Clinical Case Summary

A 48-year-old woman with locally advanced squamous cell carcinoma of the cervix received chemoradiotherapy with cisplatin, followed by brachytherapy achieving a radiologic complete response. Then, she was enrolled for PD-1 immune checkpoint inhibitor (ICI) Dostarlimab clinical trial.
After 2 years into immunotherapy, she developed severe epigastric pain, nausea and vomiting. Laboratory tests showed elevated pancreatic enzymes, cholestasis, and inflammatory markers. Magnetic resonance cholangiopancreatography (MRCP) revealed acute interstitial edematous pancreatitis, narrowing of a short segment of the common bile duct (CBD), and proximal biliary dilatation (Figure 1). Initial conservative treatment led to partial clinical improvement.
She was re-admitted with worsening jaundice. Laboratory workup ruled out common causes (e.g. IgG4-related disease) and imaging showed persistent findings with 18 mm CBD dilatation without evidence of choledocholithiasis or radiologic features of autoimmune pancreatitis (Figure 2). These findings were consistent with mild acute pancreatitis per the revised Atlanta criteria.
Given the temporal relationship with PD-1 blockade and lack of alternative causes, immune-related pancreatitis with secondary biliary involvement was strongly suspected. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary plastic stenting was performed (Figure 3), and so corticosteroids therapy (1 mg/kg tapered). The patient rapidly improved clinically, biochemically, and radiologically (figure 4), supporting the diagnosis of immune-mediated pancreatitis.
In light of this immune-related adverse event and sustained oncologic remission, Dostarlimab therapy was permanently discontinued. This case highlights the need to consider immune-related pancreaticobiliary toxicity in patients on ICI, particularly when imaging is subtle and diagnostic criteria are not yet well established. It also emphasizes the importance of early multidisciplinary intervention.

References

Figure 1: CT scan (left) and MRCP (right) images showing diffusely edematous pancreatitis with no evidence of main pancreatic duct dilatation.
Figure 2: MRCP revealing a distal common bile duct stricture, with upstream dilatation of both intrahepatic and extrahepatic bile ducts.
Figure 3: ERCP fluoroscopic view demonstrating placement of a plastic pancreatic stent within the main pancreatic duct (Wirsung).
Figure 4: CT scan (left) and MRCP (right) images showing significant improvement of the inflammatory changes of the pancreatic gland, along with reduced dilatation of the intrahepatic bile ducts, after steroids initiation.

Introduction

Cardiovascular diseases (CVDs) are often a limiting factor in cancer treatment. In our systematic review and meta-analysis we evaluated the prevalence and incidence of CVDs in pancreatic ductal adenocarcinoma (PDAC).

Aims & Methods

We conducted the systematic search on 5 February 2024 in three databases (PubMed, EMBASE, CENTRAL). Studies reporting the prevalence or incidence of CVDs in PDAC were included. Subgroup analyses based on cancer stage and treatment type were performed. Pooled proportions with the 95% confidence interval (CI) were calculated using a random effect model. We evaluated the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal. (PROSPERO CRD42023482295).

Results

We included 198 articles. The prevalence of CVDs other than thrombotic events at PDAC diagnosis was similar to the one in the general population: hypertension 33 % (95%CI:27-40%), ischemic heart disease 6% (95%CI:3-12%), heart failure, arrhythmia, and stroke affecting each 2-3% of cases. Their incidence during treatment was low (1%-10% overall). Thrombotic events other than embolism affected 11% (95%CI: 7%-18%) of cases at diagnosis and the incidence during treatment was between 8-10% regardless of cancer stage or treatment type. Pulmonary embolism affected 3% of cases at diagnosis and occurred in a similar proportion during treatment. The included studies had an overall low-moderate risk of bias.

Conclusion

Thrombotic events affect around 10% of PDAC patients at baseline. A similar proportion develop thrombotic events during follow-up regardless of disease stage or treatment type. The prevalence of CVDs other than thrombotic events is equivalent to the one in the general population.

