Role of the immune system in pancreatic cancer progression and immune modulating treatment strategies

Traditional chemotherapeutics have largely failed to date to produce significant improvements in pancreatic cancer survival. One of the reasons for the resilience of pancreatic cancer towards intensive treatment is that the cancer is capable of high jacking the immune system: during disease progression the immune system is converted from a system that attacks tumor cells into a support structure for the cancer, exerting trophic actions on the cancer cells. This turn-around of immune system action is achieved through mobilization and activation of regulatory T cells, myeloid derived suppressor cells, tumor-associated macrophages and fibroblasts, all of which suppress CD8 T cells and NK cells. This immune suppression occurs both through the expression of tolerance-inducing cell surface molecules, such as PD-L1, as well as through the production of "tolerogenic" cytokines, such as IL-10 and TGF-β. Based on the accumulating insight into the importance of the immune system for the outcome of pancreatic cancer patients multiple new immunotherapeutic approaches against pancreatic cancer are being currently tested in clinical trials. In this review we give an overview of both the immune escaping mechanisms of pancreatic cancer as well as the new immune related therapeutic strategies currently being tested in pancreatic cancer clinical trials.

European experts consensus statement on cystic tumours of the pancreas

Cystic lesions of the pancreas are increasingly recognized. While some lesions show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). European expert pancreatologists provide updated recommendations: diagnostic computerized tomography and/or magnetic resonance imaging are indicated in all patients with cystic lesion of the pancreas. Endoscopic ultrasound with cyst fluid analysis may be used but there is no evidence to suggest this as a routine diagnostic method. The role of pancreatoscopy remains to be established. Resection should be considered in all symptomatic lesions, in mucinous cystic neoplasm, main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm as well as in branch duct intraductal papillary mucinous neoplasm with mural nodules, dilated main pancreatic duct >6mm and possibly if rapidly increasing in size. An oncological partial resection should be performed in main duct intraductal papillary mucinous neoplasm and in lesions with a suspicion of malignancy, otherwise organ preserving procedures may be considered. Frozen section of the transection margin in intraductal papillary mucinous neoplasm is suggested. Follow up after resection is recommended for intraductal papillary mucinous neoplasm, solid pseudo-papillary neoplasm and invasive cancer.

Carotid intima-media thickness and liver histology in hemodialysis patients with nonalcoholic Fatty liver disease

The prevalence of atherosclerotic cardiovascular disease in chronic hemodialysis (HD) patients has been demonstrated to be higher than in healthy people. Severe liver fibrosis is strongly associated with early carotid atherosclerosis and it might reduce the survival of patients who undergo both renal replacement therapy and transplantation. We wanted to assess whether nonalcoholic fatty liver disease (NAFLD) was associated with altered intima-media thickness (IMT) in HD patients as an independent marker of subclinical atherosclerosis. We enrolled 42 patients undergoing HD and 48 patients with normal renal function, all of them with high levels of aminotransferases and an ultrasonographic diagnosis of liver steatosis. The control group consisted of 60 healthy subjects. Laboratory tests for inflammatory and oxidative markers, ultrasonographic liver evaluation, carotid IMT measurement, and liver biopsy were performed. Different degrees of fibrosis were detected in our study cohort. Worse liver histopathological scores and higher plasmatic levels of C-reactive protein, reactive oxygen species, and vascular cell adhesion molecule-1 were found in HD patients. Carotid IMT was significantly higher (p < 0.005) in patients with histological steatosis. HD patients may develop active and progressive chronic hepatitis faster than patients with normal renal function and the thickness of their carotid intima-media might be markedly increased. These two conditions seem to be independent on classical risk factors and on metabolic syndrome. They might be related to the high levels of oxidants and to the inflammatory state, which are typical of patients undergoing HD. Independently related with the traditional risk factors for cardiovascular disease, nonspecific inflammation and oxide-reductive imbalance may play an important role in the progression of NAFLD and atherosclerotic disease in HD patients.

Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

BACKGROUND AND AIMS

Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic pancreatitis.

METHODS

Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline.

SUMMARY OF SELECTED RECOMMENDATIONS

For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones ≥ 5 mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B). For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e. g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D).For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A).For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).

[Establishment of a keloid model by transplanting human keloid onto the backs of nude mice]

Keloid scar is a proliferative healing dysfunction formed by an excessive build-up of collagen fibers on the dermis. It is responsible of aesthetic and functional disabilities. There is no ideal treatment and recurrence occurs very often. Keloid scars occur only to human, that's why animal model needs to be made to study this pathology and new treatments. Few models have been described using human keloid scars implanted into subcutaneous tissue of nude mice or rat. To allow study of topical and laser treatment we have developed a new animal model using human keloid scar fragment with epidermal and dermal tissue implanted into back of nude mice like a full thickness skin graft. Keloid fragments from five donors have been grafted onto 40 nudes mice. Macroscopic and microscopic studies have been made at day 28, 56, 84 and 112. We observed integration of the fragments in all cases. Hyalinized collagen bundles were observed in all implant biopsies confirming the stability of the keloid architecture within 112 days. This model is easily reproducible and allows the study of topical treatment and laser due to the accessibility of the keloid.

Optical devices in highly myopic eyes with low vision: a prospective study

AIMS

To compare, in relation to the cause of visual impairment, the possibility of rehabilitation, the corrective systems already in use and the finally prescribed optical devices in highly myopic patients with low vision. Some considerations about the rehabilitation of these subjects, especially in relation to their different pathologies, have also been made.

