Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure

Background and objectives

Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality without liver transplantation (LT). The selection criteria for LT in these patients are not well defined. The objective of this study was to determine factors associated with post-transplant survival in ACLF.

Methods

This was a single-center retrospective study of patients who underwent living donor liver transplantation (LDLT) for ACLF between 2012 and 2022. Out of 1093 transplants, 110 patients had underlying ACLF, based on the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. We looked at factors associated with 1-year posttransplant survival.

Results

The median model for end-stage liver disease (MELD) score was 33.5 (31-38), and the 1-year posttransplant survival was 72%. Six risk factors were associated with posttransplant survival, namely, body mass index > 30 kg/m2 [HR, 4.4; 95% CI, 1.8-10.7], platelet count < 66,000/μl [HR, 2.91; CI,1.2-6.6], poor response to medical treatment [HR, 2.6; CI, 1.1-5.7], drug-resistant bacterial or fungal cultures [HR, 4.2; CI, 1.4-12.4], serum creatinine > 2.5 mg/dl [HR, 3.4; CI, 1.5-7.7], and graft-to-recipient weight ratio < 0.7 [HR, 4.8; CI, 1.4-16.3]. The 1-year post-transplant survival was 84% in patients with 0-2 risk factors (n = 89) and was 6% with 3 risk factors (n = 15) (P < 0.001). For 1-year posttransplant survival, the area under curve (AUC) for the current model was 0.8 (0.69-0.9). The AUC for CLIF-ACLF, Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and EASL-CLIF ACLF grades was < 0.5.

Conclusion

In LT for ACLF, acceptable survival can be achieved when less than three high-risk factors are present.

Metastatic tumors to the pancreas: Balancing clinical impression with cytology findings

Backgrounds/Aims

Metastatic lesions of the pancreas (PMET) account for 1%–5% of all malignant solid pancreatic lesions (SPL). In this study we evaluated the utility of endoscopic ultrasonography with fine needle aspiration (EUS-FNA) in diagnosing PMET.

Methods

Patients who underwent EUS-FNA at a community referral center between 2011–2017 for SPL were identified. Clinical, radiologic, and EUS-FNA features of those with PMET were compared to those with primary solid tumors of the pancreas: pancreatic adenocarcinoma (PDAC) and neuroendocrine tumors (PNET).

Results

A total of 191 patients were diagnosed with solid pancreatic malignancy using EUS-FNA: 156 PDAC, 27 PNET, and eight (4.2%) had PMET. Patients with PMET were less likely to have abdominal pain (25.0% vs. 76.3% vs. 48.2%; p < 0.01) or obstructive jaundice (37.5% vs. 58.3% vs. 0%; p < 0.01) compared to PDAC and PNET. Those with PMET were more likely to have mass lesions with/without biliary or pancreatic ductal dilatations (100% vs. 86.5% vs. 85.2%; p < 0.01) and lower CA19-9 (82.5 ± 43.21 U/mL vs. 4,639.30 ± 11,489.68 U/mL vs. 10.50 ± 10.89 U/mL; p < 0.01) compared to PDAC and PNET. Endosonographic features were similar among all groups. Seven (87.5%) patients with PMET had a personal history of malignancy prior to PMET diagnosis. The primary malignancy was renal cell carcinoma in five PMET.

Conclusions

PMET are exceedingly rare, comprising less than 5% of SLP. Patients with PMET are less likely to present with symptoms and mostly identified by surveillance imaging for the primary malignancy.

Granular Cell Tumor - An Important Entity to Consider on Upper Gastrointestinal Endoscopy

Granular cell tumors (GCT) are benign, submucosal tumors derived from neural or Schwann cells. They are commonly found in the oral cavity, skin, breast and tongue. Less commonly, they can also occur in the gastrointestinal tract, usually in the esophagus. We describe two cases of esophageal GCT which were discovered by upper endoscopy (EGD). Case one underwent endoscopic ultrasound (EUS) guided fine needle aspiration and biopsy and case two underwent biopsy of a submucosal nodule. Both biopsies were histologically diagnosed as GCT with supportive S100 positive immunostaining. GCTs are an important diagnosis for physicians to consider in their differential of esophageal nodule or lesion. Though benign, they may rarely show malignant transformation. Therefore, it is essential to have surveillance with EGD/EUS every two to three years if they are not surgically resected.

Distinct Clinical Characteristics in Young-Onset Pancreatic Neuroendocrine Tumor

BACKGROUND

We aimed to study the effect of socioeconomic differences and molecular characteristics on survival in patients with young-onset pancreatic neuroendocrine tumors (YOPNET) and typical-onset PNET (TOPNET).

METHODS

We identified the patients with YOPNET (<50 years) and TOPNET (≥50 years) who underwent definitive surgery diagnosed between 2004 and 2016 using the National Cancer Database. We evaluated overall survival (OS) using the Kaplan-Meier and Cox regression methods before and after propensity score matching. A publicly available genomic dataset was used to compare mutation frequencies among the two groups.