Introduction

Tuberculous lymphadenopathy represents a challenging diagnostic scenario, particularly in regions with high TB prevalence. Its diagnosis is challenging due to the nonspecific clinical and radiological findings. Blood and skin tests for TB have variable sensitivities and specificities, so histopathologic diagnosis and molecular tests for diagnosis of TB in tissue samples may be more accurate than blood tests. Obtaining tissue samples under ultrasonography or CT guidance is sometimes very difficult and risky especially in the intra-abdominal and mediastinal regions. Endoscopic ultrasound (EUS) with EUS fine needle biopsy (EUS-FNB) is a safe technique in obtaining tissue samples for diagnosis of abdominal and mediastinal TB. EUS introduces a critical advantage of real-time imaging and precise tissue sampling. Many studies found that EUS-FNB yielded significantly higher diagnostic yield in complex TB presentations, with detection rates ranging from 78-92% across various anatomical sites. Comparative analysis with Gene X-pert MTB/RIF assay and Polymerase Chain Reaction (PCR) techniques demonstrated nuanced diagnostic capabilities. Gene X-pert provides rapid molecular detection with high specificity for rifampicin resistance while PCR offers molecular amplification of bacterial DNA.

Aims & Methods

In this prospective cross-sectional study, we explored the diagnostic efficacy of molecular techniques, specifically PCR and Gene X-pert MTB/RIF assay, in detecting Mycobacterium tuberculosis in tissue samples obtained through EUS-FNB. We also aim to evaluate the sensitivity, specificity, and rapid detection capabilities of these molecular methods compared to traditional diagnostic techniques. Patients and Methods: This study included 56 patients, 28 males and 28 females with mean age of 50 ±16 years. TB PCR or Gene X-pert was done in tissue samples including mediastinal and intra-abdominal lymphadenopathy in 75% of cases, obtained by EUS-FNB. Results: PCR or Gene X-pert for TB were true-positive in 7 cases and false negative in one case with sensitivity of 88%, specificity of 100%, positive predictive value of 100% and negative predictive value of 98%.

Results

PCR or Gene X-pert for TB were true-positive in 7 cases and false negative in one case with sensitivity of 88%, specificity of 100%, positive predictive value of 100% and negative predictive value of 98%.

Conclusion

We concluded that PCR and Gene X-pert of TB in tissues obtained by EUS-FNB are of great value in diagnosis of extrapulmonary TB.

References

Mukhida S, Vyawahare CR, Mirza SB, Gandham NR, Khan S, Kannuri S, Bhaumi S. Role of GeneXpert MTB/RIF assay for the diagnosis of cervical lymph node tuberculosis and rifampicin resistance. Tzu Chi Med J. 2022 Sep 5;34(4):418-422. doi: 10.4103/tcmj.tcmj_86_22. PMID: 36578636; PMCID: PMC9791852.
Tadesse M, Abebe G, Abdissa K, Aragaw D, Abdella K, Bekele A, et al. GeneXpert MTB/RIF assay for the diagnosis of tuberculous lymphadenitis on concentrated fine needle aspirates in high tuberculosis burden settings. PLoS One. 2015;10:e0137471. doi: 10.1371/journal.pone.0137471.
Penz E, Boffa J, Roberts DJ, Fisher D, Cooper R, Ronksley PE, et al. Diagnostic accuracy of the Xpert® MTB/RIF assay for extra-pulmonary tuberculosis: A meta-analysis. Int J Tuberc Lung Dis. 2015;19:278–84. doi: 10.5588/ijtld.14.0262. i-iii.
Ligthelm LJ, Nicol MP, Hoek KG, Jacobson R, van Helden PD, Marais BJ, et al. Xpert MTB/RIF for rapid diagnosis of tuberculous lymphadenitis from fine-needle-aspiration biopsy specimens. J Clin Microbiol. 2011;49:3967–70. doi: 10.1128/JCM.01310-11.

