Factors Associated With Difficult Endoscopic Ultrasonography-guided Biliary Drainage

BACKGROUND AND AIMS

When endoscopic retrograde cholangiopancreatography-guided biliary drainage is challenging, endoscopic ultrasound-guided biliary drainage (EUS-BD) can be used as an alternate treatment; however, this method requires operator expertise. Therefore, this study aimed to clarify the factors that are associated with a difficult EUS-BD.

PATIENTS AND METHODS

Patients who successfully underwent EUS-BD were enrolled in this study. The patients were divided into the easy group and difficult group depending on whether the procedural time was more than 60 minutes, which was the cutoff value elicited from past reports. Patient characteristics and procedural factors were compared between the two groups. The factors associated with difficult procedures were also investigated.

RESULTS

The patient characteristics were not significantly different between the easy group (n=22) and the difficult group (n=19). The diameter of the punctured bile duct was significantly different between the two groups. In the multivariate analysis, the diameter of the punctured bile duct was the only factor associated with a difficult EUS-BD (odds ratio 0.65, 95% confidence interval 0.46-0.91, P value=0.012). The cutoff value for the diameter of the punctured bile duct in predicting a difficult EUS-BD was 7.0 mm (area under the curve: 0.83, sensitivity 84.2%, specificity 86.4%).

CONCLUSIONS

A nondilated bile duct might be a predictive factor for a difficult EUS-BD. For beginners of EUS-BD, the cutoff value for the punctured bile duct diameter found in this study, 7.0 mm, might become a barometer for puncture point selection.

Prevalence of Cardiac Amyloidosis in Patients Undergoing Carpal Tunnel Release With Amyloid Deposition

BACKGROUND

Carpal tunnel syndrome (CTS) is considered an early sign of cardiac amyloidosis (CA) because amyloid deposition is often confirmed in the tenosynovium removed during carpal tunnel release (CTR); however, the prevalence of concomitant CA is unclear.Methods and Results: We prospectively examined 700 patients who underwent CTR and evaluated amyloid deposition after tenosynovium removal. Amyloid deposition was observed in 261 (37%) patients, who were significantly older and predominantly male (P<0.05). Of them, 120 agreed to cardiac screening. We performed ^{99 m}Tc-labeled pyrophosphate (^{99 m}Tc-PYP) scintigraphy in 12 patients who met either of the following criteria: (1) interventricular septal diameter (IVSd) ≥14 mm or (2) 12 mm ≤ IVSd < 14 mm with above-normal limits in high-sensitivity cardiac troponin T (hs-cTnT). Six patients (50%) had positive findings on ^{99 m}Tc-PYP scintigraphy and were diagnosed with wild-type transthyretin CA. Concomitant CA was observed in 6/120 (5%) CTR patients with amyloid deposition and 50% (6/12) in patients with left ventricular hypertrophy (≥12 mm) with increased hs-cTnT levels.

CONCLUSIONS

Amyloid deposition was frequently observed in the removed tenosynovium of elderly men with CTS. Cardiac screening may be useful for early diagnosis of CA in patients undergoing CTR with amyloid deposition.

Novel Photodynamic Therapy for Esophageal Squamous Cell Carcinoma following Radiotherapy

Radiotherapy (RT) or chemoradiotherapy (CRT) are frequently selected as treatments for esophageal squamous cell carcinoma (ESCC). However, salvage treatment remains challenging when endoscopic resection is not indicated for residual or recurrent ESCC following RT or CRT. Recently, owing to the emergence of second-generation photodynamic therapy (PDT) using talaporfin sodium, PDT can be performed with less phototoxicity and therefore has regained popularity in the treatment of ESCC. In this study, the effectiveness and safety of second-generation PDT in patients with residual or recurrent ESCC following RT or CRT were examined. Local complete response (L-CR) rates, procedure-related adverse events, and prognosis were evaluated. In 12 patients with 20 ESCC lesions, the L-CR rates were 95.0%. Perforation, postoperative bleeding, and photosensitivity were not observed. Esophageal stricture following PDT developed in one patient, but this could be addressed using balloon dilation. During a median follow-up period of 12 (range, 3-42) months, the 3-year cause-specific survival rate was 85.7%. Even in patients with a Charlson comorbidity index score ≥ 3, the 2-year overall survival rates were 100%. In conclusion, PDT was an efficacious and a safe salvage treatment in patients with local residual or recurrent ESCC following RT or CRT.

Clinical benefit of subsequent chemotherapy after drug-induced interstitial lung disease in pancreatic cancer patients: a multicenter retrospective study from Japan

PURPOSE

Drug-induced interstitial lung disease (ILD) is not a rare adverse event in the current chemotherapy strategy for pancreatic ductal adenocarcinoma (PDAC). Thus, we aimed to find the optimal management for PDAC patients with a history of ILD induced by a gemcitabine-based regimen.

METHODS

We conducted a multicenter retrospective study. The primary endpoint was the overall survival (OS) of patients who underwent either S-1 monotherapy or FOLFOX after the onset of ILD. Toxicity data was also analyzed in the 2 groups.

RESULTS

Twenty-four patients were diagnosed with ILD and 17 patients who received subsequent chemotherapy were enrolled in the study. Among 17 patients who were managed with subsequent chemotherapy after recovering from ILD, we did not observe significant difference in OS between S-1 and FOLFOX (290.0 days vs. undefined, p = 0.39). Relapse of drug-induced ILD was not observed in all cases during the course. Overall, severe adverse events (CTCAE Grade 3 or 4) were observed in 3 patients (23.1%) in S-1 treatment group and 1 patient (25.0%) in FOLFOX treatment group (p = 0.93).

CONCLUSIONS

S-1 monotherapy and FOLFOX are comparable as the subsequent chemotherapy after gemcitabine-based chemotherapy-induced ILD in unresectable PDAC.

Endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma in patients with cirrhosis and esophageal varices

Endoscopic submucosal dissection (ESD) has become the standard treatment for superficial esophageal squamous cell carcinoma (SESCC). However, the treatment strategy for SESCC complicated by esophageal varices (EVs) has not been established. We report two cases of SESCC in patients with alcoholic cirrhosis complicated by EVs who underwent ESD. Case 1 presented with EVs on the anal side of the SESCC, and endoscopic variceal ligation (EVL) was performed before ESD. After EVL, the SESCC was successfully treated by ESD without any adverse events. Case 2 presented EVs from the anal side of the SESCC to the submucosa just below the SESCC. Then, EVL and endoscopic injection sclerotherapy with polidocanol were performed before ESD. However, ESD was not completed because of severe bleeding by uncontrolled blood flow below and around the SESCC. Bleeding during ESD was controlled in case 1, but not in case 2.

Comparison of time to recurrent biliary obstruction between plastic stents and metallic stents for endoscopic ultrasound‑guided biliary drainage

Endoscopic ultrasound-guided biliary drainage (EUS-BD) may prevent stent placement at the bile duct stricture. Therefore, whether a plastic stent (PS) or metallic stent (MS) should be used for EUS-BD remains to be undetermined. The present study aimed to clarify whether a PS or MS was more efficient for EUS-BD. Patients with malignant biliary obstruction who were successfully treated with EUS-BD were enrolled in the present study. The clinical characteristics, procedural outcomes and time to recurrent biliary obstruction (TRBO) were compared between patients treated with a PS (PS group) and patients treated with an MS (MS group). Consequently, 28 patients underwent PS placement and 11 patients underwent MS placement. In the PS group, 12 patients also underwent EUS-antegrade stenting (AGS) using an MS. The TRBO was not significantly different between the two groups (P=0.25). When the patients with AGS were excluded, the TRBO was significantly longer in the MS group than in the PS group (P=0.036). However, the TRBO was not significantly different between the patients in the MS group and those in the PS group who underwent AGS (P=0.61). In EUS-BD, MS is expected to be associated with a longer TRBO than PS. However, combining EUS-BD with AGS may help overcome the shorter TRBO associated with the use of PS.

