Rapid tumor progression complicated with liver abscess in a patient with gastric cancer receiving nivolumab therapy.

Immune checkpoint inhibitors have been approved for treating various cancer types. However, several studies reported rapid tumor progression, a condition known as hyperprogressive disease, after treatment with immune checkpoint inhibitors. We present the case of a 73-year-old man diagnosed with recurrent gastric cancer with liver and lymph node metastases detected in the presence of obstructive jaundice. Concomitant administration of nivolumab with cytotoxic chemotherapy as first-line chemotherapy effectively controlled the tumor. Nevertheless, once cytotoxic chemotherapy was discontinued and nivolumab monotherapy was initiated to treat liver abscess complications, the tumor rapidly progressed, ultimately leading to the patient's death. This is the first report on rapid tumor growth observed during subsequent treatment with nivolumab after initial antitumor effects were confirmed. This case report describes the possibility of rapid tumor growth in patients receiving immune checkpoint inhibitor therapy, including in cases where this therapy showed antitumor efficacy in the initial therapeutic evaluation. Therefore, patients receiving immune checkpoint inhibitor therapy need to be monitored.

Therapeutic Effects of CDK4/6 Inhibitors in Gastric and Colonic Metastases From Breast Cancer: A Case Report.

Breast cancer often metastasizes to the lungs, bones, liver, and brain; however, gastric and colonic metastases from breast cancer are rare. Nevertheless, here, we present the case of a 50-year-old woman diagnosed with recurrent breast cancer, exhibiting gastric and colonic metastases that were detected when she experienced intermittent abdominal pain. The differentiation between primary gastric cancer and metastasis from breast cancer was made through immunohistochemical staining. The patient underwent treatment with palbociclib, a cyclin-dependent kinase (CDK)4/6 inhibitor, and anastrozole, with no significant adverse effects. Subsequent upper and lower endoscopic examinations following the initiation of these treatments revealed tumor shrinkage in both gastric and colonic metastases. This case report presents the first instance in which morphological changes in gastrointestinal metastasis induced by CDK4/6 inhibitors could be evaluated.

Sustained effect of leukocytapheresis/granulocytapheresis versus anti-human TNF-α monoclonal antibody on ulcerative colitis: A 2-year retrospective study.

Although anti-tumor necrosis factor-α monoclonal antibody biological preparations (BP) agents are widely used as an established treatment tool for refractory ulcerative colitis (UC), whether leukocytapheresis/granulocytapheresis (L/G-CAP) has similar beneficial impact on the disease activity remains undetermined. Furthermore, the costs defrayed for the treatment with these 2 modalities have not been compared. We retrospectively evaluated whether L/G-CAP offered sustained beneficial effects over 2-year period. The patients who had moderately to severely active UC (Rachmilewitz clinical activity index (CAI) ≧ 5) and were treated with a series (10 sessions) of L/G-CAP (n = 19) or BP (n = 7) as an add-on therapy to conventional medications were followed. Furthermore, the cost-effectiveness pertaining to the treatment with L/G-CAP and BP was assessed over 12 months. At baseline, L/G-CAP and BP groups manifested similar disease activity (CAI, L/G-CAP; 7.0 [6.0-10.0], BP; 10.0 [6.0-10.0], P = .207). The L/G-CAP and BP treatment suppressed the activity, with CAI 1 or less attained on day 180. When the L/G-CAP group was dichotomized into L/G-CAP-high and L/G-CAP-low group based on CAI values (≥3 or < 3) on day 365, CAI was gradually elevated in L/G-CAP-high group but remained suppressed in L/G-CAP-low group without additional apheresis for 2 years. Anemia was corrected more rapidly and hemoglobin levels were higher in BP group. The cost of the treatment with L/G-CAP over 12 months was curtailed to 76% of that with BP (1.79 [1.73-1.92] vs 2.35 [2.29-3.19] million yen, P = .028). L/G-CAP is as effective as BP in a substantial number of patients over 2 years. The cost for the treatment of UC favors L/G-CAP although the correction of anemia may prefer BP. Thus, L/G-CAP can effectively manage the disease activity with no additional implementation for 2 years although further therapeutic modalities might be required in a certain population with high CAI observed on day 365.

Eldest gastric cancer patient with high microsatellite instability responding to pembrolizumab.

