Optimizing First-Line Chemotherapy in Metastatic Pancreatic Cancer: Efficacy of FOLFIRINOX versus Nab-Paclitaxel Plus Gemcitabine.

Pancreatic cancer (PC) is one of the most lethal tumors in Europe with an overall 5-year survival rate of 5%. Since 1992, gemcitabine (Gem) has been the treatment of choice for metastatic disease with significant improvement in median overall survival (OS) compared to fluorouracil. A good performance status (PS) at diagnosis appears to be a strong predictive factor for better survival. Overall, 50% of PC are metastatic or locally advanced at diagnosis, and more than 70% of the resected patients will experience a recurrence, with a median OS ranging from 4 to 10 months (mos). FOLFIRINOX (5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) and Nab-paclitaxel (Nab-p) plus Gem have recently increased survival of patients with metastatic PC, over Gem. Treatment with FOLFIRINOX is generally considered more effective with respect to the doublet, with toxicity concerns, FOLFIRINOX achieves an overall response rate (ORR) of 31.6%, while for Nab-p plus Gem ORR is 23%; however, FOLFIRINOX was associated with higher rates of grade 3 and higher adverse events. Although the international guidelines indicate that both regimens can be used as first-line therapy for patients with metastatic PC, FOLFIRINOX is the most widely used; Nab-p plus Gem is more frequently used in patients with lower PS. In this review, we critically analyze these two regimens to give a pragmatic guide to treatment options.

Circulating tumor cells and microemboli can differentiate malignant and benign pulmonary lesions.

The presence of circulating tumor cells (CTC) or microemboli (CTM) in the peripheral blood can theoretically anticipate malignancy of solid lesions in a variety of organs. We aimed to preliminarily assess this capability in patients with pulmonary lesions of suspected malignant nature. We used a cell-size filtration method (ScreenCell) and cytomorphometric criteria to detect CTC/CTM in a 3 mL sample of peripheral blood that was taken just before diagnostic percutaneous CT-guided fine needle aspiration (FNA) or core biopsy of the suspicious lung lesion. At least one CTC/CTM was found in 47 of 67 (70%) patients with final diagnoses of lung malignancy and in none of 8 patients with benign pulmonary nodules. In particular they were detected in 38 (69%) of 55 primary lung cancers and in 9 (75%) of 12 lung metastases from extra-pulmonary cancers. Sensitivity of CTC/CTM presence for malignancy was 70.1% (95%CI: 56.9-83.1%), specificity 100%, positive predictive value 100% and negative predictive value 28.6% (95%CI: 11.9-45.3%). Remarkably, the presence of CTC/CTM anticipated the diagnosis of primary lung cancer in 3 of 5 patients with non-diagnostic or inconclusive results of FNA or core biopsy, whereas CTC/CTM were not observed in 1 patient with sarcoidosis and 1 with amarthocondroma. These results suggest that presently, due to the low sensitivity, the search of CTC/CTM cannot replace CT guided percutaneous FNA or core biopsy in the diagnostic work-up of patients with suspicious malignant lung lesions. However, the high specificity may as yet indicate a role in cases with non-diagnostic or inconclusive FNA or core biopsy results that warrants to be further investigated.

Consensus guidelines on severe acute pancreatitis.

This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.

A novel type of ureteral stents in the treatment of a bilateral iatrogenic transaction of the ureters.

This report illustrates the case of a patient who suffered an iatrogenic complete injury of both ureters after a complex surgical procedure to remove a large sacral chordoma. Ureteral recanalization was achieved with two removable, autoexpandable, and polytetrafluoroethylene covered nitinol stents. To our knowledge, we describe the first application of this type of stents to treat a bilateral ureteral transection. Despite the bad general conditions of the patient, the ureteral stents successfully restored and maintained the bilateral ureteral continuity.

Pancreatic fistula: A proposed percutaneous procedure.

