An Endoscopic Biopsy Specimen Contains Adequate Lymphocytes for Flow Cytometric Analysis of Light Chain Expression in the Gastrointestinal Mucosa

OBJECTIVE

Flow cytometry has not been widely used in routine clinical practice for the diagnosis of gastrointestinal lymphoma; this is mainly because of the absence of an appropriate protocol. Here, we established a protocol for flow cytometric analysis of a single biopsy specimen from the gastrointestinal mucosa and investigated its sensitivity and specificity.

DESIGN

In this prospective study, we enrolled patients with previously diagnosed gastrointestinal lymphoma and patients with gastrointestinal lesions that were suspected to be lymphoma.

RESULTS

Overall, 15 patients with gastric extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (N=8), duodenal follicular lymphoma (grade 1; N=5), and benign lymphoid hyperplasia (ileum, N=1, and rectum, N=1) were included in this study. Of these, lymphocytes were isolated from 14 patients (93.3%). There were 200,000-1,500,000 viable cells per patient. Biopsy specimens from 10 out of the 12 patients with lymphoma were positive for light chain restriction; the two patients with benign lymphoid hyperplasia showed negative results.

CONCLUSIONS

An adequate number of lymphocytes for flow cytometry could be isolated from a single specimen of endoscopic mucosal biopsy from 93.3% of the patients. Overall, the sensitivity of flow cytometric analysis of light chain expression for the diagnosis of B-cell lymphoma was 83.3%, and the specificity was 100%. Although further investigation is required as the sample size of the present study was small, our study suggests a potential option for diagnosing B-cell lymphoma in the gastrointestinal mucosa.

Small early gastric cancer with synchronous bone metastasis: A case report

Bone metastasis during the early stages of gastric cancer is rare, and synchronous bone metastasis is even less common. The present report outlines a case of a small early gastric cancer, which was detected due to bone metastasis. A 63-year-old man was referred to Fukuyama Medical Center with back pain and anorexia of 2 weeks' evolution. MRI revealed multiple metastatic lesions in the thoracic and spinal bone. Fluorodeoxyglucose positron emission tomography revealed focal uptake in the lesser curvature of the stomach and in the spinal bone, pelvic and thigh bone, but uptake was not detected in the stomach. Esophagogastroduodenoscopy revealed a 10 mm slightly elevated lesion with a central depression in the middle-third of the stomach. Endoscopic ultrasonography confirmed that the tumor was confined to the mucosa. A biopsy specimen acquired from the gastric lesion indicated signet-ring cell carcinoma, and the specimen acquired from the lumbar spine revealed cell aggregation such as that found in signet-ring cell carcinoma. The patient received first-line chemotherapy with S-1 and cisplatin, and second-line chemotherapy with nab-paclitaxel. However, the patient died 120 days after consultation at Fukuyama Medical Center.

Feasibility of flow cytometric analysis of restricted light chain in endoscopic biopsy specimens from patients with gastrointestinal tract B cell lymphoma: a pilot study

OBJECTIVE

Gastrointestinal tract lymphomas are currently detected more frequently due to advances in endoscopic technology. The aim of this study was to assess the feasibility of flow cytometric analysis of restricted light chain in endoscopic biopsy specimens for the diagnosis of gastrointestinal tract B-cell lymphoma. We prepared viable cell suspensions from unfixed specimens obtained from 10 consecutive patients who had a previous histological diagnosis of gastrointestinal tract B-cell lymphoma. We performed immunophenotypic studies with multi-color flow cytometry and assessed clonality through examination of immunoglobulin light chain expression exclusively in a population identified by anti-CD45 or CD20 antibodies.

RESULTS

We could perform light chain expression analysis with 2 endoscopic biopsy specimens from all 10 patients with gastrointestinal tract B-cell lymphoma. We conclude that flow cytometric analysis of endoscopic biopsy specimens is feasible and thus likely useful for the diagnosis of gastrointestinal tract B-cell lymphoma in clinical settings. Trial registration UMIN Clinical Trials Registry, UMIN000027730. Registered 12 June 2017.

