Nisa Kubiliun

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.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.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.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.

Background and Aims The efficacy and safety of endoscopic gallbladder drainage (EGBD) performed via endoscopic retrograde cholangiography (ERC)-based transpapillary stenting or EUS-based transmural stenting are unknown. We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these procedures and to compare them with percutaneous gallbladder drainage (PGBD). Methods We searched several databases from inception through December 10, 2015 to identify studies (with 10 or more patients) reporting technical success and postprocedure adverse events of EGBD. Weighted pooled rates (WPRs) for technical and clinical success, postprocedure adverse events, and recurrent cholecystitis were calculated for both methods of EGBD. Pooled odds ratios (ORs) were also calculated to compare the technical success and postprocedure adverse events in patients undergoing EGBD versus PGBD. Results The WPRs with 95% confidence intervals (CIs) of technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis for ERC-based transpapillary drainage were 83% (95% CI, 78%-87%; I2 = 38%), 93% (95% CI, 89%-96%; I2 = 39%), 10% (95% CI, 7%-13%; I2 = 27%), and 3% (95% CI, 1%-5%; I2 = 0%), respectively. The WPRs for EUS-based drainage for technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis were 93% (95% CI, 87%-96%; I2 = 0%), 97% (95% CI, 93%-99%; I2 = 0%), 13% (95% CI, 8%-19%; I2 = 0%), and 4% (95% CI, 2%-9%; I2 = 0%), respectively. On proportionate difference, EUS-based drainage had better technical (10%) and clinical success (4%) in comparison with ERC-based drainage. The pooled OR for technical success of EGBD versus PGBD was .51 (95% CI, .09-2.88; I2 = 23%) and for postprocedure adverse events was .33 (95% CI, .14-.80; I2 = 16%) in favor of EGBD. Conclusions EGBD is an efficacious and safe therapeutic modality for treatment of patients with acute cholecystitis who cannot undergo surgery. EGBD shows a similar technical success as PGBD but appears to be safer than PGBD. The efficacy and safety of endoscopic gallbladder drainage (EGBD) performed via endoscopic retrograde cholangiography (ERC)-based transpapillary stenting or EUS-based transmural stenting are unknown. We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these procedures and to compare them with percutaneous gallbladder drainage (PGBD). We searched several databases from inception through December 10, 2015 to identify studies (with 10 or more patients) reporting technical success and postprocedure adverse events of EGBD. Weighted pooled rates (WPRs) for technical and clinical success, postprocedure adverse events, and recurrent cholecystitis were calculated for both methods of EGBD. Pooled odds ratios (ORs) were also calculated to compare the technical success and postprocedure adverse events in patients undergoing EGBD versus PGBD. The WPRs with 95% confidence intervals (CIs) of technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis for ERC-based transpapillary drainage were 83% (95% CI, 78%-87%; I2 = 38%), 93% (95% CI, 89%-96%; I2 = 39%), 10% (95% CI, 7%-13%; I2 = 27%), and 3% (95% CI, 1%-5%; I2 = 0%), respectively. The WPRs for EUS-based drainage for technical success, clinical success, postprocedure adverse events, and recurrent cholecystitis were 93% (95% CI, 87%-96%; I2 = 0%), 97% (95% CI, 93%-99%; I2 = 0%), 13% (95% CI, 8%-19%; I2 = 0%), and 4% (95% CI, 2%-9%; I2 = 0%), respectively. On proportionate difference, EUS-based drainage had better technical (10%) and clinical success (4%) in comparison with ERC-based drainage. The pooled OR for technical success of EGBD versus PGBD was .51 (95% CI, .09-2.88; I2 = 23%) and for postprocedure adverse events was .33 (95% CI, .14-.80; I2 = 16%) in favor of EGBD. EGBD is an efficacious and safe therapeutic modality for treatment of patients with acute cholecystitis who cannot undergo surgery. EGBD shows a similar technical success as PGBD but appears to be safer than PGBD.

Background Existing guidelines aim to stratify the likelihood of choledocholithiasis to guide the use of ERCP versus a lower-risk diagnostic study such as EUS, MRCP, or intraoperative cholangiography. Objective To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy. Design Retrospective cohort study. Setting Tertiary-care hospital. Patients Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period. Interventions Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis. Main Outcome Measurements The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP. Results A total of 179 (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 patients (56.3%) had a stone/sludge on subsequent confirmatory test. Of patients not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based on data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends do not improve performance. Limitations Retrospective study, inconsistent timing of the second set of biochemical markers. Conclusion In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary to meet the goal of eliminating unnecessary diagnostic ERCP. Existing guidelines aim to stratify the likelihood of choledocholithiasis to guide the use of ERCP versus a lower-risk diagnostic study such as EUS, MRCP, or intraoperative cholangiography. To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy. Retrospective cohort study. Tertiary-care hospital. Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period. Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis. The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP. A total of 179 (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 patients (56.3%) had a stone/sludge on subsequent confirmatory test. Of patients not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based on data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends do not improve performance. Retrospective study, inconsistent timing of the second set of biochemical markers. In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary to meet the goal of eliminating unnecessary diagnostic ERCP.

This is one of a series of documents prepared by the American Society for Gastrointestinal Endoscopy (ASGE) Training Committee. This curriculum document contains recommendations for training and is intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training in endoscopic retrograde cholangiopancreatography (ERCP) and to serve as a guide to published references, videos, and other resources available to the trainer.

Background & AimsThere is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy.MethodsWe performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost.ResultsAfter screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics.ConclusionsOn the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy. There is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy. We performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost. After screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics. On the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy.

The two most common interventions used to treat painless jaundice from pancreatic cancer are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD). Our study aimed to characterize the geographic distribution of ERCP-performing hospitals among patients with pancreatic cancer in the United States and the association between geographic accessibility to ERCP-performing hospitals and biliary interventions patients receive.This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for pancreatic cancer from 2005 to 2013. Multilevel models were used to examine the association between accessibility to ERCP hospitals within a 30- and 45-min drive from the patient's residential ZIP Code and the receipt of ERCP treatment. A two-step floating catchment area model was used to calculate the measure of accessibility based on the distribution across SEER regions.7464 and 782 patients underwent ERCP and PTBD, respectively, over the study period. There were 808 hospitals in which 8246 patients diagnosed with pancreatic cancer in SEER regions from 2005 to 2013 received a procedure. Patients with high accessibility within both 30- and 45-min drive to an ERCP-performing hospital were more likely to receive an ERCP (30-min adjusted odds ratio [aOR]: 1.53, 95% confidence interval [CI]: 1.17-2.01; 45-min aOR: 1.31, 95% CI: 1.01-1.70). Furthermore, in the adjusted model, Black patients (vs. White) and patients with stage IV disease were less likely to receive ERCP than PTBD.Patients with pancreatic cancer and high accessibility to an ERCP-performing hospital were more likely to receive ERCP. Disparities in the receipt of ERCP persisted for Black patients regardless of their access to ERCP-performing hospitals.

We report the development and validation of a combined DNA/RNA next-generation sequencing (NGS) platform to improve the evaluation of pancreatic cysts.Despite a multidisciplinary approach, pancreatic cyst classification, such as a cystic precursor neoplasm, and the detection of high-grade dysplasia and early adenocarcinoma (advanced neoplasia) can be challenging. NGS of preoperative pancreatic cyst fluid improves the clinical evaluation of pancreatic cysts, but the recent identification of novel genomic alterations necessitates the creation of a comprehensive panel and the development of a genomic classifier to integrate the complex molecular results.An updated and unique 74-gene DNA/RNA-targeted NGS panel (PancreaSeq Genomic Classifier) was created to evaluate 5 classes of genomic alterations to include gene mutations (e.g., KRAS, GNAS, etc.), gene fusions and gene expression. Further, CEA mRNA ( CEACAM5 ) was integrated into the assay using RT-qPCR. Separate multi-institutional cohorts for training (n=108) and validation (n=77) were tested, and diagnostic performance was compared to clinical, imaging, cytopathologic, and guideline data.Upon creation of a genomic classifier system, PancreaSeq GC yielded a 95% sensitivity and 100% specificity for a cystic precursor neoplasm, and the sensitivity and specificity for advanced neoplasia were 82% and 100%, respectively. Associated symptoms, cyst size, duct dilatation, a mural nodule, increasing cyst size, and malignant cytopathology had lower sensitivities (41-59%) and lower specificities (56-96%) for advanced neoplasia. This test also increased the sensitivity of current pancreatic cyst guidelines (IAP/Fukuoka and AGA) by >10% and maintained their inherent specificity.PancreaSeq GC was not only accurate in predicting pancreatic cyst type and advanced neoplasia but also improved the sensitivity of current pancreatic cyst guidelines.

