Kiyoshi Hajiro

Gastric aberrant pancreas : EUS analysis in comparison with the histology

BACKGROUND Histologic diagnosis of aberrant pancreas is usually difficult when tissue samples are obtained with a standard biopsy forceps. The aim of this study was to describe the endosonographic (EUS) features of gastric aberrant pancreas. METHODS EUS was performed in 10 patients with aberrant pancreas before resection. EUS features of the lesions were analyzed and compared with resected specimens retrospectively. RESULTS EUS in 5 lesions (50%) demonstrated the ectopic pancreatic tissue as located in the third and fourth sonographic layers (submucosa and muscularis propria) and in the third layer (submucosa) in the other 5 lesions. The margin appeared for the most part indistinct (80%) because of the lobular structure of the acinous tissue. The internal echo pattern in all cases was heterogeneous, mainly a hypoechoic image (acinous tissue) accompanied by scattered small hyperechoic areas (adipose tissue). An anechoic area (duct dilatation) (80%) and fourth-layer thickening (muscular hypertrophy) (80%) were commonly visualized. CONCLUSION Gastric aberrant pancreas has characteristic EUS features that correlate with specific histologic components and is variable with regard to sonographic layer of origin.

COMPARISON BETWEEN CHEMORADIATION PROTOCOL INTENDED FOR ORGAN PRESERVATION AND CONVENTIONAL SURGERY FOR CLINICAL T1-T2 ESOPHAGEAL CARCINOMA

PURPOSE This retrospective study was designed to compare treatment results of the chemoradiation protocol with conventional surgery for thoracic T1-T2 esophageal squamous cell carcinoma. METHODS AND MATERIALS Sixty-six patients with esophageal carcinoma, clinically diagnosed as T1 (tumor invading lamina propria or submucosa) or T2 (tumor invading muscularis propria) were treated for 12 consecutive years, from July 1986 to January 1998. The conventional surgery group included 30 patients who underwent esophagectomy with regional lymph node dissection. Twenty-one of them received postoperative radiotherapy. Thirty-six patients were assigned to the chemoradiation protocol, consisting of neoadjuvant chemoradiotherapy (44 Gy; CDDP: 60 mg/m2, day 1, bolus; 5-FU: 400 mg/m2, day 1-4, continuous), followed by either definitive radiotherapy with high-dose-rate intraluminal brachytherapy (total 70 Gy) for responders or surgery for nonresponders as in the conventional surgery group. Surgical candidates in both groups received intraoperative radiotherapy for abdominal lymphatics since 1991. RESULTS In the protocol group, 4 patients underwent radical surgery after neoadjuvant chemoradiotherapy, and the remaining 32 underwent definitive chemoradiotherapy. Local control rates at 1 and 3 years were 85% and 70% in the T1/protocol group versus 91% and 80% in the T1/surgery group, and 83% and 83% in the T2/protocol group versus 94% and 80% in the T2/surgery group, respectively. There was no statistical significance. Overall 1- and 3-year survival rates were 100% and 83% in the T1/protocol group versus 82% and 72% in the T1/surgery group (p = 0.36), and 100% and 51% in the T2/protocol group, versus 95% and 68% in the T2/surgery group p = 0.61), respectively. There was no treatment-related mortality in either group. The rates of esophageal conservation were 92% in the T1/protocol group and 58% in the T2/protocol group. CONCLUSION The chemoradiation protocol can result in comparable survival with conventional surgery for patients with T1-T2 esophageal carcinoma. A randomized trial between definitive chemoradiotherapy and surgery is required.

Endoscopic mucosal resection of gastric tumors located in the lesser curvature of the upper third of the stomach

Endoscopic mucosal resection (EMR) is increasingly used for the removal of small gastric tumors with surrounding mucosa 1 and is a useful therapeutic method as well as a diagnostic approach to mucosal lesions. EMR for early gastric cancers has been widely accepted as a standard procedure because of its minimal invasiveness and satisfactory postprocedure results in maintaining a good quality of life for patients. Several different EMR procedures have been reported and their usefulness is well established. 2 Strip biopsy method or lift-and-cut EMR (LC-EMR), introduced by Tada et al., 3 has been used most widely in Japan. 4 If the target lesion is located in the l esser curvature of the upper third of the stomach, LC-EMR using a double-channel endoscope is quite difficult to perform because of the tangential location of the tumor to the endoscope. 5 In this article, we describe the use of a cutting EMR (C-EMR) technique, based on the original procedure ofHirao et al.,6 for gastric tumors located in the lesser curvature of the upper third of the stomach. We prospectively evaluated its clinical usefulness in comparison with LC-EMR.

