Prediction of recurrence free survival for esophageal cancer patients using a protein signature based risk model.

BACKGROUND: Biomarkers to predict the risk of disease recurrence in Esophageal squamous cell carcinoma (ESCC) patients are urgently needed to improve treatment. We developed proteins expression-based risk model to predict recurrence free survival for ESCC patients. METHODS: Alterations in Wnt pathway components expression and subcellular localization were analyzed by immunohistochemistry in 80 ESCCs, 61 esophageal dysplastic and 47 normal tissues; correlated with clinicopathological parameters and clinical outcome over 86 months by survival analysis. Significant prognostic factors were identified by multivariable Cox regression analysis. RESULTS: Biomarker signature score based on cytoplasmic ß-catenin, nuclear c-Myc, nuclear DVL and membrane α-catenin was associated with recurrence free survival [Hazard ratio = 1.11 (95% CI = 1.05, 1.17), p < 0.001, C-index = 0.68] and added significant prognostic value over clinical parameters (p < 0.001). The inclusion of Slug further improved prognostic utility (p < 0.001, C-index = 0.71). Biomarker Signature Scoreslug improved risk classification abilities for clinical outcomes at 3 years, accurately predicting recurrence in 79% patients in 1 year and 97% in 3 years in high risk group; 73% patients within low risk group did not have recurrence in 1 year, with AUC of 0.76. CONCLUSIONS: Our comprehensive risk model predictive for recurrence allowed us to determine the robustness of our biomarker panel in stratification of ESCC patients at high or low risk of disease recurrence; high risk patients are stratified for more rigorous personalized treatment while the low risk patients may be spared from harmful side effects of toxic therapy.

Strategic approach to minimally invasive necrosectomy for necrotizing pancreatitis: technique, complications and predictors of outcome.

BACKGROUND: Minimally invasive retroperitoneal necrosectomy has been an integral component of 'step-up' approach for infected pancreatic necrosis. Even though the clinical outcome of nephroscopic necrosectomy has been studied earlier, its predictor and morbidities following surgery have not been extensively evaluated. We aimed to evaluate the clinical outcome and early and late complications after percutaneous nephroscopic necrosectomy (PCNN). METHODS: The pre- and intra-operative as well as post-operative and follow-up data of severe pancreatitis patients undergoing PCNN were collected prospectively. RESULTS: Out of 115 patients requiring intervention, 40 patients (34.78%) improved with percutaneous drain alone and another 40 proceeded for PCNN. After exclusion, 37 patients successfully underwent 48 sessions of PCNN. Median number of PCNN session was 1 (1-4). Early complications were seen in 21 (56.75%) patients and mortality was experienced in eight (21.62%) patients. On median follow-up of 36 months, 12 (32.43%) patients experienced late complications. Persistent post-operative pancreatic fistula was observed in six (16.21%) patients. Of these, three developed late-onset pseudocyst, whereas one patient had disconnected duct syndrome. Seven patients experienced new-onset diabetes. Age, severity of pancreatitis, preoperative organ failure and multiorgan failure were significant predictors of mortality on univariate analysis (P ≤ 0.05 for each). The logistic regression analysis revealed presence of multiorgan failure before surgery as the sole predictor (P = 0.007; odds ratio 10.417; 95% confidence interval 1.759-61.672). CONCLUSION: Preoperative multiorgan failure was the most important predictor of mortality following PCNN. Late complications were seen in nearly one-third of patients emphasizing the need for long-term follow-up.

Pancreaticojejunostomy: Does the technique matter? A randomized trial.

BACKGROUND: Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial. METHODS: This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications. RESULTS: A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes. DISCUSSION: The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531).

Hepatic resection for predominantly large size hepatocellular carcinoma: Early and long-term results from a tertiary care center in India.