Pembrolizumab has been associated with a high tumor response rate among high microsatellite instability (MSI-H) cancer patients. The efficacy and safety of pembrolizumab in the treatment of MSI-H gastric cancer (GC) patients aged ≥ 85 years have not been reported. This study reports the case of an 89-year-old woman diagnosed with stage IIA MSI-H GC based on her chief complaint of abdominal pain. We considered surgery, but it was contraindicated due to the patient's age and cardiovascular comorbidity. Therefore, we administered pembrolizumab after receiving approval from the ethics committee, and no significant adverse events were noted. The tumor was markedly responsive to pembrolizumab, and the computed tomography and endoscopic findings revealed a complete response. This is the first report on the efficacy and safety of pembrolizumab in the treatment of GC in an "oldest old" patient with MSI-H.

Transcatheter arterial embolization for postoperative hemorrhage complicating surgical repair of incarcerated umbilical hernia subsequent to Denver peritoneovenous shunting: A case report.

A 50-year-old man with a refractory ascites was inserted a peritoneovenous shunt under local anesthesia. On the fifth postoperative day, abdominal pain occurred and were diagnosed as incarcerated umbilical hernia. Due to unsuccessful manual reduction, emergent hernia repair was performed. Postoperatively, wound bleeding was not controlled, and endovascular treatment was planned because enhanced computed tomography detected arterial extravasations. Bilateral inferior epigastric arteries were embolized with a 33.3% n-butyl-2-cyanoacrylate lipiodol mixture. The patient's symptoms subsequently improved without complications. Patients with refractory ascites develop incarcerated umbilical hernia after the decompression procedure, such as a peritoneovenous shunt. The coagulopathy caused by the Denver peritoneovenous shunt makes perioperative bleeding control difficult. Therefore, physicians should be aware that laparotomy performed after Denver peritoneovenous shunting sometimes requires transarterial embolization for hemostasis.

Cerebral Venous Thrombosis as an Initial Presentation of Ulcerative Colitis.

Cerebral venous thrombosis (CVT) is a rare complication of ulcerative colitis (UC) that is potentially fatal once it occurs. This report describes a case of CVT that led to a diagnosis of UC. A 48-year-old woman was diagnosed with CVT due to paresthesia and weakness and was hospitalized for treatment. She developed bloody diarrhea on admission and was further diagnosed with UC based on endoscopic and pathologic findings. Treatment of UC with steroids and sulfasalazine was administered immediately. Her condition improved significantly within several days following treatment. After discharge, the patient experienced no recurrence of either CVT or UC flare-up over the last five years. This report describes CVT as an initial presentation of UC. This is also the first report of a long-term follow-up following successful treatment of CVT with concomitant UC.

Disseminated tuberculosis following invasive procedures for peripancreatic lymph node tuberculosis with portal vein obstruction: a case report.

Peripancreatic tuberculous lymphadenopathy can mimic pancreatic cancer on imaging. There have only a few reports on varices from portal vein obstruction due to abdominal tuberculous lymphadenopathy. Iatrogenic disseminated tuberculosis is also rare. Herein, we present a rare case of peripancreatic tuberculous lymphadenopathy with ruptured duodenal varices due to portal vein obstruction. The patient presented to our hospital with hematemesis. Computed tomography revealed a peripancreatic mass. Duodenal varices rupture from portal vein obstruction due to pancreatic cancer were initially suspected. The patient underwent portal vein stenting for portal vein obstruction and endoscopic ultrasound-guided fine-needle aspiration for diagnosis, which revealed granulomas indicative of tuberculosis. The patient was discharged once because fine-needle aspiration did not lead to a definitive diagnosis of tuberculosis. Subsequently, he developed disseminated tuberculosis. Peripancreatic tuberculous lymphadenopathy can cause ectopic varices with portal vein obstruction. Tuberculosis should also be included in the differential diagnosis in the case of portal vein obstruction, to facilitate early treatment and avoid unnecessary surgery. Furthermore, fine-needle aspiration or portal vein stenting for tuberculous lesions can cause disseminated tuberculosis. Since a diagnosis might not be made until after several fine-needle aspirations have been conducted, careful follow-up is necessary after the procedure for such lesions.

Intraductal papillary neoplasm of bile duct with invasive carcinoma as an intrahepatic cystic lesion, with successful preoperative diagnosis.

An 82-year-old man presented to the emergency department with abdominal pain and febrile symptoms that had been present for 4 days. Blood tests showed elevated liver enzymes and white blood cell count, and abdominal contrast-enhanced CT revealed a 35 mm cystic lesion in the left lateral liver lobe. On closer examination, the cystic lesion was found to have contiguous bile duct dilatation and internal nodules. Furthermore, mucus production was observed during endoscopic retrograde cholangiopancreatography, which led to the diagnosis of intraductal papillary neoplasm of the bile duct (IPNB), with cystic infection. Although the patient was an older adult, there was no background disease that would have prevented surgery, and resection was performed. Pathological examination revealed type 1 IPNB, with invasive carcinoma. The number of reports of IPNB is expected to increase with an increasing older population in Asia, and we report the findings of this case.

