Co-Inhibitors of Second Signal of Lymphocyte Response in Human Renal Transplants: PD-L2, GITR, and ILT-2/3/5 Positive Cells from Aspiration Biopsies Associate with Acute Rejection-Freedom

Following organ transplantation, the outcome of the encounter between an APC and a T lymphocyte is strongly dependent on the presence of costimulatory and co-inhibitory molecules, the former associated with allograft rejection and the latter with allograft acceptance. We evaluated the expression of PD-L2, GITR, ILT-2/3/5, and ILT-4 on graft-infiltrating cells procured by Fnab from human KTx under different immunosuppressive regimens. Methods: Fnab biopsies were performed on days 7 or 14 - 30 in stable KTx and on the day of acute rejection diagnosis. Cytopreparations were studied by the enzymatic avidin biotin complex staining. Results: Acute rejection group showed a significant down-regulated expression of PD-L2, GITR, and ILT-2/3/5 as compared to stable group, while for ILT-4 we did not find significant difference. Anti-IL2αR and rapamicyn treatment trend to down-regulate ILT-4 expression, although meaningless. A significantly positive correlation was observed between PD-L2 and GITR expression in Fnab. The PPV for acute rejection diagnosis for both PD-L2 and GITR was clearly above 0.8. Conclusions: Our findings point to an early entrance of cells expressing PD-L2, GITR and ILT-2/3/5 inside human KTx who are going to remain rejection-free. Both PD-L2 and GITR shared a high ability to rule-in and rule-out acute rejection.

Ultrasound-guided fine needle aspiration biopsy in differential diagnosis of portal vein tumor thrombosis

BACKGROUND: Portal vein tumor thrombosis(PVTT) is a serious complication and a major metastatic way of hepa- tocellular carcinoma (HCC). But portal vein benign throm- bosis(PVBT) always appears in patients with hepatocirrho- sis, and PVTT should be differentiated from PVBT. The aim of this study was to probe the value of ultrasound- guided fine needle aspiration biopsy in differential diagnosis of PVTT. METHODS: Twenty-two HCC patients with portal vein thrombosis and 8 hepatocirrhosis patients with portal vein thrombosis were studied by ultrasound-guided fine needle aspiration biopsy. Twelve portal vein thrombosis filling portal vein embranchment of the 30 portal vein thrombosis patients were examined by 18G automatic biopsy. The positive rates of aspiration biopsy cytology and histology were calculated and compared with those of automatic biopsy. RESULTS: The positive rates of fine needle aspiration biop- sy cytology and histology were 93.3% (28/30) and 90.0% (27/30), respectively. They were not different markedly from that of automatic biopsy 91.7% (11/12). In aspira- tion biopsy of 22 HCC patients with PVTT, HCC cellular was found in 19 portal vein thrombosis patients (86.4%) by cytology examination and in 18 portal vein thrombosis patients (81.8%) by histology examination. In total, 20 tumor thrombi were detected. The other two were diag- nosed as benign thrombosis. No HCC cell and/or tissue was observed in 8 patients with hepatocirrhosis associated with portal vein thrombosis. CONCLUSIONS: Ultrasound-guided fine needle biopsy in detecting PVTT shows a high positive rate and is of diag- nostic value. The positive rate is not apparently different from that of automatic biopsy. Hence the case that fails to be diagnosed by color Doppler flow imaging ( CDFI) and pulsed Doppler can be detected early by ultrasound-guided fine needle aspiration biopsy.

Electronic Synoptic Reporting of Thyroid Nodules: Potential for Reduction in Number of Patients Undergoing Thyroid Nodule Biopsies

