Emanuele Meroni

Results of EUS in detecting perirectal lymph node metastases of rectal cancer: the pathologist makes the difference ☆ ☆☆

BACKGROUND Accurate preoperative staging of primary rectal cancer is mandatory because the result may affect therapeutic decisions. Endoscopic ultrasonography (EUS) is considered the most accurate method for locoregional staging, but the issue of possible variations in the assessment of its accuracy related to technical aspects of pathologic staging has never been raised. The aim of this study was to assess EUS results as determined by two different methods of dissection of surgical specimens. METHODS Among all cases with primary rectal cancer staged with EUS from April 1991 to April 1997, 131 patients underwent surgery without preoperative radiotherapy; EUS results for nodal staging were compared with those obtained by pathology. Resected specimens were examined using two different techniques (conventional vs. special dissection). RESULTS There was a significant decrease in diagnostic accuracy of EUS according to pathologic technique. Overall accuracy, sensitivity, specificity, positive and negative predictive values for conventional versus special dissection were as follows: 74.6% vs. 43. 3% (p = 0.0001), 67.8% vs. 21.8% (p = 0.0002), 79.1% vs. 67.8% (p = 0.14), 67.8% vs. 43.7% ( p = 0.02), and 79.1% vs. 43.2% (p = 0.0003), respectively. EUS sensitivity according to size of metastatic lymph nodes was significantly lower for nodes smaller than 5 mm in diameter (p = 0.025) when special dissection was performed because of a larger number of lymph nodes harvested. CONCLUSIONS Our findings raise concern about the results of EUS staging of lymph node metastases in rectal cancer. Further prospective studies on a node-by-node basis could clarify the real diagnostic yield of EUS.

Observation of thoracic duct morphology in portal hypertension by endoscopic ultrasound

BACKGROUND Thoracic duct dilation has been demonstrated in portal hypertension and hepatic cirrhosis by lymphangiography and laparotomy and at autopsy. It is thought to be secondary to increased hepatic lymph flow and has been described in the absence of ascites or esophageal varices. The aim of the present study was to observe thoracic duct morphology by endoscopic ultrasound in various subsets of patients with portal hypertension and hepatic cirrhosis and also to validate existing radiologic/surgical data. METHODS The thoracic duct of 33 patients with cirrhosis and portal hypertension was studied by endoscopic ultrasound. Patients were divided into four groups: 1, patients with ascites and esophageal varices; 2, esophageal varices without ascites; 3, without esophageal varices or ascites; 4, extrahepatic portal hypertension due to pancreatic malignancy. The thoracic duct diameter was also measured in 14 control subjects (group 5). RESULTS When the thoracic duct diameter for the five groups was compared with analysis of variance, significance was p < 0.0001; by pairwise comparison, group 1 differed from the other four groups (p < 0.05). Thoracic duct dilation (5.61 mm) was seen in group 1 patients, whereas no dilation was present in groups 2 through 4. Additionally, thoracic duct diameter in 33 portal hypertensive and/or cirrhotic patients was significantly different from that in the 14 control subjects (p = 0. 003). CONCLUSION The thoracic duct can be reliably identified by EUS in patients with hepatic cirrhosis and portal hypertension. Dilation of the duct is seen only in patients with hepatic cirrhosis, ascites, and esophageal varices. No thoracic duct dilation is present in extrahepatic portal hypertension. Contrary to existing radiologic/surgical data, thoracic duct dilation is not seen in all patients with hepatic cirrhosis and portal hypertension signifying advanced disease. A dilated thoracic duct by endoscopic ultrasound should be considered yet another sign of portal hypertension.

Two-step endoscopic resection of gastric leiomyomas

SummaryOur two-step technique for endoscopic treatment of gastric leiomyomas is illustrated. From January 1979 to June 1991, nine symptomatic patients with sessile leiomyomas of the stomach were treated at the Endoscopy Division of Istituto Nazionale Tumori, Milan.The diagnosis was achieved by means of endoscopic observation of the lesion and, when possible, by ultrasound endoscopy.This new technique consists of first removing superficial portion of the tumor by electrosurgical snare. Second, a cleavage plane is found within the proper muscle layer; the tumor is enucleated as much as possible by tightening the snare around it and creating a pseudo-stalk. No major complication occurred nor were any recurrences observed at 21.8 months in the 7/9 patients treated by endoscopy alone. Endoscopic therapy was performed on an outpatient basis and only large lesions required short hospitalization.

Self-expanding tracheobronchial stents using flexible bronchoscopy

Endoscopic insertion of tracheobronchial stents is indicated to achieve patency of the airway in case of malignant or benign obstructing lesions. Until now, the placement of prostheses has required a rigid bronchoscope with specially designed insertion instruments. Self-expanding stents are currently used to treat stenoses of different hollow organs (vessels, urinary tract, gastrointestinal tract, bile duct, respiratory tract). We report the first case of a self-expanding stent implanted in the trachea and right main stem bronchus using flexible videobronchoscope under local anesthesia. The procedure was easy, safe, effective, and well tolerated. No complications occurred.