A neonate with multiple hand flexor tendon ruptures due to methicillin-susceptible Staphylococcus aureus sepsis: a case report

BACKGROUND

Neonatal pyogenic tenosynovitis is a highly emergent soft tissue infection. We report a case of a neonate with pyogenic tendinopathy and tendon rupture diagnosed by ultrasonography (US). He subsequently developed pyogenic arthritis and osteomyelitis during antimicrobial therapy.

CASE PRESENTATION

A 7-day-old boy was admitted to our hospital with redness and swelling of the right index finger. US on admission showed rupture of the flexor tendon of the right index finger with inactivity. The day after admission, he developed pyogenic arthritis of the right elbow and, subsequently, pyogenic osteomyelitis. Staphylococcus aureus was identified through bacterial culture, and the patient was treated with intravenous antibiotics for 6 weeks. However, after discharge from our hospital, rupture of the flexor tendon of the left thumb was confirmed. A two-stage flexor tendinoplasty was completed at the age of 2 years and 1 month for the flexor tendon rupture on his right index finger.

CONCLUSIONS

In addition to blood culture, ultrasonographic evaluation should be performed in neonates with erythematous and swollen joints to identify the focus of infection as soon as possible. Moreover, repeated regular US examination is important in the follow-up of bone and soft tissue infections.

A multicenter comparative study of endoscopic ultrasound-guided fine-needle biopsy using a Franseen needle versus conventional endoscopic ultrasound-guided fine-needle aspiration to evaluate microsatellite instability in patients with unresectable pancreatic cancer

BACKGROUND/AIMS

Immune checkpoint blockade has recently been reported to be effective in treating microsatellite instability (MSI)-high tumors. Therefore, sufficient sampling of histological specimens is necessary in cases of unresectable pancreatic cancer (UR-PC). This multicenter study investigated the efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using a Franseen needle for MSI evaluation in patients with UR-PC.

METHODS

A total of 89 patients with UR-PC who underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or EUS-FNB using 22-G needles at three hospitals in Japan (2018-2021) were enrolled. Fifty-six of these patients (FNB 23 and FNA 33) were followed up or evaluated for MSI. Patient characteristics, UR-PC data, and procedural outcomes were compared between patients who underwent EUS-FNB and those who underwent EUS-FNA.

RESULTS

No significant difference in terms of sufficient tissue acquisition for histology was observed between patients who underwent EUS-FNB and those who underwent EUS-FNA. MSI evaluation was possible significantly more with tissue samples obtained using EUS-FNB than with tissue samples obtained using EUS-FNA (82.6% [19/23] vs. 45.5% [15/33], respectively; p<0.01). In the multivariate analysis, EUS-FNB was the only significant factor influencing the possibility of MSI evaluation.

CONCLUSION

EUS-FNB using a Franseen needle is desirable for ensuring sufficient tissue acquisition for MSI evaluation.

Efficacy of a novel large-cell Niti-S stent with a slim delivery system for hilar biliary obstruction: a preliminary study

OBJECTIVES

The large-cell Niti-S stent is useful for multiple stenting in patients with malignant hilar biliary obstruction (MHBO). Recently, a novel uncovered self-expandable metallic stent (USEMS) (a Niti-S large-cell SR slim delivery system) was developed. In this study, we aimed to evaluate the efficacy of this USEMS slim delivery system in MHBO patients.

MATERIALS AND METHODS

Outcomes related to USEMS placement, the clinical course, and the period to recurrent biliary obstruction (RBO) were evaluated in MHBO patients who received multiple USEMSs with the Niti-S large-cell SR slim delivery system.

RESULTS

Twenty-two MHBO patients underwent the placement of multiple USEMSs, including the novel slim-delivery stent. Six patients had a past history of upper gastrointestinal reconstruction (Billroth I: 1, Billroth II: 4, Roux-en-Y: 1). The number of USEMSs placed in each patient was 2-6. Three procedures were reinterventions. The new slim delivery system was placed as the first stent in ten patients and as an additional stent in the remaining patients. Seven patients were drained using only Niti-S large-cell SR slim delivery stents. The technical and clinical success rates were both 100%.

CONCLUSIONS

Placing multiple USEMSs in patients with a past history of abdominal surgery or in reintervention is difficult. Although difficult cases were included in this study, stent-in-stent placement with the novel Niti-S large-cell SR slim delivery system was useful in treating MHBO patients. In addition, this novel stent might be the first choice for MHBO patients.KEY MESSAGESEndoscopic multistenting for MHBO is challenging. In addition, reintervention or multistenting for MHBO patients with a past history of abdominal surgery becomes more difficult.The novel Niti-S large-cell SR slim delivery USEMS is useful as an additional stent because the delivery system is thin and suitable for a 0.025 guidewire. In addition, the novel stent is of the braided type and has a large mesh. Therefore, the novel stent is expected to have strong radial force and can be used as the first SEMS.The Niti-S large-cell SR slim delivery stent is long enough to be used in patients with upper gastrointestinal reconstruction. Although this study included patients with reintervention or a past history of upper gastrointestinal reconstruction, the technical success rate of multiple stenting for MHBO patients was 100%. The slim-delivery stent might overcome several difficulties of endoscopic multistenting.

Association between Submucosal Fibrosis and Endoscopic Submucosal Dissection of Recurrent Esophageal Squamous Cell Cancers after Chemoradiotherapy

Simple Summary

The efficacy and safety of endoscopic submucosal dissection for early esophageal cancer after chemoradiotherapy have not been established. In this study, we focused on the fibrosis of the submucosa. As a result, we found that endoscopic submucosal dissection for early esophageal cancer can be performed reliably without adverse events, but the procedure takes longer for lesions with strong fibrosis of the submucosa.

Abstract

Endoscopic resection is a treatment of choice for a metachronous early-stage esophageal squamous cell carcinoma (ESCC) appearing after a radical cure of esophageal cancer by chemoradiotherapy (CRT). However, non-curative resection, and procedural complications including perforation due to radiation-induced submucosal fibrosis, are a concern. This study aimed to evaluate the association between submucosal fibrosis and the usefulness and safety of endoscopic submucosal dissection (ESD) in ESCC after CRT. This study retrospectively analyzed 13 lesions in 11 patients in our institute. Submucosal fibrosis under the lesion (F score) was classified into three levels (F0: none or mild, F1: moderate, and F2: severe) based on endoscopic and histopathologic findings. All lesions were F1 or greater (F1: 8 lesions and F2: 5 lesions). En bloc and R0 resection rates were both 100%. The procedural speed was slower in F2 than in F1 (F1 vs. F2; 15.1 mm²/min vs. 7.1 mm²/min, p = 0.019), without procedure-related adverse events. At a median follow-up of 42 months (range: 14–117 months) after ESD, 7 of 11 (63.6%) patients were alive without recurrence, and without ESCC-related death. ESCC after CRT reliably and safely resected en bloc by ESD but was more difficult in lesions with strong submucosal fibrosis.

Screening for hilar biliary invasion in ampullary cancer patients

BACKGROUND

The treatment for ampullary cancer is pancreatoduodenectomy or local ampullectomy. However, effective methods for the preoperative investigation of hilar biliary invasion in ampullary cancer patients have not yet been identified.

AIM

To determine the necessity of and an appropriate method for investigating hilar biliary invasion of ampullary cancer.

METHODS

Among 43 ampullary cancer patients, 34 underwent endoscopic treatment (n = 9) or surgery (n = 25). The use of imaging findings (thickening and enhancement of the bile duct wall on contrast-enhanced computed tomography, irregularity on endoscopic retrograde cholangiography, thickening of the entire bile duct wall on intraductal ultrasonography (IDUS), and partial thickening of the bile duct wall on IDUS) and biliary biopsy results for diagnosing hilar biliary invasion of ampullary cancer was compared.

RESULTS

Hilar invasion was not observed in every patient. Among the patients who did not undergo biliary stent insertion, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results showed the highest accuracy (100%) for diagnosing hilar biliary invasion. However, each imaging method and biliary biopsy yielded some false-positive results.

CONCLUSION

Although some false-positive results were obtained with each method, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results was useful for diagnosing hilar biliary invasion of ampullary cancer. However, hilar invasion of ampullary cancer is rare; therefore, the investigation of hilar biliary invasion of ampullary cancer might be unnecessary.

