Splenic vein tumor thrombosis is a major prognostic factor in distal pancreatic adenocarcinoma

BACKGROUND

The prognostic value of splenic vessel involvement in distal pancreatic adenocarcinoma remains controversial. The aim of the study was to assess its prognostic relevance in a large multicenter cohort.

METHODS

Patients who underwent pancreatosplenectomy for distal pancreatic adenocarcinoma were identified from 5 pancreatic surgical centers. A pathology review of the surgical specimens was performed to assess splenic vessel involvement, defined as invasion of the vessel's adventitia or deeper, and confirm the presence of splenic vein tumor thrombosis. Prognostic factors associated with overall and relapse-free survival were evaluated.

RESULTS

149 patients underwent upfront surgery. Splenic vascular involvement was observed in 69 of them (46.3%). A parietal infiltration of the splenic artery or splenic vein was observed in 26 (17.5%) and 49 patients (32.8%), respectively. A pathologic tumor thrombosis of the splenic vein was identified in 22 patients (14.8%) and associated with larger tumors (>20 mm) (P = .023), more perineural (P = .017), and lymphovascular (P = .002) invasion, and more positive lymph node (P = .001). After a median follow-up of 50.8 months (95% confidence interval: 44.3-57.3), the cumulative 5-year overall and relapse-free survival were 46.2% and 33%, respectively. In multivariate analysis, in addition to lymph node metastasis (hazard ratio = 1.8; 95% confidence interval [1.1-3.1]; P = .023) and perineural invasion (hazard ratio = 3.5; 95% confidence interval [1.3-9.7]; P = .016), presence of splenic vein tumor thrombosis was the only splenic vascular involvement that affected independently the overall survival (HR = 2.3; 95% confidence interval [ 1.3-4.3]; P = .006).

CONCLUSION

In resectable distal pancreatic adenocarcinoma, a pathologic tumor thrombosis of the splenic vein is an independent prognostic factor of overall survival. To define the perioperative oncological strategy, a preoperative evaluation of splenic vessel involvement and thrombosis is needed.

Impact of surgery after endoscopically resected high-risk T1 colorectal cancer: results of an emulated target trial

BACKGROUND AND AIMS

We aimed to compare the long-term outcomes of patients with high-risk T1 colorectal cancer (CRC) resected endoscopically who received either additional surgery or surveillance.

METHODS

We used data from routine care to emulate a target trial aimed at comparing 2 strategies after endoscopic resection of high-risk T1 CRC: surgery with lymph node dissection (treatment group) versus surveillance alone (control group). All patients from 14 tertiary centers who underwent an endoscopic resection for high-risk T1 CRC between March 2012 and August 2019 were included. The primary outcome was a composite outcome of cancer recurrence or death at 48 months.

RESULTS

Of 197 patients included in the analysis, 107 were categorized in the treatment group and 90 were categorized in the control group. From baseline to 48 months, 4 of 107 patients (3.7%) died in the treatment group and 6 of 90 patients (6.7%) died in the control group. Four of 107 patients (3.7%) in the treatment group experienced a cancer recurrence and 4 of 90 patients (4.4%) in the control group experienced a cancer recurrence. After balancing the baseline covariates by inverse probability of treatment weighting, we found no significant difference in the rate of death and cancer recurrence between patients in the 2 groups (weighted hazard ratio, .95; 95% confidence interval, .52-1.75).

CONCLUSIONS

Our study suggests that patients with high-risk T1 CRC initially treated with endoscopic resection may not benefit from additional surgery.

Diagnostic Yield of Repeat Endoscopic Ultrasound-Guided Fine Needle Biopsy for Solid Pancreatic Lesions

PATIENTS AND METHODS

we performed a retrospective case-control study, including cases with repeat EUS FNB for a solid pancreatic lesion, matched on a 1:2 ratio on age, sex, tumor location and presence of chronic pancreatitis with cases diagnosed on the first EUS FNB.

RESULTS

thirty-four cases and 68 controls were included in the analysis. Diagnostic accuracies were 80% and 88% in the repeat and single EUS FNB groups, respectively (p = 0.824). The second EUS FNB had a sensitivity of 80%, a specificity of 75%, a positive predictive value of 96%, and a negative predictive value of 33%. Of the 34 patients in the repeat EUS FNB group, 25 (74%) had a positive diagnosis with the second EUS FNB, 4 (12%) after surgery due to a second negative EUS FNB, 4 (12%) during clinical follow-up, and 1 (3%) after a third EUS FNB. Of the 25 patients diagnosed on the repeat EUS FNB, 17 (68%) had pancreatic adenocarcinomas, 2 (8%) neuroendocrine tumors, 2 (8%) other autoimmune pancreatitis, 2 (8%) chronic pancreatitis nodules, 1 (4%) renal cancer metastasis, and 1 (4%) other malignant diagnostic. There were no complications reported after the second EUS FNB in this study.

