Volume 85 - 2022 - Fasc.1 - Original articles
Prevalence of microsatellite instable and Epstein-Barr Virus-driven gastroesophageal cancer in a large Belgian cohort
Introduction: Patients with gastroesophageal adenocarcinoma
(GEC) with microsatellite instability-high (MSI-H) or Epstein
Barr Virus positivity (EBV+) might be good candidates for
immunotherapy. Incidences of about 10% have been reported
for both features, but are dependent on geographical region and
disease stage.
Aim: The aim is to study the prevalence of MSI-H and EBV+ in
a Belgian single center cohort of patients with GEC.
Methods: We retrospectively assessed the files of all patients
with a newly diagnosed GEC between August, 1st 2018 and
February, 29th 2020 at the University Hospitals Leuven, Belgium.
Microsatellite instability (MSI) status was determined using
immunohistochemistry (IHC) and polymerase chain reaction
(PCR). EBV+ was assessed using in situ hybridization (ISH). A case
report is provided to illustrate the importance of testing for MSI
in GEC.
Results: 247 gastroesophageal adenocarcinomas were included
in this analysis. 62 (56% stage IV) of those were tested for EBV, but
only 1 turned out to be EBV positive (1.6%). 116 patients (44.0%
stage IV) were tested for MSI, of which 11 were MSI-H (9.5%).
Half of the MSI-H tumors identified were at the gastroesophageal
junction (GEJ). A patient with MSI-H metastatic GEC obtained
a complete response with nivolumab, which persisted after
discontinuation of treatment.
Conclusion: While we confirm that about 10% of GECs are
MSI-H, the incidence of EBV+ in our cohort (1.6%) is clearly lower
than expected. Given the important prognostic and predictive
implications, every gastroesophageal cancer should be tested for
MSI.
Long-term outcomes of hemostatic therapy for variceal bleeding and the challenge pending in the post-direct-acting antivirals era
Abstract
Background and study aims: This study evaluated the longterm
outcomes of mainly endoscopic hemostatic therapy for
gastrointestinal variceal bleeding and of the transition of hemostatic
therapy.
Patients and methods: Among 1,163 patients treated for
gastrointestinal varices between April 2006 and June 2020, a total
of 125 patients who underwent emergency hemostatic therapy
were enrolled. Survival rates and secondary evaluation points were
analyzed. Additionally, patients were classified into two groups:
the previous and latter term. Patients’ background, therapeutic
method, and treatment results were compared between the groups.
Results: 94.4% had cirrhosis. The average Child-Pugh score
was 8.90. Successful primary hemostasis rate was 98.4%, and
5.6% died within 2 weeks, all with a Child-Pugh score ≥9. The
respective 1- and 5-year survival rates for Child-Pugh grade
A/B were 81.3% and 55.4%, while those for Child-Pugh grade C
were 58.1% and 17.8%. Child-Pugh grade C or hepatocellular
carcinoma was significantly associated with poor prognosis. In
total, 21.6% experienced variceal re-bleeding; 62.9% of these cases
were triggered by continued alcohol consumption. There was no
significant difference in survival between patients with and without
variceal re-bleeding and in post-treatment survival between the
previous and latter terms. In the latter term, the number of cases
caused by continued alcohol consumption significantly increased.
Conclusions: Multidisciplinary treatment and continuation of
proper management after hemostatic therapy for variceal bleeding
are crucial. Continued alcohol consumption leads to variceal
bleeding and re-bleeding; its proper management, including alcohol
abstinence, is one of the major challenges left in the post-directacting
antivirals era.
Stimulating peristalsis improves esophagogastric junction observation during sedated esophagogastroduodenoscopy in children and adolescents
Background and study aims: Sedation impairs full visualization
of the esophagogastric junction (EGJ) and Z line (the
squamocolumnar junction) during esophagogastroduodenoscopy
(EGD). The aim of this study was to determine whether induction
of esophageal peristalsis could improve the ability to evaluate the Z
line in children and adolescents.
Patients and methods: Study 1: Consecutive patients (10-15
years) undergoing EGD with propofol or midazolam sedation were
enrolled. The proportion of Z line observed was compared between
the two groups. Study 2: The effect of an air infusion near the EGJ
following deflation of the stomach to induce esophageal peristalsis
was investigated in the patients (15-18 years), undergoing EGD
with propofol sedation. The proportion of Z line observed was
compared between the stimulated group and control group.
