in ESCC cells affects tumorigenesis, especially cell cycle progression via the BTG2-related signaling pathway, as well as the prognosis of patients with ESCC. NOX2 may be a novel biomarker and therapeutic target for ESCC.

Microwave for focal therapy of prostate cancer: Non-clinical study and exploratory clinical trial

OBJECTIVE

The objective of this non-clinical study and clinical trial (phase II) was to examine the safety and efficacy of microwave tissue coagulation (MTC) for prostate cancer and assess its use in lesion-targeted focal therapy.

METHODS

In the non-clinical study using Microtaze®-AFM-712 (Alfresa-pharma Corporation) with an MTC-needle, MTC was performed by a transperineal approach to canine prostatic-targeted tissue under real-time ultrasound guidance. Using various MTC-output and irradiation-time combinations, the targeted and surrounding tissues (rectum, bladder, and fat) were examined to confirm the extent of coagulative necrosis or potential cell death, and to compare intra-operative ultrasound and pathology findings. The exploratory clinical trial was conducted to examine the safety and efficacy of MTC. Five selected patients underwent transperineal MTC to clinically single magnetic resonance imaging (MRI)-visible lesions with Gleason score 3+4 or 4+4. Prostate-specific antigen (PSA), MRI, and Expanded Prostate Cancer Index Composite questionnaire findings were compared before and 6 months after surgery.

RESULTS

The region of coagulative necrosis was predictable by monitoring of ultrasonically visible vaporization; thus, by placing the MTC-needle at a certain distance, we were able to perform a safe procedure without adverse events affecting the surrounding organs. Based on the non-clinical study, which used various combinations of both output and irradiation time, MTC with 30-W output for 60-sec irradiation was selected for the prostate. Based on the predictable necrosis, the therapeutic plan (where to place the MTC-needle to achieve complete ablation of the target and how many sessions) was strictly determined per patient. There were no serious adverse events in all patients and only temporary urinary symptoms related to MTC-therapy were observed. Furthermore, satisfaction of having undergone treatment was very high. All pre-operative MRI-visible lesions disappeared, and PSA decreased 55% 6 months after surgery.

CONCLUSION

MTC may be an option for lesion-targeted focal therapy for prostate cancer.

The usefulness of combining the pocket-creation method with a traction device using a scissor-type knife for colorectal endoscopic submucosal dissection

INTRODUCTION

Technical issues and long procedure time still remain a concern in colorectal endoscopic submucosal dissection (ESD). We examined the usefulness of combining the pocket-creation method (PCM) with a traction device (S-O clip; SO) using a scissor-type knife (Clutch Cutter 3.5 mm; CC) for decreasing ESD procedure time.

METHODS

We retrospectively analyzed 95 ESD cases of PCM + SO + CC managed from August 2017 to April 2020 and 103 cases of PCM + CC treated from July 2016 to July 2017. We compared these two groups through propensity score matching. The main outcome was the analysis of the ESD procedure times under various conditions in each group.

RESULTS

After matching, 52 cases in the PCM + SO + CC and PCM + CC groups were analyzed. The PCM + SO + CC group showed a significantly shorter ESD procedure time than the PCM + CC group (57.8 ± 31.4 vs. 81.7 ± 33.5 min, p < 0.01). Additionally, the ESD procedure time was significantly shorter in the PCM + SO + CC group than in the PCM + CC group: tumor size (tumor size < 40 mm: 45.6 ± 15.8 vs. 72.7 ± 22.9 min, p < 0.01; tumor size ≥ 40 mm: 83.1 ± 40.1 vs. 111.8 ± 45.3 min, p = 0.04), tumor location (right side: 64.7 ± 33.3 vs. 81.0 ± 29.7 min, p = 0.03; left side: 50.5 ± 28.0 vs. 82.3 ± 36.9 min, p < 0.01), tumor morphology (polypoid: 39.2 ± 18.6 vs. 74.7 ± 28.6 min, p < 0.01; nonpolypoid: 62.3 ± 32.3 vs. 84.5 ± 35.2 min, p < 0.01), endoscopist (expert: 67.3 ± 41.2 vs. 91.9 ± 40.2 min, p = 0.02; nonexpert: 50.4 ± 18.3 vs. 73.6 ± 24.9 min, p < 0.01), and fibrosis (severe fibrosis: 82.0 ± 20.5 vs. 99.8 ± 40.4 min, p = 0.169; non-severe fibrosis: 52.1 ± 23.8 vs. 75.6 ± 29.0 min, p < 0.01).

CONCLUSIONS

The combination of the PCM and SO using CC achieved a reduction in the colorectal ESD procedure time.

Linked Color Imaging and Blue Laser Imaging for the Diagnosis of Superficial Non-Ampullary Duodenal Epithelial Tumors

BACKGROUND AND OBJECTIVE

This study aimed to evaluate endoscopic findings using linked color imaging (LCI) and blue laser imaging (BLI) and to determine a diagnostic predictor for duodenal adenocarcinomas.

METHODS

All consecutive patients who underwent endoscopic resection for superficial non-ampullary duodenal epithelial tumors (SNADETs) between October 2012 and June 2019 were enrolled in this study. Two highly experienced endoscopists investigated six morphological findings using both white light imaging and LCI and three magnifying endoscopic findings using magnifying BLI (M-BLI).

