Efficacy and histologic frequencies of endoscopic ultrasonography-guided tissue acquisition using conventional fine-needle aspiration needles for gastric subepithelial hypoechoic mass.

Introduction/Purpose: For gastric subepithelial lesions (GSELs) showing a hypoechoic mass (HM) on endoscopic ultrasonography (EUS) imaging, the utility of EUS-guided tissue acquisition using conventional fine-needle aspiration needles (EUS-TA-CFNAN) and the frequency of histological types remain unclear. This study aimed to examine this issue. Methods: This prospective observational study enrolled 291 consecutive patients who underwent EUS-TA-CFNAN for GSELs showing an HM (GSELHM) on EUS imaging. Immunohistochemical analysis was performed for all EUS-TA-CFNAN and surgically resected specimens. The main outcome measures were the technical results of EUS-TA-CFNAN and the frequency of histological types in GSELHM. Results: The endoscopic ultrasound-guided tissue acquisition using conventional fine-needle aspiration needle diagnosis rate for GSELHM was 80.1% (95% confidence interval [CI]: 75.0-84.5, 233/291). It was significantly lower for antrum (P = 0.004) and lesions smaller than 2 cm (P = 0.003). There were no adverse events. The immunohistochemical diagnoses of EUS-TA-CFNAN included 149 cases of gastrointestinal stromal tumour (GIST) (51.2%), 48 cases of leiomyoma (16.5%), 11 cases of schwannoma (3.8%), 8 cases of the ectopic pancreas (2.7%), 5 cases of subepithelial lesion like cancer (1.7%), 12 cases of other lesions (4.1%), and 58 cases of undiagnosable lesions (19.9%). The frequency of malignant or potentially malignant tumour in GSELHM was 55.0% (95% CI: 49.1-60.8, 160/291). Surgery was performed in 149 patients according to the conclusive EUS-TA-CFNAN results, in which the diagnostic accuracy of EUS-TA-CFNAN was 97.3% (95% CI: 94.7-99.9, 145/149). Conclusion: The use of EUS-TA-CFNAN for GSELHMs is safe and accurate. Gastric subepithelial lesions showing a hypoechoic mass have a reasonably high possibility of containing malignant or potentially malignant tumours, including GISTs.

A case of erythema multiforme-like rash induced by everolimus in a patient with a pancreatic neuroendocrine tumor.

A 66-year-old Japanese woman had been diagnosed with a neuroendocrine tumor of the pancreatic head (G2) 3 years previously and undergone pancreaticoduodenectomy. Nine months postoperatively, recurrence with multiple liver metastases developed and she was referred to our department. A regimen of 10 mg of everolimus for 2 weeks plus 1-week washout was instituted, and no adverse events were observed. Fourteen months after treatment initiation, she developed severe generalized erythema multiforme (EM). Skin biopsy revealed spongiosis in the epidermis and interface change and edema in the superficial dermis. Mast cells were observed from the dermis to the subcutaneous tissue, as well as perivascular eosinophilic infiltration, leading to EM being diagnosed. Oral everolimus was discontinued, and the EM was relieved by treatment including steroid therapy. Everolimus is an inhibitor of the mammalian target of rapamycin, and its indications include neuroendocrine tumors. Skin disorders are commonly seen in the early stages of everolimus treatment, but their severity is almost always mild and never severe. This is the first report on a patient who presented with severe generalized EM more than 1 year after everolimus treatment initiation. Patients on everolimus therapy should be monitored for skin disorders on a long-term basis.

Three cases of synovial sarcoma of gastric wall: A case report and review of the literature.

Synovial sarcoma (SS) is a malignant soft tissue neoplasm that occurs in various parts of the human body, but most commonly affects the extremities. Its diagnosis of synovial sarcoma often requires adjunctive techniques such as immunohistochemical staining and molecular studies, especially for synovial sarcoma at unusual locations. SS at a gastrointestinal location is exceedingly rare. We report here three cases of primary gastric synovial sarcoma. Malignant gastric mesenchymal tumor has many differential diagnoses other than synovial sarcoma, such as gastrointestinal stromal tumor (GIST), leiomyosarcoma, schwannoma, malignant peripheral nerve sheath tumor (MPNST) and so on. In our three cases, using reverse transcription polymerase chain reaction (RT-PCR) and direct sequencing, we detected an SS18-SSX1 fusion gene, which is specific to synovial sarcoma. In addition, we found the reduced expression of SMARCB1/INI1 in the tumor cells in two of the three cases. Through histopathological, immunohistochemical, and molecular analyses, we confirmed the diagnosis of primary gastric synovial sarcoma.