BACKGROUND AND AIM: There are no large series on hepatic resection for hepatocellular carcinoma (HCC) from India. We present the results of consecutive patients of HCC treated with hepatic resection at a tertiary care center in India. METHODS: The records of all patients who underwent hepatic resection for HCC in the Department of Gastrointestinal Surgery, All India Institute of Medical Sciences (New Delhi), were reviewed. The relevant perioperative and follow up data were extracted from a prospectively maintained database. RESULTS: Between January 1987 and December 2013, 81 patients [71 males; mean age: 49.2 ± 15.6 years] underwent hepatic resection for HCC. Of these, 23 (28 %) were cirrhotic and 36 (49 %) had hepatitis B. Hepatitis B was significantly more common in cirrhotic (77 % vs. 37 %; p = 0.001). Most patients had locally advanced disease at presentation [tumor size ≥10 cm in 61 (75 %); vascular tumor thrombus in 10 (12 %)]. Anatomical resection was done in 61 (75 %) including 56 major hepatic resections (≥3 segments). Overall in-hospital mortality was 13 (16 %) [cirrhotic 5 (22 %) vs. noncirrhotic 8 (14 %), p = 0.503]. Grade III-V complications (modified Clavien-Dindo classification) occurred in 25 (31 %) patients (cirrhotic 48 % vs. noncirrhotic 24 %; p = 0.037). Follow up information was available for 51 (75 %) patients. The median time to recurrence was 12 months, and most (86 %) occurred within 1 year. The recurrence-free survival at 1, 3, and 5 years was 48 %, 40 %, and 36 %, respectively. Positive resection margin and vascular invasion were significantly associated with very poor prognosis. CONCLUSION: Majority of Indian HCC patients present with locally advanced disease. Despite this, surgical resection provides a chance for long-term recurrence-free survival in a third of them.

Mitogen activated protein kinase kinase kinase 3 (MAP3K3/MEKK3) overexpression is an early event in esophageal tumorigenesis and is a predictor of poor disease prognosis.

BACKGROUND: Mitogen-activated protein kinase kinase kinase3 (MAP3K3/MEKK3) was identified to be differentially expressed in esophageal squamous cell carcinoma (ESCC) using cDNA microarrays by our laboratory. Here in we determined the clinical significance of MEKK3 in ESCC. METHODS: Immunohistochemical analysis of MEKK3 expression was carried out in archived tissue sections from 93 ESCCs, 47 histologically normal and 61 dysplastic esophageal tissues and correlated with clinicopathological parameters and disease prognosis over up to 7.5 years for ESCC patients. RESULTS: MEKK3 expression was significantly increased in esophageal dysplasia and ESCC in comparison with normal mucosa (ptrend < 0.001). Kaplan Meier survival analysis showed significantly reduced median disease free survival median DFS = 10 months in patients with MEKK3 positive ESCCs compared to patients with no immunopositivity (median DFS = 19 months, p = 0.04). ESCC patients with MEKK3 positive and lymph node positive tumors had median DFS = 9 months, as compared to median DFS = 21 months in patients who did not show the alterations (p = 0.01). In multivariate Cox regression analysis, combination of MEKK3 overexpression and node positivity [p = 0.015, hazard ratio (HR) = 2.082, 95% CI = 1.154 - 3.756] emerged as important predictor of reduced disease free survival and poor prognosticator for ESCC patients. CONCLUSIONS: Alterations in MEKK3 expression occur in early stages of development of ESCC and are sustained during disease progression; MEKK3 in combination with lymph node positivity has the potential to serve as adverse prognosticator in ESCC.

Slug is a predictor of poor prognosis in esophageal squamous cell carcinoma patients.

