Tomoe Katsumata

Indications of Endoscopic Polypectomy for Rectal Carcinoid Tumors and Clinical Usefulness of Endoscopic Ultrasonography

PURPOSEThis study was designed to define the indications of endoscopic polypectomy for rectal carcinoid tumors and evaluate the diagnostic value of endoscopic ultrasonography.METHODSA total of 66 rectal carcinoid tumors treated at our hospital were analyzed histopathologically to clarify risk factors for metastasis. The depth of invasion was determined for 52 lesions examined by endoscopic ultrasonography, and the value of endoscopic ultrasonography for deciding whether a lesion is indicated for endoscopic polypectomy was assessed.RESULTSNone of the 57 lesions measuring ≤ 10 mm in diameter invaded the muscularis propria or had metastasis. Of nine lesions with a diameter of ≥ 11 mm, five invaded the muscularis propria and four had metastasis. A central depression was found in three of the lesions with metastasis. The depth of invasion of 49 lesions examined by endoscopic ultrasonography was limited to the submucosa; 3 lesions invaded the muscularis propria. The depth of invasion of all lesions was correctly diagnosed by endoscopic ultrasonography. Ninety-six percent of the lesions that had submucosal invasion with narrowing of the upper two-thirds of the third layer (submucosa) as evaluated by endoscopic ultrasonography could be completely resected by endoscopic polypectomy.CONCLUSIONSRectal carcinoid tumors that satisfy the following three conditions are indicated for local resection, including endoscopic polypectomy: a maximum diameter of ≤ 10 mm, no invasion of the muscularis propria, and no depression or ulceration in the lesion. Endoscopic ultrasonography also is useful for estimating the depth of invasion of rectal carcinoid tumors and for determining whether endoscopic polypectomy is indicated.

Dye spraying and magnifying endoscopy for dysplasia and cancer surveillance in ulcerative colitis

PURPOSEThe aim of this study was to investigate detection of dysplasia or colitic cancer with ulcerative colitis by use of magnifying endoscopic observation.METHODSFrom 1986 through 2000, ulcerative colitis was diagnosed and treated in 886 patients at Kitasato University East Hospital. Of the total, we studied 25 patients in depth: 14 who had dysplasia alone, 5 in whom cancer was diagnosed during follow-up after the detection of dysplasia, and 6 who had colitic cancer.RESULTSDysplasia was detected in 11 (3.2 percent) of 345 patients with extensive colitis and in 8 (3.7 percent) of 217 with left-sided colitis. Colorectal cancer was diagnosed in nine patients (2.6 percent) with extensive colitis and in two (0.9 percent) with left-sided colitis. Neither dysplasia nor colitic cancer was found in patients with proctitis-type colitis. Endoscopically, dysplasia and early cancer were characterized by granular or nodular protruding mucosa or by lowly protruding or flat mucosa, often associated with redness. Dye-spraying endoscopy was useful for detection. Magnifying endoscopy of ten regions of dysplasia (7 patients) and five early cancers (4 patients) showed IIIS to IIIL type pits or IV type pits. Biopsy of sites showing tumorous pits on magnifying endoscopy revealed dysplasia and early cancer. Observation of the pit pattern was found to be diagnostically useful.CONCLUSIONSDye spraying and magnifying endoscopy are useful for the detection, targeted biopsy, and diagnosis of dysplasia and colitic cancer in patients with ulcerative colitis.

Autoimmune enteropathy with severe atrophic gastritis and colitis in an adult: proposal of a generalized autoimmune disorder of the alimentary tract.

