Safety Aspects of Perinatal Ultrasound.

Ultrasound safety is of particular importance in fetal and neonatal scanning. Fetal tissues are vulnerable and often still developing, the scanning depth may be low, and potential biological effects have been insufficiently investigated. On the other hand, the clinical benefit may be considerable. The perinatal period is probably less vulnerable than the first and second trimesters of pregnancy, and ultrasound is often a safer alternative to other diagnostic imaging modalities. Here we present step-by-step procedures for obtaining clinically relevant images while maintaining ultrasound safety. We briefly discuss the current status of the field of ultrasound safety, with special attention to the safety of novel modalities, safety considerations when ultrasound is employed for research and education, and ultrasound of particularly vulnerable tissues, such as the neonatal lung. This CME is prepared by ECMUS, the safety committee of EFSUMB, with contributions from OB/GYN clinicians with a special interest in ultrasound safety.

An electrospray ionization mass spectrometry study of azidoacetic acid/transition metal complexes.

RATIONALE: The complexation behavior of transition metals with organic azides by electrospray ionization (ESI) tandem mass spectrometry (MS/MS) is not completely understood. In this study, fragmentation patterns of complex ions having azidoacetic acid coordinated to Ni/Co/Fe were elucidated. The role of transition metals in the mediation of ligand rearrangements in gas phase is experimentally supported. METHODS: The complexation of some transition metals, nickel, cobalt and iron, by azidoacetic acid was studied by means of ESI and MS/MS. Fragmentation patterns were discerned via consecutive MS/MS experiments on an ion trap mass spectrometer and confirmed by high-resolution (HR) Fourier transform ion cyclotron resonance MS. Density functional theory (DFT) calculations were used to characterize the major ions observed in MS. RESULTS: Only singly positively charged complex ions were detected presenting various stoichiometries. MS/MS and theoretical calculations allowed us to confirm assignments and coordination sites. Structural evidence suggested that the azidoacetic acid can behave as monodentate and/or bidentate and coordination through the oxygen and nitrogen atoms are both possible. Experimental evidence strongly points to a role of Ni/Co/Fe, in oxidative state (I), in mediating C-C bond activation in the gas phase. CONCLUSIONS: MS/MS and HRMS experiments were able to elucidate azidoacetic acid complexation with Ni/Co/Fe and several gas-phase processes involving metal reduction and rearrangements. The definition of the coordination pattern dictated by the competition between the nitrogen and the oxygen atoms is also dependent on the metal centre in a very dynamic process. Copyright © 2017 John Wiley & Sons, Ltd.

Resilience in the face of peer victimisation and discrimination: The who, when and why in five patterns of adjustment.

Victimisation has a negative effect on psychosocial functioning. Based on the resilience theory, and with a sample of 2975 Portuguese students, the present study aims to: i) identify patterns of adjustment in the face of peer victimisation and perceptions of discrimination; ii) explore the association between the patterns of adjustment and the characteristics of participants (the who) and of the victimisation (the when and why). Cluster analysis revealed five patterns of adjustment: Unchallenged; Externally Maladjusted; Internally Maladjusted; Resilient, and At-Risk. The results suggest that there is no complete resilience in the face of social victimisation. Group differences were found regarding: i) gender, type of course, sexual orientation, ethnicity, nationality, parental educational level and religious beliefs; ii) the age at which peer victimisation was more frequent, and; iii) the motives underlying discrimination. Globally considered, peer victimisation is representative of the wider cultural environment and interventions should also target social prejudices.

Conversion of cellulosic materials into glycolipid biosurfactants, mannosylerythritol lipids, by Pseudozyma spp. under SHF and SSF processes.

