Pancreatic Neuroendocrine Neoplasms: Correlation between MR Features and Pathological Tumor Grades

This study investigated the accuracy of MRI features in differentiating the pathological grades of pancreatic neuroendocrine neoplasms（PNENs）. A total of 31 PNENs patients were retrospectively evaluated, including 19 cases in grade 1, 5 in grade 2, and 7 in grade 3. Plain and contrastenhanced MRI was performed on all patients. MRI features including tumor size, margin, signal intensity, enhancement patterns, degenerative changes, duct dilatation and metastasis were analyzed. Chi square tests, Fisher＇s exact tests, one-way ANOVA and ROC analysis were conducted to assess the associations between MRI features and different tumor grades. It was found that patients with older age, tumors with higher TNM stage and without hormonal syndrome had higher grade of PNETs（all P〈0.05）. Tumor size, shape, margin and growth pattern, tumor pattern, pancreatic and bile duct dilatation and presence of lymphatic and distant metastasis as well as MR enhancement pattern and tumor-topancreas contrast during arterial phase were the key features differentiating tumors of all grades（all P〈0.05）. ROC analysis revealed that the tumor size with threshold of 2.8 cm, irregular shape, pancreatic duct dilatation and lymphadenopathy showed satisfactory sensitivity and specificity in distinguishing grade 3 from grade 1 and grade 2 tumors. Features of peripancreatic tissue or vascular invasion, and distant metastasis showed high specificity but relatively low sensitivity. In conclusion, larger size, poorlydefined margin, heterogeneous enhanced pattern during arterial phase, duct dilatation and the presence of metastases are common features of higher grade PNENs. Plain and contrast-enhanced MRI provides the ability to differentiate tumors with different pathological grades.

The prognostic significance of clinical and pathological features in hepatocellular carcinoma

The prognosis of patients with HCC still remains dismal. The life expectancy of HCC patients is hard to predict because of the high possibility of postoperative recurrence. Many factors, such as patient's general conditions, macroscopic tumor morphology, as well as tumor histopathology features, have been proven of prognostic significance. Female HCC patient often has a better prognosis than male patient, which might be due to the receptor of sex hormones. Younger patients often have tumors with higher invasiveness and metastatic potentials, and their survival and prognosis are worse than the older ones. Co-existing hepatitis status and hepatic functional reserve have been confirmed as risk factors for recurrence. Serum alpha-fetoprotein (AFP) is useful not only for diagnosis, but also as a prognostic indicator for HCC patients. AFP mRNA has been proposed as a predictive marker of HCC cells disseminated into the circulation and for metastatic recurrence. Many pathologic features, such as tumor size, number, capsule state, cell differentiation, venous invasion, intrahepatic spreading, and advanced pTNM stage, are the best-established risk factors for recurrence and important aspects affecting the prognosis of patients with HCC. Marked inflammatory cell infiltration in the tumor could predict a better prognosis. Clinical stage is still the most important factor influencing on the prognosis. Extratumor spreading and lymph nodal metastasis are independent predictors for poor outcome. Some new predictive systems have recently been proposed. Different strategies of treatment might have significant different effects on the patients' prognosis. To date, surgical resection is still the only potentially curative treatment for HCC, including localized postoperative recurrences. Extent of resection, blood transfusion, occlusion of porta hepatis, and blood loss affect the survival and prognosis of HCC patients. Regional therapies provide alternative ways to improve the prognosis of HCC patients who have no opportunity to receive surgical treatment or postoperative recurrence. The combination of these treatment modalities is hopeful to further improve the prognosis. The efficacies of neoadjuvant (preoperative) or adjuvant (postoperative) chemotherapy or chemoembolization in preventing recurrence and on the HCC prognosis still remain great controversy, and deserve further evaluation. Biotherapy, including IFN-alpha therapy, will play more important role in preventing recurrence and metastasis of HCC after operation.

