L. Camellini

Ga-68 DOTATOC PET, endoscopic ultrasonography, and multidetector CT in the diagnosis of duodenopancreatic neuroendocrine tumors: a single-centre retrospective study.

Purpose: In this report, we compared endoscopic ultrasonography (EUS), multidetector CT (MDCT), and Ga-68 DOTATOC PET/CT in patients with neuroendocrine tumors (NETs). We report our experience with use of these methods in patients suspected to have duodenopancreatic primitive NET. Methods: Nineteen consecutive patients (mean age, 56; 21–80), who underwent both Ga-68 DOTATOC PET/CT and EUS between March 2007 and November 2008 were retrospectively included in the study (16 underwent MDCT). Suspicion of NET was confirmed by EUS-FNA and/or surgery. Operative characteristics of PET, EUS, and MDCT were compared. Results: Twenty-three neuroendocrine lesions were diagnosed in 13/19 patients. EUS, PET, and MDCT correctly identified as affected 13/13 (100%), 12/13 (92%), and 10/11 (91%) patients, respectively. On a lesion basis, EUS, PET, and MDCT identified correctly as NETs 22/23 (96%), 20/23 (87%), and 13/18 (72%) lesions (P = 0.08 EUS vs. CT). Both on a patient and on a lesion basis, specificity was 67%, 83%, and 80% for EUS, PET, and MDCT, respectively. Conclusions: EUS, Ga-68 DOTATOC PET, and MDCT seem to have comparable accuracy in diagnosis of duodenopancreatic NET and their combination may allow an optimal preoperative diagnosis.

The natural history of upper gastrointestinal subepithelial tumors: a multicenter endoscopic ultrasound survey.

Goals To evaluate the natural course of <3-cm upper gastrointestinal subepithelial tumors by endoscopic ultrasound (EUS) and to determine the appropriate timing for EUS follow-up. Background Subepithelial tumors (SETs) can range from benign lesions to tumors with malignant behavior or potential to become malignant such as gastrointestinal stromal tumors (GISTs). EUS is considered a valuable tool for their evaluation as it estimates the exact size and layer of origin, and also additional morphologic features that can suggest the diagnosis. For high surgical risk patients and when no worrisome EUS features are seen, EUS surveillance of subepithelial tumors is often used. Methods Fifty-one patients (mean age, 61.2±11.8 y; median, 63 y) with asymptomatic <3-cm SETs of second and fourth echolayer were followed for a mean period of 29.7 months (range, 3 to 84; median, 23 mo) in 3 tertiary care institutions. Evaluation included location, echolayer, tumor diameter, internal echo pattern, and outer margin of lesions by EUS. EUS was performed by using miniprobes, radial and linear echoendoscopes. Results Follow-up revealed increase in size and/or change in echogenic features in 7/51 (13.7%) patients. Surgical follow-up was available for 3 of 7 of these patients. Two of the fourth layer SETs, which had both increase in size and change in echogenicity were found to be GISTs (+c-kit). Conclusions The majority of <3-cm SETs does not change during a median of 23 months. The change in echogenicity and increase in size may indicate a GIST.

Proposal of a new clinical index predictive of endoscopic severity in ulcerative colitis.

Assessment of disease activity by clinical parameters in ulcerative colitis is still controversial. Different clinical indexes have been proposed. Colonoscopy provides detailed information on mucosal damage. The aim of this study was to identify, among 21 clinical and laboratory parameters, which were predictive of endoscopic activity. We included 137 consecutive patients with ulcerative colitis who underwent colonoscopy, clinical examination, and blood tests within 4 weeks. Endoscopic severity was recorded using a simple score (range, 0–30). The multiple stepwise regression coefficient of each significant variable predictive of mucosal damage was used to develop a new activity index predictive of endoscopic appearance (Endoscopic–Clinical Correlation Index; ECCI). We tested the ability of our score to discriminate patients with severe endoscopic disease, calculating the area under the receiver operator characteristic curve, and we compared it to activity indexes proposed by other authors. Endoscopic severity was significantly influenced by four parameters: bloody stool, nocturnal bowel movements, body temperature >37.5°C, and serum albumin. The new scoring system was calculated as ECCI = {[serum albumin × (−26)] + (bloody stool × 17) + (nocturnal bowel movements × 16) + [fever (0 or 1) × 39]} + 107. The ECCI accurately identified patients with severe endoscopic disease in our sample (sensitivity = 81%, specificity = 95%). In conclusion, the ECCI should be useful in clinical practice because it is simple and strongly related to endoscopic activity.

Alpha but not beta interferon is useful in chronic active hepatitis due to hepatitis C virus. A prospective, double-blind, randomized study.

