Feasibility of a modified search, coagulation, and clipping method with and without the use of polyglycolic acid sheets and fibrin glue for preventing delayed bleeding after gastric endoscopic submucosal dissection.

BACKGROUND: Methods have been developed for preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (GESD). However, none of the methods can completely prevent DB. We hypothesized that DB could be prevented by a modified search, coagulation, and clipping (MSCC) method for patients at low risk for DB and by combining the use of polyglycolic acid sheets and fibrin glue with the MSCC method (PMSCC method) for patients at high risk for DB (antibleeding [ABI] strategy). This study assessed the technical feasibility of this novel strategy. METHOD: We investigated 123 lesions in 121 consecutive patients who underwent GESD in Kushiro Rosai Hospital between April 2018 and January 2020. The decision for continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment. RESULTS: Oral antithrombotic agents were administered to 28 patients (22.8%). The en bloc R0 resection rate was 98.4%. The MSCC method and the PMSCC method for preventing DB were performed in 114 and 9 lesions, respectively. The median time of the MSCC method was 16 min, and the median speed (the resection area divided by the time of method used) was 3.6 cm2/10 min. The median time of the PMSCC method was 59 min, and the median speed was 1.3 cm2/10 min. The only delayed procedural adverse event was DB in 1 (0.8%) of the 123 lesions. CONCLUSIONS: The ABI strategy is feasible for preventing DB both in patients at low risk and in those at high risk for DB after GESD, whereas the PMSCC method may be necessary for reduction of time.

Validation and comparison of prognostic values of GNRI, PNI, and CONUT in newly diagnosed diffuse large B cell lymphoma.

Diffuse large B cell lymphoma (DLBCL) is the most common type of aggressive non-Hodgkin lymphoma. Emerging evidence indicates that poor nutritional status determined with nutritional indices such as geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI), and controlling nutritional status score (CONUT) was associated with poor prognosis of DLBCL. We conducted this multicenter retrospective study to validate and compare prognostic values of the three indices in 615 newly diagnosed DLBCL patients. The overall survival (OS) in patients with poor nutritional status determined with each of these nutritional indices were significantly inferior compared with that in those without nutritional risks (5-year OS in patients with GNRI < 95.7 and GNRI ≥ 95.7 were 56.4% and 83.5%, P < 0.001; PNI < 42.4 and PNI ≥ 42.4 were 56.1% and 81.0%, P < 0.001; CONUT > 4 and CONUT ≤ 4 were 53.1% and 77.1%, P < 0.001). GNRI and CONUT were independent prognostic predictors for OS (GNRI < 95.7, hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.22-2.74, P = 0.0032; CONUT > 4, HR 1.53, 95% CI 1.05-2.23, P = 0.028) after multivariate analyses. Nutritional status determined with GNRI affected OS more strongly in the patients with nongerminal center B cell-like (nonGCB) DLBCL compared with that in those with GCB-type DLBCL. In conclusion, baseline poor nutritional status determined based on GNRI or CONUT was an independent risk factor of newly diagnosed DLBCL, and GNRI was also useful as an independent prognostic factor for patients with nonGCB-type DLBCL.

Pericardial tamponade during pembrolizumab treatment in a patient with advanced lung adenocarcinoma: A case report and review of the literature.

Several studies have demonstrated increased pericardial effusion during anti-PD-1 immunotherapy, and treatment in patients who have developed pericardial tamponade is controversial. In this study, we describe a 63-year-old woman with stage IVA lung adenocarcinoma given pembrolizumab as a first-line therapy. After four cycles of pembrolizumab treatment, the patient suddenly developed a pericardial tamponade. Although pericardial effusion was increased, her tumor lesions were reduced. After an emergency pericardiocentesis, she continued the pembrolizumab therapy without recurrent pericardial effusions for three months until the primary tumor and lymph node metastasis progressed. Nine months after the pericardiocentesis, the patient died of progressive lung cancer, but pericardial effusion did not recur throughout the treatment course. This case study suggests that pembrolizumab therapy can be continued with a strict follow-up in some patients with pembrolizumab-induced pericardial tamponade. KEY POINTS: • Significant findings of the study Our patient developed pericardial tamponade during pembrolizumab treatment but continued pembrolizumab treatment after emergency pericardiocentesis without recurrent pericardial effusions. • What this study adds Pembrolizumab treatments may be resumed with a strict follow-up in some patients with treatment-related pericardial tamponade.

