Accuracy of endoscopic ultrasound-guided fine-needle aspiration in the suspicion of pancreatic metastases

Abstract Background Metastases to the pancreas are rare, and usually mistaken for primary pancreatic cancers. This study aimed to describe the histology results of solid pancreatic tumours obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis of metastases to the pancreas. Methods In a retrospective review, patients with pancreatic solid tumours and history of previous extrapancreatic cancer underwent EUS-FNA from January/1997 to December/2010. Most patients were followed-up until death and some of them were still alive at the end of the study. The performance of EUS-FNA for diagnosis of pancreatic metastases was analyzed. Symptoms, time frame between primary tumour diagnosis and the finding of metastases, and survival after diagnosis were also analyzed. Results 37 patients underwent EUS-FNA for probable pancreas metastases. Most cases (65%) presented with symptoms, especially upper abdominal pain (46%). Median time between detection of the first tumour and the finding of pancreatic metastases was 36 months. Metastases were confirmed in 32 (1.6%) cases, 30 of them by EUS-FNA, and 2 by surgery. Other 5 cases were non-metastatic. Most metastases were from lymphoma, colon, lung, and kidney. Twelve (32%) patients were submitted to surgery. Median survival after diagnosis of pancreatic metastases was 9 months, with no difference of survival between surgical and non-surgical cases. Sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA with histology analysis of the specimens for diagnosis of pancreatic metastases were, respectively, 93.8%, 60%, 93.8%, 60% and 89%. Conclusion EUS-FNA with histology of the specimens is a sensitive and accurate method for definitive diagnosis of metastatic disease in patients with a previous history of extrapancreatic malignancies.

Body packing by rectal insertion of cocaine packets: a case report

Background: Body packing is used for international drug transport, immediate drug concealment during a police searching or introducing drugs inside prisons. Despite the high level of specialization of dealers who have started to manufacture more complex packs, up to 5% of patients could develop intoxication due to pack rupture. Bowel obstruction is another acute complication. Case presentation: A 27-year-old black male patient was sent to the hospital by court order for clinical evaluation and toxicological examination. The patient was conscious, oriented, had good color, normal arterial pressure and heart rate, and no signs of acute intoxication. Abdominal examination revealed discrete pain upon deep palpation and a small mass in the left iliac fossa. A plain abdominal radiograph revealed several oval structures located in the rectum and sigmoid. Fasting and a 50 g dose of activated charcoal every six hours were prescribed. After three days, the patient spontaneously evacuated 28 cocaine packs. Conclusion: Adequate clinical management and prompt identification of potential complications are of fundamental importance in dealing with body packing.

Identification of SL addition trans-splicing acceptor sites in the internal transcribed spacer I region of pre-rRNA in Leishmania (Leishmania) amazonensis

Trypanosomatidae is a family of early branching eukaryotes harbouring a distinctive repertoire of gene expression strategies. Functional mature messenger RNA is generated via the trans-splicing and polyadenylation processing of constitutively transcribed polycistronic units. Recently, trans-splicing of pre-small subunit ribosomal RNA in the 5' external transcribed spacer region and of precursor tRNAsec have been described. Here, we used a previously validated semi-nested reverse transcription-polymerase chain reaction strategy to investigate internal transcribed spacer (ITS) I acceptor sites in total RNA from Leishmania (Leishmania) amazonensis. Two distinct spliced leader-containing RNAs were detected indicating that trans-splicing reactions occur at two AG acceptor sites mapped in this ITS region. These data provide further evidence of the wide spectrum of RNA molecules that act as trans-splicing acceptors in trypanosomatids.

Perineal rectosigmoidectomy on treatment of rectal procidentia: analysis of 48 cases

OBJECTIVE: To evaluate results obtained in 48 cases of perineal rectosigmoidectomy in patients with rectal procidentia. METHODS: 48 medical records of patients undergoing PRS were analyzed, retrospectively. RESULTS: Before surgery, 44 patients (77.1%) reported complaints of anal mass and rectal bleeding was reported 13 times (22.8%). The period of hospitalization was 3.91 days (2 to 12 days). Women were the majority (85.4%). The mean age was 73.8 years (49 to 101 years). The average time of surgery was 72 minutes (40 to 90 minutes). Mechanical anastomosis was performed in 72.9% and manual in 27.1%. Among the 12 (25%) patients with fecal incontinence, continence was achieved in 2 cases. Postoperative complications occurred in five cases - 10.5% (two pneumonia and three anastomotic leakages). Recurrence was verified in four patients (8,3%). There were no deaths related to the procedure. CONCLUSION: Perineal rectosigmoidectomy is a good surgical option for rectal procidentia, with low morbidity and mortality, low recurrence rate and short hospitalization length.

