Circular RNA circ-LDLRAD3 as a biomarker in diagnosis of pancreatic cancer

AIM

To analyze the diagnostic value of a circular RNA (circRNA), circ-LDLRAD3, in pancreatic cancer.

METHODS

Expression levels of circ-LDLRAD3 were tested in both cells and clinical samples; the latter included 30 paired pancreatic cancer tissues and adjacent non-tumorous tissues, 31 plasma samples from patients with pancreatic cancer, and 31 plasma samples from healthy volunteers. Real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed to measure expression levels of circ-LDLRAD3 in cells and clinical samples; then, the relationship between clinicopathological factors of patient samples and expression of circ-LDLRAD3 in pancreatic cancer was analyzed. The diagnostic value of circ-LDLRAD3 was verified by receiver operating characteristic (ROC) curve analysis.

RESULTS

Circ-LDLRAD3 was up-regulated in pancreatic cancer cell lines (P < 0.01), pancreatic cancer tissues (P < 0.01), and plasma samples from patients with pancreatic cancer (P < 0.01). High expression of circ-LDLRAD3 was significantly associated with venous invasion, lymphatic invasion, and metastasis. The area under the ROC curve of circ-LDLRAD3 alone or combination with CA19-9 was 0.67 and 0.87, respectively, with a sensitivity and specificity of 0.5738 (alone) and 0.7049 (alone), and 0.8033 (combination) and 0.9355 (combination), respectively.

CONCLUSION

These data suggest that circ-LDLRAD3 may be a biomarker in the diagnosis of pancreatic cancer.

Endoscopic ultrasound-guided interstitial brachytherapy of unresectable pancreatic cancer: results of a pilot trial

BACKGROUND AND STUDY AIMS

Intraoperative interstitial brachytherapy has been found to be effective when used during laparotomy to improve local control in patients with locally advanced pancreatic cancer. In this study, we report the results of using endoscopic ultrasound- (EUS-)guided interstitial brachytherapy in patients with advanced pancreatic cancer, with respect to tumor response, clinical response, safety, and complications.

PATIENTS AND METHODS

Fifteen patients (eight men, seven women; median age 61 years) with unresectable pancreatic adenocarcinoma were enrolled into the study, eight patients with stage III disease and seven patients with stage IV disease. A mean number of 22 radioactive seeds per patient were implanted into the tumors by EUS-guided needle puncture. The mean total implanted activity was 20 mCi, the minimum peripheral dose was 14,000 cGy, and the mean volume of implants was 52 cm3. Patients were followed-up by examination and by imaging tests every 2-3 months: clinical end points included the Karnofsky performance status and pain responses, tumor response (assessed by computed tomography and/or EUS), and survival.

RESULTS

During a median follow-up period of 10.6 months, the objective tumor response was classified as "partial" in 27% of patients (with a median duration of partial response of 4.5 months), "minimal" in 20% patients, and indicative of "stable disease" in 33% of patients. Clinical benefit was shown in 30% of patients, mostly due to reduction in pain, but this lasted for a limited time. Local complications (pancreatitis and pseudocyst formation) occurred in three patients; grade III hematologic toxicity occurred in three patients without serious clinical sequelae.

CONCLUSIONS

EUS-guided intraoperative interstitial brachytherapy had a moderate local tumor effect and showed some clinical benefit in 30% of the patients in this study. Combination of this form of treatment with external radiation and/or chemotherapy should be tested in future trials.

