Sebastiano Saccomanno

Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study☆☆☆★

BACKGROUND Nonsurgical pathologic confirmation of malignant bile duct strictures is desirable for defining subsequent treatment and prognosis. Endoscopic retrograde cholangiopancreatography is frequently performed in patients suspected of having pancreaticobiliary obstruction, but there exists no standardized method for defining the nature of obstructing lesions by ERCP. METHODS We prospectively evaluated the yields of endoscopic retrograde brush cytology and biopsy for the diagnosis of malignant bile duct strictures. Fluoroscopically guided endobiliary biopsy and brush cytology (52) or cytology alone (42) were performed during endoscopic retrograde cholangiopancreatography in 94 consecutive patients, 64 with malignant strictures and 30 with benign strictures. A single cytopathologist classified the results of these studies as positive or negative for malignancy. RESULTS The sensitivities of the two procedures were identical (53%) and the gain achieved by combining the two techniques (61%) was small. Specificity proved excellent for both methods. One major complication that occurred was perforation of the common hepatic duct with leakage of bile, which was managed by surgical oversewing. This complication was ascribed to biopsy and untimely removal of the nasobiliary drain by the patient herself. CONCLUSIONS This study indicates that endoscopic retrograde brush cytology alone may be sufficient in daily practice, at least in centers that have access to experienced cytopathologists. We recommend use of forceps biopsy in selected cases where brush cytology is negative.

Tissue sampling from the common bile duct through endoscopic retrograde cholangiopancreatography, endoscopic papillo(sphinctero)tomy and drainage in juxtapapillary malignancies

SummaryIn 22 patients with radiological evidence of a malignant stricture or an obstruction of the common bile duct, endobiliary tissue specimens were obtained through endoscopic retrograde cholangiopancreatography. An endoscopic papillo(sphinctero)tomy was necessary in 9 of the 22 patients. The following techniques were employed: (1) forceps biopsy of the papillary infundibulum and/or of the common bile duct; (2) brush cytology in the same sites as above; (3) biliary juice cytology obtained by a nasobiliary drainage tube. In 8 patients, two different sampling techniques were used. The final diagnosis was established by means of pathological evaluation of surgical or necroscopic material. The diagnostic adequacy was 100% for biopsy, 88% for brush cytology, and 62% for bile cytology. The sensitivity was 100%, 66%, and 25%, respectively, for the above techniques. From 6 cases without biliary cancer, the specificity was 100%. These data show that biopsy specimens alone provide a definitive preoperative diagnosis in most cases, provided adequate samples are obtained.

Outcome of follow-up programs in patients previously resected for colorectal cancer.

The survival of a group of 115 patients (group A) who entered a follow-up program after apparently « curative » surgery for colorectal cancer was compared with that of 62 similar patients (group B) who did not join such a program. No significant difference was found. Clinical benefits to single patients in group A, in terms of anticipated diagnosis and effective treatment of recurrences and of metachronous neoplasias, appeared to be, if any, extremely limited. In light of the high costs of intensive follow-up programs, it is concluded that their use can be justified only within controlled perspective trials aimed to evaluate their usefulness.

Mixed pleomorphic-osteoclast-like tumor of the pancreas. Light microscopical, immunohistochemical, and molecular biological studies.

SummaryThe morphological, immunohistochemical, and molecular biological features of a case of giant cell tumor of the pancreas are described. This neoplasm showed mononuclear and multinucleated tumor giant cells as well as numerous osteoclast-like cells with multiple foci of osteoid-osseous metaplasia. The pleomorphic and osteoclastic giant cells displayed extensive homologies in their immunohistochemical profiles. Neither the pleomorphic nor osteoclast-like portion of the tumor showed neither c-Ki-ras nor p53 mutation and did not express the mutated p53 protein. The results suggest that the pleomorphic and osteoclast-like components are histogenetically related and that this rare neoplasm originates from a precursor cell capable of differentiating along divergent cell type.

