Review article: Asia-Pacific consensus recommendations on endoscopic tissue acquisition for biliary strictures

BACKGROUND

Pre-operative tissue diagnosis for suspected malignant biliary strictures remains challenging.

AIM

To develop evidence-based consensus statements on endoscopic tissue acquisition for biliary strictures.

METHODS

The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia-Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted "agree completely" or "agree with some reservation."

RESULTS

Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%-72%) and 99% (98%-100%), and 48% (15%-100%) and 99% (97%-100%), respectively, in diagnosing malignant biliary strictures. Probe-based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent-labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy-guided biopsy and EUS-guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%-88%) and 98% (83%-100%), and 80% (46%-100%) and 97% (92%-100%), respectively, in diagnosing malignant biliary strictures.

CONCLUSION

These consensus statements provide evidence-based recommendations for endoscopic tissue acquisition of biliary strictures.

[Advances in diagnosis and treatment of undifferentiated pancreatic carcinoma with osteoclast-like giant cells]

Undifferentiated pancreatic carcinoma with osteoclast-like giant cell(UOC) published to date, and most have been in Asia, is a rare occurrence making up 1% of all pancreatic malignancies.With the increasing number of reported cases of the disease, the degree of awareness of the disease also gradually deepened, but there are few summary articles for the clinical features, imaging features, pathological features, treatment programs, prognosis and other aspects of UOC.Hence, this article is going to introduce pathological features, clinical manifestations, diagnosis and treatment of adjuvant advances of UOC in detail.

[Clinical features of acute diffuse pulmonary exudative disorders]

Objective: To analyze the clinical features of acute diffuse pulmonary exudative disorders. Methods: The data were collected from patients who were hospitalized in respiratory intensive care unit (RICU) of Beijing Chaoyang Hospital affiliated to the Capital Medical University during January 2009 to December 2011, and had acute clinical course with imaging findings of diffuse pulmonary infiltrated shadows (similar to acute respiratory distress syndrome (ARDS)). The causes of disease and clinical features were analyzed. Results: A total of 86 patients with acute diffuse pulmonary exudative disorders were included. Sixty-two (72.1%) were males, with a mean age of (58.6±16.4) years old; 24(27.9%) were females, with a mean age of (48.2±18.3) years old. The duration of the disease before administration was (11.5±5.2) days, and RICU stay was (15.5±9.5) days, with hospital mortality of 40.7% and the average hospitalization cost of 101 thousand RMB. The main cause was infection, which occurred in 53 cases (61.6%) (virus in 21 cases, bacteria in 14 cases, fungus in 11 cases, pneumocystis in 15 cases and others in 3 cases, mixed infection in 11 cases). Interstitial pneumonia occurred in 12 cases (idiopathic interstitial pneumonia in 9 cases: cryptogenic organizing pneumonia in 3 cases, the acute exacerbation of idiopathic pulmonary fibrosis in 3 cases, nonspecific interstitial pneumonia in 1 case, acute interstitial pneumonia in 2 cases, and connective tissue disease in 3 cases), aspiration pneumonia in 10 cases, acute left heart failure in 6 cases, and exogenous pulmonary ARDS in 5 cases. Conclusions: The main cause of acute diffuse pulmonary exudative disorders is pulmonary infection, followed by interstitial pneumonia. The hospital mortality and hospitalization cost are high.

Comparative Analysis of Diffusional Kurtosis Imaging, Diffusion Tensor Imaging, and Diffusion-Weighted Imaging in Grading and Assessing Cellular Proliferation of Meningiomas

BACKGROUND AND PURPOSE

An accurate evaluation of the World Health Organization grade and cellular proliferation is particularly important in meningiomas. Our aim was to prospectively evaluate and compare diffusional kurtosis imaging, DTI, and DWI metrics in determining the grade and cellular proliferation of meningiomas.

MATERIALS AND METHODS

Ninety-six consecutive patients with histopathologically confirmed meningiomas were included in this study. Mean kurtosis, radial kurtosis, axial kurtosis, fractional anisotropy, mean diffusivity, and ADC were semiautomatically obtained in the solid components of tumors. Each normalized diffusion value was compared between high-grade meningiomas and low-grade meningiomas using the Mann-Whitney U test. Receiver operating characteristic, multiple logistic regression, and Pearson correlation analysis were used for statistical evaluations.

