[A Case of Diffuse Large B-Cell Lymphoma Which Was Diagnosed during the Best Supportive Care of Recurrent Ascending Colon Cancer]

A 70s male, who had undergone single-incision laparoscopic ileocecal resection for ascending colon cancer with pathological diagnosis of T3N3M0, Stage Ⅲc(without adjuvant chemotherapy), had enhanced-computed tomography(CT)for 3-month follow-up and a hepatic low-density area, an newly emergent nodule behind inferior vena cava and distal ileal tumor were found. Three months later, enhanced CT showed that the distal ileal tumor got exponentially larger and the diagnosis of"malignant lymphoma"was suspected. The patient became sepsis, so we planned and safely performed partial resection of the tumor. The pathological diagnosis was diffuse large B-cell lymphoma. Postoperative course was smooth except for the Clostridium difficile colitis and he was discharged on postoperative day 19. Although the regrowth of the remnant tumor was observed soon after surgery, partial response was confirmed after introduction of systemic chemotherapy. When we cope with malignant lymphoma of small intestine, we need to keep it in mind that surgery is an option for the prevention of perforation and bacterial translocation.

Small bowel adenocarcinoma in Crohn's disease: a systematic review and meta-analysis of the prevalence, manifestation, histopathology, and outcomes

BACKGROUND AND AIMS

Small bowel adenocarcinoma (SBA) is a rare neoplasm that is associated with Crohn's disease (CD). This study aims to quantify the prevalence of CD-SBA, review the current evidence of histopathology and molecular analysis findings, and identify the clinical presentation and outcomes of CD-SBA.

METHODS

Electronic databases Medline and Embase were searched for articles describing SBA in inflammatory bowel disease patients. The histopathology, molecular analysis findings, clinical presentation, prevalence, and outcomes of CD-SBA were extracted, and results were pooled with random effects.

RESULTS

In total, 33 articles were included in the analysis. Prevalence of SBA was 1.15 (CI: 0.31-2.33) per 1000 CD patients. Only 11% (CI: 0.04-0.21) of CD-SBA patients had observable radiological features. CD-SBA was most commonly found in the ileum (84%), diagnosed at stage 2 (36%), with main presenting complaints including obstruction, weight loss, and abdominal pain. Significant histopathological findings included adjacent epithelial dysplasia, and an equal distribution of well-differentiated (49%) and poorly differentiated subtypes (46%). Most prevalent genetic mutation was KRAS mutation (18%), followed by mismatch repair deficiency (9.7%). The 5-year overall survival for CD-SBA patients was 29% (CI: 0.18-0.41), and 33% (CI: 0.26-0.41) for de novo SBA. No statistically significant increase in risk for CD-SBA was noted for treatment with thiopurines, steroids, and 5-ASA.

CONCLUSION

Our meta-analysis found the prevalence of CD-SBA to be 1.15 per 1000 CD patients. The 5-year overall survival for CD-SBA was poor. The presenting symptoms were non-specific, and therefore the diagnosis requires a high index of suspicion.

[A Case of Metastatic Small Intestinal Tumor Diagnosed with Intestinal Obstruction]

A 76-year-old man with a past history of liver transplantation because of liver cirrhosis visited a hospital in October 2018 because of vomiting and abdominal pain. Although the patient underwent conservative medical treatment, no improvement of the symptoms was observed, and he received consultation at our hospital. After thorough examination, and because of the policy of inpatient treatment after the diagnosis of adhesion ileus obstruction post liver transplantation surgery, intestinal decompression was performed using an ileus tube. However, there was no improvement in the symptoms even after inserting the ileus tube, and intestinal obstruction was diagnosed in November 2018. During the preoperative examination, a tumorous shadow was found in the right lung, although it became a policy of scrutiny after improvement of the bowel obstruction. During the laparotomy, a macroscopic tumor exposed on the serosal surface was observed on the anal side at 120 cm from the Treitz ligament, and this site was considered to be the blocking origin. Partial resection of the small intestine including the blockage site was performed. The pathological result revealed the diagnosis of adenosquamous carcinoma. Furthermore, immunostaining was CK7 positive, CK20 negative, TTF-1 negative, and Napsin negative, suggesting the possibility of a metastatic tumor derived from lung cancer. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. On day 30 after surgery, the left pleural effusion increased and pleural effusion cytology revealed a diagnosis of primary lung adenocarcinoma Stage Ⅳ. Considering the patient's PS, it became a best supportive care(BSC)policy after consultation with the family, and it ended on postoperative day 70. Here, we report about a case diagnosed with metastatic small bowel cancer and intestinal obstruction and conduct a literature review.

