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Incidental gallbladder cancers （IGBCs） refer to gallbladder cancers （GCs） that are not preoperatively diagnosed but are diagnosed only after cholecystectomy for benign gallbladder diseases. This exploratory study aimed to investigate the diagnostic performance of bile cytology with percutaneous transhepatic gallbladder drainage （PTGBD） and tumor markers in preoperatively detecting IGBC. Data on consecutive acute cholecystitis cases between January 2018 and March 2020 at the Showa University Hospital in Tokyo, Japan, were retrospectively analyzed. Patient characteristics, bile cytology results, collection date, and blood test results were assessed. Concerning the bile cytology results, classes I–III were categorized as negative, whereas classes IV and V were positive. Bile cytology was performed in 102 patients; of these, 2 cases were diagnosed as GC. The bile cytology results were as follows: class I in 15 cases; class II in 84; class III in 2; class IV in 1; and class V in 0. Therefore, 101 and 1 cases were judged as negative and positive, respectively. Bile cytology had a sensitivity of 50％, specificity of 100％, positive predictive value of 100％, and negative predictive value of 99％. Among 47 patients in whom carcinoembryonic antigen （CEA） and carbohydrate antigen 19-9 （CA19-9） levels were measured, 3 and 12 patients exhibited elevated CEA and CA19-9 levels, respectively. Tumor markers were elevated in IGBC cases; however, several false-positive results were present in cases without GC. Bile cytology from PTGBD may be useful for the preoperative diagnosis of IGBC with acute cholecystitis. Measurement of CEA and CA19-9 levels as tumor markers should be performed with caution, as false-positive results due to inflammation would be included.

To identify the risk factors and clinical results for acute cholecystitis after covered self-expandable metal stent （SEMS） placement for distal malignant biliary obstruction （MBO）, we have retrospectively examined the clinical outcomes in patients with acute cholecystitis after endoscopic biliary SEMS placement for distal MBO. This was a retrospective study. Between January 2014 and June 2017, 90 patients who were identified to have underwent endoscopic covered SEMS placement for distal MBO at our institution were included in this analysis. Patients with benign biliary strictures after cholecystectomy were excluded. After covered SEMS placement, we followed up with physical examination and laboratory data and continued with the follow-up for as long as possible. The risk factors for acute cholecystitis after covered SEMS placement were then evaluated. Acute cholecystitis was observed in 15 patients （17％） after covered SEMS placement. The median time to the onset of acute cholecystitis after covered SEMS placement was 19 days （interquartile range, 5-127 days）. Cholecystitis was initially treated with percutaneous gallbladder aspiration （PTGBA） in 11 patients, percutaneous gallbladder drainage （PTGBD） in 2 patients, and antimicrobial therapy alone in 2 patients. Five patients （including four patients treated with PTGBA and one patient treated with antimicrobial therapy alone） had cholecystitis recurrence. In a multivariate analysis of the risk factors for cholecystitis after covered SEMS placement, bile duct cancer （odds ratio （OR）, 12; P＝0.028）, thin bile duct diameter （≤8mm） （OR, 5.2; P＝0.048）, and chemotherapy （OR, 12.6; P＝0.008） were identified as the significant risk factors. Bile duct cancer, thin bile duct diameter, and chemotherapy were identified as risk factors for acute cholecystitis after endoscopic covered SEMS placement for distal MBO. PTGBA is useful as the initial treatment for acute cholecystitis after covered SEMS placement for distal MBO; however, cholecystitis recurrence should be taken into consideration.

Surgical resection for colorectal cancer（CRC）that deeply invades the submucosa（≥1,000µm）（T1b）has been recommended to reduce the potential risk of lymph node metastasis. In clinical settings, cases of pathological T1b exist, and these cases are treated with endoscopic resection（ER）for various reasons. However, factors that influence the choice of ER to treat T1b CRC remain unknown. Therefore, in this study, we investigated the factors associated with the choice of endoscopic treatments in patients diagnosed with pathological T1b or a more deeply invading CRC. To achieve this aim, we conducted a case series investigation of the previously conducted endoscopic diagnoses, after which we selected treatments for colorectal lesions. The case series comprised 83 lesions endoscopically diagnosed as early CRC, which was subsequently reviewed by eight endoscopists with various levels of experience in magnifying colonoscopy at Showa University Hospital. Then, pathological T1b or T2 lesions were extracted from the case series. We also assessed factors related to ER selection for these lesions using multiple logistic regression and analyzed their contributions using decision tree analysis. Eighteen cases with pathological T1b or more deeply invading lesions were extracted, and the analyses were conducted using 144 data obtained from these 18 lesions as interpreted by the eight reviewers. With multivariate logistic regression, a low estimation level for T1b and high confidence to perform ER were identified as independent factors affecting the selection of ER for T1b. The decision tree analysis further indicated that confidence levels to perform ER influenced treatment selection, especially in lesions diagnosed as probable T1b. Our study therefore demonstrated that factors affecting the selection of ER to treat T1b CRCs were low estimations during endoscopic diagnosis and high confidence to conduct the ER procedure.

