Hiroaki Yoshikane

Carcinoid tumors of the gastrointestinal tract: evaluation with endoscopic ultrasonography

To evaluate the usefulness of endoscopic ultrasonography for carcinoid tumors, we examined 29 patients with gastrointestinal carcinoid tumors (5 gastric, 7 duodenal, and 17 rectal). The smallest size detectable by endoscopic ultrasonography was 2 mm in diameter histologically. The cross-sectional image of the tumors was primarily oval to round. The internal echo was generally hypoechoic and homogeneous. The margins were clearly visualized, and the contour was somewhat smooth. The tumors were mainly located in the third layer. The second layer covered the tumor with the third layer at its base, and it abutted the tumor and became indistinct near its upper interface. These findings were especially recognized in lesions with submucosal invasion and were similar at all sites. The overall accuracy of determining the depth of invasion using endoscopic ultrasonography was 75% (27 of 36 lesions). Limited to the lesions detectable by endoscopic ultrasonography, the accuracy was 90%. Endoscopic ultrasonography was useful in determining the presence of local metastases. Moreover, endoscopic ultrasonography allowed direct detection of perigastrointestinal lymph node metastases (75%, three of four patients). In conclusion, endoscopic ultrasonography was found to be useful for the staging of gastrointestinal carcinoid tumors by determining depth of involvement and presence of perigastrointestinal lymph node metastases.

Evaluation of upper gastrointestinal tumors with a new endoscopic ultrasound probe

During endoscopic ultrasonography (EUS), an ultrasound transducer is used to provide images of the gastrointestinal wall structure, which supplement endoscopic pictures of the mucosal surface. The technique is useful to evaluate the extent of malignant invasion of the intestinal wall and the location and histologic nature of intramural and extramurallesions.1-3 However, EUS entails certain problems. The endoscopic view is limited, especially in the esophagus, because of obliqueor side-viewing optics, so that most patients must undergo two separate examinations: conventional endoscopy and conventional EUS. Additionally, the large diameter and rigid tip of the EUS fiberscope make it difficult to pass through a malignant stricture, and considerable experience is required to learn to use the fiberscope and orient the ultrasound image. Recently, several types of ultrasound probes have been developed to overcome such problems, some of which are commercially available.4-7 These probe systems differ from conventional EUS systems in that the ultrasonic transducer is separate from the endoscope. Because they present some disadvantages, they are not widely used clinically. In this paper, we report both in vitro and in vivo (via the biopsy channel of an endoscope during conventional endoscopy) use of a new ultrasound probe.

Endoscopic resection of small duodenal carcinoid tumors with strip biopsy technique.

BACKGROUNDnMost cases of duodenal carcinoid have conventionally been treated by surgical resection. The aim of our study was to explore the feasibility of endoscopic resection in small duodenal carcinoids.nnnMETHODSnThe study population consisted of seven patients with small duodenal carcinoids. The diagnosis was confirmed by preoperative biopsies. The depth of tumor invasion was evaluated by endosonography.nnnRESULTSnThe carcinoid was detected by endosonography in all cases. Size ranged ultrasonographically from 1.5 mm to 7 mm. Tumor invasion was confined to the submucosa in all patients. Endoscopic resection was performed with the strip biopsy technique using a two-channel endoscope. In six patients, the specimens were resected without severe complications. Five of them were confirmed histologically to be typical carcinoids. In one patient, carcinoid was not detected histologically in the specimen. In the remaining patient, a perforation occurred. However, the huge ulcer was managed conservatively. Follow-up endoscopy revealed no evidence of recurrent or residual tumor in any patient.nnnCONCLUSIONnSmall duodenal carcinoids confined to the submucosa can be resected endoscopically and preoperative endosonography is necessary for the determination of endoscopic resectability.

Giant Splenic Cyst with High Serum Concentration of CA 19-9 Failure of Treatment with Percutaneous Transcatheter Drainage and Injection of Tetracycline

BACKGROUNDnRecently, several cases of nonparasitic true splenic cyst with high serum concentration of carbohydrate antigen (CA 19-9) have been reported.nnnCASEnWe report a giant splenic cyst presenting with high serum concentration of CA 19-9 in a 21-year-old man without a history of previous trauma. Imaging techniques showed a huge monolocular cyst of the spleen, and laboratory data showed increased serum CA 19-9 levels (326 U/ml; normal, < 37 U/ml). Serologic test was negative for parasitic infection. These findings led us to the diagnosis of epithelial splenic cyst. Percutaneous transcatheter drainage and injection of tetracycline were performed for 2 weeks. The cyst shrank, and the serum CA 19-9 level decreased favorably. However, cystic fluid reaccumulated in a month.nnnCONCLUSIONSnThe accumulation of cystic fluid in splenic epithelial cysts may be attributable not only to the secretion of the lining cells but also to influx from the splenic sinuses.

