New observations on the utility of CA19-9 as a biomarker in Lewis negative patients with pancreatic cancer.

BACKGROUND: Carbohydrate antigen 19-9 (CA19-9) is the best-validated biomarker for pancreatic cancer. The National Comprehensive Cancer Network (NCCN) guideline asserts that "CA19-9 will be undetectable in Lewis antigen-negative individuals". However, reports of CA19-9 secretion and its significance in Lewis (-) patients with pancreatic cancer have been inconsistent. This study was to examine serum CA19-9 levels in patients with pancreatic cancer according to Lewis status. METHODS: Patients with pancreatic cancer (1482 cases) were retrieved from a prospectively maintained database. Patients with benign pancreatic disease (210 cases) and normal subjects (315 cases) were used as controls. Lewis genotypes were examined by fucosyltransferase 3 (FUT3) sequencing. RESULTS: In patients with pancreatic cancer, 8.4% of subjects were Lewis (-), but only 41.9% of Lewis (-) subjects had CA19-9 values ≤ 2 U/mL. CA19-9 was even elevated (>37 U/mL) in 27.4% of Lewis (-) patients. The area under the receiver operating characteristic (ROC) curve for CA19-9 as a diagnostic biomarker was 0.842 in Lewis (-) patients with pancreatic cancer, which is closing to that of CA19-9 applied in all of patients with pancreatic cancer (0.898). Lewis (-) status was an independent prognostic factor for shorter survival in a multivariable analysis (hazard ratio (HR), 1.30, 95% confidence interval (CI), 1.03-1.64; P = 0.028). CONCLUSIONS: Not all Lewis (-) patients with pancreatic cancer are non-secretors of CA19-9. Contrary to general understanding, CA19-9 can retain its utility as a biomarker in these patients in spite of Lewis (-) genotype.

Hepatobiliary and pancreatic: Comparison between Chinese herbal medicine and Western medicine-induced liver injury of 1985 patients.

BACKGROUND AND AIM: Chinese herbal medicine (CHM), as well as Western medicine (WM), is an important cause of drug-induced liver injury (DILI). However, the differences between CHM and WM as agents implicated in liver injury have rarely been reported. METHODS: Overall, 1985 (2.05%) DILI cases were retrospectively collected from the 96 857 patients hospitalized because of liver dysfunction in the 302 Military Hospital between January 2009 and January 2014. RESULTS: In all the enrolled patients with DILI, CHM was implicated in 563 cases (28.4%), while 870 cases (43.8%) were caused by WM and the remaining patients (27.8%) by the combination of WM and CHM. Polygonum multiflorum was the major implicated CHM. Compared with WM, the cases caused by CHM showed more female (51 vs 71%, P < 0.001) and positive rechallenge (6.1 vs 8.9%, P = 0.046), a much greater proportion of hepatocellular injury (62.2 vs 88.5%, P < 0.001), and a higher mortality (2.8 vs 4.8%, P = 0.042); however, no differences in the rates of chronic DILI and ALF were found (12.9 vs 12.4%, P = 0.807; 7.6 vs 7.6%, P = 0.971). Based on Roussel Uclaf Causality Assessment Method, 75.6% of cases caused by CHM were classified as probable and only 16.6% as highly probable, significantly different from WM (38.4 and 60.3%, all P < 0.001). CONCLUSIONS: The causal relationship between CHM and liver injury is much complex, and the clinical characteristics of DILI caused by CHM differ from those caused by WM.

"Ductal adenocarcinoma in anular pancreas".

INTRODUCTION: The annular pancreas is a congenital anomaly in which pancreatic tissue partially or completely surrounds the second portion of the duodenum. Its often located above of papilla of Vater (85%), rarely below (15%). This pancreatic tissue is often easily dissociable to the duodenum but there is same cases where it the tissue is into the muscolaris wall of the duodenum. MATERIAL AND METHODS: We describe three case of annular pancreas hospitalized in our facility between January 2004 and January 2009. There were 2 male 65 and 69 years old respectively and 1 female of 60 years old, presented complaining of repeated episodes of mild epigastric pain. Laboratory tests (including tumor markers), a direct abdomen X-ray with enema, EGDS and total body CT scan were performed to study to better define the diagnosis. EUS showed the presence of tissue infiltrating the muscle layer all around the first part of duodenum. Biopsies performed found the presence of pancreatic tissue with focal areas of adenocarcinoma. Subtotal gastrectomy with Roux was performed. The histological examinations shows an annular pancreas of D1 with multiple focal area of adenocarcinoma. (T1aN0M0). RESULTS: We performed a follow up at 5 years. One patients died after 36 months for cardiovascular hit. Two patients, one male and one female, was 5-years disease-free. DISCUSSION: Annular pancreas is an uncommon congenital anomaly which usually presents itself in infants and newborn. Rarely it can present in late adult life with wide range of clinical severities thereby making its diagnosis difficult. Pre-operative diagnosis is often difficult. CT scan can illustrate the pancreatic tissue encircling the duodenum. ERCP and MRCP are useful in outlining the annular pancreatic duct. Surgery still remains necessary to confirm diagnosis and bypassing the obstructed segment.

