Spectrum of endoscopic gastric subepithelial lesions encountered on EUS-FNA: A single center experience.

BACKGROUND AND OBJECTIVES: Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a minimally invasive and reliable non-surgical technique for the diagnosis of gastrointestinal lesions. The present study aimed to evaluate the spectrum of lesions encountered in the gastric subepithelium on EUS-FNA at a tertiary care center. MATERIALS AND METHODS: Archival data of all patients undergoing EUS-FNA for gastric submucosal lesions over a period of 5 years was retrieved. Patient demographics, clinical presentation, and EUS findings were recorded along with the FNA results. RESULTS: A total of 78 EUS-FNA samples were analyzed. Material was adequate in 62 cases (79.48%) and inadequate in 16 cases (12.82%) patients due to scant cellularity. Of the adequate samples, 34 (43.5%) were reported as neoplastic while 20 (25.64%) were non-neoplastic, and 8 (10.25%) were reported as suspicious of a neoplasm. In the neoplastic category, the predominant diagnosis was of spindle cell neoplasm comprising gastrointestinal stromal tumor (13), benign neural tumor (03), leiomyoma (02), and spindle cell tumors (03). The latter could not be categorized further due to a lack of IHC material. The next common diagnosis was adenocarcinoma (06) followed by neuroendocrine tumor (02) and poorly differentiated carcinoma (01). The non-neoplastic lesions included non-specific pathology (15), inflammatory lesions (08), and one case each of tuberculosis, pancreatic rest, and Brunner gland hamartoma. Cell blocks for ancillary testing were available in 54 cases (65.23%) and follow-up was available in 42 cases (53.84%). CONCLUSION: EUS-FNA is a good modality for the diagnosis of gastric submucosal lesions with a high diagnostic yield.

Anaplastic (undifferentiated) carcinoma of pancreas, an uncommon variant: Diagnosed on endoscopic-guided fine needle aspiration.

Anaplastic carcinoma of pancreas (ACP) are rare pancreatic neoplasms. They are well known to be associated with more aggressive tumor behavior and less favorable prognosis than usual pancreatic ductal adenocarcinoma. Endoscopic-guided fine needle aspiration (EUS-FNA) is now a widely accepted modality in diagnosis of pancreatic lesions. However, only a few reports are available describing cytological features of anaplastic carcinoma. Here, we report two cases of ACP diagnosed on EUS-FNA.

Diagnostic Utility of Claudin4 and Comparison with BerEp4 as a Marker for Metastatic Adenocarcinoma in Serous Effusions.

INTRODUCTION: Fluid cytology for malignant cells is important for diagnosis and staging of malignancies. Morphological overlap between reactive mesothelial cells and adenocarcinoma poses challenges, for which many immunohistochemical markers like BerEp4 and MOC-31 have been used extensively. Claudin4 is a new marker with promising results; however, further studies are required to establish its role as a pan-carcinoma marker in serous effusions. This study aimed to determine the utility of Claudin4 in diagnosing metastatic adenocarcinoma in effusions and comparing its performance with BerEp4. METHODS: Claudin4 immunohistochemistry (IHC) was performed on effusion cell blocks (n = 60) reported as positive or suspicious for metastatic adenocarcinoma on cytology over a 1-year period and was scored for intensity (0-3) and percentage of positive cells (0-4). The results were compared with BerEp4 IHC and correlated with follow-up. Ten benign effusions were included as negative controls. RESULTS: Claudin4 IHC was positive in all 60 (100%) cases, irrespective of the primary site. BerEp4 IHC was positive in 58 (96.7%) fluids and negative in 2 (3.3%) cases. All 10 benign effusions were negative for Claudin4 and BerEp4. Claudin4 showed higher intensity and proportion scores as compared to BerEp4 in cases where tumor cells were predominantly singly scattered and was comparable to BerEp4 where tumor cells were arranged in groups. Sensitivity, specificity, PPV, and NPV of Claudin4 in our study was 100%. Sensitivity, specificity, PPV, and NPV of BerEP4 was 96.7%, 100%, 100%, and 83.3%, respectively. CONCLUSION: Claudin4 IHC staining results were comparable to BerEp4, irrespective of the primary site, and it performed better in cases where tumor cells were predominantly scattered singly.

