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.

Efficacy and Feasibility of Magnifying Blue Laser Imaging without Biopsy Confirmation for the Diagnosis of the Demarcation of Gastric Tumors: A Randomized Controlled Study

BACKGROUND

Accurate diagnosis of the demarcation line (DL) of gastric tumors is essential for curative complete resection by endoscopic submucosal dissection (ESD). It is controversial to perform only magnifying endoscopy for diagnosing the DL of gastric tumors prior to ESD. This study aimed to evaluate the diagnostic accuracy for the DL of gastric adenomas and well-differentiated adenocarcinomas using only magnifying blue laser imaging (M-BLI) compared with that using both M-BLI and biopsy confirmation.

METHODS

In this prospective, single-center study, 96 well-differentiated adenocarcinomas and 32 gastric adenomas were enrolled between July 2015 and December 2016. A total of 122 lesions with a clear DL on M-BLI were randomly allocated to undergo M-BLI only (the M-BLI group) or M-BLI with biopsy confirmation (the M-BLI-BC group), performed as biopsies in 4 directions from noncancerous tissues ≈ 5 mm outside the lesion before ESD. The primary end point was to clarify the noninferiority of M-BLI without biopsy confirmation compared with that with biopsy confirmation, in terms of the diagnostic accuracy and complete resection.

RESULTS

There were no significant differences in sex, median age, color, circumference, macroscopic type, biopsy-based diagnosis, and Helicobacter pylori infection between the 2 groups. The diagnostic accuracy for the DL was 100 and 95.0% and the complete resection was 100 and 100% in the M-BLI and M-BLI-BC groups, respectively.

CONCLUSION

The diagnostic ability of M-BLI is excellent in diagnosing the demarcation of gastric adenoma and well-differentiated adenocarcinoma. Biopsy confirmation is not needed for these lesions with a clear DL by M-BLI.

High-Risk Comorbidity Influences Prognosis in Early Gastric Cancer after Noncurative Endoscopic Submucosal Dissection: A Retrospective Study

BACKGROUND

There are few studies reporting the clinical outcomes of noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) from the perspective of patient health condition/status. Thus, the aim of this study was to investigate clinical outcomes of noncurative ESD considering not only curability but also patient factors such as advanced age, comorbidities, and nutritional status.

METHODS

Between April 2007 and March 2012, 95 patients who underwent noncurative ESD for EGC were enrolled in the study. Patients were categorized by treatment after ESD: additional gastrectomy (49 patients) and follow-up (46 patients). Clinical outcomes were evaluated between the 2 groups for overall survival (OS).

RESULTS

The absence of lymphovascular involvement and age ≥80 years were significantly associated with decision-making for observation after noncurative ESD. The OS rates were higher in female patients, patients with better Eastern Cooperative Oncology Group performance status (≤1) or low-risk comorbidity (Charlson Comorbidity Index [CCI ≤ 2]), patients with ulcerative findings, and those who underwent radical gastrectomy. Multivariate Cox proportional hazards analysis indicated that presence of a high-risk comorbidity (CCI ≥ 3) was a significant prognostic factor (hazard ratio: 16.43, p = 0.024) in patients who underwent noncurative ESD for EGC.

CONCLUSION

High-risk comorbidity is the primary prognostic parameter in terms of patient factors after noncurative ESD for EGC. The CCI should be considered as a prognostic factor in patients who underwent noncurative ESD for EGC.

Comparison Between Linked Color Imaging and Blue Laser Imaging for Improving the Visibility of Flat Colorectal Polyps: A Multicenter Pilot Study

INTRODUCTION

Linked color imaging (LCI) and blue laser imaging-bright (BLI-b) improve the visibility of gastrointestinal lesions. In this multicenter study, we compared the effects of LCI and BLI-b on the visibility of flat polyps with visibility scores and color difference (CD) values, including fast-withdrawal and large-monitor observation.