Clinical usefulness and acceleratory effect of macrophage inhibitory cytokine-1 on biliary tract cancer: an experimental biomarker analysis

BACKGROUND

Biliary tract cancer (BTC) has a poor prognosis; therefore, useful biomarkers and treatments are needed. Serum levels of macrophage inhibitory cytokine-1 (MIC-1), a member of the TGF-β superfamily, are elevated in patients with pancreaticobiliary cancers. However, the effect of MIC-1 on BTC is unknown. Therefore, we investigated the effect of MIC-1 on BTC and assessed whether MIC-1 is a biomarker of or therapeutic target for BTC.

METHODS

MIC-1 expression in BTC cells was determined by performing histological immunostaining, tissue microarray (TMA), western blotting, and reverse transcription PCR (RT-PCR). Cell culture experiments were performed to investigate the effect of MIC-1 on BTC cell lines (HuCCT-1 and TFK-1). The relationships between serum MIC-1 levels and either the disease state or the serum level of the apoptosis marker M30 were retrospectively verified in 118 patients with pancreaticobiliary disease (individuals with benign disease served as a control group, n = 62; BTC, n = 56). The most efficient diagnostic marker for BTC was also investigated.

RESULTS

MIC-1 expression was confirmed in BTC tissue specimens and was higher in BTC cells than in normal bile duct epithelial cells, as determined using TMA, western blotting and RT-PCR. In cell culture experiments, MIC-1 increased BTC cell proliferation and invasion by preventing apoptosis and inhibited the effect of gemcitabine. In serum analyses, serum MIC-1 levels showed a positive correlation with BTC progression and serum M30 levels. The ability to diagnose BTC at an early stage or at all stages was improved using the combination of MIC-1 and M30. The overall survival was significantly longer in BTC patients with serum MIC-1 < the median than in BTC patients with serum MIC-1 ≥ the median.

CONCLUSIONS

MIC-1 is a useful diagnostic and prognostic biomarker and might be a potential therapeutic target for BTC.

Biliary metal stents should be placed near the hilar duct in distal malignant biliary stricture patients

BACKGROUND

Endoscopic biliary drainage using a self-expandable metallic stent (SEMS) has been widely performed to treat distal malignant biliary obstruction (DMBO). However, the optimal position of the stent remains unclear.

AIM

To determine the ideal position for SEMS placement.

METHODS

In total, 135 DMBO patients underwent SEMS (uncovered or covered) placement over a ten-year period. A total of 127 patients with biliary obstruction between the junction of the cystic duct and Vater's papilla were enrolled. An SEMS was placed through the upper common bile duct 2 cm from the biliary hilar duct in 83 patients (Hilar group) or near the top of the biliary obstruction in 44 patients (Lower group). Technical and functional success, adverse events, and risk factors for SEMS dysfunction were evaluated.

RESULTS

The stent patency period was significantly longer in the Hilar group than in the Lower group (P value < 0.01). In multivariate analysis, the only statistically significant risk factor for SEMS dysfunction was being in the Lower group (hazard ratio: 9.94, 95% confidence interval: 2.25-44.0, P < 0.01).

CONCLUSION

A longer patency period was achieved by positioning the SEMS near the biliary hilar duct.

Drug treatment for chemotherapy-induced peripheral neuropathy in patients with pancreatic cancer

Pancreatic cancer (PC) is a lethal disease where most tumors are too advanced at diagnosis for resection, leaving chemotherapy as the mainstay of treatment. Although the prognosis of unresectable PC is poor, it has been dramatically improved by new chemotherapy treatments, such as the combination of 5-fluorouracil, oxaliplatin, irinotecan, and leucovorin (FOLFIRINOX) or gemcitabine plus nab-paclitaxel. However, as oxaliplatin and paclitaxel are common neurotoxic drugs, chemotherapy-induced peripheral neuropathy (CIPN) is a common and severe adverse effect of both treatments. As there are no agents recommended in the ASCO guidelines, we review the methods used to treat CIPN caused by PC treatment. The efficacy of duloxetine was observed in a large randomized controlled trial (RCT). In addition, pregabalin was more effective than duloxetine for CIPN in two RCTs. Although duloxetine and pregabalin can be effective for CIPN, they have several side effects. Therefore, the choice between the two drugs should be determined according to effect and tolerability. Mirogabalin is also used in patients with PC and there is hope it will yield positive outcomes when treating CIPN in the future.

Transjejunal endoscopic ultrasound‐guided pancreatic drainage for pancreatic jejunostomy stricture using a forward‐viewing echoendoscope in a patient with altered anatomy

Pancreatic jejunostomy stricture (PJS) is one of the major late complications after pancreaticoduodenectomy. Endoscopic ultrasound‐guided pancreatic drainage (EUS‐PD) is considered a salvage treatment for symptomatic PJS after endoscopic retrograde pancreatography failure; however, the technical success rate of the endoscopic treatment of PJS remains unsatisfactory, mainly due to surgically altered anatomy. Herein, we describe a case of PJS successfully treated with transjejunal EUS‐PD using a forward‐viewing echoendoscope. A 62‐year‐old man who suffered from repetitive severe back pain due to PJS was referred to our hospital. Since transgastric EUS‐PD was difficult, we attempted transjejunal EUS‐PD using a forward‐viewing echoendoscope. To facilitate scope insertion, we first straightened the afferent jejunal loop and placed a stiff guidewire. With this scheme, we successfully performed transjejunal EUS‐PD and placed a 5‐Fr plastic stent. In conclusion, this technique is useful for treating patients with PJS when transgastric EUS‐PD is difficult.

The Complement C3a-C3a Receptor Axis Regulates Epithelial-to-Mesenchymal Transition by Activating the ERK Pathway in Pancreatic Ductal Adenocarcinoma

BACKGROUND

We aimed to clarify the role of complement C3a and its receptor C3aR in progression of pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

We evaluated the serum levels of C3 and C3a in patients with PDAC. C3aR expression in tissue was assessed using a tissue microarray. To confirm the protumoral effects of C3a in PDAC, we conducted in vitro experiments using PDAC cell lines (Panc-1 and MiaPaca-2) that exhibit high C3aR expression.

RESULTS

Serum levels of both C3 and C3a were higher in 26 patients with PDAC than in 28 nontumor-bearing controls. In the tissue microarray, we observed increased expression of C3aR in PDAC cells, especially in cases with metastatic lesions. In vitro experiments showed that C3a facilitated tumor cell proliferation, migration and invasion by activating the extracellular-regulated kinase signaling pathway and inducing epithelial-to-mesenchymal transition. Inhibition of the C3a-C3aR axis by pharmacological blockade and short-hairpin RNA-mediated knockdown of C3aR alleviated its protumoral effect.

CONCLUSION

These findings provide a new approach for the development of treatments targeting the C3a-C3aR axis.

Dysbiosis of the duodenal microbiota as a diagnostic marker for pancreaticobiliary cancer

BACKGROUND

Pancreaticobiliary cancer (PB Ca) is a lethal disease, and a useful diagnostic marker is urgently needed. A correlation between the human microbiota and malignant gastrointestinal diseases was recently reported.

AIM

To investigate the efficacy of the duodenal microbiota for diagnosing PB Ca.

METHODS

We recruited 22 patients with benign pancreaticobiliary diseases (benign group) and 12 patients with PB Ca (malignant group). The duodenal microbiota of each patient was analyzed by the 16S rDNA terminal restriction fragment length polymorphism method. Patient characteristics, tumor markers, and relative abundances of the duodenal microbiota were compared between the benign and malignant groups.

RESULTS

Cancer antigen 19-9 (CA19-9), Bifidobacterium, Clostridium cluster XVIII, and Prevotella levels differed significantly between the benign and malignant groups. Clostridium cluster XVIII had the greatest area under the receiver operating characteristic curve (AUC) among the four factors with respect to diagnosing PB Ca (cutoff value: 3.038%; sensitivity: 58.3%; specificity: 95.2%; AUC: 0.81). The combination of Clostridium cluster XVIII (cutoff value: 3.038%) and CA19-9 Levels (cutoff value: 18.8 U/mL) showed 91.7% sensitivity and 71.4% specificity for diagnosing PB Ca.