CONCLUSION

repeat EUS FNB made a diagnosis in three fourths of patients with solid pancreatic lesions and a first negative EUS FNB, with 26% of benign lesions. This supports the repetition of EUS FNB sampling in this clinical situation.

Factors associated with suicidal ideation in the French nationwide EPICOV study

Introduction

The COVID-19 pandemic seems associated with a worsening in mental health issues as well as a widening of pre-existing social and health inequalities. Assessment of its impact on suicidal behavior might therefore be relevant.

Objectives

To assess factors associated with suicidal ideation in the general population, using data from the French nationwide Epicov study

Methods

In the nationally representative Epicov study, data on occurrence of suicidal ideation from November 2019 to November 2020 were available, including timing with respect to France’s lockdown periods. We studied the incidence of suicidal ideation among participants without a prior history of suicidal behavior, after May 11, 2020, when first COVID-19 related lockdown was suspended. Studied factors assessed sociodemographic and health status, including mental health, as well as COVID-19 related information such as symptom. Associations between selected factors and suicidal ideation were assessed in sex-stratified adjusted logistic regression models.

Results

In the Epicov study, prevalence of suicidal ideation was of 2,9%, as opposed to around 4% pre-pandemic. Among 48 702 female and 41 016 male participants, health or financial issues were associated with a higher incidence of suicidal ideation. Interestingly, Covid19-like symptoms were also associated with higher risk of suicidal ideation. While an impaired mental health has been observed in survivors of past pandemics, given the unprecedented context of the current pandemic, this association needs further investigation.

Conclusions

While the COVID-19 pandemic might have lowered suicidal ideation, it’s aftermaths may reverse the trend. To prevent this rise, identification of vulnerable groups is crucial to promote tailored public health strategies.

Disclosure

No significant relationships.

Endoscopic ultrasound guided fine needle biopsy in patients with suspected gastric linitis plastica

BACKGROUND

Gastric linitis plastica (GLP) is a diffuse infiltrating type of gastric adenocarcinoma. It is associated with a poor prognosis and a five-year survival of 3-10%. The infiltrating profile of this tumor explains the low yield of the superficial mucosal biospies. The objective of this study was to investigate the role of endoscopic ultrasound-fine needle biopsy (EUS-FNB) in the diagnosis of GLP.

METHODS

We performed a retrospective analysis including all patients who had an EUS-FNB, at a tertiary referral center, over the last 3 years. The primary outcome was the sensitivity of EUS-FNB in patients with suspected GLP.

RESULTS

Between January 2017 and December 2020, 34 patients had an EUS-FNB for suspected GLP. Ten patients had a diagnostic of GLP. This diagnosis was obtained by EUS-FNB in 90% (9/10) of the cases. Eight patients had at least one previous esophagogastroduodenoscopy (EGD) with negative mucosal biopsies. Gastric EUS-FNB helped diagnose other serious conditions in 47% (16/34) of cases with inconclusive mucosal biopsies.

CONCLUSION

Gastric EUS-FNB in patients with suspected GLP and normal endoscopic mucosal biopsies may lead to a positive diagnosis of GLP in 90% of cases without notable adverse events. This technique should be considered as a second step in the setting of suspicion of GLP after inconclusive mucosal biopsies.

Symptoms of emotional difficulties and hyperactivity/inattention among children during the COVID-19 epidemic and associated lockdown: data from the SAPRIS project

Background

COVID-19 limitation strategies led to widespread school closures around the world. The present study aims to provide a description of children's mental health and associated factors during the COVID-19 school closure in France.

Methods

We conducted a cross-sectional analysis in the SAPRIS study during the COVID-19 pandemic in France, relying on 2 ongoing national birth cohorts, ELFE and EPIPAGE 2. Using weighted multinomial logistic regression models, we estimated associations between children's mental health (i.e., hyperactivity/inattention and emotional symptoms; assessed by the Strengths and Difficulties Questionnaire), children's health behaviors, schooling, as well as sociodemographic and socioeconomic characteristics of children family.

Results

The sample consisted of 5702 children aged 8 - 9 years and 49.3% girls. Sleep disturbance and parents' dominant socio-professional category were associated with both hyperactivity-inattention (adjusted Odds Ratio (aOR)=2.10 95%Confidence Interval [1.85-2.38]; aOR=0.45 [0.33-0.61] respectively) and emotional symptoms and (aOR=6.33 [5.26-7.63]; aOR=0.62 [0.39-0.98] respectively). Specifically associated with hyperactivity/inattention were: male sex (aOR=2.51 [2.24-2.82]), presence of regular care and its pursuit during school closure (aOR=1.69 [1.33-2.15]), emotional symptoms (aOR=2.74 [2.23-3.37]), school situation (aOR=2.19 [1.69-2.82]), presence of tutoring and difficulties with it (aOR=2.56 [2.13-3.08]), type of housing (aOR=0.79 [0.70-0.89]). Factors associated with emotional symptoms were: presence of covid cases in the household (aOR=2.33 [1.92-2.82]), hyperactivity/inattention (aOR=2.94 [2.45-3.52]) and financial difficulties (aOR=1.71 [1.39-2.11]).

