Nomogram to predict overall survival after gallbladder cancer resection in China

AIM To integrate clinically significant variables related to prognosis after curative resection for gallbladder carcinoma(GBC) into a predictive nomogram.METHODS One hundred and forty-two GBC patients who underwent curative intent surgical resection at Peking Union Medical College Hospital(PUMCH) were included. This retrospective case study was conducted at PUMCH of the Chinese Academy of Medical Sciences and Peking Union Medical College(CAMS & PUMC) in China from January 1, 2003 to January 1, 2018. The continuous variable carbohydrate antigen 19-9(CA19-9) was converted into a categorical variable(cCA19-9) based on the normal reference range. Stages 0 to IIIA were merged into one category, while the remaining stages were grouped into another category. Pathological grade X(GX) was treated as a missing value. A multivariate Cox proportional hazards model was used to select variables to construct a nomogram. Discrimination and calibration of the nomogram were performed via the concordance index(C-index) and calibration plots. The performance of the nomogram was estimated using the calibration curve. Receiver operating characteristic(ROC) curve analysis and decision curve analysis(DCA) were performed to evaluate the predictive accuracy and net benefit of the nomogram, respectively.RESULTS Of these 142 GBC patients, 55(38.7%) were male, and the median and mean age were 64 and 63.9 years, respectively. Forty-eight(33.8%) patients in this cohort were censored in the survival analysis. The median survival time was 20 months. A series of methods, including the likelihood ratio test and Akaike information criterion(AIC) as well as stepwise, forward, and backward analyses, were used to select the model, and all yielded identical results. Jaundice [hazard ratio(HR) = 2.9; 95% confidence interval(CI): 1.60-5.27], cCA19-9(HR = 3.2; 95%CI: 1.91-5.39), stage(HR = 1.89; 95%CI: 1.16-3.09), and resection(R)(HR = 2.82; 95%CI: 1.54-5.16) were selected as significant predictors and combined into a survival time predictive nomogram(C-index = 0.803; 95%CI: 0.766-0.839). High prediction accuracy(adjusted C-index = 0.797) was further verified via bootstrap validation. The calibration plot demonstrated good performance of the nomogram. ROC curve analysis revealed a high sensitivity and specificity. A high net benefit was proven by DCA.CONCLUSION A nomogram has been constructed to predict the overall survival of GBC patients who underwent radical surgery from a clinical database of GBC at PUMCH.

Pancreatic carcinosarcoma: First literature report on computed tomography imaging

Carcinosarcoma of the pancreas is an extremely rare tumor and has a dismal prognosis. To the best of our knowledge, the histopathological features of the lesion have been illustrated in the literature but to date no reported cases have been documented on imaging characteristics. We report a female case of pancreatic carcinosarcoma presenting as a mucinous cystadenoma on computed tomography(CT). We also summarize the CT characteristics according to the appended CTimages in the reported cases. This is the first report of CT features of pancreatic carcinosarcoma in the English literature.

CT manifestations and features of solid cystic tumors of the pancreas

Objective: To study retrospectively the manifestations and characteristics of solid cystic tumor of the pan- creas(SCTP) on CT. Methods: Nine patients with solid cystic tumor of the pancreas underwent resection with pathological and immunohistochemical confirmation. All the patients were female, aged 27.7 years on average at onset of the disease. CT scan was performed in patients with or without intravenous injection of contrast medium; it was also performed in the arterial phase in 4 pa- tients. Results: Solid and cystic structures were observed in tumors of the pancreas. Solid structure demonstrated low or iso-density on unenhanced CT, poor enhance- ment in the arterial phase and marked enhancement in the portal venous phase on contrast material-en- hanced CT. Cystic structure showed low density on both pre- and pro-contrast views. The CT findings of tumors with predominantly cystic or equal propor- tion of solid and cystic structure: mural nodules for solid structure, 'floating cloud' signs, or solid and cystic crossing distributions. Cystic structure of tumors predominately solid presenting as a beading appearance under capsule. In round, oval and com- pletely encapsulated tumors in the pancreas, the greater vessel enhanced with well-defined margins on pro-contrast images. No dilatation was observed of the common bile and pancreatic ducts. Conclusion: The characteristics of solid cystic tumor of the pancreas revealed by CT could confirm the di- agnosis of the disease in combination with onset age and sex of patients.

Special diaphragm-like strictures of small bowel unrelated to non-steroidal anti-inflammatory drugs

AIM:To summarize clinical,endoscopic,radiologic and pathologic features of special diaphragm-like strictures found in small bowel,with no patient use of nonsteroidal anti-inflammatory drugs(NSAIDs).METHODS:From January 2000 to fecember 2009,5 cases(2 men and 3 women,with a mean age of 41.6 years) were diagnosed as having diaphragm-like strictures of small bowel on imaging,,operation and pathology.All the patients denied the use of NSAIDs.The clinical,endoscopic,radiologic and pathologic findings in these 5 patients were retrospectively reviewedfrom the hospital database.Images of capsule endoscopy(CE) and small bowel follow-through(SBFT) obtained in 3 and 3 patients,respectively,and images of double-balloon enteroscopy and computed tomography enterography(CTE) obtained in all 5 patients were available for review.RESULTS:All patients presented with long-term(2-16 years) symptoms of gastrointestinal bleeding and varying degrees of anemia.There was only one stricture in ?our cases and three lesions in one case,and all the lesions were located in the middle or distal segment of ileum.Circumferential stricture was shown in the small bowel in three cases in the CE image,but the capsule was retained in the small bowel of 2 patients.Routine abdomen computed tomography scan showed no other abnormal results except gallstones in one patient.The lesions were shown as circumferential strictures accompanied by dilated small bowel loops in the small bowel on the images of CTE(in all 5 cases),SBFT(in 2 cases) and double-balloon enteroscopy(in all cases).On microscopy,a chronic inflammatory infiltrate and circumferential diaphragm were found in all lesions.CONCLUSION:fiaphragm-like strictures of small bowel might be a special consequence of unclear damaging insults to the intestine,having similar clinical,endoscopic,radiologic and pathologic features.