A multi-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy

There is a lack of consensus on how endoscopic ultrasound (EUS)-guided pseudocyst drainage and endoscopic necrosectomy should be performed. This survey was carried out amongst members of the EUS Journal Editorial Board to describe their practices in performing this procedure. This was a worldwide multi-institutional survey amongst members of the EUS Journal Editorial Board in May 2017. The responses to a 22-question survey with respect to the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy were obtained. Twenty-two endoscopists responded to the questionnaire as follows: 72.7% (16/22) were of the opinion that lumen-apposing metal stents (LAMS) should be the standard of care for the creation of an endoscopic cystenterostomy in patients with pancreatic walled-off necrosis (WON); 95.5% (21/22) recommended large diameter (d=15 mm) LAMS for drainage in patients with WON; 54.5% (12/22) would not dilate LAMS after placement into the WOPN; 86.4% (19/22) would not perform endoscopic necrosectomy during the same procedure as the creation of the cystenterostomy; 45.5% (10/22) recommend that agents, such as diluted hydrogen peroxide, should be used to lavage the peri-pancreatic fluid collection (PFC) cavity in patients with WON; and 45.5% (10/22) considered a naso-cystic or other tube to be necessary for lavage of WON after initial drainage. The mean optimal interval recommended for endoscopic necrosectomy procedures after EUS-guided drainage was 6.23 days. The mean optimal interval recommended for repeat imaging in patients undergoing endoscopic necrosectomy was 12.32 days. The mean time recommended for LAMS removal was 4.59 weeks. This is the first worldwide survey on the practice of EUS-guided pseudocyst drainage and endoscopic necrosectomy. There were wide variations in practice and randomized studies are urgently needed to establish the best approach for management of this condition. There is also a pressing need to establish a best practice consensus.

Endoscopic full-thickness resection with defect closure using an over-the-scope clip for gastric subepithelial tumors originating from the muscularis propria

BACKGROUND

Endoscopic full-thickness resection (EFTR) is a mini-invasive technique for gastric subepithelial tumors originating from the muscularis propria, which enables a full-thickness resection of tumors and can provide a complete basis for pathological diagnosis. Gastric fistula closure after EFTR is a challenge for endoscopists. In this study, we introduced EFTR with fistula closure using the over-the-scope clip (OTSC) system for gastric subepithelial tumors originating from the muscularis propria.

OBJECTIVES

To evaluate the feasibility and safety of fistula closure with OTSC by a retrospective analysis on the cases of EFTR with defect closure using OTSC for gastric subepithelial tumors originating from the muscularis propria in our hospital.

METHODS

The patients were selected who underwent EFTR for gastric subepithelial tumors originating from the muscularis propria (tumor diameter ≤2 cm) in our hospital from October 2013 to March 2014. After a full-thickness resection of tumors, the bilateral gastric mucous membranes of defect were clamped using twin graspers and then drawn into the transparent cap of OTSC, and the OTSC was released to close the defect after full suctioning. The success rate of defect closure with OTSC was observed, and the endoscopic follow-up was performed at 1 week, 1 and 6 months after operation to check OTSC closure.

RESULTS

Totally 23 patients were included into the study. The full-thickness resection rate of gastric tumors in the muscularis propria was 100 % (23/23), the success rate of defect closure was 100 %, and the average time of defect closure was 4.9 min (range 2-12 min). All patients experienced no postoperative complications such as bleeding and perforation. The postoperative follow-up time was 1-6 months (mean 3 months), and no OTSC detachment was found.

CONCLUSIONS

OTSC can be used to perform EFTR with defect closure for gastric tumors in the muscularis propria (tumor diameter ≤2 cm). It is simple, convenient, safe and effective.

Endoscopic band ligation of small gastric stromal tumors and follow-up by endoscopic ultrasonography

BACKGROUND

Gastrointestinal stromal tumor (GIST) is a relatively common gastric submucosal tumor with potential for malignant transformation. The efficacy of a new method for resection of these tumors, endoscopic band ligation, was evaluated.

METHODS

The study included 29 patients with small gastric stromal tumors arising in the gastric muscularis propria as determined by endoscopy, endoscopic ultrasonography (EUS), and deep endoscopic biopsies. A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. Beginning two weeks after banding, the lesions were observed endoscopically once per week until healing was complete. Thereafter, all patients underwent EUS every two to three months on schedule.

RESULTS

The 28 GISTs sloughed completely. The mean time required for complete healing after band ligation was 4.8 weeks. One lesion did not slough because they were not completely ligated. The lesion was ligated for the second time and sloughed completely. Bleeding occurred in one patient three days after ligation because the lesion sloughed early. The bleeding was managed successfully with metallic clips. No perforation and other complications occurred. Followup ranged from 36 to 51 months, during which time only one recurrence was observed four months postoperatively.

CONCLUSIONS

Endoscopic band ligation with systematic followup by EUS is an effective and safe treatment for small GISTs.

