Intraductal papillary neoplasm of the bile duct with metachronous development in the downstream bile duct after radical resection

We report a case of intraductal papillary neoplasms of the bile duct (IPNB) that metachronously developed twice in the downstream bile duct after radical resection. The first lesion was located in the left intrahepatic bile duct, the second lesion in the perihilar bile duct, and the third lesion in the distal bile duct. All lesions were IPNBs with associated invasive carcinoma (pancreatobiliary type). The depth of invasion was to the Glisson's capsule in the first lesion, to the subserosa in the second lesion, and to the fibromuscular layer in the third lesion, without lympho-vascular/perineural invasion and lymph-node metastasis. These were resected radically and had no biliary intraepithelial neoplasia and hyperplasia in the surrounding mucosa. In immunohistochemical examination, each lesion showed a different pattern. Although the downstream occurrence suggests intrabiliary dissemination, the mechanism of these metachronous developments may be multicentric. A literature review revealed that most metachronous cholangiocarcinomas have a grossly papillary appearance and tend to arise downstream. Our findings suggest that IPNB may develop metachronously in the residual bile duct after radical surgery, which may assist in early detection.

Ultrasonographic Features of Nonneoplastic Protrusions in Pancreatic Cysts by Contrast-Enhanced Endoscopic Ultrasound

OBJECTIVES

Most of the pancreatic cyst protrusions detected by B-mode endoscopic ultrasound (BM-EUS) are nonneoplastic and are not enhanced by contrast-enhanced EUS (CE-EUS) using ultrasound contrast agent (USCA). This study aimed to identify useful findings for distinguishing between neoplastic and nonneoplastic pancreatic cyst protrusions on BM-EUS to facilitate efficient USCA use.

MATERIALS AND METHODS

A total of 151 pancreatic cyst protrusions in 119 consecutive patients who underwent CE-EUS were analyzed. We focused on the echo level (hyperechoic/isoechoic/hypoechoic/anechoic), base type (sessile without a basal waist/sessile with a basal waist/pedunculated), surface type (smooth/irregular), and the presence/absence of a hyperechoic surface layer. Enhanced and unenhanced protrusions on CE-EUS were interpreted as neoplastic and nonneoplastic, respectively.

RESULTS

Forty-five and 106 protrusions were enhanced and unenhanced, respectively, on CE-EUS performed using USCA. In univariable analysis of predictors of nonneoplastic protrusion on BM-EUS, the following factors were found to be significant: echo level (hypoechoic/anechoic), base type (sessile with a basal waist/pedunculated), a smooth surface, and a hyperechoic surface layer. Of these, only a hyperechoic surface layer remained significant in the multivariable analysis ( P < 0.0001; odds ratio, 40.74; 95% confidence interval, 7.07-387.49).

CONCLUSIONS

Pancreatic cyst protrusions with a hyperechoic surface layer on BM-EUS are suggestive of nonneoplastic disease.

Early tumor shrinkage and depth of response in patients with metastatic esophageal cancer treated with 2-weekly docetaxel combined with cisplatin plus fluorouracil: an exploratory analysis of the JCOG0807

BACKGROUND

We herein investigated the association between early tumor shrinkage (ETS) and depth of response (DpR) and clinical outcomes in patients with metastatic esophageal cancer treated with 2-weekly docetaxel combined with cisplatin plus fluorouracil (bDCF) using data from the JCOG0807, a phase I/II trial of bDCF as first-line chemotherapy for metastatic esophageal cancer.

METHODS

ETS was defined as a percent decrease in the sum of the target lesions' longest diameter after 8 weeks, whereas DpR was defined as a percentage of the maximal tumor shrinkage during the treatment course. Multivariable analyses were conducted to identify significant prognostic variables in progression-free survival (PFS) and overall survival (OS): one for ETS and covariates, and another for DpR and covariates.

