Duodenal Ampulla Neuroendocrine Tumor with GISTs of the Proximal Jejunum: A Case Report.

Neuroendocrine tumors (NEN) are a type of heterogenous, slow-growing tumors, that only in about half of the cases can be found in the gastrointestinal tract. Half of these is in the small intestine. The ampullary NENs are rare, accounting for less than 1% of gastroenteropancreatic NENs. Gastrointestinal stromal tumors (GIST) are a more common type of tumors of the gastrointestinal tract that consist of pacemaker cells. The occurrence of both tumors simultaneously is rare, but in patients with neurofibromatosis type 1, the co-existence of NEN and GIST is more often. Here we report a case of simultaneous occurrence of a well-differentiated NEN and a GIST in a patient without neurofibromatosis. Also, we provide a short review of the current knowledge and treatment strategies regarding these tumors.

Endoscopic Ultrasound-guided Biopsy of Liver Tumors.

BACKGROUND/AIM: Endoscopic ultrasound (EUS)-guided liver tumor biopsy has some advantages over the percutaneous and surgical route and, in many cases, should be preferred. The aim of this study was to evaluate the role of EUS-fine needle aspiration (FNA) in the diagnosis of liver tumors with an emphasis on its diagnostic accuracy and histological quality of the acquired specimen. PATIENTS AND METHODS: We followed 30 consecutive patients who underwent liver tumor biopsy using EUS guidance. Tissue was acquired using a 22-gauge FNA needle. RESULTS: In 97% of patients, the results of EUS-FNA were adequate for diagnosis. In one case, the pathologist recommended a repeat biopsy. The acquired specimen was a core fragment in 81% of cases while in 19% of cases the specimen was fragmented and subsequently used as a cell block. No complications were reported. CONCLUSION: EUS-FNA is characterized by a high success rate on the acquisition of good-quality tissue specimens, a low rate of complications, and decreased patient discomfort. This procedure should be especially considered in the case of liver lesions that are inaccessible via the percutaneous route or when concurrent biopsies are required for accurate diagnosis.

Wilkie's syndrome as a cause of anxiety-depressive disorder: A case report and review of literature.

BACKGROUND: Superior mesenteric artery syndrome is a disease with a complex diagnosis, and it is associated with complications that make it even harder to identify. Currently, a frequent association with psychiatric disorders has been noted. Despite numerous case reports and case series, the variability of the disease has not allowed the development of protocols regarding diagnosis and management. CASE SUMMARY: A 33-year-old woman presented with abdominal pain, nausea, and bile vomiting over the last 15 mo, associated with a 15-kg weight loss over the last three months. After the onset of the symptoms, the patient was diagnosed with anxiety-depressive disorder and treated appropriately. Standard examinations excluded an organic cause, and the cause of the symptoms was considered psychogenic. The persistence of symptoms, even under treatment, prompted a computer tomography angiography examination of the abdomen and pelvis. The examination identified emergence at a sharp angle of 13.7° of the superior mesenteric artery, with a reduced distance between the artery and the anterior wall of the aorta up to a maximum of 8 mm. A diagnosis of aortomesenteric clamp was established. Surgical treatment by laparoscopic duodenojejunostomy was performed. Postoperative evolution was marked by a patent anastomosis at 1 mo, with a 10-kg weight gain and improvement of the associated anxiety. CONCLUSION: This case report underlines two major aspects. One aspect refers to the predisposition of patients with superior mesenteric artery syndrome to develop psychiatric disorders, with an excellent outcome when proper treatment is administered. The second aspect underlines the key role of a multidisciplinary approach and follow-up.

Ultrasound Image Computerized Analysis for Non-invasive Quantitative Evaluation of Hepatic Fibrosis.