RESULTS

A total of 6259 patients with PNET were included, of which 27% were YOPNET. Patients with YOPNET were more likely to be Black, Hispanic, female, and have private insurance versus patients with TOPNET (all p < 0.001). Patients with YOPNET had a lower comorbidity score, but higher stage and tumor size (all p < 0.001). YOPNET was associated with a greater improved OS than TOPNET before and after propensity score matching (p < 0.001). On multivariable analysis, this survival difference persisted for YOPNET as an independent prognostic factor (unmatched p = 0.008; matched p = 0.01). For genomic analysis, patients with YOPNET had a lower rate of multiple endocrine neoplasia type-1 (MEN-1) mutation than patients with TOPNET (26% vs. 56%, p < 0.001).

CONCLUSIONS

YOPNET represents a disease with distinct clinical features. Patients with YOPNET who underwent definitive surgery had better OS than patients with TOPNET despite having higher stage and tumor size. YOPNET also had lower rate of MEN-1 mutation.

Extramedullary Myeloid Sarcoma with Symptoms of Acute Pancreatitis Mimicking Pancreatic Carcinoma

Extramedullary myeloid sarcomas are extramedullary tumors of immature myeloid cells, often associated with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), or other myeloproliferative diseases. They are usually found in connective/soft tissues, skin, breast and gastrointestinal system. Pancreas is an uncommon site to be involved. We present a case of pancreatic myeloid sarcoma presenting with symptoms of acute pancreatitis including epigastric pain associated with nausea and vomiting, with imaging findings (abdominal CT) suggestive of pancreatic carcinoma, both presenting as hypoattenuating mass. It is important to consider myeloid sarcoma as a differential for pancreatic mass, especially given the history of AML as in our patient, which would lead to timely diagnosis and initiation of chemotherapy.

Diagnostic Challenge With Auto-Immune Pancreatitis and IgG4-Related Disease

IgG4-related disease (IgG4RD) is a chronic immune mediated condition primarily affecting the hepato-pancreatico-biliary system. We report a case of IgG4RD with extensive pancreatic and hepatic involvement masquerading as metastatic pancreatic malignancy posing a diagnostic and therapeutic dilemma.

Utility of Endoscopic Ultrasound in the Work Up for Solitary Hepatobiliary Neuroendocrine Lesions

A 43-year-old woman, with an unremarkable past medical history, presented with a three-week history of generalized itching, jaundice, and abdominal pain. Initial workup showed amorphous, regionally invasive, and obstructing soft tissue mass in the region of the hepatic hilum. The middle third of the main bile duct was subsequently found to harbor a polypoid mass on endoscopic retrograde cholangiopancreatograph. Biopsy revealed nests of neoplastic cells that was subsequently identified as well-differentiated neuroendocrine tumor. A search for a possible primary neuroendocrine tumor was performed and included imaging of the chest, abdomen, and pelvis, a colonoscopy, capsule endoscopy, and an octreotide scan; however, no primary tumor outside of the liver was identified. Surgical debulking was performed, during which intraoperative exploration and ultrasound failed to reveal any extra-hepatic tumor sanctuaries. A few months later, patient underwent endoscopic ultrasound (EUS) for evaluation of recurrent abdominal pain which revealed a small lesion in the pancreas. It was unclear, however, whether it was primary or a metastatic lesion. This case represents a diagnostic challenge and emphasizes the potential utility of EUS in the preoperative work up for any presumable primary hepatobiliary neuroendocrine tumor.

Distinct clinical characteristics in young-onset pancreatic neuroendocrine tumor: A propensity-adjusted analysis

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Background: Pancreatic neuroendocrine tumor (PNET) is a rare disease. There is a lack of data on the association of age and sociodemographic characteristics on survival in patients with NET. Our study aimed to evaluate clinical, molecular differences, and survival outcomes in young-onset PNET (YOPNET) and late-onset PNET (LOPNET). Methods: We used the National Cancer Database to identify patients with YOPNET ( < 50 years) and LOPNET (≥50 years) who underwent definitive surgery diagnosed between 2004 and 2015. We calculated the survival outcomes using Kaplan Meier and Cox regression methods before and after 1:1 nearest neighbor propensity score matching. We used the AACR Genie cohort to compare mutation frequency with the Benjamini-Hochberg method between YOPNET and LOPNET. Results: A total of 6,259 patients with PNET were selected, of which 27% were YOPNET. Patients with YOPNET were more likely to be female, black, and Hispanic, have private insurance versus LOPNET (all p < .001). Patients with YOPNET had less comorbidity score, but greater tumor size ( > 4 cm) and higher stage (all p < .001). Patients with LOPNET were more likely to be treated in an academic/research facility ( p < .001). Patients with YOPNET were more likely to be located in the head of the pancreas ( p = .004). Patients with YOPNET had better overall survival (OS) as compared to patients with LOPNET which persisted after propensity score matching ( p < .001). This difference continued after adjusting for clinically significant variables (unmatched p = .008; matched p = .01) (Table). For genomic analysis, we identified 177 patients; 27% was YOPNET, and patients with YOPNET had a significantly lower rate of MEN1 mutation than patients with LOPNET (26% vs. 56%, p < .001). Rate of other mutations was not different. Conclusions: Patients with YOPNET who underwent surgery had better OS than LOPNET and were more likely to have higher stage and greater tumor size. YOPNET represents a disease with distinct clinical and molecular features. [Table: see text]

Finding a needle in a haystack: Endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic masses in the setting of chronic pancreatitis

Background:

The mainstay for the definitive diagnosis of pancreatic lesions is endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). However, there is evidence that EUS-FNA has low sensitivity in the setting of chronic pancreatitis (CP). This single-center retrospective study aimed to compare and analyze the diagnostic yield of EUS-FNA for solid pancreatic lesions in the presence and absence of CP, and to further investigate strategies for overcoming the low diagnostic yield in the setting of CP.