Results: Study 1: 149 patients were evaluated; 87 received
propofol (43 boys; average age 13.2 years (range, 10-15)) and
62 received midazolam (30 boys; average age 12.8 years (range,
10-15)). The proportion of the Z line visualized was low but was
greater with propofol vs. midazolam sedation (36.8% vs 16.1%,
P=0.0059). Study 2: 102 patients were evaluated; 62 had induction
of peristalsis (34 boys; average age 16.2 years (range, 15-18)) and 40
controls (20 boys; average age 16.8 years (range, 15-18)). Complete
visualization of the Z line achieved in 95% (59 of 62) following
induction of peristalsis vs. 37.5% (15 of 40) of controls (P<0.001).
Conclusions: Induction of esophageal peristalsis greatly
improved visualization of the Z line during sedated EGD in
children and adolescents.
Validation and psychometric properties of the Turkish version of Neuromuscular disease Swallowing Status Scale (NdSSS) in patients with oro-pharygo-esophageal dysphagia in neuromuscular disorders
Objective: Dysphagia is one of the most disabling conditions
arising from neuromuscular disorders(NMD). There is no specific
methods to use in the evaluation of dysphagia in NMD patients.
We aimed both to evaluate the applicability of the Neuromuscular
Disease Swallowing Status Scale (NdSSS) for dysphagia in all
phases of swallowing in various NMD patients and to investigate
psychometric properties of this scale.
Methods: Patients with NMD were enrolled. Functional
Oral Intake Scale (FOIS), Fiberoptic Endoscopic Evaluation of
Swallowing (FEES), NdSSS and High-Resolution Esophageal
Manometry (HRM) were performed on all subjects within 72
hours. While the convergent and concurrent validities were used as
validation method, Cohen’s kappa and Cronbach’s alpha coefficient
were calculated for inter-rater reliability. The correlation between
FOIS, PAS and HRM diagnosis according to Chicago version 3.0
(CCv3) were analyzed.
Results: 115 NMD patients were included. There was good
correlation between NdSSS and FOIS and PAS scores (Spearman’s
rank correlation coefficient (r):0.927, r:0.927 and r:-0.836, r:0.841,
respectively). Also, there was a positive good correlation between
NdSSS and CCv3 evaluating disorders of esophageal peristalsis
(r:0.677-0.679, p=0.001). When evaluated separately, there were
good correlation between NdSSS levels; and PAS (r:-0.648-0.656);
and CCv3 (r:0.514-0.573) levels for ALS. For Myasthenia gravis
there was a good correlation between NdSSS levels; and CCv3
(r:0.577-0.622); FOIS (r:0.508-0.521); and PAS (r:-0.504-0.519)
scores. Also, for myopathy; a very good(CCv3(0.976-0.982)) and
good(FOIS (0.511-0.581) and (PAS (-0.516-0.550)) correlations
were defined for myopathy.
Conclusion: The NdSSS was found applicable to detect both
oropharyngeal and esophageal dysphagia risk in patients with
NMD and is a valid and reliable swallowing screening tool that can
evaluate oro-pharyngo-esophageal dysphagia in NMD patients.
Underlying disease for percutaneous endoscopic gastrostomy tube placement predicts short- and long-term mortality
Background: PEG (percutaneous endoscopic gastrostomy)
is a well established endoscopic procedure for enteral feeding.
However, patients with a shorter life expectancy will not benefit
from PEG tube placement. Furthermore, some specific evolving
diseases will never benefit from PEG. The aim of the study focuses
on short and long term mortality rates after PEG tube placement
in a referral gastroenterology centre (Geneva University Hospital).
219 patients were enrolled in this study.
Patients and methods: All patients scheduled for a PEG
procedure between January 2011 and December 2014 were
included. Nine patient parameters were collected for further
analysis as well as the main underlying disease requiring PEG
tube placement. Patients were subsequently divided into 4 groups
according to underlying disease: Group 1) swallowing disorders of
neurologic origin; Group 2) swallowing disorders associated with
upper digestive tract neoplasia ; Group 3) nutritional support for a
non GI reason ; Group 4) Other.
Results: 219 patients had undergone a PEG tube placement. 33
patients died within 60 days after the procedure. After one year, 71
patients died. Global survival was 870 days. The nutritional support
group had the better survival rate with 1276 days compared to
the swallowing groups and others. The multivariate analysis has
highlighted the underlying disease as the only associated parameter
with short and long term mortality.
