Development and Validation of a Classification System to Identify High-Grade Dysplasia and Esophageal Adenocarcinoma in Barrett's Esophagus Using Narrow-Band Imaging.

BACKGROUND & AIMS: Although several classification systems have been proposed for characterization of Barrett's esophagus (BE) surface patterns based on narrow-band imaging (NBI), none have been widely accepted. The Barrett's International NBI Group (BING) aimed to develop and validate an NBI classification system for identification of dysplasia and cancer in patients with BE. METHODS: The BING working group, composed of NBI experts from the United States, Europe, and Japan, met to develop a validated, consensus-driven NBI classification system for identifying dysplasia and cancer in BE. The group reviewed 60 NBI images of nondysplastic BE, high-grade dysplasia, and esophageal adenocarcinoma to characterize mucosal and vascular patterns visible by NBI; these features were used to develop the BING criteria. We then recruited adult patients undergoing surveillance or endoscopic treatment for BE at 4 institutions in the United States and Europe, obtaining high-quality NBI images and performing histologic analysis of biopsies. Experts individually reviewed 50 NBI images to validate the BING criteria, and then evaluated 120 additional NBI images (not previously viewed) to determine whether the criteria accurately predicted the histology results. RESULTS: The BING criteria identified patients with dysplasia with 85% overall accuracy, 80% sensitivity, 88% specificity, 81% positive predictive value, and 88% negative predictive value. When dysplasia was identified with a high level of confidence, these values were 92%, 91%, 93%, 89%, and 95%, respectively. The overall strength of inter-observer agreement was substantial (κ = 0.681). CONCLUSIONS: The BING working group developed a simple, internally validated system to identify dysplasia and EAC in patients with BE based on NBI results. When images are assessed with a high degree of confidence, the system can classify BE with >90% accuracy and a high level of inter-observer agreement.

Acquisition of Portal Venous Circulating Tumor Cells From Patients With Pancreaticobiliary Cancers by Endoscopic Ultrasound.

BACKGROUND & AIMS: Tumor cells circulate in low numbers in peripheral blood; their detection is used predominantly in metastatic disease. We evaluated the feasibility and safety of sampling portal venous blood via endoscopic ultrasound (EUS) to count portal venous circulating tumor cells (CTCs), compared with paired peripheral CTCs, in patients with pancreaticobiliary cancers (PBCs). METHODS: In a single-center cohort study, we evaluated 18 patients with suspected PBCs. Under EUS guidance, a 19-gauge EUS fine needle was advanced transhepatically into the portal vein and as many as four 7.5-mL aliquots of blood were aspirated. Paired peripheral blood samples were obtained. Epithelial-derived CTCs were sorted magnetically based on expression of epithelial cell adhesion molecules; only those with a proper morphology and found to be CD45 negative and positive for cytokeratins 8, 18, and/or 19 and 4',6-diamidino-2-phenylindole were considered to be CTCs. For 5 samples, CTCs also were isolated by flow cytometry and based on CD45 depletion. ImageStream was used to determine the relative protein levels of P16, SMAD4, and P53. DNA was extracted from CTCs for sequencing of select KRAS codons. RESULTS: There were no complications from portal vein blood acquisition. We detected CTCs in portal vein samples from all 18 patients (100%) vs peripheral blood samples from only 4 patients (22.2%). Patients with confirmed PBCs had a mean of 118.4 ± 36.8 CTCs/7.5 mL portal vein blood, compared with a mean of 0.8 ± 0.4 CTCs/7.5 mL peripheral blood (P < .01). The 9 patients with nonmetastatic, resectable, or borderline-resectable PBCs had a mean of 83.2 CTCs/7.5 mL portal vein blood (median, 62.0 CTCs/7.5 mL portal vein blood). In a selected patient, portal vein CTCs were found to carry the same mutations as those detected in a metastatic lymph node and expressed similar levels of P16, SMAD4, and P53 proteins. CONCLUSIONS: It is feasible and safe to collect portal venous blood from patients undergoing EUS. We identified CTCs in all portal vein blood samples from patients with PBCs, but less than 25% of peripheral blood samples. Portal vein CTCs can be used for molecular characterization of PBCs and share features of metastatic tissue. This technique might be used to study the pathogenesis and progression of PBCs, as well as a diagnostic or prognostic tool to stratify risk of cancer recurrence or developing metastases.

