[A case of non-invasive IPMC with fibrotic lesion-like "tubular complex"].

A 73-year-old man was incidentally diagnosed with a cystic lesion in the pancreatic body. Ultrasonography, abdominal computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound were performed, and a nodule was detected in the cystic lesion along with an irregularity of the main pancreatic duct. An initial diagnosis of a mixed-type intraductal papillary mucinous neoplasm was made, and a central pancreatectomy was performed. However, the final diagnosis was altered to non-invasive intraductal papillary mucinous carcinoma (IPMC). The histopathological examination revealed a fibrotic lesion that was similar to "tubular complex" findings observed in mouse models of pancreatic cancer. The fibrotic lesion was placed between the main pancreatic duct lesion and branch-duct cystic lesion. The changes reflected in branch-level stenosis may be caused by IPMC growth.

Ramucirumab as second-line treatment in patients with advanced hepatocellular carcinoma: Japanese subgroup analysis of the REACH trial.

BACKGROUND: REACH evaluated ramucirumab in the second-line treatment of patients with advanced hepatocellular carcinoma. In the intent-to-treat population (n = 565), a significant improvement in overall survival (OS) was not observed. In patients with an elevated baseline α-fetoprotein (AFP) level (400 ng/mL or greater), an improvement in OS was demonstrated. An analysis of the Japanese patients in REACH was performed. METHODS: An analysis was performed with the subset of the intent-to-treat population enrolled in Japan (n = 93). RESULTS: The median OS was 12.9 months for the ramucirumab arm (n = 45) and 8.0 months for the placebo arm (n = 48) [hazard ratio (HR) 0.621 (95 % confidence interval (CI) 0.391-0.986); P = 0.0416]. The median progression-free survival was 4.1 months for the ramucirumab arm and 1.7 months for the placebo arm [HR 0.449 (95 % CI 0.285-0.706); P = 0.0004]. The objective response rates were 11 % for the ramucirumab arm and 2 % for the placebo arm (P = 0.0817). The grade 3 or higher treatment-emergent adverse events occurring in more than 5 % of patients with a higher incidence for the ramucirumab arm (n = 44) than for the placebo arm (n = 47) were ascites (7% vs 2 %), hypertension (7 % vs 2 %), and cholangitis (7 % vs 0 %). In patients with a baseline AFP level of 400 ng/mL or greater, the median OS was 12.9 months for the ramucirumab arm (n = 20) and 4.3 months for the placebo arm (n = 22) [HR 0.464 (95 % CI 0.232-0.926); P = 0.0263]. CONCLUSIONS: In the Japanese patients in REACH, ramucirumab treatment improved OS, including in patients with a baseline AFP level of 400 ng/mL or greater; improvements in progression-free survival and objective response rate were also demonstrated. The safety profile of ramucirumab was acceptable and well tolerated in Japanese patients. ClinicalTrials.gov identifier NCT01140347.

A Case of Intussusception Associated with Pneumatosis Cystoides Intestinalis.

Pneumatosis cystoides intestinalis (PCI) is an uncommon disease that generally lacks symptoms and is rarely associated with intussusception. A 29-year-old man visited our hospital for right upper abdominal pain. Computed tomography (CT) scan revealed multiple air-filled cysts along the intestinal wall and a pseudokidney sign in the transverse colon. A gastrographin enema examination showed a so-called crab finger appearance and multiple elevated translucency in the transverse colon. From these findings, the diagnosis of intussusception associated with PCI was made. The enema and manipulative reduction improved the intussusception. Comparing the enema findings before and after the reduction, we thought that mobile cecum could play an important role in the intussusception. Colonoscopy was performed after the reduction and showed multiple elevated lesions in the ascending colon, which were similar to cluster of grapes. The CT scan of the next day revealed no recurrence of the intussusception, and the patient has not had symptoms of recurrence ever since.

A case report of segmental arterial mediolysis in which computed tomography angiography was useful for diagnosis.

