Belgian guidelines for pathology reporting of neuroendocrine neoplasms of the pancreaticobiliary and gastrointestinal tract

Since neuroendocrine neoplasms are rare tumors, registration of patient data in national and multinational registries is recommended. Indeed, this will facilitate multicenter studies on the epidemiology, efficacy and safety of diagnostic and therapeutic strategies for well-differentiated neuroendocrine tumors as well as for neuroendocrine carcinomas. In Belgium, data on patient and tumor characteristics of all newly diagnosed malignancies have been collected in the Belgian Cancer Registry since 2004 including anonymized full pathological reports. The Digestive Neuroendocrine Tumor (DNET) registry collects information on classification, staging, diagnostic tools and treatment in a prospective national online database. However, the terminology, classification and staging systems of neuroendocrine neoplasms have changed repeatedly over the past 20 years as a result of a better understanding of these rare tumors, by joining forces internationally. These frequent changes make it very difficult to exchange data or perform retrospective analyses. For optimal decision making, for a clear understanding and to allow reclassification according to the latest staging system, several items need to be described in the pathology report. This paper provides an overview of the essential items in reporting neuroendocrine neoplasms of the pancreaticobiliary and gastrointestinal tract.

Joint Belgian recommendation on screening for DPD-deficiency in patients treated with 5-FU, capecitabine (and tegafur)

OBJECTIVES

Fluoropyrimidines such as 5-Fluorouracil (5-FU), capecitabine and tegafur are drugs that are often used in the treatment of maliginancies. The enzyme dihydropyrimidine dehydrogenase (DPD) is the first and rate limiting enzyme of 5-FU catabolism. Genetic variations within the DPYD gene (encoding for DPD protein) can lead to reduced or absent DPD activity. Treatment of DPD deficient patients with fluoropyrimidines can result in severe and, rarely, fatal toxicity. Screening for DPD deficiency should be implemented in practice.

METHODS

The available methods in routine to screen for DPD deficiency were analyzed and discussed in several group meetings involving members of the oncological, genetic and toxicological societies in Belgium: targeted genotyping based on the detection of 4 DPYD variants and phenotyping, through the measurement of uracil and dihydrouracil/uracil ratio in plasma samples.

RESULTS

The main advantage of targeted genotyping is the existence of prospectively validated genotype-based dosing guidelines. The main limitations of this approach are the relatively low sensitivity to detect total and partial DPD deficiency and the fact that this approach has only been validated in Caucasians so far. Phenotyping has a better sensitivity to detect total and partial DPD deficiency when performed in the correct analytical conditions and is not dependent on the ethnic origin of the patient.

CONCLUSION

In Belgium, we recommend phenotype or targeted genotype testing for DPD deficiency before starting 5-FU, capecitabine or tegafur. We strongly suggest a stepwise approach using phenotype testing upfront because of the higher sensitivity and the lower cost to society.

Long term response on Regorafenib in non-V600E BRAF mutated colon cancer: a case report

Background

^Non-V600E BRAF mutated colorectal cancer (CRC) is a rare disease entity with specific clinical features. These tumors are less likely to have microsatellite instability than CRC with a V600E BRAF mutation and often harbor a KRAS or NRAS mutation. Notably, median overall survival is longer than in wild-type BRAF CRC. Little is known about treatment possibilities in these patients.

Case presentation

We present the case of a 59 year old patient with a rare mutation in BRAF codon 594, who progressed rapidly on all classical therapies but experienced a clear and long lasting response on treatment with Regorafenib.

Conclusion

Little is known about therapies that can be effective in the rare ^non-V600E BRAF mutated CRCs. We present a patient who had a definite response to treatment with Regorafenib. There are no predictive markers that define a subset of CRC patients who benefit most from Regorafenib. The specific features of this ^non-V600E BRAF mutated CRC may be relevant in the exploration of predictive biomarkers for the efficacy of Regorafenib.

Percutaneous stenting in malignant biliary obstruction caused by metastatic disease: clinical outcome and prediction of survival according to tumor type and further therapeutic options

BACKGROUND AND STUDY AIMS

Obstructive jaundice caused by metastatic disease leads to deterioration of general condition and short survival time. Successful decompression can offer symptom control and enable further treatment with chemotherapy, which can improve survival.