Endoscopic Therapy With Lumen-apposing Metal Stents Is Safe and Effective for Patients With Pancreatic Walled-off Necrosis.

BACKGROUND & AIMS: Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with pancreatic walled-off necrosis (WON). Lumen-apposing metal stents (LAMS) have shown success in the management of pancreatic fluid collections. However, there are few data on their specific roles in management of WON. We investigated the efficacy and safety of LAMS in treatment of WON. METHODS: We performed a retrospective multicenter case series of 124 patients with WON who underwent endoscopic transmural drainage by using LAMS at 17 tertiary care centers from January 2014 through May 2015. Patients underwent endoscopic ultrasound-guided cystogastrostomy or cystoenterostomy with placement of an LAMS into the WON collection. At the discretion of the endoscopist, we performed direct endoscopic necrosectomy, irrigation with hydrogen peroxide, and/or nasocystic drain placement. We performed endoscopic retrograde cholangiopancreatography with pancreatic duct stent placement when indicated. Concomitant therapies included direct endoscopic debridement (n = 78), pancreatic duct stent placement for leak (n = 19), hydrogen peroxide-assisted necrosectomy (n = 38), and nasocystic irrigation (n = 22). We collected data for a median time of 4 months (range, 1-34 months) after the LAMS placement. The primary outcomes were rates of technical success (successful placement of the LAMS), clinical success (resolution of WON, on the basis of image analysis, without need for further intervention via surgery or interventional radiology), and adverse events. RESULTS: The median size of the WON was 9.5 cm (range, 4-30 cm). Eight patients had 2 LAMS placed for multiport access, all with technical success (100%). Clinical success was achieved in 107 patients (86.3%) after 3 months of follow-up. Thirteen patients required a percutaneous drain, and 3 required a surgical intervention to manage their WON. The stents remained patent in 94% of patients (117 of 124) and migrated in 5.6% of patients (7 of 124). The median number of endoscopic interventions was 2 (range, 1-9 interventions). CONCLUSIONS: On the basis of a retrospective analysis of 124 patients, endoscopic therapy of WON by using LAMS is safe and effective. Creation of a large and sustained cystogastrostomy or cystoenterostomy tract is effective in the drainage and treatment of WON.

Safety and efficacy of EMR for sporadic, nonampullary duodenal adenomas: a single U.S. center experience (with video).

BACKGROUND AND AIMS: EMR is increasingly used for resection of sporadic, nonampullary duodenal adenomas (SNDAs), but there are no guidelines for the management of these lesions. The aims of this study were to evaluate the safety and efficacy of EMR exclusively for SNDAs and to determine the factors predictive of outcomes. METHODS: We performed a retrospective review of patients with SNDAs referred for endoscopic therapy from 2006 to 2013. The outcomes studied were successful endoscopic resection, major adverse events, early and late recurrences, and clinical remission. RESULTS: Sixty-eight patients with SNDAs were included and 51 (75%) underwent EMR. The mean adenoma size was 22.0 ± 8.9 mm. Successful resection was achieved in 49 of 51 patients (96.1%), and major adverse events were noted in 8 of 51 patients (15.7%). Early and late recurrences were noted in 25.6% and 5.2% of patients, respectively, and were treated endoscopically. Clinical remission was achieved in 89.7% of patients after a median follow-up of 15 months. Presence of villous histology was associated with increased recurrence (P = .019), but no association of recurrence was noted with other endoscopic features or resection technique. Large adenoma size (P = .0057) and need for intraprocedural hemostasis (P = .006) were associated with increased adverse events, but no association of adverse events was noted with location or resection technique. CONCLUSIONS: Large duodenal adenomas can be effectively managed with EMR at a referral center with experienced endoscopists. However, EMR has a significant recurrence rate, especially early recurrence, and the risk of adverse events is not negligible. Endoscopic therapy is successful in managing recurrent adenomas.

Performance of endoscopic ultrasound in staging rectal adenocarcinoma appropriate for primary surgical resection.

