151
|
Abdelkader A, Hunt B, Hartley CP, Panarelli NC, Giorgadze T. Cystic Lesions of the Pancreas: Differential Diagnosis and Cytologic-Histologic Correlation. Arch Pathol Lab Med 2019; 144:47-61. [PMID: 31538798 DOI: 10.5858/arpa.2019-0308-ra] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT.— Pancreatic cystic lesions (PCLs) are very common, and their detection is increasing with the advances in imaging techniques. Because of the major implications for management, distinguishing between neoplastic and nonneoplastic PCLs is critical. Neoplastic cysts with potential to progress into cancer include mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) and nonmucinous cysts (solid pseudopapillary tumors, serous cystic neoplasms, and neuroendocrine tumors with cystic degeneration). Nonneoplastic cysts with no risk of malignant transformation include pseudocysts, retention cysts, lymphoepithelial cysts, cystic pancreatic lymphangioma, and duplication cyst/ciliated foregut cysts. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology with cyst fluid analysis in the diagnosis of PCLs has evolved during the last decade; however, a definitive diagnosis on cytologic specimens is hampered by the sparse cellularity and can be challenging. EUS-FNA can play an important role to differentiate low-risk from high-risk pancreatic cysts and to distinguish between patients with cysts who need clinical follow-up versus those who require surgery. OBJECTIVE.— To provide an integrative approach to diagnose pancreatic cystic lesions using EUS-FNA cytology and cyst fluid analysis, along with clinical, radiologic, histologic, genetic, and molecular characteristics. DATA SOURCES.— The review and analysis of the latest literature describing pancreatic cystic lesions. CONCLUSIONS.— Accurate diagnosis of PCLs requires a multidisciplinary and multimodal team approach, including the integration of clinical findings, imaging, cytology, cyst fluid analysis, and molecular testing.
Collapse
Affiliation(s)
- Amrou Abdelkader
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Bryan Hunt
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Christopher P Hartley
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Nicole C Panarelli
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Tamara Giorgadze
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| |
Collapse
|
152
|
Pancreatic Cysts: Diagnostic Role of EUS-Guided Microforceps Biopsy and Confocal Laser Endomicroscopy. Gastroenterol Res Pract 2019; 2019:3431048. [PMID: 31611915 PMCID: PMC6757287 DOI: 10.1155/2019/3431048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/22/2019] [Accepted: 08/06/2019] [Indexed: 02/08/2023] Open
Abstract
Frequent use of high-quality cross-sectional imaging has led to a significant rise in diagnosis of pancreatic cystic lesions (PCLs). Despite the fact that enormous effort has been put into the research of PCLs within the last two decades and multiple guidelines have been developed, our clinical decision-making especially in regard to mucinous lesions remains limited. Currently, clinical assessment, cross-sectional imaging and EUS with fluid analysis (if appropriate) belong to the standard care in patients with PCLs. For differentiation of mucinous from nonmucinous cysts, the sensitivity of cytological investigation and CEA in the cyst fluid is 42% and 52-79%, respectively. Due to the limited accuracy, further diagnostic tools are warranted. Two EUS-guided approaches have been introduced recently. Through-the-(19-gauge EUS) needle Moray microforceps have been developed, and several studies have acknowledged their contribution to the correct diagnosis as they help to overcome limited cellularity of the EUS-guided cyst fluid aspiration and traditional cytology. Confocal laser endomicroscopy offers real-time images and seems to be a promising method for the diagnosis and differential diagnosis of pancreatic PCLs. Example images of the needle-based confocal laser endomicroscopy criteria for the diagnosis of PCLs have been suggested recently. Before both, Moray microforceps and confocal laser endomicroscopy can be widely accepted, further studies are necessary to determine the real diagnostic yield and the clinical efficacy.
Collapse
|
153
|
Jhala N, Srimunta P, Jhala D. Role of Ancillary Testing on Endoscopic US-Guided Fine Needle Aspiration Samples from Cystic Pancreatic Neoplasms. Acta Cytol 2019; 64:124-135. [PMID: 31509835 DOI: 10.1159/000502372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/22/2019] [Indexed: 12/11/2022]
Abstract
Pancreatic cysts are increasingly detected on imaging studies. Accurate determination of the cyst type is important to provide appropriate care for the patients. It is also very clear that not one single modality can provide adequate diagnostic information. A multidisciplinary approach is the key to the diagnosis of pancreatic cysts. In this setting, the role of ancillary testing, which includes biochemical testing (carcinoembryonic antigen and amylase levels in the cyst), molecular testing (e.g., KRAS, GNAS, VHL, and CTNB1), and/or immunohistochemical tests are very important to obtain an accurate diagnosis. This review will discuss helpful ancillary tests in common pancreatic cyst neoplasms and how to approach the diagnosis of pancreatic cysts.
Collapse
Affiliation(s)
- Nirag Jhala
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA,
| | - Piyachat Srimunta
- Visiting Fellow, Department of Pathology and Laboratory Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Darshana Jhala
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Pathology and Laboratory Services, CMC Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
| |
Collapse
|
154
|
Recurrent Mutations in APC and CTNNB1 and Activated Wnt/β-catenin Signaling in Intraductal Papillary Neoplasms of the Bile Duct: A Whole Exome Sequencing Study. Am J Surg Pathol 2019; 42:1674-1685. [PMID: 30212390 DOI: 10.1097/pas.0000000000001155] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This study aimed to elucidate the genetic landscape of biliary papillary neoplasms. Of 28 cases examined, 7 underwent whole exome sequencing, while the remaining 21 were used for validation studies with targeted sequencing. In the whole exome sequencing study, 4/7 cases had mutations in either APC or CTNNB1, both of which belong to the Wnt/β-catenin pathway. Somatic mutations were also identified in genes involved in RAS signaling (KRAS, BRAF), a cell cycle regulator (CDC27), histone methyltransferase (KMT2C, KMT2D), and DNA mismatch repair (MSH3, MSH6, PMS1). Combined with discovery and validation cohorts, mutations in APC or CTNNB1 were observed in 6/28 subjects (21%) and were mutually exclusive. When the cases were classified into intraductal papillary neoplasms of the bile duct (IPNBs, n=14) and papillary cholangiocarcinomas (n=14) based on the recently proposed classification criteria, mutations in APC and CTNNB1 appeared to be entirely restricted to IPNBs with 6/14 cases (43%) harboring mutations in either gene. These genetic alterations were detected across the 3 nonintestinal histologic types. In immunohistochemistry, the aberrant cytoplasmic and/or nuclear expression of β-catenin was found in not only 5/6 IPNBs with APC or CTNNB1 mutations, but also 6/8 cases with wild-type APC and CTNNB1 (total 79%). In addition, APC and CTNNB1 alterations were exceptional in nonpapillary cholangiocarcinomas (n=29) with a single case harboring CTNNB1 mutation (3%). This study demonstrated recurrent mutations in APC and CTNNB1 in nonintestinal-type IPNBs, suggesting that activation of the Wnt/β-catenin signaling pathway is relevant to the development and progression of IPNBs.
Collapse
|
155
|
Das KK, Geng X, Brown JW, Morales-Oyarvide V, Huynh T, Pergolini I, Pitman MB, Ferrone C, Al Efishat M, Haviland D, Thompson E, Wolfgang C, Lennon AM, Allen P, Lillemoe KD, Fields RC, Hawkins WG, Liu J, Castillo CFD, Das KM, Mino-Kenudson M. Cross Validation of the Monoclonal Antibody Das-1 in Identification of High-Risk Mucinous Pancreatic Cystic Lesions. Gastroenterology 2019; 157:720-730.e2. [PMID: 31175863 PMCID: PMC6707850 DOI: 10.1053/j.gastro.2019.05.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 04/29/2019] [Accepted: 05/13/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Although pancreatic cystic lesions (PCLs) are frequently and incidentally detected, it is a challenge to determine their risk of malignancy. In immunohistochemical and enzyme-linked immunosorbent assay (ELISA) analyses of tissue and cyst fluid from pancreatic intraductal papillary mucinous neoplasms, the monoclonal antibody Das-1 identifies those at risk for malignancy with high levels of specificity and sensitivity. We aimed to validate the ability of Das-1 to identify high-risk PCLs in comparison to clinical guidelines and clinical features, using samples from a multicenter cohort. METHODS We obtained cyst fluid samples of 169 PCLs (90 intraductal papillary mucinous neoplasms, 43 mucinous cystic neoplasms, and 36 non-mucinous cysts) from patients undergoing surgery at 4 tertiary referral centers (January 2010 through June 2017). Histology findings from surgical samples, analyzed independently and centrally re-reviewed in a blinded manner, were used as the reference standard. High-risk PCLs were those with invasive carcinomas, high-grade dysplasia, or intestinal-type intraductal papillary mucinous neoplasms with intermediate-grade dysplasia. An ELISA with Das-1 was performed in parallel using banked cyst fluid samples. We evaluated the biomarker's performance, generated area under the curve values, and conducted multivariate logistic regression using clinical and pathology features. RESULTS The ELISA for Das-1 identified high-risk PCLs with 88% sensitivity, 99% specificity, and 95% accuracy, at a cutoff optical density value of 0.104. In 10-fold cross-validation analysis with 100 replications, Das-1 identified high-risk PCLs with 88% sensitivity and 98% specificity. The Sendai, Fukuoka, and American Gastroenterological Association guideline criteria identified high-risk PCLs with 46%, 52%, and 74% accuracy (P for comparison to Das-1 ELISA <.001). When we controlled for Das-1 in multivariate regression, main pancreatic duct dilation >5 mm (odds ratio, 14.98; 95% confidence interval, 2.63-108; P < .0012), main pancreatic duct dilation ≥1 cm (odds ratio, 47.9; 95% confidence interval, 6.39-490; P < .0001), and jaundice (odds ratio, 6.16; 95% confidence interval, 1.08-36.7; P = .0397) were significantly associated with high-risk PCLs. CONCLUSIONS We validated the ability of an ELISA with the monoclonal antibody Das-1 to detect PCLs at risk for malignancy with high levels of sensitivity and specificity. This biomarker might be used in conjunction with clinical guidelines to identify patients at risk for malignancy.