DNA Aneuploidy Is an Independent Factor of Poor Prognosis in Pancreatic and Peripancreatic Cancer

SummaryThe purpose of this study was to investigate the clinical significance of DNA ploidy, as assessed by flow cytometry, for pancreatic and peripancreatic cancers. Between 1988 and 1990, we examined fresh/frozen samples from 49 patients who had histologically confirmed adenocarcinomas of the bilio-pancreatic carrefour: They had 23 cancers of the pancreas, 21 of the Vaters papilla, and 5 of the common bile duct. All patients were selected among a cohort of subjects who underwent Endoscopic Retrograde Cholangio Pancreatography (ERCP) and/or surgery. No prognostic impact of age, sex, stage, and surgical treatment on survival was observed by univariate analysis. When the affected organ was considered, a statistically significant difference in survival was observed: At 88 wk, survival was 0% for pancreatic and common bile duct cancer patients, and 18.2% at 175 wk for Vaters papilla cancer patients (p=0.04). In addition, we found, irrespective of affected organ, that the patients with DNA diploid tumors had a statistically significant survival advantage as compared to those with DNA aneuploidy (p=0.02). Furthermore, the statistically significant prognostic power of DNA ploidy was confirmed when patients with tumors of the pancreas and those with tumors of the Vaters papilla were separately analyzed. Finally, multivariate analysis showed that DNA content and affected organ were the only independent prognostic factors: Relative risks of dying were 3.9 (95% confidence interval CI=1.6–9.7) for patients with pancreatic cancer and 2.5 (CI=0.7–8.8) for those with common bile duct tumor when compared to those with ampullary cancer; the relative risk for DNA aneuploid tumors, as compared to DNA diploid ones, was 2.4 (CI=1.2–5.0). In conclusion, our results indicate that abnormal nuclear DNA content in pancreatic and peripancreatic cancers is an independent and powerful, indicator of poor prognosis.

Socioeconomic characteristics, life style, diabetes, family history of cancer and risk of pancreatic cancer

Objective: To investigate the relationship between socioeconomic characteristics, life style (coffee, alcohol and tobacco consumption), diabetes mellitus, first-degree family history of cancer and risk of exocrine pancreatic cancer. Design: Hospital-based case-control study. Methods: One hundred and fifty patients with exocrine panceatic cancer and 160 hospital controls were interviewed by trained personnel when still in hospital. Results: A statistically significant trend of increased risk of exocrine pancreatic cancer with a higher level of education was observed [relative risk (RR) = 1.55, confidence interval (Q) 1.10–2.19]. No association with other social characteristics (marital status, occupation and place of residence) and coffee, alcohol and tobacco consumption was found. There was a significantly increased risk of exocrine pancreatic cancer as the weekly consumption of spirits increased (RR = 1.52, Cl 1.06–2.19). Diabetes was associated with an increased risk of exocrine pancreatic cancer only when diagnosed less than 1 year prior to the interview (RR = 8.14, Cl 2.19–30.4). Conclusions: Our study confirms that there is an increased risk of exocrine pancreatic cancer associated with alcohol consumption. In addition, we observed a relationship between high socioeconomic status and risk of developing exocrine pancreatic cancer.

Cancer of the pancreas: Clinical outcome in 76 cases

A final diagnosis of pancreatic cancer was established in 76 consecutive patients during 4 years. The clinical outcome was evaluated retrospectively, as well as clinical presentation and its impact on the rate of resectability. Even though the diagnostic techniques showed a high sensitivity, only 18.4% of patients had a radical resection performed. In 77.6% of the cases a tissue diagnosis had been obtained. However, in only 1/5 of them was the tissue proof obtained preoperatively. This review confirms that the survival of patients with pancreatic cancer is poor, with slight advantages in the few resectable cases. Therefore, an earlier diagnosis should be attempted in high-risk symptomatic patients, selected by means of nonaggressive tests and evaluated by means of more accurate diagnostic techniques, when suitable.

