Differences in pancreatic immunohistochemical staining profiles of TGF-beta1, MMP-2, and TIMP-2 between autoimmune and alcoholic chronic pancreatitis.

OBJECTIVES: Tumor growth factor beta (TGF-beta) is an immunosuppressive cytokine and has been implicated in a variety of disease processes, including those in autoimmune disease. Tumor growth factor beta is also involved in fibrosis by regulating matrix metalloproteinases (MMPs) and the tissue inhibitor of MP (TIMP). The purpose of this study was to compare the expression patterns of TGF-beta1, MMP-2, and TIMP-2 between autoimmune chronic pancreatitis (AIP) and alcoholic chronic pancreatitis (ACP) by immunohistochemical staining of pancreatic tissue specimens. METHODS: Pancreatic tissue specimens were obtained from 16 of 57 patients who had a diagnosis of AIP at the Asan Medical Center. Pancreatic tissue specimens of ACP were obtained from 10 patients who were surgically treated. Immunohistochemical staining was performed with antibodies specific for TGF-beta1, MMP-2, and TIMP-2. RESULTS: The degree of immunohistochemical staining for TGF-beta1 was significantly weaker in AIP than in ACP in the pancreatic ductal epithelial and mononuclear cells (P = 0.029 and P = 0.018, respectively). CONCLUSIONS: This finding suggests that there may be a defect in the function of regulatory T (Treg) cells, which normally prevents autoimmune disease progression via a suppressor mechanism. Further studies are needed to identify the type of regulatory T cell involved in this process.

Endoscopic ultrasound guided fine needle aspiration biopsy in diagnosis of pancreatic and peripancreatic lesions: a single center experience in Korea.

BACKGROUND/AIMS: Although endoscopic ultrasound guided fine needle aspiration (EUS-FNA) has been introduced and its use has been increasing in Korea, there have not been many reports about its performance. The aim of this study was to assess the utility of EUS-FNA without on-site cytopathologist in establishing the diagnosis of solid pancreatic and peripancreatic masses from a single institution in Korea. METHODS: Medical records of 139 patients who underwent EUS-FNA for pancreatic and peripancreatic solid mass in the year 2007, were retrospectively reviewed. By comparing cytopathologic diagnosis of FNA with final diagnosis, sensitivity, specificity, and accuracy were determined, and factors influencing the accuracy as well as complications were analyzed. RESULTS: One hundred twenty out of 139 cases had final diagnosis of malignancy. Sensitivity, specificity, and accuracy of EUS-FNA were 82%, 89%, and 83%, respectively, and positive and negative predictive values were 100% and 46%, respectively. As for factors influencing the accuracy of FNA, lesion size was marginally significant (p-value 0.08) by multivariate analysis. CONCLUSIONS: EUS-FNA performed without on-site cytopathologist was found to be accurate and safe, and thus EUS-FNA should be a part of the standard management algorithm for pancreatic and peripancreatic mass.

Is pancreatic core biopsy sufficient to diagnose autoimmune chronic pancreatitis?

OBJECTIVES: This study aimed to evaluate the adequacy of pancreatic core biopsy in histological diagnosis of autoimmune chronic pancreatitis (AIP). METHODS: Histopathologic study as well as immunohistochemical staining using anti-IgG4 antibody was done with pancreatic tissue specimens of 26 AIP patients (19 transabdominal ultrasound (US)-guided core biopsies, 3 intraoperative wedge biopsies, and 4 surgical resections). Eight patients with alcoholic chronic pancreatitis and 10 patients with pancreatic cancer served as controls. RESULTS: Lymphoplasmacytic sclerosing pancreatitis (LPSP) histology was observed in 26% (5/19) of US-guided core biopsy specimens, 33% (1/3) of open biopsy specimens, and all 4 resection specimens in AIP patients. None of the patients in the control group showed the full spectrum of changes of LPSP. Abundant IgG4-positive cells (>10 cells/high-power field) in the pancreas were observed in 21% (4/19) of AIP patients with US-guided core biopsy specimen. Abundant IgG4-positive cells in the pancreas were also observed in 2 of 8 patients with chronic alcoholic pancreatitis and 1 of 10 patients with pancreatic cancer. CONCLUSIONS: Transabdominal US-guided pancreatic core biopsy may not provide enough tissue to evaluate characteristic histopathologic features of AIP that include LPSP or abundant IgG4-positive cell infiltration. The LPSP histology may be specific to AIP, but abundant IgG4-positive cells in the pancreas may not.

