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Cancer-cell-derived sialylated IgG as a novel biomarker for predicting poor pathological response to neoadjuvant therapy and prognosis in pancreatic cancer
Cui, Ming; Shoucair, Sami; Liao, Quan; Qiu, Xiaoyan; Kinny-Köster, Benedict; Habib, Joseph R; Ghabi, Elie M; Wang, Junke; Shin, Eun Ji; Leng, Sean X; Ali, Syed Z; Thompson, Elizabeth D; Zimmerman, Jacquelyn W; Shubert, Christopher R; Lafaro, Kelly J; Burkhart, Richard A; Burns, William R; Zheng, Lei; He, Jin; Zhao, Yupei; Wolfgang, Christopher L; Yu, Jun
BACKGROUND:Neoadjuvant therapy (NAT) is increasingly applied in pancreatic ductal adenocarcinoma (PDAC); however, accurate prediction of therapeutic response to NAT remains a pressing clinical challenge. Cancer-cell-derived sialylated immunoglobulin G (SIA-IgG) was previously identified as a prognostic biomarker in PDAC. This study aims to explore whether SIA-IgG expression in treatment-naïve fine needle aspirate (FNA) biopsy specimens could predict the pathological response (PR) to NAT for PDAC. METHODS:Endoscopic ultrasonography-guided FNA biopsy specimens prior to NAT were prospectively obtained from 72 patients with PDAC at the Johns Hopkins Hospital. SIA-IgG expression of PDAC specimens was assessed by immunohistochemistry. Associations between SIA-IgG expression and PR, as well as patient prognosis, were analyzed. A second cohort enrolling surgically resected primary tumor specimens from 79 patients with PDAC was used to validate the prognostic value of SIA-IgG expression. RESULTS:SIA-IgG was expressed in 58.3% of treatment-naïve FNA biopsies. Positive SIA-IgG expression at diagnosis was associated with unfavorable PR and can serve as an independent predictor of PR. The sensitivity and specificity of SIA-IgG expression in FNA specimens in predicting an unfavorable PR were 63.9% and 80.6%, respectively. Both positive SIA-IgG expression in treatment-naïve FNA specimens and high SIA-IgG expression in surgically resected primary tumor specimens were significantly associated with shorter survival. CONCLUSIONS:Assessment of SIA-IgG on FNA specimens prior to NAT may help predict PR for PDAC. Additionally, SIA-IgG expression in treatment-naïve FNA specimens and surgically resected primary tumor specimens were predictive of the prognosis for PDAC.
PMID: 36799816
ISSN: 1743-9159
CID: 5427352
Surgical Decision Making in Pancreatic Ductal Adenocarcinoma: Modeling Prognosis Following Pancreatectomy in the Era of Induction and Neoadjuvant Chemotherapy
Habib, Joseph R; Kinny-Köster, Benedict; Bou-Samra, Patrick; Alsaad, Ranim; Sereni, Elisabetta; Javed, Ammar A; Ding, Ding; Cameron, John L; Lafaro, Kelly J; Burns, William R; He, Jin; Yu, Jun; Wolfgang, Christopher L; Burkhart, Richard A
OBJECTIVE:To develop a predictive model of oncologic outcomes for patients with pancreatic ductal adenocarcinoma (PDAC) undergoing resection after neoadjuvant or induction chemotherapy use. BACKGROUND:Early recurrence following surgical resection for PDAC is common. The use of neoadjuvant chemotherapy prior to resection may increase the likelihood of long-term systemic disease control. Accurately characterizing an individual's likely oncologic outcome in the perioperative setting remains challenging. METHODS:Data from patients with PDAC who received chemotherapy prior to pancreatectomy at a single high-volume institution between 2007-2018 were captured in a prospectively collected database. Core clinicopathologic data were reviewed for accuracy and survival data were abstracted from the electronic medical record and national databases. Cox-proportional regressions were used to model outcomes and develop an interactive prognostic tool for clinical decision-making. RESULTS:A total of 581 patients were included with a median OS and RFS of 29.5 (26.5-32.5) and 16.6 (15.8-17.5) months, respectively. Multivariable analysis demonstrates OS and RFS were associated with type of chemotherapeutic used and the number of chemotherapy cycles received preoperatively. Additional factors contributing to survival models included: tumor grade, histopathologic response to therapy, nodal status, and administration of adjuvant chemotherapy. The models were validated using an iterative bootstrap method and with randomized cohort splitting. The models were well calibrated with concordance indices of 0.68 and 0.65 for the final OS and RFS models, respectively. CONCLUSION/CONCLUSIONS:We developed an intuitive and dynamic decision-making tool that can be useful in estimating OS, RFS and location-specific disease recurrence rates. This prognostic tool may add value to patient care in discussing the benefits associated with surgical resection for PDAC.
