The impact of the multidisciplinary tumor board (MDTB) on the management of pancreatic diseases in a tertiary referral center.

BACKGROUND: The implementation of multidisciplinary tumor board (MDTB) meetings significantly ameliorated the management of oncological diseases. However, few evidences are currently present on their impact on pancreatic cancer (PC) management. The aim of this study was to evaluate the impact of the MDTB on PC diagnosis, resectability and tumor response to oncological treatment compared with indications before discussion. PATIENTS AND METHODS: All patients with a suspected or proven diagnosis of PC presented at the MDTB from 2017 to 2019 were included in the study. Changes of diagnosis, resectability and tumor response to oncological/radiation treatment between pre- and post-MDTB discussion were analyzed. RESULTS: A total of 438 cases were included in the study: 249 (56.8%) were presented as new diagnoses, 148 (33.8%) for resectability assessment and 41 (9.4%) for tumor response evaluation to oncological treatment. MDTB discussion led to a change in diagnosis in 54/249 cases (21.7%), with a consequent treatment strategy variation in 36 cases (14.5%). Change in resectability was documented in 44/148 cases (29.7%), with the highest discrepancy for borderline lesions. The treatment strategy was thus modified in 27 patients (18.2%). The MDTB brought a modification in the tumor response assessment in 6/41 cases (14.6%), with a consequent protocol modification in four (9.8%) cases. CONCLUSIONS: MDTB discussion significantly impacts on PC management, especially in high-volume centers, with consistent variations in terms of diagnosis, resectability and tumor response assessment compared with indications before discussion.

SARS-CoV2 RNA detection in a pancreatic pseudocyst sample.

The involvement of gastrointestinal system in SARS-CoV2 related disease, COVID-19, is increasingly recognized. COVID-19 associated pancreatic injury has been suggested, but its correlation with pancreatic disease is still unclear. In this case report, we describe the detection of SARS-CoV2 RNA in a pancreatic pseudocyst fluid sample collected from a patient with SARS-CoV2 associated pneumonia and a pancreatic pseudocyst developed as a complication of an acute edematous pancreatitis. The detection of SARS-CoV2 within the pancreatic collection arise the question of whether this virus has a tropism for pancreatic tissue and whether it plays a role in pancreatic diseases occurrence.

QSAR modelling of synergists to increase the efficacy of deltamethrin against pyrethroid-resistant Aedes aegypti mosquitoes$.

Space spraying of deltamethrin allows the control of adult Aedes (Stegomyia) aegypti mosquitoes. Unfortunately, many vector control programs are threatened by the development of resistances that decrease the efficacy of this adulticide. Faced with this situation, we can either try to use another insecticide presenting a different mechanism of action or find a strategy that brings back the efficacy of the insecticide at a satisfying level to pursue its use in vector control. Restoration of the efficacy of an insecticide can be obtained by means of a synergist. In this context, QSAR modelling was used to find synergists to combine with deltamethrin for increasing its efficacy against resistant strains of Ae. aegypti. Seventy-four structurally diverse chemicals with their 24-hour LD50 values, obtained under the same experimental conditions on Ae. aegypti females, were used. Molecules were described by means of autocorrelation vectors encoding lipophilicity, molar refractivity, H-bonding acceptor and donor ability. A three-layer perceptron (TLP) was employed as statistical tool. The performances of the models were evaluated through the analysis of the prediction results obtained on the different training and test sets (80%/20%) as well as from an out-sample test set. A 6/4/1 TLP computed with the Broyden-Fletcher-Goldfarb-Shanno second-order training algorithm led to the best prediction results. The convergence was obtained in 132 cycles. The sum of squares was used as error function. The hidden and output activation functions were tanh and exponential, respectively. Various chemical structures were identified as potential synergists and searched for their commercial availability. Molecules of interest were tested in vivo on Ae. aegypti by using the susceptible reference Bora Bora strain and two resistant strains from Martinique island. This led to the identification of the PSM-05 molecule that shows interesting synergistic activity.

EUS-guided fine needle tissue acquisition for the diagnosis of pleural metastases from endometrial cancer.

