Gastric type III heterotopic pancreas presenting as adenomyoma in the antrum of the stomach: a case report

Although heterotopic pancreas usually occurs in the stomach and rarely presents as a submucosal tumor, an accurate preoperative diagnosis is often difficult because of the variety of clinical symptoms and findings depending on the size and location of the lesion. We experienced a case of gastric type III heterotopic pancreas presenting as a gastric adenomyoma in the antrum of the stomach. A 62-year-old woman visited a local hospital for epigastric discomfort. An esophagogastroduodenoscopy study indicated a submucosal tumor in the greater curvature of the gastric antrum. The patient underwent surgical resection of the tumor because it was enlarged. The histological sections of the resected specimen showed that the tumor was composed of ductular structures lined by tall columnar epithelia and a prominent smooth muscle stroma with no atypical cells. The tumor was compatible with Heinrich's type III heterotopic pancreas, which presented as an adenomyoma of the stomach. These findings provide useful histological features and some insight into a better understanding of the embryonic origin and development of adenomyoma and heterotopic pancreas in the antrum of the stomach.

Assessment of the albumin-bilirubin grade as a prognostic factor in patients with non-small-cell lung cancer receiving anti-PD-1-based therapy

Introduction

The albumin-bilirubin (ALBI) grade is a novel indicator of the liver function. Some studies showed that the ALBI grade was a prognostic and predictive biomarker for the efficacy of chemotherapy in cancer patients. The association between the ALBI grade and outcomes in patients with non-small-cell lung cancer (NSCLC) treated with cancer immunotherapy, however, is poorly understood.

Methods

We retrospectively enrolled 452 patients with advanced or recurrent NSCLC who received anti-programmed cell death protein 1 (PD-1)-based therapy between 2016 and 2019 at three medical centers in Japan. The ALBI score was calculated from albumin and bilirubin measured at the time of treatment initiation and was stratified into three categories, ALBI grade 1-3, with reference to previous reports. We examined the clinical impact of the ALBI grade on the outcomes of NSCLC patients receiving anti-PD-1-based therapy using Kaplan–Meier survival curve analysis with log-rank test and Cox proportional hazards regression analysis.

Results

The classifications of the 452 patients were as follows: grade 1, n = 158 (35.0%); grade 2, n = 271 (60.0%); and grade 3, n = 23 (5.0%). Kaplan–Meier survival curve analysis showed that the ALBI grade was significantly associated with progression-free survival and overall survival. Moreover, Cox regression analysis revealed that the ALBI grade was an independent prognostic factor for progression-free survival and overall survival.

Conclusion

The ALBI grade was an independent prognostic factor for survival in patients with advanced or recurrent NSCLC who receive anti-PD-1-based therapy. These findings should be validated in a prospective study with a larger sample size.

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ALBI grade is calculated from albumin and bilirubin.

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We evaluated the impact of ALBI grade on survival in NSCLC patients receiving immune checkpoint inhibitors.

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ALBI grade was an independent prognostic factor for progression-free survival (PFS) and overall survival (OS).

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ALBI grade effectively stratified PFS and OS in patients with performance status 1-3.

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ALBI grade was significantly associated with PFS and OS, regardless of programmed death ligand-1.

Computer-Based Exercises in Anemia Diagnosis (PlanAlyzer)

PlanAlyzer is a microcomputer-based, event-driven system for instructional research in medical education. Aimed at the second year medical student, PlanAlyzer elicits and critiques a student´s approach to the diagnosis of a common medical disorder. In this paper we discuss the concept, development, implementation and formative evaluation of the PlanAlyzer system for the evaluation of anemia.

A multicenter phase II study of carboplatin and paclitaxel for advanced thymic carcinoma: WJOG4207L

BACKGROUND

Thymic carcinoma (TC) is an exceptionally rare tumor, which has a very poor prognosis differing from thymoma. Till date, there has been no report of any results of clinical trials focusing on TC. The role of non-anthracycline-based chemotherapy has not been elucidated since the previous studies included a relatively small number of TC patients. This single-arm study evaluated carboplatin and paclitaxel (CbP) in chemotherapy-naive patients with advanced TC.