Use of endoscopic ultrasound-guided injection in endoscopic resection of solid submucosal tumors

AIMS

Submucosal tumor (SMT) is a common disease. We used endoscopic ultrasound (EUS)-guided puncture to inject saline before resection of SMTs, and evaluated the usefulness of this method.

PATIENTS AND METHODS

We selected 16 symptomatic patients with solid SMTs in the upper gastrointestinal tract, confirmed by endoscopy and EUS. We first used EUS-guided puncture to inject saline to separate the submucosal lesions from the deeper normal tissues. Lesions in the muscularis mucosa and submucosa were then removed directly by snare cauterization. Lesions in the muscularis propria were treated by means of a two-step approach: first, we incised the superficial tissue of the tumors using an electrosurgical needle, and second, we enucleated SMTs as much as possible by tightening the snare around them and creating pseudo-stalks. After snare excision of SMTs, the cleavages of the superficial tissues were closed using metal clips.

RESULTS

Among the 16 patients, one lesion was in the muscularis mucosa, six were in the submucosa, and nine were in muscularis propria. All the lesions were resected thoroughly. No perforation occurred nor had any recurrences been observed at follow-up of 12 - 17 months.

CONCLUSIONS

EUS-guided puncture to inject saline before resection is a safe and accurate procedure in the treatment of submucosal tumors.

Endoscopic band ligation without electrosurgery: a new technique for excision of small upper-GI leiomyoma

BACKGROUND

Leiomyoma is a relatively common submucosal tumor in the upper-GI tract. The efficacy of a new method for resection of these tumors, endoscopic band ligation, was evaluated.

METHODS

The study included 59 patients with 64 small upper-GI leiomyomas arising in the muscularis propria as determined by endoscopy, EUS, and EUS-guided FNA. The distribution of the 64 leiomyomas was the following: esophageal, 50; gastric, 12; duodenal, 2. A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. Beginning 2 weeks after banding, the lesions were observed endoscopically once per week until healing was complete.

RESULTS

The 50 esophageal leiomyomas sloughed completely. The mean time required for complete healing after band ligation was 3.6 weeks. Nine of the 12 gastric leiomyomas sloughed completely; the resulting ulcer defect was healed at a mean of 4.5 weeks. The other 3 lesions did not slough because they were not completely ligated. The two duodenal lesions sloughed completely after banding, and the mean time until healing of the defect was 4.5 weeks. No perforation occurred. Follow-up ranged from 16 to 31 months, during which time no recurrence was observed.

CONCLUSIONS

Endoscopic band ligation is an effective and safe treatment for small upper-GI leiomyoma.

EUS-guided interstitial brachytherapy of the pancreas: a feasibility study

BACKGROUND

Intraoperative interstitial brachytherapy has been effective when used at laparotomy to improve local control in locally advanced pancreatic cancer. Our aim in this study was to investigate the feasibility and the safety of EUS-guided brachytherapy of the pancreas in a porcine model.

METHODS

A modified 18-gauge needle with radioactive seeds was inserted, under EUS guidance, into the pancreas. The radioactive seeds were implanted into the tissue by the needle. After 14 days of clinical observation, the animals were euthanized, and the tissue response to brachytherapy was examined.

OBSERVATIONS

All the seeds were successfully implanted, and no migration occurred. Localized tissue necrosis and fibrosis was achieved in the pancreas, without significant complication. One pig had mild hyperlipasemia. Biochemical parameters were normal in the remaining pigs.

CONCLUSIONS

EUS-guided implantation of radioactive seeds is a safe, simple, and minimally invasive technique for interstitial brachytherapy.

A multi-institution consensus on how to perform EUS-guided biliary drainage for malignant biliary obstruction

BACKGROUND AND OBJECTIVES

EUS-guided biliary drainage (EUS-BD) was shown to be useful for malignant biliary obstruction (MBO). However, there is lack of consensus on how EUS-BD should be performed.

METHODS

This was a worldwide multi-institutional survey among members of the International Society of EUS conducted in February 2018. The survey consisted of 10 questions related to the practice of EUS-BD.

