Long-term outcomes of autoimmune pancreatitis: a multicentre, international analysis

OBJECTIVE

Autoimmune pancreatitis (AIP) is a treatable form of chronic pancreatitis that has been increasingly recognised over the last decade. We set out to better understand the current burden of AIP at several academic institutions diagnosed using the International Consensus Diagnostic Criteria, and to describe long-term outcomes, including organs involved, treatments, relapse frequency and long-term sequelae.

DESIGN

23 institutions from 10 different countries participated in this multinational analysis. A total of 1064 patients meeting the International Consensus Diagnostic Criteria for type 1 (n=978) or type 2 (n=86) AIP were included. Data regarding treatments, relapses and sequelae were obtained.

RESULTS

The majority of patients with type 1 (99%) and type 2 (92%) AIP who were treated with steroids went into clinical remission. Most patients with jaundice required biliary stent placement (71% of type 1 and 77% of type 2 AIP). Relapses were more common in patients with type 1 (31%) versus type 2 AIP (9%, p<0.001), especially those with IgG4-related sclerosing cholangitis (56% vs 26%, p<0.001). Relapses typically occurred in the pancreas or biliary tree. Retreatment with steroids remained effective at inducing remission with or without alternative treatment, such as azathioprine. Pancreatic duct stones and cancer were uncommon sequelae in type 1 AIP and did not occur in type 2 AIP during the study period.

CONCLUSIONS

AIP is a global disease which uniformly displays a high response to steroid treatment and tendency to relapse in the pancreas and biliary tree. Potential long-term sequelae include pancreatic duct stones and malignancy, however they were uncommon during the study period and require additional follow-up. Additional studies investigating prevention and treatment of disease relapses are needed.

Asian diagnostic criteria for autoimmune pancreatitis: consensus of the Japan-Korea Symposium on Autoimmune Pancreatitis

In 2002, the Japan Pancreas Society (JPS) was the first in the world to propose diagnostic criteria for autoimmune pancreatitis (AIP). Since the concept of AIP has changed with the accumulation of AIP cases, the Research Committee of Intractable Pancreatic Diseases (RCIPD) provided by the Ministry of Health, Labour and Welfare of Japan and the JPS issued revised clinical diagnostic criteria of AIP in 2006. The Asan Medical Center of Korea also proposed diagnostic criteria for AIP in 2006. However, there are subtle but clinically challenging differences between the Japanese and Korean criteria. This inconsistency makes it difficult to compare data in studies from different centers and elucidate the characteristics of AIP. To reach a consensus on AIP, the RCIPD and the Korean Society of Pancreatobiliary Diseases established the following Asian criteria for the diagnosis of AIP: I-1. Imaging studies of pancreatic parenchyma show a diffuse/segmental/focally enlarged gland, occasionally with a mass and/or a hypoattenuation rim. I-2. Imaging studies of pancreaticobiliary ducts show diffuse/segmental/focal pancreatic ductal narrowing, often with stenosis of the bile duct. (Both I-1 and I-2 are required for diagnosis). II. Elevated level of serum IgG or IgG4, and detection of autoantibodies. III. Common lymphoplasmacytic infiltration and fibrosis, with abundant IgG4-positive cell infiltration. AIP should be diagnosed when criterion I and one of the other two criteria are satisfied, or when histology shows the presence of lymphoplasmacytic sclerosing pancreatitis in the resected pancreas. A diagnostic trial of steroid therapy can be applied carefully by expert pancreatologists only in patients fulfilling criterion I alone with negative diagnostic work-up results for pancreatobiliary cancer.

Clinical usefulness of carbohydrate antigen 19-9 as a screening test for pancreatic cancer in an asymptomatic population

BACKGROUND AND AIM

Although the prognosis for pancreatic cancer is generally poor, it is well known that the survival rate for resected pancreatic cancer is much higher than that for more conservative treatment. The importance of early detection is emphasized for resection of pancreatic cancer. Measurement of serum carbohydrate antigen (CA) 19-9 has shown satisfactory sensitivity and predictive value in symptomatic patients, but no available data has been found on healthy asymptomatic subjects. Thus, the authors aimed to determine the clinical usefulness of CA 19-9 as a screening tool for pancreatic cancer in asymptomatic subjects.

METHODS

From December 1994 to November 2000, 70 940 asymptomatic persons visiting the Health Promotion Center at the Samsung Medical Center, Seoul, Korea, participated. All subjects underwent abdominal ultrasonography and serum CA 19-9 measurement. The authors analyzed the sensitivity, specificity, and predictive values of CA 19-9 for detecting pancreatic cancer. Also, those subjects who had a serum CA 19-9 level above the cut-off value were followed up using a serial check of CA 19-9, computed tomography, or endoscopic retrograde cholangiopancreatography.

RESULTS

The number of subjects with a level of CA 19-9 above the cutoff of 37 U/mL was 1063 (1.5%), including four cases diagnosed with pancreatic cancer. The prevalence of pancreatic cancer over the age of 30 years is 13.66 per 100 000 population in Korea. Therefore, the sensitivity is 100% and the specificity 98.5%. However, the positive predictive value of CA 19-9 for detecting pancreatic cancer is only 0.9% in the asymptomatic population.

