A combination treatment of entecavir and early-phase corticosteroid in severe exacerbation of chronic hepatitis B

Of patients with severe exacerbation of chronic hepatitis B accompanied by jaundice and coagulopathy,20%-30%have a fatal outcome.In this report,we describe 2 cases of severe exacerbation of chronic hepatitis B with jaundice and coagulopathy who were successfully treated with a combination of entecavir and corticosteroid.In both cases,rapid reductions in serum hepatitis B virus(HBV)-DNA levels were observed,and corticosteroid was stopped after serum HBV-DNA levels became undetectable.Entecavir treatment was continued.Generally,entecavir treatment reduced serum HBV-DNA levels rapidly,although the improvement in liver function was delayed by a few weeks.During this time lag,liver cell injury continued and the disease progressed.Corticosteroid suppressed the excessive host immune response and was useful for stopping progressive deterioration.A combination of entecavir and early-phase corticosteroid may be a useful treatment in severe exacerbation of chronic hepatitis B.

A case of hepatic angiomyolipoma difficult to distinguish from hepatocellular carcinoma

We report a case of hepatic angiomyolipoma with uncommon clinical features. A 56-year-old man presented with a hepatic tumor in the caudate lobe. The tumor was hypoechoic on ultrasonography, showed early-phase hyperattenuation on enhanced computed tomography and did not absorb iron on superparamagnetic iron oxide-enhanced magnetic resonance imaging. Hepatocellular carcinoma was highly suspected, and the patient underwent hepatic resection. Histologically, the tumor was mainly composed of smooth muscle cells and contained small amounts of adipose cells and blood vessels. On immunohistochemical staining, the smooth muscle cells were positive for a melanocytic cell-specific monoclonal antibody. In cases with uncommon features of angiomyolipoma, it is quite difficult to distinguish angiomyolipoma from hepatocellular carcinoma.

Management of gastric mucosa-associated lymphoid tissue lymphoma in patients with extra copies of the MALT1 gene

AIM To identify the clinical features of gastric mucosaassociated lymphoid tissue(MALT) lymphoma with extra copies of MALT1.METHODS This is a multi-centered,retrospective study. We reviewed 146 patients with MALT lymphoma in the stomach who underwent fluorescence in situ hybridization analysis for t(11;18) translocation. Patients were subdivided into patients without t(11;18) translocation or extra copies of MALT1(Group A,n = 88),patients with t(11;18) translocation(Group B,n = 27),and patients with extra copies of MALT1(Group C,n = 31). The clinical background,treatment,and outcomes of each group were investigated.RESULTS Groups A and C showed slight female predominance,whereas Group B showed slight male predominance. Mean ages and clinical stages at lymphoma diagnosis were not different between groups. Complete response was obtained in 61 patients in Group A(69.3%),22 in Group B(81.5%),and 21 in Group C(67.7%). Helicobacter pylori(H. pylori) eradication alone resulted in complete remission in 44 patients in Group A and 13 in Group C. In Group B,14 patients underwent radiotherapy alone,which resulted in lymphoma disappearance. Although the difference was not statistically significant,event-free survival in Group C tended to be inferior to that in Group A(P = 0.10).CONCLUSION Patients with t(11;18) translocation should be treated differently from others. Patients with extra copies of MALT1 could be initially treated with H. pylori eradication,similar to patients without t(11;18) translocation or extra copies of MALT1.

Dual therapy for third-line Helicobacter pylori eradication and urea breath test prediction