BACKGROUND: Assessing the diagnostic value of liver ultrasound image computerized analysis (USICA) for hepatic fibrosis (HF) staging in respect to the "gold standard" provided by liver biopsy (LB). METHODS: Two-hundred twenty-eight patients with chronic hepatopathies were prospectively enrolled in the study. All the patients underwent LB and abdominal ultrasound (US). For quantitative US assessment of HF, an image analysis software was developed and 3 parameters were extracted by wavelet processing of the region of interest: mHLlivermHHliver, mHLlivermLLliver, and mHLlivermHLspleen. To assess the relevance of each feature, the support vector machine (SVM) classifiers were employed to discriminate between the 2 severity classes (i.e., incipient F1-F2 vs advanced F3-F4 fibrosis). The statistical significance of the HF staging was assessed using SVM classifiers, in terms of sensitivity (Se), specificity (Sp), and receiver operating characteristic (ROC) curves. RESULTS: A cut-off value of 0.342 of mHLlivermHHliver allowed the discrimination between the incipient and advanced HF with 79.5% Se and 77.4% Sp, at an area under receiver operating characteristic (AUROC) value of 0.867 (P < .001). CONCLUSION: The proposed USICA using wavelet filter parameters proved to be an innovative method that is useful for the initial noninvasive evaluation and quantification of HF, with the advantages of simplicity, short calculation time, accessibility, and repeatability. The mHLlivermHHliver parameter has demonstrated good accuracy in distinguishing incipient and advanced HF and can be considered an effective non-invasive imaging marker for the assessment of HF in patients with chronic hepatic disease.

Accuracy of endoscopic ultrasound-guided biopsy of focal liver lesions.

AIM: Endoscopic ultrasound (EUS) has become an indispensable method for diagnosis in gastroenterology and new indications for EUS continue to emerge. However, there are limited data regarding the accuracy of EUS-guided biopsy of hepatic focal lesions. The aim of this study was to assess the diagnostic yield of EUS-guided fine needle aspiration (FNA) of focal liver lesions. MATERIAL AND METHODS: We conducted a prospective study in which patients with focal liver lesions, detected by transabdominal ultrasound and computed tomography or magnetic resonance imaging, underwent EUS-guided FNA to determine the diagnostic yield of the procedure. RESULTS: In 47/48 of patients, the results of EUS-FNA were positive for malignancy, while in one case the acquired fragment was insufficient for appropriate histological analysis. Diagnostic yield was 0.98. In 83% of the cases biopsies were taken from the left lobe and in 17% from the right lobe with the same technical success rate. The most common diagnosis was metastatic adenocarcinoma of the pancreas (26% cases) followed by cholangiocarcinoma (17% cases). Concurrent sampling of other sites in addition to the liver and/or primary tumor was realized in 35% of the cases, with results that correlated with the liver biopsy and with the primary tumor biopsy. We reported no immediate or long-term complications in any of the patients. CONCLUSIONS: EUS guided fine needle aspiration/biopsy of focal liver lesions is safe, provides a very high diagnostic accuracy and should not be considered only as a rescue method after failure of percutaneous guided biopsies.

New inductive proximity sensor platform for precise localization of small colorectal tumors.

Location of small gastric or colorectal tumors during a laparoscopic procedure is often imprecise and can be misleading. There is a real need for a compatible and straightforward tool that can be used intraoperatively to help the surgeon in this regard. We emphasize in the present work on the fabrication of a new and innovative inductive proximity switch architecture, fully compatible with laparoscopic surgery and with direct application in precise localisation of bowel tumors. An electromagnetic detection probe optimized for laparoscopic surgery and preconditioned for sterilisation was designed and constructed. Various metallic markers designed to be attached to the gastrointestinal mucosa were used for detection by the probe, from standard endoscopic and laparoscopic haemostatic clips to other custom made tags. Experiments were performed in dry and wet-lab experimental laboratory environment using ex-vivo segments of calf's small bowel and colonic surgical specimens from human patients. The dry-lab detection range varied considerably depending on the metallic component of the tags, from 0.5 mm for the endoscopic hemostatic clip to 3.5 mm for the 0.9 mm thickness stainless-steel custom tags. The latter was actually detectable from the serosal side of the fresh colonic surgical specimens in 85% of the attempts if the scanned area was less than 150 cm2 and less than 2 mm of fat was interposed between the probe and the bowel. The newly designed system has the potential to discover metallic tags attached to the bowel mucosa for precise intraoperative laparoscopic location of digestive tumors. Further work is in progress to increase the sensitivity and detection range of the system in order to make it fully compatible with the clinical use.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of paraesophageal lung tumors - diagnostic yield and added value.