METHODS

We recorded 120 videos of 40 consecutive flat polyps (2-20 mm), adenoma, and sessile serrated adenoma and polyp (SSA/P), using white light imaging (WLI), BLI-b, and LCI from July 2017 to December 2017. All videos were evaluated by eight endoscopists according to a published polyp visibility score of 4 (excellent) to 1 (poor). Additionally, 1.5 ×faster and 1.7 ×sized videos were evaluated. Moreover, we calculated the CD values for each polyp in three modes.

RESULTS

The mean LCI scores (3.1 ± 0.9) were significantly higher than the WLI scores (2.5 ± 1.0, p < 0.001) but not significantly higher than the BLI-b scores (3.0 ± 1.0). The scores of faster videos on LCI (3.0 ± 1.1) were significantly higher than WLI (2.0 ± 1.0, p < 0.001) and BLI-b (2.8 ± 1.1, p = 0.03). The scores of larger-sized videos on LCI were not significantly higher than those of WLI or BLI-b. The CD value of LCI (18.0 ± 7.7) was higher than that of WLI (11.7 ± 7.0, p < 0.001), but was not significantly higher than that of BLI-b (16.6 ± 9.6). The CD value of LCI was significantly higher than that of BLI-b for adenoma, but the CD value of BLI-b was significantly higher than that of LCI for SSA/P.

CONCLUSIONS

The superiority of LCI to BLI-b was proven for the visibility of adenoma and fast observation.

Promotion of wound healing by acetate in murine colonic epithelial cell via c-Jun N-terminal kinase activation

BACKGROUND AND AIM

Mucosal healing is an important clinical goal in patients with inflammatory bowel disease. Recently, short-chain fatty acids (SCFAs) have been reported to have multifaceted effects to host. However, the effects of SCFAs on wound healing in intestinal epithelial cells are unclear. In the present study, we investigated the effects of acetate, one of the major SCFAs, on the wound healing of murine colonic epithelial cells.

METHODS

Young adult mouse colonic epithelial cells were used to determine the effect of acetate using wound healing assay. Mitogen-activated protein kinase and Rho kinase inhibitor were used to elucidate intracellular signal of wound healing treated with acetate. Meanwhile, Rho activation assays were utilized to measure Rho activation levels. To assess in vivo effects, C57B6 mice with dextran sodium sulfate for 7 days were treated with enema administration of acetate for 7 days. Body weight, disease activity index, colon length, and mucosal break ratio in histology were examined.

RESULTS

Acetate enhanced wound healing and fluorescence intensity of actin stress fiber compared with control. These effects were canceled with pretreatment of c-Jun N-terminal kinase (JNK) inhibitor or Rho kinase inhibitor. Furthermore, JNK inhibitor reduced the activation of Rho induced by acetate. In the dextran sodium sulfate-induced colitis model, the mice with enema treatment of acetate significantly exhibited recovery.

CONCLUSIONS

In this study, we demonstrated that acetate promoted murine colonic epithelial cell wound healing via activation of JNK and Rho signaling pathways. These findings suggested that acetate could have applications as a therapeutic agent for patients with intestinal mucosal damage, such as inflammatory bowel disease.

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 Clutch Cutter for Standardizing Endoscopic Submucosal Dissection for Early Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND/AIMS

The purpose of this study was to evaluate the safety and efficacy of gastric endoscopic submucosal dissection (ESD) using the Clutch Cutter (CC), a scissor-type knife, compared with those of procedures using conventional devices.

METHODS

This single-center retrospective study evaluated 237 patients with early gastric cancer: 83 who underwent ESD using the CC group and 154 who underwent ESD using the insulated-tip knife 2 (IT2 group). Clinicopathological features and technical outcomes were compared between the 2 groups using a propensity score-matched analysis.