Interferon-α has been widely used in chronic hepatitis C, but controlled studies with intramuscular interferon-β are lacking. We therefore performed a prospective, double-blind, randomized study comparing intramuscular IFN-α and -β in patients with chronic hepatitis C. Sixty patients were randomly assigned to receive 3 MU thrice weekly intramuscularly of either recombinant IFN-α or leukocyte IFN-α or fibroblast IFN-β for six months. Nine of 20 patients (45.0%) in the recombinant IFN, 5/19 (26.3%) in the leukocyte IFN, and none in the IFN-β group had a complete response during therapy (recombinant IFN vs IFN-β:P<0.01). Only in IFN-α-treated patients, was infection with a single HCV genotype (type 2a or 2b) associated with significantly better long-term outcome. IFN-α is useful in chronic hepatitis C while intramuscular IFN-β interferon does not exert any beneficial effect. This is probably due to an insufficient bioavailability of IFN-β when given intramuscularly.

Clearance of irretrievable bile duct and pancreatic duct stones by extracorporeal shockwave lithotripsy, using a transportable device: effectiveness and medium-term results.

Background and Goals Extracorporeal shockwave lithotripsy (ESWL) is an established treatment of irretrievable biliary and pancreatic stones, but the cost of the shockwave generators limits its widespread use. We revised data about the effectiveness of our treatment for refractory stones using a transportable shockwave generator. Study We retrospectively evaluated the short and medium-term outcomes of patients who underwent ESWL using a transportable electromagnetic shockwave generator between 1998 and 2003 at our unit, for the treatment of irretrievable bile duct or pancreatic duct stones. All patients received intravenous conscious sedation and antibiotic prophylaxis. Results Complete stone clearance was achieved in 70/82 patients (85.4%), in 66 of the patients (94.2%) with 1 session of ESWL. Despite the insertion of a stent in the bile duct, 2 patients had moderate cholangitis, while they waited for the next ESWL session. We did not record any moderate-severe complication of ESWL, but 2 patients underwent surgery owing to perforation/bleeding during endoscopic removal of residual fragments. A symptomatic recurrence of stones was recorded in 10/69 (14.5%) patients, who had been previously cleared and whose follow-up data (median follow-up 29 mo; range 7 to 66) were available. Conclusions We obtained satisfactory stone clearance by using a transportable shockwave generator. Most patients required 1 session. Our experience confirmed the safety of the treatment, even though patients may experience cholangitis while awaiting definitive treatment. The use of a transportable ESWL generator may be a valuable option in centers, while ensuring a sufficient proficiency in biliary endoscopy.

Frequency of constitutional MSH6 mutations in a consecutive series of families with clinical suspicion of HNPCC.

A large majority of constitutional mutations in hereditary non‐polyposis colorectal cancer (HNPCC) are because of the MHL1 or MSH2 genes. In a lower fraction of cases, another gene of the mismatch repair (MMR) machinery, MSH6, may be responsible. Families with MSH6 mutations are difficult to recognize, as microsatellite instability (MSI) may not be detectable and immunohistochemistry (IHC) may give ambiguous results. In the present study, we proposed (i) to determine the frequency of MSH6 mutations in a selected population of colorectal cancer patients obtained from a tumor registry, (ii) to assess whether IHC is a suitable tool for selecting and identifying MSH6 mutation carriers. One hundred neoplasms of the large bowel from suspected HNPCC families were analyzed for MSI (BAT25 and BAT26 markers) and immunohistochemical expression of the MSH6 protein. We found on 12 tumors (from different families) showing instability or lack of MSH6 expression. Among these, four potentially pathogenic MSH6 mutations were detected (del A at 2984; del TT at 3119; del AGG cod 385; and del CGT cod 1242) by direct gene sequencing. These represented 12.9% of all families with constitutional mutations of the DNA MMR genes. Thus, some 5% of all HNPCC families are featured by constitutional mutation of the MSH6 gene. This appears, however, as a minimum estimate; routine use of IHC and the study of large numbers of individuals and families with little or no evidence of Lynch syndrome might reveal that mutation of this gene account for a large fraction of HNPCC.

Endoscopic submucosal dissection of scar-embedded rectal polyps: a prospective study (Esd in scar-embedded rectal polyps).

BACKGROUND & AIMS Endoscopic submucosal dissection (ESD) was developed for en bloc resection of superficial neoplasm of the digestive tract. We evaluated feasibility and safety of ESD, as a salvage therapy of large refractory rectal polyps, in a tertiary care setting. METHODS We prospectively enrolled in the present study and treated by ESD 11 consecutive patients with rectal polyps (median diameter 3.5 cm; range 2-5 cm), who had previously undergone several attempts of endoscopic resection and not suitable for further standard endoscopic treatment. The ESD was carried out with a standard needle knife. Follow up examinations were scheduled at 3, 6, 12 and 24 months. RESULTS We achieved apparently complete resection of polyps in 10/11 patients. In one patient ESD was interrupted and the pathology of the resected fragment showed deep submucosal infiltration; this patient underwent surgery. Deep and lateral margins were shown to be free of neoplasm (radical resection) in six out of 11 patients. However all the 10 patients with apparently complete resection were free of recurrence after a mean follow up of 19.2 months (12-24). A T1 adenocarcinoma was radically resected by ESD, with no recurrence. We recorded 2 cases of subcutaneous emphysema, both treated conservatively. CONCLUSIONS Radical resection is difficult to be achieved by ESD in patients with rectal scar-embedded polyps. Nevertheless ESD may be proposed as a definitive treatment of selected patients with refractory polyps, avoiding surgery in the majority of them.