Improved oral bioavailability of febuxostat by liquid self-micro emulsifying drug delivery system in capsule shells.

PURPOSE: Febuxostat is a non-purine xanthine oxidase inhibitor which belongs to the BCS class II. Main aim of this study is to enhance dissolution and bioavailability of a drug by formulating a liquid self-micro emulsifying drug delivery system (SMEDDS) in different capsule shells. METHOD: Compatability of gelatin and cellulose capsule shells was checked with different oils, surfactants and co-surfactants. Solubility studies were then carried out in selected excipients. Capryol 90, labrasol, and PEG 400 were used in a liquid SMEDDS formulation based on phase diagram and the drug loading. Further SMEDDS was characterized for zeta potential, globule size and shape, thermal stability and in vitro release. Based on the in vitro release, pharmacokinetic study was carried out using SMEDDS in gelatin capsule shells. RESULT: The diluted SMEDDS had globule size of 157.9±1.5d.nm, zeta potential of -16.2±0.4mV and they were thermodynamically stable. The formulation was found stable for 12 months in capsule shells. When tested in different media (0.1N HCl and pH 4.5 acetate buffer), the in vitro release of newly produced formulations differed substantially from that of commercially available tablets, while the release rate in alkaline medium (pH 6.8) was comparable and the highest. According to in vivo findings in rats, a threefold increase in plasma concentration, a fourfold increase in AUC0-t, and a reduction in oral clearance increased fuxostat's oral bioavailability. CONCLUSION: This investigation revealed that the novel liquid SMEDDS formulation sealed in capsules has considerable potential as a vehicle for enhancing the bioavailability of febuxostat.

Grading of pancreatic neuroendocrine tumors on endoscopic ultrasound-guided fine-needle aspiration using Ki-67 index and 2017 World Health Organization criteria: An analysis of 32 cases.

OBJECTIVES: Biological behavior of pancreatic neuroendocrine tumors (Pan NETs) is difficult to predict on morphology alone. The assessment of proliferation by the Ki-67 proliferation index (PI) is considered to be an important prognostic parameter in these tumors and has been endorsed by the 2017 World Health Organization (WHO) grading system for Pan NETs. Although widely accepted on surgical specimens, there is varied opinion on grading of these tumors on cytology samples. This study aimed at classification and grading of Pan NETs on endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using the recent 2017 WHO criteria and assess the reliability of Ki-67 grading by comparing it with histology samples wherever available. MATERIAL AND METHODS: Search of cytopathology lab records over a 3-year period (June 2015-May 2018) revealed 33 cases of pancreatic NETs diagnosed on EUS-FNA specimens. Using the guidelines of 2017 WHO classification and grading of Pan NETs, retrospective grading of these Pan NETs was done. They were graded as Grades 1, 2, and 3 well differentiated Pan NETs and poorly differentiated Grade 3 neoplasms based on Ki-67 PI and cytomorphology. Cytomorphological features were compared across the three grades. The cytological grading was then compared with the histological grading where available. RESULTS: Ki-67 grading on cytology was done in 32 cases (22 on cell block and 10 on smears), of which 19 (59.4%) were Grade 1, 8 (25%) were Grade 2, and 5 (15.6%) were Grade 3 tumors. The most common cytomorphological features observed in Grade 1 tumors were small round uniform cells with granular chromatin and prominent plasmacytoid morphology. As the grade increased, tumor cells showed increased pleomorphism, angulated nuclei, and less frequent plasmacytoid cells. Histopathology (biopsy/resected specimens) was available in 11 of the 32 cases. Comparison of grading on cytology and histology showed concordance in ten of the 11 cases (k value = 0.862). CONCLUSION: Our data suggest that grading of Pan NETs by assessing Ki-67 PI on cytology samples collected by EUS-FNA shows good agreement with that measured on histology samples.

