Endoscopic ultrasound in patients with obstructive jaundice and inconclusive ultrasound and computer tomography findings.

The clinical work-up of patients with presumed pancreaticobiliary obstruction is usually straightforward including laboratory investigation, abdominal ultrasound and computer tomography. Ultrasound and computer tomography may, however, yield inconclusive findings regarding underlying cause. We report a case series (n = 10) demonstrating the usefulness of endoscopic ultrasound in the work-up of patients with inconclusive ultrasound and computer tomography findings, clinically suspected of pancreaticobiliary cancer.

An unusual cause of hematemesis: Goiter.

Downhill varices are located in the upper part of the esophagus and are usually related to superior vena cava obstruction. Bleeding from these varices is extremely rare. We describe a 77-year-old patient with hematemesis due to downhill varices as a result of recurrent goiter. A right lobe thyroidectomy was carried out with disappearance of the varices.

Inhibition of angiogenesis and HGF-cMET-elicited malignant processes in human hepatocellular carcinoma cells using adenoviral vector-mediated NK4 gene therapy.

NK4 is an hepatocyte growth factor (HGF)-antagonist and a broad angiogenesis inhibitor. NK4 gene therapy has confirmed antitumor efficacy on cancers with intact HGF-cMET signaling pathway. However, the feasibility to treat tumors in which the effect of the HGF-cMET signaling pathway is less unambiguous or may even be inhibitory on carcinogenesis, such as hepatocellular carcinoma (HCC) with NK4 needs further assessment. Therefore, we evaluated the effects of adenoviral vector-mediated expression of NK4 on the biological behavior of a series of HCC cell lines in vitro and on HepG2 xenografts in vivo. In vitro, transduction of HCC cell lines with the replication-deficient recombinant adenoviral vector AdCMV.NK4 resulted in significant inhibition of proliferation over and above the antimitogenic effects of HGF. In addition, HGF-induced scattering and invasion through matrigel were inhibited effectively. Moreover, transduced HCC cells produced sufficient amounts of NK4 protein to achieve bystander effects involving reduced migration of nontransduced tumor cells and reduced proliferation of endothelial cells. Finally, treatment of established HepG2 xenografts with AdCMV.NK4 resulted in significant tumor growth delay and significant reduction of intratumoral microvessel density. In conclusion, NK4 gene therapy is a promising strategy to treat HCC based on the pleiotropic functions of NK4 interfering with tumor growth, invasion, metastasis and angiogenesis.

Selective gene transfer into primary human gastric tumors using epithelial cell adhesion molecule-targeted adenoviral vectors with ablated native tropism.

Currently, application of adenoviral vectors (AdV) in gastric cancer gene therapy would be improved by increases in the specificity of transduction. Previously, we found that epithelial cell adhesion molecule (EpCAM) was expressed on gastric tumors but not on gastric epithelium. In this study, we evaluated doubly-ablated AdV lacking native binding ability together with bispecific single-chain antibodies targeted toward EpCAM for gene therapy of gastric cancer. Specific binding to EpCAM augmented the gene transfer efficiency of doubly-ablated AdV on gastric cancer cell lines up to 144-fold, reaching levels similar to or exceeding those achieved with native AdV. In contrast, EpCAM-targeted doubly-ablated AdV-mediated gene transfer into an EpCAM-negative cell line was reduced 38-fold compared with transduction by native AdV. Most importantly, EpCAM-targeted doubly-ablated AdV showed selectivity for primary human gastric tumors versus the surrounding nonneoplastic gastric mucosa of the same patients and normal liver tissue samples. Targeting these doubly-ablated AdV toward EpCAM resulted in similar transduction efficiency as obtained with native AdV for EpCAM-expressing primary human gastric tumors, whereas transduction of gastric epithelium and liver tissue was reduced at least 10-fold. This study thus indicates that application of EpCAM-targeted doubly-ablated AdV for gastric cancer gene therapy results in a favorable tumor-over-normal tissue transduction ratio.

Birt-Hogg-Dubé syndrome: clinical and genetic studies of 20 families.

Birt-Hogg-Dubé syndrome (BHD) is an autosomal-dominant genodermatosis characterized by skin fibrofolliculomas and an increased risk of spontaneous pneumothorax, renal and possibly other tumors. A causative gene (FLCN) on chromosome 17p has recently been identified. We here report clinical and genetic studies of 20 BHD families ascertained by the presence of multiple fibrofolliculomas or trichodiscomas in the proband. Pathogenic FLCN germline mutations were found in 11 (69%) of 16 probands tested and in 14 family members. Six different FLCN germline mutations were detected, four of which have not been reported previously. The clinical features were variable. None and less than 10 skin lesions were observed in two mutation carriers at the age of 67 and 29 years, respectively. Spontaneous pneumothorax was reported in four and renal carcinoma of mixed histological types in two of 36 BHD-affected individuals and/or FLCN mutation carriers. Both the prevalence of spontaneous pneumothorax and renal tumors appeared to be relatively low compared with previously reported data. Various other extracutaneous tumors were observed in 11 of 36 BHD-affected individuals and/or FLCN mutation carriers. This study of the second largest cohort to date contributes to the expanding data on the variable phenotype and underlying gene defects in BHD.

