Mantle cell lymphoma (MCL) is a B cell lymphoma derived from the mantle zone of the lymph node follicle. MCL is immunohistochemically positive for CD5 and cyclin D1 and negative for CD10. These markers are useful for a definitive diagnosis. Specific gene abnormalities include a t (11 ; 14) (q13 ; q32) translocation. About 75% of MCL cases are diagnosed at an advanced stage III or IV, with gastrointestinal involvement detected at a high rate.
A review of 71 Japanese patients with gastrointestinal involvement of MCL revealed that 67% were diagnosed at stage IV. Gastrointestinal involvement included stomach (2/3) and colon lesions (2/5). Esophageal involvement was uncommon (4 cases). Stomach lesions varied morphologically, including protruded, ulcerative, and fold-thickening types and multiple lymphomatous polyposis (MLP). MCL is often observed as MLP from the duodenum to the colon.
The prognosis of MCL is poorer among B cell lymphoma cases, with a median survival of 48-68 months. A hyper-CVAD/MA regimen (fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone, alternating with high doses of methotrexate and cytarabine) was designed to improve the therapeutic effects of the CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisone) or rituximab plus CHOP. Following this therapy, high-dose chemotherapy with autologous peripheral blood stem cell transplantation is performed to improve the rates of complete remission and relapse-free survival.

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We examined the usefulness and safety of intragastric observation employing a small diameter rigid telescope (external diameter : 2.7 mm, Nisco Co., Ltd.), which can be inserted through the catheter lumen of a gastric fistula tube made by percutaneous endoscopic gastrostomy. While exchanging the catheter, fistula and intragastric observations were carried out with a rigid telescope E02700 (direct view type) or E02770 (oblique view type) to verify the optimal path and location of the catheter tip.
Endoluminal visualization of the stomach as well as the fistula was possible in all 30 patients examined without any clinically significant adverse event. A direct view type telescope was more preferable for observing the fistula lumen and the bumper of the catheter with guidewire introduction, while an oblique view type telescope provided better visualization of the gastric mucosa around the bumper.

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Background : Although there have been reports of the usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-guided FNA) for malignant lymphoma, its utility for the diagnosis of the subclassification of malignant lymphoma has not been confirmed.
Objective : Evaluating the utility of EUS-guided FNA for the diagnosis of the subclassification of malignant lymphoma.
Methods : We retrospectively examined data on 50 patients with malignant lymphoma who underwent EUS-guided FNA between February 2008 and May 2012 at our hospital. First, we evaluated the concordance rate for diagnosis of the subclassification by EUS-guided FNA and other diagnostic options such as surgery, endoscopy or percutaneous biopsy. Secondly, we investigated the diagnostic accuracy of methods of analysis of the sample specimens obtained with EUS-guided FNA which were Southern blotting, multiparameter flow cytometry (MFCM), G-band karyotyping, and fluorescence in situ hybridization (FISH).
Results : In 27 patients both EUS-guided FNA and another method of examination were performed. In all 27 patients, EUS-guided FNA diagnosis corresponded with the diagnosis by other methods of examination. The diagnostic accuracy of MFCM was 87.2%, Southern blotting was 87.0%, G-band karyotyping was 57.6% and FISH was 85.3%. The subclassification type was diagnosed in all 50 cases : diffuse large B-cell lymphoma, 22 ; follicular lymphoma, 25 ; Burkitt lymphoma, 1 : and peripheral T-cell lymphoma, 2. No serious complications occurred with the procedure.
Conclusion : With EUS-guided FNA we could safely and successfully diagnose the subclassification of malignant lymphoma. Our results suggest that EUS-guided FNA may be a useful and less invasive replacement for surgical or percutaneous biopsy in the diagnosis of subclassification of malignant lymphoma.