BACKGROUND: Mannosylerythritol lipids (MEL) are glycolipids with unique biosurfactant properties and are produced by Pseudozyma spp. from different substrates, preferably vegetable oils, but also sugars, glycerol or hydrocarbons. However, solvent intensive downstream processing and the relatively high prices of raw materials currently used for MEL production are drawbacks in its sustainable commercial deployment. The present work aims to demonstrate MEL production from cellulosic materials and investigate the requirements and consequences of combining commercial cellulolytic enzymes and Pseudozyma spp. under separate hydrolysis and fermentation (SHF) and simultaneous saccharification and fermentation (SSF) processes. RESULTS: MEL was produced from cellulosic substrates, Avicel® as reference (>99% cellulose) and hydrothermally pretreated wheat straw, using commercial cellulolytic enzymes (Celluclast 1.5 L® and Novozyme 188®) and Pseudozyma antarctica PYCC 5048(T) or Pseudozyma aphidis PYCC 5535(T). The strategies included SHF, SSF and fed-batch SSF with pre-hydrolysis. While SSF was isothermal at 28°C, in SHF and fed-batch SSF, yeast fermentation was preceded by an enzymatic (pre-)hydrolysis step at 50°C for 48 h. Pseudozyma antarctica showed the highest MEL yields from both cellulosic substrates, reaching titres of 4.0 and 1.4 g/l by SHF of Avicel® and wheat straw (40 g/l glucan), respectively, using enzymes at low dosage (3.6 and 8.5 FPU/gglucan at 28°C and 50°C, respectively) with prior dialysis. Higher MEL titres were obtained by fed-batch SSF with pre-hydrolysis, reaching 4.5 and 2.5 g/l from Avicel® and wheat straw (80 g/l glucan), respectively. CONCLUSIONS: This work reports for the first time MEL production from cellulosic materials. The process was successfully performed through SHF, SSF or Fed-batch SSF, requiring, for maximal performance, dialysed commercial cellulolytic enzymes. The use of inexpensive lignocellulosic substrates associated to straightforward downstream processing from sugary broths is expected to have a great impact in the economy of MEL production for the biosurfactant market, inasmuch as low enzyme dosage is sufficient for good systems performance.

Identification and characterisation of xylanolytic yeasts isolated from decaying wood and sugarcane bagasse in Brazil.

In this study, yeasts associated with lignocellulosic materials in Brazil, including decaying wood and sugarcane bagasse, were isolated, and their ability to produce xylanolytic enzymes was investigated. A total of 358 yeast isolates were obtained, with 198 strains isolated from decaying wood and 160 strains isolated from decaying sugarcane bagasse samples. Seventy-five isolates possessed xylanase activity in solid medium and were identified as belonging to nine species: Candida intermedia, C. tropicalis, Meyerozyma guilliermondii, Scheffersomyces shehatae, Sugiyamaella smithiae, Cryptococcus diffluens, Cr. heveanensis, Cr. laurentii and Trichosporon mycotoxinivorans. Twenty-one isolates were further screened for total xylanase activity in liquid medium with xylan, and five xylanolytic yeasts were selected for further characterization, which included quantitative analysis of growth in xylan and xylose and xylanase and ß-D-xylosidase activities. The yeasts showing the highest growth rate and cell density in xylan, Cr. laurentii UFMG-HB-48, Su. smithiae UFMG-HM-80.1 and Sc. shehatae UFMG-HM-9.1a, were, simultaneously, those exhibiting higher xylanase activity. Xylan induced the highest level of (extracellular) xylanase activity in Cr. laurentii UFMG-HB-48 and the highest level of (intracellular, extracellular and membrane-associated) ß-D-xylosidase activity in Su. smithiae UFMG-HM-80.1. Also, significant ß-D-xylosidase levels were detected in xylan-induced cultures of Cr. laurentii UFMG-HB-48 and Sc. shehatae UFMG-HM-9.1a, mainly in extracellular and intracellular spaces, respectively. Under xylose induction, Cr. laurentii UFMG-HB-48 showed the highest intracellular ß-D-xylosidase activity among all the yeast tested. C. tropicalis UFMG-HB 93a showed its higher (intracellular) ß-D-xylosidase activity under xylose induction and higher at 30 °C than at 50 °C. This study revealed different xylanolytic abilities and strategies in yeasts to metabolise xylan and/or its hydrolysis products (xylo-oligosaccharides and xylose). Xylanolytic yeasts are able to secrete xylanolytic enzymes mainly when induced by xylan and present different strategies (intra- and/or extracellular hydrolysis) for the metabolism of xylo-oligosaccharides. Some of the unique xylanolytic traits identified here should be further explored for their applicability in specific biotechnological processes.

