Quality of reporting in endoscopic ultrasound: Results of an international multicenter survey (the QUOREUS study)

Background and study aims  The endoscopic report has a key role in quality improvement for gastrointestinal endoscopy. High quality standards have been set by the endoscopic societies in this field. Unlike other digestive endoscopy procedures, the quality of reporting in endoscopic ultrasound (EUS) has not been thoroughly evaluated and a reference standard is lacking. Methods  We performed an international online survey concerning the attitudes of endosonographers towards EUS reports in order to understand the needs for standardization and quality improvement. Endosonographers from different countries and institutional setting, with varying case volume and experience were invited to take part to complete a structured questionnaire. Results  We collected replies from 171 endosonographers. Overall analysis of results according to case volume, experience and working environment of respondents (academic, public hospital, private) are provided. In brief, everyone agreed on the need for standardization of EUS reporting. The use of minimal standard terminology and a structured tree with mandatory items was considered of primary importance. Image documentation was also deemed fundamental in complementing EUS reports both for patient documentation and research purposes. A strong demand for connection and consultation among endosonographers for clinical and training needs was also found. In this respect, a formal expert consultation network was advocated in order to improve the quality of reporting in EUS. Conclusions  Our survey showed a strong agreement among endosonographers who expressed the need for a standardization in order to improve the report and, as a consequence, the quality of EUS.

Endoscopic Ultrasound Assessment of Pancreatic Duct Diameter Predicts Neuroendocrine Tumors and Other Pancreas Masses

OBJECTIVES

Distinguishing neuroendocrine tumors (NETs) and other pancreas lesions from adenocarcinomas via endoscopic ultrasound (EUS) requires additional tissue for special staining and processing. Our aim was to determine if main pancreatic duct (PD) diameter on EUS helps to differentiate NET and other unusual tumors from adenocarcinoma.

METHODS

We evaluated 30 consecutive patients diagnosed with NET or other pancreas lesions by EUS with 90 matched patients who were found to have adenocarcinoma. Dilated PD was defined as greater than 3 mm. Multivariate logistic regression was used to evaluate associations between lesion type and PD diameter.

RESULTS

Among the 30 patients with NET/other pancreas lesions, 21 had NETs, 7 had metastases, and 2 had lymphomas. A dilated PD was demonstrated in only 3.3% of pancreatic NET/other lesions but present in 88.9% of cases of primary adenocarcinoma (P < 0.01). In multivariate analysis, a normal PD diameter and absence of clinical symptoms strongly predicted the presence of pancreatic NET/other versus adenocarcinoma (P < 0.01).

CONCLUSIONS

The absence of PD dilation upstream of the lesion suggests NET or other lesions rather than adenocarcinoma. This finding should prompt endosonographers to obtain additional tissue at the time of EUS to send for special studies.

Opposing effects of aspirin and anticoagulants on morbidity and mortality in patients with upper gastrointestinal bleeding

OBJECTIVE

We aimed to determine the effect of antithrombotics on in-hospital mortality and morbidity in patients with peptic ulcer disease-related upper gastrointestinal bleeding (PUD-related UGIB).

METHODS

The study cohort was retrospectively selected from a tertiary center database of patients with PUD-related UGIB, defined as bleeding due to gastric or duodenal ulcers, or erosive duodenitis, gastritis or esophagitis. Outcomes were compared among patient groups based on their antithrombotic medications before admission. Patients on no antithrombotics served as controls. The composite adverse outcomes, in-hospital mortality, rebleeding and/or need for surgery were measured. Severe bleeding and in-hospital complications were also recorded.

RESULTS

Of 398 patients with PUD-related UGIB, 44.5% were on aspirin or anticoagulants only. The composite adverse outcome was most common in patients taking anticoagulants only (40.5%), intermediate in controls (23.1%) and least in those taking aspirin only (12.1%). On multivariate analysis, patients taking aspirin alone had a significantly lower risk of adverse outcome events (odds ratio [OR] 0.4, 95% CI 0.2-0.8) and a shorter length of hospital stay (regression coefficient = -3.4, 95% CI [-6.6, -0.6]). In contrast, taking anticoagulants was associated with a greater risk of adverse outcome events (OR 2.3, 95% CI 1.0-5.3), severe bleeding (OR 2.6, 95% CI 1.2-5.8) and in-hospital complications (OR 2.9, 95% CI 1.3-6.6).

