[Show abstract][Hide abstract]ABSTRACT: Background and aims:
EUS-guided FNA biopsy has been widely performed to aid in the diagnosis of submucosal tumors (SMTs). However, in cases of small tumors, the diagnostic yield of EUS-FNA is poor. Therefore, it is necessary to develop a new needle for the diagnosis. We developed a device with a new mechanism that we refer to as a drill needle aspiration biopsy (DNAB). The aim of this study was to evaluate the use of DNAB in resected gastric SMT specimens.
A drill needle with a sharp tip and wide ditch was inserted into a catheter for angiography. Continuous suction is enabled through the catheter at the tip. DNAB was performed with one pass and one stroke in 13 gastric SMTs resected by operation. Similarly, FNA was performed by one pass and ten strokes. These gastric tumors included nine diagnosed gastrointestinal stromal tumors and four undiagnosed SMTs by preoperative examinations. The tissue quantity between DNAB and FNA was macroscopically and microscopically examined.
All 13 drill biopsy specimens were obtained. Additionally, all 13 gastric SMTs, including 4 undiagnosed tumors, could be diagnosed by DNAB. The quantity of each specimen obtained by DNAB was macroscopically and microscopically much greater than that by FNA. In particular, for tumors <25 mm in the longer axis, the ratio of microscopic diagnosable cases was 100 % (7/7) for DNAB and 42.9 % (3/7) for FNA.
DNAB is a novel method that can obtain more tissue than FNA for small gastric SMT.
[Show abstract][Hide abstract]ABSTRACT: Background/aims:
Totally laparoscopic distal gastrectomy (TLDG) has become a feasible and safe surgical option for early gastric cancer. However, determining the transection line of the stomach without palpation is still difficult. This study aimed to assess the efficacy of TLDG for gastric resection under retroflexed endoscopic guidance (GRREG) in patients with gastric cancer in the middle third of the stomach.
Fifteen patients with gastric cancer underwent TLDG using GRREG. Preoperative tumor localization using endoscopic metal clips was performed in all cases. After lymphadenectomy, two-thirds of the estimated transection line was occluded by an endoscopic stapler, beginning at the lesser curvature. Under gastric occlusion, the gastroscope was passed via the narrow lumen along the greater curvature followed by retroflexion to reveal the occlusion line, marking clips, and tumor in the same field of view. This view verified the safe oncological transection line.
All patients had cancer-free margins and did not require additional surgery. The mean (±SD) proximal margin was 23.5 ± 10.4 mm. There were no procedure-related complications.
GRREG was a safe and effective technique for TLDG. Ideal transection of the stomach was achieved using a combination of an endoscopic stapler and gastroscope retroflexion.
[Show abstract][Hide abstract]ABSTRACT: Background
We performed endoscopic ultrasound real-time tissue elastography to more accurately diagnose lymph node metastasis of esophageal cancer. The aim of this study was to evaluate the ability of EUS elastography to distinguish benign from malignant lymph nodes in esophageal cancer patients.
The present study had two steps. As the first step (study 1), we developed diagnostic criteria for metastatic lymph nodes using elastography and verified the validity of the criteria. Three hundred and twenty-two lymph nodes from 35 patients treated by surgical resection were included in the study. As the second step (study 2), we preoperatively examined the lymph nodes of esophageal cancer patients with EUS elastography and compared its diagnostic performance with that of the conventional B-mode EUS images. A total of 115 lymph nodes from 31 patients were included.
In study 1, lymph nodes were considered malignant if 50 % or more of the node appeared blue, or if the peripheral part of the lesion was blue and the central part was red/yellow/green. The sensitivity and specificity of the elastography were 79.7 and 97.6 % with an accuracy of 93.8 %, which was significantly higher than the values for conventional B-mode imaging. In study 2, the sensitivity and specificity of the EUS elastography were 91.2 and 94.5 % with an accuracy of 93.9 %, which was also significantly higher than the values for conventional B-mode EUS imaging.
The present study demonstrated that EUS elastography is useful for diagnosing lymph node metastasis of esophageal cancer.