Exceptional response to alectinib for duodenal carcinoma with ALK fusion: A case report and literature review.

Patients with advanced duodenal carcinoma usually have a poor prognosis due to limited effective chemotherapy options. The study for genotype-directed therapy in patients with duodenal carcinoma is progressing. However, no clinical data assessing the efficacy of molecularly targeted therapy are presently available. We report the case of a 64-year-old woman who was diagnosed with anaplastic lymphocyte kinase (ALK) fusion-positive advanced duodenal carcinoma. Echinoderm microtubule associated protein like-4 (EML4)-ALK rearrangement was detected by comprehensive genomic profiling after resistance to first-line chemotherapy. The patient received alectinib, an ALK inhibitor, with marked shrinkage in primary tumor and liver metastases. She is currently being treated with alectinib for 6 months or more. This is the first report of the efficacy of alectinib in a patient with duodenal carcinoma harboring ALK fusion. Additionally, this case report suggests that the practical use of next-generation sequencing may expand optimal treatment choices in rare solid tumors, including duodenal carcinoma.

An incidentally identified 15 cm cavernous hemangioma of the small intestine: Case report and literature review.

INTRODUCTION: Hemangiomas of the small intestine are rare, usually present with symptoms such as anemia, gastrointestinal bleeding or abdominal pain and are resected. We report resection of an incidentally identified cavernous hemangioma of the small intestine that did not present symptoms referable to the hemangioma. Although it was a large lesion, it was resected using laparoscopy and a mini-laparotomy. PRESENTATION OF CASE: A 29-year-old otherwise healthy man was referred for evaluation of ileal wall thickening found on a contrast-enhanced computed tomography scan obtained for the workup of chronic diarrhea. Double balloon enteroscopy (DBE) showed a cavernous hemangioma of the small intestine. The lesion was 15 cm and resected using laparoscopy and a mini-laparotomy to prevent future bleeding. The histopathological diagnosis was a cavernous hemangioma of the ileum. DISCUSSION: Though there have been no reports of the asymptomatic patients of the disease, the recent spread of double balloon enteroscopy and capsule endoscopy will allow us to diagnose more asymptomatic hemangiomas like this patient. Also, this large lesion was able to be resected through a small incision due to its compressible nature. CONCLUSION: Future studies in asymptomatic patients of the disease may help to determine the optimal management for these patients. Even large hemangiomas are compressible, facilitating minimally invasive resection.

[A case of amebic colitis that developed after corticosteroid therapy in which perforation occurred during metronidazole treatment].

Although amebiasis is usually asymptomatic, fulminant amebic colitis is associated with a high mortality rate. Here, we report the case of a patient with amebic colitis in which bowel perforation occurred despite treatment with metronidazole. A man in his 70s underwent steroid pulse therapy to treat serious acute hepatitis A. After corticosteroid therapy, he developed acute abdomen because of amebic colitis. We immediately administered metronidazole and his symptoms improved. After completing treatment, he developed colon perforation. Amebic colitis can progress to bowel perforation even after administering the appropriate medication, so this abdominal symptom requires careful attention.

Asymptomatic Colonic Anisakiasis: Is It So Rare?

Most cases of anisakiasis occur in the stomach. Colonic anisakiasis, especially when asymptomatic, is extremely rare. We report a case of asymptomatic colonic anisakiasis and present a literature review of cases of colonic anisakiasis. A 52-year-old man underwent colonoscopy for colorectal cancer screening. Although no colorectal neoplasm was found, an Anisakis larva was detected in the transverse colon and the larva was removed by grasping forceps. Our review of PubMed revealed that 40% of cases of colonic anisakiasis are asymptomatic. We conclude that asymptomatic colonic anisakiasis may not be as rare as conventionally assumed.

Nasogastric Tubes Can Cause Intramural Hematoma of the Esophagus.