[A Case of Laparoscopic Assisted Resection for Small Intestinal Cancer Diagnosed Preoperatively]

A 50-year-old woman was admitted to our hospital due to intermittent epigastric pain and vomiting for 2 months. Contrast enhanced CT scan showed stenosis in the upper jejunum. She was diagnosed with small intestinal ileus. A small enteroscopy revealed a peripheral type 2 lesion in the upper jejunum, approximately 10 cm from the Treitz's ligament. Upon biopsy, she was diagnosed with a well-differentiated adenocarcinoma. A laparoscope-assisted extracorporeal operation was performed due to the ease of raising the umbilical wound. Swollen lymph nodes were found in the mesentery. A surgical margin of 5 cm on the oral side and 20 cm on the anal side was secured. We performed partial resection of the small intestine, including the mesentery with the enlarged lymph nodes. The histopathological diagnosis was a Type 2, 3×2 cm, tub2, pT4aN1aM0, pStage Ⅲb small intestinal cancer. Due to the development of small intestinal ileus, the small bowel cancer was diagnosed preoperatively. Hence, it was slightly we will report including the literature consideration of.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

Abdominal CT Findings in Patients with Primary Lymphoma Causing Small Bowel Obstruction

The purpose of this study was to investigate retrospectively CTfindings in patients with primary lymphoma causing small bowel obstruction. CTscans of 11 patients with small bowel lymphoma were separately analysed in terms of affected section of the small bowel, focality, wall thickness, pattern and degree of contrast enhancement, lymphadenopathy, organ involvement, perforation, and the presence of intraabdominal fluid. Eight patients had diffuse large B-cell lymphoma, and one patient each had marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT), T-cell lymphoma, and anaplastic T-cell lymphoma. Affected sections of the bowels involved were jejunum (n=5, 45.4%), ileum (n=2, 18.1%), and one case (9%) each of distal ileum, distal jejunum, distal jejunum and ileum, and distal jejunum and colon. Primary gastrointestinal (GI) lymphoma is an uncommon disease, that may lead to small bowel obstruction sometimes.

[CD56-positive peripheral T-cell lymphoma primarily presenting with tonsillar swelling]

A 51-year-old woman was admitted to our hospital with tonsillar swelling. After tonsillectomy was performed, she was diagnosed as having CD56-positive T-cell lymphoma, mainly composed of small and medium-sized atypical cells. An immunohistochemical study showed that the malignant lymphocytes were positive for CD3, CD8, CD56, TIA-1 and granzyme B, while negative for CD20, CD5 and CD10. Flowcytometry demonstrated the lymphocytes were positive for CD56. Southern blot analysis revealed a rearrangement of the T-cell receptor gamma chain. The disease stage by Ann Arbor staging classification was II B. We provided MCEC therapy followed by autologous peripheral blood stem cell transplantation, and complete remission (CR) was achieved. Two months after CR, however, the patient relapsed with peritonitis due to perforation of an ileal tumor, and died of sepsis. It is rare for CD56-positive T-cell lymphoma to occur primarily in the tonsils. Because small bowel ulcers were revealed during the course of induction chemotherapy, we report a valuable case in which suspected CD56-positive enteropathy-type T-cell lymphoma (ETL) occurred primarily in the tonsils.

