Retrospective cohort study Lower incidence of complications in endoscopic nasobiliary drainage for hilar cholangiocarcinoma

AIM:To identify the most effective endoscopic biliary drainage technique for patients with hilar cholangiocarcinoma.METHODS:In total,118 patients with hilar cholangiocarcinoma underwent endoscopic management[endoscopic nasobiliary drainage(ENBD)or endoscopic biliary stenting]as a temporary drainage in our institution between 2009 and 2014.We retrospectively evaluated all complications from initial endoscopic drainage to surgery or palliative treatment.The risk factors for biliary reintervention,post-endoscopic retrograde cholangiopancreatography(post-ERCP)pancreatitis,and percutaneous transhepatic biliary drainage(PTBD)were also analyzed using patient-and procedure-related characteristics.The risk factors for bilateral drainage were examined in a subgroup analysis of patients who underwent initial unilateral drainage.RESULTS:In total,137 complications were observed in92(78%)patients.Biliary reintervention was required in 83(70%)patients.ENBD was significantly associated with a low risk of biliary reintervention[odds ratio(OR)=0.26,95%CI:0.08-0.76,P=0.012].Post-ERCP pancreatitis was observed in 19(16%)patients.An absence of endoscopic sphincterotomy was significantly associated with post-ERCP pancreatitis(OR=3.46,95%CI:1.19-10.87,P=0.023).PTBD was required in 16(14%)patients,and Bismuth type III or IV cholangiocarcinoma was a significant risk factor(OR=7.88,95%CI:1.33-155.0,P=0.010).Of 102 patients with initial unilateral drainage,49(48%)required bilateral drainage.Endoscopic sphincterotomy(OR=3.24,95%CI:1.27-8.78,P=0.004)and Bismuth II,III,or IV cholangiocarcinoma(OR=34.69,95%CI:4.88-736.7,P<0.001)were significant risk factors for bilateral drainage.CONCLUSION:The endoscopic management of hilar cholangiocarcinoma is challenging.ENBD should be selected as a temporary drainage method because of its low risk of complications.

Influence of the safety and diagnostic accuracy of preoperative endoscopic ultrasound-guided fine-needle aspiration for resectable pancreatic cancer on clinical performance

AIM:To evaluate the safety and diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA)in a cohort of pancreatic cancer patients.METHODS:Of 213 patients with pancreatic cancer evaluated between April 2007 and August 2011,82were thought to have resectable pancreatic cancer on the basis of cross-sectional imaging findings.Of these,54 underwent EUS-FNA before surgery(FNA+group)and 28 underwent surgery without preoperative EUSFNA(FNA-group).RESULTS:All 54 lesions were visible on EUS,and all54 attempts at FNA were technically successful.The diagnostic accuracy according to cytology and histology findings was 98.1%(53/54)and 77.8%(42/54),respectively,and the total accuracy was 98.1%(53/54).One patient developed mild pancreatitis after EUS-FNA but was successfully treated by conservative therapy.No severe complications occurred after EUS-FNA.In the FNA+and FNA-groups,the median relapse-free survival(RFS)was 742 and 265 d,respectively(P=0.0099),and the median overall survival(OS)was1042 and 557 d,respectively(P=0.0071).RFS and OS were therefore not inferior in the FNA+group.These data indicate that the use of EUS-FNA did not influence RFS or OS,nor did it increase the risk of peritoneal recurrence.CONCLUSION:In patients with resectable pancreatic cancer,preoperative EUS-FNA is a safe and accurate diagnostic method.

Relationships of early esophageal cancer with human papillomavirus and alcohol metabolism