CONCLUSION

Mass screening for pancreatic cancer using CA 19-9 levels in asymptomatic subjects is ineffective because of a very low positive predictive value, despite its high sensitivity and specificity.

Clinical profile of autoimmune pancreatitis and its histological subtypes: an international multicenter survey

OBJECTIVE

The objective of this study was to clarify the clinical and pathophysiological characteristics of autoimmune pancreatitis (AIP) and its subtypes (lymphoplasmacytic sclerosing pancreatitis [LPSP] and idiopathic duct-centric pancreatitis [IDCP]) seen around the world.

METHODS

An international multicenter survey of AIP was conducted in 15 institutes from 8 countries. We compared clinical and pathologic profiles of AIP (n = 731) and the clinical profiles of LPSP (n = 204) and IDCP (n = 64) patients.

RESULTS

Patients with LPSP were approximately 16 years older than IDCP patients. Obstructive jaundice was a more frequent presentation in LPSP versus IDCP (75% vs 47%, P < 0.001), whereas abdominal pain (41% vs 68%, P < 0.001) and acute pancreatitis (5% vs 34%, P < 0.001) were more frequent in IDCP patients. Patients with LPSP were more likely to have diffuse swelling of the pancreas (40% vs 25%, P = 0.037) and elevated serum IgG4 levels (63% vs 23%, P < 0.001) but less likely to be associated with ulcerative colitis (1% vs 16%, P < 0.001). Clinical profiles of non-histologically confirmed AIP from Asia, the United States, and United Kingdom corresponded with that of LPSP, whereas those from Italy and Germany suggested a mixture of LPSP and IDCP.

CONCLUSIONS

Autoimmune pancreatitis is seen all around the world, with regional differences in the pathologic and clinical features. Lymphoplasmacytic sclerosing pancreatitis and IDCP have distinct clinical profiles.

Efficacy of EUS-guided and ERCP-guided biliary drainage for malignant biliary obstruction: prospective randomized controlled study

BACKGROUND AND AIMS

ERCP-guided biliary drainage (ERCP-BD) is a criterion standard treatment for malignant biliary obstruction when curative surgery is not an option. Alternative methods such as percutaneous transhepatic biliary drainage would significantly lower the quality of life. EUS-guided biliary drainage (EUS-BD) has been developed and performed by experienced endoscopists. Therefore, the aims of this study were to evaluate the efficacy and safety of EUS-BD compared with ERCP in malignant biliary obstruction.

METHODS

The prospective randomized controlled study was conducted, and 30 patients were enrolled: 15 for each EUS-BD and ERCP-BD arms. The technical success, procedural time, clinical success, and adverse events were evaluated.

RESULTS

Thirty patients had extrahepatic malignant biliary tract obstruction (19 men, 11 women). Twenty-seven patients had unresectable pancreatic ductal adenocarcinomas, 1 patient had distal common bile duct cancer, and 2 patients had metastatic malignant lymphadenopathy. There were no significant differences both in terms of technical success rate and clinical success rate (100% vs 93% and 93% vs 100% in ERCP-BD vs EUS-BD, respectively; P = 1.00, P = 1.00). Four patients (31%) had tumor ingrowth-caused stent dysfunction in the ERCP-BD group, whereas 2 patients had food impaction and 2 patients had stent migration in the EUS-BD group. No significant procedure-related adverse events occurred in either group.

CONCLUSIONS

This prospective randomized controlled study suggests that EUS-BD has similar safety to ERCP-BD. EUS-BD was not superior to ERCP-BD in terms of relief of malignant biliary obstruction. EUS-BD may have fewer cases of tumor ingrowth but may also have more cases of food impaction or stent migration. (Clinical trial registration number: NCT01421836.).

Cholangiocarcinoma and Clonorchis sinensis infection: a case-control study in Korea

BACKGROUND/AIMS

The authors conducted a hospital-based case-control study to evaluate the role of Clonorchis sinensis infection as a risk factor for the development of cholangiocarcinoma (CC), including extrahepatic CC, in Korea.

METHODS

Cases of 185 patients with CC (intrahepatic, 51; hilar, 53; and distal extrahepatic, 81) and matched controls underwent stool microscopy, pathological examinations, serologic test for C. sinensis using ELISA, skin test for C. sinensis, radiologic examinations, and interview concerning history of eating raw freshwater fish.

RESULTS

Radiologic evidence of C. sinensis, history of eating raw freshwater fish, and positive serologic result for C. sinensis were found to be related to an increased risk of CC, with the odds ratios (OR)=8.615 (95% confidence interval [CI]=5.045-16.062), OR=2.385 (95% CI=1.527-3.832), and OR=2.272 (95% CI=1.147-4.811), respectively. The risk factors for distal extrahepatic CC were radiologic evidence of C. sinensis (OR=6.571; 95% CI=3.170-15.943) and history of eating raw freshwater fish (OR=2.6; 95% CI=1.294-5.66).

