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Rida M, Chalhoub M, Mansour M, Younan T, Chahine G, Nassar J, Slaba S. Ectopic hepatocellular carcinoma, an unexpected diagnosis of a retroperitoneal mass: A case report and literature review. Radiol Case Rep 2024; 19:4429-4434. [PMID: 39185436 PMCID: PMC11343981 DOI: 10.1016/j.radcr.2024.06.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 06/15/2024] [Accepted: 06/30/2024] [Indexed: 08/27/2024] Open
Abstract
Ectopic hepatocellular carcinoma (HCC) is defined as HCC arising from hepatic parenchyma located in an extrahepatic organ or tissue without any communication with the mother liver. It is very rare and difficult to diagnose by imaging alone. We report a case of a rare ectopic HCC mimicking a right para-aortic retroperitoneal mass and present a review of the literature. It is about a 79-year-old female patient, who presented with a progressive enlarged right paraaortic retroperitoneal mass, thought first to be leiomyosarcoma of vena cava on imaging. Subsequently, high alpha-fetoprotein (AFP) level and biopsy allowed the diagnosis of primary extrahepatic hepatocellular carcinoma.
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Affiliation(s)
- Mohammad Rida
- Department of Radiology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Mariam Chalhoub
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maryam Mansour
- Department of Radiology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Tonine Younan
- Department of Radiology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Georges Chahine
- Department of Hematology and Oncology, Hotel Dieu de France Hospital, Beirut, Lebanon
| | - Jinane Nassar
- Department of Radiology, Mount Lebanon Hospital, Hazmieh, Lebanon
| | - Sami Slaba
- Department of Radiology, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
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Wu WK, Patel K, Padmanabhan C, Idrees K. Hepatocellular carcinoma presenting as an extrahepatic mass: A case report and review of literature. World J Gastrointest Oncol 2024; 16:2241-2252. [PMID: 38764834 PMCID: PMC11099426 DOI: 10.4251/wjgo.v16.i5.2241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/03/2024] [Accepted: 03/20/2024] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a primary liver tumor generally diagnosed based on radiographic findings. Metastatic disease is typically associated with increased tumor diameter, multifocality, and vascular invasion. We report a case of a patient who presented with extrahepatic HCC metastasis to a portocaval lymph node with occult hepatic primary on computed tomography (CT). We review the literature for cases of extrahepatic HCC presentation without known hepatic lesions and discuss strategies to differentiate between metastatic and ectopic HCC. CASE SUMMARY A 67-year-old male with remotely treated hepatis C was referred for evaluation of an enlarging portocaval, mixed cystic-solid mass. Serial CT evaluations demonstrated steatosis, but no cirrhosis or liver lesions. Endoscopic ultrasound demonstrated a normal-appearing pancreas, biliary tree, and liver. Fine needle aspiration yielded atypical cells. The differential diagnosis included duodenal or pancreatic cyst, lymphoproliferative cyst, stromal or mesenchymal lesions, nodal involvement from gastrointestinal or hematologic malignancy, or duodenal gastro-intestinal stromal tumor. After review by a multidisciplinary tumor board, the patient underwent open surgical resection of a 5.2 cm × 5.5 cm retroperitoneal mass with pathology consistent with moderately-differentiated HCC. Magnetic resonance imaging (MRI) subsequently demonstrated a 1.2 cm segment VIII hepatic lesion with late arterial enhancement, fatty sparing, and intrinsic T1 hyperintensity. Alpha fetoprotein was 23.3 ng/mL. The patient was diagnosed with HCC with portocaval nodal involvement. Review: We surveyed the literature for HCC presenting as extrahepatic masses without history of concurrent or prior intrahepatic HCC. We identified 18 cases of extrahepatic HCC ultimately found to represent metastatic lesions, and 30 cases of extrahepatic HCC found to be primary, ectopic HCC. CONCLUSION Hepatocellular carcinoma can seldomly present with extrahepatic metastasis in the setting of occult primary. In patients with risk factors for HCC and lesions suspicious for metastatic disease, MRI may be integral to identifying small hepatic lesions and differentiating from ectopic HCC. Tumor markers may also have utility in establishing the diagnosis.
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Affiliation(s)
- Wei Kelly Wu
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Krutika Patel
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Chandrasekhar Padmanabhan
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Kamran Idrees
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, United States
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Someko H, Kataoka Y, Obara T. Drug fever: a narrative review. ANNALS OF CLINICAL EPIDEMIOLOGY 2023; 5:95-106. [PMID: 38504950 PMCID: PMC10944987 DOI: 10.37737/ace.23013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Drug fever is an adverse drug reaction accompanied by a febrile response and is a common problem among clinicians, hence an updated knowledge of drug fever is important. A consensus regarding the definition of drug fever is lacking. Thus, descriptions of drug fever in previous literature are often inconsistent. In this narrative review, we summarized various features of drug fever, including its definition, epidemiology, risk factors, clinical presentation, diagnosis, treatment and prognosis, based on the earliest literature. Recent advances in information technology have encouraged researchers to use pharmacovigilance databases for clinical and pharmacological research. We outlined how a pharmacovigilance database, along with recently developed research methods, could be used to research drug fever.