RESULTS

Forty-six endoscopists of them completed the survey. The majority of endoscopists felt that EUS-BD could replace percutaneous transhepatic biliary drainage after failure of ERCP. Among all EUS-BD methods, the rendezvous stenting technique should be the first choice. Self-expandable metal stents (SEMSs) were recommended by most endoscopists. For EUS-guided hepaticogastrostomy (HGS), superiority of partially-covered SEMS over fully-covered SEMS was not in agreement. 6-Fr cystotomes were recommended for fistula creation. During the HGS approach, longer SEMS (8 or 10 cm) was recommended. During the choledochoduodenostomy approach, 6-cm SEMS was recommended. During the intrahepatic (IH) approach, the IH segment 3 was recommended.

CONCLUSION

This is the first worldwide survey on the practice of EUS-BD for MBO. There were wide variations in practice, and randomized studies are urgently needed to establish the best approach for the management of this condition.

Endoscopic ultrasound: Elastographic lymph node evaluation

Different imaging techniques can bring different information which will contribute to the final diagnosis and further management of the patients. Even from the time of Hippocrates, palpation has been used in order to detect and characterize a body mass. The so-called virtual palpation has now become a reality due to elastography, which is a recently developed technique. Elastography has already been proving its added value as a complementary imaging method, helpful to better characterize and differentiate between benign and malignant masses. The current applications of elastography in lymph nodes (LNs) assessment by endoscopic ultrasonography will be further discussed in this paper, with a review of the literature and future perspectives.

Pan-cancer Landscape of the RUNX Protein Family Reveals their Potential as Carcinogenic Biomarkers and the Mechanisms Underlying their Action

BACKGROUND

The RUNX family of transcription factors plays an important regulatory role in tumor development. Although the importance of RUNX in certain cancer types is well known, the pan-cancer landscape remains unclear.

MATERIALS AND METHODS

Data from The Cancer Genome Atlas (TCGA) provides a pan-cancer overview of the RUNX genes. Hence, herein, we performed a pan-cancer analysis of abnormal RUNX expression and deciphered the potential regulatory mechanism. Specifically, we used TCGA multi-omics data combined with multiple online tools to analyze transcripts, genetic alterations, DNA methylation, clinical prognoses, miRNA networks, and potential target genes.

RESULTS

RUNX genes are consistently overexpressed in esophageal, gastric, pancreatic, and pan-renal cancers. The total protein expression of RUNX1 in lung adenocarcinoma, kidney renal clear cell carcinoma (KIRC), and uterine corpus endometrial carcinoma (UCEC) is consistent with the mRNA expression results. Moreover, increased phosphorylation on the T14 and T18 residues of RUNX1 may represent potential pathogenic factors. The RUNX genes are significantly associated with survival in pan-renal cancer, brain lower-grade glioma, and uveal melanoma. Meanwhile, various mutations and posttranscriptional changes, including the RUNX1 D96 mutation in invasive breast carcinoma, the co-occurrence of RUNX gene mutations in UCEC, and methylation changes in the RUNX2 promoter in KIRC, may be associated with cancer development. Finally, analysis of epigenetic regulator co-expression, miRNA networks, and target genes revealed the carcinogenicity, abnormal expression, and direct regulation of RUNX genes.

CONCLUSIONS

We successfully analyzed the pan-cancer abnormal expression and prognostic value of RUNX genes, thereby providing potential biomarkers for various cancers. Further, mutations revealed via genetic alteration analysis may serve as a basis for personalized patient therapies.

