Srbislav Knezevic

Angiotensin-Converting Enzyme Gene Insertion/Deletion Polymorphism in Patients with Chronic Pancreatitis and Pancreatic Cancer

The purpose of this study was to determine the frequency of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and to investigate its role as a potential risk factor in patients with chronic pancreatitis and pancreatic cancer. Deletion polymorphism of the 287-bp fragment of intron 16 of the ACE gene results in higher levels of circulating enzyme and therefore may represent a risk factor for disease development. The study included 55 patients with chronic pancreatitis, 45 patients with pancreatic cancer and 128 healthy subjects. The presence of I and D variants in the ACE gene was analyzed by a polymerase chain reaction (PCR) method. Distribution of ACE ID genotypes was analyzed by means of logistic regression. When chronic pancreatitis and pancreatic cancer groups were compared in the univariate analysis, the following factors were identified as statistically significant predictors of pancreatic disease: age, gender, smoking, fat intake, ACE II genotype and ACE DD genotype. However, in the multivariate analysis, only age, gender and smoking were singled out as predictors for the occurrence of pancreatic disease. Our findings indicate that the ACE I/D polymorphism could play a role in the development of chronic pancreatitis and pancreatic cancer through interaction with other genetic and environmental factors.

Invasive Lobular Breast Cancer Presenting an Unusual Metastatic Pattern in the Form of Peritoneal and Rectal Metastases: A Case Report

Gastrointestinal metastases from invasive lobular breast cancer are uncommon with the stomach and small intestines being the most common metastatic sites. Peritoneal and rectal metastases are very rare and only rarely occur as the first manifestation of disease. We herein report the case of a 47-year-old woman who presented with abdominal carcinomatosis as a first sign of invasive lobular breast carcinoma (ILC). Identifying the most important immunohistochemical markers for ILC: gross cystic disease fluid protein 15, estrogen and progesterone receptors enabled a correct diagnosis. After a six year disease-free period, relapse occurred with severe obstruction due to rectal metastasis from lobular breast carcinoma. Since there was no widespread metastatic disease, surgery with concomitant hormonal therapy was performed.

Structural and functional analysis of SMAD4 gene promoter in malignant pancreatic and colorectal tissues: Detection of two novel polymorphic nucleotide repeats

BACKGROUND The tumor suppressor gene SMAD4 (DPC4) encodes for the common intracellular mediator of the TGF-β superfamily pathway, which regulates numerous cellular processes, such as cell proliferation, cell differentiation, apoptosis, cell fate and migration. This study was aimed to investigate the presence of genetic variants in SMAD4 gene promoter in malignant pancreatic and colorectal tissue and to analyze their functional consequences. METHODS The study was performed on genomic DNA isolated from malignant tissue samples obtained on surgery from 50 patients with pancreatic carcinoma and 50 patients with colorectal cancer. Screening for mutations within an 800bp-long fragment of the SMAD4 gene promoter was performed by DNA sequencing and two mononucleotide repeats, at positions -462 and -4, were found to be polymorphic in malignant tissue. The exact number of thymidines in the tracts -462T(15) and -4T(12) was determined by PCR with fluorescently labeled primers followed by capillary electrophoresis. Functional analysis of -462T(15)/-4T(12) haplotypes was performed by luciferase reporter assays. RESULTS Haplotype -462T(14)/-4T(10) was found in 85% of pancreatic cancer tissues, but it was not present in any of colorectal cancer tissues. Statistically significant reduction (p<0.001) in activity was observed in the haplotype -462T(14)/-4T(10) in comparison with the haplotypes -462T(15)/-4T(12) and -462T(14)/-4T(11). CONCLUSION Results of this study indicate that novel genetic variant -4T(10) in the SMAD4 gene promoter affects its activity and that element -4T(12) may play a role in transcriptional regulation of SMAD4 gene expression. Obtained results, though preliminary, also indicate that SMAD4 gene promoter haplotype -462T(14)/-4T(10) may represent a genetic marker of potential relevance for pancreatic and colorectal cancer. The findings of this study should be confirmed by further investigation in these two and other tumors, on larger number of patients and with different tumor stages. Translational research aimed at investigating potential application of mononucleotide repeats -462T(15) and -4T(12) in SMAD4 gene promoter as molecular markers in cancer may also prove useful.