Methods:

This study identified patients who underwent EUS-FNA at Sanford USD Medical Center (SD, USA) for a solid pancreatic lesion between July 15, 2011, and November 30, 2017. Data on demographics, clinical features, cross-sectional imaging findings, EUS findings, cytology/pathology, and clinical follow up were collected.

Results:

The final diagnosis was adenocarcinoma in 156 patients (67%), neuroendocrine tumor in 27 (12%), lymphoma in 6 (3%), metastatic malignancy in 8 (4%), and benign etiologies in 35 (15%). CP was identified in 44/234 (19%) patients. The overall diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for EUS-FNA were 92.9%, 97.1%, 99.5%, 70.8%, and 93.5%, respectively. The sensitivity (80% vs. 95%, P=0.020) and accuracy (86% vs. 95%, P=0.043) were significantly lower in patients with CP compared to those without CP.

Conclusion:

CP can significantly affect the EUS-FNA diagnostic yield of solid pancreatic neoplasms. A high index of clinical suspicion is required in these cases to make a definitive diagnosis.

Distinct clinical characteristics of young-onset pancreatic cancer patients

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Background: Young-onset pancreatic adenocarcinoma (YOPC) is uncommon but there are limited studies for these patients. We used a population based registry to compare the characteristics and outcomes of young-onset vs. older patients with pancreatic adenocarcinoma. Methods: We selected the patients with pancreatic adenocarcinoma from the SEER registry diagnosed between 2004 and 2015. Cases with age of diagnosis less than 50 were termed young-onset pancreatic cancer. Stage 4 patients were excluded. We compared baseline characteristics of YOPC vs. older using Chi-square. Kaplan Meier and Cox regression were used for survival analysis of these patients. Results: Of 28,904 patients, 1,415 (4.9%) had YOPC while 27,489 (95.1%) were older. YOPC were more likely to have stage 3 compared to older patients with PC (31.6% vs. 25.3%). YOPC had a higher rate of surgery than older patients (40% vs. 29.1%, p < 0.001), were more likely to be male, black and of Hispanic ethnicity. The primary tumor location was not different between the two groups. Overall survival (OS) was higher in YOPC versus older patients (12 vs. 9 months, p < 0.001). The analysis of multivariable Cox regression confirmed that there is a significant association between survival and YOPC group after adjusting for stage, grade, gender, ethnicity, surgery and race (HR 1.23, 95% CI: 1.13-1.33, p < 0.001). Conclusions: Patients with non-metastatic YOPC represent a group of patients with distinct clinical characteristics. YOPC have a higher rate of surgery and better overall survival compared to older patients. [Table: see text]

Prognostic implications of tumor sidedness in colorectal cancer patients in South Dakota, 2006-2015

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Background: Tumor “sidedness” is emerging as an important prognostic and predictive factor in patients with metastatic colorectal cancer (CRC), with right sided colon cancer (RC) associated with poorer overall survival (OS) than left sided colon cancer (LC). This distinction has been noted in clinical trials and large databases, where American Indian (AI) populations are generally underrepresented. This project aims to investigate the prognostic implications of CRC sidedness in the state of South Dakota, focusing on the AI population. Methods: Data from patients diagnosed with CRC in the South Dakota cancer registry from January 1, 2006 to December 31, 2015 were analyzed for demographic and presenting features as well as survival outcomes. A total of 3,637 cases were included in the analysis, of which 191 (5%) were AI. Tumors arising from the cecum, ascending colon, hepatic flexure and transverse colon were considered RC while those arising from the splenic flexure, descending colon, sigmoid colon and rectum were considered LC. Results: In all patients, 47.1% of cases were RC; Caucasians (C) were significantly more likely to have RC, as 47.7% of cases in Caucasians were RC, whereas in the AI population, 35.6% cases were RC (p=0.005). Patients with RC were more likely to be female and older and less likely to present with metastatic disease than LC. Tumor sidedness was not associated with OS when analyzing all patients regardless of stage or in patients with non-metastatic disease. In patients with metastatic disease, RC was associated with inferior OS compared to LC [Median OS (mo): 9.9 v. 23.6, p<0.001]. When analyzed by race, RC was associated with inferior OS in C [Median OS (mo): 9.6 v. 23.6, p=0.002] but not in AI [Median OS (mo): 10.2 v. 10.4, p=0.082]. Conclusions: Although limited by small sample size, this analysis is hypothesis generating, as AI patients with CRC were more likely to have LC than Caucasians and the well described prognostic implications of RC were not noted in the AI population. Larger population studies and further investigation as to potential explanations for this finding are recommended.

