Introduction

Pancreatic Cancer (PC), a highly lethal malignancy of the digestive system, is associated with a poor prognosis, as evidenced by a less than 7% 5-year survival rate ^[1]. Projections suggest that by 2030, PC will rank as the second leading cause of cancer-related deaths ^[2-3]. A crucial aspect of the progression of pancreatic cancer involves its crosstalk with endothelial cells (ECs), particularly in the regulation of vascular homeostasis ^[4]. Numerous studies have demonstrated the significant involvement of Vascular Endothelial Growth Factor (VEGF) in the process of ECs functional remodeling ^[5-6]. Activation of the PI3K/AKT signaling pathway has been shown to enhance VEGF-mediated vascular formation, thereby contributing to the normal development and repair of the vascular system ^[7-8]. Considering the aberrant vascular features observed in tumors, targeting specific pathways to revert immature and unstable vessels to a normal vasculature state appears to be a promising therapeutic strategy for the treatment of the disease. Previous studies have indicated that the combination of Formononetin and Salvianolic acid B (FcS) significantly inhibits pancreatic xenograft tumors in vitro. However, it remains unclear whether this combination can inhibit the abnormal vascularization of pancreatic tumors to achieve its anti-cancer effect.

Aims & Methods

This study aimed to investigate the efficacy of FcS in modulating the effects of pancreatic cancer on endothelial cells, explore the alterations in molecular mechanisms within these cells, and elucidate the intricate molecular mechanisms underlying this interaction.
To elucidate the interaction between endothelial cells and pancreatic cancer cells, a co-culture system using Human Umbilical Vein Endothelial Cells (HUVECs) and PANC-1 cells was established to investigate the potential of targeting abnormal vasculature as a promising avenue for anti-tumor therapy. The proliferation, migration, invasion, and lumen formation of HUVEC were compared in mono-culture (HUVECs) and co-culture with PANC-1 (H-P), followed by treatment of H-P with FcS to assess its anti-angiogenic properties. Then, molecular docking was utilized to predict the interactions between Formononetin and Salvianolic acid B with RhoA, and the expression of RhoA in HUVECs post-FcS treatment was assessed. Furthermore, the role of RhoA in the effects of FcS on HUVECs was explored using shRhoA lentivirus. In vivo investigations were conducted using a zebrafish xenograft tumor model to assess the anti-tumor effects of FcS, focusing on cancer cell proliferation, migration, apoptosis, and vascular sprouting.

Results

The treatment with FcS showed a dose-dependent inhibition of PANC-1-induced alterations in HUVECs, including proliferation, migration, invasion, and tube formation. Molecular docking analysis indicated potential interactions between FcS and RhoA. FcS downregulated the expression of RhoA and modulated the PI3K/AKT pathway in PANC-1-induced HUVECs. Furthermore, the inhibitory effects of FcS on HUVEC phenotypic changes were attenuated by RhoA knockdown. In vivo experiments using a zebrafish xenograft model demonstrated the anti-tumor effects of FcS, including the inhibition of proliferation, metastasis, and vascular sprouting, and promotion of tumor cell apoptosis.

Conclusion

This study illuminates the potential of FcS in inhibiting pancreatic cancer-induced changes in endothelial cells. FcS exhibits pronounced anti-abnormal vasculature effects, potentially achieved by downregulating RhoA expression, inhibiting the PI3K/Akt signaling pathway.