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Affiliation(s)
- Hidehiro Someko
- Department of General Internal Medicine, Asahi General Hospital
- Scientific Research WorkS Peer Support Group (SRWS-PSG)
| | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG)
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/Public Health
| | - Taku Obara
- Department of Pharmaceutical Sciences, Tohoku University Hospital
- Division of Molecular Epidemiology, Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University
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Gan L, Ren S, Lang M, Fang F, Chen L, Song T. Ectopic hepatocellular carcinoma of the right adrenal gland: a case description. Quant Imaging Med Surg 2023; 13:1248-1252. [PMID: 36819251 PMCID: PMC9929416 DOI: 10.21037/qims-22-629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 11/23/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Leijuan Gan
- Liver Cancer Center, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China;,Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Shaohua Ren
- Liver Cancer Center, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China;,Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Mengran Lang
- Liver Cancer Center, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China;,Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Feng Fang
- Liver Cancer Center, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China;,Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Lu Chen
- Liver Cancer Center, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China;,Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Tianqiang Song
- Liver Cancer Center, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China;,Tianjin’s Clinical Research Center for Cancer, Tianjin, China
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Yang Y, Lu Q, Li Z, Wang C, Li Y. A large ectopic hepatocellular carcinoma with adrenal infiltration: a rare case report. Front Oncol 2023; 13:1116684. [PMID: 37168375 PMCID: PMC10165008 DOI: 10.3389/fonc.2023.1116684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/05/2023] [Indexed: 05/13/2023] Open
Abstract
Ectopic hepatocellular carcinoma (EHCC) originates from the ectopic liver, which refers to a liver organ or tissue unrelated to surrounding tissues. EHCC is a rare disease that lacks specific clinical signs, and preoperative diagnosis is often difficult. In a 61-year-old male patient with positive hepatitis B virus antibody, abdominal contrast-enhanced computed tomography scan showed a large heterogenously enhancing mass both on arterial and portal venous phase imaging arising from the right adrenal gland. Similar enhancement features were seen on magnetic resonance imaging. Serum potassium, aldosterone, cortisol, and plasma metanephrines were normal. The tumor markers of serum alpha-fetoprotein and alpha-fetoprotein-L3% were increased to 23.69 ng/mL and 82.1%, respectively. Exploratory laparotomy was performed and operative findings showed that the retroperitoneal tumor was disconnected from the right kidney and the liver, but invaded the right adrenal gland. Immunohistochemical examination showed that Arginase-1 was positive expression, and the retroperitoneal tumor was finally diagnosed as EHCC. We report a rare EHCC with adrenal infiltration that is difficult to diagnose preoperatively and mimics a retroperitoneal tumor or adrenal tumor, and we present a review of the literature on EHCC case reports.
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Liu Q, Li J, Pan Y, Zheng X, Gao B. Challenge in Diagnosis and Treatment of Ectopic Hepatocellular Carcinoma: A Case Report and Literature Review. Front Surg 2022; 9:827006. [PMID: 35433804 PMCID: PMC9008362 DOI: 10.3389/fsurg.2022.827006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Findings of ectopic hepatocellular carcinoma (EHCC) have been rarely documented. Complicated clinical features and unpredictable medical prognosis make diagnosis and treatment difficult. Case Presentation We reported a 59-year-old male patient who came to the hospital with epigastric discomfort and regurgitation of gastric acid. An enhanced CT scan revealed a 1.8 cm × 1.4 cm mass in the tail of pancreas without any positive finding in the liver. Postoperative MRI scan was performed but did not reveal any evidence of hepatic tumor. The tumor was resected in toto. Meanwhile, a 1 cm × 1 cm mass in the body of the stomach was found that was removed simultaneously. Histopathology showed that the pancreatic tumor was ectopic hepatocellular carcinoma (EHCC), and that the gastric nodule was gastrointestinal stromal tumor (GIST). The patient had an uneventful postoperative recovery. He has been living without recurrence for over 7 years since surgery. Owing to our knowledge, this is the second-longest disease-free survival time for EHCC in the literature. Conclusion Here, we present a rare case of EHCC in the pancreas, and review the current literature on EHCC. Operation was an effective treatment for patients with curable EHCC. EHCC with metastasis still needs more practice to improve the poor prognosis.
