Differential diagnosis of benign and malignant branch duct intraductal papillary mucinous neoplasm using contrastenhanced endoscopic ultrasonography

AIM: To elucidate the role of contrast-enhanced endoscopic ultrasonography(CE-EUS) in the diagnosis of branch duct intraductal papillary mucinous neoplasm(BD-IPMN).METHODS: A total of 50 patients diagnosed with BDIPMN by computed tomography(CT) and endoscopic ultrasonography(EUS) at our institute were included in this study. CE-EUS was performed when mural lesions were detected by EUS. The diagnostic accuracy for identifying mural nodules(MNs) was evaluated by CT, EUS, and EUS combined with CE-EUS. In the patients who underwent resection, the accuracy of measuring MN height with each imaging modality was compared. The cut-off values to diagnose malignant BD-IPMNs based on MN height for each imaging modality were determined using receiver operating characteristic curve analysis.RESULTS: Fifteen patients were diagnosed with BD-IPMN with MNs and underwent resection. The remaining 35 patients were diagnosed with BD-IPMN without MNs and underwent follow-up monitoring. The pathological findings revealed 14 cases with MNs and one case without. The accuracy for diagnosing MNs was 92% using CT and 72% using EUS; the diagnostic accuracy increased to 98% when EUS and CE-EUS were combined. The accuracy for measuring MN height significantly improved when using CE-EUS compared with using CT or EUS(median measurement error value, CT: 3.3 mm vs CE-EUS: 0.6 mm, P < 0.05; EUS: 2.1 mm vs CE-EUS: 0.6 mm, P < 0.01). A cut-off value of 8.8 mm for MN height as measured by CE-EUS improved the accuracy of diagnosing malignant BDIPMN to 93%. CONCLUSION: Using CE-EUS to measure MN height provides a highly accurate method for differentiating benign from malignant BD-IPMN.

Treatment strategies for advanced hepatocellular carcinoma:Sorafenib vs hepatic arterial infusion chemotherapy

Sorafenib is used worldwide as a first-line standardsystemic agent for advanced hepatocellular carcinoma(HCC) on the basis of the results of two large-scale Phase Ⅲ trials. Conversely,hepatic arterial infusion chemotherapy(HAIC) is one of the most recommended treatments in Japan. Although there have been no randomized controlled trials comparing sorafenib with HAIC,several retrospective analyses have shown no significant differences in survival between the two therapies. Outcomes are favorable for HCC patients exhibiting macroscopic vascular invasion when treated with HAIC rather than sorafenib,whereas in HCC patients exhibiting extrahepatic spread or resistance to transcatheter arterial chemoembolization,good outcomes are achieved by treatment with sorafenib rather than HAIC. Additionally,sorafenib is generally used to treat patients with Child-Pugh A,while HAIC is indicated for those with either Child-Pugh A or B. Based on these findings,we reviewed treatment strategies for advanced HCC. We propose that sorafenib might be used as a first-line treatment for advanced HCC patients without macroscopic vascular invasion or Child-Pugh A,while HAIC is recommended for those with macroscopic vascular invasion or Child-Pugh A or B. Additional research is required to determine the best second-line treatment for HAIC non-responders with Child-Pugh B through future clinical trials.

Supportive therapies for prevention of hepatocellular carcinoma recurrence and preservation of liver function

Hepatocellular carcinoma(HCC) is one of the deadliest cancers in the world and is associated with a high risk of recurrence. The development of a wide range of new therapies is therefore essential. In this study, from the perspective of supportive therapy for the prevention of HCC recurrence and preservation of liver function in HCC patients, we surveyed a variety of different therapeutic agents. We show that branched chain amino acids(BCAA) supplementation and late evening snack with BCAA, strategies that address issues of protein-energy malnutrition, are important for liver cirrhotic patients with HCC. For chemoprevention of HCC recurrence, we show that viral control after radical treatment is important. We also reviewed the therapeutic potential of antiviral drugs, sorafenib, peretinoin, iron chelators. Sorafenib is a kinase inhibitor and a standard therapy in the treatment of advanced HCC. Peretinoin is a vitamin A-like molecule that targets the retinoid nuclear receptor to induce apoptosis and inhibit tumor growth in HCC cells. Iron chelators, such as deferoxamine and deferasirox, act to prevent cancer cell growth. These chelators may have potential as combination therapies in conjunction with peretinoin. Finally, we review the potential inhibitory effect of bone marrow cells on hepatocarcinogenesis.

