Extensive Acute Inflammation Research Articles

S3595 "Cutting Edge Honjo Masamune Saving Lives" ESD Preferred and Popular for Early Gastric Cancer

INTRODUCTION: Gastric cancer (GC) is the second leading cause of cancer-related mortality worldwide and complete resection is the only curative treatment. Historically, total or subtotal gastrectomy was the only curative option. However, with the advances in therapeutic endoscopy, endoscopic submucosal dissection (ESD) has emerged as a minimally invasive treatment option for precancerous lesions and early stage gastric cancer. Here we present a case of large gastric mass that was able to be fully resected using ESD, which was found to be rare GC. CASE DESCRIPTION/METHODS: A 50-year-old female with multiple comorbidities who presented to our Gastrointestinal (GI) clinic for further evaluation of iron deficiency anemia. Her initial endoscopic gastroduodenoscopy (EGD) revealed a 5–6 cm large gastric mass in the greater curvature of the stomach. The mass was hyperechoic, heterogeneous, and extended to the deep mucosal layer on endoscopic ultrasound (EUS). No adjacent lymphadenopathy was noted. Endoscopic biopsies of the mass revealed atypical glandular proliferation with extensive acute inflammation. Resection of the lesion by ESD was planned. After the lesion and its borders were carefully evaluated, the entire circumference of the lesion was marked with the Dual Knife (Olympus, Tokyo, Japan). A submucosal cushion was created using ORISE gel (Boston Scientific) expanding the submucosa and lifting the lesion away from the muscularis propria layer. The Dual Knife was then used to perform incision at the oral aspect of the lesion. Following this, the submucosa was partially dissected using swift coagulation. The submucosa was then further injected with ORISE gel to expand the submucosal space. Further dissection was performed until the lesion was completely separated from the surrounding gastric mucosa. The lesion was removed en bloc from the patient via Roth net. The resected mass measured 5 × 8 cm. Final histopathology revealed Epstein-Barr virus (EBV)-associated gastric adenocarcinoma with lymphoid stroma with negative margins. Metastatic workup was negative, and the tumor was staged as stage 1. No complications were reported. The patient was referred to the Medical and Surgical Oncology clinic and underwent subtotal gastrectomy and lymphadenectomy despite negative margins and against GI recommendation. Notably, all of the surgically resected tissue was negative for malignancy. DISCUSSION: ESD is an effective minimally invasive treatment for premalignant and early stage gastric cancer.

TNF and IL-1 Play Essential but Temporally Distinct Roles in Driving Cardiac Inflammation in a Murine Model of Kawasaki Disease.

Kawasaki disease (KD) is a leading cause of pediatric heart disease, characterized by the emergence of life-threatening coronary vasculitis. Identifying which cytokines drive KD has been a major research goal, and both TNF and IL-1 have been identified as potential candidates. Using a murine model of KD induced by the injection of the water-soluble component of Candida albicans, we therefore undertook a mechanistic study to determine how and when these two cytokines mediate cardiac inflammation. In this study, we show that TNF signaling is active in the acute phase of cardiac inflammation, which is characterized by a diffuse myocarditis that precedes the development of coronary vasculitis. Mechanistically, TNF is produced by the myeloid cells and triggers acute cardiac inflammation by stimulating both stromal and immune compartments of the heart. In contrast to this early involvement for TNF, IL-1 signaling is dispensable for the development of acute myocarditis. Critically, although mice deficient in IL-1 signaling have extensive acute inflammation following C. albicans water-soluble complex challenge, they do not develop coronary vasculitis. Thus, TNF and IL-1 appear to play temporally distinct roles in KD, with TNF being active in acute cardiac inflammation and IL-1 in the subsequent development of coronary vasculitis. These observations have important implications for understanding the progression of cardiac pathology in KD and the relative therapeutic use of targeting these cytokines.

Funisitis is associated with adverse neonatal outcome in low-risk unselected deliveries at or near term.

This study aimed to determine the incidence and clinical outcomes for varying patterns of placental histological inflammation (consistent with fetal or maternal inflammatory response) in an unselected population of >1000 women with a singleton pregnancy resulting in live birth delivering at or near term. One thousand one hundred nineteen cases were studied in a blind, prospective, unselected study with placentas categorized into five histological subgroups reflecting underlying maternal or fetal inflammatory response. Clinical outcomes studied included interventional delivery, an Apgar score <7 at 1 min, neonatal acidosis (pH < 7.2) and admission to neonatal special care. One hundred eighty-eight placentas (17 %) showed histological evidence of acute inflammation: 64 with funisitis (with or without other inflammation; 6 %); 16 with extensive acute inflammation across the chorionic plate, free membranes and subchorionic fibrin (1 %); 28 with acute inflammation restricted to the chorionic plate (2 %); 12 with acute inflammation restricted to the free membranes (1 %) and 68 with acute inflammation restricted to the subchorionic fibrin (6 %). Features of extensive acute inflammation were significantly associated with increased rate of interventional delivery (assisted vaginal delivery or emergency caesarean section; P < 0.01). The presence of funisitis was significantly associated with interventional delivery and other adverse outcomes including an Apgar score <7 at 1 min, clinical evidence of sepsis and admission to the neonatal intensive care unit (P < 0.05 for all). The data represent a quantitative rather than purely qualitative analysis of the contribution of histological lesions related to inflammation on short-term adverse neonatal outcomes and interventional delivery. Funisitis and extensive inflammation are associated with adverse clinical outcomes, but the precise mechanism underlying these remains to be elucidated.