[Show abstract][Hide abstract]ABSTRACT: The patient was a 78-year-old woman. He suffered from a elevated colon necrosis after esophagectomy, total gastorectomy for esophageal cancer, and gastric cancer. For this case, early resection of the necrotic colon, esophagus skin fistula set, and colon fistula catheter fistula set were performed. Second reconstruction was made by using the pedunculated jejunum with additional microvascular anastomosis between the jejunal and internal mammary vessels. He was discharged in good postoperative course. We chose the pedicled jejunum recoustruction by adding a revascularization rather than a free jejunum reconstruction, because the distance was longer in this case. This supercharge method would be effective for the elevation colonic necrosis case, a worrisome case in which the circulation of the distal part of the reconstructed substitute might be poor.
[Show abstract][Hide abstract]ABSTRACT: We report a case of the appendiceal carcinoma with direct invasion to the ascending colon. A 73-yearold man who pointed out an ulcerative lesion in the ascending colon admitted to our hospital. Colonoscopy showed an ulcerative tumor in the ascending colon, and histlogical findings of biopsy specimens revealed adenocarcinoma (tub1). Contrast enhanced computed tomography (CT) showed appendiceal tumor which had invaded to the ascending colon. This tumor was diagnosed as tubular adenocarcinoma of the appendix (V, cT4b (ascending colon), cN1, cM0, cStageIIIa). Right hemicolectomy with lymph node dissection (D3) was performed. The tumor was diagnosed as mucinous adenocarcinoma of the appendix (V, Type5, muc>tub1, pT4b (ascending colon), pN1 (1/28, No. 201), pStageIIIa). Five courses adjuvant chemotherapy with UFT (uracil-tegafur) and UZEL (calcium folinate) following surgery was additionally performed and the patient remains alive without a sign of recurrence 9 months after the surgery.
[Show abstract][Hide abstract]ABSTRACT: A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer (T3N2M0 Stage III) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation, including redness, erosion, edema, bleeding, friability, and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine, gastrografin-filled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly, endoscopic balloon dilatation was performed and anti-fungal therapy was started in the hospital. Seven weeks later, endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently, the patient was discharged. At the latest follow-up, the patient was symptom-free and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.
[Show abstract][Hide abstract]ABSTRACT: Objectives In patients with obstructive esophageal cancer (OEC) with stenosis of the tract to the stomach, the percutaneous endoscopic gastrostomy (PEG) procedure cannot be performed if the endoscope is unable to pass through to the stomach. Our aim was to describe the safety and utility of the gradual tube dilation method (GTD) before PEG in cases of OEC. Methods This study enrolled 38 consecutive patients. If an ultrathin transnasal endoscope (UTNE) could successfully reach the stomach through the esophageal stenosis, then PEG was performed without using the GTD. If even the UTNE could not be passed to the stomach, PEG was performed after the GTD. The GTD shows the method that gradually increases the size from an 8 Fr to 16 Fr nasogastric tube which passed through the obstruction before performing PEG. We conducted a retrospective review of all patients who received the GTD. The complications were examined from the first UTNE to the completion of PEG. Results Seventeen of 38 patients received the GTD. All 17 patients successfully underwent the PEG procedures. The intubation period was 9.8 ± 3.4 days. The mean number of replacements was 2.5. Regarding complications, only three of the 17 patients experienced a sore throat. No significant differences were found in the PEG procedure times between the patients with the GTD and those without the GTD (P = 0.360). Conclusions If patients with progressive esophageal cancer, such as OEC, need to undergo PEG, then the GTD is considered to be a useful modality for dilating the stenosis simply and safely.