RESULTS

A total of 90 patients with 110 SNADETs, including 87 adenocarcinomas and 23 adenomas, were analyzed in this study. Among the non-magnifying endoscopic findings, the presence of reddish color, orange color on LCI (orange color sign), lobulation, depression, and marginally white opaque substance were found significantly more frequently in adenocarcinomas than in adenomas (p = 0.015, p < 0.001, p = 0.048, p < 0.001, and p = 0.007, respectively). Among the magnifying endoscopic findings, a mixed microsurface pattern (MSP), irregular MSP, and irregular microvascular pattern were found significantly more frequently in adenocarcinomas than in adenomas (p < 0.001, p < 0.001, and p = 0.002, respectively). In the multivariate analysis of all endoscopic findings associated with adenocarcinoma, orange color sign (odds ratio [OR] 10.46; 95% confidence interval [CI]: 1.42-77.08; p = 0.021), mixed MSP (OR 4.66; 95% CI: 1.02-21.40; p = 0.048), and irregular MSP (OR 13.11; 95% CI: 1.41-121.99; p = 0.024) were independent predictors of adenocarcinoma.

CONCLUSIONS

The presence of orange color sign on LCI and mixed/irregular MSP on M-BLI were independent diagnostic predictors that were frequently observed in duodenal adenocarcinoma.

A Case of Fifteen Simultaneous Rectal Neuroendocrine Tumors and Endocrine Cell Micronests Resected by Both Endoscopic Treatments and Surgery

Case Report

A 65-year-old man without any symptoms received colonoscopy for cancer screening and underwent cold snare polypectomy (CSP) for a 3-mm rectal lesion at a local clinic. A histopathological examination revealed neuroendocrine tumor (NET) G1 with a positive margin. The patient was referred to our hospital for further treatment. Then, the post-CSP scar was removed by endoscopic submucosal dissection (ESD), with a sufficient endoscopically normal margin. Histopathology showed 4 NETs and endocrine cell micronests (ECMs) distant from the post-CSP scar, with a positive lateral margin. We considered that the possibility of other NETs was high. Additional surgery was performed. After a histopathological examination, 11 NETs and ECMs were found in the whole rectum, without lymph node metastasis. The patient had no recurrence at 24 months after surgery. In the past 10 years, we have experienced 4 cases (including the present case) of multiple rectal NETs among 56 cases of rectal NETs of ≤10 mm (7.1%). None of our 4 cases showed any recurrence (follow-up period: 12–32 months).

Conclusions

We herein report a case involving a patient with 15 rectal NETs and ECMs. We reviewed our experience with multiple rectal NETs, and the rate of multiple rectal NETs was 7.1%. Endoscopists should consider that multiple lesions may be present in cases of rectal NET and be aware that some cannot be detected endoscopically.

Recurrence rate and lesions characteristics after cold snare polypectomy of high-grade dysplasia and T1 lesions: A multicenter analysis

BACKGROUND AND AIM

High-grade dysplasia (HGD) and T1 lesions are accidentally resected by cold snare polypectomy (CSP) and the characteristics, and follow-up of them has not been reported. In this study, we analyzed the histopathological findings and recurrence of them.

METHODS

This was a multicenter retrospective-cohort study. We collected HGD and T1 lesions of ≤ 10 mm resected by CSP among 15 520 patients receiving CSP from 2014 to 2019 at nine related institutions, and we extracted only cases receiving definite follow-up colonoscopy after CSP of HGD and T1 lesions. We analyzed these tumor's characteristics and therapeutic results such as R0 resection and local recurrence and risk factors of recurrence.

RESULTS

We collected 103 patients (0.63%) and extracted 80 lesions in 74 patients receiving follow-up colonoscopy for CSP scar. Mean age was 68.4 ± 12.0, and male rate was 68.9% (51/80). The mean tumor size (mm) was 6.6 ± 2.5, and the rate of polypoid morphology and rectum location was 77.5% and 25.0%. The rate of magnified observation was 53.8%. The rates of en bloc resection and R0 resection were 92.5% and 37.5%. The local recurrence rate was 6.3% (5/80, median follow-up period: 24.0 months). The recurrence developed within 3 months after CSP for four out of five recurrent cases. Comparing five recurrent lesions to 75 non-recurrent lesions, a positive horizontal margin was a significant risk factor (60.0% vs 10.7%, P < 0.001).

CONCLUSIONS

High-grade dysplasia and T1 resected by CSP were analyzed, and the local recurrence rate of them was substantially high.

Effects of the combined use of a scissor-type knife and traction clip on endoscopic submucosal dissection of colorectal tumors: a propensity score-matched analysis

Background and study aims  This study evaluated the technical aspects of colorectal endoscopic submucosal dissection (ESD) with the Clutch Cutter (CC) (Fujifilm Co., Tokyo, Japan), a scissor-type knife, and the S-O clip (SO) as a traction clip, and compared the safety and efficacy to ESD using a needle-type knife. Patients and methods  This was a single-center retrospective study. In Study 1, we evaluated 125 ESD patients: 60 using the SO and CC (SO group) and 65 using the CC (CC group). In Study 2, we evaluated 185 ESD patients: the CC group (N = 65) and 120 using the Flush knife BT-S (Flush group) (Fujifilm Co., Tokyo, Japan). In both studies, the clinicopathological features and therapeutic outcomes were compared using a propensity score-matched analysis. Results  In 36 pairs of matched patients in Study 1, the rates of en bloc resection, R0 resection, perforation, and postoperative bleeding (POB) were 97.2 %, 88.9 %, 2.8 %, and 0 %, respectively, for the SO group and 100 %, 91.7 %, 0 %, and 0 % for the CC group (not significant). The mean procedure time for the SO group among less-experienced endoscopists was significantly shorter than in the CC group (42 vs. 65 minutes, P  = 0.036). In 49 pairs of matched patients in Study 2, the rates of en bloc resection, R0 resection, perforation, and POB were 100 %, 95.8 %, 0 %, and 0 %, respectively, for the CC group and 98.0 %, 95.8 %, 0 %, and 2.0 % for the Flush group (not significant). The mean procedure time in the CC group among less-experienced endoscopists was significantly shorter than in the Flush group (52 vs. 67 minutes, P  = 0.038). Conclusions  CC and the combined use of CC and SO reduced colorectal ESD procedure time among less-experienced endoscopists.

