Physiological ageing and tumorigenesis are both associated with epigenomic alterations in human tissue cells, the most extensively investigated of which entails de novo cytosine methylation (i.e., hypermethylation) within the CpG dinucleotides of CpG islands. Genomic regions that become hypermethylated during tumorigenesis are generally believed to overlap regions that acquire methylation in normal tissues as an effect of ageing. To define the extension of this overlap, we analysed the DNA methylomes of 48 large-bowel tissue samples taken from women of different ages during screening colonoscopy: 18 paired samples of normal and lesional tissues from donors harbouring a precancerous lesion and 12 samples of normal mucosa from tumour-free donors. Each sample was subjected to targeted, genome-wide bisulphite sequencing of ~2.5% of the genome, including all CpG islands. In terms of both its magnitude and extension along the chromatin, tumour-associated DNA hypermethylation in these regions was much more conspicuous than that observed in the normal mucosal samples from older (vs. younger) tumour-free donors. 83% of the ageing-associated hypermethylated regions (n = 2501) coincided with hypermethylated regions observed in tumour samples. However, 86% of the regions displaying hypermethylation in precancerous lesions (n = 16,772) showed no methylation changes in the ageing normal mucosa. The tumour-specificity of this latter hypermethylation was validated using published sets of data on DNA methylation in normal and neoplastic colon tissues. This extensive set of genomic regions displaying tumour-specific hypermethylation represents a rich vein of putative biomarkers for the early, non-invasive detection of colorectal tumours in women of all ages.

Background and study aims Virtual chromoendoscopy with Fuji Intelligent Color Enhancement (FICE) has never been studied in prospective trials of endoscopic surveillance for ulcerative colitis ( UC). We compared FICE and white light endoscopy (WLE) in differentiation of visible lesions in UC. Patients and methods In a prospective parallel study, we compared consecutive outpatients with UC submitted to surveillance colonoscopy with FICE or WLE. At least one visible polypoid or non-polypoid lesion for each patient was required. Random biopsies from normal mucosa, targeted biopsies or removal of suspected neoplastic lesions and targeted biopsies of unsuspected lesions were performed. In the FICE arm, neoplasia was suspected according to a modified Kudo classification (FICE-KUDO/inflammatory bowel disease [ IBD]). Sensitivity (SE), specificity (SP), positive and negative likelihood ratios (LR) and negative predictive value ( NPV) were analyzed. Results One hundred patients were submitted to FICE ( n = 46) or WLE (n = 54). Twenty-two patients (11 in WLE, 11 in FICE) had a least one neoplastic lesion. No neoplasia was found in random biopsies. Among 275 lesions, 17 of 136 by FICE and 27 of 139 by WLE were suspected neoplasia, but 28 ( 14 in each arm) were true neoplastic lesions. The accuracy of FICE-KUDO/ IBD vs WLE (per lesion) was: SE 93% vs 64% ( P = 0.065), SP 97% vs 86% ( P = 0.002), positive-LR 28.3 vs 4.5 (P = 0.001), negative-LR 0.07 vs 0.42 (P = 0.092), NPV 99% vs 96% (P = 0.083). FICE-KUDO/IBD detected more non-polypoid lesions than WLE (P = 0.016). Conclusions Targeted biopsies of polypoid and non-polypoid lesions, using the modified Kudo classification with FICE are more accurate than WLE in UC surveillance.

Background and Objective:EUS-FNA sensitivity for malignancy in parenchymal masses of patients with concurrent chronic pancreatitis (CP) has been reported to be unsatisfactory. The aim of the present study was to directly compare the diagnostic accuracy of EUS-FNA and EUS-fine-needle biopsy (FNB) in differentiating between inflammatory masses and malignancies in the setting of CP.Methods:We performed a retrospective analysis of prospective, multicentric databases of all patients with pancreatic masses and clinico-radiological-endosonographic features of CP who underwent EUS-FNA or FNB.Results:Among 1124 patients with CP, 210 patients (60% males, mean age: 62.7 years) with CP and pancreatic masses met the inclusion criteria and were enrolled. In the FNA group (110 patients), a correct diagnosis was obtained in all but 18 cases (diagnostic accuracy 83.6%, sensitivity 69.5%, specificity 100%, positive predictive value [PPV] 100%, and negative predictive value [NPV] 73.9%); by contrast, among 100 patients undergoing FNB, a correct diagnosis was obtained in all but seven cases (diagnostic accuracy 93%, sensitivity 86.8%, specificity 100%, PPV 100%, and NPV 87%) (P = 0.03, 0.03, 1, 1, and 0.07, respectively). At binary logistic regression, focal pancreatitis (odds of event occurrence [OR]: 4.9; P < 0.001), higher Ca19-9 (OR: 2.3;P= 0.02), and FNB (OR: 2.5; P < 0.01) were the only independent factors associated with a correct diagnosis.Conclusion:EUS-FNB is effective in the differential diagnosis between pseudotumoral masses and solid neoplasms in CP, showing higher diagnostic accuracy and sensitivity than EUS-FNA. EUS-FNB should be considered the preferred diagnostic technique for diagnosing cancer in the setting of CP.