RESULTS

Diffusional kurtosis imaging metrics (mean kurtosis, radial kurtosis, and axial kurtosis) were significantly higher in high-grade meningiomas than in low-grade meningiomas (P ≤ .001). Mean diffusivity and ADC were significantly lower in high-grade meningiomas than in low-grade meningiomas (P = .003 and .002). Mean kurtosis had significantly greater area the under curve values than mean diffusivity and fractional anisotropy in differentiating high-grade meningiomas from low-grade meningiomas (P = .038 and .002). Mean kurtosis was the only variable that could be used to independently differentiate high-grade meningiomas and low-grade meningiomas (P < .001). Significant correlations were found between the Ki-67 labeling index and kurtosis metrics (P < .001), as well as for mean diffusivity and ADC (P = .004, and .007).

CONCLUSIONS

Compared with other diffusion metrics, mean kurtosis may serve as an optimal parameter for evaluating and predicting the meningioma grade. Moreover, diffusion metrics may potentially reflect cellular proliferation.

Infusion of Lymphocytes Treated With 8-Methoxypsoralen and Ultraviolet A Light Induces CD19+IL-10+ Regulatory B Cells and Promotes Skin Allograft Survival

Extracorporeal photopheresis (ECP) represents an alternative to immunosuppression as a means of reducing rejection after thoracic organ transplantation. The mechanism by which ECP exerts its protective effects, until now, has remained elusive. Infusion of ECP-treated splenic lymphocytes (PUVA-SP) can induce CD4⁺CD25^highFoxp3⁺ regulatory T cells. However, the regulatory effect of PUVA-SP on B cells remains poorly understood. In the present study, we measured IL-10 secretion from CD19⁺ B cells of peripheral blood mononuclear cells. Our results demonstrate that infusion of PUVA-SP (PUVA-BSP from BALB/c or PUVA-CSP from C57BL/6 mice), in the absence of an immunosuppressant, significantly promotes skin allograft survival. This effect was associated with upregulation of circulating regulatory B cells exhibiting preferential IL-10 secretion and a shift of cytokine profile from helper T cell type 1 to helper T cell type 2. Our results suggest that effective treatments involving infusion of PUVA-SP is likely related not only to the modulation of T cell and regulatory T cell functions but also to the function of B cell and regulatory B cells.

[Effects and underlying mechanism of berberine on renal tubulointerstitial injury in diabetic rats]

Objective: To investigate the effect of Berberine on renal tubulointerstitial injury and its potential mechanism in rats with type 2 diabetes mellitus (T2DM). Methods: Thirty Sprague-Dawley rats were randomly divided into 3 groups: normal control rats (NC group), diabetic rats without drug treatment (DM group), diabetic rats treated with Berberine (BBR group) for 8 weeks. At the end of the study, blood and urine samples were collected for biochemical examination, and tubulointerstitial fibrosis was quantified by Hematoxylin and Eosin (HE) and Masson staining. The expressions of E-cadherin (E-cad), α-smooth muscle actin (α-SMA), nuclear factor-κB (NF-κB) and monocyte chemoattractant protein 1 (MCP-1) were detected by immunohistochemistry analysis, real-time polymerase chain reaction (RT-PCR) and Western blot analysis. Results: 24 h urinary microalbumin (mAlb)[(170.5±58.1) vs (253.7±53.0) mg]and urinary N-acetyl-glucosaminidase (NAG)[(33.5±7.2) vs (49.5±9.3)U/L]in diabetic rats were significantly decreased by BBR treatment(both P<0.05). The apparent renal tubulointerstitial injury was found in the DM group, which was ameliorated by BBR treatment. The expression of α-SMA, NF-κB and MCP-1 were significantly decreased, accompanied by increased expression of E-cad in BBR-treated DM rats (all P<0.05). Conclusion: BBR could ameliorate renal tubulointerstitial injury in diabetic rats, the mechanism of which may be associated with the amelioration of epithelial-mesenchymal transition (EMT) through suppressing the expression of the NF-κB and MCP-1.

