Factors Related to Liver Stiffness in Patients with Hepatitis C During Direct-acting Antiviral Agent Treatment

Background and Aim：The purpose of this study was to observe the changes over time in liver stiffness measured by shear wave elastography（SWE）in hepatitis C patients during direct-acting antiviral agent（DAA）treatment and evaluate the factors affecting the liver stiffness.Methods：The subjects were 206 consecutive patients diagnosed with hepatitis C in the Dokkyo Medical University Saitama Medical Center treated with DAAs. SWE was performed to measure the propagation velocity of shear waves（Vs）before starting treatment（baseline）, at the end of treatment（EOT）, and 12 weeks after EOT（follow-up 12）. The change in Vs（ΔVs）was calculated for the difference between baseline and follow-up 12. Clinical parameters were obtained on the same day as SWE. Multiple regression analysis was used to identify factors related to ΔVs.Results：Data from 149 patients were used；all 149 patients achieved sustained virological response. Mean Vs decreased significantly, from 1.58±0.92 m/s at baseline to 1.46±0.27 m/s at EOT（P＝0.00045）. Mean Vs at follow-up 12 was 1.42±0.28 m/s, significantly lower than at EOT（P＝0.00002）. The mean ΔVs was 0.147±0.164 m/s. On multiple regression analysis, prothrombin time％（PT％）and the change in alanine aminotransferase（ΔALT）from baseline were significantly related to ΔVs. Baseline ALT and the FIB4-index tended to affect ΔVs.Conclusions：In hepatitis C patients, Vs measured by SWE improved with 12 weeks of DAA therapyand continued to improve to follow-up 12. Baseline PT％ and ΔALT contributed significantly to theimprovement of Vs during DAA treatment, and the FIB-4 index also had a great effect

Pocket Creation Method of Endoscopic Submucosal Dissection to Ensure Curative Resection of Rectal Neuroendocrine Tumors

Purpose: Pancreatic/gastrointestinal tract neuroendocrine neoplasm (NEN) is divided into neuroendocrine tumor (NET) and neuroendocrine carcinoma (NEC) according to the grade of malignancy, and differences are seen in clinical prognosis. NET, and rectal NET in particular, is often treated endoscopically. Endoscopic mucosal resection (EMR) was previously the main intervention for rectal NET, but EMR with a ligation device (EMR-L) and endoscopic submucosal dissection (ESD) are now also used. However, complete resection with these therapies is not always achieved. The pocket creation method (PCM) is a safe ESD method for colon tumors that offers a high en bloc resection rate compared with conventional colonic ESD. We performed ESD using the PCM for rectal NET and evaluated the complete resection rate. Methods: We performed ESD using the PCM in 4 patients. This procedure was technically feasible in all patients. Results: Endoscopically, all cases were resected en bloc, and pathological complete resection was achieved in all cases. No complications such as perforation or delayed postoperative bleeding were encountered. Conclusions: PCM should be considered when treating NET of appropriate size

Infliximab 治療中のクローン病にStreptococcus intermedius による肝膿瘍と膿胸を合併した1例

症例は31歳女性．クローン病再燃に対して抗TNF-α抗体製剤であるInfliximab治療中に，Streptococcus intermediusによる肝膿瘍と膿胸を発症し，治療に難渋するも抗菌薬治療，経皮経肝膿瘍ドレナージにて軽快した．Infliximab投与は，易感染性により様々な感染症を合併する可能性があるが，肝膿瘍の合併は非常にまれながら診断・治療の遅れが重篤になりやすく注意が必要である

Measurement of Tissue Stiffness with Virtual Touch Tissue Quantification in Two Cases of Spleen Tumor

We performed non-invasive measurement of tissue stiffness in the spleen for two patients using virtualtouch tissue quantification (VTTQ). Case 1 was an 82-year-old woman with Hodgkin lymphoma. Stiffnessmeasured using VTTQ was lower than normal spleen in tumor areas and higher than normal spleen in nontumorareas. Case 2 was a 66-year-old man with ascites and gastric cancer involving the entire spleen. Stiffnessof the spleen tumor as measured by VTTQ was higher than normal spleen. These cases demonstratedtwo new factors associated with elevated spleen stiffness:compression of healthy spleen tissue by tumorand cancer invasion

Positioning of novel tumor marker NX-PVKA-R in the diagnosis of hepatocellular carcinoma in comparison with PIVKA-II