Transesophageal EUS-FNA have become a useful tool in the evaluation of the mediastinum, especially during the staging work-up examination of patients with non-small-cell lung cancer (NSCLC) or other malignancies. We report a challenging case of a 53 years-old woman with an endometrial adenocarcinoma who subsequently presented with right pleural effusion, diffuse pleural thickening with few pleural lesions. The patient referred a long history of exposure to amiantum, this posing a differential diagnosis between primary pleural tumour (mesothelioma) and neoplastic pleural localization of the endometrial cancer. The cytological examination of the pleural effusion (sampled via thoracenthesis) was not adequate to reach a diagnosis. Although a right-video-assisted thoracoscopy was considered the gold standard in this clinical setting to achieve a tissue acquisition of the pleura, an EUS (as the least invasive procedure) was attempted to reach a definitive diagnosis. EUS-FNTA of the pleura was done using a 19-Gauge needle and the pathological and immunophenotypic features were diagnostic for a pleural metastasis of high-grade endometrial serous carcinoma. The patient received adjuvant chemotherapy with a complete regression of the pleural lesions. We take the opportunity of this challenging case to discuss the efficacy and safety of EUS-FNAT to sample the pleural lesions with the use of a large calibre needle if the lesion lies just under the EUS cursor. We may assume that, in selected patients, this technique could be presented as a viable option to the more invasive surgical procedure, which has been previously the gold standard for the pleural tissue acquisition.

Prevalence and risk factors of extrapancreatic malignancies in a large cohort of patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas.

BACKGROUND: The objectives of this study are to estimate prevalence and incidence of extrapancreatic malignancies (EPMs) among intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, and to identify risk factors for their occurrence. PATIENTS AND METHODS: We conducted multicentric cohort study in Italy from January 2010 to January 2011 including 390 IPMN cases. EPMs were grouped as previous, synchronous (both prevalent) and metachronous (incident). We calculated the observed/expected (O/E) ratio of prevalent EPMs, and compared the distribution of demographic, medical history and lifestyle habits. RESULTS: Ninety-seven EPMs were diagnosed in 92 patients (23.6%), among them 78 (80.4%) were previous, 14 (14.4%) were synchronous and 5 (5.2%) were metachronous. O/E ratios for prevalent EPMs were significantly increased for colorectal carcinoma (2.26; CI 95% 1.17-3.96), renal cell carcinoma (6.00; CI 95% 2.74-11.39) and thyroid carcinoma (5.56; CI 95% 1.80-12.96). Increased age, heavy cigarette smoking, alcohol consumption and first-degree family history of gastric cancer are significant risk factors for EPMs, while first-degree family history of colorectal carcinoma was borderline. CONCLUSION: We report an increased prevalence of EPMs in Italian patients with IPMN, especially for colorectal carcinoma, renal cell and thyroid cancers. A systematic surveillance of IPMN cases for such cancer types would be advised.

Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline.

This article is the second of a two-part publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided Trucut biopsy. The first part (the Clinical Guideline) focused on the results obtained with EUS-guided sampling, and the role of this technique in patient management, and made recommendations on circumstances that warrant its use. The current Technical Guideline discusses issues related to learning, techniques, and complications of EUS-guided sampling, and to processing of specimens. Technical issues related to maximizing the diagnostic yield (e.g., rapid on-site cytopathological evaluation, needle diameter, microcore isolation for histopathological examination, and adequate number of needle passes) are discussed and recommendations are made for various settings, including solid and cystic pancreatic lesions, submucosal tumors, and lymph nodes. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling. A two-page executive summary of evidence statements and recommendations is provided.

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.

Pancreatic cancer: diagnosis and endoscopic staging.

Early diagnosis and appropriate staging of pancreatic adenocarcinoma is of vital importance to possibly detect this otherwise lethal disease at a curable phase and to stratify patients who would benefit the most from surgical resection. The availability of endoscopic ultrasound (EUS) with its unique capability of obtaining refine images of the pancreas has represented a major breakthrough in the management of these difficult tasks. Furthermore, the ability to perform fine needle aspiration (FNA) under real time EUS guidance has offered the possibility to reach a definite diagnosis which has a major impact on the decision making process in the care of patients with both resectable and unresecectable pancreatic cancer. In parallel to the widespread importance of diagnostic EUS, the therapeutic applications of EUS are increasing and may further expand the role of this procedure in the management of pancreatic cancer. This article focuses on the current role of EUS and EUS-FNA in the diagnosis and staging of solid pancreatic lesions in different clinical scenarios, including those individuals at a high risk of developing pancreatic cancer and who may be candidates for a EUS-based screening and surveillance program. Data on the emerging therapeutic role of EUS for pancreatic cancer treatment will also be reviewed.