Prediction of recurrence and prognosis in patients with hepatocellular carcinoma after resection by use of CLIP score

AIM: The survival time of patients with hepatocellular carcinoma (HCC) after resection is hard to predict. Both residual liver function and tumor extension factors should be considered. A new scoring system has recently been proposed by the Cancer of the Liver Italian Program (CLIP). CLIP score was confirmed to be one of the best ways to stage patients with HCC. To our knowledge, however, the literature concerning the correlation between CLIP score and prognosis for patients with HCC after resection was not published. The aim of this study is to evaluate the recurrence and prognostic value of CLIP score for the patients with HCC after resection. METHODS: A retrospective survey was carried out in 174 patients undergoing resection of HCC from January 1986 to June 1998. Six patients who died in the hospital after operation and 11 patients with the recurrence of the disease were excluded at 1 month after hepatectomy. By the end of June 2001, 4 patients were lost and 153 patients with curative resection have been followed up for at least three years. Among 153 patients, 115 developed intrahepatic recurrence and 10 developed extrahepatic recurrence, whereas the other 28 remained free of recurrence. Recurrences were classified into early (【 or =3 year) and late (】3 year) recurrence. The CLIP score included the parameters involved in the Child-Pugh stage (0-2), plus macroscopic tumor morphology (0-2), AFP levels (0-1), and the presence or absence of portal thrombosis (0-1). By contrast, portal vein thrombosis was defined as the presence of tumor emboli within vascular channel analyzed by microscopic examination in this study. Risk factors for recurrence and prognostic factors for survival in each group were analyzed by the chi-square test, the Kaplan-Meier estimation and the COX proportional hazards model respectively. RESULTS: The 1-, 3-, 5-, 7-,and 10-year disease-free survival rates after curative resection of HCC were 57.2%, 28.3%, 23.5%, 18.8%, and 17.8%, respectively. Median survival time was 28, 10, 4, and 5 mo for CLIP score 0, 1, 2, 3, and 4 to 5, respectively. Early and late recurrence developed in 109 patients and 16 patients respectively. By the chi-square test, tumor size, microsatellite, venous invasion, tumor type (uninodular, multinodular, massive), tumor extension (【 or = or 】50% of liver parenchyma replaced by tumor), TNM stage, CLIP score, and resection margin were the risk factors for early recurrence, whereas CLIP score and Child-Pugh stage were significant risk factors for late recurrence. In univariate survival analysis, Child-Pugh stages, resection margin, tumor size, microsatellite, venous invasion, tumor type, tumor extension, TNM stages, and CLIP score were associated with prognosis. The multivariate analysis by COX proportional hazards model showed that the independent predictive factors of survival were resection margins and TNM stages. CONCLUSION: CLIP score has displayed a unique superiority in predicting the tumor early and late recurrence and prognosis in the patients with HCC after resection.

p16 gene methylation in colorectal cancers associated with Duke's staging

AIM: To explore the association of methylation of the CpG island in the promotor of the p16 tumor suppressor gene with the clinicopathological characteristics of the colorectal cancers. METHODS: Methylation-specific PCR (MSP) was used to detect p16 methylation of 62 sporadic colorectal cancer specimens. RESULTS: p16 methylation was detected in 42% of the tumors.Dukes'staging was associated with p16 methylation status.p16 methylation occurred more frequently in Dukes'C and D patients (75.9%) than in Dukes'A and B patients (12.1%). CONCLUSION: p16 methylation plays a role in the carcinogenesis of a subset of colorectal cancer, and it might be linked to poor prognosis.