Widespread applications of host-guest interactive cyclodextrin functionalized polymer nanocomposites: Its meta-analysis and review.

Cyclodextrins are cyclic oligosaccharides, having tyroid shape of the molecule which has a hydrophobic cavity and outer hydrophilic surface. This characteristic feature of the dextrins allows it to function as a functionalizing as well as a stabilizing agent. Polymer nanocomposites are nanoscale composites of polymers with enhanced and synergized properties of its components and have been known to have applications in various fields of chemistry, biomedical, pharmaceutical and environmental purposes to name a few. To impart specificity, thermal, mechanical stability, resistance to solvents and biodegradability to the polymers, cyclodextrins have been incorporated in the nanocomposites. The utilization of the aforementioned properties of cyclodextrins to the polymer nanocomposites, implications of the incorporation of cyclodextrins to polymer nanocomposites and their subsequent applications in various fields have been discussed in this review systematically, using PRISMA guidelines.

Role of EUS-FNA for gallbladder mass lesions with biliary obstruction: a large single-center experience.

Background and study aims Although endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) is an established modality for pathological sampling of pancreatic and biliary lesions, limited data are available on the diagnostic value of EUS-FNA for evaluation of gallbladder mass lesions, a common cause of obstructive jaundice. We aimed to evaluate the usefulness of EUS-FNA for diagnosis of gallbladder mass lesions presenting with biliary obstruction. Patients and methods This study was a retrospective analysis of data from patients who had undergone EUS-FNA for gallbladder mass lesions. FNA was performed on either a gallbladder mass, metastatic node or liver lesions. Outcome measures were diagnostic yield of EUS FNA and adverse events. Results From April 2011 to August 2018, 101 patients with gallbladder mass lesions with biliary obstruction underwent EUS-FNA. The final diagnosis was malignancy in 98, benign disease in one, and two patients were lost to follow-up. EUS-FNA confirmed the diagnosis in 89 of 98 patients with malignancy (sensitivity 90.81 %); was false negative in nine of 98 cases with malignancy; and was truly negative in the solitary patient with benign disease (specificity 100 %). Positive predictive value, negative predictive value (NPV), and accuracy were 100 %, 10 %, and 90.90 %, respectively. Two patients had self-limiting pain. Conclusion EUS-FNA is a sensitive tool for evaluation of gallbladder mass lesions presenting with obstructive jaundice. However, because of low NPV, lesions in which FNA is negative should be further evaluated.

Enhancement in the Transdermal and Localized Delivery of Honokiol Through Breast Tissue.

Honokiol is a natural phenolic anti-cancer compound isolated from an extract of seed cones from Magnolia grandiflora. This study investigated the transdermal delivery of honokiol using various enhancement methods and to explore the potential of honokiol to treat breast cancer directly via delivery through mammary papilla. Poration of dermatomed human skin with microneedles significantly increased the delivery of honokiol by nearly 3-fold (97.81 ± 18.96 µg/cm2) compared with passive delivery (32.56 ± 5.67 µg/cm2). Oleic acid was found to be the best chemical penetration enhancer, increasing the delivery almost 27-fold (868.06 ± 100.91 µg/cm2). Addition of oleic acid also resulted in better retention of drug in the porcine mammary papilla (965.41 ± 80.26 µg/cm2) compared with breast skin (294.16 ± 8.49 µg/cm2). Anti-cancer effect of honokiol was demonstrated with the decrease in the release of cytokine IL-6 and further suppression of Ki-67 proliferative protein. In addition, the topical honokiol formulation investigated was found to be safe and non-irritant. In summary, both microneedles and chemical enhancers can improve the absorption of honokiol through skin. Directly applying honokiol on mammary papilla is a potential administration route which can increase localized delivery into breast tissue.

Formulation Development and Characterization of Nanoemulsion-Based Formulation for Topical Delivery of Heparinoid.

