51
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Yamada D, Kobayashi S, Takahashi H, Yoshioka T, Iwagami Y, Tomimaru Y, Shigekawa M, Akita H, Noda T, Asaoka T, Gotoh K, Tanemura M, Doki Y, Eguchi H. Pancreatic CT density is an optimal imaging biomarker for earlier detection of malignancy in the pancreas with intraductal papillary mucinous neoplasm. Pancreatology 2022; 22:488-496. [PMID: 35396159 DOI: 10.1016/j.pan.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/04/2022] [Accepted: 03/22/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are typically detected as incidental findings by computed tomography (CT); however, the conventional surveillance is not valid for the early detection of concomitant pancreatic cancer. The pancreas of IPMN is often accompanied by fatty infiltration in the parenchyma, and pancreatic fatty infiltration could be evaluated by pancreatic CT density (pancreatic index, PI). We aimed to investigate whether PI could be an imaging biomarker for the early prediction of malignancies in the pancreas with IPMN. METHODS Two different cohorts were investigated. (Investigation cohort): A total of 1137 patients with initially low-risk IPMN were compensated by initial IPMN findings, and 2 groups (malignancy/possible benign, 50 cases each) were investigated for yearly changes in PI and for the cutoff value of PI indicating the development of malignancies. (Validation cohort): To validate the cutoff value, 256 patients radiologically suspected of having IPMNs were investigated. RESULTS (Investigation-cohort): The malignancy group showed a gradual decrease in PI every year, and PI significantly differed among the 2 groups 1 year prior to the last investigation. The cutoff value of PI was set at 0.65. (Validation-cohort): A total of 55% of the patients with a PI below the cutoff value had malignancy in the pancreas, including concomitant pancreatic cancer, and the cutoff value was the most significant risk factors for the development of malignancies in the pancreas compared to the conventional risk factors for IPMN. CONCLUSIONS Decreasing PI would be an optimal imaging biomarker for earlier detection of malignancies in the pancreas with IPMN.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Teppei Yoshioka
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Minoru Shigekawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan; Department of Surgery, Osaka Police Hospital, Tennoji-ku Kitayamacho 10-31, Osaka, 543-0035, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan; Department of Gastroenterological Surgery, Rinku General Medical Center, Rinku-Ourai-Kita 2-23, Izumisano, Osaka, 598-8577, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
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Shipley LC, Ahmed AM. New and emerging technology in the diagnosis and treatment of pancreatic cysts. Transl Gastroenterol Hepatol 2022; 7:15. [PMID: 35548473 PMCID: PMC9081918 DOI: 10.21037/tgh-2020-09] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 06/05/2020] [Indexed: 08/27/2023] Open
Abstract
Pancreatic cysts have always presented as a diagnostic dilemma due to the difficulties in identifying patients with current imaging modalities that could most benefit from surgical intervention. Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystadenomas (MCNs) carry the highest malignant potential of all pancreatic cysts and pancreatic adenocarcinoma carries a high mortality as the fourth leading cause of cancer-related deaths. However, surgery to remove benign cysts also carries a high morbidity and occasional mortality. Opportunities to identify and reduce pre-cancer lesions must be aggressively pursued. Multidetector helical CT (MDHCT) or an up-to-date MRI is the first diagnostic tool to evaluate a suspected pancreatic lesion. Currently, review by a multidisciplinary group who specialize in pancreatic cysts and pancreatic cancer is advised to review factors such as a patient's comorbidities, the type of surgery needed to remove the cyst and the estimated morbidity and mortality associated with the procedure. Some recent data are emerging to assist with identifying those at highest risk such as cyst fluid analysis, laser endomicroscopy, and artificial intelligence (AI). This article reviews the current status, benefits, challenges and future prospects on diagnosis and treatment of pancreatic cysts. Further prospective randomized control trials are needed to determine the optimal management and treatment for patients with pancreatic cysts.
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Affiliation(s)
- Lindsey C. Shipley
- Department of Internal Medicine, University of Alabama, Birmingham, AL, USA
| | - Ali M. Ahmed
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA
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Ferguson S, Yang KS, Zelga P, Liss AS, Carlson JCT, del Castillo CF, Weissleder R. Single-EV analysis (sEVA) of mutated proteins allows detection of stage 1 pancreatic cancer. SCIENCE ADVANCES 2022; 8:eabm3453. [PMID: 35452280 PMCID: PMC9032977 DOI: 10.1126/sciadv.abm3453] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 03/07/2022] [Indexed: 05/02/2023]
Abstract
Tumor cell-derived extracellular vesicles (EVs) are being explored as circulating biomarkers, but it is unclear whether bulk measurements will allow early cancer detection. We hypothesized that a single-EV analysis (sEVA) technique could potentially improve diagnostic accuracy. Using pancreatic cancer (PDAC), we analyzed the composition of putative cancer markers in 11 model lines. In parental PDAC cells positive for KRASmut and/or P53mut proteins, only ~40% of EVs were also positive. In a blinded study involving 16 patients with surgically proven stage 1 PDAC, KRASmut and P53mut protein was detectable at much lower levels, generally in <0.1% of vesicles. These vesicles were detectable by the new sEVA approach in 15 of the 16 patients. Using a modeling approach, we estimate that the current PDAC detection limit is at ~0.1-cm3 tumor volume, below clinical imaging capabilities. These findings establish the potential for sEVA for early cancer detection.
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Affiliation(s)
- Scott Ferguson
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA 02114, USA
| | - Katherine S. Yang
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA 02114, USA
| | - Piotr Zelga
- Department of Surgery, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114, USA
| | - Andrew S. Liss
- Department of Surgery, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114, USA
| | - Jonathan C. T. Carlson
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA 02114, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Carlos Fernandez del Castillo
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA 02114, USA
- Department of Surgery, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114, USA
| | - Ralph Weissleder
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA 02114, USA
- Department of Systems Biology, Harvard Medical School, 200 Longwood Ave, Boston, MA 02115, USA
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54
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Ohno E, Ishikawa T, Mizutani Y, Iida T, Uetsuki K, Yashika J, Yamada K, Gibo N, Aoki T, Kawashima H. Factors associated with misdiagnosis of preoperative endoscopic ultrasound in patients with pancreatic cystic neoplasms undergoing surgical resection. J Med Ultrason (2001) 2022; 49:433-441. [PMID: 35411413 DOI: 10.1007/s10396-022-01205-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/24/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Pancreatic cystic lesions (PCLs) include various types of cysts. Accurate preoperative diagnosis is essential to avoid unnecessary surgery on benign cysts. In this study, we aimed to identify the factors associated with misdiagnosis in preoperative endoscopic ultrasound (EUS) imaging and clinicopathological findings for PCLs. METHODS This study included 302 surgically resected patients with PCLs who underwent preoperative EUS. The preoperative EUS findings were re-evaluated and compared with the pathological diagnosis. Additionally, the factors associated with misdiagnosis of PCLs were investigated by multivariate analysis. RESULTS The preoperative diagnoses of PCLs were intraductal papillary mucinous neoplasm (IPMN) in 213 patients (70.5%), mucinous cystic neoplasm (MCN) in 33 patients (10.9%), serous neoplasm (SN) in 7 patients (2.3%), cystic degeneration cyst of solid tumor in 46 patients (15.2%), and pancreatic cancer with cystic degeneration in three patients (1.0%). A discrepancy between preoperative and postoperative diagnosis was found in 47 patients (15.6%). Based on the pathological diagnosis, the sensitivity of preoperative EUS imaging was IPMN 97.6% (206/211), MCN 90.0% (18/19), cystic degeneration 87.1% (27/31), and SN 15.4% (2/13). Multivariate analysis revealed that main pancreatic duct (MPD) communication ( - ) (odds ratio (OR), 4.54; 95% confidence interval (CI) 1.29-15.9), honeycomb-like structure ( +) (OR, 14.7; 95% CI 2.61-83.3), and MPD size ≦ 2 mm (OR, 16.3; 95% CI 3.93-67.6) were independently associated with misdiagnosis. CONCLUSION For cases in which MCN and cystic degeneration of solid tumor are presumed based on preoperative EUS imaging and cases with PCLs with a honeycomb-like structure, diagnosis with multimodalities or fluid analysis with EUS-guided fine-needle aspiration should be considered.
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Affiliation(s)
- Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Kota Uetsuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Jun Yashika
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Kenta Yamada
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Noriaki Gibo
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Toshinori Aoki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
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55
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Hirabayashi K, Saika T, Nakamura N. Background features in the cytology of pancreatic neoplasms. DEN OPEN 2022; 2:e105. [PMID: 35873514 PMCID: PMC9302047 DOI: 10.1002/deo2.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/09/2022] [Accepted: 02/13/2022] [Indexed: 11/05/2022]
Abstract
Cytology is a useful method for diagnosing pancreatic neoplasms. Although endoscopic ultrasound‐guided fine‐needle aspiration has recently become the mainstream method for the diagnosis of pancreatic neoplasms, pancreatic juice and pancreatic duct brushing cytology continue to be useful diagnostic methods for the investigation of pancreatic neoplasms. Diagnoses using pancreatic cytology are primarily based on the features related to tumor cells; however, evaluation of the background features provides important information that could further aid the diagnosis. Pancreatic neoplasms show various histological types, each of which is associated with its own characteristic background features. The necrotic background, desmoplastic stroma, and presence of cancer‐associated fibroblasts are background features of pancreatic ductal adenocarcinoma, a mucinous background is associated with intraductal papillary mucinous neoplasms and mucinous cystic neoplasms, and hyaline globules are observed in solid pseudopapillary neoplasms. However, some background features are associated with more than one histological type of pancreatic neoplasm, highlighting the importance to base a diagnosis on the results of a comprehensive analysis of not only the background features but also the tumor cells. Here, we provide a review of the key background cytological features of pancreatic neoplasms, which can serve as a guide to improve diagnosis and research.
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Affiliation(s)
| | - Tsubasa Saika
- Diagnostic Pathology Center Tokai University Hospital Kanagawa Japan
| | - Naoya Nakamura
- Department of Pathology Tokai University School of Medicine Kanagawa Japan
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56
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Hu F, Hu Y, Wang D, Ma X, Yue Y, Tang W, Liu W, Wu P, Peng W, Tong T. Cystic Neoplasms of the Pancreas: Differential Diagnosis and Radiology Correlation. Front Oncol 2022; 12:860740. [PMID: 35299739 PMCID: PMC8921498 DOI: 10.3389/fonc.2022.860740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/04/2022] [Indexed: 12/18/2022] Open
Abstract
Although the probability of pancreatic cystic neoplasms (PCNs) being detected is raising year by year, their differential diagnosis and individualized treatment are still a challenge in clinical work. PCNs are tumors containing cystic components with different biological behaviors, and their clinical manifestations, epidemiology, imaging features, and malignant risks are different. Some are benign [e.g., serous cystic neoplasms (SCNs)], with a barely possible that turning into malignant, while others display a low or higher malignant risk [e.g., solid pseudopapillary neoplasms (SPNs), intraductal papillary mucinous neoplasms (IPMNs), and mucinous cystic neoplasms (MCNs)]. PCN management should concentrate on preventing the progression of malignant tumors while preventing complications caused by unnecessary surgical intervention. Clinically, various advanced imaging equipment are usually combined to obtain a more reliable preoperative diagnosis. The challenge for clinicians and radiologists is how to accurately diagnose PCNs before surgery so that corresponding surgical methods and follow-up strategies can be developed or not, as appropriate. The objective of this review is to sum up the clinical features, imaging findings and management of the most common PCNs according to the classic literature and latest guidelines.
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Affiliation(s)
- Feixiang Hu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yue Hu
- Hefei Cancer Hospital, Chinese Academy of Sciences (CAS), Hefei, China
| | - Dan Wang
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Xiaowen Ma
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yali Yue
- Children's Hospital, Fudan University, Shanghai, China
| | - Wei Tang
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Liu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Puye Wu
- General Electric (GE) Healthcare, Shanghai, China
| | - Weijun Peng
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tong Tong
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Zhang Y, Hammonds A, Tran-Harding K, Schaberg KB, Nair RT, Wang C, Wu Y, Pandalai PK, Kolesar J, Kim J, Cavnar MJ. Targetable IDH1 mutation identified in a rare case of pancreatic serous cystadenocarcinoma but not a series of serous cystadenomas. J Surg Case Rep 2022; 2022:rjac096. [PMID: 35350224 PMCID: PMC8944732 DOI: 10.1093/jscr/rjac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 02/26/2022] [Indexed: 11/17/2022] Open
Abstract
Serous cystadenocarcinoma (SCAC) of the pancreas is rare, with only 35 cases reported in the literature. We present a case of SCAC, comparing the clinical presentation, management and molecular features of this case to a series of serous cystadenoma (SCA), which may be a precursor. Compared with SCAs (n = 5), SCAC was larger (11.5 vs median 3.6 cm). The case of SCAC invaded the spleen and exhibited distant metastasis, a requirement for diagnosis since pathologic features are otherwise indistinguishable from SCA. VHL mutations have been reported in about half of SCA in the literature. Accordingly, we identified either somatic or germline VHL mutations in 3 of 5 SCAs (60%), yet no pathogenic mutation was identified in the SCAC. A somatic mutation in IDH1 was found in SCAC only. This has been associated with multiple malignancies, is targetable with the drug ivosidenib and should be studied as a progression factor in SCAC.
