Giant splenic cyst and solid pseudopapillary tumour of the pancreas managed with distal pancreatectomy and splenectomy.

Solid pseudopapillary tumours of the pancreas and giant splenic cysts are very rare entities, and their coexistence in a young female patient has not been previously reported in the literature. We present the case of a 27-year-old woman who presented with abdominal pain and two masses on abdominal imaging. A mass located in the right upper quadrant was biopsied, and histological and immunohistochemical analysis showed a solid pseudopapillary tumour of the pancreas. A giant cystic splenic lesion was also noted. The patient underwent a distal pancreatectomy and splenectomy in our referral centre. Margins were negative on histopathological examination. Negative surgical margins were achieved with distal pancreatectomy and splenectomy despite the large size of the pancreatic tumour. The management of solid pseudopapillary tumours of the pancreas is often challenging and the concomitant presence of a giant splenic cyst poses additional challenges to the surgical management of such tumours.

[Acute small bowel obstruction: conservative or surgical treatment?]. / Occlusion grêle aiguë: traitement conservateur ou chirurgical?

Small bowel obstruction (SBO) is a common clinical syndrome caused mainly by postoperative adhesions. In complement to clinical and biological evaluations, CT scan has emerged as a valuable imaging modality and may provide reliable information. The early recognition of signs suggesting bowel ischemia is essential for urgent operation. However appropriate management of SBO remains a common clinical challenge. Although a conservative approach can be successful in a substantial percentage of selected patients, regular and close re-assessement is mandatory. Any persistance or progression of the critical symptoms and signs should indeed lead to surgical exploration. Here we review the principles of adhesive SBO management and suggest a decision procedure for conservative versus surgical treatment.

Cell encapsulation technology as a novel strategy for human anti-tumor immunotherapy.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) as an adjuvant in autologous cell-based anti-tumor immunotherapy has recently been approved for clinical application. To avoid the need for individualized processing of autologous cells, we developed a novel strategy based on the encapsulation of GM-CSF-secreting human allogeneic cells. GM-CSF-producing K562 cells showed high, stable and reproducible cytokine secretion when enclosed into macrocapsules. For clinical development, the cryopreservation of these devices is critical. Thawing of capsules frozen at different time points displayed differences in GM-CSF release shortly after thawing. However, similar secretion values to those of non-frozen control capsules were obtained 8 days after thawing at a rate of >1000 ng GM-CSF per capsule every 24 h. For future human application, longer and reinforced capsules were designed. After irradiation and cryopreservation, these capsules produced >300 ng GM-CSF per capsule every 24 h 1 week after thawing. The in vivo implantation of encapsulated K562 cells was evaluated in mice and showed preserved cell survival. Finally, as a proof of principle of biological activity, capsules containing B16-GM-CSF allogeneic cells implanted in mice induced a prompt inflammatory reaction. The ability to reliably achieve high adjuvant release using a standardized procedure may lead to a new clinical application of GM-CSF in cell-based cancer immunization.

Characterization of two Ashkenazi Jewish founder mutations in MSH6 gene causing Lynch syndrome.

Founder mutations are an important cause of Lynch syndrome and facilitate genetic testing in specific ethnic populations. Two putative founder mutations in MSH6 were analyzed in 2685 colorectal cancer (CRC) cases, 337 endometrial cancer (EnCa) cases and 3310 healthy controls of Ashkenazi Jewish (AJ) descent from population-based and hospital-based case­control studies in Israel, Canada and the United States. The carriers were haplotyped and the age of the mutations was estimated. MSH6*c.3984_3987dupGTCA was found in 8/2685 CRC cases, 2/337 EnCa cases, and 1/3310 controls, consistent with a high risk of CRC (odds ratio (OR) = 9.9, 95% confidence interval (CI) = 1.2­78.9, p = 0.0079) and a very high risk of EnCa (OR = 19.6, 95% CI = 1.8­217.2, p = 0.0006). MSH6*c.3959_3962delCAAG was identified in 3/2685 CRC cases, 2/337 EnCa cases and no controls. Each mutation was observed on separate conserved haplotypes. MSH6*c.3984_3987dupGTCA and MSH6*c.3959_3962delCAAG probably arose around 585 CE and 685 CE, respectively. No carriers were identified in Sephardi Jews (450 cases and 490 controls). Truncating mutations MSH6*c.3984_3987dupGTCA and MSH6*c.3959_3962delCAAG cause Lynch syndrome and are founder mutations in Ashkenazi Jews. Together with other AJ founder mutations, they contribute substantially to the incidence of CRC and EnCa and are important tools for the early diagnosis and appropriate management of AJ Lynch syndrome patients.

Clinicoradiological score for predicting the risk of strangulated small bowel obstruction.

BACKGROUND: Intestinal ischaemia as a result of small bowel obstruction (SBO) requires prompt recognition and early intervention. A clinicoradiological score was sought to predict the risk of ischaemia in patients with SBO. METHODS: A clinico-radiological protocol for the assessment of patients presenting with SBO was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would predict ischaemia requiring resection. RESULTS: Of 233 consecutive patients with SBO, 138 required laparotomy of whom 45 underwent intestinal resection. In multivariable analysis, six variables correlated with small bowel resection and were given one point each towards the clinical score: history of pain lasting 4 days or more, guarding, C-reactive protein level at least 75 mg/l, leucocyte count 10 x 10(9)/l or greater, free intraperitoneal fluid volume at least 500 ml on computed tomography (CT) and reduction of CT small bowel wall contrast enhancement. The risk of intestinal ischaemia was 6 per cent in patients with a score of 1 or less, whereas 21 of 29 patients with a score of 3 or more underwent small bowel resection. A positive score of 3 or more had a sensitivity of 67.7 per cent and specificity 90.8 per cent; the area under the receiver operating characteristic curve was 0.87 (95 per cent confidence interval 0.79 to 0.95). CONCLUSION: By combining clinical, laboratory and radiological parameters, the clinical score allowed early identification of strangulated SBO.