CONCLUSIONS

Radiologic evidence of C. sinensis, history of eating raw freshwater fish and positive serologic result for C. sinensis were significantly associated with CC, including extrahepatic CC.

A prospective, comparative trial to optimize sampling techniques in EUS-guided FNA of solid pancreatic masses

BACKGROUND

There is no standardization of the use of suction during puncturing of a target in pancreatic EUS-guided FNA (EUS-FNA). It is also debatable whether expressing aspirates from the needle by the traditional method of reinserting the stylet is more effective than by air flushing, which is easier and safer.

OBJECTIVE

To optimize sampling techniques in pancreatic EUS-FNA.

DESIGN

Prospective, comparative trial.

SETTING

Tertiary-care referral center.

PATIENTS

Eighty-one consecutive patients with solid pancreatic masses.

INTERVENTION

Four punctures were performed for each mass in random order by a 2 × 2 factorial design. Sample quality and diagnostic yield were compared between samples with suction (S+) versus no suction (S-) and expressed by reinserting the stylet (RS) versus air flushing (AF).

MAIN OUTCOME MEASUREMENTS

Sample quality by the number of diagnostic samples, cellularity, bloodiness, and air-drying artifact; diagnostic yield by accuracy, sensitivity, and specificity.

RESULTS

The number of diagnostic samples (72.8% vs 58.6%; P = .001), cellularity (odds ratio [OR] 2.12; 95% confidence interval [CI], 1.37-3.30; P < .001), bloodiness (OR 1.46; CI, 1.28-1.68; P < .001), accuracy (85.2% vs 75.9%; P = .004), and sensitivity (82.4% vs 72.1%; P = .005) were higher in S+ than in S-. Bloodiness was lower in AF than in RS (OR 1.16; CI, 1.03-1.30; P = .017).

LIMITATIONS

Single-center trial, 2 kinds of needle gauges, and no immediate cytopathology evaluation.

CONCLUSION

Puncturing with suction and expressing by air flushing may be used preferentially in pancreatic EUS-FNA because they were more effective and convenient techniques. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01354795.).

Utility of 18F-FDG PET/CT for differentiation of autoimmune pancreatitis with atypical pancreatic imaging findings from pancreatic cancer

OBJECTIVE

This study was conducted to evaluate the clinical usefulness of PET/CT in differentiating autoimmune pancreatitis from pancreatic cancer.

MATERIALS AND METHODS

To differentiate autoimmune pancreatitis from pancreatic cancer, we analyzed the cases of 17 patients with autoimmune pancreatitis and atypical pancreatic imaging findings who underwent integrated PET/CT. The PET/CT findings on the 17 patients with autoimmune pancreatitis were compared with those of 151 patients with pancreatic cancer.

RESULTS

Fluorine-18 FDG uptake by the pancreas was found in all patients with autoimmune pancreatitis and in 82% (124/151) of patients with pancreatic cancer. Diffuse uptake by the pancreas was significantly more frequent in patients with autoimmune pancreatitis (53% vs 3%, p < 0.001). FDG uptake by the salivary glands and kidneys was seen only in patients with autoimmune pancreatitis, the former reaching statistical significance (p = 0.003). Follow-up PET/CT after steroid therapy was performed for eight patients with autoimmune pancreatitis. After steroid therapy, none of the patients had intense FDG uptake by the pancreas or extrapancreatic organs.

CONCLUSION

In difficult cases, at PET/CT the presence of diffuse uptake of FDG by the pancreas or concomitant extrapancreatic uptake by the salivary glands can be used to aid in differentiation of autoimmune pancreatitis and pancreatic cancer.

A Phase II study of gemcitabine and cisplatin in advanced biliary tract cancer

BACKGROUND

The authors performed a Phase II study of combination chemotherapy with gemcitabine and cisplatin in patients with inoperable biliary tract cancer to evaluate efficacy and toxicity of this combination. In addition, the correlation between the CA 19-9 response and clinical outcome was analyzed.

METHODS

The eligibility criteria for this study were 1) histologically or cytologically confirmed inoperable biliary tract cancer in patients with metastatic or recurrent disease; 2) age between 18 and 70 years; 3) at least 1 measurable lesion according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria; 4) an Eastern Cooperative Oncology Group (ECOG) performance status < or = 2; 5) a life expectancy of at least 3 mos; and 6) adequate bone marrow, hepatic, and renal function. The patients received gemcitabine (1250 mg/m(2), Days 1 and 8) and cisplatin (60 mg/m(2), Day 1) every 3 weeks. Tumor response was assessed by RECIST criteria every 2 cycles of chemotherapy. Treatment was continued until progression of disease was documented.