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Affiliation(s)
- Yuxi Zhang
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Autumn Hammonds
- Department of Pathology, University of Kentucky, Lexington, KY, USA
| | | | - Kurt B Schaberg
- Department of Pathology, University of Kentucky, Lexington, KY, USA
| | - Rashmi T Nair
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Chi Wang
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Yuanyuan Wu
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | | | - Jill Kolesar
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Joseph Kim
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Michael J Cavnar
- Department of Surgery, University of Kentucky, Lexington, KY, USA
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Cho SH, Song TJ, Seo DW, Oh D, Park DH, Lee SS, Lee SK, Kim MH. Efficacy and safety of EUS-guided through-the-needle microforceps biopsy sampling in categorizing the type of pancreatic cystic lesions. Gastrointest Endosc 2022; 95:299-309. [PMID: 34624305 DOI: 10.1016/j.gie.2021.09.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/24/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS EUS-guided through-the-needle biopsy sampling (EUS-TTNB) using microbiopsy forceps is performed for the accurate diagnosis of pancreatic cystic lesions (PCLs). However, there are no standardized protocols for this procedure, and the amount of data on its efficacy is limited. Here, we evaluated the feasibility, efficacy, and safety of EUS-TTNB in categorizing the types of PCLs and identified the factors associated with diagnostic failure. METHODS The prospectively collected and maintained EUS-TTNB database at Asan Medical Center was reviewed to identify patients with PCLs who underwent EUS-TTNB between January 2019 and January 2021. The primary outcomes were technical success, diagnostic yield, and adverse events. Factors contributing to diagnostic failure and the discrepancies in the diagnosis made by conventional modalities (ie, EUS morphology, cross-sectional imaging, and cystic fluid analysis) were also evaluated. RESULTS Forty-five patients were analyzed. EUS-TTNB was successfully performed in all patients (technical success, 100%). Histologic diagnosis of PCLs was made in 37 patients (diagnostic yield, 82%). When comparing EUS-TTNB with a presumptive diagnosis, EUS-TTNB changed the diagnosis in 10 patients in terms of the categorization of the types of PCLs. The diagnostic yield was significantly higher in those who had 4 or more visible biopsy specimens per session (93%) than in those with fewer than 4 visible biopsy specimens per session (67%; P = .045). During follow-up, 3 patients (7%) experienced adverse events (2 acute pancreatitis, 1 intracystic bleeding), and no life-threatening adverse event occurred. CONCLUSIONS EUS-TTNB showed high technical feasibility, diagnostic yield, and good safety profile. EUS-TTNB may improve the categorization of the types of PCLs. Studies with standardized procedure protocols are needed to reduce the diagnostic failure for the types of PCLs.
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Affiliation(s)
- Sung Hyun Cho
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dongwook Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Do Hyun Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Soo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung Koo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Myung-Hwan Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Sakihama K, Koga Y, Yamamoto T, Shimada Y, Yamada Y, Kawata J, Shindo K, Nakamura M, Oda Y. RNF43 as a predictor of malignant transformation of pancreatic mucinous cystic neoplasm. Virchows Arch 2022; 480:1189-1199. [PMID: 35066614 DOI: 10.1007/s00428-022-03277-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/23/2021] [Accepted: 01/12/2022] [Indexed: 11/26/2022]
Abstract
Mucinous cystic neoplasm (MCN) of the pancreas rarely progresses to invasive carcinoma, but few studies have analyzed genomic alterations involved in its malignant transformation. The relationships of ring finger protein 43 (RNF43) mutations with cytological atypia, RNF43 protein expression, and Wnt signaling proteins in MCN remain unclear. This study included 106 MCN cases, classified into 89 low-grade dysplasia (LG), 9 high-grade dysplasia (HG), and 8 invasive carcinoma (INV). We analyzed HG/INV and LG lesions of 9 HG/INV cases and LG lesions of 9 LG cases using targeted sequencing and confirmed the protein expression of RNF43 and β-catenin. The frequency of RNF43 mutations was significantly higher in HG/INV cases than in LG cases. Furthermore, HG/INV lesions (56%) and LG lesions (33%) of HG/INV cases possessed RNF43 mutation, whereas no such mutation was detected in any LG cases. The expression of RNF43 was reduced in 71% of HG/INV cases and significantly correlated with histological grade and aberrant expression of β-catenin. In 3 of 5 RNF43-mutated cases, the expression of RNF43 was reduced, but there was no significant correlation between RNF43 mutation and protein expression. MCNs frequently harbored KRAS mutations, at rates of 100% in HG/INV lesions and 50% in LG lesions of HG/INV and LG cases. There was no significant difference in mutation frequency in LG lesions between HG/INV and LG cases. These results suggest that RNF43 mutations may be involved in and predictive of malignant transformation from an early stage of MCN.
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Affiliation(s)
- Kukiko Sakihama
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, 812-8582, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Koga
- Department of Pathology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Takeo Yamamoto
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, 812-8582, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuki Shimada
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, 812-8582, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Yamada
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, 812-8582, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Kawata
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, 812-8582, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Shindo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, 812-8582, Japan.
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Nikas IP, Mountzios G, Sydney GI, Ioakim KJ, Won JK, Papageorgis P. Evaluating Pancreatic and Biliary Neoplasms with Small Biopsy-Based Next Generation Sequencing (NGS): Doing More with Less. Cancers (Basel) 2022; 14:cancers14020397. [PMID: 35053560 PMCID: PMC8773813 DOI: 10.3390/cancers14020397] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Pancreatic cancer and cholangiocarcinoma are aggressive diseases mostly diagnosed at an advanced and inoperable stage. This review presents the value of next-generation sequencing (NGS) when performed on small biopsies—including fine-needle aspiration/biopsy samples, brushings, pancreatic juice and bile, and also blood—in the field of pancreatobiliary neoplasia. NGS could guide physicians while evaluating pancreatic solid and cystic lesions or suspicious biliary strictures, performing surveillance in high-risk individuals, or monitoring the disease and assessing prognosis in already diagnosed cancer patients. Evidence suggests that NGS performed on small biopsies is a robust tool for the diagnosis and pre-operative risk stratification of pancreatic and biliary lesions, whereas it also carries significant prognostic and therapeutic value. However, effective standardization of the pre-analytical and analytical assay parameters used for each clinical scenario is needed to fully implement NGS into routine practice and provide more personalized management in patients with suspected or established pancreatobiliary neoplasia. Abstract Pancreatic cancer and cholangiocarcinoma are lethal diseases mainly diagnosed at an inoperable stage. As pancreatobiliary surgical specimens are often unavailable for further molecular testing, this review aimed to highlight the diagnostic, prognostic, and therapeutic impact of next-generation sequencing (NGS) performed on distinct small biopsies, including endoscopic ultrasound fine-needle aspirations and biopsies of pancreatic solid and cystic lesions, biliary duct brushings, and also “liquid biopsies” such as the pancreatic juice, bile, and blood. NGS could clarify indeterminate pancreatic lesions or biliary strictures, for instance by identifying TP53 or SMAD4 mutations indicating high-grade dysplasia or cancer. It could also stratify pancreatic cystic lesions, by distinguishing mucinous from non-mucinous cysts and identifying high-risk cysts that should be excised in surgically fit patients, whereas the combination of cytology, elevated cystic CEA levels and NGS could improve the overall diagnostic accuracy. When NGS is performed on the pancreatic juice, it could stratify high-risk patients under surveillance. On the plasma, it could dynamically monitor the disease course and response to therapy. Notably, the circulating tumor DNA (ctDNA) levels have been associated with staging, grading, and survival. Lastly, NGS has shown potential in identifying potentially actionable molecular alterations. In conclusion, NGS applied on small biopsies could carry significant diagnostic, prognostic, and therapeutic value.
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Affiliation(s)
- Ilias P. Nikas
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus; (G.I.S.); (K.J.I.)
- Correspondence:
| | - Giannis Mountzios
- Fourth Department of Medical Oncology and Clinical Trials Unit, Henry Dunant Hospital Center, 11526 Athens, Greece;
| | - Guy I. Sydney
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus; (G.I.S.); (K.J.I.)
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL 62702, USA
| | - Kalliopi J. Ioakim
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus; (G.I.S.); (K.J.I.)
- Department of Internal Medicine, Limassol General Hospital, Limassol 4131, Cyprus
| | - Jae-Kyung Won
- Department of Pathology, Seoul National University Hospital and College of Medicine, Seoul 03080, Korea;
| | - Panagiotis Papageorgis
- Tumor Microenvironment, Metastasis and Experimental Therapeutics Laboratory, Basic and Translational Cancer Research Center, Department of Life Sciences, European University Cyprus, Nicosia 2404, Cyprus;
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Luthra A, Hart PA, Papachristou GI, Porter K, Dillhoff ME, Manilchuk A, Cloyd JM, Pawlik TM, Tsung A, Conwell DL, Krishna SG. Cost-Benefit Analysis and Resource Implications of Endoscopic Ultrasound-Guided Confocal Endomicroscopy in Pancreatic Cysts. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:35-44. [DOI: 10.1016/j.tige.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
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Kim GH, Choi K, Paik N, Lee KT, Lee JK, Lee KH, Han IW, Kang SH, Heo JS, Park JK. Diagnostic Concordance and Preoperative Risk Factors for Malignancy in Pancreatic Mucinous Cystic Neoplasms. Gut Liver 2021; 16:637-644. [PMID: 34933278 PMCID: PMC9289824 DOI: 10.5009/gnl210231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/24/2021] [Accepted: 09/03/2021] [Indexed: 11/04/2022] Open
Abstract
Background/Aims Methods Results Conclusions
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Affiliation(s)
- Ga Hee Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Namyoung Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Kyun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Hoon Kang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea
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Gonzalez-Mancera MS, Ahmadian SS, Gomez-Fernandez C, Velez-Torres J, Jorda M, García-Buitrago MT. Risk of malignancy associated with the diagnostic categories proposed by the Papanicolaou Society of Cytopathology for pancreaticobiliary specimens: An institutional experience. Diagn Cytopathol 2021; 50:49-56. [PMID: 34856075 DOI: 10.1002/dc.24910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/13/2021] [Accepted: 11/22/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The guidelines published by the Papanicolaou Society of Cytopathology (PSC) intend to unify the reporting language in pancreaticobiliary specimens and improve communication between cytopathologists and clinicians. The six categories in the system will determine the best management for patients. However, there is limited evidence regarding the risk of malignancy (ROM) associated with each category. METHODS A retrospective search was performed for pancreaticobiliary fine-needle aspiration (FNA) reports with corresponding surgical follow-up. Cases were reclassified according to the PSC. The ROM, sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each category. RESULTS A total of 297 cases were identified and reclassified as: 30 nondiagnostic (category I), 45 negative for malignancy (II), 20 atypical (III), 42 neoplastic: other (IVB), 19 suspicious for malignancy (V), and 141 malignant (VI). The absolute ROM was 10% for category I, 8.9% for category II, 60% for category III, 4.8% for category IV when the neoplasms were not characterized as malignant, and 100% when categorized as malignant; 100% for category V, and 95.7% for category VI. Sensitivity, specificity, positive predictive value, and negative predictive value for neoplasia and malignancy, including categories IV to VI, were 96.6%, 88.4%, 97.5%, and 84.4%, respectively. CONCLUSIONS The categories developed by the PSC stratify the ROM. Aspirates designated as categories V and VI had the highest ROM. Our rate of atypical category complies with the recommended rate of <10%. This scheme provides valuable information to clinicians treating patients with pancreatic lesions.