PMID: 33843794
ISSN: 1528-1140
CID: 4864782
Liver
Chapter by: Sohail, Amir H.; Whittington, Jennifer; Wolfgang, Christopher
in: The ABSITE Blueprints by
[S.l.] : Springer International Publishing, 2023
pp. 73-100
ISBN: 9783031326424
CID: 5717642
Prospective, Multi-Institutional, Real-Time Next-Generation Sequencing of Pancreatic Cyst Fluid Reveals Diverse Genomic Alterations That Improve the Clinical Management of Pancreatic Cysts
Paniccia, Alessandro; Polanco, Patricio M; Boone, Brian A; Wald, Abigail I; McGrath, Kevin; Brand, Randall E; Khalid, Asif; Kubiliun, Nisa; O'Broin-Lennon, Anne Marie; Park, Walter G; Klapman, Jason; Tharian, Benjamin; Inamdar, Sumant; Fasanella, Kenneth; Nasr, John; Chennat, Jennifer; Das, Rohit; DeWitt, John; Easler, Jeffrey J; Bick, Benjamin; Singh, Harkirat; Fairley, Kimberly J; Sarkaria, Savreet; Sawas, Tarek; Skef, Wasseem; Slivka, Adam; Tavakkoli, Anna; Thakkar, Shyam; Kim, Victoria; Vanderveldt, Hendrikus Dutch; Richardson, Allyson; Wallace, Michael B; Brahmbhatt, Bhaumik; Engels, Megan; Gabbert, Charles; Dugum, Mohannad; El-Dika, Samer; Bhat, Yasser; Ramrakhiani, Sanjay; Bakis, Gennadiy; Rolshud, Daniil; Millspaugh, Gordon; Tielleman, Thomas; Schmidt, Carl; Mansour, John; Marsh, Wallis; Ongchin, Melanie; Centeno, Barbara; Monaco, Sara E; Ohori, N Paul; Lajara, Sigfred; Thompson, Elizabeth D; Hruban, Ralph H; Bell, Phoenix D; Smith, Katelyn; Permuth, Jennifer B; Vandenbussche, Christopher; Ernst, Wayne; Grupillo, Maria; Kaya, Cihan; Hogg, Melissa; He, Jin; Wolfgang, Christopher L; Lee, Kenneth K; Zeh, Herbert; Zureikat, Amer; Nikiforova, Marina N; Singhi, Aatur D
BACKGROUND AND AIMS/OBJECTIVE:Next-generation sequencing (NGS) of pancreatic cyst fluid is a useful adjunct in the assessment of patients with pancreatic cyst. However, previous studies have been retrospective or single institutional experiences. The aim of this study was to prospectively evaluate NGS on a multi-institutional cohort of patients with pancreatic cyst in real time. METHODS:The performance of a 22-gene NGS panel (PancreaSeq) was first retrospectively confirmed and then within a 2-year timeframe, PancreaSeq testing was prospectively used to evaluate endoscopic ultrasound-guided fine-needle aspiration pancreatic cyst fluid from 31 institutions. PancreaSeq results were correlated with endoscopic ultrasound findings, ancillary studies, current pancreatic cyst guidelines, follow-up, and expanded testing (Oncomine) of postoperative specimens. RESULTS:Among 1933 PCs prospectively tested, 1887 (98%) specimens from 1832 patients were satisfactory for PancreaSeq testing. Follow-up was available for 1216 (66%) patients (median, 23 months). Based on 251 (21%) patients with surgical pathology, mitogen-activated protein kinase/GNAS mutations had 90% sensitivity and 100% specificity for a mucinous cyst (positive predictive value [PPV], 100%; negative predictive value [NPV], 77%). On exclusion of low-level variants, the combination of mitogen-activated protein kinase/GNAS and TP53/SMAD4/CTNNB1/mammalian target of rapamycin alterations had 88% sensitivity and 98% specificity for advanced neoplasia (PPV, 97%; NPV, 93%). Inclusion of cytopathologic evaluation to PancreaSeq testing improved the sensitivity to 93% and maintained a high specificity of 95% (PPV, 92%; NPV, 95%). In comparison, other modalities and current pancreatic cyst guidelines, such as the American Gastroenterology Association and International Association of Pancreatology/Fukuoka guidelines, show inferior diagnostic performance. The sensitivities and specificities of VHL and MEN1/loss of heterozygosity alterations were 71% and 100% for serous cystadenomas (PPV, 100%; NPV, 