Consensus on the digestive endoscopic tunnel technique

With the digestive endoscopic tunnel technique (DETT), many diseases that previously would have been treated by surgery are now endoscopically curable by establishing a submucosal tunnel between the mucosa and muscularis propria (MP). Through the tunnel, endoscopic diagnosis or treatment is performed for lesions in the mucosa, in the MP, and even outside the gastrointestinal (GI) tract. At present, the tunnel technique application range covers the following: (1) Treatment of lesions originating from the mucosal layer, e.g., endoscopic submucosal tunnel dissection for oesophageal large or circular early-stage cancer or precancerosis; (2) treatment of lesions from the MP layer, per-oral endoscopic myotomy, submucosal tunnelling endoscopic resection, etc.; and (3) diagnosis and treatment of lesions outside the GI tract, such as resection of lymph nodes and benign tumour excision in the mediastinum or abdominal cavity. With the increasing number of DETTs performed worldwide, endoscopic tunnel therapeutics, which is based on DETT, has been gradually developed and optimized. However, there is not yet an expert consensus on DETT to regulate its indications, contraindications, surgical procedure, and postoperative treatment. The International DETT Alliance signed up this consensus to standardize the procedures of DETT. In this consensus, we describe the definition, mechanism, and significance of DETT, prevention of infection and concepts of DETT-associated complications, methods to establish a submucosal tunnel, and application of DETT for lesions in the mucosa, in the MP and outside the GI tract (indications and contraindications, procedures, pre- and postoperative treatments, effectiveness, complications and treatments, and a comparison between DETT and other operations).

Factors associated with endoscopic full-thickness resection of gastric submucosal tumors

OBJECTIVE

To identify factors that impact the procedure and treatment outcomes for endoscopic full-thickness resection (EFTR) of gastric submucosal tumors (SMTs).

METHODS

Medical records were collected for all patients with gastric SMTs who underwent EFTR procedures in Shengjing Hospital between June 2012 and April 2014. The data from each patient were reviewed, including gender, age, maximum tumor size on endoscopic ultrasound (EUS), tumor location in stomach, length of EFTR procedure, pneumoperitoneum during EFTR, cost to close defects, length of hospital stay after the procedure, and procedure-related complications.

RESULTS

Endoscopic full-thickness resection of gastric SMTs was successfully performed in all 41 patients. Maximum size on EUS [parameter estimate (PE) = 4.443, 95% confidence interval (CI) 2.191-6.695; p = 0.000] and tumor location in the greater curvature (PE = 44.441, 95% CI 5.539-83.343; p = 0.026) were significantly associated with the length of the procedure. A pneumoperitoneum was more likely to occur during EFTR in tumors with a larger EUS size [odds ratio (OR) = 1.415, 95% CI 1.034-1.936; p = 0.03], and less likely to occur during EFTR for tumors located in the posterior wall (OR = 0.003, 95% CI 0-0.351; p = 0.017). The use of the over-the-scope clip (OTSC) system was significantly associated with shorter hospital stays (PE = -1.006, 95% CI -1.998 to -0.014; p = 0.047) and a higher cost of closing defects (PE = 854.742, 95% CI 358.377-1351.107; p = 0.001).

CONCLUSIONS

Endoscopic full-thickness resection is an effective and safe method for removing gastric SMTs. Tumor size on EUS and location of the tumor were associated with the duration of EFTR and the occurrence of a pneumoperitoneum during the procedure. The use of an OTSC system was significantly associated with shorter hospital stays and a higher cost of closing defects.

Endoscopic ultrasound-guided interstitial chemotherapy in the pancreas: results in a canine model

BACKGROUND AND STUDY AIM

Interstitial chemotherapy using surgically implanted, biodegradable polymers has been reported. Our aim in this study was to investigate the feasibility and safety of endoscopic ultrasound- (EUS-) guided interstitial chemotherapy of the pancreas in a canine model.

MATERIALS AND METHODS

A therapeutic 19-gauge needle with a large channel was inserted into the pancreas under EUS guidance. The polymers for sustained intratumoral release of 5-fluorouracil were implanted into the tissue by the needle. After 14 days of clinical observation, the animals were sacrificed and the tissue response to the local chemotherapy was examined.

RESULTS

All the polymers were implanted successfully and no implant migration occurred. Localized tissue fibrous necrosis was achieved in the pancreas, without significant complications. The apoptotic index of the tissue within 1 cm of the focus increased. Biochemical parameters were normal in all the dogs.

CONCLUSIONS

EUS-guided implantation of polymers is a safe, simple, and minimally invasive technique for interstitial chemotherapy in the pancreas.