CONCLUSIONS

Patients with PUB-related UGIB while taking aspirin had fewer adverse outcomes compared with those taking anticoagulants. Aspirin may have beneficial effects in this population.

Spiritually based intervention to increase colorectal cancer awareness among african americans: intermediate outcomes from a randomized trial

Colorectal cancer screening, while effective for reducing mortality, remains underutilized particularly among underserved populations such as African Americans. The present study evaluated a spiritually based approach to increasing Health Belief Model-based pre-screening outcomes in a Community Health Advisor-led intervention conducted in African American churches. Sixteen urban churches were randomized to receive either the spiritually based intervention or a nonspiritual comparison of the same structure and core colorectal cancer content. Trained Community Health Advisors led a series of two educational sessions on colorectal cancer early detection. The educational sessions were delivered over a 1-month period. Participants (N = 316) completed a baseline survey at enrollment and a follow-up survey one month after the first session. Both interventions resulted in significant pre/post increases in knowledge, perceived benefits of screening, and decreases in perceived barriers to screening. Among women, the spiritually based intervention resulted in significantly greater increases in perceived benefits of screening relative to the nonspiritual comparison. This finding was marginal in the sample as a whole. In addition, perceived benefits to screening were associated with behavioral intention for screening. It is concluded that in this population, the spiritually based was generally as effective as the nonspiritual (secular) communication.

Diagnostic yield of EUS-guided FNA and cytology in suspected tubercular intra-abdominal lymphadenopathy

BACKGROUND

Intra-abdominal lymphadenopathy is a common diagnostic challenge faced by clinicians. In the absence of palpable peripheral nodes, tissue is usually obtained from the abdominal nodes by image-guided biopsy or surgery. We speculate that EUS-guided FNA (EUS-FNA) avoids the morbidity of a laparotomy and might be equally effective.

OBJECTIVE

To evaluate the role of EUS-FNA in abdominal lymphadenopathy.

DESIGN

Prospective study conducted over 42 months.

SETTING

Tertiary care center in New Delhi, India.

PATIENTS

Patients with abdominal lymphadenopathy in whom image-guided node biopsy failed were considered for EUS-FNA.

INTERVENTION

A total of 3 passes were performed at each site. Slides were prepared per protocol and sent for cytopathologic evaluation.

RESULTS

A total of 142 patients were enrolled, but only 130 (91.5%) underwent FNA. The mean lymph node size was 22 ± 3.2 mm; 71.8% of the nodes were hypoechoic (n = 102), and 28.1% were heterogeneous with an anechoic center (n = 40). In 120 patients (84.5%), the lymph nodes were intra-abdominal only, and in 22 patients (15.5%), they were both intra-abdominal and mediastinal in location.

MAIN OUTCOME MEASUREMENT

EUS-FNA was successful in establishing a diagnosis in 90.8% of these patients; 76.1% were found to have tuberculosis, 7.04% sarcoidosis, 6.33% Hodgkin's lymphoma, and 0.74% non-Hodgkin's lymphoma.

LIMITATIONS

In 8.4% patients, nodes were inaccessible because of their retropancreatic location.

CONCLUSIONS

EUS-FNA is a safe, accurate, and minimally invasive modality for diagnosing the cause of abdominal lymphadenopathy. In highly endemic areas, tuberculosis is the most common cause.

Lymph-node ratio is an independent prognostic factor in patients with stage III colorectal cancer: a retrospective study from the Middle East

Background

In this retrospective study, we evaluated the prognostic effect of positive lymph-node ratio (pLNR) on patients with stage III colorectal cancer (CRC). Our paper is the first analysis, to our knowledge, to deal with such data from the Middle East.

Methods

We analyzed the clinicopathological data of 535 patients diagnosed with colorectal cancer at our institution between 1983 and 2003. The 164 patients diagnosed with stage III disease were divided into two categories based on lymph-node ratio (LNR) being the ratio of positive lymph nodes over total lymph nodes dissected: LNR ≤0.4 and LNR >0.4. We used Kaplan-Meier and Cox proportional hazard models to evaluate the prognostic effect of pLNR.