Conclusions

Policy makers need to balance pros and cons of closing schools, taking into consideration educational and psychological consequences for children and the various factors associated with mental health.

Endoscopic ultrasound efficacy in staging gastric linitis plastica lesion: a retrospective multicentric French study

BACKGROUND

Endoscopic ultrasound (EUS) is a key imaging technique in gastric cancer (GC). The aim of this study was to evaluate the performance of EUS in the staging of parietal and lymph node involvement in linitis plastica (LP) compared to "classical" GC.

METHODS

A retrospective multicentric French study was conducted on patients with no metastatic LP and operated by gastrectomy. A 2/1 matching based on pTNM stage and center was performed with GC.

RESULTS

Forty-three patients were included, sixteen patients in the LP group and 27 in the control group. Sensitivity and specificity of EUS for diagnosis of T3-T4 parietal invasion were 77% and 100% respectively in the LP group and 89% and 56% respectively in the control group. Sensitivity and specificity of EUS for diagnosis of lymph node involvement were 73% and 80%, respectively in the LP group and 88% and 50%, respectively in the control group. Patients from LP group had significantly more advanced histological lesion, and frequent undiagnosed peritoneal carcinomatosis.

CONCLUSIONS

This study evaluated for the first time in a European population, the preoperative EUS performance in LP. Our study identified a similar sensitivity and specificity of the EUS in LP compared to "classical" GC paving for a broader use of EUS in preoperative settings.

"Chronic Disseminated Aspergillosis," a Novel Fungal Immune Reconstitution Inflammatory Syndrome

We report a case of chronic hepatosplenic aspergillosis following immune reconstitution complicating colic aspergillosis in an AIDS patient with multicentric Castleman disease. Symptoms mimicked the clinical presentation of chronic disseminated candidiasis and responded to corticosteroid. This emerging entity enlarges the spectrum of fungal immune reconstitution inflammatory syndrome in the HIV setting.

Cancer information overload and multiple prevention behaviors

Background

Many people feel overwhelmed by the increasing amount of cancer-related material available in the information environment. Our aims was to evaluate the psychometric properties of the brief version of the cancer information overload (CIO) scale and to examine the association between CIO and multiple cancer prevention behaviors.

Methods

A large survey using a self-administered online questionnaire was proposed to all adult members of the Seintinelles, a French national non-profit organization. The psychometric properties of the CIO scale were evaluated. Measurement invariance across French and English languages was studied using an additional sample of 224 Australian cancer survivors from Register4. We also collected functional, communicative, and critical health literacy (FCCHL), deprivation (EPICES index), current smoking, alcohol misuse, frequent sunburns, and rare skin self-examination.

Results

Between June 16th and 30th 2016, 2 363 French participants answered the online questionnaire. The five-item CIO scale demonstrated the best balance between psychometric properties and number of items. It showed satisfactory internal consistency and adequate fit. No measurement invariance issue was found across age, gender, education level, and language groups.

CIO was increased among people with higher deprivation, lower education and a cancer information avoidant profile. In multivariate analyses, CIO was associated with tobacco use (OR = 1.05, 95%CI [1.00-1.10]), rare skin checks (OR = 1.05 [1.01-1.08]) and frequent sunburns (OR = 1.04 [1.01-1.07]), but not with alcohol misuse.

Conclusions

The 5-item CIO scale is ready to be used in French and English-speaking countries. The links observed between CIO and multiple prevention behaviors encourage further research in order to better characterize the psycho-cognitive and environmental phenomena at play. Efforts are needed to communicate adequately and empower citizens to limit the growing burden of cancer.

Key messages

The 5-item CIO scale is ready to be used in French and English-speaking countries. Efforts are needed to communicate adequately and empower citizens to limit the growing burden of cancer.

Validation of the Sexual Activity Questionnaire in women with endometriosis

STUDY QUESTION

Is the Sexual Activity Questionnaire (SAQ) a valid tool for patients treated for symptomatic endometriosis?

SUMMARY ANSWER

For women having surgical treatment for endometriosis, we determined that the SAQ is a valid and responsive tool.

WHAT IS KNOWN ALREADY

Endometriosis adversely affects sexual quality of life. Suitable validated sexual quality of life instruments for endometriosis are lacking both in clinical practice and for research.

STUDY, DESIGN, SIZE, DURATION

A total of 367 women with proven endometriosis undergoing medical or surgical treatment were included in an observational study conducted between 1 January 2012 and 31 December 2014 in two French tertiary care centers. Both hospitals are reference centers for endometriosis treatment. Of these 367 women, 267 were sexually active and constituted the baseline population.