AIMS: There are few data on the use of endoscopic ultrasound (EUS) for the biopsy of suspected malignant lesions of the lung. The main objective of this study was to evaluate the performance of transesophageal EUS fine needle aspiration (EUSFNA) for the diagnosis of paraesophageal lung tumors and also for the confirmation of metastatic sites of lung cancer during the same procedure. MATERIAL AND METHODS: We performed a retrospective study in a tertiary care unit including 19 patientswith paraesophageal lung tumors referred to our department for a lung biopsy. Transesophageal EUS-FNA was performed using a linear echoendoscope and 22G needles. RESULTS: In all 19 patients with suspected lung tumors the confirmation of the malignant disease was achieved. Pathological examination revealed 16 cases of non-small cell lung cancers, 2 small cell lung cancers and one case of lung metastases. Diagnostic yield of lung EUS-FNA was 1, with no post-procedural complications. In 7 cases, we performed also biopsies of suspected metastasis and all biopsies revealed the same histopathological type as the primary tumor. CONCLUSIONS: Our study supports the use of this minimally invasive technique for paraesophageally locatedlung tumors and demonstrates that EUS-FNA is safe and has an excellent diagnostic yield.

Hepatocellular carcinoma in patients with autoimmune hepatitis - a systematic review of the literature published between 1989-2016.

BACKGROUND AND AIMS: Liver cancer is one of the most common cause of deaths from cancer. Hepatocellular carcinoma (HCC) was reported at a frequency of 7% of patients with autoimmune hepatitis (AIH) - related cirrhosis in 1988. We aimed to provide a systematic literature review on the frequency of HCC in patients with AIH, after the discovery of hepatitis C virus (HCV), in order to avoid any possible confounding etiology. METHODS: A literature search of the PubMed database between 1989-2016 was performed, using the relevant keywords "hepatocellular carcinoma" and "autoimmune hepatitis". We followed the PRISMA statement guidelines during the preparation of this review. RESULTS: Eleven studies (n=8,460 patients with AIH) were retained for the final analysis. HCC was diagnosed in 0-12.3% of the AIH patients included in these studies. The overall occurrence of HCC in patients with AIH was estimated in two studies, at 5.1% and 6.2%, respectively. In patients with AIH and cirrhosis, the percentage of HCC varied between 0.2%-12.3%. The proportion of HCC in patients with AIH without cirrhosis was estimated at 1.03%. The percentage of cirrhosis in AIH patients varied from 18.7% to 83.3% in Japan, and from 12% to 50.2% in the other areas. The mean follow-up of the patients with AIH was of 10 years. CONCLUSIONS: The development of HCC in patients with AIH appeared to be similar before and after the discovery of HCV, and it was mainly associated to cirrhosis. The number of patients developing cirrhosis in relation with AIH was impressive. The long evolution of AIH to cirrhosis and, eventually, to HCC, has been be suggested.

Ultrasound-guided biopsy of osteolytic metastasis - could be less than three cores enough?

AIMS: The purpose of this study was to analyze the diagnostic yield and accuracy of the ultrasound (US) guided core biopsy in a population of patients with osteolytic metastasis. MATERIALS AND METHODS: We performed a retrospective analysis of 16 consecutive cases of US-guided core biopsies of osteolytic lesions performed in our Ultrasound Unit, from January 2006 to May 2017. We used 18G or 16G Tru-cut needles coupled with automated biopsy guns. We procured a maximum number of two tissue specimens per patient. RESULTS: We obtained a diagnostic yield and accuracy of 93.75% (15 of 16 patients) for US-guided core biopsy of osteolytic metastasis. Most of our cases were metastasis of adenocarcinomas (8 patients), squamous cell carcinomas (3 patients) followed by multiple myelomas (2 patients). Other pathologic lesions recorded were undifferentiated carcinoma (1 patient) and mesenchimal undifferentiated tumor (1 patient). The pathologic result was inconclusive in one patient. CONCLUSIONS: Our study supports the important diagnostic role of US-guided core biopsy for osteolytic bone metastasis. Two US-guided passages may be sufficient to procure a diagnostic tissue samples from osteolytic bone metastasis, if theirlength is at least 10 mm.

The Value of Staging Laparoscopy for Optimal Multidisciplinary Treatment in Patients with Gastric Cancer.

