[Significance of upper and lower gastrointestinal endoscopy for screening small intestinal lesions in non-Hodgkin's lymphoma]

The gastrointestinal tract is a common site for the occurrence of non-Hodgkin's lymphoma (NHL). NHL with gastrointestinal lesions may lead to clinically relevant intestinal complications such as obstruction, perforation, and exsanguination during the course of the disease. Consequently, patients with NHL are often examined by means of upper and lower gastrointestinal endoscopy at the initial visit. There are no clear guidelines regarding which patients should undergo capsule endoscopy (CE) and balloon enteroscopy for detecting small intestinal lesions. We retrospectively examined the feasibility of detecting small intestinal lesions in NHL using upper and lower gastrointestinal endoscopy. Between January 2007 and October 2015, 198 patients with primary NHL were admitted to our hospital. We collected data from 51 patients with NHL with gastrointestinal lesions diagnosed through upper and lower gastrointestinal endoscopy, CE, or double balloon enteroscopy (DBE). We chosed these cases that gastrointestinal lesions was doubted by an examination for image. Nineteen of these patients presented with lymphoma at the duodenal bulb/descending part when examined by upper gastrointestinal endoscopy and at the distal ileum when examined by lower gastrointestinal endoscopy. Ectopic jejunoileal lymphoma was simultaneously detected in 13 of the 19 patients (68.4%) through the use of CE or DBE. Conversely, of the 32 patients who did not exhibit lesions at the duodenal bulb/descending part or at the distal ileum, 6 patients (18.8%) presented with small intestinal lesions, indicating a smaller percentage compared to the patients with ectopic jejunoileal lymphoma. Based on these findings, a proactive search for small intestinal lesions using CE or DBE is recommended in patients with NHL presenting with lymphoma at the duodenal bulb/descending part or at the distal ileum, as examined using both upper and lower gastrointestinal endoscopy during the initial visit.

Intrahepatic Cholangiolocellular and Cholangiocellular Carcinoma - Differences in the 18F-FDG PET/CT Findings

Cholangiolocellular carcinoma is a minor primary cancerous tumor of the liver and its coexistence with intrahepatic cholangiocarcinoma in the liver is rare. We herein report a case of concurrent cholangiolocellular carcinoma and intrahepatic cholangiocarcinoma in the liver, in addition to a rectal G1 neuroendocrine tumor, a so-called carcinoid. The intrahepatic tumors showed a different uptake in the ¹⁸F-fluoro-2-deoxyglucose (FDG) positron-emission tomography (PET)/computed tomography (CT) findings. In addition to conventional dynamic contrast-enhanced CT, we concluded that FDG PET/CT could therefore be a helpful modality to identify the properties of both cholangiolocellular carcinoma and intrahepatic cholangiocarcinoma.

[Cardiac Diffuse Large B-Cell Lymphoma Presenting with Acute Heart Failure Due to Cardiac Tamponade]

A 75-year-old man was admitted to our hospital in May 2016 with progressive shortness of breath. We considered him to be experiencing acute heart failure caused by atrial fibrillation. Contrast-enhanced computed tomography showed a hypodense mass involving the right atrium and left ventricle, pericardial effusion, and lymphadenopathy of the groin. Histological finding from the groin and pericardial effusion analysis showed diffuse large B-cell lymphoma(DLBCL). We thus diagnosed this patient with cardiac tamponade owing to the involvement of the heart by DLBCL. Treatment was initiated with tetrahy- dropyranyldoxorubicin/cyclophosphamide/vincristine/prednisolone(THP-COP)therapy(50% dose)and continuous pericardial drainage. We carefully added rituximab 4 days after monitoring his symptoms and vital signs. There were a few adverse effects, and after treatment, the mass and pericardial effusion disappeared. Subsequently, 8 courses of THP-COP therapy accompanied by rituximab(R-THP-COP)(full dose)were administered, resulting in a complete response.

Progression process and safety assessment adaptation of endometrial lesions in ENU-induced 2-stage uterine carcinogenicity in a Tg-rasH2 mouse model

Although acotiamide hydrochloride hydrate (acotiamide-HH) has not been reported to have genotoxic findings in any of the genotoxicity studies or treatment-related toxicological findings in reproductive and developmental studies, suspicious uterine tumorigenesis was observed in the results of a long-term rat carcinogenicity study. To clarify the uterine tumorigenesis of acotiamide-HH, we performed a 2-stage uterine carcinogenicity model in the transgenic rasH2 mouse initiated by N-Ethyl-N-nitrosourea (ENU). This model facilitated the short-term detection of uterine carcinogenic potential, and it appears to be a very useful testing method for assessing the safety of chemicals that may affect uterine tumorigenesis. However, there have not been many reports on this model, and accumulation of case studies using this model is recommended to support its usability. In this study, we performed this carcinogenesis model to not only confirm uterine tumorigenesis of acotiamide-HH but also to confirm the reliability of the model. The results of this study revealed that the endometrial adenocarcinoma found in the long-term rat carcinogenicity study possibly arose spontaneously. Also, we confirmed early induction of a uterine tumor as in previous reports and confirmed that 26 weeks is the appropriate treatment period for this rasH2 mouse model according to time-course observations of uterine tumor development.