Drain amylase value as an early predictor of pancreatic fistula after cephalic duodenopancreatectomy.

AIM To determine predictors of clinically relevant pancreatic fistulas (CRPF) by measuring drain fluid amylase (DFA) in the early postoperative period. METHODS This prospective clinical study included 382 patients with periampullary tumors that were surgically resected at our department between March 2005 and October 2012. A cephalic duodenopancreatectomy (DP) was performed on all patients. Two closed suction drains were placed at the end of the surgery. The highest postoperative DFA value was recorded and analyzed during the first three postoperative days and on subsequent days if the drains were kept longer. Pancreatic fistula (PF) was classified according to the International Study Group of Pancreatic Fistula (ISGPF) criteria. Postoperative complications were defined according to the Dindo-Clavien classification. All data were statistically analyzed. The optimal thresholds of DFA levels on the first, second and third postoperative days were estimated by constructing receiver operating curves, generated by calculating the sensitivities and specificities of the DFA levels. The DFA level limits were used to differentiate between the group without PF and the groups with biochemical pancreatic fistula (BPF) and CRPF. RESULTS Pylorus-preserving duodenopancreatectomy was performed on 289 (75.6%) patients, while the remaining patients underwent a classic Whipple procedure (CW). The total incidence of PF was 37.7% (grade A 22.8%, grade B 11.0% and grade C 3.9%). Soft pancreatic texture (SPT) was present in 58.3% of patients who developed PF. Mortality was 4.2%. The median DFA value on the first postoperative day (DFA1) in patients who developed PF was 4520 U/L (range 350-99000 U/L) for grade A fistula (BPF) with a SPT and a diameter of the main pancreatic duct (MPD) of ≤ 3 mm. For grade B/C (CRPF), the median DFA1 value was 8501 U/L (range 377-92060 U/L) with a SPT and MPD of ≤ 3 mm. These values were significantly higher when compared to the patients who did not have PF (122; range 5-37875 U/L). The upper limit of DFA values for the first 3 postoperative days in the examined stages of PF were: DFA1 1200 U/L for the BPF and CRPF; DFA3 350 U/L for BPF and DFA3 800 U/L for CRPF. The determined values were highly significant and demonstrated a reliable diagnostic test for both BPF and CRPF. CONCLUSION DFA1 ≥ 1200 U/L is an important predictive factor for PF of any degree. The trend of DFA3 (decrease of < 50%) compared to DFA1 is a significant factor in the differentiation of CRPF from transient BPF.

Primary retroperitoneal mucinous cystadenoma: A case report

Primary retroperitoneal mucinous cystic tumors are extremely rare. These tumors can be classified as a primary retroperitoneal mucinous cystadenoma with or without borderline malignancy or primary retroperitoneal mucinous cystadenocarcinoma. The most common of these is primary retroperitoneal mucinous cystadenoma, which almost always occurs in female patients; only ten cases have been reported in males. The most common clinical findings for this tumor type include nonspecific abdominal pain and a palpable abdominal mass. A definitive diagnosis is usually obtained from histopathology after surgical excision. Here, we report the case of a 60-year-old female patient who complained of abdominal pain that had been present for 3 mo and presented with a palpable abdominal mass. Multidetector computed tomography scanning revealed a large, unilocular cystic mass in the left retroperitoneal space. Surgical intervention was performed and the tumor was completely removed. Histopathologic examination confirmed that the tumor was a primary retroperitoneal mucinous cystadenoma. Two years after surgery, the patient remains disease free.

Hepatobiliary and Pancreatic: Pancreatic VIPomas associated with multiple endocrine neoplasia type I