BACKGROUND We describe the case of an adult with autoimmune enteropathy consistent with both severe atrophic gastritis accompanying antral stenosis and colitis. METHODS AND RESULTS The patient, positive for anti-intrinsic factor antibody, had intractable diarrhea and protein-losing enteropathy. In the ileum inflammatory cells were observed infiltrating the lamina propria along with villus atrophy, and similar inflammation was also found in the lamina propria of the colon and stomach, with complete loss of specialized glands. The myenteric ganglion cells of the hypertrophied muscularis propria in the stenosed antrum showed degeneration with surrounding T-lymphocyte infiltration. There were more CD8+ than CD4 lymphocytes in the lamina propria of the stomach and colon. CONCLUSIONS The CD8+ (suppressor-cytotoxic) T lymphocytes may have played an important role in the production of lesions in the stomach, small intestine, and colon, so we propose this case as an example of a generalized autoimmune disorder of the alimentary tract.

Submucosal Fibrosis and Basic-Fibroblast Growth Factor-Positive Neutrophils Correlate with Colonic Stenosis in Cases of Ulcerative Colitis

Background and Aims: The frequency of benign stenosis in ulcerative colitis (UC) is low, reported as being 3.2–11.2%, with fibrosis in the submucosa or deeper pointed out as one of the causes. The aim of the present study was to assess stenosis in UC cases using immunostaining and to analyze differences between stenotic and nonstenotic cases, focusing on basic-fibroblast growth factor (b-FGF) expression and myofibroblasts. Methods: Totals of 9 stenotic and 17 nonstenotic UC cases were histopathologically examined and immunohistochemically stained for b-FGF, α-smooth muscle actin (α-SMA), CD34, CD68 and IL-6. To identify b-FGF-positive cells, double immunostaining for b-FGF and myeloperoxidase or CD68 was performed. Results: In addition to submucosal fibrosis, a significant increase of b-FGF-positive inflammatory cells and myofibroblasts was observed in stenotic portions. Most b-FGF-positive cells were also positive for myeloperoxidase, and a correlation between b-FGF-positive and total neutrophil counts was found. Conclusions: One of the major causes of stenosis in long-standing UC is fibrosis in the bowel wall, possibly induced by infiltrating inflammatory neutrophils producing b-FGF.

Intestinal Behçet's disease--pathognomonic changes in intramucosal lymphoid tissues and effect of a "rest cure" on intestinal lesions.

To clarify the pathognomonic changes of intestinal lesions of Behçet’s disease and to determine effective therapeutic measures, we recruited 13 patients with the intestinal form of this disease for study. We performed pathology studies on the resected specimens of 7 patients and treated 5 of the other 6 patients with a low-residue diet. Pathology examination revealed that 6 of the 7 had inflammatory ulcerations in the ileocecal region. The ileal ulcers were mainly on the antimesenteric side. We observed remnants of Peyer’s patches at the margins of the major ulcerative lesions in 2 of 2 patients examined. There were aggregations of lymphocytes resembling destroyed lymph follicles in the superficial layer at the mouths of small fissuring lesions, and ulcer scars were also noted in Peyer’s patches in 4 of 5 other patients. X-ray and endoscopic examinations revealed the disappearance of intestinal lesions in 5 patients within 1 month during, or following the low-residue diet treatment. We found the intestinal lesions of Behçet’s disease at sites coinciding with intramucosal lymphoid tissue. The “rest cure” for the affected bowel was effective, i.e., there was significant alleviation of gastrointestinal symptomas and the intestinal lesions disappeared. We speculated that acute exudative inflammation, abscess formation, and consequent ulceration may occur in these tissues by the same mechanisms as those that operate in the positive needle-prick reactions seen in patients with Behçet’s disease.

A new disk method for the endoscopic determination of gastric ulcer area

The authors devised a new method using measure plates for the endoscopic measurement of gastric ulcer area. A grid composed of 2.5-mm squares was photographed by the endoscope with lens-object-distance (LOD) being changed every 2.5 mm precisely, and the obtained images of the square pattern were printed on glass plates, which were used as measure plates. The ulcer size was determined by mounting an endoscopic photograph of the ulcer on the corresponding glass plate with the same LOD, projecting them on the screen by a projector and counting the number of squares within the ulcer area. In this way the gastric ulcer size could be determined with an average aberration ratio of 5.6% or less, irrespective of LOD.