PARTICPANTS/MATERIALS, SETTINGS, METHODS

Women >18 years old with histological or radiological proven endometriosis, consulting for painful symptoms of at least 3 months duration, infertility, or other symptoms (bleeding, cysts) were invited to complete self-administered questionnaires before (T0) and 12 months after treatment (T1). Tests of data quality included descriptive statistics of the data, missing data levels, floor and ceiling effects, structural validity and internal consistency.The construct validity was obtained by testing presupposed relationships between previously established SAQ scores and prespecified characteristics of the patients by comparing different subgroups of patients at T0. Sensitivity to change was subsequently calculated by comparing the SAQ score between T1 and T0 overall and for different subgroups of treatment. Effect sizes (to T1) were calculated according to Cohen's method. The minimally important difference was estimated by a step-wise triangulation approach (including anchor-based method).

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 267 sexually active patients (204 surgical and 63 medical treatment) completed the SAQ at T0 and 136 (50.9%) at T1. The SAQ score ranged from 2.0 to 28.0 (mean ± SD: 16.8 ± 5.7).The SAQ score was one-dimensional according to the scree plot with good internal consistency (Cronbach alpha = 0.78, 95% CI 0.74-0.81) and had good discriminative ability according to pain descriptors and quality of life in endometriosis. The SAQ was responsive in patients treated by surgery but the effect size was low (0.3, 95% CI (0.0-0.6), P = 0.01). The minimally important difference was determined at 2.2.

LIMITATIONS, REASONS FOR CAUTION

The effect size for medical treatment was non-significant. Other effect sizes were low but statistically significant. This could be explained by lower libido due to progestin intake, which was used for both surgically and medically treated patients.

WIDER IMPLICATIONS OF THE FINDINGS

The SAQ is easy to use, valid and effective in assessing sexual quality of life in patients with endometriosis. This patient-reported score could be used as a primary outcome for future clinical studies. The minimally important difference estimation will be useful for future research. We recommend using 2.2 for the minimally important difference of the SAQ.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the 'Direction à la Recherche Clinique et à l'Innovation' of Versailles, France and the 'Institut de Recherche en Santé de la Femme' (IRSF). The authors have no conflicts of interest to declare.

P1272 Echocardiographic evaluation of left ventricular filling pressure in patients with heart failure with preserved ejection fraction : usefulness of inferior vena cava measurement

Methods

Invasive hemodynamics and echocardiographic measurements were documented in 132 consecutive patients referred to our centre with dyspnea, left ventricular ejection fraction (LVEF) ≥50%, and suspected pulmonary hypertension on a previous echocardiogram. Echocardiographic measurements of mitral flow (E and A wave velocities), the E/e’ratio, indexed left atrial volume (LAV), tricuspid regurgitation velocity (TRV) and the IVC size and collapsibility were obtained. Increased LVFP was defined by an invasive pulmonary artery wedge pressure (PAWP) > 15 mmHg.

Results

In sinus rhythm patients, the sum of the criteria (E/e’ ratio > 14, TRV > 2.8 m/s and indexed LAV > 34 ml/m²) ≥ 2 had a positive predictive value (PPV) of 63% for PAWP > 15 mmHg, whereas a dilated (> 2.1 cm) and/or non collapsible (≤ 50%) IVC had a PPV of 83%. In atrial fibrillation (AF), a dilated and/or non collapsible IVC had an 86% PPV for increased LVFP. We found that 16% of patients with elevated LVFP were more accurately classified using IVC evaluation than using the current guidelines criteria (net reclassification improvement = 0.25, p <0.05).

Conclusion

Echographic measurements of the IVC size and collapsibility outperformed the classic 2016 recommendations algorithm to evaluate LVFP in sinus rhythm patients with suspected HFpEF. The IVC study was also valuable in patients with atrial fibrillation.

McCune Albright syndrome is a genetic predisposition to intraductal papillary and mucinous neoplasms of the pancreas associated pancreatic cancer in relation with GNAS somatic mutation - a case report

RATIONALE

Intraductal papillary and mucinous neoplasms of the pancreas (IPMN) are preneoplastic lesions diagnosed with an increasing incidence. Recently, several groups have described, in up to 70% of IPMN, activating mutations of the G-protein alpha stimulatory sub-unit (Gsα subunit) gene (GNAS). GNAS-activating somatic, post-zygotic, mutations are also associated with McCune-Albright syndrome (MCAS) characterized by fibrous dysplasia, precocious puberty, and café-au-lait spots.

PATIENT CONCERNS

We herein report a patient with McCune Albright Syndrome that presented with malignant IPMN and underwent pancreatic resection.

DIAGNOSES AND INTERVENTIONS

Leucocyte and duodenum juice DNA analysis, endoscopically collected from secretin-stimulated pancreatic juice revealed the same (GNAS) activating mutation also found in the invasive pancreatic colloid adenocarcinoma arising from intestinal subtype IPMN.