References

1. Siegel, R. L., Giaquinto, A. N., Jemal, A., 2024. Cancer statistics, 2024. CA Cancer J Clin. Jan-Feb. 74, 12-49.
2. The Lancet Gastroenterology Hepatology, 2023. Cause for concern: the rising incidence of early-onset pancreatic cancer. Lancet Gastroenterol Hepatol. Apr. 8, 287.
3. Neoptolemos, J. P., Kleeff, J., Michl, P., Costello, E., Greenhalf, W., Palmer, D. H., 2018. Therapeutic developments in pancreatic cancer: current and future perspectives. Nat Rev Gastroenterol Hepatol. Jun. 15, 333-348.
4. Kishimoto, T., Saito, K., Ishikura, H., 1995. Mechanism of blood-borne metastasis in relation to the interaction between pancreatic carcinoma and endothelial cells. Nihon Rinsho. Jul. 53, 1765-9.
5. Goel, S., Duda, D. G., Xu, L., Munn, L. L., Boucher, Y., Fukumura, D., Jain, R.K., 2011. Normalization of the vasculature for treatment of cancer and other diseases. Physiol Rev. Jul. 91, 1071-121.
6. Jain, R.K., 2001. Normalizing tumor vasculature with anti-angiogenic therapy: a new paradigm for combination therapy. Nat Med. Sep. 7, 987-9.
7. Brazil, D. P., Hemmings, B. A., 2001. Ten years of protein kinase B signalling: a hard Akt to follow. Trends Biochem Sci. Nov. 26, 657-64.
8. Sarbassov, D. D., Guertin, D. A., Ali, S. M., Sabatini, D. M., 2005. Phosphorylation and regulation of Akt/PKB by the rictor-mTOR complex. Science. Feb. 18, 1098-101.

Introduction

With the advent of EUS guided biliary interventions, there is a lot of hype created that ERCP will cease to be performed. The most important and limiting factor for ERCP is successful bile duct cannulation. We have studied a large series of our cases and tried to study the impact of properly performed precut on success of bile duct cannulation.

Aims & Methods

Aim: To analyze the efficacy of freehand precut for selective cannulation in difficult ERCP and its role in improving technical success rate, obviating need for EUS guided / other rendezvous techniques.
Methods: Retrospective analysis of 3000 patients undergoing ERCP from 2017 till date for varied etiologies. No. of patients required precut accessotomy were noted and technical success rate was measured.

Results

No. of patients analyzed- 3000. Selective biliary cannulation- 2452 (81.74%). Difficult cannulations requiring freehand precut accessotomy- 548 (18.26%). Technical success after precut achieving biliary access- 539 (98.36%). Failure of biliary cannulation even after precut- 09 (1.64%). Most common etiology in precut casesstone disease 360 (65.70%) followed by malignant lesions 118 (21.53%), benign strictures 28 (5.11%), post cholecystectomy biliary leak 28 (5.11%), post traumatic biliary leak 10 (1.82%), post hydatid surgery biliary leak 02 (0.36%), post central hepatectomy biliary leak 02 (0.36%). Most common cause for failure in precut cases was extensive edema and deformed anatomy. Of all failed cases 3 were large stones who were subjected to surgery and 6 were malignant lesions who were subjected to EUS guided biliary drainage.

Conclusion

Free hand precut technique, done correctly, is a savior in difficult cannulation cases and it increases the success rate of selective biliary cannulation significantly avoiding the need for other costlier techniques such as EUS guided / Rendezvous techniques.

References

Mariani A, Di Leo M, Giardullo N, Giussani A, Marini M, Buffoli F, Cipolletta L, Radaelli F, Ravelli P, Lombardi G, D'Onofrio V, Macchiarelli R,
Iiritano E, Le Grazie M, Pantaleo G, Testoni PA. Early precut sphincterotomy for difficult biliary access to reduce post-ERCP pancreatitis: a randomized trial. Endoscopy. 2016 Jun;48(6):530-5. doi: 10.1055/s-0042-102250. Epub 2016 Mar 18. PMID: 26990509.
Davee T, Garcia JA, Baron TH. Precut sphincterotomy for selective biliary duct cannulation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol. 2012;25(4):291-302. ​PMID: 24714256; PMCID: PMC3959408.

Introduction

Parkinson's disease (PD) is a neurodegenerative disorder characterized by both motor and non-motor symptoms, such as gastrointestinal symptoms. Emerging evidence suggests that gut permeability and inflammation play a role in PD pathophysiology via the gut-brain axis. According to Braak’s theory, the pathological degeneration associated with PD may originate from the gut and subsequently develop in the brain through the vagus nerve.