Collapse
MESH Headings
- Adult
- Aged
- Antibodies/analysis
- Antibodies/immunology
- Antibodies, Monoclonal/immunology
- Antibody Specificity
- Biomarkers, Tumor/analysis
- Biomarkers, Tumor/immunology
- Enzyme-Linked Immunosorbent Assay
- Female
- Humans
- Male
- Middle Aged
- Neoplasms, Cystic, Mucinous, and Serous/chemistry
- Neoplasms, Cystic, Mucinous, and Serous/immunology
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreatic Cyst/chemistry
- Pancreatic Cyst/immunology
- Pancreatic Cyst/pathology
- Pancreatic Cyst/surgery
- Pancreatic Intraductal Neoplasms/chemistry
- Pancreatic Intraductal Neoplasms/immunology
- Pancreatic Intraductal Neoplasms/pathology
- Pancreatic Intraductal Neoplasms/surgery
- Pancreatic Neoplasms/chemistry
- Pancreatic Neoplasms/immunology
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Predictive Value of Tests
- Reproducibility of Results
- Risk Assessment
- United States
Collapse
Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Washington University, St Louis, Missouri.
| | - Xin Geng
- Division of Gastroenterology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jeffrey W Brown
- Division of Gastroenterology, Washington University, St Louis, Missouri
| | | | - Tiffany Huynh
- Deparment of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ilaria Pergolini
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Martha B Pitman
- Deparment of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohammad Al Efishat
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dana Haviland
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth Thompson
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Anne Marie Lennon
- Division of Gastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Peter Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan C Fields
- Department of Surgery, Washington University, St Louis, Missouri
| | | | - Jingxia Liu
- Department of Surgery, Washington University, St Louis, Missouri
| | | | - Kiron M Das
- Division of Gastroenterology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Mari Mino-Kenudson
- Deparment of Pathology, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
156
|
Mutational Patterns in Pancreatic Juice of Intraductal Papillary Mucinous Neoplasms and Concomitant Pancreatic Cancer. Pancreas 2019; 48:1032-1040. [PMID: 31404021 DOI: 10.1097/mpa.0000000000001371] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aims of this study were to identify genetic characteristics of intraductal papillary mucinous neoplasm (IPMN)-associated pancreatic ductal carcinoma (PDC) and to detect these markers using pancreatic juice. METHODS From 76 cases, 102 tissues were obtained: 29 cases were noninvasive IPMN, 18 were PDC derived from IPMN (D-PDC; noninvasive part, n = 16; invasive part, n = 18), and 29 were PDC concomitant with IPMN (C-PDC; IPMN part, n = 10; PDC part, n = 29). Moreover, pancreatic juice samples from 28 cases were obtained (noninvasive IPMN, n = 13; D-PDC, n = 7; C-PDC, n = 8). Fifty-one cancer-related genes were analyzed by next-generation sequencing. RESULTS TP53 mutation rates in D-PDC, C-PDC, and noninvasive IPMN were 67%, 66%, and 10%, respectively. Moreover, KRAS mutational patterns between 2 simultaneous tumors differed in 1 (6.3%) of the 16 D-PDC cases and in 8 (80%) of the 10 C-PDC cases (P = 0.0006). TP53 or multiple KRAS mutations were detected using pancreatic juice more frequently in C-PDC cases than in noninvasive IPMN cases (75% and 23%, respectively, P = 0.03). CONCLUSIONS Multiple KRAS mutations along with TP53 mutation are genetic markers for C-PDC, which could be detected using pancreatic juice preoperatively.
Collapse
|
157
|
Abstract
PURPOSE OF REVIEW Pancreatic cystic lesions (PCLs) are increasingly identified on abdominal imaging. Given the malignant potential of certain cyst subtypes and the poor survival rates of pancreatic cancer, accurate diagnosis and appropriate management of these cysts are critical. RECENT FINDINGS Advances in endoscopic ultrasound (EUS)-guided diagnostics have increased the accuracy of differentiating PCLs. These include cyst fluid molecular analysis, EUS-guided needle-based confocal laser endomicroscopy, and EUS-guided through the needle microforceps biopsy. This review encapsulates recent advances in the endoscopic management of PCLs with a specific focus on EUS-guided diagnosis. SUMMARY It is important to accurately diagnose pancreatic cystic lesions with malignant potential where the definitive management is surgical resection. Misdiagnosis can result in inadvertent surgery of an otherwise benign lesion or malignant progression of a precancerous cyst. Moreover, pancreatic surgery is associated with significant morbidity and mortality. Recent advances in EUS-guided tissue acquisition, imaging, and molecular biomarkers have resulted in improved diagnostic accuracy of pancreatic cystic lesions. Future studies need to define efficient and accurate diagnostic algorithms for improved management of pancreatic cysts.
Collapse
|
158
|
Novel Methylated DNA Markers Discriminate Advanced Neoplasia in Pancreatic Cysts: Marker Discovery, Tissue Validation, and Cyst Fluid Testing. Am J Gastroenterol 2019; 114:1539-1549. [PMID: 31306149 PMCID: PMC7294458 DOI: 10.14309/ajg.0000000000000284] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatic cystic lesions (PCLs) may be precancerous. Those likely to harbor high-grade dysplasia (HGD) or pancreatic cancer (PC) are targets for surgical resection. Current algorithms to predict advanced neoplasia (HGD/PC) in PCLs lack diagnostic accuracy. In pancreatic tissue and cyst fluid (CF) from PCLs, we sought to identify and validate novel methylated DNA markers (MDMs) that discriminate HGD/PC from low-grade dysplasia (LGD) or no dysplasia (ND). METHODS From an unbiased whole-methylome discovery approach using predefined selection criteria followed by multistep validation on case (HGD or PC) and control (ND or LGD) tissues, we identified discriminant MDMs. Top candidate MDMs were then assayed by quantitative methylation-specific polymerase chain reaction on archival CF from surgically resected PCLs. RESULTS Of 25 discriminant MDMs identified in tissue, 13 were selected for validation in 134 CF samples (21 cases [8 HGD, 13 PC], 113 controls [45 ND, 68 LGD]). A tree-based algorithm using 2 CF-MDMs (TBX15, BMP3) achieved sensitivity and specificity above 90%. Discrimination was significantly better by this CF-MDM panel than by mutant KRAS or carcinoembryonic antigen, with areas under the receiver operating characteristic curve of 0.93 (95% confidence interval: 0.86-0.99), 0.71 (0.57-0.85), and 0.72 (0.60-0.84), respectively. Cutoffs for the MDM panel applied to an independent CF validation set (31 cases, 56 controls) yielded similarly high discrimination, areas under the receiver operating characteristic curve = 0.86 (95% confidence interval: 0.77-0.94, P = 0.2). DISCUSSION Novel MDMs discovered and validated in tissue accurately identify PCLs harboring HGD/PC. A panel of 2 MDMs assayed in CF yielded results with potential to enhance current risk prediction algorithms. Prospective studies are indicated to optimize and further evaluate CF-MDMs for clinical use.
Collapse
|
159
|
Impact of needle-based confocal laser endomicroscopy on the therapeutic management of single pancreatic cystic lesions. Surg Endosc 2019; 34:2532-2540. [PMID: 31410626 PMCID: PMC7214514 DOI: 10.1007/s00464-019-07062-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/05/2019] [Indexed: 12/14/2022]
Abstract
Background and aim The diagnosis and therapeutic management of large single pancreatic cystic lesions (PCLs) represent major issues for clinicians and essentially rely on endoscopic ultrasound fine-needle aspiration (EUS-FNA) findings. Needle-based confocal laser endomicroscopy (nCLE) has high diagnostic performance for PCLs. This study aimed to evaluate the impact of nCLE on the therapeutic management of patients with single PCLs. Methods Retrospective and comparative study. Five independent pancreatic disease experts from tertiary hospitals independently reviewed data from a prospective database of 206 patients with single PCL, larger than 2 cm and who underwent EUS-FNA and nCLE. Two evaluations were performed. The first one included the sequential review of clinical information, EUS report and FNA results. The second one included the same data + nCLE report. Participants had to propose a therapeutic management for each case. Results The addition of nCLE to EUS-FNA led to significant changes in therapeutic management for 28% of the patients (p < 0.001). nCLE significantly increased the interobserver agreement of 0.28 (p < 0.0001), from 0.36 (CI 95% 0.33–0.49) to 0.64 (CI 95% 0.61–0.67). nCLE improved the rates of full agreement among the five experts of 24% (p < 0.0001), from 30 to 54%. With nCLE, the surveillance rate of benign SCAs fell by 35%, from 40 (28/70) to 5% (4/76). Conclusion The addition of nCLE to EUS-FNA significantly improves reliability of PCL diagnosis and could impact the therapeutic management of patients with single PCLs. ClinicalTrials.gov number, NCT01563133. Electronic supplementary material The online version of this article (10.1007/s00464-019-07062-9) contains supplementary material, which is available to authorized users.
Collapse
|
160
|
New Era of Endoscopic Ultrasound-Guided Tissue Acquisition: Next-Generation Sequencing by Endoscopic Ultrasound-Guided Sampling for Pancreatic Cancer. J Clin Med 2019; 8:jcm8081173. [PMID: 31387310 PMCID: PMC6723875 DOI: 10.3390/jcm8081173] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/20/2019] [Accepted: 08/02/2019] [Indexed: 12/14/2022] Open
Abstract
Pancreatic cancer is a lethal cancer with an increasing incidence. Despite improvements in chemotherapy, patients with pancreatic cancer continue to face poor prognoses. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is the primary method for obtaining tissue samples of pancreatic cancer. Due to advancements in next-generation sequencing (NGS) technologies, multiple parallel sequencing can be applied to EUS-TA samples. Genomic biomarkers for therapeutic stratification in pancreatic cancer are still lacking, however, NGS can unveil potential predictive genomic biomarkers of treatment response. Thus, the importance of NGS using EUS-TA samples is becoming recognized. In this review, we discuss the recent advances in EUS-TA application for NGS of pancreatic cancer.
Collapse
|
161
|
Gaiser RA, Pessia A, Ateeb Z, Davanian H, Fernández Moro C, Alkharaan H, Healy K, Ghazi S, Arnelo U, Valente R, Velagapudi V, Sällberg Chen M, Del Chiaro M. Integrated targeted metabolomic and lipidomic analysis: A novel approach to classifying early cystic precursors to invasive pancreatic cancer. Sci Rep 2019; 9:10208. [PMID: 31308419 PMCID: PMC6629680 DOI: 10.1038/s41598-019-46634-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 06/03/2019] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic neoplasms (PCNs) are a highly prevalent disease of the pancreas. Among PCNs, Intraductal Papillary Mucinous Neoplasms (IPMNs) are common lesions that may progress from low-grade dysplasia (LGD) through high-grade dysplasia (HGD) to invasive cancer. Accurate discrimination of IPMN-associated neoplastic grade is an unmet clinical need. Targeted (semi)quantitative analysis of 100 metabolites and >1000 lipid species were performed on peri-operative pancreatic cyst fluid and pre-operative plasma from IPMN and serous cystic neoplasm (SCN) patients in a pancreas resection cohort (n = 35). Profiles were correlated against histological diagnosis and clinical parameters after correction for confounding factors. Integrated data modeling was used for group classification and selection of the best explanatory molecules. Over 1000 different compounds were identified in plasma and cyst fluid. IPMN profiles showed significant lipid pathway alterations compared to SCN. Integrated data modeling discriminated between IPMN and SCN with 100% accuracy and distinguished IPMN LGD or IPMN HGD and invasive cancer with up to 90.06% accuracy. Free fatty acids, ceramides, and triacylglycerol classes in plasma correlated with circulating levels of CA19-9, albumin and bilirubin. Integrated metabolomic and lipidomic analysis of plasma or cyst fluid can improve discrimination of IPMN from SCN and within PMNs predict the grade of dysplasia.
Collapse
Affiliation(s)
- Rogier Aäron Gaiser
- Division of Clinical Diagnostics and Surgery, DENTMED, Karolinska Institutet, Huddinge, Sweden
| | - Alberto Pessia
- Metabolomics Unit, Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, Finland
| | - Zeeshan Ateeb
- Division of Surgery, CLINTEC, Karolinska University Hospital, Stockholm, Sweden
| | - Haleh Davanian
- Division of Clinical Diagnostics and Surgery, DENTMED, Karolinska Institutet, Huddinge, Sweden
| | - Carlos Fernández Moro
- Department of Clinical Pathology/Cytology, Division of Pathology, Karolinska University Hospital, Huddinge, Sweden
- Division of Pathology, LABMED, Karolinska Institutet, Huddinge, Sweden
| | - Hassan Alkharaan
- Division of Clinical Diagnostics and Surgery, DENTMED, Karolinska Institutet, Huddinge, Sweden
- College of Dentistry, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Katie Healy
- Division of Clinical Diagnostics and Surgery, DENTMED, Karolinska Institutet, Huddinge, Sweden
| | - Sam Ghazi
- Department of Clinical Pathology/Cytology, Division of Pathology, Karolinska University Hospital, Huddinge, Sweden
| | - Urban Arnelo
- Division of Surgery, CLINTEC, Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Valente
- Division of Surgery, CLINTEC, Karolinska University Hospital, Stockholm, Sweden
- Department for Digestive Diseases, Sapienza University of Rome, Rome, Italy
| | - Vidya Velagapudi
- Metabolomics Unit, Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, Finland
| | - Margaret Sällberg Chen
- Division of Clinical Diagnostics and Surgery, DENTMED, Karolinska Institutet, Huddinge, Sweden.