Complete one-to-one correspondence between magnifying endoscopic and histopathologic images: the KOTO method II

Recent advances in magnifying endoscopy with narrow-band imaging/blue laser imaging have aided in the diagnosis of gastrointestinal lesions. However, it requires knowledge of the relationship between magnifying endoscopic and histopathological images. We propose a novel method which makes possible a complete correspondence between magnifying endoscopic and histopathological images at the single glandular duct level. The KOTO method II enables three-dimensional visualization of the correlation between the endoscopic surface pattern of the mucosa and histopathological images. This method may be helpful in the development of diagnosis using magnifying endoscopy.

An analysis about the function of a new artificial intelligence, CAD EYE with the lesion recognition and diagnosis for colorectal polyps in clinical practice

OBJECTIVES

Recently, CAD EYE (Fujifilm, Tokyo, Japan), an artificial intelligence for the lesion recognition (CADe) and the optical diagnosis (CADx) of colorectal polyps, was released. We evaluated the function of CADe and CADx of CAD EYE.

METHODS

In this single-center retrospective study, we examined consecutive polyps ≤ 10 mm detected from March to April 2021 to determine whether CAD EYE could recognize them live with both normal- and high-speed observation using white-light imaging (WLI) and linked-color imaging (LCI). We then examined whether the polyps were neoplastic or hyperplastic live with magnified or non-magnified blue-laser imaging (BLI-LASER) or blue-light imaging (BLI-LED) under CAD EYE, comparing the retrospective evaluations with 5 experts and 5 trainees using still images. All polyps were histopathologically examined.

RESULTS

We analyzed 100 polyps (mean size 3.9 ± 2.6 mm; 55 neoplastic and 45 hyperplastic lesions) in 25 patients. Regarding CADe, the respective detection rates of CAD EYE with normal- and high-speed observation were 85.0% and 67.0% for WLI (p = 0.002) and 89.0% and 75.0% for LCI (p = 0.009). Regarding CADx for differentiating neoplastic and hyperplastic lesions, the diagnostic accuracy values of CAD EYE with non-magnified and magnified BLI-LASER/LED were 88.8% and 87.8%. Regarding magnified BLI-LASER/LED, the diagnostic accuracy value of CAD EYE was not significantly different from that of experts (92.0%, p = 0.17), but that of trainees (79.0%, p = 0.04). We also found no significant differences in CADe or CADx between LED (53 lesions) and LASER (47 lesions).

CONCLUSIONS

CAD EYE was a helpful tool for CADe and CADx in clinical practice.

Diagnostic Ability of Magnifying Blue Light Imaging with a Light Emitting Diode Light Source for Early Gastric Cancer: A Prospective Comparative Study

INTRODUCTION

An innovative endoscopic system using 4-color light-emitting diodes (LED) was released between 2016 and 2017 in locations that had not approved laser endoscopes for use, including the United States and Europe.

OBJECTIVE

This study compared the diagnostic efficacy between magnifying blue light imaging with an LED light source (LED-BLI) and magnifying blue laser imaging with a laser light source (Laser-BLI) for early gastric cancer (EGC).

METHODS

In this prospective, single-center, noninferiority study, 80 gastric lesions were evaluated between January 2017 and July 2017. The magnifying findings of gastric lesions - including the demarcation line (DL), microvascular pattern (MVP), and microsurface pattern (MSP) - were evaluated using Laser-BLI and LED-BLI according to the vessel plus surface classification system (VSCS). The primary end point was to determine whether the diagnostic accuracy of LED-BLI for EGC was noninferior to that of conventional Laser-BLI.

RESULTS

Overall, we evaluated 79 gastric lesions histopathologically diagnosed as adenocarcinomas from the specimens obtained via endoscopic submucosal dissection. A DL was observed by Laser-BLI and LED-BLI in 98.7% (78/79) and 96.2% (76/79) of EGCs, respectively. The MVP observed using Laser-BLI and LED-BLI was irregular in 92.4% (73/79) and 89.9% (71/79), respectively. The MSP observed using Laser-BLI and LED-BLI was irregular in 83.5% (66/79) and 82.2% (65/79), respectively. According to the VSCS, diagnosable cancers were found in 94.9% (75/79) and 93.7% (74/79) of cases when using Laser-BLI and LED-BLI, respectively (p = 0.73; difference ratio, 1.2%; 95% CI -8.5 to 6.0%).

CONCLUSIONS

LED-BLI could accurately visualize the DL, MVP, and MSP of EGCs and was not inferior to Laser-BLI. Therefore, LED-BLI can be used to diagnose EGC accurately according to the VSCS-based diagnosis criteria.

Improved Visibility of Early Gastric Cancer after Successful Helicobacter pylori Eradication with Image-Enhanced Endoscopy: A Multi-Institutional Study Using Video Clips

The visibility and diagnostic accuracy of early gastric cancer (EGC) after Helicobacter pylori (HP) eradication have been reported to improve using image-enhanced endoscopy (IEE) compared with white light imaging (WLI). The present study clarified the appropriate IEE for the detection and diagnosis of EGC in clinical settings. This prospective and cross-sectional study evaluated the visibility of EGC and endoscopic findings of gastric mucosa after successful HP eradication (n = 31) using videos with WLI and IEE. Three endoscopists evaluated high-definition videos in a randomized order. The mean visibility scores (MVSs) on linked color imaging (LCI) for atrophic border, intestinal metaplasia, map-like redness, and EGC were the highest among each modality (3.87 ± 0.34, 3.82 ± 0.49, 3.87 ± 0.50, and 3.35 ± 0.92, respectively). The MVSs with blue laser imaging (BLI) were highest for magnifying view of the demarcation line (DL), microsurface pattern (MSP), and microvascular pattern (MVP) for EGC (3.77 ± 0.49, 3.94 ± 0.25, and 3.92 ± 0.34, respectively). LCI had the highest visibility among findings of gastric mucosa and EGC after HP eradication, and BLI had the highest visibility of MVP, MSP, and DL in magnifying observation. These results suggest that LCI observation in the entire stomach and further magnifying BLI are the best methods for detecting and diagnosing EGCs after HP eradication, respectively.