Conclusions: PEG tube placement is associated with high short
and long term mortality depending on the underlying disease. We
outlined the potential role of PEG tube insertion as a supportive
transient approach for nutritional support.
Relationship of prognostic factors in stomach cancer with Helicobacter pylori: A retrospective study
Background and study aims: The prognostic value of H. pylori,
which infects more than half of the human population living
in the world and plays a role in gastric cancer pathogenesis, is
controversial. Our aim is to investigate the relationship between H.
pylori and prognostic factors in gastric cancer.
Patients and methods: The data of 110 patients (38 females and
72 males) that underwent surgeries due to gastric cancer between
2014 and 2017 were retrospectively analyzed. The relationships
between survival (disease-free and overall) and factors such as p53,
HER2/neu, Ki-67, neutrophil and platelet lymphocyte ratio (NLR
/ PLR), histopathological and demographic characteristics were
examined. In addition, the results of H. pylori positive and negative
groups were compared.
Results: Sixty-one (55%) patients were H. pylori negative and 49
(45%) were positive. In multivariate analysis, TNM stage, lymph
node capsule invasion and NLR were determined as independent
prognostic factors in both disease-free and overall survival. Age>62
and PLR>14.3 were determined as independent predictive factors
of poor prognosis in overall survival. In univariate analysis, tumor
diameter of >4.3 cm, lymphovascular and perineural invasion, and
diffuse p53 expression were determined as predictive factors of poor
prognosis in disease-free and overall survival. The effectiveness of
these markers in prognosis was not different between H. pylori
negative and positive groups.
Conclusion: While age, tumor diameter, TNM stage, lymph
node capsule invasion, perineural and lymphovascular invasion,
diffuse p53, PLR, and NLR were determined as prognostic factors
in gastric cancer, these factors were not affected by the presence of
H. pylori.
Endoscopic mucosal resection of colorectal polyps: results, adverse events and two-year outcome
Background and study aims: Endoscopic mucosal resection
(EMR) is the first-line treatment for large sessile and flat colorectal
polyps in Western centres, however recurrence after EMR continues
to be a challenge. The aim of this study is to assess efficacy, safety
and recurrence rate of EMR in a tertiary centre and to identify risk
factors for recurrence at first surveillance endoscopy (SE1).
Patients and methods: We performed a retrospective study of
165 sessile and flat colorectal lesions ≥15 mm, treated by EMR
between 2017-2019. We used multivariate logistic regression to
identify independent risk factors for recurrence at SE1.
Results: EMR was performed for 165 colorectal polyps in 142
patients with technical success in 158 cases (95,2%). SE1 data for
117 of 135 eligible cases (86,7%) showed recurrent adenoma in 19
cases (16,2%) after a median time of 6,2 months (IQR 5-9,9). This
was primarily treated endoscopically (78,9%). Independent risk
factors for recurrence at SE1 were lesion size ≥40 mm (OR 4,03;
p=0,018) and presence of high-grade dysplasia (HGD) (OR 3,89;
p=0,034). Early adverse event occurred in 4 patients (2,4%), with 3
bleeding complications and one perforation. Twelve patients (7,2%)
presented with delayed bleeding of which 3 required transfusion,
with radiological intervention in one case. All other complications
were managed either conservatively (n=8) or endoscopically (n=5).
Conclusions: EMR is a safe and effective treatment for large
sessile and flat colorectal lesions with low recurrence rates. Lesion
size ≥40 mm and presence of HGD were identified as risk factors
for early recurrence, highlighting the importance of compliance to
follow-up in these cases.
A long-term study of liver-related events in Caucasian hepatitis B patients with normal ALT values and high viremia
Background and study aims: There is ongoing debate whether antiviral therapy should be initiated in hepatitis B e antigen (HBeAg)-negative patients with normal alanine aminotransferase (ALT) levels but high HBV DNA levels >2,000 IU/mL. Since the need for antiviral therapy might be different between Asian and Caucasian patients, we studied the long-term disease outcome in Caucasian patients living in Western Europe.
Patients and methods: One hundred sixteen patients with high HBV DNA levels (>2,000 IU/mL) at diagnosis were included in the high viremia group, while those with HBV DNA <2,000 IU/mL were used as controls (n = 327). All patients were Caucasian, HBeAg negative, had normal ALT levels and had no significant liver disease at diagnosis.
