Missed Pancreaticobiliary Malignancy: The Flaw of the Expedited Cholecystectomy

Background: Early cholecystectomy has been recommended for patients with acute cholecystitis and gallstone pancreatitis. However, patients with pancreaticobiliary malignancy may present acutely with similar symptoms. We hypothesize that the diagnoses of these malignancies may potentially be delayed as an unintended consequence of expedited cholecystectomies. This study reviews a cohort of patients who underwent pancreaticoduodenectomy (PD) to identify those who underwent a separate cholecystectomy before their PD. Methods: We retrospectively reviewed 162 PDs performed between 2012 and 2022. Data collected included: demographics, disease etiology and the presence of cholelithiasis. We identified patients who had a previous cholecystectomy and the time elapsed before PD as well as procedures done during the interval. We reported detailed case summaries on those patients who had a cholecystectomy within 1 year of PD. Results: In the entire cohort, mean age was 65 years, 54% were males, and 83% had a malignant reason for PD. Thirty-one patients had cholelithiasis with 23 (14%) patients having had previous cholecystectomy. Six patients had cholecystectomy within 1 year of PD. They had the following malignancies: ampullary—3, pancreas—1, cholangiocarcinoma—1 and neuroendocrine—1. Four of these patients had expedited cholecystectomy on their index hospital admission and were later found to have a periampullary malignancy with further work up. Conclusions: Pancreaticobiliary malignancies can be difficult to diagnose, and surgeons should not overlook these potential diagnoses when considering expedited cholecystectomy. Future studies in large cohorts are needed to identify high risk candidates who should undergo more detailed testing to exclude malignancy before proceeding with cholecystectomy.

Risk of hepatic decompensation from hepatitis B virus reactivation in hematological malignancy treatments

In this editorial,we discussed the apparent discrepancy between the findings described by Colapietro et al,in their case report and data found in the literature.Colapietro et al reported a case of hepatitis B virus(HBV)-related hepatic decompensation in a patient with chronic myeloid leukemia and a previously resolved HBV infection who was receiving Bruton’s tyrosine kinase(BTK)inhibitor therapy.First of all,we recapitulated the main aspects of the immune system involved in the response to HBV infection in order to underline the role of the innate and adaptive response,focusing our attention on the protective role of anti-HBs.We then carefully analyzed literature data on the risk of HBV reactivation(HBVr)in patients with previous HBV infection who were treated with either tyrosine kinase inhibitors or BTK inhibitors for their hematologic malignancies.Based on literature data,we suggested that several factors may contribute to the different risks of HBVr:The type of hematologic malignancy;the type of therapy(BTK inhibitors,especially second-generation,seem to be at a higher risk of HBVr than those with tyrosine kinase inhibitors);previous exposure to an anti-CD20 as first-line therapy;and ethnicity and HBV genotype.Therefore,the warning regarding HBVr in the specific setting of patients with hematologic malignancies requires further investigation.

Immuno-oncology-microbiome axis of gastrointestinal malignancy

Research on the relationship between the microbiome and cancer has been controversial for centuries.Recent works have discovered that the intratumor microbiome is an important component of the tumor microenvironment(TME).Intratumor bacteria,the most studied intratumor microbiome,are mainly localized in tumor cells and immune cells.As the largest bacterial reservoir in human body,the gut microbiome may be one of the sources of the intratumor microbiome in gastrointestinal malignancies.An increasing number of studies have shown that the gut and intratumor microbiome play an important role in regulating the immune tone of tumors.Moreover,it has been recently proposed that the gut and intratumor microbiome can influence tumor progression by modulating host metabolism and the immune and immune tone of the TME,which is defined as the immuno-oncology-microbiome(IOM)axis.The proposal of the IOM axis provides a new target for the tumor microbiome and tumor immunity.This review aims to reveal the mechanism and progress of the gut and intratumor microbiome in gastrointestinal malignancies such as esophageal cancer,gastric cancer,liver cancer,colorectal cancer and pancreatic cancer by exploring the IOM axis.Providing new insights into the research related to gastrointestinal malignancies.

