Horng Yuan Lou

Overexpression of protein kinase cα mRNA may be an independent prognostic marker for gastric carcinoma

The variability of the prognosis of gastric carcinoma drives extensive researches for novel prognostic markers. The aims of this study were to correlate the expression of protein kinase Cα (PKCα) mRNA with clinicopathological parameters and to evaluate the significant value of PKCα in gastric carcinoma prognosis.

HEPATIC FAILURE RELATED TO ITRACONAZOLE USE SUCCESSFULLY TREATED BY CORTICOSTEROIDS

Background Itraconazole is believed to carry a low risk of hepatic toxicity owing to its low affinity for the human P-450 enzyme. Therefore, hepatic failure caused by itraconazole is exceedingly rare. Objectives We report the case of a 46-year-old woman who developed hepatic failure related to itraconazole that was administered for the treatment of onychomycosis. Her condition deteriorated after withdrawal of the drug, followed solely by supportive care initially. Case Report Treatment with corticosteroids was started 10 days after her admission, and her condition gradually improved. Unfortunately, her condition worsened when the dosage of corticosteroids was abruptly decreased. Ultimately, her condition improved with appropriate adjustments of corticosteroid dosage. Discussion We conclude that corticosteroid therapy may be effective for itraconazole-induced hepatitis, especially in those patients who do not respond to conservative treatment. Notably, any decrease in the dosage should be performed with caution. We also recommend that close monitoring of liver function is mandatory during the use of itraconazole.

Deep Infiltrating Cervical Endometriosis Mimicking Rectosigmoid Cancer

CLINICAL PRESENTATION A 35-year-old woman, with history of systemic lupus erythematosus, presented with 1-month history of hematochezia. Six months earlier, she began complaining of the symptoms of large bowel obstruction such as tenesmus and small-caliber stool. She denied dysmenorrhoea, abdominal pain and weight loss. There was no family history of familial polyposis or colon cancer. Physical examination was unremarkable except for mild distended abdomen. Colonoscopy disclosed a large friable colon tumor with reddish-nodular surface (Figure 1). Pathologic analysis of the specimens did not show malignancy. Surprisingly, sagittal T2weighted magnetic resonance imaging of the pelvis demonstrated chocolate cysts in the right ovary and an ill-defined nodule arising from posterior uterine cervix and extending to and infiltrating the rectosigmoid colon. Pathologic examination of the deeper biopsies from a second colonoscopy showed few endometrial glands (black arrow) within the lamina propria of colonic mucosa; endometrial glands are reactive for cytokeratin-7 (Figure 2). Our patient was diagnosed as cervical endometriosis with deep infiltration to the rectosigmoid colon. Later, she received laparoscopic cystectomy followed by hormonal therapy. Endometriosis is characterized by the aberrant location of endometrial tissue and mostly affects women of reproductive age. The pathogenic mechanism is accepted to be Sampson’s retrograde menstruation and implantation of endometrial tissue in the peritoneum. Deep infiltrating endometriosis is defined as endometrial tissue that penetrates the retroperitoneal space or the wall of pelvic organs more than 5 mm in depth and involves vital structures such as uterosacral ligaments, rectosigmoid, rectovaginal septum, vagina or bladder.1 Gastrointestinal endometriosis is defined as infiltration of the bowel wall by endometrial-like glands. The lesion invades the serosa, subserosa and muscularis propria. Endometriosis-related gastrointestinal involvement was seen in 3% to 37% of women, and the sigmoid colon, rectum and terminal ileum2 are the areas that are most commonly involved. Gastrointestinal endometriotic patients present with intermittent abdominal pain and distention, constipation, diarrhea, tenesmus, hematochezia, dyschezia and bowel obstruction.3 Imaging techniques include ultrasonography and magnetic resonance imaging. The gold standard diagnostic tool is laparoscopy or laparotomy.1 Treatment options including nonsurgical treatment (hormonal approaches with progestogen, danazol and GnRH agonists) and surgical treatment depend on the age, desire to maintain fertility and associated complications. In conclusion, in any female of reproductive age presenting with unexplained gastrointestinal problems, endometriosis should be considered in the differential diagnosis.

Large Early Gastric Cancers Treated by Endoscopic Submucosal Dissection with an Insulation-tipped Diathermic Knife

It is difficult to remove a large early gastric cancer (> or = 3 cm) in one-piece resection using conventional endoscopic mucosal resection. We tried to use an insulation-tipped (IT) diathermic knife to dissect these lesions. IT-endoscopic submucosal dissection (ESD) was performed in four aging patients with gastric malignancy. All lesions could be removed in one-piece resection by IT-ESD, although three of them exhibited remarkable fibrosis and ulceration. Three cases experienced curative treatment with IT-ESD after the pathologic evaluation, but it was not curative in one case because the pathology showed angiolymphatic invasion. This patient refused additional surgery in consideration of existing major systemic diseases. At 3 months to 1 year of follow-up, endoscopy showed no evidence of residual cancer. IT-ESD is effective in the treatment of large early gastric cancer and is an alternative treatment for early gastric cancer patients who are at risk for major operation.

Metachronous Esophageal Cancer and Colon Cancer Treated by Endoscopic Mucosal Resection

Most cases of esophageal cancer and colorectal cancer in Taiwan are diagnosed in the advanced stage and treated by surgery or concurrent chemoirradiation. The detection rates of early esophageal cancer and early colorectal cancer are still low in Taiwan. Metachronous early esophageal cancer and early colorectal cancer have rarely been reported. Endoscopic mucosal resection (EMR) is a well-established method for treatment of early gastrointestinal cancer in Japan. We report a 77-year-old man with metachronous early esophageal cancer and early colorectal cancer detected by chromoendoscopy with 3% Lugols iodine and 0.2% indigo carmine, respectively. These two lesions were successfully treated by EMR. Endoscopic mucosal resection of early cancer in the gastrointestinal tract may be considered in patients who are not suitable for open surgery.

Regression of Multiple Liver Adenomas after Withdrawal of Oral Contraceptives in a Hepatitis C Virus Carrier

We report on a case of multiple liver adenomas in a hepatitis C virus (HCV) carrier. A 40-year-old woman was asymptomatic and has been taking oral contraceptives continuously for 15 years. Abdominal ultrasonography revealed multiple iso-and hypoechoic tumors in both lobes of the liver. Enhanced computed tomography (CT) and magnetic resonance imaging demonstrated multiple hypervascular tumors in the lives; with the biggest one at segment Ⅳ, which measured 7cm in diameter. Cellar angiography revealed multiple hyervascular tumor staining of varying sizes in the liver. Histologically, the tumor showed features typical of a liver cell adenoma with no evidence of malignant transformation. These tumors progressively decreased in size and number after the patient discontinued the use of oral contraceptives. Eighteen months after the initial diagnosis, these tumors had almost completely disappeared on follow-up abdominal ultrasonography. We suggest that in an asymptomatic patient with contraceptives-related multiple liver adenomas, discontinuing the use of oral contraceptives is one of the choices of treatment, and close follow-up by ultrasonography or CT is mandatory.