PATIENTS AND METHODS

Ninety-nine percutaneous transhepatic cholangiography (PTC) procedures with metallic stent placement were performed in 93 patients between 2007 and 2013. Files were retrospectively studied and a review of patients' demographics, clinical and laboratory parameters, treatment and survival was performed. Kaplan-Meier survival analysis with log-rank test was done in function of bilirubin level, tumor type and treatment with chemotherapy.

RESULTS

Hyperbilirubinemia resolved in 73% of procedures. Median survival time after the procedure was 48 (95%CI 34.8 - 61.1) days. If additional chemotherapy was possible, a median survival of 170 (95%CI 88.5 - 251.4) days was noted versus 32 (95%CI 22.4 - 41.5) days without chemotherapy (p < 0.01). Survival rates greatly differed between primary tumor type, with the largest benefit of PTC in colorectal cancer. In 35 % of the procedures minor or more severe complications were noted. The 30-day mortality was 33%, with 3 procedure related deaths.

CONCLUSION

PTC with metallic stenting can bring symptom relief and enable further treatment with chemotherapy, which can lead to a longer survival time, especially in colorectal cancer. However, in patients in whom palliative stenting failed to resolve the hyperbilirubinemia survival is short.

High resolution mass spectrometry based profiling of diet-related deoxyribonucleic acid adducts

Exposure of DNA to endo- and exogenous DNA binding chemicals can result in the formation of DNA adducts and is believed to be the first step in chemically induced carcinogenesis. DNA adductomics is a relatively new field of research which studies the formation of known and unknown DNA adducts in DNA due to exposure to genotoxic chemicals. In this study, a new UHPLC-HRMS(/MS)-based DNA adduct detection method was developed and validated. Four targeted DNA adducts, which all have been linked to dietary genotoxicity, were included in the described method; O(6)-methylguanine (O(6)-MeG), O(6)-carboxymethylguanine (O(6)-CMG), pyrimidopurinone (M1G) and methylhydroxypropanoguanine (CroG). As a supplementary tool for DNA adductomics, a DNA adduct database, which currently contains 123 different diet-related DNA adducts, was constructed. By means of the newly developed method and database, all 4 targeted DNA adducts and 32 untargeted DNA adducts could be detected in different DNA samples. The obtained results clearly demonstrate the merit of the described method for both targeted and untargeted DNA adduct detection in vitro and in vivo, whilst the diet-related DNA adduct database can distinctly facilitate data interpretation.

Kinetics of butyrate metabolism in the normal colon and in ulcerative colitis: the effects of substrate concentration and carnitine on the β-oxidation pathway

BACKGROUND

Butyrate, a colonic metabolite of carbohydrates, is considered as the major energy source for the colonic mucosa. An impaired butyrate metabolism has been reported in ulcerative colitis (UC), however, the cause still remains unknown.

AIM

In the present study, we investigated whether higher butyrate concentrations could normalise the oxidation rate in UC. Furthermore, it was investigated whether carnitine could enhance the butyrate oxidation.

METHODS

Mucosal biopsies from a total of 26 UC patients and 25 controls were incubated with (14)C-labelled Na-butyrate and the produced (14)CO(2) was measured. First, the rate of oxidative metabolism was compared at three different concentrations of Na-butyrate (0.05 mm, 1 mm and 10 mm). Then, incubations of biopsies were performed with carnitine alone or combined with ATP.

RESULTS

Overall, butyrate oxidation in UC was significantly lower than that in controls. The maximum rate of butyrate oxidation was achieved in UC and control subjects from 1 mm onwards. Increasing the butyrate concentration to a level to be present in the colonic lumen, i.e. 10 mm, did not increase the rate of butyrate oxidation in UC to the rate observed in controls. Addition of carnitine alone or combined with ATP caused no effects.

CONCLUSIONS

Saturation of butyrate kinetics was achieved from 1 mm in UC and control subjects. The rate of butyrate metabolism was significantly impaired in active ulcerative colitis. The addition of compounds interfering with the β-oxidation pathway had no effect on the butyrate metabolism in UC.