Purpose: The objective of the study was to design and implement an electronic synoptic report for thyroid sonography that incorporates the thyroid imaging reporting and data system (TIRADS) and assess potential for reducing unnecessary fine needle aspiration biopsies (FNAB) of thyroid nodules. Methods: The electronic synoptic report was developed using a relational database based on elements from TIRADS and a multidisciplinary consensus statement for thyroid reporting. A retrospective analysis of 138 patients with previously reported thyroid sonographic exams was evaluated for the presence of these elements. The electronic synoptic report calculates the TIRADS score and generates a formal report. Using the TIRADS score the potential decrease in unnecessary FNAB was estimated. Results: Key TIRADS elements were variously reported ranging from 43% for the thyroid nodule’s architecture as solid or cystic. Thyroid nodule echogenicity and calcification was commented in 27% and 23%, respectively. Other features of the TIRADS score were commented in 0% to 8% of the official reports. Estimated reduction for potentially reduced need for FNAB was 34.5%. Conclusions: This study is the first implementation of synoptic reporting using a relational database for sonography of thyroid nodules. Implementation of an electronic standardized synoptic reporting system may facilitate more accurate, and more comprehensive reporting for thyroid ultrasound scanning of thyroid nodules. The use of TIRADS was estimated to be able to potentially reduce the need for FNAB which was significant.

Chemokine Receptors CCR1, CCR3, CCR7 and Chemokines CX3CL1 and CCL5 are Significantly Up-Regulated and Very Reliable for Acute Rejection Diagnosis of Kidney Transplants

Background: The allo-immune response following organ transplantation constitutes one of the main determinants concerning both short- and long- term outcomes in renal graft recipients. Chemokines and their receptors play a diversified and important role, either homeostatic or inflammatory and direct different immune-competent cell types to the allograft. While deeply studied in the last two decades, controversy persists as a result of chemokines’ pleiotropic actions. We report our analysis of CCR1, CCR3, CCR7, CCL5 and CX3CL1 expression or synthesis by graft-infiltrating cells in human kidney transplants (KTx). At the same time, we tested their robustness in diagnosing acute rejection. Methods: Fine-needle aspiration biopsies (Fnab) were performed either on days 7 or 14 post-transplantation among stable KTx and on the day of acute rejection (AR) diagnosis. Fnab cytopreparations were studied by the enzymatic avidin-biotin complex staining for CCR1, CCR3, CCR7 and CX3CL1. From another subgroup of cases, Fnab samples were cultured for 48 hours and the supernatants were analysed for CCL5 by ELISA. Results: The group of AR cases showed a significantly up-regulated expression of CCR1, CCR3, CCR7 and CX3CL1 and a significantly higher synthesis of CCL5. The positive predictive values were respectively 92%, 97%, 85%, 76% and 78% and negative predictive values were by the same order, 100%, 73%, 100%, 98% and 83%. Conclusions: Our study permits us to advance that CCR1 and CCR3 play a significant and non-redundant role in acute rejection, and it is the first report of CCR3 association with rejection, probably related to CCL5. The presence inside the graft of significant up-regulation for CCR7 surmises that part of antigen presentation may be performed there without being restricted to secondary lymphoid sites. Our results with CX3CL1 confirm other reports.

Idiopathic hypereosinophilic syndrome with hepatic sinusoidal obstruction syndrome:A case report and literature review

BACKGROUND Hypereosinophilic syndrome(HES)is classified as primary,secondary or idiopathic.Idiopathic HES(IHES)has a variable clinical presentation and may involve multiple organs causing severe damage.Hepatic sinusoidal obstruction syndrome(HSOS)is characterized by damage to the endothelial cells of the hepatic sinusoids of the hepatic venules,with occlusion of the hepatic venules,and hepatocyte necrosis.We report a case of IHES with HSOS of uncertain etiology.CASE SUMMARY A 70-year-old male patient was admitted to our hospital with pruritus and a rash on the extremities for>5 mo.He had previously undergone antiallergic treatment and herbal therapy in the local hospital,but the symptoms recurred.Relevant examinations were completed after admission.Bone marrow aspiration biopsy showed a significantly higher percentage of eosinophils(23%)with approximately normal morphology.Ultrasound-guided hepatic aspiration biopsy indicated HSOS.Contrast-enhanced computed tomography(CT)of the upper abdomen showed hepatic venule congestion with hydrothorax and ascites.The patient was initially diagnosed with IHES and hepatic venule occlusion.Prednisone,low molecular weight heparin and ursodeoxycholic acid were given for treatment,followed by discontinuation of low molecular weight heparin due to ecchymosis.Routine blood tests,biochemical tests,and imaging such as enhanced CT of the upper abdomen and pelvis were reviewed regularly.CONCLUSION Hypereosinophilia may play a facilitating role in the occurrence and development of HSOS.