98%), and 68% and 98% for pancreatic neuroendocrine tumors (PPV, 85%; NPV, 95%), respectively. On follow-up, serous cystadenomas with TP53/TERT mutations exhibited interval growth, whereas pancreatic neuroendocrine tumors with loss of heterozygosity of ≥3 genes tended to have distant metastasis. None of the 965 patients who did not undergo surgery developed malignancy. Postoperative Oncomine testing identified mucinous cysts with BRAF fusions and ERBB2 amplification, and advanced neoplasia with CDKN2A alterations. CONCLUSIONS:PancreaSeq was not only sensitive and specific for various pancreatic cyst types and advanced neoplasia arising from mucinous cysts, but also reveals the diversity of genomic alterations seen in pancreatic cysts and their clinical significance.
PMID: 36209796
ISSN: 1528-0012
CID: 5360782
Development, validation, and comparison of a nomogram based on radiologic findings for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: An international multicenter study
Kim, Hyeong Seok; Song, Wookyeong; Choo, Wonho; Lee, Sungyoung; Han, Youngmin; Bassi, Claudio; Salvia, Roberto; Marchegiani, Giovanni; Wolfgang, Christopher L; He, Jin; Blair, Alex B; Kluger, Michael D; Su, Gloria H; Kim, Song Cheol; Song, Ki-Byung; Yamamoto, Masakazu; Hatori, Takashi; Yang, Ching-Yao; Yamaue, Hiroki; Hirono, Seiko; Satoi, Sohei; Fujii, Tsutomu; Hirano, Satoshi; Lou, Wenhui; Hashimoto, Yasushi; Shimizu, Yasuhiro; Del Chiaro, Marco; Valente, Roberto; Lohr, Matthias; Choi, Dong Wook; Choi, Seong Ho; Heo, Jin Seok; Motoi, Fuyuhiko; Matsumoto, Ippei; Lee, Woo Jung; Kang, Chang Moo; Shyr, Yi-Ming; Wang, Shin-E; Han, Ho-Seong; Yoon, Yoo-Seok; Besselink, Marc G; van Huijgevoort, Nadine C M; Sho, Masayuki; Nagano, Hiroaki; Kim, Sang Geol; Honda, Goro; Yang, Yinmo; Yu, Hee Chul; Yang, Jae Do; Chung, Jun Chul; Nagakawa, Yuichi; Seo, Hyung Il; Lee, Seungyeoun; Kim, Hongbeom; Kwon, Wooil; Park, Taesung; Jang, Jin-Young
BACKGROUND:Although we previously proposed a nomogram to predict malignancy in intraductal papillary mucinous neoplasms (IPMN) and validated it in an external cohort, its application is challenging without data on tumor markers. Moreover, existing nomograms have not been compared. This study aimed to develop a nomogram based on radiologic findings and to compare its performance with previously proposed American and Korean/Japanese nomograms. METHODS:We recruited 3708 patients who underwent surgical resection at 31 tertiary institutions in eight countries, and patients with main pancreatic duct >10 mm were excluded. To construct the nomogram, 2606 patients were randomly allocated 1:1 into training and internal validation sets, and area under the receiver operating characteristics curve (AUC) was calculated using 10-fold cross validation by exhaustive search. This nomogram was then validated and compared to the American and Korean/Japanese nomograms using 1102 patients. RESULTS:Among the 2606 patients, 90 had main-duct type, 900 had branch-duct type, and 1616 had mixed-type IPMN. Pathologic results revealed 1628 low-grade dysplasia, 476 high-grade dysplasia, and 502 invasive carcinoma. Location, cyst size, duct dilatation, and mural nodule were selected to construct the nomogram. AUC of this nomogram was higher than the American nomogram (0.691 vs 0.664, P = .014) and comparable with the Korean/Japanese nomogram (0.659 vs 0.653, P = .255). CONCLUSIONS:A novel nomogram based on radiologic findings of IPMN is competitive for predicting risk of malignancy. This nomogram would be clinically helpful in circumstances where tumor markers are not available. The nomogram is freely available at http://statgen.snu.ac.kr/software/nomogramIPMN.
