Endoscopy is an established method for diagnosing gastrointestinal tract diseases, however, suspected subepithelial lesions usually cannot be appropriately evaluated by this technique alone. The ...prevalence of suspected submucosal gastric lesions at routine endoscopy has been estimated to 0.5%-1%. In this review, we evaluated the role of endoscopic ultrasonography (EUS) in the diagnosis of and management strategy for submucosal lesions. EUS has emerged as the most reliable investigative procedure of choice for evaluating submucosal tumors. EUS is the method of choice to differentiate between true intramural tumors and lesions caused by extraluminal compressions due to normal or pathologic structures. It can determine the originating layer(s) of intramural lesions; can differentiate echogenicity (anechoic, hypoechoic, hyperechoic, isoechoic), vascularity, size, shape, and border characteristics. Some endoscopic findings (color, consistency, mobility, 'pillow sign') can be helpful in narrowing the differential diagnosis. On the other hand, determination of the histologic layer and the internal echo patterns of some submucosal tumors are also predictive of benign or malignant tumors. EUS can provide an accurate diagnosis in 80% of patients with benign lesions and 64% of those with malignant lesions. Hypoechoic lesions in the 3rd and 4th layer are most prone to misclassification. If these cannot be differentiated exactly, EUS can serve as a guide on fine needle aspiration (FNA) biopsy or histologic core biopsies, providing samples for cytologic or histologic analysis. After that, the endoscopist can decide whether the lesion should be periodically followed up, or removed by endoscopy, endoscopic submucosal resection (EMR) or surgery.
Endoscopic retrograde cholangiopancreatography (ERCP) has been considered a gold standard in the diagnosis of choledocholithiasis; however, the incidence of complications is high. In literature ...reports, the morbidity rate ranges from 5% to 19% and mortality rate from 0.1% to 1.3%, therefore an effective but less invasive new method of diagnosing choledocholithiasis is required. In a number of trials, endoscopic ultrasonography (EUS) has been shown to be a less invasive method with excellent sensitivity of 94% and specificity of 95%. The aim of this study was to estimate the sensitivity and specificity of EUS in patients with suspected choledocholithiasis and to establish its role in the algorithm for diagnosing choledocholithiasis.
Patient files were retrospectively reviewed in 209 patients with a clinical picture and ultrasonography findings suggestive of choledocholithiasis, admitted to Sestre milosrdnice University Hospital during a six-month period (Sep 1, 2007 - Feb 29, 2008) and submitted to ERCP within 72 hours of admission.
In 125 patients with abdominal ultrasonography findings suggestive of choledocholithiasis (biliary obstruction without clear evidence of calculi), EUS was performed before ERCR. Choledocholithiasis or biliary sludge was identified in 66 (62.3%) patients, 29 (27.3%) patients were free from biliary abnormalities, and 11 (10.4%) patients had stenosis of different etiology. In 64 of 66 (96.9%) patients, the diagnosis was confirmed by ERCP. Another two (3.1%) patients had no evidence of choledocholithiasis on ERCP. There were no complications related to EUS.
EUS is an effective method for diagnosing choledocholithiasis with a sensitivity and specificity comparable to ERCP. Therefore, it is reasonable to use EUS as the first method of choice in patients with suspected choledocholithiasis.
The present study was designated to analyze correlation between the presence and extent of peritumoral retraction clefting and various clinicopathologic features in esophageal squamous cell carcinoma ...(ESCC), and to possibly establish the significance of this phenomenon in ESCC. Fifty-four consecutive patients with advanced ESCC were included in the study. The presence of peritumoral retraction clefting was classified on the basis of the proportion of tumor nests exhibiting this phenomenon. Tumors with clefts that affected up to 25% of tumor nests were classified as group I; with clefts that affected >25% to 50% of tumor nests as group II; with clefts that affected >50% to 75% of tumor nests as group III; and tumors with clefts that affected more than 75% of tumor nests were classified as group IV. Statistical analysis showed a correlation between presence and extent of peritumoral clefting and lymph node metastasis. T3 tumors and tumors with lymph node metastasis had significantly more pronounced peritumoral clefting compared with T2 tumors and tumors without lymph node metastasis. The presence of peritumoral clefting was not associated with the number of affected lymph nodes. There was no correlation between the presence and extent of peritumoral clefting with patient age and sex, and tumor location, diameter and grade. The association of peritumoral retraction clefting in ESCC with local invasiveness and lymph node metastasis indicated that peritumoral clefting could be a simple and useful morphological feature of tumor aggressiveness and may contribute to the pathological and clinical assessment of patients with ESCC.