Comparison of tissue culture and animal models for assessment of Cryptospridium parvum infection

The current increased interest for using tissue culture as a surrogate for mouse infection to assess Cryptospridium viability suggests that a comparison of the two models is essential for data interpretation. Therefore, a need remains for a statistical comparison that can demonstrate if infection and inactivation predicted by new tissue culture models are comparable with those predicted by animal models. Data from a total of 31 dose-response trials using both tissue culture and mouse models to assess C. parvum infectivity were compared. The dose needed to infect 50% of the tissue cultures (ID(50)) was also compared to each ID(50) in mice. Average ID(50)s developed using the logit dose-response method for tissue culture and mice were 8 and 107, respectively, suggesting that tissue culture was more sensitive to infection. However, correlation (r) between tissue culture and mouse infectivity was statistically significant (0.9167 [95% CI=0.8428 to 0.9594, p<0.0001]). Comparison of oocyst disinfection by UV and chlorine dioxide showed no significant difference between inactivation predicted by tissue culture and mouse models (p=0.8893; t=0.0141; n=21). These results demonstrate that tissue culture can successfully be used to measure C. parvum infection and can be used for determining inactivation in disinfection studies.

Five new diprenylated flavonols from the leaves of Broussonetia kazinoki

Five new diprenylated flavonols, broussonol A (1), broussonol B (2), broussonol C (3), broussonol D (4), and broussonol E (5), along with two known compounds, were isolated from an ethanolic extract of the leaves of Broussonetia kazinoki. Their structures were elucidated by chemical and spectral methods. Cytotoxic activities were evaluated against several different cell lines.

[Imaging of orbital metastasis of small-intestine carcinoid by octreotide scintigraphy. A critical evaluation of the methodology]

BACKGROUND

An orbital carcinoid metastasis can be specifically imaged by octreotide scintigraphy. Orbital metastases of carcinoid tumors are rare. In the current literature only 27 cases have been published.

CASE REPORT

We report on a 59 year-old woman who presented with diplopia 6 years after resection of a carcinoid tumor of the ileum. She also complained about flush and diarrhea. The diplopia was caused by limited extensibility of the right inferior muscle. Computed tomography with contrast revealed an enhancing tumor in the area of the right inferior rectus muscle, which appeared in the MRT as an isointense structure in the T1-weighted image. On staging, we found a contrast-enhancing nodular hepatic lesion. In octreotide scintigraphy, enhancement of the liver, thoracic and abdominal para-aortic lymph nodes and of the right inferior orbit was found.

CONCLUSION

The survival times of patients with orbital metastasis of carcinoid tumors range between 7 months and 11 years. No specific treatment is available. Surgical excision is indicated for a symptomatic solitary metastasis. Octreotide is helpful in two ways: (1) as a radiolabeled tracer to detect extra-abdominal and extrahepatic secondary tumors; (2) as a treatment modality for flush and diarrhea, which is successful in over 60% of patients (life expectancy uninfluenced). Our patient is presently being treated with 200 micrograms of octreotide three times a day subcutaneously. Flush episodes and diarrhea have been reduced, but her ophthalmologic symptoms remain unchanged, and she has recently developed cardiac insufficiency.

Efficacy of select antivirals against Cryptosporidium parvum in vitro

Cryptosporidium parvum is an intestinal pathogen associated with diarrheal disease in both humans and animals. Currently, no effective therapy exists to eliminate the parasite in the absence of a healthy, intact immune system. We used an in situ, enzyme-linked immunosorbent assay (ELISA) as a primary screen to examine the effects of 13 antivirals on the development of C. parvum in human ileocecal adenocarcinoma (HCT-8) cells in vitro. Six of the compounds displayed some efficacy, and dose-response curves and toxicity assays were generated for each of the six compounds. All six were nucleoside analogs, and five of the six were structurally related. These results suggest one potential strategy for therapeutic intervention of C. parvum may be the use and development of certain types of nucleoside analogs.