BACKGROUND & AIMS: Endoscopic ultrasound (EUS) often is used to stage rectal cancer and thereby guide treatment. Prior assessments of its accuracy have been limited by small sets of data collected from tumors of varying stages. We aimed to characterize the diagnostic performance of EUS analysis of rectal cancer, paying particular attention to determining whether patients should undergo primary surgical resection. METHODS: We performed a retrospective observational study using procedural databases and electronic medical records from 4 academic tertiary-care hospitals, collecting data on EUS analyses from 2000 through 2012. Data were analyzed from 86 patients with rectal cancer initially staged as T2N0 by EUS. The negative predictive value (NPV) was calculated by comparing initial stages determined by EUS with those determined by pathology analysis of surgical samples. Logistic regression models were used to assess variation in diagnostic performance with case attributes. RESULTS: EUS excluded advanced tumor depth with an NPV of 0.837 (95% confidence interval [CI], 0.742-0.908), nodal metastasis with an NPV of 0.872 (95% CI, 0.783-0.934), and both together with an NPV of 0.767 (95% CI, 0.664-0.852) compared with pathology analysis. Incorrect staging by EUS affected treatment decision making for 20 of 86 patients (23.3%). Patient age at time of the procedure correlated with the NPV for metastasis to lymph node, but no other patient features were associated significantly with diagnostic performance. CONCLUSIONS: Based on a multicenter retrospective study, EUS staging of rectal cancer as T2N0 excludes advanced tumor depth and nodal metastasis, respectively, with an approximate NPV of 85%, similar to that of other modalities. EUS has an error rate of approximately 23% in identifying disease appropriate for surgical resection, which is lower than previously reported.

A single-center experience of endoscopic submucosal dissection performed in a Western setting.

BACKGROUND: Compared with the piecemeal resection associated with endoscopic mucosal resection, endoscopic submucosal dissection (ESD) enables en bloc resection of larger lesions, allows for more accurate histological assessments, and has reduced recurrence rates. ESD is not widely performed in Western countries given increased technical difficulty, high complication rates, and long procedure times. AIMS: To evaluate the safety and efficacy of ESD in a single center in the USA. METHODS: A retrospective study on a prospectively collected database identified cases in which a single operator (IW) performed ESD at a tertiary referral center. Twenty cases were identified, nine in the upper digestive tract (four esophagus and five stomach) and 11 in the lower digestive tract (nine rectal and two sigmoid colon). Data regarding lesion location, pathology, method of ESD (composition/volume of lifting injection and resection method), post-procedure complications, and margin involvement were collected. RESULTS: En bloc resection was obtained in 14/20 patients (70 %). The average procedure time was 202 min in the esophagus, 148 min in the stomach, and 106 min for lower lesions. A major complication (perforation) occurred in 1/20 cases (5 %). Complete resection was obtained in 14/20 (70 %). R0 resection was obtained in 16/20 (80 %) cases. CONCLUSIONS: The complication, en bloc resection, and complete resection rates of this study are similar to those found in large studies on ESD performed in Eastern settings. ESD is safe and efficacious for en bloc resections of pre-malignant and early-invasive lesions, and should be offered to patients with suitable lesions in Western settings.

Complete endoscopic mucosal resection is effective and durable treatment for Barrett's-associated neoplasia.

BACKGROUND & AIMS: Barrett's esophagus (BE) with high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) is treated by complete eradication of areas of BE by endoscopic mucosal resection (EMR). By using this approach, histologic analysis also can be performed. We investigated the effectiveness, safety, and durability of this approach, as well as its use in diagnosis after a single referral. METHODS: We collected data from 107 patients who were referred to the Center for Endoscopic Research and Therapeutics at the University of Chicago for BE (mean length, 3.6 cm) with suspected HGD or IMC, from August 2003 through December 2012. All patients underwent EMR and were followed up through January 2014 (mean follow-up time, 40.6 mo). The primary outcome was treatment efficacy (complete eradication of BE and associated neoplasia); secondary outcomes included safety, durability, and accuracy of diagnosis. RESULTS: BE was eradicated completely by EMR in 80.4% (86 of 107) of patients based on intention-to-treat analysis, and in 98.8% (79 of 80) of patients based on per-protocol analysis. The diagnosis was changed for 25% of patients after EMR, including 4 cases that initially were diagnosed as HGD by biopsy analysis and subsequently were found to have evidence of submucosal invasion when EMR specimens were assessed. Strictures and symptomatic dysphagia developed in 41.1% and 37.3% of patients, respectively, with an average of 2.3 dilations required. Perforations occurred in 2 patients after EMR and in 1 patient after dilation. HGD and IMC recurred in 1 patient each; both were treated successfully with EMR. Based on pathology analysis of the most recently collected specimens, 71.6% of patients (53 of 74) were in complete remission from intestinal metaplasia and 100% were in complete remission from HGD (74 of 74) or cancer (74 of 74). CONCLUSIONS: For patients with BE with HGD or neoplasia, complete EMR is an effective and durable treatment and is a relatively safe technique. Specimens collected by EMR also can be analyzed histologically to aid in diagnosis. The common complication of EMR is esophageal stricture, which can be addressed with endoscopic dilation.

