Intraductal papillary neoplasm of the bile duct: A biliary equivalent to intraductal papillary mucinous neoplasm of the pancreas?

Intraductal papillary neoplasm of the bile duct (IPNB) is a variant of bile duct carcinoma characterized by intraductal growth and better outcome compared with the more common nodular-sclerosing type. IPNB is a recognized precursor of invasive carcinoma, but its pathogenesis and natural history are ill-defined. This study examines the clinicopathologic features and outcomes of IPNB. A consecutive cohort of patients with bile duct cancer (hilar, intrahepatic, or distal) was reviewed, and those with papillary histologic features identified. Histopathologic findings and immunohistochemical staining for tumor markers and for cytokeratin and mucin proteins were used to classify IPNB into subtypes. Survival data were analyzed and correlated with clinical and pathologic parameters. Thirty-nine IPNBs were identified in hilar (23/144), intrahepatic (4/86), and distal (12/113) bile duct specimens between 1991 and 2010. Histopathologic examination revealed 27 pancreatobiliary, four gastric, two intestinal, and six oncocytic subtypes; results of cytokeratin and mucin staining were similar to those of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Invasive carcinoma was seen in 29/39 (74%) IPNBs. Overall median survival was 62 months and was not different between IPNB locations or subtypes. Factors associated with a worse median survival included presence and depth of tumor invasion, margin-positive resection, and expression of MUC1 and CEA. Conclusion: IPNBs are an uncommon variant of bile duct cancer, representing approximately 10% of all resectable cases. They occur throughout the biliary tract, share some histologic and clinical features with IPMNs of the pancreas, and may represent a carcinogenesis pathway different from that of conventional bile duct carcinomas arising from flat dysplasia. Given their significant risk of harboring invasive carcinoma, they should be treated with complete resection. (HEPATOLOGY 2012).     

Can the location of the mural nodule indicate benign or malignant in branch duct-type intraductal papillary mucinous neoplasm of the pancreas?

Background/ObjectivesIntraductal papillary mucinous neoplasms (IPMNs) are classified into main duct (MD)-type IPMNs, branch duct (BD)-type IPMNs, and mixed type IPMNs. While MD-type IPMN has a high risk of malignancy and should therefore be considered for resection if the patient is fit, BD-type IPMN needs to be carefully judged for surgical indication. The decision to resect BD-type IPMN is often based on international consensus Fukuoka guidelines 2017, but further investigation is required. In this study, we focused on whether the location of the mural nodule (MN) could be an indicator of malignancy.MethodsWe enrolled 17 cases who had been diagnosed BD-type IPMNs which were surgically resected from January 2016 to December 2019. These cases were classified into benign and malignant group. Subsequently, a clinicopathological study was conducted based on the localization of MN (MN-central type or MN-peripheral type).ResultsAlthough MN was found in 57% (4/11) in the benign group, 88% (7/8) was noted in the malignant group, indicating the presence of MN to be more common in the malignant group. Those with MN consisted of 6 cases of MN-central type and 5 cases of MN-peripheral type. All cases of central type were malignant compared to only one case of the peripheral group being confirmed on histology as cancer.ConclusionBD-IPMN with central mural nodule should be considered high risk for malignancy.     

Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate?

BACKGROUND: Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas are reported to be less aggressive than the main-duct type. Hence, less aggressive treatment has been proposed for the former. AIM: To evaluate the effectiveness of a follow-up protocol for BD-IPMNs. DESIGN: Prospective study. SETTING: An academic tertiary referral centre. PATIENTS: From 2000 to 2003, 109 patients with BD-IPMNs underwent trans-abdominal ultrasound and magnetic resonance cholangiopancreatography with secretin. Patients who presented malignancy-related parameters (size >3.5 cm, nodules, thick walls, carbohydrate antigen 19.9 level >25 U/l, recent-onset or worsened diabetes) and/or complained of symptoms were submitted to surgery (arm A). All asymptomatic patients without suspicion of malignancy were followed up according to a 6-month clinical-radiological protocol (arm B). MAIN OUTCOME MEASURES: The effectiveness of conservative management of BD-IPMNs. RESULTS: 20 (18.3%) patients underwent surgery (arm A); pathological diagnosis of BD-IPMNs was always confirmed. 89 (81.7%) patients were followed up for a median of 32 months (arm B); of these, 57 (64%) patients had multifocal disease. After a mean follow-up of 18.2 months, 5 (5.6%) patients showed an increase in lesion size and underwent surgery. The pathological diagnosis was branch-duct adenoma in three patients and borderline adenoma in two. CONCLUSIONS: Surgery is indicated in <20% of cases of BD-IPMNs, and, in the absence of malignancy-related parameters, careful non-operative management seems to be safe and effective in asymptomatic patients. Although observation for a longer time is needed to confirm these results, our findings support the guidelines recently recommended by the International Association of Pancreatology.     