Endoscopic submucosal dissection with a grasping-type scissors for early colorectal epithelial neoplasms: a large single-center experience.

BACKGROUND AND AIMS: The Clutch Cutter (CC) can grasp, pull, coagulate, and incise targeted tissue with the use of electrosurgical current. It was developed as a biopsy technique to reduce the technical difficulty of endoscopic submucosal dissection (ESD) with knives. The aim of this study was to evaluate the efficacy and safety of ESD using the CC (ESD-CC) for early colorectal epithelial neoplasms (ECENs). METHODS: In this prospective study, we enrolled 437 consecutive patients with a diagnosis of ECEN between January 2009 and January 2018. They all satisfied the Japanese colorectal cancer treatment guidelines for ESD; namely, confirmation by preliminary endoscopy, EUS, and endoscopic biopsy. The CC was used for all steps of ESD (mucosal incision, submucosal dissection, and hemostatic treatment); therapeutic efficacy and safety were assessed. RESULTS: The en bloc resection rate was 99.3% (434/437), and the R0 resection rate was 87.0% (380/437). The mean operating time was 88.3 minutes. Perforation occurred in 10 cases (2.3%) and was managed with conservative medical treatment. Post-ESD-CC bleeding occurred in 10 cases (2.3%) and was successfully treated by endoscopic hemostatic treatment. CONCLUSIONS: ESD-CC is a technically efficient, safe, and easy method for resecting ECEN.

Pneumocystis jirovecii Pneumonia in an Immunocompetent Japanese Man: A Case Report and Literature Review.

We herein report the case of a 37-year-old immunocompetent man who died from Pneumocystis jirovecii pneumonia (PCP). He was initially treated for an acute exacerbation of interstitial pneumonia; however, the elevation of the patient's serum (1-3) ß-D glucan (BG) level suggested the possibility of PCP and sulfamethoxazole trimethoprim was added. A postmortem pathological examination and retrospective Grocott's methenamine silver (GMS) staining of the bronchoalveolar lavage fluid (BALF), which was obtained on the day of admission, revealed PCP. The present case suggests that it is essential to perform a BG assay and GMS staining of BALF specimens when patients show diffuse ground-glass opacity on chest computed tomography, regardless of their immune status.

Current clinical management of gastrointestinal stromal tumor.

Gastrointestinal stromal tumors (GISTs) are the most common malignant subepithelial lesions (SELs) of the gastrointestinal tract. They originate from the interstitial cells of Cajal located within the muscle layer and are characterized by over-expression of the tyrosine kinase receptor KIT. Pathologically, diagnosis of a GIST relies on morphology and immunohistochemistry [KIT and/or discovered on gastrointestinal stromal tumor 1 (DOG1) is generally positive]. The prognosis of this disease is associated with the tumor size and mitotic index. The standard treatment of a GIST without metastasis is surgical resection. A GIST with metastasis is usually only treated by tyrosine kinase inhibitors without radical cure; thus, early diagnosis is the only way to improve its prognosis. However, a GIST is usually detected as a SEL during endoscopy, and many benign and malignant conditions may manifest as SELs. Conventional endoscopic biopsy is difficult for tumors without ulceration. Most SELs have therefore been managed without a histological diagnosis. However, a favorable prognosis of a GIST is associated with early histological diagnosis and R0 resection. Endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (EUS-FNA) are critical for an accurate diagnosis of SELs. EUS-FNA is safe and effective in enabling an early histological diagnosis and adequate treatment. This review outlines the current evidence for the diagnosis and management of GISTs, with an emphasis on early management of small SELs.

Leiomyosarcoma of the stomach treated by endoscopic submucosal dissection.

