Fumika Orii

Expression of glucocorticoid receptor β in lymphocytes of patients with glucocorticoid-resistant ulcerative colitis

BACKGROUND & AIMS Recently, the glucocorticoid receptor beta (hGRbeta) was suggested to play a role as a dominant negative regulator for determining glucocorticoid response. The aim of this study was to clarify whether reverse-transcription polymerase chain reaction (RT-PCR) analysis of hGRbeta messenger RNA (mRNA) can predict the response to glucocorticoids in patients with ulcerative colitis. METHODS Total RNA obtained from peripheral blood mononuclear cells (PBMCs) of 23 patients with ulcerative colitis and 20 healthy volunteers was reverse transcribed; the resulting complementary DNA was amplified using specific primers for hGRalpha and hGRbeta. Protein expression of hGR in PBMCs was confirmed by immunoprecipitation-Western blot analysis. RESULTS The expression of hGRalpha mRNA (477 base pairs) was detected in all patients and all healthy volunteers. In contrast, a hGRbeta mRNA (366 base pairs) was detected in 1 (9.1%) of 11 glucocorticoid-sensitive patients, 10 (83.3%) of 12 glucocorticoid-resistant patients, and 2 (10%) of 20 healthy volunteers. The positive rate of hGRbeta mRNA in the resistant group was significantly higher than that in the sensitive group (P = 0.0019). The hGRbeta band could be detected by immunoprecipitation-Western blotting in hGRbeta mRNA-positive patients. CONCLUSIONS The results show that the expression of hGRbeta mRNA in PBMCs examined by RT-PCR may serve as a novel predictor of glucocorticoid response in ulcerative colitis.

Quantitative analysis for human glucocorticoid receptor α/β mRNA in IBD ☆

We have previously reported that in peripheral blood mononuclear cells (PBMC), the augmented expression of the β isoform of the human glucocorticoid receptor (hGRβ), as a putative dominant negative regulator of glucocorticoid action, is associated with glucocorticoid (GC) unresponsiveness of UC patients. In this study, we quantified the levels and serial changes of hGR transcripts in PBMC of IBD patients by a real-time fluorescence monitoring of PCR. As results, relative hGRβ mRNA expression was significantly higher in the active stage of UC than in inactive periods of UC or CD patients. Longitudinal analysis revealed that hGRβ mRNA expression in UC was increased after the relapse of inflammation, suggesting that the overproduction of cytokines during inflammation may be responsible. In in vitro culture experiments of human lymphoid cell (CEM) and human PBMC, IL-7, and IL-18 increased hGRβ mRNA expression in these cells but GC itself did not. Through these analyses, it is indicated that the inflammatory cytokines altered the splicing condition of the primary transcript of hGR gene in IBD patients.

Reversible Posterior Leukoencephalopathy Syndrome Associated with Treatment for Acute Exacerbation of Ulcerative Colitis

Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinical syndrome of varying etiologies with similar neuroimaging findings. This is a case report of a 25-year-old woman who developed typical, neurological symptoms and magnetic resonance imaging abnormalities after treatment for the acute exacerbation of ulcerative colitis (UC), which included blood transfusion, the systemic administration of prednisolone, and the administration of metronidazole. It has been reported that these treatments may contribute to the development of RPLS. RPLS should therefore be considered in the differential diagnosis of UC patients who exhibit impaired consciousness, seizures or visual deficits during treatment. We report a rare case of RPLS in a patient with UC.

Anal Canal Adenocarcinoma in a Patient with Longstanding Crohn’s Disease Arising From Rectal Mucosa that Migrated From a Previously Treated Rectovaginal Fistula

Patient: Female, 50 Final Diagnosis: Anal canal adenocarcinoma Symptoms: — Medication: — Clinical Procedure: CT • MRI • biopsy Specialty: Surgery Objective: Unknown ethiology Background: This study reports the pathogenesis of anal canal adenocarcinoma in a patient with longstanding Crohn’s disease (CD). Case Report: A 50-year-old woman with a 33-year history of CD presented with perianal pain of several months’ duration. She had been treated surgically for a rectovaginal fistula 26 years earlier and had been treated with infliximab (IFX) for the previous 4 years. A biopsy under anesthesia revealed an anal canal adenocarcinoma, which was removed by abdominoperineal resection. Pathological examination showed that a large part of the tumor consisted of mucinous adenocarcinoma at the same location as the rectovaginal fistula had been removed 26 years earlier. There was no evidence of recurrent rectovaginal fistula, but thick fibers surrounded the tumor, likely representing part of the previous rectovaginal fistula. Immunohistochemical analysis using antibodies against cytokeratins (CK20 and CK7) revealed that the adenocarcinoma arose from the rectal mucosa, not the anal glands. Conclusions: Mucinous adenocarcinoma can arise in patients with CD, even in the absence of longstanding perianal disease, and may be associated with adenomatous transformation of the epithelial lining in a former fistula tract.