BackgroundThe gastric cancer incidence rate differs widely across geographical areas. In Italy, in the province of Cremona the incidence is high, compared to the national situation. For this reason a specialized population-based registry was set up.MethodsThe collection encompasses all gastric cancers diagnosed in the three districts of the province since January 1,2010. The main data sources were the pathological and Hospital Discharge Records and patient clinical charts. Only diagnoses of primary gastric cancer were considered. For each case the following variables were registered: personal data, medical history and symptoms at diagnosis; imaging assessments performed, details on surgery and other treatments received;genetic background and biomolecular characteristics; social and environmental factors.ResultsAs of November 2017, 1087 cases were collected; of which 876, diagnosed up to December 2015, were analyzed. Male/female ratio was 1.4. The European Age-standardized Incidence Rate was 41.4 for males and 28.3 for females as compared to a national average of 33.3 and 17.0 respectively. Median age at diagnosis was 73 for male and 78 for female. Helicobacter Pylori infection was present in fewer than 20% of cases. HER-2 gene was amplified in about 25% of cases. Primary tumour location was the gastro-esophageal junction or cardia in 17.5% in males and 8.3% in females. The majority of cases (58.3%) were diagnosed at an advanced stage and overall only 41.2% underwent surgery. Median overall survival was 14.8months for men and 18.5 for women. Age standardized 5-year relative survival was 31.4% for men and 40.5% for females. Neoadjuvant treatment was performed in fewer than 10% of patients who underwent surgery, and the rate of postoperative therapy adherence was low.DiscussionThis study shows a high gastric cancer incidence in the province of Cremona, with a geographical spread across different districts. Moreover, a high percentage of gastric cancers were detected at an advanced stage of disease and a low rate of 5-year relative survival was registered. Based on these findings, effective preventive interventional health strategies and screening procedures need to be implemented to reduce the impact of this pathology in this geographical area.

Goals: The aim of this study was to analyze the performance of Fuji Intelligent Color Enhancement (FICE) using the classification of Kudo in the differentiation of neoplastic and non-neoplastic raised lesions in ulcerative colitis (UC). Background: The Kudo classification of mucosal pit patterns is an aid for the differential diagnosis of colorectal polyps in the general population, but no systematic studies are available for all forms of raised lesions in UC. Study: All raised, polypoid and nonpolypoid, lesions found during consecutive surveillance colonoscopies with FICE for long-standing UC were included. In the primary prospective analysis, the Kudo classification was used to predict the histology by FICE. In a post hoc analysis, further endoscopic markers were also explored. Results: Two hundred and five lesions (mean size, 8 mm; range, 2 to 30 mm) from 59 patients (mean age, 56 y; range, 21 to 79 y) were analyzed. Twenty-three neoplastic (11%), 18 hyperplastic (9%), and 164 inflammatory (80%) lesions were found. Thirty-one lesions (15%), none of which were neoplastic, were unclassifiable according to Kudo. After logistic regression, a strong negative association resulted between endoscopic activity and neoplasia, whereas the presence of a fibrin cap was significantly associated with endoscopic activity. Using FICE, the sensitivity, specificity, and positive and negative likelihood ratios of the Kudo classification were 91%, 76%, 3.8, and 0.12, respectively. The corresponding values by adding the fibrin cap as a marker of inflammation were 91%, 93%, 13, and 0.10, respectively. Conclusions: FICE can help to predict the histology of raised lesions in UC. A new classification of pit patterns, based on inflammatory markers, should be developed in the setting of UC to improve the diagnostic performance.