CONCLUSION

The duodenal microbiota may be useful for PB Ca screening.

Mirogabalin vs pregabalin for chemotherapy-induced peripheral neuropathy in pancreatic cancer patients

Background

The prognosis of pancreatic cancer (PC) has been improved by new chemotherapy regimens (combination of 5-fluorouracil, oxaliplatin, irinotecan, and leucovorin (FOLFIRINOX) or gemcitabine plus nab-paclitaxel (GnP)). Unfortunately, chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse event of these two regimens. The efficacy of pregabalin for CIPN has been reported in previous studies. However, the efficacy of mirogabalin for CIPN remains unknown. Thus, in this study, we aimed to clarify which drug (mirogabalin or pregabalin) was more valuable for improving CIPN.

Methods

A total of 163 PC patients who underwent FOLFIRINOX or GnP between May 2014 and January 2021 were enrolled. Among them, 34 patients were diagnosed with CIPN. Thirteen patients were treated with mirogabalin (mirogabalin group), and twenty-one patients were treated with pregabalin (pregabalin group). Treatment efficacy was compared between the two groups.

Results

In both the mirogabalin group and the pregabalin group, the grade of patients with CIPN at 2, 4, and 6 weeks after the initiation of treatment showed significant improvement compared to the pretreatment grade. Notably, the rate of CIPN improvement was higher in the mirogabalin group than in the pregabalin group (2 weeks: 84.6% (11/13) vs 33.3% (7/21), P value = 0.005; 4 weeks, 6 weeks: 92.3% (12/13) vs 33.3% (7/21), P value = 0.001).

Conclusions

Although both mirogabalin and pregabalin were effective at improving CIPN, mirogabalin might be a suitable first choice for CIPN in PC patients.

Trial registration

Not applicable

Usefulness of Endoscopic Ultrasound with the Jelly-Filling Method for Esophageal Varices

Although the importance of endoscopic ultrasound (EUS) for esophageal varices (EVs) has been demonstrated, it is difficult to obtain sufficient EUS images with the water-filling method because of poor water stagnation in the esophagus. In this study on EVs, we aimed to evaluate the usefulness of the jelly-filling method for EUS. Consecutive patients who underwent EUS for EVs were included. The quality of EUS images, the diagnostic ability of the presence of blood vessels inside and outside the esophageal wall, and the procedure time were compared between the jelly-filling and water-filling methods. Thirty cases were analyzed (jelly-filling method in 13 and water-filling method in 17). The EUS image quality score was significantly higher in the jelly-filling method (jelly vs. water; three points vs. two points, p < 0.001). Additionally, EUS image quality scores in both nonexperts and experts were significantly higher in the jelly-filling method. The diagnostic ability of the presence of perforation veins was significantly higher in the jelly-filling method (jelly vs. water; 100% vs. 52.9%, p = 0.004). However, the procedure time was significantly longer in the jelly-filling method (p = 0.024). In conclusion, EUS using the jelly-filling method for EVs provided sufficient image quality.

Efficacy of Sodium Carboxymethylcellulose Compared to Sodium Hyaluronate as Submucosal Injectant for Gastric Endoscopic Submucosal Dissection: A Randomized Controlled Trial

INTRODUCTION

Sodium hyaluronate (SH) is a useful submucosal injectant for gastric endoscopic submucosal dissection (ESD). On the other hand, sodium carboxymethylcellulose (SCMC), which has high viscosity, has also been applied clinically. We evaluated the efficacy of SCMC compared to that of SH in gastric ESD.

METHODS

A prospective randomized controlled trial was conducted to assess the efficacy of 1.0% SCMC as the injectant (SCMC group) compared to 0.4% SH (SH group) for ESD of gastric neoplasms. The primary end point was the procedure time of ESD. Secondary end points were treatment outcomes such as en bloc and R0 resection rates, number of hemostases, amount of injectant, ease of treatment (visual analog scale, 1-10 points), adverse events, and rate of ulcer healing 8 weeks after ESD.

RESULTS

A total of 60 patients were enrolled between October 2014 and October 2018, and 30 patients were allocated in each group. The procedure time (mean ± SD, minutes) was not significantly different between the SCMC (74.7 ± 54.5) and SH groups (67.1 ± 41.4) (p = 0.547). Furthermore, there were no differences between the 2 groups in terms of en bloc and R0 resection rates, number of hemostases, amount of injectant, ease of treatment, and rate of ulcer healing. No serious adverse events were observed in either group.

CONCLUSION

SCMC was comparable to SH in terms of procedure time, treatment outcome, and ease and safety of treatment in gastric ESD. Further studies are needed to demonstrate the differences between the 2 injectants.

Clinical Characteristics of Intramucosal Gastric Cancers with Lymphovascular Invasion Resected by Endoscopic Submucosal Dissection

INTRODUCTION

In patients with intramucosal gastric cancer (MGC) who have undergone endoscopic submucosal dissection (ESD), lymphovascular invasions (LVIs) such as lymphatic invasion or venous invasion are considered risk factors of lymph node metastasis (LNM). However, the rate of LNM in MGCs with LVI and their clinicopathological features are unclear.

OBJECTIVE

This study aimed to examine the rate of LNM and clinical characteristics of MGCs with LVI as compared to MGCs without LVI and minimally invasive submucosal gastric cancers (mSMGCs) with LVI.

METHODS

Among the early gastric cancers excluding the remnant stomach who underwent ESD at our hospital from July 2003 to September 2018, the MGCs with LVI were included as the target in this study. MGCs without LVI and mSMGCs with LVI were also included as control.

RESULTS

Seventeen lesions in 17 patients with MGCs with LVI, 1,149 lesions in 865 patients with MGCs without LVI, and 29 lesions in 29 patients with mSMGCs with LVI were analyzed. LVI was noted in 1.5% (17/1,166) of MGC cases. During follow-up of the MGC cases with LVI, there were no LNM or recurrences reported, and 14 patients survived and 3 died of other diseases. However, LNM occurred in 2 cases of mSMGC. Among the MGC cases, univariate analysis showed that the pap component, elevated type, and tumor diameters of 20 mm or more were statistically significant factors with respect to LVI, while multivariate analysis showed that the pap component was the only significant factor.

CONCLUSION

Careful follow-up may be appropriate for MGCs with LVI due to the low risk of LNM. Additionally, the pap component is a significant factor in MGCs with LVI.

Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.

Spontaneous disappearance of common bile duct stones following the insertion of a new dumbbell-shaped, covered self-expandable metallic stent in a patient with benign biliary stricture

The new dumbbell-shaped, covered self-expanding metallic stent can efficiently remove the choledocholiths in cases with common bile duct (CBD) strictures; moreover, it may potentially prevent a positional displacement and contribute to the better improvement of the CBD stricture.

Localized gastric amyloidosis diagnosed by endoscopic ultrasound-guided fine-needle aspiration

A 49-year-old man was found to have an elevated lesion on esophagogastroduodenoscopy (EGD) for gastric cancer screening. This lesion had been noted in EGD 13 years earlier, but the patient had not received EGD since then. Endoscopy showed a relatively soft subepithelial lesion (SEL) in the gastric antrum. In addition, endoscopic ultrasonography (EUS) showed a 20-mm-sized, slightly non-uniform hypoechoic mass in the submucosa. Since the diagnosis could not be confirmed by mucosal biopsy, EUS-guided fine-needle aspiration (EUS-FNA) was performed. Hematoxylin-eosin staining of EUS-FNA samples revealed deposition of acidophilic unstructured materials. The structure was positive on Congo red staining, and green polarized light was also observed under a polarizing microscope. Moreover, it was resistant to potassium permanganate reaction, negative for serum amyloid A protein, positive for anti-λ chain antibody, and negative for anti-κ chain, anti-amyloid A, anti-transthyretin, and anti-β2-microglobulin antibodies. Therefore, the lesion was diagnosed as AL-λ-type amyloidosis. No systemic amyloidosis findings were found; thus, the patient was finally diagnosed with localized gastric AL amyloidosis. If an SEL is seen without disease-specific endoscopic findings, amyloidosis should be included in the differential diagnosis, and EUS-FNA can contribute to obtaining tissue samples in such cases.