EGFR-immunohistochemistry in colorectal cancer and non-small cell lung cancer: comparison of 3 commercially available EGFR-antibodies

BACKGROUND

Epidermal Growth Factor Receptor (EGFR)-targeted therapies are currently used for the treatment of metastasized colorectal cancer (CRC) and non small cell lung cancer (NSCLC). Patient selection for this treatment is based on immunohistochemical (IHC) testing for EGFR. The rising amount of commercially available EGFR-antibodies makes standardisation of EGFR-IHC necessary. The goal of this study was to analyse possible discrepancies between 3 antibodies against EGFR.

PATIENTS AND METHODS

36 formalin-fixed samples of CRC (n = 26) and NSCLC (n = 10) were stained with 3 antibody-clones: 2-18C9 (Dako); 31G7 (VentanaTM) and 111.6 (Labvision Neomarkers). Interpretation of stains includes assessment of % positive cells, evaluation of cut off values and staining intensity.

RESULTS

With a 1% cut-off, the 2-18C9 clone stained 86% of the cases positive, the 31G7-clone 77% and the 111.6-clone 52%. With a 10% cut-off, percentages declined to 77%, 61% and 30% respectively. The 2-18C9-clone showed the highest staining intensity. The 2-18C9 clone and the 31G7-clone showed a concordance rate of 90%.

CONCLUSIONS

IHC staining with 3 different antibody clones directed against EGFR shows indeed differences in staining results: the percentage of positive cells and staining intensity are variable. A correct cut-off value for a positive result is important and can be different depending upon the antibody. Appropriate validation of an antibody is essential before it can be used for selection of patients.

Evidence for the involvement of infectious agents in the pathogenesis of Crohn's disease

Many advances have been made in the understanding of Crohn's disease (CD) pathogenesis during the last decade. CD is currently seen as a predominantly T-lymphocyte-driven disease characterized by the presence of a complex cocktail of interacting cytokines, chemokines and other mediators produced by a variety of cell types. Prevailing theories of CD pathogenesis suggest that patients' T-lymphocytes are inappropriately activated in the setting of an immune imbalance, which is itself caused by an unfortunate confluence of genetic and environmental factors. The T-cell response then leads to the chronic inflammation characteristic for the disease. Various environmental factors may play a role in the development of CD, but microbes are most consistently implied. This theory is based on epidemiological, clinicopathological, genetic and experimental evidence. Despite the abundance of arguments for the implication of bacteria in the aetiopathogenesis of CD, the precise role of bacteria in this disease still remains elusive. Three not necessarily mutually exclusive theories have been proposed: (1) an unidentified persistent pathogen; (2) an abnormally permeable mucosal barrier leading to excessive bacterial translocation; and (3) a breakdown in the balance between putative "protective" versus "harmful" intestinal bacteria ("dysbiosis"). At present, one cannot exclude with certainty any of these three proposed hypotheses; they may all apply to CD to a certain extent.

The influence of inulin on the absorption of nitrogen and the production of metabolites of protein fermentation in the colon

In the present study, the production and fate of bacterial metabolites in the colon were investigated in a direct way using two substrates labelled with stable isotopes: lactose [15N,15N]ureide as a source of labelled ammonia and egg proteins intrinsically labelled with [2H4]tyrosine as a precursor of [2H4]p-cresol. Both ammonia and phenolic compounds are believed to be carcinogenic. Stimulation of carbohydrate fermentation in order to prevent accumulation of these toxic metabolites was induced by inclusion of inulin in a test meal or by addition of inulin to the daily diet, allowing us to distinguish between changes induced by the actual presence of a fermentable carbohydrate and effects caused by a long-term dietary intervention. When a single dose of inulin was administered together with the labelled substrates, a significant increase in faecal15N excretion, accompanied by a proportional decrease in urinary15N excretion was observed, probably reflecting an enhanced uptake of ammonia for bacterial biosynthesis, since an increased concentration of labelled N in bacterial pellets was found. A statistically significant reduction of urinary [2H4]p-cresol excretion was also noted. Upon supplementation of inulin to the daily diet during 4 weeks, however, only a tendency towards decreased urinary excretion of both labelled and unlabelledp-cresol was noted. Further studies are warranted to confirm these results in a larger cohort.