Gastric cancer (GC) is the 5th most common cancer and the 3rd leading cause of cancer-related deaths worldwide. GC incidence and mortality rates vary widely across different geographical areas. In Italy, the province of Cremona is characterized by a high incidence, compared to the national one. For these reason a specialized population-based registry was set up. The collection encompasses all GCs diagnosed in the province of Cremona since January the 1st, 2010. The main data sources were represented by the pathological records and patient clinical charts. Up to November 2017, 1087 cases were collected. 876, those diagnosed until December 2015 to have a minimum of two years of follow-up, were analyzed. Male/female ratio was 1.4. The GLOBOCAN world age-standardized incidence rate (ASIR) per 100,000 was 20.8 for male and 12.7 for female, compared to the Italian average rates of 10.9 and 5.9, respectively. A decrease in incidence was register both in male (−1.92%) both in female (−3.21%). Overall differences between incidence across districts was noticed ( P < 0.001). Median age at diagnosis was lower for male than female ( P < 0.001). Helicobacter Pylori (HP) infection was present in less than 20% of evaluated cases, with differences across districts ( P < 0.001). The gene HER-2 resulted amplified in about 25% of cases. An association between sex of patient and site of insurgence of the tumour ( P < 0.001) was registered, as well as between sex and tumour istotype ( P < 0.05). More than half of cases was in advanced stage of disease at diagnosis and only about 40% underwent surgery. Median overall survival (OS) was 14.8 months for men and 18.5 for women. Age-standardized 5-years relative survival was 31.44% for men and 40.50% for female. Neoadjuvant treatment was performed in less than ten percent of pts who underwent surgery, and low was the rate of postoperative therapy adherence (about 40%). OS was strongly improved by adjuvant treatment ( P < 0.001) regardless the tumour istotype (HR = 0.97, P = 0.957). Overall, data available at diagnosis that impacted on survival, were: sex, age, tumour site and the grade of differentiation of cancer cells. Same analysis was made including also information available after diagnosis, resulting from a deeper tumour characterization and from the clinical pathway followed. In pts who did have surgery, parameters were: age at diagnosis (HR = 1.086, P < 0.001), the status of lymph nodes (HR = 2.027, P < 0.001), and furthermore both neoadjuvant (HR = 3.186, P = 0.003) both palliative (HR = 2.293, P = 0.013) therapies. In pts with advanced stage of disease at diagnosis, who did not have surgery, survival seemed to be impacted only by the grade of differentiation of malignant cells. This study confirms the high GC incidence in the province of Cremona, with a geographical spread across districts. Moreover, was confirmed the high percentage of GCs detected in advanced stage of disease and the low rate of 5-year relative survival. Based on these findings, effective preventive interventional health strategies and screening procedures need to be implemented to reduce the impact of this pathology for this geographical area.

Colorectal cancer (CRC) is a neoplastic disease in which normal mucosa undergoes a process of malignant transformation due to the progressive accumulation of molecular alterations affecting proto-oncogenes and oncosuppressor genes. Some of these modifications exert their carcinogenic potential by promoting a constitutive activation of the β-catenin signaling proliferation pathway, and when present, loss of cadherin expression also significantly contributes to the same effect. Using a combined approach of molecular and immunohistochemical analysis, we have previously demonstrated that most sporadic CRCs exhibit a down-regulated expression of a cadherin, named μ-protocadherin, that is generally observed in association with a higher proliferation rate and a worse prognosis. The aim of this report was to perform a comparative immunohistochemical assessment of μ-protocadherin and a similar cadherin, named protocadherin-24, in sporadic CRC and hereditary nonpolyposis colorectal cancer. The data obtained put in evidence that double-negative CRCs, lacking both the analyzed protocadherins, are more represented among sporadic tumors, whereas double-positive CRCs, maintaining their expression, exhibit an opposite trend. As expected, loss of protocadherin expression was accompanied by nuclear localization of β-catenin and increased positivity of the Ki-67 proliferation marker. This finding is consistent with the different clinical evolution of the 2 considered CRC sets according to which patients with hereditary nonpolyposis colorectal cancer experience a better prognosis as compared with those affected by a sporadic CRC.