Cystic lesions of the pancreas: challenging issues in clinical practice.

Cystic lesions of the pancreas are being recognized with increasing frequency and have become a common finding in clinical practice. Cystic lesions of the pancreas display a wide spectrum of histopathology and biologic behavior. Differentiating among lesions and choosing an optimal therapy is challenging, and evidence-based guidelines for diagnosis, management, and follow-up for cystic lesions of the pancreas are needed. This review describes the epidemiology and typical features of cystic lesions of the pancreas, including a summary of commonly used descriptive terms, as well as the primary issues in the differential diagnosis and management of these lesions.

EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: a prospective feasibility study.

BACKGROUND: Although EUS-guided drainage procedures have been used to collect peripancreatic fluids, little is known regarding EUS-guided transmural gallbladder drainage for high-risk patients with acute cholecystitis. OBJECTIVE: Our purpose was to evaluate the technical feasibility and outcomes of EUS-guided transmural cholecystostomy as rescue management in elderly and high-risk patients with acute cholecystitis. DESIGN: Single-center prospective study. SETTING: Tertiary referral center. PATIENTS: Nine elderly or high-risk patients diagnosed with acute cholecystitis. INTERVENTIONS: All inflamed gallbladders were drained by EUS-guided transmural cholecystostomy. MAIN OUTCOME MEASUREMENT: Clinical resolution of acute cholecystitis. RESULTS: After the drainage procedures, there were no immediate complications such as bleeding, bile leak, or peritonitis, except for 1 patient who had pneumoperitoneum. After EUS-guided transmural cholecystostomy, all patients showed rapid clinical improvement within 72 hours. LIMITATIONS: Small number of patients. CONCLUSION: EUS-guided transmural cholecystostomy may be feasible and safe as initial, interim, or even definitive treatment of patients with severe acute cholecystitis who are at high operative risk for immediate cholecystectomy.

The sensitivity and specificity of serum immunoglobulin G and immunoglobulin G4 levels in the diagnosis of autoimmune chronic pancreatitis: Korean experience.

OBJECTIVES: Serum immunoglobulin G (IgG) and/or IgG4 elevation is one of the notable characteristics of autoimmune chronic pancreatitis (AIP). The purpose of this study was to compare the sensitivity and specificity of IgG with those of IgG4 in the diagnosis of AIP. METHODS: From December 2005 to March 2006, patients who were diagnosed as having ordinary chronic pancreatitis of a certain cause (n = 67) and pancreatic cancer (n = 76) in Asan Medical Center were enrolled. The IgG and IgG4 levels of these patients were compared with those of 35 AIP patients diagnosed in Asan Medical Center. RESULTS: The percentage of patients with serum IgG level more than 1800 mg/dL was 10.4% (7/67), 2.6% (2/76), and 54.3% (19/35) in patients with ordinary chronic pancreatitis, pancreatic cancer, and AIP, respectively. As for serum IgG4 levels more than 135 mg/dL, it was 11.9% (8/67), 1.3% (1/76), and 73.3% (22/30), respectively. The specificity of IgG at 1800 mg/dL and IgG4 at 135 mg/dL was both 93.7%. The serum IgG4 showed high specificity (98.7%) in differentiating AIP from pancreatic cancer. The IgG4 level at 141 mg/dL was determined as the most optimal cutoff value with resulting sensitivity and specificity of 73.3% and 95.1%, respectively (area under the curve, 0.816), whereas for IgG, it was determined as 1770 mg/dL, with sensitivity and specificity of 57.1% and 93.7% (area under the curve, 0.788). CONCLUSIONS: The sensitivity of serum IgG4 tended to be higher than that of IgG in the diagnosis of AIP. The IgG4 showed high specificity in the differential diagnosis of AIP from pancreatic cancer. Serum IgG4 should be included in the diagnostic workup for AIP.