Aims & Methods

The aims were to assess the relationship between gut permeability and neuroinflammation in a cohort of patients with PD and REM behavior disorder (RBD), a condition that often precedes the onset of PD. The study prospectively included 28 PD patients and 18 RBD patients both complaining of GI symptoms. No serious organic diseases or therapies potentially affecting GI motility were reported. Relevant demographic and clinical data were collected for all patients. There was the inclusion of 14 healthy controls (HCs). A serum ELISA assay of tumor necrosis factor (TNF), caspase-1, and lipopolysaccharide-binding protein (LBP) was performed in all participants to investigate systemic inflammatory status and gut permeability, respectively. In a total of 10 PD patients, 4 RBD patients and 9 HCs, multiple colic biopsies were obtained to assay tissue expression of inflammation markers by both western blot (WB) (i.e. caspase-1 and procaspase-1) and immunofluorescence (IF) (i.e. ASC and CD68). Data were expressed as mean ± SD, and ANOVA and Dunnett's tests were used to compare the three groups.

Results

All three groups were comparable in age and sex. Serum assays showed significantly increased LBP, in patients with PD (35.0 ± 0.25; p = 0.002) and RBD (32.2 ± 1.1; p = 0.009) compared with HCs. TNF (0.1 ± 0.02; p = 0.03) and caspase-1 (16.9 ± 9.4; p = 0.04) were significantly raised only in the PD group in comparison with HCs (Table 1). WB analysis showed significant differences in the expression of procaspase-1 (157.3 ± 17.8; p = 0.02) and caspase-1 (168.3 ± 23.3; p = 0.03) only in PD patients compared with HCs. IF showed a qualitative increase in both CD68+ macrophage infiltration and ASC expression in PD and RBD groups compared with HCs.

	PD	RBD	HCs	P-value
LBP (ng/ml)	35.0 ± 0.25	32.2 ± 1.1	23.1 ± 2.1	0.009 (RBD vs HCs) 0.002 (PD vs HCs)
Caspasi-1 (ng/ml)	16.9 ± 9.4	11.4 ± 2.1	9.9 ± 2.7	0.04 (PD vs HCs)
TNF (pg/ml)	0.1 ± 0.02	0.05 ± 0.02	0.04 ± 0.02	0.03 (PD vs HCs)

Table 1. Serum ELISA assay of TNF, caspase-1, and LBP from HCs and in patients with RBD and PD.
Abbreviations: TNF = tumor necrosis factor; LBP = lipopolysaccharide-binding protein; HCs = healthy controls; RBD = REM behavior disorder; PD = Parkinson's disease.

Conclusion

Our results show a bowel activation of NLRP3 inflammasome in PD, as demonstrated both by the levels of procaspase-1 and caspase-1 on WB analysis and by the increase of CD68+ macrophages and ASC in the lamina propria of colonic mucosa. Only a qualitative increase in NLRP3 activation at IF could be observed in RBD patients. However, findings from colonic biopsies, if related to elevated serum levels of TNF and caspase-1 in PD patients, and LBP in PD and RBD patients, suggest that bowel inflammation, sustained by increased gut permeability, may represent an early stage in the develop of RBD and PD.

Introduction

Computer-Aided Diagnosis (CADx) systems have become available to assist endoscopists with optical polyp diagnosis. However, current CADx systems have not been trained to recognize sessile serrated lesions (SSLs) and currently classify SSLs incorrectly either as hyperplastic or adenomatous. We aimed to assess the effect of current CADx systems on diagnostic accuracy of SSL recognition among a diverse group of endoscopists.

Aims & Methods

We conducted a prospective video-based study including 17 endoscopists (gastroenterologists and surgeons, experts, and trainees). Each endoscopist reviewed the same video and image series of 115 polyps (33% SL, 33% Hyperplastic Polyps (HP), 34% tubular adenoma (TA)). Histopathological diagnosis of the polyps was used as the gold standard for comparison. Presentation of polyps (SSL, TA, HP) was randomized so that 50% of the polyps seen were presented with displaying a CADx diagnosis for the polyp and 50% were presented without displaying a CADx diagnosis.