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Affiliation(s)
- Miguel S Gonzalez-Mancera
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Saman S Ahmadian
- Department of Pathology and Laboratory Medicine, Jackson Health System, Miami, Florida, USA
| | - Carmen Gomez-Fernandez
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jaylou Velez-Torres
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Merce Jorda
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Monica T García-Buitrago
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Pulvirenti A, Margonis GA, Morales-Oyarvide V, McIntyre CA, Lawrence SA, Goldman DA, Gonen M, Weiss MJ, Ferrone CR, He J, Brennan MF, Cameron JL, Lillemoe KD, Kingham TP, Balachandran V, Qadan M, D’Angelica MI, Jarnagin WR, Wolfgang CL, Castillo CFD, Allen PJ. Intraductal Papillary Mucinous Neoplasms: Have IAP Consensus Guidelines Changed our Approach?: Results from a Multi-institutional Study. Ann Surg 2021; 274:e980-e987. [PMID: 31804389 PMCID: PMC8503800 DOI: 10.1097/sla.0000000000003703] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the influence of consensus guidelines on the management of intraductal papillary mucinous neoplasms (IPMN) and the subsequent changes in pathologic outcomes. BACKGROUND Over time, multiple guidelines have been developed to identify high-risk IPMN. We hypothesized that the development and implementation of guidelines should have increased the percentage of resected IPMN with high-risk disease. METHODS Memorial Sloan-Kettering (MSK), Johns Hopkins (JH), and Massachusetts General Hospital (MGH) databases were queried for resected IPMN (2000-2015). Patients were categorized into main-duct (MD-IPMN) versus branch-duct (BD-IPMN). Guideline-specific radiographic/endoscopic features were recorded. High-risk disease was defined as high-grade dysplasia/carcinoma. Fisher's exact test was used to detect differences between institutions. Logistic regression evaluated differences between time-points [preguidelines (pre-GL, before 2006), Sendai (SCG, 2006-2012), Fukuoka (FCG, after 2012)]. RESULTS The study included 1210 patients. The percentage of BD-IPMN with ≥1 high-risk radiographic feature differed between centers (MSK 69%, JH 60%, MGH 45%; P < 0.001). In MD-IPMN cohort, the presence of radiographic features such as solid component and main pancreatic duct diameter ≥10 mm also differed (solid component: MSK 38%, JH 30%, MGH 18%; P < 0.001; duct ≥10 mm: MSK 49%, JH 32%, MGH 44%; P < 0.001). The percentage of high-risk disease on pathology, however, was similar between institutions (BD-IPMN: P = 0.36, MD-IPMN: P = 0.48). During the study period, the percentage of BD-IPMN resected with ≥1 high-risk feature increased (52% pre-GL vs 67% FCG; P = 0.005), whereas the percentage of high-risk disease decreased (pre-GL vs FCG: 30% vs 20%). For MD-IPMN, there was not a clear trend towards guideline adherence, and the rate of high-risk disease was similar over the time (pre-GL vs FCG: 69% vs 67%; P = 0.63). CONCLUSION Surgical management of IPMN based on radiographic criteria is variable between institutions, with similar percentages of high-risk disease. Over the 15-year study period, the rate of BD-IPMN resected with high-risk radiographic features increased; however, the rate of high-risk disease decreased. Better predictors are needed.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnostic imaging
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Adenocarcinoma, Papillary/diagnostic imaging
- Adenocarcinoma, Papillary/pathology
- Adenocarcinoma, Papillary/surgery
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Pancreatic Ductal/diagnostic imaging
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- Female
- Humans
- Male
- Middle Aged
- Neoplasm Grading
- Neoplasm Staging
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Practice Guidelines as Topic
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Affiliation(s)
| | - Georgios A Margonis
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Caitlin A McIntyre
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sharon A Lawrence
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debra A Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew J Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Murray F Brennan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vinod Balachandran
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Duke, University School of Medicine, Durham, NC
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Li J, Wei T, Zhang J, Liang T. Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Review of Their Genetic Characteristics and Mouse Models. Cancers (Basel) 2021; 13:cancers13215296. [PMID: 34771461 PMCID: PMC8582516 DOI: 10.3390/cancers13215296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/09/2021] [Accepted: 10/19/2021] [Indexed: 12/28/2022] Open
Abstract
Simple Summary Pancreatic cancer is one of the deadliest cancers with the lowest survival rate. Little progress has been achieved in prolonging the survival for patients with pancreatic adenocarcinoma. Hence, special attention should be paid to pre-cancerous lesions, for instance, an intraductal papillary mucinous neoplasm (IPMN). Here, we reviewed its genetic characteristics and the mouse models involving mutations in specific pathways, and updated our current perception of how this lesion develops into a precursor of invasive cancer. Abstract The intraductal papillary mucinous neoplasm (IPMN) is attracting research attention because of its increasing incidence and proven potential to progress into invasive pancreatic ductal adenocarcinoma (PDAC). In this review, we summarized the key signaling pathways or protein complexes (GPCR, TGF, SWI/SNF, WNT, and PI3K) that appear to be involved in IPMN pathogenesis. In addition, we collected information regarding all the genetic mouse models that mimic the human IPMN phenotype with specific immunohistochemistry techniques. The mouse models enable us to gain insight into the complex mechanism of the origin of IPMN, revealing that it can be developed from both acinar cells and duct cells according to different models. Furthermore, recent genomic studies describe the potential mechanism by which heterogeneous IPMN gives rise to malignant carcinoma through sequential, branch-off, or de novo approaches. The most intractable problem is that the risk of malignancy persists to some extent even if the primary IPMN is excised with a perfect margin, calling for the re-evaluation and improvement of diagnostic, pre-emptive, and therapeutic measures.
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Affiliation(s)
- Jin Li
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
| | - Tao Wei
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
| | - Jian Zhang
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
- Correspondence: ; Tel./Fax: +86-571-87236688
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Prud'homme N, Galante GJ, Kaur H, Brundler MA, Beaudry P, Strother D. Comment on: Pancreaticoduodenectomy for the treatment of pancreatic neoplasms in children: A Pediatric Surgical Oncology Research Collaborative study. Pediatr Blood Cancer 2021; 68:e29074. [PMID: 33890416 DOI: 10.1002/pbc.29074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Nicolas Prud'homme
- Departments of Oncology and Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gary J Galante
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Harmeet Kaur
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marie-Anne Brundler
- Department of Pathology and Laboratory Medicine and Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Beaudry
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Douglas Strother
- Departments of Oncology and Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Keane MG, Pereira SP. The Role of Confocal Endomicroscopy in the Diagnosis and Management of Pancreatic Cysts. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/20-00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Pancreatic cystic lesions are an increasingly common clinical finding. Current diagnostic techniques cannot reliably differentiate patients with high-risk lesions requiring surgical resection from those that can be safely surveyed or discharged. As a result, some patients may undergo unnecessary surgery with associated morbidity while others enter long-term surveillance with associated healthcare costs. Needle-based confocal laser endomicroscopy enables real time microscopic examination of the epithelial lining of a cyst wall at the time of a standard endoscopic ultrasound examination. The procedure is associated with low rates of adverse events, especially when the probe is loaded into the fine-needle aspiration needle before the procedure and examination times are limited. Needle-based confocal laser endomicroscopy has consistently been shown to have better diagnostic accuracy than cytology, which is often paucicellular and non-diagnostic in pancreatic cystic lesions. Studies have shown that diagnostic accuracy in needle-based confocal laser endomicroscopy is 84–95% in mucinous lesions and 39–99% in serous lesions. However, this technology is expensive and its place in diagnostic algorithms remains uncertain. Despite this, health economic analyses in certain health systems have been favourable, largely because of its potential to be able to discharge patients with benign lesions, such as serous cystic neoplasms, from long-term surveillance. Widespread adoption of this technology is unlikely but it has the potential to have an important role in indeterminate pancreatic cystic lesions.
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Affiliation(s)
- Margaret G Keane
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland, USA
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, University College London, Royal Free Hospital Campus, UK
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Lee LS. Updates in diagnosis and management of pancreatic cysts. World J Gastroenterol 2021; 27:5700-5714. [PMID: 34629795 PMCID: PMC8473602 DOI: 10.3748/wjg.v27.i34.5700] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/14/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
Incidental pancreatic cysts are commonly encountered with some cysts having malignant potential. The most common pancreatic cystic neoplasms include serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm. Risk stratifying pancreatic cysts is important in deciding whether patients may benefit from endoscopic ultrasound (EUS) or surgical resection. Surgery should be reserved for patients with malignant cysts or cysts at high risk for developing malignancy as suggested by various risk features including solid mass, nodule and dilated main pancreatic duct. EUS may supplement magnetic resonance imaging findings for cysts that remain indeterminate or have concerning features on imaging. Various cyst fluid markers including carcinoembryonic antigen, glucose, amylase, cytology, and DNA markers help distinguish mucinous from nonmucinous cysts. This review will guide the practicing gastroenterologist in how to evaluate incidental pancreatic cysts and when to consider referral for EUS or surgery. For presumed low risk cysts, surveillance strategies will be discussed. Managing pancreatic cysts requires an individualized approach that is directed by the various guidelines.
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Affiliation(s)
- Linda S Lee
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
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Serum miRNA Profiling for Early PDAC Diagnosis and Prognosis: A Retrospective Study. Biomedicines 2021; 9:biomedicines9070845. [PMID: 34356909 PMCID: PMC8301411 DOI: 10.3390/biomedicines9070845] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/29/2021] [Accepted: 07/15/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Tumor stage predicts pancreatic cancer (PDAC) prognosis, but prolonged and short survivals have been described in patients with early-stage tumors. Circulating microRNA (miRNA) are an emerging class of suitable biomarkers for PDAC prognosis. Our aim was to identify whether serum miRNA signatures predict survival of early-stage PDAC. Methods: Serum RNA from archival 15 stage I-III PDAC patients and 4 controls was used for miRNAs expression profile (Agilent microarrays). PDAC patients with comparable age, gender, diabetes, jaundice and surgery were classified according to survival: less than 14 months (7/15 pts, group A) and more than 22 months (8/15 pts, group B). Bioinformatic data analysis was performed by two-class Significance Analysis of Microarray (SAM) algorithm. Binary logistic regression analyses considering PDAC diagnosis and outcome as dependent variables, and ROC analyses were also performed. Results: 2549 human miRNAs were screened out. At SAM, 76 differentially expressed miRNAs were found among controls and PDAC (FDR = 0.4%), the large majority (50/76, 66%) of them being downregulated in PDAC with respect to controls. Six miRNAs were independently correlated with early PDAC, and among these, hsa-miR-6821-5p was associated with the best ROC curve area in distinguishing controls from early PDAC. Among the 71 miRNAs differentially expressed between groups A and B, the most significant were hsa-miR-3135b expressed in group A only, hsa-miR-6126 and hsa-miR-486-5p expressed in group B only. Eight miRNAs were correlated with the presence of lymph-node metastases; among these, hsa-miR-4669 is of potential interest. hsa-miR-4516, increased in PDAC and found as an independent predictor of survival, has among its putative targets a series of gens involved in key pathways of cancer progression and dissemination, such as Wnt and p53 signalling pathways. Conclusions: A series of serum miRNAs was identified as potentially useful for the early diagnosis of PDAC, and for establishing a prognosis.
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Abstract
Pancreatic cancer is a genetic disease, and the recurrent genetic alterations characteristic of pancreatic cancer indicate the cellular processes that are targeted for malignant transformation. In addition to somatic alterations in the most common driver genes (KRAS, CDKN2A, TP53 and SMAD4), large-scale studies have revealed major roles for genetic alterations of the SWI/SNF and COMPASS complexes, copy number alterations in GATA6 and MYC that partially define phenotypes of pancreatic cancer, and the role(s) of polyploidy and chromothripsis as factors contributing to pancreatic cancer biology and progression. Germline variants that increase the risk of pancreatic cancer continue to be discovered along with a greater appreciation of the features of pancreatic cancers with mismatch repair deficiencies and homologous recombination deficiencies that confer sensitivity to therapeutic targeting. Wild-type KRAS pancreatic cancers, some of which are driven by alternative oncogenic events affecting NRG1 or NTRK1 - for which targeted therapies exist - further underscore that pancreatic cancer is formally entering the era of precision medicine. Given the vast developments within this field, here we review the wide-ranging and most current information related to pancreatic cancer genomics with the goal of integrating this information into a unifying description of the life history of pancreatic cancer.