BACKGROUND Intramural hematoma of the esophagus (IHE), a rare manifestation of acute mucosal injuries of the esophagus, can be caused by trauma such as endoscopic surgeries. Coagulation disorders increase the risk of IHE. The most common location of IHE is in the distal esophagus. The characteristic clinical triad of manifestations comprises acute retrosternal pain, odynophagia or dysphagia, and hematemesis. It is important to distinguish IHE from other acute conditions such as acute coronary syndrome, aortic dissection, and pulmonary embolism. CASE REPORT An 84-year-old male was scheduled for coil embolization for an endoleak after endovascular aneurysm repair. For this reason, he was taking aspirin and warfarin. A nasogastric tube had been inserted during surgery and subsequently removed without any problems reported. Postoperatively, he experienced chest pain and hematemesis of sudden onset. Urgent esophagogastroduodenoscopy demonstrated a large, dark red, non-pulsatile, submucosal, esophageal mass in the area of the mid-esophagus with a little oozing. He was diagnosed as having an IHE; other possible diagnoses were excluded by contrast-enhanced computed tomography and aortography. He was treated with fasting, a proton pump inhibitor, and cessation of anti-thrombotic drugs; he recovered completely. The bleeding spot in the esophagus was in the area of the mid-esophagus, which was around the second natural constriction site. It was possible that the nasogastric tube had contact with the esophageal wall at this second natural constriction, and caused intramural esophageal bleeding. CONCLUSIONS Nasogastric tubes are not generally recognized as a cause of IHE. However, they can cause them, especially when a patient is taking anti-thrombotic drugs.

Endoscopic Submucosal Dissection for Early Gastric Cancer using the Clutch Cutter: a large single-center experience.

BACKGROUND AND STUDY AIMS: The Clutch Cutter (CC) was developed to reduce the risk of complications related to endoscopic submucosal dissection (ESD) using knives. The CC is able to grasp and coagulate and/or incise the targeted tissue using electrosurgical current, like a biopsy technique. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early gastric cancer (EGC). PATIENTS AND METHODS: From June 2007 to March 2014, 325 consecutive patients with a diagnosis of EGC were enrolled in this prospective study. They had all satisfied the Japanese gastric cancer treatment guidelines for ESD indication, namely confirmation by preliminary endoscopy, endoscopic ultrasound, and endoscopic biopsies. The CC was used for all steps of ESD (marking, circumferential marginal incision, submucosal dissection, and hemostatic treatment). The therapeutic efficacy and safety were assessed. RESULTS: The en-bloc resection rate was 99.7 % (324/325) and the R0 resection rate was 95.3 % (310/325). The mean operating time was 97.2 minutes. Perforation during ESD-CC occurred in one case (0.3 %), which was managed with conservative medical treatment after endoscopic closure of the perforation. Post-ESD-CC bleeding occurred in 11 cases (3.4 %), which were successfully treated by endoscopic hemostatic treatment. The R0 resection rate was significantly low in tumors > 20 mm (88.9 %), and in the exclusion indication group (73.7 %). Significant differences were seen in the mean operating time, depending upon tumor size, histologic type, location, and indication criteria. CONCLUSIONS: ESD-CC is a technically efficient, safe, and easy method for resecting EGC.

Suitability of the expanded indication criteria for the treatment of early gastric cancer by endoscopic submucosal dissection: Japanese multicenter large-scale retrospective analysis of short- and long-term outcomes.

OBJECTIVE: The criteria for endoscopic resection for early gastric cancer include absolute and expanded indications. Consensus already exists for the absolute indications. However, the suitability of the expanded indications must be validated by long-term outcome analyses since such lesions have only recently become resectable with the development of endoscopic submucosal dissection. The aim of this study is to clarify the suitability of the expanded indications for the treatment of early gastric cancer with endoscopic submucosal dissection. MATERIALS AND METHODS: The medical records of 1161 patients with early gastric cancers (1332 lesions) treated by endoscopic submucosal dissection and meeting the criteria for absolute or expanded indications without additional treatment with gastrectomy were divided into absolute indication group or expanded indication group. RESULTS: Complete resection rates were 96.4% and 93.4% in absolute and expanded indication groups, respectively, with no significant differences between the groups. Delayed bleeding rates were significantly higher in the expanded indication group, whereas all cases were successfully managed conservatively. The 5-year overall survival and recurrence-free rates were 93.7%/99.77% and 90.49%/98.90% in the absolute and the expanded indication groups, respectively, with no significant differences between the groups for either measure. Multivariate analyses revealed that affected horizontal margin and tumor location were independent predictive factors for recurrence. CONCLUSION: The expanded indication group showed excellent post-endoscopic submucosal dissection short-term and long-term outcomes compared with the absolute indications group, demonstrating that expanded indications are suitable for endoscopic submucosal dissection for early gastric cancer.

Clinical usefulness of endoscopic ultrasound-guided fine needle aspiration for gastric subepithelial lesions smaller than 2 cm.