Improvement of MR cholangiopancreatography (MRCP) images after black tea consumption.

OBJECTIVE: Evaluation of the efficacy of black tea as the negative oral contrast agent in MRCP. MATERIALS AND METHODS: MRCP was performed before and 5 and 15 min after tea consumption for 35 patients. Depiction of the gall bladder (GB), cystic duct (CD), proximal and distal parts of the common bile duct (CBD), intrahepatic ducts (IHD), ampulla of vater (AV), main pancreatic duct (MPD) and signal loss of stomach and three different segments of the duodenum were investigated according to VAS and Likert scores. RESULTS: Twenty-one of the patients (60%) were female (mean age, 50.3 ± 19.2 years). Regarding visibility of different anatomical parts of the pancreatobiliary tree, the post procedure images were better visualized in the distal part of CBD, AV and MPD in Likert and VAS scoring (all P ≤ 0.001). Regarding obliteration of high signal in the stomach and three different parts of the duodenum, all post procedure images showed significant disappearance of high signal in Likert and VAS scoring systems (all Ps ≤ 0.001). CONCLUSION: Black tea is a simple and safe negative oral contrast agent which reduces the signal intensity of gastrointestinal tract fluid and provides improved depiction of the MPD, the distal CBD and the ampulla during MRCP. Key Points •Tea is an effective negative oral contrast agent for gastrointestinal MRI •Ingestion of black tea improves conspicuity of the distal CBD in MRCP.

Excessive use of Steroid Hormone & beneficial effects of True St. 36 acupuncture on malignant brain tumors--part I; how to estimate non-invasively presence of excess dose of Steroid Hormone in patients, baseball players & other professional athletes from its toxic effects on heart & pancreas, as well as persistent or recurrent infection--part II.

Using accurate organ representation areas map of the face, originally mapped by the author using Bi-Digital O-Ring Test Resonance Phenomena between two identical substances, one can make quick non-invasive screening of diseases by visual inspection, particularly if it is chronic degenerative disease, as they often develop deep crease or creases or discoloration on the pathological organ representation area. However, even if there are no visible abnormalities in the organ representation areas, the author found that when the individual is using excessive Steroid Hormones for malignant brain tumors, other medical purposes, and competitive sports, not only did the left ventricle and pancreas become very abnormal when examined by the Bi-Digital O-Ring Test, and Steroid Hormone accumulate in these organs with abnormally increased 8-OH-dG & TXB2, and Folic Acid & Telomere markedly reduce, but also the organ representation areas of the pancreas and left ventricle on the face showed similar abnormalities. Thus, using the Bi-Digital O-Ring Test, one can quickly and non-invasively screen the Steroid Hormone induced abnormalities of the heart and pancreas, and their organ representation areas of various parts of the body, including the face, tongue, ears, hands and feet. For malignant tumors including brain tumors, acupuncture on True ST. 36 or ST. 37 was found to be highly beneficial by reducing cancer cell telomere to practically 0, while increasing normal cell telomere moderately. The author's study over the past 15 years indicates that photographs of the human body, including pictures that appear in newspapers and magazines, have almost identical information as the information taken directly from the body surfaces of patients or individual athletes. Some examples of the application of this principle for the noninvasive estimation of the presence of Steroid Hormones using a photograph of the individual receiving the Steroid Hormone for medical reasons, or for the purpose of gaining an advantage in competitive sports, are shown in this article. While excessive Steroid Hormone use damages the heart and pancreas and hides symptoms of infection, additional use of Vitamin C also inhibits antibiotics and antiviral agents and cannot control severe infection, as suspected in the cases of late Pope John Paul II and late Palestinian leader Yasser Arafat.

[Giant benign gastric ulcer penetrating into the liver, pancreas and mesocolon]. / Ulcera gastrica gigante benigna penetrante nel fegato, nel pancreas e nel mesocolon.

Penetration of the liver, pancreas and transverse mesocolon by a giant benign gastric ulcer is relatively uncommon, and literature contains a few reports of this complication. The preoperative histological diagnosis may be difficult or impossible. A 63-year-old female patient with a history of seven months of lack of appetite, asthenia, epigastric pain, a remarkable weight decrease, presenting at physical examination a large, smooth margins, not pulsating, quite fixed abdominal mass, is reported. Echography confirmed the presence of a mass of approximately 14 x 19 cm, with solid and liquid content. Biopsy showed inflammatory elements and cellular detriti. Barium enema showed that the mass compressed the descendent colon, which appeared dislocated. Tumor markers (CEA, CA 19-9, alpha-fetoprotein) where in the normal range. Endoscopy showed a giant angular ulcer whose bottom was represented by necrotic material (after the definitive histological examination it proved to be hepatic tissue). At TC scan of the abdomen, a remarkable thickening of the gastric wall was present. At surgery the stomach appeared increased in volume, with remarkably thickened walls, tenaciously sticking to II and III hepatic segments, to the pancreas and transverse mesocolon. A total gastrectomy was performed because of the depth of the ulcer penetration and the extension of the alteration of the gastric wall, even if the giant gastric ulcer, in the literature, is more frequently benign than malignant.