[Effective BiRd Therapy after the Addition of Clarithromycin for Lenalidomide and Dexamethasone Resistant Multiple Myeloma Ineligible for Stem Cell Transplantation]

BiRd combination therapy, which comprises clarithromycin(CAM: Biaxin®), lenalidomide(LEN: Revlimid®), and dexamethasone( DEX), is a highly effective treatment for newly diagnosed symptomatic multiple myeloma(MM). However, its efficacy against recurrent myeloma refractory to LEN and DEX combination therapy(Rd therapy)remains unclear. In this study, we retrospectively analyzed the data of 7 patients(4 men and 3 women, median age of 76 years)with MM, who had clarithromycin added to their Rd regimen. In all patients, the starting dose of clarithromycin was 400 mg daily and the median number of prior therapies was 3(range, 1-4). Patients received a median of 9 cycles of Rd(range, 6-27 cycles)for a median duration of 8 months. Then, patients received a median of 14 cycles of BiRd(range 2-36 cycles). One patient showed partial response(PR), which was the best response, while the others showed stable disease(SD). Our results demonstrated that the addition of clarithromycin to Rd could overcome resistance to Rd and lead to durable responses, without exacerbating hematological or non-hematological toxicities. Thus, BiRd therapy may represent a therapeutic option for symptomatic MM resist- ant to Rd therapy.

A nationwide, cross-sectional survey on unusual sleep postures and sleep-disordered breathing-related symptoms in people with Down syndrome

BACKGROUND

People with Down syndrome (DS) often have sleep-disordered breathing (SDB). Unusual sleep postures, such as leaning forward and sitting, are observed in people with DS. This study aimed to clarify the prevalence of unusual sleep postures and their relationships with SDB-related symptoms (SDB-RSs), such as snoring, witnessed apnoea, nocturnal awakening and excessive daytime sleepiness.

METHODS

A questionnaire, including demographic characteristics and the presence of unusual sleep postures, as well as SDB-RSs, was completed by 1149 parents of people with DS from Japan.

RESULTS

Unusual sleep postures were recorded in 483 (42.0%) people with DS. These participants were significantly younger and had a history of low muscle tone more frequently than people without unusual sleep postures. In all ages, the leaning forward posture was more frequent than sitting. People with DS with unusual sleep postures suffered from SDB-RSs. Those who slept in the sitting posture had more frequent SDB-RSs than did those who slept with the leaning forward posture. Snoring, witnessed apnoea and nocturnal awakening were observed in 73.6, 27.2 and 58.2% of participants, respectively. Snoring increased with aging. Witnessed apnoea was more common in males and in those with hypothyroidism than in females and in those without hypothyroidism.

CONCLUSIONS

Our study shows that there is a close relationship between unusual sleep postures and SDB-RSs. We recommend that all people with DS with unusual sleep postures should be checked for the presence of SDB.

Spontaneous regression of methotrexate-related diffuse large B-cell lymphoma following bladder lesion resection

A 71-year-old woman who had been treated with methotrexate (MTX) and prednisolone for rheumatoid arthritis since 2010 presented with hematuria. Cystitis was diagnosed. Chest and abdominal CT images revealed a bladder tumor, with lung and bilateral adrenal metastases. Transurethral resection of the bladder tumor (TUR-BT) confirmed these findings in September 2014. Histological findings of the bladder included large atypical lymphoid cells indicating diffuse large B-cell lymphoma. After TUR-BT, CT imaging showed that the tumor had shrunk. Still, MTX was continued. She was diagnosed with MTX-related lymphoproliferative disorders in November 2014 and MTX was discontinued. Fluorodeoxyglucose-positron emission tomography on March 2015 showed a complete response.

[Thrombotic microangiopathy due to malignant hypertension complicated with late-onset bleeding after renal biopsy]

A 47-year-old man presented at a local ophthalmological hospital with blurred vision. He had been diagnosed with hypertensive retinopathy and renal failure and was referred to our hospital for treatment. A renal biopsy was done to evaluate pathology of high proteinuria, hematuria, and rapidly progressive glomerulonephritis. Blood pressure remained high despite antihypertensive therapy; anemia and thrombocytopenia gradually progressed. Thrombotic microangiopathy (TMA) was suspected based on red blood cell fragmentation due to hemolytic anemia, thrombocytopenia, and renal failure. However, plasma exchange resolved neither thrombocytopenia nor renal failure, and anemia gradually progressed. Backache suddenly developed 13 days later, and CT findings indicated a retroperitoneal hematoma secondary to bleeding from the kidney. Selective renal artery embolization via angiography stopped the bleeding, but the patient went into hemorrhagic shock. Pathological findings on renal biopsy were identical to those in malignant hypertension, namely an edematous membrane lining, thickened arterioles, and stenosis. We diagnosed thrombotic microangiopathy due to malignant hypertension, without decrease in activities of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motif) or its antibodies. Renal failure did not improve, and continuous hemodiafiltration was needed. This procedure stabilized blood pressure and improved the TMA.