P-glycoprotein-mediated multidrug resistance is modulated by pretreatment with chemosensitizers in HCT-8 carcinoma cells in vitro

The effects of pretreatment with the multidrug resistance (MDR) modulators verapamil (VPM), tamoxifen (TMX), cyclosporin A (CsA), and SDZ PSC833 (PSC) on drug sensitivity of the P-glycoprotein (Pgp) expressing human ileocecal carcinoma cell line HCT-8 is described. Following pretreatment of 2, 16 and 48 h with the individual modulators, rhodamine 123 efflux (RHO), transepithelial vinblastine transport (VIN) across treated HCT-8 monolayers, and chemosensitivity to doxorubicin (DOX) were determined and compared to Pgp protein expression and phosphorylation. After 2 h, VPM, TMX, CsA and PSC inhibited RHO efflux and VIN transport and increased the chemosensitivity of HCT-8 to DOX significantly. Prolonged exposure failed to further increase inhibition of Pgp-mediated transport, but in contrast maximized phosphorylation of Pgp (16 h) and Pgp protein expression (48 h), respectively.

Simplified methods for obtaining purified oocysts from mice and for growing Cryptosporidium parvum in vitro

Seven- to 8-day-old Arc/Swiss mice were infected with 100,000-120,000 Cryptosporidium parvum oocysts. At 8 days postinfection (PI) the jejunum, ileum, cecum, colon, and rectum were removed. Using a simple extraction procedure and purification by Ficoll gradient centrifugation, we rountinely obtained between 3-6 million and up to 15 million purified oocysts per mouse. For in vitro cultivation, purified oocysts were pretreated in a low pH (2.5-3) 0.5% trypsin solution for 20 min, resuspended in supplemented RPMI-1640 containing glucose 0.1 g (5.55 mM), sodium bicarbonate 0.3 g, bovine bile 0.02 g, folic acid 25 micrograms, 4-aminobenzoic acid 100 micrograms, calcium pantothenate 50 micrograms, ascorbic acid 875 micrograms, penicillin G 10,000 U and streptomycin 0.01 g per 100 ml, and 1% fetal bovine serum (pH 7.4 before filtration), and used to inoculate confluent monolayers of the human adenocarcinoma cell line HCT-8. Incubation was in a candle jar at 37 C. We tested numerous supplements to RPMI-1640, different pHs, and atmospheric conditions and found the parameters described above produced the greatest parasite numbers in vitro. We obtained significantly superior growth of C. parvum grown in HCT-8 cells using the conditions described above than in culture conditions described previously.

Carcinoid metastasis in the middle ear: anaesthetic and surgical management

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Malignant diathesis from jejunal-ileal carcinoids

A facet of carcinoid tumors often not recognized is their close association with other, noncarcinoid malignancies. The clinical course of two patients with multiple ileal-jejunal carcinoids and multiple other noncarcinoid malignancies is described. These patients were found to have elevated circulating levels of gastrin, bombesin, glucagon, enteroglucagon, pancreatic polypeptide, and peptide tyrosine tyrosine. These regulatory peptides have been demonstrated to promote trophic effects on the gastrointestinal tract as well as malignant tumors. We propose that the release of these bioactive hormones into the portal and systemic circulation by carcinoid tumors may play some role in their association with these multiple second tumors.

Carcinoid of the small intestine

Carcinoid tumour was the most common small bowel tumour found in this series of 179 patients. It occurred in 24% of patients. Forty-six percent of patients were asymptomatic during life, the tumours being found either at autopsy or during other surgical procedures. Of those that were symptomatic, half presented with intestinal obstruction and the rest with long-standing symptoms. An abdominal mass, which occurred in 14% of cases, is an uncommon physical finding since the majority present as small submucosal tumors. Fifty-eight per cent overall and 72% of those having surgery had evidence of regional spread, either by local invasion or in the form of regional nodal involvement. Seven per cent of patients have died of their disease. Excisional surgery should be performed for all cases where feasible, and repeated for recurrent symptoms.

Acute small bowel obstruction due to endometriosis

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