BACKGROUND: Slug, a regulator of epithelial mesenchymal transition, was identified to be differentially expressed in esophageal squamous cell carcinoma (ESCC) using cDNA microarrays by our laboratory. This study aimed to determine the clinical significance of Slug overexpression in ESCC and determine its correlation with clinicopathological parameters and disease prognosis for ESCC patients. METHODS: Immunohistochemical analysis of Slug expression was carried out in archived tissue sections from 91 ESCCs, 61 dysplastic and 47 histologically normal esophageal tissues. Slug immunopositivity in epithelial cells was correlated with clinicopathological parameters and disease prognosis over up to 7.5 years for ESCC patients. RESULTS: Increased expression of Slug was observed in esophageal dysplasia [cytoplasmic, 24/61 (39.3%) cases, p = 0.001, odd's ratio (OR) = 4.7; nuclear, 11/61 (18%) cases, p < 0.001, OR = 1.36] in comparison with normal esophageal tissues. The Slug expression was further increased in ESCCs [cytoplasmic, 64/91 (70.3%) p < 0.001, OR = 10.0; nuclear, 27/91 (29.7%) p < 0.001, OR = 1.42]. Kaplan Meier survival analysis showed significant association of nuclear Slug accumulation with reduced disease free survival of ESCC patients (median disease free survival (DFS) = 6 months, as compared to those that did not show overexpression, DFS = 18 months; p = 0.006). In multivariate Cox regression analysis nuclear Slug expression [p= 0.005, Hazard's ratio (HR) = 2.269, 95% CI = 1.289 - 3.996] emerged as the most significant independent predictor of poor prognosis for ESCC patients. CONCLUSIONS: Alterations in Slug expression occur in early stages of development of ESCC and are sustained during disease progression. Slug may serve as a diagnostic biomarker and as a predictor of poor disease prognosis to identify ESCC patients that are likely to show recurrence of the disease.

Endovascular management in abdominal visceral arterial aneurysms: A pictorial essay.

Visceral artery aneurysms (VAAs) include aneurysms of the splanchnic circulation and those of the renal artery. Their diagnosis is clinically important because of the associated high mortality and potential complications. Splenic, superior mesenteric, gastroduodenal, hepatic and renal arteries are some of the common arteries affected by VAAs. Though surgical resection and anastomosis still remains the treatment of choice in some of the cases, especially cases involving the proximal arteries, increasingly endovascular treatment is being used for more distal vessels. We present a pictorial review of various intra-abdominal VAAs and their endovascular management.

Overexpression of a splice variant of oncostatin M receptor beta in human esophageal squamous carcinoma.

BACKGROUND: Expression of oncostatin M receptor beta (OSMRß) has been reported in human cancers, however its role in esophageal squamous cell carcinoma (ESCC) remains unknown. Using differential display, earlier we reported the identification of an alternatively spliced variant of OSMRß in ESCC. Here in we characterized this novel variant encoding a soluble form of this receptor (sOSMRß) and determined its clinical significance and correlation with the expression of oncostatin (OSM) and leukemia inhibitory factor receptor beta (LIFR ß) in ESCC. MATERIALS AND METHODS: In silico analysis was carried out to characterize the differentially expressed transcript of OSMRß and its expression was determined in ESCCs and matched normal esophageal tissues using semiquantitative RT-PCR. The expressions of both truncated and full length OSMRß proteins were analyzed in ESCC tissues and patients' sera using western blotting and immunoprecipitation. By immunoprecipitation we have also shown direct interaction between sOSMRB and OSM. We also explored the relationship between expression of OSM and its receptors, OSMRß and LIFRß, in primary human ESCCs and normal epithelia using immunohistochemistry. RESULTS: Overexpression of alternatively spliced OSMR ß transcript was detected by RT-PCR in 9 of 11 ESCCs. Analysis of the soluble receptor revealed absence of sOSMRß protein in esophageal tissues, however, immunoprecipitation and western blot analysis showed its presence in sera of ESCC patients further confirming expression of the alternatively spliced OSMR ß in ESCC patients. Immunohistochemical analysis in tissue microarray (TMA) format showed expression of OSMR ß, LIFR and OSM in 11/50 (23%), 47/50 (94%) and 47/50 (94%) ESCCs, respectively. Strong correlation was observed between cytoplasmic expression of LIFRß and OSM in tumor cells (p = 0.000, O.R = 50, 95%CI = 8-31.9), and nuclear expression of LIFRß and OSM (p = 0.039 OR = 3.1, 95% CI = 1.1-8.2), suggesting that LIFRß serves as the major receptor in ESCCs. CONCLUSION: An alternatively spliced variant of OSMR transcribing a soluble form of this receptor has been characterized in ESCC. We speculate that the truncated OSMR characterized here in may act as a neutralizing receptor for OSM. Our immunohistochemical study showed that OSMRß and its pathway is not activated in ESCCs.