Results

A total of 1955 optical polyp diagnoses were performed. The optical diagnostic accuracy amongst various endoscopists to recognize SSLs was: expert gastroenterologists (52.3%, 95% Confidence Interval (CI) 46.3-58.3), trainee gastroenterologists (38.2%, CI 27.2-49.1), expert surgeons (22.1%, CI 16.2-28.0) and trainee surgeons (14.9%, CI 8.4-21.5). Further details are provided in Table 1. CADx identified 52.6% of SSL as HP and 47.4% as TA. CADx identified 60.5% of HP correctly and 82.1% of TA correctly. The optical diagnostic accuracy for HP and TA improved among endoscopists when a correct CADx diagnosis was displayed to the endoscopists compared to when no CADx information was displayed (HP: 63.7% vs 38.4% / TA: 81.5% vs 70.5%; p=0.05). The optical diagnostic accuracy of the endoscopists worsened when the displayed CADx diagnosis was incorrect (HP: 24% / TA: 25%). The diagnostic accuracy of the endoscopists for SSL did not differ significantly when the CADx diagnosis, which is currently untrained to diagnose SSL and can only classify polyps as hyperplastic or adenomatous, was displayed (37.2% vs 33.1%, p=0.05).

	Sessile Serrated Lesion	Hyperplastic Polyp	Adenoma
CADx Alone	HP: 52.6 (36.8-68.5) TA: 47.4 (31.5-63.2)	Sn 60.5 (49.5-71.5) Sp 82.1 (70.0-94.1) PPV 86.8 (77.7-95.9) NPV 51.6 (39.2-64.1)	Sn 82.1 (70.0-94.1) Sp 60.5 (49.5-71.5) PPV 51.6 (39.2-64.1) NPV 86.8 (77.7-95.9)
CADx diagnosis NOT displayed All Endoscopists (n=17)	Sn 37.2 (31.9-42.4) Sp 78.6 (75.5-81.8) PPV 46.2 (40.1-52.2) NPV 71.7 (68.4-75.0)	Sn 38.4 (33.1-43.7) Sp 79.8 (76.8-82.9) PPV 48.4 (42.3-54.6) NPV 72.4 (69.2-75.7)	Sn 70.5 (65.6-75.4) Sp 64.7 (61.0-68.4) PPV 50.6 (46.1-55.2) NPV 81.0 (77.6-84.4)
CADx Displayed Correct Diagnosis All Endoscopists (n=17)	Sn 33.1 (28.0-38.3) Sp 79.4 (76.3-82.5) PPV 44.2 (38.0-50.5) NPV 70.6 (67.3-73.9)	Sn 63.7 (57.4-70.0) Sp 78.7 (74.9-82.5) PPV 60.2 (53.9-66.4) NPV 81.1 (77.4-84.8)	Sn 81.5 (76.9-86.2) Sp 86.5 (83.2-89.9) PPV 80.7 (76.0-85.3) NPV 87.2 (83.9-90.5)
CADx Displayed Incorrect Diagnosis All Endoscopists (n=17)		Sn 24.0 (15.6-32.4) Sp 77.4 (71.7-83.0) PPV 33.3 (22.4-44.2) NPV 68.3 (62.4-74.2)	Sn 25.0 (14.0-36.0) Sp 45.2 (39.1-51.4) PPV 9.8 (5.1-14.5) NPV 71.7 (64.7-78.7)
Breakdown of the performance by endoscopists category GE: Gastroenterologist Expert (n=7) GT: Gastroenterologist Trainee (n=2) SE: Surgery Expert (n=5) ST: Surgery Trainee (n=3)
Overall	GE: 52.3 (46.3-58.3) GT: 38.2 (27.2-49.1) SE: 22.1 (16.2-28.0) ST: 14.9 (8.4-21.5)	GE: 35.0 (29.2-40.7) GT: 61.8 (50.9-72.8) SE: 53.7 (46.6-60.8) ST: 42.1 (33.0-51.2)	GE: 74.7 (69.6-79.9) GT: 64.1 (53.5-74.7) SE: 66.2 (59.5-72.8) ST: 74.4 (66.4-82.3)
CADx diagnosis NOT displayed	GE: 54.1 (45.7-62.6) GT: 39.5 (23.9-55.0) SE: 23.2 (14.7-31.6) ST: 19.3 (9.1-29.5)	GE: 27.8 (20.2-35.4) GT: 57.9 (42.2-73.6) SE: 53.7 (43.7-63.7) ST: 24.6 (13.4-35.7)	GE: 72.8 (65.3-80.3) GT: 66.7 (51.9-81.5) SE: 70.4 (61.4-79.4) ST: 69.5 (57.7-81.2)
CADx Displayed Correct Diagnosis	GE: 50.4 (41.9-58.9) GT: 36.8 (21.5-52.2) SE: 21.1 (12.9-29.3) ST: 10.5 (2.6-18.5)	GE: 50.6 (40.2-60.9) GT: 84.6 (70.7-98.5) SE: 67.2 (55.9-78.4) ST: 73.2 (59.6-86.7)	GE: 85.0 (78.4-91.5) GT: 75.0 (60.0-90.0) SE: 73.4 (63.7-83.2) ST: 91.5 (83.5-99.5)
CADx Displayed Incorrect Diagnosis		GE: 25.0 (12.2-37.8) GT: 25.0 (0.5-49.5) SE: 21.4 (6.2-36.6) ST: 25.0 (3.8-46.2)	GE: 37.5 (18.1-56.9) GT: 0.0 (0.0-0.0) SE: 16.7 (0.0-33.9) ST: 27.3 (1.0-53.6)