Detection of chromosomal abnormalities by fluorescence in situ hybridization (FISH) analysis has not been well-studied in FNA samples of pancreatic masses. Selective use of FISH in patients with inconclusive on-site cytopathology results may improve the sensitivity of EUS for malignancy.To determine the sensitivity and specificity of FISH analysis in patients with inconclusive on-site cytopathology results.Consecutive patients with suspected pancreatic malignancy, nonrandomized cohort study. Final diagnosis was based on either surgical biopsy or disease progression on extended follow-up or death.Academic center, tertiary-care referral cancer center.A total of 212 EUS examinations were performed in 206 patients for solid pancreatic lesions over a 24-month period (January 2009-December 2010). FISH analysis was done for 69 patients with inconclusive or nonavailable on-site cytology results.EUS-guided FNA (EUS-FNA) of solid pancreatic masses with cytology and FISH analysis for polysomy of chromosomes 3, 7, and 17 and deletion of 9p21.Sensitivity/specificity of cytology, FISH, and a composite of cytology and FISH.Patients with positive on-site cytology (110), neuroendocrine tumors (22), insufficient follow-up (1), FISH not obtained (3), and renal cancer with pancreatic metastasis (1) were excluded. Sixty-nine patients comprised the study cohort, 54 with malignancy and 15 with benign disease. Sensitivity for malignancy of cytology, FISH analysis, and the combination were 61%, 74%, and 85%, respectively (P = .009). FISH detected an additional 13 cases of pancreatic adenocarcinoma missed by cytology. There was no false-positive FISH analysis in 15 patients with benign disease. No major complications occurred from EUS-FNA.Single center, selected patients underwent FISH analysis, limited number of patients with benign disease.In patients with suspected pancreatic cancer, FISH analysis can detect additional cases missed by cytology without compromising specificity. FISH analysis to detect polysomy of chromosomes 3, 7, and 17 and deletion of 9p21 should be considered when cytology is negative for malignancy in patients with a known pancreatic mass.

This is one of a series of documents prepared by the American Society for Gastrointestinal Endoscopy (ASGE) Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of endoscopy as it relates to enteral nutrition and to serve as a guide to published references, videotapes, and other resources available to the trainer.

Introduction Immune checkpoint inhibitors (ICIs) have become a standard of care in metastatic renal cell carcinoma (mRCC) but are associated with immune-related adverse events (irAEs) including colitis. Growing evidence suggests proton pump inhibitors (PPIs) increase the risk of inflammatory bowel disease (IBD). Given the pathophysiological overlap between IBD and ICI colitis, we sought to evaluate the relationship between PPI use and ICI colitis in mRCC patients. Patients and Methods We performed a retrospective study of adult patients who received ICI therapy for mRCC between 2015 and 2018 at University of Texas Southwestern Medical Center affiliated hospitals. Clinical characteristics, oncological outcomes, ICI colitis details, and PPI use details were collected by manual chart review. The diagnosis of ICI colitis was made via biopsy when available, or by clinical criteria (symptoms and response to immunosuppressive therapy) when biopsy specimens were unavailable or inconclusive. Univariable and multivariable logistic regression analyses were conducted to assess the potential contribution of PPIs to ICI colitis. Results A total of 176 patients received ICI therapy for mRCC, of which 16 (9.1%) were diagnosed with ICI colitis. Patients with ICI colitis presented with elevated stool lactoferritin and calprotectin and a wide range of endoscopic and histologic findings. There were no significant differences between patients with and without ICI colitis in age, gender, medical comorbidities, RCC history, and overall survival. However, exposure to ipilimumab and PPI use were more frequently observed in patients with ICI colitis than those without. In univariable and multivariable logistic regression analyses, exposure to ipilimumab and chronic use of PPIs > 8 weeks were significantly associated with ICI colitis. Conclusion In addition to ipilimumab use, chronic use of PPIs may be associated with ICI colitis in patients with mRCC.