PMID: 33811460
ISSN: 1868-6982
CID: 4871112
Solid Pseudopapillary Neoplasms of the Pancreas Across Races Demonstrate Disparities with Comparably Good Prognosis
Lin, Young-Jen; Burkhart, Richard; Lu, Tzu-Pin; Wolfgang, Christopher; Wright, Michael; Zheng, Lei; Wu, Han-Yu; Chen, Ching-Hsuan; Lee, Shin-Yi; Wu, Chien-Hui; He, Jin; Tien, Yu-Wen
BACKGROUND:Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare with low-grade malignancy and unclarified clinicopathological features. This study aimed to examine their characteristics and re-evaluate current treatments. METHODS:Databases from three sources were screened for patients with SPNs. We compared the perioperative variables, clinical data, overall survival (OS), and prognostic factors for recurrence among the three corresponding cohorts. RESULTS:We identified 286 patients diagnosed with SPNs between 1988 and 2020. Patients were mostly women (81%; median age: 38 years), and peak incidence was observed in women of 20-29 years of age. SPNs had a peak incidence in Asian men at 50-59 years of age (p = 0.002) and a delayed peak incidence in Asian women at 30-39 years of age (p < 0.001). Treatment strategies differed significantly across the institutions and included variations in the number of harvested lymph nodes and rates of vascular resection. Lymph node positivity was the only predictor of postoperative recurrence (odds ratio, 2.2; 95% confidence interval, 1.38-2.99; p = 0.007). Higher rates of lymphovascular invasion (p = 0.02), perineural invasion (p < 0.001), and R1 margin involvement (p < 0.001), as seen in one institution, did not result in poorer long-term survival in terms of the overall (p = 0.43), SPN-specific (p = 0.69), and recurrence-free survivals (p = 0.067). CONCLUSIONS:In contrast to previous findings that SPNs are prevalent in young women, a racial predilection for middle-aged Asian men and a delayed female peak incidence were noted. Parenchyma-preserving pancreatectomy may be an acceptable treatment. Non-radical surgery may be appropriate in patients with multiple comorbidities.
PMID: 36066663
ISSN: 1432-2323
CID: 5336972
A novel tool to predict nodal metastasis in small pancreatic neuroendocrine tumors: A multicenter study
Javed, Ammar A; Pulvirenti, Alessandra; Zheng, Jian; Michelakos, Theodoros; Sekigami, Yurie; Razi, Samrah; McIntyre, Caitlin A; Thompson, Elizabeth; Klimstra, David S; Deshpande, Vikram; Singhi, Aatur D; Weiss, Matthew J; Wolfgang, Christopher L; Cameron, John L; Wei, Alice C; Zureikat, Amer H; Ferrone, Cristina R; He, Jin
BACKGROUND:Nonfunctional pancreatic neuroendocrine tumors display a wide range of biological behavior, and nodal disease is associated with metastatic disease and poorer survival. The aim of this study was to develop a tool to predict nodal disease in patients with small (≤2 cm) nonfunctional pancreatic neuroendocrine tumors. METHODS:A multicenter retrospective study was performed on patients undergoing resection for small nonfunctional pancreatic neuroendocrine tumors. Patients with genetic syndromes, metastatic disease at diagnosis, neoadjuvant therapy, or positive resection margin were excluded. Factors associated with nodal disease were identified to develop a predictive model. Internal validation was performed using bootstrap with 1,000 resamples. RESULTS:Nodal disease was observed in 39 (11.1%) of the 353 patients included. Presence of nodal disease was significantly associated with lower 5-year disease-free survival (71.6% vs 96.2%, P < .001). Two predictors were strongly associated with nodal disease: G2 grade (odds ratio: 3.51, 95% confidence interval: 1.71-7.22, P = .001) and tumor size (per mm increase, odds ratio: 1.14, 95% confidence interval: 1.03-1.25, P = .009). Adequate discrimination was observed with an area under the curve of 0.71 (95% confidence interval: 0.63-0.80). Based on risk distribution, 3 risk groups of nodal disease were identified; low (<5%), intermediate (≥5% to <20%), and high (≥20%) risk. The observed mean risk of nodal disease was 3.7% in the low-risk patients, 9.6% in the intermediate-risk patients, and 30.4% in the high-risk patients (P < .001). The 10-year disease-free survival in the low, intermediate, and high-risk groups was 100%, 88.8%, and 50.1%, respectively. CONCLUSION/CONCLUSIONS:Our model using tumor grade and size can predict nodal disease in small nonfunctional pancreatic neuroendocrine tumors. Integration of this tool into clinical practice could help guide management of these patients.