New approaches to gastric cancer staging:Beyond endoscopic ultrasound,computed tomography and positron emission tomography

Currently, there is no single gold standard modality for staging of gastric cancer and several methods have been used complementarily in the each clinical situation. To make up for the shortcomings of conventional modalities such as endoscopic ultrasound, computed tomography and 18F-fluoro-2-deoxyglucose positron emission tomography, numerous attempts with new approaches have been made for gastric cancer staging. For T staging, magnifying endoscopy with narrow-band was evaluated to differentiate mucosal cancer from submucosal cancer. Single/double contrast-enhanced ultrasound and diffusion-weighted magnetic resonance imaging were also tried to improve diagnostic accuracy of gastric cancer. For intraoperative staging with sentinel node mapping, indocyanine green infrared and fluorescence imaging was introduced. In addition, to detect micrometastasis, real-time reverse transcription-polymerase chain reaction system with multiple markers was studied. Staging laparoscopy using 5-aminolevulinic acid-mediated photodynamic diagnosis and percutaneous diagnostic peritoneal lavage were also evaluated. However, most studies reporting new staging methods is preliminary and further studies for validation in clinical practice are needed. In this mini-review, we discuss new progress in gastric cancer staging. Especially, we focus on new diagnostic approach to gastric cancer staging beyond the conventional modalities and briefly review the remarkable clinical results of the studies published over the past three years.

C-reactive protein,procalcitonin,interleukin-6,vascular endothelial growth factor and oxidative metabolites in diagnosis of infection and staging in patients with gastric cancer

AIM:The current study was to determine the serum/pLasma levels of VEGF,IL-6,malondialdehyde (MDA),nitric oxide (NO),PCT and CRP in gastric carcinoma and correlation with the stages of the disease and accompanying infection. METHODS:We examined the levels of serum VEGF,IL-6, PCT,CRP and plasma MDA,NO in 42 preoperative gastric cancer patients and 23 healthy subjects.There were infection anamneses that had no definite origin in 19 cancer patients. RESULTS:The VEGF levels (mean±SD; pg/mL) were 478.05±178.29 and 473.85±131.24 in gastric cancer patients with and without infection,respectively,and these values were not significantly different (P>0.05).The levels of VEGF, CRP,PCT,It-6,MDA and NO in cancer patients were significantly higher than those in healthy controls and the levels of CRP,PCT,It-6,MDA and NO were statistically increased in infection group when compared with non- infection group (P<0.001). CONCLUSION:Although serum VEGF concentrations were increased in gastric cancer,this increase might not be related to infection.CRP,PCT,IL-6,MDA and NO have obvious drawbacks in the diagnosis of infections in cancer patients. These markers may not help to identify infections in the primary evaluation of cancer patients and hence to avoid unnecessary antibiotic treatments as well as hospitalization. According to the results of this study,IL-6,MDA,NO and especially VEGF can be used as useful parameters to diagnose and grade gastric cancer.

Comparison of hydrocolonic sonograpy accuracy in preoperative staging between colon and rectal cancer

AIM:To compare the accuracy of hydrocolonic sonography (HUS) in determining the depth of invasion (T stage) in colon and rectal cancer. METHODS:A total of 1000-2000 mL of saline was instilled per rectum using a system for barium enemas,and then ultrasonography was conducted by a SSA-270A (Toshiba Co,Japan) sonolayer unit with a 3.75 MHz for 17 patients with colon cancer and 13 patients with rectal cancer before operation.After operation,T stage in HUS was compared with postoperative histological findings. RESULTS:Overall,the accuracy of T stage was 70%.It was 88% in colon cancer and 46% in rectal cancer.In evaluating nodal state,the accuracy of HUS was low in both colon (71%) and rectal cancers (46%) compared with conventional CT or MRI.The overall accuracy of N staging was 60%. CONCLUSION:HUS is valuable to evaluate the depth of invasion in colon cancer,but is less valuable in rectal cancer.Because HUS is low-cost,noninvasive,and readily available at any place,this technique seems to be useful to determine the preoperative staging in colon cancer,but not in rectal cancer.