Juxtaglomerular cell tumor diagnosed preoperatively by renal tumor biopsy

INTRODUCTION

Diagnosis of small renal tumor from imaging analysis is limited. We report a case of juxtaglomerular cell tumor diagnosed preoperatively by renal tumor biopsy.

CASE PRESENTATION

A 17-year-old male was urgently hospitalized for acute-onset congestive heart failure. Radiographic findings revealed a 2-cm mass lesion, and on renal biopsy, a juxtaglomerular cell tumor was suspected. The juxtaglomerular cell tumor was resected by laparoscopic partial nephrectomy, on suspicion of causing the heart failure. The patient's clinical symptoms improved drastically postoperatively.

CONCLUSION

Biopsy may be a promising option for preoperative diagnosis of juxtaglomerular cell tumors.

Giant cell tumor of bone - Analysis of 213 cases involving extra-craniofacial bones

We elucidated clinicopathological characteristics of giant cell tumor of bone (GCTB) in Japan, and significant clinicopathological factors for predicting local recurrence. Clinicopathological profiles of 213 patients with GCTB (100 male, 113 female) involving extra‐craniofacial bones were retrieved. Pathological slides obtained at the initial surgery were reviewed. Fourteen pathological and five clinical features were statistically analyzed to disclose prognostic significance. Patient age ranged from 12–80 years (Average 38.7). Long bones were most frequently affected (86.4%), especially around the knee (62.9%). Histological features are basically similar to those previously reported. Within a follow‐up period (24–316 months, average 106.1 months), the local recurrence rate is 29.1%. Metastasis has occurred in 9 patients. Cox regression analysis of representative clinicopathological features shows that younger age, higher mitotic count, smaller zones of stromal hemorrhage, considerable vascular invasion and absence of ischemic necrosis are significant predictors for local recurrence. Initial operative method (curettage) is a significant risk factor in univariate analysis but not by multivariate analysis (P = 0.053). Denosumab administration increases risk but not significantly (P = 0.053). Histone 3.3 G34W immunopositivity is not significant for predicting local recurrence.

Aggressive advanced gastric cancer in a patient with autosomal dominant polycystic kidney disease

A 60-year-old man with autosomal dominant polycystic kidney disease presented with malaise, melena, and epigastric discomfort. Esophagogastroduodenoscopy revealed a massive elevated gastric cancer lesion involving the cardia. Histopathological evaluation of a biopsy specimen showed poorly differentiated adenocarcinoma. Fluorodeoxyglucose-positron emission tomography revealed significant fluorodeoxyglucose uptake in the stomach, liver, bones, and bone marrow. He was diagnosed with metastatic gastric cancer resistant to chemotherapy, and he developed bone marrow carcinomatosis and disseminated intravascular coagulation and died 8 weeks after disease onset. A statistically significant association is reported between autosomal dominant polycystic kidney disease and gastric cancer. Moreover, the specific clinical features observed in our patient could be attributed to the molecular disorders like PC-1 and mechanistic target of rapamycin that are known to occur in autosomal dominant polycystic kidney disease.

Risk of lymph node metastasis after endoscopic treatment for rectal NETs 10 mm or less

PURPOSE

For rectal neuroendocrine tumors (NETs) ≤ 10 mm, endoscopic resection is a standard treatment. However, there is no consensus whether additional surgery should be performed for patients at risk of lymph node metastasis (LNM) after endoscopic resection. The purpose of this study was to analyze the results of endoscopic resection and additional surgery of rectal NETs, thereby clarify the characteristics of cases with LNM.

METHODS

This study was a multicenter retrospective cohort study conducted at 12 Japanese institutions. A total of 132 NETs ≤ 10 mm were analyzed regarding various therapeutic results. A comparative analysis was performed by dividing the cases into two groups that underwent additional surgery or not. Furthermore, the relationship between tumor size and LNM was examined.

RESULTS

The endoscopic treatments were 12 endoscopic mucosal resections (EMR), 58 endoscopic submucosal resections with ligation (ESMR-L), 29 precutting EMRs, and 33 endoscopic submucosal dissections (ESD). The R0 resection rates of EMR were 41.7%, and compared to this rate, other three treatments were 86.2% (p < 0.001), 86.2% (p = 0.005), and 97.0% (p < 0.001), respectively. There were 41 non-curative cases (31.1%), and 13 had undergone additional surgery. Then, LNM was observed in 4 of the 13 patients, with an overall rate of LNM of 3.0% (4/132). The rate of positive lymphatic invasion and the rate of LNM by tumor size ≤ 6 mm and 7-10 mm were 9.7 vs. 15.4% (p = 0.375) and 0 vs. 10.3% (p = 0.007).

CONCLUSIONS

A multicenter study revealed the priority of each endoscopic resection and the low rate of LNM for rectal NETs ≤ 6 mm.

Cold snare polypectomy for large sessile serrated lesions is safe but follow-up is needed: a single-centre retrospective study

Background and Aim

Cold snare polypectomy (CSP) is growing in popularity due to its safety and convenience. Its indication is benign tumours such as adenoma and sessile serrated lesions (SSLs) <10 mm in size. CSP for SSLs ≥10 mm in size has not been well examined. In this study, we aimed the feasibility of this treatment regarding therapeutic results and local recurrence.