Clinical significance of GPR56, transglutaminase 2, and NF-κB in esophageal squamous cell carcinoma.

Proteins do not operate as individual units, and components of intracellular canonical pathways often cross talk in tumor genesis. We hypothesized that G-protein-coupled receptor 56 (GPR56), transglutaminase (TG2), and nuclear factor-κB (NF-κB) may collaborate in interconnected pathways and contribute to the aggressive behavior of esophageal squamous cell carcinoma (ESCC). Immunohistochemical analysis of GPR56, TG2, and NF-κB was carried out using ESCC tissue microarrays. Immunostaining of all the three proteins revealed a significant increase in their expression in ESCCs as compared with normal epithelia and correlated with their concomitant expression. A significant correlation between GPR56, TG2, and NF-κB was observed that correlated with nodal metastasis and tumor invasion in ESCCs.

Giant fibrovascular polyp of the esophagus: report of a case.

A fibrovascular polyp is a peculiar nonepithelial tumor of the esophagus that invariably arises in the cervical esophagus at the level of the thoracic inlet and grows distally into a massive elongated, pedunculated, intraluminal lesion. Although it is a benign lesion that is eminently resectable, it is a dramatic entity owing to its tendency to cause bizarre complications such as asphyxia and sudden death when it regurgitates into the pharynx and causes laryngeal impaction. This report describes the multimodality imaging appearance of an archetypal case of a giant fibrovascular polyp in a patient with a seemingly innocuous presentation for the size of the lesion. The essential role of cross-sectional imaging in establishing a prompt diagnosis, defining the tissue elements of the mass, and delineation of the exact extent of the lesion in guiding the treatment approach is highlighted. The appearance of fibrovascular polyp in a single patient with a combination of barium swallow, multidetector computed tomography, and high-resolution contrast-enhanced magnetic resonance imaging has not been reported previously.

Palliative stenting for relief of dysphagia in patients with inoperable esophageal cancer: impact on quality of life.

The aim of palliation in patients with inoperable esophageal cancer is to relieve dysphagia with minimal morbidity and mortality, and thus improve quality of life (QOL). The use of a self-expanding metal stent (SEMS) is a well-established modality for palliation of dysphagia in such patients. We assessed the QOL after palliative stenting in patients with inoperable esophageal cancer. Thirty-three patients with dysphagia due to inoperable esophageal cancer underwent SEMS insertion between October 2004 and December 2006. All patients had grade III/IV dysphagia and locally advanced unresectable cancer (n = 13), distant metastasis (n = 14), or comorbid conditions/poor general health status precluding a major surgical procedure (n = 6). Patients with grade I/II dysphagia and those with carcinoma of the cervical esophagus were excluded. The QOL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3) and EORTC QLQ-Esophagus (OES) 18 questionnaire (a QOL scale specifically designed for esophageal diseases) before and at 1, 4, and 8 weeks after placement of the stent. The mean age of the patients was 56 (range 34-78) years, and 22 were men. A covered SEMS was used in all patients. The most common site of malignancy was the lower third of the esophagus (n = 18, 55%). In 23 (77%) patients, the stent crossed the gastroesophageal junction. Seven patients required a reintervention for stent block (n = 5) and stent migration (n = 2). Dysphagia improved significantly immediately after stenting, and this improvement persisted until 8 weeks (16.5 vs. 90.6; P < 0.01). The global health status (5.8 vs. 71.7; P < 0.01) and all functional scores improved significantly after stenting from baseline until 8 weeks. Except pain (14.1 vs. 17.7; P = 0.67), there was significant improvement in deglutition (22.7 vs. 2.0; P < 0.01), eating (48 vs. 12.6; P < 0.01), and other symptom scales (19.7 vs. 12.1; P = 0.04) following stenting. The median survival was 4 months (3-7 months). Palliative stenting using SEMS resulted in significant improvement in all scales of QOL without any mortality and acceptable morbidity.