There have been no reports of primary leiomyosarcoma of the stomach treated by endoscopic submucosal dissection (ESD). We report an extremely rare case of gastric leiomyosarcoma that was successfully treated by ESD. An asymptomatic 74-year-old female underwent esophagogastroduodenoscopy for screening in December 2013. A centrally depressed submucosal tumor 10 mm in diameter was detected at the posterior wall of the upper gastric body. Follow-up esophagogastroduodenoscopy conducted 5 months later showed that the tumor diameter had increased to 15 mm. Endoscopic ultrasound revealed a hypoechoic mass located in the second to the middle of the third layer. Endoscopic ultrasound-guided fine-needle aspiration demonstrated a myogenic tumor. The tumor was completely resected by ESD without complications. Immunohistopathological diagnosis of the resected specimen was gastric leiomyosarcoma derived from the muscularis mucosae, with negative lateral and vertical margins. No local recurrence or metastasis has been detected at 36 months after ESD. This is the first report of gastric leiomyosarcoma treated by ESD in the English language literature.

Insulin-like growth factor II messenger RNA-binding protein-3 is an independent prognostic factor in uterine leiomyosarcoma.

AIMS: The aim of this study was to identify the prognostic factors of uterine leiomyosarcoma (ULMS). METHODS AND RESULTS: We reviewed 60 cases of surgically resected ULMSs and investigated conventional clinicopathological factors, together with the expression of insulin-like growth factor II messenger RNA-binding protein-3 (IMP3), hormone receptors and cell cycle regulatory markers by immunohistochemistry. Mediator complex subunit 12 (MED12) mutation analysis was also performed. Univariate analyses revealed that advanced stage (P < 0.0001), older age (P = 0.0244) and IMP3 expression (P = 0.0011) were significant predictors of a poor outcome. Multivariate analysis revealed advanced stage (P < 0.0001) and IMP3 (P = 0.0373) as independent predictors of a poor prognosis. Expressions of cell cycle markers and hormone receptors, and MED12 mutations (12% in ULMSs) were not identified as prognostic markers in this study. CONCLUSIONS: IMP3 expression in ULMS could be a marker of a poor prognosis.

Clinical outcomes of Clutch Cutter endoscopic submucosal dissection for older patients with early gastric cancer.

AIM: To evaluate the clinical outcome of endoscopic submucosal dissection using the Clutch Cutter (ESDCC) in older patients. METHODS: We reviewed 232 consecutive patients with early gastric cancer who underwent ESDCC between June 2010 and February 2014 at Aso Iizuka Hospital. We divided patients into two groups according to age: Older patients (> 80 years, n = 64) and non-older patients (≤ 80 years, n = 168). We retrospectively compared the prevalence rates of pre-existing comorbidities, anticoagulant therapy, en bloc resection, mean duration of hospitalization, incidence of ESDCC-related complications, change in performance status (PS) before and after ESDCC, and financial cost of admission. RESULTS: The older group comprised 64 patients with a mean age of 84.1 years, and the non-older group comprised 168 patients with a mean age of 69.5 years. Older patients had significantly more pre-existing comorbidities than did non-older patients, specifically heart disease (P < 0.05). The en bloc resection rate in non-older patients was significantly higher than that in older patients (100% vs 95.3%, P = 0.02). There were no significant differences between the older and non-older groups in the incidence of ESDCC-related complications (i.e., postoperative bleeding and perforation) and the post-ESDCC change in PS. There were also no significant differences between the older and non-older groups in the mean duration of hospitalization (11.4 and 10.7 d, respectively) and financial cost of admission (657040 JPY and 574890 JPY, respectively). CONCLUSION: ESDCC has a good clinical outcome in older patients.

Endoscopic submucosal dissection of gastric adenomas using the clutch cutter.

AIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) using the clutch cutter (CC) (ESD-CC) for gastric adenoma (GA). METHODS: From June 2007 to August 2015, 122 consecutive patients with histological diagnoses of GA from specimens resected by ESD-CC were enrolled in this prospective study. The CC was used for all ESD steps (marking, mucosal incision, submucosal dissection, and hemostatic treatment), and its therapeutic efficacy and safety were assessed. RESULTS: Both the en-bloc resection rate and the R0 resection rate were 100% (122/122). The mean surgical time was 77.4 min, but the time varied significantly according to tumor size and location. No patients suffered perforation. Post-ESD-CC bleeding occurred in six cases (4.9%) that were successfully resolved by endoscopic hemostatic treatment. CONCLUSION: ESD-CC is a technically efficient, safe, and easy method for resecting GA.

Endoscopic resection using the Clutch Cutter and a detachable snare for large pedunculated colonic polyps.