Esophageal intubation for malignant fistulas

SummaryBetween April 1978 and December 1989 at the Endoscopy Division of the National Cancer Institute of Milan, 140 patients were intubated for esophageal neoplasms; 19 of these subjects underwent endoscopic intubation for malignant fistulas complicated by pneumonia and/or mediastinitis. The prostheses were tolerated well and enabled the restoration of oral nutrition. The mean survival was 4.7 months (range, 0.5–17 months). No major complications occurred. Tube dislodgement was observed in 2 cases (10.5%). Two patients died of causes that were not related to the procedure.

A Randomized, Placebo-Controlled, Preoperative Trial of Allopurinol in Subjects with Colorectal Adenoma

Inflammation and oxidative stress play a crucial role in the development of colorectal cancer (CRC) and interference with these mechanisms represents a strategy in CRC chemoprevention. Allopurinol, a safe molecular scavenger largely used as antigout agent, has been shown to increase survival of patients with advanced CRC and to reduce CRC incidence in long-term gout users in epidemiologic studies. We conducted a randomized, double-blind, placebo-controlled preoperative trial in subjects with colorectal adenomatous polyps to assess the activity of allopurinol on biomarkers of colorectal carcinogenesis. After complete colonoscopy and biopsy of the index polyp, 73 subjects with colorectal adenomas were assigned to either placebo or one of two doses of allopurinol (100 mg or 300 mg) and treated for four weeks before polyp removal. Change of Ki-67 labeling index in adenomatous tissue was the primary endpoint. Secondary endpoints were the immunohistochemical (IHC) expression of NF-κB, β-catenin, topoisomerase-II-α, and terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling (TUNEL) in adenomatous polyps and normal adjacent colonic tissue. Compared with placebo, Ki-67 levels were not significantly modulated by allopurinol, whereas β-catenin and NF-κB expression levels decreased significantly in adenomatous tissue, with a mean change from baseline of −10.6%, 95% confidence interval (CI), −20.5 to −0.7, and −8.1%, 95% CI, −22.7 to 6.5, respectively. NF-κB also decreased significantly in normal adjacent tissue (−16.4%; 95% CI, −29.0 to −3.8). No dose–response relationship was noted, except for NF-κB expression in normal tissue. Allopurinol can inhibit biomarkers of oxidative activation in colon adenomatous polyps and normal adjacent tissue. Further studies should define its potential chemopreventive activity. Cancer Prev Res; 6(2); 74–81. ©2012 AACR.

Esophageal tumors — treatment by endoscopic intubation

SummaryEsophageal tumors are often inoperable, because of the poor general condition of patients or the coexistance of metastatic disease. Endoscopic intubation is a safe method of palliation in these patients which can restore esophageal patency and lead to an improved nutritional status. At the Endoscopy Division of the National Cancer Institute in Milan, 141 patients with inoperable esophageal cancer underwent endoscopic intubation between 1978 and 1989. The 7-day mortality was 9/141 (6.3%) patients. In 114/132 surviving patients there was an improvement in the nutritional status and general condition. The complication rate was 17.7% (25/141 patients) and the mean survival was 5.9 months.

Treatment of nondilatable malignant pharyngoesophageal strictures by Montgomery salivary bypass tube: a new approach

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Endocytoscopic imaging of a carcinoid tumor

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The role of wireless capsule endoscopy (WCE) in the detection of occult primary neuroendocrine tumors

BACKGROUND AND AIMS Neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms with unclear etiology that may show functioning or non-functioning features. Primary tumor localization often requires integrated imaging. The European Neuroendocrine Tumors Society (ENETS) guidelines proposed wireless-capsule endoscopy (WCE) as a possible diagnostic tool for NETs, if intestinal origin is suspected. However, its impact on therapeutic management is debated. We aimed to evaluate the yield of WCE in detecting intestinal primary tumors in patients showing liver NET metastases when first-line investigations are inconclusive. METHOD Twenty-four patients with a histological diagnosis of metastatic NET from liver biopsy and no evidence of primary lesions at first-line investigations were prospectively studied in an ENETS-certified tertiary care center. Wireless-capsule endoscopy was requested before explorative laparotomy and intra-operative ultrasound. The diagnostic yield of WCE was compared to the surgical exploration. RESULTS Sixteen subjects underwent surgery; 11/16 had positive WCE identifying 16 bulging lesions. Mini-laparotomy found 13 NETs in 11/16 patients (9 small bowel, 3 pancreas, 1 bile ducts). Agreement between WCE and laparotomy was recorded in 9 patients (Sensitivity=75%; Specificity=37.5%; PPV=55%; NPV=60%). Correspondence assessed per-lesions produced similar results (Sensitivity=70%; Specificity=25%; PPV=44%; NPV=50%). No capsule retentions were recorded. CONCLUSIONS Wireless-capsule endoscopy is not indicated as second-line investigation for patients with gastro-entero-pancreatic NETs. In the setting of a referral center, it might provide additional information when conventional investigations are inconclusive about the primary site.