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Early detection of pancreatic cancer using DNA-based molecular approaches. Nat Rev Gastroenterol Hepatol 2021; 18:457-468. [PMID: 34099908 DOI: 10.1038/s41575-021-00470-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 02/08/2023]
Abstract
Due to its poor prognosis and the late stage at which it is typically diagnosed, early detection of pancreatic cancer is a pressing clinical problem. Advances in genomic analysis of human pancreatic tissue and other biospecimens such as pancreatic cyst fluid, pancreatic juice and blood have opened the possibility of DNA-based molecular approaches for early detection of pancreatic cancer. In this Review, we discuss and focus on the pathological and molecular features of precancerous lesions of the pancreas, including pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasm and mucinous cystic neoplasm, which are target lesions of early detection approaches. We also discuss the most prevalent genetic alterations in these precancerous lesions, including somatic mutations in the oncogenes KRAS and GNAS as well as tumour suppressor genes CDKN2A, TP53 and SMAD4. We highlight the latest discoveries related to genetic heterogeneity and multifocal neoplasia in precancerous lesions. In addition, we review specific approaches, challenges and clinically available assays for early detection of pancreatic cancer using DNA-based molecular techniques. Although detection and risk stratification of precancerous pancreatic neoplasms are difficult problems, progress in this field highlights the promise of molecular approaches for improving survival of patients with this disease.
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Evaluating the accuracy of three international guidelines in identifying the risk of malignancy in pancreatic cysts: a retrospective analysis of a surgical treated population. Acta Gastroenterol Belg 2021; 84:443-450. [PMID: 34599569 DOI: 10.51821/84.3.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND STUDY AIMS The international consensus Fukuoka guideline (Fukuoka ICG), The European evidence-based guideline on pancreatic cystic neoplasms (European EBG) and the American Gastroenterological Association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts (AGA IG) are 3 frequently cited guidelines for the risk stratification of neoplastic pancreatic cysts. The aim of this study was to assess the accuracy of detecting malignant cysts by strictly applying these guidelines retrospectively to a cohort of surgically resected pancreatic cysts. PATIENTS AND METHODS 72 resected cysts were included in the analysis. Invasive carcinoma, high grade dysplasia and neuro-endocrine tumour were considered as "malignant cysts" for the purpose of the study. RESULTS 32% of the resected cysts were malignant. The analysis showed that the Fukuoka ICG, European EBG and AGA IG had a sensitivity of 66,8%, 95,5%, 80%; a specificity of 26,8%, 11,3%, 43,8%; a positive predictive value of 31,8%, 35%, 47,1% and a negative predicted value of 61,1%, 83,3%, 77,8% respectively. The missed malignancy rate was respectively 11,3%, 1,5%, 7,7% and surgical overtreatment was respectively 48,4%, 59,1%, 34,6%. CONCLUSION In this retrospective analysis, the European EBG had the lowest rate of missed malignancy at the expense of a high number of "unnecessary" resections. The Fukuoka ICG had the highest number of missed malignancy. The AGA IG showed the lowest rate of unnecessary surgery at the cost of a high number of missed malignancy. There is need to develop better biomarkers to predict the risk of malignancy.
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73
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Yip-Schneider MT, Wu H, Allison HR, Easler JJ, Sherman S, Al-Haddad MA, Dewitt JM, Schmidt CM. Biomarker Risk Score Algorithm and Preoperative Stratification of Patients with Pancreatic Cystic Lesions. J Am Coll Surg 2021; 233:426-434.e4. [PMID: 34166836 DOI: 10.1016/j.jamcollsurg.2021.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pancreatic cysts are incidentally detected in up to 13% of patients undergoing radiographic imaging. Of the most frequently encountered types, mucin-producing (mucinous) pancreatic cystic lesions may develop into pancreatic cancer, while nonmucinous ones have little or no malignant potential. Accurate preoperative diagnosis is critical for optimal management, but has been difficult to achieve, resulting in unnecessary major surgery. Here, we aim to develop an algorithm based on biomarker risk scores to improve risk stratification. STUDY DESIGN Patients undergoing surgery and/or surveillance for a pancreatic cystic lesion, with diagnostic imaging and banked pancreatic cyst fluid, were enrolled in the study after informed consent (n = 163 surgical, 67 surveillance). Cyst fluid biomarkers with high specificity for distinguishing nonmucinous from mucinous pancreatic cysts (vascular endothelial growth factor [VEGF], glucose, carcinoembryonic antigen [CEA], amylase, cytology, and DNA mutation) were selected. Biomarker risk scores were used to design an algorithm to predict preoperative diagnosis. Performance was tested using surgical (retrospective) and surveillance (prospective) cohorts. RESULTS In the surgical cohort, the biomarker algorithm outperformed the preoperative clinical diagnosis in correctly predicting the final pathologic diagnosis (91% vs 73%; p < 0.000001). Specifically, nonmucinous serous cystic neoplasms (SCN) and mucinous cystic neoplasms (MCN) were correctly classified more frequently by the algorithm than clinical diagnosis (96% vs 30%; p < 0.000008 and 92% vs 69%; p = 0.04, respectively). In the surveillance cohort, the algorithm predicted a preoperative diagnosis with high confidence based on a high biomarker score and/or consistency with imaging from ≥1 follow-up visits. CONCLUSIONS A biomarker risk score-based algorithm was able to correctly classify pancreatic cysts preoperatively. Importantly, this tool may improve initial and dynamic risk stratification, reducing overdiagnosis and underdiagnosis.
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Affiliation(s)
- Michele T Yip-Schneider
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Walther Oncology Center, Indianapolis, IN; Indiana University Simon Cancer Center, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - Huangbing Wu
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | | | - Jeffrey J Easler
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - Stuart Sherman
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - Mohammad A Al-Haddad
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - John M Dewitt
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Biochemistry/Molecular Biology, Indianapolis, IN; Walther Oncology Center, Indianapolis, IN; Indiana University Simon Cancer Center, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN.
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74
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Okasha HH, Awad A, El-meligui A, Ezzat R, Aboubakr A, AbouElenin S, El-Husseiny R, Alzamzamy A. Cystic pancreatic lesions, the endless dilemma. World J Gastroenterol 2021; 27:2664-2680. [PMID: 34135548 PMCID: PMC8173383 DOI: 10.3748/wjg.v27.i21.2664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
Cystic pancreatic lesions involve a wide variety of pathological entities that include neoplastic and non-neoplastic lesions. The proper diagnosis, differentiation, and staging of these cystic lesions are considered a crucial issue in planning further management. There are great challenges for their diagnostic models. In our time, new emerging methods for this diagnosis have been discovered. Endoscopic ultrasonography-guided fine-needle aspiration cytology with chemical and molecular analysis of cyst fluid and EUS-guided fine needle-based confocal laser endomicroscopy, through the needle microforceps biopsy, and single-operator cholangioscopy/pancreatoscopy are promising methods that have been used in the diagnosis of cystic pancreatic lesions. Hereby we discuss the diagnosis of cystic pancreatic lesions and the benefits of various diagnostic models.
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Affiliation(s)
- Hussein Hassan Okasha
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Kasr Al-Aini Hospitals, Cairo University, Cairo 11562, Egypt
| | - Abeer Awad
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Kasr Al-Aini Hospitals, Cairo University, Cairo 11562, Egypt
| | - Ahmed El-meligui
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Kasr Al-Aini Hospitals, Cairo University, Cairo 11562, Egypt
| | - Reem Ezzat
- Department of Internal Medicine and Gastroenterology, Hepatology Unit, Assuit University, Assuit 71515, Egypt
| | - Ashraf Aboubakr
- Department of Gastroenterology and Hepatology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo 11441, Egypt
| | - Sameh AbouElenin
- Department of Gastroenterology and Hepatology, Military Medical Academy, Cairo 11441, Egypt
| | - Ramy El-Husseiny
- Department of Hepatology and Tropical Medicine, National Hepatology and Tropical Medicine Research Institute (NHTMRI), Cairo 11441, Egypt
| | - Ahmed Alzamzamy
- Department of Gastroenterology and Hepatology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo 11441, Egypt
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75
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Visani M, Acquaviva G, De Leo A, Sanza V, Merlo L, Maloberti T, Brandes AA, Franceschi E, Di Battista M, Masetti M, Jovine E, Fiorino S, Pession A, Tallini G, de Biase D. Molecular alterations in pancreatic tumors. World J Gastroenterol 2021; 27:2710-2726. [PMID: 34135550 PMCID: PMC8173386 DOI: 10.3748/wjg.v27.i21.2710] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/25/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
Genetic alterations in pancreatic tumors can usually be classified in: (1) Mutational activation of oncogenes; (2) Inactivation of tumor suppressor genes; and (3) Inactivation of genome maintenance genes controlling the repair of DNA damage. Endoscopic ultrasound-guided fine-needle aspiration has improved pre-operative diagnosis, but the management of patients with a pancreatic lesion is still challenging. Molecular testing could help mainly in solving these “inconclusive” specimens. The introduction of multi-gene analysis approaches, such as next-generation sequencing, has provided a lot of useful information on the molecular characterization of pancreatic tumors. Different types of pancreatic tumors (e.g., pancreatic ductal adenocarcinomas, intraductal papillary mucinous neoplasms, solid pseudopapillary tumors) are characterized by specific molecular alterations. The aim of this review is to summarize the main molecular alterations found in pancreatic tumors.
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Affiliation(s)
- Michela Visani
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna–Molecular Diagnostic Unit, Azienda USL di Bologna, Bologna 40138, Italy
| | - Giorgia Acquaviva
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna–Molecular Diagnostic Unit, Azienda USL di Bologna, Bologna 40138, Italy
| | - Antonio De Leo
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna–Molecular Diagnostic Unit, Azienda USL di Bologna, Bologna 40138, Italy
- Division of Molecular Pathology Laboratory, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Viviana Sanza
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna–Molecular Diagnostic Unit, Azienda USL di Bologna, Bologna 40138, Italy
| | - Lidia Merlo
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna–Molecular Diagnostic Unit, Azienda USL di Bologna, Bologna 40138, Italy
| | - Thais Maloberti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna–Molecular Diagnostic Unit, Azienda USL di Bologna, Bologna 40138, Italy
| | - Alba A Brandes
- Medical Oncology Department, Azienda USL/IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna 40139, Italy
| | - Enrico Franceschi
- Medical Oncology Department, Azienda USL/IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna 40139, Italy
| | - Monica Di Battista
- Medical Oncology Department, Azienda USL/IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna 40139, Italy
| | - Michele Masetti
- Division of Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40133, Italy
| | - Elio Jovine
- Division of Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40133, Italy
| | - Sirio Fiorino
- Internal Medicine Unit, Budrio Hospital Azienda USL, Bologna 40133, Italy
| | - Annalisa Pession
- Division of Molecular Pathology Laboratory, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna 40138, Italy
| | - Giovanni Tallini
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna–Molecular Diagnostic Unit, Azienda USL di Bologna, Bologna 40138, Italy
- Division of Molecular Pathology Laboratory, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
| | - Dario de Biase
- Division of Molecular Pathology Laboratory, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna 40138, Italy
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna 40138, Italy
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76
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Gonzalez RS, Raza A, Propst R, Adeyi O, Bateman J, Sopha SC, Shaw J, Auerbach A. Recent Advances in Digestive Tract Tumors: Updates From the 5th Edition of the World Health Organization "Blue Book". Arch Pathol Lab Med 2021; 145:607-626. [PMID: 32886739 DOI: 10.5858/arpa.2020-0047-ra] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The World Health Organization Classification of Tumours: Digestive System Tumors, 5th edition, was published in 2019 and shows several impactful changes as compared with the 4th edition published in 2010. Changes include a revised nomenclature of serrated lesions and revamping the classification of neuroendocrine neoplasms. Appendiceal goblet cell adenocarcinoma is heavily revised, and intrahepatic cholangiocarcinoma is split into 2 subtypes. New subtypes of colorectal carcinoma and hepatocellular carcinoma are described. Precursor lesions are emphasized with their own entries, and both dysplastic and invasive lesions are generally recommended to be graded using a 2-tier system. Hematolymphoid tumors, mesenchymal tumors, and genetic tumor syndromes each have their own sections in the 5th edition. New hematolymphoid lesions include monomorphic epitheliotropic intestinal T-cell lymphoma; duodenal-type follicular lymphoma; intestinal T-cell lymphoma, not otherwise specified; and indolent T-cell lymphoproliferative disorder of the gastrointestinal tract. This paper will provide an in-depth look at the changes in the 5th edition as compared with the 4th edition. OBJECTIVE.— To provide a comprehensive, in-depth update on the World Health Organization classification of digestive tumors, including changes to nomenclature, updated diagnostic criteria, and newly described entities. DATA SOURCES.— The 5th edition of the World Health Organization Classification of Tumours: Digestive System Tumours, as well as the 4th edition. CONCLUSIONS.— The World Health Organization has made many key changes in its newest update on tumors of the digestive system. Pathologists should be aware of these changes and incorporate them into their practice as able or necessary.
