Takuma Goto

A Randomized Study on the Effectiveness of Prophylactic Clipping during Endoscopic Resection of Colon Polyps for the Prevention of Delayed Bleeding

Backgrounds. The efficacy of clipping for preventing the delayed bleeding after the removal of colon polyps is still controversial. In order to clarify this efficacy, a randomized controlled study was performed. Methods. One hundred and fifty-six patients with colon neoplasms (288 lesions) were enrolled in the study. The patients were randomly divided into two groups: clipping or nonclipping groups using a sealed envelope method before the endoscopic resections. Eight specialists and nine residents were invited to perform this procedure. The risk factors and the rates of delayed bleeding after the endoscopic resections in each group were investigated. Results. There were no significant differences in the bleeding rate between the clipping and nonclipping groups, while the length of the procedure was significantly longer and the cost was higher in the clipping group than in the nonclipping group. The rate of bleeding was significantly higher in cases with polyps 2 cm or larger and with a longer procedure time, while none of the other factors affected the bleeding rate. Conclusions. This randomized controlled study revealed no significant effect of prophylactic clipping for preventing delayed bleeding after the endoscopic resection of colon polyps.

Reduction of E-cadherin by human defensin-5 in esophageal squamous cells.

Barretts esophagus (BE) is metaplastic columnar epithelium converted from normal squamous epithelia in the distal esophagus that is thought to be a precancerous lesion of esophageal adenocarcinoma. BE is attributed to gastroesophageal reflux disease (GERD), and therefore gastric acid or bile acids are thought to be factors that cause epithelial cell damage and inflammation in the gastro-esophageal junction. The decrease of adherent junction molecules, E-cadherin has been reported to be associated with the progression of the Barretts carcinoma, but the initiation of BE is not sufficiently understood. BE is characterized by the presence of goblet cells and occasionally Paneth cells are observed at the base of the crypts. The Paneth cells possess dense granules, in which human antimicrobial peptide human defensin-5 (HD-5) are stored and secreted out of the cells. This study determined the roles of HD-5 produced from metaplastic Paneth cells against adjacent to squamous cells in the gastro-esophageal junction. A human squamous cell line Het-1A, was incubated with the synthetic HD-5 peptide as a model of squamous cell in the gastro-esophageal junctions, and alterations of E-cadherin were investigated. Immunocytochemistry, flowcytometry, and Western blotting showed that the expression of E-cadherin protein was decreased. And a partial recovery from the decrease was observed by treatment with a CD10/neprilysin inhibitor (thiorphan). In conclusion, E-cadherin expression in squamous cells was reduced by HD-5 using in vitro experiments. In gastro-esophageal junction, HD-5 produced from metaplastic Paneth cells may therefore accelerate the initiation of BE.

A high-throughput sequence analysis of Japanese patients revealed 11 candidate genes associated with type 1 autoimmune pancreatitis susceptibility

The pathogenesis of autoimmune pancreatitis is unknown. In the present study we used high-throughput sequencing with next generation sequencing to identify the candidate genes associated with AIP. A total of 27 type 1 AIP patients and 30 healthy blood donors were recruited, and DNA samples were isolated from their mononuclear cells. A high-throughput sequencer with an original custom panel of 1031 genes was used to detect the genetic variants in each sample. Polymorphisms of CACNA1S (c.4642C>T), rs41554316, rs2231119, rs1042131, rs2838171, P2RX3 (c.195delG), rs75639061, SMAD7 (c.624delC) and TOP1 (c.2007delG), were identified as candidate genetic variants in patients with type 1 AIP. P2RX3 and TOP1 were significantly associated with AIP, even after adjusting bay means of Bonferronis correction. In addition, we also identified eight candidate genetic variants that were associated with the relapse of type 1 AIP, namely: rs1143146, rs1050716, HLA-C (c.759_763delCCCCCinsTCCCG), rs1050451, rs4154112, rs1049069, CACNA1C (c.5996delC) and CXCR3 (c.630_631delGC). Finally polymorphisms of rs1050716 and rs111493987 were identified as candidate genetic variants associated with extra-pancreatic lesions in patients with type 1 AIP. These candidates might be used as markers of AIP susceptibility and could contribute to the pathogenesis of type 1 AIP.

The Detection of Pancreatic and Retroperitoneal Plasmacytoma Helped to Diagnose Multiple Myeloma: A Case Report.

AbstractMultiple myeloma is characterized by the neoplastic proliferation of a single clone of plasma cells producing a monoclonal protein. However, the involvement of pancreas is a rare event. We herein report a rare case of pancreatic plasmacytoma, which was detected before the diagnosis of multiple myeloma.An 83-year-old male was referred to our hospital for further evaluation of obstructive jaundice and a pancreatic mass. A contrast-enhanced computed tomography (CT) scan revealed solid masses with homogenous enhancement in the pancreatic head and retroperitoneum. The histological findings of the retroperitoneal mass obtained by CT-guided biopsy showed multiple sheets of atypical plasma cells, which were positively immunostained for CD79a, CD138, and the &kgr; light chain. Serum immunoelectrophoresis detected M-component of immunoglobulin A-&kgr;, and the histological findings of the bone marrow revealed an abnormally increased number of atypical plasma cells with irregular nuclei and cytoplasmic vacuolation. The patient was therefore diagnosed to have multiple myeloma involving the pancreas and retroperitoneum. Although chemotherapy was performed, the patient died 6 months after the diagnosis.The pancreatic plasmacytoma was detected before the multiple myeloma in the present case. It is difficult to diagnose a pancreatic plasmacytoma without a history of multiple myeloma and related disease.