RESULTS

Twenty-nine patients were enrolled. The median age of these patients was 52 years (range, 37 to 69 yrs), and the median ECOG performance status was 1. No complete response was observed, and 10 of 29 patients had partial responses. The overall response rate was 34.5% (95% confidence interval [CI], 17.9-54.3) for the intent-to-treat analysis. Stable disease was observed in 4 (13.8%) patients and progressive disease in 13 (44.8%) patients. The median follow-up time was 10.0 months (95% CI, 7.2-12.8). The median time to progression (TTP) was 3.0 months (95% CI, 2.12-3.88), and the median overall survival was 11 months (95% CI, 5.49-16.5). Although these results showed a better response rate (57.1 % vs. 27.3%) and survival (12 vs. 10 mos) in patients with a decline in CA 19-9 of at least 25%, these data were statistically not significant. In addition, there was a significant positive correlation between the increment in CA 19-9 values and tumor progression as determined with RECIST criteria (r = 0.96, P < 0.01). However, there was no definite correlation between the CA 19-9 response and the response according to RECIST criteria (P = 0.087). National Cancer Institute (NCI) common toxicity criteria (CTC) Grade 3 or 4 hematologic toxicities included neutropenia in 4 (14%) patients and anemia in 1 (3%) patient. Two of 4 patients with Grade 3 or 4 neutropenia had febrile episodes (7%) and required hospital admissions. NCI-CTC Grade 3 or 4 nonhematologic toxicity included nausea in 1 (3%) patient. There were no treatment-related deaths.

CONCLUSION

The combination chemotherapy with gemcitabine and cisplatin in inoperable biliary tract cancer was tolerable for most patients and showed modest response rates. The role of CA 19-9 monitoring as a surrogate biomarker in patients with BTC treated with gemcitabine chemotherapy should be further investigated.

Clinicopathologic features of intraductal papillary neoplasm of the bile duct according to histologic subtype

OBJECTIVES

Despite an increase in the reports of intraductal papillary neoplasm of the bile duct (IPN-B), the clinical characteristics and long-term prognosis of this disease are not well known compared with those of intraductal papillary mucinous neoplasms of the pancreas. The objective of our study was to compare the clinical features, radiologic findings, and clinical outcomes of IPN-B according to histologic subtype.

METHODS

A retrospective analysis was performed on the medical records of 97 patients diagnosed with IPN-B by pathologic analysis of their surgical specimens between May 1995 and May 2010. We compared the clinical manifestations, radiological findings, pathologic grade, curative resection rate, recurrence, and overall survival according to four histologic subtypes: gastric (n=15), intestinal (n=46), pancreaticobiliary (n=33), and oncocytic (n=3), which were classified on the basis of hematoxylin and eosin staining and the immunohistochemical profile of mucin core proteins.

RESULTS

Mucin hypersecretion was significantly more frequent in patients with gastric and intestinal types than it was in those with oncocytic and pancreaticobiliary types (P=0.014). There were no significant differences between groups regarding the presence of bile duct stones or tumor location. The frequency of invasive carcinoma in the pancreaticobiliary type was significantly higher than those in the gastric and intestinal types (72.7 vs. 26.7 and 32.6%, P<0.001 and P<0.001). When comparing the survival curves according to histologic subtype, patients with pancreaticobiliary type demonstrated significantly worse survival compared to those with gastric and intestinal types (P=0.035).

CONCLUSIONS

Gastric and intestinal types of IPN-B have similar clinical characteristics compared with the pancreaticobiliary type, which has a worse prognosis.

Gene expression patterns in pancreatic tumors, cells and tissues

BACKGROUND

Cancers of the pancreas originate from both the endocrine and exocrine elements of the organ, and represent a major cause of cancer-related death. This study provides a comprehensive assessment of gene expression for pancreatic tumors, the normal pancreas, and nonneoplastic pancreatic disease.

METHODS/RESULTS

DNA microarrays were used to assess the gene expression for surgically derived pancreatic adenocarcinomas, islet cell tumors, and mesenchymal tumors. The addition of normal pancreata, isolated islets, isolated pancreatic ducts, and pancreatic adenocarcinoma cell lines enhanced subsequent analysis by increasing the diversity in gene expression profiles obtained. Exocrine, endocrine, and mesenchymal tumors displayed unique gene expression profiles. Similarities in gene expression support the pancreatic duct as the origin of adenocarcinomas. In addition, genes highly expressed in other cancers and associated with specific signal transduction pathways were also found in pancreatic tumors.

CONCLUSION

The scope of the present work was enhanced by the inclusion of publicly available datasets that encompass a wide spectrum of human tissues and enabled the identification of candidate genes that may serve diagnostic and therapeutic goals.

Differential diagnosis for intrahepatic biliary cystadenoma and hepatic simple cyst: significance of cystic fluid analysis and radiologic findings

GOALS

This study evaluated the significance of cystic fluid analysis and radiologic findings in the differential diagnosis of biliary cystadenomas (BCA) and hepatic simple cysts (HSCs).

BACKGROUND

BCA are premalignant lesions. The treatment of choice is surgical excision. It is important to differentiate BCA from HSCs because they have different clinical significances and treatment plans. However, it is difficult to preoperatively differentiate a BCA from a HSC.