Alcohol sclerotherapy of hepatic cysts: its effect in relation to ethanol concentration

While ultrasonically guided percutaneous aspiration and ethanol injection therapy has proved useful for non-neoplastic giant hepatic cysts that cause symptoms, the optimum quantity of ethanol injected into hepatic cysts has not been established. In eight patients with non-neoplastic giant hepatic cysts who were treated by ethanol injection, ethanol concentration in cystic fluid after treatment was estimated. Ethanol concentrations ranged from 5.9 to 47.6%. Hepatic cyst regressed almost completely in five cases; in all of which, the estimated ethanol concentrations were more than 40%. Our results suggest that it is desirable to drain cystic fluid as much as possible and to inject ethanol as little as possible, so that the estimated ethanol concentration in the cyst exceeds 40% for maximal effect and minimal side effects.

Endoscopic bipolar electrocoagulation in upper gastrointestinal bleeding

A new endoscopically deliverable bipolar electrocoagulator has been developed, and employed clinically to treat upper gastrointestinal bleeding in 53 patients on 61 occasions. By direct application of the electrode to the bleeding vessels immediate hemostasis was achieved in 52 out of 53 bleeding vessels. Non-bleeding visible vessels were safely coagulated. Arrest of bleeding was permanent in 44 patients (83%), of whom 20 were candidates for emergency operation because of massive, continued or recurrent bleeding. Rebleeding after hemostasis by bipolar electrocoagulation was noted in 8 patients (15%); however, the majority of rebleeds were those with acute mucosal lesions who had serious underlying medical problems. Emergency operation was performed in 5 patients, and was averted in most patients after successful hemostasis by bipolar electrocoagulation. There were no complications related to the procedure. Bipolar electrocoagulation with our coagulator is a safe and easily applicable technique that is a promising addition to currently available endoscopic hemostatic methods.

Endophthalmitis with brain, lung, and liver abscesses associated with an occult colon cancer

TO THE EDITOR: Septic endophthalmitis, a rare inflammatory process involving ocular tissues, can be the initial presentation of septicemia from abscess (1, 2). We encountered an unusual case of endophthalmitis with brain, lung, and liver abscesses, in which colon cancer was subsequently disclosed in the absence of any gastrointestinal symptoms on admission. The possible pathophysiological mechanism of these associations will be discussed here. A 46-yr-old woman, who had a 2-yr history of diabetes without medication, presented with a high grade fever and right visual disturbance. On physical examination, hypopyon, invisible optic disc, and absent light perception were noted in the right eye, and an enlarged liver was palpable. Adult T-cell leukemia virus, human immunodeficiency virus, and antinuclear antibodies tests were all negative. Computed tomography (CT) showed several nodular lesions, 1.5 cm in diameter, in the left lung field with plural effusion, and a heterogeneous hepatic mass, 10 cm in diameter. Echocardiography revealed no abnormalities. A diagnosis of right endophthalmitis with lung and liver abscesses was made. Therapy with insulin and ceftazidime, 4.0 g daily, and percutaneous drainage of the liver abscess were started. Right vitrectomy and lensectomy were then performed. Cultures of the eyeball contents and the abscess yieldedKlebsiella pneumoniae . Two weeks later, she was confused and disoriented with incontinence. Although cranial nerves, cerebellum, motor, and sensory examinations revealed no apparent abnormalities, acalculia, agraphia, and memory disturbance were disclosed. Brain CT revealed multiple enhanced lesions consistent with brain abscesses (Fig. 1). The antibiotic was changed to latamoxef sodium, 9.0 g daily for 1 month, with clinical improvement. Cultures of the cerebrospinal fluid (CSF) and blood were negative. One month later, she complained of watery diarrhea. Colonoscopy showed a large sigmoid cancer. Cultures of the stool yielded K. pneumoniae. After her condition improved, sigmoidectomy was performed. The patient had an uneventful recovery, and CT scans returned to normal with no evidence of abscesses. The endophthalmitis and brain abscesses in our case were most likely caused by hematogenous spread of K. pneumoniaeassociated with liver abscess and underlying diabetes. Because diabetics have impaired neutrophils functions (3, 4), diabetes can be an important predisposing factor of endophthalmitis with other septic lesions. Although brain abscess is considered lethal (5), large doses of broad-spectrum antibiotic therapy is effective, particularly during the phase of encephalitis (6). Because the average concentration of latamoxef sodium in CSF is greater than those of other antibiotics (7), ceftazidime was changed to latamoxef sodium, resulting in a favorable outcome. The liver abscess could result from K. pneumoniaebacteremia after the organism entered into the portal route from the surface of colon cancer. The mucosal disruption by colon cancer exposing the underlying blood vessels to the fecal flora can be the most likely mechanism of bacteremia (8, 9). Because blood samples were obtained after administration of antibiotics, blood cultures were negative. Our case was interesting in view of the unusual presentation of colon cancer with a favorable outcome. An aggressive approach in the diagnosis and therapy by both internists and ophthalmologists is definitely required. The isolation of K. pneumoniaefrom eyeball contents needs further investigations of the gastrointestinal tract for the presence of occult neoplasms.