RESULTS

In 61 pairs of matched patients, there was no significant difference in R0 resection, perforation, or postoperative bleeding between the CC and IT2 groups. Comparisons between the 2 groups showed similar treatment outcomes for an expert endoscopist. Nevertheless, there were significant differences between the 2 groups for nonexperts in terms of self-completion (61.7 and 24.5%, respectively, p < 0.001), mean procedure times (45 and 61 min, respectively, p = 0.002), and mean numbers of intraoperative bleeding points and bleeding points requiring hemostatic forceps (3 and 0 vs. 8 and 3, respectively, p < 0.001).

CONCLUSION

Better self-completion rates and shorter procedure times were noted for gastric ESD using the CC by nonexperts than for that using IT2, probably due to hemostatic efficacy.

Morphological lymphocytic reaction, patient prognosis and PD-1 expression after surgical resection for oesophageal cancer

BACKGROUND

Immune checkpoint inhibitors, such as antibody against programmed cell death protein (PD-1), have demonstrated antitumour effects in patients with malignancies, including oesophageal cancer. A lymphocytic reaction observed by pathological examination is a manifestation of the host immune response to tumour cells. It was hypothesized that a stronger lymphocytic reaction to tumours might be associated with favourable prognosis in oesophageal cancer.

METHODS

Using a database of resected oesophageal cancers, four morphological components of lymphocytic reactions (peritumoral, intranest, lymphoid and stromal) to tumours were evaluated in relation to clinical outcome, PD-1 expression by immunohistochemistry and total lymphocyte count in blood.

RESULTS

Resected oesophageal cancer specimens from 436 patients were included in the study. Among the four morphological components, only peritumoral reaction was associated with patient prognosis (multivariable P for trend <0·001); patients with a higher peritumoral reaction had significantly longer overall survival than those with a lower reaction (multivariable hazard ratio 0·48, 95 per cent c.i. 0·34 to 0·67). The prognostic effect of peritumoral reaction was not significantly modified by other clinical variables (all P for interaction >0·050). Peritumoral reaction was associated with total lymphocyte count in the blood (P < 0·001), supporting the relationship between local immune response and systemic immune competence. In addition, higher morphological peritumoral reaction was associated with high PD-1 expression on lymphocytes in tumours (P = 0·034).

CONCLUSION

These findings should help to improve risk-adapted therapeutic strategies and help stratify patients in the future clinical setting of immunotherapy for oesophageal cancer.

Efficacy of Magnifying Narrow Band Imaging for Delineating Horizontal Margins of Early Gastric Cancer

BACKGROUND/AIMS

The aim of this study was to evaluate the diagnostic accuracy of magnifying narrow-band imaging (M-NBI) with histopathological confirmation in identifying the demarcation line (DL) of early gastric cancer (EGC).

METHODS

EGCs resected by endoscopic submucosal dissection after identifying the DL using M-NBI following histopathological confirmation were included. After determining the DL for the entire EGC lesion using M-NBI, at least 4 biopsies were taken from non-cancerous tissues outside the EGC lesion for histopathological confirmation.

RESULTS

A total of 330 EGCs were analyzed in this study. The rate of biopsy-negative and negative horizontal margin were 96.7% (319/330) and 97.9% (323/330) in EGC respectively. Tumors larger than 20 mm showed a higher risk for showing remnant cancer cells on biopsies taken outside the DL. Risk factors for a positive horizontal resection margin were tumor size > 20 mm and moderately or poorly differentiated adenocarcinomas.

CONCLUSION

The assessment of demarcation of EGC using M-NBI was excellent in well-differentiated (WD) adenocarcinoma and lesions below 20 mm in size. However, histopathological confirmation is needed to assess the demarcation of non-WD adenocarcinomas and EGC over 20 mm in size.

Can image-enhanced endoscopy improve the diagnosis of Kyoto classification of gastritis in the clinical setting?