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Affiliation(s)
- Raul S Gonzalez
- The Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Gonzalez)
| | - Anwar Raza
- The Department of Pathology and Human Anatomy, Loma Linda University, Loma Linda, California (Raza, Propst)
| | - Robert Propst
- The Department of Pathology and Human Anatomy, Loma Linda University, Loma Linda, California (Raza, Propst)
| | - Oyedele Adeyi
- The Department of Pathology, University of Minnesota, Minneapolis (Adeyi, Bateman)
| | - Justin Bateman
- The Department of Pathology, University of Minnesota, Minneapolis (Adeyi, Bateman)
| | - Sabrina C Sopha
- The Department of Pathology, University of Maryland Baltimore Washington Medical Center, Glen Burnie (Sopha)
| | - Janet Shaw
- The Joint Pathology Center, Silver Spring, Maryland (Shaw, Auerbach)
| | - Aaron Auerbach
- The Joint Pathology Center, Silver Spring, Maryland (Shaw, Auerbach)
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77
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Assarzadegan N, Thompson E, Salimian K, Gaida MM, Brosens LAA, Wood L, Ali SZ, Hruban RH. Pathology of intraductal papillary mucinous neoplasms. Langenbecks Arch Surg 2021; 406:2643-2655. [PMID: 34047827 DOI: 10.1007/s00423-021-02201-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) represent a unique opportunity to treat and prevent a curable neoplasm before it has the chance to progress to incurable cancer. This prospect, however, has to be balanced with the real risk of over treating patients with lesions that would, in fact, never progress during the life of the patient. PURPOSE Informed clinical decisions in the treatment of IPMNs are first and foremost based on a deep understanding of the pathology of these lesions. CONCLUSIONS Here we review the pathology of IPMNs, with an emphasis on the clinical relevance of the important features that characterize these lesions.
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Affiliation(s)
- Naziheh Assarzadegan
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA
| | - Elizabeth Thompson
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA
| | - Kevan Salimian
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA
| | - Matthias M Gaida
- Institute of Pathology, University Medical Center Mainz, Mainz, Germany
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Laura Wood
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA.,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA
| | - Syed Z Ali
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA.,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA. .,Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21212, USA.
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78
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Detection of low-frequency DNA variants by targeted sequencing of the Watson and Crick strands. Nat Biotechnol 2021; 39:1220-1227. [PMID: 33941929 DOI: 10.1038/s41587-021-00900-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/16/2021] [Indexed: 02/07/2023]
Abstract
Identification and quantification of low-frequency mutations remain challenging despite improvements in the baseline error rate of next-generation sequencing technologies. Here, we describe a method, termed SaferSeqS, that addresses these challenges by (1) efficiently introducing identical molecular barcodes in the Watson and Crick strands of template molecules and (2) enriching target sequences with strand-specific PCR. The method achieves high sensitivity and specificity and detects variants at frequencies below 1 in 100,000 DNA template molecules with a background mutation rate of <5 × 10-7 mutants per base pair (bp). We demonstrate that it can evaluate mutations in a single amplicon or simultaneously in multiple amplicons, assess limited quantities of cell-free DNA with high recovery of both strands and reduce the error rate of existing PCR-based molecular barcoding approaches by >100-fold.
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79
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Fujikura K, Hosoda W, Felsenstein M, Song Q, Reiter JG, Zheng L, Beleva Guthrie V, Rincon N, Dal Molin M, Dudley J, Cohen JD, Wang P, Fischer CG, Braxton AM, Noë M, Jongepier M, Fernández-del Castillo C, Mino-Kenudson M, Schmidt CM, Yip-Schneider MT, Lawlor RT, Salvia R, Roberts NJ, Thompson ED, Karchin R, Lennon AM, Jiao Y, Wood LD. Multiregion whole-exome sequencing of intraductal papillary mucinous neoplasms reveals frequent somatic KLF4 mutations predominantly in low-grade regions. Gut 2021; 70:928-939. [PMID: 33028669 PMCID: PMC8262510 DOI: 10.1136/gutjnl-2020-321217] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/06/2020] [Accepted: 08/09/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Intraductal papillary mucinous neoplasms (IPMNs) are non-invasive precursor lesions that can progress to invasive pancreatic cancer and are classified as low-grade or high-grade based on the morphology of the neoplastic epithelium. We aimed to compare genetic alterations in low-grade and high-grade regions of the same IPMN in order to identify molecular alterations underlying neoplastic progression. DESIGN We performed multiregion whole exome sequencing on tissue samples from 17 IPMNs with both low-grade and high-grade dysplasia (76 IPMN regions, including 49 from low-grade dysplasia and 27 from high-grade dysplasia). We reconstructed the phylogeny for each case, and we assessed mutations in a novel driver gene in an independent cohort of 63 IPMN cyst fluid samples. RESULTS Our multiregion whole exome sequencing identified KLF4, a previously unreported genetic driver of IPMN tumorigenesis, with hotspot mutations in one of two codons identified in >50% of the analyzed IPMNs. Mutations in KLF4 were significantly more prevalent in low-grade regions in our sequenced cases. Phylogenetic analyses of whole exome sequencing data demonstrated diverse patterns of IPMN initiation and progression. Hotspot mutations in KLF4 were also identified in an independent cohort of IPMN cyst fluid samples, again with a significantly higher prevalence in low-grade IPMNs. CONCLUSION Hotspot mutations in KLF4 occur at high prevalence in IPMNs. Unique among pancreatic driver genes, KLF4 mutations are enriched in low-grade IPMNs. These data highlight distinct molecular features of low-grade and high-grade dysplasia and suggest diverse pathways to high-grade dysplasia via the IPMN pathway.
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Affiliation(s)
- Kohei Fujikura
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Waki Hosoda
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Pathology and Molecular Diagnostics, Aichi Cancer Center, Nagoya, Japan
| | - Matthäus Felsenstein
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Surgery, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Qianqian Song
- State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021 Beijing, China
| | - Johannes G. Reiter
- Canary Center for Cancer Early Detection, Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA,Stanford Cancer Institute, Stanford University School of Medicine, Palo Alto, CA, USA,Department of Biomedical Data Science, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lily Zheng
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Natalia Rincon
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA,Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Marco Dal Molin
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan Dudley
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua D. Cohen
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Ludwig Center for Cancer Genetics and Therapeutics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pei Wang
- State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 100021 Beijing, China
| | - Catherine G. Fischer
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alicia M. Braxton
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michaël Noë
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martine Jongepier
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C. Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Rita T. Lawlor
- ARC-NET: Centre for Applied Research on Cancer, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Department, The Pancreas Institute and Hospital Trust of Verona, Verona, Italy
| | - Nicholas J. Roberts
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth D. Thompson
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Karchin
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA,Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anne Marie Lennon
- Department of Medicine, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yuchen Jiao
- State Key Lab of Molecular Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Laura D. Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Correspondence: Laura D. Wood, MD, PhD, CRB2 Room 345, 1550 Orleans Street, Baltimore, MD 21231, Phone: 410-955-3511, Fax: 410-614-0671, , Yuchen Jiao, PhD, 4104 Laobingfanglou, 17 Panjiayuannanli, Beijing, China, 100021, Phone: 86-10-87787662,
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80
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Breunig M, Merkle J, Wagner M, Melzer MK, Barth TFE, Engleitner T, Krumm J, Wiedenmann S, Cohrs CM, Perkhofer L, Jain G, Krüger J, Hermann PC, Schmid M, Madácsy T, Varga Á, Griger J, Azoitei N, Müller M, Wessely O, Robey PG, Heller S, Dantes Z, Reichert M, Günes C, Bolenz C, Kuhn F, Maléth J, Speier S, Liebau S, Sipos B, Kuster B, Seufferlein T, Rad R, Meier M, Hohwieler M, Kleger A. Modeling plasticity and dysplasia of pancreatic ductal organoids derived from human pluripotent stem cells. Cell Stem Cell 2021; 28:1105-1124.e19. [PMID: 33915078 DOI: 10.1016/j.stem.2021.03.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 12/22/2020] [Accepted: 03/09/2021] [Indexed: 12/14/2022]
Abstract
Personalized in vitro models for dysplasia and carcinogenesis in the pancreas have been constrained by insufficient differentiation of human pluripotent stem cells (hPSCs) into the exocrine pancreatic lineage. Here, we differentiate hPSCs into pancreatic duct-like organoids (PDLOs) with morphological, transcriptional, proteomic, and functional characteristics of human pancreatic ducts, further maturing upon transplantation into mice. PDLOs are generated from hPSCs inducibly expressing oncogenic GNAS, KRAS, or KRAS with genetic covariance of lost CDKN2A and from induced hPSCs derived from a McCune-Albright patient. Each oncogene causes a specific growth, structural, and molecular phenotype in vitro. While transplanted PDLOs with oncogenic KRAS alone form heterogenous dysplastic lesions or cancer, KRAS with CDKN2A loss develop dedifferentiated pancreatic ductal adenocarcinomas. In contrast, transplanted PDLOs with mutant GNAS lead to intraductal papillary mucinous neoplasia-like structures. Conclusively, PDLOs enable in vitro and in vivo studies of pancreatic plasticity, dysplasia, and cancer formation from a genetically defined background.
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Affiliation(s)
- Markus Breunig
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Jessica Merkle
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Martin Wagner
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Michael K Melzer
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany; Department of Urology, Ulm University, Ulm, Germany
| | | | - Thomas Engleitner
- Institute of Molecular Oncology and Functional Genomics, Center for Translational Cancer Research and Department of Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johannes Krumm
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Sandra Wiedenmann
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany; Helmholtz Pioneer Campus, Helmholtz Zentrum München, Neuherberg, Germany
| | - Christian M Cohrs
- Paul Langerhans Institute Dresden (PLID) of the Helmholtz Zentrum München at the University Clinic Carl Gustav Carus of Technische Universität Dresden, Helmholtz Zentrum München, Neuherberg, Germany; Institute of Physiology, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany; German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Lukas Perkhofer
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Gaurav Jain
- Institute of Molecular Oncology and Functional Genomics, Center for Translational Cancer Research and Department of Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jana Krüger
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Patrick C Hermann
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Maximilian Schmid
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Tamara Madácsy
- First Department of Internal Medicine, University of Szeged, Szeged, Hungary; MTA-SZTE Momentum Epithelial Cell Signalling and Secretion Research Group, University of Szeged, Szeged, Hungary
| | - Árpád Varga
- First Department of Internal Medicine, University of Szeged, Szeged, Hungary; MTA-SZTE Momentum Epithelial Cell Signalling and Secretion Research Group, University of Szeged, Szeged, Hungary
| | - Joscha Griger
- Institute of Molecular Oncology and Functional Genomics, Center for Translational Cancer Research and Department of Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ninel Azoitei
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Martin Müller
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Oliver Wessely
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland, OH 44195, USA
| | - Pamela G Robey
- Skeletal Biology Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD 20892, USA
| | - Sandra Heller
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Zahra Dantes
- Medical Clinic and Polyclinic II, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Maximilian Reichert
- Medical Clinic and Polyclinic II, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | | | - Florian Kuhn
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - József Maléth
- First Department of Internal Medicine, University of Szeged, Szeged, Hungary; MTA-SZTE Momentum Epithelial Cell Signalling and Secretion Research Group, University of Szeged, Szeged, Hungary; HCEMM-SZTE Molecular Gastroenterology Research Group, University of Szeged, Szeged, Hungary
| | - Stephan Speier
- Paul Langerhans Institute Dresden (PLID) of the Helmholtz Zentrum München at the University Clinic Carl Gustav Carus of Technische Universität Dresden, Helmholtz Zentrum München, Neuherberg, Germany; Institute of Physiology, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany; German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Stefan Liebau
- Institute of Neuroanatomy & Developmental Biology (INDB), Eberhard Karls University Tübingen, Tübingen, Germany
| | - Bence Sipos
- Department of Internal Medicine VIII, University Hospital Tübingen, Tübingen, Germany
| | - Bernhard Kuster
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany; Bavarian Biomolecular Mass Spectrometry Center (BayBioMS), Technical University of Munich, Freising, Germany
| | - Thomas Seufferlein
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Roland Rad
- Institute of Molecular Oncology and Functional Genomics, Center for Translational Cancer Research and Department of Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Meier
- Helmholtz Pioneer Campus, Helmholtz Zentrum München, Neuherberg, Germany
| | - Meike Hohwieler
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany
| | - Alexander Kleger
- Department of Internal Medicine I, Ulm University Hospital, Ulm, Germany.