Intraductal tubulopapillary neoplasms (ITPNs) of the pancreas are rare cystic precursor neoplasms to invasive pancreatic ductal adenocarcinoma (PDAC) and account for 3% of intraductal neoplasms of the pancreas. Originally reported by Yamaguchi et al,1Yamaguchi H. et al.Am J Surg Pathol. 2009; 33: 1164-1172Crossref PubMed Scopus (148) Google Scholar the clinicopathologic features of ITPNs are distinct from other pancreatic cysts. Radiographically, ITPNs are characterized by a nodular mass within dilated pancreatic ducts (Supplementary Figure 1A and B). These nodules are histologically composed of a tubulopapillary growth of epithelium with scant cytoplasmic mucin and necrotic foci (Supplementary Figure 1C–E).2Basturk O. et al.Am J Surg Pathol. 2017; 41: 313-325Crossref PubMed Scopus (49) Google Scholar In addition to their architectural complexity, ITPNs uniformly exhibit high-grade cytologic atypia and, in most cases, have an associated invasive carcinoma component (Supplementary Figure 1F–H). Although the morphologic features of ITPNs are clearly defined, the pathogenesis of these neoplasms remains poorly understood. The genomic findings of ITPNs differ significantly from those that are typically seen in other cystic precursor neoplasms of the pancreas and PDAC. Mutations in KRAS and GNAS are often absent in ITPNs, whereas these genomic alterations are frequently detected in intraductal papillary mucinous neoplasms and associated PDAC. Other than a subgroup of ITPNs harboring FGFR2 fusion genes and mutations within chromatin remodeling genes (eg, BAP1) and genes associated with the mechanistic target of rapamycin signaling pathway (eg, PIK3CA), recurrent driver genes have yet to be described in ITPNs.3Yamaguchi H. et al.Am J Surg Pathol. 2011; 35: 1812-1817Crossref PubMed Scopus (73) Google Scholar,4Basturk O. et al.Mod Pathol. 2017; 30: 1760-1772Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar In fact, some ITPNs do not harbor alterations in genes associated with PDAC. Considering KRAS wild-type PDACs often harbor alternative drivers of the mitogen-activated protein kinase (MAPK) signaling pathway, we performed both DNA- and RNA-based targeted next-generation sequencing (NGS) and whole transcriptome sequencing (WTS) of 23 surgically resected ITPNs (Supplementary Material and Methods). Consistent with previous studies, targeted NGS detected KRAS missense mutations in a minority of ITPNs (n = 2, 9%) (Table 1). However, alterations in genes coding for members of the MAPK signaling pathway were also identified and included a BRAF missense mutation (n = 1), ERBB2 amplification (n = 1), STRN-ALK fusion gene (n = 1), BRAF fusion genes (SND1-BRAF and AGK-BRAF, n = 2), ATP1B1-NRG1 fusion gene (n = 2), TRIM24-RET (n = 1), and multiple FGFR2 fusion genes (FGFR2-BICC1, FGFR2-CIT, FGFR2-FAM76A, FGFR2-PPHLN1, and FGFR2-NOL4; n = 5). Fifteen of 23 ITPNs (65%) had MAPK driver alterations and 11 ITPNs (48%) harbored fusion genes, which were mutually exclusive from each other. Additional alterations in decreasing order occurred in TP53 (n = 10), SMAD4 (n = 9), CDKN2A (n = 7), chromatin remodeling genes (BAP1 and ARID1A, n = 5), homologous recombination-related genes (BRCA2 and CHEK2, n = 3), STK11 (n = 2), Myc family of oncogenes (MYC and NMYC, n = 2), and PTEN (n = 1). Moreover, multiple chromosomal abnormalities were identified in 10 ITPNs (43%).Table 1Clinicopathologic Findings of 23 Patients With an ITPN of the PancreasCase no.Age (y)SexLocationSize (cm)Associated carcinomaGene fusionOther genomic alterations164MPancreatic head1.1YesNoneKRAS p.G12V, TP53 p.R248W, TP53 deletion, CDKN2A/B deletion, STK11 deletion, MYCN amplification (25 copies)275MPancreatic body and tail7.0YesNoneKRAS p.G12R, TP53 p.L194R, TP53 deletion, CDKN2A/B deletion, SMAD4 deletion, chromosomal gain of 11q, chromosomal loss of 16p364FPancreatic body2.7YesNoneBRAF p.V600E, chromosomal gain of 1q, chromosomal loss of 1p469FPancreatic body and tail9.0YesNoneERBB2 amplification (19 copies), TP53 p.T125_splice, ARID1A p.A245Gfs∗113534MPancreatic head7.5YesSTRN-ALKTP53 deletion, SMAD4 deletion6aIn addition to the patient's surgical specimen, the corresponding preoperative specimen (pancreatic cyst fluid) was molecularly evaluated.62MPancreatic head3.8NoSND1-BRAFbThe gene fusion was also detected within the patient's corresponding preoperative pancreatic cyst fluid.TP53 deletion718FEntire pancreas18.0NoAGK-BRAFTP53 deletion, SMAD4 deletion, chromosomal gain of 7p and 7q, chromosomal loss of 6p and 6q8aIn addition to the patient's surgical specimen, the corresponding preoperative specimen (pancreatic cyst fluid) was molecularly evaluated.59MPancreatic body and tail3.5YescThe gene fusion was also detected within the ITPN-associated invasive PDAC.ATP1B1-NRG1bThe gene fusion was also detected within the patient's corresponding preoperative pancreatic cyst fluid.SMAD4 deletion979MEntire pancreas26.6YesATP1B1-NRG1SMAD4 deletion, CHEK2 p.S372F, chromosomal loss of 1p, 6q, and 16p10aIn addition to the patient's surgical specimen, the corresponding preoperative specimen (pancreatic cyst fluid) was molecularly evaluated.68FPancreatic body and tail6.4YescThe gene fusion was also detected within the ITPN-associated invasive PDAC.TRIM24-RETbThe gene fusion was also detected within the patient's corresponding preoperative pancreatic cyst fluid.CDKN2A/B deletion, SMAD4 deletion, chromosomal gain of 1q and 12q, chromosomal loss of 1p and 14q1161FPancreatic head5.0YescThe gene fusion was also detected within the ITPN-associated invasive PDAC.FGFR2-BICC1CDKN2A/B deletion1227FPancreatic head3.5YesFGFR2-CITBAP1 p.F46Lfs∗26, CDKN2A/B deletion13aIn addition to the patient's surgical specimen, the corresponding preoperative specimen (pancreatic cyst fluid) was molecularly evaluated.81FPancreatic body3.9NoFGFR2-TACC2bThe gene fusion was also detected within the patient's corresponding preoperative pancreatic cyst fluid.TP53 p.R273H, MYC amplification (16 copies)1473MPancreatic head8.0YesFGFR2-FAM76ATSC1 p.E1101∗1563MPancreatic body and tail7.5YesFGFR2-PPHLN1BAP1 splice site c.376-33_378del36, MYC amplification (8 copies)1678FPancreatic tail5.4YescThe gene fusion was also detected within the ITPN-associated invasive PDAC.FGFR2-TACC2SMAD4 deletion, ARID1A p.Q581∗, ARID1A deletion, chromosomal loss of 9p, 9q, 12q, and 14q1722MEntire pancreas13.4YesFGFR2-NOL4BAP1 splice site c.428-2A>G, CDKN2A/B deletion, BRCA2 deletion1853FEntire pancreas12.5NoCFTR-RASGRF2MYC amplification (7 copies), chromosomal gain of 1p1937FPancreatic head4.8YesSPTLC1-JAK2SMAD4 deletion, STK11 p.G196Afs∗912074MEntire pancreas10.5YesATXN3-MAML3TP53 p.E346∗, TP53 deletion, CDKN2A/B deletion, RB1 p.E580∗, RB1 deletion, PTEN p.D107Y, PTEN deletion2168FPancreatic head6.0YesNCOA3-MAML2TP53 p.S241F, TP53 deletion, CDKN2A/B deletion, SMAD4 deletion, chromosomal loss of 11p, 11q, 13q, 19p, and 19q2273FPancreatic head3.1YesRUNX2-MAML2TP53 deletion, CDKN2A/B deletion, BRCA2 p.K2674∗, BRCA2 deletion, chromosomal loss of 17q2347MPancreatic head5.0YesATXN3-MAML2ARID1A deletion, chromosomal loss of 11p and 11qa In addition to the patient's surgical specimen, the corresponding preoperative specimen (pancreatic cyst fluid) was molecularly evaluated.b The gene fusion was also detected within the patient's corresponding preoperative pancreatic cyst fluid.c The gene fusion was also detected within the ITPN-associated invasive PDAC. Open table in a new tab Considering the relative abundance of MAPK-associated fusion genes that were found by targeted NGS, we hypothesized that additional fusion genes may be present among the 8 ITPNs (35%) without a discernable MAPK driver alteration. Therefore, we performed WTS and detected fusion genes in the remaining 8 ITPNs: FGFR2-TACC2 (n = 2), CFTR-RASGRF2 (n = 1), SPTLC1-JAK2 (n = 1), ATXN3-MAML3 (n = 1), NCOA3-MAML2 (n = 1), RUNX2-MAML2 (n = 1), and ATXN3-MAML2 (n = 1) (Supplementary Figure 2). Analogous to the results of targeted NGS, each fusion gene was mutually exclusive from other fusion genes, thus suggesting their involvement in common pathologic mechanisms. Because many of these fusion genes have not been described in other neoplasms, fluorescence in situ hybridization using MAML2 break-apart probes (orange, 5′ end of MAML2; green, 3′ end of MAML2) was performed on cases 21, 22, and 23 and confirmed the presence of a MAML2 rearrangement (Supplementary Figure 3). Additionally, the ITPN-associated PDAC for cases 8, 10, 11, and 16 were evaluated by either targeted NGS or WTS, and the respective fusion identified within the ITPN was also detected. Matched preoperative pancreatic cyst fluid specimens were available for a subset of ITPNs (cases 6, 8, 10, and 13), and once again the respective fusion genes were identified. Overall, 17 of 23 ITPNs (74%) were found to have MAPK driver alterations that included fusion genes and were mutually exclusive from each other. These fusion genes were also present within corresponding ITPN-associated PDACs and detected in preoperative pancreatic cyst fluid. Among the remaining 6 ITPNs, novel fusion genes were identified that were once again mutually exclusive from other fusion genes and included the following: CFTR-RASGRF2, SPTLC1-JAK2, ATXN3-MAML3, NCOA2-MAML2, RUNX2-MAML2, and ATXN3-MAML2. Fusion genes involving RASGRF2 and JAK2, but with different 5′ partners, have been previously reported in melanocytic lesions and hematologic neoplasms, respectively, and shown to result in downstream MAPK activation.5Houlier A. et al.Pigment Cell Melanoma Res. 2021; 34: 1074-1083Crossref PubMed Scopus (6) Google Scholar,6Peeters P. et al.Blood. 1997; 90: 2535-2540Crossref PubMed Google Scholar Thus, although the CFTR-RASGRF2 and SPTLC1-JAK2 fusion genes have not been specifically described, these alterations likely represent genomic drivers of the MAPK signaling pathway. In further support that these fusion genes similarly affect the MAPK signaling pathway, WTS of 9 ITPNs (Supplementary Figure 4) identified analogous gene expression profiles among each ITPN; however, the profiles were distinctly different compared with 13 intraductal papillary mucinous neoplasms and further underscore that ITPNs are a separate neoplasm from intraductal papillary mucinous neoplasms. The presence of MAML2 and MAML3 fusion genes in ITPNs is an intriguing finding. Both MAML2 and MAML3 belong to the 3-member transcriptional coactivator MAML (mastermind-like) family that plays an essential role in the transcriptional activation of multiple signaling pathways. However, our current understanding of the MAML proteins in cancer, such as mucoepidermoid carcinomas (MECs) of the salivary gland, is largely based on studies of the CRTC1-MAML2 fusion gene. The generation of a genetically engineered mouse model has established CRTC1-MAML2 as a key oncoprotein in the pathogenesis of MECs.7Chen Z. et al.JCI Insight. 2021; 6: e139497Crossref Scopus (23) Google Scholar Further, both in vitro cell line experiments and protein expression analysis of primary MECs have demonstrated that the CRTC1-MAML2 fusion gene is associated with MAPK activation.8Chen Z. et al.Oncogene. 2014; 33: 3869-3877Crossref PubMed Scopus (64) Google Scholar Blockade of the MAPK pathway with anti–epidermal growth factor receptor antibodies or pharmacologic inhibitors decreases cell growth and survival in CRTC1-MAML2 fusion-positive MEC cell lines and human MEC xenografts. It is therefore reasonable to speculate that the ITPN-associated MAML2 and MAML3 fusion genes are oncogenic MAPK driver alterations. There are limitations to our study. Although it represents one of the largest series of pancreatic ITPNs to be molecularly analyzed, the number of cases evaluated is relatively small, and concluding that driver alterations, especially fusion genes, within the MAPK signaling pathway are a universal feature of ITPNs may be premature. It is important to note, however, that ITPNs can arise from the bile duct and also represent precursor neoplasms to cholangiocarcinoma.9Park H.J. et al.Pathol Int. 2010; 60: 630-635Crossref PubMed Scopus (25) Google Scholar Sequencing studies of biliary ITPNs are limited, but mutations in KRAS and BRAF are of similar low prevalence in biliary ITPNs as pancreatic ITPNs.10Gross C. et al.Cancers. 2021; 13: 2742Crossref PubMed Scopus (6) Google Scholar Moreover, FGFR2 alterations have been found in ITPNs of the bile duct. Considering the radiographic, histologic, and molecular parallels between pancreatic and biliary ITPNs, it is plausible that biliary ITPNs are also characterized by frequent MAPK-associated fusion genes. Unfortunately, WTS studies of biliary ITPNs have not been reported. Another issue with our study is the lack of orthogonal confirmation of all fusion genes described herein. Many fusion genes detected by targeted NGS were validated through WTS (Supplementary Material and Methods), and break-apart fluorescence in situ hybridization was used to confirm the presence of MAML2 rearrangements. Additionally, the identification of the same fusion gene in matched preoperative pancreatic cyst fluid and corresponding ITPN-associated PDACs provides further support to the validity of our findings. In summary, we report the results of targeted NGS and WTS of pancreatic ITPNs, and, consistent with previous findings, missense mutations in KRAS were seen in some cases. Notably, other genomic alterations implicated within the MAPK signaling pathway were identified in the remaining cases and were mutually exclusive from each other. The predominant genomic alteration found in ITPNs was the presence of a fusion gene, many of which have not been described in PDAC or other neoplasms. Finally, the detection of ITPN-associated fusion genes in preoperative pancreatic cyst fluid suggests these genomic alterations could potentially improve the early detection of these cystic precursor neoplasms to PDAC. Members of the Pancreatic Cyst Alliance are as follows: James Tucker, PhD,1 Amer H. Zureikat, MD,2 Jin He, MD, PhD,3 Alessandro Paniccia, MD,2 Kenneth K. Lee, MD,2 Herbert J. Zeh, MD,4 Melissa E. Hogg, MD,5 Anil K. Dasyam, MD,6 Kevin McGrath, MD,7 Anne Marie Lennon, MD, PhD,8 Kenneth E. Fasanella, MD,7 Elham Afghani, MD, MPH,8 Randall E. Brand, MD,7 Adam Slivka, MD, PhD,7 Nisa Kubiliun, MD,9 Christopher J. VandenBussche, MD, PhD,10 Elizabeth D. Thompson, MD, PhD,10 Michael S. Torbenson, MD,11 Daniela S. Allende, MD,12 Phoenix D. Bell, MD,4 Cihan Kaya, PhD,1 and Abigail I. Wald, PhD1; from the 1Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 2Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 3Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; 4Department of Surgery, University of Texas Southwestern, Dallas, Texas; 5Department of Surgery, NorthShore University Health System, Evanston, Illinois; 6Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 7Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 8Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; 9Department of Medicine, University of Texas Southwestern, Dallas, Texas; 10Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; 11Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota; and 12Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio. Ralph H. Hruban, MD (Conceptualization: Equal; Data curation: Equal; Formal analysis: Equal; Writing – original draft: Equal; Writing – review & editing: Equal). Lodewijk A. A. Brosens, MD, PhD (Data curation: Supporting). Vincenzo Condello, PhD (Data curation: Supporting). James Tucker, PhD (Data curation: Supporting). Amer H. Zureikat, MD (Data curation: Supporting). Jin He, MD, PhD (Data curation: Supporting). Alessandro Paniccia, MD (Data curation: Supporting). Kenneth K. Lee, MD (Data curation: Supporting). Herbert J. Zeh, MD (Data curation: Supporting). Melissa E. Hogg, MD (Data curation: Supporting). Anil K. Dasyam, MD (Data curation: Supporting). Kevin McGrath, MD (Data curation: Supporting). Anne Marie Lennon, MD, PhD (Data curation: Supporting). Kenneth E. Fasanella, MD (Data curation: Supporting). Elham Afghani, MD, MPH (Data curation: Supporting). Randall E. Brand, MD (Data curation: Supporting). Adam Slivka, MD, PhD (Data curation: Supporting). Nisa Kubiliun, MD (Data curation: Supporting). Christopher J. VandenBussche, MD, PhD (Data curation: Supporting). Elizabeth D. Thompson, MD, PhD (Data curation: Supporting). Michael S. Torbenson, MD (Data curation: Supporting). Daniela S. Allende, MD (Data curation: Supporting). Phoenix D. Bell, MD (Data curation: Supporting). Cihan Kaya, PhD (Data curation: Supporting). Abigail I. Wald, PhD (Conceptualization: Equal; Data curation: Equal; Formal analysis: Equal; Writing – original draft: Equal; Writing – review & editing: Equal). Marina N. Nikiforova, MD (Conceptualization: Equal; Data curation: Equal; Formal analysis: Equal; Writing – original draft: Equal; Writing – review & editing: Equal). Aatur Singhi, MD, PhD (Conceptualization: Lead; Data curation: Lead; Formal analysis: Lead; Writing – original draft: Lead; Writing – review & editing: Lead). Study approval was obtained from the authors’ respective institutional review boards. The anatomic pathology surgical archives from the departments of pathology at the University of Pittsburgh Medical Center (UPMC), Johns Hopkins Hospital, and University Medical Center Utrecht were queried for the diagnosis of ITPN. Cases with hematoxylin and eosin–stained slides and corresponding formalin-fixed paraffin-embedded tissue were retrieved and reviewed to confirm the diagnosis of an ITPN by a trained surgical pathologist with gastrointestinal tract and hepatopancreatobiliary subspecialty training (J.W.L., R.H.H., L.A.A.B., and/or A.D.S.). The diagnosis of an ITPN was based on the 2010 and 2019 World Health Organization classification of tumors of the digestive system.1Adsay N.V. et al.Intraductal neoplasm of the pancreas.in: WHO classification of tumors of the digestive system. 4th ed. IARC Press, Lyon2010: 304-313Google Scholar, 2Basturk O. et al.Pancreatic intraductal tubulopapillary neoplasm.in: WHO classification of tumors of the digestive system. 5th ed. IARC Press, Lyon2019: 317-318Google Scholar, 3Yamaguchi H. et al.Am J Surg Pathol. 2009; 33: 1164-1172Crossref PubMed Scopus (148) Google Scholar Twenty-three ITPNs were identified as well as 4 matched preoperative pancreatic cyst fluid specimens that were submitted for molecular testing (PancreaSeqV2) through the Molecular and Genomic Pathology Laboratory at UPMC.4Singhi A.D. et al.Gut. 2018; 67: 2131-2141Crossref PubMed Scopus (213) Google Scholar Nucleic acid extraction and subsequent DNA- and RNA-based targeted NGS were performed within the Clinical Laboratory Improvement Amendments–certified and College of American Pathologists–accredited Molecular and Genomic Pathology Laboratory at UPMC. Genomic DNA and RNA were isolated from formalin-fixed paraffin-embedded tissue (surgical resection specimens), and pancreatic cyst fluid was obtained by endoscopic ultrasound–guided fine-needle aspiration using the DNeasy Blood and Tissue kit on automated QIAcube instrument (Qiagen, Germantown, MD) or the MagNA Pure LC Total Nucleic Acid Isolation Kit (Roche, Indianapolis, IN) on Compact MagNA Pure (Roche). Extracted DNA and RNA were quantitated on the Glomax Discover using the QuantiFluor ONE dsDNA System and the QuantiFluor RNA system, respectively (Promega, Madison, WI). Targeted NGS-based testing from isolated DNA and RNA was performed for all 23 cases within the Molecular and Genomic Pathology Laboratory at UPMC using the Oncomine Comprehensive Assay v3 (OCAv3) primers (Thermo Fisher Scientific, Waltham, MA) according to the manufacturer’s protocol.5Singhi A.D. et al.Gastroenterology. 2020; 158: 573-582Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Amplicons were barcoded, ligated with specific adapters, and purified. DNA and RNA library quantity and quality checks were performed using the 4200 TapeStation (Agilent Technologies, Santa Clara, CA). The Ion Chef was used to prepare and enrich templates and enable testing using ion sphere particles on a semiconductor chip. Massive parallel sequencing was carried out on an Ion S5 XL System according to the manufacturer’s instructions (Thermo Fisher Scientific), and data were analyzed with the Torrent Suite Software v5.12 for point mutations, small insertions/deletions, and copy number alterations. Each variant was prioritized according to the 2017 Association for Molecular Pathology, American Society of Clinical Oncology, and College of American Pathologists joint consensus guidelines for interpretation of sequence variants in cancer using a tier-based system.6Li M.M. et al.J Mol Diagn. 2017; 19: 4-23Abstract Full Text Full Text PDF PubMed Scopus (900) Google Scholar Tier I, II, and III variants were reported; however, only tier I and II variants were used for subsequent analysis. The limit of detection of the assay was at 3% mutant allele frequency. The minimum depth of coverage for testing was 300 times. Copy number variation analysis was also performed as previously described.7Grasso C. et al.J Mol Diagn. 2015; 17: 53-63Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar The total depth of sequencing coverage of each sequenced region was normalized by the normal controls and calculated per sequenced case. A decrease in sequencing coverage below established cutoffs with a simultaneous presence of a sequence variant at high allele frequency was considered a copy number loss. In contrast, an increase in sequencing coverage above established cutoffs was interpreted as a copy number gain. A gene amplification was defined by the presence of ≥6 copies of a variant as previously described and validated using fluorescence in situ hybridization (FISH) analysis.7Grasso C. et al.J Mol Diagn. 2015; 17: 53-63Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar,8Nikiforova M.N. et al.NeuroOncol. 2016; 18: 379-387Google Scholar Targeted RNA expression and fusions were evaluated using the Torrent Suite Software v5.12 and an in-house bioinformatics program, Variant Explorer (UPMC). The limit of detection of the RNA assay was 1%–5% tumor cells. More than 50 fusion-specific reads that cross the fusion breakpoint are required to make a positive fusion call. RNA sequencing libraries of cases 2, 4, 8, 10, 11, 13, 16, and 18–23 were prepared using the Illumina TruSeq RNA Exome Library Prep for Enrichment, according to the manufacturer’s protocol. Cluster generation and paired-end sequencing were performed on an Illumina NextSeq 2000 using NextSeq 1000/2000 P2 Reagents (200 cycles) v3. For detection of gene fusions, sequencing data were analyzed using Chimerascan, FusionCatcher, and Star-Fusion algorithms integrated into an in-house developed bioinformatics pipeline for detection of clinically relevant fusions.9Iyer M.K. et al.Bioinformatics. 2011; 27: 2903-2904Crossref PubMed Scopus (209) Google Scholar, 10Nicorici D. et al.bioRxiv. 2014; 011650Google Scholar, 11Haas B.J. et al.bioRxiv. 2017; 120295Google Scholar Analysis of sequencing data for gene expression was performed as previously described.5Singhi A.D. et al.Gastroenterology. 2020; 158: 573-582Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar,12Nikiforova M.N. et al.Thyroid. 2019; 29: 161-173Crossref PubMed Scopus (40) Google Scholar For gene expression analysis, the filtered high-quality reads from HiSeq sequencing system were aligned to human genome (hg19-GRCh37) using TopHat aligner, and the number of reads mapped to each gene was calculated using RSeM and featureCounts tools.13Trapnell C. et al.Bioinformatics. 2009; 25: 1105-1111Crossref PubMed Scopus (9056) Google Scholar, 14Li B. et al.BMC Bioinformatics. 2011; 12: 323Crossref PubMed Scopus (11122) Google Scholar, 15Liao Y. et al.Bioinformatics. 2014; 30: 923-930Crossref PubMed Scopus (9283) Google Scholar From the read counts, the differential expression analysis was performed using the edgeR package.16Robinson M.D. et al.Bioinformatics. 2010; 26: 139-140Crossref PubMed Scopus (21414) Google Scholar The expression levels for target genes implicated in the epidermal growth factor receptor/extracellular signal-regulated kinase signaling pathways were evaluated as previously published.5Singhi A.D. et al.Gastroenterology. 2020; 158: 573-582Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Genes with a fold change of >2 and a P < .05 were selected as differentially expressed genes and used in pathway analysis. Break-apart FISH for cases 21–23 was used to evaluate for MAML2 rearrangements as previously described.17Seethala R.R. et al.Am J Surg Pathol. 2010; 34: 1106-1121Crossref PubMed Scopus (218) Google Scholar Briefly, the MAML2 break-apart probe consists of an 11q21 bacterial artificial chromosome, clones RP11-16K5 (Spectrum Orange) and RP11-676L3 (Spectrum Green), that map to the 5′ and 3′ ends of MAML2, respectively. Labeled clones were combined to create a dual-color, single-fusion probe set. Formalin-fixed paraffin-embedded sections were cut at 4 μm, mounted on positively charged slides, baked for 15 minutes at 90oC, and then deparaffinized in xylene. Slides were dehydrated in 100% ethanol and allowed to air dry. Pretreatment in 10 mM citric acid was followed by an NaCl protease treatment to remove proteins and non-DNA cellular components. The slide and probe were co-denatured and hybridized overnight. Slides were then washed, and 4′,6-diamidino-2-phenylindole counterstain was applied as well as a glass coverslip. Visualization of the FISH signals was accomplished by using a fluorescence microscope, and pictures were captured by using a FISH imaging system (CytoVision; Leica Biosystems, Buffalo Grove, IL). Two technologists experienced in FISH independently scored 50 tumor nuclei for each case with positivity defined as >15% of tumor cells demonstrating split signals (isolated green signals). Overlapping cells were excluded from analysis.Supplementary Figure 2Known MAPK fusion genes, such as those in FGFR2 (A), NRG1 (B), and RET (C) were identified by WTS of ITPNs. To the left, each box represents an exon of the designated gene with black arrows indicating the breakpoint. The color is indicative of relative expression levels, per exon basis, with red designating high expression and blue designating low expression. To the right, the specific exons of each gene are annotated. In addition to known fusion genes, WTS detected novel fusion genes that have been implicated within the MAPK signaling pathway to include RASGRF2 (D), JAK2 (E), MAML2 (F–H), and MAML3 (I).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplementary Figure 3(A) WTS of case 21 identified an NCOA3-MAML2 fusion gene. (B) The MAML2 rearrangement was confirmed using a break-apart FISH probe that exhibited isolated orange (5′ end of MAML2) and green (3′ end of MAML2) signals along with a concomitant chromosome 11q21 deletion. In comparison, (C) case 8 harbored an ATP1B1-NRG1 fusion gene and demonstrated (D) wild-type MAML2 (intact yellow signals due to overlapping orange and green signals).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplementary Figure 4Comparative WTS of intraductal papillary mucinous neoplasms (IPMNs; n = 13) and ITPNs (n = 9) and key genomic alterations associated with ITPNs to include affected signaling pathways. (A) Transcriptomic sequencing revealed increased expression of numerous genes implicated within multiple receptor tyrosine kinase (RTK) signaling pathways. However, ITPNs as compared with IPMNs exhibited differential expression for genes involved in epidermal growth factor receptor (EGFR)/extracellular signal-regulated kinase (ERK) signaling. (B) Despite the identification of multiple RTK signaling pathways and based on previous studies, the key genomic alterations that characterize ITPNs seem to converge onto the MAPK signaling pathway, which is known to regulate a variety of biologic processes, such as cell proliferation and survival. AdenoCA, adenocarcinoma; HGD, high-grade dysplasia; LGD, low-grade dysplasia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Anti-tumor necrosis factor (TNF) medications have similar efficacy in Crohn's disease (CD), but have not been compared in the real world. This study compared health costs and utilization for patients with CD newly initiating anti-TNF therapy with adalimumab (ADA) or infliximab (IFX) by using insurance data.CD patients initiating ADA or IFX therapy were identified from the MarketScan database. ADA and IFX groups were matched using a propensity score. The primary endpoint was direct costs of healthcare for the 6 months following initiation. The secondary endpoints compared healthcare utilization between groups.After propensity matching, characteristics were similar between the ADA (n = 623) and IFX (n = 623) groups. During the 6-month interval following anti-TNF initiation, healthcare costs were significantly lower for ADA compared with IFX. Total healthcare cost was $18,885 for ADA and $24,355 for IFX, a difference in cost of $5,470 (P < 0.0001). CD-related costs made up the majority of the costs: $16,454 for ADA and $22,316 for IFX (P < 0.0001). The largest difference in cost was seen in outpatient visits: $2,082 difference between the two groups (P < 0.0001). Both all-cause and CD-related hospitalization decreased for both ADA and IFX groups. Emergency room and hospitalization use in the 6-month follow-up period was not statistically different between groups, although numerically slightly higher in the IFX group.Patients with CD using ADA had lower healthcare costs than patients using IFX; this difference was partly driven by outpatient medical costs.

