Introduction

Esophageal cancer (EC) is the eight most common cancer worldwide and causes the sixth highest number of deaths per year. The incidence of EC in Norway has increased by over 20 % over the past two decades, and a similar increase is seen in other Western countries. The overall five-year survival is approximately 20 %, which makes it one of the most fatal malignancies. Tumour stage at diagnosis is the main prognostic factor, and an early diagnosis is of most importance to improve survival. Upper endoscopy (UE) with biopsies is the standard procedure for diagnosing EC. However, several studies have questioned the efficacy of UE for diagnosis of esophageal neoplasms. The rate of missed esophageal cancers (MEC) at UE is of concern in many Western countries which have been reported to account for 6.4 to 12.7 % of all ECs. We aimed to calculate the rate of MEC and identify factors associated with MEC in Central Norway.

Aims & Methods

Retrospective population-based cohort study including 625 patients diagnosed with esophageal cancer (EC) in Central Norway 2004-2021. EC cases were identified by a search in the Cancer Registry of Norway, using ICD-10 codes C15x, and contained information about histological diagnosis and tumour localization. The dataset was verified by manual review of electronic patient records. MEC was defined as EC diagnosed 6-36 months after a previous non-diagnostic upper endoscopy. Clinical and disease variables were extracted from patient records. The rate of MEC in Central Norway was calculated annually and for the study period overall. Factors possibly associated with MEC, including tumour localization, histological type, as well as symptoms and findings were recorded. The median time interval from prior UE to date of diagnosis was calculated, as well as biopsy rates of patients with Barrett´s esophagus (BE) and ulcers at the prior UE.

Results

There were 625 patients in the entire cohort. The majority (n=404, 64.6%) were localized in the lower third of the esophagus and were adenocarcinomas (n=356, 57.0%). Fifty-one (8.2%) cancers were MEC. There was a significant increase in annual numbers of EC (p=0.001) and MEC (p=0.007) over the study period, but no increase in MEC rate (p=0.393). MEC patients were older than controls (74.0 years vs. 70.2 years, p=0.038), whereas sex did not differ significantly between MEC and controls. MEC was not associated with localization, sex or histological type. The most common findings at the prior UE were hiatus hernia (n=27, 52.9%), BE (n=26, 51.0%) and esophagitis (n=10, 19.6%), while the most common alarm symptom was gastrointestinal bleeding (n=11, 21.6%). The median time from prior UE to MEC diagnosis was 23.0 (6.2-35.6) months. In all patients with histological dysplasia (n=10) at the prior UE the follow-up interval was longer than recommended in current guidelines. A total of 24% of patients with either BE or an ulceration were not biopsied at UE preceding the MEC diagnosis.

Conclusion

MEC accounted for 8.2% of esophageal cancer in Central Norway. MEC was associated with higher age at diagnosis. There was no association between MEC and histological type or localization and a thorough examination of the entire esophagus is necessary to reduce MEC rates. Inappropriate follow-up of endoscopic BE, histological dysplasia or ulcerations were identified as preventable causes. Awareness of MEC, and more consistent biopsies of ulcerations and BE could reduce the MEC rate.

Disclosure

No conflict of interest.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a cornerstone in the diagnosis and treatment of pancreatobiliary diseases. However, it carries the risk of complications including potentially fatal post-ERCP pancreatitis (PEP). Despite ongoing efforts, effective strategies for managing PEP remain unestablished. Current guidelines define PEP based on symptoms and findings occurring within 24 hours after ERCP; however, early diagnosis and intervention may prevent its incidence and severity. Recently, urinary trypsinogen-2 (UT2) has emerged as a potential biomarker for early acute pancreatitis, but its role and the optimal timing for PEP remain unclear. Therefore, we aimed to evaluate the diagnostic performance of UT2 at multiple time points following ERCP.