Percutaneous removal of a retained appendicolith causing recurrent perihepatic abscesses between the liver and diaphragm

Many cases of appendicitis can be associated with appendicoliths. These may sometimes be lost during appendectomies and may be lodged in the body. Most of these cases lead to recurrent abscess formation, and these appendicoliths invariably need removal. Typically, this used to be done as an open surgery or laparoscopically. Here we describe the case of a transcutaneous removal of an appendicolith that was lodged between the liver and diaphragm that led to recurrent perihepatic abscess formation in a 24-year-old otherwise healthy man. The patient made a successful recovery without any recurrence. A transcutaneous approach to remove a retained appendicolith may be a feasible, a safe and an easy method to extract appendicoliths that are accessible for transcutaneous removal.

Clinical presentations, management, and outcomes of acute esophageal necrosis: a systemic review

BACKGROUND

To review all the reported literature on acute esophageal necrosis.

RESEARCH METHODS

Databases were searched using the special Medical Subject Heading (MeSH) terms. All the available reported cases of acute esophageal necrosis were analyzed.

RESULTS

A total of 154 cases were identified and 130 cases were analyzed. The mean age of presentation was 61 years, and 70% of cases were males. The most common presenting symptoms were hematemesis in 66%, shock in 36%, melena in 33%, abdominal or substernal pain in 28%. The most common comorbidities reported were diabetes in 38%, hypertension in 37%, alcohol abuse in 25%, and chronic kidney disease in 16%. On upper endoscopy, 51% had a distal disease, 36% had pan esophageal, and only 2% had a proximal disease. 84% of patients were treated with IV Proton Pump Inhibitors, 22% received transfusions, 23% got antibiotics for underlying sepsis, 14% also received sucralfate, and 4% required surgery for treatment. The mortality rate was 32%, while perforation was reported in 5% and stricture formation reported in 9% of patients.

CONCLUSIONS

Patients with acute esophageal necrosis can have a favorable outcome if treated appropriately.

Spatial Epidemiology of Pancreatic Cancer in South Dakota

BACKGROUND

Pancreatic cancer is the fourth leading cause of cancer-related mortality in the United States. Descriptive epidemiology of pancreatic cancer in South Dakota has not been studied before.

MATERIALS AND METHODS

All cases of pancreatic cancer reported to the SD Cancer Registry between January 2005 and December 2014 were included in the study. Variables collected included demographics, geographical location including county of residence and zip codes, date of diagnosis, date of last contact or follow-up, size and location of the tumor, grade of the tumor, diagnostic modality as well as therapeutic interventions. Log rank test was used to compare survival curves. Kaplan-Meier product limit estimates were provided. Data was analyzed using SAS 9.1.4 software.

RESULTS

One thousand sixty-four cases of pancreatic cancer were reported. Median age was 73 years. Cumulative age-adjusted incidence rate for pancreatic cancer for 2005-2014 was 11.1. Cumulative age-adjusted mortality rate for pancreatic cancer for 2005-2014 was 10.2. Almost half of these patients had distant metastasis at the time of presentation (n = 536; 50.4%). Overall, median survival was 5 months. Median survival for patients under the age of 60 years was 9.5 months as opposed to median survival for patients 60 years or older which was 3.9 months. Median survival of patients with well-differentiated, moderately differentiated, and poorly differentiated tumors, was 20.8 months, 8.2 months and 6.3 months respectively (p value = 0.0017).

CONCLUSION

Incidence of pancreatic cancer in South Dakota is similar to the national trends in the United States. Age at presentation, location of tumor in pancreas, and biological behavior of tumor were all predictors of survival in patients with pancreatic cancer.

The Impact of Repeating Endosonography with Confocal Endomicroscopy for the Diagnosis of Cystic Neuroendocrine Tumor

Cystic pancreatic neuroendocrine tumors represent around 13% of all neuroendocrine tumors (Hurtado-Pardo 2017). There has been an increase in the incidence of cases due to improvement in imaging modalities. This is a case of a 68-year-old male with the incidental finding of a pancreatic cyst on CT. Initial Endoscopic Ultrasound with Fine Needle Aspiration (EUS-FNA) showed sonographic and cytology features suggestive of a pancreatic pseudocyst. However the cyst persisted with no change in size after aspiration leading to a follow-up EUS- FNA, which was combined with needle based confocal laser endomicroscopy (nCLE). The nCLE features were consistent with a cystic pancreatic neuroendocrine tumor, which was later confirmed on histology after surgical resection.

Indeterminate biliary strictures: a simplified approach

Pre-operative evaluation of biliary strictures remains challenging. The dilemma that exists is how to balance the risk of failing to detect malignancy and the potential morbidity caused by unnecessary surgery in patients with benign etiologies. With emerging novel diagnostic modalities, this study aims to assess the efficacy of diagnostic techniques and facilitate a clinical approach to indeterminate biliary strictures. Areas covered: Conventional imaging modalities are crucial in identifying the location of a stricture and are helpful for choosing further diagnostic modalities. Utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), is key in establishing a diagnosis. The emergence of novel diagnostic modalities, such as fluorescence in-situ hybridization (FISH), peroral cholangioscopy (POC), intraductal endoscopic ultrasound (IDUS) and confocal laser endomicroscopy (CLE), enhance the diagnostic yield in the evaluation of indeterminate biliary strictures. Expert commentary: More reliable and validated visual criteria for differentiating malignancy from benign biliary conditions, utilizing advanced imaging modalities such as POC and CLE, need to be established. It is of significance to further evaluate these novel diagnostic modalities through ongoing trials and to develop a diagnostic algorithm that reconciles cost-effectiveness with diagnostic accuracy.