Endoscopic ultrasound image of hydatid membranes in the common bile duct.

A 25-year-old Caucasian male was admitted to our Department or abdominal pain, fever, jaundice and cholestasis. Transabdomnal ultrasonography showed a cyst in the left lobe of the liver, inimal ascites, dilatation of the main biliary duct and biliary ludge in the gallbladder. The patient underwent endoscopic ultrasonography (EUS) that howed an “multi-layered circular image” in the main bile duct (Fig. , arrows 1, 2, 3). The hypothesis of Echinococcosis seemed unlikely iven that the patient had no risk factors and that our area is not ndemic. An endoscopic retrograde pancreato-cholangiography with phincterotomy was performed with removal of a collapsed cyst ithin the common bile duct (Fig. 2). Histopathologic examination as diagnostic for hydatid cyst. This is the second case of EUS documentation of hydatid embranes in the common bile duct (CBD), and the rupture f an hydatid cyst in the biliary tract is a rare, but serious omplication of Echinococcosis. In the previous case reported floatng membranes were described in the CBD [1]. In the present ase we observed a multi-layered circular “gut wall like” image hich may raise suspicion for the presence of hydatid cyst.

P.1.297: TEST AND PROGRAMME SENSITIVITIES OF SCREENING FOR COLORECTAL CANCER IN REGGIO EMILIA

OBJECTIVE to estimate the sensitivity of the immunochemical test for faecal occult blood (FOBT) and the sensitivity of the colorectal tumour screening programme in the province of Reggio Emilia. DESIGN AND SETTINGS retrospective cohort study, including a sample of 80,357 people of both genders, aged 50-69, who underwent FOBT, during the first round of the screening programme in the province of Reggio Emilia, from April 2005 to December 2007. MAIN OUTCOME MEASURES incidence of interval cancer. The proportional incidence method was used to estimate the sensitivity of FOBT and of the screening programme. Data were stratified according to gender, age and year of interval. RESULTS AND CONCLUSIONS the overall sensitivity of FOBT was 73.2% (95%IC 63.8-80.7). The sensitivity of FOBT was lower in females (70.5% vs 75.1%), higher in the 50-59 age group (78.6% vs 70.2%) and higher in the colon than rectum (75.1% vs 68.9%). The test had a significantly higher sensitivity in the 1st year of interval than in the 2nd (84.4% vs 60.5%; RR=0.39, 95%IC 0.22-0.70), a difference which was confirmed, also when data were stratified according to gender. The overall sensitivity of the programme is 70.9% (95%IC 61.5-78.5). No statistically significant differences were shown, if data were stratified according to gender, age or site. Again the sensitivity in the 1st year was significantly higher than in the 2nd year of interval (83.2% vs 57.0%; RR=0.41, 95%IC 0.24-0.69). Overall our data confirmed the findings of similar Italian studies, despite subgroup analysis showed some differences in sensitivity in our study.

4706 The rockall score is a useful prognostic tool in gastroduodenal ulcer haemorrhage.

Background and aim. Gastroduodenal ulcer bleeding is the major cause of endoscopic examination on emergency. Patients with acute upper gastrointestinal haemorrhage (UGIH) are routinely hospitalized regardless of the clinical status or the stigmata of bleeding. The Rockalls score (1) was recently tested for its prognostic value after UGIH. The aim of the present study was to validate Rockalls score in a set of patients with gastroduodenal ulcer bleeding in an Italian teaching hospital and to prove his usefulness in improving quality of care. Material and methods. From May/96 to May/97 100 consecutive patients, admitted as emergencies for UGIH, underwent endoscopy within 6 hours of admission and were found affected by gastroduodenal ulcer (peptic or malignant). All the patients with active bleeding (42) and most of the ones with stigmata of recent haemorrhage were treated endoscopically by injection of 10-20 ml 1:10,000 adrenaline. Initial Rockalls score (iR - based on age and presence of shock and comorbidity) and total Rockalls score (tR - sum of iR and a score related to endoscopic findings) were calculated for each patient. Results. Initial haemostasis was achieved in all cases, but 19 patients recurred; 12 died, 9 after at least one rebleeding. Median iR and median tR were 2 (range 0-6) and 4 (1-9) for non-rebleeders vs. 3 (0-7) and 6 (3-10) for rebleeders ( p 8 rebled and died. The average length of hospital stay was 10.3 days for all patients and 4.4 for the group with tR