Results

The 10-year survival rate for the patients with stage IIIA, IIIB and IIIC cancers were 76%, 56% and 0% respectively (P = 0.014). Using pLNR of 0.4 as the cutoff point was found to yield clinically and significant results, with a significant difference in the outcomes of patients with pLNR ≤0.4 compared to those with pLNR >0.4 (hazard ratio = 5.25, 95% confidence interval = 1.2 to 22.1, P = 0.02).

Conclusion

The ratio-based staging (pLNR) of CRC is a more accurate and clinically useful prognostic method than the number of positive LNs resected or the total number of LNs retrieved for predicting the course of patients with stage III CRC.

Your Body Is the Temple

Colorectal cancer (CRC) is third in cancer incidence and mortality, due in part to lack of awareness and low rates of screening. The purpose of the present study was to evaluate the efficacy of a spiritually based CRC educational intervention delivered by trained Community Health Advisors, in Alabama churches. The aim of the intervention was to increase knowledge and awareness of CRC and early detection, and to eventually increase CRC screening rates. Participants age-eligible for screening ( N = 122) completed baseline, 6-month, and 12-month surveys by telephone. Increases in CRC knowledge, perceived benefits of CRC screening, and awareness of the screening modalities and decreases in perceived barriers to screening suggested that this type of intervention may be promising for CRC control and should be examined further.

A phase I study evaluating the role of the anti-epidermal growth factor receptor (EGFR) antibody cetuximab as a radiosensitizer with chemoradiation for locally advanced pancreatic cancer

PURPOSE

(1) To determine the safety of the epidermal growth factor receptor (EGFR) antibody cetuximab with concurrent gemcitabine and abdominal radiation in the treatment of patients with locally advanced adenocarcinoma of the pancreas. (2) To evaluate the feasibility of pancreatic cancer cell epithelial-mesenchymal transition (EMT) molecular profiling as a potential predictor of response to anti-EGFR treatment.

METHODS

Patients with non-metastatic, locally advanced pancreatic cancer were treated in this dose escalation study with gemcitabine (0-300 mg/m(2)/week) given concurrently with cetuximab (400 mg/m(2) loading dose, 250 mg/m(2) weekly maintenance dose) and abdominal irradiation (50.4 Gy). Expression of E-cadherin and vimentin was assessed by immunohistochemistry in diagnostic endoscopic ultrasound fine-needle aspiration (EUS-FNA) specimens.

RESULTS

Sixteen patients were enrolled in 4 treatment cohorts with escalating doses of gemcitabine. Incidence of grade 1-2 adverse events was 96%, and incidence of 3-4 adverse events was 9%. There were no treatment-related mortalities. Two patients who exhibited favorable treatment response underwent surgical exploration and were intraoperatively confirmed to have unresectable tumors. Median overall survival was 10.5 months. Pancreatic cancer cell expression of E-cadherin and vimentin was successfully determined in EUS-FNA specimens from 4 patients.

CONCLUSIONS

Cetuximab can be safely administered with abdominal radiation and concurrent gemcitabine (up to 300 mg/m(2)/week) in patients with locally advanced adenocarcinoma of the pancreas. This combined therapy modality exhibited limited activity. Diagnostic EUS-FNA specimens could be analyzed for molecular markers of EMT in a minority of patients with pancreatic cancer.

Epidermal growth factor receptor (EGFR) intron 1 polymorphism and clinical outcome in pancreatic adenocarcinoma

BACKGROUND

Epidermal growth factor receptor (EGFR) intron 1 has a polymorphic region of CA repeats that is believed to be associated with increased EGFR expression, tumor aggressiveness, and worse survival in cancer patients.

METHODS

A large population of pancreatic adenocarcinoma patients was investigated to evaluate this polymorphism as a potential prognostic marker of clinical outcome. Deoxyribonucleic acid obtained from 50 resected pancreatic adenocarcinomas and from 85 diagnostic endoscopic ultrasound-guided fine-needle aspiration procedures corresponding to patients with unresectable tumors was included. The correlation between CA repeat length and EGFR messenger ribonucleic acid levels was also examined.