Clinical Case Summary

A 51-year-old male presented to the emergency department with acute back pain, suspicious for renal colic. An abdominal CT scan incidentally revealed a 30 mm hypodense lesion in the pancreatic uncinate process with central calcifications (see Fig. 1).
An endoscopic ultrasound (EUS) demonstrated a hypoechoic, heterogeneous mass in the uncinate process, with irregular margins and a huge posterior acoustic shadowing. No signs of vascular or ductal involvement were noted. Therefore, EUS-guided fine needle biopsy (FNB) with a 22-G Franseen-tip needle was performed via transduodenal and transgastric approaches, obtaining an adequate histological sample after macroscopic on-site examination (MOSE).
Histological analysis revealed spindle cells positive for CD34, BCL2, STAT6, and CD99, and negative for CKIT, DOG1, desmin, actin, S100, and cytokeratins, with Ki-67 index > 5%, suggesting for solitary fibrous tumor (SFT) of the pancreas (see Fig.2). Immunohistochemical confirmation was obtained at a tertiary referral pathology laboratory. A multidisciplinary tumor board advised conservative follow-up based on the benign histology and absence of local invasion.
Conclusion: Pancreatic SFTs are extremely rare, with only 34 cases reported to date. They are more frequently located in the pancreatic head and are slightly more common in females. Most are discovered incidentally. This case highlights the critical diagnostic value of EUS-FNB, which enabled accurate tissue acquisition for advanced immunohistochemical analysis, informing a non-surgical, surveillance-based approach. Because of the non-specific clinical presentation and radiological features of pancreatic SFTs, diagnosis is particularly challenging using preoperative imaging and laboratory tests alone. Therefore, histopathological and immunohistochemical evaluation is essential for definitive diagnosis.

References

References and Illustrative Material:

Figure 1: Abdominal CT scan showing a pancreatic mass in the uncinate process with central calcification.

Figure 2: On the left, tissue sample stained with hematoxylin and eosin. Spindle cell proliferation with disorganized architecture. The lesion is hypercellular, composed of elongated mesenchymal cells with scant cytoplasm and oval-to-tapered nuclei, suggesting a spindle cell neoplasm, such as SFT. On the right, the same tissue sample was analyzed using immunohistochemistry: strong and diffuse nuclear positivity for STAT6 was found in tumor cells.

Selected References:

1. Ronchi A et al. Solitary fibrous tumors: an update on diagnosis and management. Pathol Oncol Res.

2020;26(2):597-605.

2. Wang WW, Zhou SP, Wu X, Wang LL, Ruan Y, Lu J, Li HL, Ni XL, Qiu LL, Zhou XH. Imaging, pathology, and diagnosis of solitary fibrous tumor of the pancreas: A case report and review of literature. World Journal of Clinical Cases. 2024;12(5):995–1003.

Introduction

Systemic sclerosis (SSc) is a rare autoimmune disease marked by multisystemic fibrotic and vascular involvement, mainly affecting the skin, lungs, and upper digestive tract. Skin involvement may serve as a marker for visceral severity, particularly regarding pulmonary and upper digestive manifestations. This study examined its correlation with these systemic complications in SSc patients.

Aims & Methods

A retrospective, descriptive, bicentric study was conducted on SSc patients followed in the internal medicine department between 2004 and 2024. Clinical evaluation included cutaneous involvement via modified Rodnan score, pulmonary assessment by clinical examination, imaging, and pulmonary function tests. Upper digestive involvement was explored through symptoms, esophagogastroduodenoscopy, and esophageal manometry performed in the gastroenterology department to assess motility and mucosal integrity. Statistical analysis (descriptive and analytical) was performed using SPSS (version 26) with the Chi-square test and a significance threshold of p <0.05.