Intraductal papillary mucinous neoplasms of the pancreas: is the puzzle solved?

Intraductal papillary mucinous neoplasms (IPMN) are drawing more attention and being detected more frequently. This review focuses on current understanding of the management of IPMN, regarding morphological classification, subclassification by cell lineage features, molecular abnormalities, radiological and imaging evaluation, progression to cancer, incidence and risk factors for malignancy, risk of distinct pancreatic adenocarcinoma and extrapancreatic malignancies, treatment strategy, and types of surgical resection. In particular, missing links in solving the IPMN puzzles are described with regard to differential diagnosis, role of cyst fluid analysis, multifocal IPMN, histological evaluation of the surgical specimen, observation without resection, follow up of patients after resection, role of adjuvant therapy for invasive carcinoma, screening for other neoplasms in patients with IPMN on follow up, prognostic factors influencing long-term outcomes, and role of endoscopic therapy.     

Does serum procalcitonin aid in the diagnosis of bloodstream infection regardless of whether patients exhibit the systemic inflammatory response syndrome?

Background

Physicians frequently rely on the systemic inflammatory response syndrome (SIRS) criteria to detect bloodstream infections (BSIs). We evaluated the diagnostic performance of procalcitonin (PCT) in detecting BSI in patients with and without SIRS.

Methods

We tested the association between BSI, serum PCT levels, contemporaneous SIRS scores and serum lactate using logistic regression in a dataset of 4279 patients. The diagnostic performance of these variables was assessed.

Results

In multivariate regression analysis, only log(PCT) was independently associated with BSI (p < 0.05). The mean area under the curve (AUC) of PCT in detecting BSI (0.683; 95% CI 0.65–0.71) was significantly higher than serum lactate (0.615; 95% CI 0.58–0.64) and the SIRS score (0.562; 95% CI 0.53–0.58). The AUC of PCT did not differ significantly by SIRS status. PCT of less than 0.1 ng/mL had a negative predictive value (NPV) of 97.4 and NPV of 96.2% for BSI in the SIRS-negative and SIRS-positive patients, respectively. A PCT of greater than 10 ng/mL had a LR of 6.22 for BSI in SIRS-negative patients. The probability of BSI increased exponentially with rising PCT levels regardless of SIRS status.

Conclusion

The performance of PCT for the diagnosis of BSI was not affected by SIRS status. Only PCT was independently associated with BSI, while the SIRS criterion and serum lactate were not. A low PCT value may be used to identify patients at a low risk for having BSI in both settings. An elevated PCT value even in a SIRS negative patient should prompt a careful search for BSI.

     

Can non-invasive measurements aid clinical assessment of volume in patients with cirrhosis?

AIM:To evaluate the non-invasive assessments of volume status in patients with cirrhosis.METHODS:Echocardiography and multifrequency bioimpedance analysis measurements and short synacthen tests were made in 20 stable and 25 acutely decompensated patients with cirrhosis.RESULTS:Both groups had similar clinical assessments,cortisol response and total body water(TBW),however the ratio of extracellular water(ECW)/TBW was significantly greater in the trunk(0.420±0.004 vs0.404±0.005),and limbs(R leg 0.41±0.003 vs 0.398±0.003,P<0.05,and L leg 0.412±0.003 vs 0.399±0.003)with decompensated cirrhosis compared to stable cirrhotics,P<0.05).Echocardiogram derived right atrial and ventricular filling and end diastolic pressures and presence of increased left ventricular end diastolic volume and diastolic dysfunction were similar in both groups.The decompensated group had lower systemic blood pressure,mean systolic 101.8±4.3 vs122.4±5.3 and diastolic 58.4±4.1 mmHg vs 68.8±3.1 mmHg respectively,P<0.01,and serum albumin30(27-33)vs 32(31-40.5)g/L,P<0.01.CONCLUSION:Decompensated cirrhotics had greater leg and truncal ECW expansion with lower serum albumin levels consistent with intravascular volume depletion and increased vascular permeability.     