Circulating human CD4 and CD8 T cells do not have large intracellular pools of CCR5.

CC Chemokine Receptor 5 (CCR5) is an important mediator of chemotaxis and the primary coreceptor for HIV-1. A recent report by other researchers suggested that primary T cells harbor pools of intracellular CCR5. With the use of a series of complementary techniques to measure CCR5 expression (antibody labeling, Western blot, quantitative reverse transcription polymerase chain reaction), we established that intracellular pools of CCR5 do not exist and that the results obtained by the other researchers were false-positives that arose because of the generation of irrelevant binding sites for anti-CCR5 antibodies during fixation and permeabilization of cells.

Nanoscale markers of esophageal field carcinogenesis: potential implications for esophageal cancer screening.

BACKGROUND AND STUDY AIMS: Esophageal adenocarcinoma (EAC) has a dismal prognosis unless treated early or prevented at the precursor stage of Barrett's esophagus-associated dysplasia. However, some patients with cancer or dysplastic Barrett's esophagus (DBE) may not be captured by current screening and surveillance programs. Additional screening techniques are needed to determine who would benefit from endoscopic screening or surveillance. Partial wave spectroscopy (PWS) microscopy (also known as nanocytology) measures the disorder strength (Ld ), a statistic that characterizes the spatial distribution of the intracellular mass at the nanoscale level and thus provides insights into the cell nanoscale architecture beyond that which is revealed by conventional microscopy. The aim of the present study was to compare the disorder strength measured by PWS in normal squamous epithelium in the proximal esophagus to determine whether nanoscale architectural differences are detectable in the field area of EAC and Barrett's esophagus. METHODS: During endoscopy, proximal esophageal squamous cells were obtained by brushings and were fixed in alcohol and stained with standard hematoxylin and Cyto-Stain. The disorder strength of these sampled squamous cells was determined by PWS. RESULTS: A total of 75 patient samples were analyzed, 15 of which were pathologically confirmed as EAC, 13 were DBE, and 15 were non-dysplastic Barrett's esophagus; 32 of the patients, most of whom had reflux symptoms, acted as controls. The mean disorder strength per patient in cytologically normal squamous cells in the proximal esophagus of patients with EAC was 1.79-times higher than that of controls (P<0.01). Patients with DBE also had a disorder strength 1.63-times higher than controls (P<0.01). CONCLUSION: Intracellular nanoarchitectural changes were found in the proximal squamous epithelium in patients harboring distal EAC and DBE using PWS. Advances in this technology and the biological phenomenon of the field effect of carcinogenesis revealed in this study may lead to a useful tool in non-invasive screening practices in DBE and EAC.

Expression of structural proteins in human female and male genital epithelia and implications for sexually transmitted infections.

Men and women differ in their susceptibility to sexually transmittable infections (STIs) such as human immunodeficiency virus (HIV). However, a paucity of published information regarding the tissue structure of the human genital tract has limited our understanding of these gender differences. We collected cervical, vaginal, and penile tissues from human adult donors. Tissues were prepared with hematoxylin and eosin stains or immunofluorescence labeling of epithelial cell proteins and were analyzed for structural characteristics. Rhesus macaque genital tissues were evaluated to assess the use of this model for HIV/simian immunodeficiency virus transmission events. We found the stratified squamous epithelia of the male and female genital tract shared many similarities and important distinctions. Expression of E-cadherins, desmogleins 1/2, and involucrin was seen in all squamous epithelia, though expression patterns were heterogeneous. Filaggrin and a true cornified layer were markedly absent in female tissues but were clearly seen in all male epithelia. Desmogleins 1/2 were more consistent in the outermost strata of female squamous genital epithelia. Macaque tissues were similar to their respective human tissues. These initial observations highlight how male and female genital epithelia resemble and differ from one another. Further information regarding tissue structural characteristics will help to understand how STIs traverse these barriers to cause infection. This knowledge will be essential in future HIV pathogenesis, transmission, and prevention studies.