Heparinoid is commonly used for the treatment of superficial thrombophlebitis, a condition wherein inflammation and clotting occurs in the veins below the skin surface. However, stratum corneum is a major barrier that limits the delivery of hydrophilic heparinoid, in and across the skin. The aim of the present study was to develop a nonirritant topical formulation for heparinoid incorporating chemical penetration enhancers and investigate the delivery of heparinoid across the human epidermis using in vitro vertical Franz diffusion cells. The developed oil-in-water nanoemulsions (NEs; NE-1 and NE-2) delivered higher amount of heparinoid (91.58 ± 25.75 µg/sq.cm and 62.67 ± 5.66 µg/sq.cm, respectively) after 72 h compared with the other developed formulations, which in turn also delivered significantly higher amount compared with commercial formulations: cream (1.78 ± 0.07 µg/sq.cm), ointment (9.95 ± 4.41 µg/sq.cm), and gel (0 µg/sq.cm) (p <0.05). Transmission electron microscopy, polarizing light microscopy, and dynamic light scattering studies were performed to characterize the microstructure of these NEs with chemical enhancers. NE-1 was tested to be nonirritant with cell viability greater than 50% and a minimal release of IL-1α by using the "in vitro Epiderm tissue" model. Our results demonstrate that NE formulations represent a potential strategy for providing a localized therapy for the treatment of superficial thrombophlebitis.

Development and validation of an HPLC-UV method for analysis of methylphenidate hydrochloride and loxapine succinate in an activated carbon disposal system.

Unused medications have the possibility of being abused, causing serious harm to individuals who were not prescribed the drug. The Food and Drug Administration (FDA) recommends the proper disposal of unused prescribed medications to maintain safety and prevent environmental hazards. However, many of the current disposal techniques do not properly address safety. A drug disposal pouch containing granular activated carbon offers a unique disposal method to deactivate residual or expired medication in a convenient, effective, and safe manner. A robust and validated method for methylphenidate hydrochloride and loxapine succinate was developed using high-performance liquid chromatography (HPLC) and the deactivation efficiency of the disposal system was tested. Methylphenidate hydrochloride was analyzed on a C18 analytical column (250 mm × 4.60 mm, 100Å) using acetonitrile-water (0.05% (v/v) trifluoroacetic acid) as the mobile phase at a flow rate of 1.0 mL/min with a run time of 15 min and retention time of 7.8 min. Loxapine succinate was separated on a C8 100Å (250 mm × 4.6 mm, 5 µm) column maintained at 25 °C using a flow rate of 1.0 mL/min. The run time was 10 min and the retention time of the drug was around 4.6 min. Mobile phase was composed of acetonitrile and water (0.3% triethylamine) at pH 3.0 as 40:60 (v/v). Reference standard solutions (100 µg/mL) for both drugs were prepared by dissolving in mobile phases. These methods provide good linearity (R 2 = 0.999) over the range of 5-100 µg/mL for methylphenidate hydrochloride and 0.1-100 µg/mL for loxapine succinate. The assay methods were successfully applied to study the deactivation of these drugs.

Evaluation of an activated carbon-based deactivation system for the disposal of highly abused opioid medications.

CONTEXT: The improper disposal of unused prescription opioids has a potential for abuse as well as environmental contamination. Consequently, there is an imperative need for an environmentally safe, convenient, and effective drug disposal system. OBJECTIVE: The objective of this study is to analyze the deactivation efficiency of the disposal system employing four model opioid drugs of high abuse potential. METHODS: The deactivation system used in this investigation is an activated granular carbon based disposal system in the form of a pouch, which can be used to safely and effectively deactivate unused or expired medications. HPLC method validation for each drug was performed prior to analyzing drug content in the deactivation study. Opioid drugs in different dosage forms were added to individual pouches in the presence of warm water. Pouches were shaken and sealed, then stored at room temperature. The deactivation efficiency of the system was tested by collecting samples at different time points up to 28 d. RESULTS: An average of 98.72% of medications were adsorbed by activated carbon within 8 h and continued to do so over time. At the end of the 28-d study, more than 99.99% of all drugs were deactivated. In the desorption study, almost no drug leached out from the activated carbon in larger volume of water and less than 1.3% leached out on extraction with ethanol. CONCLUSION: This unique drug disposal system successfully adsorbed and deactivated the model opioid medications by the end of 28 d, offering a safe and convenient route of disposal of unused or residual opioid drugs.