Background/Aims:To compare the use of protein induced by vitamin K absence or antagonist II( PIVKA-II) measured conventionally with the ratio between PIVKA-II measured using P-11 and P-16 antibodies(NX-PVKA) and PIVKA-II measured conventionally (NX-PVKA-R) in terms of false-positive resultsfor hepatocellular carcinoma( HCC). Methodology:Subjects comprised 318 patients with chronic liver disease,including 8 patients receiving warfarin treatment, which can result in false-positive results for HCC.HCC was present in 65 patients (HCC group) and absent in 253 (non-HCC group). PIVKA-II was measuredconventionally. NX-PVKA-R was calculated as PIVKA-II/NX-PVKA. Results:Both PIVKA-II andNX-PVKA-R were significantly higher in the HCC group than in the non-HCC group (p<0.0001 each).False-positive results were seen in 9.5% of non-HCC patients with PIVKA-II, and in 10.3% with NX-PVKA-R. False-positive results were seen for all 8 patients (100%) on warfarin with PIVKA-II, but for 0%with NX-PVKA-R. Sensitivity, specificity, and accuracy were all lower for NX-PVKA-R than PIVKA-II.Conclusions:NX-PVKA-R is not more useful than PIVKA-II for diagnosing HCC, but is very useful insubpopulations such as patients on warfarin and patients with jaundice. The characteristics of NX-PVKA-Rcan be best exploited by selecting patients in which these factors are present

C 型肝炎患者に対するインターフェロン療法後の肝発癌についての検討

目的：C型慢性肝炎患者に対するインターフェロン(IFN)療法後の肝発癌について検討した．方法：C型慢性肝炎に対してIFN療法が施行された180例を対象とした．非発癌群と発癌群の間で，治療前の背景因子と半年後のウイルス学的著効(SVR24)の有無，治療後のALT，AFPについて比較した．また，それぞれの因子別に発癌曲線を作成して発癌率を比較した．結果：IFN治療によるSVR24の達成率は68.9％(124/180)であり，36.3ヶ月の観察期間で全体の発癌率は2.3％(5/180)であった．発癌群では非発癌群に比べ，高齢者，男性，SVR24非達成例，ALT高値例が多い傾向にあった．治療後のALT高値，AFP高値例は発癌が多かったが，特にAFPでは統計学的な有意差を認めた．結論：IFN治療前の線維化進展例と高齢者，男性，治療後ALT高値，AFP高値は肝発癌率が高い傾向にある．特に治療後AFP高値は肝発癌予測因子になる

粘液性嚢胞腺腫の悪性化との鑑別に苦慮した膵未分化癌の1例

症例は70歳代の女性．7年前に膵尾部単純性嚢胞と診断され，経過観察中であった．4ヶ月持続する発熱と心窩部痛の精査を目的として入院した．入院時のCTでは多発肝腫瘍を認め，嚢胞内には結節病変を，嚢胞周囲には出血・感染を示唆する所見を認めた．以上より，嚢胞性病変が癌化して転移・浸潤をきたし，嚢胞周囲に膿瘍を形成したものと考えて対症的に治療したが，第15病日に死亡した．剖検所見から嚢胞の癌化は否定され，嚢胞に近接して発生した膵未分化癌と，肝転移，肺転移等の多臓器転移，腹膜播種と診断された

A Case of Hemangiosarcoma of the Liver which led to a Diagnosis with Hemoptysis

Angiosarcoma is a vascular endothelium-derived malignant tumor that arises in blood vessel walls, accounting for only 2.3% of soft tissue sarcomas in adults. Primary hepatic angiosarcoma(PHA)is rare, comprising< 5% of all angiosarcomas. We report a case of PHA in a 61-year-old man evaluated by another clinic around our hospital for a chief complaint of hemoptysis in May 2012. Chest computed tomography(CT) showed abnormal shadows in bilateral lung fields, so he was referred to Department of Respiratory Medicine at our hospital in late July. However, no definitive diagnosis was not made, even after bronchoscopy. In mid-August, he presented to the outpatient clinic of the respiratory department with a chief complaint of right-sided abdominal pain. Abdominal CT showed a liver lesion, and he was urgently admitted to our department. Initial physical examination was unremarkable except for palpable liver in the right hypochondrium. Tumor markers for liver and biliary cancers were all within normal limits, and negative results were obtained for hepatitis B and C virus. CT, ultrasonography, and(MRI)identified a large lesion replacing the right hepatic lobe and medial segment of the left hepatic lobe. Hemangioma or hepatic angiosarcoma was suspected, accompanied by intraperitoneal rupture. Transcatheter arterial embolization was attempted, but had to be discontinued, and the patient died from hemorrhagic shock due to tumor rupture after onset of abdominal pain. The PHA which assumes hemoptysis primary symptom is extremely rare, and by reports for the past ten years searched using PubMed, this is the second report in the world