Endoscopic diagnosis of Helicobacter pylori (H. pylori) infection, the most common cause of gastric cancer, is very important to clarify high-risk patients of gastric cancer for reducing morbidity and mortality of gastric cancer. Recently, the Kyoto classification of gastritis was developed based on the endoscopic characteristics of H. pylori infection-associated gastritis for clarifying H. pylori infection status and evaluating risk factors of gastric cancer. Recently, magnifying endoscopy with narrow-band imaging (NBI) has reported benefits of the accuracy and reproducibility of endoscopic diagnosis for H. pylori-related premalignant lesions. In addition to NBI, various types of image-enhanced endoscopies (IEEs) are available including autofluorescence imaging, blue laser imaging, and linked color imaging. This review focuses on understanding the clinical applications and the corresponding evidences shown to improve the diagnosis of gastritis based on Kyoto classification using currently available advanced technologies of IEEs.

The clinical impact of preoperative body composition differs between male and female colorectal cancer patients

AIM

Patient body composition is an important indicator of metabolic status and is associated with cancer progression. Because body composition varies between men and women, we aimed to examine the difference in clinical impact of preoperative body composition according to sex.

METHOD

We used an integrated dataset of 559 colorectal cancer (CRC) patients. The association between preoperative body composition indices [body mass index (BMI), visceral to subcutaneous fat area ratio (VSR) and skeletal muscle index (SMI)] and patient outcome, clinicopathological factors and preoperative inflammation and nutritional status was analysed, comparing men and women.

RESULTS

Preoperative low BMI and low SMI in men was significantly associated with unfavourable overall survival (OS) [BMI: hazard ratio (HR) 2.22, 95% CI 1.28-4.14, P = 0.004; SMI: HR 2.54, 95% CI 1.61-4.07, P < 0.001] and high VSR in women was significantly associated with unfavourable OS (HR 1.79, 95% CI 1.03-3.02, P = 0.040). Additionally, low SMI in men was significantly associated with deeper tumour invasion and greater distant metastasis and high VSR in women was significantly associated with advanced age, right-sided tumour, lower total lymphocyte count and lower albumin levels. Interestingly, low BMI in men was significantly associated with deeper tumour invasion, but also with favourable inflammation and nutritional status (lower C-reactive protein and higher albumin).

CONCLUSION

The clinical impact of preoperative body composition differed between men and women: SMI in men and VSR in women were good prognosticators. Our findings may provide a novel insight for CRC treatment strategies.

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.

Early administration of pegfilgrastim for esophageal cancer treated with docetaxel, cisplatin, and fluorouracil: A phase II study

Preoperative or induction chemotherapy with docetaxel, cisplatin, plus 5‐fluorouracil (DCF) is a promising regimen for advanced esophageal cancer. However, the DCF regimen is associated with a high risk of severe neutropenia or febrile neutropenia (FN). However, the current guidelines fail to recommend an optimal dosing schedule of pegfilgrastim along with the DCF regimen to prevent FN. In the present study, we assessed the efficacy and safety of giving pegfilgrastim early on day 3 during DCF therapy for esophageal cancer. In this single‐arm phase II study, patients with squamous cell carcinoma of the esophagus were recruited. They were treated with the DCF therapy on days 1‐5, with pegfilgrastim given on day 3. Primary endpoint was the occurrence of grade 4 neutropenia. Secondary endpoints included the incidence of FN, grade 3 neutropenia, dose delays/reductions, antitumor effect, and safety. Between July 2016 and December 2018, 23 patients were enrolled. The incidence of grade 4 neutropenia was 8.7% (95% confidence interval 1.1%‐28.0%). No patient experienced FN. Of the 19 patients who received two cycles of DCF, one required a dose reduction/treatment delay due to hematological toxicity in the second treatment cycle. No serious adverse events, considered relevant to pegfilgrastim, were observed. This is the first prospective study that showed an efficacious dosing schedule of pegfilgrastim for preventing hematological toxicity during DCF therapy. The results might be generalized to other similar regimens where continuous infusions of 5‐fluorouracil are used.