Results: Median follow-up was 7 + 9.8 years in the high viremia group and this was 10 + 12.5 years in controls. The cumulative probability of a liver-related event over 10 years was 4.8% vs 0.0% in the control group (p=.008). In multivariable analysis, high viremia group was associated with the occurrence of a liver-related event (hazards ratio (HR) 95% confidence interval (CI): 1.20-11.98, p=.023). In this subgroup, older age at diagnosis (HR 95% CI: 1.01-1.16, p=.023) predicted a higher risk of liver-related event. In the high viremia group, liver-related mortality was 0.9% and none of the patients developed hepatocellular carcinoma.
Conclusions: HBV DNA >2,000 IU/mL influences the long-term disease outcome in Caucasian HBeAg-negative patients living in Western Europe. Nevertheless, the risk of liver-related events is low.
GPR, King’s Score and S-Index are superior to other non-invasive fibrosis markers in predicting the liver fibrosis in chronic Hepatitis B patients
Background and study aims: In this study, we investigated the efficacy of nine non-invasive fibrosis markers in the assessment of the degree of fibrosis in patients with chronic Hepatitis B (CHB) in comparison with liver biopsy.
Patients and methods: A total of 1454 untreated CHB patients from two different centers who underwent liver biopsy were included in the study. Laboratory results of patients were reviewed retrospectively and the pathology slides were re-evaluated in accordance with the Ishak score. Degree of fibrosis ≥ 3 was accepted as “significant fibrosis”, ≥ 4 as “advanced fibrosis”, and ≥ 5 as cirrhosis. The diagnostic performance of the markers Aspartate aminotransferase to Platelet Ratio Index (APRI), Fibrosis-4 score (FIB-4), Aspartate aminotransferase to Alanine aminotransferase Ratio (AAR), AAR to Platelet Ratio Index (AAPRI), Gamma-glutamyl transpeptidase to Platelet Ratio (GPR), King’s Score, Fibro quotient (Fibro-Q), S Index and Platelet to Lymphocyte Ratio (PLR) were evaluated with ROC analysis.
Results: In detecting significant fibrosis, APRI, GPR, King’s Score and S Index had AUROC values over 0.70. For advanced fibrosis, all of the models except AAPRI; and for cirrhosis, all of the models had AUROC values over 0.70. In accordance with the chosen staging system, GPR, King’s Score and S Index had high diagnostic efficacy whereas APRI, FIB-4, FibroQ and PLR had moderate diagnostic efficacy, AAR and AAPRI had low diagnostic efficacy.
Conclusions: GPR, King’s Score and S Index had moderate diagnostic performance in detecting significant fibrosis and advanced fibrosis, and high diagnostic performance in detecting cirrhosis.
Serum serotonin as a non-invasive marker of portal hypertensive gastropathy in Egyptian patients with HCV-related liver cirrhosis
Background and study aims: Portal hypertensive gastropathy
(PHG) is an important complication of portal hypertension (PHT)
in cirrhotic patients. We aimed in the current study to investigate
the validity of serum serotonin as a probable non-invasive marker
for PHG in cirrhotic patients with PHT. We conducted this study
on 100 HCV-related cirrhotic patients divided into three groups
according to their endoscopic findings; group I: patients with
no endoscopic signs of PHG; group II: patients with mild PHG;
and group III: patients with severe PHG. All subjects had routine
laboratory investigations, serum serotonin level using ELISA kits,
calculation of Child’s score, abdominal ultrasound, and upper GIT
endoscopy.
Results: Serum serotonin was significantly higher in those with
PHG than those without (t= 5.128, p <0.001). Moreover, it was
significantly higher in patients with severe degree of PHG than
those with mild PHG (t=7.357, p<0.001). Furthermore, a significant
positive correlation was observed between serum serotonin and
Child Pugh score (t=7.357, p<0.001). Roc curve analysis revealed
that serum serotonin at a level ? 26.5 ng/ml had a 78.82% sensitivity,
73.33% specificity, and accuracy of 78% to discriminate between
those with signs of PHG and those without.
Conclusion: Serum serotonin is a valuable non-invasive
marker of PHG in HCV-cirrhotic patients. Furthermore, its serial
measurements could be used to monitor disease progression