Feasibility of a new ligation using the double-loop clips technique without an adhesive agent for ulceration after endoscopic submucosal dissection of the colon (with video).

BACKGROUND AND AIMS: Several ligation techniques for ulceration after endoscopic submucosal dissection (ESD) have been reported, but none have been established for clinical use because of technical complexity and the need for expensive equipment. Therefore, the technical feasibility of a new ligation method using the double-loop clips (D-L clips) technique without an adhesive agent for ulceration after ESD of the colon was assessed. METHODS: Among 35 patients who underwent ESD of the colon in Kushiro Rosai Hospital between April 2019 and September 2019, 26 patients who underwent ligation using the D-L clips technique for the post-ESD ulcer bed were included in this retrospective study. Continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment. RESULTS: The rate of en bloc R0 resection was 97.1%, the median length of the resected specimen was 3.2 cm (interquartile range [IQR], 2.8-3.8 cm), and the complete ligation rate was 88.5% (23 of 26). Excluding patients with lesion sites in the rectum below the peritoneal reflection, the complete ligation rate was 95.5% (21 of 22). The median duration of the ligation procedure was 20 minutes (IQR, 16-24 minutes). The only delayed procedural adverse event was post-ESD coagulation syndrome in 1 patient. Incomplete ligation was significantly more frequent in patients with lesion sites in the inferior rectal valve/anal verge area (P = .0269). CONCLUSIONS: Ligation using the D-L clips technique without an adhesive agent is feasible for closing ulceration after ESD of the colon, whereas other techniques may be necessary for lesions in the rectum below the peritoneal reflection.

Interferon-free therapy with sofosbuvir plus ribavirin for successful treatment of genotype 2 hepatitis C virus with lichen planus: a case report.

Hepatitis C virus (HCV) infection remains the main cause of liver disease and can lead to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. HCV may also develop extrahepatic manifestations in the skin, eyes, joints, kidneys, nervous system, and immune system. In fact, several studies reported that up to 70% of HCV patients experienced extrahepatic manifestations. Lichen planus (LP), which is an immune system disorder that is triggered by viral infections, allergens, and stress, can affect the skin, mouth, nails, and scalp. The association of LP with HCV has been reported, but the effect of HCV treatment on LP remission is controversial. We encountered a 53-year-old man with HCV genotype 2a and LP that were successfully treated with sofosbuvir and ribavirin for 12 weeks. After treatment, he achieved sustained virological response against HCV and remission of erosive LP lesions on the lip. In the era of interferon (IFN)-based treatment for HCV, exacerbation of autoimmune diseases is a common adverse event. Therefore, use of an IFN-free regimen of direct-acting antivirals for HCV might prevent the extrahepatic manifestation of an immune disorder.

[Clinical impact of addition of bevacizumab to the first-line chemotherapy regimen in the treatment of patients with metastatic colorectal cancer].

BACKGROUND: Combination regimens containing bevacizumab(BV)are regarded as one of the standard first-line chemotherapy (1stCTx) regimens in the treatment of metastatic colorectal cancer (mCRC). However, some patients cannot be treated with BV because of the short interval from the palliative operation or other reasons. We present a study of some patients who were treated with add-on BV in the middle of the 1stCTx before disease progression(referred to as "midway BV" regimen hereafter), and here, we report the efficacy of the midway BV regimen as observed in our patients. RESULTS: We retrospectively analyzed the data of 74 mCRC patients, who were undergoing 1stCTx treatment at our hospital from January 2010 to September 2012. We divided the patients into 3 groups, depending on when BV was introduced in their regimen: 40, 25, and 9 patients were respectively included in the "no-BV" group (patients who were treated without BV in the 1stCTx), BV group(patients treated with BV from the 1st cycle in the 1stCTx), and the midway-BV group (patients who were initially treated without BV and then received add-on BV). The response rates of patients in the no-BV, BV, and midway-BV groups were 27.5%, 44.0%, and 55.6%, respectively. The median progression-free survival (PFS) and median survival time of patients in the no-BV, BV, and midway-BV groups were, respectively, 9.7 months, 9.3 months, and 12.8 months, and 20.3 months, 22.2 months, and N. R. CONCLUSION: Although few cases were analyzed and there might be many confounding factors, our study suggests that midway BV is potentially useful for patients with metastatic colorectal cancer who are not initially treated with BV in the first cycle of the 1stCTx regimen.