Pathology of early lower GI cancer

Early colorectal cancer can be treated with curative resection if the depth of invasion is limited to the submucosa (pathologic T category pT1 in the TNM classification). Macroscopically early colorectal cancer and its precursor lesions present as elevated polyps or non-polypoid flat lesions. Microscopically, precursor lesions are characterized by intraepithelial neoplasia and present as classic adenomas or serrated adenomas. Precursor lesions may already contain foci of early colorectal cancer. Early colorectal cancer can be treated by endoscopic resection. Careful handling of the specimen is required in order to optimally identify the factors that may predict an adverse outcome. Whenever a favourable tumour grade is found, without vascular invasion and tumour budding, there seems to be a low risk for adverse outcome and laparotomy may thus be avoided.

Validation of lactose[15N,15N]ureide as a tool to study colonic nitrogen metabolism

In vitro experiments have shown that fermentation of carbohydrates prevents accumulation of nitrogen in the colon. Variable results have been obtained on modulation of dietary intakes in vivo. Lactose[15N,15N]-labeled ureide has been proposed as a tool to study colonic nitrogen metabolism. However, on oral administration of the marker, different urinary excretion patterns of the 15N label have been found. In this study, 50 mg lactose[15N,15N]ureide was directly instilled in the colon through an orocecal tube to investigate the colonic handling of this molecule in a direct way. In basal conditions, 42% (range, 37-48%) of labeled nitrogen administered as lactose[15N,15N]ureide was retrieved in urine after 72 h. A substantial variability in total urinary excretion of the label was found, but the urinary excretion pattern of the label was similar in all volunteers. When inulin, a fermentable carbohydrate, was administered together with the labeled marker, a significant decrease in urinary excretion of 15N after 72 h was found, to 29% (range, 23-34%). The effect of a smaller dose of inulin (250 mg) on colonic handling of lactose[15N,15N]ureide (50 mg), was investigated in another group of volunteers, and this time, fecal excretion of the marker was also evaluated. The results seem to indicate that fermentation of inulin causes an increased fecal excretion of the marker, thereby reducing urinary excretion but not retention in the human nitrogen pool. This instillation study shows that lactose[15N,15N]ureide is a tool with good properties to investigate the effect of different types of carbohydrates on nitrogen metabolism in the proximal colon in vivo.

Crohn's-like changes in the colon due to mycophenolate?

OBJECTIVE

Mycophenolate mofetil (MMF) is used for prevention of allograft rejection in kidney transplant patients. A subset of patients suffers from chronic diarrhoea of unknown origin. The aim of the study was to investigate the effect of MMF on the colonic mucosa.

MATERIALS AND METHODS

Colonic mucosal biopsies from 24 kidney transplant patients receiving MMF and presenting with chronic diarrhoea were analysed using routine stainings and immunohistochemistry for Ki67 and E-cadherin. Results were compared with a control group of 19 kidney transplant patients not receiving MMF. In all patients routine clinical and laboratory investigations were performed in order to explain the diarrhoea.

RESULTS

In 11 patients, the diarrhoea seemed to be of infectious origin. Furthermore, 19/24 of MMF-patients showed characteristic histological alterations of the mucosa that were Crohn's disease-like: discontinuous crypt architectural distortion, increased epithelial mucin secretion, mildly active inflammation and focal presence of dilated and inflamed crypts. Ki67 staining was abnormal in 6/24 MMF patients but also in 4/19 control patients. E-Cadherin staining was normal in most MMF and control patients.

CONCLUSIONS

Diarrhoea following MMF treatment is frequently infectious in origin and associated with morphological changes with a Crohn's-like pattern in the colonic mucosa in a subset of patients. MMF does not induce major alteration in the proliferative compartment of colonic epithelium. The diarrhoea is not associated with altered E-cadherin expression in the colonic epithelium.