Malignancy risk factors and prognostic variables of pancreatic mucinous cystic neoplasms in Chinese patients

BACKGROUND Pancreatic mucinous cystic neoplasms(MCNs)represent one of the precursor lesions of pancreatic ductal adenocarcinoma,and their detection has been facilitated by advances in preoperative imaging.Due primarily to the rarity of MCNs,however,there is limited knowledge regarding the prognostic variables and high-risk factors for malignant transformation.A more comprehensive and nuanced approach is necessary to fill this gap and provide a basis for improved treatment decisions and patient outcomes.AIM To investigate the high-risk factors associated with malignant MCNs and to explore the prognostic factors of MCN with associated invasive carcinoma(MCNAIC).METHODS All cases of resected MCNs from a single high-volume institution between January 2012 and January 2022 were retrospectively reviewed.Only cases with ovarian-type stroma verified by progesterone receptor staining were included.Preoperative features,histological findings and postoperative course were documented.Multivariate logistic regression was employed to investigate variables related to malignancy.Survival analysis was performed using the Kaplan-Meier curve,and the prognostic factors were assessed to evaluate the postoperative course of patients with MCN-AIC.RESULTS Among the 48 patients,36 had benign MCNs,and 12 had malignant MCNs(1 high-grade atypical hyperplasia and 11 MCN-AIC).Age,tumour size,presence of solid components or mural nodules and pancreatic duct dilatation were identified as independent risk factors associated with malignancy.The follow-up period ranged from 12 mo to 120 mo,with a median overall survival of 58.2 mo.Only three patients with MCN-AIC died,and the 5-year survival rate was 70.1%.All 11 cases of MCN-AIC were stage I,and extracapsular invasion was identified as a prognostic factor for poorer outcomes.CONCLUSION The risk factors independently associated with malignant transformation of MCNs included age,tumour size,presence of solid components or mural nodules,and pancreatic duct dilatation.Our study also revealed that encapsulated invasion was a favourable prognostic factor in MCN-AIC patients.

Ex vivo liver resection and auto-transplantation as an alternative for the treatment of liver malignancies: Progress and challenges

Hepatectomy is still the major curative treatment for patients with liver malignancies.However,it is still a big challenge to remove the tumors in the central posterior area,especially if their location involves the retrohepatic inferior vena cava and hepatic veins.Ex vivo liver resection and auto-transplantation(ELRA),a hybrid technique of the traditional liver resection and transplantation,has brought new hope to these patients and therefore becomes a valid alternative to liver transplantation.Due to its technical difficulty,ELRA is still concentrated in a few hepatobiliary centers that have experienced surgeons in both liver resection and liver transplantation.The efficacy and safety of this technique has already been demonstrated in the treatment of benign liver diseases,especially in the advanced alveolar echinococcosis.Recently,the application of ELRA for liver malignances has gained more attention.However,standardization of clinical practice norms and international consensus are still lacking.The prognostic impact in these oncologic patients also needs further evaluation.In this review,we summarized the principles and recent progresses on ELRA.

Impact of endoscopic ultrasound-guided radiofrequency ablation in managing pancreatic malignancy

Pancreatic malignancy is still the most lethal gastrointestinal malignancy.It has a very poor prognosis with low survival rate.Surgery is still the main treatment option for pancreatic malignancy.Most patients already have locally advanced and even late stage disease due to non-specific abdominal symptoms.Even though some cases are still suitable for surgical treatment,due to its aggressiveness adjuvant chemotherapy is becoming the standard treatment for controlling the disease.Radiofrequency ablation(RFA)is a thermal therapy that has been used as one of the standard treatments for liver malignancy.It can also be performed intraoperatively.There are several reports on percutaneous RFA treatment for pancreatic malignancy using transabdominal ultrasound and guided by computed tomography scan.However,due to its anatomical location and the risk of high radiation exposure,these methods seem to be very limited.Endoscopic ultrasound(EUS)has been widely used for pancreatic abnormality evaluation due to its ability to detect more accurately,especially small pancreatic lesions,compared to other imaging modalities.By the EUS approach,it is easier to achieve good visualization of tumor ablation and necrosis as the echoendoscope position is closer to the tumor area.Based on studies and a recent meta-analysis,EUS-guided RFA is a promising treatment approach for most pancreatic malignancy cases,but most studies only collected data from a small sample size.Larger studies are needed before clinical recommendations can be made.