[Research advances in anatomical study on the diffusion routs of acute pancreatitis]

The retroperitoneum space comprises anterior pararenal space, perirenal space and posterior pararenal space. Pancreas is a retroperitoneal organ and located in the anterior pararenal space of the retroperitoneum. Left and right sides anterior pararenal space are potentially communicated, which contains many adipose tissues and a little connective tissues. The exacerbation of acute pancreatitis results in the lesion spreading into adjacent area of pancreas in the retroperitoneal space. In addition, the lesion could spread into bare area of stomach, posterior colonic region, subperitoneal space and pelvic retroperitoneal space through the same anatomical space or communicating space. Due to the fascia destruction by pancreatic enzymes or the lesion directly diffuse through the weak fascia, the lesion could also diffuse across fascia to perirenal space, posterior pararenal space, the peritoneal cavity and abdominal wall. Finally, a series of complications are developed. The diffusion paths of acute pancreatitis are complex and diverse. Familiarity with these diffusion paths is useful for determining the severity and guiding therapy.

Characteristics, management, and outcome of primary hyperparathyroidism at a single clinical center from 2005 to 2016

This study presents the clinical and biochemical profiles of patients with PHPT between 2005 and 2016 at our center. Most PHPT patients in China show symptomatic features. The number of symptomatic and asymptomatic patients increased during that time, and the number of individuals with parathyroid carcinoma is now increasing.

INTRODUCTION

Over the last decade, the prevalence of primary hyperparathyroidism (PHPT) has increased sharply, and the number of individuals with parathyroid cancer is still trending upward. Little is known about the clinical outlook of the disease over the last decade in China. The aim of this study was to describe the clinical characteristics of PHPT patients at our center from January 2005 to December 2016.

METHODS

Two hundred sixty patients with PHPT visiting Shanghai Jiao Tong University Affiliated Sixth People's Hospital were enrolled retrospectively. The clinical manifestations and biochemical abnormalities of these patients were analyzed.

RESULTS

Among all patients, 73.1% had symptomatic PHPT, while the number of symptomatic and asymptomatic patients increased 1 to 2.5 times and 1.5 to 3 times, respectively, from 2005 to 2016. Bone pain and single adenoma were the most frequent signs and pathological results. The patients with parathyroid carcinoma over the last 5 years accounted for 90% (9/10) of all parathyroid carcinoma patients from 2005 to 2016, and parathyroid carcinoma patients had higher levels of serum calcium, parathyroid hormone (PTH), and serum creatinine (P < 0.05) than parathyroid hyperplasia and parathyroid adenoma patients.

CONCLUSIONS

Most patients with PHPT in China still exhibit classic clinical and biochemical features. Both symptomatic and asymptomatic patients have increased over the last 12 years. Although the proportion of parathyroid carcinoma was small, a noticeable upward tendency was observed at our center.

MUC1- and Survivin-based DNA Vaccine Combining Immunoadjuvants CpG and interleukin-2 in a Bicistronic Expression Plasmid Generates Specific Immune Responses and Antitumour Effects in a Murine Colorectal Carcinoma Model

DNA vaccination is a promising cancer treatment due to its safety, but poor immunogenicity limits its application. However, immunoadjuvants, heterogeneous prime-boost strategies and combination with conventional treatments can be used to improve the antitumour immune effects. A CpG motif and interleukin-2 (IL-2) cytokine are often used as adjuvants. In this study, a DNA vaccine containing a CpG motif was constructed to evaluate its adjuvant effect. The results show that the cytotoxicity of the DNA vaccine was increased fivefold, and survival lifetime was prolonged twofold by the CpG motif adjuvant. To simplify the industrial production process, a bicistronic plasmid was constructed to carry the fusion genes of survivin/MUC1 (MS) and IL-2 and with a CpG motif in its backbone. The results showed that the antitumour effect of the bicistronic vaccine was the same as that of the two vaccine co-injected regime. Furthermore, the vaccine could suppress metastatic tumour foci by 69.1% in colorectal carcinoma-bearing mice. Moreover, the vaccine induced survivin- and MUC1-specific immune responses in splenocytes and induced the immune promoting factor CCL-19 and GM-CSF upregulated, while metastatic-associated factor MMP-9 and immunosuppressing factor PD-L1 downregulated in tumour tissue. When combining the vaccine with the chemotherapy drug oxaliplatin, the survival was prolonged by about 2.5-fold. In conclusion, the DNA vaccine containing a CpG motif in bicistronic form showed good effects on colorectal cancer by inhibiting both tumour growth and metastasis, and combination with oxaliplatin could improve its antitumour effects.

