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Paolino G, Basturk O, Esposito I, Hong SM, Brosens LA, Tarcan Z, Wood LD, Gkountakos A, Omori Y, Mattiolo P, Ciulla C, Marchegiani G, Pea A, Bevere M, De Robertis R, D'Onofrio M, Salvia R, Cheng L, Furukawa T, Scarpa A, Adsay V, Luchini C. Comprehensive characterization of intraductal oncocytic papillary neoplasm (IOPN) of the pancreas: a systematic and critical review. Mod Pathol 2024:100554. [PMID: 38950698 DOI: 10.1016/j.modpat.2024.100554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/23/2024] [Accepted: 06/20/2024] [Indexed: 07/03/2024]
Abstract
Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas is a recently recognized pancreatic tumor. Here, we aimed to determine the most essential features with the systematic review tool. PubMed, SCOPUS, and Embase were searched for studies reporting data on pancreatic IOPN. The clinicopathological, immunohistochemical, and molecular data were extracted and summarized. Then, a comparative analysis of the molecular alterations of IOPN with those of pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasm from reference cohorts (including The Cancer Genome Atlas) was conducted. The key findings from 414 IOPNs were as follows: 1) Clinicopathological Features: Male-to-female ratio was 1,5:1. Pancreatic head was the most common site (131/237, 55.3%), but a diffuse tumor extension involving more than one pancreatic segment was described in about 1/5 of cases (49/237, 20.6%). The mean size was 45.5 mm. An associated invasive carcinoma was present in 50% of cases (168/336). In those cases, most tumors were pT1/pT2 and pN0 (>80%), and vascular invasion was uncommon (20.6%). Regarding survival, more than 90% of patients were alive after surgical resection. 2) Immunohistochemical and Molecular Features: The most expressed mucins were MUC5AC (110/112, 98.2%) and MUC6 (78/84, 92.8%). Compared with pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasm, the classic pancreatic drivers KRAS, TP53, CDKN2A, SMAD4, and GNAS were less altered in IOPN (p<0.01). Moreover, fusions involving PRKACA or PRKACB genes were detected in all of 68 cases examined, with PRKACB::ATP1B1 as the most common (27/68 cases, 39.7%). These genomic events emerged as an entity-defining molecular alteration of IOPN (p<0.01). Thus, such fusions represent a promising biomarker for diagnostic purposes. Recent evidence also suggests their role in influencing the acquisition of oncocytic morphology. IOPN is a distinct pancreatic neoplasm with specific clinicopathological and molecular features. Considering the clinical/prognostic implications, its recognition is essential for pathologists and, ultimately, patients' management.
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Affiliation(s)
- Gaetano Paolino
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; Pathology Unit, ASST Spedali Civili Di Brescia, Brescia, Italy
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Irene Esposito
- Institute of Pathology, University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Zeynep Tarcan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, and Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anastasios Gkountakos
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Yuko Omori
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Calogero Ciulla
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
| | - Antonio Pea
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Michele Bevere
- ARC-Net Research Center, University of Verona, Verona, Italy
| | - Riccardo De Robertis
- Department of Diagnostics and Public Health, Section of Radiology, University and Hospital Trust of Verona, Verona, Italy
| | - Mirko D'Onofrio
- Department of Diagnostics and Public Health, Section of Radiology, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, The Warren Albert Medical School of Brown University, Lifespan Academic Medical Center, and the Legorreta Cancer Center at Brown University, Providence, RI, USA
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; ARC-Net Research Center, University of Verona, Verona, Italy
| | - Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey.
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy; ARC-Net Research Center, University of Verona, Verona, Italy.
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Manukyan I, Hsiao SJ, Fazlollahi L, Remotti H, Mansukhani MM. Molecular and morphologic characterization of intraductal tubulopapillary neoplasms of pancreas with novel potentially targetable fusions. Hum Pathol 2024; 150:36-41. [PMID: 38914167 DOI: 10.1016/j.humpath.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/11/2024] [Accepted: 06/20/2024] [Indexed: 06/26/2024]
Abstract
Intraductal tubulopapillary neoplasms (ITPNs) are rare pancreatic tumors with distinct histological and molecular features. Distinction of ITPN from other pancreatic neoplasms is crucial given the known favorable prognosis and the high frequency and diversity of potentially targetable fusions in ITPN. While the histological features of ITPN are well documented, there are few reports on the cytological features, and molecular characterization of ITPN. The authors reported three cases diagnosed in their laboratory between 2016 and 2021. Clinical data, cytomorphological and histological features, with immunophenotypic and molecular characterizations of these cases are described and compared with those reported in the literature. All 3 cases were diagnosed as ITPN based on the microscopic presence of intraductal nodules composed of tightly packed small tubular glands lined by cuboidal cells lacking apparent mucin. On molecular profiling KRAS and TP53 variants were found in Case 1, FGFR2-INA fusion in Case 2, and STARD3NL-BRAF fusion was detected in Case 3. Immunohistochemistry (IHC) revealed that the neoplastic cells in Case 1 were MUC2 positive and MUC6 negative, but in Cases 2 and 3, were negative for MUC2 and positive for MUC6. These results demonstrate the immunophenotypic and molecular variabilities of histologically similar pancreatic neoplasms. The absence of alterations characteristic of more common pancreatic neoplasms should prompt the consideration of fusion studies in morphologically relevant cases. The combination of morphological, IHC, and molecular analyses is important for reliable identification of ITPN given its potential clinical management implications.