Thromboelastographic evaluation of coagulation in patients with extrahepatic portal vein thrombosis and non-cirrhotic portal fibrosis: a pilot study.

BACKGROUND AND AIMS: Non-cirrhotic portal hypertension due to extrahepatic portal vein thrombosis (EHO) and non-cirrhotic portal fibrosis (NCPF) is a major cause of upper gastrointestinal hemorrhage in India. Hypercoagulability has been proposed to explain the thrombosis in the portal vein in EHO and intrahepatic portal vein radicals in NCPF. However, some authors have reported hypocoagulability in these patients. Thromboelastography (TEG), which gives a dynamic assessment of coagulation, has potential for evaluating coagulation in these patients but has not been used so far. It was the aim of this study to evaluate the coagulation status in patients of EHO and NCPF using TEG. METHODS: Thirty patients with EHO and 19 patients with NCPF were studied. TEG was done in all patients. R (reaction time), K (constant), alpha (angle), MA (maximal amplitude), A 60 (width of tracing after 60 min) were recorded and TEG index calculated and compared to controls. RESULTS: Seven patients (23.3%) in the EHO group and eight (42.1%) in the NCPF group had severe thrombocytopenia (platlets, < 50 000 cells/dL). TEG showed significantly shorter R, higher MA and larger A in both EHO and NCPF compared to controls (P < 0.01). Thrombocytopenia normalized A but R continued to be significantly shorter in EHO and NCPF. Overt hypercoagulability (TEG index, > +2.5) was seen in two patients with EHO and one patient with NCPF. CONCLUSION: A latent hypercoagulable state exists in patients with EHO and NCPF which is partially masked by the thrombocytopenia secondary to splenomegaly and hypersplenism.

Endoscopic or percutaneous biliary drainage for gallbladder cancer: a randomized trial and quality of life assessment.

BACKGROUND & AIMS: Patients with carcinoma of the gallbladder (GBC) and obstructive jaundice are usually not amenable to curative resection. Effective palliation by biliary decompression is the goal of treatment. Endoscopic stenting (ES) and percutaneous transhepatic biliary drainage (PTBD) can provide biliary decompression. We compared unilateral PTBD and ES in patients with a hilar block caused by GBC and assessed their quality of life (QOL). METHODS: Consecutive patients with GBC not suitable for curative resection with Bismuth type 2 or 3 block were randomized to either PTBD or ES with a 10F plastic stent. Technical success, successful drainage, early cholangitis, complications, procedure-related mortality, 30-day mortality, survival, and QOL before and 1 and 3 months after stenting were compared between the 2 groups. All patients were followed up until death. RESULTS: Fifty-four patients were randomized to PTBD or ES (27 each). Successful drainage was better in the PTBD group (89% vs 41%; P < .001). Early cholangitis was significantly higher in the ES group (48% vs 11%; P = .002). Procedure-related (4% vs 8%) and 30-day mortality (4% vs 8%) and median survival were similar (60 days in both; P = .71). Although the World Health Organization-Quality of Life 1- and 3-month physical and psychological scores were better after PTBD, the difference was not significant. The European Organization for Research and Treatment of Cancer (EORTC)-Quality of Life Questionnaire 30 global health status at 3 months was significantly better after PTBD (75 vs 30.5, P = .02). The EORTC symptom scores improved in both groups, but only fatigue was significantly better after PTBD. CONCLUSIONS: PTBD provides better biliary drainage and has lower complication rates in patients with GBC and hilar block.