Results

A total of 160 patients were included, mostly female (91.2%), with a median age of 50 years (range:13–81). Localized scleroderma was diagnosed in 76.2%. Skin involvement was assessed in 121 patients using the Rodnan score (mean:15.31; range:0–51), categorized as mild (0–10) in 35%, moderate (11–20) in 15%, severe (21–30) in 16.3%, and very severe (>30) in 9.4%.
Upper digestive involvement was observed in 31.4%, 14.9%, 18.2%, and 9.1% of patients with mild to very severe skin involvement, respectively. Among associated symptoms: epigastric pain was present in 8.4%, 5%, 5%, and 3.4%; gastroesophageal reflux disease (GERD) in 21.2%, 9.3%, 16.9%, and 8.5%; and dysphagia in 15.3%, 7.6%, 13.6%, and 6.8%, respectively.
Esophageal manometry was performed in 36.2%, showing lower esophageal sphincter (LES) hypotonia in 5%, 2.5%, 5%, and 3.3% of mild to very severe cases, respectively. Aperistalsis was noted in 3.3%, 1.7%, 0.8%, and 0.8%, with rare ineffective motility and hypocontractility. No significant association was found between skin severity and upper digestive involvement, either clinically (p=0.458) or manometrically (p=0.98).
Similarly, no correlation was found between skin and pulmonary involvement. Lung disease was observed in 56.3% of localized and 19.4% of diffuse forms. Among these, interstitial lung disease was present in 26.3%, 12.7%, 16.1%, and 9.3%; pulmonary fibrosis in 15.6%, 6.4%, 8.3%, and 1.8%; and restrictive syndrome in 15%, 9.3%, 13.1%, and 5.6%, across increasing skin severity (all p >0.3).
However, pulmonary involvement was noted in 60% of patients with upper digestive symptoms. Dyspnea was reported in 66.9%, crackles in 29.4%, cough in 27.5%, and chest pain in 6.3%. Radiology showed interstitial lung disease in 58.8% and pulmonary fibrosis in 28.8%. Among these, GERD was present in 46.5%, dysphagia in 36.1%, epigastric pain in 19.2%, and isolated abdominal pain in one case. Manometry revealed LES hypotonia in 13.1%, aperistalsis in 5%, and ineffective motility in 0.6%. In contrast to skin involvement, a significant association was found between pulmonary and upper digestive manifestations (p<0.01).

Conclusion

No correlation was found between the severity of cutaneous involvement and digestive disorders. However, a significant link was observed between pulmonary involvement and upper digestive symptoms, suggesting that uncontrolled acid reflux may contribute to pulmonary fibrosis in SSc patients. This highlights the need for early management and multidisciplinary monitoring.

Clinical Case Summary

An 82-year-old man with Child B alcoholic cirrhosis, complicated by portal hypertension, underwent surveillance upper digestive endoscopy (UDE), revealing large esophageal varices and a 20 mm exophytic lesion, 40 cm from the dental arch, with an infiltrative and ulcerated appearance. Biopsies were inconclusive. Endoscopic ultrasound identified a heterogeneous, amorphous lesion with poorly defined borders and disruption of all wall layers, complicated by numerous large varices, preventing biopsy due to hemorrhagic risk. Computed tomography revealed parietal thickening in the distal esophagus and multiple varices, complicating lesion delineation. An oncology consultation recommended clinical surveillance, considering the patient's age, comorbidities, indeterminate nature of the esophageal lesion, and low suspicion for adenocarcinoma on ultrasound. One year later, surveillance UDE showed regression of the lesion.Histological samples were reviewed, revealing changes consistent with pyogenic granuloma. Pyogenic granuloma is a rapidly growing capillary hemangioma that may occur within the lumen of a pre-existing vessel (intravascular variant). The case is supported by appropriate iconography.

This case is presented with imaging, highlighting the challenge due to the macroscopic appearance suggestive of a neoplastic lesion and the pyogenic granuloma's growth within esophageal varices, limiting diagnostic and therapeutic management.

References