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A 50-year-old woman was referred to our hospital for a depressed lesion on the anterior greater curvature of the middle body of the stomach that had been identified by screening endoscopy. The pathology of biopsy specimens obtained from the lesion demonstrated adenoma. However, we diagnosed the lesion as a well differentiated adenocarcinoma confined within the mucosal layer using EUS and magnifying endoscopy with narrow band imaging. The lesion was excised by ESD in December 2009. Histopathology of the resected specimen revealed a well differentiated adenocarcinoma within the mucosal layer [0-IIc, UL(-), ly0, v0]. The tumor's phenotype was classified as the gastric type. Helicobacter pylori (H. pylori) infection was not identified by the histological examination, blood antibody test or the urea breath test even though there was no history of H. pylori eradication therapy. We therefore considered that the patient had not been infected with H. pylori. This paper reports on a rare case of a well differentiated adenocarcinoma with a gastric type phenotype without H. pylori infection treated by ESD.

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A 68-year-old woman had visited a medical clinic because of abdominal bloating. Endoscopic examination had shown diffuse granular lesions in the entire stomach. Histological examination of the lesions revealed non-caseous granulomas. After clinically differentiation such as various diseases such as Crohn's disease, tuberculosis, or histoplasmosis, she had been diagnosed as having gastric sarcoidosis. Esophagogastrodudenoscopy (EGD) had been performed once a year as an annual screening. During a follow-up EGD on April 2011, lacerations with bleeding spontaneously occurred at the lesser curvature from the middle to the upper parts of the stomach. Thus, she was admitted to our hospital. Three days later, follow-up EGD examination showed improvement in the gastric lesions, and she was discharged from our hospital. It is important to gently manipulate the scope without excessive air insufflation in patients with gastric sarcoidosis because of mucosal friability.

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We reported an extremely rare case of minute signet ring cell carcinoma of the stomach and described the clinicopathological findings of this lesion. A 59-year-old woman was referred to our hospital with minute gastric signet ring cell carcinoma. It was revealed to be a round discolored lesion 4 mm in diameter and type 0-IIb according to the Japanese classification of gastric carcinoma (superficial flat type) by routine gastroduodenoscopy for health screening. The gastroduodenoscopy examination showed that the color change of this lesion was pathognomonic. This lesion was unclear upon examination of the gastric biopsy specimen, but it was again identified by magnifying endoscopic diagnosis using NBI. Subsequently this minute lesion was treated with endoscopic submucosal dissection. The patient has been free of recurrence for 30 months.

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A 47-year-old male with a history of alcoholic chronic pancreatitis presented with epigastralgia over a period of several days. Laboratory data showed elevated hepatobiliary enzymes and amylase. CT images revealed a pancreatic pseudocyst with an intracystic aneurysm. Imaging also demonstrated stenosis of the inferior bile duct and proximal dilation. We performed transcatheter arterial embolization for the aneurysm and percutaneous transhepatic biliary drainage for the obstructive jaundice. Subsequent ERCP showed stenosis of the biliary duct and the main pancreatic duct in the pancreatic head in addition to a pancreaticobiliary fistula. We performed stenting of the biliary and pancreatic ducts and exchanged stents repeatedly at 1- to 2-month intervals. Thirteen months after the fistula appeared, we removed both stents after confirmation that the stenosis of both ducts was resolved and that the fistula had disappeared. Half a year after the removal of both stents, the patient remains in good condition without clinical recurrence.

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A 46-year-old woman who underwent pancreaticoduodenectomy with Child's reconstruction for pancreatic cancer developed jaundice because of recurrence at the anastomotic site of the hepaticojejunostomy. Bilateral metal stenting across the anastomotic site of the bile duct was achieved successfully using double balloon enteroscopy ; thus, the obstructive jaundice was resolved rapidly. The outcome in this case suggests that the placement of metal stents across the anastomotic site of the hepaticojejunostomy effectively dilated the malignant stricture due to the anastomotic recurrent tumor. Metal stent placement also may facilitate re-intervention if stent dysfunction would occur. If necessary, multiple stents for other proximal branches can be placed through mesh of the original distal metal stent.