- Tenth People's Hospital, Tongji University, Shanghai, China.
| | - Marco Del Chiaro
- Division of Surgery, CLINTEC, Karolinska University Hospital, Stockholm, Sweden.
- Division of Surgical Oncology, Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| |
Collapse
|
162
|
Faias S, Pereira L, Luís Â, Chaves P, Cravo M. Genetic testing vs microforceps biopsy in pancreatic cysts: Systematic review and meta-analysis. World J Gastroenterol 2019; 25:3450-3467. [PMID: 31341368 PMCID: PMC6639554 DOI: 10.3748/wjg.v25.i26.3450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/17/2019] [Accepted: 05/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Carcinoembryonic antigen (CEA) and cytology in pancreatic cystic fluid are suboptimal for evaluation of pancreatic cystic neoplasms. Genetic testing and microforceps biopsy are promising tools for pre-operative diagnostic improvement but comparative performance of both methods is unknown.
AIM To compare the accuracy of genetic testing and microforceps biopsy in pancreatic cysts referred for surgery.
METHODS We performed a literature search in Medline, Scopus, and Web of Science for studies evaluating genetic testing of cystic fluid and microforceps biopsy of pancreatic cysts, with endoscopic ultrasound with fine-needle aspiration (EUS-FNA) prior to surgery and surgical pathology as reference standard for diagnosis. We evaluated the diagnostic accuracy for: 1- benign cysts; 2- mucinous low-risk cysts; 3- high-risk cysts, and the diagnostic yield and rate of correctly identified cysts with microforceps biopsy and molecular analysis. We also assessed publication bias, heterogeneity, and study quality.
RESULTS Eight studies, including 1206 patients, of which 203 (17%) referred for surgery who met the inclusion criteria were analyzed in the systematic review, and seven studies were included in the meta-analysis. Genetic testing and microforceps biopsies were identical for diagnosis of benign cysts. Molecular analysis was superior for diagnosis of both low and high-risk mucinous cysts, with sensitivities of 0.89 (95%CI: 0.79-0.95) and 0.57 (95%CI: 0.42-0.71), specificities of 0.88 (95%CI: 0.75-0.95) and 0.88 (95%CI: 0.80-0.93) and AUC of 0.9555 and 0.92, respectively. The diagnostic yield was higher in microforceps biopsies than in genetic analysis (0.73 vs 0.54, respectively) but the rates of correctly identified cysts were identical (0.73 with 95%CI: 0.62-0.82 vs 0.71 with 95%CI: 0.49-0.86, respectively).
CONCLUSION Genetic testing and microforceps biopsies are useful second tests, with identical results in benign pancreatic cysts. Genetic analysis performs better for low- and high-risk cysts but has lower diagnostic yield.
Collapse
Affiliation(s)
- Sandra Faias
- Department of Gastroenterology, Instituto Português de Oncologia de Lisboa de Francisco Gentil, EPE, Lisboa 1099-023, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- GRUBI-Grupo de Revisões Sistemáticas, Universidade da Beira Interior, Covilhã 6200-506, Portugal
| | - Luisa Pereira
- GRUBI-Grupo de Revisões Sistemáticas, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- Centro de Matemática e Aplicações (CMA-UBI), Universidade da Beira Interior, Covilhã 6200-506, Portugal
| | - Ângelo Luís
- GRUBI-Grupo de Revisões Sistemáticas, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- Centro de Investigação em Ciências da Saúde (CICS-UBI), Universidade da Beira Interior, Covilhã 6200-506, Portugal
| | - Paula Chaves
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã 6200-506, Portugal
- Department of Pathology, Instituto Português de Oncologia de Lisboa de Francisco Gentil, EPE, Lisboa 1099-023, Portugal
| | - Marília Cravo
- Department of Gastroenterology, Hospital Beatriz Ângelo, Loures 2674-514, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisboa 1099-023, Portugal
| |
Collapse
|
163
|
Roy-Chowdhuri S, Pisapia P, Salto-Tellez M, Savic S, Nacchio M, de Biase D, Tallini G, Troncone G, Schmitt F. Invited review-next-generation sequencing: a modern tool in cytopathology. Virchows Arch 2019; 475:3-11. [PMID: 30877381 DOI: 10.1007/s00428-019-02559-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 02/05/2023]
Abstract
In recent years, cytopathology has established itself as an independent diagnostic modality to guide clinical management in many different settings. The application of molecular techniques to cytological samples to identify prognostic and predictive biomarkers has played a crucial role in achieving this goal. While earlier studies have demonstrated that single biomarker testing is feasible on cytological samples, currently, this provides only limited and increasingly insufficient information in an era where an increasing number of biomarkers are required to guide patient care. More recently, multigene mutational assays, such as next-generation sequencing (NGS), have gained popularity because of their ability to provide genomic information on multiple genes. The cytopathologist plays a key role in ensuring success of NGS in cytological samples by influencing the pre-analytical steps, optimizing preparation types and adequacy requirement in terms of cellularity and tumor fraction, and ensuring optimal nucleic acid extraction for DNA input requirements. General principles of the role and potential of NGS in molecular cytopathology in the universal healthcare (UHC) European environment and examples of principal clinical applications were discussed in the workshop that took place at the 30th European Congress of Pathology in Bilbao, European Society of Pathology, whose content is here comprehensively described.
Collapse
Affiliation(s)
- Sinchita Roy-Chowdhuri
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pasquale Pisapia
- Department of Public Health, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Manuel Salto-Tellez
- Northern Ireland Molecular Pathology Laboratory, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Spasenija Savic
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
| | - Mariantonia Nacchio
- Department of Public Health, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Dario de Biase
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Giovanni Tallini
- Anatomic Pathology, University of Bologna Medical Center, Bologna, Italy
| | - Giancarlo Troncone
- Department of Public Health, University of Naples Federico II, Via Sergio Pansini 5, 80131, Naples, Italy.
| | - Fernando Schmitt
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Department of Pathology, Medical Faculty of Porto University, Porto, Portugal
| |
Collapse
|
164
|
KRAS in Cyst Fluid Obtained by Endoscopic Ultrasound-Fine-Needle Aspiration in Pancreatic Cystic Lesions: A Systematic Review and Meta-analysis. Pancreas 2019; 48:749-758. [PMID: 31206466 DOI: 10.1097/mpa.0000000000001325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
To evaluate the diagnostic accuracy of KRAS mutation in pancreatic cystic fluid and compare it with carcinoembryonic antigen and cytology, we identified studies with cyst fluid obtained by endoscopic ultrasound prior to surgery. We classified cysts as malignant, premalignant, and benign. A random-effects model was used for quantitative meta-analysis. Pooled sensitivities, specificities, and summary receiver operating characteristic curve analysis were conducted. We analyzed 16 studies, with 3429 patients, including 731 referred for surgery. Carcinoembryonic antigen was better for clinically significant cysts (premalignant and malignant) with sensitivity = 0.58 (95% confidence interval [CI], 0.53-0.65), specificity = 0.9 (95% CI, 0.76-0.97), and area under the curve (AUC) = 0.69. Cytology performed better in malignant cysts, with sensitivity = 0.37 (95% CI, 0.27-0.48), specificity = 0.96 (95% CI, 0.93-0.98), and AUC = 0.78. Isolated, KRAS mutation failed the diagnosis of malignant and significant cysts, with sensitivities = 0.43 (95% CI, 0.34-0.43) and 0.46 (95% CI, 0.42-0.51), specificities = 0.62 (95% CI, 0.56-0.68) and 0.97 (95% CI, 0.92-0.99), and AUCs = 0.56 and 0.53, respectively. Carcinoembryonic antigen and cytology are more accurate than KRAS. Additional studies are lacking to recommend KRAS as a single diagnostic test.
Collapse
|
165
|
Yang D, Trindade AJ, Yachimski P, Benias P, Nieto J, Manvar A, Ho S, Esnakula A, Gamboa A, Sethi A, Gupte A, Khara HS, Diehl DL, El Chafic A, Shah J, Forsmark CE, Draganov PV. Histologic Analysis of Endoscopic Ultrasound-Guided Through the Needle Microforceps Biopsies Accurately Identifies Mucinous Pancreas Cysts. Clin Gastroenterol Hepatol 2019; 17:1587-1596. [PMID: 30471456 DOI: 10.1016/j.cgh.2018.11.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/01/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is a challenge to accurately assess pancreatic cystic lesions (PCLs) and determine their risk. We compared the yield of tissue acquired with endoscopic ultrasound (EUS)-guided microforceps (through the needle tissue biopsy [TTNB]) with that of samples collected by EUS-guided fine-needle-aspiration (EUS-FNA), and the accuracy of analyses of each sample type in the diagnosis of mucinous PCLs. METHODS We performed a prospective open-label study of 114 consecutive adults (56.1% women; mean age, 64.2 y) undergoing EUS-FNA evaluation of PCLs (mean size, 35 mm) at 7 centers, from June 20, 2016, through August 31, 2018. Samples were collected from each cyst by FNA and microforceps; samples collected by FNA were analyzed by cytology and samples collected by TTNB were analyzed by histology. Acquisition yield was defined as the percentage of specimens collected that were adequate for cytologic or histologic analysis. Diagnoses of mucinous cysts were made based on identification of pancreatic mucinous epithelium by cytology analysis of FNA samples or histologic analysis of TTNB samples. Surgical specimens were used as the reference standard when available. RESULTS The EUS-guided microforceps were successfully inserted into 97.4% (111 of 114) of PCLs. Tissue acquisition yield was significantly higher with TTNB (95 of 114; 83.3%) than FNA (43 of 114; 37.7%) (P < .001). Sixty-one PCLs were determined to be mucinous based on TTNB analysis (53.5%) vs 11 with FNA analysis (9.6%) (P < .001). Among PCLs categorized as equivocal, based on the level of carcinoembryonic antigen, TTNB analysis found 50% (41 of 82) to be mucinous and FNA analysis found 8.5% (7 of 82) to be mucinous (P < .001). Findings from analyses of samples collected by TTNB were 100% concordant with findings from histologic analysis of surgical specimens (14 of 14), whereas only 3 of 14 findings from analysis of samples collected by FNA were in agreement with findings from surgical specimens (21.4%) (P < .001). Four of 5 mucinous PCLs with advanced neoplasia (80%) were detected with TTNB compared with none with FNA (P = .04). Self-limited intracystic bleeding occurred in 7 patients (6.1%), and acute pancreatitis in 6 patients (5.3%). CONCLUSIONS In a multicenter prospective study of patients undergoing EUS-FNA for evaluation of PCLs, we found TTNB collection of tissues for histologic analysis to be safe and feasible, with an acquisition yield of 83.3%. Histologic analysis of samples collected by TTNB identified a larger proportion of mucinous PCLs compared with cytologic analysis of samples collected by FNA-even among samples categorized as equivocal, based on the level of carcinoembryonic antigen. More samples collected by TTNB than FNA were found to have advanced neoplasia. Clinicaltrials.gov no: NCT02979509.