Response letter to “Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the outcomes?” with imaging aspects

Radiological imaging findings may contribute to the differentiation of malignant biliary obstruction from choledocholithiasis in the etiology of acute cholangitis.

Post-transplant malignancy:Focusing on virus-associated etiologies,pathogenesis,evidence-based management algorithms,present status of adoptive immunotherapy and future directions

Modern immunosuppression has led to a decrease in rejection rates and improved survival rates after solid organ transplantation.Increasing the potency of immunosuppression promotes post-transplant viral infections and associated cancers by impairing immune response against viruses and cancer immunoediting.This review reflects the magnitude,etiology and immunological characteristics of various virus-related post-transplant malignancies,emphasizing the need for future research.A multidisciplinary and strategic approach may serve best but overall literature evidence targeting it is sparse.However,the authors attempted to provide a more detailed update of the literature consensus for the prevention,diagnosis,management and surveillance of post-transplant viral infections and associated malignancies,with a focus on the current role of adoptive immunotherapy and the way forward.In order to achieve long-term patient and graft survival as well as superior post-transplant outcomes,collaborative research on holistic care of organ recipients is imperative.

Acute myelomonocytic leukemia and T-lymphoblastic lymphoma as simultaneous bilineage hematologic malignancy treated with decitabine:A case report

BACKGROUND Simultaneous bilineage hematologic malignancies are rare;however,several cases of acute myeloid leukemia(AML)and T-lymphoblastic lymphoma(T-LBL)cooccurrence have been reported.A standard treatment for simultaneous AML and T-LBL has not yet been established,and its prognosis is very poor.Further studies to develop standard treatments are required to increase patient survival rates.CASE SUMMARY A 69-year-old man complaining of pleuritic chest pain visited the emergency room.Computed tomography revealed multiple enlarged lymph nodes(LNs)in the neck and groin and pulmonary thromboembolism with pulmonary infarction.Furthermore,a peripheral blood smear performed due to leukocytosis revealed circulating blasts.Acute myelomonocytic leukemia(AMML)was diagnosed after bone marrow examination,and T-LBL positivity for terminal deoxynucleotidyl transferase,cluster of differentiation(CD)34,and CD4 was confirmed by cervical LN biopsy.Decitabine and dexamethasone were administered because he could not receive intensive chemotherapy due to poor performance status.Complete remission of AMML and T-LBL was achieved after 4 cycles of decitabine plus dexamethasone.CONCLUSION We report the therapeutic effect of decitabine,a hypomethylating agent(HMA),in patients with concurrent bilineage hematologic malignancies and suggest that further studies are required to evaluate the therapeutic effect of HMAs on both lymphoid and bilineage hematologic malignancies.

Cancer Occurrence and Associated Factors to Malignancy in BIRADS-3 Lesions in Yaoundé: The Need to Be More Proactive for Patients above 40, Non-Compliant with Imaging Follow-Up and Presenting with Nipple Discharge

Background and objectives: Breast Imaging Reporting and Data System in Category 3 (BIRADS-3) includes probably benign lesions which need a short-term imaging follow-up. However, in our context, the lesions graded BIRADS-3 remain insufficiently evaluated. We therefore conducted this study to assess the cancer occurrence and associated factors in BIRADS-3 lesions during the follow-up in order to propose an adaptation of the management for lesions in this category in our setting. Patients and methods: A retrospective longitudinal study of patients with lesions initially classified as BIRADS-3 and who realised each at least one additional imaging check-up between January 2014 and December 2022 in five Yaoundé hospitals. All clinical and imaging data were analysed using SPSS® 21.0 software with a significant p-value Results: Patients were aged 13 to 73 (33.0 ± 13.4) years, with a history of breast mass (315 cases;79.7%), breast pain (25 patients;6.3%), nipple discharge (20 patients;5.1%) or past family history of breast cancer (25 cases;6.3%). The most common baseline abnormalities were mammogram opacities (64.8%) and microcalcifications (48.6%), whereas initial breast ultrasound showed solid masses (77.0%) and cystic lesions (11.1%). Compliance with imaging appointment periods was low with only 23.9% of all patients performing an imaging control at the scheduled moment. During the follow-up, 115 patients (29.1%) were upgraded to BIRADS-4 and histology performed revealed 43 cancers (10.9% of overall initial BIRADS-3 sample). The presence of malignancies was associated to age above 40 years (p = 0.0001) and to the presence of nipple discharge (p = 0.0375). Conclusion: The frequency of malignancies among initial BIRADS-3 lesions in our series is higher than that described in the guidelines. This study highlights the need to be more proactive in the management of BIRADS-3 lesions in our setting as the compliance with follow-up is low. So, biopsy should be considered as an alternative to long-term follow-up for patients above 40, non-compliant with imaging check-ups and presenting with nipple discharge.