A simple method for diagnosing gallbladder malignant tumors with subserosa invasion by endoscopic ultrasonography

BACKGROUND

If the depth of gallbladder malignant tumor (GBMT) invasion is deeper than the subserosa (ss), cholecystectomy is insufficient. In past reports that used endoscopic ultrasonography (EUS) to diagnose the depth of tumor invasion, it was difficult to diagnose GMBT invasion in the ss without a narrow or disrupted lateral hyperechoic layer (LHEL). Therefore, we developed a simple preoperative method to diagnose GBMTs with ss invasion.

METHODS

Forty-nine GBMT patients who underwent both EUS and surgery were enrolled: 15 patients whose tumors invaded the mucosa (m) or muscularis propria (mp) were classified as the "shallow group", and 34 patients whose tumors invaded the ss were classified as the "deep group". The EUS findings were compared between the two groups.

RESULTS

An irregular (narrow or thickened) LHEL was significantly more frequently observed on EUS in the deep group than in the shallow group. The diagnosis of ss invasion based on an irregular LHEL had the highest sensitivity and accuracy among the EUS imaging parameters (sensitivity 97.1% (33/34), specificity 86.7% (13/15), accuracy 93.8% (46/49)). When the deep group was limited to patients with a tumor depth of ss, the results were similar. When an irregular LHEL was used, the diagnostic accuracy of GBMTs with ss invasion was not significantly different between EUS specialists and beginners.

CONCLUSIONS

The observation of an irregular (thickened or narrow) LHEL observed on EUS could be a reliable and simple method of diagnosing GBMTs with ss invasion and could contribute to choosing an appropriate surgical method.

The Dramatic Haemostatic Effect of Covered Self-expandable Metallic Stents for Duodenal and Biliary Bleeding

Bilio-duodenal bleeding, such as post-endoscopic sphincterotomy (EST) bleeding, common bile duct (CBD) bleeding after endoscopic retrograde cholangiopancreatography (ERCP), and duodenal bleeding due to malignant tumour invasion, can sometimes become severe. Six cases of refractory bilio-duodenal bleeding were stanched via covered self-expandable metallic stent (CSEMS) insertion, even though three of the patients had a history of gastrectomy. The dumbbell-shaped CSEMS was useful for managing post-EST bleeding. Additional duodenal CSEMS insertion was useful for the patient who had previously undergone uncovered SEMS insertion, and no migration of the CSEMS was observed. CSEMS insertion was useful for treating refractory bilio-duodenal haemorrhaging.

Prevention of Stricture after Endoscopic Submucosal Dissection for Superficial Esophageal Cancer: A Review of the Literature

Endoscopic resection has been the standard treatment for intramucosal esophageal cancers (ECs) because of the low risk of lymph node metastases in the lesions. In recent years, endoscopic submucosal dissection (ESD), which can resect large ECs, has been performed. However, the risk of esophageal stricture after ESD is high when the mucosal defect caused by the treatment exceeds 3/4 of the circumference of the lumen. Despite the subsequent high risk of luminal stricture, ESD has been performed even in cases of circumferential EC. In such cases, it is necessary to take measures to prevent stricture. Therefore, in this review, we aimed to clarify the current status of stricture prevention methods after esophageal ESD based on previous literature. Although various prophylactic methods have been reported to have stricture-preventing effects, steroid injection therapy and oral steroid administration are mainstream. However, in cases of circumferential EC, both steroid injection therapy and oral steroid administration cannot effectively prevent luminal stricture. To solve this issue, clinical applications, such as tissue shielding methods with polyglycolic acid sheet, autologous oral mucosal epithelial sheet transplantation, and stent placement, have been developed. However, effective prophylaxis of post-ESD mucosal defects of the esophagus is still unclear. Therefore, further studies in this research field are needed.

Efficacy of EUS-guided FNB using a Franseen needle for tissue acquisition and microsatellite instability evaluation in unresectable pancreatic lesions

Background

The efficacy of immune checkpoint blockade in the treatment of microsatellite instability (MSI)-high tumors was recently reported. Therefore, the acquisition of histological specimens is desired in cases of unresectable solid pancreatic lesions (UR SPLs). This study investigated the efficacy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using a Franseen needle for UR SPL tissue acquisition and MSI evaluation.

Methods

A total of 195 SPL patients who underwent EUS-guided fine-needle aspiration (EUS-FNA) or EUS-FNB (EUS-FNAB) between January 2017 and March 2020 were enrolled in this study. Among them, 89 SPL patients (FNB: 28, FNA: 61) underwent EUS-FNAB using a 22-G needle (UR SPLs: 58, FNB: 22, FNA: 36) (UR SPLs after starting MSI evaluation: 23, FNB: 9, FNA: 14).

Results

The puncture number was significantly lower with FNB than with FNA (median (range): 3 (2–5) vs 4 (1–8), P <  0.01, UR SPLs: 3 (2–5) vs 4 (1–8), P = 0.036). Histological specimen acquisition was more commonly achieved with FNB than with FNA (92.9% (26/28) vs 68.9% (42/61), P = 0.015, UR SPLs: 100% (22/22) vs 72.2% (26/36), P <  0.01). The histological specimen required for MSI evaluation was acquired more often with FNB than with FNA (88.9% (8/9) vs 35.7% (5/14), P = 0.03).

Conclusions

EUS-FNB using a Franseen needle is efficient for histological specimen acquisition and sampling the required amount of specimen for MSI evaluation in UR SPL patients.

Clinical utility of a newly developed microfluidic device for detecting circulating tumor cells in the blood of patients with pancreatico-biliary malignancies

BACKGROUND

The development of an optimal screening method is required to improve the prognosis of pancreatico-biliary (PB) cancers. A recently developed microfluidic device achieved a high diagnostic yield by detecting circulating tumor cells (CTCs) in the blood of cancer patients. We conducted this study to investigate the clinical utility of measuring CTCs in peripheral venous blood to diagnose PB cancer.

METHODS

Sixty-three subjects were enrolled in this study (29 with pancreatic cancer [PC], 19 with biliary cancer [BC] and 16 non-tumor controls). Using a microfluidic chip device and image analyzer, circulating blood cells were selected based on their size and immunocytochemistry staining pattern. The primary endpoint was the diagnostic accuracy of CTCs with regard to distinguishing between PB cancer patients and controls. We divided all cases into the training set (n = 32) and validation set (n = 31). The diagnostic accuracy of CTCs, carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA19-9) were analyzed.

RESULTS

In both the training set and validation set, CTCs showed the highest diagnostic accuracy (training set: CTCs 90.6%, CA19-9 90.6%, CEA 65.6%, validation set: CTCs 87.5%, CA19-9 78.1%, CEA 81.2). Regarding non-metastatic PC (cStage I-III, n = 11), CTCs also had the highest diagnostic accuracy among the three markers tested (CTCs: 84.6%, CA19-9:80.7%, CEA 73.0%).

CONCLUSIONS

A newly developed microfluidic device could diagnose PB cancers by detecting CTCs. This trial was registered with the UMIN Clinical Trials Registry, no. UMIN000029808.

A Blood-based Gene-expression Scoring System for Cancer Screening in Patients With Branch-duct Intraductal Papillary Mucinous Neoplasms

BACKGROUND

In patients with branch-duct intraductal papillary mucinous neoplasms (BD-IPMN), we aimed to develop a novel blood-based biomarker utilizing a gene-expression profile for the detection of pancreatic malignancies, such as IPMN-derived carcinoma (IPMC) or pancreatic ductal adenocarcinoma (PDAC).

PATIENTS AND METHODS

We enrolled 40 patients with pancreatic tumors (24 BD-IPMNs, four IPMCs and 12 PDACs) and identified the characteristic gene-expression profiles in pancreatic malignancies. Subsequently, we constructed a gene-expression scoring system for the proper diagnosis of pancreatic malignancies. The result was validated in 14 patients (five IPMNs, three IPMCs and six PDACs).

RESULTS

The scoring system utilizing the expression levels of 13 genes showed high diagnostic yield (sensitivity=94.0%, specificity=92.0% and area under the curve=0.94), which was confirmed in the validation set. Furthermore, its diagnostic yield was not reduced even in early-stage pancreatic malignancies (sensitivity=85.0%, specificity=93.0% and area under the curve=0.88).