Endoscopic ultrasound in the evaluation of pancreaticobiliary disorders.

The close proximity of the endoscopic ultrasound probe to the pancreas coupled with the ability to perform fine needle aspiration has made endoscopic ultrasound an extremely important technique for the evaluation of both benign and malignant pancreaticobiliary disorders. In parallel to the widespread importance of diagnostic endoscopic ultrasound, the therapeutic and interventional applications of this procedure are expanding and may become a major breakthrough in the management of pancreaticobiliary diseases. This article focuses on the utility and recent advances of endoscopic ultrasound in the diagnostic evaluation pancreaticobiliary disorders and analyses the data of well established interventional procedures such as celiac plexus neurolysis and pseudocyst drainage. Moreover, the more innovative procedures, such endoscopic ultrasound-guided biliary and pancreatic ducts access and drainage and the experimental use of direct endoscopic ultrasound-guided therapy of both solid and cystic pancreatic lesions will also be reviewed.

Concomitant intraductal papillary mucinous neoplasm and pancreatic endocrine tumour: Report of two cases and review of the literature.

It has been suggested that the occurrence of intraductal papillary mucinous neoplasms in association with pancreatic endocrine tumours is more frequent than expected [Goh BK, Ooi LL, Kumarasinghe MP, Tan YM, Cheow PC, Chow PK, et al. Clinicopathological features of patients with concomitant intraductal papillary mucinous neoplasm of the pancreas and pancreatic endocrine neoplasm. Pancreatology 2006;6:520-6]. Up to now, 10 patients with concomitant intraductal papillary mucinous neoplasms and pancreatic endocrine tumours have been reported [Goh BK, Ooi LL, Kumarasinghe MP, Tan YM, Cheow PC, Chow PK, et al. Clinicopathological features of patients with concomitant intraductal papillary mucinous neoplasm of the pancreas and pancreatic endocrine neoplasm. Pancreatology 2006;6:520-6; Zhao X, Stabile BE, Mo J, Wang J, French SW. Nesidioblastosis coexisting with islet cell tumor and intraductal papillary mucinous hyperplasia. Arch Pathol Lab Med 2001;125:1344-7; Marrache F, Cazals-Hatem D, Kianmanesh R, Palazzo L, Couvelard A, O'Toole D, et al. Endocrine tumor and intraductal papillary mucinous neoplasm of the pancreas: a fortuitous association? Pancreas 2005;31:79-83]. In most cases the synchronous existence of both tumours was incidentally discovered after the examination of the surgical specimen. We report two additional patients with intraductal papillary mucinous neoplasms and pancreatic endocrine tumours, in whom both tumours were diagnosed before surgery.

Long-term follow-up of complete Barrett's eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma.

BACKGROUND AND STUDY AIMS: In patients with Barrett's esophagus (BE), targeted endoscopic mucosal resection (EMR) of visible lesions of high grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is effective, but carries the risk of leaving in place synchronous lesions and Barrett's epithelium with the potential for recurrent disease. We evaluated the safety and long-term efficacy of complete Barrett's eradication EMR (CBE-EMR) for the treatment of patients with HGD or IMC, independently of the presence of macroscopically visible lesions or surgical risk. PATIENTS AND METHODS: 26 consecutive patients with BE and HGD or IMC underwent CBE-EMRs, which were performed with the endoscopic cap suction method and/or a 2.3-mm monofilament mucosectomy snare. Endoscopic follow up after completion of resection was carried out to assess the rate of residual or recurrent BE with or without HGD or IMC. RESULTS: 24 patients completed the study. They underwent a total of 44 EMR sessions with a median of 3 pieces (range 1-8) removed per session. Two patients with immediate bleeding were successfully managed endoscopically. Three patients developed an early esophageal stricture that was completely resolved with a single endoscopic dilation. After a median follow-up of 28 months (range 15-51 months), persistent endoscopic and histologic eradication of BE was demonstrated in 21 patients (87.5 %). In two patients, Barrett's epithelium was detected beneath the neosquamous epithelium 3 months after completion of the resection. In the remaining patient, IMC was found in a nodule seen and removed by EMR at 12-month surveillance endoscopy. CONCLUSIONS: CBE-EMR is a safe and highly effective long-term treatment that should be offered to all patients with Barrett's esophagus with HGD and IMC.

Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography.