Hepatic perivascular epithelioid cell tumors:Benign,malignant,and uncertain malignant potential

In 2013,the World Health Organization defined perivascular epithelioid cell tumor(PEComa)as“a mesenchymal tumor which shows a local association with vessel walls and usually expresses melanocyte and smooth muscle markers.”This generic definition seems to better fit the PEComa family,which includes angiomyolipoma,clear cell sugar tumor of the lung,lymphangioleiomyomatosis,and a group of histologically and immunophenotypically similar tumors that include primary extrapulmonary sugar tumor and clear cell myomelanocytic tumor.Clear cell tumors with this immunophenotypic pattern have also had their malignant variants described.When localizing to the liver,preoperative radiological diagnosis has proven to be very difficult,and most patients have been diagnosed with hepatocellular carcinoma,focal nodular hyperplasia,hemangioma,or hepatic adenoma based on imaging findings.Examples of a malignant variant of the liver have been described.Finally,reports of malignant variants of these lesions have increased in recent years.Therefore,we support the use of the Folpe criteria,which in 2005 established the criteria for categorizing a PEComa as benign,malignant,or of uncertain malignant potential.Although they are not considered ideal,they currently seem to be the best approach and could be used for the categorization of liver tumors.

Unraveling the nexus between cellular senescence and malignant transformation:a paradigm shift in cancer research

Cellular senescence, a natural process wherein cells cease division and undergo irreversible growth arrest, has long captivated the curiosity of scientists because of its many implications in aging and disease. Recent research has shed light on the nexus between cellular senescence and malignant transformation, thus leading to a paradigm shift in understanding cancer development and progression.

Advanced hepatocellular carcinoma in a patient with neurofibromatosis type 1 and malignant peripheral nerve sheath tumor

To the Editor: Neurofibromatosis type 1(NF-1), or Von Recklinghausen disease, is a genetic disorder inherited in an autosomal dominant pattern. It is caused by a mutation in the neurofibromin gene located on chromosome 17, accounting for 96% of all neurofibromatosis cases. This condition can affect multiple systems and often leads to the formation of tumors along the nervous system [1]. Patients with NF-1 may exhibit various symptoms, including Lisch nodules, neurofibromas, scoliosis, café au lait spots, learning disabilities, vision disorders, and epilepsy.

Recurrent malignant hyperthermia after scoliosis correction surgery

Malignant hyperthermia(MH)is a genetic disorder of skeletal muscle cells that affects muscle cytoplasmic calcium homeostasis,with high mortality and low morbidity.Generally,it presents with non-specific signs of a hypermetabolic response,including high fever,tachycardia,and elevated end-tidal carbon dioxide(ETCO_(2)).The successful treatment lies in the timely recognition and early use of dantrolene.[1]As an inhibitor of Ca2+release through ryanodine receptor(RYR)channels,the skeletal muscle relaxant dantrolene has proven to be both a valuable experimental probe of intracellular Ca2+signaling and a lifesaving treatment for MH.[2]Dominant mutations in the skeletal muscle RYR1 gene are well-recognized causes of both malignant hyperthermia susceptibility(MHS)and central core disease(CCD).