Background and study aims Endoscopic snare polypectomy with prophylactic detachable snare of large pedunculated colonic polyps (PCPs) is technically demanding. To facilitate removal of such polyps, we developed endoscopic resection using the Clutch Cutter and a detachable snare (ERCCDS). This study aimed to evaluate the efficacy and safety of the procedure. Patients and methods From April 2010 to July 2015, 14 consecutive patients who had PCPs with head > 10 mm, stalk width > 5 mm, and stalk length > 10 mm were enrolled in this single-center prospective uncontrolled study. They were treated using ERCCDS by a single endoscopist. The efficacy and safety were assessed using a database prospectively formatted from the medical records. Results The Clutch Cutter was able to cut the distal side of the stalk an adequate distance from the detachable snare under good visual control. R0 resections were obtained in all lesions. There were no immediate or delayed complications. Conclusions ERCCDS appears to be a safe, easy, and technically efficient method for large PCPs, although larger studies are needed to compare ERCCDS and standard resection.

Positron Emission Tomography Findings in Atypical Polypoid Adenomyoma.

Atypical polypoid adenomyoma (APAM) is a rare polypoid tumor of the uterus composed of atypical endometrial glands surrounded by smooth muscle. A 29-year-old nulligravida, was clinically diagnosed with endocervical myoma and underwent trans-uterine cervical resection with hysteroscope. The histopathological diagnosis of specimens was APAM. Eight months later, she diagnosed recurrent uterine tumor. The positron emission tomography (PET-CT) imaging showed an increased fluorodeoxyglucose uptake. She has performed hysterectomy and was diagnosed APAM. Therapy for APAM depends on multiple factors such as age at presentation and desire for childbearing among others. This is the first report of PET-CT findings in APAM.

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.

Gastric Hyperplastic Polyp with Xanthoma Observed by Magnification Narrow-Band Imaging Endoscopy and Endoscopic Ultrasonography : Report of a Case.

We experienced an extremely rare case of gastric hyperplastic polyp with xanthoma. A 73-year-old Japanese man was transferred to our hospital from a referral hospital for further evaluation of a pedunculated gastric polyp and early gastric cancer. Esophagogastroduodenoscopy (EGD) revealed a yellow-whitish pedunculated polyp arising from the anterior wall of the fornix. Magnification narrow-band imaging (NBI) endoscopy revealed extended and tortuous microcapillaries and a swollen interfoveolar pattern on the polyp's surface, but there was no sign of malignancy. Endoscopic ultrasonography (EUS) revealed an irregularity of the first layer and a thickened second layer. The third layer was intact. A hyperechoic area was seen in the thickened second layer. Endoscopic submucosal dissection (ESD) for early carcinoma of the antrum and endoscopic mucosal resection (EMR) for a polyp in the fornix were performed in one session. Histological examination of the specimen of the fornix polyp revealed lengthened, branched and dilatated gastric foveolae and a tight sheet of foamy histiocytes in the stroma. The background mucosa of the polyp was atrophic. The pathologic evidence was gastric hyperplastic polyp with proliferation of xanthoma. The early cancer of the antrum was intramucosal tubular adenocarcinoma and was resected curatively.

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.

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.

Endoscopic submucosal dissection for rectal carcinoid tumour using the Clutch Cutter.

BACKGROUND: To reduce the risk of complications related to endoscopic submucosal dissection (ESD) using knives, we developed the Clutch Cutter (CC), which can grasp and incise the target tissue similarly to biopsy techniques using an electrosurgical current. The aim of this study was to evaluate the efficacy and safety of ESD using the CC for removal of rectal carcinoid tumours. METHODS: Between December 2009 and December 2011, we prospectively enrolled seven patients (seven lesions) on 7 different days. Patients were endoscopically diagnosed with rectal subepithelial lesions (upper rectum, n = 3; lower rectum, n = 4) within the level 3 layer and without lymph node involvement, with the diagnosis confirmed by preliminary endoscopy, endoscopic ultrasound and endoscopic biopsies. ESD using the CC was performed in all cases, and the therapeutic efficacy, safety and tumour recurrence were assessed. RESULTS: All lesions were treated easily and safely, and there were no inadvertent incisions. En bloc resection was obtained in all cases, and histologic tumour-free lateral/basal margins were obtained in six of the seven patients. No delayed haemorrhage, perforation or tumour recurrence occurred. CONCLUSION: ESD using the CC appears to be an easy, safe and technically efficient method for resecting rectal carcinoid tumour.