MATERIALS AND METHODS

25 highly myopic subjects were enrolled. We evaluated both visual acuity and retinal sensitivity by Scanning Laser Ophthalmoscope (SLO) microperimetry.

RESULTS

20 patients (80%) were rehabilitated by means of monocular optical devices while five patients (20%) were rehabilitated binocularly. We found a good correlation between visual acuity and retinal sensitivity only when the macular pathology did not induce large areas of chorioretinal atrophy that cause lack of stabilization of the preferential retinal locus. In fact, the best results in reading and performing daily visual tasks were obtained by maximizing the residual vision in patients with retinal sensitivity greater than 10 dB. A well circumscribed area of absolute scotoma with a defined new retinal fixation locus could be considered as a positive predictive factor for the final rehabilitation process.

DISCUSSION

A more careful evaluation of visual acuity, retinal sensitivity and preferential fixation locus is necessary in order to prescribe the best optical devices to patients with low vision, thus reducing the impact of the disability on their daily life.

Early lamellar macular hole in Alport syndrome: case report and review of the literature

PURPOSE AND METHOD

To present a 26-year-old Italian woman affected by genetically ascertained Alport syndrome. The patient underwent a complete ophthalmological examination including: visual acuity, anterior and posterior segment biomicroscopy, MP1-microperimetry, colour fundus retinography, electrofunctional examinations (electrooculogram, electroretinogram, visually evoked potentials), computerized perimetry and Spectral Domain Optical Cohrence Tomography.

RESULTS AND CONCLUSIONS

Nephritis, haematuria but no hearing impairment was observed. Visual function was normal, also confirmed by electrofunctional tests and computerized perimetry. The ocular involvement was only expressed by an early lamellar macular hole characterized by a density rarefaction in the tomographic images of both inner retina and superficial choroid. A rarefaction of the inner choroid in the whole macular region and in the peripapillary area, unusual for the young age of the patient, was also evident. We suppose that these tomographic findings might be caused by alterations of type IV collagen, typical of Alport syndrome.

Negative predictive value of endoscopic ultrasound in patients referred for fine-needle aspiration

AIM

Endoscopic ultrasound (EUS) is a valuable diagnostic tool in pancreatic diseases and its high negative predictive value (NPV) in excluding malignancies is universally recognized. Moreover, EUS with fine-needle aspiration (EUS-FNA) can significantly impact on diagnosis and management of many clinical conditions. However, there are circumstances in which EUS-FNA cannot or should not be performed. We evaluated the factors that prevented us from performing or induced us not to perform FNA.

METHODS

The study was conducted in a tertiary university hospital. A total of 211 patients suspected of having solid pancreatic malignancy on the basis of clinical presentation and computed tomography and/or magnetic resonance imaging was included. When FNA was withheld because not deemed necessary by the operator, the NPV of EUS was calculated.

RESULTS

In 9 patients (4.3% of the procedures), FNA was withheld because of contraindications that should have been foreseen by the referring physician. In 30 subjects, FNA was not accomplished as no lesions requiring biopsy were actually found at EUS exploration. In this group, EUS reached a NPV of 96.7% in excluding malignancy, but it reached 100% in patients without chronic pancreatitis.

CONCLUSION

In a cohort of patients with high pre-test probability of malignancy, the high NPV of EUS was confirmed. False negative results should be expected in patients with chronic pancreatitis and they need a strict follow-up.

Spontaneous closure of bilateral full thickness macular holes without surgery: an eleven-year follow-up

PURPOSE AND METHOD

To present a 60-year-old woman affected by bilateral full thickness macular hole, showing without surgery a spontaneous resolution of the disease in both eyes that remains unchanged during an eleven-year follow-up. To our knowledge, this clinical case is uncommon as no similar reports with such a long follow-up have been published in the scientific literature at this time.

RESULTS AND CONCLUSIONS

A spontaneous and bilateral closure of full thickness macular holes was detected, as a consequence of a complete posterior vitreous detachment documented by optical coherence tomography images. An initial reduction up to a complete resolution of the central macular scotoma was also observed by performing scanning laser ophthalmoscope microperimetry. Both these anatomical and functional results did not change during the whole period of follow-up. According to this study, the release or the weakening of the vitreous tractions at the foveal edges seems to play a key role in the spontaneous resolution of macular holes in not surgically treated patients.

Endoscopic banding for esophageal variceal bleeding: technique and patient outcome

AIM

Endoscopic variceal ligation (EVL) is recommended for the treatment of esophageal variceal bleeding. The aim of this study was to assess the most cost-effective timing of endoscopic follow-up after variceal eradication.

METHODS

Cirrhotics with esophageal varices treated between January 2008 and January 2009 until reached variceal obliteration were retrospectively analyzed for technical aspects and for outcomes.

RESULTS

Out of 127 patients treated with EVL, 103 were included. Number of sessions to achieve variceal obliteration and number of bands for each session were 2.8±1.3 (range 1-7) and 4.6±1 (range 2-7), respectively. The placement of >5 bands per session was not associated with higher incidence of complications (19.6% vs. 17.8%, P=ns). Esophageal ulcers were observed in 42% of patients when the interbanding interval was <20 days (versus 15% for interval >20 days, P<0.05). Once obliteration was achieved, varices reappeared in 28% of patients; the early appearance of small varices was not associated with bleeding.

CONCLUSION

A longer interbanding interval reduces the incidence of procedural-related complications. After variceal obliteration an early endoscopic control is not useful because it does not influence the approach and does not change the patient outcome.