Gene Bakis

Significant understaging is seen in clinically staged T2N0 esophageal cancer patients undergoing esophagectomy

This study aimed to determine the impact of preoperative staging on the treatment of clinical T2N0 (cT2N0) esophageal cancer patients undergoing esophagectomy. We reviewed a retrospective cohort of 27 patients treated at a single institution between 1999 and 2011. Clinical staging was performed with computed tomography, positron emission tomography, and endoscopic ultrasound. Patients were separated into two groups: neoadjuvant therapy followed by surgery (NEOSURG) and surgery alone (SURG). There were 11 patients (41%) in the NEOSURG group and 16 patients (59%) in the SURG group. In the NEOSURG group, three of 11 patients (27%) had a pathological complete response and eight (73%) were partial or nonresponders after neoadjuvant therapy. In the SURG group, nine of 16 patients (56%) were understaged, 6 (38%) were overstaged, and 1 (6%) was correctly staged. In the entire cohort, despite being clinically node negative, 14 of 27 patients (52%) had node-positive disease (5/11 [45%] in the NEOSURG group, and 9/16 [56%] in the SURG group). Overall survival rate was not statistically significant between the two groups (P = 0.96). Many cT2N0 patients are clinically understaged and show no preoperative evidence of node-positive disease. Consequently, neoadjuvant therapy may have a beneficial role in treatment.

Molecular Marker Expression Is Highly Heterogeneous in Esophageal Adenocarcinoma and Does Not Predict a Response to Neoadjuvant Therapy

A reliable method to identify pathologic complete responders (pCR) or non-responders (NR) to neoadjuvant chemoradiation therapy (NAT) would dramatically improve therapy for esophageal cancer. The purpose of this study is to investigate if a distinct profile of prognostic molecular markers can predict pCR after neoadjuvant therapy. Expression of p53, Her-2/neu, Cox-2, Beta-catenin, E-cadherin, MMP-1, NFkB, and TGF-B was measured by immunohistochemistry in pre-treatment biopsy tissue and graded by an experienced pathologist. A pCR was defined as no evidence of malignancy on final pathology. Molecular profiles comparing responders to non-responders were analyzed using classification and regression tree analysis to investigate response to NAT and overall survival. Nineteen patients were pCRs and 34 were NRs. pCRs were more likely to be alive at follow-up than NRs (p < 0.01). Thirty-seven distinct profiles were identified. Expression of molecular markers was highly heterogeneous between patients and did not correlate with a response to NAT, survival (p = 0.47) or clinical stage (p = 0.39) when evaluated either as individual markers or in combination with other expression patterns. NAT dramatically impacts survival through a mechanism independent of known molecular markers of esophageal cancer, which are expressed in a highly heterogeneous fashion and do not predict response to NAT or survival.

A wrinkle in ON-time - A GI structural abnormality confounding levodopa therapy with Duodopa rescue; a case study

Response to levodopa is one of the criteria for the diagnosis of iPD (idiopathic Parkinsons disease). (UK PD Society Brain Bank Gibb and Lees, 1988) Failure to respond to levodopa is often an indication of other parkinsonian syndromes. In contrast, a fluctuating response to levodopa is common in advanced iPD and can often be attributed to dosing regimen, competition for absorption during high protein meals, and delayed gastric emptying (in addition to central pharmacodynamic changes). While alternate diagnoses and late-stage PD may explain these various dose-responses, this case study aims to shed light on hiatal hernia as an overlooked and understudied confounder of standard levodopa therapy. A 74 yo man with progressive parkinsonian features for 7 years dogmatically claimed to have no response to 400 mg of levodopa and this had been observed by several neurologists who found no response to his medication an hour or more after a dose of levodopa. Nevertheless, the patient described that he occasionally had an hour of good mobility and also had involuntary movements which was not related to when he took a dose of levodopa. He was referred to our movement disorders center because his lack of response to levodopa raised the concern for a Parkinson Plus syndrome. When seen in clinic the patient was slow, very rigid with dystonia in his left foot and unable to get out of his wheel chair. However, toward the end of his visit and three hours after his morning dose of levodopa he very rapidly turned on and could stride down the hall with a good gait and minimal dyskinesia. Suspecting a problem with absorption of levodopa, he was referred to Gastroenterology for placement of a nasoduodenal tube to see if delivery of levodopa into the duodenum would

Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know

Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patients clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ©RSNA, 2018.

Oncologic Emergencies: Gastroenterology

Technologic advances in gastroenterology (GI) have changed the nature of GI’s involvement in cancer care from staging to surveillance to management of tumor or treatment-related emergencies. GI-related oncologic emergencies represent a small proportion of all oncologic emergencies. This chapter discusses the most important including GI bleeding, luminal and biliary obstruction, acute pancreatitis, hepatic decompensation, and dislodgement of enteral devices. These disorders require early recognition so that management can be directed efficiently. A multidisciplinary approach to such patients and conditions including consultation with oncology, radiation oncology, surgery, primary care, and gastroenterology to assist in management, which may include a therapeutic GI procedure, is likely to lead to optimal patient outcomes.

Therapeutic challenges of pancreatic ascites and the role of endoscopic pancreatic stenting

Management of pancreatic ascites poses significant therapeutic challenges. Treatment usually consists of either conservative management or interventional therapy with little consensus between the two options. Conservative therapy is the most common initial treatment option but has high failure rates hence arguing for interventional therapy as a preferred primary treatment option. Endoscopic treatment is particularly appealing due to lower failure rates and mortality than conservative therapy or surgery. We describe a patient with recurrent pancreatic ascites who was successfully managed with endoscopic transpapillary stenting. This report contributes to the limited but growing literature on the management of pancreatic ascites.