CONCLUSION

We developed a blood-based gene expression scoring system for cancer screening in patients with BD-IPMNs.

Esophagobronchial fistula complicated by esophageal achalasia treated by per-oral endoscopic myotomy

A 48-year-old man who underwent balloon dilation for esophageal achalasia more than 20 years prior developed severe dysphagia and cough during mealtimes. Endoscopic findings showed a markedly dilated esophagus with residue, narrowing of the esophagogastric junction (EGJ), and a fistula in the middle thoracic esophagus. Esophagography showed narrowing of the EGJ and outflow of contrast from the esophagus to the bronchus. In addition, computed tomography showed marked esophageal dilatation and diffuse granular shading in both lungs. Based on these imaging findings, the patient was diagnosed with deterioration of esophageal achalasia and an esophagobronchial fistula (EBF) secondary to achalasia. The increased intra-esophageal pressure caused by the achalasia was suspected to have inhibited the closure of the EBF. Therefore, we believed that per-oral endoscopic myotomy (POEM) would help treat the achalasia and simultaneously contribute to closing of the EBF. Immediately after POEM, the dysphagia and cough improved. Furthermore, the EBF was closed. 14 months after POEM, the patient did not exhibit deterioration of esophageal achalasia and EBF. To the best of our knowledge, there have been no reports of POEM implemented in cases of esophageal achalasia complicated by EBF. Therefore, this case is worth reporting.

Into which Region Should a Prophylactic Pancreatic Stent Be Inserted? A Propensity Score Matching Analysis

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the diagnosis and treatment of pancreaticobiliary diseases. However, post-ERCP pancreatitis (PEP) is sometimes a mortal adverse event. Though pancreatic stent (PS) insertion has proven to be a useful prophylaxis for PEP in several past reports, the region of the pancreas into which the PS should be inserted is unknown. Therefore, this study investigated where a prophylactic PS for PEP should be inserted.

METHODS

In this retrospective study, we targeted 282 patients without past history of abdominal surgery and who underwent initial ERCP and insertion of prophylactic PS to prevent PEP between January 2007 and April 2019. Patients with PS insertion to the pancreatic head (head group) were compared with patients with PS insertion into the pancreatic body or tail (body/tail group) using propensity score matching for patient characteristics, ERCP procedures, and post-ERCP adverse events.

RESULTS

After propensity score matching and removing the cases with the PS passing spontaneously for ERCP procedures, 52 head group patients and 54 body/tail group patients were selected. The PEP rate was significantly higher in the head group than in the body/tail group (9.6% vs. 0%, p=0.026).

CONCLUSION

Pancreatic stent insertion in the pancreatic body/tail was more effective for preventing PEP than PS insertion in the pancreatic head.

Which scope is appropriate for endoscopic retrograde cholangiopancreatography after Billroth II reconstruction: An esophagogastroduodenoscope or a colonoscope?

BACKGROUND

Recently, with the advent of more advanced devices and endoscopic techniques, endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II (B-II) patients has been increasingly performed. However, the procedures are difficult, and the techniques and strategies have not been defined.

AIM

To reveal the appropriate scope for ERCP in B-II patients.

METHODS

Sixty ERCP procedures were performed on B-II patients between June 2005 and May 2018 at Fukushima Medical University Hospital, and in 44 cases, this was the first ERCP procedure performed by esophagogastroduodenoscopy (EGDS) or colonoscopy (CS) after B-II gastrectomy. These cases were divided into two groups: 17 cases of ERCP performed by EGDS (EGDS group) and 27 cases of ERCP performed by CS (CS group). The patient characteristics and ERCP procedures were compared between the EGDS and CS groups.

RESULTS

The procedural time was significantly shorter in the EGDS group than in the CS group [median (range): 60 (20-100) vs 90 (40-128) min, P value < 0.01]. CS was an independent factor of a longer ERCP procedural time according to the univariate and multivariate analyses (odds ratio: 3.97, 95%CI: 1.05-15.0, P value = 0.04).

CONCLUSION

Compared to CS, EGDS shortened the procedural time of ERCP in B-II patients.

Pancreatic Neuroendocrine Neoplasm Invading the Entire Main Pancreatic Duct Diagnosed by a Preoperative Endoscopic Biopsy

A 78-year-old man was referred to our hospital for a detailed examination of a pancreatic tumor that filled the main pancreatic duct (MPD). The histological diagnosis of the endoscopic biopsy specimen was neuroendocrine tumor (NET) G3. The patient subsequently underwent total pancreatectomy. The histological diagnosis of the surgical specimen was also NET G3. This is the first report of a NET that occupied the MPD and was diagnosed by a preoperative endoscopic biopsy through the papilla of Vater. This case is a good example of a histopathological diagnostic method for pancreatic tumors invading the entire MPD.

Rare coincidence of intraductal papillary mucinous neoplasm and type 1 autoimmune pancreatitis

The present case involved a 60-year-old man with autoimmune pancreatitis (AIP). While his AIP was in remission for 6 years, a follow-up CE-CT revealed a dilated main pancreatic duct (MPD) and an enhanced mural nodule. Fluorodeoxyglucose uptake was positive on positron emission tomography. Endoscopic retrograde pancreatography showed a filling defect of the MPD, and pancreatoscopy revealed a nodule partially covered with papillary lesions. Although a repeat biopsy revealed no evidence of malignancy, we speculated that there was a high likelihood of main-duct-type intraductal papillary mucinous neoplasm (IPMN)-derived carcinoma concomitant with AIP. Subsequently, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy. A surgical specimen showed a 35 mm protuberant papillary lesion with abundant stroma, located in the main duct of the pancreas. Further histological evaluation revealed that the nodule was predominantly composed of IPMN with low-grade dysplasia, which was accompanied by abundant IgG4-positive lymphoplasmacytic infiltration, and fibrosis existed predominantly around the IPMN. The epithelium of the cyst showed mucinous hyperplasia with focal papillary structures of gastric phenotype (MUC5A+, MUC6+, MUC1-, MUC2-, CDX-). After surgical resection, we did not find any imaging evidence suggesting a recurrent tumor and AIP relapse in the remnant pancreas. In conclusion, we report a case of IPMN coincidentally found in a patient with type 1 AIP. Active AIP may exaggerate the morphology of IPMN, and careful evaluation should be performed to select appropriate management.

Acquired resistance to trastuzumab/pertuzumab or to T-DM1 in vivo can be overcome by HER2 kinase inhibition with TAS0728

HER2‐targeting antibodies (trastuzumab, pertuzumab) and a HER2‐directed antibody‐drug conjugate (trastuzumab emtansine: T‐DM1) are used for the treatment of HER2‐overexpressing breast cancer. However, these treatments eventually become ineffective due to acquired resistance and there is an urgent need for alternative therapies. TAS0728 is a small‐molecule, irreversible selective HER2 kinase inhibitor. In the present study, we established new in vivo models of cancer resistance by continuous exposure to a combination of trastuzumab and pertuzumab or to T‐DM1 for evaluating the effect of TAS0728 on HER2 antibody‐resistant populations. Treatment with trastuzumab and pertuzumab or with T‐DM1 initially induced tumor regression in NCI‐N87 xenografts. However, tumor regrowth during treatment indicated loss of drug effectiveness. In tumors with acquired resistance to trastuzumab and pertuzumab or to T‐DM1, HER2‐HER3 phosphorylation was retained. Switching to TAS0728 resulted in a significant anti‐tumor effect associated with HER2‐HER3 signal inhibition. No alternative receptor tyrosine kinase activation was observed in these resistant tumors. Furthermore, in a patient‐derived xenograft model derived from breast cancer refractory to both trastuzumab/pertuzumab and T‐DM1, TAS0728 exerted a potent anti‐tumor effect. These results suggest that tumors with acquired resistance to trastuzumab and pertuzumab and to T‐DM1 are still dependent on oncogenic HER2‐HER3 signaling and are vulnerable to HER2 signal inhibition by TAS0728. These results provide a rationale for TAS0728 therapy for breast cancers that are refractory to established anti‐HER2 therapies.

