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Gupta NK, Zhang CS, Singh K, Glass T, Patel N, Aburajab M, Al-Satie M, Crawford C, Anand A, Tian J, Rowe M, Cantafio A, Alkimawi K, Gorantala K, Swingley A, Puri S, Yousef M, Shiyab A, Harshberger C, Saxe J. Utilization of liquid biopsy for advanced gastrointesinal malignancies in a community oncology practice. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
127 Background: Liquid biopsy (LB) offers a non-invasive alternative for obtaining genomic signature of malignancies to develop a tailor-made treatment plan. We evaluated the feasibility and impact on clinical management of liquid biopsies performed on patients with advanced gastrointestinal malignancies in a community setting. Methods: A retrospective chart review of adult patients with stage-IV gastrointestinal malignancies was conducted to gather all the pertinent information, including diagnoses, treatment regimens, results of liquid biopsies and any impact on further management. Results: Data on 42 liquid biopsies performed between Aug 2018 and Mar 2020 was collected. M:F ratio was 1.4: 1. Median age was 57yrs (range 31-86). The diagnoses were; Colo-rectal Ca 22(54.7%), pancreatic 9(21.9%), gastric 2(4.7%), biliary 2(4.7%), HCC 2(4.7%), Appendix 1 (2.3%), CUP 1(2.3%) and others 3(7.1%). One (2.3%) LBs was done before first line treatment and 41(97.7%) were done after the failure of first line treatment. There was insufficient sample in the bx to do tissue-NGS for the pt. who had LB before starting treatments. Majority of LBs, 37(88%) were done after the failure of second line/later treatments compared to 5(12%) done after failing the first line treatment. Patient preference and technical challenge to obtain adequate tissue were the commonest reasons for getting the LBs. Results were available in all (100%) the cases. Median turnaround time was 8 days (range:7-13). The commonest mutations were TP53,APC, KRAS, PIK3CA, BRAF, SMAD4. BRCA-2 was identified in 1 pancreatic ca pt. MSI-H was noted in 3 patients; 2 with Colon ca, and 1 with CUP. An actionable alteration was seen in, 40 (95.2%) of the patients. A FDA approved target-matched drug was available for 27/40(67.5%) pts., if we also consider off-label usage. For those who had an alteration, but no FDA approved target-matched drug was available, 13/40 (32.5%), a clinical trial was available for all 13/13 (100%) of the pts.. 43% of those who had a FDA approved target-matched treatment available, but not approved for their disease, were able to receive the drug off-protocol. Two out of 13(15.3%) of the pts. who had a clinical trial available, were enrolled on a study. Conclusions: Liquid biopsies can be efficiently utilized in a community oncology practice. It offers an attractive option to gather genomic information of malignant cells in patients with advanced GI malignancies to be able to deliver state of the art care to all patients, including those who may not have a convenient access to a tertiary center.
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Gupta NK, Singh K, Aburajab M, Mathavan V, Al-Satie M, Glass T, Leagre CA, Rowe M, Tigges T, Liebross RH, Davis C, Tandra S, Tumati V, Tian J, Martinez B, Dowell J, Schmidt KK, Flanders V. Neoadjuvant gemcitabine and nab-paclitaxel followed by concurrent capecitabine/radiation in borderline resectable (BR) pancreatic cancer: A single-institution experience. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
718 Background: Neo-adjuvant therapy is becoming a preferred approach in the management of BR pancreatic cancer patients. There is no consensus on an ideal treatment regimen. We report our experience with a combination of nab-Paclitaxel/Gemcitabine followed by concurrent Capecitabine and radiation treatments in BR pancreatic cancer patients. Methods: A prospectively maintained database of patients with BR pancreatic cancer undergoing neo-adjuvant treatments at our cancer center between 01/2013- 11/2017 was reviewed. Patients were treated with Gemcitabine(1gm/m2) and nab-paclitaxel (125mg/m2) given on D1-8-15 every 28 days. Pts. were re-assessed after two cycles and the responding pts received two additional cycles. Pts. who continued to respond after four cycles were treated with capecitabine (825mg/m2) and radiation treatments(50.4Gy). Results: A total of 32 patients with PS 0/1 were treated. Median age was 59 yrs (42-76), 19 Males and 13 females. After 2 cycles of Gem/nab-paclitaxel, none of the pts. had progressive disease. Thirty patients (93%) were able to complete all four cycles of Gem/nab-paclitaxel. Twenty nine (90%) received capecitabine and radiation treatments. Imaging to assess response was done 4 weeks after completing radiation and the results were were; 2 CR, 11 PR, 14 SD, 2 PD. Surgery was performed 6-8 weeks after completing radiation. Twenty six (81%) underwent planned resection, 2 had PD, 3 declined surgery and 1 had significant decline in PS. Twenty two out of Twenty six patients undergoing surgery had a R0 resection (80%). Grade-III/IV toxicities with the neo-adjuvant treatments were seen in 41% and 7 % of the pts., respectively. No thirty day post-op mortality, pancreatic leaks or re-operations were observed. The median PFS among all patients was 11.7 months, 2 yr OS 49% and median OS was 27.6 months, compared to 23.4 months, 65% and median OS not reached, in patients who underwent surgical resection. Conclusions: Nab-Paclitaxel and Gemcitabine followed by Capecitabine and radiation is an effective neo-adjuvant treatment strategy with acceptable toxicity-profile for patients with BR pancreatic cancer.