PMID: 36192215
ISSN: 1532-7361
CID: 5351462
Classification of pancreatic cystic neoplasms using radiomic feature analysis is equivalent to an experienced academic radiologist: a step toward computer-augmented diagnostics for radiologists
Chu, Linda C; Park, Seyoun; Soleimani, Sahar; Fouladi, Daniel F; Shayesteh, Shahab; He, Jin; Javed, Ammar A; Wolfgang, Christopher L; Vogelstein, Bert; Kinzler, Kenneth W; Hruban, Ralph H; Afghani, Elham; Lennon, Anne Marie; Fishman, Elliot K; Kawamoto, Satomi
PURPOSE/OBJECTIVE:A wide array of benign and malignant lesions of the pancreas can be cystic and these cystic lesions can have overlapping imaging appearances. The purpose of this study is to compare the diagnostic accuracy of a radiomics-based pancreatic cyst classifier to an experienced academic radiologist. METHODS:In this IRB-approved retrospective single-institution study, patients with surgically resected pancreatic cysts who underwent preoperative abdominal CT from 2003 to 2016 were identified. Pancreatic cyst(s) and background pancreas were manually segmented, and 488 radiomics features were extracted. Random forest classification based on radiomics features, age, and gender was evaluated with fourfold cross-validation. An academic radiologist blinded to the final pathologic diagnosis reviewed each case and provided the most likely diagnosis. RESULTS:214 patients were included (64 intraductal papillary mucinous neoplasms, 33 mucinous cystic neoplasms, 60 serous cystadenomas, 24 solid pseudopapillary neoplasms, and 33 cystic neuroendocrine tumors). The radiomics-based machine learning approach showed AUC of 0.940 in pancreatic cyst classification, compared with AUC of 0.895 for the radiologist. CONCLUSION/CONCLUSIONS:Radiomics-based machine learning achieved equivalent performance as an experienced academic radiologist in the classification of pancreatic cysts. The high diagnostic accuracy can potentially maximize the efficiency of healthcare utilization by maximizing detection of high-risk lesions.