Interstitial lung disease in advanced pancreatic ductal adenocarcinoma patients treated with gemcitabine and nab-paclitaxel combination therapy: a retrospective analysis

PURPOSE

Gemcitabine and nab-paclitaxel (GnP) combination therapy is a standard regimen for advanced pancreatic ductal adenocarcinoma (PDAC) worldwide; however, concerns regarding the unexpectedly high incidence of interstitial lung disease (ILD) have emerged. We investigated the incidence and predictive factors of ILD in PDAC patients who were treated with GnP combination therapy.

METHODS

Thirty-seven patients treated with GnP therapy as either 1st or 2nd line treatment were included, among whom seven developed ILD (18.9%). The clinical characteristics (age, etc.) were compared between patients with and without ILD. The diagnostic yield of the markers to predict the presence of ILD was calculated. The clinical course of the seven patients with ILD was summarized. Survival analysis was performed using the Kaplan-Meier method and log-rank test.

RESULTS

The median age was higher in patients with ILD (73.0 vs. 65.0 years old, p = 0.03), while no differences were observed in the other clinical characteristics. Among the three investigated markers, SP-D showed the best diagnostic yield (AUC = 0.94) for diagnosing ILD. Though one patient required steroid therapy and the discontinuation of GnP therapy, all patients could undergo subsequent treatment. In the survival analysis, the median survival time of PDAC patients with ILD was comparable to that of patients without ILD (25.1 vs. 24.5 months, p = 0.98).

CONCLUSION

ILD was observed in 18.9% of PDAC patients treated with GnP therapy. With appropriate management, no prognostic influence was observed.

Can the wet suction technique change the efficacy of endoscopic ultrasound-guided fine-needle aspiration for diagnosing autoimmune pancreatitis type 1? A prospective single-arm study

BACKGROUND

Other than surgery, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the only procedure for histologically diagnosing autoimmune pancreatitis (AIP). However, adequate specimens are difficult to obtain. Recently, more adequate specimens were reported to be obtained with EUS-FNA with a wet suction technique (WEST) than with conventional EUS-FNA.

AIM

To histologically diagnose AIP by EUS-FNA with a WEST.

METHODS

Eleven patients with possible type 1 AIP between February 2016 and August 2018 underwent EUS-FNA with a WEST (WEST group), with four punctures by 19 or 22 G needles. As a historical control, 23 type 1 AIP patients who underwent no fewer than four punctures with 19 or 22 G needles were enrolled (DRY group). Patient characteristics and histological findings were compared between the two groups.

RESULTS

Three histopathological factors according to the International Consensus Diagnostic Criteria were significantly greater in the WEST group than the DRY group [lymphoplasmacytic infiltrate without granulocytic infiltration: 9 (81.8%) vs 6 (26.1%), P = 0.003, storiform fibrosis: 5 (45.5%) vs 1 (4.3%), P = 0.008, abundant (> 10 cells/HPF) IgG4-positive cells: 7 (63.6%) vs 5 (21.7%), P = 0.026]. Level 1 or level 2 histopathological findings were observed more often in the WEST group than in the DRY group [8 (72.7%) vs 3 (13.0%), P = 0.001].

CONCLUSION

EUS-FNA with a WEST was more successful than standard EUS-FNA in histologically diagnosing AIP.

Abstract A126: Acquired resistance to trastuzumab/pertuzumab, or to T-DM1 in vivo can be overcome by HER2 inhibition with TAS0728

Background: HER2-targeting antibodies (trastuzumab, pertuzumab) and an antibody-drug conjugate (trastuzumab emtansine: T-DM1) are available for the treatment of HER2 overexpressed breast cancer. TAS0728 is a small molecule, covalent-binding, selective inhibitor of HER2 kinase, and its assessment in humans is ongoing. Although HER2 targeting therapies with trastuzumab/pertuzumab, or T-DM1 initially show clinical activity, those treatments eventually become ineffective due to acquired resistance. Various resistant models to the therapies have been established in vitro to explore novel therapies for resistance. However, those models may not mimic patients’ tumors, because antibody dependent cellular cytotoxicity (ADCC) and/or pharmacokinetics of the drugs were not involved in the establishment of the models. In our previous report, we have established an acquired resistant model to T-DM1 in vivo. The model was sensitive to TAS0728. In the present study, we analyzed the molecular mechanism of T-DM1 resistance and mode of action of TAS0728 in the established model. Furthermore, we established another model with acquired resistance to trastuzumab and pertuzumab in mice, and investigated the sensitivity to TAS0728. Materials and Methods: To establish a resistant model to T-DM1, T-DM1 was administered at 10 mg/kg (q3w, i.v.) in NCI-N87 xenograft model until tumor regression and the subsequent re-growth of tumor were observed. Pharmacodynamics of T-DM1 at 10 mg/kg (q3w, i.v.) or TAS0728 at 60 mg/kg (q.d., p.o.) was evaluated in the tumors. To clarify the resistant mechanisms to T-DM1 and mode of action of TAS0728, molecular profiling of the resistant tumors was conducted by phospho-RTK array, RNA sequencing, and Western blotting. To establish a resistant model to trastuzumab/pertuzumab in vivo, the antibodies were administered concomitantly at 20 mg/kg each (q1w, i.p.) in the NCI-N87 xenograft model until tumor regression and the subsequent re-growth of tumor were observed. The mice were treated with the antibodies at 20 mg/kg each (q1w, i.p.) or TAS0728 at 60 mg/kg (q.d., p.o.) to compare antitumor effects. Results: In the T-DM1 resistant model, TAS0728 exerted antitumor effect associated with HER2 signal inhibition. RNA sequencing revealed that expression level of a candidate gene, which may be involved in the intracellular metabolism of T-DM1, was decreased in the T-DM1 resistant tumor. Alternative RTK activation was not observed. Next, we established a resistant model to trastuzumab/pertuzumab combination therapy in vivo. Although the antibodies initially induced tumor regression in the NCI-N87 xenograft model, ultimately, regrowth of tumors was observed. Once the tumors regrew during the treatment, the antibodies were no longer effective. On the other hand, switching to TAS0728 resulted in significant antitumor effect. Collectively, these results suggested that tumors with acquired resistance to trastuzumab/pertuzumab or T-DM1 are still addicted to the active HER2 signal, and were vulnerable to HER2 inhibition by TAS0728. Conclusion: The acquired resistance models to trastuzumab/pertuzumab or T-DM1 were established in vivo. Selective inhibition of HER2 kinase by TAS0728 is effective in the both resistant models. These results provide a rationale for therapy with TAS0728 in patients refractory to the established anti-HER2 therapy.

Citation Format: Hiroki Irie, Rumi Kawabata, Yayoi Fujioka, Fumio Nakagawa, Hideki Nagase, Hiraku Itadani, Kimihiro Ito, Junji Uchida, Shuichi Ohkubo, Kenichi Matsuo, Takeshi Sagara, Teruhiro Utsugi. Acquired resistance to trastuzumab/pertuzumab, or to T-DM1 in vivo can be overcome by HER2 inhibition with TAS0728 [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr A126. doi:10.1158/1535-7163.TARG-19-A126

Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length

Although endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the diagnosis and treatment of pancreaticobiliary diseases, post-ERCP pancreatitis (PEP) is the most frequent adverse event that can sometimes be fatal. However, prophylactic pancreatic stent (PS) insertion has been performed to prevent PEP in high-risk patients. In some randomized controlled trials (RCTs) and meta-analyses, the efficacy of prophylactic PS insertion has been shown to prevent PEP. In addition, several types of stents have been used to decrease PEP. In this review, we introduce the details of these RCTs and meta-analyses and reveal the specifications for stent placement, for example, the stent diameter and length and the pancreatic region into which the stent should be inserted.