A 48-year-old male presented to our hospital with abdominal pain. Laboratory studies showed no abnormality, the severity of his abdominal pain decreased, and the patient was discharged. Five days later, the patient visited a neighborhood clinic because of fever with a 3-day history of temperatures of approximately 38 °C. The patient was admitted to our hospital 6 days after his initial visit. Laboratory investigation revealed a C-reactive protein level of 18.2 mg/dL. Abdominal computed tomography (CT) showed an 80 × 60 mm hematoma behind the descending colon, but no extravasation was detected. Thin-slice maximum-intensity-projection images from CT angiography (CTA) showed irregular narrowing and intermittent fusiform dilatations of the left colonic artery, suggesting a vascular disease, such as segmental arterial mediolysis (SAM). Digital subtraction angiography showed local irregularity, and 'beading and narrowing' of the left colonic artery, similar to the findings on CTA. Left hemicolectomy was electively performed on the twenty-fifth hospital day. Histological findings were consistent with SAM. Thus, CTA was a useful modality for the early diagnosis of SAM.

[A case of calcineurin-inhibitor induced pain syndrome associated with tacrolimus therapy for ulcerative colitis].

A 23-year-old woman was admitted with a relapse of ulcerative colitis. Tacrolimus therapy was initiated following inadequate response to corticosteroid therapy. Although the symptoms partially improved, she suddenly developed severe pain localized to the lower limbs on day 16 of tacrolimus therapy. By day 17, she was unable to move. Magnetic resonance imaging revealed born marrow edema in the lower limbs. We suspected calcineurin-inhibitor induced pain syndrome (CIPS) due to tacrolimus therapy. The pain improved within approximately four weeks of tacrolimus cessation. CIPS that is not associated with organ transplantation is a rare occurrence. Here we report a rare case of CIPS that was caused by tacrolimus therapy in a patient with ulcerative colitis.

[A case of ascending colon neuroendocrine carcinoma drained through a fistula of the descending part of the duodenum].

A 70-year-old woman was admitted for investigation of an abdominal tumor. Abdominal CT revealed an ascending colonic mass measuring 10 × 10 cm, with evidence of liver and lung metastasis. Colonoscopy revealed a cancerous lesion with a central ulcer in the ascending colon. Upper gastrointestinal endoscopy revealed an ulcerative lesion in the descending part of the duodenum. Histologically, the tumor showed features of neuroendocrine carcinoma. The patient died of the primary cancer two and a half months after admission. Autopsy revealed a fistula connecting the ascending colonic mass with the ulcerative lesion in the duodenum.

Flare up of ulcerative colitis during pregnancy treated by adsorptive granulocyte and monocyte apheresis: therapeutic outcomes in three pregnant patients.

PURPOSE: Treatment of ulcerative colitis with drugs during pregnancy potentially may harm the mother and the unborn child. Granulocytapheresis depletes elevated/activated myeloid lineage leucocytes as sources of inflammatory cytokines. We were interested in the safety and efficacy of granulocytapheresis in patients who had ulcerative colitis flare up during pregnancy. METHODS: Three pregnant cases with active ulcerative colitis received Adacolumn granulocytapheresis, up to 10 sessions within 3-6 weeks. Case 1: a 33-year-old woman with left-sided colitis and bloody diarrhoea 7-9 times/day showed loss of mucosal vascular patterns, and contact bleeding from the rectum to the sigmoid colon. Case 2: a 36-year-old woman with pancolitis and bloody diarrhoea 6-8 times/day had loss of mucosal vascular patterns and pus from the rectum to the sigmoid colon. Case 3: a 36-year-old woman with pancolitis and diarrhoea 4-5 times/day (first episode) had erosions and pus in the mucosa from the rectum to the transverse colon. RESULTS: Colitis flare was in weeks 5, 13 and 22 of pregnancy in cases 1, 2, 3, respectively. The corresponding granulocytapheresis sessions were 5, 7, and 10, reflecting an increasing trend with the pregnancy week. Patients 1 and 2 achieved complete remission, patient 3 achieved clinical remission. CONCLUSION: In these three cases with active ulcerative colitis during pregnancy, granulocytapheresis as a non-pharmacologic treatment was effective and safe. In case 3 that did not respond well to the initial granulocytapheresis sessions, a moderate dose of prednisolone enhanced the efficacy of granulocytapheresis and tapering of prednisolone shortly after administration was not associated with relapse.