Table 1. CADx and endoscopists performance in optical diagnosis of SSL, HP and adenomas depending on the polyp histology in percentages of correct optical diagnoses with 95% confidence intervals. For SSL, CADx is not able to provide correct diagnosis; thus is presented as CADx shown as either HP or TA)
Sn: sensitivity; Sp: specificity; PPV: positive predictive value; NPV: negative predictive value

Conclusion

Optical polyp diagnosis that includes SSL, TA, and HP recognition remains challenging. Current CADx systems when displaying correct diagnostic outputs improve diagnostic accuracy of the endoscopists. CADx systems not trained for SSL recognition do not significantly affect SSL recognition among endoscopists even if an incorrect diagnostic output (TA or HP) is displayed. Development of improved CADx systems with SSL recognition and higher diagnostic accuracy is warranted.

Disclosure

Dr Jeffrey Marks: Consultant for Boston Scientific and Steris Endoscopy

Introduction

Intestinal Ultrasound (IUS) is a point-of-care tool that is increasingly utilised in the management of ulcerative colitis (UC) as a marker of active disease and response to medical therapy. IUS has the advantage of being non-invasive, non-irradiating, well tolerated, cost-effective with good reproducibility when compared to ileo-colonoscopy and magnetic resonance enterography. There is however limited evidence that sonographic remission on IUS predicts UC disease course.

Aims & Methods

This study aimed to examine the relationship of IUS and clinical outcomes in UC patients in clinical remission and determine if presence of sonographic inflammation was associated with medication escalation, corticosteroid use, hospitalisation or surgery.
A retrospective study at The Royal Melbourne Hospital included all UC patients who underwent IUS for IBD between 2017 and 2022 in clinical remission (Simple Colitis Clinical Activity score ≤2) at the time of IUS and followed up for at 6 months. Patients with rectum-confined disease (E1), a stoma, or suboptimal IUS were excluded. Sonographic healing, defined as BWT ≤3 mm without hyperemia, inflammatory fat, or disrupted bowel wall stratification was the combined endpoint.
Kaplan-Meier analysis was performed to compare medication-escalation-free survival, corticosteroid-free survival, hospitalisation-free survival and surgery-free survival in those with and without sonographic healing. Univariate and multivariate Cox proportional hazard regression analyses were performed to identify predictors of these clinical outcomes.

Results

2,113 ultrasound reports were assessed for eligibility, and 394 patients had a confirmed UC diagnosis. Of 149 consecutive patients in clinical remission met inclusion criteria (43% male), sonographic inflammation was present in 45%.
During mean follow-up of 634 days, medication escalation occurred in 40%, corticosteroid use in 27%, hospitalisation in 13% and UC related surgery in 2%.
Sonographic inflammation did not emerge as a predictive factor for these outcomes; the only factor predictive of significant outcomes was the baseline Montreal classification (Table 1). Patients with sonographic inflammation on the whole had worse outcomes however.

Table 1: Univariate and multivariate predictors of medical escalation in patients with ulcerative colitis. Data is shown as hazard ratio (95% confidence intervals)

OR = Odds Ratio, CI = Confidence Interval

Conclusion

This study is the first to examine the predictive utility of IUS in the setting of clinical remission and interestingly demonstrates that IUS does not appear to predict clinical complications. The role of IUS in UC has been slower to be established compared to Crohn’s disease due to concerns about poor rectal views and lower sensitivity to detect mild mucosal inflammation.
This retrospective study challenges the utility of intestinal ultrasound in predicting clinical outcomes in UC patients in clinical remission, highlighting the need for further research to establish its role in guiding real time treatment decisions.