Sessile serrated adenomas/polyps (SSA/Ps) are the putative precursors of the ~20% of colon cancers with the CpG island methylator phenotype (CIMP). To investigate the epigenetic phenotype of these precancers, we prospectively collected fresh-tissue samples of 17 SSA/Ps and 15 conventional adenomas (cADNs), each with a matched sample of normal mucosa. Their DNA was subjected to bisulfite next-generation sequencing to assess methylation levels at ~2.7 million CpGs located predominantly in gene regulatory regions and spanning 80.5Mb; RNA was sequenced to define the samples’ transcriptomes. Compared with normal mucosa, SSA/Ps and cADNs exhibited markedly remodeled methylomes. In cADNs, hypomethylated regions were far more numerous (18,417 vs 4288 in SSA/Ps) and rarely affected CpG islands/shores. SSA/Ps seemed to have escaped this wave of demethylation. Cytosine hypermethylation in SSA/Ps was more pervasive (hypermethylated regions: 22,147 vs 15,965 in cADNs; hypermethylated genes: 4938 vs 3443 in cADNs) and more extensive (region for region), and it occurred mainly within CpG islands and shores. Given its resemblance to the CIMP typical of SSA/Ps' putative descendant colon cancers, we refer to the SSA/P methylation phenotype as proto-CIMP. Verification studies of six hypermethylated regions in an independent series of precancers demonstrated DNA methylation markers’ high potential for predicting the diagnosis of SSA/Ps and cADNs. Surprisingly, proto-CIMP in SSA/Ps was associated with upregulated gene expression; downregulation was more common in cADNs. In conclusion, the epigenetic landscape of SSA/Ps differs markedly from that of cADNs. These differences are a potentially rich source of novel tissue-based and noninvasive biomarkers.

"Crohn’s disease and acquired von Willebrand syndrome: a rare dangerous affair?." Scandinavian Journal of Gastroenterology, 52(5), pp. 613–614

Targeted proteomic methods can accelerate the verification of multiple tumor marker candidates in large series of patient samples. We utilized the targeted approach known as selected/multiple reaction monitoring (S/MRM) to verify potential protein markers of colorectal adenoma identified by our group in previous transcriptomic and quantitative shotgun proteomic studies of a large cohort of precancerous colorectal lesions. We developed SRM assays to reproducibly detect and quantify 25 (62.5%) of the 40 selected proteins in an independent series of precancerous and cancerous tissue samples (19 adenoma/normal mucosa pairs; 17 adenocarcinoma/normal mucosa pairs). Twenty-three proteins were significantly up-regulated (n = 17) or downregulated (n = 6) in adenomas and/or adenocarcinomas, as compared with normal mucosa (linear fold changes ≥ ±1.3, adjusted p value <0.05). Most changes were observed in both tumor types (up-regulation of ANP32A, ANXA3, SORD, LDHA, LCN2, NCL, S100A11, SERPINB5, CDV3, OLFM4, and REG4; downregulation of ARF6 and PGM5), and a five-protein biomarker signature distinguished neoplastic tissue from normal mucosa with a maximum area under the receiver operating curve greater than 0.83. Other changes were specific for adenomas (PPA1 and PPA2 up-regulation; KCTD12 downregulation) or adenocarcinoma (ANP32B, G6PD, RCN1, and SET up-regulation; downregulated AKR1B1, APEX1, and PPA1). Some changes significantly correlated with a few patient- or tumor-related phenotypes. Twenty-two (96%) of the 23 proteins have a potential to be released from the tumors into the bloodstream, and their detectability in plasma has been previously reported. The proteins identified in this study expand the pool of biomarker candidates that can be used to develop a standardized precolonoscopy blood test for the early detection of colorectal tumors.

A 50-year-old man with amyotrophic lateral sclerosis was admitted to the intensive care unit because of acute respiratory failure and worsening dysphagia. Because of these considerations, an endoscopic percutaneous gastrostomy (PEG) was performed during the hospitalization. Two days after the beginning of enteral nutrition, the patient experienced symptoms of intestinal subocclusion (nausea and vomiting, recurrent abdominal pain, abdominal distension, and constipation) without signs of peritonitis; a clear bowel hyperperistalsis was evident at auscultation. Blood tests showed normal results except for a mild neutrophilic leukocytosis (white blood cell count 11.900; N 81%). The bowel symptoms did not improve after the use of prokinetic agents or by the reduction of the total volume of enteral nutrition. As a consequence, a diagnostic workup was performed. A radiograph showed air distension of dilated jejunal loops (A); after administration of gastrografin through the gastrostomy, opacification of the stomach with a very slow transit of contrast material was also evident (B). Contrast-enhanced abdominal CT revealed a volvulus of a jejunal loop around the PEG (C) with a swirl of mesenteric vascular axis at the region of Treitz with associated dilated jejunal loops upstream (D). The patient therefore underwent urgent laparotomy, and the PEG tube was found to have penetrated the jejunal mesentery at 2 points, thereby acting as a focus for a volvulus. After detorsion of the volvulus without bowel resection, the PEG was left at the site. Previous abdominal surgery and postoperative adhesions can transfix the small bowel in the upper abdomen, particularly if the omentum has been resected. This can promote the development of this exceptional adverse event.