BACKGROUND It is well known that an alcohol consumption habit together with inactive heterozygous aldehyde dehydrogenase-2(ALDH2)is an important risk factor for the development of esophageal squamous cell carcinoma(ESCC).It remains controversial whether human papillomavirus(HPV)infection contributes to the occurrence/development of ESCC.There has been no study in which the relationship between ESCC and HPV in addition to alcohol dehydrogenase-1B(ADH1B)and ALDH2 genotypes was evaluated.AIM To evaluate relationships between HPV infection and development of esophageal cancer,particularly early esophageal cancer,based on ADH1B/ALDH2 polymorphisms.METHODS We conducted an exploratory retrospective study using new specimens,and we enrolled 145 patients who underwent endoscopic resection for superficial ESCC and had been observed for more than two years by both physical examination and endoscopic examination in Hokkaido University Hospital.Saliva was collected to analyze genetic polymorphisms of ADH1B/ALDH2.We performed in situ hybridization for resected specimens to detect HPV by using an HPV type 16/18 probe.RESULTS HPV was detected in 15(10.3%)of the 145 patients with ESCC.HPV-positive rates in inactive ALDH2*1/*2 and ALDH2*1/*1+*2/*2 were 10.8%and 9.8%,respectively(P=1.00).HPV-positive rates in slow-metabolizing ADH1B*1/*1 and ADH1B*1/*2+*2/*2 were 12.0%and 10.0%,respectively(P=0.72).HPV-positive rates in the heavy or moderate alcohol consumption group and the light or rare consumption group were 11.1%and 8.7%,respectively(P=0.68).HPV-positive rates in the heavy smoking group and the light or no smoking group were 11.8%and 8.3%,respectively(P=0.59).The 3-year incidence rates of secondary ESCC or head and neck cancer after initial treatment in the HPV-positive and HPVnegative groups were 14.4%and 21.4%(P=0.22),respectively.CONCLUSION In the present situation,HPV status is considered to be less important than other risk factors,such as alcohol consumption,smoking habit,ADH1B/ALDH2 polymorphisms,and HPV status would therefore have no effect on ESCC risk management.

Prospect of lenvatinib for unresectable hepatocellular carcinoma in the new era of systemic chemotherapy

The phase III clinical trial of the novel molecular targeted agent(MTA)lenvatinib for patients with advanced hepatocellular carcinoma(HCC)(REFLECT trial)found that lenvatinib was non-inferior to sorafenib in overall survival.Recently,the efficacy of multiple MTAs,including lenvatinib,in practice has been reported,and therapeutic strategies for Barcelona Clinic Liver Cancer(BCLC)intermediate stage HCC are undergoing major changes.Based on these results,lenvatinib could be recommended for patients with transcatheter arterial chemoembolization(TACE)-refractory,ALBI grade 1,within the up-to-seven criteria in the BCLC intermediate stage.Lenvatinib provides a more favorable outcome than TACE,even in cases with large or multinodular HCC beyond the up-to-seven criteria with Child-Pugh grade A.When patients meet the definitions of TACE-refractory or TACE-unsuitable,switching to systemic chemotherapy,including lenvatinib,is for favorable for preserving liver function.If initial treatment,including MTA,has a significant therapeutic effect and downstaging of HCC is obtained,additional TACE or surgical resection should be considered.Lenvatinib also has a therapeutic effect for poorly differentiated type and non-simple nodular type HCC thanks to the survival-prolonging effect of this drug.Furthermore,a significant therapeutic effect is expected in tumors with more than 50%liver involvement or main portal vein invasion,which have traditionally been considered to have a poor prognosis in patients.This suggests that at the start of lenvatinib treatment,HCC patients with ALBI grade 1 may be able to maintain liver functional reserve.

Preliminary study of automatic gastric cancer risk classification from photofluorography

AIM To perform automatic gastric cancer risk classificationusing photofluorography for realizing effective mass screening as a preliminary study. METHODS We used data for 2100 subjects including X-ray images, pepsinogen Ⅰ and Ⅱ levels, PGⅠ/PGⅡ ratio, Helicobacter pylori (H. pylori) antibody, H. pylori eradication history and interview sheets. We performed two-stage classification with our system. In the first stage, H. pylori infection status classification was performed, and H. pylori-infected subjects were automatically detected. In the second stage, we performed atrophic level classification to validate the effectiveness of our system.RESULTS Sensitivity, specificity and Youden index(YI) of H. pylori infection status classification were 0.884, 0.895 and 0.779, respectively, in the first stage. In the second stage, sensitivity, specificity and YI of atrophic level classification for H. pylori-infected subjects were 0.777, 0.824 and 0.601, respectively. CONCLUSION Although further improvements of the system are needed, experimental results indicated the effectiveness of machine learning techniques for estimation of gastric cancer risk.

Recent advances in endoscopic ultrasonography-guided biliary interventions

Interventional endoscopic ultrasonography(EUS) based on EUS-guided fine-needle aspiration has rapidly spread as a minimally invasive procedure. Especially in patients with failed endoscopic retrograde cholangiopancreatography, EUS-guided biliary intervention is reported to be useful as salvage therapy. EUS-guided biliary interventions are carried out using three techniques: EUS-guided bilioenteric anastomosis, EUS-guided rendezvous procedure, and EUS-guided antegrade treatment. Although interventional EUS is not yet a standardized procedure, there have been recent advances in this field that address various biliary diseases. Here, we summarize the indications, techniques, clinical results of previous studies, and future perspectives.