Collapse
Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida.
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Petros Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York
| | - Jose Nieto
- Borland-Groover Clinic, Jacksonville, Florida
| | - Amar Manvar
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sammy Ho
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ashwini Esnakula
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Anthony Gamboa
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University, Medical Center-New York Presbyterian Hospital, New York, New York
| | - Anand Gupte
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Harshit S Khara
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania
| | - David L Diehl
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania
| | - Abdul El Chafic
- Division of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, Louisiana
| | - Janak Shah
- Division of Gastroenterology and Hepatology, Ochsner Medical Center, New Orleans, Louisiana
| | - Christopher E Forsmark
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| |
Collapse
|
166
|
Ivry SL, Knudsen GM, Caiazza F, Sharib JM, Jaradeh K, Ravalin M, O’Donoghue AJ, Kirkwood KS, Craik CS. The lysosomal aminopeptidase tripeptidyl peptidase 1 displays increased activity in malignant pancreatic cysts. Biol Chem 2019; 400:1629-1638. [DOI: 10.1515/hsz-2019-0103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/27/2019] [Indexed: 12/15/2022]
Abstract
Abstract
Incidental detection of pancreatic cysts has increased dramatically over the last decade, but risk stratification and clinical management remain a challenge. Mucinous cysts are precursor lesions to pancreatic cancer, however, the majority are indolent. Current diagnostics cannot identify mucinous cysts that harbor cancer or reliably differentiate these lesions from nonmucinous cysts, which present minimal risk of malignant progression. We previously determined that activity of two aspartyl proteases was increased in mucinous cysts. Using a global protease activity profiling technology, termed multiplex substrate profiling by mass spectrometry (MSP-MS), we now show that aminopeptidase activity is also elevated in mucinous cysts. The serine aminopeptidase, tripeptidyl peptidase 1 (TPP1), was detected by proteomic analysis of cyst fluid samples and quantitation using targeted MS demonstrated that this protease was significantly more abundant in mucinous cysts. In a cohort of 110 cyst fluid samples, TPP1 activity was increased more than 3-fold in mucinous cysts relative to nonmucinous cysts. Moreover, TPP1 activity is primarily associated with mucinous cysts that harbor high-grade dysplasia or invasive carcinoma. Although only 59% accurate for differentiating these lesions, measurement of TPP1 activity may improve early detection and treatment of high-risk pancreatic cysts when used in conjunction with other promising biomarkers.
Collapse
Affiliation(s)
- Sam L. Ivry
- Department of Pharmaceutical Chemistry , University of California , San Francisco, 600 16th Street , San Francisco, CA 94143 , USA
- Pharmaceutical Sciences and Pharmacogenomics Graduate Program , University of California , San Francisco, San Francisco, CA , USA
| | - Giselle M. Knudsen
- Department of Pharmaceutical Chemistry , University of California , San Francisco, 600 16th Street , San Francisco, CA 94143 , USA
| | - Francesco Caiazza
- Department of Pharmaceutical Chemistry , University of California , San Francisco, 600 16th Street , San Francisco, CA 94143 , USA
| | - Jeremy M. Sharib
- Department of Surgery , University of California , San Francisco, San Francisco, CA , USA
| | - Katrin Jaradeh
- Department of Surgery , University of California , San Francisco, San Francisco, CA , USA
| | - Matthew Ravalin
- Department of Pharmaceutical Chemistry , University of California , San Francisco, 600 16th Street , San Francisco, CA 94143 , USA
| | - Anthony J. O’Donoghue
- Skaggs School of Pharmacy and Pharmaceutical Chemistry , University of California , San Diego, La Jolla, CA , USA
| | - Kimberly S. Kirkwood
- Department of Surgery , University of California , San Francisco, San Francisco, CA , USA
| | - Charles S. Craik
- Department of Pharmaceutical Chemistry , University of California , San Francisco, 600 16th Street , San Francisco, CA 94143 , USA
| |
Collapse
|
167
|
Sakhdari A, Moghaddam PA, Ok CY, Walter O, Tomaszewicz K, Caporelli ML, Meng X, LaFemina J, Whalen G, Belkin E, Zivny J, Wassef W, Woda BA, Hutchinson LM, Cosar EF. Somatic molecular analysis augments cytologic evaluation of pancreatic cyst fluids as a diagnostic tool. Oncotarget 2019; 10:4026-4037. [PMID: 31258847 PMCID: PMC6592293 DOI: 10.18632/oncotarget.26999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Objective: Better tools are needed for early diagnosis and classification of pancreatic cystic lesions (PCL) to trigger intervention before neoplastic precursor lesions progress to adenocarcinoma. We evaluated the capacity of molecular analysis to improve the accuracy of cytologic diagnosis for PCL with an emphasis on non-diagnostic/negative specimens. Design: In a span of 7 years, at a tertiary care hospital, 318 PCL endoscopic ultrasound-guided fine needle aspirations (EUS-FNA) were evaluated by cytologic examination and molecular analysis. Mucinous PCL were identified based on a clinical algorithm and 46 surgical resections were used to verify this approach. The mutation allele frequency (MAF) of commonly altered genes (BRAF, CDKN2A, CTNNB1, GNAS, RAS, PIK3CA, PTEN, SMAD4, TP53 and VHL) was evaluated for their ability to identify and grade mucinous PCL. Results: Cytology showed a diagnostic sensitivity of 43.5% for mucinous PCL due in part to the impact of non-diagnostic (28.8%) and negative (50.5%) specimens. Incorporating an algorithmic approach or molecular analysis markedly increased the accuracy of cytologic evaluation. Detection of mucinous PCL by molecular analysis was 93.3% based on the detection of KRAS and/or GNAS gene mutations (p = 0.0001). Additional genes provided a marginal improvement in sensitivity but were associated with cyst type (e.g. VHL) and grade (e.g. SMAD4). In the surgical cohort, molecular analysis and the proposed algorithm showed comparable sensitivity (88.9% vs. 100%). Conclusions: Incorporating somatic molecular analysis in the cytologic evaluation of EUS-FNA increases diagnostic accuracy for detection, classification and grading of PCL. This approach has the potential to improve patient management.
Collapse
Affiliation(s)
- Ali Sakhdari
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
- MD Anderson Cancer Center, Department of Hematopathology, Houston, TX, USA
| | - Parnian Ahmadi Moghaddam
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
- Massachusetts General Hospital, Department of Pathology, Boston, MA, USA
- University of Texas, Health Science Center, Department of Pathology, Houston, TX, USA
| | - Chi Young Ok
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
- MD Anderson Cancer Center, Department of Hematopathology, Houston, TX, USA
| | - Otto Walter
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Keith Tomaszewicz
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Mandi-Lee Caporelli
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Xiuling Meng
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Jennifer LaFemina
- University of Massachusetts Medical School, Department of Surgery, Worcester, MA, USA
| | - Giles Whalen
- University of Massachusetts Medical School, Department of Surgery, Worcester, MA, USA
| | - Edward Belkin
- University of Massachusetts Medical School, Department of Medicine, Worcester, MA, USA
| | - Jaroslav Zivny
- University of Massachusetts Medical School, Department of Medicine, Worcester, MA, USA
| | - Wahid Wassef
- University of Massachusetts Medical School, Department of Medicine, Worcester, MA, USA
| | - Bruce A. Woda
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Lloyd M. Hutchinson
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Ediz F. Cosar
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| |
Collapse
|
168
|
Durkin C, Krishna SG. Advanced diagnostics for pancreatic cysts: Confocal endomicroscopy and molecular analysis. World J Gastroenterol 2019; 25:2734-2742. [PMID: 31235996 PMCID: PMC6580353 DOI: 10.3748/wjg.v25.i22.2734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/29/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
Technological advances and the widespread use of medical imaging have led to an increase in the identification of pancreatic cysts in patients who undergo cross-sectional imaging. Current methods for the diagnosis and risk-stratification of pancreatic cysts are suboptimal, resulting in both unnecessary surgical resection and overlooked cases of neoplasia. Accurate diagnosis is crucial for guiding how a pancreatic cyst is managed, whether with surveillance for low-risk lesions or surgical resection for high-risk lesions. This review aims to summarize the current literature on confocal endomicroscopy and cyst fluid molecular analysis for the evaluation of pancreatic cysts. These recent technologies are promising adjuncts to existing approaches with the potential to improve diagnostic accuracy and ultimately patient outcomes.
Collapse
Affiliation(s)
- Claire Durkin
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University College of Medicine, Columbus, OH 43210, United States
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University College of Medicine, Columbus, OH 43210, United States
| |
Collapse
|
169
|
Lopes CV. Cyst fluid glucose: An alternative to carcinoembryonic antigen for pancreatic mucinous cysts. World J Gastroenterol 2019; 25:2271-2278. [PMID: 31148899 PMCID: PMC6529890 DOI: 10.3748/wjg.v25.i19.2271] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/30/2019] [Accepted: 04/20/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cystic lesions (PCLs) have been increasingly recognized in clinical practice. Although inflammatory cysts (pseudocysts) are the most common PCLs detected by cross-sectional imaging modalities in symptomatic patients in a setting of acute or chronic pancreatitis, incidental pancreatic cysts with no symptoms or history of pancreatitis are usually neoplastic cysts. For these lesions, it is imperative to identify mucinous cysts (intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) due to the risk of their progression to malignancy. However, no single imaging modality alone is sufficient for a definitive diagnosis of all PCLs. The cyst fluid obtained by endoscopic ultrasound-guided fine needle aspiration provides additional information for the differential diagnosis of PCLs. Current recommendations suggest sending cyst fluid for cytology evaluation and measurement of carcinoembryonic antigen (CEA) levels. Unfortunately, the sensitivity of cytology is greatly limited, and cyst fluid CEA has demonstrated insufficient accuracy as a predictor of mucinous cysts. More recently, cyst fluid glucose has emerged as an alternative to CEA for distinguishing between mucinous and nonmucinous lesions. Herein, the clinical utility of cyst fluid glucose and CEA for the differential diagnosis of PCLs was evaluated.
Collapse
Affiliation(s)
- César Vivian Lopes
- Department of Gastroenterology and Digestive Endoscopy, Santa Casa Hospital, Porto Alegre 91410-000, Brazil
| |
Collapse
|
170
|
Wood LD, Yurgelun MB, Goggins MG. Genetics of Familial and Sporadic Pancreatic Cancer. Gastroenterology 2019; 156:2041-2055. [PMID: 30660730 DOI: 10.1053/j.gastro.2018.12.039] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/14/2018] [Accepted: 12/05/2018] [Indexed: 12/14/2022]
Abstract
In the previous decade, comprehensive genomic analyses have yielded important insights about the genetic alterations that underlie pancreatic tumorigenesis. Whole-exome and whole-genome sequencing of pancreatic ductal adenocarcinomas have confirmed the critical driver genes altered in the majority of pancreatic cancers, as well as identified numerous less frequently altered driver genes, and have delineated cancer subgroups with unique biological and clinical features. It is now appreciated that pancreatic susceptibility gene alterations are often identified in patients with pancreatic cancer without family histories suggestive of a familial cancer syndrome, prompting recent efforts to expand gene testing to all patients with pancreatic cancer. Studies of pancreatic cancer precursor lesions have begun to elucidate the evolutionary history of pancreatic tumorigenesis and to help us understand the utility of biomarkers for early detection and targets to develop new therapeutic strategies. In this review, we discuss the results of comprehensive genomic characterization of pancreatic ductal adenocarcinoma and its precursor lesions, and we highlight translational applications in early detection and therapy.