Red cell apheresis with automated in-line filtration.

BACKGROUND: The aim of this study was to provide data on concurrent red blood cell (RBC) and platelet (PLT) apheresis with RBC in-line leukoreduction and automated addition of saline-adenine-glucose-mannitol (SAGM) using the new version (V6.0) of Trima Accel®. METHODS: In this two-center paired study, each subject completed a test and a control procedure with an interval of 9 weeks between procedures. In the test arm, single RBC and PLT units were collected on the Trima Accel V6.0 (in-line leukofiltration and automated addition of SAGM). In the control arm, they were collected on Trima Accel V5.1/V5.2 (post-collection leukoreduction, manual SAGM addition). RBC percent hemolysis, potassium concentration and adenosine triphosphate over storage, hemoglobin (Hb) yield, and residual white blood cells (WBC) were determined. RESULTS: 34 subjects successfully completed both test and control procedures. Post-storage hemolysis was similar in both groups, and all values were less than 0.8% for both arms. Residual WBC counts in all RBC units were less than 1 × 10(6)/unit. In-line processed RBC units (V6.0) have a significantly higher volume and more Hb/unit due to filtration recovery improvements. All procedures were well tolerated by the subjects. CONCLUSION: In-line filtration and automated addition of storage solution on Trima Accel V6.0 allows collection of ready-to-use RBC units that meet EU requirements.

Polyhydroxyalkanoate Production from Eucalyptus Bark's Enzymatic Hydrolysate.

In recent years, polyhydroxyalkanoates (PHAs) have gained notoriety because of their desirable properties that include proven biodegradability, biocompatibility, and thermal stability, which make them suitable alternatives to fossil-based polymers. However, the widespread use of PHAs is still challenging because of their production costs, which are greatly associated with the cultivation medium used for bacterial cultivation. In Portugal, one-quarter of the forest area is covered by Eucalyptus globulus wood, making its residues a cheap, abundant, and sustainable potential carbon source for biotechnological uses. In this work, eucalyptus bark was used as the sole feedstock for PHA production in a circular bioeconomic approach. Eucalyptus bark hydrolysate was obtained after enzymatic saccharification using Cellic® CTec3, resulting in a sugar-rich solution containing glucose and xylose. Although with differing performances, several bacteria were able to grow and produce PHA with distinct compositions, using the enzymatic hydrolysate as the sole carbon source. Pseudomonas citronellolis NRRL B-2504 achieved a high cellular growth rate in bioreactor assays (24.4 ± 0.15 g/L) but presented a low accumulation of a medium-chain-length PHA (mcl-PHA) comprising the monomers hydroxydecanoate (HD, 65%), hydroxydodecanoate (HDd, 25%), and hydroxytetradecanoate (HTd, 14%). Burkholderia thailandensis E264, on the other hand, reached a lower cellular growth rate (8.87 ± 0.34 g/L) but showed a higher biopolymer accumulation, with a polyhydroxybutyrate (PHB) content in the cells of 12.3 wt.%. The new isolate, Pseudomonas sp., revealed that under nitrogen availability, it was able to reach a higher accumulation of the homopolymer PHB (31 wt.%). These results, although preliminary, demonstrate the suitability of eucalyptus bark's enzymatic hydrolysate as a feedstock for PHA production, thus offering an exciting avenue for achieving sustainable and environmentally responsible plastic products from an undervalued forestry waste.

Sugiyamaella xylanicola sp. nov., a xylan-degrading yeast species isolated from rotting wood.

Four strains of a novel yeast species were isolated from rotting-wood samples in an Atlantic rainforest site in the state of Minas Gerais, Brazil. These yeasts were obtained from enrichments using yeast nitrogen base (YNB)-d-xylose or YNB-xylan media. The novel yeast species produces bacilliform ascospores typical of the genus Sugiyamaella, and its closest described relative in terms of sequence similarity is Candida (iter. nom. Sugiyamaella) marionensis. The yeast is able to grow in medium with xylan as sole carbon source and produces extracellular enzymes with xylanolytic activities. The novel species Sugiyamaella xylanicola sp. nov. is proposed to accommodate these isolates. The type strain is UFMG-CA-32.1(T) (=CBS 12683(T) =CBMAI 1467(T)).

