Jürgen Feisthammel

Inactivation of the INK4a/ARF locus and p53 in sporadic extrahepatic bile duct cancers and bile tract cancer cell lines

The tumor‐suppressor genes p14(ARF), p16(INK4a) and Tp53 are commonly inactivated in many tumors. We investigated their role in the pathogenesis of 9 bile tract cancer cell lines and 21 primary sporadic extrahepatic bile duct carcinomas. p53 and p16 protein expression was examined by Western blot analysis and immunohistochemistry. Mutation screening of p53 was done by SSCP and direct sequencing. Inactivating mechanisms of p14 and p16 were addressed by screening for mutations, homozygous deletions, chromosomal loss of 9p21 (loss of heterozygosity [LOH] analysis) and promoter hypermethylation of the p14/p16 genes. p53 overexpression could be detected in 7 of 9 cell lines and 7 of 21 primary tumors, but mutations were found in 3 cell lines only. p16 expression was absent in all cell lines, due to homozygous deletion of the gene in 8 of 9 cell lines and hypermethylation of the p16 promoter in one cell line (CC‐LP‐1). p14 exon 1β was homozygously deleted in 6 of 9 cell lines, while retained in CC‐LP‐1 and 2 additional lines. No p14 promoter hypermethylation could be detected. p16 expression was lost in 11 of 21 primary tumors. p16 promoter hypermethylation was present in 9 of 21 primary tumors, all with lost p16 expression. Allelic loss at 9p21 was detected in 13 of 21 primary tumors, 10 of 11 with lost p16 expression and 8 of 9 with methylated p16 promoter. No p14 promoter hypermethylation or p14/p16 mutations could be detected. Neither Tp53 nor p16 alterations showed obvious association with histopathologic or clinical characteristics. In conclusion, inactivation of the p16 gene is a frequent event in primary sporadic extrahepatic bile duct cancers, 9p21 LOH and promoter hypermethylation being the principal inactivating mechanisms. Therefore, p16, but not p14, seems to be the primary target of inactivation at the INK4a locus in bile duct cancers. Other mechanisms than Tp53 mutations seems to be predominantly responsible for stabilization of nuclear p53 protein in bile duct cancers.

Irinotecan with 5-FU/FA in advanced biliary tract adenocarcinomas: a multicenter phase II trial.

Objectives:Biliary cancer has a poor prognosis and lacks a standard palliative chemotherapy. The purpose of this prospective single-arm phase II study was to determine the activity and tolerability of irinotecan, 5-fluorouracil, and folinic acid in advanced biliary cancer. Patients and Methods:Patients with inoperable intrahepatic cholangiocarcinoma (ICC) or gallbladder cancer (GBC) and no prior chemotherapy were eligible. Irinotecan 80 mg/m2, followed by folinic acid 500 mg/m2 and 5-FU 2000 mg/m2 infused over 24 hours (Fufiri) were administered weekly 6 times, every 8 weeks. The primary endpoint was response rate, and secondary endpoints were overall survival (OS), progression-free survival (PFS), and toxicity. Results:Seventeen patients with ICC and 13 patients with GBC were enrolled. All patients were evaluable for safety. WHO grade 3/4 drug-related adverse events occurred in 8 patients (27%), consisting of diarrhea and leukopenia in 5 and 3 patients, respectively. One patient with diarrhea grade 4 finally succumbed to sepsis. Objective response rate was 10% (95% confidence interval, 2.1%–26.5%), with an additional 10% of patients showing stable disease. Median overall survival was 166 days and 273 days, and median progression-free survival was 84 days and 159 days for ICC and GBC, respectively. Conclusions:Fufiri is a well-tolerated regimen in patients with ICC and GBC but has only modest activity in advanced biliary tract cancer.

Epidemiology and Resistance Patterns of Bacterial and Fungal Colonization of Biliary Plastic Stents: A Prospective Cohort Study

Background Plastic stents used for the treatment of biliary obstruction will become occluded over time due to microbial colonization and formation of biofilms. Treatment of stent-associated cholangitis is often not effective because of inappropriate use of antimicrobial agents or antimicrobial resistance. We aimed to assess the current bacterial and fungal etiology of stent-associated biofilms, with particular emphasis on antimicrobial resistance. Methods Patients with biliary strictures requiring endoscopic stent placement were prospectively enrolled. After the retrieval of stents, biofilms were disrupted by sonication, microorganisms were cultured, and isolates were identified by matrix-associated laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry and/or biochemical typing. Finally, minimum inhibitory concentrations (MICs) were determined for various antimicrobial agents. Selected stents were further analyzed by fluorescence in situ hybridization (FISH). Results Among 120 patients (62.5% males, median age 64 years) with biliary strictures (35% malignant, 65% benign), 113 double pigtail polyurethane and 100 straight polyethylene stents were analyzed after a median indwelling time of 63 days (range, 1–1274 days). The stent occlusion rate was 11.5% and 13%, respectively, being associated with a significantly increased risk of cholangitis (38.5% vs. 9.1%, P<0.001). Ninety-five different bacterial and 13 fungal species were detected; polymicrobial colonization predominated (95.8% vs. 4.2%, P<0.001). Enterococci (79.3%), Enterobacteriaceae (73.7%), and Candida spp. (55.9%) were the leading pathogens. Candida species were more frequent in patients previously receiving prolonged antibiotic therapy (63% vs. 46.7%, P = 0.023). Vancomycin-resistant enterococci accounted for 13.7%, extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae with co-resistance to ciprofloxacin accounted for 13.9%, and azole-resistant Candida spp. accounted for 32.9% of the respective isolates. Conclusions Enterococci and Candida species play an important role in the microbial colonization of biliary stents. Therefore, empirical antimicrobial treatment of stent-associated cholangitis should be guided toward enterococci, Enterobacteriaceae, streptococci, anaerobes, and Candida. To determine causative pathogens, an accurate microbiological analysis of the extracted stent(s) may be helpful.