Non-surgical management of Boerhaave's syndrome: a case series study and review of the literature

BACKGROUND AND STUDY AIMS

 Boerhaave's syndrome (BS) is a life-threatening condition with morbidity and mortality rates as high as 50 % in some reports. Until recently, surgical intervention has been the mainstay of management plans. With advances in therapeutic endoscopy, however, there has been increasing interest in non-surgical options including endoscopic esophageal stenting.

PATIENTS AND METHODS

 We reviewed the medical records of all patients diagnosed with BS and managed with endoscopic interventions between November 2011 and November 2016. The following variables were collected: patient demographics, clinical presentations, locations of esophageal perforation, primary interventions, complications, and outcomes.

RESULTS

 Six patients were found to be diagnosed with BS during the study period. The median age at presentation was 55. There were 4 males and 2 females. The most common site of perforation was in the distal esophagus. The most common presenting symptom was chest pain (67 %) following an episode of vomiting or retching. Four patients (66.7 %) developed septic shock. Endoscopic treatment with a fully covered esophageal stent was the primary intervention in all patients (100 %). Interventional radiology was consulted in all cases for fluid drainage and chest tube placements. Clinical resolution of the BS was achieved in all patients (100 %) without any subsequent surgical interventions. There were no deaths within the study group, and the average follow-up duration was 2 years.

CONCLUSION

 Endoscopic treatment seems to be an effective management strategy in patients with BS. We also noted satisfactory results in patients presenting with sepsis, presumably due to urgent, interventional radiology-guided fluid drainage.

Evaluation of dose conformity and coverage of target volume for intensity-modulated radiotherapy of pelvic cancer treatment

BACKGROUND

Better conformity may help in delivering minimum dose to organs at risk (OARs) and maximum dose to planning target volume (PTV). As per the requirements of modern radiotherapy, 95% isodose should cover the PTV, so conformity indices (CIs) are used for evaluating quality of conformation of treatment plans.

AIM

This study aimed to investigate degree of conformity for pelvic patients using intensity-modulated radiotherapy (IMRT) technique. Three formulas of CIs described in literature were analyzed in this study.

SETTINGS AND DESIGN

This study was performed to evaluate degree of conformity of 18 patients treated with radiotherapy treatment plan using cumulative dose volume histogram. Effectiveness of different CIs was explored for IMRT plans using 15 MV photon beam. Doses delivered to OAR were also studied.

STATISTICAL ANALYSIS USED

CI suggested by the International Commission on Radiation Units and Measurements, radiation CI and CI prescription isodose to target volume (PITV) had mean ± standard deviation values of 1.02 ± 0.018, 0.98 ± 0.017, and 1.63 ± 0.333, respectively.

RESULTS AND CONCLUSION

Dose distribution for all patients was highly conformal and clinically acceptable. Values of CI PITV exceeded acceptable value for 27% patients with minor deviation. No statistically significant differences were observed for three CIs reported. Target volume lies between 95% and 107% of prescribed dose which shows ideal target coverage. This simple parameter is advantageous since it is easy to interpret and helped determine quality of treatment plan. This study clearly demonstrated that favorable dose distribution in PTV and OARs is achieved using IMRT technique, and hence, the risk of damage to normal tissues is reduced.

Glycogenic Hepatopathy: Thinking Outside the Box

Glycogenic hepatopathy (GH) remains underrecognized in adults as most clinicians mistake it for the more common hepatic abnormality associated with uncontrolled diabetes mellitus in this age group, non-alcoholic fatty liver disease. This is also complicated by the fact that both entities are indistinguishable on liver ultrasound. We herein describe a similar predicament in which a young adult female presented with bilateral upper quadrant abdominal pain, tender hepatomegaly, lactic acidosis and a >10-fold increase in liver enzymes, which worsened after the administration of high-dose steroids. Despite intravenous normal saline resuscitation, serum transaminitis persisted in a fluctuating manner. Ultimately, a liver biopsy confirmed GH. Biochemically, GH is driven by high amounts of both circulating glucose and insulin or by the administration of high-dose steroids. Improving glycemic control is the mainstay of treatment for GH. However, in our case, improvement in glycated hemoglobin of just 0.6% was enough to achieve symptomatic relief, supporting recent claims of the involvement of other identified factors in disease development.

Undifferentiated carcinoma of pancreas: a rare entity with aggressive behavior and possible genetic link

An aggressive undifferentiated carcinoma of pancreas is a rare tumor, especially with a strong personal and family history of malignant melanoma. Limited literature review and few case reports described a genetic association between distinct types of pancreatic cancer and malignant melanoma.