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Affiliation(s)
- Irena Manukyan
- Columbia University Irving Medical Center, United States.
| | - Susan J Hsiao
- Columbia University Irving Medical Center, United States.
| | | | - Helen Remotti
- Columbia University Irving Medical Center, United States.
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Gkountakos A, Singhi AD, Westphalen CB, Scarpa A, Luchini C. Fusion genes in pancreatic tumors. Trends Cancer 2024; 10:430-443. [PMID: 38378317 DOI: 10.1016/j.trecan.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/22/2024]
Abstract
Gene fusions and rearrangements play a crucial role in tumor biology. They are rare events typically detected in KRAS wild-type (WT) pancreatic tumors. Their identification can inform clinical management by enabling precision oncology, as fusions involving BRAF, FGFR2, RET, NTRK, NRG1, and ALK represent actionable targets in KRAS-WT cancers, and serve diagnostic purposes since fusions involving PRKACA/B represent the diagnostic hallmark of intraductal oncocytic papillary neoplasms (IOPNs). Although they are rare, the therapeutic and diagnostic importance of these genomic events should not be underestimated, highlighting the need for quality-ensured molecular diagnostics in the management of cancer. Herein we review the existing literature on the role of fusion genes in pancreatic tumors and their clinical potential as effective biomarkers and therapeutic targets.
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Affiliation(s)
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - C Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Centre (CCC), LMU University Hospital Munich and German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Aldo Scarpa
- ARC-Net Research Center, University of Verona, Verona, Italy; Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy.
| | - Claudio Luchini
- ARC-Net Research Center, University of Verona, Verona, Italy; Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy.
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Ciulla C, Luchini C. Genomic determinants of biological aggressiveness and poor prognosis of pancreatic cancers: KRAS and beyond. Expert Rev Mol Diagn 2024; 24:355-362. [PMID: 38708441 DOI: 10.1080/14737159.2024.2348676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/24/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION A marked histomolecular heterogeneity characterizes pancreatic cancer. Thus, different tumor histologies with divergent genomic profiles exist within the same category. AREAS COVERED Using data from PubMed, SCOPUS, and Embase (last search date: 04/04/2024), this expert-based, narrative review presents and discusses the essential molecular determinants of biological aggressiveness and poor prognosis in pancreatic cancer. First, KRAS mutation still represents one of the most critical difficulties in treating pancreatic cancers. In this district, it is mutated in > 90% of malignant tumors. Notably, actionable alterations for molecular-based therapies are typically lacking in KRAS-mutated pancreatic cancer. Furthermore, transcriptome-based studies clarified that the squamous phenotype is characterized by poorer prognosis and response to standard chemotherapy. We also discuss molecular biomarkers related to dismal prognosis in specific subsets of pancreatic cancer, such as SMAD4 in signet-ring cell carcinoma and TP53 in invasive cancers derived from intraductal tubulopapillary neoplasms. EXPERT OPINION The identification of the subgroups of pancreatic cancer with particularly unfavorable prognoses is a critical step for addressing specific research efforts. In addition to implementing and strengthening current precision oncology strategies, the decisive step for improving the survival of patients affected by pancreatic cancer must pass through targeting the KRAS gene.
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Affiliation(s)
- Calogero Ciulla
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, Verona, Italy
- ARC-Net Research Center, University of Verona, Verona, Italy
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Jiang Z, Zheng X, Li M, Liu M. Improving the prognosis of pancreatic cancer: insights from epidemiology, genomic alterations, and therapeutic challenges. Front Med 2023; 17:1135-1169. [PMID: 38151666 DOI: 10.1007/s11684-023-1050-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/15/2023] [Indexed: 12/29/2023]
Abstract
Pancreatic cancer, notorious for its late diagnosis and aggressive progression, poses a substantial challenge owing to scarce treatment alternatives. This review endeavors to furnish a holistic insight into pancreatic cancer, encompassing its epidemiology, genomic characterization, risk factors, diagnosis, therapeutic strategies, and treatment resistance mechanisms. We delve into identifying risk factors, including genetic predisposition and environmental exposures, and explore recent research advancements in precursor lesions and molecular subtypes of pancreatic cancer. Additionally, we highlight the development and application of multi-omics approaches in pancreatic cancer research and discuss the latest combinations of pancreatic cancer biomarkers and their efficacy. We also dissect the primary mechanisms underlying treatment resistance in this malignancy, illustrating the latest therapeutic options and advancements in the field. Conclusively, we accentuate the urgent demand for more extensive research to enhance the prognosis for pancreatic cancer patients.