Methods

This was a single‐centre retrospective cohort study. We reviewed SSLs with or without dysplasia of 10–20 mm that were resected by CSP from 2014 to 2020. All tumours were diagnosed endoscopically as SSLs without dysplasia before CSP with the help of magnifying narrow band imaging or blue laser imaging. We analysed the lesion characteristics, en bloc resection, histopathological diagnosis, adverse events and local recurrence. We analysed risk factors for recurrence, comparing recurrent lesions to non‐recurrent lesions. We also compared risk factors for lesions 10–14 mm in size to those for lesions 15–20 mm in size.

Results

We analysed 160 lesions in 100 patients (M_age ± SD = 67.7 ± 10.1 years). The polyp size (M ± SD) was 11.8 ± 2.8 mm, and the en bloc resection rate was 60.0% (96 cases). The rates of massive perioperative haemorrhage, postoperative haemorrhage and perforation were 1.3%, 0% and 0%, respectively. Regarding histopathological diagnosis, two (1.2%) cases showed SSLs with high‐grade dysplasia. The recurrence rate in 101 lesions with a median follow‐up period of 18 months (interquartile range 12–24 months) was 5.0%. There were no significant risk factors such as tumour size, location, morphology and so on in terms of recurrence. All recurrent cases could be resected by repeat CSP. The recurrence rates of lesions 10–14 mm in size and 15–20 mm in size were 4.7% and 6.3%, respectively (p = 0.713).

Conclusion

CSP of SSLs ≥10 mm in size according to magnifying endoscopic diagnosis was safe and promising, but the rate of recurrence was slightly high, meaning that close follow‐up is required.

Mycosis fungoides in a patient with ulcerative colitis on anti-tumor necrosis factor-alpha therapy

A 46-year-old man with a history of ulcerative colitis (UC) for over 25 years was treated with infliximab for 7 years. He noticed gradually spreading erythema on his right lower abdomen, femur, and buttocks. Skin biopsy from the right lower abdomen revealed massive invasion of lymphocytes in the papillary dermis and epidermal layer. In conjunction with the findings of immunohistochemistry, the skin lesion was diagnosed as mycosis fungoides (MF) at infiltration stage. Infliximab was discontinued, and narrow-band ultraviolet light B therapy was initiated to treat the skin lesion. The patient achieved remission for MF following treatment and UC has not relapsed for more than 1 year with 5-aminosalicylic acid treatment alone. This is the first case of MF in a UC patient treated with anti-tumor necrosis factor-alpha (anti-TNFα). Lymphoma occurrence is a complication of treatment with anti-TNFα agent or thiopurine. However, there is no evidence regarding the relationship between MF and UC. Hence, these immunomodulatory agents may have triggered the occurrence of MF in this case. When treating UC patients with immunomodulatory agents, the possibility of MF or other types of lymphoma as rare complications must be considered.

Mantle cell lymphoma with EBV-positive Hodgkin and Reed-Sternberg-like cells in a patient after autologous PBSCT: Phenotypically distinct but genetically related tumors

The case of 70-year-old man with mantle cell lymphoma (MCL) carrying t(11;14) translocation that relapsed as nodal lymphoma combining MCL and classic Hodgkin lymphoma (cHL) 9 years after autologous peripheral blood stem cell transplant (auto-PBSCT) is reported. Lymph nodes contained two separate areas of MCL and cHL-like components. Hodgkin and Reed-Sternberg (HRS)-like cells were accompanied by a prominent histiocyte background. HRS-like cells were CD5^- , CD15⁺ , CD20^- , CD30⁺ , PAX5⁺ , Bob.1^- , Oct2^- and EBER⁺ . The MCL component expressed cyclin D1 and SOX11, whereas cyclin D1 and SOX11 expressions were reduced and lost, respectively, in HRS-like cells. Polymerase chain reaction results showed a single clonal rearrangement of the IGH gene in MCL and cHL-like components. CCND1 break apart fluorescence in situ hybridization showed split signals in both MCL and HRS-like cells, suggesting that MCL and cHL-like components were clonally related. Acquisition of p53 expression and Epstein-Barr virus (EBV)-positivity was seen in HRS-like cells. The patient died of disease progression with elevated hepatobiliary enzymes. The autopsy showed both MCL and cHL-like components around the bile ducts, splenic white pulp and bone marrow. The two components were phenotypically distinct, but genetically related, suggesting that transformation of MCL to HRS-like cells during the course of MCL in association with EBV infection.

Efficacy and safety of endoscopic submucosal dissection using a scissors-type knife with prophylactic over-the-scope clip closure for superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND STUDY AIM

This study aimed to assess the safety and feasibility of endoscopic submucosal dissection (ESD) using a scissors-type knife with prophylactic closure using over-the-scope clip (OTSC) for superficial non-ampullary duodenal epithelial tumors (SNADETs).

PATIENTS AND METHODS

Consecutive patients who underwent ESD for SNADETs >10 mm between January 2009 and July 2019 were retrospectively enrolled. We performed ESD using either a needle-type knife (Flush Knife-ESD) or a scissors-type knife (Clutch Cutter-ESD). Mucosal defects were prophylactically closed using three methods: conventional clip, laparoscopic closure, or OTSC.

RESULTS

A total of 84 lesions were resected using the Flush Knife-ESD and the Clutch Cutter-ESD (37 and 47 patients, respectively), and conventional clip, laparoscopic closure, and OTSC for mucosal defect closure after ESD were applied in 13, 13, and 56 lesions, respectively. The R0 resection rate was significantly higher in the Clutch Cutter-ESD than that in the Flush Knife-ESD (97.9% vs 83.8%, respectively, P = 0.040). The intraoperative perforation rate was significantly lower in the Clutch Cutter-ESD than in the Flush Knife-ESD (0% vs 13.5%, respectively, P = 0.014). Complete closure rates of conventional clip, laparoscopic closure, and OTSC were 76.9%, 92.3%, and 98.2%, respectively (P = 0.021); and delayed perforation rates were 15.4%, 7.7%, and 1.8%, respectively (P = 0.092).