RESULTS

Among 53 patients, 35 patients with ETS ≥ 20% (66.0%) had longer PFS (7.5 vs. 3.4 months, hazard ratio [HR]: 0.26, 95% confidence interval [95% CI] 0.14-0.49), OS (13.8 vs. 6.1 months, HR 0.20, 95% CI 0.11-0.39), and PPS (6.4 vs. 2.8 months, HR 0.38, 95% CI 0.20-0.72) than those with ETS < 20%. In addition, 37 patients with DpR ≥ 30% (69.8%) had longer PFS (7.5 vs. 2.9 months, HR 0.17, 95% CI 0.08-0.34), OS (13.8 vs. 6.0 months, HR 0.14, 95% CI 0.07-0.27), and PPS (6.8 vs. 2.8 months, HR 0.30, 95% CI 0.15-0.58) than those with DpR < 30%. Multivariable analyses revealed that each ETS and DpR was an independent factor of longer PFS and OS.

CONCLUSIONS

ETS and DpR might be associated with clinical outcomes in patients with metastatic esophageal cancer treated with bDCF.

An unusual reversible color change in a gastric lesion during real-time endoscopy

During endoscopy, a light purple flat lesion suddenly appeared at the antrum and the lesion disappeared subsequently. This is an unusual reversible color change that is associated with blood flow, and that must be differentiated from neoplasia.

Usefulness and Limitations of a Serum Screening System to Predict the Risk of Gastric Cancer

Objective The aim of the present study was to evaluate the effectiveness and limitations of a serum screening system for predicting the risk of gastric cancer. Methods Serum pepsinogen I (PG I)/pepsinogen II (PG II) and Helicobacter pylori (HP) antibody levels were measured. Subjects were classified into four groupsaccording to their serological status (the ABC classification system). The grade of atrophic gastritis was assessed endoscopically. We evaluated gastric cancer detection rates according to the ABC classification system and the endoscopic grade of atrophy. Patients Individuals who underwent esophagogastroduodenoscopy (EGD) in a health check were prospectively enrolled in the present study. Results According to the ABC classification system, the gastric cancer detection rates in groups A, B, C, and D were 0.07% (4/6,105), 0.5% (8/1,739), 0.8% (16/2,010), and 1.1% (3/281), respectively. The gastric cancer detection rates in subjects with no atrophy, closed type (C-type) atrophy, and open type (O-type) atrophy were 0% (0/4,567), 0.2% (4/2,581), and 0.9% (27/2,987), respectively. In group A (HP(-)/PG(-)), the proportions of subjects with no atrophy, C-type atrophy, and O-type atrophy were 71.2%, 22.8%, and 6.0%, respectively. In group A, the gastric cancer detection rates in subjects with no atrophy, C-type atrophy, and O-type atrophy were 0%, 0.07%, and 0.8%, respectively. Conclusion The ABC classification system is useful for predicting the risk of gastric cancer. However, this system was limited in group A, which included individuals with a high risk of developing gastric cancer. An endoscopic diagnosis of atrophy may be more effective than the ABC classification system for predicting the risk of gastric cancer.

Efficacy and Safety of Adsorptive Granulocyte and Monocyte Apheresis in Elderly and Pregnant Patients With Ulcerative Colitis

In patients with active ulcerative colitis (UC), adsorptive granulocyte/monocyte apheresis (GMA) is expected to promote remission. We conducted a retrospective cohort study to evaluate the efficacy and safety of GMA in patients with active UC. Twenty-one UC patients including five pregnant or lactating mothers and four elderly patients (aged >60 years) received up to 10 GMA sessions. UC severity was evaluated at baseline and after GMA therapy according to Lichtiger's Clinical Activity Index (CAI). We defined clinical remission as CAI ≤4. Overall, the median CAI score after GMA therapy had decreased from 9 to 4 (P < 0.001). The clinical remission rate was 62%, but in the elderly and pregnant or lactating mothers, the remission rates were 100% and 60%, respectively. No severe adverse effects were seen in this study. Our results may support GMA as an effective and safe treatment for active UC patients, including elderly patients and pregnant cases.