Echinococcosis infection diagnosed based on the histological findings of a lymph node involvement obtained by EUS-FNA

A 78-year-old male with ulcerative colitis underwent computed tomography (CT) to assess his liver condition due to chronic hepatitis C infection. He had received interferon therapy in 1999 and achieved a sustained serological response. Routine blood data, including measurements of tumor markers, were within the normal ranges. The hepatitis C virus RNA titer was negative, and an enhanced CT scan revealed a multinodular lesion in the right lobe of the hilar liver (segment fifth; S5), measuring 20 mm in size without calcification or enhancement in the arterial, portal, or equivalent phases. A heterogeneous low-density mass with an unclear margin in the hepatoduodenal ligament measuring 20 mm in size was also detected, suspected to be a necrotic lymph node [Figure 1a and b]. Ultrasonography (US) revealed a hyperechoic and multicystic lesion in the S5 of the liver [Figure 1c], and contrast-enhanced US in postphase revealed a mild defect [Figure 1d], with no findings of biliary or vascular involvement. Although biopsy specimens were obtained from the lesion of the S5 of the liver, no abnormal findings were histologically observed in these specimens. In general, biopsy is not necessary for the diagnosis of alveolar echinococcosis due to the risk of dissemination of the disease. It was very difficult to differentiate the lesions from malignancy. Thus, endoscopic US-guided fine needle aspiration (EUS-FNA) was performed after obtaining written informed consent. EUS scanning from 2nd portion of the duodenum visualized a lymph node measuring 20 mm in size as a hypoechoic lesion with a multiple hyperechoic punctiform pattern in the hepatoduodenal ligament [Figure 1e], and EUS-FNA was subsequently performed to determine the cause of the lymph node swelling using convex-type endoscopes (GF-UCT260; Olympus, Tokyo, Japan). Puncture and aspiration were performed using standard 22-gauge needles (EchoTip ProCore® HD Ultrasound Biopsy Needle, Cook Medical, Tokyo, Japan). The number of punctures with aspirations was 2; movements were performed for 20 times during each puncture. The biopsy specimen showed cuticular layers, a typical finding of echinococcosis [Figure 2]. EM18 antigens specific to alveolar echinococcosis[1] were positive on serologic tests with Western blotting and immunochromatography. Taken together, the lesions are diagnosed as alveolar echinococcosis extending to the lymph node, P1N1M0, Stage IIIb, based on the PNM classification of alveolar echinococcosis.[2] Images and Videos

Pancreatic metastasis of angiosarcoma (Stewart-Treves syndrome) diagnosed using endoscopic ultrasound-guided fine needle aspiration: A case report.

Background: Pancreatic involvement of angiosarcoma is extremely rare. Methods: We herein report a rare case of angiosarcoma associated with chronic lymphedema (Stewart–Treves syndrome) with pancreatic metastasis that was diagnosed using endoscopic ultrasound (EUS)/fine needle aspiration (FNA). Results: A 43-year-old woman with a history of radical hysterectomy with bilateral inguinal lymphadenectomy and chemoradiotherapy for cervical cancer 15 years prior noticed the presence of erythematous indurative plaques on her right femoral region, where chronic lymphedema had developed. Contrast-enhanced computed tomography (CT) revealed not only multiple nodules in the subcutaneous tissue of the right femoral region but also a 25 mm × 20 mm solid mass in the region of the pancreatic tail. A histological analysis of the specimens obtained using EUS/FNA revealed angiosarcoma that was immunohistochemically positive for platelet/endothelial cell adhesion molecule-1 but negative for cytokeratin. The patient was diagnosed as Stewart–Treves syndrome that had metastasized to the pancreas. Chemotherapy was performed, but the patient died 14 months after her diagnosis. Conclusion: Unfortunately, this patient was not followed up, even though she had chronic lymphedema of the right femoral region due to the repeated occurrence of phlegmon. To improve the survival rate of this fatal secondary malignant complication of radical lymphadenectomy, an early diagnosis with consecutive and long-term clinical follow-up and close monitoring for Stewart–Treves syndrome is therefore important.

Primary Poorly Differentiated Squamous Cell Carcinoma of the Extrahepatic Bile Duct.

Squamous cell carcinoma of the extrahepatic bile duct is quite rare. A 77-year-old woman with jaundice and general fatigue was referred to our hospital. Multiphase contrast-enhanced computed tomography visualized a 17-mm solid mass in the junction of the cystic and common bile ducts. The patient underwent pylorus-preserving pancreaticoduodenectomy. The pathological findings demonstrated keratin-positive poorly differentiated squamous cell carcinoma of the extrahepatic bile duct (T3N0M0, stage IIIA). Although adjuvant chemotherapy with gemcitabine was administered, the patient exhibited local recurrence at the site of anastomosis of biliojejunostomy 20 months after resection and died 32 months after resection.