PATIENTS AND METHODS

The study treatment consisted of carboplatin (area under the curve 6) and paclitaxel (200 mg/m(2)) every 3 weeks for a maximum of six cycles. The primary end point was objective response rate (ORR) by independent review. The secondary end points included overall survival (OS), progression-free survival (PFS), and safety. Based on the SWOG 2-stage design, the planned sample size of 40 patients was determined to reject the ORR of 20% under the expectation of 40% with a power of 0.85 and a type I error of 0.05.

RESULTS

Forty patients from 21 centers were enrolled for this study from May 2008 to November 2010. Of the 39 patients evaluable for analysis, 36 were pathologically diagnosed by independent review, and 97% patients were eventually TC. There was 1/13 complete/partial responses with an ORR of 36% (95% confidence interval 21%-53%; P = 0.031). The median PFS was 7.5 (6.2-12.3) months, while OS did not reach the median value. Major adverse event was grade 3-4 neutropenia in 34 patients (87%). There was no treatment-related death.

CONCLUSIONS

In this largest trial with TC, CbP showed promising efficacy in advanced TC when compared with anthracycline-based chemotherapy, which is the current standard treatment of thymic neoplasm. Our results established that CbP, one of the standard treatments for non-small-cell lung cancer, might be an option as a chemotherapy regimen for TC.

Bence-Jones protein-type myeloma with amyloid myopathy presenting as amyloidomas and extensive amyloid deposits in the muscularis propria: a rapidly fatal autopsy case

This study reports a 59-year-old man who suffered from multiple skeletal muscle amyloidomas and showed a rapidly fatal course. He noticed left inguinal pain and gait disturbance due to muscle weakness of the left leg. Protein in urine (3.3 g/d) and Bence-Jones protein of the κ type (2.3 g/d) were detected. Bone marrow aspiration showed 11.6% monoclonal plasma cells in nucleated cells. A core needle-biopsied and resected left inguinal tumor showed the deposition of eosinophilic amorphous materials positive for Congo red stain and the κ-light chain. He was diagnosed with plasma cell myeloma with AL (amyloid light chain) amyloidosis. Multiple soft-part tumors developed, grew rapidly, and he died 3 months after admission. At autopsy, 3 large amyloidomas were observed in the skeletal muscles, and prominent amyloid deposits were also seen in the diaphragm, intercostal muscle, iliopsoas muscle, and cervical skeletal muscles examined. Massive amyloid materials deposited diffusely in the propria muscularis of the gastrointestinal tract: the tongue to the rectum.

LKB1 mutations in mucinous bronchioloalveolar carcinoma occurring in Peutz-Jeghers syndrome patients

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Background: Mutations in the gene encoding Liver Kinase B1, LKB1, are common in patients with Peutz-Jeghers syndrome (PJS), which is characterized by mucocutaneous pigmentation, intestinal polyps and a high incidence of cancers at variable sites (colorectal, gynecological, breast, pancreas, and lung). Although tumors occurring in PJS patients are known to contain mucin-rich conmponents, mucinous bronchioloalveolar carcinomas (mBACs) arising from the PJS background have only rarely been reported. Here we report two mBAC patients with PJS. We further explored the LKB1 gene in these two patients and, in addition, eight sporadic mBAC patients. Methods: Frozen tissue specimens were collected from ten mBAC patients who underwent surgery in our department from 2002 to 2008, and high molecular weight genomic DNA was extracted from them and stocked in the bio-bank. Written informed consent was obtained from each patient, and ethical approval was obtained from the IRB. The nucleotide sequence of LKB1 (EX01–09) was determined by genomic PCR-direct sequencing. Loss of heterozygosity (LOH) was analyzed by high resolution fluorescent microsatellite analysis (HRFMA) using two microsatellite markers that encompass the LKB1 locus, D19S886 and D19S565. Results: Among 11 tumors derived from the 10 patients, 9 distinct LKB1 mutations were found in 7 tumors (4 G:C to A:T transitions; 3 G:C to C:G transversions; 2 single nucleotide insetion/deletion). All of three tumors obtained from the two PJS patients harbored a same sequence alteration. Although LOH was not observed in these tumors, independent sequence alterations were found in two of the three tumors, which may suggest biallelic inactivation of LKB1 in tumors occurred in the PJS patients. Conclusions: The relatively high frequency of LKB1 mutation in mBAC patients may suggest its implication in lung carcinogenesis, at least in mBAC, and its potential as a therapeutic target.