Role of endoscopic ultrasound in the characterization of solid pseudopapillary neoplasm of the pancreas

BACKGROUND Solid pseudopapillary neoplasm(SPN)is an uncommon pathology of the pancreas with unpredictable malignant potential.Endoscopic ultrasound(EUS)assessment plays a vital role in lesion characterization and confirmation of the tissue diagnosis.However,there is a paucity of data regarding the imaging assessment of these lesions.AIM To determine the characteristic EUS features of SPN and define its role in preoperative assessment.METHODS This was an international,multicenter,retrospective,observational study of prospective cohorts from 7 large hepatopancreaticobiliary centers.All cases with postoperative histology of SPN were included in the study.Data collected included clinical,biochemical,histological and EUS characteristics.RESULTS One hundred and six patients with the diagnosis of SPN were included.The mean age was 26 years(range 9 to 70 years),with female predominance(89.6%).The most frequent clinical presentation was abdominal pain(80/106;75.5%).The mean diameter of the lesion was 53.7 mm(range 15 to 130 mm),with the slight predominant location in the head of the pancreas(44/106;41.5%).The majority of lesions presented with solid imaging features(59/106;55.7%)although 33.0%(35/106)had mixed solid/cystic characteristics and 11.3%(12/106)had cystic morphology.Calcification was observed in only 4(3.8%)cases.Main pancreatic duct dilation was uncommon,evident in only 2 cases(1.9%),whilst common bile duct dilation was observed in 5(11.3%)cases.One patient demonstrated a double duct sign at presentation.Elastography and Doppler evaluation demonstrated inconsistent appearances with no emergence of a predictable pattern.EUS guided biopsy was performed using three different types of needles:Fine needle aspiration(67/106;63.2%),fine needle biopsy(37/106;34.9%),and Sonar Trucut(2/106;1.9%).The diagnosis was conclusive in 103(97.2%)cases.Ninety-seven patients were treated surgically(91.5%)and the post-surgical SPN diagnosis was confirmed in all cases.During the 2-year follow-up period,no recurrence was observed.CONCLUSION SPN presented primarily as a solid lesion on endosonographic assessment.The lesion tended to be located in the head or body of the pancreas.There was no consistent characteristic pattern apparent on either elastography or Doppler assessment.Similarly SPN did not frequently cause stricture of the pancreatic duct or common bile duct.Importantly,we confirmed that EUS-guided biopsy was an efficient and safe diagnostic tool.The needle type used does not appear to have a significant impact on the diagnostic yield.Overall SPN remains a challenging diagnosis based on EUS imaging with no pathognomonic features.EUS guided biopsy remains the gold standard in establishing the diagnosis.

CD16+ Cells and Costimulatory Molecules of Lymphocyte Activation Present inside Human Kidney Grafts and in Blood Circulation

Background: We studied the expression of important costimulatory molecules of lymphocyte activation and the presence of CD16+ cells on aspiration biopsies of kidney transplants, measured three soluble factors and when indicated tested their robustness in diagnosing acute rejection. Methods: Fine-needle aspiration biopsies were performed either on days seven or 14 - 30 post-transplantation among stable kidney transplants and on the day of acute rejection diagnosis, while a sample of peripheral blood was collected simultaneously. The cyto preparations were studied by the enzymatic avidin biotin complex staining. The immunocytochemistry was directed to CD16, CD28, CD152, ICOS, CD40, CD154, CD26 and CD27. We performed the analysis in the peripheral blood by ELISA for soluble(s) CD16, CD26, and CD154. Results: The group of acute rejection cases showed a significant up-regulated expression of CD16, CD26, ICOS and CD40 as compared to the group of stable cases. Both sCD16 and sCD154 were significantly higher in the blood samples of the group with acute rejection. Thymoglobulin down-regulated CD154 and sCD16. CD16, CD26 and ICOS exhibited very high sensitivity and specificity for acute rejection diagnosis. Conclusions: The presence of CD16+ cells inside the graft emerged as a distinct player in acute rejection, confirming other previous reports whereas we first document that in human kidney transplants, ICOS and CD26 are significantly up-regulated and both reached positive predictive values for acute rejection ≥ 80%. The other costimulatory molecules, with the exception of CD40, though widely known, did not show robust association with immune events.