Present state of endoscopic ultrasonography-guided fine needle aspiration for the diagnosis of autoimmune pancreatitis type 1

Autoimmune pancreatitis (AIP) is defined as pancreatitis caused by irregular narrowing of the pancreatic duct accompanied by pancreatic swelling, fibrosis and lymphocyte infiltration, events that are related to autoimmune mechanisms. The 2010 International Consensus Diagnostic Criteria for AIP defined pancreatitis as “type 1” when increased levels of serum IgG4 were present and other organs were involved; lymphoplasmacytic sclerosing pancreatitis was the main histological characteristic. Apart from surgery, endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is the only method for the histological diagnosis of AIP; however, this method is difficult. The use of larger-diameter FNA needles and trucut biopsy did not improve the diagnostic performance of EUS-FNA, but it has improved gradually. In this review, we look back at past efforts to improve the diagnostic performance of EUS-FNA and reveal the present state of EUS-FNA for the histological diagnosis of AIP type 1.

Pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: A meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the investigation and treatment of pancreaticobiliary diseases. However, post-ERCP pancreatitis (PEP) is a severe adverse effect. Prior meta-analyses have shown that prophylactic PS was useful for preventing PEP. However, abstract reports and patients who underwent endoscopic ampullectomy were included in the previous analyses. In addition, two meta-analyses involved non-randomized controlled trials (RCTs). The efficacy of PS for preventing severe PEP was different in each meta-analysis. Therefore, we performed the current meta-analysis, which included only full-text articles, and added new findings.

AIM

To reveal the efficacy of prophylactic pancreatic stent (PS) placement for preventing PEP.

METHODS

We searched the MEDLINE, Cochrane Library and PubMed databases for related RCTs. Among the reports retrieved, 11 studies were included in this meta-analysis. All full-text articles were published between 1993 and 2016. A total of 1475 patients were enrolled in the included studies; of these patients, 734 had a PS inserted, and 741 did not have a PS inserted. PEP and severe PEP occurrence were evaluated in this meta-analysis.

RESULTS

PEP was observed in all studies and occurred in 39 (5.3%) patients who received a PS. On the other hand, PEP occurred in 141 (19%) patients who did not receive a PS. The occurrence of PEP was significantly lower in the patients who underwent PS placement than in the patients who did not receive a PS (OR = 0.32; 95%CI: 0.23-0.45; P < 0.001). In addition, the occurrence of severe PEP was evaluated. Notably, the occurrence of severe PEP was not observed in the stent group; however, the occurrence of severe PEP was observed in 8 (1.3%) patients who did not have a PS inserted. Severe PEP occurred significantly less often in the stent group than in the no stent group (OR = 0.24; 95%CI: 0.06-0.94; P = 0.04).

CONCLUSION

In conclusion, prophylactic PS placement is useful for preventing PEP and severe PEP.

Appropriate number of biliary biopsies and endoscopic retrograde cholangiopancreatography sessions for diagnosing biliary tract cancer

BACKGROUND

Biliary ductal cancer (BDC) is a lethal disease; however, diagnosing BDC is challenging. Biliary biopsies are performed to pathologically diagnose BDC, but the appropriate parameters for biliary biopsy [number of biliary biopsies, number of endoscopic retrograde cholangiopancreatography (ERCP) sessions, etc.] are unknown.

AIM

To clarify what constitutes an adequate method for biliary biopsy.

METHODS

In total, 95 patients who underwent endoscopic biliary biopsy without choledochoscopy and who were pathologically diagnosed with BDC were enrolled in this study. The patients were divided into two groups. Seventy-six patients who were diagnosed by biliary biopsy were defined as the positive group (P group), and nineteen patients who were not diagnosed by biliary biopsy were defined as the negative group (N group). The patient characteristics and ERCP-related procedures were compared between the P and N groups.

RESULTS

The numbers of ERCP sessions and biliary biopsies were significantly different between the two groups [ERCP sessions (one/two), P group 72/4 vs N group 15/4, P value = 0.048; number of biliary biopsies, P group 2 (1-6) vs N group 2 (1-7), P value = 0.039]. In a multivariate analysis, fewer than 2 ERCP sessions was an independent factor influencing the positivity of the biliary biopsies.

CONCLUSION

This study clarified that ERCP and biliary ductal biopsy should only be performed once. If biliary cancer is not pathologically diagnosed after the first ERCP session, other methods (Endoscopic ultrasonography-guided fine needle aspiration or choledochoscopy-guided biliary ductal biopsy) should be employed.

TAS0728, A Covalent-binding, HER2-selective Kinase Inhibitor Shows Potent Antitumor Activity in Preclinical Models

Activated HER2 is a promising therapeutic target for various cancers. Although several reports have described HER2 inhibitors in development, no covalent-binding inhibitor selective for HER2 has been reported. Here, we report a novel compound TAS0728 that covalently binds to HER2 at C805 and selectively inhibits its kinase activity. Once TAS0728 bound to HER2 kinase, the inhibitory activity was not affected by a high ATP concentration. A kinome-wide biochemical panel and cellular assays established that TAS0728 possesses high specificity for HER2 over wild-type EGFR. Cellular pharmacodynamics assays using MCF10A cells engineered to express various mutated HER2 genes revealed that TAS0728 potently inhibited the phosphorylation of mutated HER2 and wild-type HER2. Furthermore, TAS0728 exhibited robust and sustained inhibition of the phosphorylation of HER2, HER3, and downstream effectors, thereby inducing apoptosis of HER2-amplified breast cancer cells and in tumor tissues of a xenograft model. TAS0728 induced tumor regression in mouse xenograft models bearing HER2 signal-dependent tumors and exhibited a survival benefit without any evident toxicity in a peritoneal dissemination mouse model bearing HER2-driven cancer cells. Taken together, our results demonstrated that TAS0728 may offer a promising therapeutic option with improved efficacy as compared with current HER2 inhibitors for HER2-activated cancers. Assessment of TAS0728 in ongoing clinical trials is awaited (NCT03410927).

Abstract OT3-03-01: Open-label, single-arm study evaluating the antitumor activity and safety of niraparib as neoadjuvant treatment in patients with localized, HER2-negative, BRCA-mutant breast cancer

Background: Neoadjuvant chemotherapy is administered to patients with operable breast cancer to downstage the tumor to allow for less extensive surgery and to provide prognostic information about drug efficacy and risk of disease recurrence. Patients who achieve a pathological complete response (pCR) following neoadjuvant treatment have a more favorable outcome than patients with residual invasive disease. Single-agent poly(ADP-ribose) polymerase (PARP) inhibitors have clinical efficacy in BRCA-mutated breast cancer. Niraparib, a potent and selective PARP1/2 inhibitor, is approved for maintenance treatment of patients with recurrent ovarian cancer and has demonstrated strong antitumor activity in in vivo studies with BRCA1-mutant breast cancer. The objective of this study is to evaluate the antitumor activity of single-agent niraparib in the neoadjuvant treatment of patients with localized, human epidermal growth factor receptor 2 (HER2)-negative, BRCAmut breast cancer.

Trial Design: This is an open-label, single-arm pilot study with a target enrollment of 20 evaluable patients. Eligible patients are those ≥18 years old with histologically-confirmed HER2-negative localized breast cancer and either a BRCA1 or BRCA2 mutation (germline or somatic) and no prior anti-cancer therapies for the current malignancy. Patients will receive 200 mg of oral niraparib once daily for 2 months, after which they may either proceed directly to surgery or receive chemotherapy at the discretion of the physician. The primary endpoint is tumor response rate based on the change in tumor volume as measured by breast MRI after 2 months of treatment with niraparib; a response is defined as ≥30% reduction of tumor volume from baseline. Secondary endpoints include pCR rate, tumor response rate based on the change in tumor volume as measured by breast ultrasound, and safety and tolerability. Data will be summarized in a descriptive nature by frequency distributions (number and percentage of patients) for categorical variables and by the mean, median, and standard deviation for continuous variables. Tumor response rate will be tabulated together with its 95% binomial exact confidence interval.

Funding: TESARO, Inc., Waltham, MA, USA sponsored the study.

Citation Format: Han H, Hamilton E, Irie H, Isakoff S, Jelovac D, Liem A, Liu MC, Milillo A, Nangia J, Page D, Reeves J, Santa-Maria C, Duncan M, Graham JR, Chen J, Dezube BJ, Spring L. Open-label, single-arm study evaluating the antitumor activity and safety of niraparib as neoadjuvant treatment in patients with localized, HER2-negative, BRCA-mutant breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-03-01.