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic procedure of choice in patients with biliary strictures and no culprit mass lesion on abdominal imaging, but it is limited in its diagnostic accuracy. The aim of this prospective study was to determine the value of intraductal ultrasound (IDUS) in distinguishing between benign and malignant biliary strictures in this clinical setting. PATIENTS AND METHODS: Sixty-one patients with painless jaundice and no mass lesion on abdominal computed tomography, who were found to have a biliary stricture at ERCP, underwent IDUS with a high-frequency (20-MHz) wire-guided probe. Histopathological confirmation or clinical follow-up was used to establish the final diagnosis. The diagnostic performances of IDUS, ERCP, and IDUS plus ERCP in the identification of malignant strictures were evaluated. RESULTS: Forty-three patients had malignant strictures and 18 had benign strictures. ERCP produced 25 false-negative diagnoses, 22 of which were identified as malignant by IDUS. IDUS provided seven false-negative and three false-positive diagnoses. The proportion of patients with malignant strictures who tested positive with IDUS was 2.06 times that of ERCP (95 % CI, 1.37 - 3.10; 83.3 % vs. 40.5 %, P = 0.0004). When used in conjunction, IDUS increased the accuracy of ERCP from 58 % to 90 %. Patients with operable lesions on IDUS and no contraindication to surgery underwent resection; most patients with pancreatic parenchymal invasion on IDUS underwent EUS, which identified a pancreatic mass in more than 50 % of cases. Patients with negative IDUS and a low clinical suspicion for malignancy were treated endoscopically, while a more aggressive work-up was performed in all patients with high pretest probability, regardless of the IDUS results. CONCLUSIONS: IDUS is a valuable adjunct to ERCP in the characterization of biliary strictures in patients who present with painless jaundice in the absence of a culprit mass on abdominal imaging.

Therapeutic endoscopic retrograde cholangiopancreatography without fluoroscopy in four critically ill patients using wire-guided intraductal ultrasound.

Emergent endoscopic retrograde cholangiopancreatography cannot be performed at the bedside in critically ill patients in an intensive care unit because of the requirement for fluoroscopy. Moving such patients to a safe location where fluoroscopy is available can pose practical problems, and can lead to delayed intervention, which may adversely affect the outcome. We report the use of intraductal ultrasound to facilitate therapeutic biliary interventions in four critically ill patients in an intensive care unit. Cannulation was performed endoscopically at the bedside using a sphincterotome and a guide wire. Intraductal ultrasound, rather than fluoroscopy, was then used to confirm the location of the wire within the common bile duct prior to performing endoscopic sphincterotomy or stent placement. This technique was successful in all four patients.

Prevalence of GB virus-C/hepatitis G virus infection in patients with cryptogenic chronic liver disease and in patients with primary biliary cirrhosis or Wilson's disease.

OBJECTIVE: To assess the role of hepatitis G virus (HGV) in cryptogenic chronic liver disease (CLD), we investigated the prevalence of HGV RNA among patients with cryptogenic CLD, patients with nonviral CLD (primary biliary cirrhosis [PBC] and Wilson's disease [WD]) and subjects without clinically evident liver disease (controls). METHODS: Ninety patients with cryptogenic CLD (43 with chronic hepatitis, 20 with cirrhosis, and 27 with hepatocellular carcinoma [HCC]), 143 patients with PBC, 22 patients with WD, and 134 controls were recruited. HGV RNA was detected by reverse transcription-polymerase chain reaction (RT-PCR) and antibodies against HGV E2 protein (anti-E2) by an immunoassay test. RESULTS: HGV RNA was detected in 7.8% of patients with cryptogenic CLD (chronic hepatitis, 9.3%; cirrhosis, 5.0%; HCC, 7.4%), in 2.4% of patients with PBC or WD, and in 2.2% of controls. As a consequence, a positive association of HGV infection with cryptogenic CLD was found (odds ratio, 3.1; 95% confidence interval [CI], 1.0-9.7; p = 0.05). No difference was observed between HGV RNA-positive and -negative patients by age, sex, histology, or liver function tests. Anti-E2 prevalence did not differ between patients with cryptogenic CLD (26.5%), patients with PBC (28.1%), and controls (22.1%). Transfusion history was associated with HGV RNA but not with anti-E2 seropositivity. CONCLUSIONS: Although an association was found between cryptogenic CLD and HGV infection, the role of the virus seems far from important, the proportion of cryptogenic CLD attributable to it being only 5.2%.