Blockade of CD300A enhances the ability of human NK cells to lyse hematologic malignancies

Objective: The human cluster of differentiation(CD)300A, a type-I transmembrane protein with immunoreceptor tyrosine-based inhibitory motifs, was investigated as a potential immune checkpoint for human natural killer(NK) cells targeting hematologic malignancies(HMs).Methods: We implemented a stimulation system involving the CD300A ligand, phosphatidylserine(PS), exposed to the outer surface of malignant cells. Additionally, we utilized CD300A overexpression, a CD300A blocking system, and a xenotransplantation model to evaluate the impact of CD300A on NK cell efficacy against HMs in in vitro and in vivo settings. Furthermore, we explored the association between CD300A and HM progression in patients.Results: Our findings indicated that PS hampers the function of NK cells. Increased CD300A expression inhibited HM lysis by NK cells. CD300A overexpression shortened the survival of HM-xenografted mice by impairing transplanted NK cells. Blocking PS–CD300A signals with antibodies significantly amplified the expression of lysis function-related proteins and effector cytokines in NK cells, thereby augmenting the ability to lyse HMs. Clinically, heightened CD300A expression correlated with shorter survival and an “exhausted” phenotype of intratumoral NK cells in patients with HMs or solid tumors.Conclusions: These results propose CD300A as a potential target for invigorating NK cell-based treatments against HMs.

Application of Fusobacterium nucleatum as a biomarker in gastrointestinal malignancies

The morbidity and mortality of gastrointestinal(GI)malignancies are among the highest in the world,posing a serious threat to human health.Because of the insidious onset of the cancer,it is difficult for patients to be diagnosed at an early stage,and it rapidly progresses to an advanced stage,resulting in poor treatment and prognosis.Fusobacterium nucleatum(F.nucleatum)is a gram-negative,sporefree anaerobic bacterium that primarily colonizes the oral cavity and is implicated in the development of colorectal,esophageal,gastric,and pancreatic cancers via various intricate mechanisms.Recent development in novel research suggests that F.nucleatum may function as a biomarker in GI malignancies.Detecting the abundance of F.nucleatum in stool,saliva,and serum samples of patients may aid in the diagnosis,risk assessment,and prognosis monitoring of GI malignancies.This editorial systematically describes the biological roles and mechanisms of F.nucleatum in GI malignancies focusing on the application of F.nucleatum as a biomarker in the diagnosis and prognosis of GI malignancies to promote the clinical translation of F.nucleatum and GI tumors-related research.

Prevalence of malignant neoplasms in celiac disease patients-a nationwide United States population-based study

BACKGROUND Celiac disease(CeD)is an autoimmune disorder triggered by the immune response to gluten in genetically predisposed individuals.Recent research has unveiled a heightened risk of developing specific malignant neoplasms(MN)and various malignancies,including gastrointestinal,lymphomas,skin,and others,in individuals with CeD.AIM To investigate the prevalence of MN in hospitalized CeD patients in the United States.METHODS Using data from the National Inpatient Sample spanning two decades,from January 2000 to December 2019,we identified 529842 CeD patients,of which 78128(14.75%)had MN.Propensity score matching,based on age,sex,race,and calendar year,was employed to compare CeD patients with the general non-CeD population at a 1:1 ratio.RESULTS Positive associations were observed for several malignancies,including small intestine,lymphoma,nonmelanoma skin,liver,melanoma skin,pancreas myelodysplastic syndrome,biliary,stomach,and other neuroendocrine tumors(excluding small and large intestine malignant carcinoid),leukemia,uterus,and testis.Conversely,CeD patients exhibited a reduced risk of respiratory and secondary malignancies.Moreover,certain malignancies showed null associations with CeD,including head and neck,nervous system,esophagus,colorectal,anus,breast,malignant carcinoids,bone and connective tissues,myeloma,cervix,and ovary cancers.CONCLUSION Our study is unique in highlighting the detailed results of positive,negative,or null associations between different hematologic and solid malignancies and CeD.Furthermore,it offers insights into evolving trends in CeD hospital outcomes,shedding light on advancements in its management over the past two decades.These findings contribute valuable information to the understanding of CeD’s impact on health and healthcare utilization.