Collapse
Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Matthew B Yurgelun
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Michael G Goggins
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
171
|
Singhi AD, Koay EJ, Chari ST, Maitra A. Early Detection of Pancreatic Cancer: Opportunities and Challenges. Gastroenterology 2019; 156:2024-2040. [PMID: 30721664 PMCID: PMC6486851 DOI: 10.1053/j.gastro.2019.01.259] [Citation(s) in RCA: 402] [Impact Index Per Article: 80.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/08/2019] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Abstract
Most patients with pancreatic ductal adenocarcinoma (PDAC) present with symptomatic, surgically unresectable disease. Although the goal of early detection of PDAC is laudable and likely to result in significant improvement in overall survival, the relatively low prevalence of PDAC renders general population screening infeasible. The challenges of early detection include identification of at-risk individuals in the general population who would benefit from longitudinal surveillance programs and appropriate biomarker and imaging-based modalities used for PDAC surveillance in such cohorts. In recent years, various subgroups at higher-than-average risk for PDAC have been identified, including those with familial risk due to germline mutations, a history of pancreatitis, patients with mucinous pancreatic cysts, and elderly patients with new-onset diabetes. The last 2 categories are discussed at length in terms of the opportunities and challenges they present for PDAC early detection. We also discuss current and emerging imaging modalities that are critical to identifying early, potentially curable PDAC in high-risk cohorts on surveillance.
Collapse
Affiliation(s)
- Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Anirban Maitra
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
172
|
Whittle MC, Hingorani SR. Fibroblasts in Pancreatic Ductal Adenocarcinoma: Biological Mechanisms and Therapeutic Targets. Gastroenterology 2019; 156:2085-2096. [PMID: 30721663 PMCID: PMC6486863 DOI: 10.1053/j.gastro.2018.12.044] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/05/2018] [Accepted: 12/18/2018] [Indexed: 12/13/2022]
Abstract
The desmoplastic reaction of pancreas cancer may begin as a wound healing response to the nascent neoplasm, but it soon creates an insidious shelter that can sustain the growing tumor and rebuff therapy. Among the many cell types subverted by transformed epithelial cells, fibroblasts are recruited and activated to lay a foundation of extracellular matrix proteins and glycosaminoglycans that alter tumor biophysics and signaling. Their near-universal presence in pancreas cancer and ostensible support of disease progression make fibroblasts attractive therapeutic targets. More recently, however, it has also become apparent that diverse subpopulations of fibroblasts with distinct phenotypes and secretomes inhabit the stroma, and that targeted depletion of particular fibroblast subsets could either provide substantial therapeutic benefit or accelerate disease progression. An improved characterization of these fibroblast subtypes, along with their potential relationships to tumor subtypes and mutational repertoires, is needed in order to make anti-fibroblast therapies clinically viable.
Collapse
Affiliation(s)
- Martin C. Whittle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109,Correspondence: Martin C. Whittle, PhD, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M5-C800, Seattle, WA 98109-1024, , Sunil R. Hingorani, MD, PhD, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M5-C800, Seattle, WA 98109-1024,
| | - Sunil R. Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109,Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA, 98195,Correspondence: Martin C. Whittle, PhD, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M5-C800, Seattle, WA 98109-1024, , Sunil R. Hingorani, MD, PhD, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M5-C800, Seattle, WA 98109-1024,
| |
Collapse
|
173
|
Gaujoux S, Parvanescu A, Cesaretti M, Silve C, Bieche I, Rebours V, Lévy P, Sauvanet A, Cros J. GNAS but Not Extended RAS Mutations Spectrum are Associated with a Better Prognosis in Intraductal Pancreatic Mucinous Neoplasms. Ann Surg Oncol 2019; 26:2640-2650. [DOI: 10.1245/s10434-019-07389-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Indexed: 12/28/2022]
|
174
|
Farrell JJ, Al-Haddad MA, Jackson SA, Gonda TA. Incremental value of DNA analysis in pancreatic cysts stratified by clinical risk factors. Gastrointest Endosc 2019; 89:832-841.e2. [PMID: 30447214 DOI: 10.1016/j.gie.2018.10.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/31/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We determined the incremental predictive value of pancreatic cyst fluid molecular analysis to assessing malignancy risk over long-term follow-up of a well-characterized cohort, given the underlying predictive value of imaging parameters routinely used to triage such patients. METHODS Patients who lacked initial cytologic malignancy in cyst fluid and had final pathology or a follow-up period of more than 2 years were included. Patient outcomes determined the malignancy-free survival of patients with high-risk stigmata (HRS), worrisome features (WFs), and DNA abnormalities. DNA analysis included 3 abnormalities: loss of heterozygosity mutations among a panel of tumor suppressor genes, Kras mutation, and elevated DNA quantity. RESULTS Included were 478 patients; 209 had surgical pathology-derived outcomes and 269 had clinical follow-up of >2 years. Eleven percent had malignant outcome. Forty-two patients had HRS, 272 lacked both HRS and WFs, and 164 lacked HRS but had WFs. DNA abnormalities did not statistically change long-term malignancy risk in patients with HRS or in patients lacking both HRS and WFs. Among patients with WFs, the presence of ≥2 DNA abnormalities significantly increased malignancy risk (relative risk, 5.2; P = .002) and the absence of all DNA abnormalities significantly decreased risk (relative risk, .4; P = .040). Sensitivity analysis confirmed results of survival analysis over differing baseline malignancy probabilities. CONCLUSIONS Our study defines the clinical characteristic of patients in which DNA abnormality testing has the greatest impact on patient outcomes. Use of DNA abnormality testing is supported in a carefully selected patient population limited to cysts with WFs.
Collapse
Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University, New Haven, Connecticut, USA
| | | | | | - Tamas A Gonda
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
175
|
Madhani K, Yousaf M, Aamar A, Ooka K, Muniraj T, Aslanian H, Salem R, Farrell JJ. Impact of endoscopic ultrasound on diagnosis and management of presumed mucinous neoplasms when done for pancreatic cyst morphology change on non-invasive surveillance imaging. Endosc Int Open 2019; 7:E389-E395. [PMID: 30931368 PMCID: PMC6420337 DOI: 10.1055/a-0824-6240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Guidelines for management of presumed neoplastic pancreatic cysts have encouraged noninvasive imaging for low-risk surveillance, while reserving endoscopic ultrasound for worrisome features including morphologic change. We aim to study the impact of endoscopic ultrasound on diagnosis and management compared with non-invasive imaging. Patients and methods A single-institution pancreatic cyst database was retrospectively queried for patients who underwent endoscopic ultrasound for the indication of change in cyst morphology. Diagnoses were classified as presumed mucinous neoplasm with or without worrisome features or high-risk stigmata and non-mucinous lesions. Management decisions were defined a priori as surgical evaluation for patients with high-risk stigmata, positive cytology or mural nodule, or continued surveillance for all others. Results Between January 2013 and October 2016, 709 pancreas cyst endoscopic ultrasounds were performed of which 89 were for cyst morphology change seen on noninvasive imaging including 10 presumed pseudocysts, nine presumed serous cystadenomas, and 70 presumed mucinous cystic neoplasms. Cyst morphologic changes included increase in caliber of the main pancreatic duct (7 cases), increase in cyst size (68 cases), cyst ≥ 30 mm (10 cases), and presence of a solid nodule (1 case). Median cyst size increase was 5 mm with interquartile range of 4 mm over 2.1 ± 1.9 years. Endoscopic ultrasound done for morphologic change resulted in a change in diagnosis and management in 16 % and 13 % of cases, respectively. Conclusion Endoscopic ultrasound has a modest but clinically significant role in impacting diagnosis and management for presumed mucinous cystic neoplasms when performed for the indication of cyst morphology change.
Collapse
Affiliation(s)
- Kamraan Madhani
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Muhammad Yousaf
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT
| | - Ali Aamar
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kohtaro Ooka
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Thiruvengadam Muniraj
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT
| | - Harry Aslanian
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT
| | - Ronald Salem
- Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT,Department of Surgical Oncology, Yale School of Medicine, New Haven, CT
| | - James J Farrell
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT,Corresponding author James J. Farrell, MD Section of Digestive DiseasesYale School of MedicineLMP 1080, 15 York StNew Haven, CT 06510-3221+1-203-737-1755
| |
Collapse
|
176
|
Abstract
Cancers that appear morphologically similar often have dramatically different clinical features, respond variably to therapy and have a range of outcomes. Compelling evidence now demonstrates that differences in the molecular pathology of otherwise indistinguishable cancers substantially impact the clinical characteristics of the disease. Molecular subtypes now guide preclinical and clinical therapeutic development and treatment in many cancer types. The ability to predict optimal therapeutic strategies ahead of treatment improves overall patient outcomes, minimizing treatment-related morbidity and cost. Although clinical decision making based on histopathological criteria underpinned by robust data is well established in many cancer types, subtypes of pancreatic cancer do not currently inform treatment decisions. However, accumulating molecular data are defining subgroups in pancreatic cancer with distinct biology and potential subtype-specific therapeutic vulnerabilities, providing the opportunity to define a de novo clinically applicable molecular taxonomy. This Review summarizes current knowledge concerning the molecular subtyping of pancreatic cancer and explores future strategies for using a molecular taxonomy to guide therapeutic development and ultimately routine therapy with the overall goal of improving outcomes for this disease.
Collapse
Affiliation(s)
| | - Peter Bailey
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Glasgow, Scotland, UK
| | - David K Chang
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Glasgow, Scotland, UK
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Andrew V Biankin
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Glasgow, Scotland, UK.
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Liverpool, Australia.
| |
Collapse
|
177
|
Clinical assessment of the GNAS mutation status in patients with intraductal papillary mucinous neoplasm of the pancreas. Surg Today 2019; 49:887-893. [PMID: 30879148 DOI: 10.1007/s00595-019-01797-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/07/2019] [Indexed: 12/28/2022]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is characterized by cystic dilation of the pancreatic duct, caused by mucin hypersecretion, with slow progression via the adenoma-carcinoma sequence mechanism. Mutation of GNAS at codon 201 is found exclusively in IPMNs, occurring at a rate of 41-75%. Recent advances in molecular biological techniques have demonstrated that GNAS mutation might play a role in the transformation of IPMNs after the appearance of neoplastic cells, rather than in the tumorigenesis of IPMNs. GNAS mutation is observed frequently in the intestinal subtype of IPMNs with MUC2 expression, and less frequently in IPMNs with concomitant pancreatic ductal adenocarcinoma (PDAC). Research has focused on assessing GNAS mutation status in clinical practice using various samples. In this review, we discuss the clinical application of GNAS mutation assessment to differentiate invasive IPMNs from concomitant PDAC, examine the clonality of recurrent IPMNs in the remnant pancreas using resected specimens, and differentiate pancreatic cystic lesions using cystic fluid collected by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), duodenal fluid, and serum liquid biopsy samples.