CONCLUSIONS

Endoscopic submucosal dissection using a scissors-type knife with prophylactic OTSC closure is safe and feasible for the low-invasive treatment of SNADETs.

Fumarate hydratase-deficient renal cell carcinoma: A clinicopathological study of seven cases including hereditary and sporadic forms

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) has been incorporated into the recent international histological classification of renal tumors. However, to date, there are limited studies describing the clinicopathological features of fumarate hydratase (FH)-deficient RCC, including the hereditary (HLRCC) and sporadic forms. Herein, we present a clinicopathological study of seven cases with FH-deficient RCC. The age of patients ranged from 26 to 70 years with mean and median age of 51.7 and 57 years, respectively. The follow-up data of all patients were available. One patient was alive without the disease and five patients were alive with active disease. One patient died of the disease. Family history of RCC, or skin or uterine smooth muscle tumor within second degree of kinship was present in four of seven patients. Metastasis was observed in all tumors. Metastatic sites included bone, lungs, liver, peritoneum, ovaries, tonsils, or lymph nodes. Grossly, the cut surface of the tumor usually showed light brown, brown, or whitish color. Microscopically, the cytoplasm of the tumor cells was predominantly eosinophilic and all tumors displayed various architectural patterns such as papillary, tubular, solid, or microcystic patterns. Furthermore, two tumors demonstrated a tubulocystic pattern. Sarcomatoid change and rhabdoid features were seen in five tumors and two tumors, respectively. Large cytomegaloviral (CMV) inclusion-like eosinophilic nucleoli surrounded by a clear halo were identified in all tumors. All tumors showed negative immunohistochemical reaction for FH protein. False positive results of TFE3 protein were observed in three tumors. Furthermore, a germline mutation of FH gene was identified in one patient with family history of the disease. In conclusion, FH-deficient RCC includes hereditary and sporadic forms. Grossly, this tumor is solitary and occurs unilaterally. Histologically, the tumor is characterized by various patterns such as papillary, tubular, solid, tubulocystic, or microcystic, has eosinophilic cytoplasm and CMV-like high-grade nuclei. FH-deficient RCCs frequently metastasize to other anatomic sites. TFE immunoreactivity may occur in some FH-deficient RCCs, and immunohistochemistry can accurately diagnose these tumors and mutational analysis of FH gene.

Unexpected tumor-to-tumor metastasis of synovial sarcoma within leiomyoma: A case report and literature review

A tumor metastasis within another tumor is known as tumor-to-tumor metastasis (TTM). We report a 43-year-old woman who presented with hypermenorrhea and an abdominal mass. She had history of a soft tissue tumor on her left ankle at 38 years of age. Laboratory data showed slight elevation of CA125 and no other abnormal findings and magnetic resonance imaging revealed a circumscribed margin mass in the uterine fundus. We diagnosed the mass as benign leiomyoma and performed total laparoscopic hysterectomy. Postoperative pathological examination revealed TTM of synovial sarcoma within the uterine leiomyoma. A database search identified 29 cases of TTM within uterine leiomyoma. The donor tumor was mostly breast cancer (in 23 cases). To the best of our knowledge, this is the first report of a sarcoma TTM to a uterine leiomyoma. Despite the difficulty of preoperative diagnosis, TTM should be considered during the treatment approach for a patient with leiomyoma and a history of malignant tumors.

The efficacy of tumor characterization and tumor detectability of linked color imaging and blue laser imaging with an LED endoscope compared to a LASER endoscope

OBJECTIVES

An endoscope with a light-emitting diode (LED) light source which has a 2-mm close-distance observation function without magnification, has been marketed, enabling linked color imaging (LCI) and blue laser imaging (BLI) for tumor detection and characterization. We analyzed the efficacy of a LED endoscope compared to a LASER endoscope.

METHODS

We retrospectively reviewed 272 lesions observed using the LED endoscopic system (Fujifilm Co., Tokyo, Japan) from May 2018 to September 2019. The Japanese NBI Classification was used for tumor characterization. We analyzed the diagnostic accuracy and confidence level. Sixty-one lesions observed with both the LED and magnified LASER endoscopes were also analyzed to compare the diagnostic accuracy. Regarding the tumor detectability, we calculated color difference values (CDVs) and brightness values (BVs) of white-light imaging, BLI, and LCI modes between the two endoscopes for each tumor.

RESULTS

The mean polyp size was 9.2 ± 11.3 mm. Histology showed 71 sessile serrated lesions, 193 adenoma and high-grade dysplasias, and 8 T1 cancers. The diagnostic accuracy of tumors ≥ 10 and < 10 mm was 72.0% and 92.9% (p < 0.001), respectively and the high confidence rate was 93.8%. The diagnostic accuracy of LED (77.0%) was a little higher than that of LASER without magnification (65.6%, p = 0.16) but was not inferior to that of LASER with magnification (82.0%, p = 0.50). The respective CDVs of LED and LASER endoscopes were 20.6 ± 11.2 and 21.6 ± 11.2 for LCI (p = 0.30), and the respective BVs were 210.0 ± 24.2 and 175.9 ± 21.1 (p < 0.001).

CONCLUSIONS

A LED endoscope with close-distance observation improved tumor detection and characterization due to high brightness.