IL-17D: A Less Studied Cytokine of IL-17 Family

The interleukin-17 (IL-17) family is a relatively new family of cytokines consisting of 6 related factors (IL-17A-IL-17F), while the receptor family consists of 5 members: IL-17RA-IL-17RE. IL-17A is the prototype member of this family, which is also the signature cytokine of T helper 17 (Th17) cells. Th17 cells are involved in the development of autoimmune disease, inflammation, and tumors. Although IL-17D is similar to IL-17A in its ability to induce inflammatory cytokine production, there are fewer studies on IL-17D. Recently, the role of IL-17D in tumors and infections has attracted our attention. Some knowledge of function of IL-17D has been gained by studies using nonmammalian species. In this review, we introduce the structural characteristics, expression patterns, and biological characteristics of IL-17D along with its potential function in the pathogenesis of disease.

Do we need elastography for EUS?

We recently introduced a series of papers "What should be known prior to performing EUS exams." In Part I, the authors discussed which clinical information and whether other imaging modalities are needed before embarking EUS examinations. In Part II, technical controversies on how EUS is performed were discussed from different points of view. In this article, important practical issues regarding EUS elastography will be raised and controversially discussed from very different points of view.

Clinical impact of strain histogram EUS elastography and contrast-enhanced EUS for the differential diagnosis of focal pancreatic masses: A prospective multicentric study

BACKGROUND

Recent advances in EUS techniques (real-time EUS elastography and contrast-enhanced EUS) have allowed a better characterization of focal pancreatic masses. Mean strain histograms (SHs) are considered a good parameter for the semi-quantitative evaluation of focal pancreatic masses, alongside complementary contrast-enhanced EUS parameters which can be quantified during both the early arterial and late venous phase.

MATERIALS AND METHODS

The study design was prospective, blinded, and multicentric, assessing real-time EUS elastography and contrast-enhanced EUS results for the characterization of focal pancreatic masses using parametric measurements, in comparison with pathology which is the gold standard. SHs were performed based on the embedded software of the ultrasound system, with the values being reversed as opposed to our initially published data on hue histograms. Consequently, a cutoff of 80 was derived from previous multicentric trials. Contrast-enhanced EUS also allowed the focal masses to be classified as hyper-, iso-, or hypoenhanced in comparison with the normal pancreatic parenchyma. EUS-FNA was then performed for all patients, with a positive cytological diagnosis taken as a final proof of malignancy for the pancreatic masses. The diagnoses obtained by EUS-FNA were verified further either by surgery or during a clinical follow-up of at least 6 months.

RESULTS

A total number of 97 consecutive patients with focal pancreatic masses were included in the study. Based on previously defined cutoffs of 80, the values of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the mean SHs for the diagnosis of pancreatic cancer were 100%, 29.63%, 78.65%, 100%, and 80.41%, respectively. Corresponding values for contrast-enhanced EUS (taking into consideration hypoenhencement as a predictive factor of malignancy) were 98.57%, 77.78%, 92%, 95.45%, and 92.78%, respectively. Combining contrast enhancement-EUS (hypoenhencement) and semi-quantitative EUS elastography (SH cutoffs <80), the resulting values corresponding for sensitivity, specificity, and accuracy were 98.57%, 81.48%, and 93.81%, respectively.

CONCLUSION

The current study using objective parametric tools for both EUS elastography and contrast-enhanced EUS confirmed the results of previous studies and meta-analyses that indicated a complementary role for the differential diagnosis of focal pancreatic masses. Moreover, the best values for the receiver operating curves were obtained using a sequential clinical algorithm based on the initial use of elastography, followed by contrast enhancement.

Endoscopic ultrasound-assisted transmural cholecystoduodenostomy or cholecystogastrostomy as a bridge for per-oral cholecystoscopy therapy using double-flanged fully covered metal stent

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the 'gold standard' for the treatment of symptomatic gallstones. Innovative methods are being introduced, and these procedures include transgastric or transcolonic endoscopic cholecystectomy. However, before clinical implementation, instruments still need modification, and a more convenient treatment is still needed. Moreover, some gallbladders still have good functionality and cholecystectomy may be associated with various complications. The aim of this study was to evaluate the trans-gastrointestinal tract cholecystoscopy technique in the treatment of gallbladder disease without cholecystectomy.

METHOD

Endoscopic ultrasound (EUS)-guided cholecystoduodenostomy or cholecystogastrostomy with the placement of a double-flanged fully covered metal stent was performed and endoscopic sphincterotomy (EST) was also performed during this procedure for those patients with accompanying common bile duct stones. One or two weeks later the stent was removed and an endoscope was advanced into the gallbladder via the fistula, and cholecystolithotomy or polyp resection was performed. Four weeks later gallbladder was assessed by abdominal ultrasound.