BACKGROUND AND AIMS: There is no evidence of postoperative metastasis of gastric gastrointestinal stromal tumors (GISTs) smaller than 2 cm. The aim of this study was to evaluate the clinical usefulness of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) for gastric subepithelial lesions (SELs) smaller than 2 cm. PATIENTS AND METHODS: Using a prospectively maintained EUS-FNA database, 90 consecutive EUS-FNAs of gastric hypoechoic solid SELs smaller than 2 cm diagnosed by EUS were evaluated retrospectively. The reference standards for the final diagnosis were surgery (n=44) and/or clinical follow-up (n=46) using esophagogastroduodenoscopy (EGD), CT, and/or ultrasonography (US). Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens were compared. RESULTS: The diagnostic rate of EUS-FNA for gastric hypoechoic solid SELs smaller than 2 cm was 73% (66/90). Histological diagnosis of EUS-FNA showed 47 (52%) malignant SELs (44 GISTs, 1 glomus tumor, 1 SEL like cancer, and 1 malignant lymphoma), 19 (21%) benign SELs (14 leiomyomas, 4 ectopic pancreas, and 1 neurinoma), and 24 (27%) indeterminate SELs. In 44 surgically resected cases, the diagnostic accuracy of EUS-FNA using immunohistochemical analysis was 98% (43/44). There were no complications. Appropriate management was performed in 65 out of 66 SELs (98%) diagnosed by definitive EUS-FNA. After surgery, there was no recurrence of malignant SELs. CONCLUSIONS: EUS-FNA is an accurate and safe method in the pre-therapeutic diagnosis of gastric SELs smaller than 2 cm. EUS-FNA for gastric SELs smaller than 2 cm is a promising way to permit early management of patients with gastric SELs including GIST.

Immediate detection of endoscopic retrograde cholangiopancreatography-related periampullary perforation: fluoroscopy or endoscopy?

AIM: To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations to support immediate or early diagnosis. METHODS: Consecutive patients who underwent ERCP procedures at our hospital between January 2008 and June 2013 were retrospectively enrolled in the study (n = 2674). All procedures had been carried out using digital fluoroscopic assistance with the patient under conscious sedation. For patients showing alterations in the gastrointestinal anatomy, a short-type double balloon enteroscope had been applied. Cases of perforation had been identified by the presence of air in or leakage of contrast medium into the retroperitoneal space, or upon endoscopic detection of an abdominal cavity related to the perforated lumen. For patients with ERCP-related perforations, the data on medical history, endoscopic findings, radiologic findings, diagnostic methods, management, and clinical outcomes were used for descriptive analysis. RESULTS: Of the 2674 ERCP procedures performed during the 71-mo study period, only six (0.22%) resulted in perforations (male/female, 2/4; median age: 84 years; age range: 57-97 years). The cases included an endoscope-related duodenal perforation, two periampullary perforations related to endoscopic sphincterotomy, two periampullary perforations related to endoscopic papillary balloon dilation, and a periampullary or bile duct perforation secondary to endoscopic instrument trauma. No cases of guidewire-related perforation occurred. The video endoscope system employed in all procedures was only able to immediately detect the endoscope-related perforation; the other five perforation cases were all detected by subsequent digital fluoroscope applied intraoperatively (at a median post-ERCP intervention time of 15 min). Three out of the six total perforation cases, including the single case of endoscope-related duodenal injury, were surgically treated; the remaining three cases were treated with conservative management, including trans-arterial embolization to control the bleeding in one of the cases. All patients recovered without further incident. CONCLUSION: ERCP-related perforations may be difficult to diagnose by video endoscope and digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate diagnosis.

Gastric glomus tumor diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy: report of a case.

A glomus tumor of the stomach is rare. It is difficult to diagnose the tumor before surgery by only endoscopic biopsy and radiography, and there is no established method of diagnosis before surgical treatment. Esophagogastroduodenoscopy (EGD) on a 50-year-old Japanese woman revealed a 10 mm submucosal tumor in the anterior wall of the gastric angle. Follow-up EGD revealed an increase in the size of the tumor to 15mm. Endoscopic ultrasonography (EUS) demonstrated a 15mm subepithelial hypoechoic solid tumor with continuity to the proper muscle layer. Histologic diagnosis by endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) was glomus tumor. The tumor was treated by laparoscopic local resection. The histologic diagnosis of the resected tumor was similar to the preoperative EUS-FNA results. EUS-FNA would appear to be an effective histologic test for early diagnosis of gastric glomus tumor.