BET protein proteolysis targeting chimera (PROTAC) exerts potent lethal activity against mantle cell lymphoma cells

Bromodomain extraterminal protein (BETP) inhibitors transcriptionally repress oncoproteins and nuclear factor-κB (NF-κB) target genes that undermines the growth and survival of mantle cell lymphoma (MCL) cells. However, BET bromodomain inhibitor (BETi) treatment causes accumulation of BETPs, associated with reversible binding and incomplete inhibition of BRD4 that potentially compromises the activity of BETi in MCL cells. Unlike BETi, BET-PROTACs (proteolysis-targeting chimera) ARV-825 and ARV-771 (Arvinas, Inc.) recruit and utilize an E3-ubiquitin ligase to effectively degrade BETPs in MCL cells. BET-PROTACs induce more apoptosis than BETi of MCL cells, including those resistant to ibrutinib. BET-PROTAC treatment induced more perturbations in the mRNA and protein expressions than BETi, with depletion of c-Myc, CDK4, cyclin D1 and the NF-κB transcriptional targets Bcl-xL, XIAP and BTK, while inducing the levels of HEXIM1, NOXA and CDKN1A/p21. Treatment with ARV-771, which possesses superior pharmacological properties compared with ARV-825, inhibited the in vivo growth and induced greater survival improvement than the BETi OTX015 of immune-depleted mice engrafted with MCL cells. Cotreatment of ARV-771 with ibrutinib or the BCL2 antagonist venetoclax or CDK4/6 inhibitor palbociclib synergistically induced apoptosis of MCL cells. These studies highlight promising and superior preclinical activity of BET-PROTAC than BETi, requiring further in vivo evaluation of BET-PROTAC as a therapy for ibrutinib-sensitive or -resistant MCL.

Genome-wide association analysis of residual feed intake in Junmu No. 1 White pigs

Residual feed intake (RFI) is a measure of feed efficiency. Pigs with low RFI have reduced feed costs without compromising their growth. For marker-assisted selection, it is helpful to identify genes or genetic markers associated with RFI in animals with improved feed efficiency at an early age. Using Illumina's PorcineSNP60 BeadChip, we performed a pilot genome-wide association study of 217 Junmu No. 1 white male pigs phenotyped for RFI. Two-step and one-step methods were used separately to identify associated SNPs. Both methods obtained similar results. Twelve SNPs were identified as significantly associated with RFI at a Bonferroni adjusted P-level < 9.7 × 10^-7 , and 204 were found to have suggestive (moderately significant) association with RFI at P < 5 × 10^-5 . NMBR, KCTD16, ASGR1, PRKCQ, PITRM1, TIAM1 and RND3 were identified as candidate genes for RFI.

Composition and Variation Analysis of the T Cell Receptor β-Chain Complementarity Determining Region 3 Repertoire in Neonatal Sepsis

T cell receptor (TCR) diversity is clearly related to protection from infection. However, the characteristics of TCR diversity in neonates are not clear. In this study, we investigated the TCR diversity of neonates with sepsis. Twenty neonates with severe sepsis and eight matched neonates without infection were enrolled in the study. For the neonates with sepsis, EDTA-anticoagulated blood was collected on day 1 after the diagnosis of sepsis and on day 7 of treatment. For the neonates without infection, blood was collected one time. DNA was extracted from peripheral blood mononuclear cells. The complementarity determining region 3 (CDR3) gene was analysed by multiplex PCR and high-throughput sequencing. The CDR3 types and lengths were similar in patients and healthy controls. There was a significant difference in VJ gene usage among the three groups. Compared to the healthy neonates, the neonates with sepsis had different VJ pairs and generated different clonotypes. Although the TCR β-chain diversity was generally lower in the neonates with sepsis, there was no significant difference in TCR β-chain diversity between the patients and the healthy controls. Our data showed the characteristics of the TCR repertoire in neonates with sepsis, which represents a potentially valuable data set. This result is useful for understanding neonatal susceptibility to infection.