Pre-sarcopenia and Mac-2 binding protein glycosylation isomer as predictors of recurrence and prognosis of early-stage hepatocellular carcinoma

BACKGROUND The Mac-2 binding protein glycosylation isomer(M2BPGi),a fibrosis marker in various liver diseases,is reportedly a prognostic marker in patients with hepatocellular carcinoma(HCC)who underwent hepatectomy.AIM To evaluate whether the M2BPGi value,M2BP,and pre-sarcopenia before radiofrequency ablation(RFA)could be useful recurrence and prognostic markers in patients with early-stage HCC.METHODS In total,160 patients with early-stage primary HCC treated with RFA were separately analyzed as hepatitis C virus(HCV)-positive and HCV-negative.Factors contributing to recurrence and liver-related death,including M2BP,M2BPGi,and skeletal muscle mass index,were statistically analyzed.Eighty-three patients were HCV-positive and 77 were HCV-negative.RESULTS In HCV-positive patients,only des-γ-carboxy-prothrombin≥23 mAU/mL was a significant poor prognostic factor affecting survival after RFA.In HCV-negative patients,M2BPGi≥1.86 cutoff index was significantly associated with tumor recurrence,while M2BP was not.M2BPGi≥1.86 cutoff index(hazard ratio,4.89;95%confidence interval:1.97-12.18;P<0.001)and pre-sarcopenia(hazard ratio,3.34,95%confidence interval:1.19-9.37;P=0.022)were independent significant poor prognostic factors in HCV-negative patients.CONCLUSION In HCV-negative patients with primary HCC treated with RFA,lower M2BPGi contributed to a lower tumor recurrence rate and longer survival period.Pre-sarcopenia contributed to the poor prognosis independently in HCV-negative patients.These factors might be useful recurrence and prognostic markers for early-stage primary HCC.

Visualization and Management Platform with Augmented Reality for Wireless Sensor Networks

Recently a ubiquitous sensor network which collects our environmental information gets increasingly popular, a visualization application is necessary for users to manage complicated wireless networks, however, these applications are developed individually for wireless communication standard or a type of wireless device. Therefore, users are forced to adopt and use the application individually according to the target of the wireless network. In this paper, we propose a visualization platform for wireless network environments using augmented reality technology, and evaluate the effectiveness of the platform. From the result of the evaluation, we have confirmed the proposed platform has availability for visualization and management of wireless networks.

Novel Treatment of Hepatitis C Virus Infection for Patients with Renal Impairment

Prevalence of hepatitis C virus (HCV) infection is high in patients with end-stage renal dysfunction,including patients undergoing hemodialysis (HD).The HCV infection itself can cause glomerulonephritis and puts individuals at increased risk of developing end-stage renal disease;fortunately,successful HCV eradication sometimes restore HCV-related renal dysfunction.Moreover,the prognosis of dialysis patients infected with HCV is significantly worse and the renal allograft survival in HCV-infected patients is also worse than in dialysis patients without HCV infection.If life prognosis is favorable,therefore,anti-HCV therapy is strongly recommended for HCV-infected patients with severe renal dysfunction.The standard therapy for HCV-infected patients with severe renal dysfunction has historically been interferon-based therapy.However,this therapy remains ineffective in achieving high,sustained viral response rates and the rate of adverse events and treatment discontinuation due to treatment-induced adverse events continues to be high in patients with severe renal dysfunction.Safe and effective anti-HCV therapies are urgently needed,and crucial,for patients with severe renal dysfunction.Recently,direct-acting antivirals (DAAs) that specifically target viral proteins have been developed,and these targets include the NS3,NS5A,and NS5B of HCV.Clinical trials have revealed high efficacy and safety of the DAA-based therapies,but patients with severe renal dysfunction were not included in the majority of these trials.However,several recent reports have shown high efficacy and safety for some regimens of DAA combination therapy for HCV-infected patients with severe renal dysfunction.In this review,we discuss novel treatments for HCV-infected patients with severe renal dysfunction and the pharmacokinetics of these drugs.

Anterior mediastinal abscess diagnosed in a young sumo wrestler after closed blunt chest trauma

Most mediastinal abscesses result from infections after thoracotomy, esophageal perforation or pene- trating chest trauma. This disease is rarely caused by closed blunt chest trauma. All previously reported such cases after closed blunt chest trauma presented with hematoma and sternal osteomyelitis resulting from sternal fracture. Here we report a 15-year-old sumo wrestler who presented with an anterior mediastinal abscess without any mediastinal fracture. The mediastinal abscess resulted from the he- matogenous spread of Staphylococcus aureus to a hematoma that might have been caused by a closed blunt chest trauma incurred during sumo wrestling exercises.