RESULTS

EUS guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 4) with double flanged mental stent deployment was successfully performed in all of 7 patients. After the procedure, fistulas had formed in each of the patients and the stents were removed. Endoscopic cholecystolithotomy(7) and polyps resection(2) were successfully performed through the fistulas. Common bile duct stones were also successfully removed in 5 patients. The ultrasound examination of the gallbladder 4 weeks later showed no stones remaining and also showed satisfactory functioning of the gallbladder.

CONCLUSION

The EUS-guided placement of a novel metal stent is a safe and simple approach for performing an endoscopic cholecystoduodenostomy or cholecystogastrostomy, which can subsequently allow procedures to be performed for treating biliary disease, including cholecystolithotomy.

Practice guidelines for endoscopic ultrasound-guided celiac plexus neurolysis

OBJECTIVES

The objective of guideline was to provide clear and relevant consensus statements to form a practical guideline for clinicians on the indications, optimal technique, safety and efficacy of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN).

METHODS

Six important clinical questions were determined regarding EUS-CPN. Following a detailed literature review, 6 statements were proposed attempting to answer those questions. A group of expert endosonographers convened in Chicago, United States (May 2016), where the statements were presented and feedback provided. Subsequently a consensus group of 35 expert endosonographers voted based on their individual level of agreement. A strong recommendation required 80% voter agreement. The modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria were used to rate the strength of recommendations and the quality of evidence.

RESULTS

Eighty percent agreement was reached on 5 of 6 consensus statements, 79.4% agreement was reached on the remaining one.

CONCLUSIONS

EUS-CPN is efficacious, should be integrated into the management of pancreas cancer pain, and can be considered early at the time of diagnosis of inoperable disease. Techniques may still vary based on operator experience. Serious complications exist, but are rare.

Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors

Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.

AKR1C3-dependent lipid droplet formation confers hepatocellular carcinoma cell adaptability to targeted therapy

Rationale: Increased lipid droplet (LD) formation has been linked to tumor metastasis, stemness, and chemoresistance in various types of cancer. Here, we revealed that LD formation is critical for the adaptation to sorafenib in hepatocellular carcinoma (HCC) cells. We aim to investigate the LD function and its regulatory mechanisms in HCC. Methods: The key proteins responsible for LD formation were screened by both metabolomics and proteomics in sorafenib-resistant HCC cells and further validated by immunoblotting and immunofluorescence staining. Biological function of AKR1C3 was evaluated by CRISPR/Cas9-based gene editing. Isotopic tracing analysis with deuterium3-labeled palmitate or carbon13-labeled glucose was conducted to investigate fatty acid (FA) and glucose carbon flux. Seahorse analysis was performed to assess the glycolytic flux and mitochondrial function. Selective AKR1C3 inhibitors were used to evaluate the effect of AKR1C3 inhibition on HCC tumor growth and induction of autophagy. Results: We found that long-term sorafenib treatment impairs fatty acid oxidation (FAO), leading to LD accumulation in HCC cells. Using multi-omics analysis in cultured HCC cells, we identified that aldo-keto reductase AKR1C3 is responsible for LD accumulation in HCC. Genetic loss of AKR1C3 fully depletes LD contents, navigating FA flux to phospholipids, sphingolipids, and mitochondria. Furthermore, we found that AKR1C3-dependent LD accumulation is required for mitigating sorafenib-induced mitochondrial lipotoxicity and dysfunction. Pharmacologic inhibition of AKR1C3 activity instantly induces autophagy-dependent LD catabolism, resulting in mitochondrial fission and apoptosis in sorafenib-resistant HCC clones. Notably, manipulation of AKR1C3 expression is sufficient to drive the metabolic switch between FAO and glycolysis. Conclusions: Our findings revealed that AKR1C3-dependent LD formation is critical for the adaptation to sorafenib in HCC through regulating lipid and energy homeostasis. AKR1C3-dependent LD accumulation protects HCC cells from sorafenib-induced mitochondrial lipotoxicity by regulating lipophagy. Targeting AKR1C3 might be a promising therapeutic strategy for HCC tumors.