Is the pancreas affected in patients with septic shock?——a prospective study

BACKGROUND:Hyperamylasemia can be observed anecdotally during the course of severe sepsis or septic shock.This study aimed to investigate the possibility of pancreatic involvement in patients with septic shock using serum pancreatic enzyme determinations and imaging techniques in 21 consecutive patients with septic shock and 21 healthy subjects as controls. METHODS:The serum activity of pancreatic amylase and lipase was assayed initially in all subjects and 24 and 48 hours after the initial observation in t...     

Age of patients with papillary thyroid carcinoma: is it a key factor in the development of variants?

BACKGROUND: Although the majority of papillary thyroid carcinomas (PTC) have an excellent prognosis, certain aggressive variants do occur. The tall cell variant (TCV) of PTC, which tends to occur in elderly patients, is the most common among the aggressive variants and the most aggressive of all variants. OBJECTIVE: To compare the age of patients with major variants of PTC and correlate age with certain cytomorphological features of diagnostic importance. METHODS: 53 PTC cases with available information on age and diagnosed by fine needle aspiration cytology were categorized into various variants following a review of smears. There were 6 TCV (>or=30% tall cells) cases, 8 cases with a significant tall cell component (sig. TCC; 10-29% tall cells), 16 usual variants (UV), 17 follicular variants (FV), and 6 miscellaneous variants. These groups were compared with respect to age (mean+/-SD, median). Further, the age of all patients with PTC was correlated with cytological features such as tall cell count and count of cells with reddish cytoplasm, intranuclear cytoplasmic inclusion, and nuclear grooves. RESULTS: The median age of patients with TCV, PTC with a sig. TCC, UV, FV and miscellaneous variants was 47.5, 44.5, 31.5, 34.0 and 42.0 years, respectively. The age of PTC (TCV) cases (52.0+/-17.84 years) and of those with a sig. TCC (45.9+/-12.12 years) was significantly higher than the age of PTC (FV) cases (34.2+/-8.21 years) (p=0.004 and 0.027, respectively). The combined age of PTC (TCV) and PTC (sig. TCC) cases (48.5+/-14.54 years) was significantly higher than the age of PTC (UV) cases (p=0.038) as well as of PTC (FV) cases (p=0.005). Six (42.9%) of the patients with PTC (TCV and sig. TCC) were >or=50 years of age as opposed to 3 (9.1%) of PTC (UV and FV) cases (p=0.0134). The age of patients with PTC in general showed a significant correlation with tall cell count (p<0.01). CONCLUSION: The age of the patients with PTC seems to play a role in the morphological manifestations of the neoplasm, which is related to the prognostic outcome.     

Is analysis of the reticulocyte haemoglobin equivalent a useful test for the diagnosis of iron deficiency anaemia in geriatric patients?

BackgroundIron deficiency anaemia (IDA) and anaemia of chronic disease (ACD) are common in elderly patients but there are no standard diagnostic criteria. The reticulocyte haemoglobin equivalent (Ret-He) is routinely measured by modern automated blood analysers and is an early indicator of iron deficiency. The aim of this study was to investigate whether the Ret-He level as calculated by the Sysmex XE-5000 automated blood analyser is a useful parameter for the diagnosis of IDA in a geriatric hospitalized population.MethodsIn a prospective study, blood samples were collected in 26 geriatric patients with IDA and 111 patients with ACD diagnosed according to generally accepted laboratory and clinical criteria. A blood count including Ret-He, mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and standard iron parameters was performed in each patient.ResultsHaemoglobin, Ret-He, MCV, MCH and MCHC levels were all significantly lower in IDA as compared to ACD patients. However, the area under the curve (AUC) was greater for MCH (0.87, 95% CI 0.78–0.95) and MCHC (0.86, 95% CI 0.76–0.96) then for Ret-He (0.828, 95% CI 0.73–0.93) and MCV (0.80, 95% CI 0.68–0.91). A Ret-He cut-off value of 26 pg had a sensitivity and specificity based on its optimal combination of 85% and 69% respectively.ConclusionAnalysis of Ret-He does not perform better than the classical red cell indices such as MCH and MCHC in differentiating IDA and ACD in geriatric patients.     