Doppler-guided hemorrhoidal artery ligation with rectal mucopexy technique: initial evaluation of 42 cases

The treatment of hemorrhoidal disease (HD) by conventional hemorrhoidectomy is associated with significant morbidity, mainly represented by the postoperative pain and the late return to daily activities. Doppler-guided hemorrhoid artery ligation (DGHAL) is a minimal-invasive surgical treatment for HD that has been used as an alternative method in order to reduce these inconveniences. OBJECTIVE: To analyze the initial results of the DGHAL technique associated with rectal mucopexy in the treatment of HD. METHODS:Forty-two patients with stage I, III and IV hemorrhoids who were submitted to DGHAL were analyzed from December 2010 to August 2011. Eleven patients (26%) were stage II; 21 (50%), stage III; and 10 (24%), stage IV HD. All patients were operated by the same surgeon under spinal anesthesia and using the same equipment and technique to perform the procedure. The 42 patients underwent ligation of six arterial branches followed by rectal mucopexia by uninterrupted suture. Nine patients needed concomitant removal of perianal skin tag. In the postoperative, the following parameters were evaluated: pain, tenesmus, bleeding, itching, prolapse, mucus discharge and recurrence. The mean postoperative follow-up lasted four months (one to nine months). RESULTS: Tenesmus was the most common postoperative complaint for 85.7% of patients followed by pain, in 28.6%, perianal burning, in 12.3%, mucus discharge and perianal hematoma in 4.7%. Two patients had severe postoperative bleeding and required surgical haemostasis, one of which needed blood transfusion. Ninety-five percent of the patients declared to be satisfied with the method. CONCLUSION: Even though DGHAL has complications similar to those of other surgical methods, its results present less postoperative pain, allowing faster recovery and return to work. Studies with more cases and a longer follow-up are still necessary to assess the late recurrence.

Limited value of ultrasound assessment in patients with poor outcome after carpal tunnel release surgerys

[EN] OBJECTIVE: To determine the value of ultrasonography in the assessment of patients with idiopathic carpal tunnel syndrome (CTS) and poor outcome after carpal tunnel release. METHODS: A total of 88 consecutive patients with CTS (104 hands) underwent open surgical release of the median nerve. Ultrasound (US) examination was performed blind to any patient's data. The median nerve area at tunnel inlet and outlet, the retinaculum distance, and the flattening ratio were measured. The main outcome variable was the patient's overall satisfaction using a five-point Likert scale (1 = worse, 2 = no change, 3 = slightly better, 4 = much better, 5 = cured) at 3 months postoperatively. Pre- and postoperative ultrasonographic findings in relation to clinical outcome were analysed. RESULTS: Improvement (scores 4 or 5 on the Likert scale) was recorded in 75 hands (72%). After carpal tunnel release, the cross-sectional area at tunnel inlet decreased from a mean of 14.2 to 13.3 mm2 in the group with clinical improvement and also from a mean of 12.5 to 11.6 mm2 in the group with no change or slight improvement. No significant changes in the cross-sectional area at tunnel outlet, retinaculum distance, and flattening ratio were observed. CONCLUSION: Reduction of the median nerve cross-sectional area at tunnel inlet at 3 months after carpal tunnel release was similar in patients reporting cure or great improvement and in those with slight or no improvement. Ultrasonography is of limited value in assessment of patients with poor outcome after median nerve release.

Metachronic malignant transformation of small bowel and rectal endometriosis in the same patient

[ES] Background: Malignant transformation of intestinal endometriosis is a rare event with an unknown rate of incidence. Metachronous progression of endometriosis to adenocarcinoma from two distant intestinal foci happening in the same patient has not been previously reported. Case presentation: We describe a case of metachronic transformation of ileal and rectal endometriosis into an adenocarcinoma occurring in a 45-year-old female without macroscopic pelvic involvement of her endometriosis. First, a right colectomy was performed due to intestinal obstruction by an ileal mass. Pathological examination revealed an ileal endometrioid adenocarcinoma and contiguous microscopic endometriotic foci. Twenty months later, a rectal mass was discovered. An endoscopic biopsy revealed an adenocarcinoma. En bloc anterior rectum resection, hysterectomy and bilateral salpingectomy were performed. A second endometrioid adenocarcinoma arising from a focus of endometriosis within the wall of the rectum was diagnosed. Conclusion: Intestinal endometriosis should be considered a premalignant condition in premenopausal women.