We evaluated the efficacy and tolerability of a dual therapy with rabeprazole and amoxicillin (AMX) as an empiric third-line rescue therapy. In patients with failure of first-line treatment with a proton pump inhibitor (PPI)- AMX-clarithromycin regimen and second-line treatment with the PPI-AMX-metronidazole regimen, a third-line eradication regimen with rabeprazole (10 mg q.i.d.) and AMX (500 mg q.i.d.) was prescribed for 2 wk. Eradication was confirmed by the results of the 13C-urea breath test (UBT) at 12 wk after the therapy. A total of 46 patients were included; however, two were lost to followup. The eradication rates as determined by per-protocol and intention-to-treat analyses were 65.9% and 63.0%,respectively. The pretreatment UBT results in the subjects showing eradication failure; those patients showing successful eradication comprised 32.9 ± 28.8 permil and 14.8 ± 12.8 permil, respectively. The pretreatment UBT results in the subjects with eradication failure were significantly higher than those in the patients with successful eradication (P = 0.019). A low pretreatment UBT result (≤ 28.5 permil) predicted the success of the eradication therapy with a positive predictive value of 81.3% and a sensitivity of 89.7%. Adverse effects were reported in 18.2% of the patients, mainly diarrhea and stomatitis. Dual therapy with rabeprazole and AMX appears to serve as a potential empirical third-line strategy for patients with low values on pretreatment UBT.

Efficacy and safety of endoscopic submucosal dissection for gastric tube cancer:A multicenter retrospective study

BACKGROUND Recent improvements in the prognosis of patients with esophageal cancer have led to the increased occurrence of gastric tube cancer(GTC)in the reconstructed gastric tube.However,there are few reports on the treatment results of endoscopic submucosal dissection(ESD)for GTC.AIM To evaluate the efficacy and safety of ESD for GTC after esophagectomy in a multicenter trial.METHODS We retrospectively investigated 48 GTC lesions in 38 consecutive patients with GTC in the reconstructed gastric tube after esophagectomy who had undergone ESD between January 2005 and December 2019 at 8 institutions participating in the Okayama Gut Study group.The clinical indications of ESD for early gastric cancer were similarly applied for GTC after esophagectomy.ESD specimens were evaluated in 2-mm slices according to the Japanese Classification of Gastric Carcinoma with curability assessments divided into curative and non-curative resection based on the Gastric Cancer Treatment Guidelines.Patient characteristics,treatment results,clinical course,and treatment outcomes were analyzed.RESULTS The median age of patients was 71.5 years(range,57-84years),and there were 34 men and 4 women.The median observation period after ESD was 884 d(range,8-4040 d).The median procedure time was 81 min(range,29-334 min),the en bloc resection rate was 91.7%(44/48),and the curative resection rate was 79%(38/48).Complications during ESD were seen in 4%(2/48)of case,and those after ESD were seen in 10%(5/48)of case.The survival rate at 5 years was 59.5%.During the observation period after ESD,10 patients died of other diseases.Although there were differences in the procedure time between institutions,a multivariate analysis showed that tumor size was the only factor associated with prolonged procedure time.CONCLUSION ESD for GTC after esophagectomy was shown to be safe and effective.

Synchronous Double Primary Combined Hepatocellularcholangiocarcinoma and Cholangiolocarcinoma in a Cirrhotic Liver

Both combined hepatocellular-cholangiocarcinoma(cHCCCCA)and cholangiolocarcinoma are rare primary liver cancers.cHCC-CCA is believed to originate from transformed hepatocellular carcinoma or liver stem/progenitor cells.Cholangiolocarcinoma is characterized by ductular reaction-like anastomosing cords and glands resembling cholangioles or canals containing hepatocellular carcinoma components and adenocarcinoma cells.According to the 2019 revision of the World Health Organization criteria,a subtype with stem cell features as a subclassification of cHCC-CCA was abolished for lack of conclusive evidence of the stem cell origin theory.That led to the classification of cholangiolocarcinoma with hepatocytic differentiation as cHCC-CCA.Consequently,cholangiolocarcinoma without hepatocytic differentiation is classified as a subtype of small-duct cholangiocarcinoma and is assumed to originate from the bile duct.Herein,we report the first case of double primary cHCC-CCA and cholangiolocarcinoma without hepatocytic differentiation in different hepatic segments of a cirrhotic liver.We believe this case supports the validity of the new World Health Organization criteria because the pathological finding of cHCC-CCA in this case shows the transformation of hepatocellular carcinoma to cholangiocarcinoma.Furthermore,this case may demonstrate that immature ductular cell stemness and mature hepatocyte cell stemness in hepatocarcinogenesis can coexist in the same environment.The results provide valuable insights into the mechanisms of growth,differentiation,and regulation of liver cancers.