OUTCOMES

Thirty months after surgery, the patient was alive with recurrence (bone only metastasis).

LESSONS

In this observation, we show that MCAS should be view as a new genetic predisposition to IPMN associated pancreatic cancer, and consequently a targeted screening in this high-risk population might be proposed.

EUS-guided pancreatic radiofrequency ablation: preclinical comparison of two currently available devices in a pig model

Introduction  Two devices are currently available to perform pancreatic radiofrequency ablation (P-RFA). Potential clinical indications might extend from the treatment of pancreatic cystic lesions to ablation of small pancreatic solid lesions or cytoreduction of advanced pancreatic adenocarcinomas, but more preclinical data from animal models are needed to optimize P-RFA operation. Methods  P-RFA was performed under laparotomy and under endoscopic ultrasonographic guidance on the liver and pancreatic parenchyma of four live swine using the Habib EUS RFA (EMcision Ltd, London, UK) probe and the EUS-RA needle (Taewoong Medical, Gyeonggi-do, South Korea). Animals were sacrificed 2 hours after the procedure. Influence of tuning ablation time and power on tissue ablation were studied by histopathological assessment of the maximal depth of tissue damage on representative slides for each P-RFA shot. Results  The Habib probe in the liver parenchyma resulted in tissue necrosis increasing within the range of 1.9 ± 0.5 mm (Power = 8 W, Time = 120 s) to 2.5 ± 1 mm (Power = 10 W, Time = 120 s). In the pancreatic parenchyma, tissue damage ranged from 3.1 ± 0.4 mm (Power = 8 W, Time = 120 s) to 2.3 ± 0.1 mm (12 W, 120 s) in depth. EUS RFA ablation of the liver parenchyma resulted in tissue damage ranging from 1.6 ± 0.2 mm (Power = 30 W, Time = 11 s) to 1.5 ± 0.1 mm (Power = 70 W, Time = 9 s); in the pancreas, ablation depth ranged from 3.6 ± 0.5 mm (Power = 30 W, Time = 15 s) to 3.8 ± 0.4 mm (Power = 70 W, Time = 11 s). Conclusion  Both devices allow for effective ablation of pancreatic tissue within 1.5 to 3.8 mm around the RFA electrode, with a modest influence of tuning power settings. Specific settings are recommended for each of the devices studied. Ablation of larger lesions may require more repeat P-RFA shots in different locations rather than a simple modulation of ablation parameters.

Impact of a dedicated multidisciplinary meeting on the management of superficial cancers of the digestive tract

Background  The recent development of endoscopic resection for superficial gastrointestinal cancers could justify the need for a dedicated oncological multidisciplinary meeting (MDM). The aim of our study was to evaluate the impact of the dedicated MDM on the management of superficial cancers of the digestive tract. Methods  A dedicated MDM was developed at our tertiary referral center. A retrospective review of the MDM conclusions for all patients referred from March 2015 to March 2017 was performed. Outcomes measurements were the outcomes of endoscopic resection, and the concordance rate between the MDM recommendations, European Society of Gastrointestinal Endoscopy (ESGE) guidelines, and final patient management. Results  In total, 153 patients with a median age of 69 years were included. Half of the patients had major comorbidities. The mean lesion size was 25 mm, and R0 and curative resection rate were 73.9 % and 56.9 %, respectively. Forty-three patients had an indication for surgery after endoscopic resection. The concordance rate between ESGE guidelines and MDM recommendation was 92.2 %, and 12 patients did not receive the treatment recommended due to comorbidities. Conclusion  A MDM dedicated to superficial tumors helped tailor the ESGE guidelines to each patient in order to avoid unnecessary surgery.

Computed tomography scan efficacy in staging gastric linitis plastica lesion: a retrospective multicentric French study

Background

Computed tomography (CT) scan is a key imaging technique in the staging of gastric adenocarcinoma and therapeutic management of patients. The aim of this study was to evaluate the performance of CT scan in the staging of parietal and metastatic invasion in gastric linitis plastica group.

Methods

A retrospective multicentric French study was conducted from January 2006 to December 2015 on patients with no metastatic gastric linitis plastica and operated by gastrec-tomy. A 2/1 matching based on pTNM stage and center was performed.

Results

Fifty patients were included in the linitis plastica group and 100 in the control group. Patients from the linitis group were significantly different from those from the control group with a lower age at diagnosis, a more advanced histological lesion, a more frequent undiagnosed peritoneal carcinomatosis, and a higher risk of R1 resection. Sensitivity and specificity of CT scan for the diagnosis of lymph node involvement were 44% and 75%, respectively, in the linitis plastica group and 55% and 60%, respectively, in the control group. The sensitivity and specificity of CT scan for the T3–T4 parietal invasion were 26% and 100%, respectively, in the linitis group and 40% and 72%, respectively, in the control group.

