Microbial growth and metabolism also can more drastically improve herb efficacy, reduce toxicity, and expand indications than physical or chemical methods and can also improve the extraction, absorption, and utilization rate of the active ingredient (Zhang et al. 2012b).
Incidental evidence of FMT benefit in comorbidities may further expand indications to conditions previously not associated with gastrointestinal dysbiosis and for which therapeutic GiMb manipulation may play a role.
A modified influenza pandemic plan might include the following components: 1) Before a pandemic, expand indications for and decrease barriers to receipt of vaccination against S. pneumoniae (36 – 38, 40 ).
Gamma-hydroxybutyrate (GHB) is currently authorized by the European Medicines Agency EMAA) to treat narcolepsy with cataplexy in adults, and by the Food and Drug Administration FDAA) to treat cataplexy in patients with narcolepsy, with an expanded indication for the treatment of excessive daytime sleepiness.
Moreover, ESD for expanded indication is reported to be technically feasible from the aspect of short-term outcome [6, 7].
As the lesion fulfilled the expanded indication for ESD according to the Japanese gastric cancer treatment guidelines [3], we elected to perform ESD as recommended treatment.
Although the expanded indication for ESD for the treatment of early gastric cancer is based on the assumption of negligible lymph node involvement, the incidence of lymph node metastasis in cases of early gastric cancer with expanded indication is higher than that in cases where there is an absolute indication for ESD [4].
In contrast, studies have reported a comparable low risk of lymph node metastasis in cases with an absolute indication for endoscopic resection, compared to cases with expanded indication [5].
Herein, we present a didactic case of undifferentiated-type mucosal gastric cancer fulfilling the expanded indication and curative criteria for endoscopic submucosal dissection (ESD), having synchronous multiple lymph node metastases.
She received an upper gastrointestinal endoscopy and found to have an undifferentiated-type mucosal gastric cancer with the size of 15 mm in diameter without ulceration, which fulfilled the expanded indication for ESD.