Esophageal perforation--the problems of late presentation.

BACKGROUND/AIMS: Esophageal perforation is an uncommon and difficult problem. Delay in diagnosis and appropriate treatment often results in a high morbidity and mortality. Along with the duration after the perforation, several other factors determine the outcome in these patients. The presentation, treatment and outcome of these patients have not been discussed adequately in recent literature. METHODOLOGY: We analyzed all the patients of esophageal perforation managed by us with respect to their presentation, treatment and outcome. RESULTS: We have managed 52 patients of esophageal perforation. The commonest cause was iatrogenic injury (50%). Thirty-two (61%) patients presented >2 days after the perforation. Twenty-two patients (42%) underwent esophageal exclusion and diversion procedures, 25 underwent other procedures and 5 were managed conservatively. Major morbidity (mainly pulmonary) was seen in 61% patients and the overall mortality was 17%. There was no mortality in patients who presented early (<2 days). Mortality was associated with late presentation beyond 2 days, low serum albumin (< 3 g/dl) and the requirement of perioperative mechanical ventilation. CONCLUSIONS: Esophageal perforation (especially late presentation) results in a high morbidity and mortality. Esophageal exclusion and diversion is a useful temporizing measure in these very sick patients. Prompt recognition, early referral and proper management of esophageal perforation are needed in order to decrease the mortality and morbidity.

Giant haemangioma of the liver: is enucleation better than resection?

INTRODUCTION: Haemangioma is the most common liver tumour. Treatment is indicated for symptomatic tumours, rapid increase in size, rupture or doubt in diagnosis. There is continuing debate regarding the ideal method of surgical treatment for liver haemangiomas, with some surgeons favouring enucleation over liver resection. PATIENTS AND METHODS: Retrospective analysis of prospectively compiled database of patients who were surgically treated for liver haemangioma. RESULTS: Between 1987 and 2003, we operated on 21 patients with liver haemangioma. Pre-operative diagnosis on imaging was made in 16 patients (13 symptomatic, 3 had progressive increase in size). In five patients, the indication of surgery was uncertain diagnosis. Enucleation was performed in 9 patients and liver resection in 12. The size of the haemangioma was similar in the enucleation and resection groups (8.9 cm versus 10 cm; P = 0.85). The mean intra-operatiive blood loss was significantly less in the enucleation group (400 ml versus 1330 ml; P = 0.004). The mean operative time was significantly less in the enucleation group as compared to the resection group (170 min versus 230 min; P = 0.035). Five patients had major postoperative morbidity in the resection group as compared to none in the enucleation group (P = 0.045). The duration of hospital stay was significantly longer in the resection group.(9.9 days versus 5.6 days; P = 0.005). CONCLUSIONS: Enucleation of liver haemangiomas is safer, quicker and associated with less morbidity than liver resection. Except for some situations, such as uncertain diagnosis or total replacement of a lobe, we recommend enucleation as the surgical procedures of choice for the treatment of hepatic haemangiomas.

Hepatobiliary and pancreatic tuberculosis: a two decade experience.

