Jun Tomoda

Risk factors for perforation and delayed bleeding associated with endoscopic submucosal dissection for early gastric neoplasms: Analysis of 1123 lesions

Background and Aim:  Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of early gastric neoplasms; however, this advanced technique has also resulted in an increase in serious complications such as perforation and delayed bleeding. This study aimed to elucidate the risk factors for these complications.

Mucosa‐associated lymphoid tissue lymphoma of the rectum that regressed spontaneously

We report a case of mucosa‐associated lymphoid tissue (MALT) lymphoma of the rectum that regressed spontaneously. A 76‐year‐old man visited our hospital because of positive faecal occult blood testing. Colonoscopic examination revealed a slightly yellowish protruded lesion with a grooved depression in the lower rectum and two flat elevations in the upper rectum. Microscopic and immunohistological studies led to a diagnosis of MALT lymphoma. As the patient exhibited severe renal dysfunction and angina pectoris, the lesions were left untreated. Three months later, the protruded lesion became flat and the other lesions became unclear. He was followed up closely with endoscopy, but no relapse of these lesions was detected 19 months after the diagnosis.

Cathepsin B and L activities in gastric cancer tissue: correlation with histological findings

Cathepsin B and L activities in cancerous and noncancerous mucosal tissues from 29 patients with gastric cancer were determined with a small amount of tissue homogenate. Both enzyme activities were significantly higher in cancerous tissues than in noncancerous tissues. The cathepsin B activity was higher with decreasing differentiation of the cancerous tissues, and also with increasing depth of invasion and metastasis to regional lymph nodes. Significantly high cathepsin B activity was observed in specimens of poorly differentiated adenocarcinomas, as well as in specimens from patients with extensive metastasis to n2 or n3 lymph nodes. These results suggest that high cathepsin B activity is characteristic of gastric cancer which invades and metastasizes. Therefore, in cases of marked elevation of cathepsin B activity in cancerous tissues, relatively extensive resection may be necessary to obtain a cure.

Clinical outcomes of ESD for early gastric neoplasms in elderly patients

Eur J Clin Invest 2011; 41 (5): 474–478

Evaluation of endoscopic injection sclerotherapy with and without simultaneous ligation for the treatment of esophageal varices.

Abstract: For more effective and simple endoscopic injection sclerotherapy (EIS) for esophageal varices, we developed an EIS procedure with ligation (EISL) that is non-invasive, in which EIS and endoscopic variceal ligation (EVL) are performed simultaneously. In this study, we compared EISL and EIS in a randomlized sample of patients (n = 14 for each procedure). For EISL, EVL was performed, including the injection site, after the injection of 5% ethanolamine oleate with iopamidol (EOI) into a varix. The mean number of treatment sessions required for eradication of esophageal varices was 2.3 ± 0.5 for EISL and 3.9 ± 0.8 for EIS (P < 0.001); the mean number of treatment sites was 6.2 ± 2.2 for EISL and 14.0 ± 5.0 for EIS (P < 0.001); the mean total amount of EOI used was 13.8 ± 5.2 ml for EISL and 26.3 ± 9.8 ml for EIS (P < 0.001). There were no significant differences in rates of recurrence of varices or in bleeding between the two groups. For EISL, fewer treatment sessions and less sclerosant were sufficient, probably because the sclerosants were more effective due to the blockage of variceal blood flow by the ligation. This method should provide a novel modification of EIS.

Immunohistochemical analysis of intercellular adhesion molecule-1 expression in human gastric adenoma and adenocarcinoma

In this study, we examined the distribution of intercellular adhesion molecule-1 (ICAM-1) in gastric adenomas and carcinomas immunohistochemically at the light and electron microscopic levels. ICAM-1 was expressed on tumour cells in 12 of 28 gastric carcinomas and in 3 of 11 adenomas but not on most normal gastric epithelial cells. ICAM-1 was localized on luminal sites of neoplastic glands in adenomas and in intestinal-type carcinomas, and rarely on the surface of tumour cells of diffuse carcinomas. Expression of ICAM-1 on the tumour cells was more frequent in intestinal-type than diffuse carcinomas (P<0.005). At the ultrastructural level, ICAM-1 was present prominently on the apical membrane and weakly on the lateral surface of the tumour cells of the intestinal-type carcinoma and also localized on the perinuclear membrane and the membrane of the endoplasmic reticulum of cancer cells. There was no significant association between. ICAM-1 expression and HLA antigen expression or the number of infiltrating lymphocyte subsets. These results may implicate the synthesis of ICAM-1 by gastric cancer cells, but the expression is infrequent and may not be sufficient for host immune surveillance of the tumour cell.