Idiopathic Hypereosinophilic Syndrome: A Case Report.

Idiopathic hypereosinophilic syndrome is a rare condition characterized by persistent severe eosinophilia and organ damage without any apparent cause. A 20-year-old male patient with no significant medical history was admitted to the Emergency Department with retrosternal chest pain, fatigue and asthenia. EKG showed ST elevation I, II, III, aVF, V4-V6 and blood tests showed elevated troponin levels. An echocardiogram was performed revealing severe global left ventricular systolic dysfunction. Further evaluations included cardiac magnetic resonance imaging and endomyocardial biopsy, confirming the diagnosis of eosinophilic myocarditis. The patient was started on systemic corticosteroid therapy, resulting in clinical improvement. The patient was discharged after 12 days of hospitalization, following a recovery of biventricular function and he was told to continue oral corticosteroid therapy at home. Further investigation ruled out other causes of hypereosinophilic syndromes, therefore the diagnosis of idiopathic hypereosinophilic syndrome was assumed. Despite the attempt to reduce corticosteroid therapy, the eosinophil count became elevated again, so the dosage was increased and associated with azathioprine with subsequent favorable analytical evolution. This case highlights the challenges in diagnosing and managing idiopathic hypereosinophilic syndrome and emphasizes the importance of prompt treatment initiation to prevent complications.

Mediastinal Abscess Formation after EUS-Guided Sampling in a Young Patient with Sarcoidosis: Be Aware of the Increased Risk!

International guidelines establish EUS-guided sampling as safe and accurate for the evaluation of mediastinal solid lesions, such as lymphadenopathies of unknown origin, and point out an increased risk of severe infectious complications induced by needle puncture in mediastinal cystic lesions. A retrospective case series and a systematic review documented an increased risk of mediastinal abscess formation after EUS-guided lymph nodes sampling in patients with sarcoidosis. The authors describe a case of a 38-year-old male patient with a final diagnosis of sarcoidosis, who developed a large mediastinal abscess after EUS-guided fine-needle biopsy of mediastinal lymphadenopathies. Endoscopists should be aware of the potential increased risk of severe infectious complications when sampling mediastinal lymph nodes in suspected sarcoidosis, and a strategy to minimize such risk should be pursued.

As normas de consenso internacionais estabelecem a biopsia guiada por ecoendoscopia como segura e precisa no diagnóstico de lesões sólidas do mediastino, tais como adenopatias de origem indeterminada, e sublinham o risco significativo de complicações infecciosas graves associado à punção de lesões mediastínicas quísticas. Uma série retrospectiva e uma revisão sistemática apontaram para um risco aumentado de abcesso mediastínico após punção guiada por ecoendoscopia de gânglios linfáticos em doentes com sarcoidose. Os autores descrevem o caso cínico de um jovem de 38 anos, com o diagnóstico final de sarcoidose, que desenvolveu um volumoso abcesso mediastínico após biopsia guiada por ecoendoscopia de adenopatias mediastínicas. Os endoscopistas deverão reconhecer o risco aumentado de complicações infeciosas graves aquando da punção de adenopatias mediastínicas na suspeita de sarcoidose e procurar definir uma estratégia preventiva para minimizar o referido risco.

Dispositional optimism is unidimensional or bidimensional? The Portuguese revised Life Orientation Test.

The aim of the study is to adapt and then discuss the appropriateness of the Life Orientation Test as a one or two dimension scale. The research includes two studies; one is composed of a sequential sample of 280 people with multiple sclerosis, 71% female, and another includes a convenience sample of 615 individuals from the community, 51.1% female. Because the construct is built upon a theoretical assumption that has one dimension, we examine the hypothesis of one or two factor solutions through confirmatory factor analysis, and the two-dimension solution premise demonstrates better adjustment for both samples. The other psychometric properties explored show appropriate results for the Portuguese sample, and similar to the original ones; the Test therefore seems appropriate for use in cross cultural studies. Based on our results, we discuss whether the questionnaire is a one or two dimension instrument, concluding that it appears appropriate to accept the recommendations of the original authors to use it as a one-dimensional tool and, when necessary, to use both dimensions.