Conclusion

CT scan has an equal sensitivity and specificity for the evaluation of lymph node and parietal involvement in gastric adenocarcinoma, including linitis plastica. CT scan remains the cornerstone of preoperative evaluation in gastric adenocarcinoma, including linitis plastica. However, CT presents a lack of sensitivity to diagnose low-volume peritoneal carcinomatosis.

Recurrent MALAT1-GLI1 oncogenic fusion and GLI1 up-regulation define a subset of plexiform fibromyxoma

Plexiform fibromyxomas are rare neoplasms, being officially recognized as a distinct entity among benign mesenchymal gastric tumours in the 2010 WHO Classification of Tumours of the Digestive System. Characteristically, these tumours have a multinodular/plexiform growth pattern, and histologically contain variably cellular areas of bland myofibroblastic-type spindle cells embedded in an abundant myxoid matrix, rich in capillary-type vessels. As yet, the molecular and/or genetic features of these tumours are unknown. Here we describe a recurrent translocation, t(11;12)(q11;q13), involving the long non-coding gene metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) and the gene glioma-associated oncogene homologue 1 (GLI1) in a subgroup of these tumours. The presence of the fusion transcript in our index case was confirmed using polymerase chain reaction (PCR) on genomic DNA, followed by Sanger sequencing. We showed that the truncated GLI1 protein is overexpressed and retains its capacity to transcriptionally activate its target genes. A specific FISH assay was developed to detect the novel MALAT1-GLI1 translocation in formalin-fixed, paraffin-embedded (FFPE) material. This resulted in the identification of two additional cases with this fusion and two cases with polysomy of the GLI1 gene. Finally, immunohistochemistry revealed that the GLI1 protein is exclusively overexpressed in those cases that harbour GLI1/12q13 genomic alterations. In conclusion, overexpression of GLI1 through a recurrent MALAT1-GLI1 translocation or GLI1 up-regulation delineates a pathogenically distinct subgroup of plexiform fibromyxomas with activation of the Sonic Hedgehog signalling pathway. Copyright © 2016 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Optimization of the generator settings for endobiliary radiofrequency ablation

AIM: To determine the optimal generator settings for endobiliary radiofrequency ablation.

METHODS: Endobiliary radiofrequency ablation was performed in live swine on the ampulla of Vater, the common bile duct and in the hepatic parenchyma. Radiofrequency ablation time, “effect”, and power were allowed to vary. The animals were sacrificed two hours after the procedure. Histopathological assessment of the depth of the thermal lesions was performed.

RESULTS: Twenty-five radiofrequency bursts were applied in three swine. In the ampulla of Vater (n = 3), necrosis of the duodenal wall was observed starting with an effect set at 8, power output set at 10 W, and a 30 s shot duration, whereas superficial mucosal damage of up to 350 μm in depth was recorded for an effect set at 8, power output set at 6 W and a 30 s shot duration. In the common bile duct (n = 4), a 1070 μm, safe and efficient ablation was obtained for an effect set at 8, a power output of 8 W, and an ablation time of 30 s. Within the hepatic parenchyma (n = 18), the depth of tissue damage varied from 1620 μm (effect = 8, power = 10 W, ablation time = 15 s) to 4480 μm (effect = 8, power = 8 W, ablation time = 90 s).

CONCLUSION: The duration of the catheter application appeared to be the most important parameter influencing the depth of the thermal injury during endobiliary radiofrequency ablation. In healthy swine, the currently recommended settings of the generator may induce severe, supratherapeutic tissue damage in the biliary tree, especially in the high-risk area of the ampulla of Vater.

Acute pain Factors predictive of post-operative pain and opioid requirement in multimodal analgesia following knee replacement

BACKGROUND

Despite the development of multimodal analgesia for postoperative pain management, opioids are still required for effective pain relief after knee arthroplasty. We aimed to identify the determinants of post-operative pain intensity and post-operative opioid requirement in this context.

METHODS

In this observational prospective study, we recorded patient characteristics, pre-operative pain intensity, anxiety and depression levels, sensitivity and pain thresholds in response to an electrical stimulus, and mu-opioid receptor (OPRM1) and catechol-O-methyltransferase (COMT) single-nucleotide polymorphisms. Multivariate linear regression models were used to identify predictors of post-operative pain at rest and opioid requirement.

RESULTS

We included 109 patients. Pre-operative pain at rest (p = 0.047), anxiety level (p = 0.001) and neuropathic pain symptoms (p = 0.030) were independently and positively associated with mean post-operative pain intensity adjusted for mean post-operative morphine equivalent dose (MED). Mean post-operative pain intensity at rest was lower (p = 0.006) in patients receiving celecoxib and pregabalin in the post-operative period, with all other variables constant. Mean post-operative MED over 5 days was low, but highly variable (78.2 ± 32.1 mg, from 9.9 to 170 mg). Following adjustment for mean post-operative pain intensity, it was independently negatively correlated with age (p = 0.004), and positively correlated with associated paracetamol treatment (p = 0.031). No genetic effect was detected in our sample.