AIM: To propose a percutaneous treatment for otherwise intractable pancreatic fistula (PF). METHODS: From 2005 to 2011, 12 patients (9 men and 3 women, mean age 59 years, median 63 years, range 33-78 years) underwent radiological treatment for high-output PF associated with peripancreatic fluid collection. The percutaneous procedures were performed after at least 4 wk of unsuccessful conservative treatments. We chose either a one or two step procedure, depending on the size and characteristics of the fistula and the fluid collection (with an arbitrary cut-off of 2 cm). Initially, 2 to 6 pigtail drainages of variable size from 8.3 (8.3-Pig Duan Cook, Bloomington, Indiana, United States) to 14 Fr (Flexima, Boston Scientific, Natick, United States) were positioned inside the collection using a transgastric approach. In a second procedure, after 7-10 d, two or more endoprostheses (cystogastrostomic 8 Fr double-pigtail, Cook, Bloomington, Indiana, United States in 10 patients; covered Niti-S stent, TaeWoong Medical Co, Seoul, South Korea in 2 patients) were placed between the collection and the gastric lumen. In all cases the metal or plastic prostheses were removed within one year after positioning. RESULTS: Four out of 12 high-output fistulas fistulas were external while 8/12 were internal. The origin of the fistulous tract was visualised by computer tomography (CT) imaging studies: in 11 patients it was at the body, and in 1 patient at the tail of the pancreas. Single or multiple drainages were positioned under CT guidance. The catheters were left in place for a varying period (0 to 40 d - median 10 and 25(th)-75(th) percentile 0-14). In one case external transgastric drainages were left in place for a prolonged time (40 d) due to the presence of vancomycin-resistant bacteria (Staphylococcus) and fluconazole-resistant fungi (Candida) in the drained fluid. In this latter case systemic and local antibiotic therapy was administered. In both single and two-step techniques, when infection was present, we carried out additional washing with antibiotics to improve the likelihood of the procedure's success. In all cases the endoprostheses were left in situ for a few weeks and endoscopically removed after remission of collections, as ascertained by CT scan. Procedural success rate was 100% as the resolution of external PF was achieved in all cases. There were no peri-procedural complications in any of the patients. The minimum follow-up was 18 mo. In two cases the procedure was repeated after 1 year, due to the onset of new fluid collections and the development of pseudocysts. Indeed, this type of endoprosthesis is routinely employed for the treatment of pseudocysts. Endoscopy was adopted both for control of the positioning of the endoprosthesis in the stomach, and for its removal after resolution of the fistula and fluid collection. The resolution of the external fistula was assessed clinically and CT scan was employed to demonstrate the resolution of peripancreatic collections for both the internal and external fistulae. CONCLUSION: The percutaneous placement of cistogastrostomic endoprostheses can be used for the treatment of PF that cannot be treated with other procedures.

High-intensity focused ultrasound provides palliation for liver metastasis causing gastric outlet obstruction: case report.

BACKGROUND: Surgery is the standard of care in several oncologic diseases. However, when non-surgical candidates are not suitable for radical treatment, palliation must be achieved at least. High-intensity focused ultrasound uses ultrasound power that can be sharply focused for highly localised application, as it is a completely non-invasive procedure. Its non-invasiveness appears to be of paramount importance in critically ill patients. CASE DESCRIPTION: We describe the use of ultrasound-guided high-intensity focused ultrasound for a large liver metastasis from breast cancer causing gastric outlet obstruction in a metastatic disease. The left liver deposit did not allow the stomach to empty due to its large volume, and the patient was unable to eat properly. The tumour was metastatic, resistant to chemotherapy and had a size that contraindicated an ablation percutaneous technique. To improve the patient's quality of life, ultrasound-guided high-intensity focused ultrasound ablation seemed the only and most suitable option. Therefore, a high-intensity focused ultrasound treatment was performed, no complications occurred and the patient's general condition has improved since the early post-procedural period. Three months after treatment, two body mass index points were gained, and the lesion decreased by 72% in volume as detected through multi-detector computed tomography follow-up. DISCUSSION AND CONCLUSION: Quality of life is an unquestionable goal to achieve, and palliation must be achieved while causing as little harm as possible. In this view, debulking surgery and percutaneous ablation technique seemed not appropriate for our patient. Instead, high-intensity focused ultrasound combined several advantages, no lesion size limit and a totally non-invasive treatment. Thus, this technique proved to be a clinically successful procedure, offering better disease control and quality of life. In circumstances where other alternatives clearly seem to fail or are contraindicated, high-intensity focused ultrasound can be used and can provide benefits. We recommend its use and development in several oncologic diseases, not only for therapeutic purposes but also for the improvement of patient's quality of life.

Isolated chest wall implantation of non-small cell lung cancer after fine-needle aspiration: a case report and review of the literature.

Percutaneous fine-needle aspiration biopsy (FNAB) is a well-established and useful procedure in the diagnosis of lung squamous cell carcinoma (LSCC). Tumor seeding has been shown to be a potential risk. We report the case and management of a 78-year-old patient affected by LSCC who developed a chest wall metastasis in a straight line from the primary lesion along the FNAB needle track. Although tumor seeding after FNAB is a rare but possible complication, we suggest that careful examination for implantation (with periodical CT scans) should be performed for at least three years after FNAB.

A challenging case of epigastric pain: diagnosis and mini-invasive treatment of a large gastroduodenal artery pseudoaneurysm.

The authors present a case of a gastroduodenal artery pseudoaneurysm in a patient with a medical history of pancreatic surgery. The lesion was found and evaluated by ultrasound, CT-angiography and then treated with trans-catheter embolisation. This mini-invasive approach led to a complete resolution of the lesion.