RESULTS

Analysis of the 135 patients revealed no correlation between EGFR intron 1 CA repeat length and tumor stage. There was no difference in overall patient survival when stratified by allele length. A correlation between EGFR intron 1 length and EGFR transcript and protein levels could not be established.

CONCLUSIONS

The length of the EGFR intron 1 CA repeats does not correlate with levels of EGFR expression and cannot be used as marker of clinical prognosis in pancreatic cancer patients.

Use of focus group data to develop recommendations for demographically segmented colorectal cancer educational strategies

Screening is available and effective in colorectal cancer (CRC) control, but underutilized. The purpose of this study was to use focus group data to develop recommendations for the development of educational interventions to increase CRC screening, using an audience segmentation strategy. Demographic segments were based on urban-rural residence, race (African-American, White) and sex. One hundred and sixty-five participants age 50+, with no history of CRC participated in 17 focus groups in Alabama urban and rural communities. Transcripts were examined by independent coders. Knowledge among participants was limited regarding age to begin screening, insurance coverage and risk factors for CRC. Perceived barriers to screening included lack of physician recommendation, cost/lack of insurance coverage, pain/discomfort and embarrassment. African-American men reported postponement in seeing their physicians. White women were proactive at initiating discussion of CRC screening with their providers while African-American women felt that providers should drive the process. No urban-rural differences were identified. This study identified cultural and gender characteristics and perceptions that can be used in the development of demographically segmented health communication interventions to increase CRC awareness and screening.

Development of a spiritually based educational program to increase colorectal cancer screening among African American men and women

This study describes the development of a spiritually based intervention to increase colorectal cancer screening through African American churches by framing the health message with spiritual themes and scripture. The intervention development phase consisted of ideas from an advisory panel and core content identified in focus groups. In the pilot-testing phase, prototypes of the intervention materials were tested for graphic appeal in additional focus groups, and content was tested for acceptability and comprehension in cognitive interviews. Participants preferred materials showing a variety of African Americans in real settings, bright color schemes, and an uplifting message emphasizing prevention and early detection. Spiritual themes such as stewardship over the body, being well to serve God, and using faith to overcome fear, were well received. The materials were then finalized for implementation and will be used by community health advisors to encourage screening.

Physician knowledge, perceptions of barriers, and patient colorectal cancer screening practices

Physician recommendation is a major determinant of colorectal cancer screening. The purpose of this study was to examine physician attitudes and self-reported colorectal cancer patient screening. In a physician survey, perceived patient barriers included preparation for the tests and patient dislike of the blood stool test. Physician semistructured interviews revealed that perception of patient barriers included cost, time off from work, and transportation. Most physicians reported low knowledge of insurance coverage for screening, and self-reported screening rates among physicians themselves were not optimal. Evidence-based interventions to increase physician recommendations for screening, such as reminder and tracking systems, may be of value. Interventions that target physician knowledge of insurance coverage and encourage physicians to adopt screening themselves could also be considered.

Endoscopic ultrasound-guided fine-needle aspiration for diagnosis of solid pseudopapillary tumors of the pancreas: a multicenter experience

BACKGROUND AND STUDY AIMS

Solid pseudopapillary tumors of the pancreas are rare, low-grade, epithelial neoplasms that are usually discovered incidentally in young women. Distinguishing solid pseudopapillary tumors from other pancreatic tumors, especially pancreatic endocrine tumors, can be challenging. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in this context remains unclear. The purpose of this study was to describe the endoscopic ultrasound features of solid pseudopapillary tumors and the role of EUS-FNA in the preoperative diagnosis of these tumors.

PATIENTS AND METHODS

Patients from five tertiary referral centers with surgically confirmed solid pseudopapillary tumors who had undergone preoperative EUS-FNA were included. The endoscopic ultrasound findings, cytologic descriptions, immunostaining results, operative records, surgical pathology, and results of the most recent clinical follow-up were reviewed.

RESULTS

A total of 28 patients were identified (four men [14 %], 24 women [86 %], mean age +/- standard deviation [SD] 35 +/- 10 years). Solid pseudopapillary tumors had been found as incidental findings on cross-sectional imaging in 50 % of cases. The mean tumor size +/- SD was 42 +/- 19.5 mm and the majority were located in the pancreatic body and tail. The endoscopic ultrasound report described a well-defined, echo-poor mass in 86 %; the tumors were solid in 14 patients (50 %), mixed solid and cystic in 11 patients (39 %), and cystic in three patients (11 %). A preoperative diagnosis of solid pseudopapillary tumor was made in 21 patients (75 %) on the basis of EUS-FNA cytology. Surgical resection was performed in all cases. Laparoscopic resection was performed in eight of these patients (29 %).