Role of endoscopic ultrasound in the diagnosis of pancreatic cancer

Endoscopic ultrasonography(EUS) with or without fine needle aspiration has become the main technique for evaluating pancreatobiliary disorders and has proved to have a higher diagnostic yield than positron emission tomography,computed tomography(CT) and transabdominal ultrasound for recognising early pancreatic tumors.As a diagnostic modality for pancreatic cancer,EUS has proved rates higher than 90%,especially for lesions less than 2-3 cm in size in which it reaches a sensitivity rate of 99% vs 55% for CT.Besides,EUS has a very high negative predictive value and thus EUS can reliably exclude pancreatic cancer.The complication rate of EUS is as low as 1.1%-3.0%.New technical developments such as elastography and the use of contrast agents have recently been applied to EUS,improving its diagnostic capability.EUS has been found to be superior to the recent multidetector CT for T stagingwith less risk of overstaying in comparison to both CT and magnetic resonance imaging,so that patients are not being ruled out of a potentially beneficial resection.The accuracy for N staging with EUS is 64%-82%.In unresectable cancers,EUS also plays a therapeutic role by means of treating oncological pain through celiac plexus block,biliary drainage in obstructive jaundice in patients where endoscopic retrograde cholangiopancreatography is not affordable and aiding radiotherapy and chemotherapy.

TNM staging of colorectal cancer should be reconsidered by T stage weighting

AIM: To verify that the T stage has greater weight than the N stage in the staging of colorectal cancer.

Relationship between preoperative staging by endoscopic ultrasonography and MMP-9 expression in gastric carcinoma

AIM: To investigate the relationship between the staging by endoscopic ultrasonography (EUS) and the expression of carcinoma metastasis associated gene in the patients with gastric carcinoma. METHODS: Sixty-three patients with gastric cancer were diagnosed by electric gastroscopy and EUS. The preoperative staging of gastric cancer was measured by EUS and compared with pathologic staging and MMP-9 expression. Peripheral serum level of MMP-9 was measured with enzyme-linked immunosorbent assay (ELISA), while the expression of MMP-9 protein was tested with immunohistochemistry and hybridization in situ in the gastric carcinoma tissues. RESULTS: The total accuracy of EUS in estimating invasive depth of gastric cancer was 80.95%, while that in estimating lymphatic metastasis was 73.02%. Serum MMP-9 levels were consistent with the expression of MMP-9 protein and MMP-9 mRNA in tissue, a result closely correlated with invasive degree, staging with EUS and lymphatic metastasis in gastric cancer (P < 0.05). The total accuracy of estimating invasive depth in gastric cancer was 95.22% using both EUS and MMP-9. CONCLUSION: The MMP-9 level of preoperative serum presents the reference value for preoperative staging by EUS in the patients with gastric cancer. When serum MMP-9 level in gastric cancer is significantly high, physicians should pay closer attention to the metastasis which reaches the serosa or beyond. Combining EUS and MMP-9 improves the accuracy in deciding the invasion and metastasis in the patients with gastric carcinoma.

Usefulness of two independent hist classifications of tumor regression iUsefulness of two independent histopathological classifications of tumor regression in patients with rectal cancer submitted to hyperfractionated pre-operative radiotherapy

AIM： To assess the usefulness of two independent histopathological classifications of rectal cancer regression following neo-adjuvant therapy. METHODS： Forty patients at the initial stage cT3NxM0 submitted to preoperative radiotherapy （42 Gy during 18 d） and then to radical surgical treatment. The relationship between ＂T-downstaging＂ versus regressive changes expressed by tumor regression grade （TRG 1-5） and Nasierowska-Guttmejer classification （NG 1-3） was studied as well as the relationship between TRG and NG versus local tumor stage ypT and lymph nodes status, ypN. RESULTS： Complete regression （ypT0, TRG 1） was found in one patient. ＂T-downstaging＂ was observed in 11 （27.5%） patients. There was a weak statistical significance of the relationship between ＂T-downstaging＂ and TRG staging and NG stage. Patients with ypT1 were diagnosed as TRG 2-3 while those with ypT3 as TRGS. No lymph node metastases were found in patients with TRG 1-2. None of the patients without lymph node metastases were diagnosed as TRG 5. Patients in the ypT1 stage were NG 1-2. No lymph node metastases were found in NG 1. There was a significant correlation between TRG and NG. CONCLUSION： Histopathological classifications may be useful in the monitoring of the effects of hyperfractionated preoperative radiotherapy in patients with rectal cancer at the stage of cT3NxM0. There is no unequivocal relationship between ＂Todownstaging＂ and TRG and NG. There is some concordance in the assessment of lymph node status with ypT, TRG and NG. TRG and NG are of limited value for the risk assessment of the lymph node involvement.