Efficacy of scissor-type knives for endoscopic mucosal dissection of superficial gastrointestinal neoplasms

Endoscopic submucosal dissection (ESD) for superficial gastrointestinal neoplasms has become widespread. However, certain aspects of the procedure remain difficult to manage, such as intraoperative bleeding and perforation. There are two kinds of scissor-type knife: the Clutch Cutter (Fujifilm Co., Tokyo, Japan) and the SB knife (Sumitomo Bakelite Co., Tokyo, Japan). These knives have different features from other types of ESD knives and enable the performance of all ESD procedures, including mucosal incision, submucosal dissection, and hemostasis. The standard approach with scissor-type knives involves first grabbing the tissue and then incising or dissecting it. Theoretically, perforation as a result of unintentional movement should never happen with scissor-type knives compared to needle- or blade-type knives, which may induce perforation through unintentional movement. Moreover, the rates of severe bleeding and self-completion of ESD with scissor-type knives by non-experts were reported to be significantly better than for other knives. Thus, scissor-type knives can resolve these problems and help to further standardize ESD globally. In this review, we summarize reports on the efficacy of such scissor-type knives for ESD of gastrointestinal tumors. We also present the pocket-creation method and the application of traction devices, such as dental floss and S-O clips (Zeon Medical Co., Tokyo, Japan) for improving the performance of ESD with a Clutch Cutter.

High Enhancement Settings for White Light Observation Improves Colorectal Polyp Visibility in Color Difference Value and an Endoscopist's Visibility

BACKGROUND/AIMS

Settings of structure and color enhancement (CE) change view of white light imaging and a preset low enhancement setting is used regularly. The aim of this study was to investigate whether higher enhancement settings increased colorectal lesions' visibility with endoscopists' visibility scoring and objective color difference (CD) value.

METHODS

From April 2015 to September 2015, we analyzed 27 pictures and 100 videos of colorectal lesions. Combinations of structure enhancement (B3, A3, A5) and CE (CE 0, 1, 3) were evaluated and CD values of 2 corresponding modes (high enhancement: A5 + CE3, preset low enhancement: A3 + CE0) were calculated using marketed software. In the video, these 2 modes were evaluated. All pictures and movies were graded by 4 endoscopists using visibility scores: score 4 (excellent) to score 1 (poor).

RESULTS

The scores of A3 + CE0 (2.74 ± 1.09) were significantly lower than those of all other higher enhancement settings such as B3 + CE1 (3.11 ± 1.08), A3 + CE1 (3.33 ± 0.91), and A5 + CE3 (3.56 ± 0.74; p < 0.001). The CD value of A5 + CE3 was significantly higher than A3 + CE0 (20.2 ± 6.9 vs. 12.9 ± 5.6, p < 0.001). In the video, the scores for A5 + CE3 were significantly higher than A3 + CE0 (3.27 ± 0.83 vs. 2.53 ± 1.05, p < 0.001).

CONCLUSIONS

Higher enhancement settings increased visibility of colorectal lesions.

Efficacy of precutting endoscopic mucosal resection with full or partial circumferential incision using a snare tip for difficult colorectal lesions

BACKGROUND

We analyzed the efficacy of precutting endoscopic mucosal resection (EMR), which is a method of making a full or partial circumferential mucosal incision around a tumor with a snare tip for en bloc resection.

METHODS

We reviewed cases from 2011 to 2018 in which precutting EMR (n = 167) and standard EMR (n = 557) were performed for lesions of 10 - 30 mm. Precutting EMR was indicated for benign lesions of 20 - 30 mm or lesions of < 20 mm for which standard EMR was difficult. Through propensity score matching of the two groups, the therapeutic outcomes for 35 lesions of ≥ 20 mm and 98 lesions of < 20 mm in each group were analyzed.

RESULTS

In the two sizes of lesion, there were significant differences between the precutting and standard groups in the en bloc resection rate (≥ 20 mm 88.6 % vs. 48.5 %, P < 0.001; < 20 mm 98.0 % vs. 85.7 %, P = 0.004) and the histological complete resection rate (≥ 20 mm 71.4 % vs. 42.9 %, P = 0.02; < 20 mm 87.8 % vs. 67.3 %, P < 0.001).

CONCLUSION

Precutting EMR enabled high en bloc resection rates in cases involving difficult lesions.

Blue Laser Imaging, Blue Light Imaging, and Linked Color Imaging for the Detection and Characterization of Colorectal Tumors

A laser endoscopy system was developed in 2012. The system allows blue laser imaging (BLI), BLI-bright, and linked color imaging (LCI) to be performed as modes of narrow-band light observation; these modes have been reported to be useful for tumor detection and characterization. Furthermore, an innovative endoscopy system using four-light emitting diode (LED) multilight technology was released in 2016 to 2017 in some areas in which laser endoscopes have not been approved for use, including the United States and Europe. This system enables blue light imaging (this is also known as BLI) and LCI with an LED light source instead of a laser light source. Several reports have shown that these modes have improved tumor detection. In this paper, we review the efficacy of BLI and LCI with laser and LED endoscopes in tumor detection and characterization.

An Additional 30-s Observation of the Right-Sided Colon with Narrow Band Imaging Decreases Missed Polyps: A Pilot Study

INTRODUCTION

Previous narrow-band imaging (NBI) was dark and reported not to be useful for polyp detection. In this study, we analyzed the efficacy of an additional 30-s observation of the right-sided colon with the recent bright high-resolution NBI.

METHODS

We enrolled patients undergoing colonoscopy from February 2015 to May 2017 in two institutions. All procedures were performed with the latest system (EVIS LUCERA ELITE, Olympus). The cecum and ascending colon were first observed with white light imaging (WLI) in both the NBI and WLI group. Then, the colonoscope was re-inserted, and the cecum and ascending colon were observed for an additional 30 s. In this second observation, NBI was performed for the first 130 patients in the NBI group and WLI for the next 130 in the WLI group. The number of adenoma and sessile serrated polyps (ASPs) in the second observation were examined in both groups. According to our initial pilot study, the sample size was estimated at 126.