Aims & Methods

This is a single-center prospective observational study conducted at The University of Tokyo Hospital. Patients who underwent their initial ERCP at our institution between February 2022 and June 2024 were enrolled. Patients with choledochojejunostomy, biliary pancreatitis, or those undergoing hemodialysis were excluded. UT2 levels were measured using a rapid dipstick test before ERCP, immediately after, and at 1 and 3 hours post-procedure. Serum amylase (AMY) levels were measured 3 hours after ERCP. We evaluated the diagnostic performance (sensitivity, specificity, and accuracy) of UT2 at multiple time points, for the diagnosis of PEP. PEP was defined as an elevation in pancreatic enzyme >3x upper limit of normal with abdominal pain at 24 hours post-pocedure.

Results

A total of 521 patients underwent initial ERCP during the study period, and 337 were included in the final analysis. The median age was 74 years, and 64% were male. A naïve papilla was present in 89% of patients. The indications for ERCP included bile duct stones (39%), malignant biliary obstruction due to pancreatic cancer (13%) or non-pancreatic cancer (18%), benign biliary stricture (5%), diagnostic pancreatogram (24%), and others (1.2%). EST, EPBD, and EPLBD were performed in 37%, 6.5%, and 4.5%, respectively. Prophylactic pancreatic stent placement and rectal NSAIDs administration were performed in 29% and 20%, respectively. PEP occurred in 10% (mild 8.6%, moderate 1.2%, and severe 0.3%) of patients. UT2 demonstrated a trend toward higher sensitivity compared to AMY (AMY: 52.9% vs. UT2 at 0 h: 52.9%, 1 h: 64.7%, 3 h: 64.7%), while AMY exhibited significantly higher specificity (AMY: 92.7% vs. UT2 at 0 h: 65.3%, 1 h: 64.7%, 3 h: 65.0%) and accuracy (AMY: 88.7% vs. UT2 at 0 h: 64.1%, 1 h: 64.7%, 3 h: 65.0%). Notably, 28.5% of patients were positive for UT2 prior to undergoing ERCP. These patients were significantly older (79 vs. 71 years, P < 0.01), more likely to have pancreatic cancer (19.8% vs. 9.5%, P = 0.02), and less likely to have chronic pancreatitis (3.1% vs. 12.9%, P = 0.01). After excluding 96 cases (28.5%) who were UT2-positive before ERCP, we further evaluated the diagnostic performance of UT2 and AMY. UT2 at 0 h had lower sensitivity compared to AMY (AMY: 54.2% vs. UT2 at 0 h: 37.5%, 1 h: 54.2%, 3 h: 54.2%). In contrast, specificity was similarly high across all markers (AMY: 91.7% vs. UT2 at 0 h: 88.9%, 1 h: 87.1%, 3 h: 87.1%). Diagnostic accuracy was comparable between AMY and UT2 (AMY: 88.0% vs. UT2 at 0 h: 83.8%, 1 h: 83.8%, 3 h: 83.8%).

Conclusion

UT2 showed slightly lower predictive performance for PEP compared to AMY. However, excluding UT2-positive pre-ERCP improved the diagnostic accuracy. The diagnostic performance plateaued at 1 hour after ERCP, suggesting its potential utility in predicting PEP earlier.

Disclosure

The author is affiliated with Nipro Corporation through a labor-related arrangement, but has received no financial support or remuneration related to this study.

Introduction

Pancreatic cancer (PC) screening can improve survival in high-risk patients by detecting preneoplastic lesions or early-stage tumors.
Surveillances is mainly based on annual magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS). However, little has been described regarding the possibility of finding other morphological changes that may be also important.

Aims & Methods

The aim of the study is to evaluate all the findings described in screening test and to analyze the correlation between these two screening techniques.
Descriptive observational single-center study that includes high-risk PC patients either due to family history (familial pancreatic cancer) or because they belong to hereditary syndromes, who have been undergone pancreatic cancer screening at our center from 2015 to 2023. Demographic variables and findings described in the EUS or MRI were collected.