Suicidal behavior in Latinos: focus on the youth.

The multicultural nature of American society presents clinicians and mental health providers with the unique challenge of working with mentally ill patients from many different cultural backgrounds. Although research investigating suicidal behavior among Latinos is limited, the literature suggests the presence of two distinct phenomena: (a) the prevalence of completed suicide among Latinos as a group is lower than the national rate and (b) the prevalence of suicidal behavior among Latino youth between the ages of 10-24 years is greater than in other ethnic groups, especially among females. Acculturation, family conflicts, physical abuse and sexual abuse, among other factors, have been suggested to increase the risk of depression and suicide among young Latinos. To ameliorate suicidal behavior among Latino youth, more research is needed about specific risk factors, diagnosis, treatment, and ultimately, suicide prevention. Research focused on identifying risk and mediating factors for suicidal behavior in young Latinos is particularly relevant, given the size and rapid growth of the Latino population in the United States of America.

Endotoxin tolerance in sepsis: concentration-dependent augmentation or inhibition of LPS-stimulated macrophage TNF secretion by LPS pretreatment.

BACKGROUND: We previously showed that macrophages (MPhi) pretreated with bacterial endotoxin (lipopolysaccharide [LPS]) develop an altered state of LPS-responsiveness--"LPS tolerance": LPS tolerance was associated with inhibition of tumor necrosis factor (TNF) release and decreased extracellular signal-regulated kinase and p38 kinase activation when MPhi were restimulated with LPS. However, the concentration of LPS used for pretreatment (most frequently 10 ng/mL) may be much higher than LPS concentrations observed in patients. Therefore, in the current study we examined the effect of lower and higher pretreatment LPS concentrations on subsequent LPS-stimulated MPhi responses. METHODS: RAW 264.7 MPhi-like cells were pretreated in vitro (PreRx) for 24 hours in medium or a range of LPS concentrations (0 ng/mL, 1 ng/mL, 10 ng/mL, or 100 ng/mL of E. coli 0111B4 LPS). Culture medium was discarded after 24 hours and MPhi were restimulated with LPS (0 ng/mL, 1 ng/mL, 10 ng/mL or 100 ng/mL). Three different lots of LPS (Sigma) were used. Supernatant TNF secretion at 3 hour was measured using enzyme-linked immunosorbent assay (pg/mL +/- SEM). Statistics by Chi-square and student's t test. RESULTS: Pretreatment with 100 ng/mL of LPS profoundly inhibited TNF release at all LPS restimulation concentrations (p < 0.05 vs. Medium PreRx). In contrast, very low dose LPS pretreatment (1 ng/mL) significantly augmented TNF release versus medium (p < 0.05). There was no further augmentation observed when even lower doses of LPS (0.1 ng/mL) were used for pretreatment. Similar results were obtained with three different lots E. coli 0111B4 LPS or using LPS from E. coli 0127B8. CONCLUSION: Prior exposure of MPhi to bacterial ligands alters MPhi cytokine production in response to subsequent LPS-stimulated activation. This modulated MPhi response is critically dependent on the concentration of LPS pretreatment.

Even ephemeral endotoxin exposure establishes endotoxin tolerance.