The clinicopathological differences of sporadic non-ampullary duodenal epithelial neoplasm depending on tumor location

BACKGROUND AND AIM

Although sporadic non-ampullary duodenal adenoma is speculated to be precancerous lesion, the relationship between adenoma and carcinoma remains unclear due to their rarity. Previous studies on sporadic non-ampullary duodenal epithelial neoplasm (SNADEN) have mainly targeted superficial tumors, like adenoma and early carcinoma. The clinicopathological features, including those of advanced carcinoma, remain poorly investigated. We assessed the clinicopathological features of SNADEN, including advanced carcinoma, focusing on tumor location.

METHODS

We retrospectively collected the data of 410 patients who had been clinically and pathologically diagnosed with SNADEN at 11 institutions in Japan between June 2002 and March 2014.

RESULTS

The SNADEN was mucosal neoplasia and invasive carcinoma in 321 (78.3%) and 89 (21.7%) patients, respectively. The proportion of invasive carcinomas in SNADEN was significantly higher on the oral side of the papilla of Vater (oral-Vater) than on the anal side (anal-Vater) (27.9% vs 14.4%, P < 0.001). Undifferentiated-type carcinoma was significantly more frequent with oral-Vater than anal-Vater (38.7% vs 14.8%, P = 0.026). The recurrence rate of surgically R0 resected locally advanced carcinomas was significantly higher with oral-Vater than anal-Vater (46.4% vs 8.3%, P = 0.021). Furthermore, the relapse-free survival with oral-Vater was significantly shorter than with anal-Vater (hazard ratio: 2.35; 95% confidence interval: 1.09-5.50; P = 0.028).

CONCLUSIONS

The clinicopathological features of SNADEN on oral-Vater were different from those on anal-Vater. SNADEN on oral-Vater was more likely to be invasive carcinomas and might behave more aggressively due to biologically higher malignancy than that on anal-Vater.

Hemorrhagic Stress-induced Gastric Ulcer in a Healthy Toddler

A 1-year-old female toddler who was under a great amount of psychological stress presented with acute hematemesis. She had no significant medical history; she displayed lethargy and was anemic. Although blood transfusion and famotidine were administered for upper gastrointestinal bleeding (UGIB), the anemia did not improve. Thus, early endoscopy was performed under general anesthesia, revealing a gastric ulcer with exposed vessels in the supra-angular region. Cauterization via bipolar hemostatic forceps was performed on the exposed vessels, and the bleeding was controlled successfully. We diagnosed the patient with hemorrhagic stress-induced gastric ulcer due to psychological stress. Three months later, endoscopy revealed that the gastric ulcer had healed.

Large Bowel Progressive Stricture after Infliximab Therapy for Crohn's Disease

This case report refers to a 31-year-old patient with an 11-year history of Crohn's disease. The patient presented with an edematous elevated lesion in the splenic flexure. Two histological analyses revealed no signs of obvious dysplasia, and the patient subsequently began infliximab treatment. Nine months later, a worsening of the stricture of the edematous elevated lesion was observed in the splenic flexure, and transverse colonic resection was performed. A histological investigation of the lesion in the splenic flexure revealed advanced adenocarcinoma. Six months after the surgery, computed tomography revealed recurrent carcinoma and peritoneal metastases. The patient was administered palliative chemotherapy.

Mantle Cell Lymphoma with a Single Protruding Lesion as the Cause of Intussusception

Mantle cell lymphoma (MCL) is a malignant lymphoma of the gastrointestinal tract that mostly presents as multiple lymphomatous polyposis (MLP); however, MLP with intussusception is rarely reported in MCL. Furthermore, a single protruding lesion with intussusception has never been reported in primary small intestinal MCL. A 70-year-old man presented with pain in the right lower abdomen. Computed tomography and colonoscopy revealed ileocecal intussusception. Ileocecal resection was performed. Histology and immunohistochemistry of the resected specimen showed MCL with a single protruding lesion. The patient was successfully treated with surgery alone and remains in complete remission at the three-year follow-up.

The Diagnosis of Gastric Mucosa-associated Lymphoid Tissue Lymphoma by Flow Cytometry and Fluorescence in situ Hybridization of Biopsy Specimens

Mucosa-associated lymphoid tissue (MALT) lymphoma and reactive inflammatory lymphoid changes are frequently difficult to distinguish based on a routine histological differential diagnosis. We were unable to diagnose gastric MALT lymphoma histologically using specimens obtained by endoscopy, although a flow cytometry (FCM) analysis demonstrated clonality of neoplastic cells by separating cells by CD45 gating. Furthermore, a fluorescence in situ hybridization (FISH) analysis showed trisomy 18. We therefore diagnosed gastric MALT lymphoma with trisomy 18. We recommend that FCM and FISH analyses of biopsy specimens be considered for diagnosing gastric MALT lymphoma if this diagnosis is suspected based on endoscopic findings.