Collapse
|
178
|
Detection of early-stage hepatocellular carcinoma in asymptomatic HBsAg-seropositive individuals by liquid biopsy. Proc Natl Acad Sci U S A 2019; 116:6308-6312. [PMID: 30858324 DOI: 10.1073/pnas.1819799116] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Liquid biopsies, based on cell free DNA (cfDNA) and proteins, have shown the potential to detect early stage cancers of diverse tissue types. However, most of these studies were retrospective, using individuals previously diagnosed with cancer as cases and healthy individuals as controls. Here, we developed a liquid biopsy assay, named the hepatocellular carcinoma screen (HCCscreen), to identify HCC from the surface antigen of hepatitis B virus (HBsAg) positive asymptomatic individuals in the community population. The training cohort consisted of individuals who had liver nodules and/or elevated serum α-fetoprotein (AFP) levels, and the assay robustly separated those with HCC from those who were non-HCC with a sensitivity of 85% and a specificity of 93%. We further applied this assay to 331 individuals with normal liver ultrasonography and serum AFP levels. A total of 24 positive cases were identified, and a clinical follow-up for 6-8 mo confirmed four had developed HCC. No HCC cases were diagnosed from the 307 test-negative individuals in the follow-up during the same timescale. Thus, the assay showed 100% sensitivity, 94% specificity, and 17% positive predictive value in the validation cohort. Notably, each of the four HCC cases was at the early stage (<3 cm) when diagnosed. Our study provides evidence that the use of combined detection of cfDNA alterations and protein markers is a feasible approach to identify early stage HCC from asymptomatic community populations with unknown HCC status.
Collapse
|
179
|
Søreide K, Primavesi F, Labori KJ, Watson MM, Stättner S. Molecular biology in pancreatic ductal adenocarcinoma: implications for future diagnostics and therapy. Eur Surg 2019. [DOI: 10.1007/s10353-019-0575-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
180
|
Maker AV, Hu V, Kadkol SS, Hong L, Brugge W, Winter J, Yeo CJ, Hackert T, Büchler M, Lawlor RT, Salvia R, Scarpa A, Bassi C, Green S. Cyst Fluid Biosignature to Predict Intraductal Papillary Mucinous Neoplasms of the Pancreas with High Malignant Potential. J Am Coll Surg 2019; 228:721-729. [PMID: 30794864 DOI: 10.1016/j.jamcollsurg.2019.02.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/01/2019] [Accepted: 02/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current standard-of-care technologies, such as imaging and cyst fluid analysis, are unable to consistently distinguish intraductal papillary mucinous neoplasms (IPMNs) of the pancreas at high risk of pancreatic cancer from low-risk IPMNs. The objective was to create a single-platform assay to identify IPMNs that are at high risk for malignant progression. STUDY DESIGN Building on the Verona International Consensus Conference branch duct IPMN biomarker review, additional protein, cytokine, mucin, DNA, and microRNA cyst fluid targets were identified for creation of a quantitative polymerase chain reaction-based assay. This included messenger RNA markers: ERBB2, GNAS, interleukin 1β, KRAS, MUCs1, 2, 4, 5AC, 7, prostaglandin E2R, PTGER2, prostaglandin E synthase 2, prostaglandin E synthase 1, TP63; microRNA targets: miRs 101, 106b, 10a, 142, 155, 17, 18a, 21, 217, 24, 30a, 342, 532, 92a, and 99b; and GNAS and KRAS mutational analysis. A multi-institutional international collaborative contributed IPMN cyst fluid samples to validate this platform. Cyst fluid gene expression levels were normalized, z-transformed, and used in classification and regression analysis by a support vector machine training algorithm. RESULTS From cyst fluids of 59 IPMN patients, principal component analysis confirmed no institutional bias/clustering. Lasso (least absolute shrinkage and selection operator)-penalized logistic regression with binary classification and 5-fold cross-validation used area under the curve as the evaluation criterion to create the optimal signature to discriminate IPMNs as low risk (low/moderate dysplasia) or high risk (high-grade dysplasia/invasive cancer). The most predictive signature was achieved with interleukin 1β, MUC4, and prostaglandin E synthase 2 to accurately discriminate high-risk cysts from low-risk cysts with an area under the curve of up to 0.86 (p = 0.002). CONCLUSIONS We have identified a single-platform polymerase chain reaction-based assay of cyst fluid to accurately predict IPMNs with high malignant potential for additional studies.
Collapse
Affiliation(s)
- Ajay V Maker
- Department of Surgery, University of Illinois at Chicago, and the Creticos Cancer Center, AIMMC, Chicago, IL.
| | - Vincent Hu
- Department of Bioinformatics, University of Illinois at Chicago, Chicago, IL
| | - Shrihari S Kadkol
- Department of Pathology, University of Illinois at Chicago, Chicago, IL
| | - Lenny Hong
- Department of Pathology, University of Illinois at Chicago, Chicago, IL
| | - William Brugge
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jordan Winter
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Büchler
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rita T Lawlor
- Department of Diagnostics and Public Health, Section of Pathology and ARC-Net Centre for Applied Research on Cancer, University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, Istituto del Pancreas, University and Hospital Trust of Verona, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology and ARC-Net Centre for Applied Research on Cancer, University of Verona, Verona, Italy
| | - Claudio Bassi
- Department of Surgery, Istituto del Pancreas, University and Hospital Trust of Verona, Verona, Italy
| | - Stefan Green
- Department of DNA Services, University of Illinois at Chicago, Chicago, IL
| |
Collapse
|
181
|
Molecular Diagnostics in the Neoplasms of the Pancreas, Liver, Gallbladder, and Extrahepatic Biliary Tract: 2018 Update. Clin Lab Med 2019; 38:367-384. [PMID: 29776636 DOI: 10.1016/j.cll.2018.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic neoplasms, including ductal adenocarcinoma, solid pseudopapillary neoplasm, pancreatic endocrine neoplasms, acinar cell carcinoma, and pancreatoblastoma, are associated with different genetic abnormalities. Hepatic adenomas with beta-catenin exon 3 mutation are associated with a high risk of malignancy. Hepatic adenoma with arginosuccinate synthetase 1 expression or sonic hedgehog mutations are associated with a risk of bleeding. Hepatocellular carcinoma and choangiocarcinoma display heterogeneity at both morphologic and molecular levels Cholangiocellular carcinoma is most commonly associated with IDH 1/2 mutations.
Collapse
|
182
|
Omori Y, Ono Y, Tanino M, Karasaki H, Yamaguchi H, Furukawa T, Enomoto K, Ueda J, Sumi A, Katayama J, Muraki M, Taniue K, Takahashi K, Ambo Y, Shinohara T, Nishihara H, Sasajima J, Maguchi H, Mizukami Y, Okumura T, Tanaka S. Pathways of Progression From Intraductal Papillary Mucinous Neoplasm to Pancreatic Ductal Adenocarcinoma Based on Molecular Features. Gastroenterology 2019; 156:647-661.e2. [PMID: 30342036 DOI: 10.1053/j.gastro.2018.10.029] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 09/14/2018] [Accepted: 10/05/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Intraductal papillary mucinous neoplasms (IPMNs) are regarded as precursors of pancreatic ductal adenocarcinomas (PDAs), but little is known about the mechanism of progression. This makes it challenging to assess cancer risk in patients with IPMNs. We investigated associations of IPMNs with concurrent PDAs by genetic and histologic analyses. METHODS We obtained 30 pancreatic tissues with concurrent PDAs and IPMNs, and 168 lesions, including incipient foci, were mapped, microdissected, and analyzed for mutations in 18 pancreatic cancer-associated genes and expression of tumor suppressors. RESULTS We determined the clonal relatedness of lesions, based on driver mutations shared by PDAs and concurrent IPMNs, and classified the lesions into 3 subtypes. Twelve PDAs contained driver mutations shared by all concurrent IPMNs, which we called the sequential subtype. This subset was characterized by less diversity in incipient foci with frequent GNAS mutations. Eleven PDAs contained some driver mutations that were shared with concurrent IPMNs, which we called the branch-off subtype. In this subtype, PDAs and IPMNs had identical KRAS mutations but different GNAS mutations, although the lesions were adjacent. Whole-exome sequencing and methylation analysis of these lesions indicated clonal origin with later divergence. Ten PDAs had driver mutations not found in concurrent IPMNs, called the de novo subtype. Expression profiles of TP53 and SMAD4 increased our ability to differentiate these subtypes compared with sequencing data alone. The branch-off and de novo subtypes had substantial heterogeneity among early clones, such as differences in KRAS mutations. Patients with PDAs of the branch-off subtype had a longer times of disease-free survival than patients with PDAs of the de novo or the sequential subtypes. CONCLUSIONS Detailed histologic and genetic analysis of PDAs and concurrent IPMNs identified 3 different pathways by which IPMNs progress to PDAs-we call these the sequential, branch-off, and de novo subtypes. Subtypes might be associated with clinical and pathologic features and be used to select surveillance programs for patients with IPMNs.
Collapse
Affiliation(s)
- Yuko Omori
- Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan; Department of Pathology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Yusuke Ono
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan; Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Mishie Tanino
- Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hidenori Karasaki
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Hiroshi Yamaguchi
- Division of Diagnostic Pathology, Tokyo Medical University, Tokyo, Japan
| | - Toru Furukawa
- Department of Histopathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Katsuro Enomoto
- Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Ueda
- Center for Advanced Research and Education, Asahikawa Medical University, Asahikawa, Japan
| | - Atsuko Sumi
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Jin Katayama
- Diagnostic Partnering, Clinical Sequencing Division, Thermo Fisher Scientific, Tokyo, Japan
| | | | - Kenzui Taniue
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan; Genomedia Inc., Tokyo, Japan
| | | | - Yoshiyasu Ambo
- Department of Surgery, Teine-Keijinkai Hospital, Sapporo, Japan
| | | | | | - Junpei Sasajima
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan; Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroyuki Maguchi
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Yusuke Mizukami
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan; Department of Medicine, Asahikawa Medical University, Asahikawa, Japan.
| | | | - Shinya Tanaka
- Department of Cancer Pathology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
183
|
Abstract
Pancreatic cysts are common and are incidentally detected in up to 13.5% of individuals. Intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN) are precursors to pancreatic adenocarcinoma. Most will never develop into pancreatic cancer. Several types of pancreatic cysts have no malignant potential. Solid tumors can present as a pancreatic cysts. Guidelines recommend surveillance. Management includes differentiating IPMNs and MCNs from other types, identifying those at highest risk of harboring pancreatic cancer or high-grade dysplasia, and referral to a multidisciplinary group for evaluation and consideration of surgical resection.