A teenager, aged 15, was referred for evaluation because of chronic diarrhea, sometimes accompanied by abdominal pain, nausea and vomiting. There had been several hospital admissions for correction of fluid and electrolyte disorders. Typical blood tests on admission showed a metabolic acidosis and severe hypokalemia. He also had hypercalcemia, an increased serum concentration of parathyroid hormone (130 pg/ml) and imaging studies showing an enlarged right parathyroid gland. He was initially treated with a total parathyroidectomy because of multiglandular hyperplasia. However, multiple endocrine neoplasia type I (MENI) was suspected and additional investigations were performed including a contrast-enhanced computed tomography (CT) scan of his abdomen and magnetic resonance imaging (MRI) scans of his abdomen and head. The MRI scan of his head revealed a small mass (5 mm) in the pituitary gland. The CT scan revealed two pancreatic tumors; a 3.8 cm mass in the head of the pancreas (Figure 1 left) and a 1.2 cm mass in the body of the pancreas (Figure 1 right, arrowheads). His surgical treatment included resection of the head of the pancreas (Whipple’s procedure) and enucleation of the tumor from the body of the pancreas. Within 1 week of surgery, his diarrhea had resolved and his serum potassium had returned to normal. Histology revealed neuroendocrine tumors of uncertain malignant potential (Figure 2, above) with positive immunohistochemical staining for chromogranin A and vasoactive intestinal peptide (VIP, Figure 2, below). The neoplasms were also focally positive for glucagon but negative for proinsulin, gastrin, serotonin and somatostatin. His family history was helpful as his father had complicated peptic ulcer disease caused by a pancreatic gastrinoma and was treated with a subtotal gastrectomy. MENI is an uncommon disease with a prevalence of approximately 1:30,000 people. It is caused by mutations in the MENI gene that encodes a protein called menin. The most common clinical manifestation is hyperparathyroidism that occurs in approximately 90% of patients. Most patients also develop neoplasms in the pancreas that may be non-functional or may result in the secretion of hormones such as gastrin, insulin, glucagon, somatostatin and VIP. VIPomas are extremely rare with an estimated annual incidence of 1:10 million people. With immunocytochemistry, some VIPomas can have positive staining with other hormones such as pancreatic polypeptide, glucagon and somatostatin. For patients without metastases, the treatment of choice is surgical excision of the neoplasms. This usually results in improvement or resolution of diarrhea.

Hepatobiliary and Pancreatic: Pancreatic VIPomas associated with multiple endocrine neoplasia type I: Education and Imaging

A teenager, aged 15, was referred for evaluation because of chronic diarrhea, sometimes accompanied by abdominal pain, nausea and vomiting. There had been several hospital admissions for correction of fluid and electrolyte disorders. Typical blood tests on admission showed a metabolic acidosis and severe hypokalemia. He also had hypercalcemia, an increased serum concentration of parathyroid hormone (130 pg/ml) and imaging studies showing an enlarged right parathyroid gland. He was initially treated with a total parathyroidectomy because of multiglandular hyperplasia. However, multiple endocrine neoplasia type I (MENI) was suspected and additional investigations were performed including a contrast-enhanced computed tomography (CT) scan of his abdomen and magnetic resonance imaging (MRI) scans of his abdomen and head. The MRI scan of his head revealed a small mass (5 mm) in the pituitary gland. The CT scan revealed two pancreatic tumors; a 3.8 cm mass in the head of the pancreas (Figure 1 left) and a 1.2 cm mass in the body of the pancreas (Figure 1 right, arrowheads). His surgical treatment included resection of the head of the pancreas (Whipple’s procedure) and enucleation of the tumor from the body of the pancreas. Within 1 week of surgery, his diarrhea had resolved and his serum potassium had returned to normal. Histology revealed neuroendocrine tumors of uncertain malignant potential (Figure 2, above) with positive immunohistochemical staining for chromogranin A and vasoactive intestinal peptide (VIP, Figure 2, below). The neoplasms were also focally positive for glucagon but negative for proinsulin, gastrin, serotonin and somatostatin. His family history was helpful as his father had complicated peptic ulcer disease caused by a pancreatic gastrinoma and was treated with a subtotal gastrectomy. MENI is an uncommon disease with a prevalence of approximately 1:30,000 people. It is caused by mutations in the MENI gene that encodes a protein called menin. The most common clinical manifestation is hyperparathyroidism that occurs in approximately 90% of patients. Most patients also develop neoplasms in the pancreas that may be non-functional or may result in the secretion of hormones such as gastrin, insulin, glucagon, somatostatin and VIP. VIPomas are extremely rare with an estimated annual incidence of 1:10 million people. With immunocytochemistry, some VIPomas can have positive staining with other hormones such as pancreatic polypeptide, glucagon and somatostatin. For patients without metastases, the treatment of choice is surgical excision of the neoplasms. This usually results in improvement or resolution of diarrhea.