Takahiro Fuji,1 Jun Arai,1 Yumi Otoyama,1 Yuta Nio,2,3 Ikuya Sugiura,1 Yoko Nakajima,1 Atsushi Kajiwara,1 Yuki Ichikawa,1 Shojiro Uozumi,1 Yuu Shimozuma,1 Manabu Uchikoshi,1 Masashi Sakaki,1 Hisako Nozawa,1 Kenji Momo,2 Tadanori Sasaki,3 Hitoshi Yoshida1 1Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, Tokyo, Japan; 2Department of Hospital Pharmaceutics, School of Pharmacy, Showa University Hospital, Tokyo, Japan; 3Department of Pharmacy, Showa University Hospital, Tokyo, JapanCorrespondence: Jun Arai, Department of Medicine, Division of Gastroenterology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan, Tel +81-3-3784-8535, Fax +81-3-3784-7553, Email araiguma10@med.showa-u.ac.jpAbstract: Systemic chemotherapy has shown a significant survival benefit in patients with hepatocellular carcinoma (HCC). However, it is associated with various immune-related adverse events (irAEs). We report a case with grade 3 diarrhea and grade 2 colitis following systemic chemotherapy, successfully treated with prednisolone. An 89-year-old man was incidentally detected with a 140-mm hypervascular intrahepatic nodule on contrast-enhanced computed tomography (CECT). Washout of the contrast medium was also detected, and protein induced by vitamin K deficiency or antagonists-II (PIVKA-II) was elevated. Since the Albumin–Bilirubin (ALBI) grade was 2a without any distant metastasis, transarterial chemoembolization (TACE) was performed to treat the HCC, but several intrahepatic nodules were seen in both lobes. Therefore, the patient was treated with lenvatinib for 1 year and 4 months. A complete response according to modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria was achieved in 2 months; however, multiple hypervascular nodules were detected again. Since the ALBI grade was 1, a second round of chemotherapy with atezolizumab and bevacizumab was initiated. Although a complete response was achieved, the therapy was discontinued due to grade 3 diarrhea and grade 2 colitis after the sixth course. Based on the stool analysis and culture, CECT, and colonoscopy, the diagnosis was atezolizumab-associated colitis. Diarrhea was controlled following the oral administration of 0.5 mg/kg/day of prednisolone, and atezolizumab-bevacizumab therapy was successfully reinitiated without recurrence of colitis. The management of irAEs is important for a significant survival benefit. Systemic chemotherapy with atezolizumab and bevacizumab can be resumed despite a grade 3 irAE due to atezolizumab.Keywords: hepatocellular carcinoma, immune checkpoint inhibitors, immune-related adverse events, ICI-mediated colitis, IL-17, PIVKA-II

This study is aimed at investigating the relationship between the polymeric immunoglobulin receptor （pIgR） expression and clinicopathological factors in advanced colorectal cancer （CRC） patients. The study involved 47 advanced CRC patients who were surgically resected and underwent KRAS gene test. The pIgR expression was analyzed by immunohistochemistry, and the patients were classified into high and low （pIgR-H and pIgR-L, respectively） groups based on the staining intensity and range. A total of 13 cases was classified under the pIgR-H group, and the remaining 34 were classified under the pIgR-L group. Results suggest no significant differences in most clinicopathological factors between the pIgR-H and pIgR-L groups, although the pIgR-L group had a significantly higher frequency of venous invasion than the pIgR-H group, whereas the frequency of KRAS gene mutation was significantly higher in the pIgR-H group than that in the pIgR-L group. The findings in this study showed little significant correlation between the pIgR expression and clinicopathological factors in advanced CRC patients. Further research on the biological behavior of pIgR as a drug treatment option for KRAS-mutated advanced CRCs is also warranted.