Index of Suspicion in the Nursery

A woman presents with decreased fetal movement, and ultrasonography reveals hydrops fetalis. Specific findings include massive ascites and a small pericardial effusion that was not present on ultrasonography 1 week ago. A 37 weeks' gestation boy is delivered via emergent cesarean section. Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. The baby is intubated endotracheally 10 minutes after delivery because of increased work of breathing from his markedly distended abdomen and transported to the neonatal intensive care unit (NICU). Physical examination findings are normal, except for increased work of breathing and a tight, distended abdomen with visibly dilated veins. Initial laboratory results include a white blood cell count of 18.3×103/mcL (18.3×109/L), hemoglobin of 9.7 g/dL (97 g/L), and platelet count of 331×103/mcL (331×109/L). Chemistry results are within normal limits. Blood is sent for cultures, and empiric therapy with ampicillin and gentamicin is initiated. The baby also receives a 15-mL/kg packed red blood cell transfusion. A Replogle tube is placed to low intermittent suction. The infant is made NPO and started on intravenous fluids. Paracentesis is performed to relieve the pressure on his diaphragm and improve breathing, and 755 mL of green/brown fluid with particulate matter that has the appearance of meconium is aspirated. Umbilical lines are placed and pediatric surgery is consulted. Abdominal radiography shows intra-abdominal calcifications. An 11-day-old term girl whose mother had a positive cervical culture for human papillomavirus (HPV) is referred for admission because of a rectal temperature of 38.6°C and a history of “gasping for air.” Four days after birth, the baby became fussy, especially with feedings, and developed an intermittent cough and hoarse cry. Over several days, she became sleepier, only waking every 4 to 5 hours to breastfeed. On the pediatric ward, the baby …

What Is Adequate Sampling of Extraplacental Membranes?: A Randomized, Prospective Analysis

It is the generally accepted practice to submit 1 or 2 membrane rolls when examining placentas. To determine whether obtaining additional sections would increase diagnostic yield and, if so, to what degree. A membrane roll section was prospectively procured from each quadrant of its respective singleton placenta. These placentas were submitted for routine pathologic examination, the process of which was entirely separate from this study. All study sections were randomized and assigned new numbers, thereby blinding the pathologist to the placenta of origin. We evaluated the incidence of acute chorionitis/chorioamnionitis (AC/A) and atherosis when 1, 2, 3, or 4 slides were examined. The diagnostic yield from all possible combinations of single, pairs, and triplets of sections was tabulated. When an additional slide identified more extensive acute inflammation than what was demonstrated initially, the AC/A was upstaged. With 1 section examined, 7 to 10 placentas had AC/A. With 2 sections, 10 to 15 placentas had AC/A; with 3 sections, 16 to 18 cases; and with 4 sections, 19 cases. Additional sections upstaged the AC/A diagnosis infrequently. A total of 4 of 53 placentas had atherosis, based on review of all 4 slides. One slide identified 1 to 3 cases of atherosis. With a second and third section, the yield increased to 2 to 4 and 3 to 4, respectively. Review of a single membrane roll identified, at most, 53% of cases of AC/A and 50% of cases of atherosis. Additional sections increased the yield for both diagnoses in a roughly linear manner.

The cytologic features of Wegener's granulomatosis.

To evaluate the role of cytopathology and its different sampling techniques in the diagnosis of Wegener's granulomatosis, we retrospectively reviewed 52 cytologic specimens from 21 patients with an established diagnosis of Wegener's granulomatosis. The smear background, cellular composition, and accompanying reactive changes were evaluated. The majority of the smears were characterized by a bloody background with necrotic debris and extensive acute inflammation. Large sheets of exfoliated reactive pneumocytes and bronchial epithelium were commonly present. Multinucleated giant cells and epithelioid histiocytes were present in 10 and 20 specimens, respectively. Numerous hemosiderin-laden histiocytes were present in variable numbers in most cases and were abundant in 15 cases. Bronchial brush and lavage were the best sampling techniques. Although fine-needle aspiration best demonstrated the granulomas, only 2 of the 6 aspirates were diagnostic. The combination of cytologic findings, negative cultures, and elevated titers of antineutrophil cytoplasmic antibody with a cytoplasmic pattern may serve to establish a presumptive diagnosis of Wegener's granulomatosis.

Bacillary angiomatosis: presentation of six patients, some with unusual features

Bacillary angiomatosis (BA) is an unusual systemic vascular proliferation seen predominantly in patients with the acquired immunodeficiency syndrome. These vascular lesions are probably due to infection with a Bartonella species, most often B. henselae and, in some patients, B. quintana. BA is treatable and often curable, but without therapy, may be life-threatening. Clinically, the lesions, when superficial, are said to often resemble pyogenic granulomas, appearing polypoid histologically with an epidermal collarette. We now report six patients, three of whom showed lesions of BA morphologically and histologically distinct from the other patients reported to date. Two patients lesions appeared clinically as violaceous plaques and tumours resembling Kaposi's sarcoma; one of them had lesions histologically reminiscent of a papular angiokeratoma; and the other had lesions histologically suggestive of a combination of Kaposi's sarcoma and BA. Another patient presented with soft subcutaneous nodules which histologically showed extensive acute inflammation characteristic of an acute abscess, but which also displayed proliferating dilated small blood vessels with bulbous endothelial cells adjacent to numerous bacteria and also containing them. The Grocott-methenamine silver stain and the Warthin-Starry stain showed the organisms to better advantage in lesions of all six patients, although bacteria were also evident with the haematoxylin and eosin, periodic acid-Schiff and alcian blue stains.