[Acute pancreatitis or the need of anticipation]. / La pancréatite aiguë ou la nécessité d'anticipation.

Acute pancreatitis is a potentially lethal inflammatory disease with an increased incidence and a decreased mortality rate. The main etiologies are biliary stones and alcohol abuse. The therapeutic approach consists of the elimination of the cause, the hemodynamic and respiratory supports and the treatment of the complications. Moreover, severe acute pancreatitis requires a collaboration between surgeons, radiologists, gastroenterologists and intensive care physicians. The administration of prophylactic antibiotics and the early oral nutritional support are still controversial. In summary, the anticipation in diagnosis, etiology, classification of the severity and early reanimation are needed for an optimal treatment of this complex disease.

Survival of encapsulated human primary fibroblasts and erythropoietin expression under xenogeneic conditions.

Allogeneic cells are the most attractive source for cell transplantation, as the use of xenogeneic cells is hampered by safety concerns and the use of autologous cells involves practical difficulties. The immune rejection of allogeneic cells can be overcome by physical immunoprotection provided by polymer encapsulation. To study the variability of cell and donor sources, we compared different primary human cells as candidates for gene therapy-mediated delivery of human erythropoietin (hEpo). DARC-3.1 fibroblasts, MDX-01 fibroblasts, and ARPE-19 retinal pigment epithelial cells were encapsulated into polyethersulfone hollow fibers and implanted for 1 month in nude mice as well as in immunocompetent and FK506-immunosuppressed mice to test their in vivo resistance, with the assumption that xenogeneic conditions constitute a stringent model for human application. DARC-3.1 fibroblasts showed the best survival, prompting us to evaluate cell lineages from the same donor (DARC-3.2) or another donor (DARC-4.3 and DARC-4.4). With the exception of DARC-4.3, the remaining three lineages showed comparable survival in immunocompetent C3H and DBA/2J mice. DARC-3.1 fibroblasts were retrovirally engineered with hEpo cDNA, reaching a secretion level of 170 IU of hEpo per 10(6) cells per day. Encapsulated DARC-3.1-hEpo cells led to significantly increased hematocrits in the various hosts and under various transplantation conditions. The present study shows that encapsulated primary human DARC-3.1 fibroblasts are able to survive under xenogeneic conditions and, once engineered with hEpo cDNA, to increase the hematocrit of transplanted mice.

In vivo calcium deposition on polyvinyl alcohol matrix used in hollow fiber cell macroencapsulation devices.

The encapsulation of genetically modified cells represents a promising approach for the delivery of therapeutic proteins. The functionality of the device is dependent on the characteristics of the biomaterials, the procedures used in its confection and the adaptability of the encapsulated cells in the host. We report conditions leading to the development of calcifications on the polyvinyl alcohol (PVA) matrix introduced in hollow fiber devices for the encapsulation of primary human fibroblasts implanted in mice. The manufacturing procedures, batches of PVA matrix and cell lineages were assessed for their respective role in the development of the phenomenon. The results showed that the calcification is totally prevented by substituting phosphate-buffer saline with ultra-pure sterile water in the rinsing procedure of the matrix. Moreover, a positive correlation was found, when comparing two fibroblast cell lineages, between the level of lactate dehydrogenase (LDH) activity measured in the cells and the degree of calcium deposition. Higher LDH activity may decrease calcium depositions because it generates in the device a more acidic microenvironment inhibiting calcium precipitation. The present study defines optimized conditions for the encapsulation of primary human fibroblasts in order to avoid potentially detrimental calcifications and to allow long-term survival of encapsulated cells.

Optimization of human erythropoietin secretion from MLV-infected human primary fibroblasts used for encapsulated cell therapy.

BACKGROUND: The transplantation of encapsulated cells genetically engineered to secrete human erythropoietin (hEpo) represents an alternative to repeated injections of the recombinant hormone for the treatment of Epo-responsive anemia. In the present study, the ability of primary human foreskin fibroblasts to secrete high levels of hEpo and the importance of cis-acting elements and infection conditions on transgene expression level were assessed. METHODS: The transduction efficiency was first evaluated with beta-galactosidase (LacZ)-encoding retroviral vectors derived from the murine leukemia retrovirus (MLV) pseudotyped either with an amphotropic envelope or with the G glycoprotein of vesicular stomatitis virus (VSV-G). Human fibroblasts were then infected with an amphotropic hEpo-expressing retroviral vector, which was modified by insertion of a post-transcriptional regulatory element from the woodchuck hepatitis virus (WPRE) and a Kozak consensus sequence (KZ). Human Epo production was further optimized by increasing the multiplicity of infection and by selecting high producer cells. The survival and the transgene expression of these fibroblasts were finally evaluated in vivo. The cells were encapsulated into microporous hollow fibers and subcutaneously implanted in nude mice. RESULTS: A secretion level of approximately 5 IU hEpo/10(6) cells/day was obtained with the basal vector. A 7.5-fold increase in transgene expression was observed with the insertion of WPRE and KZ elements. Finally, according to the optimization of infection conditions, we obtained a 40-fold increase in hEpo secretion, reaching approximately 200 IU hEpo/10(6) cells/day. The in vivo experiments showed an increase in the hematocrit during the first 2 weeks and elevated levels exceeding 60% were maintained over a 6-week period. CONCLUSIONS: These results indicate that primary human fibroblasts represent a promising source for encapsulated cell therapy.