Kenichiro Imai

Endoscopic ultrasonography-guided fine needle aspiration biopsy using 22-gauge needle in diagnosis of autoimmune pancreatitis

BACKGROUNDS The effectiveness of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has not been fully evaluated in the diagnosis of autoimmune pancreatitis (AIP). AIM To evaluate the effectiveness of EUS-FNA using 22-gauge needles in the diagnosis of AIP. METHODS EUS-FNA was examined in 85 patients with pancreatic mass, including 64 patients with pancreatic cancer and 21 patients with AIP. We investigated ability of EUS-FNA using 22-gauge needle for the differential diagnosis between AIP and pancreatic cancer. We also compared the factors concerning FNA procedures (number of needle passes, size of lesion, device, and amount of obtained pancreatic tissue) between two diseases. RESULTS Tissues obtained from 21 patients with AIP, although none of them demonstrated histology suspicious for malignancy, did not show histological evidence definitive for AIP. The amount of obtained pancreatic tissue was almost equal between two diseases in each pancreatic location. Sensitivity, specificity, overall accuracy, and negative predictive value of histological diagnosis of pancreatic cancer were 92.2%, 100%, 94.1%, and 80.8%, respectively. CONCLUSION EUS-FNA using 22-gauge needle distinguished benign from malignant pancreatic mass with >90% of accuracy, regardless of the location. Hence, it was helpful for the clinical diagnosis of AIP, however not providing satisfactory samples for the histological diagnosis of AIP.

Diagnosis of autoimmune pancreatitis

Autoimmune pancreatitis (AIP) is a distinct form of chronic pancreatitis that is increasingly being reported. The presentation and clinical image findings of AIP sometimes resemble those of several pancreatic malignancies, but the therapeutic strategy differs appreciably. Therefore, accurate diagnosis is necessary for cases of AIP. To date, AIP is classified into two distinct subtypes from the viewpoints of etiology, serum markers, histology, other organ involvements, and frequency of relapse: type 1 is related to IgG4 (lymphoplasmacytic sclerosing pancreatitis) and type 2 is related to a granulocytic epithelial lesion (idiopathic duct-centric chronic pancreatitis). Both types of AIP are characterized by focal or diffuse pancreatic enlargement accompanied with a narrowing of the main pancreatic duct, and both show dramatic responses to corticosteroid. Unlike type 2, type 1 is characteristically associated with increasing levels of serum IgG4 and positive serum autoantibodies, abundant infiltration of IgG4-positive plasmacytes, frequent extrapancreatic lesions, and relapse. These findings have led several countries to propose diagnostic criteria for AIP, which consist of essentially similar diagnostic items; however, several differences exist for each country, mainly due to differences in the definition of AIP and the modalities used to diagnose this disease. An attempt to unite the diagnostic criteria worldwide was made with the publication in 2011 of the international consensus diagnostic criteria for AIP, established at the 2010 Congress of the International Association of Pancreatology (IAP).

Endoscopic submucosal dissection for early gastric cancer in cases preoperatively contraindicated for endoscopic treatment

Background and study aims Endoscopic submucosal dissection (ESD) is an optimal treatment for early gastric cancer (EGC) with negligible risk of lymph node metastasis; however, ESD is sometimes performed to treat lesions preoperatively contraindicated for the procedure due to various reasons. Here we aim to evaluate the treatment outcomes of ESD for lesions that were preoperatively contraindicated for ESD. Patients and methods Clinicopathological data of 104 EGC lesions in 104 patients were reviewed retrospectively. The demographic characteristics of patients, reasons for ESD, treatment results, complications, and outcomes were assessed. Results The major reasons for undergoing ESD included advanced age, desire to undergo ESD, and the existence of comorbidities. En-bloc and complete resection rates were 97 and 71%, respectively. Perforation and postoperative bleeding rates were 13 and 9%, respectively. Resection was beyond the expanded Japanese criteria for endoscopic treatment of EGC in 87 patients (84%), 41 (47%) of whom underwent additional therapy, including subsequent gastrectomy (29 patients) and photodynamic therapy (12 patients). The median follow-up period was 47 months, during which seven patients died from recurrent disease. The 5-year overall and disease-specific survival rates were 70 and 91.5%, respectively. Conclusions ESD is a technically demanding procedure for lesions preoperatively contraindicated for endoscopic resection. The curative resection rate was low, but the 5-year disease-specific survival rate of 91.5% was favourable. In experienced hands, ESD may be a treatment option for patients not suitable for radical surgery, and the relevant risk of complications must be considered before treatment.