Innate Immune Response in Human Kidney Transplantation: IRF3 and IRF7 Together with Interferon-Alpha Are Significantly Up-Regulated in Acute Rejection

Background: Ischemia-reperfusion injury of organ transplantation activates several mediators which may link the innate to the adaptive immune response. Down the cascade of TLRs, we selected to study the expression of Interferon Regulatory Factors (IRF)-3 and -7 inside human Kidney Transplanted (KTx) organs and the synthesis of IFNα, the main growth factor induced by them, in KTx aspiration biopsy cultures. Simultaneously, we tested their robustness in diagnosing Acute Rejection (AR). Methods: Fine-needle aspiration biopsies (F-nab) were performed either on day 7 or 14 post-KTx among stable patients or on the day of AR diagnosis. On Fnab cytopreparations, we studied IRF3 and IRF7 by the enzymatic avidin-biotin complex staining, and in a different group of cases we quantified IFNα by ELISA in 48 hours Fnab culture supernatants. Results: AR group showed a significantly up-regulated expression for IRF3 and IRF7, reaching Positive Predictive Values (PPV) of 0.824 and 0.8, respectively, as well as Negative Predictive Values (NPV) above 0.9 for both;IFNα presented a PPV = 1.0 and a NPV = 0.9. A variation in the results was noticed according to different immunosuppressive therapies. Conclusions: Our findings suggest that IRF3 and IRF7, and IFNα which they promote, may be very important players in the early days post-KTx, linking the innate with an adaptive response and triggering acute rejection. These differences were very clear-cut, lending consistency to our speculation. It would be important to scrutinize for other potential effects derived from these IRFs up-regulation which could be of clinical relevance.

Nonfunctional pancreatic neuroendocrine tumours misdiagnosed as autoimmune pancreatitis:A case report and review of literature

BACKGROUND Nonfunctional pancreatic neuroendocrine tumours are difficult to diagnose in the early stage of disease due to a lack of clinical symptoms,but they can rarely manifest as autoimmune pancreatitis.Autoimmune pancreatitis is an uncommon disease that may cause recurrent acute pancreatitis and is therefore often regarded as a special type of chronic pancreatitis.CASE SUMMARY We report a case of a 42-year-old female who had nonspecific upper abdominal pain for 4 years and radiological abnormalities of the pancreas that mimicked autoimmune pancreatitis.The symptoms and pancreatic imaging did not improve following 1 year of steroid therapy.Finally,pancreatic biopsy was performed through endoscopic ultrasonography-guided fine-needle aspiration biopsy,and nonfunctional pancreatic neuroendocrine tumours were ultimately diagnosed.Pancreatectomy has resolved her symptoms.CONCLUSION Therefore,the differentiation of nonfunctional pancreatic neuroendocrine tumours from autoimmune pancreatitis is very important,although it is rare.We propose that endoscopic ultrasonography-guided fine-needle aspiration biopsy should be performed if imaging characteristics are equivocal or the diagnosis is in question.

First endoscopic procedure for diagnosis and staging of mediastinal lymphadenopathy

AIM:To compare a first diagnostic procedure of transbronchial needle aspiration(TBNA)with selection of endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA)or TBNA for mediastinal lymphadenopathy.METHODS:Sixty-eight consecutive patients with mediastinal lymphadenopathy on computed tomography(CT),who required cytopathological diagnosis,were recruited.The first 34 underwent a sequential approach in which TBNA was performed first,followed by EUS-FNA if TBNA was unrevealing.The next 34 underwent a selective approach where either TBNA or EUS-FNA was selected as the first procedure based on the CT findings.RESULTS:The diagnostic yield of TBNA as the first diagnostic procedure in the sequential approach was 62%.In the selective approach,the diagnostic yield of the first procedure was 71%.There was no significant difference in the overall diagnostic yield,but there were significantly fewer combined procedures with the selective approach.CONCLUSION:Selecting either EUS-FNA or TBNA as the first diagnostic procedure achieved a comparable diagnostic yield with significantly fewer procedures than performing TBNA first in all patients.