PMID: 36098760
ISSN: 2366-0058
CID: 5332802
The Influence of Intraoperative Blood Loss on Fistula Development Following Pancreatoduodenectomy
Trudeau, Maxwell T; Casciani, Fabio; Maggino, Laura; Seykora, Thomas F; Asbun, Horacio J; Ball, Chad G; Bassi, Claudio; Behrman, Stephen W; Berger, Adam C; Bloomston, Mark P; Callery, Mark P; Castillo, Carlos Fernandez-Del; Christein, John D; Dillhoff, Mary E; Dickson, Euan J; Dixon, Elijah; Fisher, William E; House, Michael G; Hughes, Steven J; Kent, Tara S; Malleo, Giuseppe; Salem, Ronald R; Wolfgang, Christopher L; Zureikat, Amer H; Vollmer, Charles M
OBJECTIVE:To investigate the role of intraoperative EBL on development of CR-POPF after pancreatoduodenectomy (PD). BACKGROUND:Minimizing EBL has been shown to decrease transfusions and provide better perioperative outcomes in PD. EBL is also felt to be influential on CR-POPF development. METHODS:This study consists of 5534 PDs from a 17-institution collaborative (2003-2018). EBL was progressively categorized (≤150 mL; 151-400 mL; 401-1,000 mL; >1,000 mL). Impact of additive EBL was assessed using 20 3-factor fistula risk score (FRS) scenarios reflective of endogenous CR-POPF risk. RESULTS:CR-POPF developed in 13.6% of patients (N = 753) and median EBL was 400 mL (interquartile range 250-600 mL). CR-POPF and Grade C POPF were associated with elevated EBL (median 350 vs 400 mL, P = 0.002; 372 vs 500 mL, P < 0.001, respectively). Progressive EBL cohorts displayed incremental CR-POPF rates (8.5%, 13.4%, 15.2%, 16.9%; P < 0.001). EBL >400 mL was associated with increased CR-POPF occurrence in 13/20 endogenous risk scenarios. Moreover, 8 of 10 scenarios predicated on a soft gland demonstrated increased CR-POPF incidence. Hypothetical projections demonstrate significant reductions in CR-POPF can be obtained with 1-, 2-, and 3-point decreases in FRS points attributed to EBL risk (12.2%, 17.4%, and 20.0%; P < 0.001). This is especially pronounced in high-risk (FRS7-10) patients, who demonstrate up to a 31% reduction (P < 0.001). Surgeons in the lowest-quartile of median EBL demonstrated CR-POPF rates less than half those in the upper-quartile (7.9% vs 18.8%; P < 0.001). CONCLUSION/CONCLUSIONS:EBL independently contributes significant biological risk to CR-POPF. Substantial reductions in CR-POPF occurrence are projected and obtainable by minimizing EBL. Decreased individual surgeon EBL is associated with improvements in CR-POPF.
PMID: 33201132
ISSN: 1528-1140
CID: 4741752
Postoperative Chemotherapy is Associated with Improved Survival in Patients with Node-Positive Pancreatic Ductal Adenocarcinoma After Neoadjuvant Therapy
Ivey, Gabriel D; Shoucair, Sami; Delitto, Daniel J; Habib, Joseph R; Kinny-Köster, Benedict; Shubert, Christopher R; Lafaro, Kelly J; Cameron, John L; Burns, William R; Burkhart, Richard A; Thompson, Elizabeth L; Narang, Amol; Zheng, Lei; Wolfgang, Christopher L; He, Jin
BACKGROUND:Postoperative chemotherapy following pancreatic cancer resection is the standard of care. The utility of postoperative chemotherapy for patients who receive neoadjuvant therapy (NAT) is unclear. METHODS:Patients who underwent pancreatectomy after NAT with FOLFIRINOX or gemcitabine-based chemotherapy for non-metastatic pancreatic adenocarcinoma (2015-2019) were identified. Patients who received less than 2 months of neoadjuvant chemotherapy or died within 90 days from surgery were excluded. RESULTS:A total of 427 patients (resectable, 22.2%; borderline resectable, 37.9%; locally advanced, 39.8%) were identified with the majority (69.3%) receiving neoadjuvant FOLFIRINOX. Median duration of NAT was 4.1 months. Following resection, postoperative chemotherapy was associated with an improved median overall survival (OS) (28.7 vs. 20.4 months, P = 0.006). Risk-adjusted multivariable modeling showed negative nodal status (N0), favorable pathologic response (College of American Pathologists score 0 & 1), and receipt of postoperative chemotherapy to be independent predictors of improved OS. Regimen, duration, and number of cycles of NAT were not significant predictors. Thirty-four percent (60/176) of node-positive and 50.1% (126/251) of node-negative patients did not receive postoperative chemotherapy due to poor functional status, postoperative complications, and patient preference. Among patients with node-positive disease, postoperative chemotherapy was associated with improved median OS (27.2 vs. 10.5 months, P < 0.001). Among node-negative patients, postoperative chemotherapy was not associated with a survival benefit (median OS, 30.9 vs. 36.9 months; P = 0.406). CONCLUSION/CONCLUSIONS:Although there is no standard NAT regimen for patients with pancreatic cancer, postoperative chemotherapy following NAT and resection appears to be associated with improved OS for patients with node-positive disease.
PMID: 35861852
ISSN: 1432-2323
CID: 5279292