[Table: see text]

No significant financial relationships to disclose.

Aggressive carcinoid tumors arising in the duodenum, ileum, and rectum with liver metastasis: a report of three cases

Three aggressive carcinoid tumors with liver metastasis arising in the duodenum (Case 1, 72-year-old man), ileum (Case 2, 72-year-old man), and rectum (Case 3, 67-year-old woman) were studied. Case 1 initially suffered from hemorrhage from an exophytic large tumor and developed a liver metastasis after operation. Cases 2 and 3 first presented as multiple liver metastases. Case 3 had a small submucosal tumor and showed a relatively high cell proliferation activity. Neoplastic cells expressed gastrin in Case 1, serotonin in Case 2, and did not express several peptides in Case 3.

Mitochondrial signal lacking manganese superoxide dismutase failed to prevent cell death by reoxygenation following hypoxia in a human pancreatic cancer cell line, KP4

One of the major characteristics of tumor is the presence of a hypoxic cell population, which is caused by abnormal distribution of blood vessels. Manganese superoxide dismutase (MnSOD) is a nuclear-encoded mitochondrial enzyme, which scavenges superoxide generated from the electron-transport chain in mitochondria. We examined whether MnSOD protects against hypoxia/reoxygenation (H/R)-induced oxidative stress using a human pancreas carcinoma-originated cell line, KP4. We also examined whether MnSOD is necessarily present in mitochondria to have a function. Normal human MnSOD and MnSOD without a mitochondrial targeting signal were transfected to KP4 cells, and reactive oxygen species, nitric oxide, lipid peroxidation, and apoptosis were examined as a function of time in air following 1 day of hypoxia as a H/R model. Our results showed H/R caused no increase in nitric oxide, but resulted in increases in reactive oxygen species, 4-hydroxy-2-nonenal protein adducts, and apoptosis. Authentic MnSOD protected against these processes and cell death, but MnSOD lacking a mitochondrial targeting signal could not. These results suggest that only when MnSOD is located in mitochondria is it efficient in protecting against cellular injuries by H/R, and they also indicate that mitochondria are primary sites of H/R-induced cellular oxidative injuries.

Overexpression of mitochondrial manganese superoxide dismutase protects against radiation-induced cell death in the human hepatocellular carcinoma cell line HLE

We investigated the potential role of mitochondrial manganese superoxide dismutase (Mn-SOD) in protective activity against irradiation by analyzing cell viability by a colony formation assay and by detecting apoptosis in stably human Mn-SOD gene-transfected HLE, a hepatocellular carcinoma cell line. We found that overexpression of Mn-SOD reduced the levels of reactive oxygen species in the mitochondria and intracellular phospholipid peroxidation product (4-hydroxy-2-nonenal) and prevented cell death. The production of intracellular nitric oxide after irradiation was not changed by Mn-SOD overexpression. The results suggested that Mn-SOD might play an important role in protecting cells against radiation-induced cell death by controlling the generation of mitochondrial reactive oxygen species and intracellular lipid peroxidation.

[Long-term clinical course and prognosis of patients with Crohn's disease]

The aim of the present study is to clarify long-term clinical course, prognosis and factors influencing prognosis of patients with Crohn's disease suffering for more than 10 years. Sixty-eight patients (47 males, 21 females) with Crohn's disease in whom the clinical course could observed well at our hospital for more than 10 years were studied. We classified these patients into three groups (good, fair, bad) according to their changes of IOIBD assessment score. And we compaired some clinical factors in these groups to clarify factors influencing prognosis. The results were as follows: 1) Twelve patients (18%) were in good prognosis group, and 24 patients (35%) in fair one, and 32 patients (47%) in bad one. 2) IOIBD assessment score at the time of diagnosis, site of leision, and radiographic findings at the time of diagnosis showed significant difference between bad prognosis group and the other two groups. Although there have been many reports that Crohn's disease is generally progressive, our results indicated that more than half of the patients showed favorable prognosis during the follow-up period for more than ten years.