An important pitfall in diagnosing gall bladder cancer

A 72 year old male was admitted for recurrent right upper abdominal pain, intermittent fever, and 12 kg weight loss over a period of six months. Some liver enzymes were elevated (that is, alkaline phosphatase 10.14 µmol/l/s (norm 1.77–4.4), gamma glutamyl transferase 7.81 µmol/l/s (0.18–0.83)). CA …

Analysis of Wire-Guided Hemostasis Introducer for Percutaneous Therapy of Bile Duct Stones

Background: Bile duct stones (BDS) are usually removed via endoscopic retrograde cholangiopancreatography (ERCP) or, if ERCP remains unsuccessful, percutaneous transhepatic cholangiodrainage (PTCD). However, PTCD provides limited access to large BDSs. We analyzed a modified approach of PTCD for percutaneous therapy of BDS. Methods: We used a modified approach of PTCD with a 13-french (Fr) hemostasis introducer for transhepatic access to BDS. Short-wired balloon or basket catheter were applied for safe removal of BDS. Patient characteristics, effectiveness, and complications were analyzed. Results: We identified 11 patients who underwent PTCD with hemostasis introducer. BDSs were either pushed forward to the duodenum (36%) or both partly pushed and extracted via hemostasis introducer (64%). In some cases, mechanical lithotripsy was necessary (45%). Complete removal of BDS was initially achieved in 36% of patients, 45% received additional PTCD, and in 19% stent implantation was performed. Finally, all BDSs could be removed. Laboratory analysis revealed significant reduction of alkaline phosphatase (p = 0.03) and C reactive protein (p = 0.03). Complications occurred only in 1 patient with post-interventional cholangitis. Conclusion: Our study showed feasibility and safety of a modified PTCD with hemostasis introducer. In addition, protection of liver tissue from sharp-edged catheters and stones was achieved. Therefore, our modification revealed an innovational approach for transhepatic removal of BDS.

Palliative Endoscopic Treatment Options in Malignancies of the Biliopancreatic System

In most of the cases, pancreatic cancer and malignancies of the bile tract can only be treated palliatively. Endoscopy offers several methods for effective control of the symptoms in those situations. In pancreatic cancer, stenting of bile ducts enables a control of jaundice most of the time. Stenting of an obstructed duodenum can relieve symptoms of gastric outlet obstruction without the need for major surgery. In biliary tract cancer, stenting of the bile ducts can provide effective drainage of the biliary system. Photodynamic therapy and radiofrequency ablation can sometimes be a valuable tool in symptom control. This review tries to provide an overview on endoscopic palliative treatment options in pancreatic cancer and biliary tract cancer.

Evidenz der laborchemischen Diagnostik des Pankreaskarzinoms

Transaminasen und Cholestaseparameter sind Bestandteil der laborchemischen Routinediagnostik bei Oberbauchbeschwerden, haben aber keine spezifische diagnostische Wertigkeit fur das Pankreaskarzinom. Unter den Tumormarkern ist CA 19–9 der bislang einzige klinisch etablierte Parameter, der fur die Prognosebeurteilung und das Ansprechen auf Chemotherapie sowie als Rezidivindikator nach Tumorresektion Verwendung findet. Aufgrund der unspezifischen Freisetzung bei verschiedenen benignen und malignen Erkrankungen ist CA 19–9 jedoch nicht fur das Screening von Risikopopulationen geeignet, sondern sollte nur bei konkretem Verdacht auf einen Pankreastumor bestimmt werden. Um die Prognose des Pankreaskarzinoms zu verbessern, sind neue Biomarker erforderlich, die auch bei geringer Tumorlast eine hohe Spezifitat aufweisen und so die Diagnose resektabler, klinisch meist inapparenter Karzinome ermoglichen.

Eine ganz normale Pankreatitis

Anamnese und klinischer Befund: Ein 55-jahriger Patient stellte sich mit schwersten akuten Bauchschmerzen vor. Das Abdomen war druckschmerzhaft und gespannt. Untersuchungsbefunde: Das Notfall-CT ergab Zeichen der intra- und extrahepatischen Cholestase sowie Gallenblasensludge; die Serum-Lipase war deutlich erhoht. Therapie und Verlauf: Es wurde eine akute biliare Pankreatitis diagnostiziert. Nach stationarer Aufnahme kam es rasch zur klinischen Verschlechterung mit dialysepflichtigem akutem Nierenversagen sowie respiratorischer Insuffizienz. Es wurde eine Intensivtherapie uber etwa 4 Wochen notig. Anschliesend wurde der Patient uber die Normalstation in die Rehabilitation entlassen. Die Pankreas-Sonographie ergab zu diesem Zeitpunkt eine Organnekrose mit darstellbarer Wand („walled-off necrosis“). Etwa 7 Wochen spater traten erneut kolikartige Oberbauchschmerzen auf. Trotz fehlender Hinweise auf eine Infektion wurde eine Spul-Saug-Drainage in eine Nekrosehohle am Pankreaskopf eingelegt. Daraufhin kam es zu einer sekundaren Infektion der Nekrosehohle, sodass uber 3 Monate in insgesamt 20 Sitzungen endoskopische Ausraumungen/Debridements notig wurden. Anschliesend konnte der Patient in stabilem Zustand in die Anschlussheilbehandlung entlassen werden. Folgerung: Auch bei vermeintlich „normaler“ biliarer Pankreatitis kann es zu Komplikationen mit schwerem Verlauf kommen. Bei sterilen Nekrosen sollte das Procedere moglichst zuruckhaltend sein.