Pancreatic cancer has a dismal prognosis and complete surgical removal remains the only potential curative treatment. The principle goal of preoperative evaluation is to identify patients with ...potentially resectable disease while avoiding surgical exploration in those with unresectable disease. There is no evidence-based consensus on the optimal preoperative imaging assessment of patients with suspected pancreatic cancer. Because of its widespread availability, computed tomography (CT) is usually the initial study for this indication, although endoscopic ultrasonography (EUS) is the most sensitive imaging modality for the detection of pancreatic masses. Due to anatomical limitations, CT and magnetic resonance (MR) are superior to EUS for detection of metastatic disease. EUS is superior to CT and angiography for detection of tumor invasion of the portal vein or confluence. Most studies found no significant differences between EUS, CT and MRI in determination of pancreatic cancer resectability. The optimal place of EUS within the diagnostic algorithm remains dependent on local referral modalities and availability.
The morphological spectrum of gallbladder carcinoma is broad and variable. Most of these tumors are tubular adenocarcinomas. There are some tumors with unusual morphology that may be difficult to ...classify due to their rarity. One of such tumors is the signet-ring cell carcinoma, which is a highly aggressive, mucin producing variant of gallbladder adenocarcinoma predominantly or exclusively composed of signet-ring cells. Histologically, these tumors are similar to their counterparts in other organs such as stomach, colon and breast, and should not be misinterpreted as metastatic carcinoma from one of these primary sites. The literature about this variant of carcinoma is sparse and little is known about it. We found only three cases of signet-ring cell carcinoma of the gallbladder previously reported. We present the case of an 86-year-old woman with signet-ring cell carcinoma of the gallbladder and discuss the potential diagnostic dilemmas
Gastric cancer is related to high mortality rates and advanced disease stage at the time of diagnosis. Its carcinogenesis is extensively studied and is associated with genetic and epigenetic changes, ...changed the interaction between tumor and adjacent stromal cells, and changes in the microenvironment molecule status. Neural precursor cell-expressed developmentally down-regulated 9 (NEDD9) affects different signaling proteins and pathways, apoptosis, adhesion, cell migration, and invasiveness. Connexin-43 (Cx43) also assists in intercellular communications and has several channel-independent functions. Aberrant expression of those two gap junction proteins plays an essential role in metastatic processes. Our scope was to detect the expression of Cx43 and NEDD9 in epithelial and stromal gastric cancer compartments and its relation to tumor progression and lymph node metastases. Cancer tissue from 53 cases of node-negative and 55 cases of node-positive primary gastric carcinoma patients was analyzed for Cx43 and NEDD9 expression by immunohistochemical assay, and the results were correlated with the remaining clinical and pathological findings and survival. In our cohort of patients with lymph node metastases, we detected higher expression of epithelial Cx43 in the primary tumor and stromal Cx43 expression correlated with both epithelial NEDD9 (rho = 0.453) and stromal NEDD9 (rho = 0.484). Higher epithelial Cx43 and NEDD9 expression were associated with higher mortality (HR 1.54, 95% CI 1.01-2.37, p = 0.048). Epithelial Cx43 expression, both epithelial and stromal NEDD9 expression, T and N status were all independently associated with shorter survival. In summary, our findings suggest that increased expression of both epithelial and stromal NEDD9 and epithelial Cx43 could potentially be used as prognostic gastric cancer biomarkers.