Should patients with locally advanced,non-metastatic carcinoma of the pancreas be irradiated?

A small number of patients exist with carcinoma of the pancreas with an inoperable but not metastasized tumor. Prospective randomized studies defined the standard of combined radiochemotherapy during the early 1980s for these patients. Since then, new drugs have shown considerable activity and in parallel improvements in radiotherapy treatment planning and delivery have been achieved. Therefore, it is time to ask whether patients with locally advanced, inoperable pancreatic cancer without metastases should still be irradiated or not. This review summarizes the current literature on combined radiochemotherapy for locally advanced carcinoma of the pancreas. Median survival times of 10–11 months and 1-year survival rates of about 40% can be achieved with modern radiochemotherapy regimens.     

How to predict the outcome of endoscopic mechanical lithotripsy in patients with difficult bile duct stones?

OBJECTIVE: Endoscopic mechanical lithotripsy is frequently used to overcome the difficulties of removing large bile duct stones endoscopically. The aim of this study was to identify predictors of endoscopic mechanical lithotripsy failure. MATERIAL AND METHODS: One hundred and thirty-four patients who underwent mechanical lithotripsy for difficult choledocholithiasis were evaluated retrospectively. Predictive factors of outcome and procedure-related complications were analyzed. The clinical outcomes of subsequent management were also evaluated in cases of unsuccessful endoscopic mechanical lithotripsy. RESULTS: Endoscopic mechanical lithotripsy was successful in 102 patients (76.1%). Stone impaction, size (>or=30 mm), and the stone size to bile duct diameter ratio (>1.0) were significant predictors of endoscopic mechanical lithotripsy failure, with estimated odds ratios of 17.83, 4.32 and 5.47, respectively. There was no difference in complication rates between the successful and failed mechanical lithotripsy groups. When mechanical lithotripsy failed, all patients were successfully treated using various modalities, including surgery, without mortality. CONCLUSIONS: An impacted stone, stone size (>or=30 mm) and stone size to bile duct diameter ratio (>1.0) were predictors of failure of endoscopic mechanical lithotripsy for a difficult bile duct stone. Alternative approaches should be considered in patients with predictors of unsuccessful endoscopic mechanical lithotripsy in order to avoid wasting time and resources.     

How to predict the outcome of endoscopic mechanical lithotripsy in patients with difficult bile duct stones?

Objective. Endoscopic mechanical lithotripsy is frequently used to overcome the difficulties of removing large bile duct stones endoscopically. The aim of this study was to identify predictors of endoscopic mechanical lithotripsy failure. Material and methods. One hundred and thirty-four patients who underwent mechanical lithotripsy for difficult choledocholithiasis were evaluated retrospectively. Predictive factors of outcome and procedure-related complications were analyzed. The clinical outcomes of subsequent management were also evaluated in cases of unsuccessful endoscopic mechanical lithotripsy. Results. Endoscopic mechanical lithotripsy was successful in 102 patients (76.1%). Stone impaction, size (≥30 mm), and the stone size to bile duct diameter ratio (>1.0) were significant predictors of endoscopic mechanical lithotripsy failure, with estimated odds ratios of 17.83, 4.32 and 5.47, respectively. There was no difference in complication rates between the successful and failed mechanical lithotripsy groups. When mechanical lithotripsy failed, all patients were successfully treated using various modalities, including surgery, without mortality. Conclusions. An impacted stone, stone size (≥30 mm) and stone size to bile duct diameter ratio (>1.0) were predictors of failure of endoscopic mechanical lithotripsy for a difficult bile duct stone. Alternative approaches should be considered in patients with predictors of unsuccessful endoscopic mechanical lithotripsy in order to avoid wasting time and resources.