Unilateral adrenal tuberculosis whose computed tomography imaging characteristics mimic a malignant tumor:A case report

BACKGROUND Adrenal tuberculosis usually presents with bilateral involvement.It has special characteristics in computed tomography(CT)images,such as small size,low attenuation in the center,and peripheral rim enhancement,which differ from those of primary tumors.CASE SUMMARY A 42-year-old female presented to the hospital with low back pain.She had been diagnosed with hypertension as well as pulmonary and cerebral tuberculosis but denied having any fever,fatigue,anorexia,night sweats,cough,or weight loss.Abdominal CT revealed an irregular 6.0 cm×4.5 cm mass with uneven density in the right adrenal gland,while the left adrenal gland was normal.No abnormalities were observed in plasma total cortisol(8 am),adrenocorticotropic hormone,aldosterone/renin ratio,blood catecholamines,or urine catecholamines.A fineneedle aspiration biopsy of the right adrenal gland provided evidence of tuberculosis.After three years of anti-tuberculosis treatments,the large mass in the right adrenal gland was reduced to a slight enlargement.CONCLUSION This is a case of unilateral adrenal tuberculosis with CT imaging characteristics mimicking those of a malignant tumor.Extended anti-tuberculosis therapy is recommended in such cases.

Anemia in ESKD Patient (End-Stage Kidney Disease): The Rare Cause Is in the Forefront

We reported a case of severe anemia in a patient with end-stage kidney disease (ESKD) on dialysis. The anemia developed when the patient is switched from hemodialysis (HD) to peritoneal dialysis (PD) when the intra-venous erythropoietin stimulating agent (ESA, Epogen) was changed into subcutaneous injection of darbepoetin. The patient’s hemoglobin dropped 2 grams in about two months during this period. Extensive work-up including, bleeding disorders, hemolysis, iron deficiency, infections including CMV, Epstein-Bar virus, parvo-19 virus infection were unrevealing The anti-Epogen neutralizing antibodies were not measured due to unavailability. Bone marrow biopsy and aspirate were negative for infiltrations or myelodysplastic syndrome (MDS). The leukocyte and platelet counts were normal. Even though anti-ESA antibodies were not measured in this case, all tentative causes of his anemia were excluded by laboratory investigations. The patient’s anemia was treated symptomatically with blood transfusion and discontinuation of the ESA treatment. He made a remarkable recovery.

Comparative Application of 5 mL Syringe and 22G PTC Needles in Thyroid Nodule Fine-Needle Aspiration

This study aims to compare the differences in sampling satisfaction rates between 5 mL syringe and 22G percutaneous transhepatic cholangiography(PTC)needles in fine-needle aspiration(FNA)to provide economical and reasonable needle selection.From January 2021 to March 2022,187 patients with thyroid nodules(a total of 200 nodules)who underwent ultrasound-guided FNA were punctured using 22G PTC and 5 mL syringe needles once for each nodule,and the sample was sent for pathological examination.The sample satisfaction rate of the two methods was statistically analyzed,and factors affecting the sample satisfaction rate were determined.Results demonstrated that the overall sample satisfaction rates of 5 mL syringes and 22G PTC needles were 83%and 85%(P>0.05),respectively.The satisfaction rates of the two specimens were 92.6%and 91.1%(P>0.05)among 136 nodules with poor blood supply.For 64 nodules with rich blood supply,the satisfaction rate of both specimens was significantly lower than that of the nodule with poor blood supply(P<0.05),and that of the 5 mL syringe needle was significantly lower than that of the latter(62.5%vs.71.8%,P<0.05).The results suggest that satisfactory sampling results can be obtained using either a 5 mL syringe or 22G PTC needles.The 22G PTC needle is more likely to yield FNA results if the nodule is rich in blood supply.