Validation of a new test meal for a protein digestion breath test in humans

Previously, overall protein assimilation after the ingestion of a pure protein meal was studied. In this study, the kinetics of protein assimilation in humans were investigated after the ingestion of a complex meal, which more closely represents a physiologically normal situation. Overall protein assimilation in humans after the ingestion of a pancake meal, containing 12 g of fat, 27 g of carbohydrate, and 19 g of protein, was evaluated in 26 normal volunteers. Both the egg white and yolk of L-[1-(13)C]-leucine-substituted eggs were used to make the batter. The labeled eggs were produced by feeding laying hens a standard chicken diet supplemented with 3 g/kg of L-[1-(13)C]-leucine (99%, mol:mol). High enrichment levels of protein with adequate labeling patterns were obtained in eggs from laying hens fed the L-[1-(13)C]-leucine-substituted diet. The isotopic enrichment of leucine at plateau was equal in egg white and yolk. The overall tracer recovery in egg proteins was 22.5%. The overall protein assimilation parameters in subjects that consumed the pancake meal did not differ from those obtained in subjects that consumed a single protein meal (mean cumulative (13)C recovery/6 h = 17.22 +/- 4.74%, with a maximal (13)C recovery/h of 5.65 +/- 1.48%, which was attained 145 +/- 25 min after ingestion of the meal). The pancake test meal prepared with eggs intrinsically labeled with L-[1-(13)C]-leucine is ideal for the study of protein assimilation. The incorporation of differently labeled substrates into a single test meal allows the assessment of different gastrointestinal processes in the overall assimilation of proteins.

Inulin is an ideal substrate for a hydrogen breath test to measure the orocaecal transit time

BACKGROUND

A better substrate is needed for a hydrogen breath test to measure the orocaecal transit time. The currently used substrate, lactulose, accelerates the orocaecal transit time by increasing the osmolality of the gut contents. The recently developed lactose 13C-ureide breath test is reliable, but a hydrogen breath test is preferred, as it allows the simultaneous investigation of the digestion and absorption of nutrients by means of 13C-labelled compounds.

METHODS

The usefulness of different types of inulin as a substrate for a hydrogen breath test was studied. Raftilin HP (>99% inulin with a degree of polymerization of between 5 and 60 and <0.5% glucose, fructose and sucrose) was further evaluated and compared with lactulose with regard to its effects on gastric emptying and the digestion of protein and lipids.

RESULTS

A good correlation was found between the orocaecal transit times using Raftilin HP (338 min; interquartile range, 300-383 min) and lactose 13C-ureide (353 min; interquartile range, 285-375 min) (r=0.85; P<0.001). The administration of 5 or 10 g Raftilin HP had no influence on the orocaecal transit time, whereas lactulose significantly shortened the orocaecal transit time. Neither inulin nor lactulose had a significant influence on gastric emptying or protein or lipid assimilation.

CONCLUSION

Raftilin HP is an ideal substrate for a hydrogen breath test to measure the orocaecal transit time.

Magnesium chloride slows gastric emptying, but does not affect digestive functions

BACKGROUND

An inverse relationship has been established between serum magnesium and serum lipid levels. By means of breath tests, we tested the hypothesis that magnesium inhibits intraluminal lipid digestion and subsequently causes changes in lipid metabolism. We also investigated the influence of the administration of magnesium chloride on protein digestion and gastric emptying.

METHODS

Five healthy volunteers performed simultaneous breath tests for gastric emptying and intraluminal lipid digestion, and six others for gastric emptying and protein digestion. Each test was performed in basal conditions and after the intake of 800 mg of magnesium chloride dissolved in water. Breath samples were taken at regular time intervals and analysed for 13CO2 and 14CO2 enrichment in order to calculate gastric emptying and lipid and protein digestion rates.

RESULTS

The oral administration of a single dose of magnesium chloride resulted in a diminished rate of intraluminal lipid and protein digestion. The most pronounced effect of magnesium chloride, however, was a decreased gastric emptying rate of both test meals. After correction for gastric emptying, no differences were noted in intraluminal lipid or protein digestion. Therefore, the lower lipid levels noted after magnesium supplementation are unlikely to be the result of altered lipid assimilation.

CONCLUSION

Magnesium chloride slows gastric emptying but does not influence lipid digestion.