Gastric obstruction after endoscopic submucosal dissection.

Background Bleeding and perforation are two major complications of gastric endoscopic submucosal dissection (ESD). There are only a few reports concerning gastric obstruction related to ESD in the stomach. Objective The aim of this study was to clarify the clinicopathological features of patients who experienced gastric obstruction after gastric ESD. Methods Clinicopathological data of 1878 patients who underwent gastric ESD from September 2002 to December 2010 were retrospectively reviewed. Data of lesion location, circumference, circumferential extent of ESD ulcer, specimen diameter, depth of cancer, ulcer findings within the lesion, curability of ESD, number of simultaneous lesions, and occurrence of post-operative bleeding and perforation were collected. The risk of gastric obstruction regarding lesion and procedure related factors were assessed, and treatment for these patients was studied. Results Gastric obstruction was observed in 2.5% of the patients (47/1878). Symptoms occurred in a median of 24 days after ESD. The incidence among patients with lesions in the upper part of the stomach was 4.7% (17/316), 0.36% (3/818) in the middle, and 3.8% (27/699) in the lower part. In relation to the circumferential extent, the incidence was 50% (33/66) among patients with a resection of >75% of the circumference. Stenosis was observed in 87% (41/47) of patients with gastric obstruction. Endoscopic balloon dilation was performed in 45 patients. Perforation due to EBD occurred in four patients; one was referred to surgery. Conclusions Patients with a wide resection of >75% of the circumference should be considered for early repeat endoscopy after ESD, and dilation should be performed with caution if found to have stenosis.

Recurrence after curative surgical resection of T1 rectal cancer: A report of two cases

Recent advances in endoscopic diagnosis and treatment techniques have led to a marked increase in the detection and endoscopic treatment of early colorectal cancers (CRC). According to the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines, T1‐CRC with a negative vertical margin, well‐ or moderately differentiated adenocarcinoma, no evidence of vascular or lymphatic invasion, and depth of invasion <1000 μm are considered to have a low risk of lymph node metastasis. However, T1‐CRC with any of these risk factors are considered to have ahigh risk of lymph node metastasis. T1‐CRC is considered to have a good prognosis if additional surgery is carried out. We experienced two cases of recurrence despite curative surgical resection of T1 rectal cancer.

Tu1238 Clinical Characteristics of Familial Intraductal Papillary Mucinous Neoplasm of the Pancreas

Background & Aim: It is reported that 4~10% of patients with pancreatic cancer (PC) have a familial predisposition to their disease, however family history of intraductal papillary mucinous neoplasm (IPMN) is not well known. The aim of this study is to determine the clinical characteristics of IPMN with family history of pancreatic cancer, or familial IPMN. Methods: We analyzed 448 cases of IPMN for their demographic data and image findings [size of IPMN, maximum width main pancreatic duct (MPD), number of IPMN lesions, macroscopic-type (MPD-type or branch-type)] depicted by contrast enhanced CT and other modalities, and these findings were compared between familial IPMN (F-IPMN) and sporadic IPMN (S-IPMN). Family history of PC was analyzed in the first degree relatives of the patients. Results: Of 448 IPMN cases, 35 cases (8%) were F-IPMN and 413 cases (92%) SIPMN. Between two groups, no difference was seen in demographic data [F-IPMN vs. SIPMN; age (years): 70 vs. 70, gender (M/F): 20/15 vs. 257/156, smoking: 57% vs. 59%, drinking: 34% vs. 42%, diabetes: 34% vs. 20%]. In image findings, sizes (mm) of the tumor (36 vs. 32) and main pancreatic duct (MPD)(7 vs. 6) were slightly larger in familial than sporadic cases (P = 0.35 and 0.18), however cases with multiple IPMNs (34% vs. 17%, odds ratio: 2.5, P = 0.01) and those with MPD-type (43% vs. 20%, odds ratio: 3.3, P = 0.0007) were more frequently recognized in F-IPMN than S-IPMN. Conclusions: IPMN is recognized in 8% of the family of cases with PC, so that kindred of IPMN is the candidate for PC surveillance. For the clinical decisions of IPMN, we must bare in mind that the familial cases tends to develop multiple lesions and MPD-type, frequently associated with malignant lesion.