Survival Analysis of Patients Undergoing Intraoperative Contrast-enhanced Ultrasound in the Surgical Treatment of Malignant Glioma

Objective:Complete resection of malignant gliomas is often challenging.Our previous study indicated that intraoperative contrast-enhanced ultrasound(ICEUS)could aid in the detection of residual tumor remnants and the total removal of brain lesions.This study aimed to investigate the survival rates of patients undergoing resection with or without the use of ICEUS and to assess the impact of ICEUS on the prognosis of patients with malignant glioma.Methods:A total of 64 patients diagnosed with malignant glioma(WHO grade HI and IV)who underwent surgery between 2012 and 2018 were included.Among them,29 patients received ICEUS.The effects of ICEUS on overall survival(OS)and progression-free survival(PFS)of patients were evaluated.A quantitative analysis was performed to compare ICEUS parameters between gliomas and the surrounding tissues.Results:The ICEUS group showed better survival rates both in OS and PFS than the control group.The univariate analysis revealed that age,pathology and ICEUS were significant prognostic factors for PFS,with only age being a significant prognostic factor for OS.In multivariate analysis,age and ICEUS were significant prognostic factors for both OS and PFS.The quantitative analysis showed that the intensity and transit time of microbubbles reaching the tumors were significantly different from those of microbubbles reaching the surrounding tissue.Conclusion:ICEUS facilitates the identification of residual tumors.Age and ICEUS are prognostic factors for malignant glioma surgery,and use of ICEUS offers a better prognosis for patients with malignant glioma.

Results of Surgical Management of Malignant Obstruction of the Common Bile Duct in Yaoundé

Introduction: In Cameroon, surgery remains the only approach in malignant obstructions of the common bile duct (MOCBD) even in palliative situations. The aim of this work was to describe the modalities of surgical treatment of MOCBD, evaluate the results and detect the factors associated with postoperative morbidity and mortality. Patients and Methods: We conducted an analytical observational study, with retrospective data collection from the files of patients operated upon for MOCBD. This was done in four referral hospitals in the city of Yaoundé for a 42-month period spanning from January 1, 2020 to June 30, 2023. Demographic data, clinical presentation, surgical data, and 30-day postoperative outcomes were collected. Results: We collected 71 files. The sex ratio was 1.4 and the mean age was 56 ± 11 years. Fifty-three (53) patients (74.6%) were overweight or obese and 10 patients (14.1%) were hypertensive. A clinical cholestasis syndrome was present in 69 patients (97.2%). Fifty-five (55) patients (77.5%) had a cancer of the head of the pancreas, 8 patients (11.3%) had an extra-hepatic cholangiocarcinoma and 8 patients (11.3%) had an ampullary adenocarcinoma. Eight (8) resections (11.3%) with curative intent had been carried out and in 63 cases (88.7%), surgery was palliative. Postoperative morbidity was 55.7%, influenced by advanced WHO stage (p = 0.02). Postoperative mortality was 25.7%, associated with a high ASA score (p = 0.01). Conclusion: Pancreatic head cancer is the main etiology of malignant obstructions of the common bile duct in Cameroon. Surgical treatment is most often palliative. Postoperative morbidity and mortality are high, influenced by high WHO and ASA scores.

Preclinical evaluation of cyclophosphamide and fludarabine combined with CD19 CAR-T in the treatment of B-cell hematologic malignancies in vivo

Background:Chimeric antigen receptor T(CAR-T)cell therapy has achieved marked therapeutic success in ameliorating hematological malignancies.However,there is an extant void in the clinical guidelines concerning the most effective chemotherapy regimen prior to chimeric antigen receptor T(CAR-T)cell therapy,as well as the optimal timing for CAR-T cell infusion post-chemotherapy.Materials and Methods:We employed cell-derived tumor xenograft(CDX)murine models to delineate the optimal pre-conditioning chemotherapy regimen and timing for CAR-T cell treatment.Furthermore,transcriptome sequencing was implemented to identify the therapeutic targets and elucidate the underlying mechanisms governing the treatment regimen.Results:Our preclinical in vivo evaluation determined that a combination of cyclophosphamide and fludarabine,followed by the infusion of CD19 CAR-T cells five days subsequent to the chemotherapy,exerts the most efficacious therapeutic effect in B-cell hematological malignancies.Concurrently,RNA-seq data indicated that the therapeutic efficacy predominantly perturbs tumor cell metabolism,primarily through the inhibition of key mitochondrial targets,such as C-Jun Kinase enzyme(C-JUN).Conclusion:In summary,the present study offers critical clinical guidance and serves as an authoritative reference for the deployment of CD19 CAR-T cell therapy in the treatment of B-cell hematological malignancies.