Endoscopic Reconstruction of an Oral Feeding Route Using a Rendezvous Approach.

Background: The approach to esophageal obstruction or discontinuity remains challenging and often involves complex reconstructive surgeries. The rendezvous endoscopic technique might be interesting in cases of complete esophageal obstruction. Case Presentation: Herein we describe a successful case of endoscopic recanalization of the esophageal lumen in a patient with a long-standing esophageal discontinuity resulting from several surgeries and chemoradiation for a squamous cell carcinoma of the hypopharynx, ending in a major cervical amputation, construction of a neopharynx, and definitive surgical closure of the superior esophagus with a PEG placement. With a rendezvous technique (peroral and through the gastrostomy) and under radiographic guidance, puncture from the neopharynx into the distal esophagus was performed, followed by balloon dilation and covered metal stent placement in order to reconstruct a neoesophagus. Five weeks later, the stent was removed (using a stent-in-stent technique). No complications occurred. The patient has been able to eat soft food and is being kept under regular endoscopic surveillance to control/treat a luminal stenosis of the neoesophagus. Conclusions: This case report illustrates a successful endoscopic treatment of post-surgical complete esophageal obstruction. This approach should be considered in the therapeutic armamentarium of these difficult clinical settings.

Introdução: A abordagem da descontinuidade esofágica permanece desafiante e frequentemente envolve cirurgias reconstrutivas complexas. A técnica endoscópica de rendez-vous pode ser interessante em casos de obstrução esofágica completa. Apresentação do caso: Descrevemos um caso de sucesso de recanalização endoscópica do lúmen esofágico de um doente com descontinuidade esofágica de longa duração, em resultado de múltiplas cirurgias e quimioradiação por um carcinoma pavimento-celular da hipofaringe, que resultou numa amputação cervical major, construção de uma neofaringe e encerramento cirúrgico definitivo do esófago com colocação de PEG. Por técnica de rendez-vous (peroral e por gastrostomia) e sob apoio radiológico, foi realizada punção da neofaringe, seguido de dilatação com balão e colocação de prótese metálica coberta para criar um neo-esófago. Cinco semanas depois, a prótese foi removida (por técnica stent-in-stent). Não ocorreram complicações. O doente tem mantido capacidade de ingerir comida pastosa e é submetido a vigilância regular endoscópica para controlar/tratar uma estenose do lúmen do neo-esófago. Conclusão: Este caso ilustra o tratamento endoscópico bem-sucedido de um doente com obstrução pós-cirúrgica completa do esófago. Esta abordagem deverá ser considerada no arsenal terapêutico destes quadros clínicos complexos.

Endoscopic Management of Symptomatic Duodenal Duplication Cysts: Two Case Reports.

Background: Duodenal duplication cysts (DDCs) are rare congenital anomalies typically manifesting during childhood. Clinical manifestations are uncommon in adulthood. DDCs were classically treated surgically, but endoscopic treatment has been increasingly reported. Endoscopic cyst marsupialization establishes a communication between the cyst cavity and the duodenal lumen so that the cystic content can be drained continuously into the duodenum. We herein describe two cases of symptomatic DDCs diagnosed in adulthood and submitted to endoscopic marsupialization using different techniques and devices. Case Summary: Case 1: A 23-year-old female patient was admitted with the diagnosis of acute pancreatitis. Endoscopic ultrasound revealed a 35-mm duodenal subepithelial lesion whose proximal limit was immediately distal to the ampulla of Vater and filled with fluid and calcifications. Using a duodenoscope, deroofing of the lesion was made with a diathermic snare. Pathology confirmed the diagnosis of DDC. Case 2: A 41-year-old female, submitted to laparoscopic cholecystectomy 1 month earlier due to suspected lithiasic acute pancreatitis, was admitted due to suspicion of iatrogenic biliary fistula. An endoscopic retrograde cholangiopancreatography was performed and the bile leak was treated. Immediately distal to the papillary orifice, a 20-mm subepithelial lesion was also detected. A biopsy forceps was used to fenestrate its wall, allowing the exit of mucous fluid and stones, and a sphincterotome was used to expand the incision. No recurrence was documented in both cases. Conclusion: These cases highlight DDC as a potential cause for acute pancreatitis in adults and endoscopy as an easy treatment option.