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81
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Aguilera KY, Dawson DW. WNT Ligand Dependencies in Pancreatic Cancer. Front Cell Dev Biol 2021; 9:671022. [PMID: 33996827 PMCID: PMC8113755 DOI: 10.3389/fcell.2021.671022] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/06/2021] [Indexed: 12/17/2022] Open
Abstract
WNT signaling promotes the initiation and progression of pancreatic ductal adenocarcinoma (PDAC) through wide-ranging effects on cellular proliferation, survival, differentiation, stemness, and tumor microenvironment. Of therapeutic interest is a genetically defined subset of PDAC known to have increased WNT/β-catenin transcriptional activity, growth dependency on WNT ligand signaling, and response to pharmacologic inhibitors of the WNT pathway. Here we review mechanisms underlying WNT ligand addiction in pancreatic tumorigenesis, as well as the potential utility of therapeutic approaches that functionally antagonize WNT ligand secretion or frizzled receptor binding.
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Affiliation(s)
- Kristina Y. Aguilera
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, United States
| | - David W. Dawson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA, United States
- Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at University of California, Los Angeles, CA, United States
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82
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Should Contrast-Enhanced Harmonic Endoscopic Ultrasound Be Incorporated into the International Consensus Guidelines to Determine the Appropriate Treatment of Intraductal Papillary Mucinous Neoplasm? J Clin Med 2021; 10:jcm10091818. [PMID: 33921949 PMCID: PMC8122438 DOI: 10.3390/jcm10091818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/04/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
This study aimed to investigate whether the incorporation of contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) into the international consensus guidelines (ICG) for the management of intraductal papillary mucinous neoplasm (IPMN) could improve its malignancy diagnostic value. In this single-center retrospective study, 109 patients diagnosed with IPMN who underwent preoperative CH-EUS between March 2010 and December 2018 were enrolled. We analyzed each malignancy diagnostic value (sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV)) by replacing fundamental B-mode EUS with CH-EUS as the recommended test for patients with worrisome features (WF) (the CH-EUS incorporation ICG) and comparing the results to those obtained using the 2017 ICG. The malignancy diagnostic values as per the 2017 ICG were 78.9%, 42.3%, 60.0%, and 64.7% for Se, Sp, PPV, and NPV, respectively. The CH-EUS incorporation ICG plan improved the malignancy diagnostic values (Se 78.9%/Sp, 53.8%/PPV, 65.2%/NPV 70.0%). CH-EUS may be useful in determining the appropriate treatment strategies for IPMN.
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83
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Reid MD. Cytologic Assessment of Cystic/Intraductal Lesions of the Pancreatobiliary Tract. Arch Pathol Lab Med 2021; 146:280-297. [PMID: 33836534 DOI: 10.5858/arpa.2020-0553-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Because of new and improved imaging techniques, cystic/intraductal pancreatobiliary tract lesions are increasingly being discovered, and brushings or endoscopic ultrasound/computed tomography/magnetic resonance imaging-guided fine-needle aspiration biopsies from these lesions have become an integral part of pathologists' daily practice. Because patient management has become increasingly conservative, accurate preoperative diagnosis is critical. Cytologic distinction of low-risk (pseudocysts, serous cystadenoma, lymphoepithelial cysts, and squamoid cysts of the pancreatic duct) from high-risk pancreatic cysts (intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) requires incorporation of clinical, radiologic, and cytologic findings, in conjunction with chemical and molecular analysis of cyst fluid. Cytopathologists must ensure appropriate specimen triage, along with cytologic interpretation, cyst classification, and even grading of some (mucinous) cysts. Epithelial atypia in mucinous cysts (intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) has transitioned from a 3-tiered to a 2-tiered classification system, and intraductal oncocytic papillary neoplasms and intraductal tubulopapillary neoplasms have been separately reclassified because of their distinctive clinicopathologic characteristics. Because these lesions may be sampled on brushing or fine-needle aspiration biopsy, knowledge of their cytomorphology is critical. OBJECTIVE.— To use an integrated, multidisciplinary approach for the evaluation of cystic/intraductal pancreatobiliary tract lesions (incorporating clinical, radiologic, and cytologic findings with [chemical/molecular] cyst fluid analysis and ancillary stains) for definitive diagnosis and classification. DATA SOURCES.— Review of current literature on the cytopathology of cystic/intraductal pancreatobiliary tract lesions. CONCLUSIONS.— Our knowledge/understanding of recent updates in cystic/intraductal pancreatobiliary lesions can ensure that cytopathologists appropriately triage specimens, judiciously use and interpret ancillary studies, and incorporate the studies into reporting.
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Affiliation(s)
- Michelle D Reid
- From the Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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84
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Liu X, Wu X, Tuo B, Wu H. Ectopic pancreas appearing as a giant gastric cyst mimicking gastric lymphangioma: a case report and a brief review. BMC Gastroenterol 2021; 21:151. [PMID: 33823798 PMCID: PMC8022400 DOI: 10.1186/s12876-021-01686-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 02/22/2021] [Indexed: 12/17/2022] Open
Abstract
Background Ectopic pancreas (EP) is defined as pancreatic tissue that lacks anatomical or vascular communication with the normal body of the pancreas. Despite improvements in diagnostic endoscopy and imaging studies, differentiating ectopic pancreatic tissue from gastric submucosal diseases remains a challenge. Case presentation Here, we present a case of a 44-year-old woman with severe epigastric pain. Initially, gastric lymphangioma was highly suspected due to a well-demarcated protruding mass with a large size that occurred in the submucosal layer of the gastric antrum and appeared as a cystic lesion. The final correct diagnosis of gastric EP was made during surgery. Conclusion Gastric EP with serous oligocystic adenoma appearing as a giant gastric cyst is extremely rare. The difficulty of making an accurate diagnosis and differential diagnosis is highlighted, which may provide additional clinical experience for the diagnosis of EP with serous oligocystic adenoma in the stomach.
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Affiliation(s)
- Xuemei Liu
- Department of Gastroenterology, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, Guizhou Province, China
| | - Xinglong Wu
- Department of Pathology, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, Guizhou Province, China
| | - Biguang Tuo
- Department of Gastroenterology, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, Guizhou Province, China
| | - Huichao Wu
- Department of Gastroenterology, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, Guizhou Province, China.
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85
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Geramizadeh B, Marzban M, Shojazadeh A, Kadivar A, Maleki Z. Intraductal papillary mucinous neoplasm of the pancreas: Cytomorphology, imaging, molecular profile, and prognosis. Cytopathology 2021; 32:397-406. [PMID: 33792980 DOI: 10.1111/cyt.12973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm (IPMN) constitutes up to 20% of all pancreatic resections, and has been increasing in recent years. Histomorphological findings of IPMN are well established; however, there are not many published papers regarding the cytological findings of IPMN on fine needle aspiration (FNA) specimens. We review the cytomorphological features, molecular profile, imaging findings, and prognosis of IPMN. METHODS The English literature was thoroughly searched with key phrases containing IPMN. OBSERVATIONS IPMN is a rare entity, affecting men and women equally and is usually diagnosed at the age of 60-70 years. The characteristic imaging features include a cystic lesion with associated dilatation of the main or branch pancreatic duct, and atrophy of surrounding pancreatic parenchyma. Cytomorphological features of IPMN include papillary fragments of mucinous epithelium in a background of abundant thick extracellular mucin, a hallmark feature. IPMNs should be evaluated for high-grade dysplasia, which manifests with nuclear atypia, nuclear moulding, prominent nucleoli, nuclear irregularity, and cellular crowding. Molecular profiling of IPMN along with carcinoembryonic antigen and amylase levels is useful in predicting malignancy or high-grade dysplasia arising in IPMN. Overall, the prognosis of IPMN is excellent except in those cases with high-grade dysplasia and malignant transformation. Postoperative surveillance is required for resected IPMNs. CONCLUSION IPMN requires a multidisciplinary approach for management. Cytomorphological findings of IPMN on FNA, in conjunction with tumour markers in pancreatic fluid cytology and imaging findings, are of paramount importance in clinical decision-making for IPMN.
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Affiliation(s)
- Bita Geramizadeh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran.,Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Marzban
- University of British Columbia, Vancouver, BC, Canada
| | - Alireza Shojazadeh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ana Kadivar
- University of Maryland, College Park, MD, USA
| | - Zahra Maleki
- Division of Cytopathology, Department of Pathology, The Johns-Hopkins Hospital, Baltimore, MD, USA
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86
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Keane MG, Afghani E. A Review of the Diagnosis and Management of Premalignant Pancreatic Cystic Lesions. J Clin Med 2021; 10:1284. [PMID: 33808853 PMCID: PMC8003622 DOI: 10.3390/jcm10061284] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic lesions are an increasingly common clinical finding. They represent a heterogeneous group of lesions that include two of the three known precursors of pancreatic cancer, intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN). Given that approximately 8% of pancreatic cancers arise from these lesions, careful surveillance and timely surgery offers an opportunity for early curative resection in a disease with a dismal prognosis. This review summarizes the current evidence and guidelines for the diagnosis and management of IPMN/MCN. Current pre-operative diagnostic tests in pancreatic cysts are imperfect and a proportion of patients continue to undergo unnecessary surgical resection annually. Balancing cancer prevention while preventing surgical overtreatment, continues to be challenging when managing pancreatic cysts. Cyst fluid molecular markers, such as KRAS, GNAS, VHL, PIK3CA, SMAD4 and TP53, as well as emerging endoscopic technologies such as needle-based confocal laser endomicroscopy and through the needle microbiopsy forceps demonstrate improved diagnostic accuracy. Differences in management and areas of uncertainty between the guidelines are also discussed, including indications for surgery, surveillance protocols and if and when surveillance can be discontinued.
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Affiliation(s)
| | - Elham Afghani
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA;
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87
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Geisler D, Khader SN. Educational Case: Pancreatic Cystic Disease: A Multimodal Diagnostic Approach to Determine Clinical Management. Acad Pathol 2021; 8:2374289521998031. [PMID: 35155743 PMCID: PMC8819742 DOI: 10.1177/2374289521998031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/30/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040 . 1
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Affiliation(s)
- Daniel Geisler
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Samer N. Khader
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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88
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Schmitz D, Kazdal D, Allgäuer M, Trunk M, Vornhusen S, Nahm AM, Doll M, Weingärtner S, Endris V, Penzel R, Kirchner M, Brandt R, Neumann O, Sültmann H, Budczies J, Kienle P, Magdeburg R, Hetjens S, Schirmacher P, Bergmann F, Rudi J, Stenzinger A, Volckmar AL. KRAS/GNAS-testing by highly sensitive deep targeted next generation sequencing improves the endoscopic ultrasound-guided workup of suspected mucinous neoplasms of the pancreas. Genes Chromosomes Cancer 2021; 60:489-497. [PMID: 33686791 DOI: 10.1002/gcc.22946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/28/2022] Open
Abstract
Pancreatic cysts or dilated pancreatic ducts are often found by cross-sectional imaging, but only mucinous lesions can become malignant. Therefore, distinction between mucinous and non-mucinous lesions is crucial for adequate patient management. We performed a prospective study including targeted next generation sequencing (NGS) of cell-free DNA in the diagnostic endoscopic ultrasound (EUS)-guided workup. Pancreatic cyst(s) or main duct fluid obtained by EUS-guided FNA was analysed by carcinoembryonic antigen (CEA), cytology and deep targeted NGS of 14 known gastrointestinal cancer genes (AKT1, BRAF, CTNNB1, EGFR, ERBB2, FBXW7, GNAS, KRAS, MAP2K1, NRAS, PIK3CA, SMAD4, TP53, APC) with a limit of detection down to variant allele frequency of 0.01%. Results were correlated to histopathology and clinical follow-up. One hundred and thirteen patients with pancreatic cyst(s) and/or a dilated pancreatic main duct (≥5 mm) were screened. Sixty-six patients had to be excluded, mainly due to inoperability or small cyst size (≤10 mm). Forty-seven patients were enrolled for further analysis. A final diagnosis was available in 27 cases including 8 negative controls. In 43/47 (91.5%) of patients a KRAS- and/or GNAS-mutation was diagnosed by NGS. 27.0% of the KRAS-mutated and 10.0% of the GNAS-mutated lesions harbored multiple mutations. KRAS/GNAS-testing by NGS, cytology, and CEA had a sensitivity and specificity of 94.7/100%, 38.1/100%, and 42.1/75.0%, respectively. KRAS/GNAS-testing was significantly superior to CEA (P = .0209) and cytology (P = .0016). In conclusion, KRAS/GNAS-testing by deep targeted NGS is a suitable method to distinguish mucinous from non-mucinous pancreatic lesions, suggesting its usage as a single diagnostic test. Results must be confirmed in a larger cohort.