Beclomethasone dipropionate administration via cecostomy in ulcerative colitis

Beclomethasone dipropionate was administered via a cecostomy to four patients with active ulcerative colitis that was refractory to conventional glucocorticosteroid therapy. From a tube cecostomy, beclomethasone dipropionate solution was administered continuously throughout the day. Clinical manifestations, laboratory examinations, and endoscopic and/or radiographic findings markedly improved within 1-2 wk. A serial decrease in the index of disease activity was observed from the time administration began (mean score, 226.0) to 2 wk later (137.4 points). An excellent clinical response was recognized without any significant side effects, and the urgent need for total colectomy was avoided in all four patients.

Significant efficiency findings while controlling for the frequent confounders of CAI research in the PlanAlyzer project's computer-based, self-paced, case-based programs in anemia and chest pain diagnosis

Richard E. Clark in his widely published comprehensive studies and meta-analyses of the literature on computer assisted instruction (CAI) has decried the lack of carefully controlled research, challenging almost every study which shows the computer-based intervention to result in significant post-test proficiency gains over a non-computer-based intervention. We report on a randomized study in a medical school setting where the usual confounders found by Clark to plague most research, were carefully controlled. PlanAlyzer is a microcomputer-based, self-paced, case-based, event-driven system for medical education which was developed and used in carefully controlled trials in a second year medical school curriculum to test the hypothesis that students with access to the interactive programs could integrate their didactic knowledge more effectively and/or efficiently than with access only to traditional textual "nonintelligent" materials. PlanAlyzer presents cases, elicits and critiques a student's approach to the diagnosis of two common medical disorders: anemias and chest pain. PlanAlyzer uses text, hypertext, images and critiquing theory. Students were randomized, one half becoming the experimental group who received the interactive PlanAlyzer cases in anemia, the other half becoming the controls who received the exact same content material in a text format. Later in each year there was a crossover, the controls becoming the experimentals for a similar intervention with the cardiology PlanAlyzer cases. Preliminary results at the end of the first two full trials shows that the programs have achieved most of the proposed instructional objectives, plus some significant efficiency and economy gains. 96 faculty hours of classroom time were saved by using PlanAlyzer in their place, while maintaining high student achievement. In terms of student proficiency and efficiency, the 328 students in the trials over two years were able to accomplish the project's instructional objectives, and the experimentals accomplished this in 43% less time than the controls, achieving the same level of mastery. However, in spite of these significant efficiency findings, there have been no significant proficiency differences (as measured by current factual and higher order multiple choice post-tests) between the experimental and control groups. Very careful controls were used to avoid what Clark has found to be the most common confounders of CAI research. Accordingly, this research proved Clark's rival hypothesis, that the computer, in itself, does not appear to contribute to proficiency gains, at least as measured by our limited post-testing. Clark's position is that the computer is primarily a vehicle--as is either a pill or a hypodermic needle for delivering a drug.(ABSTRACT TRUNCATED AT 400 WORDS)

Findings from an evaluation of PlanAlyzer's double cross-over trials of computer-based, self-paced, case-based programs in anemia and chest pain diagnosis

We report on three years of research trials of the PlanAlyzer I Project--a carefully controlled research study using a microcomputer-based, self-paced, case-based, event-driven system for medical education. PlanAlyzer presents cases, elicits and critiques a second year student's approach to the diagnosis of anemias and chest pain. PlanAlyzer uses text, hypertext, images and critiquing theory. Students were randomized, one half becoming the experimental group who received the interactive PlanAlyzer cases in anemia, the other half becoming the controls who received the exact same content material in a text format. Later in each year there was a crossover, the controls becoming the experimentals for a similar intervention with the cardiology PlanAlyzer cases. Results at the end of the first two years of trials show that the programs have achieved some significant efficiency and economy gains. 96 faculty hours of classroom time were saved by using PlanAlyzer in their place, with no loss in student achievement. In terms of student proficiency and efficiency, combining the anemia and cardiology trials, the 328 students in the two years of full scale trials were able to accomplish the project's instructional objectives. The experimentals accomplished this in 43% less time than the controls. On the average, for both the anemia and chest pain programs, this amounted to students spending 7.5 hours longer on the 30 text cases than on the same 30 computer cases to achieve the same level of mastery. There have been no significant proficiency differences (as measured by current post-tests) between the experimental and control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer-based exercises in anemia diagnosis (PlanAlyzer)