A new method for evaluating gastric ulcer healing by endoscopic ultrasonography

We observed the quantitative estimation of the transmural changes associated with gastric ulcer healing by using endoscopic ultrasonography (EUS). It was possible to diagnose the depth of ulcer by EUS. Forty-eight patients were divided into three treatment groups. Group A (n = 16) was treated with 800 mg cimetidine daily, group B (n = 22) with 20 mg omeprazole daily, and group C (n = 10) with 400 mg cimetidine + 300 mg gefarnate daily. EUS was performed before and after 2, 4, and 8 weeks of treatment. The groups were compared from the viewpoints of endoscopic findings and contraction rate of the length and the cross-sectional area of the ulcer in EUS pictures. The best healing of both the endoscopic and EUS findings was seen in group B. By estimating the changes inside the ulcer, EUS may provide useful information for choice of anti-ulcer agents.

Multiple early bile duct carcinoma associated with congenital choledochal cyst

Abstract: Emergency ultrasonography showed a protruding tumor in the markedly dilated common bile duct of a 33-year-old Japanese woman. Magnetic resonance cholangiopancreatography also demonstrated the tumor clearly, almost as clearly as did percutaneous transhepatic cholangiography. With a diagnosis of common bile duct carcinoma associated with congenital choledochal cyst, pancreaticoduodenectomy was performed. In the resected specimen, as well as the protruding tumor, there was also a small slightly elevated lesion. Pathology examination showed adenocarcinoma limited to the fibromuscular layer in the protruding tumor, and adenocarcinoma limited to the mucosa in the elevated lesion. Prophylactic total excision of the choledochal cyst before the occurrence of malignant change is strongly recommended in patients with congenital choledochal cyst. However, in those who are reluctant to undergo the operation, periodic follow-up with ultrasonography and magnetic resonance cholangiopancreatography would be ideal to achieve early detection of malignant change.

Regression of superficial gastric MALT lymphoma with unsuccessful eradication therapy for Helicobacter pylori infection

A 51-year-old man had a reddish flat granular lesion in the stomach on endoscopic examination. Histology of biopsied specimen confirmed the diagnosis of low-grade B-cell gastric lymphoma of mucosaassociated lymphoid tissue (gastric MALT lymphoma) and simultaneous infection withHelicobacter pylori. He was given antibiotic treatment. Five weeks later, endoscopy and histology of biopsied specimen showed eradication ofH. pylori, and the tumor had regressed. Six months later,H. pylori reemerged, but the tumor had not recurred. After the second antibiotic therapy,H. pylori has been eradicated. The lymphoma has been in remission for 14 months.

Familial occurrence of gastric carcinoid tumors associated with type A chronic atrophic gastritis

We present here familial occurrence of two patients with gastric carcinoid. Both patients, a sister and older sister, had type A chronic atrophic gastritis with hypergastrinemia. This is the first case report of familial occurrence of gastric carcinoid associated with type A chronic atrophic gastritis in the world literature. The possible mechanism of familial occurrence in the patients is discussed.

Sequential Observation of Gastric Ulcer Healing by Endoscopic Ultrasonography

BACKGROUNDnThe relationship between superficial findings and the inner structure of gastric ulcers is unclear. The present study was undertaken to clarify the relationship between them.nnnMETHODSnIn the first study, 43 patients with active gastric ulcers were examined by endoscopic ultrasonography (EUS) in each stage of Sakitas endoscopic classification. In the second study, 16 patients with gastric ulcer scars were examined by EUS in both S1 stage and S2 stage.nnnRESULTSnUlcer area, ulcer length, thickness of the ulcer base, and diameter of the crater differed significantly in each endoscopic stage. Ulcer area, ulcer length, and thickness of the ulcer base differed significantly even between S1 stage and S2 stage. Mean ulcer area in S1 stage was 96.9 mm2; this shows that the ulcer scar in S1 stage is incomplete with regard to tissue contraction. Although ulcer area in S2 stage had shrunk significantly compared with that in S1 stage, it still remained 53.3 mm2. This implies that the risk of local recurrence remains even in S2 stage.nnnCONCLUSIONSnSequential observation by EUS showed that the healing of the ulcer surface strongly reflected the healing within the ulcers.

Endosonographic evaluation of the quality of ulcer healing induced by proton pump inhibitors.

We studied 26 gastric ulcer patients who were treated with a proton pump inhibitor to evaluate the quality of ulcer healing using endoscopic ultrasonography (EUS), and we examined the relationship between ulcer recurrence and contraction demonstrated on ulcer echoes (study I). The effect of lansoprazole versus an H2-receptor antagonist on the contraction of ulcer echoes (study II) was also investigated. In study I, gastric ulcer patients who demonstrated early healing by endoscopy often had shallow UI-II or UI-III ulcers and small cross-sectional areas on ulcer echoes. The early contraction on ulcer echo was associated with lower rates of ulcer relapse, and might therefore be indicative of a good quality of healing. In study II, the ulcer contraction rate after 8 weeks of treatment with lansoprazole was 71.8%, significantly higher than that achieved with H2-receptor antagonists. However, the mean cross-sectional area of gastric ulcer after 8 weeks of treatment with lansoprazole was 113.9 mm2. In conclusion, although lansoprazole was suitable for initial therapy in peptic ulcer patients, the quality of ulcer healing based on EUS findings did not appear to be adequate in patients treated for the short periods of time in this study.