Clinical Case Summary

Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality globally, often compounded by underlying conditions such as hepatitis C and liver cirrhosis. Paraneoplastic syndromes (PNS), although rare in HCC, can significantly affect patient outcomes and complicate management.
Case Presentation: We report a case of a 66-year-old patient initially diagnosed with multilocular hepatocellular carcinoma BCLC stage C and Child B liver cirrhosis in February 2024, following a fall at home that resulted in lumbar vertebral fractures. This incident led to the discovery of the carcinoma through imaging, which was suggestive of HCC with an alpha-fetoprotein (AFP) level of 17,880 ng/ml. Chronic, previously untreated hepatitis C was also detected. During hospital admission in March 2024, the patient presented with reduced vigilance, progressive limb weakness, and dysarthrophonia. Neurological assessments and imaging were performed to exclude neurological causes. Laboratory findings showed hypercalcemia (3.67 mmol/l) with low parathyroid hormone (PTH) levels and an elevated parathyroid hormone-related protein (PTH-rP) of 4.7 pmol/l, indicative of a paraneoplastic syndrome. Despite treatment with intravenous (IV) isotonic saline, subcutaneous calcitonin, bisphosphonates, and atezolizumab plus bevacizumab, it was challenging to manage recurring hypercalcemia and fluctuating vigilance due to metabolic encephalopathy.
Conclusions: PNS markedly affects the survival and clinical outcomes in patients with HCC. They lead to considerable morbidity, impacting the quality of life and suitability for both curative and palliative treatments. Thus, including PNS in standard evaluations following an HCC diagnosis is crucial to better direct ongoing management and disease prognosis.

Introduction

Rectal cancer represent 30% of colorectal cancer with 46,220 new cases estimated in the United States in 2024. About 98% of rectal cancer patients have rectal adenocarcinoma. Gastrointestinal (GI) squamous cell neoplasm (SCN) is very rare with no enough studies to estimate its incidence and clinical features. Thus, our aim was to assess the risk of developing second primary GI SCN following chemo(radio)therapy after rectal adenocarcinoma.

Aims & Methods

We used the Surveillance Epidemiology and End Results (SEER) database to obtain the data of 145,789 patients with first primary rectal adenocarcinoma. We used MP-SIR session to calculate the standardized incidence ratios (SIR) ratio as (observed/Expected) with a latency exclusion period of 0 months, Excess risk (ER) was calculated per 10.000 and 95% Confidence Interval (CI). The results were significant if P> 0.05.

Results

Out of 145.789 patients with rectal adenocarcinoma, 4333 patients developed second primary SCN. Among who developed second primary GI SCN, 21.9% received chemotherapy with an O/E of 4.07 (P˂0.05, CI: 4.50 - 3.67, ER=74.53) while 3.25% received radiotherapy with an O/E of 2.23 (P ˂ 0.05, CI: 2.60- CI: 1.90, ER=42.59). The group who had no systemic therapy had an O/E of 2.83 (P˂ 0.05, 95%CI: 2.93–2.74, ER=57.27). The group who received combined chemoradiotherapy had a 2-fold increased risk of developing second primary GI SCN (O/E =2.34, P˂ 0.05, CI:2.44- 2.24, ER=34.88). There was a significant increase in the 0-11 months interval in the four groups. The group who received chemotherapy O/E was 11.73 (P ˂ 0.05, 95 % CI: 13.27– 10.32, ER=233.48) and the group who received radiotherapy had increased O/E to 5.16 (P˂0.05, ER=150.85, 95%CI: 6.51–4.03).

Conclusion

Chemotherapy increases the risk of multiple primary GI SCN after the first primary rectal adenocarcinoma, especially in the first year after diagnosis. Chemo(radio)therapy have a significantly high risk second primary GI SCN with different potential and variations across different intervals. Thus, more attention to be given for the screening of second primary GI malignancies after chemo(radio)therapy administration.