[Show abstract][Hide abstract]ABSTRACT: A male patient in his early seventies complained of swallowing difficulty and back pain. Esophagogastroscopy was performed and the patient was diagnosed as squamous cell carcinoma in the middle and lower part of the esophagus with a longitudinal submucosal elevation of 15 cm and S2 stage of gastric ulcer infected by Helicobacter pylori. Multiple lymph node swelling was detected not only in the mediastinum but also in the neck and the para-aortic area by CT scanning. The clinical stage was T3 N4 M0 Stage IVa. Systemic chemotherapy was applied first and the curative effectiveness was SD based on the RECIST criteria. PET revealed accumulation of FDG in the esophageal and stomach wall. These lesions were suspected to be HP-infected esophageal cancer, and Helicobacter pylori elimination was performed. After HP eradication, the tumor of the esophagus, submucosal elevation of esophagus, and gastric ulcer was markedly shrunk. Multiple lymph node swelling was definitely shrunk based on CT. Overall the early esophageal cancer remained. Endoscopic submucosal dissection (ESD) was performed. The pathological diagnosis was Type 0-IIc, pT1b(SM2), ly1, v2, pHM0, pVM0. After ESD, he indicated febrile neutropenia, was diagnosed as myelodysplastic syndrome (MDS) during the follow-up period and chose best supportive care (BSC).
[Show abstract][Hide abstract]ABSTRACT: Introduction:
Photodynamic therapy (PDT) is a less invasive option for cancer treatment that has evolved through recent developments in nanotechnology. We have designed and synthesized a novel liposome system that includes an indocyanine green (ICG) derivative, ICG-C18, in its bilayer. In addition to its use as an optical imager to visualize blood, lymphatic, and bile flow, ICG has also been used as an optical sensitizer. In the present report, we evaluate the use of our novel liposome system, LP-ICG-C18, in PDT for squamous cell carcinoma in an autologous murine model.
Materials and methods:
An excitation pulse beam (300 μJ/pulse) of a single band (800 nm) was used for sensitization. The cytotoxicity of the photodynamic therapy was evaluated in terms of cellular morphology changes, methyl thiazolyl tetrazolium (MTT) assay results, and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) staining. We tested the enhanced permeability and retention effect of LP-ICG-C18 in tumor-bearing C3H/He mice using a near-infrared fluorescence imaging system and fluorescence microscopy. We also examined the antitumor effect of PDT by measuring tumor volume in tumor-bearing mice.
Cell death and apoptosis were only observed in the PDT group receiving LP-ICG-C18. LP-ICG-C18 itself had no cytotoxic activity and showed good biocompatibility. LP-ICG-C18 accumulated on the tumor 24 hours after injection and was retained for approximately 3 weeks. Tumor cell apoptosis following PDT with LP-ICG-C18 was also observed under optical microscopy, MTT assay, and TUNEL staining.
These findings suggest that LP-ICG-C18 may be an effective intervening material in PDT for malignant disease.
[Show abstract][Hide abstract]ABSTRACT: Abstract Short gastric vessel division (SGVD) has been performed as a part of fundoplication for achalasia. However, whether or not SGVD is necessary is still unknown. Forty-six patients with achalasia who underwent a laparoscopic surgery with or without SGVD were analyzed. A questionnaire was administered to assess the postoperative improvement. Regarding improvement of dysphagia and postoperative reflux, there were no significant differences between SGVD (+) group and SGVD (-) group (P = 0.588 and P = 0.686, respectively). Nineteen patients (95%) in the SGVD (+) group and 24 (92%) in the SGVD (-) group answered that the surgery was satisfactory (P = 0.756). In the SGVD (+) group, the pre- and postsurgical body weight increase was +7.3%. In the SGVD (-) group, it was 8.2%. There was no significant difference of body weight increase between the 2 groups (P = 0.354). SGVD is not always required in laparoscopic surgery for achalasia.
[Show abstract][Hide abstract]ABSTRACT: We investigated the usefulness of 18F-fluorodeoxyglucose positron emission tomography(FDG-PET)for superficial esophageal squamous cell carcinoma after resection via endoscopic submucosal dissection(ESD). Our case study included 37 patients and 49 tumors resected via ESD in our hospital between January 2012 and December 2013. Histopathological diagnosis confirmed squamous cell carcinoma in all cases. Tumors located near the esophagocardiac junction were excluded. We investigated retrospectively whether the standardized uptake value(SUV)obtained by using FDG-PET could be the criterion to decide whether to perform ESD. At first, the tumor was examined via endoscopy. If tumor depth(T status)was less than cSM1, we performed ESD. When the tumor depth was less than pSM1, no infiltration of the vessel or lymph duct was observed, and the surgical margin was free; therefore, we did not perform any further therapy. On the other hand, we measured the SUV obtained via FDG-PET. The cut-off value was set as 3.0 based on the correlation between the SUV and tumor depth. We investigated if SUV<.0 could be the criterion for further therapy after ESD. In our results, the sensitivity was 95%, specificity was 67%, and accuracy was 90%. The SUV also helped to identify the malignancy of the superficial esophageal cancer and could help to decide whether ESD should be undertaken.
