Javier Parra

Endoscopic ultrasound restaging after neoadjuvant chemotherapy in esophageal cancer.

BACKGROUND:The role of endoscopic ultrasound (EUS) to evaluate treatment response postneoadjuvant therapy for restaging esophageal cancer prior to surgical resection is uncertain. Accuracy of EUS is lower but potential to predict response to chemoradiation indicates that EUS may be helpful prior to surgery.OBJECTIVE:To determine staging accuracy of EUS after neoadjuvant chemotherapy, predictors of tumor response, and survival in locally advanced esophageal cancer.METHODS:Single-center retrospective evaluation of patients with locally advanced esophageal cancer on a prospective chemotherapy study. Patients who underwent EUS without FNA pre- and postchemotherapy were included.RESULTS:A total of 49 patients (43 men and 6 women) were evaluated with EUS pre- and postneoadjuvant chemotherapy. Forty-seven patients had tumor localized at the GE junction and two had mid-esophageal lesions. The median survival time was 53 months. Tumor and nodal staging accuracy postchemotherapy were 60% (27 of 45). T-stage accuracy postchemotherapy was superior in patients without a response to chemotherapy (95.7% vs 26.1%, p < 0.0001). More than 50% in reduction of tumor thickness postchemotherapy was associated with tumor downstage and better survival. N0 disease on final pathology was the best predictor of improved survival.CONCLUSION:Accuracy of EUS postchemotherapy is lower than initial staging accuracy; therefore the ability to predict downstaging based on EUS is marginal. Pathology N1 disease postchemotherapy is the best predictor of survival. EUS staging postneoadjuvant chemotherapy should focus on improving nodal staging accuracy with FNA.

Elevated CA 19-9 Caused by Hashimoto’s Thyroiditis: Review of the Benign Causes of Increased CA 19-9 Level

Elevated CA 19-9 levels are commonly associated with an underlying neoplasm, frequently originating in the gastrointestinal tract. CA 19-9 was introduced as a monoclonal antibody to identify sialylated lacto-N fucopentaose II carbohydrate epitopes associated with glycoproteins and glycolipids expressed by colorectal carcinoma cells. Although it was first developed against the latter, its use has become more commonly indicated in detection of pancreatic cancer because of its comparatively higher sensitivity (1). It can also be elevated when bile excretion is compromised and, thus, can act as a false positive when screening for pancreatic cancer in patients who have obstructive jaundice (1). In addition, gastric, ovarian, and colon cancer can cause an elevation of CA 19-9. Thus, an elevated value triggers an extensive search for an underlying malignancy. The purpose of this case report is to describe Hashimoto’s thyroiditis causing a marked elevation of CA 19-9 levels and to review other benign causes of elevated CA 19-9.

Ulcerative Jejunoileitis: A Complication of Celiac Sprue Simulating Crohn’s Disease Diagnosed with Capsule Endoscopy (PillCam)

Jejunitis may be caused by bacterial infections, celiac sprue, Crohn’s disease, ischemia, radiation, injury, vasculitis, or toxins. The inflammatory process, regardless of its etiology, may progress from mucosal inflammation alone to involve the deeper bowel layers, resulting in ulcerations and narrowing of the jejunum. Celiac sprue typically affects the proximal small bowel and manifests as a malabsorption syndrome characterized by weight loss, abdominal distention, diarrhea, and steatorrhea [1]. Ulcerative jejunitis, a complication of celiac disease, is characterized by multiple chronic ulcers and scarring leading to stricture formation which may simulate the endoscopic and clinical manifestations of Crohn’s disease, ischemic vasculitis, or jejunal neoplasm [9]. This is the first case report describing the use of wireless capsule enteroscopy (WCE) for diagnosis of ulcerative jejunitis with documentation of healing by endoscopy. In addition, it enforces that diffuse aptheael jejunal ulcerations are part of the spectrum of intestinal findings in patients with celiac disease