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Aburajab M, Smith Z, Khan A, Dua K. Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocyst. Gastrointest Endosc 2018; 87:1248-1255. [PMID: 29233670 DOI: 10.1016/j.gie.2017.11.033] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 11/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Lumen-apposing metal stents (LAMSs) are used to perform necrosectomy in walled-off necrosis (WON). Although necrosectomy is not required for pancreatic pseudocyst (PP), an increasing number of PPs are also being drained with LAMSs in view of their ease of deployment. The aim of the present study was to evaluate the safety and efficacy of using LAMSs to drain PPs. METHODS At 1 tertiary center from January 2014 to May 2016, all consecutive patients with PPs were drained by LAMSs, and the data were retrospectively reviewed. After observing cyst-cavity infection in patients enrolled initially (group I), 10F double-pigtail stents (DPSs) were placed across LAMSs in the subsequent patients (group II). Data on technical success, PP resolution, adverse events, and reintervention rates were collected. RESULTS Forty-seven patients with PPs (mean size, 9.5 ± 4.0 cm) were enrolled (group I, 24; group II, 23). There was 1 perforation at deployment (technical success, 98%). In the remaining 46 patients, resolution of the PP was observed in 44 patients (96%). Four patients (17%) in group I presented with PP infection requiring reinterventions. Food material was observed in the cyst cavity. None of the patients in group II had PP infection (relative risk, .84; 95% confidence interval, .71-1.0; P = .054). CONCLUSIONS Similar to WON, LAMSs are also effective in endoscopic drainage of PPs. However, there was a trend toward higher PP infection with LAMSs, and placing a DPS across the LAMS minimized this risk.
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Abbas AM, Strong AT, Diehl DL, Brauer BC, Lee IH, Burbridge R, Zivny J, Higa JT, Falcão M, El Hajj II, Tarnasky P, Enestvedt BK, Ende AR, Thaker AM, Pawa R, Jamidar P, Sampath K, de Moura EGH, Kwon RS, Suarez AL, Aburajab M, Wang AY, Shakhatreh MH, Kaul V, Kang L, Kowalski TE, Pannala R, Tokar J, Aadam AA, Tzimas D, Wagh MS, Draganov PV. Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass. Gastrointest Endosc 2018; 87:1031-1039. [PMID: 29129525 DOI: 10.1016/j.gie.2017.10.044] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/30/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. METHODS This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. RESULTS A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. CONCLUSIONS Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.
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Abstract
PURPOSE OF REVIEW In 10-15% of the cases, conventional methods for removing bile duct stones by ERCP/balloon-basket extraction fail. The purpose of this review is to describe endoscopic techniques in managing these "difficult bile duct stones." RECENT FINDINGS Endoscopic papillary large balloon dilation with balloon extraction ± mechanical lithotripsy is the initial approach used to retrieve large bile duct stones. With advent of digital cholangioscopy, electrohydraulic and laser lithotripsy are gaining popularity. Enteroscopy-assisted or laparoscopic-assisted approaches can be used for those with gastric bypass anatomy. Difficulties in removing bile duct stones can be related to stone-related factors such as the size and location of the stone or to altered anatomy such as stricture in the bile duct or Roux-en-Y anatomy. Several endoscopy approaches and techniques have described in the recent past that have greatly enhanced our ability to remove these "difficult" bile duct stones.