Pancreatic cancer–Endosonography

EUS is the most sensitive imaging procedure for the detection of small solid pancreatic masses and is accurate in determining vascular invasion of the portal venous system. Even compared to the new CT-techniques EUS provides excellent results in preoperative staging of solid pancreatic tumors. Compared to helical CT-techniques EUS is less accurate in detecting tumor involvement of superior mesenteric artery. EUS staging and EUS-guided FNA can be performed in a single-step procedure, to establish the diagnosis of cancer. There is no known negative impact of tumor cell seeding due to EUS-FNA. Without FNA EUS and additional methods are not able to reliably distinguish between inflammatory and malignant masses.

Mast cells and human hepatocellular carcinoma

AIM: To investigate the density of mast cells (MCs) in human hepatocellular carcinoma (HCC), and to determine whether the MCs density has any correlations with histopathological grading, staging or some baseline patient characteristics.METHODS: Tissue sections of 22 primary HCCs were histochemically stained with toluidine blue, in order to be able to quantify the MCs in and around the neoplasm using a computer-assisted image analysis system. HCC was staged and graded by two independent pathologists. To identify the sinusoidal capillarisation of each specimen 3μm thick sections were histochemically stained with sirius red, and semi-quantitatively evaluated by two independent observers. The data were statistically analysed using Spearman′s correlation and Student′s t-test when appropriate.RESULTS: MCs density did not correlate with the age or sex of the patients, the serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels, or the stage or grade of the HCC. No significant differences were found between the MCs density of the patients with and without hepatitis C virus infection, but they were significantly higher in the specimens showing marked sinusoidal capillarisation.CONCLUSION: The lack of any significant correlation between MCs density and the stage or grade of the neoplastic lesions suggests that there is no causal relationship between MCs recruitment and HCC. However, as capillarisation proceeds concurrently with arterial blood supply during hepatocarcinogenesis, MCs may be considered of primary importance in the transition from sinusoidal to capillary-type endothelial cells and the HCC growth.

Mesenterico-portal vein invasion should be an important factor in TNM staging for pancreatic ductal adenocarcinoma: Proposed modification of the 8th edition of the American Joint Committee on Cancer staging system

BACKGROUND The 8^th edition of the American Joint Committee on Cancer(AJCC)staging system for pancreatic ductal adenocarcinoma(PDAC)excludes extrapancreatic extension from the assessment of T stage and restages tumors with mesenterico-portal vein(MPV)invasion into T1-3 diseases according to tumor size.However,MPV invasion is believed to be correlated with a poor prognosis.AIM To analyze whether the inclusion of MPV invasion can further improve the 8th edition of the AJCC staging system for PDAC.METHODS This study retrospectively included 8th edition AJCC T1-3N0-2M0 patients undergoing pancreaticoduodenectomy/total pancreatectomy from two cohorts and analyzed survival outcomes.In the first cohort,a total of 7539 patients in the surveillance,epidemiology,and end results database was included,and in the second cohort,689 patients from the West China Hospital database were enrolled.RESULTS Cox regression analysis showed that MPV invasion is an independent prognostic factor in both databases.In the MPV-group,all pairwise comparisons between the survival functions of patients with different stages were significant except for the comparison between patients with stage IIA and those with stage IIB.However,in the MPV+group,pairwise comparisons between the survival functions of patients with stage IA,stage IB,stage IIA,stage IIB,and stage III were not significant.T1-3N0 patients in the MPV+group were compared with the T1N0,T2N0,and T3N0 subgroups of the MPV-group;only the survival of MPV-T3N0 and MPV+T1-3N0 patients had no significant difference.Further comparisons of patients with stage IIA and subgroups of stage IIB showed(1)no significant difference between the survival of T2N1 and T3N0 patients;(2)a longer survival of T1N1 patients that was shorter than the survival of T2N0 patients;and(3)and a shorter survival of T3N1 patients that was similar to that of T1-3N2 patients.CONCLUSION The modified 8th edition of the AJCC staging system for PDAC proposed in this study,which includes the factor of MPV invasion,provides improvements in predicting prognosis,especially in MPV+patients.