STUDY

This retrospective study was done with 31 patients suffering from pathologically diagnosed BCA or HSC. All patients underwent surgery between May 1995 and June 2008 at a single institution and had cystic fluid analysis preoperatively or intraoperatively.

RESULTS

We discovered no statistically significant differences in cystic fluid carbohydrate antigen 19-9 (CA 19-9) levels or carcinoembryonic antigen levels when comparing BCA (n=17) and HSCs (n=14). BCA were significantly more frequently associated with female sex (17/17 vs. 10/14, P=0.032), presence of a septum (16/17 vs.5/14, P=0.001), and septal thickening (8/17 vs. 1/14, P=0.021). All 3 cases with calcifications belonged to the BCA group, but sample size was too small to demonstrate statistical significance. There were no statistically significant differences in other clinical and radiologic findings including age, presence of symptoms, serum tumor markers, serum chemistry, size, location, lobulation, septal enhancement, wall enhancement, wall thickening, mural nodule, or biliary dilatation.

CONCLUSIONS

Cystic fluid carbohydrate antigen 19-9 levels and carcinoembryonic antigen levels were not useful for differential diagnosis of BCA vs. HSC. BCA were more common than HSCs in females, patients with a septum, and patients with septal thickening.

Clinical characteristics of 327 Asian patients with autoimmune pancreatitis based on Asian diagnostic criteria

OBJECTIVES

To clarify the clinical and pathophysiological characteristics of autoimmune pancreatitis (AIP) in Asia.

METHODS

A retrospective, actual situation survey of AIP diagnosed by Asian criteria was conducted in 10 centers of Japan, Korea, Taiwan, China, and India.

RESULTS

A total of 327 AIP cases (258 male and 69 female subjects; average age, 60.0 years) were enrolled. Obstructive jaundice was the most frequent initial symptom (46%-74%), followed by weight loss (4%-51%) and abdominal pain (19%-44%). Diffuse swelling of the pancreas was frequent in Japan (64%) and Korea (81%), but segmental swelling of the pancreas was more frequent in Taiwan (70%) and China (72%) (P < 0.01). Serum immunoglobulin G4 levels were elevated in 58%-100% of cases in Japan, Korea, and Taiwan. Pathologically, almost all AIPs in Asia were lymphoplasmacytic sclerosing pancreatitis. Sclerosing cholangitis was the most frequent extrapancreatic lesion (60%-81%). Steroid therapy was a major and effective therapeutic strategy in Japan, Korea, and Taiwan. However, the rate of resection or bypass operation was higher in Taiwan (40%) and China (72%) (P < 0.01).

CONCLUSIONS

Features of AIP are fundamentally similar in Japan, Korea, Taiwan, and China. Knowledge of emerging AIP should be more widespread in Asia to avoid unnecessary operation.

Role of cyclooxygenase-2 and inducible nitric oxide synthase in pancreatic cancer

BACKGROUND AND AIM

Recently, it has been recognized that both cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) produce important endogenous factors of human tumor progression. However, the clinicopathological and biological significance of the expression of COX-2 and iNOS in pancreatic cancer remains unclear. The objective of this study is to find the possible roles and clinical significance of COX-2 and iNOS expression in pancreatic cancer.

METHODS

Seventy-two pancreatic adenocarcinoma tissue specimens were obtained through surgical resection. We investigated the immunohistochemical expression of COX-2 and iNOS in respect to variable clinicopathological characteristics, proliferation activity (by Ki-67 expression), apoptosis (by terminal deoxyribonucleotidyl transferase-mediated dUTP nick-end labeling stain), and microvessel density (by CD34 expression; angiogenesis).

RESULTS

Immunohistochemical investigations demonstrated immunolabeling of tumor cells with the primary antibodies, bovine anti-iNOS and anti-COX-2 antibodies. The COX-2 and iNOS positive rates were 41.7 and 66.7%, respectively. There was significant correlation between positive COX-2 and positive iNOS expression (P = 0.043). The proliferation index (Ki-67 labeling index) was higher in COX-2 positive specimens compared to COX-2 negative specimen (P = 0.015). The apoptotic index of positive iNOS expressions was significantly higher than negative expressions (P < 0.001). The expression of COX-2 and iNOS proteins did not correlate with age, sex, serum bilirubin, CA-19-9, location, size, American Joint Committee on Cancer stage, differentiation, distant metastasis, patient survival, or microvessel density.

CONCLUSIONS

Although the pattern of positive expression was similar in both enzymes, the effect on tumor progression differed; iNOS expression may play a role in apoptosis of tumor cell, while COX-2 expression may contribute to tumor proliferation. However, COX-2 and iNOS expression is not related to prognosis in patients with pancreatic cancer.

A Comparison of Preoperative Biliary Drainage Methods for Perihilar Cholangiocarcinoma: Endoscopic versus Percutaneous Transhepatic Biliary Drainage

BACKGROUND/AIMS

Controversy remains over the optimal approach to preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma. We compared the clinical outcomes of endoscopic biliary drainage (EBD) with those of percutaneous transhepatic biliary drainage (PTBD) in patients undergoing preoperative biliary drainage for perihilar cholangiocarcinoma.