CONCLUSIONS

A solid pseudopapillary tumor should be included in the differential diagnosis of any well-demarcated, echo-poor, solid or mixed solid/cystic pancreatic lesion seen during endoscopic ultrasound, particularly in young women. The diagnostic accuracy of EUS-FNA for solid pseudopapillary tumors was 75 % in this study. A definitive preoperative diagnosis can guide the surgical approach in selected cases.

EUS-guided FNA diagnostic yield of malignancy in solid pancreatic masses: a benchmark for quality performance measurement

BACKGROUND

The diagnostic yield of EUS-guided FNA (EUS-FNA) of solid pancreatic masses is a potential benchmark for EUS-FNA quality, because the majority of EUS-FNA of solid pancreatic masses should be diagnostic for malignancy.

OBJECTIVES

To determine the cytologic diagnostic rate of malignancy in EUS-FNA of solid pancreatic masses and to determine if variability exists among endoscopists and centers.

DESIGN

Multicenter retrospective study.

PATIENTS

EUS centers provided cytology reports for all EUS-FNAs of solid, noncystic, >or=10-mm-diameter, solid pancreatic masses during a 1-year period.

MAIN OUTCOME MEASUREMENT

Cytology diagnostic of pancreatic malignancy.

RESULTS

A total of 1075 patients underwent EUS-FNA at 21 centers (81% academic) with 41 endoscopists. The median number of EUS-FNA of solid pancreatic masses performed during the year per center was 46 (range, 4-177) and per endoscopist was 19 (range, 1-97). The mean mass dimensions were 32 x 27 mm, with 73% located in the head. The mean number of passes was 3.5. Of the centers, 90% used immediate cytologic evaluation. The overall diagnostic rate of malignancy was 71%, 95% confidence interval 0.69%-0.74%, with 5% suspicious for malignancy, 6% atypical cells, and 18% negative for malignancy. The median diagnostic rate per center was 78% (range, 39%-93%; 1st quartile, 61%) and per endoscopist was 75% (range, 0%-100%; 1st quartile, 52%).

LIMITATIONS

Retrospective study, participation bias, and varying chronic pancreatitis prevalence.

CONCLUSIONS

(1) EUS-FNA cytology was diagnostic of malignancy in 71% of solid pancreatic masses and (2) endoscopists with a final cytologic diagnosis rate of malignancy for EUS-FNA of solid masses that was less than 52% were in the lowest quartile and should evaluate reasons for their low yield.

Interobserver agreement for EUS findings in familial pancreatic-cancer kindreds

BACKGROUND

EUS is a promising modality for pancreatic-cancer screening in high-risk persons, including familial pancreatic-cancer (FPC) kindreds.

OBJECTIVE

To assess interobserver agreement for interpretation of EUS in persons at high risk for pancreatic cancer.

DESIGN

Seventeen expert endosonographers blinded to patients' clinical history rated a "training set" of pancreatic EUS video clips for the presence of a normal examination, masses, cysts, and features of chronic pancreatitis. Clips included high-risk persons and controls (normal and various pancreatic diseases). The endosonographers then participated in a workshop on EUS findings in high-risk persons and drafted a consensus statement. Three months later, they blindly rated a "test set" composed of the same video clips.

MAIN OUTCOME MEASUREMENTS

Interobserver agreement at baseline (training set) and after a consensus process (test set).

RESULTS

For the training set, interobserver agreement was good (kappa>or=0.4) for the presence of cysts and was fair to poor for all other rated EUS features and diagnosis of normal. There was no overall improvement in the test set. In both the training and test sets, agreement was worse for clips from FPC kindreds (kappa>or=0.4 for cysts and <0.4 for all other features) than for controls (kappa>or=0.4 for normal, cysts, masses, echogenic strands, and lobularity).

LIMITATIONS

Video clips were not of identical image quality and duration as a clinical EUS examination.