The correlation between the expression of ADAM17, EGFR and Ki-67 in malignant gliomas

OBJECTIVE

The aim of this study was to analyze the depolymerization in metalloproteinase (ADAM17), epidermal growth factor receptor (EGFR), the expression of Ki-67 of glioma patients and the correlations with malignancy.

PATIENTS AND METHODS

53 brain glioma samples resected from patients who had surgery from April 2015 to May 2016 at Chinese People's Armed Police Force General Hospital were selected. According to the degree of malignancy: 22 patients were divided into a deterioration group (stage I to II); 31 patients in highly deteriorated group (stage III to IV); 14 brain tissue samples of traumatic decompression from the hospital as control group. The immunohistochemical method was used to detect the expression of ADAM17, EGFR, and Ki-67 in three groups, and the correlation between the expression of ADAM17, EGFR, and Ki-67. Thus, the stages of malignancy were analyzed.

RESULTS

ADAM17, EGFR, and Ki-67 had no expression or weak expression in the control group, and increased in the low stage of deterioration group; the differences were statistically significant (p < 0.05). The positive expression rates of ADAM17, EGFR, and KI-67 were significantly higher in the high deterioration group than that in the control group (p < 0.05). Moreover, the analysis showed that the expression of ADAM17, EGFR, and Ki-67 were positively correlated with the stage of malignancy (R = 0.823, p = 0.000; R = 0.804, p = 0.000; R = 0.811, p = 0.000).

CONCLUSIONS

The results suggested that there was a significant positive correlation between ADAM17, EGFR, and Ki-67 with the stage of malignancy.

CDKN2B deletion is essential for pancreatic cancer development instead of unmeaningful co-deletion due to juxtaposition to CDKN2A

Pancreatic cancer is among the deadliest malignancies; however, the genetic events that lead to pancreatic carcinogenesis in adults remain unclear. In vivo models in which these genetic alterations occur in adult animals may more accurately reflect the features of human cancer. In this study, we demonstrate that inactivation of Cdkn2b (p15ink4b) is necessary for induction of pancreatic cancer by oncogenic KRAS^G12D expression and inactivation of Tp53 and Cdkn2a in adult mouse pancreatic ductal cells (P60 or older). KRAS^G12D overexpression in these cells activated transforming growth factor-β signaling and expression of CDKN2B, which, along with CDKN2A, led to cellular senescence and protected cells from KRAS-mediated transformation via inhibition of retinoblastoma phosphorylation. These results show a critical role of CDKN2B inactivation in pancreatic carcinogenesis, and provide a useful adult animal model by genetic engineering via lentiviral delivery.

[Interaction between family history of diabetes and hyperlipidemia on risk of diabetes in population with normotension in Harbin: a cross-sectional study]

Objective: To explore the interaction between family history of diabetes and hyperlipidemia on the risk of diabetes in population with normotension. Methods: A multistage stratified probability random sampling was conducted to select a representative sample of urban residents aged 20-74 years in Harbin. A total of 376 diabetes patients with normotension and 3 692 residents with normal blood pressure, normal fasting glucose, and normal 2 hours glucose from OGTT were surveyed. The interaction was evaluated by using crossover analysis and additive model. Results: Multivariate logistic regression analysis indicated that there was a possible additive interaction between family history of diabetes and hyperlipidemia on the risk of diabetes. The relative excess risk due to the interaction, the attributable proportion due to the interaction, and the synergy index were 1.97 (95%CI:-0.32-4.26), 0.30 (95%CI: 0.03-0.57), and 1.54 (95%CI: 0.96-2.47), respectively. There were significant combination effects between family history of diabetes and high both total cholesterol and triglyceride, isolated high total cholesterol, and isolated high triglyceride levels; the ORs were 10.55 (95%CI: 5.62-19.80), 7.81 (95%CI: 3.65-16.71) and 5.13 (95%CI: 3.22-8.16), respectively. Conclusion: There might be synergistic effect between family history of diabetes and hyperlipidemia on the risk of diabetes in population with normotension.