Vascular anatomy of the gastrointestinal tract

The blood supply of the gastrointestinal system has intramural and extramural components. The intramural vascular distribution is generally well developed with plexuses in the different layers of the bowel wall and with specializations in the liver, small intestine and gastroesophageal junction, adapted to the function of these organs. The extramural arterial supply for the oesophagus is derived from the thoracic aorta or its major branches. Blood supply to the abdominal organs is provided by three major unpaired vessels arising from the abdominal aorta, namely the coeliac trunk and the superior and inferior mesenteric arteries. The branches of these vessels form anastomotic systems that provide a rich blood supply to the adjoining organs. In many areas the systems overlap while in other regions linkages are limited. Interrelations and weak points are of significant clinical importance. As well as this, there is a great individual variability in the anatomy of the gastrointestinal vasculature.

Contribution of morphology for the comprehension of mechanisms of fibrosis in inflammatory enterocolitis

Strictures are a common complication of Crohn's disease and an indication for surgery in approximately 50% of patients. Morphologic studies have shown that fibrosis of the submucosa and muscularis propria are common in Crohn's disease, especially in strictures. Immunohistochemical and in situ hybridization studies have demonstrated a marked increase of various subtypes of collagens in Crohn's disease. Collagens type I and III are present in ulcerated areas where they appear around capillaries and in a linear deposition at the junction between the granulation tissue and the necrotic debris. Collagens type IV and V show a prominent perivascular expression, increased deposition in the muscularis propria and increased expression around ganglia. Initiation and maintenance of the connective tissue changes are related with the inflammatory infiltrate. Inflammatory cells can further alter smooth muscle proliferation and migration and promote the formation of myofibroblasts. These alterations together with increased collagen deposition are involved in the complex process of strictures and bowel wall alterations in Crohn's disease.

13C-egg white breath test: a non-invasive test of pancreatic trypsin activity in the small intestine

BACKGROUND

The recent availability of egg white protein highly enriched with (13)C has allowed breath test technology to be adapted for the study of protein digestion and absorption. Pancreatic trypsin is considered to be the key enzyme in the proteolytic cascade.

AIM

To evaluate trypsin activity in the small intestine of healthy volunteers and patients with pancreatic disease by a recently developed (13)C-egg white breath test.

METHODS

A total of 48 healthy volunteers and 30 patients with pancreatic disease were studied after ingestion of a test meal consisting of 22 g (13)C-labelled egg protein. Breath samples were taken before and after ingestion of the meal and analysed for (13)CO(2) concentration. Moreover, pancreatic trypsin output after maximal stimulation was measured in 13 patients and nine healthy volunteers.

RESULTS

The six hour cumulative (13)CO(2) excretion in breath was significantly lower in patients than controls (mean (SEM): 6.23 (0.82)% v 19.16 (0. 58)%, p<0.0001). An excellent correlation was found between the six hour cumulative (13)CO(2) excretion and trypsin activity after maximal pancreatic stimulation.

CONCLUSION

The non-invasive (13)C-egg white breath test is promising as an indirect pancreatic proteolytic function test.

Effects of 'contact laxatives' on intestinal and colonic epithelial cell proliferation

Experimental studies indicate that laxatives may induce epithelial damage. In addition, some laxatives induce the release of prostaglandins. Epithelial cell damage and release of prostaglandins are two pathways by which epithelial cell proliferation could be influenced. Furthermore, fermentable laxatives like lactulose may influence large intestine cell proliferation by the trophic effect of the fermentation products such as short-chain fatty acids. For these reasons an in vivo study in rats was performed to compare the short- and long-term effect of sennosides, bisacodyl, sodium picosulfate and lactulose on epithelial cell proliferation in the ileum and large intestine. Cell proliferation was examined by the BrdUrd labelling technique after 2, 6 and 12 weeks of continuous treatment. Studies in control animals show that the Labeling Index (LI) is higher in the cecum compared with other segments of the colon, and higher in the ileum than in the colon. Treatment with sennosides, bisacodyl and sodium picosulfate does not influence the LI in the ileum and induces no statistically significant increase of the LI when the treated groups are compared with the control group. The proliferative pattern along the crypts remains unchanged with all the laxatives throughout the study. It appears therefore that 'contact' laxatives have no major influence on ileal and colonic epithelial cell proliferation and should not be regarded as tumor-promoting substances.