Antilactoferrin Antibodies in Autoimmune Liver Diseases

Objective:Lactoferrin, an immunoregulatory protein in mucosal secretions, is one of the target antigens to perinuclear antineutrophil cytoplasmic antibodies (P-ANCAs). Circulating lactoferrin is cleared in the liver, but little is known about the implication of lactoferrin in hepatic inflammation. To evaluate the implication of immunological response to lactoferrin, we examined antilactoferrin antibodies in autoimmune liver diseases.Methods:Fourteen patients with primary biliary cirrhosis (PBC), 14 with autoimmune hepatitis (AIH), five with autoimmune cholangitis (AIC), six with chronic hepatitis C, and five with chronic hepatitis B were studied. We evaluated autoantibodies to lactoferrin in the sera of the patients by the Western Immunoblotting method.Results:Sera of five of the 14 patients (35.7%) with PBC, four of the 14 patients (28.6%) with AIH, and five of the five patients (100%) with AIC contained autoantibodies to human lactoferrin, but none with hepatitis B or C had them. The higher prevalence of serum antibodies to human lactoferrin was shown to be higher in patients with AIC than with hepatitis B (p < 0.01), hepatitis C (p < 0.01), PBC (p < 0.05), and AIH (p < 0.05).Conclusion:Lactoferrin located in bile ducts and liver cells is one of the candidates of target antigens in autoimmune liver diseases, especially in AIC.

Fibrolamellar carcinoma of the liver with a mixture of ordinary hepatocellular carcinoma: a case report.

Fibrolamellar carcinoma (FLC) of the liver is a rare variant of hepatocellular carcinoma (HCC), and only 13 cases have been reported in Japan up to 1997. We described a histologically unusual case of FLC. A 52-yr-old man was admitted to our hospital for work-up of hepatic mass. Laboratory examinations revealed no abnormalities except elevated serum alpha-fetoprotein (AFP) (2098 ng/ml). A diagnosis of HCC was made by imaging findings, and left lobectomy of the liver was performed. Histologically, the tumor was composed of areas of FLC mixed with ordinary HCC and those of pure ordinary HCC. Staining for AFP was positive in the HCC component and negative in the FLC component. Some cases of such mixed tumors have been reported in Europe and the United States, but not in Japan. We regarded our case as the first of the mixed tumor in Japan.

Downregulation of gastric mucin gene expression and its biosynthesis by dexamethasone in the human

The effect of corticosteroids on the release and biosynthesis of gastric mucin remains unclear. We studied the effects of dexamethasone on biosynthesis of mucin and MUC1 gene expression in the human stomach in vitro. Gastric mucosal specimens, obtained from six subjects at gastrectomy, were cultured with various concentrations of dexamethasone. Biosynthesis of mucin was studied by labeling gastric mucosa for 2 h with [3H]-glucosamine. After purification of mucin by CsCl gradient centrifugation, radioactivity of intra- and extracellular samples was counted. MUC1 gene expression was studied by Northern and dot-blot analysis using a cDNA encoding human gastric mucin gene MUC1. The dexamethasone treatment decreased mucin secretion from the isolated mucosa in a time- and concentration-dependent manner, with maximal inhibition of secretion (32+/-6%) observed after 8 h and 10(-5) M. Dexamethasone treatment also decreased MUC1 levels (28+/-9%). The inhibitory effect was also observed in carbachol-evoked secretion. These findings suggest that a decrease in mucin biosynthesis by corticosteroids may be involved in steroid-induced gastric mucosal damage.

Bleeding stercoral ulcer with visible vessels: effective endoscopic injection therapy without electrocoagulation

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