CONCLUSIONS

There was fair to poor interobserver agreement for the interpretation of pancreatic EUS video clips from members of FPC kindreds. Agreement was not improved by a consensus process.

Biomarkers in Diagnosis of pancreatic carcinoma in fine-needle aspirates

This study was undertaken to determine whether recently identified proteins could be translated to clinical practice as markers to distinguish pancreatic adenocarcinoma from chronic pancreatitis on fine-needle aspirate (FNA) samples. Resected pancreatic tissue sections (n = 40) and FNA samples (n = 65) were stained for clusterin-beta, MUC4, survivin, and mesothelin. For each biomarker, the staining patterns in adenocarcinoma and in reactive ductal epithelium were evaluated and compared. Clusterin-beta stained reactive ductal epithelium significantly more frequently than pancreatic adenocarcinoma (P < .001). In comparison, MUC4 and mesothelin were expressed more frequently in pancreatic adenocarcinoma on tissue sections. Positive staining for MUC4 (91% vs 0%; P < .001) and mesothelin (62% vs 0%; P = .01) and absence of staining for clusterin-beta (90% vs 7%; P < .001) were noted significantly more frequently in adenocarcinoma cells than in reactive cells in FNA samples. Clusterin-beta and MUC4 can help distinguish reactive ductal epithelial cells from the cells of pancreatic adenocarcinoma in FNA samples.

Can endoscopic ultrasonography-guided fine-needle aspiration predict response to chemoradiation in non-small cell lung cancer? A pilot study

BACKGROUND

Accurate prediction of pathologic response to chemoradiation (CHEMO-XRT) has a significant impact on the treatment of patients with non-small cell lung cancer (NSCLC) and mediastinal lymph node (LN) metastasis (N2 disease).

OBJECTIVE

This pilot study evaluates the ability of EUS-FNA to predict pathologic response in LN following CHEMO-XRT in NSCLC patients with N2 disease.

PATIENTS AND METHODS

Retrospective analysis of prospectively collected data on patients with NSCLC and biopsy-proven N2 disease who underwent restaging by EUS following CHEMO-XRT. At restaging, FNA was performed on the same LN, if present, or any other visible LN in the posterior mediastinum. Response to therapy (N0 disease) was defined by either absence of mediastinal LN or residual disease on FNA. Those staged N0 by EUS underwent tumor resection with complete LN dissection.

RESULTS

Fourteen patients met the criteria for evaluation. Restaging by EUS suggested disease response in 7 patients and residual disease in 6; tissue yield was unsatisfactory in 1 patient. Eleven of 14 patients in whom mediastinal LN were seen at restaging by EUS underwent FNA: the aspirate was benign in 4, residual disease was found in 6, and an inadequate sample was obtained in 1 patient. In 3 patients no mediastinal LN were evident at EUS. Final diagnosis on the 7 patients in whom EUS suggested N0 disease was established at surgery: EUS was true negative in 6 and false negative in 1. Of the 6 patients with residual disease, 5 underwent palliative CHEMO-XRT and 1 underwent extended tumor resection. The patient in whom tissue sampling was inadequate was found to have residual disease at surgery. The diagnostic accuracy of EUS-FNA for predicting mediastinal response to preoperative CHEMO-XRT was 86%.

CONCLUSIONS

EUS-FNA appears to qualify as an accurate, safe and minimally invasive diagnostic technique for restaging of mediastinal LN after CHEMO-XRT in NSCLC patients. Given this promising preliminary data, a prospective evaluation is justified.

Role of endoscopic evaluation in idiopathic pancreatitis: a systematic review

In approximately 20% of patients with acute pancreatitis, a cause is not established by history, physical examination, routine laboratory testing, and abdominal imaging. For those with a single unexplained attack, the role of invasive evaluation with endoscopic retrograde cholangiopancreatography is unsettled but has been generally limited to those patients with suspected bile duct stones or malignancy. Recent studies suggest that microlithiasis is causative in up to 75% of patients with an unexplained attack and gallbladder in situ, whereas sphincter of Oddi dysfunction is most prevalent in those with recurrent attacks who have previously undergone cholecystectomy. EUS has been shown to be highly accurate for the identification of gallbladder sludge, common bile duct stones, and pancreatic diseases. Given this apparent diagnostic utility, an EUS-based strategy may be a reasonable approach to evaluate patients with a single idiopathic attack. ERCP and sphincter of Oddi manometry should generally be reserved for patients with multiple unexplained attacks and negative EUS results, especially for those patients who have previously undergone cholecystectomy.