METHODS

A total of 106 consecutive patients who underwent biliary drainage before surgical treatment were divided into two groups the PTBD group (n=62) and the EBD group (n=44).

RESULTS

Successful drainage on the first attempt was achieved in 36 of 62 patients (58.1%) with PTBD, and in 25 of 44 patients (56.8%) with EBD. There were no significant differences in predrainage patient demographics and decompression periods between the two groups. Procedure-related complications, especially cholangitis and pancreatitis, were significantly more frequent in the EBD group than the PTBD group (PTBD vs EBD 22.6% vs 54.5%, p<0.001). Two patients (3.8%) in the PTBD group experienced catheter tract implantation metastasis after curative resection during the follow-up period.

CONCLUSIONS

EBD was associated with a higher risk of procedure-related complications than PTBD. These complications were managed properly without severe morbidity; however, in the PTBD group, there were two cases of cancer dissemination along the catheter tract.

Farnesoid X receptor, overexpressed in pancreatic cancer with lymph node metastasis promotes cell migration and invasion

BACKGROUND

Lymph node metastasis is one of the most important adverse prognostic factors for pancreatic cancer. The aim of this study was to identify novel lymphatic metastasis-associated markers and therapeutic targets for pancreatic cancer.

METHODS

DNA microarray study was carried out to identify genes differentially expressed between 17 pancreatic cancer tissues with lymph node metastasis and 17 pancreatic cancer tissues without lymph node metastasis. The microarray results were validated by real-time PCR. Immunohistochemistry and western blotting were used to examine the expression of farnesoid X receptor (FXR). The function of FXR was studied by small interfering RNA and treatment with FXR antagonist guggulsterone and FXR agonist GW4064.

RESULTS

Farnesoid X receptor overexpression in pancreatic cancer tissues with lymph node metastasis is associated with poor patient survival. Small interfering RNA-mediated downregulation of FXR and guggulsterone-mediated FXR inhibition resulted in a marked reduction in cell migration and invasion. In addition, downregulation of FXR reduced NF-κB activation and conditioned medium from FXR siRNA-transfected cells showed reduced VEGF levels. Moreover, GW4064-mediated FXR activation increased cell migration and invasion.

CONCLUSIONS

These findings indicated that FXR overexpression plays an important role in lymphatic metastasis of pancreatic cancer and that downregulation of FXR is an effective approach for inhibition of pancreatic tumour progression.

Can endoscopic resection be applied for early stage ampulla of Vater cancer?

BACKGROUND

Although endoscopic resection can provide a wide tumor resection with a negative resection margin, it is not yet recommended as a curative therapy for ampulla of Vater cancer.

METHODS

To investigate the microinvasion rate and the diagnostic accuracy of endoscopic biopsy to properly judge the safety of endoscopic resection for ampulla of Vater cancer.

DESIGN

Single-center, retrospective study.

SETTING

Academic medical center.

PATIENTS

One hundred fifty-nine patients who were finally diagnosed with ampulla of Vater cancer after curative surgical resection.

INTERVENTIONS

We surveyed the pathologic concordance rate of endoscopic biopsy and the surgical pathology. For the 36 early stage (Tis or T1) cancers, we surveyed the presence of microlymphovascular invasion, gross appearance (intra-ampullary type, periampullary type, or mixed type), and pathologic subtype (intestinal type or pancreaticobiliary type).

MAIN OUTCOME MEASUREMENTS

Presence of microinvasion in early staged ampulla of Vater cancer.

RESULTS

Endoscopic biopsy failed to reveal malignancy in 15.9% of the 126 cases. Microlymphovascular invasion was present in 17 cases (56.7%) of the 30 T1 cancers but was absent in all cases of the 6 Tis cancers (P = .02). Neither the gross appearance (P = .51) nor the pathologic subtype (P = .28) could predict the microinvasion rate.

LIMITATIONS

Single-center, retrospective study with small number of patients.

CONCLUSIONS

Although endoscopic resection improves the low predictability of endoscopic biopsy, surgical resection should be performed for the T1 stage ampulla of Vater cancer because of the high lymphovascular invasion rate. On the other hand, the safety of endoscopic resection should be evaluated by a large-scale study on Tis cancers to consider the absence of microinvasion.

Behavior of Small, Asymptomatic, Nonfunctioning Pancreatic Neuroendocrine Tumors (NF-PNETs)

Small nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) usually exhibit minimal or no growth over many years. However, there is a controversy regarding the optimal management of incidentally discovered, small NF-PNETs. This study aimed to gain insights into tumor behavior and potential strategies for clinical management.We retrospectively reviewed a total of 202 patients with a suspected PNET (size 2 cm or smaller) at Samsung Medical Center from January 1, 1995 to April 30, 2012. Among these patients, 72 patients were excluded and 145 patients were enrolled in our study. Patients were included if the size of the tumor was ≤2 cm without familial syndrome, radiographic evidence of local invasion or metastases.Among the 145 patients, 76 patients (52.4%) had pathologically confirmed PNETs. Eleven (14.5%) and 3 (3.9%) of these 76 patients were diagnosed with NET G2 and G3, respectively. PNETs measuring 1.5 cm or more in size had a higher probability of being classified as NET G2 or G3 compared with PNETs measuring <1.5 cm (P = 0.03). Older age (≥55 years) and a meaningful tumor growth (≥20% or ≥5 mm) were significantly associated with NET G2 or G3 (P < 0.05).Older age (≥55 years), larger tumor size (≥1.5 cm), and a meaningful tumor growth (≥20% or ≥5 mm) were associated with NET G2 or G3. Intensive follow-up could be an acceptable approach in small (especially <1.5 cm), asymptomatic, NF-PNETs.