CASE REPORT

We present an uncommon case of an aggressive undifferentiated carcinoma of the pancreas in a 50-year-old Caucasian female. Initially, she presented with intermittent epigastric postprandial pain and mild nausea. A computed tomography scan of the abdomen showed a 5 cm heterogenous pancreatic tail mass, which on biopsy was found to be a poorly differentiated non-small cell carcinoma. Past medical history included malignant melanoma, with extensive family history of pancreatic cancer and malignant melanoma. However, not genetically confirmed, a hereditary pancreatic linkage was highly suspected. A week later, repeat computed tomography demonstrated tremendous enlargement of the pancreatic tail mass. Within a few weeks, the patient developed aggressive metastasis in various organ systems, followed by multiple surgeries. An emergent first round of chemotherapy was started, followed by an intensive care unit stay, and she eventually died.

CONCLUSION

Our case exposes the aggressive behavior of undifferentiated carcinoma of pancreas, along with possible hereditary link between pancreatic cancer and malignant melanoma.

Verrucous carcinoma of the esophagus: a potential diagnostic dilemma

Verrucous carcinoma of the esophagus is a rare variant of squamous cell carcinoma associated with human papillomavirus. We report the case of a 58-year-old female who presented with ongoing symptoms of dysphagia. On previous endoscopies she had been noted to have a large polyp-like mass involving the esophagus, with negative biopsies for malignancy. Repeat endoscopy with concurrent endoscopic ultrasound showed a large semi-pedunculated polyp in the distal esophagus and a hypoechoic, irregular mass involving the gastroesophageal junction with esophageal thickening. Deep layer biopsies showed pseudoepitheliomatous hyperplasia with immunohistochemical staining positive for human papillomavirus. The patient was subsequently treated with chemo-radiation followed by esophagectomy.

Clinical decision making in the management of pancreatic cystic neoplasms

Pancreatic cystic lesions continue to pose diagnostic and management dilemmas for physicians. This may be related, in part, to the fact that these lesions represent a range of diagnostic possibilities, from inflammatory cysts and nonmucinous cysts to mucinous cysts, which may or may not have foci of invasive malignancy. Adequate characterization of cystic lesions is necessary to help devise a management plan. Moreover, patient-related factors such as comorbid conditions are often essential in deciding whether patients should be managed by a conservative approach of watchful waiting versus surgical resection, if so indicated. This review summarizes the recent advances in the management of pancreatic cystic neoplasms.

EUS-FNA for pancreatic neuroendocrine tumors: a tertiary cancer center experience

OBJECTIVES

Pancreatic neuroendocrine tumors (PNET) are fairly uncommon. Recent data highlight the importance of EUS in diagnosis of PNET. With this background, we decided to review our experience from a tertiary cancer center with regard to the presentation and clinical features of PNET and the diagnostic utility of EUS-FNA in this scenario.

METHODS

We identified patients who underwent EUS at our institution between January 1st 2001 and December 31st 2009 for a suspected PNET. Data on clinical features, cross-sectional imaging findings, EUS findings, and cytology results were collected.

RESULTS

A total of 81 patients were referred for EUS-FNA for a suspected PNET. Mean age was 58.1 years. There were 41 (50.6%) males. PNET was found incidentally in 38 (46.9%) patients. Computed tomography scanning identified a pancreatic mass in 72 out of 79 (91.1%) cases. Mean diameter of the largest lesion seen on EUS was 27.5 mm (range: 6.9-80 mm). The most common site (34; 42%) was the head of the pancreas. EUS-FNA correctly confirmed a PNET in 73 out of 81 cases with diagnostic accuracy of 90.1%. Seven (8.6%) out of 81 patients had functional lesions, including three gastrinomas and four insulinomas. Liver metastases were found in 31 out of 81 (38.3%) cases. Of the 31 patients with liver metastasis, the mean diameter of lesions on EUS was 33.9 mm compared with 23.5 mm in patients without liver metastasis (P = 0.005).

CONCLUSION

EUS-FNA is a reliable modality for further characterization of suspected lesions and for establishing a tissue diagnosis. The occurrence of complications of EUS-FNA in this setting is low. Non-functional PNET are more frequently encountered than functional PNET.

Patients with congenital atrial septal defects: effect of age at repair and defect size on pulmonary artery pressures prior to repair

BACKGROUND

Pulmonary arterial hypertension (PAH) is a major complication of atrial septal defect (ASD) and can be responsible for significant functional limitations and early mortality. Various factors have been shown to predispose ASD patients to the development of PAH. Our study aimed to determine the association between the size of the ASD, the age of the patient and the increase in pulmonary artery pressures.

METHODS

Data from 74 ASD patients was retrospectively reviewed, including the patients' presenting symptoms, vital parameters, comorbidities, as well as their preoperative diagnostic workup. Echocardiography findings were used to determine the type and size of the ASD, and pulmonary artery pressures were evaluated using tricuspid regurgitation velocity as assessed by echocardiography or based on cardiac catheterization data. All patients underwent ASD repair either surgically or via percutaneous repair. Univariate and multivariate linear regression was performed to analyze the effect of age and defect size on pulmonary artery pressures. Model adequacy check was also done for the final model. Postoperative morbidity/mortality was additionally evaluated.