Liquid-based and conventional cytology for bronchial washings/bronchoalveolar lavages in the diagnosis of malignancy - An institutional experience.

BACKGROUND: Liquid-based cytology (LBC) has been developed as an alternative for conventional cytology (CC) in cervical smears. It is now increasingly being used all over the world for cervical cancer screening. However, its role and diagnostic accuracy in bronchial wash (BW)/bronchoalveolar lavage (BAL) specimens remains undetermined. AIMS: To assess and compare the diagnostic performance and accuracy of LBC with CC for detecting malignancy in bronchial specimens. SETTINGS AND DESIGN: This was a retrospective analytical hospital-based study. MATERIALS AND METHODS: Bronchial specimens (BW/BAL) received over a period of 4.5 years were reviewed. The samples were processed by CC from June 2010 to September 2012 (2.25 years) and by LBC from October 2012 to December 2014 (2.25 years). Data were retrieved from the records of cytology laboratory and compared among both the groups. Detection rate for histologically or cytologically verified samples was calculated. RESULTS: A total of 559 cases verified by histological and cytological follow-up were evaluated. These included 247 CC cases and 312 LBC cases. The positive diagnostic rate for malignancy in CC was 28.6% whereas that for LBC was 32.9%. The negative diagnostic rates were 66.5% and 66.3% for CC and LBC, respectively. However, unsatisfactory rates had shown a good reduction from 4.4% in CC to 0.6% after LBC introduction. The smears showed more homogeneous distribution of cells with elimination of obscuring factors such as blood, inflammation, and mucus. CONCLUSIONS: The diagnostic accuracy of LBC was slightly better than CC. The unsatisfactory rates showed reduction in LBC preparation. Thus, LBC is a viable alternative to CC and has the advantages of standardization of preparation with decrease in unsatisfactory rates.

Clear cell neuroendocrine tumor of pancreas: Endoscopic Ultrasound-guided fine needle aspiration diagnosis of an uncommon variant.

The cytomorphologic features of clear cell neuroendocrine tumor of pancreas have been rarely reported in cytology literature. The cytomorphology of this rare variant mimics many primary and metastatic clear cell tumors of the pancreas. However, a precise cytological diagnosis can be rendered by awareness of this entity and judicious use of immunohistochemistry. We report one such case in a young woman diagnosed on endoscopic ultrasound fine needle aspiration. The tumor cells showed positive staining with synaptophysin, chromogranin, and also with inhibin.

Solenopsin A and analogs exhibit ceramide-like biological activity.