Article · Nov 2014 · Gan to kagaku ryoho. Cancer & chemotherapy
[Show abstract][Hide abstract]ABSTRACT: Esophageal lymphoepithelioma-like carcinoma (LELC) is extremely rare. We report the first case of esophageal LELC showing macroscopic reduction. A 67-year-old male presented with dysphagia and, by endoscopic examination, was found to have a significantly raised tumor of 10 mm in diameter in the thoracic esophagus. The biopsied material showed esophageal cancer. We performed endoscopic submucosal dissection. However, the tumor became flattened, similar to a scar, in only 2 mo. Histologically, the carcinoma cells had infiltrated the submucosal layer. Prominent infiltration of T lymphoid cells that stained positive for CD8 was observed around the carcinoma cells. Therefore, this lesion was considered to be an LELC with poorly differentiated squamous cells. Because the margin was positive, an esophagectomy was performed. Carcinoma cells were detected in the neck in one lymph node. The staging was T1N0M1b. However, the patient has been well, without adjuvant therapy or recurrence, for more than 5 years.
[Show abstract][Hide abstract]ABSTRACT: Although percutaneous endoscopic gastrostomy (PEG) is the preferred method to provide enteral nutrition for a longer time period, in obstructive esophageal cancer, we cannot safely perform endoscopic access to the stomach even with the ultrathin endoscope. We experienced 1 fatal case due to esophageal perforation caused by balloon dilation, and hence, we developed a safer method. We treated 4 patients with obstructive esophageal cancer using a 3-step gradual dilation method with nasogastric tubes (from 8 to 16 Fr). After about 2 weeks of initial dilation, we could safely perform endoscopic access to the stomach with the ultrathin endoscope and PEG placement using the introducer technique. The 3-step gradual dilation method is a safe and easy procedure for endoscopic access to the stomach. It can be used to provide enteral access as a palliative treatment for patients with obstructive esophageal cancer that is not suitable for conventional PEG placement.
[Show abstract][Hide abstract]ABSTRACT: Background:
Among patients with T4 thoracic esophageal squamous cell carcinoma (TESCC), it is unclear whether the outcomes of late responders who undergo high-dose chemoradiotherapy (CRT) followed by salvage esophagectomy differs from those of early responders who undergo low-dose CRT followed by esophagectomy.
A total of 153 patients with T4 TESCC were treated with CRT. The first evaluation was performed after 40 Gy of CRT for downstaging. Of these, 28 patients could be downstaged, and underwent subsequent surgery (early responders). For the remaining patients, additional CRT was administered, and patients were re-evaluated after treatment and underwent salvage surgery. In total, 40 patients (early + late responders) were analyzed.
The primary tumors exhibited a grade 3 response in six (21.4 %) of the early responders and two (16.7 %) of the late responders (p = 1.000). The rate of residual tumor in the primary tumor was 80 % (32/40 patients). The proportions of resected lymph nodes and positive metastatic nodes were similar between early and late responders (p = 0.406 and p = 0.859, respectively). The 5-year overall survival rates among the early and late responders were 25.9 and 36.5 %, respectively, and the median survival times were 24.8 and 24.3 months (p = 0.925), respectively. The 5-year cause-specific survival rates in the early and late responder groups were 61.5 and 72.9 % (p = 0.425), respectively.
The outcomes of both early and late responders to CRT were similar, and salvage surgery for T4 TESCC outweighs the risks in patients with T4 TESCC.