Impact of endoscopic ultrasound elastography in pancreatic lesion evaluation

Pancreatic malignancy still becomes a major global problem and is considered as one of the most lethal cancers in the field of gastroenterology.Most patients come in the late stage of the disease due to organ’s location,and until now the treatment result is still far away from satisfaction.Early detection is still the main key for good,prolonged survival.However,discerning from other types of tumor sometimes is not easy.Endoscopic ultrasound(EUS)is still the best tool for pancreatic assessment,whereas fine-needle aspiration biopsy(FNAB)is considered as the cornerstone for further management of pancreatic malignancy.Several conditions have become a concern for EUS-FNAB procedure,such as risk of bleeding,pancreatitis,and even needle track-seeding.Recently,an artificial intelligence innovation,such as EUS elastography has been developed to improve diagnostic accuracy in pancreatic lesions evaluation.Studies have shown the promising results of EUS elastography in improving diagnostic accuracy,as well as discerning from other tumor types.However,more studies are still needed with further considerations,such as adequate operator training,expertise,availability,and its cost-effectiveness in comparison to other imaging options.

Ultrasound-guided fine-needle aspiration/biopsy-based pancreatic organoids establishment:an alternative model for basic and preclinical research

Pancreatic ductal adenocarcinoma(PDAC),as one of the malignant cancers with the worst prognosis,is becoming the most urgent clinical problem.Due to the lack of early diagnosis and curable therapeutic methods,it is critical to exploit proper models that can capture the overall attributes of the primary tumor.Recently,organoid technology has emerged and flourished as a powerful tool to enable long-termculture of pancreatic tissues,including PDAC.As accumulating studies suggest,organoids can retain morphological,genetic,and behavioral traits,and have tremendous value in predicting the therapeutic response to conventional chemotherapy drugs or newfangled agents.Herein,this review comprehensively summarizes the tissue source including human fetal and adult pancreatic tissue to generate a pancreatic organoid as well as current organoids cultivate system.As PDAC organoids can be established from a small number of samples derived from endoscopic ultrasound-guided fine-needle aspiration/biopsy(EUS-FNA/FNB),we also review the literature to date on EUS-FNA/FNBbased organoid constitution and its implementation in inquiring tumor behavior and evaluating therapeutic responses.By enabling the alignment of basic and clinical research platforms,the application of organoids would open up new avenues for drug discovery and maximally benefit translational medicine in the near future.

Institutional experience of PTH evaluation on fine-needle washing after aspiration biopsy to locate hyperfunctioning parathyroid tissue

Assaying parathyroid hormone(PTH) in the washing liquid after fine-needle aspiration biopsy(FNAB) seems to be a valid approach to locate parathyroid tissue.PTH-FNAB was evaluated in 47 patients with a clinical picture of primary hyper-parathyroidism(PHP) and ultrasonography(US) suggestive of parathyroid lesion.The patients were subdivided into two groups on the basis of the absence or presence of US thyroid alterations.The result of PTH-FNAB was compared with those of cytology,scintigraphy and,in 24 patients,surgical outcome.PTH-FNAB samples with a value higher than that recorded in the serum and higher than our institutional cut-off were deemed to be probable samples of parathyroid tissue.Cytology proved diagnostic for benign thyroid lesions,non-diagnostic for thyroid lesions,hyperplastic parathyroid tissue,undetermined or malignant thyroid lesions and other lesions in 45%,30%,17%,4%,and 4% of cases,respectively.In 47% of cases,PTH-FNAB indicated that the sample had been taken in parathyroid tissue.In patients without US alterations,the diagnostic accuracy of PTH-FNAB was greater than that of scintigraphy.After surgery,comparison between the results of PTH-FNAB and scintigraphy,in terms of positive predictive value(PPV),revealed the superiority of PTH-FNAB;PPV was 94% for FNAB and 71% for scintigraphy,while sensitivity was 83% and 69%,respectively.PTH-FNAB evaluation after FNAB appears to be more diagnostic than cytology and scintigraphy.Of all the procedures used,PTH-FNAB appears to be the method of choice when the target is US suggestive and reachable.PTH-FNAB appears to be a useful method of guiding surgical intervention.