RESULTS

In the first observation, the number of ASPs was 72 in the NBI group and 72 in the WLI group (p = 1.0). In the second observation, the number of ASPs was 23 in the NBI group and 10 in the WLI group (p = 0.02). The polyp and adenoma detection rates in the second observation were 16.2% and 12.3% in the NBI group and 7.7% (p = 0.03) and 6.2% (p = 0.09) in the WLI group.

CONCLUSIONS

The additional 30-s observation with recent NBI decreased missed polyps in the right-sided colon.

A resected case of gallbladder metastasis with symptoms of acute cholecystitis in multiple metastatic ductal carcinoma of the breast

Gallbladder metastasis from breast cancer, especially from ductal carcinoma, is rare. Herein, we report a rare case of gallbladder metastasis from ductal carcinoma of the breast that was diagnosed after laparoscopic cholecystectomy (LC) for acute cholecystitis. A 78-year-old woman presented with right upper abdominal tenderness and positive Murphy's sign during chemotherapy for advanced multiple metastases of the breast cancer. Abdominal ultrasonography and computed tomography showed a slightly thickened gallbladder wall and two calculi. After a diagnosis of acute calculous cholecystitis was established, LC was performed. Pathological examination revealed poorly differentiated adenocarcinoma infiltrating the submucosal and subserosal layer over the entire gallbladder, and a lymph node metastasis in the gallbladder neck. Immunohistochemical examination revealed that the tumor cells tested positive for estrogen receptor and negative for progesterone receptor, which was consistent with primary breast cancer. The patient was uneventfully discharged without abdominal pain 7 days later. Although she subsequently underwent several chemotherapies, she died 16 months later. In conclusion, gallbladder metastasis should be considered in patients with multiple metastatic breast cancer who present with signs or symptoms of cholecystitis. Moreover, LC should be considered to relieve the symptoms of cholecystitis for improved prognosis, even in a patient with multiple metastases.

High-grade PanIN presenting with localised stricture of the main pancreatic duct: A clinicopathological and molecular study of 10 cases suggests a clue for the early detection of pancreatic cancer

AIMS

This study aimed to identify the pathological features of high-grade PanIN that presents with imaging-detectable abnormalities.

METHODS AND RESULTS

Ten cases of isolated, main-duct, high-grade PanIN as the primary clinical presentation were identified. All patients presented with stenosis of the main pancreatic duct, with two being associated with extensive upstream duct dilatation (>5 mm in diameter). Pancreatic juice cytology suggested adenocarcinoma in all seven cases examined. In resected specimens, high-grade PanIN was present chiefly in the main pancreatic duct, with longitudinal extension ranging between 3 and 40 mm in length (median = 18 mm). In four cases, in which hypoechoic or hypovascular masses were observed on imaging, radiopathology correlations suggested that they represented parenchymal atrophy and subsequent fibrosis around affected ducts, but not invasive malignancy. On immunohistochemistry, the loss of p16 expression was found in five (50%), p53 overexpression in two (20%) and loss of SMAD4 expression in none (0%). KRAS mutations were detected in nine cases, with two dominant clones being found in three by ultrasensitive droplet digital polymerase chain reaction, suggesting the genetic heterogeneity of dysplastic cells composing individual lesions. Mutant GNAS was also observed in one case.

CONCLUSIONS

Isolated high-grade PanIN may present with pancreatic duct stenosis. Therefore, intensive investigations including pancreatic juice cytology will be required for patients with unexplained pancreatic duct stenosis. The abnormal expression of p53 and SMAD4 is infrequent, while GNAS may be mutated in premalignant lesions mainly affecting the main pancreatic duct, similar to KRAS.

Rapid Bactericidal Action of Propolis against Porphyromonas gingivalis

Propolis, a resinous substance produced by bees, is used as a folk medicine for treatment of periodontal diseases. However, its mode of the action and the compounds responsible for its activities remain obscure. In the present study, we comprehensively investigated the antibacterial activities of ethanol-extracted propolis (EEP) and EEP-derived compounds toward Porphyromonas gingivalis, a keystone pathogen for periodontal diseases. Broth microdilution and agar dilution assays were used to determine the minimum inhibitory concentrations of EEP against a range of oral bacterial species, of which P. gingivalis showed a higher level of sensitivity than oral commensals such as streptococci. Its antibacterial activity toward P. gingivalis was maintained even after extensive heat treatment, demonstrating a high level of thermostability. EEP also induced death of P. gingivalis cells by increasing membrane permeability within 30 min. Spatiotemporal analysis based on high-speed atomic force microscopy revealed that EEP immediately triggered development of aberrant membrane blebs, followed by bleb fusion events on the bacterial surface. Furthermore, we isolated artepillin C, baccharin, and ursolic acid from EEP as antibacterial compounds against P. gingivalis. Of those, artepillin C and baccharin showed bacteriostatic activities with membrane blebbing, while ursolic acid showed bactericidal activity with membrane rupture. In particular, ursolic acid demonstrated a greater ability to affect bacterial membrane potential with increased membrane permeability, probably because of its highly lipophilic nature as compared with other compounds. Taken together, these findings provide mechanistic insight into the antibacterial activities of EEP and its exquisite membrane-targeting antibacterial compounds and imply the applicability of narrow-spectrum therapeutics with EEP for treatment of periodontitis. In addition, the advanced technology utilized in the present study to visualize the nanometer-scale dynamics of microorganisms will contribute to expanding our understanding of the activities of antimicrobials and the mechanism of drug resistance in bacteria.