[Successful treatment of an HIV-positive multiple myeloma patient with high-dose chemotherapy followed by autologous peripheral blood stem cell transplantation and maintenance therapy with lenalidomide].

A 45-year-old HIV positive male who had previously been administered anti-retrovirus therapy (ART) resulting in a good virological response and with a CD4 count of more than 1,000/µl, complained of general fatigue during a periodic examination. Laboratory data showed decreased Hb (10.8 g/dl) and increased T.P (12.0 g/dl) and IgG (9,077 mg/dl). Monoclonal gammopathy (IgG-λ) was identified and bone marrow aspiration revealed 37.6% atypical plasma cells, leading to the diagnosis of symptomatic multiple myeloma (MM) (ISS clinical staging III).Four courses of VD (bortezomib+dexamethasone) therapy were administered with concurrent ART resulting in VGPR (very good partial response), followed by peripheral blood stem cell collection (the mobilizing chemotherapy was cyclophosphamide). Then, together with ART, high-dose chemotherapy (Mel-200; L-PAM) was administered with autologous peripheral blood stem cell transplantation (PBSCT). Reconstitution of white blood cells was achieved at 10 days after PBSCT. There were no adverse effects of ART and the viral load of HIV was well controlled during the period of these treatments. The final assessment was VGPR and 10 mg/day of lenalidomide has since been administered as maintenance therapy. Standard treatment combined with PBSCT for juvenile-onset MM is also effective and safe for HIV-positive patients receiving ART.

Randomized phase II trial of first-line treatment with tailored irinotecan and S-1 therapy versus S-1 monotherapy for advanced or recurrent gastric carcinoma (JFMC31-0301).

The pharmacokinetics of irinotecan vary markedly between individuals. This study sought to compare tailored irinotecan and S-1 therapy with S-1 monotherapy for the treatment of patients with advanced/recurrent gastric cancer. Patients with advanced/recurrent gastric cancer were randomized to receive tailored irinotecan and S-1 (arm A) therapy or S-1 therapy alone (arm B). Arm A received S-1 (80-120 mg/m(2)/day) for 14 days, with irinotecan on days 1 and 15. The initial irinotecan dose of 75 mg/m(2) (level 0) was adjusted for toxicity during an earlier course. In arm B, S-1 (80-120 mg/day) was administered alone for 28 days, followed by 14 days without therapy. Ninety-five patients were randomized (48 patients to arm A and 47 patients to arm B). The response rate of the primary tumor (Japanese criteria) was 25.0% in arm A (12 of 48 patients) and 14.9% in arm B (seven of 47 patients), whereas the response rates according to Response Evaluation Criteria In Solid Tumors were 27.8% (10 of 36) versus 21.9% (seven of 32). Hematological toxicity, anorexia, and diarrhea were significantly more common in arm A, but both arms had similar grades 3-4 toxicities. These findings suggest the usefulness of tailored irinotecan and S-1 therapy for gastric cancer.

[Repetition of Helicobacter cinaedi infections during chemotherapy for malignant lymphoma].

A 70-year-old male, who had undergone resection of gastric malignant lymphoma in 1992, presented with cervical lymph node swelling in January 2008. Pathological examination of the lymph node biopsy demonstrated recurrence of malignant lymphoma, and he was treated with the R-CHOP regimen. Although he did not develop fever during the first through third course of R-CHOP, from the fourth course, he repeatedly demonstrated fever over 38°C for about one week after each course of chemotherapy, despite the absence of neutropenia. Helicobacter cinaedi infection was confirmed by blood culture each time. Although it is difficult to diagnose Helicobacter cinaedi infection by the standard culture method, increased numbers of recent reports especially in immunocompromised patients have emphasized the importance of diagnosing Helicobacter cinaedi infection.

POEMS syndrome complicated by follicular lymphoma.

A 59-year-old woman presented with ascites and intraperitoneal lymph node swelling. Pathological examination of the lymph node revealed follicular lymphoma. After a lymph node biopsy, she developed atypical genital bleeding, multiple endocrine disorders, polyneuropathy with a high plasma level of vascular endothelial growth factor (VEGF), and was diagnosed with POEMS syndrome. Following administration of methyl prednisolone, ascites immediately decreased and her performance status improved; however, about 18 months later, renal failure occurred, and she died despite increased steroid dosage. Lymph node swelling is often found in POEMS syndrome; however, its histological appearance is not well known, and it is very rare to be concomitant with malignant lymphoma. Therefore, it is important to perform a lymph node biopsy and investigate it in relation with VEGF.