Immuno-oncology, particularly with the development of immune checkpoint inhibitors (ICIs), has become a frontline category of cancer-directed therapy, including in the treatment of hepatocellular carcinoma (HCC). While liver transplant (LT) offers a potential cure for HCC, the use of ICIs is a topic of safety concern both pre-and posttransplant due to the risk of donor graft rejection. Nonetheless, some scenarios for which the therapeutic effects of ICI may be highly beneficial include the downstaging of unresectable HCC pre-transplant, or the treatment of recurrent HCC and secondary malignancies post-transplant. In this review, we explored the evidence surrounding the use of ICI in the peri-transplant setting, including safety and efficacy. In a comprehensive review of 28 cases of ICI use post-transplant, we found graft rejection in 9 of 28 cases (32%). Some factors that may increase the risk of rejection include younger age, less time between LT and ICI therapy, and PD-1/PD-L1 expression in the donor graft (particularly when using anti-PD-1/anti-PD-L1 ICIs). Despite these concerns, we relay a case of successful HCC downstaging with nivolumab and subsequent LT. We also describe several cases of response to ICIs post-LT (7 of 28 cases) among a group that is often heavily pre-treated. We conclude that ICIs are valuable options in the peritransplant setting that have demonstrated promising efficacy based on case reports. Controlled clinical trials are needed to further investigate the conditions that may allow safe delivery of these therapies.
AIM: Several bowel preps are currently used for colonoscopy but only limited data are available comparing the different products. METHODS:We retrospectively reviewed all colonoscopies performed at Georgetown U. Hospital from May 2013 to May 2014. A 9-point modified Boston Bowel Preparation Scale (BBPS) was utilized (best score = 9) by experienced endoscopists. Colonoscopies without a BBPS score were excluded. seen for women vs men overall for both split-dose and day-prior dosepreps (with the exception of Moviprep ® in PD preps). Higher scores were seen for a.m. procedures but were not significant. All preps had lower scores in the right colon, regardless of being splitdose or day-prior dose. CONCLUSIONS: This real world experience in nearly 3600 patients confirms that split dosing is superior to day-prior dosing. We found women had higher BBPS scores than men but no differences were seen between morning and afternoon procedures. All preps were relatively comparable, however differences in price may be an important decision-maker. RESULTS:
INTRODUCTION: Granular Cell Tumor (GCT) is generally a benign neoplasm derived from Schwann cells. Less than ten percent of GCTs are found in the gastrointestinal (GI) tract and most common site in the GI tract has been reported to be the esophagus. The current existing literature is limited. Given the rarity of these lesions, the management of GCTs remain a clinical challenge for gastroenterologists. Here we present a case series of thirteen esophageal GCTs and their characteristics, diagnosis and management. METHODS: We conducted a retrospective review of all cases of pathologically confirmed GCTs from 2010 to 2018 at our institution from our endoscopic pathology database. Data were collected regarding demographics, endoscopic, endosonographic appearance and presence of any malignant transformation. RESULTS: Thirteen total patients were identified. Mean age was 43.6 years. Six patients were females. All esophageal lesions were noted to be in the mid-distal esophagus. Majority of the lesions were subcentimeter. Mean size of the lesions was 8.2 mm. Most common endoscopic features were nodularity (11/13 cases) and white-yellow appearance (8/13). Endoscopic ultrasound (EUS) was conducted in 11/13 cases and the lesions appeared hypoechoic in the majority of cases (6/11). Extension of the lesion was limited to the submucosa in all except one case. Endoscopic mucosal resection (EMR) was performed in 8/13 cases. Pathologic diagnosis of GCT was confirmed using immunohistochemical stain of S100 in 8/13 cases. None of the cases showed any evidence of malignancy from the initial endoscopic resection or biopsies. CONCLUSION: Our institutional review of esophageal cases of GCTs not only highlights the rarity of GCTs, but provides endoscopic and endosonographic features of esophageal GCT. Based on our cohort of patients, GCTs most commonly present in mid-distal esophagus with a white-yellowish hue. Patients are generally asymptomatic. EUS findings suggest lesions are hypoechoic and arise from the submucosal layer. Given this location, lesions can be removed in entirety through EMR, which will also allow for greater depth of resection. Overall, mucosectomy may serve as an adequate modality for removal of these apparent benign lesions. Our preliminary finding delineates the success of en bloc resectability of esophageal GCTs less than 2 cm in size. Additional studies would be needed to better establish a more definitive management algorithm of esophageal GCTs and the role of endoscopic mucosal resection.
Primary adenocarcinoma of the small intestine comprises one of the rarest gastrointestinal malignancies. Further, the terminal ileum is very seldom implicated. This entity occurs sporadically and evades traditional colonoscopic evaluation in which the terminal ileum is not visualized. Herein, a case of interval development of primary terminal ileal adenocarcinoma over a 2-year period is reported as followed by direct endoscopic and colonoscopic visualization. This case demonstrates cecal involvement not found on initial evaluation without the provision of terminal ileum intubation. Relevant guidelines regarding the evaluation of the terminal ileum in routine colonoscopy are reviewed.
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