BACKGROUND: (-)-Solenopsin A is a piperidine alkaloid that is a component of the venom of the fire ant Solenopsis invicta. Previously, we have demonstrated that solenopsin exhibit anti-angiogenic activity and downregulate phosphoinositol-3 kinase (PI3K) in the p53 deficient renal cell carcinoma cell line 786-O. Solenopsin has structural similarities to ceramide, a major endogenous regulator of cell signaling and cancer therapy induced apoptosis. METHODS: Different analogs of solenopsin were synthesized in order to explore structure-activity relationships. The anti-proliferative effect of solenopsin and analogs was tested on six different cell lines, including three tumor cell lines, two normal cutaneous cell lines, and one immortalized hyperproliferative cell line. FRET-based reporters were used to study the affect of solenopsin and analogs on Akt activity and PDK1 activation and sucrose density gradient fractionation was performed to examine recruitment of PTEN to membrane rafts. Western-blotting was used to evaluate the affect of solenopsin and analogs on the Akt and the MAPK 44/42 pathways in three different tumor cell lines. Measurement of cellular oxygen consumption rate together with autophagy staining was performed to study mitochondrial function. Finally, the affect of solenopsin and analogs on ROS production was investigated. RESULTS: In this paper we demonstrate that solenopsin analogs with potent anti-proliferative effects can be synthesized from inexpensive dimethylpyridines. To determine whether solenopsin and analogs act as ceramide analogs, we examined the effect of solenopsin and analogs on two stereotypic sites of ceramide activity, namely at lipid rafts and mitochondria. We found that native solenopsin, (-)-solenopsin A, inhibits functional Akt activity and PDK1 activation in lipid rafts in a similar fashion as ceramide. Both cis and trans analogs of solenopsin reduce mitochondrial oxygen consumption, increase reactive oxygen, and kill tumor cells with elevated levels of Akt phosphorylation. However, only solenopsin induces mitophagy, like ceramide. CONCLUSIONS: The requirements for ceramide induced mitophagy and inhibition of Akt activity and PDK1 activation in lipid rafts are under strict stereochemical control. The naturally occurring (-)-solenopsin A mimic some of the functions of ceramide and may be therapeutically useful in the treatment of hyperproliferative and malignant disorders of the skin, even in the presence of elevated levels of Akt.

Mediastinal Adenopathy in India: Through the Eyes of Endobranchial Ultrasound.

OBJECTIVE: Aetiology of mediastinal adenopathy is likely to vary with geographic location and socioeconomic status of a population. Whilst most of adenopathy in the West could be attributed to malignant disorders, causes of the same in a developing country like India has not been extensively studied earlier due to lack of less invasive tools to sample these nodes for cytological and microbiological analysis. Endobronchial ultrasound (EBUS) helps us reach these nodes as a minimally invasive procedure to take aspirations under real-time ultrasound guidance. The aim of the present study is to study the aetiology of mediastinal adenopathy in our population with the help of EBUS. METHODS: This was a retrospective analysis of all EBUS procedures done by the authors and the diagnosis thus obtained at Sir Ganga Ram Hospital, New Delhi, India between April 2010 and December 2011. RESULTS: A total of 300 patients underwent EBUS in the above period. Most common aetiology encountered in our population was a granulomatous disorder (53% cases) like tuberculosis and sarcoidosis whilst malignancy was third in order of diagnosis (17% cases). Lymph node enlargement due to anthracosis was another uncommon aetiology encountered in the study (5% cases). CONCLUSIONS: Benign granulomatous disorders like tuberculosis and sarcoidosis are the most common causes of mediastinal adenopathy in our population. EBUS is proving its worth for diagnosing mediastinal adenopathy.

Can cytomorphology of granulomas distinguish sarcoidosis from tuberculosis? Retrospective study of endobronchial ultrasound guided transbronchial needle aspirate of 49 granulomatous lymph nodes.

BACKGROUND: The differential diagnosis of tuberculosis (TB) and sarcoidosis on fine needle aspiration material is very challenging in tubercular endemic regions. We carried out a pilot study to explore cytomorphologic features of granulomas which could help in differentiation between sarcoidosis and TB. Final diagnoses in these patients were based on clinical, microbiologic and follow-up studies. MATERIALS AND METHODS: Endobronchial ultrasound guided transbronchial needle aspiration smears of 49 consecutive patients with a final cytologic diagnosis of granulomatous lymphadenitis were reviewed. Based on cytologic features two cytologic categories were enunciated and the results were correlated with microbiologic studies and/follow-up of minimum of 6 months. RESULTS: The cytologic categories did not correlate with the final clinical outcome of patients. CONCLUSIONS: Different patterns of granulomas observed in cytology smears do not help distinguish TB from sarcoidosis. The novel non-invasive techniques of mediastinal sampling though help in confirming granulomatous pathology, distinction between these entities and treatment decisions still depend upon correlating cytologic, microbiologic, clinical and radiological data in a large number of cases in tubercular endemic regions.