Introduction: Despite improvements in the conventional preoperative tools used for staging of gastric cancer, their accuracy still needs to be improved. Laparoscopy has the potential to visualize and characterize the tumor, the peritoneal cavity and the lymph nodes and thus to better select patients for the optimal treatment strategy. Material and Method: Patients with gastric cancer staged initially with contrast enhanced computer tomography and endoscopic ultrasound were also evaluated by laparoscopy and laparoscopic ultrasound in a distinct preoperative staging procedure. The perioperative data was recorded in a prospective database and was used to decide within the multidisciplinary team the optimal treatment protocol for each patient. The database was retrospectively reviewed for this study. Results: Among the 20 CT-scan M0 patients analyzed, peritoneal carcinomatosis was detected in 15% of the cases. In other 15% of patients laparoscopy upstaged the tumor and directed the patient towards neoadjuvant chemotherapy. Laparoscopic guided percutaneous core biopsies settled the definitive diagnosis in 3 further cases. In total, laparoscopic staging brought important information in 65% of cases and changed the treatment plan in 30% of patients. Conclusions: In the era of neoadjuvant chemotherapy, laparoscopy has the potential to overcome some of the limitations of the conventional staging methods and offers additional informations which finally change the treatment plan in as much as a third of patients with gastric cancer.

Hemorrhagic polypoid gastric and colonic metastases nine years after uterine leiomyosarcoma - case report.

INTRODUCTION: Uterine leiomyosarcoma (ULMS) is a rare tumor, representing 1-2% of all uterine malignancies. It is highly aggressive, with high metastatic rate, especially in lungs, peritoneal cavity, retroperitoneum, bones and liver, usually during the first years after diagnosis. CASE PRESENTATION: A 58-year-old woman, with subtotal hysterectomy and bilateral adnexectomy, followed by radiochemotherapy for spindle-type ULMS nine years ago, presented with gastrointestinal bleeding and severe anemia. Three polyps ranging from 2 cm to 5 cm in diameter were found at gastroscopy, the largest being ulcerated, which required a total gastrectomy three months later. Colonoscopy identified two pedunculated polyps on the descending colon, 2 cm and 3.5 cm in diameter. Histologically, both sites revealed proliferations of spindle cells with whorled pattern, moderate to severe nuclear atypia, 5 to 8 mitotic figures (MFs)÷10 high-power fields (HPFs) and additional necrosis in the gastric tumors. Immunohistochemistry was negative for CD117, DOG1, S100 and CD34 and positive for smooth muscle actin (SMA), estrogen receptor (ER) and progesterone receptor (PR). Twenty percent of nuclei stained positive for Ki67. The diagnosis was synchronous hemorrhagic gastric and colonic polypoid metastases of ULMS. Thoracic computed tomography (CT) and abdominal ultrasonography were negative for other metastatic lesions, while abdominal CT revealed abdominal and pelvic lymphadenopathy. CONCLUSIONS: This case illustrates a distinct pattern of metastasis that is an extremely rare gastric and colonic location and an expanded disease-free period of nine years since the initial treatment. A long-term clinical and imaging follow-up of this patient is essential.

Ultrasound-guided bone lesions biopsies - a systematic review.

AIMS: Ultrasound (US) is a highly valuable imagistic tool used to guide numerous interventional procedures. The US guided bone lesions biopsy has not yet received a consensus or a guideline. We aimed to evaluate the evidence to support the US role in guiding bone lesions biopsies. MATERIAL AND METHODS: A computer literature search of PubMed was conducted using the keywords "ultrasound" and "bone biopsy", in order to detect relevant studies regarding the aim of our analysis. Records were screened for eligible studies and data were extracted and analyzed. RESULTS: We included 23 studies (n=610 patients) in the final analysis. The specificity and diagnostic yield of US guided biopsy were very good (between 78-100%), depending on the type and dimensions of the bone lesions. The type of the biopsy - aspiration or cutting - influenced theresults. The studies which included larger groups showed a better  performance for cutting needles (83.3-100% vs 50-80.5% for aspiration). The size of the bone lesion influences the diagnostic yield of the US guided bone biopsy. Most of the studies reported nil post-procedural complications. CONCLUSION: Core needle biopsy provided better diagnostic yield compared to fine needle aspiration. The number of the passages of the cutting needle biopsies in order to achieve the best diagnostic yield wasthree. Further studies are needed in order to standardize US-guided bone lesions biopsy and increase its role in the diagnosis algorithm of the bone lesions.

Adrenal glands transabdominal ultrasonography - pictorial essay.

Adrenal gland ultrasonography is one of the corner stones of the abdominal ultrasonography examination for many medical specialties. The adrenal areas can be easily overlooked though adrenal gland pathology is diverse. We present the normal aspects and various transabdominal ultrasonography findings of the adrenal glands, both common and rare. Even though ultrasound examination is operator and patient dependent, we consider the examination of the adrenal glands very important, due to relatively frequent incidental detection of an adrenal mass.