Human leukocyte antigen alleles and haplotypes associated with chronicity of hepatitis B virus infection in Koreans.

CONTEXT: Chronic hepatitis B infection is the leading cause of cirrhosis and hepatocellular carcinoma. Human leukocyte antigen may be involved in the chronicity of hepatitis B virus (HBV) infection. OBJECTIVE: To analyze the association between HBV chronicity and human leukocyte antigen alleles and haplotypes of 636 organ donors and recipients. DESIGN: Subjects were categorized into 2 groups according to their clinical and serologic profiles, specifically, an HBV natural convalescent group and an HBV chronic carrier (CC) group. RESULTS: Hepatitis B chronicity was positively associated with A33 (P = .004, odds ratio [OR] = 1.59) and DR7 (P < .001, OR = 2.58), and negatively associated with HLA-DR13 (P < .001, OR = 0.40). Coexpression of A33 and DR7 was significantly higher in the CC group (OR = 3.63), compared with that of either allele alone (OR = 1.76 in A33; OR = 2.53 in DR7). The statistically significant haplotypes were B44-DR7 (P < .001, OR = 5.44), A33-DR7 (P < .001, OR = 4.47), and A33-B44-DR7 (P < .001, OR = 7.31) in the CC group. CONCLUSIONS: Our results indicate that alleles of A33, DR7, and haplotypes containing DR7 are associated with HBV chronicity among Koreans. Moreover, the 2 antigens had an additive effect on chronicity. These findings support the theory that human leukocyte antigen class I-restricted cytotoxic T cells and human leukocyte antigen class II-restricted helper T cells play an important role in HBV chronicity.

MR cholangiography versus cholangioscopy for evaluation of longitudinal extension of hilar cholangiocarcinoma.

BACKGROUND: The utility of magnetic resonance cholangiography for assessment of longitudinal tumor extension of hilar cholangiocarcinoma was investigated with reference to findings by percutaneous transhepatic cholangioscopy. METHODS: Ninety-nine patients with hilar cholangiocarcinoma underwent both magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy. Longitudinal tumor extension was described with the Bismuth-Corlette classification. Hilar cholangiocarcinoma was classified morphologically into stenotic, diffuse sclerosing, and polypoid types based on selective cholangiographic findings obtained during percutaneous transhepatic cholangioscopy. Agreement between percutaneous transhepatic cholangioscopy and magnetic resonance cholangiography according to the Bismuth-Corlette classification was compared. The degree of agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy according to each morphologic type was also compared in each subgroup without reference to Bismuth-Corlette type. RESULTS: The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy with regard to Bismuth-Corlette types was 87.9% (kappa = 0.832, p < 0.01). The agreement of magnetic resonance cholangiography for each Bismuth-Corlette type with reference to percutaneous transhepatic cholangioscopy was as follows: type I (n = 18), 16/18 (88.9%); type II (n = 16), 14/16 (87.5%); type IIIa (n = 23), 19/23 (82.6%); type IIIb (n = 14), 14/14 (100%); and type IV (n = 28), 24/28 (85.7%). The overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy for Bismuth-Corlette type according to selective cholangiographic findings was as follows: stenotic type, 58/61 (95.1%, kappa = 0.929, p < 0.01); diffuse sclerosing type, 12/16 (75%, kappa = 0.619, p < 0.01); and polypoid type, 17/22 (77.3%, kappa = 0.696, p < 0.01). CONCLUSION: There is good overall agreement between magnetic resonance cholangiography and percutaneous transhepatic cholangioscopy on longitudinal extension of hilar cholangiocarcinoma. Especially for the stenotic type of hilar cholangiocarcinoma (based on selective cholangiographic findings), magnetic resonance cholangiography may replace percutaneous transhepatic cholangioscopy in the determination of longitudinal tumor extension. For polypoid or diffuse sclerosing types, however, percutaneous transhepatic cholangioscopy is required for accurate evaluation of longitudinal tumor extension.