Early tumor shrinkage (ETS) and deepness of response (DpR) in patients with metastatic esophageal cancer receiving a first-line treatment with DCF: Exploratory analysis of the JCOG0807

183

Background: ETS and DpR have been recognized as favorable prognostic factors of metastatic colorectal cancer. However, the effect of tumor shrinkage on clinical outcomes has not yet been reported for metastatic esophageal cancer (mEC). The purpose of the present study is to determine the associations of ETS and DpR with progression-free survival (PFS), post-progression survival (PPS), and overall survival (OS) in patients (pts) with mEC. Methods: This exploratory analysis included 53 pts, who received triplet chemotherapy with docetaxel (D) plus CF (cisplatin plus 5-fluorouracil) (DCF) as a first-line treatment during the JCOG0807. ETS after 8 weeks was defined as a relative change of 20% in the sum of the longest diameters of target lesions compared with baseline. DpR was defined as a relative change in the sum of the longest diameters of target lesions at the nadir compared with baseline. The cutoff level of DpR was 30%. PPS was calculated as follows: PPS = OS - PFS. Univariate and multivariate analysis using Cox proportional hazard model was performed to identify a predictor of PFS and OS. Results: Thirty-five of the 53 pts achieved ETS ≥ 20% after 8 weeks. Thirty-seven of the 53 pts achieved DpR ≥ 30%. Pts with ETS ≥ 20% showed longer PFS (7.5 vs. 3.4 months (M), p < 0.001, HR: 0.26, 95% CI 0.14–0.49), longer OS (13.8 vs. 6.1 M, p < 0.001, HR 0.20, 95% CI 0.11–0.39), and longer PPS (6.4 vs. 2.8 M, p = 0.002, HR 0.38, 95% CI 0.20–0.72). Further, pts with DpR ≥ 30% showed longer PFS (7.5 vs. 2.9 M, p < 0.001, HR 0.17, 95% CI 0.08–0.34), longer OS (13.8 vs. 6.0 M, p < 0.001, HR 0.14, 95% CI 0.07–0.27), and longer PPS (6.8 vs. 2.8 M, p < 0.001, HR 0.30, 95% CI 0.15–0.57). Multivariate analysis, including the following additional prognostic variables: age, ECOG PS, the lactate dehydrogenase level, and the number of organs with metastases revealed that ETS ≥ 20% and DpR ≥ 30% were predictors of PFS and OS. Conclusions: ETS and DpR were associated with longer PFS, OS, and PPS. They were also strongly prognostic of PFS and OS in mEC pts treated with DCF. These findings support the treatment strategy involving the highly effective triplet chemotherapy as a first-line treatment of mEC. Clinical trial information: UMIN000001737.

Phase I/II trial of 2-weekly docetaxel combined with cisplatin plus fluorouracil in metastatic esophageal cancer (JCOG0807)

We carried out a phase I/II trial of adding 2-weekly docetaxel to cisplatin plus fluorouracil (CF) therapy (2-weekly DCF regimen) in esophageal cancer patients to investigate its safety and antimetastatic activity. Patients received 2-weekly docetaxel (30 mg/m² [dose level (DL)1] or 40 mg/m² [DL2] with a 3 + 3 design in phase I, on days 1 and 15) in combination with fixed-dose CF (80 mg/m² cisplatin, day 1; 800 mg/m² fluorouracil, days 1–5) repeated every 4 weeks. The primary endpoint was dose-limiting toxicity (DLT) in phase I and central peer review-based response rate in phase II. At least 22 responders among 50 patients were required to satisfy the primary endpoint with a threshold of 35%. Sixty-two patients were enrolled in phase I and II. In phase I, 10 patients were enrolled with DLT of 0/3 at DL1 and 2/7 in DL2. Considering DLT and treatment compliance, the recommended phase II dose was determined as DL1. In phase II, the response rate was 62% (P < 0.0001; 95% confidence interval, 48–75%); median overall survival and progression-free survival were 11.1 and 5.8 months, respectively. Common grade 3/4 adverse events were neutropenia (25%), anemia (36%), hyponatremia (29%), anorexia (24%), and nausea (11%). No febrile neutropenia was observed. Pneumonitis caused treatment-related death in one patient. The 2-weekly DCF regimen showed promising antimetastatic activity and tolerability. A phase III study comparing this regimen with CF therapy is planned by the Japan Clinical Oncology Group. This study was registered at the UMIN Clinical Trials Registry as UMIN 000001737.