Post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is a common and potentially devastating complication of ERCP. Advances in risk stratification, patient selection, procedure technique, and prophylactic interventions have substantially improved the endoscopists’ ability to prevent this complication. This article presents the evidence-based approaches to preventing post-ERCP pancreatitis and suggests timely research questions in this important area.

Abstract Background Pancreatic cancer is projected to become the second leading cause of cancer‐related deaths by 2030. Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as first‐line therapy for biliary decompression in pancreatic cancer. The aim of our study was to characterize geographic and racial/ethnic disparities in ERCP utilization among patients with pancreatic cancer. Methods Retrospective cohort study using the US Surveillance, Epidemiology, and End Results (SEER)‐Medicare database to identify patients diagnosed with pancreatic cancer from 2003‐2013. The primary outcome was receipt of ERCP, with or without stent placement, vs any non‐ERCP biliary intervention. Results Of the 36 619 patients with pancreatic cancer, 37.5% (n = 13 719) underwent an ERCP, percutaneous drainage, or surgical biliary bypass. The most common biliary intervention (82.6%) was ERCP. After adjusting for tumor location and stage, Blacks were significantly less likely to receive ERCP than Whites (aOR 0.84, 95% CI 0.72, 0.97) and more likely to receive percutaneous transhepatic biliary drainage (PTBD) (aOR 1.38, 95% CI 1.14, 1.66). Patients in the Southeast and the West were more likely to receive ERCP than those in the Northeast (Southeast aOR 1.21, 95% CI 1.04, 1.40; West aOR 1.16, 95% CI 1.01, 1.32). Conclusion Racial/ethnic and geographic disparities in access to biliary interventions including ERCP exist for patients with pancreatic cancer in the United States. Our results highlight the need for further research and policies to improve access to appropriate biliary intervention for all patients.