6962 High frequency ultrasound probes for curative endoscopic mucosal resection for colorectal submucosal cancers.

Background: In the treatment of colorectal submucosal (sm) cancers, endoscopic mucosal resection (EMR) is limited to focally extended submucosal (sm1) cancers in which lymphnode metastasis is extremely rare. According to the retrospective study using resected specimens, risk factors of lymphnode metastasis in sm cancers were (1) invasion more than 1.5 mm into the sm layer from the muscularis mucosae (Mm), (2) vessel permeation, and (3) poorly differentiated adenocarcinoma in the deepest invasive portion (Tanaka S. et al.Gastrointest Endosc 1998, 47:AB105). However, colonoscopy is unable to evaluate the cancer-invasion distance to the sm layer even using chromoendoscopy. High Frequency Ultrasound Probe (HFUP) can precisely delineate the extension degree to submucosa in colorectal sm cancers. Aim: To evaluate whether HFUP could yield an objective invasiondistance to the sm layer; 1.5 mm of invasion distance into the sm layer that is critical for the lymphnode metastasis in sm cancers. Methods: HFUP and chromoendoscopy were performed in 35 cases of sm colorectal cancers. Invasion depth diagnosis (sm1, 2 and 3) was made and the invasion distance to the sm layer from Mm was measured on HFUP images. All the lesions were resected either by EMR (6 cases) or surgery (29 cases). Invasion distance evaluated by HFUP was compared with the microscopically determined invasion distance in the histological specimens. Results: In 35 sm cancers, 4 lesions were sessile (Is), 11 were flat elevated (IIa), 3 were slightly depressed (IIc) and 17 were flat elevated with depression (IIa+IIc). As for invasion depth, 8 lesions were sm1, 10 were sm2 and 17 were sm3. In histological specimens, average distances of cancer invasion in sm1, 2 and 3 were 0.4 mm, 2.9 mm and 4.0 mm, respectively. HFUP could delineate the cancer invasion into the sm layer in 30 (85.7%) of 35 sm cancers and sm invasion distance of those 30 cases was histologically 0.7 mm or more. The cancer-invasion distance to the sm layer evaluated by HFUP correlated well with the histologically measured distance (correlation coefficient; 0.91). HFUP correctly differentiated sm cancers with more than 1.5 mm cancer-invasion from those with 1.5 mm or less in 34 (97.1%) of 35 lesions. Conclusions: HFUP proved to provide a highly reliable cancer-invasion distance to the sm layer and to be capable of differentiating sm cancers in terms of the choice of therapy in sm cancers.

4478 Endoscopic prediction of early postsurgical recurrence in patients with crohn's disease.

Background/Aim: High relapse rate of re-stenosis at the site of intestinal anastomosis in postsurgical patients with Crohns disease is reported from several study groups. These studies revealed that appearance of endoscopic changes at the site of anastomosis frequently preceded to production of typical symptoms. However, it is still unclear when endoscopic observation should be performed, or how we can detect risky patients of earlier recurrence of anastomotic re-stenosis. To find out the predictive markers for earlier recurrence, we have prospectively observed the sequential changes of endoscopic features appeared at the site of anastomosis, from immediately after surgery to recurrence of typical stenotic lesions. Patients/Methods: Twenty-nine patients with Crohns disease who underwent intestinal/colonic resection in Asahikawa Medical College Hospital from 1990 to 1999 were subjected in this study. All the patients had ileocolonic or colo-colonic anastomosis, which were accessible by colonoscopy. Endoscopic observation and combined endoscopic retrograde ileography (ERIG) were performed at 1,6, and 12 months after surgery. One year after surgery, these observations were repeated at once a year. Results: At 1 month after surgery, 24.9% (7/29) patients already had small aphthous ulcer(s) at the site of anastomosis. These lesions were not disappeared, then incidence of relapsing these lesions were increased ( 6 months; 48.3% (14/29) 12 months; 65.5% (19/29)). Stenotic lesions due to multiple or longitudinal ulceration of anastomosis were detected from 2 years after surgery, in the patients of ulcer(+) at 12 months (31.6% (6/19)). However, no patients developed stenotic lesions within 5 years after surgery among 10 patients of ulcer (-) at 12 months. Significant statistical correlation in Logrank test was detected between ulcer (+) at 12 months and development of stenosis, or requirement of re-operation. Other factors such as disease duration, administration of 5-ASA, nocternal nutritional supprement with elemental diet, or methods of anastomosis did not correlate with postsurgical relapse rate in our patients. Conclusion: Developement of aphthous or small ulcer(s) within a year after surgery at the site of anastomosis is a risk factor of earlier re-stenosis or re-operation. Endoscopic evaluation of anastomotic areas at 12 months after surgery is necessary in management for postsurgical CD patients.