A phase I/II study of biweekly docetaxel (D) in combination with fixed-dose cisplatin plus fluorouracil (CF) in patients (pts) with advanced esophageal cancer (AEC) (JCOG0807)

e15016

Background: Thougha triplet chemotherapy with D plus CF (DCF) has shown promising activity, high incidence of adverse events (AEs) especially in febrile neutropenia (FN) was observed in previous studies for head and neck cancer (TAX323, 324) and gastric cancer (TAX325). To reduce its AEs with keeping activity, we conducted a multicenter open-label phase I/II study of biweekly D plus CF for AEC. Methods: Eligibility criteria included histologically proven AEC with measurable disease, age 20 to 75, non-resectable or recurrent disease, performance status (PS) 0 to 1. Pts received escalating doses of D (dose level (DL) 1: 30 mg/m2, DL 2: 40 mg/m2, on days 1, 15) in combination with fixed dose of CF (cisplatin 80 mg/m2 on day 1, fluorouracil 800 mg/m2on days 1-5) repeated every 4 weeks with 3+3 design in phase I part (P-I). The primary endpoint of P-I was dose limiting toxicity (DLT) and that of phase II part (P-II) was response rate (RR) defined by central peer review. Based on a SWOG two stage design (p0=35%, p1=50%; one-sided a=0.1, β =0.2) at least 22 responders among 50 eligible pts should be observed to satisfy the primary endpoint. Results: Between Feb 2009 and Mar 2010, 62 pts were enrolled for P-I and P-II. In P-I, 10 pts were enrolled with DLT of 0/3 in DL1 and 2/7 in DL2. Considering DLT and treatment compliance, the recommended dose for P-II was determined as DL1. Thus, 3 (P-I) and additional 52 pts (P-II) were analyzed: 53 for efficacy (excluded 2 ineligible pts) and 55 for safety. Pts characteristics were as follows: male/female 49/6, age median 61 (range 44 to 75), PS 0/1 39/16. The RR was 62% (95% confidence interval, 48-75%, p<0.0001) by central peer review. Median OS and PFS were 11.1 and 5.8 months. Grade 3/4 toxicity was observed in neutropenia (25%), anemia (36%), hyponatremia (29%), anorexia (24%) and nausea (11%). No grade 3/4 FN was observed. Treatment related death occurred in one patient due to pneumonitis. Conclusions: Biweekly D (30mg/m2) combined with CF showed promising activity and tolerability. A phase III study comparing CF with DCF is warranted. Clinical trial information: UMIN000001737.

Criteria for non-surgical treatment of perforation during colorectal endoscopic submucosal dissection

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has recently been applied in the treatment of large colorectal tumors. However, indications for emergent surgery and criteria for conservative treatment of perforation remain unclear. The aim of this study was to clarify the criteria for non-surgical treatment of perforation during colorectal ESD.

METHODS

219 colorectal tumors in 215 patients (136 men and 79 women; median age 69 years) were removed by performing ESD. The procedural outcomes, complications, prognoses, and criteria for non-surgical treatment of perforation were retrospectively analyzed by using our prospectively corrected database.