BACKGROUND: Macrophages previously exposed to bacterial lipopolysaccharide (LPS) develop a "tolerant" response with decreased extracellular signal-regulated kinase (ERK) activation in response to LPS rechallenge. Prior work using 21-hour LPS pretreatment showed that 100 ng/mL of LPS-inhibited tumor necrosis factor (TNF) release, whereas very low dose LPS (1 ng/mL) augmented TNF release. Endotoxin tolerance was also associated with alterations in activation of ERK and p38 kinase when cells were restimulated with LPS. We hypothesized that the interval after pretreatment, before LPS rechallenge, modulates macrophage response to LPS. METHODS: RAW 264.7 macrophage-like cells were pretreated for 4 hours in 0 ng/mL (none), 1 ng/mL, 10 ng/mL, or 100 ng/mL of Escherichia coli 0111:B4 LPS. After 4 hour pretreatment, medium was discarded. Cells were rechallenged immediately or 21 hours later with 0 ng/mL, 1 ng/mL, 10 ng/mL, or 100 ng/mL LPS. Supernatant TNF secretion at 3 hour was measured using enzyme-linked immunosorbent assay. Active phospho-ERK was examined by Western blot using specific monoclonal antibodies 30 minutes after LPS rechallenge. Statistical analysis by chi and student's t test. RESULTS: When macrophages were pretreated for 4 hour and incubated overnight (21-hour interval) 1 ng/mL of LPS augmented and 100 ng/mL inhibited TNF release with LPS rechallenge. In contrast, with immediate rechallenge, we saw additive effects with 100 ng/mL LPS and no difference with 1 ng/mL LPS versus no pretreatment. Western blot revealed that even with immediate rechallenge "tolerant" macrophages were unable to activate ERK. CONCLUSIONS: A short LPS exposure is sufficient to induce alterations in ERK activation in macrophages, but longer intervals are required to express altered cytokine release. In conjunction with other recent findings, these results suggest that both pretreatment dose and interval modulate macrophage responsiveness to LPS rechallenge.

Fully automated fiber-based optical spectroscopy system for use in a clinical setting.

While there are a plethora of in vivo fiber-optic spectroscopic techniques that have demonstrated the ability to detect a number of diseases in research trials with highly trained personnel familiar with the operation of experimental optical technologies, very few techniques show the same level of success in large multicenter trials. To meet the stringent requirements for a viable optical spectroscopy system to be used in a clinical setting, we developed components including an automated calibration tool, optical contact sensor for signal acquisition, and a methodology for real-time in vivo probe calibration correction. The end result is a state-of-the-art medical device that can be realistically used by a physician with spectroscopic fiber-optic probes. We show how the features of this system allow it to have excellent stability measuring two scattering phantoms in a clinical setting by clinical staff with ∼0.5 % standard deviation over 25 unique measurements on different days. In addition, we show the systems' ability to overcome many technical obstacles that spectroscopy applications often face such as speckle noise and user variability. While this system has been designed and optimized for our specific application, the system and design concepts are applicable to most in vivo fiber-optic-based spectroscopic techniques.

Use of volumetric laser endomicroscopy for dysplasia detection at the gastroesophageal junction and gastric cardia.

AIM: To determine specific volumetric laser endomicroscopy (VLE) imaging features associated with neoplasia at the gastroesophageal junction (GEJ) and gastric cardia. METHODS: During esophagogastroduodenoscopy for patients with known or suspected Barrett's esophagus, VLE was performed before biopsies were taken at endoscopists' discretion. The gastric cardia was examined on VLE scan from the GEJ (marked by top of gastric folds) to 1 cm distal from the GEJ. The NinePoints VLE console was used to analyze scan segments for characteristics previously found to correlate with normal or abnormal mucosa. Glands were counted individually. Imaging features identified on VLE scan were correlated with biopsy results from the GEJ and cardia region. RESULTS: This study included 34 cases. Features characteristic of the gastric cardia (gastric rugae, gastric pit architecture, poor penetration) were observed in all (100%) scans. Loss of classic gastric pit architecture was common and there was no difference between those with neoplasia and without (100% vs 74%, P = NS). The abnormal VLE feature of irregular surface was more often seen in patients with neoplasia than those without (100% vs 18%, P < 0.0001), as was heterogeneous scattering (86% vs 41%, P < 0.005) and presence of anomalous glands (100% vs 59%, P < 0.05). The number of anomalous glands did not differ between individual histologic subgroups (ANOVA, P = NS). CONCLUSION: The transition from esophagus to gastric cardia is reliably identified on VLE. Histologically abnormal cardia mucosa produces abnormal VLE features. Optical coherence tomography algorithms can be expanded for use at the GEJ/cardia.

In vivo risk analysis of pancreatic cancer through optical characterization of duodenal mucosa.