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Affiliation(s)
- Zhichen Jiang
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
- Department of General Surgery, Division of Gastroenterology and Pancreas, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, China
| | - Xiaohao Zheng
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Min Li
- Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA.
| | - Mingyang Liu
- State Key Laboratory of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Giansante V, Stati G, Sancilio S, Guerra E, Alberti S, Di Pietro R. The Dual Role of Necroptosis in Pancreatic Ductal Adenocarcinoma. Int J Mol Sci 2023; 24:12633. [PMID: 37628814 PMCID: PMC10454309 DOI: 10.3390/ijms241612633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Pancreatic cancer (PC) is the seventh leading cause of cancer-related death. PC incidence has continued to increase by about 1% each year in both men and women. Although the 5-year relative survival rate of PC has increased from 3% to 12%, it is still the lowest among cancers. Hence, novel therapeutic strategies are urgently needed. Challenges in PC-targeted therapeutic strategies stem from the high PC heterogeneity and from the poorly understood interplay between cancer cells and the surrounding microenvironment. Signaling pathways that drive PC cell growth have been the subject of intense scrutiny and interest has been attracted by necroptosis, a distinct type of programmed cell death. In this review, we provide a historical background on necroptosis and a detailed analysis of the ongoing debate on the role of necroptosis in PC malignant progression.
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Affiliation(s)
- Valentina Giansante
- Department of Medicine and Aging Sciences, Section of Biomorphology, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Gianmarco Stati
- Department of Medicine and Aging Sciences, Section of Biomorphology, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Silvia Sancilio
- Department of Medicine and Aging Sciences, Section of Biomorphology, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Emanuela Guerra
- Laboratory of Cancer Pathology, Center for Advanced Studies and Technologies (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
- Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Saverio Alberti
- Unit of Medical Genetics, Department of Biomedical Sciences, University of Messina, 98122 Messina, Italy
| | - Roberta Di Pietro
- Department of Medicine and Aging Sciences, Section of Biomorphology, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, Department of Biology, College of Science and Technology, Temple University, Philadelphia, PA 19122, USA
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Wannasai K, Boonplod C, Wongsuriyathai T, Amantakul A, Junrungsee S, Kongkarnka S. Adenocarcinoma in Intraductal Tubulopapillary Neoplasm of the Pancreas: A Case Report and Literature Review. Cureus 2023; 15:e43006. [PMID: 37674950 PMCID: PMC10478601 DOI: 10.7759/cureus.43006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/08/2023] Open
Abstract
Intraductal tubulopapillary neoplasms (ITPNs) are a subgroup of pre-malignant pancreatic epithelial lesions. The histomorphological and immunophenotypical characteristics of ITPN have been described by several authors based on case series; however, the rarity of this tumor subtype and its similarity to other entities makes the identification of ITPN challenging for radiologists and pathologists. Herein, we report a case of ITPN with associated invasive carcinoma along with a literature review that will benefit further studies and help in planning treatments for patients in the future. A pancreatic mass was incidentally discovered in a 40-year-old woman during her annual check-up. Radiological investigation revealed a mass that obstructed the main pancreatic duct and caused ductal dilatation. Endoscopic retrograde cholangiopancreatography with biopsy indicated poorly differentiated adenocarcinoma. Subsequently, total pancreatectomy with splenectomy was performed to remove the tumor. ITPN of the pancreas with associated poorly differentiated adenocarcinoma was diagnosed based on pathological and immunohistological test results. Achieving complete resection of the tumor, the patient did not require chemotherapy during follow-up care. Thus, our study demonstrated the necessity of radiological and histopathological correlation in the definitive diagnosis of pancreatic ITPN. However, the determination of an invasive component is essential because malignant transformation affects the prognosis of patients.