Clinical and Pathological Challenges in the Diagnosis of Gastric-Type Differentiated Adenocarcinoma in the Stomach: A Study of Endoscopic Submucosal Dissection Cases

BACKGROUND/AIMS

Gastric-type differentiated adenocarcinoma (GDA) of the stomach is a rare variant of gastric cancer that is highly infiltrating and exhibits early metastasis. However, the endoscopic and pathological features of "early-stage" GDA remain unknown. The aim of this study is to characterize early-stage GDA.

METHODS

We retrospectively enrolled 479 differentiated-type early gastric cancer cases who underwent endoscopic submucosal dissection (ESD). GDA cases were selected based on morphology and immunohistochemistry. Clinicopathological data were compared between gastric- and intestinal-type differentiated adenocarcinomas (IDAs).

RESULTS

Thirteen lesions were classified as GDAs. GDAs as well as IDAs showed irregular microvascular and microsurface patterns with clear demarcation line on magnifying endoscopy with narrow band imaging (M-NBI). The rate of pathological misdiagnosis of GDAs in biopsy specimens was higher than that of IDAs (p = 0.016). GDA was significantly associated with positive lymphovascular invasion (p = 0.016). There was one intramucosal lesion with lymphatic invasion in GDA.

CONCLUSIONS

Although M-NBI is useful to detect GDA, the pathological diagnosis of GDAs in biopsy specimens often remains challenging. When suspicious lesions are not diagnosed as GDA, they should be followed up intensively, or diagnostic ESD has to be performed. ESD specimens should be carefully evaluated because of a higher incidence of lymphovascular invasion.

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.

Linked color imaging identifies important risk factors associated with gastric cancer after successful eradication of Helicobacter pylori

BACKGROUND AND AIMS

Limited studies have evaluated the risk factors of gastric cancer (GC) after eradication of Helicobacter pylori (H pylori) using endoscopic findings. We aimed to investigate GC detection-related endoscopic findings after eradication of H pylori using linked color imaging (LCI), a novel image-enhanced endoscopy.

METHODS

This single-center, cross-sectional study evaluated background mucosa-associated endoscopic findings described in the Kyoto classification of gastritis in patients with newly detected GC after eradication of H pylori (CA group, n = 109) and those without GC (NC group, n = 85) using white-light imaging (WLI) and LCI.

RESULTS

Severe atrophy and map-like redness were significantly more frequent in the CA group than in the NC group using WLI (79.8% vs 63.5%, P = .01; 61.5% vs 37.7%, P = .001, respectively) and LCI (79.8% vs 63.5%, P = .01; 78.0% vs 45.9%, P < .0001, respectively). Regular arrangement of collecting venules (RAC) was significantly less frequent in the CA group than in the NC group using WLI (40.3% vs 64.7%, P = .0009) and LCI (37.6% vs 62.4%, P = .0006). Map-like redness was an independent positive risk factor (WLI: odds ratio [OR], 2.05; 95% confidence interval [CI], 1.09-3.87; P = .03; LCI: OR, 3.62; 95% CI, 1.88-6.97; P < .001), whereas RAC was an independent negative risk factor (WLI: OR, 0.42; 95% CI, 0.21-0.82; P = .01; LCI: OR, 0.46; 95% CI, 0.23-0.93, P = .03) for detection of GC after eradication of H pylori.

CONCLUSIONS

Map-like redness, which was identified more frequently using LCI than WLI, and the absence of RAC were associated with detection of GC after eradication of H pylori.

P5508Impact of CD14++CD16+ monocytes on coronary plaque vulnerability assessed by optical coherence tomography in coronary artery disease patients

Background

Diabetes mellitus has been known as an important factor of coronary artery disease (CAD) progression despite of widespread with lipid-lowering therapy. Although we have reported that large glucose fluctuation is associated with the development of cardiovascular disease in both diabetes mellitus (DM) and non-DM patients, the underlying mechanisms remain unclear.