Introdução: Os quistos de duplicação duodenais (QDD) são anomalias congénitas raras que tipicamente se manifestam durante a infância. As manifestações clínicas são pouco frequentes em adultos. Os QDD eram classicamente tratados cirurgicamente, mas o tratamento endoscópico tem sido crescentemente reportado. A marsupialização endoscópica do quisto estabelece uma comunicação entre a cavidade do quisto e o lúmen duodenal, permitindo que o conteúdo do quisto drene continuamente para o duodeno. Reportamos 2 casos de QDD diagnosticados em adultos e submetidos a marsupialização endoscópica, utilizando diferentes técnicas e dispositivos. Casos clínicos: Caso 1: Doente do sexo feminino, 23 anos, internada por pancreatite aguda. Por ecoendoscopia documentou-se lesão subepitelial duodenal com 35 mm com limite proximal imediatamente distal à ampola de Vater, preenchida por líquido e calcificações. Usando um duodenoscópio, foi feita marsupialização da lesão com ansa diatérmica. Histologia confirmou o diagnóstico de QDD. Caso 2: Doente do sexo feminino, 41 anos, submetida a colecistectomia laparoscópica 1 mês antes por suspeita de pancreatite aguda litiásica, foi internada por suspeita de fístula biliar iatrogénica. Por CPRE confirmouse fuga biliar que foi tratada. Imediatamente distal ao orifício papilar, foi também detetada uma lesão subepitelial com 20 mm. Uma pinça de biopsia foi usada para fenestrar a sua parede, permitindo a saída de fluido mucoso e cálculos e um esfincterótomo foi usado para expandir a incisão. Não se registou recorrência em nenhum dos casos. Conclusão: Estes casos destacam os QDD como causa potencial de pancreatite aguda em adultos e a endoscopia como possível opção terapêutica.

Use of the "Mental Health Inventory - 5" with Portuguese 10-15 years old.

The present study describes the psychometric properties of the Portuguese version of the Mental Health Inventory-5 for use with young adolescents. A sample of 367 Portuguese students (aged 10-15 years) completed the Portuguese-language versions of Mental Health Inventory-5 (MHI-5; Berwick et al., 1991), Children's Hope Scale (CHS; Snyder et al., 1997), Students' Life Satisfaction Scale (SLSS; Huebner, 1991a), and Global Self-Worth Sub-scale (Harter, 1985). Analysis of readability, reliability (internal consistency and 1-year stability), factor structure, and criterion-related validity suggested that the MHI-5 can be appropriately used in this age group. Implications of the findings are discussed.

The Impact of Recent Advances in Endoscopic Ultrasound-Guided Tissue Acquisition on the Management of Pancreatic Cancer.

Over the last few decades, endoscopic ultrasound (EUS)-guided tissue acquisition has become the method of choice for the pathological diagnosis of solid pancreatic lesions. Due to its high diagnostic yield and low complication rate, EUS-guided tissue acquisition has surpassed percutaneous sampling techniques. For many years, EUS-guided fine-needle aspiration (EUS-FNA) was traditionally used to obtain cytological aspirates of solid pancreatic lesions, with sensitivity values ranging from 80 to 90% for the diagnosis of malignancy. Nevertheless, despite numerous technical advances, EUS-FNA still presents some limitations. Therefore, EUS-guided fine-needle biopsy (EUS-FNB) has been introduced to provide tissue core biopsies, allowing histological assessment. A newly developed generation of FNB needles has demonstrated an outstanding diagnostic accuracy of over 95% for solid pancreatic lesions and provides samples appropriate for ancillary testing, such as immunohistochemistry and tumour molecular profiling. As a result, EUS-FNB is rapidly replacing EUS-FNA and is now the recommended technique for EUS-guided tissue acquisition in pancreatic cancer. Furthermore, with the recent expansion of neoadjuvant treatment criteria and with the advent of novel and personalised anti-cancer therapies, EUS-FNB is gaining a pivotal role in pancreatic cancer management and might soon be generalised to all patients, independent of disease stage. In this article, the authors present an updated review of the role of EUS-guided tissue acquisition in pancreatic cancer. Current indications, several technical aspects and new applications of EUS-FNA and EUS-FNB are discussed.