CONCLUSIONS

Our findings suggest that clinicians could use the pre-operative pain profile, in terms of anxiety levels, neuropathic pain symptoms, and chronic pre-operative pain intensity, to improve the efficacy of pain management after knee surgery.

Resection of Late Pulmonary Metastases from Pancreatic Adenocarcinoma: Is Surgery an Option?

Patients with recurrences from pancreas adenocarcinoma have a poor survival rate despite new chemotherapy treatment options. Recurrences are mainly hepatic metastases or peritoneal dissemination and surgical treatment is not recommended. Late and single metachronous pulmonary recurrences are uncommon and may mimic primary lung carcinoma. We report two patients with late and unique pulmonary metastasis from pancreatic cancer. These two patients underwent surgical resection; three and five years later, they did not experience recurrences. Cases called for a surgical approach in late and unique pulmonary metastases from pancreatic cancer, and paved the way for a prolonged chemotherapy free period.

A new device to expedite endoscopic submucosal dissection procedures: a randomized animal study of efficacy and safety (with videos)

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is a recognized method for the curative treatment of superficial neoplasia, but its use is limited by lengthy procedures and the lack of versatility of existing knives. We developed a prototype ESD device with the ability to work as a needle, hook, or "scythe." This new device was compared to regular ESD knives in a randomized animal study.

PATIENTS AND METHODS

Eight pigs underwent two gastric ESD procedures each, similar in size and difficulty, one with a regular ESD device and the other with the new device. The order and location of each ESD, as well as the performing operator, were randomized. Primary judgment criterion was safety of procedures. Overall and submucosal dissection procedure times were measured. Time-to-surface ratios were measured and estimated for ESDs larger than those performed. Histopathology of the resected tissue and remaining stomach was done after each experiment.

RESULTS

No complications were observed throughout the study and all resections were completed en-bloc and uneventfully. The submucosal extension of resections was similar with both the standard and the new devices. A comparison of time-consumption between groups did not show statistically significant differences, but a dramatic reduction of procedure duration was observed in some procedures with the new device; based on observed data, a potential time-saving of up to 66 % was anticipated, with a relatively short learning curve.

CONCLUSIONS

This new versatile device proved to be as safe as regular ESD knives, and seems likely to help reduce the duration of the procedure.

Myeloid HIF-1 is protective in Helicobacter pylori-mediated gastritis

Helicobacter pylori infection triggers chronic inflammation of the gastric mucosa that may progress to gastric cancer. The hypoxia-inducible factors (HIFs) are the central mediators of cellular adaptation to low oxygen levels (hypoxia), but they have emerged recently as major transcriptional regulators of immunity and inflammation. No studies have investigated whether H. pylori affects HIF signaling in immune cells and a potential role for HIF in H. pylori-mediated gastritis. HIF-1 and HIF-2 expression was examined in human H. pylori-positive gastritis biopsies. Subsequent experiments were performed in naive and polarized bone marrow-derived macrophages from wild-type (WT) and myeloid HIF-1α-null mice (HIF-1(Δmyel)). WT and HIF-1(Δmyel) mice were inoculated with H. pylori by oral gavage and sacrificed 6 mo postinfection. HIF-1 was specifically expressed in macrophages of human H. pylori-positive gastritis biopsies. Macrophage HIF-1 strongly contributed to the induction of proinflammatory genes (IL-6, IL-1β) and inducible NO synthase in response to H. pylori. HIF-2 expression and markers of M2 macrophage differentiation were decreased in response to H. pylori. HIF-1(Δmyel) mice inoculated with H. pylori for 6 mo presented with a similar bacterial colonization than WT mice but, surprisingly, a global increase of inflammation, leading to a worsening of the gastritis, measured by an increased epithelial cell proliferation. In conclusion, myeloid HIF-1 is protective in H. pylori-mediated gastritis, pointing to the complex counterbalancing roles of innate immune and inflammatory phenotypes in driving this pathology.

[Gastric signet ring cell adenocarcinoma: A distinct entity]

Gastric signet ring cell carcinoma (GSRC) is a distinct entity. Their incidence is increasing. The pathologist plays a central role in the identification of this entity. Diagnosis is based on an adenocarcinoma containing a majority of signet ring cells (above 50 %). The prognosis of GSRC is the same as gastric adenocarcinoma while GSRC appeared more aggressive. Signet ring cells present a low sensitivity to chemotherapy. This review aimed to discuss the histological, the prognostic and the therapeutic aspect of this entity.

High Ki67 expression is a risk marker of invasive relapse for classical lobular carcinoma in situ patients

BACKGROUND

The clinical management of lobular carcinoma in situ lesions remains challenging. Our aim was to evaluate the risk of relapse for lobular carcinoma in situ (LCIS) patients, diagnosed on mammography performed for microcalcifications and according to proliferation assessed by Ki67 staining.