A case of serous cystic neoplasm with form changes on an image obtained during long-term follow-up

A 45-year-old man presented with a 24-mm macrocystic lesion at the pancreatic head, which was detected by computed tomography (CT). During six years of follow-up, CT, MRI, and endosonographic images of the cystic lesion showed that the cystic lesion had enlarged to 42mm, with the appearance of a thick cyst wall. Since a cystic tumor could not be ruled out, surgery was performed. Pathological examination of the resected specimen revealed microcystic-type serous cystadenoma of the pancreas, with the presence of internal bleeding in the cyst and hemorrhage and thick fibrous tissue in the cyst wall. We could observe a serous cystic neoplasm with prismatic form changes on an image obtained during long-term follow-up. Thus, we considered this case to be useful for investigating the natural history of serous cystic neoplasm of the pancreas.

Two cases of unresectable advanced HER2-positive gastric cancer perforation during chemotherapy with trastuzumab

Case 1 was a 70-year-old man, and case 2 was a 65-year-old woman. Both were diagnosed with type 2 advanced HER2-positive gastric cancer. Capecitabine, cisplatin, and trastuzumab (HXP therapy) were administered to both patients. However, both patients developed peritonitis caused by gastric cancer perforation during HXP therapy on day 38 for case 1 and day 8 for case 2. Emergency omentum filling and gastric segmental resection were performed for both patients. The same chemotherapy regimen was continued after the surgery, and partial response was observed in both patients. Because most advanced HER2-positive gastric cancers are ulcers, we should always consider the risk of gastric cancer perforation while administering HXP therapy, which has a high cytoreductive effect. Good convalescence can be expected by continuing chemotherapy after emergency surgery due to gastric cancer perforation.

Optimal dose of ramosetron in female patients with irritable bowel syndrome with diarrhea: A randomized, placebo-controlled phase II study

BACKGROUND

Previous studies showed that 5 μg of ramosetron, a serotonin (5-hydroxytryptamine: 5-HT)-3 receptor antagonist, is only effective in male patients with irritable bowel syndrome (IBS) with diarrhea (IBS-D). We hypothesized that either dose 1.25, 2.5, or 5 μg of ramosetron would be effective in female patients with IBS-D.

METHODS

This randomized, double-blind, placebo-controlled, phase II dose-finding exploratory trial included 409 female outpatients with IBS-D treated in Japan. They were administered oral placebo (n=102), or 1.25 μg (n=104), 2.5 μg (n=104), or 5 μg (n=99) of ramosetron once daily for 12 weeks after a 1-week baseline period. The primary endpoint was monthly responder rates of global improvement of IBS symptoms in the first month. Secondary endpoints included global improvement in the other months, abdominal pain/discomfort, weekly mean changes in the Bristol Stool Form Scale (BSFS), and IBS-QOL.

KEY RESULTS

Middle dose (2.5 μg) of ramosetron significantly improved abdominal pain/discomfort at second month (62.5%, P=.002), third month (60.6%, P=.005), and the last evaluation point (63.5%, P=.002) and weekly BSFS (P<.05) except at Week 8, 11, and 12 than placebo. IBS-QOL did not change. Ramosetron induced more constipation than placebo.

CONCLUSIONS & INFERENCES

The trial suggested that 2.5 μg of ramosetron is the most effective and least harmful option for treating female patients with IBS-D (Clinicaltrials.gov ID: NCT01274000).

Clinical characteristics and associated factors of Japanese patients with adenocarcinoma of the esophagogastric junction: a multicenter clinicoepidemiological study