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Affiliation(s)
- Komson Wannasai
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, THA
| | - Chanakrit Boonplod
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, THA
| | | | - Amonlaya Amantakul
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, THA
| | - Sunhawit Junrungsee
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, THA
| | - Sarawut Kongkarnka
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, THA
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Pavlidis ET, Sapalidis KG, Pavlidis TE. Modern aspects of the management of pancreatic intraductal papillary mucinous neoplasms: a narrative review. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2022; 63:491-502. [PMID: 36588487 PMCID: PMC9926151 DOI: 10.47162/rjme.63.3.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) account for approximately 35% of all cystic tumors in the pancreas and represent the largest subgroup. They are characterized by mucin production and intraductal papillary epithelium growth. IPMNs range from benign to malignant lesions. Biomarkers combined with 18F-Fluorodeoxyglucose-positron emission tomography (18FDG-PET) is the best diagnostic tool. The risk of malignant transformation for main-duct IPMNs is between 34-68% and for low-risk branch-duct (BD)-IPMNs it is 1.1%. Monitoring is crucial for determining the optimal time of surgical excision. Novel artificial intelligence combining clinical, tumor biomarkers, imaging and molecular genomics plays a determinant role in the evaluation of such lesions. The first diagnostic tool is multidetector helical computed tomography (MDHCT) or up-to-date magnetic resonance imaging (MRI). MRI detects malignancy by enhancing mural nodules ≥3 mm. Novel endosonographic interventional techniques have been added to the diagnostic armamentarium. Pancreatoscopy is feasible and effective but challenging for evaluating the diagnosis, invasiveness, and extent of IPMNs. Its findings may change the surgical approach. Pancreatic juice and duodenal fluid have been used recently for molecular biological analysis. The genes most frequently altered include Kirsten rat sarcoma viral proto-oncogene (KRAS), tumor protein p53 (TP53), cyclin-dependent kinase inhibitor 2A (CDKN2A), SMAD family member 4 (SMAD4), and guanine nucleotide-binding protein, alpha stimulating (GNAS). Despite the advances in diagnostic modalities, assessment of this premalignant lesion of pancreatic cancer, with its poor prognosis, is a challenging task. Pancreatectomy is the indicated approach for malignant or high-risk IPMNs with potent malignancy. Conservative management or enucleation for preserving the pancreas of low-risk BD-IPMNs is recommended, but long-term follow-up for recurrence is necessary. The management of IPMNs must be individualized based on preoperative high-risk stigmata and worrisome features.
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Affiliation(s)
- Efstathios T Pavlidis
- School of Medicine, Aristotle University of Thessaloniki, 2nd Propedeutic Department of Surgery, Hippokration Hospital, Thessaloniki, Greece;
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Integrative characterization of intraductal tubulopapillary neoplasm (ITPN) of the pancreas and associated invasive adenocarcinoma. Mod Pathol 2022; 35:1929-1943. [PMID: 36056133 PMCID: PMC9708572 DOI: 10.1038/s41379-022-01143-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 12/24/2022]
Abstract
Pancreatic intraductal tubulopapillary neoplasm (ITPN) is a recently recognized intraductal neoplasm. This study aimed to clarify the clinicopathologic and molecular features of this entity, based on a multi-institutional cohort of 16 pancreatic ITPNs and associated adenocarcinomas. The genomic profiles were analyzed using histology-driven multi-regional sequencing to provide insight on tumor heterogeneity and evolution. Furthermore, an exploratory transcriptomic characterization was performed on eight invasive adenocarcinomas. The clinicopathologic parameters and molecular alterations were further analyzed based on survival indices. The main findings were as follows: 1) the concomitant adenocarcinomas, present in 75% of cases, were always molecularly associated with the intraductal components. These data definitively establish ITPN as origin of invasive pancreatic adenocarcinoma; 2) alterations restricted to infiltrative components included mutations in chromatin remodeling genes ARID2, ASXL1, and PBRM1, and ERBB2-P3H4 fusion; 3) pancreatic ITPN can arise in the context of genetic syndromes, such as BRCA-germline and Peutz-Jeghers syndrome; 4) mutational profile: mutations in the classical PDAC drivers are present, but less frequently, in pancreatic ITPN; 5) novel genomic alterations were observed, including amplification of the Cyclin and NOTCH family genes and ERBB2, fusions involving RET and ERBB2, and RB1 disruptive variation; 6) chromosomal alterations: the most common was 1q gain (75% of cases); 7) by transcriptome analysis, ITPN-associated adenocarcinomas clustered into three subtypes that correlate with the activation of signaling mechanism pathways and tumor microenvironment, displaying squamous features in their majority; and 8) TP53 mutational status is a marker for adverse prognosis. ITPNs are precursor lesions of pancreatic cancer with a high malignant transformation risk. A personalized approach for patients with ITPN should recognize that such neoplasms could arise in the context of genetic syndromes. BRCA alterations, ERBB2 and RET fusions, and ERBB2 amplification are novel targets in precision oncology. The TP53 mutation status can be used as a prognostic biomarker.
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