RESULTS

The en-bloc and complete en-bloc resection rates were 92.7% (203/219) and 85.8% (188/219), respectively. The rate of discontinued ESD was 2.3% (5/219). The immediate and delayed perforation rates were 5.0% (11/219) and 0%, respectively. One of these patients required emergent surgery because of a residual lesion and localized peritonitis caused by an unsuccessful closure. The other 10 patients recovered with conservative treatment after successful closure with hemoclips and complete resection. The defects in all patients were successfully closed by using hemoclips. None of the patients had signs of diffuse peritonitis. The other factors, i.e. absence of localized peritonitis, high-grade fever, and acceleration of inflammatory reaction, were not associated with the success or the failure of the non-surgical treatment.

CONCLUSIONS

The criteria for non-surgical treatment of perforation caused by colonic ESD were absence of diffuse peritonitis and successful closure.

Bile acid-induced expression of activation-induced cytidine deaminase during the development of Barrett's oesophageal adenocarcinoma

Activation-induced cytidine deaminase (AID) induces somatic mutations in various host genes of non-lymphoid tissues, thereby contributing to carcinogenesis. We recently demonstrated that Helicobacter pylori infection and/or proinflammatory cytokine stimulation triggers aberrant AID expression in gastric epithelial cells, causing mutations in the tumour-suppressor TP53 gene. The findings of the present study provide evidence of ectopic AID expression in Barrett's oesophagus and Barrett's oesophageal adenocarcinoma, a cancer that develops under chronic inflammatory conditions. Immunoreactivity for endogenous AID was observed in 24 of 28 (85.7%) specimens of the columnar cell-lined Barrett's oesophagus and in 20 of 22 (90.9%) of Barrett's adenocarcinoma, whereas weak or no AID protein expression was detectable in normal squamous epithelial cells of the oesophagus. We validated these results by analysing tissue specimens from another cohort comprising 16 cases with Barrett's oesophagus and four cases with Barrett's adenocarcinoma. In vitro treatment of human non-neoplastic oesophageal squamous-derived cells with sodium salt deoxycholic acid induced ectopic AID expression via the nuclear factor-kappaB activation pathway. These findings suggest that aberrant AID expression occurs in a substantial proportion of Barrett's epithelium, at least in part due to bile acid stimulation. Considering the genotoxic activity of AID, our current findings suggest that aberrant AID expression might enhance the susceptibility to genetic alterations in Barrett's columnar-lined epithelial cells, leading to cancer development.

Learning curve for endoscopic submucosal dissection of large colorectal tumors

BACKGROUND AND AIM

No studies have previously described the learning curve for colonic endoscopic submucosal dissection (ESD). The aim of the present study was to describe the learning curve for ESD of large colorectal tumors based on a single colonoscopist's experience.

METHODS

ESD was carried out for 120 colorectal tumors in 115 patients (68 males, median age 70 years). All procedures were carried out by a single experienced colonoscopist. The cases were grouped chronologically into three periods: (1st): cases 1-40; (2nd): cases 41-80; and (3rd): cases 81-120.

RESULTS

The learning curve was the changes in proficiency over time. Proficiency was expressed as procedure time per unit area of specimen. In the 1st, 2nd and 3rd periods, the proficiencies were 18.9, 12.6 and 12.9 (min/cm(2) ), respectively. The proficiencies in the 2nd and 3rd periods were significantly shorter than in the 1st period (t-test, P < 0.05). The en-bloc resection rates of the 1st, 2nd and 3rd periods were 92.5% (37/40), 90% (36/40) and 97.5% (39/40), respectively. The en-bloc and R0 resection rates of the 1st, 2nd and 3rd periods were 85% (34/40), 77.5% (31/40) and 92.5% (37/40), respectively. The perforation rates of the 1st, 2nd and 3rd periods were 12.5% (5/40), 5% (2/40) and 5% (2/40), respectively.

CONCLUSION

Based on our analysis of the learning curve, approximately 80 procedures must be carried out to acquire skill with ESD for large colorectal tumors. However, approximately 40 procedures were sufficient to acquire skill in avoiding perforations during the ESD procedure.