Gastroesophageal reflux disease-related diseases, such as Barrett's esophagus and adenocarcinoma of the esophagogastric junction (AEGJ), are believed to occur less frequently in Asia than in Western countries. However, the number of reported cases is increasing, yet little is known regarding the epidemiology of AEGJ in Japan. The primary study aim is to investigate the clinicoepidemiological characteristics of AEGJ. The secondary aim is to identify factors associated with it. In the 6.5 years between January 2008 and June 2014, we reviewed 88,199 esophagogastroduodenoscopy (EGD) reports and associated medical records (Study 1). We conducted a case-control study to identify factors associated with AEGJ (Study 2). Control subjects were randomly selected and age and sex matched from among subjects who underwent EGD during medical evaluations. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using an unconditional logistic regression method. During the study period, 83 patients with AEGJ (72 men and 11 women; mean age 68 years) were diagnosed. Six cases were Siewert type I and 77 were type II. The incidence rate of AEGJ was 0.6-1.7/100,000 person-years. Compared with the 101 control subjects, obesity (body mass index ≧ 25 kg/m2; [OR = 2.82; 95% CI: 1.13-7.01]) was associated with AEGJ. The incidence rate of AEGJ is lower in Japan than in Western countries, but associated factors similar to those in Western patients were detected, including obesity, a hiatal hernia, smoking, and the male sex.

Association between CT-Diagnosed Pneumonia and Endoscopic Submucosal Dissection of Gastric Neoplasms

BACKGROUND/AIMS

This prospective cohort study aimed to elucidate the incidence and characteristics of pneumonia associated with endoscopic submucosal dissection (ESD) of gastric neoplasms using CT.

METHODS

We included consecutive 188 patients with gastric neoplasms treated with ESD. All patients underwent CT before ESD and the day after ESD. Pneumonia associated with ESD was defined as lung ground glass opacity or consolidation by CT the day after ESD.

RESULTS

In 188 patients, 28 patients had diabetes mellitus. Pneumonia was observed by CT in 21 patients (11.2%) after ESD. Of those, 7 patients had diabetes mellitus. By univariate analysis, compared with patients with non-pneumonia complications, risk factors for pneumonia were significantly increased in patients with diabetes mellitus (p = 0.01) and in those who underwent a long procedure time (p = 0.02). By multivariate analysis, pneumonia was significantly increased in patients with diabetes mellitus (OR 4.06, 95% CI 1.35-12.19) and in those who underwent a long procedure time (OR 1.01, 95% CI 1.00-1.02).

CONCLUSIONS

The incidence of CT-diagnosed pneumonia associated with ESD was relatively high. Furthermore, it was revealed that diabetes mellitus and a long procedure time were risk factors of CT-diagnosed pneumonia.

Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation

BACKGROUND

Splenic vein ligation may result in sinistral (left-sided) portal hypertension and gastrointestinal haemorrhage. The aim of this study was to analyse the pathogenesis of sinistral portal hypertension following splenic vein ligation in pancreaticoduodenectomy.

METHODS

Patients who underwent pancreaticoduodenectomy for pancreatic cancer between January 2005 and December 2012 were included in this retrospective study. The venous flow pattern from the spleen and splenic hypertrophy were examined after surgery.

RESULTS

Of 103 patients who underwent pancreaticoduodenectomy with portal vein resection, 43 had splenic vein ligation. There were two predominant venous flow patterns from the spleen. In the varicose route (27 patients), flow from the spleen passed to colonic varices and/or other varicose veins. In the non-varicose route, flow from the spleen passed through a splenocolonic collateral (14 patients) or a spontaneous splenorenal shunt (2 patients). The varicose route was associated with significantly greater splenic hypertrophy than the non-varicose route (median splenic hypertrophy ratio 1·52 versus 0·94; P < 0·001). All patients with the varicose route had colonic varices, and none had a right colic marginal vein at the hepatic flexure.

CONCLUSION

Pancreaticoduodenectomy with splenic vein ligation may lead to sinistral portal hypertension. To avoid the development of varices, it is important to preserve the right colic marginal vein. Reconstruction of the splenic vein should be considered if the right colic marginal vein is divided.

A long-term study of acotiamide in patients with functional dyspepsia: results from an open-label phase III trial in Japan on efficacy, safety and pattern of administration

BACKGROUND

This long-term 48-week study of acotiamide was carried out to investigate the efficacy, safety and administration pattern in patients with functional dyspepsia (FD).

METHODS

This was a multicenter, open-label, single-arm, long-term phase III study in which patients with FD were given acotiamide, 100 mg t.i.d., for 48 weeks. The two major efficacy endpoints were global overall treatment efficacy (OTE) and the elimination rate of three cardinal symptoms (i.e. postprandial fullness, early satiation and upper abdominal bloating), which were evaluated weekly and daily by the patients, respectively. The long-term administration patterns were investigated by following the patients based on cessation and readministration criteria.