Unusual multiple metastatic localisations in adult Burkitt's lymphoma. A case report.

Burkitt's lymphoma is an aggressive B-cell non-Hodgkin lymphoma. It is less common in adults accounting for less than 5% of non-Hodgkin lymphoma cases. Radiological methods (ultrasonography, computed tomography) are indispensable for the initial evaluation and appreciation of organ extension; complete diagnosis is confirmed by the histopathological examination.We present the clinical case and ultrasound imaging particularities of a young patient diagnosed with multisystem involvement Burkitt's lymphoma, with rapid progressive evolution towards exitus.

Current Management of NAFLD.

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in Western countries. It affects about 1 billion individuals worldwide. While people with simple steatosis have no higher risk of death than the general population, people with non-alcoholic steatohepatitis are at increased risk of death compared to general population. Current management for NAFLD includes diet and lifestyle changes, management of underlying metabolic risk factors and pharmacological therapies. The objective of therapy is to prevent the complications. The problem with dietary and lifestyle interventions is that they are hard to implement. Compliance is the key. Until now, there is still no approved drug for the treatment of NAFLD. Insulin resistance is the main target of pharmacological therapy, but the question that we ask ourselves as physicians is who should receive medical treatment among NAFLD patients and for how long.

Computerized ultrasound image analysis for noninvasive evaluation of hepatic steatosis.

OBJECTIVE: To assess the diagnostic value of a particular set of local intensity parameters extracted from ultrasound liver images in conjunction with support vector machine (SVM) classifiers for liver steatosis grading in respect to the "gold standard" provided by liver biopsy. MATERIAL AND METHODS: We prospectively enrolled in the study 228 patients with chronic hepatopathies. All the patients underwent liver biopsy and abdominal ultrasound examination. For quantitative ultrasound assessment of liver steatosis, an image analysis software was developed, which extracts three local intensity parameters from regions of interest (ROI) in the ultrasound section and analyzes their depth variation: the coefficient of variation of luminance (CVL), the median luminance (ml ), and the hepato-splenic attenuation index (HSAI). For steatosis grading, SVM classifiers were trained on the input feature spaces provided by the above mentioned parameters. The statistical significance of the steatosis grading was assessed on a significant test set using SVM classifiers, in terms of sensibility, specificity and through the ROC curves. RESULTS: A cut-off value of 0.362 of the CVL of the liver performed the liver steatosis grading with an accuracy of 89.17% (p<0.0001). A cut-off value of 0.27 of the HSAI performed the prediction of the moderate-severe liver steatosis with an accuracy of 87%. CONCLUSIONS: The proposed computer analysis method of ultrasound images proved innovative and useful for the initial non-invasive assessment and grading of liver steatosis, with an additional advantage of reduced computational complexity and accessibility. The CVL provided a very good accuracy (89.17%) for an AUROC of 0.923 for the classification of liver steatosis in two severity categories (mild versus moderate-severe).

Is there a correlation between peripheral blood expression of angiogenic transcriptional factors/receptors and colorectal cancer?

PURPOSE: The aim of this study was to evaluate whether there is a correlation between peripheral blood expression of angiogenic transcriptional factors/receptors and colorectal cancer (CRC). METHODS: Eighty six blood samples collected from patients with CRC (N=42), adenomas and/or hyperplastic polyps(AP, N=30) and individuals without colon pathology (control group/CTR, N=14) were used for this study. Twelve transcription factors and receptors were assessed by qRT-PCR in a case-control study. The molecules with a minimum of 30% differences in gene expression for CRC and AP compared to CTR were then analyzed separately for each sample. Gene expression was evaluated relatively to the CTR after normalization to the large ribosomal protein PO (RPLPO) housekeeping gene, and the differential expression between studied groups was assessed by ANOVA. RESULTS: Seven out of 12 genes presented differences in expression between 10-29% in CRC and/or AP compared to CTR. Considering the selection criteria, we further individually evaluated the levels of expression of 5 genes that had a minimum of 30% expression in the case-control study. Our data showed a significant up-regulation of platelet derived growth factor (PDGF) C in the blood of the patients with CRC compared to CTR (p=0.007). Likewise, clusterin (CLU) was significantly up-regulated both in CRC and AP groups compared to healthy subjects (p=0.01). For VEGFR1, PDGFRA and TGFB1 we didn't find significantly differential expression between any of the studied groups, even if increased levels were observed in both CRC and AP vs CTR. CONCLUSIONS: The results of our study indicated that increased blood level of PDGFC mRNA was associated with the presence of CRC (p=0.007). Additionally, high levels of circulating CLU mRNA were observed in both malignant and benign colorectal pathologies.