Magnetic resonance imaging and Crohn's disease endoscopic index of severity: Correlations and concordance

AIM To examine the correlation between magnetic resonance imaging(MRI) and endoscopic index of severity(CDEIS) in patients with Crohn's disease(CD).METHODS This was a retrospective study of 104 patients with CD that were treated at the Ruijin Hospital between March 2015 and May 2016. Among them, 61 patients with active CD were evaluated before/after treatment. MRI and endoscopy were performed within 7 d. CDEIS was evaluated. MRI parameters included Ma RIA scores, total relative contrast enhancement(tRCE), arterialRCE(aRCE), portalRCE(pRCE), delay phaseRCE(dRCE), and apparent diffusion coefficient. The correlation and concordance between multiple MRI findings and CDEIS changes before and after CD treatment were examined.RESULTS Among the 104 patients, 61 patients were classified as active CD and 43 patients as inactive CD. Gender, age, disease duration, and disease location were not significantly different between the two groups(all P > 0.05). CRP levels were higher in the active group than in the inactive group(25.12 ± 4.12 vs 5.14 ± 0.98 mg/L, P < 0.001). Before treatment, the correlations between CDEIS and MaRIAs in all patients were r = 0.772 for tRCE, r = 0.754 for aRCE, r = 0.738 for pRCE, and r = 0.712 for dRCE(all MaRIAs, P < 0.001), followed by MRI single indexes. Among the active CD patients, 44 cases were remitted to inactive CD after treatment. The correlations between CDEIS and MaRIAs were r = 0.712 for aRCE, r = 0.705 for tRCE, r = 0.685 for pRCE, and r = 0.634 for dRCE(all MaRIAs, P < 0.001).CONCLUSION Arterial Ma RIA should be an indicator for CD follow-up and dynamic assessment. CD treatment assessment was not completely concordant between CDEIS and MRI.

Clinicopathologic characterization and abnormal autophagy of CSF1R-related leukoencephalopathy

Background:CSF1R-related leukoencephalopathy,also known as hereditary diffuse leukoencephalopathy with spheroids(HDLS),is a rare white-matter encephalopathy characterized by motor and neuropsychiatric symptoms due to colony-stimulating factor 1 receptor(CSF1R)gene mutation.Few of CSF1R mutations have been functionally testified and the pathogenesis remains unknown.Methods:In order to investigate clinical and pathological characteristics of patients with CSF1R-related leukoencephalopathy and explore the potential impact of CSF1R mutations,we analyzed clinical manifestations of 15 patients from 10 unrelated families and performed brain biopsy in 2 cases.Next generation sequencing was conducted for 10 probands to confirm the diagnosis.Sanger sequencing,segregation analysis and phenotypic reevaluation were utilized to substantiate findings.Functional examination of identified mutations was further explored.Results:Clinical and neuroimaging characteristics were summarized.The average age at onset was 35.9±6.4 years(range 24–46 years old).Younger age of onset was observed in female than male(34.2 vs.39.2 years).The most common initial symptoms were speech dysfunction,cognitive decline and parkinsonian symptoms.One patient also had marked peripheral neuropathy.Brain biopsy of two cases showed typical pathological changes,including myelin loss,axonal spheroids,phosphorylated neurofilament and activated macrophages.Electron microscopy disclosed increased mitochondrial vacuolation and disorganized neurofilaments in ballooned axons.A total of 7 pathogenic variants(4 novel,3 documented)were identified with autophosphorylation deficiency,among which c.2342C>T remained partial function of autophosphorylation.Western blotting disclosed the significantly lower level of c.2026C>T(p.R676*)than wild type.The level of microtubule associated protein 1 light chain 3-II(LC3-II),a classical marker of autophagy,was significantly lower in mutants expressed cells than wild type group by western blotting and immunofluorescence staining.Conclusions:Our findings support the loss-of-function and haploinsufficiency hypothesis in pathogenesis.Autophagy abnormality may play a role in the disease.Repairing or promoting the phosphorylation level of mutant CSF1R may shed light on therapeutic targets in the future.However,whether peripheral polyneuropathy potentially belongs to CSF1R-related spectrum deserves further study with longer follow-up and more patients enrolled.

B/S Brace as an Alternative Treatment for Ingrown Toenails

To the Editor：Ingrown toenail,also known as onychocryptosis or unguis incarnates,occurs when the periungual skin is punctured by its corresponding nail plate,resulting in a cascade of foreign body,inflammatory,infectious,and reparative processes.Most commonly,big toe is involved.Without proper treatment,it would be very painful and negatively affects the patient＇s walking and greatly hampers the quality of the individual＇s life.Till now,many different treatments have been proposed.In general,the treatment for ingrown toenails can be divided into conservative approaches （including medical and podiatric methods） and surgical approaches.The choice of treatment is usually based on the Heifetz classification stage of the ingrown toenails.Mostly ingrown toenails with Heifetz Stage Ⅱ and Ⅲ need surgical approaches or podiatric methods.