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Smith ZL, Dua A, Saeian K, Ledeboer NA, Graham MB, Aburajab M, Ballard DD, Khan AH, Dua KS. A Novel Protocol Obviates Endoscope Sampling for Carbapenem-Resistant Enterobacteriaceae: Experience of a Center with a Prior Outbreak. Dig Dis Sci 2017; 62:3100-3109. [PMID: 28681083 DOI: 10.1007/s10620-017-4669-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/27/2017] [Indexed: 12/09/2022]
Abstract
BACKGROUND Numerous published outbreaks, including one from our institution, have described endoscope-associated transmission of multidrug-resistant organisms (MDROs). Individual centers have adopted their own protocols to address this issue, including endoscope culture and sequestration. Endoscope culturing has drawbacks and may allow residual bacteria, including MDROs, to go undetected after high-level disinfection. AIM To report the outcome of our novel protocol, which does not utilize endoscope culturing, to address our outbreak. METHODS All patients undergoing procedures with elevator-containing endoscopes were asked to permit performance of a rectal swab. All endoscopes underwent high-level disinfection according to updated manufacturer's guidance. Additionally, ethylene oxide (EtO) sterilization was done in the high-risk settings of (1) positive response to a pre-procedure risk stratification questionnaire, (2) positive or indeterminate CRE polymerase chain reaction (PCR) from rectal swab, (3) refusal to consent for PCR or questionnaire, (4) purulent cholangitis or infected pancreatic fluid collections. Two endoscopes per weekend were sterilized on a rotational basis. RESULTS From September 1, 2015 to April 30, 2016, 556 endoscopy sessions were performed using elevator-containing endoscopes. Prompted EtO sterilization was done on 46 (8.3%) instances, 3 from positive/indeterminate PCR tests out of 530 samples (0.6%). No CRE transmission was observed during the study period. Damage or altered performance of endoscopes related to EtO was not observed. CONCLUSION In this pilot study, prompted EtO sterilization in high-risk patients has thus far eliminated endoscope-associated MDRO transmission, although no CRE infections were noted throughout the institution during the study period. Further studies and a larger patient sample will be required to validate these findings.
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Rajamanickam ESP, Christians KK, Aldakkak M, Krepline AN, Ritch PS, George B, Erickson BA, Foley WD, Aburajab M, Evans DB, Tsai S. Poor Glycemic Control Is Associated with Failure to Complete Neoadjuvant Therapy and Surgery in Patients with Localized Pancreatic Cancer. J Gastrointest Surg 2017; 21:496-505. [PMID: 27896658 DOI: 10.1007/s11605-016-3319-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/31/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of glycemic control in patients with pancreatic cancer treated with neoadjuvant therapy is unclear. METHODS Glycated hemoglobin (HbA1c) values were measured in patients with localized pancreatic cancer prior to any therapy (pretreatment) and after neoadjuvant therapy prior to surgery (preoperative). HbA1c levels greater than 6.5% were classified as abnormal. Patients were categorized based on the change in HbA1c levels from pretreatment to preoperative: GrpA, always normal; Gr B, worsened; GrpC, improved; and GrpD, always abnormal. RESULTS Pretreatment HbA1c levels were evaluable in 123 patients; there were 67 (55%) patients in GrpA, 8 (6%) in GrpB, 22 (18%) in GrpC, and 26 (21%) in GrpD. Of the 123 patients, 92 (75%) completed all intended therapy to include surgery; 57 (85%) patients in GrpA, 4 (50%) patients in GrpB, 16 (72%) patients in GrpC, and 15 (58%) patients in GrpD (p = 0.01). Elevated preoperative carbohydrate antigen 19-9 (CA19-9) (OR 0.22;[0.07-0.66]), borderline resectable (BLR) disease stage (OR 0.20;[0.01-0.45]) and abnormal preoperative HbA1c (OR 0.30;[0.11-0.90]) were negatively associated with completion of all intended therapy. Abnormal preoperative HbA1c was associated with a 2.74-fold increased odds of metastatic progression during neoadjuvant therapy (p = 0.08). CONCLUSIONS Elevated preoperative HbA1c is associated with failure to complete neoadjuvant therapy and surgery and a trend for increased risk of metastatic progression.
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Smith ZL, Daniel KE, Pant M, Dua KS, Aburajab M. Invasive intraductal papillary carcinoma of the bile duct masquerading as a common hepatic duct stone. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2016; 1:68-69. [PMID: 29905233 PMCID: PMC5990414 DOI: 10.1016/j.vgie.2016.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Asare EA, Evans DB, Erickson BA, Aburajab M, Tolat P, Tsai S. Neoadjuvant treatment sequencing adds value to the care of patients with operable pancreatic cancer. J Surg Oncol 2016; 114:291-5. [PMID: 27264017 DOI: 10.1002/jso.24316] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/23/2016] [Indexed: 12/14/2022]
Abstract
Treatment sequencing for resectable pancreatic cancer remains controversial and there is lack of level one evidence comparing neoadjuvant versus adjuvant strategies. However, a comparison of the cost-effectiveness analysis of the treatment strategies may help to better define the healthcare value of each approach. This review will highlight the rationale for multimodality therapy in the treatment of pancreatic cancer, discuss the advantages and disadvantages of adjuvant therapy, and conceptualize the cost-effectiveness of a neoadjuvant approach with regard to healthcare value. J. Surg. Oncol. 2016;114:291-295. © 2016 Wiley Periodicals, Inc.
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