Lynch syndrome increases risks for colorectal and other cancers. Though published Lynch syndrome cancer risk-management guidelines are effective for risk-reduction, the condition remains under-recognized. The Cancer Genetics Program at an academic medical center implemented a population-based cancer family history screening program, Detecting Unaffected Individuals with Lynch syndrome, to aid in identification of individuals with Lynch syndrome.In this retrospective cohort study, simple cancer family history screening questionnaires were used to identify those at risk for Lynch syndrome. Program navigators triaged and educated those who screened positive about hereditary cancer, and genetic counseling and testing services, offering genetic counseling if eligible. Genetic counseling was provided primarily via telephone. Genetic counselors performed hereditary cancer risk assessment and offered genetic testing via hereditary cancer panels to those eligible. Remote service delivery models via telephone genetic counseling and at-home saliva testing were used to increase access to medical genetics services.This program screened 212,827 individuals, over half of whom were considered underserved, and identified 133 clinically actionable genetic variants associated with hereditary cancer. Of these, 47 (35%) were associated with Lynch syndrome while notably, 70 (53%) were not associated with hereditary colorectal cancer. Of 3,344 patients offered genetic counseling after initial triage, 2,441 (73%) elected to schedule the appointment and 1,775 individuals (73%) completed genetic counseling. Among underserved patients, telephone genetic counseling completion rates were significantly higher than in-person appointment completion rates (P < .05). While remote service delivery improved appointment completion rates, challenges with genetic test completion using at-home saliva sample collection kits were observed, with 242 of 1592 individuals (15%) not completing testing.Population-based cancer family history screening and navigation can help identify individuals with hereditary cancer syndromes across diverse patient populations, but logistics of certain downstream service delivery models can impact outcomes.

This is one of a series of documents prepared by the American Society for Gastrointestinal Endoscopy (ASGE) Training Committee. This curriculum document contains recommendations for training, and it is intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for performance and training in EGD and to serve as a guide to published references, videos, and other resources available to the trainer.

<h2>Abstract</h2><h3>Background and Aims</h3> : Pancreatic fluid collections (PFCs) are common complications of acute pancreatitis and can cause pain, difficulty feeding, and infection. Endoscopic ultrasound (EUS)-guided drainage has become the standard of care, with lumen-apposing metal stents (LAMS) replacing double pigtail plastic stents (DPPS) as the preferred device. Coaxial placement of DPPS through LAMS is hypothesized to lower the risks of adverse events related to LAMS. We conducted a retrospective study to evaluate the safety and efficacy of this strategy. <h3>Methods</h3> : We conducted a retrospective study of consecutive patients with PFCs undergoing endoscopic cystgastrostomy with LAMS and DPPS or LAMS alone at two U.S. academic tertiary care centers from January 2016 until November 2022. Propensity scoring and an adjusted logistic regression model were used for analysis. <h3>Results</h3> : We included 68 patients with an average follow-up of 189 days. The most common etiology of pancreatitis was gallstones (35.3%), most PFCs were walled-off necrosis (61.8%), and the mean size was 14.7 cm (SD, ± 5.9 cm). Overall clinical success was 88.2%, without significant differences between LAMS and DPPS versus LAMS alone (95.7% vs. 84.4%, p=0.18; aOR 4.6, 95% CI 0.5-41.4). We found no statistically significant differences in rates of LAMS occlusion (aOR 0.47, 95% CI: 0.09-2.5), infection (aOR 1.03, 95% CI 0.17-6.2), bleeding (aOR 0.4, 95% CI 0.03-5), or stent migration (aOR 0.42, 95% CI 0.04-4.1) between the two groups. <h3>Conclusion</h3> : This retrospective cohort study found no statistically significant differences in the safety or efficacy of cystgastrostomy with LAMS and DPPS versus LAMS alone. Larger, prospective trials comparing these strategies are needed.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; Johns Hopkins University, USA; Stanford University, USA; University of Wisconsin-Madison, USA; The University of Texas Southwestern Medical Center, USA; Indiana University, USA; Moffitt Cancer Center, USA; Mayo Clinic in Florida, USA; West Virginia University, USA; Sutter Health, USA; Baylor College of Medicine, USA; Loma Linda University, USA; University of Nebraska Medical Center, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; Johns Hopkins University, USA; Stanford University, USA; University of Wisconsin-Madison, USA; The University of Texas Southwestern Medical Center, USA; Indiana University, USA; Moffitt Cancer Center, USA; Mayo Clinic in Florida, USA; West Virginia University, USA; Sutter Health, USA; Baylor College of Medicine, USA; Loma Linda University, USA; University of Nebraska Medical Center, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

University of Pittsburgh Medical Center, USA; The University of Texas Southwestern Medical Center, USA; West Virginia University, USA; VA Pittsburgh Healthcare System, USA; Loma Linda University, USA; Baylor College of Medicine, USA; University of Florida, USA; Essentia Health, USA.

Purpose: Anti-tumor necrosis factor (anti-TNF) medications have never been compared in a direct fashion under real-world circumstances. The purpose of this study was to compare health care utilization and costs using insurance data for patients with Crohn's disease (CD) who newly initiated anti-TNF therapy with adalimumab (ADA) or infliximab (IFX). Methods: Patients with ≥2 diagnoses of CD (ICD-9-CM: 555.XX) who initiated ADA or IFX therapy between January 2000 and March 2009 were identified from the Medstat MarketScan® database. Patients had to be continuously enrolled at least 6 months before and after anti-TNF initiation. Patients with prior biologic therapy (ie, anti-TNF or natalizumab) or colitis (ICD-9-CM: 556. x) were excluded. ADA and IFX groups were matched 1:1 using a propensity score stratified by age, residence, inpatient visit utilization, and steroid use at baseline. The primary endpoint was 6-month direct cost of health care. The secondary endpoints compared health care utilization between groups.Table: [1193] Mean health care costs (Per Person) during the 6 months after initiating anti-TNF Therapy (US $)Results: After propensity matching, demographic, clinical, and health care utilization characteristics were similar between the ADA (n=623) and IFX (n=623) groups at baseline. During the 6-month interval following anti-TNF initiation, health care costs were significantly lower for ADA compared with IFX therapy (table). Both all-cause and CD-related hospitalization decreased for both ADA and IFX groups (not shown). Emergency department (ED) use and hospitalization in the 6-month follow-up period were similar between groups. Conclusion: In this real-world analysis of patients with CD who newly initiated with ADA or IFX, ADA-treated patients had significantly lower health care costs. Hospitalization and ED utilization were similar between groups. Disclosure: DA Sussman: No disclosures. N Kubiliun: No disclosures. J Chao: Employee/Stock: Abbott. PM Mulani: Employee/Stock: Abbott. CA Gillis: Employee/Stock: Abbott. M Yang: Employee/Stock: Abbott. M Lu: Employee: Analysis Group; under contract with Abbott. M Abreu: Consultant: Abbott, Amgen, Elan, Opson, Prometheus, Salix, UCB.

In pancreatic carcinoma, EUS FNA cytology has a sensitivity ranging from 70% to 90%. Accuracy of cytology depends on the experience of the endosonographer and cytopathologist, the availability of on-site analysis and perhaps tumor characteristics (tumor necrosis and degree of differentiation). Utilization of FISH to detect chromosomal abnormalities in chromosomes 3, 7, 17 and 9p21 in FNA specimens may improve diagnostic accuracy of EUS FNA when combined with routine cytology.

Background: Referring provider and endoscopist impressions of colonoscopy indication are used for clinical care, reimbursement, and quality reporting decisions; however, the accuracy of these impressions is unknown.This study assessed the sensitivity, specificity, positive and negative predictive value, and overall accuracy of methods to classify colonoscopy indication, including referring provider impression, endoscopist impression, and administrative algorithm compared with gold standard chart review.Methods: We randomly sampled 400 patients undergoing a colonoscopy at a Veterans Affairs health system between January 2010 and December 2010.Referring provider and endoscopist impressions of colonoscopy indication were compared with gold-standard chart review.Indications were classified into 4 mutually exclusive categories: diagnostic, surveillance, high-risk screening, or average-risk screening.Results: Of 400 colonoscopies, 26% were performed for average-risk screening, 7% for high-risk screening, 26% for surveillance, and 41% for diagnostic indications.Accuracy of referring provider and endoscopist impressions of colonoscopy indication were 87% and 84%, respectively, which were significantly higher than that of the administrative algorithm (45%; P<.001 for both).There was substantial agreement between endoscopist and referring provider impressions (κ=0.76).All 3 methods showed high sensitivity (>90%) for determining screening (vs nonscreening) indication, but specificity of the administrative algorithm was lower (40.3%)compared with referring provider (93.7%) and endoscopist (84.0%) impressions.Accuracy of endoscopist, but not referring provider, impression was lower in patients with a family history of colon cancer than in those without (65% vs 84%; P=.001).Conclusions: Referring provider and endoscopist impressions of colonoscopy indication are both accurate and may be useful data to incorporate into algorithms classifying colonoscopy indication.