Use of VEGFR-2 targeted microbubbles (BR55, Bracco imaging) for the early ultrasound evaluation of response to antiangiogenic treatment in a xenograft model of hepatocarcinoma

Aim: To evaluate the early response to treatment to an antiangiogenetic drug (sorafenib) in a heterotopic murine model of hepatocellular carcinoma (HCC) using ultrasonographic molecular imaging. Material and Methods: the xenographt model was established injecting a suspension of HuH7 cells subcutaneously in 19 nude mice. When tumors reached a mean diameter of 5-10 mm, they were divided in two groups (treatment and vehicle). The treatment group received sorafenib (62 mg/kg) by daily oral gavage for 14 days. Molecular imaging was performed using contrast enhanced ultrasound (CEUS), by injecting into the mouse venous circulation a suspension of VEGFR-2 targeted microbubbles (BR55, kind gift of Bracco Swiss, Geneve, Switzerland). Video clips were acquired for 6 minutes, then microbubbles (MBs) were destroyed by a high mechanical index (MI) impulse, and another minute was recorded to evaluate residual circulating MBs. The US protocol was repeated at day 0,+2,+4,+7, and +14 from the beginning of treatment administration. Video clips were analyzed using a dedicated software (Sonotumor, Bracco Swiss) to quantify the signal of the contrast agent. Time/intensity curves were obtained and the difference of the mean MBs signal before and after high MI impulse (Differential Targeted Enhancement-dTE) was calculated. dTE represents a numeric value in arbitrary units proportional to the amount of bound MBs. At day +14 mice were euthanized and the tumors analyzed for VEGFR-2, pERK, and CD31 tissue levels using western blot analysis. Results: dTE values decreased from day 0 to day +14 both in treatment and vehicle groups, and they were statistically higher in vehicle group than in treatment group at day +2, at day +7, and at day +14. With respect to the degree of tumor volume increase, measured as growth percentage delta (GPD), treatment group was divided in two sub-groups, non-responders (GPD>350%), and responders (GPD<200%). In the same way vehicle group was divided in slow growth group (GPD<400%), and fast growth group (GPD>900%). dTE values at day 0 (immediately before treatment start) were higher in non-responders than in responders group, with statistical difference at day 2. While dTE values were higher in the fast growth group than in the slow growth group only at day 0. A significant positive correlation was found between VEGFR-2 tissue levels and dTE values, confirming that level of BR55 tissue enhancement reflects the amount of tissue VEGF receptor. Conclusions: the present findings show that, at least in murine experimental models, CEUS with BR55 is feasable and appears to be a useful tool in the prediction of tumor growth and response to sorafenib treatment in xenograft HCC.

Statistical methods for analysis and processing of medical ultrasound: applications to segmentation and restoration

In this thesis two major topics inherent with medical ultrasound images are addressed: deconvolution and segmentation. In the first case a deconvolution algorithm is described allowing statistically consistent maximum a posteriori estimates of the tissue reflectivity to be restored. These estimates are proven to provide a reliable source of information for achieving an accurate characterization of biological tissues through the ultrasound echo. The second topic involves the definition of a semi automatic algorithm for myocardium segmentation in 2D echocardiographic images. The results show that the proposed method can reduce inter- and intra observer variability in myocardial contours delineation and is feasible and accurate even on clinical data.

La molecola IRTA1 (immunoglobulin superfamily receptor trans location associated 1) risulta selettivamente espressa nei linfomi non Hodgkin B della zona marginale

La diagnosi di linfoma non Hodgkin B della zona marginale si basa su criteri morfologici e sulla sostanziale negatività per marcatori immunoistochimici espressi in altri sottotipi di linfoma B. L’ obiettivo di questo lavoro è stato, quindi, quello di ricercare una molecola specifica associata ai linfomi della zona marginale. Materiali e Metodi. Sono stati esaminati 2.104 linfomi periferici di entità nosologia eterogenea mediante un anticorpo monoclonale, diretto contro la molecola IRTA1, che riconosce la zona marginale nei tessuti linfoidi umani. Risultati. Si è riscontrata espressione di IRTA1 nel 93% dei linfomi della zona marginale ad insorgenza extranodale e nel 74% di quelli primitivi linfonodali suggerendo la possibilità che questi linfomi possano originare dalle cellule perifollicolari o monocitoidi IRTA1+ riscontrabili nei linfonodi reattivi. La valutazione immunoistochimica mediante doppia colorazione (IRTA1/bcl6), ha inoltre dimostrato come vi sia una modulazione fenotipica nelle cellule marginali neoplastiche nel momento in cui esse colonizzano i follicoli linfoidi e durante la loro circolazione nei centri germinativi. Le cellule marginali neoplastiche che differenziano in senso plasmacellulare perdono l’ espressione di IRTA1 Discussione. In conclusione, tali evidenze hanno permesso di ampliare la conoscenza sulla biologia dei linfomi marginali e sottolineano come IRTA1 sia il primo marcatore diagnostico positivo per queste neoplasie.