Antitumor efficacy of capecitabine and celecoxib in irradiated and lead-shielded, contralateral human BxPC-3 pancreatic cancer xenografts: clinical implications of abscopal effects

PURPOSE

X-ray therapy (XRT) remains one of the major modalities used to treat patients diagnosed with locally advanced pancreatic adenocarcinoma. However, the effect of XRT on metastatic tumors outside the field of irradiation (abscopal effect) remains largely unknown. In the current study, we examined the effect of XRT alone and in combination with capecitabine and/or celecoxib in both irradiated and lead-shielded contralateral BxPC-3 pancreatic cancer xenografts. This chemoradiation regimen was chosen based on our molecular analysis of pancreatic adenocarcinoma.

EXPERIMENTAL DESIGN

Athymic mice were injected bilaterally with BxPC-3 cells and treatment was initiated 28 days postimplant. During XRT (2 Gy for 5 consecutive days, administered on days 0 and 24), one flank was irradiated whereas the rest of the body (including the contralateral tumor) was lead shielded. Capecitabine (350 mg/kg) was administered on days 0 to 13 and 24 to 37. Celecoxib was initiated in the diet at 100 ppm (equivalent to 20 mg/kg/d p.o.) and administered throughout the study.

RESULTS

In irradiated xenografts, capecitabine and XRT showed synergistic anitiumor efficacy (P=0.008), which was further improved with the addition of celecoxib (P<0.001). In contralateral shielded xenografts, abscopal effects were observed. Whereas monotherapy with XRT showed significant reduction in tumor area in irradiated xenografts, growth was promoted by 23% (P<0.001) in contralateral lead-shielded tumors in the same animals relative to untreated tumors. Interestingly, synergistic antiproliferative efficacy occurred in these contralateral tumors when capecitabine was administered (P<0.001), despite being outside the irradiated field. The addition of celecoxib further inhibited tumor growth (P<0.001). This trimodal combination most effectively stabilized disease in both shielded and irradiated tumors; however, tumor eradication was not observed. There were no significant changes in thymidine phosphorylase, dihydropyrimidine dehydrogenase, or cyclooxygenase-2 mRNA levels in irradiated or lead-shielded tumors, suggesting that efficacy cannot be predicted solely from these previously identified indicators of response. Immunohistochemistry examining the proliferation marker Ki-67 showed concordance with tumor response in both irradiated and contralateral shielded xenografts.

CONCLUSIONS

These results have implications in the rational design of treatment paradigms for pancreatic cancer where metastatic disease remains the primary cause of patient morbidity and abscopal effects in tumors outside the field of irradiation may affect tumor response.

Histological quality of polyps resected using the cold versus hot biopsy technique

BACKGROUND AND STUDY AIMS

The monopolar hot biopsy technique is a widespread method of removing and cauterizing small colonic polyps. Due to the insulated cups of the biopsy forceps, it also allows adequate histological interpretation of the resected specimen. In our experience, polyps removed using the monopolar hot biopsy technique have been less histologically interpretable in comparison with polyps removed using cold biopsy forceps. The aim of this study was to assess and compare the diagnostic quality of polyps obtained using the hot biopsy and cold biopsy techniques.

PATIENTS AND METHODS

This was a prospective study of consecutive patients undergoing colonoscopy with removal of polyps using either hot biopsy or cold biopsy techniques. One experienced endoscopist using the same techniques carried out the biopsies. An experienced gastrointestinal pathologist, blinded to the technique used, evaluated the specimens for diameter, artifacts, cautery damage, tissue fragmentation, and general histological and diagnostic quality. Statistical analysis was carried out using the chi-squared test, Fisher's exact test, and Student's t-test.

RESULTS

Forty-three consecutive patients (84 % men; mean age 63.8 +/- 15 years) underwent 88 biopsies (45 hot biopsies and 43 cold biopsies). There were no statistically significant differences between the two study groups with regard to demographic data, indications for colonoscopy, endoscopic findings, or polyp size. Cautery damage, architectural distortion, and tissue fragmentation occurred more frequently in polyps resected using the hot biopsy technique ( P < 0.001).