METHODS

A series of 47 patient's files with LCIS and followed in our institution were retrospectively selected. All patients underwent lumpectomy without radiation therapy. The expression of E-cadherin, estrogen receptor (ER), progesterone receptor (PR), EGFR and Ki67 were determined. Four different classes were then defined with the following criteria: ER+ and Ki67 ≤ 10%; ER+, Ki67 >10%; ER-; ER-PR- and EGFR+.

RESULTS

Patient's mean age was 51.3 yrs. The majority of the lesions were classical LCIS (97%). All cases were E-cadherin either negative (71%) or weak and incomplete (29%). Among the 44 evaluable cases, 34 cases were ER or PR positive with KI67 ≤ 10% (79%), 9 cases ER positive with KI67 > 10% (21%), 1 case was ER and PR negative and expressed EGFR. At five years, all patients were alive, 1/34 ER positive and Ki67 low experienced a relapse contrasting with 3 out of 9 ER positive and Ki67 high (3 invasive carcinomas including 2 ductal and 1 lobular) (p = 0.0054).

CONCLUSION

In this retrospective study, we observed a higher risk of relapse associated with a high proliferative activity of classical LCIS. If confirmed in larger series, this observation suggests that radiation therapy or hormonotherapy could be discussed for patients with Ki67 high classical LCIS in order to decrease their risk of relapse.

Acinar cell carcinoma: a possible diagnosis in patients without intrapancreatic tumour

BACKGROUND

Acinar cell carcinomas of the pancreas are rare neoplasms. Usually diagnosed at an advanced stage, in general they are large solid pancreatic tumours with an average size of more than 10 cm.

AIMS AND RESULTS

We report 3 cases of acinar cell carcinomas involving the peripancreatic lymph nodes, the liver hilum and the colon respectively, without clinical or pathological evidence of pancreatic tumours. These highly cellular neoplasms showed a predominantly acinar cell differentiation intermingled with a ductal component, with intracellular or extracellular mucin production by at least 25% of tumour cells. In addition, one case showed endocrine differentiation. Diffuse immunoreactivity for acinar enzymes trypsin and chymotrypsin was present in all cases.

CONCLUSION

The occurrence of acinar cell carcinomas outside the pancreas underlines the notion that acinar cell carcinomas may originate in extrapancreatic sites and probably develop from heterotopic or metaplastic pancreatic foci present along the biliary tract.

[Impact of exhaled CO measurement. A randomised study among 578 smoking patients in general practice]

Nicotine addiction (NA) is a serious public health problem and helping patients to stop consumption is a major concern for general practitioners (GP). The positive effects of "brief advice" are well known. The aim of our paper is to evaluate the effectiveness of adding exhaled carbon monoxide (CO) measurement using a CO analyser to a normal smoking cessation practice in a GP's office.

METHODS

This was a descriptive study, using a questionnaire, among randomised smoking patients; one group receiving brief advice and the other brief advice plus exhaled CO analysis in their GP's office.

RESULTS

Five hundred and seventy-eight questionnaires were analysed: 60% of smoking patients wished to stop smoking and 72% within the next 6 months, without significant difference between the two groups. In the group "minimal advice plus CO analyser" (282), 60% of the smokers reported that they had been influenced by the results of the level of CO in the exhaled air and were more motivated to quit because of this.

CONCLUSION

Measuring the level of exhaled CO in smokers helps to inform them of the dangers of their addiction and helps to motivate them to quit.

Tumor-infiltrating lymphocytes in colorectal cancers with microsatellite instability are correlated with the number and spectrum of frameshift mutations

Colorectal cancers with microsatellite instability are characterized by an important density of tumor-infiltrating lymphocytes and a good prognosis. Microsatellite instability results from the inactivation of the DNA mismatch repair system and induces secondary somatic frameshift mutations within target genes harboring repeat sequences in their coding frame. By disrupting the open reading frame, frameshift mutations can result in the appearance of potentially immunogenic neopeptides. To determine the frameshift mutations inducing a T-cell response during the development of a tumor with microsatellite instability, we studied in 61 colorectal cancer patients with microsatellite instability, using a fluorescent multiplex PCR comparative analysis, the relative frequency of frameshift mutations within 19 target genes and analyzed the correlation of these frameshift mutations with the density of CD3+ tumor-infiltrating lymphocytes. The four most frequently mutated genes were ACVR2 (92%), TAF1B (84%), ASTE1/HT001 (80%) and TGFBR2 (77%). The vast majority (95%) of the tumors exhibited at least three frameshift mutations, and the number of frameshift mutations was associated with tumor progression (TNM stage, wall invasion and tumor diameter). Tumor-infiltrating lymphocyte density was associated with the overall number of frameshift mutations and with the presence of frameshift mutations within two target genes, namely ASTE1/HT001 and PTEN. These results strongly argue for the clinical relevance of immunotherapy of colorectal cancers with microsatellite instability.