PlanAlyzer is a microcomputer-based, event-driven system for instructional research in medical education. Aimed at the second year medical student, PlanAlyzer elicits and critiques a student's approach to the diagnosis of a common medical disorder. In this paper we discuss the concept, development, implementation and formative evaluation of the PlanAlyzer system for the evaluation of anemia.

Significance of mitochondrial enhancement in hepatic energy metabolism in relation to alterations in hemodynamics in septic pigs with severe peritonitis

Liver mitochondrial phosphorylative activity, hepatic adenine nucleotides, and hemodynamic parameters were studied in 23 pigs with peritonitis induced by cecal ligation and perforation. Between 2 and 7 days after treatment, the onset of an apparent hyperdynamic state, characterized by an increased cardiac index and decreased total peripheral resistance index, occurred. In this period, the energy charge level was barely maintained and the occurrence of liver mitochondrial enhancement was observed. However, 10-14 days after treatment, the onset of a hypodynamic state with its inverse patterns in hemodynamics took place. In this period, the energy charge level fell to 0.68, concomitant with a marked decrease in mitochondrial function. Further, a high positive correlation between the cardiac index and liver mitochondrial phosphorylative activity was noted (r = 0.85, p less than 0.01). These results suggest that liver mitochondria play a major role in the metabolic and hemodynamic adaptations occurring during sepsis.

Clinical experience of postoperative hepatic failure treatment with pig or baboon liver cross-hemodialysis with an interposed membrane

The present study emphasizes the principle of using liver support to restore the blood ketone body ratio (acetoacetate/beta-hydroxybutyrate), which reflects the redox potential of liver mitochondria and correlates with hepatic energy charge (ATP + 0.5ADP/ATP + ADP + AMP). Eleven surgical patients with grade IV hepatic coma were treated by an ex vivo pig or baboon liver cross-hemodialysis with an interposed Cuprophan membrane when their blood ketone body ratios had decreased to below 0.4 compared with the normal of above 0.7. Three patients were treated by cross-hemodialysis using a standard Cuprophan membrane dialyzer without increase of blood ketone body ratio and without marked beneficial effect. However, five of eight patients who had blood ketone body ratios of above 0.25 became fully alert after treatment by cross-hemodialysis using the larger pore size and greater surface area Cuprophan membrane, concurrent with a rise in the decreased blood ketone body ratio, and three of them were later discharged. By contrast, in the three patients with blood ketone body ratios below 0.25, there was no restoration of consciousness and no improvement in their blood ketone body ratios by this liver support. It is suggested that, as long as the blood ketone body ratio remained over 0.25, this metabolic liver support is effective in restoring grade IV hepatic coma.

The effects of heterologous liver cross-hemodialysis on adenylate energy charge of the remnant liver after major hepatic resection

The effect of liver support on the adenylate energy charge (ATP + 0.5ADP)/(ATP + ADP + AMP) of the remnant liver after major hepatic resection was studied in rabbits. The present study emphasized the principle of restoring the decreased energy charge level of the remnant liver after major hepatic resection by use of an ex vivo heterologous liver cross-hemodialysis with an interposed Cuprophan membrane. The energy charge level provides the cell with a very sensitive intracellular control mechanism. Regulatory enzymes from biosynthetic sequences exhibit very little activity at low levels of energy charge, and their activities increase sharply at high-energy charge levels. The energy charge level of the remnant liver maximally decreased from the control level of 0.860 to 0.767 at 24 hours after 70% hepatectomy. The energy charge level increased from 0.767 to 0.857 after two hours of cross-hemodialysis with an interposed Cuprophan membrane between the 24-hour, 70% hepatectomized rabbit and an ex vivo pig liver with high energy charge. The above results suggest that this ex vivo pig cross-hemodialysis may be effective for biosynthesis in the regenerative processes of the remnant liver.