Transient hepatic attenuation difference (THAD) in biliary duct disease.

BACKGROUND: THADs are associated with a wide spectrum of hepato-biliary pathologies. The aim of this paper is to find out the role of THADs in the imaging assessment of biliary diseases. We performed a retrospective study to establish the frequency of arterial phenomena in patients with specific biliary diseases. METHODS: Out of 1833 patients who underwent upper abdomen biphasic CT (2003-2007), we selected those with the following diagnoses: biliary duct dilation due to extrahepatic obstruction (20 patients-group A), intrahepatic-hilar cholangiocellular-carcinoma (19 patients-group B), and cholangitis (14 patients-group C). THAD presence/pattern was assessed for each group. Patients without any demonstrable clinical/imaging signs of liver/biliary pathology (1124) were the control group. RESULTS: THADs were observed in 36/53 (67.9%) and 20/1124 (1.78%) in study and control groups respectively, with significant association between each diagnostic group and THAD patterns (P < 0.0001). Eleven out of 20 (55%) group A patients showed peribiliary-THAD around dilated biliary tracts; 15/19 (79%) group B patients demonstrated portal involvement and sectorial-THAD; 10/14 (71%) group C patients revealed polymorphous-THAD all along inflamed biliary duct. CONCLUSIONS: However, THADs are complex phenomena, their evaluation can be an additional diagnostic tool in patients with a biliary pathology. Diffuse peribiliary, sectorial, and polymorphous-THADs show a good rate of correlation (P < 0.0001) with biliary duct ectasia, portal infiltration, and cholangitis, respectively.

On-site evaluation of percutaneous CT-guided fine needle aspiration of pulmonary lesions. A study of 321 cases.

PURPOSE: The aim of this study was to assess the usefulness of having a cytopathologist present during percutaneous CT-guided fine needle aspiration (FNA) of pulmonary lesions. MATERIALS AND METHODS: Three hundred and twenty-one FNAs of lung lesions were performed in 312 patients (218 males, 94 females; age range: 20-86 years; mean age: 66 yrs). Nodule sizes ranged from 0.5 to 8 cm. The sampling was performed by a radiologist under CT-guidance; the calibre of the needle used was 20-25 G. Smears were prepared in the Radiology Department and stained using a quick method by a cytopathologist: the sample adequacy was assessed and, if possible, a preliminary diagnosis was made. An additional FNA was requested if the first aspirate was considered diagnostically inadequate. The diagnostic accuracy was examined by reviewing the clinical data and by correlating with the histological material and the clinical outcome. RESULTS: Satisfactory diagnostic material was obtained in 275 of the 321 FNA (86%): 231 were malignant (72%), 8 suspicious (3%) and 36 were negative for malignancy (11%). Forty-six of the 321 specimens (14%) were considered inadequate for any diagnostic verification. An additional FNA was performed immediately in 60 cases (19%). Forty-two subjects developed pneumothorax: 21 patients (50%) of these required thoracic drainage. Blood effusion around the lesion site or adjacent to the needle path was observed in 39 patients (12%). Sensitivity was 99%, specificity was 95% and diagnostic accuracy was 99%. CONCLUSIONS: CT guided aspiration cytology can be a safe and fast procedure for lung nodule characterisation. On-site immediate evaluation of FNA specimens can be beneficial in determining the adequacy of the aspirate and in providing accurate preliminary diagnoses of the specimens, thus allowing for rapid clinical decisions.

p53 and DPC4 alterations in the bile of patients with pancreatic carcinoma.

INTRODUCTION: Pancreatic cancer is still predominantly diagnosed in advanced stages, and 85%-90% of patients are not eligible for surgery at diagnosis. This is mainly due to the great difficulty in detecting the tumour at an early stage and presently no satisfactory results have been obtained to overcome this problem. Studies on molecular genetic profile of pancreatic cancer may represent an important approach. This study was focused on the mutations of p53 and DPC4 detectable in the bile of patients with histologically proven pancreatic cancers. MATERIALS AND PATIENTS: We analysed specimens of bile collected through percutaneous transhepatic biliary catheters, placed to treat malignant biliary obstruction in 25 patients with pancreatic adenocarcinoma. A percentage of mutation was obtained of 43 % for the microsatellite D17S945 (p53), 54% and 50 % for D18S46 and D18S474 (DPC4), respectively. The percentage of amplification was 67%, 93,6%, and 80%. CONCLUSION: We consider the results encouraging enough to decide to enlarge the number of patients examined. The aim is to determine if a test for DPC4 and p53 mutations is eligible for introduction in clinical routine use. More sets of samples are required to satisfactorily answer this question.