Endoscopic ultrasound guided fine-needle aspiration and 18FDG-positron emission tomography in the evaluation of patients with non-small cell lung cancer.

The accuracy of mediastinal staging is of paramount importance in the management of patients with non-small cell lung cancer (NSCLC) to select only those patients who might benefit from upfront resection or multimodality treatment. Although CT is the imaging technique of first choice, its performance characteristics have led to an increased use of both EUS-FNA and (18)FDG-PET to improve (mediastinal) staging. In view of the relatively few studies employing both techniques simultaneously, we evaluated 20 consecutive patients (median age 70 years, range 48-83 years) with NSCLC in whom CT suggested N2 and/or N3 involvement. The sensitivity, specificity, PPV and NPV of EUS-FNA and (18)FDG-PET was 86%, 100%, 100%, 90%, and 100%, 89%, 88% and 100%, respectively. EUS-FNA confirmed the absence of malignancy in all patients with a negative (18)FDG-PET scan. Similarly, in the PET-positive patients, EUS-FNA confirmed malignancy in seven out of nine (78%) sites. Unnecessary surgery was prevented in six out of 16 patients otherwise considered as surgical candidates (37%). We conclude that both EUS-FNA and (18)FDG-PET have excellent operating characteristics. However, initial (18)FDG-PET findings should guide the complementary use of EUS-FNA to define treatment options and to prevent unnecessary surgery in selected patients.

Self-expanding metal stents for the treatment of intrathoracic esophageal anastomotic leaks following esophagectomy.

Intrathoracic anastomotic leakage following resection for esophageal malignancy is associated with significant morbidity and mortality rates. Recently, therapy consisted mainly of surgical reexploration and conservative treatment using nasogastric and perianastomotic drainage. This case report shows the feasibility of using fully covered metal esophageal stents to close the anastomotic defect in three patients with esophagectomy for cancer.

Suppression of tumor growth, invasion and angiogenesis of human gastric cancer by adenovirus-mediated expression of NK4.

BACKGROUND: To improve the prognosis of patients with gastric cancer it is important to develop novel treatment modalities targeting the malignant behavior of tumor cells. Concerning this, NK4, which acts as HGF-antagonist and angiogenesis inhibitor, might be a potential therapeutic agent for gastric cancer. The HGF-c-MET pathway plays a pivotal role in gastric tumor growth, invasion, metastasis and angiogenesis. Therefore, the current study investigates whether adenoviral vector-mediated NK4 gene therapy has therapeutic potential for gastric cancer. METHODS: Expression of HGF and c-MET in normal and (pre-)malignant gastric tissue was studied by immunohistochemistry. The effects of adenoviral vector-mediated expression of NK4 on the biological behavior of gastric cancer cells were studied in vitro and in vivo. RESULTS: The majority of gastric cancers, i.e. 76%, express c-MET and in all carcinomas HGF is expressed in either tumor or stromal cells. Normal gastric epithelial cells do not express either of these proteins. Transduction of gastric cancer cells with the replication-deficient adenoviral vector AdCMV.NK4 resulted in efficient production and secretion of NK4. Consequently, proliferation, migration and invasion of gastric cancer cells were significantly inhibited. In addition, significantly reduced proliferation of vascular endothelial cells and efficient inhibition of angiogenesis were achieved. Finally, treatment of established human gastric tumor xenografts with AdCMV.NK4 resulted in significant tumor growth delay and significant reduction of intratumoral microvessel density. CONCLUSIONS: The present study shows that adenoviral vector-mediated expression of NK4 is a promising strategy to treat human gastric cancer by simultaneous interfering with primary tumor growth, metastasis and angiogenesis.

A rapid and reliable enzyme immunoassay PCR-based screening method to identify EBV-carrying gastric carcinomas.

Epstein-Barr virus (EBV) is associated with a substantial number of gastric adenocarcinomas worldwide, as confirmed by EBER1/2-RNA in situ hybridization (RISH). In the present study, we developed a rapid and sensitive PCR-based prescreening method for the detection of EBV in gastric carcinomas to reduce the amount of laborious EBER1/2-RISH assays to be performed. The method was evaluated by testing gastric adenocarcinomas (n = 242) using both BamHI W PCR-enzyme immunoassay (EIA) and EBER1/2-RISH, in combination with appropriate DNA and RNA quality controls. Seventy-four percent of the paraffin-embedded gastric adenocarcinomas had good DNA quality as shown by beta-globin polymerase chain reaction (PCR) after proteinase K and boiling pretreatment, whereas after DNA purification this was increased to 90%. Thirty-two percent of all cases were EBV-DNA positive after PCR-EIA, whereas 10% of these gastric cancers contained EBV transcripts in the neoplastic cells as confirmed by EBER1/2-RISH. Interestingly, only samples with high optical density (OD) 405/630 values in PCR-EIA, equivalent to the maximum reading of the assay as determined by the positive control, contained EBV-positive tumor cells in the EBER1/2-RISH. In contrast, the weak positive samples, as determined by low OD readings in the PCR-EIA were EBER1/2-RISH negative. In conclusion, high OD values in EBV PCR-EIA are very valuable to prescreen EBV-carrying gastric carcinomas as confirmed by EBER1/2-RISH. Only these samples and those with poor DNA quality will require testing in the EBER1/2-RISH, thereby reducing the amount of laborious RISH assays with 85%.