Successful treatment of refractory gastric antral vascular ectasia using transcatheter arterial embolization.

In January 2008, a 67-year-old woman was admitted to our hospital because of hepatitis C virus-related cirrhosis and hepatocellular carcinoma (HCC). In February 2010, she had tarry stools and anemia resulting from gastric antral vascular ectasia (GAVE). Argon plasma coagulation (APC) treatment for GAVE was performed at that time. She revisited our hospital in July 2010 because of tarry stools and anemia caused by GAVE recurrence, which required 5 APC sessions and blood transfusion to control the bleeding. In October 2010, she arrived at our hospital by ambulance because of hemorrhagic shock resulting from GAVE recurrence. Despite performing 5 APC sessions and multiple blood transfusions, the tarry stools and anemia persisted during the hospitalization period. In December 2010 and January 2011, second-stage selective transcatheter arterial embolization (TAE) of the right gastric and right gastroepiploic arteries using microcoils was performed for the treatment of the refractory GAVE. Upper gastrointestinal endoscopy performed after TAE revealed the disappearance of mucosal diffuse spotty redness. In addition, no complications such as gastric ulcer and necrosis were observed. Selective TAE, effectively resolved the GAVE and anemia, and no recurrence has been observed during the last 24 months. Therefore, TAE may be a safe and radical treatment for refractory GAVE.

[Successful treatment of a case of advanced sigmoid colon cancer with occlusion of the common celiacomesenteric trunk].

A 74-year-old man was admitted to our hospital with abdominal pain and bloody stool. The patients' history showed that he had had occlusion of the proximal common trunk of the celiac artery (CA) and the superior mesenteric artery (SMA). The inferior mesenteric artery (IMA), and the marginal artery of the colon had developed well. It was assumed that almost the entire visceral blood might be supplied by the IMA to the CA and the SMA. Our investigation revealed that the patient had advanced cancer of the sigmoid colon, which had caused intestinal obstruction. Sigmoidectomy was performed with care to avoid injuring the IMA and the marginal arcade artery. Normal hemodynamics were successfully established followed by sigmoidectomy, and cure was obtained in this patient.

Gastric cancer following total proctocolectomy for colon cancer associated with ulcerative colitis.

Here we report a case of advanced gastric cancer seen after total proctocolectomy for an early colon cancer associated with ulcerative colitis (UC). A 42-year-old man, diagnosed with UC at the age of 21, had undergone total proctocolectomy at the age of 38 for an early ascending colon cancer. Three years later the patient developed tarry stools and epigastric discomfort. Laboratory data showed anemia together with elevated serum p53 antibody. Gastric endoscopy showed thickening folds around a lesion in the stomach body. The pathological diagnosis was poorly differentiated adenocarcinoma with signet-ring cell carcinoma. Total gastrectomy was performed and the resected specimens showed a diffuse infiltrating tumor (scirrhous gastric carcinoma), 11 × 15 cm in size, with multiple lymph node metastases. Histopathological examination revealed diffuse infiltration of cancer cells throughout the gastric wall and invasion of the serosa. Results of cytology on abdominal lavage were positive for cancer cells. Likewise, immunohistochemical staining showed gastric mucin phenotype cancer cells positive for p53. In conclusion, it is important to bear in mind that patients with UC, especially chronically active pancolitis, potentially bear the risk of upper gastrointestinal complications.

[Clonorchiasis complicated with duodenal papillary cancer in a visitor from China].

It is well known that long-term infection with Clonorchis sinensis often causes bile duct cancer, usually. It occurs in the intrahepatic bile duct. We encountered a rare case of clonorchiasis complicated with duodenal papillary cancer. The patient was a woman from China. Although clonorchiasis is rarely found in Japan, the promotion of international exchange may increase the number of visitors from endemic areas. Thus we must pay sufficient attention to this disease. Also, we reported that the microplate ELISA technique was useful in the diagnosis of clonorchiasis with high accuracy in this case.