リュウキ ケイセイ オ テイ シタ ミブンカ ガタ イ ネンマク ナイ ガン ニ タイ シ ナイシキョウ チリョウ オ シコウ シタ 1 レイ

症例は67才男性.上部消化管内視鏡検査で胃前庭部前壁に0-I+IIc型隆起性病変を指摘され,生検結果は低分化型腺癌の診断であった.適応拡大病変と診断して内視鏡的胃粘膜下層剥離術(ESD)施行し適応拡大治癒切除であった.フォローの内視鏡で初回病変の近傍に0-I+IIc型の隆起を主体とした病変を認め,生検結果は印環細胞癌であり,再度ESDを施行した.初回病変のような,隆起を主体とした未分化型粘膜内癌の症例は稀である.二回目の病変の成因は,局所再発・腫瘍移植(implantation)・異時性癌のいずれか確定は困難であったが,貴重な症例と思われたので報告したA 67-year-old man was diagnosed with a small elevated undifferentiated gastric adenocarcinoma in situ and subsequently underwent endoscopic submucosal dissection (ESD). Curative resection was achieved. Fifteen months later, a new lesion was found near the ESD scar of the first lesion. This lesion was similarly elevated, and histopathological examination of the biopsy specimen revealed signet ring cell carcinoma. We performed ESD again for this lesion. Elevated early gastric cancer in which histological examination shows undifferentiated adenocarcinoma and depth M is very rare. We searched for elevated early undifferentiated gastric cancers in the PubMed and Ichushi databases and find only nine cases. The cause of the second lesion was suspected to be either local recurrence, or implantation or metachronous cancer, but it seemed to be very difficult to diagnose exactly. It should be careful observation, even if obtained curative resection of undifferentiated intramucosal gastric cancer by ESD

ドッキョウ イカ ダイガク コシガヤ ビョウイン ニオケル, フクブ チョウ オンパ ケンサ ニヨル タンノウ リュウキセイ ビョウヘン ノ ケントウ

腹部超音波検査が施行された3572 例を対象として胆嚢隆起性病変の検討を行った.胆嚢隆起性病変は3572例中791例( 22.1%) に認められ,重複検査例を除いた773例の平均年齢は59.6±13.6歳であり,男性370 例,女性403 例であった.胆嚢隆起性病変の最大径の平均は4.7±5.8 mm で,単発が256 例 (33.1%),多発が517例( 66.9%) であった.773例中,10 mm 以上の病変を有する症例は44 例( 5.6%) であった.これら44例の最終診断は,胆嚢良性ポリープ19例( 43.2%),胆嚢腺筋症2 例( 4.6%),胆泥貯留2 例( 4.6%),胆嚢結石2例( 4.6%) 切除可能胆嚢癌6例( 13.6%),切除不能胆嚢癌6 例( 13.6%),その他の癌2 例( 4.6%),不明5例( 11.3%) であり,胆嚢癌の半数が切除不能であった.今後,超音波検査を用いて切除可能な胆嚢癌をより多く拾い上げるためには,人間ドック等による,より幅広いスクリーニングが必要であると考えられた.The present study investigated the presence and characteristicsof elevated gallbladder lesions in 3572 patients whounderwent abdominal ultrasonography in our hospital betweenApril 2011 and March 2012. Elevated gallbladder lesionswere present in 791 patients (22.1 %). After excludingpatients who underwent repeat examination, 44 of theremaining 773 patients (5.6 %) had lesions &#8805; 10 mm. Finaldiagnoses in these 44 patients were as follows:benign gallbladderpolyp, n=19 (43.2 %);gallbladder adenomyosis,n=2 (4.6 %);biliary sludge accumulation, n=2 (4.6 %);gallbladder stone, n=2( 4.6%);resectable gallbladder cancer,n=6( 13.6%);non-resectable gallbladder cancer, n=6(13.6%);other cancers, n=2( 4.6%);and unknown, n=5(11.3 %). Wider screening during routine medical examinationssuch as annual health checks is required to enable increasedidentification of gallbladder cancer at an early stagewhen resection is still possible