Preoperative localization of an insulinoma: selective arterial calcium stimulation test performance.

PURPOSE: Preoperative localization of an insulinoma is recommended to improve the cure rate, but non-invasive procedures can fail to detect the tumour. The objective of the study was to assess the performance of a selective arterial calcium stimulation test in the preoperative localization of insulinomas that were not detected by conventional imaging procedures. METHODS: We conducted a monocenter retrospective case review of 13 patients who had endogenous hyperinsulinism and were treated between 1994 and 2013. Patients were selected on the basis of negative or doubtful non-invasive preoperative imaging. A selective arterial calcium stimulation test was performed by pancreatic and hepatic arteriography with selective intra-arterial calcium stimulation and hepatic venous sampling in order to obtain the plasma insulin measurement. We evaluated the efficacy of the test by comparing the results with an endoscopic ultrasound. RESULTS: Twelve of the 13 patients underwent surgery, and the presence of an insulinoma was proven in 11 patients by pathological analysis of the tumour. An endoscopic ultrasound was consistent with surgery in 71.4 % of cases, while selective arterial calcium stimulation was consistent with surgery in 90.9 % and allowed detection of an insulinoma in two additional patients with a negative endoscopic ultrasound. One false-negative and one false-positive arterial calcium test were observed. No adverse events were recorded except transient skin flush following calcium injection in one patient. CONCLUSION: The selective arterial calcium stimulation test is a sensitive diagnostic procedure for localizing insulinomas and may be considered when non-invasive radiological imaging does not allow the detection of an occult insulinoma.

The Fcp1-Wee1-Cdk1 axis affects spindle assembly checkpoint robustness and sensitivity to antimicrotubule cancer drugs.

To grant faithful chromosome segregation, the spindle assembly checkpoint (SAC) delays mitosis exit until mitotic spindle assembly. An exceedingly prolonged mitosis, however, promotes cell death and by this means antimicrotubule cancer drugs (AMCDs), that impair spindle assembly, are believed to kill cancer cells. Despite malformed spindles, cancer cells can, however, slip through SAC, exit mitosis prematurely and resist killing. We show here that the Fcp1 phosphatase and Wee1, the cyclin B-dependent kinase (cdk) 1 inhibitory kinase, play a role for this slippage/resistance mechanism. During AMCD-induced prolonged mitosis, Fcp1-dependent Wee1 reactivation lowered cdk1 activity, weakening SAC-dependent mitotic arrest and leading to mitosis exit and survival. Conversely, genetic or chemical Wee1 inhibition strengthened the SAC, further extended mitosis, reduced antiapoptotic protein Mcl-1 to a minimum and potentiated killing in several, AMCD-treated cancer cell lines and primary human adult lymphoblastic leukemia cells. Thus, the Fcp1-Wee1-Cdk1 (FWC) axis affects SAC robustness and AMCDs sensitivity.

How to perform EUS in the pancreaticobiliary area.

EUS remains mandatory in the management of the majority of pancreaticobiliary diseases. This article fully describes with details how to examine the pancreatico-biliary region using radial and linear EUS. Pancreaticobiliary examination with a radial instrument: 1) place the patient on left lateral decubitus position, tilted towards the examination table at an angle of 30° to 40°; 2) use a moderately inflated balloon; 3) begin the examination in the stomach 45 to 50 cm from the incisors, to examine the body and tail region; 4) after advancing through the pylorus under endoscopic control, proceed from the bulb to the second part of the duodenum by pushing the echoendoscope which is in opened position of the handle gently under ultrasound control, turning the handle clockwise if the superior duodenal angle is open, then push the echoendoscope in the long position towards the ampulla of Vater, adding up angulation. Use the ERCP withdrawal manoeuvre under endoscopic control, from the apex of the bulb if the superior duodenal angle is closed (thin patient), and allow the head of the echoendoscope to fall into the second duodenum, then push the tip over the ampulla of Vater, in the long position, and start the examination at this point. Pancreaticobiliary examination with a linear instrument: place the patient in the same position as with a radial instrument. 1) balloon slightly inflated or uninflated; 2) use the neutral position of the handle as a starting point in the stomach. Move from this position to the open position by turning the handle anti-clockwise and to the closed position by turning the handle clockwise while advancing or withdrawing the echoendoscope, adding clockwise torquing to the endoscope shaft when necessary (to examine the pancreatic tail); 3) almost the whole of the pancreatic gland, apart from the juxtaduodenal segment of the head and uncinate process and in particular the ampulla of Vater, can be examined through the stomach; 4) the examination is conducted exclusively by following the vascular structures and ducts, hence the importance of anatomical knowledge; 5) use constant up angulation.

