Takaharu Masunaga

IgG4-related sclerosing mesenteritis : A rare mesenteric disease of unknown etiology

Sclerosing mesenteritis is a rare inflammatory and fibrosing disorder of unknown etiology, while IgG4‐related disease (IgG4‐RD) consists of mass‐forming, fibroinflammatory lesions characterized by high serum IgG4 levels and tissue infiltration of many IgG4‐positive plasma cells; obliterative phlebitis is common. This report describes a case of sclerosing mesenteritis that was considered a manifestation of IgG4‐RD. A 53‐year‐old man underwent right hemicolectomy because of an ileocecal mass that did not improve with conservative therapy. The ill‐defined fibroinflammatory lesion extended in the mesentery with storiform fibrosis, obliterative phlebitis, and infiltration of many IgG4‐positive plasma cells. The ratio of IgG4‐positive/IgG‐positive cells was 64%, and the ratio of forkhead box protein 3 (FOXP3)‐positive/CD4‐positive cells was elevated (13%). It is likely that at least some cases of sclerosing mesenteritis are a manifestation of IgG4‐RD. It is important to investigate this relationship because steroid therapy may benefit such cases.

Small Follicular Lymphoma Arising Near the Ampulla of Vater

A 49-yr-old Japanese woman underwent upper gastrointestinal endoscopy because of nonspecific dyspepsia. Endoscopy revealed a flat elevated lesion about 15 mm in diameter adjacent to the duodenal papilla, the surface of which was uneven and covered with whitish granules. Based on the results of histological examination with immunohistochemistry (positive for CD10, CD20, CD79a, and bcl-2 protein, negative for CD5 and cyclin D1), a diagnosis of grade 1/3 follicular lymphoma was established. Systemic staging examinations suggested the lymphoma was restricted to the mucosa and superficial portion of the submucosa in the duodenal wall. The patient was treated with a combination of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and monoclonal anti-CD20 antibody (rituximab), in addition to radiotherapy. After six courses of this combination chemotherapy, complete regression of the lymphoma was observed. Although reports of small duodenal lymphoma (<20 mm or localized to the mucosa or submucosa) are extremely rare, the features of this case are characteristic of small duodenal lymphoma in terms of evolution around the ampulla of Vater, low-grade follicular type, occurrence in a women, occurrence in the fourth decade of life, and favorable outcome, and this type of tumor may need to be distinguished by pathogenesis and clinical behavior from various other gastrointestinal lymphomas.

Assessment of still and moving images in the diagnosis of gastric lesions using magnifying narrow-band imaging in a prospective multicenter trial.

Objectives Magnifying narrow-band imaging (M-NBI) is more accurate than white-light imaging for diagnosing small gastric cancers. However, it is uncertain whether moving M-NBI images have additional effects in the diagnosis of gastric cancers compared with still images. Design A prospective multicenter cohort study. Methods To identify the additional benefits of moving M-NBI images by comparing the diagnostic accuracy of still images only with that of both still and moving images. Still and moving M-NBI images of 40 gastric lesions were obtained by an expert endoscopist prior to this prospective multicenter cohort study. Thirty-four endoscopists from ten different Japanese institutions participated in the prospective multicenter cohort study. Each study participant was first tested using only still M-NBI images (still image test), then tested 1 month later using both still and moving M-NBI images (moving image test). The main outcome was a difference in the diagnostic accuracy of cancerous versus noncancerous lesions between the still image test and the moving image test. Results Thirty-four endoscopists were analysed. There were no significant difference of cancerous versus noncancerous lesions between still and moving image tests in the diagnostic accuracy (59.9% versus 61.5%), sensitivity (53.4% versus 55.9%), and specificity (67.0% versus 67.6%). And there were no significant difference in the diagnostic accuracy between still and moving image tests of demarcation line (65.4% versus 65.5%), microvascular pattern (56.7% versus 56.9%), and microsurface pattern (48.1% versus 50.9%). Diagnostic accuracy showed no significant difference between the still and moving image tests in the subgroups of endoscopic findings of the lesions. Conclusions The addition of moving M-NBI images to still M-NBI images does not improve the diagnostic accuracy for gastric lesions. It is reasonable to concentrate on taking sharp still M-NBI images during endoscopic observation and use them for diagnosis. Trial registration Umin.ac.jp UMIN-CTR000008048

Adrenal mass and renal vessels mimicking intestinal bleeding on Tc-99m red blood cell scintigraphy

Tc-99m red blood cell accumulation in an adrenal metastatic mass and pool activity in the left renal vessels mimicked findings of intestinal bleeding. Sequential images and tomographic images could avoid a false-positive result.

Incidental detection of pulmonary infection during the evaluation of protein-losing enteropathy with In-111 transferrin

In-111 transferrin imaging was performed in a 71-year-old woman for the evaluation of protein-losing enteropathy. Although the result was negative for protein losing, the tracer accumulated in the lung suggesting an active pulmonary lesion. Pseudomonas infection was confirmed by bacteriological examination of the sputum.

Primary minute invasive de novo colonic adenocarcinoma appearing as submucosal tumor

A 4 mm white-yellow submucosal tumor-like lesion was detected in the sigmoid colon of an asymptomatic 52-yr-old Japanese man. Because the lesion was unexpectedly suspicious for adenocarcinoma by pathological examination of the biopsy specimen, it was treated by endoscopic mucosal resection. The specimen obtained demonstrated well-differentiated adenocarcinoma without any adenomatous element, and was located principally in the submucosal layer with a maximum depth of 1600 µm from the muscularis mucosae. The cancer exposed to the luminal surface was pathologically concluded to be diminutive. Intriguingly, aggregation of lymphocytes was found beneath the mucosal layer, which might have compromised the integrity of the muscularis mucosae. Because of deep submucosal infiltration and the latent aggressive nature of de novo cancer, the patient underwent an additional partial sigmoidcolectomy, which demonstrated no residual cancer and no regional lymph node metastasis. The lesion in this patient exhibited a previously undescribed appearance of de novo colon cancer as submucosal tumor in an early phase of growth.

Acute malignancy-related hydrocephalus uncovered after endoscopic manipulation: possible influence of gastrointestinal endoscopy on concurrent intracranial lesion.

A 78-year-old man underwent biliary stenting by means of endoscopy for obstructive jaundice due to common bile duct cancer. Despite uneventful operation, the patient remained comatose and began to hiccup and vomit with marked gastrointestinal gas retention. Neuroimaging studies disclosed obstructive hydrocephalus caused by a midbrain metastasis, probably from coexisting lung cancer. Ventricular peritoneal shunting restored consciousness and eliminated other gastrointestinal symptoms. This case suggests that gastrointestinal endoscopy may affect concurrent intracranial lesions, resulting in acute distress, presumably by transmission of pressure from the abdomen to a distant body compartment such as the intracranial space, or by endoscopy-related hypoventilation.

Efficacy of Endoscopic Esophageal Variceal Ligation in an Immunocompromised Host

Abstract: We successfully treated esophageal varices by endoscopic variceal ligation (EVL) in a 50‐year‐old female patient with common variable immunodeficiency and liver cirrhosis secondary to hepatitis B. Under the existing disadvantageous conditions including the immunocompromised status, hyperal‐lergic reactions to several drugs, chronic pulmonary infection, and impaired hepatic function, we considered EVL to be of greater potential benefit than endoscopic injection sclerotherapy (EIS). This case highlights the possible merits of EVL over EIS, even in the presence of various restrictions, such as the immunocompromised condition of our patient.