Colitis in chronic granulomatous disease resembling Crohn's disease: comparative analysis of CD68-positive cells between two disease entities.

Chronic granulomatous disease (CGD) is an inhe rited illne ss in which the inability of phagocytic granulocyte s to kill catalase -positive bacteria results in repeated severe infections (1). In CGD, granulocyte s show a de ® ciency of the hydroge n peroxide myelope roxidase ± halide antimicrobial system so that inge sted bacte ria that do not form peroxidase and are catalase positive continue to survive within granulocyte s (2). Thus, these bacte ria become disseminated throughout the body, resulting in the formation of multifocal absce sses and granulomas. In addition to infectious complications due to gastrointe stinal obstructive le sions, inte stinal malabsorption and ® stula formation have been reported in CGD (3± 6). We wish to discuss here the histological feature s of a patient with colitis in CGD resembling Crohn’ s disease.

Cell Kinetics, p53 and bcl-2 Expression, and c-Ki-ras Mutations in Flat-Elevated Tubulovillous Adenomas and Adenocarcinomas of the Colorectum: Comparison with Polypoid Lesions

BACKGROUND Flat(-elevated) tubulovillous adenomas and adenocarcinomas of the colorectum constitute a specific type of neoplasm with superficial spreading growth. To establish their characteristics, a comparative investigation of a series of tumors was performed. METHODS A total of 56 flat tubulovillous tumors (39 adenomas, 17 invasive carcinomas) and 154 polypoid tubular or villous tumors (77 adenomas, 77 invasive carcinomas) were comparatively assessed for cell kinetics and molecular alterations. RESULTS Ki-67 labeling and p53 expression for both types of tumors increased along with degree of dysplasia or invasion, whereas bcl-2 expression showed an inverse decrease. However, apoptotic activity was invariably low in the flat tubulovillous tumors, as compared with the polypoid tumors, in which increase was apparent with tumor progression. The flat tubulovillous tumors also showed a higher frequency of c-Ki-ras mutations (92.9%) than the polypoid tubular tumors (40.0%). CONCLUSIONS The flat tubulovillous tumor can be considered a distinct entity, with characteristics different from the polypoid counterpart.

A case of adenocarcinoma of the small intestine in a Japanese patient with Crohn disease: a report with immunohistochemical and oncogenic analyses.

We report a rare case of Crohn disease accompanied by a small-bowel carcinoma that developed in a 54-year-old Japanese man. The ulcerating tumor, which histologically proved to be a poorly differentiated adenocarcinoma and dysplasia surrounding the carcinoma, was located in the diseased ileum. The Ki-67 immunoreactive epithelial cells were increased in regenerative mucosa as compared with values for normal mucosa. The Ki-67- and p53-positive cells were increased in dysplasia and carcinoma as compared with values for regenerative or normal mucosa. In contrast, the p21(WAF1/CIP1) immunoreactive cells were decreased in this order. Intense DCC (deleted in colorectal cancer) expression was constantly shown among normal, regenerative, dysplastic and cancerous tissues. No bcl-2 expression and c-Ki-ras mutations were apparent. In conclusion, enhanced epithelial cell proliferation, p53 overexpression, and decrease of p21(WAF1/CIP1) expression may predispose the small-bowel mucosa to dysplasia and carcinoma development in Crohn disease.

Clinical role of endoscopic ultrasonography for the diagnosis of early colorectal cancer and selecting the treatment procedure

Background:  Accurate evaluation of the depth of tumor invasion, including the degree of submucosal invasion, is a prerequisite to selecting the treatment procedure for early colorectal cancer (CRC). The purpose of the present study was to evaluate the significance of endoscopic ultrasonography (EUS) for diagnosing the depth of invasion of early CRC and selecting the treatment procedure. We concurrently estimated the usefulness of three‐dimensional EUS (3‐D‐EUS) compared with that of conventional EUS.