Value of hepatic elastography and Doppler indexes for predictions of esophageal varices in liver cirrhosis.

AIMS: Non-invasive methods are required to diagnose presence and grading of esophageal varices in patients with hepatic cirrhosis and in this respect we have evaluated the role of transient elastography and abdominal ultrasound parameters. MATERIAL AND METHODS: Cirrhotic patients were prospectively evaluated by transient elastography and Doppler ultrasound for diagnosis of presence and grading of esophageal varices, the results being compared with the findings of the esophagogastroduodenoscopy. RESULTS: Sixty patients with hepatic cirrhosis were analysed. The parameters that reached statistical significance for diagnosis of esophageal varices were: liver stiffness (LSM) > 15 kPa, hemodynamic liver index (PVr1) >/= 0.66, portal vascular resistance (PVR) > 17.66 and splenoportal index (SPI) > 4.77. The only parameter that reached statistical power for the diagnosis of large esophageal varices was LSM at a cut-off value of 28.8 kPa. CONCLUSIONS: Assessment of LSM in patients with liver cirrhosis can predict both the presence of esophageal varices and of large esophageal varices. The PVr1, PVR and SPI Doppler indexes can be used to diagnose the presence of esophageal varices but have no role in the prediction of large esophageal varices. Further studies are required to confirm these results and offer a stronger clinical significance.

Pleural ultrasonography. Pictorial essay.

Pleural ultrasonography (US) represents nowadays a useful diagnostic tool in the management of pleural diseases. Detection and evaluation of pleural effusions, pneumothorax and pleural-based lesions can be performed with US, which has the advantages of wide availability, low cost, absence of radiation exposure, and portability. It is the best method for guiding interventional procedures in the pleural space. It has also limitations, due to the interposition of bony parts of the thorax, subcutaneous emphysema and inability to visualize the mediastinal pleura. US of the thorax is an operator dependent technique demanding an experienced operator in order to obtain reliable results. This pictorial essay presents various ultrasound findings of the diseases which concern the pleura.

Cancer mortality in Romania, 1955-2004. Digestive sites: esophagus, stomach, colon and rectum, pancreas, liver, gallbladder and biliary tree.

AIM: Until recently, gastric cancer was the most frequent digestive neoplasia in our country. Our study presents the first synthesis of data regarding mortality rates from digestive cancers, for a period covering 50 years, in Romania. METHODS: Age-standardized mortality rates /100,000 population, general and/or per gender, concerning six digestive cancers, were identified from the statistics of IARC/OMS (Lyon, France) (years 1955-2002) and of the Ministry of Public Health (Bucharest, Romania) (year 2004). For 2002, incidence and mortality rates per sex from digestive cancers were available and case fatality ratios could be calculated as an approximation of survival rates, as well as sex ratio. RESULTS: Age standardized mortality rates per sex and cancer site registered the following changes: esophageal cancer increased from 2.03/0.62 (M/F) to 2.8/0.5; gastric cancer registered a decrease, from 33.14/18.77 to 17.0/6.6; colorectal cancer increased from 4.65/4.57 to 13.6/9.0; pancreatic cancer increased from 5.50/2.92 to 8.1/4.2 and liver cancer (including peripheric cholangiocarcinoma) increased from 1.77/0.83 to 8.8/3.9. In our population, the case fatality ratio appeared to be better only in colorectal cancer, 0.61 in males and 0.62 in females, respectively. Sex ratio was highest for esophageal cancer (males/females 5.8/1) and lowest for colorectal cancer (1.5/1). CONCLUSIONS: Our study found opposite trends in the mortality rates from digestive cancers, with gastric cancer rates decreasing and the other five digestive cancers increasing. A new hierarchy of digestive cancers has been drawn up, with colorectal cancer as the main cause of death, and gastric cancer in second position, followed by pancreatic, liver, esophageal, and gallbladder and biliary tree cancers.