RESULTS

The study sample comprised 44.6% males and 55.4% females. The most prominent presenting features were shortness of breath (70.3%), chest pain (43.2%), and palpitations (33.8%), and arterial hypertension was the commonest morbidity. Using multiple linear regression analysis, age and size of ASD were found to be independently associated with pulmonary artery pressure. We found that for every 1 mm increase in the size of the ASD, pulmonary artery systolic pressure (PASP) increased by 0.32 mmHg ( P ≤ 0.05). Similarly, with every increase of one year in age, pulmonary artery pressure increased by 0.24 mmHg (P ≤ 0.02). No significant postoperative complications were reported following both types of repair.

CONCLUSIONS

Our study concludes that ASD patients are at greater risk of developing PAH with increasing age and increasing ASD size. This can potentially help to determine which ASD patients are at greater risk and require urgent repair of their defects. The study also shows that early repair is best to prevent complications.

Surgery in pancreatic cancer (PC): Identifying potential barriers

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Background: Due to lack of effective systemic therapy, surgical resection remains the mainstay of treatment of PC and the only potential for cure. Even though mortality of PC surgery has decreased in recent years, surgical rates remain lower than for other cancer types. We performed an analysis of early-stage PC to determine factors that may prevent patients from undergoing surgery.

Methods: PC cases diagnosed between 1996 and 2008 were identified from the Veteran's Affairs Central Cancer Registry. Patients with early stage disease, defined as AJCC clinical stage group 1-3, were included. Data were analyzed using biostatistical software SPSS. Chi-square analysis was performed for categorical variables comparing those who underwent surgery (SUR) and those in which surgery was not performed (SNP). Kaplan-Meier analysis was used for estimates of overall survival.

Results: Of 1,306 cases identified, 97.7% were male, 78% where white. Surgery was performed in 251 (19.2%) cases. Surgery was not recommended in 739 (56.6%) and contraindicated due to patient related factors in 198 (15.2%) cases. Surgery was recommended but not performed due to unknown reasons in 59 (4.5%); patient refusal in 43 (3.3%) and “other reasons” in 16 (1.2%) cases. Mean age in SUR vs. SNP was 64.1 vs. 67.5 years. Median survival was 11.1 months in SUR vs. 5.5 months SNP (p<0.001). On univariate analysis, patients with diabetes had less surgery (10.5%) compared to other comorbidities (p<0.001). Tumors in the body of the pancreas had less surgery (4.8%) compared to the head or tail (19.9%, 23.6%, p<0.001). Sex, race, alcohol, and tobacco use did not significantly impact surgery rates (p>0.05). On multivariable analysis including race, sex, primary site, comorbidity, chemotherapy, radiation, alcohol, and tobacco use, only comorbidity was independently associated with less surgery.

Conclusions: In this registry-based, retrospective analysis of early stage PC, although SUR patients had better survival than SNP, surgery was not recommended as a treatment option for most patients by their providers. Whereas comorbid conditions do seem to influence this decision, race and patient refusal was not a major factor.

No significant financial relationships to disclose.

Cholangiocarcinoma: an endoscopist's perspective

The incidence of cholangiocarcinoma is on the rise. This may be related in part to higher detection rates secondary to sophisticated endoscopic modalities. These tumors pose a significant diagnostic dilemma. High index of suspicion, careful interpretation of serum markers and utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography and endoscopic ultrasound, help to establish the diagnosis. Imaging modalities are crucial in the evaluation of these tumors. They help to define the extent of the native lesion, which may dictate its resectability, as well as evaluate for metastasis. Therapeutic options are somewhat limited, short of surgical resection. Newer chemotherapeutic agents, as well as endoscopy-targeted therapy, may improve the overall treatment success rate, although experience is somewhat limited at this time. Endoscopic intervention is essential for palliation.

Transcatheter closure of a patent ductus arteriosus in a patient with an anomalous inferior vena cava

A patient with a patent ductus arteriosus (PDA) was catheterized for device closure. Anomalous systemic venous drainage was found with interrupted inferior vena cava and persistence of hepatic vessel plexus. Using the superior vena cava route, the PDA was closed successfully.

Giant gastric hyperplastic polyp: not always a benign lesion

Giant gastric hyperplastic polyps constitute of around 76% of all gastric polyps found. They are often found incidentally on upper GI endoscopy. They often present with occult GI bleeding causing iron deficiency anemia or partial gastric outlet obstruction. Although mostly benign, they do have potential for malignant transformation and hence must be excised endoscopically or surgically, whichever may be feasible. We hereby present a couple of cases of gastric hyperplastic polyps in an attempt to add to the current literature on this rather rare entity.

Corrosive injury to the GI tract in adults: a practical approach

Corrosive injury to the GI tract still poses great challenges with regards to the initial evaluation triage, as well as the optimization of medical management. Although relatively uncommon in the adult population, these injuries can cause significant morbidity and serious sequelae of complications, such as esophageal strictures and cancer. Prompt recognition of the process and aggressive measures towards the stabilization of the patient are key to a favorable outcome.

Hepatitis E virus antibodies in patients with chronic liver disease

In the United States, the seroprevalence rate for hepatitis E virus (HEV) is ≈20%. This study examined HEV seroprevalence in persons with and without chronic liver disease. Our data indicate that HEV seropositivity is high in patients with chronic liver disease and that HEV seroprevalence increases significantly with age.