[Show abstract][Hide abstract]ABSTRACT: Aim:
To detect the criteria and cause of elevated salivary amylase activity (sAMY) in patients undergoing endoscopic submucosal dissection (ESD) under sedation.
A total of 41 patients with early gastric cancer removed via ESD under deep sedation (DS) were enrolled. The perioperative sAMY, which was shown as sympathetic excitements (SE), was measured. The time at which a patient exhibited a relatively increased rate of sAMY compared with the preoperative baseline level (IR, %) ≥ 100% (twice the actual value) was assumed as the moment when the patient received SE. Among the 41 patients, we focused on 14 patients who exhibited an IR ≥ 100% at any time that was associated with sAMY elevation during ESD (H-group) and examined whether any particular endoscopic procedures can cause SE by simultaneously monitoring the sAMY level. If a patient demonstrated an elevated sAMY level above twice the baseline level, the endoscopic procedure was immediately stopped. In the impossible case of discontinuance, analgesic medicines were administered. This study was performed prospectively.
A total of 26 episodes of sAMY eruption were considered moments of SE in the H-group. The baseline level of sAMY significantly increased in association with an IR of > 100% at 5 min, with a significant difference (IR immediately before elevation/IR at elevation of sAMY = 8.72 ± 173/958 ± 1391%, P < 0.001). However, effective intervention decreased the elevated sAMY level immediately within only 5 min, with a significant difference (IR at sAMY elevation/immediately after intervention = 958 ± 1391/476 ± 1031, P < 0.001). The bispectral indices, systolic blood pressure and pulse rates, which were measured at the same time, remained stable throughout the ESD. Forceful endoscopic insertion or over insufflation was performed during 22 of the 26 episodes. Release of the gastric wall tension and/or the administration of analgesic medication resulted in the immediate recovery of the elevated sAMY level, independent of body movement.
By detecting twice the actual sAMY based on the preoperative level, the release of the gastric wall tension or the administration of analgesic agents should be considered.
[Show abstract][Hide abstract]ABSTRACT: Gastrointestinal stromal tumors (GISTs) rarely arise in the esophagus, where carcinoma is the most common malignant neoplasm and leiomyoma is the most common benign tumor. Because of their rarity, the clinical course and treatment of esophageal GISTs are poorly understood. These lesions are generally thought to carry a poor prognosis, making the differential diagnosis of other common mesenchymal neoplasms essential, for both prognostic and therapeutic reasons. We report a case of successfully resected giant esophageal GIST, thought to be the largest resected GIST reported in Japan. The patient was a 65-year-old woman, in whom upper gastrointestinal endoscopy found a 180-mm submucosal tumor in the lower thoracic esophagus, extending just below the aortic arch. We diagnosed esophageal GIST, and the patient underwent middle and lower esophagectomy via left thoracotomy, followed by gastric tube reconstruction. The tumor was resected completely. Histopathological and immunohistochemical staining confirmed that the tumor was a high-risk lesion, and treatment with imatinib was initiated. Computed tomography showed liver metastasis 5 months later, but the patient is doing well 24 months after surgery.
[Show abstract][Hide abstract]ABSTRACT: We have encountered many cases wherein the metastatic nest of esophageal squamous cell carcinoma occupied only a small space in the lymph nodes because of which computed tomography( CT) and fludeoxy glucose( FDG)-positron emission tomography( PET) could not detect the lymph node metastasis satisfactorily. The false-negative lymph nodes that were not detected by FDG-PET before surgery were smaller in diameter, rate of occupation, and area of occupation than the true-positive lymph nodes. The smallest area of the cancer nest in the true-positive group was 7.5 mm2, and therefore, it was reasonable to consider a 5-mm diameter area as the criteria for correct diagnosis by FDG-PET. Most of the false-negative lymph nodes with a large area of carcinoma were attached to the primary tumor; therefore, they could not be precisely identified. The detection of false-negative lymph nodes by FDG-PET was not precise because of increases in the quantity of stroma-like cells in poorly differentiated carcinomas and in fibrosis caused by neoadjuvant therapy in the lymph nodes.
Article · Nov 2013 · Gan to kagaku ryoho. Cancer & chemotherapy