To determine the surveillance impact of utilizing a discrete field in structured radiology reports in patients with incidental pancreatic findings.We implemented a dictation template containing a discrete structured field element to auto-trigger listing of patients with incidental pancreatic findings on a pancreas clinic registry in the electronic health record. We isolated CT and MRI reports with incidental pancreatic findings over a 24-month period. We stratified patients by presence or absence of the discrete field element in reports (flagged versus unflagged) and evaluated the impact of report flagging on likelihood of clinic follow-up, follow-up imaging, endoscopic ultrasound, surgical intervention, genetics referral, obtaining pathologic diagnosis, and time interval between index imaging to various outcomes.Patients with flagged reports were more likely to be seen or discussed in a pancreas clinic compared with those with unflagged reports (189 of 376, 50.3% versus 79 of 474, 16.7%; P <. 001). Patients with flagged reports were more likely to get follow-up imaging than patients with unflagged reports (188 of 376, 50.0% versus 121 of 474, 25.5%; P < .001) and were more likely to undergo appropriate management of actionable findings compared with patients in the unflagged group (23 of 62, 37.1% versus 28 of 129, 21.7%; P = .036).Implementation of a structured discrete field element for reporting of patients with incidental pancreatic findings had positive impact on surveillance measures and can be applied in other organ systems with established surveillance guidelines to standardize patient care.

Clinical Fellow, Department of Internal Medicine, Division of Digestive and Liver Diseases, University of Texas, Southwestern Medical Center, Dallas Assistant Professor, Department of Internal Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas Assistant Professor, Department of Internal Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas Correspondence to: Omair Atiq, MD, 5323 Harry Hines Boulevard, Dallas, TX 75390 ([email protected]). The authors declare no conflicts of interest.

Guidelines recommend that patients with high probability of stones based on ultrasound and liver tests should be treated with ERCP while others should be investigated with EUS or MRI. In the last few years, use of MRCP has increased. MRI is an expensive test and the aim of our study was to determine if MRCP is being used appropriately and if not, the reasons for inappropriate use.

The ASGE has developed guidelines based on clinical predictors as well as imaging and serum liver tests to stratify which patients have higher likelihood of choledocholithiasis and would benefit from ERCP. These criteria describe cholangitis, bilirubin >4mg/dl, or a visualized stone in the bile duct as very strong predictors for choledocholithiasis. Other patients, who fall in the intermediate risk category, may need additional diagnostic studies such as endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP) or intraoperative cholangiography (IOC). And patients with low probability of having choledocholithiasis might not require further workup. Prior studies in this area have yielded mixed results. Our aim was to determine the performance of existing guidelines in predicting choledocholithiasis at a moderate to large volume academic endoscopy practice.

Gastric intestinal metaplasia (GIM) is an accepted pathologic precursor to gastric cancer. While surveillance of GIM in Europe and Asia is common, only limited recommendations for endoscopic surveillance strategies for GIM exist in the United States. The aim of our study is to better understand the attitudes and clinical practice patterns of U.S. gastroenterologists in the management of GIM and the role of endoscopic surveillance.

71 Background: Outcome for patients with malignant biliary obstruction is poor. While endoscopic or percutaneous procedures provide palliative benefit, stents often occlude or migrate, and drains frequently fail requiring repeat procedures in medically fragile patients. As part of a multidisciplinary effort to improve outcomes in this population, we undertook an investigation to determine rates of stent and drain failure and morbidity to identify areas of potential improvement. Methods: After Institutional Review Board approval, retrospective review of all cancer registry patients undergoing percutaneous or endoscopic intervention for biliary obstruction from 1/2004-10/2014 and billing reports from 11/2012-10/2014 identified 230 patients. Cases of biliary obstruction due to malignancy requiring intervention were selected, resulting in 94 evaluable patients. Charts were reviewed to determine dates and cause for stent and/or drain replacement and morbidity. Results: Of 94 analyzable patients, median age was 60 years and 49 were male (52%). Malignant cause of obstruction was gastric/colorectal in 16 (17%), biliary in 37 (39%), hepatocellular in 7 (7%), and pancreatic in 34 (36%). Stenting was part of the initial procedure in 47 (50%), and drain placement in 49 (52%). Ultimately 60 (64%) patients underwent stent procedures and 82 (87%) patients required drains. Of the stented patients, 27 (45%) required repeat stenting, and 13 (22%) required &gt; 1 stent replacement. Of the patients who underwent drainage procedures, 68 (83%) required repeat drainage, and 52 (63%) required &gt; 1 repeat drainage procedure. Cholangitis was observed following stent in 5 (5%) of patients, 60% in patients undergoing &gt; 1 stent procedures. Median survival after initial procedure was 12 months; for patients requiring repeat procedures, median survival was 4.5 months. Conclusions: Malignant biliary obstruction is a morbid disease with high rates of reocclusion requiring repeat procedures, which may negatively impact outcome and increase healthcare cost. Efforts to reduce the rates of repeat procedures are critical to address this clinical need.

Introduction: Referring provider and endoscopist impressions of colonoscopy indication are used for clinical care, reimbursement, and quality reporting decisions. Despite the central role of the referring provider and endoscopist in this process, there are surprisingly scant data regarding the accuracy of their impressions for determining colonoscopy indication. The aim of this project was to characterize the concordance of referring providers' and endoscopists' impressions of indication for colonoscopy as compared to “gold standard” chart review. Methods: We performed a retrospective cohort study of a random sample of 400 patients undergoing colonoscopy at a Veterans Affairs health system between January 1, 2010 and December 30, 2010. Referring providers' and colonoscopists' impressions of colonoscopy indication were compared to “goldstandard” indication, as determined by chart review performed by two authors. Indications were classified in four mutually exclusive categories: diagnostic, surveillance, high-risk screening, or average-risk screening. Concordance was defined as the ratio of colonoscopies with correctly identified indication to total number of colonoscopies. Results: Of 400 colonoscopies, 26% were performed for average risk screening, 7% high-risk screening, 26% surveillance, and 41% for diagnostic indications. The concordance of referring providers' and endoscopists' impressions of colonoscopy indication were 87% (347/400) and 84% (335/400), respectively, which were both significantly higher than concordance of a prior algorithm based on administrative data (45%, 178/400) (p < 0.001 for both). There was substantial agreement between endoscopist and referring provider impression (kappa 0.76). The concordance of endoscopists' impression was significantly lower in patients with a family history of colon cancer than those without a family history of colon cancer (65% vs. 84%, p=0.001). In contrast, referring providers' impression was not associated with any patient-level characteristics, with similar concordance among patients with and without a positive family history of colon cancer (85% and 87% respectively, p=0.81). Conclusion: Referring providers' and endoscopists' impressions of colonoscopy indication are both highly accurate and may be useful data for future algorithms to determine colonoscopy indication.

Purpose: Narrow Band Imaging (NBI) has enhanced the ability for intra-endoscopic mucosal interpretations via evaluation of surface pit patterns and vascular architecture. NBI has been reported to allow for high endoscopic accuracy in differentiating benign from potentially malignant tissue, therefore, providing the opportunity to forgo routine biopsy of small polyps. Our aim was to determine if NBI during colonoscopy would allow endoscopists to differentiate benign (hyperplastic-HP) from potentially malignant polyps (adenomas-AD) and second to compare visual interpretation accuracy of the polyps by the attendings and fellows. Methods: This prospective study, currently ongoing, allowed each eligible patient (pt) to act as their own control. All pts, over the age of 18, who presented for routine screening or surveillance colonoscopy and consented for trial participation were eligible. Patients with hematochezia, melena, history of inflammatory bowel disease and those unable to provide consent or those unwilling to participate were excluded from the study. Polyps found during the colonoscopy were visually assessed by both the attending and training fellow and independently recorded as either HP or AD based on surface architecture under both white light examination and then reassessed using NBI filtration. Both attendings and fellows underwent pre-study training in NBI interpretation of polyp characteristics. All identified polyps were removed in keeping with the current standard of care. Endoscopists assessment were compared to the pathologic analysis of all polyps biopsied. Results: During March 2010, 51 consecutive pts were enrolled. There were 24 men and 27 women (age range 35-85, mean 53). In total, forty-one polyps were identified. The fellows interpreted 29 polyps as HP: 16 were HP and 13 AD on pathology. Whereas 12 were interpreted by the fellows as AD: 6 were AD and 6 were HP on pathology. GI attendings visually interpreted 29 polyps as HP: 15 were HP and 14 AD on pathology; and 12 interpreted polyps as AD, of which 8 were AD and 4 were HP on pathology. The overall accuracy of interpretation was 54% for the fellows and 46% for the attendings (p=NS). Polyps less than 5 mm in diameter were correctly identified as HP 68% of the time and greater than 5 mm as AD 60% of the time. Conclusion: Contrary to previous published reports, we did not find that use of NBI at endoscopy enabled endoscopists to distinguish with high accuracy HP from AD polyps. Both training fellows and senior faculty had similar interpretation accuracy. Removal of all polyps at time of colonoscopy has been the standard of diagnosis for colon polyps and ultimately remains unchallenged.

Management of malignant dysphagia can be challenging given the number of options available, including esophageal stenting, radiation therapy, cryoablation, and photodynamic therapy (PDT). Our article discusses our approach to palliation of malignant dysphagia from a gastroenterologist’s perspective.