Amiodarone induced liver cirrhosis. Report of two cases

Amiodarone is used commonly in patients with cardiac diseases. Common side effects include thyroid dysfunction and hepatic abnormalities. However, recently there has been concern for developing liver cirrhosis secondary to amiodarone therapy. We present two cases of liver cirrhosis in patients taking amiodarone. Their clinical presentation as well as histological features are discussed in detail.

Biliary tract complications after liver transplantation

Biliary tract complications are an important source of morbidity after liver transplantation, and present a challenge to all involved in their care. With increasing options for transplantation, including living donor and split liver transplants, the complexity of these problems is increasing. However, diagnosis is greatly facilitated by modern noninvasive imaging techniques. A team approach, including transplant hepatology and surgery, interventional endoscopy and interventional radiology, results in effective solutions in most cases, such that operative reintervention or retransplantation is rarely required.

Pancreatic plasmacytoma presenting as variceal hemorrhage: life threatening complication of a rare entity

CONTEXT

Pancreatic plasmacytoma is a rare entity and presents with features of mass lesion of pancreas.

CASE REPORT

We present an interesting case of pancreatic plasmacytoma with life threatening gastrointestinal bleeding secondary to isolated gastric varices.

CONCLUSION

This case highlights the importance of considering it in differential diagnosis of patients with anemia, recurrent pancreatitis or jaundice and isolated gastric varices, prompting a CT scan to evaluate for any pancreatic mass lesions.

Hepatoid esophageal carcinoma: a rare cause of elevated alpha fetoprotein

AFP-producing tumors are uncommon. They have mostly been described of pulmonary origin. However, they have also been described from gastrointestinal tract. Esophageal involvement with hepatoid tumor has been rarely described. The diagnosis is clinically challenging in patients with metastatic disease to liver. We present an interesting case of AFP-producing esophageal tumor, describing its clinical presentation, endoscopic manifestation, as well as histological features.

Isolated tuberculosis of the pancreas: a case report

CONTEXT

Pancreatic tuberculosis is a rare entity. Only a few cases have been reported in the medical literature. We hereby describe a case of pancreatic tuberculosis in an immunocompromized individual.

CASE REPORT

A fifty-year-old African-American gentleman with history of HIV non-compliant on anti-retroviral therapy presented with epigastric pain for five weeks duration. CT scan of abdomen showed large necrotic node on the posterior aspect of the head of pancreas and multiple cystic masses adjacent to the pancreas. Acid fast bacilli were found on staining of CT guided biopsy of the node. Cultures grew Mycobacterium tuberculosis. Anti-tubercular therapy was initiated and resulted in gradual resolution of symptoms.

CONCLUSION

Pancreatic tuberculosis is rare and is frequently confused with pancreatic cancer on clinical presentation as well as on imaging studies. Since it is a curable disease, accurate diagnosis is paramount CT or ultrasound guided biopsy is cornerstone of diagnosis. Endoscopic ultrasound is now increasingly being used for obtaining tissue for diagnosis. Anti-tubercular therapy is curative in majority of the cases.

Impact of screening on presentation and survival of colorectal cancer

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Background: There is an increasing emphasis and utilization of colorectal cancer (CRC) screening. We evaluated the effect of screening on CRC presentation and outcome. Methods: We reviewed all the invasive CRC cases diagnosed between Jan 1995-Dec 2005 at the Cincinnati Veteran’s Affairs hospital. Individual case records were reviewed and the data collected including patient demographics, treatment, outcome, mode of presentation as well as whether CRC was detected as a result of screening. Results: Altogether 288 patients were diagnosed with CRC during the study period. The median age at presentation was 69.3 years and 18.8% were African-Americans. Early stage CRC was diagnosed in 63.4% cases (stage 1: 32.7%, stage 2: 30.8%) and 33.3% were diagnosed at advanced stage (stage 3: 18.1% and stage 4: 15.3%). Seventy seven (26.7%) CRCs were asymptomatic at presentation and were diagnosed as a result of screening. Predominant screening modalities included fecal occult blood testing (46.8%) and flexible sigmoidoscopy (22.1%). The proportion of screen- detected cases increased from 19% in 1995–1999 to 32% in 2000–05 (p = 0.047). Demographics, including age and race, as well as the site of CRC were similar to symptomatic cases. Screen-detected cancers presented early, with 77.9% presenting at early stage (stage 1: 55.8%, stage 2: 22.1%), compared to 51.5% (stage 1: 21.0%, stage 2: 30.5%) of symptomatic cancers (p <0.01). Only 1.3% of screen-detected CRC was found to be metastatic as compared to 21.0% of the symptomatic cases. The screen-detected cancers had significant survival advantage compared to symptomatic cases; with median survival being 81 months vs. 43 months in the latter (p =0.018). A proportional hazard regression analysis indicated that this improvement in survival was related to the fact that screening resulted in earlier stage at diagnosis. Only 20.3% of screen-detected CRC received adjuvant chemotherapy compared to 41.4% of symptomatic cases (p=0.002). Conclusions: An increasing proportion of CRC is being diagnosed as a result of screening. These cancers present at an earlier stage and are associated with a significantly improved survival. However, most CRC still presents symptomatically and more effective population screening is needed.

No significant financial relationships to disclose.