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MESH Headings
- Aged
- Aged, 80 and over
- Chromogranins/genetics
- Endoscopic Ultrasound-Guided Fine Needle Aspiration/methods
- Endoscopic Ultrasound-Guided Fine Needle Aspiration/standards
- Female
- GTP-Binding Protein alpha Subunits, Gs/genetics
- Genetic Testing/methods
- Genetic Testing/standards
- High-Throughput Nucleotide Sequencing/methods
- High-Throughput Nucleotide Sequencing/standards
- Humans
- Male
- Middle Aged
- Neoplasms, Cystic, Mucinous, and Serous/diagnostic imaging
- Neoplasms, Cystic, Mucinous, and Serous/genetics
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Pancreatic Cyst/diagnostic imaging
- Pancreatic Cyst/genetics
- Pancreatic Cyst/pathology
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/pathology
- Proto-Oncogene Proteins p21(ras)/genetics
- Sensitivity and Specificity
- Sequence Analysis, DNA/methods
- Sequence Analysis, DNA/standards
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Affiliation(s)
- Daniel Schmitz
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Daniel Kazdal
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Michael Allgäuer
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Marcus Trunk
- Institute of Pathology, SYNLAB GmbH Mannheim, Mannheim, Germany
| | - Sylke Vornhusen
- Institute of Pathology, SYNLAB GmbH Mannheim, Mannheim, Germany
| | - Anna-Maria Nahm
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Matthias Doll
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Simon Weingärtner
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Roland Penzel
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Martina Kirchner
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Regine Brandt
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Olaf Neumann
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Holger Sültmann
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan Budczies
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter Kienle
- Department of General and Visceral Surgery, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Mannheim, Germany
| | - Richard Magdeburg
- Department of General and Visceral Surgery, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Medical Statistics, Biomathematics and Information Processing of Mannheim University Hospital, University Hospital of Heidelberg, Mannheim, Germany
| | - Peter Schirmacher
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Jochen Rudi
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anna-Lena Volckmar
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
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Hisanaga E, Sano T, Yoshida Y, Ishii N, Shirabe K, Ikota H. A mucinous cystic neoplasm of the pancreas containing an undifferentiated carcinoma component and harboring the NRAS driver mutation. Clin J Gastroenterol 2021; 14:910-917. [PMID: 33710503 DOI: 10.1007/s12328-021-01380-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/26/2021] [Indexed: 11/25/2022]
Abstract
A woman in her 20s visited our hospital with a chief complaint of abdominal distension and back pain. She was diagnosed with a cystic tumor (diameter 16 cm) in the tail of the pancreas and underwent a combined distal pancreatectomy, splenectomy, and left adrenalectomy. Histopathologically, the tumor presented as a mucinous cystic neoplasm with an undifferentiated carcinoma component of the pancreas. In addition, the cells demonstrated a partial rhabdoid-like morphology. These findings were considered relatively typical for a mucinous cystic neoplasm in the tail of the pancreas in a young woman. However, NRAS mutation, which is rare in pancreatic tumors, was detected.
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Affiliation(s)
- Etsuko Hisanaga
- Clinical Department of Pathology, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Takaaki Sano
- Department of Diagnostic Pathology, Graduate School of Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Yuka Yoshida
- Clinical Department of Pathology, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Norihiro Ishii
- Clinical Department of Hepatobiliary and Pancreatic Surgery, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Clinical Department of Hepatobiliary and Pancreatic Surgery, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Hayato Ikota
- Clinical Department of Pathology, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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90
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Abudalou M, Vega EA, Dhingra R, Holzwanger E, Krishnan S, Kondratiev S, Niakosari A, Conrad C, Stallwood CG. Solid pseudopapillary neoplasm-diagnostic approach and post-surgical follow up: Three case reports and review of literature. World J Clin Cases 2021; 9:1682-1695. [PMID: 33728313 PMCID: PMC7942041 DOI: 10.12998/wjcc.v9.i7.1682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/23/2020] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Solid pseudopapillary neoplasm (SPN) is a rare tumor that was first described by Frantz in 1959. Although this tumor is benign, some may have malignant potential that can be predicted based on demographics, imaging characteristics, and pathologic evaluation. This case series presents 3 SPN cases with discussion on gender differences, preoperative predictors of malignancy, and a suggested algorithm for diagnostic approach as well as post-surgical follow up.
CASE SUMMARY Three adult patients in a tertiary hospital found to have SPN, one elderly male and two young females. Each of the cases presented with abdominal pain and were discovered incidentally. Two cases underwent endoscopic ultrasound with fine needle aspiration and biopsy to assess tumor markers and immuno-histochemical staining (which were consistent with SPN before undergoing surgery), and one case underwent surgery directly after imaging. The average tumor size was 5 cm. Diagnosis was confirmed by histology. Two patients had post-surgical complications requiring intervention.
CONCLUSION Demographic and imaging characteristics can be sufficient to establish diagnosis for SPN, while malignant cases require pre-operative evaluation with endoscopic ultrasound fine needle aspiration/fine needle biopsy.
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Affiliation(s)
- Mohammad Abudalou
- Department of Internal Medicine, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Eduardo A Vega
- Department of General Surgery, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Rohit Dhingra
- Department of Gastroenterology, Tufts Medical Center, Boston, MA 02111, United States
| | - Erik Holzwanger
- Department of Gastroenterology, Tufts Medical Center, Boston, MA 02111, United States
| | - Sandeep Krishnan
- Department of Gastroenterology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Svetlana Kondratiev
- Department of Pathology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Ali Niakosari
- Department of Radiology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Claudius Conrad
- Department of General Surgery, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Christopher G Stallwood
- Department of Gastroenterology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
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91
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Minimal main pancreatic duct dilatation in small branch duct intraductal papillary mucinous neoplasms associated with high-grade dysplasia or invasive carcinoma. HPB (Oxford) 2021; 23:468-474. [PMID: 32912834 DOI: 10.1016/j.hpb.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/06/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to determine the incidence of high-grade dysplasia (HGD) or invasive carcinoma in patients with small branch duct intraductal papillary mucinous neoplasms (BD-IPMNs). METHODS 923 patients who underwent surgical resection for an IPMN were identified. Sendai-negative patients were identified as those without history of pancreatitis or jaundice, main pancreatic duct size (MPD) <5 mm, cyst size <3 cm, no mural nodules, negative cyst fluid cytology for adenocarcinoma, or serum carbohydrate antigen 19-9 (CA 19-9) <37 U/L. RESULTS BD-IPMN was identified in 388 (46.4%) patients and 89 (22.9%) were categorized as Sendai-negative. Overall, 68 (17.5%) of BD-IPMN had HGD and 62 (16.0%) had an associated invasive-carcinoma. Among the 89 Sendai-negative patients, 12 (13.5%) had IPMNs with HGD and only one patient (1.1%) had invasive-carcinoma. Of note, older age (OR 1.13, 95% CI 1.03-1.23; P = 0.008) and minimal dilation of MPD (OR 11.3, 95% CI 2.40-53.65; P = 0.002) were associated with high-risk disease in Sendai-negative patients after multivariable risk adjustment. CONCLUSION The risk of harboring a high-risk disease remains low in small BD-IPMNs. However, Sendai-negative patients who are older than 65 years old and those with minimal dilation of MPD (3-5 mm) are at greater risk of high-risk lesions and should be given consideration to be included as a "worrisome feature" in a future guidelines update.
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92
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Yang KS, Ciprani D, O'Shea A, Liss AS, Yang R, Fletcher-Mercaldo S, Mino-Kenudson M, Fernández-Del Castillo C, Weissleder R. Extracellular Vesicle Analysis Allows for Identification of Invasive IPMN. Gastroenterology 2021; 160:1345-1358.e11. [PMID: 33301777 PMCID: PMC7956058 DOI: 10.1053/j.gastro.2020.11.046] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/21/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Advances in cross-sectional imaging have resulted in increased detection of intraductal papillary mucinous neoplasms (IPMNs), and their management remains controversial. At present, there is no reliable noninvasive method to distinguish between indolent and high risk IPMNs. We performed extracellular vesicle (EV) analysis to identify markers of malignancy in an attempt to better stratify these lesions. METHODS Using a novel ultrasensitive digital extracellular vesicle screening technique (DEST), we measured putative biomarkers of malignancy (MUC1, MUC2, MUC4, MUC5AC, MUC6, Das-1, STMN1, TSP1, TSP2, EGFR, EpCAM, GPC1, WNT-2, EphA2, S100A4, PSCA, MUC13, ZEB1, PLEC1, HOOK1, PTPN6, and FBN1) in EV from patient-derived cell lines and then on circulating EV obtained from peripheral blood drawn from patients with IPMNs. We enrolled a total of 133 patients in two separate cohorts: a clinical discovery cohort (n = 86) and a validation cohort (n = 47). RESULTS From 16 validated EV proteins in plasma samples collected from the discovery cohort, only MUC5AC showed significantly higher levels in high-grade lesions. Of the 11 patients with invasive IPMN (inv/HG), 9 had high MUC5AC expression in plasma EV of the 11 patients with high-grade dysplasia alone, only 1 had high MUC5AC expression (sensitivity of 82%, specificity of 100%). These findings were corroborated in a separate validation cohort. The addition of MUC5AC as a biomarker to imaging and high-riskstigmata allowed detection of all cases requiring surgery, whereas imaging and high-risk stigmata alone would have missed 5 of 14 cases (36%). CONCLUSIONS MUC5AC in circulating EV can predict the presence of invasive carcinoma within IPMN. This approach has the potential to improve the management and follow-up of patients with IPMN including avoiding unnecessary surgery.
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Affiliation(s)
- Katherine S Yang
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Debora Ciprani
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Aileen O'Shea
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert Yang
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ralph Weissleder
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Department of Systems Biology, Harvard Medical School, Boston, Massachusetts.
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93
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K-ras point mutation detection as an ancillary diagnostic biomarker: 1 step forward and 2 steps back? Gastrointest Endosc 2021; 93:605-607. [PMID: 33583519 DOI: 10.1016/j.gie.2020.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 01/18/2023]
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94
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Kenner B, Chari ST, Kelsen D, Klimstra DS, Pandol SJ, Rosenthal M, Rustgi AK, Taylor JA, Yala A, Abul-Husn N, Andersen DK, Bernstein D, Brunak S, Canto MI, Eldar YC, Fishman EK, Fleshman J, Go VLW, Holt JM, Field B, Goldberg A, Hoos W, Iacobuzio-Donahue C, Li D, Lidgard G, Maitra A, Matrisian LM, Poblete S, Rothschild L, Sander C, Schwartz LH, Shalit U, Srivastava S, Wolpin B. Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review. Pancreas 2021; 50:251-279. [PMID: 33835956 PMCID: PMC8041569 DOI: 10.1097/mpa.0000000000001762] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Despite considerable research efforts, pancreatic cancer is associated with a dire prognosis and a 5-year survival rate of only 10%. Early symptoms of the disease are mostly nonspecific. The premise of improved survival through early detection is that more individuals will benefit from potentially curative treatment. Artificial intelligence (AI) methodology has emerged as a successful tool for risk stratification and identification in general health care. In response to the maturity of AI, Kenner Family Research Fund conducted the 2020 AI and Early Detection of Pancreatic Cancer Virtual Summit (www.pdac-virtualsummit.org) in conjunction with the American Pancreatic Association, with a focus on the potential of AI to advance early detection efforts in this disease. This comprehensive presummit article was prepared based on information provided by each of the interdisciplinary participants on one of the 5 following topics: Progress, Problems, and Prospects for Early Detection; AI and Machine Learning; AI and Pancreatic Cancer-Current Efforts; Collaborative Opportunities; and Moving Forward-Reflections from Government, Industry, and Advocacy. The outcome from the robust Summit conversations, to be presented in a future white paper, indicate that significant progress must be the result of strategic collaboration among investigators and institutions from multidisciplinary backgrounds, supported by committed funders.