Collapse
Affiliation(s)
- Olaya I Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, The Johns Hopkins Hospital, Sheikh Zayed Building, 1800 Orleans Street, Suite M2058, Baltimore, MD 21287, USA
| | - Anne Marie Lennon
- Medicine, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA; Surgery, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA; Oncology, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA; Radiology, Multidisciplinary Pancreatic Cyst Clinic, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Room 7125J, Baltimore, MD 21231, USA.
| |
Collapse
|
184
|
Chandana S, Babiker HM, Mahadevan D. Therapeutic trends in pancreatic ductal adenocarcinoma (PDAC). Expert Opin Investig Drugs 2018; 28:161-177. [DOI: 10.1080/13543784.2019.1557145] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Sreenivasa Chandana
- Phase I program, START Midwest, Grand Rapids, MI, USA
- Department of Gastrointestinal Medical Oncology, Cancer and Hematology Centers of Western Michigan, Grand Rapids, MI, USA
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Hani M. Babiker
- Early Phase Therapeutics Program, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Daruka Mahadevan
- Early Phase Therapeutics Program, University of Arizona Cancer Center, Tucson, AZ, USA
| |
Collapse
|
185
|
Singhi AD, McGrath K, Brand RE, Khalid A, Zeh HJ, Chennat JS, Fasanella KE, Papachristou GI, Slivka A, Bartlett DL, Dasyam AK, Hogg M, Lee KK, Marsh JW, Monaco SE, Ohori NP, Pingpank JF, Tsung A, Zureikat AH, Wald AI, Nikiforova MN. Preoperative next-generation sequencing of pancreatic cyst fluid is highly accurate in cyst classification and detection of advanced neoplasia. Gut 2018; 67:2131-2141. [PMID: 28970292 PMCID: PMC6241612 DOI: 10.1136/gutjnl-2016-313586] [Citation(s) in RCA: 229] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 08/29/2017] [Accepted: 09/14/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE DNA-based testing of pancreatic cyst fluid (PCF) is a useful adjunct to the evaluation of pancreatic cysts (PCs). Mutations in KRAS/GNAS are highly specific for intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs), while TP53/PIK3CA/PTEN alterations are associated with advanced neoplasia. A prospective study was performed to evaluate preoperative PCF DNA testing. DESIGN Over 43-months, 626 PCF specimens from 595 patients were obtained by endoscopic ultrasound (EUS)-fine needle aspiration and assessed by targeted next-generation sequencing (NGS). Molecular results were correlated with EUS findings, ancillary studies and follow-up. A separate cohort of 159 PCF specimens was also evaluated for KRAS/GNAS mutations by Sanger sequencing. RESULTS KRAS/GNAS mutations were identified in 308 (49%) PCs, while alterations in TP53/PIK3CA/PTEN were present in 35 (6%) cases. Based on 102 (17%) patients with surgical follow-up, KRAS/GNAS mutations were detected in 56 (100%) IPMNs and 3 (30%) MCNs, and associated with 89% sensitivity and 100% specificity for a mucinous PC. In comparison, KRAS/GNAS mutations by Sanger sequencing had a 65% sensitivity and 100% specificity. By NGS, the combination of KRAS/GNAS mutations and alterations in TP53/PIK3CA/PTEN had an 89% sensitivity and 100% specificity for advanced neoplasia. Ductal dilatation, a mural nodule and malignant cytopathology had lower sensitivities (42%, 32% and 32%, respectively) and specificities (74%, 94% and 98%, respectively). CONCLUSIONS In contrast to Sanger sequencing, preoperative NGS of PCF for KRAS/GNAS mutations is highly sensitive for IPMNs and specific for mucinous PCs. In addition, the combination of TP53/PIK3CA/PTEN alterations is a useful preoperative marker for advanced neoplasia.
Collapse
Affiliation(s)
- Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Randall E Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Asif Khalid
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Herbert J Zeh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Chennat
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth E Fasanella
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David L Bartlett
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anil K Dasyam
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Melissa Hogg
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James Wallis Marsh
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sara E Monaco
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - James F Pingpank
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abigail I Wald
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
186
|
Imaging and Cytopathological Criteria Indicating Malignancy in Mucin-Producing Pancreatic Neoplasms: A Series of 68 Histopathologically Confirmed Cases. Pancreas 2018; 47:1283-1289. [PMID: 30308535 DOI: 10.1097/mpa.0000000000001182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study aims to evaluate the performance of clinical, imaging, and cytopathological criteria in the identification of high-grade dysplasia/carcinoma (HGD/Ca) in pancreatic mucin-producing cystic neoplasms. METHODS Sixty-eight consecutive, histopathologically confirmed mucin-producing cystic neoplasms, evaluated by endoscopic ultrasound-guided fine-needle aspiration, were enrolled; specifically, 39 branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), 21 main duct IPMNs, and 8 mucinous cystic neoplasms. The associations between HGD/Ca in histopathology and findings of endoscopic ultrasound and cytology, demographic, lifestyle, and clinical parameters were evaluated, separately in IPMNs and mucinous cystic neoplasms. RESULTS Age 65 years or more was associated with HGD/Ca in IPMNs. In BD-IPMNs, cyst diameter 3 cm or greater (sensitivity, 68.8%; specificity, 65.2%), a mural nodule (sensitivity, 56.3%; specificity, 78.3%), main pancreatic duct diameter 5 to 9 mm (sensitivity, 50.0%; specificity, 87.0%), and suspicious cytology (sensitivity, 81.3%; specificity, 100%) signaled the presence of HGD/Ca. Similarly, in main duct IPMNs, suspicious cytology predicted HGD/Ca with high sensitivity (88.9%) and excellent specificity (100%). Regarding cytopathological criteria, in BD-IPMNs, HGD/Ca was associated with a high nuclear/cytoplasmic ratio, background necrosis, presence of papillary structures, hypochromatic nuclei, hyperchromatic nuclei, and major nuclear membrane irregularities (thickening and/or indentations). CONCLUSIONS Clinical, imaging, and cytopathological criteria are useful in the identification of HGD/Ca in IPMNs.
Collapse
|
187
|
Robinson C, Estrada A, Zaheer A, Singh VK, Wolfgang CL, Goggins MG, Hruban RH, Wood LD, Noë M, Montgomery EA, Guthrie LC, Lennon AM, Boyce AM, Collins MT. Clinical and Radiographic Gastrointestinal Abnormalities in McCune-Albright Syndrome. J Clin Endocrinol Metab 2018; 103:4293-4303. [PMID: 30124968 PMCID: PMC6194803 DOI: 10.1210/jc.2018-01022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/09/2018] [Indexed: 12/12/2022]
Abstract
CONTEXT McCune-Albright syndrome (MAS) is a rare disorder characterized by fibrous dysplasia of bone, café-au-lait macules, and hyperfunctioning endocrinopathies. It arises from somatic gain-of-function mutations in GNAS, which encodes the cAMP-regulating protein Gαs. Somatic GNAS mutations have been reported in intraductal papillary mucinous neoplasms (IPMNs) and various gastrointestinal (GI) tumors. The clinical spectrum and prevalence of MAS-associated GI disease is not well established. OBJECTIVE Define the spectrum and prevalence of MAS-associated GI pathology in a large cohort of patients with MAS. DESIGN Cross-sectional study. SETTING National Institutes of Health Clinical Center and The Johns Hopkins Hospital. METHODS Fifty-four consecutive subjects with MAS (28 males; age range, 7 to 67 years) were screened with magnetic resonance cholangiopancreatography (MRCP). RESULTS Thirty of 54 subjects (56%) had radiographic GI abnormalities. Twenty-five (46%) of the screened subjects had IPMNs (mean age of 35.1 years). Fourteen of the 25 had IPMNs alone, and 11 had IPMNs and abnormal hepatobiliary imaging. The 30 patients with MAS-associated GI pathology had a higher prevalence of acute pancreatitis, diabetes mellitus, and skeletal disease burden of fibrous dysplasia than patients without GI disease. CONCLUSIONS A broad spectrum of GI pathology is associated with MAS. IPMNs are common and occur at a younger age than in the general population. Patients with MAS should be considered for screening with a focused GI history and baseline MRCP. Further determination of the natural history and malignant potential of IPMNs in MAS is needed.
Collapse
Affiliation(s)
- Cemre Robinson
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Program in Developmental Endocrinology and Genetics, The Eunice Kennedy Shriver Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Department of Pediatrics, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Andrea Estrada
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Division of Endocrinology and Diabetes, Children’s National Health System, Washington, DC
| | - Atif Zaheer
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher L Wolfgang
- Departments of Surgery, Radiology, and Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael G Goggins
- Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura D Wood
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michaël Noë
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth A Montgomery
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lori C Guthrie
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Anne Marie Lennon
- Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Departments of Surgery, Radiology, and Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Division of Endocrinology and Diabetes, Children’s National Health System, Washington, DC
| | - Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Michael T. Collins, MD, Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, Maryland 20892-4320. E-mail:
| |
Collapse
|
188
|
Rossi RE, Massironi S. Intraductal papillary mucinous neoplasms of the pancreas: a clinical challenge. Expert Rev Gastroenterol Hepatol 2018; 12:1123-1133. [PMID: 30264593 DOI: 10.1080/17474124.2018.1530111] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The incidental detection rate of intraductal papillary mucinous neoplasms (IPMNs) has significantly increased. However, little is known about the natural history of these tumors. Their optimal management and appropriate follow-up are still unclear. We have, therefore, reviewed the available literature on IPMN focusing on their diagnosis, treatment according to the risk of malignant transformation, and follow-up. Areas covered: Bibliographical searches were performed in PubMed for the terms 'intraductal papillary mucinous neoplasm' and 'natural history' and 'diagnosis' and 'treatment' and 'surgery' and 'follow-up' and 'prognosis.' PubMed was used to search for all the relevant articles published over the last 10 years. A total of 7244 records were identified. After filtering for year range, English language, human studies, article types, and removing duplicates, 74 articles were left with the strongest level of evidence. Expert commentary: Available guidelines for IPMN management are mainly based on expert opinions and may lack strong evidence. Further studies are warranted to better predict the risk of recurrence/future malignancy and to establish standardized guidelines. IPMNs management should be based on multidisciplinary discussion and treatment should be tailored to an individual patient according to patient and tumor characteristics.
Collapse
Affiliation(s)
- Roberta Elisa Rossi
- a Division of Gastroenterology and Digestive Endoscopy , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan , Italy.,b Department of Pathophysiology and Organ Transplant , Università degli Studi di Milano , Milan , Italy
| | - Sara Massironi
- a Division of Gastroenterology and Digestive Endoscopy , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan , Italy
| |
Collapse
|
189
|
Goggins M. Circulating Biomarkers to Identify Patients With Resectable Pancreatic Cancer. J Natl Cancer Inst 2018; 109:3053480. [PMID: 28376185 DOI: 10.1093/jnci/djx004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 01/06/2017] [Indexed: 01/02/2023] Open
Affiliation(s)
- Michael Goggins
- Departments of Pathology, Medicine, and Oncology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
190
|
Riva G, Pea A, Pilati C, Fiadone G, Lawlor RT, Scarpa A, Luchini C. Histo-molecular oncogenesis of pancreatic cancer: From precancerous lesions to invasive ductal adenocarcinoma. World J Gastrointest Oncol 2018; 10:317-327. [PMID: 30364837 PMCID: PMC6198304 DOI: 10.4251/wjgo.v10.i10.317] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cancer is a lethal malignancy, whose precursor lesions are pancreatic intraepithelial neoplasm, intraductal papillary mucinous neoplasm, intraductal tubulopapillary neoplasm, and mucinous cystic neoplasm. To better understand the biology of pancreatic cancer, it is fundamental to know its precursors and to study the mechanisms of carcinogenesis. Each of these precursors displays peculiar histological features, as well as specific molecular alterations. Starting from such pre-invasive lesions, this review aims at summarizing the most important aspects of carcinogenesis of pancreatic cancer, with a specific focus on the recent advances and the future perspectives of the research on this lethal tumor type.