Nas últimas décadas, a aquisição de tecido por ecoendoscopia tornou-se o método de eleição para o diagnóstico patológico de lesões sólidas do pâncreas. Devido à sua elevada capacidade diagnóstica e baixa taxa de complicações, a aquisição de tecido por ecoendoscopia ultrapassou as técnicas de biópsia por via percutânea. Durante muito anos, a aspiração com agulha fina guiada por ecoendoscopia (EUS-FNA) foi tradicionalmente usada para obter aspirados citológicos de lesões sólidas do pâncreas, com valores de sensibilidade que variam entre os 80% e os 90% no diagnóstico de malignidade. Contudo, apesar de numerosos avanços técnicos, a EUS-FNA apresenta ainda algumas limitações. Assim, a biópsia com agulha fina guiada por ecoendoscopia (EUS-FNB) foi introduzida para obter biópsias com cores de tecido, permitindo avaliação histológica. Uma nova geração de agulhas de FNB recentemente desenvolvida demonstra uma acuidade diagnóstica excecional acima de 95% nas lesões sólidas do pâncreas e obtém amostras adequadas para estudos ancilares, designadamente imunohistoquímica e caracterização molecular tumoral. Por conseguinte, a EUS-FNB está rapidamente a substituir a EUS-FNA e é hoje a técnica recomendada para aquisição de tecido no cancro do pâncreas. Além disso, com a recente expansão dos critérios para tratamento neoadjuvante e com o advento de terapias anti-tumorais novas e personalizadas, a EUS-FNB está a adquirir um papel essencial na abordagem do cancro do pâncreas e poderá em breve ser generalizada a todos os doentes, independentemente do estádio da doença. Neste artigo, os autores apresentam uma revisão atualizada do papel da aquisição de tecido por ecoendoscopia no cancro do pâncreas. As indicações atuais, vários aspetos técnicos e novas aplicações da EUS-FNA e EUS-FNB são discutidos.

The Role of Endoscopic Ultrasound in Pancreatic Cancer Staging in the Era of Neoadjuvant Therapy and Personalised Medicine.

Precise staging of pancreatic cancer is crucial for treatment choice. In clinical practice, this includes the TNM staging and determination of tumour resectability, based on a multimodality imaging workup. International guidelines recommend multi-detector computed tomography (CT), with a dedicated pancreatic protocol, as the first-line tool for TNM staging and evaluation of tumour-vessel relationships. In non-metastatic disease upon initial CT assessment, both magnetic resonance imaging and endoscopic ultrasound (EUS) may add relevant information, potentially changing treatment sequence. EUS may have distinct advantages in pancreatic cancer diagnosis and staging when compared with other modalities, being particularly valuable in the determination of portal venous confluence involvement (particularly in small and ill-defined/isoattenuating tumours on CT), in locoregional nodal staging and in the detection of ascites. As we step forward to a more frequent use of neoadjuvant chemotherapy and to personalised medicine, the importance of EUS-guided fine-needle biopsy (EUS-FNB) also increases. The recent availability of third-generation biopsy needles significantly increased the diagnostic yield of EUS-guided tissue acquisition, providing diagnostic cell blocks in approximately 95% of cases with only two dedicated passes and allowing ancillary testing, such as immunohistochemistry and molecular profiling of the tumour. In this article, the authors present an updated perspective of the place of EUS and EUS-FNB in the staging algorithm of pancreatic cancer. Data supporting the increasing role of neoadjuvant therapy and the importance of a patient-tailored treatment selection, based on tumoural subtyping and molecular profiling, are also discussed.