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Affiliation(s)
| | - Suresh T. Chari
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - David S. Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephen J. Pandol
- Basic and Translational Pancreas Research Program, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Anil K. Rustgi
- Division of Digestive and Liver Diseases, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | | | - Adam Yala
- Department of Electrical Engineering and Computer Science
- Jameel Clinic, Massachusetts Institute of Technology, Cambridge, MA
| | - Noura Abul-Husn
- Division of Genomic Medicine, Department of Medicine, Icahn School of Medicine, Mount Sinai, New York, NY
| | - Dana K. Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Marcia Irene Canto
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yonina C. Eldar
- Department of Math and Computer Science, Weizmann Institute of Science, Rehovot, Israel
| | - Elliot K. Fishman
- Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, MD
| | | | - Vay Liang W. Go
- UCLA Center for Excellence in Pancreatic Diseases, University of California, Los Angeles, Los Angeles, CA
| | | | - Bruce Field
- From the Kenner Family Research Fund, New York, NY
| | - Ann Goldberg
- From the Kenner Family Research Fund, New York, NY
| | | | - Christine Iacobuzio-Donahue
- David M. Rubenstein Center for Pancreatic Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debiao Li
- Biomedical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Anirban Maitra
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Lawrence H. Schwartz
- Department of Radiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Uri Shalit
- Faculty of Industrial Engineering and Management, Technion—Israel Institute of Technology, Haifa, Israel
| | - Sudhir Srivastava
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Brian Wolpin
- Gastrointestinal Cancer Center, Dana-Farber Cancer Institute, Boston, MA
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95
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Anz D, Seidensticker M, Mayerle J. [Management of Cystic Lesions of the Pancreas]. Dtsch Med Wochenschr 2021; 146:253-260. [PMID: 33592661 DOI: 10.1055/a-1221-7266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cystic pancreatic lesions are a frequent incidental finding on ultrasound or cross sectional imaging. The incidence of pancreatic lesions experience a steady climb in recent years due to an increased number of cross sectional imaging and an increasing life expectancy. The clinical challenge is to identify individuals bearing lesions with potentially malignant or pre-malignant features. Indeed, by far most cystic pancreatic lesions are not associated with an increased risk for the development of cancer. Taking into account the increasing incidence rates of cystic pancreatic lesions a rational and economic use of diagnostics is warranted. This review provides an overview on the different types of cystic lesions, the appropriate use of diagnostics and a clinical management algorithm balancing intervention and surveillance.
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96
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Herranz Pérez R, de la Morena López F, Majano Rodríguez PL, Molina Jiménez F, Vega Piris L, Santander Vaquero C. Molecular analysis of pancreatic cystic neoplasm in routine clinical practice. World J Gastrointest Endosc 2021; 13:56-71. [PMID: 33623640 PMCID: PMC7890406 DOI: 10.4253/wjge.v13.i2.56] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/22/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cystic pancreatic lesions consist of a wide variety of lesions that are becoming increasingly diagnosed with the growing use of imaging techniques. Of these, mucinous cysts are especially relevant due to their risk of malignancy. However, morphological findings are often suboptimal for their differentiation. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) with molecular analysis has been suggested to improve the diagnosis of pancreatic cysts.
AIM To determine the impact of molecular analysis on the detection of mucinous cysts and malignancy.
METHODS An 18-month prospective observational study of consecutive patients with pancreatic cystic lesions and an indication for EUS-FNA following European clinical practice guidelines was conducted. These cysts included those > 15 mm with unclear diagnosis, and a change in follow-up or with concerning features in which results might change clinical management. EUS-FNA with cytological, biochemical and glucose and molecular analyses with next-generation sequencing were performed in 36 pancreatic cysts. The cysts were classified as mucinous and non-mucinous by the combination of morphological, cytological and biochemical analyses when surgery was not performed. Malignancy was defined as cytology positive for malignancy, high-grade dysplasia or invasive carcinoma on surgical specimen, clinical or morphological progression, metastasis or death related to neoplastic complications during the 6-mo follow-up period. Next-generation sequencing results were compared for cyst type and malignancy.
RESULTS Of the 36 lesions included, 28 (82.4%) were classified as mucinous and 6 (17.6%) as non-mucinous. Furthermore, 5 (13.9%) lesions were classified as malignant. The amount of deoxyribonucleic acid obtained was sufficient for molecular analysis in 25 (69.4%) pancreatic cysts. The amount of intracystic deoxyribonucleic acid was not statistically related to the cyst fluid volume obtained from the lesions. Analysis of KRAS and/or GNAS showed 83.33% [95% confidence interval (CI): 63.34-100] sensitivity, 60% (95%CI: 7.06-100) specificity, 88.24% (95%CI: 69.98-100) positive predictive value and 50% (95%CI: 1.66-98.34) negative predictive value (P = 0.086) for the diagnosis of mucinous cystic lesions. Mutations in KRAS and GNAS were found in 2/5 (40%) of the lesions classified as non-mucinous, thus recategorizing those lesions as mucinous neoplasms, which would have led to a modification of the follow-up plan in 8% of the cysts in which molecular analysis was successfully performed. All 4 (100%) malignant cysts in which molecular analysis could be performed had mutations in KRAS and/or GNAS, although they were not related to malignancy (P > 0.05). None of the other mutations analyzed could detect mucinous or malignant cysts with statistical significance (P > 0.05).
CONCLUSION Molecular analysis can improve the classification of pancreatic cysts as mucinous or non-mucinous. Mutations were not able to detect malignant lesions.
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Affiliation(s)
- Raquel Herranz Pérez
- Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid 28006, Spain
| | - Felipe de la Morena López
- Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid 28006, Spain
| | - Pedro L Majano Rodríguez
- Molecular Biology Laboratory, Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid 28006, Spain
| | - Francisca Molina Jiménez
- Molecular Biology Laboratory, Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid 28006, Spain
| | - Lorena Vega Piris
- Methodological Support Unit, Department of Statistical Analysis, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, CP Madrid, Madrid 28006, Spain
| | - Cecilio Santander Vaquero
- Department of Gastroenterology and Hepatology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid 28006, Spain
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Kane LE, Mellotte GS, Conlon KC, Ryan BM, Maher SG. Multi-Omic Biomarkers as Potential Tools for the Characterisation of Pancreatic Cystic Lesions and Cancer: Innovative Patient Data Integration. Cancers (Basel) 2021; 13:769. [PMID: 33673153 PMCID: PMC7918773 DOI: 10.3390/cancers13040769] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cancer (PC) is regarded as one of the most lethal malignant diseases in the world, with GLOBOCAN 2020 estimates indicating that PC was responsible for almost half a million deaths worldwide in 2020. Pancreatic cystic lesions (PCLs) are fluid-filled structures found within or on the surface of the pancreas, which can either be pre-malignant or have no malignant potential. While some PCLs are found in symptomatic patients, nowadays many PCLs are found incidentally in patients undergoing cross-sectional imaging for other reasons-so called 'incidentalomas'. Current methods of characterising PCLs are imperfect and vary hugely between institutions and countries. As such, there is a profound need for improved diagnostic algorithms. This could facilitate more accurate risk stratification of those PCLs that have malignant potential and reduce unnecessary surveillance. As PC continues to have such a poor prognosis, earlier recognition and risk stratification of PCLs may lead to better treatment protocols. This review will focus on the importance of biomarkers in the context of PCLs and PCand outline how current 'omics'-related work could contribute to the identification of a novel integrated biomarker profile for the risk stratification of patients with PCLs and PC.
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Affiliation(s)
- Laura E. Kane
- Department of Surgery, Trinity St. James’s Cancer Institute, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin D08 W9RT, Ireland;
| | - Gregory S. Mellotte
- Department of Gastroenterology, Tallaght University Hospital, Dublin D24 NR0A, Ireland; (G.S.M.); (B.M.R.)
| | - Kevin C. Conlon
- Discipline of Surgery, School of Medicine, Trinity College Dublin, Dublin D02 PN40, Ireland;
| | - Barbara M. Ryan
- Department of Gastroenterology, Tallaght University Hospital, Dublin D24 NR0A, Ireland; (G.S.M.); (B.M.R.)
| | - Stephen G. Maher
- Department of Surgery, Trinity St. James’s Cancer Institute, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin D08 W9RT, Ireland;
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98
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Practical Applications of Molecular Testing in the Cytologic Diagnosis of Pancreatic Cysts. JOURNAL OF MOLECULAR PATHOLOGY 2021. [DOI: 10.3390/jmp2010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Mucinous pancreatic cysts are precursor lesions of ductal adenocarcinoma. Discoveries of the molecular alterations detectable in pancreatic cyst fluid (PCF) that help to define a mucinous cyst and its risk for malignancy have led to more routine molecular testing in the preoperative evaluation of these cysts. The differential diagnosis of pancreatic cysts is broad and ranges from non-neoplastic to premalignant to malignant cysts. Not all pancreatic cysts—including mucinous cysts—require surgical intervention, and it is the preoperative evaluation with imaging and PCF analysis that determines patient management. PCF analysis includes biochemical and molecular analysis, both of which are ancillary studies that add significant value to the final cytological diagnosis. While testing PCF for carcinoembryonic antigen (CEA) is a very specific test for a mucinous etiology, many mucinous cysts do not have an elevated CEA. In these cases, detection of a KRAS and/or GNAS mutation is highly specific for a mucinous etiology, with GNAS mutations supporting an intraductal papillary mucinous neoplasm. Late mutations in the progression to malignancy such as those found in TP53, p16/CDKN2A, and/or SMAD4 support a high-risk lesion. This review highlights PCF triage and analysis of pancreatic cysts for optimal cytological diagnosis.
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99
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Activation of the RAS pathway through uncommon BRAF mutations in mucinous pancreatic cysts without KRAS mutation. Mod Pathol 2021; 34:438-444. [PMID: 32792597 DOI: 10.1038/s41379-020-00647-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023]
Abstract
Diagnostic testing of pancreatic cyst fluid obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has traditionally utilized elevated carcinoembryonic antigen (CEA) (≥192 ng/ml) and cytomorphologic examination to differentiate premalignant mucinous from benign pancreatic cystic lesions (PCLs). Molecular testing for KRAS/GNAS mutations has been shown to improve accuracy of detecting mucinous PCLs. Using a targeted next-generation sequencing (NGS) panel, we assess the status of PCL-associated mutations to improve understanding of the key diagnostic variables. Molecular analysis of cyst fluid was performed on 108 PCLs that had concurrent CEA and/or cytological analysis. A 48-gene NGS assay was utilized, which included genes commonly mutated in mucinous PCLs such as GNAS, KRAS, CDKN2A, and TP53. KRAS and/or GNAS mutations were seen in 59 of 68 (86.8%) cases with multimodality diagnosis of a mucinous PCL. Among 31 patients where surgical histopathology was available, the sensitivity, specificity, and diagnostic accuracy of NGS for the diagnosis of mucinous PCL was 88.5%, 100%, and 90.3%, respectively. Cytology with mucinous/atypical findings were found in only 29 of 62 cases (46.8%), with fluid CEA elevated in 33 of 58 cases (56.9%). Multiple KRAS mutations at different variant allele frequencies were seen in seven cases favoring multiclonal patterns, with six of them showing at least two separate PCLs by imaging. Among the 6 of 10 cases with GNAS + /KRAS- results, uncommon, non-V600E exon 11/15 hotspot BRAF mutations were identified. The expected high degree of accuracy of NGS detection of KRAS and/or GNAS mutations for mucinous-PCLs, as compared with CEA and cytological examination, was demonstrated. Multiple KRAS mutations correlated with multifocal cysts demonstrated by radiology. In IPMNs that lacked KRAS mutations, the concurring BRAF mutations with GNAS mutations supports an alternate mechanism of activation in the Ras pathway.
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100
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Kim HS, Jang JY. Management Algorithms for Pancreatic Cystic Neoplasms: The Surgeon's Perspective. Arch Pathol Lab Med 2021; 146:322-329. [PMID: 33503225 DOI: 10.5858/arpa.2020-0395-ra] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The detection of pancreatic cystic neoplasms (PCNs) has increased owing to the advancement and widespread use of imaging modalities, resulting in differences between past and current management methods for PCNs, including intraductal papillary mucinous neoplasms (IPMNs). Therefore, clinicians should accurately diagnose and determine appropriate treatment strategies. However, previously published treatment guidelines for IPMNs present different indications for treatment. OBJECTIVE.— To review the current status of PCNs, including epidemiologic change, malignancy risk, and factors for treatment, and to provide the optimal management algorithms for PCNs, including IPMNs, from the clinician's point of view. DATA SOURCES.— Literature review of published studies and the authors' own work. CONCLUSIONS.— The treatment of PCNs relies on the type of cyst that is present or suspected. Serous cystic neoplasms are usually benign, and observation is sufficient. However, surgical treatment is required for mucinous cystic neoplasms, and malignancy risk differs according to lesion size. Solid pseudopapillary neoplasms also require surgery. The detection of small IPMNs has been increasing, and most branch duct-type IPMNs are dormant. However, cysts 3 cm or larger or growing branch duct-type IPMNs must be carefully monitored because of the increasing risk of malignancy. Therefore, surveillance strategies should be different according to the size of the lesions. A tailored approach is needed for selecting surgery or surveillance, considering the malignancy potential of the lesion and patient-associated factors such as operative risks and life expectancy. Nomograms are valuable tools for selecting treatment methods as a customized approach for IPMNs.
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Affiliation(s)
- Hyeong Seok Kim
- From the Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Young Jang
- From the Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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