A prospective, randomized trial comparing 25-gauge and 22-gauge needles for endoscopic ultrasound-guided fine needle aspiration of pancreatic masses

OBJECTIVES

Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is widely performed for pancreatic masses. The 25-gauge needle (25G) might be easier to be manipulated and expected to be associated with fewer complications since it is thinner and more flexible than the 22-gauge needle (22G) although obtaining adequate specimens is questioned. In this randomized trial, the authors tried to compare prospectively 25G and 22G in diagnostic accuracy, manipulability from the operator's viewpoint and procedure-related complications.

MATERIAL AND METHODS

A total of 188 consecutive patients undergoing EUS-FNA for solid or cystic pancreatic masses were consecutively enrolled and 94 patients were randomized to either 25G or 22G group, respectively.

RESULTS

Baseline characteristics were similar except that more masses of 25G group were located in the head or uncinate process of pancreas than those from 22G group. Although there was no difference in diagnostic accuracy (89.4% vs. 88.3% with p = 0.82), 25G was easier to be manipulated (p = 0.004) and related with fewer procedure-related complications (10.6% vs. 3.2% with p = 0.004).

CONCLUSIONS

25G can be chosen in preference to 22G when performing pancreatic EUS-FNA because 25G was significantly superior to 22G in terms of manipulability and complications although both were effective for accurate diagnosis.

Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis?

GOALS

To evaluate the safety, efficacy, and long-term outcome of percutaneous cholecystostomy without additional cholecystectomy as a definitive treatment for acute acalculous cholecystitis (AAC).

BACKGROUND

AAC mainly occurs in seriously ill patients, and for those considered to be at high-risk for cholecystectomy, immediate percutaneous cholecystostomy can be a simple alternative interim treatment. However, no consensus has been reached on the issue of additional cholecystectomy.

STUDY

The medical records of 57 patients that underwent percutaneous cholecystostomy for AAC at a single institution between 1995 and 2010 were retrospectively analyzed.

RESULTS

Percutaneous cholecystostomy was technically successful in all patients, and no major complications relating to the procedure were encountered. Symptoms resolved within 4 days in 53 of the 57 (93%) patients. The in-hospital mortality rate was 21% (11/57) and elective cholecystectomy was performed in 18/57 (31%). Twenty-eight patients were managed non-operatively and cholecystostomy tubes were subsequently removed. These 28 patients were follow-up over a median 32 months and recurrent cholecystitis occurred in 2 (7%).

CONCLUSION

Percutaneous cholecystostomy is an effective procedure and a good alternative for patients unfit to undergo immediate surgery because of severe sepsis or an underlying comorbidity. After patients with AAC have recovered from percutaneous cholecystostomy, further treatment such as cholecystectomy might not be needed.

Intraductal papillary mucinous tumour of the pancreas: differentiation of malignancy and benignancy by CT

AIM

To retrospectively identify signs predictive of malignant intraductal papillary mucinous tumour (IPMT) of the pancreas on computed tomography (CT) images.

MATERIALS AND METHODS

Thirty-four benign and 21 malignant pancreatic IPMTs were evaluated. Preoperative helical CT images in these 55 cases of pathologically proven pancreatic IPMT were reviewed by two radiologists unaware of the histological grading. Tumour morphological types, locations, numbers and sizes of cystic lesions, maximum main pancreatic duct diameters, the presence of septa, mural nodule, wall thickening, and calcification in cysts, communication with the main pancreatic duct, peripancreatic haziness, protrusion of duodenal papilla, pancreatic atrophy, lymphadenopathy and distant metastasis were analysed using univariate and multivariate analysis.

RESULTS

Main duct IPMTs were more likely to be malignant (71%) than branch duct (23%) or combined type IPMTs (28%; p=0.002). Among the branch duct type and combined types, large cystic lesion (p=0.018), the presence of a mural nodule (p=0.018), a thickened wall (p=0.009), and peripancreatic haziness (p=0.039) were found to predict malignancy.

CONCLUSION

CT is helpful in the preoperative differentiation of malignant and benign pancreatic IPMT. The presence of a dilated main pancreatic duct, mural nodules, thickened wall and peripancreatic haziness may be used as independent predictive signs of malignancy.