CONCLUSIONS

The quality of the specimens removed by cold biopsy was generally better than when using hot biopsy technique. Histological evaluation is more difficult in polyps resected with the hot biopsy technique in comparison with the cold biopsy technique. When the nature of polyps affects the patient's management, a biopsy may be obtained before polyp coagulation.

Hepatic venous pressure gradient measurements to assess response to primary prophylaxis in patients with cirrhosis: a decision analytical study

BACKGROUND

The measurement of the hepatic venous pressure gradient may identify a suboptimal response to beta-blockers in patients with varices at risk for bleeding. However, the cost-effectiveness of routine hepatic venous pressure gradient measurements to guide primary prophylaxis has not been examined.

METHODS

We used decision analysis to evaluate two hepatic venous pressure gradient measurement strategies relative to standard beta-blocker therapy in a hypothetical cohort of patients with high-risk varices: (i) hepatic venous pressure gradient measurement 4 weeks after the initiation of beta-blocker therapy; and (ii) hepatic venous pressure gradient measurement prior to and 4 weeks after the initiation of beta-blocker therapy. The total expected costs, variceal bleeding episodes and deaths were calculated over a 1-year time horizon.

RESULTS

Beta-blocker therapy was associated with total costs of $1464, seven variceal bleeding episodes, one variceal bleeding episode-related death and 15 deaths. One hepatic venous pressure gradient measurement was associated with total costs of $5015, four variceal bleeding episodes, one variceal bleeding episode-related death and 15 deaths. Two hepatic venous pressure gradient measurements were associated with total costs of $8657, four episodes of variceal bleeding, one variceal bleeding episode-related death and 15 deaths. Compared with beta-blocker therapy alone, the incremental costs per variceal bleeding episode prevented and death averted were, respectively, $108 185 and $355 100 (one hepatic venous pressure gradient measurement) and $202 796 and $719 300 (two hepatic venous pressure gradient measurements). The results were sensitive to the time horizon of the analysis, the probability of bleeding whilst on beta-blockers and the cost of hepatic venous pressure gradient measurement.

CONCLUSION

Hepatic venous pressure gradient measurement to guide primary prophylaxis is an expensive strategy for reducing variceal bleeding or death, especially in patients with limited life expectancy, such as those with advanced, decompensated cirrhosis.

Effectiveness and patient satisfaction with nurse-directed treatment of Barrett's esophagus

OBJECTIVE

Using clinical practice guidelines, a registered nurse adjusted antireflux medications, evaluated esophageal biopsy reports, determined the interval between surveillance endoscopies, and provided education for patients with Barrett's esophagus. No previous reports have assessed the effectiveness or patient satisfaction associated with registered nurse-provided primary care. Because estimates of the incidence of dysplasia and adenocarcinoma vary widely, we also prospectively followed a cohort of patients with Barrett's esophagus.

METHODS

Charts were reviewed to determine the frequency of variation from guidelines, the annual incidence of dysplasia and adenocarcinoma, and frequency of reflux symptoms. Patients were mailed a questionnaire to assess satisfaction with their medical care and with the nurse.

RESULTS

Variation by the nurse from the guidelines on surveillance endoscopy (1.9%) and the treatment of reflux (1.3%) was rare. Most patients were very satisfied (score of 6 on 0-6-point Likert scale) with overall medical care (88%), and patient education (76%), and most patients did not think that increased physician involvement would improve their care (93%). Ninety-seven percent of patients had control of reflux symptoms. Two patients with long segment Barrett's esophagus (n = 67) developed high grade dysplasia over 323 patient-yr of follow-up (1 of 162 patient-yr for an annual incidence of 0.6%). No patients with short segment Barrett's esophagus (n = 56) developed high grade dysplasia or adenocarcinoma over 172 patient-years of follow-up.

CONCLUSION

The registered nurse in our clinical setting effectively administered clinical practice guidelines for the management of Barrett's esophagus without clinically significant morbidity or patient dissatisfaction. Before these results can be generalized to other settings, further studies will need to be performed.