Can rectal endoscopic sonography be used to predict infiltration depth in patients with deep infiltrating endometriosis of the rectum?

OBJECTIVES: To evaluate the diagnostic accuracy of rectal endoscopic sonography (RES) in the prediction of the infiltration depth of rectal endometriosis and to ascertain whether RES could be used to choose between segmental bowel resection and a more conservative approach, such as shaving or discoid resection. METHODS: In this retrospective study, 38 consecutive patients with symptomatic deep infiltrating endometriosis of the rectum who underwent laparoscopic colorectal resection were included. RES results for infiltration depth of rectal endometriosis were compared with results of pathological examination. The sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), positive and negative likelihood ratios (LRs) and test accuracy were calculated for the presence of infiltration of the muscularis layers and submucosal/mucosal layers, as demonstrated by RES and confirmed by histopathological analysis. RESULTS: For the detection of muscularis layer infiltration by endometriosis, the PPV of RES was 100%, whereas for the detection of submucosal/mucosal layer involvement, the sensitivity was 89%, specificity was 26%, PPV was 55%, NPV was 71%, test accuracy was 58% and positive and negative LRs were 1.21 and 0.40, respectively. CONCLUSIONS: RES is a valuable tool for detecting rectal endometriosis as endometriotic infiltration of the muscularis layer can be predicted accurately. However, RES is less accurate in detecting submucosal/mucosal layer involvement and cannot, therefore, be used to choose between bowel resection and a more conservative approach.

[Preoperative imaging of deeply infiltrating endometriosis in: Transvaginal sonography, rectal endoscopic sonography and magnetic resonance imaging]. / Imagerie préopératoire dans l'endométriose profonde : échographie pelvienne, écho-endoscopie rectale et IRM.

OBJECTIVES: Compare the accuracy of transvaginal ultrasonography (TVUS), rectal endoscopic sonography (RES), and magnetic resonance imaging (MRI) before deeply infiltrating endometriosis surgery. PATIENTS AND METHODS: A retrospective study with 25 deeply endometriosis patients underwent the three imaging examinations before surgery. Calculation of sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the different locations: ovaries, uterosacral ligaments and torus, rectovaginal septum, rectosigmoid junction, bladder. RESULTS: Ovarian and deep pelvic endometriosis was found in surgery and confirmed by histology in all patients. Sensitivity and specificity are respectively: for ovaries: 88.2% and 71% of TVUS; 80% and 81.2% of RES; 87.5% and 71% of MRI. For uterosacral ligaments: 63% and 82,6% of TVUS; 37% and 100% of RES; 69% and 82.6% of MRI. For torus: 57.1% and 100% of TVUS; 76.2% and 100% of RES; 76.2% and 100% of MRI. For rectovaginal septum: 63.2% and 100% for TVUS; 89.5% and 66.7% of EER; 47.4% and 100% of MRI. For rectosigmoid junction: 73.7% and 66.7% of TVUS; 94.7% and 66.7% of RES; 89.5% and 50% of MRI. For bladder: 16.7% and 100% of TVUS; 16.7% and 100% of RES; 33.3% and 89.5% of MRI. DISCUSSION AND CONCLUSION: We found that TVUS is the more performant for endometriomas, it is MRI for torus, uterosacral ligaments and little bladder lesions, RES for rectovaginal septum and rectosigmoid junction. So in the clinical practice, the three imaging examinations are complementary for the preoperative assessment of deeply endometriosis.

Deep-seated rectal/anal basaloid carcinoma: useful immunocytochemistry in rare squamous cell carcinoma variants.