No cancro do pâncreas é fundamental um estadiamento preciso para a decisão terapéutica. Na prática clínica, istoinclui o estadiamento TNM e a avahação da ressecabilidade cirúrgica, baseada numa avahação imagiológica multimodal. As recomendações de consenso recomendam a tomografia computorizada (TC) multi-detector, com protocolo pancreático, como exame de primeira linha para o estadiamento TNM e determinação de invasão vascular loco-regional. Na doença loco-regional não-metastática (após TC inicial), a ressonância magnética e a ecoendoscopia poderão acrescentar informação relevante, com potencial impacto na decisão terapéutica. A ecoendoscopia apresenta vantagens únicas comparativamente a outros métodos de estadiamento, sendo particularmente útil na avahação da relação do tumor com a confluência espleno-portal (especialmente na presença de tumores pequenos e isodensos/mal-definidos na TC), no estadiamento ganglionar loco-regional (N) e na detecção de ascite. À medida que caminhamos no sentido da utilização crescente de quimioterapia neoadjuvante e da Medicina personalizada, a relevância da biopsia guiada por ecoendoscopia também aumenta. A recente disponibilização de agulhas de biopsia de terceira geração aumentou significativamente a rentabilidade diagnóstica da punção guiada por ecoendoscopia, obtendo cell-blocks para avahado histológica em cerca de 95% dos casos (com apenas duas passagens), permitindo a realização de estudos ancilares, como avahação imuno-histoquímica e caracterização molecular do tumor. No presente artigo os autores apresentam uma perspetiva do papel atual da ecoendoscopia e da biopsia guiada por ecoendoscopia no algoritmo de estadiamento do cancro do páncreas. É ainda analisada a evidência atual que favorece o papel crescente da terapéutica neoadjuvante e a importância da seleção individualizada do tratamento, baseada na definição do subtipo de tumor e na caracterizado molecular.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Fine-Needle Tattooing and Fiducial Placement in Pancreatic Cancer.

In the last 2 decades, endoscopic ultrasound (EUS) has become an important procedure for the diagnosis and management of several pancreatic diseases, including pancreatic cancer. This article presents two recently developed EUS-guided techniques for the management of pancreatic cancer: fine-needle tattooing and fiducial placement. Preoperative EUS-guided fine-needle tattooing of small pancreatic tumors helps in precise localization of these lesions during surgery, potentially ensuring adequate margins of resection while preserving healthy pancreatic tissue. In pancreatic cancer patients planned for imaging-guided radiation therapy, EUS-guided fiducial placement improves the accuracy of target delineation during stereotactic body radiation therapy (SBRT). Hydrogel, a new injectable liquid with multimodal visibility recently approved as a liquid fiducial, is currently under investigation in pancreatic head cancer as an EUS-injected spacer to potentially reduce SBRT gastrointestinal wall toxicity. In this article, GRUPUGE presents an updated perspective of these two EUS-guided techniques, addressing their current clinical applications and technical aspects and analyzing existing data on their efficacy and safety.

Durante as duas últimas décadas, a ecoendoscopia tor-nou-se um procedimento importante para o diagnóstico e abordagem de diversas doenças pancreáticas, incluindo o cancro do páncreas. Neste artigo sao apresentadas duas técnicas guiadas por ecoendoscopia desenvolvidas recentemente na abordagem do cancro do páncreas: tatuagem com agulha fina e marcação com fiduciais. A tatuagem pré-operatória com agulha fina guiada por ecoendoscopia de pequenos tumores pancreáticos ajuda na localização precisa destas lesões durante a cirurgia, potencialmente assegurando margens de resseção adequa-das e preservando parênquima pancreático saudável. Nos doentes com cancro do pêncreas com indicação para radioterapia guiada por imagem, a marcação com fiduciais guiada por ecoendoscopia melhora a acuidade da radioterapia estereotáxica corporal na delineação do alvo. O hidrogel, um novo líquido injetável com visibilidade multimodal recentemente aprovado como marcador fiducial, está atualmente em investigação como um espaçador injetado por ecoendoscopia no cancro da cabeça do páncreas para potencialmente reduzir a toxicidade da radioterapia estereotáxica corporal sobre a parede gastrointestinal. Neste artigo, o GRUPUGE apresenta uma perspetiva atualizada destas duas técnicas guiadas por ecoendoscopia, abordando as suas atuais aplicações clínicas e aspetos técnicos e analisando os dados existentes sobre a sua eficácia e segurança.