The evaluation of a bile duct stricture poses a significant challenge. Despite available diagnostic modalities, such as abdominal imaging, serum studies, endoscopic retrograde cholangiopancreatography (ERCP) and pathologic evaluation with ancillary testing, the distinction between benign and malignant biliary strictures remains a dilemma. Recently, we developed and retrospectively validated a targeted NGS assay to improve the detection of malignant strictures using ERCP-obtained biliary brushings and biopsies. A prospective, multi-institutional study was performed to rigorously evaluate the accuracy of this assay in patients with a bile duct stricture. Among four institutions, 399 patients with a bile duct stricture underwent prospective ERCP with tissue acquisition that yielded 265 brushings and 222 biopsies. These specimens were submitted for both pathologic evaluation and targeted NGS. Targeted NGS included an amplicon-based 28-cancer gene panel with the identification of a pathologic genomic alteration indicative of a malignant stricture. The molecular results were correlated with clinical presentation, history of primary sclerosing cholangitis (PSC), serum CA19-9, pathologic findings and follow-up. A stricture was designated as benign or malignant based on diagnostic pathology and/or a clinical course of >12 months. Follow-up data was available for 335 (84%) patients, and the sensitivity and specificity of NGS testing of biliary specimens for malignancy was 75% and 99%, respectively. The only false positive case corresponded to a low-grade periampullary adenoma. In comparison, an elevated serum CA19-9 and pathologic evaluation had sensitivities of 77% and 49%, and specificities of 68% and 99%, respectively. A false positive by preoperative pathologic evaluation corresponded to reactive epithelial changes due to the patient’s biliary stent. The combination of NGS testing and pathologic evaluation improved the sensitivity of both assays to 84%. Moreover, the addition of NGS testing to pathologic evaluation improved the sensitivity of biliary brushings from 39% to 79% and biliary biopsies from 49% to 85%. Among 53 PSC patients, NGS testing had an 78% sensitivity and 100% specificity. Serum CA19-9 and pathologic evaluation had sensitivities of 67% and 11%, and specificities of 84% and 100%, respectively. In addition to the detection of a malignant stricture, therapeutically relevant genomic alterations were found in 23 (7%) cases. The combination of NGS testing and pathologic evaluation of ERCP-obtained biliary specimens improved the detection of malignant bile duct strictures. Targeted NGS also increased the sensitivity of identifying malignancy in PSC patients. Further, the identification of actionable genomic alterations using NGS testing could aid in stratifying patients for targeted anticancer therapy.

The evaluation of a bile duct stricture poses a significant challenge. Despite available diagnostic modalities, such as abdominal imaging, serum studies, endoscopic retrograde cholangiopancreatography (ERCP) and pathologic evaluation with ancillary testing, the distinction between benign and malignant biliary strictures remains a dilemma. Recently, we developed and retrospectively validated a targeted NGS assay to improve the detection of malignant strictures using ERCP-obtained biliary brushings and biopsies. A prospective, multi-institutional study was performed to rigorously evaluate the accuracy of this assay in patients with a bile duct stricture. Among four institutions, 399 patients with a bile duct stricture underwent prospective ERCP with tissue acquisition that yielded 265 brushings and 222 biopsies. These specimens were submitted for both pathologic evaluation and targeted NGS. Targeted NGS included an amplicon-based 28-cancer gene panel with the identification of a pathologic genomic alteration indicative of a malignant stricture. The molecular results were correlated with clinical presentation, history of primary sclerosing cholangitis (PSC), serum CA19-9, pathologic findings and follow-up. A stricture was designated as benign or malignant based on diagnostic pathology and/or a clinical course of >12 months. Follow-up data was available for 335 (84%) patients, and the sensitivity and specificity of NGS testing of biliary specimens for malignancy was 75% and 99%, respectively. The only false positive case corresponded to a low-grade periampullary adenoma. In comparison, an elevated serum CA19-9 and pathologic evaluation had sensitivities of 77% and 49%, and specificities of 68% and 99%, respectively. A false positive by preoperative pathologic evaluation corresponded to reactive epithelial changes due to the patient’s biliary stent. The combination of NGS testing and pathologic evaluation improved the sensitivity of both assays to 84%. Moreover, the addition of NGS testing to pathologic evaluation improved the sensitivity of biliary brushings from 39% to 79% and biliary biopsies from 49% to 85%. Among 53 PSC patients, NGS testing had an 78% sensitivity and 100% specificity. Serum CA19-9 and pathologic evaluation had sensitivities of 67% and 11%, and specificities of 84% and 100%, respectively. In addition to the detection of a malignant stricture, therapeutically relevant genomic alterations were found in 23 (7%) cases. The combination of NGS testing and pathologic evaluation of ERCP-obtained biliary specimens improved the detection of malignant bile duct strictures. Targeted NGS also increased the sensitivity of identifying malignancy in PSC patients. Further, the identification of actionable genomic alterations using NGS testing could aid in stratifying patients for targeted anticancer therapy.

Next-generation sequencing (NGS) of pancreatic cyst fluid (PCF) is a useful adjunct to the identification of neoplastic pancreatic cysts. The detection of KRAS, GNAS and/or RNF43 mutations are specific for mucinous pancreatic cysts, such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs). Additional alterations in TP53, SMAD4 and the mTOR genes are associated with advanced neoplasia. In contrast, serous cystadenomas (SCAs) harbor VHL alterations and cystic pancreatic neuroendocrine tumors (PanNETs) have MEN1 and/or chromosomal copy number alterations (CNAs). While previous reports have proven the efficacy of NGS testing, these studies are largely retrospective, utilizing postoperative PCF, employing insensitive detection techniques and single institutional experiences. Therefore, we performed a prospective multi-institutional study to evaluate the accuracy of NGS testing in pancreatic cyst classification and the detection of advanced neoplasia. Within a 14-month period, 875 PCFs were collected by EUS-FNA from several institutions and prospectively tested using an NGS panel of 22 pancreatic cyst-associated genes. Molecular findings were correlated with carcinoembryonic antigen (CEA), cytology results and diagnostic pathology. Among 875 specimens, 849 (97%) PCFs were satisfactory for NGS testing. Mutations in KRAS/ GNAS/RNF43 were detected in 474 (56%) cases and correlated with elevated CEA (>192ng/mL) and mucin by cytology (p<0.001). Additional alterations in TP53/SMAD4/mTOR were identified in 63 (7%) PCFs and associated with malignant cytology (p<0.001). Mutations in VHL and MEN1/CNAs were also seen in 64 (8%) and 42 (5%) cases, respectively. Diagnostic pathology was available for 117 (14%) patients and included: 54 IPMNs with 26 harboring advanced neoplasia, 3 low-grade MCNs, 48 cystic PanNETs, 5 SCAs and 7 non-neoplastic cysts. The sensitivity and specificity of KRAS/GNAS/RNF43 mutations for IPMNs/MCNs was 93% and 100%, respectively. In conjunction with these mutations, alterations in TP53/SMAD4/mTOR had 96% sensitivity and 100% specificity for IPMNs with advanced neoplasia. In contrast, the sensitivities and specificities of main duct dilatation, an EUS mural nodule and malignant cytology were 42% and 76%, 31% and 93%, and 46% and 100%, respectively. Among cystic PanNETs, mutations in MEN1/CNAs had a 77% sensitivity and a 100% specificity. While limited in number, VHL mutations were associated with a sensitivity and specificity of 100% for SCAs. Finally, all 7 non-neoplastic cysts were devoid of any genomic alterations. NGS testing of PCF is highly sensitive and specific for mucinous pancreatic cysts, especially IPMNs, advanced neoplasia in an IPMN, and SCAs. Further, the identification of mutations in MEN1/CNAs represent a promising marker for cystic PanNETs.

e16550 Background: Immune checkpoint inhibitors (ICI) have become standard of care in metastatic renal cell carcinoma (mRCC) but are associated with immune-related adverse events (irAEs) including immune-related colitis (irC). Growing evidence suggests that proton pump inhibitors (PPIs) are associated with an increased risk of inflammatory bowel disease (IBD). Given the pathophysiological overlap between IBD and irC, we sought to evaluate the relationship between PPI use and irC in mRCC patients. Methods: We performed a retrospective study of adult patients who received ICI for mRCC between 2015 and 2018 at two tertiary care centers. Clinical characteristics, oncological outcomes, irC details, and PPI use were collected by manual chart review. The diagnosis of irC was made via biopsy when available, or when unavailable (or inconclusive) by clinical criteria. Univariable and multivariable logistic regression analyses were conducted to assess PPI use and other potential risk factors of irC. Results: A total of 176 patients received immunotherapy for mRCC, of which 16 (9.1%) were diagnosed with irC. There were no significant differences between patients with and without irC in age, gender, medical comorbidities, RCC subtype, treatment history, and overall survival. However, Caucasian race, exposure to ipilimumab, and PPI use were more frequently observed in patients with irC than those without. Patients with irC presented with elevated stool lactoferrin and calprotectin and a wide range of endoscopic and histologic findings. In univariable and multivariable logistic regression analyses, Caucasian race, exposure to ipilimumab and chronic use of PPIs &gt;8 weeks were significantly associated with irC (Table). Conclusions: PPI use may be a modifiable risk factor for irC development in patients with mRCC.[Table: see text]