RESULTS

Efficacy was analyzed in 405 patients. The OTE improvement rate was 26.1% at week 1 and increased with time. It was 60.6% at week 8 and subsequently maintained. Similarly, the symptom elimination rate increased up to week 8. Many patients who met the cessation criterion achieved remission of FD symptoms after experiencing dose interruption and readministration. The incidence rate of adverse drug reactions was 11.5% and most of the adverse drug reactions were mild in severity except increased ALT in 1 patient.

CONCLUSION

FD symptoms were controlled by intermittent administration of acotiamide even in patients with relapsing FD.

Clinical trial: dose-dependent therapeutic efficacy of acotiamide hydrochloride (Z-338) in patients with functional dyspepsia - 100 mg t.i.d. is an optimal dosage

BACKGROUND

Acotiamide is a selective acetylcholinesterase inhibitor and enhances the actions of cholinergic neurons localized in the stomach.

METHODS

The present two studies were conducted to examine the optimal dosage of acotiamide hydrochloride (Z-338) in patients with functional dyspepsia (FD) in Japan.

KEY RESULTS

The improvement rate of 'subjects global assessment of overall treatment efficacy (OTE)' at the final evaluation was approximately 10% higher in the acotiamide 100 mg group than that in the placebo group with good reproducibility though there was no significant differences at primary endpoint. The elimination rate of postprandial fullness in the acotiamide 100 mg group was significantly higher compared to placebo group. In addition, the post hoc analysis showed that in patients whose main complaints are meal-related symptoms such as postprandial fullness, upper abdominal bloating and/or early satiety, the improvement rate of 'OTE' at final evaluation in acotiamide 100 mg group was significantly superior to that in the placebo group.

CONCLUSIONS & INFERENCES

These results suggest that acotiamide possesses efficacy on FD and more specifically its meal-related symptoms of FD.

Upper-extremity deep vein thrombosis related to central venous port systems implanted in cancer patients

The purpose of the current study was to evaluate the incidence and course of upper-extremity deep vein thrombosis (UEDVT) related to an implanted central venous port (CV-port) system in cancer patients. From July 2007 to July 2008, 92 consecutive patients who underwent implantation of a CV-port for chemotherapy for colorectal cancer were prospectively enrolled in the study. All patients were examined at prescribed intervals by ultrasonography (US) to estimate the incidence of catheter-related venous thrombosis. We categorised ultrasound diagnosis into three types: Type 0, no thrombus; Type I, thrombi around catheter without obstruction of venous flow; Type II: thrombi with obstruction of venous flow. Upon initial ultrasound examination, 25 cases (27%) were categorised as Type 0, 64 (70%) as Type I and III (3%) as Type II. Of the 64 Type-I cases, 4 cases worsened to Type II within a month, and 3 others (including 1 patient who developed pulmonary embolism) became Type II after 1 month. Of the other Type-I cases, 12 cases improved to Type 0 and 45 cases remained Type I. All 10 patients categorised as Type II underwent anticoagulant therapy and resumed their chemotherapy without exacerbations of thrombosis. In cancer patients undergoing long-term chemotherapy, there is an unexpectedly high prevalence of catheter-related UEDVT, which can be detected by ultrasound at an early stage after implantation of a CV-port. Given that cancer patients with UEDVT may have worse outcomes than those without, clinicians should consider careful monitoring for UEDVT and introducing anticoagulant therapy.

Characteristic of milk whey culture with Propionibacterium freudenreichii ET-3 and its application to the inflammatory bowel disease therapy

After the screening of microorganism culture, the culture of Propionibacterium freudenreichii ET-3 in the milk whey (milk whey culture) was found to stimulate the growth of our own Bifidobacteria in the colon but not the growth of other microorganisms. One of the active substances was identified as 1,4-dihydroxy-2-naphthoic acid (DHNA).In healthy volunteers, the ingestion containing milk whey culture significantly increased the population of Bifidobacteria to total fecal bacterium. In the TNBS-induced colitis model of rats, milk whey culture significantly accelerated the healing of the colitis in a dose-dependent manner. It has been reported that DHNA inhibited the lymphocyte infiltration through reduction of MAdCAM-1 in DSS colitis model of mice and that the ingestion of milk whey culture was effective in the treatment of ulcerative colitis in human pilot study. These findings suggest that milk whey culture is a useful prebiotic for the therapy of inflammatory bowel disease.