A comparison of outcomes of endoscopic submucosal dissection (ESD) For early gastric neoplasms between high-volume and low-volume centers: multi-center retrospective questionnaire study conducted by the Nagano ESD Study Group

OBJECTIVE

Outcomes of endoscopic submucosal dissection (ESD) for early gastric neoplasms at low-volume centers have been unknown, because all previous reports have studied in advanced single centers. The aim of this study was to compare ESD outcomes between high- and low-volume centers.

METHODS

A retrospective questionnaire survey was conducted and 30 centers (96.8%) responded. The complete en-bloc resection rate (CERR) and the incidence of complications were analyzed. Early gastric cancer (EGC) was divided into three categories on the basis of pathological diagnosis-standard indication (SI), expanded indication (EI) and out-of-indication (OI).

RESULTS

A total of 703 early gastric neoplasms (586 EGCs, 117 gastric adenomas) were treated with ESD from January to December 2005. The institutions that treated more than 30 cases a year were classified as high-volume centers, and those with less than 30 cases, low-volume centers. In SI, the CERRs at high- and low-volume centers were 92.1% and 91.1%, in EI, CERRs were 86.2% and 82.6% and in OI, CERRs were 80.3% and 88.0%. The perforation rates at high- and low-volume centers were 3.6% and 4.7%. The intra-operative bleeding rates at high- and low-volume centers were 0.26% and 0%, while the delayed bleeding rates were 0% and 0.63%.

CONCLUSION

There were no significant difference in the outcomes of ESD for early gastric neoplasms between high- and low volume centers.

[Successful treatment with 5-fluorouracil and cis-dichlorodiammineplatinum combined with 60Gy of radiation in a case of advanced esophageal cancer complicated with chronic renal failure treated with hemodialysis]

5-Fluorouracil(5-FU)and cis-dichlorodiammineplatinum(CDDP)combined with 60Gy of radiation was administered to a 65-year-old man with advanced esophageal cancer complicated with chronic renal failure treated with hemodialysis(HD). Continuous infusion of 5-FU 680mg/m(2) on Days 1-5 and 8-12, and drip infusion of CDDP 40mg/m(2) on Days 1 and 8 were administered twice with a 5-week interval. The CDDP dosage was reduced to 40% and HD was started 30 minutes after CDDP administration. Concurrent radiotherapy was started on Day 1 at 2Gy/d for 5d/week. The concentration of both free CDDP and total CDDP was measured using the atomic absorption method after the second treatment period. The area under the curve(AUC)of free CDDP was 3.3microg x h/ml. Both Grade 4 anemia and Grade 3 leukopenia were observed, but the renal failure did not progress. All toxicities were tolerable and the CDDP dose reduction and HD method were appropriate for the patient.

Endoscopic submucosal dissection of early esophageal cancer

In Japan, the majority of esophageal cancers are squamous cell carcinomas. Because no lymph node metastasis was reported in squamous cell carcinomas limited to the intraepithelial layer (m1) or proper mucosal layer (m2), the Japanese Esophageal Association recommended endoscopic mucosal resection (EMR) as the treatment of choice for these cancers. However, these lesions often spread laterally, exceeding the limits of en bloc resectability with conventional EMR methods such as the EMR cap method. The lesions resected in piece-meal manner with conventional EMR methods are prone to recur locally. Therefore, we developed a method of mucosal resection with a hook-knife that enables endoscopic submucosal dissection safely and achieves a high rate of en bloc resection for larger lesions. The median size of the resected specimen and cancer by our method was 32 mm (range, 8-76 mm) and 28 mm (range, 4-64 mm), respectively. The en bloc resection rate was 95% (95 of 102) and the local recurrence rate was 0% (0 of 102). This procedure was safe, with only 6 cases (6%) of mediastinal emphysema, which improved with conservative treatment. Endoscopic submucosal dissection with the hook knife is a method of endoluminal surgery enabling large en bloc resections without increased surgical risks.