Flow cytometric analysis of the DNA content in colorectal adenomas with focal cancers

BACKGROUND & AIMS Variable results have been reported on the nuclear DNA content of colorectal polyps. The significance of DNA aneuploidy in the malignant transformation of colorectal polyps was evaluated. METHODS We analyzed by flow cytometry the nuclear DNA content of freshly frozen samples of 50 colorectal adenomas with or without focal cancers, analyzing separately the adenomatous and cancerous regions of the polyps. RESULTS In the adenomatous regions of the 50 polyps, the DNA was diploid in 43 and aneuploid in 7; the adenomas with DNA aneuploidy in the adenomatous regions were more frequently accompanied by focal cancers than were the DNA-diploid adenomas (P < 0.01). In 60% of the polyps with DNA aneuploidy in the cancerous regions, the DNA was also aneuploid in the adenomatous region and had similar DNA indices; this result suggests that the DNA aneuploidy had already occurred during the adenomatous stage, which lends support to the concept of the adenoma-carcinoma sequence. DNA aneuploidy in the adenomatous region was significantly correlated with the size of colorectal polyps (P < 0.05). CONCLUSIONS DNA aneuploidy may be an important indicator for the early diagnosis of malignant transformation of colorectal polyps.

Risk factors for non-curative resection of early gastric neoplasms with endoscopic submucosal dissection: Analysis of 1,123 lesions

Although the frequency of residual disease and recurrence following endoscopic submucosal dissection (ESD) has markedly decreased, a few cases of residual disease and recurrence following ESD are still observed. The aims of the present study were to clarify the causes of non-curative resection and to investigate the risk factors. A total of 1,123 early gastric neoplasm lesions treated by ESD were investigated. Non-curative resection was defined as histological positivity of the resected margins, vascular invasion or failure of en bloc resection. Cases of non-curative resection were classified as being caused by one of three reasons: Inadequate technique, pre-procedural misdiagnosis or problems in the histological diagnosis. Following classification, the cases of non-curative and curative resection were compared based on a range of patient characteristics: Procedure time, and size, type and location of the lesions. The frequency of non-curative resection was 16% (182 lesions). Non-curative resection occurred due to inadequate technique in 59 cases, pre-procedural misdiagnosis in 88 cases and problems in the histological diagnosis in 35 cases. Multivariate analysis revealed that a large lesion size, long procedure time and inexperienced endoscopist were associated with a significantly higher risk of non-curative resection due to an inadequate technique. Furthermore, it was found that lesions located in the upper area of the stomach and cancer with submucosal invasion were associated with a significantly higher risk of non-curative resection due to pre-procedural misdiagnosis. In conclusion, the present study has shown that the major reasons for non-curative resection are an inadequate technique and pre-procedural misdiagnosis. The risk factors for these problems have been clarified.

Prominent Telangiectasia Associated with Marked Bleeding in CREST Syndrome

A 64‐year‐old woman with CREST syndrome developed prominent telangiectases mimicking hereditary hemorrhagic telangiectasia (HHT) of Osler‐Rendu‐Weber. We have been following her since she first came to us with discrete telangiectatic mats and Raynauds phenomenon 11 years ago. Telangiectatic lesions have been seen on her larynx and esophagus in addition to commonly affected sites. She has experienced spontaneous epistaxis and marked bleeding from the lesions on her lips, oral mucous membrane, and soles.

Investigation of upper gastrointestinal bleeding after implantation of drug-eluting stents; prospective cohort study.

Abstract Objective. After implantation of drug-eluting stents (DES), two or more anti-thrombotic agents are required. The risk of upper gastrointestinal bleeding (UGIB) in cases of DES implantation is thought to be significant. However, the incidence of UGIB has not yet been investigated in DES-implanted patients. This study aimed to investigate the incidence of UGIB after DES implantation and the awareness among cardiologists about this complication. Material and methods. Subjects were 397 consecutive patients implanted with DES from August 2004 to September 2007 at two institutions. Endoscopic examinations were performed on DES-implanted patients who presented with hematemesis and/or tarry stools. The concomitant use of acid-suppressing agents was left to the cardiologists. In addition, 37 cardiologists were administered a questionnaire regarding UGIB after DES implantation. Results. Low-dose aspirin and ticlopidine were prescribed in all patients. Forty-six patients had a past history of peptic ulcer. Acid-suppressing agents were concomitantly prescribed to 224 patients (56%) including 32 patients (70%) with a past history of peptic ulcer. UGIB due to gastric ulcers developed in 5 cases (1.3%). One case had received a half dose of H2-RA. No bleeding occurred in patients who received proton pump inhibitors (PPI). The incidence of UGIB was 4.0 per 1000 patient-years. The cardiologists who were surveyed recognized the risk of UGIB after DES implantation and the necessity for its prevention. However, they indicated that adequate management for preventing this complication has not been established. Conclusions. This study reassuringly demonstrated a low incidence of UGIB after DES implantation. Further study regarding the prophylaxis for UGIB after DES implantation is necessary.