OBJECTIVES: To reduce pancreatic cancer mortality, a paradigm shift in cancer screening is needed. Our group pioneered the use of low-coherence enhanced backscattering (LEBS) spectroscopy to predict the presence of pancreatic cancer by interrogating the duodenal mucosa. A previous ex vivo study (n = 203) demonstrated excellent diagnostic potential: sensitivity, 95%; specificity, 71%; and accuracy, 85%. The objective of the current case-control study was to evaluate this approach in vivo. METHODS: We developed a novel endoscope-compatible fiber-optic probe to measure LEBS in the periampullary duodenum of 41 patients undergoing upper endoscopy. This approach enables minimally invasive detection of the ultrastructural consequences of pancreatic field carcinogenesis. RESULTS: The LEBS parameters and optical properties were significantly altered in patients harboring adenocarcinomas (including early-stage) throughout the pancreas relative to healthy controls. Test performance characteristics were excellent with sensitivity = 78%, specificity = 85%, and accuracy = 81%. Moreover, the LEBS prediction rule was not confounded by patients' demographics. CONCLUSION: We demonstrate the feasibility of in vivo measurement of histologically normal duodenal mucosa to predict the presence of adenocarcinoma throughout the pancreas. This represents the next step in establishing duodenal LEBS analysis as a prescreening technique that identifies clinically asymptomatic patients who are at elevated risk of PC.

Angiostatin potentiates cyclophosphamide treatment of metastatic disease.

PURPOSE: We examined the interaction between cyclophosphamide (CPA) and angiostatin (AS) on the growth of primary Lewis lung carcinoma (LLC) tumors and on the development of LLC pulmonary metastases. We studied the effects of AS and CPA on the stages of angiogenesis employing in vitro assays. METHODS: Primary tumor growth and pulmonary metastases were measured to evaluate the effects of treatment with AS alone, CPA alone or the combination of CPA and AS. We examined the effects of CPA plus AS on endothelial cell (HUVEC) survival, migration and tube formation. RESULTS: Combined treatment with CPA and AS did not significantly affect primary tumor growth when compared with CPA treatment alone. However, a significant decrease in the number of pulmonary metastases was observed following CPA plus AS treatment when compared with CPA treatment alone ( P<0.001). AS did not enhance CPA-mediated HUVEC cytotoxicity, and CPA failed to enhance AS-mediated inhibition of migration. However, tube formation was inhibited following combined treatment with CPA and AS when compared with either treatment alone. CONCLUSIONS: AS enhanced the antimetastatic effects of CPA without significantly influencing the effects of CPA on primary tumor growth. CPA plus AS inhibited tube formation, suggesting that interrupting specific steps in the angiogenesis process might be an effective approach to the treatment of subclinical distant metastases.

Whole blood leukocyte mitogen activated protein kinases activation differentiates intensive care unit patients with systemic inflammatory response syndrome and sepsis.

INTRODUCTION: We sought to determine whether leukocytes from intensive care unit (ICU) patients have altered ERK and p38 kinase activation and specifically if septic patients manifest changes of endotoxin (lipopolysaccharide [LPS]) tolerance. In vitro pretreatment of monocytes (Mono) with LPS induces LPS tolerance with impaired cytokine release and inhibition of ERK and p38 activation after LPS rechallenge. HYPOTHESIS: We hypothesized that macrophage dysregulation, similar to that seen with in vitro LPS tolerance, occurs in critically ill patients with severe sepsis. METHODS: Heparinized whole blood from 16 surgical ICU patients and 16 healthy controls was incubated for 15 minutes +/- 10 ng/mL LPS at 37 degrees C. Mono and neutrophil (polymorphonuclear leukocytes [PMN]) diphospho (active) ERK and p38 kinase activation were determined using flow cytometry with monoclonal antibodies. Results are expressed as mean +/- SEM of basal and percentage change (delta %) in positive cells (delta = LPS stimulated - basal). Chi2 test was used for statistics. RESULTS: Basal ERK was seen in Mono from all groups, but delta % positive only increased in healthy subjects and systemic inflammatory response syndrome (SIRS) patients. No basal Mono or PMN p38 was seen in healthy controls, but LPS significantly activated p38 in both cell types. Mono from patients with sepsis, but not SIRS, had impaired ERK activation. Both PMN and Mono from patients with SIRS had low basal but high LPS-stimulated p38, whereas p38 activation was impaired in patients with sepsis. CONCLUSION: Alterations in mitogen activated protein kinases (MAPK) activation are seen in ICU patients. Leukocytes of septic patients, but not those with SIRS, showed characteristics of LPS tolerance. Assessment of leukocyte MAPK activation may identify and differentiate patients with sepsis from those with SIRS.