Results

Thirty-five patients were included, with a mean age of 57.3 ± 8.2 years and a predominance of females (65.7%). Four patients (11.4%) were smokers, two were diabetic (5.7%), and one had a history of chronic pancreatitis (2.9%). The median follow-up time was 23 months (interquartile range 8-59 months).
The most frequent hereditary syndrome was hereditary breast and ovarian cancer syndrome (n=19, 54.3%), followed by familial atypical multiple mole melanoma syndrome (n=4; 11.4%). The BRCA2 mutation was the most common identifiable genetic factor (34.8%).
Regarding screening test findings, solid tumors were detected in three patients (8.6%) (Two stage I and IV adenocarcinomas and one stage I neuroendocrine tumor). In two individuals (5.7%) branch-duct intraductal papillary mucinous neoplasm were observed. Other pancreatic abnormalities were detected in 18 patients (51.4%) that include chronic pancreatitis-like parenchymal changes (34.3%), peripancreatic lymph nodes and fatty pancreas (5.7%). Finally, in 12 patients (34.3%) the screening tests were normal.
In relation to the concordance between MRI and EUS, in ten patients (28.6%) there was no agreement between these two techniques. EUS detected more parenchymal changes (n=5), pancreatic steatosis (n=2) and one neuroendocrine tumor that were not described on MRI. In contrast, MRI detected a cystic lesion and a pseudonodular enhancement that were not found on EUS.

Conclusion

Pancreatic cancer screening in high-risk individuals, detects neoplastic and preneoplastic lesions at a high rate.
Other findings, such as chronic pancreatitis-like parenchymal changes, peripancreatic lymph nodes or fatty pancreas, were also common in these patients
MRI and EUS have a good correlation, but EUS detects more parenchymal changes.

References

1. Goggins M, Overbeek KA, Brand R et al. Management of patients with increased risk for familial pancreatic cancer: updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium. Gut 2020; 69 (1): 7-17
2. Bogdanski AM, van Hooft JE, Boekestijn B, Bonsing BA, Wasser MNJM, Klatte DCF, van Leerdam ME. Aspects and outcomes of surveillance for individuals at high‑risk of pancreatic cancer. Fam Cancer 2024; 23(3):323-339.
3. Blackford AL, Canto MI, Dbouk M, Hruban RH, Katona BW, Chak A et al. Pancreatic Cancer Surveillance and Survival of High-Risk Individuals. JAMA Oncol. 2024;10(8):1087-1096.
4. Maurer E, Lehman B, Matthäi E, Denzer U, Figiel J, Jseinghaus M et al. Pancreatic cancer screening is effective in individuals at risk with predisposing germline gene variants, but not in gene variant‐negative familial pancreatic cancer families. United European Gastroenterol J 2024; 12 (9): 1211-1221

Introduction

Aims & Methods

Results

SVT was identified in 3.7% of patients diagnosed with acute pancreatitis (73 out of 1,969), with the splenic vein being the most commonly involved segment (69.9%). Compared to patients without SVT (n = 1,896), patients with thrombosis were more frequently male (61.6% vs. 49.0%, p = 0.030) and significantly younger (58.8 ± 14.9 years vs. 63.7 ± 16.6 years, p = 0.001). Among the 73 patients with SVT, 58.9% developed signs of PHT, including splenomegaly (16.4%), collateral circulation (39.7%), and esophageal varices (17.8%), while 8.2% developed ascites and 4.1% experienced variceal bleeding as manifestations of portal hypertension decompensation, during a median follow-up of 4.9 months (range: 0.2–68.8 months). Active smoking was significantly more common in SVT patients than in the control group (24.7% vs. 8.2%, p = 0.001). Subgroup analysis was performed on 45 patients with available follow-up CT scans. Recanalization occurred in 10 out of 45 patients (22.2%). Among the 35 non-recanalized patients, 68.5% developed PHT, and 7 (29.1%) experienced decompensation (2 with variceal bleeding and 5 with ascites). Complete thrombosis, irrespective of splanchnic site, was the only significant predictor of non-recanalization (7.7% in the recanalized group vs. 42.1% in the non-recanalized group, p = 0.006). Anticoagulation showed a trend toward association with recanalization (27.8% in the anticoagulated group vs. 0.0% in the non-anticoagulated group, p = 0.08), although it did not impact overall survival. Two deaths occurred in patients with severe AP and absence of recanalization of SVT.

Conclusion