Effects of an oral iron chelator, deferasirox, on advanced hepatocellular carcinoma

AIM To evaluate the inhibitory effects of deferasirox(DFX) against hepatocellular carcinoma(HCC) through basic and clinical studies.METHODS In the basic study, the effect of DFX was investigated in three hepatoma cell lines(Hep G2, Hep3 B, and Huh7), as well as in an N-nitrosodiethylamine-induced murine HCC model. In the clinical study, six advanced HCC patients refractory to chemotherapy were enrolled. The initial dose of DFX was 10 mg/kg per day and was increased by 10 mg/kg per day every week, until the maximum dose of 30 mg/kg per day. The duration of a single course of DFX therapy was 28 consecutive days. In the event of dose-limiting toxicity(according to the Common Terminology Criteria for Adverse Events v.4.0), DFX dose was reduced.RESULTS Administration of DFX inhibited the proliferation of hepatoma cell lines and induced the activation of caspase-3 in a dose-dependent manner in vitro. In the murine model, DFX treatment significantly suppressed the development of liver tumors(P < 0.01), and significantly upregulated the mR NA expression levels of hepcidin(P < 0.05), transferrin receptor 1(P < 0.05), and hypoxia inducible factor-1α(P < 0.05) in both tumor and non-tumor tissues, compared with control mice. In the clinical study, anorexia and elevated serum creatinine were observed in four and all six patients, respectively. However, reduction in DFX dose led to decrease in serum creatinine levels in all patients. After the first course of DFX, one patient discontinued the therapy. We assessed the tumor response in the remaining five patients; one patient exhibited stable disease, while four patients exhibited progressive disease. The one-year survival rate of the six patients was 17%.CONCLUSION We demonstrated that DFX inhibited HCC in the basic study, but not in the clinical study due to dose-limiting toxicities.

为 basaloid 的 EMRC 的一个盒子颈的食管的有鳞的癌

Basaloid squamous carcinoma (BSC) of the esophagus is a rare esophageal tumor. A 79-year-old man with a history of proximal gastrectomy for gastric adenocarcinoma in 2000 was followed-up by esophagogastroduodenoscopy (EGD) annually. In June 2010, EGD revealed a new protruding lesion in the cervical esophagus. The small lesion was approximately 5 mm in size. A biopsy specimen showed poorly differentiated squamous cell carcinoma. We performed endoscopic mucosal resection using a cap-fi tted endoscope (EMRC). The histological diagnosis of the endoscopically resected specimen was BSC and the invasion depth was limited to the muscularis mucosae. Horizontal and vertical margins were negative. We report the case of superfi cial BSC in the cervical esophagus successfully resected by EMRC.

Preliminary study of photodynamic diagnosis using 5-aminolevulinic acid in gastric and colorectal tumors

AIM:To investigate the utility of photodynamic diagnosis(PDD) using 5-aminolevulinic acid(5-ALA) to detect gastric/colorectal tumors.METHODS:This prospective single-center study investigated inter-subject variability in patients with early-stage gastric/colorectal tumor indicated for endoscopic resection.Subjects were patients with gastric or colorectal tumors who had undergone endoscopic resection between November 2012 and November 2013.Selection criteria included age 20-80 years,either sex,and provision of informed consent.Patients were orally administered 20 mg/kg of 5-ALA enteric-coated capsules(SBI ALApromo Co.,Tokyo,Japan).Administration of5-ALA was followed by endoscopic resection of gastric or colorectal tumors,and the resected specimens were examined using a video autofluorescence processor and a fluorescence endoscope(SAFE-3000 and EB-1970 AK,respectively;Pentax,Tokyo,Japan).The primary endpoint was the presence of fluorescence in tumors.Endoscopic,macroscopic,and histopathologic findings of tumors were assessed.We also evaluated adverse events of the present procedure as a secondary endpoint and examined each patient for the presence of known adverse effects of 5-ALA,namely,hematocytopenia,liver dysfunction,hypotension,nausea,and photosensitivity.RESULTS:We enrolled 10 patients(7 men,3 women)(n = 13 lesions:10 gastric/3 colorectal tumors).Fluorescence was detected in 7/13(53.8%) lesions.No significant differences in sex(male:55.6%vs female:50.5%,P = 1.00),age(67.1 ± 1.9 years vs 65.0 ±2.0 years,P= 0.45),tumor color(reddish:60.0%vs discolored:33.3%,P = 0.56),tumor diameter(15.0± 2.1 mm vs 14.2 ± 2.3 mm,P= 0.80),macroscopic type(protruded:70.0%vs depressed 0%,P = 0.07),histologic type(differentiated type:58.3%vs 0%,P = 0.46),invasion depth(mucosal layer:55.6%vs submucosal layer:33.3%,P = 1.00),lymphatic invasion(present:33.3%vs absent:50.0%,P= 1.00),venous invasion(present:0%vs absent:54.5%,P= 1.00) or procedure time of endoscopic resection(36.3 ± 8.3 min vs 36.7 ± 9.0 min,P = 0.98) were observed between the patients with and without fluorescence.Fluorescence detection rate tended to be high for elevated lesions.Liver dysfunction developed in 4/10(40.0%) patients.The extent of the liver dysfunction was a slight increase in transaminases and total bilirubin levels,which spontaneously improved in the patients.None of the patients developed photosensitivity.CONCLUSION:Results of this preliminary study suggest the utility of PDD using 5-ALA for screening of gastric and colorectal cancers.