Adenomatous polyps and familial incidence of colorectal cancer

The frequency of colonic adenomatous polyps and the incidence of colorectal cancer in close relatives were evaluated in a prospective study performed in 100 consecutive patients operated on for colorectal cancer. One hundred patients matched for age and sex, in whom double contrast enema and colonoscopy failed to show cancer, served as control group. Colorectal carcinomas in first-degree relatives were found in 11% of the surgically treated patients and 6% of the control group (the difference is not statistically significant). Solitary or discrete adenomas in patients operated on for colorectal carcinomas were significantly more frequent (32%) than in the control group (18%) (P less than 0.05). This difference is also statistically significant when considering only those patients without relatives suffering from carcinoma; however, the same cannot be statistically proven with the small group of patients with a positive family history. Present findings do not indicate that single or discrete adenomas synchronous with colorectal cancer are significantly associated with a familial history of large bowel malignancy. These findings are consistent with the hypothesis of environmental factors being involved in adenoma pathogenesis.

Papillotomie pré-coupe : évaluation de 20 cas

RésuméLes auteurs ont évalué de façon rétrospective les résultats de la papillotomie « pré-coupe » dans une série de 20 malades explorés pour ictère obstructif.Ils ont utilisé un infundibulotome rétractile, de 5 mm de long, uniquement après échec de multiples tentatives de cathétérisme de la voie biliaire principale.Chez 14 malades (70 %), la cholangiographie a été obtenue au cours de la même séance, et chez 6 patients au cours ďune deuxième séance.Dans 4 cas, les tentatives ont échoué et 2 ďentre eux ont présenté des complications sévères (1 décès, 1 perforation duodénale). Cette. technique permet de poser un diagnostic correct dans 80 % des cas et ďobtenir un succès thérapeutique dans 70 % des cas.La papillotomie « pre-coupe » n’est pas « en soi» dangereuse, mais elle doit être pratiquée exclusivement par des endoscopistes entraînes.SummaryWe evaluate retrospectively the results of precut papillotomy technique in 20 patients affected by extrahepatic jaundice. The procedure was performed using a retractable, 5 mm long needle knife, after that several standard attempts to selectively cannulate the common bile duct had repeatedly failed.In 14 (70 %) patients the technique allowed the cannulation during the same session ; in 2 patients was possible in a second session. Cannulation failed in 4 patients and 2 of them suffered serious complications (1 death, 1 duodenal perforation).The precut papillotomy can yeld a correct diagnosis in 80 % of instances and permits successful therapeutic intervention in 70 %. We conclude that this technique is a very risky procedure and should be used only in highly selected cases and by skilled endoscopists.ResumenLos autores han evaluado de manera retrospectiva los resultados de la papilotomia « pre-corte » en una serie de 20 enfermos explorados por ictericia obstructiva.Han utilizado un infundibulótomo retractil de 5 mm de largo, únicamente después de fracaso de múltiples tentativas de cateterismo de la vía biliar principal.En 14 pacientes (70 %) la colangiografía se ha obtenido en el curso de la misma sesión y en 6 pacientes en el curso de una segunda sesión.En 4 casos, las tentativas han debido ser suspendidas y dos de entre ellos han presentado complicaciones severas (1 muerte y 1 perforación duodenal). Esta técnica permite hacer un diagnóstico correcto en 80 % de los casos y de obtener un éxito terapéutico en 70 % de los casos.La papilotomía «pre-corte » no ha sido «per se », peligrosa pero debe ser practicada exclusivamente por endoscopistas entrenados.

Migration spontanée inhabituelle de calculs. A propos de 2 cas

RÉSUMÉLes auteurs rapportent deux cas d’évolution atypique de calculs multiples de la voie biliaire principale, traités par mise en place perendoscopique de prothèse et drain biliaires.SummaryThe authors report the unusual evolution of multiple choledocholithiasis in two patients treated by means of endoscopic placement of biliary drainages.ResumenLos autores refieren la inusual evolución de una multipla litiasis del conducto biliar principal en dos pacientes, curados por medio de drenajes biliares perendoscopicos.