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Affiliation(s)
- Qicen Liu
- Department of General Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingyi Li
- Department of Emergency Intensive Care Medicine, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yi Pan
- Department of Pathology, Huangshan People's Hospital, Huangshan, China
| | - Xiang Zheng
- Department of Chronic Wound Diagnosis and Treatment Center, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Xiang Zheng
| | - Bin Gao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Bin Gao
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Rinka K, Uchida-Kobayashi S, Yoshida K, Odagiri N, Kotani K, Motoyama H, Fujii H, Hagihara A, Miyazaki T, Nishioka T, Shinkawa H, Tanaka S, Enomoto M, Tamori A, Kubo S, Kawada N. A case of ectopic hepatocellular carcinoma originating from the retroperitoneum. KANZO 2020; 61:597-606. [DOI: 10.2957/kanzo.61.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Affiliation(s)
- Koji Rinka
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | | | - Kanako Yoshida
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Naoshi Odagiri
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Kohei Kotani
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Hiroyuki Motoyama
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Hideki Fujii
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Atsushi Hagihara
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Tooru Miyazaki
- Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, Osaka City University
| | - Takayoshi Nishioka
- Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, Osaka City University
| | - Hiroji Shinkawa
- Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, Osaka City University
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, Osaka City University
| | - Masaru Enomoto
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Akihiro Tamori
- Department of Hepatology, Graduate School of Medicine, Osaka City University
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Graduate School of Medicine, Osaka City University
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka City University
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Adachi Y, Hayashi H, Yusa T, Takematsu T, Matsumura K, Higashi T, Yamamura K, Yamao T, Imai K, Yamashita Y, Baba H. Ectopic hepatocellular carcinoma mimicking a retroperitoneal tumor: A case report. World J Gastroenterol 2020; 26:2268-2275. [PMID: 32476791 PMCID: PMC7235206 DOI: 10.3748/wjg.v26.i18.2268] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/22/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND An ectopic hepatocellular carcinoma (EHCC) arises from the ectopic liver which is defined as a hepatic organ or tissue not connected to surrounding tissues. EHCC is a rare disease and it is difficult to diagnose preoperatively. Furthermore, the clinical features are not fully elucidated.
CASE SUMMARY A retroperitoneal tumor (6 cm) was located at the dorsal side of the pancreas head on abdominal ultrasonography in an 81-year old woman positive for hepatitis C virus antibody. Contrast enhanced-computed tomography and gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging showed viable HCC patterns with early enhancement and delayed washout. The tumor markers — serum alpha-fetoprotein and alpha-fetoprotein-L3% — were increased to 30.1 ng/mL and 83.1%, respectively. Protein induced by vitamin K absence or antagonist-II was within normal levels (17 mAU/mL). Positron emission tomography-computed tomography showed strong accumulation into the tumor (Standardized Uptake Value max: 13.8), and the tumor cytology following endoscopic ultrasound-guided fine needle aspiration showed poorly differentiated carcinoma. Tumor extirpation was performed, and operative findings showed that the retroperitoneal tumor was disconnected from the pancreas and the liver. Swollen lymph nodes near the tumor were histologically normal. On histological examination, the tumor was finally diagnosed as EHCC with Arginase-1 positive expression.
CONCLUSION We report our experience of a rare EHCC which was difficult to diagnose, and we present a review of the literature.
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Affiliation(s)
- Yuki Adachi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Toshihiko Yusa
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Toru Takematsu
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Kazuki Matsumura
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Takaaki Higashi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Kensuke Yamamura
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Takanobu Yamao
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Yo−ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto 8608556, Japan
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Ko YL, Takata K, Tanaka T, Ohishi J, Takeshita M, Yamauchi R, Fukuda H, Miyayama T, Uchida Y, Yokoyama K, Morihara D, Takeyama Y, Shakado S, Sakisaka S, Hirai F. Unresectable Ectopic Hepatocellular Carcinoma Treated with Sorafenib. Case Rep Gastroenterol 2020; 14:226-233. [PMID: 32399007 PMCID: PMC7204886 DOI: 10.1159/000506929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/02/2020] [Indexed: 12/13/2022] Open
Abstract
Ectopic hepatocellular carcinoma (HCC) is a rare malignancy, which manifests similar morphology and immunohistochemistry to intrahepatic HCC. Herein, we report a case of ectopic HCC in a 73-year-old male. The patient presented to our hospital with gradually progressing right lower abdominal pain, and enhanced computed tomography revealed multiple nodules in the peritoneum without intrahepatic mass. A diagnostic laparoscopy was performed, and the final pathology result confirmed that it was HCC. Additional laboratory tests showed elevated serum alpha-fetoprotein and protein induced by vitamin K absence-II (PIVKA-II) levels, suggesting our diagnosis. The patient received sorafenib, a tyrosine kinase inhibitor (TKI), for unresectable ectopic HCC. However, the tumor progressed, and because of tarry stools and hemorrhagic anemia, sorafenib was ceased after 7 months of therapy. One month after the cessation of sorafenib, the PIVKA-II level increased abruptly, and the patient died 1 year after diagnosis. The effective treatment for unresectable ectopic HCC is still unknown. Additional cases should be accumulated to determine the effect of TKI on ectopic HCC.
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Affiliation(s)
- Yi-Ling Ko
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazuhide Takata
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Takashi Tanaka
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Jun Ohishi
- Division of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.,Division of Gastroenterological Surgery, Hakujuji Hospital, Fukuoka, Japan
| | - Morishige Takeshita
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ryo Yamauchi
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hiromi Fukuda
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Takashi Miyayama
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yotaro Uchida
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Keiji Yokoyama
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Daisuke Morihara
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yasuaki Takeyama
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shotaro Sakisaka
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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