BACKGROUND: Isolated hepatobiliary or pancreatic tuberculosis (TB) is rare and preoperative diagnosis is difficult. We reviewed our experience over a period two decades with this rare site of abdominal tuberculosis. METHODS: The records of 18 patients with proven histological diagnosis of hepatobiliary and pancreatic tuberculosis were reviewed retrospectively. The demographic features, sign and symptoms, imaging, cytology/histopathology, procedures performed, outcome and follow up data were obtained from the departmental records. The diagnosis of tuberculosis was based on granuloma with caseation necrosis on histopathology or presence of acid fast bacilli. RESULTS: Of 18 patients (11 men), 11 had hepatobiliary TB while 7 had pancreatic TB. Two-thirds of the patients were < 40 years (mean: 42 yrs; range 19-70 yrs). The duration of the symptoms varied between 2 weeks to 104 weeks (mean: 20 weeks). The most common symptom was pain in the abdomen (n = 13), followed by jaundice (n = 10), fever, anorexia and weight loss (n = 9). Five patients (28%) had associated extra-abdominal TB which helped in preoperative diagnosis in 3 patients. Imaging demonstrated extrahepatic bile duct obstruction in the patients with jaundice and in addition picked up liver, gallbladder and pancreatic masses with or without lymphadenopathy (peripancreatic/periportal). Preoperative diagnosis was made in 4 patients and the other 14 were diagnosed after surgery. Two patients developed significant postoperative complications (pancreaticojejunostomy leak 1 intraabdominal abscess 1) and 3 developed ATT induced hepatotoxicity. No patient died. The median follow up period was 12 months (9-96 months). CONCLUSION: Tuberculosis should be considered as a differential diagnosis, particularly in young patients, with atypical signs and symptoms coming from areas where tuberculosis is endemic and preoperative tissue and/or cytological diagnosis should be attempted before labeling them as hepatobiliary and pancreatic malignancy.

Acute cholecystitis with massive upper gastrointestinal bleed: a case report and review of the literature.

BACKGROUND: Cystic artery pseudoaneurysm is a rare complication following cholecystitis. Its presentation with upper gastrointestinal hemorrhage (UGIH) is even rarer. Thirteen patients with cystic artery pseudoaneurysm have been reported in the literature but only 2 of them presented with UGIH alone. CASE PRESENTATION: We report a 43-year-old woman who developed a cystic artery pseudoaneurysm following an episode of acute cholecystitis. She presented with haematemesis and melaena associated with postural symptoms. Upper gastrointestinal endoscopy revealed a duodenal ulcer with adherent clots in the first part of the duodenum. Ultrasonography detected gallstones and a pseudoaneurysm at the porta hepatis. Selective hepatic angiography showed two small pseudoaneurysms in relation to the cystic artery, which were selectively embolized. However, the patient developed abdominal signs suggestive of gangrene of the gall bladder and underwent an emergency laparotomy. Cholecystectomy with common bile duct exploration along with repair of the duodenal rent, and pyloric exclusion and gastrojejunostomy was done. CONCLUSION: This case illustrates the occurrence of a rare complication (pseudoaneurysm) following cholecystitis with an unusual presentation (UGIH). Cholecystectomy, ligation of the pseudoaneurysm and repair of the intestinal communication is an effective modality of treatment.

Clinical significance of sperm protein 17 expression and immunogenicity in esophageal cancer.

We recently identified sperm protein 17 (Sp17) transcripts in esophageal squamous cell carcinomas (ESCCs) by differential display. This study was designed to determine the clinical significance of Sp17 protein in different stages of esophageal tumorigenesis and to test the hypothesis that aberrant localization of Sp17 protein to immunosurveillant site may lead to production of anti-Sp17 antibodies in serum, which may be of clinical relevance in ESCCs. Sp17 transcripts were detected by RT-PCR in 26 of 30 (86%) ESCCs, while no transcripts were detected in normal esophageal tissues. Rabbit polyclonal antibody was raised against an immunogenic peptide of Sp17 and used to evaluate protein expression by immunohistochemistry. Expression of Sp17 protein was observed in 60/80 (75%) of ESCCs and 27/30 (90%) dysplastic tissues, while no detectable Sp17 expression was observed in 13 distant histologically normal epithelia. Sixteen of the 60 immunopositive ESCCs showed nuclear expression in addition to cytoplasmic localization of the protein. The circulating levels of anti-Sp17 antibodies, determined by ELISA, were significantly elevated in ESCC patients when compared with normal subjects (p < 0.001). Increasing Sp17 antibody titers were observed to be associated with the progressive disease in 4 patients. In conclusion, the study demonstrates expression of Sp17 protein in esophageal tumor as well as dysplastic tissues, suggesting it to be an early event in the development of ESCC. To our knowledge, this is the first report showing elevated levels of anti-Sp17 antibodies in ESCC patients.