Collapse
Affiliation(s)
- Giulio Riva
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona 37134, Italy
| | - Antonio Pea
- Department of Surgery, University and Hospital trust of Verona, Verona 37134, Italy
| | - Camilla Pilati
- Personalized Medicine, Pharmacogenomics, Therapeutic Optimization, Paris-Descartes University, Paris 75006, France
| | - Giulia Fiadone
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona 37134, Italy
| | - Rita Teresa Lawlor
- ARC-Net Research Center, University and Hospital Trust of Verona, Verona 37134, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona 37134, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona 37134, Italy
| |
Collapse
|
191
|
Abstract
OBJECTIVE The purpose of this study is to assess downstream costs associated with pancreatic cysts incidentally detected at MRI. MATERIALS AND METHODS Two hundred patients with an incidental pancreatic cyst detected at MRI were identified. Downstream events (imaging, office visits, endoscopic ultrasound-guided fine-needle aspiration, or chemotherapy) were identified from the electronic medical record. Radiologists' recommendations and ordering physician management were classified relative to the American College of Radiology (ACR) incidental findings committee recommendations. Costs for the downstream events were estimated using national Medicare rates and a 3% annual discount rate. Mean costs were computed. RESULTS Estimated downstream costs averaged $460 per cyst ($872 per cyst with any follow-up testing). Nine patients had a clinically relevant outcome during follow-up (increase in cyst size, development of new cyst, or development of pancreatic cancer). Downstream cost per cyst with a clinically relevant outcome was $1364. Costs were greater when ordering physicians overmanaged ($842) versus when they were adherent ($631) or undermanaged ($252) relative to radiologist recommendation. Although costs were $252 when ordering physicians undermanaged relative to ACR incidental findings committee recommendations, costs were similar when ordering physicians were adherent ($811) or overmanaged ($845) relative to ACR incidental findings committee recommendations. Costs did not vary significantly according to whether radiologists recommended follow-up testing ($317-$491) or whether radiologist recommendations were adherent, undermanaged, or overmanaged relative to ACR incidental findings committee recommendations ($344-$528). CONCLUSION The findings suggest a role for targeted educational efforts, collaborative partnerships, and other initiatives to foster greater adherence to radiologist recommendations, including critical test results notification systems, automated reminders within electronic health systems, and stronger language within radiology reports when no follow-up testing is recommended.
Collapse
|
192
|
DiMaio CJ. Current Guideline Controversies in the Management of Pancreatic Cystic Neoplasms. Gastrointest Endosc Clin N Am 2018; 28:529-547. [PMID: 30241642 DOI: 10.1016/j.giec.2018.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pancreatic cystic lesions are a common clinical entity. The majority are neoplastic and have the potential for malignant transformation. To assist with patient management, a number of clinical guidelines have been developed over the past decade. However, controversies exist in regards to the various guidelines and treatment strategies they offer. This article will review the various clinical guidelines for management of pancreatic cysts, describe the limitations of these guidelines, and present future directions for improvement in clinical decision making for patients diagnosed with a pancreatic cystic neoplasm.
Collapse
Affiliation(s)
- Christopher J DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA.
| |
Collapse
|
193
|
Kaplan JH, Gonda TA. The Use of Biomarkers in the Risk Stratification of Cystic Neoplasms. Gastrointest Endosc Clin N Am 2018; 28:549-568. [PMID: 30241643 DOI: 10.1016/j.giec.2018.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cyst fluid biomarkers may be used to identify pancreatic cyst subtypes. Biomarkers are selected based on their ability to accurately distinguish mucinous from nonmucinous cysts and to risk stratify cysts based on malignant potential. Biomarkers of interest include but are not limited to amylase, oncogenes, DNA analysis, and epigenetic markers. The introduction of next-generation sequencing and molecular panels has aided in improved diagnostic accuracy and risk stratification. This review presents the diagnostic performance of currently available biomarkers and proposes an algorithm to incorporate their use in the diagnosis of pancreatic cysts.
Collapse
Affiliation(s)
- Jeremy H Kaplan
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Tamas A Gonda
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, 161 Fort Washington Avenue, New York, NY 10032, USA.
| |
Collapse
|
194
|
Kim JY, Hong SM. Precursor Lesions of Pancreatic Cancer. Oncol Res Treat 2018; 41:603-610. [DOI: 10.1159/000493554] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/07/2018] [Indexed: 12/18/2022]
|
195
|
Affiliation(s)
- Giuseppe D'Ippolito
- Adjunct Professor in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), Radiologist of Laboratório Fleury, São Paulo, SP, Brazil
| |
Collapse
|
196
|
Levink I, Bruno MJ, Cahen DL. Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives. ACTA ACUST UNITED AC 2018; 16:316-332. [PMID: 30196428 PMCID: PMC6153570 DOI: 10.1007/s11938-018-0190-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management. Recent findings The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk. Summary International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).
Collapse
Affiliation(s)
- Ijm Levink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| |
Collapse
|
197
|
Felsenstein M, Noë M, Masica DL, Hosoda W, Chianchiano P, Fischer CG, Lionheart G, Brosens LAA, Pea A, Yu J, Gemenetzis G, Groot VP, Makary MA, He J, Weiss MJ, Cameron JL, Wolfgang CL, Hruban RH, Roberts NJ, Karchin R, Goggins MG, Wood LD. IPMNs with co-occurring invasive cancers: neighbours but not always relatives. Gut 2018; 67:1652-1662. [PMID: 29500184 PMCID: PMC10489026 DOI: 10.1136/gutjnl-2017-315062] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Intraductal papillary mucinous neoplasms (IPMNs) are precursor lesions that can give rise to invasive pancreatic carcinoma. Although approximately 8% of patients with resected pancreatic ductal adenocarcinoma have a co-occurring IPMN, the precise genetic relationship between these two lesions has not been systematically investigated. DESIGN We analysed all available patients with co-occurring IPMN and invasive intrapancreatic carcinoma over a 10-year period at a single institution. For each patient, we separately isolated DNA from the carcinoma, adjacent IPMN and distant IPMN and performed targeted next generation sequencing of a panel of pancreatic cancer driver genes. We then used the identified mutations to infer the relatedness of the IPMN and co-occurring invasive carcinoma in each patient. RESULTS We analysed co-occurring IPMN and invasive carcinoma from 61 patients with IPMN/ductal adenocarcinoma as well as 13 patients with IPMN/colloid carcinoma and 7 patients with IPMN/carcinoma of the ampullary region. Of the patients with co-occurring IPMN and ductal adenocarcinoma, 51% were likely related. Surprisingly, 18% of co-occurring IPMN and ductal adenocarcinomas were likely independent, suggesting that the carcinoma arose from an independent precursor. By contrast, all colloid carcinomas were likely related to their associated IPMNs. In addition, these analyses showed striking genetic heterogeneity in IPMNs, even with respect to well-characterised driver genes. CONCLUSION This study demonstrates a higher prevalence of likely independent co-occurring IPMN and ductal adenocarcinoma than previously appreciated. These findings have important implications for molecular risk stratification of patients with IPMN.
Collapse
Affiliation(s)
- Matthäus Felsenstein
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Michaël Noë
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David L Masica
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Waki Hosoda
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter Chianchiano
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Catherine G Fischer
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gemma Lionheart
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antonio Pea
- Department of Surgery, University and Hospital Trust of Verona, Verona, Italy
| | - Jun Yu
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Georgios Gemenetzis
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vincent P Groot
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin A Makary
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jin He
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew J Weiss
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John L Cameron
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher L Wolfgang
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ralph H Hruban
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas J Roberts
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rachel Karchin
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael G Goggins
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
198
|
Growth in Branch Duct IPMN Undergoing Surveillance: Unsafe at Any Speed? Clin Gastroenterol Hepatol 2018; 16:1401-1403. [PMID: 29775796 DOI: 10.1016/j.cgh.2018.05.007] [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: 04/30/2018] [Accepted: 05/04/2018] [Indexed: 02/07/2023]
|
199
|
Harrell K, Dowden J. Atypical Solid Serous Cystadenoma of the Pancreas. Am Surg 2018. [DOI: 10.1177/000313481808400924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kevin Harrell
- Department of Surgery University of Tennessee College of Medicine Chattanooga Chattanooga, Tennessee
| | - Jacob Dowden
- Department of Surgery University of Tennessee College of Medicine Chattanooga Chattanooga, Tennessee
| |
Collapse
|
200
|
Faias S, Duarte M, Albuquerque C, da Silva JP, Fonseca R, Roque R, Dias Pereira A, Chaves P, Cravo M. Clinical Impact of KRAS and GNAS Analysis Added to CEA and Cytology in Pancreatic Cystic Fluid Obtained by EUS-FNA. Dig Dis Sci 2018; 63:2351-2361. [PMID: 29796909 DOI: 10.1007/s10620-018-5128-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/17/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic cysts are common incidental findings with malignant potential, raising diagnostic and treatment dilemmas. AIMS To determine the added value of KRAS and GNAS mutation analysis on cyst classification and decision making. METHODS We analyzed 52 frozen samples of pancreatic cystic fluid obtained by EUS-FNA between 2008 and 2014. In addition to cytology and CEA, mutations of GNAS (exons 8 and 9) and KRAS (exons 2 and 3) genes were analyzed using Sanger sequencing. RESULTS There were 52 patients, 67% females, with a mean age of 59 ± 15 years (29-91). Cysts were classified as mucinous in 21 patients (40%) (14 low-risk, seven malignant) and non-mucinous in 31 patients (60%). After EUS-FNA, 11 patients had surgery, six had chemotherapy or palliation, one had endoscopic drainage, and 34 are on follow-up after a mean of 57 months. KRAS mutation was detected in nine and GNAS in two samples. Patients harboring cysts with KRAS mutations were older (p = 0.01), cysts were more commonly mucinous (p = 0.001) and malignant (p = 0.01). KRAS mutations were present in both low-risk and malignant mucinous lesions. For identifying mucinous lesions, CEA > 192 ng/mL performed better (AUC ROC = 93%), whereas for malignant/high-risk mucinous lesions, EUS imaging had the best accuracy (AUC ROC = 88%). After molecular analysis, a modification in cyst classification occurred in ten patients, but was correct in only two, a pseudocyst re-classified as IPMN and a malignant cyst as a non-mucinous cyst. CONCLUSIONS In this cohort of patients with pancreatic cysts, KRAS and GNAS mutations had no significant diagnostic benefit in comparison with conventional testing.
Collapse
MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biomarkers, Tumor/blood
- Biomarkers, Tumor/genetics
- Carcinoembryonic Antigen/blood
- Carcinoma/blood
- Carcinoma/genetics
- Carcinoma/pathology
- Carcinoma/therapy
- Chromogranins/genetics
- DNA Mutational Analysis
- Endoscopic Ultrasound-Guided Fine Needle Aspiration
- Exons
- Female
- GTP-Binding Protein alpha Subunits, Gs/genetics
- Genetic Predisposition to Disease
- Humans
- Male
- Middle Aged
- Mutation
- Neoplasms, Cystic, Mucinous, and Serous/blood
- Neoplasms, Cystic, Mucinous, and Serous/genetics
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/therapy
- Pancreatic Cyst/blood
- Pancreatic Cyst/genetics
- Pancreatic Cyst/pathology
- Pancreatic Cyst/therapy
- Pancreatic Neoplasms/blood
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/therapy
- Phenotype
- Predictive Value of Tests
- Proto-Oncogene Proteins p21(ras)/genetics
- Retrospective Studies
Collapse
Affiliation(s)
- Sandra Faias
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal.
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.
| | - Marlene Duarte
- Molecular Pathobiology Investigation Center, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal
| | - Cristina Albuquerque
- Molecular Pathobiology Investigation Center, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal
| | - João Pereira da Silva
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal
| | - Ricardo Fonseca
- Pathology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Ruben Roque
- Pathology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal
| | - Antonio Dias Pereira
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal
| | - Paula Chaves
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
- Pathology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Rua Prof Lima Basto, 1099-023, Lisbon, Portugal
| | - Marília Cravo
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Gastroenterology Department, Hospital Beatriz Ângelo, Av. Carlos Teixeira, 3, 2670-000, Loures, Portugal
| |
Collapse
|