Monocytes play a key role for atherosclerotic plaque formation. Monocytes in human peripheral blood are divided into three subsets: CD14++CD16− monocytes, CD14++CD16+ monocytes, and CD14+CD16++ monocytes. The CD14++CD16+ monocyte subset has recently received attention because it is reported to be associated with future cardiovascular events such as acute myocardial infarction. However, their impact on coronary plaque vulnerability in coronary artery disease (CAD) patients with or without DM remains unclear.

Purpose

The aim of this study was to investigate the impact of CD14++CD16+ monocyte levels on coronary plaque vulnerability and glucose fluctuation in stable CAD patients with well-regulated lipid levels.

Methods

This prospective observational study included 50 consecutive patients with CAD (DM [n=22], Non-DM [n=28]), receiving lipid-lowering therapy and undergoing coronary angiography and optical coherence tomography (OCT). Patients were divided into 3 tertiles according to the CD14++CD16+ monocyte percentages assessed by flow cytometry. Standard OCT parameters including lipid arc, lipid length, fibrous cap thickness (FCT) on lipid rich plaque, were assessed for 97 angiographically intermediate lesions (diameter stenosis: 30–70%). The presence of thin-cap fibroatheroma (TCFA), defined as a thin fibrous cap (<65μm) overlying a lipid-rich plaque (>90°), was also assessed. Daily glucose fluctuation assessed by using continuous glucose monitoring system was analyzed by measuring the mean amplitude of glycemic excursion (MAGE).

Results

CD14++CD16+ monocytes negatively correlated with FCT on lipid rich plaque (r=0.508, p<0.01) (Figure. 1). The presence of thin-cap fibroatheroma (TCFA) was increased stepwise according to the tertile of CD14++CD16+ monocytes (0 [tertile 1] vs. 5 [tertile 2] vs. 10 [tertile 3], p<0.01). CD14++CD16+ monocytes were a significant determinant of TCFA (OR 1.279, p=0.001). Although CD14++CD16+ monocytes were not significantly correlated with MAGE in DM patients (r=0.259, p=0.244), a significant relationship was found between CD14++CD16+ monocytes and MAGE in non-DM patients (r=0.477, p=0.018) (Figure 2).

Conclusions

CD14++CD16+ monocytes were associated with coronary plaque vulnerability in CAD patients with well-regulated lipid levels both in DM and non-DM patients. Cross-talk between glucose fluctuation and CD14++CD16+ monocytes may enhance plaque vulnerability, particularly in non-DM patients. CD14++CD16+ monocytes could be a possible therapeutic target for coronary plaque stabilization.

1436Overexpression of Cytotoxic T-Lymphocyte Associated Antigen-4 suppresses aortic immunoinflammatory responses and prevents angiotensin II-induced abdominal aortic aneurysm formation in mice

Aims

Vascular inflammation via T-cell-mediated immune responses has been shown to be critically involved in the pathogenesis of abdominal aortic aneurysm (AAA). T-cell coinhibitory molecule cytotoxic T-lymphocyte–associated antigen-4 (CTLA-4) is known to act as a potent negative regulator of immune responses. However, the role of this molecule in the development of AAA remains completely unknown. In the present study, we determined the effects of CTLA-4 overexpression on experimental AAA.

Methods and results

We continuously infused 12-week-old CTLA-4 transgenic (CTLA-4-Tg)/apolipoprotein E–deficient (Apoe−/−) mice (n=35) or control Apoe−/− mice (n=40) fed a high-cholesterol diet with angiotensin II by implanting osmotic mini-pumps and evaluated the development of AAA. Ninety percent of angiotensin II-infused mice developed AAA, with 50% mortality because of aneurysm rupture. Overexpression of CTLA-4 significantly reduced the incidence (66%), mortality (26%), and diameter (18%) of AAA (incidence: P=0.0104; mortality: P=0.031; diameter: P=0.011). These protective effects were associated with a decreased number of effector CD4+ T cells and the downregulated expression of costimulatory molecules CD80 and CD86, ligands for CTLA-4, on CD11c+ dendritic cells in lymphoid tissues. In addition, by performing in situ zymography of the abdominal aortic aneurysm lesions, we observed a trend toward a decrease in MMP activity in the aneurysmal lesion following overexpression of CTLA-4. Finally, CTLA-4-Tg/Apoe−/− mice had reduced macrophage and CD4+ T cell accumulation and MMP activity in the aneurysmal lesion, leading to attenuated aortic inflammation, preserved vessel integrity, and decreased susceptibility to AAA and aortic rupture.