Cis- und trans-Regulation bei Drosophila-T-Box-Genen

Die räumliche und zeitliche Organisation von Genexpression ist für die Entwicklung und das Funktionieren eines jeden Lebewesens von immenser Bedeutung. Dazu laufen eine Vielzahl von Regulationsprozessen auf unterschiedlichen Ebenen ab. In dieser Arbeit wurden im ersten Teil Untersuchungen zur Genregulation des Drosophila optomotor-blind Genes und zur Funktion des Omb Proteins durchgeführt. Eine Mutante, der ein großer Teil der upstream regulatory region (URR) fehlt wurde erzeugt, aus einer Vielzahl von Linien isoliert und molekular charakterisiert. Die biologischen Auswirkungen dieser Deletion werden in Shen et al. (2008) beschrieben. Plasmide zur Erzeugung transgener Fliegen, mit deren Hilfe eine bereits von Sivasankaran et al. (2000) durchgeführte Enhancer-reporter-Analyse vervollständigt werden sollte, wurden hergestellt. Die bereits bekannte Inversion In(1)ombH31 wurde molekular kartiert. Eine Reihe von Konstrukten mit Punktmutationen in der Omb T-Domäne wurden generiert, die unter anderem über deren Funktion hinsichtlich DNA-Protein Interaktion und einer potentiellen Metallionenbindefähigkeit (ATCUN) hin Aufschluss geben sollen. Des Weiteren wurde eine Reihe von P-Element-Deletionslinien auf den Verlust eines alternativen omb Transkriptionsstartpunktes hin untersucht, mit dem Ziel eine vollständige Protein-Nullmutante zur Verfügung zu haben. Der zweite Abschnitt dieser Arbeit befasste sich mit der Erzeugung von Dpp-GFP-Fusionskonstrukten, mit deren Hilfe weitere Erkenntnisse über den Dpp-Langstreckentransport erhofft werden. Es wurde außerdem damit begonnen bei einem weitern Drosophila T-Box Transkriptionsfaktor, Optomotor-blind related gene-1 (Org-1), eine Reihe von Varianten mit homopolymeren polyAlanin und polyGlutamin Expansionen unterschiedlicher Länge herzustellen. Durch Experimente mit diesen Konstrukten soll Aufschluss darüber gewonnen werden, ob Glutamin-Expansionen, wie in der Literatur vorgeschlagen, aktivierend und Alanin-Expansionen in Transkriptionsfaktoren vielleicht reprimierend auf Genaktivität wirken. Letztlich wurden in dieser Arbeit im Rahmen des DROSDEL Projektes (Ryder et al., 2004, 2007) Deletionen in der distalen Hälfte des Chromosomenarms 3R hergestellt. Der DROSDEL Deletionskit, der durch eine Kooperation europäischer Labore entstand stellt der Drosophila Forschung einen umfassenden Satz molekular basengenau definierter Defizienzen zur Verfügung.

Local Earthquake Tomography by trans-dimensional Monte Carlo Sampling

In this study a new, fully non-linear, approach to Local Earthquake Tomography is presented. Local Earthquakes Tomography (LET) is a non-linear inversion problem that allows the joint determination of earthquakes parameters and velocity structure from arrival times of waves generated by local sources. Since the early developments of seismic tomography several inversion methods have been developed to solve this problem in a linearized way. In the framework of Monte Carlo sampling, we developed a new code based on the Reversible Jump Markov Chain Monte Carlo sampling method (Rj-McMc). It is a trans-dimensional approach in which the number of unknowns, and thus the model parameterization, is treated as one of the unknowns. I show that our new code allows overcoming major limitations of linearized tomography, opening a new perspective in seismic imaging. Synthetic tests demonstrate that our algorithm is able to produce a robust and reliable tomography without the need to make subjective a-priori assumptions about starting models and parameterization. Moreover it provides a more accurate estimate of uncertainties about the model parameters. Therefore, it is very suitable for investigating the velocity structure in regions that lack of accurate a-priori information. Synthetic tests also reveal that the lack of any regularization constraints allows extracting more information from the observed data and that the velocity structure can be detected also in regions where the density of rays is low and standard linearized codes fails. I also present high-resolution Vp and Vp/Vs models in two widespread investigated regions: the Parkfield segment of the San Andreas Fault (California, USA) and the area around the Alto Tiberina fault (Umbria-Marche, Italy). In both the cases, the models obtained with our code show a substantial improvement in the data fit, if compared with the models obtained from the same data set with the linearized inversion codes.