Gene expression profiles in gallbladder cancer: the close genetic similarity seen for early and advanced gallbladder cancers may explain the poor prognosis

There is currently no data available about the gene expression profiles of gallbladder cancer. The purpose of this study was to identify potential markers for gallbladder cancer and to examine the genetic differences between early and advanced gallbladder cancers. Total RNA was extracted from 17 gallbladder tissue specimens, including 6 advanced gallbladder cancers, 6 early gallbladder cancers and 5 normal control samples. The genes were localized with DNA microarrays and their presence was verified by performing real-time PCR. When the gallbladder cancer isolates were compared to the normal control samples, we identified 4,682 genes, including 2,270 that were overexpressed genes and 2,412 that were underexpressed genes in the gallbladder cancer. We selected 9 overexpressed genes (SERPINB5, BCL10, CD44, ARHGEF11, SERPINB2, RELA, PAK4, PPARD and BUB1B) and 1 underexpressed gene (CAV2) for real-time PCR analysis. When the advanced gallbladder cancer isolates were compared with the early gallbladder cancer isolates, we identified only 12 genes with greater than a 1.7-fold change in gene expression. We have identified several genes that may be tumor markers for gallbladder cancer. The close genetic similarity found between the early and advanced gallbladder cancers may help explain the poor prognosis of this disease.

Intraductal papillary neoplasm of the bile duct associated with Clonorchis sinensis infection

Intraductal papillary neoplasm of bile duct (IPNB) is one of the precursor lesions of cholangiocarcinoma. Although hepatolithiasis has been extensively studied in its association with IPNBs, there had been no comprehensive study of IPNBs with Clonorchis sinensis infection. Twelve IPNBs were selected from 20 surgically resected cholangiocarcinomas, positive for C. sinensis tests (60%) and compared with eight IPNBs, selected from 51 resected cholangiocarcinomas, negative for C. sinensis tests (16%), by histologic and immunohistochemical studies of mucin core proteins and cytokeratin panels. The predominant immuno-phenotype of IPNB cases with Clonorchiasis was pancreatobiliary type (MUC1+/MUC2-/CDX2-; 9/12 cases), while that of IPNB cases with negative for C. sinensis was intestinal type (MUC1-/MUC2+/CDX2+; 6/8; p = 0.04). The prevalence of IPNBs was higher when patients with cholangiocarcinoma had Clonorchiasis. IPNBs with Clonorchiasis tended to have a more pancreatobiliary phenotype, which suggests IPNBs with Clonorchiasis may have a different tumorigenesis pathway from IPNBs with other etiologies.

Intraductal papillary neoplasm of the bile ducts: description of MRI and added value of diffusion-weighted MRI

PURPOSE

To evaluate MRI features of intraductal papillary neoplasm of the bile duct (IPNB) and to determine added value of diffusion-weighted MRI (DWI).

METHODS

Twenty-three patients with surgically confirmed invasive (n = 12) and non-invasive (n = 11) IPNB, who underwent preoperative liver MRI were included. Two observers performed consensus review of gadoxetic acid-enhanced MRI and combined gadoxetic acid-enhanced MRI including DWI separately, with regard to conspicuity of intraductal tumor using five point scales, extent of tumors, and the presence of invasiveness.

RESULTS

On MRI, there was no significant difference in the conspicuity of intraductal tumors between gadoxetic acid MRI (mean, 4.35) and combined MRI (mean, 4.65) (P = 0.09). However, addition of DWI led seven cases revealed excellent conspicuity as compared with good or moderate conspicuity on gadoxetic acid MRI. With regard to invasiveness, 11 cases (48 %) and 17 (74 %) were correctly diagnosed with gadoxetic acid MRI and combined MRI, respectively (P = 0.06). In invasive tumors, both of the two image sets did not help assess accurate extent of the tumor.

CONCLUSIONS

The addition of DWI to gadoxetic acid-enhanced MRI has a potency to improve conspicuity for intraductal tumors of IPNB and is helpful in determining tumor invasiveness, but not tumor extent.

Safety and effectiveness of central venous catheterization in patients with cancer: prospective observational study

This study investigated the safety and effectiveness of each type of central venous catheters (CVC) in patients with cancer. We prospectively enrolled patients with cancer who underwent catheterization involving a subclavian venous catheter (SVC), peripherally inserted central venous catheter (PICC), or chemo-port (CP) in our department. From March 2007 to March 2009, 116 patients underwent 179 episodes of catheterization. A SVC was inserted most frequently (46.4%). Fifty-four complications occurred (30.1%): infection in 23 cases, malpositioning or migration of the tip in 18 cases, thrombosis in eight cases, and bleeding in five cases. Malpositioning or migration of the tip occurred more frequently with a PICC (P<0.001); infection occurred more often with a tunneled catheter (P=0.028) and was observed more often in young patients (P=0.023). The catheter life span was longer for patients with solid cancer (P=0.002) than for those with hematologic cancer, with a CP (P<0.001) than a PICC or SVC, and for an indwelling catheter with image guidance (P=0.014) than a blind procedure. In conclusion, CP is an effective tool for long term use and the fixation of tip is important for the management of PICC.