Magnetic resonance imaging of the spleen and pancreas.

MRI of the spleen and pancreas requires specialized sequences which diminish artifacts in the upper abdomen. High temporal resolution sequences (e.g., spoiled gradient echo) acquired immediately after intravenous Gd-DTPA administration are necessary for imaging both the spleen and pancreas. In evaluating the spleen, early post Gd-DTPA images are essential as many focal disease processes (e.g., lymphomatous deposits or metastases) equilibrate rapidly (< 2 min) with splenic parenchyma. Complete pancreatic examination also requires the use of T1-weighted fat suppressed spin echo. T2-weighted images provide complementary information in a number of settings, in particular in the evaluation of islet cell tumors. Pancreatic ductal carcinoma is low signal on T1-weighted images and enhances in a diminished fashion on immediate post Gd-DTPA images. These tumors are well differentiated from focal chronic pancreatitis and islet celltumors based on their appearances on combined T1, T2-weighted and immediate post Gd-DTPA enhanced images.

Clinical evaluation of tissue polypeptide antigen (TPA) in the diagnosis of pancreatic carcinoma.

The serum values of tissue polypeptide antigen (TPA) were measured in a prospective series of 100 patients with jaundice, 54 patients with suspicion of chronic pancreatitis or a pancreatic tumour, and 19 patients with unjaundiced cholestasis to assess its value in diagnosing pancreatic cancer. There were altogether 25 patients with a cancer of the pancreas including 2 patients with a cancer of the papilla of Vater. The highest serum TPA values were noticed in patients with pancreatic cancer, but raised values were also seen in patients with malignant or benign liver diseases, and with cholangiocarcinoma. The sensitivity of TPA was 52% with a specificity of 85% and an efficiency of 80%. In comparison to CEA, CA 50 and CA 242, TPA showed lower sensitivity but higher specificity. When TPA was combined with the other markers, the specificity and efficiency improved clearly in all combinations, being highest in that of TPA and CA 242 (specificity 94.5%, efficiency 87.2%). The results suggest that the TPA test has a useful complementary role in the clinical use of the current serum tumour markers in the diagnosis of pancreatic cancer.

The effect of laxatives and enemas on the sonographic visibility of the pancreas.

Thirty-six patients were evaluated concerning the visibility of the pancreas under different conditions. One group (12 patients) was prepared with fasting for 4 hours, the second group (12 patients) was additionally given laxatives for one day prior to the examination together with a small enema (preparation for IVP). The third group (12 patients) received laxative treatment for 2 days (preparation for barium enema) but was otherwise treated in the same fashion as group 2. The study did not reveal any difference in visibility between the three groups thus indicating that routine preparation with 4 hours fasting alone can still be recommended when examining the upper part of the abdomen (except the gallbladder) with ultrasound.

Pancreatic sonography in thalassemia major.

Four patients with thalassemia major and well documented transfusional anamnesis were investigated sonographically. Beside the fibrous reaction of iron overload in the liver the outstanding finding was the grossly increased echogenicity of the normal sized fibrotic pancreas in transfusional hemosiderosis. Upper abdominal sonography may be an useful - noninvasive - method for the assessment of iron load in regularly transfused patients. Moreover, pancreatic sonography may be helpful as follow-up method of chelation therapy.

Evaluation of the 75Se-l-selenomethionine test for pancreatic disease. Studies on gel filtration.

Radioselenium-secretin-pancreozymin tests have been performed in 22 normal subjects and in 23 patients with pancreatic exocrine insufficiency. Each subject received an intravenous injection of 40-100 mu Ci 75Se-l-selenomethionine as a bolus which was followed by an intravenous infusion of secretin-CCK-PZ (1 CU/kg/h) for 2 h. Duodenal juice was collected from a double-lumen Lagerlöf tube and the 75Se radioactivity measured. Gel filtrations on Sephadex G-50 were performed from samples of duodenal juice. Total duodenal radioactivity in pancreatic insufficient patients was significantly lower than in normal subjects 60-120 min after the start of the examination. When regarding the individual values of each subject an important overlap of normal and pancreatic insufficient persons could be observed. No difference in the gel filtration pattern was demonstrable between the two groups. From these results the use of 75Se-l-selenomethionine for diagnostic purposes in pancreatic diseases cannot be recommended.