Kaiso und CTCF regulieren geprägte Gene in cis und in trans

Geprägte Gene besitzen die Besonderheit, dass sie jeweils nur von einem Allel exprimiert werden und in der Regel in Imprinting Clustern (ICs) im Genom vorliegen. Bei der Regulation in solchen ICs spielen differentiell methylierte Imprinting Kontrollregionen (ICRs) und dort stattfindende Proteinbindungen eine wichtige Rolle. Die essentielle Bedeutung der CTCF-Bindung an die ICR1 in 11p15.5 für die Expressionsregulation der geprägten Gene H19 und IGF2 ist bereits bekannt. In der vorliegenden Arbeit sollte die Bindung von Kaiso an die unmethylierte ICR1 bei humanen Zellen mit maternaler uniparentaler Disomie von 11p15 (upd(11p15)mat) nachgewiesen und die genaue Bindungsverteilung von Kaiso und CTCF in den B-Repeats der Kontrollregion bestimmt werden. Cis-regulatorische und chromosomenübergreifende transkriptionelle Effekte der ICR1-Proteinbindungen sollten dann durch qPCR-Analysen geprägter Gene bei Zellen mit maternaler und paternaler upd(11p15) und nach siRNA-basierter Herunterregulation der beiden Proteine in Zellen mit upd(11p15)mat analysiert werden. In der vorliegenden Arbeit konnte erstmals gezeigt werden, dass Kaiso an die unmethylierte ICR1 bindet. Dabei kann zumindest von einer Bindestellennutzung in der distalen ICR1-Hälfte ausgegangen werden. Für CTCF hingegen wurde eine Nutzung aller analysierten Repeats in beiden ICR1-Hälften gefunden. In der maternalen bzw. paternalen upd(11p15) entspricht die Expression der 11p15.5-Gene IGF2, H19, CDKN1C und KCNQ1OT1 dem jeweiligen Disomie-Status. Von den nicht auf Chromosom 11 gelegenen geprägten Genen zeigen MEST und PLAGL1 bei Zellen mit upd(11p15)pat sowie PEG3 und GRB10 bei der upd(11p15)mat eine stärkere Expression. Ein CTCF-knockdown in Zellen mit upd(11p15)mat führt zur IGF2-Expressionssteigerung. Dies tritt in noch stärkerem Maße beim knockdown von Kaiso auf, wobei hier zusätzlich eine gesteigerte Expression von H19 vorliegt. Des Weiteren findet man beim CTCF-knockdown einen MEST-Expressionsanstieg und beim Kaiso-knockdown gesteigerte Expressionen der Gene PEG3, GRB10 und PLAGL1. Damit lassen sich sowohl eigenständige cis-regulatorische Effekte der ICR1-Bindung beider Proteine auf geprägte Gene des IC1 als auch chromosomenübergreifende Effekte erkennen. Vor allem die starken H19-Expressionsanstiege beim Kaiso-knockdown treten korrelierend mit Veränderungen von geprägten Genen anderer Chromosomen auf. Damit unterstützen die Daten die Theorie, dass die Expressionsregulation geprägter Gene koordiniert in einer Art Netzwerk stattfinden könnte und dabei bestimmte Faktoren wie H19 und PLAGL1 eine übergeordnete Regulatorfunktion besitzen, wie es in Vergangenheit in der Maus beschrieben wurde. Die Expressionsanalysen von PLAGL1 und MEST deuten darüber hinaus durch ihre tendenziell übereinstimmenden Werte bei der paternalen upd mit hypermethylierter ICR1 und den knockdowns auf die Existenz von Chromatin-Interaktionen zwischen der ICR1 und Abschnitten auf den Chromosomen 6 und 7 hin, ggf. mit einem entsprechenden lokalen Effekt der Proteine in diesen Loci. Proteinbindungen an die maternale ICR1 scheinen damit sowohl cis-regulatorisch die Transkription der geprägten Gene IGF2 und H19 zu beeinflussen als auch durch die H19-Expression ein funktionelles Netzwerk geprägter Gene als trans-Faktor zu regulieren und für Interaktionen zwischen verschiedenen Chromosomen mit transkriptionsregulierender Wirkung verantwortlich zu sein.