Chronic intestinal pseudo-obstruction (CIPO) is a rare syndrome characterized by signs of intestinal obstruction lasting for 6 months or more, in the absence of a definitive cause of obstruction. We ...report a case of CIPO in a 49-year-old female patient with a 6-month history of ongoing irregular bowel movements, manifested as constipation and diarrhea accompanied by abdominal pain and bloated feeling. Contrast-enhanced abdominal computed tomography and magnetic resonance enterography revealed focal thickening of a segment of the lienal flexure and intermittent areas of wider and narrower caliber along the sigmoid colon. No signs of a definitive cause of obstruction were found, but evidence for dolichosigma was revealed, which was later confirmed with colonoscopy. Due to persisting symptoms, the patient agreed to elective resection of the sigmoid colon. Following the procedure, symptoms regressed with a significant improvement in the quality of life. The patient has been regularly monitored in an outpatient setting and reports absence of the symptoms since the procedure. Pathophysiology of the resected section revealed more prominent lymphatic tissue, follicular arrangement, and reactively altered germinal centers, which can suggest CIPO.
Summarized text of Croatian Consensus Conference on Viral Hepatitis of 2009 comprises the following chapters: 1) Epidemiology, 2) Clinical Picture, 3) Diagnostic Procedure, 4) Aims of Treatment of ...Viral Hepatitis, 5) Terminology, 6) Medicaments (6.1. Interferon, 6.2. Analogues of Nucleozides and Nucleotides), 7) Hepatitis B (7.1. Serologic and Molecular HBV Diagnostics, 7.2. Terminology, 7.3.Whom to Treat? 7.4. Therapy), 8) Hepatitis C (8.1. Serologic and Molecular HCV Diagnostics, 8.2. Terminology, 8.3. Whom to Treat? 8.4. Therapy). Clinical, laboratory and histologic assessment of patients with chronic viral hepatitis (algorythm of pretherapeutic treatment; histologic evaluation) and notions related to therapy of viral hepatitis (category of the patient and category of the response to treatment) are presented in related tables.
Apocrine carcinomas represent a rare group of tumors with a potential for destructive local invasion, regional and distant metastases, and are equally common in both sexes. A case of a 79-year-old ...woman with axillary apocrine carcinoma associated with apocrine adenoma and apocrine gland hyperplasia is presented. To our knowledge, this is the first case diagnosed in a Caucasian and also the first case diagnosed in a female patient. Grossly, the tumor measured 3.2x1.5x1.2 cm and on cut section appeared granular, white to gray-tanned. Microscopically, the tumor was located in the dermis, poorly demarcated, focally necrotic with ulcerated overlying skin. It was predominantly composed of complex, closely packed tubuloglandular structures but in few areas papillary structures were also observed. The cells contained abundant eosinophilic, finely granular cytoplasm with pleomorphic nuclei and showed apocrine-like decapitation. The cytoplasm contained periodic acid Schiff diastase resistant granules. Mitoses were frequent and some were atypical. In one area, the tumor was lobular and composed of tubular structures lined with one layer of uniform cuboidal or columnar eosinophilic cells, indicating a pre-existing apocrine adenoma. Beneath the tumor, in the deep dermis and subcutaneous tissue, hyperplastic apocrine glands were also found. No additional therapy was used, and one year after the surgery the patient was alive and showed no signs of tumor spread. This and previously reported cases suggest that apocrine hyperplasia and apocrine adenoma may represent successive steps in the development of apocrine carcinoma.
The aim of the study was to evaluate the efficacy of combination therapy with interferon-alpha (IFN-alpha) and ribavirin in patients with chronic hepatitis C and normal alanine aminotransferase (ALT) ...values. In this retrospective study, 12 HCV-RNA positive patients (7 males and 5 females, mean age 38.1 years), treated between 1998 and 2001, with normal or near normal ALT values on three consecutive occasions and histologically mild disease were identified. During the induction period of four weeks they received 56 MU IFN-alpha 2b and ribavirin 1000 mg daily. During the next 44 weeks they received 3 MU IFN-alpha 2b three times a week with ribavirin 1000 mg daily. Seven out of 12 (58%) patients were HCV-RNA negative at the end of the therapy (end-of-treatment-response) and 5 of 12 (42%) showed sustained virologic response at 6 months. No significant elevation of aminotransferase values was recorded during therapy. Patients with mild chronic hepatitis C and normal ALT levels respond well to combination therapy with interferon and ribavirin, similar to those with elevated ALT levels. As long as the natural history and long-term outcome of these patients are not completely known, this might be a beneficial treatment option.
PDF