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Here we describe a rare case of hemorrhagic penetration of the diverticulum at the rectosigmoid junction presenting as intramesenteric emphysema.
An 83-year-old woman was admitted to our hospital with a sudden onset of lower abdominal pain. She had a medical history of pulmonary embolism at the age of 81 years and was taking warfarin. Mild tenderness in the lower abdomen was identified by abdominal palpation without a sign of peritoneal irritation. Results of laboratory examinations did not show any significant inflammatory response. Although abdominal computed tomography revealed no obvious free air in the abdomen, indistinguishable gas around the rectum was observed.
Hematochezia was observed 2 hours after admission. Urgent colonoscopy showed a deep recess in the rectosigmoid junction located approximately 15 cm proximal to the anal verge. The opening of the cavity was enlarged to about the same size as the colonic lumen, and mesenteric tissues were observed at the bottom of the recess. Endoscopic hemostasis was considered overwhelmingly challenging, and surgical management was chosen as the treatment. During laparotomy, a 3-cm perforation was observed on the mesenteric side of the rectosigmoid junction. Sigmoidectomy and Hartmann's procedure were performed to repair the perforation. Pathological analysis of the resected specimen suggested intramesenterically penetrating diverticulum at the rectosigmoid junction. In addition, a review of recorded imaging studies indicated that the indistinguishable gas around the rectum observed at admission was intramesenteric emphysema.
In conclusion, signs of peritoneal irritation are not always recognized in cases of intramesenteric or retroperitoneal penetration of colorectal diverticular disease. Therefore, meticulous assessment with multi-imaging modalities would be helpful to accurately diagnose such conditions and achieve earlier optimal management.

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Recently prednisolone has been used for the prevention of esophageal stenosis after endoscopic submucosal dissection (ESD). However, there is hesitation to use prednisolone in patients at risk when using steroids due to concomitant diseases such as diabetes mellitus and viral hepatitis. Budesonide is a steroid antedrug, which is a locally acting corticosteroid with a minimal systemic effect and high affinity. Therefore, budesonide might be safely used even for patients at risk with steroid usage. Thus far, we have used budesonide in 5 patients aiming to prevent esophageal stenosis after ESD. No stricture was observed in patients after removal of four fifths of the esophageal circumference. However, budesonide did not prevent strictures after removal of larger lesions. We are planning to evaluate this treatment further to validate its prophylactic effects.

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Endoscopic diagnosis and therapy for various pancreatobiliary diseases have made remarkable progress in recent years. In April 2013, endoscopic pancreatic stenting was approved for coverage by the Japanese medical insurance system, and endoscopic stenting has rapidly spread as a less invasive approach.
However, endoscopic approaches for pancreatic lesions are not always readily available in many hospitals because of risks of adverse events and are still technically challenging due to their invasiveness There are certain points to be considered in maximizing the clinical benefits of endoscopic stenting. Prior to pancreatic stenting it is important to determine whether the stenosis is caused by benign or malignant lesions. Stenting without a differential diagnosis of the cause of the stenosis is not recommended is not recommended unless there are specific reasons for not obtaining a differential diagnosis. In addition, a thorough understanding of the incidental complications associated with stenting is essential. Although pancreatic stenting is a useful technique to relieve the stricture in patients with chronic pancreatitis, an array of issues, e.g., indications, duration, shape and diameter of the stricture, need to be carefully assessed for the safe performance of stenting.

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Endoscopic balloon dilation (EBD) is commonly performed for stricture after surgery, endoscopic resection or chemoradiotherapy for esophageal cancer. However, we sometimes experience intractable stricture an intractable stricture associated with long-term and severe dysphasia, which is difficult to resolve with the standard balloon dilation technique. We therefore developed a new treatment, the radial incision and cutting (RIC) method. We introduce detailed procedural steps for RIC and retrospective data on the efficacy and safety of RIC. We discuss the limitations and problems associated with RIC.

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