Conclusion

Our findings suggest that CTLA-4 protects against AAA by suppressing immunoinflammatory responses and could be an attractive therapeutic target for AAA.

Cross-national analysis about the difference of histopathological management in Tis and T1 colorectal cancer between Japan and Korea

Objectives: There are differences in each country with regards to histopathological managements of colorectal cancer (CRC), such as definition of Tis and lymphatic and venous invasion. In this study, we compared Tis and T1 CRC in Japan and Korea. Methods: We retrospectively compared various clinical characteristics of consecutive patients who had Tis and T1 CRCs and who were newly diagnosed between 2010 and 2014 at the Kyoto Prefectural University of Medicine (Japan) and the Konkuk University (Korea). Results: Three hundred and sixty-five cases of T1 cancer and 510 cases of Tis cancer from 726 Japanese and 149 Korean patients were included. The rate of Tis in Japan was higher than in Korea (59.8% vs. 51.0%, P = 0.047), according to the difference of definition of Tis. In the analyses of 365 T1 CRCs, median age was higher in Japan than Korea (67.8 ± 10.6 vs. 62.2 ± 10.1, P < 0.001). Right-sided lesions were more frequent in Japan than they were in Korea (38.7% vs. 22.2%, P < 0.001). The rates of venous and lymphatic invasion were higher in Japan than they were in Korea (venous: 18.6% vs. 1.4%, P < 0.001, lymphatic: 25.3% vs. 13.7%, P = 0.042), according to the different methods of immunohistochemical examinations used (Japan: E-HE and D2-40, Korea: ERG). Conclusions: Our study of T1 CRC showed that there were differences between Japan and Korea in tumor location, elderly incidence, and histopathological lymphatic and venous invasion. Additionally, rates of Tis were different between the two countries. In this international study for CRC, it is considered that we have to pay attention regarding the difference of histopathological definition and method in each country.

T cell-specific STAT3 deficiency abrogates lupus nephritis

Signal transducer and activator of transcription (STAT) 3 is a regulator of T-cell responses to external stimuli, such as pro-inflammatory cytokines and chemokines. We have previously shown that STAT3 is activated (phosphorylated) at high levels in systemic lupus erythematosus (SLE) T cells and mediates chemokine-induced migration and T:B cell interactions. Stattic, a small molecular STAT3 inhibitor, can partially ameliorate lupus nephritis in mice. To understand the role of STAT3 better in T-cell pathophysiology in lupus nephritis and its potential as a treatment target, we silenced its expression in T cells using a cd4-driven CRE-Flox model. We found that lupus-prone mice that do not express STAT3 in T cells did not develop lymphadenopathy, splenomegaly, or glomerulonephritis. Moreover, the production of anti-dsDNA antibodies was decreased in these mice compared to controls. To dissect the mechanism, we also used a nephrotoxic serum model of nephritis. In this model, T cell-specific silencing of STAT3 resulted in amelioration of nephrotoxic serum-induced kidney damage. Taken together, our results suggest that in mouse models of autoimmune nephritis, T cell-specific silencing of STAT3 can hamper their ability to help B cells to produce autoantibodies and induce cell tissue infiltration. We propose that STAT3 inhibition in T cells represents a novel approach in the treatment of SLE and lupus nephritis in particular.