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Paniccia A, Polanco PM, Boone BA, Wald AI, McGrath K, Brand RE, Khalid A, Kubiliun N, O'Broin-Lennon AM, Park WG, Klapman J, Tharian B, Inamdar S, Fasanella K, Nasr J, Chennat J, Das R, DeWitt J, Easler JJ, Bick B, Singh H, Fairley KJ, Sarkaria S, Sawas T, Skef W, Slivka A, Tavakkoli A, Thakkar S, Kim V, Vanderveldt HD, Richardson A, Wallace MB, Brahmbhatt B, Engels M, Gabbert C, Dugum M, El-Dika S, Bhat Y, Ramrakhiani S, Bakis G, Rolshud D, Millspaugh G, Tielleman T, Schmidt C, Mansour J, Marsh W, Ongchin M, Centeno B, Monaco SE, Ohori NP, Lajara S, Thompson ED, Hruban RH, Bell PD, Smith K, Permuth JB, Vandenbussche C, Ernst W, Grupillo M, Kaya C, Hogg M, He J, Wolfgang CL, Lee KK, Zeh H, Zureikat A, Nikiforova MN, Singhi AD. Prospective, Multi-Institutional, Real-Time Next-Generation Sequencing of Pancreatic Cyst Fluid Reveals Diverse Genomic Alterations That Improve the Clinical Management of Pancreatic Cysts. Gastroenterology 2023; 164:117-133.e7. [PMID: 36209796 PMCID: PMC9844531 DOI: 10.1053/j.gastro.2022.09.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 08/22/2022] [Accepted: 09/16/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Next-generation sequencing (NGS) of pancreatic cyst fluid is a useful adjunct in the assessment of patients with pancreatic cyst. However, previous studies have been retrospective or single institutional experiences. The aim of this study was to prospectively evaluate NGS on a multi-institutional cohort of patients with pancreatic cyst in real time. METHODS The performance of a 22-gene NGS panel (PancreaSeq) was first retrospectively confirmed and then within a 2-year timeframe, PancreaSeq testing was prospectively used to evaluate endoscopic ultrasound-guided fine-needle aspiration pancreatic cyst fluid from 31 institutions. PancreaSeq results were correlated with endoscopic ultrasound findings, ancillary studies, current pancreatic cyst guidelines, follow-up, and expanded testing (Oncomine) of postoperative specimens. RESULTS Among 1933 PCs prospectively tested, 1887 (98%) specimens from 1832 patients were satisfactory for PancreaSeq testing. Follow-up was available for 1216 (66%) patients (median, 23 months). Based on 251 (21%) patients with surgical pathology, mitogen-activated protein kinase/GNAS mutations had 90% sensitivity and 100% specificity for a mucinous cyst (positive predictive value [PPV], 100%; negative predictive value [NPV], 77%). On exclusion of low-level variants, the combination of mitogen-activated protein kinase/GNAS and TP53/SMAD4/CTNNB1/mammalian target of rapamycin alterations had 88% sensitivity and 98% specificity for advanced neoplasia (PPV, 97%; NPV, 93%). Inclusion of cytopathologic evaluation to PancreaSeq testing improved the sensitivity to 93% and maintained a high specificity of 95% (PPV, 92%; NPV, 95%). In comparison, other modalities and current pancreatic cyst guidelines, such as the American Gastroenterology Association and International Association of Pancreatology/Fukuoka guidelines, show inferior diagnostic performance. The sensitivities and specificities of VHL and MEN1/loss of heterozygosity alterations were 71% and 100% for serous cystadenomas (PPV, 100%; NPV, 98%), and 68% and 98% for pancreatic neuroendocrine tumors (PPV, 85%; NPV, 95%), respectively. On follow-up, serous cystadenomas with TP53/TERT mutations exhibited interval growth, whereas pancreatic neuroendocrine tumors with loss of heterozygosity of ≥3 genes tended to have distant metastasis. None of the 965 patients who did not undergo surgery developed malignancy. Postoperative Oncomine testing identified mucinous cysts with BRAF fusions and ERBB2 amplification, and advanced neoplasia with CDKN2A alterations. CONCLUSIONS PancreaSeq was not only sensitive and specific for various pancreatic cyst types and advanced neoplasia arising from mucinous cysts, but also reveals the diversity of genomic alterations seen in pancreatic cysts and their clinical significance.
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Affiliation(s)
- Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patricio M Polanco
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, Texas
| | - Brian A Boone
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Abigail I Wald
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Randall E Brand
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Asif Khalid
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Nisa Kubiliun
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anne Marie O'Broin-Lennon
- The Sol Goldman Pancreatic Cancer Research Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Walter G Park
- Department of Medicine, Stanford University, Stanford, California
| | - Jason Klapman
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Benjamin Tharian
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sumant Inamdar
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kenneth Fasanella
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John Nasr
- Department of Medicine, Wheeling Hospital, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Jennifer Chennat
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rohit Das
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana
| | - Jeffrey J Easler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana
| | - Benjamin Bick
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana
| | - Harkirat Singh
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kimberly J Fairley
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Savreet Sarkaria
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tarek Sawas
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Wasseem Skef
- Department of Medicine, Division of Gastroenterology and Hepatology, Loma Linda University Medical Center, Loma Linda, California
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anna Tavakkoli
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shyam Thakkar
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Victoria Kim
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Michael B Wallace
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Bhaumik Brahmbhatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Megan Engels
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Charles Gabbert
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mohannad Dugum
- Digestive Health Center, Essentia Health-Duluth Clinic, Duluth, Minnesota
| | - Samer El-Dika
- Department of Medicine, Stanford University, Stanford, California
| | - Yasser Bhat
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, California
| | - Sanjay Ramrakhiani
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, California
| | | | | | | | - Thomas Tielleman
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carl Schmidt
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - John Mansour
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, Texas
| | - Wallis Marsh
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Melanie Ongchin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara Centeno
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Sara E Monaco
- Department of Pathology, Geisinger Medical Center, Danville, Pennsylvania
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sigfred Lajara
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Elizabeth D Thompson
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ralph H Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Phoenix D Bell
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katelyn Smith
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jennifer B Permuth
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Christopher Vandenbussche
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Wayne Ernst
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Maria Grupillo
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cihan Kaya
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hogg
- Department of Surgery, NorthShore University Health System, Chicago, Illinois
| | - Jin He
- The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Christopher L Wolfgang
- The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Surgery, NYU Langone Health, New York, New York
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Herbert Zeh
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, Texas
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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