Crohn’s Disease Successfully Treated With Infliximab in a Patient Receiving Hemodialysis: Case Report and Review of the Literature

There is limited information in the use of antitumor necrosis factor α, infliximab, in patients on hemodialysis. In Crohn’s disease (CD), only 3 cases are reported.A 76-year-old man on hemodialysis for renal failure caused by immunoglobulin A nephropathy developed diarrhea and abdominal pains. A marked edema was observed in the pretibia and ankle. An increase of C-reactive protein (CRP) and erythrocyte sedimentation rate, hypoalbuminemia, hypocholesterolemia, and moderate anemia was found. Ultrasonography and computed tomography (CT) found wall thickness in the left colon. Sigmoidoscopy revealed multiple ulcers in the sigmoid colon and noncaseating epithelioid granuloma was found in the biopsy specimen. Barium enema study exhibited collar button signs and longitudinal ulcers in the left colon.A severe form of CD was diagnosed. Metronidazole seemed to decrease CRP but was ineffective in ameliorating diarrhea. Infliximab rather than steroid hormone was chosen for the treatment. Standard induction therapy with infliximab was initiated. Symptoms rapidly improved then disappeared. CD activity index decreased from 747 to a remission level of 134 after 2 infusions of infliximab. Scheduled maintenance infliximab therapy was administered after the induction therapy. Ultrasonography and CT showed a disappearance of the wall thickness of the colon. Adverse reactions were not observed.Infliximab was effective and safe in a patient with CD on hemodialysis. Our case has added additional literature in accordance with previous reports supporting infliximab as effective and safe in patients on hemodialysis.     

Is the eCura system useful for selecting patients who require radical surgery after noncurative endoscopic submucosal dissection for early gastric cancer? A comparative study

Background

We have established a risk-scoring system, termed the “eCura system,” for the risk stratification of lymph node metastasis in patients who have received noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to clarify whether this system contributes to the selection of patients requiring radical surgery after ESD.

Methods

Between 2000 and 2011, 1,969 patients with noncurative ESD for EGC were included in this multicenter study. Depending on the treatment strategy after ESD, we had patients with no additional treatment (n = 905) and those with radical surgery after ESD (n = 1,064). After the application of the eCura system to these patients, cancer recurrence and cancer-specific mortality in each risk category of the system were compared between the two patient groups.

Results

Multivariate Cox analysis revealed that in the high-risk category, cancer recurrence was significantly higher (hazard ratio = 3.13, p = 0.024) and cancer-specific mortality tended to be higher (hazard ratio = 2.66, p = 0.063) in patients with no additional treatment than in those with radical surgery after ESD, whereas no significant differences were observed in the intermediate-risk and low-risk categories. In addition, cancer-specific survival in the low-risk category was high in both patient groups (99.6 and 99.7%). A limitation of this study is that it included a small number of cases with undifferentiated-type EGC (292 cases).

Conclusions

The eCura system is a useful aid for selecting the appropriate treatment strategy after noncurative ESD for EGC. However, caution is needed when applying this system to patients with undifferentiated-type EGC.

     

Vascular endothelial growth factor expression and microvessel parameters of colonic mucosa correlate with sensitivity to steroid in patients with ulcerative colitis

OBJECTIVE: Vascular endothelial growth factor (VEGF) expression and microvessel parameters have not yet been quantified in the colonic mucosa of ulcerative colitis (UC). The aim of this study was to correlate the parameters with clinical responsiveness to steroid therapy. MATERIAL AND METHODS: Colorectal biopsy specimens from 39 UC patients with high sensitivity to steroid (H-UC), 9 UC patients with low sensitivity to steroid (L-UC) and 6 normal controls (NC) were examined. METHODS: Tissue sections were immunostained with anti-VEGF antibody for number of inflammatory cells (/mm(2)), VEGF-positive cell (/mm(2)) and VEGF-positive ratio (%), and with CD34 for microvessel counts (/mm(2)) and the mean microvessel diameter (microm). RESULTS: The H-UC group had a significantly larger total cell count (10,048+/-2751, p<0.0001) or VEGF-positive cells (2363+/-707, p<0.0001) than the NC group (7235+/-2088 or 1537+/-297, respectively) with no difference in VEGF-positive ratio (24.3+/-6.9 for H-UC versus 22.7+/-6.9 for NC). The L-UC group had a significantly lower VEGF-positive cell count (1420+/-701, p<0.0005) or VEGF-positive ratio (11.6+/-5.5, p<0.0005) than the H-UC group, whereas microvessel counts were almost constant regardless of the subject groups (345+/-7 0 for NC versus 346+/-99 for H-UC versus 349+/-114 for L-UC). Significant increases in microvessel diameter were seen when comparing NC (6.68+/-0.60) with H-UC (7.83+/-1.09, p<0.0001) and H-UC with L-UC (9.05+/-1.70, p<0.03). Out of the five parameters, VEGF-positive ratio and microvessel diameter had a predictive value for L-UC with an 88.9% sensitivity and 88.9% specificity. CONCLUSIONS: L-UC was characterized either as VEGF underexpression or enlarged microvessel. The disruption of the healing process or disturbance of microcirculation may be involved in low sensitivity to steroid therapy in UC.     