^(68)Ga-PSMA PET/CT versus CT and bone scan for investigation of PSA failure post radical prostatectomy

Objective:To evaluate the use of Gallium-68 prostate-specific membrane antigen positron emission tomography/computed tomography(^(68)Ga-PSMA PET/CT),compared with conventional CT abdomen/pelvis(CTAP)and whole body single photon emission CT bone scan(BS),for detection of local or distant metastasis following biochemical failure/recurrence in post-prostatectomy patients.Methods:We conducted a review of our prospectively maintained,institutional database to identify 384 patients with post-prostatectomy biochemical failure/recurrence who underwent PSMA PET/CT,CTAP and BS from February 2015 to August 2017 in Nepean Hospital,tertiary referral centre.The results of the three imaging modalities were analysed for their ability to detect local recurrence and distant metastases.PSMA PET/CT and CTAP imaging were separately performed on the same day and the BS was performed within several days(mostly in 24 h).Difference in detection rates was determined between the modalities and the Chi square test was used to determine significance.Results:A total of 384 patients were identified with a median prostate-specific antigen(PSA)of 0.465 ng/mL(interquartile range =0.19-2.00 ng/mL).Overall,PSMA PET/CT was positive for 245(63.8%)patients whereas CTAP and BS were positive in 174 patients(45.3%).A total of 98 patients(25.5%)had local or distant metastasis detected on PSMA only,while 20 patients(5.2%)had recurrences detected on CTAP but not on PSMA PET/CT.Conclusion:The use of PSMA PET/CT has a higher detection rate of predicted local or distant metastasis compared to CTAP and BS in the staging of patients with biochemical recurrences after radical prostatectomy.

Prognostic impact of tumor deposits on overall survival in colorectal cancer:Based on Surveillance, Epidemiology, and End Results database

BACKGROUND In colorectal cancer, tumor deposits(TDs) are considered to be a prognostic factor in the current staging system, and are only considered in the absence of lymph node metastases(LNMs). However, this definition and the subsequent prognostic value based on it is controversial, with various hypotheses. TDs may play an independent role when it comes to survival and addition of TDs to LNM count may predict the prognosis of patients more accurately.AIM To assess the prognostic impact of TDs and evaluate the effect of their addition to the LNM count.METHODS The patients are derived from the Surveillance, Epidemiology, and End Results database. A prognostic analysis regarding impact of TDs on overall survival(OS) was performed using Cox regression model, and other covariates associating with OS were adjusted. The effect of addition of TDs to LNM count on N restaging was also evaluated. The subgroup analysis was performed to explore the different profile of risk factors between patients with and without TDs.RESULTS Overall, 103755 patients were enrolled with 14131(13.6%) TD-positive and 89624(86.4%) TD-negative tumors. TD-positive patients had worse prognosis compared with TD-negative patients, with 3-year OS rates of 47.3%(95%CI, 46.5%-48.1%) and 77.5%(95%CI, 77.2%-77.8%, P < 0.0001), respectively. On multivariable analysis, TDs were associated poorer OS(hazard ratio, 1.35;95%CI, 1.31-1.38;P < 0.0001). Among TD-positive patients, the number of TDs had a linear negative effect on disease-free survival and OS. After reclassifying patients by adding TDs to the LNM count, 885 of 19 965(4.4%) N1 patients were restaged as p N2, with worse outcomes than patients restaged as p N1(3-year OS rate: 78.5%, 95%CI, 77.9%-79.1% vs 63.2%, 95%CI, 60.1%-66.5%, respectively;P < 0.0001).CONCLUSION TDs are an independent prognostic factor for OS in colorectal cancer. The addition of TDs to LNM count improved the prognostic accuracy of tumor, node and metastasis staging.