How to perform EUS-guided biliary drainage

EUS-guided biliary drainage (EUS-BD) has recently gained widespread acceptance as a minimally invasive alternative method for biliary drainage. Even in experienced endoscopy centers, ERCP may fail due to inaccessibility of the papillary region, altered anatomy (particularly postsurgical alterations), papillary obstruction, or neoplastic gastric outlet obstruction. Biliary cannulation fails at first attempt in 5%-10% of cases even in the absence of these factors. In such cases, alternative options for biliary drainage must be provided since biliary obstruction is responsible for poor quality of life and even reduced survival, particularly due to septic cholangitis. The standard of care in many centers remains percutaneous transhepatic biliary drainage (PTBD). However, despite the high technical success rate with experienced operators, the percutaneous approach is more invasive and associated with poor quality of life. PTBD may result in long-term external catheters for biliary drainage and carry the risk of serious adverse events (SAEs) in up to 10% of patients, including bile leaks, hemorrhage, and sepsis. PTBD following a failed ERCP also requires scheduling a second procedure, resulting in prolonged hospital stay and additional costs. EUS-BD may overcome many of these limitations and offer some distinct advantages in accessing the biliary tree. Current data suggest that EUS-BD is safe and effective when performed by experts, although SAEs have been also reported. Despite the high number of clinical reports and case series, high-quality comparative studies are still lacking. The purpose of this article is to report on the current status of this procedure and to discuss the tools and techniques for EUS-BD in different clinical scenarios.

Role of Glucagon and Its Receptor in the Pathogenesis of Diabetes

Various theories for the hormonal basis of diabetes have been proposed and debated over the past few decades. Insulin insufficiency was previously regarded as the only hormone deficiency directly leading to metabolic disorders associated with diabetes. Although glucagon and its receptor are ignored in this framework, an increasing number of studies have shown that they play essential roles in the development and progression of diabetes. However, the molecular mechanisms underlying the effects of glucagon are still not clear. In this review, recent research on the mechanisms by which glucagon and its receptor contribute to the pathogenesis of diabetes as well as correlations between GCGR mutation rates in populations and the occurrence of diabetes are summarized. Furthermore, we summarize how recent research clearly establishes glucagon as a potential therapeutic target for diabetes.

Evaluation of transabdominal ultrasound after oral administration of an echoic cellulose-based gastric ultrasound contrast agent for gastric cancer

BACKGROUND

With the remarkable improvements in ultrasound equipment, transabdominal ultrasound after oral administration of an echoic cellulose-based gastric ultrasound contrast agent (TUS-OCCA) has recently been suggested to be effective in initial screening of gastric cancer. The aim of this study was to evaluate the diagnostic value of TUS-OCCA for gastric cancer.

METHODS

Consecutive patients with gastric cancers who underwent resection in our hospital were enrolled. Before the lesion was resected, TUS-OCCA examination was performed by a skilled examiner who was blinded to the site, size, and endoscopy diagnosis of the lesion. TUS-OCCA findings were compared with those of endoscopy and pathological diagnoses as the gold standard.

RESULTS

There were a total of 288 consecutive patients enrolled in the study, including 228 with advanced gastric cancers (T2-T4 stage), 50 with early gastric cancer (26 with stage T1b and 24 with stage T1a), and 10 with high-grade intraepithelial neoplasia. TUS-OCCA had a detection rate of 100% (228/228) for advanced gastric cancers, 77% (20/26) for stage T1b, 67% (16/24) for stage T1a, and 60% (6/10) for high-grade intraepithelial neoplasia. The majority of patients with undetectable neoplasms using TUS-OCCA were obese (body mass index, 28.7-31.8 kg/m(2)). The overall accuracy of TUS-OCCA in determining the T stage of gastric cancer was 77.3% (62.5% for T1a, 70% for T1b, 71.1% for T2, 85.2% for T3, and 73.3% for T4).

CONCLUSIONS

These findings indicate that TUS-OCCA achieved a high detection rate for gastric cancers and was useful in assessing the degree of gastric cancer invasion.