Microvessel morphology and vascular endothelial growth factor expression in human colonic carcinoma with or without metastasis

We quantified microvessel morphology and vascular endothelial growth factor (VEGF) expression in human colonic carcinoma with or without metastasis. The cancerous growth and the noncancerous section of surgical specimens from 36 patients with colorectal carcinoma (14 without metastasis and 22 with metastasis) were studied. Tissue slices immunostained with CD34 were processed for microvessel counts (per mm(2)), the mean diameter of microvessels (microm), and the mean spatial direction of microvessels (degree), defined by the angle between the longitudinal axis of microvessels and the direction perpendicular to the surface of the mucosa. Tissue slices immunostained with anti-VEGF antibody were processed for total epithelial cell counts (per mm(2)), VEGF-positive cell counts (per mm(2)), and VEGF-positive ratio (%). Carcinoma without metastasis had significantly larger microvessel counts (213 +/- 77, p < 0.01), larger microvessel diameter (7.99 +/- 1.77, p < 0.05), and larger spatial direction (47.2 +/- 8.3, p < 0.01) than normal tissue (144 +/- 49 for microvessel counts; 7.03 +/- 0.90 for microvessel diameter; 39.5 +/- 6.6 for spatial direction). Compared with carcinoma without metastasis, carcinoma with metastasis had a significantly larger microvessel diameter (9.75 +/- 2.65, p < 0.03) and lower microvessel counts (180 +/- 92, p = 0.51). Carcinoma without metastasis had a significantly larger VEGF-positive cell count (1276 +/- 805, p < 0.05) and larger VEGF-positive ratio (53.6 +/- 39.3, p < 0.05) than normal tissue (571 +/- 553 for VEGF-positive cell counts; 24.6 +/- 23.2 for VEGF-positive ratio). Carcinoma with metastasis had a significantly lower total cell count (1443 +/- 237, p < 0.001) and lower VEGF-positive cell count (716 +/- 463, p < 0.05) than carcinoma without metastasis. With tumor progression, microvessel diameter significantly increased and microvessel counts decreased, which can be in part explained by VEGF expression. The microvessel diameter seems to be the dominant parameter responsible for cancer cell intravasation as the first step of metastasis.     

Is the new potent acid-inhibitory drug vonoprazan effective for healing idiopathic peptic ulcers? A multicenter observational study in Akita Prefecture,Japan

Journal of Gastroenterology - The incidence of peptic ulcers unrelated to H. pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs), termed idiopathic peptic ulcers (IPUs), has...     

Endoscopic mucosal resection using a cap-fitted panendoscope and endoscopic submucosal dissection as optimal endoscopic procedures for superficial esophageal carcinoma

Background  

Endoscopic mucosal resection using a cap-fitted panendoscope (EMRC) and an endoscopic submucosal dissection (ESD) are increasingly performed to treat superficial esophageal carcinoma (SEC). As an endoscopic procedure appropriate for en bloc complete resection, ESD requires a much higher level of skill and experience than EMRC.     

Visceral obesity is associated with an increased risk of developing esophago-gastric junctional adenocarcinoma in Japan: a population-based case–control study in Akita Prefecture

Esophagus - While an association between esophago-gastric junctional adenocarcinomas (EGJACs) and obesity, especially visceral obesity, has been suggested in Western countries, the association...     

Is radical surgery necessary in all patients who do not meet the curative criteria for endoscopic submucosal dissection in early gastric cancer? A multi-center retrospective study in Japan

Background

Although radical surgery is routinely performed for patients who do not meet the curative criteria for endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) due to the risk of lymph node metastasis (LNM), this standard therapeutic option may be excessive given the lower number of patients with LNM. Therefore, we aimed to investigate long-term outcomes and validate risk factors predicting recurrence after ESD.

Methods

Of 15,785 patients who underwent ESD for EGC at 19 institutions between 2000 and 2011, 1969 patients not meeting the curative criteria were included in this multi-center study. Based on the treatment strategy after ESD, patients were divided into radical surgery (n = 1064) and follow-up (no additional treatment, n = 905) groups.

Results

Overall survival (OS) and disease-specific survival (DSS) were significantly higher in the radical surgery group than in the follow-up group (p < 0.001 and p = 0.012, respectively). However, the difference in 3-year DSS between the groups (99.4 vs. 98.7 %) was rather small compared with the difference in 3-year OS (96.7 vs. 84.0 %). LNM was found in 89 patients (8.4 %) in the radical surgery group. Lymphatic invasion was found to be an independent risk factor for recurrence in the follow-up group (hazard ratio 5.23; 95 % confidence interval 2.01–13.6; p = 0.001).

Conclusions

This multi-center study, representing the largest cohort to date, revealed a large discrepancy between OS and DSS in the two groups. Since follow-up with no additional treatment after ESD may be an acceptable option for patients at low risk, further risk stratification is needed for appropriate individualized treatment strategies.