OBJECTIVES: To report the cytological aspects of ano-rectal basaloid carcinoma (BC) variant in endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) conventional and liquid-based cytology (LBC), in a series of 10 cases of deep-seated squamous cell carcinomas (SCC), and to discuss the diagnostic difficulties in interpreting the morphology and immunocytochemical findings. METHODS: Ten cases of EUS-FNA smears and LBC specimens of deep-seated pelvic masses were retrospectively collected from January 2001 to November 2006. RESULTS: Ten EUS-FNA specimen cases were SCC, eight corresponding to usual SCC and two to BC-variant. Of these two cases, only one was correctly diagnosed by EUS-FNA specimen, whereas in the second case, the initial cytological diagnosis was poorly differentiated adenocarcinoma and the final diagnosis of basaloid carcinoma variant was established on surgical resection. Immunocytochemistry (ICC) using CK7, CK20 and CK34betae12 on FNA specimens confirmed the diagnosis retrospectively. CONCLUSION: The diagnosis of basaloid variant of SCC in a rectal location can be very difficult, both on account of the uncommon location and because of the low specificity of morphological aspects on EUS-FNA smears. The immunocytochemical technique, including a limited spectrum of keratins (CK7, CK20, CK34betae12, and p63) is necessary to avoid this diagnostic pitfall.

[Surgical and functional results of rectosigmoidal resection for severe endometriosis]. / Résection rectosigmoïdienne pour endométriose profonde : résultats chirurgicaux et fonctionnels.

OBJECTIVES: Indications of colorectal resection for endometriosis are controversial because of the risk of major complications. This study aims to evaluate the value of different diagnostic tests in decision-making, and to evaluate the surgical results and complications, as well as long-term functional results after surgery. PATIENTS AND METHODS: In the set of a retrospective case series, 50 patients who have been admitted for a colorectal resection because of deep endometriosis were included. Most of them have had an MRI and an endorectal ultrasonography. Specific questionnaires have been proposed in order to evaluate symptoms, sexuality (BISF-W) and quality of life (EHP-30). RESULTS: For the diagnosis of rectal involvement, the sensitivity of MRI and endorectal ultrasonography were 55 and 100%, respectively. Forty-one colorectal amputations and nine partial colorectal resections have been done by 24 laparotomies, two laparoscopies and 24 laparoconversions. Major complications included six (12.5%) digestive fistulas, three (6%) anastomotic strictures, one ureterovaginal fistula and one ureteral stricture. Risk factors associated with digestive fistulas were the association of a vaginal opening (p=0.002) and an additional ileocaecal resection (p=0.007). The mean follow-up period was of 42 months. A significant improvement of dysmenorrhea (p<10(-4)), dyschesia (p<10(-4)), chronic pelvic pain (p<10(-4)), and of some digestive symptoms such as catamenial epreintes (p=0.002) and catamenial diarrheas (p=0.006), was noted. We noted postoperative 14 dysurias, six constipations and 12 rectal polykynesias. Four patients have had deep recurrent lesions. Twenty patients had a desire of pregnancy after the operation, 17 pregnancies were obtained (eight spontaneous and nine by ART) giving birth to 14 living children. Sexuality evaluation was below normal range. The quality of life was improved for most of the items. The global satisfaction was good (91%). DISCUSSION AND CONCLUSION: Colorectal resection for deep endometriosis improve significantly most of the pain symptoms, but the women should have detailed counselling about the risks of major complications and recurrence.

Low prevalence of Listeria monocytogenes in foods from Italy.

Listeria monocytogenes is an important foodborne pathogen that causes gastrointestinal disorders, and, especially in immunocompromised people, serious extraintestinal diseases, such as septicemia and meningitis, as well as abortion in pregnant women. Many foods, from both plant and animal origin, have been involved in listeriosis outbreaks. This article reports the results of a 12-year survey (1993 through 2004) on the presence of L. monocytogenes in several kinds of food marketed in Italy. Of 5,788 analyzed samples, 121 (2.1%) were contaminated with L. monocytogenes. The highest prevalence was found in smoked salmon (10.6%) and in poultry meat samples (8.5%) and the lowest in red meat (0.3%). L. monocytogenes was not found in 154 samples of fresh seafood products. Fifty-two isolates were also serotyped by the agglutination method. The most common serotypes detected in the 52 strains tested were 1/2a (36.5%), followed by 1/2c (32.8%), 1/2b (13.5%), 4b (11.5%), 3a (3.8%), and 3b (1.9%). The results of the present study showed low levels of L. monocytogenes in the analyzed samples. A total of 61.5% of the 52 L. monocytogenes strains analyzed belonged to serotypes 1/2a, 1/2b, and 4b, namely the serovars that are most commonly involved in extraintestinal human listeriosis outbreaks. In the ready-to-eat samples, these three serotypes were 40.0% (1/2a), 17.1% (1/2b), and 14.3% (4b). This finding highlights the need to implement strict hygienic measures during the production, distribution, and sale of foods to reduce the risk of foodborne listeriosis in humans to an acceptable level.