N2 disease in non-small cell lung cancer patients,diagnosis and evaluation:a Turkish chest surgeon s perspective

Mediastinal or N2 disease is the most important factor in selecting the optimal treatment strategy in patients without distant metastasis.A direct surgical resection has not generally been accepted as a treatment modality in whom mediastinal nodal involvement is demonstrated.Patients with lung cancer can be diagnosed as clinical N2 disease based on CT and PET-CT characteristics of the mediastinum and the clinical presentation.Invasive diagnostic modalities used in the detection of N2 disease are:mediastinoscopy,endoesophageal ultrasound guided biopsy(EUS),transbronchial needle aspiration(TBNA),endobronchial ultrasound guided biopsy(EBUS),video-assisted thoracoscopic surgery(VATS),and mediastinotomy/extended mediastinoscopy.In this article,the author discusses about invasive and noninvasive techniques on the evaluation of mediastinal disease and presents his experience on this topic.

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.

Functionality is not an independent prognostic factor for pancreatic neuroendocrine tumors

BACKGROUND Pancreatic neuroendocrine neoplasms(pNENs)that produce hormones leading to symptoms are classified as functional tumors,while others are classified as nonfunctional tumors.The traditional view is that functionality is a factor that affects the prognosis of pNEN patients.However,as the sample sizes of studies have increased,researches in recent years have proposed new viewpoints.AIM To assess whether functionality is an independent factor for predicting the prognosis of pNEN patients.METHODS From January 2004 to December 2016,data of patients who underwent surgery at the primary site for the treatment of pNENs from the Surveillance,Epidemiology,and End Results(SEER)database and West China Hospital database were retrospectively analyzed.RESULTS Contemporaneous data from the two databases were analyzed separately as two cohorts and then merged as the third cohort to create a large sample that was suitable for multivariate analysis.From the SEER database,age(P=0.006)and T stage(P<0.001)were independent risk factors affecting the survival.From the West China Hospital database,independent prognostic factors were age(P=0.034),sex(P=0.032),and grade(P=0.039).The result of the cohort consisting of the combined populations from the two databases showed that race(P=0.015),age(P=0.002),sex(P=0.032)and T stage(P<0.001)were independent prognostic factors.In the West China Hospital database and in the total population,nonfunctional pNETs and other functional pNETs tended to have poorer prognoses than insulinoma.However,functionality was not associated with the survival time of patients with pNETs in the multivariate analysis.CONCLUSION Functionality is not associated with prognosis.Race,age,sex,and T stage are independent factors for predicting the survival of patients with pNETs.

Further Discussion on the Three Methods for the Stage-Treatment of Parkinson's Disease

Based on the long-term clinical practice and scientific researches on the three methods for the stage-treatment of Parkinson＇s disease put forward by the author in the early years, this essay further discusses the division of the three stages of Parkinson＇s disease. Early stage： Appearance of the early symptoms and signs of Parkinson＇s disease, but short in duration and mild in severity, which do not affect the social communications, daily life and work of the patient; and their modified Hoehn ＆ Yahr grading is 1,0-1.5. Mid stage： With the symptoms and signs of Parkinson＇s disease getting worse and affecting the social communications, daily life and work of the patient, those who have their modified Hoehn ＆ Yahr grading 2-3 need medical treatment. Late stage： The patients have severe clinical symptoms of Parkinson＇s disease, and Levodopa preparation is insufficient for them to maintain their daily life; and their modified Hoehn ＆ Yahr grading is 4-5. The